Mind and Body

Fentanyl appears to be driving OD deaths toward record numbers in 2016

Despite a host of new interventions, programs and laws, the pledge to reduce overdose deaths by one-third in three years may be falling victim to the onslaught of fentanyl

Image courtesy of Calgary Police Service Facebook page

Illegal fentanyl that was seized by police in a drug bust in Calgary, Alberta, in Canada.

By Richard Asinof
Posted 9/1/16
Despite all the efforts by the state to implement new strategies to decrease the number of deaths from overdoses, in the short term, the death toll seems to be spiking, with some 150 confirmed deaths by the end of July in 2016 and the prospects of the total nearing 300 by the end of the year. The reason behind the jump in the number of deaths is the increase prevalence of fentanyl in the illegal drug market, according to experts.
When will the efforts to reduce stigma of addiction and to reduce incarceration for drug use become as prominent as efforts to increase medication-assisted treatment and outreach to doctors around opioid prescription practices? Do new strategies need to be developed to address the dangers of fentanyl? Is there a way to increase the use of peer recovery coaches outside of the current clinical model of combating drug addiction? What is the current demand for drug treatment in Rhode Island and what is the waiting time to enter treatment? Can those numbers be made public and shared on a regular basis? Did the questions from ConvergenceRI prompt the issuance of a news release from the R.I. Department of Health?
Will other specialist practices follow the path that Ortho Rhode Island has created, redefining the landscape in the emerging accountable care world? Are there ways that community health centers can develop new partnerships with Ortho Rhode Island around the managed Medicaid population? Will Ortho Rhode Island consider expanding its footprint and develop a clinical facility that looks at the treatment of pain management? How will wearable devices change the flow of information between patients and providers, particularly around rehab from surgery?
Will other specialist practices follow the path that Ortho Rhode Island has created, redefining the landscape in the emerging accountable care world? Are there ways that community health centers can develop new partnerships with Ortho Rhode Island around the managed Medicaid population? Will Ortho Rhode Island consider expanding its footprint and develop a clinical facility that looks at the treatment of pain management? How will wearable devices change the flow of information between patients and providers, particularly around rehab from surgery?
A number of communities, including Seattle, are publicly discussing the potential of creating safe havens to use drugs, under medical supervision, as a way to combat the epidemic of overdose deaths, as well as reduce the transmission of Hep C and HIV.
The Seattle proposal, based upon what’s known as “harm reduction,” is patterned in part on a safe consumption program called Insite in Vancouver, British Columbia.
It seeks to have the blessing and approval of the Seattle Police Department and the city attorney’s office; such safe havens would be staffed with people who can help drug users access services, including treatment, housing and medical care.
Is Rhode Island ready to have such a discussion?

PROVIDENCE – By the end of July, there were some 150 confirmed deaths by drug overdose in Rhode Island, with 145 confirmed deaths by drug overdose during the first months of 2016, with more suspected deaths remaining to be confirmed in July, according to a concerned citizen who reviewed the numbers.

Those numbers appear to put the state on the trajectory to reach a total of some 300 deaths by the end of 2016. That would be roughly a 15 percent increase over the number of confirmed deaths in 2015, despite a host of new interventions and programs and legislation enacted under the leadership of Gov. Gina Raimondo and the Overdose Prevention and Intervention Task Force plan of action – as well as a pledge to reduce the number of deaths by one-third over the next three years.

The increase in the number of deaths appears to undercut much of the progress that Rhode Island has championed in its fight against the epidemic of drug overdose death and addiction: new public awareness efforts, a new prison medication-assisted treatment program, a new law about how emergency departments respond to patients with overdoses, the enactment of a Good Samaritan law, and a new public health dashboard related to making information accessible. [See links to ConvergenceRI stories below.]

Last week, for instance, there were more positive signs reinforcing the fact that the federal government was recognizing Rhode Island’s leadership in the fight against drug addiction:

The U.S. Department of Health and Human Services announced $1.9 million in funding for Rhode Island to improve access to treatment for opioid-use disorders.

The U.S. Food and Drug Administration, in response to a citizens’ petition from numerous state public health officials, led by Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, requiring stronger label warnings about the potential dangers of mixing opioids with anti-anxiety drugs, including benzodiazepine. [See link to ConvergenceRI story below.]

Earlier this summer, Michael Botticelli, White House director of National Drug Control Policy, visited Rhode Island and met with incarcerated women who are now part of a medication-assistance treatment offered to prisoners to help them overcome their addiction. [See link to ConvergenceRI story below.]

“We know that people who leave incarceration without good connections to treatment have a significant overdose risk, often within the first 72 hours of release,” Botticelli said.

