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S. HRG. 114–254 

EXAMINING THE TRUE COSTS OF ALCOHOL AND 

DRUG ABUSE IN NATIVE COMMUNITIES 

HEARING 

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

JULY 29, 2015 

Printed for the use of the Committee on Indian Affairs 

( 

(II) 

COMMITTEE ON INDIAN AFFAIRS 

JOHN BARRASSO, Wyoming, Chairman 

JON TESTER, Montana, Vice Chairman 

JOHN MCCAIN, Arizona 

LISA MURKOWSKI, Alaska 

JOHN HOEVEN, North Dakota 

JAMES LANKFORD, Oklahoma 

STEVE DAINES, Montana 

MIKE CRAPO, Idaho 

JERRY MORAN, Kansas 

MARIA CANTWELL, Washington 

TOM UDALL, New Mexico 

AL FRANKEN, Minnesota 

BRIAN SCHATZ, Hawaii 

HEIDI HEITKAMP, North Dakota 

T. MICHAEL ANDREWS, Majority Staff Director and Chief Counsel 

ANTHONY WALTERS, Minority Staff Director and Chief Counsel 

(III) 

C O N T E N T S 

Page 

Hearing held on July 29, 2015 ............................................................................... 1 

Statement of Senator Barrasso ............................................................................... 1 

Statement of Senator Franken ............................................................................... 4 

Statement of Senator Heitkamp ............................................................................. 50 

Statement of Senator Hoeven ................................................................................. 43 

Statement of Senator Lankford .............................................................................. 48 

Statement of Senator Murkowski ........................................................................... 52 

Statement of Senator Tester ................................................................................... 3 

WITNESSES

Beadle, Mirtha, Director, Office of Tribal Affairs and Policy, Substance Abuse 

and Mental Health Services Administration, U.S. Department of Health 

and Human Services ............................................................................................ 10 

Prepared statement .......................................................................................... 11 

Benjamin, Hon. Melanie, Chief Executive, Mille Lacs Band of Ojibwe .............. 16 

Prepared statement .......................................................................................... 18 

Goggles, Sunny, Director, White Buffalo Recovery Program, Arapaho Tribe, 

Wind River Reservation ....................................................................................... 41 

Prepared statement .......................................................................................... 42 

McSwain, Hon. Robert G., Principal Deputy Director, Indian Health Service, 

U.S. Department of Health and Human Services ............................................. 5 

Prepared statement .......................................................................................... 6 

Walters, Hon. John P., Chief Operating Officer, Hudson Institute ..................... 34 

Prepared statement .......................................................................................... 36 

APPENDIX

Response to written questions submitted by Hon. Al Franken to: 

Mirtha Beadle ................................................................................................... 70 

Hon. Robert G. McSwain ................................................................................. 69 

Secatero, Lester, Chairperson, National Indian Health Board (NIHB), prepared statement ................................................................................................... 59 

Steele, Hon. John Yellow Bird, President, Oglala Sioux Tribe ............................ 64 

(1) 

EXAMINING THE TRUE COSTS OF ALCOHOL 

AND DRUG ABUSE IN NATIVE COMMUNITIES 

WEDNESDAY, JULY 29, 2015 

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 2:30 p.m. in room 

628, Dirksen Senate Office Building, Hon. John Barrasso, 

Chairman of the Committee, presiding. 

OPENING STATEMENT OF HON. JOHN BARRASSO, 

U.S. SENATOR FROM WYOMING 

The CHAIRMAN. Good afternoon. I call this hearing to order. 

Before we begin, I want to welcome Ms. Sunny Goggles to the 

hearing. Ms. Goggles serves her community in many roles. She is 

a member of the Northern Arapaho Tribe and the Director of the 

White Buffalo Recovery Center on the Wind River Indian Reservation in Wyoming. She also serves on the Tribal Committee for the 

National Association of Drug Court Professionals. Welcome. 

Tribal leaders from both tribes in the Northern Arapaho and the 

Eastern Shoshone and the Wind River Indian Reservation have remarked favorably on her leadership, on her strength and on her capabilities. Those character traits were put to the test when a recent 

terrible, tragic crime affected those very close to her and to the entire community. Our hearts and thoughts go out to you, to your 

family and to the community. Thank you for serving your community and for being here with us today. 

This month, we have examined many difficult topics. Today is no 

different. We will receive testimony regarding the true costs of alcohol and drug abuse in Native communities. Over the past five 

years, this Committee has held five hearings related to alcohol and 

drug abuse. This past March on the Wind River Indian Reservation, in my home State of Wyoming, this Committee held a field 

hearing on addressing the harmful effects of dangerous drugs. 

Nearly every single witness testified how the abuse of alcohol and 

drugs had serious and often tragic effects on Indian communities. 

Alcohol is noted to be a contributing factor in a significantly high 

number of crimes. It is also a contributing factor in too many 

deaths on the Wind River Reservation. According to the Indian 

Health Service, the average life span for Indians is 73 years. On 

the Wind River Reservation, the average age at death has for years 

hovered around 49 years of age. These premature deaths are due 

primarily to alcohol and alcohol-related injuries. 

2 

I am astonished that both the Substance Abuse and Mental 

Health Services Administration and the Indian Health Service are 

not doing more to change that death rate. I am also astonished 

that the Substance Abuse and Mental Health Services Administration, the agency devoted entirely to substance abuse and mental 

health, failed to submit its testimony on time. This has been a bipartisan concern for those of us on this Committee. The testimony 

that was submitted does little more than recite basic information 

included on the agency’s website. The testimony doesn’t even explain what the agency is actually doing to address alcohol and drug 

abuse in Indian Country. Frankly, this reflects a troubling lack of 

seriousness and commitment to the important issues we are examining here today and it is completely unacceptable. 

The many devastating impacts drugs and alcohol have had on Indian communities warrant our heightened attention. As a physician, I am especially troubled by the needless, preventable injuries 

and the deaths that often result from alcohol and drug abuse. 

These tragedies can take an immeasurable toll in individuals, families and communities. 

So as we focus on the issue before us today, while we must examine the financial burdens associated with alcohol and substance 

abuse, it is important to remember that the full cost of abuse cannot be measured in dollars and cents. In 2011, the Justice Department estimated that the total cost of alcohol and drug abuse in the 

United States exceeded $600 billion a year. Again, this is only part 

of the picture. The other financial, societal, systemic and individual 

costs of substance abuse are high. 

The National Institute on Drug Abuse states that these costs include unemployment, poor educational outcome, domestic violence, 

child abuse, motor vehicle accidents and death. Substance abuse is 

also associated with homicide, suicide and family breakdown. 

The impact of abuse is even worse in Indian Country, where one 

in ten deaths is alcohol-related. Compared to the general U.S. population, Native Americans in Indian Country are also twice as likely to live in poverty and experience two and a half times the general rate of violent victimization. This group has a shorter life expectancy and a higher infant mortality rate than the general population. 

Research by the National Institute of Drug Abuse suggests that 

addiction to and abuse of alcohol and drugs is preventable. The testimony from the Committee field hearing on addressing the harmful effects of dangerous drugs suggested that by preventing or reducing alcohol abuse, crime could be reduced as well. If that is the 

case, we must work together to find realistic solutions that will 

prevent and treat substance abuse in Indian communities. 

I am interested in hearing any solutions that target culturally 

competent prevention or treatment strategies for alcohol and drug 

abuse in Native communities. One thing is clear: there are not 

enough resources to address the high rates of abuse and addiction 

in Indian Country. These problems need to be mitigated, not intensified. 

As we will hear today, Native communities need to understand 

that if they go down the road of legalizing marijuana, it will come 

3 

at a great cost. The resulting health care costs alone would be 

crushing and have an impact on all of Indian Country. 

I want to welcome our witnesses, and I look forward to hearing 

from each of them. But before we hear from the panel, I want to 

ask the Vice Chairman, Senator Tester, if he has an opening statement. 

STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman, and thank you for 

holding this hearing today on the harmful impacts of drugs and alcohol abuse have had and continue to have in Native communities. 

While we are focused on the true costs of drug and alcohol abuse, 

including the devastating economic impacts that these behaviors 

have in Native communities, I think it is vital that we look beyond 

the economics of this issue. I know that it is the human cost that 

most of Indian Country is focused on at this point in time. It is the 

babies that are born addicted to drugs or that are that are developmental impacted by alcohol, it is the children who are separated 

from their mothers and fathers because of the pull of drugs and alcohol. It is the youth who begin experimenting with these substances far too early in life and often lose themselves and sacrifice 

their future. 

There are real human costs that are devastating Indian Country. 

I think everyone on this Committee is well aware of the impacts 

that drug and alcohol abuse has wreaked in our Native communities, especially on our Native youth. We sit here week in, week 

out, and hear about how our kids are dropping out of schools, living 

in unsafe housing and engaging in risky behaviors, largely because, 

quite frankly, they lack alternatives. Our youth and many others 

in Native communities are turning to drugs and alcohol to escape 

from the harsh realities of their life. Addiction becomes a new reality for many of these communities. 

Drug and alcohol abuse is a problem, there is no question about 

it. Yet these are issues that are entirely preventable. They are also 

issues that impact every Federal agency that plays a role in Indian 

Country. That is why I am glad to see our friends are here from 

the Indian Health Service and from SAMHSA to testify on what 

the Federal Government is doing to prevent substance abuse. 

I am also pleased that we will hear from folks in the field and 

on the ground who are working to prevent the loss of another generation of our children to drugs and alcohol. We all know that it 

will take the work of those in our Native communities to truly 

break the cycle of addiction that continues to plague too many families. 

But those on the ground cannot do it alone. They need the support and resources to carry out the programs to combat these problems. They must do a better job ensuring that the resources get to 

the ground in Indian Country. 

I look forward to hearing the testimony of the witnesses this 

afternoon. I want to thank you all for the work you do and I look 

forward to hearing some of the solutions to the crisis that is robbing Indian Country of current and future generations. 

4 

Finally, I would just like to say, all of you have great names. Bob 

McSwain, Mirtha Beadle, Melanie Benjamin, John Walters. But nobody has a name like Sunny Goggles. 

[Laughter.] 

Senator TESTER. Thank you all for being here. 

Senator FRANKEN. Actually, Melanie Benjamin means Sunny 

Goggles in Ojibwe. 

[Laughter.] 

The CHAIRMAN. Would any other members like to make an opening statement? Any opening comments? 

Senator FRANKEN. May I follow up? 

The CHAIRMAN. You may follow yourself, yes, thank you. 

STATEMENT OF HON. AL FRANKEN, 

U.S. SENATOR FROM MINNESOTA 

Senator FRANKEN. I would like to introduce Melanie, who again, 

in Ojibwe, her name means Sunny Goggles. 

[Laughter.] 

Senator FRANKEN. Senator Barrasso, Vice Chairman Tester, 

thank you for holding today’s hearing on substance abuse in Indian 

Country, a tragic subject. I am proud to introduce Melanie Benjamin, who is Chief Executive of the Mille Lacs Band of Ojibwe, as 

a witness to this Committee. 

Right now, tribes in Minnesota face a public health crisis. 

Melanie knows the devastating impact that opiate abuse is having 

on the Mille Lacs Band and on other tribes and bands in Minnesota. The impact on mothers and on children is especially sobering. Melanie is dedicated to addressing this crisis, and she has 

been working with other tribal leaders in our State to develop a response that incorporates both prevention and treatment. 

Last year, tribal leaders in Minnesota convened at the Bois Forte 

Reservation for a summit on the future of Indian children. This 

May, the Mille Lacs Band hosted a second summit where these 

leaders continued to discuss and work toward effective solutions. 

Tribes in Minnesota are working cooperatively to respond to this 

major public health problem. Our role in Congress is to make sure 

we are doing all we can to support their work. I look forward to 

hearing Melanie’s recommendations and learning what tribes need 

from the Federal Government from all our witnesses today, so we 

can fully address substance abuse. Melanie’s testimony is going to 

be mainly on opiate abuse, which has become rampant. 

Thank you, Mr. Chairman 

The CHAIRMAN. Thank you, Senator Franken. Anyone else have 

an opening statement they would like to make, any comments? 

Hearing none, we will now hear from our witnesses. The first is the 

Honorable Robert McSwain, who is the Principal Deputy Director 

of the Indian Health Service, Department of Health and Human 

Services. 

I want to thank all of you for being here. I want to remind the 

witnesses that your full written testimony will be made part of the 

official hearing today. So please try to keep your statements to 

under five minutes so that we may have time for questions. I look 

forward to hearing the testimony, beginning with Mr. McSwain. 

Please proceed. 

5 

STATEMENT OF HON. ROBERT G. MCSWAIN, PRINCIPAL 

DEPUTY DIRECTOR, INDIAN HEALTH SERVICE, U.S. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Mr. MCSWAIN. Mr. Chairman, members of the Committee, good 

afternoon. As noted, I am the Principal Deputy for Indian Health 

Service. Today I appreciate the opportunity to testify on examining 

the true costs of alcohol and drug abuse in Native communities. 

As you know, the Indian Health Service plays a unique role in 

the Department of Health and Human Services to meet the Federal 

trust responsibility to provide health care to American Indians and 

Alaska Natives. Examining the true costs of alcohol, illicit and nonmedical prescription drug use for Native communities is challenging, although we know it is substantial. In the absence of studies on the scope and cost of alcohol and drug abuse for Native communities, IHS depends largely on measures of prevalence, morbidity and mortality related to alcohol and drug abuse for American Indians and Alaska Natives. 

In the fiscal year 2015 enacted budget for IHS, the alcohol and substance abuse program was slightly more than $190 million. 

Over 80 percent of that amount is contracted or compacted with 

tribes. The IHS program approach to addressing alcohol and substance abuse disorders in Native communities is to treat, the important feature is predominantly to treat alcohol and substance 

abuse disorders and treat individuals struggling with substance 

abuse disorders, train health care providers to treat substance use 

disorders in outpatient settings and intervene early before substance use disorder develops and prevent alcohol and drug use before it begins. 

Compared with other racial groups, American Indian and Alaska 

Natives tend to begin using alcohol and drugs at a younger age, 

use them more often and in higher quantities and experience more 

negative consequences from them. A 2009 to 2012 study focusing 

on American Indian youth reveals alarming substance use patterns, including patterns of drug use beginning earlier than is typical for other Americans. For instance, 56.2 percent of American Indian eighth graders and 61.4 percent of American Indian tenth 

graders had used marijuana, compared to 16.4 percent of eighth 

graders and 33.4 percent of tenth graders nationally. 

American Indian students annually, and we will hear more about 

that a little bit later, but annual heroin and OxyContin use is 

about two to three times higher than the national averages in 

those years. To help with the substance abuse for youth, the Indian 

Health Service has actually built ten youth regional treatment centers across the Country and is preparing to build two in California, 

bringing us to a total of 12. They provide a wide range of clinical 

services to provide treatment services rooted in culturally relevant 

and holistic models of care, including group, individual and family 

psychotherapy, life skills development, medication management, 

after-care relapse prevention and post-follow-up. We can talk more 

about this as well. 

The important thing about the Indian Health Service is that we 

tend to serve small, rural populations with primary medical care. 

Then we rely on paying for care, or buying care, in the private sector through our purchase referred care. In FY 2014, IHS spent over 

6 

$5.8 million on inpatient admissions related to alcohol and substance abuse diagnoses. During the same period, over $12 million 

was expended for inpatient visits related to liver disease. 

Workforce development is an IHS resource available to Federal 

and tribal care systems as an essential part, it is by having to build 

a staff. In addition to that, where we can’t reach people, we have 

been implementing tele-behavioral health into the remote locations. 

We started this in 2008. 

IHS’ primary source of prevention funding through methamphetamine is the MSPI program, which some of you asked about the 

last time. The program funds 130 programs across the Indian 

Health Service. We have just sent out another invitation for new 

applications this year. 

The Federal coordination, certainly the Tribal Law and Order 

Act signed into law by President Obama in July 2010 contains provisions that would actually have agencies work together. With the 

high rates and the academic failures as mentioned earlier by one 

of the members, the IHS is committed to partnering with the Committee, tribes and other Federal agencies and key stakeholders on 

further examining and addressing the true costs of alcohol and 

drug abuse in Native communities. 

That ends my statement, Mr. Chairman. I am prepared to answer questions. 

[The prepared statement of Mr. McSwain follows:] 

PREPARED STATEMENT OF HON. ROBERT G. MCSWAIN, PRINCIPAL DEPUTY DIRECTOR, 

INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Chairman and Members of the Committee: 

Good afternoon, I am Robert G. McSwain, Principal Deputy Director of the Indian 

Health Service. Today, I appreciate the opportunity to testify on ‘‘Examining the 

True Costs of Alcohol and Drug Abuse in Native Communities.’’ As you know, the 

Indian Health Service (IHS) plays a unique role in the Department of Health and 

Human Services to meet the Federal trust responsibility to provide health care to 

American Indians and Alaska Natives. The IHS provides high-quality, comprehensive primary care and public health services through a system of IHS, Tribal, and 

Urban Indian operated facilities and programs based on treaties, judicial determinations, and Acts of Congress. The IHS has the responsibility for the delivery of health 

services to an estimated 2.2 million American Indians and Alaska Natives who belong to 566 Federally-recognized Tribes. The mission of the agency is to raise the 

physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. 

Two major pieces of legislation are at the core of the Federal Government’s responsibility for meeting the health needs of American Indians and Alaska Natives: 

The Snyder Act of 1921, 25 U.S.C § 13, and the Indian Health Care Improvement 

Act (IHCIA), 25 U.S.C. § § 1601–1683. The Snyder Act authorized appropriations for 

‘‘the relief of distress and conservation of health’’ of American Indians and Alaska 

Natives. The IHCIA was enacted ‘‘to implement the Federal responsibility for the 

care and education of the Indian people by improving the services and facilities of 

Federal Indian health programs and encouraging maximum participation of Indians 

in such programs.’’ Like the Snyder Act, the IHCIA provides the authority for the 

provision of programs, services, functions, and activities to address the health needs 

of American Indians and Alaska Natives. The IHCIA also includes authorities for 

the recruitment and retention of health professionals serving Indian communities, 

health services for people, and the construction, replacement, and repair of 

healthcare facilities. 

