SENATE FINANCE COMMITTEE February 7, 2019 9:01 a.m. 9:01:43 AM CALL TO ORDER Co-Chair Stedman called the Senate Finance Committee meeting to order at 9:01 a.m. MEMBERS PRESENT Senator Natasha von Imhof, Co-Chair Senator Bert Stedman, Co-Chair Senator Click Bishop Senator Lyman Hoffman Senator Peter Micciche Senator Donny Olson Senator Bill Wielechowski Senator David Wilson MEMBERS ABSENT Senator Mike Shower ALSO PRESENT Andy Jones, Director, Office of Substance Misuse and Addiction Prevention, Department of Health and Social Services; Michael Duxbury, Deputy Commissioner, Department of Public Safety; Laura Brooks, Deputy Director, Health and Rehabilitation Services, Department of Corrections; Gennifer Moreau-Johnson, Acting Director, Division of Behavioral Health, Department of Health and Social Services. SUMMARY PRESENATION: FISCAL IMPACTS OF OPIOIDS DEPARTMENT OF HEALTH AND SOCIAL SERVICES DEPARTMENT OF CORRECTIONS DEPARTMENT OF PUBLIC SAFETY ^PRESENTATION: FISCAL IMPACTS OF OPIOIDS DEPARTMENT OF HEALTH AND SOCIAL SERVICES DEPARTMENT OF CORRECTIONS DEPARTMENT OF HEALTH AND SOCIAL SERVICES 9:03:44 AM Co-Chair von Imhof thanked the testifiers for being in committee. She referenced discussions with Co-Chair Stedman regarding how to run the committee, which had touched on having overarching multi-departmental discussions of programs. She had suggested the topic matter because it was such a big multi-faceted problem in the state. Co-Chair von Imhof continued her remarks. She had personal experience with the issue of opioid addiction. She referenced a McDowell Group study that estimated that drug abuse cost the state $1.2 billion per year. Direct spending for opioid treatment in 2018 was $70 million. She discussed the spending in different departments related to the issue. She believed collaboration and cooperation was the best approach to tackling big issues. 9:06:13 AM ANDY JONES, DIRECTOR, OFFICE OF SUBSTANCE MISUSE AND ADDICTION PREVENTION, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, introduced himself and relayed that he was the deputy commander for the opioid epidemic response. He stated that a comprehensive approach was needed to address the issue of the subject matter. Mr. Jones referenced the report "State of Alaska: Addressing Alaska's Poly-Substance Epidemic Comprehensive Report" (copy on file). MICHAEL DUXBURY, DEPUTY COMMISSIONER, DEPARTMENT OF PUBLIC SAFETY, introduced himself. He relayed that he had recognized that collaboration was identified as the key piece for working on the issue of substance abuse and addiction. He relayed that the departments had been collaborating and sharing resources for the previous three years. He thought a multi-angle approach was needed, and that Alaska could not "arrest itself out of the problem." 9:08:00 AM LAURA BROOKS, DEPUTY DIRECTOR, HEALTH AND REHABILITATION SERVICES, DEPARTMENT OF CORRECTIONS, introduced herself and thanked the committee for the opportunity to share information. Mr. Jones discussed the presentation "Addressing Alaska's Poly-Substance Epidemic - Comprehensive Presentation, Department of Public Safety, Department of Corrections, Department of Health and Social Services, Department of Law" (copy on file). He stated that since 2017 when a state disaster was declared, stakeholders were identified including state departments, local unions, and workforce development. He had served for 15 years in disaster response and had not seen as complex an issue as the poly- substance epidemic. Mr. Jones continued his opening remarks. He stated that the presentation would overview the epidemic; and discuss the response structure, cost association, resources, partnerships, outcomes, results, and next steps. Mr. Jones showed slide 2, "Alaska Opioid Epidemic Response - Background Information." Mr. Jones reviewed slide 3, "Overview": ?Drug overdoses now the leading cause of accidental death in the US, exceeding deaths from automobile accidents ?More than six out of 10 drug overdose deaths in 2015 involved opioids, including opioid pain relievers and heroin ... that is almost 91 deaths a day ?In 2016, drug overdoses likely killed more Americans (65,000) than the entire wars in Vietnam and Iraq, In comparison, more than 58,200 US troops died in the Vietnam War between 1955 and 1975, and more than 4,500have died so far in the Iraq War since 2003 which adds up to more than 62,700. Mr. Jones thought it was sobering that drug overdoses were the leading cause of accidental death in the country and exceeded deaths from automobile accidents. He highlighted the third bullet, which showed that drug overdoses in one year's time exceeded the deaths than wars in Vietnam and Iraq. He had seen a skyrocketing number of deaths associated with drugs like fentanyl and other synthetic opioids. He noted that the problem was not getting better. Mr. Jones showed slide 4, "How Did This Happen?": Medical fallacies driving the increased prescribing of opioids: ?Pain can be objectively measured ?Tolerance is just under-dosing ?Pseudoaddiction: persons who display drug-seeking behavior are simply in pain and need more opioid ?"If your medicine makes you feel better, then your diagnosis must be whatever the medicine was meant to treat" Ann Lembke, MD, in Drug Dealer, MD ?When used in treatment of pain, very little risk of subsequent misuse or addiction Mr. Jones recounted the need for pain management during the Civil War, after which a pharmaceutical company had produced heroin as a pain management tool. The trend had continued. He mentioned the drug U4770, which was so addictive that it was pulled off the market. Mr. Jones continued to address slide 4 and mentioned Oxycontin and other pain medications that were being abused. He lamented the short duration of pain management education in medical school. He referenced lawsuits involving pharmaceutical companies because of mis- advertising. He reported that the United States consumed more opioids than anywhere else in the world. 9:12:45 AM Mr. Jones reviewed slide 5, "From Prescription Opioids to Heroin": ?Approximately 3 out of 4 new heroin users report having misused prescription opioids in the past ?In some places, easier access to heroin than prescription opioids ?Heroin does not require a prescription ?Street price for heroin may be more affordable than prescription opioids ?Higher risk of overdose from heroin use due to potency Morphine > Heroin 50x > Fentanyl 100x Mr. Duxbury relayed that law enforcement in the state dealt with individuals from the Sinaloa cartels because Alaska was a profitable environment. Illicit organizations marketed heroin as a money-making scheme. Mr. Jones displayed slide 6, "Poly-Substance Misuse": Heroine use is part of a larger substance abuse problem. Most used at least 3 other drugs. Heroin is a highly addictive opioid drug with a high risk of overdose and death for users. People who are addicted to Alcohol are 2x Marijuana are 3x Cocaine are 15x Rx opioid painkillers are 40x more likely to be addicted to heroin. Mr. Jones thought the state needed more of a poly-substance response to the problem. He noted that cocaine was gaining popularity. Mr. Duxbury noted that fentanyl (a more powerful additive or adulterant) was now being used in heroine products, cocaine, and methamphetamine. 