My name is Steve Pappas. I'm the editor of the Times Argus, and I will be moderating tonight's panels. I use the term plural. We were very fortunate in asking all of these folks if they would be willing to come talk. I thought if I invited a dozen people I'd get six. I got 13. We're all here to get information from the very people who are dealing with the opioid crisis on the front lines, and we're all here to have a better understanding of what's happening in our communities. And we're eager to know what's being done to tackle this crisis at all levels. The next two hours are probably going to be pretty sobering. I've been assured by some of the folks that that may not be the case, that they have some good news to report as well. Hopefully it won't be too upsetting. What these presenters are going to convey to us will be the opioid epidemic through their very specific lens. That's what I've invited them to do tonight. As a group, they are going to connect certain dots for us, and they're going to give us hopefully the most comprehensive look at how one of the most influential factors that in our culture is tearing apart much of the fabric of our communities. At its barest minimum, this forum should be a reminder that we really are all in this together. So let me take a moment to talk about the format tonight. The first panel will be mostly talking about scope, scope of the crisis of the opioid epidemic. We've had to mix and match a little bit to accommodate some schedules. Each panelist will give a brief presentation, and we will open things up afterward to questions from the audience. So after about an hour, hour and 15 minutes, we will seat the second panel, which will mostly focus on law enforcement, criminal justice, and addiction treatment. There also will be time at the close of that particular panel for questions from the audience as well. If you do have a question, and I would ask that you wait until all the presenters have made presentations come up to this microphone, because we need for everyone in the room to hear you as well as everyone who is watching this live streaming, and we are also taping it for rebroadcast on public access television. Thank you, Orca Media, for doing that. So I would ask you to please keep your questions about the topic at hand, and understand that due to privacy issues and ongoing investigations, our panelists probably are not going to discuss any specific cases with us tonight. And let me briefly introduce our panelists. They're on your program, but if you would stand, if you're seated, or wave from stage when I announce you. Tim Bombadier is the Public Safety Director for the Barrie City Police Department. Brandon Del Pozo is the Police Chief for the City of Burlington. Ann Gilbert is Director of Central Vermont New Directions Coalition. Deborah Hopkins is Director of Central Vermont Substance Abuse Services. Dr. Mark Levine is the Commissioner of the State Department of Health. Neal Martel is a Captain for the Montpelier Police Department. Dr. Javad Mushkuri is Medical Director of CVMC's Emergency Department. John Merrigan is Commander of Special Investigations for Vermont State Police, which includes the Narcotics Unit. Mary Moulton is Director of Washington County Mental Health Services. Dr. Josh Plavin is Vice President and Medical Chief Medical Officer at Blue Cross Blue Shield of Vermont. Robert Purvis is Director of Turning Point Recovery Center in Barrie. Evan Smith is Lead Clinical Care Associate for CVMC's Medication Assisted Treatment Team, and Rory Tebow is our State's Attorney. Thank you all for coming. Let's get started. Thank you. Thank you. I'm going to ask Dr. Mark Levine to start because he is the one who can probably give us the scope of the opioid crisis in the state of Vermont. Dr. Levine. Just lean right into your microphone if you wouldn't mind. Good evening. I'm the one who planted myself here to give you both good news and bad news. But it's always better to start with the good news. But I'll quickly answer the question about scope because it's a very challenging question to answer. Currently in the state of Vermont, we have over 8,000 people receiving medication assisted treatment. If you do the math with the population of Vermont and subtract everybody who's under 18, it comes out to about 1.6% of our state is receiving treatment for opioid use disorder. Estimates from across the country indicate that most people who have this disorder are not in treatment. So it becomes even more challenging to figure out how many people in Vermont actually have the problem because we only see perhaps the tip of the iceberg. But the estimates are anywhere in the 20,000 to 30,000 range. So quite a bit more than those who are actually involved in treatment now. I have to tell you in the good news department that we've really made great progress and we are a state leader when it comes to the battle against the opioid epidemic. Governor Scott and a few of us in the Agency of Human Services were invited to testify before the House Ways and Means Committee last week based on the fact that the model of care that Vermont uses is widely respected and that they thought they had something to learn from us. We had a few asks of them as well with regards to how things in Washington are paid for and how they could further encourage the country to cope with this crisis in more productive ways. But they genuinely wanted to hear from little Vermont. So we're especially noted for our efforts in treatment. And as you know, treatment in this arena is called Medication Assisted Treatment. So that's usually the use of methadone or buprenorphine as a medication to quell the cravings that people who have this substance used to sort of get so that they can function their day-to-day life. Medication Assisted Treatment comes as a package, though not everyone wants to access the whole package. It may involve counseling. It may involve lots of social supports, case management, things of that sort. It's meant to be a comprehensive approach. And it's really built on what we term a health home model or patient-centered home model that treats opioid use as a chronic disease condition, just like diabetes, heart disease, whatever. And that's a very effective model because for many individuals, it can actually pave the way back to living a pretty normal life except for the fact that they're taking a medication every day, just like somebody with one of those other diseases may be taking a medication every day. If you talk to myself and perhaps some of the other panelists and people who are actively involved in treatment programs, they will tell you that it can be quite gratifying because there are lots of people who are doing well in those programs and having a functioning life. We recently had a study commissioned of the hub and spoke treatment program and it pretty much validated why we're doing it and how effective it can be. And there were startling decreases in the ongoing use of either oral or injectable opioid medications by those who were getting medication-assisted treatment. And compared to with a group that wasn't getting the treatment, there was zero overdose deaths, zero overdoses actually in the people who had been sticking with their medication program. The good news now is we have not only evidence-based expertise at medication-assisted treatment, but we have capacity. And pretty much through the state, it is almost zero waiting list to get in. It used to be in the news all the time that there were waiting lists, hundreds of people. And that's no longer true. So the hope is, with that kind of capacity, that individuals who may not have chosen to see treatment up until this point will recognize that if they're motivated to do so, they can immediately get into that. The hub and spoke system, just to give you a sense of what it involves, there's an intake process and someone with opioid use disorder who wants to be treated. Pretty much fills out a questionnaire. And you gain an understanding of their medical history, their psychiatric history, their substance use, their support systems, family, income, employment, housing. A whole host of factors. If it's deemed appropriate for residential treatment in a facility for several weeks, there's access to that. And that's probably the minority in this state. If it's deemed that they can use methadone as a long-term treatment, they go to what's called a hub, of which there are seven around the state. And those hubs are where you would go every day to get medication and all the other comprehensive services. And there are more high-intensity settings, but they're staffed by addiction specialists and are a great resource. If, on the other hand, things are a little more together in your life, you may actually go to a spoke, which is a primary care practice, sometimes a mental health or OB practice, and receive buprenorphine. And you may actually only have to go there monthly and have a monthly prescription for a pill that you'll take every day. That system seems to work very well. And as I alluded to, it can integrate people back into a functioning life, something they might not have had when they were using heroin or prescription pills. The other good news I have is that there's active strategies in harm reduction. Everyone in the room should know that if they want access to Narcan naloxone, it's there for them for free or with a copay out of pharmacy. And you don't even need a prescription. There's a standing order for it. There are syringe and needle exchanges in the state that keep people a little safer if they're going to continue to use the injection route. And there's safe disposal and sharps disposal, and we're trying to increase the amount of medication kiosks so that people don't have to just get rid of leftover medications one time a year, but that they can do that in the future, we hope, on a 24-7 basis. In the area of prevention, doctors are now adhering to new prescriber rules, and I'll let Dr. Plavin give you some great statistics about what Blue Cross has found as a result of just six months of that. The state has a prescription monitoring system so that prescribers or pharmacists can check to make sure that a patient is going to be treated safely, is not seeking numerous sites of care or filling prescriptions in numerous places. We have strong messaging programs that many of you will never have seen from the Department of Health, and that's because they're targeted at specific audiences using the specific media those audiences use the most. And they can be very effective preventive strategies. We have some school-based programming, which we want to see increased, and we have community coalitions developing, like Project Vision in Rutland, that really can allow a community to pull itself up by its bootstraps and help determine what kind of community they want to be and what kind of resources that will require. And there are novel programs like a visiting program that just developed in Burlington that I'll let Brendan Del Pozzo tell you about that really tries to let those addicted to these substances know that people actually care about them and want to get them into treatment if they're willing. We have a strong set of recovery centers around Vermont, but they're unfortunately funded on a very shoestring budget. And we have a governor and a legislature who really have shown, I think, some courage and their willingness to embrace this crisis and try to really move us forward and not let us rest on our laurels. But I'm not going to deny that there are people in this room that have members of their family or friends or members of their community that have been impacted by this crisis because every single one of us has in some way, and I'm sure that's part of the reason you're here tonight. I always like to say that we're in a marathon and not a sprint, that this is not something that goes away overnight no matter what we do. We still, over 2017, had an average of two Vermonters per week dying of an unintentional overdose. We still think there may be as many as 8 out of 10 people with opioid use disorder who haven't sought treatment, and wouldn't it be great if we could involve them in treatment? And we have another generation growing up that we want to make sure it doesn't get afflicted by this. So now that we have this report on the hub and spoke showing how effective it is and a report by the governor's opioid coordinating council outlining a whole bunch of strategies for the state to follow, I'll just highlight a few of the challenges that we're going to face. With regard to medication assisted treatment, it's really making the hub experience a little more customer friendly, I guess what term would be because it can be a very long wait and not as personal as some of the clients would have liked. We need more capacity in our spokes so that there are more clinicians who take more patients with this disorder. We need to try to initiate treatment as quickly as the person who seeks it wants it, and you'll hear from my colleague to the left about a program that's being started right now here in this county. We are having peer recovery coaches. Those of people who understand have had the lived experience piloted in several emergency departments as a way of having people brought in with an unintentional overdose, have a person to talk to, other than a physician like us here or another medical person and somebody who has that experience and can perhaps have the kind of conversation that will profit them. In terms of recovery, as I alluded to, we need better support of our recovery centers. Recovery is really the first day of treatment, is the first day of recovery, but the most important thing about recovery is it's multi-dimensional. It's not just are you avoiding the use of what you used to use and using the thing you're now supposed to use, but it's also do you have a life? So do you have a roof over your head? Housing stability is challenging for this population, especially right after they initiate treatment. And then do you have a job that makes you feel good and makes you get up in the morning and want to go to it every day and feel productive in life? And connecting the recovery community with the employment community is a significant challenge that we're trying to reach right now. And then in the prevention arena, it's really a third of our supervisor reunion schools have curricula and a substance abuse professional in the school embedded, which are usually very well respected by the students and trusted, but I think we can do better than a third. We have community coalition efforts that have started in a few communities, as I mentioned, but there's no reason that any community can't do that, and they don't have to start from square one and invent the wheel because lots of communities can give them great advice and instruction on how to do that. And then as a healthcare professional, we really need more of an armamentarian of pain management modalities, so not just medications, but if medications, non-opioid medications, and some of those we need to have research on, but also the non-medication, integrative therapy type of modes like acupuncture, chiropractic, et cetera, because not only are those sometimes very useful, unfortunately, sometimes those aren't well covered by insurers, and we need to start having the kinds of quality studies that would warrant the insurer to cover them, but also more access to them. So I'm going to stop there because I've thrown a lot at you, and we have to let everyone else talk as well, and I'll be happy to interact about anything I said during the question and answer period. Great. Thank you. That was a very good overview, though. Dr. Mushkuri. Thank you. Thanks for inviting me here tonight to speak and be with you. Ostensibly, I'm here as a healthcare provider, but I'm also