 Okay, well good afternoon everyone and thanks for being here. I want to start by thanking the staff at Central Vermont Medical Center for hosting us today. For more than two and a half years, just about everything we did was shaped by the pandemic. And I know that was especially true for healthcare workers. So thank you for all you've done and continue to do for all of us. We know COVID affected us in so many ways. And not just because of the virus, but because of the negative impact of isolation and other measures that were necessary before vaccines. This included many people turning to or returning to harmful substances, often as a way to cope, whether due to illness, isolation, or emotional and financial stresses. Regardless of the reason, we know substance misuse and the opioid epidemic have played this for far too long. And unfortunately, the pandemic made this much, much worse here and across the country. That's why today we'll be talking about substance use, the resources available to help in our efforts to provide Vermonters who need and want it with treatment. Harm reduction strategies to protect their lives and recovery services, including employment, to support them as they rebuild their lives. Vermont has been a national leader in addressing substance use, but we have never rested on our laurels. Even before the pandemic, we were expanding on the work that had been bending the curve, reducing overdoses and getting more people than ever into treatment. But there's no doubt the pandemic created a situation that set us back, despite the very best efforts of providers who kept services going. And tragically, we, like the rest of the country, have seen an increase in the loss of life due to overdoses. We've talked a lot about the lives lost to COVID over the last few years, but we must also recognize that other lives were lost as a result, including from overdose and suicide. These were also parents, children, sisters, brothers, loved ones. That's why it's critical we focus on reversing these trends. And today we'll talk about what we're doing to meet that challenge, which includes new and enhanced measures, building on our systems of care, expanding services, and making the use of statewide partnerships. Just this year, we've invested nearly nine million more to address substance use disorder here in Vermont. It's important we approach this from all angles, which is why this new funding covers prevention, treatment, and recovery, because we can't focus on just one area or one tool, because it's just not going to give us the results we need and expect. The funding also strategically prioritizes prevention efforts at a local level, because keeping Vermonters from being addicted in the first place is the most effective way to save lives. I also want to briefly mention the fourth leg of the stool as we work to address this challenge, and that's enforcement. Vermont has been a leader in recognizing opioid addiction as substance misuse as a public health crisis, and it is. As I said before, law enforcement cannot be, should not be, and is not the primary tool in this work. But it's clear there is an important role for enforcement to cut off the supply and stop those who prey on our youth. As many of you probably saw, I introduced a framework for a public safety plan yesterday, and we'll be talking a lot more about that in the coming weeks. So I'd like to keep today focused on our prevention work and these new investments, because I believe it's where we can strengthen our state response and make a real difference, saving lives before they are put at risk. And here at CBMC, an important partner in this work, they've been pioneering some new ways to help people impacted by substance misuse. And so you'll hear from CBMC president and COO Anna Noonan and Dr. Jawad Moshkuri to talk about their innovative work to help Vermonters. But first, Dr. Levine will share more details on what the state is doing, and Melanie Sheehan, the regional prevention program manager at Mount Eskutney Hospital and vice chair of the Vermont Substance Misuse Prevention Oversight and Advisory Council will talk more about prevention. With that, Dr. Levine. Thank you, Governor. By some it's been forgotten already, but before the pandemic, Vermont had been making steady progress and slowing the rate of opioid-related deaths. But tragically, COVID-19 quickly reversed those trends as many faced isolation, anxiety, and other changes to their support systems. It's difficult to understate the challenges in getting people the substance use prevention and treatment services they needed while in the midst of the greatest public health crisis in more than a century. The loss of life to accidental overdoses and the increase in substance use have been tragic additions to the illnesses and deaths suffered these past two and a half years. According to data released in April, Vermont's opioid-related deaths increased 34.5% from 158 deaths in 2020 to 215 in 2021, the highest number we've ever seen in Vermont. Now, we must remember that these deaths represent friends, neighbors, loved ones. Each death is one too many and we feel for the families coping with their loss. We did not lose sight during the pandemic response. We are proud that Vermont was able to react quickly and adapt and work through the barriers that the pandemic created. Through state efforts in partnership with our broad network of community and medical partners to whom I am grateful, Vermont was able to ensure services critical to saving lives were again available even if somewhat different forms to meet the new realities. I'm hopeful that COVID-19's ongoing evolution to an endemic state will mean fewer barriers to care and services. Our focus is to continue to restore the statewide network and safety nuts that had us bending the curve on substance use and overdoses. In addition, as the governor has discussed here and in other briefings, we, the state and our partners, will build on these efforts keeping Vermont in the forefront of programs, services and partnerships to support the mental, emotional and physical health of Vermonters. Now, of note, the state is providing $8.7 million to support and grow enhanced capacity and the provision of innovative substance use prevention and treatment programs throughout the state. The largest component, almost half, will be in the prevention arena specifically a marked expansion in funding substance misuse prevention coalitions across the state. Melanie will tell you more about those shortly. The treatment community is being further supported by rate increases to support this workforce's critical and ever-expanding work. And $3.5 million is in support of recovery, which if you think about it is really supporting prevention of relapse for those who have already have an opioid use disorder and maximizing their