Assembly Standing Committee on Health

All right, we are going to get started. Good morning, everyone. Welcome to the first hearing of the Select Committee on Fentanyl, Opioid Addiction and Overdose Prevention. My name is Matt Haney. I am the chair of the Select Committee. This is a Joint Committee with the Assembly Public Safety Committee and Assembly Health Committee, and we have both of those chairs with us today. I want to thank all of the members who are attending today and welcome and everyone from the public and all of our witnesses who are here as well. I'm going to provide some opening remarks and then turn it over to my co-chairs to do the same. And then we will invite our witnesses and our panels to come forward. We are here to discuss the most deadly and devastating public health and public safety epidemic that is facing our state. California is now losing over 10,000 people to overdose annually. That's a number that has doubled in the last five years. That increase is attributable largely to fentanyl. This is a drug that can kill a person with a very small amount. It is impacting every city and county in our state. I come from a city where we are now losing two people a day to this drug. Over 700 overdoses in San Francisco a year. But it's not an urban issue. It's not a rural issue. It's not a suburban issue. This is an issue that is affecting all of the communities that we represent. Doesn't know partisan lines. It doesn't know age. We are now losing twice as many children to overdose than we were just two years ago. We have to come together with solutions and with leadership at the scale to match this epidemic, similar to the way the state came forward when we were faced with COVID when we were faced with the HIV AIDS epidemic. We need bold and determined leadership. I want to be clear on a few things as we get started. This is both a public health and a public safety issue. If somebody is selling a pill that is laced with a drug that kills a child, that's a public safety issue. And we need to put a stop to that. And we need to put a stop to the ways that people are able to use social media and other vehicles to sell drugs in that way. It's also a public health issue. We have people who are addicted to a drug that is many times stronger than heroin, that has such strong physiological impacts on their body that they know nothing except how to get more of that drug. People who are in that situation, they need help, they need treatment, and they need care. Right now, we have over 90% of people who are addicted to opioid not enrolled in medication, assisted treatment, or other forms of treatment that can get them off of those drugs and into recovery fully. That's unacceptable. And that's something that we need to confront. This is also an issue that both requires us to address addiction and also requires us to address poisoning. We have people, as I've said, and we're going to talk a lot about this, about how we can get them into treatment. And we need to focus on that. But we also need to focus on the fact that there are some people because of the way that this drug operates and how small of an amount can kill somebody. We also have to make sure that people are aware of those risks, that they're educated, that we address prevention, and we make sure that we take every possible action we can to save lives. We are going to hear from 14 witnesses today on three different panels. One that will address fentanyl and addiction and give us an overview. The second sorry, four different panels. One that will talk about the state and local public health response. A third that will discuss the state and local legal response. And lastly, we will have a panel focused on youth and education. I want to be clear before we get started that this is the first hearing. We included as much as we possibly could to give an overview of this epidemic, what's happening at the state level, what's happening at the legal level. But it is obviously not fully covering all of the experiences and all of the perspectives. And I hope that for my colleagues that we can continue to work together to go deeper on the areas that we learn about today and the areas that were not covered today. And you have my full commitment to work with all of you, regardless of party, regardless of ideology, to work together on this issue. I also want to say that we have deep appreciation for all of the witnesses who are here and their experiences and what they are bringing to the table and for all of the work that they are doing to confront this epidemic. We are here to find common ground. This issue and this epidemic is too serious and too deadly for us to make this a political issue where we point fingers at each other, where we divide each other. We need to come together with solutions. We need to come together with a bold plan for action and leadership. There are bills in front of us we can take action on. There's a budget in front of us we can take action on. We don't need to wait to lead on this issue. So with that, I want to turn it over to co chairs and also to thank them and their staff for their leadership and their support in preparing for this committee. And I will start first with Mr. Chair Jones-Sawyer from the Public Safety Committee.

Am I on? Okay. And I want to thank Assembly Member Haney for bringing this together because at first this was a committee that he thought of on his own select committee that he asked for early on. Dr. Wood and myself. After much discussion about fentanyl, it became advantageous for all three of us to come together to come with a comprehensive evaluation of how we deal with fentanyl. We've got to unite the fight against substance abuse and fentanyl. Time to drop the rhetoric and it's time to come together. As the chair of the select committee has said, there's just too many things that can go wrong. If we get this wrong, there's too many things that down the road could have dramatic impact not only on the lives of people we see in front of us now, but in the future. As I said before on the floor, as we think about fentanyl now, let's get ahead of what's coming in the future. Xylacine and tranqu. If we do not have a comprehensive view of how we deal with this, it's not just the demand side or the supply side. We got to attack both sides. We've got to have a comprehensive prevention, protection and suppression strategy that will for the first time, we actually get to the root causes of why we got here. And for generation after generation. We've been active since the Nixon war on drugs and I don't think we've gotten any better over time with some of the policies that we've used before. So let's find out what really works. I think this is what this committee is really about, is looking at facts and finding out what works and then amplify that so that we can focus like a laser to ensure that for the first time, not only do we get a handle, but we start winning the war on addiction because we were losing the war on drugs. So let's start the war on addiction. It's just time that we all just focused on that. As Mr. Haney said, there will be other Committees and as chair of Public Safety, there have been some things said about fentanyl dealers, others falling through the tracks and may not turn to the cracks and may not being prosecuted. We need to look at that. We need to look at ways we can get more money into the public health sector. We looked at the trail of what has been spent. So five years ago, most of the money for public health on drug interdiction came from the federal government. That has dwindled down to nothing and the state then picked it up for a while now that has dwindled down to almost nothing. And so we have not made a conscious effort on the public health side in a robust way that I think in the big picture will reap benefits way more than we could ever possibly understand. It's just time that we stop it at the borders. We just stop it when it begins. Get people off of drugs, but especially illegal drugs. We just got to stop it and we've got to make people I grew up where Nancy said just say no. I think now we just say, just say hell no to drugs right now. We just got to stop it. And I thank you again for your leadership.

I want to say thank you to Mr. Chair, both chairs, for bringing this convening, this important hearing. Our state faces multiple challenges. We've got budget deficits, homelessness, mental illness, fire prevention, and on and on. But for me, none is more devastating on a human level than this fentanyl crisis. Several years ago, the legislature tackled the issue of over prescribing of opioids. Prescription numbers decreased in California by a third, approximately 22 million a year in 2016 to 14.5 million in 2021. We thought we were making progress, and we did for a while. Overdoses and overdose deaths were decreasing even with the second wave of opioid use, switching from prescription opioids to heroin. Still, the numbers were promising, and we thought maybe we could turn the page. But boy, were we wrong. We underestimated the extent to which people would go to deal their product and wreak human destruction in the name of greed and profit. And now we find ourselves in the worst position ever related to overdose deaths. Wave three fentanyl. The human toll this crisis is taking on individuals, families, and communities is, I believe, unprecedented, especially among our youth. Families are being absolutely torn apart. In 2010, 26% of overdose deaths were in the age group of zero to 34. In 2021, the percentage had increased to nearly 40%. And it's rising. I've heard one addiction specialist say that the average age for opioid overdose death used to be in the 45 plus age range, sometimes death occurring after a lifetime of addiction. Today, the average age is less than 45, primarily because of fentanyl. Today, as abhorrent as it sounds, people are being killed even before they have an opportunity to become addicted. The human and societal costs and implications of this crisis are random and occur where one wouldn't even think of. I represent some of the least populated, most rural counties in the state, and I can assure you this is not a big city problem. Last week, my office received a call from mendocino county, population about 80,000, where fentanyl related deaths increased nearly 350% from 2019 to 21. They were inquiring about the availability of funds to help defray the hidden costs of the crisis, that of managing fentanyl related deaths in the coroner's office and the sheriff's department. They are simply overwhelmed and can't keep up with the laboratory and manpower hours required. So on the one hand, we have the very real and devastating human reality of lives ended, with fentanyl deaths being a sidebar to the business of manufacturing and dealing fentanyl for profit, no matter the cost. And on the other hand, we have the very real implications of the crisis as it relates to the inadequacies of our systems of sud care, the burden placed on institutions of service whether it be our courts, jails or coroner's offices. This is a multifaceted, complex problem and often divisive issue in which we struggle with the balance between personal health of individuals, public health concerns for our communities, public safety concerns, and a myriad of other aspects of fentanyl in our state and our nation. I'm looking forward to today's hearing to better understand the efforts underway and the challenges faced by our health, legal and educational communities so we can hopefully address this crisis with a holistic approach, with comprehensive policy and programs that best serve our constituents. We are in a unique opportunity as the legislature to push on state agencies, to push on budget priorities, to make significant change. I think people who have followed our work in the past or my work in the past, I talk a lot about prevention. As a state, we fail miserably at prevention. It's often prevention is often pushed aside because we budget from year to year. And prevention requires long term sustained investments to see long term sustained results and we simply don't do that. And if you could just invest for every dollar you can invest in prevention, you could save $6 on the treatment end of that. So here we are repeating that cycle over and over and over again at the cost, human cost and a societal cost that is enormous. We have to end that. We have to begin to shift our paradigm and invest in those strategies, those things that can help prevent this future use, prevent people from dying and begin to move past some of the other challenges we have here. So I look forward to this and I'm, as usual, not going to be shy to push on some of our agencies to get on board and help us out. Thank you.

Thank you to both of the chairs and for all the members who've joined us. We are going to get started with the panels. I just want to reiterate some of what the process will be. We have four panels today. Each of the witnesses will have three to seven minutes to testify. And the way we are going to do this is I'm going to call up each panel individually and then for members, we're going to have each of the witnesses present and then questions and comments will be available. After the entire panel presents, then we can engage with the panel collectively. We also are not accepting public comment over the phone today, but you can submit written testimony to the Committee at Assemblymember.Haney@Assembly.CA.gov. And we will also take public comment at the end of the hearing in person. So want to make sure that's clear. And so with that, I want to invite the first panel. We have 14 witnesses here, so we have a lot to cover and we're again very grateful for all of you and your time today. The first panel that I'd like to invite up to provide an introduction on fentanyl and addiction. We have Professor Keith Humphreys from Stanford School of Medicine. Laura Didier from Song for Charlie, and Aimee Dunkel from the Solace Foundation. Dr. Humphries, welcome.

Good morning.

The mic button there.

Perfect. Good morning. Am I on? Thank you. Well, Chair Haney, Chair Jones-Sawyer, Chair Wood and Vice Chairs of Standing Committees. Thank you for convening this hearing, and thank you for giving me the chance to talk to you and your distinguished colleagues today. I've been asked to give some background information so that all of us can start this process on the same page. Everyone in the room, and also anybody might be listening online or watching. So let's dive right in. First, what is fentanyl? Why is it different than other drugs? Well, fentanyl is first synthesized in 1959. It's an opioid like morphine, like oxycodone. It's designed to relieve pain. But how it's different from other opioids is that it's very efficient at crossing the blood brain barrier. That means it has a very fast and strong effect. This makes fentanyl very useful in medicine. If you've had surgery, you've probably benefited from fentanyl. But you take a drug out of the healthcare system and you sell it in illegal markets, and it can become very dangerous. The ability of fentanyl to produce euphoria at a dose as small as one 50th that of street heroin makes it very addictive for everybody, but particularly for young people, because their brains are still developing. When it's not taken at precise doses, the risk of overdose sores. And just let me make it concrete for you. If I had a pound of pure fentanyl powder in front of me, and I cut it into 500 equal sized pieces, and I took just one of those little pieces and I cut it into 500 pieces, one of those little pieces, 1500 of one 500th of a pound is enough to cause an overdose of fentanyl. Because it is so small and potent in small amounts, this makes it very hard to interdict. Experts at Rand estimate that our entire annual consumption of fentanyl, illegal fentanyl in this country is less than ten tons. That means, literally, you could fit all of it on any one of the 5 million trucks that cross the Mexico US. Border each year. Second, how did this drug become so dominant? Well, we talk about disruptive innovations all the time. Silicon Valley. This is a disruptive innovation in illegal drug markets. It is unlike heroin, morphine or any other illicit opioid in that it doesn't require agriculture. There's no farm anywhere. All the supply chains are gone. That means it can be made far more efficiently and cheaply for traffickers. In that way, it is like methamphetamine. It is like Xylazine that gets rid of the supply chains, removes a lot of interdiction opportunities, and means that in the end, fentanyl is probably going to outcompete heroin to the point that there is no heroin left in illicit drug markets in California. This has happened back east. This can happen here because the profit margin is so large. The other thing about fentanyl is it's so potent that people use it more and more each day than they would even heroin. So it's cheap to make people use it a lot. That makes it very profitable. That's why many people ask me, why would you sell a product as a drug dealer that kills people? It's because it's so profitable you can afford to before they die. You make more money in six months than you would a decade selling people heroin. That is a very cold-hearted calculation. But these are not nice people. They just want the money. Fentyl has been sold in significant quantities east of the Mississippi River for almost a decade. It's moved west from about 2017 to 2019. The share of fentanyl deaths in the United States that happened west of Mississippi went up 371%, and it's only gone up since that point. Third, what do we need to do differently in light of fentanyl and other synthetic drugs? So let's start with state and local law enforcement. A big part of what our police officers do is they do drug seizures. And unfortunately, drug seizures do not have the same impact on a synthetic drug as they do with an agriculturally derived drug. Because you don't need to wait if you're a trafficker for another growing season in Colombia. You don't have a long supply chain to have to refill things. You can, that night, make up the extra fentanyl that was seized in a lab, which could be in Mexico, it could be right here in California. Domestic law enforcement still matters, but only if we give police a mission they can reasonably fulfill. Specifically, they can use evidence-based strategies to deter some of the worst harms of illegal markets, like street violence and the open air markets that are destroying neighborhoods in some of our cities. I want to be very clear that does not mean arresting every person in sight. There are evidence based strategies that involve police working with communities side by side with health professionals that have closed down markets in other cities. That does not get rid of drug use, nor does it get rid of drug dealing. But that's not the point. The point is improving the quality of life for families in these very tough neighborhoods. I volunteered in an agency in the Tenderloin. You have to see it to disbelieve how tough it is for families to live in that neighborhood. We can make them safer, happier and healthier by at least getting rid of the open air aspect of the market. That also helps businesses that otherwise might go broke or leave. Criminal justice system can also do good work with people who offend over and over, and drug addiction is the cause by giving them the option of drug court supervised treatment instead of just locking them away. On the health policy side. What do we have to do? Well, we're lucky that our FDA-approved medications like buprenorphine, like Nltrexone, seem to work pretty well for treating fentanyl addiction. We also have some good behavioral treatments like contingency management that not only works for fentyl, but also for methamphetamine, which is a big problem for us in California. We have to make sure everyone has access to those treatments. We've done a really great job in the correctional system, and I just have to applaud Assembly Member Waldron and Dr. Wood too, for really making sure that people who are incarcerated on parole are getting these treatments that's going to be life saving. Everyone else needs them too, obviously. So we have to look at things like, what is medical reimbursed? Our providers actually prescribing these in all our various counties, because if it's not financially viable, people will not do it. And we have to get private insurers to do their part. We have good federal and state laws mandating parity in insurance, meaning that you have to provide good benefits for addiction treatment, but companies don't always follow them. That means we need our regulators to work hard to make that happen. In terms of other public health strategies, there are some challenges adapting Naloxone to this new world where people might be taking fentanyl, methamphetamine, and Xylazine put together, but it still works incredibly well. Naloxone is a cheap, life saving drug. We should be pushing it out everywhere to high risk groups, but also high risk locations like libraries, like bars, like restaurants. And I know you know this chair, Hahana. You've been doing it. We also want this new over the counter Naloxone, which is a big innovation to be covered by insurance. And I believe Assembly Member Ortega has a bill to that effect because it's too much money, $50 for a lot of the people. We want to want to get it, so we want to have insurance cover that. Even as we press forward this is a very sad thing to say. Even as we press forward with treatments and supports for recovery from addiction, with overdose rescue, with health services like syringe exchange programs, we have to be realistic about what we can achieve with people who are currently addicted. Very tragically, a number of people who are addicted already are going to die of an overdose or they're going to be addicted for many, many years, causing great suffering to them. And this brings us to a truth about epidemics. Whether it's COVID or fentanyl or HIV AIDS, in the end, you can't end an epidemic by only working with the most severely affected people. You have to prevent new cases, and that's why we have to think preventively even as we're trying to keep our fellow citizens alive. Now, when I was starting my career, there was the Dare program. It was used a lot and didn't work very well. It kind of gave prevention a bit of a bad name to say, that's not fair. There actually are very good today evidence based prevention programs that have been shown to work in diverse communities. That not only help kids develop well so that they don't have problems with drugs, but also less likely to drop out of school, less likely to have mental health problems. We need to be having those for all our kids in California. We can supplement that with public education programs. I know there's still a lot of young people who don't understand that there are pressed pills selled online that are labeled Adavan or labeled Adderall, but are in fact Fentanyl, and they take them and they die. They have no tolerance for opioids. Every time I give a talk with this, I'm shocked. Still, there's so many people don't know that we could have public education about that. And also public education for parents to tell them, any addictive medication you have, no matter what it is, be sure it's locked up just like you would lock up your liquor cabinet. Lock up your medicine cabinet. So it's hard you said it so well, Dr. Wood. It's hard to invest in prevention because you have to be patient to see the benefits accrue, but they really will accrue. I've worked with a number of you, and I know you do have the vision and leadership to make those investments for the long term. Because as much as we really want to help Californians who are addicted, it's obviously even better if we can help them not get into that very awful situation in the first place. So thank you very much for having here, and I look forward to the discussion.

