[0:01] and give the pitch a rationale

[0:04] but I don't want to take up too

[0:05] much space here

[0:09] does anybody else have anything

[0:11] before we let Dr. Winograd go

[0:12] we're just going to unleash her

[0:14] let her go

[0:21] What I'll do too from what I'm

[0:23] hearing today is we'll put

[0:24] together maybe a little bit more

[0:26] condensed list of here's the

[0:26] things that we're

[0:27] really

[0:30] like for one thing we you know

[0:31] the drug courts that's something

[0:32] I think most of us can really

[0:35] get on board with

[0:37] and we'll put we'll make a

[0:39] little bit more condensed type

[0:42] of list in an I likepresentative

[0:44] Black's idea if we can file

[0:44] things on both sides of the

[0:45] building

[0:46] and

[0:50] work on this as much together as

[0:51] we can with the consensus that

[0:52] we have

[0:53] that would be great So Dr.

[0:55] Winograd if you would like to

[0:57] take your ir0 seconds and and

[0:58] go.

[1:04] s you know 30 minutes so I had 3

[1:07] recommendations the first one

[1:10] was to legalize syringe access

[1:10] and drug checking

[1:15] the second one was to establish

[1:16] and fund two methadone units

[1:19] and the third one was to

[1:21] establish and fund embedded

[1:23] certified peer specialists

[1:25] within 3 to5 fQHCs

[1:30] so the second two I'm framing as

[1:31] treatment pilot programs

[1:34] and I'm happy to talk more about

[1:36] what those would look like what

[1:37] you would want to make sure to

[1:40] see and evaluate but the spirit

[1:42] behind the pilot programs and

[1:43] I've seen Missouri do this well

[1:47] is essentially say before we're

[1:50] going to set a goalpost way out

[1:51] here that we're going to make

[1:53] some radical change in a funding

[1:57] model or a service deployment we

[1:59] are going to keep it small and

[2:02] tight and test it among a small

[2:04] handful of ready, willing and

[2:07] able agencies who have to

[2:08] compete for it who have to

[2:10] partake in some type of program

[2:13] management and evaluation but

[2:14] when you do a

[2:15] pilot project like that and

[2:17] let's say you guarantee funding

[2:19] for three years and we're going

[2:20] to see how it goes

[2:22] I think that can be really

[2:25] helpful in giving us insights

[2:26] before we launch something or

[2:28] try to launch something big and

[2:31] statewide so I can speak to

[2:33] those in more detail

[2:35] specifically about methadone

[2:37] access outside of traditional

[2:39] opioid treatment programs and

[2:41] then peer specialists within

[2:43] federally qualified health

[2:44] centers and we can talk about

[2:45] the billing and the payment

[2:47] stuff as well but my first

[2:49] recommendation was a policy

[2:50] recommendation not a funding

[2:52] recommendation and that was to

[2:55] legalize syringe access in

[2:57] Missouri where we would join

[2:59] about 38 other states

[3:01] and

[3:04] essentially the idea here is we

[3:07] would make it allowable for

[3:09] programs to provide people with

[3:10] sterile syringes

[3:15] as they frequent the drop in

[3:16] center and then the drop in

[3:17] center staff can help people

[3:19] connect to treatment and

[3:21] recovery. There's decades of

[3:21] evidence from across the world

[3:24] that syringe programs increase

[3:27] rates of recovery increase

[3:28] access to treatment decrease

[3:31] rates of HIV and hepatitisc etc.

[3:33] and importantly to address the

[3:35] concern among many do not

[3:36] increase risky drug use.