a local. I live in Middlesex. I'm a parent in this community, and obviously I'm a concerned citizen like all you are. And it makes me happy to see people here concerned about what goes on in our community. I'm sorry. How's that? What I said was thanks for inviting me here. I'm a local parent. I'm part of this community. I'm also the medical director of the emergency department, so I see a lot of what goes on with this crisis every day. I spent a lot of time thinking about what to talk about tonight, and my wife always asks me, what are you going to say? And I say, well, what should I say? And then she asks me some smart questions and gives me good advice. So all today while I was at work, I thought about this and rewrote my comments and bounced them off a couple of friends, talked to the wall, and finally they said, stop talking on the wall and leave. So I did. And I got in the car, and all I wanted to do was not think about this, just listen to some music and get here. I hit the radio, and the first thing that comes on is VPR, and it says the maker of OxyContin is no longer going to market this drug to doctors. I said, there it is again. I can't get away from this. And what it told me is it is. It's a crisis that affects all of us. And it's not a crisis of all of our little silos we live in. It's not a crisis of the medical community. It's not a crisis of the mental health community or the addiction services community. It's not even a crisis of another town. It's here in this community. And a community crisis requires a community solution. So I am going to tell a couple stories. I'm going to tell you what we're doing, what we hope to do. And the last thing is I'm going to shamelessly ask for help because we're still learning how to do this, and there's a lot of good help out there in our community. And I want some of that help. We all want some of that help to make this work. Recently I was working in overnight shifts, which are just terrible because you have to stay up all night. And the radio went off and said there's a 20-year-old patient in a bathtub that's empty who's blue and unresponsive and not breathing. Everyone just kept doing their business. No one stopped, no one's heart rate got elevated because this is no longer a novel thing. This is an everyday occurrence. Paramedics got to the scene. They found the patient in the bathtub with no water, blue and unresponsive and not breathing. The patient's friends who were there said the patient had ejected something. The friends then left, which they always do, which leaves me to believe maybe they're not very good friends. The paramedics gave the patient an arcane. The patient started to breathe again, brought the patient to the emergency department. I noticed when they got there, the patient was breathing, conversive. The police weren't there. A lot of times they're there. They get called to these calls, but they weren't there. And I asked them, I said, where are the police? They said they're there. I said, what for? They said they're taking care of the kids. It was a 20-some-odd-year-old woman, mother of three. Children at the scene were in their own home, average age, ages four months to seven years old. They had to find someone to take care of the children before DCF could get there. So they were looking for a grandmother, an aunt, an uncle, a neighbor. That's the most dramatic presentation of somebody in crisis. But the kind of day-to-day grind doesn't really look like that. Luckily, this woman survived. She was not one of the 175 that die every day in the U.S. from this sort of overdose. She's not one of the two we lose in our own state each week. And luckily, these children will have a mother if we can get her some help. What I see a lot of times is people coming in with pain that is not well explained. It's not diagnosable. A lot of bargaining will then go on to ask for ways to take care of the pain that may involve opiates through an IV, a prescription for opiates. And again, I can't find a reason to do this. Often these encounters become contentious and combative. Bargaining goes on. These are not the highlight of your day. They're tiring. And again, a lot of times it's to feed an addiction. Either somebody wants to feel better or they don't want to feel horrible from withdrawing from an opiate. Lastly, I saw a patient that came in three times in a week complaining of abdominal pain. Could not find out why he saw me and two other people. She was newly pregnant. Finally, on the third visit, she confided that she was addicted to opiates. She was nervous and scared that these pills were going to do something to her unborn child.  And she didn't know what to do. Again, I don't want to scare people or paint a depressing picture, but you've all heard the statistics. Just like I heard on the radio coming down here, half the children in the custody of the state and DCF between the ages of zero and five are there because whoever's taking care of them is struggling with opiates and cannot care for them. Other things are unreported.  This is some of the things we don't hear about, yet we see all the time. So what are we going to do about this? And I think that's part of the conversation tonight, is that there is good news and there's hope. And the first thing we did, and you alluded to this, was we have to stop looking at addiction as a moral family, a character flaw. It's a disease like anything else. It's preventable. It's treatable. But if we don't look at it through the lens of a disease, we'll never get good at treating it. So I think we all have to agree that that's the way we're going to do this. Because otherwise we're not going to succeed. And we haven't succeeded, and we're making some strides now in our success to treating this problem. In the ED, in Central Vermont Medical Center, in 2013, my old boss, Mark Detman, real bright forward thinking guy, got a grant for something called SBIRT. SBIRT stands for Screening, Brief Intervention and Referral to Treatment. At that time, we were the only emergency department in the state to receive this funding through that program. Through the success of that program, the SBIRT program is proliferated into our Central Vermont Medical Center outpatient clinics. It's now in a number of emergency departments across the state. And what this grant did was it gave us funding and a mechanism and a framework to understand how to take care of people who were either at risk for addiction problems or struggling with addiction. And this has been a truly formative experience for our medical community. Universal screening, as some of you know, when you come to the emergency department, even if it's for a cough or a cut finger, we ask you about your use. Do you use alcohol? Do you use marijuana? Do you use opiates? Do you smoke? And we don't just leave it at that. We ask you how much, how often you use these things. And I know people get irritated sometimes, but it's for a good reason, and I'll tell you why. Universal screening is important because drinking and drugs are really common in our community, but they often go undetected. Right? If no one asks, you're probably not going to tell. We know the risks of misuse of these substances. We know the safety problems, the car crashes, the loss of work, entrance into the legal system, compounding already existing health problems. And the good news is, most people, when asked, want to talk about this. They're open to change, but you gotta ask. So when you come in next time, don't get irritated when we ask you about it. We're doing it for the right reason. Critical to the success of our SBIRT program was the funding to hire SBIRT clinicians that are embedded people in our department that are there specifically to help our patients that are struggling or at risk for problems. These have been the work courses of this program, and I know at least one of them is sitting in the back. Barb, raise your hand. There she is, my savior. And because of people like Barb, we've seen success. We have found people that came in with a cut on their head because they were abusing some sort of substance, using it inappropriately, who then wanted to get treatment, who would then meet with Barb 12 times outside of the emergency department. You could be led to other treatment options in the community by some of these providers that are here tonight. It really helped us understand that this idea of addiction, this disease, is a multifaceted process. It is not easy to understand. It is not easy to treat. And it made us realize that the way we've been doing things for a long time, we're not right and we needed to adopt different strategies. And thankfully we did. When Mark asked me to work and head up the SBIRT program, I panicked because I realized I had no idea what to do. So the first thing I did was I called Bob Purvis on the phone one day and said, hey, can you come here and talk to me and tell me what this looks like in our community? Who's out there to help us? What do we do? We got a couple other friends and we started a collaborative of all the substance abuse services in Washington County and we created something called WixARP, which is Washington County Substance Abuse Regional Partnership. We all sat around a table every month and talked about what the problems were, what services we had, what services we didn't have and how we can work together to create pathways to help people navigate through this sort of complex maze of systems to get help. And again, this has been tremendously helpful to have good friends like this that can help us get through all this. And what we learned was if we want to be successful at treating this, we have to meet people where they are. That could be in the emergency department. When they're ready, they're ready. They've just had a horrendous car crash. They've just done something and they said, you know what? I need help. We've got to be there to help them. We've got to have a way to help them. It could be in their doctor's office. It could be at their housing specialist's office. It could be anywhere. And that's what this idea has to look like and that's what we have to strive for. One of the things we realized when we had this group was we realized there was no system for someone that wanted a detox from alcohol to do it as an outpatient. So with the help of Mary Moulton and our friends at Washington County, our designated agency, we created that. People can now come to the emergency department and we can get them somewhere that doesn't require an inpatient stay in the hospital. But it wasn't easy. It took about what? Two and a half years to get there. So again, 30 years. Yes, that's right. When I met you, you said 30 years. We learned how to collaborate with our local addiction specialists and with our local law enforcement. You'll hear more talk later from Deb about the project Safe Catch where you can present to the local law enforcement and ask for help and the help is there. We have to continue this process because as I told you, a lot of people come in that don't say I'm addicted, I have a problem. So we have to screen, we have to ask, not everyone's going to come in dramatic fashion of an unintentional overdose. There are laws in place now that now sort of legislate how we approach opiate prescribing. And this has done two things. Initially, my colleagues were mad because they said the government should not tell me how to practice medicine. I'm offended. Get over your offense and move on. And understand that now we feel that the public's been educated about how horrendous some of these medications that we prescribe are. How when used judiciously and effectively, they can help you. But when not used judiciously and effectively, they can harm you. They can ruin your life. So now it's incumbent upon us. Educate patients about what opiates are. We talk about, instead of giving opiates, we use IV Tylenol, IV-IV-profen, other methods of pain control not involving opiates. We ask that we use, we give you information. We make you sign a consent form to actually receive a prescription for opiates from us. And we go through what all the downsides are and what the potential upsides are. One thing you have to remember is that unfortunately, the majority of people that are addicted to heroin started with prescription opiate drugs. So we have to educate the public, say, look, we're going to decrease your pain. It's probably not going to go away. There will still be some pain left, but we're going to get you feeling better so you can function. If you remember one thing tonight out of all the things we've talked about, most people when they receive a prescription for pain medication do not finish it. Don't keep that in your medicine box. Dispose of it safely so it doesn't get into the hands of the wrong people. When you're done using it, be done with it and get rid of it. Don't keep them. The laws have, and I think Josh can talk about this, in terms of prescribing, we saw 2100 patients in the emergency department a couple months ago. That's about what we see every month. Out of those 2100 patients, how many patients left are the prescription for an opiate? This is group participation. Someone yell out an answer. 80? Anybody else? 1,000. 1,000. Very close. 45. 2% of people leave with prescriptions for opiates. We are very, very cautious in how we prescribe these medications and with good reason. Now. Now. Now. Now. The last thing we're looking at is this idea of timely treatment. Someone comes to the emergency department and they're struggling with opiates and they want treatment. In the past, it's been somewhat of a struggle to get them to the right place to start treatment. What we are proposing is to train emergency department physicians and providers how to start that treatment when the patient's ready to meet them when they're ready. We call this medically assisted therapy, but as my colleague here said, it should be ready access treatment. Because when patients are ready, we should not have barriers or loops for them to jump through. We should help them get the help they need. I've been working with Bob Purvis on this and a ton of people in this room about how we can do this, how we can get peer recovery coaches in our emergency department to have yet another tool to help people fight addiction. So lastly, I would ask for your help. I've learned a lot about the synergistic power of collaboration with community partners. The medical community tends to keep itself in a silo, but we're making those walls crumble now. We're working with all kinds of partners across all different disciplines to attack a disease that's multifaceted and so far with just traditional sort of medical therapy has been difficult to I can't say cure, but to help. So I need help from people in the community that have ideas, skill sets, sweat equity, money if you got it, intellectual interest, because we're not going to do this alone and this community crisis requires community participation and I'm proud to be part of this community and I'm proud to try to help, but I don't have all the ideas, I don't have the answers, but I know I have a lot of people out here that certainly do. So I think I've gone well past my allotted time so I'm going to stop there. Thank you. Thank you very much and you went well past your allotted time. You both did so shame on you both and cautionary tales to the rest of you I'm going to start pounding on the podium when we get to about seven minutes so let's keep it moving otherwise we may not be out here until 11 or 12 and the rental only goes until nine. So Dr. Plavin. Thanks. So I'm Josh Plavin, I've been a primary care provider for almost 20 years in Vermont. I've been an ER doc, I've been a MAT spoke provider and for the past couple of years I've been at Blue Cross, Blue Shield, Vermont. This is not a new problem. This is a magnification of a