CITY-COUNTY HEROIN, OPIOID, AND COCAINE TASK FORCE

200 E. Wells Street City of Milwaukee Milwaukee, Wisconsin 53202 Meeting Minutes CITY-COUNTY HEROIN, OPIOID, AND COCAINE TASK FORCE BEVAN BAKER, CHAIR Hector Colon, Vice-Chair Karen Loebel, Ald. Michael Murphy, Ald. Khalif Rainey, Mayor CoryAnn St. Marie-Carls, Michael Lappen, Brian Peterson, Christine Westrich, E. Brooke Lerner, and Marisol Cervera Staff Assistant, Chris Lee, 286-2232, Fax: 286-3456, clee@milwaukee.gov Legislative Liaison, Tea Norfolk, 286-8012, tea.norfolk@milwaukee.gov Friday, March 17, 2017 1:00 PM Room 301-B, Third Floor, City Hall Meeting convened at 1:03 p.m. Ald. Murphy made introductory remarks. The country is facing public health epidemic. Too many lives have been lost needlessly. The City and County are working jointly to find solutions. There will be community meetings held to listen to those who have suffered and those who have recovered. A report was done a year ago called “888 Bodies and Counting” showing people dying now due to heroin and opioid addictions two times more than homicides and automobile accidents. Same statistics exist nationally. There is need to use resources and tools to fight this issue, which is not a matter of law enforcement but a medical one. He helped to create this task force. 1. Roll call. Mayor St. Marie-Carls joined the committee at 1:27 p.m. during consideration of item 4. Present 11 - Murphy, Baker, Colon, Rainey, Loebel, Marie-Carls, Westrich, Lappen, Peterson, Lerner and Cervera 2. Election of Chair and Vice-Chair. Ald. Murphy nominated Commissioner Bevan Baker as chair and Director Hector Colon as vice-chair. Dr. Peterson seconded. There were no objections. Director Colon questioned task force structure; formation of subcommittees focused on prevention and treatment; establishment of written charters defining responsibilities and deliverables with a road map and implementation plan to achieve deliverables and obtain baseline data; and consideration of the Surgeon General’s Report and other national initiatives to guide task force efforts to achieve good results. Ald. Murphy replied. There is baseline data through an existing partnership with the Zilber Family Foundation, Milwaukee Medical College of Wisconsin, and Milwaukee Health Department where statistics have been looked at over the last 5 years. Dr. Lerner is involved from the college. Dr. Peterson and Milwaukee County Medical City of Milwaukee Page 1 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE Examiner’s office has provided data, too. Subcommittees may be formed per the task force, and may perhaps exist at 3 levels: interdiction, prevention, and treatment. Task force staffing will be through the Milwaukee City Clerk Mr. Lee and Milwaukee Health Department Jessica Gathirimu. Additional resources are welcomed. Task force will look at best practices nationally. Much literary research information will come. The task force should focus on areas of mutual cooperation, be outcome based, and not reinvent the wheel. The City and County are jointly making an application for SAMHSA money for treatment providers. Commissioner Baker and Director Colon accepted their nominations and were elected as chair and vice-chair respectively. Commissioner Baker made remarks. There are staff and participants aiding the task force. The hope is to yield major outcomes over next few months. The statutory requirement from the Milwaukee Common Council is for the task force to issue a report of final recommendations prior to September 9, 2017, 7 months from February 9, 2017. Community meetings will be held offsite well in advance. Cocaine is part of the discussion. 3. Introduction of members, staff, and participants. Task force members made brief introductions as follows: Ald. Rainey, City of Milwaukee 7th aldermanic district, said he does not have an academic background on the issue, has family who has suffered from crack addiction, and wants to make an impact on community. Dr. Peterson, Milwaukee County Medical Examiner’s Office (MEO), said that he is the last responder with the goal of providing good data and drug patterns to the community as fast as possible. Administrator Lappen, Milwaukee County Behavioral Health Division (BHD), said his agency provides a continuum of care for patients with mental health or substance abuse challenges. Most of the treatment is through a broad network of contracted providers. The division wants to work on prevention, treatment, aftercare, and relapse prevention. Ald. Murphy, City of Milwaukee 10th aldermanic district, stated his name. Director Colon, Milwaukee County Department of Health and Human Services, said his department oversees behavior health services, delinquency in court services, disability services, and housing. The issue spans across the departments. He has family members and friends impacted by this epidemic. Commissioner Baker, City of Milwaukee Health Department, said his career has been in addiction medicine. He worked 15 years in New York. Ms. Gathirimu, Heroin Opioid Control Manager, is staff to the task force on his behalf. Director Westrich, Milwaukee County Office of Emergency Management (OEM), said her agency has 4 divisions: 911, Emergency Medical Services (EMS), Public Safety Radio, and Emergency Management. EMS relates to the task force relative to prehospital care and data collection in conjunction with Dr. Lerner. Dr. Lerner, Medical College of Wisconsin Professor of Emergency Medicine and Pediatrics, said she is an epidemiologist and director of the Milwaukee COPE project. City of Milwaukee Page 2 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE The goals of the project are to collect local data, understand what’s happening, and identify areas of prevention. Director Cervera, United Community Center Human Services, said her center provides treatment services to individuals and families suffering from substance abuse disorder. Deputy District Attorney Loebel, Milwaukee County District Attorney’s Office (DA), said the DA sees drug users for criminal prosecution at the end time intersection of the criminal justice system, tries to refer users out of the system to treatment as a small step, monitor drug trends concerning new threats to the City, and prosecute those responsible for trafficking drugs. She has family who has been affected by drug use and addiction. Mayor St. Marie-Carls, City of St. Francis, made a brief introduction when she joined the task force at 1:27 p.m. later in the meeting during agenda item 4. She has been a mayor for 4.5 years, grew up in the City and County, worked in Kenosha for a number of years running the Chamber of Commerce there, was involved in task forces in health care and studies around mental health and addiction, joined the Milwaukee County Intergovernmental Cooperation Council, and was appointed to the task force. Suburban areas are also affected by this issue. 