HomeMy WebLinkAbout10-03-2016 CITY COUNCIL MEETING AGENDACity Council Meeting
October 3, 2016 - 6:00 PM
Auburn Community and Events Center
910 9th Street SE
AGENDA
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I. CALL TO ORDER
A. Pledge of Allegiance
B. Roll Call
II. ANNOUNCEMENTS, PROCLAMATIONS, AND PRESENTATIONS
III. APPOINTMENTS
A. White River Valley Museum Board Appointments
City Council to confrim the following two appointments to the White River Valley
Museum Board for terms to expire on December 18, 2018:
• James Bothell
• Gordy Nishimoto
IV. AGENDA MODIFICATIONS
V. CITIZEN INPUT, PUBLIC HEARINGS & CORRESPONDENCE
A. Public Hearings
No public hearing is scheduled for this evening.
B. Audience Participation
This is the place on the agenda where the public is invited to speak to the City
Council on any issue. Those wishing to speak are reminded to sign in on the
form provided.
C. Correspondence
There is no correspondence for Council review.
VI. COUNCIL AD HOC COMMITTEE REPORTS
Council Ad Hoc Committee Chairs may report on the status of their ad hoc
Council Committees' progress on assigned tasks and may give their
recommendation to the City Council, if any.
VII. CONSENT AGENDA
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All matters listed on the Consent Agenda are considered by the City Council to be
routine and will be enacted by one motion in the form listed.
A. Minutes of the November 23, 2015 Council Study Session*
B. Minutes of the September 19, 2016 Regular City Council Meeting*
C. Claims Vouchers (Coleman)
Claim voucher numbers 440718 through 440914, dated October 3rd, 2016 in the
amount of $1,665,443.18 and three wire transfers in the amount of $197,042.50.
D. Payroll Vouchers (Coleman)
Payroll check numbers 536730 through 536773 in the amount of $699,694.51,
electronic deposit transmissions in the amount of $1,431,088.30 for a grand total
of $2,130,782.81 for the period covering September 15, 2016 to September 28,
2016.
E. Public Works Project No. CP1202* (Snyder)
Approve Final Pay Estimate No. 10 to Contract No. 15-01 in the amount of
$129,991.37 and accept construction of Project No. CP1202, Auburn Way South
Flooding Improvements Phase 2
F. Public Works Project No. CP1605* (Snyder)
Approve Final Pay Estimate No. 2 to Contract No. 16-16 in the amount of
$85,607.49 and accept construction of Project No. CP1605, Herr Properties
Demolition.
(RECOMMENDED ACTION: City Council approve the Consent Agenda.)
VIII. UNFINISHED BUSINESS
IX. NEW BUSINESS
X. DISCUSSION ITEMS
A. Joint Council and Junior City Council Meeting*
1. Homelessness (Hinman)
2. Parking (Snyder)
3. Distracted Driving (Lee)
4. Internet Availability (Haugan)
5. Heroin and Prescription Opiate Abuse (Stocker)
XI. MAYOR AND COUNCILMEMBER REPORTS
At this time the Mayor and City Council may report on their significant City-related
activities since the last regular Council meeting.
A. From the Council
B. From the Mayor
XII. ADJOURNMENT
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Agendas and minutes are available to the public at the City Clerk's Office, on the City
website (http://www.auburnwa.gov), and via e-mail. Complete agenda packets are
available for review at the City Clerk's Office.
*Denotes attachments included in the agenda packet.
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AGENDA BILL APPROVAL FORM
Agenda Subject:
Minutes of the November 23, 2015 Council Study Session
Date:
September 28, 2016
Department:
Administration
Attachments:
11-23-2015 Study Session Minutes
Budget Impact:
$0
Administrative Recommendation:
Background Summary:
Reviewed by Council Committees:
Councilmember: Staff:
Meeting Date:October 3, 2016 Item Number:CA.A
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City Council Study Session
November 23, 2015 - 4:30 PM
Auburn City Hall
MINUTES
I. CALL TO ORDER
A. Roll Call
City Councilmembers present: Deputy Mayor Holman, Rich Wagner, Bill
Peloza, Largo Wales, Wayne Osborne, Claude DaCorsi and Yolanda Trout.
City officials and staff members present included: Mayor Nancy Backus,
Human Resources and Risk Manager Rob Roscoe, Chief of Police Bob Lee,
Assistant Director of Community Development Services Jeff Tate, Parks, Arts
and Recreation Director Daryl Faber, City Attorney Daniel B. Heid, Director of
Administration Dana Hinman, Community Development and Public Works
Director Kevin Snyder, Assistant Director of Engineering Services/City
Engineer Ingrid Gaub, Parks Planning and Development Manager Jamie
Kelly, Economic Development Manager Doug Lein, Finance Director Shelley
Coleman, Innovation and Technology Director Paul Haugan, and Deputy City
Clerk Shawn Campbell.
II. AGENDA ITEMS FOR COUNCIL DISCUSSION
A. Presentation of Comprehensive Plan Elements (20 Minute Presentation/45
Minute Q&A) (Snyder)
Staff to introduce the Draft Comprehensive Plan Elements for Capital
Facilities; Parks and Recreation; Economic Development; and Private
Utilities
Assistant Director Tate explained this is the last presentation in a series of
three informational meetings for the Comprehensive Plan Elements. He
reviewed the schedule for approval of the Comprehensive Plan. The City has
received comments through various formats, including letters, web page
comments, feedback from a public hearing and Council meetings, all
comments made through December 1, 2015 will be included in the
Council packet for Council's review. Comments made after that will be
provided at the December 8, 2015 Council meeting.
Assistant Director Tate explained the department has engaged in
extensive outreach and provided opportunities for community feedback
including a presentation to various community groups, Citywide emails and
mailings, social media and comments from surrounding jurisdictions and
entities.
Assistant Director Tate stated staff has updated the Capital Facilities
Element of the plan to include values that align with the plan, general policy
statements with reference to various functional aspects of the plan, functional
plans that contain the details for the water, sewer, storm, parks, and school
districts. He stated the notable modifications to the Capital Facilities Element
are an emphasis on sustainability and energy efficiency, updates on data and Page 1 of 4
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system descriptions and acknowledging prior annexation activity.
Assistant Director Tate stated staff have updated the Private Utilites Element
of the plan to include values that align with the plan and the notable
modifications include relevant policies and updates on data and system
descriptions.
Assistant Director Tate said the Economic Development Element portion of
the plan has been updated to include values that align with the plan. The
notable modifications for the Economic Development Element include
updates on the data and removal of stale language that pertains to the
potential adoption of the streamlined sales tax.
Parks Planning and Development Manager Kelly stated the Parks and
Recreation Element has been updated to include values that align with the
plan and general policy statements. The notable modifications of the Parks
and Recreations Element include emphasis on sustainability and energy
efficiency and policy that enable Parks Impact Fees.
Councilmember Wagner asked if the Muckleshoot Indian Tribe had provided
input on these elements of the Comprehensive Plan. Assistant Director Tate
stated all elements have been provided to the Tribe, as of yet the Tribe has
not commented. Council encouraged staff to continue to reach out to the
Tribe.
B. Transportation Impact Fee Update (15 Minute Presentation/15 Minute Q&A)
(Snyder)
Transportation Manager Para and Traffic Engineer Webb presented the
Transportation Impact Fee update to Council. Traffic Engineer Webb
stated the impact fees are assessed to fund improvements to the street
systems that are impacted by development. The total cost of the
improvments change year to year, part of updating the plan is to update the
costs of each project.
The current fee is just over $2,900 per trip, staff is proposing and increase of
$756 per trip hour, for a total of $3,862. The broad increase would be applied
to all areas except in the downtown urban center and Lakeland Hills
which has its own rate schedule that was developed in 1998.
Councilmember Osborne suggested the City find a stable number with a
small increase each year.
Councilmember Peloza asked how the City models the downtown rates.
Traffic Engineer Webb stated the City uses models that are a national
standard.
Councilmember Peloza asked if a developer can appeal the
fee. Transportation Manager Para stated the code does have a provision for
a developer to appeal the fee if the developer feels their property does not fit
any of the designations provided. The Developer must conduct their own
study and submit that to the City for consideration.
Traffic Engineer Webb stated the department has worked with Economic
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change. Staff discussed the manufacturing uses would be impacted by this
fee and looked at what kind of adjustments could be made. Staff is
proposing a 40% reduction in manufacturing and a 40% increase for
warehouse uses.
C. Right-of-Way Vacation No. V2-15 (10 Minute Presentation/5 Minute Q&A)
(Snyder)
Assistant Director Gaub and Engineering Aide Price presented the Right-of-
Way Vacation V2-15. The City no longer has a need for the right-of-way.
Assistant Director Gaub stated the City is recommending the road be
vacated with full cost of the appraised value to be paid by the developer.
Councilmember Wales asked if the properties that are souranding
the proposed vacation would need the road for future use. Assistant Director
Gaub explained the proposed vacation area is above a steep hillside,
and she does not envision the City building a road in the area.
Councilmember Wagner asked for clarification on ensuring the Puget Sound
Energy's easement is maintained if the City vacates the right-of-way.
Engineering Aide Price stated the developer has worked with Puget Sound
Energy to ensure the easement remains in place.
D. Amendment to Franchise Agreement No. 13-37 (10 Minute Presentation/5
Minute Q&A) (Snyder)
Assistant Director Gaub and Engineering Aide Price presented the
amendment to the T-Mobile franchise agreement 13-37.
Assistant Director Gaub stated the amendment is to replace a power pole
with a new taller pole. The new pole is proposed to
have communication equipment on top.
Engineering Aide Price stated the pole is in a new location in the City right-of-
way and a residential area. The City will provide a radius mailing to inform
the area residents of the proposed change.
Councilmember Wales asked who pays for the mailings. Assistant Director
Gaub stated the applicant pays an application fee and the City pays for the
mailings out of those funds.
Deputy Mayor Holman stated T-Mobile already has an existing pole. They
are proposing a new taller pole in a new location.
III. OTHER DISCUSSION ITEMS
There was no other discussion.
IV. EXECUTIVE SESSION
For clarification of these minutes, the closed session was held immediately
following the presentation of Comprehensive Plan Elements.
At 5:43 p.m. Deputy Mayor Holman recessed the meeting to a closed session
for approximately 15 minutes in order to discuss collective bargaining agreements
pursuant to RCW 42.30.140(4)(a). City Attorney Heid and Human Resources and
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Risk Management Director Roscoe attended the closed session.
Mayor Backus reconvened the meeting at 6:00 p.m.
V. ADJOURNMENT
There being no further business before the Council, the meeting adjourned at 6:45
p.m.
APPROVED this ____ day of ________________, 2016.
___________________________________ ______________________________
NANCY BACKUS, MAYOR Shawn Campbell, Deputy City Clerk
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AGENDA BILL APPROVAL FORM
Agenda Subject:
Minutes of the September 19, 2016 Regular City Council
Meeting
Date:
September 26, 2016
Department:
Finance
Attachments:
9-19-2016 Minutes
Budget Impact:
$0
Administrative Recommendation:
Background Summary:
Reviewed by Council Committees:
Councilmember: Staff:
Meeting Date:October 3, 2016 Item Number:CA.B
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City Council Meeting
September 19, 2016 - 7:00 PM
Auburn Activities and Events Center
MINUTES
I. CALL TO ORDER
A. Pledge of Allegiance
Mayor Nancy Backus called the meeting to order at 7:00 p.m. in the Auburn
Community and Events Center located at 910 9th Street SE in Auburn.
Mayor Backus led those in attendance in the Pledge of Allegiance.
B. Roll Call
City Councilmembers present: Deputy Mayor Wales, Bob Baggett, Claude
DaCorsi, John Holman, Bill Peloza, Yolanda Trout-Manuel and Rich
Wagner.
Department directors and staff members present included: City Attorney
Dan Heid, Assistant City Attorney Jessica Leiser, Police Chief Bob Lee,
Police Commander Mike Hirman, Sergeant James Hopper, Sergeant Jon
Thorton, Community Development and Public Works Director Kevin
Snyder, Parks, Arts and Recreation Director Daryl Faber, Assistant Finance
Director Kevin Fuhrer, Assistant Director of Engineering Services/City
Engineer Ingrid Gaub, Innovation and Technology Director Paul Haugan,
and Deputy City Clerk Shawn Campbell.
II. ANNOUNCEMENTS, PROCLAMATIONS, AND PRESENTATIONS
Mayor Backus proclaimed September 2016 as Latino Voter Registration Month.
III. APPOINTMENTS
There was no appointment for Council consideration.
IV. AGENDA MODIFICATIONS
An updated version of Ordinance No. 6618 was provided to Council prior to the
meeting and a proclamation for Latino Voters Registration month was added to
the agenda.
V. CITIZEN INPUT, PUBLIC HEARINGS & CORRESPONDENCE
A. Public Hearings
There was no public hearing scheduled for this meeting.
B. Audience Participation
This is the place on the agenda where the public is invited to speak to the
City Council on any issue. Those wishing to speak are reminded to sign in
on the form provided.
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Michael Transue, 5420 N. Calumet Ave, Ruston WA
Mr. Transue represents First Cash and Cash America pawnbrokers.
He shared concerns regarding Ordinance No. 6618 for pawnbrokers. He
asked for Council to delay the vote on the Ordinance.
Kevin Opdahl, 20 Auburn Way South, Auburn
Mr. Opdahl stated he is the president of Washington Pawnbrokers
Association and owner of Cascade Loan and Sporting Goods. He stated his
business has issues with using the Leads Online system. He shared his
concerns about Ordinance No. 6618 being equally enforced.
C. Correspondence
There was no correspondence for Council review.
VI. COUNCIL AD HOC COMMITTEE REPORTS
Council Ad Hoc Committee Chairs may report on the status of their ad hoc
Council Committees' progress on assigned tasks and may give their
recommendations to the City Council, if any.
Councilmember Baggett reported on behalf of the Finance ad hoc committee
that reviews claims and payroll vouchers. Councilmember Baggett reported he
and Councilmember Wagner reviewed the claims and payroll vouchers as
presented and described on this evening's agenda and recommend their
approval by Council.
VII. CONSENT AGENDA
All matters listed on the Consent Agenda are considered by the City Council to
be routine and will be enacted by one motion in the form listed.
A. Minutes of the October 26, 2015 City Council Study Session
B. Minutes of the August 29, 2016 Special City Council Meeting
C. Minutes of the September 6, 2016 City Council Meeting
D. Claims Vouchers (Coleman)
Claim voucher numbers 440532 through 440717 in the amount of
$6,335,084.51 and five wire transfers in the amount of $728,203.36 and
dated September 19th, 2016.
E. Payroll Vouchers (Coleman)
Payroll check numbers 536696 through 536729 in the amount of
$593,376.06, electronic deposit transmissions in the amount of
$1,519,022.45 for a grand total of $2,112,398.51 for the period covering
September 1, 2016 to September 14, 2016.
F. Call for Public Hearing on Preliminary 2017-2018 Biennial Budget
(Coleman)
City Council to call for a public hearing to be held October 17, 2016 to
receive public comments and suggestions with regard to development of the
preliminary 2017-2018 Biennial Budget, including revenue estimates and
possible increases in property taxes.
G. Public Works Project No. CP0915 (Snyder)
City Council to approve Final Pay Estimate No. 15 to Contract No. 14-21 in
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CA.B Page 11 of 162
the amount of $103,621.56 and accept construction of Project No. CP0915,
Well 1 Onsite Improvements
H. Public Works Project No. CP1501 (Snyder)
City Council to award Contract No. 16-09 to Transportation Systems, Inc. on
their low bid of $339,000.00 for Project No. CP1501, Traffic Signal Safety
Improvements
Deputy Mayor Wales moved and Councilmember DaCorsi seconded to
approve the Consent Agenda.
Deputy Mayor Wales stated the Consent Agenda consists of minutes,
claims and payroll vouchers, a call for public hearing and public works
projects.
MOTION CARRIED UNANIMOUSLY. 7-0
VIII. UNFINISHED BUSINESS
There was no unfinished business.
IX. NEW BUSINESS
There was no new business.
X. ORDINANCES
A. Ordinance No. 6618 (Lee)
An Ordinance of the City Council of the City of Auburn, Washington,
amending Section 5.20.210 of the Auburn City Code relating to the
Pawnbroker and Secondhand Dealer business
Deputy Mayor Wales moved and Councilmember Holman seconded to
adopt Ordinance No. 6618.
Deputy Mayor Wales stated she supports the do not buy list.
Councilmember Holman stated he has listened to the business owners and
representatives. He said he wants to work with businesses in the future to
ensure the process works for all involved.
Councilmember Wagner stated he believes the information presented was
very sensible. He would like to start now and have the process brought
back to Council for a future study session.
Councilmember DaCorsi asked for the item to be brought back to a future
study session with additional information on how the process is working. He
believes this ordinance is a starting point. The City and businesses need to
work together to make the process work for everyone involved.
MOTION CARRIED UNANIMOUSLY. 7-0
B. Ordinance No. 6620 (Coleman)
An Ordinance of the City Council of the City of Auburn, Washington,
amending Sections 3.42.010 and 3.42.020 of the Auburn City Code relating
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to the tax levied on the total annual revenues of cable television business
operating within the City
Deputy Mayor Wales moved and Councilmember Trout-Manuel
seconded to adopt Ordinance No. 6620.
Deputy Mayor Wales stated the additional tax percentage will allow the
City to raise the cable tax to be comparable to neighboring communities.
The additional revenue will allow for six (6) additional police officers and all
of the additional technology required to support the additional staff. She
stated it is important to have sustainable funding for the positions.
All Councilmembers noted they had received a phone call from Terry Davis
the Government Relations Manager from Comcast. All Councilmembers
stated there is no conflict of interest regarding the conversation.
Councilmember Wagner stated not all jurisdictions pay a franchise fee in
conjunction with the additional tax. He feels the proposed payment is still
reasonable.
Councilmember Peloza noted the additional revenue to the City will be
approximately $1,000,000.00. The funds will be used for public safety.
Councilmember DaCorsi said the funds will be used to invest in public
safety. If the ordinance is approved the City will be able to bring the police
department staffing back up to the 2008 level.
MOTION CARRIED UNANIMOUSLY. 7-0
XI. MAYOR AND COUNCILMEMBER REPORTS
At this time the Mayor and City Council may report on their significant City-
related activities since the last regular Council meeting.
A. From the Council
Councilmember Baggett reported he attended the Mexican Independence
Day Festival.
Councilmember Trout-Manuel reported she attended the third annual
Mexican Independence Day Festival.
Councilmember Holman reported he attended a community dinner at St
Matthew's Episcopal Church. The dinner was a joint venture between the
church and the Buddhist Temple.
Councilmember Wagner reported he attended the Pierce County Regional
Council meeting. The City of Auburn received a platinum award for the
City's efforts toward wellness from the Pierce County Health Department.
Councilmember Peloza reported he attended the King County Solid Waste
Management meeting.
Councilmember DaCorsi reported he attended a debriefing session for joint
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Council on Homelessness and the State Agency Council on Homelessness.
The discussion was upcoming legislative priorities regarding homelessness
in the region.
B. From the Mayor
Mayor Backus reported she participated in the annual "Beat the Heat" 5
K, the South King County Affordable Housing Forum, the City of Auburn
Senior Center's 15th Birthday, the Association of Washington Cities
Candidates Forum, a Mayor's Forum, the Heroin and Opiate Task Force
report out, the economic development discussion for South King County
and the Les Gove Community Picnic.
XII. ADJOURNMENT
There being no further business to come before the Council, the meeting adjourned
at 7:55 p.m.
APPROVED this 3rd day of October, 2016.
___________________________________ _____________________________
NANCY BACKUS, MAYOR Shawn Campbell, Deputy City Clerk
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AGENDA BILL APPROVAL FORM
Agenda Subject:
Claims Vouchers
Date:
September 26, 2016
Department:
Finance
Attachments:
No Attachments Available
Budget Impact:
$0
Administrative Recommendation:
approve claims vouchers.
Background Summary:
Claim voucher numbers 440718 through 440914, dated October 3rd, 2016 in the
amount of $1,665,443.18 and three wire transfers in the amount of $197,042.50.
Reviewed by Council Committees:
Councilmember: Staff:Coleman
Meeting Date:October 3, 2016 Item Number:CA.C
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AGENDA BILL APPROVAL FORM
Agenda Subject:
Payroll Vouchers
Date:
September 26, 2016
Department:
Administration
Attachments:
No Attachments Available
Budget Impact:
$0
Administrative Recommendation:
approve payroll vouchers
Background Summary:
Payroll check numbers 536730 through 536772 in the amount of $699,694.51,
electronic deposit transmissions in the amount of $1,431,088.30 for a grand total of
$2,130,782.81 for the period covering September 15, 2016 to September 28, 2016.
Reviewed by Council Committees:
Councilmember: Staff:Coleman
Meeting Date:October 3, 2016 Item Number:CA.D
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AGENDA BILL APPROVAL FORM
Agenda Subject:
Public Works Project No. CP1202
Date:
September 26, 2016
Department:
CD & PW
Attachments:
CP1202 Signed Final Pay Estimate
Budget Status Sheet
Vicinity Map
Budget Impact:
$0
Administrative Recommendation:
City Council approve Final Pay Estimate No. 10 to Contract No. 15-01 in the amount
of $129,991.37 and accept construction of Project No. CP1202, Auburn Way South
Flooding Improvements Phase 2.
Background Summary:
The purpose of this project was to relieve stormwater flooding issues on Auburn Way
South near the State Route 18 underpass by diverting stormwater flows from the
flooding area to the existing storm drainage ponds located at 21st Street SE (near D
Street SE) and 17th Street SE (west of A Street SE). Phase 1 of the project was
complete in 2009 and installed a new storm line down 17th Street SE and K Street SE
between Auburn Way South and 18th Street SE which diverted stormwater to the
pond on 21st Street SE. This project (CP1202, Auburn Way South Flooding Phase 2)
constructed a new storm line on 17th Street SE between A Street SE and K Street SE
to divert stormwater to the pond on 17th Street SE. This project also replaced the
deteriorated water main and sewer line on 17th Street SE between A Street SE and K
Street SE and expanded the existing storm pond on 17th Street SE to accommodate
the increase in storm drainage flows.
A project budget contingency of $86,891.00 remains in the 460 (Water) Fund.
A project budget contingency of $12,298.00 remains in the 461 (Sewer) Fund.
A project budget contingency of $20,701.00 remains in the 462 (Storm) Fund.
The final contract amount is within the budget and within the authorized contingency
for the project.
Reviewed by Council Committees:
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Councilmember: Staff:Snyder
Meeting Date:October 3, 2016 Item Number:CA.E
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Project No: CP1202 Project Title:
Project Manager: Seth Wickstrom
Consultant Agreement Amendment
Initiation Date: _8/19/2013___ Permission to Advertise
Advertisement Date: _6/11/15__ Contract Award
Award Date: _7/6/15____ Change Order Approval
Contract Final Acceptance
Funding 2012 2013 2014
2015 2016 Total
460 Fund - Water 9,919 422,098 413,905 845,922
461 Fund - Sewer 154 11,543 281,356 380,000 673,053
462 Fund - 2013 Bond Proceeds 461 81,607 56,544 1,311,535 187,853 1,637,539
462 Fund - Storm 297,147 297,147
001 Fund - Engineering Repairs 19,255 19,255
Total 461 81,761 78,006 2,014,989 1,298,160 3,472,916
Activity 2012 (actual) 2013 (actual) 2014 (actual)
2015 (actual) 2016 Total
Design Engineering - City Costs 461 14,283 26,046 124,063 164,392
Design Engineering - Consultant Costs 67,479 51,960 119,438
Construction Contract Bid 1,737,137 903,687 2,640,824
Change Order No. 1 38,644 38,644
Change Order No. 2 81,570 81,570
Change Order No. 3 24,781 24,781
Change Order No. 4 68,873 68,873
Line Item Changes 43,867 43,867
Construction Engineering - City Costs 115,145 55,493 170,638
Total 81,761 78,006 2,014,989 1,178,271 3,353,027
2012 (actual)2013 (actual) 2014 (actual) 2015 (actual) 2016 Total
*460 Funds Budgeted ( )0 0 (9,919) (422,098) (413,905) (845,922)
460 Funds Needed 0 0 9,919 422,098 327,014 759,031
*460 Fund Project Contingency ( )0 0 0 0 (86,891) (86,891)
460 Funds Required 0 0 0 0 0 0
2012 (actual)2013 (actual) 2014 (actual) 2015 (actual) 2016 Total
*461 Funds Budgeted ( )0 (154) (11,543) (281,356) (380,000) (673,053)
461 Funds Needed 0 154 11,543 281,356 367,702 660,755
*461 Fund Project Contingency ( )0 0 0 0 (12,298) (12,298)
461 Funds Required 0 0 0 0 0 0
2012 (actual)2013 (actual) 2014 (actual) 2015 (actual) 2016 Total
*462 Funds Budgeted ( )(461) (81,607) (56,544) (1,311,535) (485,000) (1,934,686)
462 Funds Needed 461 81,607 56,544 1,311,535 464,299 1,913,986
*462 Fund Project Contingency ( )0 0 0 0 (20,701) (20,701)
462 Funds Required 0 0 0 0 0 0
2012 (actual)2013 (actual) 2014 (actual) 2015 (actual) 2016 Total
*001 Funds Budgeted ( )0 0 0 0 (19,255) (19,255)
001 Funds Needed 0 0 0 0 19,255 19,255
*001 Fund Project Contingency ( )0 0 0 0 0 0
001 Funds Required 0 0 0 0 0 0
* ( # ) in the Budget Status Sections indicates Money the City has available.
460 Water Budget Status
461 Sewer Budget Status
462 Storm Budget Status
001 Engineering Repairs Budget Status
BUDGET STATUS SHEET
Auburn Way South Flooding Imp. - Ph II
Date: September 26, 2016
The "Future Years" column indicates the projected amount to be requested in future budgets.
Funds Budgeted (Funds Available)
Estimated Cost (Funds Needed)
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Vicinity Map
Printed Date:
Information shown is for general reference
purposes only and does not necessarily
represent exact geographic or cartographic
data as mapped. The City of Auburn makes no
warranty as to its accuracy.
Map Created by City of Auburn eGIS
4/28/2015
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AGENDA BILL APPROVAL FORM
Agenda Subject:
Public Works Project No. CP1605
Date:
September 26, 2016
Department:
CD & PW
Attachments:
Budget Status Sheet
Signed Final Pay Estimate No. 2
Vicinity Map
Budget Impact:
$0
Administrative Recommendation:
City Council approve Final Pay Estimate No. 2 to Contract No. 16-16 in the amount of
$85,607.49 and accept construction of Project No. CP1605, Herr Properties
Demolition.
Background Summary:
The purpose of the Herr Properties Demolition project was to expand the City’s
existing Les Gove Park by demolishing and disposing of four commercial buildings
(Big Daddy’s Drive In, Temporary Library, Butt’s Tobacco, Vacant Retail Store) and
their respective parking lots. Additional construction activities included salvaging
specific components of a landmark carport, removal and disposal of hazardous
materials from the properties, severance of existing utilities serving the properties,
removal and disposal of the asphalt pavement, erosion control, and site restoration.
A project budget contingency of $107,868.00 remains in the 321 Les Gove Park
Improvements Fund.
Reviewed by Council Committees:
Councilmember: Staff:Snyder
Meeting Date:October 3, 2016 Item Number:CA.F
AUBURN * MORE THAN YOU IMAGINEDCA.F Page 30 of 162
Project No: CP1605 Project Title:
Project Manager: Kim Truong
Project Initiation
Initiation Date: 3/8/2016 Permision to Advertise
Advertisement Date: 5/24/2016 Contract Award
Award Date: 6/20/2016 Change Order #2 Approval
Contract Final Acceptance
Funding 2015 2016
Future Years Total
321 Les Gove Park Improvements Fund 335,000 335,000
001 Engineering General Fund 40,000 40,000
Total 375,000 375,000
Activity 2015 2016
Future Years Total
Pre-Design Engineering - City Costs 2,288 2,288
Design Engineering - City Costs 21,532 21,532
Design Engineering - Consultant Costs 5,500 5,500
Construction Contract Bid 180,284 180,284
Change Order No. 1 (Time extension only)0 0
Change Order No. 2 (3,071) (3,071)
Line Item Changes 24,543 24,543
Other - Permitting, Landscape Design, etc 12,777 12,777
Construction Engineering - City Costs*16,180 16,180
Construction Engineering - Consultant Costs 7,100 7,100
Total 267,132 267,132
*City staff cost will be adjusted after project is finalized
2015 2016
Future Years Total
*321 Funds Budgeted ( )(335,000) (335,000)
321 Funds Needed 227,132 227,132
*321 Fund Project Contingency ( )0 (107,868) 0 (107,868)
321 Funds Required 0 0 0 0
* ( # ) in the Budget Status Sections indicates Money the City has available.
2015 2016
Future Years Total
*001 Funds Budgeted ( )(40,000) (40,000)
001 Funds Needed 40,000 40,000
*001 Fund Project Contingency ( )0 (0) 0 (0)
001 Funds Required 0 0 0 0
321 Les Gove Park Improvements Budget Status
Estimated Cost (Funds Needed)
001 Engineering General Fund Budget Status
BUDGET STATUS SHEET
Herr Properties Demolition
Date: September 27, 2016
The "Future Years" column indicates the projected amount to be requested in future budgets.
Funds Budgeted (Funds Available)
H:\PROJ\CP1605 Herr Properties Demolition\3.00 Project Management\3.20 Budget\Budget Status Sheet.xls1 of 1CA.F Page 31 of 162
CA.F Page 32 of 162
CITY OF AUBURN
PROJECT SUMMARY
PAY ESTIMATE #2 & FINAL
SCHEDULE A: Demolition
Contract
Sales Tax (+9.5%)
Retainage (-5%)
$
$
Original Contract
Amount
164,643.00
15,641.09
Contract Change
Orders
$ (2,805.00) $
$ (266.48) $
$
SCHEDULE TOTAL $ 180,284.09 $ (3,071.48) $
TOTAL CONTRACT AMOUNT TO DATE (including Sales Tax)
TOTAL PAYMENT TO CONTRACTOR
PAYMENT DUE CONTRACTOR:
h:\proj\pe\CP1605 PE.xis
Period Dates
Begin: Aug. 21, 2016
End: Sept. 20, 2016
2 of 3
$
$
Total Payment
184,251.49 $
17,503.89 $
(9,212.57) $
192,542.81 $
201,755.38
192,542.81 $
$
CO. NO. 16-16
CP1605, Herr Properties Demolition
This Period
81,921.04
7,782.50
(4,096.05)
85,607.49
85,607.49
85,607.49
Percent/Contract
114%
114%
9/27/2016 at 10:57 AM
CA.F Page 33 of 162
CA.F Page 34 of 162
Herr Properties Demoliton
Printed Date:
Information shown is for general reference
purposes only and does not necessarily
represent exact geographic or cartographic
data as mapped. The City of Auburn makes no
warranty as to its accuracy.
Map Created by City of Auburn eGIS
2/22/2016
CA.F Page 35 of 162
AGENDA BILL APPROVAL FORM
Agenda Subject:
Joint Council and Junior City Council Meeting
Date:
September 27, 2016
Department:
Administration
Attachments:
Homeless Taskforce Action Plan
Parking Powerpoint
Internet Availability
Heroin & Prescription Opiate Task
Force recommendation
Budget Impact:
$0
Administrative Recommendation:
Background Summary:
Reviewed by Council Committees:
Councilmember: Staff:
Meeting Date:October 3, 2016 Item Number:DI.A
AUBURN * MORE THAN YOU IMAGINEDDI.A Page 36 of 162
Auburn Mayor’s Homelessness Task Force
Task Force Report
April 2016
Executive Summary
In response to community concerns about the growing number of homeless individuals in the
City, Mayor Nancy Backus created the “Auburn Mayor’s Homelessness Task Force” in
November 2015. The Task Force was composed of 17 individuals representing a diversity of
residents, businesses, service providers and faith community stakeholders in Auburn. The
mission of the Task Force was to: “…seek to better understand the scope and causes of
homelessness in Auburn, the systems in place to address homelessness, and…consider the
range of concerns and ideas identified by the community. The Task force will identify and
recommend a set of short-term and longer-term actions that our community can undertake
to address these issues.”
