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[Senate Hearing 114-254]
[From the U.S. Government Publishing Office]

                                                      S. Hrg. 114-254

     EXAMINING THE TRUE COSTS OF ALCOHOL AND DRUG ABUSE IN NATIVE 
                              COMMUNITIES

=======================================================================

                                HEARING

                               	BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 29, 2015

                               __________

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                      COMMITTEE ON INDIAN AFFAIRS

                    JOHN BARRASSO, Wyoming, Chairman
                   JON TESTER, Montana, Vice Chairman
JOHN McCAIN, Arizona                 MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska               TOM UDALL, New Mexico
JOHN HOEVEN, North Dakota            AL FRANKEN, Minnesota
JAMES LANKFORD, Oklahoma             BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana                HEIDI HEITKAMP, North Dakota
MIKE CRAPO, Idaho
JERRY MORAN, Kansas
     T. Michael Andrews, Majority Staff Director and Chief Counsel
       Anthony Walters, Minority Staff Director and Chief Counsel
                            
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on July 29, 2015....................................     1
Statement of Senator Barrasso....................................     1
Statement of Senator Franken.....................................     4
Statement of Senator Heitkamp....................................    50
Statement of Senator Hoeven......................................    43
Statement of Senator Lankford....................................    48
Statement of Senator Murkowski...................................    52
Statement of Senator Tester......................................     3

                               Witnesses

Beadle, Mirtha, Director, Office of Tribal Affairs and Policy, 
  Substance Abuse and Mental Health Services Administration, U.S. 
  Department of Health and Human Services........................    10
    Prepared statement...........................................    11
Benjamin, Hon. Melanie, Chief Executive, Mille Lacs Band of 
  Ojibwe.........................................................    16
    Prepared statement...........................................    18
Goggles, Sunny, Director, White Buffalo Recovery Program, Arapaho 
  Tribe, Wind River Reservation..................................    41
    Prepared statement...........................................    42
McSwain, Hon. Robert G., Principal Deputy Director, Indian Health 
  Service, U.S. Department of Health and Human Services..........     5
    Prepared statement...........................................     6
Walters, Hon. John P., Chief Operating Officer, Hudson Institute.    34
    Prepared statement...........................................    36

                                Appendix

Response to written questions submitted by Hon. Al Franken to:
    Mirtha Beadle................................................    70
    Hon. Robert G. McSwain.......................................    69
Secatero, Lester, Chairperson, National Indian Health Board 
  (NIHB), prepared statement.....................................    59
Steele, Hon. John Yellow Bird, President, Oglala Sioux Tribe.....    64

 
     EXAMINING THE TRUE COSTS OF ALCOHOL AND DRUG ABUSE IN NATIVE 
                              COMMUNITIES

                              ----------                              

                        WEDNESDAY, JULY 29, 2015

                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:30 p.m. in room 
628, Dirksen Senate Office Building, Hon. John Barrasso, 
Chairman of the Committee, presiding.

           OPENING STATEMENT OF HON. JOHN BARRASSO, 
                   U.S. SENATOR FROM WYOMING

    The Chairman. Good afternoon. I call this hearing to order.
    Before we begin, I want to welcome Ms. Sunny Goggles to the 
hearing. Ms. Goggles serves her community in many roles. She is 
a member of the Northern Arapaho Tribe and the Director of the 
White Buffalo Recovery Center on the Wind River Indian 
Reservation in Wyoming. She also serves on the Tribal Committee 
for the National Association of Drug Court Professionals. 
Welcome.
    Tribal leaders from both tribes in the Northern Arapaho and 
the Eastern Shoshone and the Wind River Indian Reservation have 
remarked favorably on her leadership, on her strength and on 
her capabilities. Those character traits were put to the test 
when a recent terrible, tragic crime affected those very close 
to her and to the entire community. Our hearts and thoughts go 
out to you, to your family and to the community. Thank you for 
serving your community and for being here with us today.
    This month, we have examined many difficult topics. Today 
is no different. We will receive testimony regarding the true 
costs of alcohol and drug abuse in Native communities. Over the 
past five years, this Committee has held five hearings related 
to alcohol and drug abuse. This past March on the Wind River 
Indian Reservation, in my home State of Wyoming, this Committee 
held a field hearing on addressing the harmful effects of 
dangerous drugs. Nearly every single witness testified how the 
abuse of alcohol and drugs had serious and often tragic effects 
on Indian communities.
    Alcohol is noted to be a contributing factor in a 
significantly high number of crimes. It is also a contributing 
factor in too many deaths on the Wind River Reservation. 
According to the Indian Health Service, the average life span 
for Indians is 73 years. On the Wind River Reservation, the 
average age at death has for years hovered around 49 years of 
age. These premature deaths are due primarily to alcohol and 
alcohol-related injuries.
    I am astonished that both the Substance Abuse and Mental 
Health Services Administration and the Indian Health Service 
are not doing more to change that death rate. I am also 
astonished that the Substance Abuse and Mental Health Services 
Administration, the agency devoted entirely to substance abuse 
and mental health, failed to submit its testimony on time. This 
has been a bipartisan concern for those of us on this 
Committee. The testimony that was submitted does little more 
than recite basic information included on the agency's website. 
The testimony doesn't even explain what the agency is actually 
doing to address alcohol and drug abuse in Indian Country. 
Frankly, this reflects a troubling lack of seriousness and 
commitment to the important issues we are examining here today 
and it is completely unacceptable.
    The many devastating impacts drugs and alcohol have had on 
Indian communities warrant our heightened attention. As a 
physician, I am especially troubled by the needless, 
preventable injuries and the deaths that often result from 
alcohol and drug abuse. These tragedies can take an 
immeasurable toll in individuals, families and communities.
    So as we focus on the issue before us today, while we must 
examine the financial burdens associated with alcohol and 
substance abuse, it is important to remember that the full cost 
of abuse cannot be measured in dollars and cents. In 2011, the 
Justice Department estimated that the total cost of alcohol and 
drug abuse in the United States exceeded $600 billion a year. 
Again, this is only part of the picture. The other financial, 
societal, systemic and individual costs of substance abuse are 
high.
    The National Institute on Drug Abuse states that these 
costs include unemployment, poor educational outcome, domestic 
violence, child abuse, motor vehicle accidents and death. 
Substance abuse is also associated with homicide, suicide and 
family breakdown.
    The impact of abuse is even worse in Indian Country, where 
one in ten deaths is alcohol-related. Compared to the general 
U.S. population, Native Americans in Indian Country are also 
twice as likely to live in poverty and experience two and a 
half times the general rate of violent victimization. This 
group has a shorter life expectancy and a higher infant 
mortality rate than the general population.
    Research by the National Institute of Drug Abuse suggests 
that addiction to and abuse of alcohol and drugs is 
preventable. The testimony from the Committee field hearing on 
addressing the harmful effects of dangerous drugs suggested 
that by preventing or reducing alcohol abuse, crime could be 
reduced as well. If that is the case, we must work together to 
find realistic solutions that will prevent and treat substance 
abuse in Indian communities.
    I am interested in hearing any solutions that target 
culturally competent prevention or treatment strategies for 
alcohol and drug abuse in Native communities. One thing is 
clear: there are not enough resources to address the high rates 
of abuse and addiction in Indian Country. These problems need 
to be mitigated, not intensified.
    As we will hear today, Native communities need to 
understand that if they go down the road of legalizing 
marijuana, it will come at a great cost. The resulting health 
care costs alone would be crushing and have an impact on all of 
Indian Country.
    I want to welcome our witnesses, and I look forward to 
hearing from each of them. But before we hear from the panel, I 
want to ask the Vice Chairman, Senator Tester, if he has an 
opening statement.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman, and thank you for 
holding this hearing today on the harmful impacts of drugs and 
alcohol abuse have had and continue to have in Native 
communities.
    While we are focused on the true costs of drug and alcohol 
abuse, including the devastating economic impacts that these 
behaviors have in Native communities, I think it is vital that 
we look beyond the economics of this issue. I know that it is 
the human cost that most of Indian Country is focused on at 
this point in time. It is the babies that are born addicted to 
drugs or that are that are developmental impacted by alcohol, 
it is the children who are separated from their mothers and 
fathers because of the pull of drugs and alcohol. It is the 
youth who begin experimenting with these substances far too 
early in life and often lose themselves and sacrifice their 
future.
    There are real human costs that are devastating Indian 
Country. I think everyone on this Committee is well aware of 
the impacts that drug and alcohol abuse has wreaked in our 
Native communities, especially on our Native youth. We sit here 
week in, week out, and hear about how our kids are dropping out 
of schools, living in unsafe housing and engaging in risky 
behaviors, largely because, quite frankly, they lack 
alternatives. Our youth and many others in Native communities 
are turning to drugs and alcohol to escape from the harsh 
realities of their life. Addiction becomes a new reality for 
many of these communities.
    Drug and alcohol abuse is a problem, there is no question 
about it. Yet these are issues that are entirely preventable. 
They are also issues that impact every Federal agency that 
plays a role in Indian Country. That is why I am glad to see 
our friends are here from the Indian Health Service and from 
SAMHSA to testify on what the Federal Government is doing to 
prevent substance abuse.
    I am also pleased that we will hear from folks in the field 
and on the ground who are working to prevent the loss of 
another generation of our children to drugs and alcohol. We all 
know that it will take the work of those in our Native 
communities to truly break the cycle of addiction that 
continues to plague too many families.
    But those on the ground cannot do it alone. They need the 
support and resources to carry out the programs to combat these 
problems. They must do a better job ensuring that the resources 
get to the ground in Indian Country.
    I look forward to hearing the testimony of the witnesses 
this afternoon. I want to thank you all for the work you do and 
I look forward to hearing some of the solutions to the crisis 
that is robbing Indian Country of current and future 
generations.
    Finally, I would just like to say, all of you have great 
names. Bob McSwain, Mirtha Beadle, Melanie Benjamin, John 
Walters. But nobody has a name like Sunny Goggles.
    [Laughter.]
    Senator Tester. Thank you all for being here.
    Senator Franken. Actually, Melanie Benjamin means Sunny 
Goggles in Ojibwe.
    [Laughter.]
    The Chairman. Would any other members like to make an 
opening statement? Any opening comments?
    Senator Franken. May I follow up?
    The Chairman. You may follow yourself, yes, thank you.

                 STATEMENT OF HON. AL FRANKEN, 
                  U.S. SENATOR FROM MINNESOTA

    Senator Franken. I would like to introduce Melanie, who 
again, in Ojibwe, her name means Sunny Goggles.
    [Laughter.]
    Senator Franken. Senator Barrasso, Vice Chairman Tester, 
thank you for holding today's hearing on substance abuse in 
Indian Country, a tragic subject. I am proud to introduce 
Melanie Benjamin, who is Chief Executive of the Mille Lacs Band 
of Ojibwe, as a witness to this Committee.
    Right now, tribes in Minnesota face a public health crisis. 
Melanie knows the devastating impact that opiate abuse is 
having on the Mille Lacs Band and on other tribes and bands in 
Minnesota. The impact on mothers and on children is especially 
sobering. Melanie is dedicated to addressing this crisis, and 
she has been working with other tribal leaders in our State to 
develop a response that incorporates both prevention and 
treatment.
    Last year, tribal leaders in Minnesota convened at the Bois 
Forte Reservation for a summit on the future of Indian 
children. This May, the Mille Lacs Band hosted a second summit 
where these leaders continued to discuss and work toward 
effective solutions. Tribes in Minnesota are working 
cooperatively to respond to this major public health problem. 
Our role in Congress is to make sure we are doing all we can to 
support their work. I look forward to hearing Melanie's 
recommendations and learning what tribes need from the Federal 
Government from all our witnesses today, so we can fully 
address substance abuse. Melanie's testimony is going to be 
mainly on opiate abuse, which has become rampant.
    Thank you, Mr. Chairman
    The Chairman. Thank you, Senator Franken. Anyone else have 
an opening statement they would like to make, any comments? 
Hearing none, we will now hear from our witnesses. The first is 
the Honorable Robert McSwain, who is the Principal Deputy 
Director of the Indian Health Service, Department of Health and 
Human Services.
    I want to thank all of you for being here. I want to remind 
the witnesses that your full written testimony will be made 
part of the official hearing today. So please try to keep your 
statements to under five minutes so that we may have time for 
questions. I look forward to hearing the testimony, beginning 
with Mr. McSwain. Please proceed.

        STATEMENT OF HON. ROBERT G. McSWAIN, PRINCIPAL 
         DEPUTY DIRECTOR, INDIAN HEALTH SERVICE, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Mr. McSwain. Mr. Chairman, members of the Committee, good 
afternoon. As noted, I am the Principal Deputy for Indian 
Health Service. Today I appreciate the opportunity to testify 
on examining the true costs of alcohol and drug abuse in Native 
communities.
    As you know, the Indian Health Service plays a unique role 
in the Department of Health and Human Services to meet the 
Federal trust responsibility to provide health care to American 
Indians and Alaska Natives. Examining the true costs of 
alcohol, illicit and non-medical prescription drug use for 
Native communities is challenging, although we know it is 
substantial. In the absence of studies on the scope and cost of 
alcohol and drug abuse for Native communities, IHS depends 
largely on measures of prevalence, morbidity and mortality 
related to alcohol and drug abuse for American Indians and 
Alaska Natives.
    In the fiscal year 2015 enacted budget for IHS, the alcohol 
and substance abuse program was slightly more than $190 
million. Over 80 percent of that amount is contracted or 
compacted with tribes. The IHS program approach to addressing 
alcohol and substance abuse disorders in Native communities is 
to treat, the important feature is predominantly to treat 
alcohol and substance abuse disorders and treat individuals 
struggling with substance abuse disorders, train health care 
providers to treat substance use disorders in outpatient 
settings and intervene early before substance use disorder 
develops and prevent alcohol and drug use before it begins.
    Compared with other racial groups, American Indian and 
Alaska Natives tend to begin using alcohol and drugs at a 
younger age, use them more often and in higher quantities and 
experience more negative consequences from them. A 2009 to 2012 
study focusing on American Indian youth reveals alarming 
substance use patterns, including patterns of drug use 
beginning earlier than is typical for other Americans. For 
instance, 56.2 percent of American Indian eighth graders and 
61.4 percent of American Indian tenth graders had used 
marijuana, compared to 16.4 percent of eighth graders and 33.4 
percent of tenth graders nationally.
    American Indian students annually, and we will hear more 
about that a little bit later, but annual heroin and OxyContin 
use is about two to three times higher than the national 
averages in those years. To help with the substance abuse for 
youth, the Indian Health Service has actually built ten youth 
regional treatment centers across the Country and is preparing 
to build two in California, bringing us to a total of 12. They 
provide a wide range of clinical services to provide treatment 
services rooted in culturally relevant and holistic models of 
care, including group, individual and family psychotherapy, 
life skills development, medication management, after-care 
relapse prevention and post-follow-up. We can talk more about 
this as well.
    The important thing about the Indian Health Service is that 
we tend to serve small, rural populations with primary medical 
care. Then we rely on paying for care, or buying care, in the 
private sector through our purchase referred care. In FY 2014, 
IHS spent over $5.8 million on inpatient admissions related to 
alcohol and substance abuse diagnoses. During the same period, 
over $12 million was expended for inpatient visits related to 
liver disease.
    Workforce development is an IHS resource available to 
Federal and tribal care systems as an essential part, it is by 
having to build a staff. In addition to that, where we can't 
reach people, we have been implementing tele-behavioral health 
into the remote locations. We started this in 2008.
    IHS' primary source of prevention funding through 
methamphetamine is the MSPI program, which some of you asked 
about the last time. The program funds 130 programs across the 
Indian Health Service. We have just sent out another invitation 
for new applications this year.
    The Federal coordination, certainly the Tribal Law and 
Order Act signed into law by President Obama in July 2010 
contains provisions that would actually have agencies work 
together. With the high rates and the academic failures as 
mentioned earlier by one of the members, the IHS is committed 
to partnering with the Committee, tribes and other Federal 
agencies and key stakeholders on further examining and 
addressing the true costs of alcohol and drug abuse in Native 
communities.
    That ends my statement, Mr. Chairman. I am prepared to 
answer questions.
    [The prepared statement of Mr. McSwain follows:]

    Prepared Statement of Hon. Robert G. McSwain, Principal Deputy 
 Director, Indian Health Service, U.S. Department of Health and Human 
                                Services
    Chairman and Members of the Committee:
    Good afternoon, I am Robert G. McSwain, Principal Deputy Director 
of the Indian Health Service. Today, I appreciate the opportunity to 
testify on ``Examining the True Costs of Alcohol and Drug Abuse in 
Native Communities.'' As you know, the Indian Health Service (IHS) 
plays a unique role in the Department of Health and Human Services to 
meet the Federal trust responsibility to provide health care to 
American Indians and Alaska Natives. The IHS provides high-quality, 
comprehensive primary care and public health services through a system 
of IHS, Tribal, and Urban Indian operated facilities and programs based 
on treaties, judicial determinations, and Acts of Congress. The IHS has 
the responsibility for the delivery of health services to an estimated 
2.2 million American Indians and Alaska Natives who belong to 566 
Federally-recognized Tribes. The mission of the agency is to raise the 
physical, mental, social, and spiritual health of American Indians and 
Alaska Natives to the highest level.
    Two major pieces of legislation are at the core of the Federal 
Government's responsibility for meeting the health needs of American 
Indians and Alaska Natives: The Snyder Act of 1921, 25 U.S.C  13, and 
the Indian Health Care Improvement Act (IHCIA), 25 U.S.C.   1601-
1683. The Snyder Act authorized appropriations for ``the relief of 
distress and conservation of health'' of American Indians and Alaska 
Natives. The IHCIA was enacted ``to implement the Federal 
responsibility for the care and education of the Indian people by 
improving the services and facilities of Federal Indian health programs 
and encouraging maximum participation of Indians in such programs.'' 
Like the Snyder Act, the IHCIA provides the authority for the provision 
of programs, services, functions, and activities to address the health 
needs of American Indians and Alaska Natives. The IHCIA also includes 
authorities for the recruitment and retention of health professionals 
serving Indian communities, health services for people, and the 
construction, replacement, and repair of healthcare facilities.
Introduction
    The economic costs of alcohol and drug misuse are enormous. The 
Centers for Disease Control and Prevention estimated the costs of 
excessive alcohol consumption in 2006 to be $223.5 billion in lost 
productivity, healthcare, and criminal justice costs. \1\ According to 
the National Drug Intelligence Center, in 2007 alone, illicit drug use 
cost our Nation more than $193 billion in lost productivity, 
healthcare, and criminal justice costs. \2\ However, examining the true 
costs of alcohol and illicit and nonmedical prescription drug use for 
Native communities is challenging, although we know it is substantial. 
In the absence of studies on the scope and costs of alcohol and drug 
misuse for Native communities, IHS depends largely on measures of 
prevalence, morbidity, and mortality related to alcohol and drug misuse 
for American Indians and Alaska Natives (AI/AN). In 2007-2009, the AI/
AN age-adjusted death rates for the following causes were considerably 
higher than those for the U. S. all races population in 2008: \3\
---------------------------------------------------------------------------
    \1\ Available at: http://www.cdc.gov/features/alcoholconsumption/
    \2\ National Drug Intelligence Center. (2010). National threat 
assessment: the economic impact of illicit drug use on American 
society. Department of Justice. Washington, D.C.
    \3\ Indian Health Service. (2015). Trends in Indian Health 2014 
Edition. Available at: https://www.ihs.gov/dps/includes/themes/
newihstheme/display_objects/documents/Trends2014Book508.pdf

   Alcohol related--520 percent greater;
   Chronic liver disease and cirrhosis--368 percent greater;
   Motor Vehicle Crashes--207 percent greater;
   Unintentional injuries--141 percent greater;
   Homicide--86 percent greater;
   Suicide--60 percent greater; and
   Firearm injury--16 percent greater.

    While these data are staggering, IHS data have shown improvements 
in the age-adjusted alcohol-related death rate for AI/AN people in 
recent years with rates decreasing from 77.5 per 100,000 people between 
1979-1981 to 49.6 in 2007-2009 per 100,000 population. However, the 
age-adjusted drug-related death rate for AI/AN residing in IHS service 
areas increased from 4.1 deaths per 100,000 in 1979-1981 to 22.7 in 
2007-2009. By comparison, the 2007-2009 age-adjusted drug-related death 
rate is 1.8 times greater than the U.S. all races rate for 2008. These 
data speak to the need for a public health strategy, informed by 
Tribes, to address alcohol and drug use. The human cost is too great to 
ignore this problem.
IHS Alcohol and Substance Abuse Program
    As alcohol and substance abuse treatment and prevention have 
transitioned from IHS direct care services to local community control 
via Tribal contracting and compacting, IHS' role has transitioned from 
primarily providing direct services to providing funding, training, and 
technical assistance to enable communities to plan, develop, and 
implement culturally-informed programs. The Fiscal Year (FY) 2015 
enacted budget for the IHS Alcohol and Substance Abuse Program (ASAP) 
was slightly more than $190 million. Over 80 percent of the ASAP budget 
is contracted or compacted by Tribes. The IHS ASAP approach to 
addressing alcohol and substance use disorders in Native communities is 
to treat AI/AN individuals struggling with substance use disorders; 
train healthcare providers to treat substance use disorders in 
outpatient settings and intervene early before substance use disorder 
develops; and prevent alcohol and drug use before it begins.
Treat Individuals Struggling with Substance Use Disorders
    Compared with other racial/ethnic groups, AI/AN tend to begin using 
alcohol and drugs at a younger age, use them more often and in higher 
quantities, and experience more negative consequences from them. A 
2009-2012 study focusing on American Indian youth reveals alarming 
substance use patterns, including patterns of drug use beginning much 
earlier than is typical for other Americans. \4\ For instance, 56.2 
percent of American Indian 8th graders and 61.4 percent of American 
Indian 10th graders had used marijuana, compared to 16.4 percent of 8th 
graders and 33.4 percent of 10th grade students nationally. \5\ 
American Indian students' annual heroin and OxyContin use was about two 
to three times higher than the national averages in those years. \6\
---------------------------------------------------------------------------
    \4\ Stanley, L., Harness, S., Swaim, R., & Beauvais, F. (2014). 
Rates of substance use of American Indian students in 8th, 10th, and 
12th grades living on or near reservations: update, 2009-2012. Public 
Health Report, Mar-Apr; 129(2): 156-63.
    \5\ Ibid.
    \6\ Stanley, L., Harness, S., Swaim, R., & Beauvais, F. (2014). 
Rates of substance use of American Indian students in 8th, 10th, and 
12th grades living on or near reservations: update, 2009-2012. Public 
Health Report, Mar-Apr; 129(2): 156-63.
---------------------------------------------------------------------------
    To help youth with substance use disorder, IHS funds ten Youth 
Regional Treatment Centers (YRTCs). The YRTCs provide a range of 
clinical services to provide treatment services rooted in culturally 
relevant, holistic models of care including group, individual, and 
family psychotherapy, life skills development, medication management, 
aftercare relapse prevention, and post-treatment follow up. YRTCs also 
provide education, culture-based prevention activities, and evidence- 
and practice-based models of treatment to assist youth in overcoming 
their challenges and to become healthy, strong, and resilient community 
members.
    The IHS and Tribes primarily serve small, rural populations with 
primary medical care and community-health services, relying on the 
private sector for much of the secondary and most of the tertiary 
medical care needs through the Purchased/Referred Care (PRC) program, 
including treatment for alcohol and substance use. In FY 2013, the 
total rate of alcohol-related discharge diagnoses for IHS and Tribal 
direct and contract hospital was 11.6 per 10,000 user population aged 
15 years or older. This is 19 percent lower than the Calendar Year (CY) 
2013 discharge diagnosis rate of 14.1 for U.S. Short Stay hospitals. In 
FY 2014, IHS PRC spent over $5.8 million on inpatient admissions 
related to alcohol and substance use diagnoses. During the same time 
period, over $12 million was expended for inpatient visits related to 
liver disease. It is important to note that the PRC dollars spent on 
inpatient admissions are likely an underrepresentation of the actual 
costs of treatment for alcohol and substance use disorders as this 
number represents PRC expenditures from Federal programs only and not 
tribal programs that are not required to report their expenditures to 
IHS.
Train Healthcare Providers to Identify Substance Use and Intervene 
        Early
    Workforce development is an IHS resource available to Federal and 
tribal healthcare systems as an essential part of effectively 
addressing mental health and substance use disorder issues in AI/AN 
communities. Established in 2008, the IHS Tele-Behavioral Health Center 
of Excellence (TBHCE), in partnership with the University of New Mexico 
Center for Rural and Community Behavioral Health, provides workforce 
training and tele-behavioral health services. The prevention and 
treatment of alcohol and substance use disorders is reinforced by 
connecting widely separated and often isolated programs of varying 
sizes together into a network of support. Whereas small clinics would 
need to develop separate contracts for addiction services, the TBHCE is 
able to provide more cost-effective specialty care conveniently located 
within the clinics where patients utilize services. IHS and Tribal 
programs are increasingly adopting and using these technologies, with 
more than 8,000 encounters provided via tele-behavioral health in FY 
2014. Specific to addiction psychiatry, the TBHCE provided 868 hours of 
direct care via tele-behavioral health. In the same timeframe, the 
TBHCE hosted trainings on substance misuse and prevention related 
topics for the Indian health system as a means to increase competent 
health care providers to treat substance use disorder in outpatient 
settings and intervene early before a substance use disorder develops. 
Training topics included: opioid use disorder; essential training on 
proper pain management; using non-opioid pain medication for chronic 
non-cancer pain; and medication management for pain: opiate analgesics 
and safe prescribing. These trainings had more than 8,000 participants.
    Screening, Brief Intervention, Referral to Treatment (SBIRT) is a 
comprehensive approach for early intervention and treatment for people 
with substance use disorders and those at risk of developing these 
disorders. IHS is broadly implementing SBIRT as an evidence-based 
practice designed to identify, reduce, and prevent problematic use, 
substance use disorders, and dependence on alcohol. SBIRT is a payable 
service under state Medicaid plans, while Medicare pays for medically 
reasonable and necessary SBIRT services in the physician office setting 
and outpatient hospitals through the Medicare Physician Fee Schedule or 
the hospital Outpatient Prospective Payment System. Another activity 
IHS is developing/promoting is Medication Assisted Treatment (MAT) for 
opioid use disorder, which uses Food and Drug Administration approved 
pharmacological treatments, in combination with psychosocial 
treatments. IHS will continue to provide the necessary MAT training 
through its TBHCE.
Prevent Alcohol and Drug Use Before It Begins
    IHS' primary source of prevention funding is through the 
Methamphetamine and Suicide Prevention Initiative (MSPI), established 
in 2009. The MSPI currently funds 130 IHS, Tribal, and Urban Indian 
Health Programs (UIHPs) in a nationally coordinated six-year 
demonstration pilot project. The MSPI promotes the use and development 
of evidence-based and practice-based models that represent culturally-
appropriate prevention and treatment approaches to methamphetamine use 
and suicide prevention from a community-driven context. The MSPI 
primarily focuses on treatment for methamphetamine under provision of 
the appropriations language; however, during the evaluation of MSPI, 
data revealed a need for prevention strategies to reduce the use of 
marijuana, alcohol, prescription drugs, and other substances.
    From 2009 to 2014, the MSPI resulted in over 9,400 individuals 
entering treatment for methamphetamine use; more than 12,000 substance 
use and mental health encounters via telehealth; over 13,150 
professionals and community members trained in suicide crisis response; 
and more than 528,000 encounters with youth provided as part of 
evidence-based and practice-based prevention activities. \7\ The 
demonstration pilot project phase ends on August 31, 2015. On July 8, 
2015, IHS announced the FY 2015 MSPI funding opportunity, which will be 
a $13.5 million five-year funding cycle to continue the planning, 
development, and implementation of the MSPI. In the new funding 
announcement, eligible applicants will be able to focus on alcohol and 
drug use and suicide prevention strategies for Native youth.
---------------------------------------------------------------------------
    \7\ U.S. Department of Health and Human Services. Indian Health 
Service, Division of Behavioral Health. http://www.ihs.gov/mspi/
aboutmspi/
---------------------------------------------------------------------------
    The high prevalence of alcohol and other substance use rates in 
Native communities, especially among AI/AN youth, alerts us to the 
urgency of implementing prevention programs to intervene at an earlier 
age. The FY 2016 President's Budget includes key investments to support 
the Generation Indigenous Initiative, which takes a comprehensive, 
culturally appropriate approach across the Federal Government that will 
help ensure that Native youth can reach their full potential. The 
request for the Tribal Behavioral Health Initiative for Native Youth is 
a total of $50 million in additional funding for IHS and the Substance 
Abuse and Mental Health Services Administration (SAMHSA). Within IHS, 
the request includes $25 million to expand the successful MSPI to 
increase the number of child and adolescent behavioral health 
professionals who will provide direct services and implement youth-
based programming at IHS, tribal, and urban Indian health programs, 
school-based health centers, or youth-based programs.
Federal Coordination to Address Indian Alcohol and Substance Use 
        Disorders
    The Tribal Law and Order Act (TLOA), signed into law by President 
Obama in July 2010, contains provisions expanding the number of Federal 
agencies that are required to coordinate efforts on alcohol and 
substance use issues in Indian Country. Agencies included in 
coordinated efforts are the IHS, Department of Justice (DOJ), and 
SAMHSA, along with the Department of Interior (DOI) Bureau of Indian 
Affairs (BIA) and Bureau of Indian Education (BIE). A key provision of 
TLOA directs SAMHSA to take the lead role in interagency coordination 
and collaboration on tribal alcohol and substance use programs through 
the establishment of an Office of Indian Alcohol and Substance Abuse.
    The permanent reauthorization of Indian Health Care Improvement Act 
(IHCIA) required the review and update of an existing memorandum of 
agreement (MOA) from 2009 between IHS and the DOI BIA and BIE on Indian 
Alcohol and Substance Abuse Prevention. This MOA serves as the formal 
mechanism to advance IHS' partnership with Federal agencies to assist 
Tribes in addressing behavioral health issues among Indians, 
specifically mental illness and dysfunctional and self-destructive 
behavior, including substance misuse, child abuse, and family violence.
Conclusion
    A wide variety of healthcare costs are associated with alcohol and 
substance use disorders, including hospital costs from injuries, 
illnesses, residential and outpatient treatment costs, pharmaceutical 
costs, nursing home and long-term facility costs, and the cost of 
treating Fetal Alcohol Syndrome, HIV/AIDS, and hepatitis B and C. Given 
the high rates of alcohol and substance use-related problems on 
reservations, such as academic failure, delinquency, violent criminal 
behavior, suicidality, and alcohol-related mortality, the costs to 
Native communities will continue to be far too high, indicating that a 
comprehensive public health strategy aimed at primary prevention and 
early intervention of alcohol and drug use in Native communities is 
essential. This approach must be a coordinated response, guided by 
Tribes, that has impacts beyond the Indian health system, including 
research of root causes, poverty, unemployment, unstable housing, 
education, food insecurity, and community infrastructure. IHS is 
committed to partnering with the committee, Tribes, other Federal 
agencies, and key stakeholders on further examining and addressing the 
true costs of alcohol and drug use in Native communities.

    The Chairman. Thank you very much, Director McSwain.
    Next is Mirtha Beadle, who is the Director of the Office of 
Tribal Affairs and Policy, Substance Abuse and Mental Health 
Services Administration, Rockville, Maryland. Thank you, 
welcome and please proceed. "

STATEMENT OF MIRTHA BEADLE, DIRECTOR, OFFICE OF TRIBAL AFFAIRS 
                AND POLICY, SUBSTANCE ABUSE AND 
          MENTAL HEALTH SERVICES ADMINISTRATION, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Ms. Beadle. Thank you, Chairman Barrasso, Ranking Member 
Tester and members of the Senate Committee on Indian Affairs. 
Thank you for inviting me to testify at this very important 
hearing on substance use and substance use disorders in Native 
communities.
    As the Chairman said, my name is Mirtha Beadle. I am the 
Director of the Office of Tribal Affairs and Policy within the 
Substance Abuse and Mental Health Services Administration.
    As you are aware, SAMHSA's mission is to reduce the impact 
of substance abuse and mental illness on America's communities. 
SAMHSA's Office of Tribal Affairs and Policy, or OTAP, as we 
refer to it, serves as a primary point of contact for tribal 
governments, tribal organizations, Federal agencies and other 
entities as well. The Office of Indian Alcohol and Substance 
Abuse, or OIASA, is an organizational component of OTAP and is 
charged with improving Federal coordination amongst a number of 
agencies and carrying out specific requirements of the Tribal 
Law and Order Act.
    In November, 2014, SAMHSA held its very first cross-agency 
tribal grantee conference. The focus was on empowering Native 
youth. We were pleased to have Ranking Member Tester 
participate in that important event. I have to tell you that 
more than 125 youth participated in that conference. Their top 
concerns were alcohol and substance use. Nearly 75 percent of 
American Indians and Alaska Native treatment admissions 
reported alcohol as a substance of abuse compared to about 56 
percent of non-American Indian and Alaska Native admissions.
    Through CDC data, we also know that American Indians and 
Alaska Natives are more likely than other racial-ethnic groups 
in the U.S. to die from drug-induced deaths.
    SAMHSA provides and supports vital technical assistance to 
tribes to address substance use and substance use disorders. 
For example, the SAMHSA Tribal Training and Technical 
Assistance Center supports Native communities with 
infrastructure development, capacity building, program planning 
implementation and also training. We also have SAMHSA's Fetal 
Alcohol Spectrum Disorders Center for Excellence, a Native 
initiative, which educates and trains policy makers and 
providers, caregivers and communities, individuals and 
families, on preventing alcohol-exposed pregnancy and improve 
the lives of individuals affected by FASD.
    SAMHSA helps to support American Indians and Alaska 
Natives. It is a priority for the agency. In fiscal year 2014, 
Congress appropriated for the first time $5 million to begin 
the Tribal Behavioral Health Grant program. Twenty grants were 
awarded in fiscal year 2014. We had grantees such as Turtle 
Mountain Band of Chippewa, Pueblo of Nambe, and they are 
working across tribal suicide prevention, mental health, 
substance use prevention and substance use disorder treatment, 
to build positive behavioral health in their communities.
    The President's fiscal year 2016 budget for the Tribal 
Behavioral Health Grant is $30 million. That will allow the 
agency to expand support to approximately 103 additional 
tribes.
    The House Appropriations Committee fully funds the Tribal 
Behavioral Health Program for fiscal year 2016 at the requested 
level of $30 million. However, the Senate Appropriations 
Committee level-funds the Tribal Behavioral Health Grant 
Program for 2016 at just under $5 million.
    The Strategic Prevention Framework-State Incentive Grant 
program supports the development of comprehensive plans for 
prevention and infrastructure development, system development 
and is providing funds to a number of important tribal 
communities, including the Confederated Salish and Kootenai 
Tribes, the Leech Lake Band of Ojibwe, Nooksack Indian Tribal 
Council, Northern Arapahoe Tribe, Oklahoma City Inter-Tribal 
Health Board and several other grantees as well.
    The Substance Abuse and Mental Health Services 
Administration also has a grant program called the Strategic 
Prevention Framework that has been very vital for tribal 
communities. That program funds a number of tribes as well, 
such as Cook Inlet Council, the Montana-Wyoming Tribal Leaders 
Council and Cherokee Nation.
    I have to say that SAMHSA also is involved in a number of 
important treatment drug court programs. The intent here is to 
break the cycle of criminal behavior, alcohol and substance use 
and incarceration, including among Native American populations. 
In fiscal year 2014, the Juvenile Treatment Drug Courts Program 
and also through the adult Tribal Healing to Wellness Program, 
we funded a number of tribes including the Lac Du Flambeau Band 
of Chippewa, Mescalaro Tribe and also Lower Brule Sioux Tribal 
Council.
    We thank you for the opportunity to discuss SAMHSA's 
efforts to address the issue of substance use and we are happy 
to take any questions that you may have. Thank you for the 
time.
    [The prepared statement of Ms. Beadle follows:]

Prepared Statement of Mirtha Beadle, Director, Office of Tribal Affairs 
and Policy, Substance Abuse and Mental Health Services Administration, 
              U.S. Department of Health and Human Services
    Chairman Barrasso, Ranking Member Tester, and members of the Senate 
Committee on Indian Affairs, thank you for inviting me to testify at 
this important hearing on substance use and substance use disorders in 
Native Communities. My name is Mirtha Beadle, and I am the Director of 
the Office of Tribal Affairs and Policy within the Substance Abuse and 
Mental Health Services Administration (SAMHSA), an agency of the 
Department of Health and Human Services (HHS).
    We all know that substance use and substance use disorders are some 
of the most severe public health and safety problems facing American 
Indian and Alaska Native (AI/AN) individuals, families, and communities 
and more must be done to diminish the devastating social, economic, 
physical, and mental consequences.
    SAMHSA's work with AI/AN populations is rooted in the belief that 
tribes know best how to solve their own problems through prevention, 
treatment, and recovery activities and engaging with and strengthening 
community partnerships. In addition, SAMHSA's work with tribal 
communities supports behavioral health and wellness through culturally-
tailored programs and initiatives that value tribal beliefs. SAMHSA 
also offers help in real time to tribes and grantees as they work to 
advance substance use prevention, mental health promotion, and 
behavioral health treatment programs.
    In November 2014, SAMHSA held its first cross-agency tribal grantee 
conference. The focus of the conference was on empowering Native youth 
through leadership and behavioral health workshops and to engage them 
in a dialogue about behavioral health. SAMHSA was pleased that Ranking 
Member Tester was able to speak at this important event at which more 
than 125 youth participated and shared challenges and opportunities for 
improving the behavioral health of their peers and communities. At the 
top of their list were concerns around alcohol and substance use and a 
range of social and economic problems, including unemployment, poor 
educational outcomes, poor housing, and insufficient access to 
behavioral health services. SAMHSA will continue efforts to support 
positive development of tribal youth through additional training 
opportunities.
SAMHSA
    As you are aware, SAMHSA's mission is to reduce the impact of 
substance use and mental illness on America's communities. SAMHSA 
envisions a nation that acts on the knowledge that:

   Behavioral health is essential for health;
   Prevention works;
   Treatment is effective; and
   People recover from mental and substance use disorders.

