Legislature(2017 - 2018)CAPITOL 106
02/13/2017 01:30 PM Senate HEALTH & SOCIAL SERVICES
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| Presentation: the Science of Opioid Use Disorder | |
| Adjourn |
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ALASKA STATE LEGISLATURE
JOINT MEETING
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
February 13, 2017
1:35 p.m.
MEMBERS PRESENT
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
Representative Ivy Spohnholz, Chair
Representative Sam Kito
Representative Jennifer Johnston
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
Senator David Wilson, Chair
Senator Natasha von Imhof, Vice Chair
Senator Cathy Giessel
Senator Peter Micciche
Senator Tom Begich
MEMBERS ABSENT
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
Representative Bryce Edgmon, Vice Chair
Representative Geran Tarr
Representative David Eastman
Representative Colleen Sullivan-Leonard
Representative Matt Claman (alternate)
Representative Dan Saddler (alternate)
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
All Members Present
COMMITTEE CALENDAR
PRESENTATION: THE SCIENCE OF OPIOID USE DISORDER
- HEARD
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
JOSHUA SONKISS, M.D.
Chief Medical Officer
Anchorage Community Mental Health Services
Anchorage, Alaska
POSITION STATEMENT: Presented a PowerPoint titled "The Science
of Opioid Use Disorder."
ACTION NARRATIVE
1:35:15 PM
CHAIR DAVID WILSON called the joint meeting of the House and
Senate Health and Social Services Standing Committees to order
at 1:35 p.m. Representatives Spohnholz and Kito and Senators
Wilson, Von Imhof, Giessel, Begich, and Micciche were present at
the call to order. Representative Johnston arrived as the
meeting was in progress.
^Presentation: The Science of Opioid Use Disorder
Presentation: The Science of Opioid Use Disorder
1:35:44 PM
CHAIR WILSON announced that the only order of business would be
a presentation on the Science of Opioid Use Disorder.
1:36:39 PM
JOSHUA SONKISS, M.D., Chief Medical Officer, Anchorage Community
Mental Health Services, presented a PowerPoint titled "The
Science of Opioid Use Disorder." He directed attention to slide
3, "Learning Objectives," and moved on to slide 4, "Outline."
He shared that he would present a review of addiction in
general, then discuss the neuroanatomy of the reward circuit
which was important in addiction, and continue with discussion
of two models of cognitive impairment in addiction as this was a
reason why addiction was so pernicious and difficult to treat.
He said that he would discuss research on executive functioning
in addiction and lastly he would talk about evidence based
treatment for opioid use disorder. He expressed his hope that
this information would "help all of you make informed policy
decisions around opioid use disorder treatment." Presenting
slide 5, "A brief review of addiction," he stated that there was
a need for four things to have addiction: tolerance,
withdrawal, dependence, "and a little something more." He
addressed slide 6, "Tolerance," and explained that tolerance was
the need to take more of a drug to get the same effect. He
offered an example of audience tolerance, noting that if his
jokes did not become increasingly funny, the audience response
would fall off. He declared that with tolerance it was
necessary to have more of something in order to get the same
response as previously, and that this was the first ingredient
of addiction. He addressed slide 7, "What Causes Tolerance?"
and explained that the brain makes adjustments so that it
functioned normally when the drug was present, and abnormally
when it was not. He offered a comparison of heroin to driving
with a heavy foot on the brake pedal, noting that it was
necessary to push even harder on the gas to get up to speed, or
stay awake, or stay breathing, or stay alive. He declared that
this was the purpose of tolerance, the body was adapting to the
drug. He said that an important mechanism for tolerance was
downregulation of receptors. He explained that neurons
communicated in the brain, as one cell would send an electrical
signal from one end to the other end, but then it would stop,
slide 8, "downregulation." He compared a neurotransmitter to a
ball crossing a neuron, sending an electrical current to the
other end of the neuron. Addressing the three cells on slide 8,
he explained that the cells had opioid receptors which needed to
be occupied at all times in order to operate as they were
supposed. He reported that these opioid receptors could be
overwhelmed with morphine, and would not function well, so some
of these receptors would be withdrawn. Consequently, if there
was morphine readily available, the remaining receptors would be
full, but would allow the cell to function in the way it was
supposed. In the event that the morphine was suddenly no longer
available to the remaining receptors, there would be withdrawal.
