Mind and Body

Embracing a strategy to reduce harm and save lives

To help protect drug users from the dangers of fentanyl, a test strip is being deployed in a coordinated outreach campaign in Rhode Island

Image courtesy of R.I. Department of Health

Some 1,000 free fentanyl test strips as well as naloxone will be distributed on Aug. 31 at events in Providence, Newport and Central Falls commemorating Overdose Awareness Day.

By Richard Asinof
Posted 8/27/18
The widespread distribution of 1,000 fentanyl test strips in Rhode Island on Friday, Aug. 31, is the first statewide effort in the nation embracing this harm reduction strategy. The next steps include creating a way to capture data from the deployment of these test strips.
Will RICARES host a forum for gubernatorial candidates following the Sept. 12 primaries? Will the candidates be willing to participate in such a forum? Why has the news media failed to cover the distribution of fentanyl test strips to occur on Aug. 31? When will the diseases of despair become part of the ongoing public conversation at the Task Force meetings? When will yoga become a reimbursable service by health insurers for those in recovery? How much of the Medicaid dollars spent on primary care can be tracked to the cost of treating substance use disorders and behavioral health conditions?
Educators in Rhode Island recently held a conversation about how to address chronic absenteeism. Missing from the discussion, it appears, judging from the reporting by The Providence Journal, was the connection between chronic absenteeism and the incidence of asthma, although the data has been known, collected and published for years. Further missing from the conversation was the connection between environmental factors and unsafe housing conditions, which often serve as the triggers for asthma.
Similarly, there are ongoing concerted efforts to improve third-grade reading levels in Rhode Island, but the connection to detrimental impacts from childhood lead poisoning never seem to become part of the conversation.
Translated, if you want to improve chronic absenteeism in schools, improve reading scores, and reduce the incidence of asthma in school-age children, the best policy may be to invest in the creation of healthy, safe, affordable housing for families.
With the new $11.5 million academic research center on Opioids and Overdose, the opportunity exists to break down existing silos and include ground-breaking neuroscience research being conducted here in Rhode Island about how toxic stress disrupts and changes brain patterns of signaling in young infants, including genomic changes that may not be able to be remediated by nurturing efforts, and the connection to substance use disorders.
Comparative databases to consider building would connect the incidences of sexual assault and childhood sexual abuse to substance use disorders and the incidences of childhood lead poisoning to substance use disorders.
When cholera afflicted London in the early 1800s, the tendency was to attribute the problem to bad air, or miasmata, until the problem was pinpointed to a sewage-contaminated well. Similarly, the cause of puerperal fever, which became rampant in the 1700s, killing thousands of women in Europe, was caused mostly by male doctors attending women in childbirth who did not wash their hands.

PROVIDENCE – The first widespread distribution of 1,000 fentanyl test strips in Rhode Island will occur this week, on Friday, Aug. 31, as part of observances planned for International Overdose Awareness Day in Newport, Providence and Woonsocket, coordinated by more than a dozen community recovery groups and agencies.

Free distribution of fentanyl test strips and naloxone will occur at the following locations:

9 a.m. to noon in Burnside Park in Providence, featuring a drum circle;

12 p.m. to 4 p.m. at Art in the Park at Eisenhower Park in Newport; and

1 p.m. to 4 p.m. at 55 Cummings Way and 800 Clinton St. in Woonsocket.

Additional outreach and distribution points include: downtown Central Falls, downtown Pawtucket, and at Elmwood, Broad and Cranston streets in Providence.

The initiative first coalesced as a result of an ad hoc conversation by community recovery advocates and then received support from state agencies.

The distribution of the 1,000 fentanyl test strips, purchased with funding from the R.I. Department of Health and the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, represents what appears to be the first statewide effort in the U.S. to use this harm reduction strategy to prevent and intervene with the plague of drug overdoses, which claimed the lives of 323 Rhode Islanders in 2017.

The distribution of fentanyl test strips is now legal in Rhode Island, under the jurisdiction of new law enacted by the R.I. General Assembly during its 2018 session and signed into law by Gov. Gina Raimondo, which amended the provisions of the Good Samaritan Law.

The biggest push for the new law came from advocacy by community recovery groups, supported by a number of legislators, including Rep. Aaron Regunberg and Sen. Josh Miller, among others.

While there is no political argument about the evidence of the devastation being caused by fentanyl – in 2017 it was involved in roughly 70 percent of all drug overdose deaths in Rhode Island, there was a bitter and protracted political battle this spring over Kristen’s Law, a drug homicide bill championed by R.I. Attorney General Peter Kilmartin as a deterrent, which was sponsored by R.I. House Speaker Nicholas Mattiello.

The new law, which provides for up-to-life sentences for drug dealers in fatal overdoses – and which was also enacted by the legislature and signed into law by Raimondo – was bitterly opposed by many in the recovery community and by medical professionals, who called it a return to the policies of past failed drug wars.

In the long run, which approach will prove more effective as a deterrent in saving lives – access to fentanyl test strips or punishing drug dealers with life sentences – offers perhaps a provocative public health research project for budding scholars at the School of Public Health at Brown University to pursue, contrasting the cost, efficacy and outcomes of stark differences in two policy choices.

Consumer protection
Many “consumers” of illicit drugs, including opioids such as heroin, cocaine, and methamphetamines, have had no way of knowing if they were using drugs laced with fentanyl – until now. They were dependent upon what the dealers told them, not a trustworthy source.

The fentanyl test strips, which cost about $1, can now provide “consumers” with the means to identify the presence of fentanyl in very small amounts, information that carries with it the potential of saving lives, changing behaviors, and limiting the power of drug dealers.

