Updated: 10/8/2019

OFFICE OF THE STATE ATTORNEY

FIFTEENTH JUDICIAL CIRCUITIN AND FOR PALM BEACH COUNTY

DAVID ARONBERGSTATE ATTORNEY

Sober Homes Task Force Meeting Minutes

Sober Home Task Force Tip Line 1-844-324-5463Meeting Location: WPB Police Community Room 600 Banyan Blvd, West Palm Beach, FL 33401

Meeting Date: July 30, 2019

Welcome/Introductions:Al Johnson opened the Task Force Meeting at 1pm. All attendees informed that meeting minutes are takenand the meetings are audio-recorded. The audio file for this meeting can be found at http://www.sa15.org.

Sign in sheets are available upon request.

“Sunshine Law” Overview:Mr. Johnson reviewed and highlighted the importance of the Sunshine Law and its implications for this TaskForce. As an example, he cautioned the group not to use “reply all” in the use of email, regarding what is comingor will be coming before the Task Force.

Next Month’s Meeting: Meetings will now continue bi-monthly. The next meeting will be September 18,2019

The theme for this meeting was medical.

Meeting Agenda – July 30, 2019 -SHTF

1. Introductions:

2. Updates:

a. FADAA: Mark Fontaine-verbal presentationb. FARR: Steve Farnsworth-add on handout-see belowc. FCB: Level II Background Check- Neal McGarry-verbal presentationd. PBC Health Care District

i. Receiving Facility (JFK)

3. Hospital Emergency Rooms-handout materils distributed

a. Practical Issues from an ER Perspective:

i. Dr. Aaron Wohl-add on material-powerpointii. Dr. Jason Fields-telephone conference call

b. Warm Hand-Offs: Effectiveness-handout materials-handout materials

i. Peer Specialists in the ERii. Admissions and Referrals/ Parity

iii. Voluntary vs. Involuntary: Andrew Burki-time did not allow for this presenation

c. Legal Liability (release/referral): Susan Ramsey-verbal presentation

d. National Alliance for Model State Drug Laws

i. Model Act Providing for the Warm Hand-Off of Overdose Survivors toTreatment

e. ER Physician Training

i. MAT waivers

4. Legislation:

a. Recovery Residence Administrators Background Check Glitch Amendmentb. NAMSDL - Model Drug Laws-handout materials

5. Public comments.6. Closing remarks-Al Johnson adjourned the meeting at 3:45pm

SOBER HOMES TASK FORCE MEETING DATES

2019WEDNESDAY JANUARY 16, 2019

WEDNESDAY FEBRUARY 20, 2019

FRIDAY MARCH 15, 2019

FRIDAY APRIL 26, 2019

WEDNESDAY MAY 22, 2019

FRIDAY JUNE 28, 2019

TUESDAY JULY 30, 2019

AUGUST-NO MEETING

WEDNESDAY SEPTEMBER 18, 2019

OCTOBER-NO MEETING

WEDNESDAY NOVEMBER 20, 2019

DECEMBER-NO MEETING

2020FRIDAY JANUARY 10, 2020

FEBRUARY-NO MEETING

WEDNESDAY MARCH 18, 2020

APRIL-NO MEETING

WEDNESDAY MAY 20, 2020

JUNE-NO MEETING

All meeting times are 1pm-4pm

WPB Police Department-Community Room600 Banyan Blvd

West Palm Beach, FL 33401For further details call: 561-355-7249

THE ATTACHED AGENDA ITEMS WERE NOT AVAILABLE WHENTHE MEETING MATERIALS WERE POSTED TO THE SOBER HOMES

TASK FORCE WEBSITE

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Certified Recovery Residences with Certified Recovery Residence Administrators (Data Source: FARR Posted on DCF Website)

As of Number of Residences

Men's Beds

Women's Beds Both Beds LBGT Beds

Total Number of Beds Change In Total Beds

Number of Counties

with Certified Recovery

Residences

Jul-17 238 1869 963 388 3280 N/A 21Oct-17 261 2125 1058 510 3693 413 23

Nov-17 271 2233 1075 579 3887 194 23Dec-17 275 2248 1075 607 3930 43 23Jan-18 287 2390 1136 627 4153 223 23Feb-18 314 2621 1205 660 4486 333 24

