Senate Standing Committee on Health

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All right, now we are going to begin the committee opening comments for me just to say I'm very glad to be here with my new colleague, chairing public safety. As we know, the opioid crisis has continued. And as that has continued, fentanyl has found its way into the stream. And I'll just say, just for the record, since the beginning of time, we can look back in history and the old coffins and tombs, and that we know. From the beginning of time, people have found ways to numb themselves, have found ways to alter their consciousness, and certainly, as time has gone on, people have found more and more creative ways.

We have historically tried to work with issues around addiction through a multi type of means, one through penalizing that, but we're trying to move more towards a foundation of a public health crisis, of harm reduction, and as a social worker, I always like to make the point that we can always try to find ways to stop the supply, but until we really decrease the amount of people who are wanting to alter themselves in really numbing ways, we'll continue to struggle with this.

So as people continue to struggle with food insecurity, housing insecurity, undiagnosed illness and self medicate in all kinds of ways, we'll continue to have these struggles. So hopefully, as we have this hearing today and hear from our experts, we hold that in our hands at the same time that this is an issue that everybody faces at some level, and we're currently today talking about fentanyl, but we acknowledge that as part of a greater issue around addiction and self medication.

To my cohost.

Good morning and thank you for joining us today for this joint hearing with the Senate Health Committee on the ongoing opioid crisis and fentanyl crisis.

This is my first hearing since being sworn in to the Senate, so bear with me as we get into the swing of things and I lean on Senator Eggman's expertise. Today, we will see the public safety and health perspectives that have shaped and continue to shape the state's response to the challenges of the widespread presence of opioids, and specifically fentanyl.

There's a great deal of misinformation, trauma and harm around this issue, and it's a priority to many residents in California. This informational hearing is to hear from the experts, learn the facts, and see what we can do as a state to help our residents.

At this hearing, we will hear from researchers who have studied addiction and opioid misuse, an attorney from the Committee on the Revision of the Penal Code who will lay out existing law as it relates to drug offenses, a district attorney who will discuss the office's approach to investigating and prosecuting drug related offenses, particularly in light of their increased presence of fentanyl in the community, as well as a police officer who chairs the California Narcotic Officer Association and a drug policy advocate.

We will also hear from staff from the Department of Health Care Services and the Department of Public Health regarding the state's programs that are designed to address the opioid crisis, as well as representatives from a healthcare system who will discuss what is happening at the local level.

It is my hope that in having the hearing today, we will all leave with a better understanding of how the state has responded to the opioid crisis and what work is still left to be done. Thank you again to our panelists and for everyone joining us. Would any other Member of the committee like to make opening remarks?

Senator Nguyen.

Thank you, madam Chair and colleagues. I just want to briefly make a few comments this morning, especially in regards to Orange County, and sadly, Southern California has really become a ground zero for the fentanyl crisis in the state.

In just 2021, there were 717 fentanyl related deaths in Orange County, and of that number, 20 of those cases were minors. In fact, our sheriff's Department and the sheriff's Orange County coroner's office reports that fentanyl related deaths was a leading cause death for persons 17 and under. Over the past six years, there have been over 12,000 deaths in California, and over 5000 of them happening just in '21.

These numbers show that we are past the point of crisis. We are facing a problem bigger than we are willing to admit, and we have a responsibility to find solutions to ending this crisis. Last year, my colleagues and I we've introduced some bills to address a fentanyl crisis and one of which I author AB 1955, which would have aligned the penalty for possession of fentanyl with that of other drugs like cocaine and heroin.

My Bill was targeted just to dealers and traffickers and would have taken them off of our streets. But unfortunately it was defeated and the problem has only continued to grow worse. And I've reintroduced that Bill this year as SB 62. And just a few more comments in just 2022 this year, I mean last year, our Orange County Sheriff's Department seized 449.9 pounds of fentanyl and 405,283 fentanyl lace pills, a significant increase from the 132.9 pounds and 16,278 fentanyl lace pills seized in 2021.

Those numbers should scare all of us. Those numbers represent thousands more deaths and hundreds more broken families. As mentioned, I truly believe we have a crisis on our hands. Our children are dying, mothers and fathers are dying. Communities across California being impacted every day by fentanyl. And I hope that today we've spent not just listening and learning, but that we will have a pathway to ending this crisis.

One thing as a mom of a ten year old and a twelve year old, what breaks my heart is when last Halloween I had to tell my children to be careful with getting candies just from their friends because they might not even know when you are having fentanyl disguised as skittles and smarties. It breaks my heart as a mom to say most of those candies you're going to get tonight, you're not going to be eating them.

We shouldn't be in that situation. And so again, to both of our chairs, thank you for hosting this and for making this a priority for us.

Thank you very much to Vice Chair Senator Nguyen.

Thank you. Now, let's start with our first panel. We'll now hear from our first panelist, Dr. Joseph Friedman with the Medical Informatics Home Area and center for Social Medicine and Humanities at UCLA. Welcome.

Okay, thank you so much for this opportunity to present this information to you, I'm going to be presenting about the overdose crisis in California: key trends. Quick disclaimer that the points made here. Are, of course, not necessarily representative of UCLA or our funders.

Now, the first point here is that overdose deaths min California are driven by fentanyl but also stimulants. and this is very important to understanding the nature of the sort of evolving crisis. Here you can see on the Y axis the number of overdose deaths each year in California, year is shown on the X axis.

One thing that jumps out is of course that overdose deaths in California have virtually tripled min the past ten years. Over 11,000 in the most recent year of data that is complete.

The color of each section of the bar shows you which substances were involved in each death. And we can see that by 2021 actually the most common category of overdose death involved both fentanyl and a stimulant, mostly methamphetamine and also cocaine at 33%. An additional 29% involved stimulants with no fentanyl, 23% involved fentanyl without Stimulants, and only 15% did not involve one of these two drug categories. So fentanyl is very important, but we also have to talk about stimulants and their co use together.

The second key point that I want to make here is that over the past five years, overdose rates have increased fastest in California of any state in the country. Here on the X axis, you can see the percent change over the past the most recent five years of finalized data that we have from 2017 to 2021. You can see that in California, overdose deaths increased by 130%, meaning they more than doubled in this period.

And we are unfortunately the national leader on this issue. And you can see that, unfortunately there have been increases in almost every state in the country. And it's also important to note that California had more overdoses in 2021 than any other state. Of course, we also have a very large population. But if there's one place to intervene on the overdose crisis in the US, it's California, right? If you had to pick one and this kind of reflects California.

For a long time we had stable low overdose trends far below the national average. And unfortunately, we have completely lost our advantage at this point and caught up to the national average. It's also important, the third point here, that black and indigenous Californians are the most affected by drug overdose now and I think we have to view the overdose crisis as a racial justice issue.

Here on the Y axis, you can see the death rate per 100,000 individuals from all types of overdose. On the X axis, again, is year.

And there is one line here for the overdose rate among Native Americans in blue, among black non Hispanic individuals in purple, among white non Hispanic individuals in red, Hispanic or Latinx individuals in green, and then Asian non Hispanic individuals in yellow.

And you can see that really for the past couple of years we've seen marked racial and ethnic inequalities and overdose. And by 2021, the black overdose death rate was 44% higher than the white overdose death rate. And the death rate among Native Americans was 51 percent higher than white individuals. I think over the past decade we've seen a lot of press coverage talking about the sort of white problem of addiction and overdose.

And in California that's never been true. I think that narrative has been kind of flawed for the duration of the time that it's existed, but really now we must consider these kind of sharp and continually rising racial inequalities in this key health issue.

And the last point that I'll make is that counterfeit pills are really a key vector for risk in California, and they are driving new risk among subpopulations not previously very vulnerable, such as teens in California.

So this is a recent headline from an LA times piece that says 7th LA unified School District student teen overdose from possible fentanyl-laced pills. Here's a graphic showing some counterfeit and authentic oxycodone sold on the black market.

And the point that I hope to make with this figure is that there is no way to tell the difference between the authentic and counterfeit pills just by looking at them. Our team was able to use sophisticated drug checking technology to tell the difference.

We found fake pills containing fentanyl, containing heroin, and containing all kinds of other novel synthetic drugs, but a teenager could never tell the difference just by looking at these things. And this is a new threat.

And our team actually was able to publish an article last year showing that for the first time in History the high school-aged teen overdose death rate is spiking after decades of flat trends where teens were kind of insulated from overdose death rates going up among adults.

And for the first time over the past two years, this issue is really affecting teens, especially in our state, in California, we showed that teens on the west coast were disproportionately affected, as well as native and Hispanic and Latinx teens, and this is entirely coming from illicit fentanyls.

Here you can access all of the articles referenced during this talk.

Thank you very much. And I think we're supposed to wait for questions till the end, but I have some already. But we'll go ahead.

Next we have Dr. Richard Rawson, Professor Emeritus with the Department of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles.

And welcome. Thank you both for being here.

Thank you very much. And I appreciate Joe's comments. Those are some excellent data he's presented.

I'm going to touch on a couple of different issues, first being fentanyl.

And just to give you a quick overview of some of the information we know about fentanyl. First thing that's important is to know how potent fentanyl is and how deadly.

These are what would be considered lethal doses of heroin and fentanyl.

As you can see with fentanyl, you're really talking about a number of grains of the drug.

It's about 30 to 50 milligrams for a fatal dose of heroin, about two to three milligrams of fentanyl.

And here's some of the data reinforcing what Joe just discovered.

64% of the deaths between 2020 and 2021 in the United States included fentanyl.

It's manufactured in Mexico using ingredients from China and other parts of the world.

And just to give you a sense of the potency, a five pound bag of fentanyl-if you can think of a five pound bag of sugar-a five pound bag of fentanyl would provide enough fentanyl to produce 1 million lethal doses.

So one of the huge challenges is that fentanyl is so potent that you don't need to bring very much of it across the border in order to have an extremely dangerous situation.

