PROVIDENCE – The heavy scuffle is on this week, with the R.I. General Assembly expected to approve the $13.6 billion FY 2023 spending budget, with little time to pore over what is in – and what is out – of the budget.

The scavenger hunt by reporters about what the budget contains often misses the big picture.

That is particularly true when it comes to the investments in behavioral and mental health care services – and, in particular, what is to be invested in response to the opioid overdose epidemic.

• No one disputes the fact that the number of overdose deaths has risen to its highest total ever in 2021, to more than 435 deaths.

• No one disputes that Rhode Island is not alone in facing the scourge of surging opioid-related overdose deaths.

As Boston Globe reporter Felice Freyer wrote in her June 8 story, ‘It’s pretty terrifying’: Mass. opioid-related overdose deaths surged to an all-time high last year: “More people died of opioid related overdoses in Massachusetts last year than in any previous year, according to a grim new report out Wednesday that reflects both the mental health toll of the pandemic and the pervasiveness of fentanyl-contaminated drugs.”

• No one disputes that many of the programs developed under the direction of the state agencies have not been as successful as many would have liked in curtailing the number overdose deaths in Rhode Island – including the R.I. Department of Health, the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals, the R.I. Medicaid Office, and the R.I. Executive Office of Health and Human Services.

• No one disputes that legal interventions by R.I. Attorney General Peter Neronha in holding drug manufacturers, distributors, and consultants accountable has resulted in a total of more than $200 million in legal settlements, with most targeted at opioid abatement strategies.

Changes in attitude
Problems, however, have arisen regarding the make-up and priorities of the new Opioid Settlement Advisory Council. [See link below to ConvergenceRI story, “Opioid Settlement Advisory Council may have stumbled out of the starting block.”]

Many in the recovery community felt that they were excluded from participation as members as community experts on the Advisory Council. The continuing differences in funding priorities and approaches were aired at the most recent meeting on Wednesday, June 8, of the Governor’s Task Force on Overdose Prevention and Intervention.

Here is what was written in the “Open Letter to the Opioid Settlement Committee,” shared by the Governor’s Task Force, following its June 8 meeting.

[Editor's Note: ConvergenceRI is sharing the contents of the letter in full, because it is a dialogue that needs to be heard in public – and not just in the backrooms of bureaucratic managers.]

As peer-based organizations and organizations serving people who live with the consequences of opioid addiction [as well as other people who use drugs or are in recovery], we feel that we were not adequately included in the settlement committee selection process.

To help ensure that the infusion of resources in the state are used where they are most needed to decrease overdose deaths and promote recovery from opioid and other addictions, it is critically important to center the voices of peer recovery specialists, street outreach workers, and people with lived experience of addiction and recovery.

However, given that the committee is already chosen, and cannot be changed, recovery and harm reduction advocates urge the committee to center the following funding priorities, suggested by some of the working groups.

We also put forth additional critical priorities for the settlement committee to consider moving forward.

Time and again we hear from officials that they want to hear from folks directly impacted, those working on the ground tirelessly through COVID - now is the time to put those words into action.

This settlement was meant to represent some form of justice. We want justice for the unnecessary deaths of our many friends, family, co-workers, and clients who were killed by the greed and dishonesty of not only pharmaceutical companies, but others who collaborated with them in creating the conditions of the epidemic.

For justice to be meaningful and substantial, it must place victims at the center – those still struggling from addiction, their families, people in recovery, and the frontline workers who work tirelessly and are collapsing in the face of the ongoing epidemic.

We are the organizations led by those whose lives are on the line and family members of folks using drugs. These are the funding priorities that will make a material difference to our clients and staff – that will help keep our people alive. We urge you to listen to us based on our experiences – and to follow these recommendations to ensure we are saving lives and upholding justice.

We support these current priorities from working groups:

• Peer-based Harm Reduction

– HR Working Group: Increase peer-to-peer harm reduction encounters in community settings and to educate, distribute supplies and make referrals to housing and other recovery services [$750,000]

– HR Working Group: Utilize a social determinants of health approach for Harm-Reduction to provide housing and other basic needs using existing infrastructure ($750,000)

– Rescue Working Group: Expanded naloxone distribution [i.e., data-driven mobile outreach, using peers with lived experience], with a focus on BIPOC communities, including stimulants users and recreational drug users

– Rescue Working Group: Pilot technology [i.e. mobile phone application] that triggers emergency response if person overdoses

• Harm Reduction Centers

– HR Working Group: Establish Harm-Reduction Centers to promote safer drug use [$1,000,000]

– Racial Equity Working Group:  Specific funding for harm reduction centers to ensure equitable accommodations for all substances used, especially safer smoking.