Thank you so much, Dr. Humphreys. And again, we're going to hold questions for Dr. Humphreys until the end of the panel, and I want to welcome Ms. Didier.

Thank you. I'm very grateful to be here today. So many of you I've had the chance to get to know. I'd like to acknowledge Assemblyman Patterson. My son died in Joe's District, and he's been a staunch supporter on this crisis and for my family. Very grateful to you, Assemblyman Haney, for inviting me to bring my voice to this discussion. I'll get through this, I promise. My name is Laura Didier, and on December 25 of 2020, I was enjoying the holiday with my parents and my three beloved children, Allie, Sam, and Zach. My children are my world, and I was extremely proud of the beautiful people that they were growing into. Zach, my baby, on my pen here. He was 17. He was a senior at Whitney High School in Rockland. He was a straight A student, an athlete, a self taught musician, a kind friend to all, a loving boyfriend, and an all around amazing kid. Two days after that fun, festive holiday, I watched a coroner take my son out of his bedroom. Zach had no medical conditions, nor was he struggling with any substance use issue. We were blindsided by his unexpected and tragic death. There were no drugs found in his room. It wasn't until we were able to open his phone the next day that we were able to put the pieces together of those fateful last two days of his life. Zach purchased what was being marketed as a Percocet pill. A dealer was operating on Snapchat, putting up menus of these drugs connected with my son at the gallery and mall in Rockland. He and a buddy each decided to experiment. Try a Percocet pill. Those pills must not have had much fentanyl in them. That's what's so sinister about these pills. They're not made with any content, uniformity. One pill might contain very little. Unfortunately, two days later, Zach decided on his own to try one more. And that pill killed him very quickly in his bedroom overnight. And there are no words to express the excruciating pain of losing someone so young, so precious, with such promise to a danger you didn't even know existed. And Zach's story is becoming all too common in our state. Fentanyl has irreversibly changed the drug landscape into this nightmare that we are witnessing today. I am not the only mom who has found their child dead in their bedroom. And bereaved parents like myself and Zach's dad were sharing our stories to warn other families, to warn other parents, to warn kids. And I'm so grateful to hear Assemblyman Wood talk about the need for primary prevention. It does work. Since I lost Zach, I began working with a nonprofit called Song for Charlie. We are directly focused on education, primary prevention, creating content aimed at students and their families to educate kids on what's going on. We've conducted targeted research to find that only that two thirds of students between the ages of 13 and 17 are not aware of counterfeit pills. To echo what Mr. Humphreys said, we think everybody should know, right, because it's in the news a lot more, but a lot of these kids don't, and their parents don't. But fentanyl is what's killing them, yet they still rank heroin and cocaine as more dangerous. This knowledge gap is killing our kids. It is imperative that we fill that gap with information, and I know that they are responsive to it. I know because since the beginning of this school year, I have spoken in front of probably upwards of 70,000 high school and middle school kids. And their parents, they receive this information willingly and gratefully. They know that this is killing their peer group. They need to see that us adults care about them. And at Song For Charlie, we've kind of taken that just say no, no. And we've changed that to just say no with a K. Know what's out there. Know about the deception. Know how lethal these drugs are. Know what an overdose looks like. Know when to call for help when your friend is in trouble. Know that you won't get in trouble for calling for help. And these kids come up to me afterwards and they say, thank you. Thank you for educating me. And all of us parents that do this work. Thank you for letting me know what is out there. I've had parents call me in tears to say, my son was at your assembly. And it opened up a conversation. I didn't even know they had tried some things, and they said, I don't want what happened to that boy to happen to me. So it's really important that we invest in our kids, and we invest in educating them and protecting them, and we send the message to them that we care. So I really appreciate being here today.

Thank you, Ms. Didier, and on behalf of the committee, we're so sorry for your loss and thankful for all you are doing to educate others and for your advocacy. And we're very grateful that you're here today. Ms. Dunkel,.

Thank you so much for inviting me here today. My name is Aimée Dunkle. I am the founder of the Solace Foundation. I'm also on the board of Broken and More, an international advocacy organization working to change harmful policies affecting people who use substances. Additionally, I am on the board of Grasp, an international grief support group for those who have lost a loved one to substance use with almost 20,000 members. My life has been directly impacted by all three phases of the opioid crisis. My husband and I lost our 20-year-old son to an overdose. Ben's first overdose occurred at his high school when he was 16. We had no idea our son was using substances, that he was battling depression, or that he was being bullied. All this became apparent when he was released from the hospital. Ben acquired pills from his best friend. The same friend who sat with us as Ben died four years later. The same friend whose life was later saved with the naloxone I distribute. The transition to adulthood was a difficult one for Ben. In November 2010, he broke his arm and was prescribed opioids. At the time, he wrote a poem about how good they made him feel. His substance use became more problematic. In March 2011, a friend who had been supplying him with pills offered Ben a cheaper opioid. He called it BTH. Ben smoked it, oblivious that the acronym stood for black tar heroin, he sank deeper into the abyss. He was now physically dependent on heroin. Following several overdoses and months of despair, Ben entered the world of treatment. Four days into his first day in a sober living home, we found our son snoring loudly at the facility in the middle of the afternoon. By the time we got him to the ER, his oxygen levels were dangerously low. We have no idea how long Ben was starved of oxygen. Ben cycled in and out of an intensive outpatient program. The program used Suboxone, but only for detox. I kept noticing that Ben was more like his old self. Each time Suboxone was initiated, then tapering would begin. Relapse would follow the pattern continued. Ben felt so much better each time. He started suboxone protocol and asked if he could stay on it. The program denied his request, so I took him out of network. He started buprenorphine maintenance. However, he missed the structure of the outpatient program and the friends within it. He was lonely and isolated and asked to return. He was allowed back under condition that his suboxone was surrendered. Ben handed it over and the facility used it to detox him. Another overdose followed, which led to several misdemeanor charges related to his substance use. These charges were used to coerce Ben into treatment. Ben's first impatient treatment sorry. Ben's first impatient treatment resulted in his transition from smoking to being injected with heroin in the facility. Ben had been transferred to this facility straight from a psychiatric hold. He was at his most vulnerable, both physically and mentally. He had given up on life. He overdosed again within days of leaving the facility. Ben spent 54 days in a residential treatment center before his death. The overdose occurred in a car with three others. A friend from high school supplied and injected Ben with the heroin. The friend was in a drug diversion program. When Ben stopped breathing, he panicked. He would not allow the other two to call 911. He was terrified of being returned to jail. We later learnt that Ben was injected with what law enforcement referred to as a hotshot of heroin. Ben's friend had no way of knowing the strength and purity of the substance. He had no intent to kill our son. They used substances together many times before. In the final moments of Ben's life, I held him and I promised him that beautiful things would happen because of who he was in life. The Solace Foundation is my gift to Ben. I have distributed more than 50,000 doses of naloxone and I've recorded over 2600 overdose reversals. The first time I administered naloxone to save a life was an extraordinary moment for me. The young man I saved returned with flowers from his mother in gratitude. Sadly, two years later, he relapsed. He found himself back on the streets. He died the same night he was arrested in a jail cell. It broke my heart. More recently, I administered naloxone to revive a fentanyl overdose. The young man collapsed just yards from me. By the time he hit the ground, he was already blue, his upper torso rigid and his eyes rolled back in his head. It took two doses of naloxone to get him back. I cradled him in my arms as the second dose took effect. A chilling reminder of the rapidity of a fentanyl overdose. We are at a pivotal moment. How we move forward will determine who lives and who dies. There will be no perfect solution. But we can protect more or we can hurt more. My heart goes out to everyone who has lost a loved one to fentanyl. I understand the pain that many parents are feeling at losing a child to an overdose. However, we should not let our emotions clown the vision of solutions that could help keep people alive. We have children purchasing what they think are opioid pills and getting lethal doses of fentanyl. This is tragic. When you purchase an illicit substance on the black market, there is always the risk of deception. These children may well have been deceived. So were all our children. My child, too. This is what a black market does. It deceives because we do not have a regulated, illicit drug supply. We never have. The call for more punitive punishments adds another layer of fear for parents whose children are struggling with an opioid use disorder. Another layer of shame for the parents whose children are incarcerated. Another layer of despair for the parents of the black and brown children who bear the brunt of incarceration to propagate stigma and shame. In this third and most deadly phase of our country's, opioid crisis is wholly inappropriate and will lead to more deaths and far more suffering. It will not protect young people who want to illegally access prescription pills any more than it will protect the adult who suffers an untreated or poorly treated substance use disorder. The word used to describe how a child dies, poisoning or overdose does not make the loss any less agonizing to a parent. My heart is no less broken. Our pain is the same. We need to follow the science and fund what works. Fentanyl kills, but so does shame, criminalization fear, stigma, and silence. Thank you so much.

Thank you so much, Miss Dunkle, and and we're so sorry for your loss and thankful for your work, your life-saving work and and advocacy. I also want to acknowledge there are other family members here who have lost loved ones and also who have children who are experiencing addiction. And we welcome you and thank you for being here and for your advocacy. I want to open it up to the committee now. I know Dr. Wood had a few questions to start, and then I will work through the other folks.

Thank you, Mr. Chair, and thank you very much to the witnesses. I don't see how anybody can sit here and not be moved by what we've heard today. And I thank you for coming forward and sharing that with us. I know how painful that must be. My questions are in respect to the number of people here asking questions. I'm going to start by asking a couple of questions to Dr. Humphreys. I don't want to put you on the spot, but I want to put you on the spot, and I just like to give if you can give us an idea. I know your work extends far beyond California. Can you give us an idea of what might be working in other states, in other countries? And are there any standouts? I don't think we have time to reinvent the wheel here in California. So if there are things that are happening and working, what are those? And can you point us in the direction of some things we might be wanting to consider?

So I think we can take some learning from what's called hub and spoke models of care which have been started in New England and there's been a little bit experimentation in California. And what this deals with is the reality is a huge number of clinical providers are not comfortable treating addiction. They're scared of the patients, or they maybe they don't like the patients and they feel they're out of their depth, and then they shun them and then people die as a result. So the way they set this up was they had specialists, people who maybe worked in a methadone clinic or they were an addiction psychiatrist or an addiction specializing nurse to back up primary care providers all over the state and say, look, you can go ahead and prescribe the buprenorphine, but I'm here for you. I will coach you. You get a difficult situation with the patient. I've dealt with these many times. I'll talk to you. And they found that hundreds and hundreds of patients started getting into care once doctors felt there was someone behind them to back them up. And we really need to do that because there's not that many specialists in the United States. You've got to activate a primary care as we would for any other condition. Primary care doctors are very important for dealing with depression, dealing with HIV, but they haven't had that engagement on this issue quite so much. I also think in terms of expansion of naloxone, everywhere that has done that has profited in terms of reversing overdoses, getting out as many places as possible. I just try to think of it like a fire extinguisher. I don't want there to be a fire, but if there's a fire, I want to have a fire extinguisher. So when I walk into a library or a house or I want to see one of them there, it needs to be that, I guess, mundane, that this is just something we do. Sure as we got fire extinguisher, we have those shock paddles too. Those things work. And I think that's worked in other states.

And a follow up. And thank you. Thank you for that. And I'll just editorialize on something before I go into that. Naloxone is not a very expensive drug to manufacture right now. It's pretty inexpensive. And I will say I am pretty appalled at the price, the cost of naloxone to people. And as a huge impediment to getting that out there, I believe we could be doing a lot better than that. And I'm really disappointed that to see the price so high, the cost so high. And my final question from a policy perspective, what should we avoid? What policies have ended up being really detrimental to trying to fight this crisis in other areas.

So I understand that people get very angry at street corner drug dealers. I don't like street corner drug dealers either, particularly. But to yield to that impulse of anger, to say, let's start putting those folks in prison for 5, 10, 20 years, that will fill up prisons for sure, but it will do nothing to alter the course of drug markets that is the most replaceable labor on earth. I mean, literally, you can find a new street corner drug dealer faster than you can fill a job flipping burgers. And we did that in the 80s, 90s it had no positive effect, and it destroyed a lot of communities who were disproportionately punished. Where you want to use your power to punish is on people with unique talents and skills who are very hard to replace. So if an accountant who can take $10 million in small bills out of a city's drug market, wire it to Europe, convert it to Euros, get it into an account in the Caymans, and no one can figure out how they did it? That case yeah. You want to go after that person? Because that's really damaging to a drug trafficking organization. But the people at the bottom, you can punish them all day, and they'll just be immediately replaced. And other thing, of course, is if you prioritize doing that, you're filling up cells that you might want to have people who've done other things in. Right. If we super criminalize low-level drug crimes, we effectively decriminalize going after rape, arson, murder, because there's only so much resource in the criminal justice system. So that, I think, was the big mistake of the early 90s that I would hope we would not repeat.

Mr. Muratsuchi.

Thank you very much. I want to thank the chair for allowing me to join this very important hearing today. And I want to start by thanking Ms. Didier and Ms. Dunkle for sharing your personal experiences. As a father of a teenager, I have definitely had that conversation, many conversations about all the dangers of fentanyl and how it's inextricably related to the overall opiate crisis. I want to follow up on Dr. Wood in asking Professor Humphreys. So I think you just stated loud and clear that we should not repeat the mistakes of the by focusing up on locking up low level offenders and dealers. At the same time. In your opening comments, you talked about how the drug seizure approach is ineffective for drugs that can be easily manufactured like fentanyl. But at the same time, you said that it's important for police and community to work together to crack down on the open air markets. Could you expand on what exactly you would propose in terms of the most effective strategies to crack down on these open air markets?

Yes, I'd be happy to. So we would follow the example of cities like High Point, North Carolina, or what Boston did with the Boston Gun Project. That's where you make a realistic appraisal that there's always going to be criminals, there's always going to be drug use and dealing. But you can shape their behavior through deterrence. And they used a program called a call in where they would bring in the drug dealers, call them in and say, look, we've got photos of you on ... We could arrest all of you right now, but we'd rather not do that. What we want to do is change your behavior and get you out of this business. And your families are here. We've been working with them and they would like to talk to you that they would like to see you out of this business. And if you need mental health or job services, we have those providers there to help you. We're giving you as many options as possible. We know that some of you are going to continue maybe carrying a gun, I'm sorry, dealing drugs and all that. But we're telling you our number one priority in this community is open-air drug markets and violence. And so if you do that, we will come after you for everything, even your overdue library books. We're giving the game away. We're telling you the rules right now. You don't know what you're going to get busted for. We're saying that is our number one priority, and everyone in this room shares that priority. Places that have done that have had dramatic drops in gun violence and dramatic drops in community disruption and disorder. Now, sometimes when I bring this up, they say, but isn't there still drug use and dealing? Yes, there's still drug use and dealing. I wish that weren't true, but it is true. But there are many, many communities around the country that have drug use and have dealing and don't have violence. They're called suburbs. Everyone deserves to live in that kind of community. I'm sure there's drugs where I live. And yet the streets are safe. Families can raise their kids. We should give that to every person in California.

So when you talk about focusing attention on whether it's taking photographs and bringing them all in, is part of that solution part of that approach? An increased presence of police, of law enforcement to crack down on these open-air markets?

