S. Hrg. 114–722 

AMERICA’S INSATIABLE DEMAND FOR DRUGS 

HEARING 

BEFORE THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

AMERICA’S INSATIABLE DEMAND FOR DRUGS, APRIL 13, 2016 

ASSESSING THE FEDERAL RESPONSE, MAY 17, 2016 

EXAMINING ALTERNATIVE APPROACHES, JUNE 15, 2016 

Available via the World Wide Web: http://www.fdsys.gov/ 

Printed for the use of the 

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22–771 PDF 2017

S. Hrg. 114–722 

AMERICA’S INSATIABLE DEMAND FOR DRUGS 

HEARING 

BEFORE THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

AMERICA’S INSATIABLE DEMAND FOR DRUGS, APRIL 13, 2016 

ASSESSING THE FEDERAL RESPONSE, MAY 17, 2016 

EXAMINING ALTERNATIVE APPROACHES, JUNE 15, 2016 

Available via the World Wide Web: http://www.fdsys.gov/ 

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs 

( 
(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

RON JOHNSON, Wisconsin Chairman 

JOHN MCCAIN, Arizona 

ROB PORTMAN, Ohio 

RAND PAUL, Kentucky 

JAMES LANKFORD, Oklahoma 

MICHAEL B. ENZI, Wyoming 

KELLY AYOTTE, New Hampshire 

JONI ERNST, Iowa 

BEN SASSE, Nebraska 

THOMAS R. CARPER, Delaware 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

TAMMY BALDWIN, Wisconsin 

HEIDI HEITKAMP, North Dakota 

CORY A. BOOKER, New Jersey 

GARY C. PETERS, Michigan 

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. VIN ̃ A, 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 
(III) 

C O N T E N T S 

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 
Page

IV 

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 
Page

V 

Ryan, Frederick: 

Testimony .......................................................................................................... 367 

Prepared statement .......................................................................................... 470 

(1) 

1The prepared statement of Senator Johnson appears in the Appendix on page 47. 

AMERICA’S INSATIABLE DEMAND FOR DRUGS 

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

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 
2 

1The prepared statement of Senator Carper appears in the Appendix on page 48. 

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 CARPER1

Senator CARPER. Thank you, Mr. Chairman. Thank you so much 

for bringing this together. 

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 de-
3 

terring 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. 
4 

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. 
5 

1The prepared statement of General Kelly appears in the Appendix on page 50. 

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. 

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 
6 

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 
7 

1The prepared statement of Mr. Caulkins appears in the Appendix on page 70. 

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. 

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. 
8 

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 ap-
9 

1The prepared statement of Ms. Healton appears in the Appendix on page 93. 

plied 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 countermarketing 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. 

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 inter-
10 

ests. 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 
11 

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. 
12 

1The prepared statement of Mr. Sgro appears in the Appendix on page 105. 

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. 

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 alternativenarratives 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 techsavvy 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, 
13 

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 peerto-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 
14 

1The prepared statement of Mr. Budsock appears in the Appendix on page 121. 

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 peerto-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. 

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 
15 

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 wellcharacterized 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 
16 

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, 
17 

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 
18 

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 
19 

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— 
20 

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 
21 

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 
22 

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 
23 

Joaquı ́n ‘‘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 
24 

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, 
25 

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? 
26 

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, be-
27 

cause 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 counternarcotics 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 counternarcotics 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 
28 

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 
29 

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 blowback, 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? 
30 

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. 
31 

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 
32 

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 inhouse. 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 
33 

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. 
34 

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 crossborder 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. 
35 

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. 
36 

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 ‘‘Peerto-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, 
37 

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 peo-
38 

ple—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. 
39 

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 
40 

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 
41 

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. 
42 

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— 
43 

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 
44 

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 medicationassisted 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. 
45 

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.] 

(47) 

A P P E N D I X 
48 

As prepared for delivery: 

Statement of Ranking Member Tom Carper 

"America's Insatiable Demand for Drugs" 

Wednesday, Apri113, 2016 

Thank you, Mr. Chairman, for calling this hearing today on Americans' devastating addiction to 

illegal drugs. I look forward to hearing from our witnesses on this difficult issue that has 

developed into a health emergency in many American communities, while also contributing to 

the security challenges that a number of our Latin American neighbors continue to face each day. 

Drug abuse, particularly prescription drug and heroin abuse, has been a growing problem across 

our country for many years now. It has led to tragic consequences not just for those who are 

suffering from addiction, but also for their families and communities. The Centers for Disease 

Control notes that between 2002 and 2013, 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 and around 3,000 adults sought treatment for heroin in the state's primary treatment 

facilities. 

American demand for heroin and other drugs also fuels the violent tactics of the tratlickers who 

move drugs, goods, and people across our borders. American drug demand is also having a 

dramatic and deadly effect in South and Central America. As our Committee has found, so much 

of the corruption and violence in the Northern Triangle - Guatemala, Honduras, and El Salvador 

and in other parts of South and Central America is fueled in large part by America's appetite 

for illegal drugs. This corruption and violence are a major cause for 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 drug users themselves. 

Today, we will 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 outreach and 

other education initiatives aimed at reducing this demand. I'm pleased that our panel includes Dr. 

Cheryl Healton, who has been an instrumental force behind successful public health initiatives 

aimed at reducing the use of tobacco, particularly among young people. Dr. Healton will share 

with us some of the reasons why the important efforts she's been a part of have been successful, 

and how we can learn from recent anti-tobacco campaigns to best reach young people who may 

be using or considering using illegal drugs. And because addiction and substance abuse are 

medical conditions that can often be treated effectively, we'll also discuss the role prevention 

and treatment can play in reducing demand. 

In sum, these problems that we're facing are complex, and the potential solutions are not quick 

or easy. 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 successfully address what drives people to 

use these harmful substances and to help them overcome their addiction. My thanks again to our 
49 

Chairman for holding this hearing and to our witnesses for their contributions and their presence 

here today. We look forward to working with each of you as we continue to take action to 

identify and address the root causes of America's demand for illegal drugs. 
50 

STATEMENT OF 

GENERAL JOHN F. KELLY, UNITED STATES MARINE CORPS (Ret) 

FORMER COMBATANT COMMANDER, 

UNITED STATES SOUTHERN COMMAND (USSOUTHCOM) 

BEFORE THE 

SENATE COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL 

AFFAIRS 

13 APRIL 2016 
51 

Introduction 

Chairman Johnson, Ranking Member Carper, and distinguished Members of the 

Committee: it is a privilege for me to appear before you today to discuss the effects our country's 

insatiable demand for drugs has on our border, our neighborhoods and communities, the heroic 

men and women oflaw enforcement, and on the individuals and their families devastated by the 

scourge of illegal drug use. You have also asked for my views as the former commander of 

United States Southern Command (USSOUTHCOM) on the Trans-National Criminal 

Organizations (TCO) and the illegal networks they manage, and how the production and 

smuggling of drugs through various countries adversely impacts these societies. Finally, you 

wanted my thoughts on what Washington-but infinitely more important what we as a society 

can do to reduce the demand for drugs in the U.S. 

To frame my remarks I think it is important for the Committee to know two things about 

me. First, that until mid-January this year I commanded the men and women ofSOUTHCOM 

one of the six geographical combatant commands. The Area ofResponsivity of that Miami 

based headquarters includes all of the countries and principalities south of the U.S., with the 

notable exceptions of Mexico, the Bahamas, Puerto Rico and the U.S. Virgin Islands. You can 

be confident that what I've submitted in my written statement, and my answers to any questions 

you may ask, will be accurate and the truth as I know it. The responses will not be coming from 

another recently retired general who is now telling all. I have said all of these things, and made 

all of these points, endlessly in innumerable official meetings in Washington, Brasilia, Bogota, 

Lima, Tegucigalpa, Guatemala City, indeed throughout the region, and in all of my open and 

closed congressional office calls and hearings, and to the press, during my 39 months in 

command ofUSSOUTHCOM. 

1 
52 

It is very important for you to fully recognize that from this region of the world-our 

own neighborhood, that effectively I 00% of the heroin and cocaine, and perhaps 90% of the 

methamphetamines that plague our fellow citizens-poor and rich, working class and middle 

class, black and white--are produced and trafficked. This region, particularly from Mexico, is 

also the source of enormous quantities of pirated pharmaceuticals. The illicit production and 

transport of these pharmaceuticals took oft' as a growth industry for the TCOs beginning not so 

many years ago when the combination of legislation from this body and the aggressive actions 

on the part of U.S. law enforcement, particularly the FBI, effectively targeted unprincipled and 

criminal medical practitioners in the U.S. These individuals in the business of writing illegal 

prescriptions for extremely addictive and routinely abused painkillers like oxycodone and 

percocet created an illicit industry likely worthy billions in its heyday. As this illicit trade was 

increasingly choked off in the U.S. the cartels, international businessmen as they are, recognized 

the demand and filled the demand including the production, trafficking and distribution into the 

U.S. Regardless of where they are produced these pharmaceuticals are still relatively expensive 

and increasingly hard to come by, which then increased the demand for very cheap, very 

addictive, and readily available heroin. Of course the cartels then responded to this demand and 

so the business of meeting our drug demands goes on. Simply put, then, Mexico is the source of 

heroin and meth-and this includes the growing and harvesting of nearly 40,000 acres of poppies 

(DEA estimates) and the labs to produce industrial quantities of both drugs using precursor 

chemicals imported in bulk from Asia. 

Cocaine bound for the U.S. market, on the other hand, is grown, manufactured and sent 

north along the network comes primarily from Colombia. Unknown to many, Colombia is our 

very best ally in the region across a range of regional and international issues, and a country with 

2 
53 

whom the U.S. has a decades long and very strong "special relationship" as specifically 

acknowledged recently by President Obama when introducing Colombian President Santos here 

in Washington. Colombia does more to help solve our demand problem than do we. For years 

they have eradicated 40,000 acres of coca annually, destroyed thousands of labs, and just last 

year seized nearly 200 metric tons of cocaine before it ever left their country. They have done 

this selflessly and at an incredibly high cost in the blood of their military and police 

professionals. We have helped them in this decades long effort particularly in the area of 

information and intelligence sharing, and encouragement. What they have done internally 

dealing with the terrorist group they have been battling for over 50 years, and in the fight against 

cocaine trafficking over the last 25 years working with the U.S. as an equal partner under "Plan 

Columbia," is nothing less than miraculous. 

Mr. Chairman I think the Committee knows this, and if it does not it should, Colombia is 

an exporter of security to the rest of the region. The relationship is a terrific example of how 

sustained U.S. support based on mutual respect and equal partnership can help a people gain 

control of their security situation, strengthen government institutions, eradicate corruption, and 

bolster their economy. As I have mentioned Colombia's turnaround is nothing short of 

astonishing, and today it is a leader among many strong partners to improve stability in the 

Western Hemisphere. Mr. Chairman, I am confident you and the Committee know that the 

United States has a special relationship with only a handful of countries. These relationships are 

based on a firm foundation of trust and are with nations that value the same things we dofamily and opportunity for our children, a free press, democracy and rule of law, safe streets, 

respect for human rights-and we rely on partnerships with such countries to work with us in 

3 
54 

achieving regional stability, countries that we look to for international involvement and 

leadership, countries that we consider our strongest friends and most steadfast allies. 

Colombia unquestionably plays that role in Latin America, but also in parts of Africa, the 

Middle East, on UN missions and other commitments including dispatching one of their frigates 

to join the international effort to counter-piracy on the high seas in the vicinity of Somalia and 

Yemen. Closer to home, and through the "U.S.- Colombia Action Plan on Regional Security," 

Colombia provides vital assistance to its Central American, Caribbean and Mexican neighbors in 

the fight against criminal networks. They are vitally important in this endeavor because the U.S. 

military given all of the demands in other more violent or potentially more violent reaches of the 

world, is unavailable for this critical duty in the Western Hemisphere. And I want to note here 

that every aspect ofU.S. collaboration under this Plan, including activities conducted by 

Southern Command, is facilitated through U.S. security assistance and governed by the same 

U.S. Jaws and regulations--especially those requiring the human rights vetting of units--

regulating the activities of our own military personnel. Colombia is also the example to every 

other nation in the region that stares into the bottomless abyss of failed statehood. Colombia 

once stared into this same darkness, an abyss due largely to the activities of the region's "narcoterrorist" organizations responding to the demand for drugs in the United States, but they 

changed everything and won. They changed their Jaws, their tax code, their business 

environment, their approach to counterinsurgency and counterterrorism operations, their 

approach to democracy and human rights-and they won. 

The vast majority of the tonnage of all four of these drugs-heroin, meth, cocaine, and 

pharmaceuticals-are then trafficked by the Trans-National Criminal Organizations via the 

Central American- Mexican criminal network(s) directly into the U.S. This network-of4 
55 

networks, by the way, is generally controlled by the Mexican cartels with many subcontractors 

interspersed throughout the region and the world for that matter. The enterprise begins in the 

jungles of Colombia, runs along the Central American transit vector, into Mexico. Once in 

Mexico so effective are the cartels in taking advantage of the laws, corruption and intimidation, 

of that country and our own, their illicit cargo--drugs, people or anything else that can pay to 

ride the network--can already be considered to be in Madison, Wilmington, Phoenix, Columbus, 

Billings, Cheyenne, Boston, and Manchester. The distribution networks reach deep inside every 

U.S. city, small town, rural community and neighborhood. The men and women involved in this 

enterprise are among the most cruel and violent on the planet, are unencumbered by morals, laws 

or regulations, other than to maximize profits. They do not check passports, inspect bags, 

conduct body scans, or test for explosive residue. Anything and anybody can travel on this 

network so long as the price can be met, and, frankly, the fare is very reasonable considering. 

As an aside, Peru with whom we have very good relations in the military, law 

enforcement and political realms, and Bolivia who we do not, are the first and second largest 

producers of cocaine in the world-which is the big profit maker. The production from these 

two nations feed the world market carried by equally efficient and violent networks that flow 

west across the Pacific, and east through Brazil and increasingly through Paraguay, Uruguay and 

Argentina to Africa, Europe and the Middle East. And with trafficking eventually comes 

consumption. For example, the U.S. is the #1 consumer of cocaine in the world. Brazil, until a 

few years ago was not a consumer nation at all, but once the network was established it is only a 

matter of time until the cartels and network "managers" develop a market until today with Brazil 

achieving the dubious status of being the #2 consumer in the world. The Paraguayans, the 

Argentines, indeed any transit country will quickly experience the same phenomenon. 

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Members of the Committee, much like Colombia was able to accomplish over the last 15 

years our friends across the region are committed to winning back their streets, indeed their 

countries, from criminal gangs and drug traffickers, and doing so while protecting human rights. 

The Hondurans, Guatemalans, El Salvadorans, Jamaicans, Dominicans, they are all ready and 

willing to partner with the United States. They are eager for expanded cooperation and increased 

learning and training opportunities with the U.S. military and law enforcement. But they are 

very frustrated by what they perceive as the low prioritization of Latin America and the 

Caribbean on our national security and foreign policy agendas, which is especially puzzling 

given the shared challenges of transnational organized crime and narco-terrorism. They are also 

frustrated in the current approach the U.S. is taking towards drugs as we move forward towards 

outright legalization or de facto legalization by expanding the "medical" use of drugs like 

marijuana. They also cringe when Americans in any capacity or role make the case that 

"recreational" use of drugs is "harmless," or that the vast majority of drug dealing on our streets 

is non-violent. All this, while we continue to encourage and often times criticize our friends to 

the south for not doing what we think is enough to reduce production, or impede the transport of 

these killer substances though their national territories to the U.S. 

In the world in which they live--the Mexicans, Central Americans, Colombians, 

Peruvians, and across the Caribbean including Puerto Rico and Virgin Islands-in their world 

there is no such thing as a "non-violent" drug deal as thousands die annually in their countries as 

a result of the business of supplying drugs to the American market. Good, decent and honest 

police officers and soldiers, judges and prosecutors, legislators and journalists, officials from the 

various ministries-and their wives, children, mothers and fathers, their entire families-are 

intimidated, corrupted or killed so that Americans can get high on weekends or spend their time 

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"Chasing the Dragon" of addiction. The word "hypocrisy" often times comes up when one 

speaks with our friends to the south because we do little, certainly in their view, to reduce the 

demand. 

If it is not obvious as this point, I will cut to the bottom line and tell you that the 

fundamental factor that drives the entire illicit enterprise is our country's demand for heroin, 

methamphetamines, cocaine, and opiates in pill form. I do not even include marijuana and the 

many synthetic offshoots which in and of itself is a major factor in so many social ills. It is in 

fact a "gateway drug" to more destructive illegal drug use, and its use results in a great many 

destructive physical effects on the brain, the user's health, and social development. Many 

hoping to cash in on the emerging commercial enterprise that is legal or medical marijuana work 

hard to discount or deny these facts, but they are facts. It is at the same time ludicrous and 

inconceivable to me why with all the Americas already struggling with drug and alcohol 

addiction that we would make available even more substances to poison the body and confuse 

the brain. To make the powerful modern-day drug that is marijuana available on demand and 

compound the problem. 

Mr. Chairman, it is a fool's position to think that the tax revenue raised by legal sales will 

offset the physical and social costs of its use. Indications and warnings are already coming in 

from those states that have legalized the drug or allowed widespread "medical" use and abuse, 

but something to consider is what the DEA would tell you and that is for every dollar raised from 

two drugs already legal-tobacco and alcohol-amounts approaching 23 and 17 dollars 

respectively are paid out by the already overburdened taxpayer to deal with the effects of these 

two drugs. If those public officials voting to legalize pot either by outright legalization, or via 

the dispensing of medical marijuana, were responsible they would most certainly, and 

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responsibly, consider the additional burden that it will have on the tax payer and add additional 

tax by say 17x onto the price of the drug at the counter. 

Our drug demand, including marijuana, to a large degree has wrought devastating 

consequences in many of our partner nations, degrading their civilian police and justice systems, 

corrupting their institutions, and contributing to a breakdown in citizen safety. The tentacles of 

global networks involved in narcotics and arms trafficking, human smuggling (including the 

18,000 young women and boys the UN tells us are smuggled into the U.S. every year to serve as 

sex slaves) , illicit finance, and other types of illegal activity reach across Latin America and the 

Caribbean and into the United States, yet we continue to almost ignore the threat TCOs present 

to our homeland and the significant and direct risk to our national security and that of our partner 

nations. Unless confronted by an immediate, visible, or uncomfortable crisis, our nation's 

tendency is to take these threats that ride the networks into and through the Western Hemisphere 

for granted or hope for the best. I believe this is a huge mistake. I believe hope was and is the 

same approach the Europeans in general, and the French and Belgians specifically, took 

regarding their borders-and they lost. 

In 2014 estimates there were nearly half a million migrants 1 from Central America and 

Mexico-including over 50,000 unaccompanied children (UAC) and families-were 

apprehended on our border, many fleeing violence, poverty, and the spreading influence of 

criminal networks and gangs. Assistant Secretary of State Roberta Jacobson testified that the 

"UAC migration serves as a warning sign that the serious and longstanding challenges in Central 

1 U.S. Customs and Border Patrol, FY 14 Border Security Report. According to the CBP, 239,229 migrants from the Northern 

Tier countries of Guatemala, Honduras, and El Salvador were apprehended in 2014, representing a 68% increase compared to FY 

13.229,178 migrants from Mexico were apprehended, a 14% decrease. 

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America are worsening."2 In my opinion, the relative ease with which human smugglers moved 

tens of thousands of people along the networks also serves as another warning sign: these 

smuggling routes are a potential vulnerability to our homeland. As I stated many times in open 

hearings to the House and Senate defense committees, terrorist organizations could easily 

leverage those same smuggling routes to move operatives or materiel with intent to cause grave 

harm to our citizens. Mr. Chairman, Members, addressing the root causes of insecurity and 

instability is not just in the region's interests, but ours as well. This is why responsible public 

officials never surrender in the effort to highlight the threat and support the Congress' and 

administration's commitment to increase assistance to Central America, Colombia and other 

partners in the region-help which should be viewed as an investment and not foreign aid. 

These and other challenges underscore the enduring importance of protecting the 

southern approaches to the U.S., and this cannot-should not-be attempted as an endless series 

of"goal-line stands" on the one-foot line at the official ports-of-entry or along the thousands of 

miles of border between this country and Mexico. The men and women of the Department of 

Homeland Security and local law enforcement that work that border are highly skilled and 

incredibly dedicated, but overwhelmed. They are overwhelmed by the efficiency of the network 

and the funding the cartels have to guarantee their illicit products and people will get through. 

The effort to get at our drug demand begins, or should begin, on the cartel's end of the field and 

with a much greater effort. The U.S. military is almost absent in the effort due to an almost total 

lack of naval forces, although the Commandant of the Coast Guard, Admiral Paul Zukunft 

USCG, seeing the dire need immediately upon assuming his current duties increased the number 

2 Testimony of Roberta Jacobson, Assistant Secretary of State, Bureau of Western Hemisphere Affairs, Before the Subcommittee 

on Western Hemisphere Affairs, United States House ofRepresentatives, November 18,2014. 

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of cutters and personnel committed to the effort. The Coast Guard's cupboard is nearly bare, 

however, given all the commitments the men and women of that organization are required to 

address in the waters surrounding the United States with an insufficient number of National 

Security Cutters and other vessels to do what they need to do globally. Our Coast Guard has 

more demands on it than it can address, but try they do and they are amazing. 

The incredibly strong partnerships I enjoyed as the SOUTHCOM commander with the 

U.S. interagency-especially with the Department of Homeland Security, the Coast Guard, 

DEA, FBI, ATF, the intelligence community and the Departments of Treasury and State all fused 

together by the Joint Inter-Agency Task Force-South (JIATF South) in Key West -were and are 

fundamental to the efforts to try and safeguard the southern defense ofthe U.S. homeland from. 

If you want a report card on how effectively the interagency is accomplishing the mission, how 

the effort to prevent malign cargo and illegal migrants from entering the country is going, I will 

let you draw your own conclusions. I will say, however, that even though we are so incredibly 

fortunate to have willing partners like Colombia, Chile, Brazil, El Salvador, Guatemala, 

Honduras, and Panama, and remarkable interagency cooperation, it's the demand ... it's always 

about the demand. 

Domestic Impact 

Americans have been consuming hard drugs in immense quantities certainly since the 

mid-1960s when the use of drugs became literally cool as projected by Hollywood, social 

"progressives," and even Harvard professors. Since then it has ebbed and flowed-although 

mostly flowed--over the years, but regardless of what the immediate use trends were along the 

time line it has always been a constant in the inner city and working class neighborhoods of our 

cities. The epidemic we talk about and are so rightly concerned with today is due in very large 

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measure because the addiction, and the associated violent crime and deaths due to overdose, are 

no longer a problem of our minority and working class neighborhoods. The death and crime has 

exploded into the suburbs. The body count is now conducted on Capitol Hill and in Georgetown, 

on Beacon Hill and the ivy league and Stanford campuses, and not just in the urban areas of our 

great cities. 

Until the last few years the number of our citizens dying from the use of hard drugs 

trafficked into the United States from abroad by narco-terrorist transnational criminal syndicates, 

or acquired through illegal prescriptions, hovered around 40,000 annually. To put it another way 

since 9/11 when 3,000 were killed by another form of terrorism, over 560,000 have been in my 

view murdered by narco-terrorists. In the past few years even the outrageous number of 40,000 

began to spike until last year the number went beyond 46,000. The DEA tells us that in 2013 

there were 8,620 heroin deaths due to overdose. These deaths are increasing everyday across the 

land but particularly in states in the Middle Atlantic, New England and the Midwest. In fact the 

Center for Disease Control puts the number at 44 a day or over 16,000 a year. To put a more 

focused face on this growing tragedy, in 2014 the New Hampshire Office of the Chief Medical 

Examiner predicted more than 400 deaths from heroin overdoses in 2015 which would have been 

more than double the amount that small state of only 1.3 million experienced in 20!3. He was 

wrong. It was higher. Senator Ayotte among others in this body has been a champion of raising 

the awareness ofthe issue not only in her own state, but nationally, but in my view it has in many 

ways fallen on deaf ears as solving this problem will be hard, really hard, maybe too hard-but I 

think it is worth trying. 

Other impacts on our society are obvious even to the numb. Law enforcement figures tell 

us that a very-large percentage of individuals arrested for major crimes-including homicide, 

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theft and assault-are under the influence of illicit drugs. The same sources tell us that 93% of 

those abusers believe they do not need help even while they are committing violent crimes or 

selling their bodies to feed their habits, in and out of rehab, or saved multiple times when they 

are found in the gutters and "crack houses" by police officers and first responders. Most of these 

abusers started with the gateway drug that marijuana most certainly is, and even while abusing 

heroin are also routinely using at least one other drug. And the dollar cost is immense with the 

estimate at over $200B to deal with drug abuse; much of it on rehabilitation that most agree is at 

best marginally effective even over the short term. 

Security Environment 

As stated in the introduction the end results of decades of rampant demand for drugs in 

the U.S.-and even if we do not care what it is doing to our own society-has caused the spread 

of criminal organizations that continue to tear at the social, economic, and security fabric of our 

Mexican, Latin American and Caribbean neighbors. Powerful and well-resourced, these TCOs 

traffic in drugs-including cocaine, heroin, marijuana, counterfeit pharmaceuticals, and 

methamphetamine-but have evolved grown in size and sophistication. They have also 

broadened the services and products they provide. The cartels and networks now largely control 

the sale and movement of small arms and explosives, precursor chemicals for use in producing 

industrial quantities of heroin and meth, illegally mined gold which is unbelievably destructive to 

fragile environments, counterfeit goods, people, and other contraband. They engage in pervasive 

money laundering, bribery, intimidation, and assassinations at every level of society from the cop 

on the street to the president of a country. They threaten the very underpinnings of democracy 

itself: citizen safety, rule of law, and economic prosperity. They have turned particularly Central 

America and Mexico into among the most dangerous nations on earth by UN numbers of deaths 

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per 100,000 citizens. They have had the very same impact on our own Puerto Rico and the 

Americans who reside there. And these criminal cartels pose a direct threat to the stability of our 

partners and an insidious risk to the security of our nation. lfthese groups were motivated 

politically to destroy these countries and bring down these governments by violence we would 

label them insurgents and lend appropriate support, as we have in Colombia and Peru, to help 

them fight the narco-terrorist organizations that are The Shining Path and FARC. But because 

they are motivated by crime and profit, and not aggressive politics or extremist ideology, and 

despite the fact that are directly and indirectly killing 40,000+ of our citizens every year, many in 

our government hide make the case that this is law enforcement as opposed to a military 

problem. I can assure you it is both and the partner nations at risk have no choice but to re-train 

their military units for internal police duties. 

While there is growing recognition of the danger posed by transnational organized crime, 

it is often eclipsed by other concerns. Frankly, Mr. Chairman, I believe we are overlooking a 

significant security threat. Despite the very effective efforts of the men and women oflaw 

enforcement, TCOs are constantly adapting their methods for trafficking anything and 

everything, and anybody, across our border. While there is not yet any indication that the 

criminal networks involved in human and drug trafficking are interested in supporting the efforts 

of terrorist groups, these networks could unwittingly right now facilitate the movement of 

terrorist operatives or weapons of mass destruction toward our borders, potentially undetected 

and almost completely unrestricted. In addition to thousands of Central Americans fleeing 

poverty and violence, foreign nationals from countries like Somalia, Bangladesh, Lebanon, and 

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Pakistan are using the region's human smuggling networks to enter the United States.3 While 

many are merely seeking economic opportunity or fleeing a "narco-insurgency" that we have 

largely created, a subset could potentially be seeking to do us grave harm. Thankfully, we have 

not observed any hard evidence ofthis occurring ... yet. That said, however, as was the case in 

Boston, or San Bernardino, or Paris or Brussels-and despite the best efforts of our overworked 

and underappreciated intelligence professionals most notably the CIA, DIA and NSA, and our 

embattled law enforcement including the FBI, ATF, CBP and Border Patrol, and the uniformed 

officers on the street-we often learn that the terrorists are here only when the bomb goes off 

and the body count has begun. I am deeply concerned, and you should be deeply concerned as 

our elected leaders, that smuggling networks are a vulnerability that terrorists could seek to 

exploit. I do not see it as a maybe, but as a when. 

You should also be troubled by the financial and operational overlap between criminal 

and terrorist networks in the region. Although the extent of criminal-terrorist cooperation is 

unclear, what is clear is that terrorists and militant organizations easily tap into the international 

illicit marketplace to underwrite their activities and obtain arms and funding to conduct 

operations.4 It's easy to see why: illicit trafficking is estimated to be a $650 billion industry 

worldwide-larger than the GOP of all but 20 countries in the world-and less than one percent 

of global illicit financial flows is seized or frozen. 5 It is estimated that the profits from cocaine 

sales alone in the U.S. go beyond $SOB. Indeed, the biggest problem the narco-terrorists have is 

not getting drugs into the U.S., but laundering the immense profits from the enterprise. The 

3 Texas Department of Public Safety, 2013 Threat Assessment. 4 According to the Drug Enforcement Administration, twenty-two ofthe fifty-nine Department of State designated Foreign 

Terrorist Organizations are linked to the global drug trade. 5 United Nations Office of Drugs and Crime. Estimating Illicit Financial Flows Resulting/rom Drug Trafficking and Other 

Transnational Crimes. Geneva, 2011. 

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terrorist group Lebanese Hezbollah-which has long viewed the region as a potential attack 

venue against Israeli or other Western targets-has supporters and sympathizers in Lebanese 

diaspora communities in Latin America, some of whom are involved in lucrative illicit activities 

like money laundering and trafficking in counterfeit goods and drugs. These clan-based criminal 

networks exploit corruption and lax law enforcement in places like the Tri-Border Area of 

Brazil, Paraguay, and Argentina and the Colon Free Trade Zone in Panama and generate 

revenue, an unknown amount of which is transferred to Lebanese Hezbollah. Unfortunately, our 

limited intelligence capabilities focused on this accumulation of funding make it difficult to fully 

assess the amount of terrorist financing generated in Latin America, or understand the scope of 

possible criminal-terrorist collaboration in this region of immense-illicit funding. 

Demand Reduction 

As a nation we cannot interdict, or shoot, or convict, or rehabilitate our way out of this 

hell. It will take all of these approaches and more to solve the problem and significantly reduce 

drug abuse. If U.S. drug demand is a large part of the problem, then reducing that demand is 

essential to getting our arms not only around the problems in our own country, but also the 

problem our demand cause our partner nations and the support it gives to terrorism. Demand 

reduction is to say the least a multi-faceted challenge. It begins in the coca or poppy fields 

hundreds of miles south of our border with Colombian soldiers killed by IEDs, and the families 

of Mexican Marines murdered in retaliation for their efforts in our drug fight. It ends in the U.S. 

in a rehab clinic somewhere inside our country. 

But we know how to do this. We know how to design a campaign to save lives and 

significantly reduce a social cancer. When I was in grade school the Center for Disease Control 

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informs us that roughly 70% percent of Americans smoked cigarettes. A pack was maybe .30 

cents. At nine or ten years old I would routinely walk down to the comer store and buy a pack of 

Chesterfields for my mother or Camels for my father. Lung cancer was off the chart. Today the 

CDC estimates that less than 20% of Americans smoke. This unbelievable behavior 

modification was accomplished first and foremost by an effective and never ending campaign to 

make Americans wake up to what smoking does to the body, then by raising the price per pack 

so that it is out of the reach of most intelligent Americans, insurance premiums went up if you 

smoked, the legal age to purchase was fixed at 18 and is now going to 21 in many states, and by 

severely limiting where one can light up and essentially making smokers outcasts. It worked. 

We also did it to battle and significantly reduce drinking-and-driving saving hundreds of 

thousands of lives and significantly reducing serious injury due to automobile accidents. The 

very same applies to seat belt use. Forty 40 years ago no one "buckled up," today only the most 

irresponsible among us would even start an automobile without first fastening their kids in, then 

themselves. The same applies to car seats for infants and small children, helmets for young 

bikers, and even to reducing littering along our streets and highways. The success of these 

campaigns was not only law enforcement, although law enforcements and penalties were without 

question part of the solution. As in the case of auto deaths and injury, the success came as a 

result of a comprehensive and an unrelenting campaign of educating our citizens across every 

age group focusing on children and young adults in school, new drivers and their parents, and the 

older generations who until the campaigns were unleashed in the early 1980s just assumed that 

the carnage our society was experiencing on the highways was simply the price required of a 

motorized society. But it wasn't. 

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Hollywood got behind the effort, as did responsible politicians and civic officials. No 

elected official in his or her right mind opposed it even with intense lobbying efforts by Detroit 

first against installing seat belts then over mandatory air bags, and certainly did not try to 

rationalize the problem away and raise tax revenue from it. Everyone got on board-and it 

worked. Anyone under the age of say 40 today simply cannot imagine a time when we did 

things differently, when we did not have seat belts and air bags, but there was a time we did. As 

with the campaign today to raise awareness of climate change-whether one agrees of disagrees 

with the cause and effect claims-all are at least fully aware of the issue. Even those who reject 

the science have reduced their energy consumption and know it is good for the environment. We 

know how to do this, and it is the only way to not only reduce the cost and misery to our own 

people, but also to the nations to our south who suffer so from our demand. We will never get to 

zero, but perhaps we can reduce the abuse of drugs by over 50% as we did with nicotine, and 

save tens-of-thousands of our citizens as we did when we protected them in their automobiles. 

And just as importantly reduce the profits available to the criminal and terrorist networks. 

I will close with a few final thoughts. The first is that we must keep the pressure on the 

cartels and destroy their crops before they are harvested, destroy their production facilities 

wherever they are, and break up the networks by arrest and prosecution. We must also combine 

these often times kinetic efforts with locating the financial institutions that knowingly or 

unknowingly support the financial aspect of drug trafficking-and seize their billions. Second, I 

want to highlight the efforts of my very good friend Mike Botticelli, the Director ofNational 

Drug Control Policy, who quite rightly tells us that with addiction we are really dealing with a 

disease and we should be focused on saving and rehabilitating those unfortunate to suffer the 

disease, and not just jailing them even for petty crimes. At the same time we must understand 

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that the overwhelming number of men and women involved in the production, transport, and 

distribution ofthese drugs are in it for the money and must be hunted down. We must also 

acknowledge that regardless of the disease, if serious crimes are committed we cannot tum a 

blind eye to the act just because the perpetrator is sick. But even while holding him or her 

accountable, and while punishing them, we should as a society still try to them well. Thirdly, we 

must develop a national campaign that appeals to the intelligence, or the good nature, or the love 

of humanity, or paranoia, or social responsibility, or pocket book, or fear of persecution, or 

whatever-it does not matter-so long as we have an effective program that significantly 

reduces demand. There are individual efforts out there in American society but they are 

uncoordinated and go unheralded. The Boy Scouts, the Young Marine Program, Drug Free 

America Foundation, and dozens of other efforts in our communities but they are individual 

points of light when what we need are floodlights. 

Of note I want to alert the Committee to a combined effort by the Director of the FBI, 

Jim Corney, and the DEA Administrator, Chuck Rosenberg. The effort, entitled, "Chasing the 

Dragon," is one that seeks to distribute a CD and study guide to I 00,000 grade school, middle 

school, and high school teachers " .... to reach youth before an addiction can set in." The CD is 

powerful, horrifying, sad, disgusting, depressing, scary, and designed to get some ofthe most 

powerful influencers in our society-teachers--{)nboard in an effort to ideally prevent, and if not 

then to reduce drug use where it typically begins. Both organizations are also offering additional 

resources, experts, speakers, anything to help reduce the demand of drugs and the human tragedy 

it causes in the lives of millions. I would strongly encourage the Committee to bring in 

representatives ofthe two premier drug fighting organizations in the world and get their 

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perspective on this critically important topic. I would also encourage all to sign onto the FBI 

website at www.FBI.gov/ChasingtheDragon for additional details and perspective. 

You might ask yourself, Mr. Chairman, "why is Jaw enforcement and the U.S. military 

not only into the business of detecting, monitoring, and interdicting the networks and 

organizations that carry drugs and so many other illicit cargoes into the United States, but 

increasingly into drug abuse prevention and demand reduction as well"? Many argue it is not 

our job, although the nation could take a lesson as to how law and enforcement and the nation's 

Armed Forces have all but set drug free environments within the two organizations. Is it not 

prevention and demand reduction the responsibility of our parents? Elected officials? 

Government health care providers? But I would submit that when the kind of men and women 

that serve in law enforcement, who see firsthand and everyday what drugs do to our children, our 

families, our society and to the nation, when these kind of men and women see what it does and 

that the effort to do something about it is too weak or non-existent-they act. I would agree that 

it might not be their job, but since no one else seems to be doing it as effectively as it could be 

done .... 

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Testimony 

of 

Jonathan P. Caulkins 

H. Guyford Stever Professor of Operations Research and Public Policy 

Carnegie Mellon University's Heinz College 

Committee on Homeland Security and Governmental Affairs 

Wednesday AprilJJ'h, 2016 

SJJ-342 Dirksen Senate Office Building 

9:30a.m. 

Assessing Efforts to Reduce the Demand for Imported Illegal Drugs 

Summary 

Violent criminal organizations earn more than $10 billion per year smuggling thousands 

of metric tons of illegal drugs across U.S. borders each year. It is reasonable to view this as a 

security concern in its own right (to the US and also to Mexico, Colombia and Peru), above and 

beyond the deaths and other harms caused by the domestic distribution and use of those drugs. 

Legalization of all drugs would largely solve this problem, but at a potentially very 

severe cost in terms of increased addiction, death, and disability. Legalizing marijuana could 

eliminate marijuana's share of the problem, but only that share. It is hard to quantity precisely 

marijuana's share of the security problems associated with illegal cross-border flows, but it is 

probably less than one-quarter and is almost certainly more like one-quarter than three-quarters. 

A variety of policy reforms short oflegalization could reduce the drug flows, but even 

under the very best of circumstances they would continue on roughly the same scale as today. 

That is, an optimist might hope that cross-border traffic could eventually be halved even without 

legalization, but it goes beyond optimism to imagine reduction by a full order of magnitude 

within a decade, or even two. If one viewed the current situation as like leaving both sides of a 

two-car garage open to thieves, the best we could hope for via better implementation of 

conventional drug policy levers is to close one of the two doors. 

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When it comes to shrinking consumption of illegal drugs, there is not much low-hanging 

fruit that hasn't been tried. Media-based prevention campaigns in particular have not 

demonstrated much efficacy. Some other forms of prevention are viewed as cost-effective, but 

mostly because they are cheap, not because they are highly effective in an absolute sense. The 

research community is generally supportive of expanding treatment, but it is important to 

recognize that the "technology" of treatment is much stronger for heroin and other opiates than it 

is for stimulants such as methamphetamine and cocaine (including crack). And even for opiates, 

treatment is better thought of as a way of easing the suffering of the person who is dependent 

than as a "cure" that eliminates their demand. 

There is one innovative strategy- called "swift, certain and fair" monitoring and 

punishment of users under criminal supervision- that has the potential to make a decisive 

difference if all the stars align. Early evaluations have produced some startlingly large 

reductions in rates of testing positive, but widespread implementation would require a very large 

change in organizational culture and practice. 

The inability to solve the border security situation by shrinking demand raises the 

question of whether and how the magnitude of the security risk might be minimized even as 

drugs continue to be smuggled across the border in significant volumes. That question is 

sensible because there is no necessary relationship between the amount of smuggling and the 

security harm created. Indeed, most drug smugglers are in it just for the money; they harbor no 

particular animus toward the United States. !flaw enforcement could engineer an environment 

within which the most damaging smuggling methods are the least profitable, and the profitmaximizing smuggling strategies are relatively benign, then greed and competitive pressures 

might mold the smuggling "industry" into practices that are less bad trom a security perspective. 

I do not know whether that principle can usefully be operationalized. Principles that are 

appealing in the abstract often stumble when confronted by practical realities. Even talking 

frankly about the trade-offs inherent in such a "realpolitik" approach might be awkward. But my 

certainty that U.S. demand for imported illegal drugs will not disappear any time soon leaves me 

curious about exploring those possibilities. 

The remainder of this document expands on these themes. Because the scope of the topic 

is so broad, for various matters I give just quick capsule summaries and references to articles in 

which I have discussed that issue in greater detail. 

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I. Different drugs present different challenges 

As Peter Reuter and I wrote in earlier Congressional testimony: 1 "To understand almost 

anything about the effectiveness of US drug policy it is first essential to distinguish between four 

categories of illegal drugs: (l) diverted pharmaceuticals, (2) all the minor illegal drugs (PCP, 

GHB, LSD, etc.): (3) the major "expensive" illegal drugs (cocaine/crack, heroin, and 

meth(amphetarnine), and (4) cannabis." 

The minor illegal drugs are not so important for present purposes. The scale of their 

markets is relatively small, some of the production happens within U.S. borders, and the 

importation is not, as far as I know, any more serious a threat, dollar for dollar, than is the more 

lucrative importation of the major drugs. 

Diverted pharmaceuticals- primarily opiate pain relievers kill an astonishingly large 

number of Americans every year. This problem is now belatedly getting considerable attention, 

though it is unclear what took so long. CDC reports that between 1999 and 2014, an astounding 

165,000 Americans died from overdoses related to prescription opioids alone- far more than 

died in the Korean and Vietnam wars combined. 2 

Nevertheless, that ongoing catastrophe has little direct bearing on border security. 

Pharmaceuticals are diverted into non-medical use primarily within U.S. borders, so that 

diversion is not a threat to U.S. border security. 

There may be an important indirect effect, however. For various reasons, many people 

who would not have proceeded directly to heroin use become dependent on prescription opioids, 

and then subsequently switch to heroin. 3 That may sound like a leap, but in terms of chemistry 

and psychoactive effects, all of the opioids- including both pharmaceutical companies' medical 

products and street heroin are close cousins. 

It is an active topic of research today trying to sort out, how much of the recent very large 

increase in heroin overdoses can be blamed on: (I) past failures to adequately monitor and 

circumvent diversion of prescription opioids, (2) recent successes- in some states- to clamp 

1 Reuter, Peter, and Jonathan P. Caulkins 2009. "An Assessment of Drug Incarceration and Foreign Interventions." 

May 19!h testimony to the Domestic Policy Subcommittee of the Oversight and Government Reform Committee. 2 http://www.cdc.gov/drugoverdose/data!overdose.html. 

3 Mars, S. G., Bourgois, P., Karandinos, G., Montero, F., & Ciccarone, D. (2014). "Every 'never' I ever said carne 

true": Transitions from opioid pills to heroin injecting. International Journal of Drug Policy, 25(2), 257-266. 

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down at least partially on that diversion, including by making the pills harder to grind up and 

inject, and/or (3) expansions in Mexico's heroin production that might have occurred anyhow. 

As far as I can tell, we do not yet know the answer and may never fully resolve the matter. For 

this sort of question, it is hard for scientists to construct counterfactuals describing what would 

have happened under alternate scenarios. 

For present purposes, the simple fact is that the large pool of people who have now 

become addicted to prescription pain killers makes it all the more difficult to imagine large 

reductions in U.S. demand for heroin in the coming years. 

In sum, neither the minor drugs nor diverted prescription pharmaceuticals are the (direct) 

source of large cross-border drug flows. The primary concern for border security is the 

traditional "big four" illegal drugs: cocaine (including crack), heroin, meth, and marijuana. 

II. The scale of the problem 

It is understandable to want to know the volume of illegal drugs flowing into the United 

States each year, and it is also understandable why the best estimates available are both highly 

imprecise and potentially inaccurate. For obvious reasons, drug traffickers do not report their 

activities to official agencies. 

Therefore, all numbers discussed in this section should be understood as good faith 

estimates of quantities that are very difficult to estimate. They could easily be off by a factor of 

two. That is, when I say that we think that (illegal) retail sales of cocaine in the U.S. are in the 

neighborhood of$25- $30 billion per year, and that the value of that cocaine at the time it 

crosses the U.S. border is perhaps one-seventh its value at retail, 4 so roughly $4-$58 per year, it 

is entirely possible that the value of cocaine crossing the border could be as low as $28 - $2.58 

per year or as great as $88 - $1 OB per year. 5 Furthermore, there is even greater uncertainty 

concerning what proportion of the revenues earned within the U.S. by moving the cocaine from 

the import level down to the street represent profits earned by the same "organizations" that 

'E.g., an import price of$17,000 per kilogram that is 82% pure vs. a retail price of$145 per pure gram gives a 1 to 

7 ratio. 5 Note: not all ofthe monetary value of the drugs imported ends up in the pockets of the smugglers who bring it 

across the U.S. border; some of that money flows further back up the supply chain because there are multiple layers 

of criminal enterprises between the farmers who grow the crops from which the drugs are made and the 

organizations that carry those drugs across the U.S. border. 

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control the importation. ("Organizations" is in quotes because the relationship between 

wholesale dealers in the U.S. and their suppliers who ship the drugs into the U.S. is more akin to 

a business partnership, than a single vertica!!y-integrated enterprise in the sense of Henry Ford's 

River Rouge industria! complex of old). 

With that big caveat, the best numbers on the scale of U.S. drug markets come from the 

series of publications called "What America's Users Spend on Illegal Drugs" (WAUSID). The 

latest in this series was produced by RAND and published by ONDCP in 2014 with annual 

estimates covering the years 2000-2010. 6 (I am a co-author.) Since the Arrestee Drug Abuse 

Monitoring (ADAM) system has been discontinued, it would be quite difficult to produce a new 

estimate updating those series. 

(There are many excellent ongoing data collection efforts, including the National Survey 

on Drug Use and Health and the Monitoring the Future studies of high school students, but the 

smaller number of heaviest users truly dominate total spending and consumption. Those heavy 

users are badly under-represented in surveys, but many are criminally involved. 7 So when we 

used to interview and collect urine samples from arrestees, it was possible to produce plausible 

estimates of total consumption and spending, whereas at present we can only estimate the 

number of users- a number that is dominated by the less frequent users who collectively account 

for a quite modest share of demand.) 

The table below reproduces the 2010 WAUSID estimates for weight and value, both of 

which are relevant. Four facts must be kept in mind when interpreting these numbers. 

For cocaine/crack, heroin, and meth, weight is expressed in terms of pure weight. So if24 MT 

of pure heroin crossed the border, but at an average purity of 50%, then it is 48 MT, not just 24 

MT, of material containing heroin that was shipped across the border. 

The dollar figures pertain to retail sales. Drugs are marked up enormously as they move 

down the multi-layered distribution chain within the U.S., so most of the retail revenue is earned 

6 Kilmer, Beau, Susan S. Everingham, Jonathan P. Caulkins, Greg Midgette, Rosalie Liccardo Pacula, Peter H. 

Reuter, Rachel M. Burns, Bing Han, and Russell Lundberg (2014). What America's Users Spend on ll/icit Drugs: 

2000-2010. RAND RR-534-0NDCP, Santa Monica, CA. 7 A quote from a journal article we wrote based on the WAUSID study makes the point. For drugs other than 

marijuana, '~he household survey under-estimates frequent use to a much greater degree. For example, based on the 

2010 NSDUH, one would conclude there are only 60,000 daily or near-daily heroin users in the United States. Our 

ADAM-based projection models suggest that the correct total is closer to 1,000,000. "Caulkins, Jonathan P., Beau 

Kilmer, Peter H. Reuter, and Greg Midgette. (2015). Cocaine's Fall and Marijuana's Rise: Questions and Insights 

Based on New Estimates of Consumption and Expenditures in U.S. Drug Markets. Addiction. l!0(5): 728-736. 

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by criminals operating within U.S. borders. In round terms, the value at import for Mexican 

marijuana may be about one-quarter of the value when sold on the street and the proportion is 

even lower for the other drugs, perhaps closer to one-seventh. 8 

Essentially all cocaine and heroin used in the United States is imported. Imports share of 

the meth market has fluctuated over time, with various rounds of precursor chemical control, but 

is generally believed to be high. The story for marijuana is more complicated because of 

domestic production and is discussed further below. 

Somewhat more is imported than is consumed, because some of what is imported is 

seized within the United States. 

Kilmer et al.'s (2014) estimates of the size of the major U.S. illegal drug markets 

Retail Sales Value Quantity Consumed 

(billions of 2010 dollars) (metric tons) 

Marijuana $41 5,700 

$30-$60 4,200 - 8,400 

Cocaine $28 145 

(including crack) $18-$44 92-227 

Heroin $27 24 

$15-$45 13-40 

Methamphetamine $13 42 

$6-$22 19-71 

There are many caveats and uncertainties surrounding these numbers, but the punch lines 

concerning U.S. border security remains clear. First, marijuana accounts for the majority of the 

weight but a minority ofthe value of the illegal drugs smuggled across U.S. borders. Second, 

these are big numbers: (l) Hundreds of metric tons of"hard drugs", (2) Thousands of metric tons 

of marijuana, and (3) The value of imports probably exceeds $JOB per year. 

Others who are expert in national security matters are better able than I to put those 

numbers in perspective through a terrorism and counter-terrorism lens, but my sense is that they 

are large. E.g., shortly after the September II th attacks, along with co-authors I wrote a paper 

8 Data on import prices- as opposed to general wholesale prices- are scarce. The appendices to Kilmer et al. 

(20 I 0) grappled with this issue and are the source for the guesses of roughly one-quarter and one-eighth. Kilmer, 

Beau, Jonathan P. Caulkins, Brittany M. Bond, and Peter Reuter (2010). Reducing Drug Trafficking Revenues and 

Violence in Mexico: Would Legalizing Marijuana in California Help? RAND OP-325-RC, Santa Monica, CA. 

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comparing the "war on terror" to the "war on drugs". 9 It was our understanding at the time that 

the direct financial cost to AI-Qaeda oflaunching the September II th attacks was on the order 

half a million dollars, not something measured in the billions. 

Law enforcement officials would be better able to characterize the mechanisms or tactics 

used to accomplish this smuggling, but they would certainly describe the method as diverse. 

Some are fairly low-tech, such as hiding the drugs within legitimate cargo or in secret 

compartments of vehicles that are crossing through ports of entry. Much also passes between 

ports of entry, whether by air, ground, sea, or even underground via tunnels. 

III. The legalization option 

When contemplating tactics for reducing this illegal flow it is useful to distinguish 

legalization from all other options, and within the discussion of legalization to distinguish 

legalizing marijuana on the one hand from legalizing cocaine/crack, heroin, and meth on the 

other. For better and for worse, it seems reasonably likely that the U.S. federal government will 

legalize marijuana within the next decade; that would largely eliminate marijuana's share of the 

cross-border drug smuggling problem. That share is the majority of the weight, but only a 

minority of the value of the illegal drugs smuggled across U.S. borders. 

There are many varieties of legalization, 10 but as a general matter, one would expect that 

legalizing large-scale production of a drug to eliminate most illegal cross-border smuggling. Of 

course there are caveats. Legalizing only home-production might not drive out the black market, 

particularly for the hard drugs. The cannabis plant lends itself to home cultivation, e.g., because 

its yield per square foot is extraordinarily large. 11 That is why I made the statement concerning 

"large-scale" production. Likewise if taxes or other regulatory hurdles were too great, there 

could still be "grey market" smuggling to evade those taxes or regulation. E.g., there is quite a 

large illegal industry smuggling cigarettes from low-tax to high-tax states, and in other regions of 

9 Mark A. R. Kleiman, Peter Reuter, and Jonathan P. Caulkins. 2002. "The War on Drugs and the War on Terror: A 

Comparison." Public Interest Report, Vol. 55, No.2, pp.3-5. 1

° For a thorough discussion of the options for marijuana, see Caulkins, Jonathan P., Beau Kilmer, Mark A. R. 

Kleiman, Robert J. MacCoun, Gregory Midgette, Pat Oglesby, Rosalie Liccardo Pacula, and Peter H. Reuter (2015). 

Considering Marijuana Legalization: Insights for Vermont and Other Jurisdictions, Santa Monica, Calif.: RAND 

Corporation, RR-864. http:/iwww.rand.org/pubs/rcscarch rcports/RRR64.html. 11 It takes more square feet of coca bushes or poppies to supply a heavy cocaine or heroin user than it does cannabis 

plants to supply a heavy marijuana user. 

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the world smuggling for purposes of tax-evasion involves transport oflarge quantities of tobacco 

and many other products across international borders. But there is nothing special about a 

commodity being a dependence-inducing intoxicant that necessarily produces cross-border 

smuggling. There is not, as far as I know, much smuggling of alcohol into the U.S. today; tax 

differentials across states are not large enough to make that worthwhile, particularly given the 

bulkiness of alcohol per dollar. Rather, it is primarily the illegality that creates the criminal 

opportunities. 

It is important to stress, though, that decriminalization or legalization of possession are 

absolutely not half-way to legalization from the perspective of border security. Quite the 

contrary. One would expect decriminalization and legalization of use in the United States to 

exacerbate, not help solve, the border security problem, and also the problems drug traffickers 

create in source and transshipment countries such as Mexico. 12 They reduce barriers and 

disincentives to use while leaving the production and distribution chains wholly in criminal 

hands. 

The conventional wisdom in the academic literature is that decriminalizing marijuana has 

not Jed to much of an increase in use, 13 but that statement comes with four qualifications: 

• Some studies do suggest notable increases in use. 14 

• Essentially no one argues that decriminalization or legalizing use reduces use. 

• In my opinion, some of the academic literature tends to have a pro-marijuana slant. 

• Decriminalizing marijuana usually comes after a period when marijuana enforcement was 

already ebbing. Ifthe U.S. were to decriminalize hard drugs, that would be a bigger 

change from the status quo and so might have a noteworthy effect on use even if the 

academic literature is correct that marijuana decriminalization has not had such an effect 

in the past. 15 

12 Caulkins, Jonathan P. and Eric Sevigny (2013). The U.S. Causes but Cannot Solve Mexico's Drug Problems. InA 

War that Can't Be Won, eds. Tony Pay an, Kathleen Staudt, and Z. Anthony Kruszewski. University of Arizona 

Press, pp.285-31 0. 13 See, e.g., Thomas Babor, Jonathan Caulkins, Griffith Edwards, David Foxcroft, Keith Humphreys, Maria Medina 

Mora, Isidore Obot, Jurgen Rehm, Peter Reuter, Robin Room, lngeborg Rossow, and John Strang. 2010. Drug 

Policy and the Public Good. Oxford University Press, or Room R., Fischer B., Hall W., Lenton S., and Reuter P. 

(2008) Cannabis policy: Moving beyond stalemate. Beckley Park, UK: Beckley Foundation. 14 E.g., Adda, Jerome, Brendan McConnell, and Imran Rasul (2014). Crime and the Depenalization of Cannabis 

Possession: Evidence from a Policing Experiment. Journal of Political Economy, 122(5):1130-1202. 15 Evidence concerning the effects of Portugal's 2001 policy changes are often presented, and often mis-represented, 

concerning this point. I would be happy to elaborate if that were useful, but in a nutshell, what Portugal did in 200 I 

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I will not discuss further legalization of hard drugs. Of course one can track down 

advocates for almost any idea, but legalizing hard drugs does not at present appear to be a viable 

option politically within the U.S. In my opinion that is a good thing. Everything about 

legalizing hard drugs is much higher stakes and much riskier than is legalizing only marijuana. 

Furthermore, legalization is essentially an irreversible act, not something a country can try out 

for a few years and then easily revoke if addiction rates soar. 16 

Legalizing hard drugs is a much more appealing option from the perspective of the 

primary production and transshipment countries, not from the perspective of final market 

countries such as the United States. So a scenario that deserves greater attention than it has 

received to date is one that involves one or more Latin American countries legalizing cocaine, or 

all drugs generally. It is not altogether clear how that would affect the United States. There are 

scenarios under which the mere fact that cocaine could be purchased legally in, say, Bolivia, 

might have very little effect on the Mexican drug trafficking organizations (DTOs) that carry 

those drugs "the last mile" across the border into the United States. But one can also spin 

scenarios in which legalization in even one country could alter the strategic landscape for all 

countries. 17 

IV. The effects oflegalizing marijuana 

The second edition of my book on marijuana legalization written with co-authors Mark 

Kleiman and Beau Kilmer came out this month. 18 Here I will just state the key points, all of 

which are elaborated in that book. 

Production of marijuana for domestic consumption has shifted back and forth between 

the United States and foreign sources primarily Mexico, but also Canada, Jamaica, and other 

was both less than and in other ways more than what is customarily meant by decriminalizing or legalizing amounts 

suitable for persona! consumption. It is a very interesting policy innovation, but does not provide as strong a basis 

for projecting what outcomes might be in the United States as some observers claim it to be. 16 Caulkins, Jonathan P. and Michael A.C. Lee. 2012. The Drug-Policy Roulette. National Affairs. 12, pp.35-51. 17 I attempt to take a first step toward exploring such scenarios in the following publication, but am very blunt that 

thinking about these scenarios is highly speculative: Caulkins, Jonathan P. 2015. After the Grand Fracture: 

Scenarios for the Collapse of the International Drug Control Regime. Journal of Drug Policy Analysis. 24(1):60-68. 

Published online: DO!: I 0.1515/jdpa-2015-000R. 18 Caulkins, Jonathan P., Beau Kilmer and Mark A.R. Kleiman (2016). Marijuana Legalization: What Everyone 

Needs to Know, 2"" Edition. Oxford University Press. 

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countries. As recently as 2000 the vast majority of marijuana consumed in the United States was 

imported. By 2008, Mexico's market share might have fallen to somewhere between two-fifths 

and two-thirds. 19 Domestic production has almost certainly increased further since then, but the 

exact share today is hard to establish. 

This shift is bound up in a change in the types of cannabis consumed. To simplifY, 

Mexico used to dominate production of"commercial grade" marijuana whose THC potency was 

typically below 5%, although that potency has been increasing and is now perhaps more 

typically 5-7%. By contrast, most of the higher potency sinsemilla (10-20% THC) was produced 

in the United States, or in Canada. U.S. production was an amalgam ranging from purely illegal 

production (e.g., in networks of grow houses operated by organized crime groups) to legal with 

respect to state medical marijuana laws, with quite a bit that operated in a gray area in between, 

e.g., excess production by people who were authorized to produce some under a medical regime, 

and also "medical" regimes that allowed essentially any user to obtain a "medical" 

recommendation. 

There was in parallel a shift from traditional forms of consumption (mostly smoking) to a 

wider range of forms, including edibles (brownies, candy, etc.), "vaping" (which can be thought 

of as analogous to an e-cigarette), and "dabbing" (flash vaporizing highly concentrated THC 

matter). Many of these newer modalities involve THC and other cannabinoids that have been 

extracted (e.g., with solvents such as butane) and concentrated, not the cannabis plant material as 

was the norm in the past. 

Also, and importantly, price per unit ofTHC has been declining. (The price per gram of 

sinsemilla today may be higher than the price per gram of commercial grade marijuana in the 

past, but since sinsemilla is so much more potent, the cost per hour of intoxication has fallen.) 

There is little question that: 

• These trends have expanded marijuana consumption greatly, and reduced imports' share 

of that consumption. 

• These trends were facilitated if not driven by liberalization of policy. 

• Legalization to date is still only partial, and more dramatic change is to be expected. 

• Legalization to date is on a continuum that is perhaps best dated to the beginning of 

quasi-regulated medical marijuana production in California in the early 2000s, not the 

19 Kilmer et al. (2010), Appendix D. 

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November 2012 passage of the legalization propositions in Colorado and Washington 

State.20 

To give a sense of the scale of the increase in marijuana consumption, the number of days 

of marijuana use that Americans self-report to the national household surveys has increased from 

2.2 billion in 2004 to 4.0 billion on the 2014 survey. 

The increase comes in part from growth in the number of users, but even more from 

increases in the intensity of use. The number of Americans who self-report that they use 

marijuana daily or near-daily (defined as 21 or more days in the past month) has increased from 

4.0 million in 2000 to 8.0 million in the 2014 survey. (Many people use Jess frequently, but 

those daily and near-daily users account for more than 80% of all marijuana consumption.) 

There is generally a positive association between the amount used per day of use and the 

frequency of use (meaning days of use per month). That correlation exists in terms of raw 

weight, and probably also does in terms ofTHC consumption because frequent users may also 

gravitate toward more potent forms. 

So although this cannot be measured directly, it is possible that on a THC-adjusted basis, 

the quantity of marijuana consumed may have increased between 2004 and 2014 to an even 

greater extent than is suggested by the increase from 2.2 to 4.0 billion days of self-reported use. 

What does this mean for imports from abroad? Even if the share of marijuana that is 

imported has fallen, the total amount of use supplied by imports could have increased since total 

consumption has grown. In particular, even if imports' share of the market today is half of what 

it was back in 2004, the amount of use supplied by imports today could be nearly as large as it 

was ten years earlier. 

Has the market share of imports fallen to 50% or less of its previous level? No one 

knows for sure. When Beau Kilmer and I, along with various colleagues, tried to look at this 

question in detail back in 20 I 0, we found that imports were a substantially larger share ofthe 

market than most people thought based on the prices users reported paying. 21 My hunch is that 

20 Among other reasons, Colorado and Washington State both already had "medical" regimes that were so 

permissive that the bigger change actually came with the Obama Administration's decision not to prosecute 

companies operating within those state regulatory regimes, not the changes in the state laws per se. 21 Kilmer, Beau, Jonathan P. Caulkins, Brittany M. Bond, and Peter Reuter (2010). Reducing Drug Trafficking 

Revenues and Violence in Mexico: Would Legali=ing Marijuana in California Help? RAND OP-325-RC, Santa 

Monica, CA. In brief, much of the consumption was by people who reported paying prices for marijuana that were 

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this gap arose because most of the "conventional wisdom" about marijuana use patterns comes 

from people who participate in the "blogosphere" or the World Wide Web more generally. But 

it is important to remember that college graduates account for only about 15% of the market; 

more than half is consumed by people with a high school education or less. Those less educated, 

and presumably less affiuent users, might be more likely to use less expensive, imported 

commercial grade marijuana and also less likely to write about it on the internet. 

Furthermore, from a security perspective, what matters is not the amount of use supplied 

by imports, so much as the weight and value of those imports. The potency of marijuana 

imported from Mexico appears to have been increasing, so the weight imported per hour or day 

of intoxication supplied from abroad may have fallen somewhat. Also, wholesale prices in the 

U.S. have been falling on a THC-adjusted basis, so it is possible that import prices have also 

been falling although data on import prices are scarcer than data on wholesale prices. 

Replicating the analysis done back in 20 I 0 is possible, but it is more of a research project 

than something I could manage in time for this testimony. Ifl had to guess now, without having 

a chance to crunch the numbers, my best guess is that the growth in total marijuana consumption 

has offset an important part ofthe decline in imports' market share, so that the liberalization of 

marijuana policy to date has not yet greatly reduced exports to the United States. I am aware that 

there are journalistic accounts extrapolating from declines in seizures to presumptions about 

declines in exports, 22 but as Alejandro Hope has discussed, 23 other factors may explain the 

declines in seizures. 

Still I want to stress that this is just my best guess based on professional judgment; the 

data systems are not adequate to answer the matter definitively. 

However, if and when the federal government repeals its marijuana prohibition and/or the 

state legal marijuana industry has time to expand, innovate, and fully exploit the economies of 

scale that is now starting to achieve, domestic production under liberalized policy regimes ought 

to be able to out-compete imports. 

This idea is discussed in detail in our book, but let me just cite two supporting facts. All 

of the THC consumed in the United States could be produced on less than 10,000 acres of 

simply too low for that marijuana to be sinsemilla, and the conventional wisdom at the time was that most domestic 

r,roduction was of sinsemilla. 2 E.g., http://time.com/380 l R89/us-le!Zalization-tru.:ldLYflml-trade/. 23 http:/ /wwv .. · .samcfacts.com/20 15/02/cri me-inca rccration/ mcx icos-mis.s ln2. -rnarij uana-m ;' stcry /. 

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farmland. Ten thousand acres sounds enormous to the typical homeowner, but a I ,000 acre farm 

is not unusual in the Mid-West. So quite literally, ten farms could supply all of the country's 

rnc. 

And production costs could become very low once production shifts to large-scale, 

professionally-run farms. Outdoor production can yield something on the order of 600 pounds of 

marijuana "flowers" per year, plus about 2,000 pounds of additional vegetable material from 

which THC can be extracted. Production costs for other crops that require transplanting is 

typically $5,000 - $20,000 per acre, suggesting production costs for flowers of around $20 per 

pound. That is just I% of current farm gate prices, which are roughly $2,000 per pound, and less 

than I 0% of the going wholesale price for (lower-quality) marijuana imported from Mexico just 

after it has crossed the border into the United States. 

In short, even if the policy liberalizations to date have not yet greatly reduced marijuana 

imports, if the trend toward liberalizing policy continues it is entirely plausible that importing of 

illegal marijuana will be largely curtailed. 

Again, that would represent a very large decline in the weight of illegal drugs imported, 

but a much more modest reduction in the amount drug traffickers earn from bringing drugs into 

the United States. 

V. Policy reforms short of legalization 

Within a regime that prohibits legal supply, the most effective way to reduce imports is 

through enforcement. Prohibition backed by a baseline level of enforcement drives up the prices 

of illegal drugs far, far beyond what they would be if drugs were legal. 24 This point has been 

made elsewhere, but consider for example that it costs cocaine producers roughly $15,000 per 

kilogram to get cocaine from Colombia into the United States, whereas any parcel delivery 

service would charge less than $I 00 per kilogram to ship any legal commodity to the customer's 

door. That spectacular increase in the cost of doing business is attributable to prohibition, 

backed by some enforcement, and it translates directly into extremely high prices. Cocaine, 

heroin, and rneth all cost user many times their weight in gold. 

24 See, e.g., Caulkins, Jonathan P. (2014). Effects of Prohibition, Enforcement, and Interdiction on Drug Use. In 

The Economics of International Drug Policy, ed. John Collins (London: LSE IDEAS Special Report), pp.l6-25 or 

Kleiman, M.A., Caulkins, J.P., & lfawken, A. (2011). Drugs and Drug Policy: What Everyone Needs to Know. 

Oxford University Press. 

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83 

When drug prices are high, people use less. Indeed, the price responsiveness can be 

surprisingly large because most of the drugs are consumed by the minority of people for whom 

buying those drugs soaks up a very large share of their disposable income. So whereas people's 

first impulse is to think that those who are drug dependent may be unresponsive to changes in 

price, that is largely incorrect, as a now substantial body of economic literature now shows. 25 

However, the fact that prohibition plus some enforcement does a terrific job of holding 

down the quantity consumed- and hence the quantity imported -there appears to be no practical 

opportunity for reducing imports by further increasing enforcement intensity beyond their 

already very aggressive levels, and for two distinct reasons. 

The first is simply that the mood of the country is sharply in favor of reducing not 

increasing enforcement "toughness". 

The second is that it probably would not work well anyhow. Opportunities for 

investigating the question empirically are understandably limited, but the academic consensus is 

that further increases in enforcement beyond that needed to give the prohibition teeth and to 

impose the "structural consequences of product illegality" are extremely inefficient ways of 

driving down consumption of drugs with long-established markets. Peter Reuter and I made this 

point in our earlier testimony, referenced above, 26 and he has a recent article with Harold Pollack 

that further elaborates the argument by drawing on more recent literature. 27 Indeed, most drug 

policy scholars would argue that toughness could be reduced substantially with relatively few 

adverse effects, because policies in recent decades have gone so far past the point of diminishing 

returns. 

As a result, most progressive discussions of improving American drug policy focus on 

so-called demand-side interventions. Here the analysis is at once promising and gloomy. There 

are of course many different types of demand-side interventions spanning a very broad range of 

modalities and target populations, but the generic finding is that they are often highly costeffective but not very effective. 

25 Gallet, Craig A. (20 14). Can price get the monkey off our back? A meta-analysis of illicit drug demand. Health 

Economics, 23:55-68, published online in 2013 at DO!: 10.l002/hec.2902. 26 Reuter, Peter, and Jonathan 1'. Caulkins 2009. "An Assessment of Drug Incarceration and Foreign Interventions." 

May 19'' testimony to the Domestic Policy Subcommittee of the Oversight and Government Reform Committee. 26 http://W\vw.cdc.guv/drugovcrduscidata!overdosc.html. See also Caulkins, J. and Reuter (2006) "Re-orienting 

Drug Policy" Issues in Science and Technology 23(1). 27 Pollack, H. A., & Reuter, P. (2014). Does tougher enforcement make drugs more expensive?. Addiction, 1 09(12), 

1959-1966. 

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That is not a contradiction. Demand-side interventions can be cost-effective, even if they 

are not very effective in any absolute sense, because they are relatively cheap (certainly 

compared to imprisonment) and the thing they seek to reduce is so extraordinarily destructive. 

The point is perhaps best made with some stylized numbers. Efforts to estimate the 

social cost of drug abuse face enormous challenges, and one should not imagine that the figures 

are terribly precise, but they give a sense that the scale of the problem is on the order of $200 

billion per year for illegal drugs. 28 Most of those costs come from the 3 million or so heaviest 

users of the "expensive" illegal drugs (cocaine/crack, heroin, and meth). Dividing $200 billion 

by 3 million suggests that such individuals impose costs on the rest of society that exceed 

$50,000 per year. Since the residual length of the "drug using career" for such individuals is 

usually a decade or longer, that means that inducing such a person to give up drugs forever 

would be worth more than $500,000. So taxpayers ought to be perfectly happy to pay for a 

$3,000 treatment program even if it only had a I% chance of causing the client to permanently 

cease use. A hypothetical $3,000 treatment program that had a 5% "cure rate" would offer 

taxpayers a spectacular "return on investment" even if it had no impact whatsoever on 95% of its 

clients. 

Treatment advocates hate any discussion couched in terms of probabilities of achieving 

permanent abstinence, let alone a "cure rate". The modern language for discussing treatment is 

as a way of managing a chronic relapsing condition, akin to the way insulin is used to manage 

diabetes. 

But the very reason that treatment advocates insist on framing the discussion in that way 

is precisely because we do not have treatment approaches which, when offered to a population of 

users, greatly reduce that population's drug consumption over the long-run. 

This means that while it could be a terrific policy to expand treatment funding and 

availability (as the Mental Health Parity and Addiction Equity Act and also the Affordable Care 

Act have begun to do29), doing so would not do much- and certainly not much quickly- to 

reduce the quantity of illegal drugs being imported, and the attendant security problems. 

28 See, e.g., Harwood, H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: 

Estimates, Update Methods, and Data. Report prepared by The Lewin Group for the Nationallnstitute on Alcohol 

Abuse and Alcoholism, 2000. 29 For more on this, see various writings by Keith Humphreys and Harold Pollack, e.g., Humphreys, K., & Frank, R. 

G. (2014). The Affordable Care Act will revolutionize care for substance use disorders in the United States. 

Addiction, 109(12), 1957-1958 or Andrews, Christina, Colleen M. Grogan, Marianne Brennan, and Harold A. 

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When discussing drug treatment it is always important to distinguish the technology for 

treating opioid dependence- for which pharmacotherapies exist- and the much less successful 

technologies for treating other substances, including the stimulants. For opioids (including 

heroin), it is possible to "maintain" dependent users on a legally supplied substitute opioid. The 

best known such substance is methadone. Buprenorphine is another. The fact that some other 

countries use (legal, pharmaceutical grade) heroin itself in this manner, and that the class of 

interventions is called opiate substitution therapies, underscores the extent to which even for 

opioids we do not have very good methods of greatly reducing drug use. Rather, we just know 

how to get dependent individuals to substitute legal opioids for illegal ones. 

The story with prevention is broadly similar. Even model-school based drug prevention 

programs tend not to be very effective in an absolute sense, 30 but they are inexpensive and 

preventing drug use is very valuable, so they can nonetheless be cost-effective. 31 Furthermore, 

many can produce diverse collateral benefits, ranging from reducing smoking and alcohol abuse 

to better academic outcomes. So again, a robust investment in drug prevention may be good 

policy, but it is not plausible that expanding those efforts will solve the border security issues 

created by drug imports. 

Furthermore, with prevention- unlike treatment there are inevitably quite long lags 

between when the program is implemented and when it affects the drug use that is of greatest 

concern. Many prevention programs target young teens; some work with much younger 

children. There are even evaluations of prenatal nurse home visitation programs from a drug 

control perspective. But the median age of initiation tor hard drugs is 21, and even crack is not 

"instantly addicting". There is a lag between initiation and progression to dependence, and then 

that dependence can continue for many years. So there can a lag of a decade or more between 

implementation of a prevention program and the beginnings of its significant effects on hard 

drug use. 

Pollack. "Lessons from Medicaid's Divergent Paths on Mental Health and Addiction Services." Health Affairs 34, 

no. 7 (2015): 1131-1138. 30 For a recent review, see Faggiano, F., Minozzi, S., Versino, E., & Buscemi, D. (2014). Universal school-based 

~revention for illicit drug use. Cochrane Database of Systematic Reviews, 12. 1 C.f., Caulkins, Jonathan P., C. Peter Rydell, Susan S. Everingham, James Chiesa, and Shawn Bushway. 1999. An 

Ounce of Prevention, a Pound of Uncertainty: The Cost-Effectiveness of School-Based Drug Prevention Program, 

RAND, Santa Monica, CA and Caulkins, Jonathan P., Rosalie Pacula, Susan Paddock, and James Chiesa. 2002. 

School-Based Drug Prevention: What Kind of Drug Use Does it Prevent? RAND, Santa Monica, CA. 

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Worse, there are many well-meaning and seemingly sensible interventions that do not 

even work that well. Indeed, many when evaluated rigorously do not show any statistically 

significant effect on drug use (even if they perhaps affect attitudes toward or knowledge about 

drugs). The most popular school prevention program, DARE, is an example of such a victim of 

rigorous evaluation. 32 

Unfortunately mass media campaigns often fall into this category. Media campaigns are 

quite difficult to evaluate; it is often hard to know for sure exactly how big a "dose" any 

individual youth received. Nevertheless, it is really no longer tenable to think that these 

campaigns are effective but just not appreciated. Despite persistent attempts, the serious 

evaluations have produced rather disappointing findings. In particular, Hornik et al. (2008) 

reached pessimistic conclusions concerning the national youth anti-drug media campaigns in the 

United States, 33 and more comprehensive literature reviews suggest that the limitations are 

systemic, not due to any particular flaws with that campaign. 34 

In sum, while there may be abundant opportunities for improving U.S. drug policy, it 

would be naive to think that doing more or better with any of the traditional drug control levers 

could close down or cut by more than half the flow of drugs across the border. 

VI. One ray of hope: Swift, certain and fair 

There is one radically innovative approach to reducing drug use that stands outside the 

usual list of programs and which may offer a real opportunity to dramatically reduce drug use 

and, hence, drug imports. The name of that approach has evolved, originally sometimes being 

referred to as "coerced abstinence" but now is more often referred to as "swift, certain, and fair" 

(SCF). 

