Legislature(2019 - 2020)CAPITOL 106

05/09/2019 03:00 PM HEALTH & SOCIAL SERVICES

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Audio Topic
03:06:01 PM Start
03:06:37 PM Presentation(s): Substance Abuse Treatment System
04:59:52 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Presentation: Substance Abuse Treatment System TELECONFERENCED
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                          May 9, 2019                                                                                           
                           3:06 p.m.                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Ivy Spohnholz, Co-Chair                                                                                          
Representative Tiffany Zulkosky, Co-Chair                                                                                       
Representative Matt Claman                                                                                                      
Representative Harriet Drummond                                                                                                 
Representative Geran Tarr                                                                                                       
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Representative Sharon Jackson                                                                                                   
Representative Lance Pruitt                                                                                                     
                                                                                                                                
OTHER LEGISLATORS PRESENT                                                                                                     
                                                                                                                                
Representative Bryce Edgmon                                                                                                     
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
PRESENTATION(S): SUBSTANCE ABUSE TREATMENT SYSTEM                                                                               
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
No previous action to record                                                                                                    
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
ANDY JONES, Director                                                                                                            
Office of Substance Misuse and Addiction Prevention (OSMAP)                                                                     
Office of the Commissioner                                                                                                      
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  As part of the presentations on the                                                                      
substance abuse treatment system, provided a PowerPoint                                                                         
slideshow titled "Addressing Alaska's Poly-Substance Epidemic."                                                                 
                                                                                                                                
GENNIFER MOREAU-JOHNSON, Acting Director                                                                                        
Division of Behavioral Health                                                                                                   
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION  STATEMENT:    As  part   of  the  presentations  on  the                                                            
substance   abuse   treatment  system,   provided   a   PowerPoint                                                              
slideshow titled "Division of Behavioral Health."                                                                               
                                                                                                                                
BRADLEY GRIGG, Chief Behavioral Health Officer                                                                                  
Bartlett Regional Hospital                                                                                                      
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:    As  part   of  the  presentations  on  the                                                            
substance   abuse  treatment  system,   described  what   Bartlett                                                              
Regional Hospital is seeing in the patients it is serving.                                                                      
                                                                                                                                
SHERRIE WILSON HINSHAW, President & CEO                                                                                         
Volunteers of America-Alaska (VOA)                                                                                              
Anchorage, Alaska                                                                                                               
POSITION  STATEMENT:    As  part   of  the  presentations  on  the                                                            
substance abuse treatment system, described what VOA is doing.                                                                  
                                                                                                                                
LANCE JOHNSON, Director                                                                                                         
Behavioral Health Services (BHS)                                                                                                
Norton Sound Health Corporation (NSHC)                                                                                          
Nome, Alaska                                                                                                                    
POSITION  STATEMENT:    As  part   of  the  presentations  on  the                                                            
substance abuse treatment system, described what NSHC is doing.                                                                 
                                                                                                                                
ADELE LANDROCHE, Advocate                                                                                                       
Anchorage, Alaska                                                                                                               
POSITION  STATEMENT:    As  part   of  the  presentations  on  the                                                            
substance  abuse treatment  system,  provided  the perspective  of                                                              
being the mother of children with additions.                                                                                    
                                                                                                                                
DOUG WOOLIVER, Deputy Administrative Director                                                                                   
Alaska Court System                                                                                                             
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:    As  part   of  the  presentations  on  the                                                            
substance  abuse  treatment  system,  discussed the  role  of  the                                                              
therapeutic courts.                                                                                                             
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
3:06:01 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  IVY  SPOHNHOLZ  called   the  House  Health  and  Social                                                            
Services  Standing  Committee  meeting   to  order  at  3:06  p.m.                                                              
Representatives  Claman, Drummond,  Zulkosky,  and Spohnholz  were                                                              
present  at the call  to order.   Representative  Tarr arrived  as                                                              
the  meeting was  in  progress.   Representative  Edgmon was  also                                                              
present.                                                                                                                        
                                                                                                                                
^PRESENTATION(S): SUBSTANCE ABUSE TREATMENT SYSTEM                                                                              
       PRESENTATION(S): SUBSTANCE ABUSE TREATMENT SYSTEM                                                                    
                                                                                                                              
3:06:37 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  announced that  the  only order  of  business                                                              
would be a presentation on the Substance Abuse Treatment System.                                                                
                                                                                                                                
CO-CHAIR  SPOHNHOLZ noted  the  committee has  been  working on  a                                                              
series of crime  bills for much of  the last month.   She said she                                                              
feels that  any conversation about  crime is incomplete  without a                                                              
discussion  about  the need  to  address addiction,  which  drives                                                              
most of the crime in the state of Alaska.                                                                                       
                                                                                                                                
3:07:35 PM                                                                                                                    
                                                                                                                                
ANDY JONES,  Director, Office  of Substance  Misuse and  Addiction                                                              
Prevention  (OSMAP), Office  of  the Commissioner,  Department  of                                                              
Health  and   Social  Services   (DHSS),  provided   a  PowerPoint                                                              
slideshow  titled "Addressing  Alaska's Poly-Substance  Epidemic."                                                              
Displaying  slide 2, he  described the  magnitude of the  problem.                                                              
He said  drug overdoses  are now the  leading cause  of accidental                                                              
death in  the U.S.,  exceeding automobile deaths.   In  2016, drug                                                              
overdoses killed  65,000 Americans  - more in  a years'  time than                                                              
were killed in  the Vietnam, Iraq, and Afghanistan  wars combined.                                                              
In 2017, the  number increased to  70,237.  In 1999, the  rate was                                                              
about  6.1  deaths  per  100,000  in population  and  in  2018  it                                                              
skyrocketed to 21.7 per 100,000.                                                                                                
                                                                                                                                
3:09:58 PM                                                                                                                    
                                                                                                                                
MR. JONES  moved to  slide [3] and  explained that epidemics  come                                                              
in waves and this  epidemic is probably the third  wave to happen.                                                              
He  said  driving   factors  in  this  epidemic   include  medical                                                              
fallacies that  resulted in over  prescribing, such as  being able                                                              
to measure  pain objectively and  the mentality that  tolerance is                                                              
just  under-dosing.   Another  fallacy  is  pseudo-addiction,  the                                                              
thought  that  persons  who  display   drug-seeking  behavior  are                                                              
simply in  pain and  need more  opioids.   These types  of thought                                                              
come from inadequate training in pain management for doctors.                                                                   
                                                                                                                                
MR. JONES displayed  slide 4 and said scaring him  the most is the                                                              
transition  from  the prescribed  opioid  problem  to the  illicit                                                              
street drug  problem of heroin,  fentanyl, and carfentanil;  three                                                              
out of  four new heroin users  report having misused  prescription                                                              
opioids.   Too  often people  with a  sports or  other injury  are                                                              
prescribed  opioids and  then become  addicted  to the  substance.                                                              
Heroin  doesn't require  a prescription  and the  street price  of                                                              
heroin is much  cheaper than prescription opioids.   The danger is                                                              
a  higher risk  of overdose  from  street drugs  because they  can                                                              
have unknown ingredients.   For example, recently  law enforcement                                                              
officials seized  fentanyl that was pill pressed  in "Mallinckrodt                                                              
30s."  A  pain patient unable  to get a prescription  anymore, and                                                              
who  bought   this  pill   on  the  street   thinking  it   was  a                                                              
Mallinckrodt  30, would  face almost  instant  death because  this                                                              
pill was  pure fentanyl.   Dealers do this  because it  is cheaper                                                              
for fentanyl  and lots of money  can be made by pill  pressing it.                                                              
He pointed out  that morphine is dangerous, heroin  very dangerous                                                              
[50 times], and fentanyl even more dangerous [100 times].                                                                       
                                                                                                                                
3:13:32 PM                                                                                                                    
                                                                                                                                
MR.  JONES turned  to  slide  5, a  graph  of drug  incidents  for                                                              
opioids and methamphetamine  provided by the Department  of Public                                                              
Safety.   The  numbers for  incidences in  2018 are  down, but  he                                                              
explained, current cases  are still open, so by the  time they are                                                              
closed the numbers  will remain close.  Methamphetamine  is one of                                                              
Alaska's biggest  problems today.   It is no longer  local cooking                                                              
in  labs -  it is  coming from  Mexico  in very  high potency  and                                                              
purity  rates.     e're moving  towards more  of a  poly-substance                                                              
approach when it  comes to our response," he continued.     es, we                                                              
focused a  lot on opioids  and yes we still  do, and the  money is                                                              
there; whenever we  secure money, we're looking at  trying to make                                                              
our  resources,  our capabilities,  our  capacities,  as broad  as                                                              
possible."                                                                                                                      
                                                                                                                                
MR.  JONES showed  slide  6 and  said  alcohol  is still  Alaska's                                                              
biggest problem.   Methamphetamine  is big,  heroin is  still big,                                                              
and cocaine is starting to come back.                                                                                           
                                                                                                                                
MR.  JONES  addressed  slide  7.   He  explained  it  is  a  poly-                                                              
substance  misuse epidemic.   Agencies  are now  focusing on  what                                                              
methamphetamine  treatment looks  like and  what the  interdiction                                                              
processes  look like  as  an attempt  to get  ahead  of the  game.                                                              
About  95 percent  of the  individuals in  Alaska who  die from  a                                                              
drug overdose have multiple substances in their bodies.                                                                         
                                                                                                                                
3:15:35 PM                                                                                                                    
                                                                                                                                
MR.  JONES  displayed slide  8  and  explained that  the  depicted                                                              
response  structure to the  opioid epidemic  is Alaska's  incident                                                              
command system and  it takes all state agencies.   He said a state                                                              
disaster was  declared in  [2017] because  people had  died, there                                                              
was crime  and property destruction  in relation to  the epidemic,                                                              
and  communities were  asking for  help.   To this  day Alaska  is                                                              
pushing more  naloxone than  any other  state in  the U.S.  and is                                                              
saving  many lives.    Alaska's  system includes  locals,  tribal,                                                              
federal,   and  [non-governmental]   state   partners  to   ensure                                                              
communication and inclusion  of the people who are  doing the work                                                              
on the  ground.   Approaches within  the system  include a  multi-                                                              
agency  approach, a  multi-agency coordination  (MAC) group  where                                                              
the  commissioners  come  together for  monthly  briefings,  joint                                                              
information  systems to  help with  coordination, and  utilization                                                              
of the  Alaska Criminal Information  and Analysis Center  which is                                                              
with the  troopers and that is  fed to the incident  commander and                                                              
deputy  incident   commander.    Mr.  Jones  said   this  provides                                                              
information on  the drug trends  that are  going on and  helps him                                                              
as an  individual to  focus his  prevention treatment  efforts and                                                              
where to put resources.                                                                                                         
                                                                                                                                
MR. JONES spoke  to slide 9. Cross-sector collaboration,  he said,                                                              
is  extremely important  because without  all the  pieces and  the                                                              
players together there will be duplicative efforts.                                                                             
                                                                                                                                
