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Description
This is the second meeting of the 2021-2022 Interim. Please see the agenda for details.
For agenda and additional meeting information: https://www.leg.state.nv.us/App/Calendar/A/
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A
Welcome
to
the
second
meeting
of
joint
interim
standing
committee
on
health
and
human
services,
we
can
call
the
role
first
members.
Would
you
please
turn
on
your
cameras
and
respond
when
you're
doing
your
name.
B
E
G
C
A
Please
mark
members
who
are
not
who
are
not
here
as
present
upon
their
arrival.
A
This
particular
area
can
be
very
personal
for
folks,
and
I
appreciate
the
emotions
that
can
come
up
from
the
discussion
of
substance,
abuse
and
recovery.
This
is
a
heavy
issue
and
I
want
to
respect
what
comes
up
for
us
in
this
area.
So
please,
let
me
know
if
you
need
to
step
away
at
any
point,
take
a
break.
Take
a
breather
turn
off
your
camera.
If
you
need
to,
depending
on
the
length
of
the
question
answer
for
the
first
few
agenda
items,
we
will
plan
to
take
a
quick
lunch
around
1pm.
A
Unfortunately,
due
to
some
unforeseen
changes
in
our
agenda,
we
will
be
skipping
agenda
item
10
today,
dr
kelly
is
unavailable
due
to
a
family
emergency,
then
send
our
thoughts
and
we'll
try
to
reschedule
those
rescheduled
that
important
topic.
Additionally,
we
will
hear
agenda
item
14
right
after
agenda
item.
5,
since
we
have
the
presenter
here
for
both
of
those
items,
a
couple
of
health
housekeeping
items
before,
let's
see
first,
I
want
to
remind
you
to
please
silence
all
of
your
electronic
devices.
Mine
just
been
off,
so
I
will
do
that
myself.
A
Please
keep
yourself
muted
and
when
you
are
not
speaking,
but
leave
your
camera
on,
so
we
can
maintain
a
quorum
of
those
who
are
on
the
meeting.
Additionally,
I
ask
our
presenters
on
the
zoom
meeting
to
leave
your
cameras
off
and
microphones
muted,
until
I
call
up
the
agenda
item
under
which
you
will
present
or
if
I
direct
any
questions
to
you,
the
zoom
meeting
has
a
chat
feature.
However,
this
feature
is
only
to
be
used
for
technical
assistance.
A
Any
links
or
information
that
you
would
like
to
share
during
your
presentation
should
be
stated
verbally
on
the
record
and
we
can
do
follow
up
with
staff.
If
there's
additional
items
you'd
like
to
share
agenda
items
may
be
taken
in
different
order
than
listed
two
or
more
agenda
items
may
be
combined
for
consideration.
A
A
A
A
A
You
can
find
all
of
this
in
the
information
on
the
agenda
and
with
that
we'll
move
to
public
comment.
Public
comment
will
be
limited
to
two
minutes
per
speaker.
Staff
will
take
time
each
speaker
during
public
comment
to
ensure
everyone
has
a
fair
opportunity
to
speak.
We
also
ask
that
you
do
not
repeat
what
is
previous.
What
a
previous
commenter
stated
an
additional
opportunity
to
make
a
public
comment
will
be
available
at
the
end
of
the
meeting.
Our
broadcast
and
production
services
or
bps
staff
will
interact
with
those
making
public
comments
to
facilitate
participation.
C
C
Thank
you.
My
name
is
leanne
mcallister.
I
am
the
executive
director
of
the
nevada
chapter
of
the
american
academy
of
pediatrics.
Thank
you
for
prioritizing
discussing
substance
abuse
at
today's
meeting.
Pediatricians
have
long
been
ringing
the
alarm
on
the
impact
of
the
opioid
epidemic
on
children's
health,
witnessing
its
devastating
consequences
in
their
clinics
and
communities.
C
The
nevada
aap
strongly
advocates
that
treatment
is
prioritized
over
criminal
prosecution
incarceration
and
the
threat
of
incarceration
did
not
do
not
reduce
the
incidence
of
alcohol
or
drug
use
and
can
deter
pregnant
women
who
need
help
from
seeking
prenatal
care.
This
is
also
harmful
to
children.
Studies
have
shown
that
receiving
prenatal
care
significantly
reduces
the
negative
effects
of
substance
abuse
during
pregnancy,
including
low
birth
weight
and
premature
birth.
The
nevada
aap
currently
has
276
members,
most
of
whom
are
board
certified
pediatricians.
C
C
C
C
C
This
list
includes
licensed
alcohol
and
drug
counselors,
marriage
and
family
therapists
and
certified
professional
counselors,
as
this
committee
turns
its
attention
to
the
efforts
to
mitigate
the
opioid
crisis
and
substance
use
disorders.
Broadly,
we
urge
you
to
consider
expanding
the
types
of
addiction,
specialists
and
other
behavioral
provider
types
to
provide
sustainable
services
to
our
most
underserved
populations.
A
Thank
you
so
much
that
we
will
go
ahead
and
move
on
to
our
next
agenda
item
this
agenda
item
consideration
for
regulations
proposed
or
adopted
by
certain
licensing
board
will
be
presented
by
our
legal
counsel.
Eric
robbins,
eric
robbins
will
make
some
opening
remarks
and
then
members
may
ask
questions
on
these
on
these
regulations.
A
Sorry,
excuse
me:
this
is
an
informational
item.
Only
staff
informed
you
about
the
status
of
the
regulatory
process
of
the
two
regulations
that
we
are
considering.
Now
we
received
an
email,
I
believe
from
our
legal
staff.
You
have
a
greater
interest
in
participating
in
the
development
of
these
regulations.
The
process
can
be
found
on
the
lcb
website
or
you
can
reach
out
to
our
staff
for
additional
assistance.
A
A
For
the
regulatory
process,
I
just
want
to
note
that
this
committee
neither
approves
nor
denies
any
of
the
regulations
before
you
today.
Instead,
each
for
a
board
adopts
its
own
regulations,
followed
by
approval
through
the
legislative
commission.
The
hhs
committee's
consideration
of
these
regulations
is
only
from
an
advisory
perspective.
I
Hello,
this
is
eric
robbins
from
the
legal
division
of
the
legislative
council
bureau.
We
have
two
regulations
for
the
review
of
the
committee
today.
Both
are
proposed
by
the
board
of
medical
examiners.
We
have
regulation
r171-20,
which
revises
various
provisions
concerning
the
licensure
and
regulation
with
regard
to
the
practice
of
medicine,
and
then
we
have
r180
20,
which
revises
qualifications
for
certain
applicants
for
licensure
as
a
physician
assistant,
and
we
should
have
sarah
bradley
from
the
board
of
medical
examiners
here
to
answer
any
questions
from
members
of
the
community.
A
J
Thank
you
just
a
quick
question
regarding
these
regulations,
mr
robbins,
where
are
they
in
the
process
have?
Are
they
close
to
being
proposed
to
for
passage
at
the
ledgecom.
I
Yes,
so
one
one
of
the
regular
r
171
has
not
had
a
workshop
or
public
hearing
yet,
and
my
understanding
is
that
the
board
plans
to
have
those
this
spring.
As
for
r180-20,.
I
The
board
has
had
a
workshop
and
public
hearing,
but
has
not
yet
formally
adopted
the
regulation
and
they
plan
to
do
that
later
this
spring.
So
neither
of
these
regulations
are
at
this
stage
yet
where
they
would
be
presented
to
the
the
legislative
commission.
A
Yes,
please
go
ahead,
see
if
they
will
pop
up
your.
J
Thank
you
great
good
morning,
so
I've
been
a
member
of
the
bme
and-
and
I
I
do
appreciate
all
the
work
that
goes
into
making
sure
the
citizens
of
the
state
of
nevada
are
protected
and
that
we
have
good.
We
have
good
medical
doctors,
we
have
good
pas
and
all
of
those
things
I'm
concerned
about
this
particular
regulation.
J
This
is
number
section
number
eight
section
number
eight
and
then
going
down
to
number
two
of
section:
eight,
where
you're
removing
the
requirement
that
the
person
is
going
to
practice
medicine
in
the
state
of
nevada.
If
they're,
not
a
citizen
or
are
here
in
good
status,
and
so
how
will
you
does
it
not
matter
to
the
state
anymore
that
they're,
a
legal
immigrant
or
that
they're
here
legally
or
can
you
can
you
clarify
that,
for
me,
is
it
is
it?
K
I
Yeah
sarah
robin's
lcb
illegal
in
just
to
clarify
the
changes
that
miss
bradley
was
talking
about.
Nrs
622.2,
which
was
added
during
a
2019
legislative
legislative
session,
provides
that
not
withstanding
any
other
provision
of
title
54.
A
regulatory
body
shall
not
deny
the
application
of
a
person
for
the
issuance
of
a
licensed.
J
I
thank
you
for
that.
So
for
clarity
I
mean
I
recognize
it's
taken
us
sometimes
eight
years
to
bring
a
nurse
in
from
say
a
say:
the
philippines,
where
we,
we
have
gotten
a
lot
of
nurses
for
our
hospital,
but
it
took
eight
years
to
get
to
happen
and
a
lot
of
process
so,
but
we
still
had
to
have
them
come
in
on
a
legal
status.
J
So
now
that's
one
of
the
things
that's
going
to
be
eliminated
for
docs
and
all
is
this
to
expedite
the
licensure
process,
because
I'm
I
just
want
to
make
sure
we
have
good
oversight.
K
Again,
madam
chair
and
members
of
the
committee,
I
mean
the
intent
here
is
to
make
this
regulation
consistent
with
the
last
rest
of
the
nrs
provisions
that
the
legislature
has
passed
and
enacted
so
the
board.
Isn't
I
mean
it's
not
my
intent
to
to
make
any
position
on
this.
We're
just
gonna
go
ahead
and
make
sure
that
people
have
the
appropriate
education
and
things
like
that,
and
what
whether
they're
able
to
lawfully
work
or
not,
is
really
not
a
question
for
the
board.
A
Thank
you
so
much,
and
I
do
appreciate
that
the
board
is
taking
those
steps
to
be
consistent
with
what
we
have
decided
in
the
legislature
is
important
to
licensing
in
nevada.
Senator
hardy,
I
see
your
hand
up
as
well.
Do
you
have
a
question
on
one
of
these
regulations?
Yeah.
C
C
I
I
I
can
I'm
happy
to
jump
in
here.
Senator
hardy.
I
Licensing
doctors
does
not
affect
any
of
the
other
educational
qualifications,
so
they
would
still
have
to
have
the
educational
qualifications
prescribed
by
by
statute
and
it
just
as
the
chair
said.
It
just
says
that
what
what
the
statute
already
says
that
you,
that
the
board
can't
deny
a
license
based
on
citizenship
status,
but
they
still
could
deny
a
license
based
on
educational
qualifications
and
in
fact
they
would
have
to
deny
the
license
if
they
don't
have
the
educational
qualifications
prescribed
in
statute.
I
C
Accept
any
other
countries
or
did
do
we
preclude
any
other
countries
from
accepting
their
medical
doctorate
degree,
or
do
we
have
in
statute
that
we
only
accept
the
medical
doctor
degrees
from
the
united
states
or
the
residencies
from
the
united
states?
Where
are
we
with
that?
Does
this?
Does
this
appreciably
change
anything
that
we
do
now
that
will
preclude
somebody
from
someplace
else,
where
getting
the
right
to
be
approved
by
the
board
of
medical
examiners,
because
they
have
an
md
somewhere
or
a
do
somewhere?
K
So,
madam
chair
members
of
the
committee,
sarah
bradley
deputy
executive
director,
again
for
the
record,
we're
already
licensing
foreign
trained
doctors
every
day,
and
this
just
again
speaks
to
the
status
to
work
this
regulation
anyway,
and
and
what
the
thought
is
that
you
can
get
a
license
and
perhaps
then
be
able
to
find
a
job
and
be
able
to
get
your
lawful
status.
K
But
I
mean
we
have
doctors
right
now
that
have
obtained
degrees
from
universities
in
india,
universities
in
mexico
all
over
the
country,
there's
a
process
in
the
statutes,
and
I
could
get
the
exact
statute
for
the
chair
and
the
members
of
the
committee
if
you'd
like
that
talks
about
the
foreign
approval
process,
because
there
are
certain
universities
that
offer
md
degrees
that
are
already
like
vetted
and
approved
it's
a
foreign
like
equivalency
review.
That's
done
again!
This
regulation
doesn't
affect
that.
It's
already
in
place
in
the
battery
by
statutes.
K
That
and
again
I
know,
because
I
look
at
applications
and
I
see
files
every
day
we
have
many
many
doctors
trained
in
other
countries
that
are
practicing
in
nevada
at
the
moment.
C
K
K
I
won't
find
it
timely
and
I
may
find
the
wrong
provision,
but
it's
it's
like
it's
an
acronym
that
we
use
and
it
stands
for
it's
a
foreign
equivalency
review
and
again
there's
many
universities
that
are
already
pre-approved
and
then
there's
others
that
they
can
submit
to
that
review
and
if
that
entity
deems
them
equivalent
to
the
approved
programs,
then
they
would
be
eligible
for
license
running
in
nevada
and
I've
worked
in
licensing
for
15
years.
K
C
K
Well,
I
mean
they
already
have
an
approved
residency.
They
have
to
meet
all
the
requirements
that
we
require
all
applicants,
so
education
is
just
one
piece,
there's
also
the
residency
as
well
as
an
exam
requirement
and
other
things,
and
so
the
entity
it's
a
foreign
entity.
It's
not
a
nevada,
I'm
sorry,
a
third-party
entity.
It's
not
a
nevada
entity
that
rates
these
schools,
and
I
you
know,
I'm
sure
on
their
website.
They
would
have
a
list.
I
don't
have
a
list
right
now.
K
A
Thank
you,
ms
bradley.
I
would
appreciate
that,
as
this
isn't
directly
related
to
the
piece
of
of
regulation
that
we're
looking
at
under
this
item,
I'm
going
to
ask
that
any
additional
questions
senator
hardy,
be
directed
to
ms
bradley
or
to
staff
off
the
line
and
that
follow-up
can
occur
there.
This
thing
seems
like
a
really
important
issue
that
you're
passionate
about-
and
I
know
from
personal
experience,
having
gone
to
try
to
go
to
school
from
an
engineering
school
in
nevada
to
an
engineering
school
in
australia
that
they're
not
always
considered
equivalent.
A
So
it's
important
to
know
where,
where
you
stand,
those
education
requirements.
C
I
think,
madam
chair,
if
I
may
not
to
belabor,
but
if
we
are
doing
this
with
other
countries,
we
need
to
open
the
doors
to
nevada
and
recruit
from
other
places,
as
well
as
recognize
that
they
have
opportunities
to
come
here.
So
I
would
love
to
to
have
the
list
of
medical
schools.
I
would
love
to
have
the
public
know
this
and
I
think
that's.
One
of
the
challenges
I
have
with
this
particular
regulation
is.
I
think
we
put
the
cart
before
the
horse.
C
A
Well,
I
want
to
just
step
in
about
what
what
our
role
here
is.
Our
role
here
is
to
provide
input
into
the
process.
It
is
not
to
make
decisions.
We
are
not
approving
these.
We
are
not
suggesting
the
approval
by
the
alleged
com
either.
We
are
just
reviewing
these
as
they
pertain
to
the
legislation
that
has
passed
in
previous
sessions.
A
There
is
a
public
input
process
and,
as
an
elected
official,
you
are
more
than
welcome
to
reach
out
to
these
boards
and
entities
who
are
proposing
these
regulations
to
provide
your
input
at
that
process
and
you're
right.
The
public
does
get
an
additional
input
process
where
they
will
have
access
to
these
regulations
from
our
website
today
and
are
able
to
then
follow
up
through
that
public
input
process
of
those
meetings
are
set
up
through
the
spring
and
summer.
A
So
I
I
additionally
agree
that
we
should
be
looking
at
how
to
encourage
folks
to
come
to
nevada,
because
our
healthcare
industry
really
could
use
that
boost
in
in
the
numbers
of
providers,
and
I
would
also
encourage
you
to
take
that
up
with
maybe
goed
or
one
of
the
economic
development
groups
that
reaches
out
to
other
countries
and
works
with
them
on
bringing
people
into
nevada
and
encouraging
those
industries.
So
well
I'm
going
to
go
ahead
and
move
on
from
this
topic.
A
Thank
you
senator
all
right
with
that.
We're
going
to
thank
you
so
much,
mr
robbins.
We're
going
to
go
ahead
and
move
on
to
agenda
item
number
four:
we
have
the
honor
today
of
hearing
from
honorable
a-ron
ford,
our
attorney
general.
He
will
be
doing
a
brief
introduction
today
on
some
of
the
work
that
their
office
has
been
doing
on
the
opioid
epidemic.
B
Good
morning,
chair
peters
and
members
of
committee,
adrian
ford,
your
attorney
general
and
I'd
like
to
begin
by
thanking
you
all
for
the
opportunity
to
provide
some
opening
remarks
for
today's
interim
standing
committee
on
health
and
human
services
and,
as
an
aside
I'd
like
to
say
hello
to
all
of
my
good
friends.
Some
of
you
are
my
former
colleagues
in
the
legislature
great
to
see
you
hello,
senator
hardy
dr
titus,
and
I
I
love
the
beard.
I
love
the
beard
similar
hayfin,
I'm
trying
to
get
that
one
day.
B
B
According
to
the
department
of
health
and
human
services,
office
of
analytics
nevada
saw
a
larger
number
of
opioid
overdose
deaths
in
2020
at
484
than
the
previous
peak
in
2011
of
460.
nevada
was
not
the
only
state
to
see
high
over
those
numbers.
In
fact,
according
to
the
cdc,
there
were
over
100
000
overdose
deaths
in
the
united
states
between
april
20th
of
20th
apartment
april,
2020
and
april
2021..
B
Many
of
these
deaths,
as
I've
alluded
to,
can
be
traced
back
to
illicit
use
such
as
fentanyl
a
a
disturbingly
common
drug
with
a
potency
more
than
100
times
that
of
heroin.
Often
people
do
not
realize
that
the
drugs
that
they
have
procured
are
laced
with
fentanyl
and
deadly
results
occur
when
they
take
too
much
unknowingly.
B
B
B
B
B
The
staff
of
dhhs
has
also
worked
so
hard
to
support
my
office's
litigation
and
providing
terabytes
of
data
through
discovery,
and
I
wanted
to
be
sure
to
recognize
and
thank
them
for
their
great
work
again.
Thank
you
all
and
I'd
like
to
extend
my
personal
gratitude
for
your
efforts
to
help
all
nevadans
affected
by
this
drug
crisis
and
with
that
your
peter's,
our
tenant.
Mike
back,
and
thank
you
so
much
for
the
opportunity
to
be
here
this
morning.
A
A
Well,
thank
you
so
much
we're
going
to
go
ahead
with
those
remarks.
Move
on
to
agenda
item
5,
our
substance,
use
overdose
of
surveillance,
data
presentation
and
we're
going
to
be
looking
at
trends,
gaps
and
policy
considerations
to
improve
data
surveillance.
We
have
quite
a
few
folks
here
to
present
this,
but
I
believe
that
kyrah
morgan,
our
state
biostatistician,
will
be
kicking
us
off.
If
I'm
incorrect,
please
go
ahead
and
correct
me.
It
looks
like
we've
got
your
presentation
up
on
the
screen.
So
please
proceed
when
we're
ready.
L
So
first
I
wanted
to
just
set
the
stage
with
some
national
and
regional
comparisons.
According
to
the
substance,
abuse
and
mental
health
services
administration,
the
prevalence
of
last
year,
substance
use
disorder
in
nevada
was
9.5
and
the
prevalence
of
last
year
alcohol
use
disorder
in
nevada
was
6.2
percent.
L
I
did
want
to
touch
on
at
a
high
level.
The
data
sources
that
we're
using.
We
do
have
three
resources
available
at
the
top
of
this
screen,
and
most
of
the
data
in
my
presentation
were
pulled
directly
from
those
resources.
They
are
publicly
available
and
updated
regularly.
The
first
is
the
behavioral
health
wellness
and
prevention
echi
profile,
which
comes
out
every
two
years.
L
We
also
have
an
opioid
surveillance
dashboard
and
a
methamphetamine
and
stimulant
surveillance,
dashboard
that
are
updated
regularly
and
then
there's
some
data
sources
listed
here,
I'm
not
going
to
get
into
in
the
interest
of
time.
But
I
did
want
to
go
through
these
definitions
because
they're
going
to
be
important
as
I
go
through
some
of
the
data
on
the
following
slides,
I'm
going
to
talk
about
alcohol
and
drug-related
emergency
department
department
encounters
those
are
visits
where
alcohol
and
drug
use
or
abuse
is
listed
as
part
of
the
diagnosis.
L
M
L
One
in
five
nevadans
surveyed
indicated
that
they
had
used
marijuana
in
the
past
30
days.
We
also
do
see
a
significant
increase,
although
the
magnitude
is
much
lower
related
to
illegal
drugs.
That's
the
orange
line
and
you
see,
respectively,
a
pretty
significant
increase
between
2019
and
2020,
even
though
the
magnitude
is
significantly
lower.
L
This
slide
looks
at
emergency
department
encounters
so
I'll.
Try
to
just
give
a
brief
interpretation
of
each
of
these
graphs,
because
I
realized
that
there's
a
lot
to
interpret
in
one
presentation,
but
this
looks
at
alcohol
and
drug
trends
in
an
emergency
department
setting
again
non-overdose
encounters
and
so
you'll
notice.
L
This
is
drilling
down
into
that
drug
category.
So
it's
the
same
exact
metric,
but
we're
looking
at
the
specific
type
of
drugs
that
were
present
in
those
individuals.
One
thing
I
want
to
make
sure
everyone's
clear
of
is
that
these
groups
are
not
mutually
exclusive.
In
other
words,
I
might
present
to
the
emergency
department
with
multiple.
You
know
being
indicated
that
I
use
or
abuse
multiple
types
of
drugs,
and
so
an
individual
could
be
counted
multiple
times
across
this
graphic.
L
But
I
want
to
draw
your
attention
to
the
trend
related
to
methamphetamines,
which
is
that
dark
orange
line
that
you
see
increasing
most
significantly,
the
the
gray
dotted
line
is
marijuana,
so
we
saw
significant
increase
and
then
it's
since
been
declining
since
about
2017
and
then
opioids.
There
and
the
blue
line
increased
until
about
2017
and
then
have
decreased
since
then.
L
This
is
the
inpatient
setting
but
same
data.
So
these
are
people
who
are
admitted
overnight,
at
least
to
the
hospital,
and
it
really
the
same
story.
Alcohol
and
drug
use
were
kind
of
on
par
until
2014,
when
drug
use
really
started
to
grow
much
more
significantly
than
alcohol
use.
I
do
also
want
to
just
express
to
use
caution,
interpreting,
2020
and
2021.
L
The
reason
for
that
is
that
we
know
that
the
19
pandemic
has
changed
utilization
patterns
in
our
hospital
setting.
A
lot
of
practices
have
been
put
in
place
to
you
know,
reserve
room
for
patients
that
really
need
it
and
we've
seen
across
the
board.
Utilization
is
down
in
2020
and
2021,
and
so
I'm
not
quite
comfortable
making
the
assumption
that
the
declines
that
we
see
here
are
related
to
a
reduced
burden
in
the
community.
L
L
When
we're
looking
at
inpatient
admissions,
there
were
approximately
5300
alcohol
and
8
400
drug-related
admissions
to
nevada
hospitals
in
any
given
quarter
of
2021
and
again
this
just
drills
down
into
that
drug
category,
to
try
to
explain
which
drugs
are
being
seen
most
frequently
as
being
used
by
these
individuals
in
the
hospital.
Marijuana
is
most
frequent
and
has
grown
pretty
significantly
over
time,
but
that
second
line
is
probably
most
concerning
that's
methamphetamines
with
just
really
significant
growth
over
the
span
of
the
graph
here
and
then
you'll
see
the
blue
line.
L
Opioids
really
was
growing
and
then
it's
kind
of
leveled
off
and
started
to
decline.
Cocaine's
been
relatively
stable.
That's
the
green
line
near
the
bottom
of
the
of
the
graphic
I
did
throw
in
just
one
slide
here
on
poisonings.