As Joe mentioned, it's presented in powder and mixed into all of the drugs now in California. Virtually all the drugs: cocaine, methamphetamine, heroin-all of them have fentanyl mixed in.

And we see it in these various pills that are sold as one of the methods of sales.

It's approximately 50 times stronger than heroin.

Many of the individuals who overdose from fentanyl, it's an unintended overdose.

They didn't know they had fentanyl in the drug that they were purchasing.

And often if they go to purchase cocaine or purchase methamphetamine, they end up overdosing from fentanyl.

You can overdose any number of ways ingesting the drug. Through a number of ways you cannot overdose.

There have been some reports of people having it on their skin and overdosing.

Fentanyl is not absorbed through the skin in adequate doses to cause an overdose.

And of course, the primary route for reversing overdose is with the use of naloxone.

Although the amount of naloxone may be higher than we've seen with other drugs, there are other things on the horizon.

Fentanyl is not the only one of these compounds that we've seen in other parts of the United States. We have other forms of fentanyl.

Para-fluorofentanyl has been seen in Tennessee and Kentucky.

Carfentanil is even 100 times more potent than fentanyl.

Luckily, that has not made its way. There was one incident in the Midwest two or three years ago, but luckily that compound has not made its way into the drug supply.

A second drug that's more recently been showing up, I understand there was an article in the San Francisco Chronicle last week on this drug, is Xylazine.

Xylazine is a drug that has been seen in the East Coast in Philadelphia, particularly for about the last ten years. It's now throughout New England.

It's an animal tranquilizer. It's widely used by your vets with large animals for horses and cows.

It's a common tranquilizer used. It's not approved for use with humans. It's only a veterinary drug. It's an anesthetic, lasts an hour to 2 hours.

It was tested for use as a treatment in humans, but the trials were terminated due to severe hypotension and central nervous system depressant effects.

Its main effects produces CNS depression, that is, a suppression of the central nervous system, profound sedation.

It takes a minute or two to act and lasts up to 4 hours. And the main reason fentanyl is now or Xylazine is now in the drug supply is as a way of extending the effects of fentanyl.

People don't use Xylazine by itself. They use it together with fentanyl to extend the very short acting effects of fentanyl.

Fentanyl by itself has a very brief effect, so they add Xylazine and they get a longer effect.

It's unknown on the street as a drug called "tranq," it produces its own sedation.

But people don't take it to get a Xylazine high. They take it mainly to extend the effects of fentanyl.

In the case of an overdose, even though Xylazine is not an opioid, it's so commonly used with fentanyl that an overdose needs to be treated with naloxone the way you wouldn't with an opioid because probably the main lethal drug in the combination is not Xylazine itself, it's the combination with fentanyl.

One of the unusual effects of fentanyl is it produces wounds, open wounds, ulcers on the skin, not just on the injection sites but all over the skin, on the legs, on the arms.

These ulcers develop very rapidly. They get infected quite commonly and they're now part of all the harm reduction packages need to include wound care for this effect that fentanyl produces.

And even in New England, where I am now, we're seeing a lot of this. The emergency rooms are seeing a lot of people coming in with these wounds.

I was asked to also make a few comments about the nature of addiction and substance use disorders.

Just to clarify that we're not dealing with a moral issue here.

We're not dealing with an issue of some soria of psychological malfeasance or disorder. But addiction is a complicated, complex disorder.

Why do some people get addicted and others do not? Initially, a person takes a drug hoping to change their mood, their perception or their emotional state. It makes them feel better.

That is, it translated into-they like to change their brain. They hope it changed the way their brain reacts.

Why do some people get in trouble with drugs and some people get addicted and others don't? It's because the vulnerability to addiction is in part genetic and in part in terms of the environment that the person has lived in.

But we now think of addiction as a brain disease.

The major reason people take a drug is to what it is because what it does to their brain. After a while, they can't stop.

Why can't they stop? Because their brains have been rewired. Addiction is a brain disease. But it's not just a brain disease.

There are other things that go into it. We have genetics, we have the environment, we have trauma.

And all those things go into determining who is it vulnerable to getting addicted, who will get addicted, and who are the people that will need treatment. And I will stop there.

Thank you. Our last presenter is Dr. Darren Urata, a research psychologist at UCLA.

Thank you for having me.

I just have a few slides, three, I think, which I now realize you probably won't be able to see very well in the room because they are incredibly dense. Sorry, we got to go past that.

I'm at the UCLA Integrated Substance Abuse Programs where I work with the state as the independent evaluator of a lot of the things that DHCS is doing.

There we go. Okay. So this is just a list. It's okay if you can't read it. The whole point of this list was just that there is a lot going on right now, which is a good thing.

There's a lot of funding coming in, which is also a good thing from many different sources.

So UCLA Isap is working in some ways on evaluating some of these projects in depth, and in other cases, monitoring them, collecting information from them on a quarterly basis through a data portal that we've created.

And so what we're struggling with right now is because there is so much going on, that how do we get this to policymakers both at DHCS and for legislators to understand what's happening out there? Traditionally, we've created these huge 200, 300 page reports, and we know it's hard for us to read it, much less those of you who have very busy lives.

So what we're working on right now is to put things into more dashboard form and data briefs. And so this is just an example.

Again, you probably can't read it very much, but these are just some shots from a dashboard that we have up currently just for SOR Two.

Now, there's been other things. SOR one, STR, DMC-ODS, a whole mishmash of acronyms. But this...just to give you an idea for SOR Two.

There was about 80,000 patients that started on MAT, things like that. And you can look at charts of either by project over time.

If you add in other projects, it's over 100,000 people. There might be some data issues with double counting, things like that across projects, but it's a large number.

But clearly it hasn't been enough to reverse the overdose trends. But it's been a lot. And we think that if these efforts hadn't been underway, then it would have been worse.

And we are undertaking a matter expansion impact analysis right now in the hope of trying to tease out, well, what would it have looked like if those efforts hadn't been in place.

These are just some ideas about what could be next that we've come to from our analyses or for talking to people from surveys, from interviews.

A lot of the stakeholders talk about continuing medication expansion, contingency management for stimulant use disorder, naloxone distribution, fentanyl strips, taking advantage really of... Recently, the requirements for the buprenorphine X waiver have gone away, giving us a new opportunity to reach out to new providers who might be able to start prescribing buprenorphine that hadn't considered doing that before.

Eliminating disparities is very important. Expanding beyond the SUD programs where right now there's a statistic that SAMHSA, the federal government, often puts out about 95% of the folks who don't get treatment. They don't think they need treatment.

So we can't just wait for them to walk into a treatment, especially substance use treatment.

We have to go out and get them integrating with primary care with harm reduction waiting for those opportunities when they are ready, so that we will be ready.

We need to address short term funding challenges. A lot of times it's these federal grants.

They come in two-year batches like SOR, and it's hard to plan and build out, not knowing if it's still going to be there in a couple of years.

I realize that's partly a federal problem, but we can advocate for it.

Youth prevention, lowering barriers to getting treatment and enrolling in Medi-Cal, those are just some ideas.

Happy to talk further and happy to take your input on what would be useful to have on things like our dashboards and our data briefs. And that's all.

Thank you, and just a reminder to the public that everybody's slides will be available for you on the Health Committee's website.

Thank you to the presenters for our first panel. I want to ask our Committee members if they have any questions.

Senator Rubio.

Good morning. And I'm not sure who said this first, but I'm hearing the committee from my office. I heard someone say that it is created across the border in Mexico. Do we know any other areas that it is manufactured?

Fentanyl has been manufactured the last five years.

The ingredients for fentanyl, the precursor chemicals come primarily from China and India. But they are turned into fentanyl on the west coast of Mexico in laboratories there.

About six to eight years ago, they were given the recipe for how to create fentanyl, how to manufacture it.

Before that, the only source of fentanyl was from pharmacies where you were getting pharmaceutical fentanyl.

But what is now on the street is virtually all manufactured in Mexico, as far as I know.

Do we have knowledge of activities going on that have been discovered in the last year or so here in the states where now they're being manufactured here?

Not that I know of.

Senator Menjivar.

Thank you.

Thank you. Good morning. Dr. Urada, you spoke about the lowering barriers of treatment.

You know, some of the concerns I hear that people are turned away for lack of insurance or that rehab treatments are only 30 days long, and that's not long enough.

But through CalAIM, we're trying to integrate everything with SUD, under SUD, under the mental and physical health of the individual.

So we're addressing that demographics, but there's still individuals that don't fall into that low, low income and still don't have insurance.

Are those some of the barriers that you spoke on, or can you speak on other barriers in specific?

I think all of that is true. I think even among the Medi-Cal population, it's important for us to make it as easy for people to get into treatment as possible and to integrate with things like harm reduction so that when they're ready for treatment, they will get linked to it.

I think there are important parts of drug medical organized delivery system which is now part of CalAIM like ASAM assessments that I think the idea is that we need to get them into the right place, the right level of care.

We also have to make sure that because these are often lengthy assessments, it doesn't stop people from getting care when they're in crisis. And so I think the HDS has done a good job of trying to create flexibility.

The assessment doesn't have to be done on Day One, but I think there's a lot more that can be done.

I'm not an expert in medical enrollment, but I've heard complaints from stakeholders in the field about that. That gets in the way when people are homeless and they need to get into treatment quickly. So I think we need to look at processes like that also.

Thank you.

Senator Wynn, did you have a question?

I do. Are there any way in this state that we can figure out an avenue to help law enforcement, like example, through banking, pharmaceutical, or trade with other nations that produce and sell these drugs? Is there any studies outside of the state of California? Maybe other states are doing that's working with these other entities?

We focus on public health. What I will say is that I think, unfortunately, law enforcement-based approaches simply won't be enough to handle this kind of issue because I think there's just a really big demand for these kinds of products.

