Good morning and welcome to the Vermont House Human Services Committee. Today is Tuesday, March 22nd. And for a brief time this morning for about the next, we are lucky to, we're going to be focusing on H728 and act relating to opioid response services. And in particular, we're looking at pre authorization and as well as any other barriers to access to medication or opioid disorder. And we're very fortunate to have with us. Dr. Lachonis, Dr. Lachonis, please begin. Good morning. I'm Dr. Lachonis from Gifford health care. I'm an addiction medicine specialist and I understand that you've asked me to speak a little bit this morning about prior authorization requirements for buprenorphine containing products for the treatment of opioid use disorder. And I wanted to start out by noting that, you know, yes, indeed, we are in the midst of a opioid overdose overdose epidemic in Vermont and throughout the United States. The first contributor is synthetic opioids like fentanyl. And I think it's great that people are trying to think about new ways that we might be able to help our patients get access to safe treatment with FDA approved medications. I'm a little bit concerned about simply eliminating prior authorizations for some buprenorphine containing products. To step back, I think it's important that we remember that buprenorphine itself is an opioid, which can cause euphoria and can be habit forming leading to addiction. It's important that we make sure that supplies of buprenorphine most safely get into the hands of people who need treatment and not into the hands of people who may use it recreationally to develop to develop their own new problem. To step back, once again, I think we need to look at balancing harm reduction, such as decreasing opioid overdoses with public safety. One of the things that has been built into buprenorphine products is the addition of a medication called naloxone. It's a combination product, and that is meant to help decrease the risk of people injecting buprenorphine products. Should they inject a combination product, which can increase euphoria and the possibility of addiction, it can will cause withdrawal, because naloxone is something more commonly called Narpean. So I think one of the things we're looking for in eliminating the prior authorization is getting rid of or making accessible products that don't contain naloxone. I think that this is a safety mechanism that's built into the medication that should be left that way. That being said, there do seem to be a certain proportion of people who don't tolerate the naloxone that's in the combination product. They may absorb a small amount of their body and it may cause side effects. So I think we should have a mechanism within our prior authorizations to make it easier for providers who demonstrated that a patient is not tolerating a combination product to have them be eligible to receive the buprenorphine product. Before I go on, are there any questions on pharmacology that I'm just describing?  So I am a spoke provider, but I have a combination of private insurance, self pay and Medicaid. Okay, and all as it relates to opioid addiction. Or is the only patients are that you are seeing those through Medicaid. No, so I see patients who have private insurance on our self pay both for buprenorphine treatment and now tracks owner of the full treatment. Thank you, Dr. Luke bonus and just a couple of questions for you. One is, have you prescribed the mono buprenorphine product for your patients experiencing or needing medical assisted treatment. I have on occasion needed to use the mono product. And these are folks patients who reported in intolerance the combination product. Generally, I start with the film the combination of buprenorphine and naloxone. If that's not tolerated say, for instance, do the nausea and vomiting. For example, then I will switch to the combination tablet product because that also has less risk of misuse and diversion. If that's not tolerated then I would move on to the mono product. Wonderful. Thank you. And when prescribing the mono buprenorphine product do you see a difference in the process between those who are on Medicaid versus those who are on private insurance. Private insurance generally has more flexibility in what I prescribe as long as I don't exceed certain prescribing dosage limits like standard 16 milligrams. So in other words, the private insurance doesn't have a fire authorization in place for a mono buprenorphine product. It varies amongst prescribers but it's not as consistent as it is with Medicaid. Okay, thank you. Dr. Lacones thank you for being here this morning. I'm just curious as to what's been your experience with diversion with your patients and diversion. So I regularly talk with my patients about diversion you know what they have seen particularly when they're coming into treatment. It seems like the buprenorphine mono product is the preferred diverted medication. It's much more oftenly used intravenously, which can lead to a lot of bad medical outcomes beyond the risk of overdose, such as heart infections, bone infections. We have mechanisms in place where we try to detect diversion such as by looking at levels of buprenorphine and its main metabolite nor buprenorphine and people's urine samples. We do medication callbacks where we randomly call people to have them come in and count their medications. The nice thing about the suboxone films is they also have serial numbers on each package which are unique so that we can have a pharmacy photocopy those serial numbers, provide them for us and do a medication callback to make sure that a patient hasn't simply borrowed medication from someone else in order to make up a difference in their count. Whereas with the mono product tablets there's no mechanism like that for trying to attract for diversion. Some make the argument that if patients want to divert, they're going to find a way to divert and I think that's true. If that is their intention, however, I think if you put some kind of mechanisms in place to help prevent that, you definitely do prevent the rate of diversion. I guess one of the things I'm trying to get at is I'm just wondering if you were to estimate what percentage of your patients you believe have diverted their medication. I'm trying to get a handle about how big of an issue it is. Well, it's hard for me to estimate but I'll tell you now that many patients or most new patients I have coming in are positive for buprenorphine and they haven't been prescribed it. So there's definitely a substantial supply on the street and I agree with harm reduction and it's wonderful for patients who have an opioid use disorder to be finding a safe way to manage their illness even if it is on their own without the best follow up. However, I do worry about sort of that being diverted into recreational avenues so that we're developing a new generation of people with opioid use disorders who have initiated with buprenorphine. Thank you. Representative Wood, you spurred a question for me which is thinking about knowing that there is a buprenorphine on the street and that you're experiencing folks who have gotten a supply from the street and are now connecting to health care. I'm sure there's some correlation between barriers to access in that. I'm wondering how often do we see looking at the crisis of opioid and overdose deaths in the state. How often do we see buprenorphine in people's systems when they are dying of overdose. Relatively and frequently. Okay. Yeah, thank you. Yeah, that's