 Welcome back to the house human services committee on Thursday, February 24th. This is our last committee segment of the day and we are continuing our research and testimony on what we can do and what the landscape is out there in terms of opioid overdose crisis response. And we have with us this afternoon, Dr. Dr. Maruti who is an addiction from addiction medicine psychiatry at UVM MC. Dr. Maruti, thank you. Thank you for being here. Thank you. Representative you and thank you to the committee for this opportunity to be present here. As you all know, we are in the midst of an epidemic here in Vermont in terms of the morbidity and mortality associated with drug overdoses and I'm very grateful to the committee for allowing me this opportunity. Drivers for this are very complex, as you know, we are in the midst of a pandemic that has affected all walks of life and multiple layers both of our society and a societal level but also individually. This has had a downstream effect where people are in greater and greater isolation and people who needed services who needed care, who were just holding on are now having difficulty accessing those services, or in some cases, having a much greater difficulty in just living their own lives in terms of their jobs access to finances and access to their own organic supports. So, these things are all connected there's a domino effect. So, we're moving into the increased potency of synthetics such as fentanyl that are more available, along with the admixture with other synthetic creations such as crystal meth. So, many things are combining and unfortunately where it leads to is greater morbidity or and mortality. And, you know, the fact that the committee feels that this is important is a good step towards the honoring the memory of those who have passed away, and honoring the loved ones of those people who will remember that absence for the rest of their lives. So, the solutions themselves are complex, the solutions themselves are complex. And if we think about immediate remedies and we think about sort of midterm long term remedies. One can really think access to treatment access to safe spaces is really what we need on a immediate level. So long term and long term, what we really need is to be investing in the infrastructure. The entire continuum of support from education on to workforce training, so that we can have people in Vermont, be able to both access services that are high quality, but also people who want to get involved, have the ability to have those jobs, so that they can stay here. So, those are sort of some opening thoughts, and I would welcome your questions and comments and look forward to those. Thank you. Thank you. Thank you very much. Dr. Maroudi. When you talk about, I will start with a question and then turn it over to other committee members. When you talk about the immediate need is access to treatment. Are there steps we can take that will improve access to treatment. You know, I think in terms of the immediate need. There are a number of infrastructure aspects that are already present, which a lot of very good people staff, everything from the different layers, whether it is the community areas such as the providing points which are nonprofit, along with the various hubs of care that are distributed throughout Vermont, along with the designated agencies, along with the tertiary medical centers, the EMS services. So, those many of those are in place. However, we're finding is that people are not able to access them in a timely way. So, in an immediate sense, perhaps, some of those sort of institutions can have some support in having a more proactive outreach so those people could be identified. I know that the mayor of Burlington has convened task forces and committees related to this I was on one earlier this week. So I know that people are aware and are doing things but I think definitely going with what's available and having a little bit more proactive outreach. Getting people into treatment, getting people into treatment in a timely way has been affected unfortunately by COVID very directly so there are places where staff are out because of COVID. They're not able to take people in a timely way. So those things where if we have greater workforce and greater redundancy. The system can keep moving, but really in the short term I think greater outreach, as well as just greater awareness, maybe there are people who are not aware of what services are available. And those things can hopefully help mitigate some of the difficulties. Thank you again for being here today. I, we heard earlier today from a few different folks from Burlington who talked a bit about removing prior authorization for quicker you know being able to have make things happen a lot quicker and I wondered what you thought about that and what the, you know, just gave us some advice on how to possibly move forward on that. Yeah, I think the more friction points we can remove, the better it is, the better it is for the patients, the providers and the systems. Removing friction points is not equivalent to removing safeguards and, but it's really, for example, if you have a prior author and you have to go through that process and it is 444 on a Friday evening. And somebody's out of the office in order to be able to provide that, or has that specialty training in order to do that, then that patient may languish without receiving their prescription. So, having that ability removed I really appreciate that sentiment and I agree with that that having less prior authorizations can be very helpful. Thank you Madam Chair. Dr. Maruti, you said that the other immediate concern or thing to address is safe spaces for folks who are using drugs. Can you expand on what that would look like as an immediate response. Yeah, you know, I think that people need alternatives to being in spaces where there's a preponderance of drugs, or the ability to access them. I have, you know, people who I know who work at Turning Point patients who have really benefited from those type of spaces, these are sober spaces where a person can come non judgmentally can come there, have a place for relaxing recreation support, along with having job training counseling, the ability to put a resume together. So those type of, I almost call them OACs in the middle of the desert