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Researcher Traci Green got the facts, and Dr. Michael Fine took action

How a story about a researcher's study of accidental ODs changed Rhode Island's public health priorities

Courtesy of Traci Green.

Traci Green's research into the causes of accidental deaths from drug overdoses has led to a change in Rhode Island's public health priorities. She is the principal researcher in a new $2 million study looking at different models of patient engagement to manage chronic pain. She is currently an assistant professor of Emergency Medicine and Epidemiology at the Warren Alpert School of Medicine of Brown University.

By Richard Asinof
Posted 2/10/14
The progressive response by Rhode Island to the epidemic in drug addiction began with a 2011 story about the work of a researcher, Traci Green, who mined medical examiner death certificates to identify the large number of Rhode Islanders who were dying from accidental overdoses.
Building upon Green’s research, Dr. Michael Fine, the director of the R.I. Department of Health, changed the state’s public health priorities, and built a broad coalition – from the state police to pharmacies to emergency room physicians – to move drug addiction out of the shadows and save lives.

What is the relationship between sexual violence and sexual abuse against women and substance abuse? What kinds of alternative treatments for chronic pain – such as massage and acupuncture – can be proven to be effective? How can patient engagement in managing pain – and more caregiver engagement in listening to patients and not just prescribing medication – change the culture of addiction? What is the responsibility of insurance companies in the way they set co-pays for opioid pain medications? These are questions that research by Green and her colleagues in Rhode Island may provide some better answers.
It’s difficult to watch anything on TV these days without being bombarded with ads promoting pharmaceutical products that promise instant relief from chronic pain and conditions – a kind of soma or lotus potion to assuage the hurts of everyday life. The ongoing efforts to legalize – and tax – marijuana has put an entire new spin on what kinds of regulation will be placed on substances that offer pleasure – and the risk of dependency. Finding a middle ground between Peter Tosh’s mantra – “legalize it, and we’ll advertise it” – and the lessons learned from the Volstead Act and the prohibition of liquor will prove to be a difficult place to navigate. As we have seen with gambling, once government becomes dependent on the tax revenue, it’s hard to end the addiction to cash flow into the state revenue coffers. More than just saying no, it’s a matter of saying “no thank you” to the products that Big Pharma keeps pushing.

PROVIDENCE – Unlike climate change, few will deny that addiction is a serious, life-threatening public health issue, with high personal, economic and health costs.

Rhode Island, as are many states in the Northeast, is confronting a full-blown addiction crisis, with a spike in the number of deaths caused by accidental ODs from heroin laced with fentanyl in recent weeks.

As Dr. Michael Fine, director of the R.I. Department of Health, often reminds everyone at each news conference, this is a story about “our brother and sisters, our children, our families and our neighbors.” It is not an “us vs. them” equation, Fine emphasizes, when he talks about the needle and the damage done.

Fine is also clear that the root causes of addiction are not known or understood. Yet, there is a direct connection between the over-prescription and abuse of inexpensive pain meds and addiction, according to many behavioral health specialists. “Percodan, percocet, oxycontin, oxycodone, or hydromorphone; they are all opiates. The brain doesn’t really care,” as Sharon Morello, RN, director of Medical Staff Services at the Providence Center, said in a 2011 interview.

A month before the death of actor Phillip Seymour Hoffman, Vermont Gov. Peter Shumlin had the courage to call it out by name. In his state-of-the-state address in early January, Shumlin said: “In every corner of our state, heroin and opiate drug addiction threatens us.” The time has come, he continued, “for us to stop quietly averting our eyes from the growing heroin addiction in our front yards while we fear and fight treatment facilities in our backyards.”

At an earlier event in November 2013 at the Brattleboro Retreat, Shumlin had linked the epidemic of prescription drug abuse to the heroin epidemic. “We pass out FDA-approved oxycontin in our society with very little thought. Now, if you think that oxycontin isn’t a pill of opiates known as heroin, you are wrong.”

Shumlin urged that the public debate be reframed to see addiction as a chronic disease, to be fought with the need for treatment and support, not just punishment and incarceration. [Imagine how apoplectic radio talk show hosts would have been if Gov. Lincoln D. Chafee had made a similar speech.]

Here in Rhode Island, over the past three years, Fine has moved forcefully to build a coalition – including the state police, emergency room physicians, pharmacists and behavioral health practitioners – to change the way the state responds to the health threat posed by accidental overdoses and to prevent the loss of life. It includes making Naloxone, a drug that counteracts overdoses, readily available to EMT technicians and to consumers. It has also meant tightening up oversight of how prescriptions of painkillers are managed by providers and pharmacies.

What was the impetus for Rhode Island’s change in policy and strategy? A key catalyst was a news feature I wrote in July of 2011 for The Providence Business New, according to both Fine and Traci Green, a researcher whose work I had documented in that story.

The story that made a difference
When I first interviewed Traci Green in April of 2011, I was a reporter in search of someone who could document the numbers – the casualty list – of the epidemic in prescription drug abuse in Rhode Island.

I knew that I needed to make sure I had good numbers, in part to allay the doubts of my editor. He had recently questioned the fact that Rhode Island had “the highest percentage of drug abuse for kids 12 and older in the entire country,” a statement made by Dale Klatzker, president and CEO of The Providence Center, in an interview I had done with Klatzker about the need for a recovery high school.

