Mind and Body/Opinion

Opioid OD crisis is not an unsolvable problem

The epidemic continues to shape shift, but our strategies are stuck in the past and need to change; the solutions are hiding in plain sight

Photo by Richard Asinof

To change the strategies to reduce the growing number of opioid OD drug fatalities, it will require investments in creating better testing and safer supplies of illicit drugs.

By Ian Knowles
Posted 9/5/22
The increased use of dangerous adulterants in the illicit drug supply has resulted in the greater risk of drug overdoses, yet our strategies and policies have not adapted to the way that the epidemic has shape shifted. The solutions include more robust street testing and creating access to a safer supply.
Will the R.I. Attorney General push to have more robust street testing devices funded by the hard-won legal settlements against drug manufacturers, distributors, and consultants? Why have the candidates running for Governor failed to talk about these issues in their debates? Do you reporters and anchors serving as debate moderators need to be better educated about the politics of drug overdoses in Rhode Island? Is the R.I. General Assembly willing to invest tax dollars in changing the strategies around drug overdoses caused by adulterants in the illicit drug supply?
Call it a huge Friday news dump. The Senate Commission that studied the structure of R.I. Executive Office of Health and Human Services issued its final report in a news release on Friday, Sept. 2, recommending huge changes for the state agency, with important budget implications – changes that would dramatically improve the ability of the state to respond more nimbly to the challenges of the epidemic of opioid ODs.
First, the Commission recommended creating an independent department for R.I. Medicaid within EOHHS, and to elevate the role of Medicaid director, requiring the advice and consent of the Senate. The current Medicaid budget, which is nearly one-third of the entire state’s budget, would enable the position of Medicaid director to be directly accountable to the Governor and the General Assembly. Such greater accountability would enable more oversight of the setting of Medicaid rates, identified as a major problem during the Commission hearings.
Second, the Commission recommended severing “hospitals” from the R.I. Department of Behavioral Healthcare, Disabilities and Hospitals, and creating an independent division – perhaps functioning as a quasi-public. At the same time, the Commission recommended adding children’s behavioral health and developmental disabilities to be under the purview of BHDDH.
Third, the Commission recommended that power of the Secretary of EOHHS be increased to provide the Governor with recommendations for hiring and removal of sub-agency directors, influenced by the testimony of MaryLou Sudders, the Secretary of the Mass. Executive Office of Health and Human Services.
Fourth, the Commission recommended that a stakeholder group be created for the rate review process that will be included in the FY2024 state budget, to be conducted by OHIC.
Stay tuned. The biggest question is: will any of the candidates running for Governor – and the reporters asking questions – be able to talk intelligently about these proposed changes?


PROVIDENCE – In PART One, I reported on how the TestRI Project at the Brown School of Public Health had revealed the presence of at least 50 adulterants [emphasis added] in the state’s illicit drug supply of heroin, fentanyl, cocaine, and methamphetamine. [See link below to ConvergenceRI story, “Entering the fourth wave of the opioid epidemic.”]

In addition to this new, increased overdose risk, we face the danger of a new set of chronic health problems, due to the nature of some of the adulterants.

We have to keep reminding ourselves that the opioid overdose crisis is not actually an unsolvable problem.

It is frustratingly clear that eight years of strategies, programs, intense work, and commitment have not been sufficient to meet the 2014 Governor’s Opioid Overdose Prevention and Intervention Task Force initial goal of decreasing the overdose fatality rate by one-third in three years.

There is no question that the on-going commitment of so many individuals and organizations in the state has saved many lives. But:

• In 2014, there were 240 fatalities.

• In 2018, there were 314 fatalities.

• In 2021, there were 435 fatalities.

We must continue to remember that these statistics are not just data points. They represent the lost lives of our family members, friends, fellow workers – all people whose life had value, and who were loved.

The lives lost to fatal drug ODs represent the challenge to our system of care – one that that has saved many lives, but continues to lose too many more lives.

It was reasonable to expect that the continued collaborations, strategies, and initiatives would have created a synergy that would result in at least a decreasing fatality rate. But there is a marked disconnect between the quantity and quality of the informed planning, work, and commitment and the outcome of that, at the time, seemed a feasible and modest goal.

Why the disconnect?
The most recent presentation of the updated “Strategic Plan to the Opioid Settlement Advisory Committee” this summer notes that a primary driver of fatal overdoses is: “Sustained presence of fentanyl and analogues in the drug supply, including nearly 75 percent of all overdose deaths in 2020. Fentanyl is now present in many types of drugs [not limited to opioids], and potentially growing in potency.”

