How is my volume? Everyone can hear me? We are using the mic mostly for the recording, so folks who weren't here can hear us. I'll probably forget, but if we're asking questions, let's try to all use the mic as well. My name is Rhiannon Straight. I'm a senior consultant with the Stedman Group. We are Denver-based, small, woman-owned organization, and we have been involved in opioid settlement work in Colorado since kind of before this all kicked off. So we now get the great pleasure of leading you all through what we've learned in helping groups like yours figure out the best way to spend their opioid settlement dollars in a well-informed, collaborative way. So that's really what we're here today to do. Can everybody see? We practiced. This worked. There we go. The slide's okay. Is there any way we could move the Zoom stuff so that people could see the bottom? There will be some data that that might be helpful with. Okay, I think we have a nice combination of different types of folks in the room. So before we get started, go through the agenda, we actually want to hear briefly from each of you. We don't have a ton of time for this, but we really do want this to be a comfortable collaborative conversation throughout the day. So we're going to go around, share our name, our organization, or maybe subject matter expertise that we represent. And please take me seriously when I say, in a few words, what you hope to get out of today's meeting. So I'm Rhiannon Strait, I'm with the Stedman Group, and today I want evidence-based collaboration in strategy development. Would you like to go next? I'm J.K., and I'm Director of Behavioral Health Consulting at Stedman Group with Rhiannon. I'm here to assist her, and I want everyone to be heard. Chris Chenoweth, McMinnville City Councilor, and I also want to hear what everybody has to say. Good morning. Kate Lynch, District Attorney for Yamhill County. I guess my expertise would be prosecution. I'm hoping for some good sharing of information today. Caroline Van Wert, I'm with the Sheriff's Office. I'm the Deflection Coordinator, and I am just here to learn. Hello, Lindsay Manfred, Yamhill County's Health and Human Services Director, and I am just hoping to get a better sense of where people are thinking they'd like to use these funds towards the end of the day, even if it's not decided, just an idea. Thanks. Jeff Towery, City Manager for the City of McMinnville. I'm hoping to learn a little bit more about next steps and opportunities to collaborate. My name is Scott Cunningham. I'm a City Councilor here in McMinnville, and I guess for me, one of the questions I brought up before is kind of best bang for your buck. Is it spending the money before people need, like, tip the scale, in essence, or is it trying to get people that are already in crisis out? Hi, I'm Carrie Martin, Executive Director for Encompass Yamhill Valley, and I am hoping to hear the diversity of projects that people are entertaining for this work. Walk the mic for you. I'm just here as an observer. I don't have anything. My name's Craig Peebles. Barry Starrett, Yamhill County Commissioner and Liaison to Health and Human Services. I'm really just trying to see how much money we can get from the city for some of the things we want to do. I'm Beth Kaiser. I'm just a citizen here observing and becoming knowledgeable so that I can hold my elected officials responsible. Kit Johnston, Yamhill County Commissioner. Good morning. Cheryl Fisher. I'm with Yamhill Community Care, YCCO, and I'm a licensed professional counselor. Yep. My name is Aaron Lopez. I'm a certified recovery mentor, peer support specialist, and traditional health worker, and I manage the harm reduction programs for addiction treatment and recovery support nonprofit called Provoking Hope. And what I hope to gain from today is just a little bit more knowledge about the infrastructure. Mainly I'm a boots on the ground kind of guy, so to see what's going on behind the scenes. Jennifer Leslie, Providence Hospital, Better Outcome Through Bridges, and I'm also a certified recovery mentor and peer support specialist, and I'm here for info sharing. Jason Hennis. I'm with Health and Human Services as the behavioral health director. I'm hoping to see what role we might play in this work and how the pieces will all fit together. I'm Tracy Dawson, operations manager for Yamhill County Health and Human Services, and I'm also a licensed therapist and a certified alcohol drug counselor, and I've been in the behavioral field for over 20 years, and my heart has always been addictions and co-occurring disorders, so I don't care what role I'm in. That's my heart, and I'm always going to try to advocate for that population. Meet them where they are. I'm going to be a broken record. Good morning. I'm Bill McKielson. I'm the manager at Yamhill County Public Health, and I'm interested in seeing how we can align with the city and our county's work. We started with you. David Leitenberg, city attorney. I'm just hoping that our city decision makers can better understand the landscape, the local landscape, with regard to this information. Noel Amaya, communications and engagement manager for the city. I'm just here to listen today. Claudia Cisneros, city recorder for the city of McMimbo. I'm here to listen and learn. My name is Sarah Canavies. I'm with the Opioid Response Network. I'm the one who got them to come here, and I'm here to continue to help you guys, and even if you can't come to a decision, that's okay. We'll still be here for the next three years, because that's how long our grant is. Okay, a couple of logistics. We've got coffee over here. There are name tags for folks. Those will be probably more useful when we're in small groups. The bathroom is out the door to the left. Please feel free to take care of yourself first and foremost today, and let's go ahead and dig in. A dramatic pause every time I try to click. Here we go. Okay, I'm going to just quickly run through the agenda. There is a stack of printed versions of this over here on the table, thanks to whoever brought those. We're going to go briefly through some expectations here in a second. Then we're going to talk for a good amount of time about the actual context and structure of the opioid settlement. We'll dig into how much money you all are expected to receive, how the state of Oregon is distributing these funds, mostly so that you all can understand the structure in order to make the educated decisions that we'll talk about in a little bit. Then we'll dig into some education on the allowable spends. We'll talk about this more, but there are certain categories, essentially, that you are allowed to spend your dollars on, and we want to make sure everyone understands what those categories are. More importantly, though, we want to give you evidence-based strategy examples where there's a ton of data and research behind each of these programs and practice. We'll also talk about return on investments. I think somebody over here was really worried about trying to figure out the bang for the buck. We will talk about various research studies that get at exactly that. Then we'll give you a little bit of a break, and then we're going to crush some data about the behavioral health landscape in McMinnville and Yamhill. That's really to help you guys understand where gaps are and where we should really target the spending priorities that we develop. Then you'll get some lunch, and from there, it's going to be pretty small group oriented. We'll walk you through a collaborative prioritization activity. By the end of today, we are hoping that you'll have a list of evidence-based and locally tailored prioritized spending strategies. This will not be the end of the conversation, so we'll have a bit of a discussion about what's next and what you all can do with this list before we call it a day. Are there any questions or concerns on the agenda? Yes, sir. Slides will be provided afterwards. Okay. These should be relatively straightforward. We are going to all be working together. Often, we don't get rooms full of elected officials and boots on the ground folks. These expectations just kind of help set the stage. Be kind to each other. I really like this practice. Wait, why am I talking? Then lastly, I'm going to just highlight if there's a point that you want to make or a question that you have that we don't have time for and I kind of kick the can on it, write it down, pass it along to us at the end. We'll call this the bike rack. Any undiscussed issues, we can take back to Lindsay and David to kind of help loop into the conversation after we leave. Any concerns, questions about expectations? Okay. Let's talk about the opioid settlement. This is a national situation. We're getting over $50 billion distributed nationally across the next 18 years. We're about two years in, so we're looking at next like 16 years. The payout is coming from a wide range of different types of entities including producers like Purdue and marketing companies and distributors like Johnson & Johnson and Walmart. All of these entities are being held accountable for the epidemic that