I_OpioidSubstance_2017A 08/22/2017 09:30 AM Committee Summary

09:36 AM Call to Order and Opening Comments



Representative Pettersen called the meeting to order and reviewed the meeting agenda (Attachment A).



17Opioid0822AttachA.pdf

































09:39 AM -- Perspectives on Opioid Issues from Other Health Professionals



Dr. Timothy Flynn, American Physical Therapy Association - Colorado Chapter, distributed a handout to the committee (Attachment B). Dr. Flynn discussed the rising opioid prescription rates in patients with low back pain and the benefits of physical therapy (PT) for low back pain. He discussed the barriers to receiving exercise therapy for pain management. He expressed his desire that patients seek PT for pain prior to receiving a prescription for opioids. Dr. Flynn responded to committee questions about the use of PT as the first line of treatment. Dr. Flynn told the committee that he would send additional information to the committee about the cost savings realized by patients receiving PT prior to other types of pain management treatments.



17Opioid0822AttachB.pdf



09:55 AM



Dr. Rebekah Griffith, American Physical Therapy Association - Colorado Chapter, discussed her experience working in an emergency department and the benefits of having a physical therapist as part of the interdisciplinary care team in an emergency room. She provided examples about how patients can benefit from PT services when presenting with pain in an emergency room and how the use of PT services reduces the use of opioids to treat pain. Dr. Griffith responded to questions about follow-up care for patients who visit emergency rooms and insurance coverage for that care. Dr. Flynn responded to questions about the willingness of patients to pay for PT and to understand the value of the service. She discussed educational efforts designed to help patients understand that pain can be managed through movement therapies rather than by opioids.





10:15 AM



Mary Weber, Colorado Nurses Association, provided a handout to the committee (Attachment C). Ms. Weber discussed the role nurses play in prescribing opiates. She discussed the use of the Prescription Drug Monitoring Program (PDMP), nursing schools' focus on education about safe prescribing, and the Centers for Disease Control (CDC) guidelines governing opioids. She spoke about the increased access and use of naloxone, and explained the recent federal law that permits properly trained nurse practitioners and physician assistants to prescribe buprenorphine, a medication used in medication-assisted treatment (MAT) for opioid addiction. Ms. Weber responded to questions about the use of buprenorphine and the need for patients to utilized supportive services such as cognitive therapy while participating in MAT.



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10:30 AM



Ms. Weber discussed the idea of providing Naloxone kits upon release from an emergency room to patients who survived an overdose to prevent another overdose while they are waiting for follow-up care. Ms. Weber discussed professional training related to prescribing buprenorphine and the the Drug Enforcement Agency (DEA) approval required in order to prescribe buperenorphine. Committee discussion and questions followed about the price of buperenorphine, the type of medical and mental health services that are part of a MAT plan, and the use of methadone and other drugs during MAT.





10:51 AM



Ms. Weber discussed Senate Bill 17-074, which established a program through the University of Colorado - College of Nursing to oversee the expansion of MAT services in Routt and Pueblo counties. She discussed her recommendations listed on page 4 of her handout (see Attachment C).





10:55 AM -- Opioid Issues in Correctional Facilities



Melissa Roberts, Division of Adult Parole, Department of Corrections (DOC), discussed the use of Vivitrol, a once-monthly medication used to help prevent relapse to opioid dependency, in MAT for parolees. She talked about the challenges facing parolees with substance use disorders and the 2013 DOC Vivtrol pilot program, which indicated that MAT is effective in reducing the chance that a parolee will return to department custody. Committee discussion and questions followed.





11:08 AM



Glenn Tapia, Community Corrections, Department of Public Safety (DPS), distributed a handout to the committee (Attachment D). Mr. Tapia provided the committee with background about Colorado's community corrections system. He discussed the cost to DPS for treating clients with substance use disorders and mental health disorders as well as the intensive residential treatment programs within DPS. He discussed matching clients to need assessments and the types of treatment needed to reduce the recidivism rates.