The Task Force met seven times, from November 2015 through April 2016. The Task Force was
supported by a team from the City of Auburn staff, representatives from the King County
Housing Authority and Valley Regional Fire Authority, and an independent facilitator. Task
Force meetings were open to the public and public comment was taken on line and at
meetings. The Task Force heard from a variety of city and other regional government
representatives, regional homelessness response coalition staff, as well as many service
providers operating in Auburn. Task Force members were able to participate in several site
visits of facilities in Auburn and within the South King County region which are serving homeless
individuals. In addition, four interviews with homeless individuals in the City were recorded and
transcribed for the Task Force’s review.
The Task Force believes that responding to homelessness is a priority for ensuring the quality of
life in our community – for residents, businesses, and visitors, as well as the individuals
experiencing homelessness. Many of the homeless in Auburn grew up in this City and went to
school here: they are our friends and neighbors.
The situation demands immediate action and the engagement of all parts of our community. It
is not simply a matter of asking the Police or others at City Hall to “do more.” There are many
things the community can do that will improve the situation, but they cannot be implemented
overnight.
The Task Force offers 46 recommendations, in seven categories of activity. The Task Force’s 15
priority recommendations within these seven categories are:
Improving public safety, sense of wellbeing
Create a program where homeless are hired daily to help clean the community
DI.A Page 37 of 162
ii
Ensure police have information to provide service and shelter referrals to homeless
individuals
Expand emergency shelter options
Open additional shelter in City –more than just the existing winter shelter for cold nights
Expand shelter services to youth under the age of 18
Increase the supply of low-barrier shelter beds in the City
Expand services
Create a hygiene center / day center with storage, showers, laundry and access to
resources. Explore siting in an existing vacant building
Expand programs, facilities and services available to address behavioral health issues of
homeless individuals
Expand permanent housing and related service capacity
Provide additional subsidized housing for single adults without disabilities, children, or
veteran status: currently, there are very limited resources for this population
Provide landlord assistance for damages as well as rent guarantee / support the
countywide Landlord Liaison Program
Improve public understanding and ability to assist
Implement a program to help educate residents about homelessness
Continue to expand City's involvement with county, state and the federal government to
better support funding for and awareness of homelessness in South King County
Advocacy
Advocate for more state funding for all types of behavioral health services-- mental
health, substance abuse, detox beds, etc.
Advocate for funding for individuals without state insurance/on disability to access
mental health and substance abuse treatment
Advocate to require utilities to expand subsidy for low income customers
Other
Create best practice training for all systems to build connections between agencies
A successful response to homelessness in Auburn will require compassion, informed action, and
a continued commitment to public safety. The Task Force strongly encourages the City and the
people within the community to consider all of its recommendations, and has asked to be
reconvened in six months to review progress. Members of the Task Force have also offered to
serve on an inter-agency implementation team which they recommend the City create to lead
the response to the recommendations in the report.
DI.A Page 38 of 162
Auburn Mayor’s Homelessness Task Force
Task Force Report
April 2016
Introduction
The Auburn Mayor’s Task Force on Homelessness was created by Mayor Nancy Backus in
November 2015. The Mayor’s action came after concern was expressed by many local business
owners and residents about visible street homelessness in the City. A “blog-spot” on the City’s
Website on the topic of homelessness received a record number of posts over much of 2015,
more than any other subject on the “Talk Auburn” blog.
At the initial Task Force meeting, Mayor Backus charged the group with the following mission:
The Task Force will seek to better understand the scope and causes of
homelessness in Auburn, the systems in place to address homelessness, and
will consider the range of concerns and ideas identified by the community.
The Task force will identify and recommend a set of short-term and longer-
term actions that our community can undertake to address these issues.
This report presents our recommendations.
Task Force Members and Process
The Task Force consists of seventeen (17) members, representing a diversity of resident,
business, service providers and faith community interests in Auburn. Three resident members
were selected after soliciting interest from the entire community. The members of the Task
Force and our affiliations are identified at Attachment A. Mayor Backus selected Denise
Daniels and Carla Hopkins to serve as co-chairs of the Task Force.
The Task Force met seven times, from November 17, 2015 through April 15, 2016. We were
supported by a team of City staff from various departments, as well as representatives from the
King County Housing Authority and the Valley Regional Fire Authority. The support team
members sat at the table with us and engaged in the dialogue at each meeting. A full list of the
support team members is presented at Attachment B. In addition to bringing the staff support
team to our table, the City also secured an independent facilitator to help shape our work plan
and facilitate our meetings.
Our meetings were open to the public and all the agendas and materials reviewed at our
meetings were posted on the City’s website, as were summaries of our meetings. We took brief
oral comments at our meetings, and encouraged written comments to be submitted from
members of the public attending our meetings, as well as on the City’s website. All comments
submitted were transcribed and provided to us.
DI.A Page 39 of 162
2
At the beginning of our deliberations, we adopted a charter to guide our decision making
process. We then spent most of our first four meetings learning about homelessness in Auburn.
We began by learning what City staff have heard from local residents and business owners
about the impacts of homelessness on their neighborhoods and places of business . Then we
heard more about the issue of homelessness regionally as well as locally: The Seattle King
County Coalition on Homelessness presented information describing how homelessness is
prevalent across King County. We reviewed the “One Night Count” data on the numbers of
homeless, and information on the causes of homelessness. “All Home,” the agency managing
the County’s overall strategies to address homelessness, described for us how governments
and service providers are responding to this challenge. As individual Task Force members, we
shared with each other our own perceptions as to the causes of, and concerns associated with,
homelessness in our community.
After that, we heard presentations from several City departments—Police, Community Services,
Parks, Planning and Development -- who deal daily with individuals experiencing homelessness
in our City. All the presenters noted that the homeless population—particularly single adults--
is increasingly visible and growing, and that there is a lack of shelters and other safe places for
homeless individuals to go in Auburn. Assistant Police Chief William Pierson stressed for us
that while the Police Department is committed to protecting the safety of the community,
being homeless in and of itself is not a crime, and the City cannot arrest its way out of this
challenge. The Parks Department and Community Development Departments spoke to the
challenges of addressing encampments and related environmental impacts on public property.
The Community Services Department noted the lack of services available to meet the needs of
the homeless—particularly, the lack of hygiene and laundry facilities.
Helpful information was also provided by staff from other government agencies. Valley
Regional Fire Authority staff also presented information to us, noting they are seeing an
increase in the homeless population, particularly among younger people—teens and those in
their early 20s. Staff from the Auburn School District spoke to us regarding the challenges of
serving homeless students and the federal McKinney Vento law requirements around this. Staff
from the Auburn Library shared with us information about their programs and how they treat
visitors to their facilities, including homeless individuals, and how library staff seek to treat
everyone consistent with their mission “to provide free, open, and equal access to ideas and
information to all members of the community.” Staff from the King County Housing Authority
shared with us an overview of that agency’s programs and services, which include several
subsidized and workforce housing developments in Auburn.
The Director of the King County Dept. of Community and Human Services also spoke with us,
noting that in the homelessness crisis, what we are experiencing is the failure of several
systems over the last several decades: lack of access to mental health care treatment and in-
patient beds; insufficient support for persons with development disabilities; and rapidly
growing housing costs. She shared with us maps showing prevalence of a series of demographic
markers around poverty, health indicators, and factors placing people at risk of homelessness,
all of which showed a heavy concentration of these challenges in South King County.
DI.A Page 40 of 162
3
Between Task Force meetings, we had the opportunity to visit sites where services for the
homeless are now provided in the City and nearby. Site visit locations included:
Auburn Youth Resources/Arcadia House
First United Methodist Church (free meal site)/Auburn Food Bank
Multi-Service Center (shelter for families, located in Kent)
Valley Cities Landing and Phoenix Rising
We wanted to ensure that we heard the persp ectives of homeless individuals in our
deliberations. To accomplish this, in addition taking public comment at the meetings (where
we heard from homeless individuals as well as residents and service providers), four interviews
were conducted with different homeless people in the City, through the efforts of our Co-Chair,
Carla Hopkins, and City staffer Erica Azcueta. Transcripts of these conversations were provided
to us.
City staff kept a running list of all our information requests and we received responses to all
these questions.
We spent our last three meetings developing a problem statement, our definition of success,
criteria for our recommendations, a framework for recommendations, and developing a list of
potential recommendations. We identified 56 different potential recommendations (presented
in Attachment B), and sorted them within categories of our adopted framework (described
below).
Our 56 ideas for recommendations were placed on a ballot and each Task Force member was
asked to rate each idea from 1 to 5, with 5 being “strongly support” and 1 being “strongly
oppose.” Results were tabulated and presented at our seventh and last Task Force meeting. In
discussion at that last meeting, some items were re-voted on. The final results of that voting
and deliberation are included at Attachment C.
Per our charter, items supported by at least 80% of the Task Force members voting were
considered to be “consensus” items; items supported by at least 60% but less than 80% were
considered to be “recommended” items. These “consensus” and “recommendation” items
together constitute our recommendations; they are presented below at Table 1.
Problem Statement
Auburn residents, business owners, nonprofit service organizations, the faith community, and
those in City Hall, have all observed an increase in the number of homeless individuals in the
City over the past few years. Their presence is seen and felt in downtown Auburn, the Library,
City parks and open spaces, in other commercial areas of town and in neighborhoods.
The January 2016 One Night Count of the homeless reported 110 homeless individuals in
Auburn. This was a decline compared to the 132 people counted in 2015, but service providers
attribute this to heavy rains flooding out traditional encampment sites along the Green River.
DI.A Page 41 of 162
4
And, of significant concern, in 2016 the South King County Region1 saw a 53% increase in the
homeless count compared to 2015. Countywide, there was a 19% increase in the number of
homeless individuals reported in the One Night Count in January 2016 as compared to January
2015.
The City’s Public Works Department reports a constant stream of homeless encampments in
City green spaces. “Unwanted person” calls have become the second highest call category for
the City Police Department, second only to traffic issues. The Valley Regional Fire Authority
reports a growing increase in the number of visible homeless in the City, particularly young
adults.
The homelessness in our City are people of all ages. The Auburn School District reports it had
265 students identified as homeless in the 2014-2015 school year—a 26% increase over the
2013-14 school year. And the 2013-14 school year had 17% more homeless students than the
2012-2013 school year.
A growing number of families in Auburn are at risk of homelessness. Indicators of this trend are
found in data about poverty levels, comparing income to rent , looking at the growing use of the
Auburn Food Bank, and tracking the number of families seeking subsidized housing:
Over 10% of families in Auburn were below the federal poverty line in the 2010 census.2
Over 41% of Auburn households pay more than 30% of their income for housing.2
4,495 families are registered with the Auburn Food Bank this year – some 118,000
people were served last year, up to 145 people a night at weekly community meals. 3
35-50 individuals per night are staying at the cold weather shelter operated by the
Auburn Food Bank.3
Rental costs in South King County have increased 27% since 2010. A person earning
minimum wage, or on TANF (welfare), or receiving social security disability income
cannot afford an average one bedroom apartment in South King County.4
In Auburn last year, 871 families applied for public housing assistance – seeking to get
on the King County Housing Authority Section 8 Voucher waiting list. Only 98 of those
applicants were fortunate enough to get a slot on the waiting list—and they can expect
to wait as long as 5 years for space in public housing to open up.5
At the same time, the City hears growing frustration from businesses and homeowners. They
ask what is being done to address the number of homeless individuals panhandling, or sleeping
1 Of that increase, 91% can be attributed to areas counted last year, most of which have been counted for many
years. The South King County Region consists of areas in: Federal Way, Kent, Renton, Au burn, and Southwest King
County (select areas of Burien, Des Moines, SeaTac, Tukwila, and White Center). Source for One Night Count data:
Seattle King County Coalition on Homelessness.
2 Source: All Home.
3 Source: Auburn Food Bank.
4 Source: Seattle King County Coalition on Homelessness, reporting 2015 information from Dupre & Scott
Apartment Advisors.
5 Source: King County Housing Authority.
DI.A Page 42 of 162
5
in doorways, or loitering in commercial areas. There is a high degree of community concern
about homelessness, as evidenced by the number of comments on the City’s web-blog on
homelessness which has received more comments than any other City blog. Most, but not all,
of the input from the community expresses support for helping the homeless in our communi ty
find the services and shelter they need. Over half of the comments received online stated there
is significant need for more supportive services including emergency shelters, mental health
and substance abuse services, and policy or system changes.
And, while the fear and frustration registered through public comments is growing, we are also
clear that the City cannot arrest its way out of homelessness. Being homeless is not a crime.
And, cycling individuals through short jail stays on trespassing or pu blic nuisance charges only
to have them released back in to the community doesn’t address the underlying causes of
homelessness or solve the problem.
What we are seeing in Auburn is not unique. Across King County, Washington state, and
nationally, we are seeing the suburbanization of poverty, as the poor are priced out of housing
in urban centers. In Washington State, decades of underinvestment in mental health care,
developmental disabilities services, and substance abuse treatment are translating into
increasing homelessness. In King County we combine those systemic failures with an alarming
increase in the cost of housing and the problem is further exacerbated.
The Task Force understands that the following conditions are being experienced and obs erved
in the City, by residents and business owners:
Problem behaviors of homeless individuals, including loitering, trespassing in private
buildings to use restrooms, get clean and sleep
Property damage including breaking of locks on buildings to gain access to private
buildings, or dumpsters
Increasing number of visible homeless individuals throughout our City, particularly
younger individuals
Customers and employees of local businesses being frightened of or confronted by
homeless individuals
Residents wanting the City to “fix” the problem of homelessness
Residents afraid to use the library due to groups of homeless adults loitering in the
entryways and in the Library
Residents afraid to visit public parks, trails and open space due to groups of apparently
homeless individuals living or loitering in these areas
Trash, debris, belongings, drug paraphernalia left behind by the homeless
Increasing numbers of homeless encampments in open space within the City
Mental illness and substance abuse issues suffered by the homeless
Significant increases in the cost of housing
Growth in poverty
As a result of these issues and conditions, community concerns include:
Auburn becoming less safe and less attractive for residents, workers, and visitors
DI.A Page 43 of 162
6
Negative community views about the homeless, a lack of public understanding and
tolerance for the homeless
Concern for the safety of the homeless in the City and concern about their human
suffering
A lack of services and housing available for the homeless – either in Auburn or in nearby
cities
Constraints and obstacles to addressing these concerns and issues include:
Lack of Places for Homeless Individuals to Be
No shelter for youth under 18 anywhere in South King County
One shelter for young adults (ages 18-24) in all of South County, here in Auburn
(Auburn Youth Resources)
Other than a limited winter shelter in severe weather conditions, there are no
emergency shelter beds to house homeless adults in Auburn
There are very few transitional shelter beds in the City
Lack of approved places for the homeless to stay anywhere in the City (e.g. parking
lots or “tent cities”)
Lack of day centers where homeless individuals can be during the day, other than
limited hours of service in a facility for youth provided by Auburn Youth Resources
No hygiene center anywhere in the City where homeless individuals can get clean, or
take care of basic bodily functions
Rents increasing far faster than incomes, and already beyond the reach of those at
the bottom of the income scale
Insufficient public housing and shelter capacity to meet the needs of the population
(housed and unhoused)
Lack of housing with supportive services to meet the needs of the homeless
Lack of sites where new homeless facilities can locate, and lack of clarity as to
whether there is public support for such siting.
Difficult for the Homeless to Help Themselves
Limited family and social networks
Lack of transportation to get to services and jobs
Lack of knowledge on the part of both the homeless and the public about resources
available to assist the homeless
Lack of service capacity, including medical care, mental health care, substanc e abuse
treatment, job training
Lack of enough outreach services to connect homeless to services they need
Lack of places for the homeless to securely store their belongings
Hard for Supportive Agencies to Help Homeless Families and Individuals
Lack of public understanding of the complexity of homelessness
Some homeless opt out of staying in shelters or using services available to them
Growing poverty in the region, increasingly generational poverty
DI.A Page 44 of 162
7
Growing housing costs place more at risk of homelessness, and make it more
expensive to find new housing for the homeless
Lack of adequate resources to address the challenges
What does success look like?
The challenge of homelessness in Auburn is growing. The Task Force believes there is an urgent
need for action. But what does success look like? Here are some of the ways we think our
community should define success in addressing homelessness:
For the homeless:
o More shelter beds in our community.
o A place in our City where the homeless can care for their personal needs—get clean, do
laundry.
o Greater access to “Housing First” resources—safe housing with wrap-around services,
that people can live in without abandoning their pets, or without the expectation that
they will be addiction-free overnight.
o Greater access to health services and better health outcomes, including but not limited
to greater access to substance abuse treatment.
o Greater access to transportation.
o Ultimately, everyone who wants a home or shelter can have one.
o Greater visibility of services available to assist homeless individuals.
For our community:
o Greater perceived and actual feeling of safety.
o A cleaner city, with less debris left behind by the homeless, and no unauthorized
encampments.
o Expanded engagement of the business community and of the entire community in
constructively addressing homelessness.
o Greater understanding of the complexity of homelessness and how we can each help to
meet this challenge.
o Broader awareness that homelessness and crime are not synonymous.
o An acknowledgement that the homeless are part of our community.
o More landlords open to renting to individuals an d families with Section 8 housing
certificates.
For our public and nonprofit service providers:
o Stronger connections between service providers across South King County .
o A seamless system that works to help the homeless and those at risk of homelessness—
understanding the barriers to homeless and efficiently and quickly connecting people
with resources.
o A reduction in emergency room visits by homeless individuals.
o Increased resources.
DI.A Page 45 of 162
8
o Police, fire/emergency medical and public works resources are able to apply more of
their resources to their core missions.
o Collaborative engagement in securing grants.
We will not end homelessness. But there is much we can and should do to address this
challenge in our City. One size does not fit all, in terms of solutions. While there are some
actions we can take that will result in immediate improvement, others will take much longer.
We need to think strategically, and be committed to sustaining our efforts over the long haul.
Criteria and Framework for Task Force Recommendations
The Task Force agreed that recommendations would be included for consideration by the Task
Force if they meet all these criteria:
Actionable – Recommendation is feasible to implement as a community. Stakeholders
needed are part of Auburn/South King County community and have means to take
action necessary to accomplish the change sought. Financial feasibility should be
included as a consideration (without setting a specific dollar threshold for what is
feasible).
Positive Community Impact – It is reasonable to expect that implementation of the
recommendation will result in overall positive community impact, and respond to the
community’s concerns.
Consistent with federal law – (But recommendations could include advocating for
changes in state law and funding)
Sustainable—phased roll-outs of solutions may be needed, but sustained action is
required.
We approved a “framework” for recommendations that sorted ideas into seven categories:
A. Improving public safety, sense of wellbeing
B. Expand emergency shelter options
C. Expand services
D. Expand permanent housing (& related service capacity)
E. Improve public understanding, ability to assist
F. Advocacy
G. Other
Task Force members and the support team identified fifty-six (56) potential action items. Staff
provided us with an initial assessment for each ideas in terms of (1) who would be the likely
“lead” to implement the action, (2) who would be an appropriate “partner” working in support
of the item, (3) roughly, how much would it cost to implement the item, and (4) how long
DI.A Page 46 of 162
9
would it take to implement. This information was included on the ballot for our consideration
when voting, and is presented in Attachment C – the final ballot results.
Our Recommendations
After voting and final deliberation, we are recommending forty-six (46) separate items. Twenty-
eight (28) of these are consensus items, receiving support of at least 80% of Task Force
Members voting; another eighteen (18) are recommendation items” supported by 60-79% of
the Task Force Members voting. The full slate of recommendations is presented at Table 1.
Among these 46 recommendations, we call out 15 priorities: those items receiving the
strongest level of support from Task Force members across the seven categories of our
recommendation framework. These priority items are noted with an asterisk (*) in Table 1.
We strongly encourage the City and community to consider all of our recommendations. The
paragraphs below explain the rationale for our recommendations, which span many areas. This
span is important, since the causes of homelessness—and effective solutions—cross many
areas of activity: from policing, to public education, to crisis intervention services, and
ultimately, housing.
A. Improving public safety, sense of wellbeing
We want Auburn to be an attractive and safe community for our residents, businesses and
visitors. Many community members have expressed safety fears related to the homeless
individuals in our City, particularly in terms of visiting City parks and the library. Community
members also expressed concern for the safety of the people experiencing homelessness. It is
important that the City respond to these issues.
B. Expand emergency shelter options
People can become homeless for many reasons—job loss, major health issue, family
relationship breakdown, or being priced out of their apartments. Shelter is the immediate
safety net that should be in place for people experiencing homelessness. There are no
emergency shelter beds in the City today, except for winter shelter beds. To stop the cycle of
homelessness, shelter beds are critical. And since many--perhaps most--people experiencing
homelessness in Auburn are from Auburn, local shelters can help them remain invested in our
community.
C. Expand services
Shelter is only one aspect of what many people need if they become homeless. Other needs
include a place to take care of personal hygiene, laundry, to store their possessions, find
employment, health care, or treatment for recovery from mental health and/or substance use
challenges. To make it possible for people to return to a sustainable housed status, services are
needed. There is a lack of sufficient appropriate services to meet the needs of homeless
individuals in Auburn.
DI.A Page 47 of 162
10
D. Expand permanent housing (& related service capacity)
Ultimately, ending homelessness requires places for people to call home. The vacancy rates in
private rental housing are extremely low and rents are very high—and growing. The market is
simply not providing housing that many people in our community can afford. And wait lists for
public housing are five years long. Additional publicly subsidized housing is needed if we are to
address the problem of homelessness.
E. Improve public understanding, ability to assist
Homelessness is an extremely complex issue. As Task Force members, we each learned things
over the course of this project about what is happening here in Auburn, increasing our
understanding of the root causes of homelessness, learning about services available and service
gaps in our community, and understanding how to create systemic, sustainable and effective
responses to homelessness. With better understanding of these issues, people can make a shift
from blaming and fearing people experiencing homelessness toward s building a collective
community consciousness that seeks to meet the needs of homeless residents. An aware and
educated community can also help identify additional private actions that can help address this
challenge.
F. Advocacy
Homeless individuals may not be able to speak for themselves in a way that is heard by those
who are in a position to help. The City, working with other governments and service providers,
should continue advocate for the larger systemic changes needed to effectively address
homelessness. Several coalitions exist today for this purpose, and the City is a member of many
of these. Advocacy for system changes—particularly around mental health and substance use
disorder treatment and increasing the supply of public housing--are necessary to improving the
situation at the local level: these are systems controlled at the regional, state and federal levels.
G. Other
We have a handful of other recommendations that do not fall neatly within the categories
above.
Our recommendations are not an implementation plan; that work is still ahead. Given the
number of recommendations we are making, and the fact that many cannot be achieved
quickly, it is important to develop a phased implementation plan that can be effectively
managed to achieve demonstrable progress.
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24
Attachment C: Final Tabulation of Task Force Votes on All Proposed Action Items
Proposed Recommendations
% of TF Members Rating
Item 1-5 Combined Rating Results
Cate-
gory Item Proposed Action
Asterisked items (*) represent Task Force Priorities
1 2 3 4 5
4
and
5
3
2
and
1
Improving Public Safety, senses of well-being A.1
More patrol and control of parks and library area to ensure safe
access for families and kids. This is important to addressing
community concerns, particularly in Les Grove and Game Farm
parks. 0% 0% 35% 24% 41% 65% 35% 0% R
A.2
Outreach and education to homeless people to encourage good
conduct (obey laws, respect other’s property) and
environmental stewardship in order to improve community
sense of safety, reduce impacts to the environment and improve
public health. 0% 6% 18% 29% 47% 76% 18% 6% R
A.3* Create a program where homeless are hired daily to help clean
the community 0% 0% 12% 29% 59% 88% 12% 0% C
A.4
Increase police patrols in vicinity/around the times of church
meal programs and other areas where homeless individuals
congregate 6% 6% 35% 29% 24% 53% 35% 12%
A.5* Ensure police have information to provide service and shelter
referrals to homeless individuals 0% 0% 0% 18% 82%
100
% 0% 0% C Expand emergency shelter B.1
Partner with agencies (businesses, governments, churches, etc.)
that have parking lots to make them available for overnight for
"safe parking" that is time limited, policed, kept clean and has a
restroom facility 6% 0% 24% 35% 35% 71% 24% 6% R
B.2
Find a location to host a Tent City in Auburn, to offer community
to homeless. Provide showers and laundry facilities 24% 12% 24% 24% 18% 41% 24% 35%
B.3
Provide short-term Shelter Housing in the City by partnering
with - motels willing to reduce price with open rooms, and with
Landlords with unrented apartments 6% 6% 12% 29% 47% 76% 12% 12% R
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25
Proposed Recommendations
% of TF Members Rating
Item 1-5 Combined Rating Results
B.4
Provide additional outdoor restroom facilities at existing
available parking lots at businesses like gas stations
6% 6% 12% 53% 24% 76% 12% 12% R
B.5*
Open additional Shelter in City –more than just the existing
winter shelter for cold nights 0% 0% 12% 24% 65% 88% 12% 0% C
B.6
Provide transitional housing in immediate Auburn area
0% 6% 18% 41% 35% 76% 18% 6% R
B.7
City should provide support for the siting and construction of the
proposed Arcadia House project (transitional housing and
shelter, with services, for young adults) 0% 0% 29% 29% 41% 71% 29% 0% R
B.8*
Expand shelter services to youth under the age of 18
This item was re-voted at Meeting 7
and moved up to a consensus
recommendation.
100
% 0% 0% C
B.9
utilize school and other public facilities as overnight shelters for
the currently underserved groups, including families with
children 12% 6% 24% 29% 29% 59% 24% 18%
B.10*
Increase the supply of low-barrier shelter beds in the City
(currently there are no shelter beds, excepting the winter shelter
open during the extreme weather) 6% 0% 6% 29% 59% 88% 6% 6% C Expanding Services C.1*
Hygiene center / Day center with storage, showers, laundry and
access to resources. Explore siting in an existing vacant building
6% 0% 0% 24% 71% 94% 0% 6% C
C.2 Engage owners of private but vacant buildings in City to host
locations for needed services 6% 0% 6% 47% 41% 88% 6% 6% C
C.3
Coordinate meal programs for each day of the week to ensure
homeless have a hot meal, a place for companionship, and
safety each and every day. (Currently 5 of 7 days of the week
are covered by such programs in Auburn.) Promote best
practices in the operation of these programs to mitigate impacts
on neighboring properties/residents. 6% 0% 12% 24% 59% 82% 12% 6% C
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26
Proposed Recommendations
% of TF Members Rating
Item 1-5 Combined Rating Results
C.4
Expand Health Care services available for homeless - Basic and
beyond with follow-up and case management 6% 0% 6% 35% 53% 88% 6% 6% C
C.5*
Expand programs, facilities and services available to address
behavioral health issues of homeless (Behavioral health =
substance abuse, addiction, mental health).
0% 0% 6% 24% 71% 94% 6% 0% C
C.6
Work with other cities and agencies to create Diversion/Crisis
solution centers in South King County. 6% 0% 12% 24% 59% 82% 12% 6% C
C.7
Expanded wrap-around services for homeless that will assist
them in addressing their barriers to stable housing. 6% 0% 12% 24% 59% 82% 12% 6% C
C.8
Enhance collaboration and communication between service
agencies to better ensure a “warm handoff” of individuals from
agency to agency -- so people don’t get lost in the system.
Include city in these efforts. 0% 0% 12% 24% 65% 88% 12% 0% C
C.9
Periodically update brochure providing information about
resources in the community (city, professional, nonprofit, etc.)
available to help homeless. (At least annual updates) 0% 0% 29% 18% 53% 71% 29% 0% R
C.10
Transportation – provide a free bus for Valley floor area, with
service centralized around Auburn to help get from one end to
the other 6% 12% 35% 24% 24% 47% 35% 18%
C.11 Expand number of bus passes available for homeless individuals.
6% 0% 18% 29% 47% 76% 18% 6% R
C.12
Find a private laundromat willing to be open for free for
homeless residents one day a week (City of Burien project) 0% 0% 12% 29% 59% 88% 12% 0% C
C.13
Create Storage facilities for homeless individuals to place their
belongings: secure, accessible and locked 6% 6% 41% 18% 29% 47% 41% 12%
C.14
Provide short-term transitional housing for those coming out of
jail or foster care to help transition people to longer term
housing and employment 6% 0% 12% 35% 47% 82% 12% 6% C
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27
Proposed Recommendations
% of TF Members Rating
Item 1-5 Combined Rating Results
C.15
Provide a central place well known in the community where
homeless can come and be connected to resources.
6% 0% 6% 24% 65% 88% 6% 6% C Expand Permanent house (and related service capacity) service capacity) D.1
Expand the supply of permanent “Housing First” low barrier
housing in and around Auburn. 0% 6% 18% 29% 47% 76% 18% 6% R
D.2
Support efforts of South King County (SKC) regional
planning/homelessness advisory group in their efforts to: (1)
Assess what housing and services currently exist and are
currently available to homeless populations; (2) Determine gap
between need and available resources; and (3) Coordinate
where and housing will be located. Each city should agree to
locate specific housing and service program in their locality,
spreading resources across SKC. 6% 0% 24% 24% 47% 71% 24% 6% R
D.3
Provide housing for everyone who would like it-- not temporary
housing-- a permanent place to call home. 12% 6% 24% 18% 41% 59% 24% 18%
D.4
Build new low-income/subsidized housing located close to
resources and services.
6% 0% 29% 29% 35% 65% 29% 6% R
D.5
Organize shared housing placement and services. Make list or
audit of all existing, available or potentially available housing
that could be used to house the homeless. 6% 0% 29% 18% 47% 65% 29% 6% R
D. 6*
Provide additional subsidized housing for Single adults w/o
disabilities, children, or Veteran status. Currently, there are very
limited resources for this population. 6% 12% 0% 35% 47% 82% 0% 18% C
D.7
Build communal / micro-housing: i.e. dormitory-like apartment,
private rooms for sleeping, individuals or couples with shared
kitchen and living rooms. 4-6 people to a pod. 6% 12% 12% 41% 29% 71% 12% 18% R
D.8 Create a fund to help offset costs of rent or purchase of housing
for qualified homeless 6% 6% 29% 35% 24% 59% 29% 12%
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28
Proposed Recommendations
% of TF Members Rating
Item 1-5 Combined Rating Results
D.9*
Landlord assistance for damages as well as rent guarantee /
support countywide Landlord Liaison Program
6% 6% 6% 41% 41% 82% 6% 12% C Improving public understanding, ability to assist E.1*
Implement a program to help educate residents about
homelessness— why people become homeless, the limits of
police action, the rights of the homeless, and how the Police,
other City Departments, and service providers are currently
responding on the issue. Tactics could include a citizen’s
academy, town halls, web-postings, news articles, etc. Being
homeless doesn’t make you less of a person but rather just
person who may need a hand up. 0% 0% 19% 19% 63% 81% 19% 0% C
E.2
Encourage residents to reach out to relatives, friends of the
homeless to help identify underlying reason for homelessness
and possibly direct help to the individual. 6% 18% 24% 0% 35% 35% 24% 24%
E.3
Encourage ministers to include discussion in parish sermons
during worship services to help parishioners with understanding
and helping the homeless 0% 6% 18% 18% 53% 71% 18% 6% R
E.4*
Continue to expand city's involvement with county, state and
feds to better support money and awareness of homelessness in
South King County as a whole. 0% 0% 18% 18% 65% 82% 18% 0% C
E.5
Clarify availability of resources to help homeless on single
website
0% 0% 29% 0% 71% 71% 29% 0% R
E.6
Fundraiser to build public awareness of issues, barriers, provide
public opportunity to provide input. Use proceeds to fund
programs 0% 0% 41% 6% 47% 53% 41% 0% Advocacy F.1
Find funding to provide more services.
0% 0% 18% 24% 59% 82% 18% 0% C
F.2*
Advocate for more state funding for all types of behavioral
health services-- mental health, substance abuse, detox beds,
etc. 0% 0% 6% 18% 76% 94% 6% 0% C
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29
Proposed Recommendations
% of TF Members Rating
Item 1-5 Combined Rating Results
F.3*
Advocate for funding for individuals without state insurance/on
disability to access mental health and substance abuse
treatment 6% 0% 6% 18% 71% 88% 6% 6% C
F.4
Encourage the state legislature to act next session to authorize a
“Medicaid Supportive Housing Services Benefit” that will allow
those providing services to residents in permanent supportive
housing to bill more of the costs of those services to Medicaid
rather than have the service providers absorb these costs. 0% 0% 24% 12% 65% 76% 24% 0% R
F.5
Provide training or tools to homeless individuals to share their
story during legislative session. 6% 0% 47% 12% 35% 47% 47% 6%
F.6* Advocate to require utilities to expand subsidy for low income
customers. 0% 0% 12% 35% 53% 88% 12% 0% C
F.7
Advocate for expanded funding available to transporting
homeless students. 0% 0% 18% 24% 59% 82% 18% 0% C
F.8
Advocate for improved bus service within Auburn and between
South King County cities to increase ease of access by the
homeless to needed services. 6% 6% 6% 24% 59% 82% 6% 12% C Other G.1
The City should undertake a short term concerted effort to
gather more accurate data on the number of homeless
individuals in Auburn. Strategies could include using yourgov
app, first responders document all contacts, include photo. 0% 12% 24% 29% 35% 65% 24% 12% R
G.2
City should continue to strengthen partnerships with service
providers whose programs serve homeless individuals 0% 0% 18% 12% 71% 82% 18% 0% C
G.3*
Create best practice training for all systems. Employees trained
together to build connections between agencies. 0% 0% 12% 41% 47% 88% 12% 0% C
28 consensus items (80%+ approval)
18 recommendation items (60-79% approval)
10 items not recommended
DI.A Page 54 of 162
AUBURN
VALUES
SERVICE
ENVIRONMENT
ECONOMY
CHARACTER
SUSTAINABILITY
WELLNESS
CELEBRATION
PARKING
KEVIN SNYDER, AICP
COMMUNITY DEVELOPMENT & PUBLIC WORKS
DIRECTOR
JOINT CITY COUNCIL/JUNIOR CITY COUNCIL
OCTOBER 3, 2016
Community Development and Public Works Department
Engineering Services Administrative Services Environmental Services
Community Development Services Maintenance & Operations ServicesDI.A Page 55 of 162
AN AGE OLD DEBATE
SERVICE ENVIRONMENT ECONOMY CHARACTER SUSTAINABILITY WELLNESS CELEBRATION
OR
DI.A Page 56 of 162
2 Types of Parking in Auburn:
On-Street Parking
Off-Street (On Property) Parking
Parking rules in Auburn City Code address:
No., size and location of off-street parking spaces
P rivate parking lots comply with all development regulations including
landscaping, improved surfaces and stormwater management
Types/hours of on-street parking
On-street locations where semi-trucks can park
Maximum h ours vehicles can be parked @ on-street (72 hours)
“Traditional” approach to parking (i.e. land use, no-fee on-
street)
Last parking regulations update for off-street parking spaces:
Established parking maximum (125% of required spaces)
Incentives for providing less than required parking
PARKING IN AUBURN
SERVICE ENVIRONMENT ECONOMY CHARACTER SUSTAINABILITY WELLNESS CELEBRATIONDI.A Page 57 of 162
Comprehensive Downtown Parking
Management Plan (Resolution No.
5031, February 3, 2014)
Addresses parking in the Downtown
Urban Center (DUC) zoning district
Approximately 5,000 public and private
parking spaces in DUC
Downtown parking situation is “unique”
Parking demand anticipated to be more
than parking supply in the future
Near-Term, Short-Term (1-5 years) and
Long-Term (6-10 Years) Strategies
DOWNTOWN PARKING
SERVICE ENVIRONMENT ECONOMY CHARACTER SUSTAINABILITY WELLNESS CELEBRATIONDI.A Page 58 of 162
City provides off-street fee parking spaces only for:
Downtown businesses
Auburn residents
City offers 3 hour off-street parking spaces
City limits hours of on-street parking (3 hours, 2 hours, 15 minutes)
Sound Transit Parking Garage:
Not owned by the City
Built for commuters to access Sounder service
Completely full & serves out of Auburn commuters and Auburn commuters
Sound Transit planning 2nd garage –5 to 7 years out
DOWNTOWN PARKING
SERVICE ENVIRONMENT ECONOMY CHARACTER SUSTAINABILITY WELLNESS CELEBRATIONDI.A Page 59 of 162
In the Downtown Area:
Is there a perceived or real parking problem?
Is the City responsible for providing parking?
Should the City build and operate a parking garage?
Should the City charge for on-street parking?
Should there be parking required for new development/redevelopment or should the “market” decide (i.e. no parking requirement)?
WHAT DO YOU THINK?
SERVICE ENVIRONMENT ECONOMY CHARACTER SUSTAINABILITY WELLNESS CELEBRATIONDI.A Page 60 of 162
Page 1 of 1
Council Briefing Update
To: Auburn City Council and Auburn Junior City Council
From: Paul Haugan, Director – Innovation and Technology
CC: Mayor Nancy Backus
Date: 10.3.2016
Re: Internet Access – Digital Parity Update
Council Members and Junior City Council Members,
Council determined, in November of 2015, that access to broadband services was critical to all
residents of Auburn. You established Council Strategic Goal # 2: Achieving Digital Parity by 2020
in support of that. This briefing will bring you up to date on progress and provide some context for
the project.
A key, driving philosophy provides the foundation for this project, that being that all residents
of Auburn have a fundamental right to equal broadband internet access. As the world we live
in today is a connected world, driven by and supported by technology in all facets of our lives,
equal access to broadband technology is critical. This is very important to our low income
neighborhoods in Auburn where we have students without 24/7 access. Our goal is to make
sure broadband access is available to all residents, equally.
Our plan to achieve Digital Parity is a multiphase plan including infrastructure expansion,
broadband delivery and partnerships with neighboring communities, Auburn Schools and, on
a regional level, Auburns involvement with the Community Connectivity Consortium.
This evenings presentation will give you a glimpse into the scope of the project, our efforts to
date, our projected plans for 2017 and 2018 and the expected end result.
Thank you
Paul Haugan, Director
Department of Innovation and Technology
DI.A Page 61 of 162
Heroin and Prescription Opiate Addiction Task Force
Final Report and Recommendations
September 15, 2016
DI.A Page 62 of 162
Cover image: Deaths involving major drugs of abuse, King County, 2013-2015, from
Caleb Banta-Green, University of Washington Alcohol and Drug Abuse Institute
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Heroin and Prescription Opiate Addiction Task Force Report Page 1 of 99
Heroin and Prescription Opiate Addiction Task Force
Final Report and Recommendations
September 15, 2016
I. Executive Summary
Heroin and opioid use are at crisis levels in King County. In 2015, 229 individuals died from
heroin and prescription opioid overdose in King County alone.1 To confront this crisis, in March
2016, King County Executive Dow Constantine, Seattle Mayor Ed Murray, Renton Mayor Denis
Law and Auburn Mayor Nancy Backus convened the Heroin and Prescription Opiate Addiction
Task Force. The Task Force, co-chaired by the King County Department of Community and
Human Services and Public Health – Seattle & King County, was charged with developing both
short and long-term strategies to prevent opioid use disorder, prevent overdose, and improve
access to treatment and other supportive services for individuals experiencing opioid use
disorder.
Task Force participants included: All Home; American Civil Liberties Union; Auburn Police
Department; City of Bellevue Fire Department; City of Seattle Mayor’s Office; Department of
Community and Human Services; Department of Social and Health Services, Children’s
Administration; Downtown Emergency Services Center; Evergreen Treatment Services;
Harborview Medical Center; Hepatitis Education Project; Kelley-Ross Pharmacy; King County
Adult Drug Diversion Court; King County Emergency Medical Services; King County Needle
Exchange; Neighborcare Health; King County Prosecuting Attorney’s Office; King County
Sheriff’s Office; Muckleshoot Tribe; People’s Harm Reduction Alliance; Public Defender
Association; Public Health – Seattle & King County; Puget Sound Educational Service District;
Recovery Community; Renton Police Department; Seattle Children’s; Seattle Fire Department;
Seattle Human Services Department; Seattle Police Department; Seattle Public Schools;
Swedish Hospital, Pregnant and Parenting Woman Program; Therapeutic Health Services;
United States Attorney for Western Washington’s Office; United States Department of Veterans
Affairs, Veterans Health Administration; United States Substance Abuse and Mental Health
Services Administration (SAMHSA); University of Washington Alcohol and Drug Abuse Institute
(ADAI); Washington State Department of Social and Health Services, Behavioral Health
Administration; and Washington State Health Care Authority.
The Heroin and Prescription Opiate Addiction Task Force met over a six month period from
March to September 2016 to review 1) current local, state and federal initiatives and activities
related to prevention, treatment and health services for individuals experiencing opioid use
disorder; 2) promising strategies being developed and implemented in other communities; and
3) evidence-based practice in the areas of prevention, treatment and health services. The Task
1 2015 Drug Trends for King County, Washington, Caleb Banta-Green et al, Seattle: University of
Washington Alcohol & Drug Abuse Institute, July 13, 2016. URL:
http://adai.uw.edu/pubs/pdf/2015drugusetrends.pdf
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Heroin and Prescription Opiate Addiction Task Force Report Page 2 of 99
Force strived to avoid redundancy with other related activities and to leverage existing
partnerships and activities where appropriate. Additionally, the Task Force applied an equity
and social justice lens to the work to ensure that recommendations do not exacerbate, but
rather lessen, inequities experienced by communities of color as a direct result of the “War on
Drugs.”
This report provides a summary of the group’s recommendations to both prevent opioid
addiction and improve opioid use disorder outcomes in King County.
Summary of the primary Task Force recommendations
Primary Prevention:
• Raise awareness and knowledge of the possible adverse effects of opioid use,
including overdose and opioid use disorder;
• Promote safe storage and disposal of medications; and
• Leverage and augment existing screening practices in schools and health care
settings to prevent and identify opioid use disorder.
Treatment Expansion and Enhancement:
• Create access to buprenorphine in low-barrier modalities close to where individuals
live for all people in need of services;
• Develop treatment on demand for all modalities of substance use disorder treatment
services; and
• Alleviate barriers placed upon opioid treatment programs, including the number of
clients served and siting of clinics.
User Health and Overdose Prevention:
• Expand distribution of naloxone in King County; and
• Establish, on a pilot program basis, at least two Community Health Engagement
Locations* (CHEL sites) where supervised consumption occurs for adults with
substance use disorders in the Seattle and King County region. Given the
distribution of drug use across King County, one of the CHEL sites should be
located outside of Seattle.
* The Task Force will refer to sites that provide harm reduction services where supervised
consumption occurs as Community Health Engagement Locations for individuals with
substance use disorders (CHEL sites). This terminology recognizes that the primary purpose
of these sites is to engage individuals experiencing opioid use disorder using multiple
strategies to reduce harm and promote health, including, but not limited to, overdose
prevention through promoting safe consumption of substances and treatment of overdose.
The Task Force’s equity and social justice (ESJ) charge emphases the importance of
providing support and services to the most marginalized individuals experiencing substance
use disorders in the County. The Task Force asserts that the designation CHEL sites is a
non-stigmatizing term that recognizes that these sites provide multiple health interventions
to decrease risks associated with substance use disorder and promote improved health
outcomes.
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II. Background
2016 Heroin and Prescription Opiate Addiction Task Force Formation:
Partnership with King County and Cities of Seattle, Renton and Auburn
In March 2016, King County Executive Dow Constantine, Seattle Mayor Ed Murray, Renton
Mayor Denis Law and Auburn Mayor Nancy Backus announced the formation of a Task Force
of subject matter experts and stakeholders to confront the epidemics of heroin and prescription
opioid addiction and overdose in King County.
Under the direction of the Executive and the Seattle, Renton and Auburn mayors, the
Department of Community and Human Services (DCHS) partnered with Public Health – Seattle
& King County to co-chair the Task Force. Task Force members represented multiple entities,
including the University of Washington Alcohol and Drug Abuse Institute (ADAI), behavioral
health services providers, hospitals, human service agencies, the recovery community, criminal
justice partners, first responders, and others. Based on a review of evidence-based and
evidence-informed practices and current strategies used in other communities, and building on
recommendations established by Johns Hopkins Bloomberg School of Public Health2 and the
2016 Washington State Interagency Opiate Plan3, the Task Force developed recommendations
to both prevent opioid addiction and improve opioid use disorder outcomes in King County.
Statement of the Problem
Opioid prescribing has increased significantly since the mid-1990s and has been paralleled by
increases in pharmaceutical opioid misuse and opioid use disorder, heroin use, and fatal
overdoses.4 These increases in morbidity and mortality were seen among those who were
prescribed opioids and those who were not. When opioid prescribing began decreasing
between 2005-2010, the number of teens in Washington State reporting use of these medicines
2 Alexander GC, Frattaroli S, Gielen AC, eds. The Prescription Opiate Epidemic: An Evidence-Based
Approach. Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland: 2015
3 Department of Health. (2016). Washington State Interagency Opiate Working Plan. Retrieved from:
http://stopoverdose.org/FINAL%20State%20Response%20Plan_March2016.pdf
4 Jones, C. M., Mack, K. A. & Paulozzi, L. J. Pharmaceutical overdose deaths, United States, 2010. JAMA
309, 657–9 (2013);
Paulozzi, L. J., Budnitz, D. S. & Xi, Y. Increasing deaths from opiate analgesics in the United States.
Pharmacoepidemiol. Drug Saf. 15, 618–27 (2006);
Paulozzi, L. J., Zhang, K., Jones, C. M. & Mack, K. A. Risk of adverse health outcomes with increasing
duration and regularity of opiate therapy. J. Am. Board Fam. Med. 27, 329–38 (2014); and
Jones, C. M., Paulozzi, L. J. & Mack, K. A. Sources of prescription opiate pain relievers by frequency of
past-year nonmedical use United States, 2008-2011. JAMA Intern. Med. 174, 802–3 (2014).
DI.A Page 66 of 162
Heroin and Prescription Opiate Addiction Task Force Report Page 4 of 99
to “get high” also decreased. As pharmaceutical opioids became less available, some people
with opioid use disorder switched to heroin because of its greater availability and lower cost.5
Heroin, however, brings with it higher risks for overdose, infectious disease and, because it is
illegal, incarceration.6
While these dynamics have affected individuals of all age groups, the impact is particularly
striking for adolescents and young adults, with research indicating that youth ages 14-15
represent the peak time of initiation of opioid misuse.7 Since 2005, this young cohort has
represented much of the increase in heroin-involved deaths and treatment admissions in King
County and Washington State.8
In King County, heroin use continues to increase, resulting in a growing number of fatalities. In
2013, heroin overtook prescription opioids as the primary cause of opioid overdose deaths. By
2014, heroin-involved deaths in King County totaled 156, “their highest number since at least
1997 and a substantial increase since the lowest number recorded, 49, in 2009.”9 Increases in
heroin deaths from 2013 to 2014 were seen in all four regions of the County, with a total
increase from 99 to 156.10 Heroin-involved overdose deaths in King County remain high with
132 deaths in 2015.11 (See Attachment A for Map of Overdose Deaths in King County, 2013-
2015.) Although prescription opioid-involved deaths have been dropping since 2008, many
individuals who use heroin, and the majority of young adults who use heroin, report being
hooked on prescription-type opioids prior to using heroin.12
5 Jones, C. M., Logan, J., Gladden, R. M. & Bohm, M. K. Vital Signs: Demographic and Substance Use
Trends Among Heroin Users - United States, 2002-2013. MMWR. Morb. Mortal. Wkly. Rep. 64, 719–25
(2015); and
Jones, C. M. Heroin use and heroin use risk behaviors among nonmedical users of prescription opiate
pain relievers - United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 132, 95–100 (2013).
6 Jenkins, L. M. et al. Risk Factors for Nonfatal Overdose at Seattle-Area Syringe Exchanges. J. Urban
Heal. 88, 118–128 (2011); and
Cedarbaum, E. R. & Banta-Green, C. J. Health behaviors of young adult heroin injectors in the Seattle
area. Drug Alcohol Depend. (2015). doi:10.1016/j.drugalcdep.2015.11.011
7 McCabe, S. E., West, B. T., Teter, C. J. & Boyd, C. J. Medical and nonmedical use of prescription
opiates among high school seniors in the United States. Arch. Pediatr. Adolesc. Med. 166, 797–802
(2012); and
Meier, E. A. et al. Extramedical Use of Prescription Pain Relievers by Youth Aged 12 to 21 Years in the
United States. Arch. Pediatr. Adolesc. Med. 166, 803 (2012).
8 Banta-Green, Caleb J., Kingston, Susan, Ohta, John, Taylor, Mary, Sylla, Laurie, Tinsley, Joe, Smith,
Robyn, Couper, Fiona, Harruff, Richard, Freng, Steve, Von Derau, K. 2015 Drug use trends in King
County Washington (2016) at <http://adai.uw.edu/pubs/pdf/2015drugusetrends.pdf>
9 Drug Abuse Trends in the Seattle-King County Area: 2014. Banta-Green, C et al. Alcohol & Drug Abuse
Institute, Univ. of Washington, June 17, 2015. adai.uw.edu/pubs/cewg/DrugTrends_2014_final.pdf
10 Drug Abuse Trends in the Seattle-King County Area: 2014. Banta-Green, C et al. Alcohol & Drug
Abuse Institute, Univ. of Washington, June 17, 2015. adai.uw.edu/pubs/cewg/DrugTrends_2014_final.pdf
11 Drug Abuse Trends in the Seattle-King County Area: 2015. Banta-Green, C et al. Alcohol & Drug
Abuse Institute, Univ. of Washington, July 2016. http://adai.uw.edu/pubs/pdf/2015drugusetrends.pdf
12 Peavy KM, Banta-Green CJ, Kingston S, Hanrahan M, Merrill JO, Coffin PO. “Hooked on Prescription-
Type Opiates Prior to Using Heroin: Results from a Survey of Syringe Exchange Clients,” Journal of
Psychoactive Drugs, 2012:44(3):259-65, and Cedarbaum ER, Banta-Green CJ, “Health Behaviors of
Young Adult Heroin Injectors in the Seattle Area,” Drug Alcohol Depend [Internet] 2015 [cited 2015 Dec
18]; available from http://www.ncbi.nlm.nih.gov/pubmed/26651427
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According to the Centers for Disease Control and Prevention, more people die In the United
States of drug-related overdose than from auto accidents, a difference that has been growing
since 2008. In 2000, there were more than 40,000 traffic-related deaths and fewer than 20,000
from drug overdose; in 2013 there were 43,982 overdose-related deaths and 32,719 traffic
fatalities.13
From 2010 to 2014 the number of people who entered the publicly funded treatment system for
heroin use disorders annually in King County grew from 1,439 to 2,886. This increase occurred
while the number of people receiving treatment for all other primary drugs of choice declined
(except for people with methamphetamine use disorders).14 In fact, for the first time, heroin
treatment admissions surpassed alcohol treatment admissions in 2015. The majority of those
entering treatment for heroin for the first time were ages 18-29; among this age group, half
reported injecting and half reported smoking heroin, a pattern that began slowly emerging in
2009.15 Heroin is also the most commonly mentioned drug among callers to the County
Recovery Help Line, totaling 2,100 in 2015, almost double the number in 2012. 16
Opioid treatment programs (OTP) that dispense methadone and buprenorphine in King County
have been working to expand capacity, and the number of admissions to these programs
increased from 696 in 2011 to 1,486 in 2014.17 As of October 1, 2015, there were 3,615 people
currently maintained on methadone at an OTP in King County.18 Statutory capacity limitations
have historically resulted in up to 150 people on a waitlist. Buprenorphine is another proven
opioid use disorder medication that cuts the odds of dying in half compared to no treatment or
counseling only.19 It can be provided at an OTP but, unlike methadone, it can also be prescribed
by a physician in an office-based setting and obtained at a pharmacy. Requests for
buprenorphine treatment by callers to the County Recovery Help Line have increased from 147
in 2013 to 363 in 2015.20 Treatment capacity for buprenorphine is limited and far exceeded by
demand.
13 Center for Disease Control. (2015, April 30). Injury Prevention & Control: Prescription Drug Overdose
Retrieved from http://www.cdc.gov/drugoverdose/data/overdose.html
14 TARGET database, Washington State Publically funded treatment, Division of Behavioral Health and
Recovery.
15 Drug Abuse Trends in the Seattle-King County Area: 2015. Banta-Green, C et al. Alcohol & Drug
Abuse Institute, Univ. of Washington, July 2016. http://adai.uw.edu/pubs/pdf/2015drugusetrends.pdf
16 Drug Abuse Trends in the Seattle-King County Area: 2015. Banta-Green, C et al. Alcohol & Drug
Abuse Institute, Univ. of W ashington, July 2016. http://adai.uw.edu/pubs/pdf/2015drugusetrends.pdf
17 TARGET database, Washington State Publically funded treatment, Division of Behavioral Health and
Recovery.
18 TARGET database, Washington State Publically funded treatment, Division of Behavioral Health and
Recovery.
19 Pierce, M., Bird, S. M., Hickman, M., Marsden, J., Dunn, G., Jones, A., and Millar, T. (2016) Impact of
treatment for opiate dependence on fatal drug-related poisoning: a national cohort study in England.
Addiction, 111: 298–308.
20 Drug Abuse Trends in the Seattle-King County Area: 2015. Banta-Green, C et al. Alcohol & Drug
Abuse Institute, Univ. of Washington, July 2016. http://adai.uw.edu/pubs/pdf/2015drugusetrends.pdf
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0
500
1,000
1,500
2,000
2,500
3,000
2005 2007 2009 2011 2013
Alcohol
Cocaine
Methamphetamines
Heroin and other
opiates
In addition to being the leading reason
for entering a drug treatment program,
heroin is now also the primary drug
used by people seeking withdrawal
management (detoxification) in the
King County publicly funded treatment
system, surpassing alcohol.21 Also,
people seeking opioid withdrawal
management are younger than in
previous years. According to the King
County Substance Abuse Prevention
and Treatment Annual Report, “From
the first half of 2008 through the second half of 2011, there was a steady increase in the number
and percentage of young adults under 30 years old entering detoxification services. The
numbers and percentages of young adults leveled off during 2012, and have remained at higher
levels. Among all individuals admitted in 2014, 85% of those younger than 30 years old
indicated opioids are their primary drug used compared to 41% of those 30 years or older.”22
Syringe exchange services remain a readily
accessible effective health intervention and the
demand for this service continues to grow.
Close to six million clean syringes are handed
out annually in King County.23 In a recent
Washington State survey of syringe exchange
users, 75% were interested in getting help
reducing or stopping their use, yet only 14%
were enrolled in treatment.24
Homelessness is also a persistent problem in our community. The 2016 King County One Night
Count found that 4,505 of our neighbors in King County were without shelter this year, a 19%
increase over 2015. W hile the leading cause of death among homeless Americans used to be
HIV, it is now drug overdose. A study in JAMA Internal Medicine found that overdoses, most of
which involved opioids, are now responsible for the majority of deaths among individuals
experiencing homelessness in the Boston area. The same trend is occurring locally, as
documented in the death reports of individuals experiencing homelessness in King County.
21 TARGET database, Washington State Publically funded treatment, Division of Behavioral Health and
Recovery.
22 King County Mental Health, Chemical Abuse and Dependency Services Division. Substance Abuse
Prevention and Treatment Annual Report, 2014 23 Drug Abuse Trends in the Seattle-King County Area: 2014. Banta-Green, C et al. Alcohol & Drug Abuse
Institute, Univ. of Washington, June 17, 2015. adai.uw.edu/pubs/cewg/DrugTrends_2014_final.pdf
24Results from the 2015 Washington State Drug Injector Health Survey, February 2016. Kingston, S. and
Banta-Green, C. Alcohol and Drug Abuse Institute, Univ. of Washington.
http://adai.uw.edu/pubs/infobriefs/2015DrugInjectorHealthSurvey.pdf
Figure 1: Heroin has Surpassed Alcohol as Primary Drug Reported on
Admission to Detoxification Services in King County
Figure 2 Syringe Exchange data 1989-2014, King County, WA
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While the causes of homelessness are multi-faceted and complex, substance abuse is both a
contributing cause and result of homelessness.
There is an urgent need for action. Fortunately, a variety of evidence-based interventions exist
that have demonstrated effectiveness at helping individuals reduce opioid use and decrease
related harms. Identifying creative ways to expand the use of, and access to, effective
interventions is paramount to curbing the effects of heroin and other opioids in the community.
Building on History and Current Actions
From 1999 to 2001, then Seattle Mayor Paul Schell and King County Executive Ron Sims
convened a multi-sector task force to address the rise in heroin use in the community. The
group generated a set of recommendations to address the heroin epidemic. In 2007, the King
County Board of Health adopted a Resolution on HIV / AIDS that endorsed a Public Health King
County Strategic and Operational Plan for HIV Prevention in King County, which supported
addressing harm from intravenous drug use through different health promotion and prevention
activities.25 In 2015, a Washington State Interagency Opiate Working Plan was drafted by a
collaboration of the Department of Health, Division of Behavioral Health and Recovery and the
University of Washington Alcohol and Drug Abuse Institute. Additionally, in 2015 a legislative
workgroup was convened by state Representatives Brady Walkinshaw and Strom Peterson
along with state Senator David Frockt to develop strategies to address the need to help people
engage in opioid treatment and reduce overdose. This current Task Force drew from those
initiatives and leveraged other activities and partnerships to develop a plan to respond to the
region’s growing heroin and opioid addiction problem.
III. 2016 Heroin and Prescription Opiate Addiction Task Force Charge
Responding to the direction of the sponsors of the 2016 Heroin and Prescription Opiate
Addiction Task Force to confront the heroin and opioid epidemic with immediate action, the
Task Force identified specific focus areas based on their potential to have the broadest and
most meaningful public health impact on the region’s heroin epidemic. The specific areas of
focus are:
A. Primary Prevention (of opioid use disorders)
• Prescriber education
• Public education for adults and youth
• Prescription drug take-back (aka secure medication return)
• Enhancing screening for opioid misuse and opioid use disorder
B. Treatment Expansion and Enhancement
• Treatment on demand for all needed modalities of treatment
• Innovative buprenorphine prescribing practices
25 Final Report and Recommendations: September 20, 2007. King County Board of Health HIV/AIDS
Committee
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C. User Health Services and Overdose Prevention
• Expansion of access to naloxone
• Community Health Engagement Locations for individuals with substance use
disorders (CHEL sites) where supervised consumption occurs
Task Force members agreed that their work and recommendations must be directly influenced
by equity and social justice considerations. The Task Force developed the following equity and
social justice charge:
The Task Force will apply an Equity and Social Justice (ESJ) lens to all of its work. We
acknowledge that the “War on Drugs” has disproportionately adversely impacted some
communities of color, and it is important that supportive interventions recommended now
not inadvertently replicate that pattern. Interventions to address the King County heroin
and opioid problem will or could affect the health and safety of diverse communities,
directly and indirectly (through re-allocation of resources). Measures recommended by
the Task Force to enhance the health and well-being of heroin and opioid users or to
prevent heroin and opioid addiction must be intentionally planned to ensure that they
serve marginalized individuals and communities. At the same time, the response to
heroin and opioid use must not exacerbate inequities in the care and response provided
among users of various drugs. All recommendations by the Task Force will be reviewed
using a racial impact statement framework. The Task Force will not seek to advance
recommendations that can be expected to widen racial or ethnic disparities in health,
healthcare, other services and support, income, or justice system
involvement. Whenever possible, these concerns should lead to broadening the
recommendations of the Task Force, rather than leaving behind interventions that are
predicted to enhance the health and well-being of heroin and opioid users.
IV. SUMMARY OF TASK FORCE PROCESS
The Executive and mayors of Seattle, Renton and Auburn, in conjunction with the Departments
of Community and Human Services and Public Health – Seattle & King County, appointed
members to the Task Force from the following entities:
1. All Home
2. American Civil Liberties Union
3. Auburn Police Department
4. City of Bellevue Fire Department
5. City of Seattle Mayor’s Office
6. Department of Community and Human Services
7. Department of Social and Health Services, Children’s Administration
8. Downtown Emergency Services Center
9. Evergreen Treatment Services
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10. Harborview Medical Center
11. Hepatitis Education Project
12. Kelley-Ross Pharmacy
13. King County Adult Drug Diversion Court
14. King County Emergency Medical Services
15. King County Needle Exchange
16. King County Prosecuting Attorney’s Office
17. King County Sheriff’s Office
18. Muckleshoot Tribe
19. Neighborcare Health
20. People’s Harm Reduction Alliance
21. Public Defender Association
22. Public Health – Seattle & King County
23. Puget Sound Educational Service District
24. Recovery Community
25. Renton Police Department
26. Seattle Children’s
27. Seattle Fire Department
28. Swedish Hospital, Pregnant and Parenting Woman Program
29. Seattle Human Services Department
30. Seattle Police Department
31. Seattle Public Schools
32. Therapeutic Health Services
33. United States Attorney for Western Washington’s Office
34. United States Department of Veterans Affairs, Veterans Health Administration
35. United States Substance Abuse and Mental Health Services Administration (SAMHSA)
36. University of Washington Alcohol and Drug Abuse Institute (ADAI)
37. Washington State Department of Social and Health Services, Behavioral Health
Administration
38. Washington State Health Care Authority
The Task Force met five times between March and September 2016 and was chaired by Brad
Finegood, M.A. (Assistant Director of the King County Behavioral Health and Recovery Division,
Department of Community and Human Services, DCHS) and Dr. Jeff Duchin, M.D. (Health
Officer, Public Health – Seattle & King County, PHSKC). A list of the Task Force members is
provided in Attachment B.
Three workgroups were initially formed to address the Task Force’s three focus areas (opioid
abuse prevention, treatment expansion and enhancement, and health services and overdose
prevention). These workgroups were comprised of Task Force members with related subject
matter expertise, and met between full Task Force meetings. The prevention workgroup was led
by Dr. Caleb Banta-Green, Ph.D. (University of Washington), and met four times between April
and August 2016. The treatment expansion and enhancement workgroup was led by Brad
Finegood, M.A. and met eight times between April and August 2016. The workgroup addressing
health services and overdose prevention of individuals using opioids was led by Dr. Jeff Duchin,
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M.D., and met nine times between April and August 2016. DCHS and PHSKC staff members
provided support to the workgroups.
A fourth workgroup was formed to address policy considerations associated with expanding the
County’s capacity for treatment, health services, and overdose prevention of individuals using
opioids. This workgroup was led by Brad Finegood and was comprised of Task Force members
and non-Task Force subject matter experts. The policy workgroup met four times between May
and August 2016. A fifth workgroup was formed to plan for evaluation of recommendations
implemented by the sponsors. This workgroup was led by Caleb Banta-Green and was also
comprised of Task Force members and non-Task Force subject matter experts. A list of the five
workgroups and their respective members is included in Attachment C.
During the course of the Task Force process, a series of community meetings was held in order
to 1) provide public education about heroin and opioid addiction, treatment and health services,
and/or 2) to obtain community input as the Task Force developed strategies and meaningful
solutions to the problem of addiction and overdose in King County. Community meetings
included the following:
• Presentation on the Heroin and Prescription Opiate Addiction Task Force to legislative
staff, which was held at Sea Mar Community Health Center in Des Moines, W ashington
on August 16, 2016
• The Sound Cities Administration Meeting, which was held in Renton on July 5, 2016
• Presentation on Practical Implementation of an Agency Opiate Overdose Response
Policy at the Washington State Behavioral Healthcare Conference in Yakima on
June 23, 2016
• A Community Conversation about Addiction and Recovery, which was held at Thomas
Jefferson High School in Auburn on June 9, 2016
• The Heroin Epidemic: A Community Conversation, which was held at the Museum of
History and Industry in Seattle on June 6, 2016 (aired on public television on July 5,
2016)
• Community Conversation: Heroin and Prescription Opiate Overdose and Addiction,
which was sponsored and facilitated by the Heroin and Prescription Opiate Addiction
Task Force, and held at the Renton Community Center on May 31, 2016 (See
Attachment D for Community Conversation [May 31, 2016]: Attendee Comments.)