4. Discussion on purpose, goals, and expected outcomes. Commissioner Baker said that Milwaukee Common Council resolution, CCFN 161061, created the task force to look at current challenges to public health and safety, by those affected by heroin, opioid and cocaine use, and to look at evidence-based scientific research in crafting recommendations. There is a wealth of information to use. Best practices should be considered from every community. The issue is affecting whole state and nation. There are 8 predetermined goals for task force discussion and consideration. Members and participants discussed the 8 goals as follows: 1. Increase Narcan availability in non-medical settings within the community. Ald. Murphy commented. Narcan is a drug that breaks the opioid connection. Some state legislation has made it more freely available for distribution outside of medical establishments. Dr. Lerner commented. The goal needs to include organized training to ensure that people are administrating it properly and know what to do and are encouraged to access the EMS system. According data from ARCW, only 15% people that are give narcan to a peer report having called 911. 2. Increase the amount of prescription drugs collected within the City/County through fixed site locations and MMSD collection days. Ald. Murphy commented. Ald. James Bohl has served on the Milwaukee Metropolitan Sewerage District and has played a major leadership role on the medicine mail back initiative with CVS pharmacy where people can discard unused medicine by mailing it free of postage charge in a plastic envelope. Excess medicine can contaminate the environment and water. Pharmacies are being robbed because of oxycodone. It is important to get unused medicine out of homes so that family members are not exposed to them. City of Milwaukee Page 3 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE 3. Coordinate a sustainable public awareness campaign around destigmatizing addiction. Ald. Murphy commented. Drug addiction has been stigmatized with the wrongful perception that addicts are at fault and responsible for coming out of addiction. The 1980s law enforcement solution to lock up people on the crack epidemic had affected African Americans and minorities resulting in criminals instead of public health victims. A silvery lining today is that a majority of people dying of opioid overdoses are 60% Caucasian, 25% African American, and small percentages Asian and Latin American. There is an honest truth to the criticism that the issue is being addressed now from a medical standpoint, as opposed to a law enforcement standpoint, due to high percentage of Caucasians being affected. There are no funds for a public education campaign, an area that can be improved, on this threat, and federal and state dollars, if available, should be pursued for doing a campaign. Commissioner Baker commented. This goal will be a critical driver of the task force and its final recommendations. To have any sustainable public awareness campaign there has to be determined the level and manner of going upstream to address adolescents and children. Smoke-free and tobacco public health awareness campaign efforts took years to penetrate. Tobacco was reaching children as cartoons. Destigmatizing should be included in the public awareness campaign. Public, private, charter, and choice schools should be part of the campaign and task force. Murphy - task force should look at the pharmaceutical industry that contributed to this problem which created the drug oxycodone said the addiction properties were not very serious. They were found guilty and fined $600 million dollars. They haven’t done enough. Campaign from removing drugs from waterways is borne by taxpayers and not industry. Look at asking legislators to assist in getting pharmaceutical industry to pick up some of the costs for public education campaign. Mayor St. Marie-Carls joined the task force at 1:27 p.m. and made a brief introduction, which can be found under agenda item 3. Ald. James Bohl, City of Milwaukee 5th aldermanic district, appeared and commented. Ald. Murphy was also involved with the CVS pharmacy arrangement that had took 2 years to implement. There is the possibility to incorporate Roundy’s in some capacity, perhaps through a public awareness campaign. Roundy’s had expressed interest to be involved during the initiation of the CVS partnership for the mail back program, but funding agreements had already been established between the sewerage district and CVS at that time. Dr. Lerner said that the goal should be expanded to include public campaigns around prevention, which Ald. Murphy concurred. Commissioner Baker said that outside comments should be reserved for the public comments portion of the meeting, but will be allowed in limited fashion if time permits. There is opportunity to modify and expand these goals. Monte Mabre, Voice of the Fatherless Child, appeared and commented. His center is putting together a presentation called “My Addiction” soliciting sponsors and donations in order to do outreach throughout the City, starting in the 15th aldermanic district where his center is located in. His center is interested to assist with a public awareness campaign. Of importance is to do outreach inside schools and to children first. Strong children build strong adults, strong adults build strong families, and City of Milwaukee Page 4 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE strong families build strong communities. He was a former drug user and stopped using since 1996. The task force is comprised of educators and professionals; however, it lacks the experience representative of people who have recovered and who understand addiction, relapse, and relapse prevention. There are other addictions and gateway drugs. Ald. Murphy said that he will work with Ald. Russell Stamper and Rainey to add an additional member, a recovery addict, to the task force. Commissioner Baker said organizations like the Voice of the Fatherless Child need to be a part of the partnership. Nancy Alberte, City of Wauwatosa resident, appeared and commented. There are communities and groups already engaged in raising awareness, and they should be used. She is a parent of a recovering addict, facilitates a parents meeting, and am involved with other groups trying to raise awareness. Boots on the ground are needed for addicts. 