17Opioid0822AttachD.pdf



11:20 AM



Committee discussion followed. Mr. Tapia discussed the use of amphetamines and opioids by individuals in community corrections. He stated that program quality matters when providing substance use disorder treatment. Mr. Tapia responded to questions from the committee about drug related deaths within DOC. He told the committee that 289 offenders in DOC receive MAT. Mr. Tapia and committee members dialogued about potential benefits of merging DOC and DPS drug rehabilitation programs. Mr. Tapia discussed treating drug abuse through a program that provides support for all of the contributing factors of the addiction.



















11:32 AM



The committee discussed the tools used by community correction to identify mental illness in clients. Mr. Tapia stated that mood disorders appear to be the most prevalent disorders of this population.





11:34 AM -- Medicaid Coverage for Opioid Medications and Addiction Treatment



Gretchen Hammer, Colorado Department Health Care Policy and Financing (HCPF), provided a general overview of Colorado's Medicaid program and a handout to the committee (Attachment E). She explained that Medicaid serves about 1.2 million individuals in Colorado. Referring to slide 6 in the handout, Ms. Hammer spoke about the Medicaid clients that are impacted by opioid misuse. She stated that Medicaid clients have a higher chance of receiving treatment for drug misuse and abuse.



17Opioid0822AttachE.pdf



11:41 AM



Dr. Judy Zerzan, HCPF, discussed the number of Medicaid clients who died as a result of an opioid overdose. Referring to slide 8 of the handout, she spoke about the various state initiatives established to combat the opioid crisis. Dr. Zerzan responded to questions from the committee regarding strategies employed by Medicaid to balance the misuse of opioids and the need to treat acute pain.





11:52 AM



The committee and Ms. Hammner discussed the unique needs in rural areas of the state related to substance use disorders and the practice of using pain as the fifth vital sign.





11:57 AM



Cathy Traugott, HCPF, addressed additional concerns about pain as the fifth vital sign.





12:00 PM



Dr. Zerzan continued her presentation. She discussed treating long-term pain and addiction. She explained that Medicaid provides coverage for MAT, social detoxification services, targeted case management, and individual, group, and family counseling. She discussed the cost of the various treatments.





12:11 PM



Committee discussion followed about the need to provide wraparound services to individuals with drug addiction.















12:13 PM



Dr. Zerzan discussed House Bill 17-1351, which requires HCPF and DHS to report to the General Assembly on the feasibility of providing residential and inpatient substance use disorder treatment as a part of the Medicaid program, and make recommendations concerning the time frame for implementing this treatment as a benefit under Medicaid. She discussed the differences between the various medications used for MAT and the need to include warparound services.





12:20 PM



Representative Pettersen recessed the committee.





01:25 PM -- Insurance Coverage for Opioid Medications and Addiction Treatment



Representative Pettersen reconvened the committee.



Dr. Elizabeth Kraft, Anthem, provided a handout to the committee (Attachment F) and discussed Anthem's efforts in providing access to substance use disorder prevention, early identification of drug misuse problems, and treatment. She discussed Anthem's efforts to: align pharmacy benefits with the Center for Disease Control (CDC) guidelines for prescribing opioids for chronic pain; create the Pharmacy Home program; promote use of naloxone and remove prior authorization for its use; and a Medicare opioid utilization management program. She explained that the Pharmacy Home program addresses health and safety concerns of patients by reviewing pharmacy data to identify patient who are prescribed opioids and potentially dangerous drug combinations by multiple prescribers. If a covered individual is identified, a letter is sent to the patient and the providers expressing Anthem's concern for the patients health and safety.



17Opioid0822AttachF.pdf



In response to committee questions, Dr. Kraft explained that health plans do not have access to PDMP, but Anthem does encourage its providers to review the PDMP when prescribing opioids. Dr. Kraft told the committee that Anthem does not require prior authorization for the use of noloxone or MAT medications. Discussion about network adequacy followed.





