Legislature(2017 - 2018)CAPITOL 106

02/13/2017 01:30 PM HEALTH & SOCIAL SERVICES

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Audio Topic
01:35:15 PM Start
01:35:44 PM Presentation: the Science of Opioid Use Disorder
03:04:18 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
-- Please Note Time & Date Change --
-- Joint with Senate HSS --
+ Presentation: The Science of Addiction by Joshua TELECONFERENCED
Sonkiss, MD
-- Testimony <Invitation Only> --
                    ALASKA STATE LEGISLATURE                                                                                  
                         JOINT MEETING                                                                                        
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                       February 13, 2017                                                                                        
                           1:35 p.m.                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                             
                                                                                                                                
 Representative Ivy Spohnholz, Chair                                                                                            
 Representative Sam Kito                                                                                                        
 Representative Jennifer Johnston                                                                                               
                                                                                                                                
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                            
                                                                                                                                
 Senator David Wilson, Chair                                                                                                    
 Senator Natasha von Imhof, Vice Chair                                                                                          
 Senator Cathy Giessel                                                                                                          
 Senator Peter Micciche                                                                                                         
 Senator Tom Begich                                                                                                             
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                             
                                                                                                                                
 Representative Bryce Edgmon, Vice Chair                                                                                        
 Representative Geran Tarr                                                                                                      
 Representative David Eastman                                                                                                   
 Representative Colleen Sullivan-Leonard                                                                                        
 Representative Matt Claman (alternate)                                                                                         
 Representative Dan Saddler (alternate)                                                                                         
                                                                                                                                
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                            
                                                                                                                                
 All Members Present                                                                                                            
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
PRESENTATION: THE SCIENCE OF OPIOID USE DISORDER                                                                                
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
No previous action to record                                                                                                    
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
JOSHUA SONKISS, M.D.                                                                                                            
Chief Medical Officer                                                                                                           
Anchorage Community Mental Health Services                                                                                      
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:   Presented a PowerPoint  titled "The Science                                                             
of Opioid Use Disorder."                                                                                                        
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
1:35:15 PM                                                                                                                    
                                                                                                                                
CHAIR  DAVID WILSON  called the  joint meeting  of the  House and                                                             
Senate Health  and Social Services  Standing Committees  to order                                                               
at 1:35  p.m.   Representatives Spohnholz  and Kito  and Senators                                                               
Wilson, Von Imhof, Giessel, Begich,  and Micciche were present at                                                               
the  call  to order.    Representative  Johnston arrived  as  the                                                               
meeting was in progress.                                                                                                        
                                                                                                                                
^Presentation: The Science of Opioid Use Disorder                                                                             
        Presentation: The Science of Opioid Use Disorder                                                                    
                                                                                                                                
1:35:44 PM                                                                                                                    
                                                                                                                                
CHAIR WILSON announced  that the only order of  business would be                                                               
a presentation on the Science of Opioid Use Disorder.                                                                           
                                                                                                                                
