Assembly Select Committee on Select Committee on Fentanyl, Opioid Addiction, and Overdose Prevention

All right, we're going to start. Good morning. Welcome to the Select Committee on Fentanyl, opioid addiction and overdose prevention. My name is Matt Haney, chair of the Committee. I think we may have a few of my colleagues join us as the hearing goes on. This was a very busy week in the Legislature, so I know some of them had to rush home.

But we'll share the video of this very important Committee with the Members of the Committee and my colleagues so that they can learn from the expertise that we have gathered here today. This Committee was formed for us to be able to develop solutions to confront the most deadly public health epidemic that is facing our state, which is the drug overdose epidemic and the epidemic of opioid addiction more broadly. We have 2.5 million Americans who are addicted to opioids.

We've lost, here in California, over 10,000 people just last year to overdose, most of those from opioid overdose. And this is a challenge and a crisis that is impacting every corner of our state. It is not an issue that is concentrated in San Jose or San Francisco.

Every single city, county, town, region is being impacted by opioid addiction, and we are in desperate need of solutions, solutions that save lives, solutions that help people get into care and treatment, and solutions that lead to us reversing these epidemic. Because, sadly, what we're seeing is it is getting worse in California every year. More and more people are becoming addicted to opioids, and more and more people are dying every year. And that has escalated very rapidly, in particular over the last few years.

So this Committee came together, it's a bipartisan, Select Committee, to develop solutions and find areas for common ground. There has been and there will continue to be and there should be a lot of conversation and a lot of efforts to confront those who are bringing these illegal, deadly drugs into our state and into our communities and how to stop that and how to hold people accountable. And we've had hearings and bills that have focused on that.

We've also focused a lot on how to ensure there's emergency interventions that are available for people so that we can save lives, expanding access to naloxone, expanding access to crisis response.

But this particular hearing, in many ways, for me, is the one where we should be putting definitely as much time as we are putting on those two areas, and one that I think does not get enough attention, does not get enough focus, and should be one where everyone can work together to solve problems and put forward policy solutions. And that's on the area of evidence based treatment for those who are experiencing opioid addiction. I said that there were 2.5 million Americans who are addicted to opioids.

Only one in five of those people are enrolled in life saving medication assisted treatment. I set out as part of the work of this Committee to make sure that, as many of my colleagues, hopefully all of my colleagues, understand not just how to say buprenorphine, but what it is and what it can do and what we can do as policymakers to make sure more people have access to it.

We passed two bills last year to help teenagers have access to care, to help mobile pharmacies to be able to carry buprenorphine. We also know that our state has some of the most restrictive policies in the country as it relates to access to methadone, which is the most proven medication assisted treatment for people with opioid addiction. If you ask anywhere in the world how they are confronting opioid addiction in their communities, they will start with methadone as the primary way that they confront this, this addiction.

And unfortunately for California, we know that we do not have enough people who should be and can be enrolled in methadone and in buprenorphine having access to those treatments. If we want to get people off of deadly drugs that we know can kill them and are killing them, we have to make it a lot easier to get onto medication assisted treatment that can save their lives and that hopefully, ultimately can lead them to be able to withdraw from these deadly drugs like fentanyl altogether.

So that's what our goal is of this Committee. How do we, as a state, make sure people have more access to treatment than they do to deadly drugs like fentanyl? How do we get people onto treatments that can save their lives? But unfortunately, right now, far too people find themselves, far too many people find themselves stuck in bureaucracy, stuck in various barriers that they have to cross, being dropped from treatment, going into one door, and having to start over again and again and again.

And the result is that they never get the care and treatment that they need and deserve. So we have some incredible experts here, people who have firsthand experience with navigating this system, people who are doctors, who help to support people in enrolling on these treatments and staying on them, and our leaders from the state who are ensuring that we align the work that we are doing here in this building and in Sacramento with the needs of our communities, including our cities and counties.

So, before I introduce the first panel, a few housekeeping. We will have three panels today. Witnesses of each panel will come up together and provide their testimony by order of introduction. After each witness has testified, the Members of Committee the Committee may ask questions or take the opportunity to make any remarks. And at the end of the hearing, there will be an opportunity for public comment, and public comment will be limited to 30 seconds per person.

We are not accepting public comment over the phone today, but you can submit written testimony for anybody who is watching, watching, or wants to at assemblymember.haney@assembly.ca.Gov. This email is also on our website. Before I introduce the first panel, I wanted to also welcome Assemblymember Kalra, and I don't know if you want to provide any introductory remarks before we start.

Thank you so much, Senator Haney. I appreciate you taking the lead on this issue that I think a lot of Californians are aware of, think about, because as you correctly stated, it's in every corner of our state. I really appreciate the fact that we're focusing on evidence based solutions, not fear based solutions.

As someone that worked as a public defender for over a decade, over five years of which I represented individuals in drug treatment court during kind of the height of the meth epidemic, there's no doubt that we do know. We do know that there are solutions that are available that are outside of the realm of making past mistakes.

Quite frankly, the war on drugs, where particularly during the eighties and nineties, there was one size fits all solution that was not evidence based, but was certainly fear based, and ravaged communities, particularly in the case of the eighties and nineties, with our black and brown communities. The reality is that fentanyl and addiction affects everyone, regardless of their race, regardless of their income level. Anyone can fall into a crisis of addiction.

And so I'm really grateful to everyone that's here to help us learn more about what the state can do to ensure that we're setting ourselves up for success in terms of saving lives, in terms of saving families, and making sure that those that have fallen into this crisis of addiction have the tools, resources, and support from the state as well as local jurisdictions to get back on track in their lives and to ensure that we have safe and healthy communities. Thank you.

Assembly Member Ortega, I know you just walked in, but I don't know if there was, if there's anything you want to say, welcome. Great. Well, we will start with our first panel. And to start the conversation on barriers and benefits to care, I want to invite Axl Kaminski, a graduate student at UC Davis who is currently enrolled in treatment. And we want to thank you for being here, Axel, and we deeply value your perspective. And whenever you're ready. You can begin. And you can just hit the button there to turn the mic on.

Oh, am I good now? Yes. All right, awesome. So thank you, Assembly Member and chair Haney, for putting together a great Committee that I think is really important. I am really happy to have the opportunity to share my personal experience with medication assisted treatment, in particular, methadone. I should have said, for the record, and anyone who's not in the room that will be watching this, my name is Axl Kaminski.

I bring to this Committee, I think, a perspective of not only just a methadone patient, but a formerly incarcerated student who studies the war on drugs and crime. Currently, I'm pursuing my graduate degree at UC Davis in sociology. Before that, I earned my law degree at UC law SF and my Ba at UCLA. I want to acknowledge my privileges. I recognize that my experience might not be the most or fully representative of all people on methadone and medication assisted treatment.

But I hope that my testimony offers insight into the complexities and barriers that are inherent in accessing and receiving medication assisted treatment in California. Because if I can't get it and it's difficult for me, is going to be difficult for people who don't have and enjoy the privileges that I do. I started using heroin in high school. It was after a traumatic car accident that left me physically, mentally, and emotionally in pain.

I think it took me a couple decades to realize that I was self medicating and undiagnosed mental and physical health issues. So after years of chaotic iv drug use, I enrolled in methadone for the first time in 2011. So it's been 15 years that I've been consistently on a clinic. There was no, like, moment where the heavens opened up or suddenly everything fell into place for me. My story's a little messier than that, and I think most people's are, you know, not.

I got treatment and then I got clean and, you know, end of the story. Right? I mean, it sounds great, but that definitely was not my experience.

Sorry. If you could just bring the mic.

Or a little closer. Sorry. Yeah, a little weird. No, I want you to be able to hear. So it just wasn't a clean, you know, narrative arc from using drugs to not using drugs for me. And I think that experience is true for most or many people. So for a variety of reasons, methadone's got kind of a bad rap stigma.

And the criminalization of people who use drugs has really resulted in onerous regulations and bureaucratic hurdles within the methadone space that impedes access to life saving treatment. Methadone patients are all too familiar with the failures of the clinic system and the regulations that control our lives and hamstring well meaning clinic staff from actually helping patients. Loosening these regulations, I believe, will save lives. Studies have shown that methadone can reduce overdoses up to 80% in certain cases.

My 15 year tenure now as a methadone patient has exposed me to some of the systemic issues patients face, including stigma, limited access, and travel restrictions. I think that having these misconceptions surrounding medication assisted treatment really exacerbates feelings of shame and inadequacy among patients. I haven't heard too many people say that they are proud to be on a methadone clinic, but you do hear people all the time talking about AA, NA, these types of modalities where people are sober, essentially.

And I think that really needs to change, because methadone is a medication just like any other medication. We don't get weird about someone taking insulin or their blood pressure medication. So even with all these regulations in place around methadone, I think at a very basic level of healthcare provision, currently, most clinics are failing to provide quality patient care, ensuring dignity and respect, and also privacy for the patients who are in treatment. Me personally, I've faced issues with my employment and education.

Having to dose every morning makes getting to work really difficult. I was actually late a little bit here today because I got stuck at the clinic for 45 minutes. It's very, I would say, irregular. You can't count on getting in and out of the clinic in a set period of time, which really makes things challenging. In fact, for an entire year, I was at a clinic in the Bay Area that had only one dosing nurse for hundreds of patients.

People would literally have tears in their eyes in line because they knew they were either going to have to leave and not get their dose and go to work, or probably get fired. I don't know why I personally stayed at that clinic for as long as I did, other than maybe feeling like that was the best that was out there or what I deserved.

So I think we have to really do a lot to make sure that patients are able to access their medication reasonably like any other medication. And it's ridiculous that people have to wait in line for sometimes three to 4 hours to get dosed. Of course, that's not the average or anything like that, but it happens. Over the years, I have had issues within the clinic.

I've been the kind of like, perfect patient, and I've also been the patient that none of the counselors want to deal with. So I was really encouraged to see in this Bill a codicil thing that you can't make the medication contingent on counseling. I've had counselors harass me. I've had counselors try to blackmail me into doing their homework. I've had counselors ask me to commit what I think is insurance fraud. I'm not saying all counselors are bad or anything like that.

There are plenty of people who are trying to do great work within the system, but there is a culture of, I believe, corruption as it currently stands. Because of the way methadone is set up, traveling is incredibly difficult. Just this past spring break, which was a couple weeks ago for me, I had to figure out how to get down to LA to visit family.

There, in theory, are a few options for methadone patients to courtesy dose at a different clinic near where they're visiting, or get an emergency exception for take home doses if you're lucky. But in practice, I think patients know that nothing at the methadone clinic ever goes as planned. If you're interested in seeing Murphy's law play out in real life, go to a methadone clinic and sit there for a while.

I've set up my courtesy dose two to three weeks in advance, called the clinic, checked everything out, did my due diligence to make sure that I would be able to receive my medication. And when I showed up on a weekend to the clinic, which was only open for 1 hour on a Saturday, there's a really narrow window.

They told me that they didn't know what I was talking about, and they did not have a way for me to dose because the Doctor is not there on the weekend because they're only open 1 hour. I left there with a sinking feeling in my stomach and a decision to make. Do I go get high and use illegal drugs to feel better, or do I tough it out and deal with the questions from my family about why I'm missing my niece's birthday?

This is common for people trying to travel on medication assisted treatment. Also unhoused people who do not have the ability to travel away from the clinic because they're tied to it. A lot of my clinical clinic cohort in Stockton actually live very near, in parks very near the clinic because they can't go outside of the city limits. You know, it's too risky. They won't be able to get back and get dose for their medication.

I could talk all day about what's wrong with our clinic system, but I like to end on what I think is right, the medication works. It's been shown to reduce illicit drug use by a third and quadruple treatment retention. Methadone's allowed me personally to accomplish a lot in my life. I definitely would not be here without it as a tool to manage my substance use.

And I think despite all of the issues that I just raised with how it's currently done, I still think it was worth it to be on this medication. But it doesn't have to be this difficult to access, it doesn't have to operate this way. We have examples, and I'm sure the doctors that are going to come up after me will talk some about this.

Of other places who have successfully instituted methadone at the pharmacy level, allowing healthcare professionals, not just doctors, advanced healthcare professionals, to prescribe it. So I really urge you all to do everything in your power to liberate methadone, because you'd be changing my life and I think a lot of other patients lives for the better if you can do that. Thank you. I'd also be open to any questions anyone has. I know I probably went over too long.

oh no, that was great. And thank you so much for both your expertise and your analysis, but for sharing your own personal experience and being so open with it. It's much appreciated and an essential part of this conversation. Assemblymember cower thank you Mister Sharon and.

Axel, thank you for sharing. I know how hard it could be, and to be able to do it in such a public forum to help inform us is really valued, especially hearing your first hand experience, which was offered with such humility. And it sounds like to me, all in all, the positives may outweigh the negatives. However, the negatives are issues that we need to contend with. Access, hours of operation, quite possibly connected to resources and or any regulatory obstacles put in place.

And so it's really good for us to know that, because that's part of the conversation is what do we need to do so that these clinics are open more hours, are not understaffed, so that as many people that need the treatment can get it. And I appreciate your recognition of those who are unhoused and how challenging it is for them just to get around town, let alone make sure they get their treatment as well when they don't have the ability to.

Or at least it's much harder for them to be in a safe environment if they're in a difficult mental, emotional and physical state for not having access to methadone. So thank you so much for your input.

Thank you.

There's a couple things I wanted to ask about and get your perspective on from your own personal experience and from what you've seen in and around the clinic. One of the things that drives a lot of the really restrictive policies that California and actually the US generally have, it's so out of step with how the rest of the world who have had success. We talk about Portugal, we talk about Spain, Scotland. These are places that have had very serious opioid addiction challenges as well, very widespread.

And they relied heavily on methadone to be able to roll that back. And really, I told this story a few times. I went to Madrid and met with their folks who are responsible for responding to addiction in Madrid. And I looked at the report they gave me and I said, I can't find anywhere on here where you're reporting your overdose data. They sort of looked at me a bit confused, and there was translation and back and forth.

They said, well, we don't really have overdoses in any significant way, that we report some people when they're already in some treatment facilities and such and older, very rare. So how is that possible? Do you not have opioid addiction? And they said, no, we definitely do. But everybody who is addicted to opioids here is able to enroll in methadone. And so we don't. And that's singularly why we don't have overdoses of significant numbers.

And of course, they described to me a very different system that they have. And my response to them was, well, we approach it very differently because methadone is still thought of and viewed almost as a, of adjacent illicit substance on its own. And I wonder if you could speak to that aspect of that and how you talked about the stigma.

But what you've seen, I mean, I think there are a lot of people who view methadone not only with a stigma, but also as something that is very often or can be sort of abused or sold, you know, on the street.

And, you know, is that something, I mean, for the people that you've come across in the clinics that you've been a part of and such, if you describe kind of how you view that issue and that concern, which I think is one, as we talk about changing how we think about methadone and how to access it, it's going to be something that comes up is, are we putting something in people's hands that they could abuse or that they could even sell illegally and have others abuse? And sort of, if you would kind of speak to that concern that I'm sure. You've heard as well?

Yeah, no, absolutely. I'm glad you raised, you know, again, the issue of stigma, because I think it is one of the bigger barriers that we got to get around. It comes externally from the community, but also from the clinics themselves. Many, you know, people who work in the clinic are hostile towards the medication that they're pursuing. So it is a weird or odd situation where this medication has really been vilified and kind of demonized as far as its abusability.

I mean, alcohol is legal and it does tons of damage in terms of long term organ damage, alcohol related accidents. Like, I think the issue is not the substance being harmful in of itself, which I don't believe it is, especially not when it's prescribed properly, you know, taken and managed properly, but rather these kind of controlling images that we have of what a methadone user is, right. That are very racialized and prejudiced and biased. And so I think a lot of work needs to be done in getting away from these narratives about drug users as being bad or criminal or, you know, dangerous.

The methadone itself, like you mentioned in your experience, finding that there was no overdoses, is really effective at lowering the risk of overdose in patients who even are still using other illicit drugs and allows them the opportunity to stop, eventually makes the transition from using illicit drugs to not using illicit drugs much, much easier and more likely that they will stick with treatment. So, yes, there's a ton of stigma.

I mean, you can read cases where police have basically posted outside of clinics and done Terry Frisk and these kinds of things. And, you know, in our media, I often see methadone being derided. So it really needs a revamp. I think.

One of the things about is you're saying this. I mean, part of the policies that, as they exist, to make it so restricted, reinforces the stigma. And it's on top of that, the policies require a certain level of vulnerability for the people who need to access it. That also add to the stigma when people are forced to line up on the street and be out there.

We don't require that for many other medications that I can think of that you have to stand out on the street of which can lead for some people to sort of add to a stigma around it because they feel like it's something bad that folks are doing.

And I'll say this, I think just the last point, and maybe if you've seen this, at least in San Francisco, one of the things that happens is that people who are selling or using illegal illicit drugs surround the clinic and some people who are selling it, and they sort of can target people.

And it's the worst possible way to have people access something that can get them away from something when you make them so vulnerable and make them so go through so many different steps and barriers and everything to access help. And so I wonder if that's something that you've seen as well, just the way that we force people to kind of constantly show up physically in such a vulnerable way and how that impacts people.

Yeah, absolutely. I think there's a million little opportunities on the way to the clinic to fall off of active treatment or active recovery, and clinics are a depressing place. I do not look forward to going there every day. I don't get treated well there. I see other people not treated well there. So it is a hard thing to do. And I think it's really unfortunate that there are some people maybe taking advantage selling drugs near clinics and stuff like that.

But it hasn't been my experience that I've seen a lot of that. Again, I can only speak to the clinics that I've been to, which actually is quite a few, maybe five different clinics throughout the State of California. But just going there and being subject to the ridicule, the dehumanization, the bureaucratic nightmare every day does weaken my will and I'm sure other people's will to keep coming back. Right.

And we need to have a. If there is going to be a clinic in the way that it is conceived of now, it needs to be a place people want to go.

Yeah, well, and I also, you know, one of the things about even just the language that we use, sometimes we even. I've heard this before, the idea that if you are not on. If you are on methadone, that you're not sober, so people think that basically you're doing something wrong. We don't talk about any other medication in that way. And in fact, it's something that I've had to reinforce. And I think, thankfully, they're understanding this, that even in our.

That in our drug free housing, our sober housing, those living facilities, that doesn't exclude people who are enrolled in methadone or buprenorphine, because those are medications and you're still sober. In that sense, obviously, people can assess for themselves where they want to be on that journey, but there's nothing that they need to be stigmatized around. For that, I want to thank you. Axl.

