Mind and Body

First, invest in reducing harm

A jarring comment at the close of the June 14 Governor’s Overdose Prevention and Intervention Task Force meeting challenged the way that strategies are being implemented, and whether they benefit the people seeking treatment and recovery

Photo by Richard Asinof

Gov. Gina Raimondo talks at the opening of the new Lifespan Recovery Center on June 19, as Dr. Timothy Babineau, president and CEO of Lifespan, listens attentively.

By Richard Asinof
Posted 6/26/17
Despite the best efforts of the Governor’s Task Force, people keep dying at an alarming rate in Rhode Island from overdose deaths. What has not yet made it onto the agenda of the Task Force and into the public conversation are harm reduction strategies to save lives. At the opening of the new Lifespan Recovery Center, the senior vice president of Psychiatry and Behavioral Health said that the only thing he knew about safe injection sites is what he had read in the newspaper.
Why are harm reduction strategies not at the top of the agenda of the Governor’s Task Force, if the goal is to save lives? How can the recovery community make its voice heard, both at the Task Force in devising strategy, and in the larger public conversation? Will R.I. Attorney General Peter Kilmartin be willing to explore potential legal action against the Purdue Pharma division in Cumberland, seeking to recover the costs of public funds spent on treating patients with substance use disorders caused by prescription painkillers? Will the U.S. Senate be able to muster 50 votes needed to pass the Republican version of Trumpcare to repeal and replace Obamacare, or will Republican Senators be willing to stand up and say no to Sen. Mitch McConnell?
As more and more evidence mounts about the links between the economic disenfranchisement and the disease of despair – deaths from alcohol, suicide and drugs, the question remains how to have a public conversation about the issues that does not feature clinical experts talking at the audience. Recent research looking at the numbers form the Centers for Disease Control and Prevention on the numbers of deaths from 2010 to 2014 found that for the demographic of young white adults, male and female, between the ages of 25-34, Rhode Island led the nation with the highest rate of deaths caused by suicide, alcohol and drugs, at 59.8 percent.

PROVIDENCE – Was it sardonic, spot on, or both? At the close of the June 14 meeting of the Governor’s Overdose Prevention and Intervention Task Force, numerous sources told ConvergenceRI, Jonathan Goyer stood up and said: If you’re going to OD, make sure you do it during 9 a.m. and 5 p.m. on weekdays, because services for treatment and recovery are hard to access on weekends.

For the last few years, Goyer has very much been a public face of the efforts to prevent overdose deaths and to promote recovery efforts, having survived an overdose and been revived by Narcan.

Goyer is one of the people featured in the advertising efforts around the messaging: addiction is a disease; recovery is possible. [See link to ConvergenceRI story below, “Revised action plan released to tackle overdose epidemic, spur recovery.”

Goyer’s comment, which closed the Task Force meeting without any further discussion, revealed what he saw as the difficulties in accessing treatment in a timely fashion in Rhode Island: there is a minimal waiting period of 48 hours to get an appointment, and residential treatment has about a three-week waiting list, according to Goyer.

Talk about honesty and courage. By standing up and saying what he did, when he did, Goyer punctured an illusion that the Governor’s Task Force’s strategic approach was working smoothly.

Goyer’s comment also shined a spotlight on a more fundamental challenge: how and when does the recovery community’s voice get heard as part of the deliberations of the Task Force, in particular when it comes to harm reduction strategies becoming part of the agenda?

Being heard
What Goyer had to say was not part of the scheduled agenda of the task force, according to Jenna Mackevich, communications coordinator with the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, in response to questions from ConvergenceRI. Rather, it occurred as part of the open public comment.

“The open comment period at the end of our Task Force meeting is vital because we’re able to hear this kind of critical feedback,” Mackevich said, in a positive reframe.

Goyer’s comments did result in an immediate reaction from Rebecca Boss, the director of BHDDH, who instructed her staff to convene a weekly call with detox managers to evaluate on an ongoing basis any issues that could arise related to access to treatment, according to Mackevich.

“They are specifically discussing the issue that Jonathan [Goyer] raised [about weekend access] to determine what gaps, if any, need to be filled,” Mackevich explained, in response to a question from ConvergenceRI.