4. Increase medication assistance treatment (MAT) capacity within the City/County. Administrator Lappen said that there is a nationwide shortage of MAT providers and prescribers. BHD is always working to try to find new resources and partners. There an emerging new world of prescribers and different ideas, which should be embraced locally. 5. Identify federal, state and other funding sources for sustainment of opioid prevention, treatment and control activities in the City/County. Director Colon added that the goal should include the term “obtain” in addition to “identify”. Commissioner Baker remarked. It should be made certain that there be the appropriate allocation of federal pass through dollars to southeastern Wisconsin when the dollars come through, which will be highly competitive. The ability of the task force to make recommendations and identify portals for citizens to access services for treatment and prevention is critical. Advocacy is going to be needed at the legislative level, at the program level with providers, and the resident level for those impacted. The City and County needs to be aggressive and make certain that incident rates and geographic rates mesh. Formulas are in place to determine how money gets distributed when at the state level. 6. Increase prevention capacity - especially looking at residential treatment options through BHD. Director Colon said the goal needs to be broader, is more of an intervention treatment than prevention, and should be moved up to goal #3. It is really about the continuum of services. Residential treatment is a key part but there are detox and outpatient therapy treatments. All services are important depending on the person coming in. Of importance is to provide successful treatment approaches. Administrator Lappen remarked. There is aftercare relapse prevention. Sober housing is critical. The Next step is getting people out of residential settings and into supportive places to go to prevent exposure to relapse environment. There is a shortage of safe and sober living that people can afford and have access to. Commissioner Bevan remarked. The turn away or diversion rate should be chronicled City of Milwaukee Page 5 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE and listed. People need to understand what the true turn away rate is for City and County. A turn away rate will help the request for more services. Turned away persons lead to increasing relapse rates, which is not sustainable. It is important to know what the prevention capacity is and the scale of increasing prevention capacity. Capacity data in aggregate and trends need to be known. Such data needs to be put into laymen’s terms so that end users can understand it. Director Westrich commented. The paramedic EMS center does have WI track capability that tracks the opening of hospital beds in OEM health systems. OEM does not have but should incorporate open beds for addiction treatment, which can serve statewide. Every hospital should have this system. A recommendation should be that open bed availability be updated in real time where a social worker or a provider of care for a victim can logged into the system and see immediately where open beds are specifically for addiction. Dr. Lerner said an area of emphasis is linking people who have opioid use disorders to treatment options. There are no great systems doing this linkage. There is law going into effect for everyone who asks for a prescription to be checked in the perscription drug monitoring program (PDMP). PDMP is a database available through the state where prescription information gets entered. Recent legislation, as part of HOPE agenda, requires all physicians to check the database before they give a prescription. Diverters or those with opioid use disorder (OUD)will be identified and will not be given a prescription. There needs to be a closing of that link to send these people with OUD somewhere for treatment and not off to find another source of prescription. Key to this recommendation is for the exchange to be added between physical and mental health care to ensure that people are getting linked at the point of overdose or acquiring drug. Elizabeth Collier, Department of Health Services (DHS) State Opium Treatment Authority, appeared and commented. DHS has a heavy list of availability on a daily basis for the residential treatment programs within the County. The availability is already being tracked, which is required, based on state funding that the County receives. MAT capacity in the County is also known. DHS has a list of all the buprenorphine providers in the State of Wisconsin. She monitors the waiting lists for the methadone clinics in the State. DHS has a lot of the information that the task force is looking for. If desired, she is happy to join the task force. Ald. Murphy said that Ms. Collier would be a great addition to the task force. Ms. Collier was questioned about sustainable funding for residential treatment, federal block grant funding, and additional State Targeted Response (STR) grants. Ms. Collier replied. Residential treatment is funded is out of DHS block grant funds, a yearly allocation that counties get. Funding also comes from other additional grants that the County receives from the State. Another funding source is the IV intervention grant that the County receives for a specific pot of money for intravenous users. These are ongoing funds that the County has had for several years. Block grant funding is every year, and the County already had its allocation for this year. The SAMHSA funding has been applied for and the hope is to hear back in May. Additional STR dollars is $7.6 million per year for two years. Commissioner Baker said the hope is to acquire SAMHSA funds, the formula used for the distribution of those funds should be known, and adequate amount of funding should be received based on the population at risk and not the number in treatment. City of Milwaukee Page 6 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE Ms. Collier added that needs assessments are done across the state based upon multiple needs and that DHS can give the formula breakdown for SAMHSA funds. The majority of funds are to be for treatment with a four month turnaround for startup. A portion of the funds are for prevention purposes. Administrator Lappen said that those STR funds are to be implemented quickly towards treatment. Demand currently exceeds funding. BHD has the infrastructure in place with people waiting for treatment. Commissioner Baker said there should be advocacy for prevention dollars to go upstream for upstream prevention methods, which more is needed. 