• Presentation on the Heroin Epidemic and Local Efforts at a summit sponsored by the
Seattle Municipal Court bench, held at the Seattle Municipal Court on May 20, 2016.
• Presentation on Medication-Assisted Treatment Services and the Opiate Epidemic at the
Kent Municipal Court on May 13, 2016
• Presentation on the Heroin Epidemic at the Seattle University Symposium: Addressing
Seattle’s Urban Disorder with Collective Efficacy Principles on May 6, 2016
• The Recovery Café Community Conversation and Screening of Frontline Documentary
Chasing Heroin, which was held at the Recovery Café in Seattle on May 2, 2016
• Presentation on Practical Implementation of an Agency Opiate Overdose Response
Policy at the statewide Conference on Ending Homelessness in Spokane on May 11,
2016
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• Presentation on the Heroin Epidemic and Local Efforts to the Ballard Community
Taskforce on Homelessness and Hunger, which was held at the Nyer Urness House on
April 28, 2016
• Presentation on Medication-Assisted Treatment Services at The Heroin Epidemic: New
Challenges for the Courts, hosted by the Lake Forest Park Municipal Court on April 11,
2016
• Presentation on the Heroin Epidemic and Local Efforts to the King County Regional Law
Safety and Justice Committee at Seattle City Hall on March 31,2016
• Lessons from the North: Canada's Safe Consumption Space, Harm Reduction, and
Seattle's Crisis, which was held at 12 Ave Arts of Capitol Hill Housing in Seattle on
March 23, 2016
• Leading the Way: Public Health & Safety Approaches to Drug Policy Locally, Nationally,
and Abroad, which was held at Seattle University on March 22, 2016
• Better is Better: Harm Reduction, Safe Consumption, and the Heroin Epidemic, which
was held at the University of Washington on March 21, 2016
• Seattle City Council Lunch and Learn with Insite Co/Founders, which was held at Seattle
City Hall on March 21, 2016
Task force members also utilized various media venues (including radio, television, print and
social media) to discuss the heroin epidemic and efforts to address this issue.
V. Recommendations
Task Force recommendations were generated by the Primary Prevention workgroup, Treatment
Expansion and Enhancement workgroup, and User Health Services and Overdose Prevention
workgroup, in collaboration with Policy and Evaluation workgroups. Workgroup
recommendations were presented to the full Task Force on two separate occasions for review,
feedback and modification, culminating in a final vote on each recommendation. The Task Force
Chairs determined that approval of recommendations would be based on achievement of a
simple majority of voting members of the Task Force. Attachment B displays the voting
members of the Task Force. City of Seattle and King County employees that report to the Task
Force conveners did not vote on the final recommendations, although they participated in work
group deliberations. Additionally, the U.S. Attorney for Western Washington, Annette Hayes,
participated as a non-voting member. In total, seven recommendations were approved during a
Task Force meeting and one recommendation was approved by e-mail vote. (See Attachment E
for Summary of Recommendation Voting Tally.)
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Primary Prevention Workgroup Recommendations
1. Raise awareness and knowledge of the possible adverse effects of opioid use,
including overdose and opioid use disorder.
Goals:
• Opioid prescribing is appropriate in terms of who receives prescriptions, indications for
treatment, and the type, amount and duration of opioid prescribed.
• Prescribers and those they serve will have sufficient understanding of evidence-based
risks and benefits of opioids, other pain management strategies, and screening for
opioid use disorder and overdose risks to make appropriate decisions regarding opioids.
• Parents of adolescents and children will receive information adequate to understand the
risks and benefits of opioids for acute pain, other pain management strategies, as well
as information on safe storage and disposal.
Rationale:
• Opioid prescribing has increased dramatically over the past 20 years. In recent years,
the increase has plateaued in Washington State (see Figure below). However, the
overall increase in prescribing of opioids over the last 20 years has contributed to
increased misuse, opioid use disorder, and fatal overdoses among both those who were
prescribed and not prescribed opioids.26
26 Jones, C. M., Mack, K. A. & Paulozzi, L. J. Pharmaceutical overdose deaths, United States, 2010.
JAMA 309, 657–9 (2013).
Paulozzi, L. J., Budnitz, D. S. & Xi, Y. Increasing deaths from opioid analgesics in the United States.
Pharmacoepidemiol. Drug Saf. 15, 618–27 (2006).
Paulozzi, L. J., Zhang, K., Jones, C. M. & Mack, K. A. Risk of adverse health outcomes with increasing
duration and regularity of opioid therapy. J. Am. Board Fam. Med. 27, 329–38 (2014).
Jones, C. M., Paulozzi, L. J. & Mack, K. A. Sources of prescription opioid pain relievers by frequency of
past-year nonmedical use United States, 2008-2011. JAMA Intern. Med. 174, 802–3 (2014).
Opioids sold in WA (Drug Enforcement Administration)
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• Education and improved opioid prescribing may help reduce the risk of substance
misuse while providing appropriate pain management.
• Providers who have registered for and use Washington’s Prescription Drug Monitoring
Program (PDMP) will have an informed understanding of the individual’s prescription
opioid use history and will be better able to assess risk for overdose and indications of
possible misuse resulting in improved care. Washington regulations27 state:
The physician shall obtain, evaluate, and document the patient's health history
and physical examination in the health record prior to treating for chronic non-
cancer pain.
(2) The patient's health history should include:
(a) A review of any available prescription monitoring program or
emergency department-based information exchange
• Education and support is critical to prevention and allows the individual seeking services
to have an active role in their care and to recognize warning signs of opioid misuse.
• Impacting inappropriate opioid access requires behavior changes on the part of
prescribers, patients, and family/household members. These same people should also
be involved in addressing motivation to use opioids, including ways to think about and
respond to physical and emotional pain as well as social pressures.
• Opioid misuse is currently an epidemic and prescribers and/or healthcare professionals
across all settings play a key role in raising awareness. To reach all consumers,
prevention practices should be implemented universally across settings and populations
to address equity and social justice concerns.
• Concerns regarding opioids need to be balanced with the need for adequate pain
control, especially in light of evidence of disparities in accessing opioid medication for
pain, particularly for African Americans.
Approach:
• Coordinate with governmental agencies, professional organizations,
medical/dental/nursing schools, health care training institutes, and health care systems
to educate physicians on responsible opioid prescribing practices and pain management
oversight.
• Create and distribute an educational flyer and counseling guide for use during opioid
prescribing visits (medical /dental office or pharmacy) that addresses risk for overdose,
addiction potential and other risk factors for those with pain conditions who are potential
candidates for opioids. (See Attachment F for Implementation and Planning Details.)
• Encourage providers to register and use the PDMP. Increased outreach efforts will occur
through King County Public Health and DCHS staff to professional organizations to
inform them of the availability and utility of the PDMP and encourage utilization.
27 http://app.leg.wa.gov/wac/default.aspx?cite=246-919-853
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• Launch education campaign to reach broad audience including the general public,
individuals using opioids, social networks, and professionals. (See Attachment F for
Implementation and Planning Details.)
• Distribute counseling guidelines and other tools to pharmacists, behavioral health
specialists, and other healthcare professionals and encourage them to provide education
on prescription opioid safety (storage, disposal, overdose prevention, risk factors for
addiction, and response to overdose).
2. Promote safe storage and disposal of medications.
Goals:
• Prevent access to and initiation of opioids by those not prescribed the medication.
• Prevent opioid overdoses.
Rationale:
• The number of non-medical users of opioid pain relievers (4.5 million in 2013 per the
Substance Abuse and Mental Health Services Administration (SAMHSA) is high. Youth
and adults access these medications through medicine cabinets, homes and sharing.
• Limiting access to opioids can potentially prevent misuse and inappropriate initiation
among adolescents. The physical and mental health consequences of opioid misuse
are significant, including fatal overdoses and opioid use disorder.
• Research indicates that the ages of 14-15 years represent the peak time of initiation of
opioid misuse.28 Adolescents who initiated misuse of opioids between 2005-2010 now
represent many of the young adults dying from heroin involved overdoses or entering
treatment across King County and Washington State.29 Washington data indicate that
5% of 10th graders in 2014 reported using prescription-type opioids to get high in the
past month and that there was a strong correlation with using heroin at some point in
time (see figure on page 15). Note that in 2006 10% of 10th graders reported past month
use and that the decline over time coincides closely with declines in prescribing of potent
opioids in Washing ton state.
• A majority of individuals using heroin report initially using pharmaceutical opioids.
• Universal education should help de-stigmatize discussing opioid safety. Focusing
educational messages on the inherent dangers of opioids may make individuals more
receptive to messaging and more likely to change behaviors.
• Note there is no known published research on the effectiveness of interventions to
specifically prevent abuse of pharmaceutical opioids or heroin.
28 McCabe, S. E., West, B. T., Teter, C. J. & Boyd, C. J. Medical and nonmedical use of prescription
opioids among high school seniors in the United States. Arch. Pediatr. Adolesc. Med. 166, 797–
802(2012); and
Meier, E. A. et al. Extramedical Use of Prescription Pain Relievers by Youth Aged 12 to 21 Years in the
United States. Arch. Pediatr. Adolesc. Med. 166, 803 (2012).
29 Banta-Green, Caleb J., Kingston, Susan, Ohta, John, Taylor, Mary, Sylla, Laurie, Tinsley, Joe, Smith,
Robyn, Couper, Fiona, Harruff, Richard, Freng, Steve, Von Derau, K. 2015 Drug use trends in King
County Washington. (2016). at <http://adai.uw.edu/pubs/pdf/2015drugusetrends.pdf>
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Approach:
• Encourage pharmacies to provide counseling on safe storage and disposal of opioids
and other controlled substances at the time of a first prescription in order to prevent
unintended access to these medications. (See Attachment G for Implementation and
Planning Details.)
• Increase pharmacy participation in promoting safe storage and medicine disposal to
expand community awareness across all areas in the County.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• Expand access to prescription-take-back programs via King County Secure Medication
Return locations and mail back envelopes. Coordinate and collaborate with the King
County Secure Medication Return program to ensure population wide education and
pharmacy based education. Incorporate consistent guidance on safe disposal methods
for medications.
• In addition to providing education on the importance of disposal of unused and unwanted
medication, engage local pharmacies to distribute mail-back envelopes with each opioid
prescription dispensed.
• Use social media to promote safe storage and disposal of medications.
• Background Information
• Sample education materials (to be amended with King County info)
http://here.doh.wa.gov/materials/safe-use-of-prescription-pain-medication
• Overview of trajectories of adolescent use and misuse of opioids
http://archpedi.jamanetwork.com/article.aspx?articleid=1149405
Trends in the use of Rx-type opiates to “get high” among 10th graders and the association with heroin use
The proportion of 10th graders reporting using
prescription-type opioids to get high in the past month
declined significantly from 10% to 5% from 2006-2014
Among 10th graders those who reported they had
used prescription-type opioids to get high in the past
month 19% had ever used heroin, compared to 3%
among those not using prescription-type-opioids to get
high.
SOURCE: Healthy Youth Survey, analysis Alcohol and Drug Abuse Institute, University of Washington
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3. Leverage and augment existing screening practices in schools and health care
settings to prevent and identify opioid use disorder.
Goals:
• Identify youth who are at risk for developing opioid-related problems or who have
developed opioid use disorder, using validated screening tools.
• Increase access to substance use disorder assessment and treatment, regardless of
income, and provide appropriate services, brief interventions and referrals for them.
Rationale:
• Behavioral health agencies, primary care clinics, hospitals and other service
organizations are currently providing screenings for substance use disorders.
• Non-medical use of opioids peaks between the ages of 14-16 indicating that screening
needs to occur prior to and during adolescence
http://www.ncbi.nlm.nih.gov/pubmed/22566514 .
• Treatment of substance use disorder is most effective when identification, referrals, and
interventions are delivered during the early stages.
• Behavioral health agencies deliver school-based services in a number of middle schools
and high schools in King County. Because opioids are so prevalent and initiation often
happens among teens, it is important to identify, as early as possible, those who are at
risk for or already misusing opioids. Providers delivering services in these settings are
not always aware of opioid-related resources or equipped with tools to discuss opioid
use.
• Behavioral health agencies can engage clients in a brief intervention and educational
dialogue for those that screen positive for opioid misuse and/or related risk factors.
• Seattle Public Schools has social-emotional development curriculum for students that
addresses holistic healthy development. There is opportunity to enhance this education
and open dialogue in an existing practice within schools.
• Education and support is critical to prevention and allows individuals to have an active
role in their care and recognize warning signs and risks of opioid misuse.
• Community education reduces stigma associated with use, promotes public health,
helps individuals recognize the complexity of the issue, and empowers people to ask for
help.
• To reach all consumers prevention practices should be universal to address equity and
social justice concerns.
Approach:
• Expand existing school based screening, brief interventions and referrals for substance
use, to include accurate and actionable information related to opioid misuse.
• Work with schools to have information available to students and families.
• Provide professionals with training on opioid use disorders, local resources, and
interventions, including research-backed interventions for opioid use disorder.
• Explore opportunities to expand screening to other settings and populations.
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• Work with the Department of Social and Health Services Children’s Administration on
referral process for high risk youth for substance use disorder treatment.
Treatment Expansion and Enhancement Recommendations
1. Create access to buprenorphine for all people in need of services, in low-barrier
modalities close to where individuals live.
Goal:
• Individuals experiencing opioid use disorder, who desire opioid agonist
pharmacotherapy with buprenorphine, will have access to treatment on demand.
Treatment on demand is defined as the individual meeting with a prescriber immediately,
or on day one or day two, to initiate treatment.
Rationale:
• This recommendation would expand access to buprenorphine, an evidence-based
treatment for opioid use disorder. Unlike methadone treatment, which is restricted to a
limited supply of licensed programs, buprenorphine treatment can be prescribed by a
general physician in an office-based setting. 30
• This recommendation would support treatment on demand by establishing access points
for treatment induction, coordination and maintenance of care at behavioral health
clinics, community health clinics, emergency rooms, and other sites already frequented
by individuals with opioid use disorder seeking opioid agonist pharmacotherapy.
• This recommendation would address equity and social justice concerns, as evidence
demonstrates racial/ethnic and socioeconomic disparities in use of buprenorphine for
treatment of opioid use disorder. 31 In particular, data suggest that individuals receiving
buprenorphine for treatment of opioid use disorder are more likely to be white and have
higher incomes than those receiving methadone. Expanding geographic access points to
include health care providers that serve traditionally underserved people throughout King
County would alleviate this disparity.
• This recommendation has the potential to reduce stigma associated with treatment of
opioid use disorder, as individuals can obtain treatment outside of federally regulated
methadone clinics if desired, and providers would obtain training on treatment of
addiction that they could integrate into their general practice of medicine.
• This recommendation would support ongoing efforts in the community to achieve
integrated and holistic care (mental health, substance use, and primary care treatment
services) for persons with physical and behavioral health problems.
30 Alexander GC, Frattaroli S, Gielen AC, eds. The Prescription Opioid Epidemic: An Evidence-Based
Approach. Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland: 2015 31 Hansen, H. B., Siegel, C. E., Case, B. G., Bertollo, D. N., DiRocco, D., & Galanter, M. (2013). Variation
in use of Buprenorphine and Methadone Treatment by Racial, Ethnic and Income Characteristics of
Residential Social Areas in New York City. The Journal of Behavioral Health Services & Research, 40(3):
367-377.
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• This recommendation, which supports the creation of low-barrier treatment, has the
potential to engage individuals in opioid use disorder treatment and other supportive
services who may not engage in traditional substance use disorder treatment.
• This recommendation, which increases access to effective treatment, has the potential
to reduce harm associated with untreated opioid addiction, including fatal overdose,32
infectious disease and other health complications, and incarceration.
Approach:
• Utilize multiple access points to facilitate buprenorphine induction and maintenance. This
approach is informed by the San Francisco Integrated Buprenorphine Intervention
Services (IBIS) program (see Attachment H for IBIS Process Protocol), adapted to meet
the needs of our local communities. Level 1 facilities will focus on induction of
buprenorphine for individuals experiencing opioid use disorder in a low-barrier modality.
A Level 1 facility would provide frequent dosing of buprenorphine treatment until an
individual has stabilized. Once stabilized on buprenorphine treatment, an individual may
transfer their care to a Level 2 or Level 3 facility of their choice to continue
buprenorphine services with a less frequent dosing regimen (referred to as
buprenorphine maintenance services). Importantly, induction will not be restricted to
Level 1 facilities; individuals may also access induction services at Level 2 and Level 3
facilities.
• Centralized client care coordination across the system will be necessary to ensure
treatment on demand and successful transfer of buprenorphine services from a Level 1
facility to a Level 2 or 3 Facility. One current model that could be built upon is the
Recovery Help Line. The Recovery Help Line offers 24-hour emotional support and
referrals to local treatment services. (See Attachment I for Buprenorphine System of
Care: Implementation and Planning Details associated with establishing buprenorphine
services in Level 1 through Level 3 Facilities.)
Level 1 Facilities
Downtown Public Health Needle Exchange Induction Site
Emergency Department Induction Sites
Recovery Center Valley Cities Detox and Residential Facility
Mobile Medical Van
King County Correctional Facilities
Level 2 Facilities
Community Health Clinics (CHCs)
Level 3 Facilities
Behavioral Health Clinics, including traditional medication-assisted treatment
(MAT) facilities
32 Banta-Green, C. J., and Coffin, P. O. (2016) Commentary on Pierce et al. (2016): Raising the bar of
addiction treatment—first do no harm. Addiction, 111: 309–310.
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• A “buprenorphine first” model of care aims to use buprenorphine treatment induction
and stabilization as the priority health intervention. A traditional approach to treatment
has provided quality care to a subset of the overall population of individuals with opioid
use disorder who are able to consistently and predictably engage in treatment and
adhere to stringent treatment requirements (regular appointment attendance, urinalysis
testing, etc.). However, individuals who 1) are experiencing homelessness, 2) have
limited or no support systems, and/or 3) have complex medical and behavioral health
needs may experience difficulty successfully engaging and receiving care at traditional
opioid treatment programs. A “buprenorphine first” model of care is an alternative
approach to opioid treatment that is client-centered, focused on harm reduction, and
designed to engage a greater number of individuals experiencing opioid use disorder in
effective opioid treatment.
• A collaborative care model, which utilizes nurses or other professionals in innovative
care management models, has been successfully implemented in other communities to
expand treatment access and is the preferred approach to support delivery of
buprenorphine services (see Attachment J, Description of Collaborative Care/Nurse
Care Manager Model). 33 The use of the collaborative care/nurse care manager (NCM)
model addresses numerous major barriers to buprenorphine prescribing that prescribers
face, including insufficient time and support to accomplish the necessary steps to initiate
and maintain a client in treatment. The Substance Abuse and Mental Health Services
Administration (SAMHSA) has provided guidance on the specific role that nurse case
managers can play in conducting screening, assessment, treatment monitoring,
counseling, education, and other supportive services to facilitate office-based
buprenorphine treatment of opioid use disorder.34
• Healthcare facilities without on-site buprenorphine (waivered) prescribers could enter
into agreements with waivered prescribers to provide buprenorphine services via
telehealth technology. This would improve access to buprenorphine services for
individuals experiencing opioid use disorder who reside in rural or underserved areas.
2. Develop Treatment on Demand for all Modalities of Substance Use Disorder
Treatment Services
Goal:
• Individuals experiencing opioid use disorder who desire opioid treatment will have
access to their treatment of choice on demand. Treatment on demand is defined as the
individual meeting with a provider to initiate the treatment of choice on day one or day
two of the request for treatment.
33 LaBelle, C. T., Han, S. C., Bergeron, A., & Samet, J. H. (2015). Office-based opioid treatment with
buprenorphine (OBOT-B): Statewide implementation of the Massachusetts collaborative care model in
community health centers. Journal of Substance Abuse Treatment, 60, 6-13.
34 Substance Abuse and Mental Health Services Administration (2009). Burprenorphine: A guide for
nurses. Technical Assistance Publication Series (TAP 30)
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Rationale:
• There are a range of substance use disorder treatment modalities, including
detoxification/withdrawal management, outpatient therapy, residential treatment, and
opioid agonist pharmacotherapy (also referred to as medication-assisted treatment or
MAT). Not every individual experiencing opioid use disorder is interested in treatment
with opioid agonist pharmacotherapy or is an appropriate recipient of MAT. Providing
individuals seeking treatment with multiple treatment options supports the many
pathways of recovery and respects client choice and autonomy.
• Research demonstrates racial/ethnic and socioeconomic disparities in service delivery.35
Providing individuals seeking treatment with a comprehensive menu of treatment
services removes barriers to treatment and promotes equity and social justice.
• Delays to treatment access can be life threatening. Every day an individual is waiting for
treatment access, they are at risk of continuing to use heroin and/or opioids. For many,
especially those experiencing opioid dependence, this means risk of overdose and
death. Creating a system of care where treatment can be accessed rapidly reduces
harm and ultimately save lives.
• According to the National Council for Behavioral Health, shorter wait periods are
associated with fewer missed appointments, and strategies to reduce waiting times
reduce no-show rates for appointments. Providing treatment on demand or “open
access” to a comprehensive array of treatment services increases the likelihood of
treatment engagement. Careful “open access” model development may also help to
increase provider revenue and reduce costs.
Approach:
• Develop a plan and protocol for all outpatient behavioral health providers in King County
to provide “open access” to services. “Open access” may include same-day access,
walk in hours or days, next-day appointments or a combination of client-driven
scheduling options. “Open access” strategies should ensure that timely, meaningful
follow-up is provided to individuals seen for “open access” services or on-demand
assessments. (See Attachment K for Implementation and Planning Details.)
• Assess treatment network adequacy on an ongoing basis to ensure all treatment
modalities (including residential and detox beds) are available to achieve treatment on
demand for King County residents. The philosophy of “treatment on demand” maintains
that treatment capacity must be flexible and able to meet the fluctuating demand for
services. Individuals experiencing opioid use disorder, clients of opioid treatment
services, and advocacy groups like the People’s Harm Reduction Alliance (PHRA) and
Voices of Community Activists and Leaders (VOCAL) should be involved in identifying
strategies for improving network adequacy and flexible access. (See Attachment K for
Implementation and Planning Details.)
35 Hansen, H. B., Siegel, C. E., Case, B. G., Bertollo, D. N., DiRocco, D., & Galanter, M. (2013). Variation
in use of Buprenorphine and Methadone Treatment by Racial, Ethnic and Income Characteristics of
Residential Social Areas in New York City. The Journal of Behavioral Health Services & Research, 40(3):
367-377.
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• Develop a plan to address the substance use disorder treatment workforce shortage and
to support achievement of treatment on demand, timely and meaningful follow-up, and
engagement of individuals seeking treatment. (See Attachment K for Implementation
and Planning Details).
• Standardize and expand access to continuation of opioid treatment for incarcerated
individuals in King County who are booked into jail and already stabilized on medication
for treatment of opioid use disorder. Develop a plan to assist individuals incarcerated
with untreated opioid use disorder, with direct referrals to a community-based MAT
program upon release. (See Attachment K for Implementation and Planning Details).
• Develop and implement a plan for establishing and maintaining good neighbor relations.
An example is provided of a neighbor relations plan that has been successfully
implemented by a local opioid treatment program and has proven to be a very effective
tool to fight stigma of clients served by opioid treatment programs and of treatment in
general. (See Attachment L for Proposed Neighbor Relations Plan).
3. Alleviate barriers placed upon opioid treatment programs, including the number of
clients served and siting of clinics.
Goal:
• King County will be able to provide readily accessible treatment to meet the needs of the
community and will be able to rapidly adjust treatment capacity to ensure demand for
services is met.
Rationale:
• Opioid treatment programs offering medication-assisted treatment (MAT) have been in
existence since the 1960s. While opioid treatment programs have historically offered
methadone treatment, they have recently been authorized to dispense buprenorphine as
well. Opioid treatment programs are sanctioned by the federal government and
Washington State as an effective way to treat withdrawal symptoms and relieve drug
cravings from heroin and prescription opioid medications.36 Research shows additional
benefits include patients reduced or stopped use of injection drugs, a reduced risk of
overdose and of acquiring or transmitting diseases, reduced criminal activity, and
improved family stability and employment potential.37 These benefits have also been
demonstrated in Washington where MAT participation results in “lower health care costs”
and “reduces arrests and convictions” for participants.38
• In 2014, opioid overdose deaths in King County were the highest ever recorded and
remain high in 2015, with 229 opioid (heroin and/or pharmaceutical) overdose deaths
36 University of Washington – Alcohol and Drug Abuse Institute – Medication Assisted Treatment for
Opioid Use Disorders: Overview of the Evidence, June 2015, available at
http://adai.uw.edu/pubs/infobriefs/MAT.pdf
37 CDC – Methadone Maintenance Treatment – February 2002, available at
http://www.nhts.net/media/Methadone%20Maintenance%20Treatment%20(20).pdf
38 DSHS Research and Data Analysis Division - Methadone Treatment For Opiate Addiction Lowers
HealthCare Costs And Reduces Arrests And Convictions - June 2004 –
https://www.dshs.wa.gov/sites/default/files/SESA/rda/documents/research-4-49.pdf
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documented.39 Buprenorphine and methadone maintenance treatment are evidence-
based treatments for opioid use disorder that reduce overdose mortality by 50%
compared to no treatment or treatment with therapy only.40 Efforts to reduce barriers to
providing effective opioid treatment for all individuals in need save lives.
• Stigmatization of people suffering from substance use disorder can impact policy
regarding treatment. Despite the overwhelming evidence that MAT works, MAT service
providers regularly face obstacles when trying to open new facilities. These hurdles
include placement of barriers to finding suitable locations that comply with zoning
regulations and obtaining operating permits from local jurisdictions. Alleviating
unnecessary barriers to opioid treatment contributes to destigmatizing substance use
disorders and overcoming prejudice and discrimination against people seeking treatment
for substance use disorders.
• Approximately 5,000 individuals in King County may be interested in treatment for opioid
use disorder (Caleb Banta-Green, University of Washington Alcohol and Drug Abuse
Institute, personal communication, August 15, 2016). Efforts to alleviate barriers placed
upon opioid treatment programs can expand access to treatment and address equity
and social justice concerns created due to stigmatization of issues related to opioid use
disorder.
Approach:
• Work to eliminate the Washington State cap on the number of clients permitted to be
served at opioid treatment programs. Currently, opioid treatment programs are capped
at 350 clients receiving opioid agonist pharmacotherapy per dispensary location, unless
the county of residence provides a waiver. In King County, the Department of
Community and Human Services, Behavioral Health and Recovery Division is authorized
to provide this waiver, renewable annually. In order to meet local demand and provide
treatment to a greater number of individuals in need, opioid treatment programs could
provide additional services with extended hours. The Task Force is recommending
changes to RCW 71.24.590 (Recodified from 70.96A.410) (Opiate substitution treatment
– Program certification by department, department duties – Definition of opiate
substitution treatment) to reduce barriers to treating individuals with opioid use disorder
and expanding treatment capacity.
• Support a call to action for community collaboration in establishing opioid treatment
programs and associated supportive and/or complimentary services. State law is
intended to allow for the operation of MAT facilities. One of the main obstacles to
opening MAT facilities results from the actions of local governments, generally via
permitting and zoning regulations. But they are counterproductive in combatting the
opioid epidemic and generally grounded in a lack of knowledge about how these
programs operate and how the facilities will impact the surrounding areas. To combat
these misperceptions, there is a great need for sharing information about the vital
39 Drug Abuse Trends in the Seattle-King County Area: 2015. Banta-Green, C et al. Alcohol & Drug
Abuse Institute, Univ. of Washington, July 2016. http://adai.uw.edu/pubs/pdf/2015drugusetrends.pdf
40 Pierce, M., Bird, S. M., Hickman, M., Marsden, J., Dunn, G., Jones, A., and Millar, T. (2016) Impact of
treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England.
Addiction, 111: 298–308.
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importance of these facilities and their social and health benefits and to use evidence to
address public safety concerns. A public education campaign and the support of elected
officials could greatly expedite getting more MAT facilities up and running in a short
amount of time. (See Attachment M for Implementation and Planning Details.)
• Work to amend RCW 71.24.585 (Recodified from 70.96A.400) (Opiate substitution
treatment – Declaration of regulation by state) to reflect the potential need for long-term
MAT as a current standard of care for effective treatment of opioid use disorder. Current
language declares the primary goal of opioid substitution treatment is to “eliminate
substance use, including opioid and opiate substitute addiction of program participants”
and suggests a small percentage of persons who participate in opioid substitution
treatment programs require treatment for an extended period of time. This is inconsistent
with current evidence-based best practice guidelines established by the Substance
Abuse and Mental Health Services Administration (SAMHSA). SAMHSA recommends a
phased approach to treatment involving medication maintenance and consideration of
individual need when determining whether to discontinue opioid agonist
pharmacotherapy or pursue long-term maintenance.41 The Office of National Drug
Control Policy suggests “ongoing MAT may be the safest and best approach for opiate
rehabilitation” due to research demonstrating opiate agonist pharmacotherapy is
associated with reduced risk of relapse and overdose relative to treatment with
psychosocial services alone.42
User Health Services and Overdose Prevention Recommendations
1. Expand distribution of naloxone in King County, Washington.
Goals:
• Reduce drug related overdose deaths by expanding the distribution of naloxone to
individuals using heroin and pharmaceutical opioids, their social networks, and
professionals who may administer naloxone through the course of their work.
• Educate service providers and the community about naloxone availability and access
points, and inform the public about the Good Samaritan 911 Overdose Law.
Rationale:
• Naloxone is an opioid overdose antidote that may be safely used by health professionals
and laypersons. When prioritizing interventions, the risks of the opioids being used, the
likelihood of the naloxone recipient having or witnessing an overdose, and the overdose
risks related to the location/timing of naloxone distribution should all be considered.
41 Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid
Treatment Programs. Rockville (MD): Substance Abuse and Mental Health Services Administration (US);
2005. (Treatment Improvement Protocol (TIP) Series, No. 43.) Available at
http://www.ncbi.nlm.nih.gov/books/NBK64164
42 The White House, Office of National Drug Control Policy. (2012). Medication-Assisted Treatment for
Opioid Addiction [Health Brief]. Retrieved from
https://www.whitehouse.gov/sites/default/files/ondcp/recovery/medication_assisted_treatment_9-21-
20121.pdf
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• Evidence exists for distributing naloxone to heroin users and their social networks at
syringe exchanges. Adequate evidence does not currently exist for other means of
distributing or administering naloxone. Given the limited financial resources, as well as
the limited opportunities to work with stakeholders and the public on issues related to
opioid use disorder and overdose, it is important to consider interventions that are most
likely to have a public health impact by preventing and reversing the greatest number of
overdoses. Outcomes may also be positively impacted by increasing awareness of
overdose prevention, overdose recognition, and overdose response including rescue
breathing and the Good Samaritan Overdose law. (See Attachment N for Naloxone
Distribution and Administration Bibliography.)
Approach:
• Expand distribution of take-home naloxone to individuals using heroin and
pharmaceutical opioids and their social networks.
Syringe exchanges
o Expand programs for take-home-naloxone at syringe exchanges so that it is free
and available to all who want it.
o Consider dispensing more than one naloxone kit per client so that they can
further distribute naloxone in their social networks.
Jail
o Expand naloxone distribution services to all correctional facilities in King County.
Funding for staffing and other resources will need to be determined.
Pharmacies
o Request that insurers provide adequate reimbursement of take-home naloxone
so that pharmacies will be willing to stock, prescribe and dispense naloxone.
o Advocate with insurers, as well as state regulators and policy makers as
appropriate, for coverage/reimbursement of take-home-naloxone for persons not
at risk for overdose but who are household members or other close contacts of
persons who are at risk for opioid overdose.
o Incorporate education about naloxone availability at pharmacies in educational
campaigns.
o Encourage pharmacies to educate individuals at risk for opioid overdose
regarding overdose prevention and treatment and to consider obtaining take-
home naloxone.
Prescribers
o Encourage prescribing of take-home naloxone to those at elevated risk for
overdose due to their prescribed opioid use.. Targeting diverse care settings is
appropriate, including emergency departments, primary care, specialty care,
behavioral health, and withdrawal management facilities.
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o Explore ways to more easily dispense naloxone directly to individuals in
emergency departments, rather than requiring patients to take a prescription to a
pharmacy.
