CommStat 1/25/18 Making Homelessness in Chittenden County Rare and - - PowerPoint PPT Presentation

CommStat 1/25/18

Making Homelessness in Chittenden County Rare and Brief Burlington Housing Authority’s Role as a Member of Chittenden County’s Continuum of Care (CoC)

BHA’s Mission

Provide low-income, vulnerable members

• f our community

access to safe, affordable housing and retention support services in ways that promote resident self-sufficiency and vibrant neighborhoods

Str trategic ic Prio iorities – Affordable le Housing

Ensure an adequate supply of affordable housing by acquiring, developing, and maintaining a variety of housing options

• 31 owned/managed properties, 680 apartments
• Certain properties provide targeted supportive housing for some of our community’s most

vulnerable residents, including the formerly incarcerated, victims of domestic violence, the elderly and disabled, and families

• BHA properties, which are conveniently located downtown and in a number of neighborhoods, are

well maintained and operated, and offer unique retention-focused resident supportive services designed to help tenants retain their housing and build a sense of community

Str trategic ic Prio iorities – Rental l Subsid idie ies

Provide rental subsidies to the most vulnerable, low-income residents of the Burlington-area, including the chronically homeless, elderly, people with mental, physical, or intellectual disabilities, survivors of domestic violence, and the formerly incarcerated

• Provide over 2,500 low-income households with more than $21 million annually in Federal rental

subsidies, through a number of programs managed by BHA, including:

• Tenant-Based Housing Choice Vouchers
• Project-Based Vouchers, subsidizing rent on specific units owned by BHA and other

Burlington-area housing providers

• Manage the housing subsidy portion of Federally-funded Permanent Supportive Housing assistance

grants, which provide housing and support services to chronically homeless households

• Offer a variety of programs serving special needs populations, though partnership

support from several organizations, including Spectrum, Howard, Pathways, VermontCares, Steps to End Domestic Violence, and CHC’s Safe Harbor Clinic

One type of subsidy BHA awards is the Family Unification Voucher (FUV)

• FUVs provide rental assistance to families where the lack of adequate housing is a primary factor in:
• The imminent placement of a family’s child or children in out-of-home care, or
• A delay in discharging a child or children to a family from out-of-home care
• BHA is currently allocated 375 FUVs, a significant resource for our community
• FUV referrals come to BHA primarily from DCF-Family Services, as well as from Economic Services

Division-Reach-Up, Lund, Spectrum, Steps to End Domestic Violence, & COTS.

• Historically the FUV program has had the highest attrition and turnover of any of the rental

assistance programs BHA manages

• Families leaving this program often cycle back into homelessness, creating additional

barriers (eviction, back rent etc.) along the way, making it harder to regain housing Our community would benefit from more/different services to better support families receiving FUV housing subsidies to better enable them to retain their housing

Str trategic ic Pri riorities: Rental l Subsid idie ies

(conti tinued)

Deliver comprehensive social services designed to prevent eviction and help end homelessness in the community

• Prioritize the most vulnerable and homeless individuals in our community when possible in offering

housing and rental subsidies, subject to Federal funding and related regulations

• Provide one-on-one and site-based supportive services to BHA residents and others in the

community designed to help people retain their housing by addressing individual challenges, e.g., financial matters, mental health, hoarding, and alcohol or drug addictions

• Offer Wellness Programs at each of BHA’s three high-rises for seniors and adults with disabilities,

including on-site health care coordination, information, referrals, and limited home-care services (financially supported by Medicare for the SASH program)

• Operate an Offender Re-Entry Housing Program, funded by the State of Vermont Department
• f Corrections, which assists offenders returning to the community find and maintain

transitional and permanent supportive housing

Str trategic ic Prio iorities – Retentio ion Services

BHA is recognized as a leader in providing eviction-avoidance retention services to our community

• BHA’s Retention Team works with vulnerable families and individuals who are at the highest risk of

becoming or returning to homelessness, to enable them to stay in their homes

• Retention specialists assess individual challenges, develop plans for addressing these issues, and

then work directly with these households to preserve their housing whenever possible

• The team also coordinates services and skilled care with other community service providers, as

needed and when appropriate

• Funded in part by grants from the State of Vermont, UVM Medical Center, and leading housing/

shelter providers allows BHA retention services to be offered more widely in our community Through these and other efforts, BHA found permanent housing for more than 100 formerly homeless or incarcerated households & prevented homelessness for more than 70 other households this past year.