1:36:39 PM                                                                                                                    
                                                                                                                                
JOSHUA SONKISS, M.D., Chief  Medical Officer, Anchorage Community                                                               
Mental  Health  Services,  presented  a  PowerPoint  titled  "The                                                               
Science of Opioid Use Disorder."   He directed attention to slide                                                               
3, "Learning  Objectives," and  moved on  to slide  4, "Outline."                                                               
He  shared  that  he  would  present a  review  of  addiction  in                                                               
general,  then discuss  the neuroanatomy  of  the reward  circuit                                                               
which was  important in addiction,  and continue  with discussion                                                               
of two models of cognitive impairment  in addiction as this was a                                                               
reason why  addiction was so  pernicious and difficult  to treat.                                                               
He said that  he would discuss research  on executive functioning                                                               
in  addiction  and lastly  he  would  talk about  evidence  based                                                               
treatment for  opioid use disorder.   He expressed his  hope that                                                               
this  information would  "help all  of you  make informed  policy                                                               
decisions  around opioid  use  disorder  treatment."   Presenting                                                               
slide 5, "A brief review of  addiction," he stated that there was                                                               
a  need   for  four  things   to  have  addiction:     tolerance,                                                               
withdrawal,  dependence,  "and  a  little something  more."    He                                                               
addressed slide 6, "Tolerance,"  and explained that tolerance was                                                               
the need  to take  more of  a drug to  get the  same effect.   He                                                               
offered  an example  of audience  tolerance, noting  that if  his                                                               
jokes did  not become increasingly  funny, the  audience response                                                               
would  fall  off.    He  declared  that  with  tolerance  it  was                                                               
necessary to  have more  of something  in order  to get  the same                                                               
response as  previously, and that  this was the  first ingredient                                                               
of addiction.   He  addressed slide  7, "What  Causes Tolerance?"                                                               
and  explained  that  the  brain makes  adjustments  so  that  it                                                               
functioned  normally when  the drug  was present,  and abnormally                                                               
when it  was not.  He  offered a comparison of  heroin to driving                                                               
with  a  heavy foot  on  the  brake  pedal,  noting that  it  was                                                               
necessary to push even  harder on the gas to get  up to speed, or                                                               
stay awake, or  stay breathing, or stay alive.   He declared that                                                               
this was the  purpose of tolerance, the body was  adapting to the                                                               
drug.  He said  that  an important  mechanism  for tolerance  was                                                               
downregulation  of   receptors.     He  explained   that  neurons                                                               
communicated in the  brain, as one cell would  send an electrical                                                               
signal from  one end to  the other end,  but then it  would stop,                                                               
slide 8, "downregulation."   He compared a  neurotransmitter to a                                                               
ball  crossing a  neuron, sending  an electrical  current to  the                                                               
other end of the neuron.   Addressing the three cells on slide 8,                                                               
he explained that the cells  had opioid receptors which needed to                                                               
be  occupied at  all  times  in order  to  operate  as they  were                                                               
supposed.   He  reported  that these  opioid  receptors could  be                                                               
overwhelmed with morphine,  and would not function  well, so some                                                               
of these  receptors would be  withdrawn.  Consequently,  if there                                                               
was morphine readily available,  the remaining receptors would be                                                               
full, but  would allow  the cell  to function in  the way  it was                                                               
supposed.  In the event that  the morphine was suddenly no longer                                                               
available to the remaining receptors,  there would be withdrawal.                                                               
When  the body  had developed  a tolerance  for a  substance, its                                                               
removal resulted in "awful physiological  symptoms."  He directed                                                               
attention to slide 10, "Withdrawal,"  stating that it reflected a                                                               
clinical opioid  withdrawal scale  which was  used by  doctors to                                                               
objectively measure  opioid withdrawal in clinical  settings.  He                                                               
stated that,  although withdrawal  from alcohol could  be deadly,                                                               
with opioids, usually  it was not.  He declared  that there was a                                                               
pronounced   physiological  response   when   the  substance   of                                                               
tolerance was removed.                                                                                                          
                                                                                                                                
DR. SONKISS  pointed to slide  11, "Dependence", and  stated that                                                               
tolerance plus  withdrawal resulted in dependence.   He addressed                                                               
slides  12 -  13,  "Is  dependence the  same  as addiction?"  and                                                               
shared that,  although anyone could become  dependent on morphine                                                               
in a  health care emergency,  it would take more  than dependence                                                               
to  have  addiction.    He   offered  some  examples  of  various                                                               
medicines that could cause tolerance  and withdrawal but were not                                                               
substances of  abuse: clonidine,  a blood pressure  medicine, and                                                               
venlafaxine, an antidepressant.                                                                                                 
                                                                                                                                
1:47:00 PM                                                                                                                    
                                                                                                                                
DR. SONKISS  pointed to slide  14, "A little something  more" and                                                               
offered a  definition for addiction:  a chronic,  relapsing brain                                                               
disease  that is  characterized  by compulsive  drug seeking  and                                                               
use, despite  harmful consequences.   He  emphasized that  it was                                                               
necessary to  have the adverse consequences,  which could include                                                               
going to jail  or having your children taken away.   He mentioned                                                               
that experts  in this  field were  referencing this  as substance                                                               
use  disorder  instead  of  addiction.   He  reviewed  slide  15,                                                               
"Models  of  addiction," and  shared  that  there could  be  some                                                               
instances, although he  hated to admit it, where  the Moral model                                                               
invoked  a weak  character.   He spoke  about the  criminal model                                                               
used with  the war on  drugs.   He mentioned the  recovery model,                                                               
which  spoke to  a personal  journey through  addiction, and  the                                                               
social  model  related  to  trauma   and  the  susceptibility  to                                                               
addiction.   He concluded with  the medical model,  which defined                                                               
addiction as  a disease.   He emphasized  that these  models were                                                               
perspectives on  addiction, were not mutually  exclusive, and the                                                               
scientific basis  of the models  increased as one moved  from the                                                               
moral model to the medical model.                                                                                               
                                                                                                                                
DR.  SONKISS  turned  to  slide   16,  "How  does  addiction  get                                                               
started?" and  slide 17,  "What sustains  addiction?"   He stated                                                               
that, fundamentally,  addiction was  started with an  overdose of                                                               
dopamine,  the  fundamental   neurotransmitter  of  pleasure  and                                                               
reward  which  everyone  had.     Everything  that  was  good  or                                                               
pleasurable resulted  in a  burst of dopamine.   He  reminded the                                                               
committee  of  the  aforementioned  example for  tossing  a  ball                                                               
across  a  synapse,  with dopamine  as  the  neurotransmitter  to                                                               
communicate  between cells.  He  pointed to  examples of  eating,                                                               
with a few  dopamine molecules in the synapse,  and cocaine, with                                                               
a  massive  flood  of  dopamine.    He  declared  that  in  every                                                               
substance use  disorder, it was a  flood of dopamine that  got it                                                               
started.  He stated that, as  these memories of the euphoria were                                                               
quickly  ingrained  in  different  parts of  the  brain,  it  was                                                               
necessary for  a cell to  take down some receptors,  as mentioned                                                               
earlier.                                                                                                                        
                                                                                                                                