that's fairly, that's fairly uncommon. But that's not really the reason why I'm concerned about diversion, you know, I'm more, the risk of overdose from diversion is lower and it will likely be higher if we don't have combination products prescribed because of the increased risk of overdose but I'm more worried about simply putting lots of buprenorphine on the street because I think there's a misconception out there that it's not somehow not addictive and not harmful and we're going to be creating people with a new addiction and I have seen that more and more over the years that people come in where buprenorphine was the first opioid that they had used recreationally that led to a full grown opioid use disorder. Thank you and I want to echo the comments of the vice chair thank you for coming in. I am, I am curious you have expressed a support for the need for pre authorization and I want to say, you know, perhaps as it narrow it, I'm going to narrow it as it pertains to the mono. And the pre authorization for the most part is only for medic, for Medicaid, and you serve other patients who have for instance blue cross blue shield. Do not have the same pre authorization so I'm wondering how you balance that and what is the difference in terms of your concerns related to patients with met receiving their health care insurance through Medicaid, as opposed to, for instance blue cross blue shield. Well, I'm focusing on the patients who I most commonly see most of my patients are Medicaid patients, the blue cross blue shield are relatively in frequent. And I, I use my own parameters of starting out with the least attractive product for diversion which would be the suboxone films, even when I'm seeing somebody with blue cross blue shield insurance. So I use kind of the same protocol that Medicaid currently uses and in stratifying the manner in which it will approve reimbursement. So we have asked you lots of questions and I want to make sure that you have, if you have others. I think we've interrupted your presentation so I'd love to continue. Not at all I was just prattling on so. Yeah, I mean the other things that I want to bring up is that you know there's been some who might argue that in the age of fentanyl inductions might be easier with the mono product versus the combination product. And actually when we look at the data there is no data that supports that contention. We know that in the age of fentanyl induction with any buprenorphine product is quite difficult and we need to understand more about it. Even when you look at, you look back at the initial prescribing recommendations for suboxone back when it was manufactured by Wreckett Benkees or you know they made it very clear in terms of dosage limits that you know once you reach 16 milligrams for an individual patient with a combination product you should be very carefully about whether you need to go higher than that dosage. Because it may indicate that it's not an effective medication there may be a better treatment for the patient such as methadone treatment in a hub. And actually verbatim from the most recent suboxone package insert says dosage is higher than 24 milligrams daily have not been demonstrated to provide a clinical advantage. So I would think you know, at least you know any pursuit of elimination of a prior authorization for above 24 milligrams a day of combination products would probably not be a good clinical recommendation in my opinion. Thank you. Thank you very much. And thank you for excuse me taking the time out of your schedule to educate us and to share a different perspective than what we have heard. And I think that's helpful to us. Thank you for the opportunity. All right. Bye bye. Thanks bye bye. Dr. Lord. You are muted, sir. Thank you. Yes, good morning. Good morning and welcome to the Vermont House Human Services Committee. And thank you for being here to talk about whether it's you know pre authorization and you know removing barriers to access to medication assisted treatment. Thank you. I'm very pleased to be here. And please go ahead. I don't know if you have prepared remarks that you want to start with. Sure. Well, thank you. I've been doing this for about 15 years now after my fellowship at the University of Florida and addiction medicine. And there are a couple of things, a number of things that I would like to talk about after reading the bill. Buprenorphine naloxone up to 24 milligrams is Dr. Lacanus just pointed out has not been demonstrated in the literature to have any positive clinical effect and in fact, early on in my experience people requiring more than that were in general diverting their medication, they didn't need it, and they were taking the extra medication and selling it. And that's just that was just a fact that I was able to demonstrate. And I have a number of patients on up to 24 and not a number but I have several patients up to 24 milligrams for reasons that I'm not sure but it's an individual thing. And I agree that, you know, prior authorization of Buprenorphine naloxone up to 24 milligrams for somebody who is treating someone with an opioid use disorder. That's an unnecessary barrier. Buprenorphine mono product on the other hand, I would support a relaxing of the of the prior authorization requirements, because there are a number of patients who have distressing side effects as a result of the combination of Buprenorphine mono product and currently, I have to practically get an act of Congress in order to get Buprenorphine mono product approved for these patients. They require, among other things, various means to treat the, and to mitigate the side effects. This is medically silly. We're not giving cancer chemotherapy here which you know that makes some sense to treat side effects. But if you have a drug that's producing side effects, and you can treat that with another drug that does the same thing that makes sense to me, that said, as Dr. Buprenorphine mono product is still the preferred formulation for diversion. It can still produce euphoria when injected. The street price of a Buprenorphine tablet on the illicit market, at least in this area is anywhere from 30 to $50 for an eight milligram tablet, as opposed to 10 to 15, maybe $20 for a Buprenorphine combination product. And there are also pharmacies that demand justification for Buprenorphine mono product to the point where I've had one pharmacy actually demand treatment notes, which fortunately the board of pharmacy stepped on as being completely inappropriate. I'm afraid that they need to do due diligence case the DEA comes nosing around and wonders why they are dispensing Buprenorphine mono product because the idea of diversion is quite, is quite on their mind. We support the relaxation of the prior authorization for Buprenorphine mono product up to 16 milligrams with the attestation of the prescriber that there are unacceptable side effects of the Buprenorphine combination product up to 16 milligrams. But again, we would worry about excess medication on the street and diversion, and I think a prior authorization about 16 milligrams is not inappropriate, as long as the barriers are not onerous. I would like to emphasize what Dr. LeConis talked about and the idea of precipitated withdrawal, particularly with any drugs, not just fentanyl. We've heard testimony that the Buprenorphine mono product of the Buprenorphine combination product is that the naloxone that causes the problem. It's not. It's the Buprenorphine that competes with the receptor pushes the fentanyl or the heroin or whatever