So, good afternoon. My name is Sarah Canovies, and I'm with the Opioid Response Network. And we are here today to get started talking about the opioid settlement money and the allowable spends. And we have two amazing consultants here, Rhiannon and JK, and they're going to be doing all the talking. I'm just here to kind of introduce ourselves. So, Rhiannon, if you want to skip through some slides. So, the Opioid Response Network is SAMHSA-funded. We are a grant, and we provide technical assistance for evidence-based best practice in prevention, treatment, and recovery. We do that with opioid use disorder and stimulant use disorder. Next slide. Can we pause just for a second? It looks like somebody's trying to get on here. I don't want to get too far ahead without them, you know, the... Sure. How are you guys doing? Busy. Well, we appreciate you taking the time. Jeff, do you have an update on your counselor trying to get on? I don't. He was having a tough time with the link that I texted him, but he said he's home and on his laptop, but I haven't gotten a message from him in the last couple of minutes, so I'm not sure if he's having problems. Let me send him another text. I'll leave it up to Jeff if he wants to proceed. I'd say, let's go ahead and get started. Okay. So just to continue, the ORN, we are across the US. We provide training and education and it's all tailored. Next slide. If you are interested in learning more, please visit our website or you can email us at ornatripleap.org. Next slide. This is just fancy language about our grant, proving that we do actually have the means to do this. Next slide. Next slide. And next slide, because they're all the same, you guys. I promise, I'm not like leaving anything important out. So that's the ORN. If you have any questions about the opioid response network, please feel free to put it in the chat. I'm happy to answer any questions. And again, you can check out our website. And so that's me and the ORN. And now I'm going to hand it over to my wonderful consultants who are going to be doing all of the actual talking and educating today. Thank you, Sarah. Hello, everyone. We will dig into official introductions in just a second. I think there are a few of us on the call that will be able to say hello and kind of let everyone else introduce themselves. But first, I wanted to walk you all through the agenda and what we are planning to do together today. So the real purpose of this virtual learning session is to make sure that all of you on the call have a good baseline understanding of the opioid settlement allowable spends. So we'll talk a little bit about the opioid settlement generally. I'll give you all some context just so you can kind of understand the foundation of this process. And then we're going to spend the bulk of our time together really digging into definitions and in-practice examples, many of which are happening in your local community, for each of these different kind of allowable spend categories. And I want to also preface this by saying this is kind of step one. The real meat and potatoes of what we get to do with your community will happen in a couple of weeks in person when JK and I are going to come visit you all. And we have a day-long learning session on Monday, February 4th, if it's the 3rd, please correct me if I'm wrong, where we will get to dig in even further to what all of these mean, what they look like, what some good evidence-based practices are for each of them, what your return on investments might look like for various projects in these categories. So today is really just step one, just to make sure you all have the information and understanding that you need to be able to play and engage in that meeting that we'll have in a couple of weeks. We should have some time at the end for questions, but this is a small group, so if you have something as we're moving along through the presentation, drop it in the chat, raise your hand, let's let this be a conversation. We really do want to make sure you all have a thorough understanding of these things. Often, you know, behavioral health jargon and some kind of technical understanding might be involved. So interrupt us, ask questions, and we will kind of learn together as we go. Any concerns or potential additions for the agenda before I move us forward? Okay. The third, February 3rd, Monday, February 3rd. Thank you, Sarah. All right, let's start off with introductions. My name is Rhiannon Strait. I'm a senior behavioral health consultant with an organization that is Colorado-based called the Stedman Group. I get the great pleasure of leading all of our opioid settlement work here in Colorado, and we'll dig in in just a second a little bit more about the Stedman Group. For now, I'm going to pass this on to my colleague, J.K., to say hello, and then I'll drive us down the list so you all can introduce yourselves. Thanks, Rhiannon. I'm J.K. Costello, and I'm a physician consultant co-owned in the Stedman Group, and I'm a person in long-term sustained recovery from opioid and other substance use disorder. So I try to bring that to our work, and I oversee our behavioral health consulting division, so I'll do a lot of subject matter expertise on treatment, recovery, and criminal justice initiatives today and during our in-person session. Thank you, J.K. I'm going to just move down the list. Please tell us your name, maybe the organization or city, county that you represent, starting with Jeff. Hi, everyone. Jeff Towery. I'm the city manager here in McMinnville. I'm going to have my camera off and my mic muted because I'm eating lunch and nobody needs to hear or see that. I hope everyone enjoys lunch. If that is happening right now, enjoy. Next up on my screen is Mary. Hi, everybody. My name is Mary Starrett, Yamhill County Commissioner. Thank you, Commissioner Starrett. And I have an individual named Johnston Kaye. Kit Johnston, Yamhill County Commissioner. Thank you for being here as well. How about Lindsay? Hello, Lindsay Manfrin, Health and Human Services Director. Thank you, Lindsay. And David. Good afternoon, everybody. David Lightenberg, City Attorney, McMinnville. Thanks for being here, David. I think last but not least, we have Scott. Yes, Scott Cunningham, City Councilor, McMinnville. Wonderful, Scott. Thanks for joining us. Quick temperature check. Who all in the room has learned anything about behavioral health, prevention, substance use? Are these terms familiar? Are we starting fresh from scratch? Some familiarity. Awesome. Okay. I think that will make today even more productive. So before we dig in, a little bit about the Stedman Group. Both JK and I are consultants with the Stedman Group. JK is principal there. We are actually a B Corporation. We're woman-owned and we identify as a health and social service consultancy. We are very learned when it comes to the opioid settlement. So we've kind of been involved with this starting in Colorado at onset. And we now lead about half of the counties in Colorado, as well as counties in North Carolina, and a handful of them in Kansas. And we are very excited to be entering the Oregon community. So thank you for having us here today. Okay. We're going to dig in here now. Before we started talking about the allowable spends, we wanted to provide a little bit of historical context so that everyone's on the same page as it pertains to the opioid settlement. Overall, this is a national settlement that is going to be distributing about $50 billion over the next 18 or so years. These payouts are coming from a variety of different companies that were originally involved in either making, distributing, marketing, or selling opioid painkillers. Some of the entities that are providing payouts include Purdue, Johnson and Johnson, and Walmart. Each state gets to dictate their own distribution process, but there is a national agreement outlining some guardrails that all states have to follow. And one of those includes Exhibit E. Exhibit E is the super detailed, frustratingly lengthy, occasionally document that outlines all of the allowable uses of funds. And it does a decent job of really trying to capture the continuum of behavioral health care, because that is what we need to address in order to really start to chip away at this epidemic. Exhibit E does include a prioritized list of approaches that they reference as Schedule A. These are just strategies that they have identified as evidence-based practices that might move the needle the most in regards to the epidemic. Drilling down just a little bit more specifically to you all, Oregon is set to receive a little over $600 million throughout the duration of the settlement. Notice that we're saying estimated because there are still settlements that are finalizing, so this dollar amount will continue to fluctuate, likely to increase a little bit, unlikely to decrease much, not going to change a lot over the duration of the settlement. The way that Oregon is actually dividing the state's share is that 45% is going directly to the state, and then 55% is going to local jurisdictions. So today, and when we meet together on Monday the 3rd, we will be really spending all of our time thinking about the local jurisdiction share. That's your all's money, the money that you have to spend in order to address the opioid epidemic. Little bit of an update on how much money we can expect in McMinnville. Thank you to David for this update. As of November 2024, you've received just over $470,000, and you've only spent $2,400, so you've got a good chunk of money left to spend, and you're projected to receive a little over $1 million throughout the duration of that settlement. I guess, actually, total projection is about $1.5 million. Now, when we meet together on Monday the 3rd, we will drill down a little bit more specifically on the difference between state and local shares and the specifics around county money versus city money and how you are able to pool dollars or not, whatever serves you all best. We have more info there. We'll get there with the full group. For now, are there any questions on the overall context? And, Lindsay, maybe an offer to see if there's a county