JILL PIPHER: Good evening.
I'm Jill Pipher, the vice
president for research
at Brown University.
Welcome to our program,
"Frontlines of the Opioid
Crisis," co-sponsored by
the American Academy of Arts
and Sciences, one
of the country's
leading scholarly organizations.
Tonight, you'll hear from
some distinguished speakers
and panelists about a
national problem that
is of great personal
significance to many families,
and about how our researchers
in Brown's schools of medicine
and public health are
working to develop solutions.
I'd like to tell you about
the order of this evening's
program.
In a moment, I'll
introduce Brown president,
Christina Paxson.
After her remarks, I will
introduce Rhode Island senator,
Sheldon Whitehouse,
and then introduce
our keynote speaker and
moderator, Michael Botticelli.
After Dr. Botticelli's
remarks, he'll
have a conversation with
three researchers from Brown,
and an important
leader from the state
government in Rhode Island.
At the end of the
discussion, there'll
be a chance to ask
some questions.
Christina Paxson is the 19th
president of Brown University.
Now in her seventh
year, President Paxson
has accomplished a great deal.
She continues to preside
over Building on Distinction,
Brown's 10-year strategic
plan she launched in 2014
to guide Brown's commitment
to addressing the defining
challenges of the 21st century.
President Paxton's
passionate belief
in the power of knowledge
infuses her leadership.
She has championed
collaboration by identifying
research partnerships
and opportunities
in biomed, public
health, entrepreneurship,
and other areas that advance
the interests of Providence
and Rhode Island.
As a result, Brown
research has been
instrumental in
advancing initiatives
that bolster the
knowledge and innovation
economy that is rising here.
A respected economist
and public health expert,
President Paxson's
career as a scholar
coalesced around how
economic insights
can inform policies that
improve the human condition.
And as an accomplished
researcher,
she will tell you that
data matters to her.
Indeed, among the reasons why
Brown's work on opioid research
has been so
compelling is the hope
it offers in reducing
the number of lives
affected by opioid addiction.
So please join me in
welcoming Christina Paxson.
[APPLAUSE]
CHRISTINA PAXSON:
Thank you, Jill.
And good evening, everybody.
Welcome to Brown.
On behalf of the university
and the American Academy
of Arts and Sciences, welcome
to our very special symposium
on the opioid crisis.
I'm particularly pleased
that we're co-hosting
this with the Academy.
The Academy of Arts
and Sciences is
one of the nation's oldest
and most prominent learned
societies and independent
policy research centers.
Last year, I was
honored to have been
named a fellow of the Academy,
joining many Brown colleagues,
including Jill Pipher.
And among the
responsibilities of being
a fellow is to invigorate
public conversation
on the issues of our times,
through symposia like this one.
Now, this is the Academy's
first event here at Brown.
I hope that there will be many
more in the years to come.
And I want to thank the
Academy for co-hosting with us.
And my thanks to
Jill and her staff,
and the Office of the Vice
President for Research,
for organizing the event.
Now, onto our topic
for the evening.
I think there are
few issues out there
that are as disturbing
as the opioid crisis.
We know that this is
a national epidemic.
We know that it's a national
public health emergency.
And it's become so pervasive
that opioid deaths have soared,
while deaths from
other leading causes,
such as cancer and heart
disease, have dropped.
Last year, more than
72,000 Americans
died from drug overdoses, a
record driven, in large part,
by the spike in opioid abuse
and the use of fentanyl to lace
heroin or cocaine.
And opioids are seen
as a major contributing
factor to lowering life
expectancy in the US
in recent years, something
that rarely happens
in the history of countries.
So research into opioid abuse
is an urgent national priority.
I think that's pretty clear
from the data, as we all know.
And against this very
bleak national picture,
Rhode Island has offered
reasons for hope.
And Brown has been a very
willing and eager partner
to make the change happen here.
In 2017, opioid-related deaths
in Rhode Island dropped by 4%
year over year, which was
the first significant decline
in almost a decade.
And the state continues
to be widely recognized
for generating innovative
research and treatment
plans that are helping
to ease the crisis.
And the hope is
that what we do here
can not only improve the
lives and well-being of Rhode
Islanders, but we
can create models
that help other
parts of the country,
and spread out the
knowledge that's created
right here in Rhode Island.
Dr. Nicole Alexander-Scott,
director of the Rhode Island
Department of Health and an
alumnus of our School of Public
Health, something
we're very proud of,
she is co-chair of the Prevent
Overdose Rhode Island Task
Force.
And while she couldn't
join us here this evening,
she has been just a key player
in addressing the opioid crisis
in the state.
We've been privileged to work
with her on several issues
and in several initiatives.
Meanwhile, at Brown, we're doing
what research universities do.
We're focused on
generating new discoveries
and developing approaches
to fight the opioid crisis.
We always want our research,
no matter what field it's in,
to be consequential, and to
have an impact on today's
important challenges.
And our expansive work
on opioid abuse, I think,
fits right into
this model of what
the research mission of
a university like Brown
should be.
Several Brown
researchers, led by three
that we'll hear
from tonight, have
been on the frontlines of
addressing the opioid crisis.
Brandon Marshall,
an epidemiologist
at the School of Public Health,
has been a national leader
in the development of
inexpensive test strips
to help addicts
avoid potentially
fatal fentanyl poisoning.
And his test findings were
published just last week
in the International
Journal of Drug Policy.
Traci Green, also in the
School of Public Health,
and Jody Rich, at the Warren
Alpert Medical School,
have worked on designing and
then documenting a program
to treat state prison inmates
for drug addiction while
in jail, and then afterwards.
And we know that
release from prison
is a time of very high
risk of opioid death.
And the program has been
shown to dramatically reduce
opioid deaths and is being
studied around the country.
And we'll hear more about
that during our discussion.
I would add that Professors
Marshall, Rich, and Green are
all special advisors to the
Prevent Overdose Rhode Island
Task Force.
Meanwhile, the Warren
Alpert Medical School
just won the 2018 AAMC
Curricular Innovation Award
from the Association of American
Medical Colleges, an honor
recognizing the opioid training
that the school integrates
into all four years of
its medical curriculum.
The future of
research in this area,
at Brown and elsewhere in
the world, is very bright.
Professor Rich was just
elected to the National Academy
of Medicine.
Professor Green will lead a
new opioid research center
at Rhode Island Hospital, backed
by an $11.8 million NIH grant.
And I'll note that Peter
Monti, somebody who's worked
in addiction for many, many
years-- alcohol and addiction--
he's director of Brown Center
for Alcohol and Addiction
Studies--
he would have been
here this evening.
He couldn't be, for
a very good reason.
Today, he's receiving the
prestigious Jack Mendelsohn
award from the National
Institute on Alcohol Abuse
and Alcoholism.
And he's giving a
lecture at the NIH.
So that's why he's not here.
So our symposium today comes
at a very timely moment
of promise.
I think despite this
very grim backdrop,
there are good things,
promising things
that are happening,
as we continue
to find ways to address this
very urgent health issue.
So I join all of you in
looking forward to hearing
from our keynote
speaker, Michael
Botticelli, our panelists,
and as well as our senator.
So thank you very much.
And thanks for coming to this.
[APPLAUSE]
JILL PIPHER: Thank
you, President Paxson.