And so what we've seen across the board is that absolutely there's an important role for kind of minimizing the availability of the most harmful substances in our society, but it has turned into a whack-a-mole, right, where you take one dealer off the street and then there's another dealer in their place the next day because of the kind of market economics of the situation.

And there's this huge demand in our country for these products. And unfortunately, as we've kind of thrown more and more money into cracking down on the availability, we just have kind of more pure, more dangerous products flooding our streets.

So I think instead of this kind of whack-a-mole of hoping to kind of use sort of militarized forces in other countries and police in our country, I think what we have to focus on is kind of the details of the lives of people who are suffering from substance use disorders and how we can best support them to kind of prevent overdose from happening in the chaos of a substance use disorder.

May I? I know that we've spent lots of money for treatment for those who are using these drugs, right? For those who are addicted.

It doesn't seem like it's working. How much more money do you want to spend? I think you have to have two approaches, right? I understand what you're saying that law enforcement, but yet you're putting so much money into an effort that is not proving to work according to your data.

I mean, California's got the highest number of addictions and the most death in the country.

So what other approaches? We can keep on handing you money, but is it working? And I'm not here suggesting mandatory forcing people. It's just that what other approaches do we need to do to at least get us in the right direction? We're not going that direction.

I would certainly agree we're not going in the right direction. I think if you look internationally, there are some helpful examples of countries that had a rising overdose crisis and were able to reverse them. And those countries didn't necessarily accomplish that through decriminalization.

A lot of those countries still criminalized the sale of these drugs. And certainly law enforcement played a role in that, but they invested heavily in health care and social services.

So the vast majority of drug policy funds in the United States are still spent on law enforcement and criminal justice based approaches.

I think relative to other countries, we spend far more on law enforcement and kind of militarized intervention in other countries as a nation, and so we spend far less on social services, on housing, on health care.

And certainly I think treatment for substance use disorders, certain medications, is a critical piece, but unfortunately, without the kind of comprehensive stabilization from an effective safety net system, it's not enough.

Medications are not a magic bullet. People need stability in every sector of their life to be able to rebuild. And so I think, unfortunately, I think it is a matter of where we've been spending money and it's not in the right places.

Thank you. Senator Ochoa Bogh.

Thank you. Madam Chairs.

So I've had the opportunity to sit on public safety for the past couple two years and it's been a learning experience for sure.

And behavioral health is one of the issues that I'm greatly interested in pursuing and trying to address here legislatively and why I've been very eager to collaborate with my colleagues on these issues especially as it relates to homelessness and others because everything has a ripple effect.

So I have a couple of questions and, well let me begin with the comments which have to do with my colleague from Orange County.

Some of the concerns that I've heard from our public safety sector is that we don't have enough teeth. Meaning that our public safety officers, law enforcement officers don't have the ability to compel people to stay in treatment or get the treatment that they need when they are under the influence of certain opioids or narcotics.

Which leads me to the question of opioid psychosis and what that entails. Is there a, and of course someone like myself who believes in government not controlling you, but is there a point where you feel there needs to be intervention by law enforcement per se, which is usually the first line of defense unless we have certain counties like my county that has the ability to have people who are specialized in dealing with people with behavioral health issues in their patrol?

But normally it's law enforcement. Is there a point where you feel that we need to start being actively engaged in helping people make those decisions because they don't have the mental capacity to be able to make that choice to seek treatment as you mentioned earlier?

I think that's an important concept that is being looked at very closely.

But I would argue that the group that should be considering involuntarily or whatever the right word is, pushing people into health services should be the mental health system and not the police.

The 5150 for people who are in danger to themselves and others. I think many of the people we see now with severe methamphetamine psychosis and fentanyl addiction are a severe danger to themselves or others.

And I do think there will need to be some consideration of how do we move these people into mental health facilities where we can properly treat them, but they need to be treated in mental health facilities, not jails. And I think that we don't really have a system set up for that at this point.

And I do think, though, that the combination of having plenty of harm reduction services so that people are reducing the risk to themselves but for those who are so profoundly addicted and psychotic that they can't take care of themselves and they can't rationally decide, I do think this issue of finding some way to link an involuntary action because they're just not capable of clear decision making.

Madam Chair.

Yes. So I absolutely agree with you with regards to our criminal justice system not being the optimal place for treatment for many of these individuals who are actually suffering from opioid psychosis.

And I've heard this from my local shares. It's one of the reasons why we introduced those bills last year and I'm introducing them again in order to expand our mental health bed capacity in our state of California because it is one of the issues that we have in sea across.

And once again, in my effort to understand the root of the problem and how to address it, these conversations came through because of the conversations that I've had with my local sheriff in San Marino County with regards to, okay, how do we divert? And as I mentioned earlier, we do have certain counties that do have the capacity or have the ability to have people with behavioral health training in working in collaboration with our local law enforcements who drive out to meet individuals that are called upon to necessitate help.

But in that order that's why I wanted to ask to make sure, is there a point where we need to come in and intervene, especially under the notion of opioid psychosis, which is becoming very prevalent.

And the other thing, once again, going back to how do we compel people to stay within the program? And this is something with regards to the bills that we've been introducing and trying to, one, expand capacity.

Number two, make sure that we have the teeth in there in order for people to be compelled to stay in there when they've reached a certain point of psychosis.

And number two-or another question, sidetracking- I think we're on the same track.

Do we know, have there been any studies that directly address the root of the increase of behavioral health concerns within our society and our communities, our culture as a whole? What is it? What factors are contributing to this increase that we've seen in the past 10, 20 years that have, one, had an impact on the suicide levels and opioid use or overdose?

Thank you for these questions. In terms of the first area, there is already kind of medical legal infrastructure in place where if people are a danger to themselves or others, they can be kind of treated medically against their will without their consent. It happens kind of all the time routinely in hospitals and in medical facilities.

I know that there's been a number of developments around the logistics around maybe we need additional mechanisms to be kind of pulling people into those cases.

I can tell you from having been in the psych ward and in hospitals in California that police do bring people in all the time and say, "this person clearly has psychosis. Can you please evaluate them to see if they're a danger for themselves?" And that kind of triggers a health care process that in many cases does lead to them being actually conserved and losing the legal right to decide about their health care.

So it does happen. And then, of course, if someone is committing crimes against other people, then similarly that triggers a criminal justice process that in many cases may include mandatory treatment.

Right. So that's all already happening. I think the debate is kind of about do we need new mechanisms? Clearly we need new resources, right? And everybody, I think both sides of the aisle, everybody across the spectrum of these issues who works on psychosis and works on addiction agrees, we don't have enough beds, as you mentioned, and so people are brought into the hospital and clearly they have psychosis, but it's very hard to find a good kind of long term spot for them to get care, even for a lot of people who do want care.

I think the issue of psychosis is especially related to stimulants. I think with opioids there is often an element of psychosis present, but stimulants are really, methamphetamine and cocaine are really the drugs that kind of bring on new levels of short term psychosis in people.

And then as far as the second question of why is our society sort of despairing to such a big degree? I mean, I think this is kind of a social science question that I find interesting, and I've studied to a great length, and I think the best answers we can find relate to race of social inequality and poverty and lack of opportunity and advancement where people are, a lot of people are really struggling and believe that this is an unfair country to live in.

Thank you, Senator Rubio.

Yes, thank you. And the question I'm going to ask, or rather comments as well, is just based on just me trying to understand it because clearly I don't understand the use of fentanyl.

And I'm just a little curious. We're talking about right now the level of despair and the use of drugs right now. But I just want to go back a little bit, you know the 60s, 70s, and 80s.

And I want to understand the difference between the use of like I heard you say maybe I'm sorry, I don't know who said this, but they're animal tranquilizers.

But I remember also, like the I would say the 70s and 80s, they were using PCP back then, which was also an animal tranquilizer. And so I'm just curious to know because I have to believe that drug use has always been part of our society.

The despair has always been part of our society. Food insecurity, housing. So again, I'm just trying to understand the difference between the 60s, 70s, and 80s and the use of those drugs.

Is it that we didn't have good data back in the days? That's just a question I'm going to pose.

Is it a fair comparison to say that now the use of drugs is way higher than it was back then? And if we're not using the drugs back that we used to use back then, not we, but in general, like PCP and other drugs, what caused those drugs to go down in usage? Can we replicate it? So I'm trying to compare the eras because I grew up in an area where the drugs were very prevalent, a lot of drug usage.

And so, I mean, in that moment, it seemed like it was the worst of the worst. So I'm trying to compare and if they're not using those drugs as often as they were before, what caused it and can we replicate it? What can we use to diminish the use of fentanyl in today's society?

So the single most important factor driving the overdose crisis and overdose death rates is the danger of the street drug supply.

You're absolutely correct. People, for different cultural reasons, have been using different drugs over the entire history of this country. And 20 years ago, the US was not an extreme global outlier.

And the drugs that people were using in our country were similar to the drugs people are using in other countries. We are now something like 20 times higher than the global average.

We're two to three times more affected by this issue than the second most affected country. We are an extreme global outlier in a kind of unique crisis that no country has really ever seen the likes of.

And it's because the drugs people are using have become incredibly dangerous.

So as people shifted from prescription opioids to heroin to fentanyl to now these polysubstance formulations based on fentanyls and all these other drugs, it's not necessarily that drug use is becoming that much more common, it's just becoming more dangerous.

And so I think absolutely getting people off of the most dangerous category of drugs, like illicit fentanyls, and onto safer options, ideally in a controlled medical setting like with buprenorphine and methadone. But whatever it is, whatever safer options we can move people onto is absolutely the right step for reducing overdose death rates.

Well, thank you for that, but you know, going back to, let's say, PCP, which was used quite a bit back in, like I said, I think it was the 70s and 80s, that was also very deadly.

It was killing people disproportionately. People were having these psychosis as well. And again, I'm just trying to understand the shift.