Yeah, you have to commit law enforcement resources, but you also have to commit health resources. A lot of the people in those markets are addicted. They need treatment. If you give them immediate access to care, they will take advantage of it, especially if they know the market is closing down. And you need family involvement because many people are trying to reconnect with their families. Families also need to reclaim the street for themselves. So everyone has to work together. It is not true. You can just parachute in a bunch of police and do a bunch of arrests and the community gets better. Nothing really changes when you do that. Thank you.

Good morning, chair. Thank you for hosting today hearing. I want to say thank you to the mothers who are here today. I want to say Ben and Charlie are here with us. Zach. Sorry, Zach. Before I became a Legislator, I'm a mother. I have four kids, and my youngest just went to prom a couple of weeks ago. And this is my worst nightmare, listening to your stories. And while I can say I commend your courage, I cannot say I feel your pain, because it's not a pain that any parent ever, ever wants to feel. So thank you for being here. As a Legislator, I want to thank the doctor for mentioning AB 1060. It's a bill that I authored as soon as I heard that the FDA was going to make narcan available over the counter. Unfortunately, while it's a medicine that's cheap to produce, it expensive to the average family and to a mother who's struggling to just put food on the table to be able to purchase a medicine that they may or may not use, but could save a life, could make a difference. And while we think about as Legislators and the Governor, and we look at the cost, right, a lot of things that we talk about in this body is cost. And we're looking at a deficit, I think about how much does it cost to really save a life? How much is my daughter's life worth? How much is your son's life worth? And that's really what I hope the Governor is listening to, what our colleagues in the Senate are listening to when they think about what can we do today to save lives while thinking about the future and addressing the public safety component to make sure that we stop the distribution of these drugs and having them come in. And so I have a question for the doctor. We keep talking about how cheap it is to produce narcan. How would insurance coverage of this drug help this epidemic?

Thank you for that question, and thank you for introducing that bill. So many people don't necessarily know that usually your insurance doesn't cover over the counter medication, like when you go in to buy your cough medicine or insurance like that. You can't or aspirin it won't. So actually, for some people, it actually is more expensive over the counter, because if you get it from the pharmacist, then you can get reimbursed by Aetna or Blue Cross. So these are being marketed at about $50 for a two dose packet. That's a lot of money for a lot of people to have, again, as you say, for something they don't know if they're going to use. And so if it's insured, if we say that if you want to do business insurance in California, you have to contribute, let's say, $50 to the cost of that, then people could pick it up for nothing or nearly nothing. And we could do that in Medi-Cal as well. It wouldn't cost that much. And, you know and, you know, it saves a lot of lives. I mean, there's very few things in my entire career I've seen that have a return on investment in health like naloxone does. It's really miraculous.

Thank you, Mr. Chair, and thank you for having this meeting today. I do want to start off by thanking the moms for being here and I know the struggle that you're going through and I also commend you for your courage in being able to speak out and help other families back in. I think it was 2000. I first became involved in this issue of opioids when I was serving on a local government and parents wheeled in their son who was the high school football quarterback, now in a wheelchair due to opioid, then heroin addiction. And I wasn't a mom yet, but I am now. And I remember sitting there and I had not heard a thing about this and it was on the East Coast and it was starting to come towards the West Coast and they were warning us about it. Some of the local sheriffs had put out the information and was holding meetings around the county and education became the big thing. And I just want to highlight that because you mentioned the black market and the black market. There's individuals that could not even be in this country who are lacing these drugs. They have an intent to do something. Then we have the people that are on the street that are selling it. That's just one segment. But I think the biggest war that we have is the education part of it. Because if we could get everyone to understand what's going on, we can fight that black market because I don't see how we're going to be able to do it when there are these ephemeral groups outside of the country that we can't even get our fingers on. That being said, the education part is such a big thing and parents, as Mr. Maratuschi said, you have to have that conversation with your kids. But if the parents don't even know about it, that's I think, a critical step. And talking to the kids about it absolutely important in this battle that we're in, talking about how the opioid drugs came and they use from the East Coast. You had mentioned Professor Humphreys about fentanyl. Now the same thing we're seeing, since it's not a new drug by any means, what accounts for this spike in fentanyl use at this time?

So initially it was unintentional for most people. This was not something that people who were using drugs called for. It really came from the supplier side because it costs about 1% of the price of heroin to make fentanyl. So traffickers wanted to make more money and they started to introduce it without telling people. And so we had a wave of overdoses and people, some of them, by the way, people knowing using opioids, but also sometimes people using methamphetamine and cocaine and getting exposed to fentanyl. But those who survive it then become addicted to it and then ask for it by name. So if you look in East Coast markets where it's been there for a while. It's no longer people being exposed to Fentanyl by accident. It's actually asking, I would like to buy Fentanyl. That's what I want. That's where it came from. It's just very profitable for them. It's an awful thing. Like I say, they're awful people, right? It was more lucrative, so they did it.

Just one quick follow up. We're talking about treatment options, we're talking about getting people into treatment. But in order to have goals, we want to make sure that what we're doing actually is effective and is saving lives instead of just a lot of money is going into this war on drugs and we're not seeing the results we need to see. How can we measure? We need some kind of metrics on the treatment and basically pathways for recovery, not just hospitalizations and deaths. I mean, how do we know when we're actually achieving something? How could we measure? Is there any type of template for that?

You're absolutely right, of course. We don't want there to be overdoses, but the limits of our ambition can't be, let's just have fewer people overdose, but then we're going to have millions of people who are addicted. And being addicted is terribly difficult for individuals, for families. And so we want to have people get into recovery. I think the most fundamental thing we need to do to make the quality of addiction care better is to move it boldly into the rest of the health care system. It sort of exists out there as a country cousin. It's sort of less connected, less resourced, less prestigious stigmatized. And if we did that with cancer care, there would be riots. And so we just need to bite that bullet and say, this needs to be a part of how healthcare system works. How every doctor is trained, every nurse is trained, every psychologist, social worker. And then we can use the quality mechanisms we have in healthcare systems already, because we have a bunch of them that inspects quality of care, patient satisfaction, outcomes, cost, all that kind of stuff. That, I think, is why there's been these quality problems. We've sort of shoved it out there as a second class system.

Thank you.

Before I call on the next colleague, I just want to reiterate for everybody, we have eleven more witnesses and three more panels. And I know there are a lot of great questions being being asked, but if people could try to keep their questions and comments to under two minutes if possible, so we can get through all of that. With that, we have seven more folks who want to speak on this one. So Mr. Jones-Sawyer.

I'll make this as quick as possible. I want to thank Ms. Didier and Dunkle for testifying at Public Safety. I want to thank you personally. I have a son that's in college right now, and when he went away to college, as a lot of African American families do we tell them as a father? Premarital sex, make sure you're protected. They gave them some condoms. When I said, if you get stopped by the police, it's 10:00 and 02:00. Make sure your hands are visible. And then I told them, drink some water if you're going to drink, so you can dilute it. Never thought about talking to him about taking drugs. I know what you're feeling because when I called him and had that difficult discussion, he said, Why are you talking to me about this? And then in the middle of it, because he got really frustrated. He said okay, dad, but what's fentanyl? And I was devastated. Devastated because I'm the Chair of Public Safety and my son really didn't know the effects of fentanyl. So on the prevention side and my question to the Doctor is, what are those signs? What is it that we can see? What would have helped these families to know ahead of time? Is it trauma? Is it depression? What is it that you might be able to see that could help stop people from buying illicit drugs? Because hopefully they're not prescribed drugs, but buying these illicit drugs that are laced with fentanyl, how can we how can we figure that out so we can have that difficult conversation? Because I will tell you, it was difficult having that conversation with my son.

Well, one of the things that's just so scary is sometimes there are no signs. There's literally a kid has been doing great at everything. Happy, achieving, loving, and it's just really horrifyingly bad luck. They take a pill at a party. A friend who doesn't want to hurt them gives them and says, you should try this. And it turns out to have fentanyl in it. That's why it's so scary. And I say this as a parent. I have two teenage sons, and we talk about this all the time, about when I was a kid. Drug prevention was very way too scary. If you touched cannabis, you were going to end up dying of a heroin overdose and one pill could kill you. And what I tell them now is, I hate to tell you this, but the lies your mother and I heard when we were little are now true. One pill can kill you. And there was very little time between when that happens and when you are lost to us forever. And that's why everyone's so scared. It's definitely true. Kids who have mental health struggles, kids who are isolated, have higher rates of risk for all kinds of things. But it's also true sometimes it really is. I think, as was said very beautifully, just like this lightning strike.

Thank you, Ms. Petrie-Norris.

Thank you. Thank you, Mr. Chair. And I, too, want to begin my comments just by saying thank you to Ms. Didier and to Ms. Dunkle for being here and more importantly, for the work that you are doing each and every day. As I've said to you before you get up each and every day to educate our kids and to save our kids. And my commitment to you as a mom and as a legislator is that we are going to do everything in our power to make sure that we are keeping California kids and our communities safe with that. I feel like the central challenge before us as we're grappling with how to respond to this crisis is how do we ensure that we are investing more in treatment, in prevention, investing more in narcan and in education and resources that can support folks who are struggling with addiction and low level dealers. We need to also balance that. In my view. And Dr. Humphreys, I think I heard you say the same thing, we need to balance that with stronger penalties and enforcement and deterrence for high level traffickers who are knowingly leaning into a tremendous business opportunity that is killing California kids. I guess my question and the challenge that I've been grappling with is how do we draw that line, particularly with a product that is so lethal and so deadly. And in your opening comments you outlined the fact that I think it's two milligrams, so two milligrams of fentanyl, it's two grains of sand is enough to kill. So shown this packet before, this is 2000. This is 2000 lethal doses of fentanyl. So how do we draw that line between who needs support, who needs treatment and where do we need deterrence to keep traffickers from importing this stuff and killing our kids?

Yeah, that's a very hard question and I always try to differentiate who makes me mad and who I want the law to come after because there's lots of people who make me mad. But the world will not be a better place if every person who does a fentanyl deal ends up in jail. I mean, part of this is about the Federal Government, right? I mean the California can't really secure international borders itself. I mean, Federal Government is doing lots of things but as I mentioned, it really is a needle in the haystack kind of situation when you only probably total consumptions make 5, 6, 7, 8 tons and we import millions of tons of avocados every year and just try to imagine find where that fentanyl is. I think we have to accept the limited ability to do that. We should try, but I don't think we're going to meaningfully dent the supply flow. There are definitely opportunities for law enforcement to take out, as I mentioned, unique major players. So people who can import huge quantities because they have incredible connections all over the world, the people who can encrypt communications extremely well, the people can move enormous quantities of money around the world. Those people are when you remove those people from the equation, that really hurts trafficking networks and it's worth putting those people away. But there aren't that many of those people. The more common person is someone who's extremely replaceable and probably also redeemable. I mean, quite a few of people who deal in low level drugs are also they may have, like, a regular job and they're trying to feed their families. And I don't approve of what they're doing. But there's still opportunities that they could turn out to be a decent, contributing citizen at some point, which will not happen if they're sent away for 20 years into a correctional facility and just the treatment. I just agree with you. I think we've had conversations before about the need for quality treatment in California. And I just think we need to think of it like other forms of health care. We do not go in the cheap for cancer, for heart disease, for other illnesses, and expect good results, but we often go for the cheap in our substance use treatment. And surprise, we don't get great results. We just have to resource it like any other healthcare service, any other life-saving health care service.

Mr. Patterson. Jim Patterson.

And thank you, Chair. I appreciate the hearing. And as you mentioned earlier, there will be others as we dig deeper into these. But I did want to remind us that there is something that has been done that could be done and is available to communities. Because last year, this Legislature, the Governor's office, worked together on a bill that I authored, AB 2365. It was establishing six pilot projects throughout the state, focused on increasing awareness and educating about the dangers of fentanyl. It was patterned after the FORT program in Fresno County. F-O-R-T. Fentanyl Overdose Response Team. And this has sort of been the blueprint for these pilot projects. Now, there's $5 million in the governor's budget. We asked for three, he gave us five. We appreciate that. That's like 1.7 million for the three regions. Two of these pilot projects in Northern California, two in Central, and two in Southern California. And they bring together educators, health professionals, law enforcement, and it creates messages and images and communication in the Idiom and on the networks that people in the age group that are going to be so heavily hurt understand. And so I wanted to just let everybody know that I appreciate the work that in the Public Safety Committee. It sailed through. The Governor gave us more than we asked for. I just want you to know that my office stands ready to help in establishing the grant program, asking for help in Central California, Northern California, and in Southern California. Because if these pilot projects are as effective as what is happening in Fresno County, we hope to see a whole lot more of those being organized up and down the state. And so I welcome the opportunity. If there are others, I know there are nonprofits here from these various areas that our office is open and ready to help as that funding process works its way through it's in the budget. It was in the May Revise. We think that it's going to survive the budget process for all the good reasons that I've just mentioned. And so we want to help as the guidelines are unfolding and as the opportunity arises to be in that competitive circumstance in which the various nonprofits say, look, this, give it to us, and we can do some wonders with it, and here's how. So that's something that's on the table. It's happening now, and it's going to be in our neighborhoods and in our streets, I think, very, very shortly, because it is in the bill and the budget, and we're ready to put it to work.

Thank you, Mr. Patterson. Thank you for your leadership. Mr. Zbur.

Thank you. I wanted to thank both of the parents who are here today for what you're doing. I appreciate it from both perspectives. I have an 18 year old daughter who I worry about every day, have had discussions with her, and know that one of the things that's happening in high schools is the kids are using Adderall and Adevan. That's a pretty common thing these days and can see how easy it would be for kids who are initially getting those from family members and prescription drugs that their parents don't know about, but then start using that at parties given to them by someone else and then that obviously could be laced with fentanyl and how the risks can be very great. While I know we have to do much, much more in terms of prevention and education of our kids, I think, at all levels, and making sure that Naloxone and other is readily available in schools and in clubs and in all the places where that could be an intervention. My question, I think, really goes to some of the issues that we've dealt with in the criminal justice system. When I serve on the Public Safety Committee, I know that simply possessing any amount of fentanyl with the intent to sell is punishable by up to four years in jail. Selling fentanyl to a minor currently under current law is punishable by nine years in prison. Twelve years if the seller is at least four years older than the minor. Existing sentencing enhancements can add up to 25 additional years and make the offense a strike under the three strikes laws here in California leading to a life sentence. An existing law allows for homicide prosecutions for overdoses. So the question I actually have is, do you believe that additional sentencing enhancements, at least at levels that are at the street possession level, is effective at providing additional protection for kids in our communities? I voted against some of the penalty enhancements because when I looked at them, they were not focused on fentanyl. What they did is they increased crimes for a broad range of drugs that are including things like illicit use of Adavan, which I don't want my kids using, or any kids using. I think the reality is that it's out there and so many of the proposals I think would have actually criminalized the victims and would have resulted in LGBTQ kids, people from vulnerable communities and the victims of many of these things actually being criminalized. So I think the question that I have is are additional penalty enhancements something that's effective? And then when we look at the issue of how we I have voted for some penalty enhancements for folks that were directed at the, at the people that are making decisions about lacing these fentanyl pills and putting them in the stream of commerce and making those available. And I think this is sort of a follow up to assembly member Petrie-Norris's question on additional criminal justice reform. How do you sort of differentiate between the street-level crimes where I think we know that the war on drugs and based on what I've just read to you, we have really significant penalties here in California. Those haven't prevented what's happening now. So where is there a line that we should be looking at in terms of additional criminal justice reforms?

That's a very good question and a very complicated one. Why do we put people in prison at all? I mean sometimes it's to deter and sometimes it's to disable because we think they're so dangerous, they're a threat to the public that it's worth keeping them out of the society for a longer period. I think for somebody on the street corner who's not deterred by four year sentence, making it eight years, twelve years I think wouldn't make any difference at all. I doubt they think that far ahead about much of anything. Neither would keeping them for eight or twelve years really help the community because they would just be immediately replaced. As you go up the chain I would start thinking about do people have unique and destructive skills that would cripple an industry? They are major importers. They are connected to international networks. They are brilliant at moving money or product in the way that very few people can do. In that case you would want to increase penalties even though they may not be deterred but because they're just so destructive you want them out of the game for as long as possible. And a lot of this is going to be case by case. I've interacted in the criminal justice system for years. I'm sure you have too. And you know there's always many, many circumstances to weigh but I think it's a small proportion of people for whom longer sentences are going to make a big difference. Overwhelmingly, I think it won't.