32 E.g., West, S. L., & O'Neal, K. K. (2004). Project DARE outcome effectiveness revisited. American Journal of 

Public Health, 94(6), 1027-1029. 33 Hornik, R., Jacobsohn, L., Orwin, R., Piesse, A., & Kalton, G. (2008). Effects ofthe national youth anti-drug 

media campaign on youths. American Journal of Public Health, 98(12), 2229-2236. 34 See, e.g., Ferri, M., Allara, E., Bo, A., Gasparrini, A., & Faggiano, F. (2013). Media campaigns for the prevention 

of illicit drug use in young people. The Cochrane database of systematic reviews, 6 and Hawks D., Scott K., 

McBride N., Jones P., and Stockwell T. (2002) Prevention of Psychoactive Substance Use. Geneva, Switzerland: 

World Health Organisation. 

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Within the academic community the idea is most closely associated with New York 

University professor Mark Kleiman and his book When Brute Force Fails, 35 although Mark 

would be quick to point out that the best-known examples of its implementation were developed 

by practitioners who arrived at the key ideas independently. Those examples include the 

Hawaii's Opportunity Program with Enforcement (HOPE) 36 and the 24/7 Sobriety program 

launched first in South Dakota.37 The Physician Health Programs (PHPs) operate on a similar 

behavioral principle, albeit with a very different population. 38 

That principle is that deterrence can work when the sanctions are swift, certain, and fair 

even in contexts where a lower likelihood of delayed but draconian sanctions fails to induce 

behavioral change. 39 For example, South Dakota's 24/7 Sobriety program required alcoholinvolved offenders to submit to twice daily breathalyzer tests or wear continuous alcohol 

monitoring (at their own expense), and imposed an automatic and instantaneous jail term for any 

positive test but the duration of that term was typically just a day or two. 

What is distinctive about all ofthese efforts is a focus on testing-with-consequences as a 

way of suppressing drug use. 40 It is not drug treatment as it is typically defined. If individuals in 

the program believe that conventional treatment will help them achieve abstinence, they are free 

to pursue it, but the program itself does not mandate or deliver drug treatment. To the extent that 

these programs fit within any of the conventional boxes it would be community supervision, 

including as an alternative to incarceration,41 but they are not just that either. 

35 Kleiman, Mark A.R. (2009). When Brute Force Fails: How to Have Less Crime and Less Punishment. 

Princeton University Press, Princeton, NJ. 36 Hawken, A., & Kleiman, M. (2009). Managing Drug Involved Probationers with Swift and Certain Sanctions: 

Evaluating Hawaii's HOPE: Executive Summary. Washington, DC: National Criminal Justice Reference Services 

and Hawken, A. (2010). HOPE for probation: How Hawaii improved behavior with high-probability, low-severity 

sanctions. Journal of Global Drug Policy and Practice, 4(3), 1-5. 37 Kilmer, B., Nicosia, N., Heaton, P., & Midgette, G. (2013). Efticacy of frequent monitoring with swift, certain, 

and modest sanctions for violations: insights from South Dakota's 24/7 sobriety project. American journal of public 

health, 103(1), e37-e43. Kilmer, B., & Humphreys, K. (2013). Losing Your License to Drink: The Radical South 

Dakota Approach to Heavy Drinkers Who Threaten Public Safety. Brown J. World A./J., 20,267. 

3JJ DuPont, R. L., McLellan, A. T., White, W. L., Merlo, L. J., & Gold, M.S. (2009). Setting the standard for 

recovery: Physicians' Health Programs. Journal of Substance Abuse Treatment, 36(2), 159-171. 39 Durlauf, S. N., & Nag in, D. S. (2010). The deterrent effect of imprisonment. In controlling crime: Strategies and 

Tradeoffs (pp. 43-94). University of Chicago Press. 40 DuPont, R. L., & Humphreys, K. (2011). A new paradigm for long-term recovery. Substance abuse, 32(1), 1-{;. 

"Kleiman, M.A. (2011). Justice reinvestment in community supervision. Criminology & Public Policy, 10(3), 651-

659. 

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What is also distinctive about these programs is their astonishingly high success rates. 42 

In South Dakota well over 99% ofbreathalyzertests come back clean (and that includes noshows in the denominator) and there is evidence that the program was associated with a 

reduction in all-cause mortality among adults for the state in its entirety, not just for offenders. 43 

Much remains to be learned about such programs, but South Dakota has extended the program 

from DUI to other alcohol-involved offenders (there is also a drug testing component) and the 

program is being adopted in other states44 and there are plans to extend a modified version of the 

program throughout London. 45 

For present purposes, the other key point is one Mark Kleiman made long ago, and that is 

that the majority of hard drugs used in the United States are consumed by people who are 

nominally under criminal justice supervision, either on probation, parole, or pre-trial release. 46 

So ifthere were a way to force those individuals to stop using, that would have a much bigger 

impact on drug use than any other plausible program. (In some respects SCF has much in 

common with drug courts, but drug courts usually focus only on nonviolent offenders and so are 

necessarily somewhat limited in scope since much drug use is by repeat and/or violent 

offenders. 47) 

Nevertheless, the program has to swim upstream in several respects. First, to at least 

some, it is a stark challenge to the dominant paradigm of the "brain disease model of addiction" 

because it seems to produce bigger changes in drug use than does drug treatment. 48 (Note, 

though, that Angela Hawken argues that testing-with-consequences can be seen as the behavioral 

triage front end to an integrated system that focuses scarce treatment resources on the minority of 

42 Kleiman, M.A., Kilmer, B., & Fisher, D. T. (2014). Theory and Evidence on the Swift-Certain-Fair Approach to 

Enforcing Conditions of Community Supervision. Fed Probation, 7 8, 71. 43 Nicosia, N., Kilmer, B., & Heaton, P. (2016). Can a criminal justice alcohol abstention programme with swift, 

certain, and modest sanctions (2417 Sobriety) reduce population mortality? A retrospective observational study. The 

Lancet Psychiatry, 3(3), 226-232. 44 Midgette,G. (2016). A New Approach to Reducing Heavy Drinking and Alcohol-Involved Crime? Insights from 

RAND Research on 2417 Sobriety Programs. Testimony presented before the California State Assembly, Committee 

on Public Safety on March 29, 2016. http://www.rand.org/pubs/testimonies/CT455.html 45 http://www.bbc.com/news/uk-england-london-35660946. 

46 Kleiman, M 1997. "Coerced abstinence: A ncopaternalist drug policy initiative," In The New Paternalism: 

Supervisory Approaches to Poverty, ed. Lawrence M. Mead, 182-219. Washington, DC: Brookings Institution and 47 Sevigny, E. L., Pollack, H. A., & Reuter, P. (2013). Can drug courts help to reduce prison and jail populations?. 

The ANNALS of the American Academy of Political and Social Science, 647(1 ), 190-212. 48 Sate!, S., & Lilienfeld, S. 0. (2012). Addiction and the brain-disease fallacy. Frontiers in psychiatry, 4, 141-141. 

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problem users who do not respect to a SCF regime.49) Second, there can be a reflexive response 

that punishing drug users is bad, or even a violation of their human rights, even if the evidence 

suggests that threatening occasional very short sentences can dramatically improve life outcomes 

for those same users, not just for the rest of society. Third, implementing SCF requires 

extraordinary cooperation across different components of the criminal justice system, and it 

remains to be seen whether it can be implemented in larger jurisdictions. 

In sum, it seems very unlikely that any traditional drug control intervention, or 

combination of those interventions, has a plausible hope of reducing drug use by as much as 50% 

over ten years. SCF is one of the very few interventions that offers even a hope of achieving 

such reductions. 50 It is not that one should bet that SCF will deliver such large reductions within 

the next decade, but if anything will produce those gains, it seems more likely that it will be SCF 

than anything else we know of today. 

VII. Another angle: Finding less awful drug traffickers 

If the chances of dramatically reducing U.S. consumption of hard drugs are slim to none 

within the next decade or so, that begs the question of whether there is some way to mitigate the 

security risk created by cross-border drug trafficking other than by shrinking its size. I certainly 

do not know. But the question is reminiscent of a line of argument I and others have suggested 

for addressing the collateral damages created by drug markets more generally. 

Oddly, perhaps, the origins of the idea lie in the so-called "harm reduction" movement. 

The term "harm reduction" is still highly controversial in some quarters, but as used here it 

should not be understood as a code word for legalization. Rather, it should be taken at face value 

as seeking to reduce the harms associated with drug use, even ifthere is no reduction in the 

49 Hawken, A. (2010). Behavioral triage: A new model for identifying and treating substance-abusing offenders. 

Journal of D11tg Policy Analysis, 3( 1). 5

° Five years ago I might have been even more decisively pessimistic, but it is now clear that US cocaine 

consumption fell by something like 50% between 2006 and 2010. (Caulkins, Jonathan P., Beau Kilmer, Peter H. 

Reuter, and Greg Midgette. (2015). Cocaine's Fall and Marijuana's Rise: Questions and Insights Based on 

New Estimates of Consumption and Expenditures in U.S. Drug Markets. Addiction. 110(5): 728-736.) 

That decline is extraordinary, all but unprecedented, and still largely not understood (Kilmer, B., 2016). 

Cunningham et al. argue the decline is associated with new controls on essential chemicals; if they are correct (and 

that is not yet widely accepted), then that could in theory offer another mechanism. Cunningham, J. K., Callaghan, 

R. C., & Liu, L. M. (2015). US federal cocaine essential ('precursor') chemical regulation impacts on US cocaine 

availability: an intervention time-series analysis with temporal replication. Addiction, 110(5), 805-820. 

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quantity of drugs used. Robert MacCoun has written some classic articles that explain the idea. 51 

In thumbnail sketch, he notes that total harm can be thought of as the product of the amount of 

drug use times the harmfulness per unit of use, so in principle total harm can be reduced by 

cutting either drug use or by cutting harmfulness, two tactics that might usefully be labeled "use 

reduction" and "harm reduction". 

The paradigmatic example of harm reduction for drug users is that if an intervention 

leaves an injection drug user (IDU) continuing to inject drugs, but now does so with a new 

syringe each time, that might reduce the spread ofHIV/AIDS, hepatitis C, or other blood-borne 

diseases even if it has zero effect on drug use. 

The literature of interest here tries to apply that sort of reasoning to the collateral damage 

caused by drug markets, rather than by drug use. In caricature, if last year drug dealers murdered 

1,000 people in the course of distributing 200 metric tons of cocaine in the United States and 

next year they murder "only" 200 people while distributing 200 metric tons, that can be seen as 

progress in reducing the societal costs associated with illegal drugs even ifthere is no change in 

cocaine consumption. 

More generally, the total harm caused by drug distribution can be expressed as the 

product of the amount of drugs distributed times the harmfulness ofthose markets per kilogram 

distributed. So one ought to be able to make the nation safer either by reducing the amount of 

drugs distributed or by reducing the threat per kilogram shipped. 

The usual focus at least in the United States has been on drug market related violence, 

with the Boston Gun Project's Operation Ceasefire and the High-Point North Carolina drug 

market intervention being among the best known examples. 52 For more general discussions of 

"E.g., MacCoun, Robert J., "The Psychology of Harm Reduction: Comparing Alternative Strategies tor ModifYing 

High-Risk Behavior," Wellness Lecture Series, Volume VI, 1996 and MacCoun, Robert J., "Toward a Psychology 

ofHann Reduction," American Psychologist, 53(11): 1199-1208, 1998. 52 See Kennedy, David M. upuJlinu Levers: Chronic Offenders. Hh!h~Crime Settings. and a Thcorv of Prevention." 

Valparaiso University Lmv Review 31, no. 2, 449-484 (Spring 1997), Braga, Anthony A., David M. Kennedy, Anne 

M. Piehl) and Elin J. Waring. !lfl.diK.i.IJg Gun, rio/em:e_: Fhe lfoston GunEr.Qi.J;_ct's Operation Cease tire. National 

Institute of Justice Research Report (September 2001), Kidd, Don (2006). The High Point West End Initiative: A 

New Strategy to Reduce Drug-Related Crime. The Criminal Justice Institute's Management Quarterly, Fall, Little 

Roek, AR: University of Arkansas, and Saunders, J., Lundberg, R., Braga, A. A .. Ridgeway, G., & Miles, J. (2015). 

A synthetic control approach to evaluating place-based crime interventions. Journal of Quantitative 

Criminology, 3/(3), 413-434. 

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the principle see Caulkins (2002), Caulkins & Reuter (2009), Caulkins and Kleiman (2011), 

Greenfield and Paoli (20 12), and Kleiman et a!. (20 15). 53 

To the best of my knowledge, no one has tried to apply the principle specifically to the 

question of security threats created by cross-border drug trafficking. The closest analog of which 

I am aware is Mark Kleiman's argument that the principle could be used to address violence 

perpetrated by Mexican DTOs within Mexico. 5

4 

The reason to hope that such strategies might work is that at least in theory it ought to be 

much easier to get drug traffickers to change the way they smuggle drugs than to get them to stop 

smuggling drugs entirely. By and large drug traffickers are in it for the money; they are 

businesses, albeit illegal businesses. If trafficking route or strategy B offered lower risks, lower 

costs, or greater profits than strategy A, then the traffickers ought to be willing to switch to B. 

They are wedded to making money, not, by and large, to using a particular tactic. This is not to 

say there is no stability in drug trafficking patterns. There is. But that stability is perhaps better 

understood as contentment with current outcomes and nervousness about the unknown risks of a 

change, not any arbitrary or ideological commitment to any given tactic. 55 

So the questions become, are there some smuggling routes, tactics, or organizations that 

pose noticeably greater security risks to the United States than do others and, if so, are there 

ways to differentially "penalize" the most noxious routes, tactics, and organizations to put them 

at a competitive disadvantage, so that over time the market naturally evolves away from them 

and toward less bad routes, tactics, and organizations? 

I genuinely do not know the answer to those questions. So to be clear, I am definitely not 

suggesting that this sort of market jujutsu is an effective way of mitigating the security risks 

posted by cross-border drug trafficking. Rather, I am merely saying that, given how unlikely it is 

"Caulkins, Jonathan P. 2002. "Law Enforcement's Role in a Harm Reduction Regime." Crime and Justice 

Bulletin Number 64. New South Wales Bureau of Crime and Justice Research; Caulkins, Jonathan P. and Peter 

Reuter. 2009. Toward a Harm Reduction Approach to Enforcement. Safer Communities, Vol. 8, No. I, pp.9-23; 

Caulkins, J.P., & Kleiman, M.A. (2011 ). Drugs and crime. The Oxford handbook of crime and crimina/justice, 

275; Greenfield, V. A., & Paoli, L. If supply-oriented drug policy is broken, can harm reduction help fix it? Melding 

disciplines and methods to advance international drug-control policy. lnlernational Journal of Dntg Policy (2012), 

23(1):6-15; Kleiman, M.A., Caulkins, J.P .. Jacobson, T .. & Rowe, B. (2015). Violence and drug control policy. 

Oxford Textbook of Violence Prevention: Epidemiology, Evidence, and Policy, 297. 54 Kleiman, M, (2011). Surgical strikes in the drug wars. Foreign Affairs, 90(5), 89-10!. 

"Note: sometimes the actual smuggling is carried out by what might best be thought of as independent contractors, 

not by the owners of the drugs. Those independent contractors might perhaps be more locked into a single tactic. 

E.g., a light airplane pilot might not be able to alter business practices if suddenly became more economical to 

smuggle drugs through tunnels. 

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that the volume of hard drugs moving across U.S. borders will shrink appreciably in the next 

decade, it seems sensible to look toward outside the box tactics for addressing the security threat. 

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TESTIMONY 

DR. CHERYL G. HEAL TON, DEAN 

COLLEGE OF GLOBAL PUBLIC HEALTH 

NEW YORK UNIVERSITY 

BEFORE THE COMMITIEE ON HOMELAND SECURITY 

AND GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

AMERICA'S INSATIABLE DEMAND FOR DRUGS 

APRIL 13, 2016 

"Un-Marketing Illicit Drugs" 

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Mr. Chairman and Members of the Committee: 

I'm privileged to appear before you this morning to testify about the hard-won 

successes to decrease use of legal addictive substances and how we might apply 

those "lessons learned" to illicit drugs here in the United States. 

My name is Dr. Cheryl Healton and I am Dean of the College of Global Public 

Health at New York University (NYU). Prior to my appointment at NYU, I 

worked for 14 years at the American Legacy Foundation, a national 501 (c) (3) 

nonprofit public charity established out of the 1998 Master Settlement 

Agreement between 46 State Attorneys General and the U.S. tobacco 

industry. The organization has a respected history of producing game-changing 

public health initiatives proven to reduce tobacco use among young people and 

adults. 

Best known for its bold counter-marketing campaign for youth, truth®- now in 

its 16th year- the campaign has been a major part of comprehensive national, 

state and local tobacco control strategies. Together, these measures have 

resulted in remarkable declines in youth tobacco prevalence rates from 23% in 

2000 to a current rate of below 7% (Monitoring the Future 2016). Indeed, youth 

smoking has plummeted since its peak of 38 percent in 1996 to 7 percent today 

and is thus a true public health success story (Monitoring the Future 2015). 

I have also served on the Board of Directors of the Betty Ford Institute and now 

serve on the board of Phoenix House, a nonprofit drug and alcohol 

rehabilitation organization operating in ten states with 150 programs. Phoenix 

House programs serve individuals, families and communities affected by 

substance abuse and dependency. Over the course of my career, I have also 

published over 100 peer-reviewed papers and special reports on a variety of 

public health related topics including HIV AIDS, public health education, health 

policy, substance abuse and tobacco. 

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My testimony today will examine how we might consider "un-marketing" illicit 

drugs to youth before they start using them and how we can work to curb adult 

demand for drugs. 

If we are to use tobacco as a case study, it is important to understand what it 

took to prompt the dramatic social norm change that has occurred over the past 

several decades here in the U.S. that resulted in these remarkably positive shifts 

in knowledge, attitudes and behavior. Public health experts know that four 

factors figure prominently in prompting and maintaining dramatic declines in 

tobacco consumption: 

1. Bold and highly targeted counter-marketing/public education campaigns; 

2. Ever-increasing excise taxes on products at the state and federal levels to 

prompt cessation among price-sensitive youth and adults; 

3. Policy initiatives that restrict access to the drug and safeguarding the 

public from secondhand exposure to it and access to cessation services for 

those addicted to tobacco products. (The Health Consequences of 

Smoking- 50 Years of Progress- A Report of the Surgeon General, 2014). 

While cumulatively, these measures combine to change social norms and save 

lives as a result, it is perhaps the unspoken fourth leg of this stool that is most 

critical: mustering the political will to enact what we know works even though it 

might ruffle feathers and annoy special interests (Healton 2001). The sad fact 

remains that public health all 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 desire. 

While today's discussion focuses on those who peddle illicit drugs to our 

vulnerable youth and the adults they soon become, the business models they 

employ are not that dissimilar. Those who are motivated to profit from drug 

sales to risk-seeking and troubled teens, do so to make long-term customers of 

them. They care very little about their health and more about highly lucrative 

sales. The strategy is the same: attract young customers when their developing 

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brains are most vulnerable to risk taking and addiction and then reap the profits 

as they age and remain addicted. 

It has been said that the definition of insanity is doing the same thing over and 

over again and expecting a different outcome. Efforts at controlling the illicit 

drug trade in the U.S. have by many accounts failed to produce measurable 

positive change, but we continue the same failed policies, hoping for a different 

result. Naturally, there are vested interests that profit from these failed policies, 

blocking needed reforms that might spark real progress and save lives. These 

are the bold reforms I hope the Committee will consider today. 

A case in point might be the small nation of Portugal, where 15 years ago "they 

decriminalized low-level possession and use of all illicit drugs." According to the 

February 2015 study, Drug Decriminalization in Portugal: A Health-Centered 

Approach, which I have submitted today for the record, "results of the 

Portuguese experience demonstrate that drug decriminalization- alongside a 

serious investment in treatment and harm-reduction services- can significantly 

improve public safety and health." 

Drug use and possession in Portugal remain illegal, albeit no longer triggering 

criminal sanctions. Drug trafficking offenses also remain illegal and continue to 

be processed through the criminal justice system. 

Independent research confirms dramatic results including no significant 

increases in drug use, reduced problematic and adolescent drug use, fewer 

people arrested and jailed for drugs, more people receiving treatment, reduced 

incidents of HIV AIDS, fewer drug-related deaths and reduced social costs of 

drug misuse. This program, and others like it, prompted the Global Commission 

on Drug Policy (2011) --and such respected public health institutions as Johns 

Hopkins University and The Lancet just last month (Csete 2016) to conclude that 

decriminalization is a path to saving lives, reducing infectious diseases and 

increasing access to much-needed substance abuse treatment. 

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The U.S. cannot be safe from drug-related criminal activity without first 

reframing the relationship between drug use and crime, and secondly, 

identifying ways to sharply reduce our apparently insatiable appetite for illicit 

drugs. This can be accomplished through the prevention of youth initiation, deglamorizing use via disruptive and innovative mass media campaigns aimed at 

"unselling" use and inducing those addicted or teetering on the verge to 

seek prompt treatment. It goes without saying that drug treatment needs to be 

available and covered by insurance plans. 

Sean Clarkin, Executive Vice President for Research and External Relations at the 

Partnership for Drug Free America (now the Partnership for Drug Free Kids), has 

summarized the most important factors in combatting youth demand as 

follows: 

• "Educate parents on the vulnerability of teens (90% of addictions begin in 

adolescence), and on the risk factors that make some kids MUCH more 

vulnerable than others (mental health issues, family history, traumatic 

events); 

• Focus youth prevention efforts not just on the risks of use, but on the 

importance of protective factors: positive adult relationships; positive 

peer relationships; supervised activities- especially after school; parental 

communication and monitoring; 

• Help kids see drug and alcohol use as one of a number of negative 

influences that make them less than they could be (the essence of the 

"Above the Influence" program: peer pressure to fit in rather than be 

themselves, to sit back rather than try, to push others around rather than 

be kind and inclusive); 

• Insist that parents, educators and clinicians pay much greater attention to 

early use-- understanding that it has to be taken seriously, especially 

when risk factors are present, and that interrupting progression to 

harmful use has to be built into our mainstream healthcare system." 

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For many complex reasons, the impact evaluations of the public education 

campaign on youth drug use by The Office of National Drug Control Policy 

(ONDCP) did not result in a strong positive effect (Hornik 2008). 

The "Above the Influence" Campaign did find positive effects but they were 

weaker than a similar campaign executed as a randomized trial (Slater 

2011). The drug of focus there was marijuana, one with fewer adverse health 

outcomes than most others. Researchers did find that among eighth grade girls, 

greater exposure to the campaign was associated with lower use of marijuana 

(Carpenter 2011). 

I have provided the committee with a number of key studies which demonstrate 

that well-designed and executed paid mass media campaigns can change youth 

knowledge, attitudes and behavior with regard to smoking. In response to a 

well-funded, major public education campaign, knowledge, attitudes and 

behavior quickly shifted both in response to a statewide Florida campaign 

(Bauer 2000) and a subsequent larger national campaign. In the first four years 

alone ofthe national campaign, 450,000 youth did not initiate smoking as a 

direct result of the campaign. The campaign-attributable decline represented at 

least 22 percent of the over-all decline in youth smoking during the period 

evaluated. (Farrelly 2002; Farrelly 2005; Farrelly 2009). 

Researchers at Johns Hopkins and Columbia Universities concluded that in four 

years alone, the campaign averted $1.9 billion in future medical care costs. 

(Holtgrave, 2009). 

These are key lessons for the primary prevention of illicit drug use, which is 

defined as stopping illicit substance abuse before it begins or becomes habitual 

and addictive. These lessons should be applied as a basis for new program 

efforts at the national level. The same impact on initiation may be achieved in 

large part by powerfully hard-hitting, youth-focused communications, especially 

designed for youth at the highest risk of drug use. Messages must be designed-

-as they were for the truth® campaign-- to reach those most likely to initiate 

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drug use with compelling reasons to avoid initiation, including the fact that 

those profiting from their potential drug use are using them even if that person 

is a low-level dealer they consider to be their "friend". 

The nation's long-standing, ONDCP-supported, Partnership for a Drug-Free 

America campaign's paid advertising effort was sharply curtailed after a decade 

of persistent budget cuts. It is urgently important to bring it back, and in doing 

so, 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 include: 

• Paid advertising at market rates to ensure the work is done by the hardest 

hitting, best team possible; 

• Youth market research, appropriately targeted and designed for sub-sets 

at high risk, which will likely result in the bold ads being exceptionally 

unpalatable to adults and government agency staff; 

• A focus on the drugs associated with the greatest harm and free of 

"approval" processes which interfere with the potential for campaign 

success due to conflicts of interest and adult sensitivities with respect to 

content and taste; 

• Vigorous evaluation, in real time, to decommission ads that are not 

resonating with intended audiences and being nimble enough to quickly 

replace them with those that do. This is especially critical given that ads 

can have boomerang effects that are difficult to predict with certainty. 

(Fishbein 2002). 

If public education efforts are also intended to reach adults to curb their 

drug consumption, a similar, laser-like focus on the actual communication target 

population must also be employed. For example, the current adult target 

includes those addicted to or habitual users of alcohol, prescription medication, 

black market opioids, cocaine and heroin. Each represents a niche 

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100 

communication market and a comprehensive public education campaign can 

speak to each group with well-designed messages and action steps. 

The current resurgent heroin epidemic sweeping our country is in substantial 

part the result of opioid addiction in young people (aged 20-34) who initially 

became addicted to prescription opioid medication used for pain or 

recreationally. Once unable to obtain the drugs through providers, many turned 

to lower cost street alternatives such as heroin. 

According to Dr. Andrew Kolodny, the most important control approaches for 

the overall opioid epidemic include "preventing new cases of opioid addiction, 

treatment for people who are already addicted with safer alternatives and 

reducing the supply from pill mills and the black market." 

Kolodny and colleagues have demonstrated that treatment with Buprenorphine 

saves lives from overdose and other opioid use complications. (Kolodny 2015). 

Buprenorphine was introduced in France in the mid 1990s, released without any 

of the limits imposed in the US and prescribed widely. Within six years, opioid 

overdose deaths decreased by a dramatic 79% (Auriacombe 2010}. 

Opioid addiction has increased 900 percent from 1997 to 2011. It is noteworthy 

that the bulk of the opioid epidemic is caused by too liberal use of painkillers 

which in turn leads to addiction. The solution rests in the hands of policy 

makers, the pharmaceutical industry and physicians. 

The figure below depicts the surge in opioid sales, opioid deaths per 100,000 

and opioid treatment admissions per 10,000. In addition to the opioid deaths 

included in these numbers, among those turning to heroin, an upswing in HIV 

and Hepatitis C infections is occurring. Public health secondary prevention 

strategies such as needle exchange programs, antiretroviral treatment and 

condom access are needed to control the spread of HIV. 

8 
101 

.Rates of Opioid Sales, 00 Deaths, and Treatment, 1999-2010 

0+---,----r--~----r---~--,----r---,----r---.----.---, 200Z 1'0::>4- too5 ~ 2007 ~ 2Q» 2010 

CDC..IIOIWRl:011 Yeor 

CDC (Cent. Dis. Control Prev.). 2011. Vital signs: overdoses of prescription opioid pain relievers-United 

States, 1999-2008. MMWR 60: 1487-92. 

Also urgently needed is the expansion of Naloxone and Narcan availability for 

law enforcement and others in close proximity of those at risk of overdose. 

If we persist in using a "moralistic," criminal justice model for those addicted 

and at risk, we will miss a critical opportunity to turn the tide on an epidemic in 

which National Institutes of Health data suggest we have been achieving some 

success. Especially with regard to youth, "despite the ongoing opioid overdose 

epidemic, past year use of opioids other than heroin has decreased significantly 

each year over the past 5 years among the nation's teens and is at the lowest 

rate since the survey began." And for heroin use, lOth and 12th grade use "did 

have an annual prevalence above 1 percent at the beginning of the 2000s, so 

their rates of heroin use have now fallen by more than half." (Monitoring the 

Future 2015). We must continue this trend, inoculating today's teens against 

future opioid use. 

9 
102 

In closing, there are proven ways to reach these young impressionable 

audiences with successful messaging. Thirty years ago, our nation's youth were 

challenged to "Just Say No" to drugs. In 2016, to truly stop the insatiable desire 

for illicit drugs in the US, it will take much more disruptive and innovative 

efforts, supported by the political will to "Just Dolt.'' 

This requires the abandonment of past failed policies for game-changing new 

ones. 

Thank you. 

10 
103 

1-Johnston LD, O'Malley PM, Miech RA, Bachman JG, Schulenberg JE. Monitoring the Future. 

National Survey Results on Drug Use 1975-2015; 2015 Overview, Key Findings on Adolescent 

Drug Use. 2016. 

2-Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE, & Miech RA. Monitoring the Future 

national survey results on drug use. 1975-2014: Volume II, college students and adults ages 19-

55.2015 

3- U.S. Department of Health and Human Services. The Health Consequences of Smoking- 50 

Years of Progress: A Report of the Surgeon General. 2014. Atlanta, GA: U.S. Department of 

Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 

4- Healton C. Who's Afraid of the Truth? American Journal of Public Health, April2001; .91:828. 

5- Drug Decriminalization in Portugal: A Health-Centered Approach, Drug Policy Alliance, 

February 2015. 

6- Global Commission on Drug Policy (2011). War on Drugs: Rio de Janiero. 

7- Csete, Jet al. Public health and international drug policy. The Lancet, March 2016; 

87(10026): 427-1480. 

8- Hornik, R., Jacobsohn, L., Orwin, R., Pi esse, A., & Kalton, G. {2008). Effects of the national 

youth anti-drug media campaign on youths. American Journal of Public Health, 98{12), 2229-

2236. 

9- Slater, M.D., Kelly, K. J., Lawrence, F. R., Stanley, L. R., & Comella, M. L. G. {2011). Assessing 

media campaigns linking marijuana non-use with autonomy and aspirations: "Be Under Your 

Own Influence" and ONDCP's "Above the Influence". Prevention Science, 12{1), 12-22. 

10- Carpenter, C. S., & Pechmann, C. (2011). Exposure to the above the influence antidrug 

advertisements and adolescent marijuana use in the United States, 2006-2008. American 

Journal of Public Health, 101{5), 948-954. 

11- Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in Youth Cigarette Use and 

Intentions Following Implementation of a Tobacco Control Program: Findings From the Florida 

Youth Tobacco Survery, 1998-2000. JAMA. August 2000, 284(6): 723-728. 

12- Farrelly MC, Healton C, Davis KC, Messeri P, Hersey JC, Haviland ML. Getting to the Truth: 

Evaluation of National Countermarketing Campaigns. American Journal of Public Health, June, 

2002; 92(6), 901-907. 

11 
104 

13- Farrelly MC, Davis KC, Haviland ML, Messeri P, Healton C. Evidence of a Dose-Response 

Relationship Between truth • Anti-Smoking Ads and Youth Smoking Prevalence. American 

Journal of Public Health. March 200S; Vol. 9S(3), 42S-431. 

14- Farrelly MC, Nonnemaker J, Davis KC, Hussin A. The influence ofthe National truth 

campaign on smoking initiation. American Journal of Preventive Medicine. May 2009; 36(5): 

379-84. 

15-Holtgrave DR, Wunderink KA, Vallone DM, Healton C. Cost-utility Analysis ofthe national 

truth Campaign to Prevent Youth Smoking. American Journal of Preventive Medicine. May 

2009; 36(5):385-8. 

16- Fishbein M., Hall-Jamieson, K., Zimmer, E., von Haeften, 1., Nabi., R. Avoiding the 

Boomerang: Testing the Relative Effectiveness of Antidrug Public Service Announcments Before 

a National Campaign. American Journal of Public Health. 2002, 92(2): 238-245. 

17- Kolodny, A., Courtwright DT., Hwang CS., Kreiner, P., Eadie, JL., Clark TW., Alexander GC. 

The Prescription Opioid Heroin Crisis: A Public Health Approach to an Epidemic of 

Education. Annual Review of Public Health, January 2015 36: 559-74. 

18- Auriacombe M, Fatseas M, Dubernet J, Daulouede J, Tignol J. French Field Experience with 

Buprenorphine. American Journal on Addictions, June 2004; 13(S1): S17-S28. 

12 
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EdVenture Partners 

Homeland Security and Governmental Affairs Committee 

Peer-to-Peer: Preventing Substance Abuse 

Development of a National Academic Partnership Campaign 

to Help Address America's Insatiable Demand for Drugs 

Program Narrative and Technical Approach 

April 13, 2016 

Tony Sgro, CEO 

EdVenture Partners 

tony@edventurepartners.com 

415.264.7666 

www.edventurepartners.com 
106 

CURRENT SITUATION 

America needs to continue its search for innovative and creative strategies to reduce 

use, abuse, and demand for drugs. Growing substance abuse is crippling and 

destroying lives, families, and communities and has encouraged transnational criminal 

activity, which is a genuine threat to the homeland. 

SOLUTION 

A Peer-To-Peer (P2P) methodology is an innovative and tested approach that can be 

adapted and utilized to help inform and empower youth to help curb America's 

insatiable demand for drugs. A P2P strategy enlists America's young people to 

engage in community-based problem solving and become part of the solution to curb 

substance abuse while enrolled in an appropriate university course and earning 

academic credit. 

This approach is modeled after the successful "P2P: Challenging Extremism" 

(P2P:CE) global university initiative currently being implemented by EdVenture 

Partners at over 1 00 universities in 30 countries, with the goal to help make the world 

a safer place from hate speech, violence, terror, and extremism. 

"P2P: Challenging Extremism", or P2P:CE as it is known, is a public-private sector 

partnership between the White House National Security Council, U.S. Department of 

Homeland Security, U.S. Department of State, the National Counterterrorism Center 

(NCTC), Facebook, and my organization EdVenture Partners (EVP). The support of 

this partnership allows EdVenture Partners to mobilize our academic partners to 

create and manage programs throughout the world. 

"The PlP: Challenging Extremism initiative is now the forefront of counter 

messaging efforts for the U.S. Government." 

National Counterterrorism Center (NCTC) 

RATIONALE 

The premise of the P2P strategy is this: "Who better to educate, inform, and affect 

behaviors of young people through credible, authentic, and peer-appropriate social 

and digital media campaigns regarding drug use, abuse, and prevention than the very 

same audience who uses drugs?" 

It makes perfect sense- empowering tech-savvy digital natives to mobilize the 

friends, neighbors, and communities they already know intimately. Consequently, they 

are in an ideal position to identify and enact effective community-based solutions that 

will be called on to push back on drug use and abuse through genuinely creative 

approaches in their communities. 

The P2P model is currently being used effectively to challenge extremism domestically 

and around the world. Similarly, it is prudent to consider implementing a pilot P2P 

academic program on America's two- and four-year college and university campuses. 

P2P zeros in on the distributive power of the Millennia! and Gen Z audience in 

Copyright 20i 6, EdVenture Partners 2 
107 

targeting and influencing their peers through various youthful campaigns, social and 

digital media strategies, and tactics focused on drug use, abuse, and prevention. 

OVERALL OBJECTIVE 

Measurably engage large networks of America's youth through social and digital 

media initiatives, products, and tools to push back on drug use and abuse and 

promote drug awareness, abstinence, and prevention through the activation of peerdriven education and behavior changing campaigns on campuses and in their local 

communities. 

PROGRAM OVERVIEW 

EdVenture Partners will develop, manage, and implement a customized "P2P: 

Challenging Substance Abuse" initiative leveraging our unique academic partnership 

model approach across the country. 

Over the course of the spring 2017 academic term, EdVenture Partners will market the 

program and secure the participation of up to twenty (20) colleges and universities. 

Sample coursework and classes for the program might include: 

Addictions: Assessment, Intervention & Treatment 

Addictive Disorders 

Advertising Management 

Community Tolerance & Social Engagement 

Contemporary Social Problems 

Designing Persuasive Communication 

Drugs and Society 

Entrepreneurship for Social Change 

Family Dynamics of Addiction 

Influencing Public Opinion 

Integrated Marketing Communications 

Marketing Communications 

Public Interest Communications 

Social Movements & Persuasion 

Social and Digital Media 

Youth. Drugs and Culture 

Students at selected colleges and universities will form a student-run agency. Each 

university team will learn and discuss the challenges of America's insatiable demand 

for drugs through a "situation of interest" contained within an expertly written project 

brief which tasks students to develop and implement their own unique campaign that 

helps halt the pervasiveness of drug and substance abuse on their campus, 

community and/or state. (Note: EdVenture Partners will collaborate with leading 

SME's in the field to write the Project Brief.) 

Students will begin the program by performing primary research on the defined target 

audience (example, persons under age 30). Their research is designed to determine 

current thoughts, perspectives and specific reference to the causes and effects of 

chemical abuse, addiction, and the process of recovery in their communities. Utilizing 

their research findings, student teams will design, implement. and measure the 

success of a social or digital initiative, product, or tool aimed at accomplishing the 

program objectives. These successes may include: 

Copyright 2016, EdVenture Partners 3 
108 

Motivating or empowering youth to become involved in constructive dialogue 

about the cause, assessment, treatment, and recovery of adolescent substance 

abuse. 

Catalyzing other students to create their own initiative, products, or tools to 

that address the cause, assessment, treatment, and recovery of adolescent 

substance abuse. 

Building communities of interest/networks focused on living shared values that 

result in constructive dialogue about the cause, assessment, treatment, and 

recovery of adolescent substance abuse. 

PROGRAM BENEFITS 

By participating in an EdVenture Partners program, HSGAC will receive the benefit of 

EVP's unique P2P approach that has been tested and validated over 2,000 times on 

over 800 colleges and universities since 1990. Some benefits to HSGAC for electing to 

support a customized social marketing program include: 

Proof of performance from over 25 years of model testing with private and 

public sector, trade association, and non-profit clients spanning several 

industry sectors; 

• Access to EVP's faculty and administration proprietary database and 

established relationships; 

Peer-developed strategies by Millennials and Gen Z; 

Campaigns in markets across the country that are activated and tested locally, 

providing program scalability of the best ideas; 

Measured advertising, marketing, online, and PR impressions; 

• Ownership of all creative and IP developed through the program; 

• Connection to specific majors and diverse student and community populations; 

Create student, faculty, and academic influencers; and 

• Access to the campus environment during the academic term. 

TECHNICAL APPROACH 

The "P2P: Preventing Substance Abuse" program will be broken into four phases: 

Program Planning; Program Period; Submission Review; and Program Closeout. 

Below is a description of each program phase. 

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109 

Program Planning 

Program Development 

EdVenture Partners will meet the HSGAC Project Manger (PM) to kick off the program. 

During this meeting HSGAC and EVP will collaborate to develop the program outline. 

Utilizing the project brief designed for the program, EVP will develop a timeline that 

outlines each phase of the program and a schedule for achieving the tasks described 

below: 

• EVP will develop a password protected project portal for faculty and student 

participation that will be used to implement the program. The project portal is 

an online third-party project management system and shall be administered by 

EVP. The project portal allows for online communication, collaboration, 

resource sharing, tracking of tasks, calendaring of milestones and events, and 

shall provide for the process by which student teams will upload their program 

submission for review. A separate and unique project page shall be developed 

for each participating school within the project portal. 

School Marketing and Selection 

• EdVenture Partners will market the program to targeted universities that offer 

the appropriate courses in which to host the program. EVP will work with 

HSGAC to secure up to twenty schools for program participation. School 

selection criteria may include, and is not limited to: 

a. Four-year college or university which offers either undergraduate 

and/or graduate level courses; 

b. Community colleges; 

c. HBCU, HACU, Native American and Pacific Islander school 

designation; 

d. Rural, suburban, and urban schools; 

e. Offer the appropriate course in which to host the Program; 

f. Have the willingness and ability of faculty to participate based on the 

sensitive nature of the subject matter; and 

g. Schools with proven results and relationships with EVP will be given 

priority. 

• After schools are selected, EVP program marketing may include: 

Copyright 2016, EdVenture Partners 5 
110 

a. Introductory email notification to Deans, Chairs, and faculty at 

selected schools about the program; 

b. EVP faculty email/phone call invitation to review the program; 

c. In-person meetings with faculty and administration to review Program 

objectives; 

d. EVP Facebook announcement; and 

e. Continual email blasts with updated announcements and program 

details throughout the program registration process. 

Program Period 

Program Launch 

After selection of schools, EVP will work to perform the following tasks: 

a. Confirm participating schools; 

b. Send a roster of all participating schools to HSGAC PM; 

c. Post faculty and student supplemental resources on project portal; 

d. Conduct user test of the project portal and resolve any errors prior to 

live program launch; 

e. Communicate program objectives, timeline, rules and regulations, 

and deliverable requirements to each Student Team; 

f. Administer and distribute $2,000.00 student budget funds per school 

to be utilized by program participants for research, creative, public 

relations, advertising, awareness building, and community 

engagement activities; and 

g. Answer questions from faculty throughout the program 

implementation period. 

Collect Program Submissions 

As determined in the Program Planning phase, each student team must electronically 

submit their campaigns to EVP. Within five (5) business days, EVP shall: 

a. Send each judge a link to download submissions for review and scoring; 

and 

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111 

b. Provide access to all program submissions to HSGAC. 

Submission Scoring 

EVP shall facilitate the judging of the program submissions by ensuring: 

a. For the first round of scoring, HSGAC shall use the program scoring 

rubric to review and rank each student team submission; and 

b. The top three (3) schools shall be identified. 

Final Presentation 

The top three (3) schools are determined and faculty and students are notified; 

a. Top domestic schools will be identified; 

b. Travel arrangements (air, ground, hotel and meal per diem) for fifteen (15) 

students and three (3) faculty to present their campaign strategy and 

results in Washington, D.C. to the HSGAC, senior U.S. Government 

leaders, industry practitioners, and media in a competition for 

scholarship awards for the national competition presentation (included 

in the program budget estimate); 

c. The top three (3) schools will receive a five thousand dollar ($5,000), 

three thousand dollar ($3,000), and one thousand dollar ($1 ,000) 

scholarship awarded to first place through third, respectively, on behalf 

of the U.S. government based upon final competition judging (included 

in the program budget estimate). 

Report of Findings 

a. EVP will notify the top student teams who will be invited to present their 

findings to HSGAC; 

b. EVP, with the approval of the HSGAC, will identify a panel of judges 

made up of senior officials, law enforcement, local community leaders, 

and substance abuse professionals to act as a review panel during the 

presentation; 

c. The review panel will interview and prep on expectations and timelines 

for critiquing and providing feedback on each school's campaign; 

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112 

d. Top teams will present their research, campaigns, results, and 

recommendations of the panel in a public forum. These presentations 

shall include a question and answer session; 

e. After the presentations, EVP will post the three (3) top submissions on 

their corporate website and Facebook page for student and faculty 

viewing; and 

f. EVP to recognize the top teams for their campaign results. 

Program Closeout 

EdVenture Partners shall provide a final report that provides an overview of the 

program and outlines the problems, successes, and gaps of the program by July 31, 

2017. 

PROGRAM BUDGET ESTIMATE 

For a pilot "P2P: Preventing Substance Abuse" program, twenty universities will be 

invited to participate. HSGAC will have the opportunity to learn a tremendous amount 

during this pilot, and will see a significant variety of campaigns being tried and 

implemented on this scale. A 20-campus amount is also EVP's base requirement 

number of campuses for clients given the ramp-up and resource requirements and 

allocations of the organization. 

Program Cost: $260,000 firm fixed cost (does not include the student operating 

budget each university gets, as that is a variable budget amount each client decides 

upon.) 

Suggested Student Operating Budget Additional Cost: $2,000 per university (X 20 

universities)= $40,000 

~School Roster & Database Development $23,660.00 

B Proaram & Resource Development $70,410.00 

c University Marketing & Outreach $27,470.00 

D Proiect Portal Development $15,720.00 

E Student Operation Budgets $40,000.00 

F Proaram Implementation $113,740.00 

G University Awards $9,000.00 

Total Program Budget Estimate $300,000.00 

"P2P is high impact, low cost and easy on U.S. taxpayer dollars." 

House Committee on Homeland Security 

Copyright 2016, EdVenture Partners 8 
113 

For the pilot of "P2P: Challenging Extremism" initiative, EVP implemented 20 

university programs. For the second tranche it expanded to 45 schools. For the 

current Spring 2016 semester, we have 55 campuses. Since P2P:CE's inception, we 

have implemented 128 P2P:CE programs on 98 different universities in 30 different 

countries. 

For the Fall 2016 semester, we are funded for 150 universities in total, allocated as 50 

domestic and 1 00 international. 

PROGRAM PERFORMANCE MEASURES 

EdVenture Partners works with each participating school to establish benchmarks that 

can be used as an effective way to analyze results for each campaign. By establishing 

a benchmark of existing audience sentiment, identifying the attitude or behavior 

change that would show a message's impact, and then using a combination of tools 

to periodically examine progress, the measure of a campaign's effectiveness can be 

captured and reported to HSGAC. Measurement tools should be tailored to the 

knowledge, behavior, or attitude change the messaging campaign is intended to affect 

based on HSGAC's objectives and would to be used before, during, and following the 

campaign. 

Intended outcomes can include: awareness building, knowledge creation, attitudinal 

shift, or behavior changes. Sample "P2P: Preventing Substance Abuse" program 

success measures for each team to capture might include: 

Number of people who access the web portal for the initiative, product, or tool. 

Number of people who "favorite" the web portal or digital platform or otherwise 

indicate their support for it. 

Number of people who join the initiative, participate in its activities, and/or 

download/use a product or tool. Teams should also measure the quality of 

involvement (participation in a single event vs. volunteering for ongoing 

activities, support for marketing a product or tool vs. simply downloading it 

once, etc.). 

Number of students on the team's university campus who are aware of the 

initiative, product, or tool. 

Number of social media references to the initiative, product, or tool. 

Number of organizational partners and/or sponsors for the initiative, product, or 

tool. 

• The degree to which the project is self-sustaining. Examples of potential 

measures include financial base for continued operation; number of individuals 

Copyright 2016, EdVenture Partners 9 
114 

or organizations that have agreed to continue the initiative, product, or initiative; 

number of independent "spin-off" initiatives and their reach; and products or 

tools that members of the target audience have created and plan to continue 

using (this is not an exhaustive list of potential measures). 

• Tracking of any opposition to the initiative, product, or tool, analyzing the 

response, and providing recommendations on how to navigate the challenge 

moving forward. 

WHAT STUDENTS DO 

Students participating in the program will interact with EVP's representatives 

throughout the course of the program. EVP works with students and faculty to support 

the performance of the following activities as part of their program participation: 

• Develop, activate, and assess the results of a marketing campaign designed to 

achieve the HSGAC objectives; 

• Conduct research within the defined HSGAC target audience to obtain 

statistical evidence and analysis of the drivers of the audience's perception, 

attitudes, belief systems, and social concerns relating to substance abuse; 

• Analyze primary and secondary research data as basis for validating strategies 

and tactics incorporated in a marketing campaign; 

Develop an initiative, product, or tool aimed at the defined target audience and 

accompanying advertising, social media, and public relations strategies 

necessary to gain awareness, engagement, and adoption for the initiative; 

• Activate a marketing campaign on campus and in the local community utilizing 

$2,000 marketing activity funds; 

• Develop a system for tracking impact, audience education, and potential 

behavior change within the target audience; and 

• Provide a detailed submission to EVP for the marketing campaign that includes: 

background and objectives, pre-campaign research, marketing strategies and 

outcomes, publicity strategies, post campaign research, measures of campaign 

effectiveness, and recommendations at the culmination of the program. 

WHAT FACULTY DO 

The program is implemented in a classroom over the course of the Spring 2017 

Copyright 2016, EdVenture Partners 10 
115 

academic term. Therefore, the program becomes part of the curriculum and is guided 

by a faculty member throughout the term. The role of participating faculty includes: 

Review program materials in their entirety and receive all necessary department 

and administration approvals before fully accepting the invitation to host the 

program on campus; 

Incorporate the program elements into the course syllabus, allocating sufficient 

time for student participation and applying an acceptable percentage of the 

grade to the program; 

Provide open, friendly, and frequent communication with EVP representative 

assigned to assist in program implementation; 

• Provide timely feedback to students on all strategies and tactics associated 

with the program; 

• Ensure all strategies, tactics, and materials created by students are vetted for 

professionalism and acceptability by the university and the HSGAC; and 

Ensure completion of all required program elements in collaboration with EVP's 

representative. 

END. 

Submitted by EdVenture Partners 

Copyright 2015, EdVenture Partners 11 
116 

Appendix 

The following two pages: 

P2P: Challenging Extremism Tri Fold 

Copyright 2016, EdVenture Partners 12 
SociaL meoia and 

propaganda by extremist 

groups is often targeted 

directly at 

young, impressionable 

messaging and "'"'""'-'"r 

each other 

extremism. 

#C:haUengeExtremism 
"Those recruiting for ISIL aren't looking for people 

devout and knowledgeable about the tenets o

They're looking for people who are guUible eno

believe that terrorists enjoy a glamorous lifes

Secretary of State John Kerry 

"Creating and promoting positive speech is an e

element to countering hate and extremism onlin

why Facebook is a strong supporter of P2

Monika Bickert, Head of Product Policy, Faceb
Social media and 

propaganda by extremist 

groups is often targeted 

rlirPrtlv at 

young, 

in 

extremism. 

#ChaUengeExtremism 
devout and knowledgeable about 

They're looking for people who are gullible eno

believe that terrorists enjoy a glamorous lifest

- Secret9JY of State John Kerry 

"Creating and promoting positive speech is an e

element to countering hate and extremism ontin

why Facebook is a strong supporter of P2P

Monika Bickert, Head of Product Policy, Facebo
121 

Robert}. Budsock 

Apri/13,2016 

Washington DC 

As Prepared for Delivery 

Thank you, Mr. Chairman. 

Chairman Johnson, Ranking Member Carper, Members of the Committee, it is 

a pleasure to join you and the other distinguished leaders here today. My name is 

Robert Budsock and I am the President and CEO of Integrity House, which is 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 treatment and recovery support to help individuals reclaim their lives. 

Addressing the demand for illegal drugs is one of our nation's great 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 includes drug 

trafficking and violence, billions of dollars in costs to 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 

which can be treated effectively. A focus on addiction treatment will reduce the 

number of active drug users, resulting in a reduced demand for illegal drugs and a 

reduction in overdose deaths. 

I would like to present some facts about the insatiable demand for illegal drugs that 

we are experiencing in America: 

o 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% of the entire population. 1 

o 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 Centers for Disease Control and Prevention (CDC) there were 

47,055 overdose deaths in 2014 and approximately 129 Americans on average 
122 

died from a drug overdose every day. 2 Tragically, overdose deaths are 

increasing in every state, in rural areas, cities, and suburbs alike, and 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 school, and in the community. 

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 society, enabling him or her to 

experience the rewards associated with abstinence. 

In addition to stopping an individual's drug abuse, the goal of treatment is to 

return that person to a productive, well-functioning part of their family, their workplace, 

and the community. According to research that tracks individuals in treatment over 

extended periods, most people who get into and remain in treatment stop using drugs, 

decrease their criminal activity, and improve their occupational, social, and 

psychological functioning. However, individual treatment outcomes depend on the 

extent and nature of the patient's problems, the appropriateness and duration of 

treatment, and related services used to address those problems, as well as the quality 

of interaction between the patient and his or her treatment providers. 

Like other chronic diseases, addiction can be managed successfully. Treatment 

enables people to counteract addiction's powerful disruptive effects on the brain and 

behavior and to regain control of their lives. But the chronic nature of this disease 

means that relapsing back to drug abuse is not only possible but also likely, with 

symptom recurrence rates similar to those for other well-characterized chronic medical 

illnesses-such as diabetes, hypertension, and asthma -that also have both 

physiological and behavioral components. 

Because drug abuse and addiction are major public health problems, a large 

portion of drug treatment is funded by local, State, and Federal governments. Private 

and employer-subsidized health plans also may provide coverage for treatment of 

addiction and its medical consequences. Unfortunately, managed care has resulted in 

shorter average stays. while a historical lack of coverage or insufficient coverage for 

substance abuse treatment has curtailed the number of operational programs. 

The mandate of parity for insurance coverage of mental health and substance 

abuse problems will hopefully improve this state of affairs. Health Care Reform stands 

to increase the demand for drug abuse treatment services, and presents a concurrent 

opportunity to study how innovations in service delivery, organization, and financing can 

improve access to and use of these services 3 

On the supply side, there has been extraordinary effort by the DEA, Federal 

Bureau of Investigation, Homeland Security Investigations, and Department of Justice's 

Organized Crime Drug Enforcement Task Forces (OCDETF) to target, disrupt, and 
123 

dismantle international drug trafficking organizations that manufacture, transport, and 

distribute illegal drugs destined for and distributed across the United States. We must 

recognize, however, that these efforts do not reduce the insatiable demand for these 

illegal substances. Clearly interdiction in and of itself is not enough. 

We also have the support of local medical personnel and law enforcement 

agencies that are saving lives through the use of naloxone (also known as Narcan) 

which reverses the effects of an opioid overdose. Today, 46 states and the District of 

Columbia have enacted statutes that expand access to naloxone or provide "Good 

Samaritan" protections for possession of a controlled substance if emergency 

assistance is sought for a victim of an opioid overdose. It should be noted that the use 

of Narcan to reverse overdose is only a temporary lifesaving intervention. It is not 

treatment, and being administered naloxone doesn't in and of itself lead to treatment. 

Based on scientific research conducted by the National Institute of Drug Abuse over 

the past 40 years, I would like to highlight five of the key principles which form the basis 

of any effective treatment program: 

• 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 and/or 

interventions are just not effective for everyone. 

It has been known for many years that the "treatment gap" is massive-that is, 

despite the large and growing number of those who need treatment for a substance use 

disorder, few receive it According to the Substance Abuse and Mental Health Services 

Administration (SAMHSA) only 2.6 million Americans-11.2 percent of those who needed 

treatment-received it at a specialty facility. 4 

I can't name another disease or chronic health condition where this is tolerated or 

allowed to perpetuate. Can you imagine if only 11 percent of people with diabetes had 

access to diabetes treatment? How about cancer? 

There was great hope with the launch of the Affordable Care Act and 

implementation of Federal Parity laws which were expected to extend access to mental 

health benefits and substance use disorder services for an estimated 62 million 

Americans. You would think that insurance coverage, even Medicaid coverage, would 

be the differentiator, providing access to the full continuum of care for SUO. 

Regrettably, if you get your health insurance coverage through Medicaid, it is 

barred from paying for community-based residential treatment at a facility of 16 beds or 
124 

more. This happens under something called the Medicaid Institutions of Mental 

Diseases (I MD) Exclusion which originated in the 1960s as part of a national effort to 

de-institutionalize large psychiatric hospitals. Though community based residential 

treatment programs for Substance Use Disorders (SUD) didn't exist when the IMD 

Exclusion was established, addiction treatment programs are considered IMDs in the 

eyes of the Centers for Medicare and Medicaid Services, thus disqualifying 

reimbursement for care at a program like Integrity House and hundreds of similar 

programs around the country. Integrity House is a longtime and active member of 

Treatment Communities of America, a national association of nonprofit residential SUD 

treatment providers, which has advocated for years for expanding access to treatment 

by eliminating the IMD Exclusion. 

This policy is unfair, and results in people on Medicaid being treated like secondclass citizens. In a health care system where the law of the land is to cover physical 

and behavior health at parity, the continued existence of the IMD is unreasonable. 

Reducing the treatment gap requires a multipronged approach. Strategies 

include increasing access to effective treatment, achieving insurance parity, reducing 

the stigma associated with drug treatment, and raising awareness among Americans of 

the value of addiction treatment. In the midst of the current opioid abuse epidemic, 

there is a huge shortage of treatment beds, and far too many barriers to accessing 

treatment. We could effectively, and quickly, expand access by simply eliminating the 

IMD Exclusion for SUD treatment, making available thousands of new treatment beds to 

those covered by Medicaid across the country. 

Senator Dick Durbin of Illinois earlier this year introduced S. 2605, the Medicaid 

Coverage for Addiction Recovery Expansion Act (Medicaid CARE) that would reform 

the IMD Exclusion as it applies to SUD treatment, allowing for Medicaid to pay for 

treatment for patients at facilities of up to 40 beds for 60 days. This is a good start 

toward reform, and I would respectfully urge the Senators here to support it as one of 

the solutions to our epidemic. 

I understand that when the Senate HELP Committee recently marked up a series 

of bills to address the opioid epidemic and mental health reform, several Senators- on 

a bipartisan basis- called for reforming or eliminating the IMD Exclusion when 

the Senate considers those bills on the floor. That should give us new reason for 

optimism, and I hope Congress can take meaningful action on this front before the year 

is done. 

Substance abuse costs our nation approximately $600 billion annually, and 

effective treatment can help to greatly reduce these costs. Drug addiction treatment 

has been shown to reduce associated health and social costs by far more than the cost 

of the treatment itself. According to several conservative estimates, every dollar 

invested in addiction treatment programs yields a return of between $4 and $7 in 

reduced drug-related crime, criminal justice costs, and theft. When savings related to 

healthcare are included. total savings can exceed costs by a ratio of 12 to 1. Major 
125 

savings to the individual and to society also stem from fewer interpersonal conflicts; 

greater workplace productivity; and fewer drug-related accidents, including overdoses 

and deaths. 

Thank you for the opportunity to testify here today. We are proud of the lifesaving work that we have been doing at Integrity House for over 48 years, and I hope 

that my testimony has helped inform the deliberations of this committee. I look forward 

to answering your questions and working with you to develop and implement solutions. 

Sources 

1. https://wwy{.fl.t:\l9abuse.gov/publications/drugfacts/nationwide-trends 

2. Rudd, RA, Aleshire, N, Zibbell, JE, and Gladden, RM. Increases in Drug 

and Opioid Overdose Deaths- 2000-2014. Centers for Disease Control 

and Prevention: Mortality and Morbidity Weekly Report. Jan. 1, 2016. 

64(50);1378-82. Available 

at: b.!!p:I/V!fvvw,cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s cid=m 

m6450&.'~'-': 

3. https://www.drugabuse.gov/publications/principles-drug-addictiontreatment-research-based-guide-third-edition/drug-addiction-treatment-inunited-states 

4. https://www.drugabuse.gov/publications/drugfacts/treatment-statistics 
126 

Post-Hearing Questions for the Record 

Submitted to General John Kelly, USMC (Ret.) 

From Senator Ron Johnson 

"America's Insatiable Demand for Drugs" 

Aprill3, 2016 

I. How much would it cost the U.S. government to interdict 90 percent ofthe estimated drug 

flow that we have visibility of? 

Senator, when I was the commander of SOUTHCOM, we worked toward meeting a goal 

levied on us by the Office of National Drug Control Policy to remove 40% of the cocaine 

moving through the transit zone. If met, this 40% goal should put a significant dent in 

the huge profit margins of transnational criminal organizations. I can tell you that the 

professionals at Joint Interagency Task Force South (JIATF-South) in Key West, who 

execute this mission on our country's behalf, require 21 vessels to meet that 40% goal. 

Those 21 vessels would ideally be medium and long range ships equipped with a flight 

deck and law enforcement teams. The experts at JIATF-South often told me that this is a 

linear equation- for every complete force package that includes a ship and aircraft, they 

estimate they can interrupt an additional 20 metric tons of cocaine. 

This is, however, complicated by what we expect will be an increase in the 

denominator-the amount of cocaine leaving Colombia. Colombia, our best ally in the 

region and a country with whom we have a special relationship both in the region and 

globally, is fighting our fight against cocaine and take annually nearly 200 metric tons 

out of the flow, destroy hundreds of labs, and eradicate thousands of acres of coca on the 

bush. But in spite of all this effort, and the lives of many of their military personnel, 

police and local officials, cocaine production is expected to increase in the coming years, 

as criminal networks adapt to a changing security environment and exploit the potential 

power vacuum created by the FARC's demobilization-which is why our continued 

support to Colombia remains essential. 

During my time at SOUTH COM, we had unmet and significantly under-resourced ISR 

requirements. We would normally receive a fraction of what we actually needed. This 

intelligence is critical to not just stopping the flow of drugs-it's critical to understanding 

and ultimately dismantling the powerful networks involved in moving those drugs, 

weapons, Special Interest Aliens (SIAs) and the like. 

SOUTHCOM's efforts in the counterdrug realm are in direct support of US and partner 

nation law enforcement agencies. If we are serious about getting after the drug problem 

we must increase funding to our law enforcement agencies-DEA, FBI, DHS, CBP, HSI, 

and others-the heroes who are on the front lines of this effort. The US Coast Guard and 

Department of Homeland Security play especially critical roles in pursuing 'end game' 

interdictions. I continue to strongly support the Coast Guard and DHS' efforts to 

recapitalize their fleet of cutters, some of which are in the fifth decade of service. 
127 

Finally, I would be remiss if I did not reiterate the need to get after and significantly 

lower demand in our country. Demand is the beginning and the end of the drug 

trafficking industry and the reason why so many of our close partners in Central and 

South America, including Mexico, experience such high levels of violence, lack of 

economic development and investment, and in some cases are nearly failed states. As 

long as there is a demand for drugs in our country, for cocaine, heroin and 

methamphetamines, drug traffickers, motivated by the extraordinary profits involved in 

this business, will rise to the occasion. 

2. What is the cost and success rate of treatment for drug addiction? Is it a cost effective 

solution? 

According to the National Drug Intelligence Center, the economic cost of drug abuse in 

the United States was estimated at $193 billion in 2007 (the last available estimate ).in 

costs related to crime and the justice system, lost work productivity, and health care. 

Even with that level of investment, the National Institute on Drug Abuse has found that 

40 to 60 percent of drugs addicts will relapse. Although I would point out that one of the 

witnesses at the same hearing, a lifelong expert in rehabilitation, indicated the overall rate 

was much less than these estimates would indicate. This is a telling statistic when 

weighing whether treatment and rehabilitation are cost effective. We spend an exorbitant 

amount of money, the same witness estimated $36,000 a year, only to have at least half of 

those treated relapse. 

Getting after the epidemic of drugs in this country is going to require a multi-faceted 

effort that includes both the supply and demand problems. We have to give our 

courageous law enforcement and military personnel the tools to address insecurity in the 

source countries and to interdict the illicit substances before they reach our shores. But 

we also need a comprehensive campaign within the American society that reaches young 

people before they begin to experiment which is the first step in a direct path to addiction 

and related violent crime, prostitution and human trafficking, burglaries, etc. We have 

been successful and many other behavior modification efforts since the 1980s as I 

mentioned in the hearing, and reinforced by others on the panels, campaigns against 

cigarette smoking, drunk driving, for seat belt and air bag use in automobiles, car seats 

for kids, and the list goes on. 

We have never had such a comprehensive campaign against drugs. The last time we had 

anything approaching a demand reduction pitch of any kind was in the early 1980s. The 

key is to target teenagers by driving the cost up and availability down. This includes 

educating and if necessary penalizing medical professionals who over prescribe powerful 

and highly addictive pain killers which is the single biggest cause of the current opioid I 

heroin addiction crisis. We must focus information campaigns like the FBI's and DEA's 

"Chasing the Dragon" on teenagers, parents, teachers, Boy and Girl Scout leaders, 
128 

medical professionals and law enforcement-but particularly on middle and high school 

students. 

The military and law enforcement role is best accomplished not on the SW border 

playing the game perpetually on the one-yard line, but on the high seas getting a ton+ at a 

time and by supporting our partners to the south especially Colombia, Peru, Honduras, 

Panama, Costa Rica, and the other Central American Republics and Mexico. This 

support should be in the form of counterdrug funding but also economic investment to reshape the economies and societies our drug demand has nearly destroyed. Rehabilitation 

and medical treatment is most certainly part of the equation, but demand reduction at 

home is the solution to everything else we do. 

Senator, as I mentioned in my testimony, 47,000 Americans died of drug-related 

incidents last year up from a historical norm of -40,000. Most, if not all, of these deaths 

are entirely preventable. That is the true cost of our inaction when it comes to drug abuse 

in our country. 
129 

Post-Hearing Questions for the Record 

Submitted to General John F. Kelly, USMC (ret.) 

From Senator Rob Portman 

"America's Insatiable Demand for Drugs" 

Apri113, 2016 

I. You stated in your written testimony that you believe that transnational crime 

organizations (TCOs) could "unwittingly" transport terrorists and even weapons of mass 

destruction (WMDs) into the United States. You also underscored these organizations' 

profit motive. While you cautioned that no indications suggest such activity is taking 

place, are there any apparent factors or motivators that would discourage these 

organizations from actively and willingly transporting terrorists or WMDs? 

Response: Transnational criminal organizations (TCOs) are motivated by profit. Some TCOs 

would avoid wittingly transporting terrorists or WMDs out of fear that doing so would invite 

greater law enforcement scrutiny on their operations, which in turn would likely have a negative 

effect on their operations and jeopardize their profits. However, other TCOs are less concerned 

with the potential for greater scrutiny by law enforcement. They don't check passports or run 

background checks on the people who enlist their services. These TCOs are willing to move 

anything or anyone if the profit outweighs the risk. 

2. Based on your professional experience and judgment, if you were given the opportunity, 

what change would you make tomorrow to inhibit the operational effectiveness of the 

TCOs that you discussed in your prepared testimony? 

Response: Transnational criminal organizations are extremely well resourced and efficient 

networks that operate with ncar impunity. At current levels of resourcing, the men and women 

tasked to counter these violent criminals are at a severe disadvantage. There are many 

intelligence gaps against these networks, as well as a lack of assets needed to disrupt the 

networks. Continued and strengthened whole-of-government collaboration is also necessary to 

disrupt the networks that operate with no stove-piping of authorities, capabilities, or territorial 

boundaries. I have come to believe that their greatest vulnerability are their bank accounts. The 

Department of the Treasury is already involved but I think we seriously need to consider upping 

our game and going after their billions in a multifaceted campaign that includes all the tools 

available to law enforcement and Treasury, but "cyber-withdrawal" as well and simply closing 

down their accounts after seizing their ill-gotten gains. 

America's insatiable demand for drugs has blazed a trail of violence and corruption from the 

source zone in South America, through the transit zone of Central America. We owe it to our 

partner nations to support them as they work to eradicate corruption, strengthen citizen security 

and the rule of law, and create educational and economic opportunities for their people. This 

will also require a whole-of government effort from both the US and partner nations to build 
130 

their capacity to establish and maintain security and stability in the region eliminating the ease 

with which the TCOs now operate. 

3. Can you describe the trends you have seen in drug trafficking operations? 

Response: As our operations target the flow of narcotics in the CENT AM region, traffickers 

look for more direct routes into the US and Mexico from source zones. Over the past year, 

DTO's have maximized profits and decreased their risk of interdiction by directly trafficking 

drugs to Guatemala and Mexico. Traffickers are also sending more cocaine to more profitable 

markets such as Europe, Asia, and Africa. Additionally, recent press reports indicate local 

consumption in Central and South America may be increasing as well; this offers DTOs limited 

profits from transit and source zone countries with minimal risk of interdiction. 

a. Are there any aspects that make heroin unique? 

Response: Heroin is a much more potent drug and its market value per kilo usually exceeds the 

value of cocaine. In some parts of the country, such as the Northeast, the value of heroin is twice 

that of cocaine. Heroin often times provides greater return and less risk when compared to 

cocaine. DTOs have to ship much larger volumes of cocaine to match the profits generated by 

heroin. 

Mexico is the primary supplier of heroin to the United States. Opium poppy cultivation in 

Mexico has increased significantly in recent years. Much smaller amounts are also produced in 

Guatemala and Colombia. 

Because heroin is often smuggled in small amounts to the United States overland across the 

Southwest Border or transported by couriers on commercial airlines, making it extremely 

difficult to intercept it once it is en route. For that reason, it would be more effective to focus our 

collective efforts on disrupting its production and processing operations as close to the point of 

origin as possible. 

4. Ohio is facing a record number of fentanyl related drug overdoses. My understanding is 

that fentanyl often comes from China smuggled across the Southern border. From there, 

heroin is laced with fentanyl and brought into the U.S. by cartels. Is this an accurate 

assessment? Can you elaborate on the challenges of fentanyl interdiction? 

Response: In China, the companies producing these chemicals are doing so legally, and the 

companies there claim that they only produce and ship it for research purposes. There is no real 

effort to identify what entities are purchasing these chemicals. It would take a concerted effort 
131 

between US and Chinese law enforcement to truly counter the shipment of illicit precursor 

chemicals. Drug traffickers continue to coordinate illegal shipments of fentanyl and its 

precursors from China. They are able to hide the shipments on mislabeled manifests in order to 

circumvent law enforcement or security forces. Law enforcement's limited interdiction 

capability only allows the search of approximately I to 3% of all commercial cargo containers. 

Mexico-based cartels are not only lacing heroin with fentanyl but are also producing fentanyl 

masked as painkillers, such as oxycodone. Mexican cartels are producing a variant of fentanyl 

called acetyl fentanyl. While the majority ofthe fentanyl causing overdoses across the U.S. is 

from this illegal stockpile produced by Mexican cartels, a portion of it also comes in legally to 

pharmaceutical companies, according to the DEA. Many fentanyl shipments and the pill presses 

required to produce the final product are shipped directly from China to the US. Notably, one 

gram of pure fentanyl is equivalent to I 00 g of high quality street heroin and has 80 to I 00 times 

the potency of morphine. 

Pharmaceutical grade fentanyl can also be acquired through doctors and insurance companies. 

Subsys is an example of a Pharmaceutical grade fentanyl prescribed to cancer patients for pain; 

from 2012 to 2015, only 2.4 percent of all Subsys prescriptions were prescribed by cancer 

doctors. 

Precursor chemicals for Fentanyl are readily available on the internet, which makes it incredibly 

difficult to monitor and track each substance. 
132 

Post-Hearing Questions for the Record 

Submitted to General John F. Kelly, USMC (Ret.) 

From Senator Claire McCaskill 

"America's Insatiable Demand for Drugs" 

Apri113, 2016 

In 2010 I chaired a hearing on our counter-narcotics efforts in Latin America. Through the 

Merida Initiative and Plan Colombia, we have spent billions of dollars on counter-narcotics 

activities in the region, with much, if not most of the money going to contractors. 

But these contracts did not have effective performance management systems and lacked 

oversight in general, so it was impossible to determine the effectiveness of these contracts. In 

fact, it was like pulling teeth just getting basic contracting information from DOD and the State 

Department. 

I know you became head of Southcom after this hearing. 

1) As head of Southern Command in the years following my hearing what actions were 

taken to improve oversight of the counter-narcotics contracts money being spent? 

Response: Where feasible SOUTHCOM consolidated contracts under a single Indefinite 

Delivery/Indefinite Quantity (IDIQ) Contract providing an indefinite quantity of 

supplies/services over a fixed period of time. This provides both flexibility and ease of 

execution for the contracts SOUTH COM executes in support of the Counternarcotics Program. 

At the direction of the Deputy Assistant Secretary of Defense for Counter-narcotics and Global 

Threats (DASD CN-GT), SOUTHCOM primarily uses the U.S. Air Force Acquisition 

Management Integration Center (AMI C) for the majority of its contract services. This provides 

consistency and rigor to the SOUTH COM contracting processes. 

As you pointed out in your testimony, 100% of the heroin and cocaine and 90% of the 

metharnphetarnines coming into the U.S. are coming from Latin America, and seizures of drugs 

at the border have remained about constant overall, with only the mix of drugs coming in 

changing some. The network that supplies these drugs starts in Colombia, according to your 

testimony. Simply put, demand in this country is as high as ever and the supply of drugs from 

Latin America continues to meet our insatiable demand. 

2) What are the metrics we've been using to measure the effectiveness of our multi-billion 

dollar investment, and are those the right metrics to use if both the supply of and demand 

for drugs are as high as ever? 

Response: I can only speak to the funding executed by SOUTHCOM; the vast majority of funds 

spent on the Merida Initiative and Plan Colombia were actually executed by the Department of 

State. SOUTHCOM has metrics for all of its major programs and report them annually as part of 

its annual Program Objective Memorandum (POM) submission. The Command assesses each of 
133 

its three counternarcotics program mission areas -detection and monitoring (D&M), building 

partner capacity, and intelligence. 

• Detection and Monitoring (D&M): It is DoD's statutory mission to detect and monitor 

all illicit air and maritime drug traffic headed toward the U.S. In FYI5 we saw a 42% 

increase in disrupted/seized drug shipments. SOUTHCOM continues to take more and 

more drugs otTthe market, which is a positive metric. 

• Building Partner Capacity: SOUTHCOM measures the ability of its partner nations to 

use, maintain, and sustain the capabilities it provides, which when integrated into the 

JJA TF-S operational architecture provide synergy to our detection, monitor, interdiction, 

and apprehension etTorts. Statistically the partner nations are directly involved in more 

than half of JlATF-S events using equipment/training/capabilities provided through 

SOUTHCOM's counternarcotics program. This mission area is particularly important as 

SOUTHCOM attempts to mitigate its significant asset shortfalls. 

• Intelligence: With limited operational assets, SOUTHCOM relies more and more on 

technological advancements. A 44% increase in detected events in FYI5 was directly 

attributed to "enhanced intelligence, .. which includes a variety of technological 

advancements providing better targeting through improved geospatial location and 

increased data analysis. 

As I discussed at length in my testimony, however, all of the efforts of military and law 

enforcement officials cannot stop the drug flow into the U.S. as long as the demand in this 

country remains as high as it is. I would again refer you to public relations campaigns we have 

run as a country in the past that have been successful in decreasing smoking and increasing the 

use of seat belts. We know how to do this successfully but have chosen to ignore the drug 

problem for too long. 

3) Have we changed tactics or strategies or developed better metrics to measure our success 

since our billions of dollars have not done much to reduce the supply of drugs coming in 

from Latin America? 

Response: l would disagree that our efforts are not reducing the supply of drugs reaching cities 

in the United States. In FY15, the etTorts ofthe men and women carrying out this mission 

yielded a 42% increase in disrupted/seized drug shipments. That translates into 193 metric tons 

that never reached our shores or the streets of St. Louis. Thus far in FYI6, those men and 

women have already removed 163 metric tons from the market. However, the heroic efforts of 

our military and law enforcement professionals cannot solve this problem. If we, as a country, 

do not put serious effort into reducing the demand for drugs in the U.S., many more billions and 

the efforts of US and partner nation forces will not solve the problem on the supply side. 

The tactics and strategies of our adversaries change often. They are well funded, adaptive, and 

committed. Those who would pilot a multi-million dollar semi-submersible from a launch in 

Ecuador to a rendezvous off the coast of Guatemala are tough and well-financed adversaries. To 

meet these challenges we must adapt and evolve as well, especially because we do function in a 

resource-constrained environment. SOUTH COM has had to compensate for its lack of US 

military assets by building the capacity of willing partner nations to disrupt the dmg flow as it 
134 

heads to the US to meet our great demand. The Command has expanded and strengthened 

partner nation maritime capabilities to include increased range and station time through use of 

"mother ships" and provision of interceptor boats. They are also streamlining intelligence 

sharing with partners to get ahead of traffickers. They are also expanding the targeting of 

broader transnational organized criminal networks. 

According to DOD, in FY 2010, we had 188 contractors supporting our counter-narcotics efforts 

in Colombia. Part of the plan involved turning over these operations to the Colombians. 

4) Do you have a sense of how many contractors were in Colombia when you left 

Southcom? 

