Mind and Body/Opinion

If nothing changes, nothing changes

OD deaths are at all-time high in RI: What is wrong with the current 2021 Governor’s Overdose Prevention and Intervention Task Force Strategic Plan, and what are the ways to fix it

Photo by Richard Asinof

Ian Knowles, third from left, at the June 2018 opening of the Jim Gillen Teen Center, posing with the extended family of RICARES, including Monica Smith, Michelle McKenzie, and Abbie Stenberg

By Ian Knowles and Roxxanne Newman
Posted 3/7/21
The rising number of OD deaths from drugs in Rhode Island reveals a disliked truth about Gov. Raimondo’s Task Force of Drug Overdose Prevention and Intervention: despite all the positive trends and metrics, the deaths keep rising. The disconnect that exists between the performance indicators and outcomes is glaring. A most recent strategic plan fails to address the needed changes in strategy.
When will there be an integrated database made public and published by the state that connects the deaths of despair – from drugs, from alcohol, from suicide, and from gun violence related to domestic violence, connected to economic conditions? What is the connection between unmet mental health and behavioral health needs for children and adults in the state and extremely low health insurance plan premiums? When will the R.I. General Assembly commission an audit of all the private contractors, including managed care organizations, providing services under contract with the R.I. Medicaid office? Will Gov. McKee add someone to his executive team, similar to the role that Tom Coderre played with Gov. Raimondo, who can serve as an active advocate for the recovery community? What are the current statistics for EMS dispatches to hospitals for the indication of alcohol intoxication? Will Gov. McKee, unlike former Gov. Raimondo, have the courage to push through legislation to create a harm reduction center in the state as a way to save lives?
Upon her swearing in as the new Commerce Secretary in the Biden administration, former Gov. Raimondo positioned herself as a “doer” – as someone who gets things done. To buttress her reputation, her staff prepared a document detailing all the accomplishments of her time in office.
Unfortunately, many of the signature programs initiated by Raimondo in her six years in office never achieved what they were set out to do. As detailed in Ian Knowles’ story, the Governor’s Task Force on Overdose Prevention and Intervention, after five years, never has achieved its principal goal: lowering the number of overdose deaths. Instead, the number of OD deaths is at an all-time record high. There may have been many good reasons for this failure
In a similar vein, the Reinvention of Medicaid and its creation of accountable entities, what one physician described as “giving clusterf*** a bad name,” did little if anything to improve the quality of care but instead proved to be a big money maker for private managed care organizations and business consultants.
The high death toll in Rhode Island nursing homes from the coronavirus can be linked directly to the policy failures of UHIP, which undercut the financial stability of skilled nursing facilities in the state, which resulted in low wages being paid to employees. However, Deloitte got its big contract renewed and no lawsuit was filed against the firm for its shortcomings.
The heavily polluted policy river that runs through all these programs follows a familiar course: high-priced corporate business consultants were asked to redesign strategic policy decisions around the delivery of health and human services, under the illusion that such initiatives would reap reduced costs, labor savings, and alleged higher quality care. The delivery of services is then transferred to for-profit entities, with no accountability. [The Raimondo legacy continues with the mess around efforts to dismantle delivery of health care at the Eleanor Slater Hospital and its Zambarano unit.]

PROVIDENCE – In 2015, Gov. Gina Raimondo established the Governor’s Task Force on Overdose Prevention and Intervention. The accompanying five-year strategic plan, “Rhode Island’s Plan on Addiction and Overdose: Four Strategies to Alter the Course of an Epidemic,” with four distinct policy ‘pillars’: rescue, prevention, treatment, and recovery.

The ambitious strategic goal of the Task Force was to reduce opioid deaths by one-third within three years. Translated, that would mean reducing the total number of OD deaths from 239 that had occurred in 2014 to about 160 in 2018.

It proved to be an optimistic yet unreachable policy goal; in 2016, the number of overdose deaths in Rhode Island soared to 336.

In response, an updated Task Force strategic plan was presented in December of 2018. The core principles were sound; the goals were informed and ambitious, most Task Force members agreed.

The total number of OD deaths in 2018 were 314, a lower amount from the high of 336 OD deaths in 2016 – but still far removed from the original policy goal of 160 OD deaths hoped for in the initial strategic plan.

Out of control
In the past five years, beginning in 2016, the annual number of OD deaths has never fallen below 300, but there have been small reductions achieved in the total number of OD deaths per year.

Those reductions had been reflected in the monthly totals in the data organized by the R.I. Department of Health on its website: Only twice since 2014, the data showed, had there been two consecutive months of 30 or more fatalities – in May/June 2016 and in May/June 2018.

However, in December of 2019, the trend shifted dramatically; there began to be an unprecedented number of consecutive monthly fatalities [some three months before the first case of COVID-19 was diagnosed in Rhode Island].

