This report responds to the questions: How did we get here? What is being done now? What can be done? RICARES spent time in the community with folks directly affected by addiction and the overdose epidemic to explore these questions.
~"Corporate America let their profits get in the way of public health.” ~former head of the DEA Office of Diversion Control
~We view recovery as the most critical, but least emphasized, element of the Task Forces strategies. This is due in part to the relative dearth of recovery research. It is also due in part to the failure of those of us in recovery to adequately educate the public and policy makers about recovery.
~In Nashville, the drug court is attached to a 100 bed long-term residential center, where people are put in treatment for as long as two years. This saves Tennessee $32,000 over what it costs to house an inmate.
There are few of us who have not been affected by the accidental opioid overdose death epidemic in our state and nation. This is an attempt to put the epidemic into a context that is relevant to the Rhode Island community.
One aspect of the World Health Organization guidance-development process involves engaging with communities to understand their values and preferences regarding elements of potential recommendations that will have a direct impact on their lives. Their views and experience are considered along with systematically reviewed evidence and expert opinion.
This report is the response of RICARES in an attempt to be helpful by informing the recovery community and the community at large about the etiology of the epidemic, about the work and progress of the Governor’s Overdose Prevention and Intervention Task Force (GTF) to combat the epidemic, and to communicate our values and preferences through a number of recommendations from RICARES, many of which are based on input from focus groups of persons with primary opioid use disorder who are in treatment or in recovery.
The continuing work of the Governor’s Task Force has been informed, collaborative, resolute, on target, and successful in meeting most targeted strategic benchmarks. The intent of the work is to reduce the opioid overdose death rate.
However, despite the progress of the effort, and despite the fact that the fatality rate from prescribed opioids has essentially flattened since 2014, the overdose fatality rate from illicit drugs (primarily heroin and fentanyl) continues to climb. The PreventOverdoseRI on the Department of Health web site explains the present situation simply and succinctly; “the number of deaths are increasing.”
This report consists of five main sections:
How Did We Get Here?
What is Being Done Now?
What Can Be Done? - Recommendations
Additional Considerations and Updates
Focus Groups Data
How Did We Get Here?
A simplified explanation of a complex process is that we got here due to a mix of good intentions, a letter to the editor, and corporate deceit and greed.
The good intentions:
Thirty years ago, there was a fundamental shift in how doctors thought about pain. Physicians historically were reluctant to prescribe opioid pain relievers that are intended for moderate to severe pain (such as after surgery or a serious injury) on a long-term basis for common chronic conditions. There were appropriate concerns about addiction, tolerance and physiological dependence. Then, a 1995 editorial in the Journal of Clinical Oncology cited studies finding that oncologists constantly underestimated their (cancer) patients’ pain, and under prescribed pain relievers as a result. A 1997 report from the National Academy of Medicine detailed how those suffering from cancer or at the end of life did not receive nearly enough relief from their suffering.
In 1996, a neurosurgeon at Johns Hopkins University argued for a major change in pain management and suggested that pain be elevated to a fifth vital sign, along with temperature, pulse, breathing rate and blood pressure. The American Pain Society developed the slogan: “Pain: The Fifth Vital Sign,” and Purdue Pharmaceutical (the manufacturer of OcyContin) who was a funder of the Society jumped on board (for the complete story read Dreamland by Sam Quinones).
The letter to the editor:
In the late 1970’s, a BU physician wondered about the addiction rate of hospital patients who had been treated with narcotic painkillers. A review of hospital records found that out of nearly 12,000 patients, only four had become addicted. This study finding was reported in a January, 1980 letter to the editor of the New England Journal of Medicine that stated: “We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction” (Porter, Hick, New England Journal of Medicine).
The letter became the basis for doctors, academics, and pharmaceutical companies to assert that more aggressive prescribing was okay.
Physician-spokespersons for opioid manufacturers published papers and gave lectures in which they described addiction as ‘rare’ and claimed that the risk of addiction was less than 1%. A 1986 study concluded that Opioid Pain Relievers could be prescribed safely on a long-term basis (The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction Kolodny et al 2015).
NOTE: The assertions ignored the fact that the study concerned only hospitalized patients whose treatment was small doses of opioids administered by doctors, not people prescribed a bottle of take-home painkillers for, e.g., minor injuries, tooth extractions, etc.!
Corporate deceit and greed:
These misstated and unsupported findings were cited to support the expanded use of opioids for chronic non-cancer pain. In fact, the opioid manufacturers and pain organizations exaggerated the benefits of long-term opioid pain reliever (OPR) use in spite of the fact that “high-quality, long-term clinical trials demonstrating the safety and efficacy of OPRs for chronic non-cancer pain have never been conducted” (Kolodny et al).
As a result, opioid prescription use increased gradually in the 1980’s, then accelerated in 1996 in large part due to the introduction of OxyContin in 1995 by Purdue Pharma. OxyContin (which came to be known as “Hillbilly Heroin”) was marketed as having no addiction potential as it was an extended release formulation.
