U.S. GOVERNMENT PUBLISHING OFFICE

32–784 PDF WASHINGTON : 2018

S. HRG. 115–383 

OPIOIDS IN INDIAN COUNTRY: BEYOND THE 

CRISIS TO HEALING THE COMMUNITY 

HEARING 

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

MARCH 14, 2018 

Printed for the use of the Committee on Indian Affairs 

( 

(II) 

COMMITTEE ON INDIAN AFFAIRS 

JOHN HOEVEN, North Dakota, Chairman 

TOM UDALL, New Mexico, Vice Chairman 

JOHN BARRASSO, Wyoming 

JOHN MCCAIN, Arizona 

LISA MURKOWSKI, Alaska 

JAMES LANKFORD, Oklahoma 

STEVE DAINES, Montana 

MIKE CRAPO, Idaho 

JERRY MORAN, Kansas 

MARIA CANTWELL, Washington 

JON TESTER, Montana, 

BRIAN SCHATZ, Hawaii 

HEIDI HEITKAMP, North Dakota 

CATHERINE CORTEZ MASTO, Nevada 

TINA SMITH, Minnesota 

T. MICHAEL ANDREWS, Majority Staff Director and Chief Counsel 

JENNIFER ROMERO, Minority Staff Director and Chief Counsel 

(III) 

C O N T E N T S 

Page 

Hearing held on March 14, 2018 ............................................................................ 1 

Statement of Senator Barrasso ............................................................................... 4 

Statement of Senator Cantwell .............................................................................. 35 

Statement of Senator Cortez Masto ....................................................................... 27 

Statement of Senator Daines .................................................................................. 56 

Statement of Senator Heitkamp ............................................................................. 33 

Statement of Senator Hoeven ................................................................................. 1 

Statement of Senator Lankford .............................................................................. 23 

Statement of Senator Murkowski ........................................................................... 4 

Prepared statement .......................................................................................... 5 

Statement of Senator Smith ................................................................................... 25 

Statement of Senator Tester ................................................................................... 31 

Statement of Senator Udall .................................................................................... 2 

WITNESSES

Anderson, Hon. John C., U.S. Attorney, District of New Mexico, U.S. Department of Justice ..................................................................................................... 6 

Prepared statement .......................................................................................... 8 

George, Jolene, Behavioral Health Director, Port Gamble S’klallam Tribe ....... 35 

Prepared statement .......................................................................................... 37 

Jones, Captain Christopher, Pharm.D., M.P.H., Director, National Mental 

Health and Substance Use Policy Laboratory, Substance Abuse and Mental 

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

Services ................................................................................................................. 10 

Prepared statement .......................................................................................... 12 

Moose, Samuel, Treasurer and Bemidji Area Representative, National Indian 

Health Board ........................................................................................................ 47 

Prepared statement .......................................................................................... 48 

Toedt, Rear Admiral Michael, M.D., Chief Medical Officer, Indian Health 

Service, U.S. Department of Health and Human Services ............................... 15 

Prepared statement .......................................................................................... 17 

APPENDIX

Lucero, Esther, CEO, Seattle Indian Health Board, prepared statement .......... 63 

National Congress of American Indians (NCAI), prepared statement ................ 64 

Response to written questions submitted by Hon. Heidi Heitkamp to: 

Stacy A. Bohlen ................................................................................................ 93 

Captain Christopher Jones .............................................................................. 89 

RADM Michael Toedt ....................................................................................... 92 

Response to written questions submitted by Hon. Tom Udall to: 

Stacy A. Bohlen ................................................................................................ 82 

Jolene George .................................................................................................... 80 

Captain Christopher Jones .............................................................................. 84 

RADM Michael Toedt ....................................................................................... 90 

Southcentral Foundation (SCF), prepared statement .......................................... 69 

Sullivan Hon. Jeromy, Chairman, Port Gamble S’Klallam Tribe, prepared 

statement .............................................................................................................. 67 

Tanana Chiefs Conference (TCC), prepared statement ........................................ 72 

United South and Eastern Tribes Sovereignty Protection Fund (USET SPF), 

prepared statement .............................................................................................. 75 

Written questions submitted to Hon. John C. Anderson by: 

Hon. Heidi Heitkamp ....................................................................................... 95 

Hon. Lisa Murkowski ....................................................................................... 95 

Page

IV 

Written questions submitted to Hon. John C. Anderson by—Continued 

Hon. Tom Udall ................................................................................................ 94 

(1) 

OPIOIDS IN INDIAN COUNTRY: BEYOND THE 

CRISIS TO HEALING THE COMMUNITY 

WEDNESDAY, MARCH 14, 2018 

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

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

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

Chairman of the Committee, presiding. 

OPENING STATEMENT OF HON. JOHN HOEVEN, 

U.S. SENATOR FROM NORTH DAKOTA 

The CHAIRMAN. I call this oversight hearing to order. 

Today we will examine the opioid abuse crisis and its effect on 

Indian Country. 

On November 9, 2017, this Committee held a roundtable on the 

opioid abuse epidemic in Indian Country. The roundtable highlighted how the opioid abuse epidemic is particularly complex in 

tribal communities given the lack of access to medical care, shortage of law enforcement and insufficient data on substance abuse. 

This hearing will build on that discussion and examine how Congress, the Administration, tribes and tribal organizations can work 

together to combat the crisis and heal Indian communities. 

The facts of the opioid abuse epidemic are tragic. Our Country 

has witnessed an 18-year increase in deaths from prescription 

opioid overdoses and a recent surge in illicit opioid overdoses. According to the U.S. Centers for Disease Control and Prevention, 

CDC, drugs now kill more Americans, nearly 40 percent more, than 

car accidents. 

Native American communities have been among those hit hardest by the opioid abuse crisis. The Substance Abuse and Mental 

Health Services Administration reports that the rates of opioid 

abuse are consistently the highest among Caucasian and Native 

peoples. 

According to the CDC, in 2016, 4.1 percent of American Indian 

and Alaska Natives age 12 and older reported opioid misuse in the 

past year, similar to whites at 4.4 percent. These statistics are serious, but they may not represent the magnitude of the crisis in Indian Country, as the epidemic may be underreported. 

Many witnesses at the roundtable highlighted that Native Americans are sometimes incorrectly classified as another race. Without 

accurate data, Congress, the Administration and tribes are limited 

in their ability to allocate resources to the area of greatest need. 

2 

The Committee is dedicated to engaging with tribes and finding 

ways to advance the Federal Government’s role in combating the 

dangers that opioids and other substances present to tribal communities. 

The Indian Health Service has established the National Committee on Heroin, Opioids, and Pain Efforts, the HOPE Committee. 

The HOPE Committee has been tasked with promoting appropriate 

and effective pain management, reducing overdose deaths from heroin and prescription opioids and improving access to culturally appropriate treatment. The IHS also now requires all IHS Federal 

prescribers, contractors, clinical residents and trainees to complete 

a course on treating pain and addiction. 

On March 29, 2017, President Trump signed an Executive Order 

establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis. On October 26, 2017, the President declared the opioid abuse crisis a national public health emergency 

and one week later, the President’s Commission released its comprehensive final report. 

The final report contains more than 50 recommendations to 

agencies and to Congress. The Commission recommended that the 

IHS remove reimbursement and policy barriers to substance abuse 

treatment. Removing these barriers would help Native American 

communities access much needed treatment. It is important to 

begin implementing these recommendations. I look forward to hearing from our witnesses on these and other efforts to find a path toward healing for Indian communities. 

Finally, I am also mindful that when Congress does appropriate 

funding to combat this epidemic, it is important that Indian Country receives an adequate share of the funding and receives this 

funding in a manner that will ensure maximized impact to their 

communities. 

With that, I would like to welcome our witnesses. Thank you for 

testifying today. I will now turn to our Vice Chairman, Senator 

Udall, for his opening comments. 

STATEMENT OF HON. TOM UDALL, 

U.S. SENATOR FROM NEW MEXICO 

Senator UDALL. Thank you, Chairman Hoeven, for calling this 

oversight hearing and continuing this Committee’s work to address 

the opioid crisis in Indian Country. 

Before I begin my formal remarks, I would like to welcome New 

Mexico’s newest U.S. Attorney, John Anderson. Thank you, John, 

for your testimony and hard work on behalf of DOJ and New Mexicans. I look forward to working with you on some of these important Indian Country issues. 

Last November, we held a roundtable on this very same issue. 

Tribal leaders and Native organizations joined us to engage in a 

dialogue with agency officials from the Indian Health Service, Department of the Interior, Department of Justice, and the White 

House. 

These participants brought with them a lot of good information 

on the need for more treatment and prevention resources, especially culturally-based services. We were reminded that Congress 

must build in flexibility when making these resources available. 

3 

Native communities require and deserve the right to design behavioral health programs that suit local needs. Any successful response to the opioid and substance abuse crisis in Indian Country 

must be driven by the tribes. Congress must support tribal efforts 

by holding Federal agencies accountable and providing sufficient 

resources. 

We are also working with our colleagues over at the Health Education Labor and Pensions Committee. Just last week, at the HELP 

hearing on State responses to the opioid crisis, three Senators, 

Ranking Member Murray, Senator Warren and Senator Smith, 

spoke about tribal opioid challenges and the need for better Statetribal coordination. 

As members of the Indian Affairs Committee, we are obligated 

to educate our Senate colleagues about what is happening on this 

Committee so that Indian Country’s priorities and the voices of 

tribal leaders are heard beyond these four walls. When members 

work across committees to amplify tribal needs, good things happen. The ideas we heard on addressing Native substance abuse disorders at the roundtable resulted in the introduction of S. 2437, the 

Opioid Response Enhancement Act, a bill led by Senator Baldwin 

and joined by 15 Senate colleagues, including myself and three 

other Indian Affairs Committee members. 

The legislation refines the 21st Century Cures Grant Program to 

make tribes eligible to receive funds, provide tribes with programmatic flexibility and includes a 10 percent tribal setaside to 

further ensure that these funds actually make it out to Indian 

Country. Last week, I joined a group of ten Senators, led by Senator Heitkamp, on a letter to the Appropriations Committee leadership outlining the dire need for tribal-specific funding streams 

within the $6 billion in opioid funding put in place as part of the 

recent budget cap agreement. 

Finally, just this morning, I joined Senator Smith and four other 

colleagues to introduce the Native Behavioral Health Access Improvement Act. Modeled after the Special Diabetes Program for Indians, this legislation would create a special behavioral health program for Indians, a mandatory program funded at $150 million annually. 

I am heartened by this robust response to Indian Country’s call 

for action but as we will learn from our witnesses today, there is 

much left to do. The substance abuse crisis has sent ripple effects 

through Native communities, straining already overtaxed tribal 

systems. Tribal schools, housing departments, social services, law 

enforcement and the courts are all being asked to address the 

broader community disruptions caused by this public health emergency. 

I look forward to hearing from all of our witnesses today about 

how Congress can work to address the full impact of the opioid crisis in Indian Country. I look forward to continuing those efforts at 

next week’s oversight hearing on the President’s fiscal year 2019 

budget proposal. 

Thank you again, Mr. Chairman, for getting this here today. 

The CHAIRMAN. Senator Barrasso. 

4 

STATEMENT OF HON. JOHN BARRASSO, 

U.S. SENATOR FROM WYOMING 

Senator BARRASSO. Thank you very much, Mr. Chairman. 

I just want to take a moment to thank you personally, Mr. Chairman, for holding this important hearing today. As a doctor, I have 

given a great deal of attention during my time as a member of this 

Committee to the delivery of health care in Indian Country, especially in rural areas. 

I have long been concerned about the serious drug addiction crisis facing our Nation. Nowhere is the challenge more apparent 

than it is in tribal communities. I have been working hard with my 

colleagues on this Committee to finalize my bill to restore accountability in the Indian Health Service, which I believe is a step in 

the right direction but specific action for opioid addiction is critical. 

Just yesterday before the Senate Energy and Natural Resources, 

we are joined now by the Chairman of that committee, Secretary 

Zinke shared his concerns and his commitment to addressing the 

opioid crisis. Successful implementation of programs requires cooperation and coordination from all sides, Interior, Justice, Health 

and Human Services and the tribes themselves. 

Last year, the Northern Arapaho and Eastern Shoshone Tribes 

joined several Montana tribes to hold the Wind River War Staff 

Symposium in an effort combat drug and alcohol abuse. The symposium was held in conjunction with their youth winter retreat. 

While symposiums are not specific to opioid addiction, it is the 

prime example of the need to educate and engage youth if we are 

going to be successful in the fight to end opioid addiction. 

I thank you, Mr. Chairman, for your continued leadership. 

The CHAIRMAN. Are there other Committee members who would 

like to make an opening statement? Senator Murkowski. 

STATEMENT OF HON. LISA MURKOWSKI, 

U.S. SENATOR FROM ALASKA 

Senator MURKOWSKI. Thank you, Mr. Chairman. I too appreciate 

that you have brought this very important issue before the Committee and thank you to the Ranking Member. 

In the State of Alaska, we joined six other States in the Country 

in declaring a public health crisis in response to the opioid epidemic. We have joined Arizona, Florida, Virginia, Maryland, Massachusetts and now Alaska has issued a State disaster declaration. 

As many in this Committee know and have heard from me, our 

very rural communities are predominantly Alaska Native communities that are being devastated by substance abuse and now 

opioids. The rate of overdose deaths attributed to opioids has increased and, in many cases, has greatly exceeded the national average. 

In 2012, our prescription opioid pain reliever overdose death was 

more than double the national average. Our heroin-associated overdose deaths were over 50 percent higher than the national rate. 

The overdose death rate by race was the highest amongst Alaska 

Native people. Our statistics are troubling to the core. 

There is a much reported story of four people who overdosed in 

the Native Village of Quinhagak a couple years ago. Quinhagak 

has a population of 700. One of these individuals did die as a conVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 S:\DOCS\32784.TXT JACK
5 

sequence of that overdose. It was determined that it was Fentanyl, 

more Fentanyl than heroin. We are seeing this in a remote, tiny, 

tiny community. 

We clearly have an opioid epidemic, Mr. Chairman. We must 

deal with it but I must say that we must not lose sight of the other 

killer we are facing in our Native communities, not only in Alaska 

but around the Country. That killer is alcohol and how alcohol has 

wrought devastation. 

The Napaskiak Tribal Council passed a resolution on March 5 

asking that the governor declare a disaster of emergency to close 

the liquor store in Bethel due to high rates of alcohol-related 

deaths, accidents and injuries in the surrounding area. It is one 

more reminder to me that when we think about those we serve and 

their cries for help, we have so very much to do. 

I thank you for bringing opioids to the attention of the Committee this afternoon. Whether it is opioids, alcohol or anything in 

between, know that I am committed to working with you. 

I do ask that my full statement be included as part of the record. 

Thank you, Mr. Chairman. 

[The prepared statement of Senator Murkowski follows:] 

PREPARED STATEMENT OF HON. LISA MURKOWSKI, U.S. SENATOR FROM ALASKA

Chairman Hoeven, Vice Chairman Udall, I appreciate this oversight hearing to 

discuss the impacts of the opioid epidemic in Native American and Alaska Native 

communities. Alaska may be a very rural state, but we are not shielded from this 

epidemic and in fact opioid abuse in Alaska has rapidly become one of our most 

pressing issues. 

Last year, Alaska Governor Bill Walker issued a State Disaster Declaration to address the growing opioid epidemic in Alaska. This meant that Alaska became one 

of the six states in the Nation to declare a public health crisis in response to the 

opioid epidemic. (Others: Arizona, Florida, Virginia, Maryland, Massachusetts) 

Many of our communities, including our very rural ones who are predominantly 

Alaska Native, are being devastated by opioids. The rate of overdose deaths attributed to opioids have steadily increased in Alaska, and in many cases has greatly 

exceeded the national average. For example, in 2012, Alaska’s prescription opioid 

pain reliever overdose death rate was more than double the national average (10.5 

vs. 5.1 per 100,000 persons, respectively), and Alaska’s heroin-associated overdose 

death rate was over 50 percent higher than the national rate (3.0 vs. 1.9 per 

100,000 persons, respectively). Furthermore, the overdose death rate by race was 

the highest among the Alaska Native people (20.2 per 100,000). 

The opioid epidemic has been increasingly more prevalent in the Alaska Native 

communities. For instance, the Native Village of Quinhagak, with a population of 

about 700, saw four people overdose (one fatally) in the span of one week in August 

2016. The heroin used in Quinhagak was tested at the Alaska State Crime Lab and 

it was discovered that the heroin used in Quinhagak contained more fentanyl than 

heroin. That was only the second time in Alaska’s history that a drug submitted 

to the state crime lab had been confirmed as mixture of heroin and fentanyl and 

it wasn’t heroin from the streets of Anchorage or Fairbanks. But in a rural village 

in remote Southwest Alaska. 

Alaska certainly has an opioid epidemic. But, I think this is indicative of a much 

larger substance abuse problem in Alaska and other areas across the country. According to the Alaska State Troopers 2016 Annual Drug Report, the single most 

abused substance in Alaska is alcohol. Not heroin, not cocaine, but alcohol. To date, 

there are 109 villages in rural Alaska that have prohibited the sale, importation, 

and possession of alcoholic beverages. I do understand wholeheartedly the seriousness of the growing issue of opioids, but I do not want to lose focus of some of the 

other issues we have that have gut-wrenching statistics as well. I have said this before, but we must have an all hands on deck, and an all-of-the-above strategy for 

solutions to make it through these complex substance abuse issues. 

Just recently, the Native Village of Napaskiak voted on and passed a resolution 

that formally asked the Governor to declare a disaster of emergency to close down 

a liquor store in Bethel, Alaska. One of the many reasons that Napaskiak voted on 

6 

this resolution was because they saw an increase in the number of preventable 

deaths in their community related to alcohol abuse. In addition to that, the tribe 

saw an increase in the number of cases brought before their ICWA program, a decrease in the attendance rate at the local school because kids weren’t getting enough 

sleep due to alcohol disturbances, and an increased caseload for law enforcement officials in the region. 

The Tribal Council specifically asked to close the liquor in Bethel, Alaska, because 

that was the primary means for their members to obtain alcohol. Napaskiak is one 

of the 109 villages that has banned alcohol and there was still alcohol in the village 

because the alcohol was imported illegally from the liquor store in Bethel. 

Despite the prevalence of opioids in rural Alaska, bootlegging alcohol continues 

to be the most lucrative and profitable criminal enterprise in Alaska. In 2016 alone, 

the Alaska State Troopers arrested 225 people for the possession or sale of alcohol 

in dry villages. This was more than any other drugs, including cocaine, heroin, and 

prescription medication. 

Alaska Native communities don’t just have an opioid epidemic, many have a substance abuse epidemic. There are tribes who are standing up against this. There are 

community members who are going out on a limb in their own communities to be 

the one to stand up against it. We must stand with them. I look forward to working 

with my colleagues in this committee to find a solution to this epidemic and thank 

you to all of the witnesses that came here today to address this issue. 

The CHAIRMAN. Without objection. 

Are there other opening statements? 

[No audible response.] 

The CHAIRMAN. Hearing none, our witnesses today are: The Honorable John C. Anderson, United States Attorney for the District 

of New Mexico, U.S. Department of Justice, Albuquerque, New 

Mexico; Captain Christopher Jones, Director, National Mental 

Health and Substance Use Policy Laboratory, Substance Abuse and 

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

and Human Services, Rockville, MD; and Rear Admiral Michael 

Toedt, MD, Chief Medical Officer, Indian Health Service, U.S. Department of Health and Human Services, Rockville, MD. 

I want to remind the witnesses that your full written testimony 

will be made a part of the official record and to please keep your 

statements to five minutes. 

With that, we will begin with you, Mr. Anderson. 

STATEMENT OF HON. JOHN C. ANDERSON, U.S. ATTORNEY, 

DISTRICT OF NEW MEXICO, U.S. DEPARTMENT OF JUSTICE 

Mr. ANDERSON. Chairman Hoeven, Vice Chairman Udall and 

members of the Committee, thank you for inviting us today to discuss this critical issue and the Department of Justice’s efforts to 

support Native communities dealing with the devastating aftermath of the opioid epidemic. 

The Department has been uncompromising in our commitment to 

combating drug abuse and drug crimes, particularly opioids, in Indian Country and across the Nation. In my district, New Mexico, 

the opioid crisis in Indian Country is particularly acute. 

Despite its staggering natural beauty, northern New Mexico and 

Espanola, New Mexico in particular, has one of the highest opioid 

death rates in the Country. For decades, Espanola has had a severe 

heroin problem. As you may know, Espanola is surrounded by Indian reservations. Many New Mexico Indian pueblos, including the 

pueblos of Santa Clara, Okawingay, San Ildefonso, Pecurist, 

Owakay, Nambe ́, and Tuzukay are all within a short distance of 

the Espanola area. 

7 

The opioid epidemic knows no boundaries, so our Pueblos are 

equally affected by heroin and prescription opioids. Individuals and 

communities alike continue to be plagued by the opioid scourge and 

its secondary effects. 

At a recent consultation in New Mexico, one Pueblo governor 

shared photographs of the parking lot of their casino. The photos 

were of the discarded needles, syringes and other drug paraphernalia scattered about the parking lot. 

At the same consultation, a Pueblo chief of police emotionally described losing a brother to a heroin overdose and a sister to a prescription opioid overdose. The chief of police explained that the 

drug epidemic is dire in northern New Mexico and that something 

needs to be done to address the problem. 

The catastrophic impact opioid abuse can have at every level of 

a community, from family units to infrastructure and economic stability, demands our best efforts to offer effective and sustainable 

support to communities in crisis. The Department has developed a 

multifaceted approach to addressing the threat and the impact of 

opioid abuse. Our approach in Indian Country is based on the belief that the tribes are in the best position to identify solutions to 

the problems in their communities. 

An important element of the Department’s support is in providing opportunities for funding. In fiscal year 2017, the Department awarded nearly $59 million to strengthen drug programs and 

combat the opioid epidemic. 

The Office of Justice Programs administers the Department’s 

Comprehensive Opioid Abuse Program. The goals of the Comprehensive Opioid Abuse Program are twofold. First is to reduce 

opioid misuse and the number of overdose fatalities. Second is to 

support the implementation of prescription drug monitoring programs to prevent the diversion of controlled substances. 

The Department understands that effective coordination among 

Federal agencies is crucial to ensuring the success of our efforts. 

We have participated in the High Intensity Drug Trafficking Areas 

Program, the HIDTA Program, which increases collaboration and 

information sharing between tribal law enforcement and Federal, 

State and local agencies to improve investigation and interdiction 

in Indian Country. 

The Indian Country Law Enforcement Coordination Working 

Group, co-chaired by the Department of Justice and the Bureau of 

Indian Affairs, includes representatives from 13 Federal law enforcement agencies. This group is an important tool for enhancing 

interagency Federal law enforcement coordination in tribal communities. 

We recognize that the crisis requires more than a law enforcement response. The Department is working closely with Indian 

Health Service to ensure that other Federal agencies are aware of 

the updated prescription drug monitoring protocols in IHS facilities. 

We have also developed a number of training opportunities to 

better equip law enforcement and secondary providers working in 

Indian Country in addressing drug crimes and the secondary effects of opioid abuse. 

8 

The DEA has conducted a prolonged community outreach in Indian Country to educate tribal leaders and citizens on opioids and 

other drugs. On October 28, 2017, the Department and the BIA collaborated on the most recent prescription drug takeback day. 

This initiative provided a safe and convenient means of disposing 

of prescription drugs while also educating Native communities on 

the potential for opioid abuse. Over 115 tribal communities participated and we intend to repeat this initiative in the near future. 

Our goal is clear. We must continue working in partnership with 

tribal, Federal, State and local partners to respond to the opioid 

epidemic and to support communities affected by the crisis. We appreciate this Committee’s focus on the issue and look forward to 

working with you in combating this threat to the health and wellbeing of our Native communities. 

Thank you again for the opportunity to participate today. 

[The prepared statement of Mr. Anderson follows:] 

PREPARED STATEMENT OF HON. JOHN C. ANDERSON, U.S. ATTORNEY, DISTRICT OF

NEW MEXICO, U.S. DEPARTMENT OF JUSTICE

Chairman Hoeven, Vice-Chairman Udall, and Members of the Committee: 

Thank you for inviting us today to discuss this critical issue and the Department 

of Justice’s (the Department) efforts to support Native communities dealing with the 

devastating aftermath of the opioid epidemic. The Department has been uncompromising in our commitment to combatting drug abuse and drug crimes, particularly 

opioids, in Indian country and across the nation. 

In my district, New Mexico, the opioid crisis in Indian Country is particularly 

acute. Despite its staggering natural beauty, northern New Mexico, and Espanola, 

New Mexico in particular, has one of the highest opioid overdose death rates in the 

country. For decades, Espanola has had a severe heroin problem. And as you may 

know, Espanola is surrounded by Indian reservations. Many New Mexico Indian 

Pueblos, including the Pueblos of Santa Clara, Ohkay Owingeh, San Ildefonso, 

Picuris, Pojoaque, Nambe and Tesuque are all within a short distance of the 

Espanola area. The opioid epidemic knows no boundaries, and so our Pueblos are 

equally affected by heroin and prescription opioids; individuals and communities 

alike continue to be plagued by the opioid scourge and its secondary effects. 

At a recent consultation in New Mexico, one Pueblo Governor shared photographs 

of the parking lot of their casino. The photos revealed discarded needles, syringes 

and other drug paraphernalia scattered about the casino parking lot. 

At the same consultation, a Pueblo Chief of Police emotionally described losing a 

brother to a heroin overdose and a sister to a prescription opioid overdose. The Chief 

of Police explained that the drug epidemic is dire in Northern New Mexico and that 

something needs to be done to address the problem. 

The catastrophic impact that opioid abuse can have at every level of a community, 

from family units to infrastructure and economic stability, demands our best efforts 

to put forth effective and sustainable support to communities in crisis. The Department has developed a multi-faceted response to addressing the threat and the impact of opioid abuse. Our approach in Indian country is based on the belief that the 

Tribes are in the best position to identify solutions to problems in their communities. We have sought to develop resources and initiatives that rely on partnership 

with the Tribes and are continually interested in hearing from our Tribal and federal partners as we adjust our efforts to better meet the needs of Native communities. 

An important element of the Department’s support is in providing opportunities 

for funding. In fiscal year 2017, the Department awarded nearly $59 million to 

strengthen drug court programs and combat the opioid epidemic. The Office of Justice Programs (OJP) administers the Department’s ‘‘Comprehensive Opioid Abuse 

Program.’’ The goals of the Comprehensive Opioid Abuse Program are twofold: First, 

the program aims to reduce opioid misuse and the number of overdose fatalities. 

Second, the program supports the implementation, enhancement, and proactive use 

of prescription drug monitoring programs (PDMPs) to support clinical decisionmaking and prevent the misuse and diversion of controlled substances. Tribes are 

eligible to apply for a variety of funding opportunities under this program. As an 

example of recent awards under this program, in Fiscal Year 2017, the Seneca NaVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00012 Fmt 6633 Sfmt 6621 S:\DOCS\32784.TXT JACK
9 

tion Peacemakers Court was awarded funds to create a community-driven, culturally competent diversion project aimed at helping Native American opioid users. 

The Port Gamble S’Klallam Tribe was awarded funds in Fiscal Year 2017 to support 

drug courts and programs that support veterans. The Department will continue to 

offer these opportunities to Tribes going forward. 

The Department understands that effective coordination among federal agencies 

is crucial to ensuring our efforts are successful. We have participated in the HighIntensity Drug Trafficking Areas (HIDTA) program, funded through the Office of 

National Drug Control Policy, for many years now. The HIDTA program increases 

collaboration and information sharing between Tribal law enforcement and federal, 

state, and local agencies to improve investigation and interdiction in Indian country. 

As the Department continues to participate in the HIDTA program, our law enforcement agencies, particularly the Drug Enforcement Administration (DEA), have been 

working to build stronger relationships with other law enforcement agencies and 

service providers active in Indian country so that we are able to adjust our Task 

Force presence in Indian country most effectively. 

The Indian Country Law Enforcement Coordination Working Group, cochaired by 

the Department of Justice and the Bureau of Indian Affairs (BIA) at the Department of the Interior, has become important to enhancing inter-agency federal law 

enforcement coordination in tribal communities. The group includes representatives 

from 13 federal law enforcement agencies and has focused heavily on several aspects 

of the opioid epidemic including proliferation, identifying top challenges to law enforcement, and coordinating responses. We will continue to use this working group 

to strengthen our coordinated efforts. For example, trafficking through the mail is 

a significant concern and we intend to use this working group as a forum to develop 

better ways to stop the movement of opioids through the postal service. 

We recognize that the crisis requires more than a law enforcement response, so 

our efforts to coordinate go beyond law enforcement. For example, the Department 

is working closely with the Indian Health Service (IHS) of the Department of Health 

and Human Services to ensure that other federal agencies are aware of updated 

Prescription Drug Monitoring Program (PDMP) protocols in IHS facilities. The updated protocols have an impact on how some drug crimes are investigated and prosecuted, and on efforts to introduce safeguards against opioid abuse. Additionally, we 

have developed a number of training opportunities to better equip law enforcement 

and service providers working in Indian country to address the drug crimes and the 

familial and community impacts of opioid abuse. The Department has presented recent trainings, often in coordination with BIA, on opioid trends, investigative techniques, drug handling precautions regarding opioids, naloxone use, and indicators 

that opioids are present in a community. Other training is available on violent crime 

associated with opioids, prescription drug diversion, and investigating and prosecuting medical professionals and others involved in distributing prescription medications outside the scope of legitimate medical practice. These training opportunities 

are available to Tribal law enforcement and, in some cases, entirely geared for a 

Tribal audience. The Department is currently working with BIA on a new opportunity tentatively slated for this summer that will bring Tribal law enforcement representatives together with a number of federal law enforcement agencies to train 

on a wide range of drug-related topics. 

Community outreach is another important aspect of our approach to this issue. 

The DEA has conducted a prolonged community outreach effort in Indian country 

to educate Tribal leaders and citizens on opioids and other drugs. Additionally, on 

October 28, 2017, the Department and BIA collaborated on the most recent Prescription Drug Take Back Day, which is a nationwide program that has also allowed the 

successful collaboration between BIA and DEA. This initiative provided a safe, convenient, and responsible means of disposing prescription drugs, while also educating 

Native communities on the potential for opioid abuse. Over 115 Tribal communities 

participated; we intend to repeat this initiative and expand participation in the future. 

Improved information sharing plays a crucial role in any law enforcement effort, 

even more so in the context of opioids as we all work to get ahead of this terrible 

epidemic. The Tribal Access Program for National Crime Information (TAP) is an 

effective tool for participating Tribes to track and contribute data on opioid-related 

crimes and to perform required background checks. TAP assists Tribes by providing 

a means of access to national crime databases maintained by the FBI Criminal Justice Information Services (CJIS) Division for both criminal justice and civil background check purposes. This has been an especially important tool for performing 

checks on those who have regular contact with children in Indian country, including 

schools and foster care. Service providers in Indian country carry much of the burden of healing communities in the wake of opioid abuse, so we believe TAP plays 

10 

an equally necessary role in ensuring safe providers as it does in sharing important 

law enforcement information. 

The use of data analytics to combat the opioid crisis is among the new tactics that 

are under development Department-wide. Attorney General Sessions formed the 

Opioid Fraud and Abuse Detection Unit to utilize data analytics, such as distribution and inventory figures, to identify patterns, trends, and statistical outliers that 

can be developed into targeted law enforcement operations. As we better understand 

the data across the country we will be able to better understand patterns and trends 

in Indian country. 

Our goal is clear: we must continue working in partnership with Tribal, federal, 

state, and local partners to respond to the opioid epidemic and to support communities that are affected by the crisis. We are committed to putting forth our best 

efforts in this joint undertaking. We appreciate this committee’s focus on this issue 

and look forward to working with you going forward. Thank you again for the opportunity to participate today. 

The CHAIRMAN. Thank you. 

Captain Jones. 

STATEMENT OF CAPTAIN CHRISTOPHER JONES, PHARM.D., 

M.P.H., DIRECTOR, NATIONAL MENTAL HEALTH AND 

SUBSTANCE USE POLICY LABORATORY, SUBSTANCE ABUSE 

AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Dr. JONES. Thank you, Chairman Hoeven, Vice Chairman Udall 

and members of the Committee. Thank you for the opportunity to 

testify at this important hearing focusing on tribes and tribal entities. 

From the start of his Administration, President Trump has been 

addressing the opioid epidemic as a top priority. At SAMHSA, we 

share the President’s commitment to ending the crisis in the U.S. 

The American Indian and Alaskan Native population has been 

significantly impacted by the opioid epidemic. Among this population, 4 percent of people 12 and older reported prescription opioid 

misuse in 2016. More than 1 percent had an opioid use disorder. 

Most concerning are the continued increases in overdose deaths. 

In 2016, American Indians and Alaska Natives had the second 

highest overdose death rate in the United States, 13.9 deaths per 

100,000 people, which represents a 400 percent increase since 

2000. 

To combat the opioid crisis, HHS launched a five-point opioid 

strategy in April 2017. The strategy aims to improve access to prevention, treatment and recovery support services; target the availability and distribution of overdose-reversing drugs; strengthen 

public health data reporting and collection; support cutting-edge research that advances our understanding of pain and addiction; and 

advance the practice of pain management. 

As the Department’s lead agency for behavioral health, SAMHSA 

has been at the forefront of the HHS response to the opioid crisis. 

Today, I want to focus on how SAMHSA is working with tribal 

communities under the HHS opioid strategy. 

Since joining SAMHSA, Assistant Secretary McCance-Katz has 

prioritized efforts to support the behavioral health needs of the 

American Indian and Alaska Native population. She has charged 

SAMHSA leadership with identifying every possible opportunity for 

tribal entities to engage with SAMHSA. This includes making tribal entities eligible for discretionary grant programs wherever posVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00014 Fmt 6633 Sfmt 6601 S:\DOCS\32784.TXT JACK
11 

sible; ensuring flexibility in how tribal entities incorporate cultural 

practices into their programs; and providing assistance to ensure 

that tribal entities are set up for success. 

Under the HHS strategy, SAMHSA focuses its work in three 

areas: building prevention, treatment and recovery capacity 

through funding; providing technical assistance and training; and 

leveraging key stakeholders to support incorporation of tribes and 

tribal populations into the opioid response. 

In the area of funding, SAMHSA administers the State Targeted 

Response to the Opioid Crisis Grants, a two-year program authorized under the 21st Century Cures Act. Although tribal entities 

were not eligible for funding under the statutory structure of the 

STR Program, SAMHSA has taken a number of steps to support 

inclusion engagement of tribes in State plans. 

Specifically, we required States to assess the needs of tribal communities and include them in their strategic plans and reviewed 

each State plan for tribal engagement. We held a webinar with 

States to clarify our expectation that American Indians and Alaska 

Natives be incorporated as a population of focus and provided examples of how States are working with tribes on the STR Program. 

Most recently, Dr. McCance-Katz sent a letter to governors calling on them to work with tribes and allocate funds directly to them 

so they can offer the essential and life-saving services their communities need to respond to the opioid crisis. Our assessment of the 

State STR plans indicates that of the 35 States with federally-recognized tribes within their borders, at least 12 have specifically 

identified tribes as a population of focus or specified actions that 

are working to combat opioids in tribal communities. 

Tribes have also received funding from a number of SAMHSA’s 

other discretionary programs. Under the Strategic Prevention 

Framework Partnerships for Success Program, First Nations Community Healthsource of New Mexico is using funding to develop 

prevention strategies for tribal communities. 

Under the Strategic Prevention Framework for Prescription 

Drugs Program, four tribes are working with their States to incorporate tribal data into State prescription drug monitoring programs 

to better target prevention efforts and reduce prescription drug 

misuse. Last September, SAMHSA awarded funding to four tribes 

under our First Responders Naloxone Grant Program. We also recently released a funding announcement for Treatment and Recovery Services for Adolescents, Transitional Aged Youth and Their 

Families that actually, for the first time, includes a $5 million setaside for tribal entities. 

In the area of technical assistance, Assistant Secretary McCanceKatz recently reinstated SAMHSA’s American Indian and Alaska 

Native Support Center which is part of our Addiction Technology 

Transfer Center Network. This center provides critical support to 

develop and strengthen the specialized behavioral and primary 

healthcare workforce that provides treatment and recovery services 

to tribal communities. 

We also fund a Tribal Training and Technical Assistance Center 

which actively engages and serves tribes across the Country. In 

fact, today, this center is conducting the first of two webinars on 

opioids in Indian Country. 

12 

Finally, SAMHSA is committed to leveraging a broad range of 

stakeholders to ensure that the behavioral health needs of tribal 

populations are a part of our Nation’s response to the opioid crisis. 

To support this commitment, SAMHSA is currently planning a 

tribal-State Policy Academy for August 2018 that will bring States 

and tribes together to develop specific, actionable plans for how 

they can collaborate to address the opioid crisis and substance use 

issues in their community. 

Thank you for inviting me to testify. I look forward to your questions. 

[The prepared statement of Dr. Jones follows:] 

PREPARED STATEMENT OF CAPTAIN CHRISTOPHER JONES, PHARM.D., M.P.H., 

DIRECTOR, NATIONAL MENTAL HEALTH AND SUBSTANCE USE POLICY LABORATORY, 

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Chairman Hoeven, Vice Chairman Udall, and members of the Senate Committee 

on Indian Affairs, thank you for inviting me to testify at this important hearing. 

The Substance Abuse and Mental Health Services Administration (SAMHSA) has 

been actively engaged in the Administration’s effort to combat the opioid epidemic. 

SAMHSA works with our colleagues at the Department of Health and Human Services (HHS), state and local governments, tribal entities, and other key stakeholders. 

Thank you for the opportunity to discuss the opioid crisis in the United States 

and the Federal response, particularly in relation to tribes and tribal entities. From 

the start of his Administration, President Trump has made addressing the opioid 

epidemic a top priority, and at SAMHSA we share the President’s commitment to 

bringing an end to this crisis, which is exacting a toll on individuals, families, and 

communities across the country. The Department, including SAMHSA, has made 

the crisis a top priority and is committed to using our full expertise and resources 

to combat the epidemic. 

Over the past 15 years, communities across our Nation have been devastated by 

increasing prescription and illicit opioid abuse, addiction, and overdose. According 

to SAMHSA’s National Survey on Drug Use and Health (NSDUH), in 2016, over 11 

million Americans misused prescription opioids, nearly 1 million used heroin, and 

2.1 million had an opioid use disorder due to prescription opioids or heroin. The 

American Indian/Alaska Native (AI/AN) population is likewise affected by the opioid 

crisis. According to NSDUH, 5.2 percent (72,000) of AI/AN aged 18 and older reported misusing a prescription drug in the past year and 4.0 percent (56,000) of AI/ 

ANs aged 18 and older reported misusing a prescription pain reliever in the past 

year. Over the past decade, the United States has experienced significant increases 

in rates of neonatal abstinence syndrome (NAS), hepatitis C infections, and opioidrelated emergency department visits and hospitalizations. Most alarming are the 

continued increases in overdose deaths, especially the rapid increase since 2013 in 

deaths involving illicit fentanyl and other highly potent synthetic opioids. Since 

2000, more than 300,000 Americans have died of an opioid overdose. Opioids were 

involved in 42,249 deaths in 2016, and opioid overdose deaths were five times higher in 2016 than 1999. 

The opioid epidemic in the United States can be attributed to a variety of factors. 

