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Mind and Body

Who controls the conversation around harm reduction, and why it matters

Is it Gov. Raimondo and her task force? Is it large academic health systems? Is it law enforcement? Is it the usual suspects in the news media? Or, is it the recovery community?

Image courtesy of the Bloomberg American Health Initiative Forecast study

One of the graphic slides from the new Forecast study, looking at the potential to distribute fentanyl testing strips as a public health harm reduction intervention. Rhode Island still lacks a statewide harm reduction strategy.

By Richard Asinof
Posted 2/12/18
The failure by the Governor’s Task Force to develop a statewide harm reduction strategy has left a widening fissure in efforts to prevent and intervene with the epidemic of drug ODs, a gap that has gone unreported by the news media. Whether Rhode Island will pursue harm reduction strategies such as safe injection sites and distribution of fentanyl testing strips, will be driven by recovery community advocates, not government officials or health systems. The difficulty will be in fighting and disrupting the prevailing narrative.
When will the Bloomberg American Health Initiative make researcher Susan Sherman available for an interview, as promised? How much of the money that will flow through the federal CARA coffers will go to harm reduction efforts, separate from medication-assisted treatment efforts? How can the conversation around substance use disorders and addiction change from “recovery from” to a focus on “recovery to?” How much money is being spent for EMS transports to hospital emergency rooms in Rhode Island for individuals with impressions of “alcohol intoxication” under Medicaid and Medicare? When will the conversation broaden to include the diseases of despair, connecting deaths from alcohol, suicide and drugs with social and economic disparities and the lack of connectedness, what Philip Slater once termed “the pursuit of loneliness?”
One of the arguments swirling about the proposed merger of Care New England and Partners Healthcare in Boston is the alleged damage that it will do the ability of Rhode Island to preserve the integrity of its academic medical research enterprise, and with it, future job creation. But, building a wall around the research enterprise in Rhode Island seems counterproductive, as if scientific researchers will somehow fall off a cliff when the 401 area code ends. The reality is that collaborative platforms of research are preferred by corporate and government funding sources.
MindImmune, a for-profit drug development research firm embedded at URI as a part of innovative MOU collaboration, recently partnered with Pfizer in both collaborative research and in an investment in the Rhode Island’s firm work on developing new therapies for Alzheimer’s and Parkinson’s diseases, at the same time Pfizer announced that it was ending its current drug research platforms for those same diseases.
The takeaway is that collaborative research attracts talent and investment.
On Feb. 8, URI announced that Peter Snyder, who has served as senior vice president and chief research officer at Lifespan since 2008, had been hired to be the vice president for Research and Economic Development and professor of Biomedical and Pharmaceutical Science. In his position at URI, Snyder will also hold appointments as an adjunct professor of neurology at the Alpert Medical School; scholar-in-residence at Rhode Island School of Design; and professor and member of URI’s graduate faculty with the George & Anne Ryan Institute for Neuroscience.
The takeaway is that investing in talent is the best way to keep that talent in Rhode Island.

PROVIDENCE – This story comes with its own warning label: By reading this story, you are about to enter controversial territory, where you will encounter accurate reporting and analysis that runs counter to the prevailing narrative. After reading the story, your consciousness may be altered.

In her July 12, 2017, executive order, Gov. Gina Raimondo called upon her Task Force on Overdose Prevention and Intervention to create a comprehensive statewide harm reduction strategy, giving a November deadline for its completion.

Yet, some eight months later, three months after that initial deadline passed, there exists no public statewide strategy document. Why is that?

Not withstanding the hard work and the good people on the Task Force that are wrestling with strategic responses to the drug overdose epidemic in Rhode Island, creating a statewide harm reduction strategy has become much like an orphaned child seeking adoptive parents, with no one willing to step up, the process caught up in the bureaucracy.

In December and again in February, ConvergenceRI queried the R.I. Department of Behavioral Health, Developmental Disabilities and Hospitals about whether a public harm reduction strategy document exists. The question has gone unanswered. Why is that?

There has been little if any media coverage about this growing fissure in the state’s strategic approach on how to prevent overdose deaths through harm reduction, save for the continued efforts by ConvergenceRI to ask the questions and bring the discussion into a broader public conversation. Why is that?

The reporting efforts by ConvergenceRI have included, most recently, publishing a report by RICARES, a community recovery advocacy group, that was released on Jan. 22, which offered an in-depth, detailed public policy analysis of potential strategy options. [See link below to the ConvergenceRI story, “A strategy of reducing harm and saving lives on the road to recovery.”]