Thirty or more people died in the consecutive months from December 2019 through May 2020. In July of 2020, 40 people died; in August of 2020, 38 people died. In comparison, the previous monthly high fatality total had been 35, in February of 2016.

The number of overdose deaths in 2020 is now at least 374, but the data is incomplete for the month of December. The fatality rate from 2019 to 2020 increased by at least 21 percent, from 308 to 374 – with the probability that it will go higher.

Shocking results
This new development is shocking, because our state’s collective efforts to address opioid overdose deaths had resulted in an overall three-year decreased mortality rate of 8 percent, from 336 deaths in 2016 to 308 deaths in 2019.

It is shocking because we have developed a better infrastructure to deal with the issue, compared to many states. The Governor’s Task Force has implemented the recommendations of the federal Centers for Disease Control and Prevention as well as a range of other innovations. The Task Force has had the willingness and the flexibility to make adjustments and adaptations as the situation has evolved.

We have built a robust opioid use disorder treatment system as well as established recovery community centers in every county. We have utilized some significant harm reduction strategies, such as consistent statewide Naloxone and fentanyl test kit distribution – and the decades-old syringe exchange program, efforts often led by recovery community peer programs.

The Task Force has engaged in five years of meaningful positive activities. The intensity of commitment of the Task Force members has been steady and could be said to have even increased.

But the slight positive change in overdose deaths trends has now dissipated. The bad news is that the accidental overdose death epidemic has never been worse.

Strategic plan update in 2021
In January, the Task Force released the ‘Strategic Plan Update, outlining strategies and actions for the next year, through December of 2021.

The update is comprehensive and informed. There are research findings, quantitative and qualitative analyses, core recommendations, short-term recommendations, and priority recommendations.[See link below to the strategic plan.]

The update said: “Performance trends are generally strong and stable, but deaths are historically high,” and emphasizes the accomplishment of “stable, strong performance metrics across all pillars.”

Yes, the trends and metrics are positive. But the disconnect between the performance indicators and the outcomes is so glaring that they seem almost irrelevant.

Our response has been visceral. It feels horrible to present these impersonal numbers. The deaths represent people that we’ve known since they were kids, people that we have worked and played with, children of our colleagues and friends, immediate and extended family members. Every loss of life was that of a valuable and unique person. Every loss of life has resulted in pain and heartbreak for family and friends.

As Roxxanne Newman wrote in a recent Medium piece: “It’s been five years, and my loved ones, friends, family, and my people are still dying.”

Newman continued, voicing her frustration: “A short while ago, I attended [virtually] our statewide Governor’s Overdose Task Force meeting. Most states around here have these Task Forces in place, and in Rhode Island, we have a good-sized crowd that shows up every month [on the second Wednesday of each month]. During the meeting, someone said something along the lines of ‘despite the overwhelming increase in overdose deaths in the past year, the state was doing a good job in terms of overdose prevention.’”

Newman reacted: “I could not believe my ears. People are dying; and yet, there was a sense of achievement and success in this meeting. I almost spit my coffee out all over my keyboard, un-muted myself, and laughed out loud. Rhode Island is failing when it comes to overdose prevention, and the rise in the overdose death toll is the evidence.”

The high cost of failure
The outcomes are frustratingly inconsonant with the expended thought, expertise, and effort of the Task Force and the community. We see the evidence every day that we are failing. Why?

There are four obvious specific drivers:

• The wide-ranging effects of the COVID convergence. As Natalia Derevyanny, spokeswoman for the medical examiner’s office in Cook County, Ill., said recently: “One epidemic began, but the other one never stopped.” We are faced with a dilemma of contradictory requirements – recovery requires personal connections; COVID prevention requires isolation.

• The accelerated introduction of fentanyl into the illicit drug supply. The reality is that the present societal strategies are very limited in their ability to address the market forces driving the distribution of fentanyl and its analogues.

• The surge in the death rate among Black Americans due to health and social inequities that are perpetuated by structural racism.

• The complex interaction with the economy. Research has established strong links between stagnating economies and increases in drug overdoses [also suicides and alcoholic liver disease]. Research indicates significant correlations between unemployment, mental health conditions, and substance use disorders.

The structural context continues to be daunting. We are all aware of the multiple social determinants that are associated with the chronic medical conditions that result in overdose deaths. We are all aware of the wide scope of racial inequities that are reflected in those social structures most associated with the overall addiction epidemic – the health care system and the criminal justice system.

We all understand the range of increasing divisions in our nation and our state, such as between the wealthy and the working poor, and between cities and rural communities. We understand that the transformation of our fragmented and disjointed community systems is beyond the present scope of the Governor’s Task Force.

So, we continue to triage and address only the symptoms that are generated from the bio-psychosocial roots of addiction. This is necessary but not sufficient.