Three more people. I also want to reiterate we have eleven more witnesses and we do not have this room all day and I want to make sure we get through all of this. And Dr. Humphreys is doing a great job addressing a lot of issues. But we do have witnesses who are here specifically on a lot of the questions, really great questions that are coming up. So I have Mr. Karla, then Mr. Patterson, then Mr. Alanie, and then I'd like to be able to move on if we can. Mr. Karla.

Thank you, Chair Haney and our chairs for putting this together. And I want to, of course, thank the moms here and all the parents that are here or watching or show up to community meetings that have suffered so much. I worked as a public defender for eleven years, over half that time in drug treatment court. And so I've seen parents firsthand go from desperation to devastation, do tough love, and cut their kids off, to spending their life savings trying to get treatment and everything in between. And so I appreciate the fact that the sense that it doesn't do us any good if our young people are afraid to call an ambulance or take their friend to the hospital. And it just leads to more death and more pain. And we want to make sure we allow for that space in the education process to let our young people know it's okay to come forward, it's okay if you don't know what to do, come to your friend's parents. We have to give that space. And that sense isn't there right now because of the fear and the stigma and how we've dealt with criminalization of drugs in the past, that we have to create a new way of doing things. And I do want to make mention of over the years, over the decades, whether it's Quaileds, opioids, you name it, these drug manufacturers have made billions of dollars at the expense of us through pain. And time and again, when we kind of push back or try to find avenues, they slow the process so they can make an extra dollar, an extra penny can squeeze that money out. And I think it's a shame and I think that we cannot let that happen again in the case of this Fentanyl crisis. Now, I really appreciate Dr. Humphreys in kind of really focusing this as a public health issue and to get rid of that stigma, to allow us to bring it under that umbrella of evidence based and not anger based, because everyone is and should be angry. But it doesn't get to the results that we want to protect our families and our communities by just letting the anger dictate our policy. And so I have a couple of questions that's also for the next panel. So in the interest of time, I'm not going to repeat it. So the folks are on the next panel if they have any insight as well. One thing you mentioned was that we have to incentivize more specialists to go in this very difficult area. And so how do we do that? I think one thing you said is by getting rid of that stigma and all that. If you have any thoughts on that, but one other thing is that the gov governor, under the Governor's leadership and support from the legislature, is producing our own insulin to get these drug manufacturers out of the picture that are not willing to let go of their profits. And so the idea and this could be something to follow up with our public or with our health committee chair, but of creating our manufacturer, our own Naloxone since it's not expensive to make. And so I want to put that out there as a potential idea and hear from our next panel as what they think that might be, what thoughts they might have, as well as any thoughts that any of you may have. Thank you.

I'll just say quickly, we have a fantastic higher education system in California that you and your colleagues oversee. It could be a requirement from all the UCs in CSU's to include adequate training for addiction for anyone who's going to become a health practitioner in California. We could also do a lot for young people who are going to do other careers who are going to be firefighters or police officers. They could also get that training as well.

Thank you, Mr. Patterson.

Thank you very much. And Mr. Chair, thank you for having one of my constituents here, ms. Didier. I've offered several pieces of legislation on this front narcan in Schools probation program and also educating people and guardians in schools through existing processes that schools go through. And I only know about Fentanyl, unfortunately, because we lost Zach in my neighborhood. And because of that, I've kind of committed myself to this cause. And it turns out after I started being public about this, that my cousin, who my family, started being more vocal about the fact that my cousin passed away from Fentanyl as well. Laura, if you wouldn't mind if I ask a question, would addiction care or treatment have prevented Zach passing away?

I appreciate that question. That's why it's so let me get this straight. Important that we address this on all of the different fronts because as was asked before, there are victims where there aren't red flags, where there are typical teenagers doing typical teenager things. I mean, I was incredibly plugged in with Zach. My older two kids are doing phenomenally well. And we thought we'd had every conversation that we needed to have. Substance use has not impacted my family or my ex-husband's family. We thought we'd had every appropriate conversation. While all of the things we're discussing about treatment is so important, I just don't want the primary prevention part of it to be neglected in the conversation. Because so many of the youth that are dying under the circumstances, like my son, wouldn't have been in that addiction care system because that's not where they were in their journey. And so that's why I feel so passionate about the education and prevention. I'd never heard of this until until I lost Zach. And not everybody that dies from Fentanyl got it. Even young people got it from a friend or someone struggling with substance use disorder. The person that sold to Zach was a businessman operating on Snapchat, selling and taking advantage of naive people like my son. He was on probation for other crimes in Sacramento. And instead of choosing to turn his life around while on probation, he continued selling drugs and sold the pill that killed my son. So we have to be able to discuss all of these ways that people are dying, all of these situations that are happening. And when I use the word poisoning to describe Zach's death, it's in no way to make any distinction between our pain or our loss. I'm heartbroken for any parent who has buried a child, no matter what their age, but we do need to look at all the different ways. And I just used that word poisoning because I know when I was still able to raise Zach, I might not have paid attention to a story on the news if they were previewing a story about overdose, I might think, oh, I don't really need to pay attention to that. None of my kids are struggling in that way. But if I had seen a story saying young people are being deceived and poisoned as we are seeing more stories framed that way, I might have said, oh, I have teenagers, I do need to listen to this story. It is happening to good kids and it always was, right? I mean, everybody that we've lost in whatever way, to a drug related death is a good person. But it's imperative to get the information out and to not neglect that piece of it. I appreciate the question.

Thank you very much. And my understanding is person who sold Zach his pill, according to his own statements, was not a drug user himself. He had used Xanax on occasion, but didn't consider himself a drug user. And I'm afraid that treatment wouldn't have been effective for somebody like that. And I have to say also, Zach, I didn't know him, but everybody who did, he was a role model. And it really bothers me that we spent a lot of time I mean, we have to address people who have substance use disorder. I mean, we need treatment for that. I don't know my cousin's entire past, but I don't think it was a one pill can kill situation. And there's two different tracks, though. And I think part of that has to be holding people accountable. And we have problem prosecuting crimes throughout the state for various reasons, so much to the extent that the DEA has stepped in on a lot of these instances. And so I don't know exactly what the solution is. I've offered some solutions, but I hope we can get to the point to where we understand that businessmen aren't going to benefit from some of the addictions treatment that we have. They're not going to benefit from education either. They don't care and they're criminals and they should be punished for it. So thank you very much for that and to both of you. I mean, honestly, we can't do enough in this building and we can't bring your loved ones back, but we'll make sure nobody else do our best. Thank you.

Thank you, Mr. Bryan. And then Mr. Alanis. And then we're going to move to the next panel.

Want to thank my colleague for his comments. I know this is a very passionate issue for him and for all of us. I have a loved one who was found unresponsive in North Park, San Diego. They found him face down on the pavement. He had taken something that was laced. He was revived in the emergency room. Thank you both for being here again. I sit on the Public Safety Committee and I have heard both of your stories many times, and they never stop losing their potency or their power to impact the way that we think about these issues. And so thank you because I know it can also be incredibly traumatic. And so I want you to know that there's still a lot of power that comes with your presence to all the families who are here. Dr. Humphreys. I don't think You Know me, but I studied under Mark Kleinman at UCLA.

I did know that.

Very familiar with your work and his and a lot of the scholarship in this area. I'm thinking about the spoke and wheel comment you made earlier. I'm thinking about Boston and North Carolina models. Was there a state role in kind of developing, amplifying or cultivating those conditions? Because I'm thinking about the gun buyback or not buyback. But the situation you explained in Boston is that something where the state facilitated resources for local communities to be innovative or didn't made sure there was no preemption for them to do that. I'm thinking, what can we do to inspire kind of local change in communities with local partners?

Yeah. So the Boston Gun Project was led by the city of Boston, but they had backup from both the feds and the state, and that was partly so they could make the deterrence credible, saying, we really are going to take this seriously. If you shoot somebody and if it's a legal firearm, did you know that this can be charged federally and you'll be sent far away and be away from your family and you don't want to do that and we don't want to have to do that. So it made that part more important. And as you know from being a student of the great Mark Kleiman, it's the certainty of penalties that motivate people far more than how serious they are. And I think the state could definitely help by bringing in people who, like the people ran the Boston Gun Project and ran the High Point, North Carolina drug market interventions. Fund them to come in, work with our communities, work with our health, our police, our mayors, and most importantly, the people who live in those neighborhoods and do these projects. I mean, create a grant program and let's try to replicate that success here.

Thank you, Allanis. And then Ms. Davies.

Thank you, Mr. Chair. Dr. Humphreys, you were asked by some members on this committee about ways that we can do things different here in California. One my colleague just asked you about was about Boston, and you were talking about how the drug dealers were brought in and told pictures and we're going to come after you and those kind of things. And then one of my colleagues also talked to you about some of the consequences that we have here in California. What do you think helped Boston so much as far as with their consequences.

There, that they did it in alliance with the community. So rather than the police seeming like an invading army in someone else's neighborhood, they had all the neighbors right there. They had families there, including people related to the members of these gangs, saying, we also do not want this to go on, and we are working with the police and we are working with Health, and we want to help you. So in the end, the best enforcement never has to be used, right? You deter the behavior and you don't have to arrest anyone because no crime has been committed. And it was that commitment, I think, to working with the community and not sort of parachuting in which just can't work. And that was back. The Boston Gun Project was when trust between police and communities was higher than it is now. So you really have to be willing to put in the hard yards of building those alliances with the people who live in those neighborhoods so that they and the police and health are all working together. It's hard work, but it really is worth it. It transformed a lot of neighborhoods in those cities.

Thank you. And I also believe in that. I have a history in law enforcement over 20 plus years in working in the court systems, working as a detective, and seeing how consequences do deter. And I strongly believe in that. And I also do believe that with the deterrence of those consequences, that the crimes will not and should not be happening. But just to give you a little insight on Boston with their laws and what their consequences are for their first prior conviction, you're looking at two and a half years to ten years in state prison. On their second, you're looking at three and a half to 15 years in state prison. And as one of my colleagues pointed out earlier, you're looking at maybe four years. And that's a local time here in California. You also have another thing just for fentanyl itself. If you were to traffic 10 grams or more, you're looking at three and a half to 20 years in state prison. So I think that also could help in Boston and probably could also help us here. Yeah, we don't need to have to lock them up. But I think also to show that we have consequences here. If they do that, then I think the program that you explained that helped in Boston would probably help here also. And thank you to the moms that were being here and testifying, and just know that we're here with you. Thank you guys. Thank you, Mr. Chair.

Thank you, Mr. Haney. Again, thank you all for coming. We know that through the CDC, about two thirds right now of schools, high schools, and middle schools are actually having educational classes. And for the last 13 years, whether I was on city council or here, I've been working with parents that have lost their loved ones, educators, doctors, trying to do this. And this was back when we had opioid problems, which we still do. And now we have this fentanyl crisis. This question is for you, Mrs. Didier, as well as we're going to be having Supervisor Thurman down the line. But obviously education is important. I had a bill out there that would mandate education into our middle schools and high schools. What type of education are you finding is actually best that works at the schools that you're doing and then I'll be finished. So thank you.

Just speaking anecdotally from my experience this past school year, the feedback that I get from the kids is that they feel when they are being talked to, not talked down to, but being talked with about these things. Like I said about just say no with the know, like know what's out there. We're going to educate you on what it's going to look like. When I talk to the kids, I try to kind of talk in their language. Like I'll say, hey, if you see a menu on Snapchat or Instagram or something like that and you see Percocet, Xanax, I want you to spell check that in your head to fentanyl because that's what it is. So it's trying to kind of talk to them in their language, respecting them, respecting their intelligence, empowering them to make those good decisions. And they really respond to that. They'll come up afterwards to say, I'm so glad you talked with me about this. I've heard the word fentanyl, but I didn't really understand how it looked and how it would happen. But it needs to be comprehensive about this change, as Dr. Humphreys mentioned, between going from the farm to the lab and how that has profoundly and forever changed the drug landscape. And I think it's very important for them to be educated about how substances affect their brains, especially when their brains are developing and why they are so much more vulnerable at their age if they do experiment or self medicate. And then just anything that you do and you just wrap it in that we're here doing this because we care about you guys. We're not doing this because we want to dictate to you or we want to control you in some way. We're doing this because this is a new crisis that we haven't seen in our country. Your demographic has never been impacted by something like this in the way you're being impacted now and we care to inform you and wrap you up in a protective blanket of information.

Thank you so much. And thank you to our panel, Rr. Humphreys, Ms. Didier, Ms. Dunkle, thank you so much for your leadership and for your courage. And we're committed to continue to work with you, and we're so grateful to have you here. To my colleagues, thank you for your great questions and to your spirit of focusing on solutions. And we're going to move on now to the next panel. Thank you.

Our next panel is focused on both the state and local health response. We have in order of testimony, Dr. David Kan, a board certified physician in general and Forensic Psychiatry and in addiction Medicine. Robin Christensen, Chief of the California Department of Public Health Substance Addiction Prevention Branch. Nathan Blacksmith, the Chief Traditional Health Officer at the Sacramento Native American Health Center and Michael Mason, Chief of Administration in the San Francisco Fire Department's Community Paramedicine Division. As you all know, we have three to seven minutes for your testimony, and Ms. Heckman, who's here next to me, will hold up when you have 1 minute remaining. And with that, Mr. Kan.

Thank you, Chair Haney. Chairwood. Chair Sawyer Jones for inviting me. I represent the California Society of Addiction Medicine and wanted to present the perspective from this standpoint of treatment. Next slide. There was a landmark study that was done that looked at the 40 year natural history of opioid use disorder. At that time, it was primarily heroin. And what they found is that they managed to maintain 88% of the study population. But over time, heroin use disorder was a fatal disorder. More than 50% of people were dead. Statistically, if you use heroin, your lifespan was shortened by 18 years. And this isn't the good old days of heroin, which makes me feel strange to say that as an addiction psychiatrist, but heroin was easy compared with fentanyl. Next slide. So what are the major treatment goals of opioid use disorder? Treatment or opioid people who take opioids? Next slide. Fatal overdose prevention. Next. Fatal overdose prevention. And next. Finally, fatal overdose prevention. Next slide. We have effective medications for opioid use disorder. There's generally three medications that are considered for the treatment. For people with addiction, there is methadone, buprenorphine, and naltrexone. Go ahead and hit the button two more times. This is small, but I'll cover the highlights. When I think about opioid use disorder, the most important part that I think of is that medications are life saving, plain and simple. If I think about different addictions, for example, stimulant addictions such as cocaine or methamphetamine, we don't have great medications for it. Yet 80% of the benefit in opioid use disorder is medications alone. And I heard the heartbreaking story of the child who was forced to taper detox. And that's not the answer that we think of. This addiction is a chronic condition. And the way that I think of medications is tantamount to insulin for diabetes. Methadone as a medication is a gold standard medication. It reduces fatal overdose by 80%. But it's fenced to federal methadone programs. Buprenorphine is much more accessible to specialists, primary care providers, and many of you have heard that the DEA requirement to have special registration was eliminated last year. This also reduces fatal overdose rates by 80%. The medication Naltrexone, which blocks the effects of opioids, are very effective. However, it does, not surprisingly, does not reduce the rates of fatal overdose itself. Next slide. We have safe and effective medications for opioid use disorder. However, there's a discrepancy between the effectiveness of medications and access. Fewer than 20% of Medicare beneficiaries access to treatment, yet overdose death rates continue to climb. So what is the answer? New solutions. Next slide. We're going to have other speakers talking about treatment in youth, and the concept of poisoning is the concept that I've seen over and over again. Not every youth who dies, dies as a result of a substance use disorder. They took a drug that was lethal, but they did not know. Adolescents, according to the American Academy of Pediatrics, should be offered medication treatment for the disorder. Medications keep kids in treatment, and more importantly, I would say that psychosocial treatment, counseling, family interventions, school based interventions are truly critical in children for the purposes of prevention, for the purposes of treatment, and the purposes of dissuasion. So working within the schools is really critical, as well as the communities that the kids are in. When it comes to adults, counseling can be profoundly helpful. However, it's the medications that really account for the vast majority of the effect size in preventing fatal overdose. Next slide. I was asked to speak on medications for opioid use disorder in the CDCR. And as an addiction psychiatrist for the longest time, I used to joke that the R in CDCR was silent. I've changed my tune. There have been serious efforts by the state to introduce treatment, including medication treatment. If we look at incarcerated populations, there are 40 times greater risk of dying from overdose upon release than the general population, and this risk continues for at least a year after being released. The Integrated Substance Use Disorder Treatment Program and CDCR as of January 2022. The program started in 2019. In 2015, they had access to Naltrexone. However, in 2019, they started using buprenorphine. Over 22,000 inmates were treated, 90% who were offered accepted treatment, which was a stunning number. The assumption would be maybe 50% at tops, and overdose deaths dropped by 58% within CDCR from 2019 to 2020, and those effects persist to this date. Also, an important piece of data is Hepatitis C, which has become a very treatable illness. Reinfection rates drop by 30%. Next slide. Now we talk about barriers, and stigma is a tremendous barrier. Stigma silence. One of the things as a physician is I practiced in San Francisco in the 1990s. That's where I got my training. And what I saw is the echoes of the HIV crisis being brought over to the Fentanyl crisis, and we need to address that stigma head on. Medication treatment is real sobriety. Next slide, please. There were questions about the effects of public policy responses. And I was pleased to see Dr. Humphreys here because this came from his paper. There are actions that can reduce overdose, death, naloxone distribution to people who use drugs, medication treatment, syringe service programs, and harm reduction. And harm reduction is not antithetical to recovery. You need to keep people alive, because the only requirement for recovery is life. And then psychosocial treatment. There are interventions that increase deaths, such as criminalization paradoxically prescription drug monitoring programs. When you take people off of controlled regimens for chronic pain, you drive them to the streets, you drive them to heroin, you drive them to fentanyl. And also critically unsafe supply, which we've been talking about. Next slide. Syringe service programs, which is something that the California legislature has been supportive of, is critically important. I was testifying for Senate Bill 57, which was a safe consumption sites bill last year, and I met with Senator Glazer's office, and I said to him, I worry more about the patient who is not in care than the patient who is in care. And the people we need to reach are the people who are not in treatment. So syringe service programs are the ones who reach out to them, and the most critical need that they have is low barrier access. And the last slide that I'll go over is that there are new programs, innovative programs. We talk about open air drug dealing or open air drug use. Well supervised consumption sites, though, unfortunately, the bill was vetoed, have been demonstrably effective in reducing open air drug use, and the people who participate access treatment. So, with that, I will finish my final slide. In summary, fatal overdose prevention is a forever goal. Medications work, but medications are not enough. We need to do everything that we can to address this topic. Thank you.

