ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  October 26, 2017 2:05 p.m. MEMBERS PRESENT Representative Ivy Spohnholz, Chair Representative Bryce Edgmon, Vice Chair Representative Sam Kito Representative Geran Tarr Representative Jennifer Johnston (via teleconference) Representative Colleen Sullivan-Leonard Representative Dan Saddler (alternate) MEMBERS ABSENT  Representative David Eastman Representative Matt Claman (alternate) OTHER LEGISLATORS PRESENT  Representative Harriet Drummond Representative Paul Seaton Representative George Rauscher COMMITTEE CALENDAR  PRESENTATION: DIVISION OF BEHAVIORAL HEALTH~ OPIOID TREATMENT IN ALASKA - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER RANDALL BURNS, Director Central Office Division of Behavioral Health (DBH) Department of Health and Social Services (DHSS) Juneau, Alaska POSITION STATEMENT: Presented a PowerPoint which focused on opioid treatment in Alaska. JAY BUTLER, MD, Chief Medical Officer/DPH Director Central Office Division of Public Health (DPH) Department of Health and Social Services (DHSS) Anchorage, Alaska POSITION STATEMENT: Answered questions during the presentation on opioid treatment. GENNIFER MOREAU-JOHNSON, Behavioral Health Policy Advisor Office of the Commissioner Department of Health and Social Services (DHSS) Anchorage, Alaska POSITION STATEMENT: Testified during the presentation on opioid treatment. CATHLEEN MCLAUGHLIN, Director Partners Reentry Center Anchorage, Alaska POSITION STATEMENT: Presented a PowerPoint titled "Justice Reinvestment Funds, An Agency's Perspective." LAURA BROOKS, Health Care Administrator Division of Health & Rehabilitation Services (DHRS) Department of Corrections (DOC) Anchorage, Alaska POSITION STATEMENT:  Presented a PowerPoint via teleconference. APRIL WILKERSON, Director Juneau/Anchorage Division of Administrative Services (DAS) Department of Corrections (DOC) Juneau, Alaska POSITION STATEMENT: Testified during the presentation. ACTION NARRATIVE 2:05:16 PM CHAIR IVY SPOHNHOLZ called the House Health and Social Services Standing Committee meeting to order at 2:05 p.m. Representatives Spohnholz, Sullivan-Leonard, Edgmon, Tarr, and Johnston (via teleconference) were present at the call to order. Representatives Kito and Saddler (alternate) arrived as the meeting was in progress. ^PRESENTATION: DIVISION OF BEHAVIORAL HEALTH, OPIOID TREATMENT IN ALASKA PRESENTATION: DIVISION OF BEHAVIORAL HEALTH, OPIOID TREATMENT IN  ALASKA  2:05:50 PM CHAIR SPOHNHOLZ announced that the first order of business would be a presentation by the Division of Behavioral Health regarding the opioid epidemic and interactions with the Justice Reinvestment programs. 2:07:50 PM RANDALL BURNS, Director, Central Office, Division of Behavioral Health, Department of Health and Social Services, shared a PowerPoint (via teleconference) regarding the Prescription Drug and Opioid Addiction Treatment Programs. He directed attention to the "Substance Use Residential Treatment Program" [Included in members' packets], stating that the right hand column, titled "Level of Care," was based on the American Society of Addiction Medicine criteria. He added that there was also a fact sheet with very good background from the American Association for the Treatment of Opioid Dependence on Medication Assisted Treatment [Included in members' packets]. He directed attention to slide 2, "Medicaid Assisted Treatment," and spoke about the federal grants received in the past few years, as they focused on medication assisted treatment. He reported that SAMHSA (Substance Abuse and Mental Health Services Administration, in the United States Department of Health and Human Services) targeted three priority areas to combat opioid abuse on which to focus: the opioid prescribing practices to reduce opioid use disorders and overdose; the expanded use and distribution of naloxone (Narcan) to help in emergencies; and the expansion of Medication-assisted treatment (MAT) to reduce opioid use disorders and overdose. He reported that Alaska was focusing on the expansion of MAT with most of its funding, adding that Department of Health and Social Services had applied for a grant in May 2016 which proposed to target Anchorage and Juneau, communities with a high prevalence of individuals with opioid use disorders, for expanded access to MAT. In September 2016, the department was awarded $1 million for each of three years. 2:12:15 PM MR. BURNS moved on to slide 3, "Medicaid Assisted Treatment (con't)" and shared that in January 2017, the funding was distributed to two grantees, the Narcotic Drug Treatment Center in Anchorage, and the Rainforest Recovery Center in Juneau. He added that these centers had committed to an increase in the caseload of 250 patients over the next 2.5 years. REPRESENTATIVE SULLIVAN-LEONARD asked about the determination for choosing Anchorage and Juneau. MR. BURNS replied that the decision was specifically based on data about the prevalence of opioid abuse, and that these two communities were the most impacted. 2:15:05 PM MR. BURNS discussed the next grant received, slide 4, "Opioid State Targeted Response (STR)," and explained that the focus of this funding was to increase provider capacity in Alaska around the MAT, and to increase the number of clients receiving appropriate treatment, while decreasing the negative impact of opioid use. He reported that this STR grant awarded two years, $2 million each year, of funding to Alaska. He shared that a four-pronged approach was being utilized to achieve the goals: fund three agencies in high-needs communities; increase the number of physicians, physician's assistants (PAs), and nurse practitioners (NPs) by facilitating access to education and case consultation; engage Alaska's reentry coalitions to facilitate access to MAT; and purchase and distribute drug disposal bags and naloxone in remote areas of the state. 2:17:25 PM MR. BURNS pointed to slide 5, "Opioid State Targeted Response (STR)," and noted the areas targeted for funding, which would begin in October 2017: the Fairbanks Native Association in Fairbanks for $400,000; the Interior Aids Association in Fairbanks for $400,000; and the Cook Inlet Council on Alcoholism and Drug Abuse in Kenai for $350,000. He noted that an additional award for $350,000 was set aside for administration by the Office of Substance Misuse and Addiction Prevention (OSMAP). He said there was an additional search for a group to target youth and young adults experiencing opioid disorders. 2:19:58 PM MR. BURNS shared slide 6, "Prescription Drug Opioid Overdose- Related Deaths" and said there was a collaboration between the Division of Behavioral Health and the Office of Substance Misuse and Addiction Prevention for implementation of Project HOPE and the distribution of Narcan kits statewide. 