I_OpioidSubstance_2017A 09/12/2017 09:00 AM Committee Summary

09:06 AM -- Call to Order and Opening Remarks



Representative Pettersen called the meeting to order. She explained the deadlines for requesting and voting on bills to the committee. Representative Pettersen described the agenda for the day's meeting, and the agenda and a handout were distributed to the committee (Attachments A and B).



17Opioid0912AttachA.pdf 17Opioid0912AttachB.pdf

























09:08 AM -- DHS Opiate Policy Analysis and Needs Assessment



Donna Lynne, Lieutenant Governor of Colorado, presented to the committee and described the impact of the opioid epidemic on public safety and the economy in Colorado. She provided statistics on abuse of prescription drugs and overdose deaths in Colorado. Lieutenant Governor Lynne mentioned possible solutions to the opioid problem in Colorado, including mandatory use of the Prescription Drug Monitoring Program (PDMP), prescribing limits, and continuing education for health care providers. Lieutenant Governor Lynne responded to committee questions regarding mandatory requirements and prior authorizations.





09:23 AM



Cristen Bates, Office of Behavioral Health (OBH), Colorado Department of Human Services (DHS), presented on a policy analysis report from OBH (Attachments C and D). She described legislation passed in other states in response to the opioid crisis. Ms. Bates summarized state prevention laws including prescribing limits, PDMP data and utilization, and safe disposal laws. She explained opioid treatment laws including provider training, expanding essential health benefits, regulations for substance use providers, and other insurer interventions. Ms. Bates summarized harm reduction laws including naloxone access, good samaritan laws, and injection drug use laws.

17Opioid0912AttachC.pdf 17Opioid0912AttachD.pdf



09:44 AM



Ms. Bates responded to questions regarding Colorado's legislation compared to other states and DHS's work with Rocky Mountain Crisis Partners regarding substance misuse.





09:49 AM



Marc Condojani, OBH, DHS, presented to the committee regarding the Colorado Needs Assessment for the SAMHSA State Targeted Response to the Opioid Crisis and distributed a handout (Attachment E). He described data on benzodiazepines, opioid prescriptions, and overdose death rates in Colorado. Mr. Condojani replied to a question regarding drugs that cause overdose deaths. He explained the benefit of Medicaid expansion to individuals with substance use disorders, opioid treatment programs, and office-based treatment programs. Mr. Condojani provided examples of barriers to access to detox, residential treatment, outpatient services, and methadone clinics. He summarized drug withdrawal management to the committee.



17Opioid0912AttachE.pdf



10:08 AM



Ms. Bates responded to questions regarding coordination of services. Ronnie Hines, Department of Regulatory Agencies, responded to a question regarding workforce issues.















10:17 AM -- Colorado Hospital Association Initiatives



Diane Rossi MacKay and Dr. Heidi Wald, Colorado Hospital Association (CHA), presented to the committee and distributed a handout (Attachment F). Ms. Rossi MacKay briefly explained the Colorado Opioid Safety Collaborative, and discussed two hospitals' experiences with the opioid epidemic.



17Opioid0912AttachF.pdf



10:27 AM



Ms. Rossi MacKay explained the emergency department pilot program, including the participation, implementation, and goals of the pilot program. Dr. Wald and Ms. Rossi McKay responded to questions regarding pain and patient satisfaction, and possible pilot program expansion beyond the emergency room.





10:37 AM



Dr. Heidi Wald summarized the Colorado American College of Emergency Physicians opioid prescribing and treatment guidelines. She described the use of the alternative treatments to opioids. Dr. Wald responded to a question regarding insurance issues with alternative treatments. She described implementation of the emergency department pilot program, and provided preliminary results of the decrease in opioid, fentanyl, and hydromorphone administrations in Yampa Valley Medical Center. Dr. Wald provided statistics on increased use of alternative administrations. She noted that there has been local and national interest in joining the emergency department pilot program. Dr. Wald explained that the pilot program will end in November and results from the pilot program will be analyzed by January.





10:49 AM



Committee members commented on hospital policies regarding patients that are in the emergency room for an overdose. Ms. Rossi MacKay and Dr. Wald responded to questions regarding additional alternative treatments and CHA cooperation with behavioral health organizations.





10:58 AM -- Problem-Solving Courts



Terry Scanlon and Brenidy Rice, Office of the State Court Administration, presented on the problem solving court system in Colorado and distributed a handout to the committee (Attachment G). Ms. Rice described the history of problem solving courts in the U.S. She described how an individual moves through the judicial system and enters into a drug court. Ms. Rice explained the resources and referrals that are offered through a drug court and described the responsibilities of the individual involved in the drug court process. She explained that a majority of prison inmates have been charged with a drug offenses, and a large number of inmates have a substance use issue.



