I_OpioidSubstance_2019A 07/30/2019 09:41:51 AM Committee Summary

Senator Pettersen called the meeting to order and an agenda was distributed (Attachment A).

Dr. Robert Valuck, Colorado Consortium for Prescription Drug Abuse Prevention, discussed the criminal justice stakeholder recommendations related to substance use disorder (SUD) and distributed a handout (Attachment B).  Dr. Valuck summarized the recommendations regarding jail-based treatment, judicial programs and education, and diversion and overdose response programs. 

Representative Herod asked about funding for criminal justice programs, in particular the Law Enforcement Assisted Diversion (LEAD) program.  Dr. Valuck discussed policy suggestions regarding sentencing reform and housing.

Dr. Valuck discussed the Consortium-specific policy recommendations, including requiring jails to provide all FDA-approved addiction medications.  Senator Kennedy asked about the risks of withdrawal and atagonists. Discussion ensued.  Senator Pettersen discussed criminal record sealing and supportive services for persons with SUD.

Chief Mike Butler, Public Safety Chief of Longmont, discussed what Longmont is doing to divert individuals and distributed a handout (Attachment C).   He discussed the diversion referral process, case management, and the addition of an operational workgroup and steering committee for diversion efforts.  Chief Butler also discussed the restorative justice program, the Angel Initiative, and LEAD program in Longmont.

Chief Butler continued to discuss diversion efforts in Longmont and stressed the importance of funding the LEAD program and other programs, beyond problem solving courts, across the state to refer individuals out of the criminal justice system.

Senator Petterson asked a question about communities that have instituted a LEAD pilot program. Chief Butler noted there are four pilot programs in the state.

Representative Herod asked Chief Butler about the recidivism rates in his community.  Mr. Butler noted that restorative justice has a recidivism rate around ten percent.  Representative Herod asked about these programs reaching communities of color and for data on individuals of color who have used these programs.

In response to a question, Chief Butler described the Angel Initiative, through which an individual can access addiction treatment. Discussion ensued.

Tom Raynes, Colorado District Attorneys' Council, discussed LEAD, the multiple diversion models that exist, and components of the most successful models.

Mr. Raynes noted that LEAD is not 'one size fits all' for all communities. Communities need flexibility and funding if this program is going to be required. Discussion ensued.

Representative Kennedy asked about expanding the LEAD pilot program, and Mr. Raynes spoke about the limited availability of SUD treatment providers in more rural judicial districts.  Representative Herod noted that diversion programs impact the state's prison population.

Terri Hurst, Colorado Criminal Justice Reform Coalition, discussed the need for more transparency in state criminal justice spending and distributed a handout (Attachment D).  She also spoke about modernizing the justice system so that those needing SUD treatment are treated in the existing healthcare system. 

Ms. Hurst continued to discuss state cash funds that have available money that could potentially be used for treatment, including the offender services cash fund in the Judicial Department and the correctional treatment cash fund in the Department of Corrections.

Ms. Hurst discussed the importance and benefits of continuity of care for justice system involved individuals. Discussion ensued. Representative Herod asked about the cost of urinary analysis.

Jeffrey Satur, Public Safety Deputy Chief in Longmont, discussed the association between SUD and non-drug related crimes.  Mr. Satur continued to discuss the importance of SUD treatment in Longmont.

In response to questions, Mr. Satur discussed the large number of persons with SUD that never enter the criminal justice system and the level of supervision required by diversion programs.

Rochelle Galey, Office of Children, Youth, and Families, Department of Human Services, presented on SUD in the Division of Youth Services.  Ms. Galey referred to a powerpoint during her discussion (Attachment E).  She discussed youth with SUD who become involved with the Division of Youth Services.

Jagruti Shah, Office of Behavioral Health, Department of Human Services, discussed the jail-based behavioral services (JBBS) program.

Ms. Shah continued to discuss the JBBS program and noted that the program was evaluated in 2018.  The evaluation found that from 2011-2016, 21,423 inmates were screened for SUD.  The evaluation also identified gaps in SUD treatment across Colorado jails.

Cristen Bates, Department of Human Services, discussed recent funding increases in the JBSS program. The FY 2019-20 budget for the JBBS program is $18 million.

Representative Wilson asked about outcomes from the funding increase for the JBBS program and alcohol-specific treatment programs in jails.