2:21:25 PM MR. BURNS spoke about slide 7, "The Strategic Partnership for Success (PFS)," which was the final grant received by the state and was a very comprehensive approach to opioid addiction in the state. The goal of this initiative was to reduce and prevent the non-medical use of prescription opioids and heroin among 18 - 25-year old's by focusing on three areas of prescription opioids: the social availability, the retail availability, and the perceptions of harm for risk. He reported that prevention and early intervention coalitions in Sitka, Juneau, Kenai, Anchorage, Matanuska-Susitna, and Fairbanks were awarded more than $1.5 million for each of the next five years. He stated that the initiative required these coalitions to implement evidence based informed, local, environmental strategies which could be sustained within the local system as well as implement a media campaign. 2:24:14 PM REPRESENTATIVE TARR expressed her desire to understand the current state resources and how these were being used, to better understand "where the gaps are." She asked for verification that each slide presented a different set of federal grants. She asked whether the dates mentioned referred to the federal fiscal year. MR. BURNS acknowledged that three federal grants had been referenced, all based on federal fiscal years, which specifically focused on opioid addiction and targeted communities to help with this crisis. REPRESENTATIVE TARR asked about the relative impact of these dollars. MR. BURNS expressed his agreement that it was too soon to tell. 2:28:01 PM REPRESENTATIVE KITO directed attention to slide 5 and asked if the individual grantees were required to provide services outside of their communities. MR. BURNS explained that the primary focus was on the local community and residents, and these were not residential treatment programs. REPRESENTATIVE KITO offered his belief that these three grants covered many Alaskans. He stated that he did not want to see these programs focused only on urban centers, and that outreach and support needed to be extended to smaller communities. He asked if the upcoming youth grant would be required to be a statewide program. MR. BURNS clarified that initially all the grants were competitively awarded, and that only three communities had responded to the four grants available. He stated that the solicitations were not limited. REPRESENTATIVE KITO stated that he wanted to ensure that the state provided coverage beyond the few urban centers, even if this necessitated a re-write of the grant solicitations. He expressed his concern that there would be a self-selection process for the grants to be awarded to communities with large populations, which would leave the smaller communities to fend for themselves during this opioid epidemic. He suggested that providers in the larger communities should also do outreach and provide services beyond the community. 2:33:03 PM REPRESENTATIVE SADDLER asked about the hub and spoke model referenced on slide 4. MR. BURNS explained that this was not the same as the common regional hub and surrounding communities, but was, instead, a reference to a Vermont model in which the hub was the office based opioid treatment provider and counseling, and the spokes were the office-based treatment and case management with local services. REPRESENTATIVE SADDLER asked if there was any correlation between unemployment levels and addiction rates. MR. BURNS replied that he did not have any information for this, although it was believed that two key tenets of recovery were housing and employment. REPRESENTATIVE SADDLER asked about the use of vivitrol as a medication. MR. BURNS replied that this was used by the Department of Corrections to individuals with a history of addiction to heroin, and that there was a study planned for its effectiveness. He said there was nothing that prevented an individual from opting for vivitrol as opposed to suboxone. 2:37:18 PM REPRESENTATIVE EDGMON asked how these grants were tying into the 6-year framework for Senate Bill 91, and if there were any matching fund relationships with state funding. He noted that criminal justice reform was largely based on evidenced based practices and measurable outcomes. He asked if the various agencies were working together and were these results measurable. He asked what could be done to reduce recidivism in crime. CHAIR SPOHNHOLZ reiterated that the purpose of this meeting was for "rolling through the work that's being done by the Department of Health and Social Services, particularly to address the issue of addiction and addiction treatment in the State of Alaska." She noted that there would also be discussion for the reinvestments into re-entry programs and treatment programs. 2:40:21 PM REPRESENTATIVE KITO referenced slide 12 and asked about "the universe of need for residential treatment beds in Alaska and then what is the plan to try and get to that bed count or is that even known." CHAIR SPOHNHOLZ pointed out that slide 12 had not yet been presented. 2:41:18 PM CHAIR SPOHNHOLZ referenced slide 2 and asked if any partners had been identified in Matanuska-Susitna. MR. BURNS reiterated that with the Medicaid assisted treatment program, Anchorage and Juneau had been targeted as these communities having the highest prevalence of need. CHAIR SPOHNHOLZ expressed her surprise that Matanuska-Susitna did not rise to the top for need. She asked if there had been any skewing of the numbers with people coming to Anchorage from Matanuska-Susitna for treatment services. MR. BURNS reported that although this was a possibility, during application for the State Targeted Response (STR) grant, Matanuska-Susitna had not applied. He mused that it depended not only on the interest but the capacity of the community to provide service. 2:44:00 PM REPRESENTATIVE TARR asked for an explanation to the medication assisted treatment and the order for usage of each drug. MR. BURNS directed attention to the handout titled "AATOD Fact Sheet" [Included in members' packets] which explained the value and the differences between Methadone, Vivitrol, and Suboxone. He stated that all three provided treatment. He explained that daily Methadone treatment was highly recommended for addiction to heroin and those subsequent changes to the brain, which required long term maintenance to "get themselves back on track." He said that it was taken each day to maintain sobriety and work on addiction. He explained that Vivitrol was administered as a shot, once a month. He reported that Suboxone was another alternative, dependent on the patient need and what works best. He declared that they all worked well for an individual to get off addiction. 