 We're back. Thank you. This is a joint meeting with Judiciary and Health and Welfare, and we're continuing a look at H-225, which whether either decriminalizes or legalizes small amounts of buprenorphine, depending on your perspective. And we've invited, actually Brenda Siegel, you've been very instrumental in supporting the bill and asking us to take a look at it. So thank you for being here. I think we'll continue the way we have earlier today. We'll listen to testimony and then try to restrict the number of questions so we can get through everyone who is on the agenda. There actually, there's at least one other person on who will be speaking with us who isn't listed. That would be Dr. Deborah Richter. So Brenda Siegel, welcome, and we look forward to your testimony. Hi there. Thank you so much for having me. For the record, I'm Brenda Siegel from New Fane, Vermont, and most of you first got to know me when I ran for office in 2018. What you may not know is that I made that decision on March 7 of 2018, and then on March 8 of 2018, the very next day, my nephew, Kaya Siegel, who was upbringing I was a big part of, died of an overdose. After a year in recovery. He was a son of my brother, Jonathan Siegel who died just over 20 years before him also while using heroin. With 20 years between them, the support still did not exist to help them survive. Kaya had severe bipolar, as did my brother, as well as trauma caused by him being abused while in an institution. Not only was it impossible from our large family to find the mental health supports that he needed, but throughout the seven years of his battle with substance use disorder. The most prominent recurring theme was that he could not consistently access bubrenorphine. This life saving medication for folks with opioid use disorder. As many of you may know, I do this work around the state and around the country of working on specifically access to MAT, but the overdose crisis overall. We as a family would search and search to find providers. What I'm describing exists still today and I want to be very clear about that. Finding none. Our family members would help access it illicitly, just to help him not use heroin sometimes. Because he was hanging off of a cliff. And when your loved one is hanging off of a cliff, you will do anything to help them not die. He would finally get on a program, but due to unnecessary and archaic rules that require folks to go receive their dose daily, and him both living in a rural community, not having transportation and having institutional trauma. He would miss a single day and be removed from the program for 60 days. The amount that you're removed from the program changes depending on what county or area you're in. This is a barrier that absolutely still exists today. Also, if an outpatient treatment center closed without notice or provider left the area, he would lose his medication and have nowhere to turn in order to find immediate access to his medication that he needed to survive. And again, we would be in the position of assuring that he had access and he had insurance. I want to be really clear that not everyone does. All of this stigma based policy led to one thing every single time. Relapse. And he would often have to endure incredible shame and stigma in order to once again access inadequate M. A. T. services. The same services available today as I've said. And they continue to come with enormous barriers with the exception of a phenomenal low barrier program at safe recovery in Burlington. But that's only in Burlington. There remains incredible barriers to accessing treatment even there. Those barriers include lack of transportation, fear of losing your children, threat of job loss, long commutes, as we've heard today, sometimes as much as three hours round trip every single day. And the same having been kicked off of a high barrier program, not believing that you're worthy of life, lack of insurance, lack of funds for co pay, lack of ID. This I've heard time and time again from people experiencing homelessness. I want to address the concern that Senator Sears had that criminalization is sometimes a tool to enter treatment. I actually did not think I would talk about this today. However, I want to be clear that entering people into the criminal justice system was the straw that broke my nephew. It is not a tool to enter treatment. It is manipulation that does not work that is not successful most of the time. When people finally do enter treatment, it's because they were ready for that step. It was because they felt worthy, they felt loved, they felt compassion, they felt that they were worthy of surviving this disease. And the criminal justice system often does not provide that. It's difficult to think that in most cases that manipulation works. If we think it as parents sometimes when we're working with our children, like maybe if we hang something over their head, then we can get them to do what we want them to. But the reality is that doesn't work and I think most of us who have raised children know that the shame and stigma of the system can be incredible hurdle for people getting it over treatment and can cause relapse. And the fear and it can cause a fear of raising their hand to ask for help. In my nephew's case, the criminal justice system after year and recovery, cause him go into a shame spiral. And he was dead three weeks later. I want to say, again, that you cannot manipulate people into treatment. There is not a single benefit to criminalizing people who choose this life-saving medication over heroin. That is almost depth and heroin that is almost definitely laced with fentanyl and risks their lives every single time. I want to talk a little bit about the benefit and safety of bubernorphine, which getting into the work that I do every day advocating. The testimony that I will submit in writing rather than boring you with studies will have attached several articles that address the safety of bubernorphine along with indicated use when people use it unprescribed. They will also be a summary of the research done by Johns Hopkins University with reference to the published and peer reviewed studies and I think it's really important that any studies we hear about today are both published and peer reviewed. These articles reference well over 100 studies, dozens of which address some of what we've heard about today in terms of diversion, why people use illicit bubernorphine fear of people who are opioid naive, having access, and more. It is important to note that these studies are published again and have peer reviewed. In house testimony, the health commissioner and I'm sure you'll hear today reference a study that that I can't find as published, although maybe I'm wrong about that. We'll hopefully we'll hear today. And I'm not sure that has been peer reviewed. And it comes to a completely different conclusion than doesn't literally dozens of stuff research done by reputable sources. And so I really would like to see the research behind it and know a little more of the background. And the questions that were asked. But I'll get to that in a moment. As you heard today it's important to understand that bubernorphine is a partial agonist. That means that it does not bind to the opioid receptors in the same way that a traditional opioid does. It does not run the same risk of addiction, nor does it provide the same type of euphoria that is often the relief that people with severe