Ms. Bates explained that the federal government has directed the states to prioritize federal funding for medicially assisted treatment (MAT) for opioid use disorders.  Representative Herod asked about marijuana charges for youth in the Division of Youth Services.

Ms. Shah discussed the LEAD program, and specifically the stakeholder committee that oversees the development of the program and the operational work group who staff cases.

Ms. Shah discussed the LEAD programs in Pueblo and Alamosa and their outcomes to date.  She described challenges in expanding the LEAD program, including harm reduction philosophy, decision maker buy-in, and community support.  Ms. Shah and Ms. Bates responded to committee questions.

Kellie Wasko, Department of Corrections (DOC), discussed treatment programs available in the DOC to inmates.  Ms. Wasko discussed MAT in prison and the implementation of DOC's vivitrol program.  In response to a question, Ms. Wasko discussed the availability of drugs, other than vivitrol, in prisons.

Lieutenant Staci Shaffer, Colorado Jail Association, discussed the perspective of local law enforcement.  Lieutenant Shaffer shared stories of inmates who have undergone MAT and the positive outcomes that have resulted.  She noted the efficacy of MAT programs in jails.

Lieutenant Shaffer discussed the treatment gaps that currently exists.  She noted that a significant barrier to offering MAT is a lack of treatment providers in near rural jails.  Lieutenant Shaffer stressed the importance of community support for jail-based SUD treatment.

Lieutenant Shaffer made a recommendation that Colorado apply for a statewide Medicaid waiver to allow inmates to be enrolled in Medicaid 30 days before release from incarceration to ensure continuum of care. Senator Kennedy asked about other states' success in obtaining a waiver.

Representative Wilson asked about inmates with SUD that choose not to participate in MAT, and if data is available on their outcomes. Discussion ensued.

Dr. Valuck discussed recommendations related to naloxone access, including extending immunity to those who use an expired naloxone kit, increasing public awareness of naloxone, and expanding take-home naloxone programs in emergency departments and hospitals.

Dr. Valuck discussed recommendations related to payment reform, including prohibiting discrimination of persons who fill naloxone and requiring insurers to reimburse hospitals for naloxone distributed in hospitals to high risk individuals and their families.  Senator Kennedy asked about the affordability of naloxone.  Dr. Valuck responded that the sale of naloxone is about $140 for a two dose package and has remained relatively steady in recent years.

Dr. Valuck discussed recommendations related to syringe access programs (SAPs) which include scaling funding for SAPs to meet statewide need, incorporating infectious disease education into the opioid response, and funding a pilot program for SAPs to offer fentanyl testing devices.  Discussion ensued.

Representative Wilson asked about options to address syringe needles left in public. Dr. Valuck noted that SAPs operate as an exchange program, and accept used needles.

Dr. Valuck continued to discuss recommendations, including creating and funding recovery residences that utilize a harm reduction approach, funding treatment programs that are compatible with a harm reduction approach, and establishing treatment-on-demand pilots for SAPs. Discussion ensued on treatment-on-demand pilot programs.

In response to a question, Dr. Valuck talked about federal laws regulating pharmacies and noted that federal law now allows a pharmacy to register as a reverse distributor to take back medications.  Dr. Valuck discussed the Consortium's advocay for a full-time medication safe disposal and take back program.

Representative Wilson asked about the feasiblity of building a medication waste incinerator in Colorado.  Dr. Valuck responded.

Greg Fabisiak, Colorado Department of Public Health and Environment (CDPHE), discussed medication collection.  He noted that as of June 2018, 4,700 pounds of medication have been collected statewide.

The committee discussed logistics and cost related to building a medication waste incinerator in Colorado, and the cost to ship drugs elsewhere with Mr. Fabisiak.

Samantha Bourdon, Colorado Syringe Access Providers Coalition, provided a handout to the committee and discussed SAPs (Attachment G). She noted that SAPs are the often to the first point of contact for an individual with SUD, and can connect these individuals to services.

Ms. Bourdon discussed the recommendation to create a pilot supervised injection use site in Denver and research around these sites' positive outcomes.

Ms. Bourdon discussed a recommendation to remove the requirement that local Boards of Health approve SAPs.  Discussion ensued.