Response: I believe there were approximately 75 contractors in Colombia supporting operations 

at various sites throughout the country. I can also tell you that many major programs under Plan 

Colombia have already been turned over to the Colombians and others are on track to be turned 

over, meeting all milestones toward that goal. The Regional Helicopter Training Center (RHTC) 

in Melgar is scheduled to be nationalized by the Colombians in the first quarter of 2019 is on 

track to do so on time. The Colombians have greatly expanded a program of unmanned aircraft 

systems initially funded by the US from one hub-and-spoke program in a limited geographic area 

to a much larger portion of the country and the maritime environment. Similarly, the backbone 

defense communications system initially sourced and supported with counternarcotics funding is 

now supported almost completely by the Government of Colombia with a total expenditure I 0 

times greater than our initial investment. This is also true of Plan Colombia funding overall -

the U.S. contribution to Plan Colombia was only about 5%. Colombians contributed the vast 

majority of the funding and all of the fighting to bring their country back from the brink of the 

abyss. 

General Kelly, in your testimony, you discussed the importance of protecting the "southern 

approaches" to the U.S. It is interesting that you used the word "approaches" instead of 

specifically discussing the border itself, because, as you go on to say in your testimony "this 

cannot- should not- be attempted as an endless series of 'goal-line stands' on the one-foot line 

at the official ports-of-entry or along the thousands of miles of border between this country and 

Mexico." 

Yet in 2013, the U.S. spent $145 million on the Central America Regional Security Initiative, or 

CARS!. There were programs devoted to economic support, rule of law improvement, good 

governance, counternarcotics, efforts, education, trade and investment, and support for Central 

American militaries. 

At the same time, we spent $1 billion on a failed border technology program that ended up 

securing just 53 miles of the U.S.-Mexican border in Arizona. All told, according to one 

estimate, we've spent $90 billion over the past decade on border security, or $9 billion per year, 

on average. 

5) Is anyone taking a 50 thousand foot view of our spending priorities to make sure we are 

not just trying to make goal-line stands forever? 
135 

Response: The Department of Defense believes in and implements a system oflayered defense 

that aims to protect the homeland by taking a multi-faceted approach that includes building 

partner capacity to secure their own borders; intelligence sharing; transit zone detection and 

monitoring; close cooperation among law enforcement agencies, the intelligence community. and 

adjacent Combatant Commands. 

SOUTHCOM implements this approach by supporting the interdiction of multi-ton drugs 

shipments in international waters that stops more drugs, more efficiently, with minimal violence. 

Our law enforcement partners are also able to gain valuable intelligence and understanding of 

how these criminal networks operate by prosecuting suspected drug traffickers in the US court 

system. Through our building partner capacity efforts, we build capable and willing partners who 

respond to cueing by JIATFS to support regional counterdrug operations and who are working 

toward interagency approaches to border security. 

6) Does it make sense to focus so many of our resources directly on the border or should we 

be spending more to help these countries improve their own economies, judicial systems 

and police forces? 

Response: I believe you have to address the root causes of any problem in order to actually 

solve it. Those root causes in Central America include astronomical levels of violence, 

corruption, and weak rule of!aw. However, given the extreme lack of citizen security and the 

high levels of corruption in the police forces in Central America, disciplined and professional 

militaries are critical to setting the necessary security environment in which the governments of 

those countries can chip away at those root causes. Like the people of Colombia, Central 

Americans will have to address all of these facets of their society before they can regain stability 

in their region. 

In a prior hearing this committee had on the southern border, Lieutenant General Kenneth Tovo, 

the Military Deputy Commander of Southcom referenced the President's National Strategy to 

Combat Transnational Crime, which was released 5 years ago. The Administration also released 

the Strategy for U.S. Engagement in Central America. 

5 years after I had my hearing looking at the lack of coordination and oversight of contractors in 

the region, Lieutenant General Tovo expressed frustration that interagency activities in the 

region were still poorly coordinated and minimally funded. 

7) Who is in charge of seeing that these strategies are implemented well and that there is 

coordination between agencies? 

Response: The President's National Strategy to Combat Transnational Crime was never 

followed up with an implementation plan, which would have outlined lead and support 

agencies/departments. The Interdiction Committee (TIC), a principals level interagency 

committee chaired by the US Coast Guard Commandant, provides the primary venue for the 

components of this strategy to be discussed. 
136 

The National Security Council has designated the State Department as the lead for 

implementation of the Strategy for US Engagement in Central America. Beginning in June, the 

Department of State Western Hemisphere AtTairs Bureau will lead monthly interagency working 

group sessions. Each month the working group will focus on one pillar of the strategy 

(Prosperity, Governance, and Security). 

8) Is anyone held accountable for the failure to coordinate efforts across federal agencies? 

Response: Interagency coordination is of course a White House (National Security Staff) so 

your efforts should focus there. Since there is seemingly no lead agency or department at the 

strategic level for the President's CTOC Strategy, accountability ultimately falls to the 

operational/tactical levels where men and women with a bias for action and a willingness to take 

action and responsibility reside. I of course am most familiar with the efforts of SOUTHCOM 

and JlA TF -S, whose coordination across federal agencies is imperative to success of this 

mission. However, this leaves a significant gap, as SOUTHCOM and ITA TF-S are focused on a 

limited portion of this strategy by the nature of its authorities to operate. Other agencies are also 

executing programs in this region aimed at greater security and stability, however, a much 

greater coordinated interagency effort is required to address the complex issues facing Central 

America. 

1 believe accountability for interagency efforts under the Central American Strategy is primarily 

held by the Oftice of the Vice President, who has been personally involved in development of 

the strategy and coordination with our Central American Partners. The Department of State 

Bureau of Conflict and Stability Operations produces a quarterly report, which provides analysis 

on the impact ofUSG programs. Congress has also been active in conducting oversight and 

holding departments accountable for efforts in Central America. 

9) How often are agencies meeting to discuss implementation and coordination? 

Response: At the tactical/operational level, ITA TF-S conducts interagency coordination on a 

daily basis. At the strategic level, the Interdiction Committee meets annually, providing 

opportunities for policy-level discussions that span across all domains. Primary interagency 

coordination at the tactical and operational level is completed on a case-by-case basis by each 

embassy and its country team. At the strategic levels, coordination is conducted via NSC sub-

! PC meetings, which have proven inadequate as coordination has been only in terms of 

programmatic and budgetary requirements the same approach that has left CARS! as an 

ineffective tool. 

Given the complexity of the environment there is a need for a strong interagency collaborative 

process wherein authorities do not dictate who gets to do what but instead what capabilities they 

bring to a larger effort. In addition, this collaboration process must have central and iterative 

opportunities to reframe the problem. 

While these partnerships are superb at the tactical level, I am frustrated by the lack of a 

comprehensive U.S. government effort to counter the TOC threat. Nearly five years after the 

release ofthe President's National Strategy to Combat Transnational Organized Crime, 
137 

interagency CTOC activities in the region--especially in Central America-remain poorly 

coordinated and minimally funded. Fortunately, there is growing recognition that the magnitude, 

scope, and complexity of this threat demand an integrated counternetwork approach 

Under the current approach, there is no discussion on the problem at large nor how programs can 

work together in a synchronizing/complimentary perspective. The focus is specifically on stovepiped programmatics and budgetary impacts. Given the static nature of the US Strategy for 

CENT AM, there are only multiple single efforts for what each agency is doing -void of any 

unity of effort or effect. 

The regularity of interagency implementation and coordination is conducted monthly by DOS 

WHAled CENT AM Strategy Working Group sessions. Previously, as the strategy was in its 

implementation development, the NSC hosted sub-IPCs on a bi-weekly process. Given we have 

entered into execution, NSC created an implementation plan that transferred interagency 

coordination to DOS WHA. 

And compared to the rest of the world, what we spend to help improve the governance of Latin 

American countries is nothing. In 2012,just 8% of U.S. foreign assistance went to Latin 

America and the Caribbean. By comparison, 35% went to the Middle East, 30% went to Africa, 

and 21% went to South and Central Asia. As of2009, the U.S. was spending just $4.4 million on 

police training in Guatemala, Honduras and El Salvador, combined. By contrast, the U.S. was 

spending $327 million in Mexico and $390 million in Iraq. The U.S. spent as much on police 

training in Albania in 2009 as was spent in these three countries. 

I 0) Are we guilty of ignoring some serious issues on our own doorstep? 

Response: Yes, Senator, I believe we are. We tend to focus on East-West relations and issues, 

all the while ignoring the great partners we have to the South. The countries share much more 

than a land mass with us. We share many common beliefs, histories, and cultures. Our partners 

in the Western Hemisphere are strong and v.cilling and want to work closely with the United 

States. Many ofthem are just as capable and in some cases more capable than our European 

Allies and willing to take on leadership roles in the hemisphere and the world. And some of 

them need our help as they struggle to restore security and stability in our shared home. Central 

America is suffering from a scourge of violence and corruption, fueled by our insatiable demand 

for drugs. We owe it to them to stand shoulder-to-shoulder with them in this fig 
138 

Post-Hearing Questions for the Record 

Submitted to Mr. Jonathan Caulkins 

From Senator Ron Johnson 

"America's Insatiable Demand for Drugs" 

April 13, 2016 

I. What is the cost and success rate oftreatment for drug addiction? Is it a cost effective 

solution? 

Answer: That is an excellent and important question, one that is better answered with a book 

than a few paragraphs. What I will try to do here is make a few general points and key 

distinctions. 

Rigorous research strongly favors expanding treatment as a cost-effective use of taxpayer 

dollars overall, and I think it is safe to say it can also help reduce the flow of drugs across U.S. 

borders. However, that is because treatment is relatively inexpensive, and the problems it seeks 

to ameliorate are so terrible, not because treatment has a high success rate in the common sense 

notion of the term. Longitudinal studies in diverse countries that track opiate dependent 

individuals recruited from treatment programs often find long-run death rates elevated by a 

factor of ten or so relative to the general population, after controlling for age, and many of those 

deaths are from overdose. That is better than for opiate dependent individuals who do not 

receive treatment, but obviously is much worse than for people who never became dependent. 

After proper treatment, a broken arm can be just as strong as it was before the injury; by contrast, 

even with the best treatment, life prospects for those who are drug dependent remain bleak 

compared to their compatriots who never became dependent. 

To elaborate on treatment not being terribly expensive dependence is a true medical 

condition, but its treatment mostly does not look like modem, high-tech medicine. There are no 

operations using expensive machinery (or expensive surgeons). Relatively little of the care is 

provided by MDs. Hospitalization is the exception, and other than opiate substitution therapy, 

there are not even many medications involved. In short, drug treatment makes little use of the 

high-priced resources that make so much of American healthcare terribly expensive. It is thus 

far most cost-effective than other widely-used treatments in American medicine for example 

coronary artery bypass surgery and arthroscopic knee surgery. 

To elaborate on the limited effectiveness one common result of offering treatment to 

someone who is drug dependent is that they never even show up for treatment or if they do 

enroll, they nonetheless drop out fairly quickly. That is one reason why partnerships between law 

enforcement and treatment have a role; criminal justice supervision can increase retention in 

treatment. 

Furthermore, while it is true that people who stick with treatment through its full course 

have much better life outcomes than those who drop out quickly, we can't take that as proof that 
139 

treatment helped those people. It is entirely possible that those who were the worst off before 

treatment will be the ones who tend to drop out quickly and also the ones who suffer the most in 

the long run, and that those whose life circumstances were less dire will be better able to remain 

in treatment and also to do better in the long run. The correlation between treatment retention 

and favorable long-run outcomes does not in and of itself prove the longer exposure to treatment 

created the more favorable long-run outcomes. 

The better metaphor is that with or without treatment the dependent individual has a 

chronic relapsing condition that will persist for many years. The main question is whether they 

struggle with that disease aided by the support of government-funded or employer-funded 

services or whether the full burden of that disease falls entirely on the individual and their 

family. 

Treatment does improve many measureable outcomes, such as life expectancy, access to 

other health and social service programs, and employment. And it does reduce substance use. 

But to put it bluntly in the context of the topic of this hearing, if in one way or another I ,000 

dependent cocaine users were assembled who would have consumed an average of 150 grams a 

year for the next I 0 years if they didn't receive treatment, and so account for a total flow of 1.5 

metric tons of cocaine shipments crossing the U.S. border over that time, and those 1,000 were 

offered the standard treatment we are able to offer at present, those 1,000 individuals might well 

still consume as much as 1.0 metric tons of cocaine over the next decade despite having been 

given access to treatment. 

I don't want to put too much emphasis on the 150 grams or the 1.5 metric tons or the 1.0 

metric tons; they are merely meant to illustrate the idea that treatment reduces but far from 

eliminates consumption. The particular best estimates of treatment's effectiveness at reducing 

consumption of black market drugs depend on the particular characteristics of the clients, how 

well-funded the treatment programs are, the future trajectory of prices and availability in the 

illegal cocaine market, and many other factors. But in broad terms, treatment can help reduce 

flows of drugs across the border but one should not think of it capable of shutting off that flow of 

drugs the way that fixing leaky pipes can shut off the flow of dripping water. 

One final point- different drugs are, as always, different. We have much better 

technologies for treating opiate and alcohol addiction than we do for treating addiction to 

stimulants such as crack, powder cocaine, or methamphetamine. And marijuana is also in a class 

by itself. The paragraphs above are written primarily with the hard drugs in mind. 

For more on the cost-effectiveness of opiate treatment, see Report 3 of the American 

Society of Addiction Medicine's project on Advancing Access to Addiction Medications, 

available at http://www.asam.org/docs/default-source/advocacy/aaam implications-for-opioidaddiction-treatment final. Unfortunately the evidence base concerning treatment of stimulants, 

like the treatment methods themselves, are much less advanced than they are for treating opiates. 
140 

Post-Hearing Questions for the Record 

Submitted to Dr. Jonathan P. Caulkins 

From Senator Rob Portman 

"America's Insatiable Demand for Drugs" 

Aprill3, 2016 

1. I firmly believe in drug prevention. I've been working on prevention for more than 20 years 

and am the author of the Drug-Free Communities, which has funded thousands of coalitions 

through a federal investment of more than 1.3 billion dollars. You testified in your about the 

importance of evidence-based prevention, particularly as it relates to youth. We know that 

the perception of risk can be one of the greatest factors in whether or not young people 

choose to experiment with drugs. The Comprehensive Addition and Recovery Act (CARA) 

would provide additional resources to community coalitions so that they can broaden their 

work to focus on the challenges of heroin and opioids create. CARA includes drug take back 

initiatives and educating the community about the risks associated with prescription drug 

abuse. What are other ways we can prevent drug abuse and show our young people that this 

behavior possesses a high risk? 

Answer: A dedicated community of scholars and practitioners has been working intensively 

for roughly 40 years trying to figure out how to dissuade youth from using dangerous drugs, 

including the legal drugs (alcohol and tobacco), the traditional illegal drugs (cocaine, heroin, 

meth, ecstasy, etc.), and now two important intermediate categories (diverted prescription 

drugs and marijuana in its current, odd, legal situation in Colorado, Washington, Oregon, 

Alaska and the District of Columbia). It is important also to recognize that these efforts 

share a great deal with efforts to prevent youth from making other poor choices (dropping out 

of school, engaging in unprotected precocious sexual activity, joining gangs, and so on). 

By and large, the wisdom of this community is to recognize the commonalities across 

these various "temptations" and to stress general skills. For example, an intervention that 

evaluations found to have striking success at reducing drug use was the "Good Behavior 

Game", which is not in any overt sense about drugs. Rather, it is a set of strategies to induce 

better classroom behavior from elementary school children by tapping positive peer pressure. 
141 

The behaviors that lead to points being charged against a student team are not drinking, 

smoking or the like; the game is implemented with kids too young to yet be using drugs. 

Rather, the focus ofthe game is more typically on disturbing and disruptive behavior in the 

classroom. But improving those fundamental behaviors apparently produces benefits across 

an extremely wide range of outcomes, including but in no way limited to substance abuse. 

These more general or comprehensive approaches to prevention emerged in part out of 

disappointment with the failures of traditional anti-drug messaging that might stress, for 

example, how dangerous drugs are. 

That is not to say that more specific campaigns never work. The "Truth" campaign was 

specific to cigarettes and was surprisingly effective, arguably in part because of its unique 

strategy of demonizing the industry, and the tobacco industry's manipulation ofthe product 

for profit, rather than demonizing the product itself. A quip I've heard that does not come 

from a randomized controlled trial, but may nonetheless contain a germ of insight is that it is 

very hard to discourage teen-agers- with their over-confidence bias and sense of immortality 

-from using something because it is dangerous, but if you tell teens the purveyors of the 

product are trying to take away the their autonomy by tricking them into becoming 

addicted- that is hitting teens in their sensitive spot. 

Nevertheless, my sense is that diversion of prescription drugs (most notably opioid pain 

killers) and marijuana during this transition time may be such special cases that behaviorspecific messaging could be valuable. One you mention -take back programs- seems 

appealing. Besides getting a certain number of bottles out of people's houses, where they 

could be diverted or used by kids, the take back programs send a message that those drugs 

are too dangerous to leave lying around. The fact that we also have take back programs for 

guns might have the additional benefit of getting people to lump prescription drugs and guns 

into a single mental category of things that are dangerous. 

And they really are both quite dangerous. It is hard to get data on the number of guns in 

the U.S., but when I made a rough attempt to estimate the numbers of: (1) guns owned in the 

US, (2) gun-related deaths in the U.S., (3) opioid prescriptions, and (4) prescription opioid 

related deaths, it seemed to me that the number of deaths per opioid prescription could be 
142 

within a factor ofthree ofthe annual number of gun-deaths per gun (all causes including 

suicides and accidents, not just homicides). 

Responsible gun owners know that guns should be stored in a locked safe, but I do not 

recall hearing a public education campaign that stressed the idea that prescription opioids 

should be stored in a locked medicine cabinet. To give a concrete example, last week my 

wife was prescribed oxycodone for her fractured leg (even though she reported no pain, and 

we will not fill the prescription), but the doctor never asked whether we have children in the 

house or otherwise gave safety instructions comparable to those we would have received if 

we'd bought a gun at Field & Stream. 

So even though drug-prevention programs of the 1970s that stressed drugs' dangers were 

not found to prevent use, in part because they tended to exaggerate and sensationalize the 

dangers, I would not let such past failures discourage us from trying to communicate to the 

public the particular lethality of these prescription pain killers. 

A second, distinct, type of public messaging relevant for prescription pain killers but not 

most other drugs is telling people about naloxone. Again there could be a double benefit: (I) 

Informing people about naloxone and (2) Associating in people's minds prescription drugs 

with overdose death. 

Concerning prevention messaging for marijuana when states are legalizing it- I am sure 

that we do not know what to do, and so I am sure that it ought to be an active topic for 

innovation, evaluation, and research. There clearly needs to be some messaging to counter 

teen's mistaken inference that since marijuana can be used as medicine it must be safe. (It is 

ironic that teens hold such views when prescription opioids arc killing so many tens of 

thousands of people, but they do.) And it is clear that we need better messaging about the 

dangers of driving after using marijuana use. Although the science suggests that driving 

under the influence of alcohol is more dangerous per mile driven, survey data suggest that 

marijuana users are much more likely to drive within two hours of using marijuana (and that 

most such episodes actually involve use of both marijuana and alcohol, not just alcohol). 

MADD and other organizations succeeded in changing social norms to make it unacceptable 

to drink and drive; we need a comparable effort to convince people it is irresponsible to drive 
143 

stoned. And that will be quite difficult since the government has such low credibility with 

regard to warning about marijuana's dangers. 

There is also the enormous question of how to prevent the spread of marijuana vaping 

from spilling over into a spread of nicotine vaping, and that from progressing to smoking of 

tobacco. But the identification of a specific behavior one would like to prevent is only the 

first of many difficult steps that might eventually lead to an effective prevention program. 

The larger history of prevention science has two sobering lessons: (1) It is easy for adults to 

invent prevention messages that they think ought to work and (2) It is hard for adults to 

actually change teen-agers behavior. The changes are so valuable that of course it is worth 

trying, but we should do so with realistic expectations concerning their likely effectiveness. 

2. You discussed the Swift, Certain, and Fair (SCF) program in South Dakota at the hearing. 

Would this be applicable to juvenile offenders, or should juvenile offenders receive 

treatment-centered care in contrast to being held accountable under a SCF program? 

Answer: My sense is that swift, certain, and fair (SCF) may have potential to help criminally 

involved youth who have substance abuse problems, but that is not the best demographic to 

start with. Everything is more complicated and controversial when working with youth. 

fear that a poor implementation of SCF with youth might sour the public to the overall 

concept. But we can think through what a good target for implementation might look like. 

First, it is important to note the SCF applies to individuals who have committed serious 

enough crimes that they could be sentenced to incarceration- or in the case of juveniles to 

some juvenile detention facility. And the proper framing of the choice is not treatment vs. 

SCF but rather: (1) Detention, (2) Community release without SCF (and perhaps with 

treatment), or (3) Community release with SCF (meaning the clients are free to get treatment 

if they chose, but typically are not required to do so although there is no reason treatment 

could not also be mandated). 

The potential target population would be youth who the criminal justice system would 

prefer not to detain, e.g., because the juvenile detention facility is over-crowded and unable 
144 

to deliver effective services, and whose parents do not believe they can control in the home 

environment. If the parents and the juvenile court concluded that substance abuse was an 

important part of the reason that the parents cannot control their child, then a SCF regimen 

might be worth trying before giving up and sentencing the youth to a long period of 

detention. Again, it is important to stress that being in SCF in no way interferes with also 

being in treatment. So the courts could mandate treatment attendance as well as SCF and 

could even construe SCF as the "stick" that gives the youth an extra incentive to stick with 

treatment. 

The target population I just described is a pretty small group -far smaller than the 

number of youth who abuse, let alone simply use, substances. But it is a very important 

group and one for which current interventions do not always produce wholly satisfactory 

outcomes. So a well-designed study that evaluated whether the SCF concept can usefully be 

extended from adults to youth may be in order. 

My fear, though, would be "net widening", a term that refers to an intermediate sanction 

being used not in place of detention but rather in place of a sentence or condition that 

involved no incarceration whatsoever. (And a related fear would be that even if the program 

were only used in lieu of detention, its critics might accuse it of increasing rather than 

decreasing the amount of detention.) 

Interestingly, I was recently party to a conversation concerning use of SCF for 

perpetrators of domestic violence who (as is not uncommonly the case) are violent when they 

are drunk (or are on drugs). Ironically, in that case the fear was the opposite, namely that 

SCF would be used in place of pure incarceration, whereas the victims advocacy groups 

might only want it to be used as a way of being tougher on those who would not otherwise be 

incarcerated (and there was also fear that critics would portray it that way even if that 

portrayal were disingenuous). 

In sum, I would rather see SCF directed first at criminally-involved, high-frequency adult 

users of stimulants (cocaine/crack and meth). There are a relatively modest number of such 

individuals (on the order of two million, or roughly 5% of Americans who have used an 

illegal drug in the last year), but they consume at such very high rates that they account for 

about half of the dollar value of illegal drugs flowing across U.S. borders. Furthermore, in 
145 

contrast with opiate dependence, we generally lack effective pharmacotherapies for treating 

people who are dependent on stimulants. 
146 

Responses to Questions; 

TESTIMONY 

DR. CHERYL G. HEAL TON, DEAN 

COLLEGE OF GLOBAL PUBLIC HEALTH 

NEW YORK UNIVERSITY 

BEFORE THE COMMITTEE ON HOMELAND SECURITY 

AND GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

AMERICA'S INSATIABLE DEMAND FOR DRUGS 

APRIL 13, 2016 

1. I firmly believe in drug prevention. I've been working on prevention for more than 20 years 

and am the author of Drug-Free Communities, which has funded thousands of coalitions 

through a federal investment of more than $1.3 billion. You testified about the importance 

of evidence-based prevention, particularly as it relates to youth. We know that the 

perception of risk can be one of the greatest factors in whether or not young people choose 

to experiment with drugs. The Comprehensive Addiction and Recovery Act (CARA) would 

provide additional resources to community coalitions so that they can broaden their work 

to focus on the challenges that heroin and opioids create. CARA includes drug take-back 

initiatives and educates the community about the risks associated with prescription drug 

abuse. What are other ways we can prevent drug abuse and show our young people that 

this behavior possesses a high risk? 

Those who are motivated to profit from drug sales to risk-seeking and troubled teens do so to 

make long-term customers of them. They care very little about their health and more about 

highly lucrative sales. They attract young customers when their developing brains are most 

vulnerable to risk taking and addiction, and then reap the profits as they age and remain 

addicted. 

The U.S. cannot be safe from drug-related criminal activity without first reframing the 

relationship between drug use and crime and, secondly, identifying ways to sharply reduce our 
147 

apparently insatiable appetite for illicit drugs. This can be accomplished through the 

prevention of youth initiation, de-glamorizing use via disruptive and innovative mass media 

campaigns aimed at "unselling" use, and inducing those addicted or teetering on the verge to 

seek prompt treatment. It goes without saying that drug treatment needs to be available and 

covered by insurance plans. 

Not all drugs (including tobacco and alcohol) in fact carry the same physical, psychological and 

social risk, and educating teens about drug use ought to include this fact. Access to prescription 

opioids in the home and those that spill over into the illicit drug market lay the foundation for 

addiction and future use of street heroin in lieu of pills. There is a crucial role for the FDA and 

others to change the prescription patterns for pain killers. Alcohol and opioids cause the 

greatest number of teen drug deaths. As the CDC has stated, it has no reported marijuana 

deaths, for example. There are other risks associated with marijuana use including 

entanglement with the legal system, reduced motivation etc. Substance control aimed at 

reducing access, and education and treatment should focus considerable attention on the drugs 

costing the most lives. 

2. How would you craft a marketing campaign in 2016 that responds to the heroin, fentanyl, 

and opioid epidemic? 

a. Would you even utilize broadcast television? 

b. Do you think television shows like Breaking Bad may be counterproductive in efforts 

to discourage illicit drug use? 

Primary prevention of illicit drug use is defined as stopping illicit substance abuse before it 

begins or becomes habitual and addictive. These lessons should be applied as a basis for new 

program efforts at the national level. The same impact on initiation may be achieved in large 

part by powerfully hard-hitting, youth-focused communications, especially designed for youth 

at the highest risk of drug use. Messages must be designed-- as they were for the truth® 

campaign-- to reach those most likely to initiate drug use with compelling reasons to avoid 

initiation, including the fact that those profiting from their potential drug use are using them 

even if that person is a low-level dealer they consider to be their "friend". 

The nation's long-standing, ONDCP-supported, Partnership for a Drug-Free America campaign's 

paid advertising effort was sharply curtailed after a decade of persistent budget cuts. It is 

urgently important to bring it back and, in doing so, 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 include: 

• Paid advertising and ad development at market rates to ensure the work is done by the 

hardest-hitting, best team possible; 
148 

Youth market research, appropriately targeted and designed for sub-sets at high risk, 

which will likely result in the bold ads being exceptionally unpalatable to adults and 

government agency staff; 

• A focus on the drugs associated with the greatest harm and free of "approval" processes 

which interfere with the potential for campaign success due to conflicts of interest and 

adult sensitivities with respect to content and taste; 

• Vigorous evaluation, in real time, to decommission ads that are not resonating with 

intended audiences and being nimble enough to quickly replace them with those that 

do. This is especially critical given that ads can have boomerang effects that are difficult 

to predict with certainty. (Fishbein 2002). 

The media marketplace has changed but network and cable advertising can still drive web 

traffic and thus have a role. Social media-based communication also do and a contemporary 

campaign should also have a grass-roots component both on the web and in communities on 

the ground in areas of highest risk. The focus should be laser-like on those who have not yet 

used and those who are occasional users but "undecided." 

If public education efforts are also intended to reach adults to curb their drug consumption, a 

similar, laserlike focus on the actual communication to target populations must also be 

employed. For example, the current adult target includes those addicted to or habitual users of 

alcohol, prescription medication, black market opioids, cocaine and heroin. Each represents a 

niche communication market, and a comprehensive public education campaign can speak to 

each group with well-designed messages and action steps. 

Media of all kinds may influence drug use either up or down. Only a systematic study could 

determine the impact on knowledge, attitudes and behavior of a show like Breaking Bad. In the 

70s at the peak of the heroin epidemic, efforts were undertaken to curtail explicit injection drug 

use in movies. 

3. What is the cost and success rate of treatment for drug addiction? Is it a cost-effective 

solution? 

According to Dr. Andrew Kolodny, the most important control approaches for the overall opioid 

epidemic include "preventing new cases of opioid addiction, treatment with safer alternatives 

for people who are already addicted and reducing the supply from pill mills and the black 

market." 

Kolodny and colleagues have demonstrated that treatment with Buprenorphine saves lives 

from overdose and other opioid use complications (Kolodny 2015). Buprenorphine was 

introduced in France in the mid-1990s, released without any of the limits imposed in the l.fS and 
149 

prescribed widely. Within six years, opioid overdose deaths decreased by a dramatic 79% 

(Auriacombe 2010). 

Opioid addiction has increased 900 percent from 1997 to 2011. It is noteworthy that the bulk of 

the opioid epidemic is caused by too liberal use or prescription of painkillers which in turn leads 

to addiction. The solution rests in the hands of policy makers, the pharmaceutical industry and 

physicians. 

The figure below depicts the surge in opioid sales, opioid deaths per 100,000 and opioid 

treatment admissions per 10,000. In addition to the opioid deaths included in these numbers, 

among those turning to heroin, an upswing in HIV and Hepatitis C infections is occurring. Public 

health secondary prevention strategies such as needle exchange programs, antiretroviral 

treatment and condom access are needed to control the spread of HIV. 

,Rates of Opioid Sales, OD Deaths, and Treatment, 1999-2010 

COC.~2011 ""' "" -'"" 

CDC (Cent. Dis. Control Prev.). 2011. Vital signs: overdoses of prescription opioid pain relievers-United 

States, 1999-2008. M MWR 60: 1487-92. 

Also urgently needed is the expansion of Naloxone and Narcan availability for law enforcement 

and others in close proximity of those at risk of overdose. 

Sadly the recently passed opioid bill has virtually no new money for prevention and treatment. 

The cost of prevention and treatment is cost effective and thus warranted to saves lives, reduce 

disability and keep people productive or return them to productivity through effective 

treatment. 
150 

NOTE: July 13, 2016 

Opioid bill passes, but there's little money to act on its wish list 

Read more here: http://www.thenewstribune.com/news/politicsgovernmentlarticle89403007.html#storylink=cpy 

WASHINGTON 

With hold-your-nose support from most Democrats, the U.S. Senate overwhelmingly approved 

legislation on Wednesday to curb heroin and opioid abuse. 

The vote all but assured that President Barack Obama will sign the measure into law despite 

concerns about its lack of assured funding to address the nation's growing drug problem. 

The Comprehensive Addiction and Recovery Act advanced in the Senate by 90-2 after Democrats 

followed their colleagues in the House of Representatives and dropped calls for the legislation to 

include additional funding. 

As with Prince. baby boomers' chronic pain means risk of opioid abuse 

Senate Majority Leader Mitch McConnell, R-Ky., called for Senate Democrats to pass the measure, 

citing support for the legislation by the National Association of Counties, the National League of 

Cities, the Fraternal Order of Police and more than 200 other groups. 

In a statement, Sen. Marco Rubio, R-Fia., praised the measure as a significant advance in the drug 

fight. 

We have a major opioid addiction problem in Florida and throughout our nation, and this legislation 

is an important step to addressing this health crisis that is taking lives and destroying families. Sen. 

Marco Rubio, R-Fia. 

"We have a major opioid addiction problem in Florida and throughout our nation, and this legislation 

is an important step to addressing this health crisis that is taking lives and destroying families," 

Rubio wrote. 

The legislation, crafted by a House-Senate conference committee, allows the federal government to 

provide state grants to fund a variety of programs aimed at curbing prescription opioid and heroin 

abuse. 

Opioids are a class of narcotic pain medications that include prescription drugs like methadone, 

oxycodone, Percocet and codeine, along with the illegal drug heroin. 
151 

From 2000 to 2014, the rate of opioid overdose deaths increased 200 percent, sparking a nationwide 

crisis that has captured the attention of police and politicians alike. 

Today, an estimated 2.1 million Americans are addicted to opioids, including about 467,000 addicted 

to illicit opioids like heroin, according to the National Institute on Drug Abuse, part of the National 

Institutes of Health. 

The bill would expand opioid prevention and education activities, boost efforts to identify and treat 

incarcerated addicts and provide police and first responders with more naloxone, a drug that blocks 

or reverses opioid overdoses. The legislation also would strengthen state programs to monitor and 

track opioid prescription activity and allow nurse practitioners to prescribe buprenorphine, a drug that 

fights opioid addiction. 

As opioid. heroin epidemic worsens, federal government takes action 

But to fully fund those initiatives, Congress will have to appropriate much more money after it returns 

from the summer recess in September, because the measure authorizes only $181 million in 

funding. 

In February, Obama asked Congress for $1.1 billion in emergency funding to assist Americans 

caught in the grip of heroin and prescription opioid abuse. But last week, Republicans on the 

conference committee blocked efforts by Democrats to add $925 million in funding for the bill. 

Republicans have called for providing $581 million to the Substance Abuse and Mental Health 

Services Administration to address opioid abuse in their 2017 fiscal-year funding bill. 

On Tuesday, Senate Minority Leader Harry Reid, D-Nev., called the opioid legislation "a missed 

opportunity to do something substantive." 

"Authorizing legislation is a start," Reid said, "but without resources, it's very, very meaningless .... 

Without real funding this legislation is far from adequate." 

Authorizing legislation is a start, but without resources, it's very, very meaningless .... Without real 

funding this legislation is far from adequate. Sen. Harry Reid, D-Nev., Senate minority leader 

But faced with the prospect of leaving for the summer with nothing to address the nation's growing 

drug problem, Reid joined other Democrats in voting for the measure despite their concerns. 

Sen. Richard Blumenthal, 0-Conn., who also voted for the measure, said it was "barely a symbolic 

step." 
152 

"The rhetoric on the floor today and throughout our consideration of this bill, unfortunately, is 

unmatched by real dollars," Blumenthal said Wednesday. "Until we commit resources, our words will 

be a glass half empty." 

Medical and drug prevention experts were equally tepid in their support for the legislation. 

In a statement on behalf of the Coalition to Stop Opioid Overdose, R. Corey Waller, an addiction 

specialist in Grand Rapids, Michigan, urged the Senate to pass the measure even though the group 

was "disappointed" that the bill lacked the funding to "meaningfully address the opioid crisis." 

"The cost of the opioid epidemic is too high to continue without real legislative solutions: every day 

that we put this off we leave hundreds of thousands without treatment and put thousands of Jives at 

risk," Waller's statement said. 

Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, said the 

group also supported Senate passage and wants President Obama to sign the legislation; which he 

called "better than nothing." He said the measure "will have very little impact without real funding." 

Kolodny also worries that Republicans seeking re-election will trumpet the bill on the campaign trail 

this summer and could return to work in September and not provide any additional funding. 

"It does worry me," said Kolodny, who's also chief medical officer for Phoenix House, a national 

nonprofit addiction treatment agency. "There's a very big risk that after the election we will not see 

members of Congress coming back and appropriating the funding that's needed." 

The legislation is important for Senate Republicans, like Rob Portman of Ohio and Kelly Ayotte of 

New Hampshire, who face tough re-election battles in states hit hard by the heroin and opioid 

problem. 

On Tuesday, Ayotte called for passage of the conference bill, arguing that she would fight for more 

funding later. She said failure to pass the bill would be "doing a great disservice to the American 

people." 

"It's time for us to rise above the politics and pass this legislation," Ayotte said. 

Read more here: http://www.thenewstribune.com/news/politicsgovernmentlarticle89403007.html#storylink=cpy 
153 

7/21/2016 Buprenorphine-natoxone underutitized by Medicare prescribers 

IN THE JOURNALS 

Buprenorphine-naloxone underutilized by 

Medicare prescribers 

Lembke A and Chen JH. JAMA Psychiatry. 2016;doi:10.1001/jamapsychiatry.2016.1390. 

July 20, 2016 

Prescription of buprenorphine-naloxone was significantly lower than prescription of opioid painkillers among 

Medicare prescribers, according to recent findings. 

"The population that uses Medicare has among the highest and most rapidly growing prevalence of opioid use 

disorder, with more than six of every 1,000 patients (more than 300,000 of 55 million) diagnosed and with 

hospitalizations increasing 10% per year. Data on patients with commercial insurance plans show just more 

than one of every 1,000 patients diagnosed," Anna Lembke, MD, and Jonathan H. Chen, MD, PhD, of 

Stanford University School of Medicine, California, wrote, "Prevention initiatives are essential for reducing 

the number of new patients with opioid use disorder, but treatment will be required for those already addicted 

to opioids." 

To compare prescription of buprenorphine-naloxone with prescription of Schedule II opioid painkillers, 

researchers analyzed data from individual prescribers from the 2013 Medicare Part D claims data set, which 

covers approximately 68% of the estimated 55 million individuals receiving Medicare. Data represented 

1,188,393,892 claims that cost $80,941,763,731. 

There were 6,707 prescribers with 486,099 claims for buprenorphine-naloxone, written for approximately 

81,000 patients, compared with 381,575 prescribers with 56,516,854 claims for Schedule II opioids. 

For every 40 family practice physicians who prescribed opioid painkillers, there was one family practice 

physician who prescribed buprenorphine-naloxone (71, 718 vs. 1, 793 ). 

"Pain physicians averaged on the order of thousands of opioid painkiller prescriptions per prescriber 

compared with a negligible number ofbuprenorphine-naloxone prescriptions (mostly< 5)," according to 

researchers. 

lluprenorphine-naloxone was prescribed most frequently by physicians whose primary specialty was 

addiction, with 98.8 claims per year. However, there were only 100 such Medicare prescribers in the United 

States. 

The top six states by buprenorphine-naloxone claims ratio, defined by researchers as the number of claims in a 

drug subset divided by total number of claims for all drugs, included Vermont, Maine, Massachusetts, Rhode 

Island, Washington, D.C., and New Hampshire. These states had claims ratios more than 300 times higher 

than the national average. 

http:/fwww.heallo.com/psychiatry/addiction/news/on!inet"/o781c5aa0c2-fa07-49b&-87Q6.85ea74a80099%7Dibuprenorphine-naloxone-underuti!ized-by-medicare. . 112 
154 

7/2112016 Buprenorphine-na!oxone underLJtl!ized by Medicare prescribers 

"Buprenorphine-naloxone is underused by Medicare prescribers. Geographic differences in buprenorphinenaloxone prescribing should be explored to assess state-level variations in advocacy for and barriers to its 

use," the researchers wrote. "To combat the current prescription opioid epidemic, integration and promotion of 

[ opioid agonist therapy) should be encouraged, and not just among addiction medicine specialists, who are far 

too few to meet the current and projected need. Physicians who prescribe high volumes of opioids and thus 

already have an established therapeutic alliance and prior experience with opioid prescribing are especially 

well-situated, with some additional training, to intervene when cases of prescription opioid misuse, overuse, 

and use disorders arise."- by Amanda 0/dt 

Disclosure: The researchers report no relevant financial disclosures. 

http"f!Www.heatio.com/psychiatry/addictiorVnew-s/on!inef'A>7B1c5aaOc2-fa07-49b6-8706-85ea74a80099%7D!buprenorphine-nafo>::one-underutJ!fzed-by-medicare... 212 
155 

EdVenture Partners 

Submitted By: Tony Sgro, CEO, and EdVenture Partners 

May 27, 2016 

How would you craft a marketing campaign in 2016 that 

responds to the heroin, fentanyl and opioid epidemic? 

I would do this: 

Take a cue from the smoking campaign that had that woman who 

had a hole coming out of her trachea, and sounded like a 

squeezebox when she spoke. She even put her cigarette in the 

hole and puffed it. We all said, "Gross!!" 

Take a cue from what is working in the countering violent 

extremism tool kit of effective techniques and that is to 

incorporate former extremist ("formers") into the messaging 

campaign. 

In both cases, these spokespersons are "users of tobacco and 

doers of extremism." For a campaign focusing on America's 

Insatiable Demand for Drugs, I would suggests using former 

addicts, current users and even former dealers to be 

spokespersons. These people are the real deal and will get the 

attention of Americans. 
156 

The power of a first person narrative cannot be understated By 

using spokespersons who have lived the hardship, pain, 

hopelessness, tragedy and horror of using drugs is going to be 

more believable, credible and authentic than crafting just a 

"message" educating about drug use, prevention and abuse. In 

this instance, it is the power of personal 'storytelling' that will get 

people's attention. Let these either former and current addicts 

speak from the heart about what it is like, the how, what, when, 

where and why. Real stories, real people from a wide swath of 

socio-economic backgrounds, ages, and geography. 

Would you even utilize broadcast television? 

In my testimony I advised that TV does not have the viewership or 

penetration to reach Gen Z and Gen Y. However, I would advise 

using national television to kick-off the campaign with these firstperson testimonial ads. It would be important to demo these spots 

with focus groups to determine the efficacy of each one. 

Then, I would roll into the social and digital media campaign to 

narrow focus the campaign on various social media platforms. 

Start big on TV (cable) to create national awareness throughout 

American society and the move down the funnel to target the 

audience. If the P2P model is utilized on a national level, these 

advertising resources could be offered to university students to 

incorporate in their localized campaigns to complement their 

social and digital media campaigns that they create and 

implement on their college campuses and communities. 
157 

Do you think television shows like Breaking Bad may be 

counterproductive in efforts to discourage illicit drug use? 

I do not. I believe most people are smart enough to realize it is 

Hollywood, however as real-life as the actors and plots are, would 

not truly impact a potential drug user to start. Question: have 

you tested this hypothesis with the American public? What about 

with drug users? 

The actors of Breaking Bad could be considered as spokespersons 

for this campaign and I believe would be highly effective. They 

could also tour high schools and college campuses on a speaking 

tour. P2P teams could use this "talent" and showcase them as part 

of their P2P campaigns. 

During the hearing, General Kelly remarked that recreational 

drugs are not victimless, citing the threats against and murders 

of public officials and their families in Central and South 

America. He continued by saying that maybe people would 

view their recreational use differently if confronted with these 

facts. Do you think this would be the case? 

No. I believe as long as the threats and murders are out of sight 

and out of mind, it will not impact behavior of the American public 

to reduce drug demand or use. However, once again, I think this 

would be a great research project for university market research 
158 

and public health students to undertake across the nation. Has 

this suggestion or hypotheses by General Kelly been tested or 

researched? 

I am sure there will be some Americans who have empathy for 

these victims. You bet. However, will it be an effective tool 

against the exploration and use of drugs? I believe not. 

Additionally, if financial resources are going to be allocated to the 

development of a drug demand campaign, I don't think you get 

the most value and bang for the buck pursuing a "kind neighbor" 

narrative in a society where everything is always "about me". 

### 
159 

Post-Hearing Questions for the Record 

Submitted to Mr. Robert Budsock 

From Senator Ron Johnson 

"America's Insatiable Demand for Drugs" 

April 13, 2016 

I. What is the cost and success rate of treatment for drug addiction? Is it a cost effective 

solution? 

The cost of addiction treatment varies based on the severity of an individual's substance use 

disorder and corollary issues that must be addressed during treatment. These corollary issues 

include physical health, mental health, housing, employment and environmental supports. 

Treatment for an individual is based on a client centered treatment plan that is established at 

admission. At Integrity House the average length of stay for residential treatment is 

approximately three months. This initial intensive treatment regimen is then followed by three to 

six months of outpatient treatment. The cost for three months of residential treatment is 

approximately $9,000. The cost for three months of outpatient treatment is approximately 

$3,600. 

I have attached several documents to illustrate components of success: 

1) The NIDA principles of addiction treatment (attached). On page 12 of the attached PDF 

Q: How long does drug addiction treatment usually last? 

A: Individuals progress through drug addiction treatment at various rates, so there is no 

predetermined length of treatment. However, research has shown unequivocally that good 

outcomes are contingent on adequate treatment length. Generally, for residential or 

outpatient treatment, participation for less than 90 days is of limited effectiveness, 

maintaining positive outcomes. For methadone maintenance, 12 months is considered the 

minimum, and some opioid-maintenance for many years. 

2) The National Center on Addiction and Substance Abuse at Columbia University- report 

from 2012 "Addiction Medicine: Closing the Gap between Science and 

Practice"(attached) Page 125 speaks to the effectiveness ofresidential therapeutic 

community treatment: 

This large, national study found that patients enrolled for at least 90 days in a TCt were 

significantly less likely to have used cocaine (28percent vs. 55 percent), tested positive 

for drug use (19 percent vs. 53 percent), reported daily alcohol use (9 percent vs. 15 

percent) or have spent time in jail (24 percent vs. 54 percent) a year after program 

participation than those who spent fewer than 90 days in the program. The year following 

successful TC completion showed lasting effects along several indicators compared to the 

year prior to TC entry: the rate of weekly cocaine use fell from 66.4 percent to 22.1 

percent; weekly heroin use, from 17.2 percent to 5.8 percent; heavy alcohol usc, from 

40.2 percent to 18.8 percent; illegal activity, from 40.5 percent to 15.9 percent; less than 
160 

full- time employment, from 87.6 percent to 77.0perccnt; and reported suicidal thoughts, 

from 23.6 percent to 13.2 percent. 

3) A CSA T study which highlights the correlation between length of stay and the 

effectiveness of treatment Effectiveness oflong-term residential substance abuse 

treatment for women: findings from three national studies (attached). The effectiveness of 

residential substance abuse treatment for women was examined using data from the 

Center for Substance Abuse Treatment's Residential Women and Children/Pregnant and 

Postpartum Women (R WC/PPW) Cross-Site Study and two other recent national studies. 

Treatment success was defined as posttreatment abstinence from further drug or alcohol 

use, measured through in-person follow-up interviews conducted 6-12 months after each 

client's discharge. Despite differences in treatment programs, client profiles, follow-up 

intervals, data collection methods, and other factors, all three studies found high 

treatment success rates--ranging narrowly from 68% to 71% abstinent--among women 

who spent six months or more in treatment. Success rates were lower, and between-study 

differences were larger, for clients with shorter stays in treatment. Controlling for salient 

client and treatment project characteristics, strong associations between length of stay in 

treatment and posttreatment abstinence rate were found in all three studies, suggesting 

that women's length of stay in residential treatment is a major deterrninant of treatment 

effectiveness. In further analysis ofRWC/PPW data, treatment completion was also 

found to be an important outcome factor. Among clients who remained in treatment for at 

least three months, those who achieved their treatment goals in three to five months 

abstinence outcomes were as good as those for clients who took more than six months to 

complete their treatment (76%-78% abstinent) and substantially better than those for 

clients who did not complete treatment (51 %-52% abstinent). Notably, however, most of 

the RWC/PPW clients who successfully completed treatment (71 %) required six months 

or more to do so. 

I have also included a link on the cost of incarceration from The Vera Institute of Justice which I 

did not have available during the hearing. 

http://www.vera.org/sites/default/files/resources/downloads/price-of-prisons-updated-version021914.pdf 
161 

Post-Hearing Questions for the Record 

Submitted to Robert Budsock 

From Senator Rob Portman 

"America's Insatiable Demand for Drugs" 

April 13, 2016 

1. The Comprehensive Addiction and Recovery Act (CARA) would provide Medication 

Assisted Treatment (MAT). What are the benefits of using MAT as part of treatment? 

Integrity House and members of Treatment Communities of America (TCA) are in full support 

of expanding MAT, but we must adjust our expectations and not expect MAT to be the quick fix, 

or ''silver bullet" to end addiction. First, it is important to note that MAT is clinically indicated to 

include therapy and psychosocial supports as part of a comprehensive treatment regimen; 

medication alone is not treatment. For many people struggling to overcome addiction to opioids, 

intensive and extended therapy is a key part of recovery. Patients need the psychosocial supports 

and other therapeutic approaches to sustain recovery as pmi of the treatment process, and 

medication is only a part of the overall means of treating patients for addiction. Prescribing 

medications such as buprenorphine in the early stages oftreatment are effective in reducing the 

intense cravings that patients experience when they first stop using opiates. The medication 

attaches to the opioid receptors in the brain and suppresses insatiable urges opiates during the 

early stages of recovery. Methadone and buprenorphine have been tested in scores of' clinical 

trials. Researchers have found that when combined with counseling. they significantly reduce 

opioid use and patients are retained in treatment longer. 

2. CARA focuses on the need for recovery and for support services for people who are 

struggling to overcome addiction. When someone leaves your treatment facility, what are 

the kinds of community support that are available? What are the most important things to 

help someone sustain recovery? 

The Integrity House approach recognizes for pillars to recovery. The first is ensuring that an 

individual receives evidence based addiction treatment from licensed professionals. The second 

and third pillars are ensuring that the individual rejoins the workforce, and that they obtain safe, 

affordable and supportive housing. The fourth pillar of recovery is ensuring that individuals have 

established a social, emotional and spiritual support system. Addiction is a chronic disorder and 

we must provide care for our patients in the same way that we would work with a diabetes 

patient who needs to continue taking their medication, regularly visiting their physician, and 

avoiding self-destructive behaviors such as eating high glycemic foods. 

At Integrity House, continuing care planning starts at admission and we ensure that each patient 

bas a detailed plan to connect with community resources when they leave of facility. Each 
162 

patient has a self-management plan upon discharge and they are encouraged to come back to our 

facility to visit. 

3. Drug courts have decreased the number of non-violent offenders going to prison on drug 

charges. Are these programs effective? 

a. Are there any changes structural changes that make some drug courts better than 

others? 

b. Are there any alternatives that are either underutilized or not utilized? 

Drug Courts have proven to be highly effective at lowering recidivism rates and for providing 

access to necessary treatment. Suggestions to improve these programs include: lower offender to 

probation officer ratios (50:1 is optimal); mandatory monthly face-to-face visits with the judge: 

the tracking and usc of metrics to ensure continuous quality improvement; and, increased use of 

incentives to recognize the progress of participants. Many Dmg Courts have been resistant to the 

use of Medication Assisted Treatment. New Jersey now has legislation that ensures the option of 

MAT for Drug Court participants. There still is a lingering bias against the usc of MAT in the 

criminal justice system, but we are seeing a gradual change in New Jersey. 
163 

Post-Hearing Questions for the Record 

Submitted to Mr. Robert Budsock 

From Senator Kelly Ayotte 

"America's Insatiable Demand for Drugs" 

Aprill3, 2016 

(1) Is it possible to adequately address the complex issue of opioid abuse through one 

approach-whether that be prevention, interdiction, law enforcement, treatment, 

recovery? Or do you believe that all these different factors play an integral role in 

ensuring that we are able to stem the nation's rising tide of substance abuse? 

Prevention, interdiction, law enforcement, treatment and recovery support are all important 

factors in stemming the tide of substance abuse in the United States. From a treatment 

provider's perspective, there is a clear intersection between prevention, treatment and law 

enforcement. At Integrity House, almost 85% of the individuals admitted to our programs for 

opiate use disorders have prior or current involvement with the criminal justice system. In 

many cases, addiction to opiates results in the possession of an illegal substance and a 

breakdown in societal norms to sustain the use of this highly addictive substance. Law 

enforcement alone won't curb our nation's insatiable demand for drugs. The coordination of 

law enforcement efforts and treatment programs, such as the local efforts in Gloucester, 

Massachusetts 1 and the soon to be launched program in West Orange, New Jersey 2 provide 

hope for many communities and individuals who are caught in the scourge of drug addiction. 

(2) Prevention is a key component in addressing the demand side of this crisis and can 

make a difference in combatting substance abuse. What do we need to do to address 

a different kind of demand-the demand for treatment? 

(3) Individuals are struggling and many in my home state of New Hampshire, as well as 

across the country, who want help are unable to receive it. Prevention-as important 

as it is-won't help those who are already grappling with a substance use disorder. 

When it comes to treatment for substance use disorders, a huge gap exists for individuals 

who don't have the resources for medical insurance. These individuals rely on treatment 

programs that are publically funded through the Substance Abuse and Mental Health 

Services Administration (SAMHSA) Block Grant and Medicaid. While there should be an 

increase in the funding for treatment to battle the opiate epidemic through the SAMHSA 

Block Grant, the Medicaid Institutions Mental Diseases (IMD) exclusion, prevents 

individuals with Medicaid coverage from accessing residential addiction treatment. Most 

individuals who are in the grips of addiction need to be immersed into residential treatment 

as the first phase of treatment while they are experiencing intense cravings for opiates. 

Repeal of the IMD exclusion would expand the resources available to individuals who are in 

the grips of addiction.J 
164 

(4) Can you expand on the demand for treatment as well as some ways that the federal, 

state, and local levels can work together to help better meet this demand? 

At Integrity House we find the demand for addiction treatment continues to exceed the available 

resources. At local levels, partnerships between law enforcement and treatment programs such as 

those in Gloucester, Massachusetts and West Orange, New Jersey are promising. In many cases, 

a brush with the law is the first opportunity for an individual struggling with addiction to connect 

with treatment resources. As opposed to arresting and releasing an individual, a referral to an 

addiction treatment program as a condition of release would introduce treatment as a way out of 

a life of addiction. At the state and federal level, we must ensure that resources are available for 

these individuals. This requires full utilization of existing resources, increase allocation for 

treatment resources in the SAMHSA Block Grant, and repeal of the IMD exclusion. 

(5) In your testimony, you allude to the promise that the parity law is supposed to hold 

for individuals with insurance who are seeking treatment for a substance use 

disorder. Can you expand on what you are seeing at Integrity House related to the 

parity law? 

(6) Are there circumstances where individuals seeking treatment are being denied by 

their insurer when you believe they should be approved for substance use disorder 

treatment coverage? 

(7) What are some common insurance-related obstacles that may be preventing some of 

the individuals seeking treatment at Integrity House from receiving it? 

At Integrity House, we see the full implementation of parity for those who qualify for funding 

through the SAMHSA Block grant. We don't see parity for individuals who have Medicaid 

coverage because of the IMD exclusion which denies reimbursement for residential addiction 

treatment. A small percentage of individuals who we see at Integrity House have commercial 

insurance coverage. While we don't see violations of the parity law, we do see insurance 

companies refusing to approve services that are deemed appropriate by our medical personnel. 

Most insurance companies will only approve services based on their preset criteria and 

frequently rule against the recommendations of medical personnel who are working closely with 

the patient. In some cases insurance companies will establish an arbitrary limit on length of 

treatment, such as 28 days, rather than utilizing a clinical diagnosis to determine length of stay. 

Insurance companies are also deferring to a "fail first" approach which is very dangerous 

considering the deadly nature of opiate addiction. 

(8) In your testimony, you explicitly mention the Institutions of Mental Disease, or IMD, 

exclusion as a barrier to treatment. Could you describe in more detail how the IMD 

exclusion impacts Integrity House? 
165 

At Integrity House, we serve Medicaid eligible clients who can't receive residential treatment 

due to the Medicaid !MD. Medicaid will cover outpatient treatment. but not residential. We have 

a subset of patients who need the more intensive level of treatment for a longer duration and 

when they can't get it leads to fewer clients with positive outcomes. 

Integrity House is a member of Treatment Communities of America (TCA), which continues to 

advocate for the repeal of the !MD exclusion. Below is a detailed explanation of the !MD 

exclusion and the consequences to individuals who need a full continuum of care which in many 

cases includes residential treatment. 

Medicaid funds are not available to certain alcohol and drug addiction community-based 

residential treatment facilities for services provided to individuals between the ages of 22 and 64 

for facilities of 17 beds or more. Specifically, Title XIX of the Social Security Act restricts 

Medicaid reimbursements to Institutions for Mental Diseases (!MD) [42USC 1396d]. 

Residential treatment facilities are unintentionally impacted by the 1965 !MD Exclusion because 

substance abuse treatment services are not distinguished from mental health services in statute or 

regulation. The Centers for Medicaid and Medicare Services (CMS) has linked substance abuse 

with mental health, categorizing addictive disorders as mental disorders under the International 

Classification of Diseases, 9th Edition (ICD-9). CMS also interprets "institution" within the !MD 

statute to include community-based substance abuse non-hospital residential treatment facilities. 

This rule originated in 1965 during the move to de-institutionalize mental health patients. 

Instead, it encourages resources to be directed instead towards community-based treatments. 

Residential treatment facilities are located mostly in the neighborhoods and communities in 

which their clients live and work. TCA does not believe the Congressional intent was to 

adversely impact the treatment of those with drug and alcohol addictions, yet the !MD Exclusion 

jeopardizes these essential services.3 

(9) Do you have an estimate as to how many people who wanted help you had to tum 

away from treatment because of this outdated policy? 

Integrity House has 420 licensed residential addiction treatment beds. As of May 20, 2016 we 

have a waiting list of ISO individuals who are in need residential addiction treatment. The 

average wait time to get into residential treatment is 8-12 weeks. 

I. http://gloucesterpd.com/addicts/ 

2. Operation Hope West Orange Police Department( attached) 

3. http://www.treatmentcommunitiesofamerica.org/index.php?option=com content&vie 

w=article&id=11&1temid=22 
166 

7:46-1 

7:46-2 

7:46-3 

7:46 

WEST ORANGE POLICE DEPARTMENT 

WRITTEN DIRECTIVE SYSTEM 7:46 

Operation Hope (Heroin - Opiate Prevention Effort) 

Effective Date: Supersedes: 

PURPOSE 

The purpose of this directive is to codify this agency's policy and procedures 

concerning Operation Hope (the Heroin- Opiate Prevention Effort). 

POLICY 

It is the policy of this agency to the West Orange Police Department's Operation 

HOPE shall seek to reduce the impact of heroin and opiate abuse on our 

community while encouraging those who suffer from addiction to seek help and 

experience recovery. We will treat those suffering from addiction with 

compassion, care and concern- while fairly enforcing the law. 

All agency supervisors are responsible for ensuring this policy is followed. 

GENERAL 

It is the philosophy of the West Orange Police Department that: 

We will support a three-prong approach to combatting illegal drugs -

Enforcement, Education, and Treatment. 

We will recognize that addiction is a disease which can benefit from medical 

intervention and treatment. 

Officers responding to any call for service or performing any police action will be 

cognizant for the potential that the involved parties may be suffering from heroin 

and/or opiate addiction. 

Officers interacting with persons suffering from addiction will be professional, 

compassionate and understanding at all times. Often times, people suffering from 

addiction ask for help only as a "last resort" and may be considering self-harm or 

suicide. Your interaction with them can help make a difference. 

• In all instances, officers will continue to take enforcement action within their 

discretion and normal scope of duties to address criminal activity. At the same 

time, officers will recognize the fact that such criminal activity may result from a 

medical condition (addiction). 

In addition to any police action taken in such circumstances involving known or 

suspected heroin - opiate addiction (i.e. citizen contacts, warnings, summons, 

arrest etc.), the officer will provide the involved parties an Operation HOPE flyer 

advising them of the program and related services. 

OPERATION HOPE 3122116 Page 1 of 5 
167 

7:46-4 

The department will make use of its social media presence (i.e. Facebook, 

Twitter etc.) to market Operation HOPE using the same messages 

communicated in the flyer. 

GENERAL PROCEDURES 

It shall be the policy of the West Orange Police Department that: 

Any person who enters the police station and requests help with their addiction to 

heroin or opiates will immediately be screened for potential participation in 

Operation HOPE. 

If the initial contact is made on the street, officers will use the discretion that is 

exercised on a daily basis. This program specifically and exclusively applies to 

persons who present for help at the police station. 

All department personnel having contact with anyone entering the West Orange 

Police Department and requesting help with their addiction will be professional, 

compassionate and understanding at all times. 

If such a person who has requested help with their addiction is in possession of 

drugs or drug paraphernalia (needles, etc.), they will not be criminally charged. 

The materials will be collected and secured as per evidence procedures for later 

destruction. 

• There shall be no questioning of the person requesting help in an attempt to 

collect drug intelligence, determine the origins of any drugs relinquished by the 

person, or any other effort which may undermine the intended purpose of this 

program which is primarily to encourage persons to seek police assistance in 

getting help for their addiction without fear of arrest or police action. 

The officer or other agency personnel having initial contact with the program 

participant will immediately notify the desk supervisor that a potential Operation 

HOPE participant is requesting help with their addiction. 

NOTE: The Operation HOPE "Angel Kit", containing program guidance and supporting 

materials, will be stored in in the Victim/Witness Room with extra copies located in 

Central Communications. 

7:46-5 

7:46 

Specific Program Implementation 

The patrol supervisor, dispatcher and/or assigned officer will take the following 

steps: 

Upon entering the West Orange Police Department, an officer will be assigned to 

monitor any person requesting assistance under Operation HOPE until such time 

Operation HOPE intake is initiated. 

The participant will be treated with respect, care and compassion and reassured that 

assistance will be provided. 

The program participant may stay in the front lobby until the assigned officer arrives. 

They will be kept under visual observation to ensure they are not ill or in distress. 

OPERATION HOPE 3/22/16 Page 2 of 5 
168 

7:46 

If at any time the participant is noted to be in medical distress, appears to be physically 

ill or requests medical assistance, EMS personnel will be assigned to respond as in any 

medical emergency. 

Participation in Operation HOPE is voluntary. If a potential program participant 

subsequently elects not to request assistance or continue with program screening, they 

will be allowed to depart and no force will be used to detain them or prevent them from 

doing so. 

Central Communications will generate a CAD entry under the Operation HOPE call type, 

an officer will be assigned to the call and an incident number generated. 

NOTE: The shift supervisor may exercise discretion in which officer is assigned to the 

call based upon call volume, conflicting calls-for-service, and other factors. 

Upon arrival of the assigned officer, the officer will ascertain and verify if the program 

participant possesses any contraband they wish to relinquish or possesses any weapons 

(i.e. prudent officer safety measures). As part of the Program Participation Agreement, 

the participant signs and agrees to allow the law enforcement officer to perform a safety 

frisk for weapons, contrabands, needles or paraphernalia. The intent of the frisk is 

provide a safe environment for the officer, angel and participant as welL 

The officer will bring the program participant to the interview room. 

The officer will assure the participant that it is our goal to assist them in partaking in the 

treatment options and the program hosted by The Integrity House. The participant will 

be treated with respect, care, and compassion. 

The assigned officer will ensure that West Orange Police Department Operation HOPE 

Program Participant Agreement and West Orange Police Department Operation HOPE 

Intake Form are completed. 

The assigned officer will take steps to positively identify the program participant through 

a photo driver's license, photo identification card, or other means. 

Upon completion of the Operation HOPE Intake Form and Program Participant 

Agreement: 

-<The assigned officer will again inquire if the program participant has any drugs 

and/or drug paraphernalia to relinquish. If so: 

The items will be inventoried. The receiving officer will enter a brief 

description of the items in the QED Property Tabs. The property should 

be classified as "Found Property" for evidence intake and destruction 

purposes. 

The items will be packaged in an appropriate manner (to include the use 

of "sharps containers" if appropriate) and marked with the Incident case 

number, officer name, date, time and item description only. There is no 

need to mention the participant's name on the evidence. 

The items will be placed in a storage locker in the Booking Room for later 

retrieval by Central Record Bureau personneL 

OPERATION HOPE 3122116 Page 3 of 5 
169 

If at any point a subject who has relinquished drugs and/or drug 

equipment under Operation HOPE subsequently withdraws their request 

for assistance or elects to discontinue program screening, they will not be 

charged with possessing the items they have already relinquished. 

The assigned officer will ensure that Central Communications conducts 

an NCIC/SCIC and any other applicable checks on the participant. 

The officer processing the Operation HOPE intake will review the 

NCIC/SCIC results to determine if any of the following Operation HOPE 

disqualifying factors exist. 

Persons in the following categories ARE NOT ELIGIBLE TO PARTICIPATE IN 

OPERATION HOPE-

'-'The subject has an outstanding arrest warrant. 

NOTE: Should the subject have an actionable New Jersey or other jurisdiction 

arrest warrant, he/she will be deemed ineligible to participate in the program, will 

be taken into custody as routinely done. They should be informed that upon 

completion of their legal obligations associated with the warrant, they may again 

seek help under Operation HOPE. 

'-'The subject is a registered sex offender and/or has previously been convicted of 

a felony sex offense. 

NOTE: Should the subject be a registered sex offender and/or has previously 

been convicted of a felony sex offense, he/she will be deemed ineligible to 

participate in the program and there is no referral information we can provide. 

'-'The officer or patrol supervisor expresses the reasonable belief that the ANGEL 

volunteer or others could be seriously harmed by the subject. 

«The subject is under age 18 and does not have parent or guardian consent 

«:If at any time the participant is noted to be in medical distress or appears to be 

physically ill or requests medical assistance, EMS personnel will be assigned to 

respond as in any medical emergency. 

NOTE: Should EMS personnel deem it medically necessary, the program 

participant may be transported to a medical facility. In such an instance, the 

responding Operation HOPE Angel(s) will be informed of the participant's status 

and location. 

FOLLOWING INITIAL SCREENING AND CONFIRMATION THAT THE SUBJECT IS 

ELIGIBLE TO PARTICIPATE IN OPERATION HOPE: 

7:46 

Dispatch will contact an Operation HOPE "Angel" from the Angel call-out list. The Angel 

will be informed that an Operation HOPE intake is occurring and be requested to 

respond to the West Orange Police Department. Dispatch will ascertain an approximate 

estimated time of arrival of the Angel and inform the officer. 

OPERATION HOPE 3122116 Page 4 of 5 
170 

Upon arrival of the Angel, the officer will brief the Angel on the situation. The officer will 

provide the Angel a copy of the participant's completed Operation HOPE Program 

Participant Agreement and West Orange Police Department Operation HOPE Intake 

Form. The officer will also provide the Angel with the "Angel Kit", stored in the 

Victim/Witness Room. 

• The officer will introduce the Angel (by first name only) and transition the program 

participant to the care of the AngeL The officer shall remain in close proximity to the 

Victim/Witness Room at all times. The safety of the volunteer Angel and the well-being 

of the participant is an integral part of the officer's responsibility. 

The officer will accomplish a brief Incident Report. An Operation HOPE (Non-Criminal 

report) category has been created in QED. Original copies of the participant's 

Operation HOPE Program Participant Agreement and West Orange Police Department 

Operation HOPE Intake Form will be forwarded up the chain of command and then 

forwarded to Records as per usual record keeping protocoL 

If the Angel subsequently advises that the participant is unable to be placed after 

exhausting all possible methods, the participant is not to leave without being given a 

plan to continue with help. The participant shall be afforded every courtesy to find them a 

safe place upon departure. 

For Additional Assistance 

In the event the Angel(s) have questions or require additional assistance, please contact 

one of the following: 

Angel Coordinator: Patricia Duffy 973-325-4105 

Placement Coordinator: Mark Ackerman 973-558-2648 

Law Enforcement Liaison: Captain Thomas Montes ion 973-325-417 4 

Lieutenant Richard McDonald 973-325-4036 

NOTE: DO NOT RELEASE THE ABOVE CONTACT INFORMATION TO ANGELS, 

PROGRAM PARTICIPANTS, OR NON-LAW ENFORCEMENT PERSONNEL. IF 

REQUIRED, DISPATCH SHOULD CONTACT THE ABOVE PERSONNEL. 

7:46 OPERATION HOPE 3122116 Page 5 of 5 
171 
172 

1-

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0 z 2 

1-

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a:: ll 0 1-

tJ 

z 

ll t:J <( 

:J 

0 
ACKNOWLEDGMENTS 

nw :'\dUOll<ll i)J; 

indi\iduals f{Jr 

to thank dw 

CONTENTS 

ii 

,\Ln!!Il \Y. :\dkt. J'h.D 

J(·mpk 

K .\fdh Ph.D v Pn.•face 

Lu!JJ,., n BJ;>!h, Ph.n 

:'lkd!(ill uf":><nvh(:,ooiin,J 

flri'-(h,m1, Ph.J), 

!m 

K,nlikn1 :vi. CarrolL l'h D 

Y,!lc CniH·r,HySdJoo](,! 

!l.lr>.aJJ '>clJIJf!l 

}{_ .\1il1CL Pb.ll Principles of Effective Treatment 

.Frequently Asked Questions 

\Yh\ do dllil';-,tddil ted k1·cp dlln.\Vhat tlt'<L1lil('fllf 

finw dk1 ti\e dtuc; addiction tn:<tlnWll\.) 

b drug ,tddil trca!!ncnl WOI th ih 

H: 

\\Jkc CniwFil\ (;<'Ide!<> Wood1, .\L!J. l l \\'iut pc(Jple iu tn:atnwne 

BPI,Ill<ll\ S1 !Jool ,! 

.-\ll ma!('fiah 1oi•mK ,m· l11 dw pnbiJ< dom,1in and m,t) bl" U'<'d 

"'\llll'ub!icAiun:\<,, 12 -t!:l!J 

l'lwr,·d 

lfi 

H1 

bmih anrl a dill(wncr 

Jlw Jilt; uf '>O!llCO!l/' lltTding lri"<I(Inl'!lJ! 

iul!Jrrn:ltion on 

lfJ llm\ dw \1orkp!ac1· play d tolo: 

jl) 

in 

\\"h,lt ,m· rhc nt!i(jllJ' needs <JI. wottwn \\ill\ \\ lt«t \\hat 

1\ith 

tllnqw: 

diqlnkr\.' 
:u 

C:au ,t ll\T'i(>tl !wcmrw addincd tu mnlicHi<Jil~ b t!wn· ,1 di!kreuce hct\W'\'11 phy:-.ic:<d 

depoJdt:nrt' and <Hidi!"\i{>fl.} 

:!.) Hov> do other tntnt<~l di~nrder~ c·ucxi·ain,t; with 

r!rug addiction afkc1 drut; :uk!i, tio11 trealmt·nt? 

h th<: lb(' of medication.~ llkt· IHrthadone 

aJtrllmnrerHJrDhirH' 

'27 

2X C,m t:xcni~r- play a rnk in thr~ treamwnr procc:-.s:' 

2H l-hM d(J!'~ drug- a(!dic!i(m tn·auncJlt 

reduce the spre.td l)f Hl\'/,\IDS. h 

C H(:\';, and otlwr inftniou~ di.~casc,:' 31 Drug Addiction Treatment in the United States 

3:! '[\pr:' of Tr('atlllcnl Proe;ram:-. 

'l're,ttill(\ Crimiual,}11qirc-Imnl\<~d l)!'Uj4 .\l>u~er~ und Addirted Individuals 

39 Evidence~Based Approaches to 

Drug Addiction Treatment 

:;9 I>Jwrmacnclwr<lpit·.~ -IH fkhad1mot! Therapies 

ljf) Bc!la\·irnaJ 'l'Jwrapk~ Primarily tl)r .\(lobrenl>. 

69 Resources 

PREFACE 

D RUG ADDICTION IS A COMPLEX ILLNESS. It is ~.·haractcrizn! by itHCJbr· ,md, at timl\~, unu;ntrntlabh· drnl\" na\int;, alrm>; <lith ~.umpubiu; dna; 

\('\'kinu; :md u~e tl~ill pcr~i~t iu tlw !itl'c ol de\ ,bttHin

cOlbt~(HteHu~s. Thi'i updah~ uf thl' :\;uion,lllmtittllt' on 

[Jruy. Addirtwn hwtmtn! 

tn ..1 \\'ide Yaricty of drug.~, and illicit 

Addktinn affi!cls mullipk brain cin·uit<>, includill.l!; 

rho:>r- im·ohr:d in tt'\Y,trd and moti\'<t\inn, karnine. aud 

1:. a brain dic-ed"('. -"omc indi\-iduab aH· 

mor.-. \'ulnenthle rhau otht·r~ \0 beo.:oming ,Hldictl'd. 

compromise thi.H ability to ch!J1N\ and ~c\·king and um~uming the drug bcumw mmpnhi\e, ofti'H duding-

<l pehon':> .~d!~ron\1'01 or willpmHT. 

or the 

the 

inH·r!(T(' witb a perstm'>- normal fuHcti(lniw.; in tlw Lm1jly

the \HJrkplan-, and th(' bmadl'r corurnnnity. 