Along with increased naloxone distribution, the fentanyl test strips are seen as an innovative part of a proposed coordinated harm reduction strategy in Rhode Island, which is now under discussion as part of a working group of the Governor’s Task Force on Overdose Prevention and Intervention, and which is scheduled to be part of the conversation at the next Task Force meeting on Wednesday, Sept. 12.

Data collection
One thing missing from the initial distribution of the first 1,000 fentanyl test strips is a way to track the results of how the test strips are being used: there is apparently coding that can be applied to the strips to record the results, according to recovery community advocates. [The process to apply the coding takes about eight to 10 weeks to do so, according to recovery community advocates, making it impossible to be done in time for the Aug. 31 events.]

The de-identified data could provide the time and location for the use of the fentanyl test strip, the results, and what was the source of distribution of the test strip, all of which can then be compiled into a database, according to several recovery community advocates. The use of the coding applied to the fentanyl test strips requires self-reporting.

There are now ongoing conversations about applying those codes to a second batch of some 3,000 fentanyl test strips that are being purchased for further distribution in Rhode Island.

Tracking naloxone
The questions about how best to track results for the distribution of fentanyl test strips has also raised issues about the gaps in tracking the use of naloxone – unless it is administered at a hospital emergency room or by emergency responders, there is no accurate way of knowing how and when naloxone is being used by consumers.

If the coding can be applied to fentanyl test strips, one community advocate asked rhetorically in a conversation with ConvergenceRI, why can’t it also be applied to naloxone supplies? Good question.

The data collection coding mechanism essentially requires a degree of self-reporting by a consumer population that does not necessarily have great faith and trust in the clinical establishment or in law enforcement.

Lack of coverage
Not surprisingly, the planned distribution of the 1,000 fentanyl tests has been missing in action from most news coverage: it was not mentioned in any of the reporting about the $11.8 million federal grant to create a new virtual research Center of Biomedical Research Excellence on Opioids and Overdose at Rhode Island Hospital, in partnership with Brown University and Women & Infants Hospital. [Was this the new academic research center “hinted” at in the MOU signed by Partners Healthcare, Brown and Care New England?]

The two principal investigators for the new COBRE are Dr. Jody Rich and epidemiologist Traci Green [who had been part of a study about the efficacy of various fentanyl testing devices published in March], both of whom are consultants with the Governor’s Task Force on Overdose Prevention and Intervention.

The COBRE proposal had been submitted more than a year and a half ago, according to one of the participants in writing the grant. One of the principal efforts will be to fund new researchers’ work to develop and support research aimed at better understanding the science of opioid addiction to facilitate treatment and prevention.

“The goal of the center is to bring basic scientists, bring geneticists, bring ethnographers, bring anthropologists, bring pharmacists, bring physicians to really understand the science and really drive the best research that can address this epidemic as quickly as possible,” Rich said, according to a news report by RIPR.

What is unclear is how the new research center will integrate the work of sociologists such as Shannon Monnat at Syracuse University and address what Monnat has described as the diseases of despair, linking mortality from alcohol, suicide and drugs to issues of economic disparities, looking at the demographic age group of young adults between the ages of 25-34.

Also missing from the initial descriptions of the intended research was the connections to ongoing neuroscience research into toxic stress in infants and how it may rewire the brain and create genomic changes. A recent effort to create screening guidelines for pediatricians in Rhode Island for toxic stress was apparently abandoned when concerns were raised about the lack of interventions available.

Similarly, the distribution of fentanyl test strips was not mentioned in the recent story in Politico Magazine, “How the Smallest State is Defeating America’s Biggest Addiction Crisis,” by reporter Erick Trickey, which focused on the medication assisted treatment program introduced into the Rhode Island’s correctional system in the summer of 2016. Why not?

Do all roads lead to treatment and recovery?
One of the conundrums of the opioid epidemic in Rhode Island and the nation has been the difficulties in transitioning those with substance use disorders into long-term treatment and recovery programs.

Some of the barriers include the cost of co-pays for medication-assisted treatment, according to comments made at the most recent Task Force meetings in August, in response to presentations by health insurers and pharmacies.

Another is the long-term nature of recovery itself: as Dr. H. Westley Clark described it in an interview, “Recovery as an Organizing Concept,” published by the Great Lakes Addiction Technology Transfer Center: “The chronic disease model recognizes that there is no acute solution. You break your leg, you put a cast on it; it heals, and you go on with an otherwise unchanged life. You don’t have a problem – unless, of course, you’re into extreme sports.”

But if you’ve got asthma, Clark continued, “You’re going to have asthma off and on for a while. If you’ve got diabetes, your diabetes is going to require different management strategies over a prolonged period of time, if not for the rest of your life. Some strategies are just diet and careful monitoring of what you eat. Other strategies include oral pills. Another strategy is insulin.”

These are different strategies, Clark concluded, “But they all require a fervent effort. Like long-term management of any other chronic disease, the substance use disorder recovery management strategy offers a framework for sustaining and actively managing recovery over a lifetime.”

A third barrier is the resistance by many to entering treatment and recovery, despite awareness of their problems. Recent data compiled by the Substance Abuse and Mental Health Services Administration showed that some 73 percent of the people who meet criteria for needing treatment for drugs perceived no need for treatment; similarly, according to SAMHSA data, 88 percent of the people who meet criteria for needing treatment for alcohol perceived no need for treatment.

Why the denial? Some, such as Clark, suggest that it is not just the individual but also the community that needs to enter into recovery, embracing that recovery is about building a full, meaningful and productive life in the community, centered around connectedness.

Moving forward, the Task Force and the new COBRE on Opioids and Overdose should consider creating a database that tracks the numbers of Rhode Islanders in treatment and recovery, versus the number of residents who self-report that they have problems with drugs and alcohol, as perhaps a better metric than counting the number of people who have died from drug overdoses.


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