3:18:35 PM                                                                                                                    
                                                                                                                                
MR.  JONES  moved to  slide  10  and elaborated  on  the  response                                                              
framework.  When  Alaska's response was started in  2007, he said,                                                              
only a  few states  had declared  disasters.   In 2016  the Alaska                                                              
Opioid  Policy Task  Force was  formed  and its  [recommendations]                                                              
were released  in [January  2017].   However, locals informed  him                                                              
that it was  a policy document  meant for people like  himself and                                                              
legislators, not  communities.  Something needed to  be changed to                                                              
make it work  for communities, but  there needed to be  a response                                                              
framework.   The question was whether  DHSS should work  on a plan                                                              
right away or save  lives.  The decision was to  save lives and it                                                              
began by saturating  the market with Narcan kits  [medication that                                                              
temporarily   blocks  or   reverses  the   effects  of   opioids].                                                              
[Addiction]  is a  chronic condition  of  the brain,  not a  moral                                                              
failing,  and people  need help  and often more  than one  chance.                                                              
Drug disposal bags  were distributed to reduce  prescription drugs                                                              
in houses;  these bags contain  activated charcoal to  which water                                                              
and the substance are added and the substance is then destroyed.                                                                
                                                                                                                                
MR. JONES  continued and  drew attention to  the graphic  on slide                                                              
10.   He explained  that tertiary  prevention [acute health  event                                                              
control and prevention]  is naloxone and working  with syringe and                                                              
needle exchanges.   He  said these  exchanges have been  extremely                                                              
helpful  because  Alaska  doesn't have  drug  paraphernalia  laws.                                                              
The  choice  is  to  either have  these  exchange  sites  or  have                                                              
needles  everywhere, which  can  cause hepatitis  outbreaks.   The                                                              
exchange sites  also help  to connect with  the individual  who is                                                              
suffering.   The secondary  prevention [chronic disease  screening                                                              
and  management] is  increasing  screening,  reducing the  stigma,                                                              
and understanding  that addiction is  a chronic disease.   Primary                                                              
prevention  [environmental   controls  and  social   determinants]                                                              
includes  things  like  adverse  childhood  experience,  judicious                                                              
prescribing, and  doing upstream  prevention that is  being talked                                                              
about and worked on right now.                                                                                                  
                                                                                                                                
3:21:29 PM                                                                                                                    
                                                                                                                                
MR. JONES discussed  the prevention resources listed  on slide 11.                                                              
He said DHSS  has secured quite  a bit of funding  for prevention.                                                              
The  Alaska Partnerships  for Success  is a  coalition across  the                                                              
state  that comes  together to  focus on  substance use  disorders                                                              
and  misuse.    The Community  Substance  Misuse  and  Abuse  Task                                                              
Forces are  local citizens who come  together, and they  have been                                                              
phenomenal  is making  changes.   The Office  of Substance  Misuse                                                              
and  Addiction  Prevention  (OSMAP)  was  created,  which  focuses                                                              
solely  on  integrating  public  health approaches  to  reduce  or                                                              
minimize  subsistence use  disorders.   Other  resources are  Data                                                              
Dashboards and the department's Opioids in Alaska website.                                                                      
                                                                                                                                
MR. JONES  spoke to slide 12  regarding the Alaska  State Troopers                                                              
and  the  Statewide Drug  Enforcement  Units.    He said  this  is                                                              
important because  while talking  about treatment there  must also                                                              
be talk  about enforcement and the  criminal.  Alaska  cannot just                                                              
arrest its  way out, but  the state can't  just treat its  way out                                                              
of this either,  it's a balanced  approach.  He advised  that drug                                                              
trafficking  organizations  (DTOs)  and cartels  are  coming  into                                                              
Alaska.    Enforcement   units  need  to  be  focusing   on  those                                                              
individuals  who  are  feeding  on  the  misery  of  Alaskans  and                                                              
hooking Alaskans  to these substances,  while DHSS  in partnership                                                              
with  the troopers  and  other  agencies  works on  enhancing  and                                                              
building the capacities  of treatment capability.   In addition to                                                              
the  troopers  there  are narcotics  interdiction  teams.    These                                                              
teams are made up of local, tribal, state, and federal agencies.                                                                
                                                                                                                                
3:23:45 PM                                                                                                                    
                                                                                                                                
MR. JONES  displayed slide 13 and  noted that about 80  percent of                                                              
the  offenders  in  custody with  the  Department  of  Corrections                                                              
(DOC)  struggle  with substance  abuse.    Thirty percent  of  the                                                              
offenders who are  assessed report abuse of opioids,  probably one                                                              
of  the state's  biggest populations  when it  comes to  substance                                                              
use disorders.   The Department  of Corrections has  been building                                                              
a comprehensive  substance abuse program.  Currently,  vivitrol is                                                              
used   for   medication-assisted   treatments  (MATs)   in   DOC's                                                              
programs.   Upon  re-entry or  release, an  offender will  receive                                                              
this  shot if  he or  she qualifies,  and then  the offender  goes                                                              
through  the re-entry  service programs  and is  connected to  the                                                              
community.   The DOC  is looking  at increasing  the footprint  of                                                              
MAT, which  could include things  like bridging with  methadone or                                                              
integration  of suboxone.   Getting offenders  treatment  and care                                                              
from day  one is much better  than giving them treatment  and care                                                              
a month before release.                                                                                                         
                                                                                                                                
MR. JONES turned  to slide 14 and discussed  policy, partnerships,                                                              
outcomes, and  results.   Regarding partnerships  he said  DHSS is                                                              
currently working  to implement  the patient Voluntary  Non-opioid                                                              
Directive that  was signed into law  by a previous governor.   The                                                              
department  now   has  the  authority  to  emergency   schedule  a                                                              
substance  if it's  on the  federal  list, allowing  DHSS to  take                                                              
immediate action if  a trend is being seen in  a certain substance                                                              
coming through a  community.  First-time opioid  prescriptions are                                                              
limited to  no more than a  seven-day supply with  exceptions; the                                                              
exceptions help with  rural Alaska.  As of 7/1/18,  the controlled                                                              
substance  prescription  database   was  required  to  be  updated                                                              
daily, which has been instrumental.                                                                                             
                                                                                                                                
3:26:05 PM                                                                                                                    
                                                                                                                                
MR. JONES addressed  slide 15 regarding community  coalitions.  He                                                              
said isolation  fuels addiction  and community  provides  the cure                                                              
and  the groups  listed on  the  slide are  the true  boots-on-the                                                              
ground individuals.   [Mat Su Opioid Task Force,  Anchorage Opioid                                                              
Task  Force,  Juneau  Opioid Work  Group,  Fairbanks  Opioid  Work                                                              
Group,  Southern  Kenai  Peninsula,   Change  4  Kenai  Coalition,                                                              
Aleutian  Pribilof  Islands  Opioid   and  Substance  Misuse  Task                                                              
Force, Ketchikan  Substance Abuse  Task Force, Bristol  Bay Opioid                                                              
Task Force, THRIVE Mat Su.]                                                                                                     
                                                                                                                                
MR.  JONES  moved  to  slide  16  and  discussed  prevention  with                                                              
partnerships.   He  reported that  Project HOPE  (HOPE stands  for                                                              
Harm  reduction,  Overdose Prevention,  Education)  currently  has                                                              
102 overdose  response programs;  has distributed 18,000  overdose                                                              
rescue kits;  and has  saved over  260 lives.   He explained  that                                                              
the number  of lives  saved is much  higher than  260, but  260 is                                                              
the  documented number.    Regarding the  medication  deactivation                                                              
disposal   bags,  he   reported   that  46,000   bags  have   been                                                              
distributed  since 2017,  which represents  a potential  reduction                                                              
of over 2 million  pills in the state.  In addition,  DHSS and the                                                              
Department  of   Education  and  Early  Development   developed  a                                                              
teaching module  called Opioids and  Opioids Epidemic 101  that is                                                              
available  to  teachers   and  parents.    There   is  also  first                                                              
responder  training,  which  is   a  compassion  fatigue  training                                                              
because  first responders  get exhausted  from  seeing this  every                                                              
day   and  often   seeing   the  same   individual.     As   well,                                                              
consideration  is being  given to  implementing  a Fatal  Overdose                                                              
Death Review  Committee that  would look  at the  cases to  see if                                                              
policy and prevention are working.                                                                                              
                                                                                                                                
3:28:26 PM                                                                                                                    
                                                                                                                                
MR.  JONES spoke  to slide  17 regarding  partnerships,  outcomes,                                                              
and results  of enforcement.   He  explained that the  designation                                                              
of  a  High  Intensity Drug  Trafficking  Area  (HIDTA)  has  been                                                              
received, which  is important  and can be  equated to  the special                                                              
operations of  narcotics.  This  designation brings in  about $2.5                                                              
million annually  from the  U.S. Office  of National Drug  Control                                                              
Policy.   This funding  goes to the  various task forces  outlined                                                              
on  [slide 15],  thereby  increasing the  footprint  to do  things                                                              
like  better interdiction  and information  sharing so  it can  be                                                              
understood  what  is being  seized  throughout the  entire  state.                                                              
Better private  sector partnerships  are also being  developed and                                                              
paying for  overtime for officers.   A director has been  hired to                                                              
build  the system  in partnership  with DHSS's  local, state,  and                                                              
federal partners.                                                                                                               
                                                                                                                                
MR.   JONES  displayed   side   18   and  elaborated   about   the                                                              
partnerships, outcomes,  and results  of strategic direction.   He                                                              
said  DHSS  traveled   to  15  communities  in   2018  to  conduct                                                              
Community Caf?  events to  build a  Statewide Opioid Action  Plan.                                                              
The department  also went to  other communities and  held townhall                                                              
events.  In the  Community Caf? events DHSS spent  one day meeting                                                              
with the  medical community  to understand  what the barriers  and                                                              
gaps  are and  another day  meeting with  community members  about                                                              
prevention,  treatment,  re-entry,  criminal  justice  population,                                                              
what is currently  in the community, what's not  working, what are                                                              
the barriers  to change, and  what is needed.   The  University of                                                              
Alaska Anchorage (UAA)  and DHSS compiled this data  and then DHSS                                                              
brought in  100 experts  from across  the state  to spend  two and                                                              
half days building  a plan.  The plan is a  long-term approach and                                                              
will  be used  to help  fund future  coalition activities  through                                                              
federal grants.                                                                                                                 
                                                                                                                                
3:31:00 PM                                                                                                                    
                                                                                                                                
MR. JONES  turned to  slide 19 regarding  the preliminary  results                                                              
of the number  of opioid-related overdose  deaths in the  U.S.  He                                                              
reported that  the percent-age-adjusted  rate in deaths  increased                                                              
from 6.1 in  1991 to 21.7 in  2017.  In 2018, Alaska  saw downward                                                              
trends across  the board.   For example,  in drug overdose  deaths                                                              
in 2015,  Alaska had  an age-adjusted  rate of  16 percent,  which                                                              
increased  to 17 percent  in 2016,  then increased  again  to 19.3                                                              
percent  in  2017, and  in  2018  it decreased  to  11.9  percent.                                                              
While  the rest  of the  U.S. is  battling  fentanyl, Alaska  went                                                              
from 28  fentanyl deaths in  2017 to 7  deaths in 2018.   However,                                                              
Alaska still  has lots of  people who need  to get  into treatment                                                              
and many  people are still  dying.  He  attributed the  decline to                                                              
the combination  of hard  work and sense  of community  in Alaska,                                                              
the partnerships  helping  to remove  the stigma  of use,  and the                                                              
use  of naloxone.    The downward  trend,  he  said, doesn't  mean                                                              
Alaska can  sit back and  think the job  is done, it  means Alaska                                                              
needs to remain diligent.                                                                                                       
                                                                                                                                
