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HomeMy WebLinkAboutBOCC.packet.spec.08262014PITKIN COUNTY COMMISSIONERS WORK SESSION AGENDA Plaza 1 Meeting Room TUESDAY, AUGUST 26, 2014 (Commissioner Owsley not present.) 10:00 SPECIAL MEETING - EXECUTIVE SESSION Oil and Gas Litigation Advice from Attorney CRS 24-6-402 (4)(b) ADJOURN SPECIAL MEETING 11:00 Civic Plus Demo - New County Website Peak Democracy Demo — Citizen Engagement Software Pat Bingham Nate Kneifel 12:00 LUNCH 1:00 Special Meeting - BOCC Convenes As Board of Health Public and Environmental Health Quarterly Update Adjourn Special Meeting - BOCC Adjourns as Board of Health Liz Stark 2:00 Special Meeting - BOCC Convenes as Board of Social Services Update with the Department of Human Services Adjourn Special Meeting — BOCC Adjourns as Board of Social Services Nan Sundeen 3:00 BREAK 3:15 Citizen Board Interview / Sue deCampo — Citizen Grant Review Committee Mitzi Ledingham 3:30 Citizen Board Interview / Emily Essig — Financial Advisory Board John Redmond 3:45 • Memos of Interest o Budget Supplemental Request for Brush Creek Connector Trail • Future Agendas/Agenda Requests/Monthly Calendar • BOCC Open Discussion • Prep for Meeting with Lake County Commissioners on September 2 Gary Tennenbaum 5:00 ADJOURN AGENDA IS SUBJECT TO CHANGE AGENDA ITEM SUMMARY SPECIAL MEETING DATE: August 26th, 2014 AGENDA ITEM TITLE: Public and Environmental Health Quarterly Update with the Board of Health STAFF RESPONSIBLE: Nan Sundeen, Liz Stark ISSUE STATEMENT: This is the third quarter update for 2014 between the Board of Health, Community Health Services, Inc. (CHS), Pitkin County Local Medical Officer, Pitkin County Environmental Public Health Advocate and Pitkin County Environmental Health manager. BACKGROUND: The Board of County Commissioners (BOCC) serves as the Board of Health (BOH) for Pitkin County. Quarterly, Liz Stark, Pitkin County Public Health Director, presents updates, issues, policies and concerns for Board of Health input and review. Today, Liz Stark, along with Kurt Dahl,-Pitkin County Environmental Health Manager, Tom Dunlop -Environmental Public Health Advocate, CJ Oliver -City of Aspen Environmental and Sustainability Manager, and Dr. Kimberly Levin- Local Medical Officer, will focus on the public health implications of the legalization of recreational marijuana, including; environmental health regulations, medical implications and the current education and prevention messages that are happening locally and at the state level. They will be looking to include the Board of Health in a discussion about all the ways they are currently involved in the subject. Update on Intergovernmental Agreement with Ci%p of Aspen Staff is currently working on a draft Intergovernmental Agreement (IGA) to present to the Board of County Commissioners and City Council by the end of September that will formally "merge" the Pitkin County and City of Aspen Boards of Health. After the IGA is approved the Pitkin County Board of Health can be expanded with one new member from City of Aspen and one from the Town of Snowmass Village (2 total). The Board of County Commissioners will solicit recommendations from the City of Aspen and Town of Snowmass Village for representation on the expanded BOH. Once the Pitkin BOH approves the two nominations, staff will draft a resolution establishing the Pitkin County Board of Health with seven members. LINK TO STRATEGIC PLAN: Livable and Supportive Community- Self Sufficient Individuals and Families Prosperous Economy — Affordable and quality health care options KEY DISCUSSION ITEMS 1. Review and discuss issues related to public/environmental health impacts of marijuana. BUDGETARY IMPACT: None at this time. RECOMMENDED BOH ACTION: None at this time ATTACHMENTS: A) Memo from Public Health Director, Liz Stark 1 COMMUNITY HEALTH SERVICES Pitkin County's Public Health Agency ATTACHMENT A To: Pitkin County Board of Health From: Liz Stark RN, Pitkin County Public Health Director; Director, Community Health Services, Inc.; Kurt Dahl, Pitkin County Environmental Health Manager; Dr. Kimberly Levin, Pitkin County Medical Officer; Tom Dunlop, Pitkin County Environmental Public Health Advocate, Date: August 20, 2014 Re: Quarterly Board of Health meeting on August 26, 2014 At this quarterly Board of Health meeting, we would like to engage you in a discussion about the public health implications of the legalization of recreational marijuana. As a group, we came together to present the impacts on our respective areas including medical and public and environmental health. We know that you as the Board of County Commissioners, have already been involved with many decision making processes related to the new law. We are not taking a position on whether the recreational use of marijuana should have been legalized but rather bringing forth points for discussion that will hopefully allow us to work together to ensure that our community approaches this new legislation proactively and with the health and wellness of its members in