1:52:37 PM                                                                                                                    
                                                                                                                                
SENATOR MICCICHE  referred to slide  15, and,  acknowledging that                                                               
addiction  was a  medical  condition, asked  if  addiction was  a                                                               
voluntary disease.                                                                                                              
                                                                                                                                
DR. SONKISS replied  that the voluntary stage of  addiction was a                                                               
very  early  stage,  though this  voluntariness  of  the  disease                                                               
quickly  becomes less  and less.    He declared  that there  were                                                               
other  diseases with  a voluntary  component, describing  Type II                                                               
diabetes as a lifestyle disease,  and adding sexually transmitted                                                               
infections as another example.                                                                                                  
                                                                                                                                
1:54:07 PM                                                                                                                    
                                                                                                                                
DR.  SONKISS  returned  discussion  to slide  17  "What  sustains                                                               
addiction?"   He  shared that  this  move away  from a  voluntary                                                               
action  was  conditioning  based  on  memories  of  that  intense                                                               
pleasure.   He explained that much  of what we learn  had nothing                                                               
to do  with what can be  articulated to people, but  instead with                                                               
behaviors that  were ingrained  and associated  with experiences.                                                               
He   directed  attention   to  slide   18,  "Think   Pavlov,  not                                                               
schoolteachers,"  explaining  that  the dog  was  conditioned  to                                                               
salivate when the  light bulb was turned on, no  matter what.  He                                                               
pointed out that  it was possible to explain to  this dog that it                                                               
was morally  wrong, to yell  at the dog, to  kick the dog,  or to                                                               
electrocute the dog,  but once there was  conditioning to respond                                                               
to the  light bulb, the  dog would  salivate.  He  emphasized how                                                               
difficult it was  to change this learned behavior.   Moving on to                                                               
slide  19,  "What  sustains addiction?"  he  explained  that  the                                                               
salience of drugs eclipsed other  stimuli for an addict, and that                                                               
drugs were  constantly in  the foreground  and remained  the most                                                               
important.  He shared an example  from slide 20, and then pointed                                                               
to slide  21, "Salience in  the healthy  brain."  He  pointed out                                                               
that  family  was  salient,  it  was  very  important,  and  most                                                               
decisions  included  some  relationship   to  the  well-being  of                                                               
family; whereas,  for the healthy  brain, drugs and  alcohol were                                                               
in the background.                                                                                                              
                                                                                                                                
1:57:45 PM                                                                                                                    
                                                                                                                                
DR.  SONKISS  turned  to  slide 22,  "Salience  in  the  addicted                                                               
brain."  He explained that, for  a severe addiction, after a drug                                                               
gets  its  grip,  the  salience of  drugs  became  paramount  and                                                               
eclipsed everything  else.  He moved  on to slides 23  - 25, "The                                                               
reward circuit,"  and explained  that every  addiction, including                                                               
opioid addiction,  moved between these  four areas of  the brain:                                                               
the  pre   frontal  cortex  (PFC),  which   was  responsible  for                                                               
judgement,  thinking,  reasoning,  and decision  making,  all  of                                                               
which allowed a person to  hold a position of responsibility; the                                                               
nucleus accumbens (NAc), which communicated  with the PFC and was                                                               
where  there was  a feeling  of pleasure;  the ventral  tegmental                                                               
area (VTA), which  was the seat of reward  and accomplishment and                                                               
would send  dopamine through the  nerve cells to the  NAc, "which                                                               
would  then feel  awesome," and  in turn  would tell  the PFC  to                                                               
allow  this;  and  finally,  the   locus  coeruleus  (LC),  which                                                               
primarily  served  to keep  a  person  awake, alert,  and  paying                                                               
attention.   This was important,  as the LC  was an area  for the                                                               
brakes to be pushed on,  addiction to opioids with its escalating                                                               
use tried to shut  down the LC.  This, in turn,  forced the LC to                                                               
work harder to  stay awake, alert, and alive.   He stated that an                                                               
overdose  caused  the  LC  to   shut  down;  whereas,  withdrawal                                                               
resulting  from  the  removal  of the  drugs,  caused  a  massive                                                               
norepinephrine rush.                                                                                                            
                                                                                                                                
2:02:15 PM                                                                                                                    
                                                                                                                                
SENATOR  MICCICHE  asked  if  a person  with  a  substance  abuse                                                               
problem had an addiction to opioids or to dopamine distribution.                                                                
                                                                                                                                