Mar-18 340 2783 1299 683 4765 279 25Apr-18 342 2765 1314 713 4792 27 25

May-18 363 2998 1330 1058 5386 594 25Jun-18 368 3022 1446 1030 5498 112 25Jul-18 379 3015 1388 1344 5747 249 25

Aug-18 380 3038 1366 1327 5731 -16 25Sep-18 393 2997 1333 1409 5739 8 25Oct-18 387 2952 1314 1325 5591 -148 25

Nov-18 393 3016 1365 1370 5751 160 25Dec-18 401 2947 1488 1370 5805 54 25Jan-19 404 2915 1493 1378 5786 -19 25Feb-19 400 2877 1493 1385 5755 -31 25

Mar-19 410 2945 1529 1383 5857 102 25Apr-19 389 2768 1468 1448 8 5692 -165 24

May-19 390 2776 1469 1463 8 5716 24 24Jun-19 391 2792 1470 1465 8 5735 19 25Jul-19 384 2735 1480 1357 8 5580 -155 25

*Color indicates a change from the previous month to this month. **Green is an increase. Orange is a decrease.

County Cities Number of Residences

Men's Beds

Women's Beds

Both Beds

LGBTQ Beds

Total Number of

BedsAlachua: Gainesville, FL 2 6 4 0 10

Brevard: Cocoa Beach, FL 1 9 0 0 9Melbourne Beach, FL 1 0 12 0 12Melbourne, FL 3 0 35 0 35

5 9 47 0 56

Broward: Deerfield Beach, FL 2 7 7 0 14Fort Lauderdale, FL 35 243 191 146 580Hallandale, FL 1 12 0 0 12Hollywood, FL 5 100 53 0 153Lauderdale By The Sea, FL 1 0 0 9 9Margate, FL 1 145 0 0 145Pompano Beach, FL 33 272 93 115 480

78 779 344 270 1393

Collier: Naples, FL 7 20 21 0 41

Duval: Jacksonville, FL 9 37 22 128 1879 37 22 128 187

Escambia: Pensacola, FL 1 44 0 0 44

Flagler: Bunnell, FL 1 6 0 0 6

Hillsborough: Riverview, FL 1 0 0 17 0 17Tampa, FL 21 116 82 0 0 198

22 116 82 17 0 215

Indian River: Vero Beach, FL 1 7 0 0 7

Lake: Eustis, FL 2 13 12 0 25

Lee: Cape Coral, FL 7 34 16 21 71Ft. Myers, FL 17 98 39 49 186

24 132 55 70 257

Manatee: Bradenton, FL 2 58 8 0 66

Marion: Ocala, FL 3 8 8 0 16

Martin: Stuart, FL 3 9 12 96 117Jensen Beach, FL 1 10 0 0 10

4 19 12 96 127

CERTIFIED RECOVERY RESIDENCES WITH CERTIFIED RECOVERY RESIDENT ADMINISTRATORSJuly 18, 2019

Miami-Dade: Miami, FL 4 33 33 0 66North Miami, FL 4 45 0 0 45

8 78 33 0 111

Orange: Maitland, FL 1 0 0 70 70Orlando, FL 6 34 20 0 54

7 34 20 70 124

Palm Beach: Boca Raton, FL 4 0 40 0 40Boynton Beach, FL 27 196 48 0 244Delray Beach, FL 67 384 193 408 985Lake Park, FL 7 32 28 0 60Lake Worth, FL 21 208 44 135 8 395Lantana, FL 3 17 35 0 52North Palm Beach, FL 5 0 20 52 72Palm Beach Gardens, FL 5 45 32 0 77Riviera Beach, FL 1 0 0 28 28West Palm Beach, FL 24 219 76 83 378

164 1101 516 706 8 2331

Pasco: New Port Richey, FL 5 30 32 0 62Port Richey, FL 2 14 5 0 19

7 44 37 0 81

Pinellas: Clearwater, FL 7 80 42 0 122St. Petersburg, FL 2 48 50 0 98

9 128 92 0 220

Polk: Lakeland 1 0 7 0 7

Sarasota: Sarasota, FL 10 48 36 0 84

Seminole: Oviedo, FL 1 0 10 0 10

St. Johns: St. Augustine, FL 2 0 13 0 13

St. Lucie: Port St. Lucie, FL 11 48 55 0 10311 48 55 0 103

Volusia: Daytona Beach, FL 3 0 46 0 46

Grand Total: 384 2735 1480 1357 8 5580

SOURCE: Certified Recovery Residences established by s.397.487, F.S, FARR; http://www.dcf.state.fl.us/programs/samh/docs/FARR%20Certified%20Recovery%20Residences.pdf