For example, there was a significant rise in opioid analgesic prescriptions that 

began in the mid-to-late 1990s. Not only did the volume of opioids prescribed increase, but also well-intentioned healthcare providers began to prescribe opioids to 

treat pain in ways that we now know are high-risk and have been associated with 

opioid abuse, addiction, and overdose, such as prescribing at high doses and for 

longer durations. One additional factor is a lack of health system and healthcare 

provider capacity to identify and engage individuals, and provide them with highquality, evidence-based opioid addiction treatment, in particular the full spectrum 

of medication-assisted treatment (MAT). It is well-documented that the majority of 

people with opioid addiction in the United States do not receive treatment, and even 

among those who do, many do not receive evidence-based care. Accounting for these 

factors is paramount to the development of a successful strategy to combat the 

opioid crisis. Further, there is a need for more rigorous research to better understand how existing programs or policies might be contributing to or mitigating the 

opioid epidemic. 

13 

HHS Five Point Strategy 

In April 2017, HHS outlined its five-point Opioid Strategy, which provides the 

overarching framework to leverage the expertise and resources of HHS agencies in 

a strategic and coordinated manner. The comprehensive, evidence-based Opioid 

Strategy aims to: 

• Improve access to prevention, treatment, and recovery support services to prevent the health, social, and economic consequences associated with opioid addiction and to enable individuals to achieve long-term recovery; 

• Target the availability and distribution of overdose-reversing drugs to ensure 

the broad provision of these drugs to people likely to experience or respond to 

an overdose, with a particular focus on targeting high-risk populations; 

• Strengthen public health data reporting and collection to improve the timeliness 

and specificity of data and to inform a real-time public health response as the 

epidemic evolves; 

• Support cutting-edge research that advances our understanding of pain and addiction, leads to the development of new treatments, and identifies effective 

public health interventions to reduce opioid-related health harms; and 

• Advance the practice of pain management to enable access to high-quality, evidence-based pain care that reduces the burden of pain for individuals, families, 

and society while also reducing the inappropriate use of opioids and opioid-related harms. 

As HHS lead agency for behavioral health, SAMHSA’s core mission is to reduce 

the impact of substance abuse and mental illness on America’s communities. 

SAMHSA supports a portfolio of activities that address the HHS Opioid Strategy. 

Today, I will address how SAMHSA is working with tribes and tribal organizations as that work relates to this strategy. 

Improving Access to Prevention, Treatment, and Recovery Support Services 

SAMHSA administers the State Targeted Response to the Opioid Crisis Grants, 

a two-year program authorized by the 21st Century Cures Act (P.L. 114–255). By 

providing $485 million to states and U.S. territories in Fiscal Year (FY) 2017, this 

program allows states to focus on areas of greatest need, including increasing access 

to treatment, and reducing opioid overdose related deaths through the provision of 

the full range of prevention, treatment, and recovery services for opioid use disorder. 

Specific areas in which states and tribes collaborate on prevention activities include: 

Prescription Drug Monitoring Program (PDMP) data-sharing; State Epidemiological 

Outcome Workgroups; overdose education on naloxone distribution; and media campaigns. In Minnesota, the state is supporting five Native American communities to 

service high-risk pregnant women with opioid use disorder (OUD) in order to 

strengthen and enhance peer recovery support services. In Montana, the state is 

working with the Rocky Mountain Tribal Leaders Council to develop culturally tailored versions of the current peer monitoring trainings and peer supervisor 

trainings. 

Tribes receive SAMHSA prevention grant funds to address opioid misuse and 

abuse. Prevention programs include a focus on change at the community level that 

will, over time, lead to measurable changes at the state and tribal levels. Under the 

Strategic Prevention Framework-Partnerships for Success (SPF–PFS) grant program, First Nations Community HealthSource in New Mexico serves four tribes: 

Pueblo de Cochiti; Pueblo of Laguna; Native American Community Academy; and 

Zuni Pueblo. First Nations Community HealthSource has developed prevention 

strategies based on research and tribal traditions, culture, language, and values 

that reduce prescription drug abuse and misuse; improve the capacity of tribal leadership to understand and support prevention strategies designed to decrease prescription drug abuse and misuse; and develops a tribal strengths based method to 

decrease prescription drug abuse and misuse. 

Other tribes are developing capacity and expertise in the use of data from staterun PDMPs. Under the Strategic Prevention Framework for Prescription Drugs 

(SPF Rx) grant program, four tribes (Cherokee Nation, Southern Plains inter-tribal, 

Nooksack, and Little Traverse Bay Band of Odawa Indians) currently work with 

their states to bring tribal data into the system and decrease prescription drug misuse in their communities. For example, in Oklahoma, the Cherokee Nation has used 

the PDMP data to develop a tribal-wide media campaign, ‘‘Think SMART,’’ that is 

educating community members on the responsible use of opioids and the risks associated with overprescribing. 

Since coming to SAMHSA, the Assistant Secretary for Mental Health and Substance Use, Dr. Elinore McCance-Katz, has reviewed all of our discretionary funding 

14 

announcements and has looked for opportunities to improve tribal access to 

SAMHSA’s discretionary grant funds. For example, tribal leaders informed her they 

have a great concern about the vulnerability of tribal youth to developing mental 

and substance use disorders. With clarity that tribal youth are a priority, Assistant 

Secretary McCance-Katz was able to ensure that a funding opportunity announcement (FOA) that SAMHSA recently released entitled ‘‘Enhancement and Expansion 

of Treatment and Recovery Services for Adolescents, Transitional Aged Youth, and 

their Families’’ included at least a $5 million set-aside for tribes, tribal organizations, urban Indian health programs, and consortia of tribes or tribal organizations. 

This amount is approximately 34 percent of the total anticipated $14.6 million available for this program. 

Targeting Overdose-Reversing Drugs SAMHSA has been a leader in efforts to reduce overdose deaths by increasing, through funding and technical assistance, the 

availability and use of naloxone to reverse overdose. SAMHSA’s ‘‘Opioid Overdose 

Prevention Toolkit,’’ first released in 2013, is one of SAMHSA’s most downloaded 

resources. The Toolkit provides information on risks for opioid overdose, recognition 

of overdose, and how to provide emergency care in an overdose situation. The Toolkit is intended for community members, first responders, prescribers, people who 

have recovered from an opioid overdose, and family members, as well as communities and local governments. 

SAMHSA provides a number of funding streams that can be used to expand access to naloxone. In September 2017, SAMHSA awarded funding for the First Responders-Comprehensive Addiction and Recovery Act (FR–CARA) grant program, 

which includes grants to four tribes: White Earth Band of Chippewa Indians; Cherokee Nation; Choctaw Nation of Oklahoma; and Lac Du Flambeau Band of Lake Superior Chippewa Indians. The First Responders grant program provides resources 

to first responders and treatment providers who work directly with the populations 

at highest risk for opioid overdose. For the White Earth Band of Chippewa Indians 

in Minnesota, prescription opiate and heroin admissions for American Indians on 

the Reservation totaled almost 30 percent of the treatment admissions. SAMHSA’s 

grant helps support the tribe’s collaborative approach to addressing the crisis 

throughout its community, including partnerships with public health, law enforcement, behavioral health, first responders, public relations, and cultural representatives. 

Strengthening Public Health Data and Reporting 

NSDUH provides key national and state level data on a variety of substance use 

and mental health topics, including opioid misuse. NSDUH is a vital part of the surveillance effort related to opioids, and the data from NSDUH has been used to track 

historical and emerging trends in opioid misuse, including geographic and demographic variability. 

According to the 2016 NSDUH, 5.2 percent (72,000) of AI/AN aged 18 and older 

reported misusing a prescription drug in the past year and 4.0 percent (56,000) of 

AI/ANs aged 18 and older reported misusing a prescription pain reliever in the past 

year, compared to national averages of 7.1 percent and 4.3 percent respectively. The 

2016 NSDUH also found that 4.1 percent (63,000) of AI/ANs aged 12 and older reported opioid misuse in the past year, in line with the national average of 4.4 percent. The 2016 NSDUH found that 1.1 percent (16,000) of AI/ANs aged 12 and older 

reported having an opioid use disorder in the past year. 

Working with Tribes and Tribal Organizations to Reduce Opioid Misuse 

and Abuse 

Assistant Secretary McCance-Katz reinstated SAMHSA’s Addiction Technology 

Transfer Center (ATTC): American Indian and Alaska Native Support Center Cooperative Agreement (AI/AN ATTC). The purpose of this program is to provide support 

for the ATTC Network, AI/AN, tribal organizations, urban Indian programs, state 

and local governments, and other organizations to develop and strengthen the specialized behavioral healthcare and primary healthcare workforce that provides substance use disorder (SUD) treatment and recovery support services to tribal communities. The University of Iowa, the grantee, works directly with SAMHSA and in collaboration with the FY 2017 ATTC National Coordinating Center and the 10 Regional ATTC Centers. The Centers focus on activities aimed at improving the quality and effectiveness of treatment and recovery, as well as working directly with 

providers of clinical and recovery support services, and others that influence the delivery of services, to improve the quality of workforce training and service delivery 

to tribal communities. 

SAMHSA also funds the Tribal Training and Technical Assistance Center, which 

actively engages and serves tribes across the Nation. Through onsite and virtual 

15 

training, targeted resources, learning communities, assistance with Tribal Action 

Plans, and intensive community engagement, our technical assistance guides tribal 

communities and organizations in using cultural knowledge and strengths to support wellness, including addressing the opioid crisis. For example, today, this Center 

is conducting the first of two webinars targeting opioids in Indian Country. 

SAMHSA is in the process of assessing the technical assistance provided to assure 

that the funding is appropriate to the need and that the tribal entities get the support they need while maximizing grant funds to communities. 

SAMHSA received input from our Tribal Technical Advisory Committee (TTAC) 

and shared TTAC’s recommendations with the Secretary’s Tribal Advisory Committee. Based on input from these tribal leaders, SAMHSA is partnering with the 

Centers for Disease Control and Prevention, Indian Health Service, Centers for 

Medicare & Medicaid Services, and National Institutes of Health to host a Joint 

Tribal Advisory Committee (JTAC) meeting. The JTAC will bring together tribal 

leaders from the tribal advisory committees for these operating divisions to discuss 

related priorities. Our plan is to host the joint meeting immediately preceding the 

National American Indian and Alaska Native Behavioral Health Conference this 

summer. 

We have heard from tribal leaders that SAMHSA also has a responsibility to improve tribal-state relationships. In response, the Agency is hosting a Tribal-State 

Policy Academy (TSPA) to advance tribal behavioral health planning. The TSPA will 

have a particular emphasis on improving current efforts to address the impact of 

the opioid epidemic in Indian Country but will also include an opportunity for tribes 

and states to work together on other primary substances of abuse affecting local 

tribal communities. Beyond supporting improved working relationships and planning, proposed outcomes include joint tribal-state plans for combating drug use in 

tribal communities and collaborative models that may be replicated by other states 

and tribes. Up to ten tribal-state teams will be able to participate in the Academy 

that is targeted for this summer. Additionally, Assistant Secretary McCance-Katz 

recently sent a letter to governors urging them to assess the behavioral health 

needs of AI/ANs in their states and to equitably distribute federal funds directed 

to states to address the opioid crisis and mental health needs. 

Finally, SAMHSA has had discussions with tribal leaders about the importance 

of recognizing and elevating tribal behavioral health as a critical step toward collaborative improvements. SAMHSA is in the process of engaging Federal and tribal 

organization partners to host a national town hall on combatting substance use in 

tribal communities. The town hall will bring together senior government officials 

and tribal leaders to explicitly address opportunities, and identify a clearer path forward, for combatting substance use in AI/AN communities. 

Thank you again for inviting me to testify today. I look forward to answering your 

questions. 

The CHAIRMAN. Rear Admiral Toedt. 

STATEMENT OF REAR ADMIRAL MICHAEL TOEDT, M.D., CHIEF 

MEDICAL OFFICER, INDIAN HEALTH SERVICE, U.S. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Dr. TOEDT. Good afternoon, Chairman Hoeven, Vice Chairman 

Udall, and members of the Committee. 

I am Dr. Michael Toedt, Chief Medical Officer for the Indian 

Health Service. Today, I appreciate the opportunity to provide information on the work that IHS has been doing to address the 

opioid crisis, which is a top priority for the agency and the Department of Health and Human Services. 

The impact of the opioid crisis on American Indians and Alaska 

Natives is immense. American Indians and Alaska Natives have 

had the highest drug overdose death rates in 2015 according to the 

CDC, and the largest percentage increase in the number of deaths 

over time from 1999 to 2015 compared to other racial and ethnic 

groups. 

During that time, deaths rose more than 500 percent among 

American Indians and Alaska Natives. Collaborating and conVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00019 Fmt 6633 Sfmt 6601 S:\DOCS\32784.TXT JACK
16 

sulting with tribes to address the opioid crisis in Indian Country 

is important. We work with our tribal advisory committees to gather input on critical next steps. The opioid crisis has been and will 

continue to be a priority for the advisory committees. 

IHS strengthened and prioritized efforts to address the opioid crisis in 2012 and developed a number of recommendations focused on 

six areas: patient care; policy development and implementation; 

education; monitoring; medication storage and disposal; and law 

enforcement. 

To address these areas, in March 2016, IHS chartered the National Committee on Heroin, Opioids and Pain Efforts referred to 

as the HOPE Committee. The Committee works to advance the Department’s multifaceted plan to combat opioid abuse including: better prevention; treatment, and recovery services; better targeting of 

overdose reversing drugs; better data on the epidemic; better pain 

management; and better research. 

Our Prescription Drug Monitoring Program policy strengthens 

the monitoring and deterrence of prescription misuse and diversion. It requires IHS providers to check State PDMP databases 

prior to prescribing opioids for longer than seven days. IHS has 

partnered with all States where IHS Federal facilities are located 

and successfully connected so far with 17 out of 18 State PDMP 

databases. As a result, 99 percent of IHS facilities offering pharmaceutical services have access. IHS pharmacies must report opioidprescribing data to State PDMPs, a proactive requirement not currently required by law. 

We are not working alone. IHS partners with SAMHSA to train 

nearly 70 physicians to treat opioid use disorders, increasing access 

to treatment services in tribal communities. In 2008, IHS established a Telebehavioral Health Center of Excellence to provide clinical services, provider education and technical assistance through 

the Indian Health system. This center supports remote, isolated 

Native communities with limited access to behavioral health services. 

We partner with the Bureau of Indian Affairs to train and equip 

law enforcement officers to recognize symptoms of overdose and intervene when necessary. As of December 2017, we have trained 

and provided naloxone at no cost to BIA for more than 300 law enforcement officers. We also certified 47 BIA law enforcement officers as naloxone trainers. 

Addiction is complex but treatable. There is no single treatment 

that is right for everyone. The IHS Alcohol and Substance Abuse 

Program provides funding, training and technical assistance to IHS 

tribal and urban Indian programs. This ensures a variety of treatment options exist. Approximately 90 percent of the fiscal year 

2017 Alcohol and Substance Abuse Program budget of $205 million 

is administered by tribes. 

IHS also supports prevention efforts through the Substance 

Abuse and Suicide Prevention Program. As of fiscal year 2017, program funds are approximately $30 million for 175 IHS tribal and 

urban Indian Health organizations. The funds are used to develop 

and implement culturally-appropriate, evidence-based and community-driven models. We fund 19 projects that focus specifically on 

17 

1https://www.cdc.gov/mmwr/volumes/66/ss/pdfs/ss6619.pdf 

methamphetamine and substance abuse prevention treatment and 

recovery programming. 

The majority of substance abuse and suicide prevention projects 

focus on reducing risk factors for suicidal behavior and substance 

use among Native youth. Furthermore, we work with tribes to develop and implement models of care that are sustainable to combat 

the opioid crisis. We focus on treatments that are evidence-based 

and culturally-appropriate that will have significant impacts on the 

prevention, treatment and recovery efforts. 

IHS collaborates with key stakeholders to develop viable reimbursement models for services provided. This comprehensive strategy will allow for a more unified approach with tribal communities. 

We will continue to work with tribes to develop coordinated responses using every available resource possible to battle the opioid 

crisis in tribal communities. Thank you for your commitment to improving healthcare for American Indians and Alaska Natives by addressing the opioid crisis as a top priority. 

I will be happy to answer any questions the Committee may 

have. 

[The prepared statement of Admiral Toedt follows:] 

PREPARED STATEMENT OF REAR ADMIRAL MICHAEL TOEDT, M.D., CHIEF MEDICAL

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

SERVICES

Chairman and Members of the Committee: 

Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members of the 

Committee. I am Dr. Michael Toedt, Chief Medical Officer, Indian Health Service 

(IHS). I earned my Doctorate of Medicine from the Uniformed Services University 

of the Health Sciences in Bethesda, Maryland. I am board certified in family medicine and I am a fellow of the American Academy of Family Physicians. I have served 

as a Commissioned Officer for 26 years in both the National Health Service Corps 

and the Indian Health Service. Today, I appreciate the opportunity to provide information on the work that IHS has been doing to address the opioid crisis, which is 

a top priority for the Department of Health and Human Services (HHS). 

IHS is a distinct agency in HHS, established to carry out the responsibilities, authorities, and functions of the United States to provide health care services to American Indians and Alaska Natives. It is the only HHS agency whose primary function 

is direct delivery of health care. The mission of IHS, in partnership with American 

Indian and Alaska Native people, is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. The IHS 

system consists of 12 Area offices, which oversee 170 Service Units that provide care 

at the local level. Health services are provided through facilities managed by the 

IHS, by Tribes and tribal organizations under authorities of the Indian Self-Determination and Education Assistance Act (ISDEAA), and through contracts and 

grants awarded to urban Indian organizations authorized by the Indian Health Care 

Improvement Act. 

The impact of the opioid crisis on American Indians and Alaska Natives is immense. The Centers for Disease Control and Prevention (CDC) reported that American Indians and Alaska Natives had the highest drug overdose death rates in 2015 

and the largest percentage increase in the number of deaths over time from 1999– 

2015 compared to other racial and ethnic groups.1 During that time, deaths rose 

more than 500 percent among American Indians and Alaska Natives. In addition, 

because of misclassification of race and ethnicity on death certificates, the actual 

number of deaths for American Indians and Alaska Natives may be underestimated 

by up to 35 percent. 1

Addressing the Opioid Crisis in Indian Country 

IHS recognizes the importance of collaborating and consulting with tribes to develop a comprehensive plan for addressing the opioid crisis in Indian country. IHS 

partners with its tribal advisory committees, including the Tribal Self-Governance 

18 

2 IHS—National Data Warehouse 

Advisory Committee, the Direct Service Tribes Advisory Committee, and the National Tribal Advisory Committee on Behavioral Health to gather input on critical 

next steps to address the opioid crisis. The opioid crisis has been a priority on recent 

meeting agendas for the advisory committees and will be a topic for future meetings 

as well. 

IHS strengthened and prioritized efforts to address the opioid crisis in 2012 and 

developed a number of recommendations focused on six areas: patient care, policy 

development/implementation, education, monitoring, medication storage/disposal, 

and law enforcement. In March 2017, IHS chartered the National Committee on 

Heroin, Opioids and Pain Efforts (HOPE). The HOPE committee, which consists of 

multidisciplinary health care professionals across IHS, works to advance the Department’s multifaceted plan to combat opioid abuse: (1) better prevention, treatment, and recovery services; (2) better targeting of overdose reversing drugs; (3) better data on the epidemic; (4) better pain management; and (5) better research. To 

address better research, IHS partners with the National Institutes of Health on research addressing health disparities and health priorities within Indian communities. 

The HOPE committee is reviewing and updating IHS policies to ensure they are 

aligned with the most current national guidelines and addressing the most urgent 

needs. For example, the IHS ‘‘Chronic Non-Cancer Pain Management’’ policy, originally published in 2014, was re-released earlier this year to align with the 2016 

CDC Guidelines for Prescribing Opioids for Chronic Pain. This policy also requires 

mandatory opioid training for all Federal controlled substance prescribers with required refresher training every three years. 

The IHS Prescription Drug Monitoring Programs (PDMP) policy strengthens the 

monitoring and deterrence of prescription misuse and diversion by requiring IHS 

providers to check state PDMP databases prior to prescribing opioids for longer than 

seven days. IHS has partnered with all states where IHS federal facilities are located and has successfully connected with 17 out of the 18 state PDMP databases, 

allowing access for 82 of the 83 IHS facilities offering pharmaceutical services. The 

IHS PDMP policy also requires IHS practitioners to conduct peer reviews of prescriber activity. Additionally, under the IHS policy, pharmacies must report opioid 

prescribing data to state PDMPs—a proactive requirement not currently required by 

law. IHS is also working to establish two additional policies to expand access to 

medication assisted treatment (MAT), and to standardize how first responders in 

American Indian and Alaska Native communities are provided naloxone, a medication for reversing opioid overdoses. 

To address the shortage of specialists who can provide MAT in rural tribal communities, IHS is training its current workforce to provide these specialty services. 

Over the last two years, IHS partnered with the Substance Abuse and Mental 

Health Services Administration (SAMHSA) to train nearly 70 physicians to obtain 

their Drug Addiction Treatment Act waivers to treat opioid use disorders, which increases access to treatment services in American Indian and Alaska Native communities. In 2008, IHS established the Telebehavioral Health Center of Excellence 

(TBHCE) which provides, clinical services, provider education and technical assistance throughout the Indian health system. The TBHCE was developed to support 

remote and isolated American Indian and Alaska Native communities and areas 

with limited access to behavioral health services. These services directly equip IHS 

staff to reduce morbidity and mortality surrounding the opioid epidemic. Currently, 

the TBHCE is providing training on MAT for opioid use disorder, which uses Food 

and Drug Administration approved pharmacological treatments, in combination 

with psychosocial treatments and social supports. 

Additionally, IHS offers weekly continuing education on pain and addiction as 

well as consultation on complex cases to further train primary care clinicians to provide these specialty MAT services. Consultation is offered through virtual clinics 

hosted by the University of New Mexico to connect primary care clinicians with expert teams to share knowledge and elevate the level of specialty care available to 

patients. There are some promising signs of the positive outcomes as a result of 

these efforts. For example, a preliminary analysis of available IHS data indicates 

a 13 percent decrease in the average number of opioid prescriptions per 100 of all 

IHS users from FY 2013–2016. 2

The Tribal Law and Order Act requires HHS, the Department of Justice, and the 

Department of Interior to coordinate efforts on alcohol and substance use issues in 

Indian country. IHS is actively involved in interagency coordination and collaboration on tribal alcohol and substance use programs. As part of this effort, tribes are 

encouraged to develop Tribal Action Plans (TAP) to address substance use and 

19 

opioid use in their communities. IHS is an integral part of the TAP workgroup that 

works with tribes to help them gain access to government resources and coordinate 

efforts in order to achieve our shared goals of preventing and treating substance use 

disorders. 

IHS partners with the Bureau of Indian Affairs (BIA) to train and equip law enforcement officers (LEOs) to recognize signs and symptoms of overdoses and intervene when the overdose is occurring. As of December 2017, the IHS trained and provided naloxone at no cost to BIA for more than 300 LEOs and certified 47 BIA LEOs 

as naloxone trainers. In direct care facilities, IHS has also been providing naloxone 

supplies, training and tool kits to tribal law enforcement. IHS encourages its pharmacists to co-prescribe naloxone to patients who are at higher risk for opioid overdose based on criteria developed with primary care clinicians, and as a result the 

number of naloxone prescriptions has increased by 518 percent from FY 2013 to FY 

2017. 

IHS has developed a data reporting system that will provide prescribing data on 

national, regional, and local levels. We will track data focusing on the overall improvements and monitoring of prescribing practices and procurement. Regional data 

will be used for comparison with state-level data from the CDC and among other 

facilities in their region, as well as nationally. We will use the information to identify areas of improvement, monitor trends, intervene early and effectively, and enhance efforts to train medical providers. 

IHS Behavioral Health and the Alcohol and Substance Abuse Program 

Addiction is complex, but treatable. Unfortunately, there is no single treatment 

that is right for everyone. The IHS Alcohol and Substance Abuse Program (ASAP) 

provides funding, policy, training, and technical assistance to local IHS, tribal, and 

urban Indian programs to ensure a variety of treatment options exist. Approximately 90 percent of the FY 2017 ASAP budget of $205 million is contracted or compacted by Tribes enabling those programs to deliver treatment services tailored to 

meet their local needs. These programs provide services at all stages of recovery 

from detoxification, behavioral counseling, outpatient and residential treatment, and 

long-term follow up to prevent relapse. 

IHS also targets suicide and substance use and misuse prevention through the 

Substance Abuse and Suicide Prevention (SASP) program. As of FY 2017, SASP 

funds approximately $30 million to 175 IHS, Tribal, and Urban Indian Health organizations to develop and implement culturally appropriate, evidence-based and/or 

practice-based, community driven models. We fund 19 projects that focus specifically 

on methamphetamine and substance abuse prevention, treatment, and recovery programming. The majority of the SASP projects focus on prevention and early intervention strategies to reduce risk factors for suicidal behavior and substance use 

among American Indian and Alaska Native youth. A total of 108 funded projects 

work with Native youth to increase resiliency, teach coping skills, promote family 

engagement, and hire behavioral health providers who specialize in treating children, youth, and families. The SASP program is currently in its third year and IHS 

will evaluate SASP data to better understand the full impact of the program, what 

is working in tribal communities, disseminate best practices, and share lessons 

learned. 

IHS is addressing the need to assist youth with substance use disorders including 

opioid dependency through twelve Youth Regional Treatment Centers (YRTCs). The 

YRTCs provide a range of clinical services to provide treatment rooted in culturally 

relevant, holistic models of care. 

IHS actively solicits feedback and works with the tribes to develop and implement 

models of care that are sustainable to combat the opioid crisis. We focus on treatments that are evidence-based and culturally effective that will have a significant 

impact on the prevention, treatment and recovery efforts. To sustain this strategy, 

IHS is collaborating with key stakeholders to develop viable reimbursement models 

for services provided, while advocating for reimbursement for traditional and culturally based practices, a critical approach to opioid recovery in tribal communities. 

This comprehensive strategy will allow for a more unified approach with tribal communities and also afford IHS the time to evaluate the impact of these interventions. 

IHS will continue to work with Tribes to develop coordinated responses using every 

available resource possible to battle the opioid crisis in tribal communities. 

Thank you for your commitment to improving health care for American Indians 

and Alaska Natives by addressing the opioid crisis as a top priority. I will be happy 

to answer any questions the Committee may have. 

The CHAIRMAN. Thank you. 

We will now start five minute rounds of questioning. 

20 

Captain Jones, your written testimony outlined the Department 

of Health and Human Services’ five point strategy which establishes a framework for substance abuse and mental health services 

and SAMHSA’s efforts to combat the opioid addiction epidemic. 

I would like to hear about benchmarks for success and how you 

gauge the effectiveness of these kinds of programs? What are your 

metrics? 

Dr. JONES. Thank you for the question. 

Through the Department, we are currently working through a 

process to finalize what are the exact measures we want to have 

over time, looking at shorter term behavioral changes, such as 

changes in opioid prescribing, increases in the number of people 

who are receiving addiction treatment, morbidity and mortality 

measures and reductions in emergency department visits and overdose deaths. Through that process of the five point strategy, we are 

working to do that. 

We have not specified exactly what our points of success are but 

we have learned from prior experience that oftentimes, as in the 

case of naloxone, we previously had a goal of increasing by 25 percent the prescriptions dispensed for naloxone. We actually found 

that there was such a tremendous movement at the State level on 

standing orders and other things for naloxone that we saw about 

a 1,000 percent increase. We want to make sure we are calibrating 

this with the facts happening on the ground. It is a process we are 

working through and have not finalized yet. 

The CHAIRMAN. You are setting metrics but are working through 

a process? 

Dr. JONES. Yes. 

The CHAIRMAN. Rear Admiral Toedt, the same question? 

Dr. TOEDT. Thank you, Mr. Chairman. 

IHS has committed to addressing the opioid crisis in American 

Indians and Alaska Native communities. The key to this approach 

is partnering with tribal communities, listening to them and being 

responsive to their concerns. 

Some of the examples IHS is looking at for metrics and is measuring at the national level include pain management and opioid-related policy implementation. This is evidenced on our National Accountability Dashboard which is on our website. 

We are looking at opioid prescribing trends, access to medicationassisted treatment, use of telebehavioral health and naloxone. 

There will be many more metrics that we need to develop. We want 

to partner with tribes to do that. 

The CHAIRMAN. Mr. Anderson, could you talk a bit more about 

the HOPE Initiative? Also, could you touch on why right now the 

High Intensity Drug Trafficking Program is under the control of 

the Office of the National Drug Control Policy and why the Administration wants to move that? 

Mr. ANDERSON. Chairman Hoeven, the HOPE Initiative, as it has 

been coordinated and implemented in my District of New Mexico, 

is a partnership between the U.S. Attorney’s Office in New Mexico 

and the University of New Mexico Health Sciences Center. It has 

a number of prongs including prevention, education, public outreach, law enforcement, as well as rehabilitation and reentry components to it. 

21 

The principal efforts of the HOPE Initiative at this point have 

been public outreach to educate the public, in particular, the youth, 

on the dangers of opioid abuse. In connection with the U.S. Attorney’s Office, the HOPE Initiative has developed an educational program called Roll the Dice that is directed at educating youth on the 

dangers of opioid misuse. That program is culturally tailored for 

presentation in our Native communities. 

The other aspect of this is the Naloxone Initiative. We have been 

at the forefront of educating first responders about the benefits of 

naloxone and educating them about how to properly use that in the 

hope that it is more widely deployed for its live-saving potential. 

The CHAIRMAN. Thank you. 

Rear Admiral Toedt, could you talk a bit about how IHS is doing 

in terms of partnering with State-based prescription drug monitoring programs? 

Dr. TOEDT. Yes, Mr. Chairman. 

Our partnership includes linking the ability for the electronic 

medical record to upload that prescription data to the prescription 

drug monitoring programs. In sites where the Indian Health Service Federal pharmacies exist, we have been able to successfully 

partner with 17 out of the 18 States so far. We are working with 

the final State to connect the prescription drug monitoring programs to the electronic medical record. 

We also work with tribes in their States as well at their request 

if they are using the IHS electronic medical record to link to the 

prescription drug monitoring programs. 

The CHAIRMAN. Are you seeing that making a real difference? 

Dr. TOEDT. Absolutely. Prescribers are able to see which of their 

patients are getting prescriptions perhaps from other providers. 

One of the things patients will do is sometimes they will have to 

seek medications from different providers both inside and outside 

our system. Using the State Prescription Drug Monitoring Database ensures we get the broadest input as to where they may be 

getting prescriptions. 

The CHAIRMAN. Vice Chairman Udall. 

Senator UDALL. Thank you, Mr. Chairman. 

Mr. Anderson, as the new U.S. Attorney for New Mexico, you will 

be directly responsible for upholding the Federal government-togovernment relationship with each of the 23 tribes in New Mexico, 

several of whom you mentioned in your testimony. 

What are your plans to engage with tribes in New Mexico to address public safety issues like the opioid epidemic in Indian Country? 

Mr. ANDERSON. Senator, the United States Attorney’s Office in 

New Mexico has an active outreach program, some of which is 

mandated by statute through the Tribal Law and Order Act. We 

do an annual consultation with all the tribes to address matters of 

concern. 

We also host regular educational outreach and communication 

opportunities. Just last week, prosecutors from my office were presenting to both the Navajo Nation and in the Espanola area on this 

very topic, heroin and opioid awareness. The thrust of that presentation was to educate in particular tribal law enforcement on this 

opioid crisis we are discussing today. 

22 

In addition, my office has a dedicated tribal liaison tasked with 

ensuring open and prompt communication between the U.S. Attorney’s Office and the tribes and ensuring that any issues they raise 

in the course of those communications are properly addressed. 

On a more basic level, line prosecutors in my office routinely 

communicate with their tribal counterparts in tribal law enforcement, in particular, on a case basis. In that context, they address 

any concerns the tribes may have. 

Senator UDALL. Thank you. Can I get your commitment that you 

will meet regularly with New Mexico’s tribal leaders to develop 

your office’s Indian Country public safety priorities? 

Mr. ANDERSON. That is certainly something we are committed to 

doing, Senator. Again, I believe we have an active and robust communication process and will maintain that in the U.S. Attorney’s 

Office. 

Senator UDALL. Just last December, DOJ’s OIG released a report 

confirming what tribes have told us. According to this report, nationally, Indian Country case declinations increased by 20 percent 

between 2013 and 2015. Even more of a concern, the report showed 

the number of referrals from DEA for crimes in Indian Country decreased by 81 percent. 

Based on this OIG report, Mr. Anderson, should DOJ law enforcement and the U.S. Attorney’s Office be doing more to investigate and prosecute drug crimes in Indian Country? 

Mr. ANDERSON. Senator, the U.S. Attorney’s Office and the Department, in general, are committed to robust enforcement of drug 

laws in Indian Country. The DEA is actively involved in that in coordination with the BIA and the Department of Justice and my office will continue to focus on robust enforcement of those laws in 

our tribal communities. 

Senator UDALL. Do you know how many current Indian Country 

cases are pending before your office and how many of those cases 

are drug-related? 

Mr. ANDERSON. Senator, in preparation for today’s remarks, I 

looked into that. I can tell you in fiscal year 2017, we prosecuted 

49 violent crimes in Indian Country cases. That is a subset of the 

total number of cases we addressed in Indian Country. It does not 

include drug crimes, assaults on law enforcement officers or sexual 

assaults in Indian Country which would vastly increase that number. 

We do not track at this point for drug cases, which ones arise in 

Indian Country and which ones do not because it is a statute of 

general applicability but again, I can tell you that in New Mexico, 

enforcement is robust. 

Just last year, we recently did the first Title III wiretap case in 

Indian Country. We also had a substantial seizure of methamphetamine on a case developed and worked on the Navajo Nation. 

Those efforts are ongoing and are certainly a priority for us in the 

Department. 

Senator UDALL. Can I get your commitment that you will speak 

to your Federal law enforcement counterparts about increasing 

their investigation efforts in Indian Country? 

Mr. ANDERSON. Certainly, Senator. We will continue to promote 

those communications. Again, Federal law enforcement is quite acVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00026 Fmt 6633 Sfmt 6601 S:\DOCS\32784.TXT JACK
23 

tive in Indian Country in partnership with the BIA and our tribal 

law enforcement. 

Senator UDALL. Will you also commit to reviewing your office’s 

Indian Country declination rates and working with tribal leaders 

to identify and resolve any barriers to prosecution? 

Mr. ANDERSON. We will certainly do that, Senator. We constantly 

reevaluate the process by which we decline cases. We carefully 

scrutinize those brought to us. We do our very best in that area, 

Senator, and will continue to make that a priority. 

Senator UDALL. Great. Thank you very much. I appreciate it. 

The CHAIRMAN. Senator Lankford. 

STATEMENT OF HON. JAMES LANKFORD, 

U.S. SENATOR FROM OKLAHOMA 

Senator LANKFORD. Gentlemen, thank you for being here and for 

the conversation. You all know this is exceptionally important, not 

only to the Nation, but obviously to Indian Country and all of us 

as well. This is a big issue and affects a lot of families and our communities. 

Let me start where I typically like to start. We have not had an 

opportunity to talk about it. In Indian Country, can you tell me a 

good example in a tribal area either in interdiction, recovery or prevention, any of those three, that you would say this particular tribe 

or this particular location or State is doing an exceptional job in 

one of those three that you can pull out and say what they are 

doing is working? Mr. Anderson. 

Mr. ANDERSON. Thank you, Senator. 

There is always room for improvement in our efforts to combat 

the opioid epidemic. I think we have had successes along the way 

in both the prevention and enforcement areas, recognizing there is 

continued room for improvement in terms of our collaborative efforts with State, local and tribal authorities. 

In New Mexico, we have had some successes to include a prosecution that centered on the Navajo Nation that happened to be a 

methamphetamine case. My office viewed it as a substantial victory 

on the enforcement front against trafficking in Native communities. 

Again, we are tribal partners and are working to improve, recognizing that certainly given the state of affairs, there is room for improvement. 

Senator LANKFORD. Can you give me a good example of any one 

location that really stands out to you more than others at this 

point? 

Mr. ANDERSON. Senator, the case we had on the Navajo Nation, 

I think, was a real victory. 

Senator LANKFORD. I will take that. Any others? 

Dr. TOEDT. Thank you, Senator Lankford. I appreciate the opportunity to highlight a program. 

The Indian Health Service has 12 Federal and tribal youth regional treatment centers. One of those youth regional treatment 

centers, Desert Visions Youth Wellness Center, has made tremendous efforts on incorporating traditional practice into the evidencebased care. It was highlighted in the Surgeon General’s report, 

Facing Addiction in America, as a best practice. Desert Visions 

used dialectical behavior therapy, an evidence-based approach for 

24 

the treatment of substances, while incorporating sweat lodge ceremonies, talking circles and smudging ceremonies. 

Senator LANKFORD. Thank you. 

Captain Jones. 

Dr. JONES. I will just identify Project HOPE which is in Alaska. 

It is not tribal specific but has had a large tribal component that 

uses SAMHSA’s funding for naloxone training. When you look at 

some of the metrics, there were 1,300 people trained, 8,900 

naloxone kits distributed, and 45 overdose reversals. 

In particular, in a very disparate, rural State like Alaska, I think 

this is an example, in particular, of where tribes can engage with 

States. I would highlight that as an example. 

Senator LANKFORD. Captain Jones, we have been able to identify 

exactly the makeup of what is the typical overdose and that individual in Indian Country, male, female, a certain age, and marital 

status. What is the normal on that? 

Again, I know it will be all over the map. Opioid addiction is no 

respecter of persons, but is there something we have identified to 

say is more typical? 

Dr. JONES. I would say the typical makeup of an overdose case 

is not necessarily different among American Indians and Alaska 

Natives than it is for say, non-Hispanic Whites, which the group 

that looks most similar as far as overdose death rates. You tend 

to see higher overdose death rates among males and more than one 

drug involved. Although we often label them as opioid overdose 

deaths, they often involve alcohol or benzodiazepines, and other 

substances of abuse. 

When you look at age groups, it is very interesting because of the 

rise in heroin use and the proliferation of illicit fentanyl and 

fentanyl analogs. We actually now see two age groups that are 

most impacted. 

The highest overdose death rates for fentanyl, synthentic opioids 

and heroin are among 25 to 34 year-olds. For prescription opioids, 

it is 45 to 54 year-olds. For many years, we just sort of saw the 

top point at 45 to 54 but now we see the distribution that is quite 

different depending on the drug. We know those things about individuals. We tend to see variations for more heroin or synthetic 

opioids in more urban areas and rural areas still tend to be heavily 

influenced by prescription opioids. 

Senator LANKFORD. Tell me about the cooperation with the Office 

of National Drug Control Policy and how that is working specifically in coordination with Indian Country because when I see the 

total budget, I have gone through it, for the Bureau of Indian Affairs and drug control funding, it is about $9.7 million. 

Obviously, brings out other areas. What is the cooperation like? 

Obviously that is not going to be enough to be able to cover it. 

Dr. JONES. I will speak from my perspective at SAMHSA. We 

work very closely with ONDCP and other components at the White 

House to plan out the national drug control strategy and the broader framework for addressing substance abuse issues in the U.S. 

From the SAMHSA perspective, in fiscal year 2017, we issued $36 million in substance use funding to tribes. There is about $83 

million currently eligible for tribes in fiscal year 2018 as part of the 

larger pot of grant funding that is available. 

25 

I cannot comment specifically on BIA but we do work closely. 

Senator LANKFORD. You have funding that is separate, BIA has 

funding, and others have funding. I am trying to figure out how the 

coordination between all of those is going as far as planning out 

how it is going to go and where it is going? 

Dr. JONES. ONDCP has responsibility for the drug control budget. They issue letters to departments each year as the budget process is in the works. We respond to those requests from the Department’s perspective. 

We say what is ONDCP asking of SAMHSA in their coordination 

role, we would respond that these are the President’s priorities, 

here is where we think our budget lines up with this or we can add 

money here or there in the budget’s request and then ONDCP, 

OMB and others work out those things. 

Senator LANKFORD. Thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Smith. 