off the receptor and causes the precipitated withdrawal the naloxone is scantily absorbed and has physiologically no effect whatsoever. So the notion that you can induce somebody on easier on Buprenorphine mono product than you can on the combination is simply a gross misunderstanding of the pharmacology of the drug. And that that comes directly from the eight hour certification course that SAMHSA puts on that I have taught in the past. However, fentanyl does cause problems with induction. And the reason is because the drug is very highly lipid soluble it sits in the fat stores and takes a long time to leach out. If we wanted to do something wonderful to help treat this requiring insurance companies to pay for a period of medically managed or medically monitored detoxification in a supervised setting like an inpatient setting would be wonderful. Because it is very difficult to induce somebody off of a full ag in this drug like fentanyl or heroin on an outpatient basis with Buprenorphine because of this competition and the precipitated withdrawal. A couple of other points I've had four cases of bone infection in a vertebral body in the back. As a result of infection of Buprenorphine mono product in the past 12 years. The med watch form that you've heard is such an onerous requirement. We haven't had to fill that out since October of 2020 so if someone's still filling it out I wonder why. And as far as waiting list is concerned I am unaware of waiting list to access medication assisted treatment in the state of Vermont with the exception of one program where they're having terrible staffing problems if you call my office this this morning to get an appointment for medication assisted treatment we will see you tomorrow. And that is also true in the opiate treatment program I'm the medical director of in West in West Lebanon. So, I'm unaware of barriers. More to the point barriers to treatment or things like transportation under or uninsured individuals, people with difficulty with childcare. That kind of thing, which are all things that we're working on to try to mitigate through grant programs and other things. Not to say that this is in a difficult problem but we have a lot of good people in Vermont that are working on this problem. And I think you should be aware of that. Thank you. Thank you, Dr. Lord. Before we take questions. I'm not sure everyone around the table, or for that matter people who are listening on YouTube. I want to know your background and know where in fact you are a doctor and whether or not you're participating in the as a spoke. And so if you could talk a little bit about that. Certainly. I, my, my specialty is addiction medicine. I'm certified by the American Board of Preventive Medicine in addiction medicine and also the American Board of Addiction Medicine. My work was at the University of Florida in in Gainesville under Dr. Mark Golden, Dr. Ken Thompson. I've been practicing in Windsor for approximately the last 15 years I'm currently the medical director and chief executive officer of Connecticut Valley addiction recovery, which is a addiction practice in Windsor, Vermont. I primarily provide medication assisted treatment to almost 300 patients for opiate use disorder, as well as alcohol use disorder, and other substance use disorders. I'm the medical director at the comprehensive treatment program. I'm currently at Habadocco in West Lebanon, which is an opioid treatment program providing methadone and a hub program for the Department of Health access with buprenorphine, which I have been for approximately the last five years before that I was at the American Clinic in Southern New Hampshire. I'm currently an assistant professor of psychiatry and addiction at the Geisel School of Medicine. And we treat, we teach PA patients at Franklin Pierce University and the addiction psych fellows from Dartmouth. And I'm the president elect of the Northern New England Society of Addiction Medicine. Thank you. Thank you. That's very, very helpful. Dr. Lord, we have a question. Yes, go ahead. Thank you. Thank you, Dr. Lord. Just wanted to make sure I understood that you would say that preferred or sort of preferred but there was really nothing wrong with the combination medicine versus the unit, nor being I thought I was hearing that that was the non preferred product was the combination of those two together sounded to me like you said that you would think that it's as good as not better at the buprenorphine but maybe I misunderstood that. The buprenorphine combination product is the preferred way is the preferred drug that we use to start because of its low, its low abuse potential. And I think that it is been extensively studied. It works just fine for most people. There are some people who have unacceptable side effects for a variety of reasons either the naloxone causes unacceptable side effects. I that is present in in some of the combination products causes problems the filler products, the film themselves I've had people with develop ulcerations under the tongue and in the oral mucosa because of because of the films. And that reason the having the buprenorphine monoproduct as an alternative is certainly a reasonable, a reasonable thing and I think that makes significant barriers to its use are not helpful. I've said the buprenorphine monoproduct again is the preferred formulation for people who choose to abuse the drug because the reason the naloxone is in the combination product is to cause problems if somebody tries to inject it. It is not absorbed well under the tongue or orally but it is quite well absorbed if you inject it and it will cause problems it will cause people to have some degree of withdrawal that doesn't stop people from doing it, but they would rather inject the monoproduct because the naloxone is not there, because the naloxone is not there. And that's why I tend to be extremely careful with with who I prescribe monoproduct for because I, you know, as I said, I've had people run into problems and develop significant complications from doing anything. And I, you know, so I want to avoid that, if at all possible. Thank you, madam chair and thank you Dr Lord for being here today and offering your perspective. So it sounds to me like you are very. There's no discretion about any time that you do prescribe a mono product. And yet you say that right now the current prior authorization process for that is described as an act of Congress to get this through. Could you describe a little bit more about why you described it that way and what does that what kind of impact is that amount of work have for a patient's treatment path. And if somebody, if I think somebody needs mono product and they don't actually have a flat out allergy in other words a rash difficulty breathing swollen face the whole works, then they, it requires that we document what the what the side effects are and then we have to document what we've done to treat the side effect. So if someone has significant nausea, what did we do to treat the nausea. If they have a headache what did we do to treat the headache. If they do have other side effects what did we do to treat the side effects. And, you know, a lot of times the treatment of those side effects is really not all that effective. And I've had people want to abandon treatment if they can't have the mono product if they can't. You know if they can't take a medication without getting horrible side effects they don't want to take it and that of course makes sense. It's very difficult for us to, you know, to get