update on settlement dollars expected. I can certainly share a bit about what funding has come through OHA directly to Health and Human Services, and then I have a rough idea of how much there may be in terms of the county dollars that came to county admin proper, but perhaps one of the commissioners may have a better figure or a more updated one as well. As far as your slide notes, 45% of the funds have gone to the state. They have what they call their Opioid Settlement Board that has represented bodies from folks around the state, representing different types of organizations and communities and whatnot. And through that process, because that's the group designated to receive and distribute the 45% that's remaining at the state, we've received $259,000 that is earmarked and specifically intended for and has restrictions around making sure we use them for primary prevention as described in Exhibit E. So those are funds that we currently have in our budget, and perhaps at the next meeting or whenever is appropriate, I'm happy to share more with our intentions around those funds. And then we've certainly been part of accessing the statewide clearinghouse that is also funded through that 45% of state funds, which is where public health is getting large doses and quantities of Naloxone or Narcan, overdose reversal medication, that we then distribute throughout the community to peer organizations, to law enforcement, and things of that nature. So those are those are the funds. And then I don't know, Commissioner Johnson or Commissioner Serrett, I don't know if you have more details around anything at the county level. I'm happy to share what I know, but let's hear from you first. Lindsay, I would just ask just clarification. The money that we used for that fentanyl prevention program that we rolled out, that was a separate grant. This didn't come out of any of that, correct? Correct. That was other funding sources. Last, we haven't had an update very recently, but I want to say we're four to five hundred thousand. But last I heard. Thank you to all three of you for those contributions. We will have some exact figures for you all when we dig in together in person. You bring up an important point, though. There are other funding sources, even within the opioid settlement context, that we can pull from and braid in order to make a bigger impact and do bigger things. So that will be part of our conversation as well when we're together in McMinnville. For now, I propose we lean in, move forward and get started with prevention. Does that sound good to anyone? Any other questions? I just want to make sure everybody feels comfortable about where this money is coming from and why there's a split and how much the split between state and local. Are there any questions on that? Yes. Go ahead and unmute yourself. Thank you. This may be part of the larger conversation in a couple of weeks, and if it is, I don't need us to jump ahead. But getting a sense of what we believe or what we know about the state's efforts to spend, I think that would be helpful in terms of a context. My general preference is that we figure out ways to really address our local issues as best we can. But because this is such a systemic issue, leveraging and or filling gaps that the state's not able to adequately address from our perspective are the kinds of things that are interesting to me. So whatever the right time and place is to dig into that, I'd appreciate it. Jeff, that's exciting that you are already thinking of that. We have almost two hours together to really dig into existing resources and gaps when we are in person on the 3rd. But we will add to our slide deck for that day a little recap of how the state has already set aside settlement dollars so we don't duplicate them. And then the other thing I would add to that is that before we start talking about resources and gaps, we'll provide a lot of data to give you kind of like the lay of the behavioral health land from a data perspective to help inform and fill those gaps. You also have a really interesting and very large, I think it's a statewide tax, and I can't remember the name of the legislation, but we actually worked on a project in Central Oregon on that. And I think that was focused on high intensity residential treatment. So we'll make sure that all your main sources of spending around behavioral health get covered and kind of the aims of those, everything from federal grants that flow down to the state, safer prevention to, I'm sorry, I'm blanking on that, the legislation and other opioid settlements too. All righty, folks, I'm going to go ahead and move us forward. So first up, we have prevention. And for each of these categories, we're going to provide kind of a general overview or definition of what that really means. And then we'll give you some in-practice examples. And again, a reminder, when we're together on Monday the 3rd, we will be talking about evidence-based approaches for prevention and some return on your investments so you can understand the economic benefit of each of these programs. So overall, prevention is really education. The main aim of prevention here is to educate and support individuals or communities in order to prevent the use or misuse of substances. Prevention is really quite frequently youth-focused. We will frequently see prevention in school settings. So in opioid settlement contexts, it's really helpful to have folks from your school districts kind of in the room to help guide these prevention conversations. And even if it's not youth-based or school-based, prevention is usually delivered kind of directly in the community. So this isn't in like a clinical healthcare setting. Prevention is not billable. Billable is important when you are trying to identify other funding sources or ways to make the programs that you're funding with opioid settlement dollars more sustainable. Often prevention programming will be grant-funded and we are always looking for additional dollars in order to stand up prevention programming. There are really three different types of prevention. So you might hear folks talking about primary or secondary prevention. I'm going to give you some examples of each. Primary prevention, the goal is to prevent something before it ever even starts. So this is where you'll hear about the classic school-based D.A.R.E. program, for example. D.A.R.E. is outdated, no longer considered evidence-based, but it's an example that most folks know of when you think about primary prevention, a program developed in order to educate kiddos and keep them from ever actually initiating substance use in the first place. There are quite a few other primary prevention programs that have a bunch of great evidence behind them and we'll dig into those when we're together in person. Then we have tertiary, or I'm sorry, secondary prevention. Secondary prevention aims to identify an issue really early on and keep it from getting worse. So something that you might have heard of that is considered secondary prevention recently is fentanyl testing strips. There's a lot of fentanyl that has gotten in the drug supply and in order to identify what is in your substances, you can use fentanyl testing strips, identify that your substance might have fentanyl in it, and then hopefully, you know, not use or use with safeguards that substance. And then lastly, we have tertiary prevention. This is ultimately the same thing as harm reduction or overdose prevention, and I'm going to talk more about that next. It's kind of its own category when you think about Exhibit E under the National MOU. Then we wanted to throw some key audiences for prevention at you. Prevention is really universal in that you can almost deliver it to any audience and get some type of benefit. So you can have prevention programming aimed at providers like prescribers, pharmacists, treatment providers. You could also have prevention aimed at policymakers, patients or clients, and as we talked about earlier, youth-based prevention. Are there any questions on what prevention is and means before I move on to the spotlight for prevention? Often, we do these types of presentations and we're just kind of spewing technical words at you and it can be difficult to really tie what we are saying to what this actually looks like in the community. So that is why we are sharing these program spotlights. We will continue to do this. Many of these are tailored locally to your community. This one is actually specific to Colorado and it's a program that's kind of near and dear to JK and my hearts, but this is an anti-stigma campaign that we helped develop in rural Northwest Colorado. And they utilized both traditional and social marketing campaigns and really tried to hone in on local stories. There's a lot of data that show that putting folks in front of audiences that are relatable and look like that audience really goes far in regards to successful campaigns. And importantly, this program not only showed those stories and got the campaigns out into the community, but the campaigns were linked to local community resources. So in addition to increasing education and awareness, we were hoping that this might increase service utilization as well. Something for you all to think about, this was originally started by a grant funded outside of the opioid settlement, but they are now currently using opioid settlement dollars to maintain and sustain and kind of expand this program. So a neat example of how to braid funding sources. And then just a little bit about the campaign logistics. Prevention is pretty affordable, and that's an exciting thing. There's a big return on your investment for prevention. This only costs about $70,000 to build and stand up. Most of this was market ad buys. And we got a ton of website visits, especially for a very small community. A lot of impressions and some good earned media as well. And you can see on the slide, this is a screenshot directly from the website, and this is an actual ranching family that lives in the community that came forward and kind of shared their story. Thank you, J.K., only 40,000 people in the community. So the initial cost is about $2 a resident. Any questions, comments on prevention before I move us to harm reduction? Next up is harm reduction. You will often hear harm reduction as overdose prevention or even tertiary prevention. We will kind of use the terms interchangeably. Just wanted to make sure everyone had an understanding of each. At the end of the day, harm reduction is all about reducing the bad stuff associated with substance use. It's very important that when doing harm reduction work, you meet people where they are. Just like prevention, this is typically provided in community settings, often not a clinical space. There's a lot of street outreach involved in harm reduction, and you might even be visiting homeless encampments or going to talk with folks who might actively be using on the streets in order to make sure that they have safe use supplies or testing strips to, if they're going to use, do so with as much safety as possible. When you are doing harm reduction, it's really important to include people with substance use disorders, that's SUD, substance use disorders, in decision making. We need to hear from those who are active users or in recovery or with lived experience of substance use in order to best serve them, especially from a harm reduction perspective. Before I move to the spotlight, a couple of examples of overdose prevention, Naloxone. You might have heard a lot about Naloxone or Narcan. This is a tool that we can use to actually prevent someone from dying from an opioid-related overdose. Naloxone is a very effective tool because even if you suspect someone might be overdosing and you use Naloxone and they were not overdosing or they were not overdosing on an opioid, you cannot hurt them with Naloxone. It's a great thing to have. I always have it in my car or in my backpack when I'm traveling. Some other less common examples, supporting staff or supplies and space needed for harm reduction organizations who are going out there and meeting people on the streets and getting information out. Also trainings for relevant professionals on harm reduction strategies, good use of opioid settlement harm reduction funds. Then sometimes you'll see mobile units utilized in harm reduction settings. This is just often like a van that has harm reduction supplies and education and information in them. It will travel to various locations around the community and, as I keep saying, meet the folks using directly where they are. Harm reduction mobile units will also conduct testing like hepatitis C or HIV testing in order to potentially decrease the spread of infectious diseases that are really common with injection drug use. For our harm reduction spotlight, we are highlighting a local organization. Some of you who live and play in McMinnville might be able to jump in here and contribute, but Provoking Hope is kind of a recovery-focused organization, but they have a very specific harm reduction program. I really like the way they framed this, kind of work at the intersection of evidence-based strategies and faith-based methods to reduce the harms associated with drug use. Their program, the harm reduction program, kind of spans the gamut of everything that I just talked about as potential harm reduction examples. They do conduct street outreach. They also provide something called in-reach services. In-reach is just a term to explain actually going into county jails and speaking with high-risk folks in the jails before they are released to try to educate and reduce harm once they are released. There's a lot of data that show that that is a very sensitive time for individuals just after being released from jail. Lots of overdoses, lots of fatal overdoses as well. Provoking Hope also does provide links to care or treatment for substance use disorders, and they do all of this with peers or people who are in recovery themselves and have some lived experience to what it's like to have a substance use disorder and try to navigate the system directly in your community. Commissioner Starrett? Thank you. Yes, we have a pretty comprehensive program in this non-profit that we work with, but what do other jurisdictions do that might not have something quite as robust as this? That's a great question. I can speak to what communities that don't have harm reduction programs look like in kind of my world. But Lindsay, if you wanted to come off mute and talk about what this looks like in Yam Hill, that might be helpful as well. Sure. I'm happy to speak a little bit to Provoking Hope, and then you can share kind of maybe things that we don't know about in other places. Provoking Hope is an organization that's been around for us, I don't know, at least 15 years, perhaps longer. Initially, the majority of their funding was done largely just through fundraising, and then the county began contracting with them to provide a number of services, including some of the things on the slide here. I think over the last few years, as there has been more funding streams that are directly going to non-profits, they have expanded their funding repertoire, if you will, and are getting some direct funds from the state, including the cannabis dollars that are being funded through the Measure 110 that came up earlier with JK, so they're receiving funds directly around that. But they largely do a lot of connecting to treatment services, connecting to social services, things of that nature. They have both a physical location, they drive people to detox, they do a wide variety of things. They also operate the syringe exchange program that actually is funded through our local coordinated care organization, which is the Medicaid funding mechanism for our local Medicaid health plan. Those funds actually come to HHS, and then we send them on to them. They do a lot of those types of things. Oftentimes, the people who are working in their organization are individuals, all of them have lived experience, and oftentimes they are at the early stages of their recovery, and many of those individuals continue down that path and end up working to become drug and alcohol counselors and things like that within other organizations that provide treatment because they provide this type of harm reduction outreach engagement work, but are not a treatment provider. Excellent add-on. Thank you for that. I can speak a little bit to what harm reduction looks like in communities that don't have harm reduction programs. And I'll tell you what, harm reductionists are a scrappy group of individuals, and I would say in almost every community that I've worked in where they either don't have the funding for harm reduction programs or there's maybe not the political or community will behind supporting harm reduction in that region, harm reduction is still happening. It's just very grassroots and often embedded within other treatment or recovery programs. So if there's no classic harm reduction programming in the area, recovery community organizations or nonprofits that support individuals with substance use disorders are still getting their hands on things like naloxone and distributing it. They're still conducting hepatitis C and HIV tests, but they're doing them in settings that we might typically think of as more treatment oriented or recovery oriented. So you can kind of embed harm reduction along the behavioral health continuum. It shows up everywhere. And most folks doing this work are still invested in and providing some type of harm reduction service, even if they don't define it as such. J.K., anything you would want to add or adjust with my take? Yeah, I'd say there are three enablers or barriers of harm reduction. One of them is legislation. There are still states that I think have outright bans on syringe access, Florida. I think Texas has a couple in like Austin and San Antonio, but even in states like Nebraska, where I'm from, there were people who would take it upon themselves, and this was 15 years ago, to do syringe access out of their car. Often people who use drugs themselves would do that. So but legislation can definitely enable this. I mean, Colorado's got 15 syringe access programs. But we still have counties that are against it, and it made it really difficult to operate. So even in states that have rules around it, it's certainly, people want to feel welcome. And if they don't, it can be hard for them. Size, we've found syringe access usually doesn't happen in really small areas. In fact, I would say Miami Hill County is probably one of the smaller, like 50 to 100,000 is usually the bottom range for county population where there's a full harm reduction program. That community that we showed the anti-stigma campaign from earlier, we thought about starting a syringe access program there through federal grant, but it wasn't politically palpable. And it was also just difficult because there weren't very many people there. And so they couldn't have sustainable funds. And also it made it more of a, in a smaller county, there's less anonymity. So people didn't really want to be seen accessing harm reduction. And then I think politics is the other one that I kind of covered. We've had people respond pretty severely to the mention of harm reduction, not associated with any particular service. They just have a idea of what it means, which is usually syringe access. And more recently has even been supervised injection, which is very rare and not as common. Most places now, but people still get that idea that they don't want that in their community. And the nice thing is that we've been able to make this work in areas where moving back to overdose prevention, which is pretty universally accepted politically, small rural communities, naloxone is fairly uncontroversial. So that's often our first step is not naloxone distribution. Education around what is safer drug use look like. I had a friend back in the day who got hepatitis and he thought it was because he left his syringes out to the air. But like they just, hepatitis found its way out of the syringe and into his veins. And that's not the case. So basic education really goes a long way in harm reduction. And what we did in that rural county really was look at what's the basis of harm