PROVIDENCE – In the days and nights following the election, I have found myself engrossed in reading Beth Macy’s new book, Raising Lazarus: Hope, Justice, and the Future of America’s Overdose Crisis.

Macy’s latest work, her follow-up to Dopesick, which has been transformed into the award-winning TV series of the same name, reports on the people whom she calls the stone rollers – the folks who are “meeting people who use drugs where they are, in jail cells, under bridges, next to McDonald’s dumpsters” – reviving them from the dead [with naloxone] and then struggling to keep them alive [with bupe, counseling, and kindness].

As Macy wrote: “Our institutions, if they choose to, can learn a lot from the grounded, service-oriented kind of harm reduction embodied in the work being done right now by the people in these pages and so many others.”

Rhode Island now finds itself at the center of this harm reduction drama. The question is: Whether the innovations and interventions created and honed by its own home-grown stone rollers – CODAC’s Linda Hurley, Project Weber/RENEW’s Colleen Daley Ndoye, RICARE’s Ian Knowles, and Recovery Friendly Workplace’s Jonathan Goyer, among many others – can survive the takeover by government bureaucracies, now that tens of millions of dollars in negotiated drug settlements are flowing into their coffers. [The abundance of resources is the result of the legal advocacy by R.I. Attorney General Peter Neronha, holding the bad corporate actors accountable. See link below to ConvergenceRI story, “Holding bad corporate actors accountable for their misdeeds.”]

And, in the background, always lurking, are the dark forces who champion stigma, best exemplified, as Macy reported, by the outraged Kiwanis leader at a meeting in North Carolina, who vented: “I think when they relapse, we should let ‘em die and take their organs!”

[I have heard similar sentiments expressed here in Rhode Island, at a recent Thanksgiving gathering, of all places, by a newly married young professional, who likened those whom he called drug addicts as examples that should to be featured in the next edition of The Darwin Awards: “Why not just let them die?” he asked, laughing, wondering out loud why I even bothered to report on their stories.]

Perhaps not surprisingly, that sentiment mirrored the corporate strategy developed by Purdue Pharma’s Richard Sackler: place the blame on the very people his company’s addictive painkiller, OxyContin, had put on the road to addiction, disability, and death, saying: “We have to hammer on the abusers in every way possible.”

As Macy so eloquently captured the conflict around stigma: “The idea that drug users are worthy human beings – that they are, in fact, equals – is harm reduction in a nutshell.”

Harm reduction in a nutshell
To read Raising Lazarus requires an ability to listen to, to take in difficult stories told by Macy about the heroic stone rollers in Batesville, Ind., in Binghamton, N.Y., in Hickory, N.C., and in Charleston, W.V. It is not like gulping down a page-turner suspense novel or binging on a Netfllix drama to escape the pain and trauma of surviving everyday life; it is provoking. These are not Hallmark Channel romantic fantasies.

And, with each new chapter of Raising Lazarus, my thoughts kept returning to an event I had attended as a reporter, wondering: What had I witnessed? What was wrong with this staged event? What had I missed?

The gathering was a staged news conference, put together by Gov. Dan McKee and his campaign team, highlighting new initiatives to further address Rhode Island’s overdose crisis, part of a carefully scripted parade of campaign events.

The made-for-TV media event, held on Wednesday, Nov. 2, occurred in front of the building on Royal Little Drive that will serve as CODAC Behavioral Healthcare’s new home. The new facility, which is envisioned to be a community wellness center, will not become operational until early next spring. [See link below to ConvergenceRI story, “CODAC buys new building in Providence.”]

On this bright, warm, sunny afternoon, all that was missing was perhaps a high school marching band to play oompah oompah oompah John Phillips Sousa marches, with 76 trombones leading the parade. The question was: Toward what?

For this media moment, the CODAC building served as a backdrop, a Potemkin Village, for McKee’s campaign, although there is nothing fake or insincere about CODAC, which recently celebrated its 50th anniversary, Rhode Island’s oldest and largest nonprofit, outpatient provider of treatment for opioid use disorder – and the standard bearer of redefining a major shift in strategy: meeting people where they are to combat the overdose epidemic. Parked in front of the building was the new CODAC mobile outreach van, a key component of that strategy.

The presser, with opening remarks offered by Linda Hurley, president and CEO of CODAC, was chockfull of newsy items: the appointments of a new director, Cathy Schultz, and a new community point person, Tom Joyce, for the Governor’s Task Force on Overdose Prevention; the announcement of the posting of an RFP to fund the Harm Reduction Center initiative, and a new executive order expanding the work of the Task Force, focused on developing an equity plan.

Call it serendipitous. The very same day of the staged news conference, CVS announced that it had agreed “in principle” to a financial resolution to end all opioid lawsuits and claims against the company, agreeing to pay approximately $5 billion over the next 10 years, while at the same time claiming that the potential agreement was not an admission of any liability or wrongdoing.

