U.S. GOVERNMENT PUBLISHING OFFICE

31–121 PDF WASHINGTON : 2018

A SUSTAINABLE SOLUTION TO THE EVOLVING 

OPIOID CRISIS: REVITALIZING THE OFFICE OF 

NATIONAL DRUG CONTROL POLICY 

HEARING 

BEFORE THE

COMMITTEE ON OVERSIGHT 

AND GOVERNMENT REFORM 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

MAY 17, 2018 

Serial No. 115–82 

Printed for the use of the Committee on Oversight and Government Reform 

( 

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

http://oversight.house.gov 


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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

Trey Gowdy, South Carolina, Chairman 

John J. Duncan, Jr., Tennessee 

Darrell E. Issa, California 

Jim Jordan, Ohio 

Mark Sanford, South Carolina 

Justin Amash, Michigan 

Paul A. Gosar, Arizona 

Scott DesJarlais, Tennessee 

Virginia Foxx, North Carolina 

Thomas Massie, Kentucky 

Mark Meadows, North Carolina 

Ron DeSantis, Florida 

Dennis A. Ross, Florida 

Mark Walker, North Carolina 

Rod Blum, Iowa 

Jody B. Hice, Georgia 

Steve Russell, Oklahoma 

Glenn Grothman, Wisconsin 

Will Hurd, Texas 

Gary J. Palmer, Alabama 

James Comer, Kentucky 

Paul Mitchell, Michigan 

Greg Gianforte, Montana 

Elijah E. Cummings, Maryland, Ranking 

Minority Member 

Carolyn B. Maloney, New York 

Eleanor Holmes Norton, District of Columbia 

Wm. Lacy Clay, Missouri 

Stephen F. Lynch, Massachusetts 

Jim Cooper, Tennessee 

Gerald E. Connolly, Virginia 

Robin L. Kelly, Illinois 

Brenda L. Lawrence, Michigan 

Bonnie Watson Coleman, New Jersey 

Raja Krishnamoorthi, Illinois 

Jamie Raskin, Maryland 

Jimmy Gomez, Maryland 

Peter Welch, Vermont 

Matt Cartwright, Pennsylvania 

Mark DeSaulnier, California 

Stacey E. Plaskett, Virgin Islands 

John P. Sarbanes, Maryland 

SHERIA CLARKE, Staff Director 

WILLIAM MCKENNA, General Counsel 

SARAH VANCE, Health Care, Benefits, and Administrative Rules Subcommittee Staff Director 

MICHAEL KOREN, Professional Staff Member 

SHARON CASEY, Deputy Chief Clerk 

DAVID RAPALLO, Minority Staff Director 


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C O N T E N T S 

Page 

Hearing held on May 17, 2018 ............................................................................... 1 

WITNESSES 

PANEL I 

The Honorable John Cornyn, Senator from Texas and Senate Majority Whip 

Oral Statement ................................................................................................. 1 

PANEL II 

Anand Parekh, MD, MPH, Chief Medical Advisor, Bipartisan Policy Center 

Oral Statement ................................................................................................. 8 

Written Statement ............................................................................................ 10 

Rahul Gupta, MD, MPH, MBA, FACP, Commissioner and State Health Officer, Department of Health and Human Resources’ Bureau for Public 

Health, State of West Virginia 

Oral Statement ................................................................................................. 14 

Written Statement ............................................................................................ 16 

Mr. Thomas Carr, Executive Director, Washington/Baltimore, High Intensity 

Drug Trafficking Areas Program 

Oral Statement ................................................................................................. 23 

Written Statement ............................................................................................ 25 

Ms. Gretta Goodwin, Director, Homeland Security and Justice, U.S. Government Accountability Office 

Oral Statement ................................................................................................. 31 

Written Statement ............................................................................................ 33 

APPENDIX 

Representative Gerald E. Connolly Statement ..................................................... 68 

Response from Dr. Parekh, Bipartisan Policy Center, to Questions for the 

Record ................................................................................................................... 70 

Response from Dr. Gupta, Bureau for Public Health West Virginia, to Questions for the Record .............................................................................................. 72 


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A SUSTAINABLE SOLUTION TO THE EVOLVING OPIOID CRISIS: REVITALIZING THE OFFICE OF NATIONAL DRUG CONTROL POLICY 

Thursday, May 17, 2018 

HOUSE OF REPRESENTATIVES, 

COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM, 

Washington, D.C. 

The committee met, pursuant to call, at 11:10 a.m., in Room 

2154, Rayburn House Office Building, Hon. Trey Gowdy [chairman 

of the committee] presiding. 

Present: Representatives Gowdy, Sanford, Amash, DesJarlais, 

Meadows, DeSantis, Ross, Walker, Blum, Hice, Grothman, Hurd, 

Palmer, Comer, Cummings, Maloney, Norton, Lynch, Connolly, 

Kelly, Krishnamoorthi, Welch, and DeSaulnier. 

Chairman GOWDY. The Committee on Oversight and Government 

Reform will come to order. Without objection, the presiding member is authorized to declare a recess at any time. 

Senator Cornyn, we are thrilled to have you. We realize that 

there are votes that have been called in the Senate. So my colleague from Maryland has graciously agreed to allow you to make 

your opening first, and then we will allow you to go vote. 

With that, you are recognized. 

WITNESS STATEMENTS 

PANEL I 

STATEMENT OF THE HON. JOHN CORNYN 

Senator CORNYN. Thank you Chairman Gowdy and Ranking 

Member Cummings. I appreciate your courtesy and the opportunity 

to be here today to address America’s drug addiction crisis. 

From 1999 to 2016, more than 350,000 Americans have died 

from an overdose involving opioids, more people than in the current 

population of the city in St. Louis. This epidemic is hitting every 

community in every State, with more than 2,800 deaths in my 

home State of Texas in 2016. 

But, of course, this didn’t happen overnight. The Centers for Disease Control and Prevention has outlined the rise of the opioid 

overdose deaths in three distinct waves. 

The first began in 1999 with increasing overdose deaths attributed to prescription opioids. Then, in 2010, we saw a rapid increase 

in overdose deaths involving heroin, which is cheaper than diverted 

prescription opioids. 


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The third wave began in 2013 with significant increases in overdose deaths involving synthetic opioids like illicitly manufactured 

fentanyl. Of the more than 64,000 overdose deaths in 2016, more 

than half were the result of heroin and synthetic opioids, not prescription drugs. 

What is clear is that addressing only prescription opioids will not 

remedy this crisis. We must also halt the flow of illicit drugs like 

heroin and fentanyl, including through increased detection and 

intervention efforts at America’s borders and ports of entry. 

Transnational criminal organizations and drug cartels will stop 

at nothing to exploit Americans who are addicted to these narcotics 

that are tearing apart our families and our communities. And 

sadly, demand for the illicit drugs being sold by these criminal organizations has only increased as we have stepped up efforts to 

limit prescription opioid diversion. 

Now more than ever, we need to carry out a comprehensive and 

coordinated strategy across all levels of government to address both 

the supply and the demand for illegal narcotics in the United 

States. 

That is why I am pleased to have worked with Senator Dianne 

Feinstein to introduce the Substance Abuse Prevention Act of 2018 

of the Senate. I hope you all will take a look at that. 

Our bill strengthens and reauthorizes the Office of National 

Drug Control Policy, which oversees all executive branch efforts on 

narcotics control, implements a national drug control strategy, and 

strengthens and complements State and local antidrug activities. 

This includes the High Intensity Drug Trafficking Area program, 

which provides resources for Federal, State, and local law enforcement task forces operating in our most critical drug trafficking regions. 

The bill also improves the program by targeting funds for the implementation of a coordinated drug overdose response strategy. It 

reauthorizes the Drug-Free Communities Program, one of our most 

important programs for preventing substance abuse and reducing 

demand for illicit narcotics at the community level. 

The Drug-Free Communities Program has been a central bipartisan component of our Nation’s demand reduction strategy since 

its passage in 1998, because it recognizes that the drug issue must 

be dealt with in every hometown in America. 

Solving our drug addiction crisis requires more than just law enforcement solutions. Families and communities must work together 

to implement evidence-based approaches that prevent drug addiction. 

This is exactly the mission being carried out by Drug-Free Communities Coalition partners, and their efforts are critical to solving 

the drug abuse crisis. 

And while we hope to prevent substance abuse from becoming a 

criminal matter, there is no avoiding the fact that our courts will 

always have a role to play in addressing drug addiction challenges. 

That is why this legislation would also reauthorize the Department of Justice’s Drug Court Program, which helps provide judicial 

and law enforcement officials on the front lines with the tools and 

the resources they need to help criminal defendants seek treatment 


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and rehabilitation instead of repeating the tragic cycle of addiction 

and incarceration without an opportunity to break that cycle. 

Finally, the Substance Abuse Prevention Act also builds on the 

achievements of the Comprehensive Addiction and Recovery Act of 

2016, known as CARA, to help families in substance abuse challenges by providing resources for sobriety, treatment, and recovery 

teams that pair social workers and peer mentors with these families. 

This legislation that I have described here is supported by a 

broad coalition of 102 organizations, including the Community 

Anti-Drug Coalitions of America, the Addiction Policy Forum, the 

National Association for Children of Addiction, the National Council for Behavioral Health, and the Fraternal Order of Police. 

Mr. Chairman, I know that you will soon introduce legislation 

that would also reauthorize and strengthen the ONDCP to address 

many of the issues that I have talked about today. I look forward 

to working with you and your committee as these bills move forward in our respective bodies so that we can be sure that the Federal Government is doing everything in our power to respond to 

this grave challenge facing our Nation. 

I hope this committee and Members on both sides will continue 

their efforts to find consensus solutions to our substance abuse crisis. Saving our children, our families, and our communities from 

drug addiction is a humanitarian issue, not a partisan issue. 

Mr. Chairman, thank you for allowing me to provide these comments and for your many courtesies today. 

Chairman GOWDY. Senator Cornyn, I know I speak on behalf of 

all of the members on both sides of the aisle when we thank you 

for your career in public service, in the justice system, in law enforcement, and most recently, the United States Senate, and for 

your leadership on this very important issue. And we have benefited from your opening statement, and we thank you. 

Senator CORNYN. Thank you, Mr. Chairman. I appreciate the 

visa that allows me to visit the House side. And I will return it 

promptly. 

Chair GOWDY. You are welcome any time. Yes, sir. 

We will briefly stand in recess while the second panel assembles. 

And then Mr. Cummings and I will make our opening statements. 

[Recess.] 

Chairman GOWDY. We welcome our second panel of witnesses. 

Mr. Cummings and I will make our opening statements, then we’ll 

recognize you for your opening statements. 

Our country is in an opioid crisis, and it’s getting worse. Statistics can be helpful because statistics help us quantify and provide 

scope and scale. But statistics are what usually happen to other 

people. 

What paints the most vivid image of this crisis are those who 

have lost children to overdose, those who are now and will forever 

be in the throes of addiction, and those whose lives have been 

ended, upended, and are in fear of retreat back toward addiction. 

The increasing reality is more and more as our fellow Americans 

have come face to face with this crisis within their own families, 

to say nothing of within their own communities and the broader 

American family. 


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Each year over 64,000 Americans die from a drug overdose. 

That’s more than the number of Americans killed in the entirety 

of the Vietnam war, a war which has consumed parts of the American consciousness for over half a century. 

And while consensus exists on the depth of this challenge and 

the need to confront it in an apolitical way, the problem is worsening as more potent drugs emerge and the online market for illicit 

distribution expands. 

Our country is in desperate need of a central coordinated response. The issue knows no geographic boundary, is no respecter 

of State lines, which means we need a coordinated governmental 

response at the national level. 

So 30 years ago, Congress created the Office of National Drug 

Control Policy. This office is designed to play a central role in coordinating the Nation’s drug control policy and programs. National 

drug control efforts are spread across 16 departments and agencies 

implementing programs and operations throughout the U.S. 

So a central coordinating body is essential to ensuring effective 

evidence-based drug control programs. Drug control efforts should 

be synchronized and targeted at achieving specific strategic goals. 

While the ONDCP continues to receive annual appropriations 

from Congress, it nevertheless operates under an expired authorization. Reauthorizing ONDCP with revamped and enhanced authorities will improve coordination and effectiveness of Federal 

agencies and their diverse drug control efforts. 