    In order to achieve this mission, SAMHSA has identified six 
Strategic Initiatives to focus the Agency's work on improving lives and 
capitalizing on emerging opportunities. SAMHSA's Strategic Initiatives 
are: Prevention of Substance Abuse and Mental Illness; Health Care and 
Health Systems Integration; Trauma and Justice; Recovery Support; 
Health Information Technology; and Workforce Development.
Office of Tribal Affairs and Policy (OTAP)
    SAMHSA's OTAP serves as SAMHSA's primary point of contact for 
tribal governments, tribal organizations, Federal departments and 
agencies, and other governments and agencies on behavioral health 
issues facing AI/AN populations in the United States. OTAP supports 
SAMHSA's efforts to advance the development and implementation of data-
driven policies and innovative practices that promote improved 
behavioral health for AI/AN communities and populations. The creation 
of OTAP brought together SAMHSA's tribal affairs, tribal policy, tribal 
consultation, tribal advisory, and Tribal Law and Order Act (TLOA) 
responsibilities to improve agency coordination and achieve meaningful 
progress. OTAP carries out its work in partnership with tribal nations 
and in collaboration with SAMHSA centers and offices, and other Federal 
agencies.
    The Office of Indian Alcohol and Substance Abuse (OIASA) is an 
organizational component of OTAP. OIASA is required under TLOA to 
coordinate federal partners to provide tribes with technical assistance 
and identify resources to develop and enhance alcohol and substance use 
prevention and treatment programs.
Prevalence of Behavioral Health Conditions and Treatment
    Alcohol and substance use, as well as mental health issues and 
suicide, continue to be among the most severe health and social 
problems AI/ANs face. According to SAMHSA's 2013 National Survey on 
Drug Use and Health (NSDUH), the statistics related to behavioral 
health conditions and treatment needs among the AI/AN populations are 
very troubling.
Substance Misuse and Abuse
   Though lower than in 2012, the rate of substance dependence 
        or abuse among people aged 12 and up was still higher among the 
        AI/AN population (14.9 percent) than among other racial/ethnic 
        groups. \1\
---------------------------------------------------------------------------
    \1\ Results from the 2013 National Survey on Drug Use and Health: 
Summary of National Findings http://www.samhsa.gov/data/sites/default/
files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf

   According to data from the 2011 Behavioral Risk Factor 
        Surveillance System (BRFSS), AI/AN individuals have the second 
        highest rate of binge alcohol use (18.2 percent) compared to 
        white, non-Hispanic (21.2 percent), AI/ANs report the highest 
        intensity of drinks per binge (8.4 drinks per binge episode) 
        and the highest frequency of binge drinking episodes (4.5 
        during the past 30 days) compared with other racial/ethnic 
        groups. \2\
---------------------------------------------------------------------------
    \2\ Centers for Disease Control and Prevention. CDC Health 
Disparities and Inequalities Report--United States, 2013. MMWR 
2013;62(Suppl 3):[77-80] http://www.cdc.gov/mmwr/preview/mmwrhtml/
su6203a13.htm

   The rate of tobacco use among the AI/AN population (40.1 
        percent) is higher than all other racial/ethnic groups. \3\
---------------------------------------------------------------------------
    \3\ Results from the 2013 National Survey on Drug Use and Health: 
Summary of National Findings (http://www.samhsa.gov/data/sites/default/
files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf)

   American Indians and Alaska Natives are also more likely 
        than other racial/ethnic groups in the United States to die 
        from drug-induced deaths (17.1 per 100,000 people), according 
        to 2010 National Vital Statistics System data reported in a 
        2013 Centers for Disease Control and Prevention (CDC) report on 
        U.S. health disparities and inequities. \4\
---------------------------------------------------------------------------
    \4\ CDC Morbidity and Mortality Weekly Report (MMWR) http://
www.cdc.gov/mmwr/preview/mmwrhtml/
su6203a27.htm?s_cid=su6203a27_w#x2014;%20United%20States,%201999-2010)
---------------------------------------------------------------------------
Substance Abuse Treatment \5\
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    \5\ Substance Abuse and Mental Health Services Administration, 
Treatment Episode Data Set (2012 data).
---------------------------------------------------------------------------
   76.6 percent (33,401) of AI/AN treatment admissions reported 
        alcohol as a substance of abuse. By comparison, 56.2 percent of 
        non-AI/AN admissions reported alcohol as a substance of abuse.

   Among admissions aged 15 to 24, 68.5 percent (6,885) of AI/
        AN admissions reported alcohol as a substance of abuse. In the 
        same age group, 45.2 percent of non-AI/AN admissions reported 
        alcohol as a substance of abuse.
Improving Practice
    SAMHSA, as the Federal agency that leads public health efforts to 
advance the behavioral health of the nation, has several roles. I just 
spoke about the ways in which SAMHSA provides leadership and voice and 
supports the behavioral health field with critical data from national 
surveys and surveillance. SAMHSA also has a vital role in collecting 
best practices and developing expertise around prevention and treatment 
for people with mental illness and substance use disorders. SAMHSA's 
staff includes subject matter experts that provide technical assistance 
and training to individuals, organizations, states, tribes, and others 
every day.
    The SAMHSA Tribal Training and Technical Assistance (TTA) Center 
uses a culturally relevant, evidence-based, holistic approach to 
support Native communities in their self-determination efforts through 
infrastructure development and capacity building, as well as program 
planning and implementation. It provides training and technical 
assistance on mental and/or substance use disorders, suicide 
prevention, and mental health promotion. It also offers training and 
technical assistance, ranging from broad to focused, to federally 
recognized tribes, SAMHSA tribal grantees, and tribal organizations 
serving Indian country.
    SAMHSA funds the National American Indian and Alaska Native 
Addiction Technology Transfer Center (ATTC), one of four National Focus 
Area ATTCs. The primary goal of the Center is to serve as a subject 
matter center of excellence in technology transfer for the AI/AN 
behavioral health workforce. The Center and the ATTC Network as a whole 
are charged with providing training and technical assistance to the 
behavioral health workforce. Building on the Network's experience and 
evolution over the last 20 years, the Center is working with AI/AN 
behavioral health providers, peoples, organizations and communities to 
help develop and deliver effective culturally-relevant professional 
development and behavioral health services.
    The National Native Children's Trauma Center (NNCTC) is funded by 
SAMHSA under the National Child Traumatic Stress Initiative to provide 
national expertise on childhood trauma among AI/ANs. NNCTC works in 
collaboration with Indian Health Service (IHS) providers, tribal 
leadership, and other representatives in tribal communities to utilize 
evidence-based, culturally-appropriate, trauma-informed interventions 
for AI/AN children, youth, and military families who experience 
disproportionate childhood trauma, violence, grief, poverty, historical 
and intergenerational trauma. The Center serves as a national resource 
for consultation for AI/AN youth programming with a particular focus on 
working with school communities across the United States.
    SAMHSA's Center for the Application of Prevention Technologies 
(CAPT) Training and Technical Assistance Services is a national 
substance abuse prevention training and technical assistance system 
dedicated to strengthening prevention systems and the nation's 
behavioral health workforce. Nationwide, SAMHSA's CAPT provides state-
of-the-science training and technical assistance to tribes supported 
under SAMHSA's Strategic Prevention Framework and its Substance Abuse 
Prevention and Treatment Block Grant programs, as well as to tribal 
epidemiological workgroups and innovative local programs participating 
in SAMHSA's Service to Science Initiative. Tribal governments are not 
required to waive sovereign immunity as a condition of receiving SAMHSA 
block grant funds or services.
    SAMHSA's Fetal Alcohol Spectrum Disorders (FASD) Center for 
Excellence (CFE) Native Initiative promotes prevention of FASD in 
Indian country. Native Americans have some of the highest rates of 
alcohol-related birth defects in the nation. The FASD CFE works across 
multiple disciplines to educate and train policymakers and providers, 
caregivers and communities, and individuals and families on how to help 
prevent alcohol-exposed pregnancy and improve the lives of individuals 
affected by FASD.
Public Awareness and Support
    As part of SAMHSA's highly successful ``Talk. They Hear You.'' 
underage drinking prevention campaign, a promotion video was recorded 
with Rod Robinson, the former Director of SAMHSA's Office of Indian 
Alcohol and Substance Abuse. In the video, Mr. Robinson discusses 
materials developed to help prevent and reduce underage drinking in 
American Indian communities, and he responds to questions such as why 
underage drinking is an important concern for American Indian 
populations. He also communicates ways in which the ``Talk. They Hear 
You.'' materials will help parents and adult caregivers address 
underage drinking within tribal communities. The video is available on 
SAMHSA's You Tube channel.
Strategic Grant Making
Tribal Behavioral Health Grants
    SAMHSA has made helping American Indians and Alaska Natives a 
priority. For several years, the President's Budget for SAMHSA had 
requested funding for a new program specifically focused on tribal 
communities to address the high incidence of substance use and suicide 
in AI/AN youth and young adult populations. In Fiscal Year (FY) 2014, 
Congress appropriated for the first time $5 million to begin such a 
program, Tribal Behavioral Health Grants (TBHG). In FY 2014, SAMHSA 
awarded 20 Tribal Behavioral Health grants to tribes or tribal 
organizations with high rates of suicide to develop and implement a 
plan that addresses suicide and substance use (including alcohol) and 
is designed to promote mental health among tribal youth. Grantees such 
as the Selawik Village Council in Alaska, the Turtle Mountain Band of 
Chippewa Tribe in North Dakota, and the Pueblo of Nambe in New Mexico, 
indicated in their applications how they will incorporate evidence-
based, culture-based, and practice-based strategies for tribal youth. 
Grantees are required to work across tribal suicide prevention, mental 
health, substance use prevention, and substance use disorder treatment 
programs to build positive behavioral health among youth Grantees will 
create or enhance effective systems of follow up for those identified 
at risk of suicide and/or substance use or mental health issues that 
could lead to suicide. With a focus on tribal traditions, interagency 
collaboration, early identification, community healing, and preventing 
future deaths by suicide, grantees connect appropriate cultural 
practices, intervention services, care, and information with families, 
friends, schools, educational institutions, correctional systems, 
substance use programs, mental health programs, foster care systems, 
and other support organizations for tribal youth. Attention to the 
families and friends of tribal community members who recently died by 
suicide is encouraged as well. In addition, technical assistance is 
provided to grantees through SAMHSA's Tribal Technical Assistance 
Center to support their ability to achieve their goals.
    The President's FY 2016 Budget for the TBHG program is $30 million, 
including $15 million in the Mental Health appropriation and $15 
million in the Substance Abuse Prevention appropriation. This request 
represents an increase over the FY 2015 Enacted Level of $10 million in 
the Mental Health appropriation and $15 million for a newly established 
line in the Substance Abuse Prevention appropriation. This funding 
expands work supporting Generation Indigenous, an initiative focused on 
removing possible barriers to success for Native youth. This initiative 
will take a comprehensive, culturally appropriate approach to help 
improve the lives and opportunities for Native youth. In addition to 
HHS, multiple agencies including the Departments of Interior, 
Education, Housing and Urban Development, Agriculture, Labor, and 
Justice, are working collaboratively with tribes to address issues 
facing Native youth. The FY 2016 Budget would allow SAMHSA to expand 
activities that are critical to preventing substance use and promoting 
mental health and resiliency among youth in tribal communities. The 
additional funding would expand these activities to approximately 103 
additional tribes and tribal entities. With the expansion of the TBHG 
program, SAMHSA aims to reduce substance use and the incidence of 
suicide attempts among tribal youth and to address behavioral health 
conditions which impact learning in Bureau of Indian Education-funded 
schools. The TBHG program will support mental health promotion and 
substance use prevention activities for high-risk tribal youth and 
their families, enhance early detection of mental and substance use 
disorders among tribal youth, and increase referral to treatment.
    The House Appropriations Committee (House Report 114-195) fully 
funds the THBG program for FY 2016 at the requested level of $30 
million. However, the Senate Appropriations Committee (Senate Report 
114-74) level funds the TBHG program for FY 2016 at just under $5 
million.
Strategic Prevention Framework-State Incentive Grant (SPF-SIG) Program
    The Strategic Prevention Framework-State Incentive Grant (SPF-SIG) 
program supports activities to help states and tribes build a solid 
foundation for delivering and sustaining effective substance use 
prevention services and reducing the consequences of substance use. 
Following the SPF five-step process, SPF-SIG grantees develop 
comprehensive plans for prevention infrastructure and systems at the 
state and tribal levels. Ultimately, SPF-SIG States/Tribes assist and 
support selected sub-recipient communities to implement effective 
programs, policies, and practices to reduce substance use and its 
related consequences. The SPF-SIG program provides the foundation for 
success of the SPF--Partnerships for Success (PFS) Grant Program. 
Grantees include: Confederated Salish & Kootenai Tribes (Montana); 
First Nation Community Healthsource (New Mexico); Leech Lake Band of 
Ojibwe (Minnesota); Nooksack Indian Tribal Council (Washington); 
Northern Arapahoe Tribe (Wyoming); Oklahoma City Area Inter-Tribal 
Health Board; Tanana Chiefs Conference, Inc. (Alaska); and Oglala Sioux 
Tribe and Lower Brule Sioux Tribe (South Dakota).
Strategic Prevention Framework--Partnerships for Success State and 
        Tribal 
        Initiative (SPF-PFS)
    The Strategic Prevention Framework--Partnerships for Success State 
and Tribal Initiative (SPF-PFS) grant program was initiated in FY 2009 
and one of its targeted goals is to help young American Indians and 
Alaska Natives with reducing substance use-related problems; preventing 
the onset and reducing the progression of substance use disorders; 
strengthening prevention capacity and infrastructure at the state and 
community levels in support of prevention; and leveraging, redirecting, 
and realigning statewide funding streams for substance use prevention. 
Since FY 2012, the SPF-PFS program has concentrated on addressing two 
of the nation's top substance use prevention priorities: (1) underage 
drinking among persons aged 12 to 20; and (2) nonmedical prescription 
drug use among persons aged 12 to 25. In 2014, SAMHSA funded all five 
tribal applicants for the SPF-PFS program. The grantees include: Cook 
Inlet Tribal Council in Alaska; the Montana Wyoming Tribal Leaders 
Council; and the Cherokee Nation in Oklahoma.
Criminal Justice and Juvenile Justice
    SAMHSA is committed to enhancing substance use treatment services 
in existing adult tribal healing-to-wellness courts and in all juvenile 
treatment drug courts. SAMHSA's Treatment Drug Courts grant program 
aims to break the cycle of criminal behavior, alcohol and/or substance 
use, and incarceration, including among Native Americans. The purpose 
of this program is to expand and/or enhance substance use treatment 
services in existing adult Tribal Healing to Wellness Courts and in any 
Juvenile Treatment Drug Courts, which use the treatment drug court 
model in order to provide alcohol and substance use disorder treatment 
(including recovery support services, screening, assessment, case 
management, and program coordination) to justice-involved individuals. 
With respect to the Juvenile Treatment Drug Courts program, in FY 2014, 
SAMHSA awarded a three-year grant to the Omaha Tribe of Nebraska. In 
addition, SAMHSA funded all three tribal applicants for the adult 
Tribal Healing to Wellness Courts in FY 2014. The grantees include: Lac 
Du Flambeau Band of Chippewa Indians (Wisconsin); Mescalero Apache 
Tribal Council (New Mexico); and Lower Brule Sioux Tribal Council 
(South Dakota).
Nonmedical Prescription Drug Use and Opioid Use Disorder Treatment
    Nonmedical use of prescription medications takes a devastating toll 
on public health and safety. In 2013, NSDUH data showed that 
approximately 6.5 million Americans aged 12 or older reported current 
non-medical use of prescription drugs. In 2013, among persons aged 12 
or older, the rate of current illicit drug use was 12.3 percent among 
American Indians and Alaska Natives. \6\ In response to this public 
health crisis, IHS established the Prescription Drug Abuse (PDA) 
workgroup and developed a multi-disciplinary task force to address six 
key focus areas: patient care, policy development/implementation, 
education, monitoring, medication storage/disposal, and law 
enforcement. SAMHSA and other Federal agencies have been active members 
of the IHS PDA workgroup in an effort to improve national coordination 
and collaboration. SAMHSA has national and regional resources that 
include: strategies for reducing nonmedical use of prescription drugs; 
prescriber and patient education; publications; prevention and early 
intervention; technical assistance; and prescription drug monitoring 
programs. The workgroup developed a PDA Resource Guide to support 
technical assistance, training and education for providers and 
communities.
---------------------------------------------------------------------------
    \6\ Results from the 2013 National Survey on Drug Use and Health: 
Summary of National Findings http://www.samhsa.gov/data/sites/default/
files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf
---------------------------------------------------------------------------
    SAMHSA is also leading a number of activities in support of the HHS 
Secretary's Opioid Initiative that focuses on three specific areas: 
opioid prescribing practices to reduce opioid use disorders; naloxone 
development, access, and distribution; and, medication-assisted 
treatment to reduce opioid use disorders and overdose. SAMHSA will be 
working with IHS to improve training in the use of medication-assisted 
treatment, the standard of care for opioid use disorders, by providers 
in AI/AN communities.
Supporting Successful Recovery
    SAMHSA has also funded a number of programs that focus on recovery 
support in AI/AN communities. The Inter-Tribal Council of Michigan's 
``Anishnaabek Healing Circle, ATR Network'' was funded to improve 
access to a full array of treatment and recovery supports through 
network of culturally competent providers. The grant focused on tribal 
youth aged 12 and older who were enrolled members of the federally 
recognized tribes in Michigan.
Conclusion
    Thank you again for this opportunity to discuss SAMHSA's role in 
addressing the issue of substance use that is exacting significant 
health and economic tolls in Native communities. The issue is a major 
priority for SAMHSA, and recent activities such as the establishment of 
our OTAP underscore our dedication.

    The Chairman. Thank you very much for your testimony. Now, 
Melanie Benjamin.