[3:39] so Missouri I think is a bit

[3:42] behind that we have not passed

[3:43] this legislation in the9 or10

[3:45] years that it's been up

[3:48] I know I'm not the expert here

[3:49] in the room so I'll steette

[3:51] speak I think this camera's

[3:53] small but I think you're there

[3:56] and then coupled with that is

[3:59] also legalizing drug checking

[4:01] technology and equipment so we

[4:03] heard a lot of testimony about

[4:04] the unpredictability of the drug

[4:06] supply across the country and

[4:06] here in Missouri

[4:09] that things are popping up in

[4:11] drugs that we never would have

[4:13] dreamt of and so using street

[4:16] drugs now is way riskier and

[4:19] more dangerous and unpredictable

[4:21] than it ever has been and so the

[4:22] interventions that we're seeing

[4:23] in other states who are getting

[4:25] ahead of this is that they're

[4:28] letting people test their drugs

[4:31] they're letting programs do you

[4:33] pop up on a corner and have a

[4:35] drug checking machine to say hey

[4:36] guess what's in your drugs this

[4:37] is scary

[4:41] don't use it or modify your use

[4:43] so that it doesn't kill you and

[4:45] in Missouri the only drug

[4:46] checking that we have legalized

[4:47] is fentanyl test strips which

[4:48] are good

[4:51] and they're helpful but they are

[4:53] becoming increasingly sort of

[4:56] obsolete or unnecessary as the

[4:59] drug supply is already you know

[5:00] full of fentanyl it's kind of

[5:01] like you don't need to test an

[5:03] opioid supply for fentanyl you

[5:04] just assume it is but test

[5:06] strips for xylazine and

[5:09] nidazines and metatomidine and a

[5:11] lot of these scary synthetics we

[5:13] are not allowed to give them out

[5:14] for drug checking in Missouri

[5:17] only for urine testing but at

[5:19] that point if someone's already

[5:20] consumed it and it's showing up

[5:22] in your urine you're lucky if

[5:24] they're alive so that would be

[5:26] my policy recommendation is

[5:28] focus on the life saving aspect

[5:29] of tools that we can provide

[5:32] people to in increase engagement

[5:34] in care, reduce infection and

[5:35] reduce the likelihood of

[5:36] accidental fatal overdose.