The issues surrounding how to implement harm reduction are complicated, politically and legally. There are many who conflate programs such as medically safe injection sites or the distribution of fentanyl testing strips as encouraging and enabling illegal drug use.

There are also legal concerns about whether such strategies could be seen as aiding criminal activities and enterprises. In December of 2017, U.S. Attorney General Jeff Sessions warned Vermont, which is considering opening safe consumption sites, that such facilities "would violate federal law."

And, in an election year, when Raimondo is running for re-election and her continuing work to address the epidemic in overdose deaths has become a potential wedge issue to separate her from her Republican opponents, defining and implementing controversial harm reduction strategies could be seen as politically risky, even if they save lives.

If, as sociologist Shannon Monnat says, we cannot arrest our way out of this public health crisis, Narcan our way out of it or treat our way out of it, the blunt question remains: if the goal is to save lives, to intervene to keep people from dying, why has Rhode Island failed to implement a coordinated statewide harm reduction strategy?

Here is what RICARES said in introducing its position paper, and it bears repeating:

“We recognize that people’s engagement in drug use is often fluid and that people frequently move in and out of active drug use over long periods of time even if their ultimate goal is to quit using. It is critical during this process that people have access to harm reduction services that they can access without fear of exposure or shame.

“It is critical that they can feel safe accessing harm reduction services without potentially threatening their access to drug treatment services or living in fear of losing their children, their job, their housing, etc., because they are scared of the potential to be reported for or seen accessing the harm reduction services.

“We accept the reality that people do and will use drugs. We want to focus on reducing the harmful consequences that include HIV, Hepatitis C, criminal activity, incarceration, and death. That acceptance of reality should not be conflated with our endorsing or condoning illegal drug use. We do not.”

Does that sound like a good beginning to a statewide harm reduction strategy document? Good question.

Safe injection sites
As part of its Jan. 22 story, ConvergenceRI first “broke” the news that the Rhode Island Medical Society had convened a meeting of stakeholders to discuss the possibilities of creating medically supervised safe injection sites in Rhode Island, having learned about the meeting from one of the participants.

The meeting held by the R.I. Medical Society had apparently been convened in part at the request of several members of the Task Force, allegedly frustrated by the inability to have that conversation under the aegis of the Task Force, according to sources. There were no representatives from either the R.I. Department of Health or the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals in attendance, according to sources. A representative of the governor was hooked in via speakerphone for the discussion.]

The context for the meeting is that Rhode Island, despite repeated claims of being an innovative national leader in how it has been addressing the overdose epidemic, has not been a leader when it comes to moving ahead with harm reduction strategies.

On Tuesday, Jan. 23, the city of Philadelphia announced that it was moving ahead with plans for private organizations to set up medically supervised drug injection sites, amid an unprecedented rise in overdose deaths in recent years, according to news reports. The walk-in facilities would also offer access to sterile needles, the opioid-reversing drug Narcan, wound care, and referral to social services. [See link below to story by The Philadelphia Inquirer, “Safe injections sites to fight opioid overdose deaths get green light from Philadelphia officials.”]

Similar initiatives are under consideration in Seattle, Wash., in San Francisco, Calif., and in Massachusetts, with a public hearing held on Cape Cod this past summer.

Fentanyl testing strips
Another potential harm reduction strategy is the distribution of fentanyl testing strips to enable those who are using illicit drugs to test for fentanyl content; fentanyl has been linked to more than 50 percent of the overdose deaths in Rhode Island in 2016, according to the R.I. Department of Health data.

On Monday, Feb. 5, the results of a study coordinated by the Bloomberg American Health Initiative was released about the potential use of testing strips to detect fentanyl in the illicit drug stream. The format, unlike most academic research publications, was graphically slick, with embedded videos and photographs.

The study, known as FORECAST, or Fentanyl Overdose Reduction Checking Analysis Study, was conducted by researchers Susan Sherman at the Johns Hopkins Bloomberg School of Public Health and Traci Green, a senior research scientist at Rhode Island Hospital and associate professor of Emergency Medicine and Epidemiology at the Brown schools of Medicine and Public Health. [See link to the full study below.]

Green has served as a primary consultant with Gov. Gina Raimondo’s Task Force on Overdose Prevention and Intervention since its creation, and has been involved in research and epidemiological work on overdose deaths related to prescription painkillers and opioids since 2010.

[It was ConvergenceRI’s reporting on Green’s research in July of 2011 that first highlighted the growing numbers of overdose deaths in Rhode Island from prescription painkillers and led to the director of the R.I. Department of Health at that time, Dr. Michael Fine, changing the state’s public health priorities in 2012, in what seems like light years ago.]