Well, so PCP doesn't result in a high overdose death rate. It certainly can cause psychosis.

But the unique thing about fentanyl is that it causes respiratory depression, meaning it slows your breathing to a very extreme degree.

And so with opioids are kind of the most common drug that causes overdoses because if you take too much, you just stop breathing and die, whereas it's a lot harder to overdose on other categories of drugs.

So as very potent opioids have taken over, that's really been the key factor driving overdose deaths.

Thank you.

That was very educational. Thank you. Dr. Eggman.

Could I add one thing to that? I was there with all that PCP stuff back in the 80s and 70s. The PCP had a self limiting quality.

The people who used PCP over time would start to not like it because of the psychosis.

It would make them too psychotic and they wouldn't get much of any pleasurable effect from it.

So it had a fairly self-limiting period. It was about a three or four year period where PCP was a problem.

I actually think this new drug, Xylazine, you may see the same thing with it. I think it may be a period of time and then it goes away.

But drugs like fentanyl and stimulants that affect the brain in such a sort of pure way in the reward center of the brain, those are not going to go away.

The brain is wired for those drugs. So some drugs, we've seen stimulants and opioids around for forever, but PCP was an interesting example, but it did go away. You're right.

Thank you, Dr. Eggman.

Thank you very much. Dr. Friedman, the data that you introduced in the beginning having to do with who was most impacted, do you have any additional data that says if those folks are housed or unhoused, as well as we're talking about the large degree of African Americans and indigenous people?

Yeah, thank you. That's a fantastic question. We do know that unhoused people are at an extreme kind of disproportionate risk in drug overdose. I don't have those statistics with me today. I'd be happy to share them with your office, though.

Okay, that would be fantastic.

And then also when we were talking about the same demographic issues, is that also for age control? So when we talk about the teens, are we seeing it more in African American and indigenous populations?

So in adolescence, we saw that Hispanic and Latinx teens as well as Native American teens were disproportionately affected.

There are some kind of differences in age patterns between racial groups for various reasons I'd be happy to talk about where, actually, among African Americans, the highest overdose death rates are among kind of slightly older folks, sort of 50s to 60s.

And then for white individuals, it's in a younger cohort.

And do we know have any differences? I mean, just working with a lot of the mayors around the state, they're seeing this in a lot of the homeless camps, a lot of fentanyl being distributed. It sounds like, with the combination of stimulants creating these overdoses.

But do we know if in the past and we have done public information campaigns, I am thinking that impacts a younger demographic who is just maybe doing some experimentation versus being addicted. Do you have anything that draws those two things out?

Yeah, absolutely. I mean, we actually do know that in the vast majority of teen overdose deaths, we're not talking about people who already have a substance use disorder, who are using chaotically.

In many cases, it's just someone who has experimented with fake prescription pills a handful of times when tragedy strikes. And so I think absolutely just education about the risks is a key strategy for that demographic.

Okay. Have we seen anything with the public information campaigns that we've done with fentanyl that has shown any kind of impact on decrease?

It's very, very hard to do good research about the causal impact of interventions in a context where death rates are going up across the board. But I can guarantee you that educating people about the risks is critical.

We know from surveys, when you talk to teenagers, they don't know that most pills out there are fake. When you talk to adults, they really don't understand the risks of fentanyl.

So educating the general population about these issues is essential.

And it makes sense that we see a lot of the overdose deaths in that older demographic. And we also know that that's also the largest demographic going into homelessness or people over 50.

So just for my peers to think about, we talk about different things. When you're talking about the teen overdose, that's not really an issue of addiction, but more of experimentation.

But a lot of our older folks who are dying, it's from long term addiction issues that need different kinds of treatment. Thank you.

Thank you. I have a couple of questions myself to Dr. Rawson.

You stated that fentanyl is not absorbed in skin. I just wanted to understand a little bit when police officers are dealing with fentanyl, there have been some news cases where they've been exposed and overdosed.

Can you provide a little bit more clarity on those situations or what's happening exactly there?

Yes, that's been looked at pretty extensively because the toxicology people are going, it's impossible. That can't be a fentanyl effect.

You can't absorb enough fentanyl through the skin to produce an overdose.

And the explanation, as I understand it, Joe Friedman may have more information is that it's essentially a panic attack that people have hear that this drug is so deadly, they've just come in contact with it, and you get these very rare and unusual reactions that, obviously they look like a drug reaction, but they're not based on the drug entering the bloodstream.

I'll just quickly add that there have been a number of kind of commentaries and studies where you can review videos and the symptoms that law enforcement officers are kind of exhibiting are not consistent with a drug overdose. They're consistent with a panic attack. It's sort of a mass hysteria effect.

Thank you. And then we mentioned a couple of other drugs, specifically a drug called "Frankenstein" has been in the news lately, mostly on the East Coast in Florida, and cannot pronounce it nitazine compounds or ISO.

I just wanted to understand, is current policy language in the state of California broad enough to cover these new drugs, or in your opinion, what do you think?

Well, isotonitazine, which is the ISO is an opioid, and it's one of the variants I have some slides on those that we're seeing in different parts of the country.

Your question about whether California's laws are broad enough to cover those, I don't know the answer to that but that would be a very important question. I don't know what Frankenstein is, I don't know what that drug is.

But there are a lot of new variants. I mean, Fentanyl has 40 different analogues that all would need to be covered.

I'm sure those are all covered, but your question is a good one and really does need to be carefully considered.

Thank you. And one final question is you stated that a lot of these drugs rewire the brain and addiction is primarily the cause of a lot of this.

In regards to psychedelics, which is also a big topic of concern in the state of California, do you believe that, one, it's addictive and two, the negative effects, if there are any?

I don't think there's much evidence that they produce addiction. Certainly in high doses they can produce some negative side effects.

In terms of all the data that Joe provided and staying focused on the drugs that are killing people and are causing psychosis and are contributing to people not being housed and people being of that, I think psychedelics are a very small part of all of that picture and that certainly they need to be considered, but I don't see them as being a major part of that area of concern.

Thank you. I want to thank all of our panelists for joining us today. I really appreciate the information that you guys provided.

We will be starting our second panel. Our first panelist will be Rick Owen, senior staff counsel with the Committee on the revision of the Penal Code. Thank you guys.

Good morning, chairs and Members of the Committee. My name is Rick Owen and I'm a senior staff attorney for the Committee on Revision of the Penal Code. I was asked to give a brief overview of the range of punishments available under California law for the sale of illegal drugs and specifically fentanyl.

Just a brief background on the committee on revision the penal code. The Penal Code Committee is a state entity charged with making recommendations to the Legislature and Governor about criminal law. Five Members of the Penal Code Committee are appointed by the Governor and one Member each comes from the Assembly and the Senate. The committee's goals are to improve public safety while reducing unnecessary incarceration and improving equity.

On today's topic, there are several existing laws that can be applied to the illegal sale of drugs, depending on the facts and circumstances of the case. The application of these laws can result in significant prison sentences, especially when enhancing factors such as the transportation of drugs between counties, the sale of drugs in large quantities, or the sale to minors are present.

Existing law already allows a twelve year prison sentence for a single fentanyl sale by an adult to a minor. Specifically, a conviction for selling drugs is generally punishable by up to five years in county jail, but a person can be sentenced to up to nine years in state prison. So not county jail, but state prison for selling drugs to a minor.

And three more years can be added to a sentence when there is a four or more year age difference between the buyer and the seller, for a total of twelve years in prison. And a conviction for selling drugs to a minor is a strike under the three strikes law in certain circumstances, which will result in the doubling of any future sentence.

Consecutive sentencing can also increase the punishment for drug sales because a judge can add additional punishment for any additional counts that a person is convicted of. And as noted, if a person convicted of drug sales has a prior conviction for a strike offense, the law requires that their sentence be doubled and in some cases requires the imposition of an additional five year enhancement.

The amount of drugs sold can also increase the punishment. A sentencing enhancement relating to the weight of the drugs can add anywhere from three to 25 years, depending on the amount of drugs and notably the drug weight enhancement. It only applies to certain drugs including cocaine, heroin and methamphetamine, and does not specifically apply to fentanyl. However, in practice and as you've heard, because fentanyl is often mixed with other drugs that are eligible for the enhancement, the weight enhancement could apply to many fentanyl related offenses.

Finally, many states have specific laws allowing for murder charges against people who sell fentanyl to another and the person dies. California does not have such a law. Despite this, prosecutors in California, relying on case law from the California Supreme Court have brought murder charges in certain circumstances.

How exactly these rules apply in the context of fentanyl sales has not been definitively settled by the courts. In some, existing law provides a variety of penalties for the sale of illegal drugs, including fentanyl. The penalties can vary significantly based on the facts and circumstances of an individual case, and the sale of drugs can result in lengthy terms of incarceration, including a twelve year prison sentence for a single fentanyl sale to a minor. Thank you, and I'm happy to answer any questions you may have.

Thank you. We'll hold questions till the end of this panel. Next, we'll hear from Contra Costa County District Attorney Diana Becton. She will be joining us...

Good morning.

Thank you. Welcome.

Yes, good morning. Good morning. Thank you to all of the Senate panel and the staff for hosting us. I hope I can be heard. Okay. I unexpectedly had to end up driving to Santa Clara for a various prosecutors meeting, so that's why I'm not on camera. But what I wanted to talk about this morning is really about the larger issue in our society where we call on law enforcement to address so many issues.

We call on law enforcement when we have concerns about those who are unhoused in our communities, those who have mental health issues, and as we're focused on today, those who have drug use concerns. And I strongly believe that as we are focused on fentanyl today, that the fentanyl crisis can't be solved by going back to the failed war on drug policies of the past.

Because as we've heard already today, those policies which focused on criminalizing drug use and drug possession also resulted in mass incarceration and a disproportionate impact on marginalized communities. And as we've already heard from our medical professionals, many of those same communities are most affected by the use of this drug.