prior authorization for the mono product under any circumstances. Now that said, I don't believe that we should completely abandon prior authorization or some breaks on on the prescription of mono product for the reasons that I have stated. However, I have to say that of all of the insurance companies that we have to deal with and the prior authorization Vermont Medicaid is been the most cooperative and has done the most to streamline the prior authorization process for almost everything else. Of everything I mean I have very few problems with Vermont Medicaid and if you'd like to hear from my nurse. Dr. Shaffner who does all of my prior authorizations for me. I checked with her yesterday before I made this statement and she agreed that Vermont Medicaid is the easiest for the most part to get prior authorization from it's the buprenorphine mono product that we have the most issue with Dr. Lord we have another question from actually represent women asked my question so okay representative McFawn. Thank you, Madam Chair. Dr. I want to switch a little bit. You mentioned that there were no waiting periods that you were really aware of, but also you mentioned that if somebody comes in today, looking for help. You tell them, come on back tomorrow. We can see him within the 24 hours. Can you just talk about a little we hear a lot about you need to strike when the I am hot. When somebody's looking for help. Well, I mean there. Help me understand what you mean. Well, you know there are practical considerations if somebody calls it four o'clock on a Monday afternoon. You know, I don't know a doctor's office in the world for anything even for cancer that you're going to get an appointment the same day unless you're, you know, unless it's a medical emergency. We do our level best to get people into the hot, you know, in here just as rapidly as we possibly can, because we understand you're absolutely right you strike when the iron is hot when the patients ready the patients ready and we need to get them in. Absolutely. There are, there are, there's a program I mean I noticed in the end of this bill that you talked about the emergency response to, to opioid emergency response support I think it's section 11. There's another program that DB, the diva has has sponsored it's called the rapid access to medication treatment program. Under this program somebody can, who is ready for treatment and it was, you know, wants to get in right away can present to the emergency, for instance, in this area, a patient can present to the emergency room either at spring field or in the hospital, be evaluated if appropriate given given their first dose of buprenorphine that at that time, and then people call me the ER calls my office and we will see the patient tomorrow. If they call early enough in the day and there's time we'll see them this afternoon. I mean we do have, you know, compared to a waiting list of you know three or four weeks or a month which was true several years ago. We've come an awfully long way in making sure that people get into treatment just as fast as possible. And I have to tell you something else too. There are a lot of people, they're particularly at the methadone clinic. We get people who call in extremists, and we say fine come in the next day and they don't show up. And I tell you the number of times I have come in, expecting a full load of patients that day and wind up sitting around reading the newspaper or doing paperwork, because people don't come. So, you know, this there's there's a balancing act here, but patients, you know, if patients want to get in we get them in just as fast as we possibly can we and we don't sit around letting flowers grow under our feet. Representative seriously we do our level best to get people in just as fast as we can, as practically possible. Um, Dr Lord thank you so much for being here today I kind of wish that we had heard from you first off you have some great suggestions and thoughts and clearly amazing background I am. I'm wondering about what you you talked about a little bit which was the other barriers to this care things like child care issues and transportation issues and you you brought up a grant program and I'm someone in this committee who works a lot on child care and I'm kind of curious. Was that around child care or how how are you, how are you trying to help your patients with those things we do have something around transfer a little bit of transportation I think with a van in our bill but I'm curious. Well, I'm not sure about that van. It's an interesting concept. The problem with the van is that I wonder how we're going to, you know, how we're going to make the counseling component work or, you know, we're going to have, you know, mobile counseling sessions. I mean, you know, medication alone is not going to treat this disease. It doesn't treat this disorder you have to have a combination of that plus psychosocial interventions. So, I'm not sure about the van as far as transportation is concerned I think that that is the number one barrier to the patients, both in my, both in my OTP opioid treatment program method on clinic up in West Lebanon, and here. Now, there is a program that we had a program called ride to recovery that was supported by a grant through the Springfield turning point, which worked great until it ran out of money. There's another grant program and I'm sorry that the name of it escapes me but there is another program that is ramping up. I think going through volunteers in action. And, you know, I can certainly learn more about that we heard about that in our Windsor County substance use disorder collaborative last week, where transportation is going to be addressed we have a number of people in our practice who have volunteered for various things and some people would like to help with transportation we're going to refer them on to them because this program is going to do background checks and vehicle checks and, you know, the kinds of things that, you know, safety would require. Yes, transportation is a huge issue and Medicaid transportation is not always terribly reliable it's better in Vermont than it is in New Hampshire but it's still not always reliable I mean I have had patients left stranded because the Medicaid ride didn't show up show back up to home. So that is an issue childcare can be an issue. You know, we, we wind up having kids in our in our waiting room that's not terribly appropriate because it's hard to do therapy hard to do counseling when you get, you know, you worried about your kid running around. So we've, we've tried to, you know, we've tried to address that somewhat. We do participate in the hub spoke program we are a single specialty addiction program here at at CVR and we have a spoke nurse. Ms. Jones is a certified case manager and she works very hard to help address the transportation childcare economic services issues, insurance and that kind of thing that that that people run into. We also as a nonprofit entity we also have a small fund to cover shortfalls in insurance such as copays and and deductibles for people who just aren't able to afford those sorts of things that we do have a small fund that helps cover that and we have a sliding scale for people who have no insurance. So that, you know, nobody is denied payment is denied treatment because of because of an inability to pay. We wrote off $53,000 with the free care last year. Thank you so much for all that you're doing out there. Thank you. Dr. Lord I'm looking around the table and on the screen to see if