Now I would like to introduce
US Senator Sheldon Whitehouse.
Senator Whitehouse is in
his second term as senator
from Rhode Island.
He has been a strong advocate
in our state and nation
in combating the
opioid epidemic.
In 2016, Senator Whitehouse
worked with a bipartisan group
of senators to pass the
Comprehensive Addiction
and Recovery Act, which helped
create Centers of Excellence
for the treatment of
opioid use disorder.
We appreciate his focus on
this important national issue.
And we welcome here tonight.
[APPLAUSE]
SHELDON WHITEHOUSE:
Thank you, Dr. Pipher.
It's great to be here.
I'm honored to be
invited to speak
at the first-ever
joint appearance
of the American Academy of
Arts and Sciences and Brown
University.
President Paxson, thank
you for being here.
And thank you for Brown's
leadership in this space.
The panel is wonderful.
Director Boss will stand in
for Director Alexander-Scott.
And they are both fabulous.
So there's no loss of step,
as Dr. Alexander-Scott
recovers from her injury.
Jody Rich has done
wonderful work in this area.
And we can congratulate
him on being
one of the newest members of the
National Academy of Medicine.
[APPLAUSE]
Drs.
Green and Marshall, thank
you for your great work.
I'm honored that
Tom Coderre is here,
who is leading this issue's
response in the governor's
office, after having
been the chief of staff
to the SAMHSA director
down in Washington.
And he had a really
important role
in the Comprehensive Addiction
Recovery Act as well.
I would note, also, that my
successor-- my grand successor,
I guess I should say-- as
United States Attorney,
Steve [? Danbrook ?] is here,
the acting United States
Attorney.
And I welcome Steve.
And of course, the principal
speaker, Michael Boticelli,
is a hero of mine.
He was the first director of the
Office of National Drug Control
Policy who was not out of
either the military or law
enforcement.
And he was also the first who
had the personal experience
of being in recovery.
And he brought a heart and a
passion and a point of view
to that office that made
an enormous difference
in our work.
And he had a very
significant role in CARA.
As the opiate crisis began
to emerge, some of us
saw it coming.
Rhode Island was
a hard-hit state.
Ohio was a very hard-hit state.
So I worked with
Senator Portman to try
to build a bill that
would be unstoppable,
through whatever hazards
the partisanship in Congress
might throw at it.
It took some years
to do all the work
and to do all the building
with all of the groups.
But we ultimately did.
And it was, indeed, unstoppable.
Two experiences from that--
first, we put money behind it.
We got strong pledges to
get the bill going forward,
that there would, in fact,
be serious investment.
And there has, in fact,
been serious investment.
And in Rhode Island,
we're seeing probably
$12 million more just this year.
And we expect that to
continue and increase.
The second is that the way in
which the bill was debated,
and the manner in
which it passed,
and the broad bipartisan
support for it
all confirmed that a
lot of the stigma that
had been the dark shadow on
this medical issue was abating.
I'm not Pollyanna-ish to think
that it's completely gone.
There still is stigma out there.
But it is very, very
significantly reduced.
We did not have
colleagues saying,
this is a moral failing.
These people need to be locked
up and gotten off the streets.
The only way to deal with
this is with enforcement.
None of that happened.
People understood this
was a medical issue.
It does require treatment.
And for that to work,
you need research.
And that's why this
meeting is so important,
and why Brown's commitment
to research is so important.
A lot is happening in
the treatment space,
with medication-assisted
treatment and different ways
to try to test how that
works, and different ways
to try to see how the
treatment should be delivered.
And all of that is in
a fairly nascent stage.
But there is an even
more nascent area
that I want to mention.
And that is the
area of recovery.
We have, for a long time,
invested in prevention.
We have, for a long time,
invested in intervention.
We have, for a long time,
invested in overdose response.
We've invested in treatment.
And we've invested
in inpatient care.
But once you're
through those phases,
and once you go out to
live a life in recovery,
there's been very,
very little support
for that last important piece.
For the first time,
the recent funding
focuses on that recovery piece.
And that's been one of
the important virtues
of our last round of
funding in Congress.
But it also poses a challenge,
because the recovery piece
has been so starved for
resources for so long
that we really haven't
been able to build
the evidentiary record yet.
So in order to get
things done in recovery,
we will have to take
some leaps of faith
about what is likely to work,
and be bold in our thinking
and our spending to reach
into that recovery universe.
But at the same time,
we're also going
to have to be very smart and
very prudent about tracking
what we do, and making sure
that that money is well spent,
and making sure that we
can continue to fund it.
I don't want to be
in the situation we
got into with the
Affordable Care Act, where
all the prevention money ended
up being a political target.
So at the same time, we have
to be both bold and cautious.
And I think the research work
that's happening at Brown
will position us to
take advantage of that.
It's my great honor to be here.
I'm proud of our
great university.
And I'm particularly
proud to share the stage
with this terrific panel and
with our principal speaker,
Michael Botticelli.
Thank you all so much.
[APPLAUSE]
JILL PIPHER: So
our next speaker--
thank you, Senator Whitehouse.
Our next speaker is a veteran
of drug issues in America,
and one of the nation's
leading voices about addiction.
Michael Botticelli was in charge
of national drug control policy
under President Barack Obama.
Currently, he is
executive director
of the Grayken Center for
Addiction at Boston Medical
Center.
Before his service
in Washington,
he served for nine
years as director
of the Bureau of
Substance Abuse Services
at the Massachusetts
Department of Public Health.
He will begin with
some remarks, and then
lead our panel discussion.
Welcome.
[APPLAUSE]
MICHAEL BOTTICELLI:
Good evening, everybody.
It's a pleasure to
be here this evening.
I want to thank President
Paxson for convening
us to talk about
what is, perhaps,
the most pressing public
health and social issue
that we face today.
Senator Whitehouse, it's
great to see you again.
I miss you tremendously.
But thank you for your service
and for being in Washington,
and to continue the good fight
on opioids and so many issues.
I'd also like to thank
the American Academy.
And I have to give a shout-out
in a small-world scenario,
to Dan [? Cusalino, ?]
who is now
with the American
Academy, who actually
worked for us in the Office of
National Drug Control Policy.
So it's good that we now
have champions and advocates
in other high places.
I also want to give a
shout-out to my colleague,
Tom Coderre, who I've known
for quite a long time.
I am not the only
high-serving person
in the Obama administration
that was in recovery.
And Tom and I were
often partners
in crime for many of the
things that we accomplished.
And I can't help but
think, the last time
we saw a health crisis like this
was in the height of the HIV
and AIDS epidemic.
And there was an expression
that those of us who
are affected by this
often use, as it
talked about the
inclusion of people
who were affected as part of
the solutions to the problem.
And that was, nothing
about us without us.
And I think it's a
clarion call for our work
here today, about how we involve
affected communities, affected
people, active drug
users into the highest
level of policymaking as we
think about our work ahead.
I jumped at the opportunity
to moderate a panel by people
who I have known and admired for
a very long time, who have just
been champions in this
work and have really
led the way, not only
here in Rhode Island,
but around the country, in terms
of the work that we're doing.
So I thought I'd spend a
little bit of time tonight
just talking and
framing my comments
from kind of two standpoints.