ONDCP is also tasked with administering two grant programs, 

HIDTA and the Drug-Free Communities. ONDCP is uniquely positioned to administer these programs in a way that gives those 

working at the State and local level a prominent seat at the table. 

As Congress appropriates increasing levels of funding, the need 

for a national coordinating office is more important than ever. And 

to be sure, our Nation’s drug crisis will not be curtailed merely by 

appropriating money. The money must be spent in an effective way 

rooted in evidence, experience, and expertise. 

Last week our committee shared a discussion draft of reauthorization text for the ONDCP. The committee has held hearings and 

roundtable discussions to better inform our reauthorization efforts. 

And through the posting of our draft text online we’ve received constructive feedback from the general public. 

Today, we want to hear from partners about the importance of 

reauthorizing ONDCP. By ensuring a synchronized national effort 

we’re better positioned to achieve our common goal of ending this 

devastating crisis. 

This week is the week we set aside each year in Congress to 

honor law enforcement. So I want to end it by honoring someone 

in law enforcement, an old narcotics officer by the name of Kevin 

Simmers. 

Kevin dedicated his career to the interdiction and detection and 

apprehension of drug dealers. He wanted to do his part to keep his 

community free from the scourges of addiction and trafficking. He 

felt like he was doing the Lord’s work. 

But Kevin was not just a law enforcement officer. He was also 

a father to a beautiful daughter named Brooke. Well, we know addiction is no respecter of people, not even of law enforcement offiVerDate Nov 24 2008 09:07 Sep 04, 2018 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 H:\31121.TXT APRIL

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cers who dedicate their lives to keeping drugs away from other people’s children. No one is immune. 

So when Kevin’s daughter Brooke developed an addiction, he did 

everything a father could do. He tried treatment, he tried unconditional love, he tried tough love. He tried treatment again. Even 

tried jail. 

You can imagine how hard it would be for a father to leave his 

daughter in jail. But he did so because he wanted her to be clean. 

He came home from work and parked his police car behind his 

daughter’s car so he could block off, not just her car, but also her 

path back to addiction. He wanted to keep his daughter from leaving in the middle of the night. He wanted to separate her, he wanted to protect her, he wanted to trap her. A father’s love can be a 

benevolent trap. But heroin is a trap, too. 

So Kevin woke up one morning to the ominous sound of an 

empty house and the ominous sight of tire tracks through the front 

yard. His little girl was gone again, 6 o’clock in the morning. 

Brooke went to a gas station. She called her sponsor. Her sponsor said, ‘‘Call your dad.’’ But she didn’t want to disappoint her father again. So she drove to a church where she played basketball 

as a child, crawled into the backseat of her car, and overdosed on 

heroin. 

It’s not the statistics. It’s not the money. It’s something you can’t 

count. It’s the grief of parents burying their child. 

The gentleman from Maryland is recognized. 

Mr. CUMMINGS. Thank you very much, Mr. Chairman. 

The first overdose death that I heard of, I was 6 years old, 6. I’m 

67 now. And this young man was a hero in our neighborhood, and 

I didn’t even know what drugs were. 

Then I had an opportunity later on in my life, as a 15-year old 

working in the drugstore, to watch people come in trying to get 

Robitussin. Do you remember that? Trying to get high. People that 

were in so much pain, they didn’t even know they were in pain, of 

all colors. 

That was 50-some years ago. And I am glad that we are moving 

to this moment, because I do believe that this is a destiny moment 

where we say enough is enough. 

Fighting the opioid epidemic has been one of my top priorities for 

several years. I had a family member to die from this. Not only because it’s a terrible thing that has destroyed so many Baltimoreans 

lives, but also because it’s devastating a Nation, in red states, in 

blue states, in purple states. 

It is time that we finally recognize this epidemic for truly what 

it is, a national emergency that is killing 115 Americans every single day, 115, and counting. 

In December, the Centers For Disease Control and Prevention 

warned that life expectancy in the United States dropped for the 

second year in a row, and drug overdoses are the single biggest 

reason why. In 2016, nearly 64,000 Americans died from drug 

overdoses. These numbers are only getting worse with every passing minute. 

I understand that today’s hearing is supposed to be about proposals to reauthorize the Office of National Drug Control Policy. 

But it’s hard to do that when we have not been able to speak to 


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the acting director of that office. We asked for him to testify here 

today, but our request was denied. 

It’s also hard to do it when we will not be hearing from other 

stakeholder agencies that are involved in this fight, like the DEA 

and the Coast Guard. 

We’re supposed to markup a bill next week, but we have not received any official feedback or technical assistance from the administration. We had a roundtable meeting with ONDCP staffers, and 

I thank you, Mr. Chairman for that, but I’m concerned that this 

legislation may not be ready for primetime. 

Compounding this problem is the Trump administration’s total 

lack of leadership on this issue, and they are simply missing in action. The National Drug Control Strategy was due in February, but 

they did not submit one. Remember what I said. We’ve got 115 people dying a day, but no drug control strategy. 

Now, the President has just assumed office. I got that. So maybe 

it is understandable. But this February also came and went, and 

he still has not submitted a strategy, 115 people dying a day. 

ONDCP staff told us that Kellyanne Conway is calling the shots. 

I sent a letter to the chairman on February 16, 2018, asking for 

a briefing from her, or anyone, from the White House who could 

tell us what’s going on. But that never happened. 

Ladies and gentlemen, this is the most deadly national health 

crisis we have seen in three decades, in three decades. Where 

President Trump has shown no leadership, Congress must step into 

the void and demonstrate a bipartisan commitment to taking on 

this fight in an effective and efficient manner. 

We could talk all we want about how we might want to reorganize ONDCP, require new reports, and reshuffle the lines of authority. But they are not doing their jobs now. They are already 

failing to do what Congress required. So I have little hope that 

these kinds of changes alone will make a difference. 

Here is the main point I would like to convey today, and I would 

like to place it in the DNA of every cell of our brains. Reauthorizing ONDCP is an important step. We want to ensure that we 

have a coordinated, effective, and efficient and evidence-based 

strategy. 

But rearranging the deck chairs is not enough. Nibbling at the 

edges is not adequate. If someone has a gaping wound, we cannot 

just slap a Band-Aid on it. If someone is fatally hemorrhaging, we 

cannot just hand them a new organizational chart for a government office. They need expert medical care. 

As a Nation, we need to dedicate significant and sustained new 

funding for treatment to combat this epidemic. The Department of 

Health and Human Services estimates that more than 2 million 

people in this country have opioid use disorders, which is likely an 

undercount. Yet, only 10 percent are able to access the specialty 

treatments they need. 

Imagine 10 people with cancer and you tell them that only one 

of you can get the treatment in the United States of America, with 

one of the greatest health systems ever found. Something is wrong 

with that picture. We cannot stop this crisis if 90 percent of those 

affected cannot be treated. 


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Last month, I introduced the CARE Act with Senator Elizabeth 

Warren to start treating the opioid crisis like the public health crisis it is. Our bill is modeled directly on the Ryan White Act, which 

Congress passed with bipartisan support in 1990 to address the 

AIDS crisis. This has been endorsed by more than 30 organizations, including health advocacy groups, nursing organizations, 

local government associations, and public health organizations. 

I urge all of my colleagues on both sides of the aisle to join our 

bill. My staff has already contacted each of your offices, and my 

door is open to answer any your questions. 

To conclude, I want to thank our witnesses for being here today, 

including Ms. Goodwin from GAO, Mr. Parekh from the Bipartisan 

Policy Center. 

I look forward to hearing from Mr. Carr, an old friend and the 

executive director of the Washington/Baltimore HIDTA, Intensity 

Trafficking Area. I appreciate his effective leadership and I thank 

him for his endorsement of the CARE Act. 

Finally, I thank Commissioner Gupta of the West Virginia Bureau for Public Health for joining us today. 

And as I close, let me say this. This is our watch. This is our 

watch. And it is our duty to protect our neighbors. I think the 

chairman said it quite eloquently. We’ve got to do things to protect 

our neighbors. 

And it will affect all of us. There was one time that it seemed 

that the only place that was affected was the areas like the one I 

live in today and lived in for 35 years, the Black community. 

Well, hello, there’s a big difference now. It’s everywhere. And so 

we have to address this in a bipartisan way, and I’m looking forward to it. 

And, Mr. Chairman, I want to thank you for working with me 

and for your indulgence. 

Chairman GOWDY. The gentleman from Maryland yields back. 

We’re pleased to introduce our second panel of witnesses. 

Dr.Anand Parekh, chief medical advisor of the Bipartisan Policy 

Center. Dr.Rahul Gupta, commissioner and State health officer of 

the Department of Health and Human Resources’ Bureau for Public Health, State of West Virginia. Mr. Thomas Carr, executive director of the Washington/Baltimore High Intensity Drug Trafficking Areas Program. And Ms. Gretta Goodwin, Director of Homeland Security and Justice at the Government Accountability Office. 

We welcome all of you. Pursuant to committee rules, I must administer an oath, so I would ask you to please stand and raise your 

right hand. 

Do you solemnly swear that the testimony you are about to give 

should be the truth, the whole truth, and nothing but the truth, 

so help you God? 

May the record reflect all the witnesses answered in the affirmative. 

You may take your seats. 

There’s a series of lights that should inform and instruct you. 

Just be aware that all members have your opening statement in 

full, so if you could summarize the salient points within the 5 minutes, that will allow more time for the members to ask questions. 

With that, Dr.Parekh, you are recognized. 


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PANEL II 

STATEMENT OF ANAND PAREKH 

Dr. PAREKH. Chairman Gowdy, Ranking Member Cummings, and 

members of the committee, thank you for the opportunity to appear 

before you today. 

I applaud the committee’s efforts over the last year to identify 

ways to strengthen the White House Office of National Drug Control Policy and enhance the Federal response to the opioid epidemic. 

My testimony today is based on my perspective as a physician, 

a former deputy assistant secretary of health at the Department of 

Health and Human Services, and now currently as chief medical 

advisor at the Bipartisan Policy Center, a nonprofit organization 

that combines the best ideas from both parties to promote health, 

security, and opportunity for all Americans. 

As the chairman and the ranking member noted, in 2016 alone, 

2.1 million Americans had an opioid use disorder and over 42,000 

Americans died from overdosing on opioids. This crisis, 20 years in 

the making, will get worse before it gets better. 

Fortunately, there are evidence-based interventions and solutions 

that, if scaled by the combined efforts of the public and private sectors, can bend the curve of the epidemic. 

The Bipartisan Policy Center’s Governors Council, made of up 

former governors, has previously recommended four critical approaches to tackling the opioid epidemic. 

Number one, curbing overprescribing. In 2016, 91.8 million 

adults, nearly 4 in 10 adults in this country, used prescription 

opioids. As a physician, I can tell you there is no reason, neither 

for acute pain nor chronic pain, that this many Americans should 

be prescribed or be using these drugs. 

Number two, curbing the illicit supply, specifically heroin and 

synthetic opioids, which are currently driving the evidence. 

Number three, facilitating treatment and recovery through increased training of healthcare professionals and medication-assisted treatment, public and private insurance coverage of these 

services, and increased funding to support the treatment infrastructure. We have made it far too difficult in this country to treat 

opioid addiction. 

And number four, educating America to reduce stigma and expand evidence-based harm-reduction strategies, such as making 

Naloxone more widely available. 

In order to coordinate the Federal response the Bipartisan Policy 

Center’s Governors Council has also recommended that ONDCP be 

reauthorized, adequately funding and staffed, and empowered to 

track all Federal drug control initiatives. 

On that issue, I would like to make three key points to the committee today in response to the bipartisan discussion draft to codify 

ONDCP. 

First, the opioid epidemic is a multidimensional public policy 

challenge spanning public health, criminal justice, macroeconomics, 

international diplomacy, and homeland security. 

In order to comprehensively tackle the opioid epidemic, it is critical that States and communities have a Federal partner that has 


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itself coordinated. The Federal response requires a leadership office, such as ONDCP, to ensure coordination and collaboration of 

executive branch agencies and departments that have a role in addressing the supply side and demand side of this epidemic. 

The committee’s envisioned National Opioid Crisis Response 

Plan, with goals, measures, targets, action steps and designations 

of responsible offices or officials, is urgently needed. This plan 

would also more clearly inform Congress about the appropriate 

Federal funding levels necessary to address the epidemic over the 

next several years. 

Second, the robust performance measurement and data collection 

activities that the committee envisions for ONDCP will require sufficient funding and staffing support. I encourage the committee to 

ensure ONDCP tracks both process measures and outcome measures to gauge progress in combating the epidemic. 