“The cause of the epidemic lays squarely at the feet of those who drove it, and drove it for one purpose: to make money,” said R.I. Attorney General Peter Neronha, in a statement sent out by his office following the announcement by CVS. “No amount of money we recover from opioid manufacturers, distributors, and now large pharmacy chains can undo the harm they have caused. But holding them accountable in this way brings some measure of justice, and the millions of dollars we continue to deliver to Rhode Island can do much to better the lives of residents who continue to suffer from substance use disorder.”

The news media was out in full force – as were the public relations flacks from the state’s bureaucratic behavioral health empire. Oompah, oompah, oompah.

What seemed to define the news conference was a singular lack of curiosity by some of the reporters, in ConvergenceRI’s opinion. The reporter from the Channel 10, the local TV outlet that is owned by the Sinclair network, shared her own lack of curiosity with ConvergenceRI after the event. She admitted that she had never attended a Task Force meeting, explaining that she had only started her job in January, as an excuse.

She admitted she knew nothing about the TestRI program, run by the School of Public Health at Brown University, which had identified more than 50 adulterants in the flow of illicit drugs above and beyond fentanyl, which were driving the increase in overdose deaths in Rhode Island.

Since ConvergenceRI first asked her in January, at a news conference held by R.I. Attorney General Peter Neronha, the reporter said she had never found the time to watch “Dopesick,” the TV series adapted from Macy’s book of the same name – and seemed to show no interest in ever doing so. Further, she admitted that she had never read ConvergenceRI.

Her job, she said, was focused on reporting on the prospects of harm reduction centers being created in Rhode Island. Her story about the staged press event, filed later that day, was filled with stigmatizing prose: “Addicts can enter the storefront, access clean needles and shoot up with staff nearby in case of an overdose,"  she wrote,  describing what would occur at such harm reduction centers, which might be coming to a neighborhood near you.

When the Boston Fed came to town
That same lack of curiosity seemed evident in the news reporting when Susan Collins, president and CEO of the Federal Reserve Bank of Boston, came to town last week – with the focus of the conversation on commercial real estate, and if and when there would be a return of the workforce to downtown Providence.

Buried at the end of the story by The Boston Globe’s Dan McGowan about Collins’ visit was the intriguing potential for a shared agenda on addressing substance use: “Collins said she wants officials to use the Fed as a resource, particularly when it comes to tackling challenges that reach beyond any one state or city. She pointed to the Fed’s New England Public Policy Center, and said she is especially interested in addressing the opioid crisis.” [The McGowan story then provided a link to a report published in January of 2021 by the Public Policy Center.] The follow-up story by Globe reporter Alexa Gagosz, however, made no mention of the potential for collaboration around fighting the opioid epidemic.

Collins, it seemed, grasped that there was a direct link between the substance use epidemic, the workforce crisis, and the affordable housing crisis – even if the Boston Globe reporters questioning her didn’t quite seem to get it. [Questions to ask the reporters: Have they watched “Dopesick?” Have they read Raising Lazarus? Have they ever attended a Task Force meeting?]

As Macy wrote in Raising Lazarus: “When you peer into the country’s most intractable problems – homelessness, disability, domestic violence, child neglect – you see the persistence of dopesickness everywhere.”

What the Fed study – and The Boston Globe – missed
The problem with the research study – and with the Fed’s analysis – was that it was completely out of date by the time it was published. [See link below to ConvergenceRI story, “Did a recent research study by the Boston Fed need an expiration date?”]

The author of the report, Mary Burke whose previous work had been reported on by ConvergenceRI, had been using data collected from the All Payers Claims Database, was studying the ways that Medicaid had increased the use of medication assisted treatment in Rhode Island, with the data for the study ending in 2019. The obvious problem was what occurred in 2020 – the onset of the corornavirus pandemic, which led to dramatic, wholesale changes in the way MAT was being delivered in Rhode Island.

Perhaps worse, as ConvergenceRI had reported, the subsequent story on the research study published by the Boston Globe was so inaccurate, the spokeswoman for the Fed asked ConvergenceRI to disregard the Globe’s story. Darcy Saas, the deputy director of the New England Public Policy Research Center, in an email sent to ConvergenceRI on Friday, Jan. 8, 2021, wrote: “We regret that the Globe article does not provide a full picture of the scope of Dr. Burke’s research report.”

Errors of commission
As ConvergenceRI had reported: The problem with the research paper – and specifically, the quotes by Burke in the [subsequent Boston Globe] story, is that it does not reflect wholesale changes in MAT policies related to methadone distribution in Rhode Island, which were changed in response to the Coronavirus pandemic, in order to reduce and prevent the potential for in-person transmission of the virus.

The ConvergenceRI story had continued, citing a story written six months earlier in July of 2020: Linda Hurley, the president and CEO of CODAC Behavioral Healthcare, the largest nonprofit outpatient provider for opioid treatment in Rhode Island, was recently featured in a July 15 story in Crain’s HealthPulse New York, written by Jennifer Henderson, talking about her organization’s focus on maintaining access to care during the COVID-19 crisis.

