Office of the County Administrator County of Marin February 9, 2021 Matthew H. Hymel County Administrator FEB 09 2021*

The Marin County Department of Health and Human Services, through RxSafe Marin and the Drug Medi-Cal Organized Delivery System, has initiated robust prevention and treatment programs to address the opioid epidemic. Response: Agree. The Marin County Department of Health and Human Services and its community partners have collectively worked to implement a robust system of prevention, treatment and recovery support services to address the opioid epidemic. RxSafe Marin, which is a broad-based community coalition, takes a comprehensive approach through the work of the following five Action Teams: Community-Based Prevention; Intervention, Treatment and Recovery; Law Enforcement; Pharmacists and Prescribers; and Data Collection and Monitoring. The Drug/Medi-Cal Organized Delivery System has also served to increase the accessibility and availability of substance use treatment services for individuals with opioid use disorders. These initiatives remain a priority and sustained work is essential to effectively impact the opioid epidemic, which has been exacerbated by the global pandemic.

Expanded distribution and availability of naloxone throughout Marin County could help provide additional life-saving opportunities to reverse opioid overdoses. Response: Agree. Naloxone is a potentially life-saving medication, but for it to be helpful it must be readily available at the location and at the time that it is needed. Since death occurs from an opioid overdose due to suppression of the drive to breathe, time from overdose and consequent breathing suppression to naloxone administration and resumption of breathing is critical: "time = brain." Fortunately, naloxone is currently available as both an injectable and an intranasal spray, with the latter formulation greatly expanding our ability to make this medication more available since it eliminates the need to handle needles. Laws limiting liabilities associated with administration of naloxone further enhance the expansion of naloxone availability by facilitating non-medical individual utilization. As mentioned in this report, naloxone is necessary but not sufficient to curb the opioid epidemic—naloxone is not addiction treatment, rather, it prevents deaths in individuals who then have the opportunity to engage in other treatments, such as Medication Assisted Treatment (MAT). In partnership with RxSafe Marin, Marin HHS has adopted a multi-pronged approach to increase naloxone availability: 1) facilitating the availability of naloxone through local pharmacies (pursuant to CA law that allows pharmacists to furnish naloxone without a physician's prescription); 2) securing naloxone through DHCS Narcan Distribution Program (NDP) stockpiles for distribution to HHS services and service sites; 3) providing training and naloxone kits to Marin County Jail inmates interested in having this at time of release; 4) helping facilitate community partners' applications to DHCS NDP; 5) organizing naloxone trainings at community, organizational, and individual levels; and 6) providing education to counter stigma about naloxone itself, MAT, and those suffering from addiction through media campaigns, educational events, and distribution of enduring educational literature. County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations "Opioid Misuse: Strengthening Marin County's Response" December 14, 2020

Additional recovery coaches, who play a critical role by connecting substance users to appropriate treatment, would enable more patients to obtain the support network required for their recovery. Response: Agree. National and state behavioral health systems of care are complex and navigation can be difficult. These systems can be especially difficult to navigate for Medi-Cal beneficiaries, who often have myriad simultaneous social, legal, economic, medical, housing and mental health challenges. We have found that recovery coaches provide much needed guidance to help shepherd individuals through the often-complex process of securing appropriate treatment. Recovery coaches combine personal passion for the work, intimate system knowledge and strong institutional relationships, clinical acumen as certified drug and alcohol counselors, along with a lack of specific institutional tethers that allows them to move freely between systems, which, in total, has had a profoundly positive impact on our Medi-Cal substance use system of care. We agree that expansion of the recovery coach program would further enhance our ability to help our most challenged Medi-Cal beneficiaries navigate the substance use disorder system of care to treatment and other services. In order to expand the recovery coach program there are several considerations to take into account, all of which we are currently exploring. First, securing funding (see R2 below). Second, recruitment. It is challenging to secure high-quality certified SUD counselors to serve as recovery coaches—demand simply outstrips supply. As evidence of this, Marin HHS recently posted a request for applications for a new recovery coach position three separate times over an eight-month period, without securing a viable candidate.

Marin County is unable to help some of its opioid use disorder patients who need medication-assisted treatment because of a shortage of X-waivered providers and because current X-waivered providers are serving fewer than the number of patients they are authorized to treat. Response: Agree. Due to how SAMHSA lists X-Waivered providers on their Treatment Locator website, it is difficult to know for certain the exact number of providers in our community who hold X-Waivers (e.g., providers have the option to "opt in" or "opt out" to being listed, and those who "opt out" will not appear on this locator). Nonetheless, we agree that there is a gap between need and providers available to prescribe buprenorphine. In recent months, MarinHealth Medical Center's Emergency Department has greatly expanded its ability to initiate this treatment, with perceived complexity of initiation often cited as a barrier to many outpatient prescribers prescribing buprenorphine to the extent that they are allowed under the law. Furthermore, as a positive consequence of the pandemic, restrictions on the use of telehealth to initiate and maintain individuals on buprenorphine have been lifted (e.g., Ryan- Haight Act, restrictions on use of telephone for initial buprenorphine appointments). Marin HHS has also partnered with a telehealth addiction provider, Bright Heart Health, to help expand the 24/7 availability of MAT assessments and treatment initiations. County of Marin Response to Grand Jury Report Findings and Recommendations "Opioid Misuse: Strengthening Marin County's Response" December 14, 2020 Finally, in an attempt to increase currently X-waivered providers' comfort with treating more individuals under their waiver allowance, we have undertaken a media campaign aimed at local providers. In this campaign, we share (among other resources) information about how to access real-time mentorship through both regional and national clinical mentorship programs.

Marin County lacks a sufficient number of beds in long-term recovery residences to offer needed support and aftercare for substance use disorder patients. Response: Agree. Although Marin has far greater contracted capacity than noted in the External Quality Review report referenced in the Grand Jury Report, which only included a segment of our capacity, demand for County-subsidized recovery residence beds does exceed contracted capacity. Given the importance of safe and supported housing, the Marin County Probation Department began investing in sober living many years ago and currently partners with Marin HHS to manage contracts for 66 beds across fourteen program sites. As Marin County opted into the Drug/Medi-Cal Organized Delivery System demonstration waiver, the federal government provided updated policy guidance that permitted the use of the Substance Abuse Prevention and Treatment Block Grant (SABG) funding for recovery residences for individuals that are currently engaged in either treatment or recovery support services. With this shift, in FY 2018-19, Marin HHS re-allocated existing resources toward purchasing recovery residence capacity. In FY 2020-21, SABG is being used to contract for 16 recovery residence beds, which represents an increase from the initial implementation in FY 2018-19 (10 beds). As this is not a Medi-Cal reimbursable service, there is limited funding for recovery residences. County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations "Opioid Misuse: Strengthening Marin County's Response" December 14, 2020 RESPONSE TO GRAND JURY RECOMMENDATIONS The Marin County Civil Grand Jury recommends the following: