 All right. Good evening everyone. Welcome. Welcome to Contrary's Auditorium. Welcome to Burlington City Hall. It's great to have so many with us tonight. There are a few more seats down here. People should know there are also seats up in the balcony if you get tired of standing in the back. We really appreciate so many people coming out for a conversation that we haven't really had in this format for a couple years now. We had an opioid town meeting about two years ago which I think was a really important night for our evolution in terms of how we think of this issue in city government and in the community and we thought it was a good time to bring people back together and update you and because a lot has happened in the last couple years with respect to the opioid crisis in general specifically what has happened here in Chittenden County and Burlington and frankly I think there's some hope now that you had to work really hard to find in the past. We are still and we still always are aware that we continue to lose way too many of our co-workers, our friends, our neighbors, our children and at the same time I think it's important that we recognize that the story of this epidemic is starting to change and there is some hopeful news coming out of this region and in other parts of the country. We're going to try to kind of update, bring that update, have that discussion, get your feedback over the course of the night. Here's how we're going to try to do it. We're going to start with a conversation with these three national experts that we're very fortunate to have here with us in Burlington and I'm going to introduce them in a moment. Later on in the program we are going to bring a few more chairs out here and we're going to bring up a number of local leaders, people who have been working on this effort from different perspectives and there are so many people working on this effort and many of you are in the room and it's it was hard putting this program together to figure out who you know the right set of perspectives to bring up here and we could have filled the whole stage and more with people who are working hard on this but we are we're going to bring them them up to try to get a little bit of this interaction between our local leaders and our national experts and then we will have time at the end of the the program for questions and we do have mics set up for that. Before we dive into that and we're going to do it soon I do I let me just try to kick the conversation off by setting the stage as as I understand it and as I've come to understand it after really probably spending more time on this issue over the last three or four years than probably any other issue that we're grappling with because of the size of the challenge we're facing. This crisis began in many ways in the mid-1990s with the dramatic changes in the way opioid painkillers are being prescribed in this country and the huge expansion of painkillers that were were being dispensed in the community but it wasn't really from in a lot of ways until Governor Shumlin in January of 2014 sounded the alarm bell that we fully understood as a community I think that we were in a hot crisis that needed to be needed urgent action. Burlington took its first steps to really respond to that crisis appropriately I would say on September 1st 2015 which was a day I always remember is a day that Chief Brandon Del Pozo hired him and swore him in on September 1st 2015 and said publicly that day that one of those first orders of business was going to be to review the city's response to the opioid epidemic. I think we all sensed then that that the city could be doing more and what came out of that review was a realization that although there were literally dozens of different organizations in Chittany County that were working hard to to stop this crisis they're working hard to save lives and to turn this around that they're really and even though the state was already well into what has continued to the state to be massive effort to respond to the challenge there was really no organization that was in charge of the local response and as a result there was no shared understanding locally about exactly what we were up against there was no shared understanding of how the the the crisis was evolving and there was not a shared consensus about what the right interventions should be to respond to it and coming out of that review the chief and I really came to the conclusion that the city could play a productive role into helping galvanize and and and lead and coordinate that effort and we've been trying to do that in one form or another ever since that effort really got some momentum going in the fall of 2016 when we hired Jackie Corbally who's with us tonight where'd you go Jack? Jackie's here at the back and stood up this effort we call community stat which is a monthly meeting where we sit down at a big U shape to the table and you'll hear some reference to it at various times tonight we we actually just had a community stat meeting before coming over to this and our guests joined us at that and we the the principles of community stat are that we share we look at data we try to deploy resources immediately to respond to what we identify as as opportunities in this crisis and then we relentlessly measure and follow up with those interventions and and and try to keep improving with each with each month and about two and a half years later in part because of the work in that room as well as the incredible work that continues to happen at the state level I do want to welcome AHS secretary head of our secretary of agency of human services Al Gobey and commissioner Mark Levine from the Department of Health here with us tonight and you know none of what we're going to talk about tonight at the local level would be possible I don't believe without a real leadership and and a remarkable effort from years now at the state level but what has come out of the local effort I I believe is perhaps the most robust constellation of interventions of any community of America and as we meet here tonight there is a sense that those interventions are starting to get some traction trying starting to get purchase and we are hopeful that the results that we saw in 2018 where accidental overdose deaths dropped by 50 in Chittenden County we are hopeful that that is related to this local effort and that is something that we can continue and we are doubling down on those efforts in many ways at the same time and the reason one of the reasons for gathering here tonight we know our work is far from done and we got a lot of work to do and let's dive into the conversation to help bring some shed some light and and I think contribute to where we go from from here in 2019 let me introduce our our our panel of experts so first we're going to hear from Dr Josh Sharfstein who is the vice dean at the Johns Hopkins School of Public Health and the director of the Bloomberg Bloomberg American Health Initiative and the author of the forthcoming book and topical book for tonight the opioid epidemic what everyone needs to know I will say it is remarkable Josh's impact not just on vermont he has been a major contributor to some of those interventions I mentioned before that we have been rolling out here in Chittenden County he is also for years been helping the state grapple with and work with with Al Gobey and others to set up our all-pair healthcare model and it's really quite quite an impact you've had on the state Josh it's a it's a pleasure to welcome you here to City Hall after the next we're going to hear from Chief Fred Ryan a 34-year veteran of policing and recently retired chief of the Arlington Massachusetts police force where he was the the chief for 20 years a stat that did cause some nervousness I understand over at One North Avenue and the the idea of a chief being around for 20 years was mentioned he has been the co-chair in addition to his chief duties he's been the co-chair of the national police assisted addiction recovery initiative and a national leader in small and mid-sized police departments addiction and recovery initiatives and we're we're very appreciative you're you're here chief and third we're going to hear from Gil Kurlikowski who served as America's drug czar under President Barack Obama and then was the head of the U.S. customs and border patrol we're going to get a chance to get into some of the conversation that can we hear we hear a lot about right now is very much on the minds of Americans to what degree does this debate we're having about the border and how we how we resource the border contribute to this this epidemic prior to his federal service Gil also has a background as a police chief he was a police chief in Seattle Washington so it's a privilege to have all three of you here we're going to start with approximately 10 minute opening remarks from each speaker and then we're going to go from there with some moderated discussion so and I'm going to try to serve that role through the evening so come on up Dr. Sharfstein thank you so much mr. mayor mr. police commissioner and and all of you for having me here so I am from a school of public health I've worked as a health commissioner at the city and state level and I talk all the time about approaching problems as if they're public health issues and so what does that mean you probably heard that phrase we should think about opioid addiction as a public health challenge what does that mean so our school that I come from is the first school of public health in the world it was actually created when this kind of concept of public health came into being and the most important thing to understand about public health is that it is focused on the health of a community so my number one point about what it means to think about the opioid addiction as a public health challenge is you have to think about meaningful outcomes that matter for people and you're trying to reduce the pain and suffering that communities are feeling and that means you're looking at overdose deaths you're looking at the number of people who can put their lives back together take control of their lives again go back to work put their families together all the things that really are meaningful and you're not distracted by maybe preconceptions or stigma or measures that are things that we've always counted but maybe you might wonder or whether they're really linked to the fundamental outcomes you're trying to address and so something that would come to mind there might be the number of arrests is that a fundamental outcome or is that just something that has been done but may or may not be linked to an outcome we really care about like the number of people who are dying number two to actually improve outcomes a public health approach is going to look at evidence what works and when we look at evidence we try to bring really no politics no preconceptions we look at the data and we look at multiple types of data and the data on opioids is that there are things that can work I could talk about the number of them I'll talk about one which is treatment treatment can be very effective particularly treatment that includes medications like methadone or buprenorphine and how do we know that from studies we know that from many many individual studies where some people get medicines and other people don't and the people who get medicines do much better we also know it from when entire cities like Paris or Baltimore expanded access to treatment and they saw a substantial drop in the number of people who were dying most recently there's really good evidence that when emergency departments can start people on treatment that the rate of success doubles it then if they just referred and gave a phone number and there's very strong evidence that when jails and prisons provide treatment that people are much less likely not only to overdose but to commit crimes again and now I talk about this evidence in a lot of different places but I'll tell you the what is most helpful to me in communicating about the value of treatment is the story I tell about my wife okay my wife is an addiction medicine doctor and i'm a pediatrician and we met in medical school and when she told me my medical school girlfriend now my wife told me she was going to go into addiction medicine I thought it was like she was telling me she was going to be an oncologist just for patients who were going to die and I thought my girlfriend is a saint that's what she is I really had no idea and I thought you know she is just going to be awash in misery and I am going to be collecting gifts from all the parents of the kids that I'm taking care of when the holiday season comes around they'll give me some things and turns out parents are pretty busy and I probably wasn't that good a pediatrician when I was in practice and so I never really got a gift from any family but my wife takes people who are absolutely in the most extreme condition and works with them helps them empowers them treats them and they move off the street they get housing they get their families back they start businesses and if you come around to our house at holiday time she gets so many different gifts every year from people she's incredibly close to so to me I could quote a whole bunch of studies that's the story people understand and it's completely true and I've really been inspired seeing her to understand what happens when you really can apply science to this problem number three public health is about prevention so we're always trying to think how to prevent challenges like this and obviously as you heard from the mayor the prescribing problem contributed substantially in a lot of parts of the country including in Vermont and really thinking about how to have thoughtful approaches to prescribing that and particularly better options for pain than opioids so people can really get their pain addressed without using opioids that ultimately is not may not be that effective for a lot of people is a really important strategy and if you go a little bit further back I think one of the most important things is to look to support young people who are really at risk for for not being connected to school or work and you think about I think about adolescence as a major transition point where people can either be on their developmental trajectory be in their life path be moving towards education and jobs or fall off that path and have all sorts of problems including addiction and I think you know those sort policies programs schools and jobs that are really focused on high risk adolescents preventing them from coming disconnected and helping them as soon as you start to see signs of problems is really important in preventing opioid addiction finally the fourth one I would mention is to listen to people who are affected by the problem and take what they say and try things that are different innovate and check to see whether it's working public health is constantly about a cycle of trying new things looking at the evidence see if it works try it again and really basing those innovations on what you hear from people who are really experiencing the problem or on the front lines and that's why I was so impressed to hear earlier today that's such an important and interesting meeting about the low barrier access to treatment that people have access to through the syringe exchange and other places because people were going for years to the syringe exchange saying I wish I could get treatment right now and there was nothing to offer them but because of the way Burlington responded to them there's now treatment there for them and they can and so many people are doing well there are many other kinds of innovations that people can think of innovations in law enforcement you know public health perhaps because it's so new we generally are ready to rethink traditional approaches and what your police department's doing is rethinking some traditional approaches to policing around drugs and now is every non-traditional approach going to be successful no but a public health approach would be let's try something different let's try to let's think through what's actually going on let's not take the approach of just because we did it one way we'll have to do it that way and we may try something different for example not prosecuting people who may be with small quantities of a treatment medicine in their pocket when actually that actually is going to predict they're going into treatment and that is something that can be based on listening to people about how they're using medicines in ways that can actually save their lives there are other approaches that have been developed I know that there's interesting approaches to you to testing for fentanyl in ways that can actually help reach out and engage people who are really at high risk and help them realize not just that they should test their drugs for fentanyl but that they can actually use that connection to ultimately get into treatment that can save their lives so I think as I think about these four points that I made for a public health approach focusing on outcomes that matter looking to evidence preventing and listening to people and innovating and checking the results of that I really think an important reason why Burlington is making progress is because you're taking a public health approach I'm really pleased to be with here with you all here tonight thank you thank you mayor thank you doctor chief del pozo the men and women of the Burlington PD thank you for having me my name is Fred Ryan as the mayor said recently retired police chief from Arlington Massachusetts I'm still adjusting to not being a police officer so I think I got a ticket in front of the PD today for a meter violation chief I don't have a driver anymore so I'm navigating my way around this around the city I also serve as the co-chair of the police assisted addiction recovery initiative which is a private non-profit organization made up of approaching 500 law enforcement agencies in the United States all of whom engage in some form of pre-arrest diversion approach to opiate disorder in their jurisdictions and you know you would add you might ask you know typical white irish boston cop right you know how did my career over 34 years bring me to a place where I started a non-profit well first of all I failed miserably as a drug cop you know they took me and put me to drug unit when I was a young police officer and you know I look and act like a cop so I couldn't get anybody to sell me drugs I quickly found myself back back in uniform but I was one of those uniform police officers that was out there you know making arrests and making street-level drug arrests and arresting oftentimes the same people and even early on as a young cop when my supervisors were encouraging this type activity I wondered what am I achieving here you know are we moving the dial or are we just you know recycling and wasting resources and not getting at the root cause of the problem fast forward you know as I got promoted up up through the ranks and became chief of police in my jurisdiction early in calendar 15 we were losing about one person a month and we're a small jurisdiction about 50,000 people next to the city of Boston very densely populated about five square miles and you know I started going to the funerals of my friends and and instead of wondering you know what could be what could we be doing differently here and then we had a case that that came across my desk and evolved a young lady by the name of Kayla and Kayla was beautiful in every sense of the word and successful you know by any standard of success in America a graduate of the University of Massachusetts her mom was an educator her dad a firefighter and Kayla overdosed and her family accessed 911 we sent police officers and EMS out and we reversed that overdose with Narcan and we brought Kayla to a Boston area hospital seven days later 911 Kayla read overdosed we responded we reversed that overdose we brought her to the same Boston area hospital seven hours later 911 and Kayla was dead and when that case crossed my desk it screamed of failure failure at the front end of the process at the law enforcement level I was asking myself what could we have done to prevent this young lady's death and so we went back and we reconstructed that case with the with the authorization of her family and and and the healthcare providers and what we recognized was that the systems were flawed both in the public safety side as well as the healthcare side and that we needed to do a whole lot of work around changing the paradigm around the way we approach addiction and our jurisdiction and that was sort of the case that became the catalyst that that motivated me to implement change and so as we sort of sat around the table and strategized about you know what is it we can do better and you know our crime analysts would put up a spreadsheet at one of our ComSTAP meetings and you know any any chief that succeeds for 20 years chief topozzo little advice you surround yourself with really good people and and she pointed out she she said chief I think we know who the next overdose victims are in our jurisdiction and I was shocked by that I said who and she said well they're right here on the spreadsheet these are people who have previously overdosed and they're at high risk of fatally overdosing and the question became what is public safety or public health doing to prevent their mortality the answer was nothing and so that was the point where we changed our approach in our jurisdiction we embedded clinicians into the police department to begin to do outreach work with that known population of people suffering with opiate disorder and developing a protocol a post overdose protocol where our outreach workers would go out and and and do some survival planning you know give the person in the grips of addiction Narcan and other resources harm reduction resources and that was sort of our handshake and then our our clinicians were very savvy at getting access to others invested in this person's health and wellness and and the mindset that we tried to bring to it was this survival plan plan for the next overdose that's precisely what we would say to the person suffering with substance disorder and their loved ones let's plan for your next overdose as absurd as that may sound so that we can ensure your survival the second prong was our clinician would begin to work with families to educate them around the science of addiction because there was a lot of misinformation out there about the science and the clinicians would teach families and patients around the medication treatment therapies three federally approved therapies available to them and then build a an intervention plan and and the mindset we try to bring there was let's treat this no differently than if your loved one was expecting a child right if your loved one was expecting a child you'd have a plan you'd know who the health care provider would be you'd know you know what health insurance what facility you're going to who's going to drive you pack a bag get the cigars get the balloons whatever we need to do to have a plan in place no different than somebody who's expecting a child so that when when your loved one is ready to ask for help you don't begin the planning then because you've missed your opportunities too late so in in doing that outreach and that work along with a number of community meetings and events such as this and I commend the mayor for doing this and getting the dialogue going in the community around addiction and the complexity of addiction and the therapies available to folks we started to drive down the death rate in our jurisdiction and i'll close with stigma you know the mayor and the police chief and and grace and others in the city i sat in a meeting earlier i am so so impressed with the work that's that's being done here in the city of burlington um and but success can't happen without everybody in this room and everybody in the city creating an environment where long-term recovery can happen in the community without stigma you know oftentimes detox occurs in a healthcare setting and and and a private locale but long-term recovery occurs in the in the community and if we continue to stigmatize and label those suffering with substance use disorder we'll continue to meet with barriers to success and self-imposed barriers to success so my message to you here tonight is no different than the conversations we have around bias and racism in the community when you hear the the the the term junkie and and the stigmatization of people suffering with substance disorder don't accept it stand up to it embrace the work that your city's doing and the state's doing and move the dial around addiction in in burlington congratulations you all mayor congratulations to the city i'm happy to work with you all thank you good evening this is what you call batting cleanup after two really exceptional individuals and and listening to the mayor kind of set the tone so a couple things that i'd like to to express to you i was president obama's drugs are for the first five years and in office i've been the police chief for nine years in seattle and i wanted to set a little bit of the of the historical context for you around the opioid issue it is a unique and and devastating crisis uh in in the country so in 2008 shortly after the election i'd been called by the vice president elect's office uh joe biden's office said we'd like to talk to you about the the drugs are position i'd been a police person all of my life i knew something about law enforcement i actually worked in narcotics and was able to purchase drugs but maybe that was my expertise but you know i i i knew nothing about prevention nothing about treatment nothing about recovery nothing about understanding this and so when they said look you know we'd like to talk to you about this i said gee wouldn't it be nice that we could talk about something in enforcement and and the person kind of laughed and said you don't you don't understand what you're interested in is of no concern to us we only care about us and this is what we want to talk to you about and i'm so glad they did so i was nominated and confirmed by the senate to take that job and started in may shortly just after the the inauguration a couple months after the inauguration was getting ready to leave the seattle police department the captain in charge of narcotics and i remember this is early 2009 he said you know chief