reduction? What's the lowest bar? What is the smallest thing we can do that's harm reduction? And really, it's involving people who use drugs and their allies and program planning. So we just started with that is we're going to make sure that we have input from people who use drugs and their families in every program. And that was palatable to people. So those are some of the things going on around the country and some of the barriers to harm reduction programs. Thank you, JK. Great question. Anything else about harm reduction before we move on to treatment? All righty, JK, I will pass it back to you for the treatment overview. Sure, thanks. So treatment sounds really obvious. It seems like, oh, I know what treatment is. And you probably do. First, the reason we're going through these five is to give you an idea of what is the scope of different things that you could do. And these are official categories in Exhibit E that you have to account for funds being spent in. That said, it's not that important to get the category exactly right. But we want to make sure we're comprehensive in seeking different ways to spend these funds that are also effective. And the other thing I'd say is that there are a lot of effective ways to spend funds. I think people in some counties we've worked and gotten analysis paralysis of like, what is the best way to spend money? And really, there are a lot of different ways to spend money. And Jeff, as you said earlier, the best way to spend money is really local because different places have lots of there may be lots of residential treatment within 30 minutes of you. My guess is that you probably have quite a bit being near Portland, where residential treatment is somewhat accessible in the area. And there might be less prevention or harm reduction. Obviously, we work in some areas where there's no residential treatment for hours. And so it needs a really local. And we want to go through these just so we're not missing any big areas of thinking around conceptualizing how money can be spent best for you. So don't worry about is something in treatment? Is it in recovery? But think about are we covering all our bases as far as assessment and planning? So treatment is I limit it to be very official and time limited. it's usually something that a licensed or certified clinical or medical professional, so clinical, I mean, counselor, someone who's talking, medical, someone who's prescribing, and that these are largely reimbursable services that are reimbursed by, in Oregon and Colorado, Medicaid, commercial payers, and maybe some other small pockets of funding. These are, treatment's often time-limited, so it's not ongoing, usually, although some people are in treatment for very long periods of time. There usually is a goal, and often people do graduate from treatment, whether that's counseling or even medication. Locations of service, so this has changed a little bit post-COVID in that you can be pretty much anywhere and get most types of treatment now through the phone, through video, but it used to be really limited and that you needed to be in a certain location, a hospital, residential treatment, a detox, in order to qualify something as treatment, but now, like I said, even opioid medication-based therapy is available online through the phone, and the big thing about treatment is that it is often paid for, or there's someone who has coverage of it, again, Medicaid, commercial insurance, but that doesn't mean it's unlimited because payers, especially in managed care arrangements, can put reasonable limits on access, and the bigger gatekeeper often is access, especially in rural areas. Sometimes there are not enough counselors. There might not be a methadone clinic, for example, and so people can't find treatment at the time they want it that will be paid for by their coverage, so I see treatment often, especially in more developed areas, as more of a supply-demand mismatch in that it's out there, but the person who needs it can't find it when they have coverage and they need it, and same with the programs. They can't find people who would be right for their program at the right time. Okay, next slide. All right, types of treatment. So the nice thing about substance use treatment is it's very well-organized, and this framework is used nationally, so almost every state uses this framework or a very similar framework, and I think it's really helpful at conceptualizing what types of treatment do you have a lot of, what types of treatment are less available in your community, and this is not to say that every community needs every single type of treatment. For instance, rural communities often could never staff a residential facility because it's 24 hours, and it takes so many licensed professionals, so there are, I think, greater expectations in a larger area, and yes, Yamil County is one of the larger areas we're working, actually, as to what types of treatment are available locally. With that caveat that some of these are available online, level two, level one, are usually available online through telehealth, and in fact, some of them, there are lots and lots of providers that work with Medicaid and commercial insurance. So let's start at the top. This is an ASAM criteria, so that's the American Society of Addiction Medicine, and so one of the critiques of this is that it's too focused on medical, and that is true. It is driven by doctors, physicians, prescribers, but it doesn't include clinical or talk therapy levels of care. So starting at the top four is really a hospital setting, and so this isn't usually a level of care that people seek out, because it's for people who are very, very, very sick, and they're usually, they go through an emergency department and are in a hospital setting. So this, it's important, but it's not part of the continuum as we'd usually think of. We need to fill this gap. So that starts at level three, which is residential, and I am gonna confirm, this is actually the newest version of ASAM criteria, which has just taken effect. So level three is residential, and this is actually fairly intuitive. It means that there's a bed, and so if something seems residential, it is. One thing to differentiate from this is level three and recovery residence, both of those are residential levels of care. Level three is formal treatment, so like there are physicians, there are clinicians, counselors involved. In a recovery residence, those things are not necessarily there, and so recovery residences are often peer-staffed, or they're staffed by uncredentialed people who help people maintain their sobriety or abstinence, if that's what type of recovery residence they're in. So that goes, it goes down from 3.7 to 3.1. 3.1 is lowest, 3.7 is highest, and the difference there is really in the level of medical professionals that are involved. At the 3.1 level, I think the requirement is about five hours a week of counseling. So people who are living there, often they're participating in the community, going back to work, and they're getting counseling, say, once a day while they're there. 3.5 is, 3.5 and 3.7 are really the typical levels of residential care, where you think of like, I saw a movie and somebody went to residential treatment, it's 3.5 or 3.7. Often 30 to 90 days, and really based on people's medical risk, 3.7 can handle people who may still be in light withdrawal, they can handle folks who may be on blood pressure medications or other medications they have to take daily, whereas 3.5 is really managed by the counselors, and so people are at slightly lower risk as far as their medical comorbidities. So sometimes people step down, in fact, that's pretty common, they would go from a withdrawal management setting to a medically managed residential setting, and then to a lower intensity residential setting over the course of a few months. All right, level two is intensive outpatient, and one of these is new, 2.7 is new, that's an outpatient detox level of care where somebody is actively withdrawing from substances, but not living at the facility. And so normally people would at least do a day or two or longer of detox in a residential setting, often, especially in rural or suburban areas, people will do that at home, take medications and withdraw more comfortably in the comfort of their own home, and have somebody check in on them by phone. So that's actually been a pretty hot topic in some of our settlements out here where they have a residential detox, but add an outpatient detox level of care. And then 2.1 and 2.7 are often transitional phases for people who are leaving residential, so example, I did IOP 2.1 twice, each time I left residential, I did six weeks of IOP, which is pretty common, and that's three hours a day, three days a week, so it's about nine to 10 hours of programming, high intensity outpatient is about 20 hours of programming a week, so people are really at a facility or online, I guess, five days a week, four to six hours a day, so it's really taking the place of work for them, trying to get them intensively better so that they can reenter their community or job or whatever it is. And then level one is pretty recognizable, it's once a week to once a month outpatient therapy, and that, again, you see the differentiation here between counseling, like 1.5, and more medication-based, which would be 1.7, so that's just based on what level the provider offers, do they have physicians, do they have nurse practitioners, more likely to be medically managed, outpatient therapy is strictly talk counseling, and often people are doing those two at the same time, they're doing talk therapy and they're doing medication at the same time, sometimes for weeks or months. So that would include, if you've ever heard of Suboxone Clinic, which is not an official term, also methadone clinic, those would be 1.7, medically managed outpatient. And Lindsay, do you have a methadone clinic in Yamil County? So we offer all medication-assisted treatment with the exception of methadone at the county, and there is a couple of primary care providers that provide buprenorphine, and then there is a mobile clinic that actually does provide methadone, it