MINUTES OF THE PUBLIC HEALTH COUNCIL Meeting of December 14, 2016 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH PUBLIC HEALTH COUNCIL MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH Henry I. Bowditch Public Health Council Room, 2nd Floor 250 Washington Street, Boston MA Docket: Wednesday, December 14, 2016 - 9:00 AM 1. ROUTINE ITEMS a. Introductions b. Updates from Commissioner Monica Bharel, MD c. Record of the Public Health Council November 9, 2016 Meeting (Vote) 2. FINAL REGULATIONS a. Request for final promulgation of proposed amendments to 105 CMR 123.000: Tanning Facilities (Vote) b. Request for final promulgation of proposed amendments to 105 CMR 220.000: Immunization of Students Before Admission to School (Vote) 3. PRELIMINARY REGULATIONS a. Informational briefing on proposed rescission of 105 CMR 131.000: Operation of the Advocacy Office b. Informational briefing on proposed regulatory amendments to 105 CMR 205.000: Minimum Standards Governing Medical Records and the Conduct of Physical Examinations in Correctional Facilities c. Informational briefing on proposed regulatory amendments to 105 CMR 432.000: Minimum Requirements for Personal Flotation Devices for Minor Children at Municipal and Recreational Programs or Camps d. Informational briefing on proposed regulatory amendments to 105 CMR 660.000: Cigarette and Smokeless Tobacco Products: Reports of Added Constituents and Nicotine Ratings 4. PRESENTATIONS a. Overview of Chapter 55 of the Acts of 2015 The Commissioner and the Public Health Council are defined by law as constituting the Department of Public Health. The Council has one regular meeting per month. These meetings are open to public attendance except when the Council meets in Executive Session. The Council’s meetings are not hearings, nor do members of the public have a right to speak or address the Council. The docket will indicate whether or not floor discussions are anticipated. For purposes of fairness since the regular meeting is not a hearing and is not advertised as such, presentations from the floor may require delaying a decision until a subsequent meeting. Public Health Council 2 Presented below is a summary of the meeting, including time-keeping, attendance and votes cast. Date of Meeting: Wednesday, December 14, 2016 Beginning Time: 9:17AM Ending Time: 11:40AM Attendance and Summary of Votes: PROCEEDINGS Attended Record of the Public Health Council November 9, 2016 Meeting (Vote) Request for final promulgation of proposed amendments to 105 CMR 123.000: Tanning Facilities (Vote) Request for final promulgation of proposed amendments to 105 CMR 220.000: Immunization of Students Before Admission to School (Vote) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Derek Brindisi Absent Absent Absent Absent Harold Cox Yes Yes Yes Yes Yes Yes Yes Yes Yes No present at time of vote Yes Yes Yes Yes Yes yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Absent Absent Absent Absent Yes Yes Yes Yes 11 Members Present, 2 Member Absent 10 Members Approved, 2 member Absent, 1 Not present at time of vote 11 Members Approved, 2 Absent 11 Members Approved, 2 Absent Board Member Monica Bharel Edward Bernstein Lissette Blondet John Cunningham Michele David Meg Doherty Michael Kneeland Paul Lanzikos Lucilia Prates-Ramos Michael Rigas Alan Woodward Summary 3 A regular meeting of the Massachusetts Department of Public Health’s Public Health Council (M.G.L. c. 17, §§ 1, 3) was held on Wednesday, November 9, 2016 at the Massachusetts Department of Public Health, 250 Washington Street, Henry I. Bowditch Public Health Council Room, 2nd Floor, Boston, Massachusetts 02108. Members present were: Monica Bharel, MD, MPH; Edward Bernstein, MD; Lissette Blondet; Harold Cox; John Cunningham, PhD; Michele David, MD; Meg Doherty; Michael Kneeland, MD; Paul Lanzikos; Lucilia Prates-Ramos; and Alan Woodward, MD. Absent member(s) were: Michael Rigas and Derek Brindisi Also in attendance was Margret Cooke, General Counsel at the Massachusetts Department of Public Health. Commissioner Bharel called the meeting to order at 9:17 AM and made opening remarks before reviewing the agenda. ROUTINE ITEMS Updates from Commissioner Monica Bharel, M.D., MPH Commissioner Bharel began updates by congratulating Kerry Evans DPH’s Office of Preparedness and Emergency Management or “OPEM” who has been appointed to the U.S. Health and Human Services Hospital Preparedness Working Group. This national Working Group includes healthcare preparedness representatives from across the country and serves to make recommendations to enhance communications and preparedness planning and policy. Previously, Commissioner Bharel updated the Council on the department’s progress in undergoing accreditation by the Public Health Accreditation Board “PHAB”. She informed the Council that this week, DPH passed an important milestone towards reaching accreditation, working with a site visit team made up of peer evaluators and PHAB accreditation specialists participated in meetings with over 80 DPH staff and community partners. Additional updates regarding this process will be available in Spring 