Good afternoon to the part two or three of the Vermont House Human Services Committee and today is Thursday, March 10. This afternoon, we're going to continue our discussion on our opioid overdose response services committee bill that we are in the process of developing as we want to make a response to the current uptick in overdose deaths and fentanyl. And with that, welcome Deputy Commissioner Sandy Hoffman and I will ask you to start us off. Hi, thank you for having us and for the record I am Deputy Commissioner Sandy Raymond Hoffman. I am a licensed alcohol and drug counselor and have been with the department for about five years. I just want you to have that information. And Lisa Herto is actually going to kick us off. She's the clinical pharmacist for Department of Vermont Health Access. Hi everyone, for the record I'm Lisa Brulat Herto. I'm a PharmD. I'm a clinical pharmacist with Department of Vermont Health Access. Can you hear me okay? Perfectly. Okay. I do have some slides. I want to walk through with this group. We have emailed them out. Can you see them or would you, should I share my screen, should I try to share my screen? They are all on committee. They are all on our webpage. And if you give us, you know, a minute if that to pull it all up in case we have not done it. Perfect. Committee, let me know when you have found it. And folks who are listening, it's under Thursday, March 10th, House Human Services. And it is under, I believe it's posted under the Deputy Commissioner's name in terms of prior authorization requirements. Okay. So I'll give a, I'll give a go. What we're going to go over today is regarding prior authorization requirements for medication assisted treatment for opioid use disorder with the Vermont Medicaid program. So today we're going to discuss the Department of Vermont Health Access Diva's responsibility for providing Medicaid members with the lowest cost medically necessary medication for a given disease or condition as well as its responsibility to Vermont taxpayers to carefully manage drug costs. We'll review the data telling us about timely access to medication assisted treatment for members and discuss how Diva has worked collaboratively with providers to minimize prior authorization burden and remove barriers to medication assisted treatment of substance use disorders for members. I want to start out by describing the state requirements for pharmacy best practices and cost control and consumer protection. So the Department of Vermont Health Access Diva has a preferred drug list or PDL, which includes medications for medication, medication assisted treatment of substance use disorder in accordance with 33 VSA 1998, the pharmacy best practices and cost control program. This program allows for the use of an evidence based preferred drug list of covered prescription drugs. Diva works with a drug utilization review board or DUR board who makes recommendations to Diva based on evidence based considerations of clinical efficacy, adverse side effects, safety, appropriate clinical trials and cost effectiveness. The entire medication assisted treatment class has been reviewed numerous times by the drug utilization review board and all prior authorization criteria where they exist have been reviewed and approved by the board. The DUR board, and I can talk more about this but I'll just explain briefly, the DUR board is composed of Vermont based prescribers and pharmacists and occurs four physicians and five pharmacists with an opening at the moment for an allied health professional and the idea is to ensure broad expertise on the board. In addition, Diva is compliant with 33 VSA 1999 consumer protection rules prior authorization. This protects consumers and providers from overly burdensome prior authorization requirements and processes. I also want to point out that there is a legislative requirement for an annual report on prior authorizations for medication assisted treatment. This is a result of Act 43 of 2019, which was an act relating to limiting prior authorization requirements for MAT and it was signed by the governor in May of 2019. In accordance with section four of the prior authorization for MAT Medicaid reports, the Department of Vermont Health Access is required to submit reports on or before February 1st of 2020, 2021 and 2022 regarding Vermont Medicaid's prior authorization process for medication assisted treatment. There is a link that you can all click on if you're interested to get to that report. The third and final report was submitted this year in accordance with that act. Specifically, the department is required to report on the medications that require prior authorization, how many prior auth requests the department receives, how many are approved, how many are denied, and the average and longest lengths of time the department took to process a prior auth request. I want to point out, because I feel like I'm saying prior authorization a lot, that there is no prior authorization required on several medications for MAT. Methadone, when it's used for treatment of substance use disorder, does not have a prior auth. Suboxone film and buprenorphine are naloxone tabs of 24 milligrams or less in the hubs. Suboxone film and buprenorphine naloxone tabs at 16 milligrams or less outside of the hubs. And it's also important to note that most patients are managed at this target dose of 16 milligrams or less. Actually, 85% of our prescriptions are managed at that dose or less, for which there is no PA required. Does that make sense? A lot of talking here, so feel free to jump in if I'm confusing. I'll keep going. There are no quantity limits for Suboxone film of two milligrams, or the buprenorphine naloxone tabs of two milligrams, and this is for ease of titration or induction without needing prior authorization. It's also important to note that at least one dosage form of every drug marketed for MAT is available without prior authorization. Methadone, buprenorphine, and naltrexone. Additionally, Narcan naloxone nasal spray for treating overdose is available without prior authorization. So the data tells us from the report that is submitted in the link there that Vermont Medicaid members have timely access to medication-assisted treatment. And again, remember, several medications do not require prior authorization at all. Did someone raise their hand? No, okay. On average, when a prior off is required, the Medicaid program processes it within 30 minutes. The longest length of time for processing the prior authorization request range from around seven hours to 12 hours. All authorization requests for the year were completed within 24 hours. It's also important to note that there is an emergency 72-hour override that's available for pharmacists. When they're unable to get a prior authorization in a timely manner, there is an option for the pharmacist to override that request and provide a three-day supply. The next slide is just a link, a table from the link detailing the average determination times that were already discussed in some of the specifics about the number of claims and the longest determination times. So I want to step back a minute. I'm not sure if this was already, someone has already gone over this with this group, but just to kind of, to bring us all to why, why are we using buprenorphine for opioid use disorder? We hear this often, but what does it really mean? So buprenorphine is an partial agonist at opioid receptors. What that really means is that it reduces cravings and withdrawal, and it blocks the euphoric effects of self-administered elicit opioids through mechanisms of cross-tolerance and opioid receptor occupancy. So is it safe? Yes, not for everyone, but the reason it's a good choice is that there's a ceiling effect on the opioid activity. Therefore, it's less likely than methadone or other full agonists to cause respiratory depression. It's also important to note that there is a risk of lethal overdose when buprenorphine is combined with other central nervous system depressants, like benzodiazepines, like Valium or clonopin, or alcohol, or dextromethorophan. The other thing I like to point out with risk is that it could be deadly if it's in the hands of individuals unintentionally. Excuse me, let me say that again. If it gets to people who shouldn't, who don't need it and shouldn't have it. So for example, there are multiple studies that highlight the risk of buprenorphine overdose in children. And I want to point out that a lot of the, some of the dosage forms are sublingual. Sorry, keep going. Okay, so I wasn't sure if that was for me. Our door opened and someone waved at us. A pass call. A hand club. Okay, so the ceiling effect that I mentioned on the last slide that's seen in adults doesn't seem to apply to young children and fatalities can happen in children. And there are a few studies that highlight that. And then just circling around back to basics because it was asked previously, according to the FDA prescribing information, the package insert for suboxone, for maintenance treatment, the target dose of suboxone film is usually 16 milligrams as a single daily dose. And so that's just a link to the actual prescribing information as approved by the FDA. So the next slide, I just point out a few of the common questions that may be asked. Why can't everyone be managed on 16 milligrams? For most people, the target dose is 16 milligrams. And at this dose, 97% of the receptors are already saturated. So there tends to be a minimal effect from further increasing the dose. But like with a lot of things that we know, the dosing requires individualization. That means finding the maintenance dose for the patient that alleviates cravings and withdrawal symptoms without causing sedation may take a little bit of work. This may require doses up to 24 milligrams, but 16 milligrams again is the target dose for most people. I think it's also interesting to know that there about 20% of our prescriptions are for doses that are nine milligrams or less. So not everybody needs the higher dose. Next question, why are most prior authorizations for buprenorphine dosing over 16 milligrams approved? If the patient is being treated for substance use disorder and the prescriber provides documentation of continued cravings, acute withdrawal symptoms or relapse, the request for a higher dose is clinically approved. And what are some of the reasons for the denials? For the most part, the denials for preferred products have to do with coordination of benefits. And that's because if Vermont Medicaid is not the primary insurance, Vermont Medicaid is required by law to be the payer of last resort. The other common reason is for dose consolidation. And I'll just dose consolidation basically just means if there's how to get to the same strength with the fewer number of tablets or films. So instead of having, you know, for two