L
I
know
the
people
that
my
colleagues
that
are
presenting
later
are
going
to
go
into
more
detail
related
to
regional
poisonings
in
both
clark,
county
and
washington
county,
and
I
also
realize
these
graphs
are
really
messy
and
hard
to
look
at,
but
I
think
they're
important
to
include
because
it
is
a
stark
contrast
to
what
we
saw
when
we
were
looking
at
the
situation.
That
was
not
an
actual
overdose,
but
was
just
a
presentation
of
drug
use
and
abuse.
L
When
we
looked
specifically
at
these
acute
life-threatening
drug-related
poisonings
opioids
are
still
accounting
for
the
vast
majority
of
those
and
that's
the
blue
line
on
the
left-hand
side.
You're
looking
at
emergency
department,
and
you
can
see
a
significant
increase
in
2020
and
2021
related
to
opioids,
excluding
heroin
and
even
more
significant
growth
in
the
orange
line,
which
is
your
heroin
related
emergency
department
overdoses,
also
significant
growth
in
marijuana,
and
then
methamphetamine
has
really
been
a
little
bit
more
consistent
as
it
relates
to
these
poisons
the
right
hand.
Graph.
L
I
again
it's
really
messy
and
I
apologize
for
that.
But
what
I
want
to
draw
your
attention
to
is
that
if
we
kind
of
ignore
for
lack
of
a
better
word,
2020
and
2021,
knowing
that
those
years
are
kind
of
anomalous-
and
we
looked
specifically
at
the
trend
from
2016
to
2019,
just
really
extreme
growth
in
methamphetamine
related
inpatient
admissions
for
poisonings
and
then
significant
improvement
related
to
opioids
and
heroin.
And
so
I
think
that
that's
indicative
of
a
lot
of
the
policy
changes
that
you're
going
to
hear
throughout
the
presentations
today.
L
This
is
a
slide
really
looking
at
alcohol
and
drug-related
deaths,
specifically
the
first.
The
top
half
of
this
slide
focuses
on
alcohol,
related
deaths
and
you'll
see
a
significant
increase
from
2019
to
2020
and
then
also
just
want
you
to
know
that
2021
data
are
still
preliminary,
so
we
probably
will
see
those
numbers
actually
come
in
a
little
bit
higher
when
we
have
all
of
those
reports
in
our
system.
L
The
drug
related
deaths
graph.
The
second
graph
on
your
screen
shows
consistent
increase
in
drug-related
deaths
really
from
about
2015
to
2021.,
and
I
did
just
want
to
highlight
about
1400
drug-related
deaths
in
2020,
just
over
1500
drug-related
deaths
in
2021
and
pretty
consistent
year
over
year,
growth
averaging
14
over
the
last
two
years-
and
this
is
my
last
slide.
This
looks
at
unintentional
or
undetermined
overdose
deaths
by
the
specific
substances
that
were
present.
L
I
want
to
draw
your
attention
to
methamphetamines,
which
were
involved
in
the
highest
number
of
unintentional
overdose
deaths
in
both
2019
and
2020,
and
also
observed
a
significant
increase.
Year-Over-Year
44
also
want
to
draw
your
attention
to
benzodiazepines,
which
is
here
kind
of
in
the
middle
of
your
screen.
They
observe
overdose
deaths
related
to
benzodiazepines
increased
by
91
year-over-year
fentanyl,
which
is
a
little
bit
lower
on
your
screen.
Fentanyl
and
fentanyl
metabolites
increased
by
223
from
2019
to
2020,
and
then
lastly,
prescription
opioids,
excluding
methadone
increased
by
67
from
2019
to
2020..
L
A
I
think,
for
the
sake
of
time,
that
we
should
let
the
presenters
get
their
their
presentations
get
through
their
presentations
and
then
we
can
take
questions.
I
have
a
quite
a
few
questions
for
you,
miss
morgan,
but
I
think
that,
for
the
sake
of
fairness
and
those
who
prepared
presentations
today
that
we
get
through
those
so
go
ahead.
I
I
on
my
list.
I
have
elise
monroe
and
then
monroy
next,
but
that
may
not
be
who's
on
your
list
as
being
next.
A
So
please,
whoever
is
ready,
go
ahead
and
present
when
you,
when
you
are
ready,
hi.
I
Thank
you,
yeah,
thank
you
and
good
morning,
so
my
name
is
brandon
delicie,
I'm
an
epidemiologist
at
the
southern
media,
health
district.
I've
been
an
epidemiologist
here
since
2018
and
I
lead
efforts
to
monitor,
develop
and
improve
surveillance
within
the
fields
of
drug
overdose
and
ems.
So
thank
you
all
for
attending
this
presentation,
so
monitoring
drug
overdose
indicators
should
I
be
sharing
the
powerpoint
right
now.
I
I
A
We
are
seeing
both
your
primary
slide
and
your
next
slide.
L
I
Perfect,
so
monitoring
drug
overdose
indicators
is
really
important
to
inform
community
prevention
and
response
activities.
So
in
the
next
five
minutes
I
will
provide
a
high-level
overview
of
overdose
death
data
and
non-fatal
overdose
data
in
clark
county.
So
using
the
health
district's
electronic
death
registry
system,
you
can
take
a
look
at
the
overdose
death
rate,
for
all
intents,
among
clark,
county
residents
by
drug
class,
from
2015
to
2021..
I
So
if
we
take
a
look
at
all
opioid
deaths,
so
they
are
represented
in
green.
So
what
we
see
here
is
a
general
decrease
from
2015
to
2019
and
then
from
2019
to
2020.
We
see
a
sharp
increase
in
opioid
deaths,
so
I
also
want
to
bring
to
your
attention
as
to
what
is
happening
with
a
light
purple
line
which
represents
synthetic
opioid
deaths
and
that
category
does
include
fentanyl.
I
I
Just
like
the
previous
slide,
we
can
take
a
look
at
overdose
death
rate,
for
all
intents
among
clark,
county
residents
by
drug
class,
from
2015
to
2021,
but
instead
of
all
opioids
and
besodiazepines,
this
figure
lists
psychostimulants,
which
includes
methamphetamine,
represented
in
gray
and
cocaine
represented
in
yellow,
so
the
rate
of
fatal
overdose
involving
psychostimulus
reaches
highest
in
2021,
from
2015
to
21
fatal
overdose
involving
psychostimulants
involved.
I
I
Moving
on
to
the
next
data
source,
we
will
now
look
at
non-fatal,
opioid
overdoses
in
clark
county
in
2021,
via
ems
data,
linked
with
hospital
discharge
data,
the
median
age
for
a
non-fatal
opioid
overdose
in
2021
for
men
was
42
years
for
women.
It
was
49
years
so
looking
at
the
figure
to
the
right,
the
highest
frequencies
of
non-fatal,
opioid
overdoses
in
2021,
occurred
in
april,
and
in
may
the
top
zip
codes
in
clark
county
with
the
highest
frequency
of
non-fatal
opioid
overdose.
I
I
I
I
Moving
on
to
the
last
data
source
that
I
will
be
discussing
are
emergency
department
discharge
data,
so
emergency
department
data,
along
with
the
previous
data
sources
discussed,
can
provide
critical
information
to
this
rapidly
shifting
crisis.
The
figure
to
the
left
displays
the
number
of
emergency
department
visits
due
to
poisoning
by
any
opioid
in
clark
county
from
2016
to
2020,
so
from
2019
to
2020
emergency
department
visits
due
to
poisoning
by
any
opioid
increase
markedly
median
age
for
the
emergency
department.
I
Business
due
to
opioid
poisoning
in
2020
was
38
years
for
men
and
then
41
years
for
women.
The
implications
of
these
data
that
I've
provided
over
the
past
five
minutes
do
support
evidence-based
prevention
and
response
efforts
focused
on
poly
substance
use
and
that
these
efforts
must
be
adapted
to
address
the
changing
drug
overdose
epidemic.
I
A
Thank
you
so
much,
mr
delisi.
I
appreciate
that
that
context
of
thinking
during
the
the
overview
that
miss
morgan
shared,
I
was
wondering
how
much
of
an
impact
was
split
between
our
urban
areas
and
our
rural
areas,
so
that
was
super
helpful.
Okay,
we
have
I'm
kyra,
I'm
not
seeing
your
slide
against
that
now.
So
I
don't
remember
who
on
that
is
next,
but
whoever
is
next
to
participate.
H
Good
morning,
chair
peters
and
members
of
the
committee,
my
name
is
sean
thomas
and
I'm,
the
opioid
epidemiologist
and
surveillance
coordinator
for
the
nevada,
overdose
data
to
action
team
within
the
trudy
larson
institute
for
health
impact
and
equity
within
the
school
of
public
health
at
the
university
of
nevada
arena,
and
today,
I'll
talk
briefly
about
recent
drug
overdose
trends
in
washoe
county
next
slide.
H
Please
so
drug
overdose
deaths
have
been
on
the
rise
in
washoe
county
throughout
the
past
decade
and
have
only
continued
to
increase
following
suit
with
what
kyra
showed
earlier
with
drug-related
deaths
statewide.
The
figure
here
shows
the
rates
of
drug-related
and
opioid-related
overdose
deaths
among
residents
in
washoe
county
by
year
for
the
past
three
years.
Please
note
that
2021
is
still
preliminary
and
is
subject
to
change.
H
H
H
The
most
recent
months
may
not
be
entirely
complete,
and
additionally,
I
wanted
to
also
mention
that
approx
in
approximately
15
of
incidents
the
patient
was
treated
or
released
against
medical
advice,
which
is
an
issue
because
the
ems
personnel
believed
the
person
required
further
treatment,
but
the
patient
was
unwilling
to
continue
next
slide.
Please
so
figure.
Three
here
shows
the
incidence
by
zip
code
and
both
table
and
a
zoomed
in
graphic
of
washoe
county.
H
The
top
five
zip
codes
with
the
highest
number
of
suspected
non-fatal
opioid
overdose
related
incidents
were
a9502
a9512,
a9431,
89501
and
89509
they're,
mostly
concentrated
in
downtown
reno
and
branches
out
to
northeast
moreno,
hidden
valley,
southwest
reno
and
sparks
next
slide.
Please
figure.
4
here
is
showing
incidents
by
age
group.
The
25
to
34
age
group
had
the
highest
percentage
of
incidents
as
well
as
the
highest
rate
of
incidence,
while
the
35
to
44
age
group
had
the
second
highest
percentage
rate,
also
not
pictured.
H
On
the
slide,
but
I
want
to
mention
as
well:
two
thirds
of
incidents
were
among
males
next
slide.
Please
so
figure
5
here
shows
the
percentage
of
incidents
by
race
and
ethnicity,
while
the
chart
shows
that
44
of
incidents
were
among
white
non-hispanic,
a
race
in
the
district
with
the
highest
rate
were
those
identified
as
being
black
non-hispanic.
Another
thing
to
note
as
well
is
that
a
third
of
incidents
did
not
record
race
or
ethnicity,
so
race,
ethnicity,
data
may
be
underestimated
next
slide.
H
Please,
I
just
want
to
wrap
up
with
a
key
couple
of
takeaways
drug-related
and
opioid-related
overdose.
Deaths
have
continued
to
increase
in
washoe
county
with
opioid-related
overdose
deaths
rates
expected
to
exceed
2020
rates.
There
are
375
suspected
non-fatal,
opioid
overdose
incidents
in
washington,
county
in
2021,
and
rates
of
suspected
opioid
overdoses
were
highest
among
black
non-hispanic
and
people
between
the
ages
of
25
to
34..
H
Although
drug
overdoses
are
most
common
among
people,
identifying
as
white
has
been
people
of
color,
who
have
been
seeing
the
highest
rates
suspected
overdose
and
are
disproportionately
impacted
and
then
again
want
to
mention
as
well.
The
highest
zip
codes
with
the
highest
number
of
non-fatal
opioid
overdoses
have
been
concentrated
more
near
the
downtown
region.
So
that
is
all
I
have.
Thank
you.
A
Thank
you,
mr
thomas.
I
believe
we
have
dr
kearns
up
next
for
her
presentation,
go
ahead
and
proceed
when
you're
ready.
O
Thank
you
good
morning,
chair
and
committee
members.
My
name
is
terry
kearns,
I'm
with
the
nevada
office
of
the
attorney
general
next
slide.
Police
od
map,
also
known
as
the
overdose
mapping
application
program,
is
a
program
that
was
originally
developed
by
the
washington
dc
baltimore
high
intensity,
drug
trafficking
area,
also
known
as
haida,
and
offered
free
to
agencies
who
are
interested
in
using
this
program.
O
Near
real
time,
up,
go
go
ahead
and
go
back
near
real
time
is
defined
as
within
24
to
72
hours
from
the
suspected
events.
Suspected
overdoses
means
the
information
is
not
fully
vetted,
as
you
would
find,
with
information
such
as
toxicology
results
or
autopsy
results
from
the
medical,
examiner
or
coroner's
offices.
O
In
trying
to
get
that
24
to
72
hour
data,
you
do
lose
some
of
the
fidelity,
but
it
is
a
starting
point
or
provides
a
red
flag
that
there
may
be
something
that
needs
to
be
addressed
further
within
your
community
in
our
state.
The
majority
of
suspected
overdose
data
is
from
the
ems
electronic
medical
records.
O
Od
map
data
includes
three
data
points.
Those
three
data
points
are
the
location
was
the
event
of
fatal
or
non-fatal
overdose
and
was
naloxone,
which
is
a
drug.
That's
used
to
counteract
the
effects
of
an
opiate
overdose
given,
and
if
so,
was
it
a
single
dose
or
multiple
doses
that
were
given
in
some
other
states
across
the
united
states,
such
as
in
new
jersey?
O
They
have
legislation
in
which
law
enforcement
enters
the
information
on
overdoses
and
in
that
od
map
has
a
feature
where
case
data
can
be
entered,
but
because
the
majority
of
our
overdose
information
in
our
state
is
from
ems
data.
We
currently
are
not
using
that
and
an
example
would
be
if
law
enforcement
was
on
scene
and
knew
that
it
was
a
pressed
pill
or
knew
that
it
was
heroin.
O
This
first
slide
shows
you
it
typically
when
you
pull
it
up,
you
will
get
information
from
all
over
the
united
states,
but
I've
filtered
this
down
to
the
information
on
overdoses,
suspected
overdoses
from
our
state.
From
january
1st,
of
2022
to
february
8th
of
2022.
As
you
can
see,
the
number
of
suspected
overdoses
pops
up.
There
were
631
that
the
number
of
suspected
fatal
overdoses
which
was
19
and
then
the
number
of
times
naloxone,
was
provided
at
234.
O
The
dots
on
the
screen
are
color
coded
and
they
showed
that
general
location
where
the
suspected
overdoses
occurred
and
they
color
coded
for
fatal
or
non-fatal.
It
was
naloxone
given
as
a
single
dose,
a
multiple
dose
or
no
naloxone.
The
next
slide
illustrates
the
ability
to
provide
graphically
the
the
data
on
overdoses.
You
can
see.
We
can
look
at
overdoses
by
type
and
that's
that
color
coding
I
talked
about
on
non-fatal,
naloxone
and
so
on.
O
So
that
is
how
we
can
look
at
the
data
from
some
of
these
graphs
next
slide
just
shows
an
example.
If
we
pull
up
the
day
of
week
that
the
overdoses
occurred
and
next
slide,
as
I
mentioned,
od
map
is
a
starting
point.
There
is
additional
work
that
would
need
to
be
done
to
determine
if
a
spike
in
overdoses
did
actually
occur,
which
brings
me
to
the
next
point
that,
through
the
state
opioid
response
grant
each
county
developed
a
community
overdose
spike
response
plan.
O
A
couple
of
our
counties
have
taken
it
to
the
point
of
exercising
their
community
overdose
bike
response
plans,
as
mentioned
before
the
more
real
time
and
the
limited
data
that
is
collected
in
obd
map.
We
do
not
have
as
accurate
of
information,
but
it
is
meant
to
signal
that
there
could
be
something
happening
and
a
county
should
look
at
their
community
response
plan
to
determine
who
should
be
doing.
O
N
N
So
from
these
presentations,
we
can
see
that
emergency
department
can
counter
encounters
from
drug
poisonings,
continue
to
rise
in
2021
deaths
by
methamphetamine,
fentanyl,
benzodiazepines
and
prescription
opioids
surged.
We
also
see
that
people
of
color
and
youth
are
being
disproportionately
impacted
by
use
and
overdose
and
poly
substance.
Use
and
exposure
continues
to
complicate
prevention
and
intervention
efforts
in
the
state.
N
Then
we
wait
for
the
post-mortem
talks
to
confirm
the
substances
that
are
causing
harm
and
increasing
the
state's
mortality
rates.
Nevada
needs
a
surveillance
system
that
is
both
timely
and
confirmatory
to
best
inform
public
health
prevention
and
intervention
initiatives
in
order
to
get
to
a
system
that
is
both
timely
or
quick
and
confirmatory.
N
There
are
a
couple
gaps
in
public
health's
ability
to
do.
Biosurveillance
of
the
substances
that
are
causing
harm
next
slide.
N
Currently
nevada
depends
on
a
limited
set
of
data
to
inform
what
the
state's
level
of
risk
is.
This
presents
challenges
for
implementing
appropriate
and
timely
prevention
and
intervention
programs.
At
this
time,
nevada
gets
confirmatory
talks,
data
about
what
is
in
the
drug
supply
from
the
post-mortem
exam.
N
This
is
reported
in
alignment
with
cdc
guidelines
with
a
six
to
nine
month
lag
so
by
the
time
that
public
health
has
reported
on
their
data
or
law
enforcement
has
reported
on
their
data.
The
drug
supply
and
overdose
landscape
will
have
inevitably
changed
waiting
for
mortality
data
data
to
tell
us
what
is
actively
killing
people
is
not
a
good
public
health
strategy
next
slide.
N
So
anti-mortem
testing
is
testing
that
is
done
before
death,
so
an
example
of
this
would
be
like
dui
panels
or
blood
or
urine
screens
done
in
a
hospital.
The
minnesota
od2a
program
has
a
pilot
where
they
are
actually
using
excess
urine
drug
screen
pulled
from
patients
that
come
in
off
in
on
a
suspected
overdose.
N
N
The
lab
reported
that
they
have
been
stunned
by
the
number
of
people
that
are
driving
under
the
influence
of
fentanyl.
Another
example
of
an
upstream
touch
point
to
assess
what
is
in
the
drug
supply
would
be
testing
on
syringes
returned
to
syringe
service
points.
The
washington
dc
crime
lab
is
actually
doing
this
type
of
testing
and
reporting
the
information
to
inform
public
health.
In
all
of
these
instances,
the
data
that
is
collected
as
a
result
of
these
tests
is
being
shared
with
stakeholders
and
public
health
to
inform
community
risk.
N
Another
example
of
upstream
testing
would
be
wastewater
monitoring.
Innovative
work
has
been
done
in
nevada
on
wastewater
testing
for
cobit,
but
other
states
have
been
using
wastewater
testing
to
monitor
and
inform
what's
in
the
drug
supply.
And
finally,
data
and
information
gleaned
from
seized
drug
testing
is
another
way
that
public
health
programs
in
other
states
are
informing
their
work
next
slide.
N
The
od2a
program
is
currently
working
on
a
needs
assessment
to
kind
of
understand
the
state's
capacity
for
testing
and
biosurveillance
of
the
drug
supply
to
inform
risk.
So
in
our
preliminary
findings,
we
have
identified
a
few
critical
issues
that
may
be
impacting
nevada's
ability
ability
to
drive
to
a
quick
and
confirmatory
surveillance
system.
N
N
N
Excuse
me,
the
forensic
toxicology
labs.
The
report
noted
inconsistent
testing
panels
and
thresholds
across
the
three
labs
in
the
state
was
a
significant
gap.
Specifically,
the
report
notes
that
the
three
labs
use
different
testing
panels
and
test
for
different
numbers
of
drugs,
ranging
from
one
lab
testing
for
30
drugs.
While
we
have
another
lab,
that's
testing
for
30.
N
The
report
also
noted
that
there
is
a
difference
in
the
cutoff
values
used
to
distinguish
positive
and
negative
results,
and
this
cut
off
inconsistency
also
impacts
interpretation
of
results.
So,
while
standardizing
analysis
with
these
forensic
labs
will
help
to
ensure
fair
treatment
of
all
drivers
and
ensure
the
state
knows
which
drugs
are
causing
impairment
for
forensic
purposes,
it
can
also
help
to
better
inform
public
health
prevention
and
intervention
efforts.
N
Next
nevada,
nevada's
existing
crime
labs
are
forensic
in
nature
through
our
needs
assessment,
research
and
work
with
labs.
We
understand
that
the
role
forensic
labs
play
in
the
current
system
is
to
use
science
for
the
purpose
of
criminal
proceedings,
not
for
public
health
surveillance
and
not
to
inform
community
risk.
N
Currently,
there
are
a
limited
number
of
data
sharing
agreements
in
place
between
crime,
labs
law
enforcement
and
public
health
or
prevention
partners.
We
know
that
some
of
our
local
prevention
and
overdose
spike
response
stakeholders
enjoy
informal
information
sharing
relationships
with
their
local
law
enforcement,
but
these
agreements
are
largely
relationship
and
person,
personnel
driven-
and
this
is
inconsistent
with
building
a
sustainable
system
and
finally,
through
our
work
on
the
needs
assessment,
we
have
heard
that
many
of
the
drugs
seized
in
nevada
are
actually
not
even
tested.
N
These
drugs
are
tested
if
and
when
a
case
goes
to
trial.
So
we
have
heard
that
this
could
be
a
result
of
not
enough
lab
capacity
or
and
or
funding.
So
if
these
drugs
are
tested
in
nevada,
that
data
is
sent
to
the
national
forensic
lab
information
system
or
niflis
niplus
data
is
reported
quarterly.
So,
while
our
program
has
not
had
a
chance
to
take
a
deep
dive
into
how
local
crime
labs
are
funded,
we
did
find
that
forensic
testing
is
at
least
in
part,
supported
through
a
county
general
fund.
Nrs457.575.
N
So
some
recommendations
to
address
these
critical
issues
include
developing
a
statewide
crime
lab
that
allows
for
standardized
forensic
testing,
as
well
as
a
statewide
lab
that
has
the
capacity
to
do
surveillance,
sample
testing
to
inform
public
health
risk.
Next,
the
state
should
look
to
developing
standardized
data,
sharing
agreements
and
mechanisms
statewide
and
finally
examine
the
funding
formulas
or
mechanisms
that
may
be
impacting
testing
capacity
in
nevada.
N
It's
not
inevitable
that
deaths
by
opioid,
fentanyl
and
stimulants
have
to
continue
to
rise.
Implementation
of
harm
reduction
strategies
and
public
health
interventions
can
be
done
to
curb
deaths.
However,
these
strategies
should
be
informed
by
timely
confirmatory
data
and,
if
public
health
in
nevada
has
to
continue
to
rely
on
a
surveillance
system
dependent
on
death
data
to
tell
us
what's
killing
people,
the
state
may
struggle
to
get
ahead
of
these
deaths
and
with
that.
That
concludes
this
panel's
presentation.
Are
there
any
questions.
A
Thank
you
so
much
miss
monroy.
Yes,
I
believe
we
have
a
couple
of
questions.
Hey
from
the
committee,
I'm
pulling
my
list
up,
I
did
see
senator
hardy
assemblyman
looker
both
have
questions,
and
I
have
some
follow-up
as
well,
so
we're
gonna.
I
just
want
to
let
the
community
know
that
I
have
about
10
minutes
scheduled
for
questions.
Obviously
this
is
an
important
issue,
so
we
may
go
over
that
a
little
bit,
but
I
would
encourage
if
you
are
interested
in
this
topic.
A
Please
take
down
the
note
the
names
of
these
folks
who
presented
today
reach
out
to
staff
for
their
contact
information,
if
you
don't
have
it
and
get
in
contact
with
them
over
the
interim
to
talk
about
these
issues
and
what
we
can
do.
We
also
have
an
opportunity
to
look
at
some
of
these
recommendations
as
potential
bdrs
that
come
from
this
committee,
but
we
will
do
that
at
a
later
date.
C
Thank
you,
madam
chair.
I
was
interested
in
what
cairo
was
talking
about
when
we
read
the
newspaper
we
keep
reading
about
the
school
age,
kids
that
aren't
in
school
and
how
we're
seeing
an
increase
in
mental
health
issues
and
drug
use,
and
I
didn't
see
the
differentiation
of
that
kind
of
group
and
wondering
what
we're
doing
with
that
particular
group
and
are.