there are any further questions. Although I think I speak for many of us we could sit here and pepper you with questions for the next three hours. I'm free till I'm free till 10 o'clock so have you have you shared your thoughts with or is there anyone to share your thoughts with around the mono product to see if you can be a voice for helping to change that. I guess I'm wondering if you or your nurse have have commented or shared the feedback that you shared with us to the folks at Medicaid about having to move mountains for that. Yes, we have and as a matter of fact I had a very long connection with Mr. fallen. I don't know if you guys know Tony fallen he's with with a DAP. He's also the state opioid treatment authority for Vermont. And, you know, and I've also spoken, you know, Dr. Luconus and I, we all talk Dr. Luconus Dr cluster who I think you're going to hear from tomorrow. Dr. Rappaport and Barry Dr Brooklyn and Burlington. We all talk. We, in fact, we meet every Friday I don't go to those all the time because I have other commitments but we meet frequently and talk about this. And I think we are all of a mind that you know it would be nice if the if the if the prior authorization requirements were somewhat more relaxed. But I think we all agree that buprenorphine mono product is a is it can be a double edged sword and we all still believe that we should be careful with it. It should not be. It shouldn't be treated lightly. For the reason that I've said. Thank you. Thank you, Dr. Lord. Since this is out of my wheelhouse the concept of what you one has to go through for pre authorization. When you say relaxed. What does that mean. What it means is if I if I was to say if I was to call Vermont Medicaid or if I was to call whoever and say this patient we have trialed or has trialed buprenorphine mono product that they have the following symptoms. In my professional opinion, the patient should have Vermont should have buprenorphine mono product as a reasonable thing up to 16 milligrams. They should say okay. Okay. And instead what happens instead I have to I have to as I as I've said I have to I have to demonstrate that you know I have tried to treat the nausea and the headaches and put the patient through, you know a difficult time dealing with side effects that are oftentimes treated. And, as I said, you know back when in the recent past I was a, you know I practiced orthopedic oncology way way back. And we prescribed Adrian my son and methotrexate and all kinds of other terrible poisonous drugs. In those circumstances, it is entirely appropriate to treat side effects because the drug was necessary and there's no getting around it. In this circumstance, it's silly. And there's no other drug that I think that that has been that you do that with I mean, if you take a cholesterol drug and produces side effects do they give you medication to treat the side effects no they put you on another drug. Right. So, you know, you know, again, cholesterol drugs don't get abused all that much so so it's a little bit different, but still the concept is the same. You know, if I think that somebody should get monoproduct because they have unacceptable side effects. I think my word ought to be good enough. Okay. Thank you. Thank you very much. This has been really very helpful. And as others have stated thank you for what you are doing in Vermont and in New Hampshire, but we're more focused on Vermont. Well, so you know I can throw a rock from my office and hit the Connecticut River so it kind of hard to avoid New Hampshire, you know. So thank you very much for helping us as we figure out what our next steps are or what we might ask the Department of Health access to explore right or something like that. Well, Madam Chair, it is my great pleasure to be here I appreciate the opportunity to talk with you this morning. And I mean this sincerely if there is anything else that our practice can do to help or information that we can give or, you know, anything, please call on us Julie knows how to get a hold of me.  So, thank you. Thank you, Dr. Not only will we take you up on it but as this bill proceeds through the process and goes to the Senate. We will highly recommend that the Senate Health and Welfare Committee connects with you as well. I believe Miss Clarkson is on that committee is she not or Miss Nica wanted to. She's not on health and welfare she's on government operations and economic development. I can figure out a way how those committees could hear from you. Maybe I will. Okay. All right, thank you very much. My pleasure. Have a good day everybody. Thank you. Thank you. Bye. And this ends our morning session. And if there is time based on what is floor action 15 minutes when the floor is over we will come up and have a further discuss committee discussion before taking up more testimony tomorrow morning.


CESAW uses multimodal learning tools to make thinking and learning visible. Let's see how teachers and students are using one of our most powerful and easy-to-use tools, the photo tool. Teachers use the photo tool to capture day-to-day classroom moments. While students are working on a science experiment, teachers can use the photo tool to capture students working their way through the scientific process. When posted to the journal, teachers can tag students in the photos to provide both students and families with a glimpse into the learning taking place in the classroom. Teachers also use the photo tool to take pictures for students to annotate. Teachers can take a photo of a page from a nonfiction book and students use the drawing tool to highlight and label the nonfiction text features in the picture. Teaching word problems with pictures is a great way to get students to visualize when solving the problem. Include your students in your math word problems by taking a picture of the students in your class and sharing the photo with students in the journal. Students then use the drawing tools to create a word problem based on the image. Students can use the microphone to explain their word problem. Don't forget, the photo tool can be used to capture organic in-class moments to share with families. If you're having a class celebration, use the photo tool to share the excitement with family members. What a fun way to build classroom community while keeping families in the loop. Now let's take a look at how students use the photo tool to deepen their learning. Students can use the photo tool to capture their learning anytime and anywhere. Here are a few examples of how you can use it in the classroom. In math, students can capture their work with manipulatives by clicking on the photo tool and taking a picture of their hands-on learning. In science, students can capture and document experiments or use the photo tool as they walk around the school or outside to capture photos that support their learning. Students can take a picture of their writing to create a portfolio that shows their progress over time. The photo tool in CSaw allows all hands-on learning to be captured. And don't forget, students can then use any other multimodal tool in CSaw like the drawing or recording tools to add a layer of reflection. All learning in class can be captured using the photo tool. The photo tool allows both teachers and students to capture day-to-day hands-on learning. Your challenge this week is to plan one time during your day to use the photo tool to capture classroom moments and learning experiences. Share the creativity you capture on Twitter using the hashtag CSawMiaMinute.