Be{',l\IK drug abuse and addiction haY(' so 

dimnJ-;ions and 
175 

" % 

~ 

" u~n ..., 

~ ~ 

§ ~ 

~ :§ -" ] ~ 

~~~ 
1. 

2. 

PRINCIPLES 

o·F' .. EFFECTIVE 

TREATMENT 

3. TREATMENT NEEDS TO BE READILY AVAILABLE. 

4. 

not 

posilin:tmlcrJmes. 

EFFECTIVE TREATMENT ATTENDS TO MULTIPLE 

NEEDS OF THE INDIVIDUAL, NOT .JUST HIS 

DR HER DRUG ABUSE. To be effective, treatment 

must addrc"s the indi....-idua\'s drug ahuse and any 

5. REMAINING IN TREATMENT FOR AN ADEQUATE 

PERIOD OF TIME 15 CRITICAL, The appropriate 

tlurHtion fOr an indi....-idual (kpend5 on the type and degree 

of the patiC"u(s pruhlem" and needs. Research indicates 

that mo.~t addictrd indi\'idua.ls need at least 3 months in 

t('rm process and 

treatment. As with other chrunic illnes,~es, rdap~es lo dru

abus<c can occur aud ,;houkl si~nal a need for treatment w 

be n:in::.tated or acljusted. Because incli-vidual" oflen Ieaw~ m:atment pr~malurely, to engage and k('-<'P ~tran·gw

6. BEHAVIORAL THERAPIES-INCLUDING 

INDIVIDUAL, FAMILY, OR GROUP COUNSELING

ARE THE MOST COMMONLY USED FORMS OF 

DRUG A8USE TREATMENT. flehaviorailfwrapics 

7. 

their focus and 

MEDICATIONS ARE AN IMPORTANT ELEMENT O

TREATMENT FOR MANY PATIENTS, ESPECIALLY 

WHEN COMBINED WITH COUNSELING AND 

thr:ir lives. and reduce their illicit drug usi~. Acantpro,.,ate, 

disulli.ram, and naltrexone are m(:dications a 

fi:1r treating alcohol dependence. For persom 

to nicotine, a nicotine n·placemt"nt nroduct (available 

can lw 

part ufa 

cmnpreht'n"i....-e b(·havioral treatment pro!.{rarn. 
B. AN INDIVIDUAL'S TREATMENT AND SERVICES 

PLAN MUST BE ASSESSED CONTINUALLY AND 

MODIFIED AS NECESSARY TO ENSURE THAT 

IT MEETS HIS OR HER CHANGING NEEDS. ,\ 

the treatment intensit; \'4!) in;.; acnllding u, p1·r;,on \; 

( h<mging needs. 

9. MANY DRUG·ADDICTED INDIVIDUALS ALSO 

HAVE OTHER MENTAL DISORDERS. l_kc,Ht'W 

drug all( I addiction both ()f \\ bich ;n(' mona! 

often U>-occur \dth othn nwm.J! illrw,;.s!'S, 

ill\\' condition lw 

tlw\<' Jlrobktn< nt-on·ttr, 

tn'dtmrnt both ,ur alL iw htding tlw 

nwdicatious a;.; appwpri<tk. 

10. MEDICALLY ASSISTED DETOXIFICATION 

IS ONLY THE FIRST STAGE OF ADDICTION 

TREATMENT AND BY ITSELF DOES LITTLE TO 

CHANGE LONG-TERM DRUG ABUSE. 

medically detoxification cAn sakly 1 

an1tr ofwit!Jdr;mal alld (;\!1, 

.-ome, pm:e the for dkt·tiw addidiou 

<kloxHwatwo;t!mw to !wlp 

addicted individudh achieve 

be 

inn·ntin· ,..trat('f.,rit's, lwgun at inilial patient imak(·, C<ttl 

treatmt'nt eiJgagerrwm. 

1 l. TREATMENT DOES NOT NEED TO BE 

VOLUNTARY TO SE EFFECTIVE. Sanctinn..;; Of 

bmih. and/or tl

niminal ju>;\!('e (.an <Hill) incrnrst• treatnw

rctent:on ratn, and the ultinMtt of drug 

ltTatJll<'nt ilttcrvcntiOJh. 

12, DRUG USE DURING TREATMENT MUST BE 

MONITORED CONTINUOUSLY. AS LAPSES 

DURING TREATMENT DO OCCUR. Kuowing tJKir 

drug U:•e j,., lwinQ; mouitmed can lw a powediJl incentiYc 

!ilr patienb <Illd r,Hl hdp them 

drugs. 

13. TREATMENT PROGRAMS SHOULD TEST 

PATIENTS FOR THE PRESENCE OF H!V/AJOS, 

HEPATITIS BAND C, TUBERCULOSIS, AND 

OTHER tNVECT!OUS DISEASES, AS WELL 

AS PROVIDE TARGETED RISK-REDUCTION 

COUNSELING, LINKING PATIENTS TO 

rREATMENT tF NECES!3ARY. Typically, 

ran h1cilitate to otlwr nwdint! 

onsit

le::.t po>iti\e. 
FREQUENTLY ASKED 

UESTIDNS 

1. WHY DO PERSONS KEE

USING DRUGS? 

_\;(·at !y all ,tddit ted indi\·iduab ,u th\' oUb<'l th<.tt 

can stop nsing on tlwir n\\!L ;nHl rno,t tr) 

lo qup without tn·atnH'tlt. .\lthc 

ilW·mpls IT;,ult 

term ,tll:>l lnetK('. 

LONG-TERM DRUG USE RES.ULTS IN SIGNtFII::ANT 

CHANGES IN BRAIN FUNCTION THAT CAN 

PERSIST LONG AFTER THE INDIVIDUAL STOPS 

USING DRUGS. 

l'nder,ta.ndinq tlMl addictiiJn '\l( h a !i..uJd<tJucnta! 

can triggl'r in ten:-<' 

the dilliculty 

without 
Com{JOIICJ/h of Comprehmsive Drug Abuse 11wlfment 

2, WHAT IS DRUG ADDICTION TREATMENT? 

tr\0\11\Ufi\lg, 

of .1pp11Mrhr:> 

Dru!j lrealntt'llt can indudc 

web t 

m;uta!.\l:nwnt.·. m· 

spccifii type of trc,ttnwnt or 

( muLrin;ttiuu uf h"iH \ary dqwnding UH th(· 

indi\·idtuJ lWCCb aud, off en, OH tJw types of chu

DRUG ADDICTION TREATMENT CAN INCLUDE 

MEDICATIONS, BEHAVIORAL THERAPIES, DR 

THEIR COMBINATION. Tieatlrh'lll 'iUC!J mcthadi>I1(\ 

lik

nwain(', ran treated with lwhavi(Jlal tlwrapies, tlwn

<In' nul \"l'l rnrdiratiorb li;r addinion lO 

drugs. 

ll'<.tch wa;.s to a\·oid and pn'n·n

r("l<:ljN:, and hdp indi\·idwJ-.; deal \\ ith rdapv: if it 

!)tTUl"S. lkha\·itw,d 

nJmtllunicatiun, n 

;ts tunily 
lkc<nN· 1-'.0rk \!H dilkH·nt nf addiuirm, I'<JmlJmatiwn uf a! <md 

\\hen a\\tibbk· \!,{'Jln"l!y d)!pc.n \O lw mme than 

cHhn app1nadt used ,J!unc. 

drug:-; and 1 ,·quiJ v 

TREATMENT FOR DRUG ABUSE AND ADDICTION 

IS DELIVERED IN MANY D!FTERENT SETTINGS 

USING A VARIETY OF BEHAVIORAL AND 

PHARMACOLOGICAL APPROACHES. 

3. HOW EFFECTIVE JS DRUG ADDICTION 

TREATMENT? 

RELAPSE RATES FOR AODlCTlt::IN RESf::MBLE 

THOSE OF OTHER CHRONIC DISEASES SUCH 

AS DIABETES, HYPERTENSlDN, AND ASTHMA, 

Likf' ntlwr chwnil 

thdt h<11c h(Jth phy'>ioln-;;·it·,d lH'ha\iiJLtl 
COMPARISON OF RELAPSE RATES 

BETWEEN DRUG ADDICTION AND 

OTHER CHRONIC ILLNESSES 

uot 

<tddi>t:ontypically comimul n'<thlitllOJI Hl!Hllfwation to !]w t,1h'n 

lnr oflwr ciHoni( h!! (",\ample, \\h('ll d patin,r 

acti\\' tn·atnwnt f{Jr hyptTII'lhion ,1nd 

\u lw n·imt,ltcd uJ 

llci·dcd ·'-t'c 

b·,tltut('d .. , 

4. Is DRUG ADDICTION TREATMENT WORTH 

ITS COST? 

hil!ion 

WHY IS ADDICTION TREATMENT EVALUATED DIFFERE

80TH REQUIRE ONGOING CARE 

7 

6 

s 

0 4 

> > 3 

" w 2 

, 

w 

. 

l(vper/cusion 'fi"eatmcnl Add1Ciio11 Trmtm

••• 1 ••• 

IH:alth and b\ Lll- !lHJr(" 

tn·<ttnlnlt ibl'i[ TreamH-Ht i' ,d"' rmwh 

DRUG ADDlCTIDN TREATMENT REDUCES DRUG USE AND ITS ASSOCIATED HEALTH 

AND SOCIAL COSTS. 

:\ccordintj h• ,.,c'\Tr,d c>tinJatc<, n(·ry do!l,H 

imr,tcd iu addinino 

bet"\\C('l) S'l ,md m 
5. 

6. 

HOW LONG DOES DRUG ADDICTION 

TREATMENT USUALLY LAST? 

Jndi,·idu<ils through addictioutn·atmeut 

at \·ariou:; rates, is uo pri'(ktermined length of 

l!T<ltlllenl. However, research :.hOWll U\1('tjUi\'lKaJJy 

that good ollh'il!ltcs an· nmtingent Ull adequat\' treatment 

kngtl!. G(·rwrally, !Or rnidentia! 

and tr<'atuwnt lasting sigmficantly longer i:o for 

maint<tinine; positiw outcome". Fur methadone 

12 is consid(>rt'd the minimum, and :-.onw opioidaddict<:d indi\·id11als continw· ttl benefit from rnC'th-adone 

rnaintcnann· h>r HJ.<tny )Tan" 

GOOD OUTCOMES ARE CONTINGENT ON 

TREATMENT LENGTH. 

Treatment dropout is one of tlH· problems 

encouutcrl'd by lJ(·atment therd{)rt', motiYational 

will aho improve 

ouu:nrnes. By and 

ofkting cominuin.g care and 

succeed. but this \\ill ofTen require 

,md readily n·a(lmiuing pati1·1th 

of 

WHAT HELPS PEOPLE STAY IN TREATMENT? 

Becau:w .-;urn·,.,shtl outcomes ohcn depend on a person\ 

in !ITalin('nt hmg ('nough to reap its fttll bencftts, 

kn keeping people in treatnH:nt ar(' critiraL 

\\.hether a patient in trtannent rlepend'i on factors 

with both the indi-..-idu<tl 

7. 

!!·om the criminal child prott·ction 

:.(;n·icc:;, or \\"ithin .1 treat\Hi.:nl progr<-uH

"ucn·s'>hll can a positive, t 

\vitb Lhcir patinHs. The clinician 

cn-;un· that a treatment pl<m i.s cormeratin-h 

with the seeking nYatmcnt, that the is 

{()l!<J\\t'ti, and tl1al tn:atmtnt CXJH.:'CtatiiHb ,\re 

understood . .:'\lc·diral, 

:>hnuJd be 

WHETHER A PATIENT STAYS IN TREATMENT 

DEPENDS ON FACTORS ASSOCIATED WITH 

BOTH THE INDIViDUAL AND THE PROGRAM. 

lkcauc.c somf' problems (such a& serious or 

meHtal illne:.s m crin1inal involYemt·ntJ incrca.-.e the 

likdillood of patients dropping out of treatmenL 

may be required to r<:tain them. After .a 

etJtlrse t1f iiltCtlc.iw: treatrtJtnt) tlw pn)vida slHnt!d a t.ratt-;iti<lll to intensive continuing can: to ;;:uppon 

and monitor imli,·iduals in their ongoing rcto\n'): 

HOW DO WE GET MORE SUBSTANCEABUSING PEOPLE INTO TREATMENT? 

It has lwcn known J(rr many years that tlw '·tn'atmenl 

i:. ma;,si\(' that is, amoug: \V}HJ net;d tn::.mnrll

a substan<T tN' f("w it. In :20 l 1, :2l.G 

million aged 12 or older Yl{'t·ckd treatmt·Ht fiJI· an 

illicit drug or alcohol use problem, but only '23 million 

tn:;atment at a specialty substann· abuse !ih·ilit). 

indude increasing access to efkct1w treatmenc 

achicviug iusurauce parity (now iu it<; cadie;.;t phase or 

implt·mentation\, ITdudng o:ti,gma, and raising aw<tn'HCs.-; 
B. 

both and of 

t.he \"alue of tn:atnwut. To in 

ideotit)·inl.\. tre.Hment need in th(·ir patients ,md making 

rd'i:Trah. r\JDA is 

usc ;,crecning, brief intern;ntion, and rcf(Tral to 

tre.auneut ,:sHIRT) tools fOr use in primary care 

its initiatin·, SBIKl: v,hich e\-idence 

show,., to !w dkctiw against tobacco and alcohol 

treatment 

HOW CAN FAMILY AND FRIENDS MAKE A 

DIFFERENCE IN THE LIFE OF SOMEONE 

NEEDING TREATMENT? 

program can strrngthen and extend treatment lwndits. 

9. WHERE CAN FAMILY MEMBERS GO FOR 

INFORMATION ON TREATMENT OPTIONS? 

Tryin.e; to lucak appropriak treatment tOr a loved ow·, 

(•sp("'cial!y linding a program tailored to an individuars 

parlicular needs, can be a ditlicult Howevrr, there 

<1re some resourre5 to help with proce:>s. Fix 

.:-.;IDA's handbook Sel'king Dm!{ .Abuse 'l'reatmmt: Know 

What to Ash oHCrs ,f,._ruidanet' in finding the 

The Abmc and }..lc!ltal He<\!th 

Administration ,.SAMHS,\· maintaius a WdJ 

Jmdtrealnu'nl.<:mnhYJ.gm.t• that shows dtc location of 

residentiaL and tn:atmcll

!IJr throughou

country. illl(wmation j:-; also accessible by 

calling 

The !\ational Suicide Pre\'cution Lifdim· i l-H00-:273-

'JALK:: more than _ju5t suicide prcwmion it 

can also !Jdp \\'ith a ho!:\t of is:-,tH'S, iududing drug 

and alcohol abu:.,e, and r::an rom ten iudi\:iduals \\ ith a 

nearby prof(·ssionaL 

throughout the Loited States and may be t'specially 

helpful fix pat.ients with comorbid couditiOlb. 

The Americcm .-\cademy ul' Addiction Psychiatry and 

the American Child and Adolescent 

locator tools postr·d on 

ill rwojJJHj!, and ruu:ajJ.org, rt">pectin;ly. 

wcovery from addiction to 

The at 1_dm!{/1ee.org) is an 

l)rganizJtion that provide:, inl(nTnation and n·sourc<s 

on teen drug U5t' and aJdicLion f()r p.1rents, to hcJp 

and intervene in t!H·ir 
The ,\uwrirall So( it'!) of ,\ddictiun .\Icdiciw :pvmL 

a :-:.or;il'ty ol ai1w;d <ll incn·,bing 

io addi( tiu11 tn',l(rtWlll. Ttwir \\d) a 

diJTctiJr') of addiction IHtdil·irw 

:'\:11iomd Dru!S .\busv Tn,,J!rrwnt C!ini(";d 'fridl'-

2'\dwlllk _dmgabli,lf\f.!.'!!1',rtboul-nulo/oq!WIIJJilon! 

u'!n'<lN inlimnmion for 

dru>j ahll"\'. and tn'.llmcnt. 

The :\ational!n-.titnH· on and 

prm id(·:-, iokmn;ltion on 

,,lcoho!, alcohol use. trcatnu·m uf ,1kohnl-related 

pmblnm :nirwa.nih.gm.'/\eanh!nodti!reatmtll[·. 

10. HOW CAN THE WORKPLACE PLAY A ROLE 

IN SUBSTANCE ABUSE TREATMENT? 

Ernplli)\'\' .\'i:-i»l:tiKI' 

roumding and/()t 

d contiruwd but al1>o to 

'ikiHs, 

lik. l"riw: [!·.-riog EKilities, 

trained pn>,ound, and '\(Jrl.pbce monitor-: arc nt'!'dcd w 

irnpknl\'nl t) pc nf Ue<tlnwnt. 

1 1. WHAT ROLE CAN THE CRIMINAL .JUSTICE 

SYSTEM PLAY IN ADDRESSING DRUG 

ADDICTION? 

It e'>timatcd that about one-hail' nf Std!c and F('dn,t! 

or <tn' dddictnJ lo drup;:>, hut rdatiwl; 

n:u.:i\t' \r('atm<'Bl while irwancratcd. Initiating 

treitlmnll in and continuing it 

i» vital to buth iudn·idua! 

ITkibl' 

he;dtb 

.<>alhy: \'ariuus q11din hi\\(: that ('umbining 

and trcatnwnt f(;r ;,ddinnl 

tfw of both to druArd,-ttcd criminal bd,;,\-HJr and tl) drug_ ml' \\ hkh

iuturn, huf!,e sm·ing,., iu .• \ in Baltimore. J\Ltryland, i(n exctmpk, f{mml that opimdwhu nwthadorw treatment 

coun:.ding in pri!:on J.nd tht'n continued it 

aftn had hctft·r outcorrws )wlun·d me awl 

nimin.tl ai tidty than tho,.,e \\"fl\l nnly tTn'ivcd 

\\ hik in ur who only <;tart('d mcthadorw 

Uh:ltlUCtlt alter thdr 

INDIVIDUALS WHO ENTER TREATMENT 

UNDER LEGAL PRESSURE HAVE OUTCOMES 

AS FAVORABLE AS THOSE WHO ENTER 

TREATMENT VOI,.UNTAR!LY, 

rhc nl<\jollty of o!kuckr:. imoh"l·d \\ith thl: crimill,ll 

lu\T 

nllutttal"il:. 

T!w criminal drug o!l"ctH!n:> imo 

lrr.'ltnwllt through .1 \arid> of mcch,mi:<nH, 
di\·1-rting lHlll\ i()knt to tn:ati!Wllt; 

tn·,tlnlt'lll a • onditiiHJOl inr,\H't'rali(lll, 

1 2. WHAT ARE THE UNIQUE NEEDS 

OF WOMEN WITH SUBSTANCE 

USE DISORDERS? 

tn•,mnr:m :,1\ou!d attend 

not only tn 

environnwnt.d at! of >thi< h ran mfluetHT the 

trt',HnwnL-; tll,lt ,H·e most dkcLiH', and tlw 

Df not n:cciving lrcatm\'llt .• \Iany !if(· 

pn·domiuate in \\'()!lltn which 

.1 :-[W(ialiLt·d tre,llnwnt approach. 

!M" 11 tl1at pll;,>ical .md tr,mma RJlltmnl h: 

rPTSD. mow i'l!flHWJll 

women th,tn in 111cn tn',\tlllt'!lt. 

Othn fal'lors to wnnwn that UUl inllunK<' tht' 

dHIUild hO\\ l'\11\W 

uJto trraUnf'!ll ,h 1Hll1Wtl Hl(Jn· likd\ th,UJ ltl<"ll liJ 

the of <I r;cn.·r,tl ur nwnt.tl h1·,dth 

financial indqwndenu>, and ( hild ( .m 

1 3. WHAT ARE THE UNIQUE NEEDS OF 

PREGNANT WOMEN WITH SUBSTANCE 

USE DISORDERS? 

c .,illp; dnw;;o., .tkoho!, or tolJ<l(('() during 

not ju-.t thr \\onmn hut ahn hn 

lOth(' and can hmt' potcntiall-, 

ddt•tniou:> awl tscn dkds on t·;..,p(N;d 

clti!drcll. 

Pn·nata! usc of sotlW drug;:-:, in( haling ma; 

nnt'W a \\·ithdtm>ai in called 

neonatal :\_\S \\ith :\"\S 

.lre at gn\ila ri:-,k n! 

feeding dlfficu!tics, l<l\1 birrl1 

tlw \'<thw of cvidcn< 

W!HYWH .md their 

h,r exampk . .tlthow.;h 110 

nwdi(·<ttions llil\'(· lwo1 Fllt\-;lpprowd t<> 

dcpcmktJn· ill)ll"t'J;ll!lllt worn('!l, nwtli<HltllH' 

i'omhiucd \lith pit'llatdi <'<\!'('awl a comprdwn.\intrc,mncnt program can nuny uf the 

<;utconw=- <t""'twiatcd h'tth uHtl'(·ared lK!01ll 

abtbt'. HiJ\\1;\IT, 11\'\\bonH to Hll'thadonc 
during prcgnall(Y :-:till lWJUire tn·atnwm {fJr 

Rnemly. another nwdication option f(x opioid 

ckpt·mkll((', buptcnorphinl'.lU" heel! shU\Yil to produn· 

fn\('f :\.\S 'i\'!iJDtorm in th<UJ nwtlwdoll(', n:"uhing 

in Iu gnwra!, 

10 closely monitor wotni'll who drt' trymg ro qutt drug us(· 

during prq!,llilH('Y and til prm ide tn·atrntnt 

1 4. WHAT ARE THE UNIQUE NEEDS OF 

ADOLESCENTS WITH SUBSTANCE 

USE DISORDERS? 

!lnm their imm<nur(' nennw'l>£Hitiw· 

(lf d<·\e](Jf>!llenl. has dcmon:-.tratt-clt!Jat 

the brain '' pt lllmlgcd pmces;, of dcwlopmntt 

and r<'iin1:ment from bitth through early adulthood. 

more !'('il5U1Wd and rdlerti\t'. In 

do"ely i:h'>l)( iated with of lwhm·ior such 

as dccisio!HH,lkilH!,. jude;ment, and scl!:. 

control uuden.;o <l period of during 

aml <t(ltlltlJIHJ<i. 

sem.itive tiJ 'iOci.d cue-;, with 

influential during 

parental involn-mi'nt, iutt:grat!' otlwr systt'!ll'l in \\hich the 

adoleq·ent as and athktics}, and 

l'l'('(Jh'lliZt' 

at'l' arnOU!.; tht' dkctin·. Accc:o;:-, to 

tn:atnwnL manag\'lW'lH. and 

:-,Hpport :-.nYin·, an· cu!turdl!:, and 

gi'Jldn-appropliaw .ilso integral \\hen 

aduksrt'nt addictirm, 

fi)r 

( ert.Jin ChCS be hrlpfi.ll. Currently. 

nwdica1 approwd by FDA f(>r 

onT-tlw-cowut·r tr<1nsckrrnal 

may 

dwwillg gmn. and ·:pl1ysician a{l\-ic{' !>huuld !w 

Buprenorphine, a m<·dication i()r rn·:-ning 

.addinioll that must be pre:-.critxd by 

1raiw:d has not lwen 

bu1: reecnl rc,q·arch <;ug:gcsh it C( 

young as Hi. Studies arc undn ;;;ay to (ktcrmirw !lw 

and cfftcacy of this and othn medicalinm {(JJ 

-, lticotine-, aJtd akulwl-dt:pcitdcnt 

aduksci'Hb with ClHJccurring 

1 5. ARE THERE SPECIFIC DRUG ADDICTION 

TREATMENTS FOR OLDER ADULTS? 

\\'ith 

rornp(l:-.i\ion of the gcH('ral 

with 

the 

Such il \\1th a greakr his!Or} of lill·tirn<' 

dnn.; ·thau oldn gcucr,Jtious·,, dith·t\'111 

('llhur,tluorm:-, and general attitu£ks about drug u;-;e, 

alld in the ;wai!a!Jility of p:-.ydwtherapcutic 

i-; aln·ady leading to gn·ater dmg usc bj 

oldn adult." and may wt· 

iu this popuh11ion. \\'hik . in older adulb 

gtw;, uHnTognized ,md thcrrfon· urureated, n';,c,tnh 

il\·ailable addiction trc,Hnwu! 

{{)r them f(Jr youngt'r adult
1 6. CAN A PERSON BECOME ADDICTED 

TO MEDICATIONS PRESCRIBED BY A 

DOCTOR? 

P("opk \\ho dlJu><.' drugs that f,tkiug 

dH"m i11 a mamwr or a tbi:lll pre-.,< nbr:d, 

lll<'dicatiom prcqnilwd l!x anutlwt pcr ... on 1isk 

,tddkti<Jn <tnd nthct hcahh ;.,w h 

drug:- inclmk opi(lid pain \l'>ccl to !H"it! 

ADHD, and 10 treat dn;::icl> or "kcp 

!Jtd(·t"d. in an L. t million pcopl1· 

12 or old(·J mvt <.Tiwria !(>r a!Jme ur <H dqwwkuce oli 

r!ptiull the <.,(·com! nwst Pllfl!ll<)ll illicit dnw; 

<tiler lllMijuana. T{) the'>\' ri,b," 

ht·cdth pruvider, '>iTt'cn 

mcdic<lti()n and nvmitol 

a!Jout the potl'u;i,d ri<,k<, q) thJ.t 

imtrwtil)ll:. Clithi\1lly, 

tlwir uH:dicatinu:o. ;utd o( thnn 

appnJpriatl'lj: 

1 7. IS THERE A DIFFERENCE BETWEEN 

PHYSICAL DEPENDENCE AND ADDICTION? 

Yt•<: . . \ddictinn n1 tnrnpubi\'\" druL; IN' hannfitl 

is dll to 

a drug: L1ilun· to nt\"('t \\mk or 

<1ud, ou the drug\ 

wlnancc aud \1ith<h<n1aJ. ThC' physical 

dependence in which the bod;. adapt:> to tlu· (h-ug. 

ph} sica! <•r nwnta! ::.;.mptom:! 

n:,t:;r·d ·.1\ithdrm,al,•. Phy;.,ical 

lbcof man\ 

iJP;tl ucll'd. 

not colhtilt:W .1drb tioll, hut it u!iru an nmJMlli<''> 

addwtion. T!us rh.-.,unc oon (",tn bi· difficult w 

with ]Min !i)r \thich 

C<\!1 H'jJrt:'>Vllt tuJer,UH'( 

nppu<,cd to the 

1 8, HOW DO OTHER MENTAL DISORDERS 

COEXISTING WITH DRUG ADDICTION 

AFFECT DRUG ADDICTION TREATMENT? 

Drm; addiction a of rlH; hr,lin that frequeutl:-

occms \\ id1 othr·r mt;ma! lu bet, ,h many (i iu 10 P•'np!(' \\ith au illicit <;nbst<t!!U' disurdn 

Ji·om auutlwr nwrJtal aud rafl•s an: 

/()r u,;t;J"S ur licit drne_;-; tnha('C() and akohol. FIJI 

thcs<· indiYiduab. one 'ondition lwnmws more ddlindt to treat an arldirinn,ll rondition i;-: intertwined

('!Hering- tn·,ttJnClll citlwr f()r a 

Jr !()r ,uwllwr rncnt,d diwrdn be 

(()r dw C\HJ( currenn· ol the !!lher nmdition. 

indiv,tlc'- thw tr('.l!ing both 'll' multiple_ 

in ill! iuu·t;ratcd tlw 

best trcaunnn <1ppn1,Kh !i1r th('\t pati('ll\'-. 
1 9. IS THE USE OF MEDICATIONS UKE 

METHADONE AND BUPRENORPHINE 

SIMPLY REPLACING ONE ADDICTION W!TH 

ANOTHER? 

\:o. Bnpn·nt,rphiue :llld nwthaduw: an· prn.nifwd or 

adtuini~krf"d uttdn 11Jonit1m·d, com rolled CIJHditiolH 

<tnd ,m· :-.a!{· dlHI t·H\xti\t" f(ll·trc,Hilll{ l)pioid addiction 

wlwn H\t·d dircc1nL TlH~) an· admi11i~u·n·d orally o 

npioicb. 

_1.1",. under 1hc ltm}..:;UI' m :-.pi·t·ifi.cd dow~, and 

c!ilkt Ji·om ihnc-r of heroin and nthn almst•d 

l-kmin, l(Jr t'Ail!llpk. i~ i)Jl<:n injcncd, ~nortvd, qr ~rnuh:d. cau:-.mg ,uJ almost inuuedi<~U' ··ru~h." or !Hief 

uf inwn~(· ('uphnria, that \H'iH·~ ofl cud, in 

a '"nash." Th,· indiYidu.tl dwn expcricni(':o, ,tn mtcn~~­ nm iug to m1: the drut; .1g,;1in w .~top the na~h and 

reinstate tl11: j'uphuri,L 

The cydc of !·uplliJri>~, n<t-.h. and naYilll! ~IJlllt'limes repeated stTnal tiuw~ a d.t} i:-. <i ha!l1nark of ,u{diction 

a11d n·sults in :-n·,·r<· behavioral di~luptiurL Thoc 

charactni,tic:, rc~ult tl·om hnuin\ rapid umd and .~hnn dur,uion nt aniw1 in the br,tin. 

AS USED !N MAINTENANCE TREATMENT, 

METHADONE AND BUPRENDRPHINE ARE 

NOT HEROIN(OPIO!D SUBSTITUTES. ~·oHtra~t. mctludmw and bupt('llorphirw h<~H" gradu,tl omn~ oC action diKl ptodun· c.t.tbl(· k\·cLq of til(' drug t!w braiu .• \~ ,\ n·~ult. j)dti1·ub maimairwd 011 1lw~e nwdiuttioHll do Hot 1'\.pn·inltT a nnh. w!uk 1!w; dhu 1\J,ub:rHy reduce lh('ir desire 10 nst: opioid:;;. If .tn iodiYidu,t! tn·med \<.ith t!w~w mcdic;1tiom ;;udt hnniu.t!Jc undngoiHg !Haint<"lhl.lln: tr\'otllntut do 11/Jl 1r lwha;·ioral abnunnalitie:- in dru_; l;·\·•·h a~;;ociated with !wrom help to Jncdical. 20. WHERE DO 1 2~STEP OR SELF-HELP PROGRAMS FIT INTO DRUG ADDICTION TREATMENT? group~ ("(lll (Olllp!nnt'nt and extend the dlt:(h uf prok,~itdJal trntlnwnc '["Jw mo;;t promirwnt .\d[-ht•lp group-; ,m~ thu;o,e aHiliat('d with Akulwlic.~ )1h .,\:\·,:"\an otic~ .\noo;,mnu-., ·xx. and :\nuuyrw_)th ,CA< aH of which are lM~{'d ul! dw J 2-:-,!cp modd . .\ln~l drug- addiniun trt'alnH'!lt pw_gram,; in 

<tchicn' -tlld tll<Jintaill ab~tioctHT and nthcr lw,~!tll) lwh,l\'ior~ IJ\fr dlt' rqtH:-.F nf a lit~ tim(' 
21. CAN EXERCISE PLAY A ROLE IN T!-IE 

TREATMENT PROCESS? 

y('CI, bC(iJf\1i!l.e: a compnlWII\ or 

lll,lllY tn·,ttrncm M!d !J,1:-: proven dkni-.:(>, \\htn 

rmnhincd \\ilh thnap), at lwlpiug 

people quit smDknlg. may exen bcndlci<d df(·vb 

and nct·d:- th;L! 

nicotill1' fi'jll<t<t:\nt:nt aJmw dO("" tH)t, Jry lH'!l,llti\(' 

kc!ing-. ,md strc\:-, .J.nd by hdpilli!; prevent '.-\eight g;1in 

Rc<>earch to dntnniH{' ,md hm\ 

progra1m c;m <1 "imilar rolr ill thr· tn'dtrr\('JH 

utlln f(;rrn:-. u! <1bu<>t' i<> umkr 

22. HOW DOES DRUG ADDICTION TREATMENT 

HELP REDUCE THE SPREAD OF HIV/ 

AIDS, HEPATITIS C {HCV), AND OTHER 

INFECTIOUS DISEASES? 

Dnn.;-abu,.,ita.; iudividudls. !J!dttdin.t; 

injt'cting dmg 1N'f'>, ,m· at incn'<t;-,ed risk of hwlLlll 

immun(!tkf!cinH')- virus hepatttis C Yiru:> 

HC\<,. and otlwr inllxtiotL..; di"ea;,c:;. Tlw::;c di:.cav·s 

an· by ;;h<1rim1; contaminated dru.g inj,·ctlnn 

cqniprn('nt d!ld in ri-;ky ..;1•xual bchavitll' 

-;\Hnctinws a:-<;O(i,lt('d drug u:-,<'. EflCctlq· drug 

tn·atrncnt i<> H!\'/HC\' prn·cntion lwcausc it rcdt1G::-: 

aniYitic-; that can '-Pl\'ad sudt a-; shari11_g injl'ctioo 

equipment and nH_::,aging in unprotected .:>e}wal activity 

that targets a rang<' (Jf IU\'/HC\' ri:-k 

!JchaYi!lf:>ll!'(l\ ides <-111 adde(JJn·t:l of f>rC\ClltiOJl. 

DRUG ABUSE TREATMENT IS HIV AND 

H CV PREVENTION. 

Injection drug \her.'> \\-ItO do not ('llkl tl\'<.ttrncJH arc up 10 

:>ix times morl' !!kdv t(l become inkctcd \\ith HI\' than 

thn.·w \\h() enter and rcm,Iin in trl',!inwut. Participation in 

trc,ttmcnt aho pn'H'llb fill· HI\' '>C!\'Cninu, 

,wd rd(:rral t(J t'<trly HI\' twauncllt. ln bl'!, n·cntt 

tT->earch ffom :\IDA\ .\bn:'c '{'tc·atrncnt 

Clini<:al Triab :'\\'twork -:howcd thdt pru\·idill_e: 

oll:>ih· Hl\' t<';-.ting- in trcatnwnt 

paticHb. likelihood of lwin.v; tr-:t('d <tnd of 

rccci\·ing tlwir tt'"l ruull:-,. HI\. cowbding and H'Hing 

k1·y ac,p('Cb of :-upnior drug abtbc Lrc,ttnH'llt prot.; 

and should lK' otkrcd !o all indi,·iduab t'Htcling trcalmcnL Crca!tT <J\·ailahilily of incxpfllsivc alld unuiHrusi\(' rapid 

HI\" tc!>L" inncasc to tlw:>c important <npccb 

or HI\' pr<"Wlltiou and 
DRUG ADDICTION 

TREATMENT IN THE 

UNITED STATES 

DRUG ADDICTION !S A COMPLEX DISORDER 

THAT CAN INVOLVE VIRTUALLY EVERY ASPECT 

OF AN INDIVIDUAL'S FUNCTIONING---IN THE 

PAMILY, AT WORK AND SCHOOL, AND IN THE 

COMMUNITY. lkc<tll'>l' of (01llplt•,\\ty ,\lld 

p{·n·,bhc dr-ug <to:idiniuu tr,:auneHt 

1) pir,11ly imohe uuny Sonw of thme 

him or lwr lO t·x:pcril-lHY 

rn·,mnclll J(Jl' dwg <Jbuw ami addif'ti('!l ddil-·ercd in 

to \\ ith 

lb(' diVlHkr'l. 

and nnplo,,a->ob>,idi,n' 
(UHaikd th1' nu1nbn iJC opn,ltion,ll pro!!,rams. The 

to inO(',he the dr'Hl.t!H! i(JJ drui{ abuse uc<ttmnl! 

,cn·i1 cs ;utd ,m opport11nil) to ;.,tudy huw 

and 

idlllmpnAi 

TYPES OF TREATMENT PROGRAMS 

Rc,,c'i!Xrh .. on addiui()ll tncattn('!lt 

types or modalitih. 

((H1tinur· 

30 

hlJ\1.!'\U. with detoxilkatiun <md merhcal!y 

rHO!n:1gcd l>ithdnn\aL o!kn cunsidertd t!w 

treatnwnt. D('IO.'\dic,\ticm. th,· hy 1Yhid1 

c k<11 of i;-.- dcsigtwd to manag:e the ;md 

dliYb u! 

doesnn1 

,wd rckrr.t! to drug addiction tn·amw1H. 

ctnd 

withrlra1>al !nHn \)pit•i(h, a.lcu]HJ!, 

J!i( rHimo, ,md other :-,i·da!!\'(''· 

Rnaling: 

KHwL H.n Outp<Hit'tll detoxifu-alwn from opiatb. 

E'lyduafl) 

LONG-TERM RESIDENTIAL TREATMENT 

Long-term re;.,idrnti;.d l!edl!H<'lll ("an· L·l hours 

"!"he lwq-kmmll 

indh·idua! ,md US(' tlii· program·.-. entire Ctilll!llllllit) im lwliug other resid('nt:-, .'it an; ,md dw 1 

actiH· nHnpon('llb of treamu·nt. .\ddiniuu \ie\\U! ill 

the context of an indi\ldu,il\ <tnd 

ddicitc., and tn:atment [{,cuwc. on pt•rwn,d 

acnmntability Hnd as >11'll 

Tn·atnwnt \truumcd awl c, 

w 

more and n)Jhtrunh-c to inktan \tlth 

otlwrs. indud! 

pag-e 

Fwtfw Rnuimg: 

Hilldin, R.; Flo5t, R.; ,md 
Sarh S.; Uanb, S.; \It·Erndri\ k, f\..; and S.wk~.JY Sad-.\. S.; ~Xtl'k.~,.J.: !kl,;•oJt. C.; lkrnhardt. A: ,uHi Stainc~. (;. ~fodifi(·(lill("rilpcutii Wlllnlunil~ JiJr mnt:.:d!y 

: B<~ckground: intlunJcc~: findinl',~· Sub,>ltli/U' ~tnens. SJ; ;uu.! (,J.iclcr, '1'ltr·rapnttic ;·(~mnlUllilic~: ;-.,uh:-,1<rnn· abu~<· tn·;unwnt \\Oil It'll. In: E.\L Tim'>. G. 

lkLerm, dill I ::\.Jainchil! ed-. 

,1dUWUI''i In J?l'.~l'fl)"(h Institute 

on Drug ,\bu~(; Rc-:c;;n h 

9+<Hl3:L l '.S. GmTtnment P1 inting O!lin·. pp. l ti1- J flO. 

! 1-. 

Sulli\"illl. CJ; .\lr-Kmdri(·k. K.: S.wb. S.: ,UJd !Lmk,. S )J. 

.\-1odified f}!('fi.\]lelllic (()rrJHJtauty ll:)r ofl'cll(h~ \\"lth _\[I(::\ 

5HORT-TERM RESJDENTIAL TREATMENT Shon-t(~rrn rc,.,idcmi<~l ptu~tam~ JH'OI ldc iutcn~iH' hut 

bn('f tr~·;unwnl b;b(·d (){1 il modili(·d 12-s!i:p d('~igncd to 

ln>'piml-b''·''·d inpatwn! 

thn;;py 

;md panicip<ttioH in -1 ~dt~!wlp group. su\'h ,h )L\. 

l<:illOiritH!," ,.,t<ty.~ iu n~'lidenti.Jl tn:atnwm pro!.!.,ram~, it 

important 1<11· individuals to n·maiu cng;Jg:cd ill 

kmt':-. tlw rc.;idnuiaJ wllim;. 

hulhe1 limdwg: 

llubh.ml, R.L.: Cr<tddo(k. ~.G.: .J-; <trtd Ltl:wrirL.;c, R.\L 0\0Yin\ 

l!)qg_ 

.\lilltT. ).1.\L 

uf addinioJL 

w tlw !n·atnwm 

.wd TK. Sdndtz t·d:,. 

,·HedJrlnl' .:!~td \\·a~hiu.>.;-ton. Societ; of .!\ddi<tiou lcdicitH', l :)~)g OUTPATIENT TREATMENT PROGRAMS 

tn·atrncJJt 

nr itqMtient treattw:m ,Hld ofkn ~~more suitabk' l(n· 

11itil job~ nr •:xwmi\T ,.,ncial ~uppon~. It should 

that low-int("ll~it\· program~ Hhl}' o!E·r 

mmkb

tn rc~idclllLll prmp arn, in and 

d("pt:nding on tlw iudi\idnal patient's dmrw !cri~ti<~ !i1 !H';J.l 

mental he,tltlt pwbkm~ 1n additiuu lU their drug- disordn~ hntlm llmdin[!: 

R.\L 0\"1'1Yin1· nl 1-\Tar Ollt{onw~ in the l)rn~ .\IH;~c 'l'n·atnwnt ()utcunw 

Plyt!wiogy Addu lh·r· Beluruiu,' I I t ::!:1 1 

lmtirntt· iJl' \h:dit i1w. ireatint; Dru~ Prohle!!H. \\'a~hiuJ .. ;ton, U.C.: );;,tiona! Academy Prc~s. l'J~Ifl. 
A' I'.; (;_; !)urcl!.J; .\!tnumu, ,U.: 

Brill, E: .mrl O'Brint, abuse ln·atnwut in 

Simp:;on, D.D.; and Bmwu. B.S. Trcatm1;nt reti·Htion 

aH(1 fil!low-up outcumc' in dw Drug .\bmr TITJ.tnl!:nl 

( )utnmw Study .DAn )S 1\y)w/ogy I!JAddittiVI' 

Behtwiol> 1 L +.:2() 1- :1ll7. 

Individualized Drug Counseling 

addictJO!l cou!lsdqr t:llcour.:l!.;t•s parti1·ipatinn 'at 

if:<Jq orw or l\IIJ tillh'> pn m·d,, and m<tkcs rekrrab ii>r 

nccdni :,uppknwntal medicaL crnp!oyHwnt, 

;md ullh:r qT\ i( e;,. Croup Counseling 

promule 

therapy ofkrcd in conjunnion 

mo"·"'uanzeo d1 or f()rma.twd lO 

reflect llw pnnupks uf CO!!,TlUiw-behaviora! 

nl,>llag.nn<·ut. outconw!> are 

arc muditirnH in which 

1·an be aud mack more 

TREATING CRIMINAL DRUG 

ABUSERS AND ADDICTED INDIVIDUALS 

()ftnl. t!rug n)mt· inw (iJlltan 1\itll t!w critninal 

t·arlin tb,UJ other health ur .c,ocial 

pl(' ... nning fin m!tTit:ntioJJ prinr 10, duri11g. alk1; or in lin1 nf inc!ttTtT,Hiou. Rewarc

:-:lmwu that nnnbininl! cr:iminalju:-tin: ;-.,lJH lion« \\ith 

10 

th<m 

lrt'dUlWJH. upun 

in drug ahn-;t· 

tt·nd 

continuum uf rc:-ulh in better ouH·nrnt\:i: k.\:; drng the and criminal \tore infl:mtwtiun 

:!!ll:t. 
EVIDENCE-BASED 

APPROACHES TO DRUG ADDICTION TREATMENT 

fill-: {'X<trnpko; uf UTdJJHCJ){ ,tpproadw;-;. 

;1nd tkll lu\e an n1dencc base 

to u:rtaiiJ 

Tlwlo!l1!\\in!.(vTtiou 

lb<:: This lic,t is !JOt 

awl trcalUWllb arc (ontiuua!ly 11udn (kn'lopmenL 

PHARMACOTHERAPIES 

Opioid Addiction 

Methadone 

<waibbk in all h11t three through llcemed 

11pioid treattl!i'Hl pro!!,n\1\b or mcth,u!mw mainlnwuce 

fll"O!!,f<ll1l\. 

COMBINED WITH BEHAVIORAL TREATMENT 

Re,earch <;hO>Hl tlMt mt'lhadone maillt('tl<tnre i5 

more i·Hi:ttiH· when it i11dudc-: iudi\·idual and/ or group 

COUlb<:lillg. t\ith \'\CB better vdwll 

,,<xial 

mcnt or [,!\lilt 
195 

~ ~ 

:...; ;: 

~c: 

~8 

~ 2-< 

j 2 ~ - ] 

~ 

~ 

~ ·~ 

! 0. 

~ 

? 

"' "' 
TREATMENT, NOT 5UB5T!TUTJDN 

lkcatht' tnl'!had<Jur aud !mptcl!orpllirw ;tre 

fin· opiuirl 

of o11c .tddictive drug 

abo\<'· Hut L<tkiug 

as j.lJ.t.it·ub w hold . 

• n·oid ;,tn·t·t crirue and\ iolnwc, and re(ht(e thdr 

1o n;cm.ery 

Naltrexone 

tiou drug <llld 

P,1tients 

:\altrc>,.ottr· j,., ;1 opioid it 

fr<nn bindim; tu their rt'\("plm' 

pri:\cnt:-: their ruphoric .1nd other ( Hi:yt<; 

u',(·d ff1r many 

ih('!r h;1s 110 suh]Cl'li\·\' d"fc,:h ckto:-..ificmion that 

dkct. 

prc;-,l rilwd m outp.lti{'nr 

trc.ltnH'Ill shonld bn..;in ajtn nwdi< al 

<I rnid<'Htial "''tting in ul(kr w pn;\ent \I ith\lr.t\l(d 

mptutll'> . 

. "\ah!TXUllC be takcll m·,tth \bily or 

a lnTk bulHoncnmpliann· \\·irh twa!nt!'tll 

diniciarb haH' 

qr )Ut{>kc'l. Rn ( ntl). a inj(·; 1<thk nf 

1lc:lllt'"VilH', c,t!kd \"i\itroL \\,h ,tpprmnl (() ll<::d\ opioid 

.1ddit tion. it 

holhvr nnullllg: 

-\lt-ug\'r, \\(l(ld), C.E.: D.: 

.\It CldLm, .\.T: B. ::\,dtn'.V•lW 

f(H npiuid dqwndcrn ti·dnal 

of Sub·,tonre /1h111c 1i('{lfii!Nd 

1 ! i j 7 . 

(;;J<;tfrit'JJd. J).R. t'\.(\'IHkd-rdcaw 

nctlm·:..ml'": cunent c\id,·nu·. Anno/1 1!/ thf' .\'i'U' }in·k 

/Jradctll)' of \nr'JJO'.; 1'211;:14"!· 

E.: 

Sdwnnan. B.!._ 

l111T11lli!, 

()rJcaw-,, LA. 

Tobacco Addiction 

Nicotine Replacement Therapy (NR1) 

,\ \ill·ir!; or f(Jl"!lllilatiom \lf 

thnapie'> :'\Kl ruH\· indudlng 

tlltT;t[l> 
BuprojJion (Zyban'¥-) 

marketed ,1:; .m 

It mild dfn b 

,\ c.nendipitou-> 

\\iL'> rh,n tlw 

bupropim1':' C\<H t 

'>mnking 1 arc it FD:\ 

Varenidine (ChautixJ') 

\ ·,m·nidirw i-, the llJO:->t H'( clllly fl):\-<lppro\cd mcdi<atiou 

l(lr mmkinl:, cc:-.:'<ttion. It <Kh on a of nicotinic 

receptor:- in tlw linin tlwu!.;ht lu IK in the 

JT\\·ttnlilH! of ninninc. \'drcnidill<' acts 

.Jt n'n'fHOI' this nw<lllS 

mildl} qinmhtc-, the nicotnw H'C!'ptor but not sutri<::iently 

to tlH· Idcaw of dopaminl', \\bich i,, important 

i(lr tlw fC\\iiHiing dkr I\ ui niultinc .. h ,UJ ant<tgoni.c.t, 

\itrcnidinc ,d'io the abilit\ of nicotine l!l adivak 

dnpamirw. \\!!h the rcinfincill?: dh:cl'i <lf 

tlwrc!Jy n·,!u(ill\;\ and 'ui'Purting 

!'nnn \Jlloking. 

COMBINED WITH BEHAVIORAL TREATMENT 

Each of the clb0\1' 

lilt in nHnbinaoon \\!!h 

indUiliug 

((·kph()IJ(> 

tinw T•l,lll.lgcrnnt! tlwt tlW} can prank(' in 

trc,wrwnt, soci<JL and work :wttillg'. (;(,mbuwd trt'allntm 

utr:cd IJ,;, lwJu,·Jqr,t\ pha1 

tholl.L',')Jl to ()jlt-r,ll(' h) dilkH'lll J<'t C'lH 

llK( tlML Cctll h<.m· additivr' dli:ch. 

hullwr RcadmR: 

.\ltnUJ<tlL ,\.L Cariti, P; <tnd .\luh·,uwy, E Shn11- <md 

lom.;-tntn -,moking thHT r1f iutcnsit) 

or l\yrhologT t!f.·1ddutn•e Beha;'l{)f

Ll:21il :21d, 

BalL llumflt·ct, C.L.; .Nlui'lot-. R.F: Rt'u:>. \] 

PrOf h.hka.JJ; .md 

lwha\iom! irealnwnt and nwdic.ttion to !n'<l\ dqwndn11 

:-.rnnkcr;,./lmenmnJournal 1d Publir Hmlth l01::2:1·l:l 

201 j. 

Jorclllr;-, D.E.: 

\\"atsky, EJ; \ 

K.R. \·arenidinc Phase Group. 

\<ltt:nidiuc. n4f)2 uicotit1ic acd)kholin1; Jcccptnl 

or l 

:;lfi h:S

Current <J<h-<llJ(T\ and n'::W:Jrch 

CXS Drug.\ 2:1:371 :111'2, 

:-..tmh, S.D_; Wilken. L.A.: \\'inUer, S.R.; and Lin, SJ 

ti1· rc\·icvv and of l'otnbination 

r()!· 'i.!H(Iking Oj fhe. Jmo'ita!/ 
198 

-§ 

" 

c 

~' s 

s ~ :.::; 

1 " 

~ 

., "" " 

~ yc 

;,: i 

" ] - ~ ~ 

E 

'-9., 1! ,c ; ,.. (j 

cr 

/, 

~ :7 ~ 
ln:-titul!' ()JJ .\lliJbol ,\i>u'>c ,uJd 

Hdping Patinlb \\"ilo Drink 'JfJn }dude,\ Clinician"" 

guide.htm 

BEHAVIORAL THERAPIES 

tkll,n·ir>nl .tpjJl"O;:,dw:-, 

tn·,unwnt. pw\·id,: irwcnti\1·, J\11 them to rcnuin 

modi!\ rlwn and !wh,nior.-; rdatrd 

tu dm\.\· and i1H dwir !ik UJ lnmdk 

and t·m·iromrwmal nws that 

rna) rrit.;gcr !iJr and prompt 

another cyck or\ ornpuhi\{' Below are d 

ll\lllJbrr or !whm·iuwl tlwtapil') :--huwu to fw dkctiw 

'-'llh"tJlWC ·'dkvti\t'tll'% \Ylth 

fl<lr\icuJar of alJuse in Jl<ll('JJt!K;:,CS·. 

Cognitive-Behavioral Therapy 

(Alcohol, A'larijuana, Cocaine; 

Methamphetamine, Nicotine) 

(;()gniti\1'-lkhmima! l'hn:qJ;. CB'l' dnTloptd 

<t'i a ml'lhud tu 1dwn lJl'illing pmhkm 

drinki11p;. and btcr it J(Jr mraiHc-addicrcd itltli\·idJt<Ll"-. are based Oil tlw th(:Of) lh<tt in t!w dt:\'l:lopment of 

!Jch;t\ inral oattcrm like dhtbc. k,u-uing: 

critic:JI nlk.lndi\idu.Jh in CBT lrarn to 

t'lll.ttic bdM,·ior-; by applying 

that em lw used to 'U1p dl"llg 

aJm,c and to :i fdlH.(<· of other that ohen 

('0-UC("lll" With it. 

iliHl n1h,uwiug 

d(·\dnp cffel'lt\t· ( 

lild) 

indudc cAploring tlw po:-,iti\t' dlld Jwgath·,. C<!lhUjllCJJCC' 

1 ou1mucd dru>s lh<\ to IcCOD,rliZt 

{ e<ll'h ;md :-,ituatiuth that lllighr )1\ll orw 

,u ri-.;k for u:-r, alld dndoping !or 

i.lnd ,t\·oiding: th(Jsc hig-h-risk 

iudi(a\n that the k-1rn 

thrum::l1 t og11i1JW-bdJ<t\iural rctn,!in a!kr thr 

l!lltlpktion of lrt:ctilll("[J\. c:unent lonhf•$ ()ll]h)\

to produce nTII nvm· dkcts nanbiJJin2_ Cln 

\\ilh uwdk,nions f\H .thus(' and othn ot 

CBT 

lwlpinv; redl!cc drul( us<· f<Jllowing standard dr \l\'; 

trcamlcnL 

liuther 

< :arro!L K.;\L La-;1rn1. CJ; :'\ich, C.; Hunkt"k K.A.: 

T\L Sinha. R: E>rd. H.L; \'iwln, 

l>oebrick, C . .-\.: ,md Roun,;a\ilk BJ Tlw u<>e ot 

("OJJ!in>.?,<'nt)' management iliid m'1li\ 

dt'J)("!Jdc·JJCC 

:\l,U 

C,u·rull. K.:'IL: ,md Onb•n. L.S. Behm·i{)m) thcrdpics 

Ji\r drug :tbu:,f-. D1c :!uumwnjournaf of 

!G8ifd·Ll:! l4W. 20()j. 

CarrolL K.: Fct1ton, L.R.: B,,Jl, S .. \.: :\id1, C.: Fr;_tnkJ(,JW

"LL.; ShLJ; and BJ of disulfiralll 
(:;molL K ;';I.; Ball, S.:\..; \lartillo, :\"ic!J. ( .; 

T.\.: :\11ru. K.F; Cnulon, p,lltlliJ\". (u\.; 

Jmuw;/ ofl\yluoh:r 

i 1l.-J 7 :Wll HIHL 

Contingency Management Interventions/ 

Motivational Incentives 

(Alcohol, Stimulauts, Opioids, 

lvfarUua1w, Nicotine) 

J<r,<·an It ha<> dcmo!!str.Hed tht· o! tn•ctuw·nt 

ill( u c;llmcrn retention 

I rom 

-tlhtilKJHT 

TfwchtT-!Ja,!'d ,\'HR' ;mgnwuh (lth('r 

1rc,ltnl("llt' !(Jr ,ldidb \1ho 

.\ \'OtKlwr 

nwndary \aluc that !'an lw ex( han.f.;nl !(Jr ti>ud item'>, 

or other or llldl ,tn:· 

with The \Ouclicr IIJ\\ 

lir;,t. but the number of n>rm>cn\lvc drug-free 

urine 

\'illut· of \·otwher'l to 

the 

Pri?-1' lnantml:'.; CH (b \'BR 

hw dhliHT:. 1() \'ow 

(hn tf](" coutv• nf tlw progrdm <ll ka>1 '{ rnnnth:>, ow· 

uri1w or brt·;1\l1 

ont" J.ml :nnTa,e;-, \\ith I"Oihu·utiq· 

rwg;1tin· dru:; ,md/oJ all•·ndcd 

but re:.n--; tu nne \\·ith ,my nt 

t!ll\'XCUicd ab'>ellC!". 1 Ul!lmnnin 

r.liv:d cow ern<; tlhll thi<> illt\T\!"HllUll could prmn"H" 

it an dctlWllt of .md tli,J

lS;unbling ,md sufH<UK•' di<:onkr-; em lw 

flm\ncr, c:-;.aminin.SL c uw t•rn flHm

tbal Pri;;r: lllcrn(i\·t·s C:'.I did nnt pmrno\(' >;ambling 

!wha\'im: 

Furtha neudmg.· 

.; and I S.T 

Ro!llnan, R.: R.S.: ,md \\'.1lkn. 

dqJt"JJjkun· ,md trC,Jll!lt"D(. ldt!hfton 

Sfinue :.:!C!nwol Puu:ltet:! I .:1 JG. 2(Jf)7. 

\..: \1wri, E: :\L Harw1·, :\l.; 

,\.;Gruber, A; .mel d-CuvbalJ. X. ;\hrijuaJu 

and Suhs!ann "·1/11/.\1' 29

:,!0()8. 

.).,\!.; 

E.; Sih'a-\'azqw·z, L.: Kirby, K.C.: 

Coht·n, .\.; (:(!pn:-:ino, ).LL: Kulodw·r, K.; ,lnd Li, R. 

EHl·ct' of on :otinwl.ml alhtinetwt· 

in Jll.tth.:tdtmt' mainlcnallCP twatnwnt: .\ .:\',ltirHJall)ntQ 

Abuse T1ta1nwnt Clinic<1l Tri,d-. .\'el\H;rl ArdJhW\ 

of Gmrm! 1\yt lnotl .Y (i:-1 ':!OH. 2iHJ6 
Pnr;. :\.\L l'citu .. ,J.\L Stit.tn, .\LL; B!aillc,J. Rn!L 

J\L ( :o!w11, ,·\.: ()hnt.J: KiHt·cn, T: SdLtdin, .\J.E.: 

Cum·!!. .\L K.C.: Swrlin,g, R.: 

R.E.: ,\,Ltulon<dd, :\f; Lirlwll, 

R: Di\l<tri,L L Cotwrc;lnu. :\1.; 

IJa.<.cd im r;J\ onl\ orm·;-. ill ,.rimnbtll .tbu:.er,. io 

iltltjMLH'W jh}dW\oci.ll tn'<ttllll'lll 

Ti<'alnw!lt C!ini( ,,1 

.\ :\;uimw! 

uj Generall\rthiotJy b2 !U-:JJ,fil l 

Pnr:; :\.,\L Kulodnt't. K.B.; Li, R.: Pcin·t·,J:'>.L J<.,1JL 

.f..\ I.; StitNI: \LL.; .wd l!anlih<lil.JA 

not in( n·;h(' ,>.prnbliws. 

Drpmdnu (I Wl .-r :2W 2(J0t;. 

Prcnderp;,l!:.l, ,\f.: Podm, 0,; FinHc;..J; Cn:nmdl, L.· 

and Roll,J mMlcH.;nnent l(n treatnwnt 

,\ c1ddU l!0/1 

Inanctgt'nH·nt 

di..:.,,nkr>. The 

Community Reinforcement Approach Plus 

Vouchers (Alcohol, Cocaine, Oj1ioids) 

CnmnH!!JitY I<nnloru'lll('JJt CR.\' Plu:-. 

!(Jr 

a ram:;v of lTnt·atiuual, hmilial, -;ocial, and \Oc;uimlttl 

tcin!(myr;; .• dong ;\ith nwtnial inn:ntiws. to make .1 

lllOH' rcwMdine; than e us1·. 

The tr('atownt tvvo!{Jld: 

f(, m:Jilll<lill ah1innHT long nl<lugh for D<HiulH to 

kam to help it: 

!{J rnlu1T (dl ohul !(n \\ho·w 

dtinking \\·ith eucaine: U'W 

.tlt•·nd OIH' l\\0 imli\ idua! 

(',H h \\i'!'k, \\ht'!'t' liwm on imprO\itl}.; 1:m1ily Jd<tti<!l

k,ml i\ or to miuimizr: drug rcc('he 

\OCtliUll;t{ <'OU!l'ding. (\Jld dt'\'riOp liCW lTITP,ttionaJ 

;md '1 \\hO abo 

ah·ofH>l tf'C!'l\'i' <lisulfiram 

dtt-r,tp). Paticnb utillt [\HI u1 thn·c time-. 

each \I ('Ck and rrcei>T Ynuchcrs fi1r 

\..:_in dw >alw· of the You< 

.:\ of CR.\ Plus \'oudwh called 

tlw 'llwrapcutic Edwatinn :TES· >us !m1wl to he 

ncarh ac: dl!:cti\·<· tt::> treatment ,1 

in ah,tiucnce from opiuich. awl amull!!

npi(nd·dnwn,cJnn indi' iduab in trc,t\JneiJl. , \ 

!(JJ 

( npill,l';. and \·onunuuicatinn aud acti\ c 

in and recreational 

Fwthn Urad;ug: 

Broub .. \.C.; 

in lntnnHmit: 

tiH·nttlf 

lhu,le 

( :omnumit} rciuf(m·erncnt 

td(;elleml 
202 
inl<T\in\lJH; in 

7! 

Stott-..\.! .. : Di,lcmcnt<·. and DuLtn-:'dullnL P ()])cThe Matrix Model (Stimulants) 

rlw tlwtapi,t i"IHWlion, <1, tcdchn .md 

( o.tdL J(Hning ,t Jd<lti; 

\ntlJ tlw p.llient tn 

po,itiH· !wh;t';-\Ui \ h:tll\!/"· 

tlwlapi't dlld I he patinH i.' d\ttlwutic dntl dil("( tlmt nul 

<ooflnnta!tullal Ill parcnwl. 'j lwLlpi't' uaitwd to 

zondtwt \n"dlmcnt m :t \\;\\ tll"lunHIIIJ\f"" the 

fMlicntretcll!iuJL 

TrcatnH."lll dra\1 

1nanua!-. ('f!llLlin 

drm; 

tl(":1ll!H'1l! 

utlwr nHIJpom·ub in1 lwk <·dl!c,HJon 

rccmcry gnHqh, ti"Llp'>e pn'\("lltiun 

1'2-,c.tep :nogr.lfn'-. 

.J.lld 'mppon 

f<tathn Jt.mdmf.:.: 

dunon,tr<>i<'d that pdrtic qnnh 

H11bcr, ,\ .. l.UIQ. \\: Sliupt,t\1, S.: (;ubti. \:; Brctlu·n. 

12-Step Facilitation Therapy 

(Alcohol, Stimulants, OjJioids) 

T\\ehc-,wp Lwilitatiun t!wr,rpy i, an actiH' ('!H("<t,gcmt·nt 

d<·:>igrwd \IJ iw rC,bi" i!w likdilwod uf ,,_,ub\!.mn

;dllha!nl 1\J!h and <Kli\d) imoh1·d in 
,Hlrlil ted indi\iduab. ,wd !(J!lrming tlw n'n!FlY 

L1id IJUt IJ) the lL-qcp pmgiatJJ; <lll\l :-; 

iJl\l,hi'llWtll in 

,n,t.Jin n'l'l\cry. 

htr!hr! nvodmg: 

Carroll, K.::-.1.; :\idL C., lbll, S.,\.: .\kC:awT. L: 

Fr.Jllkhrt('L ·t:J .. : and Rmtn-;,l\ilk BJ (hJt·-;c;n· l(>liO\\-ttp 

of :md 

Su;;t!Ji!wd 

DnmJ\'iHLD).l.: 

nwth,nnplH 1illlllllt' 

In, 

\\'dh. E.A. "Twc-;tking The 

SuppL l':l:.!l 

l'ruj<'i l .\L\TCH Cwup . .\late him.; ;lll oltoli>lll 

rn t lif'lll hclt'l<Hjnll'itj: Plfljt:r1 .\L\TCH 

drinkiag uutnmw.,_Jmurwf of ,'ltud/1:'.\ 

l:J97. 

Family Behavior Therapy 

Bcha\i<l! FBT. \dtich lU.\ 

ir1 bulh aitncd 

at not only the but othn 

( u-urcunin>?, \\(·]l, \mh conduct rlisordn\ 

ntarugcment. 

FHT tb\' 

mhn h ,b a (OIIdbitillfi partnn or .t pMcm .in t!w t <I">(' of r'JJLS·. .,1·ek tq (·ng.H:;<' bmi!i 

dppl:ing dw ])('h:t\·ior,\l 111 ,uHI 

,wquiring Ill'\\ to 

P,tticHts an; nH unr.Jgnltu 

mkdiiJIJ,\Ilmh 

tiJ a 

Sub'ildlln·-abu,iug p.uenh ,nt· t11 ){'( 

rdatecl tu dkrtiH· p:Hnllitl!.!, C\( b 

t!w behavioral r;•ML arc rn eeL 11 ith rn1;mh 

wht"n ;lt·l·ornplr;h

optiom. In a nf 

11ith ,md without conduct 

choo\in>; gpcn

C\'ir!I'!K\'-!J,bnf lrt'd!OWlll 

n1orc dl(·(ti\t' th;_jn \ 

fi1rther Ht<adinh,' 

,\zein, :\.If.; Donolnw. B.; lk-:,deL \:.\.:Kogan. EX: 

outcoJw' 

trc.llmcnt: ,, umtwlk

owl.·Jr/t!le.\relll .\ab,trJIII

CarrolL K . .\L; ;md Onkc11. L.S. Be!ta1·inral 

drug ·lmn1um Journal 1:/ T\y hwt1 y 

litJO.'.WO."J. 

DunolnH\ B.; .\ain, :\.: ,\!I,'IL D.:\.: Rumno, Y: HilL 

H.I-1.: Tr<H'\, K.: JL Culm'\_ S.: .\bdd+al, R.; 

\'alrkz. R.: and 

\'au Eunily 1klt;wii!r !i1r 

ahu.-;c: .\ of ib inlenTntinn t·omponcnb and a!1pli1·ability. lklun,ior ,\lodtfurriiun. 

LaPota. I-LB.; Duuo!nw. B.; \\'ann!, C. S.; ,md ,\lku, D

Iutcglatioll o! a Ht•ahhy Li\ i111; ( urrinllllln \\ithin Fam!h 

2111 
BEHAVIORAL THERAPIES PR!MARJLY 

FOR ADOLESCENTS 

M ultisystemic Therapy 

Fur!lu:1 Hemfwg: 

Multidimensional Family Therapy 

ui nH· in multiph" \\d!"' in diJlncnt indndc~ Jodi\ :du,d aml !.unl!;. 

\\h

tlw hollll\ or \\ith Ltmi!;, rnnnhn~ at tlw f:tmih r<•Uil, 

'' huul, or l)th('J ! nnuntl!Ul\ lot·ati()IJ'i. 

Dutillg indi<.iduu) dl(' tlwr~'l'i~t ;1nd ,;dok,,-ciH 
.md fi"diua;~ to 

\,·itb f«tHil) liWtnbn~. Pan·t1h n.,uniw· their parti!·uL11 

p<trcnting <.tyks. k:u nin]! 1<> mlluence from 

C<lrHlol a11d tn hm·,, ,\ po~iti\(· dppropnatc iuilucnce on fhe11 children 

Further Nuul111;_;· DcnHi~. ,\!.; (;odln: SJ f; llidnuJJl(L G.; Tims, E:\L; 

Bc1boJ: f),nwld~ml.J: I.iddk IL: Kaminn: 

Y: \\'('h\J. C., 1 Lnuih<llL :'\.: ,wd Funk, H. Cc~nrMIJis Youth Treatment C:Y l" .',tu(k: :-..fain finding~ iiom twu 

raudomizcd di11iu1! tri,lk.foumal of .\r&-:lmu;e Abu.\r 

lleatl!u·nl '27 3 2 J:J. L004. · 

ItA: DaknL C .. \.; P.:trke1; K.: l)i,tmond, 

{J .. "i.: lbrrdL K.: <llld T(:i>tb, ,\1. :\lultidimm~io1ul J(Jr ,1duk~Ct'nl drug; abu~t·: kf'sHlt~ or a 

nic<J! tri<tl. 'f he ,-lnwnwu joumrtl of ]);up.,' 

and .ill<·oltol iil)fN bHH, ~(J\J I. 

Liddk, 1-L\.: ;md !log-rw., .\. \luhidimcnsional f.uni!y 

Jor ,Jdo!l vnt ~nh~t.tnf(' abu:w. In E.F \\"ag-na 

and \r,tldnJn nb.·.h11101'fliirnll" m Ado!t'ltt'rd 

Su/11/tmrt Afllt'l' iNfer 'nrfwm. Londoo: Pt~rgamon/ Else.\i(·r :-:.(wnrc. JJ!J. '.:!.C>J,'.:!.tJOl. 

Liddk, II..\.; Ro\H'. C.L.: lhkoC <:.,\.: Cll!.\aro, R.,\.: 

and H('ndc!SO!l. C.E. E,u·Jy imnY('l!tion fi_lr ,u\ok.<>LTllt ~ub.\Ltll( r; ,tbll:--(': Pre!lcatllWnt to po:;ltn:attrwur. otlt(OJH('S 

a ramhmi;Pd diHi\ <ll triill \ <Hnparim~ multidiuu:n.~iunal <tlld pen ~roup llTatuwnl..Journal r4 

(i:), 200-L 

Schmidt. S.E.: Liddle, 1 I.A.; and Dakol: G.A. EJl\:ct~ of 1~!96. [Jl"d( tire.~ to dn\S<".Joanw1 

Brief Strategic Family Therapy famil~ Tlwr,•p: BSf'"r target:, Cm1ih 

are thotH!,ht tn maintaiu ol \'Xan:dJd\C <1bu~1· ,HJd !JiiWl LO-()('f"U((Illl!, prn!Jkm 

problem b,·kt\·ior> incl!tck nmdw r 

.11 h(JI!ll' and <H ~dwol, nppo~itimwl lwhaYim: 

\\hi(h 

that the ~ympWtn'> qf orw mnnlwr 

dw drug-abu~ing adolhwenL [()r t"A;unpk aw indir alive. ka~t in varL of \dM1 i:' occurring in dw 

those vrobkm~nlaiutairlillf!: in \'<tnou~ ltcatnwnt mndalitit·~ as <t pri1nary owpatit~llt intcrn·Jttion

in combiiMtioo with H':--itk!Hi,tl 01 

an <t!tcrt·a1r/ continuin~-( an' 

tleaUJl('tll'. 

F11rfhe1 Reading: l("~itkmial S.lm.i:.lcban, D.,\.; ,\ld{ridc, C.K.; ,md 

Brief Stnlkgic I-'alllil} T!wn1p) \TNh 

nnnrmmily control: n:ti:ntion. and an 

t·xplontlinn of I he 

Family Pma.\.\ 4rr:r::-il3 332. 2UUJ. 

Kunint•;-,., \\:~I.: ~lurr.1y. EJ; and 

of interwnlioo i!;r t'ng-,lg-im~ youth 

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'fh(' ."\aliPru! lwtitutc on Druc: .\bust" ,);Jn\ !c.td" 

NATIONAL INSTITUTE ON ALCOHOL 

ABUSE AND ALCOHOLISM (N!AAA) 

);<Hional ln,;titutc ()ll Akoho! Abuse and Akf!holi;,m 
NATIONAL INSTITUTE OF MENTAL HEALTH 

(NIMHJ 

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·::,,;n.UI) is tn 

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TREATMENT (CSATJ 

the diw·rseThe Center ((;r Abu:-<' Tre.ttrnent tCS:\T;, a 

part of the Substance Abuse and :\fent'-11 Health Services 

t.lat.a.\jJX. 

SELECTED PUBLICATIONS AND RESOURCES 

FOR DRUG ADDICTION TREATMENT 

d<':.niption: 

Blending products. Blending lnitiahn·---a 

jomt venture with SAMHSA and ib nationwide ndvvork 

Addiction Technoloe-v Transf('"r Centns (ATTCs)--· 

Addiction Severity Index. Provides a structured dinica

to collect informati1m aboul substance 

in life areas rrom aduh dirnb 

drug abust' treatment. For mort mformation on u• 

ASI and to obtain copit:".s of the mmt recent <:di\ion, 

triu•eb.tresearch.mg!index.phfJ!tuoli>/download-a.i 
Drugsj Brains, and Behavior: The Science of 

Addiction ,_Repriuted 

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gov/fmblication.l/lmmce-addu!wit 

Seeking Drug Abuse Treatment: Know What To 

Ask 1201 l'•. This la\·fiienrlh·oubliuliou oil(T.~ guidance in 

.>ecklllg-drug-abtt>e-flwtuwut. 

Principles of Drug Abuse Treatment for Criminal 

J ustke Populations: A Research~ Based Guide 

'Revised 20! 2). Provides 13 e~sential treatment principles 

and in dudes resource infOrmation and an.'i\H:rs to 

asked questions.l\Iff Publicat.ion :'\o.: J J-j3Jlj. unlin<~ at nida.nih.gw/PODAT_C]. 

NIDA DrugFacts: Treatment Approaches for Drug 

Addiction (Revised 2008). Thi~ i5 a f;tct ~hect con:rin~ rc:,e<1rch findilli.!S on cffectiYe tn'atnH·nt approaches fOr 

A\·ailahk onlin,• 

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res("" <liTh 

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nnli1w at niaa.fLnih.gm•;jmbliwtion.vjounwh-and-njNn'l.l/ 

a/rohol-1dert. 

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Clinician's Guide (published by NIAAA). Thi~ hook

p:uuit>.hfm. 

Research Report Series: Therapeutic Community 

i20W). This repmt provides intfmnation on the mk of 

({/I/IJ/ll/lllf)"· 

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p;m'/(:T.Vllndex.!ttm. 

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TREATMENT STUPIES 

:\'IDA i'> taking an 

ClJhannc tn·atmcnt 

theCT); 

involved 

with dw criminal justice system through Criminal 

Justice 

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public heahll awl public 

collaburarinn among i\ID.\; 

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practitioners. SA11HSA tra.ituTs. and ::\ID:\ 
OTHER FEDERAL RESOURCES 

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. md dPmOJb!ration prot;raJn\ to drug .tbth!' in 

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214 
Residential Wotnen's Treatment: 

Cost-Benefit and Outcome 

Findings from a CSAT CrossSite Evaluation 

Ken Burgdorf, Ph.D. 

Xiaowu Chen, M.D., M.S.P.H. 

CSAT Women's Conference, July 12,2004 

*Study conducted under Contract 270-97-7030 funded by the Center for Substance Abuse Treatment, Substance Abuse an

Health Services Administration, U.S. Department of Health and Human Services. Center for Substance Abuse Treatment

Fishers Lane, Rockwall II, Suite 740, Rockville, Maryland 20857,301/443-5052. Contents are solely the responsibility o

authors and do not necessarily represent the official views of the agency. 
The RWC/PPW Program and 

Cross-Site Evaluation 

• The Residential Women and Children (RWC)/Pregnant and Postpa

Women (PPW) programs were funded by the Substance Abuse and 

Mental Health Services Administration's Center for Substance Abu

Treatment 

• The cross-site evaluation encompassed 50 5-year R WC/PPW proje

that were funded in two cohorts: 

• 39 in FY 1993 

• 11 in FY 1995 

• Each project was required to develop a comprehensive, long-term 

12-month) residential treatment program for pregnant and parentin

women with serious substance abuse problems, including on-site c

clients' infants and young children 
RWC/PPW Projects Provided: 

• Outreach services to promote Tx entry & retent

• Screening/assessment for women, infants, & 

children 

• Medical testing for substance abuse related 

diseases/conditions 

• Medical care for clients & children 

• Individual and group therapy/counseling for 

clients & children 
RWC/PPW Projects Provided (con

• Educational & vocational services for clients & 

children 

• Other support services for clients & children 

• Individualized case management, w/ active 

involvement of clients 

• Family member involvement in children's Tx 

• Full continuum of care in residential setting 
219 
220 
221 
The RWC/PPW Cross-Site 

Evaluation 

• Cross-site evaluation collected data from October 1, 1996 to March 31

2001 

• 50 RWC/PPW projects submitted a standardized set of quantitative dat

a quarterly basis including admission, treatment services, discharge, an

month follow-up data 

• Outcome data set represents 1,768 former clients from 32 projects that 

minimal requirements for follow-up data collection (50% follow-up rat

better) 

• Follow-up data are available for 1,181 women 

• Nonresponse adjustments made to account for underrepresentation of s

stay clients 
223 
224 
225 
Child Characteristics (n==4,048) 

Male 49.0% 

Mean age 3.8 + 3.4 years 

Child Placement Legal custody Living situa

before treatment (%) 

Mother 67.1 4

Father 0.9 

Mother & Father 12.8 

Grandparent 2.1 1

Other relative 0.8 

State 13.8 1

Other 2.5 
227 
Outcome Dimensions Covere

• Abstinence vs. Relapse 

• Arrests for Illegal Activities 

• Economic/Social Outcomes 

• Physical and Mental Health 

• Pregnancy Outcomes 

• Project Sustainability 
229 

~ 

rfJ 

0 

~ I 

OJ 

~ 

~ ..... OJ 

rfJ 

~ OJ 

00 

OJ ~ u C'd 

a ~ 

~ u 

rfJ 

.,.0 

~ 

rfJ 

~ 

~ 

OJ 

....--4 ·~ 

u 
230 

t 
231 
232 
* 

** 

*** 

Pregnancy Outcomes 

n = 2,837 from 12 recent hospital-based studies of outcomes for cocaine-using wom

n = 9,737 from 10 recent hospital-based studies of outcomes for cocaine-using wom

n = 10,816 previous pregnancies ofRWC/PPW clients, as reported at treatment adm
Percentage of Clients Abstinent Po

Discharge, by LOS and Study 

-+-
235 
236 
237 
Outcome Study Conclusions 

• This type of residential treatment accrue

substantial benefits to clients in many ar

of life 

• Benefits are most widespread and 

pronounced for clients who remain in 

treatment 3 months or more, who are 

especially successful in achieving lasting 

abstinence 
239 

~ 

00 

0 

u 
Treatment Cost Data 

• Collected on-site by professional 

accounting firm (CCC) in 1997; 39 sites 

• Used CSA T -developed cost accounting 

system (SA TCAA T) 

• Comprehensive, based on full market va

of project facilities, goods, and services 

(incl. donated) 
Site Variation in RWC/PPW Unit Costs 

Mean+ SD 

Annual cost per site $928,190 + 305,11

Episode cost per client $25,744 + 13,440 

Daily cost per client, total $159 + 62 

Housing $51+ 30 

Client services $60 + 28 

Child services $48 + 26 
Average Treatment Episode Costs by Group 

Group 

Statistics Total 1-30 31-90 91-180 181+ Pregnt No

N (clients) 1768 368 362 381 657 457 

Mean LOS (days) 151.8 15.6 58.2 140.2 286.5 143.2 

Clinical intensity 1 2.9 1.6 0.9 0.9 varies 

Episode cost by component 

Intake $834 $834 $834 $834 $834 $834 

Resid. Care $11,686 $1,201 $4,480 $10,793 $22,055 $11,024 $

Clin. Care $11,670 $3,478 $7,159 $9,701 $19,824 $11,130 $

Total, per client $24,190 $5,513 $12,473 $21,327 $42,712 $22,988 

$
243 
Benefit Types Included 

• Only benefits to society 

• Only benefits that can be quantified from study 

data and then monetized based on outside 

literature 

• Include both in-treatment and post-treatment (P

benefits 

• Include both client- and child-related benefits 

• Estimate PT benefits for at least 1 year 
Benefits to be Estimated 

• In-treatment: reduced crime, reduced 

T ANF, reduced foster care 

• Post-treatment: reduced crime (1 yr), 

reduced T ANF ( 1 yr ), reduced Foster Ca

(33 mos), reduced LBW (lifetime) 
Crime Reduction, by In-tx Post-tx (1 yr

Type of Offense Unit Units Units Saving Units Units S

cost avert avert (mn) avert avert (m

($) (total) (mn) (total) (mn) 

Drug sale, dist., manfr. 26 5150 2.9 $76 9162 5.2 DWI, DUI 58 1292 0.7 $42 1973 1.1 

Forgery, fraud 690 2505 1.4 $978 5504 3.1 $

Fencing stolen propty 124 2540 1.4 $178 4291 2.4 

Gambling, bookmaking 8 1164 0.7 $5 1360 0.8 

Prostitution 54 3465 2.0 $106 6083 3.4 Burglary/auto theft 1637 1644 0.9 $1522 3534 2.0 $

Other theft 915 2153 1.2 $1114 3295 1.9 $

Robbery 5944 511 0.3 $1718 1074 0.6 $

Aggravated assault 5440 983 0.6 $3025 1469 0.8 $

Vandalism 58 836 0.5 $27 1572 0.9 

Total 22243 $8791 39317 $

__ 

" 

______________ 
Benefit type and amount Unit cost Total Mean 

($) N=1,768 clien

Crime 

In-tx: N crimes averted 22,243 

Savings vanes $15,543,283 $8

Yr post-tx: N crimes avrt. 39,317 

Savings vanes $28,288,327 $16

Crime total $43,831,610 $24

TANF (&Food Stamps) 

In-tx: N sup. days averted 121,071 

Savings $31/day $3,753,201 $2

Y r post-tx: N sup. yrs avrtd 349 

Savings $11 ,300/yr $3,943,700 $2

TANF total $7,696,901 $4
Benefit type and amount Unit cost($) Total Mean 

(continued) N=1,768 clien

LBW Deliveries 

N LBWs averted 55 

1st year med cost saving $25,413 $1,397,715 $

Lifetime med/ edu saving $423,760 $23,3 06,800 $13,

LBWtotal $449,173 $24,704,515 $13,

Foster Care (FC) 

In-tx: N days for FC kids 48,432 

Saving $64/day $3,099,648 $1,

Post-tx: FC plmts averted 1,217 

Saving $64,218/plmt $78,153,306 $44

FC total $81,252,954 $45
RWC/PPW Benefit Summary 

Benefit type and Savings Total Mean 

period Quantity ($M) ($thou) 

Total (n=1,768) 157.5 89.1 

In-tx offsets 22.4 12.7 

Foster care 48,432 days 3.1 1.8 

Crime 22,24 3 crimes 15.5 8.8 

Public support 121,071 days 3.8 2.1 

Post-tx benefits 135.1 76.4 

LB W, lifetime 55 LBWs 24.7 14.0 

Foster care, 1st plmt 1,217 placemts 78.2 44.2 

Crime, 1st yr 39,317 crimes 28.3 16.0 

Pub. assist pt yr 349 families 3.9 2.2 
140 

c 120 .! i 100 

c 80 

60 

-

! 40 

.! 

8 20 

0 

Figure 3. Average RWC/PPW Costs 

and Treatment-related 

Cost 

All clients 

(n=l768) 

Cost Benefit 

Long-stay 

clients 

(n=657) 

Cost Benefit 

Pregnant 

clients 

(n=457) 

Welfare 

Foster 
Conclusions 

Q: Do program benefits exceed costs? A: Y

Total B exceeds Total C by $65,000/client 

($89.1K-$$21.2K), for B/C=3.7:1 

• For LT, B-C=$76,000; B/C=2.8: 1 

• For preg, B-C=$103,000; B/C=5.5:1 

• Post-tx B ($76.4K)/net C ($11.5K)==6.6: 1 
Caveats 

• Outcome data from client self-rep

• No control group 

• Benefit estimates conservative and 

incomplete in type, duration 

• Analysis excluded role of leverage

• services 
(253) 

1The prepared statement of Senator Johnson appears in the Appendix on page 285. 

2The prepared statement of Senator Carper appears in the Appendix on page 286. 

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

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. 

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: Hon-
254 

duras, 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. 
255 

1The prepared statement of Mr. Botticelli appears in the Appendix on page 288. 

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. 

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. 
256 

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 drugtrafficking 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. 
257 

1The prepared statement of Ms. Enomoto appears in the Appendix on page 298. 

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. 

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 discre- tionary 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. 
258 

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 coprescribing 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 Mon-
259 

1The prepared statement of Ms. Maurer appears in the Appendix on page 308. 

itoring 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. 

Drug trafficking, drug abuse, and the associated impacts on public health and safety have been longstanding issues. Combating 
260 

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 socalled ‘‘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. 
261 

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 
262 

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 
263 

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. 
264 

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. 
265 

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. 
266 

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. 
267 

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, 
268 

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? 
269 

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, 
270 

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 buprenorphineprescribing 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 testi-
271 

monies 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 
272 

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 
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1The information submitted by Mr. Botticelli appears in the Appendix on page 329. 

my staff to see if they have specific data, as it relates to Federal 

hiring practices.1

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- 
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1The information submitted by Mr. Botticelli appears in the Appendix on page 330. 

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

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 povertystricken 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? 
275 

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.] 
276 

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 
277 

1The information submitted by Mr. Botticelli appears in the Appendix on page 332. 

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

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 
278 

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 re-
279 

lapse 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 
280 

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 Pen ̃ a 

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 
281 

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 dis-
282 

orders. 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. 
283 

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.] 

(285) 

A P P E N D I X 
286 

Statement of Ranking Member Tom Carper 

"America's Insatiable Demand for Drugs: Assessing the Federal Response" 

Tuesday, May 17,2016 

As preparedfor delivery: 

Thank you, Mr. Chairman, for holding this hearing today to examine the federal government's 

efforts to stem the demand for illegal drugs and treat the substance abuse disorders that fuel it. I 

look forward to hearing from our witnesses on this difficult issue that has developed into a health 

emergency across the country and to learning more about what the federal government is doing 

and should be doing to address the root causes of this complex challenge. 

As we all know, substance abuse, particularly prescription opioid and heroin abuse, has been a 

growing problem in our country for a number of years now. According to the Centers for Disease 

Control, there has been a dramatic increase in opioid-related overdoses in recent years with the 

number of incidents actually quadrupling since 2000. And opioids, primarily prescription pain 

relievers and heroin, are the main cause of overdose deaths. All told, there were just over 47,000 

drug overdose deaths in 2014 in our country, up from just under 44,000 in 2013, a more than six 

percent increase in just one year. Even when drug abuse is not deadly, it inflicts other damage, 

not just on those doing the drugs, but also their families and communities. And we must also be 

honest about how our country's demand for drugs has fueled violence and disorder in Mexico 

and much of Central America, breaking down communities and touching families throughout the 

region. 

This committee is familiar with the work the Department of Homeland Security and others do at 

and around our borders to stop the supply of illicit drugs coming into our country. But as former 

SouthCOMM Commander General Kelly has told us, we cannot intercept our way out of this 

problem. We must do more to address the demand for drugs. That means looking at the challenge 

we face as a public health crisis, not just a law enforcement issue. 

Simply put, substance abuse issues are complex and require a robust and comprehensive 

response. We of course need to make sure that our law enforcement agencies have the tools and 

resources they need to combat drug trafTickers and reduce the supply drugs available in our 

country. But we also need to make sure we're investing in public health and funding treatment 

and other initiatives that can reduce the demand for drugs. We also need to ensure that these 

efforts are well coordinated, and that the agencies involved arc working effectively with states 

and localities. 

That's why I'm pleased to see that the individual responsible for our national drug control 

elTorts, the Director of the Office of National Drug Control Policy, Michael Botticclli, is here to 

provide insight into what the Obama Administration has done in the last several years to address 

these issues. I'm also pleased to sec that the Principal Deputy Administrator at the U.S. 

Substance Abuse and Mental Health Services Administration (SAMHSA), Ms. Kana Enomoto, 

is here to provide us with information on the government's efforts to prevent and treat substance 

abuse disorders, as we all know that treatment and prevention are crucial if we want to reduce the 
287 

demand for drugs. Additionally, Ms. Diana Maurer, Director of Homeland Security and Justice 

at the GAO, will provide us with an overview of the progress made toward our national drug 

control strategy goals and the work that remains to be done in this area. 

In sum, this problem we're facing is complex, and the potential solutions are neither quick nor 

easy. Getting a handle on drug abuse and substance abuse disorders and the tragic problems that 

stem from them both in our communities, and in neighboring countries, will require an all-handson-deck effort. Again, my thanks to our Chairman for holding this hearing and to our witnesses 

for their contributions. I look forward to reviewing our federal efforts to reduce the supply and 

demand for illegal drugs. 
288 

EXECUTIVE OFFICE OF THE PRESIDENT OFFICE OF NATIONAL DRUG CONTROL POLICY 

Washington, D.C. 205 u;~ 

Assessing the Federal Response to Drug and 

Opioid Use 

Homeland Security and Government Affairs Committee 

United States Senate 

Tuesday, May 17,2016 

2:30p.m. 

Statement of 

Michael P. Botticelli 

Director ofNational Drug Control Policy 
289 

Overview 

Chairman Johnson, Ranking Member Carper, and members of the Committee, thank you 

for this opportunity to discuss the Office of National Drug Control Policy's authorities and 

efforts to collaboratively carry out President Obama's drug control priorities. 

The Office of National Drug Control Policy (ONDCP) was established by Congress in 

1988 with the principal purpose of reducing illicit drug use, manufacturing, and trafficking; 

drug-related crime and violence; and drug-related health consequences. As a component of the 

Executive Office of the President, ONDCP establishes policies, priorities, and objectives for the 

Nation's drug control programs and ensures that adequate resources are provided to implement 

them. We also develop, evaluate, coordinate, and oversee the international and domestic antidrug efforts of Executive Branch agencies and ensure such efforts sustain and complement state 

and local drug policy activities. 

At ONDCP, we are charged with producing the National Drug Control Strategy 

(Strategy), the Administration's primary blueprint for drug policy, along with a national drug 

control budget. The Strategy is a 21" century plan that outlines a series of evidence-based 

reforms that treat our Nation's drug problem as a public health challenge, not just a criminal 

justice issue. It is guided by what science, experience, and compassion demonstrate about the 

true nature of drug use in America. 

Status of Drug Use and Availability 

The Strategy takes a thorough and comprehensive approach to addressing .drug use and 

availability. With its inaugural 20 I 0 Strategy, the Administration stressed a public health and 

public safety approach that recognized substance use disorder is a disease of the brain that can be 

prevented, treated, and from which people can recover. It also recognized the continued 

importance of law enforcement efforts, including interdiction and cooperation with international 

partners to reduce the supply of illicit drugs. 

The Strategies have produced results. In 2012, the Nation saw the first decline in the rate 

of deaths involving opioid medications. From 1999 to 2011, these death rates increased each 

year, rising from 2.4 deaths per 100,000 population to 6.2. In 2012, they dipped to 5.8 and 

remained there in 2013 before rising again to 6.5 in 2014. 1 This rise in 2014 may likely be 

attributed to fentanyl. The rate of overdose deaths involving synthetic opioids nearly doubled 

between 2013 and 20 14; it includes prescription opioids and non-pharmaceutical fentanyl 

manufactured in illegal laboratories, and toxicology tests used by medical examiners and 

coroners are unable to distinguish between the two. 2 With the continued implementation of the 

various elements of the Administration's plan for addressing this crisis, including increasing 

access to treatment for opioid use disorders, improving prescription drug monitoring programs 

and their interoperability, expanding distribution of the opioid overdose antidote naloxone to all 

first responders, prescriber education, expanding local prescription medication disposal 

1 Centers for Disease Control and Preventwn (CDC), Natwna! Center for Health Statistics Multiple Case of Death, !999~2014 on CDC 

WONDER Online Database, released 20 I 5. Extracted by ONDCP from http ifv·,'Ondcr cdc.goY/mcd-Kd 10 ht!nl on December 9, 20 !5 2 Rose A. Rudd, MSPH, Noah Aleshire, JD, Jon E. Zibbell, PhD: R Matthew Gladden, PhD Centers for Disease Control and Prevention (CDC} 

Morbtd!ty and Mortality Weekly Repon. Increases in Drug and Opioid Overdose Deaths- United States 2000~2014 Weekly January I. 2016 

64(50}, 1378-82 Available at· http //w,.,'\V cdc gov/mmv .. r/prcvJew/mmmhtml/mm6450a3 htm 

I 
290 

programs, and continuing law enforcement actions against pill-mill operators and suppliers and 

traffickers of heroin and illicit fentanyl. we are hopeful that the Nation will see renewed declines 

in deaths involving all opioids. 

Our hope is fueled by recent reductions in the non-medical use of these powerful drugs. 

Among youth age 12 to 17, current non-medical use of these drugs declined 29 percent from 

2009 to 2014, and 39 percent among young adults age 18 to 29. Perhaps most importantly, 

initiation of nonmedical use of opioid medications is down 35 percent over this same period, 

from 2.2 million in 2009 to 1.4 million in 2014. These significant declines in the number of nonmedical prescription opioid use by youth and young adults, and in the number of new initiates, 

demonstrate the effectiveness of this Administration's policies, including education and 

prevention efforts on the harms of prescription opioid misuse. 

From 2009 to 2014, there have been reductions in the use of illicit drugs other than 

marijuana, dropping 21 percent among youth age 12 to 17, and 20 percent among young adults 

age 18 to 29. The declines have been driven by decreases in the non-medical use of prescription 

drugs, ecstasy, hallucinogens, and inhalants3 Substantial progress also has been achieved in 

reducing alcohol and tobacco use among youth, the two most frequently used substances at this 

age. Among 8'h grade students, the rate of lifetime use of these substances declined 28 percent 

for alcohol (from 36.6 percent in 2009 to 26.1 percent in 20 15) and 34 percent for cigarettes 

(from 20.1 percent to 13.3 percent in 20 15) 4 These declines exceeded the targets established for 

them in the 20 l 0 Strategy. 

Substantial progress also has been achieved in reducing the number ofHIV infections 

attributable to intravenous drug use. Such infections fell from 5,799 in 2009 to 4,366 in 2013, 

exceeding the 2015 Strategy target of 4,929. 5 Nonetheless, only certain parts of the country have 

benefitted from policies to reduce the risk of exposure to blood-borne infections. For example, in 

rural southeastern Indiana, intravenous use of prescription oxymorphone caused an HIV outbreak 

where 191 persons have tested positive since January 2015 6 This outbreak reminds us that more 

work remains. 

Despite these achievements, much remains to be done. The past five years have seen an 

alarming increase in deaths involving heroin, rising from 3,038 in 2010 to l 0,574 in 2014. 7 This 

increase has been accompanied by a sharp rise in the availability of purer forms of heroin that 

allow for non-intravenous use, a and at a relatively lower price, 9 and an increase in the initiation 

of heroin use (from 116,000 people in 2008 to 212,000 in 2014). 10 Drugged driving continues to 

be of great concern. In 2007, the National Highway Traffic Safety Administration estimated that 

16.3 percent of the Nation's weekend nighttime drivers tested positive for an illicit drug or 

1 Center for Behavwra! Health Stat! sues and Quality (CBHSQ), 2015. 20J.I .11./arwnal SwWJ' on Drug Use and Health (NSDUH;_· Detailed 

Tables Substance Abuse and Mental Health Serv1ces Admm1strat1on, Rockville, MD 4 Johnston, L.D., O'Malley, P.M_, Micch, R A, Bachman, JG.: and Schulenberg, J.E. 2015 D.: 2015. Momtoring the Future. Nat tonal Sun•ey 

Results on Dt7ig Use. 2015 Oven·iew. Key Findmgs on Adolescent Drug Use The University ofMtchigan, lnst1tute for Socta! Research. Ann 

Arbor, Ml 

'Centers for Disease Control and Prevention. February 2015 HIV Surveillance Report-Dmgnoses ofHIV Infection m the Umted States, 2013 

Vol 25. Department of Health and human Services, Washington, DC 6 Morbidity and Mortality Weekly Report (M"MWR). Community Outbreak of!HV lnfectwn Lmked to Injection Drug Use ofOxymorphonelndiana, 2015,64 (16); p 443-444, May L 2015. Data from State oflnd1ana, available at https //secur<.' m nnv/isdh/26649 htm 7 Opcit, CDC WONDER 2015 

~Drug Enforcement Admmtstration Strategic Intelligence Sectton 2015 National Heroin Threat Ass~ssment. DEA-DCT-DIR-039q 1 5 

')Drug Enforcement Administration System to Retneve lnfonnatlon from Drug Evidence (STRIDE), Price and Punty Data, 2015 10 Op Clt., C'BHSQ NSDUH 2015 

2 
291 

medication capable of impairing driving skills. Unfortunately, by 2013/2014 that estimate had 

risen to 20.0 percent. 11 

Drug Policy Priorities and Strategy Goals 

ONDCP produces the Strategy each year in partnership with our fellow Federal agencies 

and with extensive feedback and input from stakeholders across the country and around the 

world. The Strategy establishes the framework for the Nation's drug control efforts, focusing on 

prevention, early intervention, treatment and recovery support, criminal justice reform, law 

enforcement efforts, and international partnerships. The Strategy also reviews the results of 

current data and research efforts that inform our policies, and identifies areas where more 

information is needed. 

To assist in establishing policy and evaluating the success of our efforts, the Strategy 

includes two broad pol icy goals accompanied by performance measures and targets. The 

Strategy seeks to: (I) Curtail illicit drug consumption in America, and (2) Improve the public 

health and public safety of the American people by reducing the consequences of drug use. 

There are 15 data items that inform seven Strategy Measures in support of the two goals. In 

addition, for the past six years, each chapter of the Strategy has included action items assigned to 

Federal agencies. Each action item addresses an area of policy critical to improving the health 

and safety of our Nation. Completion of these action items supports the Administration's efforts 

to meet the goals of the Strategy. 

Overview of 2015 Strategy 

President Obama's inaugural Strategy, released in May 2010, labeled opioid overdose a 

"growing national crisis" and laid out specific actions and goals for reducing nonmedical 

prescription opioid and heroin use. 12 

Building on this, the Administration released a comprehensive Prescription Drug Abuse 

Prevention Plan (Plan) 13 in 2011, which created a national framework for reducing prescription 

drug diversion and misuse. The Pian focuses on: improving education for patients and healthcare 

providers; supporting the expansion of state-based prescription drug monitoring programs; 

developing more convenient and environmentally responsible disposal methods to remove 

unused and unneeded medications from the home; and reducing the prevalence of pill mills and 

diversion through targeted enforcement efforts. 

Success in each of these efforts has been the result of concerted collaboration among 

Federal agencies and coordination by ONDCP. Since the release of this plan, our efforts have 

built upon this foundation and have expanded to respond more comprehensively to the growing 

crisis. 

11 Natwna! Highway Traffic Safety Admmistration. 2015. TratTic Safety Fact<;. Research Note. Results ofthe 2013-20!4 National Roads1de 

Survey of Alcohol and Drug Use by Dnwrs. Depanment of Transportation (DOT HS 812 I 1 8) 

~~Office ofNat10nal Drug Control Policy. 2010 National Drug Control Strategy ExecutJVe Office of the President [2010] Ava!lab!e 

bll!21h'!~YW whitehouse gov/sites/dc!J.ult!!iles/ondcp/po! icv-and-r..::scarch/ndc.QO I 0 .pdf'#paec-""49 

n Office of National Drug Control Poltcy. Epidemic: Respondmg to Amenca's Prescription Dmg Abuse Cn.sis [201 1 l Available: 

http //m\ \\ \\ h ltthOl!'iC~[Sllt's/dcJ(utlt/!1 lcs/ondcph'isucs·contt'ntlprescrtr!Jnn-drugs/r' <Jbu:.c pl3Q£Qf 

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The Administration has increased access to treatment for substance use disorders, 

expanded efforts to prevent overdose, and coordinated a Government-wide response to address 

the consequences of opioid misuse. We have worked to educate prescribers and the public on the 

risks associated with misusing prescription opioids. We have worked with state and local 

governments to improve legislative and policy responses to opioid use in their communities. We 

have also continued to pursue actions against criminal organizations trafficking in opioid drugs 

and we continue our close cooperation with the Government of Mexico to disrupt criminal 

networks and reduce the flow of heroin from Mexico into the United State. 

Mexico is currently the primary supplier of heroin to the United States, with Mexican 

drug traffickers producing heroin in Mexico and smuggling the finished product into the United 

States. 14 Opium poppy cultivation in Mexico has increased substantially in recent years, rising 

from 17,000 hectares in 2014, with an estimated potential pure heroin production of 42 metric 

tons, to 28,000 hectares in 2015 with potential production of70 metric tons of pure heroinY 

Additionally, we are working with several states to obtain better reporting on the use and abuse 

of fentanyl to help us better understand the increased availability of fentanyl in the United States. 

This not only includes reporting on fentanyl seizures by law enforcement agencies but also postmortem detection of fentanyl in suspected overdose cases that may not be attributed to heroin 

alone. 

At the same time, we have focused on addressing Neonatal Abstinence Syndrome and 

opioid use disorder among pregnant women; worked with Congress to revise the ban against 

federal funds for syringe service programs; expanded the availability of medication assisted 

treatment for opioid use disorder, including increasing the number of trained and waivered 

healthcare providers that can prescribe buprenorphine; and taken budget and policy actions that 

have expanded the availability and use of the opioid overdose reversal medication naloxone, 

including by law enforcement and other first responders. In each of these areas, multiple 

agencies have come together to leverage resources and policy expertise toward a common goal. 

How the Drug Budget is Aligned with Policy Priorities 

ONDCP's authorities allow it to engage in a policy and budget development process that 

is dynamic, nimble, and responsive to the needs of communities and which allow us to 

collaborate effectively with Congress, state and local governments, community organizations, 

individual citizens, and other stakeholders. 

Nowhere is this more evident than in the Federal response to the prescription drug and 

heroin epidemic currently facing our Nation. ONDCP's oversight of the National Drug Control 

Budget ensures the Federal Government's drug control efforts are well coordinated and support 

the objectives of the Strategy. Since the Administration's inaugural2010 Strategy, we have 

deployed a comprehensive and evidence-based strategy to address opioid use disorders and 

opioid induced overdose deaths. ONDCP's annual funding guidance to Drug Control Program 

agencies emphasized the need for increased access to treatment for substance use disorders, 

expanded efforts to prevent overdose, and a coordinated Government-wide response to address 

the public health and public safety consequences of substance use-particularly heroin use and 

14 Drug Enforcement Administratwn. Strategic Intelligence Section. 2015 National Heroin Threat Assessment. DEA-DCr-DIR~039w J 5 15 US Department of St:::J.te, Bureau of International Narcotics and law Enforcement AtTairs Int~rnational Narcotics Control Strategy Report20! 5[1NCSR] (March 2015) for data from 2013- 20!4 and unpubilshed U.S. Government Estimates 

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the non-medical use of opioid medications. The guidance also recognizes the need for continued 

interdiction and enforcement actions against criminal drug trafficking organizations. 

The funding guidance provides Drug Control Program agencies notification of the budget 

priorities needed to support the objectives of the Strategy. ONDCP reviews and makes funding 

recommendations on the budget submissions of Drug Control Program agencies twice during 

each budget cycle. The budgets are first reviewed in the summer when bureaus submit budget 

data to their respective Departments for review. They are reviewed a second time in the fall 

when Departments submit their budgets to the Office of Management and Budget. ONDCP 

coordinates closely with policy and budget officials to ensure that ONDCP funding priorities are 

supported as much as possible in the President's Budget. 

ONDCP's efforts have helped to secure necessary resources for the Administration's 

priorities, and align overall funding to reflect a balanced demand reduction and supply reduction 

approach to drug control efforts. 

When the Administration took office, 37 percent of Federal drug control resources were 

devoted to demand reduction efforts such as preventing and treating substance use disorders. In 

FY 2017,51 percent of Federal drug control resources are requested for demand reduction and 

49 percent of Federal drug control resources are requested for supply reduction. This is the first 

time that more Federal funding has been requested to support drug treatment and prevention than 

for supply -reduction efforts. 

The total national drug control policy budget request in FY 2017 is $31.1 billion. This is 

half-a-billion dollars more than the FY 2016 enacted level and represents an increase of 

$6.2 billion (+25 percent) in drug control funding since the beginning of the Administration. 

Since the Administration took otlice in 2009, the policy guidance and the drug control funding 

levels supporting those policies show that ONDCP's efforts have contributed to a change in how 

the Federal government approaches substance use and its consequences. The FY 2017 

Administration's request of $15.8 billion for drug treatment and prevention includes an increase 

of$6.7 billion since the beginning of the Administration, increasing the amount of funding 

available for demand reduction programs by more than 70 percent. In FY 2017, the 

Administration requests more than $15.2 billion for supply reduction programs. Since 2009, the 

funding request for supply reduction efforts has provided increases for domestic law enforcement 

(+$63 million) and interdiction (+$439 million), but a reduction in funding for international drug 

control (-$952 million). 

The FY 2017 drug control budget matches the seriousness of the situation we face as a 

nation. The President's FY 2017 Budget takes a two-pronged approach to address the opioid 

epidemic. First, it includes $1 billion in new mandatory funding over two years to expand access 

to treatment and recovery support services for those suffering from opioid use disorder. This 

funding will boost efforts to help individuals seek and complete treatment, and sustain recovery. 

This funding includes: 

$920 million to support cooperative agreements with States to expand access to treatment 

for opioid use disorders. States will receive funds based on the severity of the epidemic 

and on the strength of their strategy to respond to it. States can use these funds to expand 

treatment capacity and make services more affordable. 
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$50 million to the National Health Service Corps to expand access to substance use 

disorder treatment providers. This funding will support approximately 700 substance use 

disorder treatment providers in areas most in need of these services. 

$30 million to evaluate the effectiveness of treatment programs employing medicationassisted treatment and to improve treatment for patients with opioid usc disorder. 

This investment, combined with efforts to reduce barriers to treatment for substance use 

disorders, is a critical step in helping every American who wants treatment access it and get the 