Introduction 

The economic costs of alcohol and drug misuse are enormous. The Centers for Disease Control and Prevention estimated the costs of excessive alcohol consumption 

in 2006 to be $223.5 billion in lost productivity, healthcare, and criminal justice 

7 

1 Available at: http://www.cdc.gov/features/alcoholconsumption/ 2 National Drug Intelligence Center. (2010). National threat assessment: the economic impact 

of illicit drug use on American society. Department of Justice. Washington, D.C. 3 Indian Health Service. (2015). Trends in Indian Health 2014 Edition. Available at: https:// 

www.ihs.gov/dps/includes/themes/newihstheme/displaylobjects/documents/ 

Trends2014Book508.pdf 4Stanley, L., Harness, S., Swaim, R., & Beauvais, F. (2014). Rates of substance use of American Indian students in 8th, 10th, and 12th grades living on or near reservations: update, 2009– 

2012. Public Health Report, Mar-Apr; 129(2): 156–63. 5 Ibid. 

6Stanley, L., Harness, S., Swaim, R., & Beauvais, F. (2014). Rates of substance use of American Indian students in 8th, 10th, and 12th grades living on or near reservations: update, 2009– 

2012. Public Health Report, Mar-Apr; 129(2): 156–63. 

costs. 1 According to the National Drug Intelligence Center, in 2007 alone, illicit 

drug use cost our Nation more than $193 billion in lost productivity, healthcare, and 

criminal justice costs. 2 However, examining the true costs of alcohol and illicit and 

nonmedical prescription drug use for Native communities is challenging, although 

we know it is substantial. In the absence of studies on the scope and costs of alcohol 

and drug misuse for Native communities, IHS depends largely on measures of prevalence, morbidity, and mortality related to alcohol and drug misuse for American 

Indians and Alaska Natives (AI/AN). In 2007–2009, the AI/AN age-adjusted death 

rates for the following causes were considerably higher than those for the U. S. all 

races population in 2008: 3

• Alcohol related—520 percent greater; 

• Chronic liver disease and cirrhosis—368 percent greater; 

• Motor Vehicle Crashes—207 percent greater; 

• Unintentional injuries—141 percent greater; 

• Homicide—86 percent greater; 

• Suicide—60 percent greater; and 

• Firearm injury—16 percent greater. 

While these data are staggering, IHS data have shown improvements in the ageadjusted alcohol-related death rate for AI/AN people in recent years with rates decreasing from 77.5 per 100,000 people between 1979–1981 to 49.6 in 2007–2009 per 

100,000 population. However, the age-adjusted drug-related death rate for AI/AN residing in IHS service areas increased from 4.1 deaths per 100,000 in 1979–1981 to 

22.7 in 2007–2009. By comparison, the 2007–2009 age-adjusted drug-related death 

rate is 1.8 times greater than the U.S. all races rate for 2008. These data speak 

to the need for a public health strategy, informed by Tribes, to address alcohol and 

drug use. The human cost is too great to ignore this problem. 

IHS Alcohol and Substance Abuse Program 

As alcohol and substance abuse treatment and prevention have transitioned from 

IHS direct care services to local community control via Tribal contracting and compacting, IHS’ role has transitioned from primarily providing direct services to providing funding, training, and technical assistance to enable communities to plan, develop, and implement culturally-informed programs. The Fiscal Year (FY) 2015 enacted budget for the IHS Alcohol and Substance Abuse Program (ASAP) was slightly 

more than $190 million. Over 80 percent of the ASAP budget is contracted or compacted by Tribes. The IHS ASAP approach to addressing alcohol and substance use 

disorders in Native communities is to treat AI/AN individuals struggling with substance use disorders; train healthcare providers to treat substance use disorders in 

outpatient settings and intervene early before substance use disorder develops; and 

prevent alcohol and drug use before it begins. 

Treat Individuals Struggling with Substance Use Disorders 

Compared with other racial/ethnic groups, AI/AN tend to begin using alcohol and 

drugs at a younger age, use them more often and in higher quantities, and experience more negative consequences from them. A 2009–2012 study focusing on American Indian youth reveals alarming substance use patterns, including patterns of 

drug use beginning much earlier than is typical for other Americans. 4 For instance, 

56.2 percent of American Indian 8th graders and 61.4 percent of American Indian 

10th graders had used marijuana, compared to 16.4 percent of 8th graders and 33.4 

percent of 10th grade students nationally. 5 American Indian students’ annual heroin and OxyContin use was about two to three times higher than the national averages in those years. 6

To help youth with substance use disorder, IHS funds ten Youth Regional Treatment Centers (YRTCs). The YRTCs provide a range of clinical services to provide 

8 

treatment services rooted in culturally relevant, holistic models of care including 

group, individual, and family psychotherapy, life skills development, medication 

management, aftercare relapse prevention, and post-treatment follow up. YRTCs 

also provide education, culture-based prevention activities, and evidence- and practice-based models of treatment to assist youth in overcoming their challenges and 

to become healthy, strong, and resilient community members. 

The IHS and Tribes primarily serve small, rural populations with primary medical care and community-health services, relying on the private sector for much of 

the secondary and most of the tertiary medical care needs through the Purchased/ 

Referred Care (PRC) program, including treatment for alcohol and substance use. 

In FY 2013, the total rate of alcohol-related discharge diagnoses for IHS and Tribal 

direct and contract hospital was 11.6 per 10,000 user population aged 15 years or 

older. This is 19 percent lower than the Calendar Year (CY) 2013 discharge diagnosis rate of 14.1 for U.S. Short Stay hospitals. In FY 2014, IHS PRC spent over 

$5.8 million on inpatient admissions related to alcohol and substance use diagnoses. 

During the same time period, over $12 million was expended for inpatient visits related to liver disease. It is important to note that the PRC dollars spent on inpatient 

admissions are likely an underrepresentation of the actual costs of treatment for alcohol and substance use disorders as this number represents PRC expenditures 

from Federal programs only and not tribal programs that are not required to report 

their expenditures to IHS. 

Train Healthcare Providers to Identify Substance Use and Intervene Early 

Workforce development is an IHS resource available to Federal and tribal 

healthcare systems as an essential part of effectively addressing mental health and 

substance use disorder issues in AI/AN communities. Established in 2008, the IHS 

Tele-Behavioral Health Center of Excellence (TBHCE), in partnership with the University of New Mexico Center for Rural and Community Behavioral Health, provides 

workforce training and tele-behavioral health services. The prevention and treatment of alcohol and substance use disorders is reinforced by connecting widely separated and often isolated programs of varying sizes together into a network of support. Whereas small clinics would need to develop separate contracts for addiction 

services, the TBHCE is able to provide more cost-effective specialty care conveniently located within the clinics where patients utilize services. IHS and Tribal programs are increasingly adopting and using these technologies, with more than 8,000 

encounters provided via tele-behavioral health in FY 2014. Specific to addiction psychiatry, the TBHCE provided 868 hours of direct care via tele-behavioral health. In 

the same timeframe, the TBHCE hosted trainings on substance misuse and prevention related topics for the Indian health system as a means to increase competent 

health care providers to treat substance use disorder in outpatient settings and intervene early before a substance use disorder develops. Training topics included: 

opioid use disorder; essential training on proper pain management; using non-opioid 

pain medication for chronic non-cancer pain; and medication management for pain: 

opiate analgesics and safe prescribing. These trainings had more than 8,000 participants. 

Screening, Brief Intervention, Referral to Treatment (SBIRT) is a comprehensive 

approach for early intervention and treatment for people with substance use disorders and those at risk of developing these disorders. IHS is broadly implementing 

SBIRT as an evidence-based practice designed to identify, reduce, and prevent problematic use, substance use disorders, and dependence on alcohol. SBIRT is a payable service under state Medicaid plans, while Medicare pays for medically reasonable and necessary SBIRT services in the physician office setting and outpatient 

hospitals through the Medicare Physician Fee Schedule or the hospital Outpatient 

Prospective Payment System. Another activity IHS is developing/promoting is Medication Assisted Treatment (MAT) for opioid use disorder, which uses Food and Drug 

Administration approved pharmacological treatments, in combination with psychosocial treatments. IHS will continue to provide the necessary MAT training through 

its TBHCE. 

Prevent Alcohol and Drug Use Before It Begins 

IHS’ primary source of prevention funding is through the Methamphetamine and 

Suicide Prevention Initiative (MSPI), established in 2009. The MSPI currently funds 

130 IHS, Tribal, and Urban Indian Health Programs (UIHPs) in a nationally coordinated six-year demonstration pilot project. The MSPI promotes the use and development of evidence-based and practice-based models that represent culturally-appropriate prevention and treatment approaches to methamphetamine use and suicide 

prevention from a community-driven context. The MSPI primarily focuses on treatment for methamphetamine under provision of the appropriations language; howVerDate Mar 15 2010 11:00 May 04, 2016 Jkt 099990 PO 00000 Frm 00012 Fmt 6633 Sfmt 6621 S:\DOCS\99990.TXT JACK
9 

7 U.S. Department of Health and Human Services. Indian Health Service, Division of Behavioral Health. http://www.ihs.gov/mspi/aboutmspi/ 

ever, during the evaluation of MSPI, data revealed a need for prevention strategies 

to reduce the use of marijuana, alcohol, prescription drugs, and other substances. 

From 2009 to 2014, the MSPI resulted in over 9,400 individuals entering treatment for methamphetamine use; more than 12,000 substance use and mental health 

encounters via telehealth; over 13,150 professionals and community members 

trained in suicide crisis response; and more than 528,000 encounters with youth 

provided as part of evidence-based and practice-based prevention activities. 7 The 

demonstration pilot project phase ends on August 31, 2015. On July 8, 2015, IHS 

announced the FY 2015 MSPI funding opportunity, which will be a $13.5 million 

five-year funding cycle to continue the planning, development, and implementation 

of the MSPI. In the new funding announcement, eligible applicants will be able to 

focus on alcohol and drug use and suicide prevention strategies for Native youth. 

The high prevalence of alcohol and other substance use rates in Native communities, especially among AI/AN youth, alerts us to the urgency of implementing prevention programs to intervene at an earlier age. The FY 2016 President’s Budget 

includes key investments to support the Generation Indigenous Initiative, which 

takes a comprehensive, culturally appropriate approach across the Federal Government that will help ensure that Native youth can reach their full potential. The request for the Tribal Behavioral Health Initiative for Native Youth is a total of $50 

million in additional funding for IHS and the Substance Abuse and Mental Health 

Services Administration (SAMHSA). Within IHS, the request includes $25 million 

to expand the successful MSPI to increase the number of child and adolescent behavioral health professionals who will provide direct services and implement youthbased programming at IHS, tribal, and urban Indian health programs, school-based 

health centers, or youth-based programs. 

Federal Coordination to Address Indian Alcohol and Substance Use 

Disorders 

The Tribal Law and Order Act (TLOA), signed into law by President Obama in 

July 2010, contains provisions expanding the number of Federal agencies that are 

required to coordinate efforts on alcohol and substance use issues in Indian Country. 

Agencies included in coordinated efforts are the IHS, Department of Justice (DOJ), 

and SAMHSA, along with the Department of Interior (DOI) Bureau of Indian Affairs (BIA) and Bureau of Indian Education (BIE). A key provision of TLOA directs 

SAMHSA to take the lead role in interagency coordination and collaboration on tribal alcohol and substance use programs through the establishment of an Office of Indian Alcohol and Substance Abuse. 

The permanent reauthorization of Indian Health Care Improvement Act (IHCIA) 

required the review and update of an existing memorandum of agreement (MOA) 

from 2009 between IHS and the DOI BIA and BIE on Indian Alcohol and Substance 

Abuse Prevention. This MOA serves as the formal mechanism to advance IHS’ partnership with Federal agencies to assist Tribes in addressing behavioral health 

issues among Indians, specifically mental illness and dysfunctional and self-destructive behavior, including substance misuse, child abuse, and family violence. 

Conclusion 

A wide variety of healthcare costs are associated with alcohol and substance use 

disorders, including hospital costs from injuries, illnesses, residential and outpatient 

treatment costs, pharmaceutical costs, nursing home and long-term facility costs, 

and the cost of treating Fetal Alcohol Syndrome, HIV/AIDS, and hepatitis B and C. 

Given the high rates of alcohol and substance use-related problems on reservations, 

such as academic failure, delinquency, violent criminal behavior, suicidality, and alcohol-related mortality, the costs to Native communities will continue to be far too 

high, indicating that a comprehensive public health strategy aimed at primary prevention and early intervention of alcohol and drug use in Native communities is essential. This approach must be a coordinated response, guided by Tribes, that has 

impacts beyond the Indian health system, including research of root causes, poverty, 

unemployment, unstable housing, education, food insecurity, and community infrastructure. IHS is committed to partnering with the committee, Tribes, other Federal 

agencies, and key stakeholders on further examining and addressing the true costs 

of alcohol and drug use in Native communities. 

The CHAIRMAN. Thank you very much, Director McSwain. 

10 

Next is Mirtha Beadle, who is the Director of the Office of Tribal 

Affairs and Policy, Substance Abuse and Mental Health Services 

Administration, Rockville, Maryland. Thank you, welcome and 

please proceed. ′′ 

STATEMENT OF MIRTHA BEADLE, DIRECTOR, OFFICE OF 

TRIBAL AFFAIRS AND POLICY, SUBSTANCE ABUSE AND 

MENTAL HEALTH SERVICES ADMINISTRATION, U.S. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Ms. BEADLE. Thank you, Chairman Barrasso, Ranking Member 

Tester and members of the Senate Committee on Indian Affairs. 

Thank you for inviting me to testify at this very important hearing 

on substance use and substance use disorders in Native communities. 

As the Chairman said, my name is Mirtha Beadle. I am the Director of the Office of Tribal Affairs and Policy within the Substance Abuse and Mental Health Services Administration. 

As you are aware, SAMHSA’s mission is to reduce the impact of 

substance abuse and mental illness on America’s communities. 

SAMHSA’s Office of Tribal Affairs and Policy, or OTAP, as we refer 

to it, serves as a primary point of contact for tribal governments, 

tribal organizations, Federal agencies and other entities as well. 

The Office of Indian Alcohol and Substance Abuse, or OIASA, is an 

organizational component of OTAP and is charged with improving 

Federal coordination amongst a number of agencies and carrying 

out specific requirements of the Tribal Law and Order Act. 

In November, 2014, SAMHSA held its very first cross-agency 

tribal grantee conference. The focus was on empowering Native 

youth. We were pleased to have Ranking Member Tester participate in that important event. I have to tell you that more than 125 

youth participated in that conference. Their top concerns were alcohol and substance use. Nearly 75 percent of American Indians and 

Alaska Native treatment admissions reported alcohol as a substance of abuse compared to about 56 percent of non-American Indian and Alaska Native admissions. 

Through CDC data, we also know that American Indians and 

Alaska Natives are more likely than other racial-ethnic groups in 

the U.S. to die from drug-induced deaths. 

SAMHSA provides and supports vital technical assistance to 

tribes to address substance use and substance use disorders. For 

example, the SAMHSA Tribal Training and Technical Assistance 

Center supports Native communities with infrastructure development, capacity building, program planning implementation and 

also training. We also have SAMHSA’s Fetal Alcohol Spectrum Disorders Center for Excellence, a Native initiative, which educates 

and trains policy makers and providers, caregivers and communities, individuals and families, on preventing alcohol-exposed 

pregnancy and improve the lives of individuals affected by FASD. 

SAMHSA helps to support American Indians and Alaska Natives. It is a priority for the agency. In fiscal year 2014, Congress 

appropriated for the first time $5 million to begin the Tribal Behavioral Health Grant program. Twenty grants were awarded in 

fiscal year 2014. We had grantees such as Turtle Mountain Band 

of Chippewa, Pueblo of Nambe, and they are working across tribal 

11 

suicide prevention, mental health, substance use prevention and 

substance use disorder treatment, to build positive behavioral 

health in their communities. 

The President’s fiscal year 2016 budget for the Tribal Behavioral 

Health Grant is $30 million. That will allow the agency to expand 

support to approximately 103 additional tribes. 

The House Appropriations Committee fully funds the Tribal Behavioral Health Program for fiscal year 2016 at the requested level 

of $30 million. However, the Senate Appropriations Committee 

level-funds the Tribal Behavioral Health Grant Program for 2016 

at just under $5 million. 

The Strategic Prevention Framework-State Incentive Grant program supports the development of comprehensive plans for prevention and infrastructure development, system development and is 

providing funds to a number of important tribal communities, including the Confederated Salish and Kootenai Tribes, the Leech 

Lake Band of Ojibwe, Nooksack Indian Tribal Council, Northern 

Arapahoe Tribe, Oklahoma City Inter-Tribal Health Board and several other grantees as well. 

The Substance Abuse and Mental Health Services Administration also has a grant program called the Strategic Prevention 

Framework that has been very vital for tribal communities. That 

program funds a number of tribes as well, such as Cook Inlet 

Council, the Montana-Wyoming Tribal Leaders Council and Cherokee Nation. 

I have to say that SAMHSA also is involved in a number of important treatment drug court programs. The intent here is to break 

the cycle of criminal behavior, alcohol and substance use and incarceration, including among Native American populations. In fiscal 

year 2014, the Juvenile Treatment Drug Courts Program and also 

through the adult Tribal Healing to Wellness Program, we funded 

a number of tribes including the Lac Du Flambeau Band of Chippewa, Mescalaro Tribe and also Lower Brule Sioux Tribal Council. 

We thank you for the opportunity to discuss SAMHSA’s efforts 

to address the issue of substance use and we are happy to take any 

questions that you may have. Thank you for the time. 

[The prepared statement of Ms. Beadle follows:] 

PREPARED STATEMENT OF MIRTHA BEADLE, DIRECTOR, OFFICE OF TRIBAL AFFAIRS

AND POLICY, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Chairman Barrasso, Ranking Member Tester, and members of the Senate Committee on Indian Affairs, thank you for inviting me to testify at this important hearing on substance use and substance use disorders in Native Communities. My name 

is Mirtha Beadle, and I am the Director of the Office of Tribal Affairs and Policy 

within the Substance Abuse and Mental Health Services Administration (SAMHSA), 

an agency of the Department of Health and Human Services (HHS). 

We all know that substance use and substance use disorders are some of the most 

severe public health and safety problems facing American Indian and Alaska Native 

(AI/AN) individuals, families, and communities and more must be done to diminish 

the devastating social, economic, physical, and mental consequences. 

SAMHSA’s work with AI/AN populations is rooted in the belief that tribes know 

best how to solve their own problems through prevention, treatment, and recovery 

activities and engaging with and strengthening community partnerships. In addition, SAMHSA’s work with tribal communities supports behavioral health and 

wellness through culturally-tailored programs and initiatives that value tribal beliefs. SAMHSA also offers help in real time to tribes and grantees as they work to 

12 

1 Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/ 

NSDUHresults2013.pdf 

advance substance use prevention, mental health promotion, and behavioral health 

treatment programs. 

In November 2014, SAMHSA held its first cross-agency tribal grantee conference. 

The focus of the conference was on empowering Native youth through leadership 

and behavioral health workshops and to engage them in a dialogue about behavioral 

health. SAMHSA was pleased that Ranking Member Tester was able to speak at 

this important event at which more than 125 youth participated and shared challenges and opportunities for improving the behavioral health of their peers and communities. At the top of their list were concerns around alcohol and substance use 

and a range of social and economic problems, including unemployment, poor educational outcomes, poor housing, and insufficient access to behavioral health services. SAMHSA will continue efforts to support positive development of tribal youth 

through additional training opportunities. 

SAMHSA 

As you are aware, SAMHSA’s mission is to reduce the impact of substance use 

and mental illness on America’s communities. SAMHSA envisions a nation that acts 

on the knowledge that: 

• Behavioral health is essential for health; 

• Prevention works; 

• Treatment is effective; and 

• People recover from mental and substance use disorders. 