DR.  SONKISS  replied that  dopamine  was  the main  mediator  of                                                               
addiction, as addiction was a  dopamine deficiency.  He explained                                                               
that removal,  or down  regulating, of  the opioid  receptors was                                                               
also the removal of the dopamine  receptors.  The result was that                                                               
only the drug  of abuse gets a person enough  dopamine to get the                                                               
satisfying rush.                                                                                                                
                                                                                                                                
2:03:49 PM                                                                                                                    
                                                                                                                                
CHAIR  SPOHNHOLZ asked  if  this process  was  similar for  other                                                               
addictions.                                                                                                                     
                                                                                                                                
DR. SONKISS  replied that this  was essentially the  same process                                                               
for  other  addictions and  many  behaviors,  such as  compulsive                                                               
gambling.   He declared  that the neuro  circuitry was  the same,                                                               
and  the deficit  in dopamine  was  fundamental to  all of  these                                                               
substances and behaviors.                                                                                                       
                                                                                                                                
CHAIR  SPOHNHOLZ declared  that  it was  important to  understand                                                               
this was the same problem with alcohol and other drugs.                                                                         
                                                                                                                                
2:05:04 PM                                                                                                                    
                                                                                                                                
DR.  SONKISS  stated  that  there  were  fundamental  differences                                                               
between  different  substances of  abuse.    He listed  some  key                                                               
differences, which included the  down regulation of receptors, as                                                               
the extent  for reversal of  brain changes  was not the  same for                                                               
every  person  or every  substance.    He declared  that  alcohol                                                               
reversal was easier than that with opioids.                                                                                     
                                                                                                                                
2:06:00 PM                                                                                                                    
                                                                                                                                
DR.  SONKISS addressed  slides  26 -  28,  "Biomedical models  of                                                               
addiction."   He explained  the changed  set point,  stating that                                                               
the changes  with opioid use  were permanent,  or semi-permanent,                                                               
structural  and chemical  changes that  created a  new biological                                                               
and behavioral baseline for the  addict.  He offered a comparable                                                               
example  to addiction  for  the difficulty  in  attempts to  lose                                                               
weight, as  there was a  set point for  body weight to  which the                                                               
body  wanted  to  return.    Once  there  were  neuro  biological                                                               
changes, these  became hard to  reverse, and relapse  was common,                                                               
especially with opioids.  He  spoke about cognitive deficits, and                                                               
shared that  opioid use  degraded prefrontal  cortical inhibition                                                               
of  the  drive  to  use,  undermining  the  addict's  will  at  a                                                               
neurological level.   He stated that there was some  truth to the                                                               
idea  that an  addict lacked  some will,  and that  this degraded                                                               
prefrontal cortical inhibition of the drive was the reason.                                                                     
                                                                                                                                
2:08:53 PM                                                                                                                    
                                                                                                                                
DR. SONKISS  stated that addiction  was very pervasive,  and that                                                               
many people with addiction were  highly functioning because there                                                               
could  be compensation,  although  this was  more difficult  with                                                               
opioid addiction  as the will  was undermined and  the prefrontal                                                               
cortex became less effective.                                                                                                   
                                                                                                                                
2:09:46 PM                                                                                                                    
                                                                                                                                
DR.  SONKISS  stated  that  he would  break  down  the  cognitive                                                               
impairment that occurred in addiction  into categories, slide 29,                                                               
"Cognitive deficit model" and slide  30, "Domains of impairment."                                                               
He  spoke  about impulsivity,  describing  those  who act  before                                                               
thinking,  and the  necessity to  exercise impulse  control.   He                                                               
said  that people  who  use drugs  to excess  tended  to be  more                                                               
impulsive, and  then become even  more impulsive.  He  noted that                                                               
reward  hypersensitivity,  really   wanting  something,  was  the                                                               
desire  for something  becoming  the most  important  thing.   He                                                               
stated that harm  hyposensitivity was forgetting how  bad it was,                                                               
and that increased  risk-taking was the attitude  that they would                                                               
not be found out.  He  offered an example of outcome myopia, that                                                               
getting  high now  was more  important than  getting a  job in  a                                                               
month,  because  it was  now,  and  that  a punishment  was  less                                                               
important as it was out in the future.                                                                                          
                                                                                                                                
2:12:47 PM                                                                                                                    
                                                                                                                                
DR. SONKISS  offered four categories of  research which supported                                                               
the theories, slide 31, "Studies  of decision-making."  The first                                                               
category was self-report, which was  telling someone how you feel                                                               
or  what you  do;  the second  category,  behavioral tasks,  were                                                               
psychological tests; the  third category, computational modeling,                                                               
was  taking  a computer  program  to  evaluate the  psychological                                                               
tests in more  detail; and the final category,  neuroimaging.  He                                                               
expanded on self-reporting, stating that  it was not known if the                                                               
responses were honest.   He declared that addicts  knew they were                                                               
more   impulsive   than    others,   slide   32,   "Self-reported                                                               
impulsiveness  in  cocaine  users,"  and  explained  the  Barratt                                                               
Impulsivity Scale graph  depicted on the slide as  a good measure                                                               
on self-report.                                                                                                                 
                                                                                                                                
