 Welcome back. This is the Vermont House Human Services Committee, our third focus of the day. At two o'clock, we are going back to the system of care for individuals with developmental disabilities. But I thought that at least for a few bits, we could have a bit of a discussion on what we heard this morning as it related to opioid overdose crisis response and what things struck us that we want to get some more information on or pursue and what things we're going to put off to another day. They're not directed at what we want to do right now quickly. Well, I think the one thing that I heard was around access to, sorry, methadone. We've heard from that it's spread out around the state, but I'd be interested to hear more about access in rural areas and barriers to treatment in rural parts of the state. I think that it's easy to look, our witness's focus was really looking at Burlington where there's access to transportation and just be more interested in access or barriers for rural Vermont and what that looks like and what we can maybe have. That van idea. The van idea. Because that's not brick and mortar. It's not creating something new, which will take lots of time, but perhaps an existing provider could do a van. Yeah. I think it also opens up a question that I think might be worth exploring along those lines is that there are mobile syringe exchange services. There may be some regulatory reason that we can't combine those two, but I think it's just worth asking the question. If we're having these vans going out for one for business, they're a way to kind of equip them for another. Okay. And we don't need more vans. And then what are you on transportation? Okay. Do we have it be electric? How about the remove all prior authorization? It seems like do we need to hear from, is that an insurance company that you had and how do we help in that area? I mean, I think we would need to hear from insurance. The other thing might be to hear from Diva as it relates to probably heroin and opioid disorder is not solely with people who are receiving Medicaid, but that might be a the first step in terms of looking at looking at that. Yeah. I think another one would be the taking a look at the sunset on Uber northing, removing criminal penalties. I know that part of that work was the Chief Prevention Officer doing a bit of an analysis of how that's going. So maybe we could hear back from Ms. Hut about that. What is the sunset? I mean, the bill that we remember the bill we passed, I think, I think it's a two year sunset and there was supposed to be a review. And I was added in the Senate, I believe. Yes, it was added. It was not in the House passed bill. The Senate added it. And in the interest of not having a stalemate, we said, okay. So what, yeah. I also would be interested in access to treatment at hospitals if someone goes to the ER. Is there any, like do all of the hospitals in Vermont emergency room have someone who can prescribe Suboxone immediately? And building on that, what was concerning is about the preferred provider network and how we're not currently able to add any more preferred providers to expand access. I don't know why that is, but I think I could also tie in to making sure that in ERs and hospitals across the state, we'd have easier access. And of course, I would love to look into the legislative barriers to overdose prevention sites, not necessarily putting the funding in per se or opening one on the state level, but maybe not being a barrier to municipalities that are looking to do such a thing. Yes. So what's one barrier? Well, I think from testimony, what we heard is that there's kind of two pathways that we could go. One is saying you can open it and we're not going to prosecute you for opening an overdose prevention site. And the other is granting municipalities the opportunity for them to decide if they would like to open an overdose prevention site. Yeah. Yeah. Also, the access to the methadone clinic state, this seems like something that might be reasonably easy, which is the hours of operation not being for people who need to work. So evenings and weekends is that the challenge with that is that the methadone clinics are not state clinics. The methadone clinics or the hubs are run by community male health centers who we don't tell community male health centers how many hours they need to be open or things like that. We potentially could put money in to be directed towards increasing the hours. And then someone would come to our door and say, we can't even staff the hours that we have now. So there is a part of me that doesn't want to put something into place that that we can't do that. That's that's doesn't work right now. A good thing to think about later, because it is sort of amazing, or even if they could switch their hours to hours that make sense for everyone, not just people who are available in the daytime during the week. But yeah, that's yeah, because that's where it worked for getting folks. But I think that's what Dan's facing down in comments. And well, I think that comes back to the same thing with that we see with a lot of just remembering that when we do Medicaid rate increases to include the preferred provider network, because that includes hubs. So if there's staffing issues at hubs, those rates are determined by Medicaid rates for the preferred provider network. I and I left before the end, but I heard some the issue of the availability of fentanyl patches or something. Yeah, we kind of talked about it later. Kind of went down a little bit of a rabbit hole in that. I'm not sure that there's something that we can do in this bill with regard to that. There are hurdles that would need to be overcome in order to do that. I think it is something for us to continue to