mental illness or trauma feel and need to replicate with heroin or other opioids. Additionally, if someone is opioid dependent then they will not get a euphoric effect from the medication in the same way at all. That we've heard over and over again from Dr. Blake, Dr. Richter, Dr. Schaefer, who's here down in New Fane, in Townsend, and hopefully is submitting testimony as well. I want to repeat that, that if no one is, if you are opioid dependent, you're not getting that euphoric effect. So recreational use may be the word people who are opioid dependent use to describe what they're doing. But in fact they are choosing life-saving medication over heroin that's laced with fentanyl. It also has a built-in safety protocol in several ways. One, it has a ceiling, which means there's only so much of the medication that is useful and then it's leveled out. In addition, bubernorphine does not cause respiratory depression. That means that the risk of overdose is almost non-existent. In fact, ER visits according to dozens of the peer reviewed studies that I will submit and that I am looking at here include bubernorphine, including bubernorphine are extremely rare. So those ER visits are rare and in the first place, when they do happen, they always include a different drug that is the actual cause of the visit. In other words, it is extraordinarily rare for bubernorphine to be the primary reason. Two, it is interruptive to being able to have a euphoric effect from heroin in other opioids. If one tries to combine, so it's very uncommon to do this and it further protects people from overdose and staves off cravings so the desire no longer exists. Three, the most readily available form of bubernorphine is suboxone, which has naloxone in it, which probably you are all familiar with, the primary drug present in Narcan. For those of you that don't know, Narcan is the medication indicated to stop active overdose. Which means that on those rare occasions that someone does use another opioid, which they will quickly find out does not have the intended effect while they're using bubernorphine, the naloxone on board helps prevent that overdose. So the benefit is that it reduces cravings, it stabilizes people with opioid use disorder and allows them to live a more stable life. Most importantly, it keeps people who are at imminent risk of dying alive. When used unprescribed, it is an important and essential harm reduction measure. And each and every person in Vermont and across this country at risk of dying of this disease deserves a lifeline immediately. My nephew deserved a lifeline. He deserved to survive, and my brother deserved to survive. And what I'm asking you to do today is to make sure that we give that lifeline to people who are dying now, who are at risk of dying now. When we talk about the concerns about diversion, I want to be really clear that dozens of the studies that I'm going to send you today say, that talk about diversion, it's going to come to a different conclusion than I think you're going to hear from Dr. Levine today, which is that people generally do not use it for recreational use. In fact, even when they think that's what they're doing, they might be using it in between heroin uses, that's true. But again, like Sarah George said, every single time they choose bubernorphine, they will not die that day. We have to be really clear about that. And what the research has found is that that use of diverted bubernorphine, that use of non prescribed bubernorphine happens to be an important path to the, to important part of their path to recovery in a very high percentage of the people who eventually find sustained recovery and 60% of those people find sustained recovery have a better quality and longer term sustained recovery due to the fact that they used it while it was non prescribed. I know that is backwards from what we normally think about when we think about this issue, but it's extremely, extremely important. I want to say something about if our children get it because I know that's on people's minds. I want to say that as someone who experienced bearing first my brother, then his son, I take that very seriously and would be lying. If I didn't say that people that our family does not have an expanded risk due to the trauma that we have suffered and the children in our family. The reality is that first of all we've addressed that with under 21 being addressed as diversion and family court. But also, I want to be really clear that if my son, for some reason decides that the trauma and depression is too much for him. And he goes and tries to get an opioid. I am praying that the first opioid he tries is bubrenorphine, because he won't die that day. And because I will have an opportunity to get him the help he needs before he dies. An opportunity I did not have with my brother or his son. I finally, I want to just read just reference instead of going on. I'm going to submit written testimony that has a lot more information, but you have such a packed schedule that I don't want to go into it. That all of the risks that we talk about that you're going to hear from Dr. Levine that you heard from the commission, Commissioner Sherling. Have not borne out in reality in Berlin, Chittenden County or in Addison County. We've heard from States Attorney Marthage in Bennington County that this that she's not concerned about this, this, these same risks. And I think it's really important to know that note that Johns Hopkins University did several studies which will also be referenced. I want to talk about what happens when we take away medication. Can you imagine taking away blood pressure medication for people because they eat steak, or because they don't exercise. Can you imagine taking away any kind of even even certain kinds of anxiety medication because you don't get therapy or depression medication because you don't get therapy. Can you imagine taking away what people need for for diabetes, because they continue to eat sugar. Here's the thing people lose buprenorphine because of these archaic rules because of the way that the disease functions. And when they lose that buprenorphine sometimes for 30 days sometimes for 10 days sometimes for 60 days. Are we really asking them. To instead of using illicit buprenorphine, unprescribed buprenorphine. When they are going to need something to choose heroin. Or do we want to tell them to choose the thing that will make sure they stay alive until the next time they can get on that prescription until we address this barrier in our state. And I want to be really clear about it is the criminal justice system diversion is the criminal justice system and enter and there's that there's no way around it. So, we can't pretend it's not we can't pretend that that's a tool that law enforcement can use this is so far too long, then part of law enforcement states attorneys, instead of medical professionals. Again, there's incredible barriers. And I want to just end by saying that before I was an advocate around the country, and around the state on this issue. I was a family member in the meetings with lots of other family members with the health department, hearing them tell me that there were no wait times and anybody could access treatment. And was family member after family member standing up and saying wait, we had to wait. There was a wait time for us. What do you mean he had to wait 72 hours in that timeframe he died. People were that there's a disconnect. And if this is a slam dunk in any state as Commissioner Levine said except Vermont, then it is a slam dunk here. If people in New Hampshire can have this. People in Vermont should have it. It's been three years. Since I got the call from my nephew's boss. At work that he had died after a year and recovery. Three years. Since I told his mom. It's been three years. Since my heart shattered. And my life changed forever. And in that three years, I've heard this same story over and over again. Not only am I urging you to pass h 225 as drafted which I have to tell you has been all the discussions we're having today about diversion and all of these issues have been discussed. Unbelievable amounts of discussion has happened on them testimony. I'm not asking you to pass it, but I'm asking you to pass it this year, because between now and January, and as drafted, because between now and January, we're right now we're losing about three people a week so between now and January, people will die. People that you all have the power to give another tool for survival. And I am begging you because once our family members die. We do not get them back. Thank you. Thank you for your testimony and we look forward to having you send that in. So we can get it on both of our web pages and we. You've been through a very difficult time and your advocacy is extremely clear. So thank you very much for that. Do you have, I know that Josh Sharfstein of Johns Hopkins testified in the House human services committee on this and sent some extensive research. Is that what will you be including that in what you're sending us. I have, I'm going to send you a list of studies I'm going to send you a few articles and I'm also going to send you Josh Sharfstein's summaries of each of the study with the study reference so that you can access it if you'd like to. And, and each and every study really I just really bear bore the same thing. And which was that this is a safe and effective way with a strong safety protocol that and also is how people enter retreat. And thank you for covering that's what we're here for. We got it. I got it. Okay. Questions for Brenda. No, I think what we should do is to move along. We have Dr. Levine is here, as well as Dr. Heward and I did want to hear it make sure a Dr. Heward welcome. I haven't had you in our committees previously, but I thought it might be helpful to hear from Dr. Levine first but I want to make sure Dr. Heward that you're what your timeframe is. So we don't lose you. Yeah, thank you. Yeah, it's nice to be with you today I am. I have time for the next 45 minutes. I'm available. So Dr. Levine I'll turn to you. Do you think your testimony will take up more than 45 minutes. You're muted commissioner. I'll talk fast. I'll talk fast and you know we can we can we can get into more of a conversation and we'll have Dr. Heward offer his testimony as well but I thought it would be important for you to go first. Commissioner Mark Levine Department of Health. Let's start out with a few introductory comments. Obviously, the concept and the motivation behind this bill. We do support we regard substance use disorder as a chronic illness. We want people to get well we want to keep them alive as has been emphasized and what you've just heard. Data on the impacts of decriminalizing buprenorphine is unlimited, often contradictory. And we don't have a lot of real world experience of actually what impact this may have had because it hasn't been done a lot. But there are a lot of ecological and descriptive studies that don't really account for the specific treatment environment we have in Vermont. When we look at the motivation of those who users seek buprenorphine through diversion. A lot of the literatures from urban settings where a majority of the cases are using injection drugs, like in Baltimore where a lot of the Johns Hopkins research has come from. In Vermont, we feel that we're seeing a little bit different portion of the population that's not yet at that stage, and may actually be using buprenorphine for its euphoric effect. I will talk about the health implications of the bill. There's a lot of judicial and legal implications which you've heard from others on. I do want to raise some provocative points so that all issues get a fair hearing. And some of the perhaps unanticipated consequences of the legislation are understood as well. And I have to tell you that, as I said, last time I testified with the House. It's a it's a difficult concept to talk about to come out from a fully evidence informed standpoint. And I have some ambivalence as well and if you sense that it is real. And above all else, whatever legislation results from these hearings, must I believe have as its primary motivating factor, providing the opportunity for Vermonters in need of treatment to be able to rapidly access treatment. And I mean treatment. I don't mean managing withdrawal symptoms from opioids on a chronic basis. I mean, entering into treatment. In my role as commissioner health, I actually have to consider the health implications for all Vermonters that might result from system and policy decisions. So let's look at a couple of those groups of Vermonters. First of all, there are Vermonters who are not using opioids at this time, but might be exposed to the opportunity due to prescription drugs becoming available on the street food diversion. Now remember how we got into the opioid crisis, it was over prescribing and diversion of strong narcotics likes oxy oxycontin. That's why we developed a prescriber rule in Vermont, so that there would be less drug circulating in the population. It is true, as you just heard that buprenorphine can be the first drug that a person uses. It can also be the first drug that a person injects. It's stronger than morphine and dependence can develop. A lot has been made about the fact that many users of illicitly obtained buprenorphine are trying to alleviate withdrawal symptoms and that is completely true. There is also literature though showing that some percent are using it to get high. The discern study which Vermont has been participating in, which really addresses hepatitis C and HIV from injection drug use, show that in Vermont, an 85% rate of using this drug to get high, and the over 400 subjects that were surveyed, at least a third of whom were from Vermont. Let's look at another group for monitors with substance use disorder who are in treatment, which is anywhere in the 8000 plus minus range at any point in time. I'm going to introduce a term destabilization. Those individuals might be destabilized by this legislation because it creates a greater incentive to divert some of their medication, which may mean that they won't get the appropriate effective dose that was prescribed to them. Now it's well known in the treatment community that if an individual has less drug available because they've sold some of it, the remainder they might actually inject so they'll get the full bioavailability of the remaining drug, which would of course expose them to then the complications of injection drug use like endocarditis and bloodstream infections. And we know it often takes years for someone to seek treatment. So we want to make sure that once they have arrived in treatment, they have the best possible environment, which will significantly impact their ability to achieve recovery. So what about the group of a monitors who are further along the path to opioid addiction