PROVIDENCE – Have you ever been at a sporting event in a stadium when the wave starts, and everyone is swept away by an enthusiastic urge to stand up and yell with joyful, outstretched arms, as the public display cascades through the crowd?

What happens if you prefer to stay seated and pay attention to what is actually happening on the field of play?

That was the contradictory feeling that ConvergenceRI experienced while attending the gathering of the latest Overdose Prevention and Intervention Task Force meeting on Wednesday, May 11, when Gov. Gina Raimondo publicly unveiled the latest updated version of the Task Force’s plan of action. [See link to ConvergenceRI article below.]

More than 80 people crowded into the second-floor conference room of the R.I. Department of Administration building, for what appeared to be an orchestrated performance, in an all-hands-on-deck show of support and approval.

To an outsider looking in, the entire event was well scripted, well managed, and well staged. Everything aligned.

[As Elizabeth Roberts, secretary of the R.I. Executive Office of Health and Human Services quipped, both she and the two co-chairs of the Task Force, Maria Montanaro, director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, and Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, had managed to wear non-clashing brightly colored orange, pink and blue outfits.] 

Later that day, after the event, a follow-up news release was issued, entitled: “What They’re Saying: Gov. Raimondo’s Overdose Prevention Action Plan.”

It featured numerous quotes from prominent corporate Rhode Islanders, including: Helena Foulkes, executive vice president of CVS Health; Blue Cross & Blue Shield of Rhode Island’s outgoing president and CEO, Peter Andruszkiewicz; Neil Steinberg, president and CEO of the Rhode Island Foundation; Dennis Keefe, president and CEO of Care New England; Dr. Russell Settipane, president of the Rhode Island Medical Society; and Barbara Goldner and Brian Goldner, CEO of Hasbro, who recently lost a son to addiction.

Not surprisingly, a number of those quotes were picked up and used in the story in The Providence Journal that recapped the event.

How long in advance did it take to coordinate getting quotes from all these folks and organizing them for inclusion in such a news release? A week? Two weeks? The event had the distinct feel of a managed public relations extravaganza.

It’s true, there was much to cheer about in the latest iterative version of the Action Plan, first released in draft form in November of 2015, which laid out its approach in a comprehensive fashion: the strategies, the goals, the deliverables, the metrics, and the collaborative approach to confront the scourge of addiction and promote recovery in Rhode Island.

It was difficult to resist not to be swept away, to stand up, throw up your arms and proclaim that I believe in gospel fashion, in part because of the strength of the messaging and the deep respect for the 32 people involved on the Task Force, and above all else, the desire to save lives.

Yet, what was left unsaid – at the event and in the plan – may turn out to be as important, if not more important, than what was said.

Timing is everything
The day before the event, as if right on cue, a news release issued by the R.I. Department of Health expressed new worries about the dangerous rise in fentanyl-related overdose deaths during the last few months, setting the stage for the Task Force show-and-tell.

What was said: “The results of initial toxicology screens suggest that Rhode Island is experiencing a significant increase in accidental opioid overdose deaths that involve the synthetic drug fentanyl,” according to the news release.

Although the results of confirmatory tests were still pending, the release continued, “These initial screenings suggest that fentanyl could have been involved in approximately 60 percent of overdose deaths in March, April, and early May. This figure is a significant increase over the approximately 47 percent of fentanyl-related overdose deaths in 2015.”

What wasn’t said: The news release marked an abrupt departure in policy by the R.I. Department of Health, releasing data on suspected overdose deaths, a policy that had been promoted by former director Dr. Michael Fine but halted under current director Dr. Nicole Alexander-Scott. Why the sudden change in strategy? Why hadn’t the news of the spike in the number of overdose deaths related to fentanyl been released earlier, in March or April, in a response to the growing awareness of a public health emergency?

The decision to release only confirmed overdose deaths has meant, in large part, that the public [and reporters] have not been kept abreast of the currency of the overdose epidemic – as witnessed by the fact that although we’re already five months into 2016, the total number of overdose deaths in 2015 is still a work in progress, listed at being 257 and counting.