Outreach workers
o Explore options for outreach workers to distribute take-home naloxone to those
not accessing it through other services such as syringe exchange.
• Evaluate police/fire/Emergency Medical Services (EMS)/social/health services
staff/schools having naloxone for administration in the course of their work.
Police and Fire
o Evaluate the utilization and health impacts of naloxone administered by police
and emergency medical technicians.
Paramedics
o Develop and implement procedures to document opioid overdose occurrence.
o Develop and implement procedures to document bystander responses to opioid
overdoses.
Social/Housing/Health Services staff
o Expand overdose education and naloxone availability for staff at facilities where
opioid overdoses are likely to occur.
o Evaluate the utilization and health impacts of naloxone administered by
social/housing/health services staff.
• Educate the public about opioid use disorder and the Good Samaritan 911 Overdose
Law.
o Incorporate education about the Good Samaritan overdose 911 law into public
education about opioid use disorder and overdose.
o Educate school staff about opioid use disorder and overdose risk as well as the
Good Samaritan overdose law so they can provide appropriate education,
referrals and interventions.
• Implement systematic and consistent ways to document naloxone distribution, utilization
and disposition.
o Encourage agencies and programs distributing and administering take-home-
naloxone to collect standardized data at the time of distribution (E.g.,
demographics, motivation for obtaining naloxone, opioid use) and when obtaining
a refill (disposition of the naloxone and health impacts of naloxone administration).
• Improve communication among stakeholders about practices and protocols related to
naloxone distribution.
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o Encourage stakeholders to meet to proactively discuss current naloxone
distribution and administration practices and protocols to ensure coordination,
consistency, clarity and good health outcomes.
2. Establish, on a pilot program basis, at least two Community Health Engagement
Locations* (CHEL sites) where supervised consumption occurs for adults with
substance use disorders in the Seattle and King County region. One site should be
located outside of Seattle, reflecting the geographic distribution of drug use in other
King County areas. The CHEL pilot program should have a provisional time limit of
three years. Continuation of the program beyond that time should be based on
evidence of positive outcomes.
* The Task Force will refer to sites that provide harm reduction services where supervised
consumption occurs as Community Health Engagement Locations for individuals with
substance use disorders (CHEL sites). This terminology recognizes that the primary purpose
of these sites is to engage individuals experiencing opioid use disorder using multiple
strategies to reduce harm and promote health, including, but not limited to, overdose
prevention through promoting safe consumption of substances and treatment of overdose.
The Task Force’s equity and social justice (ESJ) charge emphases the importance of
providing support and services to the most marginalized individuals in the County
experiencing substance use disorders. The Task Force asserts that the designation CHEL
sites is a non-stigmatizing term that recognizes that these sites provide multiple health
interventions to decrease risks associated with substance use disorder and promote
improved health outcomes.
Goals:
• Reduce drug-related health risks and harms including overdose death, transmission of
HIV and hepatitis B and C viruses, and other drug-associated adverse health effects.
• Provide access to substance use disorder treatment and related health and social
services, provide a safe and trusting environment where people who use drugs can
engage with services to improve their health and reduce criminal justice system
involvement and reduce emergency medical services utilization.
• Improve public safety and the community environment by reducing public drug use and
discarding of drug using equipment.
Rationale:
• CHEL sites (aka supervised or safe consumption sites in other jurisdictions) offer a
supervised place for hygienic consumption of drugs in a non-judgmental environment
free from stigma, while providing low-barrier access to on-site health services and
screenings, referrals, and linkages to behavioral health and other supportive services
(for example, housing).
• Supervised consumption sites (SCS) have been operating in Europe since 1988. Sites in
Sydney, Australia, and Vancouver, Canada, began operating in 2001 and 2003,
respectively. As of 2014, there are 90 SCSs operating across the globe on three
continents. (See Attachment O for Community Health Engagement Location [aka
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Supervised Consumption Site] Bibliography, and see Attachment P for World Overview
of Supervised Consumption Sites.)
• Published evaluations from existing SCSs show that SCSs can reduce overdose deaths
and behaviors that cause HIV and hepatitis C infection (such as sharing of injection
equipment and supplies), reduce unsafe injection practices, increase use of detox and
substance use disorder treatment services, reduce public drug use and the amounts of
publically discarded injection equipment; and, do not increase drug use, crime, or other
negative impacts in the area of the SCS. SCSs can also be cost-effective. (See
Attachment O for Community Health Engagement Location [aka Supervised
Consumption Site] Bibliography.)
• SCSs are intended to engage individuals in substance use disorder treatment and other
supportive services (physical and behavioral health care, housing, social services) who
may not engage in traditional treatment related to substance use. The King County
Board of Health previously endorsed and adopted the HIV/AIDS Committee’s 2007
strategic and operational plan for HIV prevention in King County that included a
recommendation to promote the use of a ”safe injection site” within King County. (See
Attachment O for Community Health Engagement Location [aka Supervised
Consumption Site] Bibliography.)
• In July, 2016 the City Council of Toronto, Canada, approved the implementation of three
SCSs for the downtown area of Toronto. In their decision making process, the City
Council of Toronto considered data published in the 2012 Report of the Toronto and
Ottawa Supervised Consumption Assessment Study (TOSCA), funded by the Ontario
HIV Treatment Network and the Canadian Institutes of Health Research, and the
Supervised Injection Services Toolkit prepared by the Toronto Drug Strategy
Implementation Panel in 2013. (See Attachment O for Community Health Engagement
Location [aka Supervised Consumption Site] Bibliography.)
• Published studies support the effectiveness of the services provided at SCSs in reducing
drug-related health risks and overdose mortality for individuals utilizing the SCSs.
Research of established SCSs also did not reveal an increase in criminal activity or
negative impacts on the communities following the implementation of SCSs in those
areas.
Approach:
• Evaluation
The Taskforce recommends a rigorous evaluation process be integrated into the
planning and design of the CHEL program. Outcomes should include fatal overdose
prevention, other health outcomes, community and environmental indicators (impact on
public drug use/injection, community impact including neighborhood perceptions and
public safety experiences, OD-related first responder calls, 911 calls, etc.), and impact of
linkage to services. Evaluation should be performed by public agencies (Public Health –
Seattle & King County and King County Department of Community Health Services)
and/or by third-party evaluators. Potential third party evaluators include the University of
Washington School of Public Health, the Alcohol and Drug Abuse Institute (ADAI), the
Harm Reduction Research and Treatment Center (HaRRT), Cardea, and Battelle. To the
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extent feasible, selected indicators should be monitored in near real time in order to
inform the need for any change in these recommendations during the pilot period.
• Planning and Implementation
• Continue to engage members of the community (including civic and business
stakeholders) and potential CHEL clients to inform the planning and implementation
process and ensure the environment and services provided adequately and
appropriately address the needs of the clients and the surrounding community.
• Community partners and stakeholders (including persons who use drugs) should
continue to be engaged in the CHEL planning and implementation process
throughout the duration of the pilot program.
• Conduct an Equity Impact Review in the planning process prior to implementation:
http://www.kingcounty.gov/~/media/elected/executive/equity-social-
justice/2016/The_Equity_Impact_Review_checklist_Mar2016.ashx?la=en
• Sponsorship
• Proposed CHEL program sponsorship options may include:
o Public Health – Seattle & King County (PHSKC) in collaboration with King
County Department of Community and Human Services (DCHS), or;
o A public-private partnership between PHSKC/DCHS and other community-
based service providers, or;
o Another entity with oversight by PHSKC/DCHS.
• See Attachment Q for Legal Framework Grid, and see Attachment R for Summary of
Legal Considerations for CHEL sites in King County
• Siting
• Consideration for siting CHELs should include the following priorities:
o Geographic concentration of drug consumption and overdose.
o Co-location with or in close geographic proximity to (if co-location not
possible) existing services utilized by the target population.
o Local governmental and community engagement.
o Fixed locations are preferred over a mobile CHEL during the pilot period
o Establish at least one site outside the city of Seattle.
• Geographic areas that have been identified as drug use/OD “hotspots”, and that
could potentially benefit from the services provided by a CHEL, should be prioritized
for potential CHEL sites.
• Services Provided at a CHEL
• The following services should be provided (essential services):
o Hygienic space and sterile supplies
o Overdose treatment: naloxone and oxygen administration
o Overdose prevention: naloxone kit distribution
o Syringe exchange services
o Sexual health resources and supplies (including male and female condoms)
o Drinking water; restrooms
o Direct provision of (preferred), or linkage to, basic medical treatment (wound
care), wraparound social services and case management
o Peer support
o Health education
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o Rapid linkage to medication-assisted treatment, detox services and
outpatient/inpatient treatment services
o Security and crisis response plan
o Post-consumption observation space
o Every effort is to be made to ensure that the provision of supplies and space
for consuming illicit drugs (NOT tobacco-containing products or marijuana)
via smoking (more precisely sublimation, meaning without combustion of the
drug itself) and nasal inhalation be incorporated into the CHEL program
design.
• The following services are highly desirable (but not essential):
o On site medication-assisted treatment (MAT, for example, buprenorphine
treatment)
o On site drug and alcohol assessment
o Basic medical treatment and screening services
o Linkage to legal services
• Staffing
• CHEL staffing should include at minimum: one (1) licensed healthcare professional
(for example registered nurse) and appropriate support staff for the size of facility
and scope of services provided, such as social workers, peer support workers, site
manager(s) and/or security workers.
• Medical supervision by a licensed healthcare professional should be provided on site
during all hours of operation.
• Funding
No current dedicated resources have been identified to support CHEL implementation
and evaluation. Possible public and private resources for this purpose should be
explored during the recommendation implementation phase.
• Partner Service Providers
• A CHEL should be an integrated part of the wide array of services and programs
available to the target population. The pilot program should work in close cooperation
with:
o Drug treatment services
o Medical and behavioral healthcare services including primary health care
providers
o Social services case management
o Housing assistance
o Employment assistance
o Legal Services
o EMS
o Law enforcement
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VI. Prioritization
The King County Heroin and Prescription Opiate Addiction Task Force proposes that its
recommendations be considered and prioritized based on the following factors:
• Evidence base for effectiveness
• Population health/safety impact
• Community support
• Equity
• Complexity/Feasibility
• Legal considerations
• Cost
• Sustainability
Each of these factors is described in further detail below.
Evidence base for effectiveness: To what extent are there published studies or other data
supporting the intervention for the population of interest? How rigorous was the research (for
example, was there a comparison group? What conflicts of interest did the researchers have?).
How big was the intervention effect compared to those who didn’t receive the intervention? Is
there statistical significance in the findings within relatively small confidence intervals (in other
words, how likely is it that the results are the result of the intervention, and not chance)? Have
the results been replicated? Do published studies include sub-group members that are
demographically distinct by race, age, gender, etc.? What do experts in the field say about the
intervention?
Population health/safety impact: How many people would potentially benefit from the
intervention? What is the magnitude of the health impact for individuals? What results do we
expect to see on specific groups of people in the target community or on the community as a
whole? Populations may be geographic and/or identity driven. Examples include all the
residents of King County, all 18-25 year olds, all individuals with an incarceration history, and all
people living below 200% of the federal poverty level in south King County.
Community support: What is known about community support or opposition within the
geographic area where the recommendation is likely to be implemented, or among the
stakeholders that would be involved in the recommendation’s implementation? Have community
meetings been held and focus groups conducted? What kinds of statements for or against have
appeared on print and social media sites? Are there any community-initiated initiatives occurring
that support or oppose the intervention? Are there strategies to address community and
stakeholder concern?
Equity: To what extent and in what ways will the proposed recommendation mitigate or
exacerbate existing population inequities or create new ones? Who would be most affected by
the change in equity?
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Complexity/Feasibility: How difficult would it be to implement the recommendation? What is
required for implementation? How long would it take to get the recommendation off the ground?
How many entities need to be engaged and in agreement to implement?
Cost: What will it cost to implement the recommendation? What costs are absolute and what
may be incremental? How will the intervention be funded? Are there alternatives to how a
strategy might be implemented that would affect cost (for example, number of facilities, program
size, staffing levels, size of target population, etc.)?
Legal considerations: Is the recommendation allowable under existing federal/state/local law?
What dispensations, if any, are needed from law enforcement or other entities? What types and
levels of difficulties and/or risk can be anticipated due to legal issues (for example, insurance
purchase, client harassment, law enforcement action)? What legislative or regulatory change
would be required, at what level of government?
Sustainability: What potential funding sources and mechanisms exist to support the
recommended interventions in future years (if continuation is desired)? How likely are these
sources to be obtained? What commitments have been secured to sustain recommendations?
The factors above should be considered when determining when and how to implement the
recommendations developed by the Task Force. All recommendations developed by the Task
Force are intended to significantly positively influence public health outcomes and community
welfare.
VII. Draft Evaluation Plan
It is essential to understand what impact interventions implemented in accordance with the King
County Heroin and Prescription Opiate Addiction Task Force recommendations have on the
target population and the community. Evaluation results can be used to make policy and
practice decisions about whether to modify or continue interventions. The initial draft evaluation
plan maps each of the key outcomes of interest to one or more of the Task Force’s three areas
of focus: primary prevention, treatment, and health services for individuals experiencing opioid
use disorder. There are eight outcomes of interest and specific measures for each outcome:
Outcome of Interest Outcome Measures
Survival • Overdose mortality
• Other drug-related mortality (acute and chronic)
Infectious Diseases • HIV diagnoses, HIV transmission risk among HIV-infected PWID,
hepatitis C diagnoses, hepatitis C treatment, hepatitis C cure
Health Indicators • Non-fatal overdose, skin and soft tissue infections,
cardiovascular outcomes, quality of life
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Drug Use
• Prevalence of drug use and injection (by type of drug), syringe
and other injection equipment sharing, unsafe injection practices,
transition to safer injection and other use practices
Drug Treatment
and Health Care
• Enrolled and maintained on buprenorphine treatment, enrolled
and maintained on methadone treatment, EMS/ER use,
enrollment in health insurance, has primary care provider
Community Impact
and public safety
• Syringes and paraphernalia around CHEL, drug-related arrests,
911 calls - number and types, public injection, property values
Community Health
Engagement
Location (CHEL)
• Number of clients, number of encounters, overdoses on site,
overdoses reversed on site, client satisfaction, feasibility and
sustainability
Implementation of
Prevention Efforts
• Education materials created and the number distributed, secure
medication return implemented and accompanying messaging
implemented, existing screening efforts augmented to include
opioid misuse and opioid use disorder
The evaluation plan includes monitoring the impact of the intervention(s) at both the population
and individual levels. In other words, these analyses would allow stakeholders to understand
how interventions impact the general population (for example, did opioid overdose mortality
rates in King County decline after an intervention was introduced?) as well as how interventions
impact individual people (for example, is someone who gets maintained on buprenorphine less
likely to have an opioid overdose?).
The evaluation plan proposes analyses of multiple existing data sources and the establishment
of a cohort study that follows people who use drugs over time. Examples of existing data
sources that will be queried include: vital statistics, administrative claims data, medical records,
HIV and HCV surveillance data, needle exchange survey, and program utilization data. The
cohort study will enroll individuals using drug s – some, but not all, of whom will seek services
related to the new interventions – and collect baseline and follow-up data, which allow for
service uptake patterns and rates to be measured and for the relationship between service
uptake and health outcomes to be assessed. The cohort study design will capture outcomes
that are most likely to be impacted by the proposed interventions but difficult to measure using
existing data sources, including: syringe sharing, public injection, skin and soft tissue infections,
and quality of life indicators.
Some of these secondary analyses are already being conducted within the University of
Washington’s Alcohol and Drug Abuse Institute (ADAI) in collaboration with King County’s
Departments of Community and Human Services and Public Health. However, the proposed
evaluation would greatly exceed current FTE capacity and require additional funding, staffing,
and new collaborations. Based on the evaluation plan described above, additional resources will
require one full time employee (FTE) to lead the secondary data analyses, including analyses to
establish baseline metrics for key outcomes.
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VIII. Current Local and National Activities
In light of the increased prevalence of heroin as a drug of abuse and associated substantial
morbidity and mortality, the Task Force was directed to confront the heroin and opioid addiction
epidemic with immediate action in King County. To respond to this directive, whenever possible,
the Task Force initiated immediate implementation of promising and/or evidence-based
interventions rather than postponing implementation for presentation of the recommendations to
the Task Force sponsors. Current status of local efforts to enhance primary prevention, opioid
treatment and the health of individuals with opioid use disorder is described below. The Task
Force also provided support to relevant state and federal initiatives and projects that would
positively impact local efforts to address the opioid challenge. These state and federal initiatives
are also described below.
Primary Prevention: Current Local Efforts
• The Task Force is partnering with organizations and entities developing countywide safe
prescription drug disposal programs. The City of Seattle enacted a resolution expressing
support for an effective, countywide disposal program for prescription drugs and
controlled substances, and requesting local pharmacies and the Seattle Police
Department install drug disposal drop-boxes across the city. Additionally, the King
County Hazardous Waste Management Program is developing a safe disposal program
(also known as a secure medicine return program) throughout the County; the Task
Force will partner in this effort to publicize and promote the availability of secure
medicine return sites. Finally, the Washington State Hospital Association has teamed up
with a toxicology company to collect unused prescription drugs and safely dispose of
them.
• The University of Washington Alcohol and Drug Abuse Institute (ADAI), represented on
the Task Force, will host a state Department of Health nurse consultant to provide
education and training, including tele-health sessions, on opioid addiction for
professionals and community members.
Treatment Expansion and Enhancement: Current Local Efforts
• The Task Force is developing a strategy for expanding access to buprenorphine
treatment by increasing the number of access points for receiving buprenorphine
induction, stabilization and maintenance services in King County. The Downtown Public
Health Needle Exchange and Public Health – Seattle & King County Mobile Medical Van
are currently designing plans for low barrier implementation of buprenorphine services
through pilot programs, effective in the fourth quarter of 2016. The pilot program at the
needle exchange will pilot a “bupe first” model that focuses on medication stabilization
as the primary goal of treatment. Other proposals for expanded access through
community health clinics, emergency departments, behavioral health clinics (including
traditional medication-assisted treatment [MAT] facilities), and local jails, have been
developed and critical resource needs have been identified. The Department of Public
Health – Seattle & King County Jail Health Services is currently evaluating the number of
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individuals booked into the King County jail who are stable on buprenorphine to
determine the feasibility of providing buprenorphine maintenance services during
incarceration. The ultimate goal is to evaluate demand for both induction and
maintenance services and devise a plan to provide these services to individuals with
opioid use disorder who desire MAT.
• The Task Force conducted GIS mapping of current service sites (opioid treatment
programs, behavioral health treatment agencies, needle exchange facilities, public
health clinics, emergency departments, and hospitals) to evaluate network adequacy
and geographic accessibility. The service map can be found at the following location:
http://kingcounty.maps.arcgis.com/apps/webappviewer/index.html?id=d9424b892f404c3
9a07cda52390ce627. The Recovery Help Line is currently developing a plan for how
King County could achieve centralized access and referral to treatment services in order
to facilitate treatment on demand.
• In 2015, King County conducted a survey of behavioral health provider agencies to learn
about recruitment and retention issues. Position vacancies were high and low wages
relative to other professional opportunities significantly contributed to staff retention
challenges. The King County Department of Community and Human Services,
Behavioral Health and Recovery Division is designing a plan to address the workforce
shortage in order to promote network adequacy and support achievement of treatment
on demand.
• The Task Force has analyzed the challenge presented by local jurisdictions that make it
difficult for opioid treatment providers to open treatment facilities. A legal analysis has
been drafted describing the legality of MAT program facilities in Washington, common
challenges in opening MAT facilities, and options to ease restrictions on opening MAT
facilities. Additionally, the Task Force is drafting proposed amendments to state
legislation that is inconsistent with the current standard of care for treatment of opioid
use disorder and poses unnecessary barriers to treatment access (RCW 71.24.585 and
RCW 71.24.590, respectively).
• The King County Department of Community and Human Services’ Behavioral Health
and Recovery Division, Washington State Health Care Authority (HCA) and Medicaid
Managed Care Organizations (MCOs) convened in June and August 2016 to discuss the
collaborative care/nurse care manager model as a means of supporting expansion of
buprenorphine services for treatment of opioid use disorder. System barriers and funding
challenges were identified. The group is currently working on developing a plan to
support implementation of a collaborative care/nurse care manager model to facilitate
buprenorphine services delivery in King County.
User Health and Overdose Prevention: Current Local Efforts
• Naloxone distribution is being expanded to ensure easy access to overdose prevention
with distribution efforts that involve many providers, first responders and locations
throughout the County. The County Department of Community and Human Services,
Behavioral Health and Recovery Division is partnering with Kelley-Ross pharmacy to
distribute naloxone to persons identified in the publicly funded treatment system.
Additionally, naloxone is now being distributed through 18 homeless housing providers
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for use in housing settings, and participating housing partners have documented two
overdose reversals prior to the date of this report. DCHS has also distributed naloxone
kits to local law enforcement including the Sheriff’s Office and the Kent, Auburn and
Redmond police departments and overdose reversals have also occurred as the result
of this project. The Marah Project has collaborated with the Seattle Police Department
and the UW Alcohol and Drug Abuse Institute (ADAI) to distribute naloxone to police
officers on bicycles and evaluate implementation. As of August, 2016, 10 administrations
of naloxone had been documented as a result of this collaboration. Finally, planning is
underway for the King County Emergency Medical Services to develop an emergency
medical technician naloxone program for County agencies; implementation of a pilot
program is slated for the fall of 2016. All of the entities noted above (DCHS; pharmacy;
housing providers; law enforcement; first responders; Marah Project; ADAI; city of
Seattle; and Sound Cities Association) are represented on the Task Force. From the
time the Task Force started until August 15, 2016 there have been at least 14
documented naloxone administrations to people in an overdose state as a result of the
efforts from Task Force members.
State and Federal Initiatives
• The Comprehensive Addiction and Recovery Act (CARA) was approved by Congress
and signed by the President on July 22, 2016. This legislation treats addiction as a
disease and prioritizes prevention, treatment and recovery support services for those
living with, and in recovery from, substance use disorders. The Act modifies the
qualifications for providers who may prescribe buprenorphine to include nurse
practitioners and/or physician assistants who meet specific licensing and training
requirements. Additionally, it expands federal funding for opioid reversal medications
and drug disposal sites, among other appropriations. (See Attachment S for Key
Potential Opportunities for Washington and King County in CARA.)
• The Centers for Disease Control and Prevention issued Guidelines for Prescribing
Opiates for Chronic Pain that provides recommendations for safer and more effective
prescribing of opioids for adults in outpatient settings.
• In response to President Obama’s call for the federal government to identify barriers to
treatment for opioid use disorders, the Centers for Medicare and Medicaid Services
(CMS) will require Medicare Part D formularies to allow access to medication-assisted
treatment for these disorders.
• In the spring of 2016, the White House announced the final proposed Health and Human
Services rules that mandated that doctor caps for prescribing buprenorphine were to be
raised to 275 individuals per each Drug Addiction Treatment Act waivered physician.
The Task Force submitted comments urging the implementation of these rule changes
which were promulgated in final form effective August 8, 2016.
• In 2013 the federal Substance Abuse and Mental Health Services Administration
(SAMHSA) provided its final rule giving opioid treatment programs (OTPs) the flexibility
to dispense buprenorphine take-homes, with no predetermined waiting period for
individuals who are stable. In June of 2016 the State of Washington confirmed the use of
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medications other than methadone that can be utilized in OTPs, including
buprenorphine/naloxone (Suboxone®) and naloxone.
• In August, 2016 the U.S. Surgeon General, Dr. Vivek Murthy, announced his Turn the
Tide Rx movement. Dr. Murthy is calling on health care professionals across the nation
to take a pledge to educate themselves to treat pain safely and effectively, screen
individuals for opioid use disorder and provide or connect individuals with evidence-
based treatment, and talk about and treat addiction as a chronic illness, not a moral
failing.
• The Department of Health, Washington State Department of Social and Health Services,
Washington State Department of Labor and Industries, Washington State Health Care
Authority, and University of Washington Alcohol and Drug Abuse Institute have created a
statewide Interagency Opioid Working Plan that outlines a strategy for addressing the
opioid abuse and overdose crisis. Priority goals include enhancing primary prevention;
treatment of opioid use disorder, overdose prevention, and data collection (for the
purposes of evaluating interventions, monitoring morbidity/mortality, and detecting
misuse). Priority actions include improving prescribing practices, expanding treatment
access, distributing naloxone to those using heroin, and optimizing and expanding data
sources. Workgroups have been created to oversee implementation of strategies
designed to address the four identified goals.
IX. Next Steps
The Heroin and Prescription Opiate Addiction Task Force recommends that local government
and other partners begin to implement the recommendations contained in the report as soon as
possible. As previously noted, the Task Force has already begun to implement some
recommendations with existing resources and the support of the County. Other
recommendations have not yet been implemented.
The Task Force recommends that existing Task Force workgroups continue to convene, and
that these can potentially transition to oversight groups to help guide implementation of the Task
Force’s recommendations.
After review of this report by the Task Force sponsors, implementation teams should be
assembled corresponding to the various recommendations. It may also be useful to assemble
special teams or work groups to help identify resources for implementation of the
recommendations and to assist with public education and communication.
The Task Force requests that within 90 days of receipt of this report the sponsors provide a
formal response to the recommendations in the report, and that the Task Force reconvene at
that time to assess the response. The Task Force should also reconvene as needed to help
facilitate and/or evaluate implementation of the recommendations, including at three to five
years to review progress made and associated outcomes, and to recommend what, if any,
further action should be taken to address the challenge of opioid abuse in King County.
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Attachment A
MAP OF OVERDOSE DEATHS IN KING COUNTY, 2013-2015
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Attachment B
HEROIN AND PRESCRIPTION OPIATE ADDICTION TASK FORCE
MEMBERS
Task Force Member Ag ency/Entity Voting Member
Brad Finegood King County Department of Community and Human Services No
Jeff Duchin Public Health - Seattle & King County No
Caleb Banta-Green University of Washington Alcohol and Drug Abuse Institute Yes
Kate Joncas City of Seattle Mayor’s Office No
Scott Lindsay City of Seattle Mayor’s Office No
Jim Pugel King County Sheriff’s Office Yes
Robert Merner Seattle Police Department No
Frank Chafee Public Health - Seattle & King County No
Karen Hartfield Public Health - Seattle & King County No
Reba Gonzales Seattle Fire Department No
Tom Rea King County EMS No
Catherine Lester Seattle Human Services Department No
Jeff Sakuma Seattle Human Services Department No
Darcy Jaffe Harborview Medical Center Yes
Mark Larson King County Prosecuting Attorney’s Office Yes
Mark Cooke American Civil Liberties Union (ACLU) Yes
Steve Stocker Auburn Police Department Yes
Kevin Milosevich Renton Police Department Yes
Tim Bondurant Veteran’s Administration Yes
Jim Walsh Swedish Hospital, Pregnant and Parenting Women Program Yes
Charissa Fotinos Washington State Department of Social and Health Services,
Behavioral Health Administration and Health Care Authority Yes
Lisa Daugaard Public Defender Association Yes
Patricia Sully Public Defender Association Yes
Annette Hayes U.S. Attorney for the Western District of Washington No
Penny Legate The Marah Project Yes
Thea Oliphant-Wells King County Needle Exchange No
Mark Putnam All Home No
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Task Force Member Agency/Entity Voting Member
Dan Cable Muckleshoot Tribe Yes
Molly Carney Evergreen Treatment Services Yes
Norm Johnson Therapeutic Health Services Yes
Michael Ninburg Hepatitis Education Project Yes
Andy Adolfson City of Bellevue Fire Department Yes
Pegi McEvoy Seattle Public Schools Yes
Shilo Murphy People’s Harm Reduction Alliance (PHRA) Yes
David Dickinson U.S. Substance Abuse and Mental Health Services
Administration, Regional Office Yes
Roger Dowdy Neighborcare Yes
Annie Hetzel Puget Sound Educational Service District Yes
Mary Taylor King County Drug Court Yes
Daniel Malone Downtown Emergency Service Center Yes
Ryan Oftebro Kelley-Ross Pharmacy Yes
Suzan Mazor Seattle Children’s Yes
Milena Stott Valley Cities Behavioral Health Yes
Natalie Green Department of Social and Health Services Children's Admin. Yes
STAFF:
• Chelsea Baylen – King County Department of Community and Human Services
• Steve Gustaveson – King County Department of Community and Human Services
• Marcee Kerr – Public Health – Seattle & King County
• Milena Stott – Valley Cities Behavioral Health
• Erin James – King County Department of Community and Human Services
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Attachment C
HEROIN AND OPIATE ADDICTION WORKGROUPS
Primary Prevention Workgroup
Member Agency/Entity
Caleb Banta-Green University of Washington Alcohol and Drug Abuse Institute
Pegi McEvoy Seattle Public Schools
Suzan Mazor Seattle Children’s
Penny Legate The Marah Project
Charissa Fotinos Washington State Department of Social and Health Services,
Behavioral Health Administration and Health Care Authority
Kevin Milosevich Renton Police Department
Andy Adolfson City of Bellevue Fire Department
Robert Merner Seattle Police Department
David Dickinson U.S. Substance Abuse and Mental Health Services Administration,
Regional Office
Annie Hetzel Puget Sound Educational Service District
Jeff Sakuma Seattle Human Services Department
Natalie Green Department of Social and Health Services Children's Administration
Milena Stott Valley Cities Behavioral Health
Erin James King County Department Community and Human Services
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Treatment Expansion and Enhancement Workgroup
Member Agency/Entity
Brad Finegood King County Department Community and Human Services
Dan Cable Muckleshoot Tribe
Molly Carney Evergreen Treatment Services
Norm Johnson Therapeutic Health Services
Daniel Malone Downtown Emergency Service Center
Mary Taylor King County Dept. of Judicial Administration
Roland Akers Community Member
Roger Dowdy Neighborcare
Darcy Jaffe Harborview Medical Center
Tim Bondurant US Veterans Administration
Tom Rea King County Emergency Medical Services
Mark Larson King County Prosecuting Attorneys' Office
Jim Walsh Swedish Hospital, Pregnant and Parenting Women's Program
Lisa Daugaard King County Public Defender Association
Jeff Sakuma Seattle Human Services Department
Shilo Murphy People's Harm Reduction Alliance
Laurie Sylla King County Department Community and Human Services
Kris Nyrop King County Public Defender Association
Cynthia Hobbs Therapeutic Health Services
Milena Stott Valley Cities
Caleb Banta-Green University of Washington Alcohol and Drug Abuse Institute
Chelsea Baylen King County Department Community and Human Services
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User Health Services and Overdose Prevention Workgroup
Member Agency/Entity
Jeff Duchin Public Health - Seattle & King County
Mark Cooke American Civil Liberties Union (ACLU)
Lisa Daugaard Public Defender Association
Annie Hetzel Puget Sound Educational Service District
Brad Finegood King County Department of Community and Human Services
Shireesha Dhanireddy University of Washington/Harborview Medical Center
Chloe Gale REACH Program
Charissa Fotinos Washington State Department of Social and Health Services,
Division of Behavioral Health and Recovery (DBHR)
Reba Gonzales Seattle Fire Department
Annette Hayes U.S. Attorney for the Western District of Washington
Karen Hartfield Public Health - Seattle & King County
Scott Lindsay City of Seattle Mayor’s Office
Joe Tinsley King County Needle Exchange
Dan Otter UW Public Health
Kris Nyrop Public Defender Association
Patricia Sully Public Defender Association
Mark Putnam All Home
Michael Ninburg Hepatitis Education Project
Ryan Oftebro Kelley-Ross Pharmacy
Shilo Murphy People’s Harm Reduction Alliance (PHRA)
Steve Stocker Auburn Police Department
Jim Pugel King County Sheriff’s Office
Thea Oliphant-Wells King County Needle Exchange
Laurie Sylla King County Department of Community and Human Services
Marcee Kerr Public Health - Seattle & King County
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Policy Workgroup
Member Agency/Entity
Brad Finegood Department of Community and Human Services
Scott Lindsay City of Seattle Mayor’s Office
Mark Larson King County Prosecuting Attorney’s Office
Mark Cooke American Civil Liberties Union (ACLU)
Lisa Daugaard King County Public Defender Association
Kris Nyrop King County Public Defender Association
Patricia Sully King County Public Defender Association
Shilo Murphy People’s Harm Reduction Alliance
Annette Hayes U.S. Attorney for the Western District of Washington
Steve Gustaveson Department of Community and Human Services
Chelsea Baylen Department of Community and Human Services
Evaluation Workgroup
Member Agency/Entity
Caleb Banta-Green University of Washington Alcohol and Drug Abuse Institute
Sara Glick Public Health – Seattle & King County
Julia Hood Public Health – Seattle & King County
Laurie Sylla Department of Community and Human Services
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Attachment D
Community Conversation (May 31, 2016): Attendee Comments
Focus One: Primary Prevention
What is Working Well?