That is the only mention [emphasis added] of the toxic and lethal drug supply that is the primary driver for the terrifying increase in the fatality rate [39 percent from 2018 to last year, 13 percent from 2020 to last year].

There are no explicit priorities or strategies to address the drug supply that is killing our family members, our friends, our neighbors, and our colleagues.

We had been informed of the effect of the introduction of fentanyl into the illicit drug supply back in 2016, with the publication of a study by Brandon Marshall, Traci Green, et al [“Exposure to fentanyl-contaminated heroin and overdose risk among illicit opioid users in Rhode Island: A mixed methods study”] that stated: “This study indicates that fentanyl is pervasive in the local drug supply.”

But, we have been late to react; it’s six years later and we haven’t been able to deal with the effect of fentanyl.

As reported in PART One, the presence of additional contaminants makes the supply even more dangerous, more complex, and more unpredictable with the potential for the rapid development of associated chronic medical problems beyond the long-existing conditions of Hepatitis C, HIV/AIDS, and bacterial infections, such as endocarditis [that requires long term hospitalization]. Trying drugs has always carried risk; but most people who try drugs don’t develop problematic use, addiction, or die.

A life-or-death gamble
Today in Rhode Island, trying drugs can be a life-or-death gamble. There has never been a worse time to experiment with drugs.

“We have to accept the fact that this foe is outrageously strong, and we also have to face the fact that none of our tools are sufficient in and of themselves to the task. Not bupe, not the treatment system, and certainly not the criminal justice system, which tends to make things worse,” said Daniel Ciccarone, a University of California epidemiologist said.

Quick overview of drug policies
Internationally, drug policy focuses on three primary areas: supply reduction, demand reduction, and harm reduction:

Supply Reduction, the responsibility of a large, complex, and expensive law enforcement network, has failed. We continue to operate as if the policy of interdiction and prohibition works. It clearly does not.

The entrenched market continues to make illicit drugs readily available and affordable; Fentanyl is far easier to obtain than Buprenorphine.

Demand Reduction is the responsibility of a multipart treatment and prevention network that continues its on-going struggle to deliver services for increasingly complex conditions. However, the demand for drugs continues to exceed the demand for treatment and prevention services.

The sad reality is: It is far simpler and easier to obtain and use illicit drugs than to access treatment for addiction and any underlying mental health issues.

• The Harm Reduction principles and strategies that have been implemented in the state [e.g., syringe exchange programs, Naloxone and Fentanyl test strips, test dosing, ‘don’t use alone’] have all been necessary, have all saved lives, and continue to save lives daily.

The work of the organizations and individuals delivering harm reduction services in Rhode Island is extraordinary and is inspiring. But it still is not sufficient. We need to do more, and there is more that we can do. As Beth Macy said in her latest book, Raising Lazurus, the epidemic continues to shape shift.

Our need to shift policies, strategies
Our policies and strategies must also shape shift in order to effectively respond. We must directly address the drug supply more aggressively and more comprehensively. As Greg Williams, a health-policy consultant and creator of the film, “The Anonymous People,” said, “We can’t wait for 10 years of evidence-based research like we did with bupe. We need to build things right now that meet people where they are in moments of crisis.”

Translated, we must find answers to the question: “How do we make the drug supply safer to use?”

Thom Browne, Jr., CEO Of the Colombo Plan Secretariat and formerly of DEA and the U.S. State Department, has been investigating the cutting agents in street drugs since 2010, when the cutting agents started to change.

Browne has made two recommendations, based on the reality that for safe use, people who use drugs must know exactly what they are using. Even experienced users in Rhode Island don’t exactly know, except for the probability of fentanyl; certainly naïve and recreational users don’t know.

There are two relatively low-cost strategies that can be implemented quickly:

• Publicizing what the adulterants are in the illicit drug supply. Thanks to the TestRI project, we receive reports twice a month with specific information about what adulterants are in the drug supply [the test results started in May and can be found at preventoverdose.ri]. The bi-weekly reports are our most up to date information. This information can be shared via the network of treatment and harm reduction organizations, community health centers, by outreach workers, etc.

In addition, information about dangerous interactions between illicit drugs and over-the counter medications, and between illicit drugs and the range of medications prescribed for physical and mental health conditions should be developed and made readily available through the community networks These are simple solutions that can be implemented quickly and at minimal cost.

• More robust street testing. The most important strategy at this point is more robust street testing than what we are able to do with fentanyl test strips [to repeat: for safe drug use, people must know exactly what they are using].

