Agenda

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C. 79

To:	Board of Supervisors
From:	David Twa, County Administrator
Date:	August 14, 2018

Contra

Costa

County

Subject:

RESPONSE TO CIVIL GRAND JURY REPORT NO. 1806, ENTITLED "THE OPIOID CRISIS"

APPROVE	OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR	RECOMMENDATION OF BOARD COMMITTEE

Action of Board On: 08/14/2018

APPROVED AS RECOMMENDED

OTHER

Clerks Notes:

VOTE OF SUPERVISORS

AYE:

Candace Andersen, District II Supervisor
Diane Burgis, District III Supervisor
Karen Mitchoff, District IV Supervisor
Federal D. Glover, District V Supervisor

ABSENT:

John Gioia, District I Supervisor

Contact:	Julie DiMaggio Enea (925) 335-1077
cc:	Health Services Director Behavioral Health Director CAO-H&HS Deputy CAO Admin

I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown.
ATTESTED: August 14, 2018
David Twa,

BY:	, Deputy

RECOMMENDATION(S):

ADOPT report as the Board of Supervisors' response to Civil Grand Jury Report No. 1806, entitled "The Opioid Crisis”, and DIRECT the Clerk of the Board to transmit the Board's response to the Superior Court no later than August 28, 2018.

FISCAL IMPACT:

No fiscal impact.

BACKGROUND:

The 2017/18 Civil Grand Jury filed the above-referenced report, attached, on May 25, 2018, which was reviewed by the Board of Supervisors and subsequently referred to the Health Services Director and County Administrator, who prepared the attached response that clearly specifies:

Whether the finding or recommendation is accepted or will be implemented;

BACKGROUND: (CONT'D)

If a recommendation is accepted, a statement as to who will be responsible for implementation and a definite target date;

A delineation of the constraints if a recommendation is accepted but cannot be implemented within a six-month period; and

The reason for not accepting or adopting a finding or recommendation.

The California Penal Code specifies that the Board of Supervisors must forward its response to the Superior Court no later than August 28, 2018 (90 days from receipt).


FINDINGS

F1. The availability of MAT (Medication-Assisted Treatment) in the County’s emergency rooms, medical offices, County health clinics, and the County’s detoxification sites does not meet the needs of people with OUD (Opioid Use Disorder).

F1 Response. The respondent agrees with the finding. The need for additional capacity is a countywide issue facing all health systems. Contra Costa Health Services (CCHS) is in the process of adding capacity to its Choosing Change Clinic, which offers MAT, as well increasing induction of MAT in the Emergency Room setting for patients in appropriate situations. Additionally, CCHS is planning on opening a sobering/respite center as a component of the Whole Person Care initiative. The Richmond Planning Commission also recently CCHS's application to restore detoxification, residential and recovery services.

F2. Only 3.2% of the nearly 5,600 private and public medical providers in the County have acquired the Drug Enforcement Agency waiver to prescribe buprenorphine, creating a MAT gap for people seeking treatment.

F2 Response. The respondent agrees with the finding. CCHS has greatly increased the number of clinical providers who are waivered to prescribe buprenorphine over the past two years, with nearly 90 providers currently waivered. A complimentary strategy is to encourage clinicians already waivered to increase the use of their waivered status.

F3. The limited open hours at the County-operated Choosing Change Clinics are a barrier to treatment for OUD users.

F3 Response. The respondent partially disagrees with the finding. The Choosing Change Clinic is designed to serve individuals insured through the Contra Costa Health Plan and other Medi-Cal eligible clients/patients served by CCHS. Since the issuance of the Grand Jury report, CCHS has expanded its capacity and now offers 13 weekly groups serving over 500 individuals, and is working towards offering evening services.

The Choosing Change Clinic should not be the only route of access to MAT. CCHS is working to leverage the capacity of both the Emergency Department and ambulatory care providers, utilizing the Hub-and-Spoke model, where stabilized patients in a Hub can be referred to a medical provider for maintenance to continue treatment. Additionally, effective July 1, 2018, patients now have access to the services provided by BAART- Behavioral Health Services that specializes in MAT as part of the Drug Medi-Cal Organized Delivery System in two different locations.

