[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