Sources tell ConvergenceRI that the actual count of overdose deaths in 2015 will be as high as 262.

What caused the apparent departure in policy to release the number of suspected and not confirmed overdose deaths?

Here’s the backstory: an emergency room doctor at Rhode Island Hospital had voiced concerns about the dramatic increase in the number of overdose deaths in recent months, according to sources, which in turn led officials at the R.I. Department of Health to reconsider its policy, in response to a perceived public health crisis, at least for the moment.

The underlying question, not directly asked, answered or addressed, was this: Did the previous effort under Dr. Michael Fine, then director of the R.I. Department of Health, to release the number of suspected overdose deaths, and to use them to publicize the perceived public health crisis facing Rhode Island, help to limit the number of overdose deaths, in a significant manner?

What was also not said: That context was missing in large part from the May 10 news release. The difference in actual numbers between 2013, when 232 overdose deaths were reported, and 2014, when some 242 overdose deaths were reported, represented a slighter increase in deaths when compared to the dramatic rise in deaths in neighboring states such as Massachusetts. [There were 1,099 overdose deaths in Mass. in 2014, a 21 percent increase from 2013, according to the Mass. Department of Public Health.]

The comparison date used in the news release was 2012; the efficacy around previous public education efforts was not discussed.

This may seem like minutiae, but when the number-one goal is to save lives, with a stated goal of reducing the number of overdose deaths by one-third, from 255 to 170 by 2018, timely access to data becomes a crucial factor – what some have called the democratization of data.

“We have a single focus in our work to address the overdose crisis: save lives,” Raimondo emphasized in the news release.

Wouldn’t giving the public timely access to transparent data about suspected overdoses do much to support that goal?

It may be time for the R.I. Department of Health to consider revising its current policy of not releasing anything but confirmed data of overdose deaths, rather than suspected data, particularly if the spike in deaths from fentanyl is so worrisome, to help inform the public in a more timely fashion about the ravages ongoing crisis, according to a number of community advocates.

Is there a way to build into the Action Plan a way to research and calculate the effectiveness of public relations efforts – not just in reducing the number of overdose deaths but also in reducing the overall misuse of substances, including alcohol?

The changing crisis
The spike in fentanyl deaths is not a new development, per se. The dangerous increases in overdose deaths as a result of fentanyl was raised by R.I. Department of Health officials in August of 2013, January of 2014, and in March of 2015, both prominently and publicly.

What is different this time around, according to Traci Green, Ph.D., a member of the Task Force, is a recognition that the nature of the overdose epidemic is changing.

“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,” she told ConvergenceRI.

Green contrasted the differences in the strategic approach being taken by Rhode Island. “Many, many states around us and across the country are launching huge campaigns and legislating medical practice,” she said. “They take aim directly at doctors and pain patients [or patients who may have otherwise received pain medications].”

Rhode Island is not doing this, Green continued, “Because we are seeing [likely earlier than most states] that the epidemic has changed – massively – and the response needed is different. That is a bold and difficult move, to break from the expected group response.”

That said, Green also emphasized that prescribers were not being “let off the hook” in Rhode Island. “They still have clinical guidelines to abide by, and they should reduce first-time opioid prescribing doses for acute pain,” she explained.

But, she continued, “We are making progress reducing excess opioid prescribing. What the epidemic in Rhode Island needs now is for prescribers to help us keep people alive: please prescribe naloxone [Narcan] and buprenorphine.”

Changing strategies
One of the positive examples in the strategic difference that the work of the Task Force has made is in the efforts to track the way that Narcan is being used by emergency services and by emergency departments, to develop a better database about how many doses are being administered and by whom. This becomes a critical component of saving lives, particularly because with fentanyl, it often requires a number of doses of Narcan to revive overdose victims.