Adverse Childhood Experiences (ACES)
• The ACES work has also been extremely successful in identifying the key trauma areas
and identifying that certain people just based on their childhood trauma may be more
inclined.
Awareness, Social Norms, Education, and Training
• Education to the community has been good.
• ‘Providing Good Choices” Parent program educates parents and gives them tools to get
children to open up about issues. It works with different languages and faiths. Talking
about issues allows more opportunities to address issues
• Altering points of view – debunking the illusion of ‘everybody else is using’. Show that
drug use is not the social norm among the kids’ peers. This can lead to a positive
‘reverse peer pressure’.
• The community was working to relay ‘positive community norms’ through groups such as
Youth Eastside Services (YES).
• These forums are working well they generate discussions, provide education, they are
informative and bring community partners outside of the traditional; law enforcement,
mental health, healthcare providers together. Adding all these other entities makes it
much more educational.
• Awareness is growing. My daughter died four years ago and we were fighting hard to
keep her alive and it was difficult. People are starting to understand it is a disease, the
stigma is going away, there is a shift towards awareness and what addiction really is and
what it does to someone. We still have a long way to go, but it’s getting better, for
instance, there is a meeting tonight in Kirkland to discuss these issues.
• It is so amazing that it is being spoken about, it is out there and people are now talking
about it openly.
• There is a lot more understanding and it has been great that people now understand that
it is not just poor people that are impacted and there is also the issue that folks
understand it is happening with younger and younger youth.
• In the past they did campaigns that I felt were effective; the faces of Meth, DARE and
while I know many feel that was a bust, I still remember it and it was helpful to some.
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• Awareness is big right now because unfortunately no community is untouched and it is
becoming really frightening. Look at across the country it is a nationwide epidemic of
Heroin and opiate use.
• It is good to see that people understand that this is not a socioeconomic issue, it is not a
problem in only one area, it is a problem that is impacting everyone, and it is touching all
spectrum of life.
• The discussion is becoming honest. There is no longer terror or the bogey man
associated with the problem. People are having honest, clear discussions.
• The discussion has become honest and moved past the bumper sticker. It has become
educational and part of a broader conversation about how to address the issue and how
officials can tie down the problem to really help those that need the help.
• The media has done a good job, have learned a lot about from the news about the
opiate crisis. It is a little late, but at least the story is being told now. I have been
informative and it is really helpful to have them at the table. (Asked for examples)
• I am from Kentucky and would not associate the issue with them, but there are so many
pill factories there and now look at the big Opiate/Heroin crisis going on there. The
Frontline story was also good.
• Students/teachers/administrators know which substances are being used in the
community and what local resources are available to assist with intervention efforts
• Training for administrators/teachers on warning signs of substance use so those
interacting with school-age children can identify those at risk and can target prevention
and intervention efforts accordingly
• Lots of people are here and it’s because people are dying and it is starting to get
people’s attention.
• Many communities are ‘’owning’’ the issue, realizing that this is a problem and it needs
to be addressed. Though there are still some areas that are in denial.
Collaboration
• Various agencies are sharing information and training opportunities.
Continuum of Care – Comprehensive Strategies
• As I approached the table I thought the prevention meant to stop people from starting to
use, but now I see it can mean several things, the prescribing habits, the reviving of
people, getting people into effective treatment and other things to be done to prevent
continued use.
Narcan/Naloxone
• The shift to harm reduction is great. Lots of attention on providing information to those in
need and the efforts to address the overdose situation has been great. There are lots of
efforts to get information out to first responders and provide the NARCAN kits. The
“MARAH Project” has funded the Seattle Police Department with NARCAN kits and in 6
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weeks has saved 6 lives – this was so encouraging and shows the importance of these
kits and getting them out to first responders.
• A study at Evergreen Treatment Services regarding the distribution of NARCAN to users
and how and is it being used has been helpful. They are keeping stats on how often the
NARCAN is being used and it has shown that it is not uncommon to have NARCAN
used by someone more than once.
PDMP
• Prescription drug monitoring program and the take-back program were very positive and
working well.
• Prescription monitoring programs are an effective tool for any prescriber who needs or
wants to use it. But it is not being used by many. If they use it they are can look at what
folks are getting and prescribe smartly
Peers
• Using peers to engage other students in prevention education and identification of peer
role models to assist with prevention and engagement efforts
Prevention Interventionists in Schools and Counselor Support
• The high schools have behavioral counselors who are termed ‘coaches’ but there is a
need for more of them
• Engaging school-aged children through the school system (Boston model)
• Providing targeted prevention intervention for school-aged children who have family
members with opiate use disorders or other substance use disorders
• Using prevention interventionists in schools (need more of these professionals)
Resources and Support
• Advocates being available for families have been really helpful. It has helped families to
not be alone through the treatment process, and knowing where to go when they need
help.
• Drug-free community grant
• Annual Prevention Conference in Kent (Kent Drug Free Coalition) and Peer to Peer
Annual Education Conference
• CVS Pharmacy grant involving prescription take-back
Syringe Exchange
• Needle and syringe exchange programs have been helpful
Take-Back Boxes
• Talked about prescription take back boxes in all of their schools and that there is a great
deal of buy in from the mayors, police chiefs, libraries and chambers of commerce in her
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area. She states that there is a lot of sharing of information among these entities
regarding ‘the word on the street’.
• Prescription drop boxes in Police Departments are well received, but many may be
intimidated by the location.
Youth Engagement
• Engaging students in the process of determining prevention content
What Needs to be Improved?
Adverse Childhood Experiences (ACES)
• ACES is a good start
Accessibility and Equity of Information
• Information needs to be in a broad spectrum of languages and written so that it is
respectful of culture
• When family are immigrants the parents often do not speak English well/at all and are
not culturally aware and so kids can take advantage of this.
• Need more culturally appropriate services (including services for those with English as a
second language)
Addressing Mental Health and Co-Occurring Disorders
• Mental health treatment is a big issue. My daughter had several diagnoses and it made
her anxious and unstable. She chose to self-medicate and even with all our efforts to
help her, we could not get to her before she died.
• All agreed that Mental Health services in the county and state are lacking.
Alternative Pain and Traumatic Injury Treatments
• Alternative medication or treatments for pain from traumatic injuries
Attitudes
• ‘If it makes you feel good, do it’ attitude
• Past culture of opioid use – early medicines that were cure-alls, some Asian cultures
where opium use was very acceptable at times in the past.
Beds and Housing
• Treatment facilities and after treatment housing needs to improve with more beds
available.
Data to inform prevention efforts and policy
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• Need access to community/neighborhood-centric data to impact and inform local
prevention efforts and policy; also need education on where/how to access county-level
and city-level data (some communities are currently utilizing national or state level data
to inform local prevention efforts)
• Need access to data on young adults/transition aged-youth (18-25 year olds)
Diversion Programs
• Diversion opportunities need to be improved. There needs to be more opportunities for
folks who are in a clean and sober situation to keep active whether it is a community
project or just creative tasks for them to have an outlet.
• Expand the Law Enforcement Assisted Diversion (LEAD) program
Education – Information Dissemination
• Smoking heroin does not seem that bad to many , so informing early and informing
accurately is important
• When we get funding we need to ensure education is a part of the requirement
• How are people teaching about it needs to be more than bumper sticker. Needs to be
more than scare tactic and abstinence
Financial resources to target problem
• It feels like we are restricted in regards to how much we can do: Federal funding can be
utilized, it feels like resources are there, the State is working with the Government for
funding. The more we can get the better, because in the long run it will not only save
lives, but money.
• Need more federal funding without strings: The problem with this is the restrictions
around the funding that often hampers the ability of who you can help
• You have to wonder if the strings are meant to clutter the path for exclusionary reasons.
One guess is that it is a manifestation of political fear - If one signs over funds to help
people their constituents feel are not worthy, there may be fear the people who voted for
you would vote you out.
Good SAM Law
• Broadcast ‘Good Samaritan Laws’ regarding calling 9-1-1 for overdoses – Police will not
arrest person calling or victim, they just want people to get medical attention.
Legalization
• I think the best thing to do is to legalize everything – I know this is a controversial
perspective, but what happens that right now we can’t safely engage the issue when we
drive them deeper into hiding. We would get more momentum to the legalize trade than
to treatment
Mental Health Screening
• Mental health screening is important – there needs to be a variety of education in this
area.
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• Maybe some kind of mental health screenings in schools, in adolescents or primary
schools that would help identify the issues. A screening and brief intervention in the
mental health setting would be great. There really need to be a lot more screening and
intervention; more of a broad based screening, need more resources, it needs to be
widespread, routine and it really needs to become common practice.
Narcan/Naloxone
• Regarding Narcan in Seattle: There are some politics around this especially with Fire –
there is pushback. Medic-one carries the kits but Fire doesn’t and wont – something to
do with first on the scene. It took a year to get Seattle Police Department (SPD) to get on
board. Approached the Mayor’s Office but they just kind of gave the run around and no
real assistance, made lots of efforts, but could not get them on board, we just heard,
“okay, yeah, we’ll look at it.” It did not happen until we approached Chief O’Toole and it
happened. She was extremely helpful and open to the idea. The project’s goal is to save
lives and it was so nice and interesting to see that it was successful and the results were
seen so quickly.
• We want everyone in Seattle Police Department to carry the Narcan kit, we want to get
parents to understand that buying a kit could save their child’s life – recommend buy a
kit, give it to them and teach them how to use it to save their child’s life.
National support and promotion
• Educational information is good at the local level, but really needs to also be at the
national level – forums like this one need to occur at a higher level. Public Service
Announcements similar to the one Obama and Macklemore did was great.
• Look at the bill Obama did: one bill for the Opiate addiction and medication-assisted
therapy.
Parent Education
• Need to train parents that prevention education will not encourage use
Patient Education
• My doctor and/or pharmacist did not tell me I could overdose
Prescription Drug Monitoring Program (PDMP)
• Prescription monitoring programs are an effective tool for any prescriber who needs or
wants to use it. But it is not being used by many. If they use it they are can look at what
folks are getting and prescribe smartly
Prescriber Education and Prescribing Practice
• Education and cooperation by prescribing doctors needs to be better.
• Supply is an issue, but informing youth early on so young people have time to make
decisions about what they are going to do.
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• You can’t buy Opiate prescription now, it is all in the medicine cabinet – doctors are
prescribing ridiculous amounts for benign things like. I had 30 for a hurt wrist and I have
30 for a pulled wisdom tooth and that is ridiculous
• Need more info on practitioners who over-prescribe
Reduce Access/Availability of Drugs
• Availability for people to get drugs
Resource Awareness for Law Enforcement/first responders
• Better educate law enforcement (first responders) about what prevention opportunities
and resources are available so they can pass info on to folks they come across in the
field.
Resource Awareness - Narcan/Naloxone and Take-Back Boxes/Events
• Provide better information on where to get Narcan
• Need more information about prescription take-back and prescription take-back events
and permanent drop-boxes at appropriate/supervised locations
Safety
• There is no way to evaluate street drugs for safety
School Policy
• Kicking kids out of school for drug use enhances the problem – keep them in class and
get them counseling.
• Random drug testing? – It is not allowed in schools; however, parents can have kids
tested.
School and Youth Prevention Programming/Education, Intervention and Mentoring
• Improve education in the schools at all levels – drug abuse programs
• Informing young people about Methadone is key – we need to inform them. The thing is
we focused on Crack, we focused on Meth and other types of drugs and maybe it made
it look like Heroin may not be so bad, if they are focusing on the others. We need to
make sure to inform youth better about heroin and opiates. People start using them and
then it is on from there. They get that thing into their brain and then it is over – addiction.
• Need more prevention-interventionists in schools
• Need more healthy support networks and mentoring programs in our schools
• We need to provide alternatives to using drugs – keep the kids engaged.
• Empower children to make educated decision.
Social Norms and Media Messaging
• Social settings where drug use is the ‘norm’ and where drug use is being ‘normalized’
and where social media messaging promotes that drugs are ‘fun’
• Movies and TV showing drugs as fun
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• Needs to be more education to youth through TV, social media, other sources
Training – administrators, teachers, and parents
• Need to provide more training to school administrators, teachers, and parents on early
identification of at-risk youth (what are the substances being used in the community?
what are red flags to be looking for? what are local resources for intervention?)
What works? – Use research-based approach – Address issues to reduce risk
• In regards to homeless youth and the use – there are many that don’t use, so what
made the difference, was it early intervention?
• What works with kids not using?
Not being homeless – housing is a huge issue
Making kids excited about life
Employment programs
The availability of other options – healthy activities
Young people need really good non-scare tactic information
There needs to be engagement and the availability of all services – especially
mental health
Focus Two: Treatment Expansion and Enhancement
What is Working Well?
Approach
• Shift in acceptance of Harm Reduction
Assigned police staff for community resource
Awareness, Attitudes, and Reduced Stigma
• More awareness and push to acknowledge the issue. The amount of discussion of
problem
• A growing understanding that recovery is a process
• Society is coming to understand that opiate addiction is a disease, not a lifestyle
• Society is also seeing this current issue as a Public Health issue rather than a criminal
justice issue.
• Shifting attitudes about medication for treatment
• Humanizing the problem
Schools are involved in the discussion
• Stigma is being addressed, compassion is happening
• Awareness and Education efforts are increasing.
Behavioral Health Integration and Language
• Merging of mental health and substance use treatment allows for better tracking of
needs
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• The County’s Department of Community and Human Services, Behavioral Health and
Recovery Division (BHRD) name change shows emphasis on recovery and holistic
wellness not “illness.”
Best Practices and Science
• Identifying ‘best practices’
• Emphasis on science instead of morals
Continuum of Care
• The focus on medication-assisted treatment is good, seeing it explored is a popular topic
because abstinence does not work. It is good to see it being recognized more as a
disease model. Telling people to say “no” and “why aren’t you strong enough to say no,”
is the wrong message, because all it does is cause people to beat themselves up.
Media
• Media is presenting factual information as well as the grief in the community
Normalizing of the topic, bringing new voices to be heard
Narcan/Naloxone Access and Promotion
• The availability of Naloxone for users and family members
• Putting Narcan into treatment plans- for example, asking “who do you trust” to help you
in an emergency and getting a plan in place just in case.
No wrong door approach
• Where it exists, the “no wrong door” approach is working.
Open Access
• Same day assessments and next day assessments are very helpful
• Next day appointments-treatment when you need it.
Opportunities and Solutions
• Feels like opportunities and new solutions are happening
Peer Support and Recovery Coaches
• Peer support, recovery support services exist, recovery houses
• Peer Bridger programs are very successful
• Recovery coaches are proving to be a promising practice
• Peer coaches seeing the community respond to peer coaches that are more client
centered than sponsors “who tell you what to do instead of asking you what you’d like to
work on”
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Programs
• Innovation in the Law Enforcement Assisted Diversion (LEAD) program
Social services and law enforcement working together
Provider Communications
• Communication between providers
Treatment, Access, and Availability
• Increase in services available
• More treatment availability in pipeline
o Greater access in areas that need it – that is, South King County
• More treatment options are serving more people
o Suboxone providers/opiate treatment programs
• Methadone treatment is effective.
• New treatment options and drugs are coming on line.
• More treatment centers are opening in south King County
• Methadone and Suboxone treatment
• There is a demand for treatment (which is a good thing.)
• Small pilots for treatment on demand working well. Need to bring them to scale
What Needs to be Improved?
Attitudes, Stigma, Need for Education
• The negative stigma that impacts family members of users (lack of education)
• The assumption that users come from poor, broken families (education)
Community Concerns – Service Locations
• Community concerns over siting future clinics
Criminal Justice
• What is criminal justice doing?
Funding Needs
• Lack of funding
Housing
• Housing is a big one – various options are needed, it cannot be the same for everyone
there needs to be different options. There are not enough treatment options that include
housing.
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Lack of Comprehensive Wraparound Systems
• Lack of a comprehensive wrap around system for users and recovering addicts. For
example ongoing counseling, job opportunities, family support, and developing skills to
transition to a drug-free lifestyle.
• 24 hour “wraparound services” in a shelter setting with a one-stop type of approach – for
example, DSHS workers, housing workers, etc. – like the San Francisco “The Navigation
Center” shelter and “radical hospitality” – and allows clients to bring with them the three
Ps – pets partners and possessions (Seattle does this some places) since King County
is more spread out that there may need to be more navigators (also Councilmember
Bagshaw)
Libraries and Social Worker Support
• In Colorado, Denver employs social workers in the library or libraries to provide support,
case management and this County should look at that option.
• Train librarians on options for people in need as well.
Low -Barrier Services and Shelter
• Develop a center like the Navigation Center in San Francisco that offers low barrier
services and shelter. This center allows all genders, dogs, and a full array of services for
people.
Meeting the needs of communities of color and priority populations
• What about communities of color in the data and media and workforce?
Family supports
Navigating the system for families and users in a culturally relevant way
A need for more trauma-focused care
Increased education across all demographics/211 system
Increased information about medications and side effects, esp. with various
populations
Getting treatment to be outside of the agency - information
More/better relapse prevention strategies such as education and when relapse
happens
More support services that are free; peers, youth
Inclusive models of care - both mental health and substance use and 1degree
care
Have treatment options in increased varied environments, greater access
Increased sober housing; integration of treatment w/ housing programs; more
housing first programs
Efficient allocation of funds - more to treatment, less to admin
Lower income, working class need more funding
Single parents, pregnant women, LGBTQ, veterans, non-native English and non-
English speaking individuals - targeted programs for groups with high barriers
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Negative Impacts on Environment (places)
• The negative impacts on public spaces such as a library – presence of users, needles,
etc.
• The feelings from librarians that they are being forced to become social workers to
respond to users and patrons of the library system.
Open Access
• Increasing the numbers of substance use next day appointments that the Crisis Clinic
has to offer. Immediate access to care was something that came up as key to
individual’s recovery. Once someone is open to detox, having quick access to a bed
would not only provide treatment, but encouragement the person is making a healthy
choice the community supports with resources.
Safe Injection and Consumption Sites – Equity Measures
• Need not only safe injection sites but safe consumption sites since this is equitable given
that there are more white people injecting and more African-American people consuming
(smoking) (From Sally Bagshaw, City of Seattle Council member)
Shortage of Treatment Professionals and Prescribing MDs
• Shortage of Chemical Dependency Professionals (CDP)
• Nursing shortage
• Lack of doctors prescribing---how do we incentivize them? Tuition forgiveness? Other
options?
Transportation Access
• Lack of transportation options
Treatment Access, Approach, and Options
• Lack of available methadone treatment centers
• Poor accessibility of current methadone treatment centers
• Lack of services outside of Seattle
• No plan for early engagement for users who have just started
• Develop standard treatment guidelines for treatment providers around overdose
prevention.
• More and expanded treatment on demand
• Less focus on abstinence based treatment more hard reduction focus
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Focus Three: User Health and Overdose Prevention
What is Working Well?
Awareness, Attitudes, and Reducing Stigma
• Awareness (PBS Frontline, Vancouver’s Insite visit and other events)
• Increasing public awareness
• Decreasing stigma
• Better attitudes of treatment whole person
• Becoming less judgment and more supportive
Behavioral Health Integration
• Behavioral Health Integration
• Behavioral Health Organizations (BHO)
Integration of primary care with Evergreen Treatment Services/Harborview
Physicians on staff @ methadone clinic
Community
• Community discussions
• Voices from community members most affected such as Voices of Community Activists
and Leaders (VOCAL)
Decriminalization
• Movement toward decriminalization of drugs
Law Enforcement and First Responders
• Police/first responders
Naloxone Access and Promotion
• Getting Naloxone into schools
• Narcan in housing programs
• Naloxone
Police are carrying, using and reversing overdoses
Change in law in Washington is resulting in increased access to Naloxone
• Naloxone access
Needle Exchange
• Needle exchange
• Needle exchange
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Parent Involvement in Programs
• Parental involvement in treatment programs (NAVOS)
Partnerships and Collaboration
• Partnerships, like between the King County Behavioral Health Organization, Kelley-Ross
Pharmacy, and agencies like Community Psychiatric Clinic (CPC).
Peer Models
• Peer-based models such as People HR Alliance
• Peer-based support is effective
Programs
• The REACH Program of Evergreen Treatment Services
Outreach services to homeless
• Law Enforcement Assisted Diversion (LEAD) criminal justice diversion program
Race, Culture and Equity
• Better recognition of need to consider issue of race and culture
Resources
• Stopoverdose.org
• Connection to info about services
Treatment Expansion, Access, and Approach
• Methadone clinics expanding due to County and increased cap (Renton, Kent, eastside)
• Buprenorphine prescriptions by some docs
• Suboxone less difficult to kick than methadone
• Medical assisted treatment overall
• Harm reduction
• Medic One
• Increased treatment capacity (Renton Youth Treatment Services, Evergreen Treatment
Services in Grays Harbor, etc.)
• Mobile Clinics (with limited primary care resources)
• Flexcare (Buprenorphine) medication-assisted treatment
• Access to methadone for pregnant women
• Access to methadone and Suboxone
User Education and Harm Reduction
• User education re-harm reduction
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Wrap Around Services/Teams
• Wraparound services/teams
`
What Needs to be Improved?
Access to Services, Equity and Social Justice, and Increasing Providers/ Capacity
• Services needed in all cities
• Not enough access – geography, level of severity, treatment slots
• Limit on Buprenorphine prescriptions
• Mobile SCF to reach homeless people with others
• Expanded access to Suboxone
• More Suboxone prescribers
Best Practice
• Info about best practices
Care Model
• Providing comprehensive care
Education for Community/Public and Outreach
• More public education needed
• Community education to reduce “not in my back yard” responses and create “yes in my
back yard” responses
• Utilize churches for outreach/education
Education for Youth
• Prevention education for kids
Education for MD Providers
• Education of next generation of doctors, those in med school
• Better education of medical professionals re: Suboxone
Equity and Social Justice, Sentencing Guidelines, medication-assisted treatment in Drug
Court and Public Health Focus
• Only focused on heroin because it affects white middle class
• Revisit drug sentencing guidelines
• Acceptance of medication-assisted treatment for people in drug court – education of
judges
• Less criminalization, more public health focus
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Expand Peer Program Resources
•Expand information/tools/recovery resources for peers
Funding
•Maintain funding support for programs
•Flexible funds for people in recovery
Homeless Population Support and Access
•Valley Cities Counseling is teamed up with the King County Library System to assist with
the homeless populations that are users within the downtown Renton branch with limited
success.
Integration of Recovery Discussion
•Integrate people in recovery and discussion of drugs into other committees (housing,
schools, etc.)
Mental Health and Co-Occurring Support
•Mental health support for those struggling with addiction issues
•More integration of primary care with behavioral health.
Narcan/Naloxone Access and Education
•More Narcan kits into hands of active users
Costs have risen, reducing number given to agencies
•After naloxone, then what?
Use media to help educate on what to do after someone is recued (next steps)
Narcan/Naloxone and medication-assisted treatment in Jail
•Jails should give naloxone and allow people to stay on medication-assisted treatment
Open Access
•Treatment on demand
•Need more treatment on demand
Utilize the Downtown Emergency Service Center (DESC) or other resources
Opportunities and Meeting Basic Needs
•Creating more opportunities for people in recovery (jobs, housing, education, etc.)
•Need more stable housing/affordable housing
Patient Education and Support
•Educate pharmacy on how to address addiction. How to talk to patients or doctors.
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Reduce Access to Prescription Opioids
•Too easy to get prescription opiates
Reducing Stigma
•Stigma – must pay attention to use of language
Supervised Consumption Sites
•Supervised consumption sites
•Insite approach
•Safe consumption for all drugs
•Supervised consumption sites connect people to treatment
•Call it “supportive consumption facility”
Systems and Leadership
•Need to challenge prison and law enforcement systems
•More civic and law enforcement leadership
•Improve power sharing among decision makers
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Attachment E
SUMMARY OF RECOMMENDATION VOTING TALLY
RECOMMENDATION VOTING TALLY
PRIMARY PREVENTION REC#1 Y=24, N=0, A=2, S=4
PRIMARY PREVENTION REC#2 Y=25, N=0, A=1, S=4
PRIMARY PREVENTION REC#3 Y=25, N=0, A=1, S=4
TREATMENT EXPANSION
& ENHANCEMENT REC#1 Y=25, N=0, A=1, S=4
TREATMENT EXPANSION
& ENHANCEMENT REC#2 Y=26, N=0, A=1, S=3
TREATMENT EXPANSION
& ENHANCEMENT REC#3 Y=26, N=0, A=1, S=3
HEALTH SERVICES & OVERDOSE
PREVENTION REC#1 Y=23, N=1, A=1, S=5
HEALTH SERVICES & OVERDOSE
PREVENTION REC#2 Y=23, N=3, A=1, S=3
Note: The Health Services and Overdose Prevention Workgroup Recommendation 1 was approved via
an electronic voting process.
Y=YES N=NO A=ABSTAIN S=SILENT
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Attachment F
IMPLEMENTATION AND PLANNING DETAILS
Primary Prevention Workgroup Recommendation 1
•Creation and Dissemination of Educational Flyer and Counseling Guide
Current implementation and planning: A new approach to education, potentially
facilitated by an educational flier, could be implemented when considering opiates for
a pain condition. The flyer is intended to help facilitate conversation about the risks
and benefits of opiate drugs, including the risk for overdose, addiction potential and
other risks associated with the medication and to provide information on non-opiate
alternatives for treating pain. Dissemination of the educational approach/flier will be
supported by King County agency staff, UW partners, local stakeholders and
professional associations.
•Education Campaign
Current implementation and planning: An education campaign will be developed in
partnership with local stakeholders, King County DCHS Prevention Staff, and
Washington state workgroups to build capacity, partnership, and overall
effectiveness in launching a comprehensive and unified educational campaign to
reach a broad audience including the general public, opiate users, social networks,
and professionals.
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Attachment G
IMPLEMENTATION AND PLANNING DETAILS
Primary Prevention Workgroup Recommendation 2
•Encourage pharmacies to counsel all individuals on opiate use, storage and disposal
Current implementation and planning: King County pharmacies will be encouraged by King
County Agency and involved community stakeholders to counsel all individuals at the time of
first prescription regarding safe storage, disposal of opiates and other controlled substances
to prevent unintended access to the medications by others, and how to prevent and
recognize overdose.
•Increase pharmacy participation in promoting safe storage and medicine disposal
Current implementation and planning: King County pharmacies will be encouraged by local
stakeholders and King County agency staff to promote safe storage and medicine disposal
with each opiate prescription to expand community opiate prevention and awareness across
all areas in the county.
•Expand access to and coordination with prescription-take-back programs
Current implementation and planning: Task Force members and King County prevention
staff are currently partnering with King County Secure Medication Return to promote the
expansion of their take-back locations and mail back program. Partnership includes unifying
messaging and incorporating consistent guidance on disposal methods for medication
types.
•Engage local pharmacies to distribute mail-back envelopes
Current implementation and planning: The Cordant pharmacy launched a program in July
2016 to provide free take-back envelopes to the public through partner agencies to collect
and dispose of unwanted medications with the aim of contributing to a reduction in the
opiate crisis. King County is ordering 5,000 Cordant mail back envelopes to begin piloting
distribution of a postage paid take-back envelope to be paired with each opiate prescription
dispensed in addition to related opiate prevention counsel by pharmacist.
•Use social media to promote safe storage and disposal of medications
Current implementation and planning: Task Force members and King County staff will
outreach and partner with agencies, prevention coalitions, and pharmacies to promote safe
storage and disposal.
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Attachment H
SAN FRANCISCO INTEGRATED BUPRENORPHINE INTERVENTION SERVICES (IBIS)
PROCESS PROTOCOL
Brief Program Description
The IBIS Program represents a collaboration between the San Francisco Department of Public
Health, Community Behavioral Health Services (CBHS) and the UCSF Department of
Psychiatry at San Francisco General Hospital. The program identifies, evaluates and provides
buprenorphine treatment to opiate dependent adults residing in San Francisco. Indigent, out-of-
treatment, injection heroin users represent the primary patient population. IBIS is a maintenance
(vs. detoxification) treatment program. Most IBIS patients begin buprenorphine treatment at the
City’s Office-based Buprenorphine Induction Clinic (OBIC), and stabilize for a period time
prior to transfer to a participating community-based IBIS provider. Community IBIS sites include
a number of Primary Care and Mental Health clinics/programs. Indigent IBIS patients can
receive Suboxone free-of-charge through the CBHS Pharmacy.
Program Eligibility
•Opiate Dependent San Francisco residents who are eligible for care in the SFDPH
Community Oriented Primary Care Clinics (COPC). Must have Healthy San Francisco,
S.F. Path, Healthy Families, Healthy Workers, San Francisco Health Plan, Medi-Cal or
other coverage accepted by the COPC.
•Absence of benzodiazepine abuse or misuse
•Absence of current alcohol dependence or binge drinking
•18 years or over or emancipated minor able to consent for medical and substance abuse
treatment
•No medical or psychiatric contraindications for buprenorphine maintenance treatment
(for example, unstable medical condition, active suicidal ideation, marked psychosis etc.)
Any hepatic dysfunction must be in the mild-to-moderate range, with LFTs no greater
then 5xs normal levels.
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•Patients with acute or chronic pain syndrome requiring regular opioid analgesics should
be carefully screened, as buprenorphine may provide less analgesia than a full opiate
agonist, and will block (or partially block) other opiate agonists.
•Patients currently receiving more than 30mgs of methadone daily will likely be required
to taper down to a dose < 30mgs prior to their first dose of buprenorphine.
•Women who are pregnant (or trying to become pregnant) should be evaluated on a
case-by-case basis. Though methadone remains the standard of care for pregnant
opioid dependent women, recent data support the safety and efficacy of buprenorphine
in pregnancy.
Patient Identification, Referral, and Program Entry
To be eligible for treatment through IBIS, a patient must meet the above eligibility criteria and be
able and willing to comply with program expectations, including compliance with counseling,
medical, and pharmacy visits. Patients may be identified at, and referred to IBIS from, multiple
sites/venues/providers across the City including, but not limited to, primary and mental health,
social and outreach services (for example, Homeless Outreach Team, Project Homeless
Connect and needle-exchange sites), and the Centralized Opiate Program Evaluation (COPE)
Service. In certain circumstances patients may self-refer to OBIC/IBIS.
Potential IBIS patients must be discussed with medical staff at OBIC (552-6242) who will
make a preliminary determination of appropriateness for buprenorphine treatment. Patients will
typically be referred to OBIC for evaluation and medication induction. On occasion, induction
can occur at the referring site.
OBIC Clinic Procedures
The Orientation Appointment
At the orientation appointment, patients meet with OBIC staff and review the OBIC/IBIS
program, as well as potential benefits and side-effects/risks of buprenorphine. Typically at this
visit, consent forms are reviewed and signed. If lab-work is indicated (for example, LFTs), the
patient will be given a lab-slip to have their blood drawn at SFGH. Patients must have or obtain
a CHN (Community Health Network) number in order to participate in IBIS. Induction
procedures and expectations are reviewed, and after preliminary work is completed an induction
appointment is scheduled. On rare occasions, the induction process may begin at the
orientation appointment. Patients may be given adjunctive medications such as clonidine and
trazadone at this appointment to help them prepare for the induction.