2:50:39 PM REPRESENTATIVE TARR asked if the reference to detox was for the early phase and then MAT was referenced after this initial recovery period. MR. BURNS explained that the terminology was changing under the American Society of Addiction Medicine (ASAM), and that detox was now called "withdrawal management" and only applied for alcohol abuse. He offered his belief that individuals with addictions to heroin and opioids never really de-toxed, but instead were treated and managed for stabilization and withdrawal. CHAIR SPOHNHOLZ offered her belief that alcohol withdrawal was the only process that could kill you. 2:54:11 PM REPRESENTATIVE TARR asked if Mr. Burns was describing sudden opioid withdrawal. MR. BURNS replied that it was best to treat the addiction and help them to stabilize by eliminating the highs and lows. 2:55:32 PM JAY BUTLER, MD, Chief Medical Officer/ DPH Director, Central Office, Division of Public Health, Department of Health and Social Services, in response to Representative Tarr, stated that the agonist Methadone and the partial agonist, Suboxone, had a role in the withdrawal management process; whereas, the complete antagonist, Vivitrol, was used after the end of the withdrawal phase as the drug could induce withdrawal. He stated that alcohol withdrawal was more dangerous for mortality, but that withdrawal from opioids could combine with other compromising health conditions for a fatal outcome. He said that there were different methods of medication delivery, including sprays, shots, implants, and a film strip placed under the tongue. He said that more than 100 providers in Alaska had prescribed Vivitrol at one time or another and it had been used in treatment for alcohol dependency. 2:59:05 PM CHAIR SPOHNHOLZ asked for clarification that Vivitrol could not be used if there was any opioid in the system. She asked if this was also contraindicated for use with methadone or suboxone. DR. BUTLER said that if there was any agonist in the system, it was necessary for a very careful transition, hence it was fairly uncommon. 3:00:34 PM GENNIFER MOREAU-JOHNSON, Behavioral Health Policy Advisor, Office of the Commissioner, Department of Health and Social Services, introduced slide 8, "Recidivism Reduction," and said that this funding was intended to break the cycle of repeat offenders. She said that the Division of Behavioral Health received $1 million in FY17, and $2 million in FY18, and that the division was able to leverage a strong grants and contracts infrastructure to coordinate targeted programming support. MS. MOREAU-JOHNSON addressed slide 9, "Funds are being used for," and reported that the funds were being used for direct service outcomes through the Partners Reentry Center in Anchorage, and through existing community reentry programs and coalitions in Anchorage, Fairbanks, Matanuska-Susitna, and Juneau to offer case management for housing placement, transitional support, linkage to treatment, employment assistance, Medicaid enrollment, transportation, and emergency assistance vouchers. She added that there was funding for rural reentry coalitions in Nome, Ketchikan, Dillingham, and Kenai which focused on provider capacity and community planning. MS. MOREAU-JOHNSON directed attention to slide 10, "Funds are being used for," and reported that recidivism reduction funding was co-funding a two-year study with the University of Alaska Anchorage to assess the Department of Corrections Vivitrol intervention program. She stated that recidivism reduction funding was funding technology platforms for therapeutic courts and reentry programs to utilize a case management module. She added that there was also funding through treatment recovery grants, which were leveraged with criminal justice-specific supports and linkages to treatment providers. 3:03:01 PM MR. BURNS stated that $400,000 in recidivism reduction funding was being used to support housing programs for individuals coming out of prison. 3:03:45 PM REPRESENTATIVE SADDLER referenced the technology platforms on slide 10 and pointed out that Senate Bill 91 did recommend expanded use of diversions, drug courts, and therapeutic courts. He asked if the broad band would support the existing platforms. MS. MOREAU-JOHNSON replied that the funding was for what was currently in place. CHAIR SPOHNHOLZ asked if these technology platform improvements would allow for a seamless coordination of services. MS. MOREAU-JOHNSON stated, "yes, that is the vision for this." In response to Chair Spohnholz, she stated that there was still work to be done to ensure compliance with regulations for criminal justice and Health Insurance Portability and Accountability Act information systems. 3:05:20 PM REPRESENTATIVE SADDLER asked if there would be a request for additional funding to expand to accommodate more diversion programs, drug courts, and tele-behavioral medicine. MS. MOREAU-JOHNSON replied, "yes." 3:05:46 PM REPRESENTATIVE EDGMON asked if there was any information to tie in the rising crime rates with the rising use of drugs. MR. BURNS offered his belief that "the answer to that is no, not at this time." He acknowledged that there was a lot of unfortunate belief that there was a correlation, though he was not aware of any studies which had been undertaken. He opined that information about individuals incarcerated for substance abuse would offer an insight into the problem. REPRESENTATIVE EDGMON replied that this was counter to what he was hearing and seeing. He stated that it was apparent that more tools were necessary in the tool box to combat the increasing statewide crime. He offered his belief that there was a correlation between the increase in drug use and the increase in crime. MR. BURNS reported that the University of Alaska Justice Center had a research arm which would be well positioned for a study. CHAIR SPOHNHOLZ asked for clarification that this had not yet been studied, and not that there was or was not a correlation or causation. MR. BURNS acknowledged that there had not yet been a study to establish any correlation. 3:09:55 PM REPRESENTATIVE KITO offered his belief that there were studies outside Alaska which related to an increase in unemployment to an increase in crime. He stated that even without studies, it was valid to have concerns. 3:10:36 PM REPRESENTATIVE SULLIVAN-LEONARD stated that her discussions with public safety officials indicated a direct correlation. CHAIR SPOHNHOLZ clarified that Mr. Burns had stated there had not been studies. 