and at high risk of overdose. Now we know that these make the best treatment candidates as they have prior experience with buprenorphine. And that's one of the reasons that's touted as a primary reason to describe decriminalize its use, and also consider that though they may benefit from access to buprenorphine on the street, as they're less likely to overdose when using buprenorphine compared to some other opioids, they're often more likely to continue a pattern of use outside of the treatment system, instead of being rapidly referred to treat. And at least some potentially many may still be using bup to get high putting themselves and others at risk. They do have an overdose resistance for as long as they have the medication, but only for as long as they have the medication through whatever channel they use to access it. In some of them, the literature tells us maybe more prone to use benzodiazepines to dampen the euphoria, which increases their risk of adverse consequences. I also want you to consider the prescriber community, because if there's an incentivization to divert prescriptions, prescribers may have a harder time ensuring that their patients are getting successful treatment, which puts them in a difficult ethical situation when they suspect the version is occurring. I spoke into enough clinicians who prescribed buprenorphine to know that at least some of them are questioning whether they would continue to participate should such a bill be passed. And I urge you to understand their testimony. Now, Miss Siegel was a correct that last time I testified I did say that if I was the commissioner of any other state in the US, I would be unequivocally for this bill as a potentially important public health measure. I did then and I still think now that Vermont is different. We don't know what flooding the streets with buprenorphine, which is some characterization of the strategy by some means in a state with no waiting list in the true capacity to treat all. And I still believe those latter two are true. We have a legacy of developing a nationally renowned hub and spoke system with a lot of protections built in. How supportive could this be to the system that we and others pray so often that we have given technical assistance on to abundant states so they can develop their own. Would there be more negative consequences than positive. There are states where people are literally dying because they cannot immediately access care, and they are on waiting lists. This kind of strategy might be their only chance to survive. I'm not sure that as a true bona fide harm reduction strategy. This would be the case here. If we look at Vermont, we think there's about two and a half percent of the age 18 to 64 adult population on medication assisted treatment. There are no other states that rival that. There's a country that rivals that is France, where it's in the two to three percent range as well, thought to be about half of its opioid use disorder population. In the French experience with buprenorphine, which is a primary care this prescribing model with little or no training, but some observational dosing has expanded access to substitution therapy and reduce the overall harm associated with treated opioid dependence, including reductions and over those. But even their diversion has been a significant concern. And a lot of strategies have been thought of to reduce the likelihood of diversion. All of those strategies have actually informed the model of care we use in Vermont. The goal is to balance access to effective care with medical controls. And the greatest predictor of success seems to be the quality of the relationship between the treatment provider and the patient, something we don't want to disrupt. Now there are health reasons for supporting this bill. I agree that we don't want to criminalize those with an illness, but we have access to pretrial services in every county of the state. We want to assure people are using the safest medication possible in the safest possible way, even if they're using it illicitly. And buprenorphine, if used as is described, and if not injected, does possess a lower risk of overdose, even though it is stronger than other opioids and can induce dependence faster. Providing reasons for people to not otherwise turn to drugs like heroin fentanyl is indeed an important public health objective. But a safer and effective treatment tool does not mean it is benign. And there are some who have written that to date, no trials have evaluated the efficacy of buprenorphine alone without medication management as the minimal standard of care. Thus, there are no data on the number of types of individuals who may respond to buprenorphine without medication management and monitoring. Now just like there are health reasons to support the bill, there are also health reasons to be cautious about the bill. One is that it could and probably will incentivize diversion. Now, unlike heroin or fentanyl, the only way you can get buprenorphine in the state of Vermont traditionally is by a prescription. So almost all of what's available is diverted medication from prescribed medication. We are more recently aware of a growing number of opportunities to buy illicit buprenorphine, but that is often cut with other illicit substances, which would make it inherently less safe. Any powder people get nowadays on the streets is guaranteed to have fentanyl in it. Most patients on buprenorphine are Medicaid patients and therefore in more financial need than most from honors. This bill would further increase demand on the street and increase the risk that a patient sells their drugs for cash. Another health reason to be cautious about the bill is it could disincentivize treatment. If a patient diverts their medications, even to a friend or other person in need, that patient is then destabilized because they're not getting their usual effective dose. Someone who uses diverted bup may be less likely to find their way to our treatment system and our recovery system supports. In comparison to other states in Vermont, we've successfully worked with providers to reduce the total dose to the minimum possible amount. This means that there's not a lot of extra padding in a patient's prescription to sell while getting all the benefits of the medication for themselves. We excel at arriving at the right dose. And I've already pointed out the risk of complications if one uses the injection route. The last point on this is, and I want to emphasize this, we lose a critical intervention point. Whatever's decided with regards to this bill, there must be immediate opportunity for an apprehended individual to be immediately connected with resources or services. Whether that be a case worker at a police department or a social worker embedded in the state police barracks. And we shouldn't minimize that power of that impact, even if it is within the criminal justice system, it is still a fact of life of how these individuals will be identified. So often the criminal citation for holding non prescription buprenorphine is what gives a person an incentive to go through pretrial services and engage in treatment. This is how we work with law enforcement and the criminal justice system to make sure those who are ill with this disease can care. Those who profit by the epidemic can be prosecuted accordingly. This is a key point so to be clear, the criminal citation currently goes away when the person enters