we see before us now. Important to note, the litigation is not complete, so the dollar estimates continue to kind of fluctuate, most likely not going to decrease, likely to maybe slightly increase over time as the litigation continues to finalize. Each state gets to figure out how they want to spend their dollars, and there are certain rules that each state has to follow when they're developing their own unique structure. Most importantly to you all is Exhibit E. Exhibit E is a document that outlines not all, but a lot of the allowable spends. This is the document that basically says this is what we want you to spend your money on, and here are a bunch of examples of what that looks like. So we'll dig into that more in a bit. It really does try to capture the continuum of behavioral health care. So while this is an opioid settlement and we are trying to address opioid-related issues, it does take into consideration co-occurring disorders and things like wraparound services. So we're not just talking about opioid use disorder treatment here. This is a little in the weeds, but Exhibit E does offer a list of prioritized strategies. They call them the core strategies in Schedule A. If you are lost later and you're not quite sure where to start, looking at the core strategies might be a good place for you all. Okay, that was a big picture. Now I'm going to distill it down a little bit and localize it for you all. Oregon is getting around $600 million, and the way that the state has decided to distribute this, a little under half, 45% goes directly to the state, and then 55% goes to local jurisdictions like McMinnville-Yamhill. The state share, so that 45%, is how it's spended is dictated by a board called the Opioid Settlement Prevention Treatment and Recovery Fund, and I think this is an elected, like the board members were selected to help figure out how to distribute the funds. We will talk in detail in a couple of slides about what they're spending their dollars on so we can either build off of or not duplicate what the state is doing. The last bullet point here starts to get a little confusing. I'm going to keep us kind of on the surface unless people really want to dig in. The way that the local jurisdiction distribution works, dollars are dependent on signing into the agreement as well as the population size, so more people get more money. The share for a city or a participating subdivision will be paid to the county in which the city is located unless the city requests direct payment. So this means that in McMinnville, Yamhill would get McMinnville's dollars and you can collaborate together or not, or McMinnville can determine they know exactly how they want to spend their money and so they're going to request to the settlement fund administrators 60 days before the deadline that they want their funds directed to them. So in Oregon there's kind of a an opportunity to really pool dollars and collaborate and make impact go further through this kind of line in the Oregon subdivision agreement. Does that follow for folks? I'm gonna I think leave it there for now. Okay. So this is tough to read, a little clearer on this version, but this is a pie chart outlining how much McMinnville has received. So as of November of last year they've received just under $500,000 and spent $2,400. They're projected to get a little over a million through 2039 for a total of about 1.5, 1.6 million. The pie chart for those of you who can't read, including me, that teeny tiny stuff. Green is money that we are still set to receive. Yellow is kind of the most recent bucket that we got 2023-2024. Red was the first fund distribution. And now we'll talk about a local example. So you may wonder why why do the county and city get 45, 55 percent and it's largely the product of negotiations between your state and your cities and counties. So Oregon's right in the middle, almost 50-50. Colorado, our counties and cities are very powerful and they got 80 percent, but there are other states where cities and counties got very little, 10-20. I think they're even somewhere the state controls a hundred percent. So Oregon's right in the middle and it seems like a pretty reasonable deal. So it's a good amount of money as you'll see on some of the future slides, but not really not compared to some other sources of funds. So here's one example from a nearby city of how they use their funds. So this was their 2022-2023 tranche of funding, $150,000. Very similar to the amount McBinville got in that same year and they chose to give it all to their school district to use on youth prevention. So I would imagine, sounds like something like D.A.R.E., not that it is D.A.R.E., but something that is youth prevention focused and enacted through their schools. So great, great example of pretty easy for the county to manage because they handed it to their school district and let them run it. On the other hand, just one thing got funded, so could fund multiple things. So that's an example of a decision-making process, a simple process nonetheless, but still a process. This is the OSPTR board's priorities. How they came to this, we're not a hundred percent sure, but a lot of governance boards do a process a little different. We have done this in the past where they look at quantitatively, not attached to specific programs, how would they like to spend their funds among prevention, treatment, recovery, harm reduction, and some smaller areas there. And so these are the categories of funding that Oregon has decided on, and I think those are part of the national settlement. Yeah, sorry, small text here. The big ones from left, counterclockwise, are recovery in yellow, treatment in gray, primary prevention in or in Siena, blue-ish gray, harm reduction, overdose prevention, and then there's two to six percent for administrative costs, emerging issues, leadership planning, coordination, and research and evaluation. So the big buckets, as you see here, are prevention, treatment, recovery, and then harm reduction. Some places put criminal justice into this, and others work criminal justice into a variety of uses like treatment in the criminal justice system. And then up top, administrative costs are for the bursar, the controller at the county level, any administrative time that you incur. Emerging issues, I really don't know what that means. Leadership planning, coordination, are for folks like facilitators like us. Research and evaluation, some folks bring in either County Public Health or a university to help them evaluate the use of their funds. So smaller uses up top, and then larger uses down here. So Oregon, as I said, we're not sure how they came to these, and one reason we've actually moved away from this quantitative is because it's great in theory, and it's great if you have a lot of money, like a hundred million dollars, because you could say, oh, twenty two million dollars are going into harm reduction, and then we're going to subgrant that or accept RFPs. In a smaller area like a city or a county where you're dealing with hundreds of thousands of dollars, that's really just a theory. It's hard to attach an exact percent that you have made through some quantitative reasoning, and then make that work for someone. So it's a better approach we found, especially in, like I said, cities or counties, to really look at what are the needs, and then look at who are the organizations that will carry this out, because often there are only one or two, and then try to match funding that way. So we often skip this step. Like I said, in smaller areas, working with states, it seems to be a little bit reasonable. So I'm not saying this is not reasonable, but it's not as relevant in a smaller area. All right, so we're going to talk about how much, in the context of all substance use spending, how much are opioid sums? And the answer is, more than some, but a lot less than others. So not life-altering, but a nice injection of funds that are not tied to a specific use. So that's really key, in that this opioid settlement funds are often your last dollar in, because there are other ways to spend funds, like Medicaid and block grants, that are bigger, especially Medicaid, but they're very focused on one thing. Medicaid is really about treatment. So you see, these are the four that I came up with, and M110 is actually Oregon-specific. The others are generalizable to all states. And there may be others I'm not aware of, local foundations, things like that, but these are kind of the big nationwide, or at least Oregon-specific, sources of funds. So there it is. Opioid settlement is more than two others, and a lot less than two others. Look, and so I'll narrate this. We're used to being online, so text size doesn't matter. Being in person, gotta make sure we make the text bigger. So you see the opioid settlement, and granted, these are broad strokes. So this is statewide, not county-specific, and it is also averaged. So opioid settlement tends to, it started at a high level, and it will go down pretty quickly. You saw that you've already received almost $500,000, and you'll only receive about a million dollars over the next 20 