PART Two

PROVIDENCE – The cholera outbreak in London in the mid 1800s claimed thousands of lives. When it hit Soho in the summer of 1854, killing 127 people in the first three days, people began to flee the city.

John Snow, an obstetrician who pioneered the use of anesthesia in Britain, hypothesized that the disease was caused by sewage pollution in the drinking water.

But Snow’s theory was ignored by physicians and by local authorities. The prevailing medical view was that, as with most diseases, the cause was ‘miasma’ or bad air.

Snow, who lived in the district, mapped the outbreaks in the area, interviewed families of victims, and determined that almost all the victims lived near the water pump on Broad Street.

His microscopic examination of a water sample from the Broad Street pump found clear evidence of pollution. [The outbreak was eventually traced to a to a single-point source: a cholera-infected baby whose diaper-wash water was emptied into a cesspool that leaked directly into the Broad Street well. That contamination caused more than 600 deaths].

Snow convinced officials to remove the pump handle and disable the pump. The number of cholera cases dropped immediately.

Snow is credited with being the forerunner of modern epidemiologists. His contributions included the mapping and use of data tables to describe infectious disease outbreaks, and the recommendation of public health measures to prevent disease [e.g., the removal of the pump handle].

Removing the pump handle to halt the overdose epidemic  
The epidemiologists at Brown and the R.I. Department of Health [RIDOH] have been consistent and active leaders in our battle against the overdose epidemic.

One of the strategies, the Overdose Spike Alerts, utilizes Snow’s principle of the use of data to inform action. RIDOH conducts daily monitoring of overdose activities in the 11 overdose regions in the state. When an overdose threshold is exceeded, community-based outreach workers are deployed to the region to provide their harm reduction supports, such as Naloxone, Fentanyl-test strips, HIV/HCV testing, and basic need items.

As importantly, they are able to provide faces and voices of recovery – and their presence demonstrates caring and compassion. Our harm reductionists and first responders are saving lives every day.

What they are not able to do is remove the pump handle, as Snow did. As a result, we have not been able to stop the deluge from the vast well of the contaminated and toxic illicit drug supply into our communities.

In December of 2023, National Public Radio reported on the following Centers for Disease Control and Prevention statement: “The overdose death rate topped 112,000 in a 12-month period for the first time.” The CDC statement continued: “Individuals of the 50-and-under age group are more likely to die from an overdose than any other cause, including heart disease and cancer, the leading two causes of death among the overall population.”

Translated, the new demands and pressures on our harm reductionists and emergency responders are consistent with the observation by Sam Quinones that, as with everything else connected to the opioid overdose crisis, “There is nothing that remains the same.”

In a recent Boston Globe article, Eliza Wheeler, co-director of Remedy Alliance, a national network of harm reduction programs, said: “Having an unregulated drug supply presents us with a constant challenge. We are learning as we go as harm reductionists – sometimes blindly.”

For example, in some cases, overdose victims are so heavily sedated on a toxic mix of substances that they can remain in a blackout stupor for hours.

Not enough time.  
In other cases, victims overdose so quickly that there’s not enough time to revive them. The noted epidemiologist Dr. Traci Green, Ph.D. [an expert advisor to the Overdose Task Force since it started] is quoted in that same Globe story, “We used to have minutes to an hour to respond” to overdoses; “Now we have seconds to minutes.”

[Editor’s Note: Thirteen years ago, in 2011, ConvergenceRI, then working for the Providence Business News, first published a story about Dr. Green’s research looking at the causes of death from overdoses, which led to a change in public health priorities in Rhode Island and the creation of the Task Force.]

The Globe story reported that the new and complex cases are requiring front-line workers to rethink how they respond to overdoses. First responders are learning that even multiple sprays of Naloxone are not enough to revive someone. So, outreach workers are deploying multiple tools and techniques, including pulse oximeters to check oxygen levels, and CPR face shields.

A new higher dose nasal Naloxone [8 mg v. the standard 4 mg] seemed to be a promising new tool. However, a study released this month by the Centers for Disease Control and Prevention found that it did not save more lives than the previous standard dose, but it did cause more withdrawal symptoms, including vomiting and disorientation.

The severity and chronic nature of our crisis continues to require a focus on prevention, rescue, treatment, and recovery strategies that address the symptoms.