So it's clear that criminalization, I think it's clear from everything that we've heard today that criminalization alone does not work because it has primarily been focused again on possession and use whereas the public health approach that was mentioned earlier today is, I believe, a much better solution.

The overdose rates. There's really no correlation to showing that criminalization alone reduces those overdose rates, but again, instead leads to mass incarceration and it has a disparate impact on certain communities. So as we shift our approach, one of the things that we've done in Contra Costa County is to certainly shift from criminalizing those who have issues with substance abuse and instead referring individuals to treatment and encouraging that treatment.

Yes, we know that we have lots of laws on the books, as you've heard about so that when we do encounter those who are trafficking in our communities, when we are dealing with those who are selling drugs in our communities, when we are dealing with those who are selling drugs to minors in our communities, all of those laws are available to us for prosecution.

But as for those who are suffering from addiction, we are strongly recommending that we not bring those cases into the criminal justice system, but instead refer them to treatment. We're also talking about not only in our office, but as today, I'll be meeting with prosecutors from all over the Bay Area.

We'll be talking about less reliance on the role of law enforcement, even in responding to these kinds of issues and really thinking about how do we get involved in the conversation to provide greater access to treatment, how do we encourage people to be more involved in treatment? How do we as a society address the root causes of addiction using this public health approach? Thinking, recognizing that there are larger economic, social and health issues that are also driving people into addiction, including working more with our communities because we know that there's also an inadequate education about the seriousness of the use of drugs in particular fits at all. So from my standpoint, I'm advocating that we reduce the role of law enforcement in terms of trying to solve this problem.

Focusing some more resources in addition to the public health approach and the services, also focusing on the supply reduction, but noting that that in and of itself is not enough because we know that the distribution and the sale is really a global issue. And a lot of times, even when we're prosecuting those who are selling in our communities, we're dealing with the low level street sellers and not really getting at the root cause or the root supply.

And so this fentanyl crisis not just a drug problem, but really symptomatic of a larger social, economic and health issues. And I'm hoping that we also concentrate on treating other issues such as poverty, trauma and mental health and providing adequate access to treatment and lessen our focus on law enforcement being the solution to this crisis. Thank you very much.

Thank you.

I'll be around for questions.

Thank you. Our next speaker is Glenn Backes with the Ella Baker Center. Backes sorry.

Good morning, senators and staff. Glenn Backes for the Ella Baker Center for Human Rights. Thank you for inviting me to be in this group today.

In brief, I wanted to say that there are four pillars in drug policy: prevention, treatment, harm reduction and law enforcement. United States and California has invested heavily in law enforcement, incarceration, interdiction and policing. Historically, we have not invested in treatment. We have not invested in harm reduction.

During the last two administrations, Bryan and Newsom, we have started to see advances in harm reduction and treatment investment and the next panel will speak to that, but it's late. The United States has not taken drugs seriously. It took law enforcement seriously. It didn't create massive investments in better treatment.

Where was the research in your lifetime, in my lifetime, on better treatment? we have had advances, Buprenorphine is more widely available, methadone the rules have been loosened up in our lifetime. But where has been the investment in treatment for methamphetamine, stimulants, cocaine? We've made very little progress because we didn't take drugs seriously. We took punishment seriously.

The crisis in the United States and in California is terrible. And almost all of us in this room have been affected. Almost everyone in this room has lost someone to overdose. I have, most of you, through extended family or friends, have lost someone to overdose.

There'll be incredible pressure in rage and sadness to increase punishment, but there's no evidence that punishment works. Putting people away for longer periods of time will not change how many people die of overdose, it will not reduce the demand for fentanyl, methamphetamine, heroin, cocaine.

To put one person in prison for one more year costs us about $150,000 a year from General Fund. To put one person in buprenorphine treatment costs approximately $6,000 a little less, put one person in methadone for a year little less than $7,000 based on 2021 numbers.

So with $150,000, you could spend put one person in prison for one more year and have no effect whatsoever on death rates. You could put 25 people in buprenorphine treatment, 21 people in methadone, reduce the demand for these drugs and save lives.

So I'd ask you to resist the emphasis on increased punishment that you'll be under intense pressure to accede to because it won't change the death rate, it won't change the rate of suffering, it won't help families who've lost someone or are in danger of losing someone.

When I work with families of people who are grieving, I say my kids are at risk kids. I am middle class and Caucasian and live in the United States, but my kids are at risk because they live in the United States. And the hunger for drugs and the market for drugs is unlike anything we've ever seen, the researcher spoke to it. We are in a crisis unlike anywhere else, my kids are at risk. Everyone's kids are at risk because America is hungry for drugs and awash in drugs.

Things that we can do that have been proven to work is increase the access to buprenorphine methadone, but also study other medications, study safe supply. If you have people who have fong term drug use histories with stimulants or opioids, consider giving them psychiatric treatment, housing, care, and safer drugs that are not off the street, supervised by physicians, as they do in Canada and other countries.

Consider safe settings. This committee, both these committees has twice passed legislation to the Governor. Public Safety and Health committees have passed legislation to two governors to create a safe environment where someone could use drugs and not die because there'd be someone there to reverse an overdose.

Also invest in outreach to the unhoused. The Chair of Health who authored one of those bills that I just referenced spoke to the high rate of death amongst the Unhoused. So invest in outreach to the Unhoused. Bring them naloxone, bring them fentanyl test strips.

Though many of them are buying fentanyl on purpose and that's so what they really need is naloxone and access to treatment. You can bring treatment to people in a motel room, in an SRO, in a homeless encampment. All you need is a van and a physician or a nurse practitioner to deliver treatment to people where they're at, bring people into housing and provide for treatment and naloxone to those in jail and those leaving jail.

Where are people? Our people are in treatment programs. They're in jails, they're in prison. These are places where you can access them. They are in contact with the system. They're in emergency rooms. So when people are leaving jail, are they getting a warm handoff to drug treatment? And are they being provided with the education they need about how dangerous it is out there right now? Give them naloxone, give them access to treatment. It's a better investment of public dollars than incarceration.

There's also efforts on better prevention. One of the four pillars of drug policy: educate students better. Dr. Randall has a Bill that speaks to that. Higher risk youth in juvenile halls and other settings need accurate information about how dangerous it is out there and access to harm reduction and treatment.

The 40 million used to educate drug users through social media that the Legislature and the Governor invested in seems like a sound investment needs to be evaluated, and that'll be discussed in the next panel, I believe, and commend Senator Skinner for her work to establish civil penalties. Not criminal penalties, but civil penalties for the marketplace, for the social media companies that are apparently creating a mall where one can buy substances and need to be held accountable for their grove in that in a way that works. And the senators ting to address that in a creative, intelligent fashion as opposed to using what we've always done, which is, "let's pass more punishment bills."

But again, in short, the punishment bills won't save lives. Other investments are better investment of California tax dollars. Thank you.

Thank you. Our next presenter is Sergeant Faye Maloney. The chair of the California Narcotic Officers Association will be joining us via Zoom or phone.

Hello. Good morning, everyone.

Can we raise her volume a little bit? Sergeant, can you speak a little louder? Yes.

Hello, can you hear me? Okay. Hello. Good morning, everyone. Thank you for having me. My name is Faye Maloney, and I am the region one chair for the California Narcotics Officers Association, and I want to thank all the speakers for everything that they have said. Fentanyl has become the number one concern for all law enforcement for all of our communities due to the potency, addiction, and unfortunately, the death numbers that we have seen that have been rising within the past years.

Youth are obviously accessing fentanyl in various ways. The black market schools, stealing it from family members. I can say in Alameda County alone, there has been a minimum of 91 kilos and 140,000 pills that were recovered last year alone. I know the numbers aye greater. For example, in Fresno County, since we monitor the whole state, the average aye for youth addicted to fentanyl is 14 to 20.

And we have seen those areas where even now, unfortunately, infants were exposed and have died from overdoses due to leftover fentanyl from family members. We're seeing the fentanyl uses in lace drugs such as marijuana, candy, fentanyl patches that dissolve in the mouth, the fake M 30 oxycodone pills that kids are unfortunately taking and not realizing it's fentanyl.

What we have been doing, obviously the law enforcement aspect of it since the decriminalization has changed the way that we are trying to raise awareness with the youth with youth programs, sharing resources with parents and teens. We also know that there is a lot of unaddressed traumas that basically force these individuals to start using these types of drugs or any drug that leads to fentanyl at the very end.

And we also have that are youth that are starting to use the fentanyl, but they're automatically becoming addicted to it just after a couple of uses, and they're so addicted to that high that's causing a large concern. And as we work with the unhoused community, it has been very challenging.

We have come across so many unhoused members of our community that either we are contacting them because law enforcement is getting complaints on some sort of low level crime that has been committed. Where in that course, specifically in the Bay Area, we have what's called the Cares Navigation Centers that are throughout, for example, Alameda County, I believe there is one in San Francisco as well, where we are giving the offender at this point of the low level crime a choice:

Either you can go to court or you are free to go to the Cares navigation center, for example, so you can receive mental health services, drug addiction services, let's try to get you access to housing. A lot of the times we are seeing those individuals that are choosing to just get the court tickets so they can go to court because they choose no treatment.

So it becomes a challenge for us because we obviously can't do this alone. We need definitely a collaboration from social services, the public health and the mental health programs that we have. We started to look into what other states have been kind of experimenting or utilizing in their areas.

One of the programs that we found is the Kodak program that Rhode Island uses. Basically, if you have a low level offense that has been committed by an individual that's suffering from either mental health or drug addiction, once they go through the district attorney's office and they are sentenced, they are not necessarily going to just a regular jail incarcerated type of setting.

They are going to a secured rehabilitation facility where they're receiving mental health services, drug addiction services, an overall health assessment of what's going on in their situation. And you have to start addressing all their past issues that led them to the drug use. So in that way you're addressing all their needs.