During the discussion that followed the unveiling of the Task Force plan about the new coordination around the use of Narcan by emergency services, one member asked if the same kind of protocols were being applied to emergency services serving neighboring states, such as Massachusetts and Connecticut. The answer was not yet, but R.I. Health Department officials were observed busy taking notes.

Another is the ways in which peer recovery coaches are being deployed at hospitals and reimbursed by some insurance companies.

Today, only one hospital in Rhode Island – Westerly Hospital, owned by Lawrence + Memorial Hospital in New London, Conn., the latter in the process of being acquired by Yale New Haven Hospital as part of a larger merger – is not yet deploying peer recovery coaches at its emergency department.

What was not said: The co-chairs of the Task Force acknowledged that one hospital was an outlier, but did not name the hospital. Why not? 

[Editor's note: Negotiations with Lawrence + Memorial Hospital have now cleared the way to have peer recovery coaches at Westerly Hospital's emergency room, according to one source.]

When the draft action plan was first released last November, commercial insurances were not yet on board with reimbursing peer recovery coaches; the payments were being made through grant programs. Today, both UnitedHealthcare and Blue Cross & Blue Shield of Rhode Island have changed their reimbursement policies to include peer recovery coaches, a big step forward.

What was not said: Neighborhood Health Plan of Rhode Island is apparently not yet reimbursing peer recovery coaches, according to a number of sources. Why not?

While it is commendable that Raimondo has decided to put her thumbprint on the Action Plan, it remains to be seen who in her administration will take on the role of public advocacy in calling out and changing the practices of the business community.

Changes in attitude
The day after the Task Force meeting, ConvergenceRI sat down with Michelle McKenzie, board chair of RICARES [the Rhode Island Communities for Addiction Recovery Efforts], and a member of the Task Force, to help sort through the latest details of the action plan and the apparent shift in strategic direction, from the community perspective, rather than from the clinical approach.

RICARES and the Anchor Recovery Community Center are partnering on a Recovery Community Legislative Day, to be held at the State House on Tuesday, May 17, with the theme that there are many pathways to support and sustain recovery.

McKenzie praised the work of the Task Force and the leadership of the Governor in reshaping the Action Plan into a more concrete document, focused on implementation. McKenzie also praised the fact that increasing the access and distribution of naloxone had been made one of the top priorities.

There were still some things, McKenzie continued, that needed further discussion, definition and resolution.

For instance, Mckenzie pointed out that under the heading of “Prevention: Safer Prescribing,” one of the key deliverables included: “Rhode Island will implement payment options to support resources for non-opioid therapy.”

That was great, she explained, but under the Strategic Action Plan Metrics, there wasn’t yet a concrete deliverable for that strategy. If there were no way to create reimbursable health insurance payments to support non-opioid therapies as a way to deal with pain management, it could prove to be a barrier to recovery.

McKenzie also pointed out the importance of creating a clear definition of what it means to be a peer recovery coach in a way that recognizes these coaches beyond the clinical model. Also, that recovery coaches need to have supports built into the work that “encourages recovery coaches to take good care of themselves” as well as their patients.

McKenzie also talked about the need to create a more coordinated system of care. “People who struggle with addiction need a lot of care, not just supported by government grants,” she said. “We need to be creative in thinking about how we pay for it.”

McKenzie also stressed the importance of including family and community as part of the recovery process, beyond the clinical model and the criminal justice model.

“People who are suffering from addiction deserve respect,” she emphasized, talking about the debilitating stigma that often faces those suffering from the disease.

Back from the dead
The May 9 issue of GQ magazine featured an interview with Jonathan Goyer, under the headline, “The Rhode Island Heroin User Who Came Back from the Dead.”

The GQ story recounts how Goyer, 28, had been brought back from the dead in 2013 when his roommate had injected Narcan into his leg to bring him back to life from an overdose.

Since then, Goyer has become a vocal advocate for recovery, working with the Anchor Recovery Community Center and, as a member of the Task Force, helping to write the Action Plan.