Browne notes that as useful as the fentanyl test strips are, they only show ‘fentanyl.’ They don’t tell how many, or which, of the [presently] 200 fentanyl analogues/derivatives are in a sample.

And, of course, they won’t show drugs such as benzodiazepines [Alprazolam has been identified as a cutting agent in the Rhode Island supply) or Xylazine [a powerful veterinary anesthetic that has also identified in the Rhode Island supply] that will create an enhanced potential for overdose.

We must bring more advanced drug testing techniques directly to the users in the streets. Thom Browne’s team uses six-to-eight pound portable testing machines, such as the TruNarc or Gemini brands. They are able to produce a test result in 15-30 seconds. The results are not confirmatory, but they are presumptive – and that is fine.

In addition, they have developed a GC-MS portable machine that weighs 42 pounds and can detect up to 15 compounds at one test. [Gas Chromatography-Mass Spectrometry is the gold standard of drug testing and is confirmatory]. The test result on their machine takes 15 minutes.

Solution: Opioid settlement money could purchase the machines and provide them to the harm reduction organizations that are doing outreach. Outreach teams could then go to the targeted hot spots that the regular CODE alerts identify. Further, CODAC’s mobile van would be able to do testing with a portable machine. While these strategies will help make drug use safer, they won’t make the drugs safer.

Disrupting the toxic, lethal drug supply
Moving forward, to make drugs safer, the toxic, lethal drug supply must be disrupted. Interdiction and prohibition have not proven to be effective disrupters.

Here are two strategies that can more effectively disrupt the illicit drug supply.

• Safe Supply. Lisa Peterson is the CEO of VICTA, a treatment program in Providence that delivers substance use disorder treatment to more than 500 patients, 265 of whom receive medication for opioid use disorder. Peterson responded to PART One of this story, saying: “Yes! We are super worried about this increasingly unpredictable supply, telling everyone they need CPR in addition to Narcan training. It’s getting so bad in Vancouver that folks are now dependent on both the fentanyl and the benzo, which makes for a nearly impossible situation. We need safe supply [emphasis added] before it’s too late.”

The notion of safe supply does not come out of left field.

A 2020 paper from Isvins, et al “Tackling the overdose crises: The role of safe supply,” said: “What is urgently needed is a safer alternative [i.e., pharmaceutical grade] to the toxic drug supply to prevent overdose events resulting from illicitly-manufactured fentanyl and fentanyl-adulterated opioids.”

The paper continued: “Providing access to pharmaceutical-grade opioids to people at high fatal overdose risk will resolve the limitations of current overdose response measures by effectively reducing the occurrence of overdose events and reduce overdose mortality.”

• A 2019 paper from Blanco and Volkow,, “Management of opioid use disorder in the USA: Present status and future directions,” said: “The medications for opioid use disorder, which include methadone, buprenorphine, and extended-release naltrexone, significantly improve opioid use disorder outcomes.”

The paper continued: “However, the effectiveness of medications for opioid use disorder is limited by problems at all levels of the care cascade, including diagnosis, entry into treatment, and retention in treatment.”

Further, the authors state: “There is an urgent need for expanding the use of medications for opioid use disorder… and for development of alternative medications and new models of care to expand capabilities for personalized interventions.”

The Isvins paper made the strong case about the benefits of providing easy access to unadulterated opiods. “Providing easy access to a consistent supply of unadulterated opioids will not only prevent overdose events, but also potentially reduce drug-related harms [e.g., violence related to the illicit drug market] and improve overall health and well-being, as evidenced by studies demonstrating the effectiveness [e.g., high retention rates, improved social functioning] of prescribed diacetylmorphine and hydromorphone.”

Of course, the simplest [simple, not easy] way to totally disrupt the illicit drug supply is to legalize drugs. However, legalization that would result in a safe and regulated drug supply continues to be an action that many [not all] of our political leaders and policy makers continue to dance around.

We ensure that the users of the legal drugs – alcohol and nicotine – have a safe supply. A cigarette smoker knows that there are long-term health dangers for the use of tobacco by the prominent warning on cigarette packs of the health hazard. The warnings will become much starker and more explicit after October of 2023, when the 11 new required warnings kick in.

Similarly, the regulation of alcohol allows the consumer to know the alcohol content of their product, and to be secure in the knowledge that any additives are safe for consumption.

The question is: Why would we not want to keep everyone safe? We have to keep reminding ourselves that the opioid overdose crisis is not actually an unsolvable problem.

Ian Knowles is the program director at RICARES. He is a frequent contributor to ConvergenceRI.

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