long held problem. Back in 2002, Blue Cross sponsored Besso Bryan's film here today and we did community talks throughout the state on the heroin epidemic which I was living through in Chelsea when I was a primary care provider there. And then we sponsored the Voices Project after that which was a workshop with the Vermont teens and then in 2013 we sponsored Longree Heart which was about the opioid epidemic caused by prescription drugs. Three out of four people who use heroin started with prescription drugs. So this is the medical community's contribution to this epidemic is significant. We can't shy away from that it's significant. And one of the things that we've been trying to do at Blue Cross is to raise awareness, public education, prevention, supporting SBIRT, looking at alternatives to chronic pain treatment and supporting the Hovinds spoke system. And I do have some good news for all this because we have access to our claims data and we've been monitoring the prescriptions of opioids before and after the institution of the rule. So I'll cut to the quick here. I will note though interestingly that raising awareness is a big piece of it. Public awareness is very important and Governor Shumlin when he announced the opioid epidemic in the state of the state in 2013 did have an effect and even between 2013 and 16 we saw a 27% decrease in the prescription of opioid medications even before we did any rules or regulations. Then we started to work with the Department of Health and then Commissioner Chen at the time with multiple different payers, prescribers and a large work group to initiate these rules. We initiate the rules in July of 2017 and these rules had to put a limit on acute opioid prescriptions to no more than seven days for adults and three days for kids and had some other issues like not starting new patients on long acting opioids, etc. What we saw soon after the initiation of the rules and after we operationalized that within our system so that there was a stop at the pharmacy that we saw a 25% additional drop in opioid prescriptions. That equals 672,000 fewer pills available per year in Vermont. So all told from 2013 to now we've seen a 48.8% decrease in the prescription of opioids from our network providers or our members. Concomitant with the rules we also supported the use and the prescription of naloxone to help to prevent overdose deaths. We actually do a fair amount of work with our providers identifying members who might be at risk of overdose and suggesting using this medication and we've also seen a 219% increase in the prescription of naloxone in the population which is very heartening. So the work that was done recently has had an effect in terms of mitigating the availability of prescription opioids available but it's not enough. As you know it's going to take multiple, multiple different venues to address this problem and we are looking at different ways to treat pain. Pain's not going away. We now are learning that opioids are probably not a good treatment for pain chronically. They're fine for a day or two but even a day or two puts you at risk. And so we are supporting the development of some new alternatives. We have been supporting cognitive behavior therapy as treatment P.T. Cairo we're looking very closely at Acupuncture we're developing in concert with UVM Medical Center and Barbara Treat two new integrative pain complex pain clinics which would include yoga massage mindfulness acupuncture as part of a treatment regimen and we hope to scale that up throughout the state over time. Those kinds of interventions have been shown to be helpful for the treatment of chronic pain and in the ER, as Jevon said the use of Tylenol ibuprofen have been shown to be as effective as opioids and so transitioning to alternative treatments from a pharmacological perspective is probably a good idea. So I think I've kind of used up my time I'm not going to go too long I think I hit my maybe five minutes here but I'm happy to answer any questions you might have when we get there. Thanks. Great. Mary? Thanks Josh. Thank you. Hi I'm Mary Moulton Executive Director at Washington County Mental Health Services Steve had asked us to kind of look through our lens at what we see with this epidemic and at Washington County Mental Health we see people from birth to death so we have very much seen an increase in substance use in our adult population serious mental illness in people coming through our doors for outpatient therapy for adults with intellectual disabilities who are also using substances that they never used to use before certainly in our emergency services where we do outreach in fact most all of our programs are outreach into the community so when Jabid says meet people where they're at we may be going into a home seeing that there's a parent that's using trying to get them hooked up into medication assisted treatment and the sooner we can do that the better so it's really all about partnerships and this is what we're talking more and more about all the time partnerships with Central Vermont substance abuse with your school system with our emergency room with our insurers with our police I mean we have got to be having partnerships out there all the time and one group I want to talk about which are the recipients of this addiction problem are our kids our children and families so when I put the question out to my staff and said you know where are you really seeing this hitting hard my children's division just was hollering back we have so many children that are experiencing trauma because of their parents addiction their parents are not able to be present for them when their little ones zero through five that's where we're seeing kids going into DCF custody we need to have more helpers out there to help parents with their addictions really in the community in their own homes wrapping them up tighter and we don't have enough workforce for that so we get back to our workforce issue here but we have you know we have children that are experiencing the trauma that are not available when they come to school for learning because they're not sleeping at night you know the case that Java talked about where the mom came in and the police you know stayed with the family we see that in our community we are so fortunate I cannot tell you how fortunate my emergency services team speaks about the police that will stay that will make a meal for the family or wives will make a meal for a family or husbands while their police officer spouse is on the job this has actually happened in our community for kids while DC while waiting for DCF so we are incredibly fortunate in our community with that but the child still is experiencing trauma so we you know when we talk about what we can do as a community and I'm a member of our community it's how do we create safe neighborhoods how do we get more housing for moms who are addicted affordable housing affordable housing is extremely difficult to find and so we need to have more housing we need to have transportation to child care and child care to take these kids some of these kids were born addicted and so they may have attachment issues definite deficits in school that need to be addressed so they need extra help as well so you know I just wanted to speak mainly on the kind of the victims as well of the addiction that we sometimes as we talk about the things we are doing which are very very good things it's a ripple it's like a pebble in the water and it ripples out and so we have another whole job to do with children and families and we need people to be able to be in our workforce to do that so workforce issues are definitely prevalent for us we need more therapists I also would like to just put out the idea of safe baby courts this is something that has been working in some communities similar to treatment court they are safe baby courts and when a child is born and a mother has some charges you know going to court you actually can have a court that helps bring all the providers together because we need to do a much better job as providers with communicating so that we can get the services in for people and if there is a court situation going on providers actually go to the court to help wrap a mom, a family with these services to give an optimal opportunity for success perhaps at keeping their child the one thing that we do have is a community that works really well is our community response team and that is a group of providers that comes together from mental health substance abuse, the OB office women's health many providers when we do have a challenging case they meet regularly bring these cases to the table and then they are able to plug the services in for children and moms for addicted families so the center of Vermont community response team is a very good model in our community for bringing providers together and getting services but again we are experiencing a weight list to get kids into early childhood programming and all that ripple effect from the opiate crisis so lots more to do lots of opportunities and I'm really enjoying the partnerships that we're experiencing when we talk about on-demand treatment when we talk about developing housing opportunities and any ideas that you have please come forth with those because we are really talking about how we respond as a community thank you thank you very much Ann hi I'm Ann Gilbert director of central Vermont community response coalition here in Montpelier and thank you Steven for arranging this and for everybody to come out and talk about this our mission at our community coalition is to increase healthy behavior and decrease substance use and one of the main ways we do that is through community partnerships really connecting with other people to make these things really focus on prevention without many many hands prevention is one part of the continuum of intervention and treatment and recovery and enforcement but I so I see this whole crisis in a different lens because I'm looking at it really from preventing it from happening in the first place how do we stop it so we don't even get to the hospital you know a crisis at school or kids being taken away so prevention is really stopping something before it happens and we learn from mistakes we learn from data and science and experience and so there are many things that we have right now as a result of that like seat belts and helmets and child lock child proof lids on packages and floss and vaccines that we've had for polio and even the flu shot and I think the flu shot is a good a good measure because it's one of those things that everybody knows that we're going to be able to prevent that and how do you know because you hear about this everywhere from your doctors from your parents from other parents their signs the pharmacies the health department it's on TV it's on the radio all the time it's not wash your hands you know don't get the flu so that's kind of what we need to prevent some of what's going on here and one way to do that is to really back it up and look at where does it all start if so many heroin users started with prescription drugs I think we can we can know that so much of the addiction even at that stage did not start there it started with a problem behavior way before that and that's where we're really trying to address preventing substances all substances in families and communities and with kids you know anywhere from flavored vaping nicotine products tobacco use underage drinking binge drinking marijuana moving on to pills and then moving on to heroin so there's really such a wide array and that's really what we're trying to address at the prevention level we do that by working with law enforcement and with medical providers with the schools there's some leadership groups in the schools there's students like students against destructive decisions really doing a lot more peer leadership among their kids because we really need to have more people more informed about what they can do the media has been a big help as well in fact we're using a Vermont Department of Health media campaign called Vermont's Most Dangerous Leftovers this is really promoting some simple practice of safe use, safe storage and safe disposal so we want kids to know this message and even new moms that have newborns or toddlers to start practicing this in their families and modeling this so that the kids understand how important it is to read the labels what is an over the counter medication compared to a prescription drug not taking a prescription that's not prescribed to you only using the correct dosage not just opening the drawer and grabbing a teaspoon or a tablespoon for a liquid medicine but treating it like you were making a really important recipe and really following the guidelines safe storage locking up your medicine keeping it out of reach of toddlers and pets putting it away if you have people looking at your home if they want to buy it or if you have a babysitter coming in or teens or friends or family visitors and then safe store safe disposal so we now have partnered with all the law enforcement in Washington County and there is a permanent drop box like we heard in every police station so when you're taking your trash to the dump or recycling you can take old pills or medications right to a police station and drop them right into the box you don't have to wait for the two times a year drug take back day and this is a better system than flushing it down the drain or putting it in the compost or into the landfill um so we're looking at all substances and we're looking at all people in the community to really play a part in this um you know it is a problem in Vermont we have 16 to 25 year olds that have uh higher than the national rate use of prescription drugs and of heroin and when we look at our high school age kids on the youth risk behavior survey that they fill out every two years we find that in Washington County some of our schools are um at the state level of uh using a prescription drug not prescribed to them in the past 30 days our school is right here where that it's double we really need to pay attention to that so my message is um you can take action everybody can help with this prevention is very important and prevention is continuous kind of like a marathon or an ultra marathon every year there's a new crop of fourth and fifth graders that are getting ready to move on to middle school where a lot of different behavior and different opportunities different trouble takes place and often there's a new trendy substance that comes about whether it's a new flavor um in vaping or a THC edible so my message is to start early start at home give uh information to your family talk about it often you know how many times you have to tell your kids to do something so this might follow the same thing and practice safe use safe storage and safe disposal and um I do have a few pill pods in the back uh where you can lock up medications if you don't have a locking medicine cabinet um at home there's also a sign up sheet if you'd like to be um on our e-news list for our community coalition or if there's some way that you might like to help out thank you thank you chief thank you when uh when Mayor Murrow Weinberger asked me to help lead Burlington's response to the opioid crisis I ended up going down a rabbit hole of uh giving up my conference room to a 30 year uh social worker and service provider hiring an opioid data analyst going to the U Penn Medical Center I just got back from uh the Johns Hopkins Bloomberg School of Public Health and I asked myself am I still a chief of police or am I a public health researcher and then I'm sitting here next to public health clinicians looking at my police colleagues down there and my identity crisis is actually uh quite profound um I assure you this is just because I have yet another engagement