In an interview with ConvergenceRI, Goyer filled in part of his story that emphasized the importance of the work being done by advocates such as McKenzie. His roommate, the one who had administered the dose of Narcan that saved his life, Goyer explained, had been trained by McKenzie and provided with the Narcan to use in just such an emergency.

For Goyer, being honest and direct is part of being in recovery, a response to the disease of addiction, which he called a “very cunning disease, baffling, insidious, and manipulative.”

The Action Plan, Goyer admitted, is not the ultimate answer, but the goal of reducing the overdose death toll by one-third was important.

Goyer drew a distinction between the draft of the Action Plan released in November of 2015, which he called more a map, a direction to go in, compared to the Action Plan released on May 11, which he described as an “in-depth implementation of that plan.”

A lot of the content had changed in the last six months, for the better. The previous version was a good read, Goyer said. The newer version had accountability.

The view from the front lines
The idea of changing policies and releasing unconfirmed numbers of suspected overdose deaths, Goyer continued, would be great.

“Particularly for me, personally, working on the front lines of all of this, I use it as motivation,” he said. “When the numbers rise, and you hear about it in real time, it kicks you to do a little more.”

Goyer also agreed with McKenzie, that it will be important, moving forward, for there to be a better definition of what exactly it means to be a peer recovery coach.

All the components of the Action Plan, Goyer said, were evidenced-based, and there was enough data in Rhode Island to support the success rate of peer recovery coaches, particularly with the Anchor Recovery model, to prove that it has been effective.

That said, he continued, there aren’t a lot of peer recovery coaches in the state; the intent is to double the number of peer recovery coaches, to go from around 80 to 160.

“The direction is not just to increase the number of peer recovery coaches employed, but to expand the environment in which we are using them,” he said. “The goal is to make it so the services are sustainable through health insurance services.”

Beyond finger-pointing
Goyer also talked about the importance of the dialogue by Task Force members to move beyond finger-pointing and blaming and passing the buck. The new Action Plan was a collaborative effort, with a delegation of responsibility and direction.

“Change can happen very, very quickly,” Goyer said, talking about the discussion around how peer recovery coaches were being dispatched, leading the implementation of the “warm phone” concept. “It was just words two months ago, and now it is being implemented, a new effective procedure.”

A new communications strategy
Within the Action Plan, there was some mention about the development of a public education and community outreach plan, focused on reducing the stigma of addiction, through the development of public dashboards with a new website.

Details were scant in what was handed out as part of the public relations around the Action Plan, but ConvergenceRI has learned that the campaign is scheduled to debut sometime in June, with the relaunch of the “Addiction is a Disease, Recovery is Possible” campaign that had first been developed in early 2015.

The campaign will featured a dedicated phone line to call, and it will have up-to-date resources about treatment and recovery options on the website. As one Task Force member told ConvergenceRI, “If you don’t share the data in a transparent fashion, in real time, people will not know where to get help.”

Evaluating the efforts
There are so many factors and moving parts involved in determining why a community outreach effort around messaging about addiction and recovery may work: were the police able to do a better job in limiting the amount of fentanyl coming into the state? How did the messaging resonate with different age groups? Building a research component into the public outreach campaign to quantify the results may be an important improvement in shaping future policy decisions about what the public needs to know, and when they need to know it.

A wider lens

In a guest blog in the May 10 issue of Scientific American, Maia Szalavitz offered the following observation, suggesting that in addressing opioid addiction, it required a wider lens to look at risk of trauma, metnal illness and unemployment: “If we want to reduce opioid addiction, we have to target the real risk factors for it: child trauma, mental illness and unemployment. 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-medicatation when they hit their teens.”

As the state grapples with how best to integrate behavioral health and mental health care into primary care, and how to combat overdose prevention and promote recovery, the essay by Szalavitz suggests that the state may want to consider embracing a more coordinated, comprehensive and holistic approach to reducing toxic stress.