treatment. There wouldn't be a criminal record or misdemeanor or otherwise specific to having been cited for possession of buprenorphine. There's evidence that a drug court model results from coerced care are equivalent to those from voluntary care. Same outcome can result. In the course of many years of progress Vermont has developed the sequential intercept model. And we can't lose fact track of the fact that this is a medical treatment for a chronic disease condition and best practice dictates that patients have a medical exam blood work to check for liver problems before being prescribed such a drug. This of course will not happen outside of formal treatment. There's also an opportunity that the availability of opioids out on the street will be increased because of this with increased potential for people to start using or to abuse. Now, it would be a tremendous error into service to presume that the latest years increase in opioid overdose deaths after a previous year of marked improvement came about because nothing was being done. We only entertained an initiative like this, which had been missing. We would rectify the situation. Now I've spoken widely at many recent press conferences on the reasons why we and the entire nation have had a more tragic year with regard to opioid overdose deaths. I don't believe this is the time to be opportunistic. It's the time to redouble efforts we know work. The last time I testified on this, there are abundant initiatives away that can all make a positive impact on the opioid crisis in Vermont and the overdose death rate through improved access to treatment. These include treatment and harm reduction strategies. For instance, one can now rapidly access medication assisted treatment in almost every emergency room in the state. One can now rapidly access medication assisted treatment and all syringe service programs, either by having a person at the program prescribing or being led to a treatment provider who was agreed to prescribe for the for the syringe service program. There is now increased access statewide, not just in Burlington to syringe service programs. There is now increased opportunity for intervention via law enforcement social service connections within their own buildings. There is now major medication for opioid use disorder availability in the Department of Corrections at entry, along with more smooth discharge and transition planning when they leave corrections. This course worked on as part of the justice reinvestment project in connecting individuals with services to reduce recidivism and improve community safety. And on the topic of differentiation by age and with the provision about those under 21 assignment to court diversion, etc. For all adults, adults should have the same provision to actually determine treatment needs and provisions and not assume adults are using illicitly obtained buprenorphine and doing so for pseudo therapeutic purposes. Illness is not age dependent. It's all about the relationship with the drug. There is no age cut off for harm reduction approaches. And please keep in mind something we're hearing about recently and know of specific cases, which is that not all people in possession of illicit buprenorphine purchased it. It may have indeed been obtained by threat of coercion or threat of domestic violence. A couple of conclusions will continue to strive for universal access to treatment. Right now we remain skeptical that the potential health benefits outweigh the potential costs in this bill. We believe that focusing on ensuring that those with misdemeanor possession charges for any opioid are diverted to pretrial services would be a more impactful investment of our efforts. In regard to earlier discussion by Commissioner Shirley on statutory preemption of diversion codifying this referral to diversion and treatment seems to me eminently rational as it aligns well with the health goal of guaranteeing the opportunity for individuals who have opioid use disorder to rapidly access truly effective treatment. I do believe we must continue to be innovative bold and courageous in addressing this crisis. And I think in Vermont, we have been and continue to be, and we continue to be funded very well by the federal government to expand the opportunities I just described to you for rapid access to medication for opioid use disorder. I don't think we should create a scenario where we might unravel some of the past good work and current work that's being done, or jeopardize the success of the hub and spoke system, just for the sake of being innovative. Recognizing the reality of drug use and developing new approaches to work within this reality is not the same as policies that result in additional opioids being available on the street. It is awful and ensure that policy decisions we make are the right decisions for all Vermonters, all of the groups I discussed with you at the beginning of this talk, those who have opioid use disorder and are in treatment. Those who are using opioids and are not yet in treatment. Those who aren't using, but maybe a greater risk of starting to use. Thank you for your time. Dr. Levine, thank you very much and thank you for being here with us. It is 11 o'clock, and we have three other witnesses here to testify. And because Dr. Heward may have time limitations I'm going to ask that we hold questions for Dr. Levine until after Dr. Hewer has testified. I also have Julia Larson and Jess Kirby so I understand that we all we each have questions but I'm going to ask that we hold those until, at least until after Dr. Heward has presented his testimony. Dr. Heward thank you for being here. It is time that you have been in our committee but this is a joint hearing meeting between the Judiciary and the Health and Welfare committees. Dr. Heward we asked you to come in just to talk a little bit about the specific effects of uprenorphine and comments that you might make from your perspective in in work with adolescents. So, thank you for being here. Absolutely. Thank you for having me it's a pleasure to be here. I have, I don't have as much of a written or a prepared testimony to provide, though I do have a couple of comments and then I would be happy to answer questions. That's perfectly fine and we'll move to questions that perhaps both you and Dr. Levine might respond to. So I am a psychiatrist. I am a child psychiatrist and an addiction psychiatrist having done specialty training in both and then board certified in all three. I do work now at the University of Vermont Medical Center in an addiction treatment program, and also in CVPH in Plans for New York on the child and adolescent psychiatry. In terms of this issue I, I haven't had a lot of time to delve into this issue and to the bill the proposed bill. A couple of thoughts from an adolescent standpoint is one of my concerns. Well, before I go into that, I should say that the University of Vermont Health Network does not have an official position on this bill. Everything that I say is is based on that and I think I will give some of my opinions and other things, but those are my personal opinions. I do think thinking of adolescents particularly under the age of 18 and looking at this bill. I do worry that we're decriminalizing some of that that they would be referred to treatment. But at the same time in with Vermont statutes. If you're under the age of 18, you are not allowed to consent for medical treatment for substance use. So