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Medication-Assisted Treatmentfor Opioid Use Disorder

WHAT YOU NEED TO KNOW ABOUT

By Aaron Wohl, MD; FACEPDepartment of Emergency Medicine,Medical Director, Opioid Use Disorder TreatmentLee HealthFort Myers, FLBoard Member, Florida College of Emergency Physicians

July 30th, 2019 | West Palm Beach, FL

ITEM 3a.a

NO DISCLOSURES

Who am I? Aaron Wohl, MD, FACEP• Grew up in Perrine, FL (between Kendall and Cutler Ridge, a suburb of Miami)

• Dad was an Emergency Nurse, now ARNP

• Biology B.S. Florida International University 1997

• University of Fla. College of Medicine 2001

• ORMC Residency Emergency Medicine 2004

• Lee Health Department of Emergency Medicine 2005-Present

• Clinical interest is Sepsis and Opioids and ED advocacy in Tallahassee

• 2012 developed Rational Prescribing of Opioids Posters

• 2015 developed ED Take Home Naloxone Program

• 2018 developing ED initiated MAT and Harm Reduction Education

• 2012-2018 very active lobbying in Tallahassee for EM patients

• Enjoy flying, powerboats, travel, scuba, motorcycles, fitness/wellness and

competing in sprint triathlons

• Overdose is the #1cause of death forAmericans underage 50

• Opioid use nowexceeds tobacco use

• Life expectancy forAmericans is fallingfor the first time inmodern history 3years in a row

• 150 deaths daily/ 1death every 10 mins

Drug Overdose Deaths1980-2016

Major

Misconceptions

PART I

“We don’t have an opioid problem,we have an addiction problem…”• Diseases/Deaths of Despair: drug dependence

(mostly opioids), alcohol dependency, and suicide

• Why so prominent now? Adverse Social

Determinants: the conditions in which people are born,

grow, live, work, and age.

• Long-term declines in education, employment, wages,

childhood trauma, marriage decline, concurrent mental

illness... a loss of connection with others leads to

hopelessness and a cumulative disadvantage or

deterioration

• When individuals feel helpless, they are more likely to

engage in risky behaviors, such as excessive alcohol and

substance use, violence and forgoing necessary health care

After 30 years of improvement, lifeexpectancy in the US hasdecreased over the past three years

MISCONCEPTION #1: “Opioids are the problem”

Addiction is a Complex Brain Disease

• Prolonged drug use causes lasting effects on brainstructure and function

• The Science: Brain changes can be managed effectivelywith medications

• Medications help people refrain from using illicitdrugs, sharply reducing the risks of overdose anddeath and leading to improvements in behaviorsassociated with addiction—more apt to succeed intherapy

MISCONCEPTION #2: “Addiction is a choice or moral failing”

Medications helpreduce fatalrelapses by

reducing cravingsand stabilizingbrain function

Main Point:

Prefrontal CortexRole:

• Decision making

• Thinking

• Reasoning

• Learning

Ext. Amygdala

• Stress response

• Need for food, sex

• Protection of kin

• Fight/Flight

• Need to Avoid Withdrawals

Reward Circuit (Cortex/Limbic System)Basal GangliaNucleus Accumbens – “MotivationalMotor”– get us to act, to pursue goals, gives us amotive to go toward something,experience reward

VTA – “Fuel Tank”/dopamine machine – itsupplies DA to the NA and tells us howimportant something is and if we need topursue it and at what cost

The limbic system controls such basicneeds as eating, drinking, mating andprotecting children and family

Overview of Conclusions

To read the full text of the committee’s conclusions, visit nationalacademies.org/OUDtreatment or scan this code.

Opioid use disorder is a treatable chronic braindisease.

FDA-approved medications to treat opioid usedisorder are effective and save lives.

Long-term retention on medications to treatopioid use disorder is associated with improvedoutcomes.