help they need. 

In addition to the request for new mandatory funding, the President's FY 2017 Budget 

request includes an increase of more than $90 million for the Departments of Justice and Health 

and Human Services to continue expanding state-level prescription drug overdose prevention 

strategies, increase the availability of medication-assisted treatment programs, improve access to 

the overdose-reversal drug naloxone, and support targeted enforcement activities. A portion of 

this funding is directed to rural areas, where rates of opioid use and overdose are high and access 

to resources is limited. 

Evaluating the Effectiveness of Drug Policy Programs. 

As for so many of the issues facing our Nation, we must continue seeking new and 

clTcctive solutions to reduce drug use and its consequences. As policy develops in response to 

the changes in drug trafficking and use, ONDCP has been able to work in partnership with the 

Federal Drug Control agencies to develop new programs and expand successful ones. 

Measuring performance is a key tool for ONDCP in its oversight of National Drug 

Control Program agencies- it enables ONDCP to assess the extent to which the Strategy is 

achieving its goals, and accounts for the contributions of individual drug control agencies. 

ONDCP's approach to performance evaluation includes several elements. 

The first element is implementation of the Strategy. The Strategy identifies Action Items 

that arc essential to achieving the Strategy's Goals and Objectives. The implementation of these 

action items by interagency partners is monitored by ONDCP's Delivery Unit, which works with 

ONDCP components to coordinate and track progress. When progress is not being achieved, 

relevant agency partners are convened to assess challenges and implement corrective actions. 

Additionally, once funds are appropriated by Congress, Drug Control Program agencies submit 

financial plans to ONDCP with account-level detail that links the drug budget to the operating 

budget, and provides policy officials with the information to make resource allocation decisions. 

Occasionally, an agency may seek to reprogram funding to address an unanticipated need. Drug 

Control Program agencies that seek to reprogram or transfer appropriated Drug Control Program 

funds exceeding one million dollars must have the request approved by ONDCP. 

The second element is the Performance Reporting System (PRS). As noted above, the 

S1rategy has two overarching goals: (I) curtailing illicit drug consumption in the United States; 

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and (2) improving the public health and public safety ofthe American people by reducing the 

consequences of drug use. ONDCP and its Federal partners use the PRS to assess progress 

toward meeting specific quantitative targets of the Strategy's Goals and Objectives. The 

Strategy's overarching goals call for reductions in the rate of young adult drug use, chronic drug 

use, and drug-related consequences, such as drug-related morbidity and drugged driving. The 

PRS' seven objectives focus on prevention, early intervention, treatment & recovery support, 

breaking the cycle of drug use and crime, drug trafficking and production, international 

partnerships, and enhancing data sources to inform policies, programs, and practices. 

Data from the Substance Abuse and Mental Health Services Administration (SAMHSA), 

National Institute on Drug Abuse (NIDA), Centers for Disease Control and Prevention (CDC), 

Health Resources and Services Administration (HRSA), Department of Justice, Department of 

State, and ONDCP are used to track 32 measures. These data are used to track progress-to-date 

compared to the baseline for each measure. In reviewing these data, ONDCP and its Federal 

partners look at trends and shifts in trends that may be a sign of an emerging issue. An example 

would include monitoring trends of drug-induced deaths. In 2009, there were 39,147 druginduced deaths; 37,004 of these were drug poisoning deaths and 20,848 of those were reported to 

involve prescription drugs. In 2013, there were 46,471 drug-induced deaths, an increase of 19 

percent compared to 2009. These data, among other data and information, prompted a more 

extensive review that was used to inform ONDCP's response to shifts in prescription drug 

misuse and heroin use. 

A third element ofONDCP's approach to performance is the Performance Summary 

Report (PSR). Individual agency performance summary reports are a component ofONDCP's 

assessment of agency performance. These reports provide the Administration and Congress with 

independent assessments of agency accountability systems- the measures, the process of 

developing targets, the quality of data systems, and the use of performance information. 

Progress on Strategy Goals 

A suite of seven measures, informed by 15 data items, was developed to assess the 

Nation's progress toward achieving the Strategy's goals. The 2015 PRS Report found good 

progress in a number of areas, including a decrease in 30-day prevalence of drug use among 12-

17 year olds, a decrease in lifetime prevalence of S'h graders using alcohol and tobacco, a 

reduction in HIV infections attributable to drug use, and reduction in the number of chronic 

cocaine and methamphetamine users. 

However, challenges remain. We have not achieved reduction targets for lifetime 

prevalence of 81

h graders using illicit drugs and have not made progress on reducing drug use 

among 18-25 year olds. The primary reason for this lack of success is the continued and 

unchanging high prevalence of past month marijuana use among young adults-nearly 20 

percent since 2009. However, when marijuana is excluded from the estimation of illicit drug 

use, the Nation has actually already doubled the targeted reduction-a 20 percent decline from 

2009 to 2013. This decline has been driven by a 25 percent decline in past month non-medical 

use of prescription drugs overall, which in turn was driven by a 31 percent decline in past month 

non-medical use of prescription opioid medications. 

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The heroin crisis is being compounded by the emergence of illicit fentanyl, a powerful 

opioid more potent than morphine or heroin. 16 Fentanyl is sometimes added to heroin to increase 

potency, or mixed with adulterants and sold as heroin with or without the buyer's knowledge. 

Some states are being hit especially hard by fentanyl-related overdoses. For example, Ohio med 

ical authorities reported 514 fentanyl-related overdose deaths in Ohio in 2014 alone up from 92 

in the previous yearY And in New Hampshire, the Office of the Chief Medical Examiner reports 

that out of 433 drug deaths in 2015, 396 involved opioids. Of those deaths involving opioids, 281 

involved fentanyl and 88 involved heroin. 18 

In response, and per the Strategy, ONDCP coordinates with Federal partners to identify. 

disrupt and dismantle criminal organizations trafficking in opioid drugs; works with the 

international community to reduce the cultivation of poppy; identifies labs creating dangerous 

synthetic opioids like fentanyl and acetyl-fentanyl; and enhances efforts along the Nation's 

borders to decrease the flow of these drugs into our country. Expanding on these efforts, in 

October, ONDCP created the National Heroin Coordination Group, a multi-disciplinary team of 

subject matter experts to lead Federal efforts to reduce the availability of heroin and fentanyl in 

the United States. This hub of interagency partners will leverage their home agency authorities 

and resources to disrupt the heroin and illicit fentanyl supply chain coming into the U.S. and will 

establish mechanisms for interagency collaboration and information-sharing focused on heroin 

and fentanyl. 

With regard to drugged driving, the data are mixed. As noted above, data from the 

National Highway Traffic Safety Administration's National Roadside Survey show the Nation 

moving in the wrong direction on drug-involved driving. Results from the 2013/2014 survey 

indicated that driving after consuming drugs on weekend nights was 20 percent, up from 16.3 

percent in 2009. ONDCP also is tracking the prevalence of drugged driving with self~report data 

from the National Survey on Drug Use and Health (NSDUH). According to data from the 2014 

NSDUH, the United States is almost at its target of reducing drugged driving by 10 percent by 

2015. The baseline rate of drugged driving for drivers 16 and older in 2009 was 4.4 percent; the 

target rate by 2015 is 4.0 percent; and in 2014 at the rate achieved was 4.1 percent. 

Coordinating Drug Control Efforts to Eliminate Duplication 

ONDCP coordinates drug control efforts and eliminates duplication through a variety of 

mechanisms. ONDCP works closely with all Federal drug control agencies to develop the 

President's National Drug Control Strategy, and the drug control budget. Additionally, ONDCP 

leads a broad range of interagency groups that support the Strategy's initiatives. Examples 

include interagency working groups on treatment, prevention, and data, the Interdiction 

Committee, the National Heroin Task Force, and the National Heroin Coordination Group. 

11' Zuunnond WW. Mecrt TF, and Noorduin H (2002). Partial versus full agonists for opwid-mediated analgesm--focus on fentanyl and 

buprenorphine. Acta Anaesthesia! Bel g. 53(3): 193-20 I 17 2014 Ohro Overdose Prelim mary Data· General Findings, Oh!O Department of Health, OtT!ce ofV1tal Statistics; Analysis Conducted by 

AvaJlab!e at 

20! 5 Current Drug Data as ofApnl 

14,2016 

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In 2013, the General Accountability Office (GAO) released a report indicating 

overlapping services in substance use prevention and treatment, which could increase the risk of 

duplication. As a follow up to this report, ONDCP undertook an assessment of the extent of 

overlap, duplication, and coordination. ONDCP found that nearly all of the identified programs 

serve distinct beneficiaries in distinct settings. In a few cases where overlap could occur, a 

review of the grantees found duplication did not occur. Further, ONDCP found that the agencies 

managing these programs have coordinated their programs to achieve the best results. In a few 

cases, ONDCP found a limited number of programs that would benefit from greater coordination 

and worked with the programs to enhance it. 

ONDCP continues to coordinate with Federal agency partners and lead interagency 

working groups to prevent program overlap. We appreciate GAO's recognition that ONDCP's 

actions mean ONDCP "will be better positioned to help ensure that federal agencies undertaking 

similar drug abuse prevention and treatment efforts better leverage and more efficiently use 

limited resources." 

Conclusion 

Achieving the Strategy's goals takes extensive effort at the federal, state and local level. 

ONDCP will continue to lead the Federal Government in addressing drug use and its public 

health and public safety consequences, including the opioid epidemic. ONDCP's guidance and 

coordination with our Federal partners maintains focus on the President's policy and funding 

priorities, and helps states and communities address illicit substance use. Together, we are 

committed partners, working to reduce the prevalence of substance usc disorders through 

prevention, increasing access to treatment, and helping individuals recover from the disease of 

addiction. These efforts are also accompanied by a focus on effective law enforcement and 

supply reduction strategies to interrupt drug trafficking networks. Thank you for the opportunity 

to testify and for your ongoing commitment to these issues. !look forward to continuing to work 

with you on these pressing matters. 

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Testimony Before the 

U.S. Senate Committee on Homeland Security and Governmental Affairs 

Hearing to Examine "America's Insatiable Demand for Drugs: Assessing 

the Federal Response" 

May 17,2016 

Statement of Kana Enomoto 

Principal Deputy Administrator 

Substance Abuse and Mental Health Services Administration 

U.S. Department of Health and Human Services 
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Good morning Chairman Johnson, Ranking Member Carper, and distinguished members 

of the Committee. My name is Kana Enomoto, and I am the Principal Deputy Administrator of 

the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency of the 

Department of Health and Human Services (HHS). I am pleased to be here, along with my 

colleagues from the Office ofNational Drug Control Policy (ONDCP), to discuss the importance 

of preventing substance misuse and ensuring appropriate treatment and recovery support services 

for individuals with substance use disorders in America. 

The problems of prescription misuse, illicit drug use, and substance use disorders are complex 

and require epidemiological surveillance, prevention, interventions, policy changes and further 

research. No organization or agency can address these problems alone; a coordinated response is 

required. The Federal Government, medical and other health partners, public health officials, 

state governments, and community organizations all are needed to implement educational 

outreach and intervention strategies targeted to a range of discrete audiences, including 

physicians, pharmacists, patients, educators, parents, students, adults at high risk, older adults, 

and many others. 

SAMHSA 

SAMHSA's mission is to reduce the impact of substance misuse and mental illness on America's 

communities. SAMHSA was established in 1992 and directed by the Congress to target 

substance usc prevention and treatment and mental health services to people most in need of 

them and to enhance the delivery of behavioral health services to all. Substance misuse, 

substance use disorders, poor emotional health, and mental illnesses take a toll on individuals. 

families, and communities. These conditions cost lives and productivity, and strain families and 

resources in the same way as untreated physical illnesses, yet the majority of those who need 

treatment do not receive it. SAMHSA strives to close this gap by raising awareness that: 

Behavioral health is essential to health; 

Prevention works; 

Treatment is effective; and 

People recover. 

SAMHSA is working with its partners across the Administration to implement the National 

Drug Control Strategy. SAMHSA is participating in various cross-departmental and intradepartmental workgroups to ensure coordination of policy and programs. 

SAMHSA also works across HHS through the Behavioral Health Coordinating Council. As a 

result, SAMHSA has partnerships with the Centers for Disease Control and Prevention 

(CDC), the Food and Drug Administration (FDA), the National Institutes of Health (NIH). 

the Centers for Medicare & Medicaid Services (CMS), the Office of the National Coordinator 

for Health Information Technology (ONC), the Office of the Assistant Secretary for Health 

(OASH), the O!Tice of the Surgeon General (SG), and the O!Tice of the Assistant Secretary for 

Planning and Evaluation (ASPE) working to prevent substance misuse and treat substance usc 

disorders. 

As you may know, in October, the Surgeon General announced that he would be developing a 

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report on substance use, addiction and health. SAMHSA is providing technical assistance with 

the development of this report and we look forward to its release. 

SAMHSA's Role in the National Drug Control Strategy (Strategy) 

In fiscal year (FY) 2017, a total of $31.1 billion, an increase of more than $500 million over FY 

2016 enacted, was requested by the President to support National Drug Control Strategy 

(Strategy) efforts to reduce drug use. The Administration's 21st century approach to drug policy 

works to reduce illicit drug use and its consequences in the United States. This evidence-based 

plan balances public health and public safety efforts to prevent, treat and provide recovery from 

the disease of addiction. In FY 2017, for the first time, the Administration proposes more funding 

for demand reduction than supply reduction. SAMHSA plays a key role in the prevention and 

treatment aspects of the Strategy, many of which also support HHS Secretary Burwell's initiative 

to address opioid misuse, abuse, and overdose. 

SAMHSA's Role in the Secretary's Evidence-Based Opioid Initiative 

SAMIISA is a key player in Secretary Burwell's initiative to address opioid misuse, abuse, 

and overdose. This initiative focuses on three specific areas targeted for their potential to produce 

the most impact: 

(I) Improving opioid prescribing practices; 

(2) Increasing the use of naloxone; and 

(3) Expanding use of medication-assisted treatment (MAT) and recovery support services 

for individuals with an opioid use disorder. 

According to the 2014 National Survey on Drug Use and Health (NSDUH), which SAMHSA 

conducts annually, 4.3 million individuals (aged 12 and older) reported non-medical use of 

prescription pain relievers during the past month and 435,000 reported using heroin. 1 That 

equals 1.6 percent of the population non-medically using prescription pain relievers and 

0.2 percent of the population using heroin. Although reports of heroin use are significantly 

lower than reported prescription opioid non-medical use, the numbers have been increasing fairly 

steadily since 2007. In fact, reported heroin use more than doubled in seven years from 161,000 

individuals in 2007 to 435,000 in 2014. 

Of the 4 7,055 drug overdose deaths in 2014, heroin was involved in 10,574 drug overdose deaths, 

while opioid analgesics were involved in 20,808 drug overdose deaths. Among the opioid 

analgesic category, there were more than 5,544 drug overdose deaths involving synthetic narcotics 

other than methadone. which includes fentanyl. The number of opioid overdose deaths involving 

synthetic narcotics more than doubled from two years earlier (2,628 in 2012). 1 

Of the individuals admitted to treatment in 2013, 18.8 percent of admissions were for heroin. 

1 Centers for Disease Control and Prevention, National Center for Health Statistics . . \lultiple Cause of Death J999-20N 

on CDC WONDER Online Database. released 2015. Data are from the Multiple Cause of Death Files, 1999-2014, as 

compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. 

Accessed at httr://\\ondt:r.cdc.e.ov/mcd~h:J 1 O.html, December 2015. 

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Another 9.2 percent of admissions were for other opioids 2 What these data do not fully reflect is 

the pain felt at losing a job, a home, or a cherished family member. Opioid and heroin use 

destabilizes families, disrupts the health care system, and imposes enormous financial and human 

costs on American society. 

SAMHSA's Opioid Proposals in the President's FY17 Budget 

Addressing the crisis of opioid overdose from prescription pain relievers, heroin, and illicit 

fentanyl is a major priority for SAMHSA. The President's Budget recognizes the need for 

immediate action and proposes to address the opioid epidemic with a $ J billion two-year 

investment in new mandatory funding. This investment of mandatory funds makes a bold 

commitment to build the addictions workforce and bolster the continuum of services for 

prevention, treatment, and recovery. 

Of the $! billion in new mandatory funding, SAMHSA proposes $920 million over two years to 

support cooperative agreements with states to expand access to treatment for opioid use 

disorders. In each of FY s 20 J 7 and 20 J 8, SAMHSA would provide $460 million in new 

mandatory funding toward State Targeted Response Cooperative Agreements for states to help 

individuals seek and successfully complete treatment and sustain recovery from opioid use 

disorders. Evidence-based strategies that states might consider include training and certifying 

opioid use disorder treatment providers and supporting delivery of MAT. Program goals 

include: reducing the cost of care, expanding access, engaging patients, and addressing the 

negative attitudes associated with accessing opioid use disorder treatment. 

Another component of the Administration's two-year initiative includes $30 million in new 

mandatory funding for SAMHSA to implement Cohort Monitoring and Evaluation of MAT, to 

evaluate the effectiveness of treatment programs employing medication-assisted treatment under 

real-world conditions. This program will help identify opportunities to improve treatment for 

patients with opioid use disorders. 

In addition to the new mandatory investments, SAMHSA continues and expands extstmg 

strategies to address opioid use disorders. SAMHSA is requesting $50. J million to double the 

size of the Medication Assisted Treatment Prescription Drug and Opioid Addiction (MATPDOA) program. The funding will support 23 new MAT-PDOA state grants in providing FDAapproved MAT in conjunction with psychosocial interventions to those living with opioid use 

disorders. 

'Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results 

ji-om the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927. NSDUH Series H50). Retrieved from http://www.samhsa.gov/data/ 2 Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results 

from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H50). Retrieved from http://www.samhsa.gov/data/ 

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To help further expand access to treatment, SAMHSA 's Budget Request includes a $10 million 

pilot project, the Buprenorphinc-Prescribing Authority Demonstration, aimed at increasing the 

types of practitioners able to prescribe buprenorphine, a medication for opioid use disorder 

treatment, where allowed by state law. This demonstration will test the safety and 

effectiveness of allowing prescribing buprenorphine by non-physician advance practice providers. 

In conjunction with these treatment efforts, SAMHSA is also proposing continued investments to 

prevent the misuse and overdose deaths related to prescription drugs, heroin, and fentanyl. The 

FY 2017 Budget maintains investments in the Prevention of Prescription Drug and Opioid 

Overdose Related Deaths program at $12 mi Ilion. This program focuses on overdose death 

prevention strategies such as naloxone distribution and education of first responders on its use 

along with other prevention strategies. Additionally, SAMHSA requests continued support ($1 0 

million) of the Strategic Prevention Framework-Rx program which enables states to enhance. 

implement, and evaluate strategies to prevent prescription drug misuse. These continued and 

expanded efforts build upon SAMHSA's numerous activities geared toward preventing 

prescription drug and opioid misuse and treating opioid use disorders, including: courses for 

healthcare professionals on prescribing opioids for pain, prescription drug monitoring program 

interoperability enhancement, development and implementation of the Opioid Overdose 

Prevention Toolkit, and clarification on the allowable use of SABG funds to support equipping 

first responders with naloxone. 

SAMHSA's Ongoing Work to Address the Opioids Epidemic 

Improving Prescriber Practices 

SAMHSA understands the importance of modifying prescribing behavior and providing 

prescribers with the information and the tools that are needed to appropriately treat patients with 

chronic pain. 

Since 2007, over 72,000 prescribing primary care physicians and other health care professionals 

have received continuing education credits from SAMHSA's courses on prescribing opioids for 

chronic pain. This technical assistance is provided through SAMHSA 's Providers' Clinical Support 

System for Opioid Therapies, a free national training and mentoring network that provides clinical 

support to physicians, dentists, and other medical professionals in the appropriate use of opioids for 

the treatment of chronic pain and screening and treating opioid use disorder. 

SAMHSA has also addressed the issue of prescribing practices through various efforts related to 

increasing Prescription Drug Monitoring Program (POMP) interoperability among states and 

intra-operability among the POMP, electronic health records (EHR), health information 

exchanges and pharmacies. The Enhancing Access to PMDPs Project was funded by SAMHSA 

and managed by ONC in collaboration with SAMHSA, CDC, and ONDCP. SAMHSA also 

funded the POMP EHR Integration and Interoperability Cooperative Agreement program in 

Fiscal Year (FY) 2012 and the Electronic Health Record and POMP Data Integration Cooperative 

Agreement in FY 2013. These programs bring funding directly to states to complete integration 

projects. 

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Congress recently provided the additional funding SAMHSA requested for opioid misuse 

prevention that will allow PDMPs to be utilized to target localities where states should focus 

their prevention efforts. In FY 2016, the Congress appropriated $10 million for a new initiative, 

the "Strategic Prevention Framework Rx" (SPF Rx), which will allow states to enhance the use of 

data from PDMPs by identifying communities by geography and high-risk populations (e.g., age 

group), including those in need of prevention programs, connect patients to treatment resources, 

and complement CDC's Prescription Drug Overdose: Prevention for States program, which 

includes a component focused on enhancing prescription drug monitoring programs and leveraging 

them as public health tools. 

SAMHSA expects grantees to continue to use the Strategic Prevention Framework (SPF) process at 

both the State/tribal and community levels to meet the goals of the SPF Partnerships for 

Success (PFS) Program. There are five steps in this process: (1) assess needs; (2) build capacity; 

(3) plan; (4) implement; and (5) evaluate. Using the SPF process is critical to ensuring that 

states/tribes and their communities work together to use data driven decision making processes to 

develop effective prevention strategies and sustainable prevention infrastructures. The SPF 

PFS grantees are using these funds to target two priorities: (l) underage drinking among 

persons aged 12-20; and (2) prescription drug misuse among persons aged 12-25. At their 

discretion, states/tribes may also use their SPF PFS funds to target an additional data driven 

priority (e.g., heroin, marijuana use). States and tribes developed an approach to funding 

communities of high need that ensures all funded communities will receive ongoing guidance and 

support from the state/tribe, including technical assistance and training for the duration of the SPF 

PFS project. 

Another core aspect of the Secretary's initiative is to provide guidance on opioid prescribing 

practices focusing on inappropriate or excessive prescribing. Recently, CDC released the 

Guideline for Prescribing Opioid~ ji>r Chronic Pain, to guide primary care providers in 

appropriate prescribing of opioids to improve pain management and patient safety. SAMIISA 

supports CDC in this effort and will help disseminate and encourage uptake of the new guideline. 

Opioid Overdose Prevention Expanding the L\~e of Naloxone 

SAMHSA is also working to carry out a significant portion of the Opioid Initiative's second 

priority area - preventing opioid overdoses by expanding the use and distribution of naloxone. 

When administered in a timely manner, naloxone rapidly restores breathing to a victim in the 

throes of an opioid overdose. Because police are often the first on the scene of an overdose, 

local law enforcement agencies can train their personnel on overdose prevention and equip them 

with naloxone as a means of improving response. 

In 2014, SAMHSA clarified that at the state's discretion its Substance Abuse Prevention and 

Treatment Block Grant (SABG) funds may be used to support first-responder naloxone 

initiatives. For example, SABG primary prevention set-aside funds may be utilized to support 

overdose prevention education and training. Additionally, SABG funds other than primary 

prevention set-aside funds may be used to purchase naloxone and materials to assemble overdose 

kits as well as to cover the dissemination of such kits. However, SAMHSA encourages public 

and private insurers to pay for this medication for those at risk or for those living with people at 

risk. 

6 
304 

SAMHSA also published an Opioid Overdose Prevention Toolkit to educate individuals. 

families, first responders, prescribing providers, persons in recovery from substance use 

disorders (SUD), and community members about steps to take to prevent opioid overdose and 

respond to overdoses (including the use of naloxone). The toolkit is the most downloaded 

document on the SAMHSA website, and SAMHSA continues to promote its availability through 

various social media outlets to reach a wide range of populations. SAMHSA also offers a 

naloxone and overdose prevention course for prescribers and pharmacists. 

The Congress provided SAMHSA an additional $12 million in FY 2016 to initiate a Prevention of 

Prescription Drug/Opioid Overdose-Related Deaths grant program, which will provide funds to 

states for the purchase of naloxone and for training first responders in communities of high 

need. 

Expanding MAT and Recovery Services 

MAT is an evidence-based approach which combines behavioral therapy with medications to 

treat SUDs, including opioid use disorders. Research shows that medications are effective for 

decreasing opioid craving and withdrawal symptoms, blocking euphoria if relapse occurs, and 

augmenting the effect of counseling. 3 

SAMHSA has a key role in ensuring access to MAT for opioid use. In FY2016, Congress 

appropriated $12 million for a new initiative at SAMHSA, the "Grants to Prevent Prescription 

Drug/Opioid Overdose Related Deaths" (PDO), which allows states to reduce the number of 

prescription drug/opioid overdose-related deaths and adverse events among individuals 18 years of 

age and older by training first responders and other key community sectors on the prevention of 

prescription drug/opioid overdose-related deaths and implementing secondary prevention 

strategies, including the purchase and distribution of naloxone to first responders and others in 

high-need communities. 

In FY 2016, Congress appropriated $25 million for MAT-PDOA, an increase of$13 million over 

FY 2015. The FY 2016 funding will increase the number of states receiving funding from II to 22, 

and will serve an additional 24 high-risk communities. 

The President's FY 2017 budget requests $1 billion in mandatory funding over two years to expand 

access to treatment, and requests more than $90 million in additional discretionary funds that will 

support targeted enforcement activities and help the federal government to continue and expand 

current efforts across the Departments of Justice (DOJ) and HHS to expand state-level prescription 

drug overdose prevention strategies, increase the availability of medication-assisted treatment 

programs, improve access to the overdose-reversal drug naloxone, and support targeted 

enforcement activities. As stated above, this epidemic requires a comprehensive approach, which 

includes funding to expand access to treatment and help individuals who seek treatment to 

successfully complete it and sustain recovery. We look forward to working with Congress to make 

the much needed investments to tackle this crisis. 

A number of other SAMHSA programs enhance access to opioid use disorder treatment, including 

MAT. Through the Pregnant and Postpartum Women's (PPW) initiative, SAMHSA encourages 

grantees to accept pregnant women with opioid use disorders into residential treatment settings, 

and in recent years many of the PPW treatment providers have begun administering MAT onsite 
305 

to the women admitted to their programs due to an opioid use disorder. As a result, pregnant 

women recovering from opioid use disorders are remaining in treatment longer, resulting in 

healthier births.' 

SAMHSA's budget request tor FY 2017 includes innovation grants through the PPW program, 

which will test different models for family-centered treatment programs, including outpatient 

treatment programs. Outpatient services are not currently an allowable use of funds, and would 

offer substance use disorder treatment for pregnant and postpartum women, without separating 

them from their minor children and other family members in the home. 

SAMHSA has also worked with ONDCP and DOJ to expand access to MAT for justice-involved 

individuals with opioid use disorders by adding language to our drug court grant applications 

ensuring clinically beneficial MAT with FDA-approved medications is not denied or restricted. 

However, a judge retains judicial discretion to mitigate/reduce the risk of misuse or diversion of 

these medications. These Drug Court program grantees are encouraged to use up to 20 percent of 

their grant awards for MAT. 

SAMHSA also funds the Providers' Clinical Support System for Medication Assisted Treatment 

which provides technical assistance on proper dispensing and prescribing of FDA-approved 

medications for opioid use disorders. Recognizing that there is a need to further educate providers 

regarding the use of injectable extended-release naltrexone in addition to the more heavily 

regulated opioid agonist therapies, methadone and buprenorphine, SAMHSA has developed a 

wide variety of guidelines. These include "Clinical Use of Extended-Release Injectable 

Naltrexone in the Treatment of Opioid Use Disorders: A Brief Guide" released in January 

2015. SAMHSA also plans to convene a meeting on the use of opioid antagonist therapies, 

like naltrexone, in May to bring together researchers, clinicians, and others specifically to review 

the literature and clinical experiences with naltrexone. 

SAMHSA also has primary responsibility for regulating Opioid Treatment Programs (OTPs). 

OTPs provide all three FDA-approved opioid use disorder medications (methadone, 

buprenorphine and naltrexone) and counseling services for opioid use disorders directly to their 

respective patients. OTPs must maintain certification with SAMI-ISA in order to operate. 

SAMI-ISA cooperates with state agencies, the Drug Enforcement Administration (DEA) and 

approved accrediting organizations to accomplish this. Currently there are L402 OTPs in 

operation, with an additional 51 pending SAMHSA certification. 

Catherine Anne Fullerton, M.D., M.P.H.; Meelcc Kim, M.A.: Cindy Parks T110mas, Ph.D.; D. Russell Lyman, Ph.D.~ Leslie R 

Montejano, M.A., C.C.R.P.; Richard H. Dougherty. Ph.D.; Allen S. Daniels. Ed. D.; Sushmila Shoma Ghose, Ph.D.: Miriam E. 

Dclphin·Rittmon, Ph.D. (2/t/2014), Medication~Assisted Treatment With Methadone: Assessing the Evidence, Psychiatric Services 

2014 Vo! 65. No.2: and Catherine Anne Fullerton. M.D .. M.P.H.: Mee!ce Kim. M.A.; Cindy Parks Thomas. Ph.D.; 

D. Russell Lyman, Ph.D.: Leslie B. Montejano, M.A., C.C.R.P.: Richard H. Dougherty, Ph.D.: Allen S. Daniels. Ed. D.; Sushmita 

Shoma Ghose. Ph.D.; Miriam E. Delphin-Rittmon, Ph.D. (2/l/2014), Medication~Assisted Treatment With 

l3uprenorphinc: Assessing the Evidence. Psychiatric Services 2014 Vol65. No.2. & Kraus eta!., 2011; NIDA, 2012. 4 Substance Abuse and Mental Health Services Administration (2014) Preliminary Cross~ site Data Analysis 

8 
306 

Consistent with the Controlled Substances Act, as amended by the Drug Addiction Treatment 

Act of 2000 (DATA 2000), physicians wishing to treat opioid use disorders with 

buprenorphine in a practice setting not subject to OTP regulations, such as a private practice or 

non-OTP treatment program, must submit a notice of intent to SAMHSA. Initially physicians in 

these settings are restricted to treating a maximum of 30 patients at a time. After one year of 

experience, physicians desiring to increase their patient limit to 100 may submit a second 

notification to SAMHSA of the need and intent to treat up to 100 patients. SAMHSA coordinates 

processing of these notifications with DEA. Of the approximately L 189,000 physicians registered 

with DEA to prescribe controlled substances, there are currently 32,243 physicians with a 

waiver to prescribe buprenorphine for opioid dependcnce. 5 Of these, 10,473 are authorized to 

treat up to 100 patients. 

SAMHSA is working to find other ways to expand access to MAT. On March 30, 2016, we 

released a Notice of Proposed Rulemaking (NPRM) that would increase the patient limit for 

certain qualified physicians that have a waiver to prescribe buprenorphine. The NPRM would 

allow a waivered practitioner to increase their patient base from 100 to 200 if they request approval 

for the higher patient limit and fulfill several additional requirements. We believe the NPRM will 

achieve the goals of expanding access to buprcnorphine, increasing the quality of treatment for 

opioid use disorders, and limiting the diversion of buprenorphine. In addition, to ascertain if 

allowing additional categories of prescribers to obtain DATA 2000 waivers would help address 

provider shortage while maintaining safety and quality of care, the President's FY 2017 Budget is 

proposing a pilot study in states where practice laws already provide advanced practice registered 

nurses and physician's assistants the necessary practice scope and prescribing authority to provide 

office-based opioid treatment. 

Finally, SAMHSA has done significant work to ensure that behavioral health treatment is 

appropriately financed and implemented to support integrated care across an array of health 

systems and programs. SAMI-ISA's report, "Medicaid Coverage and Financing of Medications to 

Treat Alcohol and Opioid Use Disorders," provides clinicians and policy makers a resource 

guide for developing beneficial medication coverage and financing policies. The report presents 

innovative coverage and financing approaches that are being used to ensure cost-effective and 

treatment-effective outcomes. To complement this effort, SAMHSA engaged with its Federal 

partners (CMS, CDC, NIDA, and the National Institute on Alcohol Abuse and Alcoholism) to 

issue a CMS Informational Bulletin on MAT to inform states and other stakeholders about 

effective practices for identifying and treating mental and substance usc disorders covered under 

Medicaid. Additionally, CMS and SAMHSA jointly issued an Informational Bulletin on 

coverage of behavioral health services for youth with substance use disorders to assist states in 

designing a benefit that meets the needs of youth with substance use disorders and their families 

and to help states comply with their obligations under Medicaid's Early and Periodic Screening, 

Diagnostic, and Treatment requirements. The services described were designed to enable youth 

to address their substance use disorders, to receive treatment and continuing care, and participate 

in recovery services and supports. 

5 SAMHSA, Retrieved March 21,2016, ffom http://\vww.sHmhsa.!!.ov/programs-campaigns/mcdication-assi.stcdtreatmt:nt!physician-program-data 

9 
307 

Criminal Justice Activities 

A public health approach to addressing substance use disorders is vital. At the same time, public 

health agencies and organizations understand the importance of working with our public safety 

colleagues in the criminal justice field. SAMHSA's criminal justice portfolio includes several 

grant programs that focus on diversion, alternatives to incarceration, drug courts, and re-entry 

from incarceration for adolescents and adults with substance use disorders, and/or co-occurring 

substance use and mental disorders. 

Drug Courts 

SAMHSA 's adult drug court programs support a variety of services, including treatment for 

diverse populations at risk; wraparound/recovery support services designed to improve access 

and retention; drug testing for illicit substances required for supervision, treatment adherence, 

and therapeutic intervention; education support; relapse prevention and long-term management; 

MAT; and HIV testing conducted in accordance with state and local requirements. 

SAMHSA's treatment drug court grant programs focus on Tribal Healing to Wellness Courts, 

Juvenile Treatment Drug Courts, and SAMHSA's collaboration with DOl's Bureau of Justice 

Assistance. In FY 2015, SAMHSA supported the continuation of 103 drug court grants, and 

provided funding to 35 new adult and family drug court grants and I 0 new BJA jointly funded 

drug court grants. Congress expanded this provision- new in FY 2015 -from $50 million for 

Drug Courts to a new total of$60 million in FY 2016. 

Offender Reentry Program 

In addition to SAMHSA's drug court portfolio, criminal justice funds also support Offender 

Reentry Program (ORP) grants, which provide screening, assessment, comprehensive treatment, 

and recovery support services to offenders reentering the community, as well as offenders who 

are currently on or being released from probation or parole. Funding for ORP may be used for a 

variety of services, including but not limited to screening, comprehensive individual assessment 

for substance use and/or co-occurring mental disorders, case management, referrals related to 

substance abuse treatment for clients, alcohol and drug treatment, wrap-around services, drug 

testing, and relapse prevention and long-term management support. 

In FY 2015, SAMHSA supported 30 three-year ORP grant continuations, and up to 18 new ORP 

grants, which will have a particular emphasis on opioid overdose prevention. 

Conclusion 

On behalf of SAMHSA, I appreciate the opportunity to testify today and share with you our 

prevention, treatment and recovery support strategies. We look forward to partnering with you as 

well and thank you for your leadership on this issue. 

I welcome any questions that you may have. 

10 
308 

GAO 

For Release on Delivery 

2:30p.m ET 

Tuesday, May 17, 2016 

GA0-16-660T 

United States Government Accountability Office 

Testimony 

Before the Committee on Homeland 

Security and Governmental Affairs, 

U.S. Senate 

OFFICE OF NATIONAL 

DRUG CONTROL 

POLICY 

Progress toward Some 

National Drug Control 

Strategy Goals, but None 

Have Been Fully Achieved 

Statement of Diana C. Maurer, Director, Homeland 

Security and Justice 
309 

OFFICE OF NATIONAL DRUG CONTROL 

POLICY 

Progress toward Some National Drug Control 

Strategy Goals, but None Have Been Fully 

Achieved 

The Office of National Drug Control Policy (ONDCP) and federal agencies have 

made mixed progress toward achieving the goals articulated in the 2010 National 

Drug Control Strategy (Strategy) and ONDCP has established a mechanism to 

monitor and assess progress. In the Strategy, ONOCP established seven goals 

related to reducing illicit drug use and its consequences by 2015. As of May 

2016, our analysis indicates that ONDCP and federal agencies have made 

moderate progress toward achieving one goal, limited progress on three goals, 

and no progress on the three other three goals. Overall, none of the goals in the 

Strategy have been fully achieved. In March 2013. GAO reported that ONDCP 

established the Performance Reporting System to monitor and assess progress 

toward meeting Strategy goals and objectives. GAO reported that the system's 

26 new performance measures were generally consistent wfth attributes of 

effective performance management. A 2015 ONDCP report on progress towards 

these measures similarly identified some progress towards overall 

achievements-some of the measures had met or exceeded targets, some had 

significant progress underway, and some had limited or no progress. 

Federal drug control spending increased from $21.7 billion in fiscal year (FY) 

2007 to approximately $30.6 billion in allocated funding in FY 2016 as shown in 

figure 1. Although total federal drug control spending increased from FY 2007 

through FY 2016, spending on supply reduction programs, such as domestic law 

enforcement, interdiction, and international programs remained relatively 

constant at $13.3 billion in FY 2007 and $15.8 billion allocated in FY 2016. 

However, federal spending for-treatment and prevention has steadily increased 

from FY 2007 through FY 2016 and spending in these two programs went from 

$8.4 billion in FY 2007 to $14.7 billion allocated in FY 2016. 

Figure 1: Federal Drug Control Spending ror Fiscal Years 2007 through 2016 

-------------United States Government At:countability Office 
310 

Chairman Johnson, Ranking Member Carper, and Members of the Committee: 

I am pleased to be here today to discuss the Office of National Drug Control Policy's (ONDCP) 

efforts to implement the National Drug Control Strategy. In recent years, policy makers, health 

care providers, and the public at large are turning their attention to the current drug epidemic 

and its impact on our nation. Deaths from drug overdose rose steadily over the past two 

decades to become the leading cause of injury or death in the United States, surpassing the 

annual number of traffic crash fatalities in recent years. In 2013, approximately 120 people died 

every day from drug overdoses. ONDCP is responsible for, among other things, overseeing and 

coordinating the implementation of national drug control policy across the federal government to 

address illicit drug use. 1 In this role, the Director of ONDCP is required annually to develop a 

National Drug Control Strategy (the Strategy), which is to set forth a comprehensive plan to 

reduce illicit drug use through programs intended to prevent or treat drug use or reduce the 

availability of illegal drugs. 2 ONDCP is also responsible for developing a National Drug Control 

Program Budget proposal for implementing the Strategy. 3 In fiscal year 2017, a total of $31.1 

billion was requested to support the Strategy. This represents an increase of more than $500 

million over the enacted fiscal year 2016 level of $30.6 billion. 

Today, I will discuss (1) what progress has been made toward achieving National Drug Control 

Strategy goals and how ONDCP monitors progress and (2) trends in federal drug control 

spending. My remarks today are based on findings from our March 2013 report on progress 

toward Strategy goals and ONDCP mechanisms to monitor progress, our December 2015 

testimony statement on these areas, updates to our analysis and findings in the report and 

testimony statement, and our analysis of ONDCP's Budget and Performance summaries• 

1

111icit drug use includes the use of marijuana (including hashish), cocaine (including crack), heroin, hallucinogens, 

and inhalants, as well as the nonmedical use of prescription drugs. such as pain relievers and sedatives. 

2For the purposes of this statement we refer to the National Drug Control Strategy as 'the Strategy' mirroring the 

reference commonly used by ONDCP. 

321 U.S.C. §§ 1703(b)-(c), 1705(a). Under 21 U.S.C. § 1701(7), the term "National Drug Control Program agency" 

means any agency that is responsible for implementing any aspect of the National Drug Control Strategy, including 

any agency that receives federal funds to implement any aspect of the National Drug Control Strategy, subject to 

certain exceptions regarding intelligence agencies. 

4

See GAO, Office of National Drug Control Policy: Office Could Better Identify Opportunities to Increase Program 

Coordination, GA0-13-333 (Washington, D.C.: Mar. 26, 2013) and Office of National Drug Control Policy: Lack of 

Progress on Achieving National Strategy Goals, GA0-16-257T (Washington, D.C.: Dec. 2, 2015). 

Page 1 GA0-16-660T Office of National Drug Control Policy 
311 

In performing the work for our March 2013 report, we analyzed the 2010 National Drug Control 

Strategy; available data on progress toward achieving Strategy goals, and documents about 

ONDCP's monitoring mechanisms. In March 2013 we made a recommendation to ONDCP to 

assess overlap in drug prevention and treatment programs. ONDCP concurred and has 

implemented it. For our December 2015 testimony statement, we analyzed ONDCP's reported 

progress on Strategy goals in its 2015 Strategy and performance report. More detail on our 

scope and methodologies can be found in our March 2013 report and December 2015 

statement. For updates to these reports, we analyzed publically available data sources, ONDCP 

reports on progress toward the Strategy's goals and objectives, and reviewed ONDCP's Fiscal 

Year 2015 and Fiscal Year 2016 Budget and Performance reports, and interviewed ONDCP 

officials. 5 We previously reported on progress toward meeting Strategy goals in our December 

2015 testimony based on results provided in ONDCP's 2015 Strategy and performance report, 

which were issued in November 2015. To assess progress on Strategy goals, we updated 

results for the goals using publically available data sources as of May 2016. The data sources 

for the goals were determined by ONDCP when developing the 2010 Strategy, based on their 

availability and quality. We used the same data sources that ONDCP uses to assess progress 

on Strategy goals to update results and did not independently assess the reliability of these 

data. 

This statement is based on our prior work issued from July 2012 through December 2015, with 

select updates as of May 2016. The work upon which this testimony is based was conducted in 

accordance with generally accepted government auditing standards. Those standards require 

that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a 

reasonable basis for our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings and conclusions based 

on our audit objectives. 

5

0ffice of National Drug Control Policy FY 2015 and FY 2016 Budget and Performance Summaries Companion to the 

National Drug Control Strategy, July 2014 and November 20 15; and National Drug Control Budget FY 2017 Funding 

Highlights, February 2016. 

Page 2 GA0-16-660T Office of National Drug Control Policy 
312 

Background 

ONDCP was established by the Anti-Drug Abuse Act of 1988 to, among other things, enhance 

national drug control planning and coordination and represent the drug policies of the executive 

branch before Congress. 6 In this role, the office is responsible for (1) developing a national drug 

control policy, (2) developing and applying specific goals and performance measurements to 

evaluate the effectiveness of national drug control policy and National Drug Control Program 

agencies' programs, 7 (3) overseeing and coordinating the implementation of the national drug 

control policy, and (4) assessing and certifying the adequacy of the budget for National Drug 

Control Programs. 

The 2010 National Drug Control Strategy is the inaugural strategy guiding drug policy under 

President Obama's administration. According to ONDCP officials, it sought a comprehensive 

approach to drug policy, including an emphasis on drug abuse prevention and treatment efforts 

and the use of evidence-based practices-approaches to prevention or treatments that are 

based in theory and have undergone scientific evaluation. Drug abuse prevention includes 

activities focused on discouraging the first-time use of controlled substances and efforts to 

encourage those who have begun to use illicit drugs to cease their use. Treatment includes 

activities focused on assisting regular users of controlled substances to become drug free 

through such means as counseling services, inpatient and outpatient care, and the 

demonstration and provision of effective treatment methods. 

ONDCP established two overarching policy goals in the 2010 Strategy for (1) curtailing illicit 

drug consumption and (2) improving public health by reducing the consequences of drug abuse, 

and seven subgoals under them that delineate specific quantitative outcomes to be achieved by 

2015, such as reducing drug-induced deaths by 15 percent. To support the achievement of 

these two policy goals and seven subgoals (collectively referred to as goals), the Strategy 

6See 21 U.S.C. § 1702. ONDCP was created and authorized through January 21, 1994, by the National Narcotics 

Leadership Act of 1988, which was enacted as title 1 of the Anti-Drug Abuse Act of 1988. Pub. L. No. 100-690, 102 

Stat. 4181 (1988). ONDCP has continued to operate since the conclusion of its first authorization through multiple 

reauthorizations or as a result of legislation providing continued funding. 

7Department of Agriculture; Court Services and Offender Supervision Agency for the District of Columbia; 

Department of Defense; Department of Education; Federal Judiciary; Department of Health and Human Services; 

Department of Homeland Security; Department of Housing and Urban Development; Department of the Interior; 

Department of Justice; Department of Labor; Office of National Drug Control Policy; Department of State; Department 

of Transportation; Department of the Treasury; and Department of Veterans Affairs. 

Page3 GA0-16-660T Office of National Drug Control Policy 
313 

included seven strategic objectives and multiple action items under each objective, with lead 

and participating agencies designated for each action item. Strategy objectives include, for 

example, Strengthen Efforts to Prevent Drug Use in Communities and Disrupt Domestic Drug 

Trafficking and Production. Subsequent annual Strategies provided updates on the 

implementation of action items, included new action items intended to help address emerging 

drug-related problems, and highlighted initiatives and efforts that support the Strategy's 

objectives. 

ONDCP is required annually to develop the National Drug Control Strategy, which sets forth a 

plan to reduce illicit drug use through prevention, treatment, and law enforcement programs, 

and to develop a Drug Control Budget for implementing the strategy .a National Drug Control 

Program agencies follow a detailed process in developing their annual budget submissions for 

inclusion in the Drug Control Budget, which provides information on the funding that the 

executive branch requested for drug control to implement the strategy. 9 Agencies submit to 

ONDCP the portion of their annual budget requests dedicated to drug control, which they 

prepare as part of their overall budget submission to the Office of Management and Budget for 

inclusion in the President's annual budget request. ONDCP reviews the budget requests of the 

drug control agencies to determine if the agencies have acceptable methodologies for 

estimating their drug control budgets, and includes those that do in the Drug Control Budget. 10 

In FY 2016, the budget contains 38 federal agencies or programs. 

There are five priorities for which resources are requested across agencies: substance abuse 

prevention and substance abuse treatment (both of which are considered demand-reduction 

areas), and drug interdiction, domestic law enforcement, and international partnerships (the 

8Jn 2008, the National Academy of Public Administration's report entitled Building the Capacity to Address the 

Nation's Drug Problem recommended that ONDCP develop a comprehensive budget to ensure policymakers and the 

public have a full understanding of the federal drug control expenditures. In response to this recommendation, 

ONDCP undertook a review of the National Drug Control Budget to determine which agencies and programs should 

constitute the National Drug Control Budget. As a result, it decided to restructure the budget. 

9See 21 U.S.C. § 1703(c). 

10An acceptable methodology relies on availability of empirical data at the agencies for estimating their drug control 

budgets. These data include determining which portion of an agency's funding is for drug control programs or 

activities versus non-drug control programs. See GAO, Office of National Drug Control Policy: Agencies View the 

Budget Process as Useful for Identifying Priorities, but Challenges Exist, GA0-11-261 R (Washington, D.C .. May 2, 

2011 ). Agencies may administer programs that include drug abuse prevention and treatment activities but do not 

meet ONDCP's standards for having an acceptable budget estimation methodology. Such programs are not 

represented in the Drug Control Budget. 

Page 4 GA0-16-660T Office of National Drug Control Policy 
314 

three of which are considered supply-reduction areas) as shown in figure 1. ONDCP manages 

and oversees two primary program accounts: the High Intensity Drug Trafficking Areas (HIDTA) 

Program and the Other Federal Drug Control Programs. ONDCP previously managed the 

National Youth Anti-Drug Media Campaign which last received appropriations in fiscal year 

2011. 

Figure 1: Federal Drug Control Program Priority Areas 

ONDCP and Other Federal Agencies Have Not Fully Achieved 2010 Strategy Goals; 

ONDCP Has Established a Mechanism to Monitor Progress 

Although Limited Progress Has Been Made for Some Goals. None of the National Drug Control 

Strategy Goals Have Been Fully Achieved 

In the 2010 National Drug Control Strategy, ONDCP established seven goals related to 

reducing illicit drug use and its consequences to be achieved by 2015. As of May 2016, our 

analysis indicates that ONDCP and federal agencies have made moderate progress toward 

achieving one goal, limited progress on three goals, and no demonstrated progress on the 

remaining three goals." ONDCP officials stated that they intend to report on updated progress 

11Three of the Strategy's goals have multiple sub-measures. Limited progress indicates that progress has been made 

toward goals on at least one of these measures but not aiL We previously reported on progress toward meeting 

Strategy goals in our December 2016 testimony based on results provided in ONDCP's 2015 Strategy and 

perfonmance system report, which were issued in November 2015. See GA0-16-257T. We updated results for five of 

the seven goals based on available data sources as of May 2016. 

Page 5 GA0-16-660T Office of National Drug Control Policy 
315 

toward meeting the strategic goals in summer 2016. As of May 2016, overall, none of the goals 

in the Strategy have been fully achieved. Table 1 shows the 2010 Strategy goals and progress 

toward meeting them. 

Table 1: 2010 National Drug Control Strategy Goals and Progress toward Meeting Them, as of May 2016 

2009 2015 

2010 Strategy goals (baseline) Progress to date' (goal) 

Curtail illicit drug consumption in America 

1. Decrease the 30-day prevalence of drug use among 

12-to 17-year-olds by 15 percent' 1 0.1 percent 9.4 percent (2014) 8.6 percent 

2. Decrease the lifetime prevalence of eighth graders 

who have used drugs, alcohol, or tobacco by 15 percent 

Illicit drugs' 19.9 percent 20.5 percent(2015) 16.9 percent 

Alcohol 36.6 percent 26.1 percent (2015) 31.1 percent 

Tobacco 20.1 percent 13.3 percent (2015) 17.1 percent 

3. Decrease the 30-day prevalence of drug use among 

young adults aged 18-25 by 10 percent' 21.4 percent 22.0 percent (2014) 19.3 percent 

4. Reduce the number of chronic drug users by 15 

percen18 

Cocaine 2.7 million 2.5 million (2010) 2.3 million 

Heroin 1.5 million 1.5 million (201 0) 1.3 million 

Marijuana 16.2 million 17.6 million (201 0) 13.8 million 

Methamphetamine 1.8 million 1.6 million (201 0) 1.5 million 

Improve the public health and public safety of the American people by reducing the consequences 

of drug abuse 

5. Reduce drug-induced deaths by 15 percent 39,147 49,714 (2014) 33,275 

6. Reduce drug-related morbidity by 15 percent 

Emergency room visits for drug misuse and abuse 2,070,452 2,462,948 (2011) 1,759,884 

HIV infections attributable to drug use 5,799 3,852 (2014) 4,929 

7. Reduce the prevalence of drugged driving by 10 16.3 percent 20.0 percent 

percent!l (2007) (2013) 14.7 percent 

Source GAO analysis of ONDCP's 2015 Performance Reportmg System report and data from {1) Substance Abuse and Mental Health SeiVices 

AdmmlstratJon's (SAMHSA) National Survey on Drug Use and Health (NSDUH); (2) National Institute on Drug Abuse's Momtoring the Future, (3) What 

America's Users Spend on fflegaf Drugs. (4) Centers for D1sease Control and Prevention's (CDC) National VItal StatistiCS System: {5} SAMHSA's Drug 

Abuse Warning Network drug-related emergency room visits, (6) CDC's HIV Surveillance Reporl·D1agnoses of H!V lnfed1on in the Uruted States; and 

(7) National Highway Traffic Safety Administration's National Roadside Survey 1 GA0·16·660T 

"Year for which the most recent data were available is in parenthesis. 

0

According to the 2014 NSDUH, 7.4 percent of 12· to 17-year-olds reporting having used marijuana in the past month and 3 6 percent reported havrng 

used i!Hat drugs other than marijuana. 

cAccording to the 2015 Momtonng the Future survey, 15.5 percent of eighth graders reported haVIng used mariJuana in their lifetimes and 10.3 percent 

reported having used any illicit drug other than mariJuana. 

dAccording to the 2014 NSDUH, 19.6 percent of 18- to 25-year-olds reported having used marijuana in the past month and 6.4 percent reported having 

used illicit drugs other than marijuana 

eThe data source for this measure is a report entitled What America's Users Spend on Illegal Drogs, which is sponsored by ONDCP and prepared by 

RAND Corporation As of May 2016, the most recent report had been released in February 2014 and provided data from 2000 through 2010 

1

According to ONDCP's 2015 Performance Reporting System report, the data source for this measure-the Drug Abuse Warning System-was 

discontmued by SAMHSA m 2011. and SAMHSA and CDC are currently workmg to implement a replacement system to proVIde data on drug. related 

emergency department vis1ts 

!l"fhe pnmary data source for this measure is the National Roadside Survey conducted by the National Highway Traffic Safety Administratton. The 

baseline survey was conducted in 2007. The NSDUH, which also measures the prevalence of drugged dnving, serves as a secondary data source to 

the National Roadside Survey ONDCP reported that the drugged driving goal was met when 2013 data from the NSDUH source is used 

Page 6 GA0·1G-660T Office of National Drug Control Policy 
316 

ONDCP and federal drug control agencies have made mixed progress but have not fully 

achieved any of the four Strategy goals associated with curtailing illicit drug consumption. For 

example, progress has been made on the goal to decrease the 30-day prevalence of drug use 

among 12- to 17-year-olds by 15 percent. The data source for this measure-SAMHSA's 

National Survey on Drug Use and Health (NSDUH)-indicates that in 2014, 9.4 percent of 12- to 

17-year-olds reported having used illicit drugs in the past month. This represents a 7 percent 

decrease from the 2009 baseline for this measure. However, progress has not been made on 

the goal to decrease the 30-day prevalence of drug use among young adults aged 18 to 25 by 

10 percent. Specifically, the rate of drug use for young adults increased from 21.4 percent in 

2009 to 22 percent in 2014, moving in the opposite direction of the goal. This increase was 

primarily driven by marijuana use. According to the 2014 NSDUH, 19.6 percent of young adults 

reported having used marijuana in the past month and 6.4 percent reported having used illicit 

drugs other than marijuana. 12 The rates of reported marijuana use for this measure increased 

by 8 percent from 2009 to 2014 while the rates of reported use of illicit drugs other than 

marijuana decreased by 24 percent. 

Progress has also been mixed on the remaining three Strategy goals associated with reducing 

the consequences of drug use. For example, the goal to reduce drug-related morbidity by 15 

percent has two measures, and progress has been made on one but not the other. Specifically, 

HIV infections attributable to drug use decreased by 34 percent from 2009 to 2014, exceeding 

the established target. However, the number of emergency room visits for substance use 

disorders increased by 19 percent from 2009 to 2011. The data source for this measureSAMHSA's Drug Abuse Warning Network-indicates that pharmaceuticals alone were involved 

in 34 percent of these visits and illicit drugs alone were involved in 27 percent of them. '

3 

According to the 2013 Drug Abuse Warning Network report, the increase in emergency room 

visits for drug misuse and abuse from 2009 to 2011 was largely driven by a 38 percent increase 

in visits involving illicit drugs only. In addition, progress has not been made on the goal to 

reduce drug-induced deaths by 15 percent. According to the CDC's National Vital Statistics 

System, 49,714 deaths were from drug-induced causes in 2014, an increase of 27 percent 

12Marijuana includes marijuana and hashish. Illicit drugs other than marijuana include cocaine (including crack), 

heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used non medically. 

13These numbers do not include visits that involved a combination of illicit drugs, pharmaceuticals, and/or alcohol, 

which accounted for 35 percent of emergency room visits for substance use disorders. 

Page7 GA0·16·660T Office of National Drug Control Policy 
317 

compared to 2009. This represents a significant departure from the 2015 goal. The CDC's 

January 2016 Morbidity and Mortality Weekly Report stated that 47,055 of these deaths were 

from drug overdoses, the majority of which (61 percent) involved opioids. 

ONDCP Established a System to Monitor Progress toward Strategy Goals 

In March 2013, we reported that ONDCP established the Performance Reporting System (PRS) 

to monitor and assess progress toward meeting Strategy goals and objectives and issued a 

report describing the system with its 2012 Strategy. 14 The PRS includes interagency 

performance measures and targets under each of the Strategy's seven objectives, which 

collectively support the overarching goals discussed above. For example, one of the six 

performance measures under the Strategy's first objective-Strengthen Efforts to Prevent Drug 

Use in Our Communities-is the average age of initiation for all illicit drug use, which has a 

2009 baseline of 17.6 years of age and a 2015 target of 19.5 years of age. These PRS 

measures were established to help assess progress towards each objective. According to 

ONDCP, they are a tool to help indicate where the Strategy is on track, and when and where 

further attention, assessment, evaluation, and problem-solving are needed. 

As part of our review for our March 2013 report, we assessed the PRS measures for the 

Strategy's seven objectives and found them to be generally consistent with attributes of effective 

performance management identified in our prior work as important for ensuring performance 

measures demonstrate results and are useful for decision making. 15 For example, we found that 

the PRS measures for the objectives were clearly stated, with descriptions included in the 2012 

PRS report, and all 26 of them had or were to have measurable numerical targets. In addition, 

the measures were developed with input from stakeholders through an interagency working 

group process, which included participation by the Departments of Education, Justice, and 

Health and Human Services, among others. The groups assessed the validity of the measures 

and evaluated data sources, among other things. At the time of our review, the PRS was in its 

early stages and ONDCP had not issued its first report on the results of the system's 

performance measures. 

14See GA0-13-333 

15See GAO, Tax Administration: IRS Needs to Fwther Refine Its Tax Season Performance Measures, GA0-03-143 

(Washington. D.C .. Nov. 22, 2002). 

Page 8 GA0-16-660T Office of National Drug Control Policy 
318 

ONDCP released its most recent annual PRS report in November 2015. The 2015 report 

assesses progress on the Strategy's goals and the 28 performance measures and 

sub measures related to each of the Strategy's seven objectives, which support the achievement 

of the goals. 16 For each objective, the report classifies results on performance measures into 

five categories and identifies areas of progress on and challenges with achieving objectives. 17 

For example: 

Objective 1-Strengthen Efforts to Prevent Drug Use in Our Communities. The report 

indicates that sufficient progress has been made on reducing the average age of initiation 

for all illicit drugs to enable meeting the 2015 target. However, it notes that accelerated effort 

is needed to prevent youth marijuana use and counter youth perceptions that marijuana 

(including synthetic marijuana) use is not harmful. The report shows that the percent of 

respondents aged 12 to 17 who perceive a great risk in smoking marijuana once or twice a 

week decreased from 2009 to 2013, moving in the opposite direction of the 2015 target. 

• Objective 3--lntegrate Treatment for Substance Use Disorders into Health Care and 

Expand Support for Recovery. The report shows that the percent of treatment facilities 

offering at least four specified recovery support services, such as child care, employment 

assistance, and housing assistance, increased from 2008 to 2013 and exceeded the 2015 

target. However, the report states that challenges persist in the integration of substance 

abuse treatment services into mainstream health care. For instance, the percent of the 

Health Resources and Services Administration's Health Center Program grantees providing 

substance use counseling and treatment services decreased from 2009 to 2013. According 

to the report, implementation of the Affordable Care Act presents opportunities to provide 

greater access to treatment for substance use disorders by, for example, efficiently 

integrating such treatment into the health care system and providing non-discrimination for 

coverage for preexisting conditions. 

• Objective 5--Disrupt Domestic Drug Trafficking and Production. According to the report, 

progress is being achieved in domestic law enforcement and efforts to disrupt or dismantle 

160NDCP included new submeasures for one of the performance measures in the 2015 PRS report, which accounts 

for the difference in the number of measures between the 2012 and 2015 reports. 

17The categories are (1) target met or exceeded, progress should be maintained through 2015; (2) progress sufficient 

to enable meeting 2015 target; (3) progressing, accelerated progress required to meet 2015 target; (4) no progress to 

date, accelerated progress required to meet 2015 target; and (5) significant (or considerable) progress required to 

meet 2015 target. 

Page 9 GA0~16~660T Office of National Drug Control Policy 
319 

domestic drug trafficking organizations. The 2015 targets for both measures related to these 

efforts have been exceeded. The report also indicates that progress has been made on 

reducing the number of methamphetamine lab seizure incidents (a proxy for lab activity) 

from 2009 to 2013 but accelerated progress is needed to meet the 2015 target. 

• Objective 6-Strengthen International Partnerships and Reduce the Availability of Foreign 

Produced Drugs in the United States. According to the report, key source and transit 

countries continue to demonstrate increased commitment to reducing drug trafficking and 

use through demand and supply reduction efforts. The targets for the two measures related 

to such commitments have both been met. However, the report states that accelerated 

progress is needed in working with partner countries to reduce the cultivation of drugs and 

their production potential in Afghanistan, Burma, Laos, Mexico, and Peru. 

See attachment I for performance measures under each Strategy objective, progress toward 

2015 targets, and ONDCP's assessment categorizations. ONDCP officials stated that actions 

taken in response to PRS results include Department of Education grants for school-based 

prevention activities to help educate students on the risks of using marijuana and increased 

funding to expand access to treatment to help address the rise in drug-induced deaths from 

opioid use, as discussed below. 

Total Federal Spending for Drug Control Programs Has Increased since FY 2007 

Federal Drug Control Spending on Treatment and Prevention Increased. While Law 

Enforcement and Interdiction Spending Remain Relatively Constant 

According to ONDCP, federal drug control spending increased from $21.7 billion in FY 2007 to 

approximately $30.6 billion that was allocated for drug control programs in FY 2016 as shown in 

figure 2. 18 Though, total federal drug control spending increased from FY 2007 through FY 

16We reviewed the fiscal year 2017 National Drug Control Budget Funding Highlights that describes fiscal year 2016 

allocations. ONDCP refers to these funds as enacted in the National Drug Control Budget, while we use the term 

allocated funding. All FY 2016 funding is considered allocated funding for purposes of this statement. At the 

beginnmg of a fiscal year. agencies may allocate certain amounts from available appropriations for specific programs. 

However. to the extent that an appropriation has not identified a particular amount for a specific program, an agency 

may reallocate unobligated funds from that program to another during the course of a fiscal year To the extent other 

statutory authority results in making mandatory funding for programs that may include drug abuse prevention and 

treatment, such as Medicare and Medicaid, we also include these as allocated funds. 

Page 10 GA0-16-SSOT Office of National Drug Control Policy 
320 

2016, spending on supply reduction programs, such as domestic law enforcement, interdiction, 

and international programs remained relatively constant at $13.3 billion in FY 2007 and $15.8 

billion in FY 2016. 19 However, federal spending for demand programs-treatment and 

prevention steadily increased from FY 2007 through FY 2016 and spending in these two 

programs went from $8.4 billion in FY 2007 to $14.7 billion in FY 2016. As a result, the 

proportion of funds spent on demand programs increased from 39 percent of total spending in 

FY 2007 to 48 percent in FY 2016. 

Figure 2: Federal Drug Control Spending for Fiscal Years 2007 through 2016 

Dollars 1111 i)!!ltoos) 

35 

20 

1$ 

1Q 

2001 zooe 

Fiscal year 

2009 

289 

2010 2011 2012 2013 2014 

According to ONDCP's Fiscal Year 2016 Budget and Performance Summary, ONDCP has 

prioritized treatment and recovery support services stating that they are essential elements of 

the Strategy's efforts to support long-term recovery among people with substance use 

disorders. Allocated funding for treatment increased in FY 2016 to approximately $13 billion, a 5 

percent increase over FY 2015. These funds are used for early intervention programs, treatment 

programs, and recovery services. For example, according to ONDCP, approximately $8.8 billion 

19AII FY 2016 funding is considered allocated funding for purposes of this statement. 

Page11 GA0-16-660T Office of National Drug Control Policy 
321 

was the amount estimated for benefit outlays by the Department of Health and Human Services' 

(HHS) Centers for Medicare and Medicaid Services for substance use disorder treatment in 

both inpatient and outpatient settings for FY 2016. ONDCP also stated that preventing drug use 

before it starts is a fundamental element of the Strategy. Funding for prevention increased in FY 

2016 to about $1.5 billion, a 10 percent increase from FY 2015, as shown in figure 3. Funding 

for treatment also increased from $12.5 billion in FY 2015 to $13.2 billion in FY 2016 in 

allocated funding. Figure 3 shows the increase in treatment and prevention spending for fiscal 

years 2007 through 2016. 

Figure 3: Federal Spending for Drug Treatment and Prevention for Fiscal Years 2007 through 2016 

Dol1an(r;t;: ons-

•• 

tO 

2007 2008 2010 2{.112 2014 2:0-15 2016 (etlo!IC!ed) 

Fis.c.atyear 

Additionally, in FY 2017, HHS' Substance Abuse and Mental Health Services Administration 

(SAMHSA) requested $460 million for a new program (State Targeted Response Cooperative 

Agreements) to help expand access to treatment for opioid use disorders, as well as $15 million 

for evaluating the effectiveness of medication-assisted treatment programs to improve service 

delivery and decrease the incident of opioid-related overdose and death (Cohort Monitoring and 

Page12 GA0~16-660T Office of National Drug Control Policy 
322 

Evaluation of Medication Assisted Treatment Outcomes). 20 These programs could result in 

increasing SAMHSA's budget request for treatment programs to approximately $3 billion in FY 

2017 from $2.5 billion enacted in FY 2016. 

Addressing the drug supply is categorized by three main functions, which are Domestic Law 

Enforcement, Interdiction, and International. For Domestic Law Enforcement, ONDCP noted 

that federal, state, local, and tribal law enforcement agencies play a key role in the 

Administration's approach to reduce drug use and its associate consequences. ONDCP also 

stated that interagency drug task forces, such as the High Intensity Drug Trafficking Areas 

(HIDTA) program, are critical to leveraging limited resources among agencies. Allocated funding 

for domestic law enforcement in FY 2016 is approximately $9.7 billion, a 4 percent increase 

from FY 2015 funding. Regarding Interdiction, the United States continues to face a serious 

challenge from the large scale smuggling of drugs from abroad which are distributed to every 

region in the Nation. These funds support collaborative activities between federal law 

enforcement agencies, the military, the intelligence community, and international allies to 

interdict or disrupt shipments of illegal drugs, their precursors, and their illicit proceeds. 

Allocated funding in support of Interdiction for FY 2016 is approximately $4.5 billion, an increase 

of 12 percent from FY 2015. International functions place focus on collaborative efforts between 

the U.S. Government and its international partners around the globe. According to ONDCP, illicit 

drug production and trafficking generate huge profits and are responsible for the establishment 

of criminal networks that are powerful, corrosive forces that destroy the lives of individuals, tear 

at the social fabric, and weaken the rule of law in affected countries. In FY 2016, approximately 

$1.6 billion was enacted, a 0.4 percent decrease from FY 2015. Figure 4 shows federal drug 

spending for Domestic Law Enforcement, Interdiction, and International activities. 

20SAMHSA's FY 2017 request proposed a 2-year $920 million support cooperative agreements with states to expand 

access to treatment lor opioid use disorders. In each of FY 2017 and 2018, SAMHSA would provide $460 million in 

new mandatory funding toward State Targeted Response Cooperative Agreements. 

Page 13 GA0-16-660T Office of National Drug Control Policy 
323 

Figure 4: Federal Spending for Drug related Domestic Law enforcement, Interdiction, and 

International Activities for Fiscal Years 2007 through 2016 

10 

2009 2.01tl lOH 1011 201l 201$ 2016 (enactoo) 

- t'IOIT\f!$l1C ~ enlotOOM>?rlt spervdmg 

- lt1tf!!l:liCI\o"\~~f!difl-!} 

- lntilml.lt!C!Il:s!spern:Mg 

ONDCP Spending Account For One Percent of Total Federal Drug Control Spending 

In addition to advising the President on drug-control issues and coordinating drug-control 

activities and related funding across the Federal government, ONDCP also directly oversees 

two drug-related functions for which it receives federal drug control funding -HITDAs and other 

federal drug control programs, such as the Drug Free Community (DFC) coalition grant 

program. Based on ONDCP's spending in FY 2012 through its allocated funding in FY 2016 for 

these two functions, ONDCP's drug-related spending account for 1 percent of the total federal 

drug control spending in the federal government. ONDCP's requested funding for FY 2017 is 1 

percent of the total federal drug control request. See figure 5 for allocated percentages. 

Page14 GA0-16-660T Office of National Drug Control Policy 
324 

Figure 5: ONDCP Spending Fiscal Years 2012 through 2016 

Chairman Johnson, Ranking Member Carper, and Committee members, this concludes my 

prepared statement. I would be happy to respond to any questions you may have. 

Page15 GA0-16-660T Office of National Drug Control Policy 
325 

Attachment 1: ONDCP 2015 Performance Reporting System Report-Performance 

Measures for Strategy Objectives, Progress toward 2015 Targets, and Assessment 

Categorizations 

Objective 3-lntegrate Treatment for Substance Use Disorders into Health Care and Expand Support for 

Recovery 

Page16 GAOM16~660T Office of National Drug Control Policy 
326 