mind. We would like to pose a few broad questions for you to consider as we present our perspectives on this substantially complex topic. This should give us a starting place to build on future discussions. We hope to continue this dialogue, particularly with the newly formed Board of Health. What are your biggest public health concerns around the legalization of marijuana? (Edible overdoses, drugged driving, decreased perception of harm and increased youth use, unintentional poisonings of kids and/or adults, poor product labeling, long-term effects of regular marijuana use, lack of standardized education for customers, effects of secondhand smoke) What are your biggest environmental health concerns around the legalization of marijuana? (Safe production of marijuana infused products, safe extraction of marijuana concentrates, licensing of marijuana processing facilities, standard regulations) What prevention efforts do you think would be most important to focus on? 1 For your information, I have included the minutes from the Joint CHS Board and Pitkin County Board of Health meeting held on July 22 (EXHIBIT 1). PITKIN COUNTY MEDICAL OFFICER: Submitted by Dr. Kimberly Levin In January 2014 Colorado was the first state to legalize recreational use of marijuana, although the drug had been legalized in 21 states for medicinal purposes. Marijuana has a long history of use in the US, and was formally recognized as a medical drug from 1850-1942, at which point the drug was made illegal. It was not until 1985 when the FDA approved two cannabis drugs for medical use, Marinol and Cesamet. Recreational use of marijuana, however, has a much longer world history, with widespread use in the Middle East in the 12`h century, popularity in Europe (esp. France) in the late 1700s, and not until the 1900s was it commonly used for recreational use in the US. Used in low doses in healthy individuals, marijuana has been generally considered safer when compared to the known health effects and deaths from alcohol and tobacco use. However, with recent decriminalization, increased potency, and delayed policy -making and regulation, marijuana use has presented new public health issues. In terms of physiology, there is a complex "endocannabinoid system" in our brains that is believed to regulate appetite, pain, mood and memory. In the 1980s it was discovered that chemical compounds in marijuana bind to the cannabinoid receptors (called CBI and CB2) in our nervous system in the same way that our own endocannabinoids do. Marijuana contains hundreds of chemical compounds that may have varying effects. THC, tetrahydrocannabinol, is the main psychoactive component of cannabis that interacts with this system. Cannabidiol (CBD) is another main component but does not have psychoactive properties. Scientific literature in support of the medicinal uses of marijuana is not substantial, although considerable consensus exists that marijuana is beneficial in defined conditions. Several studies have shown beneficial effects on pain relief, (especially nerve pain, for instance in multiple sclerosis painful spasms), glaucoma, appetite stimulation in cancer patients and AIDS wasting syndrome, and control of chemotherapy -related nausea and vomiting. The two approved drugs mentioned above have been prescribed for these conditions. More recently, the Epilepsy Foundation has strongly advocated the use of marijuana for treatment of seizures, and clinical trials have begun studying the effects of cannabidiol (CBD) on seizures. Anecdotal cases have reported marijuana to treat uncontrolled seizure disorders in children. CBD is also being studied as an anti -anxiety medication and a potential treatment for schizophrenia. While marijuana has well-known medicinal benefits, its recreational use has led to several serious disorders that have now been incorporated into formal medical diagnoses, including: cannabis use disorder, cannabis intoxication, and cannabis withdrawal. Single use of marijuana can overactivate the endocannabinoid system causing a relaxed "high" feeling. Physical symptoms can include red eyes, dry mouth, hunger, dizziness, increased heart rate and blood pressure, confusion, anxiety/panic. In addition, the effects may alter perceptions 2 and mood, impair coordination, create difficulty with thinking and problem -solving, and disrupt learning and memory. "Cannabis -use disorder" is associated with long-term daily use that leads to an addiction with drug tolerance. This can lead to academic, occupational or social impairment. These include lower life satisfaction, more relationship problems, less academic and career success. It decreases overall motivation at school or work, termed "amotivational syndrome." The drug had been considered to have no addiction qualities, however there is evidence now that a small percent (9%) of users become addicted, and this is higher in those who start young (17%). A recent study from New Zealand documented IQ declines in those who start young. There are no known treatments for this disorder