if it creates this interesting situation where a 17 year old could not consent to go to a doctor and get prescription of uprenorphine but could get it on the street. They would be referred for treatment but it is an interesting position to be in. So I do think, and to echo Dr Levine sentiment I think overall my feeling is whatever we can do to promote access to treatment is, is the most important and I do agree that medication including uprenorphine is a key part of that, but it's only one part that medication management so meeting with the prescriber and other providers is another key important part of treatment. I'm happy to comment specifically about the mechanism of action of uprenorphine. It is an opioid that we use for treatment. It is different than heroin different than fentanyl that different than oxycodone and many of the other opioids that you've heard of because it is a partial drug which provides for a number of therapeutic advantages. Primarily, the risk of overdose on uprenorphine is significantly less than any of the other opioids and really it's virtually negligible without other substances on board as well. So that makes it incredibly safe and I think it provides a lot of benefits. What I think about uprenorphine I think about most of the other or all the other opioids being a light switch that turns completely on and uprenorphine is a dimmer that turns it on halfway. It is true that there is a dependence risk for uprenorphine and it can be very challenging to get people to come off of uprenorphine because of that physiologic dependence. However, most of the data support long term use of uprenorphine to prevent the risk of relapse on other opioids. So that's a brief overview of some of my opinions and thoughts but I'm happy to answer additional questions or provide other comments. Thank you. You know what I think that was that is extremely helpful for us as we sort through the sort of the medical side of this and the health care side of this. And it obviously feels like there aren't two sides. It's, it's all together but Senator White has a question and then Senator Hardy has a question. Thank you, Madam Chair. My question is for Dr. Levine. And I, I know that you said that we have no waiting lists, and then we have the capacity to treat all. But I also know that AHS closed down some units and programs at the Brattleboro retreat that were actually treating people and that that resulted in waiting times and no treatment available and, and it wasn't just the initial treatment that somebody could get at the emergency room in the hospital and the hospital told me that they were not giving ongoing treatment. And, and I know that the, even as simple as getting an appointment with a licensed alcohol drug counselor took six weeks, six weeks to just get an appointment so there were, there are lots and lots of waiting times and they have limited they have opened up that a little bit now at the retreat, but I have to admit that I do not trust that AHS won't do this again, and close down those very programs that result in our area for with tremendous time. So I, I can't accept the fact that we have no waiting times and have the capacity to treat all. I do know that when the Brattleboro retreat did what you just described, we had other treatment providers in the area that we worked with and continue to work with. We just see the specifics of the individuals who had difficulty and work with our ADAPS section so that we can understand if there were indeed problems that should have been handled in a more timely fashion. So happy to hear about that for sure. Whether that be true or not be true. I'm not sure how much bearing it has on why one would be in favor or not in favor of this bill. In terms of the decriminalizing of uprenorphine and use of the medication in an unregulated if I could say way. My only response to that is that you said that in any other state. Yeah, okay. Support it but in Vermont we didn't need to have it because we had no waiting times and we had the capacity to treat all and I'm. I simply don't believe that. Okay, no I appreciate that. We're going to move on to Senator Hardy and then Senator Sears. Thank you Madam Chair and thank you, Dr Levine for being here so it's nice to see you even, even when I disagree with you. And my question is similar to Senator whites except for I'm trying to put together your testimony with Commissioner Sherling's testimony because I think you guys contradict each other, because if I'm understanding your testimony and if I disagree with you, because he was saying that he believes we should have this automatic court diversion, because we don't have the infrastructure for a health response to this crisis and a health response to getting enough people in treatment and he was, I heard him say, we have to have court diversion because we don't have enough of an infrastructure, and that it's a health problem that our health care system is not taking care of. And you're saying, we do have the infrastructure we have this hub and stuff spoke model we're better than everyone else in the country and therefore don't need this. So I see a disconnect between your perspective and his perspective, even though you said you agree with each other so could you explain that to me. Not sure I can because I didn't hear his testimony today and I haven't had a chance to review it yet. But the bottom line is I know we agree on the fact that there should be a smooth and reasonable pathway to treatment, if one is confronted by someone in the criminal justice system in the public safety sector. There needs to be a way to make sure that that does not turn into a criminal interaction that turns into an opportunity for treatment interaction. I don't know what he said about the access and the rationale. Beyond that, but I can say our interest is only that that not be a criminal interaction that be an opportunity, a cry for help if you will, that we can use to help the person access the treatment they're not otherwise access. I have trouble going beyond that to what he may have said. I appreciate that you didn't hear what he said and I could be misunderstanding it but what I heard him say was that we need to have a law enforcement and court response to this epidemic because there's not a sufficient health and medical response to it and we don't have the tools in our state to provide treatment directly to people and therefore we need to have this, you know, court diversion aspect to it and, and that seems to contradict your testimony that we have sufficient treatment options that are readily and easily available to people and, and therefore this this bill is unnecessary so that's what I'm trying to reconcile in my mind. Thank you Senator and I think that Commissioner Sherling did leave us some language that we can look at that might clarify his understanding it's on our web page. The language actually just confuses it more senator. I appreciate what Commissioner Sherling said and I don't think we, we have time to do that right now but we can, as we go forward we can fully evaluate what we have and what we don't have in terms of treatment and referral in our state that we all know that we need the support for patients with the chronic illness of addiction. Yeah, I just wanted to make two points and then ask both Dr Levine and Dr Wood to comment. It appears to me anyway, listening to the comments from the states attorneys that we've already decriminalized