In response to a question, Ms. Bourdon explained that syringes are often only available from pharmacies or SAPs.  She discussed the lack of Medicaid coverage for SAP clients for inpatient SUD treatment.  Senator Pettersen noted that the committee will discuss a related Medicaid waiver at the next committee meeting.

Ms. Bourdon discussed development of an integrated state harm reduction plan that is inclusive of infectious diseases in the context of the opioid problem to allow for a significant public health impact.

Lisa Raville, Harm Reduction Action Center, discussed supervised drug injection use sites.  Ms. Raville noted that multiple stakeholders have recommended the creation of a supervised injection use site in Colorado.  She discussed the research in support of supervised injection use sites, including possible health care cost savings.

Ms. Raville continued to discuss supervised drug injection use sites.  She noted that legislation authorizing these sites would need to allow for community input and local control.  Committee discussion ensued.

Ms. Raville responded to committee questions regarding the legal framework and location for a supervised injection use site pilot program and data on utilization of the sites in other countries.

Dr. Camilla Sasson, American Heart Association, discussed activities of the organization to address the opioid epidemic, including offering a training course on administering naloxone.

Dr. Sasson discussed a connected pulse system to collect real-time data from a variety of sources on the use of naloxone.  She recommended pairing naloxone kits with AED devices in public, where possible.

Lindsey Myers, CDPHE, discussed CDPHE's naloxone standing order that authorizes pharmacists to dispense naloxone to a variety of actors and referred to a powerpoint presentation (Attachment H).  Ms. Myers discussed CDPHE's statewide naloxone needs assessment.

Ms. Myers continued to discuss the naloxone needs assessment.  The needs assessment found that 80 percent of pharmacies contacted in Colorado had naloxone readily available and 58 percent distributed naloxone without a prescription.

Senator Petterson commented on the results of the assessment and asked if pharmacies were aware that a perscription is not necessary to distribute naloxone. 

Ms. Myers explained that the Office of Behavioral Health has distributed 28,256 naloxone kits through federal grant funds.  She described the OpiRescue application and how law enforcement are being encouraged to use it.  Ms. Myers discussed the antagonist bulk order fund that was created in CDPHE, and noted a potential funding gap for FY 2020-21, because the bill authorized a one-time appropriation of $250,000.  

Ms. Meyers discussed fentanyl test strips for opioids and a pilot program to distribute them.  She explained that 90 percent of participants in the pilot program that reported a positive result for fetanyl took action to protect themselves from overdose, and 43 percent of participants with a positive result for fetanyl reported less opioid use.

Della Cox-Vieira, Alamosa County Public Health, discussed harm reduction from a rural perspective.  A handout was distributed to the committee (Attachment I).  Ms. Cox-Vieira discussed Alamosa's implementation of harm reduction strategies and their comprehensive harm reduction program.  She mentioned that it was challenging to find a location for the harm reduction programs and to obtain sustainable funding.

Ms. Cox-Vieria discussed success of Alamosa's programs and noted that out of 61 individuals who have received naloxone, 59 survived.

Kelsey Fife, Mesa County Public Health, discussed harm reduction efforts in Mesa County.  A handout was distributed to the committee (Attachment J).  Ms. Fife described the work of the Mesa County Opioid Response Group and she noted that Mesa County was able to create two safe disposal locations outside of the Grand Junction area.

Andrea Calstrom, Chaffee County Public Health, discussed harm reduction efforts in Chaffee County. A handout was distributed to the committee (Attachment K).  She explained that several law enforcement officers and community members have been trained to administer naloxone.  Ms. Calstrom also discussed difficulties in implementing harm reduction programs, including community stigma and organizing across four counties.

The committee discussed the members' interest in criminal justice and harm reduction.  Representative Herod, Senator Priola, and Representative Kennedy expressed interest in working on bills in those subject areas.  Senator Pettersen proceeded with public testimony.

Dr. Chris Stock, Consortium Harm Reduction Workgroup, expressed his support for the Consortium's recommendations.  He discussed pharmacies' role in public health and abating opioid use disorder.  He recommended that the committee amend Colorado law to clarify that pharmacies may distribute naloxone without a prescription.

Dr. Mike Nerenberg, representing himself, discussed leveraging the various points of contact for persons with SUD, including SAPs.  He commented on safe injection sites and noted that those who utilize the sites are more likely to seek treatment.  Dr. Nerenberg responded to committee questions.