7. Increase toxicology capacity through medical examiner – seek funding to modernize equipment to get faster/more accurate data points. Dr. Peterson commented. The number of deaths in the County last year from overdoses was about 3%, which is at the same level as homicides, suicides, motor vehicle accidents altogether. The mix of drugs is changing. A big wave of oxycodone was seen at one time, was reformulated, and was followed by the turn to heroin. MEO is seeing fentanyl and fentanyl analogs in the last 3 years. Death from those drugs has quintupled. A third of overdoses were from fentanyl and derivatives. These drugs are being driven by market forces, are cheaper, more potent, available, and misbranded, and require specific tests to be detected. His office is the only accredited ME lab in the state. MEO screening tests largely do not pick up fentanyl analogs. New machinery and technicians are needed to pick them up. MEO has three people doing all toxicology tests with some older machines and is providing the science. Better capacity is important to drive response and treatment for user types as well as improving turnaround time for drug results, which some other offices are able to give drug results the same day a case comes in the morning. Law enforcement needs that kind of data. Commissioner Baker added that the forensic analysis that happens downstream is critical to go upstream for prevention. 8. Provide data to various consortiums through Office of Emergency Management (OEM), Behavioral Health Division (BHD), and Medical Examiner Office (MEO) to streamline data needs and reduce duplication. Director Westrich commented. Data collected by OEM is very precious. OEM has 911 data that is dispatched for law enforcement for the sheriff’s department. OEM is well connected with the other thirteen 911 dispatch centers. Much data is not analyzed on a countywide level and is primarily prehospital data. OEM has a $300k grant awarded with the Medical College of Wisconsin, ME, and DOJ for the purpose of unscrambling data, looking at how to collect all data into one depository for eventual open access to the public, such as to researchers and students. The grant would contribute to task force goals. Linking analysis in an initial report by COPE is very informative going forward. Ald. Murphy commented. There is a website created for the data analysis report. The Zilber Foundation made the initial contribution. Sarah Zarate initiated the first study of data analysis through the efforts of Dr. Peterson to provide a report. The report data is important, useful, and should be made available to the public. The data has shown that the average person dying of overdose in the County is 44 years of age. That data plays a big role in the public education campaign in terms of prevention. Of importance is to tailor the education component to different audiences in addition to youths. The ultimate aim is to use the data for outcome-based City of Milwaukee Page 7 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE measurements. The ultimate outcome is to reduce opioid addiction, use, and deaths. Dr. Lerner said that the plan is to complete 2016 data this month, expand, and update the report every six months. One eye opening aspect of the data collection was the ability to show that for every death there are an estimated 6 overdoses. The surface is just being scratched on seeing the appalling number of deaths. Director Colon added remarks. Regarding residential capacity BHD does not have all of the capacity for the County. BHD does not own, operate, or oversee all of the residential capacity in the County. BHD has 112 slots but there are a lot more slots in the private sector. The County has really acted as a safety net for those historically who are not able to get services or lack insurance. Ald. Murphy moved to approve the eight goals discussed as part of task force goals. Administrator Lappen seconded. There were no objections. Members discussed expected long-term outcomes from task force recommendations. Ald. Murphy said there should be an aggressive reduction of deaths in City and County by half in 5 years. 269 people died last year of opioid and heroin deaths. Dr. Lerner said to reduce the amount of time Narcan is used by EMS system. The amount is available and easy to track. Reduction by half would be pretty bold. Commissioner Baker said to reduce the number of cases for repeat offenders in terms of monitoring drug court volume. Deputy District Attorney Loebel added comments. DA office can monitor three goals related to drug court: reduce referrals to drug court for drug-related offences, inclusive of cocaine and opiates; increase admissions to drug treatment program; and reduce the recidivism rate. DA has a general good success in drug treatment court at 70% currently. The recidivism rate is not monitored for years at a time. It is monitored for a year to two years. Commissioner Baker said to identify and increase sustainable funding for treatment and prevention for the City and County. Public-private partnership is needed to increase the amount of sustainable funding. The amount of funding can be baselined from the present. Any increase, even 5%, would be better. Ald. Murphy said to reduce the number of homicides associated with drug-related incidents by half. Last year, the number was at 16%. Director Colon said to have better alignment and leveraging of all resources. There are many efforts from the community. Mayor St. Marie-Carls said to have baseline commitment from municipalities to participate in a public awareness campaign. There are many tools that should be introduced to the municipalities. There can be further discussion to determine the level of commitment. Municipalities should step up. Director Westrich said have 100% participation of all 14 hospital emergency departments in the County engaging in warm handoff for overdosed victims. OEM is planning to measure that. Commissioner Baker said to sustain and expand the DEA's 360 Degree Strategy pilot program within a 2-3 year period. Milwaukee is one of four cities in the program. City of Milwaukee Page 8 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE The program is a model program, a game changer for looking at the aspect of illicit drugs in the community, and great at keeping law enforcement as a critical boots on the ground partner. Ald. Rainey said to also give attention to address the drug promethazine codeine, which is being highly abuse in many communities. The drug contains a compound of codeine, is highly addictive, and is being used by many youths. Commissioner Baker added comments. There should be understanding of gateway and pathway drugs and how to interrupt them, identification of how early a public education campaign should be done upstream for adolescents, and inclusion of critical partners at the table inclusive of educators over the next several months. School districts from surrounding areas should share their efforts and challenges and know that they have to move a needle towards educating students. Ald. Murphy moved to approve the outcomes discussed as part of task force outcomes. Dr. Lerner seconded. There were no objections. 