When shown the documentation, he said: “I’m not saying we don't need the [recovery] high school, just that it’s easy to presume that people who are doing good don't exaggerate for effect, which in fact they do,” the editor said. “I wonder if there is a story at some point about what the hell the state is doing with its drug-addled population. Is this because of all those Brown students (and the reason they are so happy)?”

At that time, Green was assistant professor of Medicine and Community Health at the Warren Alpert School of Medicine at Brown University. She was conducting research by mining the data from medical examiner case files in Rhode Island and Connecticut, funded by a two-year, $250,000 grant from the Centers for Disease Control and Prevention.

Her research addressed a fundamental problem in Rhode Island, related to accidental deaths from overdose of prescription pain killers: no one – hospital emergency rooms, community mental health agencies or the R.I. Department of Health – was collecting or tabulating data in a comprehensive, standardized fashion.

“The only thing we know is that the number of deaths are extraordinarily high,” Green told me at the time.

The preliminary results from Green’s research – a systematic review of medical examiner case files from accidental drug overdoses in Rhode Island and Connecticut – showed a disturbing trend emerging: the demographic most at risk for death by accidental overdose were women and men between the ages of 35-to-54 who are also being treated with anti-depressant prescription drugs and sleeping aids. The geographic trend was that these deaths occur more frequently in suburban, small town settings than in urban areas.

“Opioids now outrank marijuana as the first drug of use [for young adults],” Green told me. “Young adults in their prime are the ones that are dying, in a large swath of the population, people ages 35 to 54. It is not the future taxpayer, it’s the current taxpayer.”

Women who abuse prescription painkillers may have a history of physical, emotional or sexual trauma, according to Green. “Biologically, people who experience a traumatic event respond to pain differently,” she said. “They are ‘rewired’ by that traumatic experience, they may feel pain very differently, and require different prescribing approaches.”

Changing the state’s public health priorities
When my story ran in The Providence Business News on July 4, 2011, it attracted scant attention or follow up from other news media or state officials. At a news conference two weeks later, I asked Fine, the newly appointed director of the R.I. Department of Health, if he had seen the story; he hadn’t. But he asked me to send it to them, which I did.

After reading the story, Fine immediately got in touch with Green, and that began a series of conversations that led to a dramatic change in state health priorities.

Today, Green chairs the R.I. Drug Overdose Prevention and Rescue Committee, working closely with the R.I. Department of Health in responding to the crisis in drug addiction.

One result of the committee’s collaborative efforts has been the development of new pain medication guidelines for Emergency Departments at Lifespan hospitals. Another is the development of a new digital data collaboration focused on emergency room practices in Rhode Island.

Green is also the lead investigator in a $2 million research effort, “Optimizing Patient Engagement in a Novel Pain Management Initiative, being conducted by Inflexxion, an health care technology firm in Newton, Mass. Funding for the study was awarded by the federal Patient-Centered Outcomes Research Institute.

The three-year study will focus on better understanding the challenges of engaging in a novel chronic pain care initiative within the R.I. Medicaid Communities of Care program, to develop and test a cell phone text message intervention, compared to a patient-navigation approach, in order to increase patient engagement and self-management of chronic pain.

The Communities of Care program is inclusive of all Medicaid-eligible persons in Rhode Island that have used the emergency room four or more times in a one year period. Its goal is to improve health outcomes by helping members address their health care needs and in the process reduce avoidable or inappropriate emergency room use.

“We want to study how we can use technology to build a more effective, patient-centered approach to managing chronic pain for patients in Rhode Island’s Communities of Care program,” Green said, who will be working with colleagues from The Miriam Hospital in conducting the research.

Out of the shadows
In a recent interview with ConvergenceRI, Green talked about how rewarding, personally and professionally, it has been for her to be a participant in the change in how addiction is being addressed in Rhode Island. “It’s been so satisfying to be part of the shift,” she said. “It took a while to get everyone involved,” saying that at first, her committee had six or seven regular participants, and now, it had grown to more than 60.

“It’s very satisfying to see everyone coming together,” Green continued. “Overdoses were in the shadows. All we knew was that there were bodies. Not how to stop it, or how to slow it down.”

Green credited the huge leadership role played by Fine in building the statewide coalition. “Building coalitions has had a major impact in shaping policy and improving the lives of people in Rhode Island,” she said. “We’ll try to use every tool we can.”

The challenges, she continued, are still daunting. “We’re still at ground zero at what’s changing in the illicit market.” But, she added, the new 11-point plan introduced by Lifespan to create guidelines for prescription painkillers has been having “a profound effect for the better.”

Green acknowledged that it can be a “very scary thing if you have to live with chronic pain,” and that she expected that there would be some pushback from patients. “We’ll have to see what happens.”

Green said that Rhode Island was fortunate to have a “super responsive health department” trying to get ahead of the curve when it came to responding to addiction.

Digital data initiative
Green said that Rhode Island is building a digital data initiative – “it’s not a center" – focused on collecting and sharing data from hospital emergency rooms. The effort, she explained, “is a collective of researchers in emergency medicine and in technology.” Among the research that is being built into a collaborative database is the work that Green is doing with her patient engagement study, studies looking at adolescent girls and depression, with a focus on violence reduction, and substance abuse and women. “We trying to bring together all the people engaged in research initiatives in emergency health,” she said, whether it involves “big data or very intimate data.”

Green concluded by saying: “We’re human. We are probably going to have to learn to live with the need to identify, support and treat people with drug addiction forever.

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