except to stop use, and some effects may be irreversible. There may be a genetic predisposition to this addiction. "Acute cannabis intoxication" or overdose may include extreme anxiety/panic, confusion, paranoia, fast heart rate, high blood pressure, psychosis including hallucinations and delusions. There have been no documented deaths due directly to cannabis overdose, however there are marijuana -related accidents and deaths that are multifactorial. In March, a 19 year -old jumped to his death from a 4`h floor hotel balcony in Denver after eating a "marijuana cookie" causing severe anxiety and psychosis. Other examples of deaths have involved high doses that have been synergistic with other drug use. One important factor is the significantly higher concentrations of THC in products now that may be more likely to contribute to overdose, such as synthetic compounds and hash oil (may contain up to 60% THC). "Cannabis withdrawal" symptoms after long-term use include increased irritability, sleeplessness, decreased appetite, anxiety, depressed mood, and drug -craving, making it difficult to stop. Symptoms may include abdominal pain, tremors, headache, sweating. These are uncomfortable but not lethal. In addition to the psychotropic effects, marijuana use can lead to other medical problems. Marijuana smoke is an irritant to the lungs, and frequent smokers may have similar respiratory problems experienced by tobacco smokers, such as chronic cough, increased risk of lung infections, missed days of work due to respiratory illness. Although suspected, it is not yet scientifically known whether marijuana smoking leads to an increased risk of lung cancer. In terms of its effects on the heart, it is believed that people with underlying cardiac conditions may have increased risk for heart attacks or dangerous heart rhythms. Other problems include cannabis -induced anxiety and sleep disorder, and mental illness. More recently, explosions from butane hash oil labs have led to severe burns and death, and neurotoxic effects from inhaling the gas A newer diagnosis we are seeing in Emergency Departments is called cannabis hyperemesis syndrome, where a patient presents with severe and uncontrollable cycles of nausea and vomiting, and colicky abdominal pain. There is a link with daily, long-term marijuana use, and is reportedly reversible with cessation. Below are recommendations and related areas of concern for discussion: 1. Well -labeled packaging of edible products that are sectioned into single doses. 3 a. Delayed effects of edibles, accidental overdose from poor labeling, lack of standardized strengths/concentrations and regulations. 2. Youth and adult education campaigns regarding the adverse effects. a. Evidence that marijuana is a "gateway drug" for youth. b. Potential dangerous effects on driving. May have adverse effects on reaction time, hand -eye coordination, concentration, short-term memory, perception of time and distance. Current Colorado regulation is a limit of 5 nanograms of THC per milliliter of blood, however no road -side test exists as legalization has preceded policy -making and technology. c. Education and labeling about dosing, safe use, effects of second hand smoke, and accidental overdoses. Caution in pregnancy, misuse in combination with other drugs, cautious use in people with underlying heart and other medical conditions. d. Education about long-term effects of marijuana for those who start in their teens, including IQ declines, amotivational syndrome, and cannabis -use disorder. 3. Education campaigns on the proper use of marijuana. a. Product labeling b. Consider mandatory education at dispensaries c. Childproof containers PUBLIC HEALTH/COMMUNITY HEALTH SERVICES, INC.: Submitted by Jordan Sabella, Public Health Planner The Colorado Department of Public Health and Environment (CDPHE) is currently working in several ways to review, promote, and learn more about the medical implications of marijuana. Senate Bill 283 required the formation of a Retail Marijuana Public Health Advisory Committee. This group will review evidence on the health impacts of marijuana and draft public health messages around topics related to young children and adolescents, pregnancy/breastfeeding, respiratory and cardiovascular health, injuries, and dosage. Data on the prevalence of marijuana use and of the health effects are being collected from a variety of sources and tracked by CDPHE. In many cases, questions about marijuana have been added to existing surveys in order to gather more robust and meaningful data. Additionally, $10 million dollars of Medical Marijuana Registry surplus cash funds have been allocated to study the health effects of medical marijuana. There are several education and prevention messages being promoted at the state level. CDPHE's website, https://sites.google.com/a/state.co.us/marijuana/ was launched on March 20, 2014, and contains information related to marijuana from all major state agencies whose work is related to the legalization of marijuana CDPHE launched the "Don't Be a Lab Rat" on August 11, 2014, with the goal of increasing the awareness among youth of the risks associated with underage marijuana use. The core premise of the campaign acknowledges that more research is necessary, but it also poses the question of whether or not teens should risk the potential negative effects of using marijuana. The campaign's website is: http://dontbealabrat.com/. 