One is that the etiology and
evolution of this epidemic
has challenged us in
every step along the way,
in terms of how this
epidemic started,
how it's evolved over
time, and our ability
to see around the corner
in devising public health
interventions and policies
that meet the challenges.
And then the second frame
is to talk about the fact
that this epidemic
comes on the heels
of some long historic
deficits that we've had,
in terms of our attitudes
to people with addiction,
our public policy for
people with addiction,
and quite honestly, our
treatment and intervention
framework to do that.
So I think all of you know,
and President Paxson talked
about the fact that in
the early years, and still
today, that we see the
most significant morbidity
and mortality attached to
the vast overprescribing
of prescription pain
medication in the United States
by our medical community.
In 2012, at the peak
of opioid prescribing,
we were prescribing
enough medication
to give every adult American
their own bottle of pain
medication.
And many perceived opioid
prescribing as safe.
They were told by pharmaceutical
companies and doctors
that it was non-addictive.
It led to widespread
diversion and misuse,
with a quadrupling of
overdose deaths linked
to opioid-based pain medication.
We had to devise ways to undo
decades of medical training,
often against the powerful sway
of pharmaceutical companies
and medical associations
and practitioners who
loathe government
oversight and mandates.
We needed to retrain
people to dispose
of unused and
unwanted medications,
and to change regulations to
allow for more ongoing drug
disposal.
While many communities in
parts of the United States
have long been impacted by
opioids, and particularly
those of us in New England,
we saw many rural communities
dramatically impacted,
communities with little
to no health infrastructure,
let alone addiction treatment
capacity.
Many of us remember the
expression, hillbilly heroin,
that ascribed to the influx
of opioid medications,
particularly in rural areas,
like Appalachia and rural New
England.
This required us to
devise strategies
to develop and increase
treatment capacity, often
against the virulent opposition
from those same communities
that needed help the most.
We saw the influx of very
cheap, very pure heroin
in parts of the country
that historically
saw very little of it.
And because of the
economics of drug use,
this precipitated the
transition of many addicted
to pain medication to its
cheaper and more powerful
relative, heroin.
We saw, and still see,
unprecedented levels
of overdoses that require us
to develop and expand new ways
to reverse overdoses
by everyone who is
in a position to witness one.
We had to speed development
and approval of new naloxone
delivery devices and
convince law enforcement,
first responders, that it was
safe and effective to carry
naloxone.
We have also seen the
emergence of very powerful
illicit synthetic
opioids, like fentanyl,
that accelerated in
overdose, leaving us
very little time to intervene.
And it required new public
health communications
and interventions and strategies
to both detect these synthetics
and to provide information--
adequate information and
appropriate information--
to drug users.
I'm not an epidemiologist.
But epidemics don't
develop in a vacuum.
Conditions must be ripe
for epidemics to flourish.
And it has laid bare
longstanding challenges
that we have faced.
And I can't give a talk
without this epidemic,
while first and foremost
focusing on stigma--
stigma reflected in public
attitudes, in clinical care,
in the language that we use,
in the media representation,
in coverage and policy issues.
A recent survey in Massachusetts
done by Blue Cross Blue Shield
Foundation, in my good old
home state of Massachusetts,
that among survey
respondents, while it's good
that more than half
of people believe
that the opiate epidemic is
a public health issue rather
than a matter for
law enforcement,
only one in four people believe
that addiction is a disease.
28% believe that
addiction is a choice.
82% of people
believe that people
who are addicted to
opioids bear all, most,
or some of the blame
for their addiction.
And disturbingly,
a lack of desire
to give up their addiction is
seen as the biggest barrier
for people entering recovery.
Those attitudes are borne
out in our public policy.
And my colleagues at the
Johns Hopkins Bloomberg
School of Public Health,
in a recent survey,
showed that when even
compared to mental illness,
people are more reluctant
to want a treatment
benefit for people with
substance use disorders,
that employers should be
able to deny employment
to people with a history
of substance use disorders,
and landlords should be
able to deny housing.
They went further
to say that they
would be unwilling to have a
family member marry someone
with a history of
addiction, or work closely
with someone on the job.
So these public attitudes,
I think, most dramatically,
have affected our approach
federally to drug policy.
My former office-- I still
have a hard time saying former
office, Senator--
was established by Congress in
1988, with two main functions--
one, to set the current
administration's drug
policy, and second, to work
with our federal agencies
in making sure that the budget
supported those drug policies.
So if you look at the
history of federal funding,
that the largest
percentage of funding
until the end of the
Obama administration
focused largely on criminal
justice and supply reduction
approaches as it
related to addiction.
And that approach has led to
the vast over-incarceration
of people with
substance use disorders,
particularly people of color.
And it's estimated that about
70% of our jails and prisons
are there as a result of people
who are there with addiction.
We've had vast lack
of insurance coverage,
as well as equitable
coverage of treatment,
by both public and private
insurance companies.
The Affordable Care Act actually
required substance use disorder
treatment as one of the 10
essential mandated health
benefits for both Medicaid
expansion and marketplace
plans, leading to the dramatic
expansion of treatment,
particularly in
those states that
actually did expand Medicaid.
We've had a significant lack of
medical training on addiction.
We have long considered the
diagnosis, intervention,
and treatment of addiction as an
optional health care activity.
According to the National
Survey on Drug Use and Health,
only a mere 15% of people who
need treatment actually get it.
And disturbingly, only 8% are
those referred from our health
care delivery system.
The biggest referral source to
treatment in the United States
is our criminal justice system.
We have also had a
significant lack of attention
to social determinants
of health.
The health of an individual
is intertwined with the health
of their community.
And issues like poverty,
racism, violence, early trauma,
lack of educational and
vocational opportunities,
homelessness, and
unstable housing
often lead to these poor
determinants of health.
We will be back again
in another 10 years
if we don't address the social
underlying causes that cause
addiction and a wide variety
of other health concerns.
We've had lack of
access to and support
for the most highly effective
treatment for people
with opioid use disorders.
So if I said to
you, we have drugs
that decrease
mortality, that decrease
infectious disease, that
decrease drug use and increase
quality of life, you
would say, bring it on.
But unfortunately, only 20%
of those with an opioid use
disorder actually
get on a medication.
Only 4% of primary care
physicians in the United States
have gone through
the waiver training
to be able to prescribe
these medications.
And only about 50%
of those actually
prescribe them at every level.
At Boston Medical
Center, we are now
requiring every emergency room
physician, every primary care
provider, every family
doc, every OB/GYN doc,
and every psychiatrist to
complete the waiver training
by the end of this year.
We have 60% of rural counties
in the United States,
and 26% of urban counties, that
have no waivered physicians.
And again,
disturbingly, only 23%
of publicly funded treatment
programs, and less than 50%
of privately funded
programs, provide access
to medications as
part of their program.
50% of drug courts offer
access to medications.
In only one state, and I'm
glad I'm in that state--
Rhode Island--
reported full access
to all three forms of
opioid addiction medications
while incarcerated.
16 states only offer
naltrexone, one medication.
And the remaining 28 don't
fully offer any medication
to prisoners with
opioid use disorders,
despite rates of 120
times the overdose than
in the general population.
And a significant
belief, stigma,
that being on a medication
is not fully in recovery.
So the final two
points I want to make
is that up until
recently, we have
lacked a widespread advocacy
movement and visible recovery
community in the United States.