back in Burlington at about 830 but it doesn't help actually to look down and see that I should have worn a uniform I'd feel more confident about my identity um you're gonna have to drive really fast I'll tell ya 830 oh no it's that we have time come on so the state police are here anyway so all of that said listen I gotta say though the uh you know the we can use a a dose oh by the way if you don't know I'm not from Vermont um and I get reminded of that very lovingly at least once a day but you can learn something from the manic like tyrannosaurus wrecks like focus and rage of the New York City Police Department when it comes to attacking a problem and that's to my perspective uh the nation's response to the opioid crisis is unfolding at uh really a maddeningly slow pace uh we have 60,000 people give or take who died of uh drug overdoses last year um if this was a war it would be like fighting the entire Vietnam war every year and losing the same amount of people every year it would be like taking the 82nd Airborne Division the 101st Airborne Division and the 1st Infantry Division sending them all off to war and having all of them killed every single one every year if that was happening politically in some other way than the opioid crisis none of us would stand for this um the chief of the commissioner the Baltimore Police Department was was just fired for not bringing the homicide rate under control in Baltimore uh I think the problem with the the opioid crisis to be candid is we don't know who to fire uh for not reacting more swiftly and I know that I'll tell you if if I was presiding over a crime crisis like this in Burlington and the mayor handed me my walking papers I couldn't I couldn't possibly possibly object so one of the things I'd urge is that people bring uh a real sense of urgency and focus and one of the things that I've learned from public health is that the goal here is to reduce morbidity and mortality and that if the current infrastructure can't do it then you have to be a little more urgent a little more course one of the things that public health focuses on is population level interventions that reduce mortality what does that mean to a cop if I had a violence crisis or a robbery crisis happening in one neighborhood I put a cop on each corner for all the hours that the sun was up and even after the sun was down and you'd say well you're not going to catch the crime that's happening indoors you're not going to catch the crime that's happening down a particular alleyway there's things happening in apartments you're missing no but we would in our imperfect and effective way for example suppress street level crime at that location what does that mean for opiates well we'll start with the AIDS epidemic think of condoms one of the responses during the height of the AIDS epidemic was to give out millions and millions of condoms right and people said well that's not stopping certain types of behavior it's not going to catch all of the behavior that we're looking to catch some people aren't going to have one handy we didn't let the perfect be the enemy of the good and giving out millions of condoms until we could find the cocktail that served to suppress the HIV virus but we knew it was a population level intervention cholera what do they do to fight cholera they don't say to people they don't scold people for drinking dirty water they don't say don't touch your feces and if you do you're going to have to suffer the consequences they give out millions and millions of bottles of water and say just drink this water we're going to drop it by helicopter until we can bring this under control it doesn't reach everybody some people it misses the latrines that they give out don't work for everybody but it's a population level intervention that brings things under control potassium iodide is what they give out when there's a worry about radiation exposure in a community so these are all again population level interventions that help bring an epidemic or an exposure under control a lot of the long-term solutions that we talk about are very important jobs shelter skills I'm not discrediting any of them I'm just saying 60,000 people have died we've got to do something a little more quickly so one of the things I urge that you can do is to hold us everyone here the gentlemen and ladies in policing in public health and medicine hold us accountable for giving you evidence-based interventions that are effective and that we implement very quickly without delay they've got to be evidence-based what does that mean if they're evidence-based and they're working the number of people dying should start to go down and get under control right there's a few other evidence-based things that you should be looking for in my opinion this is number one that opioid prescribing levels return to pre-epidemic levels this requires transparency about how many opioids are being delivered to Vermonters it might require opening up the Vermont prescription monitoring system not to look at the amount of pills that Dr. Levine himself is prescribing but at the right level of de-identification to be sure that the government and the public health people in the hospital are pushing fewer and fewer opioids out into the population we have a monitoring system that would tell you down to the pill what's getting out there and the law is written so that all of us have absolutely no access to it that is not the right response to an epidemic second thing number of people receiving medication for a response to their opioid overdose abstinence does not work buprenorphine I've come to believe in researching this until I want to stab myself in the eyes is that methadone and buprenorphine work to address this chronic condition just giving out buprenorphine alone with no counseling, no wraparound services no job, no shelter, no nothing will keep at least 80% of the people using it completely free of heroin and opioids for at least 12 weeks and that's just as long as the trial runs that's better than nothing if you can't get someone into a bespoke or properly done or comprehensive treatment plan just giving out the drugs if you ask folks that are struggling with opioid overdoses just getting the drugs is 80% of what they need and I know that that's not perfect but let's not let the perfect be the enemy of the good another thing I'll say is medication assisted therapy in prison if you are desperate enough to commit a burglary or a robbery or a car break or to traffic somebody to get your opioid fix and you wind up in prison and you're in danger of dying but you're in danger of infecting other people with opioid use especially if you're dealing and you're also having other negative effects on the community if we ask and this is not our corrections folks are very very conscientious hardworking people and they're on top of this but I do say if we were to say that we're going to judge the effectiveness of a warden or a correction official on the recidivism rate of their prison population they would be in Montpelier demanding therapy in prison now and we'd have it in every state in the country and the last thing is we have to look at every possible place to induct people into treatment primarily medication assisted evidence treatment it could be the needle exchange it could be the hospital at the emergency department level it could be police departments fire departments every place in Vermont has to be a vector towards getting people into the right type of treatment so I guess I'll close by saying when I was young I was a fan of World War II history because my grandfather was a paratrooper in the 82nd Airborne and then I thought oh I grew up and I got away from that but I've actually returned to World War II history to see how our nation deals with crises and resolves them in a matter of years and not decades and I never thought that I'd say this but I think General George S. Patton has a lesson for us and he said a plan violently executed today is better than a perfect plan executed next week I think that's what we have to keep in mind so we want to keep our eyes on the long-term goal of the right type of treatment but if the rate of death persists as it does we need a good plan violently executed today that's medication assisted therapy and that's given out with very very very low barriers and that's that Vermonters demanded people pursue evidence based responses to this crisis thank you very much thank you Hi my name is Bob Purvis I'm the director of the Turning Point Center in Barrie and I'm a person in long-term recovery which for me means that I haven't had to take a drink or a drug in 13 years and 9 months and as a result my life has been incredibly better than I could have imagined and I'm a responsible member of the community I say that not for any kind of applause or anything which I didn't get anyway but to help do my share to kind of reduce the stigma there's still a huge problem a huge barrier both to treatment and recovery I want to give a thank you to Dr. Levene for the nice things he said about the recovery centers and our needs where our shoestring budget is such that I wear loafers these days so for those who don't know I'll just give you a brief idea what a recovery center is there are 12 recovery centers in Vermont and our mission is to support people in getting into recovery and we do that through providing peer supports which means a person who's been through addiction and recovery supporting another person who's trying to do the same thing and we are trained and learn how to ask the powerful questions that can help a person identify what their needs and wants are what the vision for their life is and then we support them in getting it that's what we call a recovery coach that's the highest form of service that we have and as Javid mentioned we're about to have recovery coaches in the ED and we're looking forward to getting that underway we have in addition to peer supports we do educational programs everything from exercise yoga to writing groups to workshops on recovery what's entailed in recovery what are the 12 step groups about are you interested in possibly in that or not and also we do we have recovery groups we have what we call an all recovery meeting which is a recovery support group that supports people in all pathways to recovery now we're also a safe place for recreation and social events so back in early 2013 the Vermont Recovery Network which is an organization that we formed to help support our statewide activities as recovery centers we could see the hub and spoke system was going to be coming into effect and we envisioned all of these people with opioid addictions who would be getting into medication this is a treatment and then would have really a chance to go from there or not know where to go from there and they'd be kind of bumping into each other on the street and so we proposed to SAMHSA the federal government that we would create a statewide recovery system for people in medications as a treatment and we did that we got the grant and we created what we call the pathways to recovery program and we have what we call a pathway guide who works out of each recovery center to connect with the local hub the regional induction center and support center for people in medication and also to connect with the spokes which are the doctors and the clinics which also prescribe medication and I have to say that I've been director of my recovery center for about seven years now and my life has been totally changed by the opioid crisis you know it's no opioid addiction is unique in certain respects in terms of of the powerful nature of the cravings of the way a person becomes obsessed with the drugs because of the pain of withdrawal and of the fact that when you go down the food chain in addiction to opioids you end up committing crimes and you're not a criminal but you're committing crimes and so you face imprisonment and you face death if you happen to take fentanyl by accident we have two things that we haven't really had before with people who are trying to be in recovery which is it used to be you could say well maybe he's not ready yet we'll see him again in a few months maybe or a year but with opioid crisis it's a totally different, the stakes are so much higher because now we have prison or death being two of the more dramatic but foreseeable consequences of not getting into recovery you know the importance of the recovery centers is that we are the long haul the treatment is a short term intervention now you may be on medication for the rest of your life or you may be on it for years but in either case you're eventually going to be getting prescriptions from a family doctor and you won't have the same supports at the clinic that you start off with so what do you do well you know the best Reacher says that long term recovery doesn't start until you have five years of continuous recovery and at that point you have about five percent chance of remaining absent or in recovery for the rest of your life this is a long process and so what do people do well we're what they do they come to talk to us they come to hang out they come to be with other people in recovery to become part of a community that can be that supports each other in recovery that's a very powerful force it's as powerful as the peer pressure that these people into using the peer supports can be just as powerful if they connect well there's a problem for people in medication they suffer not only the stigma of addiction and sometimes of having a criminal history they also suffer the stigma of being to look down upon by many people in the 12 step community because they're not considered to be clean at the turning point centers and all of the recovery centers we pursue an all pathways to recovery approach we believe that we don't measure people by what they need to take by way of a medication to support we take them by what they do for their recovery what steps are they taking to change their lives we accept anybody who is doing the same things that everybody else does in recovery and many of those people are on medication some will eventually get off some will remain for the rest of their life but damn it they're not dying in the process as long as a person is alive they have the chance of getting into recovery recovery is a whole lot more than incidents and people who get into it they sometimes look back a few years later I don't know if this bunch was involved I never would have done this but the fact is that every day that you're in recovery your life gets a little bit better no I change that and that's what I mean your life doesn't get better necessarily but you get better at handling your life and that's what recovery really is about okay so I have some pamphlets with me and one of them shows that after the three years of the federal grant we had we had data collection of course for that but this show increases in recovery capital for people between their intake and six months later that connected with us their housing has improved measurably and their abstinence has reduced I mean their abstinence has increased measurably as well so we have an employment another biggie people's employment levels go up substantially even after six months so we're still doing it we're now into our fifth year of this program this looks like it's going to be fully funded next year which means that it's going to even be better but the key thing is that the clinics are terrific and I know the people up there and I know the people working at the clinics and the Matt teams these are all terrific people who are working very hard but they simply can't when the person walks out the door they can't go with them and so that's where we are and we hope to stay there it's a really challenging it's a really challenging time people getting into opiate recovery have often more