We could have a much longer conversation about this, and it's really, really meaningful to start this hearing with your perspective, and I look forward to working with you on many of these issues and helping to address what has been, unfortunately, a part of your experience with this. But I also want to congratulate you on your journey and your success. I look forward to reading all the books that you write about how we're going to do better as a state and country on this issue.

Thank you. Thank you so much for the Committee's time. I really appreciate the work that you're doing.

Absolutely. Thank you. All right, I am going to move right along to our second panel. We have three esteemed doctors and professors, all three here with us today. I want to invite up Doctor Leslie Suen, an addiction medicine physician and researcher at UC San Francisco, Doctor Aimee Moulin, Professor in the Department of Emergency medicine and chief of the division of addiction medicine at UC Davis Health, and Doctor Lee Trope, pediatric hospitalist at Santa Clara Valley Medical center and affiliated clinical instructor at St. University. Welcome. Thank you. And I believe we are going to have Doctor Swen start.

Thank you, Chairman Haney, and thank you, distinguished Committee Members. My name is Doctor Leslie Suen. No, no soon, and I'm an addiction medicine specialist and researcher at UCSF. I treat patients with substance use disorders in San Francisco, and I also conduct policy research on ways to improve our substance use treatment systems. Next slide. So I hope it comes to no surprise to anyone that our state is in the midst of the worst overdose crisis in history.

To put things in perspective, in San Francisco, where I'm from, we had 257 deaths from COVID in 2020. In comparison, we had 679 deaths from overdoses in that same year, almost three times as high. This has only increased in the years since, where we had over 800 deaths in the last year. So this overdose crisis is only increasing. Next slide. I also would not say that overdoses are only a San Francisco crisis, but a statewide crisis all across California.

The graph on the left shows from Kaiser Family foundation that California parallels the rest of the country in rising overdose deaths, with 17.8 deaths out of every 100,000 Californians in 2021. And again, that number is only increasing. Further, the map on the right shows that the counties most hard hit in California are actually not the San Franciscos or the Los Angeles of the state, but rather more rural areas, particularly in the northern region, where access to treatment and resources are more sparse. Next slide.

So what are the treatment options for opioid use disorder in the United States? We have three FDA approved medications to treat opioid addiction, including methadone, buprenorphine, and naltrexone. And all of these three medications work differently on the opioid receptor in the brain. We know that when people stop using opioids, those empty opioid receptors can lead to really distressing withdrawal symptoms.

And these medications interact at the receptor in different ways, all with the goal of allowing people to go about their lives without having to think about withdrawal or cravings. Methadone is what we call a full agonist opioid, meaning it fully activates the receptor just like any other opioid, while buprenorphine is a partial opioid agonist, meaning that it partially activates the receptor, just like kind of like a dimmer switch turning the light on halfway.

Finally, naltrexone is an opioid antagonist, meaning that it fully blocks the receptor and so that it has no opioids, cannot have any effect on the body. And it should be noted that methadone and buprenorphine are only the medications that have been shown to reduce death, whereas naltrexone has shown, has not had that finding. Next slide.

So we, in the, we have over five decades of evidence showing that methadone and buprenorphine work when people are taking these medications, they have, are known to be less likely to use drugs, have lower crime rates, increase quality of life, are more able to pursue employment and connect with family and loved ones. These medications are also lifesaving with greater than 50% reduction in all cause mortality.

By comparison, as a Doctor, I prescribe many different medications and other drugs like statins for cholesterol or aspirin for heart disease and metformin for diabetes only have a 24% to 33% reduction, which is only half of how much buprenorphine in methadone save people's lives. Next slide.

Next slide. So next slide, please. So what we know is that buprenorphine is easier to access. However, in the era of fentanyl, initiating buprenorphine has actually become more challenging because of its high risk of causing severe withdrawal symptoms when people start taking them. Buprenorphine, however, remains a very effective tool for opioids, but to address this crisis, we really need to leverage all available options. And as mentioned earlier, methadone is our oldest medication to treat opioid addiction and is highly effective.

However, as Axl Kaminski earlier said, there are significant restrictions on how to access these medications due to state and federal policies. Next slide. So in the United States, methadone is highly regulated by federal and state guidelines. Methadone clinics not only have to follow federal rules, they also have to follow state rules as well. One recent study from the New York University found that across all states, California is actually one of the most restrictive states when it comes to state regulations for methadone treatment.

What we've learned from COVID-19 is that during the COVID-19 pandemic. Next slide, please. The federal guidelines actually loosened methadone restrictions so that people were able to get more methadone and actually shelter in place safely at home. And what the research from the past four years has found that when people had better access to methadone, they were more likely to be retained in care. They had better improved quality of treatment from both patients and clinicians. And importantly, there were no increases from overdoses from methadone.

And this is from Jama psychiatry, including data from the CDC and the National Institute on Drug Abuse. And so in earlier this year, the Biden Administration, through the substance Use and Mental Health Services Administration, codified these regulations. As of this month, however, our federal regulations are in direct conflict with our federal guidelines, and so our current state laws actually prevent us from following the federal rules. Next slide.

So, for example, one particular methadone regulation that is different between federal and state guidelines are take home methadone privileges. So, as mentioned, people on methadone have to go to a clinic every single day, often for long periods of time, before they're allowed the privilege of a take home dose that they can take at home. According to federal regulations, they now, as of this month, people are now allowed up to seven doses of take homes as soon as they enter treatment.

And after two weeks, they are increased to two weeks of take home doses. And then after one month of treatment, they can immediately get up to one month. And so this hugely allows people to increase their access to medications however, in California, we are still tied to old restrictions where people still have to be in treatment every day, showing up to clinic for three months before they can even get one take home dose.

And so this really highlights how we in California are adding on additional restrictions that are preventing people from getting the care that they need. Next slide. I think it's important to note that the Federal Government, through the Drug Enforcement Administration, the agency most responsible for public safety and reducing diversion, have actually made also new federal updates, including in 2021, introducing the 72 hours methadone rule.

And so this would allow hospitals and clinics to dispense up to 72 hours supply of methadone while patients await linkage to an opioid treatment program. So if you are an emergency Department and you want us to get started on methadone, hospitals could give you three day supply while you await intake at a methadone clinic. However, again, California State law is in conflict with this allowance, and it prevents us as doctors from being able to give this new allowance to patients in 2022.

The drug enforcement agency also allowed people to start implementing mobile methadone, where methadone vans can actually deliver methadone to rural, rural areas. And this is something that I know is currently being looked into by the Department of Healthcare Services. And so, next slide, please. What are the policy recommendations for how we can address this crisis? What we can do is we can amend state and health regulations to allow California health systems to adopt the 72 hours rule, which would increase access to methadone.

We can align our state policies to align with the federal recommendations from the Substance Abuse and Mental Health Services Administration. And that includes increasing available methadone take home doses during earlier periods of treatment, removing the requirements for counseling, and then following federal guidelines on urine drug testing and methadone treatment, among many other recommendations. And it's important to note to thank Assemblymember Haney for introducing AB 2115 which would implement all of these updates.

Finally, expanding methyl mobile methadone medication units can deliver methadone to more areas with lower access, especially in places that do not have access to counties. So, next slide. I thank you for your time, and I welcome any questions.

Thank you so much. Next we have Doctor.

Very good. Thank you very much. It's easier than buprenorphine, so I figured you're .

That one. Took me a while.

I knew you were going to do well. Thank you. I don't know if the slides are up, but I'm Doctor Aimee Moulin. I'm an emergency physician and addiction medicine physician. I also work for California bridge which is an effort to expand access to addiction treatment. And. Next slide. One of our key tenets, and I think this should be the piece that drives us, is that all people deserve rapid action, rapid access to addiction treatment.

We are very far from hitting that goal and so that should be the main driver of all of our policies, is how well are we delivering rapid access to all Californians. Next slide. This is where we are nationally. This is from the national Survey on Drug use and Health. And what you see is that 95% of people who have substance use disorders in the past year did not receive substance use disorder treatment. And what people will tell you is that, that 95% does not want treatment.

And I can tell you from my experience, that is simply not true. We are not offering treatment. We have put drug treatment behind lock and key and made it really difficult to access. So the very people who are experiencing the social chaos in their lives, we have made it excessively hard to access evidence based treatment. Next slide. The radical and obvious solution that we have approached, that we have taken in our emergency departments is to universally offer treatment on demand.

So currently someone walks into the emergency Department, has a substance use disorder, and we start treatment on demand. This is both radical but extremely obvious that all people should have access to addiction treatment. So this to has been our program. We are primarily using buprenorphine through the emergency departments, functionally, because it is easier. Next slide. As my colleague mentioned, buprenorphine is a partial agonist. Because it is a partial agonist, it can be prescribed.

So I can write a prescription for buprenorphine and that individual can go to a pharmacy and pick it up and then attend a clinic appointment in two weeks time can be prescribed currently by any physician with a DEA license. Previously it was so difficult to access. Only special physicians could prescribe it in a limited number. We have a long history of providing very difficult to access, highly stigmatized care and we are just starting to dig out of it.