The headline on the news release for the study read: “Low-tech, low-cost test strips show promised for reducing fentanyl overdoses; the highly accurate strips hold potential for a public health approach to the overdose crisis.”

The study tested three different technologies for their efficacy in detecting fentanyl in illicit drug samples; it also interviewed 335 drug users in Baltimore, Boston and Providence about their willingness to use such fentanyl strip technology and the reasons why.

84 percent of the respondents said they were worried about the drugs they were using containing fentanyl in them; one in four [26 percent] stated a preference for drugs with fentanyl, according to the study. Those numbers refuted the idea that people who use drugs were actively looking for fentanyl, according to researchers Green and Sherman.

Ironies abound
There were, however, a number of ironies attending the study’s release:

First, without a statewide harm reduction plan in place in Rhode Island, how such a fentanyl strip testing program might work or be implemented becomes emblematic of the Task Force’s failure to develop such a comprehensive plan.

Second, the potential relationship between a medically supervised safe injection site and the distribution of fentanyl testing strips would need to be discussed in the context of a statewide harm reduction strategy, which does not yet exist.

Third, the release of the news about the study in Rhode Island was delegated to the Lifespan communications department by the Bloomberg American Health Initiative, working under the apparent assumption that major health systems were the best way to disseminate the story, given Green’s affiliation with Rhode Island Hospital.

However, it has been ConvergenceRI's experience that Lifespan is not, ah, what could be termed an equal opportunity disseminator of information. The news of the study was not shared equally or equitably with Rhode Island news media.

What apparently happened was that Rich Salit, a former Providence Journal reporter now working for Lifespan, arranged advanced briefings for two of his former colleagues, so that they could publish their stories on the study when the findings were officially released, according to Dori Henry, the communications director at the Bloomberg American Health Initiative at Johns Hopkins.

When ConvergenceRI emailed Salit the morning of the release to ask the reasons why ConvergenceRI had been excluded from the advanced briefings, Salit said he needed to kick the question up to his supervisor at Lifespan, David Levesque. Salit gave Levesque’s telephone number as 277-7299, which is a non-working number at The Providence Journal. Call it a Freudian slip of providential proportions. [The mistake was later corrected.]

Who controls the conversation, and why it matters
The lack of inclusiveness in media outreach about the fentanyl study underscores a much bigger question: who controls the conversation about harm reduction moving forward?

The Governor’s Task Force, despite being tasked to do so, has not yet developed a statewide public harm reduction strategy. Questions about whether a statewide harm reduction strategy document exists remain unanswered by state officials.

The failure to talk about safe injection sites within the Task Force apparently led members to go outside and have the Rhode Island Medical Society convene a meeting of stakeholders.

The choice of Lifespan to be the broker of advanced briefings on the release of the fentanyl strip testing study by the Bloomberg American Health Initiative at Johns Hopkins reinforces the idea that big hospital systems are the best arbiters for news about public health interventions.

One consistent factoid, looking at the public health crisis around addictive prescription painkillers and overdose deaths, both here in Rhode Island and across the nation, is the fact that hospital systems and the medical establishment have often been late to the party in responding, in changing practices and interventions, from prescribing practices to drug monitoring to emergency department protocols, having to be pushed and prodded by community activists to do so.

At the recent visit by the U.S. Surgeon General Jerome Adams at the Anchor Recovery Community Center, organized and orchestrated by Sen. Sheldon Whitehouse, the harm reduction strategies of fentanyl testing strips and safe injection sites never came up as part of the official conversation.

The high number of EMS transports to hospitals in 2017 for the “impression” of alcohol intoxication has not yet become part of the conversation around the Task Force’s work on overdose prevention and intervention, despite alcohol use being a co-morbidity. [See the link to the ConvergenceRI story below, "Moving beyond dilly dilly.”]

Further, the lack of “treatment” options for chronic alcoholics was recently documented in a story written by an ER doctor, that was republished by ConvergenceRI, “The recurring dance of chronic intoxication and the ER.”]

Finally, there is a lack of discussion in recognizing the “diseases of despair,” linking deaths from drugs, alcohol and suicide to a growing economic and social disruption, reflecting health and wealth disparities. As recovery advocate Jonathan Goyer told U.S. Surgeon General Adams, recovery is not about sobriety, it is about connectedness.