When the body had developed a tolerance for a substance, its
removal resulted in "awful physiological symptoms." He directed
attention to slide 10, "Withdrawal," stating that it reflected a
clinical opioid withdrawal scale which was used by doctors to
objectively measure opioid withdrawal in clinical settings. He
stated that, although withdrawal from alcohol could be deadly,
with opioids, usually it was not. He declared that there was a
pronounced physiological response when the substance of
tolerance was removed.
DR. SONKISS pointed to slide 11, "Dependence", and stated that
tolerance plus withdrawal resulted in dependence. He addressed
slides 12 - 13, "Is dependence the same as addiction?" and
shared that, although anyone could become dependent on morphine
in a health care emergency, it would take more than dependence
to have addiction. He offered some examples of various
medicines that could cause tolerance and withdrawal but were not
substances of abuse: clonidine, a blood pressure medicine, and
venlafaxine, an antidepressant.
1:47:00 PM
DR. SONKISS pointed to slide 14, "A little something more" and
offered a definition for addiction: a chronic, relapsing brain
disease that is characterized by compulsive drug seeking and
use, despite harmful consequences. He emphasized that it was
necessary to have the adverse consequences, which could include
going to jail or having your children taken away. He mentioned
that experts in this field were referencing this as substance
use disorder instead of addiction. He reviewed slide 15,
"Models of addiction," and shared that there could be some
instances, although he hated to admit it, where the Moral model
invoked a weak character. He spoke about the criminal model
used with the war on drugs. He mentioned the recovery model,
which spoke to a personal journey through addiction, and the
social model related to trauma and the susceptibility to
addiction. He concluded with the medical model, which defined
addiction as a disease. He emphasized that these models were
perspectives on addiction, were not mutually exclusive, and the
scientific basis of the models increased as one moved from the
moral model to the medical model.
DR. SONKISS turned to slide 16, "How does addiction get
started?" and slide 17, "What sustains addiction?" He stated
that, fundamentally, addiction was started with an overdose of
dopamine, the fundamental neurotransmitter of pleasure and
reward which everyone had. Everything that was good or
pleasurable resulted in a burst of dopamine. He reminded the
committee of the aforementioned example for tossing a ball
across a synapse, with dopamine as the neurotransmitter to
communicate between cells. He pointed to examples of eating,
with a few dopamine molecules in the synapse, and cocaine, with
a massive flood of dopamine. He declared that in every
substance use disorder, it was a flood of dopamine that got it
started. He stated that, as these memories of the euphoria were
quickly ingrained in different parts of the brain, it was
necessary for a cell to take down some receptors, as mentioned
earlier.
1:52:37 PM
SENATOR MICCICHE referred to slide 15, and, acknowledging that
addiction was a medical condition, asked if addiction was a
voluntary disease.
DR. SONKISS replied that the voluntary stage of addiction was a
very early stage, though this voluntariness of the disease
quickly becomes less and less. He declared that there were
other diseases with a voluntary component, describing Type II
diabetes as a lifestyle disease, and adding sexually transmitted
infections as another example.
1:54:07 PM
DR. SONKISS returned discussion to slide 17 "What sustains
addiction?" He shared that this move away from a voluntary
action was conditioning based on memories of that intense
pleasure. He explained that much of what we learn had nothing
to do with what can be articulated to people, but instead with
behaviors that were ingrained and associated with experiences.
He directed attention to slide 18, "Think Pavlov, not
schoolteachers," explaining that the dog was conditioned to
salivate when the light bulb was turned on, no matter what. He
pointed out that it was possible to explain to this dog that it
was morally wrong, to yell at the dog, to kick the dog, or to
electrocute the dog, but once there was conditioning to respond
to the light bulb, the dog would salivate. He emphasized how
difficult it was to change this learned behavior. Moving on to
slide 19, "What sustains addiction?" he explained that the
salience of drugs eclipsed other stimuli for an addict, and that
drugs were constantly in the foreground and remained the most
important. He shared an example from slide 20, and then pointed
to slide 21, "Salience in the healthy brain." He pointed out
that family was salient, it was very important, and most
decisions included some relationship to the well-being of
family; whereas, for the healthy brain, drugs and alcohol were
in the background.