is a statewide pilot of a program, and so it's actually operated through our tribal partners, the Confederated Tribes of Grand Ronde received a grant from the state to pilot this, so in that process, someone has to go to Salem to do their intake, but then they can get their daily dosing through this mobile clinic in the county, in McMinnville. Wow, very cool, and a great use of mobile clinics, too, to get to counties that don't have other, otherwise have methadone clinics. All right, finishing up on this slide, bottom left kind of covers the same thing that we just covered, on the lower right, there are medications for opioid use disorder, there are three of them that are FDA approved, the two big ones are buprenorphine or Suboxone, which we'll use interchangeably, and methadone, and there are a lot of restrictions around methadone, there are also medications for alcohol use disorder, people don't usually use the M.O.D. acronym, but it is true, there are medications that help people quit or reduce, more often, their alcohol use, and then there's also medications for psychiatric disorders, because a lot of people with substance use also have psychiatric conditions, either independent of their substance use caused by their substance use, so it's important not to forget about psychiatrists or psychiatric nurse practitioners in this whole continuum of care. Okay, any questions on treatment before we move on to the example program? I have a question. Yeah. Just in terms of that, would the provider bill the county or the jurisdiction that would be, you know, basically using their particular funding stream for that, would they be able to bill us? I'm happy to take this, I think I might have an answer. Thank you. Generally, are you specifically thinking about the outpatient treatment services or the medication treatment, or both? I think both. Yeah, so generally, they are billing whatever insurance that is. So if someone is on our local Medicaid plan that you are very familiar with, they'd be billing YCCO. If they are on the state plan, they'd be just doing a fee-for-service billing to the state itself, or in many cases, just billing private insurance. I think if someone doesn't have insurance, generally, those individuals come to the county for care, and we were able to use our state funding to pay for those. But we are billing those insurance companies for people who are health and human services clients, and then say, if another provider is providing that same care, they are billing under that patient's insurance through their mechanisms. And it doesn't have to go through the county. But if the funding is strictly from our opioid settlement dollars, how is that differentiated? Like, if we were to use opioid settlement dollars for these things, I would suspect, and certainly, y'all who have been working with other places can speak to this, I would think that we wouldn't be paying for ongoing things of that nature, and it would be more operational costs that would be for things that they couldn't bill. So either they would have to find some way to, quote unquote, eat the cost of the billable services, or figure out how to bill for those things, whereas these funds could be used for things that wouldn't be billable. The alternate of that could be that the opioid settlement dollars could be used to just give funding for these things, and then there would be no billing mechanism in place. So, but we couldn't use opioid settlement dollars to pay for this, and then also bill, that would be considered double dipping, and so we'd have to mitigate that. Yeah. Thank you. Almost exactly what I would say, accurate, that this is actually why we're a little more bearish on treatment, just because there's a lot of money. Treatment, out of the five categories, is like this big, and all five other, all four others put together are like this big. So certainly there's a need to expand treatment, but often we would want people to exhaust their many different layers sometimes of reimbursable services before turning to opioid settlement. In states like Oregon and Colorado, where Medicaid is large, and I would guess it's pretty rare that you see folks who are not covered or are not eligible, it's more of the money ends up going toward capacity, so that would be capital renovations to help a clinic get started up. Once in a while, we would say there was a really niche population that we knew was not gonna occupy somebody full-time, that you could pay for part of their time that was not gonna be reimbursed. Say they were only seeing 10 patients a week, but it was a crisis situation, so they needed to be there 24 hours a day, you could pay for, say, 75% of their salary, $75,000, and re-bill for the other part. And so there is a braiding of funding, but you wanna be really careful to make sure that there's not double-dipping, that this person's not billing 40 hours a week and then charging you for their salary. And so that's why we tend to favor things like capital, just because it's very clearly defined. Medicaid doesn't pay for capital expenses, it doesn't pay for startup costs, doesn't pay for buildings or anything like that. And they can pay for salaries, though. So it's easier to structure things as a reimbursement for salary than as a reimbursement for services, both so that there's a clear definition, also so that the county's not necessarily in the business of auditing charts or reimbursing for visits. So that's usually how we'd structure treatment-oriented services, either through a project or through a salary, instead of you're paying for this person to get a single service. Other questions on treatment? Also, we may have used the term MAP earlier, medications for medication-assisted treatment or medications for addiction treatment. When this site page says MOUD or MAUD, those are essentially the same thing. Medication-assisted treatment, medications for addiction treatment, MOUD is just specific for opioid use disorder treatment. All right, this is local example, treatment spotlight. And so this is interesting. I think Oregon has more of these types of facilities than Colorado does. And so there is both housing and treatment, and here they have it for families, and so youth can be here, which is pretty cool. That's very rare and not always covered under a lot of insurance plans. So Deer Creek Family Stabilization Home, as you can see, just a home, and they have abstinence testing. Some people there are abstinent from drugs or alcohol, and they provide treatment there, as well as family stabilization services, automatic childcare, and things like that for both men and women and their families. And this is really cool. We have a few places like this in Colorado, but not nearly as many as you have in Oregon. So good example of how treatment can really work for people, because I think your traditional residential treatment doesn't involve families, and so there's a disruption of families and their children, families and their significant other, and the coming back together process is often very fraught. So it's very beneficial to have folks in a setting with their loved ones, family members undergoing treatment. Yeah. Lindsay, David, any other comments on this? Because I don't personally know this organization, but it sounds amazing. Yeah, this is like one of the things I consider a county gem. I'm actually right next door to the house that you're looking at on the screen right now, and get to hear little kids playing every once in a while, which is always fun. But we have several of these houses, and they really have been what saved families. I mean, these are generally children who are about ready to be removed through the child welfare system. And instead, families are given this option instead of having children removed, and the success rate is enormous. And we often see these families continue on through that sort of recovery process into supported housing. We employ several people who have been through these programs and are now active members of the workforce. So it is just really, really profoundly changes people's lives. Yeah. Having been to residential twice, I can tell you that it's very difficult for kids when mom and dad were gone before when they were using services, and then they're gone again to undergo treatment, and there's often a lot of resentment that builds up from both significant others, like, hey, I'm working, and you just get to go off to treatment, as well as from kids who just want their parent back often. And also, there's usually more support than, like, traditional treatment treats the person as the problem, and the focus is on them, and often, I'm not saying the family is the problem, but there are interpersonal problems within the family, which are best dealt with together, and that is almost impossible to do in a traditional residential setting where you may, if you're lucky, have the family come for a visit, or they even come for a week. My family actually came for a week, which is really cool, but it's not the same as healing together, and so, yeah. These programs, they have family coaches, parenting coaches that are part of the program, and they're on a regular basis, all sorts of things. I mean, oftentimes, we're working with families who this is the first time they have parented without substances on board, and there's a lot of learning, and there's challenging behavior with the children, and so it's really about all of those things, just like you said, coming together and figuring it out. And the last thing I'd say, I'm conjecturing, but this says treatment. My guess is they have a wide variety of both billable treatment services and non-billable recovery and coaching services like that, so just because we're covering in treatment does not mean that there's, like, this unified source of funding that they just bill Medicaid and everything's fine. It is rarely like that. They usually have grants, Medicaid billing, and donations, and other things that are coming in to support them. It's a great example of what you mentioned earlier about the braided funding to make it all work together, yeah. Next slide. And next slide again. All right, recovery. Also