Mind and Body

To recovery and beyond

Making it in Rhode Island, where addiction is recognized as a disease and recovery is a comeback strategy that works

Photo by Richard Asinof

Holly Cekala, executive director of RICares, in front of a poster featuring her story as part of a new media campaign promoting recovery in Rhode Island, following a news conference to launch the campaign.

By Richard Asinof
Posted 1/12/15
The recovery community in Rhode Island has issued a challenge to the new Raimondo administration that no comeback in the state can work without renewed focus on the epidemic of substance use. Moving forward, the new administration will need to develop an economic equation for future economic growth that devotes resources for mental health, behavioral health, and the recovery continuum. Raimondo campaigned on the belief that the state needed to prioritize treatment over punishment; will she keep her promises?
Who will be the new director replacing Craig Stenning at BHDDH? How will that department be reorganized? What kinds of political capital will Raimondo invest in the efforts to change the conversation? How can the holistic model developed by Continuum, the for-profit arm of The Providence Center, Care New England and Blue Cross & Blue Shield of Rhode Island, be replicated? What kinds of resources would be needed to jumpstart a clinical practice or medical center devoted to the treatment of chronic pain in Rhode Island that did not use steroid injections or prescribed addictive painkillers? Is there a way to create a confidential database that tracks outcomes and metrics for recovery and treatment, developing an evidence-based approach?
The drug price war developing between CVS Health and Express Scripts, mirroring the competition between competing drug manufacturers for control of the market for high-priced hepatitis C medicines, gets to the heart of the problem with the current way that the health care delivery system deals with disease and how drugs are prescribed and paid for.
The treatment of chronic pain with drugs is a recent medical development, a treatment that has resulted in tragic consequences in addiction and death. It was more of a business decision than a medical decision, supported by aggressive pharmaceutical practices.
As behavioral health and mental health treatments come under scrutiny, with the dramatic increase in the demand for services, an underlying question, not often asked and not yet answered, is: what are the differences in efficacy between talk therapy and drug therapy. Giving someone a drug to manage symptoms may prove cost-effective, but does it result in the long-term behavioral changes sought?
Further, the way that mental health and behavioral services are reimbursed in Rhode Island deserves more scrutiny. Recently, a commercial health insurer operating in Rhode Island reportedly limited reimbursements for “therapy” at a PCMH, except by a psychiatrist, putting patients at risk that they could be billed for things such as a $400 facilities fee if they continue counseling with a therapist who is not an MD.

PAWTUCKET – A new dawn, a new day, a new life for me, and I’m feeling good. For many who gathered in the bitter cold at the Waterplace Restaurant on the evening of Jan. 6 to celebrate the inauguration of Gov. Gina Raimondo as Rhode Island’s first woman governor, and to witness the ritualistic lighting of WaterFire by the state’s newly elected leaders, it was a moment to channel the hopefulness captured by Nina Simone’s cover of Anthony Newley’s song, “Feeling Good.”

Raimondo’s message, asking Rhode Islanders to join with her in igniting a comeback, to “make it in Rhode Island,” had particular resonance for many within the state’s recovery community.

During her campaign, Raimondo had pledged that she would “take to the Governor’s office my belief that we need to prioritize treatment over punishment,” at a candidates’ forum held last summer at the Anchor Recovery Community Center.

In making the case for prioritizing treatment over prevention, Raimondo had cited the breakdown of costs from Vermont, where she said it cost about $100 a week for someone to be treated and more than a $1,000 a week for someone to go to prison. “Even my 10-year-old can do the math,” she said. [See link to ConvergenceRI story below.]

What better example of a roadblock to Rhode Island’s comeback could there be than the ongoing epidemic of substance abuse, with its death toll of 232 accidental overdoses in 2014, the same number as in 2013?

To make sure that this issue did not get lost in the pomp and circumstance of Raimondo’s inauguration [perhaps channeling a bit of Ronald Reagan’s advice, “Trust, but verify”], more than 100 people staged a die-in on the steps of the State House on Jan. 6, shortly after Raimondo’s inauguration concluded.

“We are here to send a message that too many people are dying,” said Holly Cekala, executive director of RICares, as reported by The Providence Journal.

The next day, in an interview with ConvergenceRI at her offices in downtown Pawtucket, Cekala posed the question: “How are you going to make a comeback, with hundreds of dead people from overdoses, without addressing this epidemic?” The die-in, she continued, explaining the thinking behind the public demonstration: “We wanted to be proactive about making [the Governor] aware that [the crisis] hasn’t gone away.”