4 The Colorado Department of Transportation launched the Drive High, Get a DUI campaign in March 2014 as well. http://www.coloradodot.info/programs/alcohol-and-impaired- driving/druggeddriving Locally, the Valley Marijuana Council (VMC) was formed by Sheriff Joe DiSalvo in January 2014, in order to work together with community stakeholders to make the introduction of retail marijuana in the community safe and responsible. Representatives from public safety, health, schools, parents, drug prevention specialists, the business community and more serve on the VMC, and have worked together to provide community education events and to respond in a unified way to marijuana related issues when they arise. The goals of the VMC are to: prevent short and long term health and safety issues related to the introduction of recreational marijuana; involve a variety of community stakeholders to develop and implement SMART community goals; and to document efforts to develop a model for future communities considering the introduction of recreational marijuana use. http://www.vallevmjcouncil.org/ There has been growing concern both locally and across the state, with regard to the need to educate consumers at the point of sale regarding responsible marijuana use. Anecdotally, we hear that Aspen area dispensaries aim to educate customers regarding how to responsibly smoke or ingest marijuana products, however there is no standardized messaging or educational requirements of dispensary workers. An idea that is gaining momentum in various municipalities is to require a training program for all marijuana dispensary workers, so that they have the basic knowledge to educate customers at the point of sale. Public Health supports the adoption of a required, standardized training to ensure dispensary workers have the knowledge to educate customers on responsible recreational marijuana use. ENVIRONMENTAL HEALTH: Submitted by Kurt Dahl, Pitkin County Environmental Health Manager and CJ Oliver, City of Aspen Environmental Health Director The Pitkin County and City of Aspen Environmental Health Departments have several programs that have been impacted by the legalization of medical and recreational marijuana. We have seen impacts to our programs in air quality, water quality, wastewater management, and land use. In addition we have concerns about the regulation of edibles and we would like to focus on this issue for this presentation. Both the City and County Departments have contracts with the State Health Department to administer consumer protection programs that provide for education, licensing, and inspections of retail food facilities in Aspen and Pitkin County. The FDA Food Code considers food infused with marijuana (edibles) to be "adulterated" and in violation of the Code. In other words, edibles cannot be made in a licensed retail food facility or licensed wholesale manufacturer and the manufacturing and sales of edibles must be done in a completely separate facility. If a local jurisdiction does not have regulations for the production of edibles, then the responsibility of regulating the manufacturing and retail of edibles is with the Colorado Department of Revenue (DOR). The State Health Department has chosen, for a number of reasons, to not regulate the production and sale of edibles but does give advice on food safety to the DOR and locals. 5 The City and County of Denver's Environmental Health Department has developed and implemented regulations pertaining to the food safety of edibles for both medical and recreational operations. Denver's Environmental Health Department recently gave a presentation on the challenges of their program and a few slides from that presentation are attached (EXHIBIT 2). Basically, Denver is seeing a lack of knowledge in food safety in part due to few workers with restaurant or wholesale experience. Common violations include: unapproved sources, labeling, temperature holding violations, hazardous contaminants are present in the final product after the extraction process (i.e. solvents, benzene, etc.). The Environmental Health departments from the City of Aspen and Pitkin County would like to explore creating a set of similar regulations to implement for the purpose of inspecting marijuana facilities, particularly those that are producing infused edible products. The current marijuana regulations set forth a number of general guidelines for safe practices but do not offer any context or definition for terminology. Environmental Health would like to see the applicable sections of the Colorado Retail Food Service Regulations applied to the marijuana code. Applicable sections and