01:36 PM



Dr. Kraft discussed alternative treatments for pain, such as massage and PT. She discussed access to mental health services via telehealth and efforts to track and address substance use disorders. Committee questions and discussion ensued about in-patient substance use disorder treatment, access to physical therapy, and parity laws for substance use disorders.























01:53 PM



Tom Denberg, Pinnacol Assurance, provided a handout to the committee (Attachment G). He explained the workers' compensation system and clarified that employers pay the entire cost, and benefits are determined by state statute. He listed the types of treatments that are covered, including alternatives to opioids. He explained the correlation between opioid use and the level of disability of the worker. He told the committee that opioid prescriptions account for 17 percent of the prescriptions written for workers receiving workers' compensation benefits. Referring to pages 4 and 5 of the handout, Mr. Denberg discussed strategies employed by the Division of Workers' Compensation and Pinnacol to treat opioid misuse. Committee questions and discussion followed.



17Opioid0822AttachG.pdf



02:05 PM



Mr. Denberg outlined Pinnacol's recommendations to address opioid use among workers receiving care under the workers' compensation program listed on page 7 of his handout, and responded to questions from the committee about the laws and rules affecting the care provided under workers' compensation.





02:12 PM



Amy Newton, Pinnacol Assurance, responded to questions from the committee about the way Pinnacol provides information about prescriptions written for patients and alternative treatments.





02:17 PM -- Federal Perspectives and Initiatives



United States Senator Michael Bennet and Scott Gottlieb, Commissioner, US Food and Drug Administration (FDA), came to the table. Senator Bennet commented on the opioid epidemic in Colorado. He discussed the desire of members of Congress to address the opioid epidemic.





02:20 PM



Commissioner Gottlieb addressed the committee. He told the committee that the misuse of opioids is a major concern to many elected officials in Washington. He stated that the FDA plays a role in the crisis and discussed the FDA's withdrawal of an opioid from the market due to its highly addictive nature, efforts to reduce overuse of opioids, and regulatory oversight around dispensing and prescribing procedures.





02:27 PM



Commissioner Gottlieb responded to questions about access to and the cost of Naloxon. He explained that the price of drugs may be related to the lack of competition from generic equivalents. He addressed committee questions about co-packaging drugs.

















02:31 PM



Commissioner Gottlieb said that the lack of generic equivalents for some name brand drugs directly correlates to the cost of the drug and clarified that generic drugs must have the same delivery directions as the name brand equivalent. He explained that this requirement can be problematic since many of the delivery systems are patented, and to make a delivery system with the exact same instructions can be difficult.





02:41 PM -- Impact of Opioid Crisis on Law Enforcement



Sheriff Kirk Taylor, Pueblo County Sheriff, provided a handout to the committee (Attachment H) and discussed the efforts of Pueblo County in addressing opioid addiction within the jail population. He discussed the use of Vivitrol in the Pueblo County jail and the success realized by using this course of treatment. He pointed out that individuals with substance use disorders need additional resources and assistance to be successful in treatment and recovery.



17Opioid0822AttachH.pdf



02:50 PM



Sheriff Jaime FitzSimons, Summit County Sheriff, provided a handout to the committee (Attachment I). He discussed the unique needs of Summit County's population. He stated that most people addicted to opioids became addicted while using prescription opioids. He discussed the drug take-back program in Summit County, detox facilities, the experience of users who detox while in jail, good samaritan laws, and drug courts.



17Opioid0822AttachI.pdf



02:58 PM



Sheriff Taylor responded to questions about the Vivitrol program and the wraparound services available to individuals involved in the criminal justice system. Committee discussion and questions followed about drug prevention programs, detox facilities, and Portugal's law which decriminalizes all drugs and requires mandatory treatment for users.