And we need to rapidly ramp up our ability to provide treatment to people who need it. So buprenorphine treats cravings and withdrawals. It is a partial agonist. It is not a full opioid, which allows us those flexibilities to prescribe it and then refer someone to any outpatient clinic. They do not need to be connected to a specific opioid treatment program which is a lot more geographic flexibility occurs. The state. Next slide. I want to reiterate, these medications are highly effective. They are not new.

These are medications that we have had for a long time. We have decades of studying these medications. Buprenorphine. This is something we talk about in medicine is how many patients do I need to treat to have an impact, to give someone to have an impact by giving aspirin. You all have heard of this. For a heart attack, I need to treat 42 people to have an impact.

The entire EMS system that we have developed, which is designed to address cardiac arrests and provide defibrillation, they need to treat two and a half people to have an effect. I only need to treat two people with buprenorphine to get someone into treatment. These are highly effective medications that we have studied for a long time. Next slide. This is our California bridge program.

What I want to highlight for you from this data that is statewide, looking at the number of people that we have engaged in treatment is of the folks that we have identified. And just keep in mind, this is a tiny fraction of the people we could be reaching. 176,000 people we identified with opioid use disorder. 76,000 were started on treatment in that visit. So remember the myth of 95% of the people who don't want treatment here.

I can tell you about 40% of the people that we encountered in the emergency Department accepted treatment on that visit. These are the traditionally hardest to reach individuals. People with co occurring mental illness, people with unstable housing, people who are currently disconnected from traditional sources of care. This is the population that has. That most people will have you believe is treatment resistant. And we can see that it is not true. Next slide.

What we have learned is that Low barrier, easy to access treatment drives increased demand for treatment. The reason we do not have more people in treatment is because we have not asked if they want it. Next slide. Currently our outpatient treatment, we have focused on the specialty drug medi Cal System, which is primarily our methadone clinics. But we need to incorporate all areas of care. We need to incorporate primary care, emergency departments, federally qualified healthcare centers.

We need an all hands on deck approach so that all places where an individual can access care is able to provide them that rapid access to treatment. So I'm going to leave you with the final piece where we should all be, which is all people deserve rapid access to treatment. We are very far from hitting that goal. But overdose, particularly opioid use disorder, is a highly treatable disease process. This is a solvable problem and we actually know how to solve it. We just need to do it. Happy to answer any questions.

Thank you. Appreciate that. Doctor Trope.

Doctor Lee Trope. I'm actually a pediatrician. Can you hear me? I'm a pediatric hospitalist, so I work in the hospital taking care of kids with all sorts of diseases. Since 2020, I've started to focus on admitting patients who are under 21 to the hospital to treat them for opioid use disorder. And I'm going to talk a little bit about the opioid epidemic. My slides are up in young Californians, so I really appreciate, Axl, your comments.

He kind of brought to life something that we see, which is that most people start using when they're minors or adolescents or young adults, but they don't actually have access to care for a decade. And so this is a pediatric disease that the pediatric community and our systems are not treating in a timely fashion. So next slide, please. I'll talk a little bit more about that. So if you look at kids now, this is looking at teens.

The graph to the left is national data, and the graph to the right is California data. To the left, you can see just a huge increase around 2019-2020 in death. And that gray line is probably too small to see is because of fentanyl. So that's overdose deaths in teens, and California's no different. I mean, it's just staggering. When you look at the graph, this is actually in the context of record downtrending substance use in teens.

So, actually, when we look at the data, less and less young people are using drugs than it used to be. But these drugs are so deadly that they're killing a lot more people. Next slide, please. This is just talking about national data on young people and opioids. Fentanyl is now behind 90% of all overdose testing teens. And when we do autopsies, we find that most of them have another substance in their system at the time of death. This next section talks about overdose deaths.

So I'm gonna talk about opioid use disorder and treatment, but I'm also gonna talk about overdose today. And when you look at overdose deaths in teenagers, you find that 60% occurred at home. 67% of the time. Somebody else was also home. 60% of the time, a teen was pulseless. By the time the EMS arrived, and Narcan was given in less than one third of overdoses. So, huge opportunity opportunities to improve our overdose care.

If you go to the next slide, when you talk to our patients, you ask, where do you get, where do they get opioids from? And you may be shocked to find out, or you may already know this, but a lot of people are shocked to find out that a lot of it is on social media.

So a lot of our kids will say they went out looking for specific substances, and we've actually found some kids after overdose, when we look at their search history, that they were like, what dose of Percocet do I need to help with my back pain? What would be safe for me? And what they don't realize is that that Percocet is actually laced with a lethal dose of fentanyl.

So we've recently discovered that 60% of the counterfeit pills that are out in the community around here contain a potentially lethal dose of fentanyl. If you're opioid naive and to the right, you can look at the DEA. I'm sure this is anytime we, as adults, find out about Emojis or anything online, it's already outdated. But the DEA put out kind of a set of Emoji codes that teens are using on social media to ask for different substances.

So this is at least the latest evidence that we have. Though, of course, this is a fast changing phenomenon if you go to the next slide. Because the current drug supply is so different, we need a different approach to educating youth about the drug landscape. So when I was in high school or middle school, we had this idea of just say no with the D A R E program that you guys probably know a lot about.

And there's this movement for a new drug talk with young people. Just say no. K N o w. When we were young, it was kind of told to us that if we use substances, we may end up on the wrong path, and that wrong path may lead us to all sorts of things. The truth is, is that it's more like a minefield now out there. For young people, their first or second step out can be deadly.

And so young adulthood or adolescence is a normal time for risk taking. There's always been a subset of people who are going to experiment with substances, but they really do need to understand the risks that they and their friends are taking these days, which is very different than it used to be.

And so our education system needs to kind of understand that the current landscape, and not to scare kids, but to kind of arm them with information so that they can make the best decisions for themselves and their friends. Next slide. So, just briefly, the young people in opioid use disorder. So these overdose deaths that we see, we don't know. There's no data that I'm aware of where we can split.

How many of these kids are thinking, zero, I'm just taking some other substance for fun, and it actually has a lethal dose of fentanyl, and they die versus how many kids have opioid use disorder and they die? There's some subset of the kids that are dying because. Because they already have addiction and some subset that are dying because they mean to use something else. But when we ask adults, and I kind of emphasize this in the beginning, when did you start using?

We find that two thirds of them, say, before 21 and one third before 18. So this is a pediatric disease in a lot of ways that we're failing to treat. And young people, because they're young people, have a tendency to rapidly escalate their opioid use. They underestimate the risks, and they have a high risk of overdose as a consequence. And on the right, I have the. There's this DSM manual that we use in medicine to kind of diagnose certain conditions I have on the right here.

Just, you know, just using opioids doesn't make you addicted to opioids or have opioid use disorder. You have to use, it has to have negative consequences on your life. You have to have, you know, get tolerance where you need more and more in order to have the same effects. And then, you know, you have this withdrawal phenomenon.

So I'm not going to belabor this point, but I just want to emphasize that just because somebody young is using substance doesn't necessarily mean they have an opioid use disorder. The next slide is just. We kind of already talked about this, but I love this graph. It's actually from California Bridge Doctor Mullin's program. And what it just shows you is why do we need medication to treat opioid use disorder?

You could see that when people start using, they feel normal, and then they use, and they feel high or some sense of euphoria. And over time, that euphoria kind of goes down. As you look at this slide, they'll need more and more substances to have the same effect. But once they develop tolerance and dependence, many, many people will describe to us that they're not using to get high or for euphoria. They're using to feel normal. They don't want to be in this terrible State of withdrawal.

And so you find that they're just using to stay in that middle range. And what methadone and buprenorphine allow them to do is stay in that normal range. They're going to school, they're at their job. They're with their family and friends without this cycle of withdrawal use. Withdrawal use. And the next slide is just, again, emphasizing what the other doctors already said, that when we actually study this, we find that these medications save lives.

And we've talked about this already, but we're underutilizing a tool that's life saving. Next slide, please. So we have a treatment access crisis. It's hard out there for adults to access treatments. It is nearly impossible for somebody under 18 to access treatment. Buprenorphine is the only treatment that's approved for adolescents. So if you're under 18, we don't have methadone approved for that age group for a variety of reasons.

But a recent study showed that less than 5% of young people who have opioid use disorder have any timely access to any treatment. And this has to do with so many different things that we've already discussed today. And part of that is my profession, pediatrics, our field, has not totally realized this and taken this on as a priority, which is something that I think needs to change dramatically.

Part of the challenge, though, next slide that we haven't talked too much about today is just the logistics of starting buprenorphine specifically. Like everyone's been saying, we need timely access. But it is a little bit of a tricky medication to start. It's not the same as starting your blood pressure medicine, and you just get a. Actually, I don't know much about blood pressure. I shouldn't say that, but I'm a pediatrician.

But it's not like starting other medications where you just kind of go in and then you start taking it. You have to. There's multiple different ways to start buprenorphine that we can all talk about at length if there's questions.

But the most common way is that you want to start when someone's in a little bit of a mild withdrawal before they start, and why that makes it a challenge is that you really need to be able to catch people when they're safe to start treatment, because if you start too early, you can precipitate a severe and very uncomfortable withdrawal. But if you start too late, they're just gonna go out and use because it's so uncomfortable to be in withdrawal.

And so that timing, especially for young people, has made it a challenge to start in the clinic where they have a very hard time timing their withdrawal symptoms with a 10:00 a.m. Appointment time at home, where they have all their triggers and all their access to substances. The emergency Department has been amazing, but a lot of our youth find that they have trouble getting there at the right moment when they're ready to start treatment. Emergency departments can't wait for 24 hours for them.