years. So what that means is lots for the first three or four years, and less over the last 10 to 15 years. The reason for that is the settlements get paid out as they get paid, and a lot of settlements got paid up front. So Purdue's not paid yet, but a lot of the distributors got just paid a one-time, like here's all the money, and so they pay that out. Other distributors have a 10-year settlement or a 15-year settlement. So the great thing is that you get the money almost as soon as the national administrator and the state get it. It's funneled down. The bad news is that will tail off very quickly. Most of the money you will receive by about 2027. So opioid settlements over on the left, I am pretty sure I annualized this, and so you see about $30 million a year in opioid settlements. Again, that is higher in the first few years, and it'll go down, but over the 20 years, that's average. Second is state opioid response. So this is a pretty large bucket of funding that every state gets through what's called a formula grant from SAMHSA, Substance Abuse and Mental Health Services Administration, and it started in 2018, I believe, 2017 or 2018, and has gone on in two- and three-year bunches, and I think we're just starting the second year of a three-year grant for all states. So that's a very significant amount. You see there's about $10 million a year, $11 million a year in Oregon, and then next to that is a substance abuse block grant. So that's an ongoing, long-term grant that the state gets, again, through SAMHSA. So opioid settlement is about the combination of those two, and I know it doesn't look like much on this graph compared to Medicaid, but that's a lot of money because SOR and substance abuse block grant are the main sources of non-treatment grant money flowing into states. So it's a really big deal in our world because before there was just that middle one, substance abuse block grant, and then 2017 opioid response came out, and then in 2022 opioid settlements came on board. So it's about quadrupled the amount of money that is more discretionary in substance use over the last five to ten years. Now we get to the big ones. Medicaid is huge. It's the primary payer for substance use and mental health treatment services in every state, and it dwarfs everything else. Things to know about this is Medicaid can't be used for capital expenses, it can't be used for school-based prevention, it can't be used for harm reduction, it can't be used for anything residential. There's some caveats to that. Residential treatment, but not sober living, and it actually can't be used for the housing aspect of residential treatment. So Medicaid is much more limited. It's focused on outpatient and inpatient treatment services, although you do have a peer recovery benefit, and I think there's community health worker benefit also. So it is getting more into the prevention and recovery aspects, but really focused on treatment. And it's also limited to certain population, probably about 20% of your state's individuals. So think about it as a lot bigger, but a lot more focused. And then M110 is a really unique measure. I think that passed in 2021 here in Oregon, and it's Oregon specific. I believe, and correct me if I'm wrong, it was part of the bill to decriminalize drugs, and they added a very kind of mind-bogglingly large amount of money into treatment that actually gets distributed to all the different counties through competitive grants, partially. So I don't know where those funds have gone in Yamile County yet, but you can find them on- what's that? Oh good, okay, so you're familiar with it. So like I said, I mean a huge amount of money compared to what we're used to as far as grants go. Way more than all the other grants put together among the state. We actually helped a group out in eastern Oregon apply for this, and we're just like mind-boggled. We don't have anything like this in Colorado, so really cool. And the other thing to know is that because it's a discretionary state grant, there are many more uses for M110 than there are for Medicaid. And so, in order, Medicaid, most restricted, and then really everything else, but opioid settlement is the least restricted and can apply to the most people. It's not just low-income people, not just high-income people. It can go to whatever you deem appropriate. And it can go to anything from prevention to criminal justice and recovery. Questions on this graph? Okay, we talked about the context, we talked about the money, now let's dig in a little bit deeper to the allowable spends that you hear us continue to mention. I want to say first, we did a virtual learning session a couple of weeks ago where we focused a little bit more on actual definitions and in practice examples of some of these things. We didn't want to be too duplicative of that training session in today's meeting. So for some of you who were present at both, apologies for some repetition, but we'll try to dig in more specifically to evidence-based and return on investments. If you have a question about what something means or what an acronym is, please interrupt us and ask. It's important by the end of this section that we've all leveled the playing field and everybody is working forward with the same or-ish knowledge base. Cool? Before we talk specifically about each category, I wanted to just show you how Exhibit E is organized because it's a little bit different than the way that we are educating you all on these topics. They have this categorized first by treatment and then each of these sub-bullets have multiple examples in Exhibit E of exactly what that might look like in practice. I am going to fly through these. You all read them and know that later when you're in small groups and you're coming up with ideas, these slides are going to be a good resource for you. Okay, so treatment, support for treatment and recovery has literally dozens of things, connections to care, needs of the criminal justice and pregnant and postpartum populations. Then they have prevention. Prevention is including prescribing what you might typically think of as prevention as well as the whole category of harm reduction. We'll talk in a little bit about how prevention and harm reduction are quite connected. And then they have these other strategies including first responders, leadership, planning and coordination. That is a bucket of money that you could use to pay folks like us who kind of help facilitate and guide this or maybe like a McMinnville city program manager who oversees the funding like path that you all put in place. Then there is also a section for training and a section for research. This is really broad. It's overwhelmingly broad when you look at all of Exhibit E. In order to better kind of explain and compartmentalize this for folks, we have simplified and we're going to talk about it in the categories of prevention, recovery, harm reduction, treatment and criminal justice. Know when we're talking about those things, all of the Exhibit E subcategories are present and this is very much a continuum. So you can kind of be in multiple categories at one time and don't get too stuck on the bucket, like the title. Another quick context set, we're going to talk about cost benefits or return on investments and we just wanted to frame why we're doing this. Often this decision can be very overwhelming. We have a lot to do. There are a lot of problems to solve and we don't have enough money to do it all. How can we figure out where to get the best bang for our buck? Research on cost benefits is one way to do this. The other thing that we really like about cost benefit analyses is that it will break down the benefits from a program by kind of population type, who's really benefiting. And opioid settlement money is unique in that we're working with elected officials and community members and so having an understanding of kind of where the benefit lands is helpful for decision making as well. Really though, we're talking about this so you can figure out how to figure out how far your settlement dollars are going to go. First up, prevention. For each of these categories, we will quickly give you kind of an overview or a definition of what it is. This will be duplicative for those of you who were with us a few weeks ago. Prevention. I don't like reading from the slide but I really like this definition so I'm going to read it. SAMHSA defines prevention as activities that work to educate and support individuals and communities to prevent the use and misuse of drugs and the development of substance use disorders. SUD, you saw that acronym earlier, substance use disorder. Prevention is really frequently youth focused but it doesn't have to be. You do get the most bang for your buck when it's youth focused, however, because if you think about all of the life years that a young person has left to live, there's a lot of economic benefit and life benefit that that individual still gets to live if we can prevent this and stop it before it happens. Prevention is often community based. Boots on the ground folks are conducting prevention activities in your community. This means