Between 1996 and 2002, Purdue Pharma funded more than 20,000 pain-related educational programs through direct sponsorship or financial grants and launched a multifaceted campaign to encourage long-term use of OPRs for chronic non-cancer pain. As part of this campaign, Purdue provided financial support to the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, the Joint Commission on the Accreditation of Hospitals, pain patient groups, and other organizations. These groups all advocated for more aggressive identification and treatment of pain, especially the use of OPRs.
For example, in 1995 the American Pain Society and the American Academy of Pain Medicine issued a consensus statement endorsing opioid use for chronic non-cancer pain. The statement asserted that the risk of addiction and tolerance was low, risk of opioid-induced respiratory depression was short-lived, and concerns about drug diversion and abuse should not constrain prescribing.
NOTE: In 2016 the pharmaceutical/health product industries reported spending almost $246 million lobbying; almost $100 million more than the next highest spending industry (insurance). Since 1999, the pharmaceutical/health product industries have been the highest spending lobbying industries (Center for Responsive Politics).
OxyContin prescriptions for pain rose from 670,000 in 1997 to 6.2 million in 2002.
The sales of opioids increased from $3.97 billion in 2001 to $8.34 billion in 2012 – a 110% increase (NY Times, June 2013).
In 2012, U.S. health care providers wrote 259 million prescriptions for opioid painkillers (e.g., Vicodin, Percocet, OxyContin), enough for a bottle of pills for every adult in the country (Center for Disease Control and Prevention).
The prescribing rate for Rhode Island providers in 2012 was 82.2 - 95 prescriptions per 100 persons (CDCP Monthly Mortality Review).
Where was the governmental oversight?
A decade ago, the Drug Enforcement Administration (DEA) launched a campaign to curb the rising epidemic. The DEA began to target wholesale companies that distributed hundreds of millions of highly addictive pills to the corrupt pharmacies and “pill mills” that illegally sold the drugs for street use.
For example, between 2007-12, drug wholesalers shipped 780 million hydrocodone (Vicodin) and oxycodone (Oxycontin) to West Virginia: that’s 433 pain pills for every man, woman and and child in West Virginia. (Note: the 3 biggest U.S. wholesalers are McKesson Corp, Cardinal Health, and AmerisosurceBergen Drug Co. (Charlestown Gazette Dec 2016).
NOTE: Although the U.S. comprises less than 5% of the world’s population, we consume 80% of the global opioid painkillers and 99% of the global supply of hydrocodone, the active ingredient in Vicodin (Markey Report)
However, even when alerted by the DEA about suspicious pain clinics or pharmacies, some distributors ignored the warning. The former head of the DEA Office of Diversion Control stated, “Through the whole supply chain, I would venture to say no one was doing their job…and because no one was doing their job, it just perpetuated the problem. Corporate America let their profits get in the way of public health.” (Washington Post October 2016)
The industry actively resisted all mitigating efforts. In 2007, Washington state established a guideline for general practitioners when prescribing these drugs: If the patients were taking more than 120 mg a day with no reduction in pain, they should stop and get a pain specialist’s opinion before prescribing higher doses. The pain specialists concurred that “not every increase in pain should be met with higher doses of narcotics.”
The guidelines were challenged in court briefs by the drug companies as an example of “an extreme anti-opioid discriminatory animus or zealotry know as Opiophobia that informs, permeates, and perniciously corrupts the development and management of public health policy.”(Dreamland)
Former DEA and Justice Department officials hired by the drug companies began pressing for a softer approach.
Then, in 2013, at the peak of the crisis, some officials at DEA headquarters began to block and delay enforcement actions against wholesale drug distributors and others, frustrating investigators in the field (Washington Post, October 2016)
It’s not all about the docs: Physicians seem to have been blamed by many as the primary cause of the epidemic. However, most prescribing doctors were following recommended practices that were promulgated by the authoritative sources. The under treatment of pain was identified as a public health problem. The research that was available was presented as conclusive. The authorities (American Pain Foundation, American chronic Pain Association, American Academy of Pain Medicine) assertions resulted in actions such as hospital lawyers advising doctors that their patient could sue them for not adequately treating their pain if they didn’t prescribe these drugs.
A Boston pain specialist said that the conventional wisdom became, “…it was our holy mission to cure the world of its pain…that opiates were safe. All those rumors of addiction were misguided...the only reason we didn’t use it was stigma and prejudice.”
An epidemiologist from Washington state recalls, “…physicians (had) been convinced by the drug companies that it’s okay to prescribe these medications for people with chronic pain because here’s the studies that show very few of them will become addicted. They don’t want to hear that the people that they’re prescribing these drugs to might die. They’re physicians and they’re trying to help people” (Dreamland).
The primary cause of the epidemic seems to have been the predatory practices of a few pharmaceutical companies and their allied industries. This may partly explain why there has been little progress in mitigating the epidemic, despite the efforts of public health and law enforcement agencies to stop it.