5. Discussion on staffing, participation, tasks, and responsibilities. Commissioner Baker said that responsibilities are delineated in the resolution. Staffing consists of clerk staff Chris Lee, LRB liaison Tea Norfolk, and Health Department staff Jessica Gathirimu. Subcommittees may be formed if necessary to get work done at the discretion of the task force. Expertise from experts in the community should be used to make recommendations. Ald. Murphy added that Ms. Norfolk and Gathirimu are capable researchers and can be made available for all members. 6. Discussion on City and County efforts, programs, initiatives, grants, or activities. -DHS application for SAMHSA grant funds Commissioner Baker said that an application is underway for these funds, $7.5 million per year over the biennium. There would be a quick turnaround with money coming to the state and then distributed across the state. Sarah Zarate, Intergovernmental Relations Division, appeared and commented. DHS applied for the grant in February 2017. Wisconsin is eligible for $7.6 million per year or $15.7 million over the biennium. One of targeted purposes is to support community coalitions like the task force that are focused on nonmedical use of opioids among 12-25 year olds, which the task force should consider in its outcomes and recommendations. Commissioner Baker said that the grant funds are really looking at treatment through prevention by moving money to established providers who are treating individuals. He further inquired about youths at BHC for heroin or opioid use and the criteria used to come up with the 12-25 age range. Those impacted in the County are not in that age range. Data suggests the County is dealing with much older cohorts downstream. The fear is that the money will go elsewhere. Administrator Lappen replied that it is not typical to have youths at BHC for heroin or opioid use. Ms. Zarate replied. She does not know the criteria used but can follow up to find out. City of Milwaukee Page 9 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE Other goals of funds are to establish a hotline on treatment services and recovery support, expand access to treatment for uninsured and underinsured individuals, establish new opioid specific treatment programs to reduce the distance people have to travel for services, establish a network of individuals in long term recovery for the misuse and abuse opioids, train to coach people through the treatment and recovery process, and develop training for professionals on proven intervention and treatment strategies for opioid misuse and abuse. Ald. Murphy said the county can fit into those goals somewhere. -Milwaukee Community Opioid Prevention Effort (COPE) Dr. Lerner gave a brief overview. COPE resources have already been alluded to and are freely available through the website at http://www.mcw.edu/Emergency-Medicine/Milwaukee-COPE.htm. Resources include the data report and literature search for evidence-based community activities. Work has been done with local organizations to create an inventory of 48 local organizations that participate in some form of trying to address the drug epidemic. The list is a living document and can include additions, especially for those groups present at the meeting today. Those local groups gave recommendations about what needs to happen in Milwaukee, and those community recommendations have been forwarded to members. The goals that the task force has established do align well with community recommendations. Public comments are important to understand what the community says what is needed. Resources, reports, and data will continue to grow. COPE is looking to expand out to other places for obtaining data. Commissioner Baker said that the effort surrounding COPE is a great catalyst for the task force process. -DHS CDC grant funds Lisa Bullard-Cawthorne, Division of Public Health at DHS, appeared and gave an overview. DHS has an Opioid Harm Prevention Program Team consisting of five people: herself as coordinator, an epidemiologist, evaluation consultant, communications specialist, and community outreach. Concerning the goal of identifying funding sources, there are funds from the Centers for Prevention and Disease Control (CDC). There are two different grants looking at four different strategy areas: community intervention, overdose fatality reviews, policy, and primary prevention for women. Community intervention will be looked at primarily with a prevention perspective in prescribing practices upstream. For overdose fatality reviews, an area being worked on is enhancing the Prescription Drug Monitoring Program PDMP, now the EPDMP, which DHS has funded for updates to make it useful as clinical and public health surveillance tools. For policy DHS is looking at implementing the statewide standing order for a lock zone to allow pharmacies to be able to dispense in a lock zone as well as looking at policy relating to complementary and integrated health. First couple years will be focused on pilots. Third and fourth years will have resources available to local communities. Desire is to have a multifaceted and multidisciplinary approach, something that the task force is doing and where CDC funds can be provided for. RFPs will go out in the summer to local communities. Aside from funding DHS has a team offering support for recipients of funding. A great opportunity for the County are overdose fatality reviews, which there is funding for. There has been some conversations with the County and local health City of Milwaukee Page 10 