the session of Suboxone in Vermont that nobody's getting charged. I don't know how many have been for small amounts. So some of the concerns that have been expressed here. Then I, and I'm not a believer that this is going to be a silver bullet, it's going to solve the problem. It may play a role, but some of the points attributed to it we've already seen the results. But I'm concerned about what harm just voice just asking a bill like this, that either of you see, and particularly in terms of adolescents that you are dealing with, either either That's a question for both Dr Hewitt and Dr Levine. Yes, yeah. Yeah, I'll let Dr Hewitt start with the, especially the adolescent focus and then I'll pick up. Yeah, so the question being what the risks are to. What's the harm since we've already decriminalized it based upon states attorney's testimony. Yeah, and I think if we get adolescent opioid use by and large most of it is prescription opioid use that adolescents are getting from family and friends. So it's the pill boxes and in the pills above the kitchen sink or the bathroom sink, they're taking those and that's what they're using. There is a degree of heroin use as well, though that's lesser. And I guess one of the concerns could be it will this increase access to buprenorphine and allow adolescents to use that as well. I would say overall the overwhelming evidence right now is that the diversion that's happening for adolescents is mostly other prescribed opioids. And we haven't seen a lot of diversion of buprenorphine, though there's also not a lot of evidence the Vermont it participates in the Youth Risk Behavior Survey, which is a federal survey. And there's no data as far as I know that asks about buprenorphine use monitoring the future is another large survey that also does not really evaluate for buprenorphine use. The National Survey of Drug Use and Health really doesn't provide a lot of information that way either so I would say there's really a lack of evidence to know how this may impact it. And I will say, in addition, in my work, I'm taking care of a lot of patients that are coming in, having already gotten buprenorphine from others and from a diverted source. In fact, I've seen estimates between 50 and 80% of people coming in to seek treatment have already been on buprenorphine. And whether that's occasional use of buprenorphine or regular use, I think that's something that I have seen in my in my own clinical practice. So it's out there already. I don't know that this is, I honestly don't know and I don't know if there is data to support whether this will actually lead to increased access to buprenorphine for adolescents and others. I think Dr. Levine, if it can be maybe a shorter answer, simply because we have two other folks and I would like them to have at least five minutes a piece. Absolutely. Thank you. Yeah, my short answer is just that I agree that diversion is the pathway no matter what drug, whether it's a traditional opioid or if it's buprenorphine. I have great data that shows that. I look at the possession of buprenorphine. If you will as a cry for help. Even though it may not be voiced that way by the individual at the time, but clearly they needed to have something to give them the same kind of feeling and that same connection with those receptors in their brain that are keeping them comfortable. So I would just hate to make, I would hate to see that if decriminalization meant nobody even talk to anybody, you know, that that would be a bad result, you know, if an officer encountered someone in the field, and it was like, ah, he's got a little bup on him, but that's not criminal anyways. Move on to something more serious and abandon that encounter. That would be a bad outcome because that cry for help could be responded to then rather than when the person is further into an opioid use disorder. And good things can happen from the standpoint of management of their disorder. So that's where actually some of the things that you may have heard from Shirley regarding his suggestions could be useful because it would guarantee that there would be an encounter and then that encounter could lead to direction into treatment. Thank you. And I'm going to turn to Julia and then to Jess and you just as explanation before when after we scheduled you folks for testimony, we learned that our committee meeting would be shortened by a half an hour. We didn't want to lose you and your testimony. So please, please go right ahead. Julia. Thank you for being here. Thank you and thank you for having me. You know, I wanted to bring up. I go door to door with Savita who's a bup in working for Scriber. We try and do this twice a month to to engage people on a quit date we're using the 802 quits motto for cigarettes to try and get people to find a quick date for heroin, or for opiate use. A lot of people that we encounter that are using what is called streets of oxen are using it for various reasons. I will let you know that we cannot get people instantly into treatment. So, if we get somebody on a Friday afternoon who's in opiate withdrawal, we can't even make an appointment for them to make an appointment to do an intake until Monday. You know, at four o'clock Friday night, there are no services available until Monday morning at 8am. We do utilize MIT through the emergency department, but there are various reasons that people might not want to go to the emergency department they have family that works there. I've seen their people have issues going into different MIT clinics because they're actively trying to change their lifestyle and they're going in with all the people that they just recently used with, or used in the past with or, you know, not everyone that's in an MIT program is on the path to recovery. They may be clean and sober but they're not engaging in recovery lifestyles. We also know that individuals, when they're ready, they're ready that moment. They're not ready four days later. Four days later they might be dead. And so, I urge you to think of it in terms of destigmatizing buprenorphine and letting people know that, you know, you're not a big bad criminal if you have a very small amount of buprenorphine. We're not talking about large amounts here, you know, where we're talking about small amounts and it's for usually personal survival, we see people come out of corrections where they're not connected with a provider, and their choices they're released on a Friday. You know, sometimes it just happens. They go to court, everything's resolved, goodbye out the door at the courthouse, nothing's set up. So their choice is, oh, my cousin's on buprenorphine, maybe I can get a couple of buprenorphine to hold me over until I can get a provider or I can get a couple of bags of heroin but either way I'm chemically dependent now on buprenorphine. So there are so many different scenarios in this, and in terms of harm reduction, I think that it sends a strong message to people that are on buprenorphine professionals that are embarrassed because they don't want to be seen taking buprenorphine. Parents who have children on buprenorphine and are embarrassed their children are on buprenorphine, I think that this sends a really strong statement to destigmatize buprenorphine treatment. I also think that it helps in terms of making that choice between the bag of heroin or, you know, a piece of buprenorphine. I do agree that there should be safe falls. I don't want to see, you