2017. She concluded by thanking Antonia Blinn, Paul Oppedisano, and Glynnis LaRosa for leading our efforts to achieve accreditation. The Commissioner then announced the following staffing updates. Dr. Tom Land, Director of the Office of Data Management and Outcomes Assessment, has reached a point in his career where he is looking to transition towards retirement. In the past, senior leader retirements have sometimes been challenging due to the loss of institutional knowledge and skills. However, Tom has agreed to transition to become the Director of Special Analytics Projects, allowing him to focus more squarely on our many priority data projects. As Tom is so important to our collective successes here at DPH, this change will ease the transition and allow the Department to continue to benefit from his considerable skills, knowledge, and leadership. 4 The Commissioner then announced that Natalie Nguyen Durham, Chief of Staff, has moved into the role of Interim Director of the Office of Data Management and Outcomes Assessment. In her time at DPH, Natalie has provided key leadership around data analytics and data management and this transition will provide continued focus in this important priority area. On November 29th, Commissioner Bharel announced Allison Bauer as the new Director of the Bureau of Substance Abuse Services or “BSAS”. As the Director of BSAS, she will serve as DPH’s point person for implementation of prevention, intervention, treatment, and recovery strategies to combat the ongoing opioid crisis. She will also oversee substance use disorder treatment services and prevention initiatives offered by the Department. Commissioner Bharel went on to thank Jennifer Barrelle for serving as Interim Director of BSAS and announced that she will assume the role of Chief of Staff and previously served as Director of Constituent Services, Deputy Chief of Staff, and Director of Policy and Regulatory Affairs. The Commissioner informed the Council that DPH has launched a new public information campaign on Zika virus prevention, focused specifically on reaching people who may be traveling to areas where Zika virus can be found. The key messages of the campaign are that pregnant women, women who are thinking of becoming pregnant, and their partners should postpone travel to Zika affected areas if possible; and that if they must travel to these areas, they should check with their health care provider before they go, do everything they can to avoid mosquito bites while they’re there, and seek prenatal care as appropriate when they return. This new campaign features a significant investment in materials and outreach efforts to non-English speaking populations in Massachusetts, including communities, which speak Spanish, Portuguese, and Haitian Creole. All of these materials are available online and can be ordered free of charge, and this prevention effort will be supported by radio spots in Spanish and Portuguese, plus online and Facebook advertising. On a somber note, Commissioner Bharel addressed the December 3 rd 10 alarm structural fire affecting 18 Cambridge properties, representing 75 residential units. Sadly most of residential units were heavily damaged or destroyed, affecting more than 135 individuals. Thankfully, there were no fatalities. She then went on to discuss recovery efforts, supported by DPH and a number of local and state agencies. Mary Clark and her team at OPEM, the Region 4B Health and Medical Coordinating Coalition activated the region’s Medical Reserve Corps to support residents in shelters and at the Disaster Recovery Center. Additionally, DPH staff from OPEM and the Bureau of Family Health and Nutrition were deployed to the Disaster Recovery Center to support the City of Cambridge. And, the Registry of Vital Records and Statistics is providing ongoing assistance to the city to facilitate a process for replacing lost birth, death, and marriage certificates. 5 Commissioner Bharel concluded by thanking DPH staff for their ongoing response. Before proceeding, the Council was asked if they had any questions on the updates. Seeing none, she proceeded with the agenda. 1. ROUTINE ITEMS c. Record of the Public Health Council November 9, 2016 Meeting (Vote) Commissioner Bharel asked if any members had any changes to be included in the November 9, 2016 meeting minutes. Dr. Woodward commented on the update section of the November 9 th minutes and noted that it would helpful is Ron O’Connor and DPH would assist local boards of health with overseeing marijuana outlets in their community. Commissioner Bharel confirmed with Dr. Woodward that his statement is not a change to the minutes but a comment. Dr. Woodward concurred. Commissioner Bharel further responded to Dr. Woodward’s statement that the PHAB accreditation team commended the Department for its strong relationship with local boards of health. With no further questions or comments the Commissioner asked for a motion to approve the minutes. Dr. Woodward made a motion to approve, and Dr. Bernstein seconded the motion. All present members approved. 