Are
we
not
seeing
that
kind
of
drug
alcohol
use
in
our
school-aged
kids,
or
is
it
just
something
that
isn't
as
pronounced?
L
This
is
tyra
morgan
for
the
record
and
then
I
might
phone
a
friend
for
dr
order,
who
I
think
is
also
on
the
call.
I
didn't
prepare
data,
unfortunately,
at
an
age
level,
just
because
I
had
a
10
minute
time
crunch
and
I
couldn't
fit
everything
in
there
that
I
wanted
to
fit,
but
I
can
surely
follow
up
with
that
age
breakout.
L
I
do
believe
that
we've
seen
increases
most
specifically
in
teenage
years
and
early
adulthood,
so
I
think
it
last
time
I
left
it
was
up
through
age
30
or
something
where
we
saw
the
most
significant
increases.
But
I
can
follow
up
with
the
committee
with
specific
numbers
and
then
dr
woodard,
I
don't
know
if
you
can
address,
or
maybe
elise,
on
on
what
we're
doing,
for
targeted
intervention.
A
M
Hi
good
morning,
cher,
I'm
here
so
stephanie,
ordered
for
the
record.
Through
you
chair
to
senator
hardy,
we
have
actually
seen
a
pretty
significant
increase
in
indicators
that
suggest
that
the
amount
of
youth
behavioral
health
has
increased.
This
includes
both
substance
use,
as
well
as
mental
health
conditions.
M
A
That
would
be
appreciated.
Dr
word,
thank
you.
Thank
you.
So
much
if
you
wouldn't
mind
working
with
staff
on
getting
us
that
information,
you
can
pass
that
around
to
the
committee
I
assemblyman
ortlicker,
please.
C
Thank
you,
madam
chair,
and
thank
you
presenters
this
day
is
very
illuminating,
and
I
appreciate
you
presenting
to
us
one
question.
I
had
was
helpful
when
you
gave
us
the
absolute
amounts
and
then
the
relative
amounts
that
some
populations
have
higher
proportionate
drug
use
and
do
you
have
a
urban
rural
comparison?
C
L
This
is
kyrah
morgan
for
the
record.
I
we
do
have
that
information.
I
just
don't
have
it
again
in
this
presentation,
but
I
will
add
that
to
my
follow-up
for
the
group
and
just
a
reminder,
we
do
have
most
of
that
online,
so
I'll
be
able
to
pull
that
together
quickly
as
a
follow-up
to
this.
A
Thank
you
so
much
us,
dr
titus
has
a
question
as
well.
Please
go
ahead.
J
Great.
Thank
you,
madam
chair.
Thank
you
for
the
presentation,
scary,
scary
data.
I've
been
on
the
hhs
committee
now
four
terms
and
the
interim
committee
four
terms,
and
I
just
for
a
while
we
were,
we
were
making
a
difference.
The
numbers
were
going
down
and
this
that
this
data
is
pretty
alarming,
that
it's
going
back
up
again.
J
I
need
some
clarification
and
we
can
send
it
to
all
of
us.
Maybe
afterwards
you
did.
You
did
briefly
mention
narcan
and
that
on
the
odapt
maps,
od
maps
you
can
chart
whether
or
not
narcan
was
given
and
how
many
times
I'd
be
interested
in
seeing
kind
of
a
breakdown.
A
number
from
I
quickly
did
some
math
and
it
looked
like
at
least
on
the
one
chart
you
had.
There
was
probably
520
deaths
prevented
because
narcan
was
used,
and
I
know
we.
J
I
know
both
dr
hardy
and
myself
have
supported
having
narcan
and
schools,
certainly
allowing
our
police
force
to
use
it,
allowing
it
in
businesses,
and
I
just
wonder
if
we
have
any
breakdown
of
where
this
narcan
is
being
used
and
what
the
actual
numbers
were
prescriptions.
And
if
you
have
any
of
those
that
information
and
if
so,
could
you
send
that
to
us.
N
I
think
that's
go
ahead.
I'm
sorry
assemblywoman!
This
is
elise
monroy
with
the
od2a
program.
So
I
believe
the
state's
opioid
response
grant
collects
that
information.
So
I
will
coordinate
with
the
sor
program
on
following
up
with
the
committee.
J
Right
because
I
would
really
like
to
know
if
it's
been
given
in
a
store
or
how
often
was
it,
the
police
that
gave
it
versus
ems,
because
ems
should
be
given
it,
but
we
really
expanded
access
to
that.
We
actually
put
it
in
bags
and
we
prescribe
medication
and
then
that's
the
next
takeaway
I
have
for
and
also
by
the
way.
I
really
appreciate
you
bringing
up
the
state
crime
lab,
because
I've
met
with
many
sheriffs.
J
I
represent
multiple
counties
and
and
to
a
sheriff,
they
all
say
they
would
like
to
have
the
crime
lab.
But
what
the
sheriff
is
also
saying
is
a
concern
to
me
because
we
have
restricted
over
my
sessions.
Doctors
from
prescribing
we've
reigned
in
our
you
know,
because
we
were
the
bad
folks
prescribing
too
many
narcotics
and
we
really
regulated
our
prescription
that
I
know
our
board
of
pharmacy
will
be
addressing
some
of
this
later
and
then
our
attorney
general
sued,
the
bad
pharmaceutical
companies
because
they
created
these
drugs
that
got
everybody
addicted.
J
What
I'm
hearing
actually
is
that
we
are
having
still
more
drugs
and
despite
those
efforts
and
what
the
sheriffs
that
I've
met
with
have
said,
is
that
they're
really
concerned
they've
seen
almost
a
four-fold
increase
in
illegal
drugs
in
the
rural
counties
and
their
belief
is
because
of
open
borders
that
more
drugs
are
coming
across
our
into
our
state
from
it
doesn't
matter
what
country
it
doesn't
matter,
what
state
but
they're,
coming
into
nevada,
and
so
is
anybody
addressing
where
these
drugs
are
coming
from,
or
are
we
going
to
hear
that
later
today?.
N
So
this
is
elise
monroy
for
the
record.
I
will
take
that
one,
my
my.
I
would
think
that
maybe
haida
will
be
addressing
that
later
or
the
law
enforcement
presentation
from
a
public
health
perspective.
We
get
very.
We
get
limited
data
from
law
enforcement
related
to
drug
seizures
and,
like
I
mentioned
local
prevention
and
spike
response
agencies,
have
really
great
informal
information
sharing
relationships
with
their
local
law
enforcement.
N
N
In
order
for
us
to
really
get
ahead
of
what's
in
the
drug
supply
and
to
inform
prevention
and
intervention
efforts,
we
have
to
know
what's
in
the
drug
supply
and
unfortunately,
we
currently
have
to
wait
until
we
have
death
data
to
tell
us
what
people
are
dying
from
so
an
effort
to
kind
of
increase
awareness
about
what's
in
the
drug
supply
and
what
substances
are
causing
harm
could
help
to
help
public
health.
Do
more
informed
strategies.
J
A
Thank
you,
dr
titus,
and
thank
you
miss
monroy.
I
don't
see
any
other
questions
from
my
committee,
but
I
have
one.
I
have
a
couple
of
questions,
but
I
will
take
most
of
my
outline
the
one
that
I
would
like
to
ask
those
to
miss
morgan.
A
You
had
some
indicators,
co
collected
for
diagnoses
in
of
folks
who
come
in
with
with
drugs
in
their
system,
and
I
wanted
to
know
whether
we're
collecting
information
on
whether
that
diagnosis
is
for
behavioral
mental
or
physical
problems
when
they
are
presented
in
the
hospital
and
in
that
ems
data.
And
if
you
have
any
breakdown
of
that
as
percentages
of
the
cases
that
we're
seeing
in
those
diagnosis
as
they
pertain
to
drug
use,.
L
Yeah
this
is
kyra
morgan
for
the
record.
That's
a
really
interesting
and
great
question.
The
slides
that
I
prepared
for
this
meeting
are
very
high
level,
so
those
are
truly
anyone
in
an
emergency
department
setting
who,
during
that
encounter,
it
was
indicated
in
their
bill
that
they
either
had
drug
use
or
abuse.
L
It
was
not
limited
in
any
way
to
behavioral
health
or
mental
health
diagnoses,
but
we
can
absolutely
pull
that
information
by
looking
at
other
diagnosis
codes
on
those
billing
claims,
and
I
can
follow
up
with
with
that
information
to
the
committee.
A
That
would
be
great.
Thank
you
so
much.
I
think
that
that
would
really
help
us
understand
what
kind
of
our
limitations
are
in
those
emergency
rooms
and
where
we
can
focus
some
energy
for
this,
that
that
piece
all
right
with
that
we're
gonna
go
ahead
and
move
on
to
our
next
agenda
item
which
we're
taking
out
of
order,
because
we
have
dr
terry
kearns
with
us
right
now,
we're
going
to
move
on
to
agenda
item
14,
which
is
an
update
on
assembly
bill
374
from
the
2021
legislative
session.
A
This
establishes
the
statewide
substance,
use
response
working
group
miss
currently
or
dr
kern.
Please
go
ahead
whenever
you
are
ready.
O
If
you
look
at
the
bottom
of
this
slide,
you
can
see
the
references
on
where
to
find
assembly
bill
374
on
the
nellis
home
site,
and
you
can
also
find
information
on
the
surge
on
the
ag's
website
as
well.
If
you
go
to
the
ag's
website,
scroll
down
to
committees
and
boards,
and
then
that
will
take
you
to
where
you
scrolled
over
to
the
substance,
use
response
working
group.
O
O
Director
of
shine
a
light
foundation
of
freedom
house,
one
person
who
is
in
recovery
from
substance
use,
disorder,
jessica,
johnson
senior
health,
educator
from
southern
nevada,
health
district,
a
representative
of
local
government
that
provides
or
oversees
a
provision
of
human
services
in
a
county
whose
population
population
is
700
000
or
more
lisa.
Lee
human
services
program,
specialist,
washoe
county
human
services
agency.
O
She
is
a
representative
of
local
government
that
provides
or
oversees
provision
amendment
services
in
a
county
of
a
population
of
a
hundred
thousand
or
more
but
less
than
seven
hundred
thousand
debbie
nadler,
co-founder
moms
against
drugs.
One
advocate
for
persons
who
have
substance,
use
disorder
or
family
members
of
such
christine
payson
representative
from
the
nevada
sheriff
and
chiefs
association.
O
The
law
enforcement
representative
eric
shone
executive
director
of
community
chest
inc,
one
representative
of
a
substance
use
disorder,
prevention
coalition,
steve
shell,
vice
president
behavioral
health,
renowned
health,
a
representative
of
a
hospital
claire
thomas
state
assembly,
woman,
district
17,
the
nevada
assembly
speaker,
appointee,
danny
thomas
executive
director
of
ridge
house.
One
person
who
provides
services
related
to
the
treatment
of
substance,
use
disorders,
jill
tolls,
state
assembly,
woman,
district
25
nevada
assembly,
minority
leader
appointee
and
dr
stephanie
woodard
advisor
for
behavioral
health
to
dhhs
dhhs
director
appointee
ab374
does
a
lot.
O
There
are
16
items,
labeled
a
three
through
q
in
the
legislation
that
the
surge
is
to
address
and
straight
from
the
legislation.
This
bill
requires
a
surge
to
comprehensively
review
various
aspects
of
substance,
misuse
and
substance,
use
disorders
and
programs
and
activities
to
combat
substance,
misuse
and
substance
use
disorders
in
our
state.
The
activities
include,
assessing
studying,
examining,
evaluating
and
then
making
recommendations
concerning
substance
use
and
misuse.
O
Based
on
these
findings,
the
surge
works
in
conjunction
with
senate
bill
390's
advisory
committee
for
a
resilient
nevada
acrn,
which
you've
already
heard
about,
and
you
will
hear
more
on
later,
recommendations
from
the
surge
and
the
and
assist
with
how
the
funds
from
the
fund
for
resilient
nevada
that
was
established
out
of
sb
390
are
directed,
as
you
heard
from
general
ford.
A
major
source
of
funds
for
the
fund
for
a
resilient
nevada
come
from
the
opioid
litigation
settlement
funds.
O
Much
of
that
first
meeting
was
laying
out
the
form
and
structure
of
the
surge
to
include
electing
general
ford
as
a
chair
and
assemblywoman
tolls.
As
the
vice
chair,
the
adoption
of
the
bylaws
and
setting
up
the
priorities
for
2022.,
this
included
setting
up
meetings
in
2022
and
being
briefed
on
the
state
needs
assessment,
the
state
plan
and
state
and
local
funding
of
programs
to
address
substance,
misuse
and
substance
use
disorders
that
will
all
be
provided
through
dhhs.
O
The
formation
of
subcommittees
based
on
the
priorities
discussed
in
the
november
2021
meeting,
were
outlined.
The
framework
for
the
three
subcommittees
that
are
being
formed
are
one
prevention,
two
treatment
and
recovery
and
three
response.
The
16
items
that
were
laid
out
in
ab3
374
to
be
addressed
by
the
surge
were
used
as
guidelines
for
these
three
subcommittees.
O
There
were
some
items
that
are
overarching
and
will
be
addressed
by
all
subcommittees,
such
as
special
populations
and
special
populations
defined
in
ab
374
is
veterans,
elderly
persons
and
youth.
It's
the
first
group.
The
second
group
is
persons
who
are
incarcerated
persons
who
have
committed
non-violent
crimes,
primarily
driven
by
a
substance,
use
disorder
and
other
persons
involved
in
the
criminal
justice
or
the
juvenile
justice
system.
O
Pregnant
women
and
parents
of
dependent
children
are
the
third
group,
the
fourth
group,
lesbian,
gay,
bisexual,
transgender
and
questioning
persons.
The
fifth
group
persons
who
use
intravenous
drugs,
the
sixth
group,
children,
who
are
involved
with
the
child
welfare
system
and
the
seventh
group,
as
other
populations,
disproportionately
impacted
by
substance
use
disorders.
O
Another
overarching
item
that
will
be
addressed
by
each
of
the
three
subcommittees
is
data
and
information
sharing,
the
surge
will
meet
quarterly
in
2022
and
the
subcommittees
will
meet
monthly
and
then
the
subcommittees
will
report
back
to
the
larger
surge.
I
invite
everyone
to
read
the
2021
surge
annual
report
that
I
provided.
It
provides
a
much
more
in-depth
review
of
the
surges,
2021
activities
and
the
priorities
for
2022,
and
this
will
conclude
my
overview
of
ab34374
and
the
2021
activities
of
the
surge,
and
I
welcome
any
questions
anyone
may
have.
A
O
Scheduled
there
was
one
meeting
in
2021
that
was
november
16th.
There
was
a
also
a
meeting
in
2022
that
was
january
19th
and
we're
here.
We
have
another
meeting
scheduled
on
march
9th
and
then
we'll
look
to
june
to
schedule
the
next
one.
A
Great
great
well,
we
look
forward
to
updates
from
your
meeting
and
how
things
are
coming
through
on
on
how
what
your
recommendations
come
out
of
those
meetings
and
hopefully
we'll
get
to
hear
from
you
later
on
those.
Thank
you.
Thank
you.
So
much.
A
Thank
you.
We're
gonna
go
ahead
and
go
back
into
our
regular,
regularly
scheduled
agenda
item,
we're
going
to
move
on
to
item
number
six,
which
is
an
overview
of
opioid
and
stimulant
prescribing
patterns
in
nevada,
and
I
hope
some
of
this
information
gets
that
some
of
the
questions
that
were
asked
during
the
previous
presentation.
I
G
G
G
It
was
established
in
1997
and
co-administered
by
the
it's
co-administered
by
the
state
board
of
pharmacy
and
the
nevada
division
of
investigation.
It
is
currently
housed
at
the
state
board
of
pharmacy.
It
was
originally
designed
to
identify
potential
doctor
shoppers.
However,
the
role
has
expanded
to
help
identify
inappropriate
prescribing
and
prescription
forgeries.
G
G
G
There
are
two
major
bills
that
have
been
passed
to
fight
the
opioid
epidemic
assembly,
bill
474
in
the
2017
session
and
assembly
bill
239
in
in
the
2019
session.
Next
slide.
Please
one
goal
of
ab474
is
to
prioritize
patient
prioritize
patient
safety
and
inform
patients
of
the
risks
of
taking
an
opiate.
It
was
designed
to
create
an
open
dialogue
between
the
patient
and
the
provider
to
ensure
prescribing
a
controlled
substance
is
medically
necessary
and
appropriate.
G
Another
goal
was
to
prevent
addiction
and
misuse
of
controlled
substances.
This
was
accomplished
by
requiring
a
prescriber
to
check
the
patient's
pmp
prior
to
prescribing
a
prescription
and
then
every
90
days
thereafter,
if
they're
going
to
continue
that
course
of
treatment,
it
also
stabs
established
guidelines
for
writing
an
initial
controlled
substance
prescription.
G
G
G
Assembly
bill
239,
which
was
passed
in
2019
legislative
session,
provided
further
clarification
and
guidance
on
ab474.
The
patient
risk
assessment
was
limited
to
the
relevant
medical
history
of
the
patient's
pain,
not
the
entire
patient
history.
The
initial
prescribing
guidelines
were
now
allowed
to
exceed
a
14-day
supply
or
daily
90,
mme.
If
the
practitioner
deemed
that
it
was
medically
necessary.
G
G
However,
they
were
required
to
check
the
pmp
as
soon
as
possible
and
at
least
90
days
thereafter.
If
they
were
going
to
continue
the
course
of
treatment,
they
were
not
required
to
perform
a
patient
risk
assessment,
enter
into
a
patient
medication
agreement
or
adhere
to
the
initial
day
supply
or
daily,
mme.
L
Thanks
darla,
this
is
kyra
morgan
again,
but
chair
peters.
Would
you
like
to
take
questions
now
or
do
you
want
me
to
keep
powering
through.
A
Let's
go
ahead
and
make
it
through
the
presentations
and
then
we
will
ask
questions
at
the
end.
L
Okay,
perfect
so
again,
kyra
morgan,
state
biostatistician
for
the
department
of
health
and
human
services,
I'm
going
to
touch
just
briefly
on
opioid
prescribing
patterns
and
then
doctor
best
family.
Our
senior
policy
advisor
on
pharmacy
is
also
going
to
chime
in
on
prescribing
policies
within
fee
for
service
medicaid.
L
So
here
we're
looking
at
a
couple
of
maps
showing
prescribing
patterns
per
capita,
and
you
can
see
national
comparisons
as
well
as
kind
of
how
that
progress
has
been
made
over
time.
In
2020,
nevada
providers
wrote
47.4,
opioid
prescriptions
for
every
100
people
compared
to
an
average
u.s
rate
of
43.4
prescriptions,
and,
although
nevada
is
still
slightly
higher
than
the
national
average,
we
have
observed
a
decline
from
73.
Oh
food
prescriptions
for
every
100
persons
in
2017,
which
is
a
35
decrease.
L
I
also
wanted
to
take
this
time
to
let
the
committee
know
that
we
do
maintain
all
of
the
data
I'm
about
to
go
over
also
public
facing
on
a
dashboard.
That's
updated,
monthly,
the
nevada
prescription,
drug
monitoring
program,
dashboard
in
case
anyone's
interested
in
monitoring
this.
After
the
meeting.
L
L
Here,
I'm
looking
at
opioid
prescription
counts
and
rates
by
day
supply,
so
how
many
days
were
supplied
in
those
prescriptions,
and
I
included
some
detailed
data
from
2017
and
2021
that
you
can
reference,
but
I
really
just
wanted
to
make
some
high-level
conclusions,
and
that
is
that
we
have
seen
a
good
prescribing
rates
decrease
across
all
supply
volumes
over
this
time
frame.
More
specifically,
for
prescriptions
with
less
than
30
days
supply,
we
observed
a
52
decrease.
L
We
saw
a
36
percent
decrease
in
prescriptions
from
with
90
30
to
90
day
supply
and
then
a
55
decrease
in
prescriptions
with
more
than
90
days
supply.
L
We
can
also
look
at
this
using
a
morphe
milligram
milligram
equivalent
or
mme
potency
can
be
compared
across
the
spectrum
of
opioid
drugs,
using
a
conversion
factor
to
an
mme,
essentially
by
converting
different
opioids
to
the
standard
unit
of
measure.
A
prescriber
is
more
able
to
assess
the
patient's
potential
risk
for
overdose
related
to
dosing
and
nevada,
observes
decreasing
trends
across
all
enemies.
From
january
2017
to
december
of
2021,
the
largest
declines
were
observed
in
patients
receiving
the
highest
level
of
mme.
L
L
P
Thank
you
kyra,
sorry,
chair
peters
and
the
rest
of
the
members
of
the
committee.
My
name
is
beth
slamlitz
and
I
am
the
senior
policy
advisor
on
pharmacy
for
the
department
of
health
and
human
services.
I'm
just
going
to
do
a
really
high-level
overview
of
current
prescribing
policies
within
fee-for-service
medicaid.
P
The
first
bullet
point
there
just
for
reference.
Chapter
1200
of
the
medicaid
services
manual
does
set
the
guidelines
and
limitations
regarding
coverage
for
prescription
drugs
for
medicaid,
so
the
link
is
there
in
case.
Anyone
is
interested
in
exploring
any
further
a
few
of
the
high-level
policies
that
are
currently
effective
for
fee
for
service
medicaid.
We
do
have
limitations
on
early
fills
refills
for
controlled
substances.
P
Currently,
90
of
the
controlled
substance
has
to
be
used
before
refill
will
be
authorized.
We
also
have
policies
on
transdermal,
fentanyl,
long-acting,
narcotics
and
both
of
those
locations
within
the
medicaid
services.
Manual
chapter
are
identified
for
further
review.
P
What
I
did
want
to
point
out
here
is
that
when
this
policy
was
put
in
place,
we
were
anticipating
the
passage
of
ab474
but
did
put
in
requirements
that
were
a
little
more
restrictive
than
what
ab474
did
pass,
and
so
the
limitations
on
the
medicaid
fee
for
service
policy
is
for
prescriptions
of
60
ml
15,
60
milligram,
morphine
equivalence
or
less
per
day,
as
well
as
for
a
seven
day.
Initial
prescription
versus
the
14
and
90
morphine
melee
equivalents
that
exist
within
nrs
for
ab474.
P
If
the
initial
prescription
is
for
three
days
or
less,
and
there
is
an
exceptions
policy
to
allow
for
treatment
of
cancer-related
pain,
post-surgery
that
has
greater
than
a
three-month
recovery
time,
palliative
care,
long-term
care,
hiv
and
aids,
or
in
consultation
with
a
pain
specialist
for
the
opioid
containing
cough
preparation,
there's
also
an
age
limitation
of
18
years
or
older.
P
P
Lastly,
what
I
just
wanted
to
mention
is
that
when
the
opioid
policy
was
implemented
in
may
of
2017
prior
to
the
passage
of
ab474,
there
were
roughly
just
over
19
000
opioid
prescription
claims
per
month
that
we
saw
the
average
prescription
claims
per
month
in
2021
was
just
over
11
000.
So
we
have
seen
a
decrease
on
average
of
about
six
percent
year
over
year.
So
that
concludes
my
one
slide
presentation.
So
I'm
gonna
go
ahead
and
stop
there
and
see
if
there's
any
questions
from
the
committee.
A
Thank
you
so
much.
I
appreciate
your
presentations
today.
I'm
looking
it's
like
senator
hardy,
dr
hardy,
has
a
question
and
we'll
go
from
there
go
ahead,
dr
hardy.
Thank.
C
L
This
is
tyra
morgan
for
the
record.
We
did
decrease,
opioid
overdose
deaths
into
until
a
point,
and
I
think
we
saw
those
unfortunately
start
climbing
again
and
2021.
L
A
A
So
I
believe
that
dr
friedman
is
the
next
up
for
presentations
and
then,
after
this
there
may
be
one
more
you
and
I'm
I'm
gonna.
Let
you
guys,
let
me
know
and
we'll
we'll
take
presentation,
take
questions
on
the
presentation
after
that.
G
Our
results
were
largely
in
accordance
with
the
findings.
G
For
the
outcomes
that
we
both
looked
at
so
we
observed
decreases
in
the
proportion
of
patients
with
initial
opioid
prescriptions
over
both
50
and
98
mma,
as
well
as
decreases
in
days
supply
over
seven.
We
also
observed
desired
decreases
in
co-prescribed,
opioids
and
benzodiazepines,
and
desired
increases
in
urine
drug
testing
and
physical
therapy.