In order to achieve this mission, SAMHSA has identified six Strategic Initiatives 

to focus the Agency’s work on improving lives and capitalizing on emerging opportunities. SAMHSA’s Strategic Initiatives are: Prevention of Substance Abuse and Mental Illness; Health Care and Health Systems Integration; Trauma and Justice; Recovery Support; Health Information Technology; and Workforce Development. 

Office of Tribal Affairs and Policy (OTAP) 

SAMHSA’s OTAP serves as SAMHSA’s primary point of contact for tribal governments, tribal organizations, Federal departments and agencies, and other governments and agencies on behavioral health issues facing AI/AN populations in the 

United States. OTAP supports SAMHSA’s efforts to advance the development and 

implementation of data-driven policies and innovative practices that promote improved behavioral health for AI/AN communities and populations. The creation of 

OTAP brought together SAMHSA’s tribal affairs, tribal policy, tribal consultation, 

tribal advisory, and Tribal Law and Order Act (TLOA) responsibilities to improve 

agency coordination and achieve meaningful progress. OTAP carries out its work in 

partnership with tribal nations and in collaboration with SAMHSA centers and offices, and other Federal agencies. 

The Office of Indian Alcohol and Substance Abuse (OIASA) is an organizational 

component of OTAP. OIASA is required under TLOA to coordinate federal partners 

to provide tribes with technical assistance and identify resources to develop and enhance alcohol and substance use prevention and treatment programs. 

Prevalence of Behavioral Health Conditions and Treatment 

Alcohol and substance use, as well as mental health issues and suicide, continue 

to be among the most severe health and social problems AI/ANs face. According to 

SAMHSA’s 2013 National Survey on Drug Use and Health (NSDUH), the statistics 

related to behavioral health conditions and treatment needs among the AI/AN populations are very troubling. 

Substance Misuse and Abuse 

• Though lower than in 2012, the rate of substance dependence or abuse among 

people aged 12 and up was still higher among the AI/AN population (14.9 percent) than among other racial/ethnic groups. 1

• According to data from the 2011 Behavioral Risk Factor Surveillance System 

(BRFSS), AI/AN individuals have the second highest rate of binge alcohol use 

(18.2 percent) compared to white, non-Hispanic (21.2 percent), AI/ANs report 

the highest intensity of drinks per binge (8.4 drinks per binge episode) and the 

13 

2 Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report—United States, 2013. MMWR 2013;62(Suppl 3):[77–80] http://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a13.htm 3 Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings (http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/ 

NSDUHresults2013.pdf) 4 CDC Morbidity and Mortality Weekly Report (MMWR) http://www.cdc.gov/mmwr/preview/ 

mmwrhtml/su6203a27.htm?slcid=su6203a27lw#x2014;%20United%20States,%201999–2010</ 

a>) 5Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set 

(2012 data). 

highest frequency of binge drinking episodes (4.5 during the past 30 days) compared with other racial/ethnic groups. 2

• The rate of tobacco use among the AI/AN population (40.1 percent) is higher 

than all other racial/ethnic groups. 3

• American Indians and Alaska Natives are also more likely than other racial/ 

ethnic groups in the United States to die from drug-induced deaths (17.1 per 

100,000 people), according to 2010 National Vital Statistics System data reported in a 2013 Centers for Disease Control and Prevention (CDC) report on 

U.S. health disparities and inequities. 4

Substance Abuse Treatment 5

• 76.6 percent (33,401) of AI/AN treatment admissions reported alcohol as a substance of abuse. By comparison, 56.2 percent of non-AI/AN admissions reported 

alcohol as a substance of abuse. 

• Among admissions aged 15 to 24, 68.5 percent (6,885) of AI/AN admissions reported alcohol as a substance of abuse. In the same age group, 45.2 percent of 

non-AI/AN admissions reported alcohol as a substance of abuse. 

Improving Practice 

SAMHSA, as the Federal agency that leads public health efforts to advance the 

behavioral health of the nation, has several roles. I just spoke about the ways in 

which SAMHSA provides leadership and voice and supports the behavioral health 

field with critical data from national surveys and surveillance. SAMHSA also has 

a vital role in collecting best practices and developing expertise around prevention 

and treatment for people with mental illness and substance use disorders. 

SAMHSA’s staff includes subject matter experts that provide technical assistance 

and training to individuals, organizations, states, tribes, and others every day. 

The SAMHSA Tribal Training and Technical Assistance (TTA) Center uses a culturally relevant, evidence-based, holistic approach to support Native communities in 

their self-determination efforts through infrastructure development and capacity 

building, as well as program planning and implementation. It provides training and 

technical assistance on mental and/or substance use disorders, suicide prevention, 

and mental health promotion. It also offers training and technical assistance, ranging from broad to focused, to federally recognized tribes, SAMHSA tribal grantees, 

and tribal organizations serving Indian country. 

SAMHSA funds the National American Indian and Alaska Native Addiction Technology Transfer Center (ATTC), one of four National Focus Area ATTCs. The primary goal of the Center is to serve as a subject matter center of excellence in technology transfer for the AI/AN behavioral health workforce. The Center and the 

ATTC Network as a whole are charged with providing training and technical assistance to the behavioral health workforce. Building on the Network’s experience and 

evolution over the last 20 years, the Center is working with AI/AN behavioral 

health providers, peoples, organizations and communities to help develop and deliver effective culturally-relevant professional development and behavioral health 

services. 

The National Native Children’s Trauma Center (NNCTC) is funded by SAMHSA 

under the National Child Traumatic Stress Initiative to provide national expertise 

on childhood trauma among AI/ANs. NNCTC works in collaboration with Indian 

Health Service (IHS) providers, tribal leadership, and other representatives in tribal 

communities to utilize evidence-based, culturally-appropriate, trauma-informed 

interventions for AI/AN children, youth, and military families who experience disproportionate childhood trauma, violence, grief, poverty, historical and 

intergenerational trauma. The Center serves as a national resource for consultation 

for AI/AN youth programming with a particular focus on working with school communities across the United States. 

14 

SAMHSA’s Center for the Application of Prevention Technologies (CAPT) Training 

and Technical Assistance Services is a national substance abuse prevention training 

and technical assistance system dedicated to strengthening prevention systems and 

the nation’s behavioral health workforce. Nationwide, SAMHSA’s CAPT provides 

state-of-the-science training and technical assistance to tribes supported under 

SAMHSA’s Strategic Prevention Framework and its Substance Abuse Prevention 

and Treatment Block Grant programs, as well as to tribal epidemiological 

workgroups and innovative local programs participating in SAMHSA’s Service to 

Science Initiative. Tribal governments are not required to waive sovereign immunity 

as a condition of receiving SAMHSA block grant funds or services. 

SAMHSA’s Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence (CFE) 

Native Initiative promotes prevention of FASD in Indian country. Native Americans 

have some of the highest rates of alcohol-related birth defects in the nation. The 

FASD CFE works across multiple disciplines to educate and train policymakers and 

providers, caregivers and communities, and individuals and families on how to help 

prevent alcohol-exposed pregnancy and improve the lives of individuals affected by 

FASD. 

Public Awareness and Support 

As part of SAMHSA’s highly successful ‘‘Talk. They Hear You.’’ underage drinking 

prevention campaign, a promotion video was recorded with Rod Robinson, the 

former Director of SAMHSA’s Office of Indian Alcohol and Substance Abuse. In the 

video, Mr. Robinson discusses materials developed to help prevent and reduce underage drinking in American Indian communities, and he responds to questions 

such as why underage drinking is an important concern for American Indian populations. He also communicates ways in which the ‘‘Talk. They Hear You.’’ materials 

will help parents and adult caregivers address underage drinking within tribal communities. The video is available on SAMHSA’s You Tube channel. 

Strategic Grant Making 

Tribal Behavioral Health Grants 

SAMHSA has made helping American Indians and Alaska Natives a priority. For 

several years, the President’s Budget for SAMHSA had requested funding for a new 

program specifically focused on tribal communities to address the high incidence of 

substance use and suicide in AI/AN youth and young adult populations. In Fiscal 

Year (FY) 2014, Congress appropriated for the first time $5 million to begin such 

a program, Tribal Behavioral Health Grants (TBHG). In FY 2014, SAMHSA awarded 20 Tribal Behavioral Health grants to tribes or tribal organizations with high 

rates of suicide to develop and implement a plan that addresses suicide and substance use (including alcohol) and is designed to promote mental health among tribal youth. Grantees such as the Selawik Village Council in Alaska, the Turtle Mountain Band of Chippewa Tribe in North Dakota, and the Pueblo of Nambe in New 

Mexico, indicated in their applications how they will incorporate evidence-based, culture-based, and practice-based strategies for tribal youth. Grantees are required to 

work across tribal suicide prevention, mental health, substance use prevention, and 

substance use disorder treatment programs to build positive behavioral health 

among youth Grantees will create or enhance effective systems of follow up for those 

identified at risk of suicide and/or substance use or mental health issues that could 

lead to suicide. With a focus on tribal traditions, interagency collaboration, early 

identification, community healing, and preventing future deaths by suicide, grantees 

connect appropriate cultural practices, intervention services, care, and information 

with families, friends, schools, educational institutions, correctional systems, substance use programs, mental health programs, foster care systems, and other support organizations for tribal youth. Attention to the families and friends of tribal 

community members who recently died by suicide is encouraged as well. In addition, 

technical assistance is provided to grantees through SAMHSA’s Tribal Technical Assistance Center to support their ability to achieve their goals. 

The President’s FY 2016 Budget for the TBHG program is $30 million, including 

$15 million in the Mental Health appropriation and $15 million in the Substance 

Abuse Prevention appropriation. This request represents an increase over the FY 

2015 Enacted Level of $10 million in the Mental Health appropriation and $15 million for a newly established line in the Substance Abuse Prevention appropriation. 

This funding expands work supporting Generation Indigenous, an initiative focused 

on removing possible barriers to success for Native youth. This initiative will take 

a comprehensive, culturally appropriate approach to help improve the lives and opportunities for Native youth. In addition to HHS, multiple agencies including the 

Departments of Interior, Education, Housing and Urban Development, Agriculture, 

Labor, and Justice, are working collaboratively with tribes to address issues facing 

15 

Native youth. The FY 2016 Budget would allow SAMHSA to expand activities that 

are critical to preventing substance use and promoting mental health and resiliency 

among youth in tribal communities. The additional funding would expand these activities to approximately 103 additional tribes and tribal entities. With the expansion of the TBHG program, SAMHSA aims to reduce substance use and the incidence of suicide attempts among tribal youth and to address behavioral health conditions which impact learning in Bureau of Indian Education-funded schools. The 

TBHG program will support mental health promotion and substance use prevention 

activities for high-risk tribal youth and their families, enhance early detection of 

mental and substance use disorders among tribal youth, and increase referral to 

treatment. 

The House Appropriations Committee (House Report 114–195) fully funds the THBG program for FY 2016 at the requested level of $30 million. However, the Senate Appropriations Committee (Senate Report 114–74) level funds the TBHG program for FY 2016 at just under $5 million. 

Strategic Prevention Framework-State Incentive Grant (SPF–SIG) Program 

The Strategic Prevention Framework-State Incentive Grant (SPF–SIG) program 

supports activities to help states and tribes build a solid foundation for delivering 

and sustaining effective substance use prevention services and reducing the consequences of substance use. Following the SPF five-step process, SPF–SIG grantees 

develop comprehensive plans for prevention infrastructure and systems at the state 

and tribal levels. Ultimately, SPF–SIG States/Tribes assist and support selected 

sub-recipient communities to implement effective programs, policies, and practices 

to reduce substance use and its related consequences. The SPF–SIG program provides the foundation for success of the SPF—Partnerships for Success (PFS) Grant 

Program. Grantees include: Confederated Salish & Kootenai Tribes (Montana); First 

Nation Community Healthsource (New Mexico); Leech Lake Band of Ojibwe (Minnesota); Nooksack Indian Tribal Council (Washington); Northern Arapahoe Tribe 

(Wyoming); Oklahoma City Area Inter-Tribal Health Board; Tanana Chiefs Conference, Inc. (Alaska); and Oglala Sioux Tribe and Lower Brule Sioux Tribe (South 

Dakota). 

Strategic Prevention Framework—Partnerships for Success State and Tribal 

Initiative (SPF–PFS) 

The Strategic Prevention Framework—Partnerships for Success State and Tribal 

Initiative (SPF–PFS) grant program was initiated in FY 2009 and one of its targeted goals is to help young American Indians and Alaska Natives with reducing 

substance use-related problems; preventing the onset and reducing the progression 

of substance use disorders; strengthening prevention capacity and infrastructure at 

the state and community levels in support of prevention; and leveraging, redirecting, and realigning statewide funding streams for substance use prevention. 

Since FY 2012, the SPF–PFS program has concentrated on addressing two of the 

nation’s top substance use prevention priorities: (1) underage drinking among persons aged 12 to 20; and (2) nonmedical prescription drug use among persons aged 

12 to 25. In 2014, SAMHSA funded all five tribal applicants for the SPF–PFS program. The grantees include: Cook Inlet Tribal Council in Alaska; the Montana Wyoming Tribal Leaders Council; and the Cherokee Nation in Oklahoma. 

Criminal Justice and Juvenile Justice 

SAMHSA is committed to enhancing substance use treatment services in existing 

adult tribal healing-to-wellness courts and in all juvenile treatment drug courts. 

SAMHSA’s Treatment Drug Courts grant program aims to break the cycle of criminal behavior, alcohol and/or substance use, and incarceration, including among Native Americans. The purpose of this program is to expand and/or enhance substance 

use treatment services in existing adult Tribal Healing to Wellness Courts and in 

any Juvenile Treatment Drug Courts, which use the treatment drug court model in 

order to provide alcohol and substance use disorder treatment (including recovery 

support services, screening, assessment, case management, and program coordination) to justice-involved individuals. With respect to the Juvenile Treatment Drug 

Courts program, in FY 2014, SAMHSA awarded a three-year grant to the Omaha 

Tribe of Nebraska. In addition, SAMHSA funded all three tribal applicants for the 

adult Tribal Healing to Wellness Courts in FY 2014. The grantees include: Lac Du 

Flambeau Band of Chippewa Indians (Wisconsin); Mescalero Apache Tribal Council 

(New Mexico); and Lower Brule Sioux Tribal Council (South Dakota). 

Nonmedical Prescription Drug Use and Opioid Use Disorder Treatment 

Nonmedical use of prescription medications takes a devastating toll on public 

health and safety. In 2013, NSDUH data showed that approximately 6.5 million 

16 

6 Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/ 

NSDUHresults2013.pdf 

Americans aged 12 or older reported current non-medical use of prescription drugs. 

In 2013, among persons aged 12 or older, the rate of current illicit drug use was 

12.3 percent among American Indians and Alaska Natives. 6 In response to this public health crisis, IHS established the Prescription Drug Abuse (PDA) workgroup and 

developed a multi-disciplinary task force to address six key focus areas: patient care, 

policy development/implementation, education, monitoring, medication storage/disposal, and law enforcement. SAMHSA and other Federal agencies have been active 

members of the IHS PDA workgroup in an effort to improve national coordination 

and collaboration. SAMHSA has national and regional resources that include: strategies for reducing nonmedical use of prescription drugs; prescriber and patient education; publications; prevention and early intervention; technical assistance; and 

prescription drug monitoring programs. The workgroup developed a PDA Resource 

Guide to support technical assistance, training and education for providers and communities. 

SAMHSA is also leading a number of activities in support of the HHS Secretary’s 

Opioid Initiative that focuses on three specific areas: opioid prescribing practices to 

reduce opioid use disorders; naloxone development, access, and distribution; and, 

medication-assisted treatment to reduce opioid use disorders and overdose. 

SAMHSA will be working with IHS to improve training in the use of medicationassisted treatment, the standard of care for opioid use disorders, by providers in AI/ 

AN communities. 

Supporting Successful Recovery 

SAMHSA has also funded a number of programs that focus on recovery support 

in AI/AN communities. The Inter-Tribal Council of Michigan’s ‘‘Anishnaabek Healing Circle, ATR Network’’ was funded to improve access to a full array of treatment 

and recovery supports through network of culturally competent providers. The grant 

focused on tribal youth aged 12 and older who were enrolled members of the federally recognized tribes in Michigan. 

Conclusion 

Thank you again for this opportunity to discuss SAMHSA’s role in addressing the 

issue of substance use that is exacting significant health and economic tolls in Native communities. The issue is a major priority for SAMHSA, and recent activities 

such as the establishment of our OTAP underscore our dedication. 

The CHAIRMAN. Thank you very much for your testimony. Now, 

Melanie Benjamin. 

STATEMENT OF HON. MELANIE BENJAMIN, CHIEF EXECUTIVE, 

MILLE LACS BAND OF OJIBWE 

Ms. BENJAMIN. Thank you, Mr. Chairman, Senator Franken and 

members of this Committee. 

Like most tribes, our fight against alcohol addiction has been ongoing for more than a century as a byproduct of colonization. In the 

1980s, crack and meth invaded our communities. My focus today 

is on a terrible family of drugs now hitting our Minnesota tribal 

communities, claiming our youngest and most precious as victims, 

our babies, our future. 

Minnesota now leads the Nation in babies being born addicted to 

opiates. It is with profound sadness and concern that I report that 

my community is among the hardest hit. Babies born addicted to 

opiates are now the single greatest threat to the future of my band. 

The opiate explosion in Minnesota is so new that there is a great 

deal of information we do not know yet. Here is what we do know. 

Prescription opiates, including Vicodin, OxyContin, Percoset, morphine and codeine are each a pathway to heroin use. Nearly, 100 

percent of heroin addicts repot their addiction began with an opiate 

17 

prescription. More than 28 percent of the babies born addicted to 

opiates in Minnesota are Native Americans, even though we are 

only about 2 percent of the population. 

Seventy-eight percent of opiate-addicted Indian babies are born 

in rural Minnesota. So this is more of a reservation problem. Indian women are 8.7 times more likely than non-Indians to be diagnosed with opiate dependency or abuse during pregnancy. Fiftyseven percent of these women have a legal opiate prescription for 

pain given to them by a doctor, even throughout pregnancy, 57 percent, Mr. Chairman. 

The Mille Lacs Band is conducting a study that appears to show 

that our band members may be rapid metabolizers of many addictive drugs. This means that those who are addicted need more of 

the drug more frequently in order to maintain that effect, which 

means higher addiction rates. Babies born addicted to opiates go 

through horrifying withdrawal, struggling with pain, seizures, 

rapid breathing, sweating, trembling, vomiting, diarrhea, slow 

weight gain. They are at a high risk of premature birth and sudden 

infant death syndrome. 

The financial costs are high. Last year 262 Indian babies were born with opiate addiction in Minnesota and cost about $8 million 

in medical care during withdrawal. That is about $30,000 per baby, 

and this is in the first year. But the social and financial costs continue to mount after their hospital stay. Most of these babies must 

be placed in foster care until the mother is able to care for them. 

But when the baby is removed, all the other children in the home 

are also usually removed as well. 

Mr. Chairman, we simply do not have enough Native foster families to take in this high number of children, nor do we have enough 

resources. Their medical issues are complex and may include high 

rates of cerebral palsy and other serious complications, the same 

as with victims of fetal alcohol syndrome. FAS spending can average $2 million over the lifetime of a child. 