Typically, they're busy places. And so what we found is actually admitting some of the young folks to the hospital, waiting for them to be ready to start, and then starting them there in a controlled environment, has found some success. And we've treated now almost 100 teenagers and young adults in my hospital and have had a lot of success doing that. I think that the young population, I think probably the entire population, but I can only speak to the young population.

Some subset of that is going to need some TLC that a hospital and a pediatric environment can give when they're initiating this treatment, and then we, of course, link them to outpatient care. But at the end of the day, what everybody's emphasizing here, I can't emphasize strongly enough. Different people are going to need to start in different places, and there should be no wrong door to starting treatment in our state.

The next slide, I'm getting to the end here, but I just wanted to graphically show you guys what the problem is in youth. I think this slide really shows us that if the overall prevalence in young adults in adolescents and young adults in our country who have opioid use disorder is about 1%, a very small portion of those are being diagnosed.

The blue part of the graph is showing the proportion that's being diagnosed even less, receive any treatment, way less, start medication even less than that, stay in treatment at one month, and then even less than that, stay in treatment by six months. So there's opportunities for legislation at each part of this graph. And then I wanted to just talk in the next slide briefly about harm reduction. So, overdose prevention, this is really big.

So we try to equip all of our young people, and this is something that I think has a role in the education system, in how to prevent overdose. And so we remind them never to use alone. And there's actually a national hotline now that you can call use your substances, and if you don't respond in a certain amount of time, they'll call ems in. But never using alone fentanyl test strips, which are useful in certain situations and a little bit more complicated in others.

I'm happy to talk more about that, but we're trying to give our young people fentanyl test strips, reminding them to start with a small amount to watch and wait before the next person uses narcan is huge. Have naloxone or narcan ready. There's been a huge effort to get Narcan into all different places in our community, and I think that's really useful. And then, you know, reminding people to call right away. Next slide. We had a big legislative win.

Thank you, Assemblymember Haney, for allowing us now Assembly Bill 816 passed last year, allowing us now to treat teens that are 16 and older with buprenorphine and they can consent to their own treatment. That is, we always, always want to have parents and families involved when appropriate. But in rare situations, family Members are unable to consent for treatment, and that should absolutely not be a barrier to care.

And we've already had on the ground a lot of teens that have been able to access treatment because of this law. So thank you for that. My last slide just has some potential legislative opportunities that I think could be really useful. I think we need to do better with prevention and education. We need universal school based education and resources to prevent substance use and overdose. Using sex education as a model. Every California middle schooler has to take sex education high schooler.

I think there needs to be a similar approach to substance use and the current drug landscape. We also need funds to evaluate these prevention strategies and to inform implementation and also De implementation, because as we learned through D A R E, some of these programs actually do not work. So it's important that we are constantly assessing if we're having an impact. The next section is just on Low barrier care for youth with substance use and substance use disorders.

So just overarching doors and, you know, I'm excited to work with this group and the state to develop more specifics around this, but overarching goals are there should be no wrong door to enter care. That treatment should be available 24/7 because if you miss the window where somebody is ready to start, you really, because of the withdrawal phenomenon, many people will then use, and then you lost your opportunity.

So this treatment available at all times is huge for substance use, especially with buprenorphine treatment and then integration into General Health Services. So something I see a lot of legislative efforts going to is kind of more beds for opioid use disorder, more specific providers, and it's very narrowly focused on opioid use disorder. But this disease is part of a holistic care, and folks need, it needs to be integrated into our General medical health system and not just siloed into specialty clinics and providers.

We need availability of residential facilities that offer medication treatment to minors. Very few of our residential beds are open to anybody under 18, and it's a huge barrier. My program is treating opioid withdrawal and treatment initiation in the hospital. And I think in the spirit of no wrong door, that there should be hospital reimbursement for that across the board. And then we need to incentivize screening, prevention, harm reduction, and evidence based treatment in the outpatient setting using aces as a model.

You guys came up with legislation recently to increased reimbursement of aces. And I've just watched the entire pediatric outpatient community change their clinic structure to now screen for that. We can do the same thing for opioid use disorder. And the very last thing I know I'm talking a lot, but it's just that a lot of teens will tell me that they went to using substances because of untreated mental health conditions.

And there's been a lot of work into improving our mental health system in youth, but that is completely related to our overdose crisis. And so innovative solutions for mental health treatment access is also, in my opinion, opioid overdose and opioid addiction prevention access. Thank you guys for your time.

Thank you, Mister chair. And thank you, doctors. Very informative and very helpful in giving us greater context as well as understanding that some of the things that we're doing, like, as referred to Semer Haney's Bill of reducing the age of consent to for treatment.

You know, it's critically important, of course, Semmery Haney has further legislation this year, which I think will be not just for all of us that will be supporting his efforts, but also informing the author and our staffs on what it should look like and how the legislation should move forward in a way that's effective. Doctor trope, thank you for your service to Valley Medical Center. Valley Medical center, one of the. You had mentioned that methadone is disallowed for use on minors. Is that a federal regulation?

Okay, good to know. Because we can also work with our federal partners. Even though, as Doctor soon indicated, that the federal rules have become much more flexible than the California rules, it doesn't mean there aren't some things that we can still advocate for at the federal level with our federal partners. Doctor Mullen, you had mentioned buprenorphine is easier in the hospital setting to use, but is that simply because methadone is.

Yes.

Much more regulated, it is easier to connect that person to outpatient treatment with buprenorphine. So we do start methadone, but there are swaths of the state where getting to methadone is almost impossible. Also, if you have challenges with transportation, getting to a methadone clinic can be impossible. If you have childcare, getting to a methadone clinic almost every day can be impossible. So it's really that we focus on that linkage to care and what will work for people. And most of the time, that is buprenorphine.

And so a lot of that decision making is based upon the regulatory hurdles that exist.

Yes. On the logistics for that individual.

Okay, thank you. And then, Doctor soon. I think this actually goes to that in terms of the federal regulations allowing for greater flexibility, the 72 hours rule in particular, but just the ability to more easily have kind of take home dosage, I think that speaks to the physical presence of Methadone Clinics, how challenging they can be.

I remember, and this was some time ago, but even back when I was a public defender and have clients that the court would try to get into methadone clinics and how challenging that would be. Do you? Well, a couple questions. One is, would you suggest that California moved in a similar direction in terms of at home dosage as well as a 72 hours rule?

I would, based on the evidence, just because of the many studies that have come out since COVID over the past four years, with the adoption of the take home flexibilities, we found really great outcomes of treatment retention and improved quality of care without the feared consequences of overdose. And so that really points us to really rethink our regulations and really think about how we're delivering this treatment.

And then also the 72 hours methadone has already been delivered in many other states in the United States, including Massachusetts, Colorado, Connecticut. And we in California are incredibly jealous that we can't do this. And so we would really, really appreciate, you know, being able to provide care that aligns with federal guidance.

I think the COVID the pandemic taught us a lot of things. You know, the silver lining is, I think we learned a lot about how we can do a lot of things better. But I think in this case, this is really, truly about saving lives.

And the last question to you or to any of the doctors, but when it comes to the use of methadone, and I know this, and Axel spoke to it, I've had clients that have been on methadone treatment for many, many, many years. Is there a method or procedure to wean folks off of it? How successful is that?

And I'm assuming it's patient specific, rather than talking about individual on the macro scale, is that something that is kind of that we should be considering as part of an overall plan of allowing access to methadone?

Yeah, no, that's a wonderful question. I think that right now, our system is just so limited with access that I appreciate that you're thinking about the future of, like, well, what happens afterward. And I also, you know, what the evidence shows is that when people are on these medications for anywhere from a year to six months to a year, I often tell patients, give me a year and I will give you your life back. And so I often think of that in the short term.

And then what happens? Once their lives are stabilized, once they are able to find employment or reconnect with family, then we can have that conversation of what happens. Many people stay on it for many, many years. Some people taper off and they're fine. And so it's very much individualized. But what the evidence really emphasizes is, give us a year.

Great. Well, I'm very grateful to all of you. I'm going to shortly head back to my district. So I apologize to the state folks. But you know, this is stream I'm watching, my staff is watching.

But all in all, I'm very grateful to all of you for helping to better educate all of us as to how we create policies, like in the case of Summer Haney's Bill, that actually helps you help your patients, because that's really what this is about in terms of the regulatory hurdles and the resources that are necessary, whether it's resources that go to the hospitals that are providing treatment in the hospitals, or to make sure that either there's at home accessibility, or that the in clinic, in methadone clinic experience is made better and more efficient and more resourced so that we don't have as much the negativity of that experience so that more people stay on their treatment.

So thank you all so much. Thank you, Mister Kalra, Miss Ortega.

Thank you, chair. Thank you, doctors. Last year, you know, I was new to the Legislature and very quickly started to learn more and more about the fentanyl crisis. And there was a slide you showed earlier. I don't know if it can go back up, but where we talked about the small amounts of dosage that can kill, you know, an individual.

And that's where my interest kind of peaked in terms of not just as a policymaker, but also as a parent and seeing the rise of overdoses in young children in middle school, high school, and many of them, you know, the stories I was hearing, they had never experimented with any other drug. It was whether they purchased it online or they thought they were getting something else and then died. The parents would find them deceased the next morning. It was horrifying.