The critical drug control information and evidence plan the committee is envisioning should include assurances from ONDCP that 

performance metrics can be tracked using existing data surveillance systems or that systems be developed if not currently in operation. 

I also encourage the committee to build in some flexibility with 

respect to performance measurement. The committee should ensure 

agency accountability while not being overly prescriptive. 

And third, for ONDCP to truly succeed it must be empowered by 

Congress and supported by the administration. The President 

should underscore ONDCP’s authorities to Federal agencies and 

departments who must be accountable for their role in implementation of the response plan. 

Ultimately, ONDCP needs to be the quarterback of the Federal 

response to the opioid epidemic and needs the staffing, funding, 

and authority so it can lead and inspire disparate agencies and departments in tackling the opioid epidemic and other threats that 

may come down the road. 

Thank you for the opportunity to address this committee. And I 

look forward to your questions. 

[Prepared statement of Dr. Parekh follows:] 


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Chairman GOWDY. Thank you,Dr. Parekh. 

Dr.Gupta. 

STATEMENT OF RAHUL GUPTA 

Dr. GUPTA. Chairman Gowdy, Ranking Member Cummings, and 

distinguished committee members, thank you for the opportunity to 

appear in front of you today to discuss an issue of significant importance to the lives the American people, the opioid epidemic. 

State and territorial health agencies are on the front lines responding to the current crisis of substance misuse, addiction, and 

drug overdose. 

As a public health official and as a practicing physician for nearly 25 years, I have witnessed the consequence of this crisis in the 

form of overdose deaths, substance-related interaction with the 

criminal justice and welfare systems, HIV, hepatitis, prenatal substance exposure effects, and the burden on the healthcare system. 

This crisis is unweaving the very fabric of our society. 

In West Virginia, we continue to experience the highest rate of 

overdose fatalities in the Nation. We are also enduring a surge in 

the rate of neonatal abstinence syndrome among infants, a condition in which babies are born drug-dependent. Currently, 1 in 20 

babies are diagnosed with NAS, and 1 in 6 expecting mothers are 

found to have intrauterine exposure to drugs. 

Children are being placed in foster care at a higher rate than 

ever before, causing a tremendous demand on the social and early 

childhood resources. In fact, we estimate that there is an additional 

cost of at least $1 million for each baby born with NAS diagnosis. 

Our State is not alone. The number of babies born in the United 

States with a drug withdrawal symptom has quadrupled over the 

last 15 years. 

Under the leadership of Governor Jim Justice, West Virginia has 

made significant strides to take major steps in the right direction. 

Last year, we conducted a social autopsy of deaths and then engaged the public, a broad array of stakeholders and experts, to inform policymaking. 

Throughout this initiative, there was significant support for reducing the harms of overprescribing, improving access to evidencebased treatment, and increasing the use of Naloxone and other 

harm-reduction strategies. I would be happy to share with you the 

findings today. 

Recently, as a practicing internist, I saw a young woman who 

was brought into the clinic by her teenage daughter, being afraid 

of going through withdrawals, and having received Naloxone so 

many times that she was told she would not get it again. She was 

desperate to enter treatment. And we got her into treatment, but 

it wasn’t easy. 

But for three other patients that afternoon, I tried every possible 

way, but the best I could do was to listen to their story, their struggles, counsel them, offering them help whenever they were ready. 

As I left the clinic that afternoon, I sincerely hoped we would be 

able to help these folks before they became a statistic. 

Today, as we keep these real Americans in mind, I would like to 

stress upon three major points in my testimony. 


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One, to develop a sustainable solution to this contemporary challenge, we must have authentic national leadership that can envision and coordinate robust and wide-ranging, cross-cutting support 

from multiple organizations to develop an evidence-based comprehensive response strategy. 

ONDCP provides this leadership. As the committee explores the 

reauthorization, its position should be strengthened, resourced, and 

allowed the expertise to develop robust leadership potential. 

ONDCP has done in recent years more to narrow the divide between public health and public safety than any other agency. 

Second, Congress and States must work towards further expanding access to evidence-based treatment. We know that there are a 

number of barriers in accessing treatment, including stigma, homelessness, and poverty. 

Individuals often need ancillary services, such as housing, recovery support, employment assistance and training, childcare support, and others. 

Therefore, we should consider establishing a program to provide 

treatment and services to individuals with substance use disorders 

modeled on the Ryan White program, which provides treatment for 

AIDS patients. 

With that in mind, I urge you to ensure that any changes in statute are building upon the existing system and programs that currently exist without creating an undue burden to State and local 

communities. 

And finally, we must understand that this fight has to be fought 

on multiple fronts. In order to fully address this epidemic as well 

as substance use and misuse disorders as a whole, we must move 

further upstream to address the exposures during the life course 

that can lead to addiction, such as toxic stress in infants and adverse childhood experiences. 

We must bolster efforts to work with schools, school-age children, 

build resilient communities, and increase investments in programs 

that work to address the social-psychological determinants of 

health. 

In conclusion, the opioid crisis and substance misuse will not be 

solved by an individual agency or State. Instead, we need a comprehensive science-driven approach. As my patient rebuilds her 

life, she is going to need addressing her health, her home, her community, and the relationships with having a purpose in life. 

So I applaud your commitment, and I implore the committee to 

take swift action. 

Thank you. 

[Prepared statement of Dr. Gupta follows:] 


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Chairman GOWDY. Thank you, Doctor. 

Mr. Carr. 

STATEMENT OF THOMAS CARR 

Mr. CARR. Chairman Gowdy, Ranking Member Cummings—and, 

Congressman, it’s nice to see you back in the office again. 

Mr. CUMMINGS. It’s good to be back. 

Mr. CARR. And distinguished members of the committee, it’s an 

honor to appear before you today to discuss the proposed transfer 

of the HIDTA Program and the revitalization of the Office of National Drug Control Policy. 

I come to you today as a representative of the National HIDTA 

Directors Association, but also with a sense of deja vu, since 13 

years ago to this month I testified against a similar proposal that 

was before this committee. That proposal would have transferred 

HIDTA to the Department of Justice, and I’m glad to say it was 

rejected by Congress, and I urge you to do the same with this 

iteration. 

The administration’s rationale for the proposed transfer is to improve coordination among drug enforcement efforts. I submit the 

coordination that the proposal claims to seek already exists in the 

HIDTA program. 

The most significant feature of the HIDTA program is a longstanding policy that each HIDTA is managed by an executive 

board. Moreover, the voting power on that executive board must be 

equally divided between Federal and State and local and tribal 

agencies. 

The executive board is vital to the success of the HIDTA program, and it has unlimited discretion over activities and ensures 

that each HIDTA can tailor its strategy to the situation in that 

neighborhood. 

In 2017, HIDTA has funded 825 initiatives. More than 22,000 

personnel participated in these initiatives. As a result of the discretion afforded the executive boards, the makeup of the executive 

boards, and the top-to-bottom commitment to interagency cooperation, HIDTAs have established a track record of quickly devising 

and implementing creative responses to the drug challenges. 

I said earlier I had a sense of deja vu. And I think you should 

know that since 2005, HIDTAs have disrupted on average 2,882 

drug trafficking organizations each year. They’ve dismantled 

17,000 methamphetamine labs, taken more than 7,700 tons of 

drugs off the street, including 44 tons of fentanyl, heroin, and prescription drugs, seized $8.5 billion in cash, and provided training 

for 556,000 personnel. 

Now, as impressive as these statistics are, they don’t tell the 

whole story, so let me tell you a little bit more about it. 

One of the things we did was we developed something called the 

Heroin Response Strategy. This is the first multidisciplinary approach that I’m aware of that was focused on combating heroin and 

opium. The initiative brings public health and public safety partners together to reduce overdose fatalities. Common sense, if you 

ask me. 

The HRS includes 10 HIDTAs in 22 States. And I think it’s important to note that in their recent review of the HIDTA program 


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the GAO states, and I quote: ‘‘As demonstrated through its management of programs like HIDTA’s HRS, an agency like ONDCP is 

uniquely positioned to collaborate with its law enforcement and 

public health counterparts.’’ 

GAO also recognized that a major obstacle to dealing with the 

opioid crisis has been the lack of shared methodology to track 

overdoses in real time across jurisdictions. 

In 2017, the Washington/Baltimore HIDTA developed what we 

call ODMAP to address this need. ODMAP tracks overdoses as one 

would track a disease and issues alerts to public safety and health 

agencies about overdose spikes. More than 650 agencies across the 

country are now using ODMAP to share information. 

So what makes this all possible? Well, we believe the discretion, 

balance, and independence of the executive boards is a direct result 

of the HIDTA program being administered by the Office of the National Drug Control Policy. 

As you’re well aware, ONDCP is charged with preparing a National Drug Control Strategy. Key to ONDCP’s strength is its ability to coordinate the formulation of the President’s drug control 

budget. It needs that hammer. 

ONDCP’s responsibilities cross the entire spectrum of drug activities, including enforcement, treatment, and prevention, and we 

believe those responsibilities give ONDCP the unique perspective 

to accept a wide variety of approaches to the opioid epidemic. 

It is more urgent today than ever before for ONDCP to be reauthorized to continue its mission. Our members and our executive 

boards believe that the HIDTA program has been extremely efficient and effective under ONDCP and there’s no evidence that 

demonstrates any benefits from moving the HIDTA program out of 

ONDCP. 

We think the neutrality of the HIDTA program is a key ingredient for its success, and we also know that it would be difficult 

for DOJ to remain neutral and objective should they become our 

parent agency. Further, our non-DOJ representatives, and there 

are many, believe DOJ cannot operate as a neutral broker as well 

as ONDCP. 

The success of the DOJ is determined by how well each of its 

agencies fulfills the mission of the Attorney General. The success 

of the HIDTA is determined by how well it carries out the assignments given to it by the executive board. 

So as was cited before, we have 115 people dying every day from 

this crisis. We cannot afford now to abandon the ONDCP, abandon 

our mission, and we have to move forward. 

And I thank you very much. 

[Prepared statement of Mr. Carr follows:] 


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Chairman GOWDY. Thank you. 

Ms. Goodwin. 

STATEMENT OF GRETTA GOODWIN 

Ms. GOODWIN. Chairman Gowdy, Ranking Member Cummings, 

and members of the committee, I am pleased to be here today to 

discuss GAO’s recent work on combating the opioid problem, including the role of the Office of National Drug Control Policy, 

ONDCP. 

Today, I will talk with you about two topics. 

First, Federal agencies’ opioid-related strategies and the extent 

to which each agency is measuring its performance. 

Second, Federal agencies’ efforts to enhance collaboration and information-sharing to limit the availability of illicit opioids, the ongoing challenges to doing so, and ONDCP’s role in that process. 

In particular, there are five strategies that ONDCP and the Department of Justice have implemented to specifically combat illicit 

opioids. These include ONDCP’s Heroin Availability Reduction 

Plan, HARP, and DOJ’s 360 Strategy, which the Drug Enforcement 

Administration implements. 

We found that of the five strategies, only one, HARP, included 

outcome measures or measures that are results-oriented. The others either did not include performance measures at all our measured outputs instead of outcomes. 

For example, one of the goals in the HARP is to significantly reduce the number of heroin-involved deaths. ONDCP measures its 

progress towards this goal in part by using cause-of-death data. 

This is an example of a strategy with a clearly defined goal and 

a quantifiable measure that helps officials understand outcomes. 

Most importantly, an outcome measure of this kind helps the 

agency understand if what it is trying to achieve is actually happening. 

In contrast, the 360 Strategy captures the number of participants 

attending its activities, which is an output. Measuring outputs has 

some utility, but it does not allow the agency to assess the impact 

of its efforts or whether or not the resources it is investing are 

yielding the intended result. 

We recommended that ONDCP and DOJ develop outcome-oriented performance measures for their respective strategies. 

ONDCP raised concerns about the recommendation, and DOJ disagreed, stating that it would be difficult to do so. 

We continue to believe that our recommendations are valid and 

that finding meaningful ways to measure the effectiveness of these 

approaches is essential, despite being difficult. 

With respect to coordination, I will touch on some of the challenges agencies are experiencing and the role we recommended for 

ONDCP. 

Federal law enforcement agencies are increasingly coordinating 

with the public health sector to share overdose information. However, both sectors reported ongoing data-sharing obstacles and related challenges with the timeliness, accuracy, and accessibility of 

overdose data. 