STATEMENT OF HON. TINA SMITH, 

U.S. SENATOR FROM MINNESOTA 

Senator SMITH. Thank you very much, Chairman Hoeven and 

Ranking Member Udall. Thank you very much to all of you gentlemen for being here today. 

I would like to talk with you a little bit and get your thoughts 

on the question of culturally-based treatment and dive into that a 

little more. 

We often talk a lot about the immediate impacts of the opioid addiction on people but also we know we need to think about this in 

terms of two generations or multiple generations. Children of mothers who are addicted to opioids are at risk of being born of course 

with Neonatal Abstinence Syndrome which is a particularly terrible problem. 

The Leech Lake Band in Minnesota has actually declared a public health emergency related to the opioid epidemic in maternal and 

child health because so many babies are being born with Neonatal 

Abstinence Syndrome. 

I would like to hear from Captain Jones or Rear Admiral Toedt 

if you could tell us a little bit about what you are doing to expand 

access to treatment for pregnant women? 

Dr. JONES. Thank you for the question. 

I think this is an important area and certainly an area that has 

received increased attention over the last several years. Our perspective at SAMHSA is that we need to look at this comprehensively, not neonates who are born physically dependent and siloed 

from the mother who was addicted during the pregnancy. 

A couple of programs we have in place are trying to build a comprehensive suite of services to address the needs of mother and 

baby and even family, and include our pregnant and postpartum 

women grant programs. 

We have two different programs. One is a residential-based program. We funded 19 grantees last year. Under CARA legislation, 

we have a new pilot program at the State level for essentially outpatients, trying to move that comprehensive suite of services to the 

outpatient setting. 

26 

We know sometimes going in-patient is very much needed for 

post-partum women or someone who is pregnant. Also that brings 

its own constraints of, how do you manage your responsibilities as 

a parent if you have older kids and trying to make sure those systems are in place to support residential care when needed. Also 

looking at, if we provide high quality evidence-based treatment in 

the outpatient setting, how does that help connect them to the regular part of their day, to other kids or other family responsibilities? 

We are looking at both of those. 

We also have family treatment drug courts which use the drug 

court model but try to address the family aspect of this issue. I 

think across all three of those programs, it is very important that 

it is not just about providing the medication or addiction treatment, it is what are the recovery supports, the housing, employment and what are the other supports that really set a family as 

well as the individual who is addicted up for success as they are 

leaving? 

We have also issued a variety of different guidance documents 

and communications around how to do this in practice. If you are 

not one of our grantees, how do you go about doing it because many 

communities are affected by this? 

Most recently, we issued a clinical guidance for treating pregnant 

and parenting women who have opioid use disorder and treating of 

the infants. It is really the playbook of how the clinicians go about 

doing this in a comprehensive manner. We are trying to address 

both through our funding streams as well as training and technical 

assistance that system that needs to be built to address the needs 

of those individuals. 

Senator SMITH. Thank you very much. I think what you said is 

very important because the old way of thinking about this is to separate moms from their babies. Oftentimes, that is exactly the 

wrong thing to do if you want everyone to recover. 

Dr. JONES. We know people often do much better if they are 

there. Certainly, if you are a mom and preoccupied with thinking 

about what is going on with your kids, it is really hard to pay attention to treatment and address the things right in front of you. 

Senator SMITH. Thank you very much. 

Admiral Toedt, would you like to add anything? 

Dr. TOEDT. Yes, Senator Smith. Thank you. 

I agree entirely with your comment about the importance of 

bonding between mothers and infants. All of our hospitals in the 

Indian Health Service which deliver babies are baby friendly hospitals in support of the mother-baby dyad of keeping them together. 

The Indian Health Service is partnering with professional organizations such as the American College of OB–GYN and the American Academy of Pediatrics to create culturally appropriate guidelines for care such as the Neonatal Withdrawal Syndrome guideline. 

We also are increasing screening to mothers identified as at risk 

who may benefit from early referral to medication-assisted treatment programs. We are increasing the number of treating providers by training nurse practitioners and midwives through inVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00030 Fmt 6633 Sfmt 6601 S:\DOCS\32784.TXT JACK
27 

creased authority through the Comprehensive Addiction and Recovery Act. 

Senator SMITH. Thank you very much. 

Mr. Chairman, I see I am almost out of time but I want to thank 

Senator Lankford for his question about giving us examples of 

what works. 

The CHAIRMAN. I am sorry, Senator Smith. We do not have time 

for thanking Senators. 

Senator SMITH. I am still learning all the rules, Chairman 

Hoeven. 

The CHAIRMAN. Please go ahead. 

Senator SMITH. I appreciated that question. I wanted to mention 

that on the White Earth Reservation in Minnesota, we have a program called the MOMS Program which specifically focuses on what 

we have just discussed, how to help support pregnant women and 

then moms and babies. I think it is a good example of something 

that could be applied in lots of different places. 

Thank you. 

The CHAIRMAN. Thank you, Senator. 

Senator Cortez Masto. 

STATEMENT OF HON. CATHERINE CORTEZ MASTO, 

U.S. SENATOR FROM NEVADA 

Senator CORTEZ MASTO. Thank you. 

Thank you, gentlemen, for being here today. Let me start with 

Captain Jones and Rear Admiral Toedt. 

After talking with our Washoe Tribes of Nevada and California, 

what I am hearing from many of our tribes is that tribal-specific 

funding streams to address the opioid epidemic in our tribal communities was not included in the 2017 State-targeted response to 

the opioid epidemic grants. Is that true? 

Dr. JONES. Correct. The statute basically limits eligibility to 

States. 

Senator CORTEZ MASTO. Don’t you think there should be targeted 

grant funding to address these issues in tribal communities? 

Dr. JONES. We certainly would be willing to carry forward however Congress appropriates or authorizes those dollars. 

Senator CORTEZ MASTO. Are they needed? 

Dr. JONES. I think we have described today that there is a substantial problem in Indian Country. We have taken as many flexibilities as we can. 

Senator CORTEZ MASTO. I will take that as a yes. 

My colleague talked to you about culturally-appropriate treatment. I believe in it. I think not only do we need culturally-appropriate but we need trauma-informed treatment as well. Can both 

of you talk a bit about that? Do you provide trauma-informed treatment as well when we talk about substance abuse needs and treatment in the tribal communities? 

Dr. TOEDT. Yes, ma’am. 

We entirely support trauma-informed care. It is very important 

to get to the root of the problem. So many patients that are seeking 

relief from opioids may actually be suffering from untreated mental 

illness. They may also be suffering from economic disparity, historVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00031 Fmt 6633 Sfmt 6601 S:\DOCS\32784.TXT JACK
28 

ical trauma, or a lot of issues that came up through childhood as 

well. 

Having an understanding of a person’s background and culture, 

where a person is coming from, is very important to being able to 

effectively bond with them, make a connection and deliver effective 

treatment. 

Senator CORTEZ MASTO. Thank you. 

Dr. JONES. I think trauma-informed care and the importance of 

addressing co-occurring substance use and mental disorders are infused throughout our grant programs. 

Senator CORTEZ MASTO. Fantastic. 

Rear Admiral, do you have the resources you need to provide 

that level of care? 

Dr. TOEDT. I appreciate the question. 

The IHS wants to be responsive to tribal concerns. I have heard 

from tribes that there are not enough resources out there. Certainly any funding that Congress can provide will definitely be appreciated. 

Senator CORTEZ MASTO. I also hear from our tribes that it is difficult to get that treatment. I have heard a lot of conversation 

about working with our States but the States already have tapped 

out trying to find the treatment they need for substance abuse 

within their States. 

Requiring our tribes to work with the States to fight for that 

money is difficult and makes it much harder to get the resources 

to our tribal communities. Wouldn’t you agree with that? 

Dr. JONES. I think building the capacity is really the importance 

of the STR funding and other training and technical assistance we 

are applying broadly across the U.S., even specific to tribes around 

training and technical assistance. 

We could have multiple billions of dollars that could be spent on 

treatment but if we do not have providers who can provide that 

care, whether you are in Indian Country or not, you are not going 

to be able to get access to evidence-based care. Really a core part 

of the work we are doing is to build that foundational capacity. 

Senator CORTEZ MASTO. Would you agree that a special behavioral health program for Indians that parallels the structure of the 

existing Special Diabetes Program for Indians to provide substance 

abuse prevention, intervention and other needed behavioral health 

services might be an answer to addressing these substance abuse 

needs in tribal communities? 

Do you think the Diabetes Program is a good model to emulate? 

Dr. TOEDT. Thank you, Senator. 

We absolutely think that the Diabetes Program has been an excellent model. Emulation of that funding model is something we 

have heard from tribes. Yes, it is an excellent idea. 

Senator CORTEZ MASTO. Thank you. 

I have one final question for Mr. Anderson. Thank you for everything you do. 

First of all, I do know U.S. Attorneys and AUSAs across the 

Country are working very hard in our tribal communities. You are 

tapped for resources. I know that. I will say that as somebody who 

worked in my State in law enforcement. 

29 

Chairman Hoeven asked you about the impact of moving HIDTA 

out of the Office of National Drug Control Policy. Can you talk a 

bit about HIDTA and how important those grants are and how effective HIDTA is in our communities? 

Mr. ANDERSON. Senator, HIDTA certainly is an important part 

of what we do with the Federal partnership focusing on those high 

intensity drug corridors throughout the Country. 

In terms of the structure of HIDTA or its funding, that is not 

something I can discuss today but I can tell you that they are, from 

the Federal law enforcement perspective, a critical aspect of our efforts to interdict the flow of illegal drugs, including opioids, heading to and that end up in our tribal communities. 

Senator CORTEZ MASTO. Thank you. Critical and effective, right? 

Mr. ANDERSON. Yes. 

Senator CORTEZ MASTO. Let me just say this. We are combating 

opioids now and it is a crisis across the Country. Ten years ago, 

it was methamphetamines. It is black tar heroin. I can promise you 

that unless we address this through treatment, dollars and fighting, not just assuming law enforcement will do it all, we are going 

to constantly see this shifting from methamphetamines to black tar 

heroin to the opioids in our communities. 

It is a scourge that we need to address. We have to come together on the treatment and law enforcement sides and adequately 

fund in all of our communities, including our tribal communities to 

really combat the crisis we have across this Country. 

Thank you. 

The CHAIRMAN. Senator Murkowski. 

Senator MURKOWSKI. Thank you, Mr. Chairman. 

Gentlemen, thank you all for what you do respectively. I apologize that I was not able to hear some of the colleagues’ questions. 

Again, these are issues that are so key and important. 

Captain Jones, I appreciate you mentioning the Project HOPE 

Program and how it is working or helping in Alaska. 

I mentioned in my opening not just the opioids and how that has 

ravaged us but also alcohol. I will just cite our annual drug report 

which acknowledges the multifaceted drug abuse problem in the 

State. Drug abusers in Alaska tend to abuse more than one substance, oftentimes multiple substances. The drug of choice is alcohol, heroin, meth, cocaine, prescriptions and marijuana. They emphasize that alcohol was the single-most abused substance. 

As we have been focusing our efforts here in Congress on opioid, 

opioid, opioid, I don’t want us to lose sight of the fact that underlying so much of this is alcohol and fail to provide the support for 

programs and grants in that alcohol space as well. When we talk 

about substance and substance abuse, we need to make sure that 

it is alcohol and substance programs. Everyone is shaking their 

heads like you agree with me. We do not need to bifurcate these. 

These are all one big, ugly, horrible problem with which we are 

dealing. 

Let me ask about what I will call a workforce issue. Our reality 

is that we have identified the problem and some of the solutions. 

However, we know so much of this comes back to making sure we 

have mental professionals able to be there, to be that support. 

30 

I have been working with my colleague from Indiana, Senator 

Donnelly, on an effort that would incentivize those to go into substance use disorder treatment work. Basically, it is a loan forgiveness program we think will be helpful in incentivizing more. 

I have to assume part of the challenge we are facing is we simply 

do not have enough mental professionals to help us. Is that so? I 

am getting head nods. We need to work on that as well. 

Here is my question to you. This is intended to help at least 

three individuals in the audience. I met with the Mayor of 

Utqiagvik who is with us today and two others who are part of her 

council. They mentioned that in Utqiagvik, formerly Barrow, the 

issue relating to opioids and drugs, again the intensity we cannot 

single out enough. 

From an enforcement perspective, I will look to you, Mr. Anderson. They say they do not have a district attorney there and that 

prosecution for these drug offenses is not moving forward. 

The drugs come in by mail and plane. We know how they get in 

but we cannot get attention on anything unless it is at the full felony level. People know that they can sell, deal, and use. There is 

no follow up, consequence and no enforcement. 

What would you tell the Mayor of Utqiagvik? 

Mr. ANDERSON. Senator, I would urge the Mayor to work to seek 

Federal grants to develop that type of thing. There are Federal 

grants available through the Department of Justice’s Comprehensive Opioid Abuse Program. I would hope those could be used to 

develop that type of legal infrastructure described in your question 

in posing that issue. 

Certainly it is an important component of addressing this crisis, 

that we have that law enforcement infrastructure in place. I understand that in your State and many of our tribal communities, there 

is a shortage of access to courts and related resources. 

I would urge those communities to apply to the Department’s 

grant program to be able to fund that type of infrastructure. I 

think that is critical to proper enforcement in combating the opioid 

epidemic. 

Senator MURKOWSKI. I appreciate that. 

Mr. Chairman, I also recognize we hear from a lot of our constituents that we are basically setting tribes up to compete with 

other tribes when they all have significant need. You have some 

tribes that perhaps might not have the band width to submit. I 

think a community like Utqiagvik is probably positioned a bit differently. 

It is something I recognize. We have some gaps. We have been 

talking about tribal courts and the opportunities they may present 

to help address some of these issues on the enforcement side. We 

know we have a lot of work to do. 

I am over my time. I could spend all afternoon with you. Thank 

you again and thank you for your work. 

The CHAIRMAN. Senator Tester. 

31 

STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman. 

I want to thank you all for being here. I want to follow up a bit 

on the Ranking Member’s line of questioning on declinations. 

Ten years ago, if my memory serves me correctly, when Byron 

Dorgan was chairman of this Committee, we talked about how declinations were way, way too high in Indian Country. From 2013 to 

2015, the U.S. Attorney’s Office declinations increased by another 

20 percent, according to the Ranking Member’s information. 

In this case, increase is not a good thing. Declinations increased 

by 20 percent. Can you tell me why? 

Mr. ANDERSON. Senator Tester, we are committed, obviously, to 

constantly look at why the declination rate in Indian Country 

moves the way it does. It is an important figure for us to follow 

and to work to reduce that declination figure. 

Senator TESTER. I got you. But that does not answer my question. It does not make any sense to me. Is it that we do not have 

enough FBI agents or you do not have enough people on your staff? 

What is going on? 

As I said, it has been fully 10 years, probably 11, and was probably a problem 10 years before that. I am not blaming you. I just 

need to know why because it is unacceptable. What can this Committee do to make it work so there aren’t these kinds of declinations in Indian Country? In Montana, that is what the highest 

crime rate is. 

Mr. ANDERSON. Senator, I am not sure I can give you an answer 

for why over a period that long, for example, 10 years, the declination rate has gone the way it did. I can hypothesize and am hopeful 

that it may be an increasing number of reported crimes. Obviously, 

every case that is opened by my office in New Mexico is carefully 

examined by an Assistant U.S. Attorney and worked by an FBI 

agent. 

Senator TESTER. I will use the Ranking Member’s numbers 

again. Between 2011 and 2014, the numbers referred to the U.S. 

Attorney’s Office decreased by 81 percent. 

Here is the problem and what I would love to have you do. I 

know you are fairly new to this position. Could you take it back 

to your group and tell us why? That is all I want. Is it because of 

the sovereignty issue and there is no cross work being done as far 

as law enforcement or is it because the FBI has not put enough 

people in this Country? As I said, is it your staff? 

We are not getting it done. I think it is a big issue in Indian 

Country because of violence against women, which could have to do 

with drugs, poverty or something else but it is crimes and is serious stuff. 

I think it is something we have always talked about. People have 

come before committees like this and answered and it continues to 

get worse. This position is not forever for you but maybe it is. Udall 

says you are a good guy, by the way. 

The truth is, in fact, if you can do something about this and give 

us some instruction, put it back on us. Say, Indian Affairs Committee, here is what you need to do and we can get this fixed. We 

would be more than happy to work with you. 

32 

I want to talk to you, Captain Jones. You discussed the budget request for fiscal year 2019 being $10 billion in new resources 

across the Department of Health and Human Services. This follows 

a question maybe Senator Smith asked. 

Would you be opposed, when the Appropriations Committee gets 

done with massaging these numbers, if they carve out a certain 

percentage of that $10 billion for Indian Country? 

Dr. JONES. Again, we are absolutely ready to carry forward what 

direction we get from Congress. 

Senator TESTER. The question is if you oppose it, we will never 

get it done. If you do not oppose it, then we would probably do it 

and get it done. 

Dr. JONES. I will say our posture has been where we have been 

able to be flexible in putting setasides in place, when there is not 

a statutory prohibition that funds can go to different groups, we 

have tried to include tribe in setasides or other means. 

Senator TESTER. I will try, and I think Senator Murkowski would 

probably maybe do the same thing, to peel some of this money off 

and dedicate it to Indian Country. I would hope you would not oppose that when it comes through, okay? That is just a little heads 

up. 

I will make the last thing quick because I know Heidi has some 

important questions to ask you guys. Can the money only be used 

for opioids? Can it be used for meth also? 

Dr. JONES. The STR dollars are an opioid-specific grant but certainly we recognize that individuals have co-occurring disorders 

using other substances. 

Senator TESTER. Are the STR dollars the $10 billion in resources? Is STR what that is called? 

Dr. JONES. The STR Program is the program created under the 

21st Century Cures Act in the 2019 budget. 

Senator TESTER. That is fine, that is different. I am talking about 

the $10 billion of new resources across the Department of Health 

and Human Services. Can that be used for opioids, meth and heroin, as far as that goes? 

Dr. JONES. STR would be a component of that. Under the 2019 budget, that is an increase of $1 billion for the STR Program, 

which is specific to prescriptions or illicit opioid. Heroin would be 

in that group. The specifics of the remainder of the dollars are still 

being worked out. 

Senator TESTER. Would meth be a part of it? 

Dr. JONES. Again, to the extent they are co-occurring and co-use 

of other substances. 

Senator TESTER. But it would not be in and of itself. That is 

good. I would just ask you go back to your people. 

Dr. JONES. I just want to say in the budget, we also have requested $30 million for the Tribal Behavioral Health Grant which 

is much broader. 

Senator TESTER. Did you say $30 million? 

Dr. JONES. Yes, $30 million. Again, we try to be very flexible. 

Senator TESTER. I am way, way over. I would just say we need 

your help on this stuff. This is your budget and not mine. I need 

to know what you had in mind when you crafted your budget for 

this. 

33 

With that, I appreciate you being here. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Heitkamp. 

STATEMENT OF HON. HEIDI HEITKAMP, 

U.S. SENATOR FROM NORTH DAKOTA 

Senator HEITKAMP. Mr. Anderson, I want you to know that I 

have asked all these questions of FBI Director Wray as well, so I 

am not just picking on you. Do you think we need more FBI and 

DEA agents in Indian Country, yes or no? 

Mr. ANDERSON. Senator, I would have to figure it out. I think it 

depends on each specific reservation. 

Senator HEITKAMP. No. I will tell you this. We need more DEA 

and FBI agents in Indian Country. It does not depend on anything. 

The reason why you have declinations is you do not have quality 

investigations. I will tell you that. The other reason why you have 

declinations is because your limit in FBI and DOJ is too high. It 

is too high because you guys treat it the way you would if you 

worked in Indian Country. 

You are the only jurisdiction in Indian Country. When you do not 

show up, we do not have law enforcement. When there is no law 

enforcement, we have mayhem and give out jail free zones for drug 

dealers. 

We have to have protection for people in Indian Country. I can 

tell you it frustrates me to no end to hear a discussion, Captain 

Jones, about well, you know, if you use opioids but maybe you have 

a co-utilization. That is nonsense. Our problem in North Dakota is 

not opioids. It is methamphetamine. It is methamphetamine. It is 

killing whole generations of people in my State. It has to end. 

It has to end first from a law enforcement standpoint. We can 

do all the treatment in the world but if these drugs flow freely into 

Indian Country with no opportunity for change, we will not change 

anything. We have to get law enforcement. 

Mr. Anderson, you are just the brunt of my frustration today. I 

have had this conversation with Directory Wray, the then-nominee 

for the Attorney General and with DOJ officials who deal with Indian Country, on drugs and trafficking in Indian Country. We are 

screaming for help. We are screaming for help. There is no one who 

lives in Indian Country who does not recognize this. I just want to 

read the comments from Vice Chairman Headdress from the Ft. 

Peck Assiniboine and Sioux Tribes who attended our roundtable on 

this issue. 

He asked ‘‘Why service units or tribes cannot funnel some of 

their purchase and referred care dollars for prevention and treatment of opioid misuse?’’ I will tell you in our neck of the woods, 

there does not seem to be a coordinated response to this problem 

in Indian Country. I mean across the board. You see it right there. 

I am telling you we are an endangered species in many tribal organizations. It is because we are losing generations to addiction 

whether it is alcohol, opioids or methamphetamines. I cannot state 

it more clearly. 

We need to do better. Hearings like this give us a chance to vent 

but I hope a unified plan comes out of this. We are all going to supVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00037 Fmt 6633 Sfmt 6601 S:\DOCS\32784.TXT JACK
34 

port setasides. I do not think there is any doubt about it. Maria has 

been working on setasides for tribal organizations. 

To give you just a little example, in my State, the first grants 

that went out, the opioid grants, there were I think seven or eight 

applications. Two were denied; both were in Indian Country. We 

eventually complained and the Governor found some additional 

money to send to Indian Country. 

It has to be culturally significant in the way Senators Cortez 

Masto and Smith discussed. We need a plan. It cannot just be 

about treating the addiction. It has to be a plan about getting law 

enforcement on the ground. I hope you guys will take from this an 

opportunity to sit down and actually come up with a plan in consultation with the tribes because they are screaming for help. 

I ask to tell one story. A friend of mine, Paul Iron Cloud, who 

was Chairman and head of housing for Pine Ridge, came to me in 

one of his last visits. Unfortunately, he died of cancer after his visit 

with me. 

He was very frustrated. He said, ‘‘Senator Heitkamp, we need 

help. We need law enforcement. We need the FBI. We need people 

to come help us.’’ I said, ‘‘Paul, where are the tribal elders and 

where are the tribal communities?’’ He looked at me incredulously 

and said, ‘‘We are afraid. All the good people are hiding. They are 

afraid of what is happening in their homes.’’ 

This cannot continue, not in the United States of America. We 

have murder rates that are unsurpassed in any other part of the 

Country. This is driven by drugs and addiction and we need to get 

to the bottom of this. 

I am pleading with you, on behalf of all the people that I represent who are pleading with me, please, please, please, make this 

a top priority. If you care about law and order, this has to be a top 

priority. If you care about Indian healthcare, this has to be a top 

priority. If you care about changing the dynamic for children in the 

future, this has to be a priority or we will be nowhere. 

I want to thank the Chairman for having the hearing. I want to 

thank this Committee for being so engaged and involved. And I 

want to pledge to you, as Senator Tester did, tell us what you need 

and what will change the outcome. We will work with you to make 

it happen. Tell Director Wray I had some strong words. 

The CHAIRMAN. I would like to thank our witnesses. Members 

may also submit follow-up questions for the record. The record will 

be open for two weeks. I want to thank the witnesses for being 

here and for your testimony today. Panel One is adjourned. 

We will now set up our second panel. We will now hear from our 

second panel. Our witnesses today are: Ms. Jolene George, Behavioral Health Director, Port Gamble S’Klallam Tribe of Kingston, 

Washington and Mr. Samuel Moose, Treasurer and Bemidji Area 

Representative, National Indian Health Board, Bemidji, Minnesota. 

Ms. GEORGE. 

Ms. GEORGE. Thank you, members of the Committee, on behalf 

of the Port Gamble S’Klallam Tribe. 

The CHAIRMAN. Ms. George, I am sorry to interrupt. I understand Senator Cantwell wanted to give you a glowing introduction 

and I do not want to get in the way of that. I apologize. 

Senator Cantwell. 

35 

STATEMENT OF HON. MARIA CANTWELL, 

U.S. SENATOR FROM WASHINGTON 

Senator CANTWELL. Thank you, Mr. Chairman. I know we are 

tight on time because there is a vote. 

I did want to point out that Ms. George is Behavioral Health Director for the Port Gamble S’Klallam Tribe in Kingston. S’Klallam 

means ‘‘strong people,’’ by the way. 

I am really happy she is here because she has been on the front 

lines of the opioid crisis with her tribe and the surrounding community. They have had numerous overdoses and deaths stem from 

the opioid epidemic. Many of these deaths stem from the fact that 

the drugs were prescribed by medical professionals. 

I believe Ms. George will talk about this crisis, how it has impacted families and put a strain on law enforcement and tribal 

services. She is also going to talk about the collaborative approach 

that the Port Gamble S’Klallam Tribe has used to address this 

abuse. 

I think the Federal Government can learn something from her 

and the Port Gamble S’Klallam Tribe in tackling this epidemic. 

Thank you for being here today and thank you for the good work 

in this area. 

STATEMENT OF JOLENE GEORGE, BEHAVIORAL HEALTH 

DIRECTOR, PORT GAMBLE S’KLALLAM TRIBE 

Ms. GEORGE. Thank you again, members of the Committee, on 

behalf of the Port Gamble S’Klallam Tribe, for this opportunity to 

present the impacts of the opioid epidemic on our tribe and what 

we need from Congress to effectively confront this issue. 

I ask that my written statement also be included in the record. 

My name is Jolene George. I am a tribal member and the Behavioral Health Director. We are a federally-recognized, self-governing 

tribe, owning 100 percent of our reservation lands with over 1,200 

enrolled members. 

As this Committee knows, we are disproportionately impacted by 

opioids. The statistics you hear reflect our heartbreaking reality as 

we struggle to confront the drug epidemic caused by opioids flooding our community. Every family on our reservation has been impacted by this epidemic. Many are grieving the loss of loved ones 

because of it. 

At a government level, these impacts cut across all departments, 

complicating funding priorities and creating competition for already 

scarce resources. I shared statistics from our department to highlight the strain on staff and resources. 

At least 75 percent of our substance abuse patients are opioiddependent. These complex patients often utilize behavioral health 

resources at a higher rate than other patients. In our health clinic, 

pain management patients overwhelm the schedule. Our family 

medicine physician has become a pain management specialist. 

In social services, 98 percent of our dependency cases are due to 

drug use. In one year, 100 percent of our housing program evictions 

were drug-related. Creating homeless drug addicts does nothing 

but perpetuate the vicious cycle. 

Opioids have increased crime and police focus on drug interdiction means less time for other police priorities. Our court system 

36 

has had a 90 percent increase in drug and alcohol-related cases 

over the past four years. Again, the impacts of the opioid crisis cut 

across all aspects of our community and our government. 

The opioid epidemic is a complex issue and there is no quick and 

easy fix for resolving it. We need a multi-faceted, comprehensive 

approach with tactics that work. 

We took note of the November 2016 Surgeon General’s report on 

Alcohol, Drugs and Health, which identified prevention as key to 

the fight against abuse and addiction. Our tribe has been working 

to implement just such an approach but we need your help. 

We have shown leadership and are aggressive in our comprehensive response to the opioid epidemic with the following. We have 

developed THOR which stands for Tribal Healing Opioid Response. 

Unique about THOR is the coordination among all departments, 

community engagement and the custom strategies. THOR has 

three main goals: preventing opioid misuse and abuse; expanding 

access to opioid use and disorder treatment; and preventing deaths 

from overdose. We have self-funded the opioid response. 

While we have made a thoughtful and deliberate attempt to combat this epidemic, we still experience many barriers. Adequate and 

direct funding is necessary to continue our coordinate efforts. 

We support Senator Daines’ bill which reflects the governmentto-government relationship and would make the tribes eligible for 

direct funding. Our tribe participated in the Indian Health Service 

Tribal Budget Formulation Work Group and we support that request, including full funding of contract support costs. 

Forty-two CFR Part 2 is our biggest regulatory hurdle towards 

behavioral health integration. Segmented care does not work. 

Health care providers need to see a patient’s complete health 

record, including CD records to provide whole person care. Congress can eliminate this hurdle by aligning the status of chemical 

dependency records with medical and mental health records under 

HIPPA. 

The lack of co-location of primary care and behavioral health 

services on our reservation only adds to our struggle. We look to 

Congress for innovative ideas, perhaps through its infrastructure 

package, for facilitating construction of co-located health care facilities on tribal lands. 

We support Senator Cantwell’s bill, the CARES Act. This is a 

good bill that would increase opioid prevention and treatment funding, limit opioid prescriptions and enhance prescription drug monitoring programs. We appreciate her work on behalf of Indian Country and her early consultation with us on the bill. 

As our chairman said, ‘‘Our tribe has been devastated by this 

epidemic. Opioids keep taking from our community. They have torn 

apart our families and taken away loved ones.’’ It is my hope that, 

with your help and the agencies here, we can put an end to the 

opioid crisis. The Port Gamble S’Klallam Tribe is happy to share 

any of the resources we have developed with other tribes. We formally invite the Committee members to visit our tribe to learn 

more about our ongoing work and continue this discussion. 

I am going to leave with you a postcard with our THOR logo designed by our tribal member and comic book artist, Jeffrey 

Veregge, with our three main goals on the back. 

37 

1 Austin Jenkins, Inslee Wants Washington State to Declare Opioid ‘‘Public Health Crisis,’’ 

KUOW.org (Jan 12, 2018), available at http://kuow.org/post/inslee-wants-washington-state-declare-opioid-public-health-crisis. 2Washington Department of Health Death Certificate Data. 

I thank you for this opportunity to testify and I am happy to answer any questions. 

[The prepared statement of Ms. George follows:] 

PREPARED STATEMENT OF JOLENE GEORGE, BEHAVIORAL HEALTH DIRECTOR, PORT

GAMBLE S’KLALLAM TRIBE

Thank you, members of the Committee, on behalf of the Port Gamble S’Klallam 

Tribe, for the opportunity to present the impacts of the opioid epidemic on our Tribe, 

our response, and what we need from Congress in order to effectively confront this 

issue. 

I. About the Tribe, our Health Care System and Relevant Programs 

The Port Gamble S’Klallam Tribe is a federally recognized, self-governing tribe 

owning 100 percent of its reservation lands. We are located on the northern tip of 

the Kitsap Peninsula in Kitsap County Washington. The Tribe’s Reservation is 

home to about two-thirds of the Tribe’s 1,200 enrolled members. The Tribe is the 

only Indian health care provider of both primary and behavioral health services in 

Kitsap County, and proudly provides culturally appropriate health care to our members and approximately 800 other American Indians and Alaska Natives (AI/AN) 

and community members living on our Reservation. 

The Tribe joined the Tribal Self-Governance Project, a consortium of self-governing Indian Tribes, in 1990 and has directly provided health services to its members for over 20 years. We fund our health services though a compact with the Indian Health Service under the Indian Self-Determination and Education Assistance 

Act, and operate and manage our entire health system on our Reservation. 

Our health system includes primary care, dental, mental health and substance 

abuse services. We provide our primary care services out of our outpatient primary 

care health clinic, which is staffed with 2 physicians, a physician assistant, and 4 

registered nurses. Our dental building is next door and includes 2 dentists, 1 dental 

health aide therapist, and a dental hygienist. Our behavioral health clinic is approximately two miles away. It includes 1 physician, 1 Advanced Registered Nurse 

Practitioner (ARNP), 4 substance abuse counselors, 5 mental health counselors and 

2 prevention specialists. It provides outpatient substance abuse treatment, relapse 

prevention, group, individual and family mental health counseling, psychiatric evaluation and medication management, and Medication Assisted Treatment (MAT). 

Over 98 percent of our behavioral health clients are also served by our primary care 

clinic. Community Health Representatives and transporters fill an essential role for 

both clinics, providing clinical linkages to the community and transportation services. 

In addition, relevant to the opioid issue, our Tribe operates a police department, 

which consists of nine officers and places a strong emphasis on community-oriented 

policing for all residents and visitors. We also operate a Tribal Court with jurisdiction over criminal, civil and juvenile matters. Appeals are heard by our three-judge 

Court of Appeals. 

Our Children & Family Services Department includes our Behavioral Health Division and the Community Services Division and works to enhance the quality of life 

of our Tribal members and their families through a culturally sensitive approach 

that encourages living a healthy lifestyle and promotes self-sufficiency. The Port 

Gamble S’Klallam Tribe operates all eligible programs under Title IV of the Social 

Security Act; Temporary Assistance to Needy Families (TANF) Part A, Child and 

Family Services (Part B), Child Support (Part D), and lastly, Foster Care and Adoption Assistance (Part E). 

II. Impacts of the Opioid Crisis on the Tribe 

In Washington State, the Native American overdose rate is more than twice as 

high as that of white Washingtonians. 1 The data shows that AI/AN in Washington 

State die of drug overdoses at a rate of 34.4 per 100,000 people, more than twice 

the rate of the next highest group (15.1 for Pacific Islanders), and almost three 

times that of whites at 12.4 and African Americans at 12.3. Other rates are 1.1 per 

100,000 for Latinos, and 1.2 for Asian Americans. 2 For every opioid overdose death, 

38 

3 National Institute on Drug Abuse. Opioid Abuse Crisis. Available at https:// 

www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis (last accessed March 8, 2018). 4Dan Nolan and Chris Amico, How Bad is the Opioid Epidemic?, PBS.org (Feb. 23, 2016), 

available at https://www.pbs.org/wgbh/frontline/article/how-bad-is-the-opioid-epidemic/ (last 

accessed Feb. 27, 2018). 5 CDC Morbidity and Mortality Weekly Report (MMWR), available at https://www.cdc.gov/ 

mmwr/volumes/66/ss/ss6619a1.htm?slcid=ss6619a1lw (last accessed March 8, 2018). 6 National Congress of American Indians, Reflecting on a Crisis Curbing Opioid Abuse in Communities (Oct. 2016), available at http://www.ncai.org/policy-research-center/research-data/ 

prc-publications/OpioidlBrief.pdf (last accessed Feb. 27, 2018). 

there are 10 treatment admissions for abuse, 32 emergency room visits, 130 people 

who are addicted to opioids, and 825 nonmedical users of opioids. 3

Misuse of prescribed opioids frequently leads to other drugs such as heroin. According to the National Institute of Drug Abuse, 21 to 29 percent of patients prescribed opioids for chronic pain misuse them, and 4 to 6 percent who misuse prescription opioids transition to heroin. About 80 percent of people who use heroin 

first misused prescription opioids. The death rate for heroin overdoses among Native 

Americans has also skyrocketed, rising 236 percent from 2010 to 2014. 4

The CDC reports that American Indians/Alaska Natives had the highest national 

drug overdose death rates of any race in 2015, and a 519 percent increase in the 

number of non-metropolitan overdose deaths from 1999–2015. 5 Alarmingly, approximately 1 in 10 American Indian youths ages 12 or older used prescription opioids 

for nonmedical purposes in 2012, double the rate for white youth. 6

These statistics reflect the heartbreaking reality on the Port Gamble S’Klallam 

Reservation as we struggle to confront the drug epidemic caused by opioids flooding 

our community. We have had numerous overdoses and deaths in our community as 

a result of the opioid crisis, and not only from the vast supply of drugs available 

on the black market. It has been estimated that approximately 60 percent of the 

opioids that are abused come, directly or indirectly, through doctors’ prescriptions. 

On our Reservation, the deaths include members who were prescribed opioids as 

pain medication and accidentally overdosed. In the recent past, the Tribe experienced an overdose by a young mother and the death of a toddler, just two years 

old, who got into his parents’ opioid medication. We have grieving children, parents, 

grandparents, and great-grandparents who have lost family due to this scourge. 

Every family on our Reservation has been impacted by this epidemic. 

At a government level, these impacts cut across all departments, complicating 

funding priorities and creating competition for scarce resources. Our Health, Behavioral Health, Children & Family Services, and Housing Departments, as well as our 

courts, law enforcement, and administration, all have a role to play in responding 

to this crisis. 

Our Children & Family Services Department feels the effects of the opioid crisis 

acutely. One of its roles is to keep children with their families. When children are 

removed, we have both relative placements and 20 Tribal licensed foster homes, but 

the increased number of dependency cases due to opioid abuse or overdose has challenged our capacity. Opioid abuse impacts the whole family. Our Tribal member 

grandparents are often raising their grandchildren. In addition to this role, they 

often struggle to help their own child who is suffering from addiction. 

One specific example of the impacts we face involves dependency cases that the 

Tribe files to ensure a child’s safety and well-being. Ninety-eight percent of all dependency cases are due to drug use. In the first eight weeks of 2018, the Tribe filed 

four new dependency cases, three of which were related to parent(s) opioid abuse. 

This already surpasses the total new cases filed in 2017. These new cases are in 

addition to the open dependency cases that the Tribe has already filed. 

The increased number of dependency proceedings burden existing child welfare 

services staff and resources, and require additional hires. Every child who comes 

into the Tribe’s care and custody needs an array of intervention and services, including mental health counseling, medical services, substitute care, and housing. The 

parents who survive need treatment and counseling as well. Children who are exposed to opioids in utero suffer from opioid withdrawal and Neonatal Abstinence 

Syndrome, and often bear scars that will last a lifetime. These infants are immediately transferred to a neonatal intensive care unit for a period of days, weeks, or 

even months, frequently requiring emergency evacuation for care to save the infant’s life. Such emergency transportation costs the Tribe thousands of dollars for 

each occurrence. 

The crisis has forced the Tribe to staff new positions at great expense, including 

additional substance abuse counselors to deal with the substantial increase in opioid 

addiction, a nurse specializing in substance abuse disorders for case management 

39 

related to the opioid epidemic, and physicians to provide Medication Assisted Treatment with drugs such as naltrexone for opioid addiction and abuse. 

The Tribe has provided naloxone HCl, also known as ‘‘Narcan’’, a nasally administered overdose reversal drug, and the training to use it, to all law enforcement personnel and natural resource officers. Due to their work in the field in our Tribal 

community, those officers and personnel regularly encounter individuals suffering 

from opioid overdose symptoms who can only be assisted and saved from death by 

timely administration of Narcan. The Tribe provides Narcan and training in its use 

to other members of our community, because the need for such emergency treatment 

is severe. Approximately 120 Tribal members have been provided with Narcan and 

trained on how to administer the drug. These steps are necessary, but they also cost 

money, which affects our Tribe’s budget and priorities for budget spending. 

In terms of housing, the Tribe receives federal funding under the Native American 

Housing Assistance and Self-Determination Act (NAHASDA) to develop and operate 

affordable housing for low-income Indian families. Due to the substantial increase 

in opioid abuse, the Tribe has seen a parallel increase in evictions of Tribal members and other Indian families (since NAHASDA requires all leases to have language authorizing eviction for ‘‘drug-related criminal activity’’). When those families 

are evicted from the Tribe’s housing they generally become homeless, and as a result they are then in even greater need of social, medical, and child welfare services 

from the Tribe. 

The opioid crisis is overwhelming to our law enforcement and social services programs as they are not presently resourced sufficiently to meet the needs arising 

from the opioid epidemic. We are working as hard and as efficiently as we can with 

the resources we have, but additional resources in terms of funding, personnel and 

authorities are needed to combat the myriad problems the opioid crisis causes. 

This epidemic is a complex issue, and there is no quick and easy fix for resolving 

the problem. Rather, we need a multifaceted, comprehensive approach with tactics 

that work. Our Tribe has been working to implement just such an approach, but 

we need your help. 

