Mind and Body

Addiction: the disease that keeps on killing us

At some point, does the strategy need to move from triaging the crisis to thinking more about how best to tackle the upstream causes?

Courtesy of Shannon Monnat, from her talk on Oct 27 at RIC, "The Landscapes of Despair."

For whatever reason, the research by Shannon Monnat, analyzing the demographics for deaths from suicide, alcohol and drugs, has been missing from the conversation at the Governor's Task Force on Overdose Prevention and Intervention.

By Richard Asinof
Posted 12/11/17
The Governor’s Task Force on OD Prevention and Intervention is launching a new initiative, to help municipalities develop their own community OD engagement plan, following the precepts of the overarching strategies that the task force has endorsed. But, is it time to move from triaging a public health crisis to focusing on the upstream roots of the epidemic?
What is the delay in sharing publicly the harm reduction strategy promised as a deliverable in the July 12 executive order by Gov. Gina Raimondo? What is the status of the state Medicaid office reimbursing peer recovery "support specialists? When will health insurance companies reimburse acupuncture, massage therapy and yoga as an evidence-based pain reduction therapies? Which physicians' group practice will launch the first integrated pain management center in the state? What is the aversion by the Governor’s task force to discussing the research and findings by Shannon Monnat? Will the action plans developed by Health Equity Zones to address substance abuse in their communities be shared with municipalities at the Dec. 12 Community Overdose Engagement summit?
The proposed $69 billion merger between CVS Health and Aetna, if approved by regulators, promises to speed up the ongoing transformation of the health care delivery landscape, blurring the distinction between retail pharmacies, big box stores, insurance companies, pharmacy benefit managers, and hospital-based health care systems.
How might that affect consumers? Take flu shots. The flu season is off to an early start, according to the Centers for Disease Control and Prevention report released on Dec. 7. The current flu vaccine is considered to be only 10 percent effective against the H3N2 flu virus that is the prevalent virus circulating this season.
A potentially more effective flu vaccine, particularly for older citizens, known as Flublok, is available – but apparently not at many retail pharmacies in Rhode Island, including CVS stores and its MinuteClinics.
Flublok costs more; you have to ask for it; and you could be told by the pharmacist that the store doesn't carry it.
The problem is about cost and profit margins, not about promoting the best health choices for consumers, or offering a more effective flu shot.
With insurers and big pharmacy retailers getting hitched, so to speak, consumers seeking to make the best health choices may have a harder time doing so.

PROVIDENCE – As the first snow of the season falls, covering our small corner of the Earth with a cold white quilt, creating the illusion of a clean slate upon which it is easy to imagine we can create and follow new paths not yet taken, however dark the night.

Yes, the state motto is hope, but I believe sometimes it requires some pushing and pulling to create those islands of hope to survive the current darkness.

It is a time when I find myself rereading Robert Frost, in the hope that I, too, can write in such sparse, eloquent lines, describing the way that neighbors continue to build walls between themselves, in these highly partisan times, as well as finding an antidote to the venom.

Something there is that doesn’t love a wall, that sends the frozen-ground-swell under it, Frost begins in “Mending Wall.”

The poem tells the story of how Frost and his New England neighbor arrange a time each spring to mend a stone wall marking the property line of their farms.

There is, of course, Frost’s sly wit: that unnamed something which causes the boulders to tumble and spill is “frost” itself, his own namesake, the freezing of the soil beneath the wall, followed by thawing in spring.

Frost ends his poem, describing the boundaries we create in our own lives, often dependent on repeating bad patterns of family or tribal behavior that we have become comfortable with:

He moves in darkness as it seems to me,
Not of woods only and the shade of trees.
He will not go behind his father's saying,
And he likes having thought of it so well
He says again, “Good fences make good neighbors.


The darkness of silos
This year’s final meeting of the Governor’s Task Force on Overdose Prevention and Intervention will take place on Wednesday morning, Dec. 13. The first item on the agenda is a five-minute progress update on 20 items listed in the most recent executive order signed by Gov. Gina Raimondo on July 12 of this year.

Dr. Nicole Alexander-Scott, director of the R.I. Department of Health, and Becky Boss, the director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, will deliver the update.