“It’s not like what we’re doing isn’t working. It is working. But what we’re doing isn’t enough,” said Dr. James McDonald, the former director of the R.I. Department of Health and the current Health Commissioner for New York State, in a 2022 Boston Globe interview.

As a result, we occasionally get a little relief [the slight decrease of our mortality rate in 2018 and 2019 and, hopefully, in 2023, if the current data trend line holds).

Moving beyond treating symptoms  
It’s hard to imagine that our existing initiatives that include Naloxone, drug testing, the soon-to-be-opened overdose prevention and harm reduction site, safer use supply distribution, robust overdose surveillance, addiction treatment, recovery supports, and reclassifying personal drug use are just not enough.

But, it seems clear by now that our collaborative years of effort to reduce the opioid crisis that primarily seek to address the symptoms continue to provide only temporary and localized relief.

The acknowledged and long-time systemic driver of our national and statewide crisis, of course, is the range of social determinants of health [SDH]. Those determinants are the non-medical factors that influence population health outcomes. They are the conditions into which people are born, grow, work, live, and age – the wider set of forces and systems that shape the conditions of our daily lives.

In its 2019 Strategic Plan of the Overdose Task Force, “confronting the Social Determinants of Health [such as “housing, community environment, employment, and education”] is recognized as a “Core Principle.”

In turn, the Task Force’s 2023 Strategic Plan update prioritizes the following principles:

•    “Addressing social determinants of health by investing in foundational needs such as housing and employment.”
•    “Addressing social determinants of health throughout all pillars of the Task Force and throughout the overdose continuum of care.”
•    “Addressing health disparities associated with social determinants of health and racial inequities.”

It is clear that addressing the social determinants of health are better done now rather than later. However, as the 2019 strategic plan acknowledges: “We cannot fix the social determinants of health immediately…”

We know that the required management of our state’s diseases and deaths of despair, generally characterized as hopelessness and depression, suicide, and alcohol/other drug related diseases, are overwhelming our health care system.

To complicate the problem, there is the more immediate and pressing consideration: the main driver of the overdose crisis today is an illicit drug supply that is toxic and unpredictable.

We have been unable to reduce the demand for, or the supply of, illicit drugs. We believe that the priority is to limit exposure to Fentanyl, its analogues, and the powerful new synthetics that have started to emerge.

Translated, we must disrupt the illicit drug supply.If we are not at the point where this must be done by any means necessary, when we will be?

The safe, effective alternatives  
There are safe and effective alternatives to the unregulated drug supply.

The Overdose Task Force, now led by longtime recovery community leaders Cathy Schultz as the Task Force Director and Tommy Joyce as Community Co-Chair, have included safe supply as a “potential activity” in its 2021 Harm Reduction Workgroup Strategic Outline. One of the harm reduction activities of the Task Forces 2023 Strategic Plan Refresh is “continued community policy discussions around drug supply.”

Safe supply is not a radical notion that exists out on the public health fringe. In August of 2020, Patty Hajdu, the Canadian Minister of Health, in an open letter regarding treatment and safe supply, wrote: “I ask you to do all you can to help provide people who use drugs with a full spectrum of options for accessing medication…that will help them avoid the increased risks from the toxic drug supply. This includes your support for programs that provide greater access to a safer, pharmaceutical-grade alternative to the toxic street supply.”

What is safe supply?  
Safe supply for people who use drugs is a harm reduction strategy that provides legal and regulated medications as a safer alternative to the toxic illicit drug supply now used by people who are at high risk of overdose – and for whom currently available care options have not been effective or desirable.

The safe supply strategy can be implemented as an emergency response when public health, treatment, and existing harm reduction strategies have not been able to rapidly decrease overdose fatalities.

At this point, an immediate scale-up of low barrier opioid distribution systems are urgently needed in order to disrupt the toxic drug supply and make safer opioids widely available to people at high risk of fatal overdose.

There is a robust safe supply movement in Canada that includes prescribers and harm reductionists. One of the prescribers is Dr Andrea Sereda, a family physician at a community health center in Ontario, who was featured in a June 2019 Global News story. She prescribes hydromorphone tablets to select patients who were relying on the illicit market. She said that the results have been positive. None of the patients had fatally overdosed; half of them found housing; and they have weekly contact with health care providers.

Dr. Sereda said: “We have to be willing to step outside of our comfort zone and out of the medical establishment comfort zone and say that we need to keep people alive.”