know, people profiting off other people suffering ever. So I do think that, you know, referrals and, and maybe including something in the harm reduction kits from ADAP where there's an 800 number to call and get an instant access to medication maybe that's something we could do as a state. But I think in terms of this bill, I would much rather have see somebody have, you know, several doses of buprenorphine versus several bags of heroin, several fentanyl patches, several doses of oxycontin that's sent from Mexico or made wherever. And I just, I feel really strongly that buprenorphine is very, very stigmatized. Unfortunately, and I think that part of this bill would would help destigmatize people getting treatment and and help people get treatment. And that's all I really have to say. I, you know, I deal with people that just really are trying it, but they're, they're holding on by a ledge. And, you know, if we can prevent one of those people from falling, then I think that it's worth it. Thank you. Thank you and what we may be that we ask you to testify another time at least in health and welfare. This is very helpful. Yes. Thank you for being here and just Kirby. Thank you for being here and you are at the Howard Center. Yep, you are at turning point so just want to make sure that folks understood that it is on the agenda. So just please go ahead. Um, I everyone has spoken so beautifully and I still even with a lot of practice get really nervous. I'm going to read something I know we don't have a lot of time but I went through it it takes like three minutes so yeah I'm a person in long term recovery from opiate disorder and I work at safe recovery program at the Howard Center, a syringe service program and we have a low barrier buprenorphine program. Okay, so this is a really important bill to me low barrier or unprescribed buprenorphine was an important part of my path into recovery. I started using opiates in the bathroom at my middle school when I was in seventh grade. And then for the first time that day and never stopped until I got into long term recovery, many years later. Last year, I submitted written testimony which described the use of non prescribed bup as my first step in a treatment. When I reread that last night. It really gave me goosebumps just remembering what an important part of my journey it was and thinking about where I am today. I had a lot of people I didn't have positive experiences with or trust for the medical or social services systems. I had had one too many dirty looks men discharge or turn away from one too many programs. When I really needed help and I just didn't trust that the system was where to help there to help me anymore. And I definitely still think that that is the case for a lot of clients today. But like a lot of my clients I really really wanted to stop using. I ended up using non prescribed bup that I accessed like through friends or partners. Sometimes I used it for longer periods sometimes intermittently starting and stopping us again. I remember being filled with relief when I first gave it a try like a real go and realizing that it really worked in that I could be free from the withdrawal symptoms that have been debilitating my life for years. And pretty much having you know it had control over my life and not having to think about where to get more every day throughout the entirety of my use. I had never known a way out and I could never see a way forward I truly didn't know how I was going to get out of it and it's really hard to stop something when you have no idea how like what's the path and am I going to be able to accomplish this goal so it's really hard to stop anything in that case let alone something that causes physical dependency and something like obese disorder which we know is so all consuming. And so using non prescribed bup like it has done for a lot of my clients showed me a way forward and I was able to use it on my terms without the judgments of others in a safe way. So I had to deal with the dirty looks and without the hoops and barriers which you know I really strongly want to say that although we do have low barrier options and and rapid access options that there are still barriers to every program that have to be made, there are ways that have to happen, they're waiting periods still. If you go to the ED, we've all been to the ED, it can take hours and hours and hours and when you're getting often dirty looks in between or judgment or just feeling that stigma. You know that's asking a lot of people and often people aren't able to access it for those reasons. Today, I, you know, eventually I did find my way to the traditional system and have been in long term recovery for a very long time. You know getting that relief from what I was going through every day and finally being able to see a path forward made it easier for me to take those steps. So, today, like I said I work out safe recovery program at the Howard Center where we have a low barrier program we have a syringe exchange, lots of other harm reduction services. My job is to engage and support and provide case management to people that are at risk of dying every day every time I see them. Many of my clients use fentanyl every day, several times a day it's very short acting as we know that means they're extremely at extremely high risk of dying, several times every single day. I want my clients to have every incentive possible to make the safer choice. I want them to have as much access and incentive incentive as possible use buprenorphine. We know that it works with or without a prescription. It worked for me and it's worked for many, many clients that I've had. It works without being attached to a treatment program or counseling it works for people who access it on the street. I know a lot of people who are in long term recovery with the use of non prescribed bup people have jobs take care of children are living healthy lives and people who even with the lowest of barriers have not been able to access treatment or don't have a desire to be in treatment. And that's okay and they're living healthier and they're alive and that's the most important thing. So, you know, in closing, I would like to say that, you know, I hope that we can take, you know, pass this bill forward and take another step in fighting the fentanyl crisis, which we have done so much to do. So, I would like to say that, you know, like I already said, there are still a lot of barriers, even though we do have much more access than maybe other states, there are still many barriers, I talked to people about it every day, all day, you know, I experienced them myself, even in the programs that are low barrier there are still barriers and there are hoops and there are things that deter people away. And, you know, on another touchy subject which I'm not an expert on but I did start using as an adolescent myself. I have children I have an adolescent. And I, you know, I would like to say that, in my opinion, any child who's at risk of using non prescribed buprenorphine is at risk of using heroin fentanyl or other opiates other opiates even prescription opiates are going to be more dangerous than buprenorphine. Even as a mom myself, I would prefer my child if he had to go down that path to use buprenorphine over any of those other things. So, Jess, thank you. Thank you so much. And Julia, thank you. You've actually. We're getting, I'm getting called to the car. We're going to have to close.