[5:40] and then I had the two pilots

[5:41] yeah yeah I think

[5:43] Representativesinnett wanted to

[5:45] make a comment just before that

[5:47] if you don't mind I wanted to

[5:49] let you know Dr. Winograd the70H

[5:50] bill should be in your inbox now

[5:53] and then a lot of dinging

[5:57] I just had a question on this

[6:01] drug checking device on a corner

[6:02] so is this just a little

[6:02] machine? What is this? I've

[6:03] never heard about this

[6:07] so I am no expert it's the inner

[6:11] section of chemistry and

[6:14] addiction services so when you

[6:16] get as high tech as some of

[6:17] these states are doing they're

[6:20] called mass spectrometers or FIR

[6:23] machines and you need a trained

[6:25] drug teching drug checking

[6:26] technician

[6:28] who's trained to use these

[6:29] machines. I saw one when I was

[6:31] visiting Illinois last year. I

[6:34] saw someone do a demo so but it

[6:35] essentially it's a piece of

[6:37] equipment and people bring a

[6:38] drug supply and you take a

[6:40] little sample and it takes like

[6:42] 10 minutes but it reads out like

[6:45] an ingredient list and potency

[6:47] list of exactly what's in that

[6:48] illicit drug supply and so they

[6:53] may put up a station at a dance

[6:55] festival you know a music

[6:56] festival a

[6:59] concert and people utilize it so

[7:01] I do acknowledge that this might

[7:03] be farther down the line for us

[7:06] to actually be training people

[7:07] and purchasing the equipment to

[7:09] use it but step one would be

[7:11] making it legal to do so so that

[7:13] if someone could get a grant and

[7:15] buy a machine they could do it

[7:17] but right now we're not even

[7:18] able to compete with other

[7:20] states because it's not legal on

[7:20] the books for us to do that

[7:22] that's

[7:25] a pretty so

[7:27] like any type of drug can

[7:29] somebody bring a bag of weed and

[7:30] have it checked

[7:33] excuse me, marijuana marijuana I

[7:36] assume I can text my drug

[7:39] checking colleague but I

[7:40] wouldn't worry as much about

[7:42] cannabis as I would about little

[7:44] powders yeah no I know I'm just

[7:45] trying to wrap my brain around

[7:47] how this thing works think ok

[7:49] I'll get back to you. I'm going

[7:51] to send a text message yeah and

[7:52] I know Representative Stinnett

[7:55] wants to speak as well and I'll

[7:56] say this to both of you if you

[7:57] can send some research about the

[7:59] syringes and how effective

[8:00] that'd be

[8:03] yeah the most has done some

[8:05] given us information in prior

[8:06] sessions so that's certainly

[8:09] available and I can send to you

[8:11] the bill that I filed in

[8:13] prior sessions which I would

[8:15] plan to file again really just

[8:17] removes the paraphernalia laws

[8:19] from approved facilities that

[8:21] DHSS would approve so it

[8:23] wouldn't be available to just

[8:25] anybody anywhere it would be

[8:29] public health entities or in

[8:30] Springfield there's an

[8:30] organization called

[8:32] APO that does this type of work

[8:34] so it would be you know

[8:35] restricted to the organizations

[8:37] that are doing this type of work

[8:39] and approved through DHSS and it

[8:41] would just remove those

[8:43] paraphernalia laws that would

[8:44] right now restrict them from

[8:47] being able to do that with the

[8:48] the syringes but the most

[8:49] important piece of the bill

[8:52] really is the requirement that

[8:54] it be associated with a

[8:56] treatment option and so they

[8:57] would have to have a

[8:58] collaborative agreement with

[8:59] some organizations or within

[9:02] themselves offer a treatment

[9:04] option to these individuals that

[9:05] are accessing the program

[9:06] because that's really the

[9:09] benefit right and what the

[9:10] research shows is that

[9:12] individuals are4 to5 times more

[9:14] likely to access treatment if

[9:15] they're utilizing something like

[9:17] these syringe access programs

[9:19] and that's what the most paper

[9:21] showed as well so I can

[9:24] definitely send that you know

[9:25] I think it's an important

[9:27] conversation I'm not as familiar

[9:29] with the drug checking component

[9:30] of it

[9:32] but one of the reasons and I

[9:33] think I've shared this

[9:35] previously and may have done so

[9:36] in our prior task force hearing

[9:37] but I have a lot going on in my

[9:39] life right now so I can't

[9:41] remember but you know one of the

[9:42] reasons it felt really important

[9:44] to me is because in my community

[9:47] we have people just everyday

[9:48] people living in neighborhoods

[9:49] going into areas around our

[9:51] elementary school and cleaning

[9:54] up needles and I see this as not

[9:55] an overall solution right it's

[9:56] not going to clean that up

[9:58] completely but I think it is an

[9:59] opportunity to clean that

[10:03] up some and so I want to take

[10:05] every opportunity we can to help

[10:07] our neighbors not have to do

[10:09] things like that and instead

[10:10] have opportunities for these

[10:11] individuals who are obviously

[10:13] struggling with something to

[10:15] have access to those treatment

[10:17] options and this gives a door to

[10:19] that so it's a really narrowly

[10:23] tailored bill that I think could

[10:25] make a good difference for

[10:26] people and you're planning on

[10:27] filing that ok great

[10:30] very good

[10:33] any other questions about

[10:35] that

[10:39] OK Doctor Winograd did you want

[10:40] to continue

[10:41] Sure.