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For example, toxicology results can take months to obtain, and 

this affects the timeliness of data on overdose deaths. These data 

are needed to anticipate and respond to threats. 

Additionally, some of the data can be incomplete because medical 

examiners or coroners may not always test for opioids, especially 

synthetic opioids, thereby leading to inaccurate or incomplete data. 

Further, legal restrictions to protect patient privacy on how data 

can be shared and analyzed affect how much information law enforcement and public health officials can access and share, respectively. 

ONDCP is uniquely positioned to collaborate with its law enforcement and public health counterparts to identify solutions to 

these challenges. We recommended that ONDCP lead a specific review on ways to improve the timeliness, accuracy, and accessibility 

of overdose data. ONDCP neither agreed nor disagreed with our 

recommendation, but did say it would consider it. 

I will note that during our review the lack of timely, accurate, 

and accessible information was one of the most pervasive concerns 

we heard from the public health and law enforcement officials we 

interviewed. 

Given ONDCP’s role in framing a national strategy, GAO believes the agency should bring together law enforcement and public 

health officials to improve national-level data and support data-improvement efforts at the State and local levels. 

Chairman Gowdy, Ranking Member Cummings, and members of 

the committee, this concludes my remarks. I am happy to answer 

any questions you have. 

[Prepared statement of Ms. Goodwin follows:] 


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Chairman GOWDY. Thank you. 

The gentleman from Alabama is recognized for his questions. 

Mr. PALMER. Thank you, Mr. Chairman. We’ve talked about the 

overdose deaths, the crisis that we have there. And first of all, I 

think we’re talking about 64,000 people possibly that died last 

year. I think that is understated. 

Dr.Parekh, in your experience, are you seeing where the death 

certificate does not show death by overdose but perhaps natural 

causes? 

Dr. PAREKH. I think you’re right. I think that’s probably an underestimate. Certainly, the 42,000 for opioids is likely an underestimate as well. A lot of times the death certificates don’t get into the 

specific cause of drug overdose deaths. Toxicology reports take a 

long time. 

So, unfortunately, these are likely underestimates, and these 

numbers will get worse, Congressman. 

Mr. PALMER. That’s what concerns me. I think Ranking Member 

Cummings made this point, that the CDC has lowered the life expectancy for Americans is not just because of drug overdoses, it’s 

also because of suicide. For people 10 to 24 years old, the secondleading cause of death is suicide. 

And to follow up with you, are we seeing suicides that are linked 

to drug abuse? 

Dr. PAREKH. We are. And these are overall called the deaths of 

despair. So you see drugs, alcohol, suicides taking a toll across the 

country, leading to the reductions in life expectancy, as you suggested. 

There are lot of factors here, economic factors as well, that lead 

to this, but they all, unfortunately, interrelated and driving the 

lowering of life expectancy, as you cited. 

Mr. PALMER. Well, it ought to be shocking to people that the suicide issue for 10-year-olds to 24-year-olds is the second-leading 

cause of death. 

And I’m going to get into some area I probably shouldn’t get into 

right here, but it has to do with the number of children, the percentage of children that are on psychotropic drugs that have adverse effects that might lead them to other issues like opioid abuse. 

I mean, in my own district it’s no longer shocking to hear that 

a young high school student has committed suicide. We had a 1- 

week period where a high school that’s 4 miles from my house had 

two in 1 week, and another one just a few miles from there. 

Mr. PALMER. And I think when we’re looking at this crisis, we’ve 

got to look at the totality. It’s just not the people who are dying 

from overdose, it’s also the suicide aspect and link it all together. 

I think if we did, we would all just be shocked at the total numbers. 

I mean, we’ve got veterans, 22 a day committing suicide. I wonder if any of you have any information about that, any of those related to adverse reactions to drugs that cause them to have these 

suicidal tendancies. Do you know anything about that? 

Dr. PAREKH. I think they’re all—I’ll start—I think they’re all— 

they can all be related, they’re interrelated. I think, Congressman, 

what you’re getting at is the overall importance of looking at the 

determinants of health and taking a prevention approach. 


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Mr. PALMER. Exactly. 

Dr. PAREKH. I think the Drug-Free Communities Program, for 

example, is trying exactly to do that with community coalitions. 

But that’s what we need to do, prevention, prevention, prevention, 

look at the underlying causes, the determinants of health. That’s 

the best way to reduce all these deaths of despair, whether it’s 

drugs, alcohol, or suicide. 

Mr. PALMER. Well, there is profiling can be done through looking 

at DNA before anyone is prescribed a drug that would lay down 

some markers about the effectiveness of the drugs and the propensity to lead them to other things. I think that might be part of the 

solution. 

Mr. Carr, we’re talking about fentanyl, and one of the things that 

I talked about with some of the folks in law enforcement is that 

they’re now deploying dogs that can sniff this out, particularly 

what’s coming in the mail. A lot of this is coming from China. A 

lot it is produced by North Koreans. 

I made this comment to former Governor Chris Christie, that 

we’ve gone from a war on drugs to a war with drugs, it seems like, 

and thousands of Americans are falling victim. 

One of my concerns is, and I don’t know if you can answer this, 

is that if we’re going to try to interdict this through the mail, what 

are we doing to interdict it through the mail that goes from Mexico 

and to Central America and Canada that comes across our border? 

Mr. CARR. Congressman, that’s a big problem. One of the biggest 

facilitators of drug trafficking by virtue of the fact that they are 

such good shippers is the U.S. Postal Service. 

I know there are efforts underway that the U.S. Postal Inspection Service has that are using computers and computer programs 

to profile packages. We’re working with them right now with our 

ODMAP project, because when we detect spikes in overdoses in geographic areas, then we hope to work backwards and target the 

packages that did come and are coming into that particular area 

so we can be more effective in the interdiction. 

But one of the problems with the way that they are shipping now 

is the fact that they are shotgunning. They are not sending big 

loads, they are sending multiple, multiple smaller loads. So it takes 

a lot of manpower and time to pick off those loads. And so if we 

got to 10 percent—I’ll pick a number out of the air—we got 10 percent of them, 90 percent of them are still getting through, which 

is still a problem. 

Can I go back to one comment you made, and it touched on prevention. We’re using the ACEs model, Adverse Childhood Experiences, to help us profile young children. 

We are working with the schools in Jefferson County, West Virginia, particularly the city of Martinsburg, the police, the schools, 

the board of education, the counselors in the schools, public health 

officials, all working together to identify those kids most at risk 

and to do something not only with them, but with their parents. 

And that’s the future of this, we have to look at long-term prevention if we’re going to be successful in it. 

Mr. PALMER. I agree 100 percent. 

Mr. Chairman, if I may, I just want to comment on your opening 

comments. One of the things that indicates how widespread and seVerDate Nov 24 2008 09:07 Sep 04, 2018 Jkt 000000 PO 00000 Frm 00049 Fmt 6633 Sfmt 6633 H:\31121.TXT APRIL

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rious this crisis is, I don’t think I know anyone who does not have 

a personal story of a friend or a colleague or a family member similar to what you delivered. And I thank you for that and for your 

indulgence. 

And I yield back. 

Chairman GOWDY. The gentleman from Alabama yields back. 

The gentleman from Massachusetts is recognized. 

Mr. LYNCH. Thank you, Mr. Chairman. 

And I want to thank the witnesses for coming here and trying 

to help us grapple with this problem. 

Just referring back to the gentleman from Alabama’s comments 

regarding suicide, in my district a few years ago we had a suicide 

cluster. And I lost 14 young boys, the oldest probably 17, the 

youngest probably 14, in a very short period. 

And there is definitely a correlation between this opioid epidemic, not one-to-one correlation, but there is definitely a connection there with the desperation that comes with addiction, and 

then these young people have no way out. 

The problem is bigger than that, but I think the gentleman from 

Alabama is spot on in trying to identify, drill down on that, and 

deal with that. 

In our community I didn’t know what to do. I reached out to 

CDC and a lot of other folks. I reached out to my construction 

unions. We actually built a residential facility for young people. Because up to that point we were actually collocating kids with 

adults, which is a bad situation. 

But we established a Cushing House for boys, and now we’ve established a Cushing House for girls. It is an adolescent residential 

facility dealing with this problem. And got the support of the Tufts 

Medical Center and also my local community health center and set 

it up. But the line is out the door. We’ve got 40 beds and I’ve got 

a list probably several hundred long trying to get in. 

I was touched by the chairman’s initial remarks. There’s 42,000 

stories out there last year alone of similar situations with families 

losing their kids. 

I do want to say that step one, though, is to have the director 

of the Office of National Drug Control Policy at this hearing, at 

that table right there. And we did not ask him to come here, and 

that just blows my mind. Because this is all about accountability. 

And I’m proud of Congress because the last bill that we put out 

has $3.5 billion to deal with this problem and we don’t have a director here who is willing to testify. We don’t have a President that 

has a drug policy that we can articulate to families out there that 

are in the situations that we just described. We are dragging our 

feet on this and this is inexcusable. 

And each witness here has talked about having leadership on 

this issue and a direction and a strategy on this issue, and we have 

a big fat zero because President Trump has somebody there for 8 

months and that didn’t work out. And now we’ve got a new person 

and we won’t even ask him to come here and describe what the 

President’s policy is because we don’t have one. So we’ve got $3.5 

billion to support a policy that does not exist at this point, and that 

is inexcusable. 

I’ve got 2 minutes left. 


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Let me ask you, Dr. Parekh and Dr. Gupta, so there’s a strategy 

for the Suboxone. It is a replacement therapy when our kids are 

hooked on opioids. And they are handing this stuff out like candy. 

And we’re replacing opioid addiction with Suboxone addiction, 

which is also an opiate. 

And I don’t see any improvement there. We’re just substituting 

drugs, one drug for another drug, and we’re spending a lot of 

money on it. And I end up with an addict in each case. 

Can I get your sense of this? 

Dr. PAREKH. Thank you, Congressman. 

So I think the short answer is, in fact, they are different drugs. 

One is a full opioid, the other is a partial opioid. That makes a big 

difference. And it allows this Buprenorphine or Suboxone to actually treat opioid addiction. And the best evidence we have, the gold 

standard evidence for treatment of opioid—— 

Mr. LYNCH. I’m down to 45 seconds. 

My follow up, Dr. Gupta, Vivitrol, it’s another version, it’s a nonopiate, it doesn’t seem to have the abuse potential that some others 

do. I that you didn’t come prepared for this, but that’s my question, 

is it better? 

Dr. GUPTA. Congressman, what I would say, just like diabetes or 

any other chronic disease, this is a chronic brain relapsing disease. 

We wouldn’t tell somebody with diabetes don’t take insulin, because otherwise you are artificially giving insulin, what your body’s 

missing. Just like this. 

These drugs go, they have been studied, they do four things. 

They prevent relapse into the system, they prevent overdoses and 

deaths, they reduce infectious disease risk, and lastly, they reduce 

the risk of somebody having criminal activity. 

So there are documented, evidence-based measures behind the 

use of MAT in the population. The best science we have today, it 

seems to work. 

Mr. LYNCH. Okay. 

Mr. Chairman, thank you for your indulgence, and I yield back. 

Chairman GOWDY. The gentleman from Massachusetts yields 

back. I will tell the gentleman, my friend from Massachusetts, that 

the nominee was invited to the roundtable. And I am disappointed 

that he did not come. The membership participation was good 

and—— 

Mr. LYNCH. Well, I apologize then. 

Chairman GOWDY. No, no, no. 

Mr. LYNCH. I did not know that he was invited. 

Chairman GOWDY. He was invited. 

Mr. LYNCH. You ought to subpoena him if he didn’t come. 

Chairman GOWDY. I think it would have benefited him and us 

to have him present, but he decided not to do so. 

The gentleman from North Carolina, Mr. Meadows. 

Mr. MEADOWS. Thank you, Mr. Chairman. 

And I thank both sides of the aisle for their heart and passion 

on this particular issue, because it does affect every community. 

And yet, at the same time, it is critically important that we recognize that as important as it may be to have a new director of this 

agency/subset of the executive branch, it is far more critical that 

we actually start doing something about it. Because this did not 


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start with this administration. We’ve had this issue for a long time. 

And I know the gentleman from Massachusetts would agree with 

that. 