it's not often billable. JK just talked a little bit about this on the slide where you saw how much money goes to Medicaid. You can't reimburse prevention activities with Medicaid. At the end of the day, prevention is education. We're trying to raise awareness, increase understanding, and help folks really kind of know what maybe they're getting into so that they can make their own informed choices. Yes, sir. Can you describe the reason why you talk about billable versus non-billable because that was one of the things that I got out of the last one. That was a good question that you asked. JK, do you want to unpack this? You can do it better than I. Sure. Yeah, great question. Billable. When I say billable, I'm generally referring to Medicaid just because it's such a massive payer for substance use services and in an expansion state like Oregon, a lot of people relative to a place like Texas have Medicaid. The key to talking about billable is that if something is billable, there are a lot of organizations that say before Medicaid expansion 10 years ago, they were grant funded non-profits and they continue to fund things through grants and haven't moved over to billable. That's frankly, I think that's not a good use of funds. If they have a billable, sustainable place to get funds from Medicaid, they should do it and then use grant dollars as the last dollar. I'm going to use your organization as an example. I don't know if you bill Medicaid or not, but in Colorado, we have recovery and harm reduction organizations that do peer services. That recently became a billable service under Medicaid in the last couple of years. It's not perfect. It's difficult, but it's still money. It's not just money, it's an entitlement. Grants can supplement that. Let's say that you had a recovery professional and they billed about half their time and they just needed to be supplemented. Grants could fund the half of their time that's not billable, but they could still bill for that half. If they're not doing that, I feel like, do it. Take the step and then get the grant. It's really important as a county and a city to know what organizations or what services are otherwise billable. Therapy, good example. People get grants for therapy and there's places where that's necessary. Say you have some folks that are not eligible for Medicaid, say you have some folks that make too much for Medicaid, but not enough to pay their co-pays. Grants could be really useful for that, but knowing that therapy is generally a billable service is important so that you're not spending a bunch of money on things that have an alternate source of funding. Does that make sense? Answer your question? Okay. Yeah, I think to oversimplify that eloquent explanation, if something is billable, maybe not the best for settlement funds. If something is not billable, maybe we should really be considering it for settlement funds. We have pulled these evidence-based practices from a wide range of places. Know that everything that we show you on the evidence-based slides have a ton of research behind them. That's why we've picked them. That's why they're in front of you. For prevention, because it is a really broad category, we've tried to break this down into some easier to distill categories. For the general population, there's a ton of information or research behind PDMPs, prescription drug monitoring programs. Prescribers and clinicians actually can tap into this system, and it helps eliminate over-prescribing. It also can identify high-risk individuals who might be seeking substances from other doctors, so they can get ahead of it in that way. There are also a ton of good and kind of emerging clinical pain management interventions that are a good alternative to prescribing an opiate, like give me an example of a ... I just thought of Altos, but you'll talk more about that. Moving forward then, for kiddos whose parents have had substance use disorders, integrating treatment with family services is extremely helpful and important. Kiddos with parents who have SUDs are more likely to have them themselves, and getting in there a little bit earlier and giving them the wraparound support that they need can really go a long way. Similarly, home visitation programs does really similar work. We'll talk more about this on the next slide, but there are a couple programs that have been developed around family skills trainings, lots of good evidence behind them, as well as drug treatment courts. I don't know if ... do we have a ... we do have one in ... okay, cool. Glad there are some justice experts in the room. When it pertains to youth prevention, this is kind of where most people think about prevention most frequently. There are kind of two different approaches that have the most evidence behind them for school-based youth prevention. One is social resistance, the other is normative education. Social resistance basically teaches kiddos how to figure out when they're in a high-risk situation and what to do about it when they are there. Normative education is something that Colorado has really leaned into with their settlement dollars. Or explaining to kids what is normal. Often they are overestimating how much their peers are using. Through this type of education, you can decrease drug-seeking behavior before it starts. I'm going to save the examples for the next slide. You want to expand? One thing we haven't talked about, but is really important, is some of these are actionable at the city and county level and some are not. This has a really good example of two that are different. A PDMP is not a city or county program. It's a statewide program. In my opinion, it would not be worth trying to take action on at a city or county level. They are statewide. In fact, they are in every state and they are run at the state level. Generally prescribers have rules through their licensure on that. I don't think, in my opinion, this would not be a good place to use funds. The second one, pain management interventions, is something you could fund through a hospital education on alternatives to opioids in the emergency department. Great example of two things right next to each other that are both prevention focused. Both focused on prescribing. One which could be more of interest to a city or county and one of which is state. There are still other things that are more federal in nature. We'll try to guide to things that are better actionalized at a city or county level today. Thank you. A question about the school-based youth prevention. What greater grades are these prevention efforts focused on? There are different programs for different grade levels. The younger that you start, typically the better the outcomes are. Often we feel a little scared to have these conversations with like elementary age children, but the data show that that is actually beneficial and a good place to start. Often we see these in middle school, high school. Anything you want to add, JK, to that? Some examples, the ones we funded in a rural school, we ended up funding very primary prevention that was elementary and junior high school focused. And then in a more urban area, we actually had a leadership program, and it was essentially a summer program for high-risk kids. So it was kids who had gotten in trouble at school suspension stuff to keep them busy throughout the summer. And so, yeah, high schools. So both is the answer, and I think it really depends on what your school district has in place already or, and some of these are outside of school, like Boys and Girls Club, really depends what do you have and what's accessible, because generally building a new program through a new organization is a lot harder than, hey, we're going to fund you to expand this program. So I would say a great example, the high school leadership one was functioning in a school district called Cherry Creek, and we just gave them funding to expand it in other schools. So it was a pretty easy lift from the county's standpoint. Clinical pain management interventions, you spoke about that being in a hospital. Do we have numbers on, are people beginning their abuse more coming out of hospital situations or alternatively in the outside world? That's a tough question to answer. I think from a hospital setting or like an emergency department setting, when folks are there for something substance-related, they are well in it, and they're in a really risky, high-risk situation to be discharged from the hospital. They're more likely to overdose. They're more likely to die from an overdose. And so a hospital intervention is a really great place to catch the folks who already have substance use disorders. Did that get at your question? Yeah, remember when we talked about the different types of prevention and there were some that were like intervene before it starts, there were others that were like catch it early and then try to reduce negative outcomes, that hospital intervention would be one of them. So great question on where people's addictions start, I think. Used to be prescribed drugs was like the route to opioids. That's not, I haven't seen percents, but it's definitely not