– Communications Working Group: New Campaign Request: Explain the many public benefits of harm reduction centers’ resources and services and reduce stigma. [$250,000]

• Increased access to treatment

– Treatment Working Group: Fund Contingency Management, the evidence-based practice [EBP] for opioid and methamphetamine treatment and add ‘safe location’ housing for clients that are new to treatment and involved in either an OTP or SUD Partial Hospitalization Program, or just leaving the ACI [where residential is not the appropriate placement]. [$450,000]

– Treatment Working Group: Fund the SUD system by increasing the Medicaid reimbursement rate by supporting the required funding match.

Missing or inadequate priorities
These are specific requests that were either not identified by the working groups or were not adequately addressed and/or funded. The voices of people directly impacted, those with lived experience, and those working on this crisis every day, put forth these additional priorities as critical to making a sustained impact on this crisis.

The inadequate priorities include:
• Housing for people who use drugs. The Recovery Working Group suggested the following priority: “Fund incentives to expand recovery housing. Increase the length of time allowed to stay in a recovery house in order to receive assistance from paid employment/benefit specialists and housing navigators.”

We see the importance of recovery housing and recognize this is a critical step, but we also want to emphasize the importance of increased housing options for people who are not ready for/not interested in recovery.

For people who are unstably housed, the risk for overdose and other health issues remains high without a stable place to live. Individuals who are stably housed in a supportive setting have higher engagement in services [MAT, primary care/mental health services, etc.]. Stable housing allows for consistency of care, which is crucial in overdose prevention.

• Post-Overdose Response. Recovery Working Group [suggested the creation of a] “Post Overdose Placement Team – a team of professionals working together to provide coordinated placement for adults with serious substance use disorders [SUD]. The team will connect individuals to SUD treatment and/or other basic needs that include a housing first model, peer support and harm reduction materials.” [$600,000]

We propose that this funding be increased and replace the HOPE Initiative as the State’s primary overdose outreach effort and be led by Recovery and Harm Reduction peer specialists in coordination with other key stakeholders.

Centering police in this response reinforces the idea that this is a criminal justice issue, rather than the public health issue that it truly is. Furthermore, we feel that peer recovery specialists are better suited for this, and police can create a counterproductive response.

The missing priorities not addressed include:
• Harm Reduction Training. We see consistently the messages of support for harm reduction that are being shared by those in executive leadership of many organizations [recovery housing, treatment providers, etc.] are not being shared, communicated, or reflected by those on the ground in those same organizations.

This is a paradigm shift that we need to invest in beyond our harm reduction community. Harm reduction materials [such as Narcan and fentanyl test strips], as well as anti-stigma training and training on the principles of harm reduction, need to be provided for the following types of organizations: treatment providers; recovery housing providers, and medical providers.

• Infrastructure. Infrastructure support for peer-based or smaller “boots on the ground” organizations. Much of the funding for direct response to the overdose crisis focuses solely on the purchase of Narcan, or the funding of people doing outreach and working directly with clients.

However, the organizations that hire, support, train, and promote these critical staff do not have the infrastructure in place to continue to grow and support this response without significant infrastructure growth, including financial, administrative, human resources, training, and supervision support.

Many of the organizations that represent a large portion of the state’s overdose response are one non-renewed grant away from a financial crisis. Many of the staff that do this difficult work are burnt out, and need supports to continue doing the work.

More emphasis and funding needs to be placed on creating a strong foundation for staff and organizations to work within.

• Treatment. Treatment on demand. We recognize that treatment only works if people can access it at the moment they are ready for it - we need to prioritize access to low-barrier treatment such as street-based medicine with medication for opioid use disorder [MOUD] prescribing, co-locating treatment in harm reduction centers, etc.

We also feel that this dovetails with the specific funding for suboxone from the settlement funding, which could be used to help ensure that people who have additional challenges [e.g. people experiencing homelessness] are accessing this medication.