STATEMENT OF HON. MELANIE BENJAMIN, CHIEF EXECUTIVE, MILLE LACS 
                         BAND OF OJIBWE

    Ms. Benjamin. Thank you, Mr. Chairman, Senator Franken and 
members of this Committee.
    Like most tribes, our fight against alcohol addiction has 
been ongoing for more than a century as a byproduct of 
colonization. In the 1980s, crack and meth invaded our 
communities. My focus today is on a terrible family of drugs 
now hitting our Minnesota tribal communities, claiming our 
youngest and most precious as victims, our babies, our future.
    Minnesota now leads the Nation in babies being born 
addicted to opiates. It is with profound sadness and concern 
that I report that my community is among the hardest hit. 
Babies born addicted to opiates are now the single greatest 
threat to the future of my band.
    The opiate explosion in Minnesota is so new that there is a 
great deal of information we do not know yet. Here is what we 
do know. Prescription opiates, including Vicodin, OxyContin, 
Percoset, morphine and codeine are each a pathway to heroin 
use. Nearly, 100 percent of heroin addicts repot their 
addiction began with an opiate prescription. More than 28 
percent of the babies born addicted to opiates in Minnesota are 
Native Americans, even though we are only about 2 percent of 
the population.
    Seventy-eight percent of opiate-addicted Indian babies are 
born in rural Minnesota. So this is more of a reservation 
problem. Indian women are 8.7 times more likely than non-
Indians to be diagnosed with opiate dependency or abuse during 
pregnancy. Fifty-seven percent of these women have a legal 
opiate prescription for pain given to them by a doctor, even 
throughout pregnancy, 57 percent, Mr. Chairman.
    The Mille Lacs Band is conducting a study that appears to 
show that our band members may be rapid metabolizers of many 
addictive drugs. This means that those who are addicted need 
more of the drug more frequently in order to maintain that 
effect, which means higher addiction rates. Babies born 
addicted to opiates go through horrifying withdrawal, 
struggling with pain, seizures, rapid breathing, sweating, 
trembling, vomiting, diarrhea, slow weight gain. They are at a 
high risk of premature birth and sudden infant death syndrome.
    The financial costs are high. Last year 262 Indian babies 
were born with opiate addiction in Minnesota and cost about $8 
million in medical care during withdrawal. That is about 
$30,000 per baby, and this is in the first year. But the social 
and financial costs continue to mount after their hospital 
stay. Most of these babies must be placed in foster care until 
the mother is able to care for them. But when the baby is 
removed, all the other children in the home are also usually 
removed as well.
    Mr. Chairman, we simply do not have enough Native foster 
families to take in this high number of children, nor do we 
have enough resources. Their medical issues are complex and may 
include high rates of cerebral palsy and other serious 
complications, the same as with victims of fetal alcohol 
syndrome. FAS spending can average $2 million over the lifetime 
of a child.
    My written statement goes into more detail about associated 
costs. But I want to close with providing you with some 
suggestions of what Congress can do. We need research to study 
this crisis. We must know more about the long-term impacts of 
newborn opiate addiction. We need funding for a culturally-
based treatment center for pregnant Native women in Minnesota. 
Currently the only program like this in Minnesota has just 21 
beds. At Mille Lacs alone, we had 21 babies born addicted to 
opiates in 2014.
    We need support to mount a massive public education 
campaign to highlight the risks of opiates. And we need the 
Federal and State governments to crack down on physicians who 
are prescribing these dangerous drugs without good reason. In 
the late 1800s, a genocide nearly occurred after Indian people 
were given blankets infested with smallpox. Dr. Barrasso, for 
Indian Country, opiates are a 21st century version of smallpox 
blankets.
    There is no reason for a teenager with depression to be 
prescribed Vicodin, but it happens every day. We need the 
medical community and the pharmaceutical companies to step up 
and police themselves. If they will not, then we ask you to 
help us police them. As tribal leaders we cannot do this by 
ourselves.
    Thank you, Mr. Chairman.
    [The prepared statement of Ms. Benjamin follows:]

  Prepared Statement of Hon. Melanie Benjamin, Chief Executive, Mille 
                          Lacs Band of Ojibwe
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    The Chairman. Thank you, and I especially want to thank you 
for that list of suggestions. It wasn't just one thing, it was 
an entire list and a broad list and encompasses a lot of 
different areas. I think that is going to be one of the most 
helpful parts of this Committee hearing today. Thank you very 
much for that.
    Next is Mr. John Walters. Mr. Walters, thank you for being 
with us. Please proceed.

  STATEMENT OF HON. JOHN P. WALTERS, CHIEF OPERATING OFFICER, 
                        HUDSON INSTITUTE

    Mr. Walters. Thank you, Mr. Chairman, members of the 
Committee. I am the former director of the Office of Drug 
Control Policy from the last Administration and am now the 
Chief Operating Officer of the Hudson Institute and Co-Director 
of the Center on Substance Abuse Policy Research.
    I am pleased to be with you and pleased to be with some of 
the people who are working with Native American and Alaska 
Native communities as I did back when I was in government.
    I will not repeat the detail not only in my testimony, but 
you have already heard about the disproportionate effect of 
substance abuse in Indian Country. It is staggering. The 
estimates of national cost of $200 billion or $600 billion 
don't capture the real human cost. These are our models, they 
are imprecise. The data here is embarrassingly bad.
    What we should do and what we can do to get national 
leaders and local leaders better help is begin to look at the 
problem as if it were as serious to us as it is to the people 
living in these communities.
    First thing I would recommend is that someone direct the 
Centers for Disease Control to treat this as an epidemic and 
begin to collect monthly data and precise geographic monthly 
data on the spread of this disease. If this were a virus, the 
Centers for Disease Control, I can tell you from my experience, 
resists this topic. It doesn't like substance abuse, in my 
experience. I have been out of government a while and maybe 
attitudes have changed. It also wants to say that it only deals 
with infectious diseases. That is not acceptable. The cost and 
the devastation is too high and you need to localize the 
particular knowledge about the spread of these phenomenon, 
because they are an epidemiological phenomenon.
    And if you are going to tie resources where they are 
needed, you need to know where the problem is and you need to 
know how well the resources are reaching the people who need 
them. That is not happening. And it is unacceptable, in my 
view.
    In addition, I think it is important to recognize that we 
do not do a very good job of providing the care, as you have 
heard from previous witnesses. Even if we expand resources 
under the Affordable Care Act and other programs, the problem 
is that the geographic isolation, the limits of infrastructure, 
the limits of referral and support programs after immediate 
detoxification and other services create a failure of treatment 
to work in these communities and a failure of prevention to be 
effective and comprehensive.
    We need to be more specific about how we can create 
targeted, culturally sensitive programs in these areas. 
Demonstration programs are nice, but demonstration programs are 
by definition inadequate to meet the real need. There has to be 
a plan and a consistent effort. I think someone in the Federal 
Government has to be targeted such that their job is on the 
line to give you a solution that reaches the real scope and 
focus of the problem. And given a fixed period of time, not 
four years and not eight years.
    I started working on the drug problem in the Reagan 
Administration at the Department of Education. The same 
agencies have been telling you they are going to get a national 
plan with real estimates and real achievement and real output 
data for decades. It is not happening.
    So until somebody's job in six months or twelve months or 
eighteen months is to produce such a plan or be fired, it is 
not going to happen.
    In addition, I want to just mention in connection with the 
overall problem the danger that was referred to, Mr. Chairman, 
in your opening remarks. There is now a movement to legalize 
the production of marijuana on Native land. On top of all that 
you have heard of the consequences of addiction and substance 
abuse, in all the areas you have heard of those consequences, 
this is devastating. If there ever was a bad idea that we ought 
to stop, it is this one. And of course, it doesn't just affect 
people in Indian Country. But it is a terribly, terribly 
destructive additional harm that we are inflicting on people 
who are already suffering.
    My testimony goes into detail about the latest research and 
what the findings are for educational, health, illness, 
violence, and other problems including family violence 
associated with marijuana and its connection to other substance 
abuse. It is worsening with regard to impaired driving, as well 
as educational performance. Recent research has suggested very 
strongly in multiple cases that the current high potency 
marijuana has the ability to not only reduce the educational 
performance but perhaps permanently reduce i.q. in young 
people. That is not the kind of additional ingredient we need 
to add to the mix here.
    In terms of the promises of profits, my testimony has some 
of the research that suggests this is as illusory as it is to 
say the taxes on alcohol are paying the cost of alcoholism in 
Indian Country. It is a lie. It is not going to happen and it 
is never going to happen.
    In short, I would say for the purposes of this Committee, 
we need to have not only a better understanding of the cost but 
how to drive our resources effectively to scale our resources 
and to hold people accountable. We can do that at the Federal 
level. But in addition, we are at a crossroads now with this 
latest movement. We can not only improve, but we also need to 
stop something that is going to be devastating to people who 
live in these communities who have already suffered enough.
    With that, I am going to conclude. I will be happy, when it 
is my turn, to answer any questions.
    [The prepared statement of Mr. Walters follows:]

 Prepared Statement of Hon. John P. Walters, Chief Operating Officer, 
                            Hudson Institute
    Chairman Barasso, Vice Chairman Tester, and members of the 
Committee, thank you for this opportunity to address the public health 
and public safety issues surrounding the costs and consequences of 
substance abuse on the Native population of the United States.
    In this testimony, I will briefly review what is currently known 
about the consequences of substance abuse on Native American and 
Alaskan Native communities--specifically focused on costs, expressed 
both in public health and in dollars. I also wish to draw attention to 
treatment need and address proposals to expand access to marijuana in 
these communities.
    According to a recent report from the Centers for Disease Control 
and Prevention (CDC) on minority health populations, there are 566 
Federally-recognized tribes plus an unknown number of tribes that are 
not Federally-recognized, each with its own culture, beliefs, and 
practices. \1\
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    \1\ http://www.cdc.gov/minorityhealth/populations/REMP/aian.html
---------------------------------------------------------------------------
    As the CDC report notes, according to U.S. Census Bureau in 2013, 
there were roughly 5.2 million American Indians and Alaska Natives 
living in the U.S., representing approximately 2 percent of the U.S. 
total population.
    The projected U.S. population of American Indians and Alaska 
Natives for July 1, 2060 is estimated to reach 11.2 million, 
constituting approximately 2.7 percent of the U.S. population by that 
date.
    In the 2010 U.S. Census, tribal groupings with 100,000 or more 
responses were: Cherokee (819,105), Navajo (332,129), Choctaw 
(195,764), Mexican American Indian (175,494), Chippewa (170,742), Sioux 
(170,110), Apache (111,810), and Blackfeet (105,304).
    In 2013, there were 14 states(with more than 100,000 American 
Indian and Alaska Native residents: California, Oklahoma, Arizona, 
Texas, New Mexico, Washington, New York, North Carolina, Florida, 
Alaska, Michigan, Oregon, Colorado and Minnesota.
    In 2013, the(states with the highest percentage of American Indian 
and Alaska Native population were Alaska (14.3 percent), followed by 
Oklahoma (7.5 percent), New Mexico (9.1 percent), South Dakota (8.5 
percent), and Montana (6.8 percent).
    A precise accounting of the true costs of substance abuse on 
Natives is difficult to establish, owing in large measure to 
deficiencies in our data sets, which is an on-going and frankly 
disturbing incapacity affecting all of drug policy. Broadly, for the 
United States population as a whole, estimates have been provided 
showing approximately $193 billion per year (measured in 2011 based on 
2007 datad the figure has since been updated to $209 billion in 2009 
dollars) as the costs to society of illicit drug use. The majority of 
those costs are attributed to law enforcement activities, lost 
productivity, and public health/health care impact. \2\
---------------------------------------------------------------------------
    \2\ http://www.justice.gov/archive/ndic/pubs44/44731/44731p.pdf
---------------------------------------------------------------------------
    Some proportion of those costs can be allocated to Native 
communities, but we must acknowledge that the true impact is almost 
surely far worse than one would find by simply dividing those costs by 
population share. Native communities are adversely situated with 
regards to substance abuse impact, in many instances facing 
vulnerabilities driven by, among other issues, poverty, geographic 
remoteness, and insufficient health care resources. Even in 
circumstances where the largest Native populations are found in urban 
settings, similar vulnerabilities pertain.
    In addition to the economic costs, we must acknowledge the personal 
and social costs measured in both lives and human potential lost, as 
well as diminished economic opportunity and well-being.
    The current human cost is staggering. As measured by the National 
Survey on Drug Use and Health (NSDUH), in 2013, American Indians and 
Alaskan Natives had the highest rate of substance abuse or dependence 
when compared to other racial or ethnic groups. The percentage who 
needed treatment for an alcohol or illicit drug use problem in the past 
year was nearly 88 percent higher than the national average for adults.
    Such high rates of abuse/dependence are linked with a host of 
health problems, including premature death. Yet the Substance Abuse and 
Mental Health Services Administration (SAMHSA) of the Health and Human 
Services Department (HHS) reports that Native Americans and Alaskan 
Natives are not well served by the publically-funded health care 
system. For instance, they are three times more likely than whites to 
lack health insurance, with approximately 57 percent depending on the 
Indian Health Service for treatment care.
    While the Affordable Care Act allows for enrollment in state 
exchanges for Natives, a 2004 study in the American Journal of Public 
Health found that less than half of low-income uninsured Native 
Americans/Native Alaskan had access to Indian Health Service care. \3\
---------------------------------------------------------------------------
    \3\ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449826/
---------------------------------------------------------------------------
    The American Psychiatric Association Fact Sheet on Mental Health 
Disparities American Indians and Alaskan Natives summarized what we 
know all too well about the struggle of Native communities. Natives are 
twice as likely to live in poverty than the rest of the US population, 
have lower life expectancy, higher infant mortality, and two and a half 
times the rate of violent victimization faced by whites. They face 
significantly higher rates of death from tuberculosis, diabetes, 
unintentional injury, while dying from alcohol-related causes at 
significantly higher rates than the national average.
    In 2008, the Centers for Disease Control and Prevention (CDC) 
released a report finding nearly 12 percent of deaths, between 2001 and 
2005, among Native Americans/Alaskan Natives to be alcohol related, 
compared to 3.3 percent nationally. \4\ Finally, suicide is the second 
leading cause of death for those between ten and thirty-four years of 
age.
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    \4\ http://www.nbcnews.com/id/26439767/ns/health-addictions/t/
native-american-deaths-alcohol-related/#.VbOpcVy76fR
---------------------------------------------------------------------------
    According to the White House 2014 Native Youth Report, more than 
one in three Native youth live in poverty, while their rate of high 
school graduation (67 percent) is the lowest of any racial/ethnic group 
across all schools, falling to 53 percent for Bureau of Indian 
Education schools, compared to a nationwide rate of 80 percent 
graduation.
    The lessons are painfully clear. In regards to the substance abuse 
of Native Americans, there is one thing that we must do, and one thing 
that we must not do.
    Finding ways to increase resources for substance abuse treatment is 
the critical one thing that we need to advance. Targeted, culturally-
competent, and tailored specialty treatment drug and alcohol programs, 
especially for youth, are urgently needed.
    Even with expanded potential health care access offered under the 
Affordable Care Act, substance abuse treatment parity will be difficult 
to obtain in reality. Regardless of insurance coverage, insufficient 
access to treatment providers, both physicians and treatment 
facilities, will hinder the actual delivery of services.
    And now the thing that we must not do: either willfully or 
inadvertently increase the burden in their lives by making things 
worse. For instance, allowing the cultivation, production, and sale of 
marijuana on Native lands, either through programs of so-called medical 
marijuana dispensing or by outright commercial legalization, would be 
perversely the wrong thing to do, and would actively foster harm.
    This preventable harm would begin with increased drug availability, 
use, and addiction and all the related threats they pose to public 
health. It will also create greater threats to public safety by 
increasing the risk of enhanced drug smuggling and black market 
activities by criminal organizations. Additionally, there is a serious 
risk of corruption and loss of integrity for banking and governance 
through the presence of a cash business illegal at the federal level.
    These threats would affect Native peoples, as well as neighboring 
non-Native communities.
    Some have argued that Native communities might benefit economically 
from being allowed to operate commercial operations involving 
marijuana, the cultivation and sale of which might generate jobs and 
tax revenue for those on Reservations. It is my judgment that such 
benefits are illusory, and that whatever economic benefit is promised 
will be overwhelmed by the accompanying criminal justice and public 
health costs that will accrue to communities that pursue such paths.
    Experience has shown us that in the presence of legalized marijuana 
markets, price declines, availability increases, prevalence rates rise, 
and one still finds the operation of a criminal black market. Potential 
financial savings from legalization and taxation fail to account for 
the economic and social costs of drug use. As a RAND Corporation study 
argued, legal marijuana places a dual burden on tribal governments of 
regulating the new legal market while continuing to pay for the 
negative effects associated with the underground market, which likely 
will be enhanced in the legalized environment. \5\
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    \5\ http://www.rand.org/content/dam/rand/pubs/testimonies/2009/
RAND_CT334.pdf
---------------------------------------------------------------------------
    There is a basis for my doubts concerning net benefits found in 
studies of alcohol markets. Some studies \6\ have estimated, for 2009 
dollars, that federal and state revenues from alcohol sales total no 
more than six percent of the $237.8 billion in alcohol-related costs 
from health care, treatment services, lost productivity and criminal 
justice imposed by alcohol use.
---------------------------------------------------------------------------
    \6\ http://www.ajpmonline.org/article/S0749-3797(11)00538-1/
fulltext
---------------------------------------------------------------------------
    Similar ratios can be expected for any commercial marijuana market. 
We have learned already from our experience in Colorado that users will 
evade regulated taxation schemes, and whatever revenue is attained will 
be swamped by the accompanying costs associated with drug use. In 
circumstances where treatment resources are already inadequate, and 
facing a population already at great risk for negative consequences, 
the promise of revenue and benefit for these communities is a misguided 
hope.
    Simply put, offering more drugs is a bad bargain, especially for 
communities already struggling under the weight of history, oppression, 
marginalization, and impoverishment.
    Further, Native communities that might chose to engage in marijuana 
cultivation and production will face additional negative impact on 
their already stressed environment. Marijuana cultivation results in 
chemical contamination, degraded water supplies, elimination of native 
vegetation, wildlife alteration, toxic wastes and garbage, food chain 
contamination, and wildfire risks, according to studies by the National 
Park Service of the Department of the Interior. \7\
---------------------------------------------------------------------------
    \7\ https://www.whitehouse.gov/ondcp/frequently-asked-questions-
and-facts-about-marijuana
---------------------------------------------------------------------------
    These negative effects and costs would come in addition to current 
degradation of Native lands associated with the operations of criminal 
organizations, which currently traffic marijuana and other drugs 
through Native territory, often with legal impunity because of 
jurisdictional complexities.
    And now let us turn in greater detail to the specifically human 
cost, especially to youth. Marijuana is the most widely-used illegal 
drug in the United States, and the health impairments associated with 
this drug, especially in newer high potency forms, are well known.
    Yet the Department of Justice (DOJ) has issued a determination that 
Native American reservations may become centers for ``legal'' marijuana 
sales and use, notwithstanding that this policy stands in stark 
violation of the federal Controlled Substances Act. \8\
---------------------------------------------------------------------------
    \8\ http://www.latimes.com/business/la-fi-marijuana-indians-
20141211-story.html
---------------------------------------------------------------------------
    The Attorney General's subcommittee on Native American issues has 
proposed to allow growing or selling marijuana on ``sovereign'' lands, 
even if encompassing state law, as well as federal law, prohibit the 
practice. Moreover, DOJ has expressed that there will be no federal law 
enforcement on their lands if a tribe does express opposition.
    This new push for expanding marijuana use is legally suspect on 
many grounds. Prior DOJ memoranda suspending enforcement of federal 
law, such as in Colorado, were contingent on the alignment of marijuana 
sales and use with prevailing state laws or regulatory regimes. But 
Native reservations are not legally equivalent to statesd rather, they 
are ``dependent domestic sovereigns,'' broadly subject to federal law. 
Hence, the proposal appears contradictory on the face of it.
    But there is worse in store. The impact on both Native Americans 
and upon the broader principles of political and economic integrity is 
deeply damaging.
    Native history teaches that they have suffered as much from well 
intentioned but devastating policies offered by ``friends'' as they 
have from the malign attacks from those who sought to destroy their 
cultures.
    In addition to the damage from addiction, there is damage to the 
wider community. Internationally, ``legal'' drug markets are known to 
be accompanied by organized crime, \9\ prostitution, theft, violent 
coercion, neighborhood degradation, and economic loss, as documented by 
the Netherlands' \10\ ``cannabis cafes.'' Meanwhile, Colorado is 
already experiencing law suits \11\ filed by businesses claiming harm 
from marijuana sales operations, based on racketeering and organized 
crime statutes.
---------------------------------------------------------------------------
    \9\ http://www.dutchamsterdam.nl/686-amsterdam-coffeeshops-
organized-crime
    \10\ hhttps://www.washingtonpost.com/world/europe/new-law-
threatens-amsterdams-cannabis-culture/2012/05/03/gIQAvQ570T_story.html
    \11\ http://www.washingtonpost.com/blogs/govbeat/wp/2015/02/18/
group-opposed-to-legal-marijuana-plans-to-sue-colorado-and-industry-
participants/
---------------------------------------------------------------------------
    There is the threat to Native lives from ongoing substance abuse, 
which shows a history of degradation, violence, and pathology for First 
Americans. As we have seen, alcohol and marijuana abuse is pronounced, 
while heroin and methamphetamine are established criminal threats, 
especially for tribes adjacent to Southwest Border smuggling routes, 
which exploit the interstitial nature of Reservation boundaries and 
competing jurisdictions.
    Let me conclude with a brief review of recent studies of marijuana 
use in association with negative health and criminal justice outcomes, 
associations that are of particular pertinence to Native populations.
    As reported by the Washington Post, \12\ last year Congress 
approved a law \13\ that for the first time will allow Indian tribes to 
prosecute certain crimes of domestic violence committed by non-Indians 
in Indian country. The Justice Department announced it had chosen three 
tribes for a pilot project to assert the new authority. \14\
---------------------------------------------------------------------------
    \12\ https://www.washingtonpost.com/world/national-security/new-
law-offers-a-sliver-of-protection-to-abused-native-american-women/2014/
02/08/0466d1ae-8f73-11e3-84e1-27626c5ef5fb_story.html
    \13\ http://www.justice.gov/tribal/violence-against-women-act-vawa-
reauthorization-2013-0
    \14\ https://www.washingtonpost.com/world/national-security/3-
tribes-authorized-to-prosecute-non-native-american-men-in-domestic-
violence-cases/2014/02/06/27bc1044-8f58-11e3-b46a-
5a3d0d2130da_story.html
---------------------------------------------------------------------------
    In 1978, in a case widely know in Indian country as ``Oliphant,'' 
\15\ the Supreme Court held that Indian tribes had no legal 
jurisdiction to prosecute non-Indians who committed crimes on 
reservations. Even a violent crime committed by a non-Indian husband 
against his Indian wife in their home on the reservation could not be 
prosecuted by the tribe.
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    \15\ https://supreme.justia.com/cases/federal/us/435/191/case.html
---------------------------------------------------------------------------
    While it is laudable to have domestic violence addressed, there is 
a striking irony when seen in relation to the proposed marijuana 
measure. A recent study of factors driving domestic violence found that 
consistent use of marijuana in adolescence was the single most 
predictive factor examined. \16\
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    \16\ http://jiv.sagepub.com/content/27/8/1562.abstract
---------------------------------------------------------------------------
    How could it possibly help the tragedy of domestic partner violence 
to increase access and use of marijuana?
    Sadly, very similar questions can be asked regarding the 
association of marijuana use explicitly with the social and public 
health threats faced by Native communities. Alcohol and drunk driving 
are already threats faced on many Reservations. Yet a recent study \17\ 
found that concurrent marijuana use worsened these risks, approximately 
doubling the odds of drunk driving, social consequences, and harms to 
self.
---------------------------------------------------------------------------
    \17\ http://onlinelibrary.wiley.com/doi/10.1111/acer.12698/abstract
---------------------------------------------------------------------------
    Native youth are at particular risk of suicide. Yet perversely, an 
increase in suicidal ideation is associated with all levels of 
marijuana use, regardless of duration. \18\
---------------------------------------------------------------------------
    \18\ http://www.ncbi.nlm.nih.gov/pubmed/25772435
---------------------------------------------------------------------------
    Faced with sexual abuse and unintended pregnancy, tribes should 
know that in a study of African American girls, use of marijuana at 
last episode of sex is associated, for youth, with non-use of condoms, 
acquisition of sexually transmitted diseases (STD), and unintended 
pregnancy. \19\
---------------------------------------------------------------------------
    \19\ http://www.ncbi.nlm.nih.gov/pubmed/25929200)
---------------------------------------------------------------------------
    And in the context of the unemployment challenges faced by many 
tribes, according to recent research, chronic use of marijuana 
increases the risk of unemployment. \20\
---------------------------------------------------------------------------
    \20\ http://www.ncbi.nlm.nih.gov/pubmed/25955962
---------------------------------------------------------------------------
    These are just a few of the recent findings, supplementing a well-
established host of research results showing marijuana use, 
particularly in adolescence, associated with serious psychological 
problems, such as schizophrenia, depression, and psychosis, including 
findings that marijuana use is associated with a greater than 60 
percent increase in school drop out risk. \21\
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    \21\ http://www.hudson.org/research/11298-marijuana-and-school-
failure
---------------------------------------------------------------------------
    How conceivably could adding increased supply (and acceptability) 
of an addictive drug associated with psychosis, IQ and learning loss, 
increased susceptibility to suicide, school failure and greater need 
for drug treatment, be anything other than a needless disaster? \22\
---------------------------------------------------------------------------
    \22\ http://www.hudson.org/research/10777-why-we-believe-marijuana-
is-dangerous
---------------------------------------------------------------------------
    But there is another threat emerging, one that portends to affect 
all Americans. Consider that Southern California alone is home to 
nearly 30 recognized Indian tribes, with a total population of nearly 
200,000. Were they to become purveyors of marijuana, by the experience 
of Colorado, they could quickly become ``smuggling centers'' for black 
market marijuana distribution to surrounding communities and states.
    Reservation boundaries could turn into ``domestic borders'' 
comparable to international borders, where drug operations by criminal 
organizations thrive in driving illegal cultivation and trafficking.
    This also presents an obvious course for fueling corruption in 
reservation politics, and equally worrying, U.S. financial affairs, for 
the emerging market in illicit drugs threatens our economic integrity 
nationwide. Not only has the DOJ set about dismantling, in states that 
have legalized, basic banking and money-laundering protections against 
criminal organizations penetrating the financial system, \23\ there is 
further risk from another center of illicit finance and money-
laundering: The cash business of casinos.
---------------------------------------------------------------------------
    \23\ http://www.fincen.gov/statutes_regs/guidance/pdf/FIN-2014-
G001.pdf
---------------------------------------------------------------------------
    There are nearly 500 Indian ``gaming'' operations found in nearly 
30 states, \24\ and while the revenues are great (estimated at $27 
billion annually), many are in serious debt. \25\ What would another 
cash business, dealing in addiction and in violation of federal law, 
presumably paying no federal taxes, do to tribal integrity? What could 
this contribute to the power of transnational criminal cartels?
---------------------------------------------------------------------------
    \24\ http://www.nigc.gov/LinkClick.aspx?fileticket=0J7Yk1QNg-
0%3D&tabid=943
    \25\ http://www.huffingtonpost.com/2012/01/22/indian-casinos-
debt_n_1222121.html
---------------------------------------------------------------------------
    Already, marijuana-related law firms from Colorado are guiding 
those tribes with casinos in setting up high-potency marijuana 
operations. \26\ The potential for public corruption is high, as is the 
certainty of increased suffering within America's Native communities.
---------------------------------------------------------------------------
    \26\ http://www.denverpost.com/business/ci_27284773/united-
cannabis-denver-help-calif-indian-tribes-grow
---------------------------------------------------------------------------
    In conclusion, it is clear that we need an integrated substance 
abuse strategy for responding to the current health crisis faced by 
Native Americans, and that response must include greater support for 
prevention and treatment programs.
    In addition to the traditional threat of alcohol, Native 
communities today are at risk from rising heroin and methamphetamine 
use and the presence of criminal operations within their borders. These 
are extremely tough challenges. But one thing that is directly in our 
hands is to refuse to do greater harm.
    It should be painfully clear that greater harm is precisely the 
most likely outcome from increased access and availability of high-
potency marijuana in Native communities. It would be irresponsible of 
us to allow this to happen.
    Thank you.