F4. The 2016 California Marijuana Tax Fund (AB 1748) requires that a portion of taxes paid be used for youth drug abuse treatment programs.

F4 Response. The respondent agrees with the finding.

F5. The demands for programs addressing high-school drug abuse throughout the County exceed the resources available.

F5 Response. The respondent agrees with the finding.

F6. The demand for programs throughout the county to educate high school students and their parents on overdose prevention, the dangers of opioid use, and responses to overdoses exceed the available supply.

F6 Response. The respondent agrees with the finding.

F7. There are no in-County adolescent residential treatment facilities. Youth requiring residential treatment are directed to seek care outside the County.

F7 Response. The respondent agrees with the finding.

F8. Stigma of drug addiction is a barrier to treatment, and presents barriers to providing more in-County recovery facilities.

F8 Response. The respondent agrees with the finding. Historic stigma has created barriers to treatment and resources. Fortunately, newer Substance Use Disorders (SUD) parity laws require health insurance providers to offer a comparable level of benefits for SUD conditions as they do for traditional physical health conditions. This will stimulate an increase in capacity for SUD services, as they are now a covered benefit for most insured individuals.

F9. For incarcerated opioid addicts, there are staffing gaps in the detention facilities during the week for intake screening, withdrawal management, and clinical treatment.

F9 Response. The respondent agrees with the finding. To address opioid use disorder in detention facilities will require programming, process redesign and potentially increased staffing.

CCHS has recently applied for a Learning Collaborative Grant for the expansion of MAT in jail and continuity of treatment after release. If awarded, Contra Costa County will collaborate with 19 other counties to explore strategies and best practices that can be implemented to better address the need for treatment of SUD for persons who are incarcerated and also for those persons transitioning out of incarceration.

F10. The majority of those who abuse opioid prescription medications do not get them from the street. Instead, they obtain these from the homes of family and friends. The danger is exacerbated by the lack of sufficient public awareness.

F10 Response. The respondent partially disagrees with the finding. The misuse of prescription opioids is a complex clinical and social issue. While some individuals seek prescription opioids in the medicine cabinets of family and friends, many who misuse do so by over-medicating beyond the prescribed limits of their treatment plan, subsequently seeking increased frequency and dosage of medicating. This is often done by doctor shopping and/or by repeatedly seeking treatment with opioids, a warning sign for addiction. We agree with the finding regarding the lack of sufficient public awareness due to limited resources.

F11. In a 2018 Substance Abuse and Mental Health Services Administration (SAMHSA) study of patients seeking medical care and entering a rehabilitation intake center, the average wait time to enter a treatment program after initial contact with a provider was 42 days. Only about a third received an appointment within 24 hours.

F11 Response. The respondent agrees with the finding. The 2018 SAMHSA Study is commenting on national statistics and illustrates the need for increased capacity to address SUDs.

F12. Among the County’s estimated 54,000 persons with opioid use disorder, fewer than 10% can be treated long-term, given current care capacity.

F12 Response. The respondent agrees with the finding. This is a countywide estimate, illustrating the size and scope of the challenged faced by all health systems across the county. As noted in Finding #3 above, CCHS has expanded and is continuing to expand its capacity to serve individuals with opioid use disorder, through its Choosing Change (MAT) Clinic, as well as its network of ambulatory care providers and the Emergency Department. Additionally, an agreement with BAART (private opioid addiction treatment program) for the provision of MAT to include: Methadone, Buprenorphine, Naloxone and Disulfuram, will contribute to increased treatment availability.

RECOMMENDATIONS

R1. The BOS should consider requesting Behavioral Health Services to develop a plan by December 2018 to motivate more physicians to complete their qualifications for a waiver to prescribe and dispense buprenorphine starting in 2019.

R1 Response. The recommendation has not yet been implemented but will be implemented within six months. It should be noted that the need for communication, education, and MAT spans the entire Contra Costa health system. As an integrated health system, CCHS is leveraging efforts across all its Divisions, including the Contra Costa Regional Medical Center and Clinics, Contra Costa Health Plan, Behavioral Health and Public Health, to increase the number of clinicians who are waivered and actively using their waiver to prescribe buprenorphine. As noted in the County's response Finding #2, CCHS has some 90 clinicians who are currently waivered.