can be really very, very encouraging for people and create a safe and positive alternative. And thank you for that one I appreciate the need for sober spaces, especially for folks who are in recovery. The other piece that came up in earlier testimony was was kind of on the opposite end of that and folks who are actively in addiction and the movement towards overdose prevention sites and I would love to get your insight and thoughts on those. Well, as you know it's a it's a complex topic and it creates very strong feelings. There are places in the world and in our country and other countries where people have access those and have been able to receive support as they're using. You know, as a psychiatrist one of the things that we think a lot about is motivational interviewing, which is we try to meet people where they're at. And that if there's evidence for something, and there is community support for it. That's, that's really important that's really critical. But the other aspects that I mentioned like I said those turning points like I said, having greater access to things like Narcan having greater access to fentanyl testing strips. We also need to be concurrently supported and encouraged. Thank you. Another. When you talk about greater access to treatment and idea that we have heard about is a mobile van. In other words, rather than having a brick and mortar hub, for lack of a better term that there is a van that goes around to wondering what you think of something like that. Yeah. As you know, what we need is innovation. We need innovation quickly in this space so that we're able to prevent more needless deaths. So, there's some complex federal laws that are in place, and as long as we can have sort of respect for those and have our sort of legal councils that initiatives that we are in accordance with those having greater outreach and that's what I was saying that having greater outreach, whether it is for testing, whether it is for treatment, whether even if it is for a warm contact can be a very good thing. We live in a rural state. We are seeing increases in fuel prices happening, even in the most recent few weeks. And these are all things that trickle downstream. We live in a state where people have a difficult time, leaving their jobs, and we tied up at different places so anything that can increase outreach can only build good bridges for people that need it the most. I have another. We heard a lot of suggestions or ideas this morning and so I'm throwing them at you to hear what your views are in terms of them, and you talked about sort of safe spaces or sober places or recovery centers and one of the suggestions that we heard this morning was to have a, for lack of a better term, a separate type of sober space for people coming out of the criminal justice. People coming out of jail. And on some level, that sounds very good. And the other, the argument against it might be that you're, you're, you're separating out of a group of individuals that maybe we need to put with others. And that maybe it would be in competition to the other recovery centers. I don't know. But I'm curious from the point of view of, you know, you as an addiction medicine expert or practitioner, think about having a sort of population specific recovery center. I think that, you know, when something is population specific, if it's value added, if it can encourage treatment if it can encourage access, that's something I definitely support so for example, if it is somebody who has a history of trauma. And they are able to feel safer in a, let's say, women's only area or LGBTQI specific safe space. So anybody who's underrepresented or marginalized, there's virtue in that. However, this condition, it goes across economic lines, it grows across gender, it goes across ages. And, and there's a lot to be gained a lot to be learned from having it be more of a open access community space where everybody is on a road to recovery. And that people come at it from different places. So it's a little bit of a both and answer but if there's a biologic or clinical or medical rationale that can support recovery that can support safety support access, then it could be a good thing. But overall it should be as open and as accessible as possible. Thank you. Thank you. This is, this is very helpful. I appreciate it. I'm looking. Oh, I'm sorry. Representative McFawn, you have a question. Thank you Madam chair. Dr. Could you talk a little bit about the use of fentanyl in somebody's treatment program. Do you feel that's appropriate, or how do you feel it should be used, you know that kind of just talk about the actual use of fentanyl. Yes, fentanyl. It is a really, really powerful and aesthetic. And it is really if it is used it's in a very highly monitored operating room or ICU type of setting under great clinical vigilance and monitoring. So in terms of opioid use disorder, the FDA approved medications are more in the category of methadone, or the morphine or naltrexone. So, are you saying that you probably don't think it's a good idea to use fentanyl in in anybody's treatment and in an addicts treatment program. The FDA approved for that. So, you know, there's no way that, you know, I mean the studies need to be done and and really, it is so powerful that it needs very very strict monitoring so really as as prescribers fentanyl patches. Oh, you're just you're talking fentanyl patches. So again it's not FDA approved for treatment of any addiction it is FDA approved for pain management. And I'm going to send a microphone. Would you mind if I clarify your question I think I understand where you're coming from based on earlier testimony, which was that and helping folks to be on buprenorphine to allow an off label use of fentanyl patches as a way to get on to buprenorphine and not have an exaggerated reaction or immediate withdrawal which could actually push folks away from using that treatment and long term. It might be a new idea coming in and harm reduction model. I think that as prescribers, we are under a great DEA scrutiny and vigilance for any medications that we prescribe, but specifically controlled controlled substances controlled medications. And we really have to be very mindful that things that are prescribed are, you know, within a DEA regulatory, you know, requirements, as well as FDA