Once they have completed their 14 or 15 or 16 week rehab program, then they have access to their county medical services where they can continue to receive those services. And the success rate of this program is high. Those are the types of programs that would be amazing if we can have in the state of California. Because again, I'm going to reiterate law enforcement cannot do this alone. We need the help of all of our basically our partners within the community.

Thank you. Thank you to our panelists. Yes. We will ask all our senators to have concise questions as we are limited on time. But do we have any questions or comments? Senator Menjivar?

Thank you, Madam Chair. My question is to Glenn. You spoke about were you speaking on users or sellers and the history that shows us that obviously you're putting a lot of punishment on the users. It doesn't help. But were you speaking on increasing the punishment for sellers?

Two things to be real quick. There's been a lot of punishment of sellers going back to the Rockefeller mandatory minimums and in California. So stiff penalties and long terms of incarceration did not reduce the availability of drugs because each drug, and the researcher mentioned it too, drug seller is replaced by another drug seller as long as the demand is in place.

This is why we support treatment rather than longer sentences. So locking up sellers and the increased penalties for sellers will not change the overdose numbers in California.

The other point was the differentiation between seller and user is generally a false dichotomy. Many people who are selling or furnishing or sharing are themselves addicted or have a substance use disorder. And so they can get caught up with a possession for sales charge early in their grinding addiction.

They're grinding homelessness and they're grinding poverty. You can get an early sentence. You can get another sentence. You get another sentence when you're in the throes of a mental health, addiction and homelessness and poverty crisis. So it's not hard for someone to pick up early charges and then come back in a second and third time. It's the access to treatment, housing that will make the greatest difference.

Thank you, Senator Rubio.

Thank you, Madam Chair. The question is for Diana. You mentioned something about offenders having a choice between courts or care navigation centers. So I'm a little curious about can you expand on the Care navigation center?

Sorry Senator, that was not my comment. I did not speak about care and navigation.

That was Sergeant Maloney.

Sergeant Maloney. That was Sergeant Maloney.

Thank you.

Yes. So the Cares navigation center is a program that in the area. Let's say we have a I'm sorry, there is a lot of echo. I don't know if you can hear me. Well, anytime there is a low level offender type of crime that has been committed, where law enforcement is called out, where violence is not associated.

So let's say it's a trespassing issue, a low level theft, and the offender is given a choice either go to adult Law Enforcement Diversion, which is through the Cares Navigation Center, or they can go to court.

And we've been using that system here for probably the last year and a half, and we're seeing a lot of individuals that are giving that option, choosing the court route. I could probably say in the Bay Area alone, we maybe had 40 individuals that you've utilized those services.

And when they reoffend, we send them back to the program, the Cares Navigation Program. This program offers them resources into job placement, drug addiction services, mental health services. They connect them to all the different resources that they have. And it's just very rare that we're able to convince all the individuals that we come in contact to go into this type of program because they don't want to get the help. They tell us verbally to our face, I'm not interested in rehabilitation. I just want to go to court.

Just one last comment. That's what worries me because I'm hearing you loud and clear saying that you offer these programs and they just absolutely tell you to your face that they don't want to be treated.

And then we have Glenn, you're talking about how we need to give them treatment. So there's clearly a disconnect here because they're offering treatment and they're not accepting it, but you're offering that we need to treat them. So how do we fix that disconnect? Anybody have any ideas?

I really like the Kodak program level of it, where if there is some sort of incarceration, it's not a jail system, it's a secured rehabilitation. I don't know what kind of maybe reinvention of some sort of secured rehab facility where if a person is sentenced to some sort of a jail sentence, instead it's a secured rehab facility to make sure that person is forced to go into that treatment because a lot of the times they're not taking it by choice.

Thank you for that.

Thank you, Senator Nguyen.

Thank you. Sergeant, I have a few questions I wanted to ask. One is, are we in California using evidence based research to better assist our law enforcement community in addressing the opioid and fentanyl crisis facing our state?

I believe so.

And is the DOJ's office working with the local jurisdiction to better support your local efforts?

Yes they are.

Then I have a comment, Madam Chair. To Glenn.

I'm sorry. I have to respectfully disagree because we've seen what happened in San Francisco, and not to pick on San Francisco in any disrespectful ways, but we've seen in the last few years when we were giving out needles. It's all over the city. It's talked about across the state, whether they want to admit it or not. It's in newspapers. It's in pictures and articles.

I'm here not to say that we don't help treatments, but what you're basically saying to me is that we need mandatory treatment because if not, these individuals aren't going to go into it. And second is that you said that under the last two Administration that we've invested heavily in treatment, well it hasn't changed anything.

And so it's like, do we get to the point where we have to one, there's lots of arguments that we need to have higher penalty for higher distributors, dealers. We got to get these higher the main key players who are giving these thousands and millions of fentanyls into our communities off the street. And do we now go into in the direction of mandatory treatment? Because we know also the crisis of homelessness. And the conversation we have to have about homelessness is drug treatment as well, because if we don't, they're literally dying on the street, and that's not very compassionate of us in California.

So that's my thing, is that you can talk about more money in treatment and less in enforcement, but I think enforcement needs to be heavily concentrated on going after these drug dealers. I'm not talking about those who needs treatment for users at all because I've got so many families come up to me in my district whose children have died.

Thank you, Senator.

And we have one more panel after this. We'll talk more about some of the treatments that are going on.

I appreciate you guys'time. We'll move on to our next panel.

Thank you.

Thank you very much.

And now we'll hear from our last panel. First we have Tyler Sadwith, deputy Director of behavioral Health, and Marlies Perez, chief of the community services division with the Department of Health Care Services. Welcome.

You. Hello. Good morning. Thank you for the opportunity to participate in this joint informational hearing.

My name is Tyler Sadwith, and I am deputy Director of Behavioral Health at the Department of Healthcare Services.

I'd like to start by sharing some key background and context before turning it over to Marlees.

Prior to the start of the opioid epidemic, DHCS was already redesigning the Substance Use Disorder delivery system across the state.

In 2015, California was the first state to receive federal approval to implement a comprehensive Section 1115 waiver for substance use disorder.

To date, over 30 states have followed our lead and implemented these waivers.

The Drug Medical Organized Delivery System, or DMCODS, provides a continuum of care for addiction treatment for medical Members.

The DMCODS enables local control and accountability, provides greater administrative oversight, establishes utilization controls to improve care and efficient use of resources, implements evidence based, practices and coordinates across systems.

Today, 96% of medical Members live in counties that participate in the DMOCDS.

Under the California Advancing and Innovating Medical or the Cal Aim Initiative, DHCS implemented several Dmcods policy updates to improve access and quality of care and improve administrative efficiency.

DHCS recently expanded medical mobile crisis benefits, peer support services, and contingency management.

While contingency management has been tested using other sources of federal funding, California is the first state in the nation to receive federal approval to implement contingency management in the Medicaid program.

This is important because of the increasing rates of opioid overdoses involving stimulants as you've hart, and because contingency management is the intervention that has demonstrated the most robust outcomes for people with stimulant use disorder.

California has been leading the work in mathis redesign of the SUD delivery system and with work specific to opioids as well.

Opioid Use Disorder is a preventable and treatable disease.

Medications for opioid use disorder are evidence based, and effective long stern recovery is possible and outcomes improve with retention in treatment.

California must take a stand against stigma because it can prevent individuals from seeking help.

Since 2017, DHCS has allocated approximately $1.4 billion across the state through federal, state and opioid settlement funds to implement opioid Prevention, Harm Reduction, Treatment and Recovery Services grants programs.

The majority of grant funding focused on opioids is administered through our Medication Assisted Treatment expansion Project or Mat expansion project.

The MAT Expansion Project has accelerated the implementation of medications for addiction treatment in primary care in jails and min emergency departments.

It has supported tribal and urban Indian communities to implement culturally centered education and treatment.

It has launched campaigns to engage youth and educate them about the dangers of fentanyl laced in pills, and it has distributed over 2 million units of naloxone, leading to over 130 reported overdose reversals.

California has received funds from opioid settlements, including $59 million from McKinsey and Company and most recently, the Janssen and distributor settlements from which the state is expected to receive approximately $2.2 billion, which will be overseen and administered by DHCS DHCS, the California Department of Public Health and the Department of Rehabilitation.

Weber allocated a total of $127.8 million in opioid settlement funds in fiscal year 22-23 for state identified projects.

Thank you for the opportunity to comment.

At this point, I'll turn it over to Marley's Perez, Chief of Community Services Division at DHCS, to walk through some of these critical initiatives.

Thank you, Tyler.

The MAT Expansion Project was established in 2018 and aims to increase access to medication assisted treatment, reduce UNMIT treatment need, and reduce opioid overdose related deaths through the provision of prevention, harm reduction, treatment and recovery services activities.

The primary focus of Allen DHCS opioid related projects is to ensure equity and inclusion for all populations while reducing opioid related overdose deaths, increasing access to medication assisted treatment, and reducing unmet harm reduction, prevention, treatment and recovery services needs.

The project focuses on populations with limited MAT access, including Black, tribal and urban Indian, Hispanics, LGBTQ plus communities, people experiencing homelessness, and people in criminal justice settings and youth.

The California Min Expansion Project supports more than 20 projects across the state and has expanded access to MAT and more than 650 access points, including hospitals, Bains, Indian health programs, mental health, substance use disorder programs, community health centers, and more.

Some of the key projects include our California Opioid Response for Youth.

This provides grants to nonprofits schools and other groups tackling opioid use among Fong people to support prevention, treatment and recovery services for our youth ages twelve through twenty-four who are at risk of an opioid use disorder or a stimulant use disorder.

Since September of 2020, more than 16,000 youth have received one on one engagement.

Approximately 7000 youth received early intervention and more than 3000 youth received treatment for an opioid use disorder.

