Mind and Body

Billions and billions of pain pills delivered, at what cost?

Meanwhile, the leader of Portugal’s efforts to decriminalize drugs makes grand rounds in Rhode Island to pitch a public health approach

Photo by Richard Asinof

Dr. Joao Goulao, the general director of the Portugal Directorate for Intervention on Addictive Behaviors and Dependencies in the Ministry of Health.

By Richard Asinof
Posted 1/20/20
The director of Portugal’s program to decriminalize drug use visited Rhode Island to spread the gospel about that country’s approach, at the same time new evidence emerged about the fact that more than 100 billion doses of addictive prescription painkillers were pushed on Americans between 2006 and 2014.
Will the Rhode Island medical establishment and the Brown medical school be forceful in leading the charge to change the use of pain as a fifth vital sign? Why did the recent data analysis on emergency room overdoses leave out alcohol intoxication? Is Rhode Island ready to endorse the use of safe injection sites, following the lead of Philadelphia? Will the R.I. General Assembly [and perhaps the R.I. Attorney General] address the inequities and lack of parity in Medicaid reimbursement rates for mental health and behavioral health services? Is there a way to better integrate nurses into the strategy to deliver comprehensive substance use disorder services in Rhode Island? What is the correlation between substance use disorders by parents and children in protective custody of DCYF?
The Anchor Recovery Community Center, a division of The Providence Center under Care New England, may finally have a new home, at 310 Reservoir Ave. in Providence. For more than a year, Anchor has been sharing cramped space at the Jim Gillen Teen Recovery Center on North Main Street in Providence after being forced to move from their downtown Pawtucket offices. The move to the Reservoir Avenue location is still months away, but it is a positive development in efforts to support recovery efforts in the community.

PROVIDENCE – It is an inconvenient but brutal truth in understanding the history of the deadly path of a recurring tornado that swept across the nation during the last two decades: more than 100 billion highly addictive prescription painkillers were distributed in the U.S. in nine years, from 2006 through 2014.

“Newly disclosed federal drug data showed that more than 100 billion doses of oxycodone and hydrodocone were shipped nationwide between 2006 and 2014, 24 billion doses of highly addictive pain pills than previously known to the public,” reporters Steven Rich, Scott Higham and Sari Horwitz wrote in The Washington Post story published on the Jan. 14, 2020.

The newly released data, which traces the path of pills from manufacturers and distributors to pharmacies across the country, confirmed again that six companies distributed the vast majority of the pain pills, according to The Washington Post story. They included: CVS, Walgreens, McKesson and Cardinal.

Translated, pushing addictive prescription painkillers was no secret. Everyone knew what was going on: the government, the Drug Enforcement Agency, the drug manufacturers, the pharmacies, and the distributors, even the doctors. The data on the total number of painkiller does came the government’s own tracking system. Everyone was in the loop – save for the patients. Why was that?

Now, the blame game about who was responsible for what’s known as the “opioid epidemic” is being played out in lawsuits in courtrooms across the U.S. Was it the manufacturers such as Purdue Pharma, who misled doctors about the addictive nature of their pain pills? Was it the distributors and pharmacies that flooded states such as West Virginia with 66.8 pain pills per person per year? Was it caused, as many of the companies involved have asserted, by over-prescribing doctors – and by customers who abused the drugs?

No one, really, disputes the high cost of death, the destruction of families, the disruption of the social fabric, the lost productivity in the workplace, the soaring health costs associated with addiction, recovery and treatment – and how the epidemic has reshaped the future of the American dream, as the deaths of despair, from alcohol, suicide and drugs, tied to economic conditions, have decreased life expectancy in the U.S.

As much as the billions and billions of addictive prescription painkillers pushed onto patients proved to be a critical gateway, the “opioid epidemic” has morphed beyond pain pills and heroin to fentanyl, which has proven to be the leading cause of death in most of the more than 300 annual overdose deaths in Rhode Island during the last few years. There has also been a documented resurgence in the use of cocaine and methamphetamines, often laced with fentanyl.

What is now being argued in the courtroom in the lawsuits and counter-lawsuits are the formulas for calculating the liability for the damages done – who gets to pay, and how much. Call it bare-knuckle politics when corporate health care and the law collide.

