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FENTANYL: THE NEXT WAVE OF THE OPIOID 

CRISIS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

MARCH 21, 2017 

Serial No. 115–16 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

GREG WALDEN, Oregon 

Chairman 

JOE BARTON, Texas 

Vice Chairman 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

DEBBIE DINGELL, Michigan 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

TIM MURPHY, Pennsylvania 

Chairman 

H. MORGAN GRIFFITH, Virginia 

Vice Chairman 

JOE BARTON, Texas 

MICHAEL C. BURGESS, Texas 

SUSAN W. BROOKS, Indiana 

CHRIS COLLINS, New York 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

GREG WALDEN, Oregon (ex officio) 

DIANA DEGETTE, Colorado 

Ranking Member 

JANICE D. SCHAKOWSKY, Illinois 

KATHY CASTOR, Florida 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Tim Murphy, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 4 

Hon. Greg Walden, a Representative in Congress from the State of Oregon, 

opening statement ................................................................................................ 6 

Prepared statement .......................................................................................... 7 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 8 

Prepared statement .......................................................................................... 10 

WITNESSES

Kemp L. Chester, Acting Director, Office of National Drug Control Policy ....... 12 

Prepared statement .......................................................................................... 15 

Additional information for the record ............................................................. 127 

Answers to submitted questions ...................................................................... 163 

Louis J. Milione, Assistant Administrator, Diversion Control Division, Drug 

Enforcement Administration ............................................................................... 26 

Prepared statement .......................................................................................... 28 

Answers to submitted questions ...................................................................... 172 

Matthew C. Allen, Assistant Director, Homeland Security Investigative Programs, Homeland Security Investigations, Immigration and Customs Enforcement, Department of Homeland Security .................................................. 38 

Prepared statement .......................................................................................... 40 

Answers to submitted questions ...................................................................... 188 

William R. Brownfield, Assistant Secretary of State for International Narcotics and Law Enforcement Affairs, Department of State .............................. 48 

Prepared statement .......................................................................................... 50 

Answers to submitted questions ...................................................................... 211 

Debra Houry, M.D., Director, National Center for Injury Prevention and 

Control, Centers for Disease Control and Prevention ....................................... 57 

Prepared statement .......................................................................................... 59 

Answers to submitted questions ...................................................................... 219 

Wilson M. Compton, M.D., Deputy Director, National Institute on Drug 

Abuse, National Institutes of Health, Department of Health and Human 

Services ................................................................................................................. 72 

Prepared statement .......................................................................................... 74 

Answers to submitted questions ...................................................................... 227 

SUBMITTED MATERIAL

Subcommittee memorandum .................................................................................. 129 

Article of December 13, 2016, ‘‘Where opiates killed the most people in 2015,’’ 

by Christopher Ingraham, Wonkblog, The Washington Post, submitted by 

Mr. Murphy .......................................................................................................... 143 

Letter of March 21, 2017, from Acadia Healthcare, et al., to Hon. Paul 

Ryan and Hon. Nancy Pelosi, submitted by Mr. Tonko .................................... 151 

Letter of March 20, 2017, from Michael Seville, Executive Director, Oregon 

AFSCME Council 75, to Mr. Murphy and Ms. DeGette, submitted by Ms. 

DeGette ................................................................................................................. 161 

(1) 

FENTANYL: THE NEXT WAVE OF THE OPIOID 

CRISIS 

TUESDAY, MARCH 21, 2017 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:20 a.m., in Room 

2123 Rayburn House Office Building, Hon. Tim Murphy (chairman 

of the subcommittee) presiding. 

Members present: Representatives Murphy, Griffith, Barton, 

Burgess, Brooks, Collins, Walberg, Walters, Costello, Carter, Bilirakis, Walden (ex officio), DeGette, Schakowsky, Castor, Tonko, 

Peters, and Pallone (ex officio). 

Staff present: Jennifer Barblan, Chief Counsel, Oversight and Investigations; Elena Brennan, Legislative Clerk, Oversight and Investigations; Adam Buckalew, Professional Staff Member, Health; 

Karen Christian, General Counsel; Zachary Dareshori, Staff Assistant; Jordan Davis, Director of Policy and External Affairs; Paige 

Decker, Executive Assistant and Committee Clerk; Scott 

Dziengelski, Policy Coordinator, Oversight and Investigations; Brittany Havens, Professional Staff, Oversight and Investigations; Alex 

Miller, Video Production Aide and Press Assistant; David Schaub, 

Detailee, Oversight and Investigations; Jennifer Sherman, Press 

Secretary; Alan Slobodin, Chief Investigative Counsel, Oversight 

and Investigations; Hamlin Wade, Special Advisor for External Affairs; Jeff Carroll, Minority Staff Director; Waverly Gordon, Minority Counsel, Health; Christopher Knauer, Minority Oversight Staff 

Director; Miles Lichtman, Minority Staff Assistant; Kevin McAloon, 

Minority Professional Staff Member; Jon Monger, Minority Counsel; Dino Papanastasiou, Minority GAO Detailee; and C.J. Young, 

Minority Press Secretary. 

OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA 

Mr. MURPHY. Good morning. Welcome to this hearing called 

‘‘Fentanyl: The Next Wave of the Opioid Crisis.’’ 

America is in a full-on opioid crisis. About two decades ago, it 

started with the over prescribing of opioid drugs and then shifted 

more to heroin. Today, thesubcommittee examines the next wave of 

the opioid crisis, an even more dangerous threat on our streets— 

fentanyl. 

2 

Fentanyl is made in the lab and for many years it has been a 

powerful pain medicine used by patients with cancer or for those 

with extreme pain. 

I might add to this, I remember when I was injured in Iraq a 

few years ago, battlefield medicine meant in recovery they gave me 

lots of fentanyl patches, and I know what it is like to have the reaction to that. 

It is 50 times more potent than heroin and 100 times more potent than morphine. Now illicit fentanyl has become a potent additive to heroin, cocaine, or even counterfeit prescription drugs. 

This is the way the drug dealers increase profits: Stretch out 

their supply and expand the number of addicts by juicing the potency of heroin or other street drugs, sort of what people have done 

with MSG in foods. 

Users often don’t even know that fentanyl is in the heroin. The 

fentanyl crisis is exceptionally dangerous because of its high potency and the speed with which it reaches the brain. Just 2 milligrams of fentanyl can kill, whether swallowed, inhaled, or absorbed 

through skin. 

To appreciate how small an amount 2 milligrams is: A sweetener 

packet that you see at your restaurant table is about 1,000 milligrams. Two milligrams of fentanyl can kill you. 

Those suffering from an overdose involving fentanyl may require 

both higher doses and multiple administrations of naloxone to reverse the overdose and to become stabilized. Even the police and 

first responders are at risk from inadvertently touching or inhaling 

fentanyl powder at a crime scene or helping an overdose victim. 

In March 2015, the Drug Enforcement Administration, or DEA, 

issued a nationwide alert on fentanyl as a threat to health and 

public safety. 

A year later, the DEA sent another alert, calling the spike in 

fentanyl seizures an unprecedented threat. Customs and Border 

Protection data shows an 83-fold increase in the amount of fentanyl 

seized in 3 years. 

An added challenge is that there are many chemical variations 

of fentanyl, commonly referred to as analogues. There are about 30 

known analogues. 

However, only 19 of these analogues are controlled substances 

under Federal law. Since 2013, fentanyl overdoses and deaths have 

surged with no end in sight. Fentanyl and its analogues have contributed to at least 5,000 overdose deaths in the United States, including the death of music star Prince last year. In my district 

alone, fentanyl-related deaths have exploded since 2014. 

Last year, 86 people in Westmoreland County died from drug 

overdoses linked at least in part to fentanyl, and even these statistics seriously undercut the fentanyl threat nationally because most 

States and localities are not testing or tracking fentanyl in drug 

overdose cases. So we are flying blind. 

At this rate, the capacity of law enforcement and the healthcare 

system will be overwhelmed. China is the primary source of 

fentanyl, and there are thousands of labs making illicit pure 

fentanyl as well as the source of ingredients or precursors needed 

to manufacture fentanyl. 

3 

Traffickers ship these ingredients to secret labs in Mexico run by 

drug cartels and then smuggle pounds of fentanyl over the Southwest border through our porous borders, launching it through catapults or drones and into the U.S. 

Chinese labs are also a primary source for fentanyl ordered on 

the open internet and on the dark web. Pure fentanyl is delivered 

through the mail or air express carriers. 

Finally, China is the main source of pill presses that can make 

thousands of pills an hour to support fentanyl press mill operations. I might add here I am pleased that China is saying that 

they are taking some action in helping to reduce this and we look 

forward to working with them because it is so deadly. 

The fentanyl problem is spreading and going to get worse because the money and profit is enormous. According to the data 

from the DEA, a kilogram of heroin can be purchased for roughly 

$6,000 and sold wholesale for $80,000. 

However, a kilogram of pure fentanyl can be purchased for less 

than $5,000 and is so potent that it can be stretched into 16 to 24 

kilograms of product when using cutting agents such as talcum 

powder or caffeine. 

Therefore, while each kilogram of fentanyl can be sold wholesale 

for $80,000, it can result in a total profit in the neighborhood of 

$1.6 million. That is about 20 times more profit. 

We need a Federal strategy dedicated to combating fentanyl as 

the clear and present danger it presents to our national security 

and public health. 

We welcome our panel of witnesses today. We salute you for your 

work, thank you for appearing today, and look forward to working 

together to stop the spread of this epidemic. 

[The prepared statement of Mr. Murphy follows:] 

PREPARED STATEMENT OF HON. TIM MURPHY

America is in a full-on opioid crisis. About two decades ago, it started with the 

overprescribing of opioid drugs and then shifted more to heroin. Today the subcommittee examines the next wave of the opioid crisis, an even more dangerous 

threat on our streets—fentanyl. 

The surge of fentanyl is having a dramatic and deadly effect on our communities. 

We all see the headlines-these are our neighbors, our families, our friends. We need 

an ‘‘all hands on deck approach’’ to fight this problem, which will involve not just 

the Federal Government, but States, localities, and even international partners. 

Fentanyl is made in a lab. For many years, it has been a powerful pain medicine 

used by patients with cancer or for those with extreme pain. It is about 50 times 

more potent than heroin and 100 times more potent than morphine. 

Now illicit fentanyl has become the MSG of narcotics, a potent additive to heroin, 

cocaine, or even counterfeit prescription drugs. This is the way the drug dealers increase profits, stretch out their supply, and expand the number of addicts by juicing 

the potency of heroin or other street drugs. Users often don’t even know that 

fentanyl is in the drugs they are buying. 

The fentanyl crisis is exceptionally dangerous because of its high potency and the 

speed with which it reaches the brain. Just 2 milligrams of fentanyl can kill, whether swallowed, inhaled, or absorbed through skin. To appreciate how small an 

amount 2 milligrams is, a sweetener packet at a restaurant table contains 1,000 

milligrams. 

Those suffering from an overdose involving fentanyl may require both higher 

doses and multiple administrations of naloxone to reverse the overdose and to become stabilized. Even the police and first responders are at risk from inadvertently 

touching or inhaling fentanyl powder at a crime scene or helping an overdose victim. 

4 

An added challenge is that there are many chemical variations of fentanyl—commonly referred to as analogues. There are about 30 known analogues, however only 

19 of these analogues are controlled substances under Federal law. 

Since 2013, fentanyl overdoses and deaths have surged with no end in sight. 

Fentanyl and its analogues have contributed to at least 5,000 overdose deaths in 

the United States, including the death of music star Prince last year. In my district 

alone, fentanyl-related deaths have exploded since 2014. Last year, 86 people in 

Westmoreland County died from drug overdoses linked at least in part to fentanyl. 

Even these statistics seriously undercount the fentanyl threat nationally because 

most States and localities are not testing or tracking fentanyl in drug overdose 

cases. At this rate, the capacity of law enforcement and the healthcare system will 

be overwhelmed. 

China is the primary source of fentanyl. There are thousands of labs making illicit 

pure fentanyl as well as the source of ingredients or precursors needed to manufacture fentanyl. Traffickers ship these ingredients to secret labs in Mexico run by drug 

cartels and then smuggle pounds of fentanyl over the southwest border into the U.S. 

Chinese labs are also a primary source for pure fentanyl ordered on the open internet and on the dark web and delivered through the mail or air express carriers. Finally, China is the main source of pill presses that can make thousands of pills an 

hour to support fentanyl press mill operations. 

The fentanyl problem is spreading and going to get worse because the money and 

profit is enormous. According to data from the DEA, a kilogram of heroin can be 

purchased for roughly $6,000 and sold wholesale for $80,000. However, a kilogram 

of pure fentanyl can be purchased for less than $5,000 and is so potent that it can 

be stretched into 16 to 24 kilograms of product when using cutting agents such as 

talcum powder or caffeine. Each kilogram of cut fentanyl can besold wholesalefor 

$80,000, resulting in a total profit in the neighborhood of $1.6million. That is 

about20 times more profit than heroin. 

We need a Federal strategy dedicated to combattingfentanylas the clear 

andpresent danger it presents to our national security and publichealth. 

We welcome our panel of witnesses today. We salute you for your work, thank 

youforappearing today, and look forward to working together to stop the spread of 

thisepidemic. 

Mr. MURPHY. Now I recognize my friend from Colorado, Ms. 

DeGette. 

OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO 

Ms. DEGETTE. Thank you so much, Mr. Chairman. 

Every day somewhere in this country there is a news account 

about how opiate addiction has wrecked a small town or family. 

Personal stories about Americans who have become addicted to 

pain pills and then they get hooked on heroin. 

These are heartbreaking stories about Americans dying and leaving loved ones, often their children, to pick up the pieces. The 

opioid epidemic is unprecedented and it is escalating, and I think 

we all agree that we need a comprehensive strategy to confront it. 

In 2015, more than 33,000 Americans died of an overdose involving a prescription or illicit opioid and more than 2 million people 

had an opioid use disorder. 

Fentanyl is, of course, an even deadlier layer to this crisis. It can 

be up to 50 times more potent than heroin and a 100 times more 

potent than morphine. It’s lethal at even the tiniest amounts and 

anyone exposed to it can be—can have its detriments. 

You know, illicit fentanyl is not a new problem. What is new, 

though, is its growing prevalence. Since 2010, that number covered 

by American law enforcement nationwide has risen twentyfold, 

from 640 samples tested to 13,000 samples tested in 2015, according to information from the DEA. 

5 

U.S. law enforcement, as the chairman said, believes China is 

the primary source of illicit fentanyl and precursor chemicals. Chinese producers ship fentanyl or chemicals to make it directly into 

the United States. 

Precursor chemicals, or finished fentanyl, is shipped to Mexico 

and Canada where it is trafficked across our borders in pure form 

or is mixed with other illicit drugs like heroin. 

Today, we want to ask the panel some tough questions about law 

enforcement and diplomatic efforts to stem the tide of fentanyl 

flowing from China and whether they are sufficient. 

We are also going to ask which vectors drug traffickers use to 

ship this drug into our country, like express consignment carriers 

and international mail. 

I think this is another important step that this subcommittee 

had been taking to address the opioid epidemic, and for the record 

I want to continue this bipartisan work. 

That said, Mr. Chairman, I also think we need to find a way to 

address the treatment side of this epidemic and this is, sadly, 

where I have significant differences with my majority colleagues. 

Passage of the Affordable Care Act, as you know, has led to nearly 20 million Americans gaining healthcare coverage. In addition, 

the ACA has enabled Governors to expand the Medicaid services 

they offer, which was critical in States that were overwhelmed by 

the opioid epidemic. 

Studies estimate that, since 2014, 1.6 million uninsured Americans gained access to substance abuse treatment across the 31 

States like mine that expanded Medicaid coverage. 

This is particularly important for hard-hit States like Kentucky, 

where one study reports that residents saw a 700 percent increase 

in Medicaid beneficiaries seeking treatment for substance use. 

Two weeks ago, the majority rushed through this committee a 

bill to repeal the ACA that many believe will threaten the progress 

that Medicaid expansion has made in getting people suffering from 

addiction into treatment. 

In its assessment of that bill last week, the Congressional Budget 

Office said that millions of Americans—24 million of them—will 

lose health coverage. 

Many of those will be people currently receiving Medicaid assistance which include people receiving treatment for opioid addiction. 

In January, healthcare experts from Harvard and NYU wrote 

and op-ed for the Hill about how repealing the ACA would reverse 

important public health gains. They focused primarily on my baby, 

the 21st Century Cures Act which I did with Fred Upton and all 

of this whole committee. We approved it unanimously. 

But it really—we can have a whole hearing just about how badly 

the GOP’s ACA repeal bill will hamper the progress that we just 

passed in 21st Century Cures. 

I just want to draw attention to one part of this op-ed, though, 

where they authors wrote ‘‘repealing the ACA and its behavioral 

health provisions would have stark effects on those with behavioral 

health illnesses. We estimate that approximately 1,253,000 people 

with serious mental disorders and about 2.8 million Americans 

with a substance abuse disorder of whom about 222,000 have an 

opioid disorder would lose some or all of their insurance coverage.’’ 

6 

The end of the day, we don’t know what kind of bill is going to 

reach the president’s desk. But if we really want to address the 

opioid crisis, I suggest that we don’t pass this very poorly thought 

out piece of legislation. 