Supporting Community’s Focus on Retention

The Coordinated Entry System of Identifying, Assessing, and Prioritizing Services and Housing for Chittenden County’s Most Vulnerable Will Inform BHA Housing Policies and Procedures

• The new Coordinated Entry System will:
• Produce a real-time, “By Name List” that provides accurate homelessness data for our

community, including identifying all individuals known to be currently homeless or at risk of being homeless

• Enable our community to collectively prioritize and utilize our limited resources optimally

as we work to secure permanent housing for the most vulnerable people on that list

• The CoC is hosting an upcoming Action Lab, facilitated by housing experts, which will develop

best practices we can use in creating, maintaining, and using this By Name List, as the means by which we will make homelessness rare and brief in our community

• BHA is updating its rental subsidy and leasing processes, as appropriate, to

incorporate Coordinated Entry referrals of individuals and households determined to be our community’s most vulnerable

CoC’s Coordin inated Entry try System

Vermont Hub-and-Spoke Model of Care for Opioid Use Disorders: An Evaluation

Richard A. Rawson, Ph.D. Research Professor Vermont Center on Behavior and Health Department of Psychiatry University of Vermont Burlington, Vermont 05401

Acknowledgement

• This work was funded through the Centers for Disease Control

and Prevention’s Preventive Health and Health Services Block Grant (NB01OT009090-01) and the Substance Abuse and Mental Health Services Administration’s Substance Abuse Prevention and Treatment Block Grant (TI010055-17).

The Vermont Hub and Spoke System

• Vermont has been significantly impacted by the opioid epidemic. In

response, Vermont developed a statewide system to expand medication-assisted treatment (MAT) with methadone and

• buprenorphine. MAT has strong empirical support as the most

effective form of treatment for opioid use disorders. (OUDs; U.S. Department of Health and Human Services, Office of the Surgeon General, 2016).

• Vermont’s innovative treatment system is the Care Alliance for

Opioid Addiction, also known as the “hub-and-spoke” system (Brooklyn and Sigmon, 2017; Simpatico, 2015).

The Vermont Hub and Spoke System

• Vermont’s opioid treatment service system is organized by

geographic regions—Northwest, Northeast, Central, Southeast, and Southwest.

• Each region has a “hub,” which is a licensed specialty
• utpatient treatment program (OTP) with the authority to

dispense buprenorphine and methadone to treat individuals with OUDs.

• “Spokes” are medical (and mental health) practices that

provide office-based opioid treatment (OBOT) with buprenorphine (and to a lesser degree, naltrexone).

The Vermont Hub and Spoke System

• Hubs have an extensive staff of addiction-trained MDs,

nurses, and counselors who provide intensive specialty care addiction treatment.

• Spokes are primary care settings that are staffed by at least
• ne buprenorphine-prescribing physician who is supported by

a “MAT team” consisting of a registered nurse (RN) and a master’s-level licensed counselor.

• Patients transfer between hubs and spokes when appropriate

The H&S Evaluation: Objectives

• Primary objective:
• To gain preliminary information (quantitative and qualitative) on the

impact of participation in the Vermont H & S system and to assess the usefulness of these services to opioid users.

• Secondary objectives:
• To determine when and why individuals with opioid use disorders in

Vermont (1) avoid treatment or (2) discontinue treatment prior to completion or discharge.