milligrams, you would want one eight milligram, for example. So prior authorization requirements for medication assisted treatment and the Vermont Medicaid program. The Department of Vermont Health Access requires prior authorizations for its non preferred products, all of which are clinically reviewed and determined to be equal to or clinically inferior to preferred products or more costly to the state of Vermont. Examples would be the buprenorphine mono tablets, ZubSol, Sublacate and Pro-Bufine. Does anybody have questions about those specifically? I'll keep moving, if not. So the next slide just outlines a highlight from our pharmacy best practice and cost control report that is submitted every year in October. And what you can see at the top of the list, under therapeutic class, the opioid partial agonist or substance abuse treatments, is that buprenorphine products are divas number one product for both spend and utilization. So we have the most number of claims and the highest number of dollars spent. And this, this data is just including pharmacy numbers. If we included medical claims, that would add an additional couple million. I'm going to defer to Sandy to go through the next slide about team care. Okay. Thank you, Lisa. Are there any questions up to now? Okay. So I wanted to talk to you about the team care program, which is the care management. I apologize. I did not say we do have a question. Okay. Thank you, Madam Chair. Back on slide 11, when you talked about the coordination of benefits, because Medicaid is the pair of last resort, I'm wondering if that could be done retroactively. You mean have Medicaid pay and then like a pay and chase or something like that? That I don't have an answer to. I could certainly take it back. I don't know if Sandy can speak to it. There's no mechanism that would allow that right now because of the way that the program is set up. But I don't know if there's, I can certainly take it back. Thank you. Okay. Carl. Good. I just, for summary, I know you talked about this, but I forgot what the answer was, I guess. And that is, I know the number of denials, let's do something you call it, number of PAs denied in that one slide showed like 53 out of 106,000. So why would those 53 be denied? I know you mentioned it, but if you just repeat it. Yeah, sure. So and actually primarily it's for that reason of the coordination of benefits. So the person has another insurance that would be, that would pay for their prescription. So Medicaid is not the primary payer. So that's one of the main reasons. The other reason is for that dose consolidation. And so what that means is if, you know, if there's, if there's, if there's three tablets that you can put into one tablet, then we would want you to take, have the lesser numbers, instead of having, you know, nine tablets for three days, you would have maybe one tablet. So we're consolidating that dose. So it's not multiple of the same of a smaller dose, if that makes sense. Thank you. Just to build on Representative Rosenquist's question, you said dose consolidation is one of the reason for denial of prior authorizations. Yet on the previous slide you talk about, had doing four milligram dosing throughout the day up to 16 milligrams, which would, I would say, have those smaller quantities or a larger quantity of medication or tabs, but is in those smaller dosages. So it seems conflicting if we're allowing folks to be able to hydrate and do that, but also denying because of dose consolidation. Are you able to explain that a bit more? Yeah, I think I can. I think what you're talking about is the two milligram strength. And so that's usually used where we, there's no prior authorization on the two milligram strength. And so there wouldn't be dose consolidation. That's, that's exactly what that means. Actually, that's a great way to look at it. There wouldn't be forced dose consolidation for a two milligram strength, especially, and we've done that so that in the, in the beginning, that induction or titration can happen. So you wouldn't, if in the beginning, if you were starting, you know, you're, you're new to the medication, the two milligram would be the strength that would help, that you would get initially, and there would be no limit on that. Once you're at a maintenance dose, you wouldn't want to take eight films, eight tabs of two milligrams, you would take a 16 milligram or two eight milligrams, I guess, technically. And so you wouldn't be maintained on a two milligram strength. Right, that absolutely makes sense. But it even says on day two that it's the 16 milligrams with the four milligram tablets. So would that four milligram not be approved, but the two milligram would? So I guess I'm not sure if I was from the, which slide number you're looking at. Slide 10. Slide 10. Okay. Let me, let me know exactly what it says here. Okay. So this is just from the package. It's not a six station of buprenorphine and naloxone. It's 16 milligrams of the buprenorphine and four milligrams of the naloxone. Okay. That helps clarify. And one other question going back to slide 11. And the reasons for denial of prior authorizations that specifically starts out with for the preferred products. Does that mean non preferred products are just automatically denied or prior authorization? No, no, it doesn't. I think we'd have to look at a specific example. So all of our prior authorization criteria on a non preferred product is laid out on the preferred drug list. And so we'd have to look at those individually and specifically, and they would be based on what the criteria that required criteria. So it may be that there's a preferred product that the patient could use. If that's, if they've already tried and failed, then they would meet the, you know, may meet the criteria. So we'd have to refer specifically to that criteria for that specific drug because they're all different. Okay. So what I hear there is that patient might have to try a preferred drug first for it to fail then to move on to a prescription that is not on the preferred drug list that works for them. We would have to look specifically at the drug and question on the preferred drug list. Okay. Thank you. I just have a quick question on seven. So it looks like there were on each one, you've got the numbers denied, you have 53 claims denied out of 1670 of the claims.  Looking at that, right? So if you take, someone tell me if I'm wrong, but if you take the fact that you take 19 million into 106,000 claims, that works out to $184 per claim. You denied 53. So that's $9,700 worth of denials.  Am I reading that right? Out of 22 million. So I think what you're doing is doing the math on the dollar state, which isn't the way that this report is designed to look at. And I haven't done that math to be able to confirm what you're saying. I'm not sure we could come back to it though. Right. So I just was looking at trying to figure out because it's all numbers. Anyways, thank you. Yeah, I'd be interested to find out how much was denied versus how much you paid. Yeah, I think the denials really aren't about the money necessarily. It's often, again, the reason the reasons were about dose consolidation partly in a coordination of benefits, which is that other insurance. And so those, you know, there are kind of a different way of looking at things. Wouldn't all these prescriptions be from a doctor who's working with the patient? Yes. But if there's another, if there's a primary insurance, then the primary insurance would be the payer on that. I'm not sure if we can get someone else to explain that better than I can for the next time. Okay, thank you. So I guess it wouldn't matter in that case if I, how do I say it better? Then the preferred agent or non-preferred agent, it wouldn't, it wouldn't really matter if they have a primary insurance that's paying for it. Ask the question. So Representative Noyes is prompting me to think about a question. So, you know, his math may or may not be right, but I think it's, I think it's probably not that far off in terms of in the realm, let's just say. So I guess it then begs the question to me is how much does that prior authorization process cost the department if you're in this, and I realize this is, we're just talking about one class of drugs here. I don't know if I'm using the right terminology, but we're talking about one, one aspect of the program, I realize.  I'm just pondering the question that I'm wondering how, you know, you're speaking about Medicaid being the payer of last resort, which I'm very familiar with and understand the need, but I'm hearkening back to Representative Garifano's question about, you know, really what is more cost effective for the taxpayer, you know, I don't know how much is spent on the prior authorization process, but it seems like the majority of it is more an issue about coordination of benefits. So I'm just pondering that, Madam Chair. Well, good, and I'm reading articles provided by Representative Whitman that it was talking about Medicare, not Medicaid, but the findings suggest that policies to remove prior authorization on buprenorphine and naloxone may be associated with both with increased use, improved healthcare, and less use of the emergency room, which I think costs more money. So I don't know how you figure out, because one of your slides puts in red costs money, will cost money. So it may, I mean, how much money would it save if we were not paying for emergency room visits? Yeah, that's a great question. I'm not sure if it's meant for me to answer. I think part of the point is saying that with removal of some prior authorization that limits the ability of Medicaid to manage the preferred drug list, which affects rebates that are allowed. And so there's a couple of different things. Also, some categories, you know, the injectable medications, for example, may cost 10 to 15 times more per prescription than, let's say, like a suboxone, a film, or tablets. So those are things that would be taken into account also when there's no real proven clinical superiority in some cases. Lisa, do you have a fiscal impact, an estimate of what removing that would be? Yeah, some of the estimates, I don't have a slide, but I would roughly guess between $8 and $12 million for a year, probably. Increase. Increase, increase. So with prior, just a quick question, just that made me up. So with prior authorization, are you moving people more towards the generic? Is that the goal? No, not always, actually. Our preferred, I'm trying to think if I have a slide that would go through that, but some of our preferred products right now are a suboxone film, so that would be a brand. And that's because of Medicaid's, you know, rebate process and the net cost to Medicaid. That's a whole nother topic to go through, which I can certainly do if you have a few more hours. I have a question just following up on that statement that you made, and thank you for presenting today and for being here and all the work that you've done to prepare for this. Really appreciate it. The $8 and $12 million figure that you presented, that's for full removal of prior authorization for MAT.  