I yield back. 

Mr. MURPHY. Gentlelady yields back. 

I now recognize the chairman of the full committee, Mr. Walden, 

for 5 minutes. 

OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON 

Mr. WALDEN. I thank the gentleman and I thank you for holding 

this very important hearing. 

The opioid crisis, as we know, has touched every corner of our 

Nation. Just like my colleagues, I have met with community leaders, physicians, first responders, law enforcement and families on 

this issue. 

Each have shared their heartbreaking stories on the effects of 

this crisis in our communities. You see, addiction doesn’t understand politics. It doesn’t understand income. It doesn’t understand 

race or where someone’s from. It is an equal opportunity destroyer. 

This crisis has hit close to home for all of us. 

Last Congress, this committee worked in a bipartisan way to advance sweeping legislation to fight the Nation’s opioid epidemic. It 

was an effort that actually began in this subcommittee, which held 

a series of hearings that examined the growing problems of prescription drug and heroin abuse. 

We should be proud of those efforts but as we will discuss today 

there is a new threat emerging. Last year, there were encouraging 

reports that showed that the number of prescriptions for opioids in 

the United States had finally declined. That was good news. For 

the first time in 20 years that had happened. Yet, we saw the number of opioid-related overdoses and overdose-related deaths continuing to surge upward and we ask why. 

That is why we are having the hearing today. Emerging data 

strongly suggests the main driver is fentanyl and its chemical variations. Fentanyl essentially represents a third wave in the Nation’s 

ongoing opioid crisis. It is why we are here. 

Fentanyl is a more challenging threat within the opioid crisis in 

comparison to threats of prescription opioids and heroin. The 

fentanyl threat is multifaceted. It’s been produced as a legitimate 

pain medication by drug companies for decades but it is also produced illicitly in black market operations in China. 

Illicit fentanyl is hard to detect and, unlike prescription pain killers, it is not primarily diverted from the legitimate market nor is 

it strictly comparable to the black market of heroin. It can be purchased over the internet openly or on the dark web. 

Precursor chemicals used to make fentanyl are produced in 

China and shipped to clandestine labs in Mexico. Drug cartels are 

smuggling massive amounts of fentanyl with other narcotics from 

Mexico across the Southwest border. 

Drug traffickers in the United States not only are getting deliveries of fentanyl from China through the mail or express carriers 

but they are also getting direct or indirect shipments from China 

7 

of pill presses that can make thousands of pills an hour to fuel 

their operations and distribution networks into our towns, our communities, and the lives of our citizens. 

Pure fentanyl is not considered a replacement drug for 

OxyContin or heroin. It is too potent. Just 2 to 3 milligrams can 

kill an individual, and has. 

More often than not, it is added in to heroin, cocaine, or counterfeit drugs to boost the potency and increase the likelihood of addiction. What’s even scarier is people taking these drugs may not even 

know that they are taking fentanyl, let alone what it is. 

Fentanyl makes the deadly threat of opioid abuse even deadlier. 

In 2014 and 2015 in my home State of Oregon, a reported 49 people died from fentanyl. The number of deaths from fentanyl appears to be rising, and that is just what we know. 

As we work to combat this quickly evolving public health threat, 

there is an important question to be asked—how can we fight this 

threat when we don’t even know how quickly it is spreading. 

Combating this growing multi-faceted fentanyl threat will require more than drug control strategies aimed at opioid overprescribing and heroin. 

Fentanyl is a global problem that requires an urgent response. 

I commend the efforts of our Government, ONDCP, DEA, and the 

State Department particularly for their success in gaining cooperation with China and the United Nations. We need to continue and 

support this international engagement to be successful. 

Like our work on the opioid epidemic last Congress, combating 

fentanyl truly requires an all-hands-on-deck effort. We need to 

think outside the box to find ways to stop the surge of the fentanyl 

crisis, and I look forward to your testimony and working with all 

of you to solve this problem. 

[The prepared statement of Mr. Walden follows:] 

PREPARED STATEMENT OF HON. GREG WALDEN

The opioid crisis has touched every corner of our Nation. Just like my colleagues, 

I have met with community leaders, physicians, first responders, law enforcement, 

and families on this issue. Each have shared heartbreaking stories on the effects 

of this crisis in our communities. You see, addiction doesn’t understand politics. It 

doesn’t understand income, race, or where someone is from. It is an equal opportunity destroyer. This crisis has hit close to home for each of us. 

Last Congress, this committee worked in a bipartisan way to advance sweeping 

legislation to fight the Nation’s opioid epidemic. It was an effort that actually began 

in this subcommittee, which held a series of hearings that examined the growing 

problems of prescription drug and heroin abuse. We should be proud of those efforts. 

But as we will discuss today, there is a new threat emerging. 

Last year, there were encouraging reports that showed that the number of prescriptions for opioids in the United States finally declined—for the first time in 20 

years. Yet, we saw the number of opioid-related overdoses and overdoserelated 

deaths continuing to surge upward. Why? 

Emerging data strongly suggest the main driver is fentanyl, and its chemical variations. Fentanyl essentially represents a third wave in the Nation’s ongoing opioid 

crisis. It’s why we are here today. 

Fentanyl is a more challenging threat within the opioid crisis, in comparison to 

the threats of prescription opioids and heroin. The fentanyl threat is multi-faceted. 

It has been produced as a legitimate pain medication by drug companies for decades. But it is also produced illicitly in black market operations in China. Illicit 

fentanyl is hard to detect, and unlike prescription painkillers it is not primarily diverted from the legitimate market. Nor is it strictly comparable to the black market 

of heroin. It can be purchased over the internet openly, or on the dark web. Precursor chemicals used to make fentanyl are produced in China, and shipped to clanVerDate Mar 15 2010 10:21 Feb 27, 2018 Jkt 037690 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 I:\115THCONGRESS\115X16FENTANYLSCANS021618\115X16FENTANYLWORKING WA
8 

destine labs in Mexico. Drug cartels are smuggling massive amounts of fentanyl 

with other narcotics from Mexico across the Southwest border. Drug traffickers in 

the U.S. not only are getting deliveries of fentanyl from China through the mail or 

air express carriers, but they are also getting direct or indirect shipments from 

China of pill presses that can make thousands of pills an hour to fuel their operations and distribution networks into our towns and communities. 

Pure fentanyl is not considered a replacement drug for OxyContin or heroin. It 

is too potent. Just 2 to 3 milligrams can kill an individual. More often than not, 

it is added into heroin, cocaine, or counterfeit drugs to boost the potency and increase the likelihood of addiction. What’s even scarier is people taking these drugs 

may not even know that they are taking fentanyl, let alone what it is. 

Fentanyl makes the deadly threat of opioid abuse even deadlier. In 2014 and 2015 

in my home State of Oregon, a reported 49 people died from fentanyl. The number 

of deaths from fentanyl appears to be rising, and that’s just what we know. As we 

work to combat this quickly evolving public health threat, there’s an important 

question to be asked. How can we fight this threat when we don’t even know how 

quickly it is spreading? 

Combating this growing, multi-faceted fentanyl threat will require more than the 

drug-control strategies aimed at opioid overprescribing and heroin. Fentanyl is a 

global problem that requires an urgent response. I commend the efforts of our Government, ONDCP, DEA, and the State Department, particularly, for their success 

in gaining cooperation with China and the United Nations. We need to continue and 

support this international engagement to be successful. Like our work on the opioid 

epidemic last Congress, combating fentanyl truly requires an allhands- on-deck effort. 

We need to think outside the box to find ways to stop the surge of the fentanyl 

crisis. I look forward to your testimony, and working with all of you to solve 

thisproblem. 

Mr. WALDEN. And I yield the balance of my time to the gentleman, the chairman of the Health Subcommittee, Mr. Burgess. 

Mr. BURGESS. Thank you, Mr. Chairman, and thank you, Mr. 

Chairman, for holding the hearing. 

I want to thank the DEA. Mr. Milione, I think you have been in 

to my office to talk about this issue in the past one on one. It is 

of concern to me. 

You know, I have been on the Health Subcommittee long enough 

that in 2005 we were having a hearing about why doctors weren’t 

prescribing adequately for pain, and now the past two Congresses 

we have been concerned about the appearance of the opioid epidemic. 

Fentanyl is not a new product. It has been around for some time. 

But on the other hand, the analogues of fentanyl are relatively new 

and it is the fueling of the illicit trade with the ability to get things 

over the internet, which I think has been probably been the crux 

of this problem. 

We do have problems with the overseas market with the way the 

supply comes in to our country. 

So I hope that we can hear some insight this morning on perhaps 

some additional things that might be done to stop that flow. 

Thank you, Mr. Chairman, and I will yield back—yield back to 

the gentleman from Oregon, who then yields back, correct? 

Mr. MURPHY. Thank you. The gentleman’s time has expired. 

I recognize the ranking member of the committee, Mr. Pallone, 

for 5 minutes. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. 

9 

The opioid epidemic in our country continues to grow at an 

alarming rate. In 2015, more than 33,000 Americans died of an 

opioid overdose and more than 2 million individuals have an opioid 

use disorder. According to the Center for Disease Control, 91 Americans die every day from an opioid overdose. 

Today we are focusing on fentanyl, a powerful synthetic opioid 

that is 50 times more potent than heroin and up to a hundred 

times more potent than morphine. 

Because of its potency, fentanyl is a dangerous substitute for heroin and it results in frequent overdoses that can cause respiratory 

depression and even death. 

The number of overdose deaths is rapidly increasing and the 

death rate from synthetic opioids other than methadone increased 

by 72 percent from 2014 to 2015. 

This substantial increase in the death rate from synthetic opioids 

is largely attributable to the increased availability of illicit 

fentanyl. 

I want to thank our witnesses today for their testimony and work 

on this very important issue. Fentanyl is dangerous not only to 

users but also to our law enforcement and public health officials on 

the front lines of this epidemic and I look forward to working together to explore ways that we can better confront the supply of 

the fentanyl now plaguing our communities. 

I also would like to talk today about the treatment side of the 

opioid epidemic. Just two weeks ago committee Republicans rushed 

Trumpcare through the committee, a bill which repeals the Affordable Care Act. The ACA has been instrumental in addressing the 

current opioid crisis and, inexcusably, Trumpcare would only exacerbate the crisis. 

Thanks to Medicaid expansion under the ACA, 1.6 million people 

with substance use disorders now can receive the treatment they 

need in the 31 States and Washington, DC, that expanded the program. 

But Trumpcare effectively ends Medicaid expansion in 2020. According to the CBO, Trumpcare also cuts $880 billion in Federal 

outlays for Medicaid over the next 10 years, which will severely undermine our efforts to fight the opioid crisis. 

These drastic cuts in Medicaid made possible by Republican 

plans to end Medicaid expansion in the CAPTA program will ration 

care for millions of Americans including the rationing of substance 

abuse treatment. 

Trumpcare also repeals the central health benefits for Medicaid 

expansion enrollees at the end of 2019. States would no longer 

have to offer benefits like substance abuse, mental health services 

or prescription drugs to millions of Americans who rely on such 

care. 

Repealing the essential benefits packages effectively repeals the 

mental and substance use disorder coverage provisions of the ACA 

and would remove approximately $5.5 billion annually from the 

treatment of low-income people with mental and substance use disorders. 

Repeal will take away care from those who are actively seeking 

treatment and preventive services and we simply cannot afford to 

eliminate this care in what is oftentimes a life and death situation. 

10 

Trumpcare threatens access to lifesaving treatment for more 

than 1 million people with opioid disorders. 

Our hearing today explores the fentanyl problem. However, I 

would argue that this issue is a part of a much wider opioid problem that we are battling. 

To address this properly, we must make sure Americans with 

substance abuse disorders can access effective treatment. 

And so, Mr. Chairman, I want to work with you to confront 

fentanyl and the larger opioid problem. However, in my opinion, repealing the ACA and cutting Medicaid by nearly a trillion dollars 

over the next 10 years will do nothing but undermine our efforts 

to treat Americans who are suffering from opioid addiction. We will 

not be able to arrest our way out of this problem. 

Without adequate treatment options for those suffering from an 

opioid addiction, this problem will only worsen and so will the 

deaths and destruction we have seen play out across the United 

States. 

I don’t know if anybody wants my extra minute. If not, I will 

yield back. 

[The prepared statement of Mr. Pallone follows:] 

PREPARED STATEMENT OF HON. FRANK PALLONE, JR. 

Mr. Chairman, the opioid epidemic in our country continues to grow at an alarming rate. In 2015, more than 33,000 Americans died of an opioid overdose, and more 

than 2 million individuals had an opioid use disorder. According to the Center for 

Disease Control, 91 Americans die every day from an opioid overdose. 

Today we are focusing on fentanyl, a powerful synthetic opioid that is 50 times 

more potent than heroin and up to 100 times more potent than morphine. 

Because of its potency, fentanyl is a dangerous substitute for heroin and results 

in frequent overdoses that can cause respiratory depression and even death. The 

number of overdose deaths is rapidly increasing. 

The death rate from synthetic opioids, other than methadone, increased by 72 percent from 2014 to 2015. This substantial increase in the death rate from synthetic 

opioids is largely attributable to the increased availability of illicit fentanyl. 

I want to thank our witnesses today for their testimony and work on this very 

important issue. Fentanyl is dangerous not only to users, but also to our law enforcement and public health officials on the front lines of this epidemic. 

And I look forward to working together to explore ways that we can better confront the supply of the fentanyl now plaguing our communities. 

I would also like to talk today about the treatment side of the opioid epidemic. 

Just two weeks ago, committee Republicans rushed TrumpCare through the committee, a bill which repeals the Affordable Care Act. The ACA has been instrumental in addressing the current opioid crisis, and, inexcusably, TrumpCare would 

only exacerbate the crisis. 

Thanks to Medicaid Expansion under the ACA, 1.6 million people with substance 

use disorders now can receive the treatment they need in the 31 States and Washington, DC, that expanded the program. TrumpCare effectively ends Medicaid Expansion in 2020. 

According to the Congressional Budget Office, TrumpCare also cuts $880 billion 

in Federal outlays for Medicaid over the next 10 years, which will severely undermine our efforts to fight the opioid crisis. These drastic cuts in Medicaid, made possible by Republican plans to end Medicaid Expansion and to cap the program, will 

ration care for millions of Americans, including the rationing of substance abuse 

treatment. 

TrumpCare also repeals Essential Health Benefits for Medicaid expansion enrollees at the end of 2019. States would no longer have to offer benefits like substance 

abuse, mental health services or prescription drugs to millions of Americans who 

rely on such care. 

Repealing the mental and substance use disorder coverage provisions of the ACA 

would remove approximately $5.5 billion annually from the treatment of low income 

people with mental and substance use disorders. 

11 

Repeal will take away care from those who are actively seeking treatment and 

preventive services. We simply cannot afford to eliminate this care in what is oftentimes a life and death situation. TrumpCare, threatens access to life-saving treatment for more than one million people with opioid disorders. 

Our hearing today explores the fentanyl problem. However, I would argue that 

this issue is a part of a much wider opioid problem we are battling. To address this 

problem, we must make sure Americans with substance abuse disorders can access 

effective treatment. 

Mr. Chairman, I want to work with you to confront fentanyl and the larger opioid 

problem. However, repealing the ACA and cutting Medicaid by nearly a trillion dollars over the next 10 years, will do nothing but undermine our efforts to treat Americans who are suffering from an opioid addiction. 

We will not be able to arrest our way out of this problem. Without adequate treatment options for those suffering from an opioid addiction, this problem will only 

worsen, and so will the deaths and destruction we have seen play out across the 

U.S. 

Thank you, and I yield back. 

Mr. MURPHY. I thank the gentleman. Yields back. 

For a minute, I want to offer for the record, if unanimous consent, an article from the Washington Post called ‘‘Where opiates 

killed the most people in 2015.’’ It has interesting maps of where 

these occur throughout the country. 

[The information appears at the conclusion of the hearing.] 

Mr. MURPHY. For example, synthetic opioid rates in Ohio, West 

Virginia, and Kentucky, and pockets in New Hampshire, Massachusetts, Rhode Island, and other aspects, which kind of tell us 

that there is not one opiate epidemic but several, and no silver bullet. 

We are going to have to make sure whatever this committee does 

and finds today from our esteemed witnesses, we are going to have 

to work in a way to give flexibility—maximum flexibility to States 

to work this out. 

I ask unanimous consent that the Members’ written opening 

statements be introduced in the record, and without objection those 

documents will be entered in the record. 

Now I’d like to introduce our panel of Federal witnesses for today’s hearing. We will start with Mr. Kemp Chester, Acting Deputy 

Director in the Office of National Drug Control Policy; Mr. Louis 

Milione, assistant administrator at the Diversion Control Division 

within the Drug Enforcement Administration, or DEA; Mr. Matthew Allen, Assistant Director of Homeland Security Investigative 

Programs at the U.S. Immigration and Customs Enforcement Division within the Department of Homeland Security, or DHS; the 

Honorable William Brownfield, Assistant Secretary of State, International Narcotics and Law Enforcement Affairs of the U.S. Department of State; Dr. Debra Houry, Director, National Center for 

Injury Prevention and Control at the Centers for Disease Control 

and Prevention; and Dr. Wilson Compton, Deputy Director at the 

National Institute on Drug Abuse within the National Institutes of 

Health. 