we're seeing a lot of these pills out here opioid painkillers and he said you know we're not quite sure what what's going on with this i said oh that's interesting i had no idea well you know as a police person you know police chief officer you take a sworn oath of office to protect the people you serve if they're dying if you're not protecting them then you know you're not really doing your job so then the head of a federal law enforcement agency in seattle came to me and he said i know you're getting this job you're moving to washington dc from seattle he said i want to tell you about painkillers he said i have a son he should be a high school senior he's in drug rehab as a junior varsity football player he had an injury he was prescribed opioids and became addicted pretty common story and i i said you know i i really knew nothing so we made it a signature issue one of the and i want to tell you a little bit the office of national drug control policy was created in the 1980s after the death of a of a university of maryland basketball player who had been the first round draft pick for the cell ticks and he died of a drug overdose just outside of washington dc and so it caused a lot of questions about what is the united states how does the united states respond to a drug problem a drug crisis cocaine then we saw methamphetamine etc well you couldn't open the book for these hundreds of millions of dollars that are spent in the federal budget and say well what let's look at the line items you can look at your city budget and you can tell how much money is spent in different places but you couldn't tell at the federal government level well the department of defense spends some money and before it customs and border protection or the border patrol on drug interdiction oh and the drug enforcement administration oh etc well i came here a number of years ago with senator lehi and as members of congress like to say they like nothing more than to sit on high behind a dais and then point their finger at somebody and say you're responsible you're accountable what are you doing about it but if you were to do that with the hundreds of millions of dollars that are spent on drugs you you couldn't you'd say well we'll call in the head of the drug enforcement administration we'll call in the justice department prosecutors we'll call in health and human services on the treatment and you just couldn't find anything and so the push was on then to say we're going to create a white house office of national drug control policy and for want of a better term the term is czar and but it's actually quite a powerful position it is the only position other than the president and the head of the office of management and budget that you can decertify a budget of the department of defense or the department of justice say you know what you're not really doing enough on the drug issue we're going to decertify your budget that's incredibly powerful when you have the the purse strings you're reporting to the president and so the office was met not as an enforcement arm not to go out and solve the problem by seizing drugs or getting people into treatment it was meant to coordinate all of these hundreds of millions of dollars in these diverse different parts of the federal government under one auspice the president's national drug control strategy which he has the letter on the first page it's authored and it's signed by the head of the office of national drug control policy and it's that we need to bring all of you together so that we're not going to be redundant we're not going to have overlap and we're going to support each other on prevention on treatment on the training of law enforcement personnel on enforcement on working with other governments around the world about about the drug issue so it was an incredibly fascinating time to come in because i think you couldn't count on both hands the number of articles in 2009 about opioids it was an issue it was known but it really wasn't anything that you're going to read in the local newspaper you're going to see much about on television and now look tonight look at the city i mean the the number of people here and the amount of interest that you're generating about the opioid problem the opioid crisis because it has impacted everyone in the united states i have never spoken to a person who hasn't known somebody in school a friend a relative themselves others that has not been severely distressed severely impacted or even lost someone or lost multiple someone's as a result of opioids but it is an incredibly complex problem it isn't solved at the federal government level it's really solved like right here at the community level and when i saw the reduction of the statistics i saw the leadership of the mayor i saw the leadership of of the police chief and all of the people at the table today i i think chief ryan and i could often be called sometimes cynical because we spent a long long time in law enforcement i don't think we couldn't have been more heartened by what we saw today and the work being done and then to see this tonight and to see all of you here uh expressing interest taking time out of it and realizing that you really are making the difference so thank you for having me all right great we are oddly on schedule which uh rarely happens we got about 20 minutes now where like to kind of build on um just the remarks you each gave have a few questions for you and then we're gonna bring up bring some other people in the conversation but you know i i appreciate where you ended there gill um it was great to have the three of you with us at community stat at the police station earlier this afternoon we had a couple hours um where we were able to kind of lay out for you this low barrier uh buprenorphine initiative that has been running since october now at our needle exchange where people um have the opportunity to uh basically a facility that many of them have been going to for a long time to exchange clean needles we have added the service of people being immediately being able to go to start receiving this lifesaving medicine buprenorphine there before they leave we talked about the a similar effort now happening at the emergency room up at uvmc where um that emergency room is one of just a handful i believe in the country still where uh they're most of the emergency room doctors and many of the physician assistants now have gotten the waivers that they need to and can prescribe buprenorphine um in the emergency room and every person that is coming in for any reason is getting some level of screening um and that is starting to show uh as a promising strategy we have this um since last july romant prisons have also been a place where people can start getting medically assisted treatment um you heard of an effort they were hoping to stand up in a few weeks where the police are going to be taking on a new role i you had a chance to sit there with the dozens of different providers that are involved in this effort in one way or another um i i'd love any reactions you can share with us what what where you think we uh if there are municipal local level strategies because i agree with you that i think this is uh the local communities have a lot to do with impacting this are there things that are missing in our approach are their reactions to this for improving it further that um that you came out of that meeting having let me let me start for a second i think the most important thing to to kind of recognize the mayor is in elected position isn't it it is elected fortunately don't need to be reelected for a couple years now but yes it is uh oh good for you there are a number of elected officials that will try and give you a pretty simple and direct answer to what in the opioid issue is an incredibly complex problem involving the pharmaceutical industry doctor training uh the commission on accreditation of hospitals and the pain management the lack of any type of curriculum for new doctors although now massachusetts i think requires a certain amount of training takes a great deal of courage for an elected official to hold a meeting and say let's talk about this in the depth and with the complexity that this problem deserves rather than try to give you kind of a a shorthand simple answer to what is an unbelievably difficult situation president obama used to say you know what if it was easy it wouldn't be on my desk and it's on your desk and it's hard congratulations the only thing that i would add um is i was hearten to see the medical center staff there you know i talked about keila and a boston aerial hospital and although we've improved you know that boston aerial hospital kick keila to the curbside you know released against medical advice is what the what the documentation said but the reality is is that hospital at that time didn't have the desire of the capacity to treat an overdose patient they wanted to free up the bed and move on to the next case so to see the medical center involved in in such a meaningful way i think it's huge and and there's no more important time the history of our country for public health and public safety to come together than now a third year in a row josh that our life expectancy has gone down largely due to opiate disorder and mental health we've got a country in despair it requires the partnerships that we're seeing outstanding i would say what struck me was the incredibly focused discussion on what would really make a difference for people and that respected some basic aspects of opioid addiction you know people who are addicted to opioids will go into withdrawal every certain number of hours if it's heroin it's every six to eight hours and they will need another dose to avoid a very very painful horrible withdrawal and so if you say to someone i really want to help you here's the number you can get an appointment in two days you're basically sending them out probably to use four to six times in that period and by then who knows whether they'll still actually go to treatment and so when people come in to the syringe exchange or to the emergency department and are ready to start treatment you don't want to let them go into a draw and you don't want to you know give them a 10 hour assessment you don't want to tell them the waiting list is a year or even a few days you want to treat them right away and it's that recognition that you know that's so important what i really appreciated particularly coming from the medical center was that they realized that it's their job that it's a medical condition and that they can really make a difference by providing timely medical treatment and i think one of the physicians said you know if it were diabetes we wouldn't send someone out and say here's an appointment three days if we need to save their life now that's what we would do well i appreciate you both picked up on that i think we are very fortunate and i know a number of people from the medical center are here and i do think uvmc has for years now really taken on the the challenge of viewing this as a disease as a public health epidemic and and really tried to make good on that notion that if this is a disease we need to treat it as such and i find that that is helpful in other areas we talk a lot about buprenorphine this this medication and one of the things we have been promoting is thinking of this as something akin to a medicine that's like insulin for for diabetics and that it may be something that people need to be on for a very long time and shouldn't be treated as as a as a sort of dangerous substance in itself to urge people to go off of i think both those realizations speak to something you were talking about fred that the and then i think is a main purpose for having this event is the stigma still looms very large in in this country and even in a community that's been grappling with this for for some time like burlington the state of ramon has i am stunned by the anger and the venom i hear directed towards people who are suffering from these powerful addictions to this day even after years of this discussion can you i i think the hospital treating this like a disease is a destigmatizing action are there other examples of that that sort of change people's frame and that you think we should kind of hold up as actions that communities can actually do to destigmatize this disease well one thing is access to federally approved medications you know in massachusetts only 4.5 percent of the treatment providers provide all three federally approved therapies for for opiate disorder i mean that's a problem right and the other thing is is you know some of the harm reduction strategies that that have been employed you know where else do we make people wait in line out on a city block to get their meds but at a methadone clinic right and in boston we have what's known as a methadone mile which enhances the stigma associated with addiction and i've told grace's story the boston globe did a story on methadone mile and they had a photo intended to perpetuate the stigma it was two young men using in an alleyway and to the untrained eye that looked terrible two men using an alleyway but when i looked at that photograph more closely and others look at it more closely what we saw was hope there was clean