III. What Port Gamble S’Klallam Tribe is Doing to Combat the Crisis 

The Tribe has shown leadership in its aggressive and comprehensive response to 

the opioid epidemic through our cross-governmental Tribal Healing Opioid Response 

(THOR) program, collaboration with Washington State, through participation in the 

Three County Coordinated Opioid Response Project (3CCORPS), and, most recently, 

like many other state and tribal governments, by seeking to cut the flow of opioids 

into our community by filing a lawsuit against the manufacturers and distributors 

of these drugs. 

A. THOR—Tribal Healing Opioid Response 

The Tribe convened two Tribal town hall meetings last year to share the local impacts of the opioid crisis and determine a path forward. The extraordinary attendance at these community events demonstrated the intense and widespread impact 

of the crisis. Our Tribal Council then met with Kitsap County officials to discuss 

a response to the opioid crisis. The Tribe recognized that the crisis affects all our 

members and Tribal agencies and requires a cross-government response. These efforts led to the creation of our Tribal Healing Opioid Response, a project led by the 

Tribe’s Behavioral Health and Health Services Departments. THOR is now the 

heart of our opioid response on our Reservation. 

THOR has three main goals, and Departments across the Tribe—not just healthrelated entities—are responsible for achieving them. These three main goals and the 

associated strategies are: 

(1) preventing opioid misuse and abuse by changing prescription practices, raising awareness of the danger of overdose, youth prevention programs, safe 

storage and disposal education, and drug supply reduction; 

(2) expanding access to opioid use disorder treatment by training health providers to recognize disorder symptoms, increasing access to treatment, applying treatment practices in the criminal justice system, implementing syringe exchange and overdose prevention/treatment training, and reducing 

instances of opioid withdrawal in newborns; and 

(3) preventing deaths from overdose by educating the Tribal community in how 

to recognize and respond to an overdose, and expanding access to overdose 

reversal medication. 

Since January 2017, the Tribe has convened monthly THOR workgroup meetings 

composed of Tribal Council Members, Department Directors, staff, and other community members to implement the THOR goals. The workgroup is responsible for 

40 

7Tribal Healing Opioid Response Program, https://www.nihb.org/docs/12032017/ 

Tuesday%20Sessions/THOR%20Presentation.pdf (last accessed March 11, 2018). 

developing, reviewing and updating the Tribe’s local response plan. It reviews the 

statewide opioid response plan and other best practices, identifies appropriate strategies, and assigns tasks and responsibilities to workgroup members. 

Significantly, our Tribe took note of the November 2016 Surgeon General’s Report 

on Alcohol, Drugs and Health which identified prevention as key to the fight against 

abuse and addiction. We pulled strategies from this report and put them into practice in our effort to get ahead of potential addictions by creating a Prevention Team. 

Our Prevention Team is responsible for numerous programs that focus on youth and 

using evidenced-based approaches to keep youth active in the community. The youth 

services program offers extended hours, a safe space, and education about substance 

abuse and suicide prevention 6 days a week. Through our Chi-e-chee Tribal Coalition, we collaborate with adults in the community and provide substance abuse education and prevention activities to adults and families. Chi-e-chee can be translated 

to ‘‘the workers or the do-ers.’’ The coalition has been active for over 20 years and 

is identifying and implementing events and activities around issues that are significant to our community. 

The Tribe provides education to the community, focusing on pain treatment with 

exercise, mental health and non-opioid medications. Our ultimate goal through this 

effort is to significantly reduce the number of opioid prescriptions. Town hall meetings are held quarterly to help educate the community on current issues/topics that 

are significant to the community and are well attended. 

THOR assigns specific responsibilities to each of the Tribe’s departments to reach 

the THOR goals. 7 For prevention, the Health Department is responsible for promoting best practices in prescribing and promoting safe storage and disposal of prescriptions; the Behavioral Health Department is responsible for awareness programs; Chi-e-chee is responsible for preventing misuse in youth; and the Police Department is responsible for attempting to interdict and decrease the supply of illegal 

opioids. For treatment, the Health and Behavioral Health Departments, along with 

the Police Department, train providers to recognize abuse, and the Behavioral 

Health Department, Health Department and Re-Entry Program work together to increase access to treatment and offer syringe and needle exchange. To prevent overdose deaths, Chi-e-chee, Human Resources, Behavioral Health and Health work together to educate the entire community to recognize and respond to overdoses, including through the administration of naloxone. 

As a tribal government, we are focused on providing culturally appropriate treatment to our members suffering from opioid addiction and the host of health and 

mental health issues that come with it. These include programs such as our 

wellness activities, talking circles, and group therapy. The Healing of the Canoe 

Project is a collaborative project among the Port Gamble S’Klallam Tribe, the 

Suquamish Tribe, and the Alcohol and Drug Abuse Institute at the University of 

Washington. Its central mission is to develop a life skills curriculum for tribal youth 

that includes drug abuse materials. The Project has made its curriculum available 

and has trained a total of 350 attendees from 46 Tribes and 14 tribal organizations 

in how to adapt and implement the curriculum. 

One of central reasons why our THOR program is so effective is because the Tribe 

is not only a health care provider for our community, we are also a government with 

the ability to coordinate with State, County, and regional groups. Our clinics, Police 

Department and social services departments have the ability to quickly work 

through bureaucracy for cross departmental collaboration, providing better services 

to both Tribal members and the community as a whole. 

B. Collaboration with Washington State and Accountable Communities of Health 

(ACH) 

Washington State has a Section 1115 waiver under the Social Security Act which 

funds experimental, pilot, or demonstration projects that are found by the United 

States Secretary of Health and Human Services to be likely to assist in promoting 

the objectives of the Medicaid program. These demonstration projects provide states 

additional flexibility to design and improve their programs with an eye toward evaluating state-specific policy approaches to better serve Medicaid populations. 

Through its Section 1115 waiver authority, Washington State has created Accountable Communities of Health, which bring together leaders from multiple health sectors around the state with a common interest in improving health and health equity. ACHs seek to align resources and activities to support wellness and a system 

that delivers care for the whole person. ACHs are also working to shift health care 

41 

8 ‘‘Can This Judge Solve the Opioid Crisis?’’, New York Times, March 5, 2018, available online 

at https://www.nytimes.com/2018/03/05/health/opioid-crisis-judge-lawsuits.html, (last 

accessed March 8, 2018). 

reimbursement strategies away from a system that pays for volume of service to one 

that rewards quality and outcomes. 

Through the Section 1115 waiver and the creation of these ACHs, the Tribe has 

been able to form partnerships that were not otherwise easily accessible or workable. Now, on the opioid issue, specifically, the Tribe has multiple partners at different levels with whom it can and has been coordinating to develop and implement 

a variety of tactics to address the many issues arising from the epidemic. The Tribe 

collaborates with Washington State on the Washington State Opioid Response Plan 

and, on the regional level, the Olympic Community of Health (OCH) which is implementing the Three County Coordinated Opioid Response Project (3CCORPS). 

C. Olympic Community of Health and 3CCORPS 

OCH is an Accountable Community of Health whose objectives are to improve patient care, reduce the cost of health care and improve the health of the population 

in Clallam, Jefferson and Kitsap Counties. Each of the seven Tribal Nations within 

the three county region, including our Tribe, is represented on the OCH Board of 

Directors. 

3CCORPS, OCH’s specific opioid response, was launched in September of 2016 

and convened an opioid summit in January 2017. It was not long before this summit 

that one of our Tribal members died due to missing a dose of naltrexone. This tragedy spurred momentum for our Tribe’s active opioid response. 

3CCORPS is currently in the implementation phase of its opioid response plan. 

Addressing the opioid epidemic is a required project in the Medicaid Transformation 

Project (MTP) of the OCH. 3CCORPS’ foundations are the same 3 goals and strategies that the Tribe has adopted and adapted as our own opioid response plan. They 

also align with the statewide plan. The alignment of goals and strategies allows for 

quick duplication of evidence-based strategies and the ability to coordinate within 

the broader regional and state level, and also facilitates evaluation and data collection efforts. 

3CCORPS is our work on the regional level with the OCH. Other groups that participate in 3CCORPS are independent clinics, police departments, and social service 

agencies that serve many different communities. 

D. Litigation to Curtail Oversupply of Opioids 

On March 5, 2018, the Port Gamble S’Klallam Tribe, along with the Suquamish 

Tribe and the Jamestown S’Klallam Tribe, filed a complaint in federal district court 

naming various opioid manufacturers and distributors, including Purdue Pharma 

LP, McKesson Corp., Cardinal Health Inc., AmerisourceBergen Corp. and others. 

Our complaint alleges that these companies spread false and misleading information 

about the safety of opioids, negligently created an illicit market for opioids, and 

failed to control the flow of opioids to our Tribal members. The complaint details 

the same devastating impacts that we report to you today, and asks the court to 

find that the defendants broke the law though fraud, negligence, public nuisance, 

violation of Washington State consumer protection laws, other laws, and racketeering. Through the lawsuit, we seek compensation for the cost of responding to and 

treating opioid-related addiction and punitive damages. In filing this lawsuit, we 

join over 400 other plaintiffs across the country, 8 including state and tribal governments, in seeking to hold these companies accountable for the destruction caused 

by the opioid crisis. 

IV. Lessons Learned and Strategies All Tribes Can Choose to Put in Place 

A. Cross-Government Coordination 

Through THOR and our 3CCORPS program with the OCH, we have learned many 

lessons in the fight against opioid addiction and efforts to treat those affected. At 

the forefront, we learned that coordination and communication across our government is key as well as ensuring that all of our Departments pitch in to the effort 

however they can. As the opioid epidemic affects all facets of our community, we 

have taken an ‘‘all-hands-on-deck’’ approach as a government. As explained above, 

we draw on any and all of our Departments that can help so that we can attack 

the crisis from many angles. Our monthly THOR workgroup meetings have been 

key to synchronizing our programs and generating action items to address the 

opioid problems in our community. 

42 

B. Culturally Appropriate Care 

Recognizing that traditional healing practices, cultural beliefs regarding approaches to treatment, and differences in interpersonal communication contribute to 

significant variances in effectively meeting the healthcare needs of AI/AN, cultural 

competency is an inherent part of who we are, who we serve and what we do. 

C. Abuse Prevention 

Prevention is the cornerstone for any opioid response, as the Surgeon General’s 

Report on Alcohol, Drugs and Health (November 2016) states. We realize that availability of resources is different in different parts of Indian Country. Yet, there are 

strategies that any Tribe can put into place in its fight against the opioid epidemic. 

Our Tribe has a ‘‘toolkit’’ which we share with other Tribes in their opioid fight. 

We are happy to share our ‘‘toolkit’’ with any Tribe who would like access to it. Our 

‘‘toolkit’’ includes: 

(1) Our Pain Agreement—used in the clinic for clients with opioid prescriptions 

for chronic pain; 

(2) Our Narcan Standing Orders & Policy—provides Narcan to any Tribal member or household that requests it, and to any patient with an active opioid 

prescription; and 

(3) Our Good Samaritan Tribal Code—provides liability protection for those who 

act in good faith and seek medical assistance for any person who is experiencing a drug-related overdose. 

Collaborating with federal agencies has been very helpful in our Tribe’s fight 

against the epidemic. We suggest that Tribes regularly call upon their regional federal agency officials from IHS, SAMHSA, HRSA, BIA, DOJ, and others. These agencies have resources, technical assistance and connections that they can share. Further, Tribes may find that partnering with their neighboring governments on this 

particular issue yields a variety of benefits. Accessing additional resources is always 

a benefit, whether they are financial resources or non-financial resources such as 

experience, expertise and technical assistance. Brainstorming and sharing ideas 

with federal agencies and neighboring governments with mutual interest in stemming the opioid crisis can lead to innovation and cooperation. 

The Tribe has benefited from having close collaboration with federal agencies at 

the regional level. The Acting Regional Director of the Department of Health and 

Human Services (HHS), and the Regional Director of the Substance Abuse and Mental Health Services Administration (SAMHSA), have both visited the Tribe recently, 

participating in robust discussions on opioid prevention. As a specific example, our 

SAMHSA discussion helped clarify 42 CFR Part 2 updates and requirements. 

V. Barriers and Needs to More Effectively Fight the Opioid Crisis 

A. Funding Needs 

There are several barriers that Tribes face in their efforts to overcome the opioid 

epidemic. We have run into several. 

1. Adequate Funding and Direct Funding 

Adequate funding to combat this behemoth opioid crisis is, of course, a major barrier. Getting funding out to Tribes for their on-the-ground work is an issue not only 

in the amounts, but also in the manner in which such monies flow to Tribes. We 

strongly encourage Congress to not only work on increasing available funding, but 

to also provide direct funding to Tribes and ensure that any additional funds for 

opioid crisis response do not decrease services in other areas. 

We truly appreciate Congress’s inclusion of authorization for $6 billion over 2 

years for opioid efforts in the recently passed Bipartisan Budget Act of 2018. We 

ask the Committee to advocate for full funding of the authorization and ensure that 

these funds go directly to tribal governments for them to spend in their own communities. Such funds should not be passed through the States. Direct funding of tribal 

programs is important as it ensures that funds are available to tribal governments 

like ours that have culturally appropriate programs and mechanisms in place for 

fighting the opioid epidemic. 

An important bill that includes the requested direct funding mechanism is S. 

2270, the Mitigating the Methamphetamine Epidemic and Promoting Tribal Health 

Act. This bill, introduced by Senator Daines, a member of this Committee, would 

make Tribes and tribal organizations eligible for direct funding under the 21st Century Cures Act, which provides an allocation to states for opioid prevention and response. S. 2270 would allow such allocation to also be used for prevention and reVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00046 Fmt 6633 Sfmt 6621 S:\DOCS\32784.TXT JACK
43 

9 2019 Budget in Brief https://www.hhs.gov/sites/default/files/fy-2019-budget-in-brief.pdf. As 

of the preparation of this testimony, HHS has not released its detailed FY 2019 Budget Justification, including for IHS. 10 Id. 

sponse for other substances, such as methamphetamines, if they are having a substantial impact on the state or Tribe. 

2. Full Funding of IHS Budget 

Additionally, we ask you to work toward providing sufficient funding to the Indian 

Health Service (IHS) for opioid treatment and prevention. The FY2019 Budget Request provides $10 billion in new resources across HHS to combat the opioid epidemic and address serious mental illness. As part of this effort, the Budget Request 

includes an initial allocation of $150 million to IHS to provide multi-year competitive grants based on need for opioid abuse prevention, treatment, and recovery support in Indian Country. 9

The Public Health Service Commissioned Corps plays a vital role in providing direct patient care throughout the Indian Health Service, and also has a direct role 

in the work of Tribes combating the opioid crisis. Any restructuring of the Corps 

should be done in close collaboration and consultation with Tribes. 

The FY 2019 Budget Request eliminated both Community Health Representatives 

and Health Education from the IHS budget. These two line items support the front 

line work of Tribes and the IHS on both the opioid crisis and daily operations and 

patient care. 

They need to be restored. 

3. Full Funding of Contract Support Costs 

The FY 2019 Budget Request fully funds Contract Support Costs at an estimated $822 million and continues the use of an indefinite appropriation, which allows IHS 

to guarantee full funding of this program. Funding for Contract Support Costs supports the costs incurred by Tribes for activities that are necessary for administering 

health care service programs under self-determination contracts and self-governance 

compacts. 10 This is an important funding mechanism for self-governing Tribes like 

ours to administer our opioid prevention and treatment programs. 

B. Barriers Beyond Funding 

1. Regulatory Hurdles 

There are several barriers in the fight against the opioid crisis that are beyond 

funding. One such barrier relates to funding, but is an administrative limit on accessing already available funding. The Health Resources and Services Administration (HRSA) has behavioral health integration funding available, but it is restricted 

to rural locations. Kitsap County does not qualify as ‘‘rural’’ and so the Tribe is ineligible for these grants. We recently raised this issue to HRSA, and received assurances that this issue would be addressed. However, it would be helpful for members 

of Congress to encourage HRSA to reconsider the rural restriction and develop a 

mechanism for channeling such monies to Tribes. This could be through revising the 

definition of ‘‘rural’’ to include Tribes regardless of location or ‘‘geographic trait’’ of 

its reservation. 

2. Barriers to Medication Assisted Treatment 

We also want to point out certain other barriers to our efforts to combat the opioid 

crisis. Current regulations impose onerous training and waiver requirements for 

providers of Medication Assisted Treatment (MAT) prescribing drugs such as 

buprenorphine, even though no such limitation exists on providers prescribing 

opioids. This creates barriers to accessing MAT. Medicaid dollars used to fund transportation to opioid services could be reduced significantly if buprenorphine, an 

opioid addiction treatment drug also known as Suboxone, was easier to access at 

primary care facilities. Those saved funds could be used for prevention or treatment. 

In addition, nurse care management as an adjunct to MAT has been shown to be 

successful and is an evidence-based practice in treating opioid addiction. We need 

to expand Tribes’ access to this treatment. 

3. Physician Access to Medical Records 

Federal regulations at 42 CFR Part 2, related to the privacy of substance abuse 

treatment records, currently prevent the Tribe’s primary care and mental health 

providers from accessing patient records from dependency providers so the whole 

person can be treated. 

This lack of access is a barrier to coordinated, safe, and high-quality medical care 

and can cause significant harm. Part 2 regulations may lead to a doctor treating 

44 

a patient and writing prescriptions for opioid pain medication for that individual 

without knowing the person has a substance use disorder. 

In August 2017, Congressmen Tim Murphy and Earl Blumenauer introduced bipartisan legislation that would help align 42 CFR Part 2 with HIPAA rules, ensuring that substance use disorder patients can receive proper care while their data 

remains secure. The Overdose Prevention and Patient Safety (OPPS) Act (HR 3545) 

allows access by doctors to patients’ full medical records with all the safeguards of 

HIPAA, but also makes use of such information in criminal investigations unlawful. 

The Tribe joins others such as the Partnership to Amend 42 CFR Part 2, a coalition 

of over 20 healthcare stakeholders including the American Hospital Association, in 

support of HR 3545. 

4. The Lack of Co-location of Health Services on Our Reservation 

The Tribe is actively working to align substance use disorder treatment with primary care to address a person’s overall health, rather than treating it as a substance misuse or a physical health condition alone or in isolation. As stated, our 

Health Facility and Dental Facility are nearby each other, but our Mental Health 

Facility and Rehabilitation Facility are some distance away. This causes extra administrative burden and expense of resources. Co-locating these services would improve behavioral health integration, but a new integrated facility for all health services would cost over $8 million dollars. We suspect other Tribes face similar problems with respect to the lack of co-location of services. We look to Congress for innovative ideas, perhaps through its infrastructure package, for facilitating the construction of co-located health care facilities on tribal lands. 

5. The Need to Modernize the IHS’s Health Information System 

This issue impacts the ability of Tribes to confront the opioid epidemic. Barriers 

to integration within the health information system are being addressed at significant cost to the Tribe as we left the Indian Health Service RPMS system for direct 

patient care documentation years ago, although we continued to utilize that system 

for Purchased & Referred Care (PRC). The system we use, NextGen, is adequate 

for primary care, but has limitations for mental health and substance abuse. This 

has impacted our behavioral health integration work. 

The Veteran’s Administration announcement that it will pursue a contract with 

Cerner as a replacement for the RPMS Parent system may provide an opportunity 

for both IHS and Tribes. IHS needs to ensure that the replacement of RPMS will 

include options for non-RPMS tribes and pathways for cost saving programs such 

as the VA Consolidated Mail Outpatient Pharmacy Service (CMOPS). 

6. The Need for Pilot Projects for Residential Post-Treatment Facilities on Tribal 

Lands 

Our Tribe is particularly interested in initiating a pilot program for residential 

post-treatment facilities. The Tribe would like to provide treatment and support 

past the prevailing 28-day model, utilizing evidenced-based practices with a robust 

evaluation component. The Tribe has partnerships with Oxford House and Habitat 

for Humanity to construct and operate such facilities, and is well positioned to start 

such a pilot program. We ask Congress to support the establishment of a pilot program by an agency such as SAMHSA, HUD, or IHS to fund residential post-treatment facilities on reservations to be operated by Tribes for their members and families. 

7. Lack of Easy Access to Methadone Clinics 

Our Tribal Members must travel to Tacoma or the greater Seattle area to a methadone facility to receive such treatment. We are working with OCH to obtain a 

methadone facility in Kitsap County to save our Members the burden and cost of 

traveling so far for that treatment. We ask Congress to consider ways it can facilitate the construction and operation of these facilities in locations accessible to tribal 

and rural communities like ours. Kitsap County, where we are located, has a restriction limiting service to one methadone clinic in the county. This limitation hampers 

our ability to provide expanded services in the future. 

C. Beneficial Legislation: Senator Cantwell’s Bill, S. 2440 

In addition to S.2270 (Senator Daines’ bill), we ask this Committee to support 

S.2440, introduced by our Senator and Committee Member, Senator Cantwell. We 

appreciate Senator Cantwell’s work on behalf of Indian Country and, specifically, on 

the opioid issue. We also note that the Senator’s consultation with our Tribe for receiving early input about this bill could serve as a model for tribal consultation 

when developing legislation. Our Tribe supports S. 2440. 

45 

S. 2440, known as the Comprehensive Addiction, Recovery, Education and Safety 

(CARES) Act, would, among other things, hold opioid manufacturers accountable for 

failure to report suspicious drug orders. The intent of the CARES Act is to increase 

opioid prevention and treatment funding, limit opioid prescriptions and enhance 

prescription drug monitoring programs. The Act would increase civil and criminal 

penalties on companies that fail to reasonably curtail their drugs from entering the 

illicit drug market. The legislation increases civil penalties from $10,000 to $100,000 

per violation for negligence in reporting suspicious transaction activity, and doubles 

the maximum criminal penalty from $250,000 to $500,000 for willful violations. The 

Act increases funding for the DEA’s Tactical Diversion Squad which investigates 

drug manufacturers that fail to prevent their drugs from entering the illicit drug 

market. The legislation also authorizes $50 million for the DEA’s heroin enforcement groups. 

This important bill aligns with the Tribe’s goals in our federal lawsuit to hold 

drug companies responsible for failing to track orders and for creating an illicit market for their drugs, and will be an enormous boost in the fight against opioid addiction. We applaud Senator Cantwell and ask all on this Committee to cosponsor and 

support this bill. Increased response funding and manufacturer accountability could 

drastically curtail shipments of the prescription pills that result in crippling addiction for our Tribal members. 

VI. Conclusion 

The crisis has ripped the fabric of our community. The loss (through death or addiction) of parents, children, brothers and sisters, uncles and aunts, nieces and 

nephews, and cousins to this crisis has been devastating, and will impact the Port 

Gamble S’Klallam Tribe for generations. We are doing what we can to fight it, and 

we want to work with you to eradicate this crisis once and for all. 

Thank you for the opportunity to provide this testimony. We invite you to visit 

our Tribe to learn more about our ongoing work. 

The CHAIRMAN. Senator Smith, I believe you wanted to give an 

introduction of Mr. Moose. 

Senator SMITH. Very briefly, Mr. Chair, because I know we are 

rushed for time. 

I want to welcome you to this Committee. It is wonderful to see 

you. 

Mr. Moose is a member of the Mille Lacs Band of Ojibwe from 

Minnesota and is an important leader on Native health issues 

broadly, not just issues related to the opioid epidemic. As Chairman Hoeven said, he serves as Treasurer and the Beidji Area representative to the National Indian Health Board. Thank you so 

much for being here. 

I am going to have to run to go vote but I have read your testimony and look forward to hurrying back so that I can ask you a 

question or two. 

Senator CANTWELL. [Presiding] I thank the witnesses for their 

testimony. Did you want to ask a question at this moment? If you 

want, go ahead, Senator Smith. 

Senator SMITH. I will do that. That way I don’t have to run back. 

Thank you. 

Mr. Moose, I am very interested in talking to you about the opportunities we have with the special behavioral health program 

modeled on the Diabetes Program. Earlier today, I was able to introduce legislation that several Committee members, including 

Senators Udall, Tester, Cortez Masto and Heitkamp, also introduced. 

This bill would provide Native communities with flexible funding, 

as we have discussed so much today, to create programs that can 

really build on the work you are already doing. Could you talk a 

bit from your perspective on what we could do at the Federal level 

46 

to make sure we are not just reacting to current events but are 

really giving tribes the flexibility they need to take action? 

Mr. MOOSE. One of the things that is really good about the bill 

you are looking at introducing is the fact that it does look at long 

range infrastructure funding for Indian Country. One area we often 

struggle with is grants, from time to time, are kind of dropped into 

Indian Country and then go away. 

One of the issues we have in Indian Country is infrastructure development, ongoing support and flexibility to utilize funding that 

meets our specific needs. Unfortunately, at times, States, under 

good pretenses, provide funding large areas of tribes within their 

State systems. 

Oftentimes that funding gets so specific that it does not meet the 

needs of every tribe within the State. Some States may need that 

specific direct funding, whether it is recovery, case manager support or other specific support. However, other tribes may have 

moved on from that funding and have a hard time utilizing that 

funding or using that funding to leverage other funding. I think it 

is really good to see that the bill supports ongoing funding for Indian Country, specifically what we have seen with the Special Diabetes for Indians. 

Senator SMITH. Thank very much. I will leave it at that but I 

thank you and look forward to working with you on the bill. Also, 

thank you very much, Ms. George, for being with us. 

Senator CANTWELL. Thank you, Senator Smith. 

Ms. George, you mentioned the CARES Act, which we have introduced. One key focus of that legislation is putting stiffer penalties 

on manufacturers who fail to meet the standard DEA has set up 

for some drugs as addictive as opioids. 

The DEA really wants to follow the distribution of that product 

and make sure the failure to report distribution of something as 

highly addictive as opioids is penalized if manufacturers fail to do 

that. That is what I and Senator Harris of California have introduced. 

In our State, we have had over 10,000 fatal overdoses in basically a 17-year period of time. I know the rate in Indian Country 

is more than twice as high as the rest of the population. What do 

you think this kind of partnership with law enforcement in tracking and distribution of drugs would do to help the problem in Indian Country? 

Ms. GEORGE. I really believe that collaboration between law enforcement and all sectors needs to be represented in this process 

to really combat this crisis as a whole. Law enforcement is definitely key. 

In our community, although we are a small community, our law 

enforcement sometimes is the only people that have interactions 

with some of our folks having overdose incidents. Not only are they 

able to keep them alive in that instance they experience, but also 

bring them directly to our programs that service them. They play 

a very integral part in fighting this. At least in our community, I 

think our law enforcement recognizes that and is willing to take 

the steps necessary to move forward. 

Senator CANTWELL. Thank you for that answer. 

47 

Unfortunately, we are going to have to take a short recess and 

will resume shortly. The Committee will be in recess. 

[Recess.] 

Senator UDALL. [Presiding.] The Committee is reconvened. 

We apologize for the inconvenience. These votes are an occupational hazard and if we do not vote, we get in a lot of trouble. 

Thank you for your patience. 

I believe we were at the point in the proceeding where next to 

testify was Mr. Samuel Moose, the Treasurer and Bemidji Area 

Representative of the National Indian Health Board. 

Before you start, Sam, both of you obviously have real admirers 

in Senators Cantwell and Smith who really appreciate all the good 

work you are doing. 

Thank you. 

STATEMENT OF SAMUEL MOOSE, TREASURER AND BEMIDJI 

AREA REPRESENTATIVE, NATIONAL INDIAN HEALTH BOARD 

Mr. MOOSE. Chairman Hoeven, Vice Chairman Udall and members of the Committee, on behalf of the National Indian Health 

Board and the 573 tribal Nations we serve, I thank you for holding 

this important hearing. 

My name is Samuel Moose. I am the Human Services Director 

for the Fond du Lac Band of Lake Superior Chippewa and an enrolled member of the Mille Lacs Band of Ojibwe. 

The current opioid epidemic represents one of the most pressing 

public health crises affecting tribal communities. While this epidemic is affecting many communities throughout America, it has 

disproportionately impacted tribes and has strained the limited 

public health and health care resources available to tribes. 

American Indians and Alaska Natives have had the highest rate 

of drug overdose deaths every year since 2008 to 2015. In my home 

State of Minnesota, the age adjusted death rate due to drug poisoning is five times higher among the American Indian population 

compared to Whites. 

American Indians accounted for 15.8 percent of those who entered drug treatment for opioid use despite only being 1.1 percent 

of tribal or the State population. These statistics demonstrate the 

critical need for more comprehensive intervention in tribal communities to improve prevention and treatment services. 

This epidemic is so bad that several tribes throughout the Country, including three within Minnesota, declared a state of emergency to tackle this crisis. Historic and intergenerational trauma 

along with current trauma that spans a lifetime for American Indians, a lack of funding for IHS, and the failure to include tribes in 

State level prevention and public health programs all contribute to 

the current crisis in tribal communities. 

In Minnesota, pregnant American Indian women were 8.7 times 

more likely to be diagnosed with maternal opioid dependence. 

American Indian infants were 7.4 times more likely to be born with 

Neonatal Abstinence Syndrome, meaning that the repercussions 

and trauma of this crisis are intergenerational. 

The deferral of healthcare in the Indian health care system due 

to funding and workforce shortages has created greater dependency 

on opiates. Limited funding resulted in nearly 80,000 Purchased/ 

48 

Referred Care service denials in fiscal year 2016 alone. Instead of 

being referred for surgeries and support treatment, patients are 

simply placed on prescription opiate medication as they wait for access to additional care. This endless cycle of deferral and opiate dependency is a direct result of underfunding in the IHS system contributes to the issue. 

Solutions should focus on allowing tribes to access long term, 

sustainable resources, improve data and disease surveillance and 

enhance tribal practice of traditional healing and culturally-based 

treatment. Congress should allow tribes access to the State Targeted Response to Opiate Epidemic Grants. NIHB supports the provisions in S. 2270, the Mitigating METH Act, and S. 2437, the 

Opioid Response Enhancement Act. 

Congress should: establish tribally-specific funding streams such 

as a Special Behavioral Health Program for Indians, modeled after 

the very successful Special Diabetes Program for Indians; ensure 

parity between States and Tribes in any new opioid-related legislation advanced in Congress, not only including tribes as eligible entities, but also requiring tribal consultation, information and data 

sharing, and funding set asides; establish trauma-informed interventions in coordination with tribes to reduce the burden of substance use disorders including those involving opioids; and include 

set asides for tribes within the $6 billion in opioid program funding 

for fiscal years 2018 and 2019. 

In addition, health IT and data issues represent a serious challenge when it comes to the opiate crisis. IHS’ current Electronic 

Health Record system has difficulty tracking data across various 

systems, including those tribes who operate different EHRs. RPMS 

is often not compatible with State-based prescription drug monitoring programs which makes tracking access to opiates a severe 

challenge. 

Congress should make investments in the health IT resources at 

IHS, especially as the VA system begins to transition from Vista. 

It should require that States consult with tribes on use of prescription drug monitoring programs and incentivize providers to adopt 

E–Prescribe as a way of reducing the needless and harmful spread 

of opiates. 

I would also like to highlight the importance of integrating traditional healing practices with conventional strategies in Indian 

Country and tribal communities that have been healing their people for thousands of years. Although Federal grants and Medicare 

do not reimburse for traditional healing services, it is critical that 

Congress support these traditional practices by providing funding 

and including them in the Medicaid reimbursement. 

Again, thank you for allowing this time for me to be here with 

you today and holding this hearing. 

[The prepared statement of Mr. Moose follows:] 

PREPARED STATEMENT OF SAMUEL MOOSE, TREASURER AND BEMIDJI AREA

REPRESENTATIVE, NATIONAL INDIAN HEALTH BOARD

Introduction 

Chairman Hoeven, Vice Chairman Udall, and Members of the Committee, the National Indian Health Board (NIHB) thanks you for holding the hearing, ‘‘Opioids in 

Indian Country: Beyond the Crisis to Healing the Community.’’ On behalf of NIHB 

49 

1 National Institute on Drug Abuse. 2017. Overdose Death Rates. Retrieved from https:// 

www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates 2 Indian Health Service. New effort targets drug overdoses in Indian Country. Retrieved from 

https://www.ihs.gov/newsroom/pressreleases/2015pressreleases/new-effort-targets-drugoverdoses-in-indian-country/ 3Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit Drug Use Disorders, and Drug 

Overdose Deaths in Metropolitan and Nonmetropolitan Areas—United States. MMWR Surveill 

Summ 2017;66(No. SS–19):1–12. DOI: http://dx.doi.org/10.15585/mmwr.ss6619a1 

and the 573 federally-recognized Tribes we serve, I, Sam Moose, Director of Human 

Services at Fond du Lac Band of Lake Superior Chippewa submit this testimony. 

NIHB is a 501(c)3, not for profit, national Tribal organization founded by the 

Tribes in 1972 to serve as the unified, national voice for American Indian and Alaska Native (AI/AN) health in the policy-making arena. Our Board of Directors is comprised of distinguished and highly respected Tribal leaders in AI/AN health. They 

are elected by the Tribes in each region to be the voice of all 573 Tribes at the national level. 

Since 1972, NIHB has advised the U.S. Congress, Indian Health Service (IHS), 

and other federal agencies about health disparities and service issues experienced 

in Indian Country. The current opioid epidemic represents one of the most pressing 

public health crises affecting Tribal communities. While this epidemic is affecting 

many communities throughout America, it has disproportionately impacted Tribes 

and has further strained the limited public health and healthcare resources available to Tribes. The Federal Government must take concrete action to ensure Indian 

Country has the tools it needs to address opioid abuse and heal Tribal communities. 

Trust Responsibility 

The federal promise to provide Indian health services was made long ago. Since 

the earliest days of the Republic, all branches of the Federal Government have acknowledged the nation’s obligations to the Tribes and the unique trust relationship 

between the United States and Tribes. 

The Indian Health Service is the primary agency by which the Federal Government meets the trust responsibility for direct health services. IHS provides services 

in a variety of ways: directly, through agency-operated programs and through Tribally-contracted and operated health programs; and indirectly through services purchased from private providers. IHS also provides limited funding for urban Indian 

health programs that serve AI/ANs living outside of reservations. Tribes may choose 

to receive services directly from IHS, run their own programs through contracting 

or compacting agreements, or they may combine these options based on their needs 

and preferences. 

Today the Indian healthcare system includes 46 Indian hospitals (1/3 of which are 

Tribally operated) and nearly 630 Indian health centers, clinics, and health stations 

(80 percent of which are Tribally operated). When specialized services are not available at these sites, health services are purchased from public and private providers 

through the IHS-funded purchased/referred care (PRC) program. Additionally, 34 

urban programs offer services ranging from community health to comprehensive primary care. To ensure accountability and provide greater access for Tribal input, IHS 

is divided into 12 geographic Service Areas, each serving the Tribes within the Area. 

It is important to note that Congress has funded IHS at a level far below patient 

need since the agency’s creation in 1955. In FY 2017, national health spending was 

$9,207 per capita while IHS spending was only $3,332 per patient. 

Overview of the Opioid Epidemic in Indian Country 

The national opioid epidemic represents one of the great public health challenges 

of the modern era. The Centers for Disease Control and Prevention (CDC) noted 

over 64,000 drug overdose deaths in 2016 alone, largely driven by prescription and 

illicit opioids. 1 Among AI/ANs, the rate of drug overdose deaths is twice that of the 

general population, according to the IHS. Deaths from prescription opioid overdoses 

increased four-fold from 1999 to 2013 among AI/ANs. 2 The CDC reported that AI/ 

ANs consistently had the highest drug overdose death rate by race every year from 

2008–2015, and the highest percentage increase in drug overdose deaths from 1999– 

2015 at 519 percent. 3 Deaths from prescription opioid overdoses increased four-fold 

from 1999 to 2013 among AI/ANs, with an opioid overdose death rate of 9.6 per 

100,000 in 2015—second only to whites. 

Regional data trends further demonstrate the high burden of the opioid epidemic 

within Tribal communities. According to the State of Alaska Epidemiology Center, 

AI/ANs had the highest overdose death rate by race from 2009–2014 at 20.2 deaths 

per 100,000 population. Similarly, the Washington State Department of Health reported that from 2011–2015, the opioid overdose death rate was highest among AI/ 

50 

ANs at a rate of 29 deaths per 100,000 compared to 12 deaths per 100,000 for 

Whites. 

In my home state of Minnesota, the Department of Human Services reported that 

the age-adjusted death rate due to drug poisoning is four times higher among AI/ 

ANs compared to whites. Further, despite representing roughly 1.1 percent of the 

population for the state, AI/ANs accounted for 15.8 percent of those who entered 

treatment for opioid use disorder. These statistics illuminate the critical need for 

more comprehensive interventions in Tribal communities to improve prevention and 

treatment measures. 

The Indian Health system is chronically underfunded, understaffed and overextended. Limited Tribal and IHS public health and healthcare resources have been 

further inundated by this highly deadly and superbly costly epidemic. While the 

treatment and recovery costs are certainly great, the human toll of the epidemic on 

our Tribal communities is even greater. The state of Minnesota reported that pregnant AI/AN women were 8.7 times more likely to be diagnosed with maternal opioid 

dependency, and that AI/AN infants were 7.4 times more likely to be born with neonatal abstinence syndrome (NAS)—meaning that the repercussions and trauma of 

this crisis are intergenerational. Other secondary impacts include the undue burdens imposed on many AI/AN families struggling with opioid and substance use disorders, the children forced into foster care, and the kinship care networks that are 

strained beyond their ability. 

While Tribal communities are certainly in need of expanded treatment resources, 

public health prevention must not be forgotten. This includes upstream prevention 

activities such as comprehensive substance use education in youth, expanded substance and alcohol use education and training for our providers, prevention of adverse childhood experiences, healing from historical and intergenerational trauma, 

and investment in culturally appropriate and Tribally-driven programming. 

Bolstering Tribal public health surveillance infrastructure is also a major need. 

The CDC noted in 2017 that the actual drug overdose death count among AI/ANs 

may be underestimated by as much as 35 percent due to racial misclassification on 

death certificate data. That is truly unacceptable. Data is the backbone of any public 

health system, and without it the Tribes and IHS are unable to maintain accurate 

records of vital statistics, to quantify disparities in health outcomes between AI/ANs 

and other populations, and to ultimately make true assessments of need. More importantly, Tribal leaders must have this information to make informed policy decisions and implement targeted programs. 

Tribes also remain behind many other communities in their public health infrastructure, capacity, and workforce capabilities as a result of being largely left behind 

when the United States was modernizing its public health infrastructure. These obstacles have made it particularly difficult for Tribal communities to assemble a coordinated and comprehensive defense against major health emergencies, including 

the opioid epidemic. 

At IHS, and indeed even at many Tribal facilities, deferral of care due to funding 

and workforce shortages has pushed more and more Tribal members towards prescription opioids to treat health conditions that would otherwise successfully be 

treated with non-opioid therapies. For instance, limited funding resulted in nearly 

80,000 Purchased/Referred Care (PRC) services (an estimated total of $371 million) 

being denied in FY 2016 alone. This endless cycle of deferral and opioid dependency 

is a direct result of the underfunding of the IHS system, and must be stopped. 

The CDC Guideline for Prescribing Opioids for Chronic Pain describes how opioid 

therapy should not be the first line of treatment for acute or chronic non-cancer related pain management, and should rarely, if ever, be prescribed with other medications such as benzodiazepines. Nevertheless, many Tribal members still report that 

opioids are some of the only options available to them to address their pain symptoms. Lack of reimbursement and access to non-opioid therapies, traditional medicine and other alternatives leaves both providers and patients in a catch-22 that ultimately leads to more harm. 

Tribes throughout the country are finding that the systemic problems with the 

current Indian health system are impacting their ability to confront the opioid crisis. Bay Mills, a Tribe located on the Upper Peninsula in Michigan, has capacity 

issues so severe that, even if that Tribe received federal funds to operate an opioids 

treatment outpatient program, the Tribe reports that their facilities are too small 

and outdated to be able to operate such a program on-site. NIHB has noted in previous testimony to Congress that IHS’s facilities construction budget is so underfunded that a facility built today would not be able to be replaced for 400 years. 