I want to thank all our witnesses today for being here and providing testimony. We look forward to a very productive hearing. 

Let me charge you with this, though, which I usually don’t do. 

More people are dying of drug overdose deaths than of guns. 

We have reached the point where more people are dying of drug 

overdose deaths than deaths in the entire Vietnam War, almost in 

a per-year basis. 

12 

What you are going to tell us today is falling on ears that are 

open to anything you can offer us. The families in America—and 

you have heard the stories, impassioned stories from Members 

here—stories of the deep concerns of the number of the deaths, the 

devastation in communities—what you’re saying here is extremely 

important. 

So we look forward to hearing from you on this growing threat 

of fentanyl- and opioid-related deaths. 

So as you are aware, this committee is holding an investigative 

hearing, and when doing so it is our practice of taking testimony 

under oath. 

Do any of you have any objection to giving testimony under oath? 

Seeing no objections, the Chair then advises you are under the 

rules of the House and rules of the committee. You’re entitled to 

be advised by counsel. 

Do any of you desire to be advised by counsel during your testimony today? Seeing none, in that case, will you all please rise and 

raise your right hand and I’ll swear you in. 

[Witnesses sworn.] 

Thank you. You are all sworn in. You are now under oath and 

subject to the penalties set forth in Title 18 Section 1001, the 

United States Code. 

I will call upon you each to give a 5-minute summary of your 

written statement. Just watch the lights there and you’ll have a 

sense of that. 

I’ll begin with Mr. Chester. You are recognized for 5 minutes. 

STATEMENTS OF KEMP L. CHESTER, ACTING DIRECTOR, OFFICE OF NATIONAL DRUG CONTROL POLICY; LOUIS J. 

MILIONE, ASSISTANT ADMINISTRATOR, DIVERSION CONTROL DIVISION, DRUG ENFORCEMENT ADMINISTRATION; 

MATTHEW C. ALLEN, ASSISTANT DIRECTOR, HOMELAND SECURITY INVESTIGATIVE PROGRAMS, HOMELAND SECURITY 

INVESTIGATIONS, IMMIGRATION AND CUSTOMS ENFORCEMENT, DEPARTMENT OF HOMELAND SECURITY; WILLIAM R. 

BROWNFIELD, ASSISTANT SECRETARY OF STATE FOR 

INTERNATIONAL NARCOTICS AND LAW ENFORCEMENT AFFAIRS, DEPARTMENT OF STATE; DEBRA HOURY, M.D., DIRECTOR, NATIONAL CENTER FOR INJURY PREVENTION AND 

CONTROL, CENTERS FOR DISEASE CONTROL AND PREVENTION; WILSON M. COMPTON, M.D., DEPUTY DIRECTOR, NATIONAL INSTITUTE ON DRUG ABUSE, NATIONAL INSTITUTES 

OF HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES 

STATEMENT OF KEMP L. CHESTER 

Mr. CHESTER. Chairman Murphy, Ranking Member DeGette and 

members of the subcommittee, thank you for inviting me and my 

interagency colleagues to discuss the public health and public safety issues surrounding the opioid epidemic, particularly that of illicit 

fentanyl and what the Federal Government is doing to address this 

problem. 

I appreciate the committee’s strong support of our work to reduce 

drug use and its consequences. I currently serve as the acting director of the Office of National Drug Control Policy, which crafts 

13 

the president’s drug control policy and oversees all Federal Government counter drug activities and related funding. 

This is a critical mission because, as you are aware, more than 

52,000 Americans died from a drug overdose in 2015. That’s an average of 144 per day with 91 of those deaths involving opioids such 

as prescription pain medications, heroin and illicit fentanyl. 

Overdoses involving opioids have nearly quadrupled since 2000 

and between 2013 and 2015 the number of deaths involving synthetic opioids other than methadone, a statistical category that includes fentanyl, has more than tripled, reaching nearly 10,000 in 

2015, and this number is likely low because not every overdose 

death investigation looks for fentanyl. 

The majority of the illicit fentanyl in the U.S. is smuggled in 

after being produced in Mexico or China. Both heroin and clandestinely produced fentanyl can be manufactured, packaged and smuggled by the same drug trafficking organization. 

The reemergence of illicit fentanyl represents a complex problem. 

It is considerably more powerful than heroin, its precursor chemicals are not fully controlled in other countries. 

It’s being added into the heroin supply or pressed into counterfeit 

prescription opioid pain pills, meaning users are often unaware 

they are taking fentanyl, and because of its potency it can be 

shipped in small packages and transactions then involve relatively 

low dollar amounts, making it much harder to detect. 

First responders and police officers report that they need to use 

much more than the standard dose of naloxone to reverse an overdose caused by fentanyl, which strains resources. 

We also have a limited capacity to treat those who habitually use 

illicit opioids. Only one in nine people in the U.S. who need treatment are receiving it, and we have seen outbreaks in many States 

where fentanyl, carfentanil and other fentanyl analogues have 

played a role in the wave of overdose deaths that devastate communities. 

In short, illicit fentanyl is exacerbating an already challenging 

problem that the Federal Government is working extremely hard 

to address. 

The reality of this epidemic has led us to adopt new ways of addressing drug use and trafficking. That’s why the heart of our effort is the partnership between public health and law enforcement, 

some of whom are represented here today, to help address the 

problem in communities across the country. 

We are also working with our State Department colleagues to engage foreign partners to prevent illicit drugs from being manufactured and trafficked into the United States. 

In terms of public health, we are working to prevent new initiates to drug use by encouraging prescriber and public education, 

encouraging prescribes to use the CDC’s guidelines and their State 

prescription drug monitoring programs and emphasizing prevention efforts to deter drug use initiation, including ONDCP’s DrugFree Communities Program.We are also working to expand access 

to treatment including evidence-based medication assisted treatment for opioid use disorder and help people sustain long-term recovery. 

14 

In this regard, we deeply appreciate Congress’ support for treatment expansion through the funds authorized under the 21st Century Cures Act. 

Another critical innovation is that we are helping to build new 

partnerships between local law enforcement partners and the public health community to end this crisis and to establish routine cooperation between the Federal Government and the State, Tribal. 

and local levels. 

In terms of reducing the availability of these drugs in the United 

States, the Federal Government’s efforts are centered on stopping 

illicit drugs before they cross our borders and dismantling the organization that traffic drugs into and through our communities. 

Within ONDCP, the National Heroin Coordination Group was 

created in October 2015 in partnership with the National Security 

Council to synchronize Federal Government efforts to reduce the 

availability of heroin and illicit fentanyl across the country and address gaps in redundancies in department and agency activities 

through its interagency-coordinated Heroin Availability Reduction 

Plan, which addresses heroin and fentanyl as a single problem set. 

ONDCP also funds the High-Intensity Drug Trafficking Areas 

program that coordinates anti-trafficking efforts and intelligence 

across State, local, Tribal, and Federal law enforcement communities, and in 2015, ONDCP developed the Heroin HIDTA Response 

Strategy, a coordinated effort across 20 States and the District of 

Columbia in response to the heroin and fentanyl crisis. 

And internationally we are working with foreign partners like 

Mexico, China and Canada to reduce the supply of illicit fentanyl, 

its precursors and its analogues into and across North America. 

While we are working diligently to turn the tide on this epidemic, and perhaps are making some progress, we continue to work 

through numerous challenges such as detecting illicit fentanyl at 

our borders and in our mail and parcel system, working with our 

international partners to reduce the manufacturing and trafficking 

of heroin and fentanyl, and finding and disrupting the internet 

marketplaces where illicit fentanyl is purchased and delivered. 

Mr. MURPHY. Could you finish up because we are—— 

Mr. CHESTER. Yes, sir. 

As the Federal Government works to reduce the size of the 

opioid-using population through prevention and treatment and reduce the availability of these drugs in our communities, your support for these efforts is critical to our success. 

Thank you, and I look forward to answering your questions. 

[The prepared statement of Mr. Chester follows:] 

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Mr. MURPHY. Thank you, Mr. Chester. 

Mr. Milione, you’re recognized for 5 minutes. 

STATEMENT OF LOUIS MILIONE 

Mr. MILIONE. Thank you, Committee Chair Murphy, Ranking 

Member DeGette, distinguished members of the subcommittee. 

I want to put these overdose death numbers in some context. So 

spring is here today and major league baseball will kick off their 

season next month. 

Picture the MLB stadium in any of your respective cities. The 

more than 52,000 Americans we lost in 2015 to drug overdoses 

would overflow any of those MLB stadiums, bar none. 

I’m sure we all agree that this is an unimaginable tragedy. To 

the DEA, the fentanyl threat and the broader opioid epidemic are 

the number-one drug threats facing our country. 

With illicitly produced fentanyl, you have substances many times 

more potent than heroin, sold as heroin, mixed with heroin and, increasingly, pressed into pill form before being sold by criminal networks on our streets as prescription pain killers. 

There are five pills that represent five counterfeit pain killers. 

Based on laboratory analysis of the thousands of seized counterfeit 

pills, one of every five will contain three times the lethal amount 

of fentanyl—lethal at 2 milligrams, as was mentioned earlier. To 

the unsuspecting user, death is lurking in just one of these pills. 

Sadly, but not unexpectedly, Mexican cartels are exploiting the 

opioid use epidemic and aggressively purchasing illicitly produced 

fentanyl from China, shipping it to Mexico, mixing it with heroin 

and other substances and shipping it back into the United States 

through established distribution networks where it is sold in our 

communities. 

Illicitly made fentanyl is also being shipped from China into Canada for distribution across our northern border. It’s also being 

shipped directly from China into the United States for domestic 

distribution cells. 

Why are they doing this? Greed and a complete disregard for 

human life. There is a massive profit potential with fentanyl. One 

kilogram of pure fentanyl costs approximately in China about 

$3,500. 

If you project that kilogram of fentanyl all the way through the 

supply chain to the distribution level, that $3,500 kilogram will potentially yield millions of dollars in revenue. 

For the DEA and broader U.S. Government to deal successfully 

with this threat we need a balanced holistic approach that attacks 

supply and reduces demand. Most importantly, we must be 

proactive. 

We need to use any and all available investigative techniques to 

identify, infiltrate, indict, capture and convict all members of these 

criminal organizations both domestic and foreign. 

With 221 domestic offices in 21 field divisions and 92 foreign offices in 70 countries, DEA, working with our Federal, State, local, 

international partners is well positioned to engage in this fight. 

Throughout DEA’s proud history, our greatest successes have 

come from our collaborative efforts with the U.S. interagency and 

27 

our foreign counterparts. Our approach to this threat is no different. 

We have had success and we will continue to have successes 

against members of these fentanyl manufacturing and distribution 

networks. But here is the most frustrating part. 

Foreign-based fentanyl manufacturers and the domestic Pied 

Pipers of this poison often operate with impunity because they exploit loopholes in the analogue provisions of the Controlled Substances Act and capitalize on the lengthy resource-intensive reactive process required to temporarily or permanently schedule these 

dangerous substances. 

As we speak, criminal chemists in foreign countries are tweaking 

the molecular structure of different fentanyl analogues, keeping the 

same dangerous pharmacologic properties as the controlled substances but helping the manufacturers and distributors avoid 

criminal exposure because of an altered molecular structure. 

Since July of 2015, DEA has emergency scheduled five illicitly 

produced fentanyls. Four are currently in process. We are tracking 

19 more. 

Scheduling actions are critically important, but they are reactive, 

resource-intensive processes. We will continue to do everything we 

can on the scheduling front, but in the short-term, this esteemed 

body could provide DEA and our law enforcement partners immediate relief by placing the identified fentanyls and the other dangerous synthetic substances into Schedule I. 

This would allow us to keep these drugs out of country and bring 

to justice the egregious domestic and foreign traffickers preying on 

our youth and flooding our country with these dangerous drugs. 

I would like to end with two oppositive but interconnected images—sunlight and shadows. DEA will always operate in the sunlight. We will always follow the rule of law. We will work to reduce 

demand with our community outreach and prevention efforts 

throughout the country. 

But we have to also operate in the shadows. We need to infiltrate 

these secretive, dangerous transnational criminal organizations, 

whether they are here in the United States or in foreign countries. 

We need to develop and collect the necessary evidence to bring 

those that exploit human frailty for profit out from the shadows 

and into the sunlight of our transparent judicial system for prosecution in the U.S. 

The brave men and women of DEA will continue to do the necessarily difficult and dangerous work to address this threat. 

Thank you for the opportunity to appear before you and I look 

forward to answering any of your questions. 

[The prepared statement of Mr. Milione follows:] 

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Mr. MURPHY. Thank you, Mr. Milione. 

Now, Mr. Allen, you’re recognized for 5 minutes. 

STATEMENT OF MATTHEW C. ALLEN 

Mr. ALLEN. Chairman Murphy, Ranking Member DeGette and 

distinguished members, thank you for the opportunity to appear 

before you today to discuss the heroin and fentanyl crisis in the 

United States and the efforts of U.S. Immigration and Customs Enforcement to target, investigate, disrupt, and dismantle and bring 

to justice the criminal elements responsible for manufacturing, 

smuggling, and distribution of dangerous opioid. 

As the largest investigative agency within DHS, ICE Homeland 

Security Investigations investigates and enforces more than 400 

Federal criminal statutes. 

HSI special agents use their authority to investigate all types of 

cross-border criminal activity and work in close coordination with 

U.S. Customs and Border Protection and the Drug Enforcement 

Administration in a unified effort with both domestic and international law enforcement partners to target transnational criminal 

organizations that are supplying heroin and fentanyl to the United 

States. 

Today, I would like to highlight our efforts to reduce the supply 

of heroin and fentanyl to the U.S. and the operational challenges 

that we encounter. 

The United States, as you have heard already, is in the midst of 

a fentanyl crisis that is multifaceted and deadly. Fentanyl is a 

Schedule II synthetic opioid used medically for severe pain relief 

and it is 50 to 100 times more potent than morphine. 

United States law enforcement has identified two primary 

sources of the U.S. illicit fentanyl threat—China and Mexico. China 

is a global supplier of illicit fentanyl and Chinese laboratories 

openly sell fentanyl. 

In China, criminal chemists work around their government’s control efforts by modifying chemical structures to create substances 

referred to as analogues not recognized as illicit in China but having the same deadly effects. 

Although there is ongoing collaboration with China, the lack of 

current Chinese laws that prohibit analogue manufacturing or export is one of the challenges we face in stemming the flow of illicit 

fentanyl from China. 

Mexican drug cartels also obtain illicit fentanyl and precursor 

materials required to manufacture fentanyl-related substances 

from China and primarily use fentanyl as an adulterant in heroin 

that is produced in Mexico. 

The cartels have discovered that manufacturing fentanyl is much 

more cost effective, efficient and draws less law enforcement attention than cultivating opium poppies to produce heroin. 

Fentanyl seized at our U.S. Southwest border is typically 5 to 10 

percent in purity. Once illicit fentanyl is distributed in local American drug markets, many people who use drugs, whether heroin or 

prescription pain pills, are unaware of the presence of more potent 

fentanyl in their narcotic. 

As fentanyl used in suspected heroin or counterfeit pills is more 

potent than the drugs they resemble, it readily leads to overdosing 

39 

and this is often how law enforcement first learns that fentanyl or 

an analogue has been introduced into a local drug market. 

The addictive nature and demand for opioids paired with the low 

cost and high potency of fentanyl used in counterfeit opioid production has led TCOs to compete for a portion of the illicit U.S. drug 

market. 

Illicit fentanyl is not only dangerous for people who abuse drugs 

but also for law enforcement, public health workers and first responders who could unknowingly come into contact with it. 

Accidental skin contact or inhalation of the substance during law 

enforcement activity or during field testing of the substance is one 

of the biggest dangers and challenges we face in law enforcement. 

In response to the dramatic increase in the availability of opioids, 

the Office of National Drug Control Policy, in close coordination 

with other Federal departments and agencies, developed a Heroin 

Availability Reduction Plan to reduce the supply of heroin and illicit fentanyl in the United States. 

ICE has been supporting HARP since its inception. We are targeting supply chain networks, coordinating with domestic and 

international partners and providing field training to highlight officer safety and collaboration efforts. 

ICE is also fully engaged with the DEA Special Operations Division and the CBP National Targeting Center to identify shipment 

routes, targeting parcels that may contain heroin, illicit fentanyl 

and fentanyl-related substances and manufacturing materials that 

go into making pills in the United States, fully exploiting financial 

and other investigative analyses along the way. 

ICE is committed to battling the U.S. heroin and illicit fentanyl 

crisis that demands urgent and immediate action across law enforcement interagency lines in conjunction with experts in the scientific, medical and public health communities. 

Thank you for the opportunity to appear before you today and I 

look forward to your questions. 

[The prepared statement of Mr. Allen follows:] 

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Mr. MURPHY. Thank you very much. 

Now, Mr. Brownfield, you are recognized for 5 minutes. Make 

sure your microphone is on, please. 

STATEMENT OF WILLIAM R. BROWNFIELD 

Mr. BROWNFIELD. Thank you, Chairman Murphy, Ranking Member DeGette, and members of the subcommittee. Thank you for the 

opportunity to appear before you today. 