Lost in translation
However, five days later, Goyer’s critical observation was not part of the conversation when the ribbon was cut on June 19 at the new Lifespan Recovery Center, which featured Gov. Gina Raimondo, Sen. Jack Reed, Rep. Jim Langevin and State Sen. Joshua Miller, among others.

After the formal ribbon cutting, ConvergenceRI spoke with Sen. Joshua Miller and Dr. Josiah “Jody” Rich, both members of the Task Force, to ask what they thought about Goyer’s comments. Did they see it as sardonic?

Miller and Rich disputed the idea that the comment should be termed “sardonic,” calling it “accurate” instead.

When ConvergenceRI asked Rich about how the Task Force planned to address harm reduction strategies, he demurred, saying ConvergenceRI should ask Traci Green instead.

Further explanation
ConvergenceRI reached out to Goyer, to get a further explanation of the context and meaning of what he said.

“We must capitalize on people’s willingness [to seek treatment] if we are to find our way out of this epidemic,” Goyer told ConvergenceRI.

Was it sardonic?

“Sardonic? I won’t argue that,” Goyer explained.

His comment, Goyer continued, was along the lines of commending the state for their treatment initiatives, expansion of services and the center of excellence.

“However, these services only operate on a typical Monday through Friday, 9 a.m.-to-5 p.m. model,” Goyer said. “The disease of addiction does not operate on a schedule, nor does someone’s window of willingness when asking for help.”

For example, let’s take medication-assisted treatment, Goyer explained. “Treatment facilities only initiate folks onto MAT during normal business hours [typically 35 hours a week],” he said. “There are actually 168 hours in every week. Mathematically speaking, we therefore only accommodate about 21 percent of the time. Most times, there is a minimal waiting period of 48 hours to get an appointment. Residential treatment has about a three-week waiting list.”

The problem, Goyer continued, is that the schedule of someone using drugs does not fit into the typical business workweek.

“People use opiates 24 hours a day; people decide to get help 24 hours a day. When someone reaches out for help, it’s our job to get help to them,” Goyer said. “They want to feel better now, to get help now. They don’t want an appointment for next week, or even an appointment the next day. In the waiting period, people’s addiction resurfaces and they lose interest.”

New recovery center messaging
The opening of Lifespan’s Recovery facility brought with it a common thread when it came to messaging from elected officials and medical experts: too many people were dying in Rhode Island and in the nation, with almost every speaker quoting the number of overdose deaths, 336 in Rhode Island in 2016, and with it, an admission that current strategies were not working.

Steven Pare, Providence’s Commissioner of Public Safety and a Lifespan board member: “There are too many people dying, over 300 last year, and it’s going to continue. It’s not working the way we’re doing it.”

In his speech, Pare cited the fact that Providence’s EMS had picked up one individual 250 times in one calendar year from the streets of Providence. Afterward, when questioned by ConvergenceRI, Pare clarified that the individual had problems with mental health and alcohol, not opioids.

Unmentioned in Pare’s speech was the fact that the new Lifespan Recovery Center was designed to deal with patients using drugs, not alcohol, according to Dr. Richard Goldberg, Lifespan’s senior vice president of Psychiatry and Behavioral Health.

Sen. Jack Reed: “This is an epidemic, it’s a scourge. Over 330 Rhode Islanders lost their lives last year. We just can’t sit back and do nothing. So I commend Lifespan for taking the lead on this effort.”

Reed called attention to the fact that the Republican Senate version of the Trumpcare to repeal and replace Obamacare promised to gut Medicaid, the primary source of accessing health care for mental health and recovery services.

Rep. Jim Langevin: “Rhode Island had 336 drug related deaths in 2016, 15 percent more than the previous year. It has to stop, and we have to do more to turn this around.”

Margaret Van Bree, president of Rhode Island Hospital: “[There were] 336 people who died in 2016 in Rhode Island. It is important to know, addiction doesn’t discriminate; it crosses all boundaries.

Van Bree said, on a personal note, that her nephew died two years ago from a heroin overdose.

Gov. Gina Raimondo: “The opioid overdose crisis is the greatest public health crisis that we face. We’re trying everything we can, but it isn’t working. I am more motivated than ever to work to [achieve] the goals that I set out, which is reducing the deaths by a third within three years.”