My written statement goes into more detail about associated 

costs. But I want to close with providing you with some suggestions 

of what Congress can do. We need research to study this crisis. We 

must know more about the long-term impacts of newborn opiate 

addiction. We need funding for a culturally-based treatment center 

for pregnant Native women in Minnesota. Currently the only program like this in Minnesota has just 21 beds. At Mille Lacs alone, 

we had 21 babies born addicted to opiates in 2014. 

We need support to mount a massive public education campaign 

to highlight the risks of opiates. And we need the Federal and 

State governments to crack down on physicians who are prescribing these dangerous drugs without good reason. In the late 

1800s, a genocide nearly occurred after Indian people were given 

blankets infested with smallpox. Dr. Barrasso, for Indian Country, 

opiates are a 21st century version of smallpox blankets. 

There is no reason for a teenager with depression to be prescribed Vicodin, but it happens every day. We need the medical 

community and the pharmaceutical companies to step up and police themselves. If they will not, then we ask you to help us police 

them. As tribal leaders we cannot do this by ourselves. 

Thank you, Mr. Chairman. 

18 

[The prepared statement of Ms. Benjamin follows:] 

PREPARED STATEMENT OF HON. MELANIE BENJAMIN, CHIEF EXECUTIVE, MILLE LACS

BAND OF OJIBWE


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The CHAIRMAN. Thank you, and I especially want to thank you 

for that list of suggestions. It wasn’t just one thing, it was an entire list and a broad list and encompasses a lot of different areas. 

I think that is going to be one of the most helpful parts of this 

Committee hearing today. Thank you very much for that. 

Next is Mr. John Walters. Mr. Walters, thank you for being with 

us. Please proceed. 

STATEMENT OF HON. JOHN P. WALTERS, CHIEF OPERATING 

OFFICER, HUDSON INSTITUTE 

Mr. WALTERS. Thank you, Mr. Chairman, members of the Committee. I am the former director of the Office of Drug Control Policy 

from the last Administration and am now the Chief Operating OffiVerDate Mar 15 2010 11:00 May 04, 2016 Jkt 099990 PO 00000 Frm 00038 Fmt 6633 Sfmt 6601 S:\DOCS\99990.TXT JACK

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cer of the Hudson Institute and Co-Director of the Center on Substance Abuse Policy Research. 

I am pleased to be with you and pleased to be with some of the 

people who are working with Native American and Alaska Native 

communities as I did back when I was in government. 

I will not repeat the detail not only in my testimony, but you 

have already heard about the disproportionate effect of substance 

abuse in Indian Country. It is staggering. The estimates of national 

cost of $200 billion or $600 billion don’t capture the real human 

cost. These are our models, they are imprecise. The data here is 

embarrassingly bad. 

What we should do and what we can do to get national leaders 

and local leaders better help is begin to look at the problem as if 

it were as serious to us as it is to the people living in these communities. 

First thing I would recommend is that someone direct the Centers for Disease Control to treat this as an epidemic and begin to 

collect monthly data and precise geographic monthly data on the 

spread of this disease. If this were a virus, the Centers for Disease 

Control, I can tell you from my experience, resists this topic. It 

doesn’t like substance abuse, in my experience. I have been out of 

government a while and maybe attitudes have changed. It also 

wants to say that it only deals with infectious diseases. That is not 

acceptable. The cost and the devastation is too high and you need 

to localize the particular knowledge about the spread of these phenomenon, because they are an epidemiological phenomenon. 

And if you are going to tie resources where they are needed, you 

need to know where the problem is and you need to know how well 

the resources are reaching the people who need them. That is not 

happening. And it is unacceptable, in my view. 

In addition, I think it is important to recognize that we do not 

do a very good job of providing the care, as you have heard from 

previous witnesses. Even if we expand resources under the Affordable Care Act and other programs, the problem is that the geographic isolation, the limits of infrastructure, the limits of referral 

and support programs after immediate detoxification and other 

services create a failure of treatment to work in these communities 

and a failure of prevention to be effective and comprehensive. 

We need to be more specific about how we can create targeted, 

culturally sensitive programs in these areas. Demonstration programs are nice, but demonstration programs are by definition inadequate to meet the real need. There has to be a plan and a consistent effort. I think someone in the Federal Government has to 

be targeted such that their job is on the line to give you a solution 

that reaches the real scope and focus of the problem. And given a 

fixed period of time, not four years and not eight years. 

I started working on the drug problem in the Reagan Administration at the Department of Education. The same agencies have 

been telling you they are going to get a national plan with real estimates and real achievement and real output data for decades. It 

is not happening. 

So until somebody’s job in six months or twelve months or eighteen months is to produce such a plan or be fired, it is not going 

to happen. 

36 

1http://www.cdc.gov/minorityhealth/populations/REMP/aian.html 

In addition, I want to just mention in connection with the overall 

problem the danger that was referred to, Mr. Chairman, in your 

opening remarks. There is now a movement to legalize the production of marijuana on Native land. On top of all that you have heard 

of the consequences of addiction and substance abuse, in all the 

areas you have heard of those consequences, this is devastating. If 

there ever was a bad idea that we ought to stop, it is this one. And 

of course, it doesn’t just affect people in Indian Country. But it is 

a terribly, terribly destructive additional harm that we are inflicting on people who are already suffering. 

My testimony goes into detail about the latest research and what 

the findings are for educational, health, illness, violence, and other 

problems including family violence associated with marijuana and 

its connection to other substance abuse. It is worsening with regard 

to impaired driving, as well as educational performance. Recent research has suggested very strongly in multiple cases that the current high potency marijuana has the ability to not only reduce the 

educational performance but perhaps permanently reduce i.q. in 

young people. That is not the kind of additional ingredient we need 

to add to the mix here. 

In terms of the promises of profits, my testimony has some of the 

research that suggests this is as illusory as it is to say the taxes 

on alcohol are paying the cost of alcoholism in Indian Country. It 

is a lie. It is not going to happen and it is never going to happen. 

In short, I would say for the purposes of this Committee, we need 

to have not only a better understanding of the cost but how to 

drive our resources effectively to scale our resources and to hold 

people accountable. We can do that at the Federal level. But in addition, we are at a crossroads now with this latest movement. We 

can not only improve, but we also need to stop something that is 

going to be devastating to people who live in these communities 

who have already suffered enough. 

With that, I am going to conclude. I will be happy, when it is my 

turn, to answer any questions. 

[The prepared statement of Mr. Walters follows:] 

PREPARED STATEMENT OF HON. JOHN P. WALTERS, CHIEF OPERATING OFFICER, 

HUDSON INSTITUTE

Chairman Barasso, Vice Chairman Tester, and members of the Committee, thank 

you for this opportunity to address the public health and public safety issues surrounding the costs and consequences of substance abuse on the Native population 

of the United States. 

In this testimony, I will briefly review what is currently known about the consequences of substance abuse on Native American and Alaskan Native communities—specifically focused on costs, expressed both in public health and in dollars. 

I also wish to draw attention to treatment need and address proposals to expand 

access to marijuana in these communities. 

According to a recent report from the Centers for Disease Control and Prevention 

(CDC) on minority health populations, there are 566 Federally-recognized tribes 

plus an unknown number of tribes that are not Federally-recognized, each with its 

own culture, beliefs, and practices. 1

As the CDC report notes, according to U.S. Census Bureau in 2013, there were 

roughly 5.2 million American Indians and Alaska Natives living in the U.S., representing approximately 2 percent of the U.S. total population. 

37 

2http://www.justice.gov/archive/ndic/pubs44/44731/44731p.pdf 

3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449826/ 

4http://www.nbcnews.com/id/26439767/ns/health-addictions/t/native-american-deaths-alcohol-related/#.VbOpcVy76fR 

The projected U.S. population of American Indians and Alaska Natives for July 

1, 2060 is estimated to reach 11.2 million, constituting approximately 2.7 percent 

of the U.S. population by that date. 

In the 2010 U.S. Census, tribal groupings with 100,000 or more responses were: 

Cherokee (819,105), Navajo (332,129), Choctaw (195,764), Mexican American Indian 

(175,494), Chippewa (170,742), Sioux (170,110), Apache (111,810), and Blackfeet 

(105,304). 

In 2013, there were 14 states(with more than 100,000 American Indian and Alaska Native residents: California, Oklahoma, Arizona, Texas, New Mexico, Washington, New York, North Carolina, Florida, Alaska, Michigan, Oregon, Colorado and 

Minnesota. 

In 2013, the(states with the highest percentage of American Indian and Alaska 

Native population were Alaska (14.3 percent), followed by Oklahoma (7.5 percent), 

New Mexico (9.1 percent), South Dakota (8.5 percent), and Montana (6.8 percent). 

A precise accounting of the true costs of substance abuse on Natives is difficult 

to establish, owing in large measure to deficiencies in our data sets, which is an 

on-going and frankly disturbing incapacity affecting all of drug policy. Broadly, for 

the United States population as a whole, estimates have been provided showing approximately $193 billion per year (measured in 2011 based on 2007 datad the figure 

has since been updated to $209 billion in 2009 dollars) as the costs to society of illicit drug use. The majority of those costs are attributed to law enforcement activities, lost productivity, and public health/health care impact. 2

Some proportion of those costs can be allocated to Native communities, but we 

must acknowledge that the true impact is almost surely far worse than one would 

find by simply dividing those costs by population share. Native communities are adversely situated with regards to substance abuse impact, in many instances facing 

vulnerabilities driven by, among other issues, poverty, geographic remoteness, and 

insufficient health care resources. Even in circumstances where the largest Native 

populations are found in urban settings, similar vulnerabilities pertain. 

In addition to the economic costs, we must acknowledge the personal and social 

costs measured in both lives and human potential lost, as well as diminished economic opportunity and well-being. 

The current human cost is staggering. As measured by the National Survey on 

Drug Use and Health (NSDUH), in 2013, American Indians and Alaskan Natives 

had the highest rate of substance abuse or dependence when compared to other racial or ethnic groups. The percentage who needed treatment for an alcohol or illicit 

drug use problem in the past year was nearly 88 percent higher than the national 

average for adults. 

Such high rates of abuse/dependence are linked with a host of health problems, 

including premature death. Yet the Substance Abuse and Mental Health Services 

Administration (SAMHSA) of the Health and Human Services Department (HHS) 

reports that Native Americans and Alaskan Natives are not well served by the publically-funded health care system. For instance, they are three times more likely 

than whites to lack health insurance, with approximately 57 percent depending on 

the Indian Health Service for treatment care. 

While the Affordable Care Act allows for enrollment in state exchanges for Natives, a 2004 study in the American Journal of Public Health found that less than 

half of low-income uninsured Native Americans/Native Alaskan had access to Indian 

Health Service care. 3

The American Psychiatric Association Fact Sheet on Mental Health Disparities 

American Indians and Alaskan Natives summarized what we know all too well 

about the struggle of Native communities. Natives are twice as likely to live in poverty than the rest of the US population, have lower life expectancy, higher infant 

mortality, and two and a half times the rate of violent victimization faced by whites. 

They face significantly higher rates of death from tuberculosis, diabetes, unintentional injury, while dying from alcohol-related causes at significantly higher rates 

than the national average. 

In 2008, the Centers for Disease Control and Prevention (CDC) released a report 

finding nearly 12 percent of deaths, between 2001 and 2005, among Native Americans/Alaskan Natives to be alcohol related, compared to 3.3 percent nationally. 4 Finally, suicide is the second leading cause of death for those between ten and thirtyfour years of age. 

38 

5http://www.rand.org/content/dam/rand/pubs/testimonies/2009/RANDlCT334.pdf 6http://www.ajpmonline.org/article/S0749-3797(11)00538-1/fulltext 

7https://www.whitehouse.gov/ondcp/frequently-asked-questions-and-facts-about-marijuana 

According to the White House 2014 Native Youth Report, more than one in three 

Native youth live in poverty, while their rate of high school graduation (67 percent) 

is the lowest of any racial/ethnic group across all schools, falling to 53 percent for 

Bureau of Indian Education schools, compared to a nationwide rate of 80 percent 

graduation. 

The lessons are painfully clear. In regards to the substance abuse of Native Americans, there is one thing that we must do, and one thing that we must not do. 

Finding ways to increase resources for substance abuse treatment is the critical 

one thing that we need to advance. Targeted, culturally-competent, and tailored specialty treatment drug and alcohol programs, especially for youth, are urgently needed. 

Even with expanded potential health care access offered under the Affordable 

Care Act, substance abuse treatment parity will be difficult to obtain in reality. Regardless of insurance coverage, insufficient access to treatment providers, both physicians and treatment facilities, will hinder the actual delivery of services. 

And now the thing that we must not do: either willfully or inadvertently increase 

the burden in their lives by making things worse. For instance, allowing the cultivation, production, and sale of marijuana on Native lands, either through programs 

of so-called medical marijuana dispensing or by outright commercial legalization, 

would be perversely the wrong thing to do, and would actively foster harm. 

This preventable harm would begin with increased drug availability, use, and addiction and all the related threats they pose to public health. It will also create 

greater threats to public safety by increasing the risk of enhanced drug smuggling 

and black market activities by criminal organizations. Additionally, there is a serious risk of corruption and loss of integrity for banking and governance through the 

presence of a cash business illegal at the federal level. 

These threats would affect Native peoples, as well as neighboring non-Native communities. 

Some have argued that Native communities might benefit economically from 

being allowed to operate commercial operations involving marijuana, the cultivation 

and sale of which might generate jobs and tax revenue for those on Reservations. 

It is my judgment that such benefits are illusory, and that whatever economic benefit is promised will be overwhelmed by the accompanying criminal justice and public health costs that will accrue to communities that pursue such paths. 

Experience has shown us that in the presence of legalized marijuana markets, 

price declines, availability increases, prevalence rates rise, and one still finds the 

operation of a criminal black market. Potential financial savings from legalization 

and taxation fail to account for the economic and social costs of drug use. As a 

RAND Corporation study argued, legal marijuana places a dual burden on tribal 

governments of regulating the new legal market while continuing to pay for the negative effects associated with the underground market, which likely will be enhanced 

in the legalized environment. 5

There is a basis for my doubts concerning net benefits found in studies of alcohol 

markets. Some studies 6 have estimated, for 2009 dollars, that federal and state revenues from alcohol sales total no more than six percent of the $237.8 billion in alcohol-related costs from health care, treatment services, lost productivity and criminal 

justice imposed by alcohol use. 

Similar ratios can be expected for any commercial marijuana market. We have 

learned already from our experience in Colorado that users will evade regulated taxation schemes, and whatever revenue is attained will be swamped by the accompanying costs associated with drug use. In circumstances where treatment resources 

are already inadequate, and facing a population already at great risk for negative 

consequences, the promise of revenue and benefit for these communities is a misguided hope. 

Simply put, offering more drugs is a bad bargain, especially for communities already struggling under the weight of history, oppression, marginalization, and impoverishment. 

Further, Native communities that might chose to engage in marijuana cultivation 

and production will face additional negative impact on their already stressed environment. Marijuana cultivation results in chemical contamination, degraded water 

supplies, elimination of native vegetation, wildlife alteration, toxic wastes and garbage, food chain contamination, and wildfire risks, according to studies by the National Park Service of the Department of the Interior. 7

39 

8http://www.latimes.com/business/la-fi-marijuana-indians-20141211-story.html 

9http://www.dutchamsterdam.nl/686-amsterdam-coffeeshops-organized-crime 

10hhttps://www.washingtonpost.com/world/europe/new-law-threatens-amsterdams-cannabisculture/2012/05/03/gIQAvQ570Tlstory.html 11http://www.washingtonpost.com/blogs/govbeat/wp/2015/02/18/group-opposed-to-legalmarijuana-plans-to-sue-colorado-and-industry-participants/ 12https://www.washingtonpost.com/world/national-security/new-law-offers-a-sliver-of-protection-to-abused-native-american-women/2014/02/08/0466d1ae-8f73-11e3-84e1- 

27626c5ef5fblstory.html 13http://www.justice.gov/tribal/violence-against-women-act-vawa-reauthorization-2013-0 14https://www.washingtonpost.com/world/national-security/3-tribes-authorized-to-prosecutenon-native-american-men-in-domestic-violence-cases/2014/02/06/27bc1044-8f58-11e3-b46a5a3d0d2130dalstory.html 15https://supreme.justia.com/cases/federal/us/435/191/case.html 

These negative effects and costs would come in addition to current degradation 

of Native lands associated with the operations of criminal organizations, which currently traffic marijuana and other drugs through Native territory, often with legal 

impunity because of jurisdictional complexities. 

And now let us turn in greater detail to the specifically human cost, especially 

to youth. Marijuana is the most widely-used illegal drug in the United States, and 

the health impairments associated with this drug, especially in newer high potency 

forms, are well known. 

Yet the Department of Justice (DOJ) has issued a determination that Native 

American reservations may become centers for ‘‘legal’’ marijuana sales and use, notwithstanding that this policy stands in stark violation of the federal Controlled Substances Act. 8

The Attorney General’s subcommittee on Native American issues has proposed to 

allow growing or selling marijuana on ‘‘sovereign’’ lands, even if encompassing state 

law, as well as federal law, prohibit the practice. Moreover, DOJ has expressed that 

there will be no federal law enforcement on their lands if a tribe does express opposition. 

This new push for expanding marijuana use is legally suspect on many grounds. 

Prior DOJ memoranda suspending enforcement of federal law, such as in Colorado, 

were contingent on the alignment of marijuana sales and use with prevailing state 

laws or regulatory regimes. But Native reservations are not legally equivalent to 

statesd rather, they are ‘‘dependent domestic sovereigns,’’ broadly subject to federal 

law. Hence, the proposal appears contradictory on the face of it. 

But there is worse in store. The impact on both Native Americans and upon the 

broader principles of political and economic integrity is deeply damaging. 

Native history teaches that they have suffered as much from well intentioned but 

devastating policies offered by ‘‘friends’’ as they have from the malign attacks from 

those who sought to destroy their cultures. 

In addition to the damage from addiction, there is damage to the wider community. Internationally, ‘‘legal’’ drug markets are known to be accompanied by organized crime, 9 prostitution, theft, violent coercion, neighborhood degradation, and 

economic loss, as documented by the Netherlands’ 10 ‘‘cannabis cafes.’’ Meanwhile, 

Colorado is already experiencing law suits 11 filed by businesses claiming harm from 

marijuana sales operations, based on racketeering and organized crime statutes. 

There is the threat to Native lives from ongoing substance abuse, which shows 

a history of degradation, violence, and pathology for First Americans. As we have 

seen, alcohol and marijuana abuse is pronounced, while heroin and methamphetamine are established criminal threats, especially for tribes adjacent to Southwest 

Border smuggling routes, which exploit the interstitial nature of Reservation boundaries and competing jurisdictions. 

Let me conclude with a brief review of recent studies of marijuana use in association with negative health and criminal justice outcomes, associations that are of 

particular pertinence to Native populations. 