MR.  JONES discussed  the next  steps outlined  on slide  20.   He                                                              
said these  next steps  include a transition  out of  the Incident                                                              
Command  System  (ICS)  and  going   more  towards  the  long-term                                                              
recovery  approach.   Execution  of  the Statewide  Opioid  Action                                                              
Plan  needs to be  continued  as part  of the next  steps.   Other                                                              
steps  include implementation  and  building  of  the Alaska  High                                                              
Intensity  Drug  Trafficking  Area.    As  well,  the  next  steps                                                              
include  continuing  to  secure  more  federal  funding  to  build                                                              
capability and capacity.                                                                                                        
                                                                                                                                
3:33:25 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  TARR drew  attention  to slide  7 regarding  poly-                                                              
substance misuse and  noted that in her work in  Anchorage she has                                                              
heard the term "garbage  addict" for people who will  use any kind                                                              
of  substance that  they  can  obtain.   She  asked  how a  person                                                              
addicted to  alcohol is  defined and what  "addicted to"  means in                                                              
that context.                                                                                                                   
                                                                                                                                
MR. JONES  replied that a  person using multiple  substances might                                                              
get counted  more than once.   He said  he would consult  with the                                                              
state medical  officer and get back  with an answer as  to how the                                                              
medical officer picks  a substance and defines it.   When multiple                                                              
substances are  found in the body  it often will be  attributed to                                                              
poly-substance.   Regarding "garbage addict," he  said he personal                                                              
believes  that  this  term  would  put  more of  a  stigma  on  an                                                              
individual.   He said he doesn't  even like the term  "addict" and                                                              
would  prefer  it  be called  "somebody  who  is  struggling  with                                                              
substances" to reduce  stigma and prevent these  people from being                                                              
returned to the shadows.                                                                                                        
                                                                                                                                
REPRESENTATIVE TARR  pointed out  that people who  are compromised                                                              
by  their health  conditions might  be willing  to use  substances                                                              
that  are typically  considered  recreational  drugs, for  example                                                              
anti-anxiety  medication,  as  opposed   to  substances  that  are                                                              
considered recreational drugs.                                                                                                  
                                                                                                                                
MR. JONES  concurred.   A problem is  being seen with  stimulants,                                                              
he  said.   People don't  understand what  a stimulant  can do  if                                                              
misused and  what a stimulant  can do if  misused with  an opioid.                                                              
That  is  some of  the  messaging  that  DHSS  wants to  get  out.                                                              
Through  partnering  with  methadone   clinics  and  drug  testing                                                              
companies,  things like  gabapentin are  coming up  on the  radar.                                                              
Through this  public health work, radar  is being kept  on all the                                                              
different systems  to see what  the trends  are and to  then begin                                                              
messaging and education prior to enforcement.                                                                                   
                                                                                                                                
3:36:57 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ  said one  of the things  she learned  from Dr.                                                              
Butler  was  the value  of  medication-assisted  treatment  (MAT),                                                              
particularly  for  opioid  addition.     She  inquired  about  the                                                              
barriers to accessing medication-assisted treatment.                                                                            
                                                                                                                                
MR. JONES  responded that  there is  a definite stigma  associated                                                              
with treatments.   There  has been a  movement from  substance use                                                              
as a  stigma to the treatment  use and that  feels like more  of a                                                              
battle in  the communities.   What  he means  by that is  suboxone                                                              
versus vivitrol,  abstinence versus MAT,  and he sees that  as one                                                              
of  the  biggest   barriers  other  than  building   capacity  and                                                              
capabilities   on  services   across  the   state  and  doing   it                                                              
appropriately  with  the  medication  aspect  of  it  as  well  as                                                              
assisted therapy.   It must be ensured that the  providers who are                                                              
popping up  are providing a  complementary service.   Getting past                                                              
the stigma of MAT is needed.                                                                                                    
                                                                                                                                
3:38:33 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  noted  that   the  history  of  the  recovery                                                              
community  is an  abstinence-only  model, which  doesn't work  for                                                              
everyone because  moving away from  dependence is  a physiological                                                              
process  that takes  a lot  of time.   Dr. Butler  related to  her                                                              
that  diabetics wouldn't  be  told they  didn't  need insulin  and                                                              
they should just  muscle through it.  The same is  true for people                                                              
who are  experiencing withdrawal  from opioids; the  person's body                                                              
must change significantly  and access to medication  can be access                                                              
to a normal productive  healthy life.  She asked  whether there is                                                              
anything beyond vivitrol for MAT in Alaska's prisons.                                                                           
                                                                                                                                
MR. JONES answered  that vivitrol is currently the  only thing and                                                              
he  would love  to see  this changed  in  Alaska's prisons;  other                                                              
states  have  been  introducing  suboxone.   He  related  that  he                                                              
shadowed  someone  who was  released  from  jail and  this  person                                                              
struggled  with going  to treatment  and having  a job because  it                                                              
was very  difficult.   He said  he thinks  that if  MAT and  other                                                              
treatment  were begun  as soon as  a person  entered jail,  rather                                                              
than a month before release, the recidivism rate would drop.                                                                    
                                                                                                                                
3:40:49 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE DRUMMOND  requested that an easier-to-read  copy of                                                              
the response  structure on slide  8 be provided to  the committee.                                                              
She said  numerous constituents  have contacted  her because  drug                                                              
takeback doesn't  happen every  day and  she has distributed  drug                                                              
disposal bags  to these constituents.   She  asked how to  get the                                                              
word out  about the drug disposal  bags and where to  obtain them.                                                              
She further  asked where the disposal  bags should be  disposed of                                                              
once they have been filled with medications.                                                                                    
                                                                                                                                
MR.  JONES agreed  to provide  the  committee with  copies of  the                                                              
appropriate  slides  on response  structure.    He said  he  would                                                              
provide drug  disposal bags  to those  committee members  who send                                                              
him their email addresses.                                                                                                      
                                                                                                                                
REPRESENTATIVE  DRUMMOND asked  whether drug  disposal bags  could                                                              
be made available at all pharmacies in the state.                                                                               
                                                                                                                                
MR JONES  replied that there  is no sustainable  long-term funding                                                              
source  for  this.   He  said  he  would like  for  pharmacies  to                                                              
purchase the  bags and provide them  for discount or free,  but it                                                              
may not make sense  for a business model.  However,  it would make                                                              
sense  for community-based  models.   He said  DHSS is having  the                                                              
different coalitions  distribute  the bags because  it is  a great                                                              
way for  them to connect with  individuals who are  struggling and                                                              
with  individuals  who don't  understand  the opioid  epidemic  or                                                              
addiction.   If he had unlimited  funding and an  unlimited supply                                                              
of the bags, he would have them everywhere.                                                                                     
                                                                                                                                
3:44:17 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  expressed her surprise at hearing  there is a                                                              
stigma  around going  to treatment.   She requested  Mr. Jones  to                                                              
elaborate further.                                                                                                              
                                                                                                                                
MR.  JONES  responded   that  the  recovery  community   was  very                                                              
abstinence based  and everyone is learning  as they go  along.  He                                                              
said treatment  plans are  extremely important  in this  epidemic.                                                              
Somebody who  has been using for  30 years may be on  suboxone for                                                              
forever, but  maybe somebody  who has used  for 15-20  years could                                                              
be on  suboxone under  a step-down plan.   The recovery  community                                                              
has  been  asking  for  that.   In  the  criminal  justice  world,                                                              
abstinence  based is  a lot  more  eye opening  and probably  more                                                              
appropriate than  a non-abstinence based.  When  courts across the                                                              
country  tell  someone  on  suboxone  to  taper  off  and  get  on                                                              
vivitrol it  puts a stigma on people  and doesn't work  and is why                                                              
there  is a  high  failure rate.    He noted  that  DHSS has  been                                                              
working on use and now it is working on treatment.                                                                              
                                                                                                                                
3:46:27 PM                                                                                                                    
                                                                                                                                
GENNIFER MOREAU-JOHNSON,  Acting Director, Division  of Behavioral                                                              
Health,  Department   of  Health   and  Social  Services   (DHSS),                                                              
provided  a PowerPoint  slideshow titled  "Division of  Behavioral                                                              
Health."   Displaying  slide 1,  she explained  she will  describe                                                              
how  the   division  oversees  services,   how  it   is  currently                                                              
delivering  services across  Alaska,  how it  got  here, what  the                                                              
challenges  are,  and  where  the   division  is  looking  to  go.                                                              
Addressing slide  2, she said  the programs and services  overseen                                                              
by  the division  include:    Prevention and  Early  Intervention,                                                              
Alcohol   Safety   Action  Program,   Tobacco   Compliance   Unit,                                                              
Treatment  and Recovery  Grants  Services,  and Behavioral  Health                                                              
Medicaid Services.   She noted that, for the division,  the use of                                                              
the  word  "prevention"  is a  specific  reference  to  preventing                                                              
these conditions before the behavior starts.                                                                                    
                                                                                                                                
3:48:20 PM                                                                                                                    
                                                                                                                                
MS. MOREAU-JOHNSON  showed slide 3 regarding Prevention  and Early                                                              
Intervention.  She  said the division engages with  communities to                                                              
determine community  needs and form coalitions.   These coalitions                                                              
and grantees use  the Strategic Prevention Framework  (SPF), which                                                              
is from  the federal  Substance Abuse  and Mental Health  Services                                                              
Administration (SAMHSA).   Through these SPFs,  coalitions assess,                                                              
plan,   strategize,   implement,  and   evaluate   community-based                                                              
services.   Every community  and coalition  is different,  but one                                                              
example is the  positive messaging of the Be(You)  Initiative that                                                              
is  aimed  at preventing  underage  drinking  by  challenging  the                                                              
misconception  that most  teens  drink.   She said  78 percent  of                                                              
Alaskan  teens  do  not  drink  alcohol  and  noted  that  Be(You)                                                              
campaigns are active  in ten locations throughout  Alaska.  Moving                                                              
to slide 3, she played a video from the Be(You) Initiative.                                                                     
                                                                                                                                
3:50:30 PM                                                                                                                    
                                                                                                                                
 MS.  MOREAU-JOHNSON noted  the  Be(You) Initiative  is funded  by                                                              
state dollars  through the Division  of Behavioral Health.   These                                                              
state  dollars leverage  other funders  of  the initiative,  which                                                              
are:   Alaska Native Tribal  Health Consortium, the  Mat-Su Health                                                              
Foundation,  Rasmuson Foundation,  Alaska Wellness Coalition,  and                                                              
the Mental Health  Trust Authority.  With all  those funders there                                                              
is a keen  interest in knowing how  well it's doing and  the Youth                                                              
Risk  Behavior Survey  (YRBS)  assesses how  well  it is  working.                                                              
This survey, done  every two years, asks specific  questions about                                                              
teen drinking.                                                                                                                  
                                                                                                                                
MS.  MOREAU-JOHNSON  said  that  during  fiscal  year  (FY)  2020,                                                              
statewide and local  community partners will assemble  a statewide                                                              
alcohol  prevention  alliance  to  revise  and  to  implement  the                                                              
moving of  prevention upstream.   That is  the strategic  plan for                                                              
underage  drinking  and  adult   binge  and  heaving  drinking  in                                                              
Alaska.  It is  anticipated that the plan will  include community-                                                              
based  intervention,  statewide  intervention,  mass-reach  health                                                              
communications,   surveillance   and  evaluation   infrastructure,                                                              
administration and  management, and will promote  screening, brief                                                              
intervention, and referral to treatment.                                                                                        
                                                                                                                                