This viewpoint is reinforced by past and recent national actions:
-In 2007, Purdue Pharma paid $635 million in settlement fines related to its ‘misrepresentation’ of the addictive qualities of OxyContin and three Purdue executives pled guilty to criminal misbranding.
-In 2015, a lawsuit was filed by Mississippi against pharmaceutical companies
-This April (2017), the Cherokee Nation sued 6 distributors and pharmacies (including CVS, Walgreens and Walmart) for distributing what amounts to 360 pills for each prescription opioid user in the 14 counties that make up the Cherokee Nation
-In May 2017, Senator Claire McCaskill (D, Missouri) launched a Senate investigation into whether 5 drug companies marketed their opioid painkillers in a manner that may have contributed to the national opioid epidemic. She has demanded internal documents that include evidence of “behind-the-scene efforts to block increased regulation, and sales quotas that may have led drug representatives to use kickbacks to encourage physicians to prescribe the drugs.” She has called the epidemic, “the direct result of a calculated sales and marketing strategy…over the past 20 years…to expand market share and increase dependency on powerful -and often deadly – painkillers.” She cites a remark made by the former sales vice president of the company that markets Subsys, a Fentanyl spray, “If you can keep (patients) on (Subsys) for 4 months, they’re hooked. Then they’ll be on it for a year, maybe longer.” (Journal of the American Medical Association, May 9, 2017).
-In May 2017, the Ohio Attorney General filed suit against 5 major drug manufacturers for flooding the market with opioid pain relievers, for giving doctors misleading information about the benefits and addiction risks, and for spending “…millions of dollars to deceptively market their drugs…” (WSYX/WTTE, Columbus Ohio, May 2017)
-In June 2017, Missouri filed a lawsuit against Endo Pharmaceutical, Purdue Pharma and Janssen Pharmaceuticals saying that their “campaign of fraud and deception” led to the opioid crisis in the state (Providence Journal, 2017).
We are now, fortunately, at the point where policymakers and doctors have pulled back unfettered access to opioid pain relievers. In November 2015, two pain doctors from the University of Washington wrote an article in the New England Journal of Medicine arguing that doctors need to think less about pain levels entirely. Last June, the American Medical Association denounced the use of pain as a vital sign. In July 2016, the Obama administration made changes to how Medicare pays doctors including the announcement that it no longer would give bonus payments to hospitals that did a better job of reducing their patients’ pain scores; hospitals said the reward “created pressure on hospital staff to prescribe more opioids to achieve higher scores.” (Federal Register/Vol. 81, No. 135/Thursday, July 14, 2016/Proposed Rules).
One of the results of theses actions in Rhode Island is a leveling off of the death rate from prescribed opioid pain relievers in the last three years.
However, many people didn’t just quit the drugs altogether: they moved to heroin (a lower-cost, more-accessible and more potent opioid) and now have moved (or have unknowingly been moved) to the even stronger synthetic opioid, fentanyl. So, while opioid pain reliever-related deaths have plateaued, heroin and fentanyl related deaths have skyrocketed in our state.
As noted, users have moved on from opioid painkillers to seek out more potent, cheaper drugs; there has been a destructive race to find the most affordable high.
Fentanyl is an opioid invented in 1959. Its primary use is in transdermal patches given to people for end-of-life care, and it has recently been adopted as a spray for pain relief.
In 2016, more than half (58%) of the Rhode Island overdose deaths had fentanyl involved. The trend in 2017 is increasing – presently 66% of the overdose deaths are fentanyl involved (PreventOverDoseRI).
Unlike heroin, fentanyl and its analogs can be made fairly easily in a lab. That makes fentanyl far cheaper to produce, without the hassle of growing the opium poppy and then converting the poppy into morphine and then into heroin.
One of multiple dangers associated with fentanyl use is that, according to a user in Mass., the fentanyl high fades much more quickly than heroin, so other drugs like a benzodiazepine or cocaine are used to extend the fentanyl high (WBUR). The primary danger, of course, is that fentanyl often requires more Naloxone for reversal than heroin. “Multiple doses of naloxone may be needed to revive a patient after a fentanyl overdose…In particular, non-pharmaceutical fentanyl — that is, illegally manufactured fentanyl and its analogs, often mixed with heroin or cocaine — tends to be especially potent.” (NEJM, Oct. 2015)
Rhode Island seems to have been caught by surprise by the fentanyl wave. We should not have been. In March 2015, the DEA issued a nationwide alert about both illegally manufactured fentanyl (IMF) and non-pharmaceutical fentanyl (NPF). This was followed by an October 2015 CDCP official health advisory and an August 2016 Health Update. These all alerted public health departments, health care professionals, first responders, and medical examiners and coroners to the new developments that placed more people at risk for fentanyl-involved overdoses. Those developments included: a sharp increase in the availability of counterfeit pills containing varying amounts of fentanyl and fentanyl-related compounds (e.g., labeled as Oxycodone, Xanax, and Norco); the widening array of toxic fentanyl-related compounds being mixed with heroin or sold as heroin, including extremely toxic analogs such as carfentanil; and continued increases in the supply and distribution of IMF.