As reported by the Washington Post, 12 last year Congress approved a law 13 that 

for the first time will allow Indian tribes to prosecute certain crimes of domestic violence committed by non-Indians in Indian country. The Justice Department announced it had chosen three tribes for a pilot project to assert the new authority. 14

In 1978, in a case widely know in Indian country as ‘‘Oliphant,’’ 15 the Supreme 

Court held that Indian tribes had no legal jurisdiction to prosecute non-Indians who 

committed crimes on reservations. Even a violent crime committed by a non-Indian 

husband against his Indian wife in their home on the reservation could not be prosecuted by the tribe. 

While it is laudable to have domestic violence addressed, there is a striking irony 

when seen in relation to the proposed marijuana measure. A recent study of factors 

40 

16http://jiv.sagepub.com/content/27/8/1562.abstract 17http://onlinelibrary.wiley.com/doi/10.1111/acer.12698/abstract 18http://www.ncbi.nlm.nih.gov/pubmed/25772435 19http://www.ncbi.nlm.nih.gov/pubmed/25929200) 20http://www.ncbi.nlm.nih.gov/pubmed/25955962 21http://www.hudson.org/research/11298-marijuana-and-school-failure 22http://www.hudson.org/research/10777-why-we-believe-marijuana-is-dangerous 23http://www.fincen.gov/statuteslregs/guidance/pdf/FIN–2014–G001.pdf 24http://www.nigc.gov/LinkClick.aspx?fileticket=0J7Yk1QNg-0%3D&tabid=943 25http://www.huffingtonpost.com/2012/01/22/indian-casinos-debtlnl1222121.html 26http://www.denverpost.com/business/cil27284773/united-cannabis-denver-help-calif-indian-tribes-grow 

driving domestic violence found that consistent use of marijuana in adolescence was 

the single most predictive factor examined. 16

How could it possibly help the tragedy of domestic partner violence to increase 

access and use of marijuana? 

Sadly, very similar questions can be asked regarding the association of marijuana 

use explicitly with the social and public health threats faced by Native communities. 

Alcohol and drunk driving are already threats faced on many Reservations. Yet a 

recent study 17 found that concurrent marijuana use worsened these risks, approximately doubling the odds of drunk driving, social consequences, and harms to self. 

Native youth are at particular risk of suicide. Yet perversely, an increase in suicidal ideation is associated with all levels of marijuana use, regardless of duration. 18

Faced with sexual abuse and unintended pregnancy, tribes should know that in 

a study of African American girls, use of marijuana at last episode of sex is associated, for youth, with non-use of condoms, acquisition of sexually transmitted diseases (STD), and unintended pregnancy. 19

And in the context of the unemployment challenges faced by many tribes, according to recent research, chronic use of marijuana increases the risk of unemployment. 20

These are just a few of the recent findings, supplementing a well-established host 

of research results showing marijuana use, particularly in adolescence, associated 

with serious psychological problems, such as schizophrenia, depression, and psychosis, including findings that marijuana use is associated with a greater than 60 

percent increase in school drop out risk. 21

How conceivably could adding increased supply (and acceptability) of an addictive 

drug associated with psychosis, IQ and learning loss, increased susceptibility to suicide, school failure and greater need for drug treatment, be anything other than a 

needless disaster? 22

But there is another threat emerging, one that portends to affect all Americans. 

Consider that Southern California alone is home to nearly 30 recognized Indian 

tribes, with a total population of nearly 200,000. Were they to become purveyors of 

marijuana, by the experience of Colorado, they could quickly become ‘‘smuggling 

centers’’ for black market marijuana distribution to surrounding communities and 

states. 

Reservation boundaries could turn into ‘‘domestic borders’’ comparable to international borders, where drug operations by criminal organizations thrive in driving 

illegal cultivation and trafficking. 

This also presents an obvious course for fueling corruption in reservation politics, 

and equally worrying, U.S. financial affairs, for the emerging market in illicit drugs 

threatens our economic integrity nationwide. Not only has the DOJ set about dismantling, in states that have legalized, basic banking and money-laundering protections against criminal organizations penetrating the financial system, 23 there is further risk from another center of illicit finance and money-laundering: The cash business of casinos. 

There are nearly 500 Indian ‘‘gaming’’ operations found in nearly 30 states, 24 and 

while the revenues are great (estimated at $27 billion annually), many are in serious debt. 25 What would another cash business, dealing in addiction and in violation 

of federal law, presumably paying no federal taxes, do to tribal integrity? What 

could this contribute to the power of transnational criminal cartels? 

Already, marijuana-related law firms from Colorado are guiding those tribes with 

casinos in setting up high-potency marijuana operations. 26 The potential for public 

corruption is high, as is the certainty of increased suffering within America’s Native 

communities. 

In conclusion, it is clear that we need an integrated substance abuse strategy for 

responding to the current health crisis faced by Native Americans, and that response must include greater support for prevention and treatment programs. 

41 

In addition to the traditional threat of alcohol, Native communities today are at 

risk from rising heroin and methamphetamine use and the presence of criminal operations within their borders. These are extremely tough challenges. But one thing 

that is directly in our hands is to refuse to do greater harm. 

It should be painfully clear that greater harm is precisely the most likely outcome 

from increased access and availability of high-potency marijuana in Native communities. It would be irresponsible of us to allow this to happen. 

Thank you. 

The CHAIRMAN. Thank you very much for your testimony and for 

your passion. Thank you, Mr. Walters. 

Now, Sunny Goggles. 

STATEMENT OF SUNNY GOGGLES, DIRECTOR, WHITE 

BUFFALO RECOVERY PROGRAM, ARAPAHO TRIBE, WIND 

RIVER RESERVATION 

Ms. GOGGLES. Thank you to Chairman Barrasso and Committee 

members for inviting me to testify on this important subject. I 

come to you from one of the most beautiful places in the world, The 

Wind River Reservation in Wyoming. Our community is rich in culture and tradition and we are blessed with our youth shining with 

promise and potential. And we are struggling. 

We suffer high rates of alcohol and drug abuse as well as unemployment and poverty. Our beautiful community has been classified 

as notorious, deadly and renowned for brutal crime in the media. 

We directly see and feel the cost of alcohol and drug abuse in our 

community. 

Many times we think of the cost of alcohol and drug abuse and 

we focus on the financial costs. We consider how much money we 

are spending on the justice system, including law enforcement, 

courts and corrections. On Wind River, over 90 percent of the crime 

is drug and alcohol related. There are also the costs to victims of 

crime, property destruction and theft. 

In 2014, a victim incurred over $500,000 of medical costs from 

one single incident. Medical costs related to alcohol and drug abuse 

deplete already limited resources in our community. On Wind 

River, those high-cost patients that abuse alcohol and tobacco outnumber patients who do not use 16 to 5. High-cost patients are 

those that incur over $100,000 of expenses in a year. 

Employers lose thousands of dollars a year due to high turnover 

rates in our community. There is an increase in the rate of illness 

and job abandonment due to alcohol and drugs. If a person is willing to get help, the cost of treatment includes the average stay of 

inpatient at $450 a day. For a stay of 90 days for one person, it 

is over $40,000. 

In 2014, at the White Buffalo Recovery Program in Arapaho, we served over 100 individuals. The cost is $4 million to accommodate 

this need. This is not considering the cost of transportation to and 

from the closest inpatient facility, which is 264 miles away from 

our community. Families who would like to participate and support 

an individual must travel these distances also. 

Many of these individuals have always lived on the reservation 

in which they are the majority. We place them in these facilities 

where they are subject to a minority experience for months. Facilities are limited in knowledge and understanding of Native culture 

42 

and tradition and treatment is a difficult process. We expect somebody to change their life in a matter of months. 

Alcohol and drug abuse is not limited to the person. Children, 

parents, grandparents, aunts and uncles suffer the costs of their 

family members’ abuse. It is overwhelming to watch a family member destroy their life with alcohol and drugs. This can lead to family members felling anxiety, fear, anger, concern, embarrassment or 

guilt and shame. 

Due to the correlation with violence, many families are subject 

to trauma from witnessing violence or being subject to physical or 

sexual abuse. This adds pressure to the limited resources of mental 

health services and social services. 

One of the most devastating costs is the human cost, the loss of 

life which can never be included in an additional line item on next 

year’s budget. No amount of funding can replace this cost. On Wind 

River, 76 percent of unnatural deaths, such as accidents, suicide 

and homicide, are alcohol and drug related. Alcohol and drug use 

increases the odds of death 16.9 times and equals 42.3 years of life 

lost in our community. 

Cancer, heart disease, cirrhosis and diabetes are also major 

causes of death to our tribal population in Wyoming, and are directly related to or contributed to by substance abuse. Individuals 

that use alcohol are more likely to die at 35 to 39 years of age on 

Wind River. Based on mortality rates in our close-knit community, 

we lose a life nearly every week of the year. The loss of life contributes to more trauma on our families and our community. The loss 

of a tribal member is also a cost to our language, our culture, our 

traditions and our future. 

It is disheartening to think of all these costs to a real life, especially because it is preventable. Thank you. 

[The prepared testimony of Ms. Goggles follows:] 

PREPARED STATEMENT OF SUNNY GOGGLES, DIRECTOR, WHITE BUFFALO RECOVERY

PROGRAM, ARAPAHO TRIBE, WIND RIVER RESERVATION

Tous’ Neneeninoo Nii’eihii Honobetouu. Thank you to Chairman Barrasso and 

committee members for inviting me to testify on this important subject. I come to 

you from one of the most beautiful places in the world, the Wind River Reservation 

in Wyoming. My community is rich in culture and tradition. We are blessed as our 

youth shine with promise and potential. 

And we are struggling. We suffer high rates of alcohol and drug abuse as well 

as unemployment and poverty. Our beautiful community has been classified as ‘‘notorious’’, ‘‘deadly’’ and ‘‘renowned for brutal crime’’ in the media. We directly see and 

feel the costs of alcohol and drug abuse on our community. 

Many times when we think about the costs of alcohol and drug abuse we focus 

on the financial costs. We consider how much money we are spending on the justice 

system including law enforcement, courts and corrections. On Wind River over ninety percent 90 percent of the crime is drug and alcohol related. There are also the 

costs on victims of crime, property destruction and theft. In 2014 a victim incurred 

over $500,000 dollars of medical costs in one single incident. 

Medical costs related to alcohol and drug abuse deplete already limited resources 

in our community. On Wind River those high cost patients that abuse alcohol and 

tobacco outnumber patients who do not use, 116 to 5. High cost patients are those 

who incur more than $100,000 of expenses in a year. 

Employers loose thousands of dollars a year due to high turnover rates in our 

community. There is an increase in the rate of illness and job abandonment due to 

alcohol and drugs. 

If a person is willing to get help, the cost of treatment services include the average stay in inpatient at $450 per day. For a stay of ninety days for one person is 

over $40,000. In 2014 at the White Buffalo Recovery program in Arapaho, we served 

43 

over 100 individuals that were in need of this level of care. The cost is four million 

dollars to accommodate this need. This is not considering the cost of transportation 

to and from the closest inpatient facility which is 264 miles from our community. 

Families that would like to participate and support an individual must travel these 

distances also. Many of these individuals have always lived on the reservation in 

which they are a majority. We place them in the facilities where they are subject 

to a minority experience for months. Facilities are limited in knowledge and understanding of Native culture and tradition. And treatment is a difficult process. We 

expect someone to change their life in a matter of months. 

Alcohol and drug abuse is not limited to the person. Children, parents, grandparents, aunts and uncles suffer the costs of their family member’s abuse. It is overwhelming to watch a family member destroy their life with alcohol and drugs. This 

can lead to family members feeling anxiety, fear, anger, concern, embarrassment 

and guilt or shame. Due to the correlation with violence many families are subject 

to trauma from witnessing violence or being subject to physical or sexual abuse. 

This adds pressure to the limited resources for mental health services and social 

services. 

One of the most devastating costs is the human cost. The loss of life which can 

never be included in an additional line item on next year’s budget. No amount of 

funding can replace this cost. On Wind River 76 percent of unnatural deaths such 

as accidents, suicide and homicide are alcohol and drug related. Alcohol and drug 

use increase the odds of death 16.9 times and equal 42.3 years of life lost in our 

community. 

Cancer, Heart Disease, Cirrhosis and Diabetes are also major causes of death to 

the tribal population in Wyoming and are directly related to or contributed to by 

substance abuse. Individuals that use alcohol are more likely to die at 35 to 39 

years of age on Wind River. Based on mortality rates in our close knit community 

we lose a life nearly every week of the year. 

The loss of life contributes to more trauma on our families and community. The 

loss of a tribal member is also a cost of our language and culture, our traditions 

and our future. It’s disheartening to think of all the costs to our way of life, especially because it is preventable. 

The CHAIRMAN. I want to thank you for sharing all of that information and for your very thoughtful testimony. We appreciate your 

comments and we are happy to have everyone here today. 

We are going to start with a series of questions. I would like to 

start with Senator Hoeven. 

STATEMENT OF HON. JOHN HOEVEN, 

U.S. SENATOR FROM NORTH DAKOTA 

Senator HOEVEN. Thank you, Mr. Chairman. I would like to 

thank all the witnesses for being here with us today. 

I would like to start with Mr. McSwain. My question to you is, 

when dealing with the challenges of drug abuse, particularly in the 

Native American community, very often we are talking about rural 

areas. What is IHS doing and what can IHS do to provide services 

to deal with substance abuse and treatment in these rural areas? 

Mr. MCSWAIN. Thank you, Senator. I believe that, well, I actually 

don’t believe, but we are in fact addressing it through a number 

of programs we have. Certainly the alcohol and substance abuse 

programs that we have put in the communities to provide services, 

we actually have in many cases clinics and hospitals and health 

centers that are in rural America whereby we provide behavioral 

health services. 

We have a number of programs that we have actually addressed. 

It is a great question from the standpoint of, we are doing a lot of 

treating. We are a health care delivery system, so we treat a lot 

of folks who hit our system. 

The biggest thing that we are working on now is on the prevention side. That is our meth-suicide prevention initiative program 

44 

that is actually providing behavioral and the prevention side of the 

equation. But to provide care through our health care system. 

It is a growing issue for us, because we are doing basically health 

care, ambulatory and inpatient care. But now the growing need to 

address behavioral health is a challenge for us, simply because we 

need to have trained health care professionals to help us in that 

regard. 

Senator HOEVEN. The statistics I have, in 2012, over 20 percent 

of Native American youth were using alcohol. Twelve percent of 

Native American youth over the age of 12 were using illegal drugs 

in 2013. So clearly more needs to be done. 

What do we need to do? One, two, maybe three steps, what needs 

to happen? 

Mr. MCSWAIN. I believe that one of the things we need to do is 

engage the youth. The one thing that we haven’t done and we need 

to do as a system, whether it is IHS or SAMHSA or other Federal 

agencies, actually need to, and I think that, well, number one, our 

budget for 2016 has a generation indigenous initiative for actually 

addressing youth mental health issues. That budget piece for us is 

$25 million. SAMHSA has $25 million. And between the two of us 

we are putting those resources toward youth. 

Senator HOEVEN. Well, let me come at it this way. I am going 

ask all of you, what is the number one thing we need to be doing? 

And is there agreement on it? What can make this better? What 

is the one thing you would say should be done? I know there are 

a lot of things, but what is the first thing you would do? 

Mr. MCSWAIN. The first thing we need to do is engage the youth. 

Senator HOEVEN. And that means? 

Mr. MCSWAIN. That means talking to them, because they will tell 

us what they need. 

Senator HOEVEN. I would like to ask each witness to comment 

on that. 

Mr. MCSWAIN. That would be my response, is to engage the 

youth in a conversation about what help they need as opposed to 

us simply telling them what we think they need. 

Senator HOEVEN. I would ask each of the witnesses to react to 

that. And fairly briefly, I am limited here on time. 

Ms. BEADLE. Thank you, Senator. 

I would agree with Mr. McSwain. I think the critical issue is the 

fact that Native communities are relatively young in age. If we 

don’t engage the youth in identifying the critical things that must 

be done, we are not going to get anywhere. The funding is limited. 

We have tried very hard to coordinate with one another. I think we 

are doing some great things, we are doing a lot of work. But we 

have to bring the youth in. 

We also have to work with tribal leaders differently. They have 

asked SAMHSA to work with them differently on their programs. 

As an agency, we have increased the amount of funding that is 

going to tribal communities. 

The question now is how will we bring those resources together 

to be as effective as possible. I think the chairman talked about the 

limited resources that there are available. But it is that connection 

of those resources, because tribes have funds, the Federal governVerDate Mar 15 2010 11:00 May 04, 2016 Jkt 099990 PO 00000 Frm 00048 Fmt 6633 Sfmt 6601 S:\DOCS\99990.TXT JACK
45 

ment has funds, States have funds and other community organizations have funds. 

The question that we are grappling with now is how do we improve the coordination and work together differently to maximize 

and leverage those funds. They are not going to grow. So part of 

the solution the tribal leaders have come to us about is working together differently. 

Senator HOEVEN. Ms. Benjamin? 

Ms. BENJAMIN. The Mille Lacs Band of Ojibwe, what I know is 

when we have young men coming from prison, and if they connect 

to the spiritual and cultural aspects of the reservation, they seem 

to really focus on taking the right path. So anything that we have 

to do has to be culturally specific to our communities, because the 

way we communicate and the way they can get to the inner spirit 

has to be through that language and that culture. That has to be 

the basis for anything that we do, whatever program it is. They 

have to be able to communicate in a way and educate in a way that 

they understand. 

That is, for the Mille Lacs Band, that you have to think like an 

Anishinaabe or an Ojibwe, then you can understand and move forward. 

Senator HOEVEN. Mr. Walters? 

Mr. WALTERS. I’m more practical on some of these specific things. 

I think we are, given the magnitude of the problem and the use 

rates you see here, you must try to help do screening in health care 

system. We have not adequately dealt with the stigma we have in 

society for substance abuse. We have to understand that it is a disease. We have to understand it is a disease we can treat. We have 

to understand it is a disease we can screen for in routine medical 

care, wellness care and routine health care. 

We have introduced some of those programs in the past, supported by the Federal Government as models. They ought to be 

routine in the medical system. The rates of involvement that you 

see in Indian Country dwarf anything you see in almost any other 

community in the United States. There ought to be an automatic 

screening. It would be confidential. 

Then you need to also obviously build the infrastructure that is 

culturally appropriate to refer families and individuals to both 

early intervention care, which may be before somebody gets heavily 

involved and addicted, or when they are addicted refer them into 

care. But you need an intake system that is going to be systematic 

and comprehensive. The health care system needs to do that and 

you may want to encourage screening on a wider level to get people 

into care. 

Now, that is going to obviously display the fact that you don’t 

have infrastructure to care for everybody. But right now, you don’t 

have the infrastructure and nobody is screening. Let’s create a 

drive to create the infrastructure to save lives and not watch people die at higher rates. 

Look, what you are hearing here and what you already know as 

the members of this Committee is the system is failing here. It is 

not close. It is getting worse at a very great rate, especially in some 

of these communities. It is not uniform, but right now, the status 

46 

quo is not sustainable. And it is only because people don’t hear 

these cries that it hasn’t become more of an outrage. 

Senator HOEVEN. Mr. Chairman, do I have time to finish or shall 

I relinquish? 