• The primary goal was to mitigate exposure to the virus,” Hurley told Henderson. To help do so, between April 1 and May 15, the organization provided nearly 160,000 doses of methadone to be self-administered outside of the clinic. The medication went to those who usually visited daily or several times a week, had been released early from prison, were in a homeless shelter or had been self-isolating. Some 60 percent of the doses would not have been distributed outside of the clinic before the pandemic, Hurley said. However, less than 1 percent of the medication was not managed well, with people losing it or taking too many doses.

The ConvergenceRI story continued: Translated, the alleged problems around methadone distribution cited by Burke in The Globe story have dramatically changed. Burke’s statements are out of date and misleading, in ConvergenceRI's opinion.

Further, in the July 20, 2020, story, in response to a question from ConvergenceRI about the most important things learned from the COVID-19 pandemic, Hurley said:

• One, that our field has been both over-regulated relative to methadone and under-regulated relative to the use of buprenorphine as a medicine for opioid use disorder. Both of these conditions are very clearly the result of historic fears, bias and discrimination. In other words, stigma.

• In Rhode Island, the relaxation of regulation and the ability of patients to self-manage their medications has not resulted in an increase in diverted medications in the community. This perception of those who come to us for care for substance use disorder is not supported by the facts. Importantly, we have learned that these regulations actually have become a barrier to care for many, many individuals.

• Two, we have learned that telehealth is an incredibly effective component of a menu of services for the treatment of substance use disorder and other behavioral health care disorders. We have learned that it is effective and has met with a great deal of patient satisfaction.

• Three, telehealth creates increased utilization that creates more revenue. Within the context of Rhode Island having one of the lowest Medicaid rates in New England [emphasis added] and the Mid-Atlantic states, this becomes even more vitally important. 
Most importantly, we have been permitted to prove that our patients are courageous responsible individuals who have come together with us as their medical providers and their communities in order to help to navigate together through this pandemic.

Digging deeper
In the story published in January of 2021, in response to the out-of-date research study and the inaccurate story then published by The Boston Globe, ConvergenceRI conducted a brief interview with Hurley. Here is that interview:

ConvergenceRI: In particular, what was inaccurate in the Globe story, regarding the current practices for MAT?
HURLEY: CODAC and other OTPs [opioid treatment programs] created methods to decrease risk and provide increased support for our patients. So, CODAC began curbside dosing, delivering medication to homes, nursing homes and other living spaces for quarantine, providing medication to those in the early release program at the DOC [Department of Corrections], providing medication to temporary shelters for the homeless in quarantine, etc.

These methods of delivery and expanded take-home status are examples [that debunk] the community mythology that methadone equals daily trips to clinic. Individuals can receive up to 28 days of medication for self-administration.

ConvergenceRI: I found it curious that BHDDH was promoting the report and the story, which contained such “errors,” without any attempt to correct them in the memo sent out. How harmful is it to perpetuate wrong information about access to methadone, for instance?
HURLEY: Not addressing the science of this disease and the medications is a further demonstration of the stigma – the fear, bias and discrimination – that our communities hold.

Inadequate compensation and over-regulation of methadone are financial and regulatory stigma. Further, substantiating myths about care builds upon the cultural stigma, which is the primary barrier to individuals not accessing treatment. It is not about inadequate access to buprenorphine.

ConvergenceRI: I have heard that there are additional millions in new federal money going to R.I. BHDDH. Have you heard that? Where do you think the money should go?
HURLEY: We truly need dollars to support care for the sickest of our Rhode Island residents. Our patients have the highest percentage of co-morbidities, of co-occurring mental health issues, and lowest access to social determinants for wellness. Treatment providers who hold the expertise for this highly complex disease need dollars to expand care, both for programming and capital expansion.

The takeaways
The election is now over in Rhode Island, but the recriminations are not. Many of the problems facing Rhode Island involved with governing, problems that were kicked down the road during the election season, remain unresolved – the burgeoning mental health crisis, the rising number of overdose deaths, the health workforce crisis, the growing number of “unhoused” Rhode Islanders, the threat to a woman’s right to control her own health care choices, and the urgency of the climate crisis.

Yes, Gov. Dan McKee has been elected Governor for the next four years, along with Lt. Gov. Sabina Matos, despite the daily angst broadcast for months over talk radio.

In Rhode Island, as in neighboring Massachusetts, Democratic candidates swept all the elections for statewide offices, despite the news media’s penchant for bad polling, bad punditry, and just plain bad reporting. The Democrats maintained control of the U.S. Senate, and perhaps even the U.S. House of Representatives.

Dopesickness is not going to go away. “It is a worrisome paradox that our nation, which leads the world in medical research spending, has among the world’s worst outcomes for addiction and mental health,” Macy wrote. “The War on Drugs,” Macy argued, “is a war on Black people and the poor. It’s Old Testament lizard brain.”

Who will read Raising Lazarus? Who will watch “Dopesick?”