1:57:45 PM
DR. SONKISS turned to slide 22, "Salience in the addicted
brain." He explained that, for a severe addiction, after a drug
gets its grip, the salience of drugs became paramount and
eclipsed everything else. He moved on to slides 23 - 25, "The
reward circuit," and explained that every addiction, including
opioid addiction, moved between these four areas of the brain:
the pre frontal cortex (PFC), which was responsible for
judgement, thinking, reasoning, and decision making, all of
which allowed a person to hold a position of responsibility; the
nucleus accumbens (NAc), which communicated with the PFC and was
where there was a feeling of pleasure; the ventral tegmental
area (VTA), which was the seat of reward and accomplishment and
would send dopamine through the nerve cells to the NAc, "which
would then feel awesome," and in turn would tell the PFC to
allow this; and finally, the locus coeruleus (LC), which
primarily served to keep a person awake, alert, and paying
attention. This was important, as the LC was an area for the
brakes to be pushed on, addiction to opioids with its escalating
use tried to shut down the LC. This, in turn, forced the LC to
work harder to stay awake, alert, and alive. He stated that an
overdose caused the LC to shut down; whereas, withdrawal
resulting from the removal of the drugs, caused a massive
norepinephrine rush.
2:02:15 PM
SENATOR MICCICHE asked if a person with a substance abuse
problem had an addiction to opioids or to dopamine distribution.
DR. SONKISS replied that dopamine was the main mediator of
addiction, as addiction was a dopamine deficiency. He explained
that removal, or down regulating, of the opioid receptors was
also the removal of the dopamine receptors. The result was that
only the drug of abuse gets a person enough dopamine to get the
satisfying rush.
2:03:49 PM
CHAIR SPOHNHOLZ asked if this process was similar for other
addictions.
DR. SONKISS replied that this was essentially the same process
for other addictions and many behaviors, such as compulsive
gambling. He declared that the neuro circuitry was the same,
and the deficit in dopamine was fundamental to all of these
substances and behaviors.
CHAIR SPOHNHOLZ declared that it was important to understand
this was the same problem with alcohol and other drugs.
2:05:04 PM
DR. SONKISS stated that there were fundamental differences
between different substances of abuse. He listed some key
differences, which included the down regulation of receptors, as
the extent for reversal of brain changes was not the same for
every person or every substance. He declared that alcohol
reversal was easier than that with opioids.
2:06:00 PM
DR. SONKISS addressed slides 26 - 28, "Biomedical models of
addiction." He explained the changed set point, stating that
the changes with opioid use were permanent, or semi-permanent,
structural and chemical changes that created a new biological
and behavioral baseline for the addict. He offered a comparable
example to addiction for the difficulty in attempts to lose
weight, as there was a set point for body weight to which the
body wanted to return. Once there were neuro biological
changes, these became hard to reverse, and relapse was common,
especially with opioids. He spoke about cognitive deficits, and
shared that opioid use degraded prefrontal cortical inhibition
of the drive to use, undermining the addict's will at a
neurological level. He stated that there was some truth to the
idea that an addict lacked some will, and that this degraded
prefrontal cortical inhibition of the drive was the reason.
2:08:53 PM
DR. SONKISS stated that addiction was very pervasive, and that
many people with addiction were highly functioning because there
could be compensation, although this was more difficult with
opioid addiction as the will was undermined and the prefrontal
cortex became less effective.
2:09:46 PM
DR. SONKISS stated that he would break down the cognitive
impairment that occurred in addiction into categories, slide 29,
"Cognitive deficit model" and slide 30, "Domains of impairment."
He spoke about impulsivity, describing those who act before
thinking, and the necessity to exercise impulse control. He
said that people who use drugs to excess tended to be more
impulsive, and then become even more impulsive. He noted that
reward hypersensitivity, really wanting something, was the
desire for something becoming the most important thing. He
stated that harm hyposensitivity was forgetting how bad it was,
and that increased risk-taking was the attitude that they would
not be found out. He offered an example of outcome myopia, that
getting high now was more important than getting a job in a
month, because it was now, and that a punishment was less
important as it was out in the future.
2:12:47 PM
DR. SONKISS offered four categories of research which supported
the theories, slide 31, "Studies of decision-making." The first
category was self-report, which was telling someone how you feel
or what you do; the second category, behavioral tasks, were
psychological tests; the third category, computational modeling,
was taking a computer program to evaluate the psychological
tests in more detail; and the final category, neuroimaging. He
expanded on self-reporting, stating that it was not known if the
responses were honest. He declared that addicts knew they were
more impulsive than others, slide 32, "Self-reported
impulsiveness in cocaine users," and explained the Barratt
Impulsivity Scale graph depicted on the slide as a good measure
on self-report.