Yet, despite all these positive developments, the death toll in Rhode Island keeps climbing.

Death toll keeps mounting
What is causing the numbers to go in the wrong direction?

ConvergenceRI reached out to a number of members of the governor’s task force and the recovery community to get their insights and answers.

Dr. Josiah “Jody” Rich, professor of Medicine and Epidemiology at the Warren Alpert Medical School at Brown University and a member of the expert team supporting the Overdose Prevention and Intervention Task Force, gave a blunt, one-word answer: “Fentanyl.”

Some 66 percent of the overdose deaths confirmed in April, May and June involved the use of fentanyl, according to another task force member.

Rich, who is co-founder and director of the Center for Prisoner Health and Human Rights at the Miriam Hospital, was equally direct about what Rhode Island needed to do in response: [“We need to] double down on treatment with medication-assisted therapy at every turn – the entire medical and criminal justice systems, especially [at] emergency departments and the ACI.”

Traci C. Green, deputy director of the Boston Medical Center Injury Prevention Center at the Boston University School of Medicine and associate professor of Emergency Medicine and Epidemiology at the Warren Alpert Medical School at Brown, as well as a member of the expert team with the Overdose Prevention and Intervention Task Force, concurred with Rich.

When asked what was causing the continued spike in overdose death, Green replied: “Fentanyl in the illicit drug supply,” related to the way that fentanyl is being cut into heroin.

Green was also blunt about what was needed in terms of steps to take to stem the increase in the number of deaths: “More medication-assisted treatment, more Naloxone, less stigma, less incarceration.”

Recently, the U. S. Surgeon General sent a letter to some two million physicians in the U.S., saying that there was a more substantive role for doctors to play in combating the epidemic of addiction and overdoses related to opioid use.

What was that role, from Green’s perspective?

Green’s Rx for doctors went like this: “Prescribe Buprenorphine and prescribe Naloxone. But if you don’t want to prescribe either, learn about substance use disorder and how to prevent overdose. And talk to your patients about the importance of medication-assisted treatment [It works! It’s available!]. And, how to protect themselves and their family from overdose by getting Naloxone at the pharmacy today.”

Recovery community responses
Michelle McKenzie, board chair of RICARES and a member of the governor’s task force, also attributed the rise in the number of overdose deaths to the presence of fentanyl in the illegal drug supply.

“I’m guessing that the continued rise in deaths is related to the constant presence of fentanyl in our drug supply, given that over half of deaths so far this year are fentanyl-involved,” McKenzie told ConvergenceRI.

Unfortunately, she continued, the supply and demand of illegal drugs continues to be a huge market. “I think there is too much money to be made to see a decrease in fentanyl or similar opioid [use] because there are so many people in our state with opioid use disorder,” she said. “[It’s] a huge market.”

In turn, McKenzie said that she believed that it would take some time to see the results of the increased availability of medication-assisted treatment and decreases in opioid prescribing by physicians.

Moving forward, the questions for McKenzie were these: what is the status of treatment in Rhode Island? Has medication-assisted treatment increased, and by how much?

Equally important, McKenzie continued, was the question: for whom has the decreased opioid prescribing happened?

“If the decrease in prescriptions has been focused on new prescriptions – that is, decreased reliance on opioids in both acute and chronic pain situation among opioid naïve patients, then the decrease is fabulous,” she said.

But, she cautioned: “To the degree that the decreased prescribing is happening among people already struggling with addiction, then we are setting them up to use illicit opiates and die from overdose.”

McKenzie said that physicians could continue to play a key role in slowing the epidemic.

“Physicians play a role in that not only do they need to prescribe less opioids to naïve patients and see alternative pain management [which is a goal of the task force and its imperative that alternatives be made available for doctors],” McKenzie said, saying that doctors and nurses must work closely with their patients who are struggling with opioid addiction, through the use of medication-assisted treatment and/or working closely with behavioral health specialists and recovery support.

McKenzie summed up the challenge facing Rhode Island as follows: “Finally, I guess the question is how to support people to not use fentanyl or use it more safely,” she said. “I think we need to fall back on harm reduction techniques that have proven to be successful in other settings – safe injection facilities, prescribed heroin, treatment on demand, and decriminalizing drug use.”

McKenzie also focused on the inherent contradiction between treating addiction as a disease and as a crime.

“On one hand, we talk about how addiction isn’t a crime,” she said. “But we keep putting people in jail for drug use. As long aswe do that, it will keep people who need help underground.”

Recovery efforts
Jonathan Goyer’s poignant story about coming back from the dead, after overdosing and then being revived by Narcan, has been told numerous times. He has become an outspoken advocate for recovery efforts.