Perverse metrics
One perverse metric, often used to measure “progress,” is the body count: how many people in Rhode Island have died as a result of drug overdoses each year. Saving lives, rightfully, is the mantra; health agencies, community coalitions, police, medical practitioners and academics have come together to become the veritable catchers in the rye, attempting to rescue the falling victims.

When the Task Force’s action plan was first unveiled on May 11, 2016, the overarching ambitious goal pledged was to reduce the number of overdose deaths by one-third in three years.

Translated, to reach that goal, using the number of 258 confirmed drug OD deaths in 2015, as was posted at that time by the Department of Health, the number of confirmed OD deaths would need to drop from 258 to 172 in three years.

The epidemic morphs
But, bad things can happen to good ideas. The total number of OD deaths for 2015 was revised upward in December of 2016 to 290, because of apparent clerical errors in tabulation.

The targeted one-third reduction in OD deaths was, as one recovery community leader described it to ConvergenceRI, a “pre-fentanyl realization” goal. It was chosen before there was a better understanding of the dramatic impact that fentanyl was playing in overdose deaths in Rhode Island: in 2016, more than 50 percent of all OD deaths involved fentanyl.

In 2016, the number of confirmed drug OD deaths soared, reaching a body count of 336 Rhode Islanders, a 14 percent increase from the revised number of 290 in 2015 [and a 34 percent increase from the 258 figure used when the task force’s goal was first announced in May of 2016].

In 2017, the body count from drug ODs seems to be slowing down a bit, although the exact figures will not be confirmed until sometime in February of 2018, when the last three months of 2017 are tabulated as “confirmed.”

Call it a glimmer of good news. Currently, as of Dec. 10, the 2017 tabulated total of confirmed deaths is at 230 deaths and counting, with the months of September, October, November and December still incomplete. The likelihood is that the final number in this perverse metric will be around 300 deaths, a 10 percent reduction, which will no doubt be hailed, in the cause-and-effect world of government interventions, as a victory for the Governor as she heads into the 2018 election season.

The tragedy is that whatever the final OD death body count for 2017 is, too many people are dying, despite the best evidence-base strategies. Whether the total is 280, 290, 300 or 310, it is not something that we should allow to become “normalized.”

Deaths of despair
But the underlying roots of the epidemic, what researchers such as sociologist Shannon Monnat have called “the deaths of despair,” tracking the landscape of the mortality from alcohol, drugs and suicides, correlated with the forces of economic and social disruption, have not yet been discussed publicly by the Task Force.

In the last year, ConvergenceRI has reported extensively on Monnat’s work, in particular, her research findings that 59.8 percent of all deaths between 2010 and 2014 in Rhode Island for white adults, male and female, between the ages of 25 and 34, were caused by alcohol, suicide and drugs, the highest rate of such deaths in the nation.

ConvergenceRI also sponsored a talk by Monnat on Oct. 27 at Rhode Island College, “The Landscapes of Despair,” which included Holly Cekala, Sen. Josh Miller and Traci Green as members of a response panel.

And, on Nov.13, ConvergenceRI published an op-ed by Monnat, “We can’t treat our way out of this.”

Yet, Brandon Marshall, associate professor of Epidemiology at the Brown University School of Public Health, one of the epidemiologists working on data analysis for the Task Force, told ConvergenceRI last week that he was unfamiliar with the work of Monnat.

Why was that? Why aren’t the folks at the Department of Heath and BHDDH or members of the Brown School of Public Health faculty sharing ConvergenceRI with members of the Task Force? Are the walls of the academic silo around data that impervious to sharing research and analysis?

Good fences may make good neighbors, but silos don’t make for good, evidenced-based public health strategies.

A community OD engagement response plan
On Tuesday afternoon, Dec. 12, the day before the last Task Force meeting of the year, the Department of Health and BHDDH will be hosting the first-ever Rhode Island Community Overdose Engagement summit, or CODE, advertised as a guide to developing individual municipal overdose response plans, organized around the four pillars of the Task Force action plan: prevention, rescue, treatment, and recovery.

Each municipality will be given a modest $5,000 grant to assist in developing their individual community OD engagement plans, a potential $195,000 investment if all 39 cities and towns in the state decided to participate.