3:52:12 PM                                                                                                                    
                                                                                                                                
MS. MOREAU-JOHNSON  stated that the  graphic on slide 5  shows the                                                              
intersection  and  efforts  around substance  use  disorder  (SUD)                                                              
treatment,  which is  when  the problem  appears.   She  explained                                                              
that  primary   prevention   is  the  effort   to  prevent   these                                                              
conditions from ever  happening and SUD is the  early intervention                                                              
of  the continuum.    The  graphic  depicts the  intersection  and                                                              
efforts  across  various  components  that  are all  part  of  the                                                              
system.    These  components  are  made up  of  services  that  an                                                              
individual may have  contact with and that identify  the person as                                                              
someone  who needs  help.   They  are the  treatment and  recovery                                                              
providers  and  services,  the agencies  that  provide  the  grant                                                              
funding, agencies  that receive  the grant funding,  data sources,                                                              
and data  sets.  The  graphic identifies  these at the  community,                                                              
state,  and federal  levels -  the components  interact with  each                                                              
other within  a ring and flow  both inward and outward  within the                                                              
circle.  For example,  data about an individual may  end up at the                                                              
federal  level in  the Treatment  Episode Data  Set (TEDS),  while                                                              
funding from  the federal  level gets  funneled through  the state                                                              
down to the individual.                                                                                                         
                                                                                                                                
3:53:46 PM                                                                                                                    
                                                                                                                                
MS. MOREAU-JOHNSON  requested committee members to  keep the image                                                              
of this  graphic in mind  as they look  at slide 6,  which depicts                                                              
the distribution of  SUD funding by service area  and program type                                                              
across  Alaska.   She said  slide  6 illustrates  much effort  and                                                              
great achievement  on the part  of the state, federal  government,                                                              
and provider  agencies  in piecing  together a  system.  But,  she                                                              
noted,  it  also represents  a  system  that is  pieced  together.                                                              
Using  state  general  funds,  a myriad  of  federal  grants,  and                                                              
Medicaid   -  each   with  its   own   reporting  and   management                                                              
requirements  and each with  its own set  of unique  regulations -                                                              
the result  is that there are  these services, which is  good, but                                                              
service  providers   are  struggling  to   keep  on  top   of  the                                                              
administration and  yet still provide  the service.  It  also ends                                                              
up with  an uneven distribution  based on a variety  of influences                                                              
for how these how these services are available across the state.                                                                
                                                                                                                                
MS.  MOREAU-JOHNSON continued  discussing  slide  6, pointing  out                                                              
that  Alaska has  26 outpatient  programs  specifically funded  by                                                              
the Division  of Behavioral  Health for  SUD treatment,  including                                                              
youth.   The  state  also  has four  methadone  clinics  - one  in                                                              
Wasilla, two in  Anchorage, and one in Fairbanks.   Alaska has 366                                                              
medical   professionals  certified   to   treat  addiction   using                                                              
buprenorphine and  22 residential treatment programs  which is 300                                                              
beds,  four  women  and  children's   programs,  and  three  youth                                                              
programs.   While  the graphic  shows that  Alaska has  a lot,  it                                                              
also  represents  the  fragmentation.     She  said  she  will  be                                                              
discussing  some  of  the  division's  solutions,  which  includes                                                              
reducing  the administrative  burden  to providers  by  onboarding                                                              
the  administrative  services  organization   with  a  performance                                                              
measure  of  reducing  the  administrative   burden  on  providers                                                              
providing these services.                                                                                                       
                                                                                                                                
3:56:10 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ  observed the chart  on slide 6 shows  that for                                                              
2019  Alaska  will  spend $26.8  million  in  addition  treatment.                                                              
That is  just in  the grants,  she pointed  out; missing  from the                                                              
chart are  the Medicaid  payments for  substance abuse  treatment.                                                              
She  cited another  chart  that  was provided  to  her earlier  by                                                              
DHSS, which showed  that in 2015 Alaska spent  about $38.5 million                                                              
on addiction treatment  through Medicaid billing and  by 2018 that                                                              
number was  up to almost  $151 million.   Co-Chair Spohnholz  said                                                              
this  other  chart further  showed  that  Alaska went  from  about                                                              
13,000  people   getting  addiction  treatment   through  Medicaid                                                              
billing  in 2015  to about  30,734  in 2018.   This  big piece  of                                                              
Alaska's addiction  treatment system isn't  shown in the  chart on                                                              
slide 6.   She said she will  provide committee members  with this                                                              
chart  because  it  is  important  to  know  that  most  addiction                                                              
treatment in the state of Alaska is being paid for by Medicaid.                                                                 
                                                                                                                                
3:57:44 PM                                                                                                                    
                                                                                                                                
MS. MOREAU-JOHNSON  moved to  slide 7  and said Medicaid  coverage                                                              
for  SUD  treatment   is  essential  funding  to   the  state  for                                                              
treatment  and   is  also  how   [the  state]  looks   forward  to                                                              
developing a  more robust  continuum of care.   It is  anticipated                                                              
that  implementation of  Alaska's Section  1115 Behavioral  Health                                                              
Waiver  ("Section 1115  Waiver")  will expand  funding to  include                                                              
federal match,  which will  be a more  sustainable source  and the                                                              
continuum  will  be  equally  distributed  regionally  across  the                                                              
state.    The   Mental  Health  Trust  Authority   has  funded  an                                                              
infrastructure  analysis study  by  the division  that is  nearing                                                              
completion.   Given these  new federal  funding opportunities  for                                                              
the Section  1115 Waiver and  the new federal funding  opportunity                                                              
through the  Family First  Prevention and  Services Act,  this gap                                                              
analysis explored  the capacity  of existing service  providers to                                                              
leverage these new  funding sources, including Medicaid,  in order                                                              
to  expand  existing  services  or  onboard  new  services.    The                                                              
division and  the Office of  Children's Services (OCS)  visited 14                                                              
communities  [Anchorage,   Mat-Su,  Fairbanks,   Soldotna,  Homer,                                                              
Nome,  Kotzebue,  Utqiavik,  Bethel,   Juneau,  Sitka,  Ketchikan,                                                              
Kodiak, Dillingham].   At  this point the  division has  met face-                                                              
to-face in  these communities with  68 agencies across  Alaska and                                                              
has  about 6  left to  go.   The  visits allowed  candid and  deep                                                              
conversations  with  providers about  what  it  means  to them  to                                                              
bring  on  the  Section  1115 Waiver.    Specific  data  is  being                                                              
collected  related to  the volume  of  screens in  and out,  child                                                              
protective  service  reports,  and   the  number  of  children  in                                                              
custody.   The report  will include  recommended actions  and will                                                              
be complete and available to the public by summer's end.                                                                        
                                                                                                                                
4:00:05 PM                                                                                                                    
                                                                                                                                
MS. MOREAU-JOHNSON  concluded with  slide 8 regarding  the Section                                                              
1115  Waiver demonstration  project,  which  was  required of  the                                                              
department in 2016  through Senate Bill 74.  She  related that the                                                              
state submitted  its application  in 2018  and received  its first                                                              
approval  from the  Centers  for  Medicare and  Medicare  Services                                                              
(CMS)  in November  2018.  Alaska  received approval  from  CMS to                                                              
fast track  its substance use  disorder components of  the Section                                                              
1115 Waiver  and has negotiated  an implementation plan  with CMS.                                                              
The approved  implementation plan  is available  to the  public on                                                              
the division's website.   The division is now  getting regulations                                                              
in  place  and is  targeting  July  1 implementation  of  the  SUD                                                              
services  through the  Section 1115  Waiver.   She  noted she  has                                                              
distributed  the list  of services  that are  approved, and  it is                                                              
the full  continuum from community-based  services all the  way up                                                              
to  exemption from  the  Institutions  for Mental  Diseases  (IMD)                                                              
exclusion for facilities of 16 beds or more.                                                                                    
                                                                                                                                
4:02:11 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ  stated she is  thrilled that the  Section 1115                                                              
Waiver includes  allowing for larger  facilities because  a 16-bed                                                              
facility  is  a  financial  strain.   She  requested  Ms.  Moreau-                                                              
Johnson to elaborate about the community-based services.                                                                        
                                                                                                                                
MS. MOREAU-JOHNSON  replied that "a  bucket of services"  is being                                                              
offered  through Community  Recovery  and Support  Services.   She                                                              
said  she  calls  it a  "bucket"  because  it  includes  component                                                              
services.    These   component  services  include   peer  support;                                                              
assistance   navigating   social   services,   including   housing                                                              
assistance  and transportation;  support in  employment, which  is                                                              
essential for  the recovery  model of  care; and case  management.                                                              
These   multiple  component   services   are   delivered  to   the                                                              
individual in the  community setting to help people  recover fully                                                              
and become contributing members of their community.                                                                             
                                                                                                                                
CO-CHAIR  SPOHNHOLZ requested  Ms. Moreau-Johnson  to explain  how                                                              
people will be identified as eligible for these services.                                                                       
                                                                                                                                
MS.  MOREAU-JOHNSON responded  that  anyone with  a substance  use                                                              
disorder  diagnosis  would be  eligible  for  this full  array  of                                                              
services.   People will be identified  as the Section  1115 Waiver                                                              
demonstration  project promotes  universal screening.   Screening,                                                              
brief   intervention,   referral,    and   treatment   are   being                                                              
implemented  in every  setting from  hospitals  to primary  doctor                                                              
offices.   Provider  roundtables are  being used  to identify  the                                                              
best  screening tools,  practices, and  assessments for  universal                                                              
screening.                                                                                                                      
                                                                                                                                
4:04:36 PM                                                                                                                    
                                                                                                                                
MS.  MOREAU-JOHNSON  returned  to  slide  8 and  added  that  [the                                                              
division]  is continuing  to  negotiate for  the  services in  the                                                              
remaining sections  of the Section 1115 Waiver.   Relevant to what                                                              
the committee  is looking at is  the target population  of at-risk                                                              
family and youth.   Addressing adverse childhood  experiences is a                                                              
way to  bend the  curve.   At-risk families  and youth  population                                                              
will be  identified through  screening for  indicators of  adverse                                                              
childhood  experiences,  one of  which  is  substance  use in  the                                                              
home.  If  at a well-child check  a child is identified  as living                                                              
in a substance  use home, the  child would be eligible  to receive                                                              
in-home support to help the family remain whole and healthy.                                                                    
                                                                                                                                
4:05:54 PM                                                                                                                    
                                                                                                                                
BRADLEY   GRIGG,  Chief   Behavioral   Health  Officer,   Bartlett                                                              
Regional Hospital,  stated he will  describe what the  hospital is                                                              
seeing in the patients  it is serving.  He said  Bartlett Regional                                                              
Hospital  has  a  broad addictions  program  on  its  campus  that                                                              
includes  a  co-ed  adult residential  treatment  facility  of  16                                                              
beds.  Mainly  because of the  IMD exclusion, Bartlett  has had to                                                              
attend to  this business model in  order to bill Medicaid  for its                                                              
services, which  is about 95 percent  of its population  both pre-                                                              
and  post- Medicaid  expansion.    Bartlett is  therefore  excited                                                              
about  the possibility  of  the Section  1115  Waiver helping  the                                                              
hospital   to  expand   its  [residential   treatment   facility].                                                              
Through funding  by the  City and Borough  of Juneau  and Bartlett                                                              
general funds, the  number of residential treatment  beds is being                                                              
expanded.    As  well, four  specific  withdrawal  management,  or                                                              
detox,  beds are  being added  to the  Rainforest Recovery  Center                                                              
facility,  which  will  provide   detox  for  alcohol  and  opioid                                                              
withdrawal.    The  bid  has been  awarded  for  the  project  and                                                              
construction will begin in about two months.                                                                                    
                                                                                                                                