I introduced a Bill, it was vetoed. But in that process, I spent a lot of time going into the high schools and talking to parents and educating students and parents, understanding the failure of other, you know, I think you mentioned earlier, say no to, you know, don't use drugs. Say no to drugs.

So trying to figure out ways to talk to parents and talk to youth about these dangerous things that were out there and understanding that at some point or another, whether they knew it or not, they were going to be interacting with some of these and how to save their lives. My entire focus last year was about saving lives. So I guess my question to you is, how do we continue that work from a policy perspective? You had one bullet point about working with the school system.

So just wanted to get your thoughts about how do we continue, you know, educating folks about what's happening and in a way that gets to our ultimate goal of saving lives, particularly young lives.

Yeah, I think that, you know, part of there's so many different innovative programs out there that are trying to educate young people, but they're pretty fragmented, and there's not, like, a universal state program that's then being evaluated to see if it's effective. And so I do think there's an opportunity there. I mean, we have. That's why I gave the example of sex education. I mean, we have examples of other programs that are universal, state based.

Every middle school or every high school student has to take this curriculum. And then that curriculum is sort of evaluated by the state and updated. And so I do think that there needs to be a universal, state based approach to education, and I think, think it should be school based. And critically, because we did do something for years and years that was found to be ineffective and in some ways harmful, it should be consistently evaluated for effectiveness and edited as needed.

The other question I have is around social media. A lot of these drugs are being bought or sought after and all these different sites. And so wondering if you have any data or any information that you could share with us around some of this increased access through social media to youth.

I don't have any data, but I know that some of our law enforcement partners do. I can tell you every teenager that we see after an overdose, they get it off of Instagram. Instagram or Snapchat. I mean, it's pervasive. I think we used to think about drug dealers in the park, but really they're on Instagram and Snapchat. And so that is one of the challenges is that because access has become so pervasive but also anonymous, so we don't see it.

Some of the other studies that look at dangerous use in children, part of the national survey on Drug use and Health for pediatric patients, show that over 30% of teens who are using opioids are using them alone, which is very risky. So part of that education that you talked about could be around one. These are dangerous, but the concept of harm reduction don't use alone. Have access to Narcan, how you use, because smoking fentanyl has a much higher risk, has a higher concentration.

So we also will see overdoses in the ED. Someone who was previously ingested now smoked. And so I think there's a lot that we can do around education on harm reduction.

I had a neighbor who died from fentanyl poisoning. He was a 19 year old Eagle Scout and took one pill and unfortunately passed away. And that was my first exposure when I was on the Rockland City Council. Later on, my family indicated to me that my cousin, who had died just a few months before that, who may have been a drug user, more active drug user, had passed away from fentanyl as well.

And there were a lot of problems, by the way, in terms of, this was not in California, but when emergency personnel arrived to the scene and what lack of assistance in that state they were able to give him. But I got all sorts of thoughts on my three pronged approach. One of them that we don't get a lot of as much love in this building as I think we need, and that's accountability.

And I'm not necessarily talking about for the users per se, although I think there's some of that that can be added, too, but really to the trafficking that's coming into this country. I mean, the DEA says it, President Biden says it. Everybody says that we know exactly where this is coming from, and, and we don't do enough to prevent it from coming into our country.

The other thing is, in terms of the education component, which is very important to me, I passed a Bill last year and was signed by the Governor that would require, would require schools to notify parents of the dangers of fentanyl and other opioids. So parents now annually, starting this year, will receive a notification from their schools. Because I think parents knowing about this has been a huge hurdle overcome.

Every individual that I've known who, it's getting a lot better, but every time I met a parent, a family of one of these young children or young adults who've died, their parents had no idea what this was, what fentanyl was. Now, I think things are changing rapidly on that, and I think that's really good. But I wanted to comment briefly, and if you have comments, I'd love to hear it, but I remember the D A R E program as well.

And I think for a while, it became kind of like this mocking was mocked a lot for just say no or whatever. And I like your reframing, know, by the way of that. But I mean, I thought it. I don't know how effective it was. I mean, there's data that sort of says, like, different things on that. But, you know, for me, it's, it continues, I think, about some of those items that we learned.

But I still believe that the mocking of the D A. R. E. Program, which, by the way, I think is kind of coming back, but it continues in this building to this day, that for some reason, educating children. And again, I'm not talking about any of my particular colleagues up here who have been advocates for addressing this issue, but continue to dismiss educational efforts because of the D. A. R. E. Program.

And, hey, if we create this new program, then is it going to be like dare or whatever, you know, and that's really frustrating to me because we know that, I mean, you're seeing it all the time with the youth are getting access to this, and sometimes it's accidental. They don't even know, you know, and this whole emoji stuff and whatever. You're right. These guys sort of develop new emojis to communicate with each other. So, anyways, I don't.

I would love to see solutions or recommendations that the Legislature could bring in on creating sort of a program within schools, even if it was privately funded, because I know my county would probably work on funding something in the schools to educate children about the dangers of not only accidental fentanyl use, but if you start using drugs in General. So if you have any thoughts now or in the future, I'd love to know about them.

And if you ever contact my office, there are two pattersons and legislators. Just remember Joe Patterson, the new improved version.

You know, it's such an important point. And even if we were to, you know, I don't, I'm not an expert on the dare and all the literature on dare, and I don't even want to go there, because even if we, right now, we're not in the D. A. R. Era. We're in a totally different era. We're in the fentanyl era. And so even if we were, even if D A. R. E was a huge success, it wouldn't apply.

It wouldn't apply to our current landscape, because the drug landscape has changed. And I do think that it's critical that young people and their parents are just aware and have the knowledge. We do have data in young people that when they really understand, when adolescents really understand risks, and we treat them like people who can make decisions for themselves, and we explain to them what is really going on and what the risks are of their behaviors.

In other areas, like, for example, sex education, we have data that. That works. And so, you know, I would advocate for robust programming that reflects the current drug landscape that is constantly and continuously evaluated for efficacy and changed as needed.

So I'm glad you said that, because I was actually thinking about, somebody's gonna steal my idea. Probably a Democrat will steal my idea and run it as a Bill next year, huh? Yeah, yeah. Mister Haney's taking notes. Miss Ortega, too. But in. In my notification legislation, I mean, look, I have four kids. I mean, I. I can't even read emails from the school, you know, I mean, but I always said, hey, look, it costs $150,000 a year for the state to implement this program statewide.

And if 1% of the 6 million people read that thing, that's 60,000 people in California. Right. So. So I figured, okay, you know, this is a very Low cost help, but I. Instead of saying, hey, look, we need to do fentanyl or other opioids notification, I thought about creating some kind of task force or something at the Department of Education that can sort of update the kind of notification that goes to parents. Because what was fentanyl in 2023 is quickly becoming tranq in 2024. Right?

So the risks are changing, as you say, they evolve. Right? And I think our statutes need to reflect the evolution of drug abuse, because whether it's 20, whether it's fentanyl now, it could be something else in next year or the year after.

I do also just want to emphasize that something that I mentioned at the end, which I do think that part of prevention for young people is mental health treatment and access that is separate from drug use. We still have. This has been a huge problem nationwide over the last several years, and we still have barriers to accessing just General mental health support, whether that be psychiatry or therapy. In young people, whether they're private payer or Medicaid, that's still a big barrier.

And I see them as very much interrelated to prevention of substance use disorder, opioid use disorder. Many of our patients say that they had severe anxiety or severe trauma, and they use fentanyl because it's easier to get than actually medical treatment or counseling. And that is part of the prevention. That is part of the prevention toolkit that I think is critical.

I do think that's a good idea, so I won't steal it. But if you want a co author, we can do that. You've got probably two up here. Well, I appreciate all of your insight and expertise, and I hope that we can continue to work together. We've been able to collaborate, I know, with my office, on a number of bills, and I'm sure the other folks on the Committee would love to continue to work on a lot of these issues.

There's four a good reason, a lot of interest in how we address youth overdose and youth addiction, and to be able to support young people so that they don't get on this longer and deeper path of addiction. And so I know that there's a lot of interest in how we address that.

I think that the point that was made or the statement about how we are in the, the fentanyl era now and how that has changed everything, I think, could apply to everything that we're doing and that we're talking about here. When you have a drug like this that in such a tiny amount can kill somebody, is so addictive and addictive in ways that cause withdrawals, that lead to certain behaviors and a need to constantly access that drug.

And I think it does change things on all of these fronts. It certainly changes things on how we think about enforcement and accountability on the law enforcement side of things. I think it changes things on prevention and how we talk about education. It changes things on harm reduction and what our responsibility is there and what needs to be accessible. And it also absolutely changes things on what the main focus of our hearing is today, which is on treatment.

Everybody who comes into the emergency room who is diagnosed in any way with a substance use disorder has to be enrolled in treatment, has to immediately have access to medication assisted treatment, not you have to go to this clinic that is 100 miles away, and you can only get there at a certain time. When we know that that's not even the right time to be enrolled in a treatment. There are so many things about the way we approach treatment.

We make it, we put up all of these barriers. It's almost, I mean, if you could design, I'm not sure you could design a worse system if the goal is to get people onto treatment and keep them on treatment, all of the barriers and roadblocks and hurdles that they have to go through when they can just walk out into the street or go online and for a tiny amount of money get access to this drug that their body is telling them they need.