The broad interagency panel here today demonstrates that this 

is a health issue, a law enforcement issue and an international 

issue. 

This opioid crisis is perhaps our worst drug crisis in 30 years. It 

kills tens of thousands of our fellow citizens every year. Illicit 

fentanyl is responsible for many of those deaths and virtually all 

of that fentanyl is sourced from abroad through foreign drug trafficking organizations. 

To solve the problem, we must cut off international supply. That 

is where my INL bureau comes into play. 

Our strategy is three-part—work the neighbors, work China, 

work the United Nations. First, we realize that most illicit opioids 

reaching the United States enter through Mexico and Canada. 

Mexico produces more than 80 percent of the heroin consumed in 

the U.S. and Mexican heroin trafficking networks introduce 

fentanyl into the supply chain. 

Since the start of Merida Initiative cooperation in 2008, we have 

developed a close relationship with Mexican Federal law enforcement. We have delivered hundreds of millions of dollars in border 

inspection and law enforcement equipment, training and capacity 

building and intelligence exchange. Mexico invests $20 for every one of ours. Mexico has increased 

efforts to eradicate opium poppies and we recently agreed to expand those efforts further. 

Canada is suffering its own opioid crisis, although most of its 

heroin comes from Afghanistan. We coordinate closely with Canada 

to address a shared crisis, ensuring both governments have statutory authority to address the problem and sharing real-time law 

enforcement intelligence. 

And all three governments cooperate through the new North 

American Drug Dialogue where we share information on narcotics 

research, exchange best practices and develop actions to protect our 

citizens. 

Second, we have expanded cooperation with China, a major 

fentanyl source country. In 2015, China moved to regulate 116 new 

synthetic drugs and on March 1st of this year it added four critical 

fentanyl analogues to its domestic control including carfentanil, 

sometimes described as fentanyl on steroids—100 times more potent than fentanyl. 

We asked China to do more, but I acknowledge these steps by 

the Chinese Government. They improve our ability to track and 

control fentanyl and other synthetic drugs entering the United 

States. 

We are also using, targeting and sanctions programs like the 

narcotics reward and drug kingpin authorities to target fentanyl 

traffickers. 

49 

For nearly 20 years, the U.S. and China have coordinated law 

enforcement policy through the U.S.-China Joint Liaison Group on 

Law Enforcement and that dialogue produces valuable cooperation. 

Third and finally, we are working through the U.N. system to 

regulate dangerous opioids and precursors throughout the world. I 

was in Vienna last week for the annual meeting on the Commission on Narcotic Drugs, the governing body for all U.N. drug policy. 

By a vote of 51 to 0, the CND approved our proposal to regulate 

two essential fentanyl precursors. The entire process took four 

months rather than the normal 2 years, and while the regulation 

will not stop illicit fentanyl production, it will be more difficult for 

criminals to obtain the chemicals needed to make it and easier for 

countries to prosecute them. 

We also support programs by the U.N.’s drug control organization, UNODC, to eliminate opium poppy cultivation and heroin production in Afghanistan, Mexico, Colombia and Guatemala. 

Mr. Chairman, members of the committee, we have an international strategy. We are committed to that strategy. We welcome 

ideas to improve that strategy. 

I have learned two lessons in 25 years engagement in international drug policy. First, it takes decades to get into a drug crisis 

and will take years of patient persistent effort to get out. Second, 

no strategy is so perfect it cannot be improved. 

Thank you, Mr. Chairman. I look forward to the committee’s suggestions. 

[The prepared statement of Mr. Brownfield follows:] 

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Mr. MURPHY. Thank you. 

Dr. Houry, you are recognized for 5 minutes. 

STATEMENT OF DEBRA HOURY 

Dr. HOURY. Chairman Murphy, Ranking Member DeGette, I 

would like to thank you for inviting me here today to discuss this 

very important issue. 

As the director of the National Center for Injury Prevention and 

Control at the CDC, I would also like to thank the committee for 

your continued interest in the prevention of opioid misuse and prevention and overdose. 

As an emergency physician, I have seen first hand this devastation all over the country. Drug overdose deaths in the United 

States have nearly tripled in the last 15 years. In 2015, there were 

approximately 52,000 drug overdose deaths and of those 63 percent 

involved an opioid. 

The large increase in deaths seem to be primarily driven from 

heroin and synthetic opioids such as fentanyl. fentanyl is an opioid 

analgesic 80 times more potent than morphine and is almost administered in hospital settings for painful conditions. 

Illegally manufactured fentanyl can be mixed with or sold as heroin and is fast acting. Overdoses can occur in seconds after consumption and an overdose from fentanyl is much more difficult to 

reverse because it is so powerful. 

The rate of drug overdose deaths involving fentanyl more than 

doubled from 2013 to ’14, and some States have seen the dramatic 

effect of this drug much more so than others. 

For example, Massachusetts experienced a surge of opioid-related 

deaths from 698 in 2012 to 1,747 in 2015. To examine this increase, the Massachusetts Department of Public Health requested 

CDC’s assistance in an epidemiological investigation, or Epi-Aid. 

CDC determined that over 74 percent of the recent drug overdose 

deaths involve fentanyl and recommended conducting outreach to 

high risk groups such as people with substance abuse problems recently released from incarceration. 

The rise in fentanyl, heroin and prescription drug overdoses are 

not unrelated. In Ohio, CDC found that approximately 62 percent 

of fentanyl and heroin overdose deaths were preceded by at least 

one opioid prescription during the 7 years prior to death and one 

in five people who died from a fentanyl overdose had an opioid prescribed to them at the time of their death. 

CDC is committed to three strategies that comprehensively protect the public’s health and prevents all opioid misuse and overdose 

deaths. 

The first approach is improving data quality and timeliness to 

better track trends, identify communities at risk and evaluate prevention strategies. 

CDC funds 12 States to improve tracking and reporting of illicit 

opioid overdoses including fentanyl. Improved surveillance is crucial for States to facilitate faster identification in response to spikes 

in overdoses, leading to quicker, more tailored interventions. 

The second approach is supporting States in their efforts to implement effective solutions and interventions. CDC has funded 44 

58 

states and Washington, DC, for prevention efforts and surveillance 

activities. 

For example, we have funded Ohio to use their prescription drug 

monitoring program to identify high-risk patients and they have 

achieved full data integration with Kroger Pharmacies as part of 

their integration with electronic health records. 

Our third approach is to equip health care providers with the 

data and tools needed to improve the safety of their patients. To 

aid primary care providers and evidence-based prescribing practices, CDC developed and published the CDC guideline for prescribing opioids for chronic pain. 

In addition to the critical partnership with States, CDC knows 

this epidemic requires partnerships across sectors and we’ve been 

working side by side with law enforcement. We are working with 

the Drug Enforcement Agency to implement prevention strategies 

and have initiated a personnel exchange. 

The heroin response strategy, which is funded by ONDCP and 

deployed in eight high-intensity drug trafficking areas, sets out to 

link public health and public safety. CDC is working to coordinate 

public health workers on the ground. Successfully addressing this 

problem requires focused efforts in prevention. All three components—law enforcement, treatment and prevention—must work together to reverse this dangerous threat. We each have a critical 

role to play. Without effectively preventing more Americans from 

developing opioid use disorder in the first place we will never get 

ahead of the problem. Without prevention, more Americans will require treatment, often for the rest of their lives, and more will 

overdose. 

Thank you again for the opportunity to be here with you today 

and for your continued support of CDC’s work in protecting the 

public’s health. I look forward to your questions. 

[The prepared statement of Dr. Houry follows:] 

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Mr. MURPHY. Thank you, Doctor. 

Now, Dr. Compton, you’re recognized for 5 minutes. 

STATEMENT OF WILSON M. COMPTON 

Dr. COMPTON. Chairman Murphy, Ranking Member DeGette and 

members of the subcommittee. Thank you for inviting me to provide an overview of how science can help us address the rise in 

fentanyl use in overdose deaths. 

My name is Dr. Wilson Compton and I’m the deputy director of 

the National Institute on drug abuse. As a physician and researcher, I’ve seen first hand the devastating impact of the opioid 

crisis on families and communities and have conducted numerous 

studies to better understand trends in opioid use and ways to respond. 

What is fentanyl and its relationship to the opioid crisis? 

Fentanyl’s high potency and fat solubility allow it to rapidly enter 

the brain, leading to a fast onset of effects which increases the risk 

for addiction and overdose. 

The emergence of fentanyl and other even higher potency synthetic opioids creates enormous challenges for controlling supply 

since very small amounts can cause large-scale damage to users as 

well as to law enforcement and first responders who may come into 

contact with the drugs. 

Fentanyl is one part of the ongoing opioid overdose epidemic 

which also includes prescription opioids and heroin. While recent 

Federal and State efforts have begun to help curb over prescribing 

of the prescription opioids, overdoses continue to rise mainly due 

to the rise in heroin in fentanyl-related deaths. 

NIDA’s efforts in this area are part of the broader initiatives of 

the Office of National Drug Control Policy and the Department of 

Health and Human Services. 

The population of people using fentanyl largely overlaps with 

those using heroin and so the strategies being implemented to address the ongoing opioid crisis are expected to help address 

fentanyl addiction and overdoses. 

NIDA, along with FDA, co-chairs the Opioid Subcommittee of the 

Department of Health and Human Services Behavioral Health Coordinating Council and in this role we help to coordinate interagency efforts. 

So how is research helping to address the opioid crisis? NIDA 

has supported the development of the three medications that have 

been FDA approved to treat opioid addiction. Methadone, 

buprenorphine and naltrexone all have strong evidence of effectiveness. 

Despite this effectiveness, only a fraction of people with opioid 

use disorders are being treated with these medications due to limited treatment capacity, stigma, lack of provider training and cost. 

Therefore, NIDA research is helping to develop strategies to promote wider adoption of these medications in variety of settings. For 

example, initiating buprenorphine treatment in emergency departments has been shown to help ensure that people who overdose are 

effectively engaged in ongoing treatment for their underlying opioid 

use disorder. 

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Other studies have found that providing interim buprenorphine 

or methadone while awaiting admission to a treatment program reduces opioid use and increases the likelihood of engaging in treatment. 

How can research specifically inform our response to fentanyl? 

Through NIDA’s national drug early warning system, we are supporting research to better understand fentanyl’s use patterns and 

trends in hot spots such as Ohio and New Hampshire. 

In the first phase of the New Hampshire study, for example, researchers reported that about one-third of fentanyl users knowingly 

use the drug and may seek out a certain dealer or product when 

they hear about overdoses because they think it must be highly potent. 

What about overdose treatment? Although naloxone can rapidly 

reverse an opioid overdose, the current standard dose of naloxone 

is likely not adequate to reverse some overdoses from high-potency 

opioids like fentanyl. 

In response, we are supporting research to develop new longer 

lasting naloxone formulations and new administration protocols. 

NIDA also supports research on prevention and treatment. For 

instance, in partnership with the CDC, SAMHSA and the Appalachian Regional Commission, NIDA is testing interventions to address opioid misuse in rural America. 

In addition, we are planning a research initiative to study treatment expansion models resulting from the additional resources provided to states via the 21st Century Cures Act. 

Research is also underway to develop a vaccine for fentanyl to 

keep fentanyl from entering the brain, thereby protecting against 

addiction and overdose. 

In summary, over 33,000 deaths for opioid overdoses occurred in 

2015 with nearly 10,000 involving synthetic opioids like fentanyl. 

Science-based solutions are available. The challenge is often in 

their implementation. 

NIDA will continue to work closely with the other Federal agencies, both those that are here today and many others, community 

organizations and private industry to address these complex challenges. 

Thank you. I look forward to your questions. 

[The statement of Dr. Compton follows:] 

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Mr. MURPHY. Thank you, Doctor. 

We will now begin with questions. I will recognize myself for 5 

minutes. 

Mr. Chester, does the ONDCP believe that fentanyl is another 

wave of the opioid epidemic? 

Mr. CHESTER. Yes, sir. It really is two things. I think it is an outgrowth of the heroin crisis, and then once fentanyl has found its 

way into the supply chain it represents a unique aspect of that particular problem. 

Mr. MURPHY. So do we have a strategic plan? Does the Federal 

Government have a strategic plan to address that unique issue? 

Mr. CHESTER. We do. As I mentioned, the Heroin Availability Reduction Plan included both heroin and fentanyl as part of its problem set and that particular plan guides and synchronizes Federal 

Government activities against the opioid problem set, specifically 

heroin and fentanyl. Yes, sir. 

Mr. MURPHY. Mr. Milione, do you believe that with this unprecedented threat of fentanyl that we have a Federal plan solidly in 

place as broad as it needs to be? 

Mr. MILIONE. I always think there is more to do, based on the 

level of the threat. Certainly, at DEA it is a priority. We have programs in place to deal with it. But as Ambassador Brownfield said, 

there is always room for improvement based on the need of the 

threat. 

Mr. MURPHY. Mr. Allen, based on the data that our law enforcement places at international mail facilities at nine different airports in 2015 and 2017, I find it amazing that not one package of 

fentanyl was detected out of 8,473 that were examined. 

Is there more difficulty in coming up with a targeting profile for 

fentanyl shipments than we know about and what can be done to 

prove this? 

Mr. ALLEN. Detection of fentanyl in—you know, at the land border and in consignment packages and mail is a challenge that we 

continue to deal with. I think we have better success in certain 

channels than we do in others. Because Customs and Border Protection gets advanced information from the express consignment 

companies, their ability to target packages that are inbound to the 

United States is much better than our ability to target mail that 

is coming to the United States because the universal postal union 

that we operate under does not mandate that international shippers including China and others provide advanced information 

about packages and mail that is coming to the United States. 

Mr. MURPHY. So requiring that would help? Would requiring that 

information help with the postal service? 

Mr. ALLEN. Yes, it would. 

Mr. MURPHY. Can I also ask where is—who can answer this 

question? Where is it coming over the border with Mexico? I understand it is places in California and Arizona, am I correct? Do we 

know specifically? 

Mr. ALLEN. The two areas where we’ve seen it most prevalent is 

in southern California and southern Arizona. The vast majority has 

been detected. 

Mr. MURPHY. And how do they bring it across the border? 

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Mr. ALLEN. In personally owned vehicles or on bodies coming— 

people that are coming as pedestrians across the land border detected at ports of entry. 

Mr. MURPHY. People—so people walk across or people who come 

through—legally through ports of entry and it is either way? Illegal 

or legal, they’re both coming through? 

Mr. ALLEN. Legal. Where we are not detecting it is between the 

ports of entry. We are seeing it come in at designated points of 

entry and it is being detected and seized and arrests are being 

made by Customs and Border Protection at ports of entry. 

Mr. MURPHY. But in other parts we are not seeing it? They’re 

coming across the border in other places and they’re not picked up 

there? 

Mr. ALLEN. On the land border we are not seeing it come between the ports of entry. The other method of it coming into the 

United States is through express consignment packages and mail, 

which generally is detected in the interior at express consignment 

hubs where all consignment packages are cleared by CBP or at 

international mail facilities that are designated around the United 

States. 

Mr. MURPHY. Thank you. 

Dr. Houry, the most recent available data of fentanyl-related 

overdose deaths come from 2015. Am I correct or do you have more 

recent data for 2016? 

Dr. HOURY. So we have data through 2015 but we’ve also released a quarterly report for 2016 through the National Center for 

Health Statistics and that is death data. 

I think what is really helpful is, with the funding that we received this past year, we’ve stood up a surveillance system in 12 

States that looks at nonfatal data also. That has been in place for 

six months. 

That allows us to have some DROMIC data from emergency departments to capture more quickly emerging trends. 

Mr. MURPHY. With all that, is it—do you think it is still underreported significantly? 

Dr. HOURY. I do think it is significantly under reported because 

many medical examiners and coroners aren’t testing for fentanyl 

analogues. Up to 20 percent of times, you know, the type of drug 

is not reported. We are working with AFSO and with the National 

Association of Medical Examiners to improve death certificate reporting. 

Mr. MURPHY. Dr. Compton, in just a few seconds—it is a scientific challenge. Can you explain how it is that fentanyl is more 

dangerous than other opioids medically? 

Dr. COMPTON. Well, the key is through both its strength as well 

as its fat solubility. So not only is it inherently more potent but it 

can more rapidly enter the brain where it exerts its respiratory depression, which is what kills people. 

Mr. MURPHY. And all right. We will get to more of these but I 

will go to Ms. DeGette now for 5 minutes. Thank you. 

Ms. DEGETTE. Thank you very much, Mr. Chairman. 

Mr. Milione, as I mentioned in my opening statement, I think we 

all agree the amount of fentanyl recovered by American law enVerDate Mar 15 2010 10:21 Feb 27, 2018 Jkt 037690 PO 00000 Frm 00105 Fmt 6633 Sfmt 6633 I:\115THCONGRESS\115X16FENTANYLSCANS021618\115X16FENTANYLWORKING WA
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forcement has risen from 640 samples tested to 13,000 samples 

tested in 2015. Would you agree with that statistic? 

Mr. MILIONE. I would, not having them in front of me. But that 

sounds right. 