as common anymore. Opioid prescribing has dropped across the country by a lot, a lot, a lot. I think in Colorado it's about 50%, so just gross levels of opioid prescribing have dropped by about 50%. And some systems, like hospitals, have, I wouldn't say eliminated, but they've reduced opioid administration by huge amounts. Like Kaiser, most places go to is not an opioid anymore, and so the amount of people who start using and misusing through prescribed opioids is a fraction of what it used to be. There's also a lot of dark web accessibility now where people can get opioids through other routes. So I don't have numbers for you, but it's a very different landscape as far as people starting substance use in general and opioid use specifically. We almost don't even talk about prescribing rates that much anymore because they have decreased so much. That's not like an entry point to the problem. I mean, it's still a problem, but it's improved significantly. Okay, this one is quite a bit easier to read than this one here. But this is a graph that shows four or five different prevention-oriented programs and the cost benefits for each. Since this is really hard to read, let me kind of summarize for you. Bars that are lime green and big are showing you basically a better or larger return on your investment than the lime green bars that are skinnier or smaller. Notice that every program listed here does have a positive benefit-cost ratio. So if you look, for example, at that big bar in the middle for SBIRT, which is Screening Brief Intervention and Referral to Treatment, SBIRT is a really easy-to-implement prevention program for a lot of different types of providers. Even peer recovery coaches can do SBIRT. You get about $20 back for every dollar that you spend on SBIRT. Now this chart also includes the far right side that talks about other societal benefits. You can get a really advanced cost-benefit analysis that takes into account things like dollars spent on crime, quality of life, and kind of some other more external societal benefits that we don't more readily think about here. And even when you are widening the net and looking at the wider range of benefits from these activities, each of these prevention programs still continue to show really positive returns. And you'll see on some of our other return on investment slides, the biggest bang for your buck, without a doubt, is in prevention. It's affordable, it's impactful, it's relatively easy to implement, and especially if you start with young folks, you can really chip away at the economic cost to your community, to your hospitals, to your justice system, and save a lot of lives while you're doing it. So in the slides and on the bottom right, there's like the actual study that this came from. So you'll be able to, when you get access to the slides, see where some of this is coming from. Cool. There's an incredible resource that's just one website, Washington State Institute, Policy Institute, WSSIP, something like that, that a lot of this has come from. And it's cool because you can look at substance use, but you can also look at mental health and some other different categories. And then there are like 50 subcategories with all of the meta-analyses and data right there in front of you. So we'll definitely make sure you get access to that resource. No, it's national, yeah. Life skills training. Do you know what life skills training is like in practice? It is, yeah. So things on the left, I don't not pay attention to them, but some of them are very proprietary. Like Project Northland, I have no idea what it is. It's some prevention curriculum that somebody came up with, and they paid for a study. Same family, families of new deaths, they probably did one study. So some of these have a lot of studies, like SBIRT, there are hundreds of studies. And so there are, on the website you can see how much literature is there behind them. But those are each often proprietary trainings. That's called Botman Life Skills Training. It's one of the more evidence-based prevention trainings. And it's really not substance use focused. So a lot of the youth preventions are more healthy behaviors, how to be a good person, for lack of a better word. And it actually is really helpful, not just at substance use, but at interpersonal violence and a lot of outcomes, early onset of sexual behavior. It is. Correct. No, no, but Botman Life Skills is a specific proprietary training course. And I think a couple of these others are, too. Most of them are SBIRT is proprietary, BASICS probably is. So there are things that do need to be paid for, but are universally applicable. Okay, we feeling okay on prevention? Ready to move on? No, we could talk about this all day. I'm going to move us on for time. All right, next up. We have harm reduction, often also referred to or known as overdose prevention. Somebody said this earlier, meet people where they are at. And I really was happy to hear you say that, because I knew the slide was coming. At the end of the day, that's what harm reduction is all about. You got to see people for who they are and how they are, and start their support from there up. At the end of the day, harm reduction is about reducing negative consequences associated with drug use. It is very similar, if not the same, as tertiary prevention. So when we were talking about the different types of prevention earlier, you and I, that's what I was referring to. It's almost always provided in community settings, although we are starting to see harm reduction pop up in places like hospitals or justice systems. Rarely billable, so remember when we talked about that on the other slide. This is not reimbursable through Medicaid. Harm reduction is time doing street outreach in the community. We've got to find, you know, grant funding or some other funding resource for. And I feel very personally attached to this. I love harm reduction because it involves people who are struggling in all parts of the process. So in harm reduction, you're working with active drug users, and you're learning from them, and you're listening to them in order to kind of refine your approach, in order to continue to better serve them. Any questions about what harm reduction is generally before we move to examples? In our Tuesday learning session, we got to highlight provoking hope. I got to research your organization. Y'all are doing some really cool stuff. Yeah. Okay, so here are some evidence-based harm reduction practices. Notice the picture here. This is naloxone. I actually have some in my bag if anybody wants to see what it looks like and you've never seen it before. There is a ton of good data behind naloxone distribution. Naloxone is an overdose reversal drug, and so you would give it to someone who you think might be having an opiate overdose, and it will hopefully, if not after a couple doses, immediately bring them back. The benefit to this is that if you give it to someone and it's not an opioid overdose, nothing happens. I could take it right now, and I would be okay. So this is really good for folks out in the community who want to be able to do some good but don't know what the heck to do. Have Narcan or naloxone in your back pocket, and it's really easy to learn how to give also. Next up, hepatitis C or HIV screening, testing, and treatment. This is really important because of the commonality and negative issues that happen with injection drug use, and if you can get hepatitis C or HIV prevention in high-risk communities, often you can really decrease a lot of the negative consequences associated with drug use. This is something that harm reduction entities will do, but you can also embed in a treatment clinic, so it doesn't have to be directly in the community. And then last up, we have syringe service programs. So a syringe service program is a place that folks can go and access clean-use supplies. This is kind of a hot topic in today's world. There is a ton of data that show that this is a productive activity for the community, for the users, and it's also an entry point to connecting with people, and maybe when they are ready or if they are ready, eventually getting them to maybe seek treatment or look for a version of recovery that works for them. Ultimately, though, harm reduction does not directly address opioid use disorder. It is all about reducing those risks and hoping to keep folks alive, keeping people in all of this. Any questions about evidence-based practices? Okay, some return on investment stuff. How do I want to talk about this? So this study is a meta-analysis that looked at the return on investment for naloxone. Intranasal is just the way that you give it. There's actually injection naloxone. What I have, what most folks in the community have, you put it up your nose like nose spray. The take here is that all of the studies that they reviewed found that community naloxone distribution was cost-effective, and the incremental cost-utility ratio range, incremental cost-utility ratio is a fancy way to talk about cost-benefit that includes some of those other societal benefits that I talked about on the other slide. So for