The Induction Appointment
At the induction appointment, preliminary labwork is reviewed, and a diagnosis of opiate
dependence is confirmed. A point-of-service urine toxicology screen will be obtained. The
patient receives a thorough medical, mental health, substance use and psychosocial
assessment, and a physical examination is performed. If a recent physical exam, history, and/or
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labwork have been conducted by the referring physician, a copy should be faxed to OBIC for
review. Patients must be in opiate withdrawal in order to be induced. The only exception is
a patient who has not used opiates for several days prior to the appointment. Patients who have
recently ingested an opiate and do not appear to be in withdrawal may be asked to return at a
later time. If deemed ready for induction, an initial dose of Suboxone will be administered. The
patient is observed for 1-2 hours, and may receive additional Suboxone doses as determined by
the OBIC physician. Adjunctive medication such as clonidine and trazadone may be dispensed
to the patient to help them through the first days of the induction. Follow-up appointments to
stabilize the dose are scheduled by OBIC staff.
Induction and Stabilization at OBIC
OBIC patients are generally seen daily during the first week of treatment (the induction period).
The frequency of appointments typically decreases over the ensuing weeks. Most patients will
reach a stable dose in less than 2 weeks, and typically progress to a weekly then bi-weekly
dispensing schedule as determined by the IBIS physician. Buprenorphine is dispensed through
the CBHS Pharmacy located 1 floor below OBIC at 1380 Howard Street.
Substance abuse counseling is required at OBIC during the induction and stabilization process.
In addition, all OBIC/IBIS patients are encouraged to attend weekly group sessions with other
patients in office-based opiate treatment. Urine toxicology screens are obtained at regular
intervals while the patient is at OBIC. Communication with the referring site will occur while the
patient is at OBIC.
For those patients who are not already engaged in Primary Care or Mental Health treatment at a
participating community IBIS site, OBIC staff will review previous and current medical, mental
health, substance use and psychosocial needs and work to match the patient to a community
IBIS provider. Once an accepting community IBIS site is identified, OBIC staff will facilitate a
transfer for ongoing care. Typically, patients spend 4 to 8 weeks at OBIC for stabilization and
are then transferred to a community site; however, care at OBIC is based on individual needs
and the treatment timeline will vary. In rare instances, if approved by the OBIC Director and
Medical Director, a patient may remain at OBIC for ongoing treatment.
Transfer to Community IBIS
When the patient is clinically stable and has an appointment scheduled at an IBIS community
site, OBIC will fax a treatment summary and any other requested information (for example,
consents, H & P, etc.) to the referring/accepting community physician. The patient will receive
buprenorphine at the CBHS Pharmacy. The OBIC physician will write the “transfer” prescription
for Suboxone, and fax this to the pharmacy. This prescription will carry the patient through to
their next community IBIS physician appointment. Patients with MediCal may have their
Suboxone dispensed from a local community pharmacy other than the CBHS Pharmacy. All
subsequent prescriptions will similarly be written by the IBIS community physician and faxed to
the community pharmacy. The CBHS Pharmacy will accept only faxed and phoned
prescriptions. NO WRITTEN PRESCIPTIONS SHOULD BE GIVEN TO PATIENTS.
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Maintenance Treatment Considerations
Clinic Visits
Some form of counseling is recommended for all IBIS patients. Physicians, nurses, social
workers, behaviorists, and/or counselors can provide counseling. The prescribing physician may
require the patient to attend support groups. Patients should meet with their prescribing
physician regularly, with physician-determined visit frequency based on patient functionality,
response to treatment, and adherence to the treatment plan.
Toxicology Screening
Toxicology screening is recommended for IBIS patients, particularly early in treatment, during
periods of instability, and when indicated by patient history or appearance on examination.
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Attachment I
BUPRENORPHINE SYSTEM OF CARE: IMPLEMENTATION AND PLANNING DETAILS
Treatment Workgroup Recommendation 1
Level 1 Facilities
•Downtown Public Health Needle Exchange Induction Site
Current implementation and planning: A design team has been established by Public
Health-Seattle & King County to implement a centrally located, low-barrier
buprenorphine induction site at the Downtown Public Health Needle Exchange. This
facility has an on-site pharmacy and will provide individuals in need of buprenorphine
treatment with treatment on demand utilizing a “Buprenorphine First” model of care and
intensive oversight dosing. Similar to the San Francisco model, a Nurse Care Manager
model will be utilized to support treatment on demand and address barriers to
buprenorphine prescribing; additionally other supportive services will be available on site
(see Attachment E for Description of Collaborative Care/Nurse Care Manager Model). A
Collaborative Care/NCM model has also been successfully implemented in
Massachusetts to expand treatment access. 43 Implementation of induction services is
tentatively scheduled for end of September 2016.
•Emergency Department Induction Sites
Current implementation and planning: A subset of the Task Force is working on
determining feasibility of buprenorphine induction in Emergency Departments (ED).
Harborview Medical Center, represented on the Task Force, has drafted a proposal for
induction of buprenorphine in their ED in conjunction with a brief intervention and referral
for ongoing care, similar to the intervention ED staff use to treat other chronic and
relapsing health conditions. Harborview Medical Center is considering leveraging an
existing Substance Abuse Mental Health Service Administration (SAMHSA) grant to
provide induction services, and will continue to identify and address barriers to
implementation.
•Recovery Center Valley Cities Detox and Residential facility
Current implementation and planning: The Recovery Center will re-open by the second
quarter of 2017. This facility (previously Recovery Center King County, RCKC), will
provide approximately 30 to 35 detox beds and the same number of residential
substance use disorder treatment beds. Valley Cities, represented on the Task Force,
has drafted a proposal for inclusion of buprenorphine medication (induction and
maintenance services) as part of the treatment resources offered to individuals seeking
43 LaBelle, C. T., Han, S. C., Bergeron, A., & Samet, J. H. (2015). Office-based opioid treatment with
buprenorphine (OBOT-B): Statewide implementation of the Massachusetts collaborative care model in
community health centers. Journal of Substance Abuse Treatment, 60, 6-13.
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treatment at the Recovery Center. Valley Cities will work with the King County
Behavioral Health Organization to address barriers to implementation.
•Mobile Medical Van
Current implementation and planning: As of July 2016, Public Health - Seattle & King
County operate two Mobile Medical Vans (MMVs). These vans provide an array of
health care services including basic medical care, behavioral health assessments and
initial interventions, social service assistance, and referral to ongoing care. The MMV
staff have the ability to prescribe buprenorphine, monitor the induction process, and
provide brief intervention and referral for ongoing care. As such, the MMV offers a
unique opportunity to reach individuals experiencing homelessness. Effective September
2016, Public Health-Seattle & King County, represented on the Task Force, will
implement a pilot program to provide buprenorphine induction and maintenance through
the South King County MMV to a small number of individuals that present with opioid
use disorder. The pilot program will be evaluated to determine ongoing implementation
and the possibility of program expansion.
•Jail
Current implementation and planning: A design team has been established by Public
Health-Seattle & King County, Jail Health Services to determine feasibility of providing
buprenorphine induction and maintenance services to individuals incarcerated in the
King County jail. The first phase of implementation will focus on developing a plan to
provide buprenorphine maintenance services to individuals that present to jail stable on
buprenorphine. The second phase of implementation will focus on developing a plan to
provide buprenorphine induction services to incarcerated individuals in need of opiate
treatment. To inform implementation efforts, the design team is currently examining the
number of individuals booked into the King County jail who are stable on buprenorphine
treatment for opioid use disorder.
Level 2 Facilities
•Community Health Clinics (CHC)
Current implementation and planning: Primary care settings can provide a non-
stigmatizing, low-barrier environment for the provision of medication-assisted treatment.
Providing buprenorphine treatment of opioid use disorder through a primary care setting
would also expand treatment availability to individuals who historically have not had
equal access to buprenorphine services. 44 Neighborcare Health, represented on the
Task Force, has drafted a proposal for implementation of buprenorphine induction and
maintenance services within the King County network of CHCs. The proposal involves
the identification of senior leaders and physician champions within each CHC to provide
education to staff regarding community need for medication-assisted treatment. Each
44 Hansen, H. B., Siegel, C. E., Case, B. G., Bertollo, D. N., DiRocco, D., & Galanter, M. (2013). Variation
in use of Buprenorphine and Methadone Treatment by Racial, Ethnic and Income Characteristics of
Residential Social Areas in New York City. The Journal of Behavioral Health Services & Research, 40(3):
367-377.
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CHC would identify prescribers to become waivered to prescribe buprenorphine for
treatment of opioid use disorder, and buprenorphine services would be offered utilizing a
Nurse Care Manager model to support treatment on demand.
Level 3 Facilities
•Behavioral Health Clinics, including traditional Medication-Assisted Treatment (MAT)
facilities
Current implementation and planning: There are 44 behavioral health providers in the
King County network; as such, behavioral health clinics represent a unique opportunity
to significantly expand access to buprenorphine treatment, a standard of care for
treatment of opioid use disorder. As behavioral health clinics disproportionately serve
individuals with limited income, and people of color are overrepresented among those
with limited income, adding buprenorphine treatment to the array of services offered by
behavioral health clinics improves access and equity. Downtown Emergency Services
Center (DESC), represented on the Task Force, submitted a proposal for
implementation of buprenorphine services in behavioral health clinics, and identified
critical resource needs. DESC also highlighted opportunities to deliver buprenorphine
services outside of the clinic in community settings (for example, supportive housing,
homeless shelters, etc.), in order to engage individuals who are reluctant to present to a
behavioral health clinic. Since the implementation of the Task Force, MAT facilities
(which have traditionally provided methadone treatment for opioid use disorder) have
received state approval to dispense buprenorphine, in addition to methadone. This
liberalizing legislation provides an opportunity for conventional MAT facilities (which offer
methadone treatment services) to also offer buprenorphine induction and stabilization
services via an intensive oversight dosing program (in accordance with a Level 1 facility)
and buprenorphine maintenance services. Evergreen Treatment Services (ETS),
represented on the Task Force, submitted a proposal for implementation of
buprenorphine services in MAT facilities, and highlighted opportunities for increased
collaboration between opiate treatment programs (providing induction and stabilization
services) and the greater medical community (providing maintenance services). Medical
providers in the community may be less hesitant to offer buprenorphine services for
treatment of opioid use disorder if more intensive oversight services and clinical backup
will be available through MAT facilities when clinically indicated.
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Attachment J
DESCRIPTION OF COLLABROATIVE CARE/NURSE CARE MANAGER MODEL
Judith Tsui MD, MPH
The Collaborative Care/Nurse Care Manager (NCM) model uses NCMs as the hub of the
medical care team to coordinate and manage patients, supported by a program manager. The
use of the NCM addresses major barriers to buprenorphine prescribing that physicians face,
including insufficient time and support to accomplish the necessary steps to initiate and maintain
a patient in treatment. Treatment for opioid use disorders with buprenorphine/naloxone
(BUP/NX) is particularly time-intensive for the first 2-3 months. Clinical steps include: an initial
screening for the appropriateness of BUP/NX; a comprehensive assessment of substance use
and consequences, medical and mental health screening, and current barriers to and supports
for recovery; medical review of assessment data and formal diagnosis of opioid use disorder
and appropriateness for buprenorphine (that is, medication-assisted treatment, MAT);
scheduling and monitoring of the induction (which typically takes place in clinic) and intensive
monitoring thereafter, consisting of phone contacts and weekly visits, prescriptions, and urine
drug testing for the first 1-2 months. It is unlikely that a typical prescriber could accomplish these
steps within a real-world practice setting with time and scheduling constraints, yet these early
steps are crucial to enhance patient engagement in care. In this model, the program manager
and NCM, who are specifically trained to support office-based treatment for opioid use
disorders, perform many of the initial activities, as well as the support with the induction,
provision of prescriptions, and monitoring activities. This allows the prescriber time to be more
efficiently concentrated on key clinical decisions (such as decisions to initiate; adjust dosage;
taper; etc.). Weekly team meetings with the prescriber, NCM and program manager occur,
during which team members can monitor progress and update treatment plans together.
The team roles are as follows:
•Nurse Care Manager is responsible for patient screening, assessment, education, care
planning, medication induction, stabilization, and maintenance. Also, ongoing coordination
of follow-up care, telephone monitoring when needed, relapse prevention, and support for
patient self-management. Caseload capacity per nurse is 100 patients (with expected drop-
out/new patients). The NCM will be available for patients during all open clinic hours, and
will be a bridge to physicians, who typically have more restricted hours in clinic. The NCM
may also serve as a consult/bridge to engage patients who are “non-treatment seeking”
from other sites such as the emergency room or in-patient setting.
•Prescribers will maintain a federal waiver to prescribe OBOT medications, will conduct the
medical intake to assure the patient’s diagnosis of opioid use disorder, appropriateness for
MAT, determine induction setting (on-site vs at-home), write orders and prescriptions,
supervise clinical services, and refer patients for counseling, psychosocial or primary care
services. Prescribers at primary care clinics may provide primary care services directly to
their patients, or may prescribe buprenorphine for patients who already have a primary
provider in the practice.
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•Program Manager will provide administrative support to the MAT team, conduct initial
telephone screenings over the phone, help with insurance and prior authorization
requirements, staffing and program issues, collaborate with referral sources, and seek
referrals. He/she will also assist with assuring compliance with DEA and state licensure
requirements and reporting activities.
The Collaborative Care/Nurse Care Manager Model allows patients to be more efficiently
started on buprenorphine, with the process of intake as outlined below:
After enrollment, the NCM continues to see the patient weekly for the first 1-2 months, followed
by every 2 week visits for 1-2 months. The prescriber sees the patient monthly or more
frequently if desired at the beginning of treatment, then monthly or less frequently after the
patient stabilizes. Such a schedule of visits is in compliance with the WA State Healthcare
Authority’s expectations for monitoring patients while on treatment with BUP/NX. The NCM can
increase or decrease visit frequency depending on the stability of the patient, the mental health
and substance use counseling frequency needed or desired, and the availability of the
prescriber.
Telephone screening
(screen for OUD,
describe clinic, assess
barriers, insurance)
In-person RN visit
(history, clinical exam,
utox, labs, assess
counseling)
Prescriber
visit (clinical
assessment
only, no Rx)
Supervised induction
with RN
(or home induction)
Timeline: 1-3 weeks
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Attachment K
IMPLEMENTATION AND PLANNING DETAILS
Treatment Workgroup Recommendation 2
•Open Access
Current implementation and planning: The Task Force identified that central access and
referral is an integral component to achieving treatment on demand. Central access and
referral will provide a coordinated model for referral management across the behavioral
health treatment system and will help individuals receive care as quickly as possible and
in the most suitable location. One model that is currently available that could be built
upon is the Recovery Help Line (RHL). The Washington RHL offers 24-hour emotional
support and referrals to local treatment services. RHL staff are supervised by state-
certified mental health and chemical dependency professionals who ensure callers
receive the most effective response. There is current planning at the RHL to develop
what a model for local implementation would look like.
•Ongoing Assessment of Network Adequacy
Current implementation and planning: The Task Force conducted GIS mapping of
current service sites (opiate treatment programs, behavioral health treatment agencies,
needle exchange facilities, public health clinics, emergency departments, and hospitals)
to assess current network adequacy and geographic accessibility. This map can be
accessed electronically at the following location:
http://kingcounty.maps.arcgis.com/apps/webappviewer/index.html?id=d9424b892f404c3
9a07cda52390ce627. The Task Force also identified that the Substance Abuse and
Mental Health Services Administration (SAMHSA) maintains a list of physicians
authorized to treat opioid use disorder with buprenorphine by state, city, and zip code. A
review of the SAMHSA list suggests a slow steady growth of waivered physicians.
•Workforce Shortage
Current implementation and planning: The King County Department of Community and
Human Services (DCHS) surveyed behavioral health provider agencies in early fall 2015
about recruitment and retention issues. Of 29 responding agencies, 23 had vacant
clinical positions, most often for four to seven weeks but some for 15 or more weeks.
Most of the vacant positions were for psychiatrists, advanced registered nurse
practitioners (ARNPs), or counseling staff. Over 80% of responding agencies reported
that they lost employees to programs that offered better pay or benefits.45 The King
County Behavioral Health Organization is designing a plan to address the workforce
shortage in order to achieve treatment on demand and maintain delivery of high quality
services.
45 Workforce Shortage Survey, King County Department of Community and Human Services, September
28 through November 2, 2015
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•Opiate Treatment in Jail
Current Implementation and Planning: Currently, individuals stable on methadone for
treatment of opioid use disorder, who are booked into a King County jail facility (King
County Correctional Facility or Norm Maleng Regional Justice Center), are continued on
methadone treatment during incarceration. However, this is not a policy practiced by
municipal jails in King County (for example, Kent Jail; Issaquah Jail; Enumclaw Jail;
Kirkland Jail; or South Correctional Entity, SCORE), and represents a significant equity
issue. The Task Force has identified representatives to address this issue from a policy
standpoint. Currently, individuals stabilized on buprenorphine treatment will not be
continued on buprenorphine during incarceration at any of the jails in King County
(county or municipal). A design team has been established by Public Health - Seattle &
King County, Jail Health Services to determine feasibility of providing buprenorphine
induction and maintenance services to individuals incarcerated in the King County jail.
The first phase of implementation will focus on developing a plan to provide
buprenorphine maintenance services to individuals that present to jail stable on
buprenorphine. The second phase of implementation will focus on developing a plan to
provide buprenorphine induction services to incarcerated individuals in need of opiate
treatment. To inform implementation efforts, the design team is currently examining the
number of individuals booked into the King County jail who are stable on buprenorphine
treatment for opioid use disorder.
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Attachment L
PROPOSED NEIGHBOR RELATIONS PLAN
Molly Carney, Executive Director at Evergreen Treatment Services
Opiate treatment programs and other locations providing care for individuals experiencing opioid
use disorder (for example, syringe exchange programs, community health engagement
locations for persons with substance use disorders) should consider the following practices to
establish and maintain good neighbor relations.
Clearly articulated hours and rules of business: For facilities where medication is being
dispensed, hours of dispensing should be publicly available and followed. Any terms that clients
must abide by should be readily available to the neighbors and the public.
Public Safety staff: Public Safety staff should be employed by the facility who are to be active
during the dispensing hours. These staff should be specially trained in how to work with
individuals experiencing opioid use disorder, mental health issues, and trauma histories. These
staff should also be specially trained to work with clientele varying in age, race, ethnicity,
gender, sexual orientation, primary language, and cognitive ability.
Numbers: There should be sufficient Public Safety staff to lend order inside and outside of the
facility to at least the organization’s property line (where authority is explicit) or to nearby
manageable landmarks (for example, an intersection). Inside, Public Safety will help the clinic
staff maintain any Code of Conduct or admission criteria established by the business. Outside,
the staff will be attending to issues of loitering, dealing, or behavior that interferes with the
neighboring businesses (for example, shoplifting).
MOU: Businesses adjacent to the target business may be encouraged to enter into a
Memorandum of Understanding (MOU) which is intended to help facilitate communication
between the entities. This MOU may permit the target business to allow their Public Safety staff
to patrol the business property. The MOU should be reviewed and renewed on an annual basis.
Monthly rounds to business neighbors: Public Safety staff should make rounds to business
owners or their managers on at least a monthly basis. Inquiries should be made regarding
what’s working well, what could be improved and/or escalation information if necessary (for
example, who to contact if a business manager desires to escalate a complaint upward). These
staff shall summarize their monthly rounds in a written document that is to be circulated to the
executives and operation managers of the target business and a review team member who is a
client that represents the intervention population. This summary shall include recommendations
for how to rectify any complaints or problems. The target business shall be expected to help the
Public Safety staff address or resolve complaints or problems within one week of the original
complaint and shall include either a written response to the business owner/manager or a return
visit by the Public Safety staff with the proposed resolution. The target business may consider
implementing a monthly newsletter to neighboring businesses, which summarizes clinical
outcomes (for educational purposes) and the response to neighborhood issues.
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Attachment M
IMPLEMENTATION AND PLANNING DETAILS
Treatment Workgroup Recommendation 3
Mark Cooke, Policy Director at American Civil Liberties Union
Members of the Task Force participating in the policy workgroup have analyzed the challenge
presented by local jurisdictions that make it difficult for MAT service providers to open facilities.
The following legal analysis describes the legality of MAT program facilities in the state of
Washington, common challenges in opening MAT facilities, and options to ease restrictions on
opening MAT facilities. The legal analysis primarily focuses on methadone clinics, but similar
circumstances exist in the siting of mental health and chemical dependency treatment facilities
generally, and facilities providing other supportive services (for example, needle exchange
facilities, community health engagement locations for persons with substance use disorders,
etc.).
The Legality of MAT Program Facilities in Washington State
MAT facilities like methadone clinics are regulated by the federal government (21 U.S.C. §823;
42 CFR Part 8) and by Washington state (RCW 71.24.585 et seq.; WAC 388-877 and 388-
877B). Clinics are considered “essential public facilities” and cannot be banned outright (RCW
71.24.590 (1)(b), RCW 36.70A.200). The Department of Social and Health Services is also
tasked with consulting with local jurisdictions where a MAT service provider hopes to locate and
to consider the need of treatment in the area. Approximately 25 clinics currently operate in
Washington.46
Federal courts have ruled that clinic participants are legally designated as disabled and
protected by the federal Americans with Disabilities Act, and that local governments cannot
discriminate against clinics. MX Group Inc. v. City of Covington, 293 F.3d 326, (6th Cir. 2002);
Bay Area Addiction Research and Treatment v. City of Antioch, 179 F.3d 725 (9th Cir. 1999).
Common Challenges in Opening MAT Facilities
Despite the heavy regulation of MAT facilities and a state law that requires local jurisdictions to
provide permitted locations for their operation, many facilities never open. Here is a common
scenario:
46 DSHS – Appendix Q - Opiate Substitution Treatment Programs in Washington State, available at page
244
https://www.dshs.wa.gov/sites/default/files/BHSIA/dbh/Cert%20%26%20LIcensing/Directory%20of%20Ce
rtified%20CD%20Svcs.pdf
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A MAT service provider seeks to open a new facility in a local jurisdiction, identifies a suitable
location (most frequently a building currently zoned for healthcare services), and the service
provider seeks a permit from the jurisdiction to begin operations. During this process DSHS
should be performing its duties to notify the local government about the facility and
demonstrating the need for it (pursuant to RCW 71.24.590 (1). The local jurisdiction objects to
the opening of the MAT facility and utilizes various regulatory procedures to slow the process.
These obstacles could come in the form of requiring conditional or special use permits (allowed
under RCW 71.24.590 (1)(b)) or by issuing a moratorium on MAT facilities. This can significantly
slow things down and ultimately force the MAT provider to stop pursuing the facility, especially if
there are pending financial or real estate transactions contingent on obtaining permits in a timely
fashion.
Media accounts illustrate this problem:
•Puyallup – Tacoma News Tribune – “Clinic hopes to offer methadone treatment in Puyallup;
city not yet sure,” December 2016, available at
http://www.thenewstribune.com/news/local/article48078615.html
•Bremerton – Kitsap Sun – “Bremerton council to consider moratorium on methadone
treatment facilities,” July 2011, available at http://www.kitsapsun.com/news/local/bremerton-
council-to-consider-moratorium-on-methadone-treatment-facilities-ep-418347397-
357153961.html
•Lynnwood – The Seattle Times – “Methadone-treatment company sues Lynnwood over clinic
plans,” February 2003, available at
http://community.seattletimes.nwsource.com/archive/?date=20030212&slug=methadone12n0
Options to Ease Restrictions on Opening MAT Facilities
Amend State Law
RCW 71.24.590 could be amended to make the siting of MAT facilities easier. Currently, DSHS
make a determination of need and local jurisdictions can require onerous conditional or special
use permits, as well as moratoriums. Due to the emergent nature of the opiate epidemic and
statewide need for treatment, the DSHS need process may be unnecessary at this point. The
legislature could also remove local jurisdictions’ ability to require special permits and require
that MAT facilities be treated like any other healthcare facility.
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Attachment N
NALOXONE DISTRIBUTION AND ADMINISTRATION BIBLIOGRAPHY
1. European Monitoring Centre for Drugs and Drug Addiction (2015), Preventing fatal
overdoses: a systematic review of the effectiveness of take-home naloxone, EMCDDA
Papers, Publications Office of the European Union, Luxembourg.
2. Drug Abuse Trends in the Seattle-King County Area: 2014. Banta-Green, C et al. Alcohol
& Drug Abuse Institute, Univ. of Washington, June 17, 2015.
http://adai.uw.edu/pubs/cewg/DrugTrends_2014_final.pdf
3. 2015 Drug Use Trends in King County, Washington, Caleb Banta-Green et al, Seattle:
University of Washington Alcohol & Drug Abuse Institute, July 13, 2016.
http://adai.uw.edu/pubs/pdf/2015drugusetrends.pdf
4. Doe-Simkins et al. Overdose rescues by trained and untrained participants and change in
opiate use among substance-using participants in overdose education and naloxone
distribution programs: a retrospective cohort study. BMC Public Health 2014, 14:297
http://www.biomedcentral.com/1471-2458/14/297
5. Substance Abuse and Mental Health Services Administration. SAMHSA Opiate Overdose
Prevention Toolkit. HHS Publication No. (SMA) 16-4742. Rockville, MD: Substance Abuse
and Mental Health Services Administration, 2016.
6. Banta-Green CJ, Kuszler PC, Coffin PO, Schoeppe JA. Washington’s 911 Good
Samaritan Drug Overdose Law - Initial Evaluation Results. Alcohol & Drug Abuse Institute,
University of Washington, November 2011. URL: http://adai.uw.edu/pubs/infobriefs/ADAI-IB-
2011-05.pdf
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Attachment O
COMMUNITY HEALTH ENGAGEMENT LOCATION (AKA SUPERVISED
CONSUMPTION SITE) BIBLIOGRAPHY
1. Hedrich D, Kerr T, Dubois-arber F. Drug consumption facilities in Europe and beyond. Harm
Reduct Evidence, Impacts Challenges. 2010:305-331. doi:10.2810/29497.
2. Hedrich D. European report on drug consumption rooms. 2004;(June):1-92.
3. Marshall BD, Milloy MJ, Wood E, Montaner JS, Kerr T. Reduction in overdose mortality after
the opening of North America’s first medically supervised safer injecting facility: A retrospective
population-based study. Lancet. 2011;377(9775):1429-1437. doi:10.1016/S0140-
6736(10)62353-7.
4. Milloy MJS, Kerr T, Tyndall M, Montaner J, Wood E. Estimated drug overdose deaths averted
by North America’s first medically-supervised safer injection facility. PLoS One. 2008;3(10):1-6.
doi:10.1371/journal.pone.0003351.
5. Salmon AM, Van Beek I, Amin J, Kaldor J, Maher L. The impact of a supervised injecting
facility on ambulance call-outs in Sydney, Australia. Addiction. 2010;105(4):676-683.
doi:10.1111/j.1360-0443.2009.02837.x.
6. Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services:
What has been demonstrated? A systematic literature review. Drug Alcohol Depend.
2014;145:48-68. doi:10.1016/j.drugalcdep.2014.10.012.
7. Milloy M-J, Wood E. Emergin Role of Supervised Injecting Facilities in Human
Immunodeficiency Virus Prevention. Addiction. 2009;104:620-621. doi:10.1136/sti.2008.032524.
8. Stoltz JA, Wood E, Small W, et al. Changes in injecting practices associated with the use of a
medically supervised safer injection facility. J Public Health (Bangkok). 2007;29(1):35-39.
doi:10.1093/jpubhealth/fdl090.
9. Marshall BDL, Wood E, Zhang R, Tyndall MW, Montaner JSG, Kerr T. Condom use among
injection drug users accessing a supervised injecting facility. Sex Transm Infect.
2009;85(2):121-126. doi:10.1136/sti.2008.032524.
10. Bayoumi AM, Zaric GS. The cost-effectiveness of Vancouver’s supervised injection facility.
CMAJ. 2008;179(11):1143-1151. doi:10.1503/cmaj.080808.
11. Pinkerton SD. Is Vancouver Canada’s supervised injection facility cost-saving? Addiction.
2010;105:1429-1436. doi:10.1111/j.1360-0443.2010.02977.x.
12. Kerr T, Stoltz J, Tyndall M, et al. Impact of a medically supervised safer injection facility on
community drug use patterns: a before and after study. BMJ. 2006;332(7535):220-222.
doi:10.1136/bmj.332.7535.220.
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13. Kerr T, Tyndall MW, Zhang R, Lai C, Montaner JSG, Wood E. Circumstances of first
injection among illicit drug users accessing a medically supervised safer injection facility. Am J
Public Health. 2007;97(7):1228-1230. doi:10.2105/AJPH.2006.086256.
14. Evan Wood, Mark W Tyndall, Calvin Lai, Julio Montaner TK. Impact of a medically
supervised safer injecting facility on drug dealing and other drug-related crime. Subst Abuse
Treat Prev Policy. 2006;4(1):34. doi:10.1186/1747-597X-1-Received.
15. Donnelly N, Mahoney N. Trends in property and illicit drug crime around the Medically
Supervised Injecting Centre in Kings Cross: An update. 2016;(90):3-5.
16. Woods S. Drug Consumption Rooms in Europe: Organisational Overview. 2014.
17. Collier R. Medical journal or marketing device? Can Med Assoc J. 2009;181(5):E83-E84.
doi:10.1503/cmaj.091326.
18. Mangham C. A Critique of Canada’s INSITE Injection Site and its Parent Philosophy:
Implications and Recommendations for Policy Planning. J Glob Drug Policy Pract. 2007.
doi:10.1016/S0022-3913(12)00134-5.
19. Schäffer D, Stöver H, Weichert L. Drug consumption rooms in Europe: Models, best practice
and challenges. 2014:18.
20. BECKETT K. RACE AND DRUG LAW ENFORCEMENT IN SEATTLE. Seattle; 2008.
21. Kingston S, Banta-green C. Results from the 2 Washington State Drug Injector Health
Survey Results from the 2015 Washington State Drug Injector Health Survey. 2015:1-10.
22. Seattle Community Police Commission: Report & Recommendations Pursuant to SPD’s
Disparate Impact Policy: Part I – Public Consumption (April, 15, 2016).
23. Bayoumi AM and Strike C (co-principal investigators), Jairam J, Watson T, Enns E, Kolla G,
Lee A, Shepherd S, Hopkins S, Millson M, Leonard L, Zaric G, Luce J, Degani N, Fischer B,
Glazier R, O’Campo P, Smith C, Penn R, Brandeau M. Report of the Toronto and Ottawa
Supervised Consumption Assessment Study, 2012. Toronto, Ontario: St. Michael’s Hospital and
the Dalla Lana School of Public Health, University of Toronto.
http://www.stmichaelshospital.com/pdf/research/SMH-TOSCA-report.pdf
24. Drug Abuse Trends in the Seattle-King County Area: 2014. Banta-Green, C et al. Alcohol &
Drug Abuse Institute, Univ. of Washington, June 17, 2015.
http://adai.washington.edu/pubs/cewg/Drug%20Trends_2014_final.pdf
25. 2015 Drug Use Trends in King County, Washington, Caleb Banta-Green et al, Seattle:
University of Washington Alcohol & Drug Abuse Institute, July 13, 2016.
http://adai.uw.edu/pubs/pdf/2015drugusetrends.pdf
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26. Implementing Supervised Injection Services in Toronto. Staff Action Report presented to the
Toronto Board of Health (June 16, 2016).
http://www.toronto.ca/legdocs/mmis/2016/hl/bgrd/backgroundfile-94548.pdf
27. Supervised Injection Services Toolkit. Toronto Drug Strategy Implementation Panel, June
2013. http://www.toronto.ca/legdocs/mmis/2013/hl/bgrd/backgroundfile-59914.pdf
28. BOH Resolution 07-07, adopting recommendations of the BOH HIV/AIDS Committee,
September 20, 2007, available at http://www.kingcounty.gov/depts/health/board-of-
health/~/media/depts/health/board-of-health/documents/resolutions/res0707.ashx
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Attachment P
WORLD OVERVIEW OF SUPERVISED CONSUMPTION SITES
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Source: Schatz, E. and Nougier, M. IDPC Briefing Paper: Drug consumption rooms, evidence and practice (June 2012).
DI.A Page 146 of 162
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Attachment Q
LEGAL FRAMEWORK GRID
Mark Cooke, Policy Director at American Civil Liberties Union
Governing and
Operating Structure
Legal Authority/State
and Federal Conflicts
Insurance Options Onsite Smoking Healthcare
Professional Liability
Public Health - Seattle
& King County
(PHSKC) in
collaboration with King
County Department of
Community and
Human Services
(DCHS) governs and
operates the CHEL
site.