DR.  SONKISS  addressed  slide  33,  "Iowa  Gambling  Task,"  and                                                               
explained  that this  was one  of the  most common  psychological                                                               
tests used  to measure impulsivity  and addiction.   He explained                                                               
that  this test  used four  decks  of cards  and the  participant                                                               
pulled cards  off each  deck, the  object being  to make  as much                                                               
money as possible without going into  debt.  He reported that the                                                               
first  two  decks, A  and  B,  offered  big rewards  right  away,                                                               
similar to a dopamine rush;  however, the returns then diminished                                                               
very  quickly and  soon became  money  losers.   He compared  the                                                               
third and fourth  decks, C and D, to certificates  of deposit, as                                                               
they paid slow, but steady, returns.   He reported that most non-                                                               
addicts would very  quickly recognize the need to  just draw from                                                               
the C  and D decks; however,  addicts would draw many  more cards                                                               
from the  A and  B decks.   He relayed  that this  behavior could                                                               
predict who would do well in a rehabilitation setting.                                                                          
                                                                                                                                
DR. SONKISS described the graph on  slide 34, "IGT and relapse in                                                               
substance-dependent  individuals," which  depicted test  subjects                                                               
in a six week residential  treatment facility for mixed substance                                                               
use.  He pointed out  that the abstinent participants scored much                                                               
higher than those who relapsed.                                                                                                 
                                                                                                                                
2:17:47 PM                                                                                                                    
                                                                                                                                
SENATOR BEGICH  asked about the  dip on  the graph, slide  34, in                                                               
week 3.                                                                                                                         
                                                                                                                                
DR.  SONKISS, in  response,  explained that  data  points in  any                                                               
study had random variation in  the results, and he attributed the                                                               
dip, most  likely, to this  random variation.  He  suggested that                                                               
it was more important to focus on the trend.                                                                                    
                                                                                                                                
2:19:25 PM                                                                                                                    
                                                                                                                                
DR.  SONKISS  moved  on  to  slide 35,  "IGT  and  abstinence  in                                                               
methamphetamine  users"  and  explained the  comparison  of  non-                                                               
addicts with  addicts taking  the IGT (Iowa  Gambling Test).   He                                                               
pointed out  that it was very  difficult and took a  long time to                                                               
reverse the brain changes which  occurred in addiction.  He added                                                               
that a  30-day rehabilitation program  would not return  a person                                                               
even close to where they were prior to addiction.                                                                               
                                                                                                                                
2:21:16 PM                                                                                                                    
                                                                                                                                
SENATOR MICCICHE  asked if this  addiction affected  all decision                                                               
making.                                                                                                                         
                                                                                                                                
DR. SONKISS stated  that this was a fundamental  take home point,                                                               
the  impulsiveness   and  bad  decision  making   from  addiction                                                               
generalized to the rest of life.                                                                                                
                                                                                                                                
2:22:09 PM                                                                                                                    
                                                                                                                                
DR.  SONKISS  addressed  slide  36,  "Decision-making  in  opioid                                                               
users."   He  explained that  most  experts looked  at groups  of                                                               
studies  which  were carefully  compared  in  a weighted  average                                                               
(meta-analysis).  He  emphasized that all but two  of the studies                                                               
favored  the control  groups,  and not  the  opiate users,  which                                                               
illustrated   that  even   well  designed   studies  had   random                                                               
variations.  He  pointed out that the studies  which included ex-                                                               
users  of more  than three  years reflected  substantial decision                                                               
making   deficits  in   opioid  users,   which  underscored   the                                                               
difficulty to reverse the brain changes.                                                                                        
                                                                                                                                
2:25:12 PM                                                                                                                    
                                                                                                                                
DR.  SONKISS shared  slide 37,  "Computer  modeling of  decision-                                                               
making in cannabis  users," and he stated  that computer modeling                                                               
could get into  the nuances and break down  further the cognitive                                                               
deficits that  gave rise to the  test scores.  He  explained that                                                               
this graph  reflected a consistent  difference between  users and                                                               
non-users as  users ignored loss  magnitude, made  decisions that                                                               
were  less  consistent with  their  expectancies,  and were  more                                                               
influenced by recent gains.                                                                                                     
                                                                                                                                