9:16:13 AM Mr. Jones showed slide 7, "Alaska Opioid Epidemic Response - Response Structure." Mr. Jones turned to slide 8, "Alaska's Opioid Epidemic Response": ?State Disaster Declaration ?February 14, 2017 ?Administrative Order 287 ?Multi-agency approach ?Local, Tribal, State, Federal, and Non- Governmental Agencies ?Multi-Agency Coordination (MAC) Group ?Incident Command System ?Alaska Criminal Information and Analysis Center ?Joint Information System Mr. Jones spoke to the flow chart on the slide, which showed an "Incident Command System" chart. The system was a time intensive but effective way to meet the initial response priorities. He likened the epidemic to a fire, flood, or flu outbreak. He noted that Dr. Jay Butler had served as the Incident Commander. Mr. Jones showed slide 9, "Cross-Sectoral Collaboration is Key." The slide showed the importance of collaboration. He explained that Department of Administration administered state health insurance, through which it was possible to track data. Mr. Jones turned to slide 10, "Alaska's Response Framework": ?Alaska Opioid Policy Task Force 2016-2017 ?AOPTF Recommendations Document ?Opioid Initial Response Framework (Prevention Model) 2017 ?Statewide Opioid Action Plan 2018 Mr. Jones identified that the Alaska Opioid Policy Task Force (AOPTF) did not start out with a strategic plan, but rather with Dr. Butler's prevention framework. He spoke about the high-level document created by the task force listed on the slide. He stated that a prevention model was built. The Statewide Opioid Action Plan was built from the ground up and had involved community recommendations. Mr. Duxbury stated he had been a member of AOPTF and stressed that front-loading prevention and harm reduction on the front end of a law enforcement program seemed to be the best way to spread the message and save lives. He discussed community outreach and thought police officers had saved up to 30 lives. He emphasized the need for a multi-faceted approach. 9:20:38 AM Co-Chair Stedman noted that commissioners from the Department of Corrections and the Department of Public Safety were in attendance. Co-Chair Stedman commented that people were using village areas for drug distribution because of the low concentration of law enforcement. Mr. Duxbury noted that the opioid enterprise was driven by profiteering and was sucking money out of Alaskan communities. Co-Chair von Imhof referenced Mr. Duxbury's comment about Alaska being more lucrative than other areas in the drug business. Mr. Duxbury opined that the demand and less enforcement contributed to making Alaska a lucrative place to sell drugs. It was understood that the collaborative efforts had started to make an impact on the ability of drug dealers to profit. Mr. Jones discussed the logistical movement of goods and the expense. He thought there was not a big competing market in Alaska as with other places in the United States. Ms. Brooks emphasized that the Department of Corrections (DOC) had a captive audience and had a comprehensive plan for substance abuse issues. She recognized the increase in the opiate effect over the last several years and stated that the department had tailored its efforts in response. Co-Chair Stedman asked the testifiers to identify themselves when speaking. 9:24:12 AM Senator Wilson mentioned DOC and substance abuse treatment. He asked if the department had looked into other methodologies for treatment. Ms. Brooks stated that DOC had made a concerted effort to focus on medication-assisted treatment. There was a control program in which individuals leaving facilities were given injections before re-entering the community. Methadone bridging was also used. There were community providers that participated. The department was also exploring adding additional medication-assisted treatment options. Mr. Jones showed slide 11, "Alaska Opioid Epidemic Response - Costs Association to the State of Alaska." He highlighted that there were hardly any other states that attempted to put a cost association together with a plan. He noted that the task force was required to submit a report to the legislature, and it would include ongoing cost information. 9:26:22 AM Mr. Jones reviewed slide 12, "Costs Association to the State of Alaska: Data Elements": ?Data will be pulled for years 2017 and 2018 to calculate the cost association to address the opioid epidemic. This timeframe represent when the State of Alaska began the response to the epidemic. ?To calculate the cost association to the State of Alaska addressing the opioid epidemic the following data sources were utilized; ?Department of Health and Social Services Medicaid Drug Treatment Reimbursement Claims ?Department of Health and Social Services Medicaid Opioid Related Diagnosis Reimbursement Claims ?Department of Health and Social Services, Division of Behavioral Health Substance Use Disorder, Treatment/Recovery, Prevention, and Associated Grants ?Department of Health and Social Services, Division of Public Health Hospital Discharge Data ?Department of Corrections, Substance Use Disorder funding ?Department of Law, Therapeutic Court funding ?Department of Public Safety, Drug incidents/costs ?Figures represented in this document reflect estimates based on certain existing and evolving data, and do not reflect the costs that the State of Alaska might seek to recover in litigation based on fuller evaluation of the damages and other remedies available to the State. Mr. Jones referenced slide 13, "Medicaid Opioid Treatment Drug Reimbursement FY17/18," which showed two pie charts and a data table. The pie charts showed the FY 17 and FY 18 opioid treatment drug reimbursements in relation to Medicaid. In 2017, there was 1,400 recipients that received the medications and in 2018 there were 2,300 recipients. There was an increase in $1.7 million increase in 2018 in the suboxone category, which was one of the most popular treatment methods. Mr. Jones showed slide 14, "Medicaid Opioid Related Diagnoses Reimbursement FY17," which showed a pie chart and data table. The data table was broken down into categories of in-patient treatment, out-patient treatment, professional behavioral health services, and professional general services. The chart showed that 4,000 Medicaid recipients received treatment for opioid related diagnoses in 2017. Senator Hoffman thought the slide gave a good analysis of what was happening throughout the state. He asked how the information was disseminated by region of the state. He asked about the differences in how extensive the problem was in various areas of the state. Mr. Jones stated that the numbers on the slide were from Medicaid. He offered to provide the regional information at a later time. Senator Micciche asked what the state was doing to guard against abuse of the actual treatment drugs, particularly in DOC. He wondered if there was a way to quantify the cost of internal abuse. Ms. Brooks informed that when an individual came into the correctional system on methadone, the drug was brought in and administered in the department. None of the medication was kept on site, which was one way the department mitigated abuse within the system. Narcotic medication was very rarely prescribed within the system; only for an acute injury or something to address cancer and only administered in the infirmary. 