approval. Thank you. Thank you. I just one, I think just one more question you never know. Dr. Maruti, what I'm understanding most from your testimony today is just how complex this issue is and I think, I think we all understand it and are hoping to take action. Next week and a half or so through legislation and so my question is if there is one action that we could take as a legislative body right now to make a change in Vermont to impact and reduce overdose deaths. What action would you suggest that we take an action that can be implemented in the next week and a half. I wish it could be implemented in the next week and a half, but from a legislative perspective we're putting the legislation together. So it could be implemented in the next six months to a year, the next six months as quickly as possible. Yeah, I have so much respect and gratitude for the way we do things in Vermont, which is it's very community oriented. It's a great tradition of helping each other looking out for each other. The designated agencies that are really at the front lines and I have the privilege of interacting with them once across the state actually have much of the infrastructure in place, but they also require more support from us. And I think that if if we were to be able to engage them. They are really in the front lines in the front lines of everything from addiction but also co occurring mental health conditions, and they are very very connected to the local communities. And they all are through your constituents. So I think that's for me in terms of highest yield that could be a really good starting point of really getting a similar type of assessment and needs assessment of okay what is really needed if you could have one thing in your mobile van. Is it the ability to staff your center so it's open 24 seven. What is it and it might be variable from different counties across the state because their needs are variable and their cultures have some variability. So I think engaging the designated agencies, doing a very sort of clear needs assessment that's not prolonged that's very very sort of rapid, and then having the ability to channel some funds to support those needs could be something that I would consider would be highest Thank you. Thank you madam chair, and thank you Dr Mariti. I have one question that sounded like one of the bigger sorts of calls to action that you gave to us was to give organization support for further outreach, and that a lot of people living with substance use disorder may not be aware of the resources that are already there. And I think that if we were to, you know, have ADAP in the room right now they would not to speak for them but maybe point to Vermont help link. Right, which is I think one of their main outreach tools connected to designated agencies. What are your thoughts on the current state of Vermont help link as an outreach tool and how could it be built on and maybe more incorporated with some of the organizations that you mentioned. Yeah, it's a Vermont help link is is great. It's a it's a very good effort. I'm thinking in terms of sort of a multi channel strategy. So that could be one way it's it's present it's there. So here is, you know, in medicine we use the term warm handoffs. And, and, you know, we've really seen the potency of recovery coaching. So a lot of peer led type of initiatives. So augmenting Vermont help link with, you know, organizations like Turning Point, creating some funding. So if somebody wants to become a recovery coach they don't have barriers of finances related to that. So then you can sort of address the outreach from multiple angles. Thank you. I represent McFawn, do you give a question. No, it's a legacy. I wanted before. Another question. Yeah, thank you madam chair. And Dr. Maruti one of the things that we heard from one of our witnesses earlier today is that syringe exchange sites as a service providers as a harm reduction tool and believing that those have been historically underfunded. Any positions on syringe exchange sites role within our, our work here. Yeah, I think as you rightly said that it's, it's in the harm reduction category. And, and, you know, again it comes back to, you know, is the community behind that initiative for there is evidence that syringe exchange sites. can be beneficial. However, one of the things that I was saying that if something is part of a continuum, where we have other aspects that really do need additional funding, then it's a it's something you can consider. But it just needs to be part of a broader strategy that's very local and individual. A lot of the activity that happens a lot of the people that obtain access to the drugs. There are some local networks, and, and especially in our state that has a low population but large surface area. Really focusing on access to everything is really I think where we need to be pointing. Thank you. Thank you. We are taking a lot of your time I'm going to take a look around the table. We don't have any more questions. I want to just express our, our deep appreciation for you for making yourself available to us at such short notice and for providing us with such helpful testimony. As we as we approach trying to do something quickly, what you might say is you know that the immediate than the, than the longer term or whatever we're focusing right now on the more immediate. And so thank you for your suggestions and your thoughts and the way you talked about removing friction points. It's not the same as removing safeguards, and I think you know some points that you made in terms of that. And I love the, the metaphor of recovery centers are an oasis in the middle of a desert. And so some of that is, and how we get access to treatment immediately, or more immediately. Dr. Marruti, thank you very, very much. Really appreciate your assistance. Thank you. Thank you for the kind words and thank you to this committee for this opportunity to testify in front of you. We represent our communities, and I know that these initiatives will bring a lot of hope, having your strength and having your attention to this problem will contribute to us preventing preventable deaths and injuries so thank you also for the work that you do, and we appreciate it very much. Thank you. Thank you very much. And this ends our testimony and our committee.