likelihood for a successful future free of substances. In this category are investments in recovery housing, recovery employment pilots, increased financial support for recovery centers and innovative recovery, community recovery facilities and an investment in those transitioning out of the criminal justice system. At the same time, we recognize the pandemic will have long-term impacts for many, particularly related to substance use and overdose prevention. This is why our work will continue to be responsive to changing needs, ensuring access to prevention, intervention, treatment and recovery programs for opioids and all substances. For example, we continue to find fentanyl at the heart of so many incidences of accidental overdoses. In 2021, it was involved in 93% of opioid related fatal overdoses. The health department worked to help prevent and reverse overdoses by supporting the distribution of over 47,000 doses of naloxone, Narcan and more than 83,000 fentanyl test strips to our community partners to provide to individuals. Vermont Emergency Medical Services are key partners in our efforts. As required, EMS responders offer naloxone to any person who overdosed on opioids and refused transportation to the hospital for additional care. In 2020, this protocol also required naloxone leave behind kits to be given to people who may exhibit signs of opioid misuse when the EMS personnel arrive at a scene for a non-overdose emergency. The kits can also be given to a bystander or family member who may later on be in a position to save a life. Now, our prescribers, healthcare professionals, also play a critical role in reducing the risk of overdoses. Between 2016 and 2022, we've seen a 54% reduction in prescription opioids dispensed and the percentage of opioid related fatal overdoses involving prescription opioids has dramatically decreased in that same time frame. These successes are due in large part to the Vermont Medical Community's implementation of the universal precautions for prescribing opioids and their partnership with the Department of Health's prescription monitoring system. Our work through take-back days, collecting unwanted and expired medications also continues to help prevent medication misuse from ever starting. And I do need to mention Vermont Helplink, vthelplink.org. Whether you're seeking help for yourself or a loved one, this statewide public resource offers caring and expert advice and support for navigating the Vermont treatment and recovery system and has been successfully connecting Vermonters to drug and alcohol support services since 2020. I'd like to end my comments on harm reduction and stigma. We know one of the best ways to save lives is through harm reduction, meaning people where they are at and encouraging substances be used safely. Our dedicated syringe services programs ensures Vermonters at highest risk of overdose have access to recovery and referrals and overdose prevention resources in a non-stigmatizing environment. We also focus on reaching people at risk of an overdose and their loved ones through a campaign called NoID, that's K-N-O-W-O-D campaign. These steps include never use a loan. If you OD while alone, you can die. Go slow. Start with a small amount of drug to test strength. Call 911 in case of an overdose. Use new syringes to reduce the risk of infections and help protect vein health. Test for fentanyl with fentanyl test strips as we know how dangerous that drug can be and of course, carry naloxone to reverse any overdose. Let me emphasize as I have many times in the past how critical it is to acknowledge the stigma that substance use disorders can create and that stigma can in turn prevent people from seeking the help that they need. We can all help people understand that these disorders are medical conditions and we should remain non-judgmental and empathetic to those working through treatment and recovery. As a department and a state, we are committed to providing the services, supports and information to change how we view substance use disorder. You can learn more about this at endaddictionstigmavt.com. I now like to turn over the comments to Melanie Sheehan from Mount Escutney Hospital who will talk more about prevention. Thank you Dr. Levine. Good afternoon. It's my pleasure to be with Governor Scott and Dr. Levine and all of you today. As Governor Scott said, I am the Regional Prevention Program Manager at Mount Escutney Hospital in Windsor, Vermont and also the Vice Chair of Vermont's Substance Misuse Prevention Oversight and Advisory Council which we call the SMPC because the other thing is a mouthful. So I'm here today to talk specifically about prevention. First of all, I would like to thank Governor Scott for his vision to fund prevention with state dollars. I want to thank our legislators for seeing that vision through. Funding prevention with state dollars shows that Vermont is committed to investing in the root causes of substance use and working to create a generational shift that will decrease the need over time for substance use crisis services, harm reduction approaches and overdose death interventions. Until this year, state dollars have not been allocated to prevention. My colleagues and I for decades have worked solely on federal grant funds either directly or flowing through the state and while we have good outcomes in regions with strong prevention representation not every area of the state has the capacity to manage federal system requirements and federal dollars can also be restrictive. This means that we do not always reach the populations of our communities who are in greatest need or target the issues that are most relevant to the communities. Until now, Vermonters have not had equal access and opportunity to prevention resources either geographically or programmatically. So these investments will help stabilize the prevention infrastructure across the state. This means that regardless of the presence of a prevention organization working directly in a hometown every community will experience prevention strategies. These dollars will help us overcome silos created by federal funding streams either by substance use or by population group. We will be able to work across all substances and across all age groups. By doing so, we are addressing gaps identified by a prevention inventory conducted by the SNPC in September of 2020. These funds will also allow us to be responsive to our local communities and the places where we see and feel very tangibly the dilemma of substance use. We target effective interventions based on community need. What works here in Barrie may not be what works in Windsor. So we can adjust the work according to each community individual each community's needs. For those of you who are not aware substance use prevention is a professional field of practice established