9:30:54 AM Mr. Jones moved to slide 15, "Medicaid Opioid Related Diagnoses Reimbursement FY18," which showed a data table and pie chart. He noted that there had been an increase by about $10 million, and there had been about 4,800 Medicaid recipients treated with opioid-related diagnoses. The increase could be related to Medicaid expansion or because word had gotten out about increased choices for treatment. Co-Chair Stedman noted that asked what was expected for the substance abuse problem in the state in the future. Mr. Jones thought that the drug problem was a moving cycle. He offered to provide more information at a later time. Mr. Jones showed slide 16, "Medicaid Opioid Related Diagnoses Reimbursement FY17/18," which showed two pie charts to demonstrate the increase in cost from FY 17 to FY 18. Senator Wilson referenced federal funding shown on the previous slide. He asked about utilization of federal funds and asked if the state had returned any federal funds for unspent needs. Mr. Jones stated that in the last two years the group had received $35 million in federal grant funds. The group looked at all available grants and applied if the grant was a good fit for the state's needs. He noted that some grants had extremely short cycles and stated that the group had been successful with receiving no-cost extensions to move funding into the next year. The goal was to move the funding out. Of the $35 million, the funds spanned between enforcement, to DOC reentry programs, and to the Department of Health and Social Services (DHSS) prevention and treatment programs. 9:34:07 AM Senator Wilson asked to hear from other departments with regard to utilization and possible return of federal funds. Mr. Duxbury stated that in his experience with collaboration with DHSS and DOC, the departments had utilized cross-funding facilities. He was not aware of any returned funding that was intended for opioids. Co-Chair Stedman asked Mr. Duxbury to get back to the committee with more information. Mr. Duxbury answered in the affirmative. Ms. Brooks identified that DOC's primary federal funding for substance abuse treatment was a grant for resident treatment programs. The funding was through the Bureau of Justice Assistance. She specified that the previous year there was an added requirement to apply for additional fund for opioid treatment. The department continued to look at other grant opportunities. The department had received quite a bit of state funding to enhance and grow substance abuse treatment programs. For the previous two years the department had been challenged with growing the treatment programs and had not had the capacity to seek further funding. Mr. Jones showed slide 17, "Treatment/Recovery and Prevention/Intervention Grant Funding FY17/18," which showed two pie charts. The state and federal cost was shown. He shared that the grants were primarily used to get entities and organizations up and running, after which the organizations transitioned to a fee-for-service model. He discussed the sustainability of sending federal grants to a local jurisdiction. He expressed concern about the over- reliance on the federal funds at a local level. Mr. Jones continued to address slide 17. He detailed that the community grants supported 18,000 recipients, roughly 2,000 of which were treated for opioid disorders. He noted that there were co-occurring disorders. Senator Hoffman referenced Mr. Jones remark about the sustainability of starting programs with federal funds that were not sustainable. He thought the people of Alaska were less concerned about the issue. He questioned the path forward if there was truly an epidemic, which he thought was far more salient than whether the programs were sustainable. He thought the people of Alaska needed to know how the problem was being addressed and how the public was being made safe. Mr. Jones stated that a subsequent slide would address Senator Hoffman's question. Senator Wielechowski asked if Mr. Jones had any statistics on the effectiveness of treatments that were being provided. Mr. Jones stated that he would provide the information at a later time. 9:39:49 AM Senator Wilson followed up on Senator Hoffman's question about sustainability of programs and program transition. He recalled that a few years previously many behavioral health/substance abuse centers had transitioned from grant funding to fee-for-service when Medicaid expansion came into effect. Many of the centers had difficulty with billing, and he wondered if billing had offset the grant match for some agencies. He thought many agencies had closed up shop in Fairbanks, Kenai, and Mat-Su because the organizations couldn't sustain with the diminished grant funds. He asked if there was a plan to reverse the grant funding trend so agencies could keep pace with the growing demand for treatment and backlog. Mr. Jones agreed to bring the information to the committee at a later time so that he could work with the director for the Division of Behavioral Health. Senator Micciche discussed Medicaid treatment options, funding for which had been increased by 50 percent between FY 17 and FY 18 while grant funding was reduced. He asked for an explanation of the relationship, and why there was not a better federal response on grant funding options. Mr. Jones thought the director of the Division of Behavioral Health was better equipped to answer the question. GENNIFER MOREAU-JOHNSON, ACTING DIRECTOR, DIVISION OF BEHAVIORAL HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, stated that there had been an ongoing effort to increase federal funding, and mentioned SB 74 [legislation passed in 2016 that enacted comprehensive reform of Alaska's Medicaid program]. She posted that the best way to increase federal funding was to incrementally decrease grant funding and support agencies to bill Medicaid for substance misuse disorder. The department had been providing technical assistance to agencies to become Medicaid billers; as well as through a long process of negotiating with the Centers for Medicare and Medicaid Services (CMS) for a Section 1115 waiver for the demonstration project to reboot and enhance the behavioral health system. 9:43:28 AM Senator Micciche stated he was a co-sponsor of SB 74. He referenced a ten million increase, largely because of Medicaid. He wondered if the bill had been the correct approach, or if the state was "leaving money on the table." Ms. Moreau stated that the negotiation with CMS was long and arduous and took longer than expected. She detailed that in November the state received approval from CMS for the substance use disorder component of the Section 1115 demonstration project. The approval allowed for approval of the implementation plan, which was due February 19, 2019; after which time she hoped the state would start to gain traction through Medicaid financing. Mr. Jones showed slide 18, "FY 2017 Total DBH Grant Funding by Service Area and Grant Type," which showed a map of the state and a data table. He stated that the slide correlated with the previous slide. The slide showed where the grant funds went but did not represent all the services available statewide. Mr. Jones showed slide 19, "FY 2018 Total DBH Grant Funding by Service Area and Grant Type," which was the same as the previous slide but updated for FY 18. 