And so what we expect of people to be able to overcome that is entirely unrealistic. And as a result, we have what we have. We have an opioid epidemic. We have a substance use disorder, challenge overdose epidemic that is getting worse and worse and worse and worse. And so we have to change these laws right now, immediately. And so I know we have this Bill this year, but there are clearly a lot of other efforts that we need to take.

I'm taking note of the mobile methadone is how, as I noted in many other countries, that's how they deliver access to methadone. You don't have to go 100 miles away or longer and wait every day they actually bring it to where you are. That's ultimately where we're going to need to get as well if we're going to get people off of this drug that is killing so many of our constituents and residents and also really impacting communities broadly.

I mean, you can go, there's downtown Sacramento and walk on the way after this, when I walk to my hotel to get my bag, I'm going to see all of the visible impacts of the failures of these policies that we have here.

And so I want to appreciate all of you for your expertise, for your commitment, for your service, and for your partnership with us, because you truly are advocating for your patience and seeing firsthand how laws that have been made in this building and in DC have tragically contributed to the crisis we're facing. Thank you for your time. Appreciate it. Thank you so much for joining us. And I'm sure we'll continue to be in touch in partnership with, with you, you all. Thank you.

All right, we were going to bring up our last panel here and thank them for their patience. Our third panel is on the state efforts by the Department of Healthcare Services. And we have Tyler Sadwith, who is the state Medicaid Director, and Paula Wilhelm, who is the assistant Deputy Director of behavioral health at DHCS. Welcome and thank you so much.

Thank you and good afternoon. My name is Tyler Sadwith, and I serve as the state Medicaid Director for the Department of Healthcare Services. Thank you to Assembly Member Haney and the Select Committee for the opportunity to participate in this hearing. Before I begin, I just want to say thank you to Axl for sharing your experience and to the other panelists. My family has been impacted by opioid addiction and long term recovery from opioid use disorders. So this issue has personal significance to me.

Reducing overdose deaths and expanding access to evidence based interventions is a top priority for the Department of Healthcare Services. The Department is taking significant steps to expand prevention, treatment recovery, and overdose reversal resources in a variety of healthcare and community based settings.

Our emphasis has been on deploying resources to the communities that have been hit hardest by the opioid epidemic, on developing initiatives that meet people where they are, on partnering with trusted messengers and on strategically investing grant funding in capacity development, clinical practice transformation, and evidence based programs that can be sustained and supported through Medi Cal.

The Department is funding investments, strengthening and reforming policies, and providing technical assistance to expand access to medications for addiction treatment, to distribute naloxone across the state and at scale to cultivate a well trained and diverse workforce to expand infrastructure to close gaps across the entire continuum of care to support harm reduction, peer services and housing, and to tackle stigma, which we know can prevent people from reaching out for help. Some Californians experience challenges when they seek treatment.

Major barriers include gaps in access to key levels of care, including clinically intensive outpatient treatment and residential treatment for populations such as adolescents. And closing these gaps is made even more challenging by the acute behavioral health workforce shortage that we're experiencing in California. Other gaps include a longstanding barrier is a specialty addiction treatment system that has historically not embraced medications and historically has expected patients to be ready for full abstinence on day one when we know addiction is recurrent and chronic.

And not all individuals are at the same stage of readiness to change. And a final barrier is a lack of healthcare settings that are willing to engage this vulnerable population. The Department works in close partnership with state and county agencies, the substance use disorder treatment provider, community hospitals, jails, tribal partners, primary care and harm reduction organizations to tackle these barriers and to expand access to evidence based interventions in every setting and in every service system.

Just as a brief snapshot that Paula Wilhelm will walk through in further detail, the California Opioid Response Project has accelerated the implementation of medications for addiction treatment in federally qualified healthcare settings, jails, emergency departments, tribal and urban Indian healthcare settings, and communities through culturally centered education and community awareness approaches.

It has launched campaigns to engage youth and to educate them about the dangers of the presence of fentanyl in fake pills, and it has distributed nearly 4 million kits of naloxone, resulting in over 247,000 reported overdose reversals. This project has supported some of the initiatives and efforts that were shared today, including the California Bridge program and Sung for Charlie, which was the youth education approach. Our cross sector partnership is guided by three key principles.

Opioid use disorder is a preventable and treatable medical condition medications for opioid treatment are evidence based and effective, and long term recovery as possible and with that, I will turn it over to Paula Wilhelm, interim Deputy Director for behavioral health, to provide additional detail.

Thank you, Tyler, and I think I can say good afternoon at this point. Thank you all again for convening the hearing and inviting DHCS to talk about some of our work. I wanted to share just a few highlights from DHCS's efforts to to advance harm reduction and prevent overdose deaths to maximize the effectiveness of our drug Medi Cal organized delivery system, to improve access to medications for addiction treatment, or mat, and to invest in new workforce development, treatment and recovery programs.

We've talked a lot today about the importance of having naloxone available to reverse overdoses, and the Committee Members may be aware that through our naloxone distribution project, DHCS provides free naloxone to community organizations and entities. To date, the project has distributed more than 3.9 million units of naloxone to more than 3900 unique organizations, and those organizations have reported using this to reverse more than 247,000 overdoses.

To further promote patient centered care and reduce barriers to treatment, DHCS is providing technical assistance to treatment providers to to help them incorporate harm reduction philosophies into their programs. The Department has commissioned the American Society for Addiction Medicine to develop formal clinical guidance on this topic, and we've been convening harm reduction summits to facilitate dialogue and catalyze change across the state. In combination with these harm reduction and overdose prevention strategies, we have an ongoing focus on expanding treatment options and resources.

So since 2017, DHCS and California counties have been implementing expanded substance use disorder treatment services in Medi Cal via the drug Medi Cal organized delivery system, or DMCODs. Today, 97% of our Medi Cal Members reside in participating counties and are able to access expanded services under the DMCODs, California has also become the first state in the nation to receive federal approval for coverage of contingency management in in Medicaid.

As part of our Calaim waiver, contingency management is the only evidence based treatment for individuals with stimulant use disorder. This intervention is a critical strategy to address increasing rates of overdoses that involve stimulants, and to date, 74% of our Medi Cal population lives in a county that has at least one medi Cal contingency management provider.

Calaim also includes a first in the nation approval to cover a targeted set of pre release services, including mature under Medi Cal, for individuals who are preparing to reenter the community from prison, jail, or a youth correctional facility. Because these individuals reentering from correctional settings are over 100 times more likely to die from an overdose compared to the General population. We know that offering Medi Cal covered services during this time and making those warm linkages and connections to community based treatment is an incredibly powerful opportunity.

DHCS is also focused on strengthening access to mat more broadly, and as our physician panel explained, MAT is the standard of care for treating opioid use disorder and has been shown to improve quality of life, reduce substance misuse, lower emergency Department and hospitalization costs, and reduce overdose deaths. So all of our providers in the DMCODs are required to offer MAT directly or have an effective referral mechanism for Medi Cal Members who need MAT.

We are also implementing Senate Bill 184, Chapter 47, statutes of 2022, and this legislation requires all licensed and certified substance use disorder providers to also meet that standard for offering MAT directly or having a referral mechanism, and to have a comprehensive MAT policy that ensures every single patient who needs it receives an evidence based assessment for MAT, is educated and informed about the benefits and risks of MAT, and is able to receive all forms of MAT.

DHCS also continues to promote and expand access to narcotic treatment program services. We recently released guidance that will enable the operation of mobile narcotic treatment programs and will help Fund startup costs for mobile programs. Finally, we continue to administer unprecedented state and federal investments in opioid response. Since 2017, DHCS has allocated approximately 1.5 billion in federal, state, and opioid settlement funds to implement prevention, harm reduction, treatment, and recovery services through grant programs.

The bulk of this funding is administered through our California Opioid Response Project, formerly known as the Mat Expansion Project, and I'll share just a couple of successes from the Opioid response project, but there is a great website with a lot of resources to show where these dollars are going. So as of March 2024, 43,124 individuals have received MAT while incarcerated in county jails in 41 counties that participated in a learning collaborative focused on jail mat access and funded through our Opioid Response project.

We talked about the California Bridge program on the previous panel that is also part of the California Opioid Response Project locates navigators and hospital emergency departments to facilitate mat access and coordinate follow up community based care. California Bridge engaged 276 emergency departments, or over 80% of the emergency departments in the state, and became the single greatest source of new MAT initiations between 2020 and 2022. Just a note on expanding treatment programs more broadly. We have also awarded 225 grants through the Behavioral Health Continuum Infrastructure program.

This is to expand behavioral health treatment infrastructure in settings that serve Medi Cal beneficiaries. So this is 1.7 billion in funding that will underwrite 129 outpatient and 94 new residential behavioral health facilities for mental health, substance use treatment, or both. Finally, DHCS is taking steps to address the statewide shortage of qualified behavioral health providers.

One workforce initiative we'd like to highlight is part of our California Behavioral health community based organized networks of equitable care and treatment demonstration, which we referred to as BH Connect, and we are requesting expenditure authority for 2.4 billion from our colleagues at the Centers for Medicare and Medicaid Services over the course of the five year demonstration to invest in the behavioral health workforce.

This request was submitted last October and pending federal approval, and should enable California to leverage federal funding to expand, expand the number and expertise, diversity and cultural competency of our behavioral health workforce serving Medi Cal Members. So I will close here and note that DHCs remains deeply committed to continuing to partner with all of our stakeholders and the Legislature to improve our policies, provide technical assistance, and make funds available to close gaps and access.