What Has Been Done?
There has been an informed and vigorous public health response at both the state and federal level. These are a few examples:
Multiple reports have been issued. They include, but are not limited to:
The Centers for Disease Control and Prevention (CDC) issued guidelines for states to follow to combat the opioid accidental overdose death epidemic that included the need to improve prescribing of opioids, expansion of addiction treatment, and reduced access to illegal opioids. In addition, CDC issues continual updates, advisories, and is a primary information source
-In 2011, the Office of National Drug Control Policy issued a plan, Epidemic: Responding to America’s Prescription Drug Abuse Crisis, that identified four main priorities for a comprehensive approach to preventing prescription drug misuse and abuse: education, implementing PDMPs in every state, proper medication disposal, and law enforcement.
-In 2014, The Markey Report, Overdosed: A Comprehensive Federal Strategy for Addressing America’s Prescription Drug and Heroin Epidemic, recommended a federal strategy with a focus on Prevention, Treatment, Naloxone, and Enforcement
-In 2015, Johns Hopkins issued The Prescription Opioid Epidemic: An Evidence-Based Approach with seven specific and detailed recommendations for action
We are fortunate to live in a progressive state that has been a national leader in our response to the accidental overdose death epidemic. Among public health researchers, there is broad agreement about what's needed: access to addiction treatment and medications; tighter regulation of prescription opioids; widespread distribution of naloxone; needle exchanges or supervised injection centers; and law enforcement efforts to reduce the supply of heroin and illicitly manufactured fentanyl, the bulk of which is thought to come from China and Mexico. Most of these are recommendations have been implemented in our state and are ongoing.
In 2011, a study by Traci Green, PhD that mined data from medical examiner files showed a new trend in accidental opioid overdose deaths in the state. The demographic most at risk were women and men between the ages of 35-54 who were also being treated with anti-depressant drugs and sleeping pills, and who most frequently lived in suburban, small town settings. The study also stated that, “ Opioids now outrank marijuana as the first drug of use (for young adults). Young adults in their prime are the ones that are dying, in a large swath of the population…It is not the future taxpayer, it is the present taxpayer” (Richard Asinof article in the Providence Business News).
Subsequent to these findings, in 2012 the RI Department of Health, under the leadership of Dr. Michael Fine, formed the Drug Overdose Prevention and Rescue Coalition comprised of a wide range of over 100 stakeholders. Workgroups were established: First Responders, Naloxone, Treatment/Recovery, and Data/Surveillance, and the group implemented a number of the CDC recommendations and started to implement others.
In 2015, Governor Raimondo formed the Governor’s Overdose Prevention and Intervention Task Force, also comprised of a wide range of stakeholders and utilizing the leadership and enhanced strategies from the 2012 coalition group. A strategic plan quickly emerged: Rhode Island’s Plan on Addiction and Overdose: Four Strategies To Alter the Course of an Epidemic. The plan is informed by the national strategies and by evidence-based practices. The plan details an approach directed at treatment, reversal, prevention, and recovery, with specific metrics to measure the success of each part of the strategy. The stated goal is to reduce opioid deaths by one-third within three years. Translated, that means reducing the number of overdose deaths in Rhode Island from 239 in 2014 to about 160 in 2018 (ConvergenceRI, October 2015).
The Task Force and its committees meet regularly to continue the implementation of plan elements. Significant notable benchmarks have been attained. They include:
The PreventOverdoseRI (PORI) web page at the Department of Health website. The data dashboard is a rich and dynamic source of data that other states are asking for assistance to replicate.
Rhode Island is first in New England and second in the nation in reducing the number of opioid prescriptions filled within the past three years (Providence Journal, May 2017). (One of the CDC’s strategies states that the best way to prevent opioid overdose deaths is to improve opioid prescribing to reduce exposure to opioids, prevent abuse, and stop addiction)
A sampling report on some Task Force strategies (PORI):
Increase the number of people receiving Medication Assisted Treatment
Buprenorphine treatment (monthly average) slightly increased from 4288 patients in 2016 to 4489 thus far in 2017
Methadone treatment (monthly average) is essentially flat, from 6128 patients in 2016 to 6085 thus far in 2017
Opioid treatment admissions increased from 1675 in 2015 to 1914 in 2016, a 14% increase
Increase the distribution and dispensing of naloxone kits
In 2016, 6341 naloxone kits were distributed by community agencies, hospitals and pharmacies compared to 2762 in 2015, a 129% increase.
We have about run out of words to describe how bad the situation is. Despite the power of intellect and experience applied in the last few years, despite the virtually unprecedented stakeholder collaborations, despite the progress toward and attainment of benchmarks of the strategic plan, and despite the fact that deaths caused by prescription drugs have leveled in the last few years: “the number of deaths are increasing” (PreventOverdoseRI).