3:11:53 PM MR. BURNS moved on to slide 11, "Alcohol Safety Action Program," and reported that the Adult Substance Abuse Program (ASAP) had received a modest amount of funding, specifically to train ASAP staff on the use of screening tools. These tools included use of local referral and services. CHAIR SPOHNHOLZ asked for a more detailed description for the function of this program. MR. BURNS explained that the Alcohol Safety Action Program was created for individuals with misdemeanors, primarily a misdemeanor DUI (driving under the influence), as an option to being placed in jail and would include regular monitoring, urine analysis, appointments, and drug screening. He noted that there was now risk assessment for suggestions to the levels of treatment. CHAIR SPOHNHOLZ asked if this included the 24/7 program. MR. BURNS replied, "it does." CHAIR SPOHNHOLZ asked if this program was currently on line. MR. BURNS explained that it had been the subject of a protracted contractual issue and was currently only being provided to those already in the program. 3:16:48 PM REPRESENTATIVE SULLIVAN-LEONARD asked about the Alaska Justice Information Centers report on the effectiveness of the adult criminal justice program and the benefits of investment on recidivism. MR. BURNS replied that he had not seen the study. REPRESENTATIVE SULLIVAN-LEONARD asked about the success rate of ASAP. MR. BURNS replied that did not have exact numbers and opined that the program had been "pretty successful with the individuals who stay in the program." He allowed that some individuals did choose to leave the program, although they were then required to "deal with the judge and the consequences of that decision." He offered his belief that those who stayed in the program and were monitored had been very successful. 3:19:31 PM MR. BURNS directed attention to slide 12, "Increased Substance Use Disorder Treatment Services," and spoke about the $31 million funding which the legislature had added for behavioral health services, which had ultimately been reduced to $6 million for substance use disorder services over three years. He added that the Central Peninsula Hospital Withdrawal Management program had been funded for six beds, with a plan for expansion to ten beds. He reported on funding for the Tanana Chiefs Conference Sobering Center day program, which had expanded to a 12-bed capacity. 3:22:09 PM REPRESENTATIVE KITO directed attention to slide 12 and asked if there was any information or a plan to identify the universal need in Alaska for in-patient treatment beds. MR. BURNS said that there had not been a total statewide needs assessment. He stated that a large part of this issue should be driven by regionally identified needs. He reported that a significant component of the $6 million funding was that the communities share a needs assessment indicating the value of this service. He expressed his agreement that each region determine which service was best for that region. He reported that the federal grants each had a significant evaluation component, which the department would collect and evaluate. REPRESENTATIVE KITO asked to clarify that there was not any information to identify the number of beds needed in the state. He offered a comment that it was difficult for policy makers to make decisions without statewide data and that a regional approach could result in overwhelming use from other regions that had not adequately identified needs. MR. BURNS reported that statewide there were 311 residential treatment beds. He said that these were tracked for capacity and wait lists. He acknowledged that the reporting was somewhat erratic, and that it was necessary to account for beds being held open for someone transitioning. 3:27:46 PM REPRESENTATIVE SADDLER pointed to the challenge that the costs were the same to maintain a stand-by equipped and staffed facility. He spoke in support of a regional approach because of the flexibility and efficient utility for demand. He asked if there was any national data to determine treatment beds per population, which could be modified to the unique situations in Alaska. MR. BURNS said that he was not aware of any data, and he pointed to the difficulties posed by Alaska's geography and small communities for using national data. REPRESENTATIVE SADDLER reported on the treatment facility currently under construction within his district, in Eklutna. 3:29:59 PM REPRESENTATIVE TARR declared that she wanted to get a sense for how much money spent so far had been from grants. She listed the various grants and asked if there would be equal spending over the next five years. She mused that there was $6-8 million coming in the next few years. MR. BURNS offered to provide a chart of what had been extended to date and what remained to be spent for each grant. REPRESENTATIVE TARR opined that this would allow a more strategic approach by the legislature in its spending distribution. She asked if the Kenai detox program included beds available for anyone experiencing alcohol or opioids addiction or in treatment. MR. BURNS replied that it was an alcohol withdrawal management treatment center. He reported that there were 17 residential treatment programs in Alaska with 311 beds. He stated that none of these programs treated for anything other than alcohol withdrawal. He pointed out that opioid medication assisted treatment did not require residential treatment, as it included any necessary medication and counseling. 3:35:29 PM DR. BUTLER spoke about the Office of Substance Abuse and Addiction Prevention within the Department of Health and Social Services. He declared that this was a wise move to institutionalize some of the functions for coordination, communication, and community engagement. He pointed out that there was assistance from other agencies. He explained that the focus was for both primary prevention and prevention of bad outcomes. He mentioned that this would address both the supply and demand side for drivers to substance misuse and addiction. He spoke about Adverse Childhood Experiences (ACEs), and unemployment, noting that "a healthy economy makes healthy Alaskans." He brought attention to slide 7, "The Strategic Partnership for Success," which explained prevention activity. 3:39:43 PM REPRESENTATIVE EDGMON asked about the impact if Senate Bill 91 was repealed. MR. BURNS opined that should the programs and services lose the recidivism reduction funding, those communities with organized services for those individuals leaving prison would be affected. He noted that programs with federal or legislative funding would be less affected. 3:41:34 PM REPRESENTATIVE SADDLER offered his belief that Senate Bill 91 anticipated future savings because of a reduction to incarceration and asked whether the programs would still have the necessary resources even should Senate Bill 91 be repealed. DR. BUTLER explained that the work through the Office of Substance Abuse and Addiction Prevention was primarily driven with federal grant monies and would most likely continue. He pointed out that treatment programs within prisons would be affected and admitted that he was unsure what other actions would be a result from the repeal of Senate Bill 91. 