    The Chairman. Thank you very much for your testimony and 
for your passion. Thank you, Mr. Walters.
    Now, Sunny Goggles.

          STATEMENT OF SUNNY GOGGLES, DIRECTOR, WHITE 
BUFFALO RECOVERY PROGRAM, ARAPAHO TRIBE, WIND RIVER RESERVATION

    Ms. Goggles. Thank you to Chairman Barrasso and Committee 
members for inviting me to testify on this important subject. I 
come to you from one of the most beautiful places in the world, 
The Wind River Reservation in Wyoming. Our community is rich in 
culture and tradition and we are blessed with our youth shining 
with promise and potential. And we are struggling.
    We suffer high rates of alcohol and drug abuse as well as 
unemployment and poverty. Our beautiful community has been 
classified as notorious, deadly and renowned for brutal crime 
in the media. We directly see and feel the cost of alcohol and 
drug abuse in our community.
    Many times we think of the cost of alcohol and drug abuse 
and we focus on the financial costs. We consider how much money 
we are spending on the justice system, including law 
enforcement, courts and corrections. On Wind River, over 90 
percent of the crime is drug and alcohol related. There are 
also the costs to victims of crime, property destruction and 
theft.
    In 2014, a victim incurred over $500,000 of medical costs 
from one single incident. Medical costs related to alcohol and 
drug abuse deplete already limited resources in our community. 
On Wind River, those high-cost patients that abuse alcohol and 
tobacco outnumber patients who do not use 16 to 5. High-cost 
patients are those that incur over $100,000 of expenses in a 
year.
    Employers lose thousands of dollars a year due to high 
turnover rates in our community. There is an increase in the 
rate of illness and job abandonment due to alcohol and drugs. 
If a person is willing to get help, the cost of treatment 
includes the average stay of inpatient at $450 a day. For a 
stay of 90 days for one person, it is over $40,000.
    In 2014, at the White Buffalo Recovery Program in Arapaho, 
we served over 100 individuals. The cost is $4 million to 
accommodate this need. This is not considering the cost of 
transportation to and from the closest inpatient facility, 
which is 264 miles away from our community. Families who would 
like to participate and support an individual must travel these 
distances also.
    Many of these individuals have always lived on the 
reservation in which they are the majority. We place them in 
these facilities where they are subject to a minority 
experience for months. Facilities are limited in knowledge and 
understanding of Native culture and tradition and treatment is 
a difficult process. We expect somebody to change their life in 
a matter of months.
    Alcohol and drug abuse is not limited to the person. 
Children, parents, grandparents, aunts and uncles suffer the 
costs of their family members' abuse. It is overwhelming to 
watch a family member destroy their life with alcohol and 
drugs. This can lead to family members felling anxiety, fear, 
anger, concern, embarrassment or guilt and shame.
    Due to the correlation with violence, many families are 
subject to trauma from witnessing violence or being subject to 
physical or sexual abuse. This adds pressure to the limited 
resources of mental health services and social services.
    One of the most devastating costs is the human cost, the 
loss of life which can never be included in an additional line 
item on next year's budget. No amount of funding can replace 
this cost. On Wind River, 76 percent of unnatural deaths, such 
as accidents, suicide and homicide, are alcohol and drug 
related. Alcohol and drug use increases the odds of death 16.9 
times and equals 42.3 years of life lost in our community.
    Cancer, heart disease, cirrhosis and diabetes are also 
major causes of death to our tribal population in Wyoming, and 
are directly related to or contributed to by substance abuse. 
Individuals that use alcohol are more likely to die at 35 to 39 
years of age on Wind River. Based on mortality rates in our 
close-knit community, we lose a life nearly every week of the 
year. The loss of life contributes to more trauma on our 
families and our community. The loss of a tribal member is also 
a cost to our language, our culture, our traditions and our 
future.
    It is disheartening to think of all these costs to a real 
life, especially because it is preventable. Thank you.
    [The prepared testimony of Ms. Goggles follows:]

 Prepared Statement of Sunny Goggles, Director, White Buffalo Recovery 
             Program, Arapaho Tribe, Wind River Reservation
    Tous' Neneeninoo Nii'eihii Honobetouu. Thank you to Chairman 
Barrasso and committee members for inviting me to testify on this 
important subject. I come to you from one of the most beautiful places 
in the world, the Wind River Reservation in Wyoming. My community is 
rich in culture and tradition. We are blessed as our youth shine with 
promise and potential.
    And we are struggling. We suffer high rates of alcohol and drug 
abuse as well as unemployment and poverty. Our beautiful community has 
been classified as ``notorious'', ``deadly'' and ``renowned for brutal 
crime'' in the media. We directly see and feel the costs of alcohol and 
drug abuse on our community.
    Many times when we think about the costs of alcohol and drug abuse 
we focus on the financial costs. We consider how much money we are 
spending on the justice system including law enforcement, courts and 
corrections. On Wind River over ninety percent 90 percent of the crime 
is drug and alcohol related. There are also the costs on victims of 
crime, property destruction and theft. In 2014 a victim incurred over 
$500,000 dollars of medical costs in one single incident.
    Medical costs related to alcohol and drug abuse deplete already 
limited resources in our community. On Wind River those high cost 
patients that abuse alcohol and tobacco outnumber patients who do not 
use, 116 to 5. High cost patients are those who incur more than 
$100,000 of expenses in a year.
    Employers loose thousands of dollars a year due to high turnover 
rates in our community. There is an increase in the rate of illness and 
job abandonment due to alcohol and drugs.
    If a person is willing to get help, the cost of treatment services 
include the average stay in inpatient at $450 per day. For a stay of 
ninety days for one person is over $40,000. In 2014 at the White 
Buffalo Recovery program in Arapaho, we served over 100 individuals 
that were in need of this level of care. The cost is four million 
dollars to accommodate this need. This is not considering the cost of 
transportation to and from the closest inpatient facility which is 264 
miles from our community. Families that would like to participate and 
support an individual must travel these distances also. Many of these 
individuals have always lived on the reservation in which they are a 
majority. We place them in the facilities where they are subject to a 
minority experience for months. Facilities are limited in knowledge and 
understanding of Native culture and tradition. And treatment is a 
difficult process. We expect someone to change their life in a matter 
of months.
    Alcohol and drug abuse is not limited to the person. Children, 
parents, grandparents, aunts and uncles suffer the costs of their 
family member's abuse. It is overwhelming to watch a family member 
destroy their life with alcohol and drugs. This can lead to family 
members feeling anxiety, fear, anger, concern, embarrassment and guilt 
or shame. Due to the correlation with violence many families are 
subject to trauma from witnessing violence or being subject to physical 
or sexual abuse. This adds pressure to the limited resources for mental 
health services and social services.
    One of the most devastating costs is the human cost. The loss of 
life which can never be included in an additional line item on next 
year's budget. No amount of funding can replace this cost. On Wind 
River 76 percent of unnatural deaths such as accidents, suicide and 
homicide are alcohol and drug related. Alcohol and drug use increase 
the odds of death 16.9 times and equal 42.3 years of life lost in our 
community.
    Cancer, Heart Disease, Cirrhosis and Diabetes are also major causes 
of death to the tribal population in Wyoming and are directly related 
to or contributed to by substance abuse. Individuals that use alcohol 
are more likely to die at 35 to 39 years of age on Wind River. Based on 
mortality rates in our close knit community we lose a life nearly every 
week of the year.
    The loss of life contributes to more trauma on our families and 
community. The loss of a tribal member is also a cost of our language 
and culture, our traditions and our future. It's disheartening to think 
of all the costs to our way of life, especially because it is 
preventable.

    The Chairman. I want to thank you for sharing all of that 
information and for your very thoughtful testimony. We 
appreciate your comments and we are happy to have everyone here 
today.
    We are going to start with a series of questions. I would 
like to start with Senator Hoeven.