• To determine from the perspective of the individuals in treatment the

most helpful and positive aspects, as well as the least helpful and most challenging aspects, of treatment.

• To understand family members/significant others’ perspectives on the

strengths and weaknesses of treatment.

• To collect data/information on the extent to which the H & S system is

providing adequate access to opioid care throughout the state of Vermont.

The H&S Evaluation: Quantitative Component

In-Treatment Group

• Quantitative data on drug use and functioning were collected

from 80 individuals receiving treatment in the H & S system.

• Patients were self-selected and from all regions in the state.
• Participants had to have been receiving continuous treatment

for at least 6 months at the time of the interview.

• The groups were stratified to include 40 patients on methadone

in the hubs and 40 on buprenorphine in spokes.

• Each group was 50% male and 50% female and 18 years old or
• lder.

The H&S Evaluation: Quantitative Component

Out-of-Treatment Comparison Group

• A comparison group of 20 individuals currently not in

treatment.

• 10 received treatment for OUDs in the past, but not

in the past 12 months

• 10 never had never been in treatment for OUDs

The H&S Evaluation: Data Collection Time Points

• Evaluation time points- self-reported opioid and other drug use and

functioning is collected regarding to two points in time – In-treatment group:

• 90 days before the date of admission to treatment (T1)

(retrospective recall)

• 90 days before the in-person interview (T2)

– Out-of-treatment group

• 90 days before the date 12 months before the interview (T1)

(retrospective recall)

• 90 days before the date of interview (T2)
• T1 - T2 interval In-treatment group: Mean duration: 30 months
• T1 - T2 interval Out-of-treatment group: Duration: 12 months

The H&S Evaluation: Assessment Domains

• Drug and alcohol use
• Opioid use
• Injection use
• Education/employment
• Criminal justice involvement
• Family and relationship functioning
• Health and healthcare utilization
• Multiple areas of mental health functioning
• Opioid overdose
• Satisfaction with life areas
• In addition, patients were asked about stigma and their views of the

treatment received and its overall effectiveness.

The H&S Evaluation: Qualitative Evaluation

Qualitative data provides the “voice” of participants in and

• ut of treatment and of family members/significant others of

those in treatment. Three types of qualitative information were collected:

– Open-ended questions at the end of the quantitative interview; – In-depth qualitative interviews with 24 individuals in H & S treatment (equally distributed by gender and H & S service locations) on perception of care and the factors that facilitated

• r obstructed care; and

– Interviews with 12 family members/significant others to determine how participation in treatment is viewed by family members and significant others of patients in treatment.

Hub and Spoke Evaluation Project Results

The H&S Evaluation: Participant Characteristics

• Mean age at time of interview: 37 years old
• Marital status: Single-47%; Divorced-21%;

Married/living together-32%

• Education: 12.5 years
• Currently employed: full time-22%; part time-20%
• Currently in school: 8%
• On parole or probation: 27%

The H&S Evaluation: Participants’ Trajectory of Substance Use

Vermont Department of Health

The H&S Evaluation: Out-of-treatment Participants

• Out-of-treatment participants showed no

statistically significant change between T1 and T2 in any measure of functioning, including drug use, over a 12-month period.

The H&S Evaluation: Change in Opioid Use

10 20 30 40 50 60 70 80 90 Any Opioid Use Prescription Opioids without a Doctor's Prescription Illicit Opioids Opioid Treatment Medication, without Prescription Opioid Injection

Number of Days of Use

Opioid use of in-treatment participants

90 days before treatment 90 days before interview

Self-Reported Changes in Opioid Use: T1 to T2

Measure In Treatment Out of Treatment

Change in Ave Days Used Percent Using at T2 Change in Ave Days Used Percent Using at T2

Days of Opioid Use

• 96%

15% +12% 100% Days of Opioid Injection

• 92%

11%

• 1%

85%

Vermont Department of Health

Designates statistically significant change

Opioid use decreased substantially for people in both hubs and spokes. Those not in treatment continued to use at high levels.