Thank you so much, Ms. Christensen.

Thank you, chairs and members of the committee. My name is Robin Christensen. I am the Chief of the California Department of Public Health, Substance and Addiction Prevention Branch. Thank you so much for inviting me here to join you here this morning. In 2021, more than 71,000 people died from synthetic opioid related drug overdose in the United States. Recent data suggests that that number continues to increase each and every year. Today, I will be speaking to you about the CDPH's role to address research, primary prevention and harm reduction strategies. CDPH's Overdose Prevention Initiative, or OPI, was formed in 2014 when we brought together an interdisciplinary group to address what was then our prescription drug overdose epidemic. Since 2015, the OPI has been supported primarily for the Centers for Disease Control and Prevention, and over time, that drug of focus has shifted from prescription drugs to heroin and now to fentanyl. OPI leads our department's approach to the opioid epidemic, which has seven objectives which aim to improve and promote both primary and secondary prevention strategies. We focus on interagency collaboration, improving our access to data and surveillance and providing that data to the public and our primary prevention strategies of individual and community resiliency, public awareness and education and our secondary prevention strategies of boosting access to naloxone, increasing access to harm reduction services and strategies across the state and improving access to stigma free treatment. As part of Governor Newsom's Master Plan for tackling the fentanyl and opioid crisis, CDPH has received an additional influx of funding from the state to help bolster this plan. And this support has most recently allowed us to expand our public awareness and our surveillance programs. Now, with respect to surveillance, the OPI has developed and provides to the public ongoing support for the California Overdose Surveillance Dashboard. This provides state and local data on fatal drug related overdoses, as well as our emergency department visits and hospitalizations related to nonfatal overdose. For example, in 2021, we saw that there were more than 7000 Californians died from an opioid related overdose. Over 80% of those were related to fentanyl. Fentanyl related overdose deaths have skyrocketed and they disproportionately impact males. They disproportionately impact adults, vulnerable adults between the ages of 25 and 44 and Native American, Alaskan Native residents and black Californians rural counties. We see experience lower total overdose deaths in the county, but they experience much higher rates per capita. Our prevention strategies focus on primary prevention and secondary prevention solutions, and we use this to address large scale public awareness campaigns and our harm reduction strategies. CDPH administers the statewide Standing Order for Naloxone, which authorizes entities in California, such as schools, community based organizations and libraries, to administer and to distribute naloxone to others without a prescription. This is a sister project to the Department of Healthcare Services Naloxone Distribution Project, which provides free Naloxone to entities that apply and are approved to participate in the program. As part of our efforts to increase access to naloxone and to promote those harm reduction strategies. CDPH also supports a network of 71 syringe services programs, or SSPs, that are in 42 counties across the state. These programs form the backbone of California's workforce, dedicated to working with marginalized people who use drugs to prevent both infectious disease and overdose. The department's California Harm Reduction Initiative provides funding for frontline Navigator staff at 37 of those 71 locations. Harm reduction is effective. And the success of this work can be measured by the number of Syringe services programs in California, which have nearly doubled over the past five years, and a 2022 survey of over 1500 Syringe services program clients who reported that more than half of them had used naloxone to reverse an overdose in the prior six months, and 95% of those individuals had received their naloxone directly from an SSP. Not all corners of our state have access to harm reduction services. CDPH also works with a distribution partner to provide life saving harm reduction supplies and treatment information to individuals who are across the state at risk of overdose or harm from substance misuse who may not have access to an SSP in their services. Now, the Governor's proposed budget for 23 24 also includes an additional 4 million for innovative approaches to make Fentanyl, test strips and naloxone more widely available. In the current fiscal year, CDPH has received funding to support a statewide media campaign with three primary aims and audiences. This is our primary prevention approach to prevent substance misuse among teens and young adults, to stop overdose and overdose death among the vulnerable adults with a harm reduction lens and to raise awareness, share life saving information, and reduce stigma among families and communities so that we reduce overdose death in our state. Separate from this campaign and its core prevention messages, we do also work to provide clear information to stakeholders and the public on emerging topics such as rainbow, Fentanyl, and Xylazine. CDPH works closely with our state and local partners to address the opioid epidemic. We work with the Department of justice to promote the state's Prescription drug monitoring program. We work with our colleagues at the Department of Healthcare Services to support first responders and other work with DHCS, and we also work with our educational partners to expand resources and information available to schools, colleges and universities. We work with Public Safety. We currently are working with Northern and Central Valley High Intensity Drug Trafficking Areas to share data pertinent intelligence and to promote public health and safety partnerships. And we are also currently preparing for the implementation of 2022's AB 2365, which will fund the six regional grantees to implement strategies on education, testing, recovery and support services. Governor Newsom's recently released Master Plan outlines the steps that this Administration is taking to support overdose prevention efforts, hold the industry accountable, and raise awareness among both youth and the general public around the dangers of opioids, including Fentanyl. CDPH is just one department among many. We welcome the opportunity to expand our partnerships with both our local partners and with other state agencies. And I'm happy today to respond to any questions from the committee. And I'm also joined here today by Marlies Perez, who's Chief of the Community Services Division at the Department of Healthcare Services, who's able to respond to any questions regarding DHCS and its Naloxone distribution program.

Mr. Blacksmith.

Good afternoon. Thank you, Chair Committee, for taking this time to sit with the community and go over this important hearing. Harm reduction principles are focused on providing strategies aimed at reducing the negative consequences associated with drug use. These strategies specifically include or applied specifically to opioids and fentanyl include education, fentanyl, test strips, medication, assisted treatment, and naloxone. However, opioid overdoses and deaths continue to rise, which indicate that these strategies may need to be reevaluated or delivered in a different manner. Some of the issues being experienced with the current strategies are access to educate the youth, access to fentanyl, test strips, and Naloxone, as well as addressing community stigma. Many schools in Sacramento and surrounding areas refuse to allow and distribute allow and distribute test strips and naloxone. Naloxone and test strips should be available for service providers without having to navigate through unnecessary grant requirements. And access to the community needs to expand to allow access without having to attend special events or community gatherings where they usually typically get access. The Loczone should be in every first aid kit and easily accessible in community settings and schools. Service providers need support to provide greater education to the community about these life saving strategies. Individuals need to understand the importance of working together as a community to address the issues. Our youth need us to do more to prevent the next overdose death. Just to add on to that working. I work in residential treatment facilities for a good part of my career and specifically with the American Indian population. And so what we found effective in working with that population is framing our care and recovery as a ceremony of recovery and healing. Over the course of the past decade and a half, that ceremony has been kind of cut down from like a three month treatment stay to anywhere from 20 to 30 days. And so on the first panel, Dr. Humphrey humphreys mentioned grouping addiction treatment with under the umbrella of medical care. And that's something that I also support and think it's time that we make that type of investment. We used to consider somebody making into treatment as an opportunity for us to potentially save a life. Now, when you're at a table and somebody takes a dose of naloxone and walks away with it, that is now an opportunity to save a life. And it gives me the same gratitude as I would when we would receive people in treatment. So thank you for taking the time to listen.

Thank you, Mr. Blacksmith, Mr. Mason.

Thank you committee chairs, assembly members and colleagues gathered today. My name is Michael Mason. I serve as the Section Chief of Administration in the San Francisco Fire Department's Community Paramedicine division. I am a Paramedic, a father, a husband, and a community member. And like everyone in this room, this state, and this nation, I have been deeply impacted by the Fentanyl crisis. My goal for the next several minutes is to share through the lens of a first responder, the novel and unique role that emergency medical service providers and systems have to play in this crisis. Evidence based, strategies. That our EMS and 911 systems are implementing in your districts currently or could be implementing across California. And the resources that our first responders so urgently need to continue their work in this area. Next slide. Our best means of knowing how many overdoses are occurring in our counties and state starts with the data collected from our paramedics and EMTs in the field. EMS data is aggregated in what's known as the National EMS Information System, aka Nemsys, and it's one of the best real time surveillance tools we have to understand the frequency, location and characteristics of drug overdoses in our communities. San Francisco first responders are encountering this scene over 14 times a day. And as Chair Haney mentioned, on average, two people are being declared dead every day from drug overdoses in San Francisco. It should be noted that in San Francisco, paramedics outside of the hospital are the individuals required to declare death. And while this tragic scene pictured here is occurring outdoors in San Francisco's Tenderloin district, it's important for us to recognize that the majority of overdose deaths occur indoors in people's homes. I can tell you're looking. That's Larkin. And Eddie, if you're thinking Chair Haney where that is while my fellow paramedics, EMTs and firefighters had little role to play in the decades of policy and regulatory failures or the deep racial and socioeconomic inequalities that have contributed to this epidemic. We are the ones tasked with responding to the daily reality of what we see here. Next slide. As I stated in my introduction, EMS providers have a unique and novel role to play in this epidemic. And let me illustrate that to you with two pieces of data. First, San Francisco Fire Department data shows our paramedics have contact with the majority of individuals who will go on to die from drug overdoses prior to their death. So we are engaging in the back of our ambulances in our community paramedic units, folks who we know are going to go on to die in the proceeding or following year or two. Second, peer reviewed study from Massachusetts shows that of those folks that go on to die after experiencing a nonfatal overdose, 5% will die in the subsequent 48 hours and 20% will die in the subsequent month. What does this data narrative tell us? First responders are frequently in contact with a population we're all seeking to save and there isn't an hour or a day to spare in trying to provide them care and change their trajectories. Next slide. So what do we know that amongst providers working in this field, first responders are filling the gaps in our systems of care and playing a unique role. We can actively engage the very individuals we're seeking to treat without waiting for folks to passively seek out care themselves. The nature of our work in our organizations allows us to provide near realtime responses and services to individuals we know are at extreme risk of near term mortality. And again, the nature and values of first responders is that we go everywhere and anywhere, whether that be a shelter, a home, an RV, or a highway underpass, we respond 100% of the time 24-7, 365. We're never closed for holidays, and we never turn down a call for help. Lastly, paramedics have proven the ability to provide direct connections to care, whether that be from street to shelter or from a home to medication assisted treatment. Overdose survivors and individuals with substance use disorder can be provided with a spectrum of harm reduction and withdrawal management services by EMS professionals. I'll expand upon this in the next slide. I'd like to briefly highlight and expand on the evidencebased, programs and concepts highlighted here, some of which are already being implemented in many of your districts. Community paramedicine programs such as the programs in Chair Haney's district in San Francisco. Community paramedicine is a developing field of prehospital care pioneered here in California, which provides paramedics with additional training, trauma-informed training, cultural competency and stigma training, and an expanded scope of practice. We see community paramedics being utilized, an alternative to policing and mental health response teams such as San Francisco's Street Crisis Response Team, as well as overdose-specific teams such as our Street Overdose Response Team, which has received international attention. EMS Narcan distribution in San Francisco and other counties. We see great benefit from first responders providing narcan and training to patients, family members, and community members directly at the scene of an overdose. Truly targeted distribution efforts. I'm going to have to cruise here if I got 1 minute. Okay? Low Barrier Shelter housing is healthcare is a well turned phrase, but during COVID we proved it. Thanks to the work at San Francisco's Department of Public Health and Dr. Barry Zevin and his colleagues, we can show a strong correlation between providing emergency shelter and reductions in mortality. Alternate destinations are nonemergency department locations that paramedics can transport patients to. These can include alcohol or drug sobering centers and mental health facilities. Beyond benefiting patients, they serve as a pressure relief outlets for our historically overcrowded emergency departments and hospital systems. Overdose receiving facilities designated overdose receiving centers pioneered by California Bridge Foundation, especially Dr. Jean Hearn, dr. Andrew Herring, and Dr. Mary Mercer for hospitals which have increased services and staffing specifically tailored to individuals with substance use disorder. Prehospital buprenorphine, also known as suboxone. We've heard about it already. At this hearing in San Francisco and other counties around California, pilot programs have been approved for paramedics to induce or initiate and administer suboxone directly in the field, directly in the time window that folks might be in withdrawal and amenable to these services. Data sharing and multiagency coordination speaks for itself. Next slide, please. EMS providers and 911 systems are being asked to do more now than ever before. 911 is the safety net of last resort, but unfortunately is becoming overwhelmed as failures from our current systems of care end up being handled by our first responders. I've shared how we're uniquely positioned, and I'd like to note that this is a new crisis, one whose likes we've never seen before and one that's required EMS personnel to adapt and fill system gaps to serve our communities in new and novel ways. Next slide. I would ask the members here to continue their support for community paramedicine and pilots in EMS programming. Pilots allow for policies that support sustainable EMS systems, including activities that are not currently reimbursed, such as ambulance crews bringing patients to nonemergency room destinations, and recognition and care for the EMS providers who serve as our community's ultimate safety net and think about their mental health and resiliency. Next slide. I share this photo to remind everyone that first responders are working in some of the most challenging conditions we can imagine, day in and day out. And while this value is part of the oath that many of us take the day we don our uniforms the way things are is not the way they have to be. Allow me to express my gratitude to everyone in this room who is actively working towards change and end my time by sharing the unofficial motto of the San Francisco fire department's community paramedicine division. If not us, who? Thank you.

Thank you so much to all of you for your presentations and for your leadership. As you know, those photos are just blocks from where I live, and I can't count the number of times I've also witnessed that scene and had to, in some cases, administer narcan myself. And I want to thank you and your colleagues for your leadership and the number of lives that you all have saved that I've seen firsthand just is extraordinary, and I'm sure it's true for all of your colleagues and also for everyone who is on the front lines of this epidemic. I want to open it up to my colleagues for questions, and I know I first have. Dr. Arambula.