Dr. Sereda stressed that safe supply should not be considered as “a replacement for methadone or suboxone. It’s an option for the subset of people for whom methadone and suboxone don’t work, and it serves as a bridge for people who may not be ready for those treatment.”

Other Canadian studies have found that access to a prescribed tablet hydromorphone for people using illegal opioids reduced overdose risk, provided improvements in health and well-being, improved pain management, and led to economic improvements.

The research dates back to 2009, 15 years ago. Dr. Eugenia Oveido-Joekes, Ph.D., is an Assistant Professor at the School of Population and Public Health, University of British Columbia. She was the lead investigator of “Diacetylmorphine versus Methadone for the Treatment of Opioid Addiction,” published in the New England Journal of Medicine in 2009.

The study found that: “Methadone…has been shown to reduce major risks associated with untreated opioid dependence in patients who are willing to undergo and are successfully retained in treatment. However, 15 percent to 25 percent of the most adversely affected persons do not have a good response to this treatment. Such persons are either not retained in methadone maintenance treatment for very long or continue to use illicit opioids while in treatment.”

The 2009 study concluded that for the participant cohort of long-term users with opioid dependence that was refractory to treatment, “Injectable diacetylmorphine was more effective than oral methadone.”

A follow-up research work, the “Study to Assess Long-Term Opioid Maintenance [SALOME] published in 2016 by JAMA Psychiatry, found that hydromorphone is just as effective as prescription diacetylmorphine for the patients. The study also found that the patients engaged in far less criminal activity and were getting counseling and other health care treatments, often for the first time.

“We have so much evidence supporting heroin-assisted treatment, it’s not even funny,” Dr Oveido-Joekes was quoted as saying in a 2017 Vice News story. “I have never heard of a doctor telling a patient that two medicines work, but then saying that only one or neither is available. Nobody does that with any other illness.”

Further research findings tend to confirm the previous studies. In a 2020 International Journal of Drug Policy commentary, “Tackling the Overdose Crisis: The Role of Safe Supply,” Isvins et al wrote: “Not all people who use opioids are interested in treatment, nor is conventional treatment suitable for all people who use opioids. Continuing to rely on conventional treatment models amidst evidence that these do not work for everyone represents a fundamental failure of our attempt to adequately address the overdose crisis.”

Our concerned epidemiologists, other public health professionals, and harm reductionists often remind us that several countries, including Germany, the Netherlands, Norway, and Switzerland, have authorized providers to prescribe diacetylmorphine to people with opioid use disorder who have not responded to standard opioid addiction treatments.

They remind us that multiple clinical trials and follow-up studies since 2003 from countries such as Germany, the Netherlands, Norway, Switzerland, and Canada have demonstrated that prescribed diacetylmorphine is safe, feasible, and effective.

It is noteworthy that the overdose rate in those countries is much lower than ours. For example, according to the Commonwealth Fund, in 2020, our national overdose rate was 277 persons per million; Canada’s was 171 per million; Germany’s was 19 per million; and Netherlands (2019) was 15 persons per million.

A statement from the 2020 study by Bonn et al, "Addressing the Syndemic of HIV, Hepatitis C, Overdose, and COVID-19 among People Who Use Drugs: The Potential Roles for Decriminalization and Safe Supply," published in the Journal of Studies on Alcohol and Drugs is both instructive and gives direction.

“It is extremely challenging for public health policy makers and clinicians to think beyond traditional treatment strategies and embrace new ways to reduce the death and suffering associated with prohibition and criminalization that has led directly to a toxic and unpredictable illicit drug supply. We absolutely need to improve quality and access to addiction treatment and harm reduction services, but we argue that this is not enough…we do know that people who receive a safe supply are more likely to engage in treatment, creating more opportunities to reduce harm and improve their quality of life."

To compete with the poisoned illicit drug supply, we must provide substances that people who use drugs are seeking and want to use. If not, it doesn’t matter what treatment is available, and this is a matter of life and death.”

Our state’s concerted response to our long overdose death crisis has been progressive, innovative, sustained, and compassionate.

We are grateful for the many lives that the work of so many have saved. However, Dr. McDonald's  statement must still direct us, “It’s not like what we’re doing isn’t working. It is working. But what we’re doing isn’t enough.” [emphasis added]

It is now time to more explicitly, more intentionally, and more meaningfully open the discussion about safe supply. It is now time to develop a framework and principles for a safe supply strategy, and to implement that strategy.

If not now, when?