Another project is our MAT in jails and drug courts.

This project increases access to mat in county Bains and drug courts while also building county capacity to effectively respond to individuals within the justice system those that are impacted with a substance use disorder.

The goal is for the county teams to have at least two forms of FDAapproved medication within their jail to treat opioid use disorder.

As of August of 2022, over 32,000 individuals have received MAT while incarcerated across 36 counties.

Due to this project, California's efforts are also expanded under our new CalAIM Justice Involved Initiative Waiver, which will offer a targeted set of Medicaid services, including medication assisted treatment to youth and adults in prisons, jails and youth correctional facilities for up to 90 days prior to release.

The funding opportunity wilk serve as a key resource to support jails to offer mat and facilities, warm handoffs and linkages to communitybased mat providers.

Another project I want to highlight is our Naloxone distribution project.

This is a key intervention in California's effort to curb the opioid overdose crisis.

It provides free Naloxone, which is a medication used to reverse opioid overdoses to community organizations and entities to date, the NDP has distributed more than 1.9 million units to more than 3300 unique organizations.

As Tyler reported, we've had more than 130,000 overdoses just from the NDP alone.

To address the opioid crisis min Roth the NDP has distributed more than almost 46,000 kits of Naloxone to over 700 unique K through twelve entities.

However, the NDP is not the sole source for Naloxone in California.

It's available to Allen medical Members with a prescription and many other sources of health coverage such as Medicare and private insurance.

Naloxone can also be purchased by participating community pharmacists to individuals if applicable.

Requirements are met.

Counties also have federal grant funding and opioid settlement funding that can be used to provide Naloxone to local communities as well.

The last MAT project I'd like to highlight is the Calbridge Behavioral Health Navigator Program Cabridge, launched at 52 hospitals in 2018 with a grant from the Mat expansion project.

In 2020, a state appropriation of $20 million extended funding to 52 more hospitals as a part of the Behavioral Health Pilot Project.

In the spring of 2022, a new appropriation of 40 million with funding through the Home and Community Based Services launched where now we have 331 hospital emergency departments in California that aye providing these.

They're utilizing these grant funds and providing substance use navigator services and adding mental health navigators to their emergency departments.

And this helps individuals that are seeking addiction treatment and supportive care in the emergency Department setting.

Since 2018, there has been over 240,000 patients who have been seen by substance use navigators in the emergency Department.

Of these, approximately 140,000 have been identified as having an opioid use disorder and 82,000 encounters occurred where Mat was prescribed or administered.

And we're happy to answer any questions.

Thank you.

Our next speaker is Robin Christensen, chief of the Substance and Addiction Prevention Branch, Department of Public Health.

Welcome.

Thank you.

Good morning Chairs Wilk and Eggman and Members of the committee.

My name is Robin Christensen.

I'm the chief of the California Department of Public Health, Substance and Addiction Prevention Branch.

Thank you so much for inviting me here today.

So, Substance and Addiction Prevention Branch was formed in 2020 to bring together a dispersed set of programs and create a home for behavioral health prevention and are really a home for our approach for substance misuse and addiction prevention under the center for Healthy Communities.

Our branch aims to prevent and reduce the Hart that are caused by substance related and addictive disorders.

And we're home to four programs which include youth Cannabis prevention, alcohol misuse prevention, problem gambling, and our Overdose Prevention Initiative.

The Overdose Prevention Initiative leads the California Department of Public Health's approach to the opioid epidemic and our strategies address research and surveillance primary prevention activities including public awareness, harm reduction and strengthening community capacity and partnerships.

So, as part of the OPI, we've developed and provide ongoing support for the public facing California overdose surveillance dashboard, which provides data on fatal drug related overdoses, emergency Department visits and hospitalizations related to nonfatal overdoses, and scheduled prescription opioids.

We make this data available at the state, county, and zip code level, and it is available online on our dashboard.

Some of what we've learned is that in 2021, more than 7000 Californians died from an opioid related overdose, and over 80% of these deaths were related to fentanyl.

From 2019 to 2021, we experienced a 128% increase in the rate of opioid related overdose death in California.

Over that same time period, the mortality related to fentanyl increased by nearly 300%.

Overdose deaths associated with stimulant drug use have also been increasing, although the rates of that increase aye a bit less.

When we break this down by demographic, opioid related overdose deaths disproportionately impact men, adults between the ages of 25 and 44, and Native American, Alaskan Natives and Black African Americans.

We can also look at this information by county and start to look at some trends and variation, and we see that there are some counties, such as Mendocino and Lackey County, which have the largest opioid related overdose death ayes per 100,000 residents.

So when you're thinking about this as a rate in terms of the burden on the population, los Angeles County experienced the highest burden by count, with nearly Jones 600 opioid related overdose deaths in 2021.

San Francisco County continues to be of concern due to both the high opioid related overdose mortality rate at 42 per 100,000 residents, and also coupled with the high total counts, we saw 435 deaths in 2021.

In addition to our surveillance, we conduct additional examination of case reports.

We take the medical examiner coroner reports from the overdose deaths, and we look at drug related overdose deaths rates in particular, and we look at this in depth in 21 participating counties.

This helps us to better understand some of the circumstances surrounding overdose death where it occurred, were there people around? Were there opportunities for intervention? We're also piloting a project to get overdose information more rapidly, and this is called Syndromic surveillance.

It is a way of monitoring symptoms and conditions as they appear at the hospital or the emergency Department.

This information then becomes available to us in near real time, and it can be used to provide overdose spike alerts.

In terms of our prevention work, our strategies also include prevention, including increasing awareness through large scale public awareness campaigns and working with local partners.

Min the current fiscal year, the Substance and Addiction Prevention Branch received funding to support a statewide media campaign with three primary aims and audiences to prevent substance misuse among teens and young adults.

To stop overdose and overdose death.

Among adults with a harm reduction approach and to raise awareness among families and communities, reducing stigma and equipping individuals to be able to have the information that they need to respond with life saving strategies, such as the use of naloxone.

The campaign will be using trusted and preferred channels, prioritizing digital and social media, and we will be engaging with local community partners to provide families and communities with the information that they need and also helping to lift up local success stories given the urgency of the overdose crisis.

The initial campaign messages are anticipated to be launched later this spring and the full media campaign launched later this year.

We also have additional state level partnerships.

For example, we work with the Department of justice to promote the expansion and the use of the state's prescription drug monitoring program known as Cures.

This tracks and monitors schedules two, three and four drugs, and it looks at the prescriptions that are written and dispensed in California, and it provides the Department of justice and others across the state with information that they need to monitor for patterns that might indicate prescription diversion or potentially risky prescribing practices.

We also partner with our colleagues here at the Department of Healthcare Services through their Medication Assisted Treatment Program, their expansion program to help support EMS first responders to provide initial treatment and then some connections to longer term substance use disorder treatment options.

We partner with Educational Leadership.

So we have been working to expand resources and information available to schools, colleges and universities, and this includes providing training to educators on Naloxone, providing technical assistance on Naloxone access and distribution policies, and really bringing together partners so that we are able to lift up and highlight some of the excellent work that's already being done.

At schools and colleges across our state.

We have local partnerships.

We support 21 local Overdose Safety coalitions, which represent 25 counties across the state.

They are working to reduce opioid and other drug related overdoses and deaths across California.

Our colleagues at the CDPH Office of AIDS also support 68 harm reduction programs in 42 counties, which help to support the work that some of those coalitions are doing.

Our coalitions are working on a range of strategies that align with the Department's own strategies.

They tailor the work to their community needs through grants that we provide to them.

Some of the examples of the work that they do include strengthening Hart reduction approaches at the local level, building connections with law enforcement, strengthening youth prevention education, and increasing access to treatment and services.

However, not all corners of our state have access to harm reduction services.

So we work with a distribution partner who provide life saving harm reduction supplies and treatment information to individuals across the state who are at risk of overdose or harm from substance use.

Finally, we partner with DHCS related to the Naloxone distribution program.

CDPH's role here is to administer the statewide standing order Flora Naloxone.

This authorizes entities in the state, such as schools, community based organizations and libraries, to administer and distribute Naloxone to others without a prescription.

It kind of works hand in hand as they're able to access that free Naloxone through Dhcs's program.

CDPH welcomes the opportunity to expand its local partnerships and to strengthen the state's response to this crisis.

I wood also be happy to respond to any questions.

Thank you.

We have one last speaker.

Ryan Miller, deputy Director of Behavioral Health with Riverside University Health System.

Good morning everyone.

Can you hear me all right through Zoom? Ayes.

Thank you.

Good morning.

And so thank you for having us here.

We really appreciate our partners and everything everyone is doing.

First thing I want to say is a lot of what I will cover is more of a local impact of initiatives rolled out that you can refer back to Darren's Slide on all those projects.

That was quite a list.

And then everything kind of that Tyler and Marley's kind of covered.

And I also want to just thank Senator Nguyen, your comments around the Roth and why we're all doing this and the impact it has on our society. It just really rang true at the beginning of this. So set the tone.

If we jump right into Calam and the DMC organized delivery system that you heard from Tyler and Marleise at a local impact pre rollout of this, we had about a $4.5 million annual contract with the state for drug medical dollars.

And we aye now currently around 90 million. So besides the impact on funding being pushed into our system, what that translates to in a human world is we've had over 800% increase of services to our adults and a 200% increase for services for our Roth.

One of those big factors that they worked into the Waiver was the ability for Sud programs to now work in the field as opposed to being locked within the four walls of a clinic.

So we're able to go out to where our humans are and deliver them service and bring them back into treatment, which has increased everything significantly.

One of the newer elements of Calam that we really excited about is the fact that they are now going to be reimbursable services for Asam .5 early intervention for youth which just enhances our ability to get in those school systems and really get to our youth in a preventative culture before they end up in our treatment culture.