with public health science and accountable to the strategic prevention framework. The strategies and initiatives implemented by prevention professionals and coalitions are evidence based and comprehensive. This means that we ensure a public health approach by implementing a portfolio of strategies at every level across the socio-ecological model. At the individual level, just to give you some examples, one of the root causes of substance use is youth not feeling they matter to their community. So we work with our local schools, law enforcement, PTO groups to figure out ways to encourage youth to participate in decision making, to gather and hear their voice. We also do a lot of education around the impacts that substance use has on the developing brain. The brain develops up until the age of 25. Substance use especially before age 18 can really hijack that developing brain. So encouraging youth to focus on their achievements, what their goals are, who they see themselves to be and we do that through multiple stakeholder relationships in our communities. But again, we don't just run programs, we don't just work on the individual level. We work with organizations, we work with schools on looking at restorative practices for vaping violations rather than suspending students. We want there to be some restorative practices where youth are able to talk about what's going on in their lives and also be referred to health policies and systems. A lot of the work that we're doing recently with the changes in our cannabis work is looking at how do we decrease access to adult-only substances for youth. So working with our towns at limiting advertising if we're able to do that. Things like that. Looking at the environment and creating the healthy conditions where youth can access healthy choices regardless of what's going on at home. Again, one of the root causes of substance use for kids especially is a feeling that they need to belong. If there's substance misuse happening in the family, it's very powerful to want to belong to your family. So culturally, substance use can make sense in a family if that's a particular, you know, what's going on. So we try to look at the risk of substance use but also build with community partners those protective factors that can help youth rise above that. So again, we do not just run programs. We operationalize any funding opportunity to engage and effectively reach a greater proportion of Vermonters than direct service or individual level approaches alone are able to do. So again, thank you Governor Scott and legislators. First for establishing the SNPC and then for valuing our work and supporting individual needs by allocating resources. But also for trusting in our partners at the Vermont Department of Health to create a strong and sustained prevention infrastructure and prevention professional workforce in Vermont. On the heels of the pandemic, we have a very real example of how prevention works. Substance use prevention may not be as easily understood as wearing a mask or using hand gel, but the concept is the same. Careful planning and effective collaboration to put resources where they are needed most can save lives. To find the prevention coalition or professionals in the region where you live, you can visit preventionworksvermont.org. And want to thank you all again for having me here. Next, I would like to introduce Anna Nunez, President and COO at CVMC. I'd like to thank Governor Scott, Dr. Levine and Melanie for being here today to share the state's commitment to supporting innovative approaches to substance use prevention, treatment and recovery. Addressing substance use is a public health priority here in central Vermont, also across the state of Vermont and throughout our nation. The pandemic as you've heard has created additional challenges for individuals with substance use disorders. Improving treatment remains a population health priority for central Vermont and for the UVM Health Network as a whole. It's incumbent upon us as health care providers to create the conditions for success in helping people recover from alcohol and drug addiction. At Central Vermont Medical Center, we understand that the entire community needs to be engaged and committed to bring the expertise and resources together to support individuals in prevention, treatment and recovery. CVMC is proud to have helped found the Central Vermont Prevention Coalition, a group of over 25 organizations in our region all dedicated to developing innovative, collaborative approaches to treatment and support to those who need it. We are fortunate to have so many dedicated partners in the Central Vermont Prevention Coalition, including organizations like the Turning Point Center, Washington County Mental Health, Vermont Cares, Treatment Associates, the Community Justice Centers in Barrie and Montpelier, among many, many others. I'm grateful for their deep commitment and dedication to this partnership. At its core, alcohol and substance use touches each and every one of us. It arose not only the health of the individual but our community as a whole. The work we and our partners do each and every day makes a difference and we're committed to continuing to make a difference going forward. I want to acknowledge the incredible work of Dr. Javed Meshkuri, Dr. Mark Deppman and Dr. Ben Smith. These physicians, along with other team members, have been integral to driving treatment practices in our ED department for over 10 years. I'm fortunate now to have the privilege of welcoming Dr. Javed Meshkuri to the podium. Javed? Good afternoon. Thanks, Anna, and thank you for your continued leadership and support of the work that we do. Thank you, Dr. Brumsted, for coming down from the network. We appreciate the support of the network and the interest in our work. And thank you, Ben, or Dr. Smith, I should say, for the continued leadership of our department. He's got a lot to deal with, and he puts this on the front burner all the time. We have community partners that Anna just mentioned, and they really do a lot of the heavy lifting for the work we do with problematic substance use. They are the real sort of heroes of this problem. And thank you to Governor Scott and Dr. Levine for your continued support and the importance of your commitment and funding for our efforts. I got to go to a lot of these meetings over the last decade, and somewhere along the line someone said, treatment starts in a room and recovery starts in a community. I don't know who said that, but if you're out there, take credit for it. It's pretty good. And it's true, and it discusses, it really sort of illuminates the journey we've had together. Ten years ago, if you came to an emergency department, even this emergency department and had an issue with a substance, maybe you were intoxicated and withdrawal or struggling