The CHAIRMAN. No, no, please, go right ahead. Let me ask Senator Franken if it is okay with him. 

Senator FRANKEN. Absolutely. 

Ms. GOGGLES. I just wanted to say, our youth are our resource. 

I have amazing youth back at home and we are utilizing them to 

be peer mentors for our younger people. Because we are seeing a 

lot of our youth actually start around nine or ten years old. So we 

are really focusing on using those teenagers who are sober, who are 

following their culture. I really believe that we have to integrate 

that cultural part of it. 

But we can work with the youth as much as we can, but if we 

don’t have the parents on board, they are going back home to a 

really toxic environment. So it has to be a family approach. We 

have to look at the youth, we have to look at the adults and utilize 

those resources that we have available. Thank you. 

Senator HOEVEN. Thank you. Interesting, the dialogue and 

screening, interesting that those two come up together. Seems one 

would generate a lot of the other. So thank you. 

The CHAIRMAN. Thank you, Senator Hoeven. 

Senator Franken? 

Senator FRANKEN. I am struck with how, when we have hearings 

on youth suicide, when we have this hearing, and you start to get 

asked what is the first step. Of course, that is a very logical question. And you just realize how big and endless and circular these 

problems are. 

Because when you go to youth, the first thing I would like to do 

is give youth hope. And that means having economic activity, that 

means having housing and it means not being witness to other 

pathologies like abuse and neglect, violence. 

So this again, we are faced with this. I want to say this one more 

time to all of us on this Committee. We need to be ambassadors 

to the rest of the Senate and tell them the scale of the problems 

in Indian Country. Because every time we start talking about resources, it is woefully inadequate. The problems are so cyclical. 

I went to a rehab, Oshki Manidoo, in Bemidji, that is for White 

Earth, they are also a band of the Ojibwe. I have been to a number 

of rehabs in my life. I have never seen, this is for young people, 

I had never seen a more bummed out group at a rehab. Most people at rehabs are hopeful, they are happy, they have finally, whether they make it or not, at this point there is some hope. Every one 

of these kids, I asked them, started using with their parents. 

So Melanie, thank you for your testimony, all of you, thank you, 

especially Ms. Goggles, and you too, Mr. Walters. You talked in 

your testimony about a number of things, a lot about opiates, a lot 

of kids being born, a lot of babies being born addicted to opiates. 

You talked about Project Child and HCMC, Hennepin County Medical Center. They seem to be having a lot of success in taking these 

moms and intervening so that the babies aren’t born addicted. Is 

that right? 

47 

That is with the general population and not an Indian population. Because you talk about the culturally, using a cultural element in the treatment. What does that look like? What does it feel 

like? Obviously AA and any of those kinds of things, it is a spiritual program. So is that part of it? That is what you were saying. 

Ms. BENJAMIN. We do look at the Anishinaabe or the Ojibwe. 

There is a way of how to get to our spirit. Over the centuries that 

that inner strength, that self-esteem that we have as Anishinaabe 

has been taken away from us. Through just endless land steals, 

racism, lack of good housing, things of that sort over the years of 

living on the reservation. Also, a lot of the religions had to go underground. You couldn’t practice your religion out in the open because you were arrested, you were just made to feel terrible for 

practicing your own religion. 

I think that spirituality has been put down and kept down. But 

if we can bring that back through cultural programs and give that 

worth back to the people as tribal governments, provide some opportunities for economic development, education, good health care, 

good housing, that we can start to see success in a lot of these negative social behaviors. 

Senator FRANKEN. Let me ask anybody here, is there any data 

on culturally inclusive treatment? And if there isn’t, shouldn’t 

there be? Shouldn’t we be collecting data on what works? Does anybody have any knowledge of whether that has been done? 

Mr. WALTERS. Senator, yes and no. There has been some particular evaluations on programs. The Administration I served in, 

we started a program that was referred to in earlier testimony and 

still exists, screening, brief interventions, referral treatments, so 

there was a screening program. But there is also a program called 

Access to Recovery based on the view that it is not just the immediate 28 days or whatever, but part of the recovery process, especially for people who are heavily involved. It becomes a process of 

re-entry, sometimes job training, sometimes family support and a 

variety of other things. It needs to be wrapped together. 

We did a series of test sites. Two of them were in California and 

involved Native tribes that ran these programs. There should be 

evaluation. It was started near the end, but there should be evaluation data on all those. 

But all these programs ought to be producing more evaluation. 

We say that, we don’t require it. We are paying in health care now 

for more and more information about how well providers are providing. It is important to have tailored programs for Native peoples. 

But there also are going to be good and bad programs in that 

mix. So I think what you want to have is established criteria that 

you can use and you can look at, because then you can also make 

the case to your fellow members, everybody wants more money for 

programs. You have a better case for things that are working. 

So it doesn’t help the recipients if they get bad services for the 

money you win for them. 

Senator FRANKEN. I am out of time. Speaking of research, Ms. 

Benjamin, you mentioned metabolizing opiates at a different rates. 

We should be doing research, I assume, on that, in terms of how 

American Indians metabolize that. 

48 

Thank you, Mr. Chairman, for this very important hearing. 

The CHAIRMAN. Thank you, Senator Franken. 

Senator Lankford? 

STATEMENT OF HON. JAMES LANKFORD, 

U.S. SENATOR FROM OKLAHOMA 

Senator LANKFORD. Thank you, Mr. Chairman. Thank you to all 

the witnesses for coming today and for the conversations. It is extremely helpful information. 

Mr. Walters, you raised something in your testimony that has 

been discussed widely, and that is about tribes on tribal lands producing and selling marijuana and trying to decriminalize that. You 

seem to have a fairly strong opinion about that, and I would be interested to be able to hear more about it. 

Mr. WALTERS. The Administration has acted, I believe unilaterally, to encourage that option for tribes in the United States. 

Again, you already heard, and as a member of this Committee, you 

already know the damage that substance abuse does in Indian 

Country. The argument about marijuana is very political in this 

Country and I certainly understand that. You live in that environment. 

But the facts about marijuana are something that we have a 

blind spot about. My testimony includes a great deal of the information about what now current research is showing. It is all going 

one way. It is worse than we thought. The kind of high potency 

marijuana that is being created by these almost industrial kinds of 

productions you see in Colorado, some of those individuals that 

have started those have now gone into Indian Country, seeking the 

ability to cultivate there. 

It will not only be a much bigger problem among the Native peoples where it is produced but obviously surrounding areas. It does 

not get rid of the criminal element. The criminal element thrives 

as the industrial production thrives. 

The consequences for health, the consequences for behavior, the 

consequences for failure in school by young people, the consequences for young people that we see, including as I mentioned 

earlier, it is in my testimony, research showing permanent i.q. loss 

by heavy and continued marijuana use in adolescence and onward. 

But it is tied directly, we think other drugs are more serious, but 

it is tied directly to everything from family violence to now obviously impaired driving, but also things like schizophrenia, psychosis and other serious health problems. And it leads directly into 

poly-drug use, which not only involves alcohol, but obviously it involves meth, heroin and a whole range of substances. 

Senator LANKFORD. Can I ask the rest of the panel, do any of you 

believe that if marijuana was decriminalized on the reservation, or 

was allowed to be cultivated and sold in the reservation legally, 

that would help the drug use problem on the reservation or with 

the tribe? Does anyone think that? I would say let the record reflect everyone shook their head. 

This conversation has been amazing to me, the number of people 

that I have heard say, you know what, this is a bad problem because people have to do it in secret. And because it is done in secret and because it is illegal, it is a really bad issue. If we only deVerDate Mar 15 2010 11:00 May 04, 2016 Jkt 099990 PO 00000 Frm 00052 Fmt 6633 Sfmt 6601 S:\DOCS\99990.TXT JACK
49 

criminalized it, if we only made marijuana legal, then this wouldn’t 

be an issue any more, that this would suddenly be okay. Has anyone been able to track marijuana use around reservations around 

States that have decriminalized marijuana? Has that had an effect 

on the amount and the flow that is coming into the reservation 

areas? Yes, ma’am? 

Ms. GOGGLES. Being from Wyoming, and having Colorado just 

down the road, I can comment on that. We have actually seen a 

dramatic increase in the marijuana use in our community. One 

State legalized marijuana, Colorado. 

But I would also like to add our sixth leading cause of death is 

COPD. So not only our tobacco use is 50 percent, our commercial 

tobacco, so you add marijuana in the mix and it is just adding to 

the COPD cases. 

So we have definitely seen the negative effects, being in Wyoming and having Colorado legalize. 

Senator LANKFORD. Any other comments about that? This is a 

big issue Congress has to deal with, obviously. There is an enormous push to say, you know what, let States decide this, it will 

have no negative effects, they can choose to do what they choose 

to do on it. But the real practical effects on families and on generations are pretty traumatic. I think it is us turning a blind eye to 

our responsibility to say, decriminalizing it is no big deal, it is ‘‘just 

marijuana,’’ I am tired of hearing ‘‘it is just marijuana’’ when we 

see our families falling apart and we see i.q. levels dropping and 

productivity dropping and saying ‘‘it is just marijuana.’’ 

So this is a serious issue. I appreciate you all spending your lives 

trying to invest into some of these. 

Ms. Benjamin, I want to ask you about what you are doing. Just 

recently you had a two-day conference, I understand, trying to deal 

with some of the drug issues. How do you evaluate the effectiveness for any program, that program in particular, doing a conference and such? I assume there are going to be multiple steps in 

the process. So how do you track the metrics of that? Is this effective? How do you improve for next year and what else needs to be 

done? 

Ms. BENJAMIN. One of the outcomes from that conference that we 

did for our own reservation members is that there were a lot of 

people in the community, a lot of the women that said, I will do 

whatever I can to help. There have been a lot of support groups 

that have started from just participants, people understand, we 

gave a lot of statistics and what happens. We showed a film of babies going through some of the withdrawal, it is pretty devastating. 

We had religious people there as well to support. 

Also, we are looking to do a safe house for pregnant women as 

well. We want to give them the opportunity to let them know that 

we want to help, we don’t want to put them in jail just because 

they are using illegal drugs. A lot of them will not come forward 

and even get prenatal care, because they are afraid of their babies 

and being taken care of. So we want to send that message out. 

We have been working with our elders in our community to take 

that stronger leadership role in their families, to make sure that 

whatever assistance they need that we can offer that and provide 

50 

that for them as well. So we see a little progress and people are 

getting engaged and wanting to be part of the solution. 

Senator LANKFORD. Thank you. Thanks to all of you as well. I 

yield back. 

The CHAIRMAN. Thanks, Senator Lankford. 

Senator Heitkamp? 

STATEMENT OF HON. HEIDI HEITKAMP, 

U.S. SENATOR FROM NORTH DAKOTA 

Senator HEITKAMP. Thank you, Mr. Chairman. 

This is a continuation of, I call it the Committee of despair, as 

we continue to see these issues and feel like generation after generation we fail. And I don’t mean to pick on you, Mr. McSwain, and 

I know you are acting. But I don’t think there is one Native American who lives in Indian Country who thinks that Indian Health 

Service is providing any kind of treatment for behavioral and mental health. Not anyone that I think who lives in North Dakota. 

So when your answer to Senator Hoeven was, you provide treatment, I am going to ask you a simple question. Every person who 

you are responsible for as a constituent and a patient of Indian 

Health, if they needed behavior and mental health services, would 

they get it from you? 

Mr. MCSWAIN. They could come into the clinic, and whether or 

not we have the professionals there, we have had a real challenge 

in hiring behavioral health professionals. 

Senator HEITKAMP. So the answer is no. 

Mr. MCSWAIN. The answer is—— 

Senator HEITKAMP. No. 

Mr. MCSWAIN.—not exactly no. 

Senator HEITKAMP. You can’t, it is not even not exactly no, it is 

no. And that is one of the problems. And I completely appreciate 

the health care workforce problem that we have, because it is combined with a rural workforce health care worker problem that we 

have. So it is extraordinarily difficult. 

But once again, Indian Health, which should be providing treatment, let’s forget about prevention. I am not even going to put that 

on you. But you should be providing treatment, because we have 

heard here that without families, Senator Franken just told you 

that when he visited a center, all these kids said they started using 

with their parents. 

So if we think we can just visit with kids and that is going to 

solve the problem, kids do what they see, not what they are told. 

And what they see every day, kids who are in this situation, is they 

see a culture of abuse, they see a culture of drug abuse. And they 

feel a lot of despair. So Indian Health has been unrelentingly unable to address health care crises in Indian Country. And this is 

a huge part of it, behavior and mental health. 

So let’s not pretend that we are providing services. The worst 

thing that we can do here is pretend that we are doing the right 

thing. Mr. Walters, I don’t know if you got a page out of my speeches or whatever it is. I think you are trying to speak truth about 

what is actually going on and where we go from here. But one of 

the issues that I have a lot of concern about is, generation after 

generation, and we can talk about generational trauma. This ComVerDate Mar 15 2010 11:00 May 04, 2016 Jkt 099990 PO 00000 Frm 00054 Fmt 6633 Sfmt 6601 S:\DOCS\99990.TXT JACK
51 

mittee has held a hearing on trauma, and I think there is some 

hope in some of the research. 

But there is an amazing lack of scanning and looking back at 

fetal alcohol effects and fetal alcohol syndrome. We know that one 

of the symptoms of fetal alcohol is really a lack of consequential 

thinking. So while we say, well, why don’t you just get it, that bad 

things happen that you drink and you should just quit drinking, 

well, when you are dealing with somebody who already has a genetic impairment, it is very difficult. 

So when we are talking about screening, which I thought was an 

excellent point, maybe too late after the fact, if we get them in 

Head Start maybe we have a shot. But what about screening for 

fetal alcohol effect and fetal alcohol syndrome? And what strategies 

would you deploy in terms of treatment? 

Mr. WALTERS. I agree with you. I think this Committee should 

obviously also include alcohol. What it allows is, it helps people understand that this is a disease, so it gets rid of some of the resistance and shame by having a medical professional say, this is what 

we are doing, this is why we are doing it, and provide some information at the time of the screening. 

But also, you are right, there has to be, when you find a positive, 

you are going to have to have people who are able to do family 

intervention and you have to have people who are going to be able 

to work with people in a way that meets them where they are. 

Now, again, we do have problems in the workforce. But part of 

the reason we can’t get the urgency to get the workforce fixed is 

because we are not presenting people with the number of illnesses. 

We do that with a whole bunch of other diseases. We say, we need 

the capacity to treat this disease at these numbers. And in other 

venues, that is what generates the infrastructure. 

Senator HEITKAMP. And when you don’t do that, when you don’t 

recognize you have a problem, then you have no solutions to that. 

Mr. WALTERS. Right. You are just part of the noise in the budget 

debate and the debate about what the community needs to do. And 

there is a lot of stuff to do. You have to get up to the part of the 

to-do list that gets done. 

I don’t think you have to be the Committee of despair. This can 

be done. It just takes some people who are going to be able to lead. 

And the government has the ability now to show people where this 

is and to reinforce what these people are doing and saying it is a 

priority, in a State, in a region and in the government of the 

United States. You can fix these bureaucracies. It just takes 

enough pressure. 

Senator HEITKAMP. I can’t agree with you more. Just a couple 

more points. 

I once went to a high school, it actually was a junior high school. 

I asked how many kids were drinking. This was not a Native 

American school. About 30 percent raised their hand, they reported 

that their friends were drinking, so you can take it from there. I 

said, why are you drinking? The kids started saying, peer groups 

and all this. I said, you are drinking to get high. 

So it is, we need to recognize that there is some amount of secondary effect here. This is a very complicated problem. 

52 

Mr. WALTERS. But also back to your original point, no matter 

what the demographic, substantial underage drinking, in my experience, cannot exist unless adults enable it. 

Senator HEITKAMP. I think that is correct. 

Ms. Goggles, your testimony has a huge impact on all of us as 

we kind of look forward. I want to know what kind of services Indian Health could provide at Wind River that could make a difference to you that would be altering for your tribe. 

Ms. GOGGLES. Thank you. I think one of the biggest parts is the 

MSPI program. We utilize MSPI funding to do a horse culture program. It is a way of getting our youth back to utilizing their traditional values as far as taking care of their horses. They show them 

how to ride, show them how to take care of them. It is just a really 

good program. It gives our youth an opportunity to get in touch 

with their culture. 

Now the funding is competitive. So that makes things a little bit 

more difficult. I don’t know what these other tribes are doing. 

Senator HEITKAMP. To Senator Franken’s point, do you have any 

long-term studies that show that a program like this would actually result in a 20, 30 year history of sobriety? 

Ms. GOGGLES. No, because the program just started this last 

year. 

Senator HEITKAMP. That is the problem. 

Ms. GOGGLES. And the funding actually, that is one of the things, 

though, you fund things for a year, or things are funded for three 

years. You are not going to get long-term funding. 

Senator HEITKAMP. We don’t have a strategy, we just have a series of events. Right? 

Ms. GOGGLES. Yes. 

Senator HEITKAMP. Thank you, Mr. Chairman, for the extra 

time. 

The CHAIRMAN. Thank you, Senator Heitkamp. 

Senator Murkowski? 

STATEMENT OF HON. LISA MURKOWSKI, 

U.S. SENATOR FROM ALASKA 

Senator MURKOWSKI. Thank you, Mr. Chairman, for having yet 

another very important hearing. As I listened to my friend from 

North Dakota, you just kind of get a here we are again feeling of 

despair. I appreciate your saying that we don’t have to be the Committee of despair. But I do think that these are problems that we 

recognize we have been struggling with for generations. 

Despite efforts, we are not making the progress that we should. 

There has been some discussion, and I appreciate what you have 

said about fetal alcohol spectrum and the syndrome. We have actually made some headway in Alaska, when it comes to our Alaska 

Native women and the number of children who are being born afflicted with FASD. We are seeing a reduction in the number of 

those afflicted at birth in the Native population. But at the same 

time we are seeing a drawdown there, we are seeing an increase 

in our urban population. So go figure. 

We are not hitting it right if we are not able to make a difference 

across the spectrum when it comes to something that is 100 percent preventable. This is where I get so, so really distraught talkVerDate Mar 15 2010 11:00 May 04, 2016 Jkt 099990 PO 00000 Frm 00056 Fmt 6633 Sfmt 6601 S:\DOCS\99990.TXT JACK
53 

ing about fetal alcohol syndrome. We talk a lot here in the Congress about the diseases that we deal with and the funding that 

we have to do for research. 

There is no research that we need to fund on how to end FASD. 

You just don’t drink when you are pregnant and you will not have 

a child that is afflicted with fetal alcohol spectrum disorder. We 

know how to stop it. Yet we go up and we go down. We are just 

not there yet. 

I think we recognize in Alaska that alcohol is still the substance 

of choice in my State when it comes to just the things that are 

leading to incredibly horrific episodes and destructive behavior. So 

much of our problem is we have our local governments, we have 

our villages that say, we want to control alcohol that comes into 

the community. We vote to be a dry community. And you have 

bootleggers that are coming in, a bottle of liquor that you could get 

for $10 in town you might get a couple hundred for that same bottle out in a dry village. 