Thank you. Mr. Chair. I'm going to begin with an appreciation of the first responders who are on the front lines. Having worked shoulder to shoulder with you for a decade as an emergency room doctor, I know the hard work that you're doing out there in community, meeting people where they're at. And so I want to start by just acknowledging and following up that if not you, who? But if not now, when? It's about time for us to make sure we're making the necessary changes to programs so that we can save lives. And so I'd like to follow up on what Mr. Blacksmith had said about the power of being able to distribute and to give naloxone and Narcan into our communities and how that has the ability to empower our community members to save lives, just like you're doing on the front lines as paramedics. And so I want to be able to ask the administration, if I can, to expound on the Naloxone distribution project, the amount of medications that we've helped to distribute. And I'll bring all my questions into one if I can, Mr. Chair. But I want you to talk about all of the programs, if you can, the importance of the California Bridge Program. You spoke about the California Harm Reduction and the doubling of the syringe programs in our state over the last five years. You may want to bring up the California AIM the advancing and innovating Medi-Cal the behavioral health payment reform that was spoken about the importance of ensuring that we're not treating substance use disorder any different in health care as well as the fact that we've evolved in our learning from the Mental Health Services Act, which originally only focused on mental health and not on substance use disorder. And the Governor's proposal to evolve that. As we take that back to the voters, I'd elevate since Dr. Kan talked about the need for psychosocial treatment, the Children's and Youth Behavioral Health Initiative, as well as since we've seen such success within Buprenorphrin, within CDCR, the importance of the Path program, which will allow us to enroll inmates into Medi-Cal prior to them being released. And finally, since our colleague asked about it earlier, there is a proposal on the table from the Governor for us to start to manufacture naltrexone ourself and So naloxone ourselves. Excuse me that I want to give you the opportunity to inform the rest of the panel who are here about all of the efforts that are being done, acknowledging that there is so much more we need to be doing and working on this front. I want to at least give you a chance to describe in breadth some of those programs.

Great. Thank you so much. You did a wonderful job yourself. So thank you for pointing out some of the initiatives that the administration has been undertaking over the years. I do want to start with the Naloxone distribution program. This program to date, as we've all heard about today, just to go back really quick, naloxone, what we are distributing is the Narcan version. It's four milligrams. There's two doses that come in the kit. It's really for non-health professionals. We started this project back in 2018, was coming to our attention. There were a lot of overdoses in libraries, which was really pretty alarming to us. Libraries aren't a typical place that you think of having an overdose. But the more we put research out, we opened it up to our first responders, to our law enforcement entities, to schools. So we really have it quite widespread. So entities can apply. It's a very easy application. It's one page. They can get the standing order from our sister department and then they can receive the Naloxone right shipped directly to them for free. And so to date, just through the Naloxone distribution program, we've distributed 2.4 million units and from that there's been to about approximately 4000 unique organizations. It was mentioned harm reduction organizations. They actually received the most of our Naloxone. We have since added for them having the injectable Naloxone, it is cheaper and it is also just something easier for that group to utilize. But just from that Naloxone, just through the Naloxone distribution project, we have a reported over 170,000 overdose reversals just from that program alone. So while it is heartbreaking to hear the stories this morning from the mothers and I just want to just personally thank them for just speaking to us today, those are 170,000 lives that could have resulted in unfortunate death. I do just want to clarify though, that Naloxone is also available to all Medi-Cal beneficiaries that is widely available. Now it's for free. So I know that came up earlier. I just want to make sure that's known. And then there are other insurances that are starting to carry it. But also we have Naloxone counties and cities have funding available through either local funds or federal or state funds where they can purchase it. And then more recently opioid settlement funds that are most of those funds are going to the local level and Naloxone is an available use of those funds. I would be here all day and I would get the warning sign up front. So I won't be able to touch on all of the various projects that have been the administration has been rolling out over the last several years. But I do just want to touch on a few of them very quick. I do want to mention because the prior panel was talking about the hub and spoke model, we actually worked with Vermont and did implement that model here in California and pilot it out and we are continuing to see the results of that. Today we have over 100 I have so many notes look at all this because there's so much going on. I knew this would happen. Where is it? But basically we have over here it is a 105 sites with more than 400 mat prescribers. These are new prescribers that can prescribe the medicines that Dr. Kan was speaking about. And we've had a result of over 66,000 new patients. We've also been doing a lot of work with our justice partners. We have gotten medication-assisted treatment in jails and drug courts to date and we've been working over the last five years with our county partners and jail systems, and 36 counties now offer medication-assisted treatment in their jail, which they didn't have that before, and they have at least two formulations of the medication-assisted treatment. So now, to date, we've had over 30,000 individuals now that are receiving medication-assisted treatment. It's also mentioned our California Bridge project, which we started with one hospital in California. For those of you that don't know, we have over 400 hospitals to date. Now we have almost 300 of our hospitals that are now providing mat in that setting. So really, what we've been looking at doing with state funding that we've received from you, and I want to thank you all for your support today and the support of budgets and all the legislation that you have passed. But we have taken a look at not only the health system, because that's very important, that we have these medications available, but also anywhere where an individual with a substance use disorder may touch a system. Therefore, we looked at the jails, we looked at our emergency departments. We have over 40 different projects with our California Medication Assisted Project to where we're expanding that to all these different entities and not just treatment. I know we've talked a lot today about prevention. There's a lot of initiatives that the administration has taken around prevention, but it is very important we must provide treatment for individuals that have an opioid use disorder. But far more important is getting those individuals before they have an opioid use disorder and really having the clear distinction that I want to thank our mothers for earlier talking about there are individuals with an opioid use disorder, and they're the dangers of Fenty pills. And those are very unique situations. So we have to approach them separately. And I do just want to quickly say that Mrs. Didier, you spoke at my kids school. I had to know there was a Fentanyl awareness night, and my kids came running home. Mom, are you speaking? I said no, I'm not. But I'm going to go. And her story was so touching. And the work that her non-profit organization that she works with sung for, Charlie, really touched my heart. And so I went back the next day and I said, we've got to support them. We have to support them. So we do have a contract with them where they are providing this education in our school systems, because it's extremely important to hear it right, not only from those that have experienced this loss, but also reaching our heads. So lots of other efforts I didn't touch on. I'm open to any sort of questions around them. But thank you so much.

Thank you. Thank you so much for that. Mr. Zbur.

Thank you for your question. Let me add the huge caveat that my lawyer is not your lawyer. My lawyer is not the lawyer of any of these businesses and schools. And CDPH cannot offer legal advice for anybody outside of CDPH. So what I would say, though, is that if somebody is concerned about liability, what they should first do is look into California's Good Samaritan Law, which does protect the individual from intervening in the case of an overdose, including providing Naloxone if they are having all intentions of saving a life. So that relieves the individual. And my understanding is, and again, not your lawyer, but my understanding is that those protections also extend to a business. So I would suggest that businesses first look into the Good Samaritan Law. Secondly, I would also look into some of the trainings that are provided under the provision of the Statewide Standing Order. So one of the coverages that the Statewide Standing Order provides, in addition to the Good Samaritan Law is that it does provide additional coverages for people who have signed up for a statewide Standing Order and have taken that training. So that is Civil code 1714.22. That is something that anybody can look up and look into and see if that applies to them and their business. Now, regarding schools, that's a bit more complicated. We have had conversations with schools a lot about expanding naloxone access through school policies. And one of the things that I think is a fairly easy ask is for schools to have Naloxone on campus. That is understandable, right?

They understand. They want to have it near their AED. They want to have it near their EpiPen. It makes sense for the school nurse, for the administrative staff when it comes to distribution. I think there's a bit more nuance there, and that is something that I would defer to my colleagues in education to respond to more completely. But I will remind folks that in most school districts, even if a nurse wants to distribute Tylenol or Advil, there needs to be some degree of permission granted from parents. So I think that this is probably a more complicated question that could be better answered by my colleagues later today.

Thank you.

Ms. Waldron.

Thank you, Mr. Chair. Just one quick question. I'll throw it out to whoever can answer. Regarding rural areas, my district is very rural. I have more tribal governments in my district than any other county in the nation. And I know Chairman Wood also has a huge rural district. We're dealing with lack of services out there, especially when it comes to mental health and substance use treatments. And I was wondering, I mean, we've worked on trying to incentivize providers to go to rural areas. We don't really have that much of a foundation or a framework that works. Are there any successes you can point to of being able to get into these rural areas that works? And what more can be done to address that, especially on tribal lands and in rural areas?

I can start. So we are also very concerned. Like our colleagues here mentioned, there are high overdose rates for our American Indian Alaskan Native population. We did start the Tribal MAT Project, and that project was started by tribal members. And so there's lots of different parts of that. They distribute naloxone. We have the first Tribal opioid coalition that is run by tribal members. They also have local opioid coalitions. We have increasing access to mat for tribal members. We have integrating evidence based practices because we want to ensure that we are honoring their cultural beliefs and engaging the individuals that have an opioid use disorder. They also have some prevention programs that we've been working on. But to your point around access, in California, we have the first Tribal Narcotic treatment program that just opened up. I went up to visit it a few months ago, which is really exciting. It's serving not only the tribal members, but also members of the community. It's in UK. And then also, as you all have approved, the Behavioral Health Continuum Infrastructure Program, where you dedicated $2.2 billion to increase access to mental health and substance use disorder facilities. We've been funding new tribal projects all over California, and we continue to as the program runs out. So I think we're making steps forward. There's definitely more to do. But as was mentioned in the earlier panel, this is not just an urban crisis, it's also a rural crisis as well. So thank you for your question.

I'd like to just add on one of the issues, both with tribal communities and also with rural communities, is access to safe harm reduction supplies. CDPH currently funds Next Distribution, which is the third party provider I mentioned in my notes. They distribute to a wide variety of groups and individuals across the state who are seeking out safe supplies, Narcan, and access to treatment information. It is both harm reduction and also creating those linkages to care within their region. So I want to just make sure folks are aware, including listening in on the phone today. Next Distribution is available to our rural partners.

I'll just share that one of our partners in Southern California and San Diego area were able to make Naloxon accessible on the rural reservation areas via vending machines. And so that was an amazing opportunity to create access, and they did it. And I'd like to see that replicated for our relatives in the northern part of the state as well. Thank you.

And one of the things for the record, I'm getting over a cold. I've tested negative for COVID three times. One of the things that the Pandemic has taught us is that telemedicine is an incredibly effective form of treatment. We've seen research into it being very effective, and it provides low barrier access. I work with a company that does telemedicine to rural areas, tribes, but we also do EMS surveillance, meaning that in Marin County, if you've overdosed, we are going to reach out to you and affirmatively try to get you into treatment. So continued support, particularly medical funding for telemedicine efforts, will expand that reach. You don't have to go into a clinic. You don't have to drive 50 miles to get care. You just get on your phone and you can connect to care in the moment.

If I could expand on my colleagues comments here. My professional work is primarily in urban areas, but community paramedicine is a powerful tool in rural areas, especially, where some folks only contact with the healthcare system might be 911. And the good doctor here, when he mentions telemedicine, there are pilot programs underway that allow paramedics to open an iPad and directly connect the residency or district to a doctor who can prescribe you or treat you or assess you. I would encourage members here, especially with rural districts, to work with their local EMS agencies to empower and develop alternate destination programs, narcan distribution programs that would allow paramedics to directly connect folks to care.

Mrs. Ortega.

I have a clarifying question. I'm sorry, I missed your name. Oh, Marlies Perez from Department of Healthcare Services. Thank you, Marlies. So you mentioned that Narcan is already covered by medical and private insurance, but my understanding is that it's by prescription. Is that correct? So for Medi-Cal, you actually don't need a prescription and it is covered. Some insurance is covered, but not all. Thank you for that. And it's not currently covered for over the counter since the FDA just made it available over the counter. Correct. So, yes, the FDA just did make it available. Well, excuse me, they just approved it, but it hasn't been released yet.

Ms. Bonta.

I want to thank the panel for being able to provide us with a very comprehensive analysis of all of the things that we are doing that are right. I think one of the points of incredible frustration is that we can't seem to be doing enough. And I want to one, highlight, just and appreciate the focus on the role of paramedicine in this in my district have in Oakland, both in Alameda based and an Oakland based paramedicine unit that's been incredibly effective around community medicine. I think for me, one of the things that would be helpful to hear is really thinking about the way in which perhaps along with mental health and fentanyl, we were caught flat footed because we didn't build as a state the kind of infrastructure that we needed to be able to really, truly address the fentanyl crisis and the mental health crisis in this particular time from the perspective of the 25% or the 20% of people, even in San Francisco or in others, where they've been touched by some aspect of our public health system but are still dying. What can we do? Where are the gaps? As policymakers, we also need to think about some of the gaps, right? We have so many programs and so many task force money units getting put up at this point, but we're still experiencing this incredible crisis. So if you all could speak to some of the gaps that you recognize that are still out there in terms of really threading together a holistic system that is actually going to be able to catch every individual, I think that would be incredibly helpful for us.

I'm happy to start. I want to acknowledge that we have done a lot in California. We were the first state to put in our Medicaid program a substance use disorder. We put forward an 1115 waiver and added levels in our continuum of care. We did that in 2015, which has been phenomenal. 30 other states have moved forward with that. I think it's also important to acknowledge, though, as was mentioned earlier today, substance use disorders has a tremendous amount of stigma against it. So if you have somebody that passes away from cancer or diabetes, that family is not shamed. And I guarantee you, these mothers that were here today could talk about the shame that they had to undertake and even now undertake talking about it publicly. And so I really want to first acknowledge just you having this hearing and the work that you've been doing personally on this is really beneficial because we have to bring this disease out of the darkness. It is not a moral failing. And until it is recognized as a disease, our kids are going to be afraid to say that their friend is utilizing drugs. Our older adults, we've seen high rates of abuse there. They're afraid to come forward. So really taking a strong hit at stigma is essential. That is a huge gap. When you heard about the statistics earlier this morning, how many people don't get treatment? And we automatically think that's because there isn't treatment available. Yes, we need to make more treatment available. Yes. It has to be evidence based. Totally believe California is on the right track, there's more to be done. But until we reduce that stigma, people are not going to come to those doors. So stigma is a huge, huge gap. But I do want to applaud you for your efforts today and your continued efforts, because we have to talk about this. And if you haven't already, you all got to go home and talk to your kids about it, because this research shows that most of kids and young adults that are in treatment said their parents never talk to them about it over and over again, that statistic. So there's things that we can do in our own families and our own lives to just debunk that stigma. And there's more we can do in that space too. And then you've heard a lot about some amazing pilot efforts, some amazing efforts in certain counties in certain areas. We just need to keep working forward on that, moving forward, making those things, not just a pilot and having those set into the system. So I think California has made a lot of strides forwards. We have a lot of states watching us. We've done a lot of innovations, which is great. We still have a ways to go.

Um, this crisis has changed right from year to year. We started off with great success addressing prescription drug opioid overdoses. And one of the things that I think that we've learned there is that when we all come together and bring a multidisciplinary approach and we are working with holistic approaches that are supported by both the Legislature and the Administration and the public and we get people behind it, we can do great things. And we have done that in the past. This problem is now not just 100 times more deadly, it is in some ways 100 times more difficult for us to solve. And so I'm really grateful for this group coming together today to be thinking about some of these critical gaps that may still exist and where we can be directing our attention to in the future. There are evidence-based prevention strategies. I will hone in on the prevention strategies because I'm here representing the Department of Public Health, but I don't want to downplay the importance of treatment and a first response. But primary prevention is key to making sure that we prevent people from experiencing substance use disorder in the first place, and awareness at the community level among our teenagers, among people who may be considering experimenting with substances. These are key strategies that are evidence-based and are supported by both the federal government and also by this Administration. I would encourage people to we've heard it again and again in the panel so far primary prevention, secondary prevention, and treatment, as well as thinking about our public safety approach, we are all needing to work together on this.

Assembly Member Bonta, I appreciate your candid question, and I want to dovetail on the interdisciplinary approach highlighted by my colleague here and also recognize the Macro program in Oakland, which is a community paramedicine expression of community paramedicine. I recently sat on a panel with them at the National Association to End Homelessness. And now why is a paramedic here talking to you about shelter access and homelessness? It's because I'm sure my colleagues would agree we cannot treat folks or change their trajectory if they're living in a tent on the sidewalk, full stop. Thanks to Chair Haney's work in San Francisco. San Francisco provides more permanent supportive housing per capita than anywhere else in the Bay Area, probably California. I can't say that with confidence, but certainly the Bay Area San Francisco provides more shelter beds per capita than anywhere in the Bay Area. And as UCSF Benioff Health and Homeless Initiative figurehead, Dr. Margot Cachell would tell you housing is healthcare. And when we talk about where the gaps are and where we're failing and what we're missing, it is housing folks. And that's a fundamental. We cannot ask folks or treat folks effectively if they are not housed or sheltered.