[10:46] my second recommendation was

[10:47] to establish and fund two

[10:50] methadone units as a reminder

[10:53] these are methadone dispensing

[10:55] sites that are outside of

[10:57] traditional methadone clinics

[10:58] also known as opioid treatment

[10:58] programs

[11:03] the pilot would fund one within

[11:05] an FQHC and one within a

[11:07] substance use treatment center

[11:09] to see which model works better

[11:10] or if they both work well

[11:13] this funding and supporting

[11:16] methadone units is a way to

[11:18] increase access to methadone

[11:20] that is really really hard to

[11:23] get. We only have 13 to15

[11:25] methadone sites in the entire

[11:27] state so in many rural areas

[11:28] it's just a nonstarter

[11:31] for you to access methadone even

[11:33] though methadone is the gold

[11:34] standard treatment medication

[11:35] especially in the age of

[11:36] fentanyl

[11:37] so this would be a way to

[11:40] increase access to methadone and

[11:44] also testing out a new delivery

[11:44] method

[11:48] outside of the the the walls of

[11:49] an opioid treatment program

[11:51] where it's historically been

[11:53] relegated Federal laws

[11:55] officially changed in2024 to

[11:57] encourage states to establish

[12:00] more methadone units. Missouri

[12:01] has yet to establish a single

[12:03] one. I think we're really

[12:05] missing an opportunity not only

[12:06] to increase access

[12:09] but to learn about how to do it

[12:11] and how to do it well and that's

[12:12] why I'm suggesting a three year

[12:12] pilot

[12:14] and my third recommendation

[12:17] is regarding certified peer

[12:19] specialists we heard a ton of

[12:20] testimony about the valuable

[12:23] role of peers in the substance

[12:24] use disorder treatment and

[12:27] recovery space and specifically

[12:30] that there is a disconnect

[12:32] between the behavioral health

[12:33] treatment setting that is able

[12:36] to bill for peer services and

[12:37] the federally qualified health

[12:39] care setting which wants to

[12:41] employ peers but cannot bill for

[12:43] them throughmohealthnet so I do

[12:44] think in the background we

[12:44] should be working

[12:51] with MPCA and DSs and DHSS to

[12:53] figure out how to get peers

[12:55] billable through Medicaid but

[12:56] that is a longer term process so

[12:59] in the meantime I suggested a

[13:01] three year pilot where 3 to5

[13:04] health centers apply and get

[13:07] funding to hire a peer who is

[13:08] supported with appropriate

[13:11] supervision and guardrails and

[13:13] scope etc and there's evaluation

[13:14] and project support to see

[13:14] really what it

[13:17] would look like to have fulltime

[13:19] peers embedded in a health

[13:21] center and we could learn in the

[13:23] process as we are also working

[13:24] toward Medicaid reimbursement

[13:28] so methadone is one and peers in

[13:29] FQHCs is another.

[13:33] excellent so now I need to ask

[13:34] you a question about this

[13:35] methadone dispensing

[13:39] unit. What what what is that

[13:40] exactly what does it look like?

[13:41] Where would it go

[13:43] yeah I admit

[13:47] for the first year or so when I

[13:49] heard about a methadone unit I

[13:50] thought it was like an ATM

[13:51] machine. I thought it was a

[13:53] physical thing.

[13:53] it is not

[13:57] it's a it's a a confusing name.

[13:59] it just means more like a

[14:00] satellite site

[14:03] so a methadone unit could be

[14:08] health center ABc They work

[14:09] through a collaborative

[14:11] agreement with methadone

[14:13] clinicXYz that might be 30 miles

[14:14] away

[14:17] but there's a good amount of

[14:18] patients who could benefit from

[14:19] methadone who live much closer

[14:21] to the health center than the

[14:22] methadone clinic

[14:24] so if the health center was

[14:26] allowed to be a methadone unit

[14:27] maybe got a little bit of

[14:29] funding I'd be happy to look

[14:30] into like what is funding even

[14:30] look like

[14:33] and they'd have a relationship

[14:35] with this the hub site the

[14:37] methadone clinic and patients

[14:39] once they get established at the

[14:40] hub site could then do their

[14:42] daily medicine visits at the

[14:42] health center

[14:47] yeahpresentativesennett Drnograd

[14:49] what's keeping us from doing

[14:50] that now?

[14:57] I don't know.unding a bandwidth

[14:58] oversight

[15:03] ok so we have we said we have 13

[15:06] ish places across the state that

[15:06] are

[15:09] doing this

[15:13] are they only at specific types

[15:15] of healthcare sites currently

[15:17] what what are those specific

[15:18] types

[15:21] yeah it is it is one specific

[15:23] type it is called an opioid

[15:25] treatment program referred to as

[15:27] an OTP. they're also just

[15:29] referred to colloquially as

[15:31] methadone clinics. If you walk

[15:33] into a methadone clinic it is

[15:34] specific

[15:35] it looks very different than

[15:37] like a primary care clinic or

[15:39] even an addiction broader

[15:40] addiction clinic

[15:43] a methadone clinic

[15:45] feels a little bit more

[15:45] carceral. there's like locked

[15:47] doors you have to walk into

[15:49] someoneone has to buzz you in.

[15:51] there's a dosing window with a

[15:53] glass pane. People wait in line

[15:55] to visit the nurse at the front

[15:56] who gives them the methadone

[15:56] dose etc.

[16:01] and so those are methadone

[16:03] clinics also known as OTPs don't

[16:05] quote me on the 13 number it

[16:09] might be like 16 now but yeah

[16:10] they set up in that

[16:13] way regulatory wise through one

[16:17] of the departments yes they are

[16:17] overseen by the department of

[16:21] Mental Health. there's a single

[16:22] roll called the state opioid

[16:23] Treatment Authority the SOTA

[16:25] every state has to have one

[16:31] in missouri we have a soda who's

[16:33] embedded at DMH now he also has

[16:35] like5 other jobs

[16:39] so that's you know part of the

[16:40] the problem across state

[16:41] agencies from my vantage point

[16:43] is that you know people have a

[16:45] bunch of jobs and so to kick off

[16:49] a pilot project like this you

[16:49] need to have some funding for

[16:51] some staff to help get it off

[16:52] the ground and evaluate it.