works there was a stereo wipe that that those that were using had used to clean the site before injecting and a number of other pieces of evidence in that photograph that demonstrated hope and that the city was making a difference but the point is is the media but the point is the media missed the point they you know in in their intent to to further the stigma really what to a trained eye it showed that wow our harm reduction strategies are working so we had a meeting in washington dc um couple of your burlington team were down there chief del pozo and grace was there um from and um we also had in that meeting where we heard about low barrier treatment there was a group there from huntington west virginia hunting west virginia has been just so severely impacted by the opioid epidemic and we had one of the lead emt's ambulance workers there and the mayor and uh they were talking about a program where they provide mental health support to the emt's and to people who they were resuscitating and how it came about because this epidemic is traumatic not just for the people who are affected by it it's traumatic for family members it's traumatic for caregivers it was unbelievably traumatic to the ambulance workers in huntington people there talked about having to respond to overdoses of four or five six of their high school classmates and what the mayor said was that he was just um just incredibly shaken by the way that people were defending themselves against that trauma they were you know not being very caring they were saying things like here we go again you know another overdose how many times we have to go back out and that was really reflecting just a tremendous desperation and pain that the actual caregivers were feeling and one of the the the focus areas they they did was to talk to the the emt's to give them support and then they actually deployed um mental health workers on the ambulances both to help the emt's and to help people when who were being resuscitated they found more people going into treatment and it was actually much more inspiring for the emt's to know that their activities were making a difference just a quick message with when I picked and recommended a deputy to be senate confirmed to be the deputy director was Michael Botticelli who's in recovery he's been in recovery 30 years office of personnel management in the in the president's office is designed to do one thing protect the president don't let don't have somebody that you're going to recommend its name is going to be out there uh that is going to embarrass the what embarrass the white house and they said you're recommending somebody that's in recovery that's gotten in trouble and it was many years ago and uh but went on to have a successful career and on and on and the senate confirmation process not everybody gets along in that process that's just the rumor that I've heard so uh Michael the the president supported nominated Michael Michael went through senate confirmation glowingly it was just it was just amazing I could never understand I couldn't get on the front page of the wall street journal or the any other paper Michael could do he got all of these things they just loved him because actually he'd been there and he'd seen it from the ground up well we don't always get along in hearings here at the local level either here but we we do work hard to to try to move the community together I am really pleased to see how many city counselors have joined us tonight and do want to welcome counselor pine president right counselor busher counselor Karen Paul who's been a real leader on this issue and Franklin Paulino who will soon be joining us and counselor Ali Jang I believe what's here you might have stepped out for a moment but that is the fact that our city council has been very much on board with addressing this effort has been a big part of the story here in Burlington as well so I want to shift gears later just let's hit a couple kind of hot topics and then and then we'll bring in the rest of our our panel tonight you know we are having this incredible national debate about immigration and you know in particular about putting up a all increasing the amount of wall that we have on the border there's been the notion you know the argument explicit argument made by our president that that would have an impact on the conversation we're having tonight that that would reduce the amount of illicit opioids and drugs in our community Gil can you can you speak to that argument and how you see it and how how you specifically how the mall would impact the opioid epidemic so the wall would have almost zero impact on stopping drugs coming into the united states the drugs that are killing people heroin fentanyl um methamphetamine certainly and and cocaine is on the rise come through our ports of entry universally whether it's JFK or Los Angeles or San Ysidro or very small ports and it either is hidden in vehicles or it comes in by people bringing it in they do not backpack it across the border they don't try to sneak across the border the only drug that comes across the border on the southern border is marijuana marijuana seizures on the southern border have gone down for eight or nine years we have ten states that have legalized marijuana and there is marijuana grown in hydroponics and a number of other places so it's not a particularly big issue but i testified three different times three senate hearings including new hampshire and the question was asked well if we could just interdict more drugs then we could reduce the amount of the drug problem here in the country so the same analogy to interdicting more drugs and reducing the amount of drug use would be that if you want to reduce the number of diamonds in the united states you just need to seize all the lumps of coal safe to say gill enjoys retirement you won't be getting called by the administration anytime soon now i'd love to get all your thoughts quickly on a big debate we're having here in the state which you know we have a lot of consensus in the state about this being the opioid epidemic being a top public health priority we have a lot of consensus that the spug and hope system hub and spoke system that has been pioneered here in vermont is is is working and needs to be expanded and a lot of what we're doing i think is here at the local level is trying to leverage that hub and spoke model so that helps as many people as possible but we are having a debate this year as one of the and it's a you know it's a i think a welcome debate that it's good to hear from both sides on this over the current whether the possession of non-prescribed buprenorphine should be prosecuted as a crime here in vermont and whether it should and i would welcome your perspectives on that from both law enforcement and public health debate i think there are people who believe we should continue to enforce it because it is the right thing for public health i'd welcome your perspectives on that i do want to say we are joined by states attorney sarah george who's been quite courageous i believe in being one of the probably one of the first and only prosecutors in the country to say she will not prosecute for non-prescribed buprenorphine possession in chitney county and we are joined by selena colburn who i think has a response has been the lead sponsor on this bill that is being debated and it's really unclear what the outcome is going to be and i think you could help the community by sharing your thoughts on that sure um so i would say my opinion is informed by a few points of data there are a number of studies about non-prescribed buprenorphine in the united states and what why people are carrying out what they're doing with it very rarely is it used for euphoria but people generally don't you know feel euphoric when they take it they're almost always used to prevent withdrawal people just don't want to go into withdrawal like i said before and so they will take buprenorphine one of the interesting findings is that um it per use of buprenorphine that's not prescribed predicts wanting it for treatment and showing up in treatment and actually being successful in treatment and being able to put your life back together we actually heard earlier today from an emergency room physician here in burlington who said he's had multiple patients come in seeking treatment after trying buprenorphine um that they had gotten and so um you put those facts together and the the data that i've seen and i think um it is um what you know in public health the key question is compared to what you know if there was no opioids anywhere you know would it be good that some people are carrying around buprenorphine that's not prescribed you know you'd want to know why they were doing that but that's not the world we live in that compared to what is people actually using much more harmful opioids and to the extent that people will use buprenorphine to prevent withdrawal they're not using more harmful opioids and then they're more likely to go into treatment um you wind up with a positive benefit for people um doing it and so for that reason i personally would be supportive of the measure that's been introduced and i think if you look at some other countries and how they pursue this they make it very very easy to get treatment drugs much much easier than um in the united states people can wander in to overdose prevention site in barcelona and just get a day's worth of methadone right there and i think um and what what they tell me when i talk to them is someone will wander in on monday then they'll wander in on tuesday you know i don't feel like using heroin today i'll just use methadone or buprenorphine and then by the end of the week or maybe the next week they want treatment they're ready to move it is a pathway to recovery and and i think what the legislation is seeking to do is to use evidence to support like i said before an innovation that makes sense and then you want to do it and then see whether it works excellent i agree enforcement and prosecution of um possession of of buprenorphine is a distraction you know fentanyl lace heroin is killing people that's where our energy and our focus needs to be and getting people access to evidence-based patients and the treatment that's where our focus needs to be i don't need great excellent all right well excellent let's uh i'm not quite sure how this is gonna happen but i think uh we're now gonna shift gears here and some chairs are gonna materialize and we're gonna open up this conversation so um if you are part of the panel come on up and uh great i'll follow you i guess i'll just stand i think we need a few more yeah there's a lot of yeah cheers i'm the director of neurology and psychiatry okay more chairs how long have you been there 16 years oh my god i'm thinking of making it a career are you still okay great okay we're gonna dive back in and um in the interest of time we will introduce people as we go here um and what um we were hoping is that uh each of the local experts leaders who have just come up could um uh if if there is one thing you've heard from the conversation tonight or the most of you are if not all of you were at the conversation earlier today if there's anything uh any reaction any lesson from our national experts or just reaction from what's going on locally that you want to make sure the public kind of takes home from today now's your chance to share so let's start with dr kimberley blake who um is uh you've heard referenced tonight a couple times to this new program we have at safe recovery which is our needle exchange site where we are now prescribing buprenorphine this lifesaving medicine uh two people in in the needle exchange site for something that has only been possible since october and the main reason that this is possible is because dr blake um has joined the team and is providing that service so we're we're really thankful dr blake for the uh the pioneering service you're providing um especially as someone who's uh whose family has been impacted by this crisis so thank you for being here tonight and sharing your thoughts what a great forum tonight and i'm so excited for our community that we're having meetings like this and comm stat not much of a public speaker well it's just it's these mics everyone should know you really have to speak straight into them where they don't register a long time burlington uh physician my um son passed away from an overdose about a year and a half ago um which is still a little bit hard to talk about but um i think there were a couple of take home points that um led me to be interested in working at safe recovery and probably the biggest thing was the research that i read that study after study shows that people who visit a syringe exchange are actually would take treatment if it were available and the idea that i could offer my um capabilities as a physician to provide treatment on site i know that 77 percent of people seeking a syringe exchange materials would take treatment if it were offered and that's what i found is that people come in sometimes after a recent overdose last week i saw someone who had seen his friend die that day and he saw treatment um it's very empowering to be able to do something for somebody when they're in that moment