2:27:44 PM                                                                                                                    
                                                                                                                                
DR. SONKISS  moved on to  slide 38, "Imaging studies,"  which was                                                               
the fourth  of the aforementioned categories  of decision making.                                                               
He pointed to  the composite image of the  orbital frontal cortex                                                               
and  the dopamine  receptors for  cocaine abusers  and non-users.                                                               
This showed that "normal fun does  not do it anymore when you are                                                               
severely addicted to  a substance."  He added  that although this                                                               
depicted cocaine use, it would  be similar for any substance use.                                                               
He  directed  attention to  slide  39,  "Why Can't  Addicts  Just                                                               
Quit?"   He explained  that this was  a conceptual  slide showing                                                               
what different  brain structures did, noting  the increased drive                                                               
to  use and  the decreased  control in  the addicted  brain.   He                                                               
added that the  saliency and the memory of drugs  was enormous in                                                               
the addicted brain.                                                                                                             
                                                                                                                                
2:31:28 PM                                                                                                                    
                                                                                                                                
DR. SONKISS  spoke about slide  40, "Treatment," and  stated that                                                               
12-step and peer support groups  were not strictly treatment, but                                                               
were interventions which  did help a lot of people.   He reported                                                               
that  there   were  many  forms   of  detoxification,   and  that                                                               
psychosocial  treatment  referred  to  different  intensities  of                                                               
counseling and psychotherapy.  Although  these were effective for                                                               
most  substance  use  disorders,  they were  less  effective  for                                                               
opioid   use  disorder.      He  referenced   medication-assisted                                                               
treatment, which could  include treatment for alcohol  abuse.  He                                                               
declared that detoxification was not  really a treatment, but was                                                               
more similar to  debridement, the cleaning of a  wound to prepare                                                               
it for  an intervention, slide  41, "Detoxification."   He stated                                                               
that  it was  mostly effective  as  a bridge  to more  definitive                                                               
treatment,  and was  often a  practical  and economic  step.   He                                                               
reported  that  detoxification from  opioids  did  not have  much                                                               
impact on the relapse rates.  He  added that the risk of death by                                                               
overdose was highest after a  month of detoxification of opioids,                                                               
sharing  that he  often counseled  continuation of  use until  an                                                               
addict  could  enter a  methadone  program.   He  declared  that,                                                               
although  naloxone was  a wonderful  drug to  reverse respiratory                                                               
arrest during heroin  or opioid overdose, an  addict would return                                                               
to  where  they  started,  slide  43,  "Naloxone  rescue  is  not                                                               
treatment."                                                                                                                     
                                                                                                                                
2:34:44 PM                                                                                                                    
                                                                                                                                
DR.  SONKISS declared  that "Psychosocial  Treatment," slide  44,                                                               
was very  effective for many  types of addiction,  especially for                                                               
cannabis  and  alcohol  use  disorder.    He  said  that  it  was                                                               
essential  as a  component to  medication assisted  treatment for                                                               
opioid  use   disorder,  although  many  studies   reported  that                                                               
outcomes were  the same with or  without psychosocial counseling.                                                               
He stated that  psychosocial counseling as a  stand-alone did not                                                               
work on most disorder populations.                                                                                              
                                                                                                                                
2:36:05 PM                                                                                                                    
                                                                                                                                
DR.   SONKISS  spoke   about  slide   45,  "Medication   Assisted                                                               
Treatment,"   reporting  that   there   were  buprenorphine   and                                                               
methadone, which replaced  the opioids in the  addict's brain and                                                               
normalized  the imbalance  of receptor  densities.   He explained                                                               
that methadone, dosed correctly, should  not make the person high                                                               
and  that it  occupied the  receptor  for a  long time;  whereas,                                                               
buprenorphine  was  somewhat  safer  than methadone  as  it  only                                                               
opened the receptors  part way and made  overdose more difficult.                                                               
He addressed  naltrexone, which blocked  the receptor so  that an                                                               
addict could not get high.                                                                                                      
                                                                                                                                
DR. SONKISS  discussed slide 46, "Full  Agonist Treatment (ORT),"                                                               
declaring that  methadone was  a full agonist  with a  long life,                                                               
and  was  only  administered   in  specially  licensed  methadone                                                               
clinics,  unless  it  was  only  used for  pain  treatment.    He                                                               
explained   that  it   was  more   difficult  to   overdose  with                                                               
buprenorphine  and  that it  could  be  prescribed in  an  office                                                               
setting,  although  special  training was  necessary,  slide  47,                                                               
"Partial  Agonist Treatment  (ORT)."   He stated  that there  was                                                               
very  consistent  evidence  to  support the  efficacy  of  opioid                                                               
replacement  therapy   (ORT),  as  there  was   better  treatment                                                               
retention, fewer overdose deaths  because tolerance was not taken                                                               
away through  detoxification, and less hospitalization  with less                                                               
cost, slide 48, "Advantages of  ORT."  He acknowledged that there                                                               
was   a   potential   for  abuse   and   diversion,   slide   49,                                                               
"Disadvantages  of ORT."    He  added that  this  was a  lifelong                                                               
treatment for  many, and  there was  up to  a 95  percent relapse                                                               
rate within  12 months if taper  was attempted.  He  relayed that                                                               
many people felt this was only a substitute addiction.                                                                          
                                                                                                                                