Ms. DEGETTE. Yes. I mean, it is really raised—going up in crisis 

proportions, right? 

Mr. MILIONE. That’s correct. 

Ms. DEGETTE. And have arrests for counterfeit pills or sources 

increased as well? 

Mr. MILIONE. I would have to get back to you as far as if there 

has been an increase. We have been studying—we have been very 

aggressively investigating these networks. 

Ms. DEGETTE. But I think you would agree that the amount of 

fentanyl recovered has been growing exponentially, right? 

Mr. MILIONE. It has. 

Ms. DEGETTE. Now, Dr. Compton, I want to ask you, because 

other opioids sometimes—often lead to fentanyl use some have suggested that to stem the demand for fentanyl we also need to treat 

opioid addiction because addiction drives the users to seek those 

other drugs that contain fentanyl. Would you agree? 

Dr. COMPTON. Yes. I think the fentanyl issue is most closely related to heroin addiction. So it is the very same people using heroin 

that seem to have the most trouble with fentanyl. 

Ms. DEGETTE. And treatment, as we’ve learned in many, many 

hearings in this subcommittee, is an important component in the 

addiction fight. Is that right? 

Dr. COMPTON. Absolutely. We think expanding treatment access 

is a key component of our—of our attempts to address this. 

Ms. DEGETTE. Now, based on—I assume you have had experience with opioids and with heroin. You just can’t stop this by arresting people. Would that be fair to say? You have got to also have 

treatment. 

Dr. COMPTON. I think it is either—to point out that it is the combined public health and public safety approaches that look most 

promising. 

So we look at models that include criminal justice systems as 

well as public health as showing reductions in crime as well as important health outcomes. 

Ms. DEGETTE. OK. But health outcomes are a key part of that, 

right? 

Dr. COMPTON. Of course. 

Ms. DEGETTE. And so this what I am concerned about. When 

you’re trying to treat opioid addiction, as we have also learned in 

our many hearings in this subcommittee it is a comprehensive 

treatment that is very extensive. Wouldn’t you agree with that? 

Dr. COMPTON. Yes. We have certainly learned that the treatment 

needs to last quite a long time. It takes people a long time to turn 

their lives around and recovery is not an instantaneous process. 

Ms. DEGETTE. And these drugs, they sometimes change the 

chemistry of the brain so that you have to have to medication-assisted treatment and other types of tools to be able to treat this. 

Is that right? 

Dr. COMPTON. Yes. NIDA research has certainly demonstrated 

that. 

103 

Ms. DEGETTE. And so in some of these States that have been hit 

hard with the opioid and fentanyl epidemic, the Medicaid expansion that they have been able to get has been able to help them 

really target populations for addiction treatment and prevention. 

Would that be fair to say? 

Dr. COMPTON. Certainly treatment expansion is a shared goal for 

all of us and making sure that the research we support is embedded within the health care system is essential. 

Ms. DEGETTE. Now, in the past few years after the passage of 

the Affordable Care Act Medicaid was now able to pay up to 50 

percent of medication treatment in some of these hardest-hit 

States. Is that right? 

Dr. COMPTON. Well, I would really want to refer the specific 

questions about how Medicaid is funded to the State officials that 

implement those programs or the CMSes. 

Ms. DEGETTE. So you are not familiar about how some States in 

the last years have been able to increase their treatment? 

Dr. COMPTON. I’m certainly familiar with the States’ efforts to expand treatment in the last few years. 

Ms. DEGETTE. Well, let us talk about Ohio, for example. In Ohio, 

Republican Governor John Kasich recently said, ‘‘Thank God we 

expanded Medicaid because that Medicaid money is helping to 

rehab people,’’ and in fact a February 6th, 2017, Pew Report noted 

that Ohio added 700,000 new Medicaid recipients under its expanded program, and roughly a third were diagnosed with a substance abuse disorder. 

According to the CBO, the Republican ACA repeal’s proposal 

would cut $880 billion in Federal outlays for Medicaid over the 

next 10 years. Would you disagree with any of those figures? 

Dr. COMPTON. Well, certainly, we are interested in research that 

can look at changes in the health care system. We are partnering 

with SAMHSA to study the implementation of the 21st Century 

Cures Act. 

Ms. DEGETTE. Right. But would you—would you disagree, for example, that Ohio added 700 [sic] new Medicaid recipients under its 

expanded program and a third were diagnosed with substance 

abuse disorders? 

Dr. COMPTON. Those figures sound reasonable. 

Ms. DEGETTE. OK. So what I’m worried about is probably pretty 

clear. If you reduce the Medicaid expansion that in States like 

Ohio, Kentucky, West Virginia, other States that have been hard 

hit by fentanyl and opioid and heroin that that is also going to reduce the treatment programs we are able to give them. 

Thank you, Mr. Chairman. 

Mr. MURPHY. You’re right. We can’t arrest our way out of this. 

We have to treat it. And just a follow-up to what you’re saying: Do 

we even have enough providers? Does anybody know? We know 

that half the counties in America don’t have psychiatrists, psychologists, social workers. Do we have enough trained drug treatment providers in America? 

Dr. COMPTON. We do not have enough to fully meet the needs 

and they are not evenly spread across the country. So that is why 

we are engaging in the rural initiative to address the particularly 

severe shortages in rural areas. 

104 

Mr. MURPHY. Thank you very much. 

Dr. HOURY. And I would just add to that treatment is important 

but preventing people from needing addiction services in the first 

place will also save the health care system a lot of money. So making sure we are using safe prescribing practices is a key component. 

Mr. MURPHY. And we’ll get to that as well. 

Ms. Walters of California is recognized for 5 minutes. 

Ms. WALTERS. Thank you, Mr. Chairman. 

We have seen the opioid and heroin epidemic ravage every part 

of our country. Even affluent areas like my home of Orange County, California, are struggling with over 200 deaths per year. 

Now we are witnessing a far deadlier iteration, fentanyl-laced 

drugs. This incredibly powerful pain killer reserved for the most severe and acute pain are being added to heroin, cocaine and counterfeit drugs. 

As a mother of four young adults, it breaks my heart every time 

I see or hear of another life lost. Just last year, a 19-year-old from 

Orange County overdosed after taking fentanyl-laced cocaine. 

This epidemic again hit home when a DEA investigation resulted 

in four arrests for an alleged fentanyl importation and distribution 

conspiracy in Long Beach. 

The DEA reported that the men had over 30,000 acetyl fentanyl 

tablets and 13 kilograms of the narcotic. 

Mr. Milione, I want to commend your agency for this investigation and keeping this deadly drug off the streets of Orange County. 

Mr. Milione, the making and distributing of pills containing 

fentanyl has been disguised by molding the pills in a wide variety 

of counterfeit brands and colors. What are the most prevalent pill 

types being discovered? 

Mr. MILIONE. Thank you for the question. It’s a pretty broad 

range but oxycodone—they are going to mimic whatever is popular 

on the street depending on the market, depending on the area. 

So if there is a real market for oxycodone 30s, they’ll replicate 

those. If it is more a powdered substance that they want in a capsule because they’d rather snort the substance, that market will influence how they package it. 

Ms. WALTERS. What types of pill making machinery are most 

commonly associated with these counterfeit drug operations? 

Mr. MILIONE. There is a broad range. I mean, anywhere from an 

inexpensive pill machine to ones that cost $10,000, $15,000, 

$20,000 that can produce 250,000 pills an hour. 

Some of them are handheld that can be very easily used. So it 

is a broad spectrum there. 

Ms. WALTERS. OK. And what are the most likely sources of these 

counterfeit drugs? 

Mr. MILIONE. China is the primary source for the fentanyl. But 

then, as I said before, going into Mexico and then the networks are 

shipping the merchandise up into the United States, and what we 

are seeing more and more is that actually the pills—the counterfeit 

pills—are being made in the United States at different domestic 

transportation cells around the country. 

Ms. WALTERS. OK. Thank you. And Dr. Houry, we understand 

that the typical victim of a fentanyl overdose can be extremely 

105 

hard to define since it does not follow economic structure or community locales. 

What can you tell us about current trends and tendencies? 

Dr. HOURY. So you are right, we are seeing this epidemic really 

increase in all demographics. It’s most hardest hit in those 20 to 

44 and really that—or 25 to 44 and we are seeing it more in men. 

What I think is important, though, is people—like in Rhode Island we saw that a third of the decedents had had a prescription 

within the past 90 days for an opioid and a third of those had had 

a high dose of morphine milliequivalent prescription. 

So what we had said in the guideline to really be cautious was 

that people are getting exposed to opioids and then going on to fuel 

their addiction through heroin and fentanyl. 

Ms. WALTERS. OK. Thank you. 

And Mr. Chester, in recent months fentanyl was first identified 

as a major problem in the Northeast, parts of the Midwest and certain States like Florida and Maryland. What do you see as trends 

or directions of its spread? 

Mr. CHESTER. We have begun to see some indications that it has 

moved west. Obviously, Sacramento, California was the first one. 

That was about a year ago that we had begun to see it move a little 

bit farther west. 

I think fentanyl found its way into the Northeast simply because 

it was easier to mix into the powdered white heroin that was popular in the northeast United States. 

And so in the western part of the United States we are beginning 

to see more of the pill form that Mr. Milione was discussing as 

well. 

But fentanyl, even though it began being geographically concentrated in the Northeast, we’ve seen indicators of areas throughout the United States. 

Ms. WALTERS. OK. Thank you. And I yield back the balance of 

my time. 

Mr. MURPHY. Ms. Castor is recognized for 5 minutes. 

Ms. CASTOR. Well, thank you, Mr. Chairman, for calling this 

hearing and thank you to all of our expert witnesses for shining a 

light on this. 

It does feel like we are in the Twilight Zone though because as 

we are talking about the seriousness of the opioid epidemic we are 

faced in two days with a vote on a health bill that will recede in 

this country’s responsibility in health services to families who are 

addicted, who need substance abuse treatment, mental health 

treatment. 

Mr. Chester, you said that only one in nine are receiving treatment who need it. Mr. Milione, you say we have to reduce demand 

as part of a balanced strategy. 

And yet, this GOP health care bill that is coming to the floor will 

take a hatchet to coverage for millions of Americans plus it will 

end Medicaid health services as we know it that provide in Florida, 

in most States, the most important mental health and substance 

abuse health services. 

So this is very important. But, boy, this bill that is coming up 

for a vote would really take us backwards when we are talking 

about opioids. 

106 

In fact, my—one of my local sheriffs in Pinellas County, which 

is St. Petersburg and Clearwater, says we cannot and we never will 

solve this problem at the law enforcement level. 

This needs to be treated as an addiction problem—a mental 

health problem. We may have had great success in beating back 

the pill mills but all that meant is we are going to see a switch 

to different drugs and different dealers. 

And I wanted to highlight what’s happening in West Virginia because it is startling and there is a good investigative reporter that 

is shining a light on it. 

Mr. Milione, according to a December 2016 article in the Charleston Gazette Mail, opioid wholesalers ship mass quantities of opioid 

medicines that appear to be foreign excess of what certain communities in West Virginia should receive based on sound medical 

needs. 

The article says, ‘‘In six years, drug wholesalers showered the 

State with 780 million hydrocodone and oxycodone pills while 1,728 

West Virginians fatally overdosed on those two painkillers. The unfettered shipments amount to 433 pain pills for every man, woman 

and child in West Virginia.’’ 

This reporting strongly suggests that West Virginia appears to 

have been receiving quantities of hydrocodone and oxycodone pills 

that would clearly be more than what would be medically necessary. 

Mr. Milione, are you familiar with some of the reporting which 

suggests West Virginia may have been grossly oversupplied with 

dangerous prescription opiates? 

Mr. MILIONE. I am. 

Ms. CASTOR. I mean, this is really shocking. It would appear that 

addiction to pain pills can, according to all of the reporting and 

what you all have testified here today that once you have oxy and 

hydrocodone that takes over someone’s life that that will quickly 

lead to the user seeking more powerful opiates such as heroine or 

counterfeit pills, both of which may be adulterated with fentanyl. 

Dr. Houry, in your testimony you say reversing epidemic—the 

epidemic requires changing the way opioids are prescribed. Is it 

therefore reasonable to assume that addiction to prescription pain 

medicines have a connection ultimately to the fentanyl problem 

and the larger opioid epidemic? 

Dr. HOURY. Yes. Many of the people who have overdosed on 

fentanyl have had a opioid prescription at the time of their death. 

So I believe all of these fentanyl, heroin and prescription opioid 

overdose deaths are linked. 

Ms. CASTOR. And Mr. Milione, MSNBC also ran a story about the 

substantial influx of opioids into West Virginia. It reported on a 

small town called Kermit, which I understand only has 392 people. 

They reported that Kermit received 9 million hydrocodone pills 

in 2 years. If this reporting is true, it is hard to believe that we 

have sufficient systems in place to spot dangerous trends. 

Is the DEA familiar with the reports regarding what happened 

in this small town with the oversupply of addictive pills and what 

can you tell us about it? 

Mr. MILIONE. I am familiar with that report, but we are all—we 

are familiar that that has happened in many, many locations 

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across the country. So we have an obligation, obviously, across the 

whole supply chain from the manufacturers to the distributors. 

Ms. CASTOR. What is happening with the wholesalers? 

Mr. MILIONE. Well, the wholesalers have to uphold their regulatory obligations and we have taken action recently against the 

big—two of the big three, McKesson and Cardinal. 

Our hope is that their compliance programs, like any good corporate citizens, would work to prevent diversion and they would 

uphold those obligations. But it is not just the wholesalers. We 

have to go all the way down the supply chain in order to kind of 

try to maintain this closed system of distribution. 

So it is certainly complex and it is a challenge. But we are well 

aware of all the issues across the country. 

Ms. CASTOR. Thank you. My time has run out. 

Mr. MURPHY. Thank you. 

Dr. Burgess, you’re recognized for 5 minutes. 

Mr. BURGESS. Thank you, Mr. Chairman. 

Mr. Milione, let me stay with you if I can, and I don’t know if 

we can get this map of the opiate deaths in 2015 up on the screen. 

But the map is almost counterintuitive to me. We talk about—that 

is not the one. It is the total opiate deaths in 2015, just for the purposes of illustration. Thank you. 

Almost counterintuitive—six of the States with the lowest numbers—go back one slide, please—six of the States with the lowest 

numbers, of those six, four are border States—Texas, California, 

North Dakota, and Montana—which would be counterintuitive if 

we talk about things that are coming in across the border. 

But also if you look at the map, boy, it seems like there is a 

bullseye on the Midwest, and what are you doing to sort of interrupt those supply chains that seem to have targeted a portion of 

the country? 

Mr. MILIONE. A great question. So you’re right, it is transiting 

in and it is going to—it is not staying at the border where it 

crosses. It is going to locations around the country. 

The Northeast is getting hit. The Midwest is, unfortunately, increasingly getting hit. But now the West is also getting hit. 

So what are we doing? Applying law enforcement techniques. We 

are working with our Federal partners, infiltrating the supply 

chain but also looking at the distributors and trying to disrupt 

them with the judicial process. 

Mr. BURGESS. Ambassador Brownfield, let me ask you a question 

and anytime we have a Texan on the panel that is a good thing. 

So I thank you for being here today. 

And just for the record, you are career at the State Department. 

Is that correct? 

Mr. BROWNFIELD. I am, Congressman. 

Mr. BURGESS. Well, and thank you for your service to the State 

Department. 

Now, of course, the secretary is in China or has been in China 

recently. Your testimony today—your written testimony that you 

provided and your—and your verbal testimony kind of indicated 

that perhaps things were looking up. Things were—there were 

positive developments, and I guess I am just not feeling that there 

are positive developments. 

108 

And in fact, Mr. Milione, please don’t arrest me but I went online 

and looked at how to order fentanyl online just while we are sitting 

here and there are a lot of opportunities and I suspect those opportunities many of them come from Asia or come through China. 

Mr. Brownfield, do you—Ambassador Brownfield, do you think 

we are doing enough to interrupt those? 

Mr. BROWNFIELD. Congressman, I will say we are starting very 

close to point zero in terms of our cooperation with China. We have 

moved in a positive direction. 

We are dealing with a country that has somewhere between 

170,000 and 400,000 companies that produce pharmaceuticals 

somewhere in the People’s Republic of China. 

As recently as 2 or 3 years ago, there was largely no control over 

their production whatsoever. Since then, 116 synthetic drugs are 

now controlled by the Chinese Government and within the last 

month and a half—literally, within the last month, 4 new ones, including important fentanyl analogies, are now controlled by the 

Chinese Government. 

We have a dialogue. We are talking to one another. Three years 

ago, their answer was—by the way, is not unusual—around the 

world was we do not have a fentanyl problem and therefore we are 

not particularly interested in cooperating with you because it is not 

being abused in China. 

We have gotten beyond that. Are we where we want to be? No, 

of course not. What you have just proven is we have not yet solved 

the problem. But are we in fact ahead of where we were 2 or 3 

years ago? On that, I say yes. 

Mr. BURGESS. Well, and that—I thank you for that effort. I agree 

with you that is a positive development. But given the distributional aspects on our United States map, is it possible—and, really, 

it is for anyone on the panel—is it possible to identify from which 

laboratories or manufacturing houses overseas, which are causing 

us the greatest problems in these areas that we are seeing on our 

United States map. Does anyone have an answer for that? 