G
G
The
next
two
slides
help
us
see
the
magnitudes
of
the
changes
in
two
of
our
outcomes
of
interest.
This
first
slide
shows
the
trend
in
initial
prescriptions
within
me
over
50.,
the
average
proportion
with
of
a
patient
with
patient
months.
With
this
outcome
after
the
law
decreased,
10
percentage
points
from
19
to
9
percent.
G
We
saw
substantial
decreases
both
in
the
months
immediately
after
the
law
and
throughout
the
rest
of
2018..
Our
adjusted
analyses
where
we
controlled
for
patient
characteristics,
time
and
state
found
strikingly
similar
results.
The
proportion
of
opioid
knife
patients
getting
prescriptions
over
this
threshold
would
have
been
substantially
higher
about
20
percent
in
january
of
2019.
G
G
On
the
next
slide,
we've
collected
some
related
evidence
from
other
states
finding
results
that
are
generally
consistent
with
what
we
found
here
in
nevada,
seeing
decreases
in
dosages
and
days
supply.
I
won't
go
through
this
slide
in
detail,
but
I'll
leave
it
here
for
your
reference
and
then
finally,
here
on
the
next
slide,
is
my
contact
information.
G
We've
also
learned
that
this
committee
may
be
interested
in
prescription
stimulants,
which
we
haven't
looked
at
in
this
study,
but
going
forward.
We
would
be
interested
in
investigating
trends
and
stimulants
in
the
medicaid
claims
data
if
that
would
be
of
interest.
Thank
you
so
much
for
your
attention.
A
C
Yeah,
thank
you,
madam
chair.
The
question
would
be
have
we
actually
decreased
the
number
or
the
rate
or
the
average
or
the
number
of
deaths
by
opioids,
because
my
theory
is,
we've
done
a
great
job,
decreasing
prescriptions
of
opioids
and
we
have
had
people
turn
to
fentanyl
from
the
corner,
not
the
corner
drug
store,
but
the
corner
virtual
store,
and
so
I
I
think,
we've
we've
seen
heroin
go
up
and
we've
seen
fentanyl
go
up.
L
And
this
is
kyrah
morgan
for
the
record,
I'd
like
to
follow
up
with
a
detailed
response
on
that.
I'm
looking
at
our
opioid
dashboard
now-
and
I
have
some
numbers
in
front
of
me,
but
I
think
it
I
would
do
the
committee
more
justice
if
I
could
provide
something
a
little
more
thoughtful
as
a
follow-up
to
this
meeting.
A
I
think
that
would
be
great.
Thank
you
so
much
for
offering
the
follow-up.
If
you
can
work
with
staff
on
making
sure
we
get
that
we'll
get
that
out
to
the
committee
as
well.
I
think
it's
a
good
point:
dot
cardi.
We
are
we're
looking
at
decreasing
debts
and
we're
seeing
increasing
overdoses,
and
where
can
we
put
in
some
additional
effort
to
address
those
okay?
I
have
dr
warren
liquor
on
my
list
as
a
next
person
with
a
question.
Please
go
ahead.
C
Thank
you,
madam
chair.
I
also
have
an
unintended
consequences.
Question,
but
look.
My
guess
is
that
the
decrease
in
prescribing
is
good,
that
we're
eliminating
inappropriate
prescribing.
But
I
know
at
the
time
that
these
bills
were
passed.
There
were
concerns
of
practitioners
that
it
would
make
it
harder
to
prescribe
appropriately
and
one
you
did
mention
that
there's
been
increased
use
of
physical
therapy,
which
suggests
to
me
that
we're
seeing
a
good
transition
from
opioid
prescribing
to
more
appropriate
therapies.
But
are
we
seeing
any
unintended
consequences
in
terms
of
inadequate
use
of
opioids.
G
Thank
you
for
your
question.
I
can
address
try
to
address
that.
Although
you
know
we
we're
not
able
to
always
look
at
appropriateness
of
care
for
every
patient,
for
whom
who
claims
we
examined.
G
It
was
encouraging
to
see
increased
use
of
physical
therapy
for
patients
with
with
joint
pain,
and
we
also
looked
at
use
of
non-opioid,
not
opioid
pharmaceuticals.
We
did
not
see
the
desired
increase
in
that
outcome,
which
was
less
encouraging.
C
A
You,
okay,
we're
good!
Thank
you
so
much
for
their
information.
Dr
friedman.
Are
there
any
other
questions
from
the
committee
looking
at
my
multiple
ways
of
communication,
and
I
don't
see
any
other
hands
up,
please
unmute
yourself.
If
I
missed
you
all
right,
we're
going
to
go
ahead
and
move
on
to
the
next
agenda
item.
Thank
you
all
so
much
for
your
presentation
today.
Our
next
agenda
item
is
agenda
item
seven,
the
drug
of
land,
state
high
intensity,
drug
trafficking,
areas
within
nevada
trends
and
public
health
implications.
A
D
Good
morning,
first
of
all,
I'd
like
to
thank
the
committee
for
inviting
me
here
today
to
talk
about
the
high-intensity
drug
trafficking
program
and
and
what
we
do
in
terms
of
what
this
committee
deals
with
and
just
for
purposes
of
an
introduction,
since
it's
the
first
time
that
I've
been
here
as
the
director
of
the
statewide
program,
I'd
like
to
just
give
you
an
a
brief
overview
of
what
the
high-intensity
drug
trafficking
program
is
and,
of
course
I
want
to
give
a
shout
out
to
my
my
comrade
terry
kearns,
who
also
discussed
one
of
our
premier
programs,
od
maps,
which
was
developed
through
haida
several
years
ago
and
now
has
gone
nationwide.
D
Haida,
as
it's
called,
is
a
it's
a
comprehensive,
overarching
program
that
has
been
in
the
state
of
nevada
since
2001
were
primarily
a
law
enforcement
program.
However,
recently,
in
the
last
few
years,
we
have
partnered
with
the
cdc
and
have
created,
what's
called
the
overdose
response
strategy.
D
Many
of
the
people
on
today's
committee
that
have
talked
are
very
familiar
to
me.
They're
they're
people
that
that
my
program
and
my
personnel
deal
with
frequently,
and
so
it
has
been
a
a
collaboration
that
really
has
has
helped.
D
D
Today,
I've
been
asked
to
talk
about
our
drug
threats,
and,
and
so
I'm
going
to
take
it
from
a
little
bit
of
a
different
view
than
what
we've
heard
today
and
also
understand
that
it
can
be
complicated
to
really
you
know
understand
what
our
our
drug
threats
are
in
our
state
there's
a
lot
of
information
to
decipher,
but
and
it
depends
on
what
your
needs
are
and
how
deep
you
want
to
look
through
that
information
and
the
best
example
I
can
give
of
that
is
in
law
enforcement.
D
They
respond
to
a
situation,
they
take
action,
they
move
very
quickly
and
move
on
to
the
next
situation,
and
so
sometimes
the
information
that
law
enforcement
collects
is
is
subject
to
change
as
it's
merged
with
long-term
data
research
and
and
that's
one
of
the
the
areas
that
we
rely
on
our
public
health
partners
is
to
do
that
long-term
research
and
a
lot
of
the
information
you
heard
today.
D
We
utilize
that
to
develop
a
total
threat
picture,
but
over
and
above
that,
the
information
that
we
collect
in
in
in
developing
what
are
the
the
drug
threats
to
our
community
and
I'm
just
going
to
go
through
some
of
those.
So
you
kind
of
understand
that
we
really
take
a
very
wide
spectrum
of
information
and,
first
off
is
investigative
data.
So
we
look
at
our
investigations.
What
are
the
investigators
really
investigating
and
often
that
information
is
in
real
time
and
over
a
period
of
time
we
may
see
some
of
that
change.
D
We
also
survey
annually
about
2
000
law
enforcement
personnel
in
our
state.
We
want
to
know
what
it
is
they're
seeing
on
the
streets,
what
changes
they
have
seen
really
what's
happening
now
we
take
an
extensive
view
of
drug
seizures,
overdose
investigations
as
well
as
overdose
trends
and,
as
I
said,
information
from
public
health
and
also
information
from
our
border.
D
D
D
D
In
the
past
we
had
drug
users
who
primarily
used
cocaine
or
primarily
used
heroin,
but
today
that
that
has
changed
quite
a
bit,
and
that
complicates
what
it
is
that
we
all
do.
It
complicates
our
our
prevention.
It
complicates
our
our
investigations
and
it
cons.
It
complicates
our
ability
to
reduce
the
supply,
so
I'm
going
to
kind
of
look
at
our
those
drugs,
those
illegal
and
illegitimate
drugs
and
what
we
call
a
threat
order.
What's
what
is
the
worst
in
our
state?
Meth
is
by
far
the
worst
drug
that
we
have
on
our
street.
D
D
D
It's
seized
in
powder
pills,
a
user
smokes
marijuana,
I
mean
smokes,
excuse
me
smokes
meth,
snorts
meth,
and
we
find
it
in
a
pill
form,
and
I
want
to
talk
a
little
bit
about
the
history
of
meth
and
that
may
help
some
of
the
questions
on
overdoses
and
have
we
made
a
a
difference.
I
heard
I
heard
that
question
from
one
of
the
committee
members
back
in
the
1990s
methamphetamine
labs
were
pervasive.
D
D
Today
we
find
very
few
methamphetamine
labs,
but
what
has
happened
is
we
have
more
methamphetamine
today
than
what
we
had
when
we
had
it
being
manufactured
in
our
own
state
and
it's
a
higher
quality
than
what
we
had
manufactured
here.
So
is
it
an
unintended
consequence?
It
may
have
been
we
we
just
don't
know.
D
There's
too
many
factors
involved
in
in
and
there's
too
many
when
you
look
at
what's
occurred
in
mexico
in
the
manufacturing,
where
all
of
our
meth
is
manufactured
in
meth
in
mexico
and
brought
to
our
state,
there's
been
significant
changes
there.
So
it's
it's
hard
to
answer
that
question.
D
Meth
is
100
man-made,
which
complicates
our
ability
to
reduce
the
supply
it's
different
than
than
other
drugs
that
are
grown
by
on
plants
and
I'll
talk
about
some
of
those
in
in
a
little
bit.
D
We
consider
fentanyl
a
a
very
significant
significant
threat
to
our
citizens,
and
the
difference
with
fentanyl
and
meth
is
fentanyl
in
the
in
terms
of
illicit
drugs
on
the
streets
is
relatively
new
began,
2014
2015
for
our
state,
and
now
it's
it's
essentially
everywhere,
unfortunately,
and
as
several
presenters
have
discussed,
fentanyl
is
a
very
potent
drug
most
of
the
illicit
illegitimate.
Again
that's
the
drug.
D
I'm
talking
about
is
manufactured
in
mexico,
transported
to
our
state
in
either
powder
form,
but
primarily
in
pill
form
the
pills
that
we
see
primarily
resemble
an
oxy
30
pill
and
to
a
person
who
is
not
an
expert
they're,
very
difficult
to
determine
the
the
difference.
D
We
also
know
that
when
it
comes
to
fentanyl,
we
find
drug
users
that
are
not
your
typical
drug
addict,
which
adds
to
our
complication
in
in
dealing
with
this
the
situation.
We
also
know
from
investigating
overdose
deaths
of
fentanyl,
that
some
of
these
deaths
are
instant,
where
there
is
no
opportunity
to
use
narcan.
D
D
Last
year,
just
in
clark,
county
alone,
there
were
well
over
a
hundred
thousand
pills
ceased
by
law
enforcement.
So
it's
very
it's
it's
on
the
streets
very
easy
to
get
a
pill
typically
of
fentanyl
ranges
from
about
25
dollars
to
65,
depending
on
who
the
drug
trafficker
is.
We
also
find
that
our
drug
traffickers
are
also
poly
drug
dealers,
in
that
it's
rare
to
find
someone
who
is
only
trafficking
fentanyl.
D
Next,
we
would
classify
heroin
as
our
our
next
threat.
The
use
of
heroin
has
is
relatively
stable.
However,
it
has
not
gone
down.
D
The
price
of
heroin
has
remained
stable
and
and
again
it
remains
available
on
the
streets
in
nevada.
We
see,
what's
called
black
tar
heroin
brown
heroine,
not
the
typical
white
heroine
that
you
might
see
in
hollywood
movies
heroin
is
manufactured
from
a
plant.
D
Cocaine
is
next
on
our
list.
Cocaine,
many
people
believe
cocaine
is
a
designer
drug,
a
drug
that
is
not
addictive,
that
they
can
use
cocaine
and
on
saturday
and
go
to
work
on
monday.
D
D
And
next
I'll
group
pharmaceutical
drugs,
all
together
from
from
law
enforcement
perspective,
if
you
will
in
any-
and
I
agree
that
our
state
has
done
a
fantastic
job
of
changing
the
availability
of
pharmaceutical
drugs
and
it
has
made
changes
whether
there's
there's
unintended
consequences,
it's
really
complicated
to
answer
that
that
question,
especially
in
when
we're
in
a
situation
we
face
now
or
our
borders
are
more
open
than
what
they
have
been
in
the
past
and
our
our
border
patrol
has
the
ability
to
search
about
five
percent
of
the
vehicles
that
cross
our
border.
D
We
do
still
still
see
some
pharmaceutical
drugs
on
the
streets.
We
also
see
some
pharmaceutical
drugs
mixed
in
with
the
the
illicit
drugs.
We
don't
know
exactly
when
that
happens.
It
could
happen
during
the
manufacturing
process.
It
could
happen
during
a
transportation.
It
could
happen
at
the
dealer
level
as
well.
D
There
are
some
new
trends
that
we
have
run
across,
although
at
this
point
we
don't
call
them
emerging
threats
because
they're
they're
few-
and
I
alluded
to
that
earlier-
and
that's
the
mixing
of
drugs
mixing
of
stimulant
drugs
with
depressants,
the
mixing
of
some
of
some
illicit
drugs
with
marijuana
with
fentanyl
cocaine,
meth
we've
even
found
all
of
those
together
in
pill
forms.
D
A
Thank
you
so
much
for
that
presentation,
mr
carter,
our
director
carter,
are
there
any
questions
from
the
committee
on
this
issue.
J
Thank
you
and
thank
you
for
that
information,
because
that's
what
I've
been
hearing,
also
that
the
the
big
concern
of
these
drugs
being
brought
in
curious
about
that
statement
about
methamphetamines
and
for
years.
Methamphetamine
use
has
gone
down,
and
you
mentioned
it's
not
a
designer
drug.
I
mean
it
does
as
a
doc.
J
I've
seen
many
meth
addicts
and
not
only
what
it
does
to
you
mentally,
but
what
it
does
to
you
physically.
So
so
it
became
less
of
a
designer
drug
or
it
never
was
a
designer
drug
and
it's
really
kind
of
fell
off.
So
I'm
very
disappointed
to
hear
about
the
dramatic
increase
of
the
math
that's
being
brought
in
here,
and
so,
when
you
mention
only
five
percent,
you
say
people
are
check
coming
across
the
borders.
Is
that
what
has
traditionally
been
happened?
J
D
J
So
well,
I
was
just
saying
in
rural
nevada,
methamphetamine
labs
has
been
a
tremendous
problem.
They
folks
think
it's
a
good
place
to
come
out
and
hide,
and
so
it's
been
an
issue
for
us
out
in
the
rules
on
our
law.
Enforcement
will
testify
to
this
that
they'll
they'll
they'll
in
my
own
little
community
smith
valley,
which
you
think
would
be
protected
from
any
of
that.
J
We've
had
multiple
meth
labs
they'll,
they
rent
a
little
storage
container,
they
think
nobody's
paying
attention
to
them,
and-
and
you
know
they
they
will
produce
their
product
there,
and
so
it's
real
and
but
we
had
seen
some
improvement
and
so
very
discouraging,
to
hear
this
pretty
dramatic
increase.
D
D
J
Thank
you
for
that,
because
that's
something
I
hadn't
mentioned
actually
is
the
cost
of
these
drugs.
I
think
that
the
fentanyl
and
perhaps
have
gone
up
in
cost
because
they
they're
not
getting
it
via
prescription
and
having
to
buy
it,
and
maybe
that
is
why
so
that
that's
a
good
insight
there.
I
hadn't
kind
of
thought
about
that
correlation.
Thank
you.
Thank
you,
madam
chair,
for
the
question.
A
Thank
you
for
that
in
the
court.
Clarification
from
the
presenter
are
there
any
other
questions
from
the
committee
on
this?
Not
seeing
any.
Thank
you
director
carter
for
pleasing,
thank.
D
A
And
we'll
move
on
to
agenda
item
eight.
This
is
a
really
interesting
area
that
I'm
looking
forward
to
hearing
some
of
the
progress
on
we're
looking
at
medication,
assisted
treatment,
options
for
substance
use
disorders
and
an
update
on
senate
bill
390
from
the
2021
legislative
session.
A
A
F
Wonderful
yeah,
thank
you,
madam
chair
and
committee
members,
thanks
for
having
us
today
to
present
on
this
topic.
Medication
assist
treatment,
options
for
substance
use
disorders,
so
my
name
is
farzad
kami,
I'm
a
physician.
I
specialize
in
psychiatry
and
addiction
medicine,
I'm
the
director
of
collaborative
care
at
high
risk
pregnancy
center,
where
we
have
the
mother
program.
F
F
Okay,
so,
let's
start
off.
I
mean
everyone's
been
talking
ad
nauseam
about
how
substance
use
basically
is
an
issue,
and
it
is
a
problem,
but
some
more
stats
here.
So
in
2020,
40
million
people
in
the
nation
had
a
substance,
use
disorder
so
close
to
15,
which
is
significant.
We're
setting
records
every
year,
so
in
2020,
more
than
90
000
drug
overdose
deaths,
which
was
a
record.
I
wouldn't
be
surprised
that
2021
was
even
higher
than
that
when
that
data
comes
in.
F
Unfortunately,
because
of
this
landscape
overdose
is
now
the
leading
cause
of
accidental
death
among
adults
and
amongst
the
pa.
The
patient
population
that
we
work
with
so
overdose
is
the
leading
cause
of
death.
For
reproductive
age,
women
in
the
united
states
and
that's
all
causes
more
than
cancer,
more
than
heart,
disease,
etc.
F
Next
slide,
okay.
So
what
what
is
addiction
substance
use
disorder?
I
think
it's
important
to
frame
this,
because
then
it
leads
into
how
we
should
be
approaching
treatment
right.
If
you
look
at
a
sam's
definition
back
in
2019,
so
asam
is
the
american
society
of
addiction
medicine.
They
basically
say
addiction
is
a
chronic
disease,
much
like
others
such
as
diabetes
or
hypertension,
here's
sort
of
how
they
define
it.
So
it's
a
treatable,
chronic
medical
disease
involving
complex
interactions
among
brain
circuits,
genetics,
the
environment
and
an
individual's
life
experiences.
F
Now
what
you'll
notice
is
that
there's
no
mention
of
it
being
sort
of
this
choice,
a
moral
weakness
or
a
failure
which
is
fantastic
because
it
sort
of
medicalizes
addiction
and
substance
use
next
slide.
So
why
like?
What?
What's
going
on?
What's
happening
again,
a
little
it's
important
to
to
sort
of
understand
what
changes
are
occurring
and
a
lot
of
it
has
to
do
with
the
brain,
obviously,
but
dopamine
specifically.
So
what
we're
seeing
is,
is
you
know
in
in
in
the
way
that
humans
work,
life-sustaining
activities,
release
dopamine
in
aka?
F
This
is
the
reward
neurotransmitter
we're
familiar
with
this,
as
in
hey,
it
kind
of
makes
us
feel
good.
Why?
Well?
It
was
designed
to
have
us,
replicate
life-sustaining
activities,
you'll
see
in
the
chart
on
the
left,
things
such
as
food
and
sex,
what
we
call
natural
rewards.
You
know
this
brings
some
pleasure
and
so
ideally
for
the
continuation
of
the
human
species.
These
are
things
that
we
want
to
want
to
continue
doing
right
where
we
get
into
troubles.
F
Just
notable
notable
here
is
the
amount
of
increase
that
happens
with
various
substances
when
you
compare
it
to
sort
of
natural
rewards
significantly
speaking
here,
amphetamine
you'll
notice
that
it
goes
from
a
baseline
of
100
to
almost
a
thousand
eleven
hundred,
so
it
increases
the
amount
of
dopamine
ten
times.
What
something
like
food
would
next
slide
all
right
and
then
so
that
this
sort
of
you
know
repetitive
exposure
to
these
vastly
increased
amounts
of
dopamine.
They
lead
to
physiological
changes,
and
what
we
see
is
that
these
physic
physiological
changes
they
mimic.
F
What
other
you
know?
Physiological
changes
happen
in
other
chronic
diseases,
so
on
the
chart
in
the
left,
you'll
notice
that
there's
a
comparison
for
someone
who
has
a
heart
disease
right,
we're
looking
at
metabolism
here,
red
being
areas
of
metabolism
and
low.
You
know
darker
colors,
blues
little
metabolism
in
the
healthy
heart
lots
of
stuff
is
going
on.
F
The
heart
is
contracting,
diseased
heart,
not
so
much
so
similar
in
the
brain
right,
healthy
brain
you've
got
metabolism
going
on
and
then
sort
of
someone
who's
been
using
or
abusing
cocaine,
not
so
much
on
the
right.
This
is
looking
at
dopamine
and
how
dopamine
functions
and
transporters
that
are
available
again
just
notable
here.
You
see
that
in
a
healthy
brain
they
do
exist
and
then
the
unless
and
someone
who's
been
using
methamphetamine.
Here,
it's
like
they're
gone
right
next
slide.
F
Fortunately,
in
the
in
the
realm
of
thinking
of
chronic
diseases,
you
know
we
we
like
to
think
that
for
things
like
asthma,
hypertension,
diabetes,
there's
effective
treatments
and
we
are
lucky
that
we've
made
advances
and
that
there
is
effective
treatment
for
addiction,
substance
use.
F
It
cannot
be
effectively
cured
right
of
the
the
modalities
and
treatments
that
we
have
now,
but
they
can
be
managed
a
combination
of
medications
when
they
are
available
for
that
substance
with
behavioral
therapy
is
the
most
effective
and
so
much
so
that
when
you
put
these
effective
treatments
in
place,
the
quote-unquote
relapse
rates
or
return
to
substance
use
are
comparable
to
the
relapse
rates
and
other
chronic
diseases
such
as
diabetes
and
hypertension,
so
trying
to
sort
of
normalize
that
that
notion-
we've.
You
might
have
heard
this
before
that
you
know.
F
Oh
you
know
those
with
addiction,
they're
always
relapsing,
it's
like
they're,
they
go
into
treatment,
and
then
they
fall
out
of
treatment,
etc,
etc.
Next
line,
so
this
this
notion
of
medication
assisted
treatment
it
pretty
much.
What
it
means
is
is
where,
when
we
can,
let's
use
medications
that
are
effective
to
treat
that
patient
very
important
here.
That
medications
when
available,
are
the
standard
of
care.
F
F
For
someone
who
has
diabetes
medications
to
treat
these
issues
are
life-saving
for
those,
but
the
the
definition
is
basically
matte
is
the
use
of
fda
approved
medications
in
combination
with
counseling
and
behavioral
therapies,
to
provide
what
we
call
a
whole
patient
approach
to
the
treatment
of
substance,
use
disorders
and
again
touching
on
how
effective
this
is
when
someone
is
effectively
in
treatments
beforehand,
when
they're
using-
let's
say,
illicit
substances
like
heroin,
the
risk
of
morbidity
and
mortality,
so
basically
sickness
and
death
is
astronomical,
but
when
they
are
effectively
in
treatment
with
medication-assisted
treatments,
it
reduces
it
that
risk
of
morbidity
and
mortality
almost
six
volts.
F
F
This
is
where
we
we
view
treatment
differently
on
this
notion
of
parity
right,
where
we're
required
to
treat
mental
health
and
substance
use
disorders
the
same
exact
way,
so
they
should
be
the
same
as
we
view
and
treat
other
physical
issues.
I'll
tell
you
that's
not
where
we
are
there's
a
lot
of
work
that
needs
to
still
go
into
making
that
a
reality,
but
in
the
same
way
that
someone
might
be
insulin
dependent
for
the
rest
of
their
lives.
F
We
shouldn't
have
this
sort
of
bias
or
stigma
associated
with
someone
who's
in
mat
for
an
opioid
use
disorder,
for
example,
and
what
do
medications
do
ultimately
they're
effective
for
treating
withdrawal
having
people
stay
in
treatment
and
then
preventing
what
we
call
relapse
or
return
to
substance
use
so
things
that
are
all
kind
of
good
right,
very
positive,
next
slide.
