PROVIDENCE – In early July, when ConvergenceRI interviewed Neil Steinberg, the president and CEO of The Rhode Island Foundation, one of the questions posed to Steinberg, who described himself as an avid reader of the newsletter, was: What should I be covering better? What should I be doing differently? What would you like to read more about?

Steinberg responded: “One of the things that I like best are the questions you ask in your sidebar, The Questions That Need To Be Asked. It has great value. Many times there are questions that I have never thought about, so I like that.”

Steinberg continued: “I like your focus and expertise and in-depth approach. What do I want to see? What I can’t see anywhere else. I’m not looking for a watchdog; I’m looking for smart questions and observations and analysis, more depth than I can find in other places.”

Then Steinberg suggested: You ask such good questions, but have any of them been answered? What are the answers? I’d like to see that.”

Thanks, Neil. In response, ConvergenceRI is inaugurating a new feature, to appear on a regular basis, “Answers To The Questions That Needed To Be Asked.”

ConvergenceRI: What happened to the vanished 2016 legislative commission approved by the R.I. House of Representatives studying lead contamination in drinking water?
ANSWER: The commission, officially known as the “Special Legislative To Study The Presence and Treatment of Lead in Drinking Water in the State of Rhode Island,” will reconvene this fall under the leadership of Deputy Majority Leader Mia Ackerman, according to House spokesman Larry Berman.

Further, the commission will now be expanded to have nine members, one more than the original eight. The commission is charged with making a report to the House of Representatives on or before Jan. 2, 2018.

The initial commission had been approved on June 16, 2016, with then Rep. Eileen Naughton serving as the chair. After she was defeated in a primary challenge, the commission went in a prolonged slumber.

An initial draft process document prepared by Naughton in August of 2016 offered the following suggested framework for the approach to be taken by the commission:

• Defining the problem: How does lead get into our kids and where does it come from?
a.] How much of the problem is the result of lead in water?
b.] How much is a result of lead from paint in old, poorly maintained housing?
c.] How much comes from soil contaminated from leaded gasoline?
d.] Are there any other significant sources of lead poisoning?

Context: The answers to these questions are going to vary by neighborhood and community.

Context: Before you can address “gaps” in primary lead prevention, you need to look at existing data, because the problem of lead poisoning is more complex than just looking at lead pipes that carry water.

• Analyzing the initial data set: What do we know, what don’t we know, what do we need to know?
a.] What is the geographic distribution of lead poisoning?
b.] Where is school performance most affected by lead poisoning?
c.] What do we know about kids and childhood lead poisoning, from the existing data?
d.] What are the gaps in the data, and who can fill in those gaps?
e.] What do we need to know that we don’t have data on?
f.] How much data is there available on lead and water – from health department inspections, from water companies, from property owners, and from rental housing, regulated by Housing Resources Commission?
g.] Where do we go if the current data set doesn’t tell us what we need to know?

• Once having identified the sources of lead that are poisoning kids, and which communities are at the greatest risk, how does that interface with primary prevention?
a.] What are the policy gaps in preventing and reducing exposure to lead?
b.] What are the existing strategies for reducing exposure of lead in kids? In water, from paint, or from soil?
c.] Which have the potential for becoming more effective: how do we invest out resources to have the greatest impact, to have the biggest return on investment?
d.] Acknowledge that there are going to be a significant group of children who have been poisoned, and what do we need to do for them, such as nutritional intervention and enriched early childcare. Also, can we do a better job of expanding available resources offered to those families who have been exposed?
e.] Identify what are the funding streams of resources that can be leveraged

The broad scope of the proposed framework for the legislative commission developed in 2016 may or may not inform the newly revitalized commission and its work, but it does offer a starting point from where such a discussion could begin.

There have been a series of news stories reporting on potential lead contamination of drinking water in Rhode Island during the past year [but yet outside of ConvergenceRI, none have mentioned the dormant commission].

The reborn commission now has the opportunity to provide some answers in identifying and clarifying how much lead is actually in Rhode Island’s drinking water, where the contamination is coming from, and how much it will cost to fix it – and, in doing so, put those numbers in the context of other sources of lead contamination that are occurring and threatening children in Rhode Island.

Nearly 1,000 children a year are newly poisoned by lead for the first time in Rhode Island, according to the R.I. Department of Health and, with that exposure, creating the potential of damaging lifelong mental impairments. Yet, as part of the recent budget debate, nearly $600,000 in the Governor’s proposed budget to support childhood lead poisoning prevention efforts and better enforcement was stripped out during negotiations. [See link to ConvergenceRI story below, “Short changing kids.”]

What appears to be missing from the conversation around childhood lead poisoning and where it comes from is its connection to consequences and additional costs to the Rhode Island taxpayer from the potential lifetime of brain disability and impairment: the barriers to reading at a third-grade level, the increases in delinquency and violent behaviors in adolescence, the extra resources devoted to special education needs, and the diminished workforce capabilities.

