PROVIDENCE – It promises to be a big week for championing what has been called an innovative approach being taken by Rhode Island “to prevent drug overdose and support recovery.”

White House Director of National Drug Control Policy Michael Botticelli is scheduled to tour the Gloria McDonald Women’s facility at the Adult Correctional Institute on July 26, where he will speak with state officials and inmates about efforts to provide medication-assisted treatment for “opioid use disorder,” according to the news release about the event.

The tour comes just four days after President Barack Obama signed the Comprehensive Addiction and Recovery Act into law on July 22, one of the few examples of a dysfunctional Congress passing legislation this year, breaking through the partisan logjam.

In an election year, with so many communities devastated by the toll of overdose death and addiction, a number of Republican senators in closely contested re-elections in 2016 decided there was an impetus to act.

[By contrast, an emergency request for $1.9 billion in funding by President Obama to combat the threat of the emerging Zika virus is still languishing, a victim of partisan wrangling. The request may or may not be taken up again in September when Congress reconvenes, despite the fact that the number of Zika cases keeps expanding rapidly across a growing geography. Not only mosquitoes but sexual contact has been found to spread the virus, leading reporter Laurie Garrett to wonder in a recent story for CNN: “Could Zika be the next HIV?” See link to story below.]

The new law, known as CARA, will place greater federal emphasis on prevention, treatment and recovery over incarceration by giving those “on the front lines of the ongoing opioid abuse epidemic in America better tools to combat,” according to the news release issued by Sen. Sheldon Whitehouse, one of the authors of the legislation.

Here in Rhode Island, efforts to put more emphasis on prevention, treatment and recovery over incarceration stumbled a bit in the R.I. General Assembly. [See link below to ConvergenceRI story.]

While a package of seven bills targeted at helping to reduce the epidemic of drug overdose deaths and promote recovery and prevention efforts was passed in one of the last actions taken by legislators in the 2016 session as part of the madcap rush to beat the final gavel, recommended reforms to the criminal justice system targeting probation and parole practices, bills developed in partnership with a 27-member Governor’s task force on “justice reinvestment,” died on the vine, leaving R.I. Senate President M. Teresa Paiva Weed distraught at the defeat, as reported by The Providence Journal. R.I. House Speaker Nicholas Mattiello told reporters afterward that he thought the reforms were “a little soft on crime.”

The development of medication-assistance treatment programs at correctional facilities in Rhode Island is clearly a big step forward in the state’s effort to combat drug overdose death and promote recovery.

But the ongoing tensions and distrust between law enforcement authorities and drug-users remain palpable and real, despite the passage earlier this year of The Good Samaritan Law, exacerbated by the current atmosphere following an explosion of police shootings, targeted attacks on police, and acts of terrorist violence.

The role of the recovery community
What is also true, but not often featured as equal part of the narrative, is the role that the recovery community, both here in Rhode Island and across the nation, has played in becoming a constituency of consequence.

It’s a phrase first coined by Tom Coderre, a former top staff member with R.I. Senate President Paiva Weed, who now works under Botticelli. It was embraced as a watchword for the recovery community by advocates such as the late Jim Gillen, [who died a year ago, on July 18, 2015, after a long struggle with illness.]

It was also championed by recovery community leaders such as Holly Cekala, formerly of RICARES, who worked with Gillen to help to develop a system of peer recovery coaches.

It under girds much of the success of the 32-member Governor’s Overdose Prevention and Intervention Task Force in developing its action plan, ensuring that community voices are heard, including members Michelle McKenzie and Jonathan Goyer.

It is part of the ethos that Task Force consultants Traci Green, Ph.D., and Dr. Josiah Rich bring to their work.

It also speaks to the efforts by Dr. Michael Fine, former director of the R.I. Department of Health, to develop an inclusive, collaborative stakeholder coalition in 2011, bringing together both health professionals and recovery community members.

The emergence of the recovery community in Rhode Island as a constituency of consequence has always been about teamwork and inclusion.

However, the concept of a constituency of consequence sometimes appears to get lost in translation in the writing of the current political narrative.

No greater public health crisis
In advance of Botticelli’s visit, Gov. Gina Raimondo said in the media advisory: “There is no greater public health crisis faced by Rhode Islanders today than drug overdose.”

Raimondo continued: “Rhode Island stands out as a leader among states for our comprehensive approach to addressing this national crisis, and for our focus on getting people into treatment – including inmates, who are incredibly vulnerable to overdose when they re-enter society.”

No one can fault Raimondo’s earnestness, leadership and advocacy in 2016, two years into her first term as governor, nor fail to acknowledge the heartfelt connection she has developed with the recovery community. It has been an impressive part of her learning curve on the job, and she wears it well.