of wanting treatment and that has been a big um powerful message that i hope that everyone could hear the other piece that i think that is really very important is that um stigma is is dangerous and it is a reason that a lot of young people are not seeking um treatment and the more that we can do to reduce that stigma the better finally i appreciate the thought and the um knowledge that buprenorphine is a very safe alternative to what's out there most of my patients who come in are testing positive for fentanyl um when we do their year your analysis and that's a very dangerous situation to be in so i'm really grateful that we have something that's a safer alternative excellent next we have grace keller who um is the director of the of safe recovery and has been for many years and has played a key role in standing up this new effort so grace welcome hi uh thank you i would react to similar things that dr blake reacted to um when we're talking about people visiting a syringe exchange what the secret to syringe exchange that people don't know automatically is that it's a great conduit to treatment and recovery and for a long time we had the esteem recognition of being the program that put the most people on the waiting list and we put more people on the waiting list every year than any other program in the state and then we moved towards being the program that got more people in medication assisted treatment in the state and we got 228 people in 2017 into treatment but those even with no waiting list we still had a little gap in in time and at that time people were using fentanyl in that gap so we really wanted to fill it we also knew that the waiting list wasn't the only barrier to treatment so we really wanted to wrap these clients in a lot of services and make sure that we were there when they decided they wanted help the system was ready to help them and we could help them immediately so as Dr. Sharfstein said you want to give it treatment to people when they ask for it in that moment because that moment can be fleeting and when that moment can be fleeting it also can result in death so we worked really hard to make sure that we're giving people treatment in the same hour most times that they ask for it at times we've had the police drop people off and get them into treatment immediately and it's really been working and the reason we did that is we knew from what we've seen in our practice for a very long time that that would be effective but that's what science tells us would be effective also so i think the way that we move forward is safe recovery and the way that dictates our life all day every day is focusing on science and compassion and i think through those two ways of looking at this and compassion is where stigma comes in i mean we really have to look at at people as human beings and give them the dignity and respect that they deserve our clients are survivors they've been through more than any of us in many cases i had clients that come in came in last year and we hadn't seen them in six months and i asked them where have you been and they said we've been in recovery this entire time and i said did you find a safe place to live and they said no we've been in a tent and they've been in a tent all winter long getting up out of that tent unzipping it and walking all the way to the clinic every day and that's resiliency that we need to see in this population as as a public we need to be looking at these at folks and seeing them as survivors and and like dr scharfstein said listening to what they say is going to help them and so when we're in the syringe exchange we know what we're asking them what they want help is they want help now so that's really what we've worked on is reducing stigma and making sure our services are our anti-stigma and getting and getting people treatment exactly when they ask for it in within the same hour same day so thank you excellent okay uh next we welcome sarah george our state's attorney who in addition to uh being a leader on the debate we were just discussing about buprenorphine has also uh really spearheaded the conversation in this community about safe injection sites and we're welcome he'd been here tonight sarah thank you mayor um i just wanted to kind of say briefly a couple of things one i think that within law enforcement both by prosecutors and by police officers we imagine that our job means to enforce laws and it you know over the eight years i've been a prosecutor it's become clear to me that our job really isn't necessarily to enforce laws it's to protect the public and too often we forget that the individuals who are using drugs and people with substance use disorder are just as much a part of this public as um you and i are and that we have just as much responsibility to protect them and you know when we when we made the announcement that i wasn't going to prosecute individuals who were possessing misdemeanor amounts of suboxone there was pushback from law enforcement on that and i think with really good intentions a lot of the law enforcement officers in chitin and county anyway have um the idea and i think based on how our system has worked that we need to arrest people in order to get them treatment and frankly that has been the case in a lot of um a lot of the time i've been a prosecutor that if we want to get people treatment we need to arrest them because it's the only way to force them to get it or it's the only way that they'll have access to it and frankly this new program i think just to completely negates that need we don't need to arrest somebody in order to get them that treatment anymore and in fact we want to encourage people to possess a drug that will save their life versus the possession of heroin that is likely to kill them and i've i've talked to multiple police officers in chitin and who have come into contact with somebody who did possess a strip of suboxone illicitly and they were able to tell not only tell them about the new programs that we have at the ed or at safe recovery but actually bring them there and get them a valid prescription and in my mind that is true public safety that is exactly what law enforcement's job is in that moment and they have been really not only receptive to it but really glad and proud to have been able to do it because they saw that person have a moment of hope and access a medication that they didn't know they could and brought to it in order to get it by a law enforcement officer which is exactly what we all want and it's something that i'm incredibly proud to have been a part of and i'm really humbled to see how many people are here having this discussion and i would just ask in case i don't have any other time that if there's something that you learned tonight that goes against maybe an idea or an opinion that you had i would really just encourage you to tell somebody else about it because i think that that there aren't enough as much as it's really great how many people are here a lot of the people that maybe hold a lot of those stigmas and ideas are still out there and maybe aren't here and that's one way that i think we can spread this in a way that will make a really big difference in the community thank you so much great well said sarah and i gotta say i really believe in the power of the people in this room to help spread this knowledge one thing that i've heard from many doctors including Dr. Levine is we have succeeded already in starting to change attitudes in important ways that impact this epidemic most patients when they go to the doctor now have an entirely different posture and relationship to these questions about whether they're going to go on to painkillers i think that is a change a cultural change that has happened because of conversations like this one and i think we can we can do this in other areas as well and it's needed i continue to be stunned i was on a panel recently and which the remaining just again anger and misunderstanding of this addiction and how challenging it is to fight continues to be very much part of the what's out there even here in vermont where there's been so much of so much discussion of this already next we've got Maureen Leahy who's the director of the university of vermont medical group who has personally been very committed to much of what you heard of tonight in terms of the uvm medical center's response to this crisis and has been at i think every community staff meeting and every shittinna county opioid alliance meeting and we really welcome her being here tonight to share her perspective thank you i think one of the things that resonated most was one of my i'll say new colleagues comment that we're responsible we're accountable and we need to do something differently and as the academic medical center in this region i feel fortunate that we are taking an approach i feel fortunate to work for a place where we're taking an approach that we're responsible to a solution we're accountable to finding a solution and we need to be doing something differently we've had many successes in the work that we've done we're working on some things currently and then we have a long way to go in other areas so we've had some successes in decreasing our prescribing rates which has been very impactful in the in this the work we've done we've expanded some of our treatment programs with both the addiction treatment program expansion of the hub and spoke and then the new ed distribution program and then we're working on some things that are are challenging but are very rewarding to hopefully be able to add to the arsenal of ways that we are going to attack this we have an alternative treatment model that we are trying we're working on standing up i would say we're 75 percent there and you know some of the things that have to change are in in our health system really our payment models and recognition of alternative therapies that can work in place of opioids and then it you know it goes without saying we're the we're the largest employer in the state and it's incumbent on us to create a supportive work environment for people who are living in long-term recovery and that's another body of work that's important for us to take on to model and to lead for other employers who may not have the same resources that an institution the size of ours would have and i think finally i think the most important thing we need to do is to stop stop being okay with status quo so when somebody comes up with an idea like you guys should distribute buprenorphine from the emergency department we can't be sitting up here saying here's all the reasons we can't do it we have to we have to lead by example and we have to figure out how to remove all of those barriers and help move this forward chief brandon del pozo uh let's give that man a mic at your own risk so when i became a police officer in 1997 uh it was because new york city was in the middle of a of a homicide epidemic where well over 2000 new yorkers were getting killed i majored in philosophy i didn't major in criminal justice so you can say maybe i had a hard time finding a job after college and i'm not going to comment on that but i became a police officer to save lives and if you look at the first job of american cops to protect and rescue people in danger the second job is to enforce criminal statutes it's to collect evidence and people and bring them to a judge and a prosecutor but i'll tell you if you ever have to choose between saving a life or enforcing a law and you choose to enforce the law while you watch people die i question your motives as a cop so one of the things i worry about when i talk to my peers and i i i am a full-throated supporter of sarah george's decision not to prosecute for the misdemeanor possession of non-prescribed buprenorphine is they look at me and say this is a sheep in wolf's clothing we have a guy here with a uniform and a gun and a badge and a baton and he just wants to let criminals go by not enforcing the law you know what i've been very very humbled by this opioid epidemic because more vermonters have been killed under my watch and the watch of the public officials in this room than at any other time in vermont history and if the answer to that is to say you know what i'm going to do just enforce the same misdemeanor laws that i've always enforced that have done nothing to save lives so far that i wonder if we're fulfilling our obligations to the public so we're going to go after drug dealers we have a great narcotics unit i have an officer in the drug enforcement task force we're going to bring felony cases i know there's a federal drug court judge in the room right now who we have animated conversations about the best way to hold people to account for making a profit off of destroying lives but if you have something like a strip of addiction medication in your pocket because you're not in the right headspace to say you want treatment but you like the way it makes you feel and clinically it's a predictor of seeking treatment and when it's in your system the chance of you dying of a heroin overdose is almost nil i don't feel like a sheep to say i'm not going to arrest that person i feel like a wolf like i'm going to be a guardian and save their life and i just wish that my peers would understand that not my cops