Course corrections?
One constant element in the ongoing tragedy, little talked about, is the way measuring pain as the fifth vital sign continues to be deployed by every practicing physician in the U.S. Why is that? What would be a better question to ask patients? Great questions.

The basic mechanics of brain receptors, if that is the right phrase, show that prescription painkillers interrupt the circuitry. And, when the receptors are no longer being fed the painkiller, it triggers reactions in the brain circuitry that result in withdrawal symptoms, cravings and pain that is often much more intense and magnified than the original source of the pain.

The most recent TV ad blitz targeting Rhode Island, a series of four ads targeting people between the ages of 24-35, warn about the dangers of addiction that can begin with prescription painkillers, repeating the premise that “opioid dependence can happen in just five days.”

The launch of the new campaign, developed by the Truth Initiative, an organization that features Gov. Gina Raimondo as a board member, was announced on Wednesday, Jan. 8, at the monthly meeting of the Governor’s Task Force on Overdose Prevention and Intervention, and covered prominently in the news media.

The new campaign seems to put the onus of blame on the young adult patient, not the subscribing doctor, in highly manipulative fashion to “know the truth.”

[When asked about the accuracy of that claim that “opioid dependence can happen in just five days,” Dr. Josiah “Jody” Rich, co-director of the COBRE on Opiods and Overdose, who had cautioned against using that data point in a previous series of ads produced by the Truth Initiative, told ConvergenceRI in a phone conversation that he liked the new set of ads but, he added, that medically, the response to the addictive qualities of prescription painkillers known as opioids was related to what he called “tolerance,” which varies greatly by individual.]

Can you imagine an TV advertising campaign, instead, targeting doctors, asking them to change the way that they talk about pain with patients, to “know the truth” about the problems with asking patients to describe their pain on a scale from 1 to 10, at the beginning of most clinical visits? Good question.

Grand rounds in Rhode Island
Against the backdrop of “knowing the truth” about the billions upon billions of addictive prescription painkillers that flooded the U.S. between 2006 and 2014, the leader of Portugal’s efforts to combat drug addiction by making it a matter of public health visited Rhode Island recently.

During the first full week in January, Dr. Joao Goulao, the general director of the Portugal Directorate for Intervention on Addictive Behaviors and Dependencies in the Ministry of Health, made what could be termed the “grand rounds” in Rhode Island, invited by the COBRE on Opiods and Overdose, as a kind of expanded medical education engagement, promoting Portugal’s approach.

Goulao appeared in a number of settings: in a lecture at the COBRE on Opioids and Overdose at 70 Ship St. in Providence on Monday afternoon, Jan. 6; before the Governor’s Task Force on Overdose Prevention and Intervention on Wednesday morning, Jan. 8; delivering an address in the library at the State House on Thursday, Jan. 9, even having a private meeting with R.I. Speaker of the House Nicholas Mattiello, to talk about Portugal’s approach to decriminalizing drugs and its potential adoption in Rhode Island.

Mattiello and Goulao agreed to disagree about whether Rhode Island would, could or should pursue a public health strategy of decriminalizing drugs, according to one source familiar with the meeting.

Unfortunately, for whatever reason, the details of the conversation between Mattiello and Goulao did not make it into the ongoing conversations about local politics, either on “A Lively Experiment” or in WPRI’s Ted Nesi’s Saturday column. Why is it that the head still seems to be disconnected from the body politick when discussing drugs?

The results in Portugal

In his presentation, Goulao traced the evolution of Portugal from having the highest prevalence of problematic drug use in Europe – at 1 percent of its 10 million population, mostly on heroin in the 1990s – to its adoption of a public health approach, what was called the “dissuasion” model through decriminalization, where “the drug addict is considered to be a person in need of health and social care.”

Goulao stressed the importance of setting an objective limit on illicit substances as part of the process of intervention. The basic premises of the intervention were that drug policies should be based on health and not on imprisonment.