I do agree that it should be all hands on deck. And I think the 

problem that you’re hearing is a frustration of the fact that we 

have a drug that is being used and there are so many deaths each 

and every day, as, Ms. Goodwin, as you pointed out that, that we’ve 

got to deal with it. 

Now the other thing is—and I would encourage—the ranking 

member of this committee has been very vocal in this area and I 

appreciate his leadership. It also goes into other areas, like FDA. 

We’ve got to find other alternatives for pain management that are, 

quite frankly, in the hopper waiting to be approved. 

And so we need to work in a bipartisan way on areas that perhaps have a less addictive nature. This was supposed to be the 

wonder drug and it has really taken over in a critical area. 

Ms. Goodwin, I want to come to you, because you talked about 

the coordination and where we are and that it’s critical that we 

have coordination. And yet I think what I understand is, is so 

whether it’s the DEA coordinating with the Coast Guard, coordinating with other areas on domestic illegal synthetic opioids, GAO 

found that only one of five strategies it reviewed actually included 

a results-oriented matrix or measurement. Is that correct? 

Ms. GOODWIN. That’s correct. So we looked at the five strategies 

that are out there and the only one that had a performance-related 

metric was the HARP program. 

Mr. MEADOWS. Okay. So if we have five programs and only one 

of them has a measurement, how do we know when we’re succeeding or making progress? Is it all just—— 

Ms. GOODWIN. Well, that’s something we recommended. In our 

recommendation we submitted to ONDCP we talked about the 

need for them to come together and kind of pull all of those strategies together, have a conversation, and help each of those strategies develop metrics. Because you can’t really get to the heart of 

the problem or begin to address the problem if you don’t have evidence-based information. 

Mr. MEADOWS. So if it is evidence-based, I think we will find 

Democrats and Republicans alike that will want to look and say: 

Are we making progress here? 

And what you’re saying is, is that the only progress that we see 

currently is really whether deaths go down from overdose? I mean, 

how do we measure whether we’re making progress with any policy, no matter how great it is? What would be your recommendation? 

Ms. GOODWIN. We didn’t talk through or we don’t put out there 

as GAO like what each of the entities are supposed to do. We ask 

that ONDCP start a review to develop a strategy that crosses all 

of the different stakeholders. 

And working very closely with the public health officials, law enforcement, and the other stakeholders, we think that’s a way to 

come to a strategy and begin to think about—— 

Mr. MEADOWS. Yeah, let me interrupt because I’ve only got 1 

minute left. And I appreciate your answer. 


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But I guess my question is, if you’ve identified it as a concern, 

you obviously have areas that you believe need to be measured, do 

you not? 

Ms. GOODWIN. Yes. 

Mr. MEADOWS. So have you made those recommendations in the 

areas that need to be measured? Because you just said you didn’t 

make a recommendation. But when you’re doing the analysis, you 

have to run across what your areas of concern are. 

Ms. GOODWIN. Yeah, one of things we are look for when we are 

doing our analysis, when we looked at HARP we noticed that they 

were actually collecting data, paying attention to the information, 

and reporting out. The other four strategies we looked at were just 

measuring whether someone showed up to a meeting or participated in an activity. We didn’t feel like that that went a long 

enough way—— 

Mr. MEADOWS. Far enough. 

Ms. GOODWIN. —went far enough to actually getting at a conversation about what’s the extent of the problem, what’s the nature 

of the problem, and how can you best develop strategies around 

that. 

So when GAO goes in to look at something the first thing we 

want to know is, where are the data? And we weren’t finding the 

type of data we thought would be useful for this conversation. 

Mr. MEADOWS. So, Mr. Chairman, may I offer this. In a bipartisan fashion, I know you have made this a priority for the reauthorization and really moving forward. 

Mr. Chairman, I know where your heart is, I know where the 

heart of the ranking member is on this particular issue. And if we 

only reauthorize, to not actually have a plan that implements with 

a measurable tool like Ms. Goodwin did, we will have failed. 

And so I’m committed to work in a bipartisan fashion with both 

of you on the leadership on this particular issue. I thank you. 

Chairman GOWDY. I thank the gentleman from North Carolina. 

The gentlelady from Illinois is recognized. 

Ms. KELLY. Thank you, Mr. Chair. 

And I just wanted to let the ranking member know that I can 

really relate to what you were saying. When I was much, much, 

much younger than I am now, a little girl, I lost an aunt to heroin. 

She had three children and her oldest daughter died of a heroin 

overdose, a dirty needle. So this is something near and dear to me. 

One of the most critical tools in addressing the opioid epidemic 

is the overdose reversal drug Naloxone. Naloxone is a generic drug. 

It was first approved in 1971. Yet the prices of these products have 

increased so dramatically in recent years that State and local communities are now having trouble stocking the drug. They are being 

forced to ration. One of these products, an auto injector like the 

EpiPen, now costs $4,500 for a pack of two. 

Dr. Gupta, as part of West Virginia’s opioid response plan, all 

first responders are now required to carry Naloxone. Is that correct? 

Dr. GUPTA. Yes, Congresswoman. 

Ms. KELLY. And some of the first responders are from volunteer 

organizations. Isn’t that correct? 

Dr. GUPTA. That is very true. 


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Ms. KELLY. So how does the price of Naloxone affect the ability 

of first responders to adequately equip themselves? 

Dr. GUPTA. I think that’s the important part. So one of the things 

that Governor Justice did, he actually put money behind, State 

money. So he’s put about $10 million into the plan, with specifically $1 million, and repurchased over 37 doses of Naloxone with 

State money. And we got about $26 a piece. But smaller agencies 

do not have that capacity and ability to have the purchasing power 

to do that. 

And we are very worried that the price increases and the price 

policies that are created are going to be a stumbling block no matter how many discounts are given, how many free Naloxone is distributed. 

We’re afraid that the average person who needs it isn’t going to 

be able to get it because they feel it’s something that’s, while life 

saving, is also extremely expensive in their perspective. 

Ms. KELLY. One of my hospitals I know has a program and they 

give it to our law enforcement in my rural area of my district. 

We’ve heard similar testimony from county officials who testified 

at a hearing on the opioid epidemic last month in our Health Subcommittee. One witness said because of price increases local communities have to, and I quote, ‘‘fly by the seat of our pants all the 

time in terms of coming up with the medication.’’ 

Dr. Gupta, from a public health perspective, how do these pricing 

issues affect your ability to truly combat this epidemic? 

Dr. GUPTA. Congresswoman, I can tell you from data, when we 

conducted a social autopsy we found that of the people EMS went 

to who have died from overdose, only a third of them actually got 

the Naloxone. And when we talk about elderly and African American, it was even worse. 

So what we’re seeing is that people are having—we have evidence to show that people—first responders are having to decide 

who to give, who not to give. And then there is always the issue 

of stigma because folks think that maybe the elderly aren’t dying 

because of overdose. So that adds to the problem. 

Ms. KELLY. The CARE Act, which I am cosponsoring, would invest $500 million per year in a Naloxone distribution program. 

Under this program the Federal Government would negotiate discounted prices for the product and then distribute it to the States, 

to first responders, local health officials, and the public. 

Would this kind of Federal role in negotiating, purchasing, and 

distribution of the product help West Virginia equip your first responders in your community? 

Dr. GUPTA. Yes, Congresswoman, that would be critical in ability 

to help that person. Because, again, if they have to have breath in 

their lungs in order to meaningfully have a chance to enter treatment, then we have to build the rest of the system as well to make 

sure that those folks, we save them first and then provide them the 

help. But this would be very helpful. 

Ms. KELLY. And I think we would all agree that it is unacceptable that communities all across the country are health hostage by 

these arbitrary price increases, especially for a life-saving drug. 

And it is also unacceptable that drug companies would use the 


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opioid crisis as a way to profiteer at the expense of all of our constituents. 

And I’m interested in working in a bipartisan way to see how we 

can combat this issue. And also I hope my colleagues will help by 

cosponsoring the CARE Act so we can bring these prices down and 

provide States and local communities with the tools they need to 

address the problem. 

I yield back. 

Chairman GOWDY. The gentlelady yields back. 

Dr. DesJarlais. 

Mr. DESJARLAIS. I thank the chairman and thank the panel for 

being here today. 

Ms. Goodwin, I’ll start with you. I’ve met with many groups over 

the years that stress the importance of instituting a nationwide 

prescription database. As you know, or may know, Tennessee borders eight different States and the congressional district I represent borders two. 

This poses a unique problem because in the absence of a nationwide prescription database, drug abusers in my district will frequently get a prescription for an opioid in Tennessee and then simply cross the border into Alabama or Georgia and attempt to fill 

another. 

What steps are you taking to address this problem? 

Ms. GOODWIN. So GAO has not looked into that specifically. 

When we did some of our review, we did talk to a number of representatives from the HIDTA program. So I think actually Mr. 

Carr can speak more eloquently to that than GAO could. 

Mr. CARR. Thank you, Congressman. I’ll try. 

Several years ago we were detecting people that were getting 

prescriptions written for them in Kentucky and they were driving 

to Miami to fill them. I don’t know how many pharmacies they 

passed on the way. So I think you can know what they are up to. 

With the PDMP that’s been implemented, prescription drug monitoring program, I think that’s a good first step. There are some 

issues with PDMP in that they are all activated at the State level. 

So in some cases doctors are required in that State to look at the 

PDMP to find out if their patient before them has in fact been 

given a prescription for an opioid or the like by another doctor. 

In other States however, it is only recommended and they don’t 

have to look. So I think we need to do some more work on that. 

I think, personally speaking, I think a national database makes 

sense, especially as fluid as our population is today. 

Mr. DESJARLAIS. And I would agree with you. Thank you. 

This is for any of the panelists, regarding hospice care. Under 

the current law, to my understanding, hospice care staff are not allowed to dispose of the patient’s prescriptions when the patient 

passes away. This often leaves the family sometimes taking narcotics or opioids home with them, or they may end up in their medicine cabinet and be forgot about, or somehow taken out of the 

home. And it leads to an increase of the drugs being distributed 

back into the community. 

What safeguards can we enact to ensure that this problem is 

dealt with? 

Dr. GUPTA. Thank you, Congressman. 


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I think it’s important for us to be able to have either, again, the 

take back days, as well as enhanced efforts to destroy the medications going back to. 

I think we’re get to go a place where opioids as they are in the 

market are going to have to have companion mechanisms dispensed to patients to be able to destroy the medications. 

Also a blister pack. We’ve just enacted laws to limit the initial 

prescribing in ERs and outpatient. So what happens? We would 

like to see blister packs for 3 days’ or 7 days’ use and then a parallel system where they can put it in a package and then destroy 

it. So I think that technology is needed. 

Nationalizing, I just want to be real careful about that, because 

we need systems that will connect State PDMPs with other State 

PDMPs, rather than federalizing or nationalizing, because we are 

able to use our data in ways, creative ways in advance as a laboratory in States that would be a little bit difficult from federalizing 

the PDMP. 

Dr. PAREKH. Congressman, I’ll just add that FDA, I think Dr. 

Gupta is absolutely correct, FDA is looking into this blister pack 

idea and I think that’s very, very promising. 

To your point, there are 15 billion pills of opioids dispensed every 

year. Only 6 billion, 40 percent, are consumed. So 9 billion pills 

are, as you suggest, going different places and oftentimes end up 

in families’ medicine cabinets. 

Mr. DESJARLAIS. If you can answer this for me, I’ve heard that 

of the prescription opioid related deaths, over 90 percent of those 

are not the person that the drug was originally prescribed to. Is 

that your understanding? 

Dr. PAREKH. I think it’s a large number. There are 11 million 

Americans who are misusing opioids. Either they didn’t have a prescription or they are not following the prescription. 

Mr. DESJARLAIS. So I mean think that’s a really important point 

to drive home, is that the physicians that are prescribing the 

opioids were doing that at a lower rate, but the opioids are getting 

in the wrong hands. And there needs to be a focus on punishment 

for distributing controlled substances, and the patients need to be 

educated before they leave the office and probably at the pharmacy 

as well. 

And if the chairman would indulge just one last question, I recently met with a group of pharmacists that explained to me how 

e-prescribing can prevent overprescribing opioids by allowing 

healthcare providers to see a patient’s medication history at the 

point of care, thereby helping them determine if the patients are 

doctor shopping. 

Have any of you all been paying attention to this movement in 

States toward electronic prescribing for controlled substances? And 

if so, have the results been positive? 