2. FINAL REGULATIONS a. Request for final promulgation of proposed amendments to 105 CMR 123.000: Tanning Facilities (Vote) Commissioner Bharel invited Jack Priest, Director of the Radiation Control Program within the Bureau of Environmental Health, and Jim Ballin, Deputy General Counsel for the Department, and Jana Ferguson, Deputy Director of the Bureau of Environmental Health to the table to present proposed amendments to 105 CMR 123.000: Tanning Facilities and request approval of these changes from the Council. Upon the conclusion of Mr. Priest’s presentation, Council members were asked if they had any questions or comments. Dean Cox asked if the group can explain the change in having a warning that is read versus having a written warning for an individual. Mr. Ballin informed Dean Cox that in the original draft there was language that required a translation of the written document into a language non-English speakers understand. There was feedback that this task would be particularly burdensome 6 and the requirements were changed so that someone, a friend or family member, can translate/read the document to the customer. The main purpose of this would be for the protection of the tanning salon owner, so that if someone did get injured, they can state they were fully aware of the risks. Dean Cox stated that someone now has to read it to the customer in a language they understand as opposed to having it written in their language. Mr. Ballin responded that the salon is welcome to have it written in various languages however, this was an option to have it a friend or family member translate instead of having it written in various languages. Ms. Blondet asked how is the warning process done for English speaking clients. Mr. Ballin informed Ms. Blondet that there is a written statement that they are required to give to a customer annually. The language of that warning statement is specified in the regulation as well as the law specifically, with regard to the risk of tanning. Ms. Blondet inquired why the specification for English cannot be used for other languages. She further stated that to rely on a family member for translation may be difficult as some individuals do not frequent tanning salons with friends or family members. She further stated that it leads to assumption that people cannot read the language they speak. Commissioner Bharel stated that from her understanding, Mr. Ballin was not asserting that a customer may not be able to read in their own language but the tanning facilities felt that they would not be able to effectively provide the written translations. Mr. Ballin confirmed Commissioner Bharel’s statement. He then informed the Council that they received comments from proprietors that have customers that speak a number of different languages and to have that translated would be a burden, so this was an alternative option. Ms. Prates Ramos stated that it seems our concern is of the salon owner rather than the customer. If we are concerned with the health outcomes of the consumer the warning notice should be written in various languages. Mr. Lanzikos commented on the sun tanning association testify and doesn’t find the change acceptable. Dr. Bernstein believes there should be options for individuals who do not read. He suggested the use of interpreter phone lines. Mr. Ballin stated that their efforts were to make it more accessible and assuring the customers have the information. For example, some individuals cannot read in any language, while others have visual impairments. If there is a strong opinion that translations be required in every language in which they have customers, we can certainly consider adding that back in. 7 Dr. Woodward suggests adding that back in and suggests 5-6 languages for the locale. In addition, if they cannot read someone has to be able to convey the risks in their language. He would suggest they do both. Michele David arrives 9:44 AM. Commissioner Bharel asks Mr. Ballin for the original proposed language and what was changed. Mr. Ballin informed Commissioner Bharel and the Council that the original language required that the warning be written in a language that the customer can understand. It was changed so that the warning could be verbally conveyed to the customer. Dr. Woodward suggested going back to the original language and adding that if they cannot read, the warning should be communicated to them verbally in their native tongue. Mr. Ballin stated that language is already in the regulation. Ms. Blondet stated that interpreter services should be an option as well. Ms. Cooke confirmed with Dr. Woodward that he is making a motion to return to the original language of the proposed amendment. Mr. Lanzikos expressed the need for language requirements to be clear in order not set a negative precedent. Ms. Blondet asked if the amendment calls for a written translation along with access to a verbal translation. Dr. Woodward stated that that is correct and goes back the original language where it calls for both verbal and written translation options. Ms. Cooke and Commissioner Bharel asked for the original language to be read to the Council. It was then proposed that the group break in order to provide the original proposed language to the Council. Dr. Woodward requested that before they do so he would like to raise other concerns. He further stated that he was concerned about changing supervision of a licensed physician to a health care provider. He stated that he would be in favor of the language stating at the very least a physician if not a dermatologist. He then suggested that tanning device be used throughout instead of sun lamp. Ms. Ferguson and Mr. Priest informed Dr. Woodward that this excludes tanning facilities. 