and wanted help. A lot of times you maybe got a kind of judgmental glance from a nurse or a doctor or a PA and kind of got a lecture about how bad this was for you and it makes your mom cry and your dad upset and your wife leave you. And then we gave them, as their treatment, if they were not in any medical emergency, something called the LIST. And the LIST was a group of vowels of different organizations somewhere in this community that could offer help to them. We didn't know where they were, who they were, half the phone numbers were defunct and out of service. But we gave, that was our treatment. And as you can imagine, it was not very satisfying for patients, their family. It was not satisfying for us as providers. We had no help that we could give them. We had no hope and no plan. So we started to get better. And Dr. Deppman got us a grant about 2013 for something called SBIRT, which was screening, brief intervention, referral to treatment. And what it did was transform the way we give care for people that struggle with substance use. We would screen every person that came to the emergency department. As long as they were talking and breathing, we would ask them, not, do you do this? Yes or no? We said, do you drink? Yes. How much? How often? Do you binge drink? Have you had an opioid in the last year that wasn't prescribed to you? Did you obtain it illegally? We got into the weeds with it because we wanted to know what kind of risky behaviors these patients were exhibiting. And then if you're going to ask a question, certainly in medicine and public health, you better have something to offer. And this time we did. We had counselors and clinicians that we hired that were not medical people but understood addiction medicine and understood what it takes to help people. They would come. We would say to the patient, can I get you some help? Are you interested in talking about this? And most people say yes. They don't hide from it. They know there's an issue and they're going to get to it. We'd have someone come in and talk to them, ask them where they were. Are they ready to try something? And we didn't just ask them to quit. We said, if you don't want to quit, do you want to cut down? Do you want to decrease what you're doing? If you don't want to stop at all, do you want to try to maybe do more healthy practices? This was the beginning of the harm reduction philosophy for all of us. And it really changed the way we approached it. What we did was we made substance use a medical chronic relapsing condition. We chose to look at it that way and that removed a lot of stigma and the trouble around it. And we said, OK, we're going to offer treatment like we would for congestive heart failure, diabetes, COPD. It's the same thing. It's the same process. The treatments are different. But how do we do it? And what we learned was that from that list, we had all these partners in the community and we didn't know who they were. We went out and we met with them and we said, OK, this is what you do. And embarrassingly, some were literally across the street from this hospital. And we met with them and learned names and faces. And we said, OK, you're going to go to treatment associates. You're going to go to the hub. You're going to follow up at the Turning Point Center. And then we decided to meet as a group. And Anna, we haranged her for free lunch. And everyone would come once a month and we'd talk. We'd talk about patients. And we started to know each other and trust each other. And we built this coalition that at first was called the Washington County Substance Abuse Regional Partnership, which was WICSAR, which is crazy because no one can remember it. I have trouble remembering it. So it became the Central Vermont Prevention Coalition. It's been together for 70 years now and done a lot of work together because we respect each other. And what we've developed is a treatment pathway. We knew we had all these pieces in the community, but we didn't know how to put them together. But we knew the important thing was to put them together and give people options. Not everyone needs medication. Some people need counseling. Some people need someone to talk to. How do we provide that? How do we shape a treatment pathway? So that's what we developed. And that's what's called now Recovery-Oriented Systems of Care. That's the word now for how we treat problematic substances. And that's what we kind of unknowingly stumbled ourselves into. So what does a community treatment pathway really look like? Well, a couple of things. You have to offer a lot of different options to people. You have to really buy into this idea of harm reduction, of meeting people where they're at. But as one of the recovery coaches told me, he's like, you meet them there, but don't leave them there. That means give them help, give them hope, give them a plan. So we started to do that. And what we looked at was the emergency department, that door right there, is probably the greatest low barrier access point in the history of healthcare. Anyone can come in at any time when they're ready. And when they're ready is when you want to be there for them. But they don't just come to see doctors and nurses and other people. They come also to see other people, that if you have, makes this job a lot easier. So in 2018, amidst the opioid crisis, Bob Purvis from the Turning Point Center said, hey, I've got a grant for recovery coaches. And we're like, what? And these are people that have lived experience. They've walked in the shoes of people that are struggling. And they come here and they understand what it is to struggle with a substance. They understand how difficult it is to change behavior. And they also understand the difficulty sometimes of navigating the system. And they can use all this experiential expertise to help our patients and the clients that we serve in the community. So they can meet with them. They can reassure them that there's hope, there's help. And we're going to come up with something that's going to work. So we really, really like that. And then in 2018, when we were having all the trouble with opioids and waiting lists, we started saying, wait a minute, not only can we offer these sort of, you know, services, but we can actually, we have the medications that they have in the hub and spokes. Why don't we give patients the medicine when they're here, when they're in withdrawal, protect them from overdose, so that they have, they feel okay and they're going to get to the appointment that we're going to guarantee them. So we started what we called the RAM program, which is rapid access to medication-assisted treatment. And it was really, again, sort of a life-changing event, not only for the people in our community, but for us, because we finally felt like we were, now we were doing something. We had