2:40:31 PM                                                                                                                    
                                                                                                                                
DR. SONKISS  shared slides  50 -  51, "Antagonist  Treatment (not                                                               
ORT),"  and  declared that  this  was  a long-acting  injectable,                                                               
naltrexone.   He stated  that it was  popular in  policy circles,                                                               
especially for  those who favored abstinence,  and its advantages                                                               
included that it blocked the high  from opioids.  It also avoided                                                               
the  stigma of  ORT, as  it did  not replace  one addiction  with                                                               
another because it  blocked the receptor which the  drug of abuse                                                               
used to get a  person high.  He pointed out that  it could not be                                                               
abused  or  diverted.    He  explained  the  disadvantages:  oral                                                               
naltrexone did not  work; retention in treatment was  low, only 7                                                               
-  8 weeks  because, although  it blocked  the high,  it did  not                                                               
remove the  craving or make a  person feel normal; and,  it could                                                               
interfere with pain  treatment.  He emphasized  that addicts when                                                               
sober did not  feel normal, they only felt normal  when they were                                                               
using.   The idea behind ORT  was to make an  addict feel normal,                                                               
by normalizing the ratio between the receptors and the opioids.                                                                 
                                                                                                                                
2:42:58 PM                                                                                                                    
                                                                                                                                
DR. SONKISS  reported that multiple  studies supported  the cost-                                                               
effectiveness  of  ORT,   and  that  one  study   of  a  Medicaid                                                               
population  reported that  it  had  reduced emergency  department                                                               
visits  and  hospital  admissions for  those  beneficiaries  with                                                               
opioid  addiction, compared  with other  treatments, slides  52 -                                                               
53,  "Economic  Studies."    He recapped  that  addiction  was  a                                                               
learning  disorder  with  biological,  psychological  and  social                                                               
components; that historically,  biology had taken a  back seat in                                                               
public policies for  managing OUD, even as it had  been known for                                                               
more than 40 years that ORT  worked the best; that the science of                                                               
OUD pointed to biology as a  key component in managing the opioid                                                               
epidemic;  most people  with  OUD  could not  just  quit; and  he                                                               
suggested  to   manage  OUD  accordingly,  slide   54  "Take-Home                                                               
Messages."                                                                                                                      
                                                                                                                                
2:44:58 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JOHNSTON  asked if death was  possible from opioid                                                               
withdrawal.                                                                                                                     
                                                                                                                                
DR. SONKISS replied that, in  general, alcohol withdrawal was far                                                               
more dangerous  and more likely  to kill than  opioid withdrawal.                                                               
He added that a host  of concurrently existing medical conditions                                                               
could be  exacerbated from  opioid withdrawal  and could  lead to                                                               
mortality.   He offered  an example  that opioid  withdrawal does                                                               
kill in the corrections population.                                                                                             
                                                                                                                                
2:46:20 PM                                                                                                                    
                                                                                                                                
SENATOR  VON IMHOF  opined that  the  question now  was for  what                                                               
programs and funding mechanism to  address this issue.  She asked                                                               
if  there had  been a  scan of  existing state  programs, whether                                                               
these programs  were working  in silos,  were they  competing for                                                               
the  same  funding  sources, and  were  there  specific  targeted                                                               
programs which focused on specific populations.                                                                                 
                                                                                                                                
2:47:17 PM                                                                                                                    
                                                                                                                                
DR. SONKISS  replied that  he was  not sure if  there had  been a                                                               
study  of available  treatments.    He shared  that  it was  very                                                               
difficult  to  get  people into  chemical  dependency  treatment;                                                               
specifically,  it   was  very  difficult   to  get   people  into                                                               
medication  assisted  treatment  for  OUD,  as  there  were  long                                                               
waiting  lists,  qualification  was difficult,  and  it  required                                                               
special assessment with a fee.   He declared that there were many                                                               
hurdles for  patients which looked  relatively easy until  it was                                                               
understood how those  patients think and behave.   He stated that                                                               
he  did not  know if  there was  competition for  the same  payer                                                               
sources.    He  emphasized  that   abstinence  based  opioid  use                                                               
programs don't work  very well.  He  reported that rehabilitation                                                               
programs were a  $35 billion a year industry,  and these programs                                                               
had,  at best,  a  70 percent  relapse rate  with  an even  worse                                                               
relapse rate for OUD.                                                                                                           
                                                                                                                                
2:49:27 PM                                                                                                                    
                                                                                                                                
CHAIR  WILSON asked  about a  recommendation  for state  policies                                                               
regarding the use of relapse as a consequence.                                                                                  
                                                                                                                                