8 Mr. Priest informed Dr. Woodward and the Council that he would look back and make sure they are being consistent with the language but noted some requirements are specific. Ms. Ferguson said that this language is in the proposed statute and they have proposed to not change the language until the FDA issues their final rule so that we can be consistent. Dr. Woodward asked if the inconsistency is in the statute. Ms. Ferguson informed him that is correct. Dr. Woodward asked if we have the authority to update this based on federal guidelines. Ms. Ferguson replied that that is true and originally proposed to adopt the proposed FDA amendment but since it’s still in flux the decision has been put on hold. Dr. Woodward suggested that if we can make revisions, we should make this consistent. We need to change sunlamp in the warning devices to tanning device. Mr. Priest said we would not make that change to this document until the FDA does their approval and that language would be prescriptive of what is required to be on the warning labels. These warning labels are the large signs that hang. Ms. Ferguson and Mr. Priest went on to state that changes can be made once the FDA finalizes their approval. Ms. Blondet asked what is the standard language that is given to English speaking clients that we’re asking to be translated. Mr. Priest stated that an individual would receive warning notice in whatever language they spoke but the warning label on the machine itself is in English. Dr. Woodward made a motion to table, Mr. Lanzikos seconded it. All present members in favor. Commissioner Bharel requested that the team work on the proposed amendments to the language and inform the Ms. Cooke when it’s complete. Dean Cox commented on the need to take a proactive stand against tanning and use preventative measures. 2. FINAL REGULATIONS b. Request for final promulgation of proposed amendments to 105 CMR 220.000: Immunization of Students Before Admission to School (Vote) At this time Commissioner Bharel invited Kevin Cranston, Assistant Commissioner and Director of the Bureau of Infectious Disease and Laboratory Sciences, and Pejman Talebian, Director of the Bureau’s Immunization Program, to the table to 9 present proposed amendments to 105 CMR 220.000: Immunization of Students Before Admission to School and request approval of these changes from the Council. Upon the conclusion of the presentation, the Council was asked if they had any questions or comments. Dr. Kneeland thanked the team for their work and asked if the definition of the student include parent or guardian when the student is underage. Mr. Cranston replied that that is correct. He further stated that we’re recognizing that it is the student’s admission that is governed by the regulation and while the health care provider/parent is generating the documentation it is the student that is bringing it to school. Mr. Talebian also stated that the statute focuses on students. Dr. Kneeland asked if the students do not have to comply if they have simply been given notice of the required immunizations. Mr. Cranston stated that that references back to the language of the “shall not attend school unless” and one of the ways of meeting the requirements of the regulation is to provide the documentation that immunizations have been provided. Dr. Kneeland asked whether a student could attend school if they solely acknowledged receipt of the requirements. Mr. Cranston replied that they have to provide receipt that required immunizations have been administered. Dr. Kneeland stated he read it, perhaps erroneously, that the student supplies appropriate document (ie. a signature) rather than I received documentation and completed it. Mr. Talebian replied that legally it is in the requirements and they translate it so that the schools understand. With no further questions or comments, Commissioner Bharel asked for a motion to accept proposed amendments to 105 CMR 220.000: Immunization of Students Before Admission to School and request approval of these changes from the Council. Ms. Prates Ramos made the motion and Dr. Woodward seconded it. All present members approved. 