03:08 PM



Sheriffs Taylor and FitzSimons continued to dialogue with the committee about treatment options available to individuals being released from jail, the drug supply chain, training of first responders to administer noloxon, lack of access to treatment, statutory limitations that deter some programs and treatments from being implemented, and cooperation with the federal government regarding drug trafficking.



















03:28 PM



Tom Raynes, Colorado District Attorney Council, provided a handout to the committee (Attachment J). He discussed the role forced on law enforcement in the treatment of individuals with substance use disorders and the Law Enforcement Assisted Diversion Program (LEAD). LEAD is a pre-booking diversion program that aims to improve public health and end the cycle of recidivism. LEAD allows an arrestee to be enrolled in a diversion program and connect with a case manager rather than being booked and held in jail. Case managers connect the individuals with housing options, substance use treatment, and vocational training. Mr. Raynes explained that several district attorneys in Colorado will be applying for grants to implement this program.



17Opioid0822AttachJ.pdf



03:31 PM



Helen Morgan, Chief Deputy Denver District Attorney, discussed the increase in narcotic cases involving heroin that her office handles. She explained that in 2016, 2000 inmates in the Denver County jail experience opioid withdrawal and that inmates are 129 percent more likely die of an overdose within two weeks of release from custody than other opioid users. She spoke about the four law enforcement assisted diversion programs utilized by Denver and Denver's efforts to provide treatment services for opioid users. Committee discussion and comments followed about the difficulty of accessing treatment for drug addiction, funding for treatment and recovery programs, and efforts to address these concerns across the state.





03:44 PM



Additional discussion about the LEAD program and veterans' courts ensued.





04:02 PM -- Screening Brief Intervention and Referral to Treatment



Carolyn Swenson, Peer Assistance Services, Inc., provided a handout (Attachment K) and discussed the role of health professionals in addressing substance use disorders, and Screening, Brief Intervention, and Referral to Treatment (SBIRT). She explained that the SBIRT model of early intervention and treatment can improve health outcomes for adults and adolescents. She discussed the health effects of the misuse of alcohol. She discussed the results from SBIRT screenings in Colorado. Ms. Swenson told the committee that there was measurable reduction in alcohol and cannabis use when the provider discussed the use with the patient.



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04:19 PM



Cyrille Adam, Kognito Solutions, referred to Attachment K throughout his presentation. He told the committee that conversations can improve social, emotional , and physical health. He explained that the Kognito simulations prepare health professionals to effectively lead real-life conversation that drive measurable improvement in health behaviors.





04:29 PM



Mr. Adam continued by discussing the One Degree application that allows anyone to practice conversations with a virtual peer who uses substances in unhealthy ways. He showed the committee the online simulation tool that prepares health professionals and others to effectively lead real-life conversations about substance misuse. Committee members commented on the interest of healthcare providers to discuss substance use with patients, and the gaps in training for providers.





04:45 PM



The committee dialogued with Mr. Adam and Ms. Swenson about the tools provided by Kognito Solutions.





04:53 PM -- Task Force Update



Robert Valuck and Jose Esquibel discussed the stakeholder task force designed to support the activities of the committee. Information about the task force including meeting dates may be found on the committee's website at http://leg.colorado.gov/node/1098166/#content-title-3.





05:00 PM -- Public Comment



05:08 PM -- Marjorie Zimdars-Orthman, representing herself, described her experience as a family caregiver and her husband's journey as a patient with long-term chronic pain. Committee comments followed.



05:08 PM -- Frank Cornelia, Colorado Behavioral Healthcare Council, told the committee about the Mental Health / Point of Contact Through Jail Release Task Force. This task force is expected to address the following topics: diversion from the system for those with behavioral health issues, jails with individuals in custody because of mental health/behavior issues, and continuity of care or wraparound services to keep individuals from returning to jail.





05:12 PM



Representative Pettersen adjourned the meeting.