F
Currently,
what
we
have
basically
for
mats
or
again
that's
been
fda
approved,
is
for
three
different
substances,
so
alcohol
and
the
corresponding
treatments
that
we
use
disulfiram
and
camper
city
naltrexone,
nicotine
they'll,
be
you
might
be
familiar
with
nicotine
replacement
like
patches,
but
then
some
of
these
newer
medications,
like
chantix
wellbutrin
and
whatnots
topic
of
conversation
opioids,
is
a
big
deal.
It's
causing
a
lot
of
morbidity
and
mortality,
we're
fortunate
to
have
three
currently
approved
fda
medications,
buprenorphine,
methadone
and
naltrexone.
F
A
lot
of
times
addressing
what
we
are
now
calling
these
social
determinants
of
health
is
becoming
really
important
because
kind
of
without
addressing
those,
it's
really
difficult
to
get
people
to
be
in
treatment
to
begin
with,
there's
multiple
levels
of
care,
level
ones
or
the
lowest
intensive
treatment
is
office
space.
So
this
is
traditional,
I'm
going
to,
let's
say
a
clinician's
office,
maybe
once
a
month
or
something
like
that,
then
there's
intensive
outpatient,
where
the
designation
is
nine
or
more
hours
a
week
of
stuff
is
happening.
But
again,
that's
still
in
the
outpatient.
F
Setting
residential
is
way
more
intense
and
it's
sort
of
usually
in
this
in
a
designated
space.
Patients
might
stay
there
overnight.
Leave
for
the
you
know,
leave
for
the
night
stay
there.
What
not
and
then
the
highest
level
is
inpatient,
so
that's
traditionally
you're
in
an
institution
or
a
facility
specifically
to
treat
something
that's
going
on.
F
We
don't
currently
have
anything
for
methamphetamine
or
a
medication
option
for
methamphetamine
again
really,
unfortunately,
at
this
time,
but
ideally
future
therapies,
innovations
will
have
something
that
is
as
effective
as
it
is
for
other
substances
like
alcohol,
nicotine
and
opioids
next
slide
so
bias
and
stigma.
This
comes
in
this
plays
a
role.
I
thought
it
was
important
to
mention
this
when
we
talked
about
parity
and
how
we
view
treatment
so
a
little
bit
about
bias.
F
It's
basically,
you
know
explicit
subconscious
and
then
unconscious
things
that
affect
us
and
basically
it's
this
opinion
that
influences
our
judgment
and
then
another
buzzword
that
we
use
oftentimes
when
it
comes
to
substance
use.
Is
this
notion
of
stigma
so
a
set
of
negative
and
often
unfair
beliefs
that
a
society
or
group
of
people
have
about
something
next
slide?
F
Why
is
it
important
to
talk
about
bias
and
stigma,
because
it's
it's
very
likely
that
those
that
patients
suffering
from
addiction
or
substance
use
disorder
in
the
world
of
health
care
might
be
those
that
are
ultimately
facing
the
most
amount
of
bias
or
stigma
from
health
care
in
general,
from
members
in
in
the
just
the
regular
population,
family,
friends,
et
cetera,
et
cetera
within
the
world
of
healthcare,
multiple
studies
have
demonstrated
bias
and
stigma
associated
with
substance
use,
and
what
effectively
happens
is
that
it
it
it's
to
the
detriment
of
being
able
to
identify
these
patients,
have
them
access
care
and
treatment.
F
So
this
is
why
it's
something
that
we
are
more
and
more
being
aware
or
trying
to
become
aware
of
and
eliminate
in
our
approach
to
care
next
line.
One
of
the
studies
here
was
the
recovery
research
institute,
just
to
sort
of
highlight
that
this
does
exist.
Participants
were
asked
how
they
felt
about
two
people
who
were
quote
unquote
actively
using
drugs
and
alcohol,
and
one
was
referred
to
as
a
substance,
abuser
and
another
was
referred
to
as
having
a
substance
use
disorder.
F
So
this
more
positive
person
first
language
that
we
do
recommend
is
on
the
blue
and
the
right
versus
stigmatizing
language
on
the
left
substance
abuser
that
and
what
do
they
find
that
the
substance
abuser
was
less
likely
to
benefit
from
treatments?
They
were
more
likely
to
benefit
from
punishments
that
it
was
like
a
result
of
their
own
faults
that
they
should
be
able
to
have
control
over
their
substance
use
without
help.
So
that's
where
that
bias
and
stigma
is
coming
in
right.
F
E
M
Thank
you,
dr
papura,
so
we
will
be
talking
about
medication-assisted
treatment
for
the
opioid
use,
disorder
and
opportunities
that
we're
seeing
in
nevada
for
programming
as
well
as
policy
next
slide.
M
So
some
key
points
that
really
are
highlights
for
this
presentation.
Increasing
access
to
high
quality
medication,
assisted
treatment,
has
been
a
core
strategy
for
nevada
for
addressing
the
opioid
crisis
for
several
years.
M
We
also
have
received
the
support
act,
grant,
which
is
the
substance,
use
disorder,
prevention
that
promotes
opioid
recovery
and
treatment
grant.
M
This
grant
was
awarded
to
the
division
of
health
care,
finance
and
policy
from
cms,
and
there
has
been
an
enormous
amount
of
work
that
has
been
accomplished
through
that
planning
grant
so
much
so
that
we
have
also
received
a
demonstration
grant
that
dr
capra
will
be
talking
about
and
then
overview
of
policy
considerations
that
relate
to
medication-assisted
treatment,
including
workforce
development,
alternative
payment
strategies
and
parity
across
payers
for
collaborative
care
for
the
treatment
of
opioid
use
disorder.
Next
slide.
M
M
This
is
an
important
point,
because
we
know
now
that
we
can
work
with
prescribers
to
incentivize
them
and
help
to
really
understand
what
some
of
the
barriers
are
from
them
expanding
services
to
the
patients
that
they
serve.
We
also
have
14
opioid
treatment
programs
in
nevada
and
they
are
situated
primarily
in
our
urban
areas.
These
are
what
you
would
consider
traditional
methadone
clinics.
However,
these
clinics,
many
of
them,
have
expanded
to
also
offering
the
other
fda
approved
medications
for
opioid
use
disorder.
M
M
Essentially,
when
we
look
at
both
the
otps
as
well
as
our
buprenorphine
waiver
prescribers,
what
we
find
is
that
we
actually
have
capacity
within
the
system,
primarily
in
the
urban
areas,
but
what
we
do
lack
is
a
connection
to
high
quality,
integrated
services
across
different
systems.
M
That
has
allowed
for
greater
use
of
telemedicine,
including
initial
evaluations,
so
that
we
can
reduce
barriers
to
access,
especially
for
those
that
have
a
lack
of
geographic
access
by
introducing
telemedicine
as
a
facilitator
for
accessing
care,
and
then
increasing
access
within
primary
care
providers,
office-based
settings
and
also
hospitals
and
emergency
rooms,
and
one
issue
as
it
relates
to
stigma
and
biases
dr
camiar
was
talking
about,
is
really
finding
ways
that
we
can
reduce
chances
that
individuals
are
denied
care
because
they
are
on
medication-assisted
treatment.
M
We've
seen
this
as
an
evolution
within
our
court
system,
as
well
as
in
with
our
state-funded
providers
that
are
not
able
to
deny
access
to
care
to
individuals
who
are
currently
on
medication.
Assisted
treatment
next
slide
so
with
this
I'll
turn
it
over
to
dr
capuro,
who
will
be
talking
about
the
experience
of
the
division
of
healthcare,
finance
and
policy
with
the
support
act?
Grant.
E
Dr
woodard,
so
under
the
support
act,
cms
developed
a
planning
and
demonstration
grant
aimed
at
increasing
the
capacity
of
medicaid
providers
to
deliver
substance,
use
disorder
and
opioid
use
disorder,
treatment
and
recovery
services.
This
has
been
very
crucial
to
our
work
in
2019.
As
dr
woodard
mentioned,
nevada
was
one
of
15
states
awarded
the
24-month
support
act,
planning
grant
and
in
september
of
2022
or
2021,
I'm
sorry.
Nevada
was
one
of
only
five
states
that
were
selected
for
the
36-month
support
act.
E
So,
in
terms
of
the
the
work
that
has
been
completed
in
response
to
the
support
act,
nevada
has
developed
a
comprehensive
medication,
assisted
treatment
strategy
and
that
policy
documents
the
process
of
treatment,
the
use
of
bufanorphin
medications
and
qualifications
of
providers.
So
we
were
able
to
adapt
the
asam
criteria
for
medicaid
mit
policy
and
update
our
chapter,
its
medicaid
service
manual
or
msm,
chapter
3800,
which
includes
an
mat
policy
that
was
approved
in
june
of
2020,
and
our
mat
billing
guide
was
published
just
the
following
month
in
july
of
2020..
E
E
The
expert
toolkit
was
developed
and
training
was
also
provided
to
nevada's
largest
female
reproductive
health
practice
and
then
using
the
success
of
that
toolkit.
As
a
guide,
similar
expert
training
was
included
in
the
hersa
oral
health
workforce.
Grant
application
that
the
state
recently
completed
to
expand
expert
workforce
support
to
dental
professionals
and
the
division
continues
to
monitor
expert
trends
and
has
engaged
with
each
of
the
managed
care
plans
to
discuss
implementation
and
possible
promotion
of
expert
during
monthly
meetings
with
each
of
those
plans.
E
E
E
The
chart
illustrates
that,
with
more
focus
and
awareness,
you
can
see
that
there's
been
an
associated
upward
trend
in
the
treatment
for
oud
and
this
work,
and
these
trends
are
really
paramount.
As
noted
by
the
kaiser
family
foundation,
medicaid
covers
38
of
non-elderly
adults
with
an
opioid
use
disorder,
making
it
the
largest
source
of
coverage
for
individuals
undergoing
medicaid,
assisted
treatment.
E
Next
slide,
so
in
january,
of
2021
nevada,
medicaid
administered
a
survey
to
providers
to
assess
current
barriers
and
challenges
with
mat,
prescribing
addressing
social
determinants
of
health
and
any
challenges
with
technology
supported,
informational
exchanges.
E
The
vast
majority
of
those
were
self-reported
experiences
and
what
we
found
was
that
65
noted
a
limited
number
of
organizations
to
which
to
refer
to
23
of
respondents
currently
prescribed
mat,
but
16,
who
did
not
currently
prescribe,
did
not
even
know
if
their
organization
had
that
capability
and
of
the
80
percent,
who
were
currently
prescribing
73
were
not
prescribing
to
capacity.
So
there's
still
a
great
deal
of
workforce
needs
that
are
indicated
here
next
slide.
E
These
issues
create
barriers
to
successful
treatment
of
patients
with
oud
and
sud,
and
have
been
the
focus
of
the
state's
work
in
just
a
moment.
I'll
discuss
an
alternative
payment
model,
that's
being
designed
to
resolve
the
underlying
under
utilization
of
mat
services,
the
barriers
to
care
coordination,
reimbursement
and
these
administrative
barriers
that
were
identified
next
slide.
E
The
payments
would
be
issued
monthly
and
would
be
bundles
would
be
bundled
a
set
of
mat
services
using
the
asam
guidance
and
the
p
code
model.
As
an
alternative
payment
model
also
features
a
performance-based
adjustment
for
bundled
rates,
and
the
p
code
is
a
priority
and
a
budget
concept
that
the
division
is
planning
to
put
forward
for
the
next
budget
building
cycle.
M
So
this
qualitative
research
helps
to
bring
vital
information
and
the
voices
of
individuals
with
lived
experience
into
our
consideration
when
we
are
developing
designing
and
implementing
new
programs
within
the
state.
So
as
an
example,
a
study
that
was
conducted
by
swigert
and
lee
just
this
past
year
interviewed
30
individuals
between
the
ages
of
25
and
62.
M
16
of
those
individuals
were
currently
using
opioids
and
another
19
had
used
them
in
the
past.
Some
of
their
key
findings
include
highlighting
a
need
for
greater
access
to
harm
reduction
services,
as
well
as
outreach
and
peer
supports
greater
integration,
cohesion
and
interconnection
between
those
supports
and
services
for
treatment
and
recovery.
M
We
know
that
purpose
and
community
are
really
two
hallmarks
of
successful
recovery
programs,
and
when
these
can
be
fostered
within
individuals,
there
is
a
greater
likelihood
that
they
are
able
to
continue
on
their
recovery
trajectory
and
increase
communication
and
information
dissemination
on
educating
what
is
medication-assisted
treatment.
How
does
it
work
and
where
and
how
can
they
access
those
services?
M
So
I
had
mentioned
earlier
around
the
hub
and
spoke
model
of
care.
The
hubens
book
model
of
care
has
been
optimized
by
many
states
across
the
united
states,
really
is
a
core
best
practice
treatment
model
for
coordinating
the
treatment
for
individuals
with
opioid
use.
Disorder
states
have
used
federal
grants
to
help
to
upstart
some
of
the
hub
and
spoke
essential
practices
as
well
as
infrastructure
and
nevada
has
done
some
of
that
work
as
well
through
our
state
opioid
response
and
our
state
targeted
response
grants.
M
The
office-based
opioid
treatment
providers
can
work
with
a
multidisciplinary
staff
such
as
nurses
and
care
managers
to
provide
ongoing
care
for
individuals
with
opioid
use
disorder
that
tend
to
have
more
stable
and
less
severe
opioid
use
disorder
or
for
those
that
have
been
successful
in
maintaining
maintenance
for
some
time.
They
also
connect
patients
to
wrap-around
services,
as
well
as
supports
for
social
determinants
of
health
and
offer
an
array
of
outpatient,
behavioral
health
services,
including
counseling
and
case
management.
M
Again,
we
continue
to
talk
about
collaborative
care
and
we
see
collaborative
care
really
is
the
linchpin
that
helps
to
to
keep
this
hub
and
spoke
model
intact.
So
the
hub
is
really
the
core
of
where
the
majority
of
services
can
be
initiated,
but
as
individuals
become
more
stable
and
less
severe
and
are
on
more
of
a
maintenance
therapy,
moving
them
out
into
the
spokes
or
office
based
opioid
treatment.
M
So
some
of
the
programming
and
policy
considerations
that
really
have
been
elevated
during
the
course
of
our
work
over
the
last
several
years
and
certainly
have
been
highlighted
with
the
work
through
dhcfp
and
the
support
act
grant
include
ensuring
harm
reduction
strategies
are
available
to
all
communities,
to
support
individuals
with
opioid
use
disorder,
encouraging
greater
implementation
of
screening.
M
Brief
intervention,
referral
to
treatment
across
all
primary
health
systems,
integrating
harm
reduction,
peer
support,
navigation
to
treatment
and
recovery
services
into
mobile
crisis
teams,
recognizing
that
these
teams
will
be
going
out
into
communities
meeting
individuals
where
they
are
at
and
providing
additional
services
and
supports
to
them.
We've
already
started
to
include
having
overdose
education
and
naloxone
distribution
as
part
of
some
of
the
mobile
crisis,
teams
that
are
already
deployed
into
the
communities,
also
ensuring
that
there
is
a
no
barrier.
M
M
That
is
also
essential
to
facilitate
collaborative
care
management
and
encouraging
those
waivered
prescribers
that
we
do
have
to
pers
to
to
prescribe
by
offering
incentives
and
opportunities
to
continue
to
develop
their
competencies
next
slide.
M
And,
finally,
recognizing
withdrawal
management
is
not
a
complete
episode
of
care
and
that
follow-up
and
referral
are
essential
for
continued
support
and
care.
M
I'll
speak
a
little
bit
more
about
this
in
my
next
presentation
on
the
sequential
intercept
model,
but
especially
for
individuals
who
are
put
through
withdrawal
management,
while
they
are
incarcerated,
recognizing
that
that
in
and
of
itself
is
not
a
complete
episode
of
care
and
that
individuals
who
are
not
connected
with
care
following
incarceration
are
at
an
increased
risk
for
overdose
as
well
as
death
by
overdose,
so
making
sure
that
there
is
a
linkage
as
individuals
are
re-entering
into
the
community
also
that
pregnant
women
with
opioid
use
disorder
can
be
safely
cared
for
during
pregnancy
and
that
neonatal
abstinence
syndrome
can
be
reduced
in
both
incidence
and
severity,
with
proper
care
planning.
M
It's
been
said
many
times
already,
but
I'll
say
it
again:
parity
and
coverage
and
participation
in
a
statewide
hub
and
spoke
like
model
across
all
payers,
with
limitations
on
fail,
first
treatment
options,
prior
authorization
and
coverage
limits
really
does
need
to
be
considered
as
we're
looking
to
build
out
a
statewide
system
where
individuals
who
need
access
to
opioid
use
disorder
treatment
have
that
access,
regardless
of
their
ability
to
pay
and
regardless
of
who
their
insurance
carrier
is,
and
then,
of
course,
using
and
promoting
telehealth
as
a
modality
for
providing
medication-assisted
treatment
services
to
seek
options
to
ensure
continued
access
to
telehealth
mat,
especially
considering
the
modifications
that
have
been
made
to
some
of
those
policies
under
the
public
health
emergency
and
next
slide.
M
So
cheer
peters-
I
can
pause
here
if
you'd
like
for
us
to
open
it
up
to
questions
to
the
committee
as
it
relates
to
the
presentation
on
medication,
assisted
treatment
or
if
you
would
prefer,
I
can
go
into
the
summary
of
the
update
on
senate
bill
390..
M
A
C
M
So
this
is
stephanie
woodard
for
the
record
and
I'll
take
this
question.
We
have
heard
at
least
anecdotally
that
we
do
have
more
prescribers
that
are
willing
to
prescribe
now
that
they
have
waived
some
of
the
training
and
education
requirements,
but
we
haven't
really
fully.
I
don't
think
understood
what
the
impact
that
has
had
on
access
to
treatment,
specifically
in
nevada,
yet.
F
Yeah
absolutely
so
collaborative
care
model.
Dr
woodard
had
mentioned
this
it
it's
what
I
foresee
being
sort
of
the
wave
of
the
future
when
it
comes
to
providing
mental
health
services
for
the
u.s.
Fundamentally,
we
have
a
huge
mental
health
issue
largely
untreated
at
this
time.
F
F
Okay,
then
there's
added
complexities
right
so
and
we
don't
even
have
enough
providers.
So
if
everyone
today,
who
had
some
sort
of
mental
health
issue,
decided
to
go,
see
us
behavioral
health
specialists
overwhelmed
right,
the
system
would
probably
come
crashing
down,
but
we've
seen
that
right,
there's
not
the
first
appointment
is
six
months
out
et
cetera,
et
cetera,
so
what
collaborative
care
does
is?
Is
it
brings
that
prescribing
and
that
treatment
care
to
that
primary
care
provider?
F
So,
in
our
case,
we
have
maternal
fetal
medicine,
slash
perinatologists
in
the
realm
of
ob
gyns
right,
so
our
clinicians
are
the
ones
that
are
treating
the
high
risk
pregnancy
for
these
patients.
They
are
also
the
ones
that
are
seeing
these
patients
for
their
opioid
use
disorder
and
providing
them
with
prescriptions.
For
these
medications
and
doing
follow-up,
one
of
the
cornerstones
of
a
collaborative
care
program
is
what
we
call
a
care
manager.
F
So
it's
that's
where
the
specialist
in
behavioral
health
comes
in
and
that
person
does
oh,
my
gosh,
all
sorts
of
stuff
right,
figuring
out
how
treatment
is
going.
What
follow-ups
are
needed?
Is
the
treatment,
effective,
etc,
etc?
And
then,
over
here
sort
of
in
this
triangle,
patients,
the
primary
care
collabora
the
care
manager
over
here?
There's
the
behavioral
health
specialist
aka?
F
Let's
call
it
let's
say
psychiatrists,
for
example,
and
that's
the
role
that
I
provide
at
high
risk
pregnancy
center
and
I'm
I
basically
work
with
the
care
manager
and
that
person
is
the
conduit
to
the
primary
care
provider,
slash
the
perinatologist
to
inform
them
of
taking
care
of
these
patients
and
something
that
they
normally
would
never
do.
I
mean
I
guess
you
could
ask
dr
woodard
in
in
the
united
states
how
many
perinatologists
are
providing
buprenorphine
for
patients
right.
You
can
then
go
to
ob
gyns
primary
care
providers
right.
F
That
number
starts
to
dwindle.
When
you
go
up
the
specialties,
but
effectively
we
have
numerous
perinatologists
who
are
now
prescribing
buprenorphine
for
these
patients
that
normally
wouldn't
be
getting
care.
I
mean
we'll,
say:
pregnancy
and
postpartum
is
sort
of
this
targeted
patient
population
or
priority
patient
population,
but
that's
fundamentally
how
the
how
the
program
operates
and
what
it
what
it
ends
up
doing
is
is
collaborative
care.
Super
evidence
based
right.
There's
numerous
studies,
we'll
say
probably
close
to
100,
but
let's
say
over
80.
F
improves
access
to
care
lowers
cost
right
to
deliver
care,
but
fundamentally
it
actually
improves
outcomes.
So
the
outcomes
are
much
better
than
when
we
look
at
traditional
care
and
then
patient
and
provider
satisfaction
is
through
the
roof
compared
to
traditional
care
models,
so
it's
kind
of
the
wave
of
the
future,
but
the
reimbursement
and
all
sort
of
those
motivating
factors
for
implementing
that
aren't.
Quite
there.
E
Please,
okay,
that
was
actually
what
I
was
going.
F
Yeah
so
currently
they
are
not
being
reimbursed
right.
So
cms
has
defined
collaborative
care
codes
specifically
to
implement
this
model,
but
I,
as
I
believe
nevada,
is
working
on
it
because
we've
been
involved
in
those
discussions,
but
currently
it's
not
reimbursed
here
in
nevada.
I
think
we're
unique
we're,
probably
the
only
program
that
does
this-
that
uses
the
collaborative
care
model
we've
been
fortunate
now
to
be
sort
of
grant
funded.
F
So
that's
what's
carrying
it
outside
of
the
previous
years,
where
it
was
just
being
floated
by
high
risk
pregnancy
center,
but
we
saw
it
as
basically.
This
is
keeping
people
alive
right,
so
we're
talking
patient
and
baby
or
neonate
and
fetus.
So
it
was
super
important
to
to
offer
that.
K
A
You
very
much
thank
you.
I
agree
and
keep
us
posted
on
how
that
collaboration
is
going
with
with
medicaid
and
if
there's
anything
that
you
guys
need
from
us,
please
let
us
know
dr
like
are
on
my
list
next,
please
go
ahead
with
your
question.
C
Yeah.
Thank
you,
madam
chair,
dr
woodard.
I
want
to
pick
up
on
something
you
talked
about
at
a
couple
points
and
that
is
use
of
medically
assisted
therapy
in
the
judicial
system,
and
I
remember
hearing
a
presentation
a
few
years
ago
about
a
would
seem
like
a
pretty
substantial
resistance
and
surprising
resistance,
even
in
drug
courts,
to
using
medically
assisted
therapy,
and
is
that
getting
any
better?
And
what
can
we
do
to
get
these
drug
court
judges
to
be
more
comfortable?
M
Stephanie
ordered
for
the
record
through
you
chair
to
senator
orrin
liquor,
I
would
assembly
one
assemblyman
or
in
liquor.
Sorry,
thank
you.
It's
a
lot
to
navigate
so
related
to
your
question.
I
think
we
have
seen
some
pretty
remarkable
progress
through
our
judicial
system
as
it
relates
to
access
to
medication-assisted
treatment.
M
Some
of
the
best
practices
that
have
come
out
through
the
national
judicial
court
systems,
who
provide
training
and
technical
assistance
to
judges
and
courts,
really
have
been
quite
progressive
in
helping
courts
and
judges,
understand
the
utilization
of
medication-assisted
treatment
and
how
it
can
really
enhance
some
of
the
outcomes
for
their
drug
courts.
Specifically,
we
do
see
some
courts
actually
bifurcating
between
drug
court
in
a
specific
medication-assisted
treatment
court,
recognizing
that
some
individuals
with
opioid
use
disorder
are
going
to
benefit
from
sort
of
differentiated
treatment
where
we
do
still
see.