I would have to really crunch the numbers a little deeper before I would confirm that. I only asked because the policy that I imagine we're going to get to is not a sweeping full removal of prior authorizations for MAT, so just wanted to look at that claim and what it applies to. I am sort of curious if you have looked, maybe this is to the deputy commissioner, if you have sort of looked at the language in the proposed bill as we have written testimony from Blue Cross Blue Shield that they don't have a problem with it. So I'm wondering, I guess a deep one, do you have the language? Lisa, you have reviewed the language, correct? Yes, I have seen the language. Okay, and so I'm just, I note that Blue Cross Blue Shield does not seems to disappear consistent with our understanding. Blue Cross Blue Shield does not have prior oaths. We apply quantity limits to make this totally clear and have the existing language that allows quality limits at the end of the sentence, not in the middle, but the sentence. So that provision is not opposed by one of the larger insurers in the state. So I'm trying to understand if they'll, how it is written now, whether that is something that the department opposes. So I think there was some concerns about the, I don't have the language open in front of me, but about the removal of the FDA approved dosage in the, in the beginning. I see you're shaking your head. No, am I on the wrong? In the latest draft. Could you read, do you have the latest draft language? Sure. Would you read it in case, sorry, this is a, this is a, this is a work in progress and what we may have sent you may have been draft one. Yeah, so yeah, to be clear, it does not remove that. So I'll just read it through right here. This is on draft 1.2 from March 8th, 2022. And it would be a health insurance plan shall not require prior authorization for prescription drugs for a patient who is receiving medication assisted treatment. If the dosage prescribed is within the U S food and drug administration's dosing recommendations or during the first 60 days of medication, medication assisted treatment when the medication is prescribed to a patient for opioid or opiate withdrawal. And also includes a health insurance plan shall cover the following medications out requiring prior authorization. One medication within each therapeutic class of medication approved by the U S food and drug administration for the treatment of substance use disorders. And two, one medication that is a formulation of buprenorphine monoproduct approved by the U S food and drug administration for the treatment of substance use disorders. I wonder if you could email that to Sandy to the deputy deputy commissioner. I apologize. That'd be great. Thank you. I think that would be good. We'll take a closer look at it. I don't know if it's my place to ask, but I think there would be some questions about including the buprenorphine monoproduct just because that's not a product that is preferred in the guidelines. And so for most people, the combination product would be preferred and that's, you know, for reasons of for diversion as a potential concern with the with the mono product. And so I think part of managing the preferred drug list for Vermont Medicaid is not just cost for sure. That's not the case with the mono product necessarily. It's more of a clinical concern and that it's clinically not the right product for everyone and not even, you know, that would be more of a second or a third line agent. I just want to say it is your place to say you started this by saying, I don't know, that is why we're having this conversation. We are trying to understand and hear from different perspectives. So thank you. And I, and I, and in previous conversation, we had discussed the reason for the inclusion of the mono buprenorphine treatment and really recognizing that the the bill in front of us is a response to the fentanyl crisis and the overdose crisis and that the mono buprenorphine treatment is seeming to be one that is preferred on the provider's end to make sure that folks are maintaining in treatment. And there is this worry about the prior authorizations being put in place, especially in that induction period of making sure that folks are maintaining on MAT. So I appreciate the concern on your end and wondering where the disconnect is on on the provider in the fields and versus diva. But that's a larger question. Yeah, because that's not something the call center who, who, you know, receives and process the prior authorizations. That's not something that they're hearing from with the mono product being a concern with access to. I think that's partly because, you know, because we have the hubs. And so, you know, some of like we, like I said at the beginning, like the higher doses, hubs are allowed to use the higher doses without a prior authorization. And that's often where, where folks will start. And so, and then there also is that two milligram, no quantity limit for the combination product, which I think addresses that titration and induction, but there may be a bigger conversation that needs to be had, but it's not something that the call center is hearing access concerns about. And I just wanted to talk on to what Lisa was saying earlier, in addition to the clinical concerns that she raised, there is a fiscal impact that we didn't consider. And it was not included in the divas 23. Excuse me, deputy Kim, you're, you're, you're being garbled right now a bit. If I lean forward, is that better? Or is it the same? Oh, okay. So in addition to the clinical, the clinic, what Lisa cited clinically, there are concerns fiscally with the, with divas budget. The, these were the impact of this was not included in the 23 budget, just as a sidebar. What's not included? The potential for an increase in costs to diva with the removal of this was not included in a budget. Can I ask a question? Uh-huh. So the way I'm reading this, and I could be totally wrong about this, is that we're not removing the prior authorization. So already in state law, you know, there are certain things that we don't require prior authorization for. And we're just asking that the prior authorization continue in its process for up to 60 days, essentially. They still would need to be prior authorized. I mean, it wouldn't be prior at that point, I guess, but they would need to be authorized. I'm looking to our team members on that. Is that accurate? Can you please repeat the question? So what I'm continually hearing from the department is that we're removing all authorization. And I don't read the bill that way. And it, it, that doesn't seem to be the intent. And I'm just looking for confirmation from that from the people who have been working on the draft. Yeah. So I would say based on the information that the department just presented and some of the medications that they don't include prior authorization for, such as suboxone, correct me if I'm wrong, and methadone. The additional language that we've added here, the only real changes will be that those first 60 days, you know, it will be no prior authorization and looking at the mono tablets, not having prior authorization for the buprenorphine mono product designated specifically. And again, just to look at the pricing for this, it's been 2021 amount. The gross amount paid was 217,000. I'm on, you know, draft page, page seven of the slide. 217,000 was paid out and 10% was denied. So I guess it's $21,000. So I just wanted to be clear though, we're, we're looking that that even those things that you just mentioned represent Whitman would have to be authorized at some point in that 60 day prior to the end of the 60 days. Is that accurate or not accurate? That's, that's what I'm trying to understand. Following that 60 day period, there could be a prior authorization if it does not fit into one of the buckets, such as being within the dosage or being one of the designated medications. Okay. So on day 61. Right. So we're not removing all authorization. Okay. We're, we're sort of, we're delaying it. We're delaying and the removal is really on the buprenorphine mono. If it's within the FDA guidance for dosage. Got it. Okay. Thank you. And so I think, can I just clarify with the mono product then, if it's something that, what you're hearing from providers that the help desk isn't hearing would be during that induction period potentially, would that be then a short term allowance? Would, is that what you're, what they would be looking for, you know, just for a couple of days have access to the mono product and then be trans transferring to a combination product? I'm going to look to the team. I think really in general, the purpose is that some of what we have heard is that any kind of delay, 30 minutes to us is nothing. Hell, we probably kept you waiting for 15 before we started the meeting, but for someone who is perhaps waiting for medication, or in, in the emergency room or something like that, that 30 minutes could mean the difference between, it's like me wanting to get candy. If I can't get it right away, I'm leaving. So this helps in that, in that, you know, we're in, we're, you're calling it induction, I'm calling it getting someone engaged in treatment. And they're a little iffy. And so this is making the path in as easy and quick as possible. And realizing that there's some costs and other things, only doing it for the first couple of months. And then, and but whether or not you use that to the mono bup and whatever. Anyway, that's up to the doctor. You know, and that's up to the doctor whether or not that's something that is needed for 60 days. I'm not a, I don't even play a doctor. So I think one thing I do want to remind the group of pointed out is that for Medicaid, there is that emergency 72 hour override. So a pharmacist has access to that at any time. So if there is any sort of delay or, you know, no being able to wait for a prior authorization, they do have access to be able to do that on their own. It's not something that has to involve the call center. So that is one mechanism that we really try to offer as, you know, to help with exactly what you're talking about. So I do understand that. And I, I agree that it is extremely important for, for these people to have that, the access when they need it. And so that is, you know, one option of why that's there. There are no PAs for emergency rooms. So that's not something that, you know, from our perspective, that should hold up anybody's care from that end. And then I wanted, I don't know, ask or mention with the 60 days being allowed to authorize because it's not prior, but