Mr. MILIONE. Congressman, it is a great question, and to build 

on what Ambassador Brownfield was saying, we have had, on the 

law enforcement side in China in our Beijing country office tremendous success getting leads from the Chinese of U.S.-based recipients of their fentanyl. That’s a huge step forward and allows us 

now to kind of uncover that network in the United States. 

Yes, we have had successes uncovering what those labs are in 

China and we’ve been working cooperatively with our law enforcement counterparts over there and we are very pleased with the direction that it is going. 

Mr. BURGESS. Well, and just in the limited time I have remaining, Dr. Houry and Dr. Compton, I mean, both of you talked about 

fentanyl use patterns and I’m a big believer in prescription drug 

monitoring programs. 

Look, I was a physician. It’s important to have drugs like 

fentanyl available. We are grateful for their utility in clinical settings. Clearly, they have to be used appropriately. 

But do you have a sense of what I was talking to the DEA and 

the State Department about—do you have a sense of where the use 

patterns are occurring? 

109 

Is—are you able then to target limited resources so that perhaps 

an ER can have one of these early intervention programs? 

If you’re in a hot spot I think that is a good idea. If you’re in— 

out in Lubbock, Texas that might not be as important. 

Dr. HOURY. In Ohio we were able to do that. We did an Epi-Aid 

there and found eight counties that had highest rates. We were 

able to then, you know, help guide Ohio to where to focus their efforts. And then in Massachusetts we also saw that there was a 

high rate of overdose deaths in those that were recently incarcerated—about 50 times what we saw in other populations. 

So we were able to use the data for that. With prescription drug 

monitoring programs you can very much see people at risk for 

opioid use disorder and use that to help link to further—— 

Mr. BURGESS. Are you? 

Dr. HOURY. What we are doing right now is the program has 

been in place for 2 years and we are in 44 States and getting data 

that is quicker and better able to be used by States and letting 

States really focus on evidence-based interventions. 

Mr. BURGESS. I am way over time but, honestly, we authorized 

NASPR back in 2005. It shouldn’t be just recently. This should 

have been an ongoing exercise over the last decade, in my opinion. 

Thank you, Mr. Chairman. I will yield back. 

Mr. MURPHY. The gentleman yields back. 

Before I recognize the next one, I want to put together a couple 

pieces here we just had. So the gentlelady from Florida and Dr. 

Burgess from Texas talked about these issues. 

Kermit, West Virginia—I think that is where you mentioned this 

tremendous prescription rate—massive amount. I pulled up another chart here of disability rates in the United States and don’t 

you know, Mingo County and those areas in West Virginia are 

among the highest in the Nation, where Dr. Burgess just pointed 

out the deaths that are occurring there. 

It makes me wonder as you’re talking about collecting more data, 

Dr. Houry, how much more data do you have to have? You’re seeing these targeted areas where the amount of prescriptions is way, 

way out of control. 

You can see on that map. This is way out of control and yet— 

and these deaths are occurring. 

So are there any kind of teams, like, going into these places and 

identifying who’s writing these prescriptions and then the deaths 

that come from this? 

Dr. HOURY. Absolutely. We’ve been sending teams into Ohio, to 

Massachusetts, to Rhode Island. We’ve given specific information to 

the States on how to combat—— 

Mr. MURPHY. West Virginia? 

Dr. HOURY. West Virginia, we’ve been funding the program. I did 

the site visit myself out there to West Virginia. 

We’ve been working with each State to look at the prescription 

drug monitoring programs, and if you look at the guideline, 18 

States have now adopted or have implemented aspects of the guideline to help with safer prescribing in their States and we are starting to see significant improvements and you see things like Kentucky through our CDC funding. 

110 

Now on our prescription drug-monitoring program it has an alert 

for if there is high morphine-related equivalence to, again, make 

sure that people are getting safer prescriptions. 

Mr. MURPHY. Thank you. 

Ms. Schakowsky, you’re recognized for 5 minutes. 

Ms. SCHAKOWSKY. Thank you, Mr. Chairman, and I want to 

thank all of our witnesses. This has been a very important issue 

because it is an important fight for our communities. 

Obviously, the law enforcement piece and figuring out how we 

can stop the entry into our country of the components of fentanyl— 

very important. 

But I want to say, again, and it is been said many times before, 

this is also a very serious health issue. And to my Republican colleagues, as we face this vote that is coming up on Thursday we 

have to recognize the importance of the Medicaid program. 

It’s the second biggest payer for drug abuse treatment in the 

United States. It funded, roughly, 25 percent of public and private 

spending on drug abuse treatment in 2014. We talk about West 

Virginia. 

We are talking about a lot of low-income people and Medicaid is 

really the source of help for them. 

For my home State of Illinois, Medicaid has been absolutely vital 

to address substance abuse and providing access to treatment. 

Medicaid expansion has provided coverage to 650,000 low-income 

adults in Illinois, nearly one-third of whom have mental health or 

substance abuse disorders. 

That’s just the typical percentage all over the country. Without 

Medicaid, these individuals would be more likely to end up in 

emergency rooms or jails, which would drive up costs for State and 

local budgets. 

It’s also clear that in Illinois we need to be further expanding access to substance abuse treatment and I’m sure that is the case in 

many other States around the country. 

From 2014 to 2015, Illinois saw 120 percent increase in the number of deaths from drug overdoses. And so, you know, yet the Republican Trumpcare proposal would decimate the Medicare program that serves one in four people in Illinois—one in four people 

in Illinois. 

The Republican bill would end Medicaid expansion and pose a 

drastic per capita cap on funding. I don’t want to go more—on more 

about that because it is been certainly addressed. 

Dr. Compton, wouldn’t you agree that solving the fentanyl and 

opioid addiction problem requires that we also ensure that people 

have access to appropriate substance abuse treatment? 

Dr. COMPTON. Certainly given that the underlying issue is an 

opioid use disorder, treatment is a key component of solving this 

problem. 

Ms. SCHAKOWSKY. Thank you. 

And Dr. Houry, in your testimony you stated that ‘‘a rise in 

fentanyl, heroin and prescription drugs involve overseas are not 

unrelated.’’ I’m sorry—overdoses, not overseas. I’m going to say 

that again. ‘‘The rise in fentanyl, heroin and prescription drug-involved overdoses are not unrelated.’’ Would you agree that in order 

111 

to solve the fentanyl crisis we must also address the larger opioid 

prescription drug epidemic? 

Dr. HOURY. Yes. I think a very comprehensive approach is needed and I think prevention is a key aspect of that. 

Ms. SCHAKOWSKY. I wanted to also ask Dr. Compton how harmful would it be for a patient with an opioid disorder to have to discontinue his or her substance abuse treatment? 

Dr. COMPTON. One of the key predictors of relapse and of recidivism is stopping treatment. So when people stop treatment, particularly abruptly, they’re extraordinarily high risk of relapse to 

their underlying addiction problems as well as criminal behavior 

and other serious problems. 

Ms. SCHAKOWSKY. Thank you. 

I’m very concerned. I’m also on the Budget Committee. We know 

that there has been proposed an 18 percent cut in HHS, $5.8 billion cut in the National Institutes of Health, which I—my understanding is that you’re actually doing some research on—I don’t 

know if the right word is vaccine, but some sort of prevention, 

something that would—against opioid addiction. Is that true? 

Dr. COMPTON. Well, we even have research specifically targeting 

fentanyl where the development of a vaccine might lead to an approach that could keep the—keep the fentanyl from getting into the 

brain. 

The goal is to keep it in the circulatory system so you get antibodies developed that attach to the fentanyl and keep it out of the 

brain where it exerts its dangerous effects. 

Ms. SCHAKOWSKY. Thank you. 

Again, I want to thank all of the people who are here today testifying how you’re trying to stop it before it starts and understand 

all the sources. But I also am interested in the health services. 

Thank you. I yield back. 

Mr. MURPHY. Gentlelady yields back. 

I now recognize the chairman of the committee, Mr. Walden. 

Mr. WALDEN. Thank you very much, Mr. Chairman. I want to 

thank the witnesses again for your learned testimony and your answers to our questions. 

The fentanyl threat, Mr. Chester, has been described to us as the 

third wave of the opioid epidemic. It seems to me that individual 

States—I’ve looked at some maps—are seeing different effects, different aspects of the overall epidemic. Some are facing fentanyl 

head on right now. 

Looks like in other areas it hasn’t hit or at least not as with the 

deadly effect. Others are fighting against prescription drug or heroin overdoses. 

So I guess my question is, Are we better off to look at this as 

sort of a State-by-State basis? I realize there are national implications, but it seems like there are some real hot spots in the States. 

And so when we think about a strategy here to combat it, should 

it be multi-headed and look at this opioid epidemic in that way or 

and look at kind of all-of-the-above or sort of a one-size-fits-all? 

What, from your experience, would work best? 

Mr. CHESTER. Yes, Congressman. So we look at it as a complex 

national security law enforcement and public health issue at the 

national level, and then at the State level, there are unique enviVerDate Mar 15 2010 10:21 Feb 27, 2018 Jkt 037690 PO 00000 Frm 00115 Fmt 6633 Sfmt 6633 I:\115THCONGRESS\115X16FENTANYLSCANS021618\115X16FENTANYLWORKING WA
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ronmental factors that cause different manifestations of the opioid 

problem and as you correctly point out there is fentanyl in some 

States more than it is in others, there are prescription opioids in 

others, and in others there is heroin. And in fact we’ve seen evidence in some places that heroin deaths are the preponderant 

cause of death, and in other cases fentanyl has surpassed heroin 

as being the preponderant cause of death. 

So in the implementation of our plans we do two things. Number 

one, we try and respond to unique aspects of that State’s environment but also develop a framework to share lessons learned from 

one State to another. 

So things that certain States have found to be successful in dealing with their particular aspect of the problem can be shared with 

other States who may not be facing that particular problem but 

may see it in the future. 

Mr. WALDEN. All right. Thank you. 

And Ambassador Brownfield, first of all, I want to commend the 

State Department and the good work that you all have done and 

commend the DEA for your work in helping getting the recommendation of the March 16th effort by the U.N. Commission on 

Narcotic Drugs in favor of controlling two primary fentanyl precursors. 

And I want to thank the Chinese, too. I’ve met with the ambassador. We’ve sent them a letter thanking them for their work to 

shut down some of the facilities. 

What do you hope will be the impact from the U.N. recommendation on the fentanyl problem in the U.S.? What can we expect out 

of that? 

Mr. BROWNFIELD. First, at the risk of shameless pandering to 

you, Congressman, may I thank you for your letter to the ambassador. It makes my job enormously easier when they hear directly 

from you. 

What do we respect from—expect from the CND decision to control the two precursors? First, we have to wait another, roughly, 

170 or 168 days before it is fully implemented. 

This is a period of time during which the, roughly, 185 member 

states of the U.N. who are also part of the CND have endorsed or 

ratified the treaties—have the right to seek an exception. 

I do not expect anyone to seek an exception to the ruling, because the vote was unanimous. It was 51 to 0. 

When it comes into effect, the countries that produce these two 

precursors, the two most prevalent precursors in the production of 

fentanyl in the entire world will be required to control, register, license and verify production of these precursors there. They will—— 

Mr. WALDEN. And, again, which two countries are those? 

Mr. BROWNFIELD. I mean, the two precursors. The most important country is China which, in fact, did support—not only vote for 

but did support and assist us to some extent in lobbying for the 

passage. 

So what will happen at that point in time is whenever a company, any company in the world, is going to export either of these 

two precursors, the government of the country where it is produced 

will be required to notify the national authorities of the country to 

which it is being exported and it will have to provide the basic data 

113 

and information—how much, when, who is the receiving party, 

route by which it will be shipped. 

That then allows the national authority—in this case it might be 

HSI or ICE or DEA—to determine what is coming in and doing the 

due diligence to verify this is a legitimate and legal shipment. 

This is why I said in my oral statement this is a way to shut 

down the diversion of legal and illicitly produced fentanyl. 

Mr. WALDEN. You know, the State of Oregon and elsewhere tried 

this with methamphetamine to get at the precursor ingredients and 

it made a big difference when you put pseudoephedrine behind the 

counter and required a prescription. 

Boy, that just changed the whole dynamic in terms of the individual cooking operations that were polluting homes and killing 

people. 

And so I commend you and the State Department and the governments that were involved for taking this step. We look forward 

to being partners with you, going forward. 

And I yield back the balance of my time. 

Mr. MURPHY. Mr. Tonko, you are recognized for 5 minutes. 

Mr. TONKO. Sorry about that. Problem with the mic. 

Thank you, Mr Chair. I am quite satisfied we are holding this 

hearing today because it is literally a life-or-death issue for my constituents. 

In my hometown of Amsterdam, New York, a small community 

of about 18,000 people, we had four overdose deaths and another 

dozen treated overdoses in the month of December alone. 

If that rate of carnage were maintained for an entire year, one 

in every 375 individuals in my hometown would perish. These 

overdoses were all attributed to fentanyl—one in 375. 

When you drive down the interstate in my district, instead of 

billboards advertising for McDonald’s or Taco Bell, you see billboards advising you to call 911 in case of an opioid overdose. 

Last year, I had the opportunity to visit a clinic where I witnessed people taking their first steps to recovery aided by a law I 

helped to pass last year that raised the arbitrary limits on the 

number of patients a doctor can treat for opioid use disorder. 

Bearing witness to these success stories from the recovery community fuels my drive to push for policies that will expand the recovery opportunity for everyone. 

That is why I found it astounding that in all of the witnesses’ 

testimony today the word Medicaid was mentioned just twice and 

both times in the context of prescription drug monitoring programs. 

We can talk supply reduction all we want. But you simply cannot 

talk about a Federal response to the opioid epidemic without talking about Medicaid, which is the largest payer for behavioral 

health care services in our country. 

In New York, Medicaid pays for 38 percent of all medication-assisted treatment for opioid use disorder. In New Jersey, it is 22 

percent. Pennsylvania, 29. Indiana, 17. I could go down the list but 

you get the point. 

And as my colleagues have ably pointed out, there is a huge elephant in the room here. The Trumpcare bill this House is being 

asked to vote on later this week would be the single most devVerDate Mar 15 2010 10:21 Feb 27, 2018 Jkt 037690 PO 00000 Frm 00117 Fmt 6633 Sfmt 6633 I:\115THCONGRESS\115X16FENTANYLSCANS021618\115X16FENTANYLWORKING WA
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astating piece of legislation to individuals struggling with addiction 

in our Nation’s history. 

Trumpcare would eviscerate treatment for individuals who are 

struggling with opioid addiction by ending the Medicaid expansion, 

repealing guarantees of mental health and substance use benefits 

and gutting Medicaid to the tune of $880 billion over the next 10 

years alone. 

You don’t have to take my word for it. The American Society of 

Addiction Medicine, a professional society representing over 4,300 

professionals in the field of addiction medicine wrote to Congress 

saying we are concerned that rolling back the Medicaid expansion, 

certainly sun setting the EHB requirements for Medicaid expansion 

plans and capping Federal support for Medicaid beneficiaries will 

reduce coverage for access to addiction treatment services, changes 

that will be particularly painful in the midst of the ongoing opioid 

epidemic. 

Rolling back the Medicaid expansion and fundamentally changing Medicaid’s financing structure to cap spending on health care 

services will certainly reduce access to evidence-based addiction 

treatment and reverse much or all progress made on the opioid crisis last year. 

The mental health liaison group, an umbrella organizations for 

groups involved in mental health and substance abuse service 

wrote, and I quote, ‘‘The AHCA would leave without coverage the 

1.3 million childless nonpregnant adults with serious mental illness 

who were able for the first time to gain coverage under Medicaid 

expansion. It would also leave uncovered the 2.8 million childless 

nonpregnant adults with substance abuse disorders who gained 

coverage under expansion for the first time.’’ 

Current Ohio Governor, Governor Kasich, ‘‘Thank God we expanded Medicaid because that Medicaid money is helping to rehab 

people.’’ 

Former Arizona Governor Jan Brewer, no one’s idea of a bleeding 

heart liberal, wrote, and I quote, ‘‘It just really affects our most 

vulnerable, our elderly, our disabled, our childless adults, our 

chronically mentally ill, our drug addicted. It will simply devastate 

their lives and the lives that surround them because they’re dealing with an issue which is very expensive to take care of as family 

with no money.’’ 

I could go on but you get the point. I would, Mr. Chair, like to 

enter into the record this letter from 415 addiction groups nationwide opposing Trumpcare for the devastating impact that 

Trumpcare would have on treatment for the opioid epidemic. 

Mr. MURPHY. Without objection. 

[The information appears at the conclusion of the hearing.] 

Mr. TONKO. Thank you, Mr. Chair. 

From my vantage point, there is no one outside of a three-block 

radius of this Capitol Building that thinks that Trumpcare is anything better than a raging dumpster fire. 

Certainly, no one thinks this back room bill will improve the 

lives of those struggling with the disease of addiction. 

And with that, Mr. Chair, I yield back. 

115 

Mr. MURPHY. Gentleman yields back. I do want to note for the 

gentleman that the article referenced before—I don’t know if you’ve 

seen it—from the Washington Post. 