Page17 GAOw16w660T Office of National Drug Control Policy' 
327 

SotJrce: ONDCP 2015 Performance Reporting System report 

Page18 GA0-16-GGOT Office of National Drug Control Policy 
328 

GAO Contact and Staff Acknowledgements 

If you or your staff members have any questions about this testimony, please contact Diana 

Maurer at (202) 512-8777 or maurerd@gao.gov. Contact points for our Offices of Congressional 

Relations and Public Affairs may be found on the last page of this statement. Other contributors 

included Kevin Heinz, Assistant Director, Aditi Archer, Lyle Brittan, Eric Hauswirth, Justin 

Snover, and Johanna Wong. 

(100835) 

Page19 GA0-16-660T Office of National Drug Control Policy 
329 

ONDCP INSERT TO PAGE 50 OF MAY 17,2016, SENATE COMMITTEE ON HOMELAND 

SECURITY AND GOVERNMENTAL AFFAIRS HEARING TRANSCRIPT 

Impact on .Federal Hiring in States with Legalized Marijuana Use 

With respect to the question of whether there has been any impact on Federal hiring in those 

states that have legalized marijuana use, there is no reliable data thus far. When the Office of 

National Dmg Control Policy (ONDCP) looked at the workforce drug testing data we receive 

from Quest Diagnostic (about three-quarters of which are for pre-employment tests), there 

appears to be an increasing trend in marijuana positives from 2012 to 2016 (first quarter), but the 

Office has no information on whether the person was hired even if the person tested positive for 

illegal drugs. ONDCP also contacted the Department of Transportation (DOT) and the Substance 

Abuse and Mental Health Services Administration (SAMHSA) within the Department of Health 

and Human Services to see if they had data on the Federal programs they oversee. DOT does not 

have such data, and SAMHSA reported that they had so few marijuana positives in the relevant 

states that no conclusions could be drawn about legalization's impact on Federal hiring. 
330 

ONDCP INSERT TO PAGE 54 OF MAY 17,2016, SENATE COMMITTEE ON HOMELAND 

SECURITY AND GOVERNMENTAL AFFAIRS HEARING TRANSCRIPT 

Drug-Free Communities Support Program Outreach to Tribal Areas 

The Drug-Free Communities (DFC) Support Program, created by the Drug Free Communities 

Act of 1997, is the Nation's leading effort to mobilize communities to prevent youth drug use. 

Directed by the Oftice of National Drug Control Policy (ONDCP), in partnership with the 

Substance Abuse and Mental Health Services Administration (SAMHSA). The DFC Program 

provides grants to local drug-free community coalitions to increase collaboration among 

community partners and to prevent and reduce youth substance use. 

Recognizing the fundamental concept that local problems need local solutions, DFC-funded 

coalitions engage multiple sectors of the community and employ a variety of strategies to address 

local drug problems. Coalition members conduct ongoing community assessments to prioritize 

efforts to prevent and reduce youth drug use. These assessments are used to plan and implement 

data-driven, community-wide strategies. 

The DFC Program requires funded coalitions to employ environmental strategies in broad 

initiatives aimed at addressing the entire community through the adaptation of policies and 

practices related to youth substance use. In so doing, coalitions can address the environment as a 

whole and get the most out of available resources. 

The DFC Program has had a special interest in providing training and technical assistance to 

Tribal communities: 

DFC Applicant Workshops: Since 2007, after the release of each DFC Funding Opp01tunity 

Announcement (FOA), the DFC Program has conducted DFC Applicant Workshops to assist 

interested community coalitions successfully apply to the DFC Program. The day-long training 

provides technical assistance to help applicants better understand the DFC Program's goals, the 

DFC Statutory Eligibility Requirements, and the ability to ask questions. In addition, for 

applicants unable to attend to the DFC Applicant Workshops, DFC staff have recorded the DFC 

Applicant Workshop and posted the web address on the DFC website. Specifically related to 

Tribes: 

• In2007 DFC had a full day of training and technical assistance dedicated to the Native 

American applicants. 

In 2008 DFC had a full day of training and technical assistance dedicated to the Native 

American applicants. 

• In 2009 DFC Staff traveled to Native American communities to answer questions about 

forming community coalitions. 

• In 2010, in Utah, DFC offered a session for Native American Coalitions. 

• In2011, DFC offered a session for Native American Coalitions. 
331 

• In 2012-2016 DFC offered sessions for Native American Coalitions in all locations where 

workshops were held. 

SJmport o{CADCA 's National Youth Leadership Initiative: ONDCP and the Community AntiDrug Coalitions of America (CADCA) collaborate on the implementation of directed outreach to 

Tribal Youth through the National Youth Leadership Initiative. The goal is develop a toolkit that 

includes fact sheets, webinars, and the creation of key resources with specific messaging to 

Tribal Youth to encourage their participation in substance use prevention efforts in their 

communities. An Engaging Tribal Youth webinar was conducted in May 2016. 

Collaboration with DOJ: For the last t\vo years, the DFC Program has collaborated with the 

Department of Justice (DOJ)'s Justice Programs Council on Native American Affairs on several 

webinars to assist Tribes as they prepare for, write, and submit their Federal grant applications. 

The focus of the webinars has focused on discussing the goals of the DFC Program, the DFC 

Statutory Eligibility Requirements, and shared best practices for successful submission of a DFC 

Application. 
332 

ONDCP INSERT TO PAGE 61 OF MAY 17,2016, SENATE COMMITTEE ON HOMELAND 

SECURITY AND GOVER-"JMENTAL AffAIRS HEARING TRANSCRIPT 

Percentage oflndividuals with Alcohol Usc Disorders Who Seek Treatment 

According to the 2014 National Survey on Drug Use and Health conducted by the Substance 

Abuse and Mental Health Services Administration within the Department of Health and Human 

Services, 17.7 million people aged 12 or older were classified as needing treatment for an 

alcohol problem, meaning they met at least one of three criteria during the past year: (l) 

dependence on alcohol; (2) abuse of alcohol; or (3) received treatment for alcohol use at a 

specialty facility (i.e., drug and alcohol rehabilitation facility [inpatient or outpatient], hospital 

[inpatient only], or mental health center). Of these individuals, nine percent felt the need for 

treatment and received treatment in a specialty facility, and an additional one percent felt the 

need for treatment and made the effort to get treatment but did not receive treatment. 
333 

Post-Hearing Questions for the Record 

Submitted to Hon. Michael Bottieelli 

From Senator Ron Johnson 

"America's Insatiable Demand for Drugs: Assessing the Federal Response" 

May 17,2016 

1. What is the cost and success rate of treatment for drug addiction? Is it a cost effective 

solution? 

Agency responses to questions submitted for the record were not received. 
334 

Post-Hearing Questions for the Record 

Submitted to Hon. Michael P. Botticelli 

From Senator Rob Portman 

"America's Insatiable Demand for Drugs: Assessing the Federal Response" 

May 17,2016 

GAO's previous reports and written statement for the hearing cast doubt on the Administration's 

ability to achieve the seven strategic goals set forth in the 2010 Strategy. 

1. Based on your experience, is there anything that the Federal Government is not doing now 

that it needs to start doing? 

a. If so, what is it? 

b. Does the Oflice of National Drug Control Policy have the legal authority and 

appropriations to do it? 

Agency responses to questions submitted for the record were not received. 
335 

Post-Hearing Questions for the Record 

Submitted to Mr. Michael Botticelli 

From Senator Kelly Ayotte 

"America's Insatiable Demand for Drugs: Assessing the Federal Response" 

May 17,2016 

(I) According to results from the 2010 National Survey on Drug Use and Health, an 

estimated 2.4 million Americans used prescription drugs non-medically for the first time 

within the past year, which averages approximately 6,600 initiates per day. About onethird of this group is between I 2 and 1 7 years of age. Sixty-two percent of kids say 

opioids are "easy" to get from medicine cabinets. Seventy percent of medications 

obtained by teens are acquired by family, friends, and relatives. The last major 

technological advancement in prescription drug safety was the child-resistant cap 

instituted in I 970. Additional anti-pilfering technologies exist, but are not yet in 

use. 

What is the federal government doing to test technologies, such as lockable vials for 

prescription medications? 

What role, if any, do you believe ONDCP can take in further studying whether 

benefits could be derived from dispensing schedule II- IV drugs in lockable vials? 

Agency responses to questions submitted for the record were not received. 
336 

Post-Hearing Questions for the Record 

Submitted to the Honorable Michael Botticelli 

From Senator Claire McCaskill 

"America's Insatiable Demand for Drugs: Assessing the Federal Response" 

May17,2016 

In 20 I 0 I chaired a hearing on our counter-narcotics efforts in Latin America. Through the 

Merida Initiative and Plan Colombia, we have spent billions of dollars on counter-narcotics 

activities in the region, with much, if not most of the money going to contractors. However, 

those contracts did not have effective performance management systems and lacked oversight in 

general, so it was impossible to determine the effectiveness of these contracts. The Office of 

National Drug Control Policy has been around since 1988, long before I held hearings on the 

issues of coordination and oversight of our counternarcotics efforts. Yet the lack of coordination 

among federal agencies does not seem to have improved much. 

I) What is ONDCP doing differently than it was 5 years ago when I held my hearing to 

provide coordination and oversight over these contracts? 

As of my hearing 6 years ago, the United States had spent almost $7 billion in Latin America 

over the prior I 0 years just on counter-narcotics efforts, over half of that was spent on 

contractors. 

2) Do you have an updated figure on how much we have spent on counter-narcotics efforts 

in Latin America in the last 10 years? 

Some of this funding has undoubtedly had an effect. Colombia, as General Kelly testified before 

this committee a few weeks ago, has made incredible progress in their security situation, 

strengthening their government institutions, reducing corruption, and improving their economy. 

However, he also pointed out that 100% of the heroin and cocaine and 90% of the 

methamphetamines coming into the U.S. arc coming from Latin America, and seizures of drugs 

at the border have remained about constant overall, with only the mix of drugs coming in 

changing. He also noted that the network that supplies these drugs starts in Colombia. Simply 

put, demand in this country is as high as ever and the supply of drugs from Latin America 

continues to meet our insatiable demand. 

3) What are the metrics we have been using to measure the effectiveness of our multi-billion 

dollar investment, and are those the right mctrics to use if both the supply of and demand 

for drugs are as high as ever? 

4) Have the metrics to measure our success changed over time, and, if so, can you provide 

some examples of how these metrics have evolved') 

According to the Department of Defense, in FY 20!0, we had 188 contractors supporting our 

counter-narcotics effmis in Colombia. Part of the plan involved turning over these operations to 

the Colombians. 
337 

5) Do you have a sense of how many U.S. contractors are still in Colombia? 

6) Is there a plan to eventually get to zero U.S. contractors or is that unrealistic? 

In the 2010 National Drug Control Strategy, ONDCP established seven goals related to reducing 

illicit drug use and its consequences to be achieved by 2015. As of March 2013, GAO's analysis 

showed that primary data and results were only available for five of them. There was no data 

available for the goal of reducing the number of chronic drug users by 15 percent or for reducing 

the prevalence of drugged driving by 10 percent. 

7) What is causing the delay and when can we expect data on these two goals? 

Of the five goals for which primary data on results were available, one showed progress and four 

showed no progress. 

GAO also reported that ONDCP established a new monitoring system intended to provide 

information on progress toward Strategy goals and help identify performance gaps and options 

for improvement. At that time, the system was still in its early stages, and GAO reported that it 

could help increase accountability for improving progress. 

In November 2015, ONDCP issued its annual Strategy and performance report, which assess 

progress toward all seven goals. The Strategy shows progress in achieving one goal, no progress 

on three goals, and mixed progress on the other three goals. Overall, none of the goals in the 

Strategy have been fully achieved. 

8) How much has ONDCP spent in those 5 years on achieving these goals? 

9) How much better is the data that you are getting now with the new monitoring system, 

and how has it shaped any changes to the strategy? 

It is our natural instinct to tackle the largest parts of this problem because they're the most 

visible. We spend billions on irradiation efforts in Central America and on border technology. 

But I wonder if we are missing some small, incremental efforts we might try that can chip away 

at these issues. For example, we know that addiction, particularly among younger people, often 

starts with access to a parent's prescription drugs in the medicine cabinet. Yet, the last time we 

did anything on prevention of access to prescription medications was back in 1970 when we 

required child-proofing medicine bottles. Obviously that's not going to stop a 15-year old from 

popping open their parent's Percocet bottle, but there are companies that are making medicine 

bottles with little combination locks on the bottle cap. 

That is not going to solve this epidemic, but it's a lot cheaper than building a wall, and possibly 

more effective, too. 

10) Is ONDCP looking at piloting anything like this or other smaller efforts? 

Agency responses to questions submitted for the record were not received. 
338 

Post-Hearing Questions for the Record 

Submitted to the Honorable Michael Botticelli 

From Senator Heidi Heitkamp 

"America's Insatiable Demand for Drugs: Assessing the Federal Response" 

May 17,2016 

1. When reading your prepared testimony and then listening to your statements during the 

course of the hearing on Tuesday, May 17, 2016, I was dismayed by the lack of attention 

concerning the federal response to demand and abuse of illicit drugs within our Native 

communities and in Indian Country. I believe Sen. Tester made this point as well at the 

hearing and that you promised to follow-up as to the federal response on Montana's 

Indian reservations. I would also like a detailed response as to what ONDCP has done or 

plans to do to respond to the drug epidemic on North Dakota's Indian reservations. Can 

you please provide me with that information? 

a. In addition, if there is a national- or broader strategy within your office aimed 

specifically at addressing the unique challenges of the drug epidemic in Indian 

Country and Alaska Native Villages, can you please provide further information 

on what the strategy is and whether or not you think it has been successful up to 

this point? 

b. If such a strategy does exist, was it put together in consultation with tribal leaders 

and experts? 

2. In your testimony, you mentioned the formation, last October, of the National Heroin 

Coordination Group -a multi-disciplinary team put together to focus specifically on a 

concerted Federal effort to reduce the availability of heroin and fentanyl in the United 

States. Since the Group's formation, have any action items or recommendations been put 

forward- and if so what are they and have they been acted upon? 

a. Are you able to provide tangible statistics regarding actions that have been taken 

as a result of this collaborative effort? 

b. If no recommendations have been made or no actions taken to date by the Group 

or member agencies as a result of directive from this Group- why not? What 

more can be done to make this Group and its member agencies function better 

and react more rapidly and effectively to the heroin and fentanyl crisis? 

c. Has the Group looked at the delivery of fentanyl through the mail- and if so, 

have they come up with recommendations or methods to stem the delivery of 

these lethal drugs through the mail system? 

Agency responses to questions submitted for the record were not received. 
339 

Post-Hearing Questions for the Record 

Submitted to Ms. Kana Enomoto 

From Senator Ron .Johnson 

"America's Insatiable Demand for Drugs: Assessing the Federal Response" 

Mayl7,2016 

1. What is the cost and success rate of treatment for drug addiction? Is it a cost 

effective solution? 

Response: There are a variety of treatments available for substance use disorders. The majority 

of individuals who enter and remain in treatment are able to successfully stop using dru~s, 

although there is some variability based on patient characteristics and treatment type. 123 Like 

other chronic illnesses, relapsing is not uncommon, but these recurrences can be addressed with 

additional treatment. Among the most effective treatments is medication assisted treatment 

(MAT) which is the provision of medication alongside behavioral health services for opioid or 

alcohol use disorder. MAT has been shown to be associated with increased treatment retention, 

decreases in opioid misuse, decreases in criminal activity, increases in employment, and 

decreases in drug overdosc 5 

In 2009, approximately $24 billion were spent on substance use disorder treatment. SAMHSA 

estimates that that number will increase to $42 billion by 2020. Public funding sources account 

for nearly three-quarters of this spending. In total, roughly one percent of all health care 

spending is for substance use disorder treatmcnt6 

Despite the costs associated with the provision of substance use disorder treatment, there are 

indications of economic benefits. In one state, for every dollar spent on treatment, societal costs 

associated with substance use disorder decreased by seven dollars even excluding improved 

1 National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. 

HHS Publication No. 12-4180. Bethesda, MD. Available at 

[lt tp-. :.· '\\ ~~ }~ ,._dntggbl1S.c .gQ_\}" ill;~:'ck fault.' {i [~:.;:'mxJat~J_J!_U f 2 Hubbard, Robert L.; Craddock, S. Gail; Flynn, Patrick M.; Anderson, Jill; Etheridge, Rose M. 

Psychology of Addictive Behaviors, Vol II( 4), Dec 1997, 261-278. )lltpjj,lx~dgi,,iQ;'l(t I 0,1]_i089<: 

161:\.11.~.261. 

1 Dutra, ~~~'it;thopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., & Otto, M. W. (2008). A metaanalytic review of psychosocial interventions for substance use disorders. American Journal of 

Psychiatry. 

' Journal of clinical psychopharmacology, 24(1 ), 24-29. )( Marsch, L. A. ( 1998). The efficacy of 

methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a 

meta-analysis. Addiction, 93(4), 515-532. 5 Medication and Counseling Treatment (20 15, September 28). Retrieved 

from !lne~:hY~\ ~\.SL1Jnhsq~).}/m~dicq!iQ!l~a:..:..i~h-' .. ~-Jl·gaJJH~~}j(~L~~~-t!IlS;llJ 0 Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for 

Treatment of Mental and Substance Use Disorders, 2010-2020. HHS Publication No. SMA-14-4883. 

Rockville. MD. Available at blt.(l_;{l;il()_D;,i\\l_!lh'iJ.."'Qlb.hin conlcnt'SM,\H-·l81h1;,2;\:L\ l.::l.:.{lililJllif 

1 
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quality oflife for paticnts 7 This decrease resulted in savings from decreased medical expenses, 

reduced crime, and increased employment 

7 Ettner SL, Huang D, Evans C, Ash DR, Hardy M, Jourabchi M, Hser Yl. (2006). Benefit-cost in the 

California treatment outcome project: does substance abuse treatment "pay for itself'? Health Serv Res, 

41(1)192-213. 

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Post-Hearing Questions for the Record 

Submitted to Ms. Kana Enomoto 

From Senator Kelly Ayotte 

"America's Insatiable Demand for Drugs: Assessing the Federal Response" 

May 17,2016 

(I) Along with colleagues from both sides of the aisle, I urged the Senate 

Appropriations Committee to boost funding across key federal agencies, including 

at SAMHSA, in order to assist in the fight against opioid abuse. I was pleased that 

the omnibus passed last year included a 284 percent increase for programs at 

SAMHSA and the Centers for Disease Control and Prevention focused on 

combatting opioid abuse. 

As you can imagine, people in New Hampshire who arc grappling with the opioid 

abuse crisis on a daily basis are interested in accessing some of these newly available 

funds so that they can better assist their neighbors who are struggling with 

substance usc disorders. 

As you arc aware, the funding appropriated through the omnibus includes a mix of 

grant programs, some which are formula funded but others that are competitive 

grants. As a small state, New Hampshire may be at a disadvantage when applying 

for competitive grants because they may not have the resources that larger states 

are able to commit to the grant-writing process. 

After the passage of the omnibus, I wrote to Secretary Burwell to ask her to expedite 

the disbursement of these funds and to request that she consider designating a 

coordinator who would serve as a central point of contact within the Department 

and assist states with identifying grant opportunities, streamlining the application 

process, and providing technical assistance. 

Do you think this is an idea that would have merit and could potentially assist 

small states like New Hampshire that are trying to navigate the competitive 

grant process? 

Are there currently similar resources available at SAMHSA? 

For my constituents who are interested in utilizing some federal dollars to assist 

them in their work to treat and support individuals with substance use 

disorders, can you assure me that you and your staff will work with them to 

navigate the grant application process and be available to answer any questions 

or concerns they may have? 

Response: SAMHSA values its partnership with New Hampshire and wants all potential 

applicants in the state to have every opportunity to compete for funding to advance the 

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behavioral health of our nation. SAMHSA realizes the importance of assisting states to help 

identify potential grant opportunities. As such, SAMHSA will continue to hold conference calls 

at the beginning of each fiscal year with state behavioral health officials to present the expected 

Funding Opportunity Announcements (FOAs) for which state applicants are eligible to apply for 

that fiscal year. The calls include descriptions of each program, award size, number of awards 

expected for each program, and proposed release dates of the FOAs. 

SAMHSA has undertaken other methods to ensure all applicants can navigate the grant 

application process. For instance, potential applicants can access the grant forecast on the 

SAMHSA grant website. The forecast provides information on SAMHSA's upcoming FOAs, 

with information about each program, eligibility information, award size, number of awards 

anticipated for each program, and the proposed release date. Also, SAMHSA staff provides preapplication deadline technical assistance to potential applicants for FOAs that have been 

announced. The technical assistance can come in the form of a wcbinar which explains the FOA 

in detail and allows for questions from potential applicants, and also in the form of a Frequently 

Asked Questions document that potential applicants can use as a resource when applying for a 

particular grant. In addition, each FOA includes contact information for SAMHSA staff 

members that applicants arc instructed to contact if they have any questions about programmatic, 

grants management, and application process related issues. Potential applicants can contact 

SAMHSA Division of Grants Management at 240-276-1400 with general eligibility questions. 

Over the years, SAMHSA has incorporated changes to the application process in order to 

streamline the process for applicant organizations. This includes moving to an electronic 

application platform that helps applicants coordinate and complete the process, as well as a 

waiver process for applicant organizations that encounter technical difficulties and arc unable to 

submit an application electronically by the deadline. In addition to these changes, at the end of 

the review process each applicant organization (both funded and unfunded) is provided a detailed 

summary statement which includes reviewer comments and the organization's priority score. 

SAMHSA has made changes to the summary statement in order to enhance the type of 

information each organization receives. This was done to provide each applicant further insight 

into the strengths and weaknesses of their application so that they can make adjustments and 

improvements to applications they submit for future funding opportunities. It is by providing the 

above mentioned resources that SAMHSA will continue to work with states and applicant 

organizations to help navigate the grant application process, and to ensure that all applicants 

receive the support and guidance they need to submit a successful application. 

(2) The last two years, I have joined Senator Kaine in writing to the Senate 

Appropriations Committee to ask that they include the highest possible level of 

funding for SAMHSA's Substance Abuse Prevention and Treatment Block Grant. 

As you know, this critical program provides formula funded grants to states to assist 

with substance use disorder treatment, prevention, and recovery services. 

I was pleased that the omnibus included an increase of more than $38 million for the 

Block Grant. However, as I understand it, because of the formula used to determine 

grant amounts, New Hampshire will only see a slight increase in its Block Grant 

funding in fiscal year 2016. 

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I am a cosponsor of the Mental Health Reform Act of 2016, which in addition to a 

number of other priority items, includes a required study on the distribution 

formula for the Block Grant. Among other components, the study would require an 

analysis of whether the Block Grant distributions accurately reflect the need for 

services. 

When was the last time that SAMHSA reviewed the distribution formula? 

Do you believe that changes should be made to the formula? 

Is there a way that the formula can more accurately reflect the individual 

needs of states-especially those like New Hampshire that are facing 

especially significant challenges with substance abuse? 

Response: The Block Grant formula is established in statute. A study of the formula was 

authorized as part of the ADAMHA Reorganization Act of 1992 (Pub. L. 102-321) under Title 

VII, Section 707, Report on Allotment Formula. The report was published in 1997. 

While any changes to the formula would require a statutory change, there is a "hold harmless" 

provision in the Substance Abuse Prevention and Treatment Block Grant (SABG) that benefits 

lower-population states like New Hampshire. Without that provision, New Hampshire and other 

similarly populated states would receive significantly smaller SABG distributions. 

(3) We know that opioid misuse and addiction has become a national crisis, resulting in 

over 28,000 overdose deaths in 2014 (CDC, 2015). New Hampshire's publiclyfunded treatment system serves over 6,000 individuals with a substance use disorder 

every year, almost 40 percent of whom have an opioid use disorder. In New 

Hampshire, Nashua has the State's only residential facility that exclusively serves 

pregnant and parenting women and their children. The family-centered services 

offered at the residential program are crucial not only for the treatment and 

recovery of the women served there, but also for the wellbeing of their children and 

families. 

I introduced the Improving Treatment for Pregnant and Postpartum Women Act 

(S. 2226), which reauthorizes SAMHSA's grant program for residential treatment 

services for pregnant and postpartum women. It also creates a pilot program for 

SAMHSA's Center for Substance Abuse Treatment to make grants to State 

substance abuse agencies to support non-residential family-centered services for 

pregnant and postpartum women. SAMHSA has proposed for FY 2017 a similar 

pilot program that would allow up to 25 percent of the Pregnant and Postpartum 

Women funding to be used for a subset of new grantees to pay for family-centered 

intensive outpatient and outpatient services. The key difference between my bill 

and SAMHSA's proposal is that SAMHSA does not require grants for the pilot 

program to go to the State substance abuse agencies. As you know, these State 

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agencies oversee the publicly-funded substance use disorder delivery system, and 

they recognize the service gaps that may exist in their own State systems. 

Will SAMHSA ensure that the pregnant and postpartum women pilot program 

makes competitive grants available to the State substance abuse agencies? 

Response: Under SAMHSA's proposed pilot program, eligibility for the innovation grants 

would be limited to the lead state/territorial/Tribal entity within the respective 

state/territory/Federally-recognized American Indian/Alaska Native Tribe or Tribal organization, 

which is responsible for leading substance use disorder treatment and recovery support services 

for pregnant and postpartum women and their minor children and other family members. The 

innovation grants would be a combination of infrastructure development or improvement at the 

state/territorial/Tribal level and direct treatment services at the community-based-provider 

level. Additionally, SAMHSA anticipates a second Pregnant and Postpartum Women's (PPW) 

program funding opportunity in FY 2017 to provide residential treatment for pregnant and 

postpartum women and their minor children and other family members. Eligibility will include a 

wide range of entities, including but not limited to states, territories, Tribes, community-based 

organizations, and universities. 

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345 

Post-Hearing Questions for the Record 

Submitted to Kana Enomoto 

From Senator Heidi Heitkamp 

"America's Insatiable Demand for Drugs: Assessing the Federal Response" 

May 17,2016 

I. Many people in my state of North Dakota have to travel significant distances away 

from their families and support network to obtain treatment. What does a 

successful treatment model look like in rural and isolated areas? 

Response: Rural populations face the same behavioral health problems as other populations. 

There may be regional or demographic differences that skew toward the predominance of 

particular disorders or conditions, but this occurs in urban and suburban areas as well. A major 

distinguishing factor for rural populations is the isolation caused by great geographic distances 

and the lack of available behavioral health services. Consequently, any successful treatment 

model must take these two factors into consideration and recognize challenges related to 

transportation and access. 

Given the difficulty in attracting an adequate number of trained and qualified health 

professionals to rural areas, the provision of telchealth and/or e-therapy can be an altemative 

approach. Behavioral health service delivery in rural areas that use telehealth/e-therapy 

networks in addition to the existing brick and mortar service system can increase access to 

services including services available at all times of day and night and support in emergency 

situations. 

SAMHSA's Targeted Capacity Expansion (TCE) through the Use of Technology Assisted 

Care (T AC) in Targeted Areas of Need grants fund 48 programs that use technology to address 

rural access challenges, including one in North Dakota. The Heartview Foundation in Bismarck 

has implemented a multi-faceted progran1 that uses several types of technology to expand and 

ofler services to the Coal Country Community Health Center, the> Standing Rock Sioux Day 

Treatment Program, and providers in the North Dakota Rural Behavioral Health Network. 

Through the use of secure telehealth technology Heartview has improved communication 

between treatment programs, including patient evaluations and training/consultation for rural 

communities. 

Programs that integrate behavioral health care capacity into primary care are another possible 

approach. While increasing the behavioral health workforce or the capacity of existing primary 

care providers to provide in-person care is the ideal solution, this integration can also be 

achieved through telehealth programs and through the use of remote behavioral health 

consultants. Screening, Brieflntervcntion, and Referral to Treatment (SBIRT) is an example of a 

service that can be integrated into primary care. SBlRT can help to identifY and address 

problems with substance and alcohol use, and can also effectively be administered via tele/etherapy services. SBIRT is not effective treatment for some drug use disorders but it can be the 

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start of effective treatment when paired with evidence-based treatment-for example MAToffered in primary care clinics. 

Tclehealth also allows for the engagement of family members in care. Family members may be 

given appropriate consent procedures and receive remote support from professionals as they care 

for their loved ones. The use of peer-to-peer support services can also broaden the reach of 

treatment services to rural areas. SAMHSA plans to continue the Providers' Clinical Support 

System for Medication Assisted Treatment (PCSS-MAT), a national training and mentoring 

project to support professional development and expansion of a well-trained workforce, capable 

of delivering high quality MAT for all FDA-approved medications. 

In addition to our work at SAMHSA, we note that our sister agency HRSA also administers rural 

programs, such as the Rural Health Care Services Outreach Program (Outreach), and offers 

evidence-based toolkits (one of which specifically addresses mental health and substance use 

disorders) through its Federal Office of Rural Health Policy. 

In short, attention to coordination, overlay of telehcalth procedures over existing services 

systems, co-location of behavioral health providers in medical settings, use of SBIRT as a first 

response and early detection methodology, family involvement, and effective integration of peer 

support services are all strategies that can be used to strengthen rural systems. 

2. Many of the federal efforts discussed at the hearing address the symptoms of 

addiction, which I believe is critical. How is SAMHSA looking "upstream" of this 

epidemic to disseminate evidence-based models and best practices for prevention? 

Response: SAMHSA's Center for Substance Abuse Prevention (CSAP) disseminates 

information on evidence-based models and best practices for prevention through its Center for 

the Application of Prevention Technologies (CAPT). Recent resources developed and distributed 

by the CAPT include "Preventing Prescription Drug Misuse: Programs and Strategies,"8 which 

provides brief summaries of prevention strategies that have been evaluated to determine their 

effects on non-medical use of prescription drugs, and "Prevention Programs that Address Youth 

Marijuana Use: Using Prevention Research to Guide Prevention Practice,"9 which provides 

summaries of interventions that have been shown to prevent or reduce marijuana use among 

youth populations. 

SAMHSA also maintains the National Registry of Evidence Based Programs and 

Practices (NREPP), which is an evidence-based repository and review system designed to 

provide the public with reliable information about interventions that address mental and 

substance use disorders, including prevention interventions. In 2014 we began a major redesign 

ofNREPP and re-launched it in 2015. NREPP reviewers evaluate interventions by rating each 

outcome associated with the program as effective, promising, ineffective, or inconclusive. 

Between 2015 and 2018, all programs reviewed under the previous NREPP criteria are being rereviewed. The re-designed NREPP provides clearer information to the public on the 

effectiveness of various prevention interventions and provides an accessible means for 

SAMHSA to disseminate evidence-based models and best practices for prevention. 

8 IJIW.~': ~:_\~~ ~Y-~~~511mh~~gs1v/ q~p.ti ~ilg~/Qt; Jlilllt~n I~!_ re~()_t m~9~2l~~~ltin&J!t9~lj_m~-=-dn~ :.nJlgL"~.~_: 

;it_n~l~L~J!df 9 Jl ~ !P ~r.'f..\.\_}_'Q:\.~5a m.h5.~!:gQ) L c;:AQ~L~i!~:-;./ 5-ie f~luJj/D_l!;~r~.SP~!I~~pxeven t i(Hl-_):.C!.J.!.!h=JTtfliliiJ.i.!!lQ_-U~l' .JJ5-JJ 

8 
347 

Finally, CSAP strongly encourages states that receive Substance Abuse Prevention and 

Treatment Block Grants (SABG) and states and Tribes that receive Partnerships for Success 

(PFS) grants to maintain Evidence-Based Workgroups intended to review prevention research 

and help communities identify and select appropriate evidence-based strategies. 

3. I understand part of SAMHSA's FY2017 budget request includes innovation grants 

to test models for family-centered treatment programs, including outpatient 

treatment. How can we better support caregivers, family and children of those 

working through addiction and treatment today? 

Response: SAMHSA's Pregnant and Postpartum Women's (PPW) program uses a familycentered approach that provides comprehensive substance use disorder treatment, prevention, 

and recovery support services for pregnant and postpartum women. their minor children, and 

other family members (e.g.. fathers of the minor children, caregivers). Services include 

screening, educational services (academic, therapeutic, and parenting skills, etc.), relapse 

prevention, childcare, transportation, primary and pediatric healthcare, social services, and case 

management. 

Under the innovation grants, these comprehensive services would be provided in a variety of 

treatment settings based on the needs of the pregnant and postpartum women. Potential 

treatment settings include residential and outpatient programs. 

4. When reading your prepared testimony and then listening to your statements 

during the course of the hearing on Tuesday, May 17,2016, I was dismayed by the 

lack of attention concerning the federal response to demand and abuse of illicit 

drugs within our Native communities and in Indian Country. I understand that Sen. 

Tester made this point as well- and that you promised to follow-up as to the federal 

response on Montana's Indian reservations. I would also like a detailed response as 

to what SAMHSA has done or plans to do to respond to the drug epidemic in North 

Dakota's Indian reservations. Can you please provide me with that information? 

a) In addition, if there is a national- or broader- strategy within your office 

aimed specifically at addressing the unique challenges of the drug epidemic 

in Indian Country and Alaska Native Villages, can you please provide 

further information on what the strategy is and whether or not you think it 

has been successful up to this point? 

b) If such a strategy does exist, was this put together in consultation with tribal 

leaders and experts? 

Response: SAMHSA created the Office of Tribal Affairs and Policy (OTAP) in 2014 to address 

high rates of substance usc and mental disorders among American Indians and Alaska 

Natives. OT AP is charged with leading development of policies, priorities, and actions to 

improve the behavioral health of Tribal communities in collaboration with Tribes, SAMHSA's 

centers and offices, and Federal partners. OT AP works to improve agency-wide coordination and 

action through the SAMHSA Tribal Technical Advisory Committee comprised of Tribal leaders 

9 
348 

and the SAMHSA American Indian and Alaska Native Team (SAIANT)-a chartered committee 

composed of executives and staff from SAMHSA 's centers and offices and chaired by OT AP. 

The Office of Indian Alcohol and Substance Abuse, which was established by the Tribal Law 

and Order Act of201 0 (TLOA), now is a component of OT AP and is working with Federal 

partners to support the development of Tribal action plans (TAP) by Tribes. TAPs arc 

comprehensive strategies focused on reducing and preventing alcohol and substance use 

disorders and other misuse in Tribal communities. TAPs are instrumental in helping Tribes 

identify existing strengths and resources within their communities; assessing prevention and 

treatment needs; coordinating available resources and programs; identifying gaps in services; and 

working with their community to identify and address their urgent or emerging substance use 

issues. It is important to underscore that a TAP is an individualized strategy for a specific Tribe 

based on the unique behavioral health-related circumstances of the Tribe and supported through 

a coordination of resources. 

SAMHSA programs support some of the activities that Tribes may identify as part of their 

TAPs. For example, Tribes and Tribal Organizations are eligible to apply for a range of 

programs that support development of targeted, data-driven prevention strategies to address drug 

misuse: 

• The Strategic Prevention Framework Partnerships for Success (SPF-PFS) grant 

program addresses the Nation's two top prevention priorities: underage drinking among 

youth and young adults ages I2 to 20 and prescription drug misuse among individuals 

ages 12 to 25. Applicants to this program have the ability to identify another data driven 

priority; such as heroin or marijuana, that may be affecting their community. Tribes must 

develop an approach to funding and implementing strategies that ensures ongoing 

guidance, support and technical assistance and training to Tribal communities. SAMHSA 

has awarded SPF-PFS funding to 13 ofthe 19 Tribes and Tribal Organizations that have 

completed the SPF process. 

The Tribal Behavioral Health Grant program (TBHG/Native Connections) is a joint 

Center for Substance Abuse Prevention and Center for Mental Health Services program. 

The purpose of the TBHG program is to prevent and reduce suicidal behavior and 

substance misuse and promote mental health among American Indian/ Alaska Native 

young people up to and including age 24. SAMHSA anticipates awarding up to 94 

applications in FY 2016. 

The SPF for Prescription Drugs (Rx) program is designed to assist in developing 

capacity and expertise in the use of data from state-run prescription drug monitoring 

programs (PDMP). This grant program provides an opportunity for a Tribal entity that 

has completed an SPF State Incentive Grant (SIG) to target the priority issue of 

prescription drug misuse. The SPF Rx program will allow grantees to develop 

comprehensive plans to strategically address the emergent issue by using epidemiological 

data combined with PDMP data to improve understanding of prescription drug misuse in 

their communities and target primary and secondary prevention activities. SAMHSA 

anticipates awarding up to 25 applications in FY 2016. States and Tribes are eligible for 

these grants. 

10 
349 

In response to discussions with the Tribal Technical Advisory Committee (TTAC), SAMHSA 

initiated collaboration with the Indian Health Service (IHS) and the National Indian Health 

Board (Nil !B) to develop the National Tribal Behavioral Health Agenda (TBHA). The TBHA 

addresses TT AC and other Tribal leader requests for Tribes and Federal agencies to work 

differently together in tackling behavioral health issues that are impacting their communities. 

The TBHA was draft based on the voices and recommendations of Tribal leaders and 

representatives-it acknowledges the importance of Tribal wisdom in developing cultural 

practices that best meet the needs ofT ribal communities; provides a clear, national statement 

about prioritizing behavioral health as an essential component to improving overall health and 

wcllness; facilitates Tribal/Federal collaboration on common behavioral health issues; and 

supports opportunities for improving behavioral health-related policies and programs focused on 

Tribal communities. 

Over the course of approximately 18 months, SAMHSA, IHS, and NIHB engaged in discussions 

and received comments from Tribal leaders and representatives on the TBHA. Tribal priorities 

were developed that focus on healing from historical and intergenerational trauma, using a socioecological approach to addressing behavioral health, directing appropriate attention and support 

on prevention and recovery, improving behavioral health systems and supports, and improving 

national awareness and visibility on the behavioral health of Tribal communities. 

SAMHSA and IHS will send a "Dear Tribal Leader" letter to all Tribes in the coming weeks to 

review and provide comment on the full draft of the TBHA. Resolutions supporting the TBHA 

as a collaborative approach for targeting improvements in behavioral health have been passed by 

the National Congress of American Indians, the Board of Directors for the National Indian 

Health Board, and the Tohono O'odham Nation. 

SAMHSA has provided funding to Tribes and Tribal Organizations in North Dakota such as the 

Standing Rock Sioux Tribe through Project LAUNCH (to promote wellness of young children 

through development of networks that coordinate child-serving systems and integrate behavioral 

health and physical health) and the TBHG program; Turtle Mountain Band of Chippewa Indians 

through the TBHG program; and Cankdeska Cikana Community College through the Garrett Lee 

Smith State/Tribal Suicide grant program to address suicide prevention for Spirit Lake Nation 

youth. SAMHSA has arranged for the Three Affiliated Tribes to receive technical assistance 

from the Centers for Medicare & Medicaid Services to address reimbursement for behavioral 

health services. Tbc SAMHSA Tribal Training and Technical Assistance Center also is working 

with the Great Plains Tribal Chairman's Health Board to plan a TAP training for Tribes in the 

area. 

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350 

GAO u.s. GOVERNMENT ACCOUNTABILITY OFFICE 

441 G St. N.W. 

Washington, DC 20548 

July 1, 2016 

The Honorable Ron Johnson 

Chairman 

The Honorable Rob Portman 

"America's Insatiable Demand for Drugs: Assessing the Federal Response." Post Hearing 

Questions for the Record 

Dear Chairman Johnson and Senator Portman: 

On May 17, 2016, I testified before the United States Senate Committee on Homeland Security 

and Governmental Affairs on the Office of National Drug Control Policy and its progress towards 

achieving the goals articulated in the 2010 National Drug Control Strategy and federal drug 

control spending. This letter responds to the questions for the record that you posed. The 

responses are based on our previously issued products. Your questions and my responses are 

enclosed. 

If you have any questions about this letter or need additional information, please contact me at 

(202) 512-9627 or maurerd@gao gov. 

Sincerely yours, 

Diana C. Maurer, Director 

Homeland Security and Justice Team 

Enclosure 
351 

Enclosure 

Question submitted by Chairman Ron Johnson 

1. What is the cost and success rate of treatment for drug addiction? Is it a cost 

effective solution? 

The Office of National Drug Policy (ONDCP) reported that from fiscal year (FY) 2007 through 

FY 2015, the federal spending on treatment for drug addiction has consistently increased and, 

during this time, the federal government spent approximately $73.3 billion on drug treatment 

programs. 1 According to ONDCP in FY 2015, drug addiction treatment spending was $12.5 

billion; 2 and in FY 2016, the enacted amount for drug treatment spending is $13.2 billion, a 6 

percent increase over FY 2015. The FY 2017 treatment funding request is $14.3 billion, an 

increase of $1,033.0 million (7.8 percent) over the FY 2016 allocated amount. 3 According to 

ONDCP's Fiscal Year 2016 Budget and Performance Summary, ONDCP has prioritized 

treatment and recovery support services, stating that they are essential to supporting long-term 

recovery among people with substance use disorders. Drug treatment funds are used for early 

intervention programs, treatment programs, and recovery services. 

In 2013, we found that the federal drug control agencies we reviewed had conducted few 

studies since 2007 to assess the effectiveness of the programs they funded. 4 We reported that 

ONDCP and agency officials said they have collected and analyzed other program performance 

information or required or encouraged the programs to use evidence-based interventions. 

These approaches to prevention or treatment are based in theory and have undergone scientific 

evaluation in order to determine effectiveness. GAO has not conducted work on the success 

rates and cost effectiveness of programs for treatment for drug addiction. 

Since our 2013 report, ONDCP is taking steps towards cost effectiveness through coordination 

of drug abuse and treatment programs. In July 2014, ONDCP published its assessment of the 

1

Accordmg to ONDCP, the largest federal contributions included in the drug treatment budget for prevention and treatment reflect 

Medicare and Medicaid benefit costs and est1mated costs associated with Substance Abuse and Mental Health Services 

Administration's substance abuse prevention and treatment block grants. According to ONDCP's 2016 Budget and Performance 

Summary, combined costs assoc1ated With provisions of the TRICARE and Veteran's Affairs benefits for substance treatment and 

substance use disorders also have large contributions 

2

There are numerous types of drug treatment programs that federal funds support, such as substance use disorder treatment 

services for inpatient and outpatient settings, medical treatment settings to provide early identification and intervention to at-risk 

individuals. and treat short- and long-term consequences of alcohol misuse in youth populations, among other things. 

30ffice of National Drug Control Policy. National Drug Control Budget: FY 2017 Funding Highlights (Washington D.C .. February 

2016) 

4GAO, Office of National Drug Control Policy: Office Could Better Identify Opportunities to Increase Program Coordination, GA0-13-

333 (Washington O.C March 26. 2013) 

Page 1 
352 

Enclosure 

extent of overlap, duplication, and coordination of federal funding of drug control programs, 

including drug abuse prevention and treatment programs in its Fiscal Year 2015 Budget and 

Performance Summary released with the annual National Drug Control Strategy. The 

assessment found that nearly all of the programs serve distinct beneficiaries in distinct settings, 

which helps prevent overlap and duplication. In the cases where overlap could occur, ONDCP's 

review of grant awards made under the programs determined that duplication did not occur over 

a 3-year period ending in 2013. Further, according to the assessment, the agencies managing 

overlapping programs have effectively coordinated through interagency collaboration, 

coordinated grant applications, and other activities. However, ONDCP found that a limited 

number of programs that provide drug abuse prevention and treatment services to support 

efforts to address homelessness would benefit from greater coordination. According to ONDCP, 

it is working to ensure additional coordination in this area by, for example, providing advice and 

oversight to relevant agencies on improving coordination of drug programs that offer similar 

treatment and recovery support services to homeless clients. 

Page 2 
353 

Enclosure 

Question submitted by Senator Rob Portman 

2. You indicated in your written statement that the Office of National Drug Control Policy 

(ONDCP) has not achieved one of the seven strategic goals since ONDCP's 2010 

release of its Strategy. What has been the greatest impediment to achieving these 

strategic goals? 

a. Are the internal or external impediments to ONDCP? 

b. Are the goals achievable and/or realistic? 

a. As of May 2016, ONDCP and federal agencies had not fully achieved any of the seven 5-

year goals established in the 2010 National Drug Control Strategy. In our 2013 report, 

ONDCP officials noted that a variety of factors-both internal and external- could affect 

achievement of these goals, such as worsening economic conditions, changing 

demographics, or changing social or political environments; the passage of state laws that 

decriminalize marijuana use or allow its use for medical purposes; failure to obtain sufficient 

resources to address drug control problems; insufficient commitment from agency partners; 

and the need for new initiatives or activities beyond those that are under way or planned. 

We also reported in 2013 that ONDCP established the Performance Reporting System 

(PRS) to monitor and assess progress toward meeting Strategy goals and objectives. We 

found that the 26 new performance measures established in the PRS were generally 

consistent with effective performance management and useful for decision-making. 5 For 

example, the PRS report includes a dashboard with meaningful indicators of progress and 

clear targets. According to ONDCP's 2015 PRS report, impediments to achieving the 

Strategy's goals and objectives include perceptions that marijuana use is not harmful, 

challenges with integrating substance abuse treatment services into mainstream health 

care, and challenges with working with partner countries to reduce drug cultivation and 

production, among others. 

Further, based on federal data, the prevalence of marijuana use in comparison to other 

drugs is a key driver affecting the Strategy's goals related to illicit drug use. For example, 

according to the Substance Abuse and Mental Health Services Administration's National 

Survey on Drug Use and Health, the rates of reported past-month marijuana use among 18 

to 25 year olds increased by 8 percent from 2009 to 2014, while the rates for illicit drugs 

5GA0-13-333 

Page 3 
354 

Enclosure 

other than marijuana decreased by 24 percent. In addition, opioid use-prescription drugs 

and heroin-is a key driver affecting the goals related to reducing the consequences of drug 

use. For example, according to the Centers for Disease Control and Prevention, the majority 

of drug overdose deaths in 2014 involved opioids. 

b. We reported in 2013 that ONDCP officials responsible for overseeing the development of 

the 2010 Strategy stated that they established the Strategy's seven quantitative goals based 

in part on what they considered could realistically be achieved within designated time 

frames, among other things. Nonetheless, these officials said that the goals are aggressive 

given that drug use trends for some of the measures were increasing prior to their 

establishment. ONDCP officials stated that the office will work with the next administration to 

develop a new National Drug Control Strategy. It remains to be seen what goals will be 

established, but making progress towards such goals is a complex and multi-faceted effort 

that requires changing the behavior of millions of people and involves numerous federal 

agencies working in the fields of medicine, law enforcement, intelligence, corrections, and 

diplomacy. 

Page 4 
(355) 

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 
356 

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 
357 

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, 
358 

1The prepared statement of Dr. MacDonald appears in the Appendix on page 403. 

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. 

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 Longterm 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. 
359 

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 
360 

1The prepared statement of Mr. Nadelmann appears in the Appendix on page 410. 

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 costeffective. 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. 

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 
361 

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 
362 

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 pub-
363 

1The prepared statement of Mr. Murray appears in the Appendix on page 433. 

lic 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. 
364 

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 71⁄2 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. 
365 

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 pre-
366 

cisely 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. Twentysix 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 prob-
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1The prepared statement of Mr. Ryan appears in the Appendix on page 470. 

ably 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. 

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. 
368 

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 evidencebased 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 
369 

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, 
370 

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: longterm 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. 
371 

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 21⁄2 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 
372 

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 
373 

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 
374 

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. 
375 

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. 
376 

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 vul-
377 

nerability, 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 
378 

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 heavilyweighted 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, 
379 

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 highlevel 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 
380 

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. 
381 

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 com-
382 

municating 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 governmentcentric 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. 
383 

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 hardhitting 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 
384 

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-aday 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 polydrug 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 in-
385 

clined 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, longterm 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. 
386 

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 
387 

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 
388 

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 

Pen ̃ a 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— 
389 

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? 
390 

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 
391 

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—— 
392 

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 
393 

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 
394 

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— 
395 

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. 
396 

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, 
397 

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—— 
398 

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 
399 

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? 
400 

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. 
401 

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 
402 

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.] 
(403) 

A P P E N D I X 
404 

At the start of the study they were using illicit opioids every day and by six months their 

use was down 3 to 5 days per month. Nearly 80 percent were retained in care and that high rate 

continues through today. At outset they were engaged in illegal activities on average 14 days per 

month and with treatment that reduced to less than 4 days per month. This study was published 

this past April in the Journal of the American Medical Association Psychiatry. 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 

compassionate basis. 

Supervised injectable hydromorphone is indicated for the treatment of severe opioid use 

disorder. We are using injectable hydromorphone as a medication assisted treatment, an 

intensified medical intervention and part of the treatment continuum. Severe opioid use disorder 

is a chronic disease that needs to be managed long-term 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 do have another 

option in addition to needle exchanges. Supervised consumption rooms are legally protected 

places where drug users consume pre-obtained illicit drugs in a safe, non-judgmental 

environment. Vancouver has two such sites. The sites provide an important entry point for 

people into medical care and substance use treatment. They also provide value over needle 

exchanges alone as all needles and equipment are 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 we are providing a 

medical treatment. Providing injectable medication in a specialized opioid clinic, under 

supervision of medical professionals not only ensuring safety of the patients and the community 

but allowing for the provision of comprehensive care. 

We are able to use hydromorphone 'off-label' in Canada for treatment of substance use 

disorder but some jurisdictions restrict its use to pain. I have seen some remarkable 

transformations in our patients. Some of our patients have already returned to work or to school. 

Supervised injectable hydromorphone is safe, effective, and cost effective. A useful tool 

when the standard treatments are not effective. Treatments are dispensed within our opioid 

treatment clinic and prescribed on a 'dispensing basis' on site. 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 disorder is prohibited by law. 

In British Columbia we need every tool in the toolbox to rise to the challenge the opioid 

epidemic presents. Injectable opioid assisted treatment in supervised clinics is one effective 

approach. Supervised consumption rooms, like Insite, are valuable for public health. Of course 

we would like to see an end to people dependent on heroin but for those already suffering it is 

essential to provide care, and care based on evidence. 

2 
405 

America's Insatiable Demand for Drugs: Examining Alternative Approaches 

15 June 2016 

INJECTABLE OPIOIDS FOR TREATMENT OF SEVERE OPIOID USE DISORDER 

Prepared by Dr. Scott MacDonald, Physician Lead at Crosstown Clinic, Providence Health Care, 

with Dr. Eugenia Oviedo-Joekes, Associate Professor, School of Population and Public Health, 

UBC and Kurt Lock, Outreach Coordinator for the SALOME study. 

Medically prescribed injectable opioids in supervised settings reach and treat people with severe 

opioid use, preventing fatal overdoses. 

BACKGROUND 

Substitution treatment with long-acting oral opioids (e.g. methadone, buprenorphine) is 

effective at reducing the use of street opioids, and many of the harms associated with their use. 

However, there is an important vulnerable minority (a subgroup of 15 to 25%) that is either not 

retained in other treatments for very long or continue to use illicit opioids while in treatment. For 

these individuals, studies in Europe and Canada showed that supervised medically prescribed 

injectable diacetylmorphine (the active ingredient in heroin), is an effective and cost effective 

treatment alternative. 

The hypothesis is that by providing medically prescribed pharmaceutical-grade heroin at 

prescribed dosages in sterile conditions in clinical settings, opioid-dependent individuals who 

cannot stop injecting despite other options available will: (I) be better engaged into and retained 

in treatment; (2) be protected from harms such as overdose, HIV and hepatitis C infection; (3) be 

removed from destructive cycles of crime, prostitution, etc. that are often required to acquire the 

drugs in the streets; and (4) benefit from prolonged exposure to medical and psycho-social 

support services. 

Supervised, medically prescribed diacetylmorphine is now being used with success in a 

number of countries in Europe (e.g., Germany, the Netherlands, Switzerland, Denmark), where it 

accounts for approximately 5% to 8% of all those enrolled in substitution treatments. However, 

there are many countries around the world where diacetylmorphine is not available due to 

regulatory and/or political reasons. To overcome this barrier, a recent study conducted in 

Vancouver, Canada, tested ifhydromorphone, a licensed opioid, was as good as 

diacetylmorphine at reducing street opioid use and retaining patients in treatment. 

The SALOME study, a double-blinded non-inferiority randomized controlled trial 

demonstrated that injectable hydromorphone is as effective as injectable diacetylmorphine for 

long-term injection street opioid users not currently benefitting from available treatments. Both 

medications, delivered in identical conditions, have proven to have positive outcomes 

such as high retention rates (80%), reduction of street drug use (from daily to few days per 

month), and illicit activities. 

1 
406 

Thus, in jurisdictions where diacetylmorphine is currently not available, or in patients 

where it is contraindicated or unsuccessful, hydromorphone provides a licensed alternative. 

In the Supervised Model of Care of medically prescribed injectable opioids ensures safety for the 

patients by, for example, providing pharmaceutical-grade, unadulterated, injectable opioids in 

known doses and onsite treatment of overdoses and seizures. It also ensures the safety of the 

community (i.e., prevent diversion of a strong opioid) and most importantly ensures 

comprehensive care (e.g., support with securing housing, treating chronic illnesses, etc.), since 

patients come daily. 

KEY POINTS: 

Without a supervised injectable opioid treatment option, a small number of patients, the most 

vulnerable ones, are relegated to the illicit stream of opioids, with the tremendous associated 

risks. 

In a supervised model, within an opioid treatment clinic where the medications are prescribed, 

dispensed and used on site, there is little risk of diversion and substantial opportunities for 

expanding care. 

ACTION FOR CONSIDERATION: 

Exemption for the treatment of severe opioid use disorder for products not susceptible to 

diversion like supervised injectable hydromorphone. 

IMPORTANT REFERENCES 

Strang J, Groshkova T, Uchtenhagen A, et al. Heroin on trial: systematic review and metaanalysis of randomized trials of diamorphine-prescribing as treatment for refractory heroin 

addiction. Br J Psychiatry 2015;207:5-14. 

Oviedo-Joekes E, Guh D, Brissette S, et al. Hydromorphone Compared With Diacetylmorphine 

for Long-term Opioid 

Dependence: A Randomized Clinical Trial. JAMA Psychiatry 2016;73: 1-9. 

Oviedo-Joekes E, Brissette S, Marsh DC, et al. Diacetylmorphine versus methadone for the 

treatment ofopioid addiction. N Engl J Med 2009;361:777-86. 

Nosyk B, eta!. Cost-effectiveness of diacetylmorphine versus methadone for chronic opioid 

dependence refractory to treatment,.CMAJ 2012. DOl: 10.1 053/cmaj.l1 0669 

Ferri M, et al. Heroin maintenance for chronic heroin-dependent individuals. Cochrane Database 

Syst Rev, 2011 Dec 7;(12):CD003410 

2 
407 

Contact 

D. Scott MacDonald 

Physician Lead, Providence Crosstown Clinic 

84 West Hastings Street 

Vancouver, BC, Canada V6B IG6 

Smacdonald2@providencehealth.bc.ca 

Eugenia Oviedo-Joekes PhD 

SALOME principal investigator 

Associate Professor -Michael Smith Foundation Scholar and CIHR New Investigator 

School of Population and Public Health 

University of British Columbia 

Centre for Health Evaluation & Outcome Sciences 

Providence Health Care 

St. Paul's Hospital 

588B-1 081 Burrard Street 

Vancouver, BC. V6Z I Y6 

Tel: 604-682-2344 Ext. 62973 

Fax: 604-806-8005 

E-mail: eugenia@cheos.ubc.ca 

3 
408 

America's Insatiable Demand for Drugs: Examining Alternative Approaches 

15 June 2016 

SUPERVISED CONSUMPTION ROOMS/INJECTION SITES 

Prepared by Dr. Scott MacDonald, Physician Lead at Crosstown Clinic, Providence Health Care, 

with Dr. Thomas Kerr 

BACKGROUND 

Supervised injection sites (SISs) are healthcare facilities where people who inject drugs 

(PWTD) can inject pre-obtained illicit drugs under the supervision of nurses or other healthcare 

professionals. Within SISs, PWID are provided with sterile injecting equipment (syringes, 

alcohol swabs, cookers, etc.,), as well as safer injecting education, emergency response in the 

event of overdose, and referrals to internal and external health and social services. There are over 

90 SISs operating throughout the world in approximately 66 cities in I 0 countries, including in 

Western Europe and Australia. SIS programs take on many forms, including: large stand-alone 

facilities designed specifically for the supervision of drug injecting. 

Smaller SISs have also been integrated into other pre-existing facilities in Europe, 

including in supportive housing programs, community health clinics, and in drop-in centres. 

Mobile SISs have now been established in many European cities to increase the coverage of 

supervised injecting programming. These may be particularly helpful in reaching PWTD who are 

more street-entrenched and those who use drugs in locations far away from fixed SISs. Several 

European cities have also implemented supervised inhalation rooms, although no such facilities 

exist in BC. 

SISs have been subjected to rigorous evaluation in various settings, although most of the 

existing SIS literature has been derived from the evaluation ofinsite in Vancouver. The 

Vancouver SIS evaluation revealed many benefits oflnsite, including: declines in public 

injecting; reductions in fatal overdose; reductions in HIV risk behaviour; increases in uptake of 

detoxification and addiction treatment services. The evaluation also found no negative impacts in 

terms of increased crime, initiation into injecting, relapse into injecting, and Insite was found to 

be cost-effective. Evaluations undertaken in Australia and Europe also have shown: declines in 

ambulance call-outs; high rates of referral to external services; declines in syringe sharing; and 

one ecological study from Germany found lower rates of overdose death in cities with SIS 

compared to cities without SIS. 

IMPORT ANT REFERENCES 

I. Wood E, Tyndall MW, Montaner JS, Kerr T. Summary of findings from the evaluation of a 

pilot medically supervised safer injecting facility. CMAJ. 2006; 175(11 ): 1399-1404. 
409 

2. Potier C, Laprevote V, Dubois-Arber F, Cottencin 0, Rolland B. Supervised injection 

services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend. 

2014;145:48-68. 

3. Ti L, Buxton J, Harrison S, et al. Willingness to access an in-hospital supervised injection 

facility among hospitalized people who use illicit drugs. J Hasp Med. 2015;10(5):301-306. 

4. European Monitoring Centre on Drugs and Drug Addiction. Perspectives on drugs: Drug 

consumption rooms: an overview of provision and evidence. EMCDDA, 2015. Available at: 

http ://www.emcdda.europa.eu/attachements.cfrnfatt_ 23 9692 _EN_ Drug%20consumption%20roo 

ms_P OD2015.pdf 

Contact 

D. Scott MacDonald 

Physician Lead, Providence Crosstown Clinic 

84 West Hastings Street 

Vancouver, BC, Canada V6B IG6 

Smacdonald2@providencehealth.bc.ca 

Thomas Kerr, PhD 

Director, Urban Health Research Initiative 

British Columbia Centre for Excellence in HIV/AIDS 

Professor, Dept. of Medicine 

University of British Columbia 

St. Paul's Hospital 

608-1081 Burrard Street 

Vancouver, British Columbia 

Canada, V6Z I Y6 

(Tel) 604-806-9116 

(Fax) 604-806-9044 

Email: drtk!alcfcnet.ubc.ca 

http:/ /uhri .cfenet. ubc.cafindex. php 
410 

Testimony Before the 

U.S. Senate Committee on Homeland Security and Governmental Affairs 

Hearing in Reference to "America's Insatiable Demand for Drugs: 

Examining Alternative Approaches" 

June 15,2016 

Ethan Nadelmann 

Executive Director of the Drug Policy Alliance 
411 

Good morning. I would like to thank Chairman Johnson and the rest of the Homeland Security 

and Government Affairs Committee for inviting me to testify. I am Ethan Nadelmann, the 

founder and executive director of the Drug Policy Alliance, the leading organization in the 

United States promoting alternatives to the failed war on drugs. 

The Drug Policy Alliance (DPA) is the nation's leading organization promoting drug policies that 

are grounded in science, compassion, health and human rights. Our supporters are individuals 

who believe the war on drugs is doing more harm than good. Together we advance policies that 

reduce the harms of both drug use and drug prohibition, and seek solutions that promote safety 

while upholding the sovereignty of individuals over their own minds and bodies. We work to 

ensure that our nation's drug policies no longer arrest, incarcerate, disenfranchise, and otherwise 

harm millions -particularly young people and people of color who are disproportionately 

affected by the war on drugs. 

The war on drugs has had a devastating impact on the world: murder and mayhem in 

Mexico, Central America, and so many other parts of the planet, a global black market 

estimated at 300 billion dollars a year, prisons packed in the United States and elsewhere, police 

and military drawn into an unwinnable war that violates basic rights, and ordinary citizens just 

hoping they don't get caught in the crossfire. Meanwhile, there are just as many people 

using drugs as ever. It is our country's history with alcohol Prohibition and Al Capone, times 50. 

Even routine drug law enforcement can increase violence by destabilizing markets and creating 

power vacuums. A systematic review of more than 300 international studies found that when 

police crack dovm on people who use or sell drugs, the result is almost always an increase in 

violence. 1 Two studies conducted in 1991 and 1999 found that when there has been a major 

increase in the homicide rate in the U.S., it could be positively associated with intensified 

enforcement of alcohol Prohibition or drug prohibition. 2 In recent years, the escalation of the war 

on drugs in Mexico and other Latin American countries has led to the deaths of tens of thousands 

of people in those countries. 3 Hundreds, if not thousands, of Americans die on U.S. streets in 

drug prohibition-related violence every year, although it goes largely untracked. 4 

1 International Centre for Science in Drug Policy. Effects of Drug Law Enforcement on Drug-Related Violence: 

Evidence from a Scientific Review (20!0). 22. available at http:liwww.icsdp.org!docs!ICSDP-l%20-

%201J.NAI. r<.!f ~Friedman, Milton, '"The War We Are Losing," in Searching for Alternative: Drug-Control Policy in the United 

States, M.B. Krauss and E.P. Lazear, eds. (Hoover Institution: Stanford, CA: 1991), 53-67: Jeftrey A. Miron, 

"Violence and the U.S. Prohibitions of Drugs and Alcohol," American Law and Economics Review 1-2 ( l 999): 78-

114, available at http://aler.oxfordjoumals.orglcontent!J/l/78.full.pdf. 

'In Mexico, over 70,000 people have been killed, 25,000 have been disappeared, and hundreds of thousands have 

been internally displaced in prohibition-related violence in the past six years, while several Centra! American 

countries have some of the highest homicide rates in the world, prompting the U,N to describe the region as the most 

violent in the world outside of active war zones. See, for example. Booth, Wiltiam. Atfe.:rico 's crime wave has left 

ahout 25.000 missing, government Jocumenls show. Washington Post (2012); David A. Shirk, The Drug War in 

Mexiro Confronting a Shared Threat, Council on Foreign Relations (20 12), 

ll1Jp_;_1/i.cfr.org.\:ontenl/publications/attachmcnts/Mcxico CSR60.pdf; and United Nations, '"Drug-related violence 

has reached alarming levels in Central America- UN," (February 20 12), 

http::'/W\\'\~·.un.org/appslnc\-v:-./storv.asp?Nc\vsl 0~-41407&Cr·-drug t·traffickine.&Cr l#.UOI gr88CSo. See also Cory 

Molzahn, Octavio Rodriguez Ferreira, and David A Shirk, "Drug Violence in Mexico: Data and Analysis through 

2012," (Trans-Border Institute, 2013); "Epn En 100 Dias: 4 Mil549 Ejecuciones," Zeta, II de marzo, 2013; 

Angelica Mercado, "Violencia Saca De Sus Pueblos a 1.2 Millones," Milenio, 19 de noviembre. 2012; Gloria Leticia 
412 

Drug control strategies that seck to interrupt the supply at its source have failed over and over 

again for cocaine, heroin, marijuana, and virtually every drug to which they have been applied 

including alcohol during alcohol Prohibition5 Fundamental economic principles demonstrate 

why: As long as a strong demand f(Jr a drug exists, a supply will be made available at some price 

to meet it 6 Worse than simply being ineffective, supply-side strategies drive immutable market 

forces to expand cultivation and trafllcking, generate unintended consequences, and, in many 

instances, ultimately worsen the problem. 

I wrote my Ph.D dissertation on international drug control and have written and co-authored 

books on international policing, including drug control. I have interviewed hundreds ofDEA and 

other law enforcement agents all around Europe and the Americas and asked them what they 

think the answer is. 

In Latin America, they would tell me you can't really cut off the supply; the answer lies back in 

the U.S., in cutting off the demand. When I talked to people involved in anti-drug efforts in the 

U.S., they said you can't really cut off the demand; the answer lies over there, and you have to 

cut off the supply. Then I talked to guys in customs trying to stop drugs at the borders, and they 

would say you're not going to stop it here; the answer lies over there, in cutting off supply and 

demand. And it hit me: Everybody involved in this thought the answer lay in that area about 

which they knew the least. 

That is when I started reading everything I could about psychoactive drugs: the history, the 

science, the politics, all of it. The more I read, the more it hit me how a thoughtful, enlightened, 

intelligent approach would take us one direction whereas the politics and laws of our 

country were taking us in a far less effective and more destructive direction. That disparity struck 

me as this incredible intellectual and moral puzzle. 

Research into the history, science, and politics of psychoactive drugs reveals that there has 

probably never been a drug-free society. Virtually every society has ingested psychoactive 

substances to deal with pain, increase our energy, socialize, even commune with God. Our desire 

to alter our consciousness may be as fundamental as our desires for food, companionship, and 

sex. So our true challenge is to learn how to live with drugs so they cause the least possible 

harm and in some cases the greatest possible benefit. 

Diaz, "Desplazados 1.6 Millones De Mexicanos Por Guerra Contra El Crimen Organizado," Proceso, 28 de 

noviembre, 20 l L 

' "Crime in the United States 20 II - Arrests," FBI Uniform Crime Report, "Murder Circumstances, by Sex of 

Victim. 2011," (Washington. DC: US Dept. of Justice. October 2012). http://www.fbi.gov/about-us/cjis/ucr/crimein-the-u.s/20 11/crime-in-the-u.s.-20 II /tables/expanded-hornicide-data-table-13 (reporting that in 201 1, an estimated 

14,612 people were murdered, including at least 390 that the FBI attributes to "narcotic drug laws", another 494 

labeled ··gangland killings", and over 5,000 other homicides in which the circumstances were unknown or 

unspecified). 

5 Boyum, David, and Peter Reuter. An Analytic Assessment of U.S. Dntg Policy. Washington, D.C.: American 