17Opioid0912AttachG.pdf













11:14 AM



Ms. Rice provided statistics on reduction in recidivism and cost effectiveness of drug courts. She provided data on the type, number, and location of problem solving courts in Colorado.





11:21 AM



Ms. Rice responded to questions regarding the definition of competency and marijuana legalization. She responded to additional questions about reasons for lack of successful completion of drug courts and sanctions for relapsing while participating in drug court.





11:33 AM -- Pharmacy Benefit Managers



Michelle Mack, Express Scripts, and Rachel Lee, CVS Health, presented to the committee on pharmacy benefit manager (PBM) policies. Ms. Mack described policies related to opioid misuse including notification to patients, safe disposal options, notification to physicians, and limiting initial prescribing to seven days in certain cases. She explained additional Express Scripts policies including prior authorizations for short acting opioids, locking at-risk patients from pharmacy or doctor shopping, and increasing electronic prescriptions. Ms. Mack responded to a question regarding use of the PDMP.





11:40 AM



Senator Aguilar distributed information from Express Scripts on electronic prescribing (Attachment H). Ms. Lee explained the role of PBMs and the opioid crisis. She described a monitoring program to capture patterns of inappropriate prescribing and to suspend prescribing privileges. Ms. Lee discussed a pharmacy education program for youth regarding substance abuse.



17Opioid0912AttachH.pdf



11:49 AM



Ms. Lee explained PBM policy recommendations including limiting opioids to a seven day supply, mandating controlled substances to electronic prescribing, supporting state take back programs, and establishing a national PDMP database. Ms. Lee and Ms. Mack responded to questions regarding federal drug take back regulations and monitoring opioid prescribers.





11:58 AM



Representative Pettersen recessed the committee.





















01:24 PM -- Evidence-Based Practices and Costs/Benefits Analysis



Representative Pettersen called the committee back to order. Glenn Wright, Pew Charitable Trusts, and Jessica Corvinus and Tiffany Madrid, Office of State Budget and Planning, presented to the committee and distributed handouts (Attachment I and J). Mr. Wright explained Pew's substance use prevention and treatment research. He described medication assisted treatment and behavioral therapies, and explained cost benefit to the economy when individuals receive treatment for substance use. Mr. Wright described some barriers to treatment, including workforce gaps, lack of parity in insurance policies, and stigma around substance use.



17Opioid0912AttachI.pdf 17Opioid0912AttachJ.pdf



01:36 PM



Ms. Corvinus explained the inception and work of the Colorado Results First program. Ms. Madrid described how the Results First Program has identified the best available research on opioid use disorder treatments. She described evidence based treatments including medication assisted treatment and nonmedication assisted treatments. Ms. Madrid noted that the most effective treatment programs are those that provide the most intensive behavioral therapy and daily opiate substitutions. She explained that some treatment programs are cost-effective but not necessarily highly effective treatments. Ms. Madrid provided cost-benefit analysis of methadone treatment and noted that the Results First Program is working on analyses of treatment programs that use bupenorphine, naltrexone, and suboxone.





01:47 PM



Ms. Corvinus responded to questions regarding fidelity of programs and methodology of the Results First Program analysis. Ms. Madrid responded to a question about effective length of treatment.





01:54 PM -- Use of Opioid Medications in Other Care Settings



Becky Keller, Pathways Hospice, and Brad Evans, Hospice and Palliative Care Association of the Rockies, presented to the committee. Ms. Keller discussed pain management for patients in hospice care. She explained safe medication disposal after the death of a patient. Mr. Evans described the work of the Hospice and Palliative Care Association, including providing education on the benefits of opioid use in palliative care.





02:01 PM



Ms. Keller responded to questions regarding experimental treatments and recommendations for safe removal of medications. Mr. Evans responded to a question about medication take back locations.

























02:08 PM



Gia Forbes, Colorado Association of Nurse Anesthetists, presented to the committee and provided a handout (Attachment K). Ms. Forbes described how she became involved in pain management, and defined addiction, physical dependence, and morphine equivalents for the committee. She explained that pain management clinics attempt to help patients reduce the amount of morphine equivalents that they take. Ms. Forbes described early intervention strategies to prevent addiction, including extended release medication, medication alternative vouchers, and access to free exercise.



17Opioid0912AttachK.pdf



02:24 PM



Ms. Forbes described the average expected reduction in pain intensity for various therapies, and noted that opioids are necessary for some patients with chronic pain. She explained procedures in pain management clinics to ensure the safety of patients. Ms. Forbes noted that it can be difficult for a pain management clinic to contract with insurers if a physician is not present in the clinic. She described problems with patients abusing Suboxone, and noted that Vivitrol may be a safer alternative treatment for opioid abuse.