There’s an important statement that says, the important 

takeaway is that there is not one opioid epidemic but several. 

To policymakers this may mean that solving the problem will 

similarly require more nuanced vascular solutions than a blanket 

war on drugs. A strategy to reduce pill overdose in Utah may not 

have any effect on fentanyl deaths in Massachusetts. 

I’m sure we’ll go on and—I want to make sure we work together 

to make sure States have that kind of flexibility to do what they 

do. So I will continue to work with you on that. Thank you. 

I will now recognize Mr. Carter of Georgia, who is himself a 

pharmacist. Thank you. 

Mr. CARTER. Thank you, Mr. Chairman. Thank you all for being 

here on this—what is obviously a very serious subject. I want to 

start by talking about the legal, if you will, marketing of fentanyl. 

We talked about it some during this hearing. One of the—one of 

the questions I have, I know—I can’t remember who it was that 

mentioned that you’re working with the wholesalers, with Cardinal 

and McKesson in trying to make sure that they’re doing their part 

and accurately pointed out that you need to follow it all the way 

through the supply chain. 

I can tell you as a practising pharmacist for over 30 years that 

is very important. We need to make sure that happens. 

Have you been in contact with any of the manufacturers— 

Janssen making Duragesic or Mylan makes a generic—about how 

much they are able to manufacture and put on the market? 

Mr. MILIONE. What we are not seeing is a large-scale widespread 

diversion of legal fentanyl. 

Mr. CARTER. Right. 

Mr. MILIONE. It’s diverted for personal use mostly. What we are 

dealing with is clandestinely produced fentanyls. We do have engagement with the manufacturers, obviously, for issues that come 

up and we are happy to work with them. 

Mr. CARTER. That’s good, and, you know, that is important for 

a couple of reasons and I would be remiss if I did not point out that 

one of the problems we had at the dispensing level is not being able 

to get enough of the product so that the people who truly needed 

it—cancer patients and those who were truly in need of it—we 

would run short on them because they’d put monthly limits on us 

or something of that sort and we weren’t able to get it and that 

was really a tragedy as well. So I hope we keep that in mind as 

we go along. 

One of the things that I was very involved with as a member of 

the Georgia State legislature was our yearly update of our dangerous drugs and one of the problems we always had was trying 

to identify the analogues, and I know that has to be a challenge. 

Dr. Houry, that is got to be a challenge here, and one of my other 

colleagues mentioned about the precursors to it and how we control 

that. One of the—one of the abused substances that I was always 

chasing was synthetic marijuana and, you know, and identify it 

and add it into the—each year into the dangerous drug list and 

then the next year they’d come out with something else. 

116 

I even went as far as to try to identify the molecular structure 

and say anything with this and still it is just so difficult. Can 

you—can you address that, sir? 

Mr. MILIONE. Sure. I mean, that is—the synthetic threat, outside 

the fentanyl threat, which is significant, is massive. We have identified about 400 different substances. 

It’s kind of a misnomer to call it synthetic marijuana. It’s a synthetic cannabinoid and then you have the cathinones and then a 

whole other series of these synthetics. 

This is a major problem for us, and the same criminal chemists 

that are tweaking the molecular structures of fentanyl are doing 

the same when we schedule those cannabinoids. 

Very dangerous—one hit can send someone into a coma or have 

some kind of violent reaction. It’s a big problem for first responders 

but it is a devastating problem because it is sold legally—— 

Mr. CARTER. Absolutely, and that is one of the problems we had. 

We had deaths in my district. We had five deaths in Glyn County 

because of that. They were buying it at the convenience store. 

Mr. MILIONE. We cannot keep up—we cannot keep up pace with 

the emergency scheduling on the cannabinoid cathinone. 

Mr. CARTER. Absolutely. We are just chasing our shadows there. 

Mr. MILIONE. Right. 

Mr. CARTER. And a couple other things, real quickly. 

First of all, from what I’m being told by some of the drug agents, 

particular in Georgia, part of the problem too is just with marijuana coming over. Some of it is laced with fentanyl. Now, that is 

a big problem. 

Now, full disclosure—I am a big, big opponent to the legalization 

of marijuana. I think it is just a gateway drug. But nevertheless, 

that seemed to be a problem, too. 

Now, before I run out of time, I want to get to a subject that is 

very important to me and that is mail order drugs and mail order 

prescriptions coming through the mail, being delivered to patients’ 

houses. That’s where we find out so much. 

And listen, Mr. Chairman, one of the biggest culprits—the VA. 

I am telling you, in Georgia, three out of the five facilities that deliver drugs through the mail are the VA clinics and that is a concern and something we need to address. 

We have—we have opioids coming through the mail, being delivered, left on the—on the front porch of someone’s home. Not even 

having it signed for, just leaving a box there. 

How much of a problem have you found with what the drugs that 

are coming through our—through our mail system? 

Mr. ALLEN. Well, I don’t want to imagine what they—on the VA 

issue we have a number of open investigations and we are trying 

to work cooperatively with the compliance departments at the VA 

nationally, at their headquarters also. 

But those are definitely areas of significant concern and I think, 

you know, that is distinguished from the trafficking of counterfeit 

drugs that are often moved through the mail. 

When Representative Burgess talked about going online, there is 

just a plethora of online pharmacies that are, you know, appearing 

to sell legitimate pills when in fact they are counterfeit. 

Mr. CARTER. Absolutely. 

117 

Mr. ALLEN. Those are moved through the mail system on a daily 

basis. 

Mr. CARTER. And I see I’m out of time. But I do want to say that 

that is a problem we need to be looking at, Mr. Chairman. This 

committee and this Congress needs to be looking at mail order prescriptions and what’s going through our mail now, and I yield back. 

Mr. MURPHY. So let me ask the gentleman, who’s a pharmacist, 

along those lines then. As a pharmacist who will see that perhaps 

you would be picking up patterns of prescribing it in the community as a pharmacist and you would notice perhaps a massive 

amount coming through but you would not see that on a mail order 

system at all? You would be completely blind to that? Am I correct? 

Mr. CARTER. You—on a mail order system. In other words, pharmacies that are mailing through, if they’re legitimate, they should 

be keeping records of what’s going out, yes. 

Mr. MURPHY. Well, I used the example before—the gentlelady 

from Florida was offering West Virginia, which is ground zero for 

this. 

Mr. CARTER. Absolutely. 

Mr. MURPHY. That pharmacy may not necessarily see that people 

are getting it mailed in from out of the area. 

Mr. CARTER. Absolutely, especially if it is more than one. Now, 

you know, the PBM—excuse me, the PDMPs—sorry—that helps 

tremendously, especially if we can do it over State lines. That is 

a tremendous help. We’ve just recently started that in Georgia. 

But Florida is one of the States that is still not doing it, and that 

is a problem because it is a big problem down there. 

Mr. MURPHY. Thank you. Appreciate that. 

Mr. CARTER. Thank you, Mr. Chair. 

Mr. MURPHY. I recognize the vice chairman of the committee, Mr. 

Griffith, for 5 minutes. 

Mr. GRIFFITH. Thank you very much, Mr. Chairman, and I want 

to thank all of the witnesses for being here today. This is a very 

serious subject. But I’ve got to refute some things that I have heard 

today or at least one in particular. 

I think we are comparing apples and oranges when we try to 

bring in fentanyl and opioid abuse into the debate over whether 

you want Obamacare, Medicaid expansion or the American Health 

Care Act, and in fact what I’ve heard repeatedly is is that somehow 

Medicaid expansion has helped to solve this problem. 

But the map of deaths of opioid use that we saw earlier that Dr. 

Burgess put up—and I’ve got a paper copy here—shows us that is 

not the case and I think it is apples and oranges. 

I don’t think Obamacare caused opioid abuse. I don’t think that 

Obamacare is going to solve it on its own. We are trying to find 

those answers here today. 

I don’t think the American Health Care Act is going to be able 

to solve it in and of itself on its own. But when you look at the 

States where the deaths are—you know, if you’re just going to play 

games with numbers, the expansion States seem to have more 

deaths than the nonexpansion States. 

Now, do I think that is fair? No, I don’t. I think that is horse 

hockey. But I think that what my colleagues on the other side of 

118 

the aisle have said about us causing problems by voting for the 

American Health Care Act is irrelevant to our discussion today. 

So with that being said, Dr. Compton, you mentioned the Appalachian Regional Commission—that you’re all working on a project 

with them. What exactly are you doing? That’s my turf, in part. 

I represent southwest Virginia, the Appalachian regions of southwest Virginia, which of course border hot spot areas for opioid 

abuse in Kentucky and West Virginia and it spills over into my district as well. 

Dr. COMPTON. Well, I certainly remember a terrific meeting in 

Wise, Virginia. It’s a lovely town. They convened a group from all 

across the Appalachian region to look at this issue several months 

ago. 

Our initiative with the Appalachian Regional Commission is a 

grant program to look at demonstration projects to improve the 

public health infrastructure and determine how good a job that’ll 

do to address the opioid crisis in rural parts of the country, and the 

Appalachian Regional Commission will be co-funding this along 

with SAMHSA, the CDC and, of course, NIDA taking the lead on 

it. 

Mr. GRIFFITH. Well, we appreciate it because it is a significant 

problem and one of the issues there that we have to look at is is 

that whether or not the folks started off because of the—it is a high 

area for disabilities as well. People have done for years a lot of 

hard manual work and that they get a prescription and then they 

get hooked. 

Dr. Houry, you indicated in Ohio at least that 62 percent of the 

people who died from opioid, from heroin or fentanyl had—in the 

last 7 years had a prescription drug for an opioid. Can you talk 

more about that? 

Dr. HOURY. Sure. We’ve been seeing this in many States. Like 

in Rhode Island, a third of the people who had overdosed on 

fentanyl had had an opioid prescription within three months and 

a third of those had had a high dose opioid prescription, showing 

that, you know, people that are on prescription opioids get addicted 

to opioids and can then go on to overdose from heroin or fentanyl. 

Mr. GRIFFITH. And sometimes their prescription runs out but 

they’re hooked and is there some way we can connect the doctors 

recognizing that maybe their patient has gotten hooked to get them 

the help? 

Because if the prescription just ends and nobody’s alerting anybody, aren’t those a lot of the folks who are going out and buying 

it then illegally on the streets somewhere? 

Dr. HOURY. Well, and I think that is why we’ve got our CDC prescribing guideline where we did talk in there about if you have a 

patient that you suspect opioid use disorder on of the importance 

of linking them to treatment. 

And I think one of the things that I’ve been really proud about 

the work CDC is doing is although we are funding the States to 

do what’s most important for the States, each month we do technical assistance calls that help then with their data and provide 

scientific expertise and where to really focus resources and what 

are the best evidence-based treatments and then have a convening 

of all the States to share these best practices that way. As we are 

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seeing different things emerge in different States we can share 

those. 

I think, you know, data does drive action and I heard us talk 

about should this be a national or a State approach. New Hampshire was number 20 one year for overdoses. The following year, it 

was number 5. 

So I think we need to give States the flexibility to deal with 

what’s going on in their State, but we need to have that overall approach. 

Mr. GRIFFITH. Thank you very much. 

Mr. Milione—if I said that right, and I apologize if I messed it 

up—but I would be remiss—while I think that marijuana is a dangerous drug I think your testimony here today indicated that 

fentanyl was your number-one concern and it is—and it is not your 

jurisdiction so it is a rhetorical question. 

I ask you just to take back why don’t we let there be more research on marijuana and its ability to help patients whether it be 

epilepsy or, in this case, pain? Because while I think it is a dangerous drug, I don’t think it is as dangerous as fentanyl and other 

opioids. 

With that, Mr. Chairman, I yield back. 

Mr. MILIONE. If I could—if I could say in response to that, we 

support any approved research along those lines. So we will continue to work with the researchers on those things and we support 

that. 

Mr. GRIFFITH. Well, if I might, Mr. Chairman, it is just the problem is as a Schedule I drug it makes it tougher than it would be 

if it were Schedule II like fentanyl and other opioids. 

Mr. MURPHY. Gentleman yields back. 

Now, Mr. Pallone for 5 minutes. 

Mr. PALLONE. Thank you, Mr. Chairman. 

The Affordable Care Act, through the expansion of Medicaid, extended health insurance coverage to hundreds of thousands of 

Americans in urgent need of treatment for opioid use disorders and 

I’m concerned that if the money is cut from Medicaid, which is 

what the CBO says would happen with the Republican bill, patients could lose access to care and this could make the fentanyl 

problem even worse. 

So Dr. Compton, in your testimony you state that, and I quote, 

‘‘opioid addiction is a chronic condition, and many patients will 

need ongoing treatment for many years.’’ 

What could happen to a patient if their treatment for an opioid 

addiction was interrupted, for example, because the patient no 

longer had health care coverage for substance use disorders? 

Dr. COMPTON. Well, we do know that when treatment is interrupted or stopped, whether that is intentional or unintentional, the 

risk of relapse is extraordinary. 

Mr. PALLONE. Well, thank you. 

Now, some health experts estimate that nearly 1.3 million people 

are receiving treatment for mental health and substance abuse disorders thanks to Medicaid’s expansion. Our efforts to curb the opiate epidemic, I believe, could be severely impacted if those now receiving treatment lose their health insurance. 

120 

Should the ACA be repealed, we clearly would expect the opioid 

crisis, and by extension the fentanyl crisis, to worsen. 

So Dr. Compton, again, if people who are currently being treated 

for an opioid use disorder were to lose coverage, would we expect 

the numbers of overdoses from opioids including opioid containing 

fentanyl many increase? 

Dr. COMPTON. Well, I hesitate to make a prediction when there 

are so many factors that can play a role here in terms of how 

States will respond, how the Medicaid system in general will be organized. 

Our goal, of course, at NIH and NIDA is to make sure that the 

research we support is implemented no matter what the health 

care system is. 

Mr. PALLONE. OK. I just use this State of West Virginia as an 

example because it was very hard hit by or is very hard hit by the 

opioid epidemic. 

A February 6th article by the Pew Charitable Trust reports that 

West Virginia in fact has the highest opiate overdose death rate in 

the Nation. 

Let me ask Dr. Houry—I don’t know if I’m pronouncing it right 

there—are you aware that West Virginia has one of the highest 

death rates from opiate overdoses in the U.S.? 

Dr. HOURY. Yes. 

Mr. PALLONE. And Dr. Compton, that same Pew article reports 

that the Medicaid expansion has added 173,000 adults to West Virginia’s Medicaid program. West Virginia’s Medicaid enrollment is 

now at 573,000 people, which is about a third of the entire State’s 

population, according to the Pew article. 

Dr. Compton, Pew also reported that in 2015, the first year that 

West Virginia expanded Medicaid, the number of people in treatment for substance abuse jumped from 16,000 to 27,000. 

The increased use of Medicaid services for substance abuse would 

suggest that thousands of West Virginians went without needed 

treatment service prior to Medicaid’s expansion. Would that be a 

fair assumption, Dr. Compton? 

Dr. COMPTON. Well, certainly, when we think about States like 

West Virginia I would point out that the rural aspects make it very 

complicated to deliver services. 

So I am very proud that we are able to implement this new research program in rural areas. 

Mr. PALLONE. And it would appear to me that Medicaid is essential in West Virginia’s fight against opioid addiction, which would 

include the growing problem of fentanyl. I guess my last question, 

again, Dr. Compton, is if West Virginia were to lose these services 

would we expect that the opioid and fentanyl problems to worsen, 

assuming that they were—you know, lost Medicaid coverage—those 

people? 

Dr. COMPTON. Well, I can’t speak to the implications of the coverage issues but, certainly, for individuals who are being treated, 

if you stop their treatment abruptly that could be very deleterious. 

Mr. PALLONE. I mean, the problem that I see is that the Republican bill with regard to the expansion eliminates the essential 

services guarantee and what we have found in the past is a lot of 

times when you don’t have that kind of guarantee the first thing 

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to go is behavioral services, drug treatment, mental health services, things that are expensive and that many States didn’t provide 

until we said in the Medicaid expansion that they would have to. 

And I just think that between the cutbacks that would occur, because States would be getting less money, they’re going to get less 

money, they don’t necessarily have to cover people depending upon 

their income, you know, as the—as they reduce the Medicaid expansion population, and then even with the traditional Medicaid or 

any kind of population if there is no guarantee of essential services 

then, you know, the first thing that often is cut back is treatment 

for drugs. 

So that is my fear and that is why I think that this is devastating if we are trying to deal with fentanyl and some of these 

other opiate problems that we have. 

So thank you all. Thank you, Mr. Chairman. 

Mr. MURPHY. Thank you. The gentleman yields back. 

I recognize Mrs. Brooks for 5 minutes. 

Mrs. BROOKS. Thank you, Mr. Chairman, and thanks to everybody on the panel for your incredibly important work. 

I must say that fentanyl is not a new problem. I was U.S. Attorney in Southern District of Indiana from ’01 to ’07. I learned about 

fentanyl then. 

But, yet, we didn’t talk about it much the way we focused on 

methamphetamine and the dangers, for instance, to children, to the 

environment. 

What we are not talking about in the country is the danger. We 

talk about the overdoses and now seeing the incredible increase in 

overdoses. 