authorized after 60 days. I'm not sure how that actually would apply or how anyone would be able to operationalize applying a prior off after 60 day treatment. There, I don't know the exact rule, but there is a started and stable criteria. So once somebody is on something for 60 days, there would be no way to, you know, to make any adjustments after the fact. So I'm just kind of, that's sort of an interesting concept to me. I don't know if there's a, if there's a precedent for something like that. Yeah. Thank you, manager. The 60 day is current statute in the state of Oregon. So they could potentially provide an example. Carl. Hey, so what I was just hearing about this three day ultra option, if you will override. Are we really just talking about the difference between these periods of time? There already is a three day override sounds like that somebody would not have to wait. Or is that only for one category of subscribers or whatever you want to call or is that across the board to three, up to three days? That override is accessible to, you know, to any pharmacist. So for any prescription, if there's a, you know, if there's a prior authorization reject, for example, any time of prescription, so that there is no delay and that there's, you know, that there's no hold up that that would be able to be used. I was just going to ask, do you have any idea how often that's used? It seems like a pharmacist might be a little reticent to just say, oh, you use that puts him in charge or her in charge of deciding if they think the person is desperate rather or really need something rather than physician or the nurse practitioner who's ordering the, who's writing the script. Right? I guess I don't completely follow, but I have to pull a report on how often that is used, but it certainly is used. Yes. I could give you the details on that, have to pull some more information. I wasn't prepared to speak to those statistics. Okay. My question was just around, do you think then the pharmacy is being put in the pharmacist is making the decision how quick the patient needs the prescription rather than the provider who's working with the patient and did the whole work up and knows exactly what's going on. I hate for us to rely on the pharmacist for those three days and not the provider. That's my point. Thank you. Just to build up on that, the three day, is that like what we see for induction in the emergency room? Is that what we're talking about? Or is this something completely different? This is not part of the emergency room. No, that would be different if there was a prescription sent to your local Walgreens and it required, you know, and it rejected then the override would be able to be used. So this is separate from emergency room. There's no prior off in the emergency rooms. So that wouldn't be applicable. Okay. I guess I'm just a bit confused on this one because this is the first time hearing about this three day override and we've been working on it for. We learn more every day. You know, we learn more and representative Whitman has a question and then Representative Rosenquist has a question and learning about the three day override, I think, is important and helpful. And an override is different than a smooth passage. An override is different than a smooth passage. An override is a stop sign. And it may only, maybe a flashing yellow or flashing red, but it is still a stop sign. And it may not be a big stop sign, but it is one. And so it's a good thing and it's fabulous that we have it. And I was probably here when we did it. Many of us around the table may have been here when we did it and we didn't know we did it. But we'll take full credit for that part. Representative Whitman. Thank you, Madam Chair. I just had a question regarding the need for coordination of benefits. And are all medications subject to prior authorization and then subject to that coordination of benefits as far as who the payer is? Yes. Yeah. I think what you're saying is even if it's a preferred product, but I have another insurance, that should be my primary payer, then Medicaid would stop the paint, wouldn't cover it because they would be told, build the other insurance. I think that's what you're asking. Yeah. So even medications outside of MAT, so like ibuprofen, things like that, that will all go through. Yeah. Okay. And then I guess my following question is I noticed that the reporting due, which was included in your slide, the last report is 2022. And I was wondering your thoughts on the department's ability to continue those reports. Yeah. I mean, certainly the department would have the ability to continue those reports. The last year, as you noticed, was based on the language that was defined in the Act, which defined that 2022 was the last year that it was due, which is why that's the case. And my final question is, does the department collect data on the reason that a prior authorization is initiated, the reason that it's approved, or the reason that it's denied? You mean in more detail than what's in this report? You're looking for more specific detail? It basically it states when there was a prior authorization, but it doesn't describe why. I think it's yes and no. So this report is a specialized report to be in compliance with the Act. And so these are looked at more closely. If you're asking about every medication, that's a more specific data poll. It's not really an easy because they're actual written prior authorization forms. And so that would be a different data collection. But I think it's yes and no kind of an answer. Maybe it's going to depends. Representative Rosenquist and then Representative Wood. I'm trying to formulate this question around, you know, I'm looking at slide seven again. And I see the longest waiting time for one of the largest drugs there is 11 hours and 95 or whatever 11 some hours. So wouldn't that be eliminated by this three? What was it? We call it a three day moratorium or whatever override. I mean, I don't understand why there would be a waiting time if there's a three, three day override. You understand what I'm saying? I think there would be no long waiting times at all. If the pharmacist could use that three day override. I don't understand what the waiting times are if you have the override. Yeah, so the override is is to allow the three days to be dispensed or given to somebody. But the prior authorization determination would still need to be made. And so, you know, you would still it's allowing the three days while that prior authorization is being processed. So you still have a determination time. So the person would be able to get the drive like right at the pharmacy. Even if the prior authorization is going to take about another two or three days. Is that correct? Right. It's to allow for that time while there, you know, sometimes it's not just that it's not the call center making the determination. There's information, clinical reviews and shared information between the help desk and the prescriber. And so to allow that time for that exchange to happen, you know, may take a little bit longer. And then that yes, in that case, while that time is passing that three day override can be used. I guess I don't see the problem about the prior authorization because it seems that the person could get the drug when they need it. They're at the pharmacy and they could walk out with the drug and the pre authorization is going to happen over the next three days or so. That's that's the idea. That's correct. Well, it looks like it's taking care of its own problems. Maybe maybe I'm missing something here. So my question is more related to so if we take a step back and think about changes in policy and whether the department has any thoughts about you know, perhaps implementing a change in policy, maybe along the lines that we have in this bill, but doing it with sort of on a trial basis, you know, on a basis for which we could evaluate the real data, you know, based on experience, you know, for a period of time, you know, in this building we call that, you know, sunsetting after, you know, particular time. That that gives us an opportunity to to evaluate whether in fact those expenditures really would be that much increased or or whether in fact this has any impact on the quality of care that people entering or trying to enter treatment really experience. I'm just wondering if you have any thoughts about that. I can say we really appreciate the work that you're doing and we're hearing everything you're saying. I'm looking forward to reviewing the proposal in the email and we're always looking to improve what our members get. So possibly, yeah. Okay, thank you. That was a good government response. Other questions where or other questions from the committee or the department? I just have a quick clarifying question. I want to be sure that I understand the three day thing is the override under the is the only person making that decision whether or not to override the pharmacist. So the way that the override works, it is at the point of sale. So at the time of prescription is comes into a system and it's adjudicated, that's where the override takes place. Does that help? So that would typically come from a pharmacist because they would have to override that in the in the claim system. So it is. So it is up to the pharmacist's discretion whether or not they would allow for an override. Is that correct? Yeah, the pharmacist would have to you know to to be they'd have to apply the override. I guess I'm not I'm not sure exactly how they do it and how they determine but it is available for them to use. So you know I think about more on example of you know it's it's Friday night at eight o'clock and a prescription comes in that that that rejects for prior authorization or for whatever reason then a pharmacist would you know you're not you don't want somebody to go without a medication um for the weekend or you know depending on what what's going on and so they would be able to apply that override in in that situation any situation but that's just one example. Lisa would it also be customary or possible for the pharmacist to contact the prescriber if that made sense? Absolutely yeah they would call the physician they would talk to the patient you know um and and and find out and help decide from there yes. I want to provide a bit of history in 2019 we passed act 43 it was a senate bill and I want to say the purpose was to limit prior authorization requirements and my guess is in 2019 diva had concerns and that is why a report was being asked but the act requires health prohibits health insurance plans from imposing prior authorization for all counseling and behavior therapies and we're now just trying to limit it to one. The act requires insurance plans that provide prescription coverage to ensure that at least one medication from each drug class approved for