9:45:28 AM Co-Chair Stedman referenced slide 18. He noted that there was a disparity in grant funding in different areas of the state and did not think the funds correlated with the population bases. Senator Hoffman explained that the Bethel region comprised an area greater than the State of Washington and included 56 communities that provided services. One of the largest problems with delivery of services was transportation and the delivery of information. He noted that the Yukon- Kuskokwim Health Corporation was by far the largest corporation in rural Alaska. He invited Co-Chair Stedman to come travel in the region. Co-Chair Stedman clarified that his question was not slanted toward an over-weighting of appropriations into Bethel; but rather about the correlation of funding amounts to population size. He recognized that Bethel had a regional area, that he considered was not much different than Sitka with its regional villages. He asked about a population breakdown. Senator Hoffman stated that there were not adequate expenditures to address the problem in the Bethel region, and also in the entire state, hence the reason for the epidemic. Co-Chair Stedman did not disagree. He asked the testifiers to provide the committee with some population information. Senator Wilson thought that a base level of grant funding was sometimes needed in order for organizations to be able to bill Medicaid. Senator Micciche thought the larger question was how the funding was distributed. He wondered if the funding distribution was related to population or the difficulty of delivering services. Co-Chair Stedman hoped that some areas of the state had less need than others. 9:50:00 AM Mr. Jones spoke to slide 20, "Therapeutic Court Funding FY17/18/19," which showed three pie charts addressing funding distributed for 2017, 2018, and 2019. He clarified that the courts provided for drug courts, DUI courts, mental health courts, and family courts. He had been told that the courts were very costly but extremely effective. He thought the courts were an extremely important aspect of the state's response going forward. Ms. Brooks looked at slide 21, "Department of Corrections Treatment Cost FY17/18," which showed three pie charts. She asserted that the department had put together a comprehensive treatment program. The slide represented the amount of money that went toward the area of opioid use disorders, which comprised about one-third of the treatment. She identified about $830,000 in General Funds (GF) which went towards various treatment programs. Ms. Brooks continued to speak to slide 21. She relayed that in 2017, the department received funding through SB 91 (criminal justice reform legislation passed in 2016] to enhance substance abuse services systemwide. A large part of the funds went toward opioid treatment. She noted that the department had expanded substance abuse services in all areas, but a priority went to opioid treatment. She noted that the treatment was broken into two areas: institutional programming, and for individuals in halfway houses. Senator Wilson asked about FY 17 and understood that DOC did not have a contract provider to provide substance abuse treatment for some time in its facilities. He asked for a list of facilities to which funds were provided. Ms. Brooks agreed to provide the information. 9:53:09 AM Mr. Duxbury reviewed slide 22, "Department of Public Safety Drug Incidents," which showed a line graph depicting that the component of the opioid drug use was also a component of the poly-drug use in the state. The slide showed that methamphetamine and heroine opioids were one of the biggest issues in the state. In almost every incidence of drug trafficking, methamphetamine appeared almost five times more frequently than heroine. Co-Chair Stedman thought it looked like there had been a decline in 2018. Mr. Duxbury stated that what drugs were seized were not always indicative as to what drugs were available to the public. Interdictions were the mainstay of drug enforcement work. Co-Chair Stedman clarified that he observed a substantial increase in drug activity in the Southeast area. He expected that the substantial arrests would show up as an increase in activity. Mr. Duxbury reminded that the graph represented a state- wide perspective. He stated he would get back to the committee with more information. He informed that drug cases were intensive long-term undertakings, and open cases put constraints on the information. Co-Chair Stedman thought that the Department of Public Safety had been doing a good job in Southeast in dealing with the issue. 9:56:12 AM Mr. Duxbury reviewed slide 23, "Department of Public Safety Opioid Incident Costs 2010 - 2018," which showed a data table illustrating the average based on what it cost to do an investigation up to the point of arrest. The information was aided by a study done by the University of Alaska, which had taken components from all stakeholders. He qualified that the data did not show information such as a traffic stop which resulted in the seizure of opioids, or an investigation that involved multiple individuals and had a higher cost. Co-Chair Stedman asked if Mr. Duxbury could speak to the Village Public Safety Officer (VPSO) Program. He noted that some areas wanted to have the program and wondered how the subject might be taken into account in the data. Mr. Duxbury stated that the VPSO program was an oversight program that the Alaska State Troopers, but the officers were not state employees. When there was a case that involved a felony amount, then the troopers had purview and oversight. He could not address the specific question about where there were VPSOs. Senator Hoffman clarified that the VPSO Program provided public safety on behalf of the state and was the responsibility of the state. The state had contracted with non-profits to provide public safety in certain areas. He wanted it known that public safety in these areas, although contracted, was the responsibility of the state. Senator Bishop noted that the state spent over $50 million addressing addiction, but thought it appeared that there were 41 people in law enforcement dedicated to stopping the problem. He wondered what could happen if $50 million could be invested differently and stop the problem on the front end. Mr. Duxbury thought money could be thrown at the problem, and it would not necessarily solve the issue. He thought it was important to have compassionate towards addiction, and thought money spent in the area of treatment was important. He thought drug enforcement was still reactive to the issue and was still dependent upon human nature. He emphasized the importance of a collaborative approach to keep Alaskans happy, healthy, and productive. 