The H&S Evaluation: Non-opioid Use

10 20 30 40 50 60 70 80 90

Number of Daysof Use

Non-opioid drug use for in-treatment participants

90 days before treatment 90 days before the interview

The H&S Evaluation: Self-Reported Changes in Non-opioid Use: T1 to T2

Measure In Treatment (n=80) Out of Treatment (n=20)

Change in Ave Days Used Percent Using at T2 Change in Ave Days Used Percent Using at T2

Days of Tobacco Use

• 12%

77% 0% 95% Days of Alcohol Use

• 66%

34%

• 3%

65% Days of Cannabis Use

• 9%

47% +7% 75% Days of Hallucinogen Use

• 100%

1%

• 82%

10% Days of Cocaine Use

• 72%

27%

• 24%

45% Days of Sedative/Tranquilizer Use

• 83%

12% +1% 50% Days of Amphetamine Use

• 85%

4%

• 41%

32%

Vermont Department of Health

Designates statistically significant change

Other substance use, except cannabis, decreased significantly for those in hubs and spokes

The H&S Evaluation: Medical Utilization and Overdose

1 2 3 4 ER Visits (# of times) Overnight Hospital Stay (# of times) Outpatient or Doctor Visits (# of times)

# of times

Medical utilization

90 days before treatment 90 days before interview

25% 0%

0% 5% 10% 15% 20% 25% 30% 90 Days Before Treatment 90 Days Before Interview

% overdose in the past 90 days

Overdose history

The H&S Evaluation: Criminal Justice Measures

0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Stopped or Arrested by Police Incarcerated

Number of Days

Criminal justice involvement

90 days before treatment 90 days before interview 5 10 15 20 25 30 35 90 Days Before Treatment 90 Days Before Interview

Number of Days

Days of Illegal Activities

The H&S Evaluation: Self-Reported Changes in Functioning: T1 to T2

Measure In Treatment Group (n=80) Number of ED Visits

• 89%

OD in the previous 90 days No ODs T2 Days of school or training +257% Days of work +8% Number of police stops or arrests

• 90%

Days of illegal activity

• 90%

Vermont Department of Health

Designates statistically significant change

There were significant decreases in the number of ED visits, arrests, and days of illegal activity. No study participants overdosed in the 90 days prior to the interview. Days of school or training increased but there was not a significant change in days of work.

The out of treatment group is excluded because there were no significant changes

The H&S Evaluation: Family Conflict and Mood States

10 20 30 40 50 60 70 80 Serious Family Conflict Felt Depressed Felt Anxious Felt angry or irritable

Number of Days

Conflict and Mood among In-Treatment Participants

90 days before treatment 90 days before interview

The H&S Evaluation: Self-Reported Changes in Functioning: T1 to T2

Measure In Treatment Group (n=80) Days of serious family conflict

• 70%

Days feeling depressed

• 54%

Days feeling anxious

• 36%

Days feeling irritable/anxious

• 58%

Vermont Department of Health

Designates statistically significant change The out of treatment group is excluded because there were no significant changes

Treatment participants felt better and had less conflict within their relationships

The H&S Evaluation: Satisfaction with Life

1 2 3 4 5 6 7 8 9 10 Drug Use Satisfaction School or Work Situation Medical Situation Family or Social Relationships Legal Situation Emotional or Mental Health

Satisfaction Scores, Range 0-10

Satisfaction scores of in-treatment participants

90 days before treatment 90 days before interview

The H&S Evaluation: Self-Reported Changes in Life Satisfaction: T1 to T2

Measure In Treatment Group (n=80) Out of Treatment Group (n=20) Drug use situation score +459%

• 6%

School/work situation score +30%

• 33%

Medical situation score +95%

• 3%

Family/social relationships score +93% +10% Legal situation score +67% +16% Emotional or mental health +73% +18%

Vermont Department of Health

Designates statistically significant change

The in-treatment group consistently reported improvements in satisfaction with their lives at the time of the interviews. The out of treatment group showed little change.