M
Some
challenges
is
really
ensuring
that
individuals
who
are
entering
into
any
specialty
court
for
either
mental
health
or
substance
use
disorder
services
really
have
adequate
comprehensive
evaluations
on
the
front
end
to
determine
where
there
are
co-occurring
or
comorbid
behavioral
health
conditions
and
offering
opportunities
for
comprehensive
treatment.
While
they
are
engaged
in
care,
we
do
know
that
there
are
many
people,
the
majority
of
individuals
actually
who
engage
in
care
through
drug
courts
who
also
have
co-occurring
mental
health
conditions.
M
So,
while
we
are
mandating
individuals
to
treatment
through
those
court
systems,
we
want
to
make
sure
that
they
have
access
to
care
to
treat
all
of
the
disorders
that
they're
coming
with,
which
ultimately
will
benefit
the
individual
and
enhance
outcomes
both
in
the
short
term,
but
in
the
long
term,
for
those
individuals
to
meet
and
then
maintain
recovery.
Ongoing.
A
J
Thank
you
and
great,
all
all
great
information.
I
appreciate
that
doctor.
What
are
those
you
mentioned
in
your
early
statement
regarding,
or
you
reference
say,
prison
population
being
treated
for
substance,
abuse,
drug
abuse
and
then
making
sure
that
they
get
it
that
that,
as
we
would
say,
is
a
health
care
provider
that
warm
handoff
to
continue
treatment
after
they're
released.
So
I'm
curious-
and
you
may
not
have
this
or
you
might
be
addressing
it
on
your
next
section,
what
percent
of
our
incarcerated
nevadans
are
actually
receiving
treatment
for
their
drug
addiction?
J
Not
just
maybe
the
map
system,
where
they're
taking
medication
but
actually
counseling
and
other
treatments,
so
are
all
of
our
incarcerated
patient
people
who've
been
identified
as
either
having
substance,
abuse
or
drug
addiction
being
offered
treatment.
Are
we
able
to
reach
everybody.
M
Stephanie
woodard
for
the
record,
dr
titus.
It's
an
excellent
question
and
what
I
can
say
absent,
concrete
data
is
that
no,
we
don't
necessarily
have
access
to
adequate
treatment
for
individuals
with
mental
health
or
substance
use
disorders
within
our
criminal
justice
system,
be
they
incarcerated
in
jails
or
in
prison.
J
Thank
you
for
that,
because
one
of
my
in
my
political
world
there's
just
a
lot
of
comments
about
you
know
just
arrest
them
and
if
we
arrest
them
and
we
put
them
through
they
the
withdrawal
or
treatment
program
literally
by
withdrawing,
as
you
mentioned,
when
they
get
out,
we
may
indeed
see
an
increase
in
overdose,
and
so
I
just
have
huge
concerns
that
we're
making
sure
that
those
that
we
have
identified
get
that
treatment
and
then
that
warm
handoff,
and
so
so.
J
Thank
you
for
that
and
I'd
love
to
see
some
follow
up
on
that
and
maybe
some
actual
numbers,
and
what
how
how
much
are
we
actually
lacking?
I
mean
what
percent
of
our
prison
population
actually
is
offered
treatment
and
when,
if
you
have
a
chance
or
could
get
those
numbers
and
then
my
next
question
is
regarding
medicaid
and
one
of
the
things
that
we
heard
last
session
was
to
make
sure
and
build
a
path,
and
maybe
we've
addressed
it.
But
but
I'm
not
remembering
what
bill?
J
E
J
Great
thank
you
because
there
was
a
mention
that
there's
that
delay
in
getting
that
treatment,
if
you
even
if
you
did
have
an
appointment
with
somebody
when
you're
released,
you
can't
get
there
because
you
have
to
go
through
all
the
hoops
to
get
to
to
get
it
authorized,
and
so
I
just
want
to
make
sure
that
we're
some
of
these
changes,
we're
trying
to
make
have
been
effective,
are
actually
starting
and
some
of
the
outcome
data
that
we
might
have.
So.
Thank
you
all.
Thank
you,
madam
chair.
A
Thank
you
for
those
great
questions,
and
I
think
many
of
us
on
this
committee
are
interested
in
that
workforce
model
issue
right
or
how
many
more
do
we
need
in
the
state
to
get
to
a
place
where
we're
covering
everybody,
and
that
goes
across
the
board.
But
this
this
particular
issue
is
really
important
as
well.
I
know
that
dr
kenyar
has
to
head
out
here
shortly,
so
I
have
one
last
final
question
for
you
guys
related
to
the
mit
and
then
we
can
move
on
to
the
presentation
on
sb
390..
A
My
question
is
related
to
the
treatment
protocols
for
somebody
who
has
the
longer
term
mit
right,
so
somebody
who
can't
go
through
treatment
and
and
be
completely
off
of
some
kind
of
medication
to
to
live
a
normal
life
and
and
be
productive.
Can
you
talk
a
little
bit
about
what
the
standards
are
or
if
there
are
standards
for
that
model
and
who
in
nevada
is
providing
that
kind
of
longer-term
care
for
folks
who
need
it.
F
I
I
can
speak
to
that
dr
cameron,
for
the
record.
You
know
so
so
traditionally
I
would
say
at
its
face:
it
should
be
no
different
than
other
forms
of
treatment
for
chronic
diseases,
depending
on
the
the
medication
that
the
patient
might
be
on,
the
the
location
of
that
treatment
might
differ,
but
let's
use
one
of
the
medications
buprenorphine,
which
can
be
prescribed
in
an
office
setting
for
opioid
use
disorder.
F
I
foresee
that
a
patient
much
like
when
they
see
us
is
it's
just
like
going
to
see
the
doctor
for
their
regular
checkup
and
regular
medication.
Ideally
when
we've
sort
of
eliminated
bias
and
stigma
or
destigmatized,
we
view
this
as
a
chronic
disease
and
we
implement
treatment
as
such.
A
I
agree
with
the
that
model.
Theoretically,
I'm
just
curious
how
many
folks
are
actually
doing
that
in
their
in
their
facilities
and
what
that
long-term
treatment
looks
like
and
how
we
hand
folks
off
right
when
we
have
retirement
happening
or
or
when
facilities
are
purchased
by
other
facilities,
and
we
have
to
move
people.
What
are
we
doing
for
that
continuity
of
care,
but
I
think
that
might
be
a
longer
term
discussion
to
have
in
china.
So
I
appreciate
all
of
your
your
input
and
presentations.
A
This
is
really
some
amazing
work
and
and
an
effort
from
us
to
destigmatize
this
conversation
I
know
serving
on
the
regional
behavioral
health
policy
board
up
here
in
washington
county.
This
is
an
area
that
we're
looking
at
as
well
ensuring
we're
supporting
folks
who
are
providing
those
m
t's
for
our
community
and
getting
them
the
resources
they
need
to
continue
on
doing
that
and
working
together
with
other
community
faces.
So
thank
you
so
much
for
your
presentations
and
please
feel
free
to
take
off.
I
know
you
have
some
patience.
A
M
And
while
she's
doing
that,
I
can
go
ahead
and
get
started
so
senate
bill
390,
as
many
of
you
will
recall
from
last
session,
was
a
bill
that
was
carried
by
the
senate
committee
on
health
and
human
services
and
has
two
primary
components
to
it.
M
The
first
portion
of
sb
390
is
related
to
988
and
what
it
does
is
it
helps
to
establish
an
account
which
we
call
the
crisis
response
account
that
a
surcharge
that's
levied
against
for
telecommunications
is
deposited
into,
so
the
first
part
of
sb
390
is
primarily
focused
on
what
we
call
a
crisis
call
center.
M
So
the
goal
of
this
is
to
prepare
us
to
be
ready
for
988
and
988
is
the
three-digit
telephone
number
for
the
national
suicide
prevention
lifeline
that
will
be
going
live
nationally,
regardless
of
whether
states
are
ready
for
it
or
not
starting
july
16th
of
2022,
so
nevada
has
actually
been
working
on
its
crisis
response
system
for
the
last
several
years,
so
we
were
in
actually
a
really
good
place
to
begin
to
do
this
work
and
sb
390
is
going
to
allow
us
to
now
have
some
revenue
to
be
generated
from
the
surcharge
to
be
deposited
into
the
crisis
response
account
that
will
support
ongoing
call
center
and
care
traffic
control.
M
What
we
call
like
our
crisis
care
center
hub
to
be
able
to
have
ongoing
operations
now
and
into
the
future,
as
well
as
providing
additional
funding
to
support
mobile
crisis
teams,
as
well
as
crisis
stabilization
centers,
with
the
goal
of
ensuring
that
mobile
crisis
and
crisis
stabilization
centers
are
able
to
treat
anyone
and
everyone,
regardless
of
their
ability
to
pay
recognizing
that
they're
part
of
the
critical
infrastructure
needed
in
our
communities
to
really
effectuate
the
change
needed
within
crisis
services.
M
So
first
part
of
sb
390
is
988
in
the
crisis
response
account
the
res
the
crisis
response
account
has
been
developed
and
the
regulations
to
establish
the
fee
are
underway
and
we
are
hoping
to
get
those
approved
through
the
board
of
health.
Sometime
this
spring.
M
The
second
portion
of
the
legislation
has
to
do
with
the
fund
for
resilient
nevada.
So
this
is
the
opioid
settlement
litigation
funding
that
is
coming
into
the
state.
One
important
point
to
make
is
that
these
are
only
the
funds
that
the
state
will
be
receiving
and
not
the
funds
that
will
be
allocated
through
what
is
called
the
one
nevada
agreement
to
counties
and
cities.
M
The
one
nevada
agreement
was
a
negotiated
agreement
through
the
attorney
general's
office
with
cities
and
counties
across
the
state
who
are
also
engaged
in
their
own
opioid
litigation,
recognizing
that
large
settlements
may
come
to
the
state
and
then
need
to
be
allocated
appropriately.
According
to
this
negotiated
agreement,
two
cities
and
counties
that
are
also
participating
in
that
litigation.
With
the
remainder
of
those
funds,
then
approximately
43
of
those
funds
going
into
the
fund
for
resilient
nevada.
So
the
fund
for
resilient
nevada
has
been
established.
M
Those
funds
are
being
used
currently
to
support
the
development
of
the
state's
needs
assessment.
That
needs
assessment
is
a
critical
component
of
us
being
able
to
understand
what
the
needs
of
the
state
are
and
then
how
that
will
then
inform
the
state
plan.
The
state
plan
will
be
used
to
help
to
allocate
funding
to
specific
activities
within
the
state
and
then
around
july
we
anticipate
having
those
dollars
ready
for
distribution
for
the
priorities
that
are
identified
in
the
state
plan.
M
We
also
are
required,
through
sb
390,
to
establish
the
advisory
committee
for
resilient
nevada.
This
committee
was
established
through
appointments
from
the
attorney
general's
office,
the
director
of
the
department
of
health
and
human
services,
as
well
as
the
nevada
office
of
minority
health
and
equity.
M
The
representatives
on
the
committee
have
been
meeting
since
october
and
they've
been
meeting
monthly,
so
they
have
been
helping
to
shape
and
inform
the
conduction
of
the
state's
needs
assessment
and
we're
anticipating
that
that
needs
assessment
should
be
completed
within
the
next
month
or
so
and
so
chair
I'll
leave
it
open
for
questions.
If
anybody
has
any
questions
about
senate
bill
390
and
where
we
are
related
to
implementation,.
A
I'm
not
seeing
any
pop
up,
so
I
think
we're
ready.
I
know
that
I'm
getting
a
little
hungry
and
a
little
stir
crazy.
So
I
think
we're
gonna
go
ahead
and
move
on
to
the
next
item,
which
is,
I
believe,
presented
by
you.
Dr
woodard
item
number,
nine
sequential
intercept
model
intersection
between
criminal
justice
and
behavioral
health,
which
is
a
nice
time.
Some
of
the
discussion
that
we've
been
having
previously,
please
feel
free
to
go
to
start
when
you
are
ready.
A
I'm
gonna
take
one
second
to
stand
up
and
do
a
little
shakeout
of
my
lower
back,
while
you're
getting
ready.
M
Proceed:
okay,
great,
thank
you.
So
the
next
presentation,
really,
I
think,
is
a
in
large
part,
a
continuation
of
some
of
the
discussion
that
we've
recently
had
around
medication,
assisted
treatment
so
I'll
be
presenting
on
the
sequential
intercept
model
in
the
intersection
between
criminal
justice
and
behavioral
health
and
again
stephanie
woodard.
M
This
model
can
also
be
applied
to
mental
health
conditions,
but
for
the
purposes
of
the
meeting
today,
I
will
be
keeping
my
comments
and
my
review
of
specific
programs
solely
focused
on
substance
use
disorders,
recognizing
co-occurring
disorders
within
those
communities.
So
just
a
brief
overview
of
the
sequential
intercept
model.
We
look
at
it
as
a
continuum
with
intercept
zero,
actually
being
community
services,
including
crisis
continuum,
intercept
one
opportunities
pre-booking
for
individuals
to
be
diverted
or
deflected
away
from
the
criminal
justice
system
and
into
treatment.
M
M
Intercept
three
are
for
those
individuals
who
are
formally
incarcerated,
be
it
in
a
jail
or
a
prison,
as
well
as
individuals
who
are
sentenced
to
specialty
courts,
intercept
four
focuses
on
re-entry,
so
as
individuals
are
exiting
jail
or
prison,
and
what
services
and
supports,
as
well
as
those
warm
handoffs,
are
really
essential
in
ensuring
continuity
of
care
and
then
intercept
five,
which
we
consider
community
corrections
really
focused
on
the
role
of
parole
and
probation
to
support
individuals
in
the
communities
next
slide.
M
So
we
see
intercepts
as
opportunities
and
there's
been
a
an
entire
body
of
research
really
on
how
optimizing
these
intercepts
to
either
deflect
or
divert
individuals
away
from
the
criminal
justice
system
or
optimize
their
involvement
within
the
criminal
justice
system
to
support
their
engagement
in
treatment
and
recovery
support
services
in
some
of
the
results
or
outcomes
that
have
come
from
that.
What
we
have
found
through
a
lot
of
that
research
is
that
it
reduces
ongoing
substance
use
as
well
as
reduces
recidivism
and
an
unnecessary
incarceration.
M
It
does
end
up
ultimately
reducing
the
risk
to
public
safety,
because
it
helps
individuals
get
into
the
treatment
and
connect
with
recovery
supports
that
they
need.
It
reduces
overall
costs
of
incarceration.
It
can
be
used
to
address
racial
disparities,
especially
those
that
result
in
over-incarceration
of
individuals
from
racial
and
ethnic
minority
groups.
M
An
important
part
of
legislation
that
has
been
passed
ab236-
I
don't
know
how
many
of
you
are
familiar
with
it,
but
av-236
was
passed
in
the
80th
legislative
session
back
in
2019
and
made
significant
changes
related
to
the
eligibility
for,
and
programs
available
to
individuals
in
the
criminal
justice
system,
with
either
serious
mental
illness
or
a
substance
use
disorder.
M
This
bill
actually
fundamentally
changed
the
way
that
behavioral
health
services
can
be
utilized
not
only
for
those
who
are
incarcerated,
but
also
for
the
purposes
of
jail
diversion.
So
there
has
been
quite
a
bit
of
work.
That's
been
done
within
nevada
to
support
the
sequential
intercept
model
recognizing
that
individuals
with
substance
use
disorders
and
mental
health
conditions
who
have
high
treatment
needs
really
do
benefit
from
being
engaged
in
care
versus
being
incarcerated.
Next
slide.
M
So
ab236,
as
well
as
the
sequential
intercept
model,
can
take
what
we
call
the
risk
needs
responsivity
model
into
consideration.
M
So
when
we
talk
about
diversion
or
deflection
from
the
criminal
justice
system
for
individuals
with
behavioral
health
conditions,
we
also
want
to
make
sure
that
we
can
uphold
public
safety
and
identify
what
the
treatment
needs
are,
so
that
we
can
provide
what
we
would
consider
adequate
dosages
of
treatment
for
the
individual.
M
So
there
has
been
a
model
that
has
been
developed
and
it's
been
implemented
in
nevada
for
the
last
several
years
and
it
is
called
the
risk
needs
and
responsibility
model
when
we
apply
this
model.
What
we
do
is
we
look
at
the
risk
or
likelihood
that
the
individual
may
reoffend
and
try
to
identify
basically
the
the
propensity
for
criminogenic
behavior,
so
this
falls
into
a
category
of
low,
medium
or
high
and
believe
it
or
not,
individuals
who
are
in
drug
court.
M
We
actually
see
the
greatest
return
on
investment
when
we
identify
individuals
who
have
both
a
high
need
for
treatment,
as
well
as
a
high
risk
for
recidivism.
So
those
courts
really
do
well
when
they
can
identify
that
population
and
serve
that
population
within
drug
court.
So
risk
is
really
focusing
on
the
potential
risk
for
recidivism
or
to
reoffend
need.
A
Yes,
I
apologize
we're
having
some
technical
difficulties
on
our
youtube
to
the
public.
The
public
side
of
our
presentation
on
seeing
your
presentation.
Would
you
mind
restarting
it
for
us,
see
that
fixes
it
not
at
all.
Sorry,
thank
you.
A
N
A
M
No,
I
think
from
everywhere
was
fine,
okay,
so
kendall,
if
you
wouldn't
mind
moving,
I
think
just
another
slide
or
two
the
next
slide.
Oh
one
back,
sorry,
thank
you.
Okay,
so
again,
brief
overview
of
the
risk
meets
responsivity
model.
We
helped
you.
We
use
this
model
to
help.
M
You
identify
risk
for
recidivism
or
the
propensity
to
reoffend,
as
well
as
an
individual's
actual
needs
and
how
those
needs
might
be
best
met
as
it
relates
to
treatment
and
then
responsivity
and
responsivity
is
considered
all
of
the
different
factors
that
can
contribute
to
an
individual
being
able
to
really
benefit
from
treatment
and
interventions,
and
this
includes
their
needs,
motivations
as
well
as
learning
styles,
but
other
variables
can
also
be
considered
so
variables,
such
as
learning
disabilities,
language
and
the
ability
to
access
treatment
in
the
language
of
preference.
M
So
intercept
zero
is
really
community
services
and
we
differentiate
between
deflection
and
diversion
by
essentially
saying
that
deflection
can
occur
when
there
is
no
there's
no
offense
that
has
occurred
so
there's
no
sort
of
like
putting
charges
or
arrest
aside.
We
really
want
to
make
sure
that
individuals
can
benefit
from
deflection
prior
to
having
a
risk
for
interfacing
with
the
criminal
justice
system.
So
this
intercept
zero,
optimizes
community
crisis
services.
M
Examples
of
deflection
services
in
nevada
include
crisis
call
centers,
so
911
as
well
as
98
or
our
national
suicide
prevention
lifeline.
The
entire
continuum
of
services,
as
it
relates
to
crisis
care,
our
crisis
response
teams
and
down
in
las
vegas.
We
have
a
crisis
response
team,
which
is
a
co-responder
model
with
behavioral
health
and
ems
mobile
crisis
teams
and
mobile
outreach
safety
teams,
crisis
intervention
training
for
law
enforcement.
M
This
also
includes
harm
reduction
strategies,
so
overdose
education
and
naloxone
leave
behind
programs.
We
have
a
leave
behind
program
in
washoe
county
in
their
sheriff's
office.
So
when
law
enforcement
is
in
the
community
on
the
streets
and
they
encounter
individuals
that
may
be
at
risk
because
of
opioid
use,
they
can
actually
provide
overdose
education
and
leave
behind
naloxone
for
them.
M
It
also
includes
homeless,
outreach
teams,
as
well
as
what
is
yet
to
be
launched,
but
is
part
of
av-236,
which
is
considered
the
behavioral
health
field
response
grant,
which
would
provide
funding
to
co-responder
models
with
law
enforcement
and
behavioral
health
corresponding
to
individuals
in
the
community
and
that
are
experiencing
crisis
next
slide.
M
M
So
the
vision
of
the
crisis
response
system
in
98
will
serve
as
the
foundation
of
nevada's
behavioral
health
safety
net.
We
will
reduce
behavioral
health
crises,
strive
to
attain
zero
suicides
in
our
state
and
provide
a
pathway
to
recovery
and
well-being,
and
then
you
can
also
see
the
mission
on
the
slide
as
well.
Next
slide.
M
M
We
anticipate
that
by
year,
three
of
implementing
988,
we
will
have
upwards
of
99
000
individuals
within
nevada,
potentially
contacting
the
crisis
call
center
through
988
to
be
able
to
access
someone
on
the
other
line
to
help
to
address
their
issues.
M
We
also
know
from
our
own
data
as
well
as
that
nationally,
that
approximately
80
to
90
percent
of
individuals
who
call
a
crisis
line
are
able
to
have
their
issues
resolved
to
a
point
where
they
may
not
need
immediate
follow-up,
but
that
crisis
call
center
could
also
connect
them
to
follow-up
care
for
the
percentage
of
individuals
that
do
need
immediate
assistance.
M
We
have
mobile
crisis
teams,
so
this
is
someone
to
respond
mobile
crisis
teams
go
into
the
community
and
respond
to
an
individual
where
they
at
where
they
are
at
to
address
the
crisis
that
they
are
experiencing
and
then
also
ensuring
that
we
have
crisis
receiving
and
stabilization
centers.
There
has
been
legislation
that
nevada
legislative.
M
The
nevada
legislature
has
passed
the
last
two
sessions
in
2019
and
in
2021
to
establish
prices
stabilization
center
statewide,
and
this
offers
a
warm
and
welcoming
environment
for
individuals
who
are
experiencing
crisis
with
a
short,
more
observational,
less
than
24-hour
stay.
M
M
So
988
is
going
live,
as
I
mentioned
july
16th
of
2022,
and
we
are
working
currently
with
our
psaps,
so
our
primary
and
secondary
911
dispatch
lines
to
make
sure
that
we
have
connectivity
at
the
very
least,
a
pretty
low
tech
way
for
calls
to
be
transferred
between
911
and
988,
depending
on
the
severity
of
the
needs
of
those
calls
next
slide.
M
988
is
the
foundation
for
crisis
care,
and
we
recognize
that
when
it
comes
to
a
community
response,
law
enforcement
will
still
have
the
ability
to
deploy
within
the
community
as
the
call
comes
into
9-1-1,
and
then
there
is
also
the
need
for
a
differential
response
for
calls
that
are
coming
into
98,
but
recognizing
that
it's
more
than
just
the
call
center.
M
It's
also
having
individuals
to
to
go
into
the
community
to
work
with
individuals
where
they
are
on
the
crisis
of
crisis
that
they're
presenting
with,
as
well
as
having
crisis
facilities
as
an
alternative
door
to
emergency
rooms
and
jails,
so
that
individuals
who
are
in
crisis
can
be
diverted
from
jails
and
into
crisis.
Centers
next
slide.
M
So
those
crisis
response
partnerships
include
9-1-1
about
10
to
20
10
to
15
percent
of
calls
to
9-1-1
nationally
are
really
estimated
to
be
more
crisis
or
mental
health
related.
So
we're
recognizing
that
not
only
will
the
calls
for
988
continue
through
the
national
suicide
prevention
lifeline,
but
there
are
a
portion
of
that
10
to
15
percent
of
9-1-1
calls
that
also
could
success
could
successfully
be
diverted
over
to
9-8-8
98.
M
M
Some
deflection
programs
that
are
discussed
in
av-236
include
law
enforcement
officer
training
to
ensure
that
law
enforcement
officers
have
access
to
things
like
crisis
intervention
training,
as
well
as
how
to
identify
individuals
in
a
behavioral
health
crisis
and
how
to
adequately
intervene.
M
M
These
examples
in
nevada
include
the
law
enforcement
intervention
and
mental
health
addiction
program
in
clark,
county
again,
mobile
crisis
teams,
mobile
outreach,
safety
teams,
crisis
response
teams,
also
civil
protective
custody
and
protective
custody
for
individuals
who
are
under
the
influence
of
either
alcohol
or
controlled
substances,
crisis
stabilization,
centers
prices,
triage
centers
and
then
again,
the
behavioral
health
field
response
grant
next
slide.
M
This
is
just
a
snapshot
of
our
mobile
outreach
safety
teams
and
the
number
of
individuals
that
they're
interfacing
with
on
a
monthly
basis.
This
is
a
snapshot
out
of
our
behavioral
health
chart
pack,
which
is
generated
out
of
the
department
of
health
and
human
services
office
of
analytics.