the treatment of substance use disorder is available on the lowest cost tier of the plan's prescription drug formula and then it requires the diva to submit reports and my guess is that this is the summary not the legal language. My guess is insurance plan is excludes Medicaid and um but this is you know this is not a new issue the legislature has been concerned about this for a while and so I just I just want to give people a history this is not a new problem and um but we seem to be at the same place and we're trying to find a middle ground yes um I actually have a question for you madam chair. So in the language that we have here we continue to use a health insurance plan so would that not include Medicaid? I looked up the definition of the health insurance plan and maybe we can follow up with Katie to make sure that what I looked up was correct but the definition within this act that and reference which is the same definition we're using here is a public or private insurance plan so I believe it does pertain to Medicaid. Okay let's say the council is here and perhaps um a low legislative council we're harkening back to a bill that was passed in 2019 around prohibiting pre-authorization um and what was the definition of um health insurance? Yeah yeah yeah are you wondering if it includes um Medicaid? Yes yeah I'm pretty sure it doesn't but I'm going to double check. While she's doing that could I just ask a question because this is more of the members that are putting this bill together that uh anecdotally are we carrying that this is a major impediment okay so I mean that's like I guess the more important thing Yes and that's what I was wondering is that a major impediment for people to get the medically assisted? Katie in the bill that I was in the act that I was talking about it was health insurer as defined in 18 VSA 9402 oh it says health insurance plan includes any health benefit plan offered or administered by the state. Isn't that Medicaid? I think we've run into this problem before Jen is the expert I'm going to send the citation to her for confirmation but I'm pretty sure that if we want it to need Medicaid we specifically spell it out in the definition so I will um I will don't I will confirm but let me get back to you. I have to do that but that is but that is currently the policy that Medicaid has adopted. Well it's my question is that currently something that Medicaid is supposed to be following and are they following it or how much does the language that we have in their impact what they're supposed to be doing and this came up with the crossbow shield when we they said the same thing well we already have to do this what do you mean and I was surprised because we had just met with Medicaid and they said they didn't have to do it so they didn't have to do the pre that they did that it was okay for them. So let me say I think we have some um legal research and other to do we royal we legislative council she's smiling legislative council um try to get everyone to smile and deputy commissioner that's all the council even Linda now the pharmacist I'm doing well I feel like we're at a sort of stopping point here um that we may need to do some offline clarification and deputy commissioner uh just so you know we're on the speed train we will be making decisions about what to do about this issue and around and whether or not to include this in our opiate response bill and we'll be making that decision by tomorrow afternoon um so um with all of your non-freak time if you could look at our language hear what we've had to say and um if we can continue a conversation offline or you know hear from you um by email that would be appreciative. That'd be great I'll do it right away. Thank you because um I know that our legislative council similar to what the two of you are needing to do right now our legislative council has about seven balls in the air um that she is trying to um figure out and she may be close to a response now um yeah and we're going to um send you deputy commissioner um um a draft that um or our latest draft has that our latest draft of the bill um and this is this is a working draft this is um very much um that's great thank you so much for um paying close attention to this matter. We will I'm looking I'm not sure whether we should be waiting for legislative council or whether we should move on. Oh email Jen so it depends how quickly she can get back to me I would say move on and I will let you know when I know. Okay all right and deputy commissioner and um Lisa Herto the clinical pharmacist I never know what to call sorry um please feel free to stay on but if you have other things to do we um understand and we will get back to you. Thank you. Thank you for your questions. Thank you. Appreciate it. Um our next witness is um Teresa um um Bezzina Bezzin um Teresa I apologize how do I pronounce your name? Bezzina. Thank you Ms. Bezzina um you and I um exchanged a lot of emails um last night that you wanted to um testify as it related to the opioid overdose response services bill and the testimony that you have submitted has to do with the um H711 which is the um uh bill related to the opioid settlement which I want to say we've already passed out of committee so I'm not sure whether there is um you still want to make comments. Thank you um I actually was going to speak to the peer delivery um component of the bill that we're talking about today I think there was a so sorry that might have been titled incorrectly when I was um uh sent that testimony out to you so my apology on that for the misunderstanding. Okay. All right. Is it okay to go uh go forward? Yeah. Okay great uh thank you um everybody for giving me opportunity to speak with you uh today about this um my name is Teresa Bezzina I'm the incoming executive director of Vermont CARES and uh as I was looking over um this bill uh it really is amazing quite honestly I'm in very much in support of the most everything that's in this bill I guess I just wanted to share a little bit of context um with you uh about peer delivery services specifically and how it relates to the existing work of Vermont's SSPs um uh I was listening into uh Deputy Commissioner Doherty's testimony earlier this morning and um you know she kind of touched on this but I think from just a perspective of of um our organization and the other organizations uh just to kind of share a little bit more about what peer delivery services are already happening and have been happening in SSPs since the beginning of our work right and to just help to understand um what that looks like for us um as syringe service providers um you know everyone knows that uh the work of the of the peers is critical it is it's an invaluable um part of the work that we do together alongside the people that we serve um we've often it's been called secondary exchange and I think that might the terminology shift may be throwing people off a little bit but I just wanted to say that um you know between all four of the SSPs in Vermont, Vermont CARES, H Project of Southern Vermont, the HIV, HCV Resource Center, and Safe Recovery um we uh actually serve the entire state both with on-site services and our mobile programs um and I have shared a list um with you all uh just of the different regions that each one of us serve and the hours that we operate and that sort of thing um and I do look at uh the you know the the idea that that we all all have the infrastructure in place and have created really sustainable programs um that um when partnering with um other community-based organizations uh we're able to expand on that sort of peer delivery model um through collaboration with other organizations and um recently in the last couple of years as you all know harm reduction has really been raised up into the light and more funding has been coming through and um our organizations have been funded um with additional funding and what we've seen happen and I can only speak for uh Vermont CARES is that we were able to hire um additional staff and by hiring additional staff we have been able to double the number of people that have been accessing our programs um through our mobile program has been extremely successful um we serve in 11 of the 14 counties and um have you know gone from distributing 450,000 syringes in uh 2019 to distributing uh close to 750,000 syringes in 2020 and we're on track to exceed those numbers again this year and doubling you know the numbers more than doubling how much naloxone we're giving out and fentanyl test strips and we're not doing this alone I guess is what I'm trying to say um by working together with um the folks that we're serving um they are actually the unsung and unpaid heroes of this work quite honestly uh we learn so much from them every day um they're going out they are providing sterile syringes naloxone fentanyl test strips to their friends their family their loved ones and they do this to help save the people that they love their lives also and so we've been working alongside our peers for as long as I can remember it is a tenant of harm reduction um that people who use drugs um really be involved in programming policy and the actual work and so I just wanted to make clear that that's really happening and uh we all just received um uh funding from ADAP to launch uh pilot program with an uh hire an outreach worker and our organization chose to uh task that new outreach worker with training more peers and offering them a different level of support so that we could start to take and look at what we've been doing and grow that and expand it and and see what more we can do because we all know there are gaps we all know that um that there's more that that can be done um and so if I just look at what has been able to be done with the um additional funding that we've had in the past two years and also we know that more funding is coming through the BAA to support syringe service programs uh building out and growing peer delivery modeled um services is a high priority and we're super committed to it but the only concern that we would have is that a solely peer run program without um being either partnered with an existing SSP or embedded in an existing SSP would potentially be lacking some of the other um wraparound services like free HIV and hepatitis C testing um referrals to treatment um uh help with wound care services uh case management transportation some of the things that we know as uh that staffers can provide at this point um and can we grow a program where we can train and get peers um on on staff to do that work absolutely um one of the questions I think I would have is if there is a a strictly peer run program or uh peer delivery services currently peers are unable to be paid for their time in their effort and I just wonder if there would be an equitable wage available for a peer driven program I think it's really important