And again, I compare this to
HIV/AIDS in the United States,
when politicians failed
to utter the words,
when we had a lack of
appetite for resources
for research and treatment.
And it really fell to a bunch
of angry gay men and lesbians
to change that situation,
with the formation of ACT UP.
Tom and I also have
talked about the fact
that the recovery
movement needs an ACT UP
to lobby our officials for
more resources and treatment.
But we've also seen
a lack of support
to reduce harm for
those who still use.
We still cling to age-old
and unproven arguments
that reducing harm only
perpetuates drug use.
So we see incredible lack of
uptake for syringe service
programs, and a flat denial by
folks in our federal government
that overdose prevention sites
or safe injection facilities,
despite all of the
data, are not worth part
of our comprehensive
response to this disease.
So where does this all lead us?
And I have a few
thoughts on this,
and then we'll invite
our panelists up.
So clearly, we need better,
faster, and more localized
data to better evaluate the
consequences of our actions,
and to monitor, in real
time, changes in the patterns
in this epidemic.
I felt incredibly
frustrated as a person
in charge of federal
drug policy to be looking
at two-year-old data as it
related to this epidemic,
and to only hear about fentanyl
outbreaks in our communities
when I saw it in the press.
We need to require
training and competencies
for current and future
medical practitioners
to increase diagnosis,
intervention,
treatment of substance
use disorders
in our health care
delivery system.
We need widespread
and dramatic expansion
of community-based harm
reduction and treatment
services, particularly in
highly impacted and underserved
communities.
We need more urgent uptake
of medications for addiction
in our treatment
programs, in our courts,
in our jails and prisons, and
in our health care settings.
We need to divert people away
from our criminal justice
system, providing evidence-based
care for those currently
incarcerated and providing
continuity of coverage
for those transitioning
back to community settings.
We need to accelerate
research and innovation.
Our understanding
of this disease
is only new over the
past several decades.
And we need folks
like our panelists
to accelerate our
understanding of what works.
We need to continue
to promote and support
more widespread
advocacy, creating
a more visible and vocal
recovery community.
We need to focus on underlying
social determinants of health.
We need leadership.
And fundamentally,
we need resources.
We can only do what we
can do with so much.
And this epidemic and the
magnitude of the epidemic
requires continued leadership
and continued resources
if we want to continue to make
progress against this epidemic.
So now I'd like to
welcome our panelists.
And I'll have you
come up on the stage.
So first coming on--
I'll see how good my order
is-- is Dr. Jody Rich, who's
a professor of medicine
and epidemiology
at the Warren Alpert Medical
School of Brown University.
He's a leader on
health issues for those
who are incarcerated, and is
the director and co-director
of the Center for Prisoner
Health and Human Rights
at Miriam Hospital.
He is also co-founder
of the nationwide Center
for AIDS Research collaboration,
and HIV Corrections Initiative.
Wow.
That was perfect timing.
I just have to say
that we partially
share Dr. Green, who also works
at the Injury Prevention Center
at Boston Medical Center.
So we're thrilled
to have her here.
So you guys, please sit down.
Traci Green is an
epidemiologist,
to my left, whose
research focuses
on drug use, opioid addiction,
and drug-related injury.
Currently, I know
her well in her role
as the deputy director at the
Boston Medical Center Injury
Prevention Center.
She is also an adjunct
professor at Brown,
where she co-directs, along with
Jody, the Center of Biomedical
Research Excellence on
Opioids and Overdose
at Rhode Island Hospital.
At the end, Brandon
Marshall, who's
an associate with many of my
colleagues at Boston Medical
Center.
He is an associate professor
of epidemiology at Brown School
of Public Health.
His research focuses on
substance use epidemiology
and infectious disease.
He's a scientific director
of Prevent Overdose Rhode
Island, Rhode Island's drug
overdose information dashboard.
He worked closely with
the Department of Health
to track, measure, and
evaluate preventive efforts.
Just last week, he published
another major paper
about the use of
fentanyl test strips
to reduce harm to drug users.
I think I tweeted out
your study, Brandon.
And then we're thrilled
to have a longtime friend
and colleague, Rebecca Boss,
who is the co-chair of Prevent
Rhode Island Task Force.
She has been director of
the Rhode Island Department
of Behavioral Health Care,
Developmental Disabilities,
and Hospitals since May
of 2017, after serving
a long acting director
role for 10 months.
And many of us were glad to see
her in that role permanently.
She has more than 20
years of experience
in addiction treatment field,
and as a clinical supervisor
and a program director.
So let's welcome them all here.
[APPLAUSE]
So I want to pick up on a theme
that President Paxson said,
and that we are beginning to see
Rhode Island and other states--
for a very long time, we
saw this trajectory, upward
trajectory, with
no end in sight.
And we're seeing Rhode
Island and some other states,
particularly Massachusetts
and Vermont, in New England,
that despite significant
presence of fentanyl,
they're making some tentative
progress in reducing
opioid mortality here.
So I want you to
think about, kind of,
from your perspective,
what do you think
are the essential ingredients
that went into Rhode Island's
success and other
states' success
that we can use to replicate and
amplify with other states who
are still struggling with
dramatic year on year
increases?
So Traci, you want to start?
TRACI GREEN: Sure.
Well, I think we all have
a lot to say on this one.
There's been a huge effort
in the state from the get-go,
to work partnered with
community members,
partnered with coalitions
working in recovery,
working in harm reduction,
working in public health,
working in law enforcement.
And this particular topic, early
on, had brought many voices
to the table in ways that
other health topics or other
pernicious problems
really hadn't.
So Rhode Island did
have a strong community
base to begin with, and
that also partnered a lot
with researchers, like myself
and Dr. Marshall and Dr. Rich,
and many others who identified
this particular problem-- that
is, opiate addiction and opiate
overdose-- as an area that
needed research.
And so that was
a huge component,
I think, to what some of the
work that we've been doing.
And I'll let others add to that.
REBECCA BOSS: So I think
I'll add that, unfortunately,
opioid use is not
new in Rhode Island,
as you know, from our
longstanding history in New
England with having
an opioid issue
here, prior to the epidemic that
the rest of the country faced.
And so we have a
little bit of history.
And we had a good foundation
of evidence-based treatment
and medication-assisted
treatment
here in Rhode Island that
didn't exist elsewhere.
But really, the
leadership of the governor
in forming the task force
and bringing together
a diverse population of
people to really lead
the effort in engaging
the expert advisors
and developing a plan
for us to move forward,
and then acting on that
plan, was really key to us,
I think, bending that curve and
finally getting to the point
where we saw the decrease,
with really strategic efforts
in the four key areas.
And I've talked nationally
about the innovation
that Rhode Island
has demonstrated
in addressing this epidemic.
And you need to be flexible.
As the epidemic has changed,
we need to change our approach.
And I believe we
demonstrate that flexibility
in this state in
changing our approach
and recognizing what works
and what isn't working,
and really trying
to make sure that we
are devoting our efforts
in those that have
the most significant impact.
JODY RICH: I would certainly
echo the leadership
as one of the components
that you called for.
The governor has certainly
been very helpful with that.
It's hard to think
of this as a success
when we have hundreds
of people dying,
and people dying every day,
and people who are not dying,
and that the deaths are just
really the tip of the iceberg.