10:01:51 AM Senator Bishop referenced the war on drugs and Pablo Escobar, who had $50 billion in the bank when he was arrested. He stated that the war on drugs had not worked. He pondered the question of legalizing drugs. Co-Chair Stedman thought the state would be adding more police and drug enforcement to the budget. Senator Wielechowski referenced Senator Bishop's comments. He discussed pain management and culture. He questioned why people in the state were dealing with pain in the manner of drugs rather than in other ways. He wondered how to address the root causes of the problem. He thought there must be research on the subject. He thought education seemed like a fundamental component of the issue. Mr. Jones stated that upstream prevention was a big focus of the task force. He opined that there were biological, environmental, and social factors that were at work. He noted that the task force was partnering with the Department of Education and Early Development (DEED) and working with programs that had a great return on investment. He mentioned starting to address Adverse Childhood Experiences (ACES). He mentioned that a group had travelled to Iceland to study its model. With time, commitment and funding; he thought results could be seen in upstream prevention. He stated he would send some further information on to the committee. 10:05:06 AM Senator Wilson considered slide 23, as well as the following slide. He asked about "Detachment B." Mr. Duxbury specified that Detachment B signified the Matanuska-Susitna Borough. Senator Wilson asked about where the state was in an ongoing lawsuit against pharmaceutical entities. Mr. Duxbury stated that there was a person present that could elaborate on the lawsuit. Co-Chair Stedman asked to continue with the planned presentation. Mr. Duxbury addressed slide 24, "Department of Public Safety Methamphetamine Incident Costs 2010 - 2018," which showed a data table. He pointed that funds spent to address the opioid issue were almost three times that was spent to address methamphetamine incident costs. Co-Chair Stedman asked about the detachments listed on the slide. Mr. Duxbury described the detachment areas: Detachment A was the Southeast area, Detachment B was the Mat-Su and beyond, Detachment C was most of Western Alaska, Detachment D was the Fairbanks area and some of the outlying villages, Detachment E was the peninsula (and the Soldotna/Kenai area), Alaska Wildlife Troopers (AWT) Detachment North covered the Northern part of the state, and AWT Detachment South was for the Southern Section from Valdez and below. Co-Chair Stedman asked for another copy of the slides with more explanation as to the detachments. Mr. Duxbury agreed to provide the information. Senator Micciche asked for more information abouth the Alaska Bureau of Investigation (ABI), and assumed there was crossover with other agencies. Mr. Duxbury explained that there had been a change from 2010 to 2018 in that ABI was currently a statewide agency that provided investigative service throughout the state. Previously ABI had not included the statewide drug enforcement unit but it had changed to be under one supervision. Mr. Duxbury looked at slide 25, "National Drug Threat Survey-Drug/Property Crime," which showed a pie chart depicting the crossover between drug and property crime. He noted that the pie chart (based on a 2016 National Drug Threat Survey) showed that the property crime percentages were 35 percent attributed to heroin, and 27 percent attributed to methamphetamine. Previous slides had demonstrated that the state had a significant issue with both of the controlled illicit substances. He stated it would not be correct to assume that investigative and arrest costs demonstrated the cost for the state to take care of and respond to the opioid crisis. 10:09:43 AM Mr. Duxbury turned to slide 26, "National Drug Threat Survey-Drug/Violent Crime," which showed a pie chart. He discussed the substances which contributed to violent crime in the state. He thought it was difficult to enumerate how much it cost the state to engage in response to the opioid crisis. Mr. Jones reviewed slide 27, "Alaska Opioid Epidemic Response Total Costs 2017," which showed a pie chart and data table. He highlighted that the total response cost was $101 million, of which $30 million was the federal share. Mr. Jones turned to slide 28, "Alaska Opioid Epidemic Response Total Costs 2018," which showed a pie chart and data table. He observed that 2018 saw an increase of about $8 million in the same categories as the previous slide. Co-Chair von Imhof wondered which programs being discussed had worked the best. She hoped there would be an evaluation and prioritization of programs. She emphasized the necessity of helping the greatest number of people with the funds that were available. Co-Chair Stedman noted that Co-Chair von Imhof was the subcommittee chair for the DHSS budget. He noted that departments were ranking many programs. He thought a ranked list of the programs mentioned in the presentation would be helpful to members. Mr. Jones agreed to provide the list. 10:12:51 AM Mr. Jones looked to slide 29, "Alaska Opioid Epidemic Response Total Costs FY17/18," which showed the total cost for response for the two previous fiscal years. He noted that slide 14 listed the services that were provided. Between 2017 and 2018, 26,000 recipients were treated for opioid-related diagnoses; 3,700 recipients received opioid treatment medications; and there were a related 1,700 opioid-related incidents with DPS. Mr. Duxbury commented that it would be remiss to not address another aspect of the cost to the state and utilizing 2017 UCR reporting. The estimated cost to the public for the issues related to crime and the opioid crisis was $60,750,667. Mr. Jones read slide 30, " Alaska Opioid Epidemic Response -Resources." Mr. Jones turned to slide 31, "Prevention": ? Partnerships for Success Coalitions ? Community Substance Misuse and Abuse Task Forces ? Division of Behavioral Health, Prevention and Early Intervention Section ? Office of Substance Misuse and Addiction Prevention Data Dashboards ? Opioids in Alaska website Mr. Jones noted that the coalitions brought together multiple different agencies and community members to focus on certain topics. The current grant focused on the opioid epidemic. In partnership with the Alaska Native Tribal Health Consortium (ANTHC) the group was also focusing on alcohol. He stated that there were powerful local task forces. He referenced a book entitled "Dreamland," which highlighted that isolation fueled addiction and that community provided the cure. He noted that the graphic on the slide showed a data dashboard that showed the public what was happening. He added that there was a webpage referenced elsewhere in the presentation that discussed data and provided resources. 10:16:07 AM Mr. Duxbury noted that DPS had realized prevention should also be part of its collaboration. He discussed biodegradable bags for drug takebacks. He thought 75 to 80 percent of individuals utilizing heroin or opioids came from diverted medications. He discussed means of prevention and the importance of a multi-faceted approach. Mr. Jones reviewed slide 32, "Community Coalitions": ? 