Mind and Body

Is RI ready to talk turkey about safe injection sites?

This Thanksgiving, advocates are putting pressure on Gov. Raimondo to create harm reduction centers in Rhode Island by executive order, in order to combat soaring drug OD deaths – a solution “avoided” for more than four years by her administration

Image courtesy of digital image from the Norman Rockwell Museum

The "freedom from want" oil painting by Norman Rockwell, depicting a Thanksgiving dinner in 1941, illustrating one of President Franklin D. Roosevelt's "Four Freedoms."

By Richard Asinof
Posted 11/23/20
Will the reality of more than 400 deaths from drug overdoses in Rhode Island in 2020 force the Raimondo administration to move to create safe injection sites in the state?
What is the legal position of the R.I. Attorney General Peter Neronha on the establishment of safe injection sites? Will the leadership at the R.I. General Assembly move forcefully to create the legal framework to support such facilities? When will the deaths of despair become a renewed focus of the statewide health planning initiative of the Rhode Island Foundation? Will the emerging progressive caucus at the State House adopt safe injection sites as a lobbying priority? What kind of new investments will legislators be willing to make to support nursing homes and essential health care workers caring for the state's most vulnerable older residents in an austerity budget?
A New York Times story, published on Nov. 20, posed the question: “Why COVID caused suffering in Italy’s wealthiest region?” The answer: “The catastrophe in Italy’s most affluent region was in part a consequence of having entrusted much of the public health care system to private, profit-making companies while failing to coordinate their services. Over the previous quarter-century, substantial investment has flowed into lucrative specialties like cardiac surgery and oncology. Areas on the front lines of the pandemic, like family medicine and public health, have been neglected, leaving people excessively reliant on hospitals for care.”
Or, according to a subscriber who sent the story to ConvergenceRI, “What good is universal insurance when the delivery system is still motivated by greed and hubris?”
Rhode Island will soon confront the need to establish accountability for what went wrong with the way the state’s health care delivery system responded to the COVID pandemic, particularly in light of the proposed merger of Lifespan, Care New England, and Brown University into a huge new enterprise.
Take nothing away from the courage and heroism of the front line health care workers confronting the pandemic; they deserve great praise. But the fundamental flaws in the unsustainable business model for health care delivery still persist – and the investments in public health infrastructure remain a scant priority within an austerity state budget.
The larger question, of course, is how do we have a conversation about disrupting the status quo? Further, the promises of the Rhode Island Transformation Project, which includes the Reinvention of Medicaid and the development of Accountable Entities for managed Medicaid populations, has produced more questions than answers. Will there any appetite for accountability?

PROVIDENCE – At Thanksgiving, conversations at the dinner table are often muted to deflect ongoing family disputes, in deference to preserving an illusion of family harmony. Yes, all big families are unhappy in their own ways, as Tolstoy once observed. Not this year; we are all unhappy together. Maybe we need to talk candidly about what is happening to us, confront the truths, and not be deterred by any swift, angry kicks under the table.

This Thanksgiving, the coronavirus plague is raging across Rhode Island, the nation, and the world. Families are being urged not to travel by the Centers for Disease Control and Prevention, though many will ignore that urgent public health advice. Hospitals and health care workers are being overwhelmed by surging numbers of new cases, new hospitalizations, and rising deaths. Yet, amazingly, the proven benefits of wearing a mask in public are still being debated. How many deaths will it take ‘til we know that too many people have died?

A defeated, sulking President Trump is still refusing to concede, while his lawyers are spouting outlandish conspiracy theories. Trump’s personal attorney, Rudy Guiliani, is getting paid $20,000 an hour, but the dripping hair dye running down his cheeks under the bright lights at a recent news conference belied his clown makeup.

All bets are off – despite the news that Twin Rivers and Sinclair Broadcasting are launching a new sports betting enterprise. Did you hear about how supervisors at the Tyson Foods pork processing plant in Waterloo, Iowa, placed bets on how many workers would catch the virus, after keeping the facility open in April, according to a wrongful death suit? More than 1,000 employees eventually tested positive. Money doesn’t talk, it swears, to quote another Bob Dylan lyric.

Safe injection sites
For more than four years, the urgent need to create safe injection sites in Rhode Island to save lives and combat the opioid epidemic has festered beneath the surface as a “hidden” public policy option dogging the Raimondo administration.

The more that fentanyl has contaminated the illicit drug supply, becoming the largest factor to the higher death tolls, the more that clean, safe injection sites, supervised by health professionals,  have emerged as the best solution to save lives.

Now, with the state’s efforts to control the drug overdose epidemic flailing and failing. The number of OD deaths projected to top 400 in 2020, a 25 percent increase from the previous high of 336 in 2016, a tipping point may have been reached.

An open letter is circulating to try to force Gov. Gina Raimondo to create safe injection sites [now being called “harm reduction centers”] in Rhode Island by an emergency order in Rhode Island. [See link below to the letter and its signatories.]

“Each month at the Governor’s Overdose [Prevention and Intervention] Task Force meetings, we hear additional, devastating data about new lives lost due to fatal overdose,” the letter read, in a Twitter post by Annajane Yolken.

“What we are all doing has not been enough: we are exhausted by the constant news of another fatal overdose, tired of grieving yet another life lost, when each one of these deaths could have been prevented through proactive action,” the letter continued. “We cannot expect any different result if we do not implement new strategies; rather, we must be innovative. Rhode Islanders’ lives depend on this.”