More questions that need to be asked: When will research by Brown economist Anna Aizer on the impacts of childhood lead poisoning in adolescence directly tied to school suspensions, delinquency and incarceration in Rhode Island become part of the economic equation and legislative discussion in preventing lead poisoning?

As the state continues to re-evaluate the population housed at the R.I. Training School, is there a need to quantify the number of adolescents at the facility who may have been victims of childhood lead poisoning, using de-identified data?

ConvergenceRI: 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?
ANSWER: It is not clear why harm reduction strategies have not emerged as a top priority, but apparently it reflects major philosophical differences within the Raimondo administration team around the benefits of harm reduction and whether or not it may encourage drug use, according to sources.

One of the 20 items in the new executive order signed by Gov. Gina Raimondo on July 12 did call upon the R.I. Department of Health and the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals to propose a comprehensive harm reduction strategy for intravenous drug users “to decrease the risk of overdose, infection and assault” by November. But exactly how and when that strategy gets discussed in public by the task force has not yet been publicly disseminated.

The earliest that it could be expected to become part of the monthly task force agenda is at its Oct. 11 meeting.

What is meant by harm reduction? It includes the creation of safe injection sites, and the ability for active users to test their product to determine if it contains fentanyl, by distributing fentanyl testing strips along with Narcan.

One idea that Monica Smith, the executive director of RICARES, a recovery community advocacy group, has suggested that Rhode Island explore is whether to create a safe space for illicit drug users to test for the presence of fentanyl, similar to the pilot program to test illicit drugs at Vancouver, British Columbia’s supervised-injection site.

Vancouver Coastal Health began offering its clients fentanyl test strips in July of 2016, enabling them to find out, within a minute, whether there is fentanyl in the drug they are about to inject. As a result, clients are 25 times less likely to overdose, according to Mark Lysyshyn, a medical health office with Vancouver Coastal Health.

As Dr. Leana Wen, the Baltimore Health Commissioner, recently tweeted, “With safe injection sites, needle exchanges, and fentanyl testing, the point is to save lives, not to encourage drug use.”

By the numbers
When Raimondo created the Governor’s Task Force on Overdose Prevention and Intervention in May of 2016, the overarching goal of the task force was to reduce the number of overdose deaths in Rhode Island by one-third in three years’ time. At that time, the total number of overdose deaths in Rhode Island was tabulated as 258 in 2015, which would have meant reducing the death toll from ODs by 86, to 172 deaths, by 2019.

However, the shape of the drug overdose epidemic changed dramatically with the increased presence of fentanyl in the illicit drug supply, which is now found to be a contributing factor in half of all drug ODs, according to the R.I. Department of Health.

In 2016, the number of overdose deaths climbed to 336, and the official number of deaths from ODs in 2015 was revised upward to 290 because of what were said to be errors in calculation.

Where do the number of ODs stand today? According to the most recent statistics provided by the R.I. Department of Health, which are acknowledged to be three months behind in determining official causes of suspected deaths from ODs, during the first four months of 2017, there were 111 deaths from drug overdoses, compared with 115 deaths from drug overdoses in 2016, an apparent rate of reduction of one death per month.

While any reduction in the number of deaths is certainly welcome news, if that pace were to be sustained, it would take another four years – through 2020 – just to reach the plateau of the revised death toll from ODs in 2015 – 290.

The rate of reduction in overdose deaths, at the current rate, based upon the first four months of 2017, if sustained for the entirety of 2017, would be 3.6 percent. In contrast, the provision of fentanyl testing strips in Vancouver, British Columbia, resulted in a 25 percent drop in those likely to OD.

Stigma and resistance
While the goal is to save lives and find solutions to the epidemic of opioid addiction that is afflicting Rhode Island and the nation, tabulating the number of deaths does not necessarily tell the whole story.

On the national level, the indecision by President Donald Trump about whether there was a national emergency or not, changing his mind, echoing a mindset that the problem was simply a matter of telling kids that drugs were bad [while, at the same time, having his Attorney General Jeff Sessions plan to ramp up penalties for drug use], appeared to demonstrate a fundamental lack of understanding of the dimensions of the epidemic.

There was also been an apparent “skewing” of coverage in the local news media, in ConvergenceRI's opinion.

At its Aug. 9 meeting, members of the Task Force discussed recent numbers tracking the response by patients who had overdosed and been treated at hospital emergency rooms in the state – and the willingness of survivors to speak to a peer recovery coach.

The numbers for the first six months of 2017, as reported by the R.I. Department of Health under its regulations that require health professionals and hospitals to report overdoses within 48 hours, showed that a total of 757 overdoses were reported.

The demographics of those 757 reported ODs showed that the largest number were in the 25-34 age group, totaling 37.5 percent, or some 284 adults.