integrated services in the emergency department, and it was caring enough to give us care managers besides peer recovery services. And it was great. The staff would look at a peer recovery coach and they would see what recovery looked like when it really happens. It would be not only a positive role model for the patients and the people that came here, but for the staff. We're like, this person was that person at one point, and now look. So these were really transformative things for all of us. And we also wanted to make sure that we could continue their care when they left. So again, we had care managers, recovery people that would help them make phone calls, help them get follow-up appointments, remind them when they left. And then the beauty of the peer recovery coaches is they would call the next day and say, hey, Joe, I saw you in the ED last night, don't forget, you have your appointment day after tomorrow. Do you have a ride? Do you have gas in your car? I'm going to call you tomorrow. And they would call patients sometimes for weeks and months to see how they're doing, because some patients all they wanted was to talk to somebody. They weren't ready for medication or counseling, but they had someone to talk to. So a seed was planted and that care could continue. So we've done that now. We've treated hundreds of patients in the emergency department for opioid use disorder. And it's all the more important after you heard the statistics that we're seeing now that people have lost some of their connection to care and there's a lot of isolation in the community. But probably the most important take-home lesson for all of us was that, you know, this is not a flawed character issue. This is not somebody's fault. This is a disease that's chronic and relapses like all the other diseases. And we need to approach it that way. We need to not judge people. We need to educate and offer prevention so we can decrease the amount of stigma that surrounds us. And that's what makes this a hard disease to treat. You can ask Dr. Smith, addiction is probably the hardest disease we treat in the emergency department for a variety of reasons because there's so many layers to it. And I think now in the last year we were looking at some of the Vermont help link data and we saw that during the pandemic, at least the first year, I don't know the second year, two to one were calls for alcohol issues over opioids. So this past year we started, we're creating a hub and spoke model for alcohol use disorder. And it's been 10 months now. We've evaluated a couple of hundred patients. We've enrolled about a third of them and we're seeing follow-up rates that look pretty good. Still, we have a long way to go, but we need to keep moving forward. And this year we're going to start working on our spoke development and our local practices here because really what we want to have is any door is the right door to enter treatment. And we think that we're on to something, but again, these are modest results. They're not earth shattering, but it's a start and we need to continue with that. We need to look at our data at the end of the year after August and look about how we can make it better and improve it. We have a long way to go, but when I hear about the support of the state for funding and prevention and treatment, that reassures us that we're doing the right thing here. So anyone that's struggling, there is help out there. And our goal is if you come to here, we're going to offer you help, open a plan for something. It may not be exactly what you had in mind, but we're going to meet you where you are and not leave you there. Thank you. And now I'm going to leave it to Governor Scott for questions there. Thank you very much. And now we'll open up to questions. Yesterday, I mean, do you feel that opioids and drug use and that sort of thing, maybe coming into the state or being used in the state, is taking some of the public safety issues in the state? I will just say that with fentanyl, fentanyl has changed the game in some respects and there are many who are preying on our youth in this state. So enforcement has to be part of our strategy, not the main part of our strategy. As I said, it's about prevention, treatment, recovery. And enforcement is another leg of the stool, the fourth leg of the stool. And it's important that we focus on that as well. And we can do all of these things at the same time, but it's just one more leg of the stool. So it's not integral in terms of what we're trying to accomplish, but it's certainly part of the strategy. Last weekend, so it's like a big part of that program's kind of collaborations. Last weekend in Burlington we saw, they may have two in the morning, can we kind of see more collaborative effects like that throughout the state in the Burlington program? We'll have more on this. We'll be talking a lot more about this 10-point plan. It's more of a framework than anything else, but we need more collaboration. We need more of a regional strategy. And what we saw there was our response. The city of Burlington reached out to us and said, we need you. We need you tonight. We need your help. And we responded, as we do with others as well. So again, it's not going to be on an ongoing basis. It's going to be based on whatever we're seeing at the time. But we want to be part of the solution. So you'll see more and hear more about this as we develop it. But again, it's about all of us pulling in the same direction. All of law enforcement, whether it's the Vermont State Police, whether it's local PD, whether it's sheriffs, whether it's our department of liquor and lottery, whether it's our fishing game awardons, we're all going to be trying to focus and pull in the same direction. So it's just more of a implementation of a strategy of a broader regionalization. For Research Gears, I guess what was the catalyst behind coming up with this great work and ultimately what is your role? Well again, what we're seeing in Burlington, for instance, and I will say, I mean this was part of the city of Burlington strategy. They sought to defund the police and what we're seeing right now is a lack of enforcement on the streets of Burlington. So we're also facing another crisis. I've talked about it a lot over the last six years, and that's our workforce challenges, shortage in workforce, and that's across every single sector. And law enforcement is not immune to that. So we're facing our own struggles in terms of BSP. We're down a number of officers somewhere between 60 and 80 at this point. But that wasn't a strategy that we developed. That's the result of the workforce challenges that we're experiencing and what we're experiencing across the country. So I think it's important to distinguish between the two, but other law enforcement, local law enforcement communities across the state are