But, also notably, more than four years ago, it was Fine, then director of the R.I. Department of Health, who first changed the state’s public health priorities in Rhode Island to address the public health crisis in overdose deaths, and who in 2011 organized the first inclusive stakeholder groups to develop new strategies and approaches.

Fine also advocated for stronger regulations governing how opioid painkillers were prescribed, much to the dismay of many physicians, dentists and nurse practitioners, who strongly opposed such regulations and resisted the changes, at the time.

It was the surveillance work done by Dr. Christina Stanley, the chief medical examiner under Fine, that first linked the use of fentanyl to an increase in overdose deaths, leading Fine to talk with Botticelli numerous times about the risks of fentanyl.

When a spike in overdose deaths occurred in January of 2014, Fine went public with concerns in dramatic fashion, sharing publicly the suspected number of overdose deaths.

Fine also coordinated the launch of the first statewide communications effort to promote the concepts that recovery was possible and addiction was a treatable disease, funded with $100,000 from Daniel DelPrete of the DelPrete Family Foundation.

Will both Gillen and Fine get a shout out from the Raimondo team at the Botticelli event for their leadership? Or, will the critical role they played get written out the script?

One of the campaign pledges that Raimondo allegedly made to an association of Rhode Island dentists, who had been upset by Fine’s advocacy of tighter rules for prescribing practices for opioid painkillers, was that she would get rid of Fine, according to sources that attended the meeting.

Fine resigned in March of 2015, after Raimondo cancelled his annual State of the State Health Report to the R.I. General Assembly. He was replaced by Dr. Nicole Alexander-Scott.

Yet, in a recent story in The Providence Journal, the narrative told was that it was Raimondo who had pushed for tighter restrictions on opioid painkiller prescriptions, over the concerns voiced by Alexander-Scott about whether such efforts could be legislated.

Reducing the number of deaths
The revised version of the Action Plan unveiled by the Governor’s Overdose Prevention and Intervention Task Force on May 11 had as its number-one goal the reduction by one-third the overdose deaths occurring in Rhode Island, from some 258 in 2015 to 170 by 2018.

One of the policy changes that the R.I. Department of Health has undertaken under Alexander-Scott is to only release data on confirmed deaths, rather than on suspected deaths, as was done under the previous director. As a result, it can sometimes be difficult for the public and reporters to keep abreast of the currency of the overdose epidemic in Rhode Island.

For instance, as the agency website states: the data for the last six months, from January through June of 2016, is not complete. That said, comparisons between 2015 and 2016 data for the first four months of each year, January, February, March and April, show that there were a total of 98 confirmed deaths in 2015 and 99 confirmed deaths in 2016, with the potential for the 2016 numbers to climb at higher rate than in 2015.

The projected death toll could hit a total of 300 in 2016, one physician told ConvergenceRI.

Lowering the number of deaths by one-third promises to be a daunting task, as the epidemic of overdose deaths continues to take a high toll of Rhode Islanders, driven in large part by the increased presence and use of fentanyl in the illicit drug trade.

“The most important take-home message is that the majority of overdose deaths are due to illicit drugs, and not prescription medications. We need to shift our focus,” Traci Green, Ph.D., told ConvergenceRI earlier this year, following the release of the Governor’s Action Plan on May 11. “What the epidemic in Rhode Island needs now is for prescribers to help us keep people alive: please prescribe naloxone [Narcan] and buprenorphine [suboxone].”

As progressive as many of the interventions championed by the Governor’s Action Plan are, reducing the number of deaths may require even more dramatic steps to keep pace with the rapdily morphing epidemic.

Street smarts?
One recent twist in the efforts to increase the use of suboxone as a medication-assisted treatment to combat addiction has been the opening of a suboxone therapy clinic on Wickenden Street in Providence, the Recovery Connection, run by a former tax preparer, Michael Brier, who was sentenced to 27 months in federal prison, as first reported by GoLocalProv on July 22.

The clinic apparently falls between the cracks of government regulation: it is not licensed by the R.I Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, according to a statement by Linda Reilly, BHDDH spokeswoman.

“BHDDH licenses behavioral health treatment programs,” Reilly said in a statement to GoLocalProv. “This is different than licensing an individual suboxone provider, which is handled by the R.I. Department of Health.”

Recovery Connection is not licensed by BHDDH, Reilly continued, because it is not a behavioral health treatment program. “Neither the R.I. Department of Health, nor BHDDH have received any information or complaints suggesting that the individual asked about is prescribing suboxone. He is not a licensed physician, and no physicians in the R.I. Department of Health’s licensing database are associated with that location.”