just do what i unfortunately order them to do so i don't mean those guys but i just wish that we'd understand the motives here it's not to cede law and order it's it's to make a difference because this this epidemic of death has been so incredibly humbling for police because we tried for years and we haven't made a difference but we're on the cusp of trying some new things saving some lives and i'm proud to be a part of that oh sorry dr levine now we have commissioner dr mark levine who um you know i really want to express thanks to you for being a great partner in the local efforts we are very aware that we could not be doing the work we're doing at the local level without a full partnership from from the state and dr levine has been the embodiment of that partnership in many ways again a very constant member of these these meetings and these attempts to to stand up new innovations and interventions at the local level so thank you for being here tonight dr levine thank you mayor now as the most official cleanup hitter i can take it upon myself to offer some bullet points in summary because you've heard so many incredible comments tonight um first summarizing point is all the law enforcement colleagues in this row have basically said the opioid crisis is a public health crisis that takes courage and that took a long time coming in the history of this country and in history of this epidemic and that realization alone has been very very powerful um you've also heard this is a complex problem and not only is it complex it requires solutions that you never dreamed you would think of or even buy into things that sounded heretical are now standards of care and the list of them is so long you haven't even heard uh you've heard the tip of the iceberg tonight you've heard about science and evidence and how important that is and it is critical and we are amassing science and evidence at a really exponential pace here because this field was a little bit behind originally nonetheless there's areas that are less clear more gray that we don't have all the evidence in on and the issue there is are you courageous and innovative or are you going to stand on the sidelines and watch more people die and those are very challenging discussions to have we've had one very challenging one locally and statewide with regard to safe injection facilities and came out on the side saying we're not sure that's the best place to put our resources now because we have so many other things going on got criticized by some got praised by others but that's just one example of how you have to actually think outside the box and decide where you can put your resources and where to be courageous there's a common a common theory of change for those who are familiar with how change occurs in a society called diffusion of innovation and it says that basically originally you just have a couple of innovators and then you get the so-called early adopters that come aboard and then eventually it kind of becomes a standard for the society but you still have these laggards who never buy into it well you're living in Vermont and you're living in Burlington Vermont and almost everything going on in the opioid crisis is really on the early adopter and innovator end of the spectrum here we didn't wait around for a long time and just look at the corrections issues in corrections we were criticized widely for not buying into that early enough well no other state in the country had until Rhode Island did and we finally got some really good evidence from Rhode Island that this is successful and now we've implemented it and it's been a rocky course but it's moving along very nicely but that's the kind of courage that's required the kind of innovation that's required and frankly it costs money to do these things so people have to agree that this is a wise use of resources again all in the effort to have less people die have less kids put into custody etc you've heard about the importance of prevention and prevention comes from the physician end with prescribing and i'm happy to deliver the news that there's a in the vicinity of 25 to 35 less opioid prescriptions being written no matter where you look in the state right now and that's true progress you've heard that we need to have better payment plans for alternatives to opioids the NIH is now starting to get more funding to actually do pharmacology research on drugs besides opioids but we have a long way to go in the integrative medicine range of other therapies besides getting a prescription this week and yesterday at the governor's opioid coordinated council we heard some presentations from those who are familiar with the Icelandic model and that's a prevention model that basically engages communities that are very activated that want to see change and want their youth not to develop into people who have substance use disorders it's a great model there's good examples of it going on in vermont right now even without calling it an Icelandic model because we have really good highly motivated communities but the goal is address these very vulnerable young brains early in life provide youth with the proper activities especially in that dangerous after school environment time so called third space and you will succeed and reducing the rates of substance misuse and by the way we're confronting an opioid crisis but the goal is all substances and if you go to the legislature anytime this session you're going to hear a lot of bills dedicated to that drug we call nicotine and we should believe that nicotine is part of the pathway to how people get into trouble and respect the legislature for seizing that bull by the horn and I think you'll see by the end of the session some very substantial legislation coming out regarding that and the whole e-cigarette and vaping epidemic I'll just end by saying listening to people sounded so trite it is so critical we have always had at the ccoa and at the opioid coordinating council and other coalitions around the state the voice of people who have suffered from an opioid use disorder to a lesser extent but some extent listen to their families as well but if there's one thing we're learning now it's we need to listen even harder and more and if we want to be innovative we actually have to ask people who have been through this because they can actually help us understand how to be innovative and their families especially can help us in that critical time period that we've labeled recovery with all the issues that surround not just having the support systems you need to survive in recovery but how to get a productive life out of it meaning a roof over your heads a job transportation to your treatment centers etc finally the stigma unfortunately you've heard it by every person who's been sitting here it has not disappeared we're doing better I always try to appeal to people's scientific knowledge if you will and give them a very very rudimentary course in brain chemistry and neurobiology because one has to understand how the brains of those with substance use disorders get hijacked by the drugs that we're talking about and how that impairs rational decision making in those executive functions that we all have in our brains but that really don't play a role when we're lost in the midst of an addiction process so the more that every one of us can share with others why we need to respect that is critical thank you thank you Dr. Levine for that summary and I think especially your point about the importance of continuing to hear from people with lived experience and hear from the public is a great transition as we are now going to open open this conversation up we have a couple of microphones up here at the front of the room and we'll try to alternate from one microphone to the next and if you could quickly introduce yourself and and share any reaction you have your question if you don't have if you don't have a question for a specific panelist I'll try to play traffic cop up here a little bit let's dive in welcome hi my name is Philip Pazeski I'm a licensed alcohol and drug counselor in South Burlington and also a licensed clinical mental health counselor duly licensed I worked for four years in the chin and regional correctional facility working with the women doing substance abuse counseling under the auspices of phoenix house it was my first job and I quickly learned that I was not doing substance abuse counseling I was doing trauma counseling because this epidemic is not to my mind about drugs I really salute all the efforts that all of you and many of the people in the room have been doing about intervening at the drug and pharmaceutical level but I'm afraid that that's a band-aid you know a person's knee is bleeding but their leg is off and it's not going to really ultimately address the underlying problems to put a band-aid on that knee I also happened to have been born and raised in Portsmouth Ohio which is where the book by Sam Kenyone's Dreamland is based the reason I think in retrospect that that book was able was focused on that town and the reason that the epidemic started in that area of of Appalachia northern Appalachia is not only because of the pill mills and because of the black tar heroine coming in there but because it was a depressed area economically and socially driven by racism and devastated by unemployment I know that addiction cuts across some of the economics levels but the you know the idea that a person living in a tent and needs to receive medical treatment is really pretty disturbing to me a person living in a tent needs to be in a house needs to have a job needs to have a community needs to have the the trauma that brought that put them to an attend in the first place and led them to using drugs in the first place that the whole system needs to be addressed just one more comment and that is that my my clinical impressions at the prison were that there were essentially levels of addiction and and choices of substance that were that my patients that my clients availed themselves of based on the kinds of trauma that they'd experienced I don't have any research to back this up but but basically women who had suffered emotional abuse would drink and use marijuana women who had had physical abuse would use things like marijuana and cocaine the heroin abusers were almost by and large suffers of sexual abuse there is an epidemic of trauma and abuse in this community and again while I applaud the the efforts of of these people and all of us to to you know treat this as a medical issue it goes far beyond that and if we really want to take a public health approach then we need to take a public health approach and not just a medical one thank you all right thank you so I think that's a helpful question for framing things up here anyone Josh do you want to do you want to address that or is anyone in particular want to weigh in that or sorry Grace you were making a wish to go for Grace um what I can say is uh I agree with you around trauma I do believe that the trauma is often the gateway drug that most of our clients are facing trauma but what we're doing is getting people in the door and getting the medication immediately to save their life we also have a team so we have social workers we have case managers so that they won't be living in a tent so that they will be addressing their trauma so what what the attention tonight and focus was to get access to these medications that will save their life we have these wraparound services that are client centered that are focused on what clients need and we will be working directly with them each person will get a case manager and a social worker or is getting a case manager and a social worker so we're really fortunate to have a large SAMHSA grant that's helping us allow us to wrap services around those people very tightly you know I think you've raised a really important perspective that I think is widely held and I think is is uh is is one for us to grapple with I have to say um I uh don't fully agree with that diagnosis of the situation in that I don't think there has been an epidemic of hopelessness and trauma since the mid 1990s I think there's been an epidemic of the about availability of opioids and that that and there's a lot I believe science to back this up has more than anything else uh driven the overdose deaths that we have been very focused on here in this community and I think when we start to think of this as just one more symptom of america's problems with poverty um and trauma we actually um only see part of the story uh certainly poverty is part of it and I think people who are um in poverty have a face a tougher challenge uh in getting their way out of an addiction but I'm actually stunned with this crisis degree which it does cut across all socioeconomic classes and the degree that it does touch um everyone and uh I I think that um that actually is more alarming when you think of it that way and should cause us to take uh there there are many things we don't respond to adequately when it's seen only as something uh that is sort of a symptom of of these other problems and um I think we will lose people if we don't respond to this as a hot uh public health crisis that we can that we can do something about and and uh whereas some of fixing some of these structural problems which clearly exist in society I think if we wait to to fix them to do anything about the opioid epidemic we're going to lose a whole lot of people and uh I think a lot of us up here come from the perspective that uh we we can actually save a number of people and are starting to save people in communities across the country so um let's go over here thank you my name is Ada Poucher and I do outreach and education work for Champlain Valley Dispensary which is one of the state's medical marijuana dispensaries and I just wanted to share um some observations about cannabinoids that can be helpful in this conversation both non intoxicating CBD that people have been using for pain relief and the combination of THC and CBD which also can be non intoxicating and that people are using for to address withdrawal symptoms and also just to mention that several states now have added opioid addiction and chronic pain to the list of qualifying conditions for their state's medical marijuana programs I'm just curious if anybody has any um thoughts about that that they want to address yeah um so thank you for your comment you know the national academies did a really comprehensive review of the evidence did not find any evidence that would support the use of marijuana for treatment for opioid addiction I think more more in a grayer area is the question of whether the use of marijuana for pain might lead to less of a problem and I would say there the evidence is more mixed so there are some studies that suggest it might lead to less use of opioids there are other studies that suggests people who use marijuana might be more likely to get into trouble with the opioids so I think that's a more complicated question that probably further research will develop but in terms of acts treatment for opioid addiction I would my my sense of the evidence is and the national academies which is you know did a thorough review is that um people are much better off on effective medications that have been proven than uh any medication including marijuana or others that have not been proven to work excellent welcome hi my name is miss Jackie Robertson and I've been a citizen of Vermont for 15 years um I'm the maven of Battery Park and the bitch of North Champlain Street and I'm the other side of the story okay I have a a failed hip replacement that neurologically has been causing me agonizing pain for the last two and a half years and I can't get anything opiate based to help me manage it and I know it works because when my best friend died she gave me her bike and I spread it out over six months and only took it on the days when I didn't want to go to the emergency room I got my first suboxone patch today like I was fucked up out of my mind in the cemetery talking to Brenda this afternoon for an hour and a half until I could finally get home in one piece but I'm here to testify that it ain't hot in it but the Vicodin did so I'm the other side of the story here people that have chronic pain and and if it's spinal or usually that's where it originates but not with me um people that have chronic pain can't are no longer being able to get access to anything opiate based and people that have had their chronic pain managed for years with morphine and opiate based pain relievers it's a godsend to them I can't work anymore I can't sometimes I can't even make a cup of coffee for myself in the morning and I have medical marijuana I spend five hundred dollars a month or more on pain management and it still doesn't cut the mustard and if I have to buy it at the state dispensary then I'm giving all of my my what I can't even afford my insurance god I hope I can next month I'm giving all my my living to the pot dispensary and their pot isn't consistently effective thank god I have friends that grow it without putting chemical fertilizers in it but it's it's not cutting the mustard anymore so and I have friends that have to uh I have a friend in California she said well I can't I they won't I have Kaiser I had a pot gummy bear so they they P tested me so they're saying I'm a drug addict so I can't I have to save my opiates until for the end of the month I have to make I have to go without pain relief because I want to have 10 more to get me through because I got to argue and fight for them every single month okay thank you I think I think you're on your question if I had adequate enough pain management I could work for a living so thank you this is a question that yep all right thank you for this question very important question the one that um does come up when uh whenever we have these discussions and I think uh the speaker speaks for a lot of people um uh in in those frustrations we can one of the doctors kind of weigh in on how we try to get this balance right um here doctor I'm not a doctor either this this story is not an uncommon one and we need to have tremendous respect that she had the courage to get up here in front of an audience and talk about it uh there's an increasing medical literature uh very current medical literature looking at the fact that there's a cadre of people rather large cadre in the country who have been maintained on chronic opioids for chronic pain and seem to be suffering from if I could use such a strong term abandonment um uh pharmacy program managers health plans individual physicians you name it uh now more reluctant to continue to provide those opioids um we cannot condone abandonment by any means uh we can condone such things as compassionate tapers and also integration of other forms of pain management so it needs to be the entire package uh and we need to approach each individual with the sensitivity and compassion they deserve I will say from the other end though uh before the person gets their first opioid prescription we need to be very mindful of scientific evidence that informs us that this is not the most optimal form of chronic pain management and in fact um it actually doesn't work well as chronic pain management most of the efforts you've seen in terms of the Vermont prescriber rules and use of prescription monitoring systems are by and large focused at that first prescription for someone with acute pain knowing that even the risk of that one prescription in the several days can provide uh a higher probability that an individual who came in opioid naive and just got their one prescription would then actually remain on the same drug six and twelve months later or even years later so we need to be very mindful of the evidence that for chronic pain management this is not something that we should be routinely doing in medicine welcome hi my name is Amanda I am a graduate student I'm getting my PhD in clinical psych at the University of Vermont I'm also part of a group that treats substance use disorders among federal inmates at Northwest State Correctional Facility um it's pretty apparent and you have all made comments that articulate how unfortunately substance use and incarceration are pretty intertwined um you chief Ryan you mentioned experiences are resting the same people over and over again um and I'm wondering in our experience working with those who are in the facility about that really fragile time post release when these people are going back into the community um they're very sensitive maybe they haven't used in a really long time they're suddenly confronted with the context the peer groups the drug cues um that they had been avoiding or had uh been unable to see while they were incarcerated I'm wondering um what suggestions you all have for community providers to help mitigate reengaging in substance use um overdoses or uh criminal offending in that time great Amanda you've struck on I think one of Vermont's real success stories over the last call it eight or nine months um Vermont has uh really been focused on exactly that question uh Dr. Levine would you like to speak to the the efforts at the I don't know if we've done justice tonight to the kind of full extent to which um the state is really attempting to address exactly that question I have to be honest I was okay sorry the question is basically can you describe the what is happening for the incarceration population in terms of access to medically assisted treatment and then specifically what uh is happening in terms of a warm handoff when people are leaving incarceration to ensure that they don't uh immediately during that very vulnerable time that they don't uh become an overdose victim sure so on any given day there's fifteen seventeen hundred individuals in our systems across the state and somewhere in six to seven hundred range on the numbers that are actively on some form of treatment about half of those were already on treatment before they entered the system and that that's being continued the other half are being initiated it's always been thought that the most important time juncture is the day of release um because that's where the highest risk of overdose death is associated so um a lot of attention has been placed on just that moment in time there are people who have actually been imprisoned for years that may not be on medication assisted treatment after they've been medically assessed and screened uh with some um accepted screening instruments those individuals though still may be at very high risk when they leave uh the correction system um everyone is offered though not everyone accepts a dose of naltrexone it's the one drug we haven't actually mentioned tonight um it's a called an opioid antagonist meaning that uh it's different than the drugs like methadone and buprenorphine which have agonist activity which means that they act like the drugs that you're trying to prevent people from taking um but it's a very effective uh tool for someone to have at discharge but equally important is this warm handoff concept that uh has been referred to because the treatment system needs to be arms open appointment ready person not at risk for falling through the cracks um i'm not a member of the corrections um department but at the same time we've worked really hard on just that concept and i would like to hope and think that that is working very well at this point in time i can't give you any of the data from them at this point in time but that's really our goal um and even within the treatment system within uh corrections there are some individuals who have been offered and accepted naltrexone usually those who have been free of opioids for a number of years because they've been in the safe environment of the correction system where the drugs were not circulating does that answer what specifically yeah i think that's uh that that's great and and uh it is um that is a metric that a lot of people are really focused on to ensure that that uh you there's there's a real awareness that the chance of overdose and dying in that period is is much higher than uh at other times and we've all been impressed by one of the things that motivated vermont's efforts is an awareness that in rhodeland they saw the overall overdose accidental overdose uh death rate cut through these very progressive prison reforms and we're trying to replicate that here in vermont and i think a lot of people watching to to to see that that is uh exactly that is done well so welcome hi my name is may chow and i am a mother and so you're looking at these young kids you know you talk about this epidemic it's not getting better it's not like the population is of this epidemic is going down how are we going to help our kids not to fall prey to this epidemic because i mean i hear you know we've got the the resources hey let's get them treatment and all that but don't we need to talk more about prevention and making these kids understand hey these are the consequences and and not glorify it like these people that are out there dealing it i mean hey they get caught with it okay well you know what the the money and the and the prestige of being out there selling this stuff to these poor addicts i mean we need to put more pressure and punishment on these individuals so that that when they do serve a little time in their little punishment what do they do they go back out and they'll start dealing again we need to stop that accessibility for that especially for our kids i mean that's what i'm really worried about is our next generation that's growing up excellent great question i think it's on a couple key points um maybe someone from law enforcement here i think try to speak to i i think there's a lot of sympathy for what you're expressing there's nothing about burlington's response that uh doesn't believe that we need to be going after people who are doing significant amounts of dealing dealing chief for gil i just mentioned i think prevention is really the the the missing leg of this four-legged stool recovery is is very separate uh there hasn't been any comprehensive work done by the department of education and that goes back not just uh the obama administration the bush administration currently president trump has said that there's going to be a large prevention campaign i don't think i i've seen it yet but we haven't done anything since the dare program which was of course evaluated and shown not to be very effective when it came to preventing young people with drugs