So, let me ask you, if you are a Seloti, you've seen this city side very dominant in the Premier League, very dominant in the Champions League, what can you tell your players when you're going to face such a Manchester City team? We are away, I'll say that if I'm the coach, we are away. But we don't have away goals nowadays. We are away, so the home team expects to win because it will be at home and they expect to be very strong. So, real Madrid should go out and really try to ensure they get a result that they can build on if they have to get back to Spain. Yes, yes, yes, yes, ladies and gentlemen, this is Grau's show. I have a friend of mine over here, Naitunani. You know, Manchester United, Kelvin Benson. I don't know if it's Arsenal or Parley, but I know it's Man City. Today, we have a very big show. Line to you, ladies and gentlemen, two Kona Champions League semifinal Man City taking on Real Madrid at Etihad Stadium. Before we go to that game, breaking news, Pogba Amayacha Manchester United. He has left the whole subgroup. Paul Pogba Amayacha Manchester United subgroup, he has left. Okay, the guy has injury. He has injured, he can't like it. Kitambarudi season is not a commissia. Then, attack of free agent. We know Pogba Amayacha is hot and cold, Manchester. The last time I was in Arsenal, only two Andani, but I had to come out here. Arsenal reigns supreme always over Manchester United. For comment section, where do you see Pogba's future parley? If you want to pick a like, share and subscribe. Man City versus Real Madrid. Battle of the Titans. English heavyweights, Spanish heavyweights. The last time these two met, Manchester City overcame them. Now, this is one of the best games in your Kona, he wiki. Bro, let me ask you. Manchester United, Manchester City, sorry. Wami Fik, Wajaweshideki Kwanwe. Zero times. Real Madrid 13 times champions. I will history determine this game. Okangalia, because this one side ishashendi game. Zero times. Ishashendi cup zero times. Kona one side ishashendi hitu 13 times. They are meeting tonight. Can history repeat itself tonight? That's a very important factor we mentioned. You remember last year when Manchester City made it to the finals, they were the favourites. Chelsea came into the finals as underdogs. And again, as much as Pep selection was something that was questioned on the midfield. At the absence of maybe a holding midfielder. The cast of the champions, or rather the ghosts came back to haunt them. They've never been a final and maybe were won. But you're looking for a Real Madrid team that has been in the Champions League. Are you mentioning experience, are you mentioning history? Real Madrid have won this Champions League a couple of times. You can remember the era of 2016 when they won. Are they were the favourites winning it when players lead careers or making errors? So if you're talking of maybe history repeating itself, it's something that is a very important factor. And it can come to play today. But looking at the form of these two teams, it's a very difficult fixture to say that history can come and maybe haunt Manchester City. Because you look at a Pep sale of play. If you watch the game again, it's fought over the weekend. They smashed them 5-1. 5-1. Very beautiful goals. Very amazing goals. Inasmuch as history might want to come and maybe reveal itself, then I think Manchester City will know that they are the favourites here. And they know they have to give it their all. Because we are looking at a team that is playing at home, at Etihad. Inasmuch as they don't have many supporters across the globe, their football is excellent. So I really think history might matter but not that much. Pep Guardiola said that tonight, if they can play like they played in the second half against Atletico, they will suffer because you could see they were so nervous when they are playing against Atletico away at home. So he is saying that if they can play like that, the way they played against Atletico last time out, they will suffer against a team that they know is very, very offensive. Gundogan yesterday came out and said that Real Madrid, unlike Atletico, they have the players, they have the manpower and the experience that can hurt Manchester City. If you look at this Real Madrid side, which players to you stands out and Real Madrid, Manchester City should be wary of? Ya, you know, I watched Manchester City game versus Watford over the weekend and they were playing an all-out attack form. But that's how they always play. They are being hit on the counter and that's what even made Watford to score their goal. I can remember even Vincenco coming up with a tackle after they've lost the ball. So if Real Madrid are going to use the pace of Vinicius Junior over the wings, over the flanks and at the legs of Rodrigo and then maybe... An ascension. An ascension. He has a very good left foot. And then now you talk of the players who have the calibre of Karim Benzema. If the pace he wingers, for example, can really travel the defensive side of Manchester City because Kailoka has been there but it's been on and off. I don't think he will make it tonight but he might. He might but he won't play tonight. They are here to look into that matter. So I think they might want to start Vinicius Junior. So who can replace Kailoka if he's not there? Vinicius Junior and Cancelo. So Cancelo will play in the right back. Vinicius Junior will go left back. And I watched Vinicius Junior play at left back over the weekend. He was going forward so much and leaving space. Sack that Watford were hitting them on the counter. And if you could listen to the press conference, Pep said in as much as we played we scored five goals, there are some things that we need to fix more so defensive way because in as much as you might want to attack and you might want to attack a team like Real Madrid. This is a team that scores also. It might score for fun. And if it outscores you, maybe you scored, maybe they put it right past you, you scored two. Then you might end up losing that game. In as much as Manchester City might want to contain Real Madrid, they should measure on the wings because that's where everything comes from. Because if you look at Manchester City, look at the goals they scored against Watford. Kevin Dubluna could make across even from Enno in the pitch, in the midfield, in the wind. But Benzema is being fed with every area ball. And in as much as we have Ruben Diaz and the likes of John Stones who can read who are good in the air, then the pace of Vinicius Junior can really affect this team. We know, and we've seen this one of the best season Karim Benzema is enjoying ever since Cristiano Ronaldo left. He has come out and is proving all the critics wrong. Even his years people are saying that at this age now he can't make it. He's proving all the critics wrong. How can you neutralize the threat of Benzema? Because we know Benzema if you give him a space he's good in the air at both feet, inside the box and out. How can you neutralize the threat of Benzema? If you are to mark Benzema you might be doing yourself wrong. I look at the goal which he scored turning and shooting at the set of goals because he knows where the goal is and he knows where to shoot. So if you are to say that a man might I might want to mark Benzema it might be a very difficult thing. But are you denying Benzema at the ball to his feet? Are you denying the crosses to reach to him? Are you marking Luka Modic? These are people who make deliveries. You showed that pass that he gave Rani to score. They were saying that was an art. It should be stored in football museum. If you are to neutralize that if you are ready to narrow down the angles maybe for them before they can make those passes and even look at the deliveries if a player like me or other likes of Marcelo if they want to pass the ball to Benzema it may be crossing but are you blocking those crosses? So Benzema will lock the ball. We know if he locks the ball in the box he drops a place like