So part of this is that so
many of us have been impacted,
it's hard to find a
family that hasn't
been impacted in this state.
So I think that has
helped to wake people
up, that we need a
different approach.
BRANDON MARSHALL: Yeah.
I think two things to draw on
that point around leadership.
I've been so inspired and
impressed by the leadership
we have in Rhode
Island to listen
to people that are most
affected by the crisis,
to engage with communities,
reach out to researchers,
and develop a plan that is
evidence-based and impactful.
So that's the first
thing I've seen.
And the second thing really gets
to the title of this session--
"Frontlines on the
Opioid Crisis."
One of the favorite
parts about my job
is learning and watching
the tremendous work
done by people who are
truly on the frontline,
working every day to provide
lifesaving services to people--
people like Jonathan, who lead
some of our street outreach
services, people
like Colleen and Ray,
who provide harm reduction
programming that really does
save lives across the state.
They're the ones
on the frontlines.
And I think they're
doing tremendous work.
And I feel very fortunate
in my role as a researcher
to support some of those
efforts and to provide
the evidence around
the effectiveness
of these approaches.
MICHAEL BOTTICELLI: I
wonder, particularly
for the researchers on our
panel, you know, it must be--
I don't want to kind of
lead the witness here,
but it must be incredibly
frustrating, as researchers,
to see evidence-based
strategies that you're
producing and promoting.
Yet often, there is such
a significant lag time
between our findings of
those research studies,
and practice and policies.
And you know, Becky
and I have been
kind of those policymakers.
And I'm sure your
frustration at us,
in essence, for kind
of failure to move
with a sense of urgency.
So maybe you could kind of
talk about, are there things--
what are the levels of
frustration or barriers
that you've encountered with
this system, if you will,
around implementing
all of those things
that we know to be effective,
as well as emerging studies that
have come out, as it relates
to fentanyl test strips,
or providing people who are
incarcerated with all three
FDA-approved medications?
So maybe you can give
us your perspective,
as researchers, about what
are some of the challenges
that you've seen from
the research side,
in terms of implementing
those programs and policies.
TRACI GREEN: So I think, in
addition to getting a PhD,
I should have gotten
an MBA, a public policy
degree, and probably some
wings on the lobbying end.
But these are things
you learn along the way.
And importantly, I think Rhode
Island is a wonderful place
to conduct research, to
partner with policymakers,
to understand the
limits of our laws
and where our laws
are silent and where
they may need more structure,
where science can help give
guidance, and we can have
the kind of synergies that
have brought us here today.
So taking an idea or a pilot
idea of providing medications
for addiction treatment
behind the walls
can be a randomized
controlled trial or a pilot.
But then we can
look to the future
and say, how could
this be implemented,
and work in partnership
with the institutions,
as well as with the lawmakers
and the fiscal agents,
to make it all really a reality.
But the opportunity that I
think Brown has, in particular,
is to tear down those
walls and remove the silos,
and allow research to
really speak and rise above,
and allow the evidence-based
interventions to really lead.
And that's the amazing thing
about the strategic plan
efforts, was to have the
science be listened to.
MICHAEL BOTTICELLI: Good.
Jody?
JODY RICH: So I think it's worth
looking back to the governor's
task force and that process.
And preceding that, I
had spent decades, about,
working with this population,
studying this population,
trying to build up the
evidence base to show
that these medications
are effective
in these high-risk populations.
And I kind of naively
thought that if I just
show the evidence, that the
policy is going to change.
And I had this epiphany
in 2015, when I realized,
all this work, millions of
federal research dollars,
published papers in
prominent journals,
having a great career,
hadn't done anything.
I hadn't budged the dial.
I hadn't really
changed the policy.
And I want to give a
shout-out to Josh Sharfstein,
currently at Hopkins School
of Public Health, who
has been advising us and
giving us sage advice,
and sort of suggested some the
components of this strategy.
But it was really in
partnership with the governor,
with the directors, with the
task force chairs, that we were
able to turn things around.
Now, some of that was
the stars aligning,
that the epidemic had
reached a certain level.
But some of it was just
realizing that the research
is not enough.
Building up the
evidence is not enough.
You need to be able to actually
advocate and fight for that
to be implemented.
And so I think that is
an obligation for us,
as researchers.
Just as a physician,
if you make a diagnosis
and you write a
prescription, if the patient
doesn't have the insurance
to fill that or the ability
to get to where they need to get
it, you haven't done anything.
So you have to kind of take
a step back and look at how
you're going to have an impact.
And that's really, you
need to incorporate that
into the research.
MICHAEL BOTTICELLI: Brandon?
BRANDON MARSHALL: Yeah.
I think one of the
biggest barriers
I see to the adoption of
research into practice
is what you mentioned,
Michael, in your keynote--
the ongoing stigma
and stereotyping
of people who use drugs
as not wanting to change,
not wanting help, this false
idea that they don't want
treatment, that they can't be in
control of their health or take
steps to improve their health.
Those false
stereotypes, I think,
prevent implementation
of a lot of research,
a lot of interventions
that we know works.
And so I think,
as researchers, we
need to advocate for programs
that we know work, and be
very clear that when they're
implemented appropriately
and to scale, people do present.
And they benefit tremendously
from interventions,
such as treatment, that
we know are so effective.
MICHAEL BOTTICELLI: So
let me kind of segue
off of what you just
said, in that stigma--
and I believe, at least
from my standpoint,
that you're correct, that
stigma has manifested itself
in many different ways.
And one of those ways is a
lack of urgency, if you will,
to implement the work that
we know to have happen.
So if you were to be able
to kind of change one thing
as it relates to public
attitudes or public policy
for people who suffer from
substance use disorders,
what do you think that would be?
I'll start with Becky,
since I let you off the hook
on the last question.
REBECCA BOSS: That's fine.
So my answer is
very easy for me.
It's the negative
public attitudes
on medication-assisted
treatment.
So not only do we have a
condition that is stigmatized.
But we also have a treatment
that's stigmatized.
And I can give you
so many examples
of times when different
communities, whether it's
the recovery community,
the medical community,
the treatment community, I have
heard messages where people
don't believe that
medication-assisted treatment
is recovery, and will
stigmatize individuals
on medication-assisted
treatment.
And then that keeps
people from engaging.
And if we could really
change one thing, for me,
it would be the attitudes
around the use of medication
in the treatment of addiction.
JODY RICH: So I'm going
to kind of expand on that.
I think related
to the stigma has
been this sort of unfortunate
history of the war on drugs,
which we heard has been our
major investment in dealing
with addiction in this
country, continues to be,
in spite of the senator's help.
But that is the key problem.
And that has a sordid
and unfortunate history,
and racist history.
And I think the stigma
is part of that.
But what we showed
in Rhode Island
is that if we expanded treatment
into the correctional system,
that we dropped overdose
deaths dramatically.
And we need to continue
along that trajectory.
We need to continue
to expand treatment,
these effective
medication treatments,
and expand recovery services.
And so right now,
we have police.
And we're giving them
direction, saying
go and find people who
have these drugs, who
are using these drugs, and
arrest them and bring them
to the criminal justice system.
That is not helpful.
That is often harmful.
Sometimes people
are so crazed, they
need to just be removed
from their environment
for their own safety.
But most of the time it's
extremely detrimental.