DR. SONKISS addressed slide 33, "Iowa Gambling Task," and
explained that this was one of the most common psychological
tests used to measure impulsivity and addiction. He explained
that this test used four decks of cards and the participant
pulled cards off each deck, the object being to make as much
money as possible without going into debt. He reported that the
first two decks, A and B, offered big rewards right away,
similar to a dopamine rush; however, the returns then diminished
very quickly and soon became money losers. He compared the
third and fourth decks, C and D, to certificates of deposit, as
they paid slow, but steady, returns. He reported that most non-
addicts would very quickly recognize the need to just draw from
the C and D decks; however, addicts would draw many more cards
from the A and B decks. He relayed that this behavior could
predict who would do well in a rehabilitation setting.
DR. SONKISS described the graph on slide 34, "IGT and relapse in
substance-dependent individuals," which depicted test subjects
in a six week residential treatment facility for mixed substance
use. He pointed out that the abstinent participants scored much
higher than those who relapsed.
2:17:47 PM
SENATOR BEGICH asked about the dip on the graph, slide 34, in
week 3.
DR. SONKISS, in response, explained that data points in any
study had random variation in the results, and he attributed the
dip, most likely, to this random variation. He suggested that
it was more important to focus on the trend.
2:19:25 PM
DR. SONKISS moved on to slide 35, "IGT and abstinence in
methamphetamine users" and explained the comparison of non-
addicts with addicts taking the IGT (Iowa Gambling Test). He
pointed out that it was very difficult and took a long time to
reverse the brain changes which occurred in addiction. He added
that a 30-day rehabilitation program would not return a person
even close to where they were prior to addiction.
2:21:16 PM
SENATOR MICCICHE asked if this addiction affected all decision
making.
DR. SONKISS stated that this was a fundamental take home point,
the impulsiveness and bad decision making from addiction
generalized to the rest of life.
2:22:09 PM
DR. SONKISS addressed slide 36, "Decision-making in opioid
users." He explained that most experts looked at groups of
studies which were carefully compared in a weighted average
(meta-analysis). He emphasized that all but two of the studies
favored the control groups, and not the opiate users, which
illustrated that even well designed studies had random
variations. He pointed out that the studies which included ex-
users of more than three years reflected substantial decision
making deficits in opioid users, which underscored the
difficulty to reverse the brain changes.
2:25:12 PM
DR. SONKISS shared slide 37, "Computer modeling of decision-
making in cannabis users," and he stated that computer modeling
could get into the nuances and break down further the cognitive
deficits that gave rise to the test scores. He explained that
this graph reflected a consistent difference between users and
non-users as users ignored loss magnitude, made decisions that
were less consistent with their expectancies, and were more
influenced by recent gains.
2:27:44 PM
DR. SONKISS moved on to slide 38, "Imaging studies," which was
the fourth of the aforementioned categories of decision making.
He pointed to the composite image of the orbital frontal cortex
and the dopamine receptors for cocaine abusers and non-users.
This showed that "normal fun does not do it anymore when you are
severely addicted to a substance." He added that although this
depicted cocaine use, it would be similar for any substance use.
He directed attention to slide 39, "Why Can't Addicts Just
Quit?" He explained that this was a conceptual slide showing
what different brain structures did, noting the increased drive
to use and the decreased control in the addicted brain. He
added that the saliency and the memory of drugs was enormous in
the addicted brain.
2:31:28 PM
DR. SONKISS spoke about slide 40, "Treatment," and stated that
12-step and peer support groups were not strictly treatment, but
were interventions which did help a lot of people. He reported
that there were many forms of detoxification, and that
psychosocial treatment referred to different intensities of
counseling and psychotherapy. Although these were effective for
most substance use disorders, they were less effective for
opioid use disorder. He referenced medication-assisted
treatment, which could include treatment for alcohol abuse. He
declared that detoxification was not really a treatment, but was
more similar to debridement, the cleaning of a wound to prepare
it for an intervention, slide 41, "Detoxification." He stated
that it was mostly effective as a bridge to more definitive
treatment, and was often a practical and economic step. He
reported that detoxification from opioids did not have much
impact on the relapse rates. He added that the risk of death by
overdose was highest after a month of detoxification of opioids,
sharing that he often counseled continuation of use until an
addict could enter a methadone program. He declared that,
although naloxone was a wonderful drug to reverse respiratory
arrest during heroin or opioid overdose, an addict would return
to where they started, slide 43, "Naloxone rescue is not
treatment."
