PROVIDENCE – The opioid overdose epidemic is still the number one public health crisis in Rhode Island and the nation. It remains a confounding challenge to save lives and to help move those afflicted toward recovery, treatment and prevention, with no easy answers.

But, in the run up to the 2018 election campaign here in the Ocean State, media coverage and political crossfire on the issue has been somewhat quiescent if not muted.

[Yes, there have been some inaccurate, half-baked charges that Republican candidate Bob Flanders has thrown up in his race against Sen. Sheldon Whitehouse regarding sponsorship of federal legislation. The real culprit in the story “with blood on his hands,” it turns out, was not Whitehouse but a Republican congressman from Pennsylvania, Tom Marino, who was the prime mover of the legislation that limited the DEA’s ability to go after corporate opioid pill pushers, and who had been nominated in 2017 to become the drug czar under President Trump, until Marino was forced to withdraw following revelations about his role.]

One reason for the muted coverage is, perhaps, because under the leadership of Gov. Gina Raimondo, the work of the Governor’s Task Force on Overdose Prevention and Intervention has created a broad coalition of state agencies, community recovery advocates, public health researchers, legislative leaders, law enforcement, medical professionals, health insurers, pharmacies and families to develop strategies to combat the epidemic.

And, equally important, the Task Force has been able to make tweaks and changes to those strategies as the epidemic changes and morphs to deal with the increasing deadly presence of fentanyl in the illicit drug stream, and to promote a more inclusive, comprehensive approach to treatment and recovery.

It does not mean that it has been a smooth ride or that there haven’t been disagreements and heated discussions. But, in large part, everyone has been welcome to have a seat at the table and to participate in public discussions.

Translated, it would be difficult for Cranston Mayor Allan Fung, Rep. Patricia Morgan, Giovanni Feroce, Matt Brown or Joe Trillo to stand up and praise Raimondo for having done a good job.

Or, conversely, for the opposition candidates to make their own suggested policy improvements and proposals, considering that they all have been largely AWOL from discussions and conversations during the last few years.

A wealth of news not covered
Without any mayhem, murder, tragedy, fear and anxiety to exploit, once again, the Aug. 8 monthly meeting of the Governors Task Force on Overdose Prevention and Intervention provided a wealth of news that was not covered by the news media in Rhode Island.

Although it has not received a lot of public attention, the R.I. General Assembly approved legislation and Gov. Gina Raimondo signed it into law making the distribution of fentanyl test strips legal under the provisions of the Good Samaritan Act. [Among the legislative leaders championing the new law was Rep. Aaron Regunberg, who is running for the Democratic nomination for Lt. Governor.]

The potential importance of the fentanyl test strips as a tool of consumer protection to save lives, because the test strips can detect minute amounts of the deadly opioid in illicit drugs, was underscored by the most recent data for the Prevent Overdose RI website: in the first five months of 2018, fentanyl was involved in 87 of the confirmed 117 overdose deaths, more than 65 percent of all such deaths, according to the R.I. Department of Health data.

A study published recently in Harm Reduction Journal co-authored by Brandon Marshall, Traci Green and Dr. Josiah Rich found that there was a high willingness to use rapid fentanyl test strips among young adults who use drugs. Further, the most recent analysis of overdose death data for 2017 showed that the largest demographic for overdose deaths was for Rhode Islanders ages 25-34.

The first big push of fentanyl test strip distribution will occur on Friday, Aug. 31, as part of a statewide “Overdose Awareness Day,” with events penciled in for Providence, Newport, Woonsocket and perhaps Bristol, according to organizers, which include representatives from some 10 different groups.

To support the effort, the R.I. Department of Health and the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals have arranged to purchase 1,000 fentanyl test strips for distribution on Overdose Awareness Day. [The cost is roughly $1 per test strip, according to community advocates.]

At the events, community recovery advocates will be showing people how to use the fentanyl test strips as well as distributing naloxone. The fentanyl test strips are one part of the harm reduction strategy that will be discussed at the Sept. 12 meeting of the Task Force.

Constituency of consequence
The late Jim Gillen was famous – or was that infamous – for introducing candidates’ forums at the Anchor Community Recovery Center by saying: “I’m in long term recovery and I vote,” reflecting on the need of the recovery community to become what he termed “a constituency of consequence.”

In a development ConvergenceRI learned about at the Task Force meeting, to help realize that vision of a constituency of consequence, there will be a kickoff party and fundraiser for a new Substance Abuse Overdose Prevention PAC, on Thursday, Aug. 16, from 5:30 p.m. to 7 p.m., at Layali at 36 Weybosset St. in Providence.

The nonpartisan political action committee plans to endorse a slate of candidates across the political spectrum, according to Annajane Yolken, one of the organizers.