investigate it. So there might be language about investigating the use of fentanyl patches for, you know, yeah. It's trying to onboard people into MAT essentially trying to. Well, you and some level, I think the word is titrate them into it. Yeah. It's a more regulated amount of fentanyl. So then you know when it ends, so then they can put them onto buprenorphine and not have that overwhelming reaction. Yeah. But it's not label use. Okay. It's an awful label use. So that's where we get into that wishy-washy. Oh, okay. Because they're for paying relief. I mean, that's what. Yeah, right. Yes, we are the only, we are doing this. We are the only committee. Yeah. This is our job. Yep. They also talked about the harm reduction centers and that more dollars to help in that area. Okay. Yeah. Just to speak a bit, it's sort of, I think the prior authorization is sort of like seems like something that other states are doing a barrier that we can look into removing. I think there are so many other things that were kind of mentioned between access to methadone and that being staffing, syringe service providers, opening up the preferred provider network, like safe induction, which is the low barrier treatment. And I imagine that all of those include some investment, some need for investment. And so maybe kind of trying to get a sense of where can that investment go the furthest right now or where is something that, that's where my mind is going. Topper. Bruce? Topper. I can't see you, but I see your hand. What do you want? You have a hand up. Your hand's up. Yeah, I know. I had it up for a long while and I just turned it off. I'm listening. Oh, okay. So, I wasn't ignoring you? No, forget it. Okay. Okay, good. I was too busy looking at my piece of paper to look up at the screen. I'll tell you what it sounds like from this end. Like free-for-all. If you did it, I can't. So that's my problem and I'll just listen. It sounds like a free-for-all. Yes, it is. It is sort of a brainstorming. Like what do people get out of the testimony this morning that we might want to pursue short-term? And it sounds like there are some things that aren't for today. And whether we want to, and one of the things I heard them say was review the hub and spoke system. And so we're not going to review the hub and spoke system model here. Maybe put something in there to have that big. And there may be, I mean, I know that there has been some, in the past, some reviews, both academic and otherwise, of the hub and spoke. Is it time for another review? But not to do the review for this, but to say come back next year or something. I think what he's trying to allude to is that the ideas are bouncing so fast that if you're not right here, it's hard to follow along. Oh, thank you. So in other words, maybe this is a time for us to slow down when we talk. Be clear, pronunciate so that people online can hear. I'm right here and sorry for me. You guys are going so fast. Okay, thank you. Thank you for that feedback. I, of course, this is through my eyes. So you all can say now what about this? One of the things that strikes me as intriguing and maybe can address access to treatment quickly is the concept of a mobile van. And so that would be one, some funding. And two, a question to ask is can that be connected to what is happening already about mobile distribution of syringes? A second thing that I heard was removal of prior authorization or at least at minimum raise it above to 24 or something like that, which is what. And so the question that we would need to get some answer to is because we heard that New Hampshire and Maine and Oregon, but Oregon's far away. So New Hampshire and Maine, our neighbors don't have it at the same level. So how do we perhaps be consistent with that? So the information we would need to know is how might how might removal of prior authorization or raising of the dosage? I guess I think we would have to work with Diva in terms of the Medicaid population. And if we are curious, someone could, we could talk with an insurer in terms of private insurers, forgetting who their lobbyist is, but to put out a little inquiry or whether to, you know, we might decide to just if we go down that to limit it to Medicaid for the first step. There's the, and yes, Topper. Madam Chair, do we know why pre-authorization is there in the first place? No, I think it's because it is a maybe maybe we want to find out why it's okay. Is it the reason, Mark? I don't know myself what it is, but I may actually have an answer. Okay. The researcher in the room. The researcher in the room who's on, you know, as a teacher, I feel, excuse me, aren't you paying attention? I am. So well that I even, I need you to rewind. What was the very last thing Topper said, like the last part of the sentence? Why are prior authorizations, why did they exist in the first place? I know, but you said something after that. Oh, did you say, why did you say after that, Topper? Maybe we ought to find out why it's there. Yes. It's because buprenorphine is a schedule three narcotic as it's classified. So with any narcotics are typically higher authorizations and they have it for various medications out there. And I think, and Topper, it's a question to ask Diva when we sort of ask about what your, how open they would be to changing the level. The question, first question you're very right to ask is why is it there in the first place? And we, I want to say we we know in quotes that there is some state flexibility given the fact that our neighbors New Hampshire and Maine have either have removed it or it's a higher level. So it doesn't seem like there's a federal barrier with a lot of this stuff. The federal laws are going to limit things. Appreciate the addition, Topper. To remove the