2:34:44 PM
DR. SONKISS declared that "Psychosocial Treatment," slide 44,
was very effective for many types of addiction, especially for
cannabis and alcohol use disorder. He said that it was
essential as a component to medication assisted treatment for
opioid use disorder, although many studies reported that
outcomes were the same with or without psychosocial counseling.
He stated that psychosocial counseling as a stand-alone did not
work on most disorder populations.
2:36:05 PM
DR. SONKISS spoke about slide 45, "Medication Assisted
Treatment," reporting that there were buprenorphine and
methadone, which replaced the opioids in the addict's brain and
normalized the imbalance of receptor densities. He explained
that methadone, dosed correctly, should not make the person high
and that it occupied the receptor for a long time; whereas,
buprenorphine was somewhat safer than methadone as it only
opened the receptors part way and made overdose more difficult.
He addressed naltrexone, which blocked the receptor so that an
addict could not get high.
DR. SONKISS discussed slide 46, "Full Agonist Treatment (ORT),"
declaring that methadone was a full agonist with a long life,
and was only administered in specially licensed methadone
clinics, unless it was only used for pain treatment. He
explained that it was more difficult to overdose with
buprenorphine and that it could be prescribed in an office
setting, although special training was necessary, slide 47,
"Partial Agonist Treatment (ORT)." He stated that there was
very consistent evidence to support the efficacy of opioid
replacement therapy (ORT), as there was better treatment
retention, fewer overdose deaths because tolerance was not taken
away through detoxification, and less hospitalization with less
cost, slide 48, "Advantages of ORT." He acknowledged that there
was a potential for abuse and diversion, slide 49,
"Disadvantages of ORT." He added that this was a lifelong
treatment for many, and there was up to a 95 percent relapse
rate within 12 months if taper was attempted. He relayed that
many people felt this was only a substitute addiction.
2:40:31 PM
DR. SONKISS shared slides 50 - 51, "Antagonist Treatment (not
ORT)," and declared that this was a long-acting injectable,
naltrexone. He stated that it was popular in policy circles,
especially for those who favored abstinence, and its advantages
included that it blocked the high from opioids. It also avoided
the stigma of ORT, as it did not replace one addiction with
another because it blocked the receptor which the drug of abuse
used to get a person high. He pointed out that it could not be
abused or diverted. He explained the disadvantages: oral
naltrexone did not work; retention in treatment was low, only 7
- 8 weeks because, although it blocked the high, it did not
remove the craving or make a person feel normal; and, it could
interfere with pain treatment. He emphasized that addicts when
sober did not feel normal, they only felt normal when they were
using. The idea behind ORT was to make an addict feel normal,
by normalizing the ratio between the receptors and the opioids.
2:42:58 PM
DR. SONKISS reported that multiple studies supported the cost-
effectiveness of ORT, and that one study of a Medicaid
population reported that it had reduced emergency department
visits and hospital admissions for those beneficiaries with
opioid addiction, compared with other treatments, slides 52 -
53, "Economic Studies." He recapped that addiction was a
learning disorder with biological, psychological and social
components; that historically, biology had taken a back seat in
public policies for managing OUD, even as it had been known for
more than 40 years that ORT worked the best; that the science of
OUD pointed to biology as a key component in managing the opioid
epidemic; most people with OUD could not just quit; and he
suggested to manage OUD accordingly, slide 54 "Take-Home
Messages."
2:44:58 PM
REPRESENTATIVE JOHNSTON asked if death was possible from opioid
withdrawal.
DR. SONKISS replied that, in general, alcohol withdrawal was far
more dangerous and more likely to kill than opioid withdrawal.
He added that a host of concurrently existing medical conditions
could be exacerbated from opioid withdrawal and could lead to
mortality. He offered an example that opioid withdrawal does
kill in the corrections population.
2:46:20 PM
SENATOR VON IMHOF opined that the question now was for what
programs and funding mechanism to address this issue. She asked
if there had been a scan of existing state programs, whether
these programs were working in silos, were they competing for
the same funding sources, and were there specific targeted
programs which focused on specific populations.