                STATEMENT OF HON. JOHN HOEVEN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Hoeven. Thank you, Mr. Chairman. I would like to 
thank all the witnesses for being here with us today.
    I would like to start with Mr. McSwain. My question to you 
is, when dealing with the challenges of drug abuse, 
particularly in the Native American community, very often we 
are talking about rural areas. What is IHS doing and what can 
IHS do to provide services to deal with substance abuse and 
treatment in these rural areas?
    Mr. McSwain. Thank you, Senator. I believe that, well, I 
actually don't believe, but we are in fact addressing it 
through a number of programs we have. Certainly the alcohol and 
substance abuse programs that we have put in the communities to 
provide services, we actually have in many cases clinics and 
hospitals and health centers that are in rural America whereby 
we provide behavioral health services.
    We have a number of programs that we have actually 
addressed. It is a great question from the standpoint of, we 
are doing a lot of treating. We are a health care delivery 
system, so we treat a lot of folks who hit our system.
    The biggest thing that we are working on now is on the 
prevention side. That is our meth-suicide prevention initiative 
program that is actually providing behavioral and the 
prevention side of the equation. But to provide care through 
our health care system.
    It is a growing issue for us, because we are doing 
basically health care, ambulatory and inpatient care. But now 
the growing need to address behavioral health is a challenge 
for us, simply because we need to have trained health care 
professionals to help us in that regard.
    Senator Hoeven. The statistics I have, in 2012, over 20 
percent of Native American youth were using alcohol. Twelve 
percent of Native American youth over the age of 12 were using 
illegal drugs in 2013. So clearly more needs to be done.
    What do we need to do? One, two, maybe three steps, what 
needs to happen?
    Mr. McSwain. I believe that one of the things we need to do 
is engage the youth. The one thing that we haven't done and we 
need to do as a system, whether it is IHS or SAMHSA or other 
Federal agencies, actually need to, and I think that, well, 
number one, our budget for 2016 has a generation indigenous 
initiative for actually addressing youth mental health issues. 
That budget piece for us is $25 million. SAMHSA has $25 
million. And between the two of us we are putting those 
resources toward youth.
    Senator Hoeven. Well, let me come at it this way. I am 
going ask all of you, what is the number one thing we need to 
be doing? And is there agreement on it? What can make this 
better? What is the one thing you would say should be done? I 
know there are a lot of things, but what is the first thing you 
would do?
    Mr. McSwain. The first thing we need to do is engage the 
youth.
    Senator Hoeven. And that means?
    Mr. McSwain. That means talking to them, because they will 
tell us what they need.
    Senator Hoeven. I would like to ask each witness to comment 
on that.
    Mr. McSwain. That would be my response, is to engage the 
youth in a conversation about what help they need as opposed to 
us simply telling them what we think they need.
    Senator Hoeven. I would ask each of the witnesses to react 
to that. And fairly briefly, I am limited here on time.
    Ms. Beadle. Thank you, Senator.
    I would agree with Mr. McSwain. I think the critical issue 
is the fact that Native communities are relatively young in 
age. If we don't engage the youth in identifying the critical 
things that must be done, we are not going to get anywhere. The 
funding is limited. We have tried very hard to coordinate with 
one another. I think we are doing some great things, we are 
doing a lot of work. But we have to bring the youth in.
    We also have to work with tribal leaders differently. They 
have asked SAMHSA to work with them differently on their 
programs. As an agency, we have increased the amount of funding 
that is going to tribal communities.
    The question now is how will we bring those resources 
together to be as effective as possible. I think the chairman 
talked about the limited resources that there are available. 
But it is that connection of those resources, because tribes 
have funds, the Federal government has funds, States have funds 
and other community organizations have funds.
    The question that we are grappling with now is how do we 
improve the coordination and work together differently to 
maximize and leverage those funds. They are not going to grow. 
So part of the solution the tribal leaders have come to us 
about is working together differently.
    Senator Hoeven. Ms. Benjamin?
    Ms. Benjamin. The Mille Lacs Band of Ojibwe, what I know is 
when we have young men coming from prison, and if they connect 
to the spiritual and cultural aspects of the reservation, they 
seem to really focus on taking the right path. So anything that 
we have to do has to be culturally specific to our communities, 
because the way we communicate and the way they can get to the 
inner spirit has to be through that language and that culture. 
That has to be the basis for anything that we do, whatever 
program it is. They have to be able to communicate in a way and 
educate in a way that they understand.
    That is, for the Mille Lacs Band, that you have to think 
like an Anishinaabe or an Ojibwe, then you can understand and 
move forward.
    Senator Hoeven. Mr. Walters?
    Mr. Walters. I'm more practical on some of these specific 
things. I think we are, given the magnitude of the problem and 
the use rates you see here, you must try to help do screening 
in health care system. We have not adequately dealt with the 
stigma we have in society for substance abuse. We have to 
understand that it is a disease. We have to understand it is a 
disease we can treat. We have to understand it is a disease we 
can screen for in routine medical care, wellness care and 
routine health care.
    We have introduced some of those programs in the past, 
supported by the Federal Government as models. They ought to be 
routine in the medical system. The rates of involvement that 
you see in Indian Country dwarf anything you see in almost any 
other community in the United States. There ought to be an 
automatic screening. It would be confidential.
    Then you need to also obviously build the infrastructure 
that is culturally appropriate to refer families and 
individuals to both early intervention care, which may be 
before somebody gets heavily involved and addicted, or when 
they are addicted refer them into care. But you need an intake 
system that is going to be systematic and comprehensive. The 
health care system needs to do that and you may want to 
encourage screening on a wider level to get people into care.
    Now, that is going to obviously display the fact that you 
don't have infrastructure to care for everybody. But right now, 
you don't have the infrastructure and nobody is screening. 
Let's create a drive to create the infrastructure to save lives 
and not watch people die at higher rates.
    Look, what you are hearing here and what you already know 
as the members of this Committee is the system is failing here. 
It is not close. It is getting worse at a very great rate, 
especially in some of these communities. It is not uniform, but 
right now, the status quo is not sustainable. And it is only 
because people don't hear these cries that it hasn't become 
more of an outrage.
    Senator Hoeven. Mr. Chairman, do I have time to finish or 
shall I relinquish?
    The Chairman. No, no, please, go right ahead. Let me ask 
Senator Franken if it is okay with him.
    Senator Franken. Absolutely.
    Ms. Goggles. I just wanted to say, our youth are our 
resource. I have amazing youth back at home and we are 
utilizing them to be peer mentors for our younger people. 
Because we are seeing a lot of our youth actually start around 
nine or ten years old. So we are really focusing on using those 
teenagers who are sober, who are following their culture. I 
really believe that we have to integrate that cultural part of 
it.
    But we can work with the youth as much as we can, but if we 
don't have the parents on board, they are going back home to a 
really toxic environment. So it has to be a family approach. We 
have to look at the youth, we have to look at the adults and 
utilize those resources that we have available. Thank you.
    Senator Hoeven. Thank you. Interesting, the dialogue and 
screening, interesting that those two come up together. Seems 
one would generate a lot of the other. So thank you.
    The Chairman. Thank you, Senator Hoeven.
    Senator Franken?
    Senator Franken. I am struck with how, when we have 
hearings on youth suicide, when we have this hearing, and you 
start to get asked what is the first step. Of course, that is a 
very logical question. And you just realize how big and endless 
and circular these problems are.
    Because when you go to youth, the first thing I would like 
to do is give youth hope. And that means having economic 
activity, that means having housing and it means not being 
witness to other pathologies like abuse and neglect, violence.
    So this again, we are faced with this. I want to say this 
one more time to all of us on this Committee. We need to be 
ambassadors to the rest of the Senate and tell them the scale 
of the problems in Indian Country. Because every time we start 
talking about resources, it is woefully inadequate. The 
problems are so cyclical.
    I went to a rehab, Oshki Manidoo, in Bemidji, that is for 
White Earth, they are also a band of the Ojibwe. I have been to 
a number of rehabs in my life. I have never seen, this is for 
young people, I had never seen a more bummed out group at a 
rehab. Most people at rehabs are hopeful, they are happy, they 
have finally, whether they make it or not, at this point there 
is some hope. Every one of these kids, I asked them, started 
using with their parents.
    So Melanie, thank you for your testimony, all of you, thank 
you, especially Ms. Goggles, and you too, Mr. Walters. You 
talked in your testimony about a number of things, a lot about 
opiates, a lot of kids being born, a lot of babies being born 
addicted to opiates. You talked about Project Child and HCMC, 
Hennepin County Medical Center. They seem to be having a lot of 
success in taking these moms and intervening so that the babies 
aren't born addicted. Is that right?
    That is with the general population and not an Indian 
population. Because you talk about the culturally, using a 
cultural element in the treatment. What does that look like? 
What does it feel like? Obviously AA and any of those kinds of 
things, it is a spiritual program. So is that part of it? That 
is what you were saying.
    Ms. Benjamin. We do look at the Anishinaabe or the Ojibwe. 
There is a way of how to get to our spirit. Over the centuries 
that that inner strength, that self-esteem that we have as 
Anishinaabe has been taken away from us. Through just endless 
land steals, racism, lack of good housing, things of that sort 
over the years of living on the reservation. Also, a lot of the 
religions had to go underground. You couldn't practice your 
religion out in the open because you were arrested, you were 
just made to feel terrible for practicing your own religion.
    I think that spirituality has been put down and kept down. 
But if we can bring that back through cultural programs and 
give that worth back to the people as tribal governments, 
provide some opportunities for economic development, education, 
good health care, good housing, that we can start to see 
success in a lot of these negative social behaviors.
    Senator Franken. Let me ask anybody here, is there any data 
on culturally inclusive treatment? And if there isn't, 
shouldn't there be? Shouldn't we be collecting data on what 
works? Does anybody have any knowledge of whether that has been 
done?
    Mr. Walters. Senator, yes and no. There has been some 
particular evaluations on programs. The Administration I served 
in, we started a program that was referred to in earlier 
testimony and still exists, screening, brief interventions, 
referral treatments, so there was a screening program. But 
there is also a program called Access to Recovery based on the 
view that it is not just the immediate 28 days or whatever, but 
part of the recovery process, especially for people who are 
heavily involved. It becomes a process of re-entry, sometimes 
job training, sometimes family support and a variety of other 
things. It needs to be wrapped together.
    We did a series of test sites. Two of them were in 
California and involved Native tribes that ran these programs. 
There should be evaluation. It was started near the end, but 
there should be evaluation data on all those.
    But all these programs ought to be producing more 
evaluation. We say that, we don't require it. We are paying in 
health care now for more and more information about how well 
providers are providing. It is important to have tailored 
programs for Native peoples.
    But there also are going to be good and bad programs in 
that mix. So I think what you want to have is established 
criteria that you can use and you can look at, because then you 
can also make the case to your fellow members, everybody wants 
more money for programs. You have a better case for things that 
are working.
    So it doesn't help the recipients if they get bad services 
for the money you win for them.
    Senator Franken. I am out of time. Speaking of research, 
Ms. Benjamin, you mentioned metabolizing opiates at a different 
rates. We should be doing research, I assume, on that, in terms 
of how American Indians metabolize that.
    Thank you, Mr. Chairman, for this very important hearing.
    The Chairman. Thank you, Senator Franken.
    Senator Lankford?

               STATEMENT OF HON. JAMES LANKFORD, 
                   U.S. SENATOR FROM OKLAHOMA

    Senator Lankford. Thank you, Mr. Chairman. Thank you to all 
the witnesses for coming today and for the conversations. It is 
extremely helpful information.
    Mr. Walters, you raised something in your testimony that 
has been discussed widely, and that is about tribes on tribal 
lands producing and selling marijuana and trying to 
decriminalize that. You seem to have a fairly strong opinion 
about that, and I would be interested to be able to hear more 
about it.
    Mr. Walters. The Administration has acted, I believe 
unilaterally, to encourage that option for tribes in the United 
States. Again, you already heard, and as a member of this 
Committee, you already know the damage that substance abuse 
does in Indian Country. The argument about marijuana is very 
political in this Country and I certainly understand that. You 
live in that environment.
    But the facts about marijuana are something that we have a 
blind spot about. My testimony includes a great deal of the 
information about what now current research is showing. It is 
all going one way. It is worse than we thought. The kind of 
high potency marijuana that is being created by these almost 
industrial kinds of productions you see in Colorado, some of 
those individuals that have started those have now gone into 
Indian Country, seeking the ability to cultivate there.
    It will not only be a much bigger problem among the Native 
peoples where it is produced but obviously surrounding areas. 
It does not get rid of the criminal element. The criminal 
element thrives as the industrial production thrives.
    The consequences for health, the consequences for behavior, 
the consequences for failure in school by young people, the 
consequences for young people that we see, including as I 
mentioned earlier, it is in my testimony, research showing 
permanent i.q. loss by heavy and continued marijuana use in 
adolescence and onward.
    But it is tied directly, we think other drugs are more 
serious, but it is tied directly to everything from family 
violence to now obviously impaired driving, but also things 
like schizophrenia, psychosis and other serious health 
problems. And it leads directly into poly-drug use, which not 
only involves alcohol, but obviously it involves meth, heroin 
and a whole range of substances.
    Senator Lankford. Can I ask the rest of the panel, do any 
of you believe that if marijuana was decriminalized on the 
reservation, or was allowed to be cultivated and sold in the 
reservation legally, that would help the drug use problem on 
the reservation or with the tribe? Does anyone think that? I 
would say let the record reflect everyone shook their head.
    This conversation has been amazing to me, the number of 
people that I have heard say, you know what, this is a bad 
problem because people have to do it in secret. And because it 
is done in secret and because it is illegal, it is a really bad 
issue. If we only decriminalized it, if we only made marijuana 
legal, then this wouldn't be an issue any more, that this would 
suddenly be okay. Has anyone been able to track marijuana use 
around reservations around States that have decriminalized 
marijuana? Has that had an effect on the amount and the flow 
that is coming into the reservation areas? Yes, ma'am?
    Ms. Goggles. Being from Wyoming, and having Colorado just 
down the road, I can comment on that. We have actually seen a 
dramatic increase in the marijuana use in our community. One 
State legalized marijuana, Colorado.
    But I would also like to add our sixth leading cause of 
death is COPD. So not only our tobacco use is 50 percent, our 
commercial tobacco, so you add marijuana in the mix and it is 
just adding to the COPD cases.
    So we have definitely seen the negative effects, being in 
Wyoming and having Colorado legalize.
    Senator Lankford. Any other comments about that? This is a 
big issue Congress has to deal with, obviously. There is an 
enormous push to say, you know what, let States decide this, it 
will have no negative effects, they can choose to do what they 
choose to do on it. But the real practical effects on families 
and on generations are pretty traumatic. I think it is us 
turning a blind eye to our responsibility to say, 
decriminalizing it is no big deal, it is ``just marijuana,'' I 
am tired of hearing ``it is just marijuana'' when we see our 
families falling apart and we see i.q. levels dropping and 
productivity dropping and saying ``it is just marijuana.''
    So this is a serious issue. I appreciate you all spending 
your lives trying to invest into some of these.
    Ms. Benjamin, I want to ask you about what you are doing. 
Just recently you had a two-day conference, I understand, 
trying to deal with some of the drug issues. How do you 
evaluate the effectiveness for any program, that program in 
particular, doing a conference and such? I assume there are 
going to be multiple steps in the process. So how do you track 
the metrics of that? Is this effective? How do you improve for 
next year and what else needs to be done?
    Ms. Benjamin. One of the outcomes from that conference that 
we did for our own reservation members is that there were a lot 
of people in the community, a lot of the women that said, I 
will do whatever I can to help. There have been a lot of 
support groups that have started from just participants, people 
understand, we gave a lot of statistics and what happens. We 
showed a film of babies going through some of the withdrawal, 
it is pretty devastating. We had religious people there as well 
to support.
    Also, we are looking to do a safe house for pregnant women 
as well. We want to give them the opportunity to let them know 
that we want to help, we don't want to put them in jail just 
because they are using illegal drugs. A lot of them will not 
come forward and even get prenatal care, because they are 
afraid of their babies and being taken care of. So we want to 
send that message out.
    We have been working with our elders in our community to 
take that stronger leadership role in their families, to make 
sure that whatever assistance they need that we can offer that 
and provide that for them as well. So we see a little progress 
and people are getting engaged and wanting to be part of the 
solution.
    Senator Lankford. Thank you. Thanks to all of you as well. 
I yield back.
    The Chairman. Thanks, Senator Lankford.
    Senator Heitkamp?

               STATEMENT OF HON. HEIDI HEITKAMP, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Heitkamp. Thank you, Mr. Chairman.
    This is a continuation of, I call it the Committee of 
despair, as we continue to see these issues and feel like 
generation after generation we fail. And I don't mean to pick 
on you, Mr. McSwain, and I know you are acting. But I don't 
think there is one Native American who lives in Indian Country 
who thinks that Indian Health Service is providing any kind of 
treatment for behavioral and mental health. Not anyone that I 
think who lives in North Dakota.
    So when your answer to Senator Hoeven was, you provide 
treatment, I am going to ask you a simple question. Every 
person who you are responsible for as a constituent and a 
patient of Indian Health, if they needed behavior and mental 
health services, would they get it from you?
    Mr. McSwain. They could come into the clinic, and whether 
or not we have the professionals there, we have had a real 
challenge in hiring behavioral health professionals.
    Senator Heitkamp. So the answer is no.
    Mr. McSwain. The answer is----
    Senator Heitkamp. No.
    Mr. McSwain.--not exactly no.
    Senator Heitkamp. You can't, it is not even not exactly no, 
it is no. And that is one of the problems. And I completely 
appreciate the health care workforce problem that we have, 
because it is combined with a rural workforce health care 
worker problem that we have. So it is extraordinarily 
difficult.
    But once again, Indian Health, which should be providing 
treatment, let's forget about prevention. I am not even going 
to put that on you. But you should be providing treatment, 
because we have heard here that without families, Senator 
Franken just told you that when he visited a center, all these 
kids said they started using with their parents.
    So if we think we can just visit with kids and that is 
going to solve the problem, kids do what they see, not what 
they are told. And what they see every day, kids who are in 
this situation, is they see a culture of abuse, they see a 
culture of drug abuse. And they feel a lot of despair. So 
Indian Health has been unrelentingly unable to address health 
care crises in Indian Country. And this is a huge part of it, 
behavior and mental health.
    So let's not pretend that we are providing services. The 
worst thing that we can do here is pretend that we are doing 
the right thing. Mr. Walters, I don't know if you got a page 
out of my speeches or whatever it is. I think you are trying to 
speak truth about what is actually going on and where we go 
from here. But one of the issues that I have a lot of concern 
about is, generation after generation, and we can talk about 
generational trauma. This Committee has held a hearing on 
trauma, and I think there is some hope in some of the research.
    But there is an amazing lack of scanning and looking back 
at fetal alcohol effects and fetal alcohol syndrome. We know 
that one of the symptoms of fetal alcohol is really a lack of 
consequential thinking. So while we say, well, why don't you 
just get it, that bad things happen that you drink and you 
should just quit drinking, well, when you are dealing with 
somebody who already has a genetic impairment, it is very 
difficult.
    So when we are talking about screening, which I thought was 
an excellent point, maybe too late after the fact, if we get 
them in Head Start maybe we have a shot. But what about 
screening for fetal alcohol effect and fetal alcohol syndrome? 
And what strategies would you deploy in terms of treatment?
    Mr. Walters. I agree with you. I think this Committee 
should obviously also include alcohol. What it allows is, it 
helps people understand that this is a disease, so it gets rid 
of some of the resistance and shame by having a medical 
professional say, this is what we are doing, this is why we are 
doing it, and provide some information at the time of the 
screening.
    But also, you are right, there has to be, when you find a 
positive, you are going to have to have people who are able to 
do family intervention and you have to have people who are 
going to be able to work with people in a way that meets them 
where they are.
    Now, again, we do have problems in the workforce. But part 
of the reason we can't get the urgency to get the workforce 
fixed is because we are not presenting people with the number 
of illnesses. We do that with a whole bunch of other diseases. 
We say, we need the capacity to treat this disease at these 
numbers. And in other venues, that is what generates the 
infrastructure.
    Senator Heitkamp. And when you don't do that, when you 
don't recognize you have a problem, then you have no solutions 
to that.
    Mr. Walters. Right. You are just part of the noise in the 
budget debate and the debate about what the community needs to 
do. And there is a lot of stuff to do. You have to get up to 
the part of the to-do list that gets done.
    I don't think you have to be the Committee of despair. This 
can be done. It just takes some people who are going to be able 
to lead. And the government has the ability now to show people 
where this is and to reinforce what these people are doing and 
saying it is a priority, in a State, in a region and in the 
government of the United States. You can fix these 
bureaucracies. It just takes enough pressure.
    Senator Heitkamp. I can't agree with you more. Just a 
couple more points.
    I once went to a high school, it actually was a junior high 
school. I asked how many kids were drinking. This was not a 
Native American school. About 30 percent raised their hand, 
they reported that their friends were drinking, so you can take 
it from there. I said, why are you drinking? The kids started 
saying, peer groups and all this. I said, you are drinking to 
get high.
    So it is, we need to recognize that there is some amount of 
secondary effect here. This is a very complicated problem.
    Mr. Walters. But also back to your original point, no 
matter what the demographic, substantial underage drinking, in 
my experience, cannot exist unless adults enable it.
    Senator Heitkamp. I think that is correct.
    Ms. Goggles, your testimony has a huge impact on all of us 
as we kind of look forward. I want to know what kind of 
services Indian Health could provide at Wind River that could 
make a difference to you that would be altering for your tribe.
    Ms. Goggles. Thank you. I think one of the biggest parts is 
the MSPI program. We utilize MSPI funding to do a horse culture 
program. It is a way of getting our youth back to utilizing 
their traditional values as far as taking care of their horses. 
They show them how to ride, show them how to take care of them. 
It is just a really good program. It gives our youth an 
opportunity to get in touch with their culture.
    Now the funding is competitive. So that makes things a 
little bit more difficult. I don't know what these other tribes 
are doing.
    Senator Heitkamp. To Senator Franken's point, do you have 
any long-term studies that show that a program like this would 
actually result in a 20, 30 year history of sobriety?
    Ms. Goggles. No, because the program just started this last 
year.
    Senator Heitkamp. That is the problem.
    Ms. Goggles. And the funding actually, that is one of the 
things, though, you fund things for a year, or things are 
funded for three years. You are not going to get long-term 
funding.
    Senator Heitkamp. We don't have a strategy, we just have a 
series of events. Right?
    Ms. Goggles. Yes.
    Senator Heitkamp. Thank you, Mr. Chairman, for the extra 
time.
    The Chairman. Thank you, Senator Heitkamp.
    Senator Murkowski?