Editor's note: In an effort to bring the discussion about harm reduction front and center, RICARES and Protect Families First are hosting a community conversation about "medically supervised consumption sites" on Thursday, March 1, from 5:30 p.m. to 7 p.m., at the Brown University medical school. "Come learn about what medically supervised consumption sites [also known as safe injection facilities] are, the evidence behind them, and how they fit into a harm reduction model to prevent overdose deaths," the flyer for the event says.

Fire stations as a point of entry

One of the latest “innovative” approaches by Rhode Island, modeled on a pilot program in Nashua and Manchester, N.H., has been the opening of 12 fire stations in Providence as safe stations for those seeking help with substance use problems.

According to an AP story published by WPRO on Feb. 8, the safe stations program has attracted one person since its official launch on Jan. 2.

As reported by Amanda Milkovits with The Providence Journal, the expectation is that “anyone seeking recovery from addictions can show up at any time, at no cost, and get connected in less than 15 minutes with treatment and recovery centers.”

The plan is that firefighters will conduct an initial medical evaluation before connecting individuals with the Providence Center’s Anchor Recovery program. City officials estimate that the city will see up to four people a day seeking treatment.

In Milkovits’ story, firefighters in Nashua and Manchester spoke glowingly about the success of the New Hampshire programs, and the opportunity for everyone to become “recovery allies,” as Deb Dettor, director of The Anchor Recovery Community Center, described it. “You never know when the light is going to go on,” she said, as reported in the story. “We want them to know there’s hope.”

However, in Manchester, the story has been transformed into what to do when the lights went out at Serenity Place, a recovery service provider working with the fire stations, where the demand for services as a result of the safe stations program overwhelmed available resources for access to treatment.

In a Feb. 5 letter, the mayor, the fire chief, the director of the city’s health department, along with three service providers, wrote:

“We have all watched with dismay the closing of Serenity Place in Manchester. Unfortunately, we learned the lack of structure and demand for substance use disorder services dramatically overwhelmed Serenity’s available resources. We are now rebuilding a system that is capable of responding to need, but with new partners and a new approach.”

To be successful in the long term, the letter continued, the officials said that providers must communicate better and work together to serve the public’s need.

“Safe Station will remain an open access point to those seeking substance use disorder services,” the letter said. “However, it is an entry point, and not a substitute for care. Hospitals should never refer patients back to the fire station.”

For whatever reason, this snafu has never become part of the narrative in reporting about the new safe station program in Providence. Why not?

Food for thought
In his recent provocative article published on Feb. 7 in Daily Yonder, “The Pharmaceutical Colonization of Appalachia,” Wayne Coombs, who served as a counseling professor at Marshall University and director of research and development at the West Virginia Prevention Resource Center, connected the epidemic of addiction with the trauma brought about by the colonization of the region by the coal industry.

“Appalachians never asked for addictions and its associated problems,” Coombs wrote. “It was all bestowed on us as a direct consequence of the massive group trauma brought about by industrial colonization. Under this colonization, a large percentage of the people of Central and North Central Appalachia were seriously wounded.”

Under the imposed social order, Coombs continued, “The population’s wounds got infected, abscessed, and became chronic. The wounds were passed down from one generation to the next. The imposed context continually wounded people who, over time, showed the wear-and-tear that comes from this.”

The context, according to Coombs, became physically and socially toxic. “It was diseasing and killing the community,” he wrote. “This should not come as a surprise, because it happens all over the world. Anytime one group of people colonizes another group, there will be trauma and it has consequences that can last for generations. What has been wrought through industrial colonization has, over time, taken a great toll on the people and made them quite vulnerable to the things that ease their pain.”

Coombs concluded: “The current opioid epidemic is not surprising when you see it in its proper historical context. If you take any group of humans and force them into a wounding environment, as Appalachians were, they will become traumatized and seek relief. Any one of us would do the same because it is part of our nature as humans. The seeking of relief by this large chunk of Appalachians did not go unnoticed by other industries, particularly the pharmaceutical companies, who have been all too happy to help out with the relief seeking…at a price of course. They have flooded North Central and Central Appalachia with billions of painkillers.”

The article was shared with ConvergenceRI by a local physician, who wrote: “I’ve often wondered why Rhode Island has so many challenges with substance use – and how to reduce that use.” Reading this article, the physician continued, “I wonder whether the answer doesn't lie in our history of industrialization: in the fact that in 1900 we were the most industrialized state in the Union, but also the place with the most income inequality.”

The physician compared the working conditions in the coal mines to the industrialized process of the mills: “Coal mining itself is also an industrialized process, where people become beasts of burden, whose value is reduced to how much product they can produce. I wonder if our mills created similar emotional and social scars on our families and communities a hundred years ago.”


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