[16:57] so the issue is not regulatory

[16:59] in nature as far as like what we

[17:01] need to change something

[17:03] statutorily to open it would

[17:04] just be funding

[17:07] and then would they be able to

[17:11] sustain after initial funding

[17:13] like like a here's a little bit

[17:14] to get started and then they

[17:17] could start billing and sustain

[17:17] or would they need ongoing

[17:18] funding.

[17:21] that's a good question. I think

[17:23] that would be part of the pilot

[17:24] to look at funding

[17:25] sustainability models you know

[17:26] if there's a way where they

[17:26] could

[17:29] bill through the DMH system that

[17:31] would you know that would

[17:33] probably be what it would be is

[17:35] that how the other methadone

[17:36] clinics are billing is through

[17:36] DMH

[17:39] some of them well they all have

[17:43] a a bit of a DMH contract. some

[17:45] of them it's predominantly DMH

[17:45] and some of them they only have

[17:47] a little bit of money from DMH

[17:49] and everything else is out of

[17:51] pocket pay and it's $17 a day

[17:53] and that was a few years ago for

[17:54] a methadone patient. OK.

[17:55] thank you

[17:57] Great

[17:59] thank you Doctorinterred

[18:01] appreciate it very much. I'll

[18:02] mute myself

[18:03] for now

[18:09] any other conversation

[18:09] discussion

[18:11] about these policy

[18:11] recommendations

[18:15] anything else that you'd like to

[18:16] discuss talk about

[18:22] Representative Dolan

[18:25] thank you M She I was just going

[18:27] to make a point it's been a

[18:28] minute since I was in the drug

[18:30] courts business but when we were

[18:33] pricing the what we call

[18:35] quickest the cups and stuff like

[18:37] that you've got information from

[18:39] all of these suppliers and all

[18:41] these providers and back then

[18:44] the GCMS, which is the gas

[18:47] spectrometer mass the machine

[18:49] that you were inquiring about

[18:51] those were anywhere from 100,000

[18:53] to300,000 dollars apiece so

[18:54] you know if

[18:55] Senator Black can find that in

[18:57] his budget, I'm sure there will

[18:58] be a couple spots that

[19:01] that's going to be a

[19:05] Thank youpresentative

[19:08] Anybody else online

[19:10] in the room

[19:14] I will just say drug checking

[19:15] machines are extremely

[19:17] expensive. The ones that I've

[19:19] heard about used in other states

[19:21] in recent years are more

[19:23] like40,000 dollars apiece which

[19:25] to be clear I am not suggesting

[19:26] the state would fund

[19:29] but many local jurisdictions

[19:31] have their own pots of money or

[19:32] would go for their own grants

[19:34] and they'd be responsible for

[19:36] footing the bill as a one time

[19:38] outlay if that's in their best

[19:40] interests as a jurisdiction yeah

[19:40] ok good

[19:43] ok

[19:47] well I hope this has been

[19:48] helpful today

[19:51] I think it has been and like I

[19:53] said we'll put a list of the

[19:55] main topics we talked about

[19:57] together and get those to you

[20:00] and in the meantime I know

[20:01] most will be working on the

[20:02] budget

[20:05] report andarrah will put

[20:07] together a summary report for us

[20:08] as well

[20:10] again thank you all so much for

[20:11] your diligence, your hard work,

[20:15] your dedication to this

[20:17] particular issue it's it's a

[20:18] very critical and critical in

[20:21] saving lives and helping our

[20:22] health professionals do their

[20:25] jobs more efficiently and

[20:27] better. thank you Mr. Hummer,

[20:30] Dr. Winograd really appreciate

[20:32] it Judge Olmes thank you for

[20:33] your participation and for your

[20:37] help for your expertise as well

[20:38] thank you. I know I

[20:39] am very very dependent on your

[20:41] guys's expertise in this area

[20:45] so thank you all very very much

[20:46] and with that we are done

Substance Abuse Prevention and Treatment Task Force

Transcript