And we want to ensure all Californians can get the help they need with substance use. We really appreciate the opportunity to participate in the discussion today, and we're happy to share more information or answer questions. Thank you.

Thank you. I appreciate both your work and your presentation and your patience for being here with us. I wanted to ask a question about access. I know you mentioned that some of the work is looking at how to expand access in certain parts of the state.

It's actually not something that really is a San Francisco question in terms of my focus here, but I know that there are parts of the state where there really is not a whole lot of access to clinics, particularly methadone clinic, that may be very far from where people are and live. And considering the regulations, it just is not feasible at all for them to be able to travel those distances. Is that so?

Both on the question of how you all think about that in terms of parts of our state where there really isn't any access and how we're trying to address that. And then I know there was a point made about how some of the federal regulations may be, may allow for some mobile methadone programming. Is that something that we are looking at? Do you think that's something that we should consider or how. And do you think that the regulations allow for that? Is that your understanding?

Yeah. Thank you for the question. There are pockets and entire regions of California that do not have access to all three forms of medication that are approved for opioid use disorder treatment, in particular methadone. Given some of the federally mandated and state mandated regulations regarding the provision of methadone, the sort of physical logistical requirements in the regulatory framework to date, there are a few sort of flexibilities that are available today. One is medication units. This is permissible in federal regulation and in state regulation.

This allows for sort of local healthcare facilities to serve as a dispensing location for ntps. So this would allow, say, federally qualified health center, primary care clinic, or a substance use disorder provider located in a region to be dispensing methadone as part of the formal NTPs organization, even if that NTP is located elsewhere. We have issued guidance on this and have provided grant funding and technical assistance to ntps and to the provider community in the state. Support to support the uptake of this.

I think we just issued an opportunity for funding for $400,000 startup costs to support the uptake of medication units. Separate and distinct from medication units are mobile narcotic treatment programs. We are happy that our federal partners recently issued guidance to permit this. This had been sort of frozen in time for far too long. The Federal Government was not approving new applications for mobile NTP units. Those federal regulations were recently updated, and earlier this year, we issued guidance that would support ntps to implement mobile NTP units.

We've been providing technical assistance and grant funding to support ntps to do this, including a grant opportunity program that would provide, I believe, $1 million per application to support this.

And when you say ntps, that would be, would include methadone.

oh, I apologize for not being clear. Yes. So, in California, methadone clinics are referred to in statute and regulations as narcotic treatment programs, or NTP. So I apologize for the miscommunication.

You're an expert on this, so I appreciate that. And I just want to make sure I understand the terminology. And that's great to hear and thank you for that update and that work. And I'd imagine we're also looking at beyond the mobile units, where in the state we can expand access and be more intentional and deliberate about that.

Absolutely. So Paula referred to the Behavioral Health Continuum Infrastructure program, which provides an opportunity for brick and mortar physical infrastructure to be developed across the behavioral health continuum. And so narcotic treatment programs have been a key part of that. And looking really at across geography and demography, what are sort of the equity gaps and the key access issues that can be supported through that program.

Thank you for being here and all that you are doing in this area. You know, I had a question. So my Bill last year around accessing or having access to naloxone was veto, in part because I know that your Department and the governor's office has been working really hard to make sure that more and more people have access to this life saving medication to.

And last, I think it was earlier this year, there was a statement put out that more, we were on track to have our own naloxone produced by the state. So where are we on that timeline, and what is the distribution plan for that?

That's a great question. I would politely deferred to my colleagues at the California Health and Human Services Agency to provide the most recent and updated information on that effort. That's not something the Department is sort of tasked with leading out at this point.

But are you in communications with them? But you guys, you don't know, particularly when that.

We are supporting that effort with a goal of expanding naloxone and achieving sort of the best efficiency for our purchasing dollars. So we are supporting that effort.

Okay. The other question I had was around you mentioned the education efforts throughout the state when it comes to youth. Can you talk a little bit more about what it is that you guys are doing and is it working, and what additional support can we, as the Legislature, give you to reach as many youth as we possibly can around this issue?

Yeah, that's a great question. I think in particular, given the reality that we're living in, that the last panel provided where youth are purchasing counterfeit and illicitly manufactured Xanax or Percocet off Instagram or Snapchat, and it's laced with fentanyl, and they're. They're dying and they don't even know it. So we have been investing in a few targeted opportunities to expand prevention, education, awareness, peer mentorship, and services to youth.

One example is song for Charlie, which was highlighted in the previous panel, and that is really dedicated to promoting and raising awareness about the presence of fentanyl in, you know, they can be called fenta pills or illicitly manufactured pills. That is a common route for adolescents and youth to be exposed to fentanyl. So that is something that we are actively supporting. I'd be happy to provide more information about the other sort of youth specific programming that we are providing through our California opioid response project.

Well, again, maybe I rephrase this. You know, we talked about a lot more needs to be done. So I'm actually wondering, do we have any data, any anecdotes, anything that leads us to gives me something around what are the results? Is this education working? If not, what do we need to do more of? And again, how can the Legislature help?

That's a helpful question. I'd be happy to follow up and provide the data on the effectiveness of these programs. I apologize, I don't have them with me offhand. I would want to highlight one sort of evidence based intervention that we are implementing for youth, in particular in school based settings, which the last panel raised through the Children and Youth Behavioral Health Initiative.

We are partnering with key stakeholders, including school districts, medi Cal managed care plans and commercial payers, to implement a statewide school linked fee schedule so that all children are able to receive a universal set of mental health services in schools and that all payers, regardless of payer source, whether that child has healthcare coverage through medical or covered under a commercial plan. The plan would pay for those services that are delivered in a school setting according to a set reimbursement rate.

And that school linked fee schedule does include screening, assessment and brief intervention for substance use disorders. So that is really a key evidence based intervention that is being implemented statewide in the school setting.

Thank you and again, we appreciate your time and your work. And I also from some of the things that have come up here, I think I have some ideas for topics on future hearings as well. I think we do have a lot of interest in some of the work around education and prevention and youth as was brought up. And I know that we are all committed to continuing to support the work of expanding access to medication assisted treatment.

As we've heard, there are still far too many barriers and roadblocks for people to get into this type of treatment, whether that's because of where the clinics are, the requirements and regulations of the steps that they have to take to stay enrolled or get enrolled.

And I think we're going to try to do whatever we can on the policy side to support your work and Fund your work so that we can get more people into treatment, that can save their lives, that can get them more permanently away from these deadly drugs that we know that are taking too many lives in our state. I want to thank you for being here and thank you for your time.

Thank you.

Thank you.

All right, last but not least, I don't know if there are Members of the public who are here who would like to provide any public comment, but if so, please come up to the mic and each witness if you can. State your name, organization and brief statement on the issue. Thank you. Yes, thank you.

Chair good afternoon. My name is Trent Murphy. I'm here representing the California Association of Alcohol and Drug Program Executives. Our Members make up the bulk of the publicly funded substance use disorder treatment network for the State of California. Opioid treatment programs have long been historically stigmatized and siloed from the rest of the healthcare system, despite providing effective treatment and saving countless lives.

We invite each of the Members of the Committee and also look forward to continue to work with stakeholders in this space to help destigmatize MAT. And we also thank this Committee for taking an important first step with this hearing in helping destigmatize MAT. Thank you.

Thank you. Thank you for being here.

Good afternoon. Lisa Gardiner with the County Behavioral Health Directors Association. We represent the leaders of the public behavioral health safety net in 58 counties in two cities. We really appreciate the focus of this hearing. We're proud supporters of AB 20115 to expand access to methadone and wanted to reiterate our commitment to increasing access to Low barrier mat at all, at all levels of care.

And we believe that any efforts that pursue continuing access to these tillow barrier MAT should include all levels of care, including our drug medi Cal System. Thank you very much.

Thank you. Appreciate it.

Good afternoon. I'm Jennifer Alley. I'm with the California Opioid Maintenance Provider Group. And compas advocated for access to high quality, evidence based mat for more than 30 years, and we're glad to see others embracing mat so widely. California actually has one of the most robust networks, but unfortunately, there are some areas in the state where they do lack access. And we really want to continue, you know, the long partnership between the regulatory bodies and expansion with various grant opportunities that our Members have been engaged with.

Still, you know, we fully acknowledge we need to do better in some rural areas. And that will be possible, we think, with the new federal regulations that have already been discussed today. And we're always eager to be a resource to the Legislature showing outcome data of the efficiency of our services, and happy to host tours and show policy makers, including yourself, anyone else, the great work that comped us with our membership and our patients. So thank you very much.

Thank you. And thank you to all of the providers and stakeholders who are here. I know that there is a wide and shared commitment to expand access to mat. It's sort of awkward for me to call it mat as a mat myself, but I know that's the term and just grateful for everybody coming together today.

You have my full commitment to continue to work on this, to support all of the efforts and opportunities that come for us to make sure that we can get more people into this type of care, which is evidence based, which is proven, which is scientific. And now we need our policy and our policymakers to catch up to make sure that it's actually available to people where and it's needed and everywhere that's needed. So with that, thank you for your time today.

On behalf of my colleagues who I know are following this and the folks who are going to continue to work on this in this building, we appreciate your partnership. Thank you. Meetings adjourned.