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

    Senator Murkowski. Thank you, Mr. Chairman, for having yet 
another very important hearing. As I listened to my friend from 
North Dakota, you just kind of get a here we are again feeling 
of despair. I appreciate your saying that we don't have to be 
the Committee of despair. But I do think that these are 
problems that we recognize we have been struggling with for 
generations.
    Despite efforts, we are not making the progress that we 
should. There has been some discussion, and I appreciate what 
you have said about fetal alcohol spectrum and the syndrome. We 
have actually made some headway in Alaska, when it comes to our 
Alaska Native women and the number of children who are being 
born afflicted with FASD. We are seeing a reduction in the 
number of those afflicted at birth in the Native population. 
But at the same time we are seeing a drawdown there, we are 
seeing an increase in our urban population. So go figure.
    We are not hitting it right if we are not able to make a 
difference across the spectrum when it comes to something that 
is 100 percent preventable. This is where I get so, so really 
distraught talking about fetal alcohol syndrome. We talk a lot 
here in the Congress about the diseases that we deal with and 
the funding that we have to do for research.
    There is no research that we need to fund on how to end 
FASD. You just don't drink when you are pregnant and you will 
not have a child that is afflicted with fetal alcohol spectrum 
disorder. We know how to stop it. Yet we go up and we go down. 
We are just not there yet.
    I think we recognize in Alaska that alcohol is still the 
substance of choice in my State when it comes to just the 
things that are leading to incredibly horrific episodes and 
destructive behavior. So much of our problem is we have our 
local governments, we have our villages that say, we want to 
control alcohol that comes into the community. We vote to be a 
dry community. And you have bootleggers that are coming in, a 
bottle of liquor that you could get for $10 in town you might 
get a couple hundred for that same bottle out in a dry village.
    We mentioned the issue of marijuana. Alaska just legalized 
marijuana and we are in the process now of trying to figure out 
how we as a State regulate it. Well, one of the great issues of 
discussion was, well, what will happen in a village that is cut 
off from the rest of the State, no road access, no access 
except airplane in and out, that is dry when it comes to 
alcohol? What happens with the issue of marijuana? What do we 
do there? We are still trying to define the impact.
    But to Senator Lankford's question, I don't think that 
there is anybody who thinks that by making marijuana legal we 
are going to be helping those with substance issues. It is just 
not possible.
    So I am really very troubled about where we are with our 
solutions. We have been operating on a triage basis. We have a 
situation in a southeastern island community where we know the 
drugs, how they are coming in, they are coming in by the mail, 
we need to get cooperation between the Post Office, the DEA. We 
don't have a magistrate or a judge in the community to issue a 
search warrant. We literally pull together a SWAT team to make 
a difference in that community.
    We go ahead and we crack the case and we seize the drugs. 
And what happens is we have managed to squeeze balloon over 
here and the drugs next month end up in the next island 
community. We just had a big bust in, again, the island 
community of Kodiak, with a large heroin seizure. It is like a 
whack-a-mole game, and we are not getting ahead of it.
    I met yesterday with the head of the DEA in my office. He 
reminded me that in many ways, those bad actors, the dealers, 
they look to build a clientele. If you can capture a whole 
island community that is remote, that can be your customer 
base. On a reservation, to be able to go in and basically get 
people addicted to your drug of choice that you are dealing, 
knowing that there are no treatment facilities either in that 
area or near that area, you have them locked. It is just 
extraordinarily troubling where we are with it.
    I don't want to talk without asking questions, and I want 
to go to what Senator Heitkamp has raised with you, Mr. 
McSwain, about the trauma issue. There has been a lot of 
discussion here in this Committee, which I appreciate. But when 
you think about what we are dealing with, the levels of abuse, 
suicide, violence, other trauma that we see, and then the 
linkage between the high rates of drug and alcohol abuse, this 
is something that I do hope is being addressed in coordination 
between the departments. I think we like to think that is going 
on.
    Can you confirm or affirm to me that in fact there is 
collaboration going on within the agencies? We require that in 
the 2010 Tribal Law and Order Act. We required coordination 
efforts on alcohol and substance use issues in Indian Country 
when we expanded the number of Federal agencies that are 
involved in it.
    So are you working it and how are you working it? Do you 
have any thoughts that might be helpful as we try to focus 
further in this area?
    Mr. McSwain. Thank you, Senator Murkowski. The answer is 
yes, we are working closely with SAMHSA, we are arm in arm in 
many of the communities that we have addressed. Of course, 
then, across the system, wherever they have a grant program and 
we are present, there is another notice of coordination. Then 
we reach out to our other people. Certainly, as you just 
referenced, the Tribal Law and Order Act, we reach out to our 
sister agency, the Bureau of Indian Affairs and the Bureau of 
Indian Education. Those kinds of discussions are ongoing.
    We are actually partnering, in many respects. I can go 
example by example. A recent one, with Pine Ridge, we are hand 
in hand out there trying to address issues. Now, granted, it is 
about suicides. But SAMHSA has a program, we have an 
installation out there, several. So we are working together as 
to how to make sure we can provide all the services available, 
not only through the SAMHSA grant programs but through our 
direct care program.
    To the extent that we have also implemented tele-behavioral 
health, to make it available into the outlying communities, 
particularly a couple of very remote communities on Pine Ridge, 
that is just one example. We have other examples where we are 
actually partnering and working together on substance abuse and 
mental health in those communities.
    We have been doing this for some time. In fact, we meet 
annually. We have an annual conference, have had annual 
conferences to compare best practices. So we will continue that 
collaboration very closely.
    Senator Murkowski. Mr. Chair, thank you for the additional 
time. It is good to hear that the programs are working.
    I remain concerned that everybody has their program and 
they have to defend their program. In order for them to get 
money for the next funding cycle, they have to be able to 
establish what they have done. So the sharing, while it is good 
in theory, call me a skeptic at times, I think it is important 
that we just keep pressing on this if the ultimate goal is to 
have healthy families, healthy communities and not you worry 
about the funding for your program or the funding for your 
program, but are we getting results at the end of the day.
    That is where I think we come back year after year after 
year. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murkowski.
    Ms. Beadle, earlier this month, the White House had a 
Tribal Youth Summit. The purpose was to hear from the youth. So 
I guess the question is, what did you learn from them about how 
to address alcohol and drug abuse?
    Ms. Beadle. Thank you, Mr. Chairman. I have to say that in 
addition to the White House Tribal Youth Conference, there have 
been a number of roundtables with youth. I am glad you raised 
this topic. The youth basically are telling us the same thing 
wherever we go. What they are saying is, they want to be 
involved. We had this conversation earlier today. They believe 
that they know what is right to do in their communities. They 
believe that other youth are talking to each other. They are 
not going to listen to adults.
    So they want to be part of the solution. And part of the 
solution means incorporating them into some of the programming 
that gets done as a leader. What they have asked SAMHSA to do 
specifically, not just at the White House Tribal Youth 
Conference, but in our own conferences and roundtables, is they 
want us to bring youth together on a national scale to start 
talking about how we establish a nationwide peer support 
program among youth.
    They think that if we continue down the same path that we 
have been on, which is, we fund programs which are great things 
and not include them at the local level, at the regional level, 
and at the national level, the programs are not going to 
include their thoughts, they are not going to include their 
solutions.
    So what they are asking us to do is to get them involved.
    The Chairman. Can you point to anything specific that you 
have actually done in addition to that? We bring them all 
together, and I met with the students and young people who have 
come in from Wyoming, heard the same thing. So what is the next 
step from there?
    Ms. Beadle. We have a couple of next steps. We actually are 
establishing what is called the SAMHSA Tribal Youth Leaders, 
which is a cluster of youth from across the Country. What they 
have asked for are specific things. They want leadership 
training, we are going to provide them leadership training. 
They want training in behavioral health. We are going to do 
that. Some want very basic things like very brief intervention 
type programs. Others want to be able to figure out how to make 
a longer career out of it. So we are going to try to get them 
involved and connected. Those are two very concrete things we 
are going to do over the next year.
    The Chairman. In terms of the connection or the continued 
support, how does that work so you can keep them engaged and 
they don't just feel that they are isolated once they go back 
home?
    Ms. Beadle. One of the things they have asked us to do as 
well is to help connect them with tribal leaders. I say this 
very respectfully. The youth were amazing, and what they 
basically said is, in some communities we are acknowledged and 
we are included in the dialogue; in other communities, tribal 
leaders don't see us as leaders as well. So they are asking for 
Federal agencies, not just SAMHSA, to help bring them to the 
table more locally so that they can actually have their voices 
heard.
    Longer term, we do have a series of programs to support 
Native youth that we are going to try to connect them to so 
that they are engaged not only in this learning and development 
progress but also in the actual work that is happening in their 
communities.
    The Chairman. Ms. Goggles, when we met in Wyoming, there 
was a young man who came to testify who was, I think, part of 
this sort of an effort in the community. Could you talk a 
little bit about that and the successes you have seen there?
    Ms. Goggles. I am also an advisor for the Wind River Youth 
Council. The Youth Council was established back in the 1980s 
when we had a rash of suicides. So it has kind of come and gone 
over the years. But I think that is one of the best resources, 
is our youth. We have amazing youth on Wind River, I mean, 
amazing youth. I actually have one with me. She is sitting a 
couple of rows behind me. And I have to embarrass her, because 
I am her mom.
    But we utilize those resources. We do a lot of peer 
mentoring. In my office right now I have two peer mentors that 
teach prevention. Because they are not going to listen to me. 
So I have two 20-year olds who are trained in mentoring. They 
go to the schools. I don't go to the schools. Our staff doesn't 
go to the schools. It is our youth, because they are going to 
listen to them a lot better than they are going to listen to 
us.
    The Chairman. Mr. Walters, are there any data sets that we 
can put together to see how effective this is? It certainly 
sounds encouraging.
    Mr. Walters. They don't exist now, but we certainly could 
have those. We could have the individual sites or schools or 
communities do regular either self-repot surveys or if you 
screened in the health care system you could report what the 
rates were and you could see the difference over time.
    We could measure these effects from a variety of these 
programs, including the early reference to family court and 
custody cases, which have been used in a variety of settings to 
help get people in treatment and try and start breaking the 
intergenerational cycle here. So all these things could be 
measured, but you have to measure the underlying phenomenon 
first.
    I place some of my emphasis on CDC and the measuring on the 
health side. DEA ought to be forced to do the same thing. DEA 
does not produce national data. It could produce national data. 
Now, in the example of heroin, it hasn't produced a heroin 
signature report to tell you where the heroin is coming from in 
months, if not years. That report should be out on a quarterly 
basis, at least.
    The State Department has not produced, as far as I can 
tell, the report on heroin production from Mexico. I believe 
what you are seeing now is largely production that is probably 
an explosion of production in Mexico. If it isn't, then it is 
an explosion of importing from Afghanistan where 90 percent of 
the heroin is. Let them know that.
    But the agencies are not producing the data and providing 
it to you, who have to make decisions, and sharing with the 
American people, who are suffering, to get some idea of who is 
not doing their job or how we can get a better situation. So 
right now, we are acting in a way that is more blind than we 
need to be because information is not being given directly as 
it should be, even the stuff that is already in the pipeline.
    The Chairman. Thank you. And Mr. McSwain, Ms. Benjamin gave 
us a whole list of wonderful ideas of things that we ought to 
be talking about. Have you taken anything from this that you 
think can be helpful as you work with your folks?
    Mr. McSwain. I do. In fact, the whole business about Ms. 
Beadle's comments about the youth summit, I happened to sit on 
a panel with her. It was interesting to hear, at least the 
youth, that is what caught me earlier, when I said talk to the 
youth. That was my frame of reference.
    Because if you can talk to the youth, and then having said 
that, a recent experience we had was that the youth on Pine 
Ridge wanted counselors. They used the term, ``but not those 
old codgers.'' And that notion was younger people who can 
relate to them. So that is part of a takeaway, at least for me, 
is when we start dealing with the youth, American Indian and 
Alaska Native youth, is to ensure that we have a younger set 
that actually has the ability to relate to them.
    I really, back to Senator Heitkamp, I know that we 
basically provide care, but we have been providing grants. I 
know at the last hearing, Senator Murkowski, you were pleased 
with the progress of the MSPI program. I know that what that 
does is put the capacity in the communities to have them work 
from their end. I think that is the basis on which we are going 
to be successful.
    The Chairman. Ms. Goggles, is there anything you would like 
to add in terms of what you see that works, or other things we 
ought to be doing differently, maybe from something you have 
heard today, or something you would like to share with the 
Committee?
    Ms. Goggles. Thank you. I really want to emphasize the work 
as a family and working on the family as a whole. It is easy to 
pull youth out, provide them a good day, good leadership camp, 
then they go home to a very toxic environment, as I said 
before. We need to work with those parents, those aunties, 
those grandmas, because our family group is not just mom, dad, 
brother. It is the grandmas, it is the aunties, it is everybody 
else, the uncles. We need to include that whole portion in our 
treatment services, our behavioral health services, even our 
medical services. They need to be included in all this.
    And I really want to emphasize the speaking with youth. 
They have great ideas. They think about how to get out of the 
box. They come up with new ideas. So our youth are an amazing 
resource.
    The Chairman. Thank you.
    Senator Heitkamp, any additional questions? Senator 
Murkowski, anything you would like to add?
    Senator Murkowski. Mr. Chairman, the only thing I would 
add, I noted, Mr. McSwain, your comment about the youth and 
engagement. But you specifically said, we need to talk to the 
youth. I think we need to listen to the youth. And I think part 
of what we are dealing with is, we talk to them all the time. I 
talk to my kids. And sometimes they choose to listen. But when 
I listen to them first, that is when we have an exchange that 
actually makes it work.
    I mentioned meeting with the head of the DEA yesterday in 
my office. I had two interns with me. One is from Ketchikan, 
Ketchikan has a drug problem down there. One of them is from 
Unalaska, two island communities that are dealing with these 
issues of drugs. The comment that I got from both of them was, 
when the head of the DEA and you, Senator Murkowski, asked us 
as young women who have just graduated from high school, what 
we think would make a difference in our community, that is 
empowering. We need to remember to listen to what these young 
people have to say. They are a heck of a lot smarter than we 
would ever give them credit for.
    I appreciate what everybody is trying to do, and we will 
keep at it. Thank you, Mr. Chairman.
    The Chairman. Thank you. I want to thank all of you for 
being here to testify today. The hearing record will be open 
for two weeks. I want to thank all of you for your testimony 
and our time.
    Since Senator Murkowski mentioned interns, we have a number 
of interns from the Committee. This will be the last hearing of 
the Committee before they head back to college or to their 
life. I want to thank each and every one of the interns for 
their hard work over the summer. I know they are going to 
continue to work hard as we are back in our home districts 
visiting and listening to what people have to say.
    With that, the hearing is adjourned.
    [Whereupon, at 3:57 p.m., the hearing was adjourned.]

                            A P P E N D I X

  Prepared Statement of Lester Secatero, Chairperson, National Indian 
                          Health Board (NIHB)
    Chairman Barrasso, Vice Chairman Tester and Members of the 
Committee, thank you for holding this important hearing on ``The True 
Costs of Drugs and Alcohol in Indian Country''. On behalf of the 
National Indian Health Board (NIHB) and the 567 federally recognized 
Tribes we serve, I submit this testimony for the record. The federal 
promise to provide for the health and welfare of Indian people was made 
long ago. Since the earliest days of the Republic, all branches of the 
federal government have acknowledged the nation's obligations to the 
Tribes and the special trust relationship between the United States and 
Tribes. The United States assumed this responsibility through a series 
of treaties with Tribes, exchanging compensation and benefits for 
Tribal land and peace.
    Of the challenges facing American Indian and Alaska Native (AI/AN) 
communities and people, few challenges are greater or more far reaching 
than the epidemics of alcohol and the abuse of other substances. AI/ANs 
are consistently over-represented in statistics relating to alcohol and 
substance abuse disorders, deaths (including suicide and alcohol/
substance related homicides), family involvement with social and child 
protective services, co-occurring mental health disorders, infant 
morbidity and mortality relating to substance exposure, the diagnosis 
of Fetal Alcohol Syndrome (FAS) and other Fetal Alcohol Spectrum 
Disorders (FASD), partner violence, diabetes complications and early 
onset as a result of alcohol abuse, and other related issues. Current 
alcohol and substance abuse treatment approaches (offered by both the 
Indian Health Service (IHS) and Tribal facilities) employ a variety of 
treatment strategies consistent with evidenced-based approaches to the 
treatment of substance abuse disorders and addictions (such as 
outpatient group and individual counseling, peer counseling, and 
inpatient/residential placements, etc.) as well as traditional healing 
techniques designed to improve outcomes and align the services provided 
with valuable cultural practices and individual and community identity. 
IHS-funded alcohol and substance abuse programs continue to focus on 
integrating primary care, behavioral health, and alcohol/substance 
abuse treatment services and programming through the exploration and 
development of partnerships with stakeholder agencies and by 
establishing and supporting community alliances. Adult and youth 
residential facilities and placement contracts with third party 
agencies are funded through the IHS budget for alcohol and substance 
abuse treatment; however, as a result of diminishing resources, 
placement and treatment decisions are often attributed more to funding 
availability than to clinical findings.
Costs of Drugs and Alcohol in Indian Country
    Current research indicates that 64.8 percent of American Indians or 
Alaska Natives have used illicit drugs in their lifetimes while 27.1 
percent have used in the past year. These drastic numbers mean that 
almost two thirds of the AI/AN population has been exposed to addictive 
and illicit drugs. According to the California Tribal Behavioral Risk 
Surveillance System survey, 39 percent of AI/AN respondents reported 
heavy alcohol consumption within the past 30 days, compared to the 
national average of 24 percent.
    According to a study in 2009, \1\ AI/ANs were almost twice as 
likely to need treatment for alcohol and illicit drugs as non-Native 
people. The study found that AI/ANs needed treatment at a rate of 17.5 
percent compared to the national average of 9.3 percent. Providing this 
treatment is costly to the community and gaps in funding mean that the 
treatment is often inconsistent both from year to year and across 
Indian Country. Because funding is never guaranteed, vulnerable people 
and communities can slip through the cracks and back into drug habits 
when grant resources run out. For example, the Fort Peck Tribes of the 
Assiniboine and Sioux created a drug task force on their remote 
reservation in northeastern Montana in order to employ a 
crossjurisdictional strategy for treating and preventing substance 
abuse. The task force was funded through a state-funded program. NIHB 
Board Member, Charles Headdress, noted that the program was making 
progress, but when the funding ran out, the gains the task force made 
diminished and methamphetamine dealers were able to increase their 
presence on the reservation. Because exposure to illicit drugs is so 
common and AI/ANs are more likely to need treatment, it is clear that 
continued funding for treatment of alcohol and drug use is a top 
priority for Indian Country. During the hearing, Senator Heitkamp noted 
that ``we don't have a strategy, we just have a series of events'' when 
it comes to health care delivery in Indian Country. There is truth in 
this statement: Congress must commit considerable, consistent resources 
in the treatment and prevention of alcohol and substance abuse.
---------------------------------------------------------------------------
    \1\ Abbey, A., Parkhill, M.R., Jacques-Tiura, A.J., Saenz, C. 
(2009). Alcohol's Role in Men's Use of Coercion to Obtain Unprotected 
Sex. Substance Use & Misuse Journal, 44(9-10):1329-1348.
---------------------------------------------------------------------------
    The monetary cost of addiction treatment is just one of the major 
costs of drugs and alcohol in Indian Country. Intentional and 
unintentional injuries and hospitalizations related to drugs and 
alcohol can incur huge costs both to individuals, communities and 
healthcare facilities. Alcohol was associated with 32.2 percent of all 
unintentional injury hospitalizations among AI/ANs, yet Tribes are not 
getting significant funding from the federal government to address this 
issue. For example, in FY 2016, the unintentional injury program at the 
Centers for Disease Control and Prevention (CDC) is not receiving any 
additional funding in either the House or Senate's draft Appropriations 
bills. This is problematic for Tribes, as unintentional injury is the 
third leading cause of death among AI/ANs, and many of these are 
alcohol related. CDC is currently operating efforts in Alaska and the 
outcomes from these programs are promising--showing real behavior 
change. But the opportunities to expand these efforts into other parts 
of Indian Country will be severely limited by the proposed flat 
funding. Above and beyond funding levels, there are other 
considerations for how the allocations will be spent. For example, the 
unintentional injury prevention will be administered by states, not 
through any of the Tribes. It is critical that Congress provide 
authority for CDC to create a separate, direct funding stream or block 
grant directly to Tribes for this program eliminate a state pass-
through requirement.
    More disconcerting is the cost of intentional self-harm induced by 
drugs or alcohol. Alcohol was associated with 63.2 percent of all 
intentional injury hospitalizations nationwide among AI/ANs. In Alaska, 
three out of five (57.5 percent) suicide and self-harm hospitalizations 
were alcohol-related among Alaska Natives. Both nationally and locally, 
when American Indians and Alaska Natives do harm to themselves, alcohol 
is involved approximately 60 percent of the time. In small reservation 
communities or Alaskan villages, a suicide or incidence of self-harm 
can have a ripple effect throughout the community, and increase 
suicidal ideation among peer groups in the community. Providing 
effective and timely treatment for one at-risk person can remove the 
catalyst for a rash of responsive suicides within a community.
    During the hearing, most witnesses and Senators agreed that the 
biggest cost of drugs and alcohol is the loss of human life. NIHB 
agrees. In the Bureau of Indian Affairs Nashville Area, 9 percent of 
all AI/AN deaths from 2002-2012 were substance-abuse related. Drugs and 
alcohol can affect all members of a community. Mr. Headdress stated 
that ``prominent members of our societies are falling by the wayside 
and into addiction.'' This problem encompasses all people in a tight 
knit community and the death that comes from drugs and alcohol 
reverberates outside of the traditional family, putting even more 
individuals at risk from suicide, especially when it comes to youth. 
Drugs and alcohol truly do cost human lives.
Methamphetamines
    Although alcohol has long plagued our communities, specific drugs 
are coming in great numbers to Indian Country. Methamphetamine and 
prescription drugs (specifically opiates) are proving to be major 
destructors of our communities. Because of the accessibility and highly 
addictive nature of these drugs, healthy communities can quickly fall 
into despair. One Tribal leader described those addicted to meth and 
prescription drugs as ``skeletal zombies walking around with no 
teeth.''
    Meth is a drug that thrives in rural communities, including 
reservations and Alaska Native villages. Tribal leaders are aware that 
meth dealers target our communities because of the remote locations and 
limited law enforcement presence. In fact, many leaders know where the 
meth houses are in their communities, but do not have the law 
enforcement resources to move against these entrenched operations. For 
example, The Fort Peck Tribe in Montana has 23 police officers that 
cover a two million acre reservation. (For reference, the state of 
Delaware is 1.594 million acres.) With such a small police presence 
covering these large tracts of land, meth manufacturing and 
distribution can thrive. In addition to bad actors bringing drugs onto 
the reservations, Native people in the depths of addiction can create 
the drug themselves with household goods instead of relying on outside 
dealers. Meth labs have cropped up in Tribal housing and often times 
the subsequent damage to the homes prohibits the Bureau of Indian 
Affairs from moving in other families: the houses are uninhabitable. 
Tribes are finding that they simply do not have the money, resources or 
man power to tackle a drug like meth. When they bust one house, the 
drugs move to another place on the reservation.
    In the map below, provided by the White House Office of National 
Drug Control Policy, one can clearly see how close drug trafficking 
areas (colors) are to reservations (brown hash marks). Tribes in the 
Southwest are constantly trying to keep drugs that are coming across 
the Mexican border out of their communities. (orange). The drug 
trafficking areas in North and South Dakota (light blue) are on or near 
some of the largest and most populous reservations in the country. 
Western Washington Tribes combat drugs coming in through their ports 
from Asia (lavender). The main trafficking area between the US and 
Canada runs through New York State and Iroquois country (navy blue).