These chronic funding issues have limited the ability of Tribes to confront the opioid 

crisis without additional, sustained Congressional support. 

51 

The Red Cliff Tribe of Chippewa Indians in Wisconsin lacks resources to keep up 

with the latest training practices available to healthcare providers. While the Tribe 

has started a Harm Reduction Program to provide access to Naxolone, lack of substance abuse and addiction training among Tribal providers limits the program’s 

reach and uptake in the community. The Red Cliff Police Department reported 346 

investigations on drug use in 2016, an increase of almost 100 from the year prior. 

The total population of the reservation is under 1,000. 

Tribal Response to Opioids 

Despite these challenges and setbacks, Tribes across Indian Country have engaged in multifaceted response efforts that traverse the prevention, treatment and 

interdiction landscape. For instance, after declaring a state of emergency on the 

opioid epidemic in March 2016, the Mashpee Wampanoag Tribe in Massachusetts 

partnered with the IHS to assemble more resources to address the growing number 

of overdose deaths in their community. The Tribe worked towards establishing an 

integrated community intervention model, implementing the CDC Guideline for Prescribing Opioids for Chronic Pain, and developing an opioid response grounded in 

the social determinants of health. The Tribe worked with Tribal Police and Homeland Security to create prescription drug drop boxes, developed a 24-hour call line 

for crisis intervention, and established a Tribal Coordinating Committee to create 

a 5 year Tribal Action Plan to address alcoholism and substance abuse issues. 

In Washington State, the Muckleshoot Tribe has been operating a successful behavioral health program for the past few years. The initiative includes a medicationassisted treatment program where Tribal members are able to receive Suboxone or 

Vivitrol for treatment of opioid use disorder. The program has proven successful, as 

compliance with the program reached 94 percent in July, 2017. Muckleshoot has distributed close to 4,000 kits of Naloxone as of August 2017, and also operates a syringe service program to help reduce the risk of co-occurring health conditions such 

as HIV and Hepatitis C. 

In Oklahoma, the Chickasaw Nation launched the ‘‘Define Your Direction’’ campaign, which is an education initiative encouraging Tribal youth to make healthy 

choices and be positive role models when it comes to resisting prescription drug misuse and underage drinking in their communities. Some outcomes of the program 

thus far include equipping all Chickasaw Nation Lighthorse officers with Naloxone; 

distributing more than 400 medication lockboxes to Elders; recording significant reductions in prescription drug misuse within the past 30 days among 6th, 8th, 10th 

and 12th graders; and reductions in risk factors such as early drug use initiation 

and low neighborhood attachment among Tribal youth. 

NIHB encourages the Committee Members to connect with the Tribes in your 

home states to learn more about current initiatives and gain further insight into 

technical assistance and funding needs, so that programs such as these are replicated in more and more Tribal communities. 

Policy Solutions 

A) Access to Federal Opioid Resources 

Addressing the opioid epidemic is a nationwide priority; however, access to critical 

opioid prevention and treatment dollars are not reaching many of the Tribal communities that are in serious need of these funds. As sovereigns, Tribes are not systematically included within statewide public health initiatives such as the recent prevention and intervention efforts created through the new opioid crisis grants found 

in the 21st Century CURES Act, passed by Congress in 2016. 

The CURES Act provided $1 billion in funding over a two-year period to states 

and territories to combat the opioid crisis. Tribes were not eligible entities for this 

critically important funding. Although a small number of states subsequently allocated CURES funds to Tribes, access was not at the level of need, nor was it equitably distributed. Furthermore, as the trust responsibility is exclusive to Tribal Nations and the Federal Government, Congress must not circumvent this sacred duty 

by forcing Tribes to go through state agencies for these funds. In addition, many 

Tribes have historically had complicated relationships with state governments as a 

result of having to compete for limited dollars. Providing direct funding to Tribes 

would solve this issue. 

An example of this can be seen in Ho-Chunk Nation in Wisconsin. Like many 

Tribes, Ho-Chunk has seen an increased number of infants born with substance addiction and NAS, as well as an increase in opioid-related overdose deaths in the 

community. The Tribal government declared a State of Emergency regarding the 

opioid crisis and is in the process of developing a Tribal Action Plan within their 

departments. A major problem for the Tribe is that the grant money the state reVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00055 Fmt 6633 Sfmt 6621 S:\DOCS\32784.TXT JACK
52 

4 U.S. Department of Health and Human Services. ‘‘FY 2019 Budget in Brief.’’ February 12, 

2018. Pg. 28. 

ceives and distributes to the Tribes is not sufficient to meet the added burden the 

Tribe’s behavioral health facility is experiencing. 

To correct this dynamic and ensure that needed opioids funding is reaching the 

Tribes, Congress should: 

• Amend the CURES Act, specifically the State Targeted Response to Opioid Epidemic grants, to ensure Tribes can receive funding directly from the Federal 

Government to address the opioids crisis. NIHB supports the provisions in S. 

2270, the Mitigating METH Act, and S. 2437, the Opioid Response Enhancement Act, that address this. 

• Establish Tribally-specific funding streams such as a Special Behavioral Health 

Program for Indians, modeled off the very successful Special Diabetes Program 

for Indians, so that Tribes can develop their own programs to address substance 

misuse and dependence in their communities. NIHB supports House legislation 

that has been introduced for this purpose, H.R. 3704 the Native Health Access 

Improvement Act. 

• Ensure parity between states and Tribes in any new opioid-related legislation 

advanced in Congress. This means not only including Tribes as eligible entities, 

but also requiring Tribal consultation, information and data sharing, and funding set asides, where applicable. For example, the newly introduced ‘‘Comprehensive Addiction and Recovery Act (CARA) 2.0’’ (S. 2456) legislation should 

include Tribes and Tribal organizations in several sections of the bill. This includes Section 6 which establishes funding for regional technical assistance centers to focus on addiction recovery and naloxone training/dissemination; Section 

7 which allows states to increase the 3-day limit on first time opioid prescriptions found in Section 3 if the state passes a law or implements a statewide 

regulation should include Tribal law as well; and Section 10 which provides 

funding to states for addiction treatment programs targeted toward pregnant 

and post-partum women. Finally, we recommend adding language to Section 13 

that would require states to consult with Tribes on the implementation of prescription drug monitoring programs. 

• Establish trauma-informed interventions in coordination with Tribes to reduce 

the burden of substance use disorders including those involving opioids. 

• Include set asides for Tribes within the $6 billion in opioid program funding for 

Fiscal Years 2018 and 2019 appropriated in the February 2018 Continuing Resolution. 

FY 2019 Budget Proposal 

NIHB and Tribes were glad to see that the FY 2019 President’s budget request 

proposed $150 million in funding to ‘‘provide multi-year competitive grants based on 

need for opioid abuse prevention, treatment, and recovery support in Indian Country.’’ 4 Tribes are supportive of this additional funding, but many Tribes have expressed concerns that competitive grant programs are not the solution to long-term, 

broad-based funding. Competitive grants erode Tribal sovereignty and do not honor 

the federal trust responsibility. Furthermore, when Tribes are forced to apply for 

grants it takes away scarce staff and resources from other program-oriented work 

leading to diminished program effectiveness across the board. We look forward to 

working with you as this policy is developed to ensure that the proposed funds truly 

reach the areas with greatest need and fully honor the promises made to our ancestors. In addition, we note that other federal agencies—such as the Substance Abuse 

and Mental Health Services Administration and the Centers for Disease Control and 

Prevention—should have funding made directly available to Tribes. 

B) Health Information Technology (IT) within the Indian Health System 

The Federal Government has not met its trust responsibility as it relates to updating and modernizing the physical and technological infrastructure within IHS 

and Tribal health facilities and health IT systems. The current primary Electronic 

Health Record (EHR) system IHS uses is the Resource and Patient Management 

System (RPMS), an integrated public health information system based on the U.S. 

Department of Veteran’s Affairs (VA) VistA system. It is a comprehensive suite of 

applications that supports virtually all clinical and business operations at IHS and 

most tribal facilities, from patient registration to billing. RPMS is comprised of over 

80 software applications and is designed to track patient and population based clinVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00056 Fmt 6633 Sfmt 6621 S:\DOCS\32784.TXT JACK
53 

5Office of Management and Budget. Circular A–130. Appendix III. Security of Federal Automated Information Resources. 

ical and practice management applications. However, various concerns and challenges have been cited regarding RPMS. Some notable issues are: 

• Many Tribes utilize different EHR systems instead of RPMS; 

• Smaller Tribal health facilities do not have the bandwidth to fully 

operationalize RPMS, and would benefit from the ability to share new components such as files that contain all available drugs instead of just some; 

• Some smaller Tribal health clinics are in need of greater training and technical 

assistance on how to utilize the system most efficiently; 

• There is a need to further streamline the system and align it with other EHRs 

utilized by Tribes; 

• Robust and timely IT support is not routinely available; 

• Interoperability is incomplete, meaning that if a patient is referred to another 

clinic that utilizes a different system, the patient records are more than likely 

not cross-referenced which leads to inconsistencies in patient records. 

Issues also exist in terms of RPMS interactions with Prescription Drug Monitoring Programs (PDMPs). PDMPs are state-run electronic databases that track controlled substance prescriptions. Across the board, utilization of PDMPs is inadequate. A national survey of primary care physicians found that 86 percent of the 

time, physicians did not check their statewide PDMP prior to prescribing an opioid, 

despite the fact that 72 percent of primary care physicians are aware of their state’s 

PDMP. 5

It is important to note the limitations of the PDMP system, both generally and 

in its usefulness for IHS and Tribal providers, pharmacists and public health practitioners. One, PDMP laws and regulations differ by state. In other words, whereas 

one state may require providers to update the system within a 24 hour period, other 

states only require updating the system every few days, or even over a longer period 

of time. Further, interstate sharing of PDMP data is not streamlined, which creates 

gaps in monitoring especially for individuals living in border towns, or for reservations that traverse multiple state boundaries. Additionally, to NIHB’s knowledge, 

only the state of Alaska decreed a special consideration for IHS providers to access 

the PDMP system, which may explain why IHS established memorandums of understanding (MOU) with state agencies to permit IHS access and reporting. Also, there 

is currently no Tribally-specific PDMP system. The FY2017 House Appropriations 

Bill authorized $1 million to IHS to establish such a system; however, to NIHB’s 

knowledge, this system has not yet been implemented. 

Finally, no PDMP system collects racial demographics, limiting its value as a tool 

for public health monitoring for Tribes and Tribal Epidemiology Centers. 

Due to budgetary constraints, IHS has not been able to support operations and 

maintenance for the certified RPMS site. Other federal agencies, like the Veterans’ 

Administration, are in the process of moving away from RPMS-like systems toward 

more integrated software platforms, where EHRs and PDMPs can communicate 

under an interoperable platform. Unless Congress intervenes, this will create a disconnect between IHS and other agencies. 

NIHB supports E-prescribing, especially given its potential to reduce the spread 

of prescription opioid abuse, and encourages IHS to utilize it where practicable. 

However, most IHS and Tribally run health facilities are in rural areas where limited broadband make widespread adoption of E-prescribing unrealistic without Congressional intervention. To ensure that E-prescribing is a viable tool in the Indian 

health system, Congress must first continue, and expand, its investment in rural 

broadband to incorporate rural Tribal communities. 

Telehealth is a much-needed and successful innovation in rural areas. For example, the Eastern Aleutian Tribes, a healthcare provision organization serving 8 Alaska Native communities, has begun using telemedicine to diagnose conditions, prescribe treatment, and conduct follow up examinations. Many Tribes in remote Alaska communities, often disconnected by the road system and only accessible by plane 

or boat, do not have access to medical providers regularly and have come to rely 

on telemedicine to fill a gap in healthcare provision. However, this was only accomplished through sustained investment in rural broadband. 

Greater network bandwidth and broadband access is a critical need, demonstrated 

by a 2018 FCC report that found as many as 35 percent of individuals living in 

Tribal lands lack broadband access, while in some Tribal communities as much as 

80 percent lack broadband access. 

54 

6 (21. U.S.C. 829) Section 311(g)(2) 

To ensure Tribes are able to utilize Health IT to the greatest extent possible in 

confronting Indian Country’s opioid epidemic, Congress should: 

• Provide adequate support, funding, and oversight as IHS moves away from the 

RPMS system toward a more integrated platform that can better interact with 

E-prescriptions and EHRs. 

• Provide oversite to IHS to implement a Tribally-specific PDMP system than can 

interact with state PDMPs. 

• Review and support IHS’s list of Tribal broadband projects, and also include direct funding to Tribes to improve their broadband and telehealth infrastructure. 

• Mandate State-Tribal consultation on changes to state PDMPs. 

• Incentivize providers to adopt E-prescription as a way to reduce the needless 

and harmful spread of opioids. Should Congress provide a grant program to that 

end, a set aside of 3–5 percent would be appropriate to ensure Tribes are not 

at a disadvantage in tapping into those funds. 

• Eliminate the requirement for Tribal providers to obtain the Secretary’s authorization to be designated as an Internet Eligible Controlled Substances Provider, 

as it imposes an undue burden that delays the delivery of much-needed treatment resources, especially given that no other providers are subject to this requirement. 6

Conclusion 

Again, NIHB would like to thank the Committee for holding this hearing and soliciting input from a variety of stakeholders. Indian Country has seen over the past 

several years that opioids do not face barriers in entering Tribal communities. To 

truly address this problem, Congress must ensure that Tribes receive direct funding, 

and are included any type of national-level opioid legislation moving forward. 

SUPPLEMENTAL TESTIMONY OF THE NIHB 

Chairman Hoeven, Vice Chairman Udall, on behalf of the National Indian Health 

Board (NIHB) and the 573 American Indian and Alaska Native (AI/AN) Tribes we 

serve, I would like to thank you for holding the hearing, ‘‘Opioids in Indian Country: 

Beyond the Crisis to Healing the Community,’’ and for NIHB to offer testimony at 

the hearing. 

NIHB is a 501(c)3, not for profit, national Tribal organization founded by the 

Tribes in 1972 to serve as the unified, national voice for American Indian and Alaska Native health in the policy-making arena. Since 1972, NIHB has advised the 

U.S. Congress, Indian Health Service (IHS), and other federal agencies about health 

disparities and service issues experienced in Indian Country. 

The current opioid epidemic represents one of the most pressing public health crises affecting Tribal communities. While this epidemic is affecting many communities 

throughout America, it has disproportionately impacted Tribes and has further 

strained the limited public health and healthcare resources available to Tribes. The 

Federal Government must take concrete action to ensure Indian Country has the 

tools it needs to address opioid abuse and heal Tribal communities. 

While each witness brought a wealth of knowledge and experience to the committee, NIHB wishes to ensure the Senators on the committee have all of the information they need to make informed decisions on how best to support Tribes and 

Tribal health programs in confronting the opioid crisis. 

The 21st Century CURES Act included two years of funding to states to develop 

State Targeted Responses. As CAPT Jones from the Substance Abuse and Mental 

Health Services Administration (SAMHSA) mentioned in his testimony, of the 36 

states with Tribes, only 12 have incorporated Tribes into their State Targeted Responses or identified American Indians/Alaska Natives (AI/ANs) as a specific population under the state plan. The funding is not reaching Tribal communities. NIHB 

is supportive of the provisions in S. 2270, the Mitigating METH Act, and S. 2437, 

the Opioid Response and Enhancement Act, which would open CURES Act funding 

to Tribes directly. These needed revenue streams would allow all Tribes to replicate 

success seen in several Tribal programs across America. In her questioning at the 

hearing, Senator Cortez Masto asked witnesses from federal agencies if direct Tribal-specific funding streams were needed to combat the opioids crisis. Had that question been asked of the Tribal witnesses, the committee would have heard an unambiguous ‘‘Yes.’’ 

55 

There is an inherent structural problem with the system of Tribes through states 

to access federal funding. There is no established legal relationship between the 

states Tribes. States are not compelled to have consultation with the Tribes, or even 

listen to their needs. There is no treaty, constitutional relationship or law that sets 

forth Tribal-state collaboration. Using this type of construct essentially just cuts 

Tribes out of the system all together. Forcing Tribes to go to states diminishes the 

federal trust Tribes are not subservient to the state governments, but are recognized 

as sovereign nations within the federal system. In practice, this means, that few 

tribes actually see this funding, and if they do it is usually insufficient to meet need. 

Senator Tester similarly asked federal agency witnesses if some of the $10 billion 

for opioids included in the President’s Fiscal Year 2019 Budget Request should be 

set aside for Tribes. Again, the answer from Tribal witnesses would have been, 

‘‘Yes.’’ 

We were also pleased to see that the Consolidated Appropriations Act of 2018 contained a $50 million set-aside for Tribes in the State Targeted Response (STR) to 

opioid grants as well as a $5 million set aside for medication assisted treatment for 

Tribal communities. This funding is a critical first step in ensuring that Indian 

Country has access to the resources it needs to combat this deadly epidemic. Thank 

you for the advocacy that you and other committee members undertook to make this 

possible. We look forward to working with you to build on these gains in the coming 

year so that there is long-term sustained funding going to fight substance abuse 

among Tribal Nations. 

Senator Smith asked CAPT Jones how SAMHSA and other agencies were looking 

at intergenerational addiction, especially as relates to addicted mothers and 

newborns. He answered correctly that the agency is looking at the issue holistically 

and trying to break down siloes. However, it is crucial to note that neither program 

he cited, the residential program with 19 grantees, nor the outpatient program authorized by the Comprehensive Addiction and Recovery Act (P.L. 114–198), are open 

to Tribes. Because Congress did not list Tribes, Tribal organizations, and Urban Indian Health Centers as eligible entities, the funding for the grant programs does 

not reach Tribal communities and should not be cited as a success story in Indian 

Country. 

Furthermore, even if Congress authorized funding from those programs to go directly to Tribes, the competitive grant program is unfair to smaller Tribes which 

may lack capacity but which do not lack need. As Senator Murkowski said, the current competitive grant program ‘‘sets Tribes up to compete with other Tribes.’’ We 

could not agree more. Instead, Congress should work to empower IHS and Tribal 

health programs to implement successful, community-based, culturally competent 

care geared toward helping Tribal communities confront and heal from the opioid 

epidemic. 

While evidence-based care has many advantages in opioids treatment, Congress 

dictating a one-size-fits-all approach to this challenge will not work in Indian Country. Tribes often utilize traditional, culturally-based and promising practices as well 

as evidence-based practices. Culturally-based programming helps Tribes tailor initiatives to the specific needs of their community, while also honoring Tribal sovereignty and the right to self-determination. Evidence-based practices that do not 

integrate traditional Tribal practices are not always as effective at improving health 

outcomes as programs that do. Many Tribal public health programs—including the 

well-known and highly successful Special Diabetes Program for Indians (SDPI)— 

combine Tribal best practices with evidence-based practices. This model has worked 

and should be replicated to confront opioid addiction, with support and oversight 

from Congress. 

We hope this information clarifies some of the questions raised at the hearing. 

NIHB thanks you and the Senate Committee on Indian Affairs for holding the hearing and using Congress’s authority to support Indian Country as our communities 

confront and heal from the opioid epidemic. 

Senator UDALL. Thank you, Mr. Moose. Thank you, Ms. George 

for your testimony. Please be assured there will be a lot of questions. The staffs of all the Senators who are here and will be following very closely your testimony. We are really happy to have 

you here. 

Senator Daines, we are happy to see you back. Please proceed 

with your questions. 

56 

STATEMENT OF HON. STEVE DAINES, 

U.S. SENATOR FROM MONTANA 

Senator DAINES. Thank you, Ranking Member Udall. We have 

votes going on right now, as you understand. There is a lot of interest and they will be coming back from the Floor soon. 

I hail from the State of Montana. Opioid abuse is an issue in my 

home State. Meth use is increasingly a crisis. We know it is even 

more concentrated among Montana’s Indian tribes. That is why I 

have introduced the Mitigating METH Epidemic and Promoting 

Tribal Health Act also known as the Mitigating METH Act. 

As a matter of this government-to-government relationship between the United States and tribes, this legislation would make 

tribes, like States, directly eligible for funding that is authorized in 

the 21st Century CURES Act to combat the opioid crisis. Additionally, it would give States and tribes the flexibility to address the 

substance abuse and disorders most prevalent among their constituencies, which in Montana, would include meth. This legislation 

enjoys the support of eight co-sponsors from both sides of the aisle, 

including members of this Committee and is the only bipartisan 

legislation in the U.S. Senate that makes tribes directly eligible for 

this funding. 

Mr. Moose, I know you and Ms. George both discussed the benefits of my bill in your testimony. Could you expand on why you see 

it as important that the bill make tribes directly eligible for Federal funds to combat substance abuse? 

Mr. MOOSE. Thank you for the question. 

I think probably the most important thing we talk about among 

tribal program administrators and tribal providers is getting direct 

funding. Tribal leaders throughout Minnesota, Wisconsin and 

Michigan are always looking at direct funding for their tribal programs. It helps us enhance the things we currently do well and 

helps us target the things we need funding to expand or create access for. Anything that will provide sustainable funding for our 

tribal programs, something we can change or redirect based on how 

we see the need in our communities is critical to our addressing 

this issue. 

Senator DAINES. Thank you, Mr. Moose. 

Ms. George, I have the same question to you. Why do you see my 

bill, the Mitigating METH Act, as so important and beneficial? 

Ms. GEORGE. I think there are a couple areas where we saw significant support for us. Really, it reflects the government-to-government relationship with the tribe, allowing direct access and also 

recognizing grant funding limits creates competition for resources 

not just between tribes but even other local agencies we work with. 

We are often forced to choose between two or more very important issues. We sometimes do not get where we need to get. 

Senator DAINES. I think one of the underlying foundational principles is really tribal sovereignty and this government-to-government relationship and how the U.S. Government should be viewing 

the direct access for these funds to address the crisis we are seeing 

right now with meth and opioid abuse. 

I agree with both of you and I appreciate your support. These are 

the very reasons why I have authored this crucial, I think very 

timely, piece of legislation. 

57 

I would like to turn to a discussion of CARA 2.0. I applaud Senator Portman for continuing to lead the charge on this legislation 

to combat the drug overdose crisis and would like to explore ways 

to ensure tribes are appropriately included in this effort. 

Mr. Moose, what change would you like to see in CARA 2.0 to 

help address the drug abuse crisis in your community? I would be 

especially interested in your perspective on needed changes to the 

section which provides funding to States for addiction treatment 

targeted toward pregnant and post partum moms. 

Mr. MOOSE. We recommend allowing tribes to access the program outlined in Section 6 which establishes funding for regional 

technical assistance centers to focus on addiction recovery and 

naloxone training and dissemination. We recommend in Section 7 

allowing States to increase the three-day limit on first-time opiate 

prescriptions found in Section 3 of the bill, if the State passes a law 

or implements statewide regulations, tribal law should have the 

same authority. 

Tribes should also have access to Section 10 which provides funding to States for addiction treatment programs targeted towards 

pregnant or postpartum women. Finally, we recommend adding 

language to Section 13 that would require States to consult with 

tribes on implementation of their prescription drug monitoring program. 

Senator DAINES. Thank you. That input will be relayed to Senator Portman who is a great colleague and leader here in the Senate. I appreciate that testimony. 

I want to thank you for the input. I want to continue to work 

with you, the NIHB and my colleagues to see how we might be able 

to work some of these changes into that legislation. Indian tribes 

cannot afford to be left out. They cannot be left out of these discussions. I remain committed to seeing that their needs are addressed. 

Thank you. 

Senator UDALL. Thank you so much, Senator Daines. I really appreciate your questions. 

Early on, I think this is mentioned in your testimony, there were 

issues about the cuts that were going to take place. I think you all 

are familiar with those. These are program areas, many of them 

when you talk about programs and needing services, these are the 

same program areas where President Trump has Indian line items 

where he has proposed cutting in the 2019 budget request. 

I want to ask you both what impact would cuts to Federal funding for tribal housing, human services and public safety programs 

have on your tribe’s ability to continue its efforts to combat the 

opioid crisis? 

Mr. MOOSE. Thank you for the question, Senator. 

Funding for social safety net programs is very much linked with 

healthcare programs. When individuals do not have access to social 

safety net services, the effect of substance abuse disorder will be 

exacerbated because patients will not have the comprehensive services to support them in recovery. This includes protections of 

SNAP, Medicaid, TANF, and the Indian Housing Block Grant. 

For instance, if the proposed cuts to the Medicaid Program were 

to be enacted, it would place additional burden because there 

would be less resources available for medical treatment. Further, 

58 

many of these programs are effective in preventing substance use 

altogether. 

Research has shown access to healthy and traditional foods, stable housing and other social programs reduces substance use later 

in life. This is a very important aspect of the public health approach. Comprehensive care, the kind that promotes the whole 

health of a person, is the most effective in improving the health 

outcomes related to substance use and opioid abuse disorder. 

Senator UDALL. Ms. George? 

Ms. GEORGE. I fully support the comments Mr. Moose just made. 

In addition to that, any cuts to tribal programs hamper the tribe’s 

ability to sufficiently provide services to its members, run our governmental programs and initiate new projects. 

Senator UDALL. Aside from more direct tribal funding for behavioral health programs at HHS, for what other departments should 

we request more dedicated resources for tribal opioid and substance 

abuse efforts? 

Mr. MOOSE. Would you repeat the question? 

Senator UDALL. Aside from more direct tribal funding for behavioral health programs at HHS, for what other departments should 

we, the Committee looking into this, request more dedicated resources for tribal opioid and substance abuse efforts? 

Mr. MOOSE. One of the areas we have talked about within our 

system of care at Fond du Lac is prevention funding such as public 

health, infrastructure support and support for youth programs and 

youth prevention programs. One of the initiatives we are looking 

at starting is a children’s initiative. Having support with regard to 

these types of prevention programs is critical in our heading off the 

issue of opioid and substance abuse and healthcare disparities in 

general. I think anything that would fund prevention, public health 

infrastructure, surveillance and those types of issues would be important for us. 

Senator UDALL. Ms. George, do you want to add to that? 

Ms. GEORGE. For us, increased funding for tribal courts and law 

enforcement is important. Our tribal court also operates a reentry 

program because once we get help for these people, they also need 

to be reentered to their community, gain skills to maintain employment and be successful, thriving members again in our community. 

Those are areas I think we would identify as well. 

Senator UDALL. Thank you very much. 

One issue I have focused on throughout my entire time in Congress is Federal information technology reform. Just last year, I 

worked with another member of this Committee, Senator Moran, to 

get our bill, the Modernizing Government Technology Act, passed 

as part of another bill. The opioid crisis is just one more example 

of how outdated information technology can slowdown efforts to 

gather real-time data, in this case, prescription monitoring, people 

getting prescriptions from multiple areas. 

You both testified about the inadequacy of RPMS and PDMP systems coordination putting limitations on tribes’ trying to look at 

opioid prescription patterns. Do you believe that information technology challenges at the Indian Health Service led to shortcomings 

in implementation of a robust PDMP system? 

59 

Mr. MOOSE. Yes, I do. I was the Commissioner of Health and 

Human Services for the Mille Lacs Band. We utilized the RPMS 

system. Unfortunately, the RPMS system had challenges with regards to its being robust. I know that within our behavioral health 

program, in 2014, we started looking at implementing the Behavioral Health Electronic Health Record. That was in 2014, mind you. 

We have many programs concerning the program that I am at 

right now. The Fond du Lac Band of Lake Superior Chippewa purchased an off-the-shelf electronic health record system. We were far 

more advanced than we are at Mille Lacs. I definitely would support that. 

Senator UDALL. Thank you, Mr. Moose. 

Ms. George, did you have anything else to add? I have another 

question focusing on you, but go ahead, please. 

Ms. GEORGE. I just wanted to add that our tribe has had to 

spend an enormous amount of money creating custom templates for 

our information system. It is still not as adequate as we would like. 

That was a big burden to us. 

Senator UDALL. Ms. George, has the IHS, or any other Federal 

agency, offered support to help your tribe, or any other tribe that 

operates its own health facilities, coordinate with State-run 

PDMPs? 

Ms. GEORGE. No, they have not. 

Senator UDALL. Ms. George and Mr. Moose, what advice would 

you give the Administration and this Committee when evaluating 

replacements for RPMS systems, especially in light of the need to 

improve opioid prescription monitoring? 

Mr. MOOSE. We would suggest tribal consultation, working with 

tribes to identify the systems, creating a work group that looks and 

combs the landscape for what is best for Indian Country, along 

with hearing that input from specific Indian Country practitioners, 

tribes and tribal units for health service systems. 

Senator UDALL. Do you have anything else to add to that? 

Ms. GEORGE. I would just like to add that interoperability, reporting and population health are also important aspects. 

Senator UDALL. Thank you very much. 

Ms. George, I am impressed by your testimony describing Port 

Gamble’s experience combating the opioid crisis through State and 

local partnerships. These partnerships seem to be working and 

could be a model for other tribes across the Country. 

What advice would you give to other tribes considering 

partnering with their State and local counterparts? Do you have 

any advice for those whose State or local governments are not as 

willing as that of Washington to engage in similar partnerships? 

Ms. GEORGE. I am not sure that I have any advice to other. I 

would like to add that I do not believe there is a community, county or State that this epidemic is not touching right now. I think 

tribes would be surprised how quickly our local and State governments come to the table because none of us know how to handle 

this epidemic. 

Senator UDALL. Mr. Moose, based on your experience in developing cross-governmental partnerships, could Congress help encourage more fruitful partnerships by providing tribes with their 

60 

own direct funding to leverage and bring to the table these other 

partners? 

Mr. MOOSE. Yes, Senator. I believe it would be important to have 

tribes. One thing I keep thinking about is the discussion in our region with regards to some of the State-targeted response funding 

that a few of us put together specifically to address the opioid 

issue. 

We were trying to change our services to fit those grants. When 

I say services, I look at our traditional and cultural practices. Oftentimes when we have to go with that approach, it really takes 

us away from some of the internal infrastructure or development 

we have to deal with in some of our cultural practices or traditional 

approaches. Oftentimes, it takes up time and space when we 

should be concentrating on those issues, trying to fit our programs 

to the grant funding or other funding that is competitive, along 

with administrative time of managing those grants. 

Senator UDALL. I know I have asked a number of questions and 

you also heard from a number of Committee members with questions. Is there anything off the top of your head right now that you 

wanted to say in conclusion? 

Mr. MOOSE. One of the areas we were looking at as part of the 

information I just provided is we have a young practitioner in our 

tribal clinic. She is looking at doing her dissertation. In that dissertation, she came across something that was really interesting to 

her as a non-Indian practitioner. 

Several months ago, we started traditional healing services within our clinic. We gave access to a traditional healer we had hired 

within our clinic system to patients. This mental health practitioner was able to send her clients to this traditional healer. She 

looked at the clients going through our Core 12 program, our comprehensive opioid response program that utilizes suboxone as part 

of its treatment modality along with traditional healer services. 

One of the things she recognized, which became part of a passion 

that she wanted to do her dissertation on, was the impact those 

traditional healer services had on those clients. She saw incredible 

improvement in their depression rates, their anxiety and the overall treatment outcome for these clients which were incredibly important to us. 

Our course our tribe is definitely supporting her in identifying 

this as a piece within her research and her dissertation. I think it 

really came to us, and my comments before, that these are the 

services tribes in Indian Country need to reinvest in, our traditional and cultural practices as part of our treatment modalities. 

When we are trying to fit our services into a square peg, oftentimes we lose the ability to make that type of impact. If we could 

concentrate on those things within our communities that really enhance treatment services or gets a patient to accept that type of 

modality, I think it is really good for Indian Country. 

Senator UDALL. Thank you. 

Ms. GEORGE. I would just like to again extend the invitation to 

the Committee members and the agency directors to come and visit 

the tribes, see what we are doing and see what is working for us 

to get a better understanding of where our needs really lie. 

61 

Senator UDALL. Thank you for that invitation. You have the Rear 

Admiral in the audience, so he certainly heard that. I will convey 

that information to all the members of the Committee. I would love 

to visit you both in your respective States. 

Today, you have given very enlightening testimony and answers 

for the Committee. We really look forward to digesting all of this 

and trying to work on getting the legislation just right so we can 

get resources into Indian Country. As I mentioned earlier, you may 

get additional questions from Committee members that will be submitted to you in writing after today’s hearing. 

If there are no more questions today, which looking around, I do 

not think there are, members may also submit follow-up written 

questions for the record. The hearing record will be open for two 

weeks. 

Once again, I want to thank these witnesses for their testimony 

here today. 

The hearing is adjourned. 

[Whereupon, at 4:55 p.m., the Committee was adjourned.] 

(63) 

A P P E N D I X 

PREPARED STATEMENT OF ESTHER LUCERO, CEO, SEATTLE INDIAN HEALTH BOARD


214d6.eps
64 

PREPARED STATEMENT OF THE NATIONAL CONGRESS OF AMERICAN INDIANS (NCAI) 

On behalf of the National Congress of American Indians (NCAI), the oldest, largest, and most representative American Indian and Alaska Native organization serving the broad interests of tribal governments and communities, we hereby submit 


214d7.eps

The lack of a 100% federal Medicaid m!ttch divides the IHS' lffiU system of care, inteiTUpting 

the coordination of cere between IHS, tribal, and Urban Indian Heallh Progrems Our AllAN 

Medicaid eligible clients are highly mobile and low incDme,\hey receive eare when and where 

they can. They may sl<!lrt a cDurse of care at SIHB, and because they have to follov1work, 

family, or tribal obligations, a oontinu~y of ~:arE< is not established. Bee<iuse IHS and tribal 

programs receive 100% federal Medicaid dollars, they can coordinate with the Centers for 

Medicare and Medicaid ScNkcs to provide unique models of health care 5ervices for Native 

people. Urban Indian Health Programs, which receive a blend of state and federal Medicaid 

dollars Including our IHS contract dollars, are mostly Ineligible for these tnrtiatives, Interrupting 

the continuum of care !hal the lff/U system was intended to provide. Furthermore, I he 

Wi!!shington Slate Behavioral Heodth Organi<:ations hills designed an inpatient substance abuse 

services around 8 15-day model. However, ourcurrenllndlgenous Psychology model is bssed 

on a 4~ course of treatment- rendering the reimbursement for our treatment model 

burdensome hoNing to provide up to four times medical ~ecessity four our clietrts. Thus, the 

continuum is interrupted. disrupting cullurally,attuned care which is absolutely critical when 

providing care to help Native people overcome addiction Ia opioids. Were we "ble to beller 

coordinate care with the full backing of Medicaid billing, we would be able to work with our 

partner tribes and commumly entilie:~ lo betterUJe heallh outcomes of our AllAN community. 

Wa~hington State 11as 29 federally reo::ognl~ed tribes cmd 2 Urban Indian Health Programs. and 

a continuum of care would require patients to move seamlessly between IHS, tribal, and urban 

programelo support data consletency and continuity of care. 100% FMAP for Urban Indian 

Health Programs incentlvi~e~ the stale Ia keep the llTJU system of care intact. 

Wrthout 100% FMAP for Urban Indian Health Progre.ms, our Native patients :;~re vulner.~ble \0 

state budgetary concerns and limits to curtail slate Medicaid expenditures. States have limited 

funding for Medicaid SEtlVices and the fedEral match in Washington and many other states is as 

low as 50%. This creates an lncentlve for states to flnd new Way£ to limit Medicaid 

e~penditures, with stales such as Arkansas and ~Visconsin impasing work requirements on 

Medicaid beneficialies. These and other requirements would be devastating to those AllAN 

who need an uninterrupted course of treatment fer 3d diction to opioids and other substan~es. 

The fa~! that state dollars ere implicated in the provision of Medioaid services to AllAN is a 

violation of the federal Trust Responsibility to provide health care to Native people. The 

Supreme Court held In the 1974 case of Morton v. Rulz: that the federal responsibility to provide 

assistance to Amelioan Indians and Alaska Natives Is not limiteC to those living on a 

reservation. In 19?6, in recognition of the deplorable health status of AllAN people living in 

American cities, Congress en a~ tEd the Indian Heal\11 Care Improvement Act to ensure that 

health cere services made ava~able in Fulfillment of the Trust Responsibility reached all AllAN 

people- not just those li~ing on reservations. In 2010. Congress permanently reauthorized the 

Indian health Care Improvement Act and dec:lared that 'It Is the policy oflhe UnitOO Stales in 

rum~ment oflts special trust responslbnttles and legal ollllgations to Indians, to ensure !he 

highest possible health slats for Indiana and urban Indians and to provide all resources 

necessary to effect that policy." II is a contravention of this policy to fracture the lfTIU system of 

care and le8ve AllAN people subjEct to stale efforts to redu~e Medi~aid spending on I he general 

population. 

AllAN people 01re more li~ely than <lilY other rad81 or ethnic group Ia suffer from opioid 

addiction. SIHS is leveraging all available resources to limrt the impact of this epidemic on the 

Native community of Seattle and to sa~e lives. The inclusion of Urban Indian Health Programs 

such as SIHB within the protections of 100% FMAP willlmmedl~tely allow for states to realize 

lnereased savings to their Medicaid doll!lrs by not hBuing to pay for AllAN Medicaid encounters. 

The st81e th!!n has the opportunity Ia leverage I hose savings into reinvestment into ouri!T/U 

sy!tem of care to beller meellhe health seJVice needs of our AllAN community. It will also 

create consisten~y within the 1/f/\J system of care. ensure continuity of health care coverage for 

Native people suffering from opioid addiction, protect AllAN from state efforts to scale llsck 

Medicaid coverage, and reaffirm the federal role In providing health care to Native people, 

wherever thev reside. 
65 

the following testimony for the record of the Senate Committee on Indian Affairs 

Oversight Hearing on ‘‘Opioids in Indian Country: Beyond the Crisis to Healing the 

Community.’’ 

Impact of Opioid Epidemic on Indian Country 

While the opioid crisis is plaguing communities across the country, studies indicate that American Indians and Alaska Natives (AI/ANs) are impacted at a higher 

rate than other groups. According to the Centers for Disease Control and Prevention 

(CDC), AI/ANs had the highest drug overdose death rates compared to all other 

races in 2015. Further, the same CDC study found that the drug overdose death 

rates for AI/ANs in nonmetropolitan areas increased by more than 500 percent between 1999 and 2015. Additional studies indicated that pregnant AI/AN women are 

nearly 9 times more likely than others to be diagnosed with opioid dependency or 

abuse, and one in 10 AI/AN youths age 12 or older used prescription opioids for nonmedical purposes, which is double the rate for Caucasian youth. These statistics illuminate the critical need for a comprehensive strategy to curb the opioid epidemic 

in tribal communities. 

NCAI’s Efforts and Recommendations 

NCAI has been addressing this crisis in various ways, by utilizing NCAI’s Policy 

Research Center to conduct related research, convening meetings of NCAI’s Substance Abuse Prevention Task Force, developing policy objectives during its resolution process, collaborating with the Substance Abuse and Mental Health Services 

Administration (SAMHSA) on developing the Tribal Behavioral Health Agenda, 

holding a roundtable during Executive Council Winter Session, hosting a webinar 

series on the crisis, and congressional advocacy. Based on the findings and feedback 

from these undertakings, NCAI would like to provide the Senate Committee on Indian Affairs with the following recommendations: 

Direct Funding to Indian Country 

Tribal governments need parity with state and local governments. When Indian 

tribes have to go through states in order to access federal funding, the result is 

often unfavorable. Instead, direct federal funding to address the opioid crisis should 

be made available to Indian tribes. Currently, tribes are forced to petition states for 

access to opioid-related grants stemming from the 21st Century Cures Act (Cures 

Act). 