A CHEL site governed
and operated by the
public health authority
would be in a strong legal
position under state law,
including protections
against the prosecution of
state criminal laws.
No such protection would
exist against the
prosecution of federal
criminal laws, but having
a government run
program would likely be a
good political position to
advocate against federal
interference.
CHEL site would
likely fall under King
County’s self-
insurance pool, which
covers up to
$6.5million. Could
also obtain a
reinsurance policy on
the private market for
overages.
Use of smoked or
vaped tobacco
products at a CHEL
site may violate
RCW 70.160 and
KC BOH 19.03.
The law is not as
clear for the act of
inhalation of
cocaine, meth, or
heroin, which is
technically more
akin to “vaping”
than “smoking.”
Government
employees of a SCS
would likely be insured
to the same extent as
the facility, up to $6.5
million. The self-
insurance also applies
to professional
licensing matters.
Reinsurance for
greater losses would
be challenging to
procure.
A public-private
partnership between
PHSKC/DCHS and
other community-
based service
providers, in which
PHSKC/DCHS
authorizes the CHEL
site and contracts with
a service provider to
operate it.
A CHEL site governed by
the public health authority
and operated by a
community-based service
provider via a contract
would be in a strong legal
position under state law,
including protections
against the prosecution of
state criminal laws.
May fall under King
County’s self-
insurance pool, which
covers up to
$6.5million, if an
agency relationship
between the county
and provider is
established. Could
obtain coverage on
the private secondary
Use of smoked or
vaped tobacco
products at a CHEL
site may violate
RCW 70.160 and
KC BOH 19.03.
The law is not as
clear for the act of
inhalation of
cocaine, meth, or
heroin, which is
Government “agents”
would likely be insured
to the same extent as
the facility, including
professional licensing
matters. Otherwise,
private insurance
would be needed.
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Governing and
Operating Structure
Legal Authority/State
and Federal Conflicts
Insurance Options Onsite Smoking Healthcare
Professional Liability
No such protection would
exist against the
prosecution of federal
criminal laws, but having
the program governed by
public health authority
would likely be a good
political position to
advocate against federal
interference.
market (ex. Lloyds of
London).
technically more
akin to “vaping”
than “smoking.”
PHSKC/DCHS or local
ordinance provides
oversight of CHEL site
via some sort of
regulatory or
permitting process, in
which private
community-based
service providers
determine
independently whether
to operate a CHEL
site.
The strength of the CHEL
site legal position under
state law will depend on
the nature of the
government oversight of
the CHEL site. If it’s the
public health authority that
creates and enforces the
regulatory process for
CHEL site permitting, then
it’s possible that the legal
protections for public
health authorities could
extend to the private
community-based service
providers. If the
government oversight
comes in the form of a
local ordinance via a
legislative body, not
relying on public health
authority, the legal
protection would not be as
Could obtain
coverage on the
private secondary
market (ex. Lloyds of
London). Obtaining
private insurance
could also be a
mandate of
government
regulation of a CHEL
site.
Use of smoked or
vaped tobacco
products at a CHEL
site may violate
RCW 70.160 and
KC BOH 19.03.
The law is not as
clear for the act of
inhalation of
cocaine, meth, or
heroin, which is
technically more
akin to “vaping”
than “smoking.”
Employees would
need to find insurance
via the secondary
market.
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Governing and
Operating Structure
Legal Authority/State
and Federal Conflicts
Insurance Options Onsite Smoking Healthcare
Professional Liability
robust. However, this is
still a feasible option if
local prosecutors decide
to exercise discretion,
allowing the CHEL site to
operate, even if it’s
technically violating state
criminal law.
No protection would exist
against the prosecution of
federal criminal laws, but
having some form of
government oversight
might help in making
political arguments
against federal
interference.
No changes to existing
law, private
community-based
service providers start
operating a CHEL site
Opening a private CHEL
site under existing law
would be in a relatively
weak legal position.
However, the community-
based service provider
could point to the 2007
King County Board of
Health resolution that
recommended the
creation of a CHEL site as
an indication that this type
of program is a legitimate
Could obtain
coverage on the
private secondary
market (ex. Lloyds of
London).
Use of smoked or
vaped tobacco
products at a CHEL
site may violate
RCW 70.160 and
KC BOH 19.03.
The law is not as
clear for the act of
inhalation of
cocaine, meth, or
heroin, which is
technically more
akin to “vaping”
Employees would
need to find insurance
via the secondary
market.
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Governing and
Operating Structure
Legal Authority/State
and Federal Conflicts
Insurance Options Onsite Smoking Healthcare
Professional Liability
public health
intervention.47
Operating under the
authority of public health
or via local ordinance may
also be unnecessary if
local prosecutors decide
to exercise discretion,
allowing the CHEL site to
operate, even if it’s
technically violating state
criminal law.
No protection would exist
against the prosecution of
federal criminal laws, but
policy arguments could be
made for why the federal
government should not
get involved in a local
public health matter.
than “smoking.”
47BOH Resolution 07-07, adopting recommendations of the BOH HIV/AIDS Committee, September 20, 2007, available at
http://www.kingcounty.gov/depts/health/board-of-health/~/media/depts/health/board-of-health/documents/resolutions/res0707.ashx
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Attachment R
SUMMARY OF LEGAL CONSIDERATIONS FOR COMMUNITY HEALTH ENGAGEMENT
LOCATIONS FOR INDIVUALS WITH SUBSTANCE USE DISORDERS (CHEL sites)
WHERE SUPERVISED CONSUMPTION OCCURS IN KING COUNTY
Mark Cooke, Policy Director at American Civil Liberties Union
The King County and Seattle Task Force on Heroin and Prescription Opiate Addiction is
considering a recommendation to create Community Health Engagement Locations for
individuals with substance use disorders (CHEL sites) where supervised consumption occurs
(also known as Supervised Consumption Sites) in order to reduce drug-related health risks and
harms, including overdose deaths, transmission of HIV and hepatitis B and C viruses, and drug-
associated adverse health effects. These sites could also provide access to substance use
disorder treatment and related health and social services; reduce impact of drug use in public
spaces; provide a safe and trusting environment where individuals using drugs can engage with
services to improve their health; and reduce participant engagement with the criminal justice
system. Such a recommendation would not be unprecedented. In 2007, the Board of Health of
King County adopted a resolution that recommended a CHEL site for purposes of HIV
prevention.48 Despite this formal acknowledgement that a CHEL site is a viable public health
intervention, no such facility opened.
Due to the fact that most of the drugs consumed in a CHEL site will be obtained illicitly and are
controlled substances, there are many questions about the legality of such facilities.49 The
following analysis provides background information on some of the legal issues that could arise
in the creation and operation of a CHEL site.
A CHEL site Likely Fits Within the Legal Authority of a Local Board of Health and Local
Health Officer
Under Washington State law, a local board of health is given broad authority to preserve “the life
and health of people within its jurisdiction.”50 This authority is derived from the state legislature
and Washington Constitution.51 For purposes of a CHEL site, several of the local board of
health’s affirmative responsibilities are relevant. These include the board’s duty to:
•Enact such local rules and regulations as are necessary in order to preserve, promote
and improve the public health and provide for the enforcement thereof;
48BOH Resolution 07-07, adopting recommendations of the BOH HIV/AIDS Committee, September 20,
2007, available at http://www.kingcounty.gov/depts/health/board-of-health/~/media/depts/health/board-of-
health/documents/resolutions/res0707.ashx
49 For a more in depth analysis on the legality of SCS type facilities see – Beletsky, et al. The Law (and
Politics) of Safe Injection Facilities in the United States, American Journal of Public Health, 2008
February; 98(2): 231-237, available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376869/
50 RCW 70.05.060, available at http://app.leg.wa.gov/RCW/default.aspx?cite=70.05.060
51 Washington Constitution, Article 11 Sec. 11 – “Any county, city, town or township may make and
enforce within its limits all such local police, sanitary and other regulations as are not in conflict with
general laws.”
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• Provide for the control and prevention of any dangerous, contagious or infectious
disease within the jurisdiction of the local health department;
• Provide for the prevention, control and abatement of nuisances detrimental to the public
health.52
Similarly, a local health officer, under the direction of the local board of health, is given broad
authority to enforce public health laws.53 Several of the local health officer’s responsibilities are
relevant for purposes of creating and operating a CHEL site, including his or her duties to:
• Control and prevent the spread of any dangerous, contagious or infectious diseases that
may occur within his or her jurisdiction;
• Inform the public as to the causes, nature, and prevention of disease and disability and
the preservation, promotion and improvement of health within his or her jurisdiction;
• Prevent, control or abate nuisances which are detrimental to the public health.54
A CHEL site fulfills several of the public health aims listed above. By consuming drugs in a
clean environment and providing individuals using drugs with sterile equipment, the spread of
diseases such as HIV and hepatitis will be reduced. The board or health officer could also argue
that a CHEL site is a method to control and prevent the “dangerous…disease” of severe
substance use disorders and that a CHEL site is a gateway into treatment.55 A CHEL site could
also improve community public health by limiting the amount of public drug use and discarded
drug equipment, which could be viewed as a form of nuisance abatement.
The legality of a CHEL site and the role of public health authority could also be impacted by the
governing structure of the program. The task force has discussed three types of structures with
varying degrees of Public Health – Seattle & King County (PHSKC)/Department of Community
and Human Services (DCHS) involvement, and a fourth option is if a private CHEL site opens
without any government oversight:
A) Public Health - Seattle & King County (PHSKC) in collaboration with King County
Department of Community and Human Services (DCHS), and/or;
B) A public-private partnership between PHSKC/DCHS and other community-based
service providers, and/or;
C) Another entity with oversight by PHSKC/DCHS;
D) Private entity opens CHEL site with no PHSKC/DCHS oversight.
Arguably, the public health authority described above would be applicable in the first three
contexts, although it would be most straightforward if PHSKC/DCHS was in charge of governing
52 Id.
53 RCW 70.05.070, available at http://app.leg.wa.gov/RCW/default.aspx?cite=70.05.070
54 Id.
55 See American Psychiatric Publishing – Substance-Related and Addictive Disorders, 2013, available at
http://www.dsm5.org/documents/substance%20use%20disorder%20fact%20sheet.pdf
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and operating the CHEL site (options A and B). This structure would make it quite obvious that
public health authorizes the CHEL site for legitimate public health reasons. However, even if
public health authorities plays more of an oversight role as in option C, it also seems like public
health authority should be recognized and extend some protections to third party actors, since
they are acting with the agencies’ approval to advance public health.
Impact of State Criminal Drug Laws
Washington’s Uniform Controlled Substances Act criminalizes the possession of many of the
controlled substances that would be consumed in a CHEL site and could be applicable in other
contexts such as paraphernalia, maintaining a building where people consume controlled
substances, and civil asset forfeiture.56 Although the Task Force can recommend that the state
legislature make changes to these laws, they cannot change them on their own; therefore
conflicting legal interests must be balanced. In this instance, how do state criminal laws interact
with broad public health authority? Existing programs and laws already operating in Seattle and
King County provide useful comparisons for legal frameworks.
Needle Exchange Programs
Washington and Seattle/King County have been national leaders in adopting needle exchange
programs, which have proven to be an incredibly effective public health intervention for reducing
the spread of infectious diseases.57 When these programs originated in the late 1980’s, legal
questions were posed that are similar to those CHEL site’s face currently. For example, some
prosecutors argued that these programs illicitly distributed drug paraphernalia. In Washington
State, this legal question was eventually answered in a state Supreme Court case – Spokane
County Health District v. Brockett (1992).58
In Brockett, the Spokane County Prosecutor, Spokane Sheriff, and State Attorney General
challenged a Spokane County Health District Board of Health resolution, which directed the
health officer to “to establish and implement a needle exchange program in Spokane as a part
of an overall intervention to slow the spread of AIDS and other infectious diseases among
IVDUs and those with whom they come into contact.” The recommendation to operate a needle
exchange program was made after careful deliberation by the board of health about the need for
the intervention. In ruling in favor of the needle exchange the court in Brockett stated that, “the
broad powers given local health boards and officers under Const. art. 11, § 11 and RCW 70.05
authorize them to institute needle exchange programs in an effort to stop the spread of HIV and
AIDS,” despite the fact that they were distributing drug paraphernalia.
56 RCW 69.50 et seq., available at http://app.leg.wa.gov/RCW/default.aspx?cite=69.50
57 See Public Health – Seattle & King County Needle Exchange Program, available at
http://www.kingcounty.gov/healthservices/health/communicable/hiv/resources/aboutnx.aspx 58 Spokane County Health District v. Brockett, 120 Wn.2d 140, P.2d 324, November 5, 1992, available at
http://courts.mrsc.org/supreme/120wn2d/120wn2d0140.htm.
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Just as Washington was facing an HIV/AIDS epidemic in the 1980’s, we now face an opioid
epidemic.59 A decision by a board of health and/or local health officer to “establish and
implement” a CHEL site in an effort to prevent overdoses and the spread of infectious diseases
seems squarely within the public health authority at issue in the needle exchange context ruled
on in Brockett.
Prosecutorial Discretion, LEAD Program, and Law Enforcement Prioritization
Another crucial component of a successful CHEL site will be to work with law enforcement in an
honest and transparent manner. It will take discretion by police and prosecutors to not target the
clients of CHEL sites for the intervention to succeed. Even if public health authority sanctions a
CHEL site, that protection will not spread beyond the walls of the facility, so clients will need
some assurances that they will not be targeted when coming and going. Fortunately, this type of
law enforcement discretion and prioritization is not uncommon and Seattle/King County is again
national leaders. For example, needle exchange programs would not have flourished here
without tacit support by police and prosecutors. More recently, the Law Enforcement Assisted
Diversion program (LEAD) began operating in Seattle and King County.60 This program diverts
low-level drug and prostitution cases to harm reduction focused case management services at
the point of arrest, instead of a booking into jail and criminal charge. The legal basis for LEAD
stems from the discretion of police who choose whether someone is eligible and from the
prosecutor who chooses not to file a criminal case.
The law around this type of legal discretion is clear. For prosecutors, as stated by the U.S.
Supreme Court, “the decision to file criminal charges, with the awesome consequences it
entails, requires consideration of a wide range of factors in addition to the strength of the
Government’s case, in order to determine whether prosecution would be in the public
interest. Prosecutors often need more information than proof of a suspect’s guilt,
therefore, before deciding whether to seek an indictment.”61 A strong case can be made that
allowing a CHEL site to operate without interference from law enforcement is in the public
interest.
Similarly, this type of discretion can be codified in the form of lowest law enforcement priority
laws. Seattle passed such a law in 2003 in the marijuana context, which states that the “Seattle
Police Department and City Attorney's Office shall make the investigation, arrest and
prosecution of marijuana offenses, where the marijuana was intended for adult personal use,
the City's lowest law enforcement priority.”62 Although this type of codified law is likely not
necessary for a CHEL site to operate, it shows that discretion and prioritization are an everyday
part of life for law enforcement.
59 U.S. Department of Health & Human Services – About the Epidemic, available at
http://www.hhs.gov/opioids/about-the-epidemic/index.html
60 See – www.leadkingcounty.org
61 United States v. Lovasco, 431 U.S. 783
62 SMC 12A.20.060, available at
https://www2.municode.com/library/wa/seattle/codes/municipal_code?nodeId=TIT12ACRCO_SUBTITLE_
ICRCO_CH12A.20COSU_12A.20.060ENPRAR
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911 Good Samaritan and Naloxone Laws
Two state laws that could potentially be helpful in the operation of a CHEL site are the 911
Good Samaritan and naloxone access laws.63 Washington’s Good Samaritan law, which passed
in 2010, provides legal protection against drug possession charges for people who seek medical
assistance during an overdose. This protection extends to the people who seek medical help as
well as the person suffering from the overdose. The law also contains strong intent language –
“the legislature intends to save lives by increasing timely medical attention to drug overdose
victims through the establishment of limited immunity from prosecution for people who seek
medical assistance in a drug overdose situation.”64 Taken together, the legal protection could
help insulate CHEL site employees and clients from drug possession charges in the event of an
overdose at the facility and the intent language indicates that the state has an interest in
preventing overdose deaths via means beyond the enforcement of criminal laws.
Similarly, Washington’s naloxone access law, originally passed in 2010 with significant
amendments in 2015, shows that public health approaches are welcomed by the state
legislature. The intent of this law is “to increase access to opioid overdose medications…and to
permit those individuals to possess and administer opioid overdose medications prescribed by
an authorized health care provider."65 A CHEL site would be an ideal place to have naloxone on
site and to distribute it to an at-risk population.
Impact of Federal Criminal Drug Laws
Similar to Washington State law, the federal government criminalizes activity that is likely to
occur at a CHEL site, such as drug possession or maintaining a drug-involved premises, and
the task force cannot change federal law.66 Nonetheless, a strong case can be made that a
CHEL site can lawfully exist parallel to federal prohibition, especially at a time when the federal
government, like Seattle/King County, is trying to end the opiate epidemic.67 However, it should
be noted that it would ultimately be up to federal law enforcement to decide whether to enforce
its own laws against a CHEL site. In examining this apparent conflict, other state/federal drug
policy disconnects are worth considering.
An important consideration to keep in mind when looking at the intersection of federal and state
drug policy is that the vast majority of drug law enforcement is conducted at the state and local
level. In 2010, there were 27,200 federal drug arrests across the U.S, out of a total 1,638,846
drug arrests by all federal, state, and local agencies, which means over 98% of drug arrests are
63 RCW 69.50.315, available at http://app.leg.wa.gov/RCW/default.aspx?cite=69.50.315 and RCW
69.41.095, available at http://app.leg.wa.gov/RCW/default.aspx?cite=69.41.095
64 RCW 69.50.315, available at http://app.leg.wa.gov/RCW/default.aspx?cite=69.50.315
65 http://app.leg.wa.gov/RCW/default.aspx?cite=69.41.095
66 21 USC Secs. 844 and 856
67 The White House – Fact Sheet: Obama Administration Announces Additional Actions to Address the
Prescription Opioid Abuse and Heroin Epidemic, March 2016, available at
https://www.whitehouse.gov/the-press-office/2016/03/29/fact-sheet-obama-administration-announces-
additional-actions-address
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conducted at the state and local level.68 Federal law enforcement has also stated publicly that it
must make choices about where to commit scarce resources, and that some low-level drug
possession cases, such as for marijuana, are not worth pursuing, especially when state or local
governments have strong and effective regulatory and enforcement systems in place.69 This
decision is obviously not the Task Force’s to make, but it’s apparent that just because an activity
is illegal at the federal level doesn’t mean that a state or local government must have an
identical law. The clearest example of this is the fact that 24 states have medical marijuana laws
and 4 states and Washington D.C. have marijuana legalization and regulation laws, despite
continued federal prohibition of marijuana.70 Needle exchanges are also not officially allowed by
the federal government, yet they operate in 38 states, and the federal government’s funding ban
was recently eased.71
Similarly, arguments can be made that certain federal crimes are not intended to be applicable
in the CHEL site context. For example, the actions that give rise to the “Maintaining drug-
involved premises” crime may be technically present at a CHEL site, since individuals will be
“using controlled substances” in a “place” managed or controlled by the CHEL site operators.
But, this crime was intended to focus on illicit enterprises, while a CHEL site is a public health
intervention aimed at saving lives and getting people into treatment. Ultimately, it would be up to
federal prosecutors to make the decision of whether to bring charges for this type of crime, but
they are not required to do so.
Some might also argue that a locally authorized CHEL site would be federally preempted. This
specific legal question has not been answered in any U.S. court, but similar issues have been
emerging in the marijuana context and the answer is by no means definitive that a more liberal
drug policy at state or local level would be preempted by federal law.72 First, the federal
government cannot force a state or local government to criminalize any type of drug activity.73
Second, the Supreme Court has been very deferential to the traditional police powers of the
states. In ruling in favor of the State of Oregon in the physician-assisted suicide context, the
Court noted that the “structure and limitations of federalism … allow the States great latitude
under their police powers to legislate as to the protection of the lives, limbs, health, comfort, and
quiet of all persons” (internal quotation omitted).74 As noted above, local public health authority
in Washington is derived from the state Constitution and the legislature, so it’s likely this
deference would also be extended to local authorities in the CHEL site context.
68 See – US Census – Table 328 - https://www.census.gov/prod/2011pubs/12statab/law.pdf and FBI UCR
2010- https://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-in-the-u.s.-2010/tables/10tbl29.xls
69 See – Cole Memorandum, August 29, 2013 – Guidance Regarding Marijuana Enforcement – pg. 2,
available at https://www.justice.gov/iso/opa/resources/3052013829132756857467.pdf
70 See – National Conference of State Legislatures – State Medical Marijuana Laws, available at
http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx
71 Department of Health and Human Services Implementation Guidance to Support Certain Components
of Syringe Services Programs, 2016, available at https://www.aids.gov/pdf/hhs-ssp-guidance.pdf
72 County of San Diego v. San Diego NORML, 165 Cal. App. 4th 798, 81 Cal. Rptr. 3d 461 (2008)
73 See – Chemerinsky – LA Times, “On pot laws, respect the states -
http://articles.latimes.com/2013/mar/27/opinion/la-oe-chemerinsky-marijuana-legalization-20130327
74 Gonzales v. Oregon, 546 U.S. 243, 270, 126 S. Ct. 904, 163 L. Ed. 2d 748 (2006).
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Conclusion
If the King County Board of Health and the local public health officer adopt resolutions to
establish and implement a CHEL site, they would be in a strong legal position, despite existing
state and federal criminal drug laws. It’s also possible that these legal protections would exist if
local legislative bodies set up a regulatory system that allows private actors to operate a CHEL
site, but the outcome is less clear. Nonetheless, just as important as the legal considerations
are political ones. For this reason the Task Force should continue to deliberate the need for a
CHEL site in an open and collaborative manner.
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Attachment S
Key Potential Opportunities for Washington and King County
in S. 524, the Comprehensive Addiction and Recovery Act of 2016 (CARA)
Full text at: https://www.congress.gov/114/bills/s524/BILLS-114s524enr.xml
Chris Verschuyl, Department of Community and Human Services
The grant programs described below, authorized by the CARA legislation, are subject to
appropriation. As noted the President’s July 22, 2016 signing statement, no funding had yet
been appropriated at the time of this analysis. This analysis also includes key policy
changes that are not dependent on funding.
Analysis of Key Sections of CARA 75
Implement Comprehensive Community-Wide Strategies (Section 103)
$5M/year ($25M total) Federal Fiscal Year (FFY) 2017-2021, if appropriated.
Grants to organizations funded under the Drug-Free Communities Act of 1997 (most often
community coalitions), with documented sudden increases in opiate use or significantly higher
rates of opiate use than the national average, to:
• Implement comprehensive community-wide strategies to address local drug crises.
Expand Access to Drugs or Devices for Opioid Overdose Reversal (Section 107)
$5M total for FFY 2017-2021, if appropriated.
Grants to federally qualified health centers, opioid treatment programs, or any other entity
deemed appropriate by HHS, to:
• establish a program for prescribing a drug or device for overdose reversal
• train and provide resources for health care providers and pharmacists regarding
prescribing overdose reversal drugs and devices
• purchase overdose reversal drugs or devices
• establish protocols to connect patients who have experienced overdose with appropriate
treatment
Opioid Overdose Reversal Medication Access and Education (Section 110)
$5M total for FFY 2017-2019, if appropriated.
Grants to states that have authorized standing orders to be issued for overdose reversal drugs
or devices,76 in order to:
• implement strategies for pharmacists to dispense an opioid overdose reversal drug or
device via standing orders
75 See also a helpful section by section analysis of the entire CARA legislation, at http://nasadad.org/wp-
content/uploads/2016/07/CARA-Section-by-Section-July-2016.pdf. The analysis in this document is
informed by NASADAD’s review, but focuses solely on programs, policies, and opportunities relevant to
the state of Washington and King County. For example, most provisions relating to the Veterans
Administration are excluded.
76 In Washington, standing orders are explicitly permitted via ESHB 1671, passed by the state legislature
in 2015.
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• encourage pharmacies to dispense opioid overdose reversal medication via standing
orders
• develop or provide training materials on the administration of an opioid overdose
reversal drug or device
• educate the public about the availability of opioid overdose reversal drugs or devices
Comprehensive Opioid Abuse Grant Program (Section 201)
$103M/year ($515M total) for FFY 2017-2021, if appropriated.
Grants of up to 4 years to states, local governments, and tribes (that may not supplant state,
local, or tribal funds), to:
• develop, implement or expand any of the following:
o treatment alternative to incarceration programs, which can include:
prebooking or postbooking components
training for criminal justice agencies regarding behavioral health
conditions
mental health court, drug court, and/or veterans’ treatment court
focus on parents whose incarceration could result in children entering the
child welfare system, and
community-based substance use diversion program sponsored by a law
enforcement agency77
o medication-assisted treatment (MAT)78 programs used or operated by a criminal
justice agency
o prescription drug monitoring programs79
o the use of technology to provide a secure container for prescription drugs
o integrated and comprehensive opioid abuse response programs
• enhance planning and collaboration between state criminal justice and state substance
abuse agencies to address opioid abuse80
• train first responders on carrying, administering, and purchasing opioid reversal drugs or
devices
• locate or investigate illicit activities related to unlawful distribution of opioids
First Responder Training (Section 202)
$12M/year ($60M total) for FFY 2017-2021, if appropriated.
Grants to states, local governments, and tribes to allow first responders and other key
community sectors to:
• administer an opioid overdose reversal drug or device
o emphasis on evidence-based methodology, outcome evaluation, and broad
replication
77 This specific provision was added by Washington Rep. Suzan DelBene, who explicitly mentioned King
County’s Law Enforcement Assisted Diversion (LEAD) program as an example.
78 In this legislation, MAT is defined as the use of FDA-approved medications in combination with
counseling and behavioral therapies.
79 This potential grant purpose would be available only to states, not local governments or tribes.
80 This potential grant purpose would be available only to states, not local governments or tribes.
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Expanded Disposal Sites for Unwanted Prescription Medications (Section 203)
No new funding authorization specific to this program.
Grants to state/local/tribal law enforcement agencies, prescription medication manufacturers or
distributors, retail pharmacies, registered narcotic treatment programs, hospitals or clinics with
onsite pharmacies, eligible long-term care facilities, or any other entity authorized by the DEA to
dispose of prescription medications, to:
• expand or create disposal sites for unwanted prescription medications.
Evidence-based Prescription Opioid/Heroin Treatment and Interventions Demonstration
(Section 301)
$25M/year ($125M total) for FFY 2017-2021, if appropriated.
Grants to state substance abuse agencies, units of local government, nonprofit organizations,
and tribes that have a high rate or rapid increase in the use of opioids, to:
• expand the treatment of addiction, including expanding MAT,81 in specific geographic
areas affected by the high rate or rapid increase in opioid use, including rural areas
Building Communities of Recovery via Recovery Community Organizations (Section 302)
$1M/year ($5M total) for FFY 2017-2021, if appropriated.
Grants to recovery community organizations,82 not to exceed half of program costs, to:
• develop, expand, and enhance recovery services, including recovery support services
• build connections with behavioral health and physical health care provider networks
• reduce stigma associated with substance use disorders (SUDs)
• conduct public education and outreach related to SUDs and recovery
Changes to Prescribing Rules for Buprenorphine (Section 303)
Makes certain revisions to the maximum number of patients per prescriber as follows:
• Maintains current maximum allowable caseload numbers (30 in first year and 100
thereafter), but permits HHS to change the maximum number by regulation
• Permits states to set lower maximum numbers, between 30 and the federally allowed
maximum, or to add additional requirements for qualifying practitioners
• Excludes from any provider’s maximum number any patients to whom buprenorphine is
directly administered in the office setting
Changes the qualifications for providers who may prescribe buprenorphine, as follows:
• Includes nurse practitioners or physician assistants who:
o are licensed to prescribe schedule III, IV, or V drugs for the treatment of pain;
o have completed 24 hours of training in the treatment and management of opiate-
dependent patients from national organizations deemed appropriate by HHS
o are supervised by a qualifying physician
81 In this legislation, MAT is defined as the use of FDA-approved medications in combination with
counseling and behavioral therapies.
82 Recovery community organizations are nonprofits that mobilize resources within and outside the
recovery community to increase long-term recovery, and are principally governed by people in recovery
who reflect the community served.
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• Requires qualifying physicians to:
o Hold a board certification in addiction psychiatry or addiction medicine from the
American Board of Medical Specialties;
o Hold an addiction certification or board certification from the American Society of
Addiction Medicine or the American Board of Addiction Medicine
o Requires physicians’ 8 hours of training from national organizations deemed
appropriate by HHS to include:
opioid maintenance and detoxification
appropriate clinical use of all drugs approved by the FDA
initial and periodic patient assessments (including substance abuse
monitoring)
individualized treatment planning, overdose reversal, and relapse
prevention
counseling and recovery support services
staffing roles and considerations
diversion control
other best practices
Changes to Residential Treatment for Pregnant and Postpartum Women (PPW) (Section
501)
$1M/year ($5M total) increase for FFY 2017-2021 over $15.9M/year FFY 2016 level, if
appropriated. Up to 25% of the total authorized appropriation for PPW may be used for this pilot
program (maximum of $4.2M/year, $21.1M total, if appropriated). However, the pilot program
only moves forward if total PPW appropriation exceeds baseline level of $15.9M/year.
Reauthorization of SAMHSA’s PPW grants to state substance abuse agencies includes the
following changes:
• Prioritizes grants to programs serving rural areas, health professional shortage areas,
and areas with a shortage of family-based treatment options
• Enhances flexibility in the use of funds, to help state substance abuse agencies:
o Address service gaps across the continuum of care, including in non-residential
settings
o Promote new approaches and evidence-based models of service delivery
o Ensure delivery of certain minimum services, including but not limited to
individual, group, and family counseling, as well as follow-up relapse prevention
services83
Attorney General Grants for Justice-Involved Veterans Services and Veterans Courts
(Section 502)
No new funding authorization specific to this program.
Allows Attorney General, in consultation with the Secretary of Veterans Affairs, to make grants
to establish or expand veterans treatment court programs; peer-to-peer services or programs for
qualified veterans; practices that identify and provide treatment and other services to veterans
who have been incarcerated; and training programs for criminal justice and behavioral health
personnel in serving veterans.
83 The legislation describes a wide range of potential additional minimum services specific to the needs of
the target PPW population, to be determined by SAMSHA’s Center for Substance Abuse Treatment
(CSAT). See http://nasadad.org/wp-content/uploads/2016/07/CARA-Section-by-Section-July-2016.pdf,
page 9, for details.
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Plan of Safe Care for Infants (Section 503)
Requires state plans to ensure the safety and well-being of an infant identified as affected by
maternal substance use to include addressing the health and substance use disorder treatment
needs of the infant and the affected family member or caregiver.
State Demonstration Grants for Comprehensive Opioid Abuse Response (Section 601)
$5M/year ($25M total) for FFY 2017-2021, if appropriated.
Grants to states and combinations of states to implement an integrated opioid abuse response
initiative, including:
• Educational efforts
• Comprehensive prescription drug monitoring programs
• Expanding MAT
• Programs to treat and screen individuals in treatment for Hepatitis C and HIV
• Recovery support services in high schools and higher education institutions
• Programs to prevent opiate overdose death
• Raising public awareness of opioid use disorders
Partial Fills of Schedule II Controlled Substances (Section 702)
Allows prescriptions for Schedule II controlled substances to be partially filled, if:
• Not prohibited by state law
• Permitted under federal laws and regulations
• Partial fill is requested by patient or prescriber
• Total quantity dispensed does not exceed the total quantity prescribed
Promoting Abuse-Deterrent Formulations (Section 705)
Changes a definition to support the development and use of abuse-deterrent (including
extended-release) formulations of drugs by excluding them from a Medicaid additional rebate
requirement.
Pilot Program on Integration of Complementary and Integrative Health for Veterans
(Section 933)
No new funding authorization specific to this program.
Requires HHS to establish a pilot program to:
• Assess the feasibility and advisability of using complementary and integrative health and
wellness-based programs to complement the provision of pain management and other
health care services to veterans.
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