Surprisingly, in the planning document, no mention was made of the effort now underway to create community-based health equity zones in 10 Rhode Island communities, led by the R.I. Department of Health.

Which was somewhat strange, given the three-year investment in methodology and community engagement strategies – or the fact that some health equity zones have identified substance use and preventing drug overdose deaths as a top community priority and developed their own plans of action.

Will those HEZ action plans be shared at the summit? Good question.

The divergence, ConvergenceRI realized, was that the HEZ initiative is focused on developing health interventions that are community-based, not clinical health care interventions that are health system-based.

Translated, the response to the crisis of substance use and addiction, [first made a top public health priority in 2012 by Dr. Michael Fine when he was director of the R.I. Department of Health], has evolved into a sophisticated strategy of clinical intervention and triage.

The current strategy includes: greater access to naloxone, on the street and in pharmacies; improved emergency room protocols for treatment and reporting of overdoses; increased access to medication assisted treatment, better monitoring of prescription painkillers and limits placed on the amount of painkillers prescribed; peer recovery coaches placed in emergency rooms [and paid for by a clinical model of insurance reimbursement]; expanded insurance coverage for treatment without pre-authorization, and a system of Rhode Island Centers of Excellence for treatment of opioid use disorders.

All considered credible, evidence-based interventions, according to many experts.

However, some recovery community activists have described the juggernaut of the clinical approach as the “medical industrial complex,” where the Big Pharma companies are profiting from the growing demand for naloxone and medication-assisted treatment drugs such as suboxone and naltrexone to combat the epidemic caused in part by the marketing of addictive prescription painkillers.

What has yet to be unveiled, even though it was one of the expanded actions under the July 12 executive order signed by Gov. Gina Raimondo, to be developed by November [it is now December], is a comprehensive harm reduction strategy.

Is there such a strategy in the works? Who is responsible for developing it? Will it include the idea of safe injection sites, which public health officials in Seattle are now developing, calling them Community Health Engagement Locations, with a focus on moving active users into treatment and recovery?

A second opinion?
Recently, Rhode Island was featured in the taped broadcast on Dec. 6 of “Second Opinion,” a public television show covering medical issues, sponsored by the national Blue Cross Blue Shield Association.

The topic was “Overdose: Inside the Epidemic,” which is scheduled to be broadcast by RI PBS in January of 2018.

The program featured: Dr. Gus Manocchia, senior vice president and chief medical officer at Blue Cross and Blue Shield of Rhode Island; Dr. James McDonald, with the R.I. Department of Health; Anita Jacobson, a pharmacist and a clinical associate professor at the University of Rhode Island;, and Deb Dettor, the director of Anchor Recovery Community Center, a program of The Providence Center.

Here’s what was said, according to the Twitter feed of Gail Carvelli, the communications director at Blue Cross and Blue Shield of Rhode Island:

Manocchia: “Addiction is a chronic illness. The value of a primary care physician being involved is critical.”

“If you look at BCBSRI data, over the past three years, we have seen a 7 percent decrease year over year of opioid prescriptions.”

Jacobson: “We need a lot of education around medication management therapy and confront the stigma.”

“Within five days of exposure to an opioid, someone could develop a dependency.”

“We need to change the language. How we refer to people.”

Dettor: “We all need to understand and believe in the recovery process. Represent the truth. Learn about it.”

McDonald: “This is an issue that requires all to be involved. We need to talk about it like it is a normal disease.”

All good points. All worthwhile invocations about what needs to be done. But no one is yet talking about the diseases of despair in Rhode Island, connecting deaths from suicide, alcohol and drugs, and the way that such deaths are ravaging young adults. Why not?

Editor's note: A new initiative, Providence Safe Stations, is scheduled to be announced Monday morning, Dec. 11, according to a media advisory sent out by Mayor Jorge Elorza's office late Sunday evening. The Safe Stations are being billed as a place where "opiod dependent individuals can connect with treatment and recovery services in Providence. How many Safe Stations will be created, who will be responsible for managing them onsite, and whether they will distibute fentanyl testing strips are not yet known. ConvergenceRI did send the questions to Emily Crowell, Elorza's media contact, but no answers have yet been received.


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