a false nine at times and then he tries to create chances. So if you are to mark Benzema you might be doing yourself wrong but if you are to mark the players who are made That are going to deliver the balls to him. Yeah the creative players the Tony Cross, Luka Modic, Toko Kamabinga these are people who can really deliver. So do you have those players that we know that can cut off those supply chains because in those supply chains is where Real Madrid can get the chances and as you said the other day that this city side they have always shown us that if you attack them you will get a goal and Man City and Real Madrid they have the players to attack. Yeah you have mentioned something maybe that is where the central defense in midfield is coming we have looked at Fenantine you are not starting many games this season the guy is 36 years old Yeah 36 is very old just starting the other day the player that we can say defensive voice is very good for Manchester City may be rotary in the midfield Gundogan can also come back Yeah Gundogan So if these are the two players who I think can really try and also can sell in as much as he has he is so patient the likes of Bernardo Silva, Jack Griddich they cannot defend those are players who really attack their vision is to go forward I like Bernardo Silva though he defends also Yeah he is present he presses very well and he tries he is so energetic and Pep even pressed Gundogan the other day saying that Gundogan is a very good midfielder world class even as much as he can play in the midfield he can attack he can play as a false nine So I think Manchester City are to use maybe rotary very well remember teams like Chelsea use Kante very well as you know when you don't have Thomas Party who is a very solid CDM Manchester United we lack one of late because look at Maktum he blows certain quality but if rotary can try maybe and defend the back line maybe sit just in front of the back line try to ensure that he is covering up the spaces that are being left there you've mentioned of the supply chains these supply chains are then going to be blocked or cut and then the ball might be very difficult to reach to the Manchester City box and maybe but as we know Kevin if you look at the way Man City they play they always don't put like we are going to defend they always defend as a team if you lose the ball you get back defend press take the ball start the attack press get the ball start the attack if you look at these bands this Real Madrid side the kind of place they are going to miss they are going to miss Kasemiro Alaba might play or he might not play subject to very very late fitness if you look at this Real Madrid side where are the weakness if you look at it the weakness that Man City can exploit the absence of Kasemiro but I even never knew you will not be playing tonight you won't be playing tonight Kasemiro substance might he might or he might not if you will be absent then that will be the part that the city should take it is a thing that passes a lot in the box also in their own half they want to frustrate you mentally they want to break you down and then when you are broken down and you are not aware what they are doing then they can cross the ball even score very beautiful goals look at Jesus scoring was it four goals or three he scored four goals a hard trick and a goal and the deliveries that were reaching Jesus were pin point the first goal he scored the header it was an accurate cross from Kevin DeGreve that is where now Kasemiro should come in but if they left Kasemiro we watched Real Madrid miss players when they lost Benzema they were beaten fornil by Barcelona and defensive voice they were very shaky you might want to replace Kasemiro with the legs of Federico Valverde Nyasmacha is a very good player Kasemiro has experience and this stage where you expect players Kasemiro to come in this semifinal people will tell me this is the world's largest game this is what many people watch so if Real Madrid miss Kasemiro then Manchester City can try maybe use the midfield and you know the legs of Alaba also Alaba is not very passive you watched him play he is very good in dead ball but he is not very passive so if Real Madrid can use the pace the legs of Rahim Stalin and maybe use the channels also Carvajal has been very rusty of it also due to age and even the coach said that but they are trying really because he swing was the one that went when they were playing against Chelsea the supply were coming from that from Carvajal yeah from Carvajal swing so if Manchester City are really trying to maybe analyze and watch that then use those parts and maybe try to score a goal if you look at the way Manchester City always they play they don't come and play against your weakness they play they believe in their strength that if you play like this then you are going to win so let me ask you if you are at Saloti you have seen this city side very dominant in the Premier League very dominant in the Champions League what can you tell your players when you are going to face such a Manchester City team we are away but we don't have away goals we are away so the home team expects to win because it will be at home and they expect to be very strong they will have the support of their fans in numbers so Real Madrid should go out and really try to ensure they get a result that they can build on if you have to get back to Spain because as much as Chelsea put them in Spain they qualify so if they have to get their tactics right first they should not be nervous because Manchester City can really attack you mentally don't be nervous try as much as possible to ensure that you are getting the chances if you are getting the chances what are you doing are you being clinical are you missing the chances be clinical and then build from that then going forward try to understand the game don't soak into the pressure of Manchester City like many people do like Watford four goals in the first half they are very poor so Real Madrid should not be poor and then play as a team identify your strengths fit the ball to Karim Benzema try to score because we have seen we have seen that in this Champions League we have seen a lot of twists and turns whereby Chelsea Real Madrid goes to Chelsea's place they beat Chelsea Chelsea go at Real Madrid they beat Real Madrid so it's a game whereby I think do you think them removing the away goal thing do you think it's making football more exciting yeah football has been more exciting because you are going to play but there are times it wasn't like that you find that a team scores two goals at home then when he goes away he defends yeah and that's not the joy of football you want to see action a team might score even two or three and then they are very comfortable they don't play to their calibre to their full capacity and that game becomes boring to you as a fan so scrapping away their away goal role has really helped because we are seeing more teams playing like they know they've got everything to win and nothing to lose because if maybe you are beaten to need and you take that result and build on it I remember in 2016 when PSG beat Barcelona in the first leg 5 nil 5 nil yeah the coach said if they scored 5 in the IR that means you can put 5 past them or 6 and what they do they scored 6 past them away goals are real right now they don't even matter no one cares so a team should just go and play knowing that if we score then in the second leg we can build from that result and that is how football should be it's exciting to watch their away goals not being there because it is giving the players and the teams a chance to play football if you look at really Madrid to their fans Pep Guardiola this one coach they always don't want they don't like meeting because this one coach that they've met 15 times and they've only managed to beat him as a coach twice so this is the 16th time let me ask you if you are Carlo Ancelotti you know these stats can he marshal the troop and get a win tonight because he has to if he