definitions include areas concerning food temperatures to limit bacterial growth, proper ware washing and sanitation, hand washing, and general sanitary conditions of the facilities. There are currently no statewide regulations pertaining to food safety for these types of facilities. The City and County of Denver have the most developed set of regulations for marijuana infused foods which applies their local food regulations in their entirety to the regulation infused products. Most jurisdictions currently have no regulations for infused products other than the state guidelines. ENVIRONMENTAL PUBLIC HEALTH ADVOCATE: Submitted by Tom Dunlop My comments before the BOH regarding recreational marijuana will be limited to empirical evidence and informal conversations 1 have received in the past few months from colleagues around the United States. Comments 1 have heard have been concerning as some are intended to be humorous while others are more sobering. From a purely public health perspective it is felt that the marijuana industry is in front of public health's and clinician's ability to clearly understand the full repercussions to users of the product, either directly or in a collateral way. A comment offered to me during a recent visit with environmental public health practitioners was that Colorado is a "Train wreck waiting to happen." In other words, the public health system is in a reactive mode and may not be able to catch up with developments in the way marijuana is delivered such as edibles or by inhalation. The "tail is wagging the dog" analogy was mentioned as the image seen by outsiders to Colorado. 1 was criticized in a meeting on food safety by an attendee who felt I should not have mentioned marijuana at all, that it was irrelevant to the meeting. The thought of edible marijuana is foreign to many. Angry, worried, dangerous are but a few descriptors relayed to me by public health professionals. Social ramifications have been mentioned, such as the thought of a child taking their parents legally obtained marijuana to grade school, a chilling concept. As your Environmental Public Health Advocate 1 am supportive of comments made by Dr. Levin, Jordana Sabella, Liz Stark, Kurt Dahl, and CJ Oliver. As your former Environmental 6 Health Director, it was my position then and is now as your Advocate, that aggressive efforts must be forthcoming to educate the public about substances possibly causing physical and mental harm. In the past is has been about smoking and obesity. Today it is recreational use of marijuana. The presentations today provide a perfect example of how the various disciplines of the health care system (medical, clinical, environmental health, health educators, health planners, nutritionists and others) are working as a team to become proactive in this effort. Thank you. Respectfully submitted, Liz Stark RN BSN Pitkin County Public Health Director Director, Community Health Services, Inc. 7 EXHIBIT 1 Board of Health & Community Health Services, Inc. Joint Meeting Notes July 22, 2014 Participants: Pitkin County Board of Health Steve Child, Rob Inner, George Newman, Michael Owsley, Rachel Richards Staff: Jon Peacock, Nan Sundeen Community Health Services Amy Covington, Mark Devlin, Ginny Dyche, Mary Fox, Kimberly Levin, James Moran, Chuck Torinus Staff: Liz Stark Assessing the Board of Health and Community Health Service Relationship The Relationship between CHS and BOH has been great for many years and continues to be good. Both boards are clearly on the same page and serve similar public health goals. However, given changes in State Public Health law and new requirements for County Boards of Health, the two boards convened a joint meeting to build upon and improve their relationship and clarify items such as: • Who makes what public health decision and when? What is the process for decision -making look like? • What is the relationship between CHS and BOH? What do we want it to be like? • What does the process look like for increased cooperation? • How do we resolve the policy/executive overlap between the two organizations and be even more strategic about public health initiative in Pitkin County. o For example, the current Public Health Director is the Executive Director of CHS, which is a contractor to the County. Although not a problem now, there is the potential for a conflict of interest. 