every dollar spent, you can get $111,000 to $60,000 of quality-adjusted life years gained. That's a big range. JK, anything you want to add on ICERS and ICERS? I think the take is obvious here. Okay, one more return on investment for harm reduction. This is a syringe access program. The thing that we want you all to get from this slide is that there's a lot of savings per individual when you're looking at a syringe access program. In one particular study at a needle exchange in New York City, there was a savings of about $1,500 to $3,000 per client that they supported. Are there questions or comments for discussion on return on investments for overdose prevention or harm reduction? Yes, ma'am. It has to do with not only keeping folks, I think some of the numbers are pretty significant about whether or not there's skin infections and hep C and things like that. But in terms of what is the percentage of folks who actually choose to go into treatment, maybe our provoking hope representative can answer that. Oftentimes what I'm hearing is that when they're brought back, there's a lot of anger and that they don't often seek treatment. So in terms of the return on investment, have we just kept an addict alive, enabling them to go on to another day to use? And that's kind of the sticking point here. Okay, so with harm reduction, it's a super difficult thing to quantify the effectiveness because with substance users, it often takes them years to find recovery. So catching up with percentages and data is nigh impossible unless you're looking at a 10 to 20 year span, I would estimate. But I think that the important thing to consider here is that they're still alive. But when they aren't using the SSP services and they're acquiring these blood borne illnesses, that's where the money drain comes from. To cure chronic hepatitis C, I think the base cost is like $30,000 for treatment, things like that, when they could go get a clean 10 pack of syringes, which costs 89 cents to manufacture. But it's a very difficult thing to put into figures. Yeah, I see you, I'm coming. Mostly, it's for naloxone syringes. I mean, we offer food, clothing, referral to treatment and services, access to detox, things like that. You know, everything that a recovery mentor does. That's what's special about our harm reduction program is it's staffed by recovery mentors. You know, people who've been there and done that and gone through it and are able to use their experiences to help folks out. But I would say at least 50% of people that are coming in to the, it's called Chrome Community Harm Reduction Outreach Mentoring and Education. So the folks that are using that program, probably 50 to 60% of them are exchanging. Yeah, absolutely. Thank you. This is specific to the really important concern that I think you brought up, Commissioner Starrett, around the risk after someone utilizes naloxone and comes back, right? And if you've ever watched it, it really is pretty profound. It is like someone coming back from the dead. But they are at higher risk, right? Because you've just taken everything out of their system. And if they refuse transport to go to a hospital or somewhere else, then they are at really high risk of not only using again, but also overdosing. One of the things that we're currently working with our various ambulance service area providers, as well as emergency providers in the emergency departments, is a program where they will be able to provide a couple of doses of buprenorphine after they give someone naloxone. And then our end is a treatment provider. We are working really hard to make sure that there's access for that person to come and get continued same-day medication-assisted treatment and hopefully enroll in services and all of those different things. But we are working on that because I think it is one of those pinch points where we see an incredibly high risk in that. So technically, yes, I don't actually know the time frame. Yeah. I try to help the community know that if you inject that or if you put it up someone's nose, it blocks the receptor. So it immediately whatever's in their system, it blocks the receptor. So they're unable to fill what's in their system. But it's still in their system. It doesn't remove it from their system. So the important thing to know about that is when it wears off, you can still overdose again. So it's really important to try to help them to get into the emergency services because like we said, it can jar them awake. But if they don't get an intervention, they can still overdose because it's still in their system. I love when we have a room of educated folks. Okay. Here's this. If anybody wants to take a look, we'll keep it up here. I'm going to go ahead and move us forward for time. And I think this is on to you. Yeah. If you didn't catch that naloxone, it's pretty cool from a physician standpoint. There's not much. We did surgery on a kid one time and he like came back to life. Other than that, naloxone was the second most dramatic medical intervention I've ever seen because I was at a syringe access program and a guy overdosed in the bathroom, administered two doses of naloxone via injection and he woke up and he wasn't upset. He was very happy. I will say to your question, I'm very sure he scampered off and used drugs right away. It was not an immediate go to treatment. But another thing I'll say is of all the folks that came into the syringe access program for us in Denver, 100% of them got asked every time they came in if they wanted to go to treatment. That was part of before you got anything, they asked you if you wanted to go to treatment and people said yes all the time, all the time, every day, and got linked to treatment. And I am sure almost everybody there engaged in treatment very frequently, probably on at least an annual basis. And they didn't stay necessarily, but I don't think that would have happened if they weren't there, if they were out on the street not accessing services. They would have had, and this was 2017, far less access to Medicaid, just general healthcare for the skin infections and things like that. And so feeling enfranchised was a big part of it. And now treatment is much more accessible, even in harm reduction settings. They didn't used to partner so closely with treatment. A lot of them have treatment on site now and people can start that day. So there is a high level of folks that engage in treatment. And final, last thing I'd say on that is we don't talk about the benefits because we think about it as a drain on resources and they're going to the emergency room. And that's true. I mean hepatitis is really expensive, so preventing that's important. But also people who get into recovery in whatever aspect that means for them become taxpaying citizens. So great examples, there are people who were previously a drain and now are, you know, earning a living, some of them are earning great living and paying into the system that they used to be. So keep that in mind that that doesn't necessarily happen without the recovery and without being alive is a big part of it. The bad part of cost benefit is that people don't have costs. And so cost benefit actually is really skewed against overdose prevention. But there is a benefit to having people alive, obviously from a moral lens and also from a very utilitarian lens of people become taxpaying citizens and, you know, have relationships with their family and community and things like that. So that's my soapbox for overdose prevention, harm reduction, treatment. Sure. Interesting, good question. So it's not inhaled, it's actually through the mucous membrane in the nose, so they don't even need to be breathing hard, otherwise it wouldn't work very well. And in fact it wouldn't work because blood's not flowing well. So it actually goes through the mucous membrane. And so injection is a lot cheaper, but most people have moved away from injection just because they don't like handling needles. Still very palatable to people who use needles every day, but 90% of naloxone in circulation now is nasal. And it is not based on breathing or lung capacity or anything like that. So as long as somebody has not long since passed away, it will be effective in either injectable or nasal format. Commissioner I think for our program what we're lacking where we're not seeing people engaging is that you know that midnight citation and that warm handoff getting somebody out there with the person to get them engaged. Once we actually get them engaged they seem to be staying. We've had our first successful completion, super exciting. We still have seven other people that are in treatment that it will take them a while. It takes them a while to get to that first clean UA you know for the light bulb to come on and for them to start moving forward. That doesn't mean that they won't have a stumble but but I think for those that are that we're catching before court it's that warm handoff that we're working on trying to figure out how to partner with »» I think the latest data that I saw, we have about 20% of individuals who are eligible for deflection come in and get an assessment