3:44:04 PM CATHLEEN MCLAUGHLIN, Director, Partners Reentry Center, stated that the facility was an open, walk-in center, which was available to everyone. She introduced a short video. 3:47:19 PM MS. MCLAUGHLIN directed attention to the PowerPoint, titled "Justice Reinvestment Funds, An Agency's Perspective." She addressed slide 2, "Goals," and stated that the agency always had monthly statistics with real-time data entry available. She reported that the Center had been around for four years, and that it had enhanced its programs in the last year with justice reinvestment funds. She stated that the goal was to reduce recidivism and to enhance public safety, which she deemed went "hand in hand." She added that it was very important for the center to provide timely "reentrant-centric" services. She shared a story of a recently released inmate. She emphasized that the Center would never let anyone be homeless the night they were released from incarceration. MS. MCLAUGHLIN moved on to Slide 3, "Here is the reality," reporting that 95 percent of all offenders will be released. She offered her belief that Senate Bill 91 changed the timing of this release, not the type of people that were being released. 3:51:16 PM MS. MCLAUGHLIN shared slide 4, "The CliffsNotes Version," explaining that the Partners Reentry Center viewed life on the street level. She reported that criminal justice reform was a "heavy lift" and they were still learning at the street level. She declared that there were three things vital to criminal justice reform: collaboration, cooperation, and continuums of care. She said that as there was a lot of competitiveness for funding, people did not share as they should. She explained that collaboration should allow for an immediate referral for someone. She pointed out that they blended their funds from various sources to allow for housing for longer periods. She said that continuum of care was especially important for people with medically assisted treatment. She declared that the transfer of responsibility for each individual had to be done seamlessly. 3:54:57 PM MS. MCLAUGHLIN shared slide 6, "The Center." She stated that people needed to be able to come and go freely without feeling as if they were being watched. She reported that between 60 and 100 individuals came daily, and that people were greeted within a minute, no one was waitlisted, and services were provided that day. MS. MCLAUGHLIN moved on to slide 7, "Partners Reentry Center -" and explained that the cheapest and easiest thing to offer was to give reentrants purpose and hope. She declared that there were plenty of beds available in Anchorage and that the Center also provided supportive services, such as bus passes, and help with identification and driver licenses. She emphasized that the Center did timely referrals to services. She said the Center was open for groups to come and sign up reentrants for Medicaid and food stamps. 3:58:49 PM MS. MCLAUGHLIN explained slide 8, "Partners Reentry Center Has Received $250,000 in Justice Reinvestment Funds for 2018." She noted that the allocation was primarily for direct services, as the Center believed that the quicker someone could receive community-based services, the higher the likelihood they would not recidivate. She reported that the money went to housing, another case manager, a full-time data person, and additional bus passes, transportation, clothing vouchers, and bikes. MS. MCLAUGHLIN shared slide 10, "Statistics," and reported that since August 2013 there had been 5,110 unique individuals served, with 109 new clients in September. She explained MRT (Moral Reconation Therapy) which sought to decrease recidivism by increasing moral reasoning. She stated that the goal was to turn a "Son of Sam" into a "Mother Theresa." MS. MCLAUGHLIN stated that the average number of reentrants using the services was between 329-369. She addressed slide 11, "Being Meaningfully Engaged in Community Reduces Recidivism," which listed the components of the drive to reduce recidivism, and included: pre-release planning, housing, employment and training, behavioral modification, and social support. She explained some of the difficulties of adjustment for reentrants. 4:04:51 PM MS. MCLAUGHLIN directed attention to slide 12, "Partners' Opioid and Alcohol Pilot Project," and shared a story of a heroin overdose and the initiation of a vivitrol program. She stated that medically assisted treatments were often necessary and should be treated as a tool. She pointed out that vivitrol did not have any street value and was administered as a shot. She added that if a person left incarceration clean, then vivitrol would help him/her stay clean. 4:07:35 PM MS. MCLAUGHLIN referenced slide 13, "Partners' Opioid Pilot Project Outcomes," which reported on the 254 individuals who were offered this voluntary option to date. She noted that of the 142 individuals who had accepted the Vivitrol program for one month or more, 64 percent had remained in the community, while 36 percent had recidivated. She pointed out that although vivitrol helped with alcohol or opioids, the effect of vivitrol was diverted if the individual was still a user. She reported that alcohol was one of the highly abused substances for Alaska Native reentrants. Of the 112 individuals who had declined the Vivitrol program, 80 percent had recidivated, 16 percent had remained in the community, and 4 percent had died of a heroin overdose. 4:10:27 PM MS. MCLAUGHLIN shared that the offer of direct service in a timely fashion, community-based reentry, was a great benefit for community safety and for the reentrants. She declared that it was necessary to be honest about the homeless population, as they would break in for food or shelter. She noted that unemployment was also a problem, as there was not a purpose, and more time to do bad things. She pointed to the difficulty for avoiding these actions in many parts of the state. She offered her belief that crime should not be tied to Senate Bill 91, and that instead, there should be a review of these drivers. 