On the Recovery Connection website, as reported in the GoLocalProv story, Brier allegedly advertised his services in a video by saying: “My name is Michael, I’m an addict.” Once you’re an addict, Brier reportedly continued on the video, “You’re always going to be an addict. Come in and talk to one of our medical professionals, we’ll not only offer you suboxone and therapy, we’ll be there for your whole life.”

Rewriting the narrative
In a July 7 article in The Providence Journal, it said: “Efforts to curb opioid prescribing in Rhode Island began about six years ago, when emergency room physicians became alarmed at the number of patients being wheeled into the hospital ERs after overdosing on opioids.”

The story went on to quote Dr. Christopher P. Zabbo, president of the Rhode Island chapter of the American College of Emergency Physicians: “As emergency medicine physicians we were obviously on the front lines,” he said. “So we knew there was a problem.”

It made for a compelling story, one that portrayed the emergency room physicians as heroes, the first medical professionals to step up to the plate to battle the epidemic of opioid overdose deaths.

[It may also have helped to reframe the image of emergency room doctors, who were criticized in the aftermath of the death from a heroin overdose of Brandon Goldner, the son of Brian Goldner, the president and CEO of Hasbro, and his wife, Barbara Goldner, a nurse.

In dramatic fashion, speaking before a March 9, 2016, meeting of the Governor’s Overdose Prevention and Intervention Task Force, the Goldners faulted hospital staff for for not alerting them to the fact that their son has visited the emergency room seven times in three months for drug overdoses, with the last three visits occurring in less than a week, according to the Goldners.

In response, new legislation, sponsored by Sen. Joshua Miller, was enacted this year to establish detailed protocols on how overdose cases should be handled in ERs and urgent care centers.]

However, the story’s narrative did not align with many of the facts about what actually happened and when it happened. 

The story about what really happened
In April of 2011, when I was the health care and life sciences reporter for The Providence Business News, I attempted to find out how the actual number of overdose deaths in Rhode Island that were related to the prescription of opioid painkillers, following national stories about ongoing problems in Kentucky and elsewhere.

What I discovered was that there was no accurate record being kept on deaths by drug overdoses by hospital emergency rooms in Rhode Island, according to what drugs actually caused the deaths.

Without an accurate database, it was impossible to know the extent of the crisis in overdose deaths caused by opioids in Rhode Island.

In my research I made contact with Traci Green, a researcher working under a small grant for $250,000 from the Centers for Disease Control and Prevention, who was painstakingly researching the actual causes of death by going back and examining the medical examiner case files in Rhode Island and Connecticut. Green shared with me her insights about what her research had found.

Here’s part of the story published in PBN on July 4, 2011:

Rhode Island is one of 16 states in which death from accidental overdose is more prevalent than death from car accidents.

Rhode Island’s upward swing parallels the national trend: 14,459 people died in 2007 as a result of “poisoning deaths” involving “opioid analgesics,” the technical term for prescription painkillers, more than triple the amount – 4,041 – in 1999, according to the latest national statistics available from the CDC.

Deaths due to overdose from prescription medications are now outstripping overdose deaths from drugs such as crack cocaine, heroin or methamphetamine, the statistics show.

The new research involves mining the data from medical examiner case files, funded by a two-year, $250,000 grant from the CDC. It addresses what some health care professionals see as a fundamental problem in Rhode Island related to accidental deaths from overdose of prescription painkillers: no one – hospital emergency rooms, community mental health agencies or the R.I. Department of Health – is collecting or tabulating data in a comprehensive, standardized fashion.

“The only thing we know is that the number of deaths is extraordinarily high,” said Traci Craig Green, assistant professor of medicine and community health at the Warren Alpert Medical School of Brown University, who is conducting the research.

Preliminary results from Green’s research – a systematic review of medical examiner case files from accidental drug overdoses in Rhode Island and Connecticut – show a disturbing trend emerging: the demographic most at risk for death by accidental overdose are women and men between the ages of 35-to-54 who are also being treated with anti-depressant prescription drugs and sleeping aids. The geographic trend is that these deaths occur more frequently in suburban, small-town settings than in urban areas.

When you combine anti-depressants with prescription opioids – the technical name for synthetic opium products such as dilaudid, oxycodone and oxycontin, Green explained, “It increases the opioids’ effect, suppressing a person’s breathing, and accidental overdoses may occur,” she said. “We are working on research to more carefully quantify the relationship – and identify the context in which overdoses are occurring,” she said.

Green’s research findings have implications not only for drug-prevention and drug-treatment programs but for the workplace, she said. “Opioids now outrank marijuana as the first drug of use [for young adults],” Green said. “Young adults in their prime are the ones that are dying, in a large swath of the population, people ages 35 to 54. It is not the future taxpayer, it’s the current taxpayer.”