Enterprise Institute Press, 2005: Reuter, Peter. "The Limits of Supply-Side Drug Control." The Milken Institute 

Review Santa Monica, CA, First Quarter 2001: 15- 23: and Youngers, Coletta, and Eileen Rosin, Ed. "Drugs and 

Democracy in Latin America: The Impact of U.S. Policy." Washington Office on Latin America Special Report 

Washington, D.C., Nov. 2004: 1-5. 6 Reuter, Peter. "The Limits of Supply-Side Drug Control." The Milk en Institute Review Santa Monica, CA, First 

Quarter200l: 15-23. 
413 

The reason some drugs are legal and others are not has almost nothing to do with science or 

health or the relative risk of drugs, and almost everything to do with who uses and who is 

perceived to use particular drugs. 7 In the late 19th century, when most of the drugs that are now 

illegal were legal, the principal consumers of opiates in this country and others were middle-aged 

white women, using them to alleviate aches and pains when few other analgesics were 

available. And nobody thought about criminalizing it back then because nobody wanted to put 

Grandma behind bars. 

But when hundreds of thousands of Chinese people started showing up in our country, working 

hard on the railroads and the mines and then relaxing in the evening just like they had in the old 

country with a few puffs on that opium pipe, that's when the first drug prohibition laws were put 

in place, in California and Nevada, driven by racist fears of Chinese transforming white 

women into opium-addicted sex slaves. 8 The first cocaine prohibition laws were similarly 

prompted by racist fears of black men sniffing that white powder and forgetting their proper 

place in Southern society. 9 The first marijuana prohibition laws were all about fears of Mexican 

migrants in the West and Southwest. 10 

I used to be a professor teaching about this at Princeton. Now I'm a human rights activist, and 

what drives me is my shame at living in an otherwise great nation that has less than five percent 

ofthe world's population but almost 25 percent of the world's incarcerated population. It's the 

people I meet who have lost someone they love to drug-related violence or prison or overdose or 

AIDS because our drug policies emphasize criminalization over health. And it's the good people 

who have lost their jobs, their homes, their freedom, even their children to the state, not because 

they hurt anyone but solely because they chose to use one drug instead of another. 

So is legalization the answer? On that, I'm torn. There's the possibility that more people would 

become addicted but also no doubt that legally regulating and taxing most of the drugs that are 

now criminalized would radically reduce the crime, violence, corruption and black markets, and 

the problems of adulterated and unregulated drugs, and improve public safety, and allow 

taxpayer resources to be developed to more useful purposes. 

The markets in marijuana, cocaine, heroin, and methamphetamine are global commodities 

markets just like the global markets in alcohol, tobacco, coffee, sugar, and so many other 

things. Where there is a demand, there will be a supply. Knock out one source and 

another inevitably emerges. People tend to think of prohibition as the ultimate form of 

7 See for instance. King County l3ar Association, ''Drugs and the Drug Laws: Historical and Cultural Contexts," 

(2005), accessed June I, 2016. htips:·/www.kcba.org1druglawipdf!repott hc.pd[ Licit and Illicit Drugs; The 

Consumers Union Repo11 on Narcotics, Stimulants, Depressants, Inhalants, Hallucinogens, and MarijuanaIncluding Caffeine ( 1973). 8 Herbert Hill, Anti-Oriental Agitation, Society, 10:43-54, 1973; p. 51; Andrew Sinclair, Prohibition: Era of Excess 

(1962); Arnold Trebach, The Heroin Solution (1982). 9 Dr. Edward H. Williams, "Negro Cocaine 'Fiends' Are a New Southern Menace,"The New York Times, Feb. 8, 

I 9 I 4; Dr. Christopher Koch, Literary Digest, March 28, I 914, p. 687; Richard Ashley, Cocaine: Its History, Uses 

and Effects, p. 60; "The Growing Menace of the Use of Cocaine," New York Times, August 2, 1908. 

'" R.J. Bonnie and C.H. Whitebread, The Marihuana Conviction 

(Charlottesville: University of Virginia Press, 1974): Ernest L. Abel, Marihuana: The First 12,000 Years, p. 207 
414 

regulation when in fact it represents the abdication of regulation, with criminals filling the 

void. That's why putting criminal laws and police front and center in trying to control a dynamic 

global commodities market is a recipe for disaster. What we really need to do is bring the 

underground drug markets as much as possible above ground and regulate them as intelligently 

as we can to minimize both the harms of drugs and the harms of prohibitionist policies. 

With marijuana, that obviously means legally regulating and taxing it like alcohol. The benefits 

of doing so are enormous. the risks minimal. Will more people use marijuana? Maybe, but it's 

not going to be young people, because it's not going to be legalized for them, and quite frankly, 

they already have the best access to marijuana. Youth marijuana use is actually falling in the 

states that have legalized marijuana, as are arrests. Meanwhile, tax revenue is up. 11 

As for the other drugs, look at Portugal, where all drugs were decriminalized in 200 I. Nobody 

goes to jail there for possessing drugs, and the government is deeply committed to treating 

addiction as a health issue. People who don't fear arrest become more likely to seek help when 

they need it. Both adolescent drug usc as well as overall problematic drug use has decreased 

since 2003 in Portugal. 12 Overdose fatalities have decreased. 13 Treatment admissions are up. 14 

A growing number of national and international organizations and experts support 

decriminalization. including the American Public Health Association. World Health 

Organization, Organization of American States, International Federation of Red Cross and Red 

Crescent Societies, NAACP, Human Rights Watch. American Civil Liberties Union, National 

Latino Congreso, and UN agencies that focus on health, development, and human rights. Recent 

polls of primary voters in New Hampshire 15 and South Carolina 16 found a substantial majority of 

voters believe people caught with a small amount of drugs should be evaluated and offered 

treatment but not be arrested or face jail time. 

California and Maine recently downgraded drug possession from a felony to a misdemeanor. 

Thirty-two states and the District of Columbia have adopted 911 Good Samaritan overdose 

prevention laws, which essentially decriminalize simple possession and other minor drug 

11 http://www .dru gpo I icy .org/ sites/ defaultlfiles/Drug_Po I icy_ A II iance _Status_ Report_ Marijuana_ Legalization _in_ 

Washington_July2015.pdf: State of Colorado (2013) 'Task Force Report on the Implementation of Amendment 64: 

Regulation of Marijuana in Colorado'; Transform (2015), ''Cannabis Regulation in Colorado: early evidence defies 

the critics" http://www.tdpf.org.uk/blog!cannabis-regulation~colorado-early-evidence-deties-critics; '"As Fear And 

Intolerance Of Marijuana Declined, So Did Adolescent Use", Jacob Sullum, Forbes. June 2, 2016. 12 Hughes and Stevens, 11What Can We Learn from the Portuguese Decriminalization oflllicit Drugs?.n 999-1022: 

Mal~1lda Ferreira. Margarida Gaspar de Matos, and Jose Alves Diniz, nRisk Behaviour: Substance Use among 

Portuguese Adolescents," Procedia- Social and Behavioral Sciences 29(20 11 ): 486-92. 

L> Hughes and Stevens. uA Resounding Success or a Disastrous Failure: Re- Examining the Interpretation of 

Evidence on the Portuguese Decriminalisation of Illicit Drugs." 107: (SICA D), "Relat6rio Anual2013 """a Situat;ao 

Do Pais Em Materia De Drogas E Toxicodependencias." 64. 11 llughes and Stevens, uwhat Can We Learn from the Portuguese Decriminalization of Illicit Drugs?," 1015; 

I!JStitulo da Droga e da Toxicodepcndencia, "Rclat6rio Anual 20 II -a Situa~ao Do Pals Em Materia De Drogas E 

Toxicodcpcndencias." (20 12), Ancxo. 32. As a result of changes to Portugal's national treatment data collection and 

reporting processes, data published after 20 II are not directly comparable to data published before 20 II. Laqucur. 

"Uses and Abuses of Drug Decriminalization in Ponugal." 15 1J.WL>'" \\.drugpolicy.org'sites.default'tilcs/NIIResults 0 12616.pdf 16 http>':www.druupolicv.org:sites/clef'ault/tilesiSC poll 0216 PPP.pdf 
415 

offenses at the scene of an overdose by providing immunity from prosecution to those who seek 

help. Policies such as Law Enforcement Assisted Diversion (LEAD) which operate in Seattle 

and Santa Fe and are now being adopted in other major cities- seek to reduce the role of the 

criminal justice system at the point of contact for low-level offenses like drug possession, minor 

drug sales, prostitution, and petty larceny. Police use their discretion to refer people to voluntary, 

harm reduction-oriented treatment and other services instead of arresting and booking them. 

A growing number of countries- including Canada, Denmark, Germany, Spain, Switzerland, 

and the United Kingdom- now provide pharmaceutical heroin and helping services in medical 

clinics. The results are clear: Illegal drug abuse, disease, overdoses, crime, and arrests all go 

down while health and well-being improve, taxpayers save money, and many drug users even put 

their addictions behind them. 17 

Evaluations of these heroin-assisted treatment programs demonstrate that "prescribed pharmaceutical 

heroin does exactly what it is intended to do: it reaches a treatment refractory group of addicts by 

engaging them in a positive healthcare relationship with a physician, it reduces their criminal 

activity, improves their health status, and increases their social tenure through more stable housing, 

employment, and contact with family." 18 Moreover, these substantial benefits come with improved 

cost-savings compared to standard treatments 19 and with no negative impacts on the larger 

community. 

Though heroin-assisted treatment programs only serve a small minority of the population that 

uses heroin, it is this subgroup that consumes the majority of the heroin supply. For this reason, 

heroin maintenance can actually help destabilize local heroin markets. One published article 

concluded that heroin maintenance participants had "accounted for a substantial proportion of 

consumption of illicit heroin, and that removing them from the illicit market has damaged the 

''See. e.g .. Fischer, B., Oviedo-Joekes, E .. Blanken, P .. et al. (2007). Heroin-assisted treatment (HAT) a decade 

later: 1\ brief update on science and politics. J Urban Health, 84, 552-62; Strang, J .. Groshkova, T. & Metrebian, N. 

(20 12). New heroin-assisted treatment: Recent evidence and eunent practices of supervised injectable heroin 

treatment in Europe and beyond. European Monitoring Centre for Drugs and Drug Addiction Insights. Luxembourg: 

Publications: Sec, e.g., van den Brink. W .. Hendricks. V. M., Blanken. P., et al. (2003). Medical prescription of 

heroin to treatment resistant heroin addicts: two randomiscd controlled trials. British Medical Journal, 327,310-3 16; 

Haasen, C., Verthein, U., Degkwitz, P., et al. (2007). Heroin-assisted treatment for opioid dependence. British 

Journal of Psychiatry, I 91, 55-62; March, J. C., Oviedo-Joekcs, E., Pcrea-MilJa, E., CaiTasco. F. et al. (2006). 

Controlled trial of prescribed heroin in the treatment of opioid addiction. Journal of Substance Abuse Treatment, 3!, 

203"-21 I; Oviedo-Joekes, E.. Brissette, S., Marsh, D., et aL (2009). Diacetylmorphine versus methadone for the 

treatment of opiate addiction. The New England Journal of Medicine, 361, 777-786: Perneger, T. V., Giner, F., del 

Rio, M. & Mino. 1\. (I 998). Randomised trial of heroin maintenance programme for addicts who fail in 

conventional drug treatments. British Medical Journal 317, 13--18; Strang, J., Metrebian, N., Lintzeris, N., et al. 

(2010). Supervised injectable heroin or injectable methadone versus optimised oml methadone as treatment for 

chronic heroin addicts in England attcr persistent failure in orthodox treatment (RlOTT): a randomised trial. Lancet, 

375, 1885 I 895. See. e.g .. FeiTi, M., Davoli. M., & Perucci, C.A. (2005). Heroin maintenance for chronic heroin 

dependents. Cochrane Database Syst Rev .. 2. 18 Small, D. & Drucker, E. (2006). Policy makers ignoring science and scientists ignoring policy: The medical 

ethical challenges of heroin treatment. Harm Reduction Journal, 3, 16. 19 Bammer, G., van den Brink, W., Gschwcnd, P., et al. (2003). What can the Swiss and Dutch trials tell us about the 

potential risks associated with heroin prescribing? Drug and Alcohol Review, 22(3), 363-71; Dijkgraaf, M.G., van 

der Zanden, B. P., de Borgie, C. A., et al. (2005). Cost utility analysis of co-prescribed heroin compared with 

methadone maintenance treatment in heroin addicts in two randomised trials. BMJ, 330, 1297-1302. 
416 

market's viability." 20 The authors further state that "by removing retail workers [who] no longer 

sold drugs to existing users, and ... no longer recruited new users in to the market ... the heroin 

prescription market may thus have had a significant impact on heroin markets in Switzerland." 

66 cities around the world in nine countries have supervised injection facilities (SIFs) that get 

people who inject drugs off the streets and make sterile injection equipment, information about 

reducing the harms of drugs, health care, treatment referrals, and access to medical staff 

available. These facilities not only benefit individuals who use drugs and their families; they also 

reduce public disorder associated with illicit drug use including improper syringe disposal and 

public drug use. Hundreds of evidence-based, peer-reviewed studies have proven the positive 

impacts of supervised injection facilities internationally. 21 

Research shows that supervised injection drug use facilities reach the intended target groups of longterm addicts, street injectors, homeless drug users, and drug-using sex workers and are thus 

facilitating contact with the most problematic and marginalized drug users. 22 One study of the 

Canadian safer drug use facility found that "regular use of the [facility] and having contact with 

counselors at the [facility] were associated with entry into addiction treatment, and enrollment in 

addiction treatment programs was positively associated with injection cessation."23 

Supervised injection facilities target the "nuisance factor" of drug scenes- the hazardous litter 

and the seemingly intimidating presence of injectors congregating in city parks, public 

playgrounds, and on street corners- by offering them an alternative, supervised, and safe space. 

Another study of the Canadian safer drug use facility found "significant reductions in public 

injection drug use, publicly discarded syringes and injection-related litter after the opening of the 

medically supervised safer injections facility in Vancouver."24 

The European Monitoring Centre on Drugs and Drug Addiction's review of the evidence in 

support of safer drug use facilities found that"[ s ]urveys of local residents and businesses, as well 

as registers of complaints made to the police, generally show positive changes following the 

establishment of consumption rooms, including perceptions of decreased nuisance and increases 

2

° Killias, M., Aebi, M.F., Jurist, K. (2000). The Impact of Heroin Prescription on Heroin Markets in Switzerland. 

Crime Prevention Studies, 11. 21 Wrigb Potier, C., V. Laprevote, f. Dubois~Arber, 0. Cottencin, and B. Rolland. "Supervised Injection Services: 

What Has Been Demonstrated? A Systematic Literature Review." Drug Alcohol Depend 145C (2014): 62 Frank 

Zobel and Francoise Dubois-Arber, Short appraisal of the role and usefulness of drug consumption facilities (DCF) 

in the reduction of drug-related problems in Switzerland (Lausanne, Switzerland: University Institute of Social and 

Preventive Medicine, 2004), 27. Brandon DL Marshall et al., "Reduction in overdose mortality after the opening of 

North America's first medically supervised safer injecting facility: a retrospective population-based study," The 

Lancet 377, no. 9775 (2011): 1429-37. K. DeBeck et al., "Injection drug use cessation and use of North America's 

first medically supervised safer injecting facility," Drug Alcohol Depend 113, no. 2-3 (2011): 172-6. 

15 Broadhead et al., "Safer injection facilities in North America: Their place in public policies and health 

initiatives," 329-55. MSIC Evaluation Committee, Final Report of the Medically Supervised Injecting Centre 

(Sydney, Australia: Authors, 2003). 22 Kathleen Dooling and Michael Rachlis, "Vancouver's supervised injection facility challenges Canada's drug 

laws," Canadian Medical Association Journal 182, no. 13 (2010). 23 K. DeBeck et al., "Injection drug use cessation and use of North America's first medically supervised safer 

injecting facility," Drug Alcohol Depend 113, no. 2-3 (2011): 172-6. 24 E Wood et al., "Changes in public order after the opening of a medically supervised safer injection facility for 

injection drug users," Can MedAssocJ 171, no. 7 (2004): 733. 
417 

in acceptance of the rooms." 25 The Centre also found that "[p]o!ice, too, often acknowledge that 

consumption rooms contribute to minimising or preventing open drug scenes."26 

New Zealand recently enacted a law allowing certain synthetic drugs to be sold legally, provided 

their safety can be established. In Brazil and other countries, a remarkable psychoactive 

substance, ayahuasca, can be legally bought and consumed provided it is done so within a 

religious context. In Bolivia and Peru, products made from the coca leaf, the source of 

cocaine, are sold legally over the counter with no apparent harm to people's public health. 

Conversely, think about cigarettes: Nothing can both hook you and kill you like cigarettes. When 

researchers ask people addicted to heroin what's the toughest drug to quit, most say 

cigarettes. Yet in this country and many others, half of all the people who were ever addicted to 

cigarettes have quit without anyone being arrested or put in jail or sent to a "treatment 

program" by a prosecutor or a judge. What did it were higher taxes and time and place 

restrictions on sale and use and effective anti-smoking campaigns. Now, could we reduce 

smoking even more by making it totally illegal? Probably. But just imagine the drug war 

nightmare that would result. 

So the challenges we face today are twofold. The first is the policy challenge of designing and 

implementing alternatives to ineffective prohibitionist policies, even as we need to get better at 

regulating and living with the drugs that are now legal. But the second challenge is 

tougher, because it's about us. The obstacles to reform lie not just out there in the power of the 

prison industrial complex or other vested interests that want to keep things the way they are, but 

within each and every one of us. 

It is our fears and our lack of knowledge and imagination that stands in the way of real 

reform. Ultimately, I think that boils down to the kids, and to every parent's desire to put our 

baby in a bubble, and the fear that somehow drugs will pierce that bubble and put our young 

ones at risk. In fact, sometimes it seems like the entire war on drugs gets justified as one great 

big child protection act, which any young person can tell you it's not. 

Here's what I say to teenagers. First, don't do drugs. Second, don't do drugs. Third, if you do do 

drugs, there arc some things I want you to know. because my bottom line as your parent is that I 

\Vant you to come home safely at the end ofthe night and grow up and lead a healthy and good 

adulthood. That's my drug education mantra: safety tlrstY Putting safety tirst requires that we 

provide our young people with credible information and resources. We also need to teach our 

teenagers how to identify and handle problems \\ilh alcohol and other drugs if and when they 

occur-· and how to get help and support. 

The war on drugs has filled our jails and prisons with nonviolent offenders but hasn't made 

young people safer. Despite the incarceration of tens of millions of Americans and more than a 

25 Hedrich, Dagmar. "European Report on Drug Consumption Rooms", European Center on Drugs and Drug 

Addiction, February 2004. 26 Ibid. 

''See Safety First: A Reality-Based Approach to Teens and Drugs, Marsha Rosenbaum, Drug Policy Alliance, 

h.!lll~/ WW\\', drugpol icv .org/resourcelsa fetv-first -reality-based-approach-teens-and-drugs. 
418 

trillion dollars in spending since the modem drug war was launched 40-plus years ago, illegal 

drugs remain cheap, potent, and widely available. The harms associated with them continue to 

persist in every community. Meanwhile the war on drugs is creating problems of its ownbroken families, increased poverty, racial disparities, wasted tax dollars, prison overcrowding, 

and eroded civil liberties. 

Repeating the mistakes of the past will not improve the future. A new approach is needed, one 

that reduces both the harm caused by drugs and the harm caused by current drug control policies. 

We need to decriminalize drug use and possession and ensure that people who use drugs have 

access to good health services. We need to encourage different models for regulating marijuana. 

And we need, more broadly. to reduce the role of criminalization and criminal justice to the 

extent truly required to protect health and safety. It is time to put all options on the table and 

have a robust debate about the direction of U.S. drug policy. 
419 

June 30, 2016 

The Honorable Ron Johnson 

Chainnan 

Senate Committee on Homeland Security and Governmental Affairs 

340 Dirksen Senate Office Building 

Washington, D.C. 20510 

The Honorable Tom Carper 

Ranking Member 

Senate Committee on Homeland Security and Governmental Affairs 

442 Hart Senate Office Building 

Washington, D.C. 20510 

Dear Chairman Johnson and Ranking Member Carper, 

Thank you for inviting me to testifY before your Committee on June 15th. I am 

writing to offer supplemental testimony for the record of the committee hearing 

entitled "America's Insatiable Demand for Drugs: Examining Alternative 

Approaches." The following infonnation provides additional background on some of 

the issues and interventions that we discussed during the roundtable, as well as 

several additional recommendations to consider going forward. 

Marijuana legalization in Colorado 

As I stated during the hearing, it's really too early to say anything conclusive about 

the impact of the legal taxation and regulation of marijuana in Colorado, Washington, 

Oregon and Alaska. The implementation of such laws in all four states has only been 

underway for two years or less and it is very difficult to sort out causal relationships 

between the law and marijuana-related trends. However, in Colorado, the first state to 

implement taxation and regulation in 2014, preliminary data shows many promising 

indications that taxation and regulation in Colorado is working. Arrests for marijuana 

possession dropped dramatically by nearly 80% between 20 I 0 and 2014 with much 

of the decrease occurring after non~medicallegalization took effect. 1 As l submitted 

in testimony, the legal regulation and taxation of marijuana in Colorado and other 

places is probably not going to increase marijuana use among young people. 

Marijuana use has not been legalized for them, and quite frankly, they already 

have the best access to marijuana under prohibition. The best evidence we have of 

this again comes out of Colorado. 

Every two years, the state administers what is known as the Health Kids Colorado 

Survey (HKCS). The state administered the survey to roughly 25,000 high schoolers 

in 2013 and 17,000 high schoolers in 2015. What they found was that between 2013 

and 2015, marijuana use among high schoolers in Colorado remained flat in the 

state.2 These findings are consistent with research demonstrating that youth 

marijuana use has not increased following the legalization of marijuana for medical 

or non-medical use.3 And as I mentioned during my oral testimony before the 

Committee, a just released analysis of the National Youth Risk Behavior Survey 

Drug Policy Alliance I 131 West 33rd Street, 15th Floor, New York, NY 10001 

212 613.8020 voice I 212.613.8021 fax I www.drugpolicy.org 

Board Members 

Jodie Evans 

Ja!'T'es E Ferguson. II 

Flom 

'" Car! Hart PhD 

Mathilde Knm, PhD 

David C Lew1s. MD 

Pamela Lichty 

Ethan Nadelmann, JD, PhD 

Robert Newman, MD 

Rev Edw1n Sanders 

M1chaelSkolmk 

Ja!lnVasconcellos 

R1chardB Wolf 

Honorary Board 

Former Mayor 

Rocky Anderson 

Harry f3elafonte 

R1chard Branson 

Former Defense Secretary 

Frank C Carlucc1 HI 

(1916-2009] 

Ram Dass 

Vmcent Doie MD 

Patnck V Murphy 

[1920-2011] 

Benny J Pnmm, MD 

Dennis RIVera 

Fonner CharrMa'l ot the Federal 

ReserveP<'IuiVolcker 
420 

between 1991 and 2015 also found that prevalence of marijuana use by high school 

students decreased-- a time period when roughly half the states implemented medical 

marijuana laws.4 

In terms of the impact oflegalization in Colorado on road safety, existing ways to 

measure marijuana use among drivers do not confirm whether a driver is impaired. 

The only thing these tests establish is whether a driver consumed marijuana within 

the past several hours, days, or even weeks. They do not measure whether the person 

is unsafe to drive. It's the equivalent of an alcohol test that showed us that a driver 

consumed some amount of alcohol within the past couple of weeks, which would tell 

us nothing about whether the driver was impaired at the time of the accident. Existing 

data do not tell us that there are more impaired drivers on the road. That question has 

not yet been analyzed. Unlike with alcohol the impairment effect of marijuana is 

unclear. 

There was no significant increase in road fatalities in Colorado and road fatalities 

remained at near-historic lows through 2014. 5 Much was made of the sudden jump in 

road fatalities in 2015 but Colorado officials blamed drivers not using their seat belts 

as the underlying cause of this increase and have since launched a statewide seat belt 

use awareness campaign 6 The Colorado State Patrol (CSP) reported that the number 

of summons issued for driving under the influence in which marijuana or marijuanain-combination with other drugs actually decreased l% between 2014 and 20 !5 7 

Similarly, while the overall crime rate in Colorado- and Denver specificallyreportedly rose in 2015, the director of Rocky Mountain 1-IIDTA noted that 

marijuana·related crimes in Denver are "a relatively smatl number of crimes" and 

"When you look at overall crime in Denver, there's so many reasons that crime rises 

and falls." A spokesperson for the Denver police department did not speculate if 

there is a relationship between marijuana legalization and an increase in the Denver 

crime rate when contacted by the Denver Post. 8 It is truly too soon to know whether 

the legal non-medical marijuana market has any bearing on crime. 

As for criminal activity related to marijuana businesses, the 2016 Colorado 

Department of Public Safety report notes that "the total number of industry-related 

crimes has remained stable and makes up a very small portion of overall crime in 

Denver. The most common industry-related crime is burglary, which accounts for 

62% of all industry-related crime. There has been concern that, due to the cash-only 

nature of the industry, robbery would be prevalent but this has not proven to be the 

case,''9 Because of rederallaw, banks are afraid to provide services to state-legal 

marijuana businesses. Colorado's governor John Hickenlooper has urged the federal 

government to change federal law so that marijuana industry participants can bank 

with federally licensed banks. 10 

Through all of this we have to remember that Colorado is in the early stages of an 

evolution from illicit market to legal market (analogous to what happened with the 

repeal of alcohol prohibitions in the 1930s). Implementation of these reforms in 

Colorado appears to be working, so much so that more Coloradans support the law 

now than voted for it in 2012. Tax revenues and other economic benefits have 

exceeded expectations.'' The benefits of legally regulating and taxing marijuana like 

alcohol clearly are substantial, while the risks are minimal. Congress should give 
421 

states the flexibility they need to effectively regulate marijuana and try other 

alternative approaches to prohibition policies. 

Decriminalization 

The presence or harshness of criminal penalties for drug possession or use in open 

societies appear to have no impact on levels of use. 12 Criminalizing people who sell 

and use drugs, especially opioids, amplifies the risk of fatal overdoses and diseases, 

increases stigma and marginalization, and drives people away from needed treatment, 

health, and harm reduction servicesD Reducing the role of the criminal justice 

system is therefore critical to ensuring that people who use opioids are able to access 

vital treatment and harm reduction services that most benefit individuals, families, 

and communities. 

Decriminalization is commonly defined as the elimination of criminal penalties for 

drug possession for personal use. It means that people who merely use or possess 

small amounts of drugs are no longer arrested, jailed, prosecuted, imprisoned, put on 

probation or parole, or saddled with a criminal record. Decriminalization is not 

synonymous with legalization, which typically involves the legal regulation of drug 

sales that are currently prohibited. 

Punishment for a drug possession violation is not only meted out by the criminal 

justice system, but is perpetuated by policies denying a host of rights and privilegeseven after one)s sentence is served. A criminal conviction for drug possession can 

lead to the temporary or permanent loss of child custody, voting rights, employment, 

business loans, licensing, student aid, public housing and other public assistance. 

These "collateral consequences" of drug convictions intensify the struggles 

individuals face on the road to recovery and rehabilitation. Moreover, there is no 

evidence that criminalization actually encourages abstinence or treatment. 

Nearly two dozen countries have taken steps toward decriminalization. As l indicated 

in submitted testimony, the best and most well-documented example is Portugal, 

which in 2001 eliminated criminal penalties for low-level possession and use of all 

illicit drugs, and made a commitment to treating drug use as a health issue. 14 

Empirical evidence from the international experiences demonstrate that 

decriminalization does not result in increased use or crime, reduces incidences of 

HIV I AIDS and overdose, increases the number of people in treatment, and reduces 

social costs of drug misuse. 15 

All criminal penalties for possession of small amounts of controlled substances for 

personal use should be removed. Maryland recently introduced legislation to 

accomplish this reform. 16 Moreover, various other steps toward decriminalization 

have been taken in the United States. Twenty states and Washington, DC have 

reduced or eliminated criminal penalties for personal marijuana possession. Four 

states- California, Connecticut, Maine and Utah- recently reclassified drug 

possession from a felony to a misdemeanor. Since the passage of California's law, 

Proposition 47, more than 13,000 people have been released and resentenced 

saving the state an estimated $156 million in incarceration costs averted, which is 

being reinvested in drug treatment and mental health services, programs for at~risk 

students in K-12 schools~ and victim services. 17 
422 

Supervised injection facilities 

Every potential tool available that can help reduce overdoses and injection-related 

harms should be considered. This is especially valid in the case of some of the most 

marginalized people who use drugs in communities who are not reached by 

traditional service providers. These marginalized and high-risk drug users have little 

recourse than to consume drugs in public spaces due to lack of housing and other 

supportive care. Public drug use is associated with significantly higher rates of 

overdose, transmission of infectious diseases, and necessity of costly emergency care, 

as well as a variety of nuisance and safety issues, including improper syringe disposal 

and "open-air" dntg consumption. These users are at the greatest risk for disease and 

death, and are also the least likely to engage directly in traditional abstinence-based 

health services, and would benefit the most from access to supervised injection 

facilities. 

As I stated in submitted testimony, supervised injection facilities (S!Fs) keep people 

who inject drugs alive and off the streets. These legally sanctioned facilities provide a 

space for the most problematic and marginalized people who use drugs to consume 

pre-obtained drugs in a hygienic environment supervised by trained medical staff. 18 

Staff members do not directly assist in consumption or handle any drugs brought in 

by clients, but are present to provide sterile syringes and injection-related supplies, 

answer questions on safe consumption practices, administer first aid if needed, and 

monitor for overdose. Staff also offer general medical advice and referrals to drug 

treatment, medical treatment, and other social support programs. SIPs serve as a 

critical means to engage people who are on the margins and bridge them to drug 

treatment. The SIF environment is designed to put a marginalized person in the right 

frame of mind to accept help in this way. 

There are at least 98 S!Fs operating in 66 cities around the world in ten countries 

(Switzerland, Germany, the Netherlands, Norway, Luxembourg, Spain, Denmark, 

Greece, Australia and Canada). 19 Numerous evidence-based, peer-reviewed studies 

from those countries have demonstrated the positive impacts of S!Fs.20 Those 

benefits include increased uptake into treatment for drug dependence, especially 

among people who are unlikely to seek treatment on their own,21 reduced public 

disorder, reduced public injecting, and increased public safety,22 reduced HJV and 

hepatitis C risk behavior (i.e. syringe sharing, unsafe sex),23 reduced prevalence and 

harms of bacterial infections 24 and reductions in overdose fatalities. 25 

SIFs deliver these benefits without increasing community drug use, 26 initiation into 

injection drug use27 or drug-related crime.28 A large amount of research has also been 

conducted studying North America's only supervised injection facility in Vancouver, 

British Columbia known as InSite 29 Data indicate that supervised injection facilities 

are uniquely effective in sustaining contact with the most marginalized and chaotic 

users who consume drugs in public places and who are otherwise not reached by 

current harm reduction interventions. Despite the compelling and uncontroverted 

evidence, however, no S!Fs have been established in the United States to date. 

Heroin-assisted treatment 

In my testimony before the Committee, I discussed the pivotal role that heroin 
423 

assisted treatment can play in addressing the health needs of a small subgroup of 

heroin users who have consistently not responded to other types of medicationassisted treatment without negatively impacting the larger community. 30 

Heroin-assisted treatment involves administration of phannaceutical grade heroin or 

hydromorphone under supervision by licensed medical professionals in a specialized 

clinic and under strict controls. The drug is required to be consumed on-site, under 

the watchful eye of trained professionals. This enables providers to ensure that the 

drug is not diverted, and allows staff to intervene in the event of overdose or other 

adverse reaction. The clinic-based model also encourages interaction between clients 

and staff, which improves referrals to and uptake of health and other services. As a 

treatment modality, heroin-assisted treatment has gained traction within the scientific 

community as a tried-and-true method for dealing with particularly refractory cases 

of heroin addiction and the associated harms. 

Heroin-assisted treatment has proven enormously successful and now operate in 

Switzerland,31 Netherlands,32 United Kingdom, 33 Germany, 34 Spain? Denmark,36 

Belgium,37 Canada,38 and Luxembourg. Notably, In the United Kingdom, three 

clinics remained open after the conclusion of their trial program and currently serve 

approximately 100 people.39 In January 2012, the government gave approval for the 

roll-out of additional heroin maintenance clinics after the Department of Health 

concluded that heroin-assisted treatment "is now evidenced as a clinically-effective 

second-line treatment .. , ."40 Moreover, approximately 500 people in the United 

Kingdom receive prescription heroin directly from their physician for maintenance 

treatment.41 

Rigorous research studies examining heroin-assisted treatment in these countries 

have found that this approach reduces heroin use, improves treatment engagement 

and retention, and prevents mortality among high-risk drug users who do not respond 

to other types of medication-assisted treatment.42 Studies have also found that heroinassisted treatment is associated with decreased illicit drug use, crime, overdose 

fatalities, and risky injecting, as well as improvements in physical and mental health, 

employment and social relations.43 Additional findings from randomized controlled 

studies in countries that have implemented heroin-assisted treatment have yielded 

additional positive results, including that retention rates in heroin-assisted treatment 

surpass those of conventional treatment, heroin-assisted treatment can be a stepping 

stone to other treatments and even abstinence, heroin-assisted treatment does not 

pose nuisance or other neighborhood concerns and heroin-assisted treatment is costeffective (cost-savings from the benefits attributable to the program far outweigh the 

cost of program operation over the long-run). 44 

Every heroin-assisted treatment trial has shown a marked decrease in street heroin 

use 45 The United Kingdom trial, for instance, reported over a two-thirds (72 percent) 

reduction in illicit drug use among heroin-assisted treatment participants. 46 Similar 

reductions in street heroin use were reported from heroin maintenance trials in 

Switzerland (74 percent),47 Germany (69 percent)," and Canada (67 percent).49 As I 

stated in testimony, it is also key to consider the role that providing effective 

replacement therapy to this heroin using population that consumes the majority of the 

heroin supply can help with destabilizing local heroin markets50 
424 

An estimated one million people used heroin in the United States in 2014, almost 

triple the 2003 rate, according to a new report by the United Nations Office on Drugs 

and Crime. 51 A significant population of people who use heroin could benefit from 

heroin assisted treatment. However, zero tolerance policies and federal law have 

stood in the way of pilot heroin-assisted treatment projects in the United States. 

Drug courts 

There is no doubt that drug court judges and their staffs have helped change, even 

save, many lives, but it is important to consider the full range of drug court impacts, 

both positive and negative, on all participants as well as on the criminal justice and 

other systems. It is also important to consider drug court outcomes within the larger 

context of potential policy options and practices to reduce drug arrests, incarceration 

and problematic drug use. In this light, the benefits of drug courts pale considerably. 

My fellow witness, Arlington, Massachusetts police chief Frederick Ryan was right 

when he gave his opinion on drug courts, commenting that "When you push the 

button for the criminal justice system, it's incredibly complex and difficult to 

reverse," Chief Ryan added: "You take somebody suffering from a substance use 

disorder and put them into a complex criminal justice system- we're finding it 

creates even more challenges." 

In 2011, the Drug Policy Alliance released a report that sought to address the lack of 

critical analysis that often stymies the policy discussion on drug courts. 52 The report 

analyzed the research on drug courts and found that drug courts leave many people 

worse off than if they had received drug treatment outside the criminal justice 

system, had been left alone, or even been conventionally sentenced. Another finding 

was that drug courts have not demonstrated cost savings, reduced incarceration, or 

improved public safety. A 2011 report by Justice Policy Institute made similar 

findings. 53 

Drug courts also penalize relapse with incarceration and ultimately eject from the 

program those who are not able to abstain from drug use for a period of time deemed 

sufficient by the judge. Meeting these requirements often means that a participant 

cannot enroll in evidence~based medication~assisted treatment programs. Medication~ 

assisted treatment refers to the treatment of opioid dependence through the 

prescription of medications such as buprenorphine and methadone, which block the 

effects of opioid use and prevent or relieve withdrawal symptoms and cravings. 

Scientific research has established that medication-assisted treatment is a costeffective intervention that increases patient retention in treatment and decreases drug 

use, transmission of infectious diseases, and criminal activity. 

The White House Office of National Drug Control Policy (ONDCP) recently took the 

position that drug courts and other diversion programs that receive federal funding 

should not be permitted to prohibit participants from accessing medication-assisted 

treatment. SAMHSA subsequently implemented a rule that drug courts that receive 

federal funding to drug courts cannot deny the use of medication-assisted treatment 

when made available to the client under the care of a physician and pursuant to a 

valid prescription." The National Association of Drug Court Professionals has long 

taken the position that drug courts should permit the use of medication-assisted 

treatment for participants in need of an addiction medication. 5

5 Drug courts and other 
425 

diversion programs should at a minimum be required to demonstrate that evidencew 

based treatment practices, including the use of medication assisted treatment, can be 

utilized by participants. 

The bottom line is that drug courts have made the criminal justice system more 

punitive toward addiction- not less. As the Committee looks at options for 

addressing the nation's demand for drugs, it is pivotal that we move in the direction 

of treating drug use as a health issue and not as a criminal justice issue. In this 

context, people caught with possession quantities of drugs do not belong in the 

criminal justice system. We should divert these individuals directly into treatment 

and health~based services and reserve drug courts for cases involving offenses against 

person or property that are linked to a drug use disorder, while improving drug court 

practices and providing other options for people convicted of drug law violations. 

Recommendations going forward 

Above all, l urge the Committee to consider new approaches to dealing with drug 

demand and the harms that stem from drug use. Please review the evidence 

supporting the use of these interventions that I have provided here. We should be 

looking for ways to support further research into the viability of these interventions in 

the United States. My staff can provide additional information or answer any 

questions you may have. 

It is understandable that the Committee is focused on the management of pain. I 

made several recommendations that I hope the Committee will explore~ including 

taking steps to incentivize medical students and physicians to learn dramatically more 

about managing pain. This might take the form of incentivizing medical schools to 

place a greater focus on this subject, as well as exploring treatment alternatives to 

opioids. I also recommended that we look to the role that marijuana could play as a 

replacement therapy in the treatment of pain. I highlighted three studies during the 

roundtable that showed that the states with the most robust medical marijuana 

programs have experienced lower levels of opioids being prescribed and dramatically 

lower rates of opioid overdoses. 5

6 This deserves a closer look, especially if 

marijuana can play a more effective and far less dangerous way of dealing with pain. 

In my testimony, I pointed to the example of St. Joseph's Regional Medical Center in 

Paterson, New Jersey as a potential model to look at for addressing pain in innovative 

ways, the subject of a recent New York Times article. 57 We all agree on the need to 

reduce demand for opioids, but what is so important about the example being set at 

St. Joseph's is the importance of being smart and creative about finding other ways to 

manage pain, such as the use of less dangerous medications and other alternative 

approaches. I also believe we should focus public awareness campaigns so that they 

better reach older people who are prone to become dependent on opioids and are at 

elevated risk of overdose because of co-morbidities or the co~occurring use of 

benzodiazepines or other drugs. It is these kinds of issues that should be highlighted 

in public awareness campaigns. 

Finally, I think it is vital that the Committee look at ways that we can dramatically 

scale up funding and support for research. We need to get a better handle on the 

many facets of the problems stemming from drug demand. This should include an 
426 

examination of the underlying motivations driving the use of various drugs such as 

fentanyl and oxycodone. It will take an army of researchers, including thousands of 

ethnographers, to explore these and other aspects of this problem that could drive 

more effective policy on these issues. 

Thank you for considering these recommendations. 

Sincerely, 

&~ Ethan Nadelmann 

Executive Director 

Drug Policy Alliance 

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R..:YiC\\ of RC\iev.s to Ass..:o;5 !-:vidence of Effectiveness." International Journal o(Drug Po/1cy 

25.1(20\3): 3.t~52: :\ Bo:d. "Lcs:-;ons from INS! I'E. Vancouver's supervised facility: 1003-

2012,·· Educotion Pr.:veution 20.3 (2013}: 2.14-240: ct nl., ··overdose 

Deaths Supervised Injection ., The Lancer 379.981 I {2012):ll7: S Pinkerton . 

.. \10\\ man) \l!V Infc-ctiono; arc Prevented h> Vancouver Canada's Supcniscd Injection Facility?" 

lnlemationa/ Joumal t{l)rug Pofh:v 22 (201 I): 179 183: S Pinb:rton. "Is Ym1couvcr Canada's 

Surenised lnj~dion Facility Cost·saving?'" Addiction 105 (2010): 1419- 1436: M Andresen. N Boyd, 

"A l'ost·Bcnefit and Cost-dTcctivcnc:>:> Analysis of Vancouver's Supcrv[sc.>d Injection Facility.'' 

Jnternanww! Joumal /)rug Po!J(V 21 (20 I 0): 70· 76.: K DcBeck c-t aL, "Police ami Public llca!th 

Partnerships: h id.:nCL' from the !:valuation of Vancouver'~ SupcrYiscd Injection F::~dlity. Suhstam:e 
428 

,Jhu.w /"r..:atenT, 1~5: R Wood d aL "Nurst·~dcliwrcd Safer Injection 

l:vidcncl' from the !~valuation of Vancouver's 

19.3 (2008)\83- 1H8: A Bayoumi. 

facilitv, ,. Canandian Medical 

.·lssoswiion Journa/179.11 (200H): 1143-1151.: D Arastch. H Hagan. "Ev::~Jualing 

Vancouver's Sup.,rviscd Injection Facility: Data and Dollars. Symbols and Ethics." Canandwn Jfe&ca! 

·fssoci(lfion Journal 179.11 (2008): 1105 ~ II 06: 'I Kerr ct aL. ·'('ircumstanccs of First Injection Among 

I!! kit Drug lJs~?rs /\(.:cessing a Mo:Jical!} Supen iseJ Safer Injection ··American Jouma! of 

Puhlic 1/ea/th 97.7 (2007): !228-JO:! \1cKnight ct a!.. ''Factors \\ith Public Injecting 

/\!Hong Users of Vancouver's Sup~rviscd Injection Facility." American Journal r~(Drug Alcohol Abuse 

33.2 (2007): 319~325.: S Pctrnr ct al.. "1n,icction Dmg trs~rs' Perceptions Regarding usc of a Medically 

SJfcr lnj~ctmg ·· Addicti'.e Behaviors 32 (2007):1088~1093.: J Stoltz t'\ uL 

Practices \\ith the Use of a 1vkdica!ly Supervised Injection Facility:· 

(Oxford} 29.1 {2007): 35~39: E Wood et al.. "R<~tc of Detoxification Service 

tlsc and lmpa\.'t Among a Cohort ofSupcrvhcd Injection Facility t;sers." Addiction 102 (2007); 916~ 

919: E WooJ ct a!. --s~n ice llptake and Characteristics of Injection Drug llsers Utili7ing. North 

/\meric<~'s First Medical!) Supervised Satl::r Injecting Facihty," American .Journal of Puh/ic /leofth 96.5 

(2006): 770~773: T Kerr ct al.. "Impact of a Medically Supcrvi~cd Safer Injection Facility on 

Community Drug lise Patterns: A Before and Afler StuJy ... British .\iedical Joumal 332 (2006): 220-

222: !'Kerr et al.. Ovcrdo.~es \\'ithin a Medically Supervised Safer Injection Facility," 

17 {2006 ):436 ~ 441; r'vl Tyndall ct at., ''HTV .Scro~prcvalcncc 

in Vnnconvcr. CanaUa: Implications for 

Car~ and !'reatml;.'nL" !!arm 1~5.; M ryndall d aL 

"Attendance. Drug l ~se Pauerns. and Rel~rra!s Made from North Amerka'!:> First Supervised lnji;.'Ction 

J'adlit;... Drug ,1/cohol Dependence 83.3 (2005): 19J~I98: E Wood d a!., "Prevaknce and Correlates 

nf i kpatitis C Among. \Jsers ofNo11h Arncrica's First ~kdically Supcryiscd Safer Injection Facility." 

J>uhlic lfealth 119.2 ~2005)· 1 J! !~1115, E Wood ct a!.. "Do Supervised Attract 

lligher~r!sk !njedion U~ers?'' (2005):126~130.; D 

SmalL "\'lcntallllncss. and the Supcr\'iscd Injection Facility." Visions· BC's Jfentaf rtealth 

and Addn:lions .Journa/2.! l200<l) 37-39.; F Wood ct a!.. ''Changes in Public Order After the Opening 

ofu Safer Injection Facilit) t()r Injection Drug tlsers." Canadian Jledica/ 

!71.7 (2004): 731-73.:1: Fairbuim, N .. ~tal .. Women's experiences in Nmth 

America's First \t1edically Supervised Sa!Cr Injection Facility. Soc Sci Med. 67(8): p. 817 ~ 823. Also, 

these bcnellts include increased uptake into treatment for drug dependence, especially among people 

who arc unlikely to s...-ck treatment on their own. reduced public disorder, reduced public injecting. and 

incrc~t'ied public safety. reducing IllY and llcpatitis C risk bchuvior (Le. syringe sharing, unsafe sex). 

reducing. the prevalence and harm~ of bacterial inll:ctinns, and sw.:cessfu!!y milnaging hundreds or 

overdoses and !'t,;Jucing drug~rdat...-d oYcrdosc death rates. See: E Wood eta!.. ·'Rate of Detoxification 

Service U.'-C and its lmpact Among a Cohort nf Supervised Injection Fadlity Users," Addiction 102 

(2007): 916~919; E Wood d a!.. "Scrvil.'c Upta"-c and Characteristics of Injection Drug. Users Utilizing 

N(l!'th ,\mcnca·s 1--irst MeJically Supervised Safer !niecling ., American .Jou1'11al f?/ Public 

f!caflh 96.5 (2006); 770~773: M Tyndall ct a!.. "Attendan~'c, Patterns, and Referrals Made 

from No11h America's Fin;t Supcnisl.':d Injection Facility." 83,3 (2005): 193~ 

19/L C Potier ct al.. "Surcrvised Injection Scn·iccs: What I las A Svstcnu1tic 

Literature Rc\ie\\, .. Drug Alcohol Dependence 145(' (2014): 48~68. S PdrHr eta!., "lnjt:~tinn Drug 

Users' Perceptions Rcgmding u<>e of a :Vkdical!y Supervised Safer Injecting F<~cility," Addictive 

Ji('hal'iors J2 {2007): I 08g~ 1093: J Sto!t7. ct at., "Changes in ln.iecting Practices Associated with the Usc 

of a Supervised Injection Facility,'' Joumal q(Puhlic Health (OxforJ) 29.1 (20()7): 35-39: E 

\Vood ct a!.. in Publ1c ()rder A Her the ()pening or a tvkdical!y Supervised Safer l!~jecti(l!l 

Facilit) hlr lnj~ction Drug Users:' Canaditm Jledical .1ssuciation Joumal 171.7 (2004): 73 1-734; A.M. 

Sa!m1111 ct al.. "Five Y~ars On: What arc the Communi!) Pcrc~ptions ofDrug~rdatcd Public Amenity 

Fnl!o\\ing the Lstah!ishmcnt oftht Sydney Medically Supervised Injecting: Centre?" llllt"rnationa/ 

Jovrnal o/Omg Policy IS, I f2007): 46~53.: E \Vood. MW TynJall. JS Montan~r, f'indingsfi-om !he 

Evaluation l'ancouva :, Pilot <Hedical(v Supernsed Safer by·ection Facrhty, (Vancouver, BC: llC 

Centre for in JIIViAIDS, 2009)_ 1~62: C Potier ct aL. "Supervised lnjl.'ctinn Scniecs: What 

Has lkenlktnonstrated? A Systematic Literature Review:· Drug Ak()hnllkpcndenc~: 145C l2014): 

4!\~68: GJ ~lacArthur ct aL, "Interventions to Prevent lliV and Hepatitis C in People Who Inject Drugs: 

;\ Re\·JL\\ of Reviews to ;\sscss Evidence ofEfJCcti\cness." Fnternational Journal olDrug Policy 

25.1(20!3): 34-52; N Boyd. "Lesson::: from INS!TL Vancomcr's supervised injcctio.n f<Kility: 2003-

2012." /)rugs. Fducatum, Prel'l'nfiOn and }'oliq· 20,3 (20 13): 234~240:: S Pinkerton, ··f!m\ many I !IV 

Infections ure Prl)\ent~d by Yancnu\er Canada's Supenised Injection Faci!it) T lntt>mational JotJrn(l{ 

;lDrug Polin· 22 (2011): !79 ~ 183: I McKnight et aL "Factors Associated ,\ith Puh!ic Injecting 
429 

Facility," Amencan Jourtwl of Drug Alcohol Ahuse 

Drug Users' Perceptions Rcgurding usc of u lVledically 

Safer Injecting Fudllty:· Behaviors 32 (2007 }: I 088w 1 093; .I Stolt7 eta!. ... Changes 

AssociateJ witll the Us~ of a Medically Supcniscd Injection Facility,·· Journal of 

29.1 (2007): J5w39: M Tyndall ct al.. '"HlV Scro-prcvalcncc Among Participants 

Facility in Vancouver. CanuJa: Implications tOr Prevention. Car..: and 

1 rcatmcnt." Harm l?t>dllt'lion Journa/3.36 (1006): I ~5; T Kerr ct al.. "Safer Injecting Facility Usc and 

~baring Drug Users:· !.a nee! 366 (2005 ): 3 16- 318: r Kar et aL ··The role 

to HIV/AIDS among mjcction drug users:· Current fiJI' AIDS 

ct aL. "Potential Rok of Safer !nicdion Facilities in 

Infections and (hcrdosc Mnrtality in the UniteJ States:· Drug Alcohol 

I): l 00-110: (i Christian ct al.. "'(hcrdose Deaths and Vancou\er's Supervised 

l.ml<.·ef 379,9811 (2012)117: T K~rr eta!., Drug~rclatcd Overdoses Within a 

S<lfcr Injection Facility.·' Jntanotwmd Journal q(Drug 17 (2006):436 w 

,. A tvlicro-Environmcmal Intervention to !~educe ll<lrms 

Facll!t;. for InJection Drug Users.'' Canadian 

Sa!mnn eta! ... Five Years On: What arc the Communit) Perceptions ofDrug:wrdntcd Public Amenity 

Establishment c1fthc Sydney Ytcdically SHpcrvised lnjcding CentrcT' lntematwnal 

IIU t2007): .:J6-5~. 

,IS :Vlontancr, l:'wJ!uation of' Vancouw:r's Pilot .Hedica!lv 

(VmH'OU\'t'L BC Centre t{)r Ex..:l.'l!encc in lflV/AIDS. 2009), 1-

Scrvicl.':s: What lias !ken Demonstrated? A Systematic 

Litemturc Rc\iC\\... DcpenJem::e 145(' (2014): 48-68: GJ MacA11huret a!.. '·Interventions 

to Pn:n;nl HI\' and Hcputitis C in Po..'op!c Who Inject Drugs:!\ Rc\·ie\\ ofRc'liCv\S to Assess Evidence 

of I .m:cti\ o:ncs.'>... Polh:v 25,1 (20 13 }: 34-52; N Boyd, '·Lessons tiom 

INS!!'!~. Vancouver's supt:rviscd injection 2003-2012, .. Drugs: Education, Prevention and 

{~013): 234-2.:10;: S Pmkcrton. ·'IJow man) HIV Infection~ are Prevented by Vancom·er 

Supervised Injection International Journal of'Drup; Policy 22 (20 11 ): 179- 183; 1 

:'VlcKnight ct a! .. "Factors with Public Injecting. Among Users of Vancouver's Supervised 

";Jmerican Joumal qf'/.lrug. 1/coho/.-Jbuse 33.2 {2007): 319-325; S Petrar ct aL 

Drug l'cn.:cptions Regarding usc of a Medical!) Supervised Safer lnjecting Facility:· 

Addicrrve Rehm·ion- 32 (2007): 1 081-!-1093: J Stolt;. ct a!.. ·'Chungt'S in Injecting Practices Associated 

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(200h 35-39; rvl Tyndall ct u!.. "l IIV Scro~prcvalcncc Among Participants at a Supervised Injection 

in Vam:omer. Canada: Implications for Pr~n~ntion. Care and Trealment," llarm Redue!ion 

1-5; T Kerr ct u!.. "Safer Injecting raci!it)' llsc and Syringe Sharing Among 

Drng: l!:>ers:· /,a nee! J66 {2005 ); 3 I 6 ~ 318; T Kar ct al.. '"The role of safer injection t~~eilitics 

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158-104. 

14 S Srmaan c-t a!.. "Potential Role of Sater lnjcctlon facilities in R!.':ducing I !IV and Hepatitis C 

!nk<.·tions and ()v('rdosc Mot1ality in the United States," /)rug _,Jicoho/ Dependence 118.2-3l2011): 

! 00-1 l 0: E \\\md, ivl 'W JS Montaner. f mdmgs fi'om the E\'(duation Pi/or 

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430 

~009). 1·62: C Potier ..:t aL. "Supervised Injection Services: What Has Been Demonstrated? A 

Litw1turc Rc\icw," /)rug Ah:oho! !Jependence 145C (2014): 48·68. 

Scmaan et al.. "Potential Role of Safer Injection Facilities in Reducing HIV and Hepatitis C 

Infections and (hcrdose Mortality in the llnitcd States ... Dru~ Alcohol Dependence I I 8.2·3 (2011 ): 

l ()().JJ 0: G Christian ct al .. ·'Overdose Deaths and Vancouver's Supervised Injection Facility.·' The 

/.ancet 379,981! t20U)l17: r Kerr ct al., Drug·related Overdoses Within a McJically Supervised Sater 

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Emironmenta! lntcr'>ention to Redu~e Harms 1\:-;sociated \\lth Drug·Related Overdose: Evidence from 

the b·aluation of Vancouver's Sufcr Injection Focility .. , lnternatimwl Journal of Drug Policy 18 (2007): 

p. 37 ·- ..:15: BD .'vfnr.shall ct ol.. ·'R~duction in On:rdosc Mortality After the Opening ofN01th America's 

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(2011 ): !429·1437; J'vlJ Milloy et al.. "Non·fatal Overdose Amnng a Cohort of Active 

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]~,4 (2008): 499-509. 

::n Scmaan. S .. ct al.. Potentia! role of sati:r injection f<tcilitics in reducing I !IV and hepatitis C infections 

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M\\i JS Montaner, Evaluation (4Tancouver ·s Pilot Jfedica!Zv SupeYl'ised 

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Safer Facilit) on Community Drug tJse Patterr1s: A 

(2006 ): 220- 222. 

(Vancouver. 

Illicit Drug Users Accessing a Med1ca!ly 

Healtfl97.7 (2007): 1228·30. 

and • ··Lesson<> tforn 1\iSITI~. Vancouver's supervised injection facilit). 2003· 

2012." 1 Jrugs: /~ducal ion, Pn:Pt'ntion and Poit(V 20.3 t20 1 J}: 234~240.: S. Semaan, eta\., "Potentia! 

Ro!~ of Safer Injection Facilities in 1 J!V and Hepatitis C Infections and Overdose Mortality in 

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trom the }~\'aluation Pilot Medically Supcrl.'isc:d .)'a_li::r Injection Faciliry (Vancouver. 

BC: BC Centre for inll!V/AIDS. 2009): and C. Potier. eta!.. "Supervised Injection Services: 

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IL Brochu. S" Bonl. 'N. & Fischt'r. B. t20!0). A heroin prc!>cription trhll: Case studies from 

!vlontrca! and Vancomer tlll \:rime and disorder in the ::.urrounding. neighbourhoods. lntemational 

.Jouma! oj /)rug Polk}. 2!. 28·35: Ml!kr. P .. McKe1vie. S .. Lintlerb. N., Martin. A. & Strang. J, 

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London . . \lt'ntai flt:altlt and Substance ( 'se. Dual 248-259: Miller, P .. McKenzie. S .. 

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medica! supcnised in.]ectahk maintenance dinic Today. I\, 204-209. 11 A.A. \ iducnh<~gcn. ''Hcroi!H\ssistcd Treatment m A Case Study m Policy Change.'' 

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from Methadone to Diamorphinc: 2~ Year Results of the German ! lcroin~ 

Subsrance Use and .\Iisuse 46. 8 (201 !): 980·9L 1

' h. (hir::do-Jockes. ct <11.. "The Andtdusian Tria! on Hcmin·Assistcd Treatment: A 2-Year Follow-Up. 

Drug and Alcohol Review 29, 1 (2010): 75-80; and E. Pen:a·Mi!!u. ct at.. "Eilicacy of Prescribed 

lnjectahle Diacelylmorphine in the /\nda!usian Trial: Bayesian Analysis of Responders nnd Non· 

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l" A.A Uchtenhagen. "I fcroin Maintenance Trl'atmcnt: From Idea to Research w Practice,'' fJruJ! and 

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Belgian :vtoni10ring Co:ntrc for Drugs and Drug Addiction, 2011 Sa!iona! Report (20/ I Data) to the 

1~'.\JCDDA h.v rhe Rettox .\'atiunal Focal Point· lklgwm ~Sew Deve!O(Jml!llt.;·. Trends and In-Depth 
431 

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of Public lle<11th. 2013 ). 

~~ E. (hicdow.lockcs. d al.. "Dillcl:tylmorphinl: Versus rvle11mdonc f()r the Treatment ofOploid 

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,<) S!J"<lng. L Groshkova, T. & Mctrcbian. N. Rece!lf t:vide11ce 

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. Oroshlova. ~letrcbian. N. (10 12 ). New Recl!nt evidence 

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as treatment f()r rdractory heroin addiction. The British Journal of Psychiatry: 207: 5-14. 

~' !\1arica Ferri. M. Da\oli. and(". J\. Peru eeL "I !eroin Maintenance for Chronic lkrnin-Dependent 

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(_ ·se and .\fisuse 46.8 (201 !); P. Blanken. ct aL "Outcome ufLong-Tcrm Heroint\s,isted l reatmem Offered to Chronic. Trcatment~Re~!stanl Heroin Addicts in the Netherlands," 

,Jddlction WS, 2 (1-.-,:bruarv 2010): A. Karow. et al., "Qua! it\ of Life under Maintenance Treatment \dth 

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(20 10): A llchtcnhagcn. ''1\crohH\ssistcd Tr.:-atmcnt in Switzerland: A Case Study in Policy Clwngc.'' 

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'!n:atmcn! ofOpwid Addiction, .. Xcw f:nglandJournal ofAtedlcine 361 (2009): 777~786; C. Haasen. d 

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191 (2007): 55-62: B. Fischer. ct a!,. "llcroin-Assistcd Treatment (!I at) a Decade Later: A 

on Science and Po!Hks,'' Journal of l -'rhan Health 84, 4 (2007): iv1. P. Garcia~Porti!la. et 

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Canadwn Joumal !!f Puh!u: ffealth 102. 2 (2011): A. Karov.. c1 aL. "l.)ua\it) of Life under Maintenance 

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Oependence I !2. 3 {2010): J. Rchm. 1.:t a!., "Mortality in l!croin-Assislcd I rcatmcnt in Swit7erland 

\99-l-~1000." Drug and Afcohoi/Jep•'mknce 79. 2 (2005): Robert P Schwan~. ~t a!.. "Opioid Agonist 

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lnitiatin· {~ .. \0~:1!) in Canada. \'~<hich provided heroin b~ prescription to a select group of people \\hO 

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(jni!ed Kingdom (72 pen::enl), anJ Germany (69 perc~nt). See; E. Oviedo-Joc:kes. d al., 

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(\1ntroHcd Trial, 191 55~62. 

4 See, e g.. \an den Brink. W. ct of !tcroin to Treatment Resistant I !eroin 

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432 

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203~11; 0\ k·do-Joekes, E. ct aL vcr:;t!S" Methadone for the Treatment of Opiate 

Addi-.:tion." Xew no. 8 (August 2009): 777~86; Pemcger, T.V. eta\. 

"Randomised Trial Maintenance Programme for Addicts Who Fail in Conventional Drug 

rreatmcnts." !HfJ 317, no. 7150 (July 1998); Strang. John ct al. "Supervised Injectable llcroin or 

\;1cthadonc vcrsu~ Optimised Oral Methadone as Treatment for Chronic Heroin Addicts in 

afh.•r hrsi:-.tent Failure in 011hoJox Treatment (RIOTT): A Randomlsed TriaL" The Lancet 

no. 9729 (~vLn ::!010): J8S5-95; Ferri. M., M. Davo!L and C.A Pcrucei. "Heroin Maintenance for 

Chwnic I !croin D~pcmknts." C. 'ocft!'llne Database ol-~:vstenwtic Review. no. 8 (August 20 10). 41 !!<Jasen ct al. (2007). note 3 at 55-62: P., Vincl.'nt. M. II.. Maartcn, W. L Koctcr. Van Rcc. J.M. 

& \an den Brink. \\" IV1atching oftreatment-n:sistant hemin-dependent patients to medical 

of heroin methadone treatment: Results from lwo randomized controlled trials. 

100. 89~95: Fnullisku, G .. Gsdnvcnd. P., Schulte. IL Rchm, L & Uchtenhagcn. A. (2otH). 

long-tl.'rm effects of hcroin-a:.sistcd treatment: The rl':;:;ults of a 6~year follow-up. Huropean 

73-79: March ct al. (2006 ), supra note 3 at 203-2 I I: Oviedo-Joekes et aL 2009. 

L rvlctn:bian. :\., l.intnris. N .. ct al. (2010). Supcrvisl.'d injectable heroin or injectable 

'"ersus optimised oral methndone as treatment for chronic heroin aJdids in Engh:md aller 

failure in orthodo.\ treatment (RIOTT): a randomised triaL Lancet, 375, 18R5-J 895. 

J., C!-;ch\\cnd. P .. Steffen. T .. Gut.l.wi!kr, F .. Doblcr-Mikola, A & Lchtt:nhagl':n. A (2001). 

:-;.afcty. and ct1icacy of injectable heroin prescription for rc.fractory opioid addicts: a follow~ 

1417-2] 

C.. Verth~ln. l} ., Degkv..il/. P .. et al. (2007). I lcroin-assistccl treatment for opioid dl.'penJence. 

Hrirish .Journal of Psrchiatn'. 191. 55~2: 

9 Ovi..:do-Jocb:;, E.: Bris:-.;rtc, S .. Marsh. D., ct aL (1009). Diac..:tylmorphinc versus methadone for the 

tr~atmcnt of opiate addiction. 7he ,\ew F-1rgkmd Journal of.\-ledicine, 361. 777-786: 

~~! Kil!ias, M .. Aebi, rvl.F., Jurist, K. (2000). The Impact of llcroin Prescrirtion on Jleroin Markets in 

S\\ itlcrland, Crime Prevemion Studies, 11. 51 United Nations Office on Drugs and Crime, World Drug Report 2016 (United Nations publication, 

Sales No. E.l6.XI.7), p. 3-4 

'" Sec Drug Policy Alliance. /)rug Courts Are .\'ot the Answt>r: Toward A l!ealth-('entered Approach to 

L\£' (201 

n"""'"'"""· NADCP Board Resolutions, "Rl'solution on 1he 

• Treatment (MAT} !Or Addiction in Drug Courts.'' July 201 L 

http: 1\\ \\ \\. nadcp.or2 l.£.ill:.!.L.llositiolb-policv-statemenb~and~reso!utionsibonrd-reso!utions 

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'' ltay~;s MJ. Bnmn :VIS. L.:g<~!i.lation of rvtt:dir.:al Marijuana and Incidence ofOpioid Mortality. JA,\4A 

ltu.:m .Hed. 201~:1 7-Hl0):1673-1674.; fvkdical Cannabis Us.e Is Associate-d With Decreased Opiate 

~vkdication Usc in a Retrmpccti\.C Cross~Sectional Survey ofPatknts \\'ith Chronic Pain: Boehnke, 

Ke\in F. ct al. rhc Journal tl!"Pain. Volume !7. Issue 6. 739~744: National Bureau ofEconomlc 

Resean.:h. Do \1edical 

Cambridge. :VtA: ~ational Research: 2015. Working Paper"t\o. 21345. 51 ~C\'v" York Times. An E.R. Kicks the Habit of Opiolds for Pain, Jan HotTman, June I 0, 2016 

htlr ' \\\\\\ .!1\ lilllC'-..~nm 2l) l (J/1)6 14 1h<.'al\h. raill·tn:atrnent~cr-a!h'nMti\,c-opioids.html? !'" 1 
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Statement of David Murray 

"America's Insatiable Demand for Drugs: Examining 

Alternative Approaches" 

A Roundtable with the Senate Committee on Homeland 

Security and Governmental Affairs 

Wednesday, June 15,2016 

!O:OOA.M. 

SD-342 Dirksen Senate Office Building 

Chairman Johnson, Ranking Member Carper, and members of the Committee, 

thank you for this opportunity to address "America's Insatiable Demand for Drugs: 

Examining Alternative Approaches" before this Committee. 

In this written testimony, I shall endeavor to answer several of the Committee's 

concerns as were expressed in my invitation to testifY. In this document, I will, 

following a brief overview of decriminalization and legalization problems, present 

evidence and discussion with regards to the following: 

• I shall examine the impact of proposals to either decriminalize or legalize 

drugs such as marijuana, as currently found in several states in contravention 

of the federal Controlled Substances Act. 

• Moreover, I shall argue that the criminal black market in states such as 

Colorado has thrived, not diminished, in the presence of legalized access. 

• I shall offer a critical review of proposals to offer so-called "safe" or 

supervised injection facilities as a potential response to the current opioid 

crisis. 

• I shall offer a critical review of the state of current national drug control 

policy, as represented by the strategic undertakings of the current 

Administration. 

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• I shall also address some attention to the current state of drug treatment 

programs, and discuss how they are affected by changes recently found in 

regards to marijuana policy. 

• I shall follow that critical evaluation by addressing the specific need for a 

more robust focus on reducing drug supply and availability, with some 

specific examples. 

Has Federal Drug Control Strategy Lost Direction? An Overview 

It must be borne in mind in evaluating Obama Administration drug control 

performance across the horizon of its responsibilities that the first action taken 

upon assuming office was to remove the Director of the President's own Office of 

National Drug Control Policy (ONDCP) from Cabinet status. 

As a consequence, the very entity charged with setting and implementing drug 

control strategy, and with coordinating responses and priorities across the 

interagency as affected by the President's drug control budget, lost political power 

and impact. 

In a stunning recent development, we now learn that, as the Administration 

prepares to leave, ONDCP has suffered a substantial cut to personnel, and has 

experienced a downsizing organizational restructuring that can only hamper its 

most effective programs. The effect is to institutionalize the weaknesses that have 

been imposed beyond ready repair in successive administrations. 

As we shall see later in this testimony, these troubling developments were all 

presaged in the beginning, and can be placed in relief by reviewing Administration 

performance with respect to its own goals. 

The real contrast between the last seven years and that of previous approaches lies 

in three things: I. Failed leadership, turning away from the urgency of protecting 

Americans from this disease approaching epidemic proportions, and instead 

undermining federal law; 2. Weakening prevention by failing to defend social 

norms and allowing the normalization of drug use; and 3. Neglecting drug supply, 

thereby allowing the tide of drugs to now flood our streets. 

Instead of effective drug control, we have witnessed at the state level, for the last 

several years, widespread efforts at decriminalization or outright legalization of 

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drugs. These efforts were not countered by the Administration, which even 

declined to challenge them in court, and they have proven counterproductive 

against multiple drug control objectives. 

In summary form, to be expanded upon in the text that follows, these are the types 

of problems that follow from decriminalization/legalization: 

First, multiple legal problems are presented beyond the provisions of the 

Controlled Substances Act, which is being set aside with regards to marijuana at 

the state level. Examples include drug-related provisions regarding food safety, 

child endangerment, a drug-free workplace, federal contracting obligations, 

banking and finance protections, and even international treaty obligations, which 

are also adversely affected. 

Decriminalization undermines key expressed goals of the Administration, such as 

treatment and prevention. Not only are the incentives to remain "drug free" 

weakened when drugs are readily and legally available, but decriminalization 

commonly leads to the removal of a law enforcement/judicial role in supporting 

treatment. Positive developments such as drug courts are undermined. The 

continuing presence of laws against drug use and trafficking serve to strengthen 

treatment and prevention objectives. They must not be dismissed. 

Under liberalizing drug policies such as have been pursued, drug use prevalence 

increases, certainly among adults, as we shall see, and there is evidence that it 

happens for youth, as well. The National Epidemiological Survey on Alcohol and 

Related Conditions (NESARC), for instance, recently reported a doubling of 

marijuana use among adults and a comparable doubling of"marijuana related 

disorders" during the period 2001-2013, following liberalized marijuana policies. 

The public health, educational, and law enforcement impact is negative, and the 

costs imposed, in lives as well as public expense, outweigh whatever revenue is 

promised. The impact can be found on mental health, cognitive performance, and 

overall public well being; all are degraded. 

The black market and attendant violence, attached to the trafficking of both 

marijuana and other drugs, does not wither away, but thrives in the environment of 

decriminalization; the lessons from Colorado are particularly striking. 

Crucial public attitudes concerning the risk in using drugs and the social norms of 

disapproval tumble; among high school seniors, for instance, they are now at the 

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lowest points recorded involving marijuana. Where these norms and attitudes 

change, increased use commonly follows. 

The revenue from recreational, legal marijuana sales can be seen to feed back into 

political actions to insulate the new, liberalized markets, threatening corruption and 

the integrity of banking services; the risk of criminals exploiting these conditions is 

high. 

The U.S becomes increasingly in violation of international treaties regarding drug 

control (we have already been sanctioned by international bodies such as the 

International Narcotics Control Board of the United Nations Office of Drug 

Control) and our "moral authority" and leadership internationally is undermined. 

There appears to be a spill-over effect and a 'gateway' risk from liberalized 

marijuana policies that may well feed into related drug control problems, such as 

the emerging and climbing opioid overdose crisis. 

Law enforcement, reflected by such recent statements as those of Commissioner 

Bill Bratton in New York, indicate that marijuana markets become a serious 

problem threatening public order, while the smuggling of high potency marijuana 

from Colorado is now found in multiple states. 

Drug potency increases dramatically, as seen in the new "concentrates" flowing 

from Colorado, approaching 70 to 80 percent THC (intoxicating element in 

marijuana) found in "edibles" such as candies marketed to youth. There are yet 

other attendant legal problems, but these are some prominent concerns already 

showing up. 

Most importantly, the combined effect of both Administration policy as seen in the 

National Drug Control Strategy and the impact of broad state level 

decriminalization/legalization developments has been the weakening of a critical 

strategic pillar of effective drug control policy: efforts against drug supply, 

availability, and trafficking. 

Specific Evidence Regarding Marijuana, Drug Decriminalization and 

Legalization: Colorado's Record and the Continuing Black Market: 

Recent state-level data from the Department of Health and Human Services show 

that only 5. 5 percent of Oklahoma youth between 12 and I 7 years of age are 

"current users" (having used in the past month) of marijuana, compared with the 

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national average of 7.2 percent, according to the most recent survey. 

That's the good news. The bad news is that the percentage is much higher in 

neighboring Colorado where, as an Oklahoma lawsuit against that state has shown, 

"legalization (of marijuana) has created a dangerous gap in the federal drug control 

system." 

The notion that Colorado's first full year of commercial, "recreational" marijuana 

production and sales- in violation of federal law is some sort of"experiment" 

has been embraced by many within the Administration and members of both 

political parties. Given what's at stake- mental health, educational outcomes, 

family well-being, and even future policy decisions in other states- an accurate 

accounting is essential. 

A major new report from the National Household Survey on Drug Use and Health 

(NSDUH) with combined two-year data (2013-2014; a sample size sufficient to 

give a picture at the state level) presents the reality of marijuana use for the first 

time since the legal roll-out. 

The data are devastating to the marijuana "experiment." Use is up in Colorado, and 

has been rising steadily every year since 2009. That date matters not only because 

it marks the end of Bush administration policies that fought back against- and 

lowered substantially- teen marijuana use, but because that year saw a major 

expansion of the state's medical marijuana program. Medical marijuana drives up 

teen use; legalization drives it up even more. 

To anyone paying attention, this rise is not surprising. Recent data have clearly 

shown increases in marijuana use, including adolescent use, in states that have 

adopted either so-called "medical marijuana" programs, or have liberalized access 

to the drug. Colorado has recklessly done both, and the latest data show that it has 

the dubious distinction of being the national leader in youth marijuana use. 

A realistic assessment of impact, from 2009, shows a stunning rise of 27 percent 

by 2014 (from 9.91 percent to 12.56 percent) in teen marijuana use, as well as 

large increases for those ages 18 to 25. And there is no sign that the rate of increase 

is slackening. 

Lest we think Colorado's rise is something going on everywhere in the country, a 

comparable rise has not been seen in all states, except those, like Washington, 

Oregon, the District of Columbia, and Alaska, which also legalized, and now join 

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Colorado in the top eight states. In fact, in states like Georgia, Ohio and Texas, the 

rate of youth marijuana use is half that of Colorado. Parents should take note. 

Moreover, use by those 12 and older, which includes Colorado's young adults, is 

also steeply up, rising 99 percent in the last 10 years. 

According to the proclamations of eager advocates for the legal dope market, this 

wasn't supposed to happen to kids. In fact, they argued that they were legalizing 

marijuana with the specific intention to protect the children, since a regulated 

market would shut down the criminals (which hasn't happened, either) and ensure 

that young people couldn't get access. 

Those aged 12 to 17 are adolescents, ranging in classrooms from junior high to 

their senior year. These data now show one in every eight Colorado kids is a 

current smoker of the highest-potency dope in the nation. 

Almost weekly, the science grows stronger and more undeniable as to what this 

drug is doing to the adolescent brain; eight-point IQ loss, potentially permanent 

impact on memory, learning, cognitive performance, and risk of psychosis; these 

are but some of the damaging associations with heavy use. 

More than 6 percent of high school seniors nationwide are now "daily" marijuana 

users, says another survev released in December, which also showed that 

perceptions of risk in using marijuana by high school seniors ("perceived risk" 

being a major component of effective prevention), has dropped 62 percent since 

2008 to its lowest level ever. President Obama's drug czar Michael Botticelli has 

laid the blame on legal marijuana. For states such as California, facing legalization 

on the ballot in 2016, voters should know that legal marijuana means an epidemic 

of teen use and addiction. 

Solutions? We should enforce federal law, designed to push back on this very 

threat. Pro-drug legalizers- and their apologists- need to stop denying the 

science, and the facts before their eyes. 

The Impact of Liberalized Attitudes: More on the NESARC: 

To generalize, liberalized attitudes about marijuana appear to have the predicted 

effect, and they extend well beyond Colorado and are associated with national 

impact. I have mentioned already the latest results from the National 

Epidemiological Survey on Alcohol and Related Conditions (NESARC). To 

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demonstrate specifics, NESARC showed that by 2012-2013, past year prevalence 

of marijuana use has risen 132 percent since last measured in 2001-2002 (from 4.1 

percent of study participants to 9.5 percent). 

The results may be even worse than they appear. The NESARC is a longitudinal 

survey, tracking the subjects over time, and reporting once a decade (there were 

interim "wave" results issued in 2004-2005), meaning that the temporal trajectory 

of this change (the sharp upswing in the most recent years) is masked by looking 

only at the beginning and ending of the decade. 

There appears to be an acceleration in the most recent years, with decline occurring 

in the middle. Confirmation of this trajectory can be found in a "wave" finding in 

2004-2005, which showed a decline down to 3.57 percent "past year" use (at least 

in the 41 states that did not have medical marijuana laws). 

Collateral confirmation can be found in a parallel study of youth (the Monitoring 

the Future school-base survey done yearly by the National Institute on Drug 

Abuse), which revealed a 25 percent decline in marijuana use between 2001 and 

2008 for high school youth, only to increase thereafter, and the even larger survey 