Recovery works

Last week, amidst the hoopla, there were a number of significant new initiatives, new coalitions, and new investments in the behavioral health, mental health and recovery landscape that emerged above the radar screen.

There were also some encouraging signs by the Raimondo administration that it was going to put into action the pledge to “think differently.”

•  A new media campaign was launched, funded not with tax dollars, but with $100,000 from the DelPrete Family Foundation, focused on stories on recovery and hope, with the tag line: “Addiction is a disease. Recovery is possible.”

The media campaign features the stories of eight local men and women, who, in their own voices, share their personal stories of addiction and recovery, in radio and TV spots, in bus ads, and online at the website. The campaign is being coordinated by the R.I. Department of Health and the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, in partnership with Anchor Recovery. [See link to website below.] 

Jonathan Goyer, one of the individuals in recovery featured in the campaign, shared his own poignant story on Jan. 9 at the official rollout of the campaign at the Anchor Recovery Community Center. “Recovery is a process, with ups and downs,” the former heroin addict said, who now works two jobs. His life was saved from death in 2013 by a dose of Narcan. “Where there is breath, there is hope – hope that any individual can find recovery and become a responsible, productive member of society,” he said.

Goyer told the story about how when asked if he was ready to have his face plastered on buses, he responded, why not: “I’ve been plastered on many buses.”

Goyer also put some perspective on the media effort, saying it was just that: a media campaign. “None of this matters if we aren’t practicing the principles of love, compassion, understanding, and empathy in our relationships with others.”

•  A new broad-based coalition, Recovery Works, including many business groups such as the Greater Providence Chamber of Commerce and the R.I. Manufacturers Association, is moving ahead with plans to change the conversation around addiction, with the message: “Addiction is everyone’s business,” employing the hashtag #RecoverRI.

The Recovery Works coalition, explained Garry Bliss, the communications director at The Providence Center, involves many groups that one might think of as unusual suspects. “It is a coalition that has come together to raise awareness about substance use disorders in Rhode Island,” Bliss said.

Every home, every street, every family in Rhode Island is affected by substance use disorders, Bliss continued. “It is a workplace issue, it is a workforce issue,” he said. There is a recognition that we need to change the public’s understanding of the issue, he added, saying: “To spread the message that recovery works, to connect [those with the disease] to treatment and to long-term recovery, supporting them in rebuilding a healthy life for themselves.” That message has really begun to resonate in the business community.

The effort segues well with the media campaign launched on Jan. 9.

•  Within minutes following Raimondo’s inauguration, Craig Stenning, the long-time director at BHDDH, resigned, after being told in a phone call that he would not be reappointed, according to Stephen Neuman, Raimondo’s new chief of staff, in newspaper reports.

Accounts of exactly what happened differed. Apparently, as best can be determined, Stenning was removed from his current position, which sources said had been eliminated. But Stenning, as a long-time state employee who had been at BHDDH since 2000, in turn, was not terminated. Instead, he was moved to a new office location, said to be right across from the elevator, Room 101. 

Stenning had embarked on what many saw as a two-month public relations campaign to keep his position, coordinated by spokesman David Layman, a temporary consultant hired to replace the agency’s communications staffer, who was out on sick leave.

Indeed, the BHDDH website on the day that Stenning resigned featured eight recent stories promoting the agency’s accomplishments: one in the Providence Journal, two on Channel 12, WPRI, two in The Providence Business News, one on WPRO, one with Southern Rhode Island Newspapers.

On the morning of his dismissal, Stenning sent out a three-page e-mail to staff members, community partner agencies and advocates as a New Year’s message, detailing what he claimed were the agency’s eight key successes in 2014.

It was followed soon after by a second e-mail from Stenning that said: “Shortly after today’s Inauguration, there will be an announcement of a new BHDDH director and a new direction for this Department. I wanted you to hear the news from me directly.”

To date, Raimondo has not announced a new director nor talked about her plans to seek a new direction and a new organization of the agency. But it is clear that Raimondo intends to take a different tack.

•  Tufts Health Plan, one of the four commercial health insurers operating in Rhode Island, announced a new investment in the Care Transformation Collaborative, formerly known as the R.I. Chronic Care Sustainability Initiative. The investment of about $125,000, seeks to support the evolution and effectiveness of the patient-centered medical home model, in a move to better integrate behavioral health services in the delivery of primary care.

The money will be used to expand web-based referrals and care coordination to establish a behavioral health referral network for primary care providers in Rhode Island, because none currently exists. It will also be used to support education and training of primary care staff on how to provide integrated behavioral health services, particularly focused on substance use diagnosis and intervention. A third component will access the use of technology tools to assist patients in behavioral change in making healthier lifestyle choices, such as smoking cessation.