And I say that having been
behind bars this morning,
and just about every other
Tuesday for the last quarter
of a century.
What I think we
need to do is have
a fundamental change in there.
We need to have,
instead of bringing them
into the criminal
justice system,
bring them into treatment.
So how do we get them to
get them into treatment?
Well, that's actually
been tried in Portugal.
Now, we're not
Portugal, although we
have a lot of people from
Portugal here in Rhode Island.
18 years ago, they had the worst
drug problem in all of Europe.
They had the highest rates of
incarceration related to drugs.
They had the highest rate of
injection-drug-use-related HIV.
And they had the highest rate
of overdose in all of Europe.
And they did something radical.
They removed criminal penalties
for possession and use
of drugs.
It's still illegal
to sell drugs.
And they expanded treatment.
They still coerced people to
get into treatment, but not
into the criminal
justice system.
So the criminal justice system
got a lot less people into it.
The injection-drug-use-related
HIV dropped.
And overdose dropped.
So now, on those three
measures, they're
about the best in
all of Europe--
went from the worst to the best.
And overall drug
use has gone down.
So if we talk about, well, we
want to decriminalize syringes,
you know, first
of all, if you say
that, you're going to
alienate a lot of people
because they think that's wrong.
And there's this notion
that we're holding the dam,
like this is such a problem,
we have to hold the line here.
We have to keep these
criminal penalties.
But in fact, we're
not holding anything.
We're making things worse.
You know, when you think
about an individual who
died of an overdose,
and you look
at the situation around that
individual and the community
and all the social
determinants of health,
that individual, in this state,
didn't die because we didn't
have enough arrests,
because we didn't
have enough incarceration,
because we didn't
have enough police presence.
That individual
probably may have
died because we had too much of
that and not enough treatment.
So right now, we
have a governor who
is interested in
evidence-based approaches.
And she's proven that
in this first term.
We are about to have
an attorney general who
understands these issues, who's
compassionate, who's committed.
And we have a
state that's small.
So to convince maybe
10,000, 20,000 people that
an approach where
you expand treatment
instead of criminal justice--
we divert people out of criminal
justice and expand treatment--
is really going to make
a fundamental change
in this epidemic,
is what we need.
And if we do that
in Rhode Island,
just as we showed that
treatment in corrections
leads to dramatic
positive changes,
we're getting calls
from almost every state.
How did you do it?
How can we do it?
What led to it?
And I think we can continue
to lead the nation if we
push in that direction.
MICHAEL BOTTICELLI:
Brandon and Traci, I
want to ask you this
question, because I think
that some of that stigma
really manifests itself
in our historic approach to
lack of urgency around harm
reduction approaches, right?
That somehow, providing
people with access
to sterile syringes or safe
places to inject drugs,
there's an age-old argument.
This is what I
was talking about,
that despite all the evidence
to show that it's not true
and that, actually, things
work, and there are places
in other parts of the
country that have done these
successfully, we
still have, I think,
significant pushback, and
even pushback, quite honestly,
along the political spectrum
here, around that, much of that
tied to stigma that active
drug users don't deserve things
like to not have
infectious disease
and to not overdose and die.
What one thing or
two things would you
suggest to begin to
change people's attitudes
that those kinds of harm
reduction approaches
really deserve a
place in our community
and in our public policy?
TRACI GREEN: Do
you want to start?
BRANDON MARSHALL: Go ahead.
TRACI GREEN: Well,
I think that the--
part of that is an onus on the
research community within harm
reduction researchers to be
really explicit and to work
hard to amass the kind of
data that can be persuasive,
much like other elements of
our approaches-- treatment,
recovery--
and to make sure that
we catalog and document
the kinds of effects
and the kinds
of connections that
repeated-- for instance,
repeated exposure to
any positive change,
whether it's a syringe
exchange program or otherwise,
may then eventually lead to
treatment for their hepatitis C
or treatment for their
HIV or connections
for buprenorphine
or other outcomes
that clinically we determine
are important, and to catalog
and understand that.
So part of that, I think,
is that we need data.
And we need investments
in data and research
to allow us to be able to say
positive and important things.
And that often is
not going to come
from the federal government.
So the onus is on
our institutions
and our private partners,
private fellowships
and otherwise, to make sure
that we have investments
in these harm reduction
areas, to make
it possible for the
data to be heard.
So that's one thing.
And I think the other
piece is, importantly, we
have the opportunity to
build pilot projects into
and normalize harm
reduction, for instance,
into our experiences in
the prisons and jails,
into the primary carers
and to the hospitals.
And these environments that
we've already determined
are important
institutions for society
can all adopt harm
reduction principles,
can all adopt harm
reduction materials
and approaches to care.
And so the idea of
normalizing and systematizing
harm reduction is
eventually the way
that we can reduce stigma in
the long run, and build out,
also, a healthier
policy that begins
where people are,
instead of expecting them
in a system that may not have
ever been thinking about them
to begin with.
BRANDON MARSHALL: Yeah.
I think we could do
better, researchers.
And many of us
working in this area
could do better at communicating
why harm reduction works.
And I think to do
that, we can start
with what we know doesn't work.
What doesn't work is pushing
people out on the street,
applying punitive measures,
incarcerating folks.
This idea that people need to
hit rock bottom before they're
willing to engage in
any kind of treatment
is an incredibly
harmful false narrative
that still pervades
much of what we
see in media and in
our broader society.
So I see harm reduction
as the opposite of that.
Programs such as providing
sterile syringes,
such as supervised
consumption spaces
allow for us to connect with
people who use drugs, to engage
with folks, to build rapport.
And through that more helpful
and supportive mechanism,
we can perhaps eventually
get someone on the pathway
to treatment and recovery.
And that might not be tomorrow.
That might not be
a week from now.
That might not be
a month from now.
But I always say that
treatment doesn't
work if the person is dead.
They have to be alive
to engage with it.
So harm reduction programs
allow for that engagement
until we get to that
point, and foster
that sense of community and
connection that's so critical.
JODY RICH: I spent almost
an hour today talking
to a parent of a
young person I had
met this morning
for the first time
at the Department of
Corrections, who had suffered
with opiate use disorder
for about half their life,
and had been locked
up for several years,
and was eager to get
out and get to work.
And the family was
going to be supportive,
but didn't want medicines.
And my family doesn't want
me to be on medicines.
And you know, why
would I start that?
And I'm just going to
get on with my life.
And I said, well, you
know, that could work.
You haven't been using
since you've been locked up.
And you might.
But the data shows
that you probably
have about a 90%
chance of relapsing.
And three years ago, the stuff
that he had already overdosed
on is going to be a lot worse.
So we had a long
talk about that.
And then I asked for
permission to talk to a parent.
And he said, OK.
What are you going
to tell my parent?
But his plan was to get
out and try not to use,
and that if-- that was plan
A. And if they developed
cravings or urges
or was going to get
into some kind of counseling--
if that didn't work,
to get on to treatment
with medications.
And then I talked to the
parent, who said, well,
I'm going to support him.
And we're going
to get him a job.
And he can stay in the house.
And we really want
him to succeed.
And we want this.
But I've got a
zero-tolerance policy.
First sign of any
use, that's it.
He's going to get
fired from his job.
He's out of the house.
He's going to get kicked out.
And I said, well, is that
really what you want?