4:07:58 PM                                                                                                                    
                                                                                                                                
MR. GRIGG  stated that Bartlett  wasn't waiting for  its referrals                                                              
and  numbers  to increase  in  order  to  expand; rather,  it  was                                                              
waiting on  an opportunity  for the IMD  waiver so Medicaid  could                                                              
be billed.   He explained  that if Bartlett  had had more  than 16                                                              
beds,  it wouldn't  have been  able to  bill for  the patients  on                                                              
Medicaid, but now  it will be able to do so.   Bartlett is looking                                                              
at a  minimum of 20  beds total to  help serve these  patients and                                                              
is also  looking at  as many as  24 total  and that would  include                                                              
the detox  patients.  Given  Bartlett is  a hospital, it  has been                                                              
able to  provide detox services  for years,  which is done  on its                                                              
medical floor as  a medical service.  The challenge  has been with                                                              
the  opiate  piece  because  it  is  a  very  different  level  of                                                              
withdrawal  - the medical  concerns and  the risk associated  with                                                              
opiate  withdrawal  as  opposed  to  alcohol  withdrawal  is  very                                                              
different.   Bartlett  is grateful  for the  opportunity to  build                                                              
these beds that  will address its ongoing needs  for alcohol detox                                                              
as well as opioid detox.                                                                                                        
                                                                                                                                
MR. GRIGG  related that Bartlett-specific  data reports  show that                                                              
over the  last three years  alcohol has  been the number  one drug                                                              
of choice  on patients'  self-reports.   In FY  2018, four  out of                                                              
five of  Bartlett's patients,  80 percent,  reported that  alcohol                                                              
was either  their number  one drug  of choice  or their  only drug                                                              
abuse.  Over  the last three  years the hospital has  learned that                                                              
drug  abuse is  not a  monogamous  relationship when  it comes  to                                                              
individuals  struggling,  so a  poly-substance  approach is  being                                                              
taken.   Ironically,  compared to  three years  ago, Bartlett  has                                                              
seen a  distinct shift in the  patient populations it  is serving.                                                              
Alcohol has  now gone from 80 percent  to below 55 percent  as the                                                              
drug of  choice on  the self-reports,  with the  other 45  percent                                                              
split evenly  between methamphetamines  and  opiates.  It  doesn't                                                              
mean those individuals  aren't using alcohol, it  means that their                                                              
self-reported drug  of choice is now opiates  and methamphetamines                                                              
over alcohol.                                                                                                                   
                                                                                                                                
4:10:41 PM                                                                                                                    
                                                                                                                                
MR. GRIGG said  that in addition to its residential  treatment and                                                              
detox, Bartlett  also provides  outpatient substance  use services                                                              
to kids  and adults.  The  Division of Behavioral  Health recently                                                              
awarded Bartlett  a combination  capital and operational  grant to                                                              
build a crisis  stabilization program for adults and  kids ages 10                                                              
and  up.   Two  separate  programs  will  be  housed in  the  same                                                              
facility that  will serve behavioral  health needs as it  comes to                                                              
mental  health  crisis  stabilization,   but  also  substance  use                                                              
stabilization that  could be in the form of 23.5  hour observation                                                              
for  a person  who is  intoxicated  and possibly  suicidal at  the                                                              
same time.  But  it does not have the capacity  for Bartlett to be                                                              
able to put them in its inpatient mental health unit.                                                                           
                                                                                                                                
MR.  GRIGG  noted  that  Rainforest  Recovery  Center,  like  many                                                              
others, is  serving individuals  statewide.   On any given  day 16                                                              
patients are  in the 16-bed facility.   Over the past  6 months, a                                                              
bed is only  empty when someone  has had to be discharged  and the                                                              
center is waiting  on the arrival of the patient  that the bed has                                                              
been obligated  to.  As  of today, 12 of  the 16 patients  are not                                                              
from Southeast  Alaska.   A challenge  is that  as soon  as people                                                              
are moved  in and  the beds  full, there  are also  people on  the                                                              
waitlist.   Today, 13 people  from all over  the state are  on the                                                              
waitlist to  get into treatment.   The  average length of  stay in                                                              
the program  is about 24 days, so  a three-week period  is used to                                                              
say how  quickly someone can  get in.   This bottleneck  effect at                                                              
Rainforest  has  a  statewide  impact  because  the  center  takes                                                              
individuals from  across the state.   Juneau and  Southeast Alaska                                                              
individuals  are treated,  but the waitlist  is prioritized  based                                                              
on who  has come to  the table for  acceptance first  and possibly                                                              
who has the most complex needs.                                                                                                 
                                                                                                                                
4:13:31 PM                                                                                                                    
                                                                                                                                
MR. GRIGG  said a challenge seen  every day with patients  is that                                                              
along  with addictions,  patients  are  also struggling  with  co-                                                              
morbidities  around  medical  conditions,  such  as  diabetes  and                                                              
hypertension.   Twenty beds  are not going  to meet the  need, but                                                              
Bartlett  believes  these  [four]  additional beds  can  be  added                                                              
without putting extra  pressure on its staffing  outside of adding                                                              
additional  psychiatric and  medical coverage,  which is  critical                                                              
to the  service it  delivers.  Adding  these beds  will help  be a                                                              
part of the  solution even though  Bartlett is only one  agency of                                                              
many doing that.                                                                                                                
                                                                                                                                
MR. GRIGG  noted that Bartlett  also provides  medication-assisted                                                              
treatment, both  in its residential  and its outpatient  programs,                                                              
in the  form of  suboxone and  vivitrol.   There are no  methadone                                                              
services per se in Juneau or Southeast Alaska.                                                                                  
                                                                                                                                
4:14:52 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ  asked about the  number of people that  can be                                                              
served in Bartlett's outpatient program for addiction treatment.                                                                
                                                                                                                                
MR.  GRIGG replied  that  Bartlett currently  has  just under  100                                                              
individuals in  outpatient treatment  for addictions.   Bartlett's                                                              
outpatient program  serves both mental health and  substance abuse                                                              
and co-occurring  disorders.   The caveat is  that the  number 100                                                              
is  where   substance  abuse  is   primary  over   mental  health.                                                              
Bartlett has  200 active patients  in its outpatient program.   Of                                                              
those  other 100,  the  majority also  have  addiction history  or                                                              
current experiences  with addictions,  but mental health  seems to                                                              
be  their  driver  at the  point  in  time  when  it gets  to  why                                                              
Bartlett is serving them.                                                                                                       
                                                                                                                                
4:15:50 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE DRUMMOND  inquired whether the Section  1115 Waiver                                                              
limitations are what kept Bartlett from growing beyond 16 beds.                                                                 
                                                                                                                                
MR. GRIGG  answered that  that was a  major driver;  it definitely                                                              
wasn't meeting the  need.  Sixteen was the maximum  we've done for                                                              
over two decades now mainly because of the IMD exclusion.                                                                       
                                                                                                                                
REPRESENTATIVE  DRUMMOND  observed   from  a  list  of  facilities                                                              
provided by the co-chair that most are 16 beds or under.                                                                        
                                                                                                                                
CO-CHAIR  SPOHNHOLZ   responded  that  this  is   because  of  the                                                              
Institutes  for  Mental  Disease  limitation  on  billing  at  the                                                              
federal level,  a federal regulation  that was passed a  long time                                                              
ago.  That rule  was put into place because in  the Lower 48 there                                                              
was a  problem where  people who  experienced mental illness  were                                                              
often  housed  in  large  institutions  that  operated  more  like                                                              
prisons than health  care facilities.  It had  good intentions and                                                              
resulted  in  the  de-institutionalization   of  people  that  had                                                              
primarily  really  been warehoused  for  mental health  issues  or                                                              
developmental  disabilities.   An  unintended  consequence was  to                                                              
not be  able to have mental  health care facilities  and substance                                                              
abuse treatment  facilities that were  economic to operate.   Many                                                              
states  are applying  for waivers  that  will allow  them to  have                                                              
larger  facilities  given there  is  now a  more  patient-centered                                                              
model for doing things rather than warehousing people.                                                                          
                                                                                                                                
4:17:57 PM                                                                                                                    
                                                                                                                                
MR. GRIGG  returned to  his testimony,  stating that since  Senate                                                              
Bill 91,  the criminal justice reform  bill, went into  effect two                                                              
fiscal years  ago, a growing number  of referrals are  coming from                                                              
the Department  of Corrections  (DOC) for individuals  re-entering                                                              
the community.   So,  a new dynamic  is the  challenge of  what is                                                              
called a  bed-to-bed transfer.   Having an  available bed  when an                                                              
individual  is  discharged  from   corrections  and  getting  that                                                              
person from  bed to bed  is critical because  a lot can  happen in                                                              
the time from discharge  to the time to the hospital.   With these                                                              
additional beds,  Bartlett is trying  to increase that  access for                                                              
bed-to-bed  transfers because  it  will give  these individuals  a                                                              
better chance of being successful as they exit.                                                                                 
                                                                                                                                
4:19:02 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  ZULKOSKY asked  whether  Bartlett  has a  prioritization                                                              
process for the  wait list; for example, pregnant  women or people                                                              
who have had close encounters with overdoses.                                                                                   
                                                                                                                                
MR.  GRIGG replied  that  federal regulations  guide  part of  the                                                              
hospital's  practice  around  priority  populations  and  includes                                                              
pregnant women and  intravenous (IV) drug users.   When looking at                                                              
the wait  lists, those rise  to the top  no matter where  they are                                                              
coming  from in the  state.   Those two  priority populations  are                                                              
actively served in Bartlett's program.                                                                                          
                                                                                                                                
4:20:07 PM                                                                                                                    
                                                                                                                                
SHERRIE WILSON  HINSHAW, President  & CEO, Volunteers  of America-                                                              
Alaska (VOA), explained  VOA is an Alaska-based  company providing                                                              
behavioral  health services  to youth  since 1981.   She said  VOA                                                              
has  a residential  substance abuse  treatment  program, a  24-bed                                                              
facility,  in Eagle  River;  outpatient and  intensive  outpatient                                                              
programs  in  Anchorage;  and prevention  and  early  intervention                                                              
services in Anchorage  and other areas.  The VOA  serves youth all                                                              
over the state,  the primary ages served being 13-24.   With that,                                                              
VOA has  affordable housing, family  and senior housing,  a youth-                                                              
supportive  housing  program for  homeless  youth,  and a  kinship                                                              
care  program  for  families  who are  the  primary  caregiver  of                                                              
related children due to parental substance abuse in the house.                                                                  
                                                                                                                                
MS.  WILSON HINSHAW  explained  that  the youth  seen  at VOA  are                                                              
trying to  fill a void.  They  feel lonely, scared,  pushed aside,                                                              
and  are often  self-medicating.   There  are impulsive  behaviors                                                              
given  where  they  are  in  life and  they  don't  have  a  fully                                                              
developed  pre-frontal  cortex.   When  a  chaotic home  life  and                                                              
trauma  are added in,  they face  multiple barriers.   In  working                                                              
with them, VOA's  goal is to help them grow,  change, and overcome                                                              
the  obstacles.   The  journey  of  recovery looks  different  for                                                              
different  people  and  VOA  is  helping  them  find  meaning  and                                                              
purpose  in  their  life  beyond just  what  their  substance  use                                                              
profile says.   The impact of trauma and addiction  in communities                                                              
is seen by VOA  daily and VOA sees the state as  a partner in this                                                              
work.   Having  served families  in  Alaska for  decades, VOA  has                                                              
been  through times  of  instability  and fiscal  challenges,  but                                                              
these last  few years  have been unusually  difficult for  VOA and                                                              
many other organizations.                                                                                                       
                                                                                                                                