[These findings appear to correlate with the research by sociologist Shannon Monnat, who, using statistics from the Centers for Disease Control and Prevention, found that the leading cause of death for that age group in 2010-2014 in Rhode Island was from drugs, alcohol and suicide, what Monnat has termed the “diseases of despair,” with deaths from those causes amounting to 59.8 percent of all deaths, a rate that led the nation.]

The numbers reported also showed that 496 of the 757 reported overdose patients were discharged. Naloxone dispensed 40 percent of the time onsite at the emergency department at discharge; 17 percent of the patients refused, and 8.5 percent of the patients received a prescription for naloxone. [Some 29 percent of the time naloxone was not offered at discharge.]

In addition, the numbers reported also showed whether the patients who had been treated for an overdose were willing to talk with a peer recovering coach; some 45 percent refused, while 37 percent received onsite peer coach counseling. [No onsite peer counseling was offered to 8 percent of the patients.]

However, The Providence Journal, in reporting on the task force meeting, chose to focus in on what the reporter labeled a “distressing” statistic: “A peer counseling program in Rhode Island that has become a national model for its hospital-bed outreach to drug overdose survivors is up against a distressing statistic. Nearly half of all patients hospitalized in Rhode Island for drug overdoses – 45 percent – refused to speak with a recovery coach…” the story began.

Within the body of the story, however, numerous recovery community advocates and health professionals appeared to debunk the story’s slant that the rate of refusal by overdose patients for peer counseling was surprising or distressing.

Rather, it was symptomatic of the chronic disease of addiction. As George O’Toole, manager of the peer counseling program known as AnchorEd, told the reporter, he was not surprised by the 45 percent referral rate; he expected that it might be even higher. “A lot of people that come into the emergency room are so embarrassed and ashamed, they want to get out of there and don’t want to deal with it,” he said.

Jonathan Goyer told the reporter in an email following the meeting that the high refusal rate might be attributed to problems with the language and lack of empathy exhibited by hospital staff.

[What was not covered at all by the reporter was a detailed, comprehensive presentation by the Health Equity Zone in West Warwick, regarding the local implementation of the task force’s overdose prevention action plan, made at the meeting.]

Messaging vs. outcomes
Harm reduction, diseases of despair, and corporate responsibility. Those are three phrases missing from the news coverage and the conversation around the opioid epidemic in Rhode Island.

When Gov. Raimondo spoke at the National Governors Association meeting in July, neither she nor any of her fellow governors talked about “harm reduction” as a potential strategy to pursue, despite the meager results from the current strategies.

The messaging that Raimondo embraced at the gathering was that “all roads lead to treatment.” Of course, the larger question is whether or not treatment then leads to recovery.

A number of new strategies under the latest executive order signed by Raimondo that are to be commended: the creation of a family task force to involve families in the discussion around overdose prevention and intervention; the efforts to create a warning system to alert first responders and police when there is there is a surge in overdoses in particular regions in Rhode Island; and the ongoing efforts to embed mental health professionals with police in several Rhode Island communities to provide expertise in dealing with potential overdose situations, a strategy that West Warwick has taken the lead on.

New legislation, championed by Sen. Josh Miller, passed by the R.I. General Assembly and recently signed by Raimondo, have also added some new tools to the toolbox to aid in the treatment of addiction as a disease.

However, there are some big missing pieces of the puzzle: the failure to date in targeting corporate responsibility and liability as a major cause of the current epidemic.

Here in Rhode Island, in Cumberland, a division of Purdue Pharma, the major manufacturer of the prescription painkiller, Oxycontin, allegedly produces some 750 tons a year of the generic oxycodone, the key ingredient of the addictive painkiller.

Another question that needs to asked:
Will the R.I. Attorney General Peter Kilmartin, or his successor elected in 2018, be willing to investigate and to explore potential legal action against the Purdue Pharma division in Cumberland, seeking to recover the costs of public funds in Rhode Island spent on treating patients with substance use disorders caused by prescription painkillers?

When will the diseases of despair – deaths from drugs, alcohol and suicide – become the focus of a public conversation in Rhode Island?

One answer to that question is: ConvergenceRI is planning to bring Shannon Monnat to give a talk at Rhode Island College in late October.

ConvergenceRI: Which other drinking water sites are being investigated for potential toxic contamination from PFAs in Rhode Island?
ANSWER: Beyond the 35 drinking water systems in Rhode Island that serve more than 10,000 people being tested for a toxic chemical known as PFA, which has been linked to numerous serious health impacts, the R.I. Department of Health recently shared the list of 38 other sampling sites of potential drinking water contamination that are also being studied.

As readers of the story, “Diving into Toxic Stew,” may recall, the investigation is a collaborative effort between the Brown Superfund Research program and the R.I. Department of Health. [See link to ConvergenceRI story below.]