known as the National Survey on Drug Use and Health (NSDUH). 

There are differences in the studies rendering them not completely comparable. 

The NSDUH samples those 12 and older, while the NESARC reports on those 18 

and older. Thus, the absolute numbers are not fully compatible, but the trends 

support the interpretation of a recent rise, not a steady increase from 2002. 

In the NSDUH, between 2002 and 2007 past month use of marijuana first fell by 6 

percent, to be followed by a 29 percent increase between 2007 and 2013. Further, 

the NESARC measured in the year prior to the impact of legal commercial 

marijuana, implemented in 2014. NSDUH reveals that in the period subsequent to 

2013 (NESARC's final year), steep increases continued, rising an additional12 

percent during a single year by 2014. 

The Obama Administration's support for legal marijuana could well be reflected in 

these sharp increases in marijuana use. 

Finally, what are the consequences of our choices? While the impact of highpotency use has been well documented, the impact affects more than just current 

users. The medical report found in the Proceedings of the National Academy of 

Sciences (PNAS) addresses the future that we are sowing, showing that 

marijuana's THC affects the brain structure and functioning of the progeny of 

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maternal users (which, depending on the community, reaches as high as 41 percent 

of neonates born in North America). 

Though prenatal risks in maternal marijuana use are well known, the PNAS, 

through an animal study, hits upon a specific neural mechanism: 

"Prenatal exposure to cannabinoids (through the impact ofTHC on developing 

cortical neurons) evokes long-lasting functional alterations ... [with] remarkable 

detrimental consequences of embryonic THC exposure on adult-brain function." 

The consequences were lifelong, including an increased risk of seizure in 

adulthood. 

This is only the latest study to dispel the widely but mistakenly-held belief driving 

legalization efforts that marijuana is harmless. Pulling together the three reports, it 

seems undeniable from the weakening of attitudes against marijuana, the 

associated sharp increases in marijuana prevalence, and now the further 

demonstration of harm from maternal marijuana use for future generations, damage 

is already being done. 

While for some, that damage appears irreversible, it is not too late for responsible 

Americans to push back against this clear public health threat. The fate of future 

unintended victims is in our hands. 

Further National Survey Results: NSDUH on Adults and Increased Use: 

On September 10,2015, the Obama Administration released the results of the 2015 

National Survey on Drug Use and Health (NSDUH), the most recent of he nation's 

annual report card on illicit substance use conducted by the Department of Health 

and Human Services (HHS). 

Though it is the 2015 NSDUH, the data are for the year 2014, and were released at 

a press conference at the National Press Club. 

The survey is the largest and most comprehensive report on the population 12 and 

older in the United States. It is subdivided into sections reporting on those 12-17 

years of age, those 18-25 years of age, and those 26 and older 

The report analyzes use of illicit substances according to whether it was Lifetime 

(ever used), Past Year use, or Past Month use (treated as "current use"). The latter 

category, Past Month, is regarded as the most policy relevant, as it measures those 

whose use is not only "current," but likely reflects habitual, regular use of a 

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substance. Regular, habitual users are at greater risk of suffering the consequences 

of their drug use, including dependency and harms to health. 

The report includes several different categories of specific drugs, providing 

findings on use of"Any Illicit Drug," as well as specific drugs, such as marijuana 

use, cocaine and heroin use, or misuse of prescription medications, such as pain 

killers. 

The report comes at a time when the nation is undergoing the most dramatic 

change in drug policy driven by the Obama Administration's determination not to 

uphold the federal Controlled Substances Act, fostering a legal, commercial market 

in "recreational" marijuana use by several states, as well as a broader retreat from 

efforts to diminish the supply of illegal drugs at home and abroad. 

There are important changes in drug use to be found in this survey when one 

examines both 12-17 year olds and those between the ages of 18-25. But the most 

dramatic changes in this year's results are found in the category of adults, those 26 

and older. 

Heroin use, for those 26 and older, effectively doubled between 2013 and 2014 

(though it is mercifully a relatively small absolute number; the change was from .1 

percent to .2 percent). However, we now have the highest figure for heroin use 

since at least 2002, which is as far back as the tables released by the 

Administration cover. (All findings noted here are "statistically significant," 

including the heroin increase.) 

Yet, according to the HHS press release headline, today's news is: 

"Alcohol, tobacco, and prescription drug use by teens declines; level of youth with 

major depressive episodes remains high." 

While that narrow focus presents relatively good (and some bad) news, a far more 

troubling story lies elsewhere, and must be discovered by careful examination of 

the data tables. 

By comparing drug use over time, it is possible to discover the impact of Obama 

Administration drug policies and compare them to the previous, Bush 

Administration, drug use results. 

Taking last year of the Bush Administration, 2008, and today's results for 2014, 

here are the headlines: 

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• Between 2008 and 2014, for the population 26 and older, Past Month 

use of Any Illicit Drug has risen 41 percent. In the single year 2013-

2014, it rose 14 percent. 

• Between 2008 and 2014, for the population 26 and older, Past Month 

use of Marijuana has risen 57 percent. In the single year 2013-2014, it 

rose 18 percent. 

It is now undeniable that the Obama Administration's drug policies and its 

facilitation of commercial marijuana distribution are deeply damaging. And the 

damage is only spreading, accelerating, and deepening. 

The comprehensiveness of the impact can be seen the graphic below. Colorado, as 

seen in SAMHSA state-level drug use analysis, is the leading state for every one of 

the major drugs of abuse, as well as alcohol. That last realization tells us that 

marijuana use, for instance, does not displace high levels of alcohol use, but rather 

is coincident with them. 

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Heavy drug use, state by state 

Number of substances (marijuana, cocaine. non-medical opioids, alcohol) for which the 

state's population is a heavy consumer: 0 1 1113 

WA''O S i/WONKBLOG 

The Thriving Black Market: Rocky Mountain HIDT A and Smuggling: 

Colorado has now become a national as well as international center for 

drug smuggling. According to a recent law enforcement report from southern 

Colorado, an illegal operation there has been accused of growing marijuana 

for distribution to Cuba. Local law enforcement reports note the increased presence 

of criminal gangs, including transnational organizations, entering the state to 

capitalize on the lax legal environment. 

We can see clearly that promises to end criminal participation in drug markets, 

along with the violence that accompanies such operations, were empty, and have 

been disconfirmed. Notwithstanding the rising threat, the Administration has failed 

to provide a prosecutorial response, one moreover which was a predicate of the 

initial decision to allow legalization to go unchallenged. 

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A new government report on the Colorado "experiment" to legalize and 

commercialize marijuana sales was recently released by the multi-agency 

intelligence fusion center of the Rocky Mountain High Intensity Drug Trafficking 

Area (RMHIDTA) headquarters in Denver. In it we can witness the continued 

operation of the black market criminal activities. 

Two prior reports traced the development of marijuana legalization through 

successive stages (medical marijuana introduction, expansion of medical marijuana 

dispensaries) and the new report covers full commercial legalization beginning in 

January, 2014. The report confirms the warnings oflegalization opponents in 

considerable detail. 

Simply put, the report shows that the impact to date has affected public health 

(emergency department episodes in particular), public safety (rising crime rates, 

traffic fatalities from drugged driving), and the integrity of public institutions, such 

as schools (student violations of drug policy, disruptions and expulsions). 

And, predictably, adult use of marijuana has surged, as has increasing access and 

use by minors. 

Each of these points in presented in detail in the report, along with presentation of 

recent research showing the cognitive and psychological damage of marijuana 

exposure, especially on youth, subjected to the rising potency of Colorado 

commercial marijuana (now exceeding 17.1 percent average potency of THC, the 

intoxicant in marijuana, well above the national average of 12.6 percent). 

Each of the findings warrant a full discussion, but one in particular deserves 

immediate attention. 

As the Obama Administration progressively adapted the federal response to the 

escalating violation of the federal Controlled Substances Act represented by 

Colorado's legalization, successive memos from the U.S. Department of Justice 

(DOJ) provided rationales and excuses for not enforcing U.S. law. 

In August of2013, Deputy Attorney General James Cole provided guidance to all 

U.S. attorneys regarding marijuana criminal conduct in a memorandum, that would 

remain priorities for federal enforcement. Two of these priorities are: 

Preventing the diversion of marijuana from states where it is legal 

under state law in some form to other states; and 

Preventing state-authorized marijuana activity from being used as a 

cover or pretext for trafficking of other illegal drugs or other illegal activity. 

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The RMHIDT A report indicates that the DOJ priorities have been ignored as 

trafficking spreads rapidly. Listed below are episodes where marijuana seizures 

followed from traffic stops. Law enforcement estimates that approximately I 0 

percent of marijuana being trafficked from the state is represented in these 

seizures. 

• During 2009-2012, when medical marijuana was commercialized, 

the yearly average number interdiction seizures of Colorado marijuana 

increased 365 percent from 52 to 242 per year. 

• During 2013-2014, when recreational marijuana was legalized, the 

yearly average interdiction seizures of Colorado marijuana increased 

another 34 percent from 242 to 324. 

• The average pounds of Colorado marijuana seized, destined for 36 

other states, increased 33 percent from 2005 - 2008 compared to 2009 

-2014, rising from 2,763 pounds to 3,671 pounds. 

• In 2014, there were 360 interdiction seizures of Colorado marijuana 

destined for other states. When compared to the precommercialization average of 52 from 2005 - 2008, this represents a 

592 percent increase. The most common destinations identified were 

Kansas, Missouri, Illinois, Oklahoma, and Florida. 

In addition to traffic stops, there were parcel intercepts of marijuana. 

• U.S. mail parcel interceptions of Colorado marijuana, destined for 38 

other states, increased 2,033 percent from 2010 - 2014, rising from 15 

to 320 intercepts. 

• Pounds of Colorado marijuana seized in the U.S. mail, destined for 38 

other states, increased 725 percent from 2010-2014, from 57 to 470 

pounds. 

• From 2006-2008, compared to 2013-2014, the average number of 

seized parcels containing Colorado marijuana that were destined 

outside the United States increased over 7,750 percent (from 2 to 157 

parcels) and pounds of marijuana seized in those parcels increased 

over 1,079 percent (from 29 to 342 pounds). 

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The seizures and intercepts all are tied to criminal activity and, more importantly, 

represent a small fraction of what law enforcement believes is the actual magnitude 

of this growth in trafficking. 

In simplest terms, marijuana legalization is poisoning Colorado and Colorado is 

now poisoning more and more of America. 

Authorities say they've Intercepted 

thousands of shipments of marijuana 

leaving Colorado, destined for sale on the 

black market in other states. 

States with Colorado marjijuana 

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Safe Injection Facilities: Evaluating the Evidence From "Harm Reduction" 

My colleague John Walters, who has served as Director of the Office of National 

Drug Control Policy during the Bush administration, recently wrote on USA Today 

concerning safe or supervised injection facilities, which have recently been 

proposed as a response to the heroin epidemic in several US settings. Mr. Walters 

argues: 

''There are no "safe heroin injection sites. " The only "safe" approach to 

heroin is not to take it. For addicts, the humane public health response is to 

help them get and stay sober, or at the very least, opioid replacement 

therapy in sustained treatment. Any approach without these goals is cruel 

and dehumanizing- not healing, but perpetuating harm. 

Addiction is a treatable disease. Millions of Americans are in recovery -

living healthy, productive lives. Supporting addicts' heroin use maintains 

their disease, administering the poison that causes their illness and 

diminishes their lives. A government-approved place for unlimited heroin 

injection creates the conditions for never-ending addiction and gives 

government a drug dealer's power over the addicted. 

Advocates for injection sites claim various "successes. " In fact, very few 

who use these facilities are persuaded to enter treatment and reach 

recovery. Many addicts using such facilities do not stop using heroin and 

other such drugs from criminal sources- the "safe facility" is simply 

another place for drugs. Addicts are often abusers of multiple drugs and 

alcohol. Injection facilities sustain all of this. 

Such proposals require us to suppress common sense and adopt heartless 

indifference to the lives of the addicted. We do not protect addicts by 

reviving them from overdose death only to return them to death 's front door, 

perpetuating the self-destructive cycle of addiction. In fact, many addicts 

enter treatment because they cannot obtain heroin, and even more are 

treated under the supervision of drug courts. We treat the addicted through 

workplace interventions, medical practice and many faith-based 

organizations. We should keep vigil as they struggle to recover. 

Today's heroin deaths are caused by the drugflooding into America from 

Mexico. Giving up on fighting heroin trafficking brought a supply-driven 

epidemic to our communities. Pressure on heroin networks works, just as 

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attacks on terror networks can and must be pressed for our security. 

Heroin destroys freedom and life. Government-approved injection centers 

are shameful. " 

While such facilities have not changed fundamental high-risk health behavior, 

what they have changed is the moral and civilizational relationship between the 

state and the individual. At their worst, they risk representing servitude, and 

eroding prevention, when the government itself becomes the entity sustaining 

continued addiction. 

While many claims have been made for positive health outcomes in association 

with the operation of such facilities, there are many questions about the actual 

evidence of benefit. 

For instance, INSITE, a Supervised Injection Facility in Vancouver, Canada, 

opened in 2003. In 2007, Colin Mangham, Director of Research for the Canadian 

Drug Prevention Network published his critique of the operation and the validity of 

the evaluations. 

He argues: 

1). "The published findings actually reveal little or no reductions in 

transmission of blood-borne diseases or public disorder, no impact on 

overdose deaths in Vancouver, very sporadic individual use of the facility by 

individual clients, a failure to reach persons earlier in their injecting 

careers and very little or no movement of drug users into long-term 

treatment and recovery. The fact that the evaluators and the funders of 

INSITE nonetheless have hailed the program as successful reveals a serious 

problem in drug policy today. 

2). "(There is a) considerable overstating of findings as well as 

underreporting or omission of negative findings, and in some cases the 

discussion can mislead readers. The reports show no impact on the key 

issues that would most warrant its existence: spread of HIV or other blood 

borne disease, getting clients into treatment and off of drugs, reducing 

overdose deaths. The reported impact on public disorder that is discussed is 

questionable and so limited in scope as to be misleading. 

3). Data in all of the reports suggest that only a small percentage of IV drug 

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449 

users use INSITEfor even a majority of their injections. Most drug users use 

it only some of the time or not at all. This finding illustrates a shortcoming 

of harm reduction measures that has recently been highlighted by Neil 

McKeganey in the UK: an inability to control a free moving population of IV 

drug users sufficiently to control disease in the face of continued use of 

drugs. 

4). The article includes data that show the relative infrequent use of INSITE 

by individual IV drug users. In this evaluation, 178 of 400 participating drug 

users utilized INSITE during the study period, leaving over 50% who did not 

use INSITE at all. Of the 178 who did use INSITE, over half used it for less 

than a quarter of their injections. These findings illustrate a trend that 

precludes INSITE effectively controlling injection drug behaviours. 

5). This article mentions that no overdose deaths occurred at the site. We do 

not know if any of the overdoses would have resulted in death outside the 

site. The number of overdose deaths in Vancouver and the DTES has 

increased since IN SITE started up. This fact at least suggests that in its 3 

years of operation, INSITE has produced no impact on overdose deaths. 

6). We do not know what negative effects the facility may have had on the 

availability of treatment, given the preoccupation with JNSJTE. Neil 

McKeganey's research in the UK suggests such programs may actually have 

an adverse effect by drawing focus and efforts away from incidence 

reduction (prevention) and prevalence reduction (treatment). 

7). This report, if not read carefully, is misleading. It implies that use of 

IN SITE is associated with reduced needle sharing. Actually, only exclusive 

use of INSITE correlates with reduced sharing- an example of a "straw 

horse" finding. If someone uses IN SITE for all their injections, it goes 

without saying they would not share needles. Only about one in ten HIV 

negative participants reported using INSITE for all of their injections. Only 

four HIV positive participants reported using INSITE all the time. These are 

the most important findings in the study but are not reported. 

8). This report ignores the significant negative implications of the fact 

that, of 431 drug users studied, only 90 used INSITE some, most or all the 

time. It does not recognize adequately that half of these persons still shared 

needles. 

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450 

9). This report's only finding is that some INSITE users go to detoxification 

upon referral. It does not show that INSITE increases use of detoxification, 

nor, more importantly, does it show that INSITE produces any increase or 

effect on people proceeding to actual treatment. Detoxification is often 

called a "revolving door. " Going to detoxification is by no means the same 

as going for treatment, and this is a well-understood fact. 

In a similar vein, Professor Neil McKeganey, (already mentioned), Director of the 

Centre for Drug Misuse Research at the University of Glasgow since 1994, has 

provided (personal communication) his evaluation of the Safe Injection Facility 

evidence, extending beyond the particular case of IN SITE in Canada to the 

comparable facilities in Europe and Australia. According to Professor McKeganey: 

"The provision of a safe injecting facility as it is typically called can 

unquestionably lead to a reduction in some aspects of drug injectors risk 

behaviour. Injecting under some level of trained clinical supervision can for 

example reduce the risk of injecting being carried out with non sterile injecting 

equipment. Such settings can also enable staff working within the facility to 

provide advise on injecting techniques which may reduce the incidence of 

injection site related problems. In addition, such settings can ensure that 

medically trained staff are able to respond in the event that an individual 

experiences an overdose associated with the drugs they have used. It is 

important I believe to recognise what such settings can contribute but equally 

important to recognise their shortcomings. In short form these are summarised 

below. 

1) Typically, so called safe injecting facilities provide a setting where 

individuals can inject previously purchased street drugs rather than 

prescribed injectable medication. Street drugs are likely to be 

contaminated with a variety of cutting agents. As a result, the injection of 

these drugs can result in serious blood based infections which will occur 

irrespective of the setting where the injection is occurring. 

2} Providing a setting where individuals inject drugs runs the risk of 

encouraging injecting itself which is without doubt the single most risky 

way of administering any substance to the body. A more constructive 

approach than facilitating injecting would be to discourage injecting at 

all as a means of administering illicit substances. 

3) The provision of any facility that enables individual's illegal drug use 

runs the very real danger of undermining efforts aimed at facilitating the 

individual's recovery from dependent drug use. In a situation of limited 

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financial resources, it is more appropriate to ensure that addicts have 

access to treatment recovery oriented treatment services that can support 

their attempts at ceasing their drug use rather than providing facilities 

which actually enable such drug use. 

4) The creation of a safe injection facility where individuals can inject street 

purchased drugs without fear of prosecution requires the limited 

suspension of national laws relating to the possession of illegal drugs. 

Clearly it would not make any sense to set up a safe injecting facility and 

then simultaneously prosecute individuals for possessing the illegal drugs 

they were consuming within the facility. However, creating a setting 

where national drug laws are suspended also creates situation in which 

any individual in possession of illegal drugs could claim that he or she 

was en-route to a safe injecting facility. In this way the setting up of such 

a facility is likely to result in a much wider dilution of the existing drug 

laws well beyond the physical boundary of the injecting facility itself. 

5) It is questionable whether a national of local government (Federal or 

State) should take on the responsibility of facilitating individual's drug 

use. Indeed, it is hard to see how any such government authority taking 

on such a responsibility would not at one and the same time be 

undermining its efforts at drug prevention. 

6) Whilst there have been some studies undertaken that have reported on 

the experience of a number of safe injecting centres (specifically in 

Vancouver and Australia) most of those evaluations have been 

undertaken by centres that are firmly supportive of safe injecting 

facilities - as such it is not at all clear whether these evaluations can be 

considered as objective. Those studies have typically not shown that 

individuals who are attracted to use these facilities have been able to 

successfully cease their drug use. 

7) Whilst it is clear that such settings can attract some individuals who then 

inject some of their drugs within the injecting facility it is equally clear 

that not all injectors within a local area are inclined to use such a 

facility. Equally it is also clear that even those injectors who do use such 

a facility do so on only a proportion of the times they are injecting. As a 

result, risky injecting behaviour persists even in the areas where such 

facilities have been provided. 

8) The provision of so called safe injectingfacilities can create a deep sense 

of confusion within local drug treatment and recovery services as to what 

their role is with regard to supporting individuals to cease their drug use. 

Services cannot easily combine a focus on both facilitating and 

discouraging individuals drug use. 

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9) Relatedly it is hard to see how prevention efforts are not themselves 

undermined where a national or local government provides the means to 

inject illegal drugs and the settings within which illegal drugs can be 

used. 

Significantly, Professor McKeganey has published findings showing that the 

presence of"robust law enforcement" activity is productive of both drug use 

cessation and entry into treatment. This finding in particular argues against any 

policy of decriminalization or relaxation of the law in order to avail the operation 

of injection facilities. 

More broadly, a comprehensive review of such facilities globally undertaken by 

the European Monitoring Center for Drugs and Drug Addiction (EMCDDA) has 

pointed out very similar problems regarding the evidence. The EMCDDA review 

found not only similar limitations found in the evidence regarding public health 

effectiveness, they present a general conclusion that the evidence to date is unclear 

and hard to properly evaluate, largely because of methodological inadequacies. 

Evaluating a Specific Study of SIFs: The Methodological Weakness 

Finally, a specific recent (2007) studv has often been highlighted by advocates 

purportedly showing a raft of positive outcomes. But a review of actual findings 

and caveats shows once again the same partial, equivocal, and inconclusive results. 

Findings were that out of902 studied participants over multiple years, drug 

use "cessation" for as much as six months (they counted methadone maintenance 

as constituting "cessation") was reached by 23 percent. The study was of what 

characteristics were found as independently associated with entering that state; 

among the several such factors one finds (some) participation in SIFs (Safe 

Injection Facilities). 

This is not a demonstration that SIF participation was itself the factor, nor that 

participation increased "cessation." (Hence the use of the term "potential role" in 

the Conclusions, below.) Final analysis out of more than 900 participants in the 

study that yielded about 2000 "observations of cessation" by these terms; that is, 

a "cessation event" was achieved for some period of time in 95 "events." 

Note that the "cessation" comes from getting into treatment; since there is no 

demonstration that attending the SIF is the reason for getting into treatment, from a 

public policy perspective, why not provide the SIF funds directly to expanded 

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453 

treatment options? (Note in the below quotes that Aboriginal participants, who are 

a large percentage of participants, were significantly less likely to enter into 

treatment services if attending SIFs): 

Conclusions: While the role of addiction treatment in promoting injection 

cessation has been well described, these data indicate a potential role of SIF in 

promoting increased uptake of addiction treatment and subsequent injection 

cessation. The finding that Aboriginal persons were less likely to enroll in 

addiction treatment is consistent with prior reports and demonstrates the need for 

novel and culturally appropriate drug treatment approaches for this population. 

Further: "This study has several/imitations. Firstly, given that addiction is 

recognized to be a chronic relapsing condition (Galai eta!., 2003; Evans et al., 

2009), our definition of injection cessation is restricted to a relatively short period 

of injection cessation. Nevertheless, our findings are compelling and it is 

noteworthy that this definition of cessation has been consistently used in the 

injection drug use literature. Secondly, there are a number of limitations 

associated with the observational nature of our study. For one, the present study is 

limited in that the control group included non-frequent SIF users. As has been 

described previously (Lurie, 1997), selecting adequate control groups is 

particularly challenging in observational studies examining the use of healthcare 

services for IDU While a randomized control trial would be an optimal evaluation 

strategy, interventional study designs to evaluate SIF have been deemed unethical 

(Christie et al., 2004). Given this limitation it is possible that individuals who are 

more concerned with their health may be independently more likely to visit a 

SIF, seek addiction treatment and experience periods of injection cessation .... 

Finally: "In addition, many of our measures relied on self-report and are 

susceptible to socially desirable reporting as well as recall bias .... Although our 

observational study cannot determine causation, these findings contribute to a 

growing body of literature suggesting a link between SIF attendance and entry into 

addiction treatment. " 

In the face of insufficient evidence of effectiveness, and given the realization that 

public dollars may more effectively be spent in support of expanded drug 

treatment, the lesson seems to be that the provision of government-enabled safe or 

supervised injection facilities simply cannot suffice as an adequate policy response 

to our present drug use, overdose, and HIV I AIDs crises. 

The Overall Failure to Achieve National Drug Control Strategy Goals by the 

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Obama Administration: The Opioid Crisis and Beyond 

President Obama's National Drug Control Strategy in 2010 first proclaimed the 

major policy goals of the administration's approach to the drug problem and the 

goals were to be met by 2015. Not only have they not been met, in critical 

instances, the policies have been going in the wrong direction, rapidly. 

We learned that, in the midst of the ongoing opiate overdose crisis, heroin 

overdose deaths rose an additional28 percent between 2013 and 2014. That's on 

top of the 340 percent rise in heroin deaths since 2007, such that beyond the 8,217 

deaths of2013, we now have another 10,574. That is, we now see a 440- percent 

increase from the Bush years. 

Moreover, prescription opiate deaths also surged an additional 16 percent, taking 

us to 18,893 dead, while heroin use and Mexican production of the drug continue 

their steep climb. Overall, all drug poisoning deaths hit 47,055 in 2014. That's up 

from the last years of the Bush administration, when they were 36,450; that is, the 

rise for all drug deaths is almost 30 percent. 

But according to the Obama administration, that wasn't going to happen. Instead, it 

was supposed to drop by 15 percent between 2010 and 2015, a target confidently 

set in their own strategic goals. 

And then we discover that marijuana use by high school students, as measured by 

the largest, longest-running youth survey, Monitoring the Future (MTF), remains 

steadfastly high, unmoved from the steep rise since 2009; more than 1-in-5 high 

school seniors are "past-month" users of the drug. (Moreover, the foundation of 

prevention education, perceived "harmfulness" in using marijuana, has fallen to its 

lowest point ever among 12th graders, 62 percent lower than in 2008.) The same 

sustained high rates are found for youth use of"any illicit drug," beyond 

marijuana. 

Further, the lead researcher for MTF had issued a dire warning recently, that the 

"second relapse phase in America's youth epidemic of drug use may now be 

beginning," based on recent upturns in marijuana use. 

Many experts suspect that the actual number of users is considerably higher, were 

MTF to properly capture the new, highly potent forms of the drug now spreading 

across the country, the candies, drinks, and concentrates such as "shatter" 

consumed in vapor-pens, even in the classroom. The potency of such forms is 

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unprecedented, reaching 70 to 80 percent THC (compared to the 3-4 percent 

potency of the 1980s), the intoxicating chemical linked to such effects as IQ loss, 

memory and cognitive impairment, psychosis, and multiple social pathologies, 

including school drop-out. 

Again, that wasn't supposed to happen. By the administration's goals, youth "pastmonth" use of drugs was to decline by 15 percent. Similarly for 18-25 year olds, 

whose rates of "past-month" use were supposed to fall 10 percent; the National 

Survey on Drug Use and Health (NSDUH) shows that since 2008, their "pastmonth" use has risen 12 percent (strictly marijuana use by 18 percent). 

Drugged driving was to drop; it's up. The "lifetime" use of drugs by 8th graders 

was supposed to decline by 15 percent (surely a modest goal); MTF shows that in 

2015 it's up 8 percent since 2007. And so forth. 

These recent findings matter, as they show undeniably that the drug policies of the 

Obama administration have failed. Importantly, they have failed not according to 

editorializing critics, but according to the very metrics, required of the White 

House Office of National Drug Control Policy by law, which the administration 

itself selected as the way to evaluate their performance. That is, this evidence 

represents a self-indictment. 

For seven long years, the administration has insisted on a master narrative. It 

denounced the supposed policies of the past, and proclaimed a new, enlightened 

approach, that "ended the drug war," promised treatment insurance that never 

arrived, dispensed clean needles and overdose antidotes and other inadequate 

"harm reduction" approaches, and in an overarching manner blamed "stigma" for 

the disease of addiction. 

Never mind that the actual Bush policies had produced real results-treating drug 

addiction as a public health problem; insisting, for example, on drug courts over 

incarceration; and effectively reducing the availability and use of all drugs through 

a combined medical science, national security, and law enforcement strategy that 

reduced drug supply as it strengthened prevention and treatment. But the Obama 

administration insisted on the distorted caricature. 

The policies of the Obama administration's predecessors, we heard repeatedly, 

were the failed crack-downs of the past, trying to reduce the supply of drugs and 

fighting back against international cartels. All that was declared futile, 

notwithstanding that under Bush, the same MTF data showed a 25-percent 

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reduction in "past-month" marijuana use, for combined high school grades 8th 

through 12th, that cocaine production had fallen 75 percent in Colombia, and 

cocaine use on U.S. streets had plummeted 50 percent (by 2011 ). 

So far was this administration from achieving their goals that even the Government 

Accountability Office issued a report warning that they were seriously off track, 

based largely on data from 2012; but they did not change course, and things have 

only worsened since then. 

Then, on CBS's 60 Minutes, Obama Drug Czar Michael Botticelli termed legalized 

marijuana "bad public health policy," and worried that youth receive the message 

that because the drug is legal, it's somehow safe, eroding the perceptions of risk 

essential to good prevention programs. 

He should tell the president, the source of the policies that have led us into this 

circumstance, when he disabled federal law and enabled commercial, legalized 

marijuana. 

The Impact on Drug Treatment: Drug Decriminalization and Legalization 

Undermine Public Health Goals 

Recovery, including abstinent recovery, from long-term serious addiction is well 

attested. There is ample ground for hope, and for many recovery is in reach. Drug 

addiction is a habit, a habit that over time changes the brain, and in many forms 

becomes a type of disease. Recovery therefore is also a habit, which, over time, 

enables the brain to improve and even heal. 

Many people who are deeply dependent simply stop using drugs and liberate 

themselves, even in the absence of a treatment intervention. 

There are various forms of treatment, and ideally the form will be tailored to the 

specific needs of various populations of patients, perhaps inflected for gender, age, 

ethnicity, parenthood, resources, and co-morbidities, among many dimensions. 

There are faith-based treatments, cognitive and behavioral therapies, medicationassisted therapies, and entry into therapeutic communities, to provide but an 

incomplete sample. Some are publicly funded, some private, some in recent history 

were even voucher-ized, enabling selection by the participant for treatment with a 

demonstrated record of success, and some are insurance-covered. 

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But what remains a continuing failure on the part of the treatment community is 

clear and convincing evidence of what works and why. That there is recovery is 

true; that treatment sometimes leads to recovery is also true. But studies of 

effectiveness have fallen woefully short. 

Some studies claiming effectiveness tum out to only examine the positive behavior 

of those who are still in treatment. But after they leave treatment, their outcomes 

are not well-documented in the evidentiary literature, not the least problem is the 

attrition rate in the study population. Moreover, the attrition is differential; we are 

most likely to lose from the study just those most at risk from failure. It is a major 

weakness of claims for treatment effectiveness that treatment populations are 

commonly followed for short months into their recovery, rendering long-term 

outcomes of specific treatment modalities largely an unknown. 

Treatment must be supported as necessary part of the triad of strategic responses 

but it cannot be stressed enough that better and more honest evaluations of 

treatment effectiveness must be forthcoming or the field will lose credibility. 

That said, we are presented routinely with policy statements, such as the respective 

return on investment of a public policy dollar spent on treatment as being cost 

effective compared to other options, that are really based on unknowns. 

Unfortunately, what has happened all too often in the treatment world has been a 

call for more funding, an assurance that the investment is worth it, while at the 

same time moving the goalposts. That is, a "successful outcome" gets 

progressively re-defined in such a manner that holding treatment accountable 

becomes a semantic exercise rather than a medical one. 

Once we have been accustomed to accept that drug use is a "chronic, relapsing" 

condition from which we should not expect full and abstinent recovery, we have 

taken a partial truth about this disease and converted it into a framework of 

expectation whereby safe injection facilities or government-supported heroin 

maintenance programs come to be regarded as part of a treatment continuum. 

SAMHSA budgets approximately $1.8 billion a year on publicly funded treatment, 

while insurance and private payments greatly supplement that amount. Greater 

demonstration that this money is actually effective, meaning actually turning 

around lives and producing recovery, is a fundamental urgency in drug policy. 

What is the impact of the Affordable Care Act? Initially hailed as a 'breakthrough' 

for substance abuse treatment, the Act mandates expanded insurance coverage for 

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drug treatment with "parity" requirements (comparable to coverage of other 

medical conditions) that ACA supporters hope will revolutionize health care for 

the addicted. 

That's not where the treatment policy problem is; it lies with those who don't feel 

that they need treatment and aren't even seeking it, expanded coverage or no. Our 

problem, then, is denial. And more drugs, with greater availability and 

acceptability, can only make that denial worse. 

Of greater concern, however, is how prosecutorial neglect of marijuana use will 

harm the Administration's own efforts to treat substance abuse through the 

Affordable Care Act. 

While the Administration's new policy of neglect won't substantially reduce drugrelated incarceration, it will inflict harm on effective programs in drug prevention 

and treatment. Though the administration's rhetoric has stressed a public health 

approach to curb drug use, their policies will produce short-term harm from 

increasing marijuana use and long-term damage to the administration's stated 

prevention and treatment objectives. 

Legal marijuana undermines social norms against drugs, diminishes perceptions of 

risk, handcuffs the courts as an instrument in treatment, and makes it less likely 

that the largest category of dependent drug users in need of treatment will pursue a 

path to their recovery. 

Concerns now beset provisions of the ACA, especially concerning marijuana, 

which is the largest cause driving treatment need. While the heaviest drug using 

age cohort (18-25 year aids) should now be covered until age 26 under their 

parents' plan, ifthe ACA falters in its funding assumptions or in some other 

manner, federal funding for treatment under the old system would be wholly 

inadequate to cover expanded treatment need spurred by legal, recreational 

marijuana. 

Legal marijuana also has a perverse impact on getting people needed treatment. 

The National Survey on Drug Use and Health discloses the problem. Among the 

7.3 million Americans in 2012 who met the criteria for needing treatment (4.3 

million ofwhom were dependent on marijuana), high cost or lack of insurance 

were offered by some as the reasons that they didn't actually get the treatment they 

sought. But these problems were cited by fewer than half of those who didn't get, 

for any reason, the treatment they wanted. In fact, the entire category of those who 

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sought treatment but failed to get it represents only 1.7 percent of those who 

needed it. 

In fact, a remarkable 95 percent of those who needed treatment for a drug abuse 

disorder were not seeking it-that is, they are in denial. No provision of an 

expanded ACA can help those who do not seek their own recovery. Public policy 

should be designed to motivate those in need to seek help. 

Regrettably, widely accessible, socially acceptable marijuana provides no incentive 

for the dependent to enter recovery; rather, such a permissive environment makes it 

easier for a person to persist in denial and continue the self-destruction of 

addiction. 

There is similar jeopardy for drug courts, which serve as an alternative to 

incarceration for non-violent drug offenders. There are now more than 3,400 such 

courts, where offenders are directed to treatment, completion of which can lead to 

clearing their record, with no resort to prison. They are a huge success; in fact, the 

criminal justice system today is the largest single source of referral for treatment 

for drugs like marijuana. But the success ofthese courts in driving treatment will 

likely suffer as a consequence of legalization, which weakens the criminal justice 

system as an adjunct to treatment and recovery. 

We can add to that the misapprehension regarding the criminal justice issue, which 

is often promoted as a reason to legalize marijuana. The Obama administration, 

perhaps driven by the mistaken notion that America's prisons are unjustly filled 

with first-time marijuana offenders, has condoned marijuana use through an artful 

blend of inaction and avoidance towards legalization initiatives. Not only has the 

administration declined to challenge legalization ballot initiatives (or even speak 

against them during the state campaigns), they have turned a blind eye to 

recreational marijuana usage by ranking such activities as beneath their 

"prosecutorial priorities." 

In reality, fewer than 1 percent of inmates in a state prison system are incarcerated 

due to first-time marijuana use or possession. And many of those who are 

incarcerated have pled down from more serious charges. The fact is most inmates 

are incarcerated for multiple, non-marijuana drug offenses, often involving 

trafficking or violence. 

In the end, the administration is undermining effective responses to real problems 

by peddling a false narrative regarding incarceration and implementing public 

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health policies at odds with its own objectives. 

ROLE OF DRUG SUPPLY IN EFFECTIVE POLICY: 

To Stop the Drug Epidemic, Control Supply 

Observers agree that the U.S. is in the midst of an opiate epidemic, the most 

prominent effect being the increasing number of overdose deaths accelerating 

sharply since 2010. Opiate deaths as of2014 stand at nearly 29,000 per year, a 

function of both misused prescription opiates as well as the greatly increased 

supply from Mexico of illicit heroin and fentanyl now found on domestic streets. 

The opiate crisis is only one factor in our current exploding American drug 

problem. Comparable recent surges in supply and use are found with 

methamphetamine also from Mexico, accompanied by recent increases in cocaine 

production and availability, sourced to Colombia, and finally, significant increases 

in nationwide marijuana supply and prevalence, particularly high-potency products 

smuggled interstate from states that have "legalized." 

A primary source is, as I have noted, is Colorado, where the drug is being offered 

for recreational, commercial sale, notwithstanding its continued status federally as 

a Schedule I Controlled Substance, illegal to produce or use and deemed without 

acceptable medical use. 

While overdose deaths are most pronounced with opiates, cocaine and 

methamphetamine also produce acute, even life-threatening, drug consequences, 

and their increase can be detected in both nationwide mortality reports and 

emergency department episodes. 

Marijuana is likewise increasingly associated with medical emergencies, and while 

deaths from acute episodes are rare, the health consequences of use, especially for 

adolescents, are major, and appear most threatening in terms of mental and 

cognitive impairment, psychosis, and persisting mental disability, including 

associations with schizophrenia, all found with persistent use, especially when 

initiated in adolescence with high-potency products. 

In passing, it must be stressed that a focus on opioids as a cause of adverse drug 

use consequences, while certainly understandable, can be potentially misleading if 

it leads us to neglect a comprehensive strategy against all illicit drugs of abuse. To 

provide but one example, there has been extensive policy focus on responding to 

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the opioid crisis by resort to antidote medications, or medication-assisted therapies, 

or efforts to stem opioid medication proliferation and diversion. 

While these interventions may be necessary, we must realize that there are no such 

effective policy counterparts available for responding to drugs like marijuana, 

methamphetamine, or cocaine, for which such resources or opportunities for 

intervention are simply not available. 

Yet an effort to control the supply and availability of each of these drugs would be 

effective in mitigating the toll that they impose. 

We face serious threats from heroin, synthetic opioids, pharmaceutical diversion, 

methamphetamine, and cocaine. In each of these cases, the root cause 

underpinning the crises are the greatly increased production, available supply, and 

sheer magnitude of quantity and potency of these drugs in U.S. markets. The 

supply has led to a large criminal army of dealers and supply networks, as it has 

swollen the ranks of the addicted. We have been down this path before, and know 

that the consequences of an unopposed drug supply become intolerable. Yet we 

also know that we have powerful tools to reverse this course. 

At present, at the national level, there is silence regarding drug supply, as President 

Obama's policy rejects the primacy of supply control efforts as futile and 

alienating. In opposition, we argue that the true impact of increased drug supply is 

the most important thrust of an effective national policy, and rebuilding such 

programs is an imperative, without which we will be overwhelmed by the illicit 

markets that now threaten to consume a generation. This reality is supported by an 

honest assessment of drug control history, and has contemporary empirical 

support. 

Simply put, the way to overcome our current catastrophe of drug use is to 

effectively attack the surging abundance of production and supply. 

Further, in addition to reducing availability and use, controlling supply will 

augment the effectiveness of programs the objectives of which are prevention as 

well as treatment and recovery. 

The impact of drug supply on drug use and consequences is much misunderstood, 

even misrepresented, in current policy debates, as are the positive effects of 

reducing that supply on all drug control programs and objectives. Note that 

virtually everyone concerned with drug use calls for reducing the demand for 

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drugs, convinced quite reasonably that if demand were quenched, the problem 

would cease. 

Yet an estimated 27 million Americans in 2014 were past-month users of an illegal 

drug, with the figure rising yearly. Beyond rhetoric, how does the federal 

government reduce that demand? Programs in prevention, largely educational 

efforts, may defer new entrants, and programs in treatment provide avenues to 

recovery, notwithstanding recent efforts to define drug use as a "chronic, recurring 

condition" suffered by the brain, inclining to the temptation to just accept its 

presence. But evidence that federal programs drive out the demand for intoxication 

is dismayingly weak. 

Moreover, we have for years been offering nationwide programs, funded by 

billions, on prevention and treatment, and still demand persists. It can be argued 

that yet more resources and yet more science can be directed at drug treatment, but 

the evidence is overwhelming that while prevention and treatment are necessary 

dimensions of drug control, they cannot be sufficient. To be effective, the front 

ranks of our response must be controlling the spread of the pathogen itselfmaking drugs scarce, expensive, risky, and feared. Prevention and treatment only 

then gain traction. 

Conversely, fully eliminating the drug supply would be sufficient to drug control 

purposes, but full elimination is nearly impossible to realize. That said, evidence is 

strong that substantially reducing the drug supply, when sustained over time, does 

lower drug use, and does ameliorate attendant damage, thereby shielding potential 

users while healing and liberating current users. 

The Evidence Regarding Heroin: 

Consider this evidence. Heroin use in the United States was in decline in the mid2000s. There were no adverse changes in the federal drug treatment system, and 

prevention efforts directed at heroin were unchanged. Yet heroin use began to rise, 

increasing sharply in 2010 and continuing an ascent through today. That is, there 

has been a disease outbreak. 

As ONDCP Director Botticelli testified before the Senate this year, "The past five 

years have seen an alarming increase in deaths involving heroin, rising from 3,038 

in 2010 to 10,574 in 2014. This increase has been accompanied by a sharp rise in 

the availability of purer forms of heroin that allow for non-intravenous use, and at 

a relatively lower price, and an increase in the initiation of heroin use (jrom 

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463 

116,000 people in 2008 to 212,000 in 2014)." 

The dynamic of difference was the sharp increase in heroin production and means 

of distribution, greatly increasing availability, largely a function of significantly 

expanded Mexican production, that today yields an accessible market product of 

unprecedented low cost and high purity. The rise in production to 70 metric tons in 

2015 represents an increase in two short years of 170 percent. 

MEXICAN Poppy/Heroin Production 

2015 2014 2013 2012 2011 

Hectares under 28,000 17,000 11,00 10,500 12,00 

cultivation 0 0 

Potential pure 

production 70 42 26 26 30 

(metric tons) 

In past decades, according to the Drug Enforcement Administration's Heroin 

Signature Program (as supplemented by understanding from the Domestic 

Monitoring Program), significant heroin sources directed at the US have included 

South West Asia, South East Asia, Mexico, and South America, principally from 

Colombia. 

During the decade of the 2000s heroin production from Colombia diminished as a 

primary source, as a function of programs such as eradication, interdiction, and 

organizational pressure; the decrease coincided with comparable pressure on 

Colombian cocaine, the primary source of that drug to the US. 

This time period witnessed the increasing role of Mexican sourced heroin to the 

US, both traditional black tar and increasingly, so the DEA now argues, from white 

heroin apparently produced in a manner similar to the South American product; as 

such, it is unusually pure and potent. This heroin sourced to Mexico is now being 

adulterated with synthetic opioids such as fentanyl, and yet more potent synthetics 

are on the horizon. 

The effect has been to great increase the lethality of the heroin threat, both to users 

and to first-responders. It further offers a challenge to the administration of 

overdose antidotes such as Naloxone as the principle response. 

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The parallel prescription opiate crisis contains the same lesson. Administration 

authorities argue that excessive prescribing of opiate medications generated the 

epidemic Gust as they further argue that imposing restrictions on access to opiates 

"caused" a turning toward heroin). Leaving aside the merits of their history, the 

Administration in this case fully recognizes the critical role of drug supply and 

availability in driving drug use outcomes, and have sought to restrict access and 

overprescribing. What is remarkable is their unwillingness to apply an equivalent 

understanding against all illicit drugs. 

The Evidence Regarding Colombian Cocaine: 

But the same principle --that supply fosters outbreaks as a virus drives flu--

applies to the illicit substances. The case can be made even stronger by examining 

recent facts concerning cocaine, which has but one global source- the three 

nations of the Andes, of which the overwhelming producer of U.S. supply (95 

percent) has been Colombia. 

By effective, sustained supply control programs operated in-country 

(comprehensive efforts combining eradication, establishing the rule oflaw, and 

alternative economic development) coupled with interdiction in drug transit arenas, 

the volume of cocaine produced in Colombia and directed at U.S. targets 

(controlled in distribution through Mexican cartels) plummeted from 700 metric 

tons of potential pure cocaine in 2001 to only 165 metric tons in 2012. The drop 

was 76 percent, and cocaine thereby became scarce, costly, risky, and adulterated. 

Through Plan Colombia, the joint program sustained across successive U.S. and 

Colombian administrations, achievement was driven by year over year aerial 

eradication of the crop. Scientific field studies established that for every year of 

sustained eradication, productivity of the coca fields fell in consistent increments; 

over five years, there was a measured decrease in field productivity well more than 

hal£ 

Many economists who speculate about the drug market do not accept the impact of 

producer country supply reduction efforts such as Plan Colombia. They argue that 

raising the price of coca in Colombia has only marginal impact on the market in 

the U.S, since the major mark-up in value is provided by cross-border smuggling 

and distribution, where the value of a kilo of cocaine rises from roughly $1,500 in 

country to between $25,000 to $45,000 in the U.S. From their perspective, what is 

the point of eradication if it only lifts the price in Colombia by a few hundred 

dollars? 

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These economic analyses, however, do not portray real drug markets. It doesn't 

matter how much you're willing to pay in Miami for a kilo of top quality cocaine 

when there is no cocaine supply to satisfY the demand. Unlike other global 

commodities, there are not multiple market alternatives for cocaine when supplies 

dwindle. Producing cocaine is a specialized activity, fraught with risk and 

disincentives, coercion and violence, and it thrives in ungoverned spaces. The crop 

is not an annual, like poppy, and years of farmer effort can be destroyed quickly, 

while re-planting is intensely laborious. The impact favors movement of farmers to 

licit alternative crops as a form of sustainable agriculture. 

We further know that the induced shortages in Colombian production were 

manifested all along the supply chain. With reduced flow, interdiction efforts 

became more effective in Colombia and the transit areas moving to the U.S. Law 

enforcement noted that Mexican cartels were unable to satisfY deliveries, and 

cocaine flow at the border decreased, leading to urgent calls from dealers and sharp 

declines, beginning in 2007, in cocaine purity, accompanied by increases in price 

per pure gram. Lost revenue from cocaine sales forced cartels to scramble for 

alternatives, and set in motion battles for control of remaining supplies and supply 

lines. The cocaine market was moving towards collapse. 

Importantly, there was no "balloon effect" from reductions in Colombia felt in 

either Peru and Bolivia, as cocaine production throughout the Andes declined from 

1,055 metric tons in 2001 to only 560 metric tons by 2012, a 47 percent decline, 

led by Colombia's plummet. 

The impact led to many positive developments on the U.S. home front. Work place 

cocaine positives were cut deeply between 2007 and 2013. Cocaine overdose 

deaths and emergency department episodes fell. Regular cocaine use declined by 

as much as half. With nothing on offer but a more expensive, less pure product, 

now harder to find, treatment began to take hold, and people moved away from 

cocaine. An entire array of damaging drug consequences began to heal. Lives were 

saved. 

There is a coda to this argument about controlling drug supply, as tragic as it is 

unnecessary. By 2012, following the Obama policy line, U.S. and Colombian 

policy began to shift away from aggressive supply reduction, and a reverse 

experiment regarding the effectiveness of supply control was set in motion. 

First, broad areas of Colombia were closed to eradication, giving license to 

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produce cocaine within those borders. Cocaine cultivation began to return, while 

cocaine production rose between 2012 and 2014, 165 metric tons of cocaine rose to 

250, more than 50 percent. In the U.S., overdose deaths almost immediately rose. 

Then in May oflast year, aerial eradication was completely banned in Colombia, 

based on false scares about the health impact. Devastation has now followed in 

short order. Cocaine production is flooding the Colombian forests. Indeed, the 

White House has just acknowledged that potential pure production is now 420 

metric tons for 2015, a rise of 155 percent from its 2012 low. We fear there may 

already be even greater production in the offmg. Already, revolutionary-groupsturned narco-traffickers are in league with hungry Mexican cartels like Sinaloa, 

partnering to return the deadly cocaine circus of the 1980s to U.S. streets. 

We can anticipate the devastating consequences on the home front, as the leading 

edge of the cocaine flood moves its way north, its flow abetted by a weakened 

Administration stance in Central America, while transit arenas have experienced 

reduced interdiction assets, and Mexican cartels are poised to re-capture market 

share. Let there be no doubt- given an unprecedented policy accomplishment, this 

Administration threw it away, when they refused the clear lesson of supply control. 

Summing Up: The Neglect of Strategic Drug Supply and the Rise of 

Synthetics: 

We are witnessing drug policy cause and effect. Sadly, similar stories can be told 

with regards to not only heroin and prescription opiates, but drugs like 

methamphetamine, where use was cut nearly in half by U.S. restrictions on 

precursor chemicals, only to come back once Mexican cartels found ready 

industrial supplies of chemicals, evidently derived from China. Supply reduction 

pressure must be sustained and adapted in order to work. 

And then there's the current debacle of marijuana, demand for which had been 

successfully reduced prior to 2009, falling 25 percent among youth. But with legal, 

"recreational" state sales of the drug, added to the production of so-called "medical 

marijuana" in multiple states, supplies nationwide are surging, and prevalence of 

use is climbing steeply, most rapidly in the very states where supply is most 

abundant. 

Increased drug supply and growing markets fund those controlling the trade, and 

they capitalize by increasing supply of yet other drugs. Marijuana use by youth, 

through its well-attested 'gateway' capacity, will generate use and sales of yet 

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other drugs that will be introduced to communities through the legal marijuana 

gateway. The black market providing all drugs can be seen to thrive in the 

environment of legal drugs, that vastly increases supply and approved access. 

There can be no doubt that legal, commercial marijuana, as found in Colorado, will 

lead to many more users of marijuana, stronger cartel control, and yet more drug 

supply of other drugs, leading to many more users in a vicious cycle already 

underway. There may be time to reverse this cycle, before the large revenues from 

"legal" drugs insulate and perpetuate its political standing. 

But we know what the first and most important strike must be- shut down the 

burgeoning pathogen at its source. Reduce drug supply. Other benefits will follow. 

There are two critical lessons about how the Administration's policies have been 

deficient. First, they largely address the consequences of the epidemic, but provide 

little support for programs intended to reduce the spread and hold of the behavioral 

disease of drug use. 

Second, the policies, by ignoring supply reduction, the attack on trafficking 

organizations, and the critical role of international engagements in source countries 

(the President's most recent budget actually cuts funding for international drug 

control programs by $952 million), the policies have been at best tactical dodges 

but not strategic initiatives capable of solving the problems. 

The work to stem the tide demonstrated by Drug Enforcement Administration and 

numerous other drug control agencies (such as State INL, CBP and ICE) is 

commendable, but insufficient. Still, Administration policy has neglected (when it 

has not undercut) at the national policy level control of border movement, 

international drug control partnerships, and suppressing trafficking networks and 

gang distribution, as all the while it has simultaneously emphasized enabling of 

legal recreational marijuana production, sales and distribution. 

The result is that any achievements that have been made in controlling drug flow 

by respective agencies have had to push against the dominant policy tide and have 

not enjoyed robust national policy support. 

The rise of synthetic opioids tells us that the heroin threat has morphed already into 

a more deadly form. Synthetics present a model of production more akin to 

methamphetamine, which means industrial chemical production in makeshift 

laboratories in the midst of urban centers, freed from attachment to agricultural 

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products, drug production from which we are able to estimate from national 

technical means through crop sampling estimates. 

Testimony regarding the amounts seized by the Customs and Border Protection 

(CBP) agency capture the extraordinary volume of opioids moving across our 

borders, not only heroin production, (production of which, as have seen, has risen 

through 2015 to 70 Metric Tons, but recent seizure increases showing a surge in 

synthetic fentanyl crossing the border. 

For synthetics, the underlying production estimate is simply not known. That said, 

as the figures presented show a rise through 2015, at best, we can anticipate that 

the horrendous overdose toll represented in the literature today, which represents 

known deaths from 2014, will likely continue to rise even more steeply, given the 

available supply and distribution networks. If so, the impact will be catastrophic 

and well beyond the public health problem from which we are already reeling. 

Coupled with the rising cocaine threat from resurgent Colombian production, the 

sharply rising methamphetamine threat, and the ongoing expansion of high potency 

marijuana, both licit and illicit, a looming disaster that will engulf public health, 

law enforcement, and national security is almost upon us, as this Administration 

prepares to leave office. 

What are we doing in response? Compared to the public health reaction to the 

Ebola and Zika infectious threats, the funding has not been of the proper 

magnitude. But funding is not the complete measure of response. We must ask 

what strategic responses, with what resources and coordination, are being brought 

to bear? 

The Administration has testified concerning their program to train Customs and 

Border Protection (CBP) personnel in the administration ofthe Naloxone overdose 

antidote to those they encounter at the border. It is not clear to this observer how 

such a priority program at the border will help stem drug flow. In fact, if criminal 

cartels, controlling plazas in Mexico and migrant smuggling routes were to 

insinuate drug trafficking mules into the flow of migrants streaming across the 

southern border, how would this program, however otherwise meritorious, be a 

sufficient response, and how would it protect the lives of Americans? 

As I have argued, the risk from current Administration policy is that too much 

focus on opioids at the expense of a comprehensive, all-drug strategy (which 

supply reduction can address) will leave us unprotected. Further, with regards to 

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the opioids, a nearly exclusive focus on responding to the sequelae of initiation and 

dependency, rather than placing more effective emphasis on interrupting the spread 

of this behavioral disease by cutting supply and initiation, has proven inadequate. 

Finally, within the larger opioid crisis, the response focus has been almost 

exclusively on the problem of prescription medication opioid diversion and misuse, 

with a corresponding neglect of illicit heroin and rogue synthetic opioid production 

and distribution. 

Not surprisingly, it is this latter category of drugs that is climbing most steeply and 

causing increasing damage (prescription abuse having peaked, as a prevalence rate, 

in 2006, with small declines thereafter), while overdose deaths therefrom peaked 

around 2011 - as heroin deaths began to surge in 2010 - before the recent rise 

plausibly related to what may be misclassified illicit synthetic overdose deaths, 

such as those from fentanyl, that may account for as many as 5.500 of the most 

recent (2014) death toll. 

That said, the Administration has at least followed the right course of action, 

strategically, regarding the diversion and misuse of licit prescription opioids. They 

have addressed the supply and availability of the drugs themselves, through pillmill and doctor shopping crack-downs, through prescriber education initiatives, 

through continuing to expand Bush-era prescription monitoring programs, and 

through efforts such as restricting access to medicines such as hydrocodones 

through up-scheduling, as took place in October of 2014. 

These steps to address the supply and availability of prescription opioids are proper 

initiatives, but the challenging policy question, as I have noted, is why have 

comparable actions against the supply and availability of illicit drugs - including 

opioids, cocaine, methamphetamine, and marijuana not followed this correct 

strategic model? 

Instead, Administration policy has neglect this critical strategic tool when it comes 

to illicit drugs, and the results of that neglect are unavoidably negative, currently 

presenting an epidemic crisis that is only rising, particularly as the supply of such 

drugs, based on seizure and production estimates, already outstrips significantly 

the magnitude of the production and supply that have produced our current crisis; 

that is, the flow is already increasing, and what is to follow will likely greatly 

increase the present disaster. 

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Police Assisted Addiction Recovery Initiative 

(PAARI) 

Statement of Frederick Ryan, Chief of Police Arlington, Massachusetts, on behalf of the 

Police Assisted Addiction Recovery Initiative 

U.S. Senate Committee on Homeland Security and Governmental Affairs 

Wednesday June 15, 2016 

Chairman Johnson, honorable members of the Committee, my name is Frederick Ryan and I 

serve as Chief of Police in Arlington, Massachusetts which is a suburb next to Boston. I also 

serve as Vice-President of the Massachusetts Major City Chiefs of Police Association and I sit on 

the board of the Police Assisted Addiction Recovery Initiative (PAARI.) I very much appreciate 

the opportunity to testify today and I'm honored to do so. 

I'm here to talk about the opiate epidemic that has swept across America, an epidemic that has 

had devastating consequences to communities of all sizes and demographics. My views are 

shaped by what I have seen and done as a police officer on the streets for more than 30 years 

and what I have learned from individuals suffering from the disease of addictions. Let me 

summarize the points I want to make in the next few minutes: 

• We as law enforcement cannot solve this problem on our own and we should stop 

telling America that wit more police resources that we can. 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 long term recovery for people suffering from 

substance use disorders. 

• Every "dealer" we arrest and take off the streets is quickly replaced by one or more 

rivals who sometimes compete for the new territory by cutting prices, increasing supply 

or marketing new and more dangerous products; such as Fentanyl laced heroin, often 

making the situation worse than it already was. 

• Every person with a substance abuse problem that I have talked to has said arrest was 

never a deterrent. The physical and psychological need for the substance was far 

stronger than any seemingly rational deterrent that the police posed. 

• Those suffering from substance use disorders are not our enemies, they are our sons, 

daughters, and neighbors 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. This epidemic 

was built one drug dependent victim at a time and the solution, while complex and 

multi-disciplinary, needs to be heavily based on modern evidence based treatments. 

There are really only two choices here, long term treatment or death, and we need to 

Frederick Ryan 

Chief of Police 

112 Mystic Street 

Arlington, MA 02474 

www.arlingtonma.gov/police 
471 

bring an immediate and genuine sense of urgency to this chronic disease and public 

health epidemic. 

Police officers and Chief of Police throughout the country are stepping forward to call 

for change. Through the leadership of Chief Leonard Campanella in Gloucester MA and 

businessman John Rosenthal, the Police Assisted Addiction Recovery Initiative (PAARI) 

which already includes more than 120 police departments and new entry points into 

treatment in 28 States. These departments, and many others that are joining PAARI 

every week, have stopped arresting people merely because they have the disease of 

addiction and are instead helping them and their families enter treatment and recovery. 

I want to tell you how and why I came to these conclusions: Simply stated, we are not at war 

with our communities. 

The epiphany for me that we had to change our approach occurred when being briefed by our 

crime analyst on trending overdose fatalities in our community. One very young lady who by all 

standards of measure was an American success story: college educated; her mom an educator 

and her dad a firefighter- overdosed on heroin. Police and EMS reversed the overdose and she 

was transported a Boston hospital. About a week later, the same young lady overdosed again. 

She was again transported to the very same hospital. Seven hours later, after being released 

from the emergency room, she overdosed and died. This overdose death was predictable, and 

therefore it was preventable. It highlighted the fact that we, the police department, possess 

the identities of those at highest risk of fatal overdose (those who have previously overdosed) 

and that with every non-fatal overdose there is an opportunity to help the individual enter 

recovery. Further, this overdose death depicted the very real fact that many emergency rooms 

in America do not have the desire or 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 and Arlington) resonated swiftly and broadly across the region and, 

indeed, the nation and legislation is moving swiftly through many states to empower police 

assisted recovery initiatives that focus on reducing the demand for opiates by increasing access 

to treatment and recovery. 

Essentially there are two models; the Gloucester model in which individuals voluntarily present 

to the police department, ask for help and a police officer or volunteer "Angel" then navigates 

the complex process of finding treatment options, and the Arlington model which employs a 

Social Worker who accompanies a police officer and proactively reaches out to a known 

population of persons suffering from substance disorders and develops an intervention plan 

Frederick Ryan 

Chief of Police 

112 Mystic Street 

Arlington, MA02474 

www.arlingtonma.gov/police 
472 

with the people suffering with addiction and their loved ones. In Arlington the Police 

Department hosts regularly scheduled community meetings to train on and dispense Naloxone 

to residents (not just first responders) and to build trust and reduce the stigma associated with 

addiction. In Arlington in 2014 and the first half of 2015 we were experiencing an average of 

one FATAL overdose per month with many more non-fatal and reversed overdoses. Following 

the implementation of our program on July 1, 2015 we had only one fatal overdose in the next 

eight months. Sadly, there was a fatal overdose this past weekend, indicating not failure, but 

the urgent need to do even more. We know our program has saved lives because we have 

found narcan kits that our officers and social workers distributed at the scenes of reversed 

overdoses. Through the Boston University School of Public Health, we're tracking all our 

program participants and, although early, we're seeing significantly lower relapse rates among 

the participants in our pre-arrest diversion programs in Gloucester and Arlington. 

The Arlington and other police assisted recovery initiatives are only a year old and it is far too 

early to draw conclusions about our long term impact. After all, the disease of addiction is a 

chronic relapsing condition and it often takes several treatment episodes for a person to enter 

recovery. Nevertheless, there are important markers that demonstrate we are on the right 

course: 

• We are saving lives now and providing individuals and their families with hope of 

recovery. Crimes often associated with addiction (larceny, burglary, etc.) are trending 

down in many PAARI communities and some members are reporting as much as a 25% 

reduction in these kinds of crimes. 

• Many police departments are using drug dealer asset forfeiture funds and saving 

money. They are finding it is cheaper to the municipal government to divert people into 

treatment rather than arrest and trigger the criminal justice system. In Gloucester for 

example, the Chief found that it costs about $250 in personnel time and facilities to 

arrest, house and turn a person over to the court the next day, but only about $50 in 

personnel time and transportation costs to help find a detoxification or treatment bed 

for a person asking for help. 

Our new approach is restoring and building community trust in police. Hundreds of 

thousands of people respond favorably to our social media posts about the programs. 

Hundreds of people in our communities attend neighborhood meetings hosted by the 

police to learn how to help their loved ones with the disease of addiction. In follow up 

interviews, the participants themselves tell us that the police officers were the first 

people who really cared about them and saved their lives without judging them. 

• 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 

placed into remission rather than a crime that requires incarceration has had a positive 

impact in communities throughout America. 

Frederick Ryan 

Chief of Police 

112 Mystic Street 

Arlington, MA 02474 

www.arlingtonma.gov/police 
473 

Æ 

Conclusion 

You'll notice that in my testimony I never labeled those suffering from substance disorders as 

"addicts" and otherwise refrained from labeling these members of our communities. The very 

real individual and institutional stigma associated with addiction is among the greatest barriers 

to success, and it has inhibited the power and might of the United States government from 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 hitting every 

community-large and small. 

I was proud to be a part of the law enforcement response to the Boston Marathon bombings. 

What I witnessed first-hand was nothing short of extraordinary, and the sense of urgency from 

all levels of government to ensure that every victim of those horrific crimes realized justice was 

admirable. Four people lost their lives that day, including an Arlington resident, and countless 

others were seriously wounded. 

Today, in Massachusetts, we lose an average of four people every day to the opiate crisis. It's 

projected that more people will die this year from overdoses than automobile accidents. It's 

time that we bring a true sense of urgency to this public health epidemic and unleash the 

might of our government to address the demand side of the opiate crisis and municipal police 

departments and PAARI are very willing partners in the solution. As I stated earlier, there really 

are only two choices -long term treatment or death. Clearly we all know the answer and we 

look forward to getting started immediately. 

Thank you for the invitation to speak and for your consideration to this very serious matter. 

Frederick Ryan 

Chief of Police 

112 Mystic Street 

Arlington, MA 02474 

www.arlingtonma.gov/police