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 highlighted the efficacy of having a local point of contact in a community. Mr. Jones addressed slide 33, "Prevention and Early Intervention Grant Funding for FY 2018 by Service Area and Program Type," which showed a map and data table. The slide highlighted some grants and showed a broad look of prevention and intervention. The slide only showed grants that were delivered rather than all prevention/intervention efforts. Mr. Jones spoke to slide 34, "Treatment": Detoxification/Withdrawal Management ? Assessment/Intake ? Medication Assisted Treatment ? Inpatient/Residential Services ? Transitional Housing Outpatient Services ? Reentry Services ? Peer Recovery Support Services Mr. Jones noted that the graphic on the bottom of the slide depicted the continuum of care. He highlighted that there were four locations in the state for detox/withdrawal management. There were only 300 prescribers in the state for medication assisted treatment. He estimated that half of the 300 prescribers were actively prescribing. The state had nearly 300 beds for in-patient residential treatment. Capacity for more transitional housing was being continuously built. He discussed organizations that had offered transitional housing. Mr. Jones continued discussing slide 34. He discussed reentry services and peer recovery support services. He described the importance of peer recovery support services in guiding people through a complex system. 10:20:20 AM Senator Bishop asked about the treatment success rate. Mr. Jones did not have a figure but offered to provide the information at a later time. Senator Wilson thought that Medicaid assisted treatment and peer recovery support services had been effective ways of getting people through treatment. He noted that peer recovery programs in the State of Louisiana had done a good job working with past felons. He asked about associating with past felons in peer recovery support. Ms. Brooks stated that DOC had implemented several peer support groups in the system. She was not sure what the policy was with regard to associating with felons. There had been a shift in focus to efforts for peer supports. Mr. Jones continued to comment on slide 34. He stated that the group had built capability in the two years it had been working on the response. Mr. Jones discussed slide 35, "Treatment and Recovery Grant Funding for FY 2018 by Service Area and Program Type," which showed a data table, map, and list. The slide highlighted where services were in the state, and only showed grant funding. Mr. Duxbury showed slide 36, "Alaska State Troopers Statewide Drug Enforcement Unit": ? Statewide Drug Enforcement Unit (SDEU) is a State statute-mandated enforcement unit within the Division of Alaska State Troopers under the Alaska Department of Public Safety (DPS). AS 18.65.085.(a)(b)(c) Narcotic Drugs and Alcohol Enforcement. ? As an enforcement body among different bureaus, detachments, and units within AST, SDEU's specific assignment is to provide services designed to deter, detect, and interdict traffickers and trafficked illicit controlled substances and alcohol. ? SDEU cooperates and collaborates with a myriad of the federal, state, local, and tribal law enforcement partners as well as other stakeholders. Mr. Duxbury discussed partnerships with other agencies. Senator Hoffman asked about the number of cases over the previous four to five years and asked about the success of the unit. Mr. Duxbury agreed to provide more information on closed cases that had been adjudicated. He stated that the unit had been working heavily in the area of interdiction and noted that Alaska was not a production state. Co-Chair Stedman asked for the information to be broken down by the regions of the state. Senator Hoffman asked for the information to be broken down by alcohol and narcotics. He stated that in rural Alaska, alcohol abuse was most likely more prevalent than narcotics, but the situation was changing. Mr. Duxbury agreed to provide the information. 10:25:08 AM Mr. Duxbury addressed slide 37, "Alaska State Troopers Statewide Drug Enforcement Units/Locations": ? Anchorage Airport Interdiction Team ? Mat-Su Narcotics Team ? Fairbanks Area-wide Narcotics Team ? Southcentral Area-wide Narcotics Team ? Southeast Alaska Cities Against Drugs ? Western Alaska Alcohol & Narcotics Team ? Task Force Officer assignments DEA & FBI Co-Chair Stedman noted that there was front-line drug activity in Ketchikan due to access to the South through the ferry. He wondered how to tighten up access on the Alaska Marine Highway and force individuals to drive through Canada and go through customs or travel through an airport. Mr. Duxbury noted that the state had been designated at a high-intensity drug trafficking area (HIDTA), which would help by bringing additional resources to expand upon efforts being made. Additionally, it helped to enjoin smaller communities to work with the troopers. He mentioned the Southeast Alaska Cities Against Drugs program. Co-Chair Stedman thought many people would like to see drug-sniffing dogs at the ferry terminal in Bellingham. Mr. Duxbury thought Co-Chair Stedman had made an interesting suggestion that was worth looking at. There had been similar programs in the past. 10:27:25 AM Co-Chair von Imhof stated that one reason for having the three agencies present was to illustrate the flow of activity. She was interested in seeing how the agencies communicated and how programs were interacting. She thought the presentation did a good job of listing programs, but she did not see a connection between them. Mr. Jones highlighted a scenario in the Division of Public Health that worked with needle exchange sites. The spent needles were sent to the public health lab. The information from tested needles could be provided to DPS to inform as to what drugs were being sold/consumed on the street. He emphasized that it was a new concept for public health and law enforcement to work together. He mentioned the potential for an Overdose Review Committee to bring together multiple agencies analyze program effectiveness. He agreed to follow up with more information. Co-Chair von Imhof emphasized the importance of demonstrated cooperation between different departments. She mentioned the exchange of data and resources and prioritization of effective programs. Mr. Duxbury continued to address Co-Chair von Imhof's question. He asserted that DPS tried to be responsive to when DHSS would share funds between treatment and enforcement. He discussed training in technology to analyze fentanyl. The agencies had shared training. He recognized what Co-Chair von Imhof was looking for and would try and provide some more examples. 