Often, women who abuse prescription painkillers may have a history of physical, emotional or sexual trauma, according to Green. “Biologically, people who experience a traumatic event respond to pain differently,” she said. “They are ‘rewired’ by that traumatic experience, they may feel pain very differently, and require different prescribing approaches.”

Green’s preliminary findings are an important step in correcting the current lack of information available to medical providers and substance-abuse programs in order to change treatment.

Hospital emergency rooms, for instance, track treatment for overdoses according to billing codes, with diagnoses made by the bedside clinician into broad categories, such as “poison/overdose,” “abuse and dependence,” and “adverse effect,” according to Dr. Jason B. Hack, an emergency room physician at Lifespan with a specialty in toxicology. “Diagnosis depends on the individual bedside clinician,” Hack said.

At The Miriam Hospital emergency room in 2010, there were 176 patients – the largest number in any category – treated under the abuse and dependence category under the diagnosis, “305.90, oth mix/uns nondepend rx abs uns,” or “other, mixed or nondependant drug abuse unspecified.”

That information, however, does little to help track prescription-painkiller abuse, Green said.

Calling Dr. Fine
On July 18, 2011, I forwarded the story to Dr. Michael Fine, the director of the R.I. Department of Health, with the following questions:

1. Given your own experience with corrections, how serious is the health challenge of abuse of prescription painkillers? Physicians often ask, in relationship to pain, to measure this on a scale of 1 to 10, with 1 being no pain and 10 being excruciating. How would you measure this public health issue on a scale of 1 to 10?

2. From the preliminary results of Green's research, there seems to be a potent relationship between opioids and anti-depressants in accidental deaths. No one – the pharmacies, the physicians, the hospitals, or the mental health providers – seems to be aware of this. What kinds of public educational efforts do you believe should be undertaken so that people better understand the risks?

3. There is a prescription monitoring program in Rhode Island, but it does not appear to be really up and running. What resources are needed to do so?

4. According to sources, CVS pharmacists are allegedly not allowed to query the prescription monitoring programs in Rhode Island or Connecticut. Were you aware of this? Can this be corrected? It would seem that a pharmacist, if he or she had the knowledge about what other kinds of controlled substances the patient had been prescribed, could then have options to counsel the patient, cut them off, change the prescriptions, or change the dose.

5. The demographics of the people in Rhode Island most at risk of an accidental death involving opioids, according to Green's research, are adults between the ages of 25-54? What kinds of public health education could be introduced into the workplace?

Fine responds
In short order, Fine responded by taking action. One of his first steps was to engage in conversation with Green about her work.

Fine also put together a new ad hoc group, co-chaired by Green, bringing in numerous stakeholders to the conversation, to develop new policies and strategies to address opioid overdose deaths, particularly around the prescription of opioid pain medications.

Fine then created new guidelines for the new chief medical examiner to follow in compiling death certificates from overdoses, in order to create an accurate database. That surveillance approach led to the identification of the use of fentanyl as new deadly factor in drug overdose deaths

In early 2012, Fine also changed the public health priorities in Rhode Island, making the threat of opioid overdose deaths a top public health priority.

The moral of the story
Narratives matter. Yes, it may be important to acknowledge that a small number of emergency room doctors played a role in efforts to bring attention to the emerging overdose death epidemic in Rhode Island.

But, it is equally important to recognize the critical leadership role played by Fine, working in collaboration with Green and others in the recovery community.

The real heroes are the members of the recovery community in Rhode Island, and the truer narrative is about how they have become a constituency of consequence.

How they continue to demonstrate their new-found voice remains an unanswered challenge, particularly in times of diminishing resources.

Yes, addiction is a disease, and recovery is possible. But a more fundamental narrative may be at play here, one that needs to be recognized.

“If we want to reduce opioid addiction, we have to target the real risk factors for it: child trauma, mental illness and unemployment,” wrote Maia Szalavitz in a guest blog in the May 10 issue of Scientific American. “Two thirds of people with opioid addictions have had at least one severely traumatic childhood experience, and the greater your exposure to different types of trauma, the higher the risk becomes. We need to help abused, neglected and otherwise traumatized children before they turn to drugs for self-medication when they hit their teens.”

As Rhode Island grapples with how best to integrate behavioral health and mental health care into primary care, and how to combat overdose death and promote prevention and recovery, the essay by Szalavitz suggests that the state may want to consider embracing a more coordinated, comprehensive and holistic approach: to invest in health, not health care; to reduce toxic stress; to increase healthy housing; and to make investments in place, neighborhoods and communities.