struggling as well. So again, we have to change for the times. This isn't going to write itself overnight. And we have to work together in order to provide for the public safety of our modules. I mean that's the number one priority of government, I feel, public safety. And so we're going to step up where we know we can improve. We just have to become more efficient, more effective. And one more question. Counties like Essex and Grand Isle were a bunch of people from Wisconsin who made up the part 200 case of backlogging, the other thing that was mentioned throughout this plan. I guess my question is, because we're struggling, as you mentioned, with the job everywhere, what can these places that are mostly in part time kind of expect as it helps to try to complete these 400 cases that they have that are backlogged? Well, again, we have to do everything we can to assist the judicial branch, separate branch of government to accomplish their goals as well. So we're all in this together. And I don't pretend to have all the answers, but I will say we're a willing partner. We'll do what we can to assist. The only thing that we're doing is the executive branch that impacts them in a negative way. We'll find a way to assist. They just need to, the judicial branch in particular needs to tell us what it is they need to get through these cases. So, again, it's different strategies. We have a lot of folks that are working in silos. And what we learned in the pandemic, which is really important, we learned that by breaking down those silos within the state government, within the executive branch, we were able to manage the pandemic in the best way possible, probably better than any other state in the country. But we did that by working together to understand what we could do to assist each other, work with one another, that we weren't just the agency of transportation or the agency of human services. We were all one and we're there to help one another. And we did that across agencies to work towards the common goal of protecting Vermonters. And we can do the same thing here. Are you disappointed that there won't be a change in the county-state's attorney, apparently? And what sort of changes would you like to see in how they operate their shop? Well, again, we want to make sure that people are held accountable. I think accountability is important. And we want to recognize that law enforcement is frustrated as well because they don't see the accountability. So a lot of this is a lot of levels that we can, I think, be better. We can improve. And one of those, again, as I talked about, is a regional approach, trying to work with law enforcement, working together to try to supplement each other in terms of workforce challenges, but also the judicial branch, trying to get through their cases and doing everything we can to move those cases through their system and working with others to do whatever we can to make sure that people are held accountable for the prosecution standpoint. So two vaccine questions. So first of all, though we had thought it would be October, we're hearing messaging from Washington that perhaps in mid-September there will be a new COVID vaccine. That vaccine will be what we call bivalent, meaning it will have the so-called ancestral strain, the original SARS-CoV-2, as well as BA5, which is the current variant or subvariant, I should call it. That's going across the country. We don't know anything about the clinical data being gathered right now by the companies. I'm sure we will hear soon about its efficacy and I'm sure its safety. So that will be very important. We don't know yet numbers of doses that are going to be allocated to states on a per capita basis, but we do know that the end result is going to be hundreds of millions of doses and Vermont will certainly get its fair share of that. We have a healthcare system that is right now far better prepared to administer many of these doses. And when I say a healthcare system, I'm including traditional healthcare providers, especially primary care settings, along with pharmacies, along with our public health district offices that have always worked with populations in need. And we don't see at this point in time the need to have any other larger vaccination apparatus set up. We believe that this can be done entirely through the current systems that exist. And I think people are in a different place with regard to vaccine. Unless there's a new sub variant that mandates everyone get their shot, like on day one, people are getting their vaccines as we're seeing with the youngest kids now as part of routine healthcare. And they will get their booster shot with this new shot on their schedule. With regard to the HMPXV vaccines, Vermont has, as you know, very few doses of vaccine at this point in time because we have very little disease activity in Vermont. And it's allocated places of need much more so than anything else at this point in time. So states like Florida, Illinois, California, New York are getting much larger allocations. We are looking forward to the day when we will be getting much more. That has to do with the federal distribution apparatus more than anything else. And we are working with our community partners to make sure that anyone who is in need of vaccine due to a recent exposure perhaps or due to risky lifestyle behaviors that might make them more predisposed to the risk of getting this infection know where to get the vaccine and how to get it. We are adhering to the new FDA strategy of not using vaccines as much subcutaneously, which has been the traditional route, but using them intradermally, meaning a prick underneath the skin. That will allow more people to get vaccinated and it will allow all of those people who did get vaccinated to be guaranteed of a second dose because the government believes a fifth of the dose will be needed for this new strategy. We're hearing a little bit from our practitioners that they may not be getting five doses, they may be getting slightly less than five doses out of a vial, but they're still getting more than one dose, which is really true. We're going to see what we get first before we start designing any kind of prioritization scheme. We're going to look at what the conditions are with regard to the virus and what the allocation is to the state before we would make those kinds of decisions. Commissioner, what's the latest on adding COVID to the school vaccination regime? Neither nationwide nor regionally nor locally has there been any movement towards doing that. What is CVMC doing or what does the state do? I'll let CVMC speak for themselves, but certainly it has been shown that it is very safe to get both flu vaccine and COVID vaccine at the same administration and for many that might guarantee that they get both vaccines, and we believe that's really critical