4:22:36 PM                                                                                                                    
                                                                                                                                
MS. WILSON  HINSHAW related that  the Anchorage Health  Department                                                              
undertook a  comprehensive community  assessment around  substance                                                              
misuse,  which it  recently presented  to  an assembly  committee.                                                              
That  assessment echoes  what  VOA sees  in  its work  on a  daily                                                              
basis,  which is:   alcohol  remains the  most misused  substance,                                                              
stigma around behavioral  health treatment remains  a barrier even                                                              
though gains  have made, lack  of treatment options  and realities                                                              
prevent  access  to  care,  methamphetamine  use  and  vaping  are                                                              
increasing, and  the effect of  adverse childhood  experiences and                                                              
inter-generational  trauma  are   all  factors  that  need  to  be                                                              
focused  on.   Substance  use disorder  (SUD)  rates of  Anchorage                                                              
youth  are  among  the  highest  in  the  nation  -  6.54  percent                                                              
compared to  the U.S.  rate of 4.13.   The  teens and  high school                                                              
students  seen by VOA  is around  the misuse  of alcohol,  vaping,                                                              
marijuana, tobacco, and prescription medications.                                                                               
                                                                                                                                
MS. WILSON  HINSHAW said  she will discuss  the three  major areas                                                              
that constitute  the reality  of life as  a provider in  trying to                                                              
deliver these  services:  1)  the mission  and reasons why  VOA is                                                              
doing this  work; 2) gaps in the  system; and 3) stability  of the                                                              
system.    The   reality  of  being  a  treatment   provider,  she                                                              
explained, is operating  in a business environment -  VOA must run                                                              
a business  that is  consistent  and available  for those  who are                                                              
seeking care;  funding and system  decisions affect  VOA's ability                                                              
to  consistently  deliver those  services  and  grow to  meet  the                                                              
needs of  the community.   There  is a  high level of  uncertainty                                                              
with funding.   It  is hard  to imagine  another system  where the                                                              
expectation is  to grow to  meet demand  and live in  an uncertain                                                              
funding system  when lives  are really  on the  line.   This means                                                              
that  families  seeking services  don't  know  where to  go,  they                                                              
can't get  the care they  need at the  right level, or  they can't                                                              
get  the full  continuum  of services  that  they  need.   Funding                                                              
availability  directly ties into  VOA's ability  as a  provider to                                                              
hire  clinical  staff  to  deliver   those  services,  which  ties                                                              
directly into  VOA's ability  to serve  the number of  individuals                                                              
that need VOA's services.                                                                                                       
                                                                                                                                
4:25:10 PM                                                                                                                    
                                                                                                                                
MS.  WILSON HINSHAW  advised  that  VOA sees  gaps  in the  system                                                              
around work  with parents - working  with the whole family  is not                                                              
currently  a reimbursable  service.   She  said  the Section  1115                                                              
Waiver  does address  some of the  gaps, but  there are  concerns.                                                              
Partial hospitalization  is a  gap in  the system, especially  for                                                              
youth,  where  they   can  access  the  same  level   of  clinical                                                              
intensity of  services that  they would  in residential  except go                                                              
home at night.   Some states are  using this model to  do recovery                                                              
high  schools where  it  is really  centered  around recovery  and                                                              
trauma-informed  care while  [the youth]  are addressing  deficits                                                              
in education  and continuing  in their high  school.   She pointed                                                              
out  that  peer mentoring  and  support  is  another gap  that  is                                                              
included in  the Section 1115 Waiver,  which VOA is happy  to see.                                                              
Prevention, she continued,  is also a gap in the  system.  As seen                                                              
on  the chart  shown earlier,  about  $2 million  is provided  for                                                              
prevention.   Clearly not enough  is being invested  in prevention                                                              
in  a   way  that  is  needed   going  upstream.     Some  amazing                                                              
professionals  across   Alaska  are  taking  that   investment  in                                                              
prevention  and turning  it into  meaningful things,  such as  the                                                              
community  coalitions  of  which  VOA is  a  participant.    Those                                                              
coalitions  are a  part of  distributing naloxone  kits, but  more                                                              
must  be done in  prevention  so there  can be a  shift away  from                                                              
being a crisis response system.                                                                                                 
                                                                                                                                
4:27:10 PM                                                                                                                    
                                                                                                                                
MS.  WILSON  HINSHAW addressed  the  level  of uncertainty  and  a                                                              
well-functioning  system.  She  noted that a  system itself  is an                                                              
interconnected set  of elements that  are organized in a  way that                                                              
achieves  something.    The Alaska  behavioral  health  system  is                                                              
often focused  on crisis management  versus prevention or  being a                                                              
responsive system  that changes as the environment  changes and as                                                              
community needs  change.   On the  continuum of health  promotion,                                                              
prevention,  early  intervention,   treatment  and  recovery,  the                                                              
state must look at how to adequately address all those areas.                                                                   
                                                                                                                                
MS. WILSON HINSHAW  explained that VOA teaches its  clients to not                                                              
be reactive,  to respond  in the moment,  and to regulate  emotion                                                              
so they  can make the  best possible choice.   That  parallels the                                                              
many  wonderful   things  in  the   Section  1115   Waiver,  which                                                              
addresses so  many gaps in  the system.   But, she  cautioned, the                                                              
devil  is  in the  details  because  VOA's  current reality  as  a                                                              
provider is  that rates  do not cover  the cost of  care.   It has                                                              
been a great expense  to VOA to continue to provide  services that                                                              
it knows are  needed and to meet  VOA's mission.  Even  the recent                                                              
Medicaid rate increases  in January [2019], which  VOA is thankful                                                              
for, do  not cover the  cost of care  and limit an  organization's                                                              
ability to grow to meet the need of the community.                                                                              
                                                                                                                                
4:28:52 PM                                                                                                                    
                                                                                                                                
MS. WILSON  HINSHAW noted there are  a high number of  unknowns in                                                              
the timeline of  implementing the Section 1115 Waiver  - what that                                                              
will look  like and how  that will change  services on  the street                                                              
for those  seeking the services and  those families in  care.  She                                                              
urged that  thought be given to  rolling out change  in manageable                                                              
steps so  that the system isn't  destabilized by trying  to change                                                              
too  much  too quickly.    She  offered  her hope  that  committee                                                              
members  will  come  away  from   today's  presentations  with  an                                                              
understanding  of the reality  of trying  to offer these  services                                                              
and that without  the certainty of stable and  consistent funding,                                                              
it  is difficult  for providers  to confidently  deliver and  grow                                                              
those services that  they know are needed.  There  must be a shift                                                              
away from being  a reactive system and being crisis  driven.  This                                                              
means  looking at the  whole continuum  of care  and then  rolling                                                              
out changes  in manageable  steps that  don't destabilize  what is                                                              
already had.  She  thanked the committee members for  what they do                                                              
to address community needs and substance misuse.                                                                                
                                                                                                                                
4:30:44 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY  addressed Ms.  Wilson Hinshaw's comments  about                                                              
not destabilizing  the system  and the  need for stable  resources                                                              
to  provide  reliable  treatment  support  for  those  individuals                                                              
needing  it and  providing  opportunities  for providers  to  grow                                                              
their programs.   She said this really resonates,  especially with                                                              
the backdrop  of all the financial  decisions and  challenges that                                                              
the  legislature  is  currently  grappling with.    She  requested                                                              
identification of the specific revenues coming into programs.                                                                   
                                                                                                                                
MS. WILSON HINSHAW  replied that the $26 million  in comprehensive                                                              
behavioral  health  treatment  and  recovery  grants  is  the  gap                                                              
filler  that funds  everything Medicaid  won't.   So, any  cuts to                                                              
that -- she offered  her belief that cuts are proposed  right now.                                                              
She said the  purpose for bringing the Section  1115 Waiver online                                                              
on  [7/1/19] would  correspond with  grant cuts,  so having  grant                                                              
cuts  at the  same time  as adapting  to  a new  system with  many                                                              
things  yet  undefined  is  very concerning  for  providers.    In                                                              
particular, she was referring to those cuts.                                                                                    
                                                                                                                                
4:32:33 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  ZULKOSKY surmised  Ms.  Wilson Hinshaw  was online  when                                                              
Co-Chair  Spohnholz   talked  about  the  significant   amount  of                                                              
investment  Medicaid   has  made  in  treatment   services.    She                                                              
surmised  Medicaid treatment  funds  are critical  to  maintaining                                                              
moving forward.                                                                                                                 
                                                                                                                                
MS. WILSON  HINSHAW responded that  Medicaid rates  for behavioral                                                              
health were  not adjusted for over  10 years and do not  cover the                                                              
cost  of care  even with  the  [recent] increases.    Any cuts  to                                                              
Medicaid directly impact VOA's ability to deliver services.                                                                     
                                                                                                                                
CO-CHAIR ZULKOSKY  asked about  the impact that  would be  seen at                                                              
the community  level if cuts were  made to Medicaid funding  or to                                                              
the aforementioned grants.                                                                                                      
                                                                                                                                
MS. WILSON  HINSHAW  replied the  impact would  be a lessening  of                                                              
what availability  the system does  have right now.   For example,                                                              
VOA  would have  to lower  staffing in  its outpatient,  intensive                                                              
outpatient,  and residential  treatment programs  to a level  that                                                              
VOA could  sustain.  This  would mean VOA  serving less  youth who                                                              
are coming in for services.                                                                                                     
                                                                                                                                
4:34:40 PM                                                                                                                    
                                                                                                                                
LANCE  JOHNSON,   Director,  Behavioral  Health   Services  (BHS),                                                              
Norton Sound Health  Corporation (NSHC), offered  his appreciation                                                              
for the  comments of  his colleagues,  stating they highlight  the                                                              
issue  that is  being addressed,  which is  the rampant  substance                                                              
misuse concerns  that are had  throughout the  state.  He  said he                                                              
will  provide a  rural  perspective  and highlight  some  positive                                                              
developments  in Nome  that can  also benefit  the state as  well,                                                              
namely the wellness  center that is being built and  a day shelter                                                              
that has been opened.                                                                                                           
                                                                                                                                
MR. JOHNSON  stated Norton Sound  Health Corporation  operates the                                                              
only  hospital  and  behavioral  health  services  in  the  entire                                                              
Bering Strait  region, which includes  15 remote villages  and the                                                              
home community  of Nome.  The  region is 24,000 square  miles with                                                              
9,869 people  and is  only accessible  by airplane.   He  has been                                                              
the director for  behavioral health since 2012,  he continued, and                                                              
the needs  are high and  are visible.   Committed partners  in the                                                              
region  collaborate   around  common  concerns  that   impact  the                                                              
wellbeing of  residents.   For example,  in recognition  of public                                                              
concern  about substance  misuse in  the region,  a public  safety                                                              
coalition  was put  together in  the last month  to examine  basic                                                              
needs, wellness,  and substance misuse, and to  develop strategies                                                              
working outside of  the silos with a goal of  achieving measurable                                                              
and sustainable  change.  These partnerships are  wholly important                                                              
to the  region where  localized care and  treatment can  have most                                                              
effective  change.   The  State  of Alaska  has  been a  committed                                                              
partner in  many of  these efforts  through grants,  collaboration                                                              
with tribes and tribal entities, and to do expansion efforts.                                                                   
                                                                                                                                
