Call to Order and Roll Call
The 2nd meeting of the SB 192 Implementation Oversight Committee was held on Monday, July 13, 2015, at<MeetTime> 1:00 PM, at the Grateful Life Center in Erlanger, Kentucky. Senator Christian McDaniel, Chair, called the meeting to order, and the secretary called the roll.
Present were:
Members: Senator Christian McDaniel, Co-Chair; Representative Denver Butler, Co-Chair; Senators Morgan McGarvey and Whitney Westerfield; Representatives David Floyd, and Joni L. Jenkins.
Guests: Wayne Crabtree, Louisville Metro Public Health and Wellness; Jay Kylander, Messer; L. Rushman, PAR; Major Scott Miller, KSP; Trish Freeman, Kentucky Pharmacists Association; Catherine Troy, and Maggie Schroder, Department for Behavioral Health; Joel Brown, JPSC; Corey Buckman, SAS; John Lamius, VOA; Bryan Wright, Boyle Health Department; Noel Stegner, Northern Kentucky Hates Heroin; Jim Thaxton, HIRT; Anthony Taulbee, KSP Post 6; Steve Florian, Department for Public Advocacy, Boone County; Sharon Walsh and Robert Walker, UK CDAR; Anita Prater, Brighton Center, Lynne Saddler, Northern Kentucky Health Department; Ed Monahan, Department for Public Advocacy; Kimberly Wright, Kentucky Parents Against Heroin; J. Merrick, KCDC; Michael Burleson, and Steve Hart, Kentucky Board of Pharmacy; Jan Gould, Kentucky Retail Federation; Allen Brenzel, Cabinet for Health and Family Services; Marie Alagia Cull, Cull & Hayden; Karen Davis, Jefferson County Attorney Office; Buck Travis, Assistant Commonwealth’s Attorney Office; Daniel Shubert, Department for Public Advocacy; Ashel Kruetzkamp, St. Elizabeth Healthcare; Steve Durham and Mark Bolton, LMDS; Steve Shannon, KARP; Karen Hargett, Transitions, Inc.; Rob Sanders, Commonwealth’s Attorney Office; John Huff, AAGLC; Larry Griffin, Passport Health Care; Ann Barnum, Interact for the Health; Bruce Ripley, Transitions, Inc.; Anthony Nirtz, MHMR; Larry Wells, Citizen; and Terry Fonlman, Citizen.
LRC Staff: Jon Grate, Sarah Kidder, Alice Lyon, Jonathan Scott, and Cindy Smith.
The minutes of the June 26, 2015 meeting were approved without objection.
Heroin/Opioid Impact on Northern Kentucky
Ashel Kruetzkamp from St. Elizabeth Healthcare, Kris Knochelmann, Kenton County Judge/Executive, Gary Moore, Boone County Judge/Executive, and Steve Pendery, Campbell County Judge Executive spoke about the impact on the community. Kim Moser, Director of the Northern Kentucky Office of Drug Control Policy, Kirk Kavanaugh, Deputy Director of the Northern Kentucky Office of Drug Control Policy, and Jason Merrick, Director of Inmate Addiction Services, spoke about plans for the future.
Ms. Kreutzkamp said heroin overdoses have had an alarming increase since 2011 in the five St. Elizabeth emergency departments. Last year there were 745 overdoses, and over 1,000 are expected in 2015. A record number of 136 overdoses were reported in May, with a slight decrease in June. In 2014, there were 129 babies born with symptoms of withdrawal/neonatal abstinence syndrome (NAS) and over 250 babies born to mothers with a history of opiate use. In 2015, it is projected that 148 babies will be born with NAS.
Kim Moser discussed actual heroin deaths. She said that the top five counties for the highest number of heroin fatalities in 2013-2014 were Jefferson, Fayette, Kenton, Boone and Campbell. When adjusted for population, Northern Kentucky jumps ahead of Jefferson County in both 2013 and 2014. The decrease in fatalities in 2014 is due to the availability and the use of the overdose reversing drug, Naloxone. The number of victims saved by this drug is increasing according to emergency responders. The Northern Kentucky Methadone Clinic reports 1,200 clients are registered and receive methadone daily. This number has consistently trended upward and does not account for the 987 Kentuckians traveling to and utilizing the methadone clinic in Lawrenceburg, Indiana.
Judge Knochelmann added that to defeat this epidemic some hard facts need to be acknowledged. First, heroin is in every neighborhood. Second, the impact of heroin reaches across all socio-economic levels. Also, 80 percent of heroin addicts start with an addiction to pills, often the result of treatment for pain resulting from sports injuries, dental problems, or other medical treatments. The Kenton County Fiscal Court is committed to helping with the effort, and is funding the Commonwealth’s Attorney for Kenton County’s Heroin Expedited Addiction Recovery Treatment (HEART) Program, which is a pretrial treatment diversion program.