sounds pretty obvious about what it is. I'd say it's slightly less obvious than treatment because it happens mostly in the community, but we do have a really, we have a better definition than treatment, actually, and it's SAMHSA's definition is most widely accepted. This is, they say it's for mental health and substance use. I use this definition more for substance use, and that's also more of what I do, but many people with mental health conditions don't identify as being in recovery. They may say thriving or succeeding, and so I just wanted to give that differentiation between recovery from substance use and mental health. But the big things to take away from this slide are the four dimensions of recovery, health, home, purpose, and community. That's a very widely recognized framework for recovery and defining the ways that people in recovery are supported. Important things you see there, recovery is very, this has been a big swing. So when I started in recovery, and certainly before that, almost everything was 12-step recovery, AA being the big dog, and some other 12-step programs like NACA being kind of the secondary programs. There are many, many, many more options now. 12-step programs are still really big and really helpful for a lot of people, but this is a big change over the last 10 years is that people can now say, I'm in recovery and not be in a 12-step program and not necessarily be abstinent. So recovery, under the SAMHSA definition, and certainly the way we work, is that individuals say when they're in recovery and any positive change, I'm totally on board with calling it recovery. So it used to be called, including in medical school, a relapse or an intermittent disease. I think that softened a little bit, but does still acknowledge that recovery for many people includes brief periods of return to use or long periods of return to use and an up and down pathway. That's not everybody's story. For me, it's been abstinence all the way for 10 and a half years, which is cool, but I also don't think we should discount people who have a slip up or go back and use marijuana once in a while or whatever it is that they, whatever that happens to them. I think more of recovery as like, what's your life like? Is your life better? Do you have better relationships in particular? Can you go back to work? Is that something that's part of your recovery? So that's a big change, and I hope people know that about recovery. It's changed a lot, the definition in the last 10 years, and the resources have improved a lot. Again, mostly familiar with Colorado, I would imagine that Oregon has a similar community of recovery that is both 12-step and non-12-step based. The big thing is that recovery happens in the community. It happens outside of residential treatment. It's not what happens in counseling, although people's recoveries may be improved by participating in treatment. Recovery is something that is almost, well, this has changed a bit. It used to be totally non-billable. Now, it is more often billable. Peer recovery services are often billable, and I'm pretty sure that they are in Oregon. And so there's now a developing career path for peer support specialists that usually involves education as well as lived experience, and then they can bill Medicaid, less often commercial insurance, for services that may seem a bit like counseling, but involves more habilitation, helping people with job applications, helping them make it to meetings, and things like that. And so that's, yeah, I think that's a pretty good definition of recovery. And how far it's come over the last 10 years or so. Okay, any questions on recovery overview? Oh, the other thing is, it can go on forever, whereas treatment is usually limited, often by a payer or a clinician. Recovery can be forever. And I know people that still very much define as being recovery 40 years in, and I know other people who after 10 years, kind of leave it behind and just go back to their life and don't say they're in recovery. So it's really different and individualized for people. And I also know people who probably never had a serious use, a severe use disorder. Definitely never would have been in withdrawal or something like that, but had some incident happen and now identify as being recovery because they've moderated their use. So it's a much more heterogeneous field than it was back in, before I started. So these are some examples of fundable projects in recovery. Probably we've funded all of these through opioid settlement, as well as other types of funding over the years, and some of them overlap. So actually one of the first grants we ever wrote, I'm going to start with sober event programming, was for a group that does sports. And they focus on sports events and concerts, and they provide recovery support at those events because often people were really, really focused on using substances there. And so they turn that framework on its head and have a dance party or go to a big game and just don't drink. And it's also kind of harm reduction-y because it's not necessarily people who are aiming for long-term abstinence, but sometimes people who are just sick of going to football games and getting drunk and want to sit with other people who are not drinking that day. So sober event programming has been really important in our state. And then some of the related services here, the top and bottom, are post-treatment community recovery options. I think that's kind of our top. a blanket description for how you might fund recovery would be funding recovery community organizations, including a community center where people can drop in, including peer recovery coaches that go visit people at coffee shops or do calls with them. Some of these are more activity-based. So there's a group called the Phoenix that is a sober gym. It's really, really awesome. They do climbing and yoga, and I think they're all, they're nationwide. I'm sure they're in Portland. I don't know if they're in other places in Oregon. And then down at the bottom, you see peer network through local recovery community organization. This is kind of just another way to say the top one, post-treatment recovery supports, but it doesn't need to be post-treatment. So people's participation in treatment and recovery are often overlapping, but not necessarily so. So there are people who enter long-term recovery and never do treatment. There are people who do treatment and never enter recovery, but I would say the most common is that people do some of both. They maybe go to detox and have an outpatient counselor, and they do a 12-step, or they ended up in a hospital, and then they went into peer recovery coaching in the community. So there's a lot of overlapping communities, too. And the last one in the middle there, transportation services for treatment and recovery. I will say I was not a believer in this just because it's very hard to account for and administer transportation programs. And most states have some transportation options through their Medicaid plans, but we've made it work. And a couple different regions, one rural and one urban, actually fund transportation services. Rhiannon knows more about this, actually, if you wanted to tag along on that. Transportation has been such a doozy to try to address because you have to work with entities that typically operate outside of the behavioral health continuum. In Colorado, and I believe this is a national thing, we have something called Non-Emergency Medicaid Transportation, NEMT. And you can actually work with Medicaid to get transportation to a clinical behavioral health-related activity, but it won't fund a recovery meeting or a job interview that you might need in order to be successful in reentering the community. And so we've used opioid settlement dollars in a couple places in Colorado to identify a local transportation partner who is already providing those NEMT rides so they understand the sometimes increased needs of people with behavioral health issues. But we build a program with them so that they can provide some of the more recovery-based transportation needs, like getting someone to an AA meeting. And we actually use the settlement dollars to pay the transportation provider instead of them asking Medicaid to be reimbursed for the clinical ride. So could look a little bit different in Oregon, depending on what your local transportation providers are already or already not doing, but it's been a neat way to kind of more innovatively use opioid settlement funds. And I know transportation is an issue everywhere, especially for some of the more rural communities. And this is another good example of rating funding that opioid settlement money, part of the contract is it's the last dollar out. So if they could build any non-emergency medical transportation, they do. If they can't, then it falls on opioid settlement or other funding. And so there are ways to grade funding, but it does require some oversight. Next slide. Got a great local example. And I think it's astounding that in a town, a county your size, you have a campus because even in some of the larger communities in Colorado, the peer recovery services are done offsite. They might visit jail. They might meet people at coffee shop, but they don't have a full campus where people can go, hang out, and you see their peer-to-peer services and a lot of other supports for people who are having mental health or substance use challenges. So, yeah, and the great part is this highlights mental health. So sometimes these types of campuses or services are really focused on substance use, but there are also mental health peers who can help people with co-occurring substance use and mental health disorders. Any questions on recovery before we move to our last subtopic? Okay, let's move on. So criminal justice is pretty easy to define. And so the reason why it's a separate category for itself is that so many of these services look quite different in a criminal justice setting and are often funded very differently. And the root of a lot of that is that Medicaid, at least until very recently, was not available in jails or prisons, and that is changing nationally. So some