Several pending bills would amend the Cures Act to include Indian tribes and 

tribal organizations alongside states as eligible entities. These include S. 2270, the 

Mitigating METH Act (Daines, MT); H.R. 5140, the Tribal Addiction and Recovery 

Act (Mullin, OK); and S. 2437, the Opioid Response Enhancement Act (Baldwin, 

WI). NCAI strongly supports the goals of these bills. 

Tribal Representation on Federal Task Forces 

Tribal representatives need a seat at the table in order to ensure the unique challenges facing Indian tribes are considered. While Indian Country was disappointed 

about the lack of tribal representation on the President’s Commission on Combatting Drug Addiction and the Opioid Crisis, going forward it is crucial that tribal representatives have the opportunity to serve on federal task forces or commissions 

that are seeking to address the opioid epidemic. 

In September 2017, NCAI, along with the National Indian Health Board, sent a 

letter to former Secretary Tom Price asking him to include a tribal representative 

on the Department of Health and Human Services Pain Management Best Practices 

Inter-Agency Task Force (Task Force). NCAI remains hopeful that a tribal representative will be selected to serve on the Task Force. 

In addition, NCAI recommends that the Indian Health Service’s National Committee on Heroin, Opioid, and Pain Efforts (HOPE) include tribal representation. 

While the committee is comprised of IHS subject matter experts, it is important to 

collaborate with tribal leaders in order to fulfill the HOPE Committee’s purpose— 

promoting appropriate and effective pain management, reducing overdose deaths 

from heroin and prescription opioid misuse, and improving access to culturally appropriate treatment. 

Collaboration and Coordination among Agencies and Tribes 

In 2016, NCAI passed Resolution #PHX–16–027, which calls upon all federal 

agencies to increase resources in order to advance education, prevention, treatment 

services, and public safety programs designed to address heroin and opioid abuse 

and addiction within Indian Country. As Congress makes more resources available, 

effective collaboration and coordination among federal agencies is needed in order 

to pool together the resources that are available to tribal communities. Further, InVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00069 Fmt 6601 Sfmt 6621 S:\DOCS\32784.TXT JACK
66 

dian tribes needs flexibility in using various funding sources to develop culturally 

appropriate programs to address the crisis. 

NCAI agrees with Senator Barrasso’s statement at the hearing: ‘‘Successful implementation of programs requires cooperation and coordination from all sides—Interior, Justice, Health and Human Services, and the tribes themselves.’’ A memorandum of understanding between these agencies may be a valuable tool to help 

achieve this objective. NCAI is equipped to help ensure that Indian Country is made 

aware of the resources available throughout the Federal Government, and able to 

bring agencies together at various NCAI forums. 

There are two other important aspects to federal agency cooperation with tribes. 

First, tribal governments have increasing law enforcement and public safety needs 

as they work to address the crisis with opioids and other forms of substance abuse. 

Interagency Task Forces are a proven method of leveraging available resources by 

increasing cooperation among tribal, federal and state law enforcement, and we urge 

further consultation on using the Task Force model to address the substance abuse 

crisis. In addition, tribal courts and correctional systems need additional resources 

for treatment that can serve as alternatives to incarceration. 

Second, the conduct of large pharmaceutical companies has been a focal point in 

opioid-related litigation. Numerous state, local and tribal governments have filed 

lawsuits against opioid manufacturers and distributors in various state and federal 

courts, alleging that they helped create the crisis by improperly marketing the 

drugs. Tribes are seeking medical costs, social services costs, child welfare costs, and 

public safety costs. More importantly, tribes are seeking injunctive relief to reduce 

the flow of unregulated opioids. U.S. District Judge Dan Polster of the Northern 

District of Ohio is overseeing more than 200 of the opioid cases filed in federal court, 

in multidistrict litigation under 28 U.S.C. 1407. The Department of Justice has filed 

a statement of interest on behalf of the Federal Government. There is an opportunity for the Committee to urge the Department to coordinate and consult with 

tribal governments, and ensure that tribal interests are properly considered in the 

nationwide multi-district litigation. 

Culturally Based Solutions 

For Indian Country, factors related to historical and intergenerational trauma will 

have to be taken into account when addressing this crisis. The high rates of depression, suicide, and substance abuse in Indian Country are often deeply rooted underlying issues. The National Tribal Behavioral Health Agenda (TBHA), which is the 

result of a collaborative effort between Indian Country and its federal partners, 

serves as a valuable guide in the efforts to address the opioid crisis in Indian Country. A major tenant of the TBHA is the recognition and support of ‘‘tribal efforts 

to incorporate their respective culture wisdom and traditional practices [sic] in programs and services that contribute to improved well-being.’’ 

Legislation such as the Native Health Access Improvement Act (H.R. 3704 

(Pallone, NJ) and S. 2545 (Smith, MN)) is a step in the right direction. These bills 

would establish a Special Behavioral Health Program for Indians (SBHPI) grant 

program for the prevention and treatment of mental health and substance abuse 

disorders. The proposed SBHPI program is modeled after the Special Diabetes Program for Indians (SDPI), which has been highly successful, in part, due to its allowance for the incorporation of culture and flexibility in utilizing the funding. 

Data Collection 

In March 2018, NCAI’s Policy Research Center (PRC) published a brief titled, 

‘‘The Opioid Epidemic: Definitions, Data, Solutions.’’ The PRC brief highlights the 

need for more reliable data related to the opioid epidemic. It finds that the data on 

death rates are often underestimated in AI/ANs due to misidentification on death 

certificates and that national data does not reveal potential regional/local differences 

in impact. While some tribes indicate that opioids are a huge problem in their communities, others point to greater problems with other abused substances. This underscores the need to understand local and regional trends to inform action. As 

Chairman Hoeven indicated at the hearing, ‘‘[w]ithout accurate data, Congress, the 

Administration and tribes are limited in their ability to allocate resources to the 

area of greatest need.’’ In addition, it is important for agencies to establish benchmarks for success. 

Conclusion 

NCAI applauds the Committee for holding the hearing on this urgent matter and 

appreciates the opportunity to submit this testimony for the hearing record. Addressing this epidemic will require a multifaceted, collaborative approach across all 

levels of government. 

67 

1Through THOR, each of the Tribe’s departments have specific responsibilities for reaching 

the THOR goals. See Tribal Healing Opioid Response Program, https://www.nihb.org/docs/ 

12032017/Tuesday%20Sessions/THOR%20Presentation.pdf (last accessed March 15, 2018). 

PREPARED STATEMENT OF HON. JEROMY SULLIVAN, CHAIRMAN, PORT GAMBLE

S’KLALLAM TRIBE

Dear Chairman Hoeven: 

On behalf of the Port Gamble S’Klallam Tribe (the ‘‘PGST’’), thank you for inviting us to testify on March 14, 2018 at the Senate Committee on Indian Affairs (the 

‘‘Committee’’) hearing titled ‘‘Opioids in Indian Country: Beyond the Crisis to Healing the Community.’’ We would also like to thank Senator Cantwell for her very 

kind introduction of our witness, Jolene George, a member of the PGST and our Behavioral Health Director. 

We were pleased to share our experiences with the Committee and are proud of 

the steps we have taken towards formulating and implementing a multi-faceted, 

comprehensive approach to respond to the opioid epidemic in our community. It is 

encouraging to hear the Committee member’s commitment to bipartisan and crosscommittee efforts. We are hopeful that this dedication will result in the adoption 

of legislation specifically targeting the opioid crisis devastating Indian Country. As 

the Committee continues its endeavors. the PGST is delighted to continue assisting 

it in whatever way we can. 

One lesson that we have learned is that incorporation of traditional healing practices, cultural beliefs regarding approaches to treatment, and differences in interpersonal communication contributes significantly to the quality of care Native people need. It is also key for helping our members escape the destructive cycle of substance abuse. For over 20 years, the PGST has been actively involved in directly 

providing culturally appropriate health care services to our tribal members and Native community members living on the Port Gamble S’Klallam Reservation. Since 

joining the Tribal Self-Governance Project. a consortium of self-governing tribes, in 

1990, we have funded our health care services through a compact with the Indian 

Health Service under the Indian Self-Determination and Education Assistance Act. 

We operate and manage our entire health system on our Reservation, which includes primary care, dental, mental health, and substance abuse services. 

As Ms. George testified, the heart of our opioid response is THOR: Tribal Healing 

Opioid Response. The Tribe convened THOR out of necessity to address the intense 

and widespread impact of the crisis on our community. The main goals of THOR 

are: (1) preventing opioid misuse and abuse; (2) expanding access to opioid use disorder treatment; and (3) preventing deaths from overdose. Every department across 

the PGST is responsible for implementing strategies to achieve these goals. 1 Additionally, we coordinate with the State of Washington, Jefferson and Kitsap Counties, 

and other nearby tribes to fight opioid addiction and treat those affected. 

Support for Specific Legislation 

We have shown leadership by implementing an aggressive and comprehensive approach for responding to the opioid epidemic in our community. However, as testified, we still need the help of this Committee, Congress, and Federal agencies to 

continue our effective efforts to respond to the opioid crisis. We support several 

pieces of legislation introduced in the Senate with the hope that Congress will enact 

them soon and aid our efforts in combating the crisis. 

S. 2440, the Comprehensive Addiction, Recovery, Education and Safety (CARES) 

Act. This bill introduced by Committee Member Senator Cantwell—our Senator— 

would provide law enforcement with more tools to hold drug companies accountable 

for ensuring that their drugs do not enter the illicit drug market. Specifically, the 

bill increases civil and criminal penalties on companies that fail to keep proper 

records or report suspicious opioid distribution practices. Additionally, the bill authorizes funding for the Drug Enforcement Agency (DEA) to investigate suspect 

drug companies and drug trafficking organizations. The PGST supports S. 2440 because it aligns with our goals in our federal lawsuit to hold drug companies accountable for the destruction caused by the opioid crisis that stems from their failure to 

track orders and for creating an illicit market for their drugs. 

S. 2270, the Mitigating the Methamphetamine Epidemic and Promoting Tribal 

Health Act (the ‘‘Mitigating METH Act’’). This bill, introduced by Committee Member Senator Daines, would make tribes and tribal organizations eligible for direct 

funding (no set-aside) under the 21st Century Cures Act, which provides funding for 

prevention and response to opioids, or other substances—such as 

methamphetamines—if they are having a substantial impact on the state or tribe. 

The bill would increase the allocation of $500 million to $525 million. The PGST 

68 

supports S. 2270 because it gives us access to direct funding and important resources for combatting the crisis, in recognition of the government-to-government relationship we have with the Federal Government. 

S. 2437, the Opioid Response Enhancement Act. This bill, introduced by Senator 

Baldwin, would also make tribes and tribal organizations eligible for funding under 

the 21st Century Cures Act but through a 10 percent tribal set-aside. Like S. 2270, 

tribes and states could use this funding for prevention and response to other substances threatening public health—such as methamphetamines. Additionally, the 

bill requires the Substance Abuse and Mental Health Services Administration 

(SAMHSA) to provide technical assistance to both states and tribes for grant applications, formulating outreach and support efforts, and collecting data. The PGST 

supports S. 2437 because it has targeted funding for Indian Country, where Native 

families and communities feel the disparate impacts of the crisis hardest. 

S. 2545, the Native Behavioral Health Access Improvement Act of 2018. Recently 

introduced by Committee Member Senator Smith, this bill aims to help combat the 

opioid epidemic by creating the Special Behavioral Health Program for Indians 

(SBHPI): a grant program modeled after the Special Diabetes Program for Indians 

(SDPI) and administered by the Indian Health Service (IHS), in coordination with 

SAMHSA. The SBHPI would provide IHS, tribes and tribal organizations, and 

urban Indian health programs with access to much-needed resources for addressing 

mental health needs and substance use disorders, specifically providing $150 million 

in annual mandatory funding from FY 2018 to FY 2022. The grants would give 

tribes needed flexibility to provide tribally driven, culturally appropriate behavioral 

health care to meet the specific needs of their communities. The bill also provides 

that IHS, in coordination with SAHMSA, would create a technical assistance center 

responsible for developing grant-reporting standards in consultation with tribal 

grantees. 

The PGST has operated a robust SDPI program for many years and is confident 

that its use as a model for the SBHPI will be a success. However, we caution 

against providing tribes resources through another program funded in the form of 

grants because competitive funding pits struggling tribes and local governments 

against each other for access to limited resources when we should be working together. One of the reasons why our THOR program is so effective is that the PGST 

has good relationships with State, County, and regional groups to coordinate on response strategies. The PGST does support S. 2545, but suggests, as an alternative 

to grant funding, that self-governance tribes—such as the PGST—be able to receive 

funding through their self-governance compacts. 

Additional Information in Response to Committee Member Questions 

During the Committee’s March 14 Opioid Hearing, Committee Members were actively engaged in questioning the witnesses and we wanted to follow-up on several 

of those questions to make sure the Committee has ample information about our 

specific needs and those of Indian Country. 

In response to Vice-Chairman Udall’s questions about the impacts of funding cuts 

on the PGST’s ability to respond to the opioid crisis and what departments—other 

than behavioral health—should have direct funding, we would answer that any reduction in funding harms our ability to respond and every department that the 

PGST operates needs direct funding for its programs and services. At a government 

level, our Health, Behavioral Health, Children & Family Services, and Housing Departments, as well as our courts, law enforcement, and administration, all have a 

role to play in responding to this crisis. It affects all of our members and Tribal 

agencies. Adequate direct funding means reliable resources and flexibility for the 

PGST to continue implementing our culturally appropriate, multi-faceted, comprehensive approach to abating the opioid epidemic sweeping the community. Additionally, adequate direct funding allows us to plan long term for infrastructure development, program enrichment, and service enhancements necessary for the wellbeing of our members and local community. 

Thank you for the opportunity to speak on behalf of the PGST regarding the 

opioid epidemic. We look forward to further opportunities for discussion and to actively working with the Committee to tackle the opioid epidemic. 

We hope that you and the entire Committee will accept our invitation to come 

visit the Port Gamble SiKlallam Reservation to see our work—and significant 

needs—to respond to the opioid crisis. 

69 

PREPARED STATEMENT OF THE SOUTHCENTRAL FOUNDATION (SCF) 

Southcentral Foundation (SCF) submits written testimony to the Senate Committee on Indian Affairs to supplement its March 14, 2018 hearing entitled: ‘‘Opioids 

in Indian Country: Beyond the Crisis to Healing the Community.’’ SCF is the Alaska 

Native tribal health organization designated by Cook Inlet Region, Inc. (CIRI) and 

eleven Federally-Recognized Tribes—the Aleut Community of St. Paul Island, 

Igiugig, Iliamna, Kokhanok, McGrath, Newhalen, Nikolai, Nondalton, Pedro Bay, 

Telida, and Takotna—to provide healthcare services to beneficiaries of the Indian 

Health Service (IHS) pursuant to a contract with United States government under 

the authority of the Indian Self Determination and Education Assistance Act 

(ISDEAA) P.L. 93–638. 

SCF provides a variety of medical services, including dental, optometry, behavioral health and substance abuse treatment to over 65,000 Alaska Native and American Indian people. This includes 52,000 people living in the Municipality of Anchorage, the Matanuska-Susitna Borough to the north, and 13,000 residents of 55 rural 

Alaska villages. Our services cover an area exceeding 100,000 square miles. SCF 

employs more than 2,300 people to administer and deliver these critical healthcare 

services. 

We appreciate Committee Chairman Hoeven calling the hearing and hosting a 

roundtable discussion last November concerning opioid misuse. At the March 14th 

oversight hearing, Senator Hoeven remarked: ‘‘The roundtable highlighted how the 

opioid abuse epidemic is particularly complex in tribal communities given the lack 

of access to medical care, shortage of law enforcement and insufficient data on substance abuse.’’ 

We applaud the efforts by Committee Vice Chairman Udall, and other members 

of the Committee, who wrote to Senate Appropriations Committee leaders earlier 

this month to urge them to provide ‘‘robust direct funding to tribal communities’’ 

in the FY 2018 omnibus measure for federal programs that will aid in the prevention, treatment and recovery from opioid misuse ‘‘to address the disparate impacts 

of the opioid crisis in Indian Country’’. 

We also appreciate the day-to-day work that Committee members perform to educate your Senate colleagues about the challenges tribes and tribal organizations like 

SCF face to prevent drug abuse, successfully treat individuals with addiction disorders, and save the lives of high-risk individuals who would otherwise overdose. 

If Alaska Native healthcare providers are to stop the misuse of prescription 

opioids and illegal drugs like heroin and fentanyl, and begin to heal our Alaska Native customer-owners, we, together with the Federal Government, must attack the 

root causes that drive demand for such drugs: lack of access to appropriate care for 

medical conditions requiring pain management, trauma (domestic abuse, child 

abuse, historic trauma, etc.), mental health disorders, poverty, unemployment, overcrowded housing, and lack of access to prevention, treatment, and recovery services. 

We urge the Committee and the Congress to ensure that Alaska Native communities receive an appropriate share of federal funds to stop the illegal distribution 

of opioids, reduce overdoses, support educational awareness programs, and provide 

the facilities and medication-assisted treatment (MAT) programs that Alaska Native 

communities require to combat the opioid epidemic. It is crucial in the battle against 

opioid misuse that Indian tribes and tribal organizations, like SCF, are direct recipients of federally appropriated funds to fight the opioid crisis, consistent with the 

government-to-government relationship. 

We therefore strongly support legislation such as Senator Daines’ ‘‘Mitigating 

METH Act,’’ S. 2270, and Senator Baldwin’s ‘‘Opioid Response Enhancement Act,’’ 

S. 2437. These measures would amend the 21st Century Cures Act to include ‘‘Indian tribes and tribal organizations’’ and ‘‘Tribal entities’’ as direct recipients of federal appropriations to fight the opioid epidemic; provide tribes greater flexibility to 

prevent and treat other substances, such as methamphetamines; establish set-asides 

for tribes; and increase overall federal appropriations. We recommend that federal 

appropriations for tribes and tribal organizations be distributed in a manner similar 

to the Special Diabetes Program for Indians (SDPI) to ensure that every tribe receives funds based on well documented need. 

The opioid epidemic did not occur overnight. In April 2017, the State of Alaska 

Epidemiology noted that overdose deaths steadily increased in Alaska and throughout the country due to three sequential epidemiological phenomena: 

The first episode began in the mid-1990s with changes in standards for pain 

management, approval of new, extended release prescription opioid pain relievers, and aggressive pharmaceutical marketing to encourage the use of prescription opioids. A four-fold increase in prescribing led to a roughly four-fold increase in prescription opioid deaths and created a widespread increase in opioid 

70 

1State of Alaska Epidemiology, Bulletin No. 11, April 20, 2017, http://www.epi.alaska.gov/ 

bulletins/docs/b201711.pdf 2Testimony of RADM Michael E. Toedt, MD, FAAFP, Chief Medical Officer, IHS, March 14, 

2018. 3 Id., p. 3. 4State of Alaska Epidemiology Bulletin, No. 6, March 24, 2016, http://www.epi.alaska.gov/ 

bulletins/docs/b2016l06.pdf. 5See https://www.mcdowellgroup.net/wp-content/uploads/2017/03/mcdowell-groupeconomicimpacts-of-drug-abuse-final-3.10.17.pdf. 

dependency and addiction. The second wave emerged over the last 10–15 years 

as heroin prices decreased, and the purity increased, offering an alternative to 

prescription opioids for persons who were addicted to or dependent on opioids. 

The third wave developed over the past 3 years as illicit fentanyl began to enter 

the opioid black market. 1

According to the Centers for Disease Control and Prevention (CDC), and confirmed by Rear Admiral Michael E. Toedt, Chief Medical Officer, IHS, in his appearance before the Committee on March 14, 2018, Alaska Natives and American Indians (AN/AIs) ‘‘had the highest drug overdose death rates in 2015 and the largest 

percentage increase in the number of deaths over time from 1999–2015 compared 

to other racial and ethnic groups.’’ 2 During that time, deaths rose more than 500 

percent among AN/AIs. 3 According to IHS, among AN/Ais, the rate of drug overdose 

deaths is twice that of the general population. Rear Admiral Toedt cautioned that 

due to misclassification of race and ethnicity on death certificates, the actual number of deaths for AN/AIs may be underestimated by up to 35 percent. 

According to the State of Alaska Epidemiology, from 2009–2015, there were 774 

drug overdose deaths in the State and AN/AIs had the highest overdose death rate 

by race from 2009–2014, at 20.2 deaths per 100,000. 4 In February 2017, Alaska 

Governor Bill Walker declared the opioid epidemic a public health disaster. According to the CDC, in 2016, there were 64,000 drug overdose deaths in the United 

States, largely driven by prescription and illicit opioids. In a March 2017 study prepared for the Alaska Mental Health Trust Authority, the McDowell Group estimated 

the economic cost of the opioid crisis in Alaska alone was $1.2 billion in 2015 when 

measured in terms of lost productivity, motor vehicle crashes, health care, criminal 

justice and protective services and public assistance. 5

Senator Lisa Murkowski has remarked: ‘‘Alaska may be a rural state, but we are 

not shielded from this epidemic. . . . Opioid abuse in Alaska is devastating our communities throughout the state and has rapidly become one of our most pressing 

issues.’’ Senator Dan Sullivan also knows the great harm that the epidemic is causing to Alaska families. In August 2016, he convened a summit in Palmer, Alaska. 

He recognized that the communities hit hardest by opioid misuse are often those 

in economic distress. The opioid epidemic places a tremendous strain on Native communities already stretched too thin. SCF and other tribal healthcare providers need 

more federal resources if we are to stop the epidemic and reverse its harmful effects 

on Alaska Native families and our State. At that summit, SCF President and CEO, 

Katherine Gottlieb stated that SCF wants to expand our capacity to provide treatment for individuals struggling with addiction disorders but recurring federal resources to sustain and expand such programs remains our greatest obstacle. 

President Trump declared a nationwide public health emergency concerning the 

opioid crisis on October 26, 2017. In February 2018, Congress passed the ‘‘Bipartisan Budget Act of 2018,’’ Pub. L. 115–123, which includes $6 billion over two years 

(FY 2018 and FY 2019) to supplement federal appropriations for opioid addiction by 

funding grants, prevention programs, and law enforcement services. That legislation, however, did not make tribes and tribal organizations direct recipients of federal funding. As noted above, dedicating funding for Alaska Natives and American 

Indians is the best means to ensure that federal funds reach Indian Country and 

the tribal organizations that can make a difference in fighting the opioid epidemic. 

Give us the resources and we will expand our demonstrated ability to successfully 

treat patients with opioid addiction by using evidence-based treatment protocols performed in culturally appropriate and familiar settings. 

Sam Moose, the Treasurer of the National Indian Health Board (NIHB), testified 

at the March 14 hearing that the opioid epidemic is ‘‘one of the most pressing public 

health crises affecting tribal communities,’’ and has ‘‘further strained the limited 

public health and healthcare resources available to tribes.’’ NIHB noted that Congress has historically funded IHS at a level below patient need. In FY 2017, Moose 

testified that national health spending was $9,207 per capita while IHS spending 

was only $3,332 per patient, nearly one-third less for Alaska Native/American Indian individuals. 

71 

6Testimony of Elinore McCance-Katz, M.D., Ph.D., Assistant Secretary for Mental Health and 

Substance Use, Substance Abuse and Mental Health Services Administration (SAMHSA), Debra 

Houry, M.D., M.P.H, Director, National Center for Injury Prevention and Control, Centers for 

Disease Control and Prevention (CDC), and Francis Collins, M.D., Ph.D., Director, National Institutes of Health (NIH), on ‘‘Addressing the Opioid Crisis in America: Prevention, Treatment, 

and Recovery,’’ December 5, 2017, before the Senate Appropriations Subcommittee on Labor, 

Health and Human Services, Education and Related Agencies; https://www.nih.gov/aboutnih/ 

who-we-are/nih-director/testimony-addressing-opioid-crisis-america-preventiontreatmentrecovery-before-senate-subcommittee. Emphasis added. 

In April 2017, the U.S. Department of Health and Human Services (DHHS) outlined a five-point, evidence-based Opioid strategy: 

1. Improve access to prevention, treatment, and recovery support services to 

prevent the health, social, and economic consequences associated with opioid 

addiction and to enable individuals to achieve long-term recovery; 

2. Target the availability and distribution of overdose-reversing drugs to 

ensurethe broad provision of these drugs to people likely to experience or respond to an overdose, with a particular lbcus on targeting high-risk populations; 

3. Strengthen public health data reporting and collection to improve the timeliness and specificity of data and to inform a real-time public health response 

as the epidemic evolves; 

4. Support cutting-edge research that advances our understanding of pain and 

addiction, leads to the development of new treatments, and identifies effective public health interventions to reduce opioid-related health harms; and 

5. Advance the practice of pain management to enable access to high-quality, 

evidence-based pain care that reduces the burden of pain for individuals, 

families, and society while also reducing the inappropriate use of opioids and 

opioid-related harms. 

Last year, IHS chartered the National Committee on Heroin, Opioids and Pain 

Efforts (HOPE) to help implement the Department’s five-part strategy to combat the 

opioid epidemic. Alaska Governor Walker also established a similar Program HOPE 

(Harm reduction, Overdose Prevention, and Education) which is providing overdose 

reversal kits with naloxone and launching a public information campaign. We 

wholeheartedly agree with these approaches. 

Last December, the heads of three federal agencies; the Substance Abuse and 

Mental Health Services Administration (SAMHSA), the National Center for Injury 

Prevention and Control, Centers for Disease Control and Prevention (CDC), and the 

National Institutes of Health (NIH), presented joint testimony to Congress concerning the opioid epidemic. The agency officials confirmed the first cause of the epidemic noted by the State of Alaska Epidemiology; the significant rise in the prescription of highly addictive opioid drugs. In addition, the agency officials stated 

that delays by the U.S. healthcare system in providing effective treatment programs, especially medication-assisted treatment (MAT) programs, exacerbated the 

problem of opioid addiction brought about by the over-prescription of highly addictive opioids. They noted that: 

It is well-documented that the majority ofp eople with opioid addiction in the 

U.S. do not receive treatment, and even among those who do, many do not receive evidence-based care. Accounting for these factors is paramount to the development of a successful strategy to combat the opioid crisis. 6

Each year, SCF and other tribal organizations have urged IHS to request, and 

Congress to appropriate, increased funding for behavioral health, including funding 

for the Substance Abuse and Suicide Prevention (SASP) programs as well as increased funding for the Purchased Referred Care (PRC) program to address substance abuse, treatment and recovery programs. 

In FY 2017, IHS allocated $30 million in Substance Abuse and Suicide Prevention 

(SASP) funds to 175 IHS, tribal and urban Indian health organizations to develop 

and implement culturally appropriate, evidence-based, community driven programs. 

The average funding level was only $171,000 for the service providers. The Federal 

Government must do better and appropriate greater resources for this important 

work so that many more at-risk Alaska Natives and American Indians can recover 

from opioid addiction and lead a productive life. 

With available federal funding, SCF established The Pathway Home, a voluntary, 

comprehensive, and individualized mental health program for adolescents from 13 

to 18 years old. The Pathway Home teaches invaluable life skills to Alaska Native 

72 

youth so that they turn away from harmful behaviors. Many of these youth have 

already experienced trauma or have seen family members struggle with drug and 

alcohol dependencies, which puts them at greater risk of turning to drugs and alcohol later. The mission of the Pathway Home is to create a loving and supportive 

community environment where Alaska Native children can develop into independent, serviceminded and productive leaders. Increased funding to address root 

causes of substance abuse is crucial to combating the opioid crisis. 

SCF also operates Dena A Coy (DAC), a residential treatment program that 

serves pregnant, parenting and non-parenting women who are experiencing problems related to alcohol and other drugs and experiencing emotional and psychological issues. This program is open to all women in Alaska, regardless of ethnicity, 

and allows some women to participate in the program with their children under the 

age of 3. Our overall philosophy is to treat the person as a whole, let our customerowners drive their healthcare decisions, and give them the tools and skills to make 

healthy decisions. DAC matches national standards for successful program completion. The success rate of this program shows that our approach is working, and with 

more resources we could expand this program and treat more people who need these 

services. 

If tribal organizations such as SCF are to stop the misuse of opioids, alcohol and 

other harmful substances and begin the process of helping individuals and families 

recover, we must have more resources, personnel and, equally important, the facilities to house these programs. With a service population of 65,000 our resources are 

wholly insufficient in comparison to the crisis. Timely treatment for opioid addiction 

can mean the difference between recovery or death. 

Prevention, education and timely medication-assisted treatment programs remain 

our most potent tools to raise a new generation of Alaska Native people who practice positive, life-affirming behavioral traits and who will, in turn, pass on these life 

lessons to their children and grandchildren. Only then will the cycle of trauma and 

opioid addiction be broken. 

Thank you for convening the March 14, 2018 hearing and for allowing us the opportunity to provide testimony. 

PREPARED STATEMENT OF THE TANANA CHIEFS CONFERENCE (TCC) 

Tanana Chiefs Conference (TCC) submits written testimony to the Senate Committee on Indian Affairs to supplement its March 14, 2018 hearing entitled: 

‘‘Opioids in Indian Country: Beyond the Crisis to Healing the Community.’’ TCC is 

a non-profit intertribal consortium of 37 Federally-recognized Indian tribes and 41 

Alaska Native communities located across Interior Alaska. TCC serves 18,000 Alaska Natives living in Fairbanks and in the rural villages located along the 1,400 mile 

Yukon River and its tributaries. TCC’s service area encompasses 235,000 square 

miles, about the size of Texas. 

To help remote, Interior Alaska Native villages combat the opioid epidemic, Congress must make federal appropriations directly available to tribes and tribal organizations, and give us the flexibility we require to use such funds to prevent, treat 

and help individuals recover who are already addicted to prescription and illicit 

opioids and other illegal drugs. 

We applaud the efforts that Committee Chairman Hoeven has taken to highlight 

the destructive effect that the opioid epidemic is causing to American Indian and 

Alaska Native communities. The March 14, 2018 hearing followed a roundtable discussion Chairman Hoeven convened last November concerning the opioid misuse in 

Indian Country. Senator Hoeven remarked: ‘‘The roundtable highlighted how the 

opioid abuse epidemic is particularly complex in tribal communities given the lack 

of access to medical care, shortage of law enforcement and insufficient data on substance abuse.’’ At the March 14 hearing, Chairman Hoeven stated that: ‘‘I am also 

mindful that when Congress does appropriate funding to combat this epidemic, it 

is important that Indian Country receives an adequate share of the funding and receives this funding in a manner that will ensure maximized impact to their communities.’’ 

TCC fully supports the Chairman’s remarks. If tribes are to stop the misuse of 

prescription opioids and illegal drugs, Congress must help tribes and tribal organizations attack the root causes: deferred medical treatment of conditions that require 

pain management, domestic and child abuse, homelessness, poverty, unemployment, 

and lack of prevention, substance abuse treatment, recovery services, and adequate 

law enforcement. 

In addition to ensuring that tribes and tribal organizations have access to federal 

appropriations to educate, prevent, and treat opioid addiction, Congress must also 

73 

1 Indian Law & Order Commission, November 2013, A Roadmap for Making Native America 

Safer, Report to the President & Congress of the United States, Chapter Two, Reforming Justice 

for Alaska Natives: The Time is Now, pp. 35–43. See https://www.aisc.ucla.edu/iloc/report/ 

files/Chapterl2lAlaska.pdf. 

recognize the challenges tribes and tribal organizations face to adequately finance 

essential government services such as healthcare, education and job training, public 

safety, and the facilities to house these programs. This is especially true in remote, 

rural areas, such as Interior Alaska where TCC operates. Too often, federal appropriations make the difference between the success and failure of tribal initiatives, 

which in turn, determine whether economic and social conditions in Alaska Native 

communities improve or deteriorate. Promoting and funding Federal programs that 

keep Alaska Native families together, and help them prosper, is one of the best 

means of combating the opioid epidemic in tribal communities. 

To better inform Congress of the magnitude of the problem remote Alaska Native 

communities face to fight the opioid epidemic that threatens our way of life, Congress must better appreciate the degree of isolation that exists in rural Alaska. We 

share below excerpts from the Indian Law & Order Commission’s 2013 report: ‘‘A 

Roadmap for Making Native America Safer,’’ relevant to Alaska: 

Forty percent (229 of 566) of the federally recognized Tribes in the United 

States are in Alaska, and Alaska Natives represent one-fifth of the total State 

population. Yet, these simple statements cannot capture the vastness or the Nativeness of Alaska. The State covers 586,412 square miles, an area greater than 

the next three largest states combined (Texas, California, and Montana). There 

are only 1.26 inhabitants per square mile-as compared to 5.85 for Wyoming, 

which is the next least populous state. 

Many of the 229 federally recognized tribes are villages located off the road system and ‘‘more closely resemble villages in developing countries’’ than small 

towns in the lower 48. Frequently, Native villages are accessible only by plane, 

or during the winter when rivers are frozen, by snow-machine. Food, gasoline, 

and other necessities are expensive and often in short supply. . . . While Alaska Natives constitute a majority of the rural population, each community is 

nonetheless quite small; typical populations are in the range of 250–300 residents, many of whom share family or clan affiliations. Villages are politically 

independent from one another. . . . 

Problems with safety in Tribal communities are severe across the United 

States-but they are systematically the worst in Alaska. This is evident in an 

array of data concerning the available services, crime, and community distress. 

Most Alaska Native communities lack regular access to police, courts, and related services: 

• Alaska Department of Public Safety (ADPS) officers have primary responsibility for law enforcement in rural Alaska, but ADPS provides for only 1.0– 

1.4 field officers per million acres. . . . According to ADPS, troopers’ efforts 

‘‘are often hampered by delayed notification, long response distance[s], and 

the uncertainties of weather and transportation. 

Social distress, which can be a cause of crime or other threats to public safety, 

is also high among Alaska Natives and in Alaska’s Tribal communities: 

• The suicide rate among Alaska Natives is almost four times the U.S. general 

population rate, and is at least six times the national average in some parts 

of the State. 

• In 2011, over 50 percent of the 4,499 reports of maltreatment substantiated 

by Alaska’s child protective services and over 60 percent of the 769 children 

removed from their homes were Alaska Native children. 1

The opioid crisis came as Alaska Native communities were already confronting 

daunting public safety and public health challenges. Public safety services remain 

one of the biggest challenges for our Alaska Native communities. Alaska is one of 

six P.L. 280 States in which jurisdiction over crimes in tribal communities rests 

mainly with the States. The Bureau of Indian Affairs (BIA) simply does not have 

sufficient funding for law enforcement services, so it prioritizes its public safety efforts in non-P.L. 280 States on the false assumption that P.L. 280 States like Alaska 

are investing sufficiently in public safety and law enforcement services in tribal 

communities. This is not the case. Without basic law enforcement services for our 

tribal governments, and without sufficient funds for tribal governments to fight 

opioid addiction, our communities are at much greater risk. The statistics bear this 

74 

2Testimony of RADM Michael E. Toedt, MD, FAAFP, Chief Medical Officer, Indian Health 

Service (IHS), U.S. Department of Health and Human Services, before the Senate Committee 

on Indian Affairs, Hearing on Opioids in Indian Country: Beyond the Crisis to Healing the Community, March 14, 2018. 3 Id., p. 3. 4 Id. 

5State of Alaska Epidemiology Bulletin, No. 6, March 24, 2016, http://www.epi.alaska.gov/ 

bulletins/docs/b2016l06.pdf. 6Testimony of Christopher M. Jones, PharmD., M.P.H., Director, National Mental Health and 

Substance Use Policy Laboratory, Substance Abuse and Mental Health Services Administration 

(SAMHSA), U.S. Department of Health and Human Services before the Senate Committee on 

Indian Affairs, Hearing on Opioids in Indian Country: Beyond the Crisis to Healing the Community, March 14, 2018. 

out. TCC has been using what little resources it has to build partnerships with 

State and local law enforcement to curb the influx of drugs in to our off-road communities. A tribally led, grassroots effort raised several thousands of dollars to hire 

and train a canine unit for the Alaska State Troopers in our hub community. TCC 

supports this type of ownership of issues at a local level, but is all too aware of the 

limitations of these efforts without continued and dedicated funding. 

According to the Centers for Disease Control and Prevention (CDC), American Indians and Alaska Natives ‘‘had the highest drug overdose death rates in 2015 and 

the largest percentage increase in the number of deaths over time from 1999–2015 

compared to other racial and ethnic groups.’’ 2 During that time, deaths rose more 

than 500 percent among AIANs. 3

The Indian Health Service (IHS) notes that among American Indians and Alaska 

Natives, the rate of drug overdose deaths is twice that of the general population. 

The actual number of deaths for AIANs may be underestimated by up to 35 percent. 4

According to the State of Alaska Epidemiology, from 2009–2015, there were 774 

drug overdose deaths in the State and AIANs had the highest overdose death rate 

by race from 2009–2014, at 20.2 deaths per 100,000. 5 In February 2017, Alaska 

Governor Bill Walker declared the opioid epidemic a public health disaster. According to the CDC, in 2016, there were 64,000 drug overdose deaths in the United 

States, largely driven by prescription and illicit opioids. 

The Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health (NSDUH) found that in 2016, 5.2 percent or 72,000 

American Indian and Alaska Native persons aged 18 and older reported misusing 

a prescription drug in the past year and 4.0 percent of AIANs, or 56,000 individuals 

aged 18 and older, reported misusing a prescription pain reliever in the past year. 

SAMHSA Director Jones also noted that over the last decade, the U.S. has experienced a significant increase in the rates of neonatal abstinence syndrome (NAS), 

hepatitis C infections, and opioid-related emergency department visits and hospitalizations. 6

Alaska Governor Walker declared the opioid epidemic in Alaska a public health 

disaster in February 2017 and created project HOPE (Harm Reduction, Overdose 

Prevention and Education). Later that year, President Trump declared a nationwide 

public health emergency concerning the opioid crisis. In February 2018, Congress 

passed the ‘‘Bipartisan Budget Act of 2018,’’ Pub. L. 115–123, which includes $6 billion over two years (FY 2018 and FY 2019) to supplement federal appropriations 

for opioid addiction by funding grants, prevention programs, and law enforcement 

services. Congress has included billions of additional funding in the Consolidated 

Appropriations Act, 2018 omnibus measure, making final appropriations for FY 

2018, to combat the opioid epidemic. 

Federal legislation, however, has not made tribes and tribal organizations direct 

recipients of funding to address the opioid crisis. Direct appropriations and setasides in federal legislation for Alaska Native and American Indian tribes and tribal 

organizations is the best means to ensure that federal funds reach Indian Country 

and the tribal organizations that can make a difference in fighting the opioid epidemic. 

We therefore respectfully urge Congress and the Administration to ensure that 

Alaska Native communities receive an appropriate share of federal funds to stop the 

illegal distribution of opioids, reduce overdoses, support educational awareness programs, and provide the facilities and medication-assisted treatment (MAT) programs 

that Alaska Native communities require to combat the opioid epidemic. Direct funding for tribes and tribal organizations honors the Federal Government’s trust obligation to tribal nations and the special government-to-government relationship between the Federal Government and Indian tribes and Alaska Native Villages. 

75 

1 USET SPF member Tribal Nations include: Alabama-Coushatta Tribe of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian Nation (SC), Cayuga Nation (NY), 

Chitimacha Tribe of Louisiana (LA), Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee Indians (NC), Houlton Band of Maliseet Indians (ME), Jena Band of Choctaw Indians (LA), 

Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag Tribe (MA), Miccosukee Tribe 

of Indians of Florida (FL), Mississippi Band of Choctaw Indians (MS), Mohegan Tribe of Indians 

of Connecticut (CT), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY), Pamunkey Indian Tribe (VA), Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe at 

Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of Creek Indians (AL), Saint 

Regis Mohawk Tribe (NY), Seminole Tribe of Florida (FL), Seneca Nation of Indians (NY), 

Shinnecock Indian Nation (NY), Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag 

Tribe of Gay Head (Aquinnah) (MA). 