We mentioned the issue of marijuana. Alaska just legalized marijuana and we are in the process now of trying to figure out how 

we as a State regulate it. Well, one of the great issues of discussion 

was, well, what will happen in a village that is cut off from the rest 

of the State, no road access, no access except airplane in and out, 

that is dry when it comes to alcohol? What happens with the issue 

of marijuana? What do we do there? We are still trying to define 

the impact. 

But to Senator Lankford’s question, I don’t think that there is 

anybody who thinks that by making marijuana legal we are going 

to be helping those with substance issues. It is just not possible. 

So I am really very troubled about where we are with our solutions. We have been operating on a triage basis. We have a situation in a southeastern island community where we know the drugs, 

how they are coming in, they are coming in by the mail, we need 

to get cooperation between the Post Office, the DEA. We don’t have 

a magistrate or a judge in the community to issue a search warrant. We literally pull together a SWAT team to make a difference 

in that community. 

We go ahead and we crack the case and we seize the drugs. And 

what happens is we have managed to squeeze balloon over here 

and the drugs next month end up in the next island community. 

We just had a big bust in, again, the island community of Kodiak, 

with a large heroin seizure. It is like a whack-a-mole game, and we 

are not getting ahead of it. 

I met yesterday with the head of the DEA in my office. He reminded me that in many ways, those bad actors, the dealers, they 

look to build a clientele. If you can capture a whole island community that is remote, that can be your customer base. On a reservation, to be able to go in and basically get people addicted to your 

drug of choice that you are dealing, knowing that there are no 

treatment facilities either in that area or near that area, you have 

them locked. It is just extraordinarily troubling where we are with 

it. 

I don’t want to talk without asking questions, and I want to go 

to what Senator Heitkamp has raised with you, Mr. McSwain, 

about the trauma issue. There has been a lot of discussion here in 

54 

this Committee, which I appreciate. But when you think about 

what we are dealing with, the levels of abuse, suicide, violence, 

other trauma that we see, and then the linkage between the high 

rates of drug and alcohol abuse, this is something that I do hope 

is being addressed in coordination between the departments. I 

think we like to think that is going on. 

Can you confirm or affirm to me that in fact there is collaboration going on within the agencies? We require that in the 2010 

Tribal Law and Order Act. We required coordination efforts on alcohol and substance use issues in Indian Country when we expanded the number of Federal agencies that are involved in it. 

So are you working it and how are you working it? Do you have 

any thoughts that might be helpful as we try to focus further in 

this area? 

Mr. MCSWAIN. Thank you, Senator Murkowski. The answer is 

yes, we are working closely with SAMHSA, we are arm in arm in 

many of the communities that we have addressed. Of course, then, 

across the system, wherever they have a grant program and we are 

present, there is another notice of coordination. Then we reach out 

to our other people. Certainly, as you just referenced, the Tribal 

Law and Order Act, we reach out to our sister agency, the Bureau 

of Indian Affairs and the Bureau of Indian Education. Those kinds 

of discussions are ongoing. 

We are actually partnering, in many respects. I can go example 

by example. A recent one, with Pine Ridge, we are hand in hand 

out there trying to address issues. Now, granted, it is about suicides. But SAMHSA has a program, we have an installation out 

there, several. So we are working together as to how to make sure 

we can provide all the services available, not only through the 

SAMHSA grant programs but through our direct care program. 

To the extent that we have also implemented tele-behavioral 

health, to make it available into the outlying communities, particularly a couple of very remote communities on Pine Ridge, that is 

just one example. We have other examples where we are actually 

partnering and working together on substance abuse and mental 

health in those communities. 

We have been doing this for some time. In fact, we meet annually. We have an annual conference, have had annual conferences 

to compare best practices. So we will continue that collaboration 

very closely. 

Senator MURKOWSKI. Mr. Chair, thank you for the additional 

time. It is good to hear that the programs are working. 

I remain concerned that everybody has their program and they 

have to defend their program. In order for them to get money for 

the next funding cycle, they have to be able to establish what they 

have done. So the sharing, while it is good in theory, call me a 

skeptic at times, I think it is important that we just keep pressing 

on this if the ultimate goal is to have healthy families, healthy 

communities and not you worry about the funding for your program or the funding for your program, but are we getting results 

at the end of the day. 

That is where I think we come back year after year after year. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Murkowski. 

55 

Ms. Beadle, earlier this month, the White House had a Tribal 

Youth Summit. The purpose was to hear from the youth. So I guess 

the question is, what did you learn from them about how to address alcohol and drug abuse? 

Ms. BEADLE. Thank you, Mr. Chairman. I have to say that in addition to the White House Tribal Youth Conference, there have 

been a number of roundtables with youth. I am glad you raised this 

topic. The youth basically are telling us the same thing wherever 

we go. What they are saying is, they want to be involved. We had 

this conversation earlier today. They believe that they know what 

is right to do in their communities. They believe that other youth 

are talking to each other. They are not going to listen to adults. 

So they want to be part of the solution. And part of the solution 

means incorporating them into some of the programming that gets 

done as a leader. What they have asked SAMHSA to do specifically, not just at the White House Tribal Youth Conference, but in 

our own conferences and roundtables, is they want us to bring 

youth together on a national scale to start talking about how we 

establish a nationwide peer support program among youth. 

They think that if we continue down the same path that we have 

been on, which is, we fund programs which are great things and 

not include them at the local level, at the regional level, and at the 

national level, the programs are not going to include their 

thoughts, they are not going to include their solutions. 

So what they are asking us to do is to get them involved. 

The CHAIRMAN. Can you point to anything specific that you have 

actually done in addition to that? We bring them all together, and 

I met with the students and young people who have come in from 

Wyoming, heard the same thing. So what is the next step from 

there? 

Ms. BEADLE. We have a couple of next steps. We actually are establishing what is called the SAMHSA Tribal Youth Leaders, 

which is a cluster of youth from across the Country. What they 

have asked for are specific things. They want leadership training, 

we are going to provide them leadership training. They want training in behavioral health. We are going to do that. Some want very 

basic things like very brief intervention type programs. Others 

want to be able to figure out how to make a longer career out of 

it. So we are going to try to get them involved and connected. 

Those are two very concrete things we are going to do over the next 

year. 

The CHAIRMAN. In terms of the connection or the continued support, how does that work so you can keep them engaged and they 

don’t just feel that they are isolated once they go back home? 

Ms. BEADLE. One of the things they have asked us to do as well 

is to help connect them with tribal leaders. I say this very respectfully. The youth were amazing, and what they basically said is, in 

some communities we are acknowledged and we are included in the 

dialogue; in other communities, tribal leaders don’t see us as leaders as well. So they are asking for Federal agencies, not just 

SAMHSA, to help bring them to the table more locally so that they 

can actually have their voices heard. 

Longer term, we do have a series of programs to support Native 

youth that we are going to try to connect them to so that they are 

56 

engaged not only in this learning and development progress but 

also in the actual work that is happening in their communities. 

The CHAIRMAN. Ms. Goggles, when we met in Wyoming, there 

was a young man who came to testify who was, I think, part of this 

sort of an effort in the community. Could you talk a little bit about 

that and the successes you have seen there? 

Ms. GOGGLES. I am also an advisor for the Wind River Youth 

Council. The Youth Council was established back in the 1980s 

when we had a rash of suicides. So it has kind of come and gone 

over the years. But I think that is one of the best resources, is our 

youth. We have amazing youth on Wind River, I mean, amazing 

youth. I actually have one with me. She is sitting a couple of rows 

behind me. And I have to embarrass her, because I am her mom. 

But we utilize those resources. We do a lot of peer mentoring. In 

my office right now I have two peer mentors that teach prevention. 

Because they are not going to listen to me. So I have two 20-year 

olds who are trained in mentoring. They go to the schools. I don’t 

go to the schools. Our staff doesn’t go to the schools. It is our 

youth, because they are going to listen to them a lot better than 

they are going to listen to us. 

The CHAIRMAN. Mr. Walters, are there any data sets that we can 

put together to see how effective this is? It certainly sounds encouraging. 

Mr. WALTERS. They don’t exist now, but we certainly could have 

those. We could have the individual sites or schools or communities 

do regular either self-repot surveys or if you screened in the health 

care system you could report what the rates were and you could 

see the difference over time. 

We could measure these effects from a variety of these programs, 

including the early reference to family court and custody cases, 

which have been used in a variety of settings to help get people in 

treatment and try and start breaking the intergenerational cycle 

here. So all these things could be measured, but you have to measure the underlying phenomenon first. 

I place some of my emphasis on CDC and the measuring on the 

health side. DEA ought to be forced to do the same thing. DEA 

does not produce national data. It could produce national data. 

Now, in the example of heroin, it hasn’t produced a heroin signature report to tell you where the heroin is coming from in months, 

if not years. That report should be out on a quarterly basis, at 

least. 

The State Department has not produced, as far as I can tell, the 

report on heroin production from Mexico. I believe what you are 

seeing now is largely production that is probably an explosion of 

production in Mexico. If it isn’t, then it is an explosion of importing 

from Afghanistan where 90 percent of the heroin is. Let them know 

that. 

But the agencies are not producing the data and providing it to 

you, who have to make decisions, and sharing with the American 

people, who are suffering, to get some idea of who is not doing their 

job or how we can get a better situation. So right now, we are acting in a way that is more blind than we need to be because information is not being given directly as it should be, even the stuff 

that is already in the pipeline. 

57 

The CHAIRMAN. Thank you. And Mr. McSwain, Ms. Benjamin 

gave us a whole list of wonderful ideas of things that we ought to 

be talking about. Have you taken anything from this that you 

think can be helpful as you work with your folks? 

Mr. MCSWAIN. I do. In fact, the whole business about Ms. Beadle’s comments about the youth summit, I happened to sit on a 

panel with her. It was interesting to hear, at least the youth, that 

is what caught me earlier, when I said talk to the youth. That was 

my frame of reference. 

Because if you can talk to the youth, and then having said that, 

a recent experience we had was that the youth on Pine Ridge wanted counselors. They used the term, ‘‘but not those old codgers.’’ And 

that notion was younger people who can relate to them. So that is 

part of a takeaway, at least for me, is when we start dealing with 

the youth, American Indian and Alaska Native youth, is to ensure 

that we have a younger set that actually has the ability to relate 

to them. 

I really, back to Senator Heitkamp, I know that we basically provide care, but we have been providing grants. I know at the last 

hearing, Senator Murkowski, you were pleased with the progress 

of the MSPI program. I know that what that does is put the capacity in the communities to have them work from their end. I think 

that is the basis on which we are going to be successful. 

The CHAIRMAN. Ms. Goggles, is there anything you would like to 

add in terms of what you see that works, or other things we ought 

to be doing differently, maybe from something you have heard 

today, or something you would like to share with the Committee? 

Ms. GOGGLES. Thank you. I really want to emphasize the work 

as a family and working on the family as a whole. It is easy to pull 

youth out, provide them a good day, good leadership camp, then 

they go home to a very toxic environment, as I said before. We need 

to work with those parents, those aunties, those grandmas, because 

our family group is not just mom, dad, brother. It is the grandmas, 

it is the aunties, it is everybody else, the uncles. We need to include that whole portion in our treatment services, our behavioral 

health services, even our medical services. They need to be included in all this. 

And I really want to emphasize the speaking with youth. They 

have great ideas. They think about how to get out of the box. They 

come up with new ideas. So our youth are an amazing resource. 

The CHAIRMAN. Thank you. 

Senator Heitkamp, any additional questions? Senator Murkowski, anything you would like to add? 

Senator MURKOWSKI. Mr. Chairman, the only thing I would add, 

I noted, Mr. McSwain, your comment about the youth and engagement. But you specifically said, we need to talk to the youth. I 

think we need to listen to the youth. And I think part of what we 

are dealing with is, we talk to them all the time. I talk to my kids. 

And sometimes they choose to listen. But when I listen to them 

first, that is when we have an exchange that actually makes it 

work. 

I mentioned meeting with the head of the DEA yesterday in my 

office. I had two interns with me. One is from Ketchikan, Ketchikan has a drug problem down there. One of them is from UnVerDate Mar 15 2010 11:00 May 04, 2016 Jkt 099990 PO 00000 Frm 00061 Fmt 6633 Sfmt 6601 S:\DOCS\99990.TXT JACK
58 

alaska, two island communities that are dealing with these issues 

of drugs. The comment that I got from both of them was, when the 

head of the DEA and you, Senator Murkowski, asked us as young 

women who have just graduated from high school, what we think 

would make a difference in our community, that is empowering. We 

need to remember to listen to what these young people have to say. 

They are a heck of a lot smarter than we would ever give them 

credit for. 

I appreciate what everybody is trying to do, and we will keep at 

it. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you. I want to thank all of you for being 

here to testify today. The hearing record will be open for two 

weeks. I want to thank all of you for your testimony and our time. 

Since Senator Murkowski mentioned interns, we have a number 

of interns from the Committee. This will be the last hearing of the 

Committee before they head back to college or to their life. I want 

to thank each and every one of the interns for their hard work over 

the summer. I know they are going to continue to work hard as we 

are back in our home districts visiting and listening to what people 

have to say. 

With that, the hearing is adjourned. 

[Whereupon, at 3:57 p.m., the hearing was adjourned.] 

(59) 

1 Abbey, A., Parkhill, M.R., Jacques-Tiura, A.J., Saenz, C. (2009). Alcohol’s Role in Men’s Use 

of Coercion to Obtain Unprotected Sex. Substance Use & Misuse Journal, 44(9–10):1329–1348. 

A P P E N D I X 

PREPARED STATEMENT OF LESTER SECATERO, CHAIRPERSON, NATIONAL INDIAN

HEALTH BOARD (NIHB) 

Chairman Barrasso, Vice Chairman Tester and Members of the Committee, thank 

you for holding this important hearing on ‘‘The True Costs of Drugs and Alcohol in 

Indian Country’’. On behalf of the National Indian Health Board (NIHB) and the 

567 federally recognized Tribes we serve, I submit this testimony for the record. The 

federal promise to provide for the health and welfare of Indian people was made 

long ago. Since the earliest days of the Republic, all branches of the federal government have acknowledged the nation’s obligations to the Tribes and the special trust 

relationship between the United States and Tribes. The United States assumed this 

responsibility through a series of treaties with Tribes, exchanging compensation and 

benefits for Tribal land and peace. 

Of the challenges facing American Indian and Alaska Native (AI/AN) communities 

and people, few challenges are greater or more far reaching than the epidemics of 

alcohol and the abuse of other substances. AI/ANs are consistently over-represented 

in statistics relating to alcohol and substance abuse disorders, deaths (including suicide and alcohol/substance related homicides), family involvement with social and 

child protective services, co-occurring mental health disorders, infant morbidity and 

mortality relating to substance exposure, the diagnosis of Fetal Alcohol Syndrome 

(FAS) and other Fetal Alcohol Spectrum Disorders (FASD), partner violence, diabetes complications and early onset as a result of alcohol abuse, and other related 

issues. Current alcohol and substance abuse treatment approaches (offered by both 

the Indian Health Service (IHS) and Tribal facilities) employ a variety of treatment 

strategies consistent with evidenced-based approaches to the treatment of substance 

abuse disorders and addictions (such as outpatient group and individual counseling, 

peer counseling, and inpatient/residential placements, etc.) as well as traditional 

healing techniques designed to improve outcomes and align the services provided 

with valuable cultural practices and individual and community identity. IHS-funded 

alcohol and substance abuse programs continue to focus on integrating primary 

care, behavioral health, and alcohol/substance abuse treatment services and programming through the exploration and development of partnerships with stakeholder agencies and by establishing and supporting community alliances. Adult and 

youth residential facilities and placement contracts with third party agencies are 

funded through the IHS budget for alcohol and substance abuse treatment; however, 

as a result of diminishing resources, placement and treatment decisions are often 

attributed more to funding availability than to clinical findings. 

Costs of Drugs and Alcohol in Indian Country 

Current research indicates that 64.8 percent of American Indians or Alaska Natives have used illicit drugs in their lifetimes while 27.1 percent have used in the 

past year. These drastic numbers mean that almost two thirds of the AI/AN population has been exposed to addictive and illicit drugs. According to the California 

Tribal Behavioral Risk Surveillance System survey, 39 percent of AI/AN respondents reported heavy alcohol consumption within the past 30 days, compared to the 

national average of 24 percent. 

According to a study in 2009, 1 AI/ANs were almost twice as likely to need treatment for alcohol and illicit drugs as non-Native people. The study found that AI/ 

ANs needed treatment at a rate of 17.5 percent compared to the national average 

of 9.3 percent. Providing this treatment is costly to the community and gaps in 

funding mean that the treatment is often inconsistent both from year to year and 

across Indian Country. Because funding is never guaranteed, vulnerable people and 

communities can slip through the cracks and back into drug habits when grant resources run out. For example, the Fort Peck Tribes of the Assiniboine and Sioux creVerDate Mar 15 2010 11:00 May 04, 2016 Jkt 099990 PO 00000 Frm 00063 Fmt 6601 Sfmt 6621 S:\DOCS\99990.TXT JACK
60 

ated a drug task force on their remote reservation in northeastern Montana in order 

to employ a crossjurisdictional strategy for treating and preventing substance abuse. 

The task force was funded through a state-funded program. NIHB Board Member, 

Charles Headdress, noted that the program was making progress, but when the 

funding ran out, the gains the task force made diminished and methamphetamine 

dealers were able to increase their presence on the reservation. Because exposure 

to illicit drugs is so common and AI/ANs are more likely to need treatment, it is 

clear that continued funding for treatment of alcohol and drug use is a top priority 

for Indian Country. During the hearing, Senator Heitkamp noted that ‘‘we don’t 

have a strategy, we just have a series of events’’ when it comes to health care delivery in Indian Country. There is truth in this statement: Congress must commit considerable, consistent resources in the treatment and prevention of alcohol and substance abuse. 

The monetary cost of addiction treatment is just one of the major costs of drugs 

and alcohol in Indian Country. Intentional and unintentional injuries and hospitalizations related to drugs and alcohol can incur huge costs both to individuals, 

communities and healthcare facilities. Alcohol was associated with 32.2 percent of 

all unintentional injury hospitalizations among AI/ANs, yet Tribes are not getting 

significant funding from the federal government to address this issue. For example, 

in FY 2016, the unintentional injury program at the Centers for Disease Control 

and Prevention (CDC) is not receiving any additional funding in either the House 

or Senate’s draft Appropriations bills. This is problematic for Tribes, as unintentional injury is the third leading cause of death among AI/ANs, and many of these 

are alcohol related. CDC is currently operating efforts in Alaska and the outcomes 

from these programs are promising—showing real behavior change. But the opportunities to expand these efforts into other parts of Indian Country will be severely 

limited by the proposed flat funding. Above and beyond funding levels, there are 

other considerations for how the allocations will be spent. For example, the unintentional injury prevention will be administered by states, not through any of the 

Tribes. It is critical that Congress provide authority for CDC to create a separate, 

direct funding stream or block grant directly to Tribes for this program eliminate 

a state pass-through requirement. 