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE departments on this opportunity. DHS has partnered with the Department of Justice (DOJ). Fatality reviews provides context and an opportunity link death data with other data. Milwaukee has multiple partners enabling data connection. The review is a 3-year project anticipating a total outcome of 10 fatality reviews across the state. DHS is in its first year looking at 3 different communities that will receive DHS funds for facilitation towards data collection. Dr. Mallory O’Brien is involved and is providing training and technical assistance for those communities doing fatality reviews. DHS can offer to help to link local data with other types of data that DHS has access to. DHS can provide at the local level linkage data between PDMP and outcome data. DHS is also linking public health data with other types of data, including DOJ data. Administrator Jason Smith, Wisconsin Department of Justice (DOJ) Division of Criminal Investigation (DCI), appeared and made several comments. He was at the front line fighting drugs as the commander of police district 3 in the City. Wisconsin Attorney General (AG) Brad Schimel is committed towards law enforcement activities and prevention. The focus is on schools, young people, and the workplace. Concerning Narcan availability, the AG just renewed the deal to provide public safety entities with rebates on Narcan through Amphastar Pharmaceuticals. The bill in 2013 has allowed first responders to provide Narcan. Law enforcement, as well as DCI, across the state has that ability even before medical services get there. Concerning collecting more prescription drugs, DOJ coordinates one of the largest drug takebacks in the country, which did not happen overnight. Relative to increasing toxicology and their ability to investigate, he has access to Milwaukee ME data and can provide overdose and death data to other members of the governor’s Controlled Substances Board, which he sits on, as the board identifies and schedules some analogs from both heroin and fentanyl. Many of these drugs are coming from clandestine labs and not from manufacturers. He will be with the Department of Safety and Professional Services next week to brief the chiefs of Southeastern Wisconsin on how law enforcement contributes to PDMP. PDMP relies on data going in as well. DOJ just released the training partnership with the Pharmacies Society on preventing pharmaceutical robberies. Wisconsin was ranked between #2 and 3 in the country around 2015 and 2016 for pharmacy robberies. Only one robbery occurred the following year through close work with Walgreens, CVS, and processes that DOJ had put into place. There is excitement with overdose fatality reviews. In his experience, the juvenile justice reviews took a multidisciplinary approach looking at victims, even young offenders, as inputs and outputs of their environment. This approach helped identify gaps and positive outcomes. People intersect with law enforcement, prosecution, and social services. DOJ has partners developing all over the state. Commissioner Baker said that DHS and DOJ is an example for the need for partnerships. Ald. Murphy commented. Partnerships with the State are desired. The AG’s number one issue was to address opioid and heroin addiction in the State when running for office. -Proposal to Cardinal Health Foundation Dr. George Morris, chair of the Wisconsin Medical Society Task Force on Opioids, appeared and commented. Overdose and prescription have their origins in the provision of prescription medications. The number of prescriptions have soared and been made available to people who are not necessarily the prescribed persons. 70% City of Milwaukee Page 11 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE of children and adolescents who have their first exposure to opioids go on and become part of the opioid abuse disorder. These medicines are sitting in medicine cabinets. DEA Project 360’s point is to stem diversion. Biggest way to stem diversion is to eliminate prescriptions in the first place. Physicians take a great responsibility in this problem. Community Advocates (CA) has applied for a grant to look public health detailing in the County. New York City has applied this to opioids. The intention is to focus on a number of clinics with the goals of meeting every physician aggressively, providing them with takeaway materials for display in exam rooms depicting the addictive nature of these medications. There are estimates that 1 in 8 people are potentially susceptible to drug addiction on a single exposure to opioid medication. Advocacy should not be for less prescription but rather for smaller prescriptions. The Bureau of Staten Island was able to show this aggressive detailing project of physicians and reduce prescription volumes by 60%. CA will study volumes and the number of prescriptions issued by clinics. An undetailed clinic will serve as a control group. The intention is to come up with a model to be readily expandable citywide, countywide, and statewide. A suggestion is to consider less prescription volumes as a spigot. Ald. Murphy moved that an outcome include working with the DA office to reduce the issuance of opiates in smaller volumes. Administrator Lappen seconded. There were no objections. An appropriate percentage is to be determined. Dr. Peterson commented. A valuable website, http://takebackyourmedsmilwaukee.org/, gives a map of collection centers for unneeded opiates. Another outcome should include increasing the number of collection sites. Increasing drop boxes are helpful, and one is welcomed at MEO. Ald. Murphy said that the self-addressed envelopes are easy to use, forwarded to the police department, and then given to the DA to be destroyed. Commissioner Baker said that following through to have something similar to the aggressive detailing of providers on prescription drug practices will make a difference. The work of the Medical Society of Milwaukee County and the Wisconsin Medical Society has been important in this regard. -Other Representatives from Milwaukee Police Department, Captain Steven Caballero, Lt. Alex Ramirez, and Lt. Eric Pfeifer, appeared and provided comments. Captain Caballero commented. He is in charge of one of the investigative bureaus. Police representatives speaking today are continually on the front line of the overdoses that occur in the City. Law enforcement has realized that the County and City cannot arrest itself out of the problem. Police drug collection at district stations and through the mail-in program has been successful. 