Beyond triage
We have to consider that we are at the ceiling of the strategic plan’s current treatment, rescue, prevention and recovery strategies.

Roxxanne Newman provides us with a starting point: “Don’t get me wrong, we have made progress. Medications used to treat opioid addiction are making big changes in people’s lives. But people have to be alive to get medication in the first place. This is where the state is failing us.”

Newman continued: “According to Gov. Raimondo’s own words, as written in the state’s Overdose Task Force Action Plan: ‘We must DEMAND and make SWIFT change to address this crisis and promote treatment, prevention, and recovery. We have a single focus in this work: SAVE LIVES [emphasis added].’ I don’t know about you, but when I think of the word swift, I do not think of it taking five years, with the fifth year being the worst year for overdose deaths in the state’s history.”

In Newman’s opinion, drastic measures are required: “So, why aren’t we making any progress? My lived experience has taught me that drastic times call for drastic measures. The general public and state officials do not embrace the actions that will save lives and improve treatment and recovery outcomes. These ideas might appear to be radical and may not make sense to some, but we know that they save lives and improve the lives of people in recovery.”

Five years, without any meaningful change
To reiterate: despite five years of meaningful positive initiatives and activities, there has not been any meaningful change. The late Jim Gillen, an inspiration to so many of us in the recovery community, often said, with a wry smile: “If nothing changes, nothing changes.”

We understand change. Our recovery experience has taught us that radical change is required for meaningful, actually transformative recovery.

In that spirit of change, we again urge swift actions that have been ignored or only perfunctorily addressed in the latest Task Force Strategic Plan.

1. The overriding issue continues to be the criminalization of drug use. This de-legitimatized and ineffective policy simply creates a low ceiling for success for all our efforts. For example, a new emphasis in the updated Strategic Plan is a focus to address stigma. But stigma elimination efforts are severely limited when we’re trying to de-stigmatize a criminal activity.

2. The Strategic Plan attempts to elevate the concept of harm reduction. The most concrete recommendation was to add “Harm Reduction” to the Rescue Pillar title. The report ignored other specific and suggested strategies.

We urge:

• The most effective harm reduction strategy is to de-criminalize drug possession [note: Rhode Island decriminalized marijuana in 2013 and the sky did not fall]. The recommendation in the latest iteration of the Strategic Plan, which says: “Rhode Island should find ways to separate services for people who use drugs from the criminal justice system,” is simply inadequate.

• A report recommendation is to “review the feasibility [including impacts of federal law and potential need for legislative action] of a pilot overdose prevention site that would provide a broad range of drug user health services.”

The efficacy of such sites is well established and does not need review. In fact, legislation for a Harm Reduction Center [aka overdose prevention site] has been introduced and passed by the R.I. Senate twice, but stalled in the recalcitrant R.I. House. In December, hundreds of informed, professional organizations and individuals asked the Governor to establish an overdose prevention pilot program. The Governor’s response: she lacked the authority to do so.

3. The immediate passage of three legislative initiatives:

• A Second Chance bill that would make the simple possession of drugs a misdemeanor instead of a felony.

• A needed tightening of the Good Samaritan law. There are still gaps in the law and still actions by some police officers that discourage people from calling 911 in an overdose emergency.

• Pass and sign the bill to authorize the creation of a Harm Reduction Center [defined in the proposed bill as a “community-based resource”] for health screening, disease prevention and recovery assistance where persons may safely consume pre-obtained controlled substances.

4. The state’s opioid treatment system is robust. However, there remain significant barriers to engagement in medication-assisted treatment that the report did not choose to address. These include, but are not limited to: health care system distrust; prior negative treatment experience; fear of negative consequences as the result of engagement in treatment and/or harm reduction services; excessive regulations; and the continued lack of health insurance parity for all behavioral health disorders.

• In addition to those oft-cited barriers to treatment initiation and continuation, there is a significant patient population that has tried but not responded to treatment with one or more of the FDA-approved medications. A successful strategy for that set of patients used in other countries is maintenance with safe supply medications, e.g., diacetylmorphine or hydromorphone.

Dr. Nora Volkow, director, National Institute on Drug Abuse, recently said: “There is an urgent need for development of alternative medications and new models of care to expand capabilities for personalized interventions.”

We are not any closer to a cure for addiction than we are for any other chronic medical condition. Our substance use disorder treatment model has not significantly changed since the mid 1900s. The societal negative perception of people with addictions has diminished slightly but has not changed significantly.

Without meaningful change, we will simply continue the reactive management of our series of drug epidemics [opium in the 1800s, alcohol in the early 20th century, cocaine in the 1980s, opioids in the 2000s] into the future. And our friends, colleagues, and family members will continue to die.

If nothing changes, nothing changes…

Ian Knowles, the program director at RICARES, is a frequent contributor to ConvergenceRI. Roxxanne Newman is a research assistant at the Brown School of Public Health

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