Moving in the wrong direction
When Raimondo made that pledge, in May of 2016, the number of confirmed OD deaths in Rhode Island for 2015, as tabulated by the R.I. Department of Health, was 258. A one-third reduction, a drop of 86 deaths, would have set the goal to achieve as 172 deaths by 2019.

Even though Raimondo said she was committed to achieving that promise, the numbers keep moving in the wrong direction. As almost every speaker noted, the number of overdose deaths in Rhode Island reached 336 in 2016, more than a 20 percent increase from the initial 258 figure.

In December of 2016, the number for 2015 deaths was revised upward to 290, for which 336 deaths in 2016 represented a 14 percent increase.

Why do the number of deaths keep increasing? The answer, also provided at the June 14 meeting of the Governor’s Task Force on Overdose Prevention and Intervention, in a presentation by Traci Green in her Multidisciplinary Review of Overdose Deaths Evaluation team report was clear: “Fentanyl continues to be a causal agent in the majority of unintentional drug overdose deaths [in Rhode Island].”

During the third and fourth quarters of 2016, Green continued, some “65.5 percent of unintentional drug overdoses were attributed to fentanyl [103 out of 157 deaths].”

As reported by ConvergenceRI: “That data reinforces two studies by Brown University researchers that were recently published in the International Journal of Drug Policy, that underscored the urgency of combating the misuse of fentanyl and contradicted a common perception that many users court the drug for its potency, according to an article written by David Orenstein for Brown University.

“Most people are not asking for it,” said Jennifer Carroll, the lead author of one of the studies and an adjunct assistant professor of medicine at the Warren Alpert Medical School of Brown University, according to Orenstein’s story. “They can’t avoid it, and their desire to avoid it is not reducing their risk, Carroll said.”

Harm reduction: not yet on the task force agenda
At that same June 14 Task Force meeting, Green presented nine new recommended changes in strategies, including two that specifically addressed harm reduction, one that recommended that the development of a safe injection site in Rhode Island be explored.

After the ribbon-cutting ceremony, ConvergenceRI asked Dr. Richard J. Goldberg, about harm reduction strategies, and if and when they would become part of the Lifespan approach at its new facility. In particular, whether Lifespan would become involved with a safe injection site or with providing access to fentanyl testing strips for users to determine if there was fentanyl in their “illicit” drugs.

In regard for testing for fentanyl, Goldberg said: “We don’t have that capability now, but that’s an interesting thought that we would have to discuss with our pharmacists.”

What about the potential for Lifespan to operate a safe injection site?
Goldberg responded: “I saw that in the paper. We don’t have that.”

Would you consider it as an outgrowth of this new facility?
Goldberg: “We would [need to] work with the city. More likely, in an analogy to sober housing, it’s a community resource, a public health resource. We might have input, and provide some medical liaison, but we’d be happy to work and [enter into] discussions with the city about that.”

Goldberg continued: “I was just reading about these safe injection sites. It makes sense. Some data will emerge to see what impact it is.”

Will alcohol treatment and detox be part of the program offered at this new center?
“We are not treating alcohol addiction here.”

The responses by Goldberg to potential harm reduction strategies, particularly the fact that he said he had read about safe injection sites in the paper, but apparently had not yet been engaged by the Governor, by members of the Task Force, or by the medical professionals about such strategies, identified a big gap in the current approaches that a number of trucks could roar through.

ConvergenceRI posed the question: Is the Task Force a place where harm reduction strategies in Rhode Island will ever be put on the agenda for a full-fledged public discussion?

BHDDH’s Mackevich responded: “I can say definitively that ‘harm reduction strategies’ is not an item on the agenda for July’s meeting of the Governor’s Task Force. The agendas for the meetings are created roughly two weeks in advance, so I cannot speak to what specifically will be on agendas for meetings after July. However, there is a public comment period at every Task Force meeting. This is an opportunity for community members to voice their opinions about what else we can be doing to prevent overdoses.”

The voice of the recovery community
On Monday, June 26, RICARES will release its report to the community, entitled: “The Opioid Accidental Overdose Epidemic.” The report also includes the results of a series of focus groups recently conducted with members of the recovery community.