Goyer responded to questions from ConvergenceRI by clarifying the numbers around overdose deaths. “There were 145 confirmed deaths between January-June of 2016; there were 140 confirmed deaths from January-June of 2015,” said.

He continued: “A few more cases could trickle into the 2016 figures due to the time it takes to process and finalize.”

But, with that said, Goyer explained, “It looks like we are only five percent higher than last year, which falls in line with our usual 3 percent to 4 percent [annual] increase.”

In contrast, Goyer said, other surrounding states have seen an increase as high as 75 percent year-over-year since.

As to what was the cause of the spike in overdose deaths in Rhode Island, Goyer said: “We will never know for sure what causes the increase in deaths. It is fentanyl, but it’s also a combination of other things.”

Goyer remained optimistic about the approaches being undertaken by Rhode Island to combat the epidemic.

“Rhode Island has done so much this year in terms of creating resources and increasing access to help,” he said. “If anything is worth writing about, I would say to craft a message reminding people that addiction is a disease and recovery is possible.”

Goyer added that help is available by calling 942-STOP, visiting Anchor Recovery Community Center, or by visiting the website, www.preventoverdoseri.org.

Department of Health response
ConvergenceRI also reached out to the R.I. Department of Health, in an email at 9:58 a.m. on Thursday morning seeking to confirm the accuracy of numbers regarding confirmed overdose deaths in Rhode Island in 2016.

The questions included:

What were the total number of confirmed overdose deaths in 2015?

What were the total of confirmed overdose deaths in the first six months of 2016? How many more are “suspected?”

Through the end of July, what were the total of confirmed overdose deaths in 2016? How many more are “suspected?”

Is the use of fentanyl the major reason why the death toll seems to be increasing?

What does the R.I. Department of Health believe the best strategies are to combat the dangers of fentanyl?

No response to the questions from ConvergenceRI has yet been received. [When they are, ConvergenceRI will update the story.]

Five hours later, at 2:48 p.m. on Thursday afternoon, the R.I. Department of Health issued a news release, entitled: “Fentanyl-related Drug Overdoses Continue To Cause Deaths in Rhode Island; Gov. Raimondo’s Overdose Task Force Taking Action To Reverse the Trend.”

Editor's note: Here are the responses from the R.I. Department of Health, received this evening. The total number of confirmed overdose deaths in 2015 was 258.

The total number of confirmed overdose deaths in the first six months of 2016, from January through June, was 146.

"As a result of policy changes earlier this year, we no longer keep a count of ‘suspected overdose deaths,’” said Joseph Wendelken, the spokesman at the R.I. Department of Health.

Wendelken explained that while the agency monitors the situation in real time and can act or make announcements when it sees alarming trends, the agency no longer has a hard count of “suspected overdoses” by month in the same way that it counts confirmed overdoses.

Further, fentanyl has become a major factor in the overdose epidemic in Rhode island and it is a major reason why the death toll is increasing, Wendelken said.

According to Wendelken, fentanyl was involved in roughly 65 percent of overdose deaths this spring, confirming the reporting by ConvergenceRI that: "Some 66 percent of the overdose deaths confirmed in April, May and June involved the use of fentanyl.”

Wendelken also said the Overdose Prevention and Intervention Task Force had implemented a number of strategies to address the threat from fentanyl. They included: the launch of a statewide media campaign; the distribution of educational materials warning people who use illicit drugs about the dangers of fentanyl; connecting people who have overdosed with a recovery coach and recovery services before being discharged from emergency rooms; and educating and training correctional officers, staff, and inmates at the ACI on Naloxone use

Postscript: Call this a story about a different kind of groundbreaking. If the current trend in confirmed overdose deaths continues, Rhode Island's death toll could hit 300 in 2016, about a 15 percent increase from 258 confirmed deaths in 2015.

The spike in deaths has been attributed to the prevalence of fentanyl in illicit drugs by a number of experts and recovery community advocates.

But there is a more fundamental challenge in play: how we look at harm reduction as part of a community-based strategy, beyond a clinical approach.

For better or for worse, Gov. Gina Raimondo has chosen to own the state's strategy for Overdose Prevention and Intervention. If it is not working, and the number of deaths keep increasing, how will she change the current strategy?

One strategy that may be important to change: why not go back to the policy of publicizing and tracking the suspected number of overdose deaths on a weekly and monthly basis, to provide more currency to the ongoing public health threat?

Another important development may be the new agreement between China and the U.S., announced on Sept. 4 by National Security Council spokesman Ned Price, to enhance control measures to combat the flow of fentanyl from China by restricting the export of precursor chemicals used to manufacture illicit fentanyl.

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