4:13:55 PM REPRESENTATIVE SULLIVAN-LEONARD asked how soon there was interaction with the housing facilities for inmates in order to think about release. MS. MCLAUGHLIN shared that the model that worked best was a regular schedule as it allowed for them to get to know individuals. She added that there would be a regular telephone conference with the individual and the institution as release was upcoming. She stated that the goal was to develop relationships sooner rather than later. REPRESENTATIVE SULLIVAN-LEONARD asked about funding and budgets. MS. MCLAUGHLIN replied that initially, four years prior, the Center had been funded with a $600,000 grant divided among three non-profits. After one year, one group left, and the contract had been reduced to $550,000, which had been the operating budget for the past two years. She reported that currently there was a $550,000 contract with Department of Health and Social Services, which was enhanced with $250,000 from Justice Reinvestment funds. She summarized that the commitment from the Department of Behavioral Health was now $800,000 with an additional $150,000 for homeless assistance for housing, and a federal SNAP grant which was projected to add another $11,000 each month. REPRESENTATIVE SULLIVAN-LEONARD asked about work with unions or organizations that provided training. MS. MCLAUGHLIN replied that there were almost 700 employers who would hire. She said that apprenticeships could be "a little tricky," as the Center encouraged self-sufficiency as quickly as possible. For this reason, they did not encourage schooling until the reentrants could better understand budgets. She declared that they did look at all activities and opportunities to give purpose to individuals. 4:20:44 PM REPRESENTATIVE SADDLER asked if Senate Bill 91 was heard by the House Health and Social Services Standing Committee (HHSS). CHAIR SPOHNHOLZ said that it had not been heard by HHSS. REPRESENTATIVE SADDLER asked if Partners was the only official State of Alaska reentry program, and he shared his background knowledge of transitioning out of the military. He asked about any reentry programs through the Department of Corrections. MS. MCLAUGHLIN explained that there were several reentry model programs, and that Partners worked with the reentry coordinator at Department of Corrections. She added that there were reentry coalitions in some hub areas, as well as reentry programs through Cook Inlet Tribal Council and Alaska Native Justice Center. She reported that the only reentry programs funded through the Justice Reinvestment were the Partners Reentry Center and the coalitions. In response to further questions from Representative Saddler, she stated that there was not any religious aspect to Partners, and that about 70 percent of the clients had substance abuse issues and that 70 percent had mental health issues. 4:23:17 PM REPRESENTATIVE EDGMON asked about the impact to these reentry programs if Senate Bill 91 was repealed. MS. MCLAUGHLIN relayed that from a programmatic point of view, the programs had made headway for community-based reentry. She declared that the month to month credit in Senate Bill 91 was good incentive to behave and do the right thing. She acknowledged that there were some weaknesses in Senate Bill 91 and that the community-based programs needed to be able to take immediate control. She stated that it was necessary to "play small ball" as there were not going to be a "bunch of home runs right now." She declared that it was necessary to take the benefits offered by Senate Bill 91 and focus on the gaps, and not to ignore that headway had been made. She pointed out that Partners had been in existence prior to Senate Bill 91, and that the program would, hopefully, continue, although, she opined, there would be less interest in reentry programs if Senate Bill 91 were repealed. REPRESENTATIVE EDGMON suggested that the reentry program efforts would be less successful, and the momentum would be lost. 4:27:15 PM MS. MCLAUGHLIN, in response to Representative Tarr, reported that for individuals with more than 15 years of incarceration, their release was different as they were more motivated, more structured, and more disciplined and their release was more of a social acclimation. She added that these individuals had probably committed violent crimes. She stated that these individuals were very easy to work with, as they wanted to prove themselves, and they had a lot more to lose if they violated parole. She noted that the program had its least success with the "high flying misdemeanants," as they had not done enough time to understand the consequences of their actions. She said there were ways to improve this, now that recidivism rates had been identified for this population. She emphasized that these reentry types were totally different. In response to a further question from Representative Tarr, she explained that Partners used its funding for direct bed day rates with individual contracts for housing, and that they had 16 transitional sites in Anchorage. She said they did not use vouchers. She added that support for a permanent placement of housing required that the individual had "purposeful activity." 4:31:09 PM REPRESENTATIVE KITO reported that Juneau also had a reentry coalition, which was a regional service. He asked how to manage individuals who were not residents of the local area and wanted to return to their home community yet needed to have a parole relationship. MS. MCLAUGHLIN explained the Partners' Going Home Program, which had been created for Alaska Natives and was based on the restorative justice model. She said that involvement for reentry to their home community included asking permission from the tribal leaders and putting a safety net around them, before sending them home. She added that Partners did pay for housing and flights if they were allowed to return home. She pointed out that the village, or the region, became a part of the healing process. She said that the safety net included accountability to the community. She declared that a key was for someone to follow the individual, and that successful reentry required case management and connection to services, which could be creative. She said that she did not know the intention of the Juneau coalition. REPRESENTATIVE KITO asked if this program was something that could engage with other reentry coalitions and organizations. MS. MCLAUGHLIN said that their contract mandated for technical assistance with the other areas of the state which desired parts of the program that would work in those communities. She offered her belief that every community should create its own reentry program, and this should not be a cookie cutter model. She pointed out that Partners was unique because "we didn't have a road map, we figured it out as we went." 4:34:29 PM CHAIR SPOHNHOLZ directed attention to an earlier remark in the presentation about referrals, and asked which referrals were not being picked up in a timely manner. MS. MCLAUGHLIN explained that these were for mental health treatment, substance abuse treatment, anger management treatment, and sex offender treatment. She stated that the challenge for timely referral acceptance was the need for an immediate consultation with a medical person, and not placement on a wait list. CHAIR SPOHNHOLZ relayed that the legislature was struggling with what would be the next steps. She wanted to ensure that the necessary services were put in place. She asked about the shortages of services. MS. MCLAUGHLIN explained that the service gaps were timely referral because of bureaucratic challenges. She pointed out the difficulty of asking someone for whom English was a second language to fill out a 15-page application for a prescription refill. She opined that collaborating agencies should have their funding tied to being collaborative with other agencies. 