The H&S Evaluation: Treatment Effectiveness Scores

0% 20% 40% 60% 80% 100% Substance Use Health Personal Responsibilities Community Membership Percentage Who Scored Above 8 Improvement Domains

Treatment effectiveness assessment scores of hub vs. spoke participants

Hub Spoke

The H&S Evaluation: Methodological Limitations

• Sample sizes are under-powered
• Participants self selected
• All data is self-report
• This was not a controlled research trial and the out
• f treatment group are not a true control group
• Sample results should be used in combination of
• ther studies and data

Vermont Department of Health

The H&S Evaluation: Conclusions

The H&S Evaluation: Conclusions

Participation in MAT was associated with:

– a very large reduction in opioid use – a substantial reduction in other drug/alcohol use, except cannabis. – a substantial reduction in drug injection – a large reduction in ED visits and overdoses. – a slight increase in education/training activities, but not in days of employment. – a 90% reduction in both days of illegal activity and contacts with police. – a substantial decrease in family conflict and improvement in measures of mood.

The H&S Evaluation: Conclusions

• Participants treated in the hubs with methadone and those treated

in the spokes with buprenorphine showed similar and positive responses to MAT in virtually all measurement domains.

• Participants in both settings viewed MAT positively and as very

helpful to them.

• Spoke patients view their relationship with their MD as very

valuable.

• Spoke patients rated their care as helping them to a greater degree

in three of the four assessed domains.

• Family members/significant others (FM/SOs) were uniformly

grateful and appreciative of the availability of treatment.

• FM/SOs expressed interest in being involved in the treatment but

felt that such involvement was actively discouraged. They also identified other service deficiencies

The H&S Evaluations: Closing Thoughts

• The Vermont Hub-and-Spoke System of Care for Opioid Use

Disorders is an innovative and constructive public health response to the opioid epidemic of the 21st century in the United States.

• The H & S system has markedly expanded access to MAT and

improved participants’ lives.

• The services provided within this model have saved many

lives and have allowed many Vermonters to discontinue

• pioid use and improve their lives.

Thank you rrawson@uvm.edu

Safe Response Team (SRT)

Description of Pilot: The Opioid Policy Manager, Police Dept and Fire/EMS will go out to identified persons (IP) who have experienced a overdose. The response time of this team going out will be no more than 60 hours of the event with the preferred response time being 24 hours after the event. The purpose is to ensure that individuals are aware of the resources if treatment and or other supportive services are requested. When responding the response team will do the following: *Ensure that the IP is medically stable *Ensure that the IP is aware of the Opioid Policy Managers role and how it can support them if they are questioning and/or looking into treatment *Provide information in regards to available treatment/medical services The information shared with the IP will be: Resource card Opioid Policy Managers Business card Narcan on request

Jolinda LaClair, Director of Drug Prevention Policy jolinda.laclair@vermont.gov

INITIAL REPORT OF RECOMMENDED STRATEGIES: AN OVERVIEW

January 2018

45

Negative effect/all demographics/all communities Vermont’s opioid crisis results in increased drug and human trafficking, mortality, and costs to Vermont’s resources and quality of life To lead and strengthen Vermont’s response to the opioid crisis by ensuring full interagency and intra-agency coordination between state and local governments in the areas of prevention, treatment, recovery and law enforcement activities.