obstacles to recovery and a tougher road than people say with alcohol or even crack or some other drugs and so the need for support is even greater and we hope to be there over the long haul to be there with them thank you and thank you to this first panel we're going to take a minute and if there are questions folks should come up here we're only going to take a few questions because we don't have a lot of time so if anybody has any questions looks like Beth has a question thank you all for being here Zassan thank you all for being here I'm the director of Central Vermont Council on Aging and you've spoken about children and I wonder if somebody can speak to the effect that this is having on the older population not only directly but how they interact with their families anyone? I can tell you that there's a special initiative underway right now to address the older population because it is currently not addressed very well at all older people tend to be more isolated to start with and they tend to withdraw even more when they begin to have problems with alcohol and opiates and other drugs and so a lot more outreach is needed to find these people in the usual places that we encounter and they also need to be we do a better job of identifying we're like with Meals on Wheels from agencies who go into their homes or home health hospice whoever that goes in to help be trained to identify the signs and try to connect them with some help and we're trying to train more older recovery coaches who would be in a position to say go in our place is right near Northbury Manor and so I've connected with the SASH worker there and when there's somebody who's perhaps interested I'll meet with them but the supports generally aren't there very well for them Anyone else? I would just add that when you look at the statistics on these disorders the peak ages turn to be the early 20s through the mid to late 40s but that doesn't mean there's zero beyond that and there is still a reasonable population of people who are certainly over 55 who more quietly I would agree have this disorder the fact of the matter is that as one gets older arthritis and other aches and pains occur so the likelihood of opioid prescribing can actually go up in that population and the assumption that it would be safe can be a false assumption so I think just like in all other times that we prescribe opioids we recognize that we have to be careful across the spectrum it also adds more relevance to one of Governor Scott's requests of congress when it went to Washington which is to have medicare fund the medication assisted treatment programs in the same way that our Medicaid system does because currently it does not and we know that in our hub and spoke system they're probably around it's hard to estimate but certainly somewhere in the 500 to 1,000 range Vermonters that have medicare I agree with that I do think that as everyone said that the elder population certainly is underreported and underrepresented and when we look at our SBIRT data I also think that what we're seeing now and again I don't know if it's figures is that another generation of people are becoming caretakers for some of these children and stuff as families extended families now participate in the care of these children if the parents are not able to do that and I think that plays a significant role in the crisis as well. Hi my name is Cheryl Vince I wanted to ask Dr. Pleven you spoke about the reduction in prescribing I didn't know if it was new prescriptions or cutting off people who already had prescriptions and when there were those reductions where did those people go and isn't that a provocation to turn to heroin so how do you balance these two? The reduction was predominantly in new prescriptions opioid naive if you will patients but that's a risk in and of itself there are some good studies that suggest that people post-operatively need maybe three to five pills and they're often prescribed 45 to 90 so a lot of the numbers are in that pool not the chronic so not the chronic out of hospital prescribing but that would also you know 70% of the abused prescription opioids are sourced from family and friends it's those extra pills that put people on the wrong road Thanks Let's take one more question It's you My name is Leah Jones I live in Montpelier and I have seen friends struggle through this addiction and family members but the lens that I'm looking through it now is that I have three little boys and my husband and I are doing our best to work on the side of prevention and I'm wondering if any of you can talk more about the aspect of this you've talked a lot about how the drugs are prescribed to treat pain and that's often how people become addicted can you talk about teaching children how to deal with not just physical pain but emotional pain which my understanding is that a lot of people take drugs to quell that kind of pain too can you talk about how parents can prepare their children to better sit with emotional pain and not look for substances to help with that well I think one of the challenges we have within our society and we talk about this a lot amongst ourselves is that there are so many diversions that are natural for children to access whether it be the quick TV or the device and so just talking about coping honestly with your children talking about hard times talking about the struggles that we have in life and having honest conversations we just had a death in our family and talking to our four to six year olds around you know what that meant and how sad that was and have them experience some ritual with that and that this is part of life this is life is not easy we did a community forum in Montpellier this past year about mental health crisis and I remember somebody saying just the whole experience of life is so hard it being human is really traumatic well being human is hard and I think we do our kids a disservice if we just don't talk honestly about that and give them the opportunity to experience difficult times and walk them through it so I think being honest and thinking about where they are developmentally and trying to access good books and conversations is the best thing we could do for our kids I'm going to shamelessly advertise a website that you can access through the health department but it's called parent up Vermont and it's really a website tool for parents who never thought they'd have to have the conversations they're about to have with their kids and want to figure out ways to have those conversations in a productive way so things on there such as I think my teen is drinking or doing drugs I know my teen is drinking or doing drugs I'm concerned about my teen's mental health my teen needs help now there's a whole host of videos and examples and tips on how to start having conversations like that so I just recommend you take a look at it that's a good idea that's parent up website and also we have a parent in class called guiding good choices and one of the things that we cover with that even with older a little bit older but even for the young kids is family dinners and family time and talking about your high and your low of the day and that it's okay to have low times and what can you do to help yourself feel better and modeling like what do you do to make yourself feel better there are a lot of parents who might say I've had a rough day I've got to have a drink or I've got to have a cigarette and I've got to take something for that and kids are watching they're watching all the time so I think it's important for parents to recognize that and just be a little bit more careful about what they're modeling and always encouraging kids to have at least three helping grownups so the beginning of every school year or you know at different times maybe on their birthday you could say can you tell me who you're helping grownups are if you had a problem if something happened or you didn't feel good who would you want to talk to about that and it might be you as a parent it might be a friend's parent or a teacher or an aunt or an uncle but it's good for them to keep up that list and reevaluate that several times a year so that they always know that there's somebody they can go to without having to hold that in okay we're going to swap out the panel so stay tuned for just wait just a moment everybody can take a seat I'm actually going to go in reverse order this time because we were focusing on public health before and we've got a couple more folks who are in the public health realm so I'm going to start on the other end briefly and then we'll come back to law enforcement great so Evan hi there my name is Evan Smith I am a licensed clinical social worker up at Central Vermont Medical Center I oversee the medication assisted treatment Spokes services for the hub and Spoke in our hospital service area so it's pretty much all of Washington County I want to kind of just give you a general idea of how many people we're serving in the hub and Spokes right now the census up at Central Vermont Addiction Medicine where folks are dosed with medication up to a daily basis we have about 454 people there being served that number has actually grown significantly over the last couple years I think that would tell us that we had about 150 people a little over two years ago so you know that's a pretty significant growth of folks coming in and being able to do those services can you just restate that how many folks are being traded daily so the hub is serving 454 people yeah right we are also serving 443 people in our Spokes and you know when we talk about Spokes you heard a little bit earlier you know that's traditionally primary care practices but we also have a number of specialty providers here in the state or in our region Dr. Rappaport who works up at the Spoke up the hub also works with CVSAS and their Spoke and treatment associates another provider here in Montpelier Dr. Stone and Stu Williams are two doctors who are actually providing about 50% of the medication assisted treatment in our community and I think it's really important to recognize the benefit of having these folks working with us and being able to prescribe this medication in all there are 15 different healthcare providers prescribing medication assisted treatment in our community right now I know we've been talking about the need to increase that as Dr. Levine had said but we actually have doctors right now saying Evan give me more referrals I want more people to come forward and you know we're doing that I'd say at this point in time you know when we look at the numbers we're seeing probably between 8 and 12 people coming into either the hub and Spoke on a monthly basis in our community so you know people are still coming forward and I think that's an important thing to recognize and that people have those services available to them when they need them and want them and you know that's one of the biggest challenges I think we're up against is getting people when they're ready and want this service and so honestly I do think our community has done quite a good job we're recognized throughout the state of being one of the better coordinated communities in terms of being able to offer and provide these types of services and I think it's going to be proud of that. You know one of the things that I had heard when Dr. Levin was speaking you know he was talking about you know 8 out of 10 people aren't being identified and if we just do those numbers you know I gave you numbers on our census in the hub and Spoke that's about a thousand people so if he's saying 8 out of 10 that means we probably have another 4,000 people out there in our community who are not getting services right now that's one of our biggest challenges how do we get those people who are not ready and wanting these services to come forward and you know I don't necessarily have an easy and quick answer for that but you know the importance of being able to have family friends and people who matter in their lives be able to let them know that there is help available and that people care is really really critical and I think it's something we all have a responsibility to continue to do those loved ones that we care about and let them know that there is help Thank you Deborah Hi I'm Deborah Hopkins from Central Month Substance View Services and we are pretty much very much like the previous panel we are a provider of services we do outpatient services we do work with Dr. Rappapour with some folks around Spoke what we primarily do is run groups all the way from first three times a week to help structure their lives to address their issues all the way through to folks who come in once a month and really just need to do a check in when we were asked to think about how we see the population and how it impacts what we're doing one of the things that I think has been really important is for people to know how fast organizations have had to change how they behave to address this issue if you went to Central Month Substance View Services 10 years ago we were dabbling in working with people with these kinds of issues with prescription drugs and heroin and now that's the majority of the work that we do and I think it was addressed before that it's a very different situation than for folks who become addicted to alcohol because with alcohol your life deteriorates much slower there's a little bit more discussion in families about it you get more opportunities for others to see what's happening there are people out there that we are serving that are coming through the door saying I can't go to the clinic because my mom can't know so it's been really important for organizations like ours to really adapt to that new world so some of the things that we're doing right now and really putting our energy into is becoming more flexible taking people as a phone call saying we're sending somebody over from the emergency room digging up somebody who can see them that minute if you tried to get an appointment with us years ago you might have to wait three weeks now we're taking people as they come out of residential situations and seeing them the day they get released so we've really had to adapt what we do one of the reasons why I think they chose me to sit here is because another piece that we've done a lot of work around is connecting with public safety and what their role is with the assistance of Ann and her team we've worked with the police departments to look at how do we help support public safety because they know these folks that haven't even made it through our doors they haven't gone up to the hub to be evaluated yet but yet they just got picked up again for breaking into a car to see what change they could get and so we've been working on some creative things like a program called Project Safe Catch that chief will probably speak about and it came out of Montpelier police as well where they have rallied all of the law enforcement in the Washington County area to come to an agreement around police having the resources to be able to say to somebody they really need help they see them in their weakest moment and for them to be able to put a call in and we'll get them in we have had the police drive people up in their cruiser and drop them off and come pick them up when we were done to get them in we have worked with police who have called and said help us this kid doesn't know how to tell their mom that they've been using opiates for the last three months and they don't know what to do about it so we have to be flexible and find programs like that we're working with the Waysar group as well the interesting thing is if you look at the previous panel I think there were at least six of us in this group that have met at least once today if not twice to try to pull together the resources and look at what our pathways are like and I think that that's really