to recognize that these folks deserve and deserve to be paid equitably for their services as much as anybody else even if they are peers um so sorry I'm like I'll stop for a second and ask if there are any questions and I guess it looks like there are any questions so wait a minute there might be a question um I got a question man no okay so we're good no question I got one okay yes um the peers that you're talking about I'm going to make an assumption the peers are people who are not actively involved with drugs is that correct it can be both actually um so very often peers uh so we serve people that are still actively using a syringe service program so they're in active use and I think one of the things that is really important is they peers peer to peer work so well because people feel safe and comfortable to um to to to talk with someone that is in the same boat as them that has been there before so yes sometimes it is people that are in active use who are utilizing our program as well and other times that are it is people that are um in recovery or even I've had I've had you know people that uh are coming in they're not actively using and they they know people that are and these people it's still really scary to come into a syringe service program there are a lot of of um fears that people have and so other folks will come in and say hey you know I've got you know uh loved one in my life I've got you know two dear friends they are still too nervous to you know come in um but I want to make sure I can get them their Narcan and they need some syringes and they'll pick up um for those people so that would also be we'd also consider that to be um along those same lines but for us we look at peer delivery as a person that is actively um using and they're helping other people that are actively using um because that's what we're doing within our program um I'm okay I'm okay with syringes and I'm okay with uh you know that whatever else you're talking about what I'm not okay with is fentanyl strips passing them out testing okay um thank you thank you topper um are there any other questions I'm looking at the time and it is 230 and we have one other person to testify to answer to topper's questions or not I thought I'm apologize I thought she had answered the question and topper made a question topper made a statement that he was not comfortable with one aspect okay all right okay thank you very much appreciate your testimony um grace you thank you um we are here to um ask you to one I want to say publicly that I um believe I misspoke and I said that you all had a that a safe recovery had a mobile methadone clinic um and it is not it is um um a mobile buprenorphine and so I do want to um publicly correct my misstatement um uh but we are asking you to um come and talk about that and talk about moving it to um mobile methadone maybe not what you're doing but in the bill as we are proposing it has a mobile methadone correct yes that's right on that part so um that's totally fine I um was prepped for mobile methadone I saw it and um and I do know quite a bit about both uh safe recovery was Howard Center safe recovery was awarded a grant by the federal government to do mobile um buprenorphine prescriptions so um we actually haven't started yet we're we're waiting for our medical vehicle but we will be doing um rural Chittenden Franklin and Grand Isle counties and the idea is really getting to people in some of the areas parts of the state that really don't have very much access and offering them treatment we also will be doing syringe services through them too so it's really about making sure you have as many services under one roof as possible even if the roof is a van or a mobile vehicle and so that when we are working with people either on syringe services or through other programming when they decide they want treatment we are right there they can just get treatment the same day it also will be a hotspot a wi-fi hotspot so we can connect them to other services and um we have counseling we have case management we have a quite a few other many of other services we have legal services with Vermont legal aid so really trying to make sure that we can get to parts of the state that don't have a lot of access or have minimum minimal access one of the things that also came up for us because I think I've testified here about our low barrier buprenorphine program is there quite a few people that are just using buprenorphine on the street because they can't access treatment easily because of their job and those people emerged what we did is we stabilized many of them and put them into the regular hub and spoke system with some and and the ones that really there were barriers to we kept with us so this is really focusing on making sure that there's immediate access that access makes sense to people that is in their community and really focusing on the rural parts of the state I do know that you all heard from Andy Siemens about the what we're all seeing in the population is stress around fentanyl use and people struggling to either get inducted on buprenorphine or resume buprenorphine after fentanyl use after a relapse and that's not happening for everybody but what I can say the nice part about harm reduction is that we have a really authentic relationship with the population so we're hearing from our clients about their struggles it's not often that we see it in a UA it's more often that they're telling us about it and people who've been using and have had relapses throughout the years have never experienced what they're experiencing now which is that it's fentanyl is stored in the body differently I know Dr Siemens told you that and so people are having to wait much longer to get back on their buprenorphine and there is a risk of precipitated withdrawal that can be very uncomfortable and traumatizing and methadone does not have that that that risk so we have had more people when we first started our low barrier buprenorphine program we almost never had requests to switch to methadone and now it's a pretty regular occurrence that we're doing a warm hand off to the clinic so I think you'll probably always hear me say having a menu of options have many different options is really important having immediate access is really important and having access that makes sense you know I think when we had a waiting list oftentimes these structures were around this is what we have to do to keep the system moving but I think now we have the luxury of really looking at individual patients and making sure that we can make treatment apply to them and make treatment comfortable for them and make treatment in a way that they can get there based on their child care or their job or their disabilities so I think that we're really supportive of adding mobile methadone it's not been able to be done for a long time it is you know it's it's a different thing than buprenorphine in that we don't carry medications on our van we write prescriptions when you start to carry methadone on a vehicle it probably is going to increase the cost and probably the thing you'll hear most about is security so but I think it's really promising that that that it's something that could be available to parts of the state and I'm happy to answer any questions I also had a couple really brief things to talk about in the syringe portions of your bills if you have a second we do have a section but before we go on to that I believe we have a question or did I misread the committee you know I was just thinking that needle in a sense interesting testimony interesting testimony oh okay sorry I'm trying to read room it was hard um okay do um do talk about syringe okay yeah I think um the thing I always think of with like mobile adding new services like that is no wrong door so that for somebody that walks through walks up to a methadone van or walks into a clinic or comes to safe recovery or goes to vermont cares there's not a wrong door and that we all can engage people because you know what works for certain people doesn't work for others and we really need when when the stakes are so high I'm losing so many people we need a menu of options to help the one thing I wanted to bring up first is I saw in the bill that you all were discussing there's a the paraphernalia section and that's the section from the beginning of time when we passed syringe service programming and the concern I have is it is a bit antiquated it could use a little bit of updating in that it doesn't include all the other harm reduction supplies that we um distribute and while I haven't ever had a client charged with carrying any of those supplies I think it's time to take a look at it and update it because it is a vulnerability to the population if you had a a rogue um you know police department um or it also can have a chilling effect if people realize that it's not in there so I think if I could suggest um I would say maybe exempting all harm reduction supplies either distributed um or um uh possessed as part of an organized syringe service program I mean I think you probably know that for me I would like to see all of syringes all of the supplies decriminalized but I think at a minimum if we could look at you know it's not just the syringes that we distribute and it's not just the syringes that are preventing HIV and hepatitis C and overdose so I think it's really um it would be great if we could just make that more comprehensive I don't think it would change what's actually happening in the field I think it just would be updated Grace I'm confused I'm looking at the bill and I am looking under I guess I'm wondering what part of the bill you're looking at or are you looking at a part of the statute because I'm looking at definitions of drug paraphernalia and then it says does not include and so you're saying does not include needles and syringes and that language needs to be and I read it it only includes needles and syringes in that last sentence where it should if we could it would be great to say any harm reduction supplies distributed okay because it's not just the needles and the syringes it's everything else that we distribute that is harm reducing okay and I see that Teresa and thank you I appreciate your you're stating your agreement and this is something you don't realize but we are we need you to say it out loud because we do not which is fine just say it out loud we don't use the chat or other function and you didn't know that I didn't tell you okay I wholeheartedly agree with Grace on that sorry to go through all the permutations and I forgot to put that as part of the intro the other piece is the piece that Teresa was speaking of and I've thought a lot about this we've had discussions as syringe service programs and our you know our feelings and thoughts have evolved around it and I've talked to other parts of the country and I do think that