More disconcerting is the cost of intentional self-harm induced by drugs or alcohol. Alcohol was associated with 63.2 percent of all intentional injury hospitalizations nationwide among AI/ANs. In Alaska, three out of five (57.5 percent) suicide 

and self-harm hospitalizations were alcohol-related among Alaska Natives. Both nationally and locally, when American Indians and Alaska Natives do harm to themselves, alcohol is involved approximately 60 percent of the time. In small reservation 

communities or Alaskan villages, a suicide or incidence of self-harm can have a ripple effect throughout the community, and increase suicidal ideation among peer 

groups in the community. Providing effective and timely treatment for one at-risk 

person can remove the catalyst for a rash of responsive suicides within a community. 

During the hearing, most witnesses and Senators agreed that the biggest cost of 

drugs and alcohol is the loss of human life. NIHB agrees. In the Bureau of Indian 

Affairs Nashville Area, 9 percent of all AI/AN deaths from 2002–2012 were substance-abuse related. Drugs and alcohol can affect all members of a community. Mr. 

Headdress stated that ‘‘prominent members of our societies are falling by the wayside and into addiction.’’ This problem encompasses all people in a tight knit community and the death that comes from drugs and alcohol reverberates outside of the 

traditional family, putting even more individuals at risk from suicide, especially 

when it comes to youth. Drugs and alcohol truly do cost human lives. 

Methamphetamines 

Although alcohol has long plagued our communities, specific drugs are coming in 

great numbers to Indian Country. Methamphetamine and prescription drugs (specifically opiates) are proving to be major destructors of our communities. Because 

of the accessibility and highly addictive nature of these drugs, healthy communities 

can quickly fall into despair. One Tribal leader described those addicted to meth and 

prescription drugs as ‘‘skeletal zombies walking around with no teeth.’’ 

Meth is a drug that thrives in rural communities, including reservations and 

Alaska Native villages. Tribal leaders are aware that meth dealers target our communities because of the remote locations and limited law enforcement presence. In 

fact, many leaders know where the meth houses are in their communities, but do 

not have the law enforcement resources to move against these entrenched operations. For example, The Fort Peck Tribe in Montana has 23 police officers that 

cover a two million acre reservation. (For reference, the state of Delaware is 1.594 

million acres.) With such a small police presence covering these large tracts of land, 

61 

meth manufacturing and distribution can thrive. In addition to bad actors bringing 

drugs onto the reservations, Native people in the depths of addiction can create the 

drug themselves with household goods instead of relying on outside dealers. Meth 

labs have cropped up in Tribal housing and often times the subsequent damage to 

the homes prohibits the Bureau of Indian Affairs from moving in other families: the 

houses are uninhabitable. Tribes are finding that they simply do not have the 

money, resources or man power to tackle a drug like meth. When they bust one 

house, the drugs move to another place on the reservation. 

In the map below, provided by the White House Office of National Drug Control 

Policy, one can clearly see how close drug trafficking areas (colors) are to reservations (brown hash marks). Tribes in the Southwest are constantly trying to keep 

drugs that are coming across the Mexican border out of their communities. (orange). 

The drug trafficking areas in North and South Dakota (light blue) are on or near 

some of the largest and most populous reservations in the country. Western Washington Tribes combat drugs coming in through their ports from Asia (lavender). The 

main trafficking area between the US and Canada runs through New York State 

and Iroquois country (navy blue). 

According to The National Institute of Health, ‘‘while national trends are showing 

declines, methamphetamine abuse continues to exhibit regional variability. . .with 

the strongest effects felt in the West and parts of the Midwest.’’ States in the West 

and Midwest happen to have the largest numbers of Native populations. In addition, 

according to The California Tribal Behavioral Risk Surveillance System, 30 percent 

or AI/AN people have reported using meth, crank or ice. 

Tribes in the Northern Plains are noticing an influx of drugs due to the booming 

economy of the Bakken Oil Field. Again, drug dealers target these reservations, especially in North Dakota, South Dakota and Eastern Montana, because of their 

understaffed police forces, fluctuation of the labor population and large acreage. 

Drug cases are flooding Tribal courts in South Dakota especially with the Three Affiliated Tribes of the Mandan, Hidatsa and Arikara (MHA). MHA Nation Chief 

Judge, Diane Johnson, declared to the Los Angeles Times, before the oil boom 

‘‘about 30 percent of the cases that came to her court were drug-related and that 

number is now closer to 90 percent.’’ The effects are overwhelming Tribal administrations and Tribal courts. 

The effects of meth addictions are felt by the entire community. Many AI/ANs 

from across the country have echoed that every family has at least one member with 

a meth problem. Those addicted to meth have often given up on participating in the 


729a11.eps
62 

community and begin taking from the community to fuel their habits. Community 

members cannot leave belongings unattended for fear that they will be stolen and 

sold for drug money. Lastly, because many of these rural reservations have depressed economies, there is a financial incentive for Tribal members to participate 

in the illegal drug trade because that is often the only way they can make money. 

Opiates and Prescription Drugs 

Heroin and prescription drug use go hand in hand. Prescription painkillers like 

Vicodin or OxyContin are routinely prescribed by doctors for a myriad of medical 

concerns. However, these highly addictive prescription opioids can open the door to 

heroin and other opiate drug use. In addition, heroin leads to many public health 

concerns regarding intravenous drugs use like Hepatitis C and HIV. 

Much like meth, prescription drug abuse affects rural communities differently 

than it does urban and suburban areas. For example, in Montana, IHS doctors have 

been prescribing opioid painkillers like Vicodin or OxyContin in lieu of surgery because hospitals are often hundreds of miles away, or the IHS is unable to provide 

funding for referrals. According to the National Institute on Drug Abuse, those who 

abuse opioid prescription drugs often switch to heroin as a substitute. Exposing AI/ 

AN populations to highly addictive painkillers through the Indian Health Service 

fuels heroin addiction on reservations. An elected Tribal leader of a Tribe in California recently said that ‘‘the worst drug dealer on the reservation is IHS.’’ More 

must be done to hold physicians and IHS accountable to the damage they are doing 

by fueling this crisis in Indian Country. 

Heroin and prescription drugs are putting American Indian and Alaska Native 

youth at risk. Nationally, one in twelve high school students reported non-medical 

use of prescription drugs in the past year and one in twenty reported abusing 

Oxycontin. However, AI/ANs annual heroin and Oxycontin use was two to three 

times higher than this national average. 

During the hearing, Senator Murkowski noted how difficult it is to raid heroin 

dens on island communities in Alaska. This is a common theme throughout Indian 

Country. Local law enforcement often does not have the resources to conduct a raid: 

one obstacle is obtaining a warrant when judges are often far away. Tribal leaders 

have voiced similar concerns about policing drug areas. They have also stated that 

the Tribal Law and Order Act, while beneficial, has also not helped as much as 

Tribes have needed or expected in terms of coordination between various agencies 

or in providing additional resources to law enforcement. Drugs are overwhelming 

Tribal administrations because combating the epidemic requires additional funding 

and coordination between law enforcement, Tribal health programs, schools, and 

community members. 

Nationally, deaths involving heroin have quadrupled from 2000 to 2013. Most of 

the increase occurred after 2010 and the greatest increase was seen in the Midwest. 

These figures correlate with concerns of Tribal Leaders near the Bakken Oil Development that has reached peak development since 2010. The Bakken Oil Development has had a negative effect on the health and wellbeing of Tribes in the region 

by increasing drugs on the reservations. Remote locations, and small numbers of 

law enforcement officers make reservations in the area a primary target for drug 

traffickers. Congress must support targeted interventions in these areas so that the 

negative effects of this new development are not harming Tribal communities. 

Youth Involvement 

During the hearing, Senator Franken told a story about visiting a Native teen recovery center in Minnesota. He asked the youth how many of them started using 

drugs or alcohol with their parents and all students raised their hands ‘‘yes.’’ AI/ 

AN youth are initiating alcohol and drug use earlier than their non-native counterparts. Because drugs and alcohol are so prevalent with adult AI/AN populations on 

many reservations, it is often only a matter of time before the young people of a 

community begin to use as well. Not only are AI/AN youth starting to use drugs 

and alcohol at an earlier age, more youth are using drugs and alcohol more often 

than non-native youth. 

According to the California Department of Education’s California Healthy Kids 

Survey, between 2008 and 2010, 30 percent of AI/AN youth ages 12–17 reported 

drug or alcohol use in the past month. Of those who used alcohol in California in 

the past month, 39 percent reported heavy alcohol consumption or binge drinking. 

AI/AN youth have reported much higher percentage of binge drinking (16.7 percent) 

compared to the National Healthy People Goal (8.6 percent). Nationally, AI/AN students’ annual heroin and OxyContin use was two to three times higher than the 

national average for youth heroin and OxyContin use. 

63 

High substance use in American Indian communities contributes to a range of social problems including violence, delinquency, and mortality from suicide or alcohol 

or other substance abuse. Thus, these findings alert us to the urgency of implementing prevention programs in these communities. Research documents higher 

rates of use and earlier initiation among AI/AN adolescents compared with other 

U.S. adolescents, but the extent of disparities found varies across studies. This is 

why research for drug use and treatment programs is so important. Part of this research should analyze the use of cultural practices. 

Policy Recommendations 

Clearly, more must be done to restore alcohol and drug-free Tribal communities. 

Foremost, long-lasting reform should involve a variety of actors including Tribal, 

federal, state, and local governments; community elders; youth leaders; school leaders; and the community members themselves. However, there are several things 

that Congress can do in order to help address the true costs of alcoholism and substance abuse in Indian Country: 

• Increase funding for research on the locations and effects of alcohol and substance abuse in Indian Country. Before we are able to treat the causes, it is critical that we have better data on the incidence, prevalence, effects and locations 

that experience these problems. CDC should provide designated funding to Tribal Epidemiology Centers in order to have better data on this critical issue. This 

research should identify specific targeted locations and causes of alcoholism and 

drug abuse. 

• Provide funding to Tribes and Tribal researchers to establish indicators for evidence-based criteria that are based on traditional healing practices. Tribal communities have been healing their people for thousands of years, and are highly 

effective in the communities where they are employed and engaged. Yet, it is 

often the case that traditional healing practices are not do not meet mainstream 

criteria for data collection under federal grants, which puts Tribes at a disadvantage when applying for and administering federal programs. It is critical 

that Congress support these traditional practices by providing funding to establish evidence-based criteria related to traditional healing methods. 

• Increase and sustain funding for alcohol and substance abuse treatment and 

prevention programming in Tribal communities. This should include expanding 

the Methamphetamine and Suicide Prevention Initiative (MSPI) at IHS, which 

is currently only funding about 100 demonstration projects. It should also include specific training for Tribal members to become counselors and addiction 

professionals in order to create sustainable change on reservations. Recruitment 

and retention of medical professionals is a chronic issue at IHS. Alcohol and 

substance abuse counselors are no different. According to the IHS’ Congressional Budget Justification for FY 2016: ‘‘IHS, as a rural health care provider, 

has difficulty recruiting health care professionals. There are over 1,550 vacancies for health care professionals. . .across the IHS system. . .’’ (CJ–216). 

Given these challenges, it is critical that training be provided for community 

members already living in these Tribal communities so that they there can be 

continued support for these critically-needed services. 

For FY 2017, the Tribes have recommended that Congress increase funding for 

Alcohol and Substance Abuse at the IHS to $312.3 million (+121.3 million (+63 

percent) from FY 2015). However, it is critical that other federal agencies, including the Substance Abuse and Mental Health Services Administration, CDC, 

Bureau of Indian Affairs and the Department of Justice also provide longterm, 

designated resources to Tribes to carry out this work. In addition of funding alcohol and substance abuse treatment, these agencies should provide Tribes 

funding on the effects of alcohol and drug abuse such as unintentional and intentional injury funding. Congress should also provide additional funding to 

Tribal justice systems so that enforcing the law in terms of alcohol and drug 

abuse is possible. 

• Provide Congressional oversight and accountability to ensure that various federal, state, and Tribal agencies are coordinating to combat alcohol and substance 

abuse as referred to by law. Congress should increase oversight on Section 241 

of The Tribal Law and Order Act (P.L. 111- 211). This section of the law requires The Department of Justice, Substance Abuse and Mental Health Services 

Administration, Bureau of Indian Affairs and the Indian Health Service to coordinate efforts when addressing Indian alcohol and substance abuse prevention 

and treatment. Additional oversight and accountability provided by Congress on 

the implementation of this provision will ensure that The Tribal Law and Order 

Act is fully executed. 

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• Empower Tribal governments by providing funding to create and sustain drug 

taskforces on reservations with high need. NIHB’s conservations with Tribes indicate that funding for programs designed to bring all aspects of the community 

together (Tribal leaders, elders, youth, teachers, law enforcement, federal officials, etc.) to develop community-wide strategies to tackle these issues in Indian 

Country. 

Sustained, and continuous funding must be a key element to all of this work. A 

Tribal leader recently told NIHB, that ‘‘It’s as if funds are awarded when rates 

spike, but return to complacency with alarming rates when rates fall somewhat. 

Programs cannot be sustained with uncertainty over funding from year to year.’’ Indian Country must have continued investments in these programs from all agencies 

involved in order for there to be change. Congress must also direct the Administration to work with Tribes in forming a concrete strategy to overcome these issues so 

that we stop just moving from crisis to crisis. 

Conclusion: 

Thank you for holding this important hearing on The True Costs of Alcohol and 

Substance Abuse in Indian Country. This epidemic has created community-wide destruction on many reservations. The true costs of this disease have not only resulted 

in lowering the immediate health status of many American Indian and Alaska Native persons, but also leads long-term health costs such as feelings of depression, 

anxiety and even suicide. Over time, generations of young people grow up in homes 

ravaged by alcohol and substance abuse and experience feelings of hopelessness, and 

then turn to these avenues themselves effecting employment opportunities, placing 

serious burdens on the Tribal justice system, and eroding traditional ways of life 

in Tribal communities. We must break this cycle. 

The National Indian Health Board stands ready to work with the Committee to 

create and sustain the programs suggested in this testimony. 

PREPARED STATEMENT OF HON. JOHN YELLOW BIRD STEELE, PRESIDENT, OGLALA

SIOUX TRIBE


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RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. AL FRANKEN TO

HON. ROBERT G. MCSWAIN

Question. Mothers with opioid addiction often begin with legal prescriptions. Poor 

prescribing practices can have tragic consequences so it’s very troubling when individuals receive addictive drugs for minor conditions or receive more medication than 

is necessary. 

Many American Indians receive health care through the Indian Health Service 

(IHS). What specific steps has the IHS taken to improve prescribing standards and 

address over-prescription? 

Answer. IHS works with partners within and outside the Department of Health 

and Human Services, including the Behavioral Health Coordinating Council’s Prescription Drug Abuse Working Group on this issue. IHS has provided mandatory 

training for its providers on safe and appropriate prescribing practices. The first 

five-hour training course was held in February 2015. The training is held on a regular basis. By April 2017, all IHS health care professionals who prescribe as part 


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of their duties will have received the training at least once, with refresher courses 

at least every 3 years thereafter. 1, 2

IHS has established a national IHS chronic non-cancer pain management policy 

to provide direction to its federal hospitals and clinics on appropriate opioid prescribing. This will be updated once the Centers for Disease Control and Prevention 

(CDC) publishes final guidelines for primary care providers on safer, more effective 

care for patients with chronic pain. To assist providers with resources, IHS developed its pain management website http://www.ihs.gov/painmanagement/). 

In addition to the steps above, many IHS providers participate in State Prescription Drug Monitoring Programs (PDMPs), and IHS is working to decrease barriers 

to PDMP use. An IHS circular has been drafted on participation in PDMPs and is 

under Agency review. In 2012, IHS convened a multi-disciplinary workgroup to 

focus on Prescription Drug Abuse in Indian Country. As part of the workgroup’s recommendations, IHS has worked with ONDCP, the Bureau of Justice Assistance, and 

numerous state PDMPs to expand participation with existing state PDMPs, to develop best practice recommendations, and to report controlled substance dispensing 

data to state PDMPs. IHS has developed software compatible with five American 

Society for Automation in Pharmacy formats, deployed reporting capacity in 21 

states, and assisted tribal programs with PDMP program deployment. As these systems continue to mature, PDMPs can enable health care providers and law enforcement agencies to prevent the non-medical use and diversion of prescription opioids. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. AL FRANKEN TO

MIRTHA BEADLE

Tribes in Minnesota have noted that there is limited research on opioid abuse and 

treatment that is specific to Indian Country. 

Question. How can the Substance Abuse and Mental Health Services Administration and other federal agencies support research on the contributors to opioid abuse 

among Native Americans as well as what treatment approaches are most effective 

for this population? 

Answer. The Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality (CBHSQ) currently conducts research on the epidemiology of and factors contributing to opioid use and misuse 

among American Indians and Alaska Natives. CBHSQ collects data through the National Survey on Drug Use and Health (NSDUH) on substance use and mental 

health, including opioid use and misuse, as well as associated demographic and risk 

and protective factors. Data are also collected through the Treatment Episode 

Dataset (TEDS) on treatment admissions and discharges, as well as associated demographic factors. CBHSQ frequently reports on analyses by demographic characteristics, including for the American Indian and Alaska Native population. CBHSQ 

is developing a Public Health Research and Surveillance Agenda for the American 

Indian and Alaska Native (AI/AN) population that will include a description of what 

is known and questions that remain regarding the behavioral health epidemiology 

of the AI/AN population. Recent CBHSQ publications include: 

• 2014 National Survey on Drug Use and Health: Detailed Tables (2015) 

• The NSDUH Report: Need for and Receipt of Substance Use Treatment among 

American Indians or Alaska Natives (November 2014) 

• The TEDS Report: American Indian and Alaska Native Substance Abuse Treatment Admissions Are More Likely Than Other Admissions to Report Alcohol 

Abuse (November 2014) 

• Treatment Episode Data Set (TEDS): 2002–2013. National Admissions to Substance Abuse Treatment Services (2015) 

• Data Spotlight: Almost Half of American Indian and Alaska Native Adult Substance Abuse Treatment Admissions Are Referred through the Criminal Justice 

System (November 2012) 

To support effective treatment, SAMHSA’s Treatment Improvement Protocol 51: 

Substance Abuse Treatment Addressing the Specific Needs of Women provides substance use disorder treatment advice to clinicians and administrators for NativeAmerican Women, which includes clinical, program development, and staff training 

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components. Among these components, specific advice includes exploring women’s 

beliefs regarding healing and knowledge of cultural practices; combining contemporary approaches with traditional/spiritual practices; and training staff to address 

biases and myths associated with Native American Clients. 

The National Institute on Drug Abuse (NIDA), within the National Institutes of 

Health, also funds research on opioid misuse. Since 1975, NIDA has funded the 

Monitoring The Future (MTF) survey, which measures drug, alcohol, and cigarette 

use and related attitudes among adolescent students nationwide. Survey participants report their drug use behaviors (including prescription opioid misuse) across 

three time periods: lifetime, past year, and past month. Overall, 44,892 students 

from 382 public and private schools participated in this year’s MTF survey. NIDA 

has also funded research comparing MTF survey results with survey data specific 

to the AI/AN population. 

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