• Sustaining treatment. People engaging in any form of substance use disorder treatment [including medication for opioid use disorder] need to be able to define how they will integrate that treatment into their lives.

Currently, it is too often the other way around, people must conform to the demands of treatment facilities. We are asking for a review of state/federal regulations that serve as barriers to treatment; a review of facility policies that serve as barriers to treatment; and adequate reimbursement to treatment facilities/staff and staff support to offer services in ways that meet the needs of their clients.

• Treating peer staff with the same respect as first responders/treatment providers. Peer staff often experience the same trauma and compassion fatigue - if not more - as treatment providers and first responders, but are not thought of as either.

The specific suggestions for supports for first responders and treatment providers should be expanded to include peers. The treatment working group suggested: “Fund yearly staff bonuses to individuals working within an OTP or SUD treatment facility in order to retain current workforce and to incentivize a new workforce, include paid internships.” These bonuses should also be given to peer outreach workers and certified peer recovery specialists doing this difficult and traumatic work.

The first responders group requested “Increase access for first responders who experience secondary trauma and/or compassion fatigue associated with responding to substance related and other emergency events.”

Certified peer recovery specialists experience many of the same secondary trauma as first responders’ they are “first responders” but are often not treated as such. Training/support should be given to peers as well, with specific changes made to the training to be appropriate for peer staff.

Important principles for this funding
In addition to sharing priorities about the specific funding lines, we also wanted to highlight our overall principles for this year and future funding rounds. They include:

• Racial Equity. Funding needs to be applied in an equitable way, recognizing that mostly Black and Brown communities have been devastated by the War on Drugs, and this funding can be used as a small form of reparations in impacted communities.

• Law Enforcement Funding Moratorium. Funding should not be going to law enforcement-based programs, even for when law enforcement agencies are supporting treatment and harm reduction efforts.

As front-line providers, we see the daily impact of criminalization. In many ways, criminalization has contributed to the overdose crisis, not helped respond or address it. As a harm reduction and recovery community, we aim to move away from the criminalization of substance use because we have seen that it devastates the lives of our community.

Importantly, police are also some of the best-funded entities compared to the shoestring budgets of many harm reduction and recovery organizations. This funding is specifically to repair the harms from opioids, not to bolster agencies that have other and substantial funding streams.

• Supporting Lived Experience. Funding should prioritize organizations and entities that hire and center the voices of people with lived experience. As people and communities impacted by the overdose crisis, we feel that we are the ones best positioned to support others, if we have the appropriate resources and support to do so.

These priorities are just a few of the most specific and concrete ideas, and not a full list of what we would want funded. We also recognize that additional systems - such as housing, economic development, criminal justice reform - all play into a comprehensive and equitable way of addressing the overdose crisis.

As people who have lived this, and work daily with people struggling, we urge you to take these recommendations and ensure that we are working for this funding to be most impactful and do the most justice.

What is at stake?
The divide between what peer-based organizations with lived experiences bring to the table, compared to how government bureaucracies tend to function, is a stark difference when it comes to divvying up resources.

In covering the opioid epidemic in Rhode Island for the last 11 years, what ConvergenceRI has learned is that it has been the peer-based recovery specialists, working on the front lines, who have pushed and prodded the government bureaucrats to respond.

Even though the R.I. General Assembly has pushed through legislation to create a pilot program to establish safe injection facilities in Rhode Island, there still exists a legal limbo about if and when such a pilot program will be able to move forward.

The money, thanks to the legal advocacy of Attorney General Peter Neronha, is not a problem – unless those in charge of the government bureaucracies at R.I. EOHHS and the Opioid Settlement Advisory Committee decide to shortchange the peer-based organizations.

With the legalization of recreational marijuana in Rhode Island, some of the last vestiges of the War on Drugs, created by former President Richard Nixon, which specifically targeted racial minorities at Nixon's direction, are fading away. In a world where affordable housing is scarce, the need to emphasize investments in recovery housing becomes even more critical.

In a time when the health care workforce is in crisis, stretched to the breaking point, the need to provide financial resources to support front-line workers intervening to prevent overdose deaths becomes even more critical.

How many ears must one [bureaucrat] have before he/she can hear people cry?/ Yes and how many deaths will it take ‘til he/she knows that too many people have died?

The answers, my friends,  will be forthcoming when the Opioid Settlement Advisory Council decides on what its funding priorities will be.