8 • Public Health Act places more responsibilities on the BOH. How can we address these responsibilities given the public health structure in Pitkin County? Both boards agreed that each board brings unique strengths and perspectives to the public health issues. Community Health Services Strengths • Broad and diverse membership • Extensive experience in public health issues • Implementation experience Board of Health Strengths • Policymaking • State advocacy • Resource development and allocation Iterative Learning Model ' CHS • huplementation of seiwices -•Budgeting ASSessillenr i4' Needs,'Analysis •Goals and. Strata-6i, ?Legal,& -Policy::' • regitircntents .:, -4" I'BOH', j !Goals and 11L. Strategy ;Policy ;•Resources allocation •Evaluation.. •Sfafe advocacy: These strengths have created a mutually supportive relationship, which has increased the effectiveness of public health efforts in Pitkin County. Given the strength the BOH-CHS partnership, what is the process to confirm and clarify the roles and responsibilities of each board moving forward? Next Steps: Going forward there are at least three areas of opportunity: 1. Clarifying roles, responsibilities and structure Although the current relationship is strong, the Public Health Act and Affordable Care Act both create some opportunities to clarify and confirm the roles and responsibilities of the Board of Health & Community Health Services. The strength of the relationship and the addition of new members to the BOH (City of Aspen & TOSV) makes this a perfect time for clarification of roles and responsibilities. The current contract between Pitkin County & CHS is a good place to start. It is a broad contract that would benefit from more definition. It offers a foundation for both organizations to explore how to clarify their different roles. • Staff will begin the process of assessing what needs to be added to the contract between Pitkin County and CHS for review and discussion with both boards. • Staff will also work on clarifying staff roles (County Manager, Health and Human Services Director, Public Health Director), which would help clarify organizational roles and responsibilities and how they relate and interrelate with each other. 2. Jointly identifying strategic public health issues and goals Incorporating more time for both boards to discuss public health issues at ajoint strategic level is an important next step. It is also a good way to reaffirm what both boards do now. (Build on work CHS has done as part of their strategic planning.) 9 • Staff will look at ways to allow for more time to discuss policy issues as part of the quarterly work sessions as well as explore ways for additional joint meetings and information sharing (e.g., sharing memos and minutes). 3. Creating a budget that reflects joint strategic goals Since budgets are an allocation of values, it is important to ensure that the public health budget is adequate to our joint values. The existing budget process for 2015 could be tweaked in relation to public health to create opportunities for clarification and strategic discussion. • Instead of a budget meeting in August, CHS and BOH will host ajoint work session in late Aug/Sept to discuss strategic issues. • The budget discussion will move to a November meeting. • Staff will work out details of agenda and schedule and get back to both boards. r I0 EXHIBIT 2 • City and County of Denver's presentation on Food Safety Regulations Food Safety Regulation of Marijuana ;Produ its in Denver Public Heakh'Inspectiblis Division Denver Dept. of= Envvironmental-Health" Presentted:liy Dan ca,Lee & Thuy,. Vu 'Rocky Mountain:FoodSafet} ;Conference June 26, 201 Denver: • Home to apx 800 MJ businesses • Apx 500o regulated food businesses Denver agencies involved with licensing and/or inspections of • marijuana operations • Dept. of Environmental Health • Dept. of Excise & Licenses • Fire Dept. • Community Planning & Development (building, plumbing & electrical approvals; zoning, wastewater engineering) 11 vironmental Quality Considerations • Monitor solid waste management (plant material,: other solid waste) • Consult regarding electronic waste (light bulbs) & energy consumption • Wastewater disposal • Odor control • Fertilizer use • Pesticide use • Hazardous waste roducts Regu ated`by Food Safety Section • All marijuana products that are consumed via non- smoking oral consumption: • Infused brownies, candies, etc. • Infused sauces. dressings, pizza, ice cream, drinks • Concentrated extractions if consumed as food • Infusions such as tinctures, butters, honey, oils, etc. :. 12 .:Y Safety During Inspections Concerns: • Safety due to crime • Dangerous extraction processes • Exposure of investigators to odors • Upset operators . Precautions • Security systems at all sites • No inspection if hydrocarbon detector not present • Face masks, Febreeze for odors • Ongoing trainings for investigators ost common food safety challenges Retailers: -Unapproved source -Unwholesome products - Refrigeration of PHFs .-,Labeling _Manufacturers: - Saiiie'as other food thatitifacturers.. - Unwholesome plant material -Food safety risks of variable, complicated extraction processes have not been established 13 itzra Hash Oil Extractions • Extraction processes concentrate the cannabinoids • z Main Categories of Extraction Processes • Non -Hydrocarbon Extractions • Cold/hot water filtration • Isopropyl alcohol/Isopropanol • Ethyl alcohol/Ethanol • Acetone • COz/dry ice • Dry sieve • Hydrocarbon Extractions t Butane, propane, Ieptane. • Fire permit required pd Extraction Equipment 14 A.ppr-ov de -Extr et-� n Eq u i-jp m n 1!1 ' _ 4 Lo ev d•Extr-aet_ o Equiprriten isopropanol Extractor Hexane Extractor 15 Ethanol Extractor