10:32:30 AM Mr. Duxbury looked to slide 38, "Anchorage Airport Interdiction Team": Primary focus Interdiction of controlled substances coming into Alaska and drugs and alcohol being moved into rural parts of Alaska through the Ted Stevens Anchorage International Airport. This group is well versed in transportation related interdiction work. Agencies involved in the task force ? Alaska State Troopers (4/1) ? Anchorage Airport Police (1) ? Anchorage Police (1) ? Drug Enforcement Administration (1) ? Federal Bureau of Investigation (1) ? North Slope Borough Police (1 + K-9) ? Sand Point Police (1) This team will be the center of the Southcentral HIDTA Enforcement Initiative. Future plans include the addition of two more agencies. Mr. Duxbury stated that there had been low numbers in the detachments and few people with which to form task forces. The interdiction team would spend time at the airport and was about to grow. He noted that interdiction teams had been improved. Co-Chair Stedman did not see a Southeast member of the interdiction team. Co-Chair Stedman rephrased that his constituents had concerns about drugs shipped to areas without VPSOs. He thought drug traffickers seemed to be targeting smaller, more remote areas of the state. He was concerned about the shipping by air. Mr. Duxbury pointed out that the Anchorage airport interdiction team was not solely concerned with passengers, but also mail and baggage and the bulk shipment of money. The team worked closely with all parties including the United States Postal Service, the United States Drug Enforcement Agency (DEA), and the Federal Bureau of Investigation (FBI). He added that it was also possible to learn about human trafficking through the airport interdiction. Senator Bishop asked about the role of United States Customs. Mr. Duxbury answered that customs was part of the airport, but not necessarily part of the interdiction team. 10:36:29 AM Mr. Duxbury discussed slide 39, "Mat-Su Narcotics Team": Primary Focus Investigation of high-level drug traffickers and drug dealers in the Matanuska-Susitna Valley, Copper River Basin, Valdez and Cordova. Agencies involved in the task force Alaska State Troopers (4/1) This group will be a team attached to the Southcentral HIDTA Enforcement Initiative and future plans include the addition of Federal and Local partners. Mr. Duxbury discussed slide 40, "Southcentral Area-wide Narcotics Team": Primary Focus Investigation of high-level drug traffickers and drug dealers on the Kenai Peninsula, Whittier and Seldovia. Agencies involved in the task force Alaska State Troopers (2/0) Kenai Police (1) This group will be a team attached to the Southcentral HIDTA Enforcement Initiative and future plans include the addition of a Federal partner and the Soldotna Police Dept. Mr. Duxbury showed slide 41, "Fairbanks Area-wide Narcotics Team": Primary Focus Investigation of high-level drug trafficking and drug dealing in Interior Alaska. Agencies involved in the task force Alaska State Troopers (3/1) Fairbanks Police (1) North Pole Police (1) This group will be the center of the Interior Alaska HIDTA Enforcement Initiative. Future plans include adding Federal and additional local agencies to the task force. Mr. Duxbury detailed that the Fairbanks area team had been collaborative with the DEA, the FBI, and the Bureau of Alcohol, Tobacco, Firearms and Explosives at times. Mr. Duxbury spoke to slide 42, "Southeast Alaska Cities Against Drugs": Primary Focus Investigation of high-level drug trafficking and drug dealing in all communities of Southeast Alaska. SEACAD is based on a cooperative agreement by AST, all southeast communities and federal partners to combat drugs throughout Southeast Alaska. Agencies involved in the task force Alaska State Troopers (2/1), Juneau, Ketchikan Juneau Police (2/1) Petersburg Police (1) Sitka Police (1) Federal Bureau of Investigation (2) Coast Guard Investigative Service (2) The group in Juneau will be the center of the Southeast Alaska HIDTA Enforcement Initiative but will have the flexibility to travel to all southeast communities. Future plans include adding two DEA Agents and one US Postal Inspector to Juneau as well as additional local agencies to the task force. 10:39:19 AM Senator Micciche asked about drug houses that had been operating for years in a neighborhood. He wondered how communities could help. He asserted that the property crime cost in such neighborhoods was disproportionately large. Mr. Duxbury stated that there had been a lack of discretion on how law enforcement could operate. He stated that there had to be a great effort and energy into the quantity of drugs that were entering the state. He addressed the quality of life issues in the neighborhood of drug activity. He thought a newly proposed crime bill would have a major impact on the situation. He stated it was very difficult to do surveillance on a drug house thought it took participation by the public to mitigate the situation, and law enforcement needed a great deal of information before it could act. 10:42:21 AM Mr. Duxbury reviewed slide 43, "Western Alaska Alcohol & Narcotics Team": Primary Focus Investigation of mid to high level drug and alcohol trafficking and dealing in Western Alaska and Kodiak. Agencies involved in the task force Alaska State Troopers (5/1) ? Nome, Kotzebue, Bethel, Kodiak Bethel Police (1) Kodiak Police (1) Coast Guard Investigative Service (4/1) ? Kodiak Although this group will not be directly attached to any of the HIDTA Enforcement Initiatives, members will be working on Alaska HIDTA Enforcement Initiatives during a portion of their time. Mr. Jones reviewed slide 44, "Judicial": Alaska Therapeutic Courts (http://www.courts.alaska.gov/therapeutic/index.htm#ab out) ? Drug and DUI Courts ? Anchorage Wellness Courts (Felony Drug, Felony DUI, Municipal Misdemeanor DUI), Bethel, Fairbanks, Juneau, Kenai, Palmer ? Mental Health Courts ? Anchorage, Juneau, Palmer ? Family Court ? Anchorage, Palmer Mr. Jones noted that there was a lot of collaboration in therapeutic courts. He mentioned peer recovery services. He thought therapeutic courts were expensive but highly effective. Ms. Brooks reviewed slide 45, "Corrections": ? The Department of Corrections is the largest provider of substance abuse treatment and detox/withdrawal services in Alaska. ? Approximately 80% of offenders in custody struggle with substance abuse. ? 30% of those who are assessed report abusing opioids. Ms. Brooks detailed that mental health services had increased by more than 60 percent in the previous ten years, much of which was attributable to the increase in substance abuse. The system had seen greater acute medical needs, more complicated medical conditions, and an increase in heroin and prescription drug abuse in particular. The department's booking process had needed to change to enhance awareness for addiction. Officers were trained to recognize use, withdrawal, and overdose symptoms. She discussed long-term use over time and the effect on offenders' health. 10:45:14 AM Ms. Brooks spoke to slide 46, "Corrections": ? DOC has comprehensive substance abuse programming in place throughout the system. ? On-site and telehealth substance abuse assessments ? 64 in-patient substance abuse treatment beds ? Three intensive out-patient treatment programs ? Three dual diagnosis programs Psychoeducation programs ? Peer-based mentoring Ms. Brooks noted that remand and booking facilities had a high turnover and it was difficult to place treatment programs. She discussed peer-based mentoring programs. She noted that the department had done a lot to reduce wait lists by expanding programs. Priority was placed with those in the highest risk and highest need, those close the end of a sentence, and those who had treatment as a part of a legal requirement. Ms. Brooks turned to slide 47, "Corrections": ? Other focus areas for DOC substance abuse treatment. ? Dedicated community treatment beds and outpatient slots Medication Assisted Treatment (MAT) ? Evidence-based treatment curriculum ? CCTV substance abuse education for segregated prisoners ? Substance abuse assessment and withdrawal screening software Ms. Brooks noted that DOC had expanded its treatment in other areas, including halfway houses. There were agreements with community providers throughout the state to have dedicated out-patient slots for individuals in halfway houses. She noted that DOC had shifted to evidence-based treatment curriculums and had standardized programs across facilities. 