important for folks to know the other thing that we're doing a lot of is education we have two steps up the additional piece of advice I would give you is start talking to your kids now I just met with four seventh grade classes last week which is really eye-opening and I have to say with the exception of very few I was shocked at how much how little they actually knew and I really think it comes from us like Mary was saying protecting our children and not wanting them to be exposed we need them to be exposed they smoke a joint from a friend they may know the friend but they don't know where that joint came from and what it has in it and so I really think it's important for us as a community to keep putting that out and to keep talking with folks and also talking with each other it's easy to judge these people but behind each one of these people that we see that come through our door that their lives are a shamble they have an entire network of loved ones that want to do something and as long as we don't talk about that at the dinner table or at Thanksgiving or argue about what should happen and what the police should do we're not going to get to a place where we can accept this for the actual epidemic that it is the other thing is to call and use your resources not one person who is sitting on either of these panels is going to turn down a phone call to talk with a community member about educating them more so I am representing Central Vermont Substance Abuse Services that can be a resource now I know that Rory is going to talk a little bit about another whole project we work with we work with through the court system as well on what's called what used to be called a drug treatment court but now it's a treatment court this is a program that is specifically designed to work with what's considered high needs and high risk people high needs of residivism in the criminal justice system and high needs in that the conventional walk through the door of medication isn't working for them they need a really comprehensive program and we're working hand in hand with the judicial system to find ways to put some structures around them to actually engage in treatment and that's how we kind of segue into public safety and criminal services unfortunately we're not going to start with Rory sorry we're going to start with oh I'm sorry that's alright I want to take this moment to segue into law enforcement because a lot of the questions that were raised to me when these these forums were put together was please bring people in who can speak to where the drugs are coming from how they're being traced how they're being tracked and what's being done in our communities to show that correlation between opioids and upticks in certain kinds of crime so with that I'm going to turn it over to John and have him talk about from the state police point of view what we're seeing right now okay my name is John Merrigan I run the special investigations and that includes the Vermont Drug Task Force and the narcotics unit I spent almost my whole career doing this either in undercover capacity or supervising undercover operations this is really the only thing I know is drug work you know from our particular point of view it's all about distribution how did this happen how did it get as bad as it is today when I joined the drug unit in 99 nobody that I had worked with had ever seen a bag of heroin and I remember the first day that we bought it I think it was in 2000 we all gathered around to look at it obviously that's not the case anymore in 2003 we were doing specifically heroin investigations and heroin trying to infiltrate heroin groups and by 2008 it was a full blown off and running and of course it is today so what I'd like to do in a nutshell if I can for you is describe how opiates heroin and fentanyl which are basically sold as the same on the streets your end user doesn't know if he's shooting a bag of heroin or a bag of fentanyl that's dosed properly hopefully so you can walk away with a sense of how does this happen like a lot of things picture a pyramid at the top we've got the professional drug dealers people that do this and bring in the large amounts it's different than it used to be the classic when I first started doing this work the pyramid model would be some type of gang coming from a different city that would set up shop and they would bring at the top would be the head and there would be a couple enforcers and then there would be a whole bunch of workers and they came in with their own infrastructure and their own package they'd hit a town and they'd start the workers would start making friends and we would get introduced to them and then start buying drugs up through the ranks it was really easy I miss those days that was easy and then that group was gone that is not how it works one or two people will come in and bring an absurd amount of opioids with them that's the top of this new pyramid that I'm trying to describe the middle pyramid which consists of the Vermont infrastructure and the other ones that move heroin and opioids through the state these are people that are moving opioids above their own addictive needs for money they're making money they're introducing their friends to and girlfriends and boyfriends to these dealers they're giving them places to stay they're driving them anywhere they want to go and for them this is a good deal they know this dealer they have a measure of respect within their own there's some prestige if they're living with this dealer and of course the big things they don't have to worry about the heroin they need to not get sick so they're going to get heroin at either a reduced or free but they are absolutely contributing to the overall distribution of the product throughout Vermont and at the bottom is you've got your end user these are the people that are addicts trying to hold down the job at different levels in their addiction and different stages of their addiction those are the people that that haven't made it up into that infrastructure that second tier so the first tier is the ones those are the people we're trying to put in jail those are the people we try to put cases on and there's not a lot of us statewide there's about 20 of us and that's including me and they don't let me do that kind of work anymore so there's not a lot of people out doing that full time in a proactive sense there's a lot of other type officers that are proactively working cases not like your uniform troopers and officers that are responding in a reactive way to things that occur these are people trying to prevent things from occurring so the first tier is of course the ones we want to get but the second tier is what's killing us and why we can't make any forward progress because we are our own worst enemies and I can say we there's no family that is immune to this neither am I very difficult I've been a lifelong drug cop happened that's a snapshot of where we are in Vermont and that snapshot has been the same I would say since about 2009 or so eight or nine about one of the things that we do have going for us on the good news side of things there's a lot of enforcement and this isn't this isn't a plug and this isn't fake because you're supposed to say this this is actually true we're working to both the department of health public safety police department state police federal government we're all working really well here in Vermont it's a small state so we all know each other by first name after a little while it's not happening anywhere else in that country we're working together we work with HSI, FBI DEA very closely on cases they give us manpower we give them manpower and there's so many targets to go around that we don't fight about oh no that's my target I've been working on him for two years if you've got a better I mean I know but that's used to happen if you've got a better case we give up to you that's the good news the bad news is that there is no statement but it's true there is as much heroin now as there's ever been in the state there's more now opioids heroin and fentanyl together fentanyl I suspect we all suspect it will be the new heroin it's cheaper to produce it's 50 times more powerful and all of the economics that go along with that type of product there's more now than there was six months ago and there's reason to believe there'll be more in six months than there is now a second tier which is the people that are really affecting the distribution that's what we are that's what we're really trying to work on and for us, somebody that goes to treatment and comes out clean is a win jail is not a win for us there isn't a cop that knows this game that thinks jail is a win for anybody that is operating from an addictive point of view that's what I've got and there's a dump on the desk on you no I did not that was an important one to hear now we're going to get a little more local into what we see in our individual communities so Tim hi I'm Tim Bombardier the director of public safety for the city of Barrie and I have police, fire, EMS and some other departments but the ones that really we're talking about tonight and the subject matter we're talking about our police, fire and dispatch and what we've seen we've been doing this for 38 years now John did a great overview of one whole middle section here that I don't have to cover so Steve's not going to get the dump on the desk doubtful doubtful? we'll try it I originally started looking at this as crime stats crime stats are kind of flat there's a little bit of a deviation here and there in things like thefts, robberies and assaults and it's not really until you start getting down into the meat of the case and reading a narrative do you really make a connection I don't think anybody can just run crime stats and point and go this is obviously connected to opioids because you have to read down into the cases really what types of crime probably robberies the one thing that we have seen a little uptick in and all of the robberies when you start talking to the people when we catch them it's connected to heroin plain and simple we haven't had anybody robbing a bank for any other reason or robbing a store for any other reason other than to buy heroin in the last four to five years so those are one I feel comfortable saying these are connected to heroin but back in the day you had drugs we arrested you you went to jail unless it was marijuana but if you had cocaine which was the drug of choice which John didn't mention but that was a lot easier you got arrested you went to court you maybe went to jail you maybe got probation but the cases were easy and there were people in Vermont that could say drugs don't affect my life drugs in Vermont have no effect I really don't care about them anybody that says that today is fooling themselves heroin affects everybody in here whether it's a neighbor a family member a friend you end up being the victim of a crime of an assault or a theft or a robbery some other connection to your life something as simple as an increase in the price of things you buy because the story you go to has had so many retail thefts everybody in here is affected and I think when you look around at the panel that's here tonight you get a good idea of what it's going to take to put a dent in this it's going to take a team approach we're not going to arrest our way out of the heroin problem no one group of individuals that have been up here are going to solve this problem and when I say group of individuals I'm talking about the other people in the room this is a community problem and I see some faces I know and folks come to me and they're like chief why don't we arrest them well we need information so if you have information and you see something please tell somebody if you live in very even if you don't live in very city and you want to call me I'll make sure it gets to the right people call me little tidbits of information piled up as John will tell you help you undercover guys immensely but when we look at what's going on in very city and what we have for issues first responders we see people at the worst point of their day they're either getting arrested and they're dealing with the police or they've overdosed and they're dealing with the paramedics or they're on the phone and they're all cranked up and they're trying to get something through dispatch but they're not making any sense and first responders see people at the worst and they are for a lot of people the first point of contact for the system that's why we have partnered with Washington County mental health the emergency room Deb Rory's office the courts that's why all these systems in place because no one thing is going to stop it in very city we are part of project safe catch we have a police social worker so if you come to the door and it's not necessarily a police problem I have a person that can come help you if you know somebody that needs help send them our way you might not think it's our job but it is part of our job that's what we're there to do where do we go from wow that was loud where do we go from here I think we're building the relationships in central Vermont that we need to build with our service providers the silos that existed a decade ago between the service providers and the community are being torn down on a daily basis there are 60 plus service providers in the community we are working at making sure that people not only get the treatment the ones that need treatment the ones that need to be arrested and go through a Rory shop they get arrested and go through a Rory shop but there's other wraparound services that are components to having a healthy life like a roof over your head food money all the things a lot of us take for granted and this team approach is going to be the thing probably before Steve starts bumping on the podium at me I just want to touch on one thing about two things how it affects the elderly there was a question earlier about how it affects the elderly where we see the elderly affected in law enforcement and on the EMS side is through victimization whether grandma comes in and her diamond rings it didn't fit her anymore because she has arthritis and they've been in the teapot on top of the fridge for a decade are gone or whether pills are missing out of a medicine cabinet or whether it's great grandpa's checkbook now has a negative balance in it those are where we're seeing it affect our older citizens the other question when it first came out so I'm going to address it was Narcan and it was why are the cops giving people Narcan two-fold plain and simple, number one it saves lives and it's easy to say that but I'll give you a little story we had a young lady this is when Narcan first came out pristine young lady out partying with friends never drank, never dug in drugs the first drug she tries is heroin or she was told it was heroin it might have been heroin and fentanyl if it had not been for Narcan that would have been her first and last time trying drugs so why do we carry Narcan for law enforcement why don't we just leave it up to EMS that's the number one reason the second is officer safety whether it's EMS safety or police safety we have had officers in Central Vermont get accidental exposures to heroin and fentanyl and it had to go to the emergency room so it's two-fold it's not just, it's not as somebody put it to me well that's kind of mamby-pamby isn't it Blommer it's not there's a need for it and there's a reason all EMS and law enforcement carry it there's other questions but I'm way past seven minutes sorry Captain Martel so I can assure you Steve you probably won't have to count on it for me but good evening I'm Neil Martel I'm a captain of the Montpellier Police Department been law enforcement in Montpellier almost 31 years like Chief Bombardier said I kind of when I first was asked to sit on this I