02:35 PM



Ms. Forbes responded to questions regarding Vivitrol and patients' pain intensity over time.





02:39 PM -- Veterans Treatment Programs



Dr. Bill Massey, Cadira MD, presented to the committee and distributed handouts (Attachment L and M). Dr. Massey described his experience researching substance use and abuse. He described socioeconomic causes of the opioid crisis and the historic use of substances. He summarized the addiction process, barriers to treatment for substance abuse, and new research into effective substance abuse treatments. Dr. Massey described technological advances in personalized medicine that may be used in treating substance abuse.



17Opioid0912AttachL.pdf Attachment M can be viewed at Legislative Council.



02:51 PM



Dr. Massey responded to committee questions.





02:54 PM



Beau Gertz, Cadira MD, discussed his experience with veterans, pain management, and mental health with the committee. He explained effective alternative treatments for pain, including physical activity.













03:03 PM



Nate Watson, representing himself, discussed his experiences as a veteran recovering from physical injuries and post traumatic stress disorder. He described his use of opioids to treat pain, and his transition to alternative therapies. Mr. Watson responded to questions from the committee.





03:09 PM



Ian Newland, representing himself, discussed his experiences as a war veteran and the injuries he received on active duty. He described his struggle with post traumatic stress disorder and pain management, and the alternative therapies he employs, including physical fitness. Amy Stephens, Cadira MD, gave concluding remarks to the committee.





03:16 PM



Dr. Massey and Mr. Gertz responded to a question on policy recommendations regarding opioid use.





03:21 PM -- Law Enforcement and Drug Interdiction



Detective Ray Padilla, Colorado Drug Investigators Association, presented to the committee. He explained different reasons for the increase in overdose deaths in Colorado, including over prescribing of opioid medication and public demand for stronger, more powerful drugs. Detective Padilla explained that domestic marijuana production has resulted in increased poppy/heroin production and methamphetamine production by drug cartels in Mexico. He noted that heroin is relatively cheap to obtain in Colorado compared to prescription opioids. Detective Padilla explained that heroin is sometime mixed with potent drugs, making it more lethal, and that smuggling activities from Mexico have increased. He noted that there has been an increase in drugs purchased over the dark web.





03:32 PM



Detective Padilla explained that Colorado is both a source state and pass-through state for many narcotics in the country. He suggested creating public policy that provides higher penalties for distributors of fentanyl and carfentayl. Detective Padilla added that there are two primary routes for heroin trafficking through Colorado.





03:37 PM



Detective Padilla responded to questions regarding payment for drug transaction over the internet, specific recommendations for increased funding or legislation, and screening drug packages coming into the U.S.

























03:44 PM -- Public Comment



Representative Pettersen opened the meeting for public testimony.



3:45 PM -- Nancy Steinfurth, Liver Health Connection, testified regarding Hepatitis C infections resulting from syringe use. She recommended increased syringe exchanges in the state, increased Hepatitis C testing, and eliminating barriers to treatment for Hepatitis C.





03:50 PM -- Task Force Recommendations



Jose Esquibel, Office of the Attorney General, and Dr. Robert Valuck, Colorado Consortium for Prescription Drug Abuse Prevention, presented to the committee on the work of the Opioid and Other Substance Use Disorders Task Force and distributed a handout (Attachment N). Dr. Valuck explained that the task force held a conference call and meetings with various stakeholders with the goal of formulating policy recommendations for the committee. He detailed the process that the task force used to collect and organize ideas and recommendations from stakeholders. Mr. Esquibel noted that the task force would like to stay involved throughout the bill drafting process.



17Opioid0912AttachN.pdf



03:55 PM -- Bill Draft Requests



Kristen Forrestal and Yelana Love, Office of Legislative Legal Services, explained to the committee the procedures for requesting bills, and important deadlines related to bill requests.





03:58 PM



Representative Kennedy and Senator Tate commented on the process for requesting bills. Ms. Forrestal noted that the committee may request bills as broad or specific as they wish. Senator Priola explained and distributed a bill draft that incorporated ideas from other states addressing opioid misuse (Attachment O). Committee members dialogued regarding the bill request process.



17Opioid0912AttachO.pdf



04:06 PM



Ms. Love, Ms. Forrestal, and committee members continued to dialogue regarding the bill request process. Representative Pettersen proceeded to request bill drafts.

04:27 PM



Mr. Esquibel commented on task force points of contact for the bill requests. Representative Pettersen reminded the committee that the September 14 meeting has been cancelled. She discussed committee availability for an additional meeting.





04:30 PM



Representative Pettersen adjourned the meeting.