Dr. GUPTA. Congressman, I would say that we have attempted 

to do that in West Virginia. One of the challenges, I go back to this 

rural America divide, is that we have places we don’t even have 

broadband in West Virginia. We have places where physicians rely 

on fax to transmit data. 

So I think this links to another issue that we really have, which 

is e-prescribing is only good as the ability to get to our practices 


KING-6430 with DISTILLER
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in sometimes the rural parts of the State, and that’s a limiting factor. But we do have some type, but it is very hard to be more robust in that. 

Mr. DESJARLAIS. I thank the panel for their expertise. 

I yield back, Chairman. 

Chairman GOWDY. The gentleman yields back. 

Mr. DeSaulnier. 

Mr. DESAULNIER. Thank you, Mr. Chairman. I want to thank you 

for this hearing. 

And I want to thank the ranking member for his passion and his 

urgency. 

And I want to thank the panel members. This has been really 

interesting. 

I guess my question is in two parts. One part is the urgency of 

getting this right and the suffering that the ranking member 

talked about. 

And all of us, I think, anecdotally have had experiences, personally perhaps, but definitely professionally in this regard. I have 

constituents who have come to me over the years who have lost 

sons and daughters, and many of them are from very diverse economic aspects of my district in the bay area. 

So my question is, Dr. Gupta, you are really in a very unique position, I think, given the challenges of West Virginia, so the urgency of getting out now. But you said at some point we have to 

go upstream to look at the real cause and effect. 

So there are stories in the book of ‘‘Dreamland,’’ which is a compelling book that you’ve had a chance to read about, the evolution 

and the causes of this, some of it ascribed to Purdue Pharma and 

aspects of their marketing. So in that case, there’s pretty good evidence that they targeted the marketing specifically to West Virginia and other areas where they knew there was a lot of manual 

labor. Surely it seems intuitively that they targeted the worker’s 

compensation system, permanent disability. 

So how does that make you feel? And if you have evidence. I 

know my county just joined a whole group of counties in California 

in suing Purdue Pharma and others, because they have caused us 

to spend money, as you said, $1 million per child. 

And the context of my question is, I’m a survivor of an incurable 

cancer. I have remarkable medicine that will keep me alive, keep 

my quality of life high. I just had a meeting with constituents who 

work at the University of California were involved in the CRISPR 

system there. Looked like, very promisingly, we can use genetics to 

identify bacteria in our system. 

So I look at the system and the sustainability question of the urgency of now. But then how can we learn from this to really transform, given the context of what medical research is giving us right 

now? 

If we could take the money that we’re spending on that child, 

multiplied towards whatever number, and put it into these programs that can avoid this thing happening in the first place, including private sector companies or organized crime, using the system to divert our limited resources to stop this. 

So you were at the front lines of this. Could you respond to that? 


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Dr. GUPTA. Thank you, Congressman, very much for that question. 

You know, we as physicians began prescribing for pain, and we 

ended up over the years treating suffering instead of pain. And 

that’s what we have today. 

When we conducted our social autopsy of all the deaths in 2016 

from overdoses in West Virginia what we found was four out of five 

people actually came in contact with the health system. We were 

having a lot of lost opportunities that we could have helped these 

people. 

But as a result, what we found was if you’re 35 to 54 years old, 

single, male, less than high school educated or high school, and 

work in a blue collar industry, you have a very high risk of dying 

because of an opioid overdose. 

How we work is we are also seeing, again, a tremendous and 

such a demand on child welfare. We worry about the next generation as we sit here. We’re losing 10, 15 years from now those babies 

being born now that are going into schools. These are the kids who 

are going to have lifelong traumatic experiences. 

So as we work to address social determinants of health, as my 

colleagues have mentioned, we have got to look at those things. 

We’ve got to look at childhood experiences, we have got to look at 

traumatic communities, and we have to then work. 

NAS, for example, we have programs now looking at long-acting 

reversible contraceptives as part of the corrections system. Our corrections officers know the way they are making the math right 

now, doing the math, they are saying 33.5 correction officers equals 

$1 million a year investment, 37 inmates equals $1 million dollars 

a year. 

So they are saying we have thousands and thousands of people 

that need MAT. We don’t we start doing MAT instead of putting 

people in prison? 

So there’s this relationship that is developing in trying to get 

folks to actually go through science- and evidenced-based treatment 

on one hand, save lives on the other hand, and are connecting 

those for treatment, and then really working upstream. 

It’s really not a partisan issue for us to look at how do we help 

a woman actually get into treatment before she starts to plan a 

family? I mean, this is just a social responsibility because we are 

seeing the other side of this in society so much. 

We recently had a person, 82-year old great-grandmother, taking 

custody of a child. Those are the examples we are seeing on the 

ground every single day. 

Mr. DESAULNIER. I really appreciate that. 

And to the chair and the ranking member, I really think this is 

an amazing opportunity for us in Congress to change the dynamics 

on these reoccurring public health crises, to really look at the cause 

and effect. And not to ascribe blame to the private sector or anybody, but to look at evidence-based and say, not only can we sell 

the opioid program, but all of us can remember being told 20 years 

ago that crack babies were going to cost us money. We fall in this 

pattern of these reoccurring public health crises that maybe we can 

approach in a different way and avoid these unnecessary costs in 

human suffering dollars. 


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Thank you, Mr. Chairman. 

Chairman GOWDY. The gentleman yields back. 

The gentleman from Maryland is recognized. 

Mr. CUMMINGS. First of all, I want to thank all of you for this 

excellent testimony. 

You know, one thing you didn’t mention, Dr. Gupta, and I was 

looking at a CNN piece on West Virginia, was foster care, the cost 

of foster care, because the parents are dead or they are on drugs. 

Can you comment on that very, very briefly? 

Dr. GUPTA. Yes. Thank you, Mr. Ranking Member. 

We are not even able to now find parents to foster the children, 

it has become so bad. West Virginians are great, giving people, but 

we at the point that we have the highest levels we’ve ever seen in 

the history of the State in kids entering into foster care. It is the 

biggest, unquestionable, challenging burden of the future for our 

State and we are very worried about that. 

Dr. GUPTA. Dr. Gupta, you are from West Virginia. Your State 

has been hit extremely hard by this epidemic. This issue does not 

discriminate based on politics. It affects red States, blue States, 

and purple States. 

Last November we held a hearing with Governor Chris Christie 

of New Jersey who chaired the President’s opioid commission. The 

commission stated only about 10 percent of those who need treatment receive it and they warned that people are, and I quote, ‘‘losing their lives as a result of it.’’ 

Dr. Gupta, is that right? Are people dying today because they 

simply can’t access treatment? Is that true? 

Dr. GUPTA. That’s absolutely correct and very true. And part of 

the reason is the stigma. It’s not just they can’t receive treatment. 

Some people worry they are going to lose their job. Some people 

think that they don’t have enough coverage, they can’t travel to get 

treatment. They have to in West Virginia average wait 30 to 60 

days before they can enter outpatient treatment. 

So we have so many barriers, including stigma, why people can’t 

get treatment and as a result end up dying. 

Mr. CUMMINGS. You know, I mean, there’s a big elephant in the 

room, Doctor, okay? Anybody who has ever been around drug addicts knows that quite often they end up being another person. In 

other words, they begin to lie, steal. 

One of my earliest cases as a lawyer was a fellow who literally 

killed his—hatcheted his grandmother to death trying to get money 

for drugs. 

So they turn into another person. They look like the same person, but to somebody else. 

So I guess for an employer that’s a kind of difficult situation. I 

was just with the railroad people yesterday and they were telling 

me how hard it is for them to get people to hire, because people 

simply cannot pass the drug tests. And they worry about accidents 

big time, and they should. 

In January your State of West Virginia instituted an opioid response plan that also called for expanded access to treatment. It 

states, and I quote, ‘‘One of the most important actions that any 

State can take to address the opioid crisis is expanding access to 

effective treatment.’’ Is that right? 


KING-6430 with DISTILLER
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Dr. GUPTA. Yes, sir, that’s absolutely correct. One of the things 

we did was we had State regulations for MAT clinics. We’ve created exemptions for physicians so they don’t have to pay the registration, they don’t have to go through the whole process if they 

want to treat their own patients up to 30. We have also cut down 

on onerous regulations within our State. 

We are making every effort possible to make MAT treatment— 

and MAT is just not drugs, it’s a whole host of behavioral, social, 

cognitive therapies that go along with it—as the primary focus of 

our effort to make sure that every West Virginian who has an opportunity, wants to get into treatment, has no delay, treatment on 

demand type of—— 

Mr. CUMMINGS. And I gave you the 10 percent figure nationally 

that are able to get treatment. What’s it like in West Virginia? Do 

you have any idea? 

Dr. GUPTA. We have wait times, as I mentioned. There is a great 

COAT Program at West Virginia University and their average wait 

times are between 30 and 60 days. 

So you can imagine what happens in those 30 days, because people don’t wait 30 days when they have this monster on their head 

that they have to worry about every time, getting a dose in 3, 6 

hours, sometimes even more frequent. 

Mr. CUMMINGS. So here is the big question. We here on the committee can talk about organizing ONDCP. We can discuss moving 

things around on an organizational basis. We can even ask ONDCP 

to send us more reports. But if that’s all we do, if we fail to ensure 

sustained funding to expand access to treatment, will we be able 

to turn this crisis around as a Nation? 

And I know I’ve run out of time, but I want you also to just 

speak very briefly. We spend a lot of time talking about deaths, but 

we’ve got a pipeline. I’m talking about the living and the dead. Because a pipeline car is far bigger than the folks, the 1 in 15 I am 

talking about, that are dying daily. 

So would you comment on that, Dr. Gupta? 

Dr. GUPTA. Certainly, sir. One of the things I would say is that 

every person who has an opioid overdose, nonfatal, that comes in, 

it’s a cry for help basically. What they are saying is that is suicide 

attempt, because they know every time it’s Russian roulette when 

they inject that drug. 

The question is, are we able to then connect that cry for help and 

get those people immediate treatment? We are working on that in 

West Virginia, trying to make sure that every emergency room 

visit, first of all, that it doesn’t happen, but if it happens, how do 

we connect that cry for help back to treatment, they get that treatment. There’s a lot more people, it’s the tip of the iceberg beneath 

that. 

So the first thing is to avoid deaths. This is a preventable problem. This is something we can prevent and get people into treatment. Everyone that dies we see, they had, four out of five people, 

came into context with the health system and we failed them, to 

be really honest. 

Mr. CUMMINGS. How do you see us getting past the stigma? And 

that’s a tough one. The stigma on the part of the patient—I mean, 

the drug addict. 


KING-6430 with DISTILLER
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But there’s another stigma, too, that we haven’t talked about 

here: the doctor. A lot of doctors don’t know how to treat this stuff. 

You know, they see a drug addict come in and they say: Aw, no, 

no, no, no, no, no. They don’t want to touch it. 

So talk about that and how you deal with that end of it in West 

Virginia. 

Thank you, Mr. Chairman. 

Dr. GUPTA. Yes, sir. The most important part of this disease, how 

we differentiate this from perhaps the HIV, even, the epidemic, is 

that the stigma of this is across the communities, it’s across the 

healthcare system, law enforcement. 

And there’s a lot of good-intentioned, good-faith folks trying to 

help, but that stigma continues. And it is that reason that we need 

to have programs like harm-reduction strategies, that people will 

come in, be treated in a very nonjudgemental manner. 

We have to redo the way we look at folks, we have to redo the 

way we treat folks, address this problem. People don’t choose not 

to get treated. Folks have told me, every five times before, we were 

telling them they need help, they listened, they weren’t dead and 

not listening. It’s just that it didn’t filter in until the time they 

were ready. 

We have to build a supportive system of that stigma, whether it’s 

police officers, whether the treatment, physicians, hospitals, criminal justice system, as well as the court system, the entire society. 

I think we’re far away from being able to entirely remove stigma. 

We have stigma websites. We’re doing everything in West Virginia 

and a lot of organizations are working together. But it’s going to 

take every fabric of that society to undue the stigma aspect of this 

problem. It’s a big problem. 

Mr. CUMMINGS. I yield back. 

Chairman GOWDY. The gentleman yields back. 

The gentleman from Wisconsin is recognized. 

Mr. GROTHMAN. Sure. A couple of questions. 

I agree with you, Dr. Gupta, that I think whenever anybody 

takes heroin—and as I understand it, everybody who takes it 

knows people who’ve died from it—there is an element, suicide is 

too strong a word you, but at least you’re saying that it’s not the 

end of the world if I die. And that’s a problem. 