These
are
available
online
to
the
public
as
a
public-facing
link
on
the
office
of
analytics,
and
what
you
can
see
here
is
that
we
have
mobile
outreach
safety
teams
that
are
interfacing
with
individuals
across
regions
in
our
state,
including
clark
and
washoe
counties
and
our
rural
regions.
M
One
example
of
a
diversion
in
our
communities
is
the
law
enforcement
in
intervention
and
mental
health
and
addiction
program
called
lima.
Lima
is
a
partnership
between
clark,
county
8th
judicial
district
and
las
vegas
metropolitan
police
department,
funded
by
the
division
of
public
and
behavioral
health,
and
essentially,
what
is
happening
is
law.
M
Enforcement
is
now
empowered
in
las
vegas
metro
when
they
are
on
the
street
encountering
individuals
in
the
community
that
they
can
divert
them
into
treatment
instead
of
arresting
them
and
the
services
that
are
provided
through
this
program
include
withdrawal
management
treatment
services
really
across
the
acm
continuum
collaborative
case
management,
weekly
meetings
with
their
case
manager,
connection
to
transitional
housing
and
or
permanent
housing,
as
well
as
assistance
in
securing
vital
documents
and
assisting
with
a
positive
support
system,
including
peer
supports,
and
the
programs
that
are
utilized
by
the
lima
program,
are
all
sapta
certified.
M
Next
next
slide
intercept
2
can
occur
during
initial
detention
or
through
court
hearings,
and
this
helps
when
they
identify
individuals
that
are
coming
into
jails
that
have
a
higher
need
for
treatment
really
than
a
risk
for
recidivism
and
a
threat
to
community
and
public
safety.
There
are
opportunities
again
to
divert
out
of
the
programs
and
into
treatment,
and
these
include
our
forensic
assessment
services
and
triage
teams,
also
known
as
fast
teams
pre-trial
community
supervision.
M
So
a
more
detailed
example
of
the
forensic
assessment
services
triage
teams,
we
have
fast
programs
in
jails
in
douglas
lion.
Churchill
counties
as
well
as
carson
city,
and
these
are
partnerships
between
local
jails
and
community
behavioral
health
providers,
again
funded
through
the
division
of
public
and
behavioral
health.
These
participants
are
referred
to
services
based
on
their
needs,
and
the
services
can
include
substance,
abuse
and
mental
health
treatment,
collaborative
case
management
and
then
a
connection
to
temporary
or
transitional
housing
as
they're
re-entering
into
the
communities
next
slide.
M
Intercept
three
court
or
jail-based
care,
so
this
happens
after
the
individual
has
been
booked
into
jail.
These
programs
can
also
divert
individuals
into
community-based
services
through
jail-based
assessments
and
follow-up
for
those
warm
hand-offs
and
of
community,
as
well
as
through
court
processes
and
programs.
Examples
of
these
include
jail-based
withdrawal
management
programs,
opioid
treatment,
programs
and
affiliations.
So
I
had
mentioned
earlier.
Washoe
county
detention
center
has
started
their
own
opioid
treatment
program,
but
there
are
other
jails
that
are
actually
having
opioid
treatment.
M
Programs
in
the
community
push
in
services
into
the
jails
to
ensure
that
individuals
have
access
to
treatment
for
opioid
use
disorders,
while
incarcerated
jails
are
also
doing
a
lot
as
it
relates
to
behavioral
health
treatment
programming
and
ensuring
that
programming
is
available.
While
individuals
are
incarcerated,
medication
management,
including
medication
management
for
psychiatric
issues
and
then
the
utilization
of
specialty
courts,
including
mhe,
specific
specialty
courts,
drug
court,
youth
offender
courts
and
family
drug
courts,
as
well
as
veterans
courts.
Next
slide.
M
So,
as
I
mentioned
before,
I'll
just
touch
on
very
briefly:
washer
county
detention
center
did
start
an
opioid
treatment
program.
So
through
this
program,
individuals
as
they're
coming
into
the
jail
are
screened
for
opioid
use
and
risk
for
withdrawal
to
determine
if
they
may
have
an
opioid
use
disorder.
M
Medication,
assisted
treatment
can
be
initiated
for
withdrawal,
symptoms
and
medication.
Maintenance
is
also
provided
as
a
course
of
treatment,
and
then
there
is
a
bridge
to
the
community
for
that.
Warm
handoff
for
referrals,
for
continuity
of
care,
for
maintenance
treatment
and
recovery
support
services
next
slide
intercept
four
is
re-entry,
so,
as
individuals
are
re-entering
into
the
community
following
incarceration,
either
through
jail
or
prison.
This
involves
the
linkage
and
referral
to
community-based
services
and
supports.
M
M
So
an
example
is
the
eighth
judicial
district
re-entry
court.
So
this
is
a
partnership
between
the
department
of
corrections,
eighth
judicial
district,
as
well
as
some
grant
funding.
They
have
developed
a
re-entry
court
to
reduce
the
occurrences
of
an
overdose
and
relapse,
as
individuals
are
re-entering
into
the
community
following
released
from
prison.
So
this
is
actually
a
collaborative
program
that
started
as
the
court
system
was
noticing.
M
A
large
number
of
individuals,
reentering
after
incarceration
through
our
department
of
corrections,
were
relapsing
very
quickly,
most
often
before
they
were
able
to
actually
engage
with
parole
and
it
was
creating
a
lot
of
issues
not
the
least
of
which
is
there
were
several
overdose
deaths
as
a
result
of
the
relapse
that
was
occurring
post
re-entry.
M
So
we
got
together
and
they
have
developed
this
wonderful
reentry
court
they're
having
some
amazing
success
and
individuals
who
are
involved
in
the
court
have
access
to
medication,
assisted
treatment,
as
well
as
an
array
of
treatment,
services,
collaborative
care
management,
connection
to
housing,
again,
assistance
with
securing
vital
documents
and
assistance
with
establishing
a
positive
support
system,
including
peers.
M
And
finally
intercept
five
community
corrections,
so
community
corrections
programs
help
to
integrate
criminal
justice
supervision
through
parole
and
probation
with
additional
treatment
and
recovery
services.
The
goal
of
these
programs
is
to
support
re-entry
into
the
community
and
reduce
risk
for
recidivism
next
slide.
M
Assembly
bill
236
actually
did
a
lot
of
work
on
the
portions
of
re-entry,
so
several
provisions
regard
parole
and
probation
and
those
include
training
requirements
for
individuals
in
parole
and
probation
on
evidence-based
practices,
requirements
for
the
petition
of
early
discharge
of
a
person
who
is
on
parole
requirements
for
reentry
programming
and
coordination
with
state
agencies,
starting
before
the
individual
is
moving
into
the
community
so
that
adequate
time
can
be
allocated
to
ensuring
that
we've
got
a
warm
handoff,
but
also
ensuring
that
the
consumption
of
alcohol
or
a
positive
drug
test
cannot
be
the
sole
reason
for
revocation
of
supervision.
M
We
had
many
individuals
that
we
had
seen
being
remanded
back
to
prison
because
there
was
a
relapse
and
under
eb
236.
Now
it's
really
seen
as
a
relapse
as
an
opportunity
to
re-engage
that
individual
into
treatment
planning
and
an
opportunity
to
sort
of
re-evaluate
what
might
be
needed.
That
was
missing
before
to
help
that
individual
continue
on
their
recovery.
Trajectory
next
slide.
M
The
sequential
intercept
model
offers
many
different
pathways
to
treatment,
and
this
really
includes
sort
of
the
the
collaboration
between
law
enforcement
and
the
criminal
justice
system,
as
well
as
the
treatment
system
and
really
the
the
way
that
these
systems
can
work
best
together
is
recognizing
when
an
individual
has
a
behavioral
health
condition
that
could
benefit
so
ensuring
that
there's
identification,
screening
and
assessment,
but
also
referral
and
placement
into
treatment
that
there's
continuous
monitoring
and
reporting
of
those
programs
that
are
working
in
conjunction
with
the
criminal
justice
system,
to
provide
treatment
and
recovery
services
and
to
ensure
that
recovery
supports
are
available
to
those
who
need
them,
and
this
is
done
really
through
systems,
communication,
collaboration
and
case
management,
next
slide,
and
so
with
that
chair
peters.
A
Of
impeccable
timing,
I
have
my
timer
up
and
there's
one
minute
and
20
seconds
left.
Is
that
30
minute
period?
Are
there
questions
from
the
committee
that
they
would
like
to
ask.
A
I
don't
believe
I'm
seeing
any
he
did
lose
a
couple
folks,
I
think,
to
some
other
appointments,
but
we
will
reach
out
to
you,
dr
woodard,
if
you
have
other
questions
that
come
up
on
this
particular
issue
area.
Thank
you
so
much
for
your
time
and
effort
in
this.
We
really
appreciate
you
being
here
with
us
and
your
expertise
in
this
area.
A
You'll
appreciate
it
we're
gonna
go
ahead
and
move
into
a
lunch
break.
It
will
not
be
a
glorious
lunch
break.
Just
a
brief
lunch
break
of
about
15
minutes
get
us
back,
so
we
can
get
through
the
rest
of
our
agenda
items
for
the
day
we
have,
I
think,
three
agenda
items
plus
public
comment
and
closing
for
when
we
get
back
from
lunch.
A
So
at
this
point,
if
we
give
about
15
minutes,
we'll
come
back
around
105.,
so
please
be
back
in
your
chairs
camera's
on
105,
we'll
get
started
for
the
next
little
bit
of
the
agenda
thanks.
So
much
guys.
L
C
A
Fantastic,
thank
you
guys
so
much.
I
know
that
was
brief.
I
hope
everybody
got
some
sustenance
in
you
just
through
the
next
little
bit
of
this
important
issues
coming
up.
I
feel
like,
after
an
interlude
when
we
last
left
our
harrowing
committee,
we're
gonna
move
into
item
number
eleven.
This
is
an
overview
of
strategies
to
reduce
the
harm
caused
by
substance
use.
There
are
quite
a
few
presenters
on
this
list,
I'm
going
to
let
you
go
ahead
and
get
started.
Please
proceed
when
you
are
ready.
A
We
have
lisa
lee
on
right
now.
Yes,
I
see
her
logged
in
at
least.
N
Terrific
good
afternoon,
chair
peter,
is
in
the
committee.
Oh,
I
just
saw
them
pop
away.
Lisa
are
you
able
to
reshare?
Okay,
we
just
lost.
A
N
Good
afternoon
my
name
is
jessica
johnson,
I'm
here
from
the
southern
nevada
health
district,
a
senior
health
educator
there,
I'm
the
first
in
the
series
of
presenters
today
on
harm
reduction
options,
so
I
will
be
providing
an
overview
and
definitions
next
slide.
Please.
N
Earlier
today,
you
heard
some
sobering
statistics
from
our
colleagues
collecting
and
analyzing
data.
A
brief
reminder
on
screen
of
the
sobering
story,
we're
seeing
here
in
clark,
county
reflected
statewide
as
a
country
and
as
a
state
we're
painfully
aware
of
the
magnitude
and
cost
of
substance
use
and
associated
harms
to
our
citizens
and
our
society.
N
These
are
our
family
members,
our
friends-
and
this
is
us
in
desperate
times
such
as
these.
It's
imperative
that
we
cast
aside
old
thinking,
acknowledge
underlying
stigmas
and
really
look
to
commit
ourselves
to
public
health,
oriented
all
evidence-based
strategies
forward
approach.
This
is
an
opportunity.
A
Q
A
How
about
you
go
ahead
and
if
we
get
her
back,
maybe
we
can
swap
out
again.
But
yes,
let's
just
keep
going.
If
we
can.
Q
Okay,
so
I
actually
have
let
me
just
catch
up
here,
so
I
think
what
jessica
was
saying
was
that
in
this
moment
we
have
an
opportunity
to
hear
from
people
engaged
in
the
boots
on
the
ground,
work
that
is
saving
lives
of
people
in
nevada
and
across
the
country
who
use
drugs.
Q
It
has
a
long
history
in
this
country
long
before
it
became
a
popular
term
that
came
into
popular
vernacular
over
the
next
few
slides
we're
going
to
take
the
opportunity
to
kind
of
share
some
or
get
everybody
on
the
same
page
about
what
we
mean
when
we
say
harm
reduction,
and
then
we
have
several
of
us
on
the
panel
they're
going
to
talk
about
specific
aspects
of
harm
reduction
programming
and
what
opportunities
we
have
next
slide
please
so
harm
reduction
is
a
term
that
is,
is
used
in
many
ways,
but
just
to
get
everybody
sort
of
connected
in
terms
of
what
we're
talking
about.
Q
Today,
we
are
talking
about
a
spectrum
or
a
continuum
of
strategies.
Practical
strategies
to
reduce
the
harms
associated
with
substance
use,
harm
reduction,
happens
on
a
continuum
from
safer
drug
use,
techniques
to
reducing
or
managing
use,
all
the
way
to
abstinence
or
stopping
using
drugs
for
some
people.
But
it's
really
focused
on
promoting
the
dignity
and
well-being
of
people
who
use
drugs.
Q
It
is
more
than
a
set
of
practical
strategies,
though
it
is
a
framework
for
grassroots
and
social
activism.
It
is
a
movement
to
understand
structural
inequalities
and
we
focus
in
harm
reduction
on
upstream
determinants
of
health.
Things
like
poverty,
racism,
homophobia
and
classism
that
drive
health-related
outcomes
among
people
who
use
drugs
a
common
way
of
talking
about
harm
reduction.
Is
we
say
that
harm
reduction
promotes
low
threshold
services
and
it
is
a
way
to
meet
people
where
they're
at,
and
we
mean
that,
both
literally
and
figuratively?
Q
That
means
things
like
meeting
where
people
where
people,
where
they're
at
in
the
community
taking
services
to
them-
and
it
also
means
meeting
people
where
they're
at
in
terms
of
where
they're
at
in
their
drug
use
and
their
life
and
working
with
people
to
engender
the
kind
of
change
that
they
value
and
that
they
can
see
as
reasonable
next
steps
for
themselves.
Not
imposing
change
on
people
and
there's
a
link
here,
and
I
believe
you
have
these
slides.
Q
Q
So
there
are
six
principles
that
form
the
foundation
of
what
it
means
to
do:
harm
reduction
work.
There
is
intentionally
no
gold
standard
for
harm
reduction
programs,
they're,
usually
grounded
in
a
by
the
community.
For
the
community
approach
we
often
say
that
harm
reduction
work
is
work
that
is
done
mostly
by
people
who
use
drugs
for
people
who
use
drugs,
but
the
six
principles
that
undergird
the
work
that
we
do
are
health
and
dignity.
Acknowledging
that
drug
use
is
complex
and
exists
on
a
spectrum
of
use
and
safety.
Q
We
address
sociocultural
factors
recognizing
the
realities
of
various
systems
and
structures
and
systems
of
social
inequality,
affect
both
people's
vulnerability
and
capacity
to
to
use
drugs
and
to
reduce
drug
related
harms
and
harm
reduction
is
founded
on
principles
of
pragmatism
and
realism.
Q
N
N
Thank
you,
excellent
coverage
of
the
principles
next
slide.
Please.
N
N
These
include
the
prevention
of
blood,
borne
infections,
stopping
overdose
and
often
reducing
substance
use
for
those
engaged
in
syringe
services,
programs,
support
of
public
safety,
particularly
through
the
reduction
of
the
presence
of
discarded
syringes
in
the
community
and
needle
stick
injuries
among
first
responders
cost
effective
interventions,
so
reducing
health
care
costs
such
as
preventing
hiv
viral
hepatitis,
endocarditis
and
other
infections,
and
stigma
reduction
really
providing
an
affirming
space
to
combat
stigma.
N
N
N
Stigma
impacts
an
individual's
ability
to
participate
in
the
various
systems,
social,
economic,
health
care
access,
etc,
which
further
erodes
someone's
self-worth,
creating
social
isolation,
reducing
access
to
care
and
exacerbating
the
issue
and
increasing
risk
of
overdose
death.
The
statistics
on
this
slide
are
from
a
national
survey
conducted
by
shadow
proof
in
the
heartburn
and
demonstrates
the
pervasive
stigma,
and
that
continues.
N
This
is
among
public
and
among
health
care
professionals
when
looking
towards
improve
the
efficacy
of
harm
reduction
next
line
so
a
way
forward
as
a
state,
we
must
continue
to
come
together
around
meaningful
solutions,
including
the
treatment
recovery,
supports
and
harm
reduction,
to
end
the
overdose
epidemic
and
save
the
lives
of
nevadans.
Thank
you.
N
A
K
You
thank
you
for
having
me
today,
so
my
name
is
michelle
berry.
I
am
a
senior
project
manager
for
the
state
opioid
response
grant.
I
am
housed
at
cassatt,
which
is
in
the
school
of
public
and
behavior.
You
know
the
school
of
public
health
at
the
university
of
nevada
reno,
so
we
manage
the
state
opioid
response
grant
on
behalf
of
the
division
of
public
and
behavioral
health.
K
The
program
aims
to
address
the
opioid
crisis
by
increasing
access
to
medication,
assisted
treatment
for
our
opioid
use
disorder,
reducing
the
unmet
treatment
need
and
reduce
opioid
overdose,
related
deaths
through
prevention,
treatment
and
recovery
efforts,
and
so
we
look
at
implementing
prevention,
treatment
and
recovery
support
services
that
also
are
aimed
towards
stimulant
use
and
misuse,
and
it
includes
cocaine
and
methamphetamine
for
the
purposes
of
the
presentation
today,
I'll
be
going
over
our
overdose
education
and
naloxone
distribution
efforts
next
slide,
please
so
soar
does
cover
all
of
the
target
areas
that
were
identified
in
2016
that
were
priority
areas
for
nevada,
so
prescriber
education
and
guidelines,
treatment
options
and
third-party
payers,
criminal
justice
interventions
and
data
collection
and
intelligence
sharing
next
slide.
K
All
of
those
priority
areas
are
highlighted
through
these
eight
major
goals
of
soar,
and
I
think
that
we've
heard
a
little
bit
about
the
state,
opioid
response
grant
and
the
state
opioid
response
grant.
So
these
are
the
three
different
time
frames
and
the
dollar
amounts
that
have
been
awarded
to
the
state
for
the
reduction
in
opioid
use.
So
we
did
start
this
initiative
in
2017..
K
next
slide.
Please
so
dr
water
did
go
over
earlier
today
about
the
development
of
a
hub
and
spoke
model
and
what
that
looks
like
for
service
delivery.
That's
what
we
tried
to
really
focus
on
and
develop
during
the
state
targeted
response
years
and
then,
when
we
moved
forward
to
the
state
opioid
response,
the
additional
provision
of
getting
organizations
ready
to
provide
medication,
assisted
treatment
in
outpatient
settings
and
then
now
in
sore,
two
we've
encompassed
immune
use,
disorder
and
expanded
focus
to
funding
residential
transitional
living
and
withdrawal
management
services.
K
So
to
date,
actually
to
september
2021.
K
We
have
assembled
and
distributed
23
139
doses
of
naloxone
21,
thirty
kids
and
we've
had
one
thousand
three
hundred
ninety
one
three
hundred
ninety
one
reversals
reported
and
then
two
law
enforcement
and
first
responder
agencies,
we've
distributed
six
thousand
eight
hundred
and
seventy
one.
So
I
do
have
it
broken
up,
because
one
of
the
questions
from
this
morning
was
to
whom
these
kids
went
to.
So
I
do
have
some
numbers:
do
you
just
want
me
to
submit
that
or
talk
about
it
now.
A
K
Recipients
are
individuals
who
use
drugs,
clients
and
substance,
use
disorder,
treatment,
first
responders
and
community
community
distribution.
So
I
can
I'll
just
provide
the
numbers
instead
of
rattling
them
off.
Today
we
do
have
a
virtual
dispensary
that
outlines
where
the
sites
are
for
individuals
who
are
seeking
naloxone,
that's
real
time
and
can
be
found
on
the
website,
the
envy
opioidresponse.org.
K
So
next
I
slide
and
then
jessica
can
jump
in
and
speak
to
the
clark
county
overdose
plan
for
the
distribution
fentanyl
test
strips,
but
for
soar.
We
are
looking
at
distribution
going,
live
in
march
of
2020,
targeting
harm
reduction
organizations
and
needle
exchange
programs
for
the
distribution
of
the
fentanyl
test
strips
and
then,
after
that,
organizations
that
engage
in
street
outreach
and
work
directly
with
high-risk
populations,
followed
up
by
law
enforcement
and
first
responders,
and
then
our
existing
naloxone
distribution
sites.
That
will
also
be
distributing
the
fentanyl
test
strips
within
the
naloxone
kits
jessica.
N
I'd
be
happy
to
thanks
michelle
clark,
county's
overdose
data
to
action,
grant
received
permission
from
the
centers
for
disease
control
and
prevention
to
utilize
dollars
for
fentanyl
test
drip
distribution.
N
We
have
developed
a
training
for
community
partners
distributing
test
strips
to
date.
32
people
from
six
agencies
have
completed
the
training
process
since
the
launch
in
december
of
2021
snhd
has
four
certified
local
distribution
sites
throughout
the
county
and
approximately
2
400
strips
are
out
at
these
distribution
sites
for
clients
to
receive
training
and
pick
up.
Thank
you.
K
Great
thanks
jessica,
and
then
this
this
is
close
to
the
end
of
the
presentation,
but
I
did
also
want
to
mention
that
the
state
opioid
response
grant
does
also
look
at
other
harm
reduction
efforts
through
our
media
campaigns
that
have
that
has
looked
at
stigma,
reduction
and
naloxone
and
trying
to
normalize
the
use
of
naloxone
zero
suicide
efforts
that
dr
woodard
spoke
briefly
about
earlier.
Screening
and
brief
intervention
and
referral
to
treatment
and
then
working
with
organizations
for
neonatal
abstinence
syndrome
focus
projects.
So
that
concludes
my
part
of
the
presentation.
A
Thank
you
so
much
looks
like
we
have
dr
herrera,
I'm.
So
sorry,
if
I
didn't
say
that
correctly,
I'm
not
seeing
her
pop
up
here.
A
A
You're
comfortable
with
that,
that's
fine
or
we
could,
and
if
that
is
how
your
presentation
needs
to
go,
that's
fine
or
we
can
wait
and
come
back
to
this.
Q
Ahead:
okay,
so
christina
works
at
track
b
exchange,
which
is
one
of
the
two
brick
and
mortar,
syringe
exchange
or
syringe
service
programs
that
we
have
in
nevada,
and
so
these
next
few
slides
are
describing
some
of
their
efforts
and
jessica
johnson
may
want
to
jump
in
here
at
several
points,
just
to
kind
of
flesh
out
the
the
robustness
of
the
harm
reduction
services
that
track
b
is
offering
in
southern
nevada,
but
so
syringe
service
programs.
Q
Next
slide,
please
are
one
of
the
foundational
strategies
that
we
employ
in
a
harm
reduction
way
of
thinking
to
address
drug-related
harms.
Syringe
service
programs
provide
people
who
inject
drugs
with
sterile
injection
supplies,
which
we
know
and
have
now
30
years
of
evidence
to
demonstrate
can
reduce
the
spread
of
hiv,
hepatitis
c
and
other
blood-borne
pathogens.
Q
People
who
inject
drugs
are
also
at
risk
for
soft
tissue
infections
or
abscesses,
and
other
less
common
infections,
like
endocarditis
infections
of
the
heart
that
be,
can
be
transmitted
through
injection
with
non-sterile
equipment.
So
syringe
service
programs
ensure
that
people
have
clean
new
syringes
for
every
injection.
They
also
work
to
ensure
safe
disposal
of
used
syringes
by
giving
people
a
place
to
bring
their
used
syringes
back
to
syringe
service
program.
G
A
Thank
you.
No,
if
you
don't
mind,
jumping
back
in,
thank
you,
dr
wagner,
for
taking
that
on.
We
can
start
where
you
left
off.
Okay,
yeah.
Absolutely.
I
was.
R
So
the
last
point
there,
no,
the
second
one:
oh
okay,
sorry
yeah,
my
computer
crashed
and
I
finally
got
back
on
so
okay.
So
a
little
bit
about
strange
service
programs
and
again
my
name
is
christina
pereira.
I'm
a
health
educator
at
track
b
exchange,
which
is
the
first
syringe
service
program
in
las
vegas.
We
offer
lots
of
services
other
than
that,
though,
which
I'll
get
into
in
a
little
bit
so,
and
these
are
things
that
we
do
offer
and
and
so
do
many
other
ssps
so
naloxone,
which
you
know.