10:49:09 AM Mr. Jones showed slide 48, "Alaska Opioid Epidemic Response - Partnerships, Outcomes, Results." He noted that the remaining slides would discuss partnerships, outcomes, and results. Mr. Jones spoke to slide 49, "Policy": ? Patients to execute a Voluntary Non-opioid Directive Statewide medical standing orders ? Naloxone distribution Control substance emergency scheduling ? Limits first-time opioid prescriptions to no more than a 7-day supply with exceptions ? Strengthens reporting and education requirements for pharmacists and healthcare providers ? Requires the controlled substance prescription database to be updated daily starting July 1, 2018, instead of weekly Mr. Jones displayed slide 50, "Prevention": Project HOPE Naloxone ? 92 Overdose Response Programs ? 18,000 overdose rescue kits distributed ? Over 250 lives saved ? Medication Deactivation Disposal Bags ? Distributed 46,000 bags since 2017 ? Potential reduction over 2 million pills Opioids and Opioids Epidemic 101 teaching module ? First responder training ? Fatal Overdose Review Committee ? Community Caf? Events Mr. Jones highlighted that troopers had carried overdose rescue kits that were mentioned on the slide. He discussed the importance of the community and partners in prevention work. He discussed the opioid teaching model developed in partnership with DEED. He discussed compassion fatigue training developed in partnership with other stakeholders. Senator Micciche thought it was quantifiable that pharmaceutical companies were more directly responsible for opioid addiction than drug providers South of the border. He mentioned changes to the Prescription Drug Database, and asked how actively it was monitored. Mr. Jones went back to slide 49. He stated that the database was checked daily. He agreed to provide more information at a later time. 10:53:27 AM Mr. Jones discussed slide 51, "Treatment": Nearly 300 residential treatment beds ? 300 Medication-Assisted Treatment (MAT) prescribers ? Substance Use Disorder Expansion ? Section 1115 Behavioral Health Medicaid Demonstration Waiver ? Project ECHO Expansion of treatment, and recovery support services utilizing federal grant funding ? Open Beds platform Mr. Jones discussed Project ECHO, which allowed for providers to get together on a secure platform to discuss issues relating to substance use disorder. He discussed tools for providers to guide people through the continuum of care. Mr. Duxbury addressed slide 52, "Enforcement": ? High Intensity Drug Trafficking Area (HIDTA) Designation ? Task force expansion to include local, tribal, state, and federal enforcement agencies and entities ? Improving our technology ? More efficient ways to collect data (monitor trends) ? Increased training ? Develop private sector partnerships Mr. Duxbury explained that DPS was looking at all aspects of how to engage the public. Ms. Brooks turned to slide 53, "Corrections": ? Detoxification and withdrawal management ? Intake screening ? Housing/observation ? Medical management ? Development of detox beds for women at HMCC ? Medication Assisted Treatment ? Vivitrol ? Methadone bridging ? Narcan Ms. Brooks noted that DOC had changed its detox and withdrawal management protocols and had reached out to DHSS. She discussed research in medication assisted treatment. 10:57:22 AM Mr. Jones discussed slide 54, "Strategic Direction": Alaska Opioid Policy Task Force 2016-2017 ? AOPTF Recommendations Document ? Opioid Initial Response Framework (Prevention Model) 2017 ? Statewide Opioid Action Plan 2018 ? Community Cafe Series approach ? 15 communities(Bethel, Nome, Ketchikan, Sitka, Juneau, Fairbanks, Anchorage, Kodiak, Petersburg, Mat-Su, Kenai, Barrow, Homer, Valdez/Cordova, Dillingham) ? The SOA strategic planning includes local, tribal, state, and federal agencies Mr. Jones highlighted that the action plan was available on the department website. He added that the agencies involved gathered data and formed an over 100-person advisory group; the plan was an Alaska-based plan built by the community for the community. Mr. Jones spoke to slide 55, "Preliminary Results," which showed a map of the state, two pie charts, and a data table. He reminded that the slide reflected preliminary numbers. He noted that the trend from 2017 to 2018 was declining in every category of drug overdose death. He noted that opioid overdose deaths were down 42 percent, and fentanyl overdose deaths (which were skyrocketing in the country) were down by 75 percent. Mr. Jones advanced to slide 57, "Next Steps": ? Next Steps 1: Transition from Incident Command System (ICS) ? Implement sustainable long term recovery operation/approach, Working with States, local jurisdictions, ASTHO, NGA, NCSL ? Next Steps 2: Statewide Opioid Action Plan ? Build capability and capacity in enforcement, prevention, treatment, and recovery services. ? Next Steps 3: Implementation of HIDTA regional task forces ? Next Steps 4: Focus on economic impact of programmatic investments ? UAA's Alaska Justice Information Center (AJiC) could: ? Update Alaska's Adult Criminal Justice model (published in Fall of 2017) with current program costs for therapeutic court and DOC substance abuse treatment programs Expand the model to behavioral health areas ? Provide results to inform investment/selection of programs that are effective and efficient. Pew-MacArthur Results First Model ? Uses combined results from scientifically rigorous program evaluations to estimate the effectiveness of programs; ? Calculates the return on investment for program investment based on jurisdiction specific costs and baseline outcome measures; ? Includes modules for programs in multiple policy areas, notably Adult Criminal Justice, Substance Abuse and Mental Health. Mr. Jones pointed out that some states had an office of drug control policy or a drug policy coordinator, that could look at state systems and identify the most effective approaches. 11:00:13 AM Co-Chair Stedman asked to return to slide 55. He was surprised that the 45 to 64 age group comprised 55 percent of the opioid overdose deaths. Mr. Jones shared Co-Chair Stedman's concern, and noted that the national trend was more of the 25 to 34 year age group. He pondered if the difference was due to the fact that the state's population was aging. He stated that there had been focus on education on prescription medication. Senator Micciche observed that prescription opioids were still the cause of the vast majority of opioid fatalities. He asked to see the information on slide 55 in graph form, including the years 2013 to 2018. Senator Hoffman asked for the information by region and year. He asked about the next steps for cost implementation of the steps listed on slide 57 broken down by year and region. Co-Chair Stedman noted that the information would be helpful as the committee would soon be starting the budget process. ADJOURNMENT 11:02:45 AM The meeting was adjourned at 11:02 a.m.