sunset for the non, it was not decriminalization. It was, we called it something different. The non, what we passed last year. That's how I remember it. Moving criminal penalties, removing to to remove the sunset from that. And a question would be to Monica, where she is in her evaluation would be one thing and another might be to ask a state's attorney or a local police officer. What their thoughts would be. Yeah. One of the things that really struck me that they brought up was about the need for a lot more attention placed on re-entry for people from the criminal justice system. And the reason it struck me so much is because of the significant number of deaths in from the women's correctional facility last year when people were during COVID they were people were discharged or whatever the term is there. And I can't remember the exact number, but it was more than a handful of people died almost immediately from overdose as a result of it's sad. I mean, it makes sense because there was nothing on re-entry for them. So they the focus that they talked about on re-entry is very important as well. Burlington has been working on that piece just for that area. So it would be nice to be able to help the rural areas as well. When the Burlington piece that they're working on, they have beginnings they did. I mean, I think this is a conversation we would need to have because at the time, perhaps before this additional testimony we had, that was a one of the multitude of requests that came in as it related to recovery centers. And the decision was made at the time not to separate it out. And I don't know if you want to say what was going into your reasoning and whether then if we think about it in a different way now. Yeah, no, I mean, I'd really love to put the time into it, whether it's during this bill or I think that from what I heard, and I did speak to Thomas Dalton to our witness today mentioned, I think there were some concerns with the fact that it would be a essentially a second recovery center. And I think there are efforts put to try to collaborate and kind of intertwine their work. And there's real difficulty in finding a way to have those two organizations mesh. So I think that's just something that would need to be addressed. I know that there were concerns from a few parties about sort of a second recovery center, specifically for this purpose, as opposed to something that's more integrated. I was just struck by the comment about, I know in this body, we worked actually quite hard a couple of years back to ensure that people in the correctional system had access to MAT. And then, so if you have access, and then you begin MAT while you're in, and then all of a sudden you don't have, it needs to be immediate, you know, it can't be like in 24 hours or 48 hours, it needs to be immediate access to that support on the outside. You know, I feel like that's a I mean, I think it's something to think about. Yeah, I'm sorry. That's like discharge planning. So when someone's leaving incarceration, what's the planning? Exactly. And I do believe that that work is happening out of the Turning Point Center in Rutland. Well, so some of that's well, so some of that's happening there, some of that's happening through the Vermont, I think it's criminal justice, counsel, whatever, Thomas, Dalton's organization, and so maybe to hear from both of them as far as what or talk to both of them because I think there is something unique about individuals who are coming out of a correctional center and to end their comfort level in terms of who they are interacting with. And then the comfort level of others to use the recovery centers if what they perceive is that there are lots of people who have just come out of jail, like it or not, there is a I think some some hesitation or some perceptions of if you've been in jail, what that means. That so it might be but to talk to people. This is all I want to be clear what we're this testimony that we're doing will be individual conversations, you know, and that kind of thing. So to come back and get information and have some, you know, as we as we then correct, you know, have something on paper, we can have people come in and do take a page out of your process, which was to was to once the bill was developed to send it to all the interested parties. Yes, and in thinking about this particular area, it is something we could also ask the Joint Justice Oversight Committee to add to their work plan this summer, in terms of taking because it's a complicated it's a complicated process and there's lots of layers involved with it that we probably won't have sufficient time to unravel here, but just, you know, but so so I think a to do task is around for lack of a better term, the Tom Dalton proposal, which was referenced by one of the witnesses today, and to have further conversation with the people who are concerned, what their concerns are, and the Dalton recommendation was what specifically a recovery center specific for justice involved people in recovery. Thank you. We also heard something about places for safe induction for seven to 10 days. Are there no places like that now or is this an expand? So this is a new program or an expansion of a country. They're not they're not legally allowed in Vermont. So it would be there are some across the country. And I think there may be some federal issues. Are there federal issues? I'm looking to you around. I do not have that answer actually. Okay, where's my research? But there are there are currently legal barriers to doing that, because a different level, different line, but it would it basically would mean decriminalizing or removing the criminal penalties for places where not only could someone who is get a clean needle, but they in fact