And I would say access to treatment is critical. We're running an economy here, economics. Because if fentanyl, heroin, and other things are easier to get to than treatment, then we're going to lose that battle. Whatever actions you can make to both incentivize treatment, compensation for the providers as well as incentives to alternatives to criminalization, all those things are going to be necessary. Because if it's the choice of either getting fentanyl from the street, which is just a text message away, or going to see a doctor, that you have to make an appointment that you have to wait for at some point, I think all the efforts I hear here are the efforts that we need to fill in those gaps. But in the end, treatment needs to be easier than the alternative.

Let me move to the last question. Dr. Wood.

Yeah. I'll be brief. So, first of all, just a comment about telemedicine. I'm very supportive of telemedicine, but I will tell you, in some of the communities that I represent, we still don't have broadband. So the idea that you're going to get to some of these communities and we have some of the highest rates per capita of overdose. So when we talk about our communities, we need other modalities as well. And we need flexibility. So many times our state policies are very rigid and very process oriented with lots of feedback and such. And in some of the communities I think we're doing that. Groups are doing a good job, but there's not flexibility. And I think that's always an appeal. So it's appeal to our partners from Department of Healthcare Services, from Department of Public Health. We need flexibility in that. And then just understand, Department of Public Health has an awareness, public awareness program in this. Do you have data on this? How is this working? What kind of data? Do you have to say that we're headed in the right direction?

It's a great question. So our public awareness campaign was only just recently funded in the current year, current budget year. So what we are currently doing is developing that evaluation plan, including setting up all of the metrics that we will be tracking over time. This has received three years of funding through the Opioid Settlement Fund, and we will certainly be able to report back on some of those metrics, including not just the impressions. And in terms of how many people have seen the ads. But in terms of how many minds we've changed, how many behavior patterns we've been able to change and whether we actually had an effect. We are going to be working with an evaluator on this project and certainly we'll be able to provide that information at a later date when that's available.

How long is this going to take to roll out?

Well, the media campaign itself hasn't even been on air yet, so we're rolling out our media campaign and evaluation concurrently. And with the current timeline, we would anticipate that we would have some data available within the next year or so.

Actually. When is this going to roll out? You said we might have data in year, but I'm trying to impart a sense of urgency here. So when is this campaign going to roll out?

There is absolutely a sense of urgency and we are moving about as fast as a media campaign can move in this space. Considering that we received our funds July of 2022.

I guess I would just reflect Ms. Didier has been speaking to school groups and has reached about 70,000 kids and having an impact.

Just to jump in really quick. We have been running through the Department of Healthcare Services, the Choose Change California campaign, and that has been a statewide media effort. We've had over 3 billion impressions, but what's important is it directs folks to treatment sites. We've had folks over a million times go to different treatment sites or go to our treatment locators. So we've been kicking off that campaign and then our partners at Public Health will be rolling out their campaign campaign. So I just want you to know that there is messaging out there now about really destigmatizing mat and directing folks to get to treatment services and then our partners will be taking over with this campaign that's more focused on the areas that were discussed.

Thank you. I want to thank the panel. I had a few questions and also a comment following up on Dr. Woods point. I think one of the things that can happen when we get hit in such a short period of time, with such an overwhelming, deadly epidemic, we can and should be proud of the progress that we've made in the response. And I think we're doing a lot that's innovative, we're doing a lot that's new, we're spending a lot more money, but we're also losing. If you look at the scale of the death and the devastation that is hitting our communities and our state, it's overwhelming. We passed out some numbers here, 786 deaths from fentanyl in 2018. In 2021, it was nearly 6000. In 2022. We can expect that it would have been much more than that. And the scale of the impact is exponential. And so how do we bring ourselves to a response that meets that scale and that rolls out at the speed and the pace and the breadth of the challenge that we're facing? I think that's not on any single one of us who's here, but it's on all of us to demand that level of urgency similar to what we demanded when COVID-19 came to our state. And that's what I hope that we can step up to the challenge of. Because I think if we continue to act in the way that we're acting, even if it is so much more than we did last year, we are not going to meet the scale of this epidemic and we are going to continue to see an exponential increase in the death of people in our state on two points. And maybe any of you can, can address these two questions. You know, one is I, I do support harm reduction. I also believe that harm reduction when it comes to fentanyl, must be different. Fentanyl is dangerous and can kill people in a way that any other drug that I'm aware of, that we've used harm reduction for, is different. I don't believe there are long term fentanyl users, nor will there be. If you continue to use fentanyl, even if someone is providing you with safer ways to use it, you will eventually die. And you will die quickly, based on all of the data that I've seen. So one of the things that I'm wondering is how we are adjusting our harm reduction strategies to support the urgency of moving people off of this drug that we know will ultimately kill them. And it's different in that way even than heroin. Whereas you said that tragically and terribly, the good old days of heroin. People used heroin for a long amount of time and didn't die. They will not use fentanyl for very long. They will die. And so how do we change our strategies in light of that. And then for Mr. Mason, I think that one of the things that I would like to see, and maybe Dr. Kan can address this as well. How do we make sure that everyone who is addicted to opioids or at risk of an overdose is assessed appropriately and immediately with the lowest barriers possible enrolled in medication-assisted treatment? We see far too many people in our city. And thankfully, you all are stepping up and actually applying and administering suboxone on the way to the hospital because some people will literally jump out of the ambulance or as soon as you get to the hospital. They'll run away because their body is telling them that they need more of this substance because it's physiologically impossible to resist it. Suboxone can help with that. But then when they get to the hospital that wait time, those barriers that are there and the follow up that doesn't exist and we lose them. And so how do we close that gap for people who we absolutely need to enroll in this type of treatment? And how do we set real goals and hold ourselves accountable so that there's a real if we look at the data, we have a certain percentage of people who we know are addicted who are coming into and being enrolled in medication-assisted treatment. There are not enough people right now who are enrolled in it who we know can save their lives. So that's the one long comment I'm going to make today as chair. But if any of you could not all of you, but one or two of you address that and then we're going to move on.

What I can speak to you is that harm reduction is on the continuum of care. Harm reduction is one of the best spends that there are because they're addressing the people at very greatest risk for overdose. So adequately funding harm reduction is critical. Innovations such as EMS starts for buprenorphine is also critical. 50% of people who get 911 called on them, they're usually not calling themselves never go to the hospital. So EMS is the greatest opportunity. I presented one slide, the order of public interventions that can reduce fatal overdose deaths. The number one intervention is Naloxone distribution to people who use drugs or people who are at risk of using drugs. Second place is treatment, and it's a distant 2nd. Third place is syringe service programs, harm reduction programs. So in order of scale, we need, if California were to manufacture Naloxone, allow for easy distribution with either a text message or a click of a website, that is potentially one of the most life saving things that you can do. I've spoken in my community. I have personally written over 30 prescriptions to other, frankly, friends for their kids. They're fearful, and so therefore they have access to that level of protection. But we need to focus on the areas at greatest risk, and it seems like the risk is everywhere, but the interventions that the state has been doing have been promising and hopefully will continue to keep people alive.

Chair Haney, I want to thank you for your comments. You may remember we rode together for a shift several years ago on EMS Six, one of our community paramedicine frequent utilizer programs. And I think you have a unique perspective on the needs of your district and of California districts to speak to some of the topics you brought up when it comes to making sure the people that we encounter get the care they need. I want to point out the California Bridge program and organization that is linking EMS and hospitals special overdose receiving centers, funding substance use navigators in hospitals, and allowing paramedics to bring those folks directly to specialized sites that have that enhanced services. I want to recognize San Francisco and other counties in the Bay Area that have data systems and automated referral systems and surveillance systems so that anytime a paramedic knows or encounters someone who has overdosed, they are automatically flagged and our colleagues in the Department of Public Health receive a referral to follow up with them. But I also want to point out that when we encounter an unhoused, unsheltered individual who overdoses and we can't get them a shelter bed, it is extremely difficult to follow up with those folks. That's just being pragmatic. And I want to end by pointing out that Cherohaney's comments, when the overdose deaths go up, we are failing. There is no way around it. And I would encourage us all to take a candid look at our outcomes and our interventions and evaluate rapidly, quickly, and candidly what is working. Invest in that and focus on those interventions.

Thank you. And Mr. Blacksmith, I cut you off earlier if there's ever anything you want.

No, just the onset of this issue and the evolution of the infrastructure support. The response is just not far behind. So consistency, follow up, and hopefully we get some good action coming out of this session. Thank you.

Thank you. I want to appreciate all of you in your work and the partnership and the commitment that we have as Legislators to work with you all to confront this epidemic. We appreciate it. Thank you. I am going to because we have Mr. Thurmond here in a much, I think shorter. I apologize to the larger panel that I know who has also been waiting. But we're going to bring up the Education and Youth panel, which I think will be shorter, and then save the last panel for the longer conversation around the legal and law enforcement response. So we have Mr. Our state superintendent, Tony Thurmond is here, as well as Dr. Marty Lunch, if you could please come up. And we are going to cover the issues of education and prevention and then move to the next panel. So first we have Mr. Thurmond.

Thank you, Mr. Chair. And to all the chairs, to all the members, to the staff, thank you for the opportunity to provide a few highlights on behalf of our schools on this important panel. I'd like to just first start by just acknowledging families who've had a loss, who've lost a loved one. This is devastating and no one should have to experience this. And as each of the legislators has pointed out, there are resources to do something about this. And we must move with the speed and urgency that each of you has spoken to to save lives. Schools are very much in this conversation, as you all have noted, more than 6500 opioid deaths, 5500 of them related to fentanyl, at least 200 according to 2021 numbers, teenagers between the ages of 15 and 19. You simply have to turn on the evening news to hear the heartbreaking stories of young people who think that they're taking something and then they unfortunately are caught up in an experience of having taken a drug that's been laced with fentanyl. As they say, one pill can kill. And so the way we are trying to approach this at the California Department of Education is to do just that help educate young people, have open conversation about treatment and prevention and make sure that schools have access to Narcan in the event of the need for a life saving emergency. It's free to our schools through the California Department of Public Health. But there's a lot of work that has to be done to make sure that our schools have it and that they use it. A school board has to pass a resolution to have a policy to say that they will have a Narcan policy. Staff have to be trained. Many of you talked about having healthcare personnel at our schools. You know, many of our schools do not have a nurse or healthcare personnel. And so there have to be trainings for staff at the school districts to have access to the training and to be able to use the Narcan. I would just note that there's three and a half million dollars ongoing available and $10,000,000.01 time to make sure that there are at least two doses at every middle school and every high school in the event of an emergency. I would also note that there are dollars that schools can use to educate about the dangers of drug use and treat and support substance abuse education. And I think we all know, sadly, young people are going to try things. They're going to experiment, and sometimes what they try could cost their lives. And so this state makes community schools dollars available for substance abuse prevention. That's $4 billion. Another $8 billion through our learning recovery block. Grant. There are federal dollars that every school district has access to title $4 that can be used for drug education. There is a shortage of counselors in our state, and many of you worked with us last year on legislation that was folded into the budget that allows us to now be able to recruit 10,000 more mental health clinicians to work in our schools. And until they are in place, we do have to use every method that's available, whether it be telehealth, mental health, or local counselors. But there's a number that a student can call any time of the day, seven days a week, if they need help, if they're dealing with depression or mental health or they need to be connected to substance abuse. And that is simply to call or text nine, eight, eight. We can't say, that enough. It's 24/7. There's a trained counselor available to take those calls from students if they text or call. Nine, eight, eight. By the way, that's a statewide number for youth and adults. But in this crisis, we want to make sure that we make available information that young people can use. We've done three statewide webinars for California schools to talk to them about this. I'll tell you that some people in some schools say that we don't need narcan. And I tell them, take another look. Some people have said that students in our schools aren't using drugs. And I've told them, take another look. I don't care what community or zip code you are in. This is a crisis that we must all be thinking about as adults, as legislators, as parents, as educators, as people in the community who care. And this can impact everyone. There are plenty of resources that can help. We all have the ability to help save a life. So we encourage students who need help to call nine, eight, eight. And obviously, any one of our thousand school districts can contact the California Department of Education directly for help on how to access narcan, drug prevention, education, and substance abuse treatment programs. I'll stop there to the chairs. Happy to submit to any questions that you all may have.

Thank you so much, Mr. Superintendent. Thank you for being here and for your leadership. And we're grateful. Dr. Wunsch.

Hello, my name is Marty Wunsch. I'm speaking to you on behalf of the California Society of Addiction Medicine. I am a board-certified pediatrician and a board-certified addiction medicine physician. I really appreciate this committee drilling down to the real facts in this case and working so hard to address something that is threatening the health of all Californians. I've been tasked with three things today. Not sure I'm going to get to all three. And the first is to talk about adolescents and why they are inherently at risk. And we're just going to leave that slide up. That's the only slide I need. Okay, we're going to talk about adolescents and why they are uniquely at risk for getting in trouble with substances. I'm going to talk to you briefly about neurobiology, and hopefully I will get a little bit to prevention. So let's talk about teenagers. Teenagers. Adolescents believe they are invincible, indestructible, and immortal. If you own one in your home, you know this very well. And these are important things. Kids have to have that to face what's ahead of them. Growing up, working, partnering, getting a job, paying a mortgage. All those life tests are really scary when you're 15, and they sometimes go off to war for us, too. But I'll tell you, normal youth are more vulnerable because they like to experiment, they like to try new things. Thank heavens, right? Their brain development isn't done. Your brain's not done developing until you're 24 years old. They have decreased control in their frontal cortex up here. They are going to take more risks than normal, and they don't understand the consequences of their behavior. Many times they have a decreased awareness, and that is developmental. We know that we're talking about fentanyl today, but the drugs kids start with are alcohol, tobacco, and cannabis or marijuana. And for the first time in this country, the drug of initiation, most common drug of initiation is cannabis. And that doesn't differ if it's legal or illegal or medical. Across the nation, when we as teenagers, when we as adults say things aren't high risk, which is what we've said with cannabis, our children say, okay, I guess mom and mom and dad say it's okay, I guess I could use it. The other thing we know is the exposure and use of substances during adolescence increases your chances of developing full-blown substance use disorders by fourfold in adulthood. Although males are more likely to experiment in adolescents with substances, they're more likely to drive fast. It costs more to ensure them. Females, when they get involved with substances, have a telescoping of their addiction. They get sick really fast. So those are normal teenagers. Now, let's talk about teenagers. We really need to worry about those who are genetically at risk, for whom addiction runs in their families, because, like hypertension and diabetes and cancer, no one asks to have this disease, but when you have it, you're responsible for managing it. And we know that though European Americans have much higher rates of use and addiction. It's the black and brown folks in our communities, the indigenous people, African Americans, Asian Americans who are more likely to have health and legal consequences. And I'm sure I don't need to tell all of you why that's going on. I think we're all worried about that. And then there are kids who experience trauma. The part of the brain that helps you calm yourself in a child, it's called the hippocampus, is smaller if you are raised in poverty. It is smaller if you're raised in a place where there's gunfire and you don't know what's going to happen next. And you're spending all your time just keeping balanced. As a kid, we know that parents with substance use disorders and psychiatric use put children at risk. They're called adverse childhood experiences and incarcerating a parent is a risk for a child. So I'm glad to hear on this committee that we've decided not to incarcerate our way out of this problem. And children with psychiatric diagnoses, depression, anxiety, children who are lost in adolescence and also struggling with mental health, children who are involved in the child welfare system, children involved in juvenile justice system, children who are homeless, children who are out of school, those are the kids we need to get to and children who are learning challenged. I would like to, as a pediatrician, point to you about one group of children, neonates who are alcohol exposed during pregnancy are at special risk for getting into trouble. They may have learning disabilities. They're genetically at risk. And we don't talk about those kids and they're in our treatment centers and those kids have problems thinking. So that's my own personal little pedestal I'm going to stand on. How many minutes do I have left? Okay, well, let's briefly talk about the neurobiology of addiction. Imagine an ice cream cone with three scoops of ice cream on it. The ice cream cone is your spine and then you have going up in. Sophistication you have the fight or flight center. Everybody has it, even a cell, if you poke it will fly away. And the fight or flight center is what makes you go boo after you get in a near-miss auto collision. And that is where children who are raised in poverty and raised in traumatic areas, they don't do real well in that area. They got a lot of fight-and-flight going on. The next scoop-up is the pleasure center. Every human being, every being needs to have water, food and procreate. And we're really lucky that those three things bring us pleasure. But you know what brings us even more pleasure? Drugs. And when your kid spins on a merry go round, they're altering their state of reality. And we like to do that as adults also and as teens. And that is where addiction occurs. Now, I call it the lizard brain. And you cannot teach a lizard to walk on a leash. This is not a moral failing. This is not about controlling your lizard brain. It's about developing that top ice cream scoop, which I call the gorilla brain because there you love, there you think, there you reason. And so my patients will call me and say, oh, my lizard brain was out last night. And I'll say, is your gorilla brain there? Because you have to learn strategies to bring forth when you're triggered. So that's all I have to say to you today. I did not get to my prevention slides, but I hope I've shed some light on why our teens are so at risk. And I will tell you that overdose is the end of a tragic trajectory that begins in adolescence because addiction is a pediatric disease. Thank you.