Ms. Moser said the mission of the Northern Kentucky Office of Drug Control Policy is to provide advisory services to Boone, Campbell, and Kenton County Fiscal Courts on the best evidence-based treatment and prevention strategies for reducing substance use disorders in the community. The agency will assess the current treatment system and identify gaps and barriers to effective treatment, prevention, and community education, and will look for ways to improve the current system of wrap-around services, which will allow for complete recovery and re-engagement with families and the community. The three priorities for the first year are: prevention and education; treatment, including a jail substance abuse program and a Vivitrol Pilot; and the neonatal abstinence support network.
Mr. Kavanaugh said in order to understand best practices in the region, he and Ms. Moser have met with federal prosecutors, federal and state judges, Senator McConnell, and others. They have visited jails and the First Step Home in Cincinnati. Through meetings and conversations, and research by interns, they expect to have the best practices for Northern Kentucky.
Terry Karl emphasized that Campbell and Boone counties are having the same problems as Kenton County, but his statistics refer to Kenton County. Last month, there were 513 people who were detoxed in his jail and they are going to meet or increase that number in July. The county is dealing with pregnant females needing treatment on a daily basis. Kenton County is going to start a comprehensive drug treatment programs involving Vivitrol.
Jason Merrick said the problems are obvious with the crippling epidemic of heroin. The key is adaptability. Systems need to be created that can be adapted to heroin, or the next drug that comes along. He is developing a comprehensive jail treatment program for Kenton County, and he hopes for many other counties to follow.
In response to a question by Senator Westerfield, Mr. Merrick said the capacity of the program is at a minimum 70 beds separate from the general population.
In response to a question by Senator Westerfield, Mr. Merrick said the program is looking at a tiered system. Initially, there would be a six month state Substance Abuse Program, and then another level of care for inmates in the jail for 10 – 180 days.
Representative Jenkins noted that the Cabinet for Health and Family Services will be changing from termination to suspension of Medicaid for inmates, effective August 4.
Naloxone Protocols for Pharmacies
Speaking on Naloxone protocols for pharmacies were Mike Burleson & Steve Hart, Kentucky Board of Pharmacy, Trish Freeman, R.Ph., Ph.D, President-elect, Kentucky Pharmacists Association, and Bob McFalls, Executive Director, Kentucky Pharmacists Association.
Mr. Burleson said the Kentucky Board of Pharmacy, in conjunction with the Kentucky Board of Medical Licensure has promulgated regulations relating to the certification, educational, operational, and protocol requirements to implement the provisions of SB 192. On May 13 the board had a meeting and the emergency regulations were submitted and passed, and were subsequently filed with the Regulation Compiler’s office to become law. Under SB 192, the regulations create a physician approved protocol and provide a mandatory educational requirement. The board passed a continuing education program for the certification process, and hopes that online training for the pharmacists will be available soon.
Mr. McFalls stated that the Kentucky Pharmacists Association applauds the legislative action to address the heroin epidemic in Kentucky. One of the provisions of SB 192 grants specially-certified pharmacists the authority to initiate the dispensing of Naloxone, an opioid antagonist, subject to a physician-approved protocol. The Board of Pharmacy is directed to establish the certification process and set the guidelines for the protocol by regulation. The Association embraces and supports the role of the Board of Pharmacy in providing pharmacists with certification in Naloxone dispensing and educational information with the overarching goal of providing increased patient access to this life-saving medication for opioid overdose. Since November 5, 2014, a total of 25 states and the District of Columbia have passed Naloxone access laws, according to The Network for Public Health Law. Only New Mexico, Washington, New York, Rhode Island, and Vermont made the opioid overdose agent available from pharmacists without a prescription. Kentucky is now a leader in this.
Trish Freeman said the Advancing Pharmacy Practice in Kentucky coalition is taking a leadership role in preparing pharmacists to implement SB 192. The coalition developed a training program designed to meet Board of Pharmacy emergency regulations and the first training was held June 28, 2015 at the Kentucky Pharmacists Association annual meeting. There are other upcoming training events throughout the year. The coalition also commissioned a 36-item survey, developed by research team at UK in collaboration with Traci Green, PhD, distributed to all actively licensed pharmacists in the state. There were 5154 emails sent; 4834 were successfully delivered, 1181 responses had been received to date, with 109 excluded because they were not practicing pharmacy in Kentucky. The response rate to date is 24.4 percent. The survey asked questions relative to training in overdose prevention, certification for dispensing of Naloxone, willingness to distribute Naloxone, and barriers in implementing a Naloxone access program.
In response to a question by Senator McDaniel, Ms. Freeman said several pharmacists have applied for certification and are in the process of setting up protocols with physicians and ordering products.
In response to a question by Senator McDaniel, Mr. McFalls said the first pharmacists have already been certified.