2:47:17 PM
DR. SONKISS replied that he was not sure if there had been a
study of available treatments. He shared that it was very
difficult to get people into chemical dependency treatment;
specifically, it was very difficult to get people into
medication assisted treatment for OUD, as there were long
waiting lists, qualification was difficult, and it required
special assessment with a fee. He declared that there were many
hurdles for patients which looked relatively easy until it was
understood how those patients think and behave. He stated that
he did not know if there was competition for the same payer
sources. He emphasized that abstinence based opioid use
programs don't work very well. He reported that rehabilitation
programs were a $35 billion a year industry, and these programs
had, at best, a 70 percent relapse rate with an even worse
relapse rate for OUD.
2:49:27 PM
CHAIR WILSON asked about a recommendation for state policies
regarding the use of relapse as a consequence.
DR. SONKISS declared that behavioral principles were very
difficult to incorporate into policy. He stated that, in
general, behavior was much more effectively influenced with
rewards than with punishments. He noted that work with addicts
was almost always in the context of a bad consequence. He
suggested that a reward for abstinence as opposed to punishment
for relapse was more likely to be effective, simply based on
basic behavioral principles for all behavioral modification. He
offered his belief that the opioid use disorder population was
very, very resistant to feeling bad about punishment, and would
not respond to punishment in the same way as the general
population. He reported that the best means to maintain
sobriety was with medication assisted treatment, and, instead of
waiting for failure after three 30-day rehabilitations, have the
person assessed for the severity of the addiction and then start
ORT earlier rather than later. He declared that there was a
tendency toward fail first policies in the insurance industry
and in regulation, pointing out that this was the exact opposite
of the way the rest of medicine prescribed.
2:52:55 PM
SENATOR BEGICH asked if a substantial number of the population
already arrived with an inability to be impacted by behavioral
health decisions because of issues prior to the addiction.
DR. SONKISS expressed caution for characterizing any population
as not being able to respond to a benefit from a treatment,
specifically with fetal alcohol spectrum disorders (FASD). He
acknowledged that the FASD population struggled with learning
from experiences. He declared that it was necessary to start
interventions early and to be extremely consistent and patient.
He stated that there "was no fast fix."
SENATOR GIESSEL expressed her concern that youth will be more
readily exposed to marijuana. She asked if would there be more
addiction because of the effect on the youthful brain and was it
more impactful at younger ages.
DR. SONKISS replied that the brain was growing up to 13 years of
age, at which point the signal to noise ratio was not optimal
for optimal adult functioning. At this age, the brain begins to
prune neural connections, to disconnect them so emotionality,
impulsivity, and other cognitive and behavioral issues rectify
themselves. He declared that cannabinoids interfered with the
neural pruning process, and that the brains of kids using
cannabis did not mature, so that these 13 year old cognitive
deficits were carried into adulthood. He strongly encouraged
that kids not use it. He stated that no one knows whether it
will be a gateway drug.
2:58:01 PM
CHAIR SPOHNHOLZ asked if medically assisted treatment was the
most effective for alcohol. She also asked for an example of a
positive reinforcement for someone who was already a part of the
criminal justice system.
DR. SONKISS in response, agreed that medication assisted
treatment was the cornerstone for opioid use disorder; however,
although alcohol use disorder had some medications that helped,
they were not effective enough to be the cornerstone. He
declared that peer support groups and psycho-social
interventions were these cornerstones.
DR. SONKISS offered that a temporary time limited increase in
privileges was a good approach to reward. He referenced some
studies on stimulant disorders that showed a small monetary
reward was also successful.
3:01:46 PM
SENATOR MICCICHE asked for a reading list to be better versed on
opioid use.
DR. SONKISS directed attention to slide 55, "Further reading."
He said that correctional populations were more difficult to
work with.
3:03:22 PM
CHAIR WILSON acknowledged the need to make policy using meta-
analysis.
3:04:18 PM
ADJOURNMENT
There being no further business before the committee, the joint
meeting of the House and Senate Health and Social Services
Standing Committees meeting was adjourned at 3:04 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| Sonkiss science of opioid use disorder February 13 2017.pdf |
SHSS 2/13/2017 1:30:00 PM |
Dr. Sonkiss - Science of Opioid Use Disorder 2.13.17 |