We strongly support Senator Daines’ ‘‘Mitigating METH Act,’’ S. 2270, and Senator Baldwin’s ‘‘Opioid Response Enhancement Act,’’ S. 2437. These measures would 

amend the 21st Century Cures Act to include ‘‘Indian tribes and tribal organizations’’ and ‘‘Tribal entities’’ as direct recipients of federal appropriations to fight the 

opioid epidemic, provide tribes greater flexibility to prevent and treat other substances, such as methamphetamines, establish set-asides for tribes, and increase 

overall federal appropriations. We recommend that federal appropriations for tribes 

and tribal organizations be distributed in a manner similar to the Special Diabetes 

Program for Indians (SDPI) so that every tribe receives funding. 

At TCC we use our available funding to promote substance abuse recovery, but 

our resources are limited. We operate the Old Minto Family Recovery Camp, an 

Athabascan alternative to substance abuse treatment where healing is provided in 

a traditional setting. It is our belief that for Alaska Native people today, alcohol and 

drug use/abuse became a toxic way of coping with a loss of traditional Native values, 

cultural patterns identities, relationships, and unresolved trauma. Using Native cultural and traditional values as a foundation, our goal is to help people help themselves as they heal from trauma, choose healthy lifestyles and overcome substance 

use. 

TCC has been working with other stakeholders in the Fairbanks, Alaska area to 

address the homeless situation among individuals suffering from alcohol and opioid 

addictions. TCC also held a three-day training session in January on methamphetamine and its impact on brain and behavior. The program was facilitated by faculty 

from the University of California Los Angeles (UCLA), and provided a skill-building 

workshop for behavioral health staff and treatment providers to address the unique 

challenges meth users bring to health service providers. We have advocated tirelessly, and will continue to do so, for equal access to law enforcement and improvement of public safety services that partially due to extremely limited state funding 

are scarce. We can do so much more to reduce harmful and destructive behavior 

such as opioid prescription misuse if Congress would only appropriate more funds 

for tribes and tribal organizations. If we are to stop the misuse of opioids and other 

harmful substances and begin healing in tribal communities, we must have adequate and recurring federal resources to attract and retain qualified health professionals to come to our remote communities and fight this epidemic. We also require 

the facilities to house substance abuse programs and services. 

TCC and other tribal organizations have successfully demonstrated what we can 

accomplish in remote Alaska Native communities when given the resources. We cannot afford to lose a generation of Alaskans to the opioid epidemic. 

Thank you for allowing us the opportunity to provide testimony. 

PREPARED STATEMENT OF THE UNITED SOUTH AND EASTERN TRIBES SOVEREIGNTY

PROTECTION FUND (USET SPF) 

On behalf of the United South and Eastern Tribes Sovereignty Protection Fund 

(USET SPF), we are pleased to provide the Senate Committee on Indian Affairs 

with the following testimony for the record of the Committee’s oversight hearing, 

‘‘Opioids in Indian Country: Beyond the Crisis to Healing the Community,’’ held on 

March 14, 2018. 

USET SPF is a non-profit, inter-tribal organization representing 27 federally recognized Tribal Nations from Texas across to Florida and up to Maine. 1 Both individually, as well as collectively through USET SPF, our member Tribal Nations work 

to improve health care services for American Indians. Our member Tribal Nations 

operate in the Nashville Area of the Indian Health Service (IHS), which contains 

36 IHS and Tribal health care facilities. Our citizens receive health care services 

both directly at IHS facilities, as well as in Tribally-operated facilities under conVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00079 Fmt 6601 Sfmt 6621 S:\DOCS\32784.TXT JACK
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tracts with IHS pursuant to the Indian Self-Determination and Education Assistance Act (ISDEAA), P.L. 93–638. 

The opioid epidemic has had a devastating effect on USET SPF Tribal Nations 

and Tribal Nations across the country, who continue to experience the destructive 

effects of opioid addiction—often at higher rates than non-Indian communities. According to data from IHS, American Indians and Alaska Natives (AI/ANs) are more 

likely than any other race/ethnicity to have an illicit drug use disorder in the past 

year. In addition, according to the Centers for Disease Control and Prevention 

(CDC), AI/ANs are at the greatest risk for prescription opioid overdose, confronting 

an opioid overdose rate of 8.4 per 100,000. Though USET SPF is encouraged to see 

Congress move in an expeditious manner to identify solutions to the opioid epidemic 

nationwide, USET SPF is concerned that Tribal Nations are frequently left out of 

the conversation, despite the disproportionate impact the opioid epidemic has had 

within Tribal communities. USET SPF reminds the Committee of the unique federal 

trust responsibility to Tribal Nations, and urges the Committee to use its authority 

to ensure Tribal Nations are fully included in any subsequent legislation or other 

Congressional efforts to address the opioid crisis. 

Direct Opioid Funding for Tribal Nations 

The Federal Government has a trust responsibility to ensure Tribal Nations have 

access to resources, financial and otherwise, to combat the opioid epidemic. Among 

these vital resources is access to direct federal funding for Tribal Nations. While 

USET SPF is appreciative of the recent $50 million Tribal set-aside for this purpose 

within the Fiscal Year (FY) 2018 Omnibus, more resources are required to fully address the opioid crisis at the Tribal level. Though our data on this issue is incomplete, that which is available shows Indian Country, including USET SPF Tribal 

Nations, is among the communities affected most by this crisis. Yet, no direct funding stream currently exists to combat this epidemic in Tribal communities. Currently, Tribal Nations are ineligible for a majority of funding available under the 

21st Century Cures Act. Where Tribal Nations are eligible for funding, they are 

forced to compete with state and other entities for limited dollars. Tribal Nations 

should not have to compete to provide their citizens with the treatment they critically need. This is contrary to the federal trust responsibility to provide healthcare 

to Tribal Nations, and results in few resources delivered to Tribal citizens. In addition, the Indian Health System remains chronically underfunded, leaving many 

Tribal communities without the critical resources and funding to address opioid addiction and treatment. During the hearing, Tribal witnesses testified on the need 

for direct funding to Tribal Nations for Tribal opioid treatment and prevention programs due to the increasing levels of opioid abuse, deaths, and trafficking within 

Tribal communities. USET SPF echoes these concerns and urges the Committee to 

prioritize addressing this shortfall by working to ensure Tribal governments have 

access to direct funding. 

Despite the government-to-government relationship between Tribal Nations and 

the United States, many federal grant programs, including those available as part 

of the 21st Century Cures Act, require funding to pass through the states before 

it can be delivered to Tribal governments. Because of this, a majority of Tribal communities have difficulty accessing federal funds, with many completely unable to access them in this manner. Further, when applying for these grants, states will often 

include Tribal population numbers in the overall state population used to determine 

each state’s award. Yet, Tribal Nations are not provided with outreach for these programs and are left with minimal resources to address the opioid crisis in their communities. In order to ensure Tribal Nations are fully accessing these federal funds 

in the future, USET SPF recommends the Committee and Congress: 

1. Consider implementing a funding model utilized by the CDC’s Good Health 

and Wellness in Indian Country initiative, which allows for a direct, separate 

funding mechanism specifically for both Tribal Nations and TECs. This 

model has proven to be successful. 

2. Expand language within grant funding programs to specifically include Tribal 

Nations as direct grantees so that states cannot exclude them in grant funding disbursements. 

3. Recognize that competitive grants are not reflective of the federal trust responsibility and work to provide more funding to Tribal Nations via formulabased distribution methodologies. 

4. Explore opportunities to deliver opioid funding to Tribal Nations via self-governance contracting and compacting in recognition of Tribal sovereignty and 

self-determination. 

77 

2 USET SPF Board of Directors supporting resolution. 

With these priorities in mind, USET SPF urges the Committee and Congress to 

fully consider the following legislation, as it would provide critical opioid response 

resources to Tribal Nations, including direct funding. 

Mitigating METH Act 

As discussed above, despite Tribal advocacy, Tribal Nations are ineligible for a 

majority of funding delivered to state and local governments under the 21st Century 

Cures Act. Where Tribal Nations are eligible for funding, they are forced to compete 

with state and other entities for limited dollars. On December 21, 2017, Senator 

Steve Daines introduced S. 2270, the Mitigating the Methamphetamine Epidemic 

and Promoting Tribal Health Act, or the Mitigating METH Act. The Mitigating 

METH Act would make Tribal Nations eligible to be direct grantees of federal opioid 

funding under the 21st Century Cures Act to combat opioid abuse in our communities. In addition, S. 2270 would provide an increase in grant funding of $25 million to states and Tribal Nations under the State Targeted Response (STR) grants 

within the 21st Century Cures Act. USET SPF supports this legislation 2 that would 

bring critical direct funding to Tribal communities for the treatment and prevention 

of opioid addiction. 

Native Health Access Improvement Act 

In addition to the Mitigating METH Act, USET SPF would like to convey our support for S. 2545, the Native Health Access Improvement Act of 2018, which was introduced by Senator Tina Smith on March 14, 2018. This legislation would provide 

critical behavioral health resources to Tribal communities by creating a Special Behavioral Health Program for Indians (SBHPI). The SBHPI is modeled after the Special Diabetes Program for Indians (SDPI), a successful Tribal health program that 

has had a significant impact on diabetes within Tribal communities. Like SDPI, 

SBHPI responds to a public health crisis by providing dedicated, formula-based 

funding to Tribal Nations to address behavioral health and substance use disorders, 

including opioid abuse and addiction. In addition, it would support cultural competency by promoting the incorporation of both modern and traditional practices 

into Tribal behavioral health programs. Further, this legislation would require that 

funding standards and distribution methodology be developed in consultation with 

Tribal Nations and would provide the technical assistance necessary to develop robust programs. USET SPF requests that the Senate Committee on Indian Affairs 

ensure this legislation receive an immediate hearing. 

Opioid Response Enhancement Act 

USET SPF also conveys our support for the Opioid Response Enhancement Act, 

legislation introduced by Senator Tammy Baldwin, which would make significant investments in Indian Country to fight the opioid epidemic. The legislation would provide an additional funding of $10 billion to states and Tribal Nations over five years 

for the State Targeted Opioid Response (STR) Grant, including $2 billion for a new 

Enhancement Grant for Tribal Nations and states with high morbidity rates. The 

Opioid Response Enhancement Act would also include Tribal Nations as eligible entities for STR Grants, funded by a 10 percent set aside, which USET SPF feels reflects a commitment to ensuring this crisis is addressed in Indian Country. Other 

components of the legislation include: 

• Technical assistance delivered from SAMHSA to Tribal Nations through the 

Tribal Training and Technical Assistance Center; and 

• Flexibility to allow Tribal Nations and states to use funding to help address 

other substance abuse issues in addition to opioid prevention and treatment; 

Funding for Comprehensive Opioid Data Collection within the Indian 

Health System 

As noted by Tribal witnesses during the hearing, the available data on opioid 

abuse and mortality within the Indian Health System is inadequate and fails to 

fully illustrate the impacts opioids are having in Tribal communities. . As the Committee moves forward with recommendations on how to effectively treat and prevent 

opioid addiction, the Committee must promote the provision of adequate resources, 

including direct funding, to the IHS, Tribal Nations, and Tribal Epidemiology Centers in order improve opioid data collection. Expanding data collection and analysis 

would improve the treatment and prevention of substance abuse within Indian 

Country. Though our data on opioid abuse is incomplete, data that is available 

shows Indian Country, including USET SPF Tribal Nations, is among the commuVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00081 Fmt 6601 Sfmt 6621 S:\DOCS\32784.TXT JACK
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nities most impacted by this crisis. Without access to critical data, Tribal Nations 

will continue to feel the impacts of the opioid epidemic for generations. USET SPF 

urges the Committee to prioritize addressing this shortfall by working to ensure 

Tribal Nations have access to resources to improve opioid data and provide for the 

treatment and prevention of substance abuse. 

Tribal Prescription Drug Monitoring Programs 

During the hearing, witnesses testified on the importance of partnering with state 

Prescription Drug Monitoring Programs (PDMP). IHS stated that the agency has 

been partnering with certain states to connect IHS with state PDMP data. USET 

SPF supports these partnerships and recommends the Committee and Congress ensure IHS has the necessary resources to expand and update the Indian Health Service’s Resource and Patient Management System (RPMS) Electronic Health Record 

(EHR) to fully include and collaborate with state PDMPs on a multi-state basis. Integrating PDMP functionality into the RPMS EHR will connect Tribal Nations to 

crucial data within state PDMPs and will ensure an efficient and unified platform 

for Indian health providers to allow providers to quickly and easily make accurate 

and appropriate diagnoses (addiction, dependence, drug-seeking behavior, etc.) and 

document those in the RPMS EHR. 

Culturally Competent Treatment 

The incorporation of traditional healing practices and a holistic approach to health 

care are fundamental to successful opioid treatment and aftercare programs in Indian Country. Culturally appropriate care has had positive, measurable success 

within Tribal communities, and the incorporation of traditional healing practices 

and holistic approaches to healthcare has become central to many Tribal treatment 

programs. Tribal communities have unique treatment needs when it comes to substance abuse disorders, as AI/ANs experience high levels of substance abuse disorders, with a strong link to historical trauma. Opioid addiction treatment in Indian 

Country, then, must be cognizant of this trauma, respectful of community factors, 

and utilize traditional health care practices. Additionally, opioid addiction treatment 

within Tribal communities must include adequate culturally appropriate aftercare 

programs to help prevent substance abuse relapse. These services must be accessible 

through the Indian Health Care Delivery System. 

Even though culturally competent care has had success across Indian Country, 

treatment options that incorporate cultural healing aspects are oftentimes not available within or near Tribal communities due to a lack of resources. However, some 

USET SPF member Tribal Nations are engaging in innovative practices that have 

the potential to be replicated across Indian Country. For example, one Tribal Nation’s treatment program incorporates a culturally-based recovery model that has 

had great success, including in preventing early relapse following treatment. Other 

best practices within USET SPF Tribal Nations include: 

• Extended, culturally-based recovery support in a sober living environment; and 

• Trauma informed care training for health and behavioral health staff. 

Other notable best practices and culturally healing modalities not currently being 

employed by USET SPF Tribal Nations include: 

• Rapid entry into an acute care facility (detox/inpatient care); and 

• Prevention and control interventions developed utilizing the Community Based 

Participatory Action model. 

With additional funding and guidance, these best practices have the potential provide higher rates of recovery for our people. USET SPF encourages the Committee 

to explore how it might expand and promote these models through legislative action. 

Tribal Healing to Wellness Courts 

In addition to traditional healing practices, USET SPF urges this Committee and 

Congress to support innovative, culturally-appropriate Tribal restorative justice 

models through sustained funding. USET SPF is encouraged that the success of 

family drug courts, or Healing to Wellness Courts (HTWC), was discussed during 

the hearing. Established as alternatives to conventional sentencing for non-violent 

individual offenders, Tribal HTWCs promote long-term recovery through treatment, 

community healing resources, and the Tribal justice process by using a multi-disciplinary approach to achieve the physical and spiritual healing of participants. 

For example, USET SPF member, the Penobscot Nation, has operated an HTWC 

since 2011. Any individual Penobscot Nation citizen who is charged with a non-violent crime can petition to participate in the HTWC program. Once accepted into the 

program, the individual must agree to enter a guilty plea for the crime charged 

79 

against him/her, but his/her sentence is ‘‘deferred’’ to allow the individual to go 

through the program. Then, a comprehensive, holistic plan is developed in collaboration between 10 Tribal government departments to address the individual’s treatment needs in four phases: 

• Phase I: Introduction/Education. This phase is focused on detoxification and beginning treatment and generally lasts 180 days. 

• Phase II: Personal Responsibility. This phase is focused on stabilization and 

treatment and generally lasts 120 days. 

• Phase III: Cooperation/Accountability. This phase is focused on maintenance 

and treatment and generally lasts 120 days. ? 

• Phase IV: Completion/Continuing Wellness. This phase is focused on graduation 

and aftercare and generally lasts 120 days. 

Successful completion of the program results in a dismissal of the participant’s 

guilty plea. Over two dozen individuals have gone into the program since 2011. Recidivism is extremely low. Regrettably, the biggest challenge that the Penobscot Nation has encountered is that they do not have sufficient resources to accommodate 

all the individuals who are interested in participating in the program. While, the 

program is funded mainly through the Bureau of Indian Affairs, with supplemental 

funding from IHS, the Department of Justice, and the Department of Housing and 

Urban Development, this is administratively burdensome and unlikely to result in 

additional resources for the Court. Similarly, while some grants offered by the Substance Abuse and Mental Health Services Administration (SAMHSA) could possibly 

be used for this purpose, SAMHSA’s application requirements and standards often 

serve to preclude smaller, less resourced Tribal Nations from applying. The recovery 

model offered by Tribal HTWCs should be supported by this Congress, as it seeks 

to incentivize long-term sobriety and reduce criminal recidivism among drug offenders. In order to accomplish this, USET SPF urges this Committee to consider dedicated, sustained funding for this infrastructure in Indian Country. 

Tribal Engagement at all Levels of Government 

USET SPF reminds the Committee that Tribal Nations are sovereign governments to which each member of Congress has a trust responsibility. This trust responsibility is carried out not just through funding, but through meaningful government-to-government consultation and coordination to ensure Tribal Nations are included as full partners. When it comes to addressing the gaps in comprehensive 

Tribal programs to prevent, treat, and measure opioid addiction, this effort must include collaboration between federal, state, and Tribal governments. During the hearing, Tribal witnesses underscored the crucial need for collaboration on between Tribal Nations and all levels of government, including federal, state and local, in addressing the opioid epidemic. However, Tribal Nations are frequently excluded from 

these types of collaborative efforts as other units of government work together to 

ensure a coordinated response. 

As the trustee to Tribal Nations, the Committee and Congress must acknowledge 

the substantial challenges within Indian Country must fulfill the trust responsibility 

by facilitating and requiring collaboration between Tribal governments and state 

and local governments in the fight to end the opioid epidemic. Failure to include 

Tribal Nations, including when seeking solutions to the opioid epidemic will result 

in major gaps in the ability of the United States to eradicate opioid addiction in this 

country. These gaps in coordination are detrimental not just from a healthcare and 

treatment perspective, but from a law enforcement perspective, as well. Outreach 

from the Committee, as well as future legislation, should promote and require this 

necessary intergovernmental collaboration. 

Access to Law Enforcement Resources 

In addition to opioid addiction and treatment resources, USET SPF member Tribal Nations report a lack of adequate law enforcement infrastructure to combat the 

opioid epidemic within our region. Currently, there are only seven drug enforcement 

agents assigned to serve over one hundred Tribal Nations within our BIA Drug Enforcement Region (from ME to FL to NM to the central US). This limited number 

of law enforcement agents is unacceptable considering the persistent and growing 

problem of opioid trafficking within Indian Country, particularly the USET SPF region. As mentioned during the hearing, law enforcement within Indian Country 

needs additional resources to in order to sufficiently address the growing opioid 

abuse and trafficking within our Tribal Nations, including human capital. 

Though our Tribal patrol officers perform a vital role in addressing drug issues 

within a community, our law enforcement agencies face underfunding, understaffing, and other failures due to inadequate appropriations. Though USET SPF is 

80 

pleased that $7.5 million was recently appropriated in the FY 2018 Omnibus bill 

providing funding to the Bureau of Indian Affairs law enforcement, additional resources and continued investments must be made available to Tribal Nations when 

it comes to critical drug enforcement investigations. These services are conducted 

primarily by specialized units or task forces on departmental, statewide and federal 

levels and involve enhanced intelligence gathering, information sharing, controlled 

buys, surveillances and other factors. As the Committee approaches this crisis, it 

must not forget the importance of stopping the supply of opioids on Tribal lands 

through well-equipped law enforcement. 

Conclusion 

USET SPF appreciates the Committee’s continued attention to the opioid epidemic and the destructive effects that it has had within Indian Country. We call 

upon the Committee to take action to ensure vital resources are directed to Tribal 

communities. Failure to include Tribal Nations in future legislation is a failure to 

recognize the trust responsibility and will result in an incomplete response to this 

crisis. USET SPF urges the Committee to use the crucial information gathered during these events to educate Senate colleagues on the impact of the opioid epidemic 

within Indian Country, and to continue to voice these priorities beyond the Committee during the legislative process. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

JOLENE GEORGE

Federal Funding Access for Tribes and Native Communities 

Question 1. Legislative proposals that would give tribes access to direct access to 

dedicated funding to address opioid addition and other behavioral health challenges. 

Do you support the correction to the State Targeted Response program’s state passthrough funding model proposed by S. 2270 and S. 2437? 

Answer. Yes, we support direct funding to tribes as authorized in both S. 2270 

and S. 2437. Adequate direct funding means reliable resources and flexibility for the 

PGST to continue implementing our culturally appropriate, multi-faceted, comprehensive approach to abating the opioid epidemic sweeping our community. Additionally, adequate direct funding allows us to plan long-term for infrastructure development, program enrichment, and service enhancements necessary for the wellbeing of our members and local community. We support both bills and are encouraged by the Sponsors’ recognition of the importance of direct tribal funding. However, we note that S. 2437 provides significant increases in funding for a longer period of time, and we prefer that approach. The opioid crisis has been a long time 

in building, and its impacts are going to be long term. The additional funding is 

needed and could be put to use by Indian Country to carry out important opioid response activities in light of the magnitude and duration of the crisis. 

Further, while the PGST supports both S. 2270 and S. 2437, we would recommend, as an alternative to the grant funding contemplated in both bills, that 

Congress use the self-governance model for this funding for tribes like ours that already carry out programs and functions through self-governance compacts . Since 

joining the Tribal Self-Governance Project, a consortium of self-governing tribes, in 

1990, we have funded our health care services through a compact with the Indian 

Health Service (IHS) under the Indian Self-Determination and Education Assistance 

Act. We operate and manage our entire health system on our Reservation, which 

includes primary care, dental, mental health, and substance abuse services along 

with prevention and community health. 

We would much prefer receiving these monies through our self-governance compact if possible rather than through grants. Administering programs by competitive 

grant funding is inappropriate for meeting the critical needs of Indian Country, as 

it pits tribe against tribe to compete for limited funds and fosters uncertainty since 

funding cannot be relied on year-to-year. Moreover, having our Program Directors 

spend time pursuing grants or reporting for grants takes their energy away from 

carrying out the critical program duties. Finally, if we are competing with the states 

that will undermine our working together which is what we should be doing to combat the opioid epidemic. One of the reasons why our Tribal Healing Opioid Response 

(THOR) program is so effective is that we are working with the State, the County, 

and regional groups to coordinate response strategies. 

Question 1a. Would the authorization of a ‘‘Special Behavioral Health Program for 

Indians’’ as proposed by S. 2545 help your Tribe in its opioid response efforts? 

Answer. Yes, we support the creation of a Special Behavioral Health Program for 

Indians (SBHPI) under this legislation, as it would provide the Indian Health ServVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00084 Fmt 6601 Sfmt 6621 S:\DOCS\32784.TXT JACK
81 

ice (IHS), Tribes, Tribal organizations, and urban Indian health programs with access to $150 million in annual mandatory grant-based funding from FY 2018 to FY 

2022. As mentioned above, we operate and manage our entire health system on our 

Reservation, and we have operated a robust Special Diabetes Program for Indians 

(SDPI) program for many years. We are confident that using the SDPI program as 

a model for the SBHPI will be a success. 

The PGST supports S. 2545. However, as with S. 2270 and S. 2437, we recommend that self-governance tribes—such as the PGST—be able to receive such 

funding through their self-governance compacts rather than through grant funding. 

As we know from our SDPI experience, grant reporting requirements take away 

from clinical time, and the self-governance model would allow for more administrative efficiency. 

Federal, State, Tribal Intergovernmental Coordination 

Question 2. What else could Congress do to help encourage states and local governments to coordinate with tribes on their opioid response efforts? 

Answer. The following are some ideas that Congress could encourage state and 

local governments to work with Tribes: 

• Establish and set aside funding for demonstration/pilot programs for opioid response activities to show how cooperation leads to results. 

—Congress could base such a program on the PGST’s efforts with the Olympic 

Community of Health, implementing the Three County Coordinated Opioid Response Project. A demonstration/pilot program would provide the framework for 

bringing tribes and neighboring governments together in areas where states 

and local governments are reticent to work with tribes. The program could show 

the successes that are achievable when state, local, and tribal governments 

work together. 

• Create an opioid task force with representatives of state, local, and tribal governments, and include other relevant sectors, e.g. housing, schools, law enforcement, corrections, etc. Doing so would incentivize the governments to come together with each other and the people who are doing the work on the ground 

to develop coordinated and creative approaches to dealing with the crisis on an 

ongoing basis. The task force could advise Congress and/or relevant federal 

agencies about the challenges they face and what they need to effectively fight 

the opioid crisis. 

—Such a task force could be modeled on what the PGST is doing with Washington State and our neighboring counties. It could be set up on a regional level 

with multiple regions. 

• Encourage the use of Medicaid Demonstration Waivers for experimental, pilot, 

or demonstration projects found by the Secretary of Health and Human Services 

to be likely to assist in promoting the objectives of the Medicaid program. Washington State’s waiver formed regional Accountable Communities of Health, 

which have helped form partnerships that were not otherwise easily accessible 

or workable. 

• Include a provision in opioid legislation mandating state and local governments 

to work together with tribes to respond to the opioid crisis. One potential vehicle isS. 2437, the Opioid Response Enhancement Act, which, in part, amends 

the 21st Century Cures Act of 2017 (the ‘‘Cures Act’’) to encourage community 

and local government engagement. 

—Section 2(a)(2(B)(i)(l) ofS. 2437 would amend Section 1003(c)(2) of the Cures 

Act to read, ‘‘Grants awarded under this subsection shall be used for carrying 

out activities, including activities supported by community-based organizations 

and counties, that supplement activities pertaining to opioids undertaken by the 

State agency responsible for administering [the grant].’’ The new language is in 

italics. Congress could include a statement that directs state and local governments to work coordinate with tribes on opioid response efforts. 

—Another place in S. 2437 for additional language is Section 2(a)(4), the Technical Assistance provision. Through this proposed new mandate, Congress could 

direct the Secretary of Health and Human Services to assist tribes, states, and 

local governments with coordinating strategies and developing collaborative responses. 

• Allow special access to funding for consortium projects that involve tribes together with state agencies or local governments, which would incentivize intergovernmental collaboration. Such a provision could be included in pending 

opioid legislation. 

82 

• Provide monetary incentives for states and local governments to coordinate with 

tribes. 

• Include a requirement for a GAO report examining the hurdles that prevent effective state, local, and tribal government coordination on opioid response efforts. 

—A potential vehicle for this could be H.R. 994, the Examining Opioid Treatment Infrastructure Act of 2017. This is a bipartisan bill specific to Indian 

Country that currently calls for a GAO report on: (1) inpatient and outpatient 

treatment capacity, availability, and needs, including detoxification programs, 

clinical stabilization programs, transitional residential support services, rehabilitation programs, and treatment programs for pregnant women or adolescents; (2) treatment availability and effectiveness through Indian health programs; and (3) the barriers to real-time reporting of drug overdoses at the federal, state, and local level and ways to overcome those barriers. The scope of 

the GAO report under this bill could be expanded to include an examination of 

the barriers relating to positive state and local government coordination with 

tribes. 

Additional Issue 

We would like to make one additional point that is consistent with our responses 

above, but which does not neatly fit under any one of the specific questions asked. 

At the local level, a major challenge has been integrating behavioral health with primary care in order to optimize patient outcomes. This is the work that will reach 

people grappling with the opioid epidemic on the front lines. Federal law and regulations complicate the complexities of integrating health systems with behavioral 

health systems. Federal regulations at 42 CFR Part 2, related to the privacy of substance abuse treatment records, currently prevent the Tribe’s primary care and 

mental health providers from accessing patient records from dependency providers 

so the whole person can be treated. This lack of access is a barrier to coordinated, 

safe, and high-quality medical care and can cause significant harm. Part 2 regulations may lead to a doctor treating a patient and writing prescriptions for opioid 

pain medication for that individual without knowing the person has a substance use 

disorder. There remains a strong need for technical assistance and a potential legislative fix to align the varying levels of patient privacy under the Health Insurance 

Portability and Accountability Act of 1996 (HIP AA) and 42 CFR Part 2 that challenge the integration process. 

Conclusion 

Thank you for the opportunity to speak on behalf of the PGST regarding the 

opioid epidemic facing this Nation. We look forward to further opportunities for discussion and to actively working with the Committee to tackle the opioid epidemic. 

We hope that you and the entire Committee will accept our Tribe’s invitation to 

come visit the Port Gamble S’Klallam Reservation to see our work and significant 

needs in responding to the opioid crisis. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

STACY A. BOHLEN

Federal Funding Access for Tribes and Native Communities 

Question 1. Your written testimony states, ‘‘access to critical opioid prevention and 

treatment dollars are not reaching many of the Tribal communities that are in serious need of these funds.’’ The Senate is currently considering three different legislative proposals that would give tribes direct access to dedicated funding to address 

opioid addiction and other behavioral health challenges (i.e., S. 2270, Mitigating 

METH Act; S. 2437, the Opioid Response Enhancement Act; and S. 2545, the Native 

Behavioral Health Access Improvement Act of 2018). Do you have an estimate of 

how much funding from the 21st Century CURES Act State Targeted Response program is reaching Native communities? 

Answer. No, we do not have an overall estimate, because states are not required 

to report this data. We do know that some states have chosen to include Tribes in 

their funding distribution, but this is not guaranteed or required due to the current 

funding scheme. Of the 36 states with Tribes, only 13 have included Tribes in their 

State Targeted Response (STR) or somehow identified American Indians and Alaska 

Natives (AI/ANs) as a target population with specific needs. 

California and a few other states have used their funds to create Tribal MAT 

projects to improve the delivery of treatment services in AI/AN communities, and 

that other states like Minnesota, Washington and Oregon have outlined AI/ANs as 

83 

one of their primary target populations for the funds. In Washington for example, 

the state is looking to pilot a low-barrier buprenorphine program in Tribal communities, and is engaging at least 5 Tribes to develop a Tribal treatment outreach and 

education campaign. 

But this is far less than adequate. At the Ho-Chunk Nation in Wisconsin they 

have seen an increased number of infants born with substance addiction and neonatal abstinence syndrome, as well as an increase in opioid-related overdose deaths 

in the community. The Tribal government declared a State of Emergency regarding 

the opioid crisis and is in the process of developing a Tribal Action Plan within their 

departments. A major problem for the Tribe is that the grant money the state receives and distributes to the Tribes is not sufficient to meet the added burden the 

Tribe’s behavioral health facility is experiencing. 

Question 1a. Do you support the correction to the State Targeted Response program’s state pass-through funding model proposed by S. 2270 and S. 2437? 

Answer. Yes, the inclusion of Tribes in the correction to the STR program’s model 

is a very important first step Congress must make to address the opioids crisis in 

Indian Country. NIHB is supportive of the provisions in S. 2270, the ‘‘Mitigating 

METH Act’’ from Senator Daines, and S. 2437, the ‘‘Opioid Response Enhancement 

Act’’ from Senator Baldwin. By ensuring Tribes can receive federal funds directly, 

Congress would ensure that the funds reach Tribal communities experiencing desperate need of relief. This change would also uphold the federal trust responsibility 

by ensuring Tribes do not need to go through their states’ health department or subgranting process to receive the care that is historically promised and legally owed. 

Finally, allowing Tribes to receive these funds authorized by the 21st Century 

CURES Act of 2016 would alleviate the states of the burden of having to provide 

care to Tribes. Not all states have the expertise or capacity to provide care to Indian 

Country. Changing the STR program to include direct, formulaic federal funding for 

Tribes directly would uphold the trust responsibility, respect states, and most importantly, ensure Tribes have the resources to care for themselves. 

Question 1b. Would the authorization of a ‘‘Special Behavioral Health Program for 

Indians’’ (SBHPI) as proposed by S.2545 help your Tribe in its opioid response efforts? And, are there any particular characteristics of the SDPI model that are important to carry over to an SBHPI? 

Answer. Yes, the creation of SBHPI is a priority for the National Indian Health 

Board. American Indian/Alaska Native 12th graders are roughly twice as likely to 

have used heroin or OxyContin as 12th graders nationally. Additionally, the chronic 

underfunding of the Indian health system leaves many healthcare facilities unable 

to offer preventative services, instead resorting to distributing painkillers when the 

health issue becomes acute. The opioids crisis is real in Indian Country. The proposed SBHPI would provide funding to Tribes to develop Substance Use Disorder 

treatments at the Tribal and community level. 

A program like this would provide broad-based funding in Tribal communities for 

addressing behavioral health challenges. If the program is designed in a similar way 

to SDPI, it will be recurring, formula based funding that Tribes can count on from 

year to year. This will allow for investment in Tribal communities that focuses on 

traditional healing combined with clinical measures. The flexibility permits Tribes 

to focus on both prevention and treatment, and to create programs that are tailored 

to their communities. We know the SDPI model works. 

The SDPI model offers Tribes the flexibility they need to develop culturally competent and tailored programs that have shown enormously successful results since 

SDPI began in 1997. By supporting each Tribe’s work, SDPI reflects that a one-size 

fits all approach is inappropriate for Indian Country. NIHB is glad to see the same 

level of flexibility in Senator Smith’s SBHPI legislation. 

As impactful as SDPI is, NIHB would suggest that the legislative model for the 

program is imperfect. Historically, Congress has renewed SDPI on a 2-year cycle. 

Last year, SDPI renewal was tied to the CHIP reauthorization bill and became 

caught in a larger political battle. For several months, Tribal administrators of 

SDPI-funded programs did not have the certainty needed for effective long term 

planning. Long-term reauthorization for SDPI, such as found in the Vice Chairman’s 

bill, S. 747, would prevent this from happening again. SBHPI should be authorized 

and funded for no fewer than the five years found in S. 2545. Additionally, SDPI’s 

funding level has plateaued since 2004, with about one third of the buying power 

lost to medical inflation. NIHB would recommend that legislation for both SDPI and 

SBHPI include funding adjustments over time to compensate for rising healthcare 

costs. 

As promising as the Native Behavioral Health Access Improvement Act is, this 

is really just one small step. The $150 million outlined in this legislation will not 

84 

be nearly enough to get to Tribal communities to generate systems change. What 

we really need is comprehensive investments in IHS funding, improved staffing for 

medical professionals in our rural communities, and access to training for first responders and other enforcement activities. 

Federal, State, Tribal Intergovernmental Coordination 

Question 2. Port Gamble S’Klallam Tribe’s testimony lists ‘‘cross-government coordination’’ as one of the most important components of designing an impactful tribal response to public health crises. It goes on to cite the Tribe’s work with three 

local county efforts as evidence of the effectiveness of this recommendation to 

prioritize crossgovernment coordination. Unfortunately, not all tribes find their state 

and local counterparts willing to partner with them to address issues that span 

across multiple jurisdictions. What else could Congress do to help encourage states 

and local governments to coordinate with tribes on their opioid response efforts? 

Answer. Port Gamble S’Klallam Tribe is right to point out the potential of a wellcoordinated and interconnected collaboration across various government entities in 

creating an effective opioid response plan. Some Tribes are in ideal positions to leverage intergovernmental relationships to ensure their members receive services; 

however, this cannot be the federal government’s fallback strategy to upholding its 

trust responsibility to Tribes. As stated in the question, not all state and local governments have the will, capacity, or expertise to deliver cross-government coordinated services to Tribal communities adequately. The most productive course of action would be for Congress to require Tribal consultation in the earliest stages of 

opioid targeted response at the state and local level. Tribes need to be at the table, 

not to evaluate an otherwise-final state proposal, but to help states and local governments craft the proposals from the beginning, ensuring that the final product respects Tribal needs and sovereignty. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

CAPTAIN CHRISTOPHER JONES

Tribal Access to SAMHSA Grants 

Your testimony cites a number of grant programs operated by SAMHSA that 

allow communities to address opioid and substance abuse issues. In your written 

testimony, you mention several SAMHSA grant programs aimed at addressing the 

opioid crisis (e.g., State Targeted Response grants, two separate Strategic Prevention Framework Programs, the First Response-Comprehensive Addiction and Recovery Act Program, etc.). In your oral testimony and in the course of answering questions at this oversight hearing, you noted a residential program with 19 grantees 

that addresses intergenerational addiction and an outpatient program authorized by 

the Comprehensive Addiction and Recovery Act. 

Question 1a. Are tribes, tribal organizations, and urban Indian health organizations eligible for all of the SAMHSA grants noted above? 

Answer. By statute, eligibility for the State Targeted Response to the Opioids Crisis (section 1003 of the 21st Century Cures Act) and State Pilot Grant Program for 

Treatment for Pregnant and Postpartum Women (section 508(r) of the Public Health 

Service Act) grant programs are limited to states. Tribal entities are eligible for the 

Strategic Prevention Framework for Prescription Drugs, Strategic Prevention 

Framework Partnerships for Success, First Responders—Comprehensive Addiction 

and Recovery Act, and Residential Treatment for Pregnant and Postpartum Women 

programs. 

Question 1b. If tribal grantees are eligible for the programs mentioned in your 

written testimony (e.g., State Targeted Response grants, two separate Strategic Prevention Framework Programs, the First Response-Comprehensive Addiction and Recovery Act Program, etc..),what percentage of grant recipients are tribal grantees? 

And, what percentage of total grant funds do those tribal grantees receive from each 

of those grants? 

Answer. By statute, eligibility for the State Targeted Response to the Opioids Crisis (section 1003 of the 21st Century Cures Act) and State Pilot Grant Program for 

Treatment for Pregnant and Postpartum Women (section 508(r) of the Public Health 

Service Act) grant programs are limited to states. 

In FY 2015, tribal entities represented and received the following funds through 

the Strategic Prevention Framework Partnerships for Success Program (awards are 

for the first year of the grant): 

• SAMHSA awarded grants to 7 of the 8 applications received from organizations 

that self-identified as tribal organizations (88 percent success rate) 

85 

• SAMHSA awarded grants to 24 of the 24 applications received from non-tribal 

organizations (100 percent success rate) 

• Tribal entities represented 23 percent of recipients (7 of 31) 

• Tribal entities received 10 percent of awarded funds ($3,874,777 of $38,687,939) 

In FY 2016, tribal entities represented and received the following funds through 

the Strategic Prevention Framework for Prescription Drugs Program (awards are for 

the first year of the grant): 

• SAMHSA awarded grants to all 4 applications received from organizations that 

self-identified as tribal organizations (100 percent success rate) 

• SAMHSA awarded grants to 21 of the 24 applications received from non-tribal 

organizations (88 percent success rate) 

• Tribes/tribal organizations represented 16 percent of recipients (4 of 25) 

• Tribes/tribal organizations received 19 percent of awarded funds ($1,751,982 of 

$9,322,676) 

In FY 2017, tribal entities represented and received the following funds through 

the First Responders—Comprehensive Addiction and Recovery Act Program (awards 

are for the first year of the grant): 

• SAMHSA awarded grants to all 4 applications received from organizations that 

self-identified as tribal organizations (100 percent success rate) 

• SAMHSA awarded grants to 17 of the 48 applications received from non-tribal 

organizations (35 percent success rate) 

• Tribes/tribal organizations represented 19 percent of recipients (4 of 21 awards) 

• Tribes/tribal organizations received 8 percent of awarded funds ($936,724 of 

$11,235,881) 

Question 1c. If tribal grantees are eligible for the programs mentioned in your oral 

testimony and question responses (i.e., a residential program with 19 grantees and 

an outpatient program authorized by the Comprehensive Addiction and Recovery 

Act), what percentage of grant recipients are tribal grantees? And, what percentage 

of total grant funds do those tribal grantees receive from each of those grants? 

Answer. In FY 2017, there were no tribal recipients of the Residential Treatment 

for Pregnant and Postpartum Women Program and by statute only states are eligible for the State Pilot Grant Program for Treatment for Pregnant and Postpartum 

Women (section 508(r) of the Public Health Service Act). 