A lack of availability of behavioral interventionsis not a sufficient justification to withholdmedications to treat opioid use disorder.

1.

2.

3.

4.

Most people who could benefit from medication-based treatment for opioid use disorder do notreceive it, and access is inequitable acrosssubgroups of the population.

MAT is effective across all treatment settingsstudied to date. Withholding or failing to haveavailable all classes of FDA-approved medicationfor the treatment of opioid use disorder in anycare or criminal justice setting is denyingappropriate medical treatment.

Confronting the major barriers to the use ofmedications to treat opioid use disorder iscritical to addressing the opioid crisis.

5.

6.

7.

Medications for Opioid Use Disorder Save Lives | March 2019

Harm Reduction Strategies• Practical strategies and ideas aimed at

reducing negative consequencesassociated with opioid use, abuse, andaddiction

• Emphasizes evidence and education over neglect

• When people are valued by others (connection)they start to value themselves

• The opposite of tough love — rather kindnessand empathy

Patients come tous for care, notfor judgment.”

—Greg L. Henry, MD

MISCONCEPTION #3: “Harm reduction strategies encourage drug use”

Naloxone Co-prescribing

• Any provider in Florida may prescribe take-home naloxone to anyone at risk for having orwitnessing an overdose.

• Naloxone is also available via a pharmacy’sstanding order from a physician.

• Available in all Florida CVS pharmacies now

• Available in all Lee Health Pharmacies under asstanding order signed by me

Discharging a person addicted toopioids who is in withdrawal ismore dangerous than anydischarge we would ever considerin any other context.”

-Reuben Strayer, MD. Emupdates.com

Myths About MATPART II

OpioidADDICTION

• Desperate need to avoid withdrawal• Constant debilitating cravings• Perpetual cycling of highs/lows• Acquisition harms: poverty, crime,

frantic behavior• Injection harms: local infections,

HIV/Hep C, endocarditis• Street drug harms: accidental

overdose/death

Normal functioning impossible

OpioidDEPENDENCE

• Scheduled opioid consumption• Freedom from addiction harms

Normal life possible

PRESCRIBEDOPIOID

AGONIST

MYTH #1: MAT replaces one addiction with another

MAT of addiction results in reductions in overdose death, illicitdrug use, criminal activity, arrests, risky behaviors, HIV andhepatitis C incidence, as well as improvements in health status,functioning, and quality of life.

-Kakko et al.

“The alternative to MAT isn’t a drug freepatient; rather, it’s a continually relapsingpatient—and relapse has a high associationwith death.”

MYTH #2: MAT is a bad moral choice. It is inferior to complete, unassistedabstinence.

Even a single use of opioids after detoxification can result in a life-threatening or fatal overdose. Following detoxification, tolerance tothe euphoria brought on by opioid use remains higher thantolerance to respiratory depression.

ABSTINENCE DOES NOT WORK

Why Use Medications?Because They Work…

• MAT makes the recovery process much safer

• Addiction involves real, physical changes inthe brain

• 80-90% relapse to drug use without it

• Increased treatment retention

• 80% decreases in drug use & crime

• 50-60% decrease all cause death rate

-NIH Consensus Statement et al. JAMA. 1998

MYTH #3: “I’ve known a few people who could stop using opioids withouthelp from any kind of medication. MAT is only for the weak.”

Monthly depot opioid antagonistAbstinence therapy

withdrawalcravings

High dropout rates and lowered tolerancecan contribute to overdose rates

MAT: MEDICATION ASSISTED TREATMENT

Naltrexone

MAT: MEDICATION ASSISTED TREATMENT

Methadone

Long-acting full opioid agonist

Effective but dangerous

Daily engagement sometimes a plusbut usually a minus

Partial opioid agonistCeiling effect: much safer, less euphoria

Higher reception affinity than almost any other opioid

Less abuse-prone and blocks more abuse-prone opioids

Bupe is uniquely suited to treat opioid addiction: lessdangerous, less abuse-prone vs. methadone, more likely

to abolish craving, protects users from OD by moredangerous opioids

MAT: MEDICATION ASSISTED TREATMENT

Buprenorphine

SAFE IN PREGNANCY:Neonates exposed to buprenorphine needed 89%

less morphine to treat neonatal abstinencesyndrome (NAS), 43% shorter hospital stay, and58% shorter duration of medical treatment for

NAS compared with those receiving methadone.