4:37:45 PM REPRESENTATIVE SADDLER pointed out that as Senate Bill 91 was not before the committee, it was not necessarily fair to ask her to opine about its repeal or change. 4:40:23 PM LAURA BROOKS, Health Care Administrator, Division of Health & Rehabilitation Services, Department of Corrections, stated that the presentation would focus on the substance abuse programs. She estimated that between 70 - 80 percent of the criminal justice population had serious substance use disorders. She directed attention to slide 2, "Institutional Substance Abuse Treatment Programs," which identified the target areas related to Senate Bill 91, which included: increase availability of substance abuse services and assessments; expand services available to female offenders; expand services available to pretrial offenders; develop medical assist treatment re-entry (MATR) and implement overdose intervention response programs; and improve referral process for offenders upon reentry. 4:43:48 PM MS. BROOKS pointed to slide 3, "Institutional Substance Abuse Treatment Programs," and stated that this outlined the programs provided by the division. She spoke about each of the programs: the RSAT (residential substance abuse treatment) program, the IOPSAT (intensive outpatient substance abuse treatment) program, the Dual Diagnosis program which was also an IOPSAT 19-week program, and the PsychEd, a six week program typically found at the pre-trial facilities with a transient population and a focus on education about substance use and addictive behaviors, and the harmful consequences of high risk, high use behaviors. 4:47:45 PM MS. BROOKS addressed slide 4, "Institutional Substance Abuse Treatment Programs," and reported that offenders received a substance abuse assessment, so the true substance abuse issues and levels of treatment could be determined. She spoke about the new MATR (Medicaid assisted treatment upon reentry) vivitrol program. She reported that individuals were referred to this program and went through a screening to ensure they were healthy enough with no contraindications for vivitrol. 4:50:46 PM MS. BROOKS moved on to slide 5, "Institutional Substance Abuse Treatment Programs," which included the MATR Vivitrol and methadone treatment. She noted that vivitrol was only one choice in a true medication assisted treatment program. She reported that the program wanted to ensure there was "a healthy, safe bridge" for those people already on methadone and releasing very soon. She shared that they were working with the community methadone clinics so that it was not necessary to detox everyone on methadone. She listed the additional program planning for FY 18, which included: Full expansion of vivitrol in all the facilities and detox treatment beds which allowed for women to withdraw under medical observation. She spoke about development of a WRAP (Wellness Recovery Action Plan) program, which was a peer-based intervention program to help individuals design a relapse prevention plan and have peer support for crisis. She added that a SBIRT (screening, brief intervention, referral to Treatment) program, an evidence based brief intervention program which identified, treated and referred people with substance abuse, was also being worked on. 4:57:30 PM MS. BROOKS shared slide 6, "Community Residential Center (CRC) Substance Abuse Treatment Programs," and spoke about the Senate Bill 91 funding for substance abuse treatments in the community residential centers. She noted that there was intensive out- patient programming in three of the CRCs. She added that there was still work toward the intensive outpatient programing in Juneau and Bethel. 4:58:27 PM REPRESENTATIVE KITO addressed the high pre-trial population in correctional facilities and the release of people prior to the completion of treatment. He asked if there were any plans to work on a transition program for those individuals in initial treatment to carry that out in the pre-trial release. MS. BROOKS said the department was working on the case management system, so these individuals could go to a treatment program in the community which would match the curriculum in the facility. She acknowledged that during treatment was the best time for re-connection. REPRESENTATIVE KITO asked if the Department of Corrections had adequate resources to provide treatment for those wanting treatment or were there still some unmet needs. MS. BROOKS explained that the department was reviewing how well it would be able to fill the programs currently being planned. She said that as not everyone wanted treatment, it was not clear what was the needed capacity. She shared anecdotally that there had not been enough treatment programs; however, she expressed her hope that with the funding from Senate Bill 91 and the current plans for expanded services, [the department] would be able to better meet that need. 5:02:12 PM REPRESENTATIVE SADDLER asked if the Department of Corrections had become the default substance abuse treatment program for the state. He asked for a comparison of the relative expenditure and capacity for substance abuse treatment between Department of Corrections and Department of Health and Social Services. MS. BROOKS reported that Department of Corrections was the largest substance abuse treatment provider, as well as the largest mental health provider. She pointed out that they were, in some ways, the default provider, as they had a "captive audience," and they were attempting to take advantage of this opportunity. She stated that it was difficult because there was not ready access to treatment both before and after incarceration. REPRESENTATIVE SADDLER asked about the funding sources for treatment, and whether there was a cost-benefit analysis for the use of medication assisted withdrawal recovery. MS. BROOKS replied that the funding source for substance abuse treatment programs were almost entirely from the Department of Corrections budget. She added that there was a relatively small federal grant, although there was not any funding for substance abuse from the Alaska Mental Health Trust or other resources. 