The most striking results shared by Goulao in his presentation were the reductions in new admissions of IV drug use in the public network of outpatient services, which fell from 11 percent in 2010 to 3 percent in 2017. Readmitted patients fell from 27 percent in 2010 to 15 percent in 2017. And, all treatment entrants fell from 21 percent in 2010 to 8 percent in 2017.

Similarly, the number of new patients per year in the public network outpatient services, from a high of 9,991 when the program began in 1999, fell to 1,769 in 2017, reflected the efficacy of the strategy in reducing the number of patients.

One slide that gave some pause to members of the audience at the presentation at the COBRE on Opioids and Overdose were the details of the main substance used by new admissions between 2011 and 2017 in Portugal. While heroin fell from 51 percent in 2011 to 21 percent in 2017, cannabis soared from 26 percent in 2011 to 53 percent in 2017, while cocaine remained somewhat steady, going from 18 percent in 2011 to 21 percent in 2017.

The success of Portugal’s public health intervention, according to Goulao, as he explained in an interview with ConvergenceRI, was the ability to work in a collaborative fashion across political and social boundaries, with the police, health professionals and the church.

In response to a question about pushback the program had received, such as the church, Goulao said: “The church is an important ally. The national coordinator before me was a priest. He was very progressive and played a very important role in spreading this humane approach to the drug addiction problem.”

Goulao also said that the police and the right-wing populist parties, initially opposed to the program enacted in the Portuguese parliament, had become important supporters.

In the interview, prompted by a question from ConvergenceRI, Goulao also talked about the dominance of alcohol abuse as a drug of choice in Portugal, something not “featured” in the presentation. “We had more deaths caused by acute intoxication of alcohol than from opioids,” Goulao said.

One final observation: Leaving the interview, ConvergenceRI encountered Dr. Rich and Dr. Goulao on the sidewalk right outside 70 Ship St., where Goulao was smoking a cigarette. “You caught me,” he told ConvergenceRI. “This is my heroin,” he added, perhaps a poignant reminder of how easy it is become addicted to substances and how hard it is to stop using them, a testament to the fact that we all are human.

Here is the in-depth ConvergenceRI conducted with Dr. Joao Goulao on Monday, Jan. 6, following his presentation at the COBRE on Opioids and Overdose.

ConvergenceRI: In Rhode Island, there is an ongoing debate around harm reduction strategies. Harm reduction strategies appear to be an integral part of your entire effort in Portugal. Could you talk about how harm reduction fits into your overall strategy?
GOULAO:
Harm reduction is a crucial part of our policy. The first priority that we had to face with the heroin epidemic was to offer treatment to all those who needed it.

But then we noticed that we did not have the capacity to include everybody in need of treatment. We [also] noticed that there were a lot of people who were not responding to the treatment [opportunities].

We started [to engage] with those coming out of the treatment centers, meeting them where they lived. We started with street teams. We distributed the paraphernalia, the syringes…

ConvergenceRI: Clean needles?
GOULAO:
Yes

ConvergenceRI: And, did you provide also a space for people to use them?
GOULAO:
No, not in the beginning. Now, yes, we have safe injection sites. We just started. It was included in our harm reduction law in 2001, but the [ability] to provide safe injection sites [had to be] negotiated as an arrangement with the municipalities and the central government. For 20 years, we could not match those political wheels.

ConvergenceRI: Who participated on the outreach teams?
GOULAO:
Nurses, social workers, psychologists.

ConvergenceRI: Were there “peers” involved? One of the innovations that Rhode Island has been a leaderin is the development of a “peer recovery coaching” network. Do you also have a similar model, working with hospital emergency rooms?
GOULAO:
No. Not so elevated. We have peers as facilitators.

ConvergenceRI: In talking with advocates in the recovery community here in Rhode Island, they often make the point that the decision to change is often a very small window of time, it may be a fleeting moment. What are the strategies that you have found to work in Portugal to create those opportunities?
GOULAO:
The main thing is to never give up on people. If they refuse, you don’t disappear. Next week you will be there again. And you will explain the advantages to trying to change the lifestyle.

ConvergenceRI: So, there is a persistence to your efforts?
GOULAO:
Yes

ConvergenceRI: Have you found that there is a a difference between the needs of men and women in recovery, that women often have children, that the housing needs to be more secure, with daycare for their children?
GOULAO:
We have specific communities for women, for pregnant women, for women with little children. These communities must have nurseries included.