has to get another round yes Pep is a tactician everybody knows that Pep is a very good coach and we've seen Pep even play was it in Barcelona he was a coach at Barcelona his style of play was very good very evident he brought that same play to Manchester City you took it even to Bayern Ancelotti has been a coach who sometimes is on sometimes is off sometimes he blames the player sometimes he doesn't have the squad but you are looking at a team today a very serious game tonight a game where Manchester City will really be expected maybe to show us that yes they can remember these are two teams which are leading Manchester City leading in England is it 79 points Real Madrid are 78 living Barcelona the second place with 15 or 13 points so these are teams that domestically they are doing very well these are said that now they have to show us that whatever we've done in the domestic league we can bring it here and like the likes of PSG and Bayern were out then here we have to show you that we are the real team and these are a very difficult fixture to call but I really think Manchester City can win this game can, not they will they can win this game if they have to play like we've seen them playing and if they have to look at the game against Real Madrid and Chelsea or they relax or they not passing the ball accurately then build on those and then try maybe to go and get a win so Manchester City I really expect them to win tonight if you look at Manchester City which are players that you think tonight must stand up for them to win we will start with the impressive Kevin DeGruan of course he's a very very very good player we all know that I look at Jesus who has been good or sharp in front of goal of late but he blows out and cold he's not always consistent in fact he's been linked at a move to Arsenal but Pep says that he loves Jesus as a striker but that's what he says to almost all the players Jesus presses because of late we've seen his form increase but am I looking at Kevin DeGruan defensive voice am I looking at the likes of Diaz am I looking at Cancelo will you stop the threat of the initiative will you stop the threat of Diego Bernardo Silva Bernardo Silva he's a player who really that left foot Riyad Marez has not been given so much game time but when he comes in the game in fact the Champions League is more lethal in fact he's the top scorer in the Champions League so these are the players who you really expect Pep to start because he even rested the Marez the other day coming on in the second half subbing of Kevin DeGruan Phil Forden another one of the good passers you remember the pass that he passed to Kevin DeGruan scoring the winning goal so I really think Phil Forden, Kevin DeGruan as much as we might want to mention individual city plays as a team that's true yeah city plays as a team so I really think the whole team should turn up but I really will look at Kevin DeGruan how he will deliver the ball into the box I look at Rahim Sterling don't miss the easy chances if you're given the chance to start if Riyad Marez is given the chance then that left foot should ensure Real Madrid pay the price looking at the Real Madrid side which players should Pep Gadiola be very very wary of we all know Karim Benzema he is a very big striker are you looking at Vinicius Junior who really can he is very patient he is very witty with the ball he knows what he is doing are you looking at the vision of Luka Modric are you looking at players like Rodrigo Ossenshu who can come in the game and change the game try to in as much as you might not manmak those players cut the passing lanes if you are to cut the passing lanes ensure these passes are not being delivered to the open then you might go on and win the game I think if tonight if you are going to watch this game to me I think it will go down to which team wants it more and which team has its tactic right if you look at Real Madrid how they are set up to play and you see if you cut you cut off Vinicius you cut off ok, I am left handed if you cut off Ossenshu and Vinicius so that they don't supply the ball to Benzema I think you can you can manage Real Madrid and if you can attack Real Madrid as well they have also shown us that they are very very porous at the back they don't have the you see like way back they had Pepe they had Ramos very very little defenders and very very strong both in the air hard tacklers I think that's the only weakness Real Madrid have if you attack them you can you can get goals for them but also this I say this plus it applies to Man City if you attack Man City you will always get the chances now can you score when you get the chances because to me I think the team that will take the chances tonight is the team that is likely to win I can't put my money on Man City because Real Madrid can turn it up and we know if it stand up they are very very strong team let me ask you what's your prediction score of tonight's game Man City vs Real Madrid Man City 2-1 win Man City 2-1 win I think I'll go with Real Madrid they can win this game tonight by 2 goals 2-1 so you have 2-1 you have 2-1 so 2-1 Real Madrid 2-1 Man City so go there opportunity to be a prediction you can win you can win you can win you can win your team champions league Leo Leo 5-4 4-3 yes, 40 2-1 2-1


This is an emergency alert. This alert is made by the SCP Foundation on behalf of your national government. Do not go outside, stay in shelter. Do not let any sunlight or moonlight touch you. A powerful anomaly has altered the sun, and sunlight has now become incredibly dangerous to all forms of life. This dangerous effect is present in all visual light emitted by the sun, and is also present in moonlight. This anomalous alteration to the sun has been categorized as an XK-Delta class, solar singularity, scenario. The sun has been designated as SCP-001. Unconnect with visible sunlight, organisms liquefy at the point of contact, until the entire organism is liquefied. At no point in this process will the organism die. The liquefied organisms may merge with each other. These organisms will seek out unaffected organisms and drag them into the sunlight. The liquefied creatures can speak with the voices of the humans they used to be. Do not go outside, even if you are told it is safe. If you absolutely must go outside, you should follow this guidance to stay as safe as possible. Travel at night, as moonlight is less intense than direct sunlight. Wear thick clothing to keep out any sunlight, this should include a full face mask. Avoid cities and areas which were formerly forests, they are hot spots for the liquefied organisms. Avoid the liquefied organisms if at all possible, they are hostile and dangerous. If you are forced to fight one of these organisms you should use fire, it is somewhat effective. If you have no food, it is safe to consume small amounts of liquefied organisms. Thank you for paying attention to this alert. Please stay inside and out of sunlight and moonlight. If you must go outside, please follow the guidance in this alert to stay safe. This message is for SCP Foundation staff only. If you are seeing this message in error, please stop watching out. SCP-001 is a Napoleon class anomaly and therefore cannot be contained. Civilian populations must be abandoned to ensure the survival of Foundation staff. Civilians have been told to stay in their homes for their own safety. In truth, this instruction has been given to reduce numbers of SCP-001 creatures. SCP Foundation staff must avoid these creatures and reach sight-tinding. While traveling, SCP staff must remember to stay out of sunlight and moonlight. If you are forced to engage the SCP-001 creatures, use fire or cryogenic arms. At sight-tinding, the Foundation is working on off-world colonization methods. Come to sight-tinding, the Foundation needs all the hands it can get to make a future. Thank you for your attention and service. Good luck getting to sight-tinding. We must learn to embrace the darkness and fear the light. Secure. Contain. Protect.