could should should could put on their own in a safe place with a clean needle with someone there if they were to overdose. And there there is some beginning research. Some of their my understanding is that there's some like lots of things, there's some things that have been happening, let's say outside the outside the eyes of the law, outside the formal, let's say the formal process. And but those have been researched. And so we have some research about how effective they are. And I want to say, is it New York City is New York City has one. And I want to say somewhere in Pennsylvania, or something like that. There's I want to say New Jersey or something. I think there's more than in terms of the East Coast. There are some communities who have said, we don't want to have people dying on the street. And so bottom line, this is to prevent death. And it would be in a place where maybe, you know, there will be people there who are respected or seem safe to the IV drug user, who may then be able to the goal is to direct them to treatment. And those kinds of things. But so I mean, I want to help. At a minimum, I'd like to have us have a report on it. At a maximum, what you know, is there something there's, I understand that Burlington wants to do it. And that the mayor wants to do it and that the city council wants to do it. And I don't know why they can't do it. They said it was something that we have to take care of. So what is the something that we have to take care of that we would promise not to prosecute prosecute is what we would have is either a promise that we don't prosecute them, not that they not with someone dying there, it's because people are using drugs in the location. They also say that what if someone died there, they need to check, see if they have insurance for that. It was a great question from Carl on the piece of, well, what's the liability piece? Who's liable if someone does die? And they came back to the piece of, well, we've seen these internationally around the world. And there have been zero reported deaths in any overdose prevention site in the world to date. So not that it can't happen, but that the liability question is still out there and one that the city is willing to grapple with. So the witnesses said that there's a couple of different options. You can instruct the Department of Health to develop rules around the development and safe use of an OPS, or you could, we could authorize municipalities to be the decision makers with regard to establishments of them in their boundaries. They clearly had done some thought about what other, what has happened in other places and stuff. The problem is that we, since we are such a strategic society that even though people are going there for their protection, if something happened, the family of that person may go after the people running the side of it. So I mean, that's one of the big issues. I mean, even though the intent by all of us is to do something that's going to help these people that may if they weren't in that facility or whatever. But that's a thorny issue because I mean, how do you go ahead and protect people from self-righteousness when it comes down to them? But also from the families of those people, the people that are often in search. And there's also the question that if you were to give municipalities the ability to do that, how long would it take them to basically get through the whole process of permitting and having some sort of a, that's outside this committee? Because it might take two years. That's why I kind of liked the, if all we have to do is remove the roadblocks and you are doing the thing, right? And you figure, I think the big question on it is liability. Right. So it's making sure that we are not creating liability for the state. So yeah, so I want to say sort of like cannabis, this, you know, Spenceries or whatever they are. We're a lot at state, cities get to choose. We're not saying everyone has to do this. Cities get to choose and they're choosing by voting or whatever. Okay. So who wants to, this is called divide and conquer in terms of the various questions. Dane, is there a question or two that you are most interested in doing some more conversations? I'm interested to hear what other people are interested in. Okay. Those. Yeah. And then see what's left. Okay. Yeah. You already know what mine is. I think. Self safe injection sites. Would you like to explore that? If you would like me to Madam Chair, I'd be happy to. Realizing that there are three options. Study. Which we're not doing. Report. Authorize or instruct. Great. Connect with Mr. Englander on that. Okay. That's to say. You know, free options. I would say, I mean, if we are, I mean, and the fourth option is be silent. But if we are thinking that we're hearing that this is other, you know, I hate going international, but other countries have done it and done it successfully in the sense that they've saved lives and that it has been a path towards enter into treatment for some. But we're also hearing that there are some. Now, it's now being explored both above board and underground. And we have some, I understand we have some research as to their effectiveness, some academic or policy. Think tank kind of research. And so looking at that, if we were going to say, okay, this is something that we'll consider. Okay, sure. Option one is no, we're not even going to touch it. Talk about it. You know, option two is we report on it. Option three might be, I mean, this is what I'm thinking of options. And based on what they testified, option three would be to authorize municipalities to make their own decisions for better words. Option four is to instruct the Department of Health. Part of looking at this is they've said the legislature has to