All of our items in Riverside County, we do have a Fentanyl task force that was set up after many of these items that I'll talk about Weber here that is run by our Board of Supervisors and Executive office.

And so most everything I'll share here and a lot that I won't is all driven up through there and reported out on at that higher level.

I did want to take a chance to talk about the State Opioid Response Grants and Mat Expansion grants that Marleise mentioned and how they kind of haney really changed a culture for us and specifically in the detention and criminal justice world with collaborative courts.

Marley's mentioned mental health court, drug courts, things like that.

Pre education, if you will.

Our court systems, especially around collaborative courts and our jail systems were not very friendly to the use of medication assisted treatment.

And that's where we started.

And so with the HMA grants that the state rolled out to us and the use of coaches and technical assistance, we've been able to change that culture dramatically to where we are prescribing medication assisted treatment in our detention facilities, both adult and juvenile.

And also for a really specific example at the entry, anyone with an Oud coming into jails instantly gets a cow screening, but they also get Naloxone at the gate upon discharge.

That has gone down into more HMA grants, which is have expanded around our hospital, our county hospital in Prescribing Task Force, medication Assisted Treatment Task Force and then driving down a little bit farther, one of the big ticket items for us is knowing that those in substance use disorder treatment need a safe place to live.

And so the wraparound funds that Haney been sent down from the state that we can use for recovery residences, aka so we're living have been enormous and showing we've run our stats for the last three years in the way of recovery residences and we've shown over a 30% higher completion rate in a positive sense.

Also I wanted to mention the Naloxone Project, and this piece is more around the attitudes and the change on the street.

So when the state first grove out the Naloxone Project, we ordered mass amounts to get out to our community.

But the problem was not everybody wanted it, people said they weren't trained.

And so with the help of the state and our partners, we're able to train people.

And now if we fast forward, we can't get enough of it and we just keep ordering.

We're getting out to our police, our sheriff, Min, our jails, to our treatment staff, mental health treatment staff, our field based teams.

There's just been a huge change in that due to the environment going a little further with the Ed Bridge and navigation teams.

So the Ed Bridge we have at our county hospital and other private hospitals in our county.

But for us, what we've done is taken that idea and pressed more state resources into it, so that we're actually running a Ed Bridge program in the emergency room and in our inpatient unit in our hospital from 07:00 A.m.

To 07:00 P.m., seven days A.

Weber 365 days a year, and we see about an average.

Now, last year I think we had just under 900 screenings that we're able to do and link them out to treatment moving down to across the system and kind of back to that idea.

Around Calam and DMCO DS field based services, we have added not only AOD counselors but also Sud education to all of our field based teams.

Whether these are all of our crisis outreach teams, they work in the community that respond to hospitals, law enforcement, school systems and parks, everything in between to our homeless outreach teams and encampment teams moving down.

Then also we wanted to mention under the Centers of Disease and Control and Prevention Overdose Data Action Grant, our public health Department was also able to pull down a funding that has made a comprised set where public health behavioral Health and EMS have partnered up to do overdose surveillance related to overdose deaths, 911 calls, poison control, and all of that data is now readily available.

Paired off of what the state is public Health is doing on their main website has enabled us to really hit our high pocket points, roll out services where needed, and if at all helpful, I think around Prop 64 monies, not all counties can apply for these.

And so if we could just get a pinpoint in that task force of how to use those Prop 64 monies to enhance some of these items that I've shared today.

Thank you.

Thank you.

That concludes our presenters time.

Do we have any questions from any of the senators? Senator

Rubio I'm sorry, this is a.

Topic that I really wanted to get into and learn, but I think this is for Robin. You talked about partnering with schools, and I'm just a little curious.

I know that teachers are given this entire education about, for example, EpiPen and lee bites and all that.

Is it something that you think should become part of the natural education process, learning about these type of opioids and how to take care of the issue? I know right now you're just partnering on the side, but it's not necessarily part of what teachers get.

What is your opinion on educating them and making it part of the process every year? I don't really have an opinion on that.

It sounds like a policy angle.

My comment on overdose awareness would generally be in support of increasing substance use prevention education broadly.

Currently, within statute, schools are able to administer Naloxone, and so we've been working with them to come up with appropriate policies that work within their school based policies.

Thank you. Just one last question.

What is Naloxone? How do you administer? Is it like an EpiPen? Can you help me understand that? There are a few different forms of Naloxone, the General flora that we are talking about when we discuss this with schools, is there's a nasal form of Naloxone that is relatively easy to administer? The Department of Public Health has a training which is available on our website, which provides guidance on how to administer.

If you've used Flonase or something like that, it looks quite a bit similar, and it's essentially a nasal spray.

There's also an intramuscular injection form that is closer in line with the design of an EpiPen.

Thank you. That's all. Thank you, Madam Chair.

Dr. Eggman.

Thank you.

And I think this is, again, Ms..

Christensen and maybe Ms..

Bettez.

So all the programs that you're talking about.

All the programs that the state administers are the evaluations and the updates on those Fong on your dashboard.

And aye, those most of those evaluations on effectiveness and outcomes, those are conducted by some of our presenters on our first panel, is that correct? Is that how the relationship goes? There

are two separate dashboards.

We host administrative data which contains all of the record of mortality and morbidity for overdose and other substances.

I can speak to ours.

We Haney cannabis on there as well, for example.

But no, that does not include evaluation information.

Okay, but we do have with our MAT expansion project, as the researchers spoke at UCLA, they have put together a portal for us with all these various projects that we have, the dashboards.

We also have some independent evaluations within some of these projects, like the Ed Bridge, they have their own, so we're working on pulling all that up together.

But we do have some General dashboards, and as we get additional funding, we're putting that within that as well.

And for the drug medical organized delivery system, we do have an independent evaluator, and that is UCLA, who presented in the first panel and those independent evaluations aye available on our website.

Okay, just as we continue to talk about the interventions that we're taking, it's always really important to measure the effectiveness and outcomes of those, so we know what to keep leaning on and what to potentially shift to.

Thank you all very much for your presentations and your work.

Thank you all.

We have no further questions.

We'll move on to anyone who would like to provide public comment.

Due to constraints regarding the length of our hearing, as well as technology considerations, each individual's public comment is and will be limited to 1 minute.

Let's begin with any individuals here in the Room 1200.

Seeing no public comments, we want to thank you.

We will move on to those waiting to provide public comment via the teleconference service moderator.

If you wood, please prompt the individuals waiting to provide public comment.

We will begin again 1 minute only.

Thank you.

For those on the phone, you may press one followed by zero.

To join the queue for public comment, we'll go first to line 17.

Yes, thank you for taking my call.

I'm very concerned when they were talking about the price of keeping someone incarcerated.

The price of a human life is more important to me than what it costs for our taxpayers to put those people in jail.

I'd rather have them in jail than killing one of our children or family Members.

Second, you ought to go after some of these pharmaceutical companies that keep making this happen.

For God's sake, close our orders.

Thank you very much for your call.

Next caller, please.

Our next comment comes from line 21.

Please go ahead.

Yes, hello, can you hear me? Hello? Yes,

we can hear you.

Okay, I just want to say.

Here's the thing.

I listened to your hearing here and I understood about the anxiety that police officers are having.

But what about grandparents? What about parents? This is getting into our public school and killing people.

And just like the last Allen stated, why aren't we doing something since the concerns of this inflat? I mean, they're surfacing everywhere.

Why, if they have child or even an adult, why aye they going to jail.

It makes no sense to me.

Supposedly in prison. But I think you guys need to be consciously aware that these schools make far more money.

Heroin and cocaine right now in America, California. It's terrible. So please be conscious of that, especially if you're a parent or a grandparent. Thank you.

Thank you.

Next caller, please.

Next, we have a comment from line 24.

Thank you, senators and panelists, for this hearing.

My name is John Drevenger. I'm the senior advocate with CBHA, the California Council of Community Behavioral Health Agencies, which represents mental health and substance use, community based organizations across the state.

We're grateful for the focus of this hearing and the ongoing legislative efforts to curb the fentanyl and opioid crisis that is impacting California.

We and our Members stand ready to support and partner with the Legislature in its work to reduce overdose deaths, expand access to effective treatments, and to address the social, health and economic factors driving this crisis.

Thank you so much for your leadership today.

Thank you.

Next caller

We have line 23.

Yes, good morning, Senator and committee Members.

My name is Linda Rich, glazer county.

The previous Allen sounded great.

He supports everything and he's for everything RA.

But let's start at the basis of this, which is the border.

Border is where these items are coming over.

Number one, that should be our focus currently.

Number two, the incarceration of offenders.

We need to skip in the penalties.

If that means changing the law at the legislative level, that's what we'll have to do.

But we can't just keep putting a Band Aid on this.

Obviously, this is bigger than all of us now, and it seems to me it needs to start at the border.

Thank you very much.

Thank you.

Next caller, please.

We have a comment from line 17.

Yes.

I appreciate everything you all are trying to do, but I'm so afraid for our children. More has to be done.

I think we need more law enforcement and more penalties. Flora these people, because if they don't want to be cured, they're not going to be cured.

They're going to go to jail and come out and go back what they were doing, whether it's ting or dealing or whatever, it's really scary for our children and our families. Thank you.

Thank you.

Do we have any more speakers? All right, I appreciate the moderator's time on this.

Having completed the public comment period.

Members, are there any additional questions or comments? Seeing none.

Again, I. Want to thank you to our panelists for joining us today.

Thank you to all the individuals who provided public comment today.

If you were not able to participate, please submit your comments or suggestions in writing to either the Senate Public Safety or Senate Health Committee or visit at the committee's websites.

Your comments and suggestions are important to us and we want to include your comments in the official hearing records.

Thank you and we appreciate your participation. Again, thank you to everyone who was patient min the cooperation of everyone here.

We have concluded the agenda. The Senate public safety and health committees are adjourned. Thank you.