Lower risk of overdose for mother

Fewer drug–drug interactions

Option of receiving treatment in an outpatientsetting

Buprenorphine

Lori W. 2016

• Opioid use disorder or addiction is not “cured” by the use ofMAT; it’s better managed.

• Addiction is a long-lasting, often chronically relapsing, braindisease.

• Medical treatment for addiction can be compared to medicaltreatment for other common chronic diseases like diabetes orhigh blood pressure, COPD, CAD or stroke.

• Just as diabetes is not “cured” by the use of insulin, and peoplewith high blood pressure often continue taking medications formany years, so people with opioid addiction are not “cured” butinstead well-managed by MAT.

MYTH #4: MAT is not effective because it does not immediately end drug dependence.

• There is no one-size-fits-all duration for MAT.

• Research shows that patients on MAT for at least 1-2 years have the greatestrates of long-term success.

• There is currently no evidence to support benefits from cessation.

• For some patients, MAT could be indefinite.

• For methadone maintenance, the National Institute on Drug Abuse statesthat “12 months of treatment is the minimum.”

• Patients with long-term abstinence can follow a slow taper schedule under aphysician’s direction, when free of stressors and environmental triggers,when their brain chemistry normalizes, and they have had successfulemotional resilience training to attempt dose reduction or total cessation.

MYTH #5: MAT shouldn’t be encouraged for long term use.

NIDA, UNDERSTANDING DRUG ABUSE AND ADDICTION, (Feb. 2016) available athttps://www.drugabuse.gov/publications/teaching-packets/understanding-drug-abuse-addiction/section-iii

RETURN ON INVESTMENT:

The Financial Case for MAT• Addiction treatment decreases overall health

costs• Avoided ED visits and inpatient stays

• Treating IV drug users lowers the incidence ofexpensive complications

• Endocarditis, abscesses, HIV, and Hepatitis C

• Lowers the ED and hospital costs associated withreversed opioid overdose events

-Robin A. Int Jour Infec Dis Sept 2010; Phillips, K. Amer Jour Drug Alcohol. March 2010

MYTH #7: MAT is too costly.

A 2014 study found that patients with bupeand counseling had less use of generalmedical services and lower total healthcarecosts compared to those with little or noaddiction treatment

-A. Khemiri et al., Sept. 2014

$13,578with buprenorphine

$31,055with no addiction treatment

VS.

RETURN ON INVESTMENT:

The Financial Case for MAT

Another 2014 study on buprenorphinemaintenance demonstrated higher pharmacycharges but lower outpatient, inpatient, ED, andtotal healthcare charges for patients adherent tobuprenorphine

-Tkacz et al., 2014

$28,458Total health care chargesfor patients adherent to

buprenorphine

$49,051Total health care

charges for control group

VS.

RETURN ON INVESTMENT:

The Financial Case for MAT

A lack of availability ofbehavioral interventions isnot a sufficient justificationto withhold medications totreat opioid use disorder.

-National Academy of Sciences, March 2019

MYTH #8: “To give these meds in the ED, you must have robustoutpatient counseling available”.

Everyone needs a therapist, butmost importantly, an opioid addictneeds an opioid agonist.

-Reuben Strayer, MD. Emupdates.com

National Acad. Sciences, March 2019

Take Home Points:1. Opioid use disorder is a treatable brain disease.

2. OUD is unique in that relapses are often fatal – potency offentanyl

3. MAT is effective, saves lives, and should be available toevery OUD patient.

4. Withholding FDA-approved medication for OUD treatmentin any healthcare or criminal justice setting is denyingappropriate medical treatment.

5. Breaking down the major barriers to obtaining MAT is ourresponsibility as community and healthcare leaders.

Thank You!• What you do matters… to someone

• Starfish story

• Questions? aaronwohl@yahoo.com

• Don’t look to your job to give you value orhappiness; rather, add value to the world bydoing your job with grace, honor,compassion, and integrity and value andhappiness will follow.

The purpose of life is not to behappy.It is to be useful,to be honorable,to be compassionate,to have it make some differencethat you have lived andlived well.

-Ralph Waldo Emerson