so quite frankly that you you know you need to start early with a age and curriculum that's specific to the grade that's part of the health care process you can give parents information for instance the partnership for drug free america their website and others that help parents but frankly we spend a lot of time in in schools and my daughter is a third grade teacher being able to teach kids a lot of other things we should be teaching them about prevention and i i think you're you know i wholeheartedly support what you said it's missing and i i think it needs to be reinvigorated chief friend thank you and i would just add um you know if i didn't say it at the beginning of my presentation you know we we take our responsibility to seek out and prosecute work with our prosecutor's office to to prosecute those that would profit from somebody else's addiction uh one point i wanted to make is that in our jurisdiction many of you may be familiar with drug asset for future funds so if we if we seize the funds from a a drug dealing enterprise or individual it goes into a law enforcement account in our jurisdiction we use those funds now think about karma here here's my boss an accent um think about karma we use those funds to to fund prevention programs and our embedded clinicians into the police department to help provide services from those suffering from addiction so a lot of that work is going on in jurisdictions throughout america josh yeah i was going to respond in a slightly different way which is that um on these issues which can become quite emotional it's very important to take a step back as much as possible and look at what um evidence is if we want fewer kids to use drugs where is the evidence of what works to help prevent kids using drugs and um you know one of the most important statistics for me was that most kids who have trouble with drugs have are having trouble with school first it's overwhelmingly they're having trouble with school and they're getting into a whole range of different issues and helping kids succeed in school is one of the most important things second thing is a stable home and kids who are in uh very difficult home situations are in very different high risk of being traumatized and having all kinds of issues that lead to drugs and so when we think about the challenges we want to help kids parents get into treatment we want to make sure that kids are doing well in school and as much as we might want it to be true arresting a lot of people um is not actually something that has been shown to reduce kids using uh drugs and in fact countries in the world that do not arrest practically anyone for using drugs have declining rates of youth use in part because um people who are using drugs get treatment quickly families stay intact and you don't have these cycles that can perpetuate um school failure and drug use just one quick point I did hear a plea for prevention in that question as well not just enforcement and um a sense that what's going on out there to tell our kids what's right what's wrong you need to know that from at least the public health department strategy viewpoint there are messaging campaigns going on that parents in this room have no idea about because they're not directed at them on the eleven o'clock news they're directed to the social media and the age group that that social media uses uh and so you may never see them but there is certainly messaging going on but in addition to meld the mayor's plea about the the opioid crisis regarding pills prescribed in clinicians and our mental health and licensed alcohol counselors concerns about our society um there's a whole bunch of things that are in prevention one of them actually is having nurse practitioners visit homes at the time someone's pregnant and about to deliver or has just delivered because all those what we term adverse childhood experiences and adverse family experiences that are present get diagnosed and referred to resources at that very early time in a kid's life you also heard me talk about Iceland and prevention models that really focus on the after school third space and then there's the whole issue of schools and we have many schools that have excellent curricula and substance abuse professionals in the schools who connect with the kids very well do we have equity throughout the state no and that's one of the charges we have now is to try to make that universal across the entire state great Brenda's question I sense could be on that topic here uh I'm Brenda Siegel and as many of you know uh the day after I decided to run for governor this summer uh my nephew died of a heroin overdose and he was the son of my brother who died 20 years ago of a heroin overdose I can't quite express how much how many times a day I say I don't want to be walk running around this state advocating for change on this issue it is not what I want to do it is extraordinarily painful for me so I just want to share that when Brandon del pozo when chief del pozo was testifying in house judiciary on h162 which is the bill that decriminalizes misdemeanor amounts of non-prescribed buprenorphine he was asked if it would make it both he was that this legislator was concerned it would be both valid and respectable to use buprenorphine if it were if it were if the misdemeanor crime was no longer Brandon pause this was my experience of it looked at directly at this legislator and said well the ingestion of buprenorphine is both valid and respectable at first I thought that I felt a calm in my body and a relaxation and letting go because that was greater than I had the day I heard my nephew died and then I realized that I hadn't felt that calm since the first day I knew that he was suffering from this disease because I knew that he and many of you are fighting for this for safety for people and willing to utilize the most current science to make this change I want to really congratulate Burlington I live in the southern part of the state in my county while deaths went down 50% here deaths went up 60% in Wyndham County and that doesn't include my nephew who died in Minnesota or people that died across the border and we are on the border of everywhere and what really made me really makes me have a challenge when I'm advocating is not embracing what Chittenden County has done to reduce death because I cannot describe to you the desperation of being a family member in that county where we don't have low barrier buprenorphine where we don't have induction in the emergency rooms where we do not have easy access to buprenorphine and to medical treatment the even though we have the retreat right there we still don't have easy access and the number of times my nephew got kicked off which led to relapse when maple leaf closed it led to relapse when he was kicked out of sober houses because they didn't take treatment medically assisted treatment it led to relapse when he was prosecuted it led to his death and what I want to say is that what we need to be saying when there is a bad batch of heroin is choose buprenorphine instead we know that it indicates a pathway to treatment and I'm really concerned that the administration has not embraced that because that is going to be a life-saving measure and for families like mine we don't have time to fix this for families like mine we do not get our loved ones back thank you Brenna I think we have time for just one last question and then we're if anyone would like to respond to that we can do that I think the point was very clear Erin welcome or sorry welcome I am Jess Kel I work for Lund and I'm the kids apart parenting program coordinator based inside the women's correctional facility where I've been for the last 11 years I deeply appreciate the efforts towards saving lives I've I can count too many clients just today I had a client in my office and we were chatting and she said hey did you know about so-and-so I've attended too many funerals of clients I've so I that piece I deeply deeply appreciate I also want to validate the comments that Philip made about trauma and I very much what you talking about aces and adverse childhood experiences and I really want to speak to family-centered treatment treatment that's gender informed as well as we need to meet the needs of children whose parents are suffering from addiction and I I do want to strongly encourage that we continue to advocate for social workers in our schools to deal with trauma after school programs and it's not just low-income people who are suffering from trauma sexual abuse happens in every economic level and while while substance abuse can affect anyone people who have experienced trauma from every economic level are far more vulnerable than those who haven't so if we're going to stop this epidemic we have to save lives but we have to make sure that we're taking care of the kids in this community and meeting their needs and that we're funding programs that do that thank you okay um well I want to say uh we're gonna do two last things to finish up tonight first I want to say thank you to the panel and particularly our national experts who've traveled here to be a part of this uh remarkable day and are gonna be with us again tomorrow speaking to 160 members of law enforcement and uh we really appreciate you taking the time to come to Burlington and be part of this conversation and thank you to everyone else up here for giving their evening and committing so much to to this effort and then last thing I believe Christine Johnson who is the executive director of the Chittenden County Opioid Alliance which is and here she is uh is going to just leave us for some final thoughts on where this conversation goes from here great thank you mayor thank you Christine thank you for everything you've done in the in this challenging role that you've really figured out how to how to make have an impact in this community great thank you mayor all right all I know it's close to eight o'clock and so I want to be brief in my remarks but first I want to tell you as the executive director of the Chittenden County Opioid Alliance just what an honor it is to be in a room with such compassionate people people who are really leading this work people who are really helping shepherd and steer this work so thank you to this panel to our national experts but thank you to all of you for being in this room for those of you whose lives have been touched as many of you have spoken tonight I honor and I salute you and so does everybody up sitting up here that the reason that we do this work is because we don't want to lose another person in our city and our state or in our nation with anywhere in the world to this hope this horrible uh opioid epidemic so thank you for joining us but what I have to ask of you is that what we know from the Chittenden County Opioid Alliance's perspective is that none of us alone can answer this call none not one organization not law enforcement not the health departments the state government local city government we all have to be in this together so if you're interested in coming and doing work on this epidemic please join us and we meet uh every uh second uh friday at first congregational church and we do um some action team some strategic planning take a look at the data to really drive what it is that we're doing and really try to systemically approach in conjunction with community staff that you've heard a lot about tonight we are really working to think about how do we address this across Chittenden County and we need your help uh we cannot like I said we cannot do this alone so we heard tonight this is a complex issue we all know that we need to lead by example I heard that tonight and that is really that really resounds with me about what we can all do individually it this is going to require solutions that we haven't even dreamed of I loved that perspective things that are very out of the box they're working here we're seeing that in the reduction in our overdose deaths we know that we need to support uh our families that we have to do better by our families by our children we have to address trauma and we have to address prevention so this is an everything under the sun and that is why we need you to join us how do we work the move uh how do we move this work forward uh really again we do it with all of you we do it in every sector we do it by addressing stigma at the dinner table at the professional table um and everywhere that we go we have to do exactly what you heard tonight which is lead by example I want to thank you for being here I want to thank you for having such great partnerships again such committed and dedicated people who are really willing to wake up every day and make our city and our county and our state a better place so thank you so much for being here you took me as well I'm gonna infiltrate the addiction programs look it's easier to get up here than you would if you were a doctor oh yeah actually um oh my god from below I know that's a terrible scope model so every clinic that we have has primary care prescribers thank you so much it was great I'll see you in the morning I was more excited so done she's by me just trying to get back it's like oh I just like I got to get this one it's the last one in sad I'm gonna get there for a while bye