4:37:10 PM                                                                                                                    
                                                                                                                                
MR. JOHNSON  said the  negative  is that there  are glaring  needs                                                              
and  the  issue  is  recognized  throughout  the  state,  but  the                                                              
positive  is that  Norton  Sound  Health Corporation  has  devoted                                                              
staff  and resources  to projects  that help  with that  substance                                                              
misuse.    The  significant  contribution  of  historical,  inter-                                                              
generational, and  other trauma cannot be overlooked,  he advised;                                                              
it is often masked  through substance misuse by the  people of the                                                              
region.   The  corporation opened  a  day shelter  on 12/29/18  to                                                              
offer a warm  weather and safe  place for the several  people seen                                                              
on  the streets  who  were  chronically  homeless and  at  varying                                                              
levels of  intoxication.  The  idea was to  keep them safe  but to                                                              
meet them where  they are.  It  is foolish to think  that everyone                                                              
who has  a need  is going to  walk through  the doors  of behavior                                                              
health ready for  treatment.  Change and recovery  will not always                                                              
occur within  the four walls of a  clinic.  People need  to be met                                                              
where they are, and  trust and rapport need to be  built.  The day                                                              
shelter operates seven  days a week 8:30 a.m. to  7:30 p.m.  Since                                                              
opening  it  has  served  122  unique  individuals.    Nearly  100                                                              
percent  of the  individuals  have  claimed homelessness  and  are                                                              
misusing substances.   On triage forms all of them  have said that                                                              
their  top  priorities  are housing,  employment,  and  treatment.                                                              
The day  shelter is very  grassroots.  It's  small and is  not the                                                              
greatest  setup  physically  in  comparison  to  more  established                                                              
shelters  throughout the  state, but  it is an  important  need in                                                              
the continuum of care in this region.                                                                                           
                                                                                                                                
MR. JOHNSON  stated that  BHS currently  offers outpatient  mental                                                              
health  and substance  misuse services.    While wholly  important                                                              
treatment  options, they  are not  enough.  A  whole continuum  of                                                              
care is necessary  anywhere to address the multitude  of needs any                                                              
one group of  people may have.   Because of this, NSHC  has worked                                                              
on developing a  wellness center that will offer  a full continuum                                                              
of outpatient,  intensive outpatient,  day treatment, and  a sober                                                              
housing that  will replicate  residential  treatment.  This  means                                                              
people will  be able  to come  in from  the region's villages  and                                                              
have a  place to stay while  receiving treatment for  however long                                                              
that may  take.   A sobering  center within  the wellness  complex                                                              
will  serve as  an entry  point  for many  people  into the  other                                                              
services.  It  has been a nine-year project with  planning support                                                              
from the Alaska  Mental Health Trust Authority.  So  far, NSHC has                                                              
secured  $7.1  million towards  the  project,  with much  of  that                                                              
invested  by the  corporation.   Another $8.3  million is  needed.                                                              
Pylons were put in the ground this past year.                                                                                   
                                                                                                                                
4:40:04 PM                                                                                                                    
                                                                                                                                
MR. JOHNSON  pointed out that these  are important efforts  in the                                                              
region  because localized  care  is the  most  effective care  and                                                              
right now the  region is grossly limited.  Building  and operating                                                              
the  wellness center  will  allow  people to  stay  in the  region                                                              
surrounded by familial  and social supports, which  are imperative                                                              
to  successful  recovery.    As  importantly,  treatment  will  be                                                              
culturally  reflected and  familiar  to people  because  it is  in                                                              
their  own region.   When people  are sent  outside for  substance                                                              
misuse  treatment   they  are  most  often  isolated   from  their                                                              
supports and  their culture.   The  family component to  treatment                                                              
where  people learn  and  recover  together is  often  lost.   Mr.                                                              
Johnson said  he is grateful for  the services that are  out there                                                              
because recovery  can have  many hills and  many valleys and  is a                                                              
lifelong  journey.     Staying   home  wrapped  in   supports  and                                                              
resources offers the better and more sustainable outcomes.                                                                      
                                                                                                                                
MR.  JOHNSON shared  the  example  of "Kenny,"  who  BHS has  been                                                              
working with  for the last  two years.   Over the years  Kenny has                                                              
had more  days of  intoxication than  sobriety.   In the  last two                                                              
months Kenny  has been to the  NSHC emergency room over  30 times,                                                              
admitted to  the inpatient  unit three  times, and arrested  three                                                              
times.   He  said Kenny's  needs  will only  be  met through  high                                                              
levels  of care  that are  not had  in  the region.   Through  the                                                              
first seven months  of the relationship, Kenny would  did not want                                                              
to engage  BHS services.   But, through  BHS's commitment  to work                                                              
with Kenny  where he was  at in his life  and to offer  support, a                                                              
trusting  relationship was  built where  NSHC was  able to  scrape                                                              
beneath the  masking substances  and address those  underlying co-                                                              
occurring  issues.   The point,  Mr. Johnson  advised, is  that it                                                              
doesn't happen  in a day, trust must  be built to get  to the core                                                              
of the problem.   Right now, Kenny  can go to a 35-day  program or                                                              
he  can wait  for five  or six  months  for a  bed in  one of  the                                                              
state's long-term  residential facilities.   A 35-day  program has                                                              
its  place, but  it took  BHS  seven months  to  build trust  with                                                              
Kenny and  to gain  daylight into his  severe trauma  history, the                                                              
catalyst for his  addiction.  So, if Kenny could  stay home and in                                                              
the  place  where  he  has  said  he  would  feel  safest  getting                                                              
treatment, and do  that surrounded by his supports  in his culture                                                              
and in a care  environment he trusts and opens up  to, Kenny would                                                              
spend a lot more time on the hills than down in the valleys.                                                                    
                                                                                                                                
4:42:37 PM                                                                                                                    
                                                                                                                                
MR.  JOHNSON  expressed  his  appreciation   for  the  committee's                                                              
interest in  looking at ways to  partner with agencies  that might                                                              
have these capabilities.   He said he is interested  in having the                                                              
opportunity to  partner.  A lot  of infrastructure has  been built                                                              
in the urban areas,  he noted, but there needs to  be a new energy                                                              
in building  infrastructure in  rural Alaska.   The more  that can                                                              
be provided  locally, the less  strain will  be put on  an already                                                              
overburdened  and under-resourced  system.   The  less  he has  to                                                              
send  people out  of region  for services  and tie  up those  beds                                                              
that Mr.  Grigg has, the less  it overwhelms the system,  the less                                                              
it  costs  in  emergency  room  care,  incarceration,  and  police                                                              
resources because  people would be  getting the right care  in the                                                              
right place leading to recovery.                                                                                                
                                                                                                                                
MR.  JOHNSON   explained  that   this  happens  best   when  rural                                                              
communities  have the same  or similar  opportunities as  nonrural                                                              
communities.    For  example,  the  State  of  Alaska  released  a                                                              
Request  for  Proposals  (RFP)  for  state  opioid  response  peer                                                              
support   services  on   [11/21/18],  but   the  opportunity   was                                                              
restricted to communities  in urban areas.   Further disheartening                                                              
was  that one  month  later  there  was another  opportunity  that                                                              
would have  worked perfectly for  NSHC that was only  available in                                                              
urban areas.  While  the needs of urban areas are  just as real as                                                              
those of  rural areas, he said,  the danger is that  if investment                                                              
continues  only in the  infrastructure of  urban communities  then                                                              
rural communities  will continue to depend on  those out-of-region                                                              
services,  leading to  more  cost, more  strain,  and more  people                                                              
struggling to achieve recovery in the continuum.                                                                                
                                                                                                                                
4:44:52 PM                                                                                                                    
                                                                                                                                
The committee took a brief at-ease.                                                                                             
                                                                                                                                
4:45:18 PM                                                                                                                    
                                                                                                                                
ADELE LANDROCHE,  Advocate, stated  she is a mother,  grandmother,                                                              
and a retired teacher.  She spoke as follows:                                                                                   
                                                                                                                                
     It is  my hope that  by coming before  you I will  leave                                                                   
     you  with some  additional  knowledge  and insight  into                                                                   
     the world  of addiction.   ... Addiction  is not  just a                                                                   
     disease  of   an  individual,  it  affects   family  and                                                                   
     friends of  the addict  as well.   I am living  proof of                                                                   
     that.   While  my experiences  have  been difficult  and                                                                   
     sometimes tragic,  I'm not  all that different  from any                                                                   
     other parent of an addict.                                                                                                 
                                                                                                                                
     My  three   adult  children  have  all   struggled  with                                                                   
     substance  abuse.   My oldest  son died  of an  overdose                                                                   
     administered  by  his girlfriend  who  left him  to  die                                                                   
     alone.   My daughter  struggled through two  pregnancies                                                                   
     fighting her  heroine addiction  and has emerged  on the                                                                   
     other side  as a happy successful  adult.  My  other son                                                                   
     abused  drugs as a  teenager, went  to treatment  twice,                                                                   
     and was  clean for seven  years until his brother  died.                                                                   
     He struggles  with this and has been actively  using for                                                                   
     several years.   He's  been in and  out of jail  and was                                                                   
     recently  remanded in January.   He  wants to be  clean;                                                                   
     he wants  to be happy and  successful; he wants to  be a                                                                   
     good dad, son, and brother.                                                                                                
                                                                                                                                
     However, he  can't do it alone.   It is not  enough that                                                                   
     his friends  and family  are there for  him and  that we                                                                   
     support  his sobriety.   What matters  is the  resources                                                                   
     that are available  to him when he feels  weak and lost.                                                                   
     And   when  you   have  to   navigate   the  system   of                                                                   
     assessments  and  admission  paperwork  in  filling  out                                                                   
     forms,  et cetera,  doing it  on your own  as an  addict                                                                   
     must  be an  insurmountable task.   I'm  hoping that  by                                                                   
     sharing  my  story with  you  and  making the  world  of                                                                   
     addiction  a  little more  personal,  will help  you  to                                                                   
     understand,  to have some  insights into the  challenges                                                                   
     that the addict and his or her family faces.                                                                               
                                                                                                                                
4:47:47 PM                                                                                                                    
                                                                                                                                
     My son was  remanded to jail in January  and immediately                                                                   
     started  the process  for admission  into a  residential                                                                   
     treatment  facility.   His requests  went unanswered  or                                                                   
     were rejected  by corrections staff.   In an  attempt to                                                                   
     facilitate  his admission  to treatment,  I sent  dozens                                                                   
     of  emails and  made multiple  phone  calls with  little                                                                   
     success.   Over the next couple  of months, he  was sent                                                                   
     back and forth  between Anchorage jail, Cook  Inlet, and                                                                   
     Goose Creek.   It seemed like  every time he  started to                                                                   
     make  some   headway  they  would  transfer   him.    He                                                                   
     continued  his  efforts  to  get  on  the  list  for  an                                                                   
     assessment  and I  continued sending  emails and  making                                                                   
     phone calls, most of them went unanswered.                                                                                 
                                                                                                                                