    According to The National Institute of Health, ``while national 
trends are showing declines, methamphetamine abuse continues to exhibit 
regional variability. . .with the strongest effects felt in the West 
and parts of the Midwest.'' States in the West and Midwest happen to 
have the largest numbers of Native populations. In addition, according 
to The California Tribal Behavioral Risk Surveillance System, 30 
percent or AI/AN people have reported using meth, crank or ice.
    Tribes in the Northern Plains are noticing an influx of drugs due 
to the booming economy of the Bakken Oil Field. Again, drug dealers 
target these reservations, especially in North Dakota, South Dakota and 
Eastern Montana, because of their understaffed police forces, 
fluctuation of the labor population and large acreage. Drug cases are 
flooding Tribal courts in South Dakota especially with the Three 
Affiliated Tribes of the Mandan, Hidatsa and Arikara (MHA). MHA Nation 
Chief Judge, Diane Johnson, declared to the Los Angeles Times, before 
the oil boom ``about 30 percent of the cases that came to her court 
were drug-related and that number is now closer to 90 percent.'' The 
effects are overwhelming Tribal administrations and Tribal courts.
    The effects of meth addictions are felt by the entire community. 
Many AI/ANs from across the country have echoed that every family has 
at least one member with a meth problem. Those addicted to meth have 
often given up on participating in the community and begin taking from 
the community to fuel their habits. Community members cannot leave 
belongings unattended for fear that they will be stolen and sold for 
drug money. Lastly, because many of these rural reservations have 
depressed economies, there is a financial incentive for Tribal members 
to participate in the illegal drug trade because that is often the only 
way they can make money.
Opiates and Prescription Drugs
    Heroin and prescription drug use go hand in hand. Prescription 
painkillers like Vicodin or OxyContin are routinely prescribed by 
doctors for a myriad of medical concerns. However, these highly 
addictive prescription opioids can open the door to heroin and other 
opiate drug use. In addition, heroin leads to many public health 
concerns regarding intravenous drugs use like Hepatitis C and HIV.
    Much like meth, prescription drug abuse affects rural communities 
differently than it does urban and suburban areas. For example, in 
Montana, IHS doctors have been prescribing opioid painkillers like 
Vicodin or OxyContin in lieu of surgery because hospitals are often 
hundreds of miles away, or the IHS is unable to provide funding for 
referrals. According to the National Institute on Drug Abuse, those who 
abuse opioid prescription drugs often switch to heroin as a substitute. 
Exposing AI/AN populations to highly addictive painkillers through the 
Indian Health Service fuels heroin addiction on reservations. An 
elected Tribal leader of a Tribe in California recently said that ``the 
worst drug dealer on the reservation is IHS.'' More must be done to 
hold physicians and IHS accountable to the damage they are doing by 
fueling this crisis in Indian Country.
    Heroin and prescription drugs are putting American Indian and 
Alaska Native youth at risk. Nationally, one in twelve high school 
students reported non-medical use of prescription drugs in the past 
year and one in twenty reported abusing Oxycontin. However, AI/ANs 
annual heroin and Oxycontin use was two to three times higher than this 
national average.
    During the hearing, Senator Murkowski noted how difficult it is to 
raid heroin dens on island communities in Alaska. This is a common 
theme throughout Indian Country. Local law enforcement often does not 
have the resources to conduct a raid: one obstacle is obtaining a 
warrant when judges are often far away. Tribal leaders have voiced 
similar concerns about policing drug areas. They have also stated that 
the Tribal Law and Order Act, while beneficial, has also not helped as 
much as Tribes have needed or expected in terms of coordination between 
various agencies or in providing additional resources to law 
enforcement. Drugs are overwhelming Tribal administrations because 
combating the epidemic requires additional funding and coordination 
between law enforcement, Tribal health programs, schools, and community 
members.
    Nationally, deaths involving heroin have quadrupled from 2000 to 
2013. Most of the increase occurred after 2010 and the greatest 
increase was seen in the Midwest. These figures correlate with concerns 
of Tribal Leaders near the Bakken Oil Development that has reached peak 
development since 2010. The Bakken Oil Development has had a negative 
effect on the health and wellbeing of Tribes in the region by 
increasing drugs on the reservations. Remote locations, and small 
numbers of law enforcement officers make reservations in the area a 
primary target for drug traffickers. Congress must support targeted 
interventions in these areas so that the negative effects of this new 
development are not harming Tribal communities.
Youth Involvement
    During the hearing, Senator Franken told a story about visiting a 
Native teen recovery center in Minnesota. He asked the youth how many 
of them started using drugs or alcohol with their parents and all 
students raised their hands ``yes.'' AI/AN youth are initiating alcohol 
and drug use earlier than their non-native counterparts. Because drugs 
and alcohol are so prevalent with adult AI/AN populations on many 
reservations, it is often only a matter of time before the young people 
of a community begin to use as well. Not only are AI/AN youth starting 
to use drugs and alcohol at an earlier age, more youth are using drugs 
and alcohol more often than non-native youth.
    According to the California Department of Education's California 
Healthy Kids Survey, between 2008 and 2010, 30 percent of AI/AN youth 
ages 12-17 reported drug or alcohol use in the past month. Of those who 
used alcohol in California in the past month, 39 percent reported heavy 
alcohol consumption or binge drinking. AI/AN youth have reported much 
higher percentage of binge drinking (16.7 percent) compared to the 
National Healthy People Goal (8.6 percent). Nationally, AI/AN students' 
annual heroin and OxyContin use was two to three times higher than the 
national average for youth heroin and OxyContin use.
    High substance use in American Indian communities contributes to a 
range of social problems including violence, delinquency, and mortality 
from suicide or alcohol or other substance abuse. Thus, these findings 
alert us to the urgency of implementing prevention programs in these 
communities. Research documents higher rates of use and earlier 
initiation among AI/AN adolescents compared with other U.S. 
adolescents, but the extent of disparities found varies across studies. 
This is why research for drug use and treatment programs is so 
important. Part of this research should analyze the use of cultural 
practices.
Policy Recommendations
    Clearly, more must be done to restore alcohol and drug-free Tribal 
communities. Foremost, long-lasting reform should involve a variety of 
actors including Tribal, federal, state, and local governments; 
community elders; youth leaders; school leaders; and the community 
members themselves. However, there are several things that Congress can 
do in order to help address the true costs of alcoholism and substance 
abuse in Indian Country:

   Increase funding for research on the locations and effects 
        of alcohol and substance abuse in Indian Country. Before we are 
        able to treat the causes, it is critical that we have better 
        data on the incidence, prevalence, effects and locations that 
        experience these problems. CDC should provide designated 
        funding to Tribal Epidemiology Centers in order to have better 
        data on this critical issue. This research should identify 
        specific targeted locations and causes of alcoholism and drug 
        abuse.

   Provide funding to Tribes and Tribal researchers to 
        establish indicators for evidence-based criteria that are based 
        on traditional healing practices. Tribal communities have been 
        healing their people for thousands of years, and are highly 
        effective in the communities where they are employed and 
        engaged. Yet, it is often the case that traditional healing 
        practices are not do not meet mainstream criteria for data 
        collection under federal grants, which puts Tribes at a 
        disadvantage when applying for and administering federal 
        programs. It is critical that Congress support these 
        traditional practices by providing funding to establish 
        evidence-based criteria related to traditional healing methods.

   Increase and sustain funding for alcohol and substance abuse 
        treatment and prevention programming in Tribal communities. 
        This should include expanding the Methamphetamine and Suicide 
        Prevention Initiative (MSPI) at IHS, which is currently only 
        funding about 100 demonstration projects. It should also 
        include specific training for Tribal members to become 
        counselors and addiction professionals in order to create 
        sustainable change on reservations. Recruitment and retention 
        of medical professionals is a chronic issue at IHS. Alcohol and 
        substance abuse counselors are no different. According to the 
        IHS' Congressional Budget Justification for FY 2016: ``IHS, as 
        a rural health care provider, has difficulty recruiting health 
        care professionals. There are over 1,550 vacancies for health 
        care professionals. . .across the IHS system. . .'' (CJ-216). 
        Given these challenges, it is critical that training be 
        provided for community members already living in these Tribal 
        communities so that they there can be continued support for 
        these critically-needed services.

         For FY 2017, the Tribes have recommended that Congress 
        increase funding for Alcohol and Substance Abuse at the IHS to 
        $312.3 million (+121.3 million (+63 percent) from FY 2015). 
        However, it is critical that other federal agencies, including 
        the Substance Abuse and Mental Health Services Administration, 
        CDC, Bureau of Indian Affairs and the Department of Justice 
        also provide longterm, designated resources to Tribes to carry 
        out this work. In addition of funding alcohol and substance 
        abuse treatment, these agencies should provide Tribes funding 
        on the effects of alcohol and drug abuse such as unintentional 
        and intentional injury funding. Congress should also provide 
        additional funding to Tribal justice systems so that enforcing 
        the law in terms of alcohol and drug abuse is possible.

   Provide Congressional oversight and accountability to ensure 
        that various federal, state, and Tribal agencies are 
        coordinating to combat alcohol and substance abuse as referred 
        to by law. Congress should increase oversight on Section 241 of 
        The Tribal Law and Order Act (P.L. 111- 211). This section of 
        the law requires The Department of Justice, Substance Abuse and 
        Mental Health Services Administration, Bureau of Indian Affairs 
        and the Indian Health Service to coordinate efforts when 
        addressing Indian alcohol and substance abuse prevention and 
        treatment. Additional oversight and accountability provided by 
        Congress on the implementation of this provision will ensure 
        that The Tribal Law and Order Act is fully executed.

   Empower Tribal governments by providing funding to create 
        and sustain drug taskforces on reservations with high need. 
        NIHB's conservations with Tribes indicate that funding for 
        programs designed to bring all aspects of the community 
        together (Tribal leaders, elders, youth, teachers, law 
        enforcement, federal officials, etc.) to develop community-wide 
        strategies to tackle these issues in Indian Country.

    Sustained, and continuous funding must be a key element to all of 
this work. A Tribal leader recently told NIHB, that ``It's as if funds 
are awarded when rates spike, but return to complacency with alarming 
rates when rates fall somewhat. Programs cannot be sustained with 
uncertainty over funding from year to year.'' Indian Country must have 
continued investments in these programs from all agencies involved in 
order for there to be change. Congress must also direct the 
Administration to work with Tribes in forming a concrete strategy to 
overcome these issues so that we stop just moving from crisis to 
crisis.
Conclusion:
    Thank you for holding this important hearing on The True Costs of 
Alcohol and Substance Abuse in Indian Country. This epidemic has 
created community-wide destruction on many reservations. The true costs 
of this disease have not only resulted in lowering the immediate health 
status of many American Indian and Alaska Native persons, but also 
leads long-term health costs such as feelings of depression, anxiety 
and even suicide. Over time, generations of young people grow up in 
homes ravaged by alcohol and substance abuse and experience feelings of 
hopelessness, and then turn to these avenues themselves effecting 
employment opportunities, placing serious burdens on the Tribal justice 
system, and eroding traditional ways of life in Tribal communities. We 
must break this cycle.
    The National Indian Health Board stands ready to work with the 
Committee to create and sustain the programs suggested in this 
testimony.
                                 ______
                                 
 Prepared Statement of Hon. John Yellow Bird Steele, President, Oglala 
                              Sioux Tribe
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                ______
                                 
     Response to Written Questions Submitted by Hon. Al Franken to 
                         Hon. Robert G. McSwain
    Question. Mothers with opioid addiction often begin with legal 
prescriptions. Poor prescribing practices can have tragic consequences 
so it's very troubling when individuals receive addictive drugs for 
minor conditions or receive more medication than is necessary.
    Many American Indians receive health care through the Indian Health 
Service (IHS). What specific steps has the IHS taken to improve 
prescribing standards and address over-prescription?
    Answer. IHS works with partners within and outside the Department 
of Health and Human Services, including the Behavioral Health 
Coordinating Council's Prescription Drug Abuse Working Group on this 
issue. IHS has provided mandatory training for its providers on safe 
and appropriate prescribing practices. The first five-hour training 
course was held in February 2015. The training is held on a regular 
basis. By April 2017, all IHS health care professionals who prescribe 
as part of their duties will have received the training at least once, 
with refresher courses at least every 3 years thereafter. 
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    \2\ https://www.whitehouse.gov/the-press-office/2015/10/21/
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    IHS has established a national IHS chronic non-cancer pain 
management policy to provide direction to its federal hospitals and 
clinics on appropriate opioid prescribing. This will be updated once 
the Centers for Disease Control and Prevention (CDC) publishes final 
guidelines for primary care providers on safer, more effective care for 
patients with chronic pain. To assist providers with resources, IHS 
developed its pain management website http://www.ihs.gov/
painmanagement/).
    In addition to the steps above, many IHS providers participate in 
State Prescription Drug Monitoring Programs (PDMPs), and IHS is working 
to decrease barriers to PDMP use. An IHS circular has been drafted on 
participation in PDMPs and is under Agency review. In 2012, IHS 
convened a multi-disciplinary workgroup to focus on Prescription Drug 
Abuse in Indian Country. As part of the workgroup's recommendations, 
IHS has worked with ONDCP, the Bureau of Justice Assistance, and 
numerous state PDMPs to expand participation with existing state PDMPs, 
to develop best practice recommendations, and to report controlled 
substance dispensing data to state PDMPs. IHS has developed software 
compatible with five American Society for Automation in Pharmacy 
formats, deployed reporting capacity in 21 states, and assisted tribal 
programs with PDMP program deployment. As these systems continue to 
mature, PDMPs can enable health care providers and law enforcement 
agencies to prevent the non-medical use and diversion of prescription 
opioids.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Al Franken to 
                             Mirtha Beadle
    Tribes in Minnesota have noted that there is limited research on 
opioid abuse and treatment that is specific to Indian Country.
    Question. How can the Substance Abuse and Mental Health Services 
Administration and other federal agencies support research on the 
contributors to opioid abuse among Native Americans as well as what 
treatment approaches are most effective for this population?
    Answer. The Substance Abuse and Mental Health Services 
Administration's Center for Behavioral Health Statistics and Quality 
(CBHSQ) currently conducts research on the epidemiology of and factors 
contributing to opioid use and misuse among American Indians and Alaska 
Natives. CBHSQ collects data through the National Survey on Drug Use 
and Health (NSDUH) on substance use and mental health, including opioid 
use and misuse, as well as associated demographic and risk and 
protective factors. Data are also collected through the Treatment 
Episode Dataset (TEDS) on treatment admissions and discharges, as well 
as associated demographic factors. CBHSQ frequently reports on analyses 
by demographic characteristics, including for the American Indian and 
Alaska Native population. CBHSQ is developing a Public Health Research 
and Surveillance Agenda for the American Indian and Alaska Native (AI/
AN) population that will include a description of what is known and 
questions that remain regarding the behavioral health epidemiology of 
the AI/AN population. Recent CBHSQ publications include:

   2014 National Survey on Drug Use and Health: Detailed Tables 
        (2015)

   The NSDUH Report: Need for and Receipt of Substance Use 
        Treatment among American Indians or Alaska Natives (November 
        2014)

   The TEDS Report: American Indian and Alaska Native Substance 
        Abuse Treatment Admissions Are More Likely Than Other 
        Admissions to Report Alcohol Abuse (November 2014)

   Treatment Episode Data Set (TEDS): 2002-2013. National 
        Admissions to Substance Abuse Treatment Services (2015)

   Data Spotlight: Almost Half of American Indian and Alaska 
        Native Adult Substance Abuse Treatment Admissions Are Referred 
        through the Criminal Justice System (November 2012)

    To support effective treatment, SAMHSA's Treatment Improvement 
Protocol 51: Substance Abuse Treatment Addressing the Specific Needs of 
Women provides substance use disorder treatment advice to clinicians 
and administrators for Native-American Women, which includes clinical, 
program development, and staff training components. Among these 
components, specific advice includes exploring women's beliefs 
regarding healing and knowledge of cultural practices; combining 
contemporary approaches with traditional/spiritual practices; and 
training staff to address biases and myths associated with Native 
American Clients.
    The National Institute on Drug Abuse (NIDA), within the National 
Institutes of Health, also funds research on opioid misuse. Since 1975, 
NIDA has funded the Monitoring The Future (MTF) survey, which measures 
drug, alcohol, and cigarette use and related attitudes among adolescent 
students nationwide. Survey participants report their drug use 
behaviors (including prescription opioid misuse) across three time 
periods: lifetime, past year, and past month. Overall, 44,892 students 
from 382 public and private schools participated in this year's MTF 
survey. NIDA has also funded research comparing MTF survey results with 
survey data specific to the AI/AN population.

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