In FY 2016, there were no tribal recipients of the Residential Treatment for Pregnant and Postpartum Women Program. 

Your testimony also states that Assistant Secretary for Mental Health and 

Substance Use McCance-Katz is actively looking for ways to improve tribal 

access to SAMHSA’s grant programs. 

Question 2a. What metrics, if any, has SAMHSA identified to determine if tribal 

access to SAMHSA grants is improving? 

Answer. Dr. McCance-Katz has provided strong leadership on this priority and 

over the past five months, she has: 

• Reestablished the Addiction Technology Transfer Center (ATTC) Program: 

American Indian and Alaska Native Support Center Cooperative Agreement. 

• Will be establishing Tribal TA Centers for Mental Health as well as for Prevention. 

• Established a $5 million set-aside as part of the SAMHSA Enhancement and 

Expansion of Treatment and Recovery Services for Adolescents, Transitional 

Aged Youth, and their Families Program. 

• Will make awards to three tribal entities, out of the nine total projected awards, 

under the Statewide Consumer Network Program. 

• Will ensure that at least one of the four Healthy Transitions grants goes to 

tribes/tribal organizations. 

• Will ensure that at least four awards of Project AWARE grants go to tribes/tribal organizations. 

Additionally, in report language on the Consolidated Appropriations Act, 2018, 

Congress directed SAMHSA to ensure that $5.millionin funding from the Medication-Assisted Treatment—Prescription Drug and Opioid Addiction program goes to 

tribes/tribal organizations; that act also included a $50 million set-aside in the State 

Opioid Response Program for tribal awardees. 

86 

The metrics used for success will be the number and proportion of grant awards 

made to tribes/tribal organizations in these programs. 

Question 2b. Does SAMHSA have any information on the overall number of tribal 

applicants for all SAMHSA grant programs? If so, please provide a summary of that 

information. 

Answer. In FY 2016, SAMHSA received 126 applications from organizations that 

self-identified as tribal organizations. In FY 2017, SAMHSA received 82 applications 

from organizations that self-identified as tribal organizations. 

Question 2c. Does SAMIISA have any information on the success rate of tribal 

grant applicants compared to other types of applicants for competitive grant programs within the Agency? If so, please provide a summary of that information. 

Answer. In FY 2016, SAMHSA awarded grants to 79 of the 126 applications received from organizations that self-identified as tribal organizations (63 percent success rate). In FY 2016, SAMHSA award grants to 527 of the 1,410 applications received from non-tribal organizations (37 percent success rate). 

In FY 2017, SAMHSA awarded grants to 37 of the 82 applications received from 

organizations that self-identified as tribal organizations (45 percent success rate). In 

FY 2017, SAMHSA awarded grants to 412 of the 1,025 applications received from 

non-tribal organizations (40 percent success rate). 

Your testimony notes that Assistant Secretary McCance-Katz included a $5 million dollar tribal set-aside in a recent funding opportunity announcement for ‘‘Enhancement and Expansion of Treatment and Recovery Services.’’ 

Question 3a. Has SAMHSA included a tribal set-aside within this funding oppor- tunity in previous funding application rounds? Or is this $5 million set-aside a first 

time occurrence? 

Answer. This set-aside was done at the direction of Dr. McCance-Katz. FY 2018 

is the first time that SAMHSA included a $5 million set-aside for tribes and tribal 

organizations in its Funding Opportunity Announcement (FOA) focused on substance use disorder treatment services for adolescents, transitional aged youth, and 

their families. 

Question 3b. Please provide information about the number and amounts of tribes 

awarded to tribal applicants for this grant program under any previous grant award 

rounds. 

Answer. SAMHSA previously awarded grants to tribes and tribal organizations 

under the State Youth Treatment Initiative from FY 2012 to FY 2017. This Initiative helps to further the use of, and access to, effective evidence-based family-centered treatment approaches for adolescents (ages 12 to 17) and transitional age 

youth (ages 18 to 25) with substance use disorders and co-occurring substance use 

and mental disorders. Under this Initiative, 62 total grants have been made across 

35 states/tribes/territories. Of the 62 total awards, seven awards totaling 

$13,158,595 have been made to the following tribes and tribal organizations (the 

amounts listed represent the first-year funding award): 

—Chickasaw Nation (OK)-one grant award (FY 2013: $555,333) 

—Fallon Paiute Shoshone (NV)-one grant award (FY 2013: $950,000) 

—Pascua Yaqui Tribe (AZ)-one grant award (FY 2015: $800,000) 

—Fairbanks Native Association (AK)-two separate grant awards (FY 2016: 

$464,173; FY 2015: $249,767) 

—Kickapoo Tribe (OK)-two separate grant awards (FY 2017: $800,000; FY 2015: 

$250,000) 

Fostering Tribal-State Partnerships 

Your testimony discusses how the Cures Act State Targeted Response 

(STR) grant program interacts with Indian Country through state-tribal 

partnerships. 

Question 4a. Please provide a list of the states receiving STR funds that used tribal engagement as part of their plans for utilizing STR resources. 

Answer. Please see Chart below. 

Question 4b. Please provide a summary of the types of tribal engagement states 

identified as part of those STR plans. 

Answer. 

State State Plan Information on Tribal Engagement 

Alaska Funding to 17 tribal health organizations 

87 

State State Plan Information on Tribal Engagement 

Arizona Arizona’s needs assessment included focus on the Hopi Tribe and Navajo Nation 

in Chochino and Navajo counties. As a result, the STR funds are being used to 

address prescription drug misuse in these focus areas. 

California American Indian/Native Alaskan (AI/NA) communities have significant challenges in accessing MAT services and their issues with the opioid epidemic are 

also on the rise. The death rate from unintentional drug poisoning is almost 

twice as high in the AI/NA population compared to the population nationally. 

STR project goals for tribal communities include: improve MAT access; increase 

the total number of tribal waivered prescribers certified; provide expanded 

MAT services that include tribal values, culture, and treatments; provide innovative telehealth in rural and underserved areas and increase community capacity to support OUD prevention and treatment; and, increase treatment engagement by enhancing clinical decision tools using health information technology. 

Colorado The State will work with the two recognized tribes to help them each identify 

needs and develop their own strategic plans. 

Michigan The State identified the following objectives: (1) build the capacity of the InterTribal Council (ITC) Tribal OUD Prevention Initiative using train the trainers 

combined with extensive technical assistance (facilitators will be trained using 

the Gathering of Native American Model to either initiate the creation of a 

Tribal Action Plan (TAP) or enhance existing TAP efforts to focus specifically 

on the opioid epidemic); and, (2) provide assistance with treatment costs for 

American Indian and Alaskan Native (AI/AN) under and uninsured patients 

with an OUD (the ITC will implement the Tribal Opioid Treatment and Recovery initiative using the existing Access to Recovery infrastructure, entitled 

Anishnaabek Healing Circle). 500 uninsured or underinsured AI/AN OUD patients will be served. 

Minnesota A contract to provide treatment to Native Americans and five contracts to provide recovery support services focused on pregnant and parenting women to 

tribes. Funds have also been distributed to develop a culturally appropriate 

awareness campaign. 

Montana The State will contract with the Rocky Mountain Tribal Leaders’ Council to work 

with Montana’s Peer Network to develop culturally tailored version of the current peer mentoring trainings and peer supervisor trainings. Rocky Mountain 

Tribal Leader’s Council will also be involved in the outreach on reservations 

and with tribal providers for the implementation of peer mentoring. 

Nevada The STR Director is working with Tribal Health Medical Directors to promote 

naloxone distribution and overdose education and integration with tribal primary health providers and public health through sharing of data and resource 

referral. 

New Mexico New Mexican Pueblo communities will receive priority for overdose prevention 

education and Narcan distribution. Anecdotally, opioid overdose death rates on 

tribal lands are increasing. Tribal leaders, police, community members, and 

health and social service providers are all reporting an increase in heroin and 

prescription opioid use. Indigenous champions and local ambassadors are being 

identified to build the necessary and complex relationships with tribal leaders 

to expand STR into those communities. The State is also utilizing its Native 

American employees to advise and consult on the project. The Eight Northern 

Pueblos (ENP) currently participate and recently Pojoaque Tribal Police received training to respond to an opioid overdose. The ENP are geographically 

located in Rio Arriba and Taos Counties—Rio Arriba County is consistently the 

county with the highest overdose death rate in the United States. From 2012 

to 2016, the mortality rate in Rio Arriba County is almost 90 per 100,000. Recent discussions with tribal members reinforce the requirement that historical 

trauma will inform the development of overdose prevention projects with the 

Pueblos and be led by the community. Intervention and prevention programs 

will be coordinated with the Indian Health Service. This collaboration is already in place with the central hub through the ECHO project. Incorporation of 

current trainings and consultation regarding OUD treatment, addiction and 

Chronic pain, etc. are present in the STR. Finally, the State behavioral health 

department currently holds a liaison position to ensure incorporation of tribal 

health agencies and ‘‘638s’’ and use of this liaison will occur to disseminate 

training materials from the STR. 

88 

State State Plan Information on Tribal Engagement 

New York A targeted media campaign is being supported. The objectives are to: (1) conduct 

listening forums for input in developing targeted media campaigns; (2) deliver 

statewide media campaigns that include Native American communities; (3) 

media will focus on radio, television, digital, and social media; and (4) customized messages will focus on opioid overdose prevention to raise awareness 

of the opioid crisis, educate target populations on the risks and dangers of 

opioid use; and inform individuals on how to seek and access appropriate treatment and recovery services. 

North Dakota The action items within the strategic plan are inclusive of tribal nations. Proposals have been received from two tribal nations to increase access to MAT 

through the utilization of telehealth. 

Oklahoma Targeted media campaign 

South Dakota Develop educational materials that are culturally sensitive for Native Americans, 

and work with providers and service agencies to utilize those materials. Draft 

and issue a request for proposals for a vendor to develop materials and distribution. Select vendor and execute agreement/implement scope of work. Distribute materials/videos to Native American communities through education 

and medical services. 

Washington Tribal Entities are part of the strategic planning process and are engaged in all 

of the strategic goals for both prevention and treatment. 

Wisconsin STR funding has been awarded to tribal entities through application process to 

provide SUD/MAT. Other STR funding initiatives will focus on working within 

tribal communities. Areas of interest we are aware of from tribes are recovery 

coaching, naloxone training/distribution, prevention, and looking to expand 

OUD treatment. The application process for Wisconsin counties and tribes is 

complete to apply for STR funds to provide MAT, counseling and recovery support for individuals on their waitlists. Approximately $2.4 million was awarded 

to 19 counties and tribes who will be able to provide MAT for 841 additional 

Wisconsin residents with OUDs. 

Wyoming Treatment and prevention activities are targeted for the Wind River Reservation. 

Volunteers of America possesses a working relationship with Indian Health 

Service and has expressed intentions in their application to enhance that relationship to better serve those populations. VOA is a Wellbriety Certified Treatment Center through White Bison, Inc. VOA’s certification further enforces a 

positive working relationship between the treatment center and regional tribes/ 

tribal entities by utilizing culturally appropriate interventions. 

Question 4c. Does SAMHSA have an estimate of what percentage of the funding 

awarded to the states identified in response to part (a) is being used for those tribalspecific portions of the STR plans? If so, please provide that estimate. 

Answer. This level of detail is not required in the STR budgets as tribal participation is not a statutory requirement. 

Your written testimony notes, ‘‘We have heard from tribal leaders that 

SAMHSA also has a responsibility to improve tribal-state relationships.’’ It 

then describes two efforts undertaken by the Agency and Assistant Secretary McCance-Katz in response to this tribal feedback—hosting a TribalState Policy Academy (TSPA) and a letter to state governors. 

Question 5a. Please provide more specific information about the TSPA, including 

any available information on participation, tentative dates or locations, and goals for 

the event. 

Answer. The TSPA is part of SAMHSA’s approach for supporting improvements 

in tribal-state relations as well as advancing a more comprehensive and collaborative approach to addressing opioids and other substances of abuse in tribal communities. This first academy is planned for August 2018 and will include approximately 100 participants (50 state and 50 tribal representatives). Tribes and states 

with varying levels of engagement have been identified and planning is underway. 

On February 28, 2018, Assistant Secretary McCance-Katz sent a letter to governors with federally-recognized tribes within their borders. The letter shared the 

disproportionate impact of substance abuse on tribal communities and that addressing the behavioral health of American Indians and Alaska Natives is a priority. The 

letter further called upon governors to ensure that tribes, tribal organizations, and 

American Indians and Alaska Natives are engaged and involved in state programs 

in a meaningful and beneficial manner. These programs include the Substance 

Abuse Prevention and Treatment Block Grant and State Targeted Response to the 

89 

Opioids Crisis Programs. The collaborative plans developed through the TSPA will 

help advance the intent of Assistant Secretary McCance-Katz’s letter. 

Question 5b. How will SAMHSA and Assistant Secretary McCance-Katz ensure 

that any TSPA-identified best practices/takeaways are shared with states and tribes 

that are not able to participate directly? 

Answer. Outcomes from the TSPA will be shared with tribes and states immediately following the academy and as tribes and states complete their plans. Multiple channels will be used to disseminate information about the tribal-state plans 

and all completed plans will be posted on SAMHSA’s website to facilitate access. 

Question 5c. What other plans or initiatives, if any, does SAMHSA or Assistant 

Secretary McCanceKatz plan to undertake to improve state-tribal coordination for 

behavioral health challenges that impact both state and tribal communities? 

Answer. Technical assistance for tribal and state collaborators is planned following the TSPA to support continued engagement and progress on their plans. Two 

additional TSPAs are proposed to ensure that the remaining tribes and states are 

afforded an opportunity to develop collaborative plans. SAMHSA is also identifying 

opportunities for engaging tribes and states such as the State Block Grant Conference and other Agency events. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. HEIDI HEITKAMP TO

CAPTAIN CHRISTOPHER JONES

Tribal Access to SAMHSA Grants 

It is my understanding tribes must apply through their respective states to access 

State Targeted Response (STR) funds made available in the Cures Act. I worked 

with colleagues to introduce legislation to address this barrier for tribes and increase STR resources—the Opioid Response Enhancement Act (S. 2437) with Senator Baldwin. 

Question 1a. How can we better ensure tribes have access to these funds? 

Answer. By statute, eligibility for the State Targeted Response to the Opioids Crisis (Section 1003 of the 21st Century Cures Act) grant program is limited to states. 

However, on February 28, 2018, Assistant Secretary McCance-Katz sent a letter to 

governors of states with federally-recognized tribes within their borders. The letter 

shared the disproportionate impact of substance abuse on tribal communities and 

that addressing the behavioral health of American Indians and Alaska Natives is 

a priority. The letter further called upon governors to ensure that tribes, tribal organizations, and American Indians and Alaska Natives are engaged in state programs 

in a meaningful and beneficial manner. These programs include the Substance 

Abuse Prevention and Treatment Block Grant and State Targeted Response to the 

Opioids Crisis Programs. 

SAMHSA continues to work with states to encourage them to ensure tribes have 

access to these funds and to monitor states’ compliance with their plans as noted 

in the following State Plan Information on Tribal Engagement. (See Table in Senator Udall’s questions) 

Additionally, the Consolidated Appropriations Act, 2018 included a $50 million 

set-aside in the State Opioid Response Program for tribal awardees. 

Question 1b. What feedback have you received from tribal communities on the 

types of collaborations, technical assistance, and flexibility they need to ensure STR 

funds are best serving their communities? 

Answer. As noted in written testimony, tribal leaders have communicated to 

SAMHSA their desire to see improvements in tribal-state relationships. In response, 

SAMHSA has issued the letters to state governors noted above, reestablished the 

Addiction Technology Transfer Center (ATTC) Program: American Indian and Alaska Native Support Center Cooperative Agreement and will be hosting a Tribal-State 

Policy Academy (TSPA) to improve collaborative relationships. 

The TSPA is part of SAMHSA’s approach for supporting improvements in tribalstate relations as well as advancing a more comprehensive and collaborative approach to addressing opioids and other substances of abuse in tribal communities. 

This first academy is planned for August 2018 and will include approximately 100 

participants (50 state and 50 tribal representatives). Tribes and states with varying 

levels of engagement have been identified and planning is underway. 

Outcomes from the TSPA will be shared with tribes and states immediately following the academy as tribes and states complete their plans resulting from the 

TSPA. Multiple channels will be used to disseminate information about the tribalstate plans and all completed plans will be posted on SAMHSA’s website to facilitate access. Technical assistance for tribal and state collaborators is planned folVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00093 Fmt 6601 Sfmt 6621 S:\DOCS\32784.TXT JACK
90 

lowing the TSPA to support continued engagement and progress on their plans. Two 

additional TSPAs are proposed to ensure that the remaining tribes and states are 

afforded an opportunity to develop collaborative plans. SAMHSA is also identifying 

opportunities for engaging tribes and states such as the State Block Grant Conference and other Agency events. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

RADM MICHAEL TOEDT

Opioid Prescription Monitoring 

Question 1. Your written testimony states that IHS has Prescription Drug Monitoring Program (PDMP) partnerships with 17 out of 18 states where federally-operated IHS facilities are located. Please identify the state with which IHS does not 

have a partnership. When does IHS anticipate that it will finalize a partnership 

with that state? 

Answer. Since August 2016, Indian Health Service (IHS) has worked closely with 

the State of Nebraska to develop a Memorandum of Understanding (MOU) for a 

PDMP partnership. In 2018, Nebraska changed its PDMP to a web-based system 

that will now allow IHS pharmacies to access the PDMP. IHS is waiting for the 

state to sign the MOU and has been told it is ‘‘on the roadmap in 2018.’’ IHS is 

eager to start reporting dispensing data to the State of Nebraska. 

Question 1a. Does IHS track whether states are working with tribally operated 

facilities and Urban health programs on PDMP database access? 

Answer. IHS does not track states’ work with tribal or Urban Indian Organizations on PDMP access. 

Question 1b. What is IHS doing to help tribally-operated facilities and Urban IHS 

facilities develop similar partnerships with states to access their PDMP databases? 

Answer. IHS responds to requests for information from tribal/urban IHS facilities 

that are interested in developing MOUs with state PDMPs. Information includes 

state key contacts, MOU language, and assistance explaining requirements, and 

Health Insurance Portability and Accountability Act provisions related to PDMP reporting. Technical assistance is provided to tribal facilities that utilize the IHS Electronic Health Record (EHR), Resource Patient Management System (RPMS). 

Question 2. In FY 2017, Congress gave IHS $1 million to develop its own PDMP 

database. Your testimony mentions the ongoing development of a ‘‘data reporting 

system.’’ Is the ‘‘data reporting system’’ mentioned in your testimony the same as 

the PDMP system for which Congress appropriated $1million in FY2017? 

Answer. The data reporting system referred to in the testimony is an application 

developed by IHS called ‘‘Safe Opioid Monitoring.’’ It differs from a PDMP in that 

it does not provide individual patient and prescriber level data. 

The ‘‘Safe Opioid Monitoring’’ software extracts data from the IHS National Data 

Warehouse including opioid prescription rates, naloxone utilization, methadone prescriptions, and percentage of opioids prescribed compared to all prescriptions. This 

tool allows IHS to compile selected data into user friendly reports used to monitor 

opioid metrics by service unit and area, to determine trends within IHS. These reports identify trends and potential areas of concern that require a deeper look. 

Question 2a. What is the status of IHS’s efforts to launch its own PDMP system? 

Answer. IHS is working with the states to report to PDMPs through their systems 

and is in the planning phases for FY 2018 PDMP funding to enhance our current 

interoperability of PDMP reporting. 

Question 3. The National Indian Health Board’s testimony states that the Board 

is not aware of any tribally-specific PDMP system. Their testimony goes on to state 

that the organization is not aware of IHS’s efforts to utilize the FY 2017 funding 

for development of such a system. Is IHS communicating with tribes and urban Indian health programs about its efforts to develop a more robust tribal PDMP system? If so, how? 

Answer. Yes. In FY 2017, IHS transferred funding as tribal shares to support tribal PDMP improvements. 

In addition, tribes that use the IHS EHR/RPMS have access to the IHS PDMP 

platform and have the ability to submit data to state PDMPs. As RPMS PDMP improvements are implemented, IHS communicates the instructions for installation 

and related procedures for the software updates to all RPMS users, including the 

tribes. 

91 

1Zibbell, Jon E., et al. ‘‘Increases in Acute Hepatitis C Virus Infection Related to a Growing 

Opioid Epidemic and Associated Injection Drug Use, United States, 2004 to 2014.’’ American 

journal of public health 0 (2018): e1-e7. 

Secondary Public Health Implications 

Question 4. According to a recent report highlighted by the Centers for Disease 

Control and Prevention, the increase to the growing number of intravenous drug 

users, including intravenous opiates, correlates to a simultaneous increase in acute 

hepatitis C infections. 1 Does IHS have any data on changing numbers of IHS patients presenting with opioid or substance abuse-related blood borne infectious diseases like hepatitis C or HIV/AIDS? If so, please provide a summary of that data. 

Answer. IHS does not have data on the changing numbers of IHS patients presenting with opioid or substance abuse-related blood borne infectious diseases like 

hepatitis C (HCV) or HIV/AIDS. Moreover, IHS does not have the ability to monitor 

this correlation with its existing EHR infrastructure or personnel. However, IHS, 

in collaboration with the Centers for Disease Control and Prevention (CDC), is currently undertaking a vulnerability study looking at the risk of HIV or HCV transmission from injecting drug use. 

Question 4a. Is IHS aware of any other increases in secondary health complications related to rising rates of substance abuse (e.g., neonatal abstinence syndrome, 

respiratory illnesses, etc.)? If so, please provide a summary and description of any 

such secondary health complications. 

Answer. The IHS is in the process of quantifying the impact of secondary health 

complications related to opioids and developing strategies to reduce these health 

complications, such as Neonatal Abstinence Syndrome (NAS), or also known as Neonatal Opioid Withdrawal Syndrome (NOWS). 

Question 4b. Does IHS have a plan to address any of the increased demand 

caused by any increase in secondary health complications related to rising rates of 

substance abuse discussed above? If so, please provide a description of the plan 

here. 

Answer. The HHS five point strategy to address the opioid crisis in the United 

States is central to our response to increased demand. This includes: 

• Improving access to prevention, treatment, and recovery support services, including medication-assisted treatment; 

• Targeting the availability and distribution of overdose-reversing drugs; 

• Strengthening our understanding of the epidemic through better public health 

data and reporting; 

• Supporting cutting edge research on pain and addiction; and 

• Advancing better practices for pain management. 

As part of the overall HHS strategy, IHS believes in a holistic approach integrating physical, mental, spiritual, and cultural components is essential to addressing substance use prevention, treatment, and recovery. 

The IHS established the Heroin, Opioids, and Pain Efforts (HOPE) Committee to 

ensure appropriate and effective pain management, reduce overdose deaths from 

heroin and prescription opioid misuse, and expand access to culturally appropriate 

treatment. The HOPE response includes creating guidelines, endorsing best and 

promising practices surrounding secondary complication of opioid use, creating 

training modules for ITU providers, as well as developing mechanisms to track impact of these interventions. In addition to the HOPE Committee, IHS has involved 

all of the departments within the Agency to be more responsive and effective in addressing all needs related to substance use, including secondary health complications. 

Specific to HCV, IHS provided all IHS facilities with Guidelines for Screening, 

Management and Pre-Treatment for HCV that can be modified as needed for local 

or regional use. This guideline follows national recommendations from established 

authorities such as the United States Preventive Services Task Force, CDC, and the 

American Association for the Study of Liver Diseases. In October 2017, the IHS 

Chief Medical Officer convened the first ever IHS, tribal, and urban Hepatitis C 

Elimination Workgroup, which informs overall federal responses and strategies. 

The IHS also actively collaborates with other federal agencies through MOAs to 

leverage resources and provide more coordinated approaches to the substance use 

crisis. For example, IHS is collaborating with the American Academy of Pediatrics 

Committee on Native American Child Health to develop guidelines to manage 

NOWS including early identification and referral of mothers with suspected opioid 

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use disorders, obstetric care and delivery at IHS facilities, and care and treatment 

of babies born with NOWS. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. HEIDI HEITKAMP TO

RADM MICHAEL TOEDT

Rear Admiral Toedt, during the opioid roundtable the Committee held in November, there were a couple of points mentioned that you said you would look into, and 

I’d like to follow up on those. 

Question 1. Vice Chairman Headdress of the Fort Peck Assiniboine and Sioux 

Tribes asked why service units or tribes can’t funnel some of their purchase and 

referred care (PRC) dollars for prevention and treatment of opioid misuse, if they 

have adequate means from third-party billing. Is this a matter of flexibility or a 

matter of resources for IHS? 

Answer. The Indian Health Service (IHS) consulted with tribes on whether or not 

there should be a set-aside of Purchased/Referred Care (PRC) funds for prevention 

services. Input from this consultation indicated support for funding more prevention 

services. With this in mind, IHS Areas or Service Units, in consultation with the 

tribes, can decide whether they want to set-aside a percentage of their PRC program 

funds for prevention services. This would apply to either individual patient referrals 

at the local IHS Service Unit or for area-wide prevention services available to all 

IHS Service Units. The IHS area office and local tribes would have to consult and 

decide on the best approach. 

Question 2. I also asked you what IHS is doing to build resources to license practitioners to dispense methadone. You said you would get back to me on how many 

providers of Medication Assisted Treatment (MAT) there are within IHS and where 

they are located. Have you looked into this? 

Answer. Medication Assisted Treatment (MAT) with methadone is provided 

through Opioid Treatment Programs (OTPs), which are certified by the Substance 

Abuse and Mental Health Services Administration, registered by the Drug Enforcement Administration, and licensed by the state. MAT cannot be provided through 

office-based settings that are not OTPs. IHS has focused on buprenorphine containing products for MAT that are provided through office-based opioid treatment. 

This form of office-based MAT has been very effective in the treatment of opioid use 

disorders. 

Additionally, IHS is in the process of implementing a robust medical staff 

credentialing platform that will deliver the capability to query a national database 

to determine the number of federally-credentialed IHS prescribers with Drug Addiction Treatment Act of 2000 (DATA) waivers. 

IHS has collected information from its federal facilities and identified 21 providers 

who have a DATA waiver and are actively prescribing MAT in the following locations: Jicarilla Apache Health Care Facility in Dulce, New Mexico; Gallup Indian 

Medical Center in Gallup, New Mexico; Northern Navajo Medical Center in 

Shiprock, New Mexico; Hopi Health Center in Polacca, Arizona; Fort Duchesne Indian Health Center in Fort Duchesne, Utah; Southern Bands Health Center in Elko, 

Nevada; and Whiteriver Indian Hospital in Whiteriver, Arizona. In addition to these 

federal locations, it is important to note that MAT services are also provided 

through a combination of tribal, direct, and contract health services. 

IHS supports tracking buprenorphine prescriptions and acquisitions data for 

buprenorphine containing products. While IHS is in the final stages of implementing 

its Safe Opioid Monitoring data mart, preliminary data reveals that buprenorphine 

prescriptions have increased significantly. With the completion of this data mart, 

IHS will be able to determine the number of facilities providing buprenorphine directly to patients from IHS pharmacies. 

Question 3. Can you share the progress in data sharing and two-way communication between IHS and state Prescription Drug Monitoring Programs (PDMPs)? 

Answer. IHS has initiated a process to report (share data) and query (receive 

data) with Prescription Drug Monitoring Program (PDMP) partnerships in 17 out 

of 18 states where federally-operated IHS facilities are located. IHS is actively pursuing partnership with the last state to implement PDMP data sharing across all 

IHS pharmacies and state PDMPs. 

Question 4. When do you expect the IHS Strategic Plan will be finalized and published? 

Answer. The IHS Strategic Plan FY 2018–2022 is expected in September 2018. A 

final release date is subject to the feedback received during a 30-day public comment period, including comments from tribes and Urban Indian Organizations. 

93 

On September 15, 2017, IHS consulted and conferred with tribes and Urban Indian Organizations on the IHS Strategic Plan. An initial framework was developed 

and IHS requested comments from tribal and Urban Indian Organization leaders, 

and IHS employees, through October 31, 2017. In November 2017, an IHS-tribal 

workgroup was formed to review the hundreds of submitted comments and recommendations. Over a four month period, the workgroup developed recommendations that form the basis of the draft IHS Strategic Plan FY 2018–2022. IHS is in 

the process of finalizing a Federal Register Notice (FRN) asking for comments on 

the draft IHS Strategic Plan FY 2018–2022. The FRN is expected to be published 

in July 2018. IHS plans to conduct tribal consultation and Urban Confer sessions 

on the draft IHS Strategic Plan in July and August. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. HEIDI HEITKAMP TO

STACY A. BOHLEN

Question 1. Mr. Moose, On Tuesday, March 13th I spoke on the phone with Secretary Azar about IHS and what they are doing to support and improve services. 

We talked about things like workforce recruitment and patient wait time data. One 

thing he said to me is that IHS/HHS should target a few top priorities from the 

IHS Quality Framework that was published in late 2016 and focus on those. In your 

opinion, what should the top three priorities be to improve patient experience and 

outcome and ensure the delivery of high quality health care? 

Answer. Senator Heitkamp, thank you for the question and for your continued 

dedication to improving the quality of health services for all of Indian Country. Ensuring the delivery of the highest quality of care is a top priority across all IHS 

health service delivery areas, but is especially key in curbing the national opioid 

overdose epidemic. As you very well know, the excessive and often times indiscriminate prescribing of opioid analgesics for both chronic and acute pain symptoms 

were, and continue to be, a pervasive issue fueling the crisis. Within the Indian 

Health System, provider shortages—particularly behavioral health providers who 

have the knowledge and expertise in the intersection of addiction, mental illness 

and public health—have forced an overextended health workforce to be overly reliant on opioid medications to treat pain, as opposed to having opioid medications be 

the last resort. According to the IHS, the physician vacancy rate in 2014 was 22 

percent nationally, with some areas experiencing far higher vacancy rates. 

Access to care remains a critical need, but meeting quality of care goals are just 

as crucial. While we applaud the IHS for imposing new rules and procedures such 

as requiring all federally employed prescribers and dispensers to check the state 

prescription drug monitoring program, and updating the Indian Health Manual to 

align with the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain, much more needs to be done to improve the delivery of high quality health care. Issues include gaps in the availability and infrastructure of telemedicine, underfunded and understaffed substance use treatment 

facilities, low numbers of providers with waivers to prescribe buprenorphine for 

treatment of opioid use disorder, inconsistent access to naloxone, and low provider 

familiarity with and implementation of the CDC Guideline. 

Undoubtedly, all five of the quality priorities embedded within the 2016 IHS 

Quality Framework are essential if we are to stem the tide of this epidemic. Within 

the context of the opioid overdose epidemic, the three most critical priorities are to: 

1.) Strengthen Organizational Capacity to Improve Quality of Care and Systems 

• Providers need more training and education on the CDC Guideline and on the 

signs, symptoms and risk factors for substance misuse, addiction and overdose. 

Given that providers are at the frontlines of this epidemic, it is critical that concerted investments be made towards raising provider capacity to effectively deliver care to patients in need of pain management. 

2.)Align Service Delivery Processes to Improve Patient Experience 

• IHS efforts to align their policies with the CDC Guideline are an important step 

towards ensuring accountability and consistency in care. NIHB is hopeful that 

these changes will lead to reductions in overprescribing, but much more needs 

to be done to improve the patient experience overall. For instance, high provider 

turnover and chronic workforce shortages pose significant barriers and create 

disparities in the quality of care. In addition, limited attention to wraparound 

and comprehensive care that includes mental health treatment, case management, job training and housing services mean that patients are encountering 

gaps across the care continuum. 

94 

1Staff of Dep’t of Just., 2019 Budget Summary (2018). Available at https://www.justice.gov/ 

jmd/page/file/1033086/download#page=2. 2Staff of Dep’t of Just., Review of the Department’s Tribal Law Enforcement Efforts Pursuant 

to the Tribal Law and Order Act of 2010 11 (2017). Available at https://oig.justice.gov/reports/ 

2017/e1801.pdf. 

3.) Ensure Patient Safety 

• The crux of reducing unsafe and ineffective prescribing of opioids is ensuring 

patient safety. Too often has provider misconduct and malpractice led to tragic 

and yet largely preventable deaths within the Indian Health System. NIHB encourages Congress to review reports from the United States Department of 

Health and Human Services Office of Inspector General on deficiencies in system security and physical controls at IHS hospitals and how this impacts patient safety. 

*Responses to the following questions were not available at the time this hearing 

went to print* 

WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

HON. JOHN C. ANDERSON

Opioid Funding and Utilization in Indian Country 

Question 1. The Department of Justice’s FY2019 Budget Request summary states, 

‘‘[The Department’s FY2019 Budget Request] provides the needed resources so that 

Federal, state, local and trial law enforcement agencies can fight the opioid epidemic 

that is destroying neighborhoods.’’ 1

a. Please summarize how this Budget Request reflects the stated goal of addressing the opioid epidemic in tribal communities. 

b. What additional law enforcement and prosecution resources, if any, does this 

Budget Request propose specifically for tribal communities? 

c. Did the Department consult with tribes about design of the opioid epidemic 

response proposals included in this Budget Request? 

d. Did the Department, its budget and performance personnel, its law enforcement agencies, or the Executive Office for United States Attorneys coordinate 

with the Department of the Interior’s Bureau of Indian Affairs-Office of Justice 

Services in the design of proposals for Indian country in this Budget Request? 

Question 2. Your written testimony states, ‘‘An important element of the Department’s support [for response to the opioid crisis] is providing opportunities for funding.’’ It goes on to include several references to Department programs that grantees 

can use to address the opioid crisis—including Drug Courts funding and Office of 

Justice Programs’ Comprehensive Opioid Abuse Program. The testimony highlights 

two tribal grantees under these programs. Please provide detailed information on 

how much funding the Department awards to tribal grantees for drug courts and 

substance abuse prevention, including a list of tribes that receive such funds and 

estimates of the amount of funding available to each such tribal grantee. 

Investigations and Prosecutions of Crimes on Indian lands 

Question 3. At the hearing, several Members of the Committee discussed case referral statistics included in a December 2017 report issued by the Department’s Office of the Inspector General. 2 This report includes a description of the numbers of 

investigations referred to U.S. Attorney Offices (USAOs) for prosecution by various 

law enforcement agencies. 

a. Please provide an estimate of the number of investigations referred to USAOs 

by the Bureau of Indian Affairs, the Drug Enforcement Administration, the 

Federal Bureau of Investigation, and Tribal law enforcement in CY 2015, CY 

2016, and (if available) CY 2017. 

b. Please provide information on the types of investigations most frequently referred to USAOs by the law enforcement agencies listed in part (a) and, if possible, an estimate of the percentage of referred cases that are related to drug 

crimes. 

Question 4. The same report notes that the number of declinations for prosecution 

of crimes in Indian country by USAOs increased by 20 percent from CY 2013 to CY 

95 

3 Id. at 10. 

2015. 3 Please provide an estimate of the number of declinations and the number 

of defendants against whom charges were filed for crimes in Indian country nationally in CY 2016 and, if available, CY 2017. 

WRITTEN QUESTIONS SUBMITTED BY HON. HEIDI HEITKAMP

HON. JOHN C. ANDERSON

Question 1. I hear one consistent from all five tribes in North Dakota when it 

comes to drugs—not just opioids—but drugs in general. . . . ‘‘Please help us, we are 

being overrun’’. I know the jurisdictional challenges, the lack of law enforcement on 

the reservations, little to no DEA presence, lack of detention and treatment facilities, and the tendency for U.S. Attorney’s Offices to not pursue dealers arrested with 

small quantities on the reservation. 

(a) When you hear and know all of this—do you think we can honestly say that 

we are upholding our treaty responsibilities to our tribes? Do you truly think that 

the Department of Justice is doing everything it can to shut down the drug trafficking problem in Indian Country? 

(b) Do you think we need more FBI and DEA agents available to assist in these 

types of crimes and investigations in Indian Country in order to stem the flow of 

illicit drugs? Do you agree that FBI and DEA agents should be forming relationships with our tribes and operating on the reservation as much as possible as opposed to only responding in a crisis or in response to a major crime? 

(c) You mentioned HIDTA Drug Task forces in your testimony—do you know how 

many of these task forces are currently operating within Indian Country? My understanding is that right now in North Dakota the number is zero—is that acceptable 

if we all admit that there is a problem of illicit drugs flowing freely into and through 

Indian Country? 

(d) DOJ also has Safe Trails Task Forces that are specifically focused on combatting in crime in Indian Country—do you know how many Safe Trails Task Forces 

we have in North Dakota? Zero. So why is DOJ not doing everything in their power 

to stand up as many of these Task Forces as possible to address the supply side 

of the illicit drug problem in Indian Country? 

WRITTEN QUESTIONS SUBMITTED BY HON. LISA MURKOWSKI

HON. JOHN C. ANDERSON

Thank you Mr. Chairman and gentlemen thank you all for what you do, respectively. I apologize I was not able to hear some of the questions from my colleagues. 

But again, these are issues that are so key and so important and I appreciate your 

testimony. Thank you Captain Jones for mentioning the Project Hope Program and 

how it is working or helping in Alaska. In my opening statement, I didn’t just talk 

about the opioid epidemic and how that’s ravaged our communities. I also talked 

about alcohol and how it seems to be an underlying issue in Alaska. 

I will just cite to our annual drug report that says acknowledges there is a multifaceted drug abuse problem in the state and that drug abusers in Alaska tend to 

abuse more than one substance. Often times they are abusing multiple drugs at 

once. The Alaska State Troopers emphasized in their report that alcohol was the 

single most abused substance. So as we have been focusing our efforts here in Congress on opioids, I don’t want us to lose sight of the fact that there is an underlying 

issue and that is alcohol. We have to provide the support for programs and grants 

in that alcohol space as well and so when we’re talking about substance abuse, we 

have to make sure that we are talking about alcohol and substance abuse programs, 

too. Everyone in the crowd is shaking their heads, like they agree with me. 

We don’t need to bifurcate all of these drug issues. We all have one big, ugly, horrible problem that we are dealing with. Let me ask you this, I’ll call it a workforce 

issue, but our reality is that we have identified the problem and some of the solutions. But, we know that so much of this comes back to making sure that we have 

mental health professionals that are able to be there to and support those who need 

it. I have been working with my colleague from Indiana, Senator Donnelly, on an 

effort that would incentivize those to go into the field and work to find the best 

treatments for substance use disorders. Basically, it’s a loan forgiveness program 

that we think will be helpful in incentivizing more people to enter the mental health 

profession. I have to assume that part of the challenges that we’re facing is we simVerDate Mar 15 2010 10:58 Dec 04, 2018 Jkt 032784 PO 00000 Frm 00099 Fmt 6601 Sfmt 6621 S:\DOCS\32784.TXT JACK
96 

ply don’t have enough mental health professionals to address the substance abuse 

epidemic in the United States. I’m also getting head nods for this too. 

Question. So, here’s my question to you and this is this is intended to help at least 

three individuals that are in the audience. One of which I have met with and she 

is the Mayor of Utqiagvik. She, and two others that are part of her council, met 

with us today and they’ve mentioned that Utqiagvik has an issue with drugs, not 

just opioids. They said that we can’t single out a single drug from a law enforcement 

perspective and I’ll look to you Mr. Anderson to answer this. They are saying that 

they don’t have a district attorney and they’re (the City of Utqiagvik) is responsible 

for the prosecution of these drug offenses and they are not moving forward as fast 

as they would like because the drugs are coming in by mail the drugs and by plane. 

And that’s it. We know how they get in, but because we can’t get attention on anything unless it’s at full federal, full felony level, that people think they can get away 

with selling and dealing. They can use and there’s no here’s no follow up and no 

consequence. What would you tell the Mayor of Utqiagvik? 

Æ