The report is organized around asking and answering some direct questions: how did we get here, what is being done now, and what can be done, offering a series of recommendations.

The opening section, “How did we get here?” is a comprehensive, concise re-telling of the story of the roots of the epidemic as has been written.

Under the section, “What has been done?” the report provides, once again, a comprehensive overview of the actions on both the national and state levels.

Unlike many of the current narratives, the report gives credit to the work done by Dr. Michael Fine, who, as the director of the R.I. Department of Health, changed the state’s public health priorities in 2012 to begin to address the threat of overdose deaths.

Fine formed the Drug Overdose Prevention and Rescue Coalition, comprised of a wide range of more than 100 stakeholders, working in collaboration with Traci Green, establishing a number of workgroups, including: first responders, naloxone, treatment/recovery, and data/surveillance.

Fine’s work provided the foundation for the establishment of the Governor’s Overdose Prevention and Intervention Task Force in 2015.

Running out of words
In the introduction to the Recommendations section, the report begins with a poignant analysis: “We have about run out of words to describe how bad the situation is. Despite the power of intellect and experience applied in the last few years, despite the virtually unprecedented stakeholder collaborations, despite the progress toward and attainment of benchmarks of the strategic plan, and despite the fact that deaths caused by prescription drugs have leveled in the last few years: The number of deaths are increasing.”

In its recommendations, the report talks about the need to put more emphasis on recovery, including recovery housing, saying: “We view recovery as the most critical, but least emphasized, element of the Task Forces strategies. This is due in part to the relative dearth of recovery research. It is also due in part to the failure of those of us in recovery to adequately educate the public and policy makers about recovery.”

The report continued: “We know that, as with the other chronic medical conditions, [the effects of] treatment decay over time if not reinforced and enhanced by recovery management work. We know that recovery occurs in the community. We know that treatment can be the beginning of recovery for many, especially for those with opioid use disorders for whom treatment is necessary, but not sufficient.”

Focus group takeaways
In May and June, RICARES conducted three focus groups, one with seven patients in treatment at CODAC, a second with eight patients at SStarbirth, and a third with seven peer recovery specialists at the Parent Support Network.

The results, as published in the report, offer insights that the Task Force should consider putting on its future agenda.

Have you heard of the Governor’s Overdose Prevention Task Force?
Yes, 10; No, 12.

If yes, do you know any elements of the strategic plan?
No, 22

[If none of the members of the focus groups could identify any elements of the strategic plan, does it reveal a serious problem about whom the strategic plan is targeted to reach?]

What is your opinion about widely distributing fentanyl test strips?
Like, 19; Don’t like, 3.

What is your opinion about having safe, supervised injection sites?
Like, 17; Don’t Like, 4; Maybe, 1.

What is your opinion about having 24/7 on demand treatment?
Like, 22. Comments: “If I have to wait to get into treatment, then fuck it, I’ll get high. It’s a right-here, right-now thing.”

The results from the last question from the focus groups strongly supports what Jonathan Goyer had to say.

The question is: are the detox facilities and treatment centers in Rhode Island designed for the convenience of the medical professionals or around the needs of the patients struggling with substance use issues?

Pursuing legal recourse
We have an opioid epidemic engulfing our nation that has killed more Americans from overdose deaths in 2016 [more than 59,000] than during the entire Vietnam War [58,220], according to a recent analysis published by The New York Times.

The epidemic has been caused in large part by “greedy” corporate pushers of addictive prescription painkillers, in apparent collusion with doctors, pharmacies and health insurance companies, as has been documented in numerous investigative news reports in West Virginia and Florida, among others. [The story about what happened in West Virginia won the 2017 Pulitzer Prize.]

A number of states, such as Ohio, are pursuing legal recourse, suing the drug manufacturers for flooding the market with painkillers.

What could Rhode Island do? A division of Purdue Pharma in Cumberland, the manufacturer of OxyContin, produces some 750 tons a year of the generic of its prescription painkiller, oxycodone. Would the R.I. General Assembly consider taxing the company as a way to recoup the public monies spent on addiction prevention, intervention and recovery, in emergency rooms and in treatment centers, similar to what was done under the tobacco legislation?

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