the health department has discretion over who can be an SSP and I think that will always be the case and I am always concerned about arbitrary restrictions like you know having to be a ASO or a medical facility or a substance use facility I think in places where you could see this being important is like a domestic violence shelter that decided that they wanted to distribute or if we had an area that we couldn't get to that we don't have access with and peer support services like Teresa was talking about are really important and in many states it's considered the gold standard so I think it's while I'm probably deviating from what other people think I think the health department will always have the say over who can and can't be a syringe service program I think when we are losing people at the rate we are we should make the system as nimble as it is and let the health department make those decisions so I know that that may not be what you know what everybody thinks but I think that there is a lot of opportunity and I think for us we just don't to me I'm a purist I don't want to tie our hands in moments when we may not when we may regret it and I think we're lucky we have really good providers in the state but I don't know that there might come a time where we need something and we will have tied our hands and if somebody came in that was a rogue person or somebody that they were concerned about Teresa and I can speak to the amount of paperwork that goes into getting approved to be a syringe service program I think the health department would be very comfortable not accepting those applications but I think that there's partnerships that we could develop I don't think I also don't think we would make this about what's happening today or funding today it's about having things in place that may not be helpful in an epidemic. Thank you thank you Grace and thank you Teresa where we are with this this is an evolving concept I think that in our testimony we heard this morning from the health department looking at the section alone that talks about removing what I would call the restriction they can live with that they're thinking they have mixed feelings about further on in the section in terms of whether or not to move forward with a peer exchange a peer-delivered syringe exchange service or whether to study it or whatever but there I want to say it appears that there is agreement with the health department with that one piece and we as a committee have not necessarily come down on almost anything in this bill this is a work in progress great I think I think the sub of the confusion also comes in the definition of peer support services like we have Jess who you've all met she's a peer she's a peer recovery coach and she does peer support groups and so I think I think that what's maybe people are concerned about is like the rogue nature of something like that but I think that what I see in many of the our colleagues around the country is that peer support works I think we've not only overdosed but I have to say we had I don't know if I said this the other day we had a woman that almost died of endocarditis she was intubated she called and Jess called an ambulance for her and you know I think these so these supplies alone are keeping people alive so I know we want wrap around services and I know that there but I'm worried about you know not having the good for the perfect this woman was is very young she's going to be in the hospital for six months or for months I mean and it probably is going to cost the system hundreds and hundreds of thousands of dollars not to mention the what she's been dealing with so I think that the the the syringe alone is serving a purpose and and hopefully every I mean I think peers are people that are really always working to help people get what they need so I think that that's something that I'm happy is there and we should really be looking at and and and again it'll be at the discretion of people that that know a lot about this thank you thank you grace thank you Teresa the two of you represent organizations that are on the ground and doing important work and we're actually trying to make it easier and make it more accessible to people who need it um representative McFawn thank you madam chair um I just I want to follow up on the statement that I made um we're talking about fentanyl strips are we talking about something to test for fentanyl are we talking about a very low dose of fentanyl that I can take this event Teresa can come to transition to buprenorphine or something else so they don't go cold turkey I can take this um and then Teresa jump into um so fentanyl testing strips are actually what I need to know is I made a statement that I was not in support of fentanyl strips yes fentanyl strips that are being cast out by the peers do they contain fentanyl no they don't that what they are is they were urine testing strips that are being used off label to test substances for the presence of fentanyl and what we do see is um a lot of um behavior change because unfortunately I think I've said this before our clients um up until 2018 we'd asked them if they've witnessed an overdose and they usually 23 to 26 percent said yes in 2018 that number jumped up to 81 percent in one year so while I think the concern is around like being attracted to fentanyl we have a population that's um sufficiently afraid of it and what we give them is strips to be able to test and see if fentanyl is there we do see sometimes people throw away the drug most often we see they take other measures like the health department recommends to make sure you have Narcan to make sure that you um have a phone if you were to call for help make sure that someone else is there and that's one of the big things we should be talking about too is most people in Vermont die because they're alone um and so I think you know having mechanisms to remedy that would be really great too but I think this is just giving people more information I I see why it might feel counterintuitive to some people but it's it's giving people more information and especially for people who aren't using opioids um somebody who doesn't have a tolerance to opioids gets even a grain of fentanyl they probably will not survive so it's really just a protective factor and and unfortunately we have to do everything we possibly can because of how many people we're losing every time I come to this committee I feel like it can't get any worse than that I'm sitting here and telling you it's getting worse so um sorry to be the bearer of bad news I've just lost a lot of people every time I'm and and this last year has been like nothing we've ever seen before thank you thank you so much for your question Teresa did did I get it or you can jump into if you need it so I take back my statement thank you you got it Grace thank you um thank you all um uh we're about to go on the floor on the house floor at quarter of three um uh committee I believe that we have a um new um draft of the bill that has been distributed has it been distributed um this bill okay um I draft 2.1 yes um the draft 2.1 um if um Julie if you could distribute that to the committee um so that um we could we will be taking that up tomorrow um and I'm going to say um we are we are voting something out or not tomorrow and um people can rewrite words 17 times or they can decide that this is okay or not um you know and clearly there may be some changes but there's some clear policy things but that's what that's what we'll be focusing on tomorrow this afternoon um we have a new um when we get off the floor it looks like the floor will be um relatively quick like till four we'll be coming back here to review the department um the DCF's newest for newest um um proposal for um reach up statutory changes um we sent them away um and said please do more and they came back with more um and uh um between legislative council and silent reading or myself we will be going through that um when we get back off the floor okay yes so no proposed vote this afternoon no um we are I would know because we just got the reach up language this afternoon um and uh legislative council has not had any opportunity to even put it into um legislative form so no no vote this afternoon okay yeah no no vote this afternoon that's one from Sean Brown but yes yeah yeah so this is um I think something that we all want to see we've been waiting for um the department um as of uh the last time I looked at an email which was like 130 um they have not yet been able to give us cost estimates for those three pieces of the proposed legislation that deal with money if what I want to say you know they're parts of the um all of the bill deals with um modernizing and make making things um better for um better for families and making themselves um more self-sufficient or economically sufficient some of them are um are the work that is being done is is having having this statute reflect what in fact is the current practice that's um something that the department is all on board with um the department um it is not quite on board with the three monetary pieces and we don't have um we do not yet have any numbers to that um and I will say out loud that um the majority of the committee is in support of some of those pieces what my suggestion would be is that we put the implementation date out for a year and give them the opportunity to really look at it and take the pressure off this year and that would be my suggestion if we go forward to the movement for those oh I like you think oh god I'm in trouble and um with that um it's 10 of three and this um um we're going to take a pause um um until we get off the floor which um unless something really goes the way I don't think it will be a um before a clock or so so 10 minutes after we get


This research aimed to develop a set of ground motion parameters for the Campos Basin region of Brazil using existing data and synthetically generated accelerations. The researchers first analyzed the seismic hazard of the region by looking at historical data and then used these results to generate a synthetic acceleration time history. They also looked at two recent earthquakes in the region to further refine their model. The resulting ground motion parameters can be used to inform the design of structures in the region. This article was authored by Christian Soriano-Camello, Samuel Felipe Malapasa-Tarizona, Maria Cascaio-Ferrera Dalmeida and others.