said well look at stats and stats will tell me that was very similar over the last four years in Montpellier our criminal trends are pretty consistent they ebb and flow in the last four years some 50 to 100 excuse me, incidents per year so we're not seeing a tremendous spike in criminal activity and that is reported crimes that people are actually experiencing or are victims of but there's no denying that we only have a heroin problem that we have an opioid problem in this community we have it in this schools we have it in our communities we have it in our neighborhoods most of you here today are here because you know or because you know of someone or you have concerns about it and they're genuine and from law enforcement standpoint as John and Tim Echoed didn't exist you saw the first thing you saw was marijuana cocaine and some crack and then this thing called heroin showed up and it's changed the way how law enforcement does its daily business in a lot of ways and it's tough to put your finger on exactly what that is but you've heard some stories tonight about how law enforcement are doing things that certainly when I signed up to be a law enforcement officer 30 years ago I didn't think I would be taking care of some kids while their mom was OD'd and on the way to the hospital I signed up to be a cop to catch the bad guys that's what you did what I've realized is it's become much more complex than that it probably always was more complex than that but we have to be a lot of things to a lot of people now and that's just kind of what society asked of it but it is trying it's trying for law enforcement officers to do all these things and heroin has caused some of these things to manifest themselves families that are disrupted we see it in our schools where there's increasing rates of truancies because parents aren't doing good parental jobs because they're battling with addiction we see it in some criminal activity your petty crimes I said they haven't spiked but they're consistent those larcenies those burglars and stuff like that those people as mentioned are doing those crimes to get money to usually feed in addiction so what are we doing as mentioned again we started that about two years ago started down a path based on the Gloucester PD model of what they were doing which was getting addiction you know if they came to the police department we would get them help because their intervention is key and so based on that Gloucester PD model we started a process with Washington County called Project Safe Catch that Papkins and her group at the abuse treatment program to get intervention to anyone that came into us we would get them to treatment if they were battling addiction and I think that's an ongoing process I think it's something we take value in to be honest with you I'd like to see more people participating in it we didn't know what to expect we know we have an opioid addiction problem in our communities to be quite honest with you I think it's underachieved and I'd like to see more and that might be a shortcoming of us as law enforcement perhaps but we need to do a better job maybe getting word out there and offer these services to people as Chief Boundary mentioned Narcan about a year and a half or two ago we made a decision at our agency to have all officers who carry Narcan because it's the right thing to do it could be your son, daughter brother or sister that we use it on and save a life with that thought process you know it is the right thing to do and it does work we've seen success with that locally to use it to help save lives other things that we've done my pillar as many other PDs now we've put up a drug drop disposal box we've partnered with CVS to bring that in we have one under station we're tracking that and we're taking anywhere from 25 to as much as 40 pounds a month of unwanted prescription drugs and we're turning them into the Department of Health so we're getting those kind of unwanted prescription drugs that were out there before making a measurable impact on taking those unwanted drugs and getting them disposed of properly also recently as the City of Montpellier we put up some sharps disposal containers throughout various locations in the city including we have one at the police department we have one at the City Hall our department will accept them I think we put one in the senior setting so we have those kind of sharps disposal needle disposal sites where people can drop off unwanted needles so they're not being found in our playgrounds on the side of our streets stuff like that we're also working with the state's attorney's office with treatment court we understand as Chief mentioned we're not going to arrest our way out of this but I think it's much more evolved than that simply going out and arresting people that are addicted to drugs or opiates or heroin or whatever is not going to change that people without treatment are going to continue to be using drugs the key part of that obviously is an educational component we have to make inroads and continue to make inroads I think in our educational system we have young people about the hazards and how to make the right choices so what I'll say is in my pillar we kind of have this perception that it's a good little town it's the smallest capital things are great we're very fortunate to have all the wonderful things we have but it's not without some problems the opiates are here they're in our community they're in all of our surrounding communities and it separates Berry City from Berlin or St. Johnsbury from, you know, Montpelier or Burlington from Montpelier those drugs will travel the people that are doing drugs are selling drugs and those communities will also come to these communities as well so we have to be vigilant we have to utilize all the resources that are here tonight to be good partners as a community we have to be resilient to make an effort to make this a priority as we go forward Roy, before we get to you I'm going to make you wait again for you to a lot of people talk about the public perception of what's going on and I'm assuming that a lot of what you're seeing is the second tier that John was talking about in our communities of the kind of people living within in the community and acting out in that kind of serving as that army but how do you when someone from the community comes up to you and says, well why aren't you arresting that guy you know that's a drug house how does that happen and how does, you know why can't we stop it you kind of addressed it but you're not you're not talking specifically about and it's hurting our communities and that's the one thing that we all seem to hear kind of across the board is well there are drugs here why can't something be done about it and I agree with you 100% people come to us and say there's drugs here why aren't we arresting them I think John gave good overview of what goes on with the undercover operations in Vermont and how they run and it goes back to my statement of if you see something say something we've been very fortunate in very city and people have been very patient with me because I've been the point of contact but when I say me I mean patient with law enforcement with regards to how cases go and how cases get disposed of and the timing on those I have asked people to do nothing more than give me license plates numbers this is the car across the street send me a list of license plate numbers or if you know who the people are by name send me them by name we will get them to the right people because the majority of the time somebody in an undercover operation is connected to these folks and it does take time these are not overnight cases just in the last month you may have seen every couple of every week or so two Vermonters charged in Springfield Mass two Vermonters arrested and brought to Springfield Mass it takes time to build these cases some of the people that three weeks ago now two or three weeks ago now that were arrested and buried are looking at 30 of the white sentences for distribution of heroin and some of those people they're the top tier they're the middle tier they're the people that when it was cocaine they were like catch them or lease because they were used to get to that next tier is that a good way of putting it yeah but if you see something say something being quiet or just complaining about it on the sidelines I'd rather have you complain to me because I hope I can get you convinced to be helpful to us it's really funny because sometimes the plates end up coming back down to cover officers that's a lot of it but the information my point is that giving the reports to you doesn't end up you don't see outcomes of that immediately and that's frustrating to the community and here's the promise I have given people when they have been patient with me and said I'll put up with you we set timelines to get back to each other I might get to a point where I make a phone call to the captain and say hey we have to do something or we're going to do no drugs here weak which means kind of like what chief depozo was talking about in the corner Mark police car in front of the house that's a problem house that has probably prompted John some hair loss because he's we go way back because he's sped up investigations and made a rest just to keep me from doing that but you know those are some of the options available to us and I'm not beyond doing that and for the citizens that have been very patient with me if you're here or you're going to see this it's really appreciated because it does take care of those top echelon people and the distribution Vermonters which are in my from my perspective as big a problem because anybody with ten thousand dollars where the heroin no matter where you are can come in Vermont in three days get themselves ingrained and it doesn't matter whether it's very Montpelier St. Alvin Springfield this is the same in every community in Vermont so it goes back to if you see something say something if I ask or your chief asks you to be patient have the hard conversation okay when's the drop dead date here and I've extended to drop dead date on a couple of people it's turned out very well it is frustrating it's frustrating from our end from my end as the chief when I'm talking to undercover guys whether they're ATF agents or they're state police guys which are where I came from it's very frustrating because as the chief I really don't want you calling me complaining if we know what's going on but I also have a duty to listen to you and enlist you as someone that can help us Neil anything to add I will just add that often times when you say or somebody comes to us and they say we know this is a drug house we know it's a drug house too and we have some ongoing usually almost always we know about it but we still take that information and as they indicated these investigations into narcotics take time there's a process that needs to happen to work these cases it's not instantaneous I know that's frustrating like we say it's frustrating for all of us but it is kind of the way the process has to play out but the information is of value people should come forward and give us information often times though we're already aware alright well talking about the process continuing our state's attorney Roy Tebow so good evening I'm Roy Tebow I'm new appointed within the last month as the state's attorney for Washington County and just to finish up the chief's comment typically when those people get really upset the answer just becomes it's that review with the state's attorney so you know that said this evening I wanted to take the opportunity to talk about the judicial role and judicial response to the opiate epionemic here in central Vermont I can say as a fairly seasoned prosecutor there's no challenges greater or more complicated than this so when I think about how the court including prosecutors defense counsel and judges themselves can respond to this I feel like we're sort of sitting at a dinner table with a bowl of soup trying to share a fork and a knife to have the meal or the second course comes out of a wonderful steak and we're there with a spoon the problem with a judicial response is we are not seeing a vast majority of people who are currently using or are addicts or are watching and seeing people when they have hit a rock bottom or on their way there when they've broken the threshold and actually gone to the point of committing a crime and these crimes cut across every category assaults domestic assaults sex assaults human trafficking robbery armed robbery burglary home invasions all these things are done out by the court and the court does these actions tear apart family units and they put people in positions where they're exploiting sometimes the only people left who will help them so when we hear and I heard a question about you know is there an elder abuse element to this absolutely and right now there are two people who are bearing a disproportionate burden and the obidepinebric in central Vermont are children and the grandparents who oftentimes are having a hard time getting a child to be a prosecutor or prosecutor Kristen Ghazi earlier today to get some statistics looking at our Chin's docket. For those you don't know Chin's is child, children in need of supervision. So this is when DCF of the state has had to intervene and either take direct custody of a child or is directly involved in the management of that child. In 2016, 52% of those cases in Washington County entailed substance abuse as an issue. In 2017 it was and most of those cases are involving either direct abuse or neglect and of this past year in terms of neglect 20% of those cases involved households that were so in sanitary the children had to be removed immediately. So there is a crisis here and this crisis propagates itself. When I look at our you know if you look at it this way a profile of defendants we have they're usually one of three things that they have or sometimes a combination. They're a history of trauma a history of poverty or a history of behavioral and mental health issues. Oftentimes those things run together and oftentimes they are multi-generational and it's sometimes frightening where in the same docket or the same arraignment day we'll have sometimes two or even three generations of the same family in court for different reasons. That really demonstrates the strain and the multiple dimensions of this problem. We can't incarcerate it way out of it we can't arrest our way out of it we need to take action in areas of prevention and education. So when we talk about things of state budgeting time and town meeting time when we think about things like an education budget or school budget or what the state is going to do and where its spending priorities are you know when it comes to the opioid epidemic I think in this audience most people probably agree that there are more opportunities for kids to avoid a life that has an addiction as a component versus paying for more probation officers on the back end. It's a very complicated situation. As prosecutors today I think we face a number of challenges that probably have always been faced but they're much more pronounced now and I'd post you this question and think about it for a moment. We have an armed robbery someone goes into a gas station holds up a knife demands money from the clerk clerk refuses they slash cut the clerk and then get the money and run away that person happens to have a drug addiction problem. Let's say down the street or in another town the same exact thing happens a gentleman goes in threatens a clerk waves a knife around hurts the clerk and then gets away with money. Should we treat those two people differently? That's a really tough question. Should we have more empathy for someone who approaches the judicial system as an addict versus someone who just as a