Because that zero-tolerance
policy is great if it works.
But that's not
really what you want.
For this young person--
I want the same thing.
We all want the same thing.
We want him not to
overdose and die.
We want him to live his life.
We want him not to be
tortured by this addiction.
And so if he's got a
90% chance of relapsing,
and you, as a parent--
by doing a
zero-tolerance policy,
that's probably not
going to work out well.
And that's probably
not what you want.
What you really want is him
to be alive and healthy.
And I was talking
about the goals
in a harm-reduction
fashion, like that we
have these
medications that work,
and that if he goes in that
direction, to be tough on him
and kick him out,
you know, this kid
has been locked up for a long
time, in some tough places.
That tough love is
not really working.
So why don't we try something
that actually might work?
MICHAEL BOTTICELLI: Becky, I
want to ask you a question.
We've both been doing this work
for a very long time, as long
as the folks on the panel.
And I think we've seen, despite
all of the scientific evidence
that treatment works, that
it doesn't increase drug use
or crime in our communities.
We've seen, even today,
still significant pushback
from many of our
communities when
we talk about expanding
treatment, particularly
in those neighborhoods.
So how do we get at some of
these issues of kind of NIMB,
Not in My Backyard phenomena?
What have you seen, in terms
of successful approaches
and community engagement?
That kind of stigma
exists at multiple levels.
And certainly at
the community level,
it's really been a
challenge, I think,
to have communities understand
that treatment is important,
and actually decreases crime.
So how do we work
with community members
to really embrace treatment
in their communities?
REBECCA BOSS: That's a
really timely question,
given that that issue came
up today, and this week.
And everyone wants
treatment for individuals.
I just don't want it here.
I want it somewhere else.
I don't want it
in my neighborhood
I want it to be over
there, so other people
have it in their neighborhood.
It still exists.
And we combat it.
And one of the most successful
strategies I've seen
was when one of our
opioid treatment programs
went to be in downtown Newport--
Newport, Rhode Island--
tourist attraction,
Newport, Rhode Island.
They did a lot of work up front
with the community, with law
enforcement, with
first responders,
with the business
folks, before they even
opened, to establish
those relationships,
and made them feel
that they would
be responsive to any
issues that arose
as a result of this treatment
program being in Newport.
We still have that issue today.
There are treatment
programs that are coming up.
We encourage our providers,
get out in the community,
work with the people who are
in the community, be a partner.
And you have to be a partner.
So that's probably
the first thing.
The other thing is
that we've talked
about the ACT UP of the recovery
community that's needed.
We need individuals
in recovery who
are willing to be out there
to say, recovery works.
Here I am.
I'm a part of the solution.
And we don't want to
believe that addiction
is in our neighborhood.
Addiction's in our neighborhood.
Right?
So we know that there are
people that are living next
to us, down the road, or in
the same building that have
active substance use disorders.
I would rather have a treatment
program next door than
have people who are actively
using substances next door.
And treatment programs are going
to help address that problem.
So it's that conversation
you need to engage in.
But you have to
engage your partners.
That's one of the
things that I think
Rhode Island has done so well.
And I see Captain Moynihan here,
from Rhode Island State Police.
I saw Captain Zach Kenyon from
the Providence Fire Department.
We've engaged labor
in our discussions.
We have laborers unions
involved in the task force.
These are the partners
that we need to help share
the message, because I
can say it all day long.
But when I have mothers, like
I see here in the audience,
and others who are helping
me carry that message out,
then it's other people
speaking, and not just me.
So it's really based
on partnerships.
It's those relationships
that are so critical.
MICHAEL BOTTICELLI: Great.
So I want to pick
up on that theme
of who do we partner with.
Traci, you talked a
little bit about it.
As researchers, who
do we have to partner
with to get our message out?
And I look back and think
about naloxone distribution
by first responders, that it was
really other police officers.
And quite honestly, it
was the police officer
from Quincy, Massachusetts,
who went around the country
and convinced other police
officers about the merits
of carrying naloxone.
And now we just see that
widespread attention.
So if we think about this
from a research perspective,
or even a practice perspective,
who are unexpected messengers
in this work that
we really think,
if we can't get the message
out through science and data,
and have to rely on parents
and first responders,
who do you think we
should be partnering with
to help us kind of amplify
and promote the messages
that we want to get out?
And just, for anyone who
wants to respond to that.
TRACI GREEN: Well, I will
say, so I was, just yesterday,
in Toronto, at the Law
Enforcement and Public Health
International Conference, with
the CDC and the High Intensity
Drug Trafficking Area, a
partnership that actually
flourished under your
direction, really
focusing on partnerships
between public health
and public safety.
And thinking that the current
crisis and the emerging heroin,
and now more broadly,
fentanyl crisis,
is one that requires
different partnerships than we
had in the prescription
opioid epidemic,
and more broadly, public safety,
incorporating fire and EMS,
and all of our volunteer
services, as well as police,
really makes it possible
to have a lot more
room, a lot more
voices at the table,
and a lot more partnership
for naloxone, for medications
for addiction treatment, and
for harm reduction services,
in addition.
So that's been a really
exciting partnership.
The other group
that I'd have to say
has been really vibrant in
Rhode Island is the pharmacists.
And they have been
wonderful partners
for getting syringe access,
with Dr. Rich, and early on,
the pharmacy board at
the Department of Health,
as well as the
Pharmacists Association.
And then now, just as
of the end of August,
we have a collaborative
pharmacy practice agreement
for medications for
addiction treatment
to offer in a small study.
We're beginning
this, but to offer
buprenorphine in particular, in
a pharmacy-based environment.
So addiction care could
come to a pharmacy near you,
instead of being
specifically at a clinic
or at a particular
treatment program.
So this expands, complements,
and expands the voices
at the table, and allows
our continued message
to normalize treatment access
and normalize harm reduction
services more consistently.
So those are new partners.
BRANDON MARSHALL: Yeah.
I think something, to your
point, Michael, of looking back
at ACT UP, the
power of that voice
and how we, and myself
included, really,
could do better at engaging
with people who are using
drugs and people in recovery.
They are the true
voice of this epidemic.
And they are such
a powerful ally
in bringing the results
of the research to tables,
and say, this is what I demand.
This is what I deserve, because
it will improve my health.
And we saw that be such a potent
force in the HIV epidemic.
And I think we can see
that here as well, is
those kind of partnerships
coming together and using
the scientific evidence
that folks like us generate,
to advocate for social change.
MICHAEL BOTTICELLI: I have
often said this before.
There's a wonderful documentary
called How to Survive a Plague.
And if you haven't
seen it, I really
encourage you to look at it.
They found archival
footage of early meetings
of ACT UP and the
treatment advisory group.
And for all of us who
are doing addiction work,
I think that analogies are just
completely transparent in terms
of the work.
But I'd really
encourage you to do it,
because I think the
applicability of kind
of what happened around HIV and
AIDS, and kind of what happened
is really appropriate
for our current epidemic,
as we think about highly
stigmatized disease, highly
stigmatized people, and a
historic lack of government
response to this issue.
JODY RICH: And thinking
about unexpected messengers,
thinking about the family
members and parents, who,
people have died
or haven't died.
But this is a family disease.
It impacts everybody.