The primary, secondary and tertiary prevention strategies of the Task Force, and their implementation, are very comprehensive.
In order to inform our recommendations, RICARES has conducted a series of focus groups with persons with opioid use disorders and/or directly affected by the epidemic. A short summation is at the end of this report.
We recommend some enhancements and additions to the present strategies of the Task Force.
The Prevention element of the strategic plan is consistent with the national recommendations and has been very successful in meeting benchmarks. It has focused on modifying prescribing practices such as the co-prescribing of benzodiazepines and opioids. A few additional suggestions:
The Anchor’s MORE program is the sole, and underfunded (actually it is not institutionally funded at all), outreach program that is conducting targeted outreach. The outreach and engagement work done by the MORE team (that occurs in the street, under bridges, in shelters and the woods, etc.) is especially essential during the pre-contemplation and contemplation stages of change.
It is difficult to understand why the outreach efforts have not been expanded yet, especially as they are able to effectively utilize the continually updated information from the data dashboard to response statewide to target areas.
Widely distribute Fentanyl test strips (as a start, this could be combined with the MORE teams’ Naloxone distribution)
Ensure medical coverage on re-entry: In the first few weeks after release from custody, the health care needs of individuals are great and they are particularly vulnerable. Rates of mental illness, substance use disorders, infectious diseases and disorders, and chronic health conditions are substantially higher than rates in the general population. For people with a opioid use disorder, re-entry often means a return to drug use. Some inmates enter custody with Medicaid coverage, but states routinely terminate the Medicaid coverage. Upon discharge, individuals have to reapply – a process that may take as long as 45 – 90 days. CMS (Centers for Medicare and Medicaid Services) has encouraged states to suspend rather than terminate coverage for persons in custody. However, as of 2015, RI continued to terminate coverage (Markey Report). We do not know if that policy has changed.
Hser, et al in their review Long-Term Course of Opioid Addiction (2014) in the Harvard Review of Psychiatry, includes this finding: “There is a significant time delay between the onset of opioid use and help seeking: 6-10 years in the studies reviewed. This suggests a longer window of opportunity for identifying, engaging, and treating…than is now occurring.”
The rescue component of the plan is very robust, has been implemented very successfully, is on going, and most notably is very community based. Half of the Naloxone doses distributed in 2016 were by the Preventing Overdose and Naloxone Intervention (PONI) initiative that is funded by a private donation and completely staffed by volunteers. There is an on-going effort to engage all the pharmacies in the state in pro-active Naloxone distribution. However, there is minimal state funding and Naloxone is expensive
Expansion of the NaloxBox initiative is recommended
The Task Force Strategic Plan states: “The plan is focused on four critical, strategic initiatives. It is not meant to be comprehensive, and by design, must be flexible to adapt to changes in this dynamic epidemic.”
The Johns Hopkins report The Prescription Opioid Epidemic: An Evidence-Based Approach (2015) states: “Some evidence-based interventions exist to inform action to address this public health emergency; these should be scaled up and widely disseminated. Furthermore, many promising ideas are evidence-informed, but have not yet been rigorously evaluated. The urgent need for action requires that we rapidly implement and carefully evaluate these promising policies and programs. The search for new, innovative solutions also needs to be supported.”
Two Fentanyl-related studies by Task Force leaders (Dr.’s Traci Green, Jody Rich and Brandon Marshall) have just been published. One of the studies (Epidemiology of fentanyl-involved drug overdose deaths: A geospatial retrospective study) concludes that: “Findings suggest widespread penetration of fentanyl in the drug supply, impacting a diverse group of users. An immediate scale-up of harm reduction and overdose prevention interventions is needed.”
A sentence in a New York Times article (January 2017) jumps out: “If there is a way to save people from overdose death without creating harm, we should do it.”
In the spirit of the four preceding paragraphs, the following existing practices can be seriously discussed and considered in Rhode Island.
ED-BNI + Buprenorphine is an accepted practice: the Brief Negotiation Interview with ED initiated buprenorphine can be introduced via the existing Anchor ED Program that is now in all the state’s Emergency Departments.
Extend clinic hours significantly and streamline intake procedures (the prevalent modified bankers hours model for treatment accessibility is not, and has never really been, responsive to need).
Develop a pilot 24/7 Urgent Care model that will provide true treatment on demand. (An operative new model is Faster Paths to Treatment, a Boston Medical Center substance use disorder urgent care center that provides rapid evaluation, motivation and referral to the network of care).
Supervised Injection Facilities in which persons can inject pre-obtained illegal drugs under the supervision of medical personnel.
A pilot program for adjunct maintenance treatment with Diacetylmorphine for that subgroup (15-25%, NEJM August 2009; 40%, NIDA Nov. 2015) for whom treatment with Methadone and/or Buprenorphine just doesn’t work. “Methadone, provided according to best-practice guidelines, should remain the treatment of choice for the majority of patients. However, there will continue to be a subgroup of patients who will not benefit even from optimized methadone maintenance. Prescribed, supervised use of diacetylmorphine appears to be a safe and effective adjunctive treatment for this severely affected population of patients who would otherwise remain outside the health care system“ (New England Journal of Medicine August 2009).