for any upcoming respiratory virus season. So we will continue to recommend that unless there's something that's announced about the new vaccine that would make any different counseling required. So our basic belief is that people should take advantage of this new vaccine, assuming it satisfies the efficacy and safety criteria that we all wanted to, and should continue to get flu vaccine. Again, we are trying to prevent people from having serious outcomes from these infections, and these vaccines have great track records of preventing serious outcomes. Do you folks want to say anything about CVMC? Basically that we would follow federal and state guidance on vaccination, and we're committed to doing what we did with COVID the first time around, vaccinate the community as I'm sure all healthcare providers in the state would do the same. So we would follow those guidelines. You know, it's challenging for... There are many prevention coalitions across the state of Vermont, and each run their own programs. I think that, you know, a lot of our... Right now the biggest intersection is looking at vaping. As I spoke about before, a lot of our previous funds were limited by substance. So we'll have tobacco funding or cannabis funding, and now we're seeing the co-currence of using vapes as a delivery device to inhale either nicotine or hash oil or CBD cannabis. And so by having some of the funding that we can look across all substances, across all ages, we can start to tackle and look at education with parents, schools. What are the emerging tobacco products and what's being put in them? It sounds funny, but, you know, we used to have to have separate approaches based on what topic, you know, what substance we're talking about. So I think what's going to happen now is that we have a lot more flexibility to do education around vaping and the sort of the range of things that folks use. And also looking at changing some of that language, as I spoke about before in schools, sometimes it's very issue-specific. So I think what's different now is we're able to be a lot more flexible and look at, you know, things across multiple substances. So I don't know if you all have a treatment answer. This past year we received money from ADAP, which is called the Division of Substances Programs. So the Division of Substances Programs, formerly known as ADAP, gave us grant funding a year ago to look at the scope of alcohol use disorder and come up with a potential hub and spoke model. So that was done in the last 10 months, and we'll, like I said, it's going to end after this month. So we were able to start that system concentrating mostly on the hub and hospital side of it. The second year we're going to work on developing our local spoke program. So that was brand new to us, but it took the same principles we'd used in the past for opioid treatment and transformed it into looking at alcohol, which we still see a lot of problems with. And sometimes I think it does take a backseat to some of the other substances that are in the community, but it's equally problematic for sure. You know, we've been pretty fortunate that once we started the Rapid Access program and we have these existing relationships in the community, you know, basically we guarantee people follow-up within three days from leaving here. And depending upon staffing, as everyone knows, there are workforce issues. You know, some places are having issues keeping counselors and things like that. We've pretty much adhered to it as best we can. I think if people want to get in, they will get in, but, you know, every now and then there may be a small weight, but not really. I mean, by and large, we've had, again, we've had relationships that have existed for a long time, so we can pick up the phone and say, I really need you to see this person tomorrow and they'll clear it and it'll happen. So, again, the advantage of forming these coalitions is to give my two cents on the question as well. I didn't hear everything Melanie was saying, but one of the themes is really expansion of already known evidence-based practices that work but don't have the penetration across the entire state. We have great data that shows that some of the grants we've had from the federal government that allow for these prevention coalitions that Melanie's representing, when they are active, we see incredible results in terms of our youth rates of substance misuse. When they are interrupted and there's times that funding has run out, you see return to previous levels and then when you get more funding, you go down again. So, making this more of a sustained process and that's equitable across the states critically. With regard to recovery, I would dare say that, recovery is not just a person has stopped using opioid medications and has not had a relapse. That is maybe a medical definition of recovery, but recovery is entirely dependent on everything else in that person's life going well. If that person doesn't have housing security, if that person can't get a job because of their past track record or what have you and their lack of training in certain areas and there's no employment training opportunity or avenue for them to pursue, how are they going to maintain the kind of life that is successful in recovery? So, much of this funding is going to further expand well-known evidence-based practices that say, housing is healthcare. Employment is critical to a person's sense of well-being and self-worthiness, et cetera. And, monies that are coming now are providing more recovery housing and more employment pilot opportunities than before. Yeah, again, this was just a framework and idea that I came up with because I know a lot of troopers, they retire somewhat early even before their mandatory retirement age and our process will be reaching out to them first identifying who they are. There's a number of them. They have to have their certifications in place so they can't have been retired for too long and then reach out and see if they have any interest and then try and be as flexible as possible to fill some of the gaps that we have. And again, trying to use this concept to do everything we can to provide a more holistic approach to law enforcement and public safety throughout Vermont. But we'll see what happens. We haven't put anything out at this point, but we know we have at least a hundred retirees that we can reach out to and see what their interest is. Well, it's a constant. Whether you're in business or whether you're in government, it's a constant evolution of improvement. Every single day, I wake up thinking about how can we improve whatever it is? Whether it's in motor vehicle, the Department of Labor, or the permit process throughout the state every single day. And I know Dr. Bromstead thinks about that too when he comes in with any of the folks here. Anna