5:04:34 PM APRIL WILKERSON, Director, Juneau/Anchorage, Division of Administrative Services, Department of Corrections, reported that about $70,000 was received from Department of Health and Social Services through the alcohol tax fund, which supported the residential substance abuse program. She relayed that the remainder was general funds. MS. BROOKS, in response to Representative Saddler, explained that the primary cost to the Vivitrol program was for staff resources, as the Vivitrol injections were free samples from the pharmaceutical companies. She relayed that the department wanted to ensure that these injections were beneficial for a reduction in clinical relapse back to opioids and a reduction in recidivism. She shared that the department was in partnership with University of Alaska Anchorage (UAA) to do a study of the vivitrol program with a focus on recidivism and relapse data. She added that the cost of each injection was between $700- $1,000. CHAIR SPOHNHOLZ reported that Department of Corrections had only used 72 doses of the 1200 doses donated. She acknowledged the importance for the two-year study to evaluate the efficacy of the program, considering the steep cost for the vivitrol. 5:07:33 PM REPRESENTATIVE TARR asked about the barriers to employment upon release. She asked about consideration for the policy that allowed individuals upon release to use a homeless shelter as their home, as the shelters did not typically have the capacity for case management. MS. BROOKS expressed her agreement that the homeless shelter was not an ideal placement. She stated that there was the need for a more robust case management system for substance abusers. She acknowledged that case management in the shelters was very limited, and this created a barrier for the department follow- up. 5:09:38 PM REPRESENTATIVE EDGMON opined that although Senate Bill 91 had not come before the House Health and Social Services Standing Committee, the discussion was germane to the work of the committee and asked what would happen to the Department of Corrections if Senate Bill 91 were repealed. MS. BROOKS replied that the Department of Corrections had received $1 million to expand substance abuse treatment programs while in custody, and another $1 million to implement programs within the CRCs. She stated that she was not aware of any alternative funding sources that would allow continuation for expansion or continuation of the programming in the halfway houses. MS. WILKERSON reported that there were many elements in Senate Bill 91, and that rolling this back in full would create challenges for maintaining the efforts toward recidivism reduction and provision of the services and programs included in the bill. REPRESENTATIVE EDGMON declared that this was the opportunity for fundamental reform in criminal justice and that this momentum for reducing crime and expenses would be lost if Senate Bill 91 were repealed. 5:14:07 PM CHAIR SPOHNHOLZ declared that she was impressed with the scope of treatment offered and that even without dramatic improvement in recidivism rates, this was a step in the right direction. She asked about the two to three assessments per week referenced on slide 4. MS. BROOKS explained that each assessment would take hours to interview and write a report. She stated that this would be expanded to include more assessments, if necessary. CHAIR SPOHNHOLZ asked if there was opportunity to expand if necessary. MS. BROOKS said there was the opportunity if there were enough providers, noting that there was difficulty in some locations with finding substance abuse programs having enough staff to provide services in the facilities. CHAIR SPOHNHOLZ acknowledged the need for more workers even when the funding was available. She asked about the difficulty for finding individuals who wanted treatment upon exit from prison. MS. BROOKS stated that it was very difficult finding treatment beds for even those motivated people who were ready for treatment. She added that some criminal background could make it even more difficult. She reported that on average, it would take several weeks to get an individual into a treatment bed. CHAIR SPOHNHOLZ asked if a more proactive exit plan would help. MS. BROOKS reported that the residential treatment beds in communities were full, although there was greater success with outpatient treatment. 5:19:22 PM REPRESENTATIVE SADDLER suggested that the department expect questions regarding the efficiency and efficacy, as well as a robust cost-analysis, of the program. He asked if she would still have an opinion for the repeal of Senate Bill 91 if the money was still made available. MS. BROOKS replied that she was reluctant to offer any analysis. She said that some of these programs were already in place, but expansion for the programs was difficult without money. She pointed out that Medicaid did not pay for substance abuse treatment for individuals in custody. CHAIR SPOHNHOLZ stated that this was "a very important fact." 5:21:37 PM REPRESENTATIVE EDGMON said that he was not aware of the pre- trial aspects, given the importance of Senate Bill 91 to the Department of Corrections. MS. BROOKS said that she could only speak about her division, although Representative Edgmon was correct for the impact of Senate Bill 91 to the entire department. CHAIR SPOHNHOLZ reported that the Commissioner of Department of Corrections had been unable to attend. 5:22:48 PM REPRESENTATIVE TARR offered her belief that there had not been enough anticipation for the time necessary for programs to be funded and up and running. She asked about the timing to allow for provider capacity and for the services to be available. MS. BROOKS explained that the RFP (Request for Proposal) process was "not always a quick one." She said that it was necessary to develop RFPs for various communities, and, in some cases, it was necessary to repeat the process as there were not responses. She added that as some agencies did not feel they were able to bring in a program, it was necessary to move the program. She reported on a contract that DOC had in place with anticipation for expansion, and, instead, the contractor ended the contract. She pointed out that it was necessary to start over in some cases, while maintaining the "bare bones essential treatments going in a handful of our facilities." REPRESENTATIVE TARR asked to which substances did lack of treatment capacity refer. MS. BROOKS opined that this was a unilateral issue. CHAIR SPOHNHOLZ summarized the issues discussed. 5:31:21 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 5:31 p.m.