Obtain a waiver to allow a trial study with Ibogaine.
Develop interventions to improve access to evidence-based treatment for young adults.
Only 2.4% of adolescents in treatment for heroin use disorder receive MAT, compared to 26.3% of adults – and - .4% of adolescents in treatment for prescription opioids received MAT, compared to 12% of adults (Database of publicly funded treatment programs in the U.S., Journal of Adolescent Health 2017). Teenagers who receive maintenance therapy with MAT have better treatment retention and are less likely to engage in risk behaviors, such as drug injection…Buprenorphine, in particular has shown to be effective among youth population…it is essential to build capacity in pediatric primary care so that more physicians have the knowledge and support to prescribe MAT (JAMA editorial, June 2017)
Develop a pilot program that uses Contingency Management to increase engagement with interventions such as medication-assisted treatment (MORE could use CM as an engagement strategy)
The Task Force has demonstrated its’ understanding that Interim Methadone Maintenance is an established evidence based practice, and should no longer be considered a ‘harm reduction’ strategy; rather, it is legitimate treatment and a legitimate pathway to recovery. However, and despite the demonstrated efficacy of MAT, it continues to be generally resisted. The most damaging resistance comes from individuals in the recovery communities and from within the treatment profession and industry itself: “Almost half of substance abuse treatment professionals don’t ‘believe’ in the use of medications” [AATOD, 2012).
A revitalization of the notion of Medication Assisted Recovery is needed in our state. The initiatives and efforts of the nascent Medication Assisted Recovery Coalition can be given encouragement and material support by the Task Force.
Investigate the feasibility of adopting the ‘hub-and-spoke’ model in Vermont – office based prescribers are linked to Opioid Treatment Programs that provide buprenorphine induction for patients who require more intensive care at initial stages of treatment
The White Paper: Opioid Use, Misuse, and Overdose in Women released in 2016 from the DHHS Office on Women’s Health notes the significantly different biological pathways and social pathways to opioid use disorder (and all substance use disorders) for women.
Dr. Green’s 2011 study states that, “Often, women who abuse prescription painkillers may have a history of physical, emotional or sexual trauma. Biologically, people who experience a traumatic event respond to pain differently. They are ‘rewired’ by that traumatic experience, they may feel pain very differently, and require different prescribing approaches.”
In addition, we know that recovery for women is qualitatively different for women then for men.
Our impression is that the prevention, treatment and recovery continuum continues to minimize the unique experience of women in favor of a one-size fits all approach. We believe that this is a major contributor to the on-going generational cycle of addiction.
We recommend that the Governor’s Task Force develop an additional element that focuses on primary prevention, treatment and recovery for women.
We view recovery as the most critical, but least emphasized, element of the Task Forces strategies. This is due in part to the relative dearth of recovery research. It is also due in part to the failure of those of us in recovery to adequately educate the public and policy makers about recovery.
We know that, as with the other chronic medical conditions, treatment effects decay over time if not reinforced and enhanced by recovery management work.
We know that recovery occurs in the community.
We know that treatment can be the beginning of recovery for many, especially for those with Opioid Use Disorders for whom treatment is necessary, but not sufficient. Hser, et al (Long-Term Course of Opioid Addiction) notes that:
Professional treatment, particularly prolonged treatment and higher cumulative doses of treatment, is associated with more positive outcomes, but the effects can be ephemeral…resumption of opiate use often followed treatment, and multiple treatment episodes were often required…
This finding underscores the need for models of sustained recovery management in the treatment of opioid addiction. These models would employ creative retention strategies, assertive linkage to indigenous recovery support institutions, recovery check-ups for at least five years (five years of opioid abstinence is an important benchmark of recovery stability), and sustained family support…
A focus group participant said, “We’re all trying to go home somewhere!” Another participant related her experience with the housing cycle: ‘I lose my housing, so I lose my kids, so I use.’
In the focus groups, the issue of housing was consistent. The Task Force Recovery Committee started to address the issue by finalizing the legislation introduced by Senator Miller that required the Department of BHDDH to develop a recovery housing certification based on national recovery housing standards. This is an essential but very small first step. Certification has to be voluntary, and the incentive to certify is minimal. The lack of safe affordable housing continues to be widespread and a barrier for people to sustain early recovery.
We note these (housing) recommendations from The Society of Community Research and Action:
-Single State Authorities on alcohol and other drug problems to establish loan funds and other mechanisms that will support the development of recovery residences where the need for such resources has been established. (NOTE: Rhode Island did have a revolving loan fund for years – it disappeared)
-Enhanced funding for critical research related to recovery residences.
-Recommend strategies to educate and train addiction treatment professionals and allied health and human services professionals on the value of recovery homes.