     One  [corrections officer  (CO)]  at  Goose Creek,  Kyle                                                                   
     Thompson, took  an interest  in actually helping  my son                                                                   
     and  facilitating this  process  and he  finally got  on                                                                   
     the  list for an  assessment. ...  Paperwork didn't  get                                                                   
     to  the  treatment  facility's  intake  and  so  it  was                                                                   
     another series  of emails and phone calls  and help from                                                                   
     the  same  CO   at  Goose  Creek  until   the  necessary                                                                   
     documents were  received by the  facility.  Then  it was                                                                   
     a waiting  game until  the bed  was open  for him.   I'm                                                                   
     happy  to say  that  he's finally  in  treatment and  is                                                                   
     doing well.                                                                                                                
                                                                                                                                
     Sadly,  though,  my  son's  story  is  typical  of  what                                                                   
     happens  within [the Department  of Corrections  (DOC)].                                                                   
     Lots of  waiting, unanswered  requests, and  resistance.                                                                   
     My son had  the benefit of having me outside  the system                                                                   
     and  fortunately for  him I  am  someone who  persevered                                                                   
     until  his  assessment  and  admission  were  completed.                                                                   
     Many inmates don't have this support.                                                                                      
                                                                                                                                
     I have  also seen  the same kind  of process that  other                                                                   
     addicts  have tried to  work through  outside of  DOC to                                                                   
     get  into some  kind of  treatment program.   There  are                                                                   
     very few  detox beds  in Anchorage and  in the  state of                                                                   
     Alaska, and  if any of you know anything  about addicts,                                                                   
     if  they're  asking for  help  right  now, it  needs  to                                                                   
     happen right now.   Addicts are known for  their lack of                                                                   
     persistence and  follow through.  Expecting  someone who                                                                   
     is actively  using to  make a  phone call every  morning                                                                   
     to  see  if   a  bed  is  open  and  available   is  not                                                                   
     realistic.    The  process  of  being  admitted  into  a                                                                   
     treatment  facility is so  cumbersome that many  addicts                                                                   
     either never begin the process or give up.                                                                                 
                                                                                                                                
4:49:53 PM                                                                                                                    
                                                                                                                                
     Once a person  is fortunate enough to go  through detox,                                                                   
     then  it's a  waiting game  to  get into  treatment.   I                                                                   
     spent some time  looking at the real-time  chart of beds                                                                   
     available  and open  beds in  the state  and much of  it                                                                   
     doesn't  make sense to  me.   There are facilities  that                                                                   
     listed  a number  of open beds  yet had  a waiting  list                                                                   
     which went  from a few days  to more than a month.   For                                                                   
     instance,  on  May  3 the  men's  treatment  program  at                                                                   
     Clitheroe has  a total of 42 beds, 37 of  them occupied,                                                                   
     with  5 open  beds,  there  are 24  people  on the  wait                                                                   
     list,  and the  estimated days  wait time  for the  next                                                                   
     available  bed is 45.   If you  were the addict  waiting                                                                   
     for  your  chance for  an  open  bed, would  that  sound                                                                   
     promising to you.                                                                                                          
                                                                                                                                
     I  have seen  all kinds  of wonderful  plans in  writing                                                                   
     from  different task  forces and  committees within  the                                                                   
     state, as  well as the  mission statements that  DOC has                                                                   
     published.    This  all sounds  really  good  on  paper;                                                                   
     however,  I see  very little  evidence of  any of  these                                                                   
     great  ideas being  put into  practice.   We talk  about                                                                   
     crime in  our state and I'm  not an expert.   However, I                                                                   
     have done my  fair share of research and  a common theme                                                                   
     that   runs  through   many  of  the   people  who   are                                                                   
     committing  crimes  and are  incarcerated  is  substance                                                                   
     abuse.                                                                                                                     
                                                                                                                                
     We seem  to be attacking  this problem from  many angles                                                                   
     that  don't seem  to have  a direct  effect on  reducing                                                                   
     crime  in our communities.   I  have listened to  debate                                                                   
     after  debate and  complaints  from many  people in  the                                                                   
     state talking  about [Senate  Bill] 91 and the  problems                                                                   
     that  are inherent  in it.    I have  heard very  little                                                                   
     focus on  the causative issues  such as substance  abuse                                                                   
     and   support   for  people   following   incarceration.                                                                   
     Again, I'm not  an expert, but I know how it  goes.  The                                                                   
     person is released  from jail, has no money,  no job, no                                                                   
     place  to   live,  and  very   little  support   in  the                                                                   
     community, and  they're back on the streets.   They seek                                                                   
     out  the people  that  they previously  have  associated                                                                   
     with in the  community and return to the  lifestyle that                                                                   
     they  were living prior  to being  in jail.   This  is a                                                                   
     catch-22 for most of them.                                                                                                 
                                                                                                                                
4:51:50 PM                                                                                                                    
                                                                                                                                
     And even for  those recovering addicts who  truly want a                                                                   
     better life and  are making the effort to  be a positive                                                                   
     contributing productive  member of society, it  is truly                                                                   
     an  uphill battle.   I don't  wonder why  most of  these                                                                   
     people  don't succeed  at staying  clean  and sober  and                                                                   
     being  gainfully employed.   I  am amazed  that some  of                                                                   
     them actually make it.                                                                                                     
                                                                                                                                
     It is imperative  that after identifying  the underlying                                                                   
     causative factors  for addiction and crime in  our state                                                                   
     we  actually  develop a  plan  to address  these  issues                                                                   
     that  is reasonable,  practical, and  doable.  We  can't                                                                   
     keep  talking  about it  and  doing nothing  and  expect                                                                   
     things to get better.                                                                                                      
                                                                                                                                
4:52:36 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  said  she  respectfully  disagrees  that  Ms.                                                              
Landroche is  not an expert and  offered her appreciation  for Ms.                                                              
Landroche's testimony.                                                                                                          
                                                                                                                                
CO-CHAIR  ZULKOSKY  commented that  for  someone  who has  endured                                                              
such heartache, Ms.  Landroche has provided a very  concise, clear                                                              
description  of the  need for treatment  in Alaska.   She  thanked                                                              
Ms.  Landroche  for  courageously  sharing  what must  be  a  very                                                              
difficult story to share.                                                                                                       
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  thanked Ms.  Landroche  for  her courage  and                                                              
vulnerability in sharing her family story.                                                                                      
                                                                                                                                
4:53:28 PM                                                                                                                    
                                                                                                                                
DOUG  WOOLIVER,  Deputy  Administrative   Director,  Alaska  Court                                                              
System,  stated  that Ms.  Landroche's  testimony  highlights  the                                                              
great benefits of  therapeutic courts, which remove  the confusion                                                              
and delay  associated with  trying to find  a way into  treatment.                                                              
He agreed it seems  almost impossible to deal with  all the things                                                              
that  must be  dealt  with, to  find treatment,  and  to get  into                                                              
treatment.    Therapeutic  courts have  contracts  with  treatment                                                              
providers in  locations around  the state.   Under that  contract,                                                              
once  the person  has  shown an  interest and  looks  like a  good                                                              
candidate,  the person  is assessed  within five  days for  his or                                                              
her needs.  There  is a bit of delay while the  attorneys work out                                                              
a plea  agreement  and ensure  the assessment  is appropriate  and                                                              
the person  is a good  candidate for the  court.  Under  contract,                                                              
once accepted, that person is in treatment within five days.                                                                    
                                                                                                                                
MR.  WOOLIVER  said  the  therapeutic  courts  provide  help  with                                                              
housing,  both   finding  it  and  through   grants,  particularly                                                              
through  Partners  for  Progress,  which  has  been  a  tremendous                                                              
champion for the  therapeutic courts.  It is a  state funded grant                                                              
and  they provide  emergent funds  for  people to  help cover  the                                                              
first  and last  months'  rent, a  bus pass,  and  those types  of                                                              
things that  could otherwise make  trying to get into  a treatment                                                              
program or be  successful in treatment all but  impossible.  Those                                                              
types of programs are very helpful.                                                                                             
                                                                                                                                
4:55:30 PM                                                                                                                    
                                                                                                                                
MR.  WOOLIVER reported  that  at any  given  time the  therapeutic                                                              
courts  have  about 280  people.    More  than 1,300  people  have                                                              
graduated  over   the  years  from   therapeutic  courts.     Like                                                              
corrections,  the   court  system  is  a  direct   bridge  between                                                              
treatment  and  the  criminal justice  system.    Corrections  has                                                              
treatment  programs within  its  facilities and  the court  system                                                              
has the therapeutic  courts to provide treatment as  means to keep                                                              
people out of those facilities.                                                                                                 
                                                                                                                                
MR.  WOOLIVER pointed  out  that one  benefit  of the  therapeutic                                                              
court program  is the number  of healthy  babies that are  born to                                                              
someone who  went through or is  in the program.  He  related that                                                              
between  15  and 20  women  going  through the  therapeutic  court                                                              
programs became  pregnant and gave  birth to healthy babies.   For                                                              
example, a  fetal alcohol spectrum  disorder (FASD) child  ends up                                                              
costing the  state in the  long run.   That doesn't count  for the                                                              
human tragedy  of the  syndrome itself.   But it  is also  a crime                                                              
reduction tool.   The birth  of a healthy  baby is  prevention, it                                                              
is  keeping an  FASD baby  from coming  down the  pipeline who  is                                                              
more likely  to be in the juvenile  justice and more likely  to be                                                              
in the  adult correctional  facilities.  So,  while the  people in                                                              
the  therapeutic court  are  already in  the  system, the  healthy                                                              
babies are a piece  of the prevention angle that  comes out of the                                                              
therapeutic courts.                                                                                                             
                                                                                                                                
4:57:40 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  SPOHNHOLZ asked  what percentage  of the people  working                                                              
their  way through  the  court system  every  year participate  in                                                              
therapeutic courts.                                                                                                             
                                                                                                                                
MR. WOOLIVER  replied that  it is  a very  small percentage.   The                                                              
therapeutic court  has about 280  people at any given  time, about                                                              
400 people  over the  course of  a year,  and there are  thousands                                                              
and thousands of  people in the criminal justice system.   It is a                                                              
challenge getting people into therapeutic courts.                                                                               
                                                                                                                                
CO-CHAIR  SPOHNHOLZ   inquired  how   people  get  identified   to                                                              
participate in therapeutic courts.                                                                                              
                                                                                                                                
MR.  WOOLIVER  responded  that frequently  people's  attorneys  or                                                              
other  people in  jail will  tell them  about therapeutic  courts.                                                              
He noted  that it's  hard because the  substance abuse  courts are                                                              
about 18 months  long.  Many of the people going  into therapeutic                                                              
courts have  been to  jail many  times already  and going  to jail                                                              
for 90 days isn't  that big of a deal, but 18  months of intensive                                                              
outpatient treatment  is a  big deal and  people must be  ready to                                                              
do it before  they will start down  that path.  That is  why a lot                                                              
of the therapeutic  court's defendants are felons -  there is more                                                              
time  hanging over  their heads,  more to  avoid.   He added  that                                                              
therapeutic  courts are good  programs, and  more are  wanted, but                                                              
there are as many as possible for right now.                                                                                    
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  remarked  that  Mr. Wooliver  has  given  the                                                              
committee something  to be hopeful  about, although  she hesitates                                                              
to get  hopeful about  something that serves  such a  small number                                                              
of  people.   She said  she wishes  that  more therapeutic  courts                                                              
could be done in Alaska because she thinks they are great.                                                                      
                                                                                                                                
4:59:52 PM                                                                                                                    
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
There being  no further business  before the committee,  the House                                                              
Health  and  Social   Services  Standing  Committee   meeting  was                                                              
adjourned at 4:59 p.m.                                                                                                          

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