Many of the additional 38 sampling sites appear to be small water municipalities or sources that are dependent upon wells. They include:
• Abbey Lane Community Association, Inc., in Foster
• Ashaway Elementary School in Ashaway
• Wendy Berard, a day care provider in North Smithfield
• Bethel Village Water Association, a community water system in Hopkinton
• Briarwood Child Academy in Smithfield
• Canonchet Cliffs Water Association, Inc., a community water system in Hopkinton
• Charlestown Elementary School in Charlestown
• Chimera, Inc., in Narragansett
• Susan Chiovitti Daycare in Burrillville
• Clayville Elementary School in Scituate
• Crystal Spring Water Company in Middletown
• Cynthia Dubay, a day care provider in Hopkinton
• Empire Bottling Works in Bristol
• Exeter-West Greenwich Jr. and Sr. High School in West Greenwich
• Four Season Mobile Home Park Cooperative Association in Tiverton
• Glendale Water Association in Glendale
• Hebert Health Center in Smithfield
• Ladd Center Water System in Exeter
• Caroline Lapierre Daycare in Burrillville
• Laurel Crest-Pine Meadow Housing, in Chepachet
• Maplehill Mobile Home Park, Burrillville
• Metcalf Elementary School in Exeter
• Mobile Village, Inc. in Exeter
• Nasonville Water District in Harrisville
• New Era Enrichment Academy, Johnston
• Ninigret Realty in Charelstown
• Oakland Association, Inc, in Burrillville
• Phoenix House of New England, Exeter
• Quonochontaug East Beach Water Association, Westerly
• Roch’s Fresh Foods Facility, West Greenwich
• Scituate High School and Middle School, Scituate
• Shannock Water District, Richmond
• South County Community Action, Charlestown
• The Village on Chopmist Hill, Chepachet
• Trinity Lutheran Pre-School, Ashaway
• Wawaloam School in Exeter
• Yacht Club Bottling, North Providence

Among the potential adverse health impacts linked to the toxic chemical, according to the initial news release from the R.I. Department of Health, include: developmental effects to fetuses during pregnancy or to breastfed infants, cancer, and effects to the liver, immune system or thyroid.

According to a story published in The New York Times Magazine in January of 2016, scientists researching potential connections between PFOA and detrimental health impacts found there was a “probable link” between PFOA and kidney cancer, testicular cancer, thyroid disease, high cholesterol, pre-eclampsia and ulcerative colitis, according to Rich’s story.

In 2017, New Hampshire state epidemiologist Dr. Benjamin Chan alleged that there was a “probable link” between PFOA and serious illness, including “high cholesterol, thyroid disease, ulcerative colitis, testicular and kidney cancers, and pregnancy-induced hypertension,” according to a WMUR news story.

In a study published in Obesity in November of 2015 by Joseph Braun, a research epidemiologist at Brown University’s School of Public Health, a study of 204 Cincinnati mothers and their children that looked at the potential effects of perfluorooctanoic acid, or PFOA, a toxic industrial chemical used in the manufacture of products such as nonstick coatings, was that relatively high exposure with pregnant mothers resulted in a statistically significant association with the amount and pace of body fat gain in children during the first eight years of life.

Braun’s study added to a growing body of evidence that man-made chemicals such as PFOA may trigger obesity, with the chemical passing from the pregnant mother to her child. Excess body fat in children may increase the risk of Type 2 diabetes later in life.


Connecting the findings to the incidence of diseases
Another epidemiological approach to the potential prevalence of the toxic chemical PFA in drinking water in Rhode Island would be to look at the whether higher incidences of such contamination correlates with the prevalence of particular diseases in Rhode Island residents.

It may prove to be a difficult equation to correlate, given the toxic stew that has accumulated in Rhode Island’s ecosytem. Still, hospital records around the incidence of things such as kidney cancer, testicular cancer, thyroid disease and ulcerative colitis could provide some fascinating data interconnections.

More questions to be asked
Saint-Gobain Performance Plastics operates a manufacturing facility at 386 Metacom Ave. in Bristol. [The company also operates facilities in Worcester and Taunton, Mass.] The firm has been allegedly implicated in toxic contamination of drinking water supplies from PFOAs in Hoosick Falls, N.Y., and in North Bennington, Vt., as well as in Litchfield, N.H. What are the current measurements, if any, that may exist for potential PFOA contamination in Bristol? What are the epidemiological results, if any, that may exist for the kinds of adverse health impacts associated with PFOA contamination for Bristol residents?

Glioblastoma, the aggressive form of brain cancer that Sen. John McCain was recently diagnosed with, has a very high rate of incidence in Rhode Island. What epidemiological studies have been conducted, if any, about the potential correlation of exposure to toxic chemical contamination with the incidence of glioblastoma in Rhode Island?