46

Opioid Coordination Council Executive Order No. 02-17; 09-17 OCC’s Mission

47

OCC Mandate:

1.Identify best practices for communities to assist them in: 1) reducing the demand for opioids through prevention and education; 2) providing treatment and recovery services; and 3) reducing the supply of illegal opioids a.Develop and adopt data driven performance measures and

• utcomes

a.Review existing laws, regulations, policies, and programs and propose changes to eliminate redundancy and break down barriers a.Propose legislation to strengthen a Statewide approach to fight opioid addiction and abuse and facilitate adaptation to the changing nature and multiple facets of the opioid crisis a.Consult and coordinate with federal agencies and officials as well as those in surrounding states

Governor Scott’s Top 3 Priorities

• 1. Grow the Economy
• 2. Make Vermont More Affordable for

Families and Businesses

• 3. Protect the Vulnerable

Alignment: Vermont’s Challenges: 6-3-1

“6”: Six fewer Vermonters in the workforce every day. “3”: Three fewer children every day in the public school system. “1”: One baby born every day to a mother with addiction.

48

The Council challenges itself, and the departments, agencies and communities

• f Vermont:

The # of people with substance use disorders (SUDs) The# of opioid overdose deaths The# of babies born into addiction The# of children in state custody as a result of SUDs The# of opioid prescriptions written each year The# of youth using illegal substances The supply of illicit drugs in Vermont Prevent, reduce, eliminate opioid related crime The risk of relapse in recovery

49 . . . To REDUCE: . . . and to INCREASE:

The# of people in treatment

The# of people in recovery who have housing, jobs, social supports

Vermont communities will be strong, safe, and resilient

Goals

The Four Drivers for Systemic Improvement

 Prevention: Reducing demand. Community engagement. Addressing the social factors that lead to addiction and its

• consequences. Includes intervention and harm reduction.

 Treatment: Moving people toward seeking intervention and

• recovery. Timely, affordable and effective delivery of

services.  Recovery: Sustained, wraparound lifestyle supports that make long-term recovery possible.  Enforcement: Reducing supply. Public safety, policing, courts, prosecution practices, corrections. Includes and supports harm reduction.

50

Pathways to Effective Change

Policy: Review of state laws, legislation, policies for gaps and redundancies, and recommend improvements. Programs: Recommend strategies to replicate successes and best practices, addressing gaps and needs. Infrastructure: How can improvements in the relationships between programs, departments and agencies result in efficiencies and improved

• utcomes?

Investment: Leverage available and new funds for greatest impact.

51

52

Recommende d Strategies: Overarching/ Systemic

Develop a statewide comprehensive Continuum of Care for pregnant mothers and their children Grow and support Vermont’s workforce: Vermonters in recovery; the SUD workforce Improve data interoperability

53

Recommended Strategies: Prevention Includes:

Prevention: strengthening children, adults, families and communities with education and outreach. Education: providing curricula and programming that touches all students. Intervention: maximizing opportunities to move people away from risk and toward services. Harm reduction: helping to manage negative impacts.

54

Recommended Strategies: Prevention & Education

Implement Statewide Comprehensive School-Based Prevention Expand Health Care Education, Monitoring and Screening for Providers and Patients Build Community-Based Prevention Create a Comprehensive Drug Prevention Messaging Campaign

55

Recommended Prevention Strategies: Intervention & Harm Reduction

Intervention: Expand Syringe Exchange Availability Intervention: Supply Naloxone and Provide Training Harm Reduction: Expand Drug Disposal Options Harm Reduction: Improve Sharps Collection and Disposal

56

Ensuring timely, affordable and effective treatment is available to all in need.

Recommended Strategies: Treatment

57

Recommended Strategies: Treatment

Support, Evaluate and Improve Vermont’s Hub and Spoke System Expand Medication-Assisted Treatment in Correctional Facilities Maximize Non-Pharmacological Approaches Explore Expanded Access to Treatment Dockets Expand Medicare and Medicaid Coverage

58

Helping Vermonters sustain recovery from addiction through support systems, with emphasis on employment, housing, social supports, and engagement.

Recommended Strategies: Recovery

59

Strengthen Vermont’s Recovery Centers, and Recovery Coaching Expand Recovery Housing Expand Employment In Recovery

Recommended Strategies: Recovery

60

Reducing the supply of illicit opioids and supporting alternatives to incarceration where possible. Law enforcement spans public safety, policing, the courts, prosecution practices, and corrections.