I think it was Dr. Parekh who told—one of the two of you in your 

original testimony, and I didn’t see it in your written testimony— 

said the number of people in this country every year who are prescribed some sort of painkillers that could be described as opiates, 

could you repeat that statistic again? 

Dr. PAREKH. Sure. So this is the National Survey on Drug Use 

and Health in 2016. So 91.8 million American adults, nearly 4 in 

10, say they’ve used opioids in the preceding 12 months. Now, that 

could be that they were prescribed or they are misusing. 

And the misusing number is 11.5, so 11.5 million Americans are 

misusing opioids. So either they didn’t have a prescription in the 

first place, they got it from family, friends, or they had a prescription. 

Mr. GROTHMAN. Could you tell us the equivalent number from 

other countries? 


KING-6430 with DISTILLER
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Dr. PAREKH. I think, unfortunately, Congressman, this is a 

uniquely American problem. We have 5 percent of the world’s population, we consume 80 percent of the world’s opioids. 

Mr. GROTHMAN. Wow. So that would show it’s an American problem and it shows that other countries don’t seem to have this problem. So you wonder what they’re doing differently. 

Have we looked into at all the background of the average heroin 

user? Do we ever study family background, religious background, 

what have you? 

Dr. PAREKH. Other panelists may want to jump in, but I think 

one statistic that is important to note is if you look at first time 

heroin users, 80 percent of them first started abusing prescription 

opioids. And I think that is a critical piece. 

Mr. GROTHMAN. Okay. I mean, do we have anything else, though, 

as far as demographic examples, family background, educational 

background, age? Do we have those statistics, Dr. Gupta? 

Dr. GUPTA. Yes, Congressman. We conducted a social autopsy of 

everyone who died in 2016 in West Virginia from overdose. What 

we found was typically individuals are 35 to 54 years old, male, 

high school educated or less, single, and working in blue collar industry. So this is the social autopsy. 

Mr. GROTHMAN. Single people. What about their parents? What 

did we find out about their parents? 

Dr. GUPTA. Well, I think what we find is basically it’s one of 

those situations of hope. 

Mr. GROTHMAN. Not hope. But what was their background, what 

type of family background did the people grow up in? 

Dr. GUPTA. I couldn’t—yeah, I’m sorry. 

Mr. GROTHMAN. Put enough money into it. Next time you do a 

study, you should check into that. 

At least I felt heroin’s been around this country a long time. 

There was a time the stigma against taking heroin, I mean, there 

was a bright line, I think, between alcohol and marijuana or even 

cocaine and heroin. I know there’s been a lot of emphasis on removing the stigma. 

Are you sure we want to remove that stigma? There used to be 

a stigma. And I think at the time there was a stigma and less people took heroin. But are you sure we want to remove that stigma? 

Dr. GUPTA. Congressman, I’ll give you an example. So 71-yearold woman living with her children—her children living with her— 

every time she started to use heroin for postherpetic neuralgia, 

that’s pain after you get shingles, because her doctor took her off 

the Percocet, and she uses three syringes. 

The first time she injects a small dose, back in a bigger dose to 

make sure there’s not enough fentanyl to kill her, and then she 

gives herself the main dose. And that’s all because she actually 

trusts her dealer. 

So, yeah, there’s a lot of that because she wouldn’t go and get 

help because she thinks her family will find out and it would be 

a bad thing for people to know a 71-year-old is using heroin. So 

there’s a tremendous amount of stigma. 

Mr. GROTHMAN. I’ll give you another question. I recently had 

something in my district in which a member of law enforcement 

was very concerned. Somebody was pulled over with a substantial 


KING-6430 with DISTILLER
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amount of heroin, clearly a dealer, and they were given time served 

or something. It really bothered the law enforcement person because these people are probably as dangerous as can be. 

I know we’re stuck on kind of a trend of saying too many people 

are in prison, and there may be too many people in prison. But to 

me heroin and related drugs are a new thing. 

I am very concerned on hearing stories, and particularly in more 

liberalish areas, of people who are dealers not really going to a 

prison for a long period of time. And I know in other countries that 

don’t have these problems who are not as, oh, so afraid to put 

somebody away, they don’t have these heroin problems either. 

Usually the police aren’t the problem, the police want to put 

them away. But do you think our judges or the rest of the judicial 

system is getting too involved in this treatment stuff and are not 

sending a strong enough message to the dealers by putting them 

away for long periods of time since they are killing so many people? 

Chairman GOWDY. The gentleman is out of time, but you may 

answer his question. 

Dr. GUPTA. Congressman, I think the distinction to be made between dealers, which obviously are bad guys, and every year that 

they could be in prison for, versus the folks who have actually gotten into this and don’t understand it and have something called 

substance use disorder or opioid use disorder that actually need 

help, and they can be productive. It’s because the people, the majority of people we are dealing with, they are actually workers. 

They are work-engaged populations. We are losing work productivity in this country at a rate like never before. 

Chairman GOWDY. The gentleman yields back. 

Mr. GROTHMAN. I’ll just point out he didn’t answer my question. 

But okay. 

Chairman GOWDY. The gentleman yields back. 

My friend from Vermont is recognized. 

Mr. WELCH. Thank you, Mr. Chairman. Thanks for having this 

hearing. And I appreciated your opening statement. 

And our ranking member, Mr. Cummings, I also want to thank 

you for your incredible leadership on this, and I want to thank the 

panel. 

I’m from Vermont. I’m going to take advantage of the opportunity to talk a little bit about Vermont, and I’ll ask a few questions. But I am going to take advantage of that opportunity. 

Our Governor was the first, Governor Shumlin, to dedicate his 

entire State of the State, in 2011, to the problem we saw emerging 

in Vermont of opioid dependence and addiction. 

And I remember coming back here after the Governor did that 

and my colleague saying, ‘‘Peter, why did the Governor do that? 

That’s bad press for Vermont.’’ And the answer from our Governor 

was: We acknowledge our problem and try to face it. That’s what 

we did. 

And then a few weeks later one colleague after another would 

come up to me and say, ‘‘You know what, we’ve got a problem 

that’s as bad or worse in my State, my district.’’ 

And I think the fact that there was a focus on acknowledging the 

issue has helped us in Vermont establish a pretty good treatment 


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program, the Hub and Spoke program, that is having some significant success. 

But in the past year I’ve been having roundtables in one community after another, Brattleboro, Bennington, Newport, St. Albans, 

and just this question of who are the victims. It’s everybody is the 

victim. 

I mean, there are some folks who work, some folks who got on 

it because they had a proclivity to use excess drugs, some who 

started out with a work-related injury and got opioid prescriptions 

and it led to bad things and they couldn’t get off it, others who are 

having a crisis of hope. 

And Dr. Gupta you’re ground zero in West Virginia, which I’ve 

traveled to. And there is the real crisis here of good people. 

I don’t meet people who are addicted that want to be addicted. 

You know, the dealers are a separate question and throw the book 

at them as far as I’m concerned, but it’s a lot of good everyday citizens who would prefer to be in the workforce and aren’t. 

And this is affecting all of our communities, especially, in my 

view, rural America, where there is a collapse in the local economy. 

And a lot of the local institutions that have been so important to 

help people have a sense of purpose and live those rural values of 

helping one another, helping their community, that’s all being 

frayed. And we have got to have as part of our response a revitalization of rural America. That’s my view. 

But while we’re trying to get there, I do believe that we must 

have a Marshall Plan for attacking this, much like we did with the 

HIV epidemic with the Ryan White bill. This has got no partisan 

preference. Every one of us who represents our districts have people in it who are really suffering. 

And the Cummings bill, which does have a Marshall Plan agenda, significant resources that are applied to dealing with this issue, 

that is absolutely what we need. This crisis is not going to help 

itself. 

And by the way, on the stigma question, one of the biggest preventions of people making that step to go into treatment is the apprehension of how they will be labeled. And in our roundtables, the 

people that were most compelling to me were two groups. 

One was the people in recovery. And every single one of them 

said it was their ability to cross that line, from being private and 

secret to being open and public, which is what empowered them to 

take the difficult next step. And it’s what opened up the opportunity for other people in similar situations to provide mutual support, ultimately something really essential, as I see it. 

The other group that I was really impressed with, I mean all of 

them really, was law enforcement. They do not like the dealers. 

Their job is to arrest people. But their message to us: We’re not 

going to arrest our way out of this problem. It’s not going to happen. So they saw treatment is absolutely essential. And the biggest, 

biggest challenge was that people who had gotten to that point, 

where they’re ready for treatment, there was no treatment available. 

And that’s why I believe the Cummings bill is absolutely essential. That’s the Marshall Plan that we need in order to give folks 


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who were ready to make that step and rid themselves of this addiction can take it successfully. 

Mr. Chairman, I’m at the end of my time. 

And I thank the panel for listening to me. I really thank you all 

for your work. And I’m just speaking out on behalf of Vermonters. 

Thank you. 

Chairman GOWDY. The gentleman from Vermont yields back. 

The gentlelady from New York is recognized. 

Mrs. MALONEY. I thank you, Mr. Chairman. I want to thank you 

and all the panelists and Mr. Cummings for focusing on what has 

really become a national crisis. And I am pleased that we are jointly looking at this. 

In recent years pain has come to be called the, quote, ‘‘fifth vital 

sign,’’ end quote. And in many clinical settings, including hospitals, 

patient pain levels have been measured obsessively, including with 

the use of sad and smiley faces, and many have warned that this 

focus on eliminating all pain and getting all patients to select 

smiley faces spurred the extensive use of opioids in clinical settings. And well-intentioned policies that incorporate patient pain 

into quality ratings and other measurements may have aggravated 

the problem. 

So I want to ask Dr. Gupta, who probably has more experience 

on the level with the people with the illnesses, we want to ensure 

that individuals who are experiencing serious pain, including those 

that are at the end of their life, get the pain relief that they need. 

But on the other hand, we don’t want to move to the point that 

people are being inappropriately prescribed more pain pills that 

they really need. 

I mean, I’ve read some stories where patients were getting pain 

treatment and got addicted, which is a tragedy. And apparently it’s 

a very hard deal to get off this addiction. 

So one of the recommendations of the opioid response plan you 

just issued in West Virginia was, and I quote from your report, 

‘‘West Virginia should expand the authority of medical professional 

boards and public health officials to address inappropriate prescribing of pain addiction and medications.’’ 

So, Dr. Gupta, what additional authorities do professional boards 

and public health officials need in your State to address inappropriate prescribing? And do you think that there has been any inappropriate prescribing, in your overview? 

Dr. GUPTA. Thank you, Congresswoman. 

There certainly has been. There were over 780 million pills that 

were shipped into small towns of West Virginia. We know that 

West Virginia had one of the highest prescribing rates for opioids. 

But there’s good news. We’ve seen from 2017 data that we’ve 

made the most progress of any State in the Nation in curbing those 

prescriptions. 

Specifically—— 

Mrs. MALONEY. May I ask, of these pills that went into West Virginia, were they illegal drugs or were they prescribed through doctors? 

Dr. GUPTA. These were distributed prescription drugs that were 

distributed through distributors that came in without necessarily a 

check. 


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Governor Justice sponsored and passed with wide bipartisan support earlier this year a bill that limits the prescription of opioids 

in ER settings to 4 days, in outpatient settings for dentists, primary, optometrists, and veterinarians to 3 days, and for other physicians to 7 days. 

So one of the things we have to do is we have to turn the tap 

off for initial prescribing. Initial prescribing is sort of your tap to 

getting people hooked later on, and we know from science that beyond 3 to 5 days of prescribing really in vulnerable population 

leads to this disease of addiction. 

Mrs. MALONEY. Whoa, 3 to 5 days? That’s astronomical. 

Now, is there anything that the Federal Government can do to 

help you in your efforts in West Virginia in this overprescribing? 

Dr. GUPTA. I think one of the things, Congresswoman, that can 

do done as we move forward, we have to be cognizant about the 

people when have legitimate pain. So as we go and we see the 

crackdown that happens with our State and Federal partners on 

pain clinics, illegitimate pain clinics, we have got to find folks who 

have genuine pain to be connected back into appropriate physicians 

who do prescribe. 

So we want to make this where it’s okay to have legitimate pain 

and have prescriptions, a very important piece for a treatment armamentarium until we develop those nonopioid treatments. 

Mrs. MALONEY. Let me ask you, are the majority of people that 

are overdosing in West Virginia taking opioids that have been prescribed, either to them or someone else, or are they taking street 

drugs such as the fentanyl? 

Dr. GUPTA. We found 9 out of 10 had prescription history; 49 percent of women filled the prescription within 30 days of their death. 

Yet the death we’re seeing is because of street fentanyl and heroin. 

So what’s happening is there is a crossover happening, but prescription drugs still remain a critical component of that. 

Mrs. MALONEY. Okay. Do harm-reduction efforts create important opportunities to get individuals with substance use disorders 

into treatment? 

Dr. GUPTA. Very important opportunities. We need to look at 

harm reductions, such as syringe exchange programs, Naloxone 

distribution, and a host of social services that go along with that, 

including screening for diseases, and that as a gateway to treatment. 

Mrs. MALONEY. Well, I want to thank you. 

My time has expired. And I believe this is a bipartisan issue we 

can work together on for treatment. Thank you. 

Chairman GOWDY. The gentlelady yields back. 

The gentleman from Virginia is recognized. 

Mr. CONNOLLY. Thank you, Mr. Chairman. 

And welcome to our panel. 

Dr.Gupta, the Senator from your State, Joe Manchin, did his own 

report using the methodology used by the Council of Economic Advisers and came up with the cost of the opioid crisis in your State 

alone of $8.7 billion. Does that sound right to you? 

Dr. GUPTA. Yes, sir. That’s about 12 percent of the State’s GDP. 

Mr. CONNOLLY. Yeah. 


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Dr. GUPTA. And that’s extreme. But there’s many other States 

similarly placed, if not exact same position. 

Mr. CONNOLLY. So that would suggest whatever we’re investing 

or need to invest in treatment will have a huge return on it, given 

that cost. 

Dr. GUPTA. Yes, sir. 

Mr. CONNOLLY. And obviously we’re underfunding treatment 

right now? 

Dr. GUPTA. Yes, sir. 

Mr. CONNOLLY. I don’t know where to begin. 

So I had a constituent whose son died. He was an athlete at a 

major university in the Northeast. He had an injury. He was prescribed opioids and he developed an addiction. He was a motivated 

young man and did everything in his power to try to kick it. He 

went into rehab, he went into treatment facilities. The treatment 

was wrong and ultimately led him to need the high, he moved to 

heroin, and he died of an overdose. Tragic, tragic story. 

I’ll ask either one of you, Dr.Parekh or Dr.Gupta, are treatment 

facilities regulated for this crisis, for this problem? 

Dr. PAREKH. I think treatment facilities are regulated at the 

State level. I think that the issue, Congressman, is that not enough 

treatment facilities are offering the gold standard, which is medication-assisted treatment. 

Mr. CONNOLLY. Well, let me go back to certification, though. Can 

I put out a shingle and say, ‘‘We’ve got the expertise here to deal 

with your opioid crisis, give us a call’’? 

Dr. PAREKH. Unfortunately, that is being done right now. 

Mr. CONNOLLY. That’s right. That is my point. It’s not regulated, 

not uniformly. 

And so treatment, the idea of going for treatment, well, what 

treatment? For example, the example I gave of my constituent’s 

son. As I understand it, correct me if I’m wrong medically, but one 

of the treatment centers he went to embraced the AA model: Go 

cold turkey and follow the 10 steps or 12 steps. 

Well, it turns out, according to my constituent, that is exactly the 

wrong thing to do. You cannot simply go cold turkey with this addiction. It’s different than alcohol. And if you don’t have some intervening treatment, you put yourself at enormous risk. And the 

craving for that high will absolutely move you to something else, 

heroin or fentanyl, for example, leading to worst outcomes. 

I see you shaking your head, Dr.Gupta. Is that accurate? 

Dr. GUPTA. Yes, Congressman. Only half of the private treatment 

facilities across this country actually offered MAT. And in that, 

only a third actually get MAT. MAT is the best science-based treatment available, yet we struggle across States. 

There is going to be a small silver of the population that maybe 

the 12-step works for them. But there often seems to be a prohibition for using any mind-altering drug. 

Mr. CONNOLLY. I’m running out of time, forgive my interruption. 

But my constituent argued it is actually life-threatening. It was 

life-threatening for his son to go that route, even with the best of 

intentions. 

Dr. GUPTA. Congressman, I’ll add one more quick thing. People 

who have opioid use disorder, having other mental conditions is the 


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rule, not the exception. So you have to be treating other underlying 

medical conditions. And if organization does not accept that treatment for bipolar or depression, then you’re in trouble. 

Mr. CONNOLLY. So, Ms. Goodwin, in the time I have left, the 

President’s own Council of Economic Advisers estimates the cost of 

this crisis to the U.S. economy—we talked about West Virginia— 

is a half a trillion a year. Correct? 

Ms. GOODWIN. Correct. 

Mr. CONNOLLY. So certainly, the President has proposed a national strategy to deal with this, has he not? 

Ms. GOODWIN. Yes. 

Mr. CONNOLLY. He has? And what is that strategy? 

Ms. GOODWIN. So that strategy is kind of in the making. 

Mr. CONNOLLY. Oh, in the making? 

Ms. GOODWIN. Yes. 

Mr. CONNOLLY. Has the President declared this a national emergency, as was recommended to him? 

Ms. GOODWIN. Yes, it has been declared a national emergency. 

Mr. CONNOLLY. And what flows from that? 

Ms. GOODWIN. So the declaration of an emergency will mean that 

the different Federal agencies will start to think through and think 

about how they will address the crisis. 

You may already know that GAO has ongoing work looking at 

public health declarations around this crisis. That’s in the beginning stages. So we are in the process of designing the scope and 

methodology for that. 

Mr. CONNOLLY. My time is up. 

I want to thank the chair for having this hearing. 

There is no way we can move forward without this being on a 

bipartisan basis. This is a crisis that affects every community, 

every socioeconomic strata. This is not something limited to one 

group or another. And it’s reached crisis proportions, obviously, in 

the United States. So we’ve got to work together to find solutions. 

Thank you, Mr. Chairman. 

Chairman GOWDY. The gentleman from Virginia yields back. 

I’m going to go last. So I want to start by thanking the panelists 

for your expertise, your commitment to helping us combat this 

issue. 

Dr.Gupta, what progress, if any, is being made in the ability to 

objectively diagnose pain? As opposed to allowing the patient to 

pick which frowny face, or on a scale of 1 to 10, which is inherently 

subjective, is there any progress being made in being able to objectively diagnose pain? 

Dr. GUPTA. Mr. Chairman, I think there is some work in the research and development sort of phase of this. It’s been a difficult 

thing from a clinical aspect to be able to diagnose something that’s 

very subjective. I do think efforts need to happen there from an 

R&D standpoint in order to get more objective signage. But clearly, 

there’s a need for that. 

Chairman GOWDY. Okay. So if I were to present myself at either 

of the doctors—I assume you all are medical doctors or are you 

Ph.D.’s? Medical doctors. 


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I present myself, I tell you I have pain. You are not totally reliant upon me to quantify that, but it helps. There’s no test you 

could administer. 

What are the alternatives to habituating prescriptions? What are 

your pharmacological alternatives to something that is habituating 

right now. 

Dr. GUPTA. First of all, we would want to make sure to do the 

proper testing to find out if there’s a legitimate physical reason for 

it. But then again, opioids is just one part of it. They are not very 

good a pain treatment to begin with. There’s other options, including nonpharmaceutical options, as well as pharmaceutical options. 

So we’re talking about—back pain, for example, very common. 

Most of back pain treats itself in about a couple of weeks, so oftentimes you need supportive treatment, not really opioids. That’s 

something that opioids were traditionally used. 

Combination of medications like acetaminophen and ibuprofen, 

that really means Tylenol and Motrin put together, tends to have, 

in some studies, better outcomes or better impact on pain than 

does opioids. 

Chairman GOWDY. Okay. You put your finger on something. I 

present to one of your physician practices. I tell you I’m in pain. 

I want something that I consider to be strong. You’re recommending something I could get at CVS or Walgreens. 

So I’ve got a couple options. I can either go see another doctor 

and hope for a better result. So you’ve got—in July we were told— 

and look, I like doctors. I grew up in a house with one. I don’t get 

excited talking about prosecuting physicians. But the reality is 

there are illicit drugs that are handled in an improper way. And 

there’s money to be made doing that. 

So is this a misinformation issue? I mean, you just said there are 

better alternatives to opiates. I assume doctors know that. So if 

there are better alternatives, is it a lack of information that allows 

them to prescribe it or is it the money aspect? 

Dr. GUPTA. Mr. Chairman, there’s a whole host of issues. In my 

practice, since 2000 or so, I’ve been told by the industry that these 

are medications that are very highly effective, there is no potential 

for addiction, and all kinds of things. If short term doesn’t work, 

we have long-acting medications. They are really sold and marketed as the ultimate solution, and now we know that that’s not 

the case. 

Chairman GOWDY. All right. But you don’t get to be a medical 

doctor by not being bright. So the fact that some pharmaceutical 

rep comes in, gives you a calendar and a key chain, and says, ‘‘Hey, 

look, you really need to prescribe this medicine, even though I 

made straight C’s in college, take my word for it,’’ is a doctor really 

going to be persuaded by a pharmaceutical rep? 

Dr. GUPTA. If you look at direct-to-consumer advertising campaigns and the pharmaceutical budgets, companies’ budgets that go 

into this type of work, at least the evidence demonstrates that that 

strategy tends to have some impact on the prescribing habits. 

Chairman GOWDY. This will probably be over my head, but we’ll 

try it anyway. 

What is the pharmacology of opiates that makes it so difficult 

to—you know, last week they told us nicotine was the toughest 


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drug to beat. In a previous life, I dealt with heroin addicts. I would 

list that as the toughest drug to get off of. 

What is it about the pharmacology that makes it so difficult? 

Dr. GUPTA. Mr. Chairman, it’s the same pharmacology would be 

for heroin, which is it goes and crosses your blood-brain barrier and 

attaches to the receptors, the particular receptors that gives you a 

pleasure to begin with, as well as a number of other activities. 

And that’s the reason when people have a craving, the need for 

increasing the dose continues. People go to the cheaper, readily 

available street alternative. That is the same action of receptors 

that we work with MAT, whether they block them, they are partial 

agonists to them, or they are pure agonists. 

But ultimately, the idea here is to work on the same receptors 

that opioids have sort of stayed on in terms of heroin or prescriptions and almost cause a person to become addicted to that and 

have the disease of addiction. 

Now, we prescriptively do that with drugs like Buprenorphine 

and others to block those or actually partially work with those receptors. So it’s the same mechanism, it’s just the drugs that we 

talk about, MAT, are not something that people are going to be 

able to get high on or overdose from in the doses that they are prescribed. But they can, if they also use some of the other drugs 

along with it, the street drugs. 

Chairman GOWDY. All right. I’m out of time, and I want to hold 

myself to same standard I hold my colleagues to. So I’m going to 

give myself one more question after running out of time like I do 

them. 

I was just in your beautiful State 2 weeks ago. It’s a beautiful, 

beautiful place to be. 

Are you satisfied with DEA’s diversion, not DEA agents that 

wear guns and badges, I mean the diversion, the folks who actually 

monitor pharmacists and physician practices, are you satisfied with 

the presence of DEA diversion in West Virginia? 

Dr. GUPTA. Thank you, Mr. Chairman. 

West Virginia is a great State. We are very thankful for DEA 

folks helping us with diversion. 

One of the things that can definitely happen, we in West Virginia 

have a requirement for licensees, like myself, to have a mandatory 

training for opioid prescribing. That is perhaps something—I also 

hold a DEA license—that is something that perhaps needs to be 

nationalized where it’s important for every physician, every person 

going to medical school, nursing school, anywhere they are going 

to be close to opioids, be able to have a particular curriculum-based 

training as a part of their practice. 

That’s something of an outstanding piece, but we’re very appreciative of DEA’s partnership with us. 

Chairman GOWDY. All right. I want to thank the members for 

their participation. I especially want to thank our witnesses for 

your expertise, for your comity, with a ‘‘t,’’ with each other, and 

with the members, and look forward to visiting with you again. 

The hearing record will remain open for 2 weeks for any member 

to submit written opening statements or questions for the record. 

If there’s no further business, the committee stands adjourned. 

[Whereupon, at 1:13 p.m., the committee was adjourned.] 


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