But can we talk a little bit about truly how just dangerous 

fentanyl is as a product? And I realize that this gets a little dicey 

because we use it in medical procedures. But I think, having just 

been with law enforcement and firefighters this past weekend, 

there are dangers, are there not, Mr. Allen, and that is part of why 

you’re doing training? 

And I want to ask you, Mr. Milione, can you talk to us about the 

dangers of fentanyl and why haven’t we, for a long time now, 

talked about the incredible danger? 

Because I don’t think addicts and I don’t think their families 

really have understood how incredibly dangerous it is. 

Mr. ALLEN. I would say that in the law enforcement community 

we have been. I would say since the recent surge in fentanyl one 

of the key things that we have gotten out to the law enforcement 

community, largely following the lead of DEA, is making awareness 

to our personnel, to public safety personnel generally, what they 

could be encountering. 

For us operationally it has changed how we do some of our work. 

One of the investigative techniques that we have done historically 

is to purchase drugs, whether it is online or domestically and online. 

We stopped doing that because of the officer safety concerns that 

we have that could be inherent to an undercover agent buying 

drugs or a State and local officer buying drugs and not necessarily 

knowing what they’re purchasing. 

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There’s also a challenge for us from the perspective of field testing. You know, gone are the days, glorified in a lot of television 

shows, of agents, you know, pulling out a pocket knife and probing 

a package of suspected drugs and putting that into a test kit. 

We, particularly at DHS and within DHS Customs and Border 

Protection, have taken the lead on trying to examine and explore 

and field non-intrusive testing that would allow us to go to a place 

where agents don’t have to physically open a package in order to 

determine what the substance is inside. 

Mrs. BROOKS. Mr. Milione, why is there a surge in fentanyl? 

What is your DEA—and I know you’ve been at this for a long 

time—but what would you say is the cause behind the surge that 

we have been seeing? 

Mr. MILIONE. It’s free-market principles applied to the convergence of the opioid epidemic with massive profits that can be made, 

and cartels and criminal groups that are exploiting that, they see 

the opportunity. 

They aggressively market the small amount of fentanyl. They 

can—they don’t have to deal with the massive bulk of heroin and 

they can get so much more profit out of that. So that is one of the 

things. 

Mrs. BROOKS. But they don’t care that it is killing their customers because there are more that just—pipeline? 

Mr. MILIONE. In a perverse—in a—I mean, and it is very callous 

but it is the cost of doing business and I think some of the medical 

professionals on the panel would say unfortunately there is a perverse, sometimes, reaction when people overdose from high-potency 

fentanyl. It sometimes attracts more attention to that product. 

Mrs. BROOKS. Any idea what the stats are of how many cases 

we’ve been charging in the last year or two causing death? Federal 

cases where we are actually prosecuting drug traffickers for causing death? 

Mr. MILIONE. I would have to get back to you with specific statistics. But we are doing more and more of those around the country—death resulting cases, working with the U.S. Attorneys’ offices, engaging with the U.S. Attorneys, trying to get them to lean 

forward and work cooperatively on that. It is definitely what we 

are focused on. 

Mrs. BROOKS. And I guess going to Dr. Houry’s comment, is part 

of the challenge, maybe for a U.S. Attorney, is that coroners are 

not keeping track of and going into that much detail on the cause 

of death, which could be a problem, I could see, for a U.S. Attorney, 

but should we be—should we be asking or requiring coroners to do 

a better job on that aspect? 

Dr. HOURY. I think it is a resource issue for coroners and medical 

examiners. When you look at the opioid epidemic and the number 

of deaths that they are now doing cases on, oftentimes they don’t 

have the resources in their community to do that testing for 

fentanyl or they don’t have the labs. They have to send it out, 

which is additional funding that they need. 

Mrs. BROOKS. Besides the labs, what kind of resources would 

they need to do the testing aside a heroin death or a fentanyl 

death? 

123 

Dr. HOURY. So they would need the lab to distinguish the type 

of analogue. I think also it is helpful to have the medical examiner 

through the family history and so forth to determine if this was an 

unintentional overdose, was this a legal fentanyl where you can see 

the injection or other paraphernalia associated with it. But I would 

say it is really the testing for the laboratory and the training as 

well. 

Mrs. BROOKS. Thank you. I yield back. 

Mr. MURPHY. Mr. Walberg, you’re recognized for 5 minutes. 

Mr. WALBERG. Thank you, Mr. Chairman, and also thank you to 

the panel. It is clear from your testimony and the questions that 

you live in a world that is difficult, frustrating, challenging, ugly. 

But you’re doing a great job for us and we appreciate that. 

My home State of Michigan shares over 700 miles of land and 

water border with Canada as part of the longest border in the 

world. 

Mr. Milione, does DEA have precise data on how much fentanyl 

is coming in directly from Canada? 

Mr. MILIONE. We can—we have the data as to what’s been seized 

but that is—there is a certain flaw in that. We don’t know exactly 

what is coming in but we know what we have seized and we can 

get those statistics to you. 

It is imperfect, though, because there are networks that are finding any porous entry to be able to get it in. So—— 

Mr. WALBERG. Having flown over the entry from Detroit River 

into Lake Erie and seeing the creative and amazing ways that people will find to cross that water border and seeing the efforts by 

Customs and Border Patrol as well as ICE and others to interdict 

that, I would agree with you. It is probably very difficult. 

But significant amount coming across? 

Mr. MILIONE. Significant in the sense that that is one of our— 

the main threat streams—China to Canada, Canada across our 

northern border. 

Mr. WALBERG. Mr. Allen, do you have numbers on how much 

fentanyl ICE has interdicted from Canada and are there hot spots 

along the northern border? 

Mr. ALLEN. What we—what the DHS components, both ICE and 

CBP, have seized coming from Canada is primarily coming in 

through consignment and mail, not necessarily along the physical 

land border with Canada. 

Mr. WALBERG. Consignment and mail? 

Mr. ALLEN. And mail. 

Mr. WALBERG. OK. Mr. Allen, in your written testimony you 

mention that ISIS met with Canadian officials to share trends and 

targeting strategies in fentanyl-related investigations. 

Can you talk a little bit more about this effort and does your 

agency intend to expand the coordination with Canada? 

Mr. ALLEN. Well, we work along with the Department of State 

and DEA in that effort. We are meeting with Canadian counterparts, Mexican counterparts and Chinese counterparts, as you have 

heard today, and I do think that expanding the exchange of information with both source and transit countries is going to be part 

of how we improve what we do and recognizing that some of the 

fentanyl that makes its way to the United States either directly 

124 

from China or via other places is also in the same stream that 

makes its way to Canada and Mexico as well. 

Mr. WALBERG. I mean, it is great to have a border neighbor that 

generally we can work pretty well with. 

Mr. ALLEN. I would add, you know, one of the things that distinguishes the relationship between the U.S. and Canada and China 

and Mexico is that the Canadians have come to us and talked 

about them having a very similar and significant problem that we 

are. 

Mr. WALBERG. I have supported legislation in the last two Congresses introduced by my colleague, Pat Tiberi, called the STOP 

Act, which, as you know, aims to stop the shipment of synthetic 

drugs like fentanyl and carfentanil into the U.S. 

The bill would require shipments from foreign countries through 

our postal system to provide electronic advanced data like where 

it is coming from, who it is going to and what is in it before crossing our borders into the U.S. 

Mr. Allen, how would this information help better target illegal 

drug shipments and keep these dangerous elements out of our communities? 

Mr. ALLEN. That would assist primarily Customs and Border 

Protection, which takes the lead on interdiction, by giving them advanced information that they could use at places like the National 

Targeting Center to be more effective and more efficient in targeting mail that is coming to the United States. 

As we have heard earlier, one of the things that constrains the 

ability of the—what information the postal—U.S. Postal Service 

has in advance is the Universal Postal Union and my understanding of the STOP Act is that it would require us to update the 

UPU through negotiations led by the State Department to provide 

more and more timely information that would assist CBP in targeting. 

Mr. WALBERG. Are there additional steps Congress should consider along with that taking to assist your efforts to identify and 

stop these shipments? 

Mr. ALLEN. None that come to mind. 

Mr. WALBERG. Anyone? Thank you, Mr. Chairman. I yield back. 

Mr. MURPHY. Now I will recognize another member of the full 

committee, Mr. Bilirakis, for 5 minutes. 

Mr. BILIRAKIS. Thank you so much, Mr. Chairman. I appreciate 

it. Thanks for allowing me to ask the questions and I really appreciate the panel being here. This is such a very important issue. It 

affects all our districts. 

Mr. Chester, a lot of people are aware of opioid abuse like 

OxyContin or heroin but not fentanyl. Is that the case? 

And then what are the educational outreach programs currently 

underway and what resources are available for communities who 

want to get the message out? I think that is important. If you could 

answer that question I would appreciate it. 

Mr. CHESTER. Yes, Congressman. As I stated earlier, kind of the 

components of how we are dealing with this comprehensively is to 

prevent an issue as to drug use, provide treatment for those who 

are addicted to these drugs and then stop the flow of the drugs 

coming in to the United States. 

125 

In terms of prevention, one of the primary mechanisms that we 

use in ONDCP is the Drug-Free Communities program. The DrugFree Communities program, which is funded by ONDCP and is 

managed by the Substance Abuse and Mental Health Services Administration, is in thousands of communities around the country as 

a prevention program that is focused on individual needs of individual communities. 

Local communities require local solutions and it is a coalition of 

12 community members that are focused on the needs of that particular community not only to raise awareness of drug issues but 

prevent primary drug use or initiation of primary drug use focused 

on the demographic of about 13 to 17 years old, which is the target 

demographic for that program. Very effective program. 

Mr. BILIRAKIS. It has been effective? OK. Very good. 

Mr. Milione and Mr. Allen, as you mentioned earlier, China announced its intention to ban the manufacture and sale of four additional types of fentanyl. 

Can you discuss our working relationship with China to prevent 

entry and sale and are there mechanisms to hold China accountable to its commitment to ban fentanyl? 

Mr. MILIONE. Our relationship on the law enforcement working 

level has been tremendous. Our administrator, Acting Administrator Chuck Rosenberg, was recently in China and met with our 

counterparts. 

As a result of those meetings and shortly thereafter and working 

with the State Department they agreed to schedule these four—one 

of them carfentanil, which is 10,000 times more potent than morphine. 

These are significant steps. The other positive thing has been, 

when they initiated investigations in China, there has been real bilateral sharing. 

They provided us leads of domestic-based distributors that are— 

that are ordering fentanyl and that is really helped flush out these 

networks and now these investigations are ongoing. 

So we’ve been very pleased with the cooperation. We hope it continues and, certainly, it can expand. 

Mr. BILIRAKIS. Very good. 

Mr. ALLEN. And I would only echo that. The Chinese Government has provided DHS with seizure—information about seizures 

made in China on their way to the United States and we have been 

able to use that information to, as Mr. Milione said, identify other 

individuals and organizations that have received shipments from 

the same points of origin in China that has allowed us to begin investigation. 

Mr. BILIRAKIS. Thank you. 

Mr. BROWNFIELD. Finally, Congressman, if I could add one more 

point from the State Department’s side. 

Mr. BILIRAKIS. Please go ahead. Please. Please. 

Mr. BROWNFIELD. Beginning a little over a year ago, we reached 

a bilateral understanding with the Chinese Government that they 

would control the delivery of products from China to the U.S., even 

if they were not controlled in China if they were controlled in the 

U.S., in exchange for which we made the same commitment to 

them. 

126 

Now, it is not enforceable in any sort of international organization. But it is an agreement that we reached between ourselves as 

two governments. 

Mr. BILIRAKIS. Thank you. 

Dr. Houry, in your testimony you mentioned that CDC is committed to giving providers and health systems the tools they need 

to improve how opioids are used and prescribed. 

Can you discuss these tools and how communities can take advantage of these tools? 

Dr. HOURY. Absolutely. We have really had a multi-pronged approach. One is just through education. We have been working 

with—directly with medical schools and nursing schools on preclinical training on effective pain management and safe prescribing 

practices. 

We have also developed seven continuing education webinars 

that are available for free for providers on our Web site around 

safe prescribing of opioids, and with the guideline itself—I am a 

practising physician. I know you have to have something that you 

can use. 

So we have a checklist that is been downloaded more than 25,000 

times by providers to use and we also now have a mobile app on 

our phone around the guideline that has things on motivational 

interviewing and how do you talk with a patient about these difficult decisions on whether or not to give an opioid, a calculator to 

help you calculate what’s the appropriate and safe dose of an opioid 

to give. 

And we are also—we have piloted a community education program and awareness around the risks of opioids in 10 cities that 

were hardest hit. 

Mr. BILIRAKIS. Very good. I would like to talk to you about possibly coming to my area in Florida, the Tampa Bay area, if you 

haven’t already. 

Dr. HOURY. I would welcome that. 

Mr. BILIRAKIS. Thank you very much. I yield back, Mr. Chairman. 

Mr. MURPHY. Gentleman yields back. 

Now, just some closing comments. Ms. DeGette, 5 minutes. 

Ms. DEGETTE. Thank you, Mr. Chairman. 

I just wanted to respond to what our colleague, Mr. Griffith, said 

about the ACA. Certainly, nobody thinks that the shocking increase in opioid and heroin use is in any way related to the ACA, 

and we recognize that some of those areas where we do have the 

Medicaid expansion are the areas which are the red on the map, 

and that is quite disturbing. 

Our point, though, is that, if we hope to treat these folks who are 

getting addicted to opioids, it is important that they have access to 

medical treatment, and that is why we are concerned if the Medicaid expansion is retracted, because in those States the Medicaid 

expansion has helped many people who have—who need to have 

addiction treatment, which is extensive. 

And to that end, I have a letter dated March 20th, 2017, from 

the Oregon AFSCME which talks about the Medicaid expansion in 

Oregon and how many people would lose their Medicaid expansion 

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and their treatment for opioid addiction if the Republican alternative passed this week. 

And I would like to ask unanimous consent to put a copy of that 

letter into the record, Mr. Chairman. 

Mr. MURPHY. Without objection. 

[The information appears at the conclusion of the hearing.] 

Ms. DEGETTE. Thank you. I yield back. 

Mr. MURPHY. Gentlelady yields back. 

Just a couple of questions that I have. Mr. Chester, do you have 

any idea how many Federal agencies are there that deal with substance abuse across all spectrums and all departments? 

Mr. CHESTER. I do not have that answer off the top of my head, 

but I would like to follow up with you, if I can, on that. 

[The information follows:] 

Office of National Drug Control Policy (ONDCP): There are a total of 13 

Federal Departments and 40 independent Federal agencies and department 

bureaus designated as Drug Control Program agencies that report funding 

as part of the drug control program. An overview of the support provided 

to the drug control program by these Departments and agencies is provided 

in the ONDCP FY 2017 Budget and Performance Summary. In addition, 

ONDCP works with many other Federal departments and agencies on 

issues that relate to the development and implementation drug control policies and programs needed to support the National Drug Control Strategy. 

Mr. MURPHY. Good. And I know when we asked GAO to do the 

scenario of mental illness they said at least 112, but it is probably 

more. They just couldn’t figure this out. I don’t know how many 

there are. 

I know one of the things this committee did in our mental health 

bill was tasked the Assistant Secretary of Mental Health and Substance Abuse to coordinate these 112 Federal agencies on efforts in 

the area of mental illness. Goodness knows how many there are in 

substance abuse. 

And it is a question that I want you all to let us know—I need 

some answer to—as well as getting back to us that what would you 

suggest that this administration do in working with Congress to 

combat this deadly, deadly problem. 

I mean, we will have meetings—we will have intense hearings 

here on things like Ebola, which affects a couple American lives, 

or on flu, which is thousands of deaths every year. 

But we are far past that with fentanyl and opioids and we see 

towns devastated. And so we do need your suggestions. We want 

to work together. And I say to my colleague, too, you and I have 

a shared passion in this area. 

It is absolutely unquestionable and this is one we have to be 

working together. As I said before, there is no silver bullet. States 

have to handle this a different way. 

What was affecting things in West Virginia with perhaps some 

prescription practices that Ms. Castor pointed out and disability 

rates and unemployment rates may be very different from Massachusetts or Utah or anywhere else, and I want to make sure States 

have full flexibility. 

So I look forward to saying, let’s stay committed to this. We’ll get 

answers to this together. 

128 

And I also would ask, Mr. Chester, there is a letter we sent February 23rd, a bipartisan letter with several questions. You may be 

aware of that. 

Any idea when we can expect some answers to that? 

Mr. CHESTER. Yes, Congressman. It is in final—the letter is complete. It is in final interagency clearance. We hoped to get it to you 

this morning, but we will get it to you as soon as possible. 

Mr. MURPHY. Thank you. Appreciate that. 

Mr. CHESTER. Thank you for the letter. 

Mr. MURPHY. Yes. Now, let me just say that in conclusion I want 

to thank all the witnesses and members that participated in today’s hearing and remind members you have 10 business days to 

submit questions for the record so the witnesses have time to respond to those. 

And with that, I again thank the witnesses. This is a very important hearing on a critically important issue for our Nation. We look 

forward to working with you again until we have this issue addressed. 

And with that, this hearing is adjourned. 

[Whereupon, at 12:36 p.m., the hearing was adjourned.] 

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