DR.  SONKISS  declared  that   behavioral  principles  were  very                                                               
difficult  to  incorporate  into  policy.   He  stated  that,  in                                                               
general,  behavior  was  much more  effectively  influenced  with                                                               
rewards than with  punishments.  He noted that  work with addicts                                                               
was  almost always  in  the context  of a  bad  consequence.   He                                                               
suggested that a  reward for abstinence as  opposed to punishment                                                               
for  relapse was  more likely  to be  effective, simply  based on                                                               
basic behavioral principles for  all behavioral modification.  He                                                               
offered his  belief that the  opioid use disorder  population was                                                               
very, very resistant  to feeling bad about  punishment, and would                                                               
not  respond  to  punishment  in  the same  way  as  the  general                                                               
population.    He  reported  that  the  best  means  to  maintain                                                               
sobriety was with medication assisted  treatment, and, instead of                                                               
waiting for failure after three  30-day rehabilitations, have the                                                               
person assessed for the severity  of the addiction and then start                                                               
ORT earlier  rather than  later.   He declared  that there  was a                                                               
tendency  toward fail  first policies  in the  insurance industry                                                               
and in regulation, pointing out  that this was the exact opposite                                                               
of the way the rest of medicine prescribed.                                                                                     
                                                                                                                                
2:52:55 PM                                                                                                                    
                                                                                                                                
SENATOR BEGICH  asked if a  substantial number of  the population                                                               
already arrived  with an inability  to be impacted  by behavioral                                                               
health decisions because of issues prior to the addiction.                                                                      
                                                                                                                                
DR. SONKISS  expressed caution for characterizing  any population                                                               
as  not being  able to  respond to  a benefit  from a  treatment,                                                               
specifically with  fetal alcohol  spectrum disorders (FASD).   He                                                               
acknowledged  that the  FASD population  struggled with  learning                                                               
from experiences.   He  declared that it  was necessary  to start                                                               
interventions early  and to be extremely  consistent and patient.                                                               
He stated that there "was no fast fix."                                                                                         
                                                                                                                                
SENATOR GIESSEL  expressed her  concern that  youth will  be more                                                               
readily exposed to  marijuana.  She asked if would  there be more                                                               
addiction because of the effect on  the youthful brain and was it                                                               
more impactful at younger ages.                                                                                                 
                                                                                                                                
DR. SONKISS replied that the brain  was growing up to 13 years of                                                               
age, at  which point the  signal to  noise ratio was  not optimal                                                               
for optimal adult functioning.  At  this age, the brain begins to                                                               
prune  neural connections,  to disconnect  them so  emotionality,                                                               
impulsivity, and  other cognitive  and behavioral  issues rectify                                                               
themselves.   He declared that  cannabinoids interfered  with the                                                               
neural  pruning  process,  and  that the  brains  of  kids  using                                                               
cannabis  did not  mature, so  that these  13 year  old cognitive                                                               
deficits  were carried  into adulthood.   He  strongly encouraged                                                               
that kids  not use it.   He stated that  no one knows  whether it                                                               
will be a gateway drug.                                                                                                         
                                                                                                                                
2:58:01 PM                                                                                                                    
                                                                                                                                
CHAIR  SPOHNHOLZ asked  if medically  assisted treatment  was the                                                               
most effective for  alcohol.  She also asked for  an example of a                                                               
positive reinforcement for someone who  was already a part of the                                                               
criminal justice system.                                                                                                        
                                                                                                                                
DR.  SONKISS   in  response,  agreed  that   medication  assisted                                                               
treatment was  the cornerstone for opioid  use disorder; however,                                                               
although alcohol  use disorder had some  medications that helped,                                                               
they  were  not effective  enough  to  be  the cornerstone.    He                                                               
declared   that    peer   support   groups    and   psycho-social                                                               
interventions were these cornerstones.                                                                                          
                                                                                                                                
DR. SONKISS  offered that  a temporary  time limited  increase in                                                               
privileges was  a good  approach to reward.   He  referenced some                                                               
studies  on  stimulant disorders  that  showed  a small  monetary                                                               
reward was also successful.                                                                                                     
                                                                                                                                
3:01:46 PM                                                                                                                    
                                                                                                                                
SENATOR MICCICHE asked for a reading list to be better versed on                                                                
opioid use.                                                                                                                     
                                                                                                                                
DR. SONKISS directed attention to slide 55, "Further reading."                                                                  
He said that correctional populations were more difficult to                                                                    
work with.                                                                                                                      
                                                                                                                                
3:03:22 PM                                                                                                                    
                                                                                                                                
CHAIR WILSON acknowledged the need to make policy using meta-                                                                   
analysis.                                                                                                                       
                                                                                                                                
3:04:18 PM                                                                                                                    
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
There being no further business before the committee, the joint                                                                 
meeting of the House and Senate Health and Social Services                                                                      
Standing Committees meeting was adjourned at 3:04 p.m.                                                                          

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