thinks about what is it we can do to give a better experience, or how can we become more efficient? What can we do? We can't do things the way we did 10 years ago. So, again, thinking about what we experienced during COVID and breaking down those silos and bringing in people to help out whether it was in the agency of transportation and assisting in delivering vaccines and tests and so forth to different parts of the state, not just relying on the agency of human services and the Department of Health, but reaching out to other agencies. What can you do to help us and improve the value of government services? So, again, this is what we're going to be doing as well. We're going to reach out to retirees, see if there's any interest. We're going to continue to advocate for training in new people coming into law enforcement. But we're also going to see what other areas, whether it's, again, in motor vehicle. We have enforcement in motor vehicle. What can we do to make sure that we're not doing something at the same time in the same place? How can we better coordinate our efforts so that we can provide for more public safety for monitors? So, again, this is something that we'll be working on over the next few weeks. Hopefully, we'll have more details at that point, but this is just a framework at this point. Well, as I said before, I think public safety is a high, probably the highest priority of state government, any government. So, we need to provide that, and we need to find ways in order to do that, find better ways to accomplish that. If we know what the goal is, we're going to have to, again, rely on one another to identify ways to do it better. So, we can do that, even reaching out to UVM. They have their own law enforcement process or department. We're going to have to reach out to them as well. So, if we're all, again, pulling in the same direction, we can accomplish this. We can do things better, but there has to be a willingness to do so, and that's what we're trying to do. Just find ways to accomplish that. Well, again, I think it's premature here in Vermont. I know there are some cities across the country, densely populated cities that are doing this. We'll see what the results are there. But from a practical standpoint, and I think about that, put away whether you have philosophical differences or not. Just think about the practicality of having a safe injection site, let's say, in Burlington. I don't know how many folks from, and maybe I'll ask some of the experts, how many from Barry are going to drive to Burlington to go into a safe injection site when they want it? How many from Milton are going to drive from Milton to Burlington to go to the safe injection site? How many from Shelburne? How many from Middlebury? I mean, are they going to be in every single community? 24-7, 365? I mean, it's a practical thing. We know what works right now, and what we want to do is focus on that prevention, the treatment, recovery, and some enforcement. We know this works. We did it before. It doesn't mean we can't change. It doesn't mean that there's not going to be new strategies in the future. But right now, let's focus on what we know works with the limited resources we have, because as you said before with enforcement, we're going to rob Peter to pay Paul. So there's only so much money to go around. So are we going to take money out of prevention or treatment or recovery for safe injection sites at this point in time when it's unproven? And that's what we have to, so we'll keep an open mind, but I don't think it's now. Can I just address that a little bit? One of the harm reduction organizations are a partner in prevention, and we work with them in our area a lot. There is a network of syringe services programs that are mobilizing peer networks. So they're going into neighborhoods and communities building relationships with persons who use substances. They get them clean needles, fentanyl test strips, and they build that relationship, ask their peers to also do that education. And I think it goes along with that stigma of reducing and meeting people where they're at. I agree with what the governor says. We've seen a lot in terms of accessing services. The transportation, all that he just said is a very real barrier, and we already have those systems in place. And we are working and breaking down those silos, prevention, treatment, recovery, harm reduction, and doing that very well. Our syringe services program partners are working on innovative approaches to get telemedicine help to folks who have wounds from injection and aren't willing to come to a medical center. So I think there's a lot going on, and I think as long as we're continuing to work across silos and making those investments across the continuum is really where the outcomes are going to, that we're going to see those outcomes. I have one more quick question. Just kind of your thoughts, there's many hospitals in Vermont that are going to the Greenhound Care Board looking for a 10 to 20% high rates on commercial insurance that's going to affect a lot of people. Challenging times for all of us, obviously, with the increased labor costs throughout, inflationary costs that are real, we are going to be challenged. The Greenhound Care Board is going to go through these deliberations over the next two to three months, and then we'll see. The initiative that was passed just recently signed by President Biden yesterday will help relieve some of those pressures. I think the title of the act is a misnomer, but I do think there are portions of that that will help mitigate some of the impacts of higher costs in health care and some of those rates. We'll see, but the Greenhound Care Board is going to have its hands full. What's that? Oh yeah, no, I'm okay. Dr. Levine can stay as long as you want right now. I'm leaving, but he can stay. Governor, I've been asking some state officials the same question. What are you reading this summer? Weekly reports, anything I can get in terms of trying to improve our state government. And along those same lines, I will say I have a whole stack of books that I have no time to read, but there is one that was given to me by Governor Baker. It was a results-based government. I think that's the name of the title of the book, and that's a thriller. But it does get into some of what we're trying to do, even with what we're talking about today in terms of enforcement. It's about trying to break down those silos and what they went through with a number of things over the last few years in Massachusetts. And I can see some similarities between what we've tried to accomplish and what they have done. So that's the last book I've read. I'm not sure how many more books I'll get to read in the next month or so, but I look forward to the day when I can enjoy reading again. Thank you all very much.