-Recommend public education strategies that will address the stigma and misconceptions often attached to recovery homes and their residents.
Treatment, especially for Opioid Use Disorders, is necessary for most, but not sufficient.
The sufficiency lies at either end of the continuum of approaches: successful prevention that prevents initial exposure and use is sufficient. Self-managed recovery is sufficient.
Recovery from addictions is not just abstinence; recovery from addictions is not just remission.
Recovery is Wellness on an internal global scale: physical wellness, emotional wellness, psychological wellness, spiritual wellness, relational wellness; Wellness that makes a life of meaning and of purpose possible.
The decades of attempting to arrest and imprison our way out of the nation’s drug problem has been a failure.
The decades of using interdiction in an attempt to affect the market by restricting the illicit drug supply and thus making drugs very expensive has been a dismal failure.
Nationally, some legislators and policy makers are changing from being enamored with the phony ‘tough on crime’ talk to a ‘smart on crime’ approach.
The Markey Report (A Comprehensive Federal Strategy for Addressing America’s Prescription Drug and Heroin Overdose Epidemic 2015) states:
“The current crisis demands strategic planning that thoughtfully brings together science, medicine, public health and law enforcement in a multi-faceted solution.”
There is, of course, a role for arrest, imprisonment and interdiction; however, arresting suppliers and dealers and attacking the drug supply is necessary, but not sufficient. A chunk of the resources used for law enforcement efforts can be re-directed toward evidence-based and promising prevention, treatment and recovery practices.
The Gloucester Police Department initiative is being replicated throughout the country, but not yet in Rhode Island.
Drug Court Expansion that encourages the use of MAT can be effective.
At the Hope Squad Program in North Carolina police departments know the names of overdose survivors through 911 traffic. The Hope Squad, one officer and two recovery experts, get the report from the Police Department and visit the survivor to give overdose prevention information and provide recovery coaching.
In Nashville, the drug court is attached to a 100 bed long-term residential center, where people are put in treatment for as long as two years. This saves Tennessee $32,000 over what it costs to house an inmate.
The Markey Report states: “One of the most important tasks law enforcement has is caring for inmates with substance use disorders and helping reduce drug related recidivism.” We want to acknowledge the extraordinary leadership and actions that the RI Department of Corrections has demonstrated as it continues to be a national leader in this effort.
The DOC could look at the ‘Unit 104’ Program at the Kenton County Detention Center in Kentucky as a model for enhancement of our DOC’s present effort.
We do not know if there is a coordinated statewide pain management strategy. We do not know if any elements of the National Pain Strategy, published in 2016 by the Interagency Pain Research Coordinating Committee of the National Institutes of Health, have been implemented in Rhode Island.
We note that the Department of Health has recently updated the pain management regulations related to the prescribing of opioids for chronic pain (while opioids are necessary and effective in the treatment of acute pain, there is no convincing evidence that that is the case for long term chronic pain).
We are not aware of significant interaction between pain specialists and addiction specialists. We do not know if there have been joint conferences in Rhode Island where the two specialties might meet
Additional Considerations and Updates
Any drug, and more increasingly fentanyl, can be mail-ordered through the dark web and delivered by the USPS. In late February, a man in South Carolina was accused of receiving more than three kilograms of fentanyl ordered on the dark net — enough to kill 1.5 million adults. (New York Times, June 2017)
The Federal Drug Administration has asked the manufacturer of Opana ER, an opioid painkiller, to remove it from the market, as there has been a significant shift in the route of misuse shifting from nasal to injection (Washington Post June 2017).
In metropolitan Cleveland, the rise in fentanyl-related deaths among black drug users has increased by 900 percent from 2014 to 2016. This is attributed to the introduction of fentanyl into the cocaine supply. (Washington Post, June 2017).
Our alcohol misuse is also killing us: In 2015, more than 33,000 people died from alcohol-induced causes. When alcohol-related drunk driving and homicide deaths are included, there were 88,000 alcohol-related deaths in 2015 (Vox).
Our cigarette use is also killing us: There are more than 480,000 deaths annually caused by cigarette smoking (including deaths from second hand smoke) (CDC MMWR 2013).
Focus Groups “We didn’t just wake up one day and decide we want to shoot drugs for the rest of our life!” (SStarbirth focus group participant June 2017)
In May and June 2017, RICARES conducted four focus groups related to the overdose epidemic. They were conducted with 7 patients in treatment at CODAC, with 8 patients in treatment at SStarbirth, with 7 peer recovery specialists at Parent Support Network, and with 11 regular participants of an All-Recovery meeting in Newport. The rationale for these initial groups was to attain feedback from people close to the issue in time, and feedback from the peers whose combination of lived experience and peer training gives them a still unique perspective. A more structured and complete report will be forthcoming from RICARES.