within the timeframe. And then about half of them remain in treatment after their assessment. And I will say we do have 24-7 support with our COS team that includes both a treatment provider and a peer who are able to go on site. That sometimes gets a little trickier in the middle of the night, but that is an availability that we have. We're working with our law enforcement partners to make sure everyone knows that. Specific to deflection or specific to the whole group of people? It's a very small slice. I will say the numbers of people coming in voluntarily for substance use disorder treatment has decreased dramatically for probably a handful of reasons, right? I think there's no one cause for that, but I think we could pinpoint a handful of things that were happening simultaneously. But we are beginning to see more numbers, and when you look at our assessments in totality, I would say that the vast majority of them are for mental health, and that may be why that person is seeking treatment in that moment, and there's oftentimes an underlying co-occurring issue going on. And these folks are much better poised to speak. Thanks. Thanks. We're falling a little bit behind, so I'm going to hold us off on questions, if that's all right. Plenty more time after our break, and hopefully we'll get those answered. I am giving an overview of the treatment universe in 10 minutes, and treatment is, I think, the most easy, easiest to define area. I think of it as a set of largely billable services that are delivered in a healthcare setting, and that can be virtually, but they're delivered by a licensed or credentialed provider, and they're generally billable through insurance. So that leaves something to be desired, but there's another framework here called the ASAM, American Society of Addiction Medicine Criteria, that further define different parts of addiction medicine treatment. And they recently overhauled these to be more inclusive of recovery residences down at the bottom, and also medication-based treatment, which didn't used to be part of this specifically. But that's treatment. It's something that's billable that would generally go to an insurance company or Medicaid. Next slide. All right. And so these are the evidence-based practices. Can't emphasize enough, medication-based treatment for opioid use disorder is gold standard by a long shot. In a way, relative to the condition, much better than other standard treatments that we use for things like depression, or even things like blood pressure control. Medications for opioid use disorder work really, really well. And the two that work really well are methadone and buprenorphine, also known as Suboxone. Naltrexone, known as Vivitrol, actually doesn't work very well, but it's still FDA approved. And then you've got a host of therapies, like cognitive behavioral and family therapy, that are helpful adjuncts, but not as highly evidence-based. But I still wholly endorse, because a lot of people who've had substance use problems have a lot of issues, not just using substances. And so counseling helps them to reintegrate with their family, get a job, stay in stable housing, and things like that. So sometimes that's sequential medications, therapy later. Other people, a therapist helps them kind of light bulb come on, and they start on medication. Those are two mainstays of opioid use disorder treatment. And there's a couple kind of adjuncts down there, the collaborative care model, and ED linkage treatment. All right, so here's an example of an effective treatment called contingency management. It's a really cool treatment, and you pay people not to use drugs. So small payments help people not use drugs, often used as people leave something like residential treatment or jail. And I know this sounds counterintuitive, but it's actually the cheapest way to keep people off drugs is paying them, which is so often the case. And the reason why this is so helpful is because it's biologically proven, not just them saying it, there's got to be proof that people aren't using. And they get small $5 and $10 to $15 payments, and they start to reframe from before when they used to stop using drugs, they went into withdrawal, things were bad. Now there's something good happening, and so they start to associate, I'm not using drugs, and good things are happening to me, and I could buy a new parka at the Goodwill, or there was a guy at Denver Health who got propane, and he was still experiencing homelessness, but he could warm his place. So he started to have better things happen to him when he stopped using drugs. People associate that and are more likely to continue on a recovery program. And that is very, very cost effective, because the costs are just the money and the benefits are the good things that happen. Here's the ROI for medications, and we don't need to get into all the numbers, but it generally shows that people are much more likely to stay in treatment for longer and use less other drugs when they're on methadone or buprenorphine. So generally, retention treatment is very, very low when people are not on medications like days, because withdrawal is very challenging, and people will resolve that however they can. Medications help resolve withdrawal. That's really how they work, is they keep people coming back and not using as much outside medications. And they're also very controlled, so people don't overdose on buprenorphine, they don't overdose on methadone, they overdose on fentanyl. So generally, the rule of thumb I use is on medications, people stay in treatment about six months. Without medications, people stay in treatment for not long, days. And you see there, they also have fewer inconsistent or positive drug tests. So not 100% fewer, but about a third fewer. So combined, this makes medication, which is relatively cheap, a pretty dominant strategy. And the nice thing about medication is it's not exclusive of other treatments like detox or residential. It's best used in conjunction, whatever level of care people are at. Yeah, great question. It is a controlled substance. I think it's Schedule 4 now, it got downgraded, and it does have a sealing effect though, so it's a lot less sedating for folks, but it is still an opioid. It's a partial agonist, so it's kind of a balance of the two. It keeps people out of withdrawal, and it's less sedating. Different organizations have different rules about that. I think pilots don't like it. I think pilots have very, very stringent, but I actually, I don't want to get quoted on that, but I think over the road some people do use buprenorphine, so it is definitely more palatable by heavy machinery and operators than methadone. Is that about right? Okay. Oh, yeah, yeah. No, I think DOT Commercial drivers aren't supposed to be on them. I'm pretty sure that's the case, but buprenorphine definitely Yeah, so the the downside of buprenorphine it worked really well for heroin and prescription drugs Fentanyl often it doesn't get to the level Needed to sate people's craving. So more people I would say in areas where methadone is accessible are going to methadone instead of buprenorphine That said fentanyl is also decreasing potency of fentanyl is decreasing in street drugs and so things are things are changing rapidly Yeah, fentanyl is decreasing very rapidly in the drug supply. A lot of great articles about why that might be happening But in general it's that the the products the pills usually their blue pills coming in the country are are less Deadly so actually one of the reasons overdose is declining All right recovery is Not as easy as treatment to put in a box but also less Fundable so we'll talk about let's start less fundable through billable mechanism So it's a wider world and we see a lot of funding going into recovery because it supplements some of the treatment That is funded through Medicaid so the nice thing about recovery is it's not as definable through billable codes, but it does have a really good definition here from SAMHSA and I really like this definition other definitions of recovery involve On a survey question people often ask did you used to have a problem with drugs or alcohol and now you don't? Very simple. So what I want to get across is that recovery is self-defined people say every Okay, that doesn't necessarily mean abstinence-based recovery big difference in the last 10 years recovery used equal Go to 12-step groups and you're absent now. It is more self-defined And part of a harm reduction process and close-up groups are still really big but the process and the definitions have changed And it acknowledges that some people relapse Or return to use but not everyone Who using drugs and stop forever These are not usually billable, but this has changed a lot in the last five years and it is a billable service through Oregon Medicaid Through a peer support specialist. So there are more billable services. It's not usually completely offset the cost of recovery by billing And really when we come back to recovery The one of the core principles is involving people who who use drugs and are in recovery in decision-making Important to have folks at the table