ConvergenceRI: What kinds of pushback have your gotten in Portugal to your efforts? For instance, has there been resistance from the Catholic church?
GOULAO:
The church is a important ally. The national coordinator before me was a priest. He was very progressive and he played a very important role in spreading this humane approach to the drug addiction problem.

ConvergenceRI: Was there pushback from political parties, such as from the right-wing populist movement?
GOULAO:
We have a clear division in the [Portuguese] parliament, when the debated about decriminalization happened. Some of the populist element was opposed.

But last year, during the session of the parliament, when we made the presentation of our annual report, 20 years later, the populist party, the most far-right party, now assumes it was a good decision.

[Editor’s Note: Instead of a one-on-one interview, as requested, ConvergenceRI was asked by Dr. Rich to be part of a roundtable discussion with folks who had attended the preceding lecture.]

Woman from Scotland: Scotland has not gone to full decriminalization, although the police are very hands off, we have needle exchanges, we have open access to national health services. But the problem has not changed; if anything, it has gotten worse.

I was wondering what you thought didn’t work in Scotland that did work in Portugal. Because we have had open access to treatment. Heroin has always been there; it’s never gone away. There have been more deaths last year than in the past 10 years.
GOULAO:
I don’t know. I had some visitors from Scotland, visiting our facilities.

Woman from Scotland: Are you facing a fentanyl problem?
GOULAO:
Not yet. We have had some seizures, packages intercepted by the police. But it’s not yet a big problem.

ConvergenceRI: One common denominator is alcohol. Is that correct?
Woman from Scotland:
It’s the number-one drug of choice in Scotland.

ConvergenceRI: As part of your efforts, where does alcohol fit into the continuum of drug use in Portugal? Here in the U.S., recovery advocates say that alcohol is a co-morbidity in roughly 80 percent of all overdoses.
GOULAO:
Alcohol is included in our treatment and harm reduction efforts. More recently, we have included gambling problems as part our system.

We promote medical interventions for alcohol in the same kind of facilities created for heroin. They have the same kind of personnel and attention. In talking about overdoses last year, we had more deaths caused by acute intoxication of alcohol than from opioids.

ConvergenceRI: Is that also true in Scotland?
WOMAN FROM SCOTLAND:
Absolutely. The number-one alcohol drink of choice is vodka; it’s cheap, easy to obtain, and is very potent.

ConvergenceRI: In terms of reducing stigma, the outgoing director of one of the agencies here in Rhode Island talked about how she did not like the word stigma, instead of addressing head on what she called people’s fears and prejudices. Do you agree?
GOULAO:
I think sometimes [when we] conceptualize something it tends to complicate them too much.

Accepting the other. Accepting that someone who is a problematic user of substances deserves my sympathy and my attempt to be present and deal with the difficulties. This is [part of the outreach] job on the street.

But I don’t wan to normalize the use of drugs. In our case, there is a clear sign of disapproval: you should not do this. You should not eat too much sugar, you should not smoke; OK.

That does not imply a punitive position. I work on educating, to inform [people] about the risks.

Since the law has passed, [drug use by adults] has gone up a little bit, with slight increases in total drug use, but the level of problematic use has decreased.

Woman from the Rhode Island School of Design: When things started to change to decriminalization, what was the relationship with law enforcement in Portugal?
GOULAO:
The decision to decriminalize drug use came from the parliament. At the time, the professionals from law enforcement were strongly against the idea. They were much in line with the positions of the far-right party that the new policy would lead to an increase in drug use.

Since then, step-by-step, they have become much more in favor of the policy. They noticed that their activity against drug trafficking was more efficient. They are not completely [aligned] with us. They are working much more collaboratively with us, with health professionals, and with drug users. Today, we have a very close relationship with police professionals.

[Portugal] is a strange county. In the 1980s and 1990s, I could not find support from the health professionals [to dispense] methadone to my patients. So, I went to the police and asked: Do you mind taking care of methadone distribution to patients?

For patients, it was a strange thing to go to a police person for your methadone. But it worked; it was possible.

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