criminal or wants money. They're in you know I'd say all this is rhetorical there's really no right answer to it but as prosecutors we are often times in the position with our defense counsel counterparts and the court are trying to sort through what put that person there how do we best tailor an outcome that is one provides accountability to the community two does something to address the harm that their actions have caused and then three in the long term reduces risk. We heard the term before catching release well you're catching a release and it's maybe not the best way to describe it or the best opportunity. I think in our office we've adopted the view that when someone does have the unfortunate run-in of hitting rock bottom with an interface with the criminal justice system that's an opportunity. That's our first and perhaps the last opportunity before an overdose or before things get even worse to intervene to get them to services and to ensure that there is some meaningful response. And that response can come in many different forms. There are diversion programs that now focus on many of you may have heard the Tamarack program that is a traditional diversion program with a contract to also avail for that person to avail him or herself of treatment whether it be behavioral health and mental health treatment or substance abuse treatment. As we work our way back to the traditional court system there are a number of things and good segue to talk about adult treatment court in Washington County. In the last year 35 people in Washington County were served by adult treatment court. This is a program that involves case management both for substance abuse and for mental health. It has participation from members of the prosecution from the defense and it's overseen by one of our two presiding Superior Court judges here in Washington County. I wish I could say that every case that comes into treatment court is successful. Unfortunately not the case. But these high needs high risk cases are addressed in the most meaningful and I think powerful way we possibly can which is looking at people with hopeless amounts of felony criminal exposure for burglaries and other things that would result in years of time in jail and giving them a second chance in many respects. Or perhaps the first most important chance to rehabilitate and at least get their addiction under control. I've heard from many people in the community in my previous time as the chief deputy in Washington County now a little bit as the actual state's attorney. There are people who doubt treatment court effectiveness. There are people who question or think that it's some sort of way to let people get out of jail for free to fake it to go through treatment go through motions. It couldn't be any further from the truth. It's an intensive program and I think that I hope that people in the community recognize that a struggle with addiction and addressing it in that intensive manner is far, far harder than just going to jail cell sitting there and riding out six or nine months. This dedication, it takes time and many times that road is fraught with setbacks. Relapses are a reality of addiction medicine and treatment and we try to respond to those in the best way we can from the judicial system and from our prosecutorial office. From, and when we look at how the judicial system can respond I think the cornerstone of it is empathy. Such as empathy for an offender or for a defendant through. It's empathy for the victims who are affected by this. It's empathy for the parents who are sitting there watching their son or daughter go through this. It's empathy for the child sitting up in juvenile court sometimes moving from foster home to foster home while the parents are struggling to get their own lives back together. Prosecution without empathy is certain to fail and I think in a place like Washington County it's important and crime doesn't discriminate. There are addicts in Montpelier. There are addicts in Calis in Watesfield and Faston in Berry City in Northfield. There are victims in each of those towns and there are people affected by it everywhere. Final note I'll say on this and I'm happy to see we have a victim advocate for my office here today and also one of our deputies. I think that being involved in the community is important and one of the things we try to do in our office is be responsive and work hand in hand with law enforcement with our partners in treatment with those who are engaged in the community and trying to make a difference. Because at the end of the day every person who sits at the table at the defendants table one way or another is likely going to come back and be a part of our community. They're going to be a part of our community as our neighbors and from our office standpoint many of them unfortunately come back as either victims or witnesses in our office. It's imperative that we treat people in the judicial system who are struggling with addiction with dignity and respect and try to work towards outcomes that enable their success, reduce their risk and help them in their battle against addiction. Let's take a few questions for this panel. Hi, thanks for being out here. My name is Elaine Wang. So that 80% figure of people that are not seeking treatment was very striking. So and we've heard about risk factors. So I was wondering about ready factors. What makes people ready to pursue treatment? Can we all be enlisted in helping recognize when someone is in that place? Hopefully it's not when they're at rock bottom. Maybe we're all spotting that every day. Go ahead. Anybody? The first point is to talk about it. Statistically a person makes seven attempts. The average is seven attempts into recovery for anything, cigarette smoking, heroin, alcohol. But you have to be willing to have that conversation as a community and pull it out from it being stigmatized as much as it is. That's key. I think it's really it's a big challenge. When do you know you're ready for treatment? We heard some of these examples here of the gotten involved in the criminal justice system where their child DCF got involved and that was the leverage point to make them want to make some changes. It's different for everybody. I don't know what the bottom line is for one person to the next. Some people may get to the point where they overdose and they go right back out there and they shoot up again. I don't think there's a quick and easy answer for it. But as I was saying earlier the importance of compassion for these people who are struggling with this disease is so critical. If we can't be compassionate to them in their struggles there's not much hope for them to feel like when they're ready for it that they're going to be people there who want to help them. Anyone else have any questions? Yes. Hi. Good evening. I work in educational setting of a mandated reporter. At the present time I work in a specialized setting and our adolescent and young adult population come from a background of trauma. It's not uncommon for our students to return to a setting in which the trauma occurred and it's not unusual for that to be drug related. So as a mandated reporter when we hear of an incident at home we first call DCF and almost always it doesn't fall within their framework of responding. What would you suggest? Who would you suggest our next phone call be to? We our students are not necessarily connected with a mental health agency and they don't necessarily have a support system around them and the adults in their world may be the most secretive people with whom we would interface so who's out there to support us? That really depends on who's going to make a connection with that individual. In our school system we have school resource officers as does my superior. So this is not a public school setting public school setting? Our school resource officers go to private schools too. So they're available for private schools if you're in Berry City. The school resource officer goes to St. Monica's for example and does programs there. So there may be a connection there. It may be something as simple as reaching out in Berry City for myself or the police social worker which is Brooke. Brooke is really probably should change her name to be a resource navigator. She's a wealth of knowledge and really a compassionate individual. We're very fortunate she's worked with children for 10 years prior to coming to Berry City. So she can direct people to proper services and where that intervention might take place to get somebody some help. She may not be the person giving the help but she may know where to go. Thank you that's very helpful. So we draw from an area that extends from Milton Colchester to St. Johnsbury to Northfield so we cover a lot of supervisor unions. Is there a particular agency that can serve us? I think that a number of schools will create a relationship with an organization a treatment organization that will help assist them. I don't have a lot of information about what you're drawing from and what things Anne talked about. We're really important too. I think oftentimes what we do is we see an issue and we say who do I call to address this issue? Those kids are going to have that issue throughout their life and so not only looking for who can come in and help but how do you actually help those kids? What do they know? Narcan is an interesting adventure when you're talking about in the home knowing what it is if they have parents that are users that's pretty scary stuff but that's part of what we're doing in the state. There's two locations here in Washington County where anybody can walk in and get them treatment associates and central Vermont substance abuse services and to be able to really try to help empower those kids to identify those three people in their life who they can go to too. That isn't just the school because it is different to talk to a mandated provider rather than the neighbor that you actually trust and to try to help pull some of that together so I would encourage you to try to create a relationship with an organization that can be a resource but I also think really you know you're handed some kids with some real traumatic background. They need to feel some power in being able to take care of their own lives and it's hard work but it's going to help them in the long run. Lucas Herring City of Berry, two-part question. The first one is more about advice that we can give to the public because I talked to someone yesterday about filing a complaint just related on trash ordinances and now you're talking about something dealing with either sale or drug addiction issues so the first part is how do we get the public to actually report that information when they have a fear of either retribution or their name being attached with these complaints that are coming in and then after we get them to do that the follow-up is if there's 80% of the population out there that isn't being served that could be do we have the resources in place if there was an influx of these individuals that needed those resources. Thank you. It's an interesting phenomenon that we deal with and people are reluctant to come forward. I think it goes back to you from a police perspective you have to build relationships within your community and you have to engage those people on other occasions where they know that you as a police are there to help that community you know I think a lot of times people only go to the cops when something bad has happened and that's something that has just kind of been an evolutionary thing but all communities need to kind of break down those things so that people view police as more than just the bad response to something bad so you know building relationships within all of our communities is something that from law enforcement we need to continue to grow continue to work on and have engagement with our communities in a non-reactionary approach. The fear of retribution is really a perception thing that is kind of unfounded I think I mean more times than not that fear is just something that they think is going to happen that in reality doesn't so I mean we can try to put their mind ease at that but I think you have to think about that relationship issue if somebody is uncomfortable because of that then they don't really know what the police can do for them so in some ways if we can strengthen those relationships before they need us they'll feel much more comfortable coming to the police knowing that we're there to help them. What I would say for anybody that's in a situation where they are pretty sure they know they're not in a place where they have specific information but there is a real perceived fear of retribution and sometimes it can be legitimate. There's multiple different ways there's multiple ways to give different types of information to the police so you can come in and talk to us and everybody knows you just came and talked to the cops and the next thing you know the neighbors getting busted that doesn't look good for you that doesn't work depending on the situation it's very possible to give a completely anonymous confidential information and ship it off and when you guys do what you do with this you can meet with guys that work for me, guys that work for these guys in a confidential basis and give more detailed information and unless you consent then your name isn't going to go out so I'm trying to answer this question specifically. That's that's possible for that to happen too. Lots of times the police if we don't have any information other than what you're giving us we can't act on it. The rules of engagement here in Vermont are fairly strict and fairly tight so you may have to do something over to help the investigation. That doesn't mean you have to it may be something that a lot of people want to do it so there's a lot of different tiers of way to do it. The big thing is call somebody that knows what they're talking about somebody that you trust and and give them the information. And if you just want to get the information off your chest to make sure it gets to the right people you can use the Vermont tip line. It's for all crimes not just drug crimes but the Vermont tip line it's online you can be anonymous it goes to the Vermont Intel Center you can get it to the proper authorities in the area of concern that's probably the best mechanism if you want to stay anonymous. As far as retribution though I've been doing this close to 38 years working on more the number of times threats yes actual retribution I'm glad to say I can count them on my hands in 38 plus years so the retribution is a perceived fear and for the folks that have that fear it's a genuine fear and we understand that concern we'll do our best to talk to people about making that fear go away but if it's a genuine fear the Vermont tip line anybody that's got internet access on your phone or on a computer or on a tablet you can send one in to the Vermont tip line great I think the other part of your question is around the issue of capacity within the treatment community I think you've probably heard in the news and the media that there are challenges around the issue of capacity particularly in residential very often if somebody is appropriate for residential care there may be a wait to get into that residential care so what do you say to somebody actively using but wanting to get into residential that's a tough choice for those folks and I think in our community here there is access to services if we got an influx of 4,000 people no obviously the reality is we're not going to be seeing that many people coming forward that quickly I mentioned that we're seeing probably about 8 to 12 people coming forward a month at this point in time if we could double that that would be fantastic those numbers of seeing the number of people who come into the hub is great I'd like to