Γεια σας! Είναι Βικη, και σήμερα θα βλέπουμε έναν καλύτερο λαϊκό λαϊκό που δείχνει στις στραμπαριές. Από όλες θα προσπαθώ να τα παίρνω επίσης με μία παγγένωρα και θα προσπαθώ γιατί θα χρησιμοποιήσω ακριλεκού πόλη. Θα χρησιμοποιήσω αυτές δύο ακριλεκού πόλη με στραμπαριά και είναι από το εξοχλιάνο λαμπιλό, που είναι καλύτερο και φορτιά, και είναι καλύτερο για καμία μεγάλωση. Τα αυτοκλήτια που θα χρησιμοποιήσω είναι καλύτερα με ένα σπίτι φαρμό, σαν το ένα που βλέπεις εδώ, χρησιμοποιήσω ένα που είναι καλύτερο και σύντομα. Και τα αυτοκλήτια που χρησιμοποιήσω είναι αυτοκλήτια. Λοιπόν, όταν they dry, they do not react with water. Λοιπόν, εδώ είναι έναν τεκνικό που μπορείς να χρησιμοποιήσεις. Είναι πολύ εύκολο και βροχει στις εξεγρές και στρακές. Λοιπόν, είμαι χρησιμοποιήσω only two colors that complement each other και είμαι χρησιμοποιήσω my brush to apply the first color, the blue in this case. Βλέπεις πώς χρησιμοποιήσω the color only vertically. Λοιπόν, είμαι only moving my brush up and down. Δεν θα αυτοκλήτω το όλο πέτυο, αλλά θα αυτοκλήτω about half of the page for the other color. Τώρα θα αυτοκλήτω my brush and with the second color θα αυτοκλήτω the gaps. Όταν θα αυτοκλήτω the gaps, θα αυτοκλήτω ότι θα αυτοκλήτω a little bit of the light green over the blue. Όλα τα αυτοκλήματα που χρησιμοποιήσω στις εξεγρές είναι αυτοκλή, όπως always, just below the video, in the details area on YouTube as well as on my blog. Τώρα είμαι χρησιμοποιήσω stamperia. Έχω πολλές πολλές που μπορείς να be used in mixed media and art journaling και θα αυτοκλήτω πολλές από τους στις εξεγρές, ώστε να μπορείς να δείξεις πώς μπορείς να δημιουργήσεις αυτές τις εξεγραφές και να έρθεις με καλύτερες εξεγραφές. Όταν αυτοκλήτω τα δύο φορές, θα αυτοκλήτω ότι αυτή η πρώτη λέα της φορίας είναι αυτοκλή. Έτσι, θα αυτοκλήτω my heat gun to speed up the process και τώρα που αυτοκλήτω, θα αυτοκλήτω. Τώρα θα αυτοκλήτω my brush again και θα αυτοκλήτω a second layer using the exact same technique and making sure that everything is nicely blend and I don't have any gaps anywhere. I'm also using my baby wipe to wipe off areas. And notice how I apply the color. I'm making sure that I don't cover up the whole background and also I'm using a baby wipe to wipe off areas. Since this is going to give a nice and distressed look. And my colorful background is pretty much finished and I really love the outcome. To make my background more interesting, I am using a little bit of white acrylic paint and I am going to add some splashes. I have added a few drops of water to thin it down and now I am adding the splashes with the baby wipe. That has a nice and long bristle. This is going to make sure that I don't get only spots but also those splashes that look like thin white lines. So now I have this rice paper which is by Stamperia and I think that is a great idea to work with this product because not only it is very thin so it doesn't add bulk to your art journal but at the same time they have great designs that you can use. You can use a rice paper as it is as a whole or you can cut out areas like I am doing today. So I have cut out the brush and also one of the butterflies and I am roughly cutting it out. I am not paying any attention at the moment and this is going to be the focal point for my art journal. Now just because this is transparent if I stick it on top of my art journal then you will be able to see the colors at the background. So I decided to stick it on white paper so when I color it it will not be transparent. I will be using transfer gel which is actually gel medium by Stamperia and I am going to use that to stick the butterfly and the brush on white cardstock. I have applied a thin layer of transfer medium on my cardstock and now I am covering my butterfly. This is going to make the butterfly sturdier and it is going to be easier for me to color as well as to cut out. There are many other mediums to use for rice paper to stick it down instead of transfer gel. You can always use the media gloss gel paste which is going to dry transparent this is the gel that I am talking about and it is going to give a nice and shiny finish to your project. After sticking both my images down I am going to use my heat gun to speed up the drying process and then I am going to use my scissors to cut out both the images. To color my butterfly I will be using three different shades of purple this is Allegro acrylic paint by Stamperia and all the colors that I am using are listed below the video. Now I am using three shades of this color and I am going to apply it with a nice soft brush this is the one that I am using and you can see how thinner this flat brush is than the one that I have used for my background, at the first technique. So just because this acrylic paint is opaque I will be using a few drops of water to thin it down because if I go heavily with this it is going to cover up the whole design of the butterfly so you can see how it works if you thin it down I can still see the background I am going to cover up with the first shade and I will go heavily here so you can see how opaque it can be but I still have a few minutes before it dries to wipe off the black area mainly the black because I want to keep that detail on my butterfly. Now I will start the whole butterfly with a lighter shade I will apply the medium shade from the center towards the outside of the butterfly and finally I will be using the darker shade of purple only at the center of the two wings to color the image of the brush I am using this acrylic paint which is also by Stamperia but it's from another line this is heavy body acrylic paint it is also permanent and opaque and I am using silver which is not only going to color this part of the brush but it's also going to add some shimmer with the blending tool I am applying a little bit of brown ink on the edges of the butterfly and the brush and this is going to add a little bit of shading at the edge but at the same time I am getting rid of that white edge that shows once I have cut out the butterfly this technique gives my images a more finished look and they also look like they have been cut out perfectly I am going to place both images on my layout and decide where everything is going to go just to make sure that I can add the stenciling where I want to so this is a stencil by Stamperia again which I am going to add as my quote today I was planning to use modeling paste with my spatula all over the words but then I decided that just because those words are big enough and they fall on the fold of my book and I don't want to add dimension there so I am going to leave my spatula and modeling paste aside and instead I am going to use heavy body white acrylic paint to apply the paint I am going to use a foam tool which is specifically designed for stenciling and you can either use this to choose one of the smallest ones so that I can have better control of what I am doing or you can use one of those stencil tools with the brush that are also specifically designed for this thing so I am going to hold the stencil with my hand I am not going to stick it down anywhere and I am going to dab dab dab until all the words are there also notice that this word says dreams but I am going to use only dream but I am going to stencil the word inspire and at the end instead of stenciling the word creative I will be somehow alter this and stencil the word create you will see what I mean in a few seconds in order to have great results on this technique you need to go slowly take your time and dab all over now although it seems that I am doing it quite fast it is not because remember that this is two times the actual speed that I did it in real life I am really happy how this turned out and I really love this stencil you will be seeing me using it again because I want to use that art word at the top of that stencil so now just to make this a little bit more interesting I am going to use floral stamp by stamperia and you can see how you can stamp by using your acrylic paints this is heavy body acrylic paint again the exact same one that I have used for the stenciling I am mainly adding some details at the edges of my layout and once I finish using the stamp and the dabber I am going to wash them with water and they were as good as new and now here is a great technique that you can do for adding all around your images now all you need is your ink pads and I will be using a brown ink pad by stamperia today so as you can see I am before sticking down everything I am using my pencil to draw a line on the inside of the images so I have the outline of where everything is going to go with my blending tool I am going to apply some ink on the inside and I am going outside the lines just a little bit this is going to make sure that I have a nice and smooth shadow all around the images once I am going to stick them down notice that I go just a little bit outside of the lines I don't go heavily with the ink and I am also making sure that I avoid harsh lines and now finally the fun part it's time to stick down the butterfly and the brush this is the end of my layout now everything is stick down and the glue is dry so I can use my black marker to go all around the edges and add a few more details on the butterfly after all this is the focal point and then I am going to use my white gel pen to add a few more highlights on the butterfly as well as on the brush and as I am doing that I just want to let you know that I cannot recommend using thin and they do not add thickness to your art journal they are really inexpensive and you can draw inspiration out of them since they have so beautiful designs and you can use them either for your backgrounds as I did on my previous art journal or as the focal point just like I did today and remember you can use either rice paper or even napkins or any other thin medium that is actually made for decoupage as a finishing touch I am going to do some stenciling at the edges just to frame my layout I am using this a beautiful stencil by Stamperia and instead of using modeling paste again I will be using heavy body white acrylic paint I did that because I decided that since I haven't added any dimension at the page I am going to keep it flat after all I had so much fun dabbing with that foam tool the acrylic paint and it was a nice change from the stenciling with the spatula that I usually do also make sure that you are not using fluid acrylics for this technique or because the fluids are going to go under your stenciling you need to use heavy body acrylic paint and since I have my tool loaded with white paint I am going to go all around the edges and to finish off my layout as always I am going to stamp the date I will be using black ink pad and that was the layout for today I hope you had fun and got inspired and if you did don't forget to leave me a comment as well as give me thumbs up on my youtube channel here are some close up photos of today's project and if you haven't done so already go ahead and click the subscribe button because this is the way to tell me that you love my videos and you want to see more for more inspiration you can click on any of the videos on the screen right now or if you are watching from a mobile device you can find links to those videos just below in the details area thank you all for watching