The letter makes the case by saying that more than 90 safe injection sites are currently operating across Europe, Australia, and Canada, and that no one has ever died of an overdose at any of these sites. 

Specifically, the letter calls on the Governor to “authorize the creation of an overdose prevention pilot program via an executive order that includes a variety of potential operational models [brick and mortar facility, mobile facilities, and outreach teams] available across overdose hotspots in our state within the next year. These can be done with the collaboration of the R.I. Department of Health and a consenting municipality.”

Is a change going to come?
The strategy of an emergency executive order does not resolve potential legal issues around creation of safe injection sites, which may need the R.I. General Assembly to act to create the necessary legal framework, as they did to allow the distribution of fentanyl testing strips two years ago.

But positive signs of a sea change in public perception could be found in a recent 12 Town Hall on Facebook, hosted by WPRI news anchor Kim Kalunian on Thursday, Nov. 19.

The forum featured the avuncular Dr. Jim McDonald, medical director at the R.I. Department of Health, who is now co-hosting his own public health podcast, and Dennis Bailer, overdose prevention project director at Project WEBER/Renew, promoting the value of safe injection sites.

Of course, when it came to the way that the show’s content was promoted and being messaged, the discussion about safe injection sites was nowhere to be found in the printed content accompanying the broadcast. The “lede was buried,” in the parlance of practitioners in the new biz.

Uncovering the back story
The back story to the new push for safe injection sites has been the apparent “willful” refusal by the Raimondo administration to address the need to create safe injection sites as a harm reduction strategy to save the lives of hundreds of Rhode Islanders, despite advocacy from physicians’ groups, community recovery groups, legislators, and public health researchers.

Efforts to create a policy approach favoring safe injection sites were apparently stonewalled by Ryan Erickson, a policy advisor to Gov. Raimondo, in his role as the convener of the Harm Reduction Working Group of the Governor’s Task Force on Overdose Prevention and Intervention, so much so that a separate harm reduction working group began meeting in 2018, convened by the Rhode Island Medical Society and other recovery community advocates. [Erickson was recently “rewarded” for his efforts by being hired in August as the Director of Strategy and Public Affairs at the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals, with a boost in salary.]

For years, Rhode Island has championed its “innovative” programs to fight back against the ravages of the opioid epidemic, with the public relations machine promoting Gov. Raimondo’s efforts on this policy front working overtime.

Yet, despite all the promising initiatives – the creation of the Governor’s Task Force on Overdose Prevention and Intervention, the development and launch of BH/Link, the Safe Stations initiative, the promotion of peer recovery as a critical strategy to be deployed in emergency rooms, the creation of an academic COBRE Center of Excellence on Opioids, the purchase and distribution of Narcan and fentanyl testing strips, the outreach collaborations with law enforcement, the push for a workplace recovery initiative, and the increase in substance use medication treatment alternatives – the yearly death toll from ODs since 2016 has never fallen below 300 lives lost each year.

At the heart of this failure are flawed public policies:

• The failure to develop an integrated approach around the deaths of despair, including alcohol, suicide, drugs, and gun violence related to domestic violence, tied to economic disruption. No integrated database exists for the deaths of despair in Rhode Island. [You can read the book by Anne Case and Angus Deacon, Deaths of Despair and the Future of Capitalism, or review the research of sociologist Shannon Monnat for the details.]

• Alcohol use disorders remain the untreated wild card in the effort around ODs. Alcohol intoxication remains a leading indicator identified in emergency medical transports to hospitals in Rhode Island. Community recovery advocates have told ConvergenceRI that alcohol is a co-morbidity in some 80 percent of all overdoses in Rhode Island. The pilot diversion program in Providence begun in 2016 was shut down after a year, because the population being served could not be transitioned to Medicaid.

• The poor reimbursement rates from health insurers for mental health and behavioral health services have proven to be one of the biggest stumbling blocks to providing services, as documented in testimony before Sen. Joshua Miller’s commission on health insurance reimbursement policies in Rhode Island. Such services remain one of the biggest unmet needs in the state, marked by huge inequities for persons of color. The R.I. Attorney General’s Office has yet to investigate whether such apparent inequity in reimbursements violates Rhode Island law.

Now that the coronavirus pandemic has disrupted the entire health care delivery system in Rhode Island, threatening to undermine and cause the collapse of the existing hospital infrastructure, the question is: Will the Raimondo administration move to create safe injection sites to save lives in Rhode Island?

More than 1,300 Rhode Islanders have perished from COVID-19 in the last seven months. More than 400 Rhode Islanders are projected to die from overdoses in 2020. According to Dr. McDonald, there is even a phrase to describe the collision of the virus pandemic with the opioid epidemic -- a syndemic, or a synergistic epidemic.

More than a clever phrase or a new podcast, what is needed urgently in Rhode Island is a new public policy to save lives – a network of safe injection sites, in ConvergenceRI's opinion.

Dr. Ashish Jha, the dean of the School of Public Health at Brown University, in his keynote talk at the Rhode Island Public Health Association annual meeting two weeks ago, framed the question around harm reduction as a a public health ethos.

“The entire ethos of public health is we need to meet people where they are, and we need to help people move to a better place,” Jha said. “It is the whole ethos of harm reduction.”

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