who've been affected by substance use and can inform Here are some examples of evidence-based recovery practices and as you'll see on the next slides Recoveries because it's hard to define. It's hard to research and it's hard to do cost-effectiveness studies. So they're I would admit is somewhat lacking the cost-benefit analyses are lacking in recovery. I don't think that Means that it's not effective So great example that I think you just spoke about is a warm handoff from first responders to peer support and treatment professionals super high Very promising practice to me because people are at area people are at a place in their life where they may be willing to make a change often that's Involvement in criminal justice physical health symptoms or some type of family conflict Me personally a combination of physical health problems and family conflict for what got me into recovery so that's a really common theme you hear amongst folks that Someone confronted them or they got sick or they went to jail. Those are kind of those are the three things I think of that usually drive people into recovery Second sober living this actually does have a ton of evidence base behind it generally people do what they what people around them do I think we all know this from part of our lives if Someone close to us drinks more we tend to drink more and that's true of substances, too People hang out with other people who use substances and so removing them from that Setting is really helpful when they want to stop using substances so that's why it's sober living is so important and actually within a sober living the primary predictor of somebody's success measured by Sorority is other people's sobriety. So being around people doing what you want to do helps you do that comes no surprise Mutual support groups like 12-step and non 12-step groups. I think he said you have a medication support group Is that right for people on buprenorphine or methadone So whatever the stripe of it if it's absence-based non absence-based having someone to talk to about Struggles about successes is really helpful and actually rigorous studies have shown This is really helpful and it's as good as going to counseling. So keep that in mind, even though it's peers Really helpful not usually fundable most 12-step groups don't accept funding and peer support groups sometimes So another evidence-based use funding and then other support services To me these get a little fluffier. It's hard to define some of these but also Sometimes really helpful like sometimes transportation is somebody's barrier to getting a job getting into treatment. It is Difficult to fund those services in a way that is rigorous. So And that's one of the conundrums here is that sometimes the thing that you need most is the hardest to define and fund So don't let that scare you off But also know that some of these can get pretty feel-good and not cost-effective So that's what we're here to do is figure out what's going to be effective and also yes That's great to know. More state Medicaid agencies are funding some of those social determinants programs. Transportation has always been funded, but California has a big housing program. Colorado actually has a grant-funded program through our Medicaid agency. And so some of these are actually becoming billable services through Medicaid, which is great. Yeah. Great. Thank you. This is a return on investment. As I said before, my summary of cost benefits specifically for recovery is it's not that great yet, but it is much earlier. People have been studying treatment for 40, 50 years. Recovery is a bit newer, and it's harder to find. But you see down there, there are some findings. Peer recovery specialists are associated with treatment retention, less risky behaviors, and people going to counseling sessions. Yeah, there was a big, it's called a Cochran Review, where they do a study of a bunch of studies. About three years ago, they updated it, and it was very positive for 12-step groups. It didn't give numbers, it gave relative effectiveness, but they felt like 12-step groups, with and without other things, like counseling, were as or more effective than traditional evidence-based modalities like counseling. So, it essentially said that 12-step groups are as good or better than counseling. It didn't say 30% of people who go to 12-step groups continue in recovery, sorry. It wasn't one of their study endpoints. They just wanted to show, this is as good or better than everything else. But, one thing, as you'll see with all of these, is the more people do, the better off they are, usually. It's not like, ooh, just doing 12-steps thing. That's not the case. They can go to counseling, they can go to 12-step group, they could be on medication, they could be in sober living, and the more of those things help people address things. So, it's, I don't find it as helpful to compare one to the other, but also, try to be realistic about, people only have this much time, right? They can't go to three hours a day of treatment and an hour of individual counseling and a 12-step group and keep a job. But, some of them, many of them are kind of layered and can be given all at once, and that's really what people need. All right, criminal justice, as we talked about earlier and you see here, there are a lot of things that can happen in a criminal justice setting, because it's just either someone in jail, prison, or who's involved in community corrections. And so, this is not exclusive of any of the other aspects that we talked about, but one unique thing about criminal justice is that, sorry to use this, overuse this, but they're a captive audience, literally. And so, folks are actually pretty eager, in my experience, especially in prisons, to engage in programming because it's boring, and so people can engage in intensive therapy, sometimes medications, and because a lot of people have realized that they wanna do something different. And because criminal justice is also home to a lot of people with substance misuse and use disorders, I'm sure you've probably all heard facts and figures about what percent of people in the criminal justice system have recent substance use or substance use disorder. It's really high, really, really high. And one particular thing that we've, I'm really proud to be part of, we helped get medications, particularly Suboxone, into jails and prisons in Colorado, and that saves lives, no question about it. You've got lots of people with a big problem and an evidence-based intervention, and so helping people get on and stay on medications is a great intervention. So that's the one at the top, MOUD, which you may have heard of as MAT or Suboxone. Doing that for people in jails is really high on the list of cost-beneficial and evidence-based interventions. Other ways to help people reenter the community, so care coordination, help with enrollment on Medicaid if they're not on it already, and recovery support service organizations so people know where to go to get their recovery coaching, they know where to go for meetings when they get out of jail is really helpful. And then there are others that we talked about, like deflection, mobile crisis services are really helpful. Yeah, absolutely, great point. Sorry, I take that for granted sometimes. So people who have exited a carceral setting are not usually abstinent, but they have been using less than they did, and that's a common misconception. Most jails and prisons are fairly, drugs are fairly readily available, so people aren't abstinent, but they're not using five times a day like they may be on the street. And so opioids actually create a high level of dependence, physical dependence, and so people can use more and more, and that drops off very quickly when they stop using, say, after a jail or prison stay. And so when people leave a justice setting and think, oh, I used to use this much, so I'm gonna use this much, because it's been a long time, they're much more likely to overdose. And studies show it's 40 to 130 times as likely that they overdose as average person walking around on the street. So really, really high likelihood. And in fact, I would guess, based on national statistics, that 10 to 20% of people who overdose fatally were recently incarcerated. That's a very large number of people who overdose fatally have recently been in jail or prison. All right, these are some more statistics. I'm gonna go pretty quickly through these. So substance use treatment programs save a lot on jailing and imprisoning people. These are really old statistics. Okay, so we're gonna go to break. What time is it now? So we're a little behind. We originally gave you a 10-minute break. Everyone okay with a five-minute break? Let's say, why don't we come back by 1045? So a little over five minutes. And I'll make the point I'm about to make on the other side of that. So enjoy your break. There's still coffee.

opioid settlement

Rhiannon Straight

Stedman Group

evidence-based collaboration

funding allocations

prevention

harm reduction

treatment

recovery

criminal justice

medication-assisted treatments

ROI examples

community engagement