Thank you so much, Dr. Wunsch. We're going to now open it up to questions, and comments Mr. Muratsuchi, thank you very much.

First of all, Superintendent Thurmond, thank you for joining this important committee. Thank you for sharing what's happening in our schools. I have a question actually for Dr. Is it Wunsch?

Yes. Like lunch with the W. Okay.

Did you say that teenagers that either consume alcohol, tobacco or cannabis are four times more likely for substance abuse later in life?

The younger you start using substances and most of them start with alcohol, tobacco and cannabis, the more likely you are to have a substance use disorder in adulthood. If you start using when you're twelve versus 18, you're going to be more at risk the twelve year old than the 18 year old because the brain develops and the earlier kids start using substances, the more likely they are to change their brains and move into their adulthood. More likely to have a substance use disorder.

Okay. And you said that in terms of cannabis, your average youth would not make the distinction between whether it's legal or illegal. They're looking for signals from their parents saying, oh, it's okay for me to use cannabis.

Well, as I love to say, I'm a member of that generation long ago. This is not my cannabis these kids are using. The cannabis was 14% THC I see something called dab or wax 90% cannabis. And so we need to make sure as parents and adults that our message is alcohol and tobacco and cannabis are all really scary. Fentanyl is terrifying, but most children will experiment with those three. Does that answer your question, sir?

It does. Thank you. I think I'm also of that generation. The cannabis that I consumed as a teenager is not what appears to be on the market now, but it's out there. But I want to follow up on that.

Can I make one more point about cannabis?

Yes.

Cannabis use is the number one precipitating factor in the development of psychosis in males 18 to 24 years old.

Okay.

Badaboom.

Badaboom.

Yeah.

So given that the earlier to use substances like cannabis you're four times more likely later in life. Is there evidence that with the legalization of cannabis that that has led to an increase in opiate drug abuse, including fentanyl?

I don't have the answer to that question, and I think the answer lies in different states, in different jurisdictions, in different communities. It's been very uneven all over the United States. What legalization and medicalization of cannabis has done, I will tell you that young person who is prescribed an opioid medication, say for a broken arm or a broken leg, is eight times more likely to use heroin. Don't know what it is for fentanyl, but I'm just full of scary statistics.

Okay, yeah. Well, I just wanted to clarify for the record that although I do admit to using cannabis, as a teenager, I opposed the legalization of cannabis. And and and it's precisely because of my concern that it can be a gateway drug, that it can also, as you indicated, some physiological effects, including psychosis and other effects that can contribute there's evidence, doctor, you're indicating that there is evidence. There is evidence that the consumption of cannabis can contribute to health consequences, including the abuse of opiates, including fentanyl, any substance.

We have more deaths from alcohol and tobacco in this country than opioids and Stimulants. Fentanyl is terrifying, but we got to get a handle on all of it, and all three of them are legal, for heaven's sakes.

All right.

Thank you very much, Dr. Bains.

Thank you so much for that. Back to what you guys were just discussing. America is losing its war on drugs. That's the reality of what we are experiencing. I'm also a board certified addiction doctor currently working. I've been on the front lines of fentanyl for very many years, not just today. We have seen the emergence come, and it didn't happen just this past year. So I was very disappointed to hear that the campaign has started just this year when we've been experiencing it for years. So California has a real lack of preparation and foresight of what's around the corner. I think that's a reality that we can all agree to. And second, while we're here sitting talking about fentanyl and opioids, there's an emerging benzodiazepine that are killing people right now. So as we are very trying to get narcan into schools, we got to get ready for what's about to happen when this high potency benzo hits our schools. That's a reality. What, are we going to keep having these committee meetings every single six months when a new drug emerges? The reality of what's happening is we're losing our war on drugs. And a big critical thing is what we heard before, the panel before, is we've submerged our culture with drugs. But where is the access to treatment for our people? Yes, we have given children access to a lot of high THC potency that's out the window compared to what it was. Where's the treatment? How did we open up the floodgates for everyone to have drugs, but we didn't open up the floodgates for treatment. This is absolutely our fault.

Thank you, Dr. Bains, for your work in addiction medicine or addiction psychiatry, and along the lines of teenagers. I didn't talk to you about the developmental stages of teenagers, but treatment for a twelve-year-old is very different than treatment for an 18-year-old. A twelve-year-old's worried about the changes in their body and these hormones, and I'm growing hair in places I didn't want to, and an 18-year-old is facing getting a job, getting married. So we have to tailor adolescent treatment. Children are not little adults and we don't have enough adolescent treatment. And so if I ask a pediatrician to do screening and brief intervention and they find something, where the heck are they going to send that kid for treatment?

How much time do we have to be able to address that in the two minute patient time that we have with them? The other reality that's hitting our streets right now is, and I was discussing this with Cecilia right now, is yesterday I was told about three fentanyl overdoses in my community. Narcan failed to resuscitate these people. So while we are again trying to put so much money into Narcan, there are new emerging drugs out there that are claiming the lives, and Narcan is not the answer right now. This is a reality that will probably hit the press in a week or so. We're seeing it on the front lines right now. First responders are showing up to fentanyl overdoses, and Narcan is not resuscitating them. And I fear that's probably because there is trank that's being laced into drugs right now. The early onset cardiac arrests that are happening in our adolescence that's directly related to substance use.

Through the Chair, I would just simply say to the members here, the Legislators here, the California Department of Education stands by to work with any Legislator who would like to have help with school districts in your legislative district getting access to prevention, health, education, and certainly access to emergency resources. I think the point everyone's making here, and I think Assembly Member Bonta made it a few moments ago, we are always behind. Before the pandemic, we only had about a third of the mental health clinicians that we needed to have everywhere in this state, and we had even fewer in the rural communities that Assembly Member Wood, Chair Wood always talks about. We haven't had the personnel, and so we are always behind. But we do have access to resources. Our schools do have access to resources, but they need help. Our schools are trying to balance all kinds of things. Our schools are trying to balance learning gaps that grew during the pandemic. They're trying to balance rates of depression that have grown. And this legislature has given them a tremendous amount of resources, and they're trying to figure out how to implement those dollars. Having said that, again, our promise and pledge is the same. We will help any school district that's wanting to figure out how to get access to education, prevention, substance abuse treatment resources using the dollars that you all have provided for them and how to get connected to these programs and how to have life-saving drugs in the event of an emergency and the need for life-saving resources.

All right, I have five people who are lined up. If I can ask everybody to be as brief as possible and also with the answers because we have a panel that we jumped over who's been waiting about 3 hours. Ms. Ortega.

I will be very brief. First of all, I want to thank you, our state superintendent, for all the work you're doing in our schools across the state. And also personally thank you for attending a community hearing that I had on Fentanyl and the crisis where I had over 100 parents, community members, constituents come out to learn about what's happening in the community and how to educate others. But one thing that stood out to me in that hearing or that community event that I held was a comment made by one of our health officials who said that they had been trying to educate more people in our community about this crisis. And they had maybe four, three or four people attend their educational sessions. And so how do we, with the resources that we have, with all the information that's out there, how do we increase the number of students, parents that have access to the information more quickly and more effectively as we deal with this crisis today?

Thank you, Assembly Member Ortega, and thank you for having had the event in your community about the challenges and the dangers that our students are facing around Fentanyl. Simply put, schools have to get better at doing what we call family engagement and how do they communicate with families, in a way, right. Families are busy also. And having folks who are from the community who know how to navigate, getting to parents who can speak multiple languages, who can figure out ways to make sure that families get this information, is key. And again, we're willing to work with any school district that wants help and how they do more outreach and better outreach. It's a challenge for all of us. There's no shame, there's no blame, but we're willing to help. And I know that Dr. Wunsch is willing to go to any single school district because she's letting me know any school district to talk about substance abuse prevention and treatment and support.

I did in both my kids schools who are 35 and 40. And I still have their friends come up and say, you talked about science. You didn't just say no to drugs. It works. And I thank the moms who testified today.

So thank you both for being here. It's nice to see you, Superintendent. And Dr. Wunsch, thank you for being here. I had two questions, one directed at Superintendent Thurman. Can you give us a sense of how many school districts are actually engaging in sort of broad-scale education for kids and families through the schools, and whether or not you feel like you need additional authority in order to expand education efforts in the schools? That's one question. And then to Dr. Wunsch and to you, if you'd like to answer this. I remember that a lot of the conversations, one of the comments that was made earlier was that we all need to be having conversations, those of us who are parents, with our kids, ourselves, about these issues. I remember back when I was growing up and when I was younger, the education that was recommended at some point was just to tell kids to just say no. That didn't seem like a very effective conversation at the time. And I'm just wondering if you could talk a little bit about what effective conversations look like with our kids, what the messages should be, and whether you've thought about whether or not there can be some more education for parents about being effective in having these conversations. Thank you.

Thank you. I've been told to go first, so if I get the assignment wrong, Dr. Wunsch is going to correct my notes. I think the best communication is peer education, to be perfectly honest. We have to have real talk conversations. If we talk at kids and talk down to kids and just tell them, don't use drugs, we all know what the reality is for our schools. Our schools have historically funded great tobacco use and prevention programs. We call it Tupay, but those programs are sort of time-limited funding. It's budget season. I'll just put it out there for the California Department of Education to help more than 1000 districts. We need more staff who have special skill, who can support schools thinking through the issues of prevention and education. Let's be real. Our schools don't have expertise. Our schools don't even have nurses. So we can't expect them to have expertise in how to talk about any substance abuse prevention. Now, that's not to say that they're not doing it. They're incredible counselors and staff and peer educators and programs that support schools, but they need more resources. And we at the California Department of Education would love to be able to engage with them and how they engage with students and families in doing peer education, appropriate youth education around substance abuse, and getting folks into treatment if they need it.

Thank you for that question. Prevention isn't very sexy, but it really works. And I think bringing a good prevention program into whatever community setting that works, sometimes school doesn't work because parents don't want to go there, and teaching parents about talking with their children about all sorts of things works. How you talk to a child depends on their development. You're twelve years old. Maybe some of your friends are trying alcohol and tobacco. How about you listen, you talk to a middle schooler and an older schooler differently. But opening the communication channels with prevention between children and their parents across the board through prevention decreases risking behaviors, decreases disruptive behaviors, increases parental engagement, parents feel more effective and there are lots of evidence based prevention programs that we should be using in California in all of our communities. Thank you. It's great to see our superintendent here back with us in the assembly. And I just had a quick question for Dr. Lunch. You may have answered it really but with the prevention side, what's the biggest takeaway that you have? Is it communication or is there some other tool that we could use in prevention? Thank you for that question. Prevention, that's theory based and draws from multiple disciplines and subdisciplines with specific components, works. Prevention that has strong research designs, strong evaluation designs, strong assessment tools and that delivers some main ingredients, as I said about communication and prevention has to remain effective in different circumstances, different cultural venues, different socioeconomic venues. And the other thing about prevention that's very successful is you have to capitalize on protective factors in addition to risk factors and say, wow, you have dinner with your kids every night. That's incredible. That is actually linked. That is an indication of how well your children are going to do. We have to prevent poor regulation and conduct disorders and address them in kids. And we have to look at the whole here's the child, here's the family, here's the community. You got to do it at all different levels. And I really appreciate we're going to have a media campaign. So that is actually the contents of one of my slides that I didn't get to. And I will tell you that often prevention works, seems to only work short term, but actually the intervention effects last far beyond the intervention and are clinically valid beyond statistical significance. So you got to get your university wonks to talk to your community folks and get that dialogue going. I hope that answers your question.

Yeah, thank you very much. I mean no disrespect to this panel, but I want to shift the conversation because I think it's about time that we talk about something that's uncomfortable. Apparently. I know this is a multifaceted problem and it's a very, very powerful driving discussion and we're very rich on discussion in this body. Very rich. But we're starving on effective action. Let me just remind everybody here that we have many in our society that don't respect life. It's time to talk about the distributors. Not just the people that are falling prey to this substance, but the distributors folks. Why aren't we talking about how to deal with them?

It's the next panel.

Well, I preempted I've been here three and a half hours. I was. Hoping we'd at least talk about what I think is the most important aspect. And I will give them a chance to talk about that. And I look forward to that conversation. But let me tell you my frustration. My frustration is very simply, we refer to the problem and how we dealt with the 90s drug problem. We mishandled that. Clearly, as a conservative law enforcement person, I will tell you and admit we mishandled that. But this is a different problem. This is a poison, a very, very toxic poison. And we talk about addiction, and certainly that is not to be dismissed. But it's not the only problem. And quite frankly, I think the bigger problem is we have distributors that don't carry about life. And it comes down to three words. Three words, everyone. Risk versus gain. That is never going away. That is a fact of life. We teach it in behavior modification. I have a Special Ed degree. You don't have to have an advanced degree to understand risk versus gain drives behavior. And right now, for some reason, we are afraid to confront that reality. And shame on us because we become partners in this tragedy when we don't take action. So I'm hoping that this body and this collective discussion piece will result in some kind of action that will address that risk versus gain, because that will never go away. And it's a stark reality. We don't need to repeat what we did in the 90s because those were victims. Those were victims that had circumstances that were out of control. These distributors don't have that problem. So why do we equate it? I'm over it. And I hope that we will actually be responsible and take some affirmative action. And that's all I have to say. And I'm sorry you had to endure that.

Assembly Member Lackey. If I could, through the Chair, I would simply say that all of our conversations about how we approach this problem, we include and invite law enforcement to the table to be a part of the discussion. Everyone has a role to play. And while education doesn't have a direct way to handle the issues that you've raised around distribution, I would be remiss if we let you think that when we are talking with the Department of Public Health and when we're talking about substance abuse and prevention. We're not also talking about law enforcement partners who are very focused on where the drugs are entering our school communities and our communities from. We have those broad partnerships, deep coordination, deep collaboration. And I would just give great shout out to all the educators in our schools, including some school resource officers and others who've been very integral to this process. Thank you.

Thank you all. And thank you so much to our panel. Thank you, Mr. Superintendent and Dr. Wunsch, for your work and for your partnership. As I'm sure with any of these individual panels, we could have had an entire hearing on this, and I'm sure we'll be following up and hoping to work with you as a select committee moving forward. And thank you so much for your time. I want to invite up now thank you, our last panel, and to thank them so much for their patience and for joining us today. Mr. Wolry, the director of the Bureau of Investigation at the Division of Law Enforcement for the California Department of justice brendan woods, the public defender of Alameda County michael Mendoza, director of advocacy at the Anti Recidivism Coalition diana Becton, the Contra Costa district attorney and Netto Urias, a sergeant in the special Investigation section at the Stockton Police Department. Welcome. And again, thank you so much for your patience and for being with us here today and also for my colleagues for sticking with us and for spending time on such an important topic. Again, this is the first hearing, and as Mr. Lackey said, we will need to go in much greater depth to all of these topics. And I'm grateful for everyone's participation today. So I will start with Mr. Woolry.

Good afternoon, everyone. My name is Stephen Woolery. I'm with the California Department of Justice. I'm the director for the Bureau of Investigation, Chairs, Co-chairs, distinguished members. First, I want to thank you for holding this event, and I want to thank everyone who is here today for taking the dangers of fentanyl seriously. Conversations like these are critical to spreading awareness, prevent, and preventing fentanyl related deaths. I just want to throw out a couple of statistics, because I know we've been here all day and we've heard a lot of data, but something that really sits with me is fentanyl related. Deaths among children have increased more than 30 fold between 2013 and 2021. Something else that sits with me according to the DEA, according to the Drug Enforcement Administration, fentanyl is the single deadliest drug threat our nation has ever encountered. Fentanyl is everywhere, from large metropolitan areas to rural America. No community is safe from this poison, including our tribal communities, this synthetic.