R
R
And
the
great
thing
is
that
individuals
who
go
to
these
programs
often
end
up
engaging
in
treatment
and
being
connected
with
community
resources,
simply
because
they're
around
providers
that
they
normally
wouldn't
be
around.
So
if
you're
going
to,
let's
say
walmart's
buy
your
syringes,
you're
you're
going
in
and
out
or,
however,
you
may
get
them.
If
you're
going
to
a
syringe
service
program,
there
are
counselors
there.
There's
peer
recovery,
support
specialists.
R
R
So
a
bit
about
track
b,
exchange
services:
we
are
southern
nevada's
first
and
only
syringe
exchange
opened
in
2017..
R
We
offer
syringe
exchange
and
then
safe
disposal
is
a
big
part
of
what
we
do
to
reduce
those
needle
stick:
injuries,
naloxone
medication
and
training,
fentanyl,
test
strips
hiv
and
hepatitis
c
testing
and
linkage
to
care,
and
then
I'll
talk
a
little
bit
more
in
a
minute
about
our
public
health
vending
machines.
We
have
seven
in
las
vegas
and
one
in
hawthorne,
and
we
are
the
the
first
of
the
kind
in
the
country
it's
starting
to
catch
on
in
other
places
now,
but
we
were
the
first
to
implement
these
public
health
vending
machines.
R
We
also
offer
medication,
assisted
treatment,
suboxone
supplicated,
vivitrol,
peer
recovery
support
services,
so
our
peers
all
have
at
least
two
years
of
in
recovery,
and
they
all
have
lived
experience.
I
also
do
some
of
the
peer
work,
and
so
we
help
people
with
anything
from
housing
to
getting
to
treatment,
to
getting
id's,
basically
anything
that
we
can
that
we
can
help
with
you
know
getting
them
on
the
road
to
recovery,
so
also
counseling.
R
We
have
counselors,
and
everybody
that
is
in
the
map
program
has
to
get
counseling
at
least
once
a
month,
and
then
we
expand
our
services
to
rural
nevada,
whereas
I'm
sure
we
all
know
there's
not
a
lot
out
there,
I'm
actually
one
of
the
people
that
goes
to
some
of
the
jails,
so
the
lincoln
county
detention
center
in
ph
and
help
get
people
on
matt
they're
in
the
jail
when
they
come
in
and
withdrawal
and
then
get
them
hooked
up
with
treatment.
If
that's
something
that
they're
looking
for
next
slide,
please.
R
So
this
is
some
data
from
track
b
exchange
from
2021,
so
we
put
out
728
878
syringes
and
our
return
rate
is
actually
really
fantastic.
We
took
in
570
four
for
narcan,
seven
thousand
ninety
nine
doses
and
then
we
track
when
people
come
in
for
refills.
What
did
they
do
with
it?
Did
they
lose
it?
Did
they
use
it?
Did
the
police
take
it
so
197
refills
were
due
to
use
and
of
those
197
189
of
the
overdoses
survived
two
passed
away,
and
then
six
outcomes
were
unknown.
R
R
Next
slide,
please
so
here's
a
picture
of
one
of
our
public
health
vending
machines,
they're
they're,
discreet
they're
in
we
have
them
in
methadone
clinics.
We
have
one
actually
on
the
way
in
the
washoe
jail.
So
these
are
nice
for
people.
That
might
you
know,
be
embarrassed
to
go
into
a
syringe
exchange.
They
can
go
up.
They
have
a
unique
identifier,
identifier
id
that
they
put
in
and
they
can
just
not
even
have
to
talk.
R
Anyone
go
up,
get
their
stuff
and
leave
it's
a
novel
approach
to
an
old
problem.
It
makes
it
very
convenient
for
people,
so
all
people
need
to
sign
up
is
an
id
and
then
they
can
get
access
to
any
of
our
eight
locations
across
nevada.
Seven
of
those,
like
I
said,
are
in
clark
county
one
is
in
rural
area
and
hawthorne.
R
All
the
contents
are
free
to
our
clients
and
they
include
syringes,
narcan
hygiene
kits
pregnancy,
tests,
safer
sex
materials,
sharps
containers
and
first
aid
kits
and
what's
nice
about
these
is
we
do
tailor
them
to
the
community,
so
we've
run
into
some
communities
where
we're
still
trying
to
you
know
to
get
a
machine,
and
they
say
you
know
we're
not
comfortable
with
the
syringes.
So
we
don't
have
to
have
the
syringes.
We
completely
tailor
these
to
the
community
and
to
what
they
say
that
they
need
and
that
they're
comfortable
with
next
slide.
R
R
We
don't
have
data
on
what
we
took
back
in
as
far
as
syringes,
because
next
to
each
vending
machine,
there's
just
a
large
sharps
container
and
people
just
throw
those
right
in
there.
So
that's
obviously
harder
for
us
to
track
for
naloxone.
We
gave
out
400
excuse
me,
514
kits,
which
breaks
down
to
1542
doses,
429,
safe
sex
kits,
which
breaks
down
to
2574
condoms,
773.
R
R
Okay,
something
mine's
blocked
off
for
some
reason,
and
so
that's
our
vending
machine
data
for
2021.,
and
with
that
I
will
wrap
up
my
portion
and
thank
you
so
much.
A
I
wanted
to
take
a
point
of
privilege,
real
quick
to
just
suggest
something
we
do
in
engineering
when
we're
trying
to
collect
data
on
something
that's
a
little
bit
abstract
to
collect
it's
just
using
weight
data.
So
if
you
take
the
weight
of
the
container
before
it's
put
and
it
has
anything
put
in
it
and
then
the
way
after
you
can
make
an
estimate
of
how
many
you
get.
Q
Hi,
okay,
this
begins
my
official
presentation.
My
name
is
carla
wagner.
I
am
an
associate
professor
in
the
school
of
public
health
at
the
university
of
nevada
reno.
I
am
here
not
representing
the
university,
but
speaking
about
kind
of
best
practices,
current
research
and
some
emergent
issues
in
the
field,
as
we
think
about
harm
reduction
solutions.
Q
I
have
a
large
portfolio
of
research
funded
by
the
centers
for
disease
control
and
the
national
institutes
of
health,
much
of
which
is
involved
with
many
of
the
programs
that
you've
been
hearing
about.
So
we
have
a
study
that
is
examining
the
impact
of
the
peer
recovery
support
services
that
are
offered
in
emergency
departments
as
part
of
the
state,
opioid
response
and
state
targeted
response
grant
that
michelle
berry
just
told
you
about.
Q
Q
So
I'm
going
to
share
first
a
little
bit
about
the
history
of
and
best
practices
for,
overdose,
education
and
naloxone
distribution.
Next
slide,
please,
you
may
know
that
overdose,
education
and
naloxone
distribution
has
a
very
long
history
in
the
u.s.
Q
A
new
article
that
just
came
out
in
lancet
public
health
suggests
that,
even
despite
this
long
history,
no
states
in
the
u.s
are
distributing
enough
naloxone
to
reach
the
targets
that
would
signal
an
effective
public
health
intervention.
In
this
case
they
were
modeling
naloxone
used
at
80
of
witnessed
ods.
Q
Q
But
what
the
science
is
telling
us
is
that
we're
not
getting
enough
kids
out
there
and
we're
not
getting
them
to
the
people
who
need
them
and
not
just
we
nevada.
I
mean
we
nationally
another
thing
that
I
want
to
point
out
about:
overdose,
education
and
naloxone
distribution.
It
is
an
education
and
a
comprehensive
training
program.
So
when
we
teach
people
about
overdose,
we
teach
people
how
to
recognize
and
respond
to
overdose
using
naloxone,
and
we
also
teach
them
how
to
prevent
overdose.
Q
It's
not
clear
that
those
protections
are
sufficient
and
it's
not
clear
that
people
who
are
in
the
community
trust
that
the
law
will
be
implemented
in
a
way
that
protects
them.
So
there
is
some
conflict
between
the
public
health
imperative
that
people
respond
to
overdoses
of
naloxone
and
call
9-1-1
and
the
criminal
justice
response
that
people
fear
when
they're
doing
that.
Q
We
also
encounter
funding
hiccups
depending
on
where
the
money
is
coming
from
to
buy
the
naloxone
and
then
also
pipeline
challenges
in
terms
of
getting
naloxone
into
the
right
hands,
and
what
I
want
to
highlight
there
is
that,
when
that
happens,
the
people
who
end
up
without
naloxone
are
typically
the
most
vulnerable.
So
when
we
have
supply
disruptions
or
funding
problems,
the
folks
who
are
not
getting
the
naloxone
are
those
most
vulnerable
to
the
consequences
related
to
that,
and
so
this
is
something
that
we
need
to
pay
attention
to
moving
forward.
Q
One
more
challenge,
just
based
on
things
I
was
hearing
this
morning
as
you're
all
aware:
there
are
increases
across
the
nation
in
terms
of
stimulant-related
deaths
and
deaths
related
to
the
co-involvement
of
stimulants
and
opioids
and
opioids,
including
fentanyl
naloxone.
It
can
be
effective
in
response
to
a
fentanyl-related
overdose,
but
it
often
takes
multiple
doses,
but
it
cannot
be
effective
in
response
to
a
stimulant-related
overdose.
Q
Q
I
wanted
to
spend
a
little
bit
more
time
on
this.
This
issue
of
places
where
public
health
and
criminal
justice
efforts
have
an
opportunity
to
harmonize
one
of
the
things
we
know
about
9-1-1
good
samaritan
laws
is
they
were
enacted
to
reduce
the
perceived
consequences
of
calling
9-1-1
to
seek
medical
care
for
somebody
who
was
dying
of
an
overdose,
and
they
do
that
by
providing
protection
for
things
like
possession
of
drugs
for
personal
use
or
possession
of
paraphernalia
kind
of
low
level
charges?
Q
What
we
know
from
the
last
decade
of
research
with
people
use
drugs
is
that
they
are
afraid
of
many
many
more
things
than
what
is
protected
by
the
law.
For
example,
possession
with
intent
to
distribute
is
not
protected,
people
are
afraid
of
losing
their
housing.
If
the
police
or
ambulance
shows
up
to
their
house,
people
are
afraid
of
involvement
of
child
protective
services.
Q
There's
lots
of
things
that
people
worry
about
that
serve
as
a
barrier
to
calling
for
help
that
are
not
protected
by
a
typical
good
samaritan
law,
and
one
of
the
things
that
is
emerging
in
the
field
is
this
issue
of
drug-induced
homicide
laws?
We
have
one
in
nevada,
several
other
states
have
drug-induced
homicide
laws,
and
these
laws
punish
people
for
furnishing
a
substance
that
caused
the
unintentional
death
of
the
person
who
consumed
it.
S
Good
afternoon,
everyone,
my
name,
is
lisa
lee,
I'm
a
person
in
long-term
recovery
from
opioid
use
disorder
and
a
program
specialist
for
washoe
county
human
services
agency.
Thank
you
for
your
time
and
the
opportunity
to
speak
with
you
today.
I
am
here
to
provide
information
about
overdose
and
disease
prevention
sites
and
the
background
on
the
bill
which
was
presented
last
session.
S
What
prompted
this
collection
of
data
was
that
during
naloxone
distribution
efforts,
folks
were
reporting
that
they
were
using
four
to
five
individual
naloxone
units
to
reverse
one
overdose,
and
so
this
all
happened
very
suddenly
about
last
march,
and
so
this
prompted
this
fentanyl
test
strip
pilot
in
northern
nevada
at
that
time,
so
it
was
launched
from
april
4th
through
may
16
2021
right
before
I
joined
washoe
county
human
services
agency
and
the
data
indicated
a
93
fentanyl
positivity
rate
in
heroin
and
a
67
positivity
rate
in
methamphetamine.
S
In
my
personal
life,
I've
lost
11
folks
in
the
last
12
months,
including
two
family
members,
to
either
fatal
drug
poisoning
or
drug
related
harm,
and
unfortunately,
these
personal
losses
are
reflected
in
the
most
recently
available
surveillance
data,
problematic
substance
use,
reoccurrence
abuse
and
drug
poisonings
have
definitely
been
exacerbated
during
the
pandemic,
as
you
saw
earlier,
and
I
won't
go
over
these
slides,
because
this
is
much
older
data
than
what
you've
heard
this
morning.
S
Nevada
has
experienced
an
uptick
in
fatal
drug
poisonings,
our
data
in
nevada,
near
national
trends
of
increasing
overdose
fatalities
during
the
pandemic,
during
which
an
estimated
one
hundred
thousand
hundred
306
people
died
in
the
u.s
for
the
reporting
period
from
may
2020
through
april
20
21st
and
just
to
put
the
human
perspective
back
in
it.
That's
over
a
hundred
thousand
people
that
will
no
longer
sit
with
their
friends
and
family
during
the
holidays.
S
S
However,
again
pointing
back
to
last
legislative
session,
we
still
do
not
have
overdose
prevention
sites,
and
I
just
want
to
confirm
that
when
we
say
overdose
prevention
sites,
this
is
synonymous
with,
what's
referred
to
as
a
safe
injection
facility
or
a
safe
consumption
facility
or
an
overdose
prevention
center.
S
These
are
all
synonymous
and
I've
heard
a
whole
bunch
more
different
terms
to
refer
to
the
same
thing,
but
this
is
these
are
interventions
that
are
well
supported
in
the
literature
that
go
back
many
decades,
and
some
of
the
highlights
that
research
has
found
are
the
following
outcomes
that
people
share
less.
They
share
injection
and
other
safe
injection
equipment.
S
I'm
sorry
syringe
is
another
safe
injection
equipment,
a
lot
less,
which
lowers
blood-borne
transmission
rates
like
hiv
and
hepatitis
c.
There's
a
positive
correlation
with
linking
people
to
services,
including
substance,
use
treatment
it
all.
They
also
encourage
safe,
syringe
disposal,
which
means
less
syringes
discarded
in
public
places.
S
S
S
S
During
that
time,
there
were
six
thousand
four
hundred
and
forty
overdose
reversals
with
zero
fatalities
and
for
almost
50
000
visits
to
clinical
treatments.
So
insight
has
a
supervised
consumption
space
on
the
bottom
floor.
On
the
second
floor
is
the
substance
use
treatment
facility
and
on
the
highest
floor.
The
third
floor
is
a
transitional
living.
S
S
S
S
The
sites
would
offer
supervision
under
trained
staff
who
would
provide
sterile
consumption
equipment,
the
ability
to
reverse
overdoses
should
they
occur,
and
education
and
referrals
to
treatment
the
local
help
health
back.
Excuse
me,
the
local
health
districts
would
provide
oversight,
and
it
would
be
anticipated
that
the
sites
would
be
well
studied
by
academic
researchers.
S
The
language
from
bdr
978
8345
built
upon
existing
legal
architecture
in
nevada,
including
hypodermic
device,
decriminalization
and
operation
authorization
of
syringe
services
programs.
If
anybody
is
curious
in
looking
at
these
laws,
further
nrs
439.987
and
nrs
439.91
layperson
naloxone
distribution
and
administration,
which
is
nrs,
435,
435.110
and
453c.120,
and
the
good
samaritan
overdose
act.
Nrs
435c.100.
S
So
again,
looking
at
the
language
in
ab345
the
original
version,
the
legislation
would
enable
a
pilot
site
again
in
those
counties
with
over
a
hundred
thousand
residents
which,
after
two
years
of
lots
of
data
and
and
preliminary
review,
would
allow
for
other
pilot
sites
in
in
additional
counties
in
nevada.
Should
they
want
those
and
then,
after
four
years,
the
pilot
sites
transition
from
a
pilot.
After
again,
a
formal
program
evaluation,
they
could
transition
into
a
permanent
site.
S
And
I'd
like
to
take
a
minute
here,
because
I
think
this
is
really
important
to
discuss.
Originally.
Just
a
few
years
ago,
under
the
trump
administration,
the
department
of
justice
filed
a
civil
suit
to
stop
safehouse,
which
was
the
proposed
overdose
prevention
site
in
philadelphia
from
opening
safe
house
appeal
to
the
supreme
court
in
a
very
important
third
circuit
court
ruling.
S
A
Q
Research
on
these
sites
at
the
moment,
but
the
research
they're
doing
is
quite
robust
and
researchers
are
potentially
getting
some
signals
that
there
is
a
change
in
the
way
that
the
feds
are
thinking
about
these
things
and
there
there's
some
openness
to
considering
the
data.
So
I
think
that's
very
encouraging.
Q
I'm
going
to
present
just
a
little
bit
of
data
locally
when
assemblyman
looker
approached
us
to
start
having
conversations
about
what
an
overdose
prevention
site
legislation
could
look
like
lisa,
and
I
seized
the
opportunity
to
do
some
data
collection,
both
in
reno
and
las
vegas,
with
people
who
use
drugs
to
get
their
perspectives
on
what
they
would
think
about
a
place
like
this,
because
it
is
a
priority
of
our
research
group
to
center
the
perspectives
of
those
for
whom
interventions
are
delivered
so
lisa
and
I
in
may
2021
did
a
series
of
qualitative
interviews
with
people
who
use
drugs
that
we
recruited
mostly
through
convenience,
sampling
and
street
based
outreach.
Q
We
asked
them
essentially,
have
you
ever
heard
of
an
overdose
prevention
site,
and
what
would
you
think
about
it?
How
would
you
like
it
to
run?
What
do
you
see
as
the
benefits?
What
are
your
concerns
and
how,
if
we
were
to
consider
something
like
this
in
your
community?
How
would
you
like
it
to
be
done,
so
this
is
just
a
quick
table
on
this
slide.
That
shows
you,
the
demographics
of
the
folks.
We
were
talking
to
important
highlights
about.
Q
Q
We
identified
three
big
kind
of
overarching
themes
in
the
stories
that
people
were
telling
us
people
when
we
asked
them.
What
do
you
think
about
an
overdose
prevention
site?
How
would
you
use
it?
What
would
be
the
benefits?
What
would
be
your
concerns
people's
opinions,
kind
of
grouped
into
three
groups?
They
talked
about
benefits
to
self,
they
talked
about
benefits
to
others,
and
they
talked
more
broadly
about
benefits
to
the
community.
Q
This
person
said
I
have
people
asked
to
come
over.
This
is
a
house
person
saying
I
have
people
asked
to
come
over
here
to
my
house
to
fix
or
get
high.
I
don't
want
to.
Let
people
do
that,
but
I
let
people
do
it
here,
because
I
don't
want
them
to
do
it
in
the
street
and
that's
problematic.
I
had
one
person
overdose
on
me,
which
was
frightening
and
other
people
have
requested
to
fix
or
get
high
here,
and
I
tell
them
no
and
I
always
feel
bad,
but
I
just
can't
risk
it.
Q
Other
people,
many
people,
didn't
think
they
would
use
the
site
themselves,
but
could
see
how
this
could
benefit.
Other
people
keep
people
from
having
to
do
this
stuff
in
public.
Q
It
says
in
that
first
quote:
it
would
be
helpful.
People
are
talking
about
self-managing
their
mental
health,
their
mental
health
system.
So
in
the
second
quote,
on
the
right
hand,
side
it
would
definitely
be
helpful
because
sometimes
that's
why
we
use
this
to
get
rid
of
depression,
depression
and
anxiety.
Q
Maybe
that
particular
person
might
not
need
heroin.
They
might
need
an
antidepressant
or
something,
and
it
would
be
a
window
to
adore
for
them
to
be
able
to
walk
into
a
space
that
would
meet
them
where
they
are,
allow
them
to
do
what
they
need
to
do
and
provide
the
opportunity
to
link
to
clinical
behavioral
health
care.
Q
There
are
unique
issues
to
women,
women
who
are
using
drugs.
Women
who
are
living
on
the
street
and
women
who
are
seeking
services
so
being
a
woman
using
drugs
can
increase
vulnerability
in
certain
ways,
and
so
one
of
the
things
that
people
talked
about
was
running
a
space
where
there
would
be
women's
nights.
So
that
women
could
come
together
and
be
protected
from
some
of
the
things
that
they
face,
but
also
have
opportunities
to
link
to
services
and
care
next
slide.
Q
And
finally,
people
talked
about
benefits
to
the
broader
community.
When
we
asked
people
what
would
be
the
benefit
of
opening
a
space
like
this,
they
talked
about
the
ability
of
a
space
like
this,
to
reduce
drug
use
in
public
spaces,
to
reduce
discarded
syringes
to
reduce
crime
and
to
reduce
stress
on
ems
and
emergency
responders.
Q
The
biggest
thing
for
me
personally
is
that
you
wouldn't
walk
up
on
somebody
who
had
died
or
who
was
dying
and
if
they
were
just
able
to
go
to
this
place.
That
would
happen
less
the
only
place
for
that
horrible
stuff
to
happen
is
out
on
the
street
in
public.
Where
are
we
going
to
go?
We
don't
have
a
spot
to
go.
Q
It
happens
where
it
happens,
so
providing
people
a
space
to
come
inside
to
be
with
other
people
to
be
supervised,
not
only
reduces
the
chances
of
overdose
death,
but
also
reduces
public
exposure,
and
I
just
want
to
point
out
one
data
point
from
the
international
research
on
these
sites.
Many
overdoses
happen
in
these
overdose
prevention
sites,
but
not
a
single
person
has
died
from
an
overdose
that
they
have
experienced
at
an
overdose
prevention
site.
Q
Q
Okay,
so
I
guess
I
get
to
wrap
this
up
by
talking
a
little
bit
about
the
slide
says
gaps,
but
I
think
about
this
really
more
in
terms
of
opportunities,
as
we
think
about
how
to
move
things
forward
in
the
state
and
in
the
nation,
as
we've
talked
about,
I
think
a
fantastic
opportunity
that
we
have
to
consider
is
whether
there
is
a
space
for
overdose
prevention
sites
in
nevada
and
how
we
could
implement
those
in
a
way
that
could
really
address
some
of
the
drug
related
harms
that
we
continue
to
experience
the
data
are
out
there
and
they
are
strong
that
there
are
many
potential
benefits
of
these
sites,
including
cost
savings,
reducing
burden
on
the
hospital
system
and
decreasing
fatalities.
Q
Nevada
at
the
moment
only
has
two
syringe
service
programs
track
b
that
you
heard
from
earlier
and
change
point
up
here
in
the
north
and
even
though
trek
b
is
expanding
their
services
through
harm
reduction,
vending
machines.
This
is
really
not
enough
to
meet
the
needs
of
the
state.
Q
One
of
the
opportunities
that
we
see
moving
forward
is
to
really
make
sure
embracing
these
principles
of
harm
reduction,
that
people
who
use
drugs
are
engaged
in
the
decision
making
process.
As
subject
matter
experts
when
we
are
thinking
about
policies
and
programs
and
services
to
address
drug-related
harms,
we
need
to
be
thinking
about
how
to
get
the
people
for
whom
those
services
are
intended
in
the
room
and
at
the
table
and
amplify
those
voices,
and
we
can
also
think
about
that
in
terms
of
funding
allocation.
Q
Q
Housing
first
initiatives
is
a
a
bullet
point
here
because,
as
you
all
know,
in
nevada
and
in
many
places,
housing,
affordability
and
housing.
Instability
is
a
major
problem
and
the
link
between
housing,
instability
and
drug
overdose,
death
and
drug
related
harms
is
really
really
tight.
They
are
intimately
connected
and
so
ensuring
housing
stability
is
a
step
towards
reducing
drug
overdoses
and
reducing
drug
related
harms
and
then,
finally,
for
a
lot
of
today,
you
heard
some
really
fantastic
data.
Q
I
would
like
to
suggest
that
one
of
the
opportunities
we
have
is
to
complement
those
surveillance
efforts
with
more
granular
analysis
of
the
circumstances
of
deaths.
We
are
counting
deaths
in
our
mortality
and
morbidity
reports,
but
if
we
looked
more
closely
at
the
circumstances
surrounding
death
and
what
was
going
on
in
those
cases,
I
think
we
could
get
a
better
handle
on
where
to
place
our
resources
and
where
to
place
our
interventions.
Q
You
also
heard
a
lot
today
about
upstream
interventions,
and
we
have
to
be
doing
all
of
it
and
investigating
a
death
record
is
too
late,
but
it
could
tell
us
where
to
intervene,
so
it
doesn't
happen
again
and
again.
I
would
emphasize
that
best
practices
in
terms
of
harm
reduction
research
suggest
that
even
in
our
surveillance
efforts,
we
incorporate
the
on
the
ground
perspectives
of
people
who
are
using
drugs,
and
with
that
I
think
I
will
end
and
we
can
take
questions.