2176 lbs. of narcotics were collected in 2015, 3905 lbs. in 2016, and 770 lbs. so far for 2017, which is on pace to match 2016. About 10 lbs. of narcotics are collected daily. Police are open to assist in any capacity serving as the boots on the ground. Oftentimes, law enforcement sees family members that are also addicted along with the deceased victim. There is opportunity to provide service to those family members who are also addicted. Ald. Murphy said there is trauma informed care through the efforts of Ald. Ashanti Hamilton and Ald. Milele Coggs. The purpose of the care was initially for individuals who have experienced serious physical or emotional trauma. There should be City of Milwaukee Page 12 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE consideration of using the care for drug interjection for individuals suffering, including children who are being poisoned by drugs. DA discusses interjection as a 3-legged stool. It would be helpful to know how much drug is interjected from coming into the community. There is a big uptick in fentanyl. Lt. Alex Ramirez, MPD High Intensity Drug Trafficking, commented. He is assigned to the narcotics division at Milwaukee High Intensity Drug Trafficking Area (NITDA). Many data are collected, and trends are followed. The division has seen an increase in fentanyl coming into the community. Heroin is still present. The division’s goal is to investigate the mid and upper level drug dealers. The division tries to get to overdoses immediately. The epidemic is a medical health problem. He believes in the aspects of prevention and drug court. The division will continue to work with everyone. There are MPD members working in conjunction with about 23 other law enforcement agencies. They work closely with the DA office within their building and over at the County. Lt. Pfeifer commented. His unit started last year in September focusing on dealers on the streets. He works closely with Lt. Ramirez, MEO, and DA office. Their goal is to try to find cases to possibly prosecute in Len Bias Law. They’ve been somewhat successful. The unit continues to grow, is looking at programs from other cities, and is open to work with as many entities as possible. The issue is a medical problem and not a criminal one. Director Westrich added comments. The EMS system has been giving direction to MPD to administer Naloxone or Narcan out on the streets. EMS has 5 to 6 municipalities participating in its program with signed MOUs. EMS provides training, oversight, quality assurance, and data analysis of administration of Naloxone or Narcan out on the street. Director Westrich moved that an outcome include requiring 100% participation by every other law enforcement agency within the County participating in the EMS program regarding Naloxone or Narcan administration. Ald. Murphy seconded. There were no objections. Ald. Rainey said there is an interesting dynamic of treating victims with rehabilitation and incarcerating young black, brown, and impoverished boys who are selling these drugs. Commissioner Baker said there needs to be balance in prevention and law enforcement to address that dynamic. There is no easy solution. The work of drug court concerning referrals and treatment is a difficult task. Deference should be given to law enforcement, and prevention efforts downstream should be understood. Advocacy is need towards youth affected by heroin, opioids and cocaine. Juvenile systems are the most difficult systems due to not maturing. Deputy District Attorney Loebel commented. Officers see every day the violence. They should be commended for their efforts to reduce supply, overdose, violence, and drug trafficking. People are not only affected by use, fatal or nonfatal overdose, but also by the gun violence and devastation that are the byproduct of trafficking. Prosecutors and law enforcement officers are cognizant of and are trying to distinguish between individuals with addiction or social problems and those individuals who are predators. 7. Public comments. City of Milwaukee Page 13 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE There were public comments from 8 individuals as follows: Jon Richards testified. He is the coordinator for the Take Back Your Meds Milwaukee Coalition. The coalition is made up of medical groups, substance abuse advocates, environmental groups, and businesses. The coalition is addressing the issue of collecting unused medicine. Only 10% of unused medicine is being collected in the County. 90% of unused medicine is not being collected in the County. A study done in San Francisco in 2014 showed that in the course of two months the 14 pharmacies there collected what Milwaukee MPD had collected in 6 months in 2016. Good work is being done but more can be achieved. The coalition wants to work with the task force and be involved with anything concerning unused medicine collection. A suggestion is to require a drug drop box in every single pharmacy within next 10 years in the County. Another suggestion is to have an aggressive public education campaign to encourage people to get rid of their unused medicine properly. Mayor St. Marie-Carls moved that an outcome include the requirement of a drug drop box in every single pharmacy within next 10 years in the County. Ald. Murphy seconded. There were no objections. Jeff Hochstein testified. He has 25 years of experience in corrections and 24 years in probation and parole. Disservice is being done to recovering persons who are being forced through the criminal justice system. Individuals on the street do not fear overdosing or being homeless. They fear detoxing in jail the most due to poor staff treatment in jail. There is no follow-up in jail. There are not enough slots in the drug courts. The prescribing practices of physicians need to be looked at. Dentists are unnecessarily prescribing oxycodone, which is for treatment of cancer and orthopedics. Concerning the mental health profession, the indiscriminate use of medicines for children taking multiple drugs like Ritalin and Prozac are contributing to youth “skittle” parties. The task force is a start of taking a step. Another concern is those politicians in power who say marijuana, tobacco, and alcohol are gateway drugs to opioids and heroin. Everyone should read a book called “Chasing the Scream” by Johann Hari. The book traces the war on drugs back to the 1930s when the first laws came out for opioids, cocaine, and marijuana. He would like to be part of the task force, if needed. Jody