R2. The BOS should consider seeking funds, in the FY2019-2020 budget, for Behavioral Health Services to offer the course “Buprenorphine Treatment: Training for Multidisciplinary Addiction Professions” or equivalent to all of the County’s public medical care providers starting July 1, 2019.

R2 Response. The recommendation has not yet been implemented. Additional training is necessary across the entire Health Department. There are multiple trainings currently available, many through SAMHSA and the Department of Health Care Services. Clinical leadership in the Contra Costa Regional Medical Center, Behavioral Health and Public Health are working together to emphasize the importance of training and increasing the number of clinicians who are actively utilizing their waiver status to initiate MAT for opioid dependency. The need for additional funds will be considered on a timeline consistent with the FY 2019/20 County budget process.

R3. The BOS should consider seeking funds, in the FY2019-2020 budget, for Behavioral Health Services to hire more buprenorphine clinicians beginning July 1, 2019.

R3 Response. The recommendation requires further analysis. CCHS is evaluating the need to expand upon the Choosing Change Clinic by offering similar services at additional locations and within other Divisions of the Health Services Department, inclusive of the Behavioral Health Division. This includes consideration of offering a focused set of MAT services to patients who are both opioid dependent and still experience significant pain. Likewise, it is important to note that Divisions (Contra Costa Health Plan and Behavioral Health) are currently implementing various clinical improvement projects aimed at curbing the number of opioid based prescriptions, and offering alternatives to manage pain. The need for additional funds will be considered on a timeline consistent with the FY 2019/20 County budget process.

R4. The BOS should consider requesting the Alcohol and Other Drugs Services (AODS) division of Behavioral Health Services to use funds available under the California Marijuana Tax Fund legislation (AB 1748) for in-county adolescent outpatient and residential inpatient treatment.

R4 Response. The recommendation has not yet been implemented. It is as yet unknown as to the amount and distribution of State funds that might become available to Contra Costa County.

R5. The Contra Costa County Office of Education should consider seeking funds, in the FY2019-2020 budget, to provide free NARCAN kits in all County school districts.

R5 Response. The County defers formal response to the County Office of Education.

R6. The BOS should consider seeking funds, in the FY2019-2020 budget, for Behavioral Health Services to develop a plan to increase clinical treatment of substance use disorders in the three detention facilities.

R6 Response. The recommendation has not yet been implemented. Contra Costa Behavioral Health Services is actively working with Contra Costa Regional Medical Center’s Detention Health Services to increase screening and treatment for SUDs. The need for additional resources to develop a plan will be considered on a timeline consistent with the FY 2019/20 County budget process.

R7. The BOS should consider seeking funds, in the FY2019-2020 budget, for Behavioral Health Services to develop and deliver educational campaigns to improve public awareness of the County’s opioid addiction crisis and available treatment options, starting July 1, 2019.

R7 Response. The recommendation has not yet been implemented. Additional funding is necessary to provide a robust and unified local public education and awareness campaign. As noted in the County's response to Recommendation #1, a public awareness and education is a system wide issue that will involve a unified effort across all Divisions of CCHS, including Hospital and Clinics, Behavioral Health, Public Health, Environmental Health, Emergency Medical Services, and H3 (Health, Housing and Homeless). The State Department of Public Health has developed some public educational materials and the Division of Alcohol and Other Drugs in Behavioral Health is reviewing materials to determine those which help deliver appropriate messages to targeted audiences. The need for additional resources to develop a plan will be considered on a timeline consistent with the FY 2019/20 County budget process.

R8. The BOS should consider seeking funds, in the FY2019-2020 budget, for Behavioral Health Services to use multiple modes of communication such as news media, social media, community TV/Radio, and billboards, with a positive message to help alleviate the stigma of OUD, starting July 1, 2019.

R8 Response. The recommendation has not yet been implemented. Consistent with Recommendation #7 above, CCHS is in the process of determining how to tailor a unified local messaging campaign that addresses both public awareness and the stigma associated with opioid use disorder. The need for additional resources to develop a messaging campaign will be considered on a timeline consistent with the FY 2019/20 County budget process.