Health insurers, pharmacies join the conversation
As part of its ongoing effort to bring numerous folks into the community conversation, the Task Force meeting invited health insurers to talk about their efforts. Those speaking included: Rena Sheehan, managing director of Behavioral Health for Blue Cross and Blue Shield of Rhode Island; Gayle Dichter, vice president of Pharmacy, Neighborhood Health Plan of Rhode Island; Dr. Elizabeth Ross, medical director for Behavioral Health, Tufts Health Plan, Dr. Barry Fabius, chief medical office, UnitedHealthcare Community and State Plan for Rhode Island; and Kim Wong, UnitedHealthcare Community and State Plan for Rhode Island.

In addition, in the presentation that followed, Nicole Harrington, senior director of Pharmacy Professional Services at CVS, and Brynna Clark, regional director for Government Relations at Walgreens, spoke.

Among the questions that Task Force members probed the insurers and the pharmacies: what were the details of the plans by insurers to act on the legislative efforts to make naloxone more available and less costly to providers in clinical settings; concerns about how expensive copays for medication assisted treatment still remained a major hurdle for many Rhode Islanders; and the commitment by insurers and pharmacies to the complexities of the long-term nature of recovery using medication assisted treatment, including methadone.

What was not discussed
One of the still missing parts of the conversation by the Task Force – and not illuminated by the presentations from the health insurers or pharmacies – were the connections between what are known as the diseases of despair, which sociologist Shannon Monnat has shown in her research that Rhode Island is among the highest in the nation: the death rate from alcohol, suicide and drugs, particularly for men and women between the ages of 25-34.

Clearly, all the insurers maintain detailed, comprehensive databases for their members covered by health insurance, which might be able to be shared with government agencies, in a de-identified manner, if the ask were to be made.

A second intriguing – and missing – part of the conversation concerned the metrics for treatment for substance use disorders under the soon-to-be implemented Accountable Entity initiative, one of the cornerstones of the Medicaid reinvention law passed in 2015, scheduled to become operative in its final form on Aug. 31, 2018.

The goal of the Accountable Entity initiative, which began as a pilot program in 2015, was to create population management metrics as a way to improve outcomes and reduce costs for populations, not just individuals, in the state’s managed Medicaid programs, a Rhode Island Medicaid version of what has become known as Accountable Care Organizations, or ACOs.

It may seem a bit wonkish to the reader, but it is always important to be able to follow the money, particularly when it comes to Medicaid spending.

UnitedHealthcare and Neighborhood are the health insurers who provide the bulk managed Medicaid coverage for Accountable Entities in Rhode Island. While Tufts has recently joined the club of managed Medicaid insurers, it does not appear that Tufts has the requisite number of patients covered in managed Medicaid to participate in the Accountable Entity initiative.

When asked about the metrics, Brenna McCabe, a spokeswoman of the R.I. Executive Office of Health and Human Services, said: “We don’t have any information to share yet regarding metrics, but once we do, I would be more than happy to follow up with you.”

The operative phrase in the response, of course, is “any information to share yet.”

However, those metrics have been shared with providers, according to a number of sources.

The application to become a certified Accountable Entity provider, which was authored by R.I. EOHHS and adopted by the health plans, “strongly encouraged” Accountable Entities to form strong working relationships with behavioral health and substance use disorder providers.

As one source told ConvergenceRI: “Everyone in the food chain is aware that this is the area that is consuming most of the Medicaid dollars spent on primary care.” [Medicaid spending on long-term support services continues to dwarf primary care spending, but the state abandoned plans to create a Medicaid accountable entity around long-term care.]

Another source told ConvergenceRI that as far as the metrics around Medicaid patients diagnosed with substance use disorder and behavioral health issues, the health plans and R.I. EOHHS have asked providers to report the percentage of follow-up visits with a behavioral health provider within “seven days” of discharge from admission, including hospitalization.

While the metrics show “sensitivity” for the behavioral health care issues involved, a third source explained, the problem is more complex: because of strict confidentiality rules, providers may not receive information from the hospitals on behavioral health and substance use disorder admissions and discharges.

Translated, despite the apparent good intentions of the metrics for Accountable Entities related to behavioral health care and substance use disorders for patients enrolled in managed Medicaid, the lack of access to such information because of privacy rules makes the likelihood of providers being able to act unlikely, unless the patients willingly provide access to such information.

Should Accountable Entity metrics become a topic of one of the next Task Force meetings? Good question.

When will R.I. EOHHS be willing to share publicly the metrics around care for behavioral health and substance use disorder Medicaid patients? Another good question.

Addressing the underlying economic issues
On Wednesday afternoon, Aug. 8, Gov. Raimondo announced a new recovery-friendly workplace initiative, supported by a $4 million federal labor grant, to expand skills training and job opportunities for Rhode Islanders in recovery. The new initiative will also seek to provide guidance for employers looking to create more supportive work environments for employees and potential employees in recovery or living with addiction.

Beyond addressing the stigma associated with recovery, another important issue related to workforce training and employment is drug testing, and how that drug testing is implemented.