3. PRELIMINARY REGULATIONS a. Informational briefing on proposed rescission of 105 CMR 131.000: Operation of the Advocacy Office Commissioner Bharel invited Sherman Lohnes, Director of the Division of Health Care Facilities Licensure and Certification within the Bureau of Health Care Safety and Quality; Lauren Nelson, Director of Policy and Quality Improvement for the Bureau; and Rebecca Rodman, Deputy General Counsel for the Department, to the 10 table to present on the proposed rescission of 105 CMR 131.000: Operation of the Advocacy Office. Upon the conclusion of the presentation, the Council was asked if they had any questions or comments. Dean Cox asked how many complaints have been received. Ms. Nelson asked for clarification as to whether he’s inquiring in general or in regards to this specific issue. Dean Cox stated he’d like to know about both. Mr. Lohnes replied that in FY2016 out of 13,000 incidents and complaints received, 2 were related to the Operation of the Advocacy Office. 3. PRELIMINARY REGULATIONS b. Informational briefing on proposed regulatory amendments to 105 CMR 205.000: Minimum Standards Governing Medical Records and the Conduct of Physical Examinations in Correctional Facilities With no further questions regarding the previous presentation, Commissioner Bharel then asked Dr. Al DeMaria, Medical Director for the Bureau of Infectious Disease and Laboratory Sciences; Steven Hughes, Director of the Community Sanitation Program within the Bureau of Environmental Health; Paul Halfmann, Assistant Director of the Community Sanitation Program within the Bureau of Environmental Health; and Sondra Korman, Deputy General Counsel for the Department, to the table to present proposed amendments to 105 CMR 205.000: Minimum Standards Governing Medical Records and the Conduct of Physical Examinations in Correctional Facilities. Upon the conclusion of the presentation, Council members were invited to ask questions or comment. Mr. Lanzikos asked if these regulations apply to county houses. Dr. DeMaria replied that they apply to, prisons, jails, lock-ups anywhere people are in the care and custody. The definition of inmates includes those who are under civil commitments and those awaiting trial as well. Dr. Bernstein stated that he is concerned about the privacy and the protection of medical information for the residents. He raised the concern of medical information being allowed into their court record. Dr. DeMaria stated that is very good point and will look into how they can assure this information is protected. Ms. Korman stated that there are provisions for increased confidentiality. 11 Dr. Bernstein stated that it is important that it be clarified that SBIRT is not a diagnostic tool but a screening. He then asked about TB testing. Dr. DeMaria stated TB testing is included. Commissioner Bharel stated that she believes the desire here was to make sure the care was equitable, including screenings for substance abuse disorder, and that the privacy issues and the training around that is critical and important part of the work. Ms. Blondet leaves the room at 10:30am and returns at 10:34am. Dr. Woodward asked if they offer screening for hepatitis C will there be money in the budget to treat as well. Dr. DeMaria replied that he cannot comment on the budget. Dr. Woodward stated that it could be huge financial burden to treat. Dr. Bernstein replied that if we don’t treat it can possibly be spread into the community. Commissioner Bharel replied that it is our charge to provide individuals with community standard and align with community best practices. 3. PRELIMINARY REGULATIONS d. Informational briefing on proposed regulatory amendments to 105 CMR 660.000: Cigarette and Smokeless Tobacco Products: Reports of Added Constituents and Nicotine Ratings With no further question the Commissioner invited Patti Henley, Director of the Office of Community Health and Tobacco Use Prevention and Kay Doyle, Deputy General Counsel for the Department, to the table to present proposed amendments to 105 CMR 660.000: Cigarette and Smokeless Tobacco Products: Reports of Added Constituents and Nicotine Yield Ratings. Upon the conclusion of the presentation, the Council asked questions. Dean Cox asked Dr. Woodward if the omnibus bill passed. Dr. Woodward responded that it passed the Senate but did not come to the floor of the House. Dean Cox asked if the new proposed bill will include restricting the use of smokeless tobacco. Dr. Woodward responded that it will and put them on the forefront and mentioned that many provisions are already included by local boards of health. Dr. Bernstein congratulated Ms. Henley and asked for a copy of her report. 12 Commissioner Bharel clarified if he was referring to Ms. Henley’s notes and stated that could be done. Dr. Bernstein then asked if we consider substance use as mental health. Commissioner Bharel and Ms. Henley stated that the way it is currently mental health is not substance use. Dr. Woodward congratulated Ms. Henley and brought the need for nicotine use and abuse screenings in regards Dr. DeMaria’s presentation. He discussed his concern about vaping and e-cigarettes Commissioner Bharel stated that although we don’t track it at the Department yet, there is national data that for homeless individuals the smoking rate is 75-80%. She goes on to say that there are various groups that we should target for intervention. Ms. Blondet congratulated Ms. Henley and the program as well for their work. 3. PRELIMINARY REGULATIONS c. Informational briefing on proposed