In response to a question by Senator McDaniel, Ms. Freeman said the area furthest along in the process is Danville, Kentucky. There has been discussion that someone in Northern Kentucky may be up and running within the next month.
In response to a question by Representative Butler, Mr. McFalls said one large chain is looking at getting their own program approved, but still need to meet some necessary requirements of the regulation.
In response to a question by Representative Floyd, Ms. Freeman said the survey is still open for one more day. Looking at preliminary results, the responses seem to be more concentrated in urban areas and in Northern Kentucky, but there are responses from all across the state.
Evidence-Based Practices
Speaking on evidence-based practices were Dr. Allen Brenzel, Clinical Director, KY Department for Behavioral Health, Developmental and Intellectual Disabilities, Van Ingram, Executive Director, KY Office of Drug Control Policy, Michele Flowers McCarthy, LPCC, Corporate Director of Substance Abuse Services, Bluegrass.org, and Dr. Sharon Walsh, UK Center on Drug and Alcohol Research.
Mr. Ingram said he is excited to hear about the progress and then introduced Dr. Brenzel.
Dr. Brenzel stated that substantially more individuals with opiate addiction are eligible for healthcare benefits. Major steps taken include adding a substance abuse treatment benefit to Medicaid, the passage of legislation to create an enhanced category of Licensed Chemical and Alcohol Drug Counselors, and opening the network within the Medicaid program for behavioral health and substance use disorder treatment. He said a major component of the bill expands access to evidence-based treatments by providing resources to jails and correctional facilities, community mental health centers, and programs that treat pregnant woman at risk to deliver opiate dependent babies. He said there is a general consensus that opiate addiction is different and has unique characteristics that require unique strategies. The key is that successful treatment will require the availability of a broad array of tools, programs, and practices. Treatment professionals need the ability to tailor treatment to the individuals they serve.
The most comprehensive resource for the definition of evidence-based practice is the federal Substance Abuse and Mental Health Services Administration (SAMHSA), which defines it as a set of treatment activities that evaluation research has shown to be effective. He encouraged the members to search SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) website to view the clearinghouse of over 350 programs and practices. The bottom line for inclusion in registry listings is: the program has been assessed for outcomes, there is evidence that these outcomes are positive from at least one study using an experimental design, and that the results of the study have been published in the last 25 years. He noted that it is important to realize that an evidence-based continuum is more important than a single practice.
Ms. McCarthy said it is important to understand that with any psychiatric or health disorder, there is not one perfect treatment approach. There is no way to determine one specific evidence-based practice that will work for every person. There needs to be the ability to access as many approaches that are needed because different individuals need different treatment. Recovery will not happen overnight. It needs to be thought of as a continuum of care that individuals will flow through, and relapse is not a sign of failure. It is not just about removing the drug from the life of the addict, it is about addressing family needs, coping skills, daily living skills, how important employment is, and addressing a felony background.
Dr. Walsh said she has been involved in 25 years of opiate research and helped develop an educational program for physicians who were interested in providing treatment. There are currently over 560 physicians in Kentucky specially-waivered to provide Buprenorphine treatment to opiate addicted individuals. She said she was happy to hear about the jail pilot project with Vivitrol and she thinks that people are concerned about diversion of treatment drugs in the jails. Buprenorphine and Vivitrol help to stabilize people’s lives. One of the main reasons people use diverted Buprenorphine is because they cannot get access to treatment. She believes all available evidence-based practices need to be expanded, including Buprenorphine and Vivitrol.
Ms. McCarthy encouraged the members to visit a medication-assisted treatment program to see what they are about, and to talk to clients and to staff before making a decision about how they feel about that type of treatment program.
In response to a question by Senator McDaniel, Mr. Ingram said that the SAMHSA website is the best resource to learn about evidence-based programs. The Cabinet is also very good about offering technical assistance.
In response to a question by Senator McDaniel, Dr. Brenzel said there is not much collected data on the issue of prenatal exposure to opiates. It is difficult to study or to do controlled trials because most of the infants exposed would also have exposure to alcohol or other drugs.
In response to a question by Representative Jenkins, Mr. Ingram said there is still a lot of educating to do concerning Casey’s Law. It is very misunderstood and underutilized. It is a great tool and it is a law that the National Association of Model State Drug Laws has as a law they want to create a national model for.
In response to a question by Senator Westerfield, Dr. Brenzel said there are not specific neuro-biologic studies of opioids and infant fetal brain development. There are studies that look at outcomes, but they are confounded by a variety of other factors.
Rob Miller, citizen, spoke about his years of alcohol addiction and said he was a 20-year recovering alcoholic. He wanted the members to know that life is about the joy of wanting to live, versus the horror of living the way he used to live.
The meeting was adjourned at 2:33 p.m.