Recommended Strategies: Law Enforcement

61

Pursue Roadside Drugged Driving Testing Increase Drug Trafficking Investigations Provide Drug Recognition Training

Recommended Strategies: Law Enforcement

62 “Not every story has a happy ending, ... but the discoveries of science, the teachings of the heart, and the revelations of the soul all assure us that no human being is ever beyond

• redemption. The possibility of renewal exists so

long as life exists. How to support that possibility in others and in ourselves is the ultimate question.” ― Gabor Maté, In the Realm of Hungry Ghosts: Close Encounters with Addiction *

*In the Realm of Hungry Ghosts: Close Encounters with Addiction. Gabor Mate. North Atlantic Books, P.O. Box 12327, Berkeley, CA, 2010. p.

3.

Next Steps: 2018 Strategy Development into Action

• Deeper assessment of

best practices and needs, especially in priority strategies

• Working groups and

action steps

63

64

Discussion

65 Opioid Coordination Council 280 State Drive, Building E Waterbury, VT 05671 802-241-0572 http://www.healthvermont.gov/opioid-coordination-council

2 4 6 8 10 12 14 16 2.16 - 3.08 3.22 - 4.04 4.18 - 5.02 5.16 - 5.30 6.13-7.04 7.18-8.01 8.15 - 9.05 9.19 - 10.03 10.17 - 10.31 11.14 - 12.05 January

Opioid-Related Overdose Calls Responded to by BPD, CPD, SBPD, MPD, EPD & WPD per SubStat Period

Overdose Incidents

7

Non-Fatal Opioid-Related Overdose Incidents Among SubStat Partners Since Dec. 21st

1

Fatal Opioid-Related Overdose Incidents Among SubStat Partners Since December 21st

10 20 30 40 50 60 70 80 50 100 150 200 250 300 350

# Prescriptions > 50 pills Providers

Opioid Prescriptions > 50 pills per provider as reported by quarter

Providers who prescribed 0 or 1 prescription 7/17-9/17 were removed

10/15-12/15 10/16-12/16 01/17-03/17 4/17-6/17 7/17-9/17 10/17-12/17

Approach to Toxicology of Deceased in Other States

**All Medical Examiners have full discretion of when to conduct a toxicology screen**

New Hampshire - Dr. Jennie Duval. All individuals get a tox screen per the ME. If deemed elderly and noticeable physical injury a tox screen potentially would not occur. Boston - Dr. Mindy Hull. Similar to New Hampshire per discretion of the ME. New Jersey - Dr. Andrew Falzon. Similar to New Hampshire. Similar discretion NYC - Barbara Sampson, Head of Toxicology. All decedents receive a toxicology per discretion of the ME. Kentucky - All receive toxicology screen. Vermont - Conducts full autopsies of each and every decedent. “Compared to other states we do a very thorough job. Our numbers are completely accurate and exact the actual cause of death.” Dr. Elizabeth Bundock, Deputy Chief Medical Examiner

Kentucky Toxicology

In Kentucky, if a person dies under this very wide range of circumstances (http://www.lrc.ky.gov/statutes/statute.aspx?id=24280) Then the coroner must, as a matter of law, always do a toxicology (http://www.lrc.ky.gov/Statutes/statute.aspx?id=43997)

This is because: “In 2012, Kentucky tried to standardize part of the process for recording which drugs were involved in a death by requiring coroners to seek a post-mortem toxicology screening for every death [requiring a post-mortem- read the law, the blog made a mistake in its original]. The screening tests all overdose cases on the same standard panel of drugs, including several prescription opiates, heroin and

• fentanyl. The state’s chief medical examiner

reads through every toxicology report submitted, and that information feeds into the KIPRC database.”

https://fivethirtyeight.com/features/there-is-more-than-one-opioid-crisis/