Coren testified. She is from Genesis Behavioral Services (GBS) and is very concerned about the County recently informing her agency of cutting the agency’s residential beds by 75% in funding. There was no prior notice and no issue on quality of care. GBS has 13 beds for men and women in suffering. GBS provides substance abuse treatment and primary treatment combined with trauma informed care at all stages in life. She has been a practitioner for 30 years in mental health and substance use and has demonstrated commitment and advocacy. She is concerned about reducing available resources to address the epidemic. GBS has invested in excess of $1 million. GBS is saving lives and women involved with prostitution. GBS also has a primary 40 bed facility for men for trauma informed care on 50th and Lisbon. This facility, too, is being cut in funding to 12 beds. GBS has also been told to shut down a new facility that it is investing in the community. Carollyn Black testified. She is a Director of Operations at First Step. She has been in the treatment industry for 17 years. First Step gets the patients and residents from all over and of all races firsthand at their lowest point, especially those dealing with heroin use. Women are doing drugs because of their pimps. There are not enough facilities for females, they are turned away and placed on waiting lists, and their pimps then hold them hostage in a home and abuse them further. There are more facilities and room, but no one is using them. Use the available beds out in the community, like those for GBS. There are lives in jeopardy. City of Milwaukee Page 14 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE Freddie Smith, Matt Talbot Recovery Services, testified. He is out on the streets everyday working with the consumer. He was a consumer and an example of a positive outcome. Baby steps are needed to solve the issue. Places that already have beds should be used. Persons of color, like himself, should feel safe and not threatened by police in their own homes. Skin color should not matter when dealing with the police. Resources are out there. The task force should search for funds to spread throughout all areas inclusive of the inner city and not just the south side or suburban areas. The problem extends beyond opiates. If funding is an issue, the task force needs to find enough funding and capacity to assist those resources in the communities that are studied in the business of saving lives. Nancy Alberte, City of Wauwatosa resident, testified. She is a parent of an adult son in recovery and involved in parent support groups who have children abusing drugs. Concerning destigmatizing, addiction needs to be referred to as a chronic illness, a brain disease. Creating a database of an open bed list is fantastic. 211 needs to be supported. Her groups refer people to 211 to find services. Appointments need to be scheduled immediately without delay concerning children. People in jail and support systems outside of jail should be addressed. The judicial system is incarcerating addicts who have never been treated for their disease. Many are let out without a support system and will relapse. People in jail should be treated with medicines like Vivitrol. Most of parents’ children in the support groups are adult addicts who lack insurance. Solving the epidemic requires a long-term approach. Amy Stone testified. There needs to be better information about services and access as part of a public education campaign. The COPE inventory is a good start but needs more work. Common Council action is important to be known. Task force goals need prioritization. Evidence driven data can get awfully confusing. Matching communities, with their data, most similar to Milwaukee makes more sense. Diffusion of responsibility happens all the time. There needs to be something in place to adopt what the task force is doing and assist in identifying things that the task force is missing. Julia Dynek testified. She is a former heroin intravenous user for 9 years, former felon, and an unsuccessful case through drug court. The task force needs to individualize the addiction. There is not a way to arrest out of the problem. She is the founder of the nonprofit Sobriety Link, which offers three services: individualized treatment placement, funding, and scholarships. Going through a treatment facility saved her life. Statistics are great but do not mean anything to users. Successful recoverees should be included in the solution. She only listened to those who recovered. Many users may not have enough self-worth to seek help despite resources being available to them. Commissioner Baker said everyone’s comments and ideas gave context and were appreciated, the stories from recoverees are what the task force is all about, and the task force is just beginning. 8. Discussion on meeting frequency, dates, times, and location. Commissioner Baker said there will be one or two community meetings midstream or towards the end of the task force to have something to present for public input, ad hoc work may be necessary and do not have to mirror task force meeting frequency, and task force meetings should be held at least once a month. Ald. Murphy said staff will poll members to set the next meeting, Fridays are City of Milwaukee Page 15 CITY-COUNTY HEROIN, OPIOID, Meeting Minutes March 17, 2017 AND COCAINE TASK FORCE preferable, meeting frequency should be once a month to allow time for staff to work on objectives, and Ms. Norfolk will produce a summary report of today’s meeting for members. 9. Agenda items for the next or subsequent meetings. Commissioner Baker said that staff will work with the chair, vice-chair, and members to populate agenda items and that meetings should generally last 2 to 2.5 hours inclusive of possible public comments. Mayor St. Marie-Carls said an agenda item for next meeting is to prioritize task force goals. Commissioner Baker concurred. Task force goals need some synthetization and categorization. The goal is to make certain that this body submits recommendations and allow for the Common Council to have all the information they need to look at. 10. Adjournment. Meeting adjourned at 3:37 p.m. Chris Lee, Staff Assistant Council Records Section City Clerk's Office Matters to be considered for this meeting and materials related to activities of the task force can be found within this file: 161554 Communication relating to the activities of the City-County Heroin, Opioid and Cocaine Task Force. Sponsors: THE CHAIR City of Milwaukee Page 16