Time for the groups ranged from 45 minutes to 90 minutes
Brief (self-identified) demographics of groups (totals):
Gender: Men – 10, Women – 23;
Race: White – 26, Latina – 2, ‘Other’ – 3, Mulatto – 1, Native American - 1
Age range: 20-29, 5; 30-39, 18; 40-49, 7; 50-59, 3
Opioid Use Disorder, 29; other SUD, 3; Family member - 1
Time in Recovery: 2 months to 24 years
Four persons self-identified as homeless
We asked 3 open-ended questions, and 6 closed questions
This is a response sample:
Have you heard of the Governor’s Overdose Prevention Task Force? Yes, 17; No, 18
If Yes, do you know any elements of the strategic plan?
Why are all these overdoses happening?
Bad mixes of fentanyl and heroin; “people are scared to quit;” people want to get high and don’t know where the drug is from; If on methadone, will use (the street drug) until they can ‘feel it;’ want a more intense high; fentanyl is in coke, “they’re cutting everything;” sometimes first responders take too long – when you call in, you have to say that the person is ‘not breathing’ - if you say that they overdosed, they take longer; parents leave drugs around, they are uneducated and ‘are naïve’- are afraid to talk about drugs; kids can ‘easily’ get heroin in school; “(my pharmacist told me) that the computers will kick the scrip, so people had to switch to street heroin;” people want to get high; people don’t want to be sick, “If was sick, I didn’t care what I put in my arm, or who I got it from…”; the fentanyl is a more intense high (a specific response: “when I heard someone OD’d, I was looking for that stuff the very next day”); active users are unable to know when enough is enough; drugs are easily available; “dope’s cheap;” there is stigma with Methadone, people think you have to be on it for the rest of your life, people think it is worse than heroin; too much focus on the addiction of people, not enough on the (co-occurring) mental illness; people get thrown out of (MAT) treatment because they can’t keep paying
What can the state and local governments be doing to stop the overdose deaths?
Start age-specific drug education in grades 4-5, by the time get to high school that education is too late (“ by the time I was in middle school, I went to DARE I was all lit up”); teach kids coping skills; put faces and voices of recovery in the schools to counteract the glamor of the lifestyle and culture of dealers and users (‘cars, money’); address poverty – “slinging drugs is the only way to make a living or even just to make it;” train teachers in AOD issues; police should go ‘harder and harder’ after dealers with more severe punishment – “kick ‘em in the ass and put them away;” cops doing a good job, doing what they can, but in the cities (Central Falls, Pawtucket, Providence) the police officers are “in a bubble driving around”…squad cars knowingly drive by drug deals-don’t want to be bothered, have to “pick their battles;” stop throwing people out on the street (from treatment); provide more housing; train more people in Narcan, put Narcan in all public places;
Don’t know what they can do, no way to stop it, “drugs will still be on the street;” train the hospital staff around patient treatment; government leaders should finish what they start; politicians need to reach out to the grass roots and just listen; there needs to be a “we” and not “us” and “them;” get rid of the disconnect between people in recovery and the medical profession; medical personnel in hospitals need to learn how to deal with people with addictions; politicians don’t do anything until it affects them personally.
What can the recovery communities (people in recovery from addiction, our families, friends and allies) be doing to stop the overdose deaths?
When talk in public be honest about the battle and stress that life is way better now; “do what you say, say what you mean, take action – don’t punk out;” talk to people about the issue- have a ‘human conversation;’ go after the state and the legislature to advocate for expanded treatment – even have the state create its own rehab facility - “We’re paying for them to go to jail, why not pay for them to get help?” be there for folks; advocate for more housing - “I had a great job, lost my place to live so I lost my job;” work to get more places like recovery centers where there are people to talk to, “there is now no place to go;” speak anywhere you can about addiction and recovery; carry Narcan; treat people in a caring manner; put peers in the prison; get peer teams throughout the community; connect peers to people in treatment pre-discharge; be non-judgmental and helpful, “plant seeds;” train an advocacy team that provides education to the community; advocate for peer specialists in treatment programs; build a bridge to people who don’t understand; use the arts as a bridge between people in recovery and the rest of the community
What is your opinion about widely distributing fentanyl test strips?
Like, 28; Don’t like, 3; Maybe 2
Comments: “I wouldn’t use it, I’d rather not know that I just wasted 100 bucks;” “I don’t do heroin but I would test it for people to help them:” “Some dealers are supplying Narcan with the dope”
What is your opinion about having safe, supervised injection sites?
Like, 20; Don’t Like, 11; Maybe, 2
Comments: “Why not just legalize it?” I’m not going to a place where people know I’m going to use; the police will use it for entrapment, “they’re not supposed to but they will;”
What is your opinion about having 24/7 on demand treatment?
Comments: “If I have to wait to get into treatment, then fuck it, I’ll get high…it’s a right here right now thing”
What is your opinion about using pharmaceutical heroin for treatment (as a last resort) for long time users who continually fail at methadone treatment?
Like, 10: Don’t like, 17: Maybe/don’t know; 6
What is your opinion of the Gloucester Police Department initiative?