do something and they pointed out these two options. Is there something else that we would need to do? I mean, you know, my guess is to just say municipalities you can choose. That may not be enough. Go ahead. I was just going to say, this is something that I've been really sort of grappling with for a couple of years now thinking about this as I've heard the city of Burlington, you know, discussing it actually for a while now. And I know that we've had fellow legislators bring the concept to us before. And I feel like before I go the step of authorizing municipalities or instructing the department to develop rules or that I really would need to have more information about it. I mean, so I could see our bill instructing the department to prepare information or something or to do the research or for somebody. I feel like any more information before I would, it's a big step. I'm just saying it's big step. I am all over harm reduction as a positive thing for us to promote. It would be a big step for me and this being upfront about that. No, I appreciate that. And I think maybe this would be something that if if it looked like we wanted to go further, that we would need to have some testimony. And we would need to have someone who can speak about it. And also about the viability piece that Carl brought out. Yeah. I'm curious about that. But also I'd make this trailer brought out the possible federal intervention. We probably need an answer on that. Are there federal regulations that prohibit or have to be set aside to allow this to happen? Because you're talking about controlled substances, which the feds are pretty strong on. Okay. And you're essentially authorizing the use of these in these facilities. So it seemed like you'd have to get some sort of something from the federal government to allow it. But I don't know for sure. Yeah, I don't, you know, I don't know. And I mean, I don't know any of that. And then I'm like, we legalize cannabis. Has the feds, the feds haven't legalized cannabis. There's a whole different. I'm not equating to, but there is. There's interesting. There's also an issue around RNs being willing because you take a certain oath when you become, it's an oath, I don't remember what it's called, but there are certain things that when you become a physician or a nurse or provider that you will do. And I think being in the center, there's some issue around their licensure. And so that I just, I don't remember what it was. But as Trisa said, I've been looking at this and reading articles that come out and wondering how it's working. And I remember there were some of the providers were worried about working in this, in the center, watching something that isn't legal. Like how does that work for their license? And I don't remember what that is, but we should probably know that. That they're supposed to do no harm. Yeah. And it might, I mean, my quick answer would be no one is required. This was what we're not suggesting that this, this would be a standalone, its own thing and a lot. Yeah. Yeah. But yeah. If we even pursue it. Yeah. So this is on a relate different. Good. So thank you. Yes. Thank you. And if somebody said this already, and I missed it, I apologize. But one of the things that Dr. Seaman also said was that what could we do to enable more flexibility in the preferred provider system, how to get to be a preferred provider, what the providers do says there's no openings right now. I presume that there's a, you know, I don't know, there's some limit that is placed on that. But that's something that feels like we could have an impact on potentially. Okay. Um, like, I'm not, I'm not sure even I know that we have this thing that we call a preferred provider system. And maybe Dane knows the answer to this. I know the designated agencies are in statute, designated agencies are in statute is preferred provider system in statute the way designated agencies are, or is it something that is a construct that we have outside of state law? Yeah, that's a great question. I haven't thought about seeing it in statute itself or whether it's just part of the system. So who would be interested, willing to whether it's connecting with the Department of Health and with start with that and Katie around the preferred provider network. Okay. And I would also be interested in looking further into prior authorization, if that's unless somebody else wants to take that. And I also think that just checking in with Monica about the. Okay. About the one. The sunset. Oh, yeah. Okay. So, okay, so we've got that. Does anyone want to take the mobile van? Who suggested the mobile van? Yeah. One of them. I don't know who talking in talking about how to increase access to methadone. One there is to sort of look at the hub and spoke model. And do we do something different? That seems to be more of a report back kind of thing. And the other and maybe that maybe if they didn't say that did someone here suggested. No, they said no. Okay. Even brought it out. It is to have a mobile van to have a mobile van. And were you raising your hand? No. No, he was raising, he and Kelly both raised their hands. Okay. I'm interested in that one. Okay. I feel like in rural places that is really potentially really helpful. So and so I mean, I think with that, there's there's a little bit of one. How much would it cost? I mean, you know, whatever. And can they be connected to syringe syringe exchange services? What's the syringe exchange service? That is the Well, the biggest one is Vermont cares. They're an aid service organization. And I believe safe recovery also has one. So and so what becomes confusing? Vermont care and and AIDS project is Southern Vermont. Okay. It is where we will get back to this at a later time. But thank you.