of these differences will be breaking down very soon as we speak, in fact, in Colorado. Why criminal justice is an area of focus is because much like John Dillinger and the money at the banks, criminal justice settings are where people with substance use disorders are more so than almost any other type of setting. And they're also, for lack of a better word, a captive audience. And so programming there, often people really want more programming when they're in jail or when they're in prison because they realize that there's a problem going on in their life and they've got a lot of time on their hands. And so this is a great time to reach people, yet most jails and most prisons don't provide that for everyone. There are enough limitations on their capacity or on eligibility criteria where only a small fraction of people who could benefit from substance use treatment or recovery program actually get it. And in jails, often people are in and out, and so there's not time to set them up with programming unless they're post-sentence. So a lot of areas where we can do better in the criminal justice setting add a lot more appetite to do that in our experience. And you see there that last fact, not only is this a sensitive time where people are willing to think about treatment, leaving criminal justice settings is also a very sensitive time for overdose because people have a lot of time because people have built up a tolerance in the community and then they get in jail and they lose that tolerance because they're not using or they're not using as much. And when they leave, they use as much as they did before. And overdose is very, very, very common in this setting. One study said 40 times as high and one study said 129 times as high as community-based studies. Next slide. All right, lots of examples. And again, opioid settlements, we've worked on and funded most of these. The biggest one is medication-based treatment in jails. That is now happening in all our county jails. And I would imagine most of your county jails, but it's often an unfunded mandate. And so some of those counties have turned to opioid settlement funds to help support their buprenorphine programs or methadone programs within their jail. And so that's something where having somebody from the sheriff's office on board in discussions would be really helpful to understand what they're doing and if they wanna do something more. The second one, this is really common nationally but with a lot of bad portrayals of criminal justice reform. Bad portrayals of criminal justice professionals, law enforcement professionals in arrests or after arrests, training has gone a long way to help them understand how people with behavioral health disorders operate and how they can better work with them. So there are a number of out-of-the-box trainings for law enforcement professionals on how to work with people with substance use disorders, developmental disabilities, and mental health issues also. And those are certainly fundable through opioid settlement. Third one, DMV program to ensure exiting individuals have an ID. We've not funded this through an opioid settlement but this is a cool program in Colorado where they make sure everybody in prisons in particular has an ID when they leave. And so people are able to seek employment, seek housing, seek jobs, and be more effective just out of prison. And then the last couple are deflection diversion. So there's mobile co-response where peers or clinicians are riding along with city cops or county sheriffs and helping them respond to behavioral health related crises. Last one's diversion programs and drug courts. I guess you're probably familiar with that but people have definitely funded those with opioid settlement dollars. Next slide. All right, another local example. This is not specific, not always criminal justice oriented but there is a mobile crisis team that can assist law enforcement once they've diffused the situation. And these are definitely fundable through settlements. We've had two, three, four counties fund their co-responder programs through opioid settlement dollars. And unfortunately that's usually been after something really bad happened and they allocated funding to prevent another bad outcome for someone with mental health. The one example here in rural, just outside of Denver, rural, there is a very sad situation in which somebody called the sheriffs or city cops, I think it was sheriffs, on an individual who was acting quite strangely in their car, but not being a threat. And essentially, after a couple hours of waiting, law enforcement decided that they needed to, something needed to happen and they needed to get out of there. And that startled the individual and ended up in his death, with everybody asserting that it didn't need to happen. And in fact, the individual really hadn't done anything that was too alarming or threatening. So situations like that, where people are in mental health or substance use crisis and would be best served in a treatment setting, absolutely fundable, probably one of the more common priorities for opioid settlement is shoring up this crisis, sometimes law enforcement response. Questions on criminal justice spends. And while you're coming up with your questions, I will highlight that some of the more criticized spends have been in this realm. There's a small but significant group that kind of watch dogs, opioid settlement spending, and they definitely have some less substance use, more criminal justice related spends in their sites. So things like squad cars, different apprehension devices, one that wraps people up and prevents them from running away. Those have generally come under fire from, I tried testing dogs yesterday, generally drug testing because body scanners have come under fire. And so it's not to say that they're not allowable, but in the court of public opinion, these have been some of the most likely spending to come under scrutiny. The other one being just straight up administrative spends, where counties are funding their debts or things like that, which again, there is a portion allowed to be used on non-opioid things, but those have been more criticized and Kaiser is a big media outlet that covers those. Other questions on any of the types of spending, all five categories? I'm just going to add really quick to this slide here, which I really appreciate getting out there. The COS mobile crisis team also responds now to opioid overdoses or what we consider like close calls. And that code deployment is now happening automatically so that an officer or a paramedic doesn't have to call us independently. We have access to the dispatch CAD system, so we can never go alone. 911 can't dispatch us by ourselves, but we do have an automatic notification now based on whatever words are being used in the call and how they flag them. It automatically comes to our team for both of those types of mental health and overdose calls, which is great. Wow. Lindsay, when I was researching this a little bit to add it to the slide, I was stoked and impressed at the technology that y'all have linked in order to make this work. The fact that you can call the National Suicide and Crisis Lifeline and still get here is huge. When you're in a crisis, it can be really hard to find the 1-844 phone number and then successfully get there. So I just wanted to shout that out too. I was admiring this program. Thank you. Appreciate that. Commissioner Johnson, I think you came on a video. Do you have a question or comment? All right. Next slide. Okay. I think we'll probably end a little bit early today. So just another plug for questions. Go ahead, Commissioner. Thank you. I was wondering, I've got a conflict that day. I'm wondering if there's a virtual option. Great, great question. Currently, there is not a virtual option, mostly because it's a very interactive agenda. We'll be actually getting into small groups and kind of collaboratively creating ideas. I do know we're going to record it. And there are some other folks who have some conflicts throughout the day who are kind of coming and going as they are able. So that's something else that we could potentially offer. We would love folks, as this slide says, to be there. The more of you that can be there, the more robust and successful the kind of workshop will be. Lindsey, David, any thoughts on a hybrid situation? I would leave that to you all. I'm sorry. Go ahead. I was just going to say, we're going to be holding this at Civic Hall. And I think that the movement of the technology and making sure that it tracks with the groups and everything makes that pretty challenging. I just wanted just a sort of a plug for at least attempts at it. I know during City Council meetings, it is an option. So if perhaps the ability wasn't there to do the small groups, I can understand that. But for the larger presentation, to be able to view that would be very helpful. And I think from what I've seen so far, you guys do have that option, at least just taking a look at what your City Council meetings look like. Yeah, I can talk to the City recorder and see what's possible. I don't know. I think as long as the understanding is it's not interactive, you're just there to watch it on Zoom, I think it'd be no problem. So we'll dig in a little deeper and see if we can at least get this live recorded for you all to call in or Zoom in in that way. JK and I can also offer like a meeting minutes of the whole day, kind of like a packaged up summary of what we talk about, what gaps are identified, and what spending strategies really emerge to the top. So not the best, not ideal, but something that we could follow up with the group with as well. I will be there in person. This slide is just a shameless plug to try to get folks to come hang out with us. We are very excited to be visiting you in person. And I will give a shout out to Lindsay and David for thinking about standing up this meeting in this way. Often, when we get involved in this work, city and county entities are on the end of their process, and they are just now trying to think about involving community and involving local subject matter experts. And so it's very exciting to see this happening kind of at the front end of this. And I imagine for those of you who are unable to attend, there will be more. There are next steps that happen after this big event where you'll be able to kind of plug in and potentially get involved also. Can I ask a couple questions, actually? Please, please do. Scott Cunningham, City Council. So one of the things I noticed is that you guys spoke to like billable versus non-billable. And I assume that, and I missed this, I apologize, that the billable is specific to that Medicare, Medicaid, those types of billing the insurers. And where we want to focus on is the outside of those, the non-billable. That's where the biggest bang for our buck will go, is kind of what the gist I got of that. And then, and just to confirm that that is correct. Yeah, I mean, Medicaid is the biggest payer by far for substance use services, especially in Oregon. Commercial too, I would add to that. Medicare does have substance use reimbursement, definitely much smaller payer in our experience. But yeah, I mean, we're talking about billable to a government or private insurance. There are sometimes some other funds like for uninsured people, undocumented folks that flow through the state that are kind of a mix of billable and grant, but it's a very small amount. And so, yeah, I'm talking about a discrete service that has a person at the end of it and a licensed professional at this end of it and some third party payer. That's what I mean when I say billable. And yes, the idea being that I've seen a lot of applications where I think maybe nefarious actors tried to pull a fast one on funding agencies and were like, we need money for a counselor and we need money for this. And all those things are billable really. And so, if their program is going to be really busy, they don't need a grant because they would be billing for those things. And sometimes there are legit costs in that billable means that you will get paid in three months. And so, sometimes there are startup costs. As I mentioned, sometimes there are rare services that are still really important that it would make sense to cover somebody's salary for. But largely, I think of it as how much money goes into treatment versus how much money goes into things like prevention and recovery. And it's a very, very, very large amount. And largely, that's through fee-for-service or managed care billing. Okay. And then the other thing this would be for the next in-person meeting, but looking for a bit more insight on clearly there are the folks that, I mean, we just see them every day out in our neighborhoods, in our communities. And those would be obvious folks that we are trying to get treatment to. But I kind of correlate this to the folks that are on the cusp of becoming homeless. Obviously, there's a tremendous amount of people that we don't see and that are, in a way, trying to define what's the better investment for these dollars. Is it going after the very visible problem, or is it going specifically after the folks that are on the cusp, and so that we can really use dollars as wisely as possible to hopefully decrease the need on the visible end of it? Yeah. I mean, we worked on a homelessness prevention project a few years ago, and it's like, oh, wow. For two months' rent, you can keep somebody in their house or in their job. Like, this is where we should spend money. I think you highlighted the crux of the matter, which is that it is political. I mean, politically, like, it's visible. If you send people out to clean up encampments or do outreach, it's like, oh, they're doing something. But really, a lot of those folks are going to require a lot of help, and that's very valuable. But cost-effectiveness-wise, the secondary prevention aspects. And so a good amount of what we've done recently has, in fact, especially in one county that's fairly wealthy, is trying to figure out where are those folks, 19-year-olds that live in their parents' basement, and their parents really would rather not have them there, but they're not, like, on the streets yet, and how can we help with that? Because those are the folks that, on IOP, you know, a six-week course of treatment, it may change their lives and get them back on course for 2,000 bucks or 3,000 bucks, but those are all hidden. There's no standard internet search history where we can figure out who those folks are. So, yeah, absolutely. I mean, you hit the crux of it. Hard to find, very cost-effective, and very amenable to treatment. I mean, earlier prevention is better as far as both cost-effectiveness and just morbidity effectiveness, and that people don't have to undergo all those awful things for themselves and their family. Just one thing I would add, and I love that you all are thinking about this already. At the end of the day, you don't have a ton of money to work with, and we want to address it all, but we're not going to be able to. And so, kind of finding that sweet spot that you and JK are talking about, but also potentially funding a mix of things to include some of the cheaper, lower-hanging fruit prevention campaigns that might get a bigger return on investment and move the needle later on down the line, but that we don't see immediately. It's less shiny and exciting, and the impact feels further away, delayed. A good combo, in some ways, can be a really effective approach, both to please the community and to try to make the biggest impact with the amount of money that you have. Go ahead, Commissioner. Thank you. One of the things we always talk about is, what are the measurables, and what are the deliverables, and what determines success? Do you have anything on your end that would help guide us? Yeah. So, part of the in-person meeting will be actually reviewing the examples that have a ton of evidence base behind them. We will dig into the literature and kind of show you only the most effective things. And when we do that, part of what makes it evidence-based is that it is measurable and it's replicable. And so, all of the evidence-based examples that we talk about, that you all will be building ideas from, have this measurable evaluation loop already built into them. And we won't have time in the six or so hours that we have together on the third to really flesh out what those metrics will look like per prioritized program. But know that everything that we put out there in front of you has that literature, and we can help kind of connect you to it after the event, depending on how and where things land. Did I get at your question? Yes. Okay, cool. So, I mean, we've developed evaluations for now quite a few. We also can bring, our attorney general put together a list of evaluation measures. There's about 40 of them, and they're not perfect. But with any evaluation, particularly this, there's a huge wide variety. I think exhibit E has about 110 different specific interventions that are allowable. And then there are infinite other allowable, yet not specifically enumerated interventions. So, some of these are apples to oranges. I mean, youth prevention is going to have different outputs, different outcomes than naloxone distribution. Naloxone distribution, we'd want to see less overdoses. Youth prevention, we'd like to see yet less youth initiation of substance use. But I think what Colorado's attorney general has done is a decent list of smart metrics, measurable, time-bound outcomes and outputs that are examples of what you could use. So, yes, we will bring some pre-made examples, as well as some more in-depth logic models that are specific to some of the programs that we funded too. But absolutely, really important with this limited source funding that you're rigorous about how you're spending. We also do that up front, and that will introduce cost-benefit ratios from research of different interventions, that this over 10 or 20 different instances show that it causes these outcomes, which doesn't necessarily mean it'll cause those same outcomes in your community, but it's the best indicator we have. So, we will add that to the slide deck, as well as a slide or two that provides an overview of the various funding sources and opioid settlement-specific state-funded programs. I think those are the two requests that came out of this conversation. Anything else that you all would like to see or hear when we're together on the third to be best informed? I was just going to share that one of the things I've been asked to provide is a bit more detail around resources, programs, initiatives, etc. that exist in the county, and then where we see current gaps based on a number of different processes we've gone through to identify those gaps, as well as just the day-to-day experience of seeing what happens across the street from my office here. So, I will plan on providing that information, too, that hopefully will be helpful in the conversation. Dramatic pause to see if anyone has any last-minute questions or things they want to share. I will call your attention to the chat. Sarah asked folks to just take a brief survey that she's dropped there on, I think probably how this was for you all. We would really appreciate you taking the time to do the survey. It does help us when we provide the education and also to continue our funding. If additional questions come up or you want to dig in a little further with JK and I about something, here are our emails and ways you can tap into the Stedman Group, the consulting firm that we are with. We would love to chat. We live and breathe this opioid settlement stuff, so let us know. Again, really hope we can see you, even if it's just for a couple of hours when we come visit you on Monday the 3rd. Have I told you the date enough today? All right, my friends with that, I think we might have just successfully given you back 12 minutes of your lives. This will be recorded. Sarah, do you want to talk a little bit about how people can access this?

Opioid Response Network

opioid settlement funds

allowable uses

evidence-based practices

prevention

treatment

recovery

SAMHSA

harm reduction

Provoking Hope

community-based approaches

tangible outcomes

diversified spending

opioid crisis