“It’s a reflection of our commitment to the market,” Dr. David Brumley, senior medical director at Tufts Health Plan, told ConvergenceRI.

The new initiative resulted as a response to the need for better integrated behavioral health care identified by a legislative commission chaired by Sen. Joshua Miller, according to Dr. Debra Hurwitz, co-director of the R.I. CTC. Hurwitz told ConvergenceRI that her group created a working group on integrating behavioral health in primary care.

“We got a huge response, not only from primary care practices, but from behavioral health providers, who were anxious to participate in the discussions,” she said. Today, the working group has about 25 participants.

The first task was conducting an environmental scan, to determine what kinds of services were out there, what the capacity was, and what kinds of patients could be referred.Hurwitz said. “As providers, we needed to understand what the services are and how do you access them.” 

Gaps in the system of care

At Raimondo’s inauguration, leaders of the Rhode Island’s recovery movement were told by State Police Colonel Steven G. O’Donnell that the new governor had assured him that the issue would be on the front burner. O’Donnell said that he had already spoken with Raimondo’s chief of staff about it.

The top policy priority, according to Cekala, will be to get the Good Samaritan law recertified in the R.I. General Assembly, which is scheduled to end as of July 1, 2015. The law enables citizens to call for help from authorities in a potential overdose, without threat of prosecution. [In practice, some of the local police departments, such as Woonsocket, have not always chosen to abide by the law.]

Ian Knowles, project director at RICares, pointed to the fact that there are multiple barriers to sustained recovery – a lack of housing, a lack of education, a lack of employment, and a lack of “enough” treatment options.

“The basis of all those barriers is the stigma that is associated with addiction,” he said, and the effort at the national and local levels to switch the focus of policy makers, of the R.I. General Assembly, from treating addiction as a criminal issue and instead understand that this is a public health issue.

One of the most vulnerable points in the recovery continuum is when people leave incarceration in prison and begin the journey back into the community, according to both Cekala and Knowles.

While there are effective counseling programs, the highest risk for recurrence is often for the population that is leaving prison, because their tolerance is not as high to the drugs that they were once using, according to Cekala.

“The housing piece is really a big part of that; there is not funding available for recovery housing,” Cekala said. The average cost for a week’s stay in recovery housing is about $120 to $140 a week, she continued, which is a lot to pay when you are looking for a job, but relatively cheap when compared to the general market.

A second gap related to recovery housing, or what’s sometimes called sober housing, is that there’s no database, no oversight and no regulation, according to Knowles and Cekala. Such houses are specifically exempted from regulation.

While it may make it “affordable” for people to run them and for people to live in them, the people in recovery who reside there don’t have any rights either, Cekala said.

Cekala said there were about 50 actual recovery houses in Rhode Island, mostly in the Warwick, Cranston, Providence and Pawtucket area; there is only one house in Aquidneck Island, in Portsmouth, and that is only for men.

A lot of the recovery houses prefer to fly under the radar, so that they don’t have to confront potential problems with their neighbors, part of the stigma of addiction, according to Knowles.

In the future, Cekala and Knowles said that the recovery housing coalition has been working with BHDDH and RICares to develop a certification for recovery housing funding, with the carrot being that all state referrals would only be made to a certified house.

Virtual, or bricks and mortar?

RICares worked with BHDDH to help draft some of the language that’s in the new State Innovation Model grant, which was recently awarded $20 million over the next three years.

Knowles and Cekala said they had seen the final wording of the plans for the grant, which will provide BHDDH with about $1.25 million for transformation of the delivery of mental health care in Rhode Island. [See link to ConvergenceRI story below.]

“We don’t know if the concept of the medical home is a ‘virtual’ home, or it is an actual bricks and mortar site,” Knowles said.

Further, there is a lot of money in the grant being targeted for transitional housing for mental health, as opposed to recovery housing, according to Knowles.

Outcome data lacking

Another big gap in the treatment and recovery continuum is the fact that there is no comprehensive database that tracks people in recovery after they leave treatment. Treatment center data is up to the time a person leaves, discharged from treatment.

“Addiction is a chronic, recurring disease, which is part of the problem,” Knowles said. “But we have no idea how people are doing six months post treatment, a year post treatment, two years post treatment, that’s the critical data.”

If you don’t have the outcomes, he continued, you can’t tell which programs are most effective. And, what are the most effective interventions to create the best return-on- investment?

“Having a large database for people to look at [and analyze], that would be great,” said Cekala.

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