regulatory amendments to 105 CMR 432.000: Minimum Requirements for Personal Flotation Devices for Minor Children at Municipal and Recreational Programs or Camps Commissioner Bharel invited Steven Hughes, Director of the Community Sanitation Program within the Bureau of Environmental Health; Amy Riordan, Environmental Analyst for the Community Sanitation Program; and Jim Ballin, Deputy General Counsel for the Department, to the table to present proposed amendments to 105 CMR 432.000: Minimum Requirements for Personal Flotation Devices for Minor Children at Municipal and Recreational Programs or Camps. Dr. Woodward leaves the room at 10:56am and returns at 10:59am. Upon the conclusion of the presentation, the Commissioner asked if the Council had any questions or comments. Seeing none, she asked Jim Ballin to remain at the table and invited Jana Ferguson and Jack Priest back to address CMR 153: Tanning Facility. FINAL REGULATIONS a. Request for final promulgation of proposed amendments to 105 CMR 123.000: Tanning Facilities (Vote) Mr. Ballin presents the proposed language. They are restoring the requirement to have it translated and the Department will provide the operators, free of charge, translations for the all major languages spoken in Massachusetts. Ms. Cooke requested in order to keep the record clear, to withdraw the motion that is there and present a new motion. 13 Dr. Woodward withdrew his previous motion. The new language reads as follows: For customers who cannot read English, a warning statement shall be provided in a language that can be read by the customer. If a customer cannot read, the operator shall read or otherwise communicate the warning statement in a language and form understandable by the customer. This risk acknowledgement certificate shall then be signed by the operator and, whenever possible, by a witness who can verify that the warning was provided. Commissioner Bharel asked for a motion to adopt the amended language. Dr. Kneeland made the motion, Ms. Blondet seconded. All present members approved. Commissioner Bharel then asked for a motion to approve final promulgation of proposed amendments to 105 CMR 123.000: Tanning Facilities. Mr. Lanzikos made the motion, Dr. Woodward approved. All present members approved. Dr. Woodward asked if the final FDA language can be brought back before the Council. 4. PRESENTATIONS a. Overview of Chapter 55 of the Acts of 2015 Commissioner Bharel stated that as she shared in October and November updates, in September, DPH and the Baker Administration released an in-depth analysis of the state’s opioid-related deaths from 2013-2014. These findings, authorized by Chapter 55 of the Acts of 2015, revealed that opioid-related deaths have increased by 350 percent in Massachusetts in 15 years and marks the first time data from multiple state agencies – including DPH, the Office of the Chief Medical Examiner, the Department of Correction, MassHealth, and the Center for Health Information and Analysis – have been linked to give a comprehensive overview of deaths associated with the opioid epidemic. This powerful analytic capability has served as an example of what I believe we here at DPH can do more of – to leverage public health data to effectively highlight health inequities and to support policy makers in responding to these identified inequities by leveraging our expertise in population health programming and interventions. To this end, the Commissioner invited Tom Land, Director of Special Analytics Projects, and Scott Zoback, Director of Strategic Initiatives, to the table for an overview of this report’s findings, as well as a demonstration of the Department’s recently launched web story entitled “The Massachusetts Opioid Epidemic: A Data Visualization of Findings from the Chapter 55 Report.” Upon the conclusion of their presentation, the Council was asked if they had any questions or comments. 14 Dr. Woodward commended the format of the data being presented. He requested a link be sent to the Council members as well as local boards of health. He also stated that was alarmed by the mortality rates of the inmates who have been released due to substance abuse. He asked if those were mostly people who have been incarcerated for mostly drug offenses. Dr. Land stated that half of the people who died had treatment for substance abuse disorder while incarcerated; however, we do not know what they were incarcerated for. Commissioner Bharel stated that it is important to remember this is DOC data and finds the misconception that longer amount of time incarceration cures people and further discusses that some high potency drugs were not on the street prior to their arrest. Dr. Land stated that this a critical point, they may have gone into prison when it was heroin and come out when the drug of choice was fentanyl. Ms. Blondet commended Dr. Land and Mr. Zoback for their work. With no further questions, Commissioner Bharel reminded the Council that the next meeting is January 11, 2017 and asked for a motion to adjourn. Dr. Kneeland made the motion, Dr. David seconded it. All approved The meeting adjourned at 11:40am. 15