And just the last
week, there was,
I guess it was a Facebook
message about a young woman
died in Vermont.
And then there was a
reply by the police chief,
which is just--
MICHAEL BOTTICELLI: Yes.
JODY RICH: --very--
MICHAEL BOTTICELLI:
Chief del Pozo.
JODY RICH: Chief del Pozo.
We should probably link to that.
I think everybody watching
this should read those.
MICHAEL BOTTICELLI: Along with
some of the folks in this room
and our colleagues at the
Johns Hopkins Bloomberg Public
Health, we sat down with a
number of police officers,
both locally and federally,
and devised 10 principles
of care for police officers
as part of their response
to this epidemic.
And Traci, to your
point, I think
that they've been really
kind of unexpected champions
around a lot of
the work that those
of us in the public health
field, quite honestly,
are surprised that we've seen.
And I think the more that
we can, both from a research
and innovation perspective,
but also from a partnership
perspective, to be
able to kind of link
to public safety folks
in ways that those of us
in the public health world
used to kind of run away from,
quite honestly.
REBECCA BOSS: Can I just add
that there's no wrong partner?
You know, any partner
in this discussion
is the right partner.
And I echo Jody's sentiment,
that the power of families
cannot be understated.
You look at the
movement of the MADD,
Mothers Against Drunk Driving,
and the influence that had.
We have mothers that
are getting angry.
And angry mothers can really
move mountains, sometimes.
I would say the
recovery community
has been a tremendous
partner in Rhode Island.
I look at Jonathan and the
efforts that he's done.
Brandon talks about going
to outreach to people
who are using on the street.
Well, he's doing that on a daily
basis, and handing out Narcan.
And we've got a lot of champions
in the recovery community
that are really doing
amazing work in Rhode Island.
And there are other partners.
And I think about
the faith community.
How have we engaged
the faith community?
We had a prevention coalition
work with a Catholic parish,
in, I think it was
Portsmouth, Rhode Island.
And they talked
about how difficult
it was to get parents engaged
in discussions about drug use
and youth.
And the priest
stepped up and said,
I have a captive audience.
If they want to get
through whatever
it is that the
adolescents go through--
the parents had to attend.
And he brought in the
prevention coalition.
And they had messages
around substance use.
And so there's clear partners.
And then there's kind of
the off-the-path partners
that we need.
There is no wrong partner.
MICHAEL BOTTICELLI: I just
want to make one statement,
and then we'll open it up
to people in the audience,
get a chance to talk.
One of the things I
hope you've noticed
is the strategic
language choices
that people on our
panel are making,
whether it's medications
for addiction treatment, not
medication-assisted
treatment, people
with substance use disorders
or substance use disorders.
And this is not just about
being politically correct.
One of the things
that we've found
is the use of
stigmatizing language
when it relates to addiction,
calling people clean as opposed
to people in
recovery, when we talk
about someone with a
substance abuse problem--
researchers at the
Recovery Research Institute
found that it elicits a
punitive response, as opposed
to a therapeutic
response when you
refer to someone as a person
with a substance use disorder.
So part of our work, I think
all of our collective work,
in reframing addiction
and reframing the stigma
is reframing language.
Not calling people junkies
and addicts I think
is really important to
changing public perception.
So I hope you picked
up on kind of the use
of non-stigmatizing,
clinically appropriate language
that our panelists
have been using.
So with that, we have
two microphones here.
Just ask folks to come
up to the microphone
and ask their question.
And if you have it kind of
directed toward a person,
ask you to direct your question,
or to the panel in general.
Good.
So right here.
AUDIENCE: Cindy McCloud.
I'm a nurse working in the
HIV and addiction field.
Is there a realistic hope
of treatment on demand?
And then in that
context, could you
comment on the
deficit of treatment
providers in the state--
throughout the state,
not just in Providence?
REBECCA BOSS: So I'll take that.
MICHAEL BOTTICELLI: I think
you've got that one, Becky.
REBECCA BOSS: We just had this
discussion, actually, today,
about treatment on
demand and what it means.
And treatment on
demand, for us, means
that when an
individual says, yes,
I want treatment, that we have
the capacity within the system
to provide that treatment.
So I guess it depends upon
what you are looking for.
If treatment equates to beds
and inpatient detoxification
or residential treatment
beds, we will probably never
have enough capacity for that
kind of treatment on demand.
But we are actually
moving, in Rhode Island,
to create a new program that
will be opening in November,
called BH Link, which is a 24/7
crisis response center, where
people can go, be treated,
be assessed, be initiated
treatment, and handed off to the
next appropriate level of care,
which may or may
not involve a bed,
but will definitely involve
a clinical assessment
for the right level of care.
So we are so close to
treatment on demand.
Though I will openly
admit we will never
have enough inpatient
capacity, if that's what
we are equating to the need.
AUDIENCE: And will
that address drugs
like methamphetamines, cocaine,
in addition to opiates?
REBECCA BOSS: So the
BH Link will absolutely
address all substances, and
mental health crises as well.
So somebody who may be normally
referred to an emergency
department or may be involved
in the criminal justice
system because of the fact
that they've committed a crime,
they can be diverted
to this 24/7 site
for any type of
substance involved,
or mental health
involved crisis,
be assessed, and be
connected to a level of care.
Now, medication
used for treatment
is not in methamphetamine
and other stimulants.
There's not effective treatment
right now using medications.
So more often, inpatient
treatment is appropriate.
That will be an issue.
So we do need to
work on our capacity,
although I'm never
sure-- like I said,
I openly will admit
that we probably
won't have the capacity to
meet every inpatient need.
MICHAEL BOTTICELLI: I'm going
to add on to what Becky said.
I work at a large safety net
hospital just up the road.
And I think our health
care infrastructure
has been dramatically
underutilized,
in terms of both the
diagnosis and treatment
of people with
substance use disorders.
And I think we have an
extraordinary opportunity
to think about--
and we know, quite honestly,
that the level of emergency
department and
inpatient utilization
as a result of this epidemic.
And I quite honestly think that
hospitals and our primary care
delivery sites have been
dramatically underutilized.
We've carved out treatment to
a specialty treatment system,
and pretended like it's
not part of health care.
And I actually think it's
time for our primary care
and our other health care
delivery sites to play
a much more substantial role in
treating people with addiction.
It goes back to my saying,
we don't tell physicians,
diabetes is probably the most
prevalent disease condition
you're going to face.
But don't worry.
You really don't
have to treat it.
And so I do think that we've
got to create an understanding,
and quite honestly, a
mandate within our health
care delivery systems,
that treating addiction
is not an optional health
care activity anymore.
AUDIENCE: Yeah.
Right now, it's
don't ask don't tell.
MICHAEL BOTTICELLI: Yeah.
REBECCA BOSS: Nor is
it an optional benefit.
And so the other
piece to this is
that we need to enforce parity.
MICHAEL BOTTICELLI: Right.
Good.
AUDIENCE: Thank you
all for coming today.
I just have a question.
Over the summer, I worked
for a pain specialist.
And he really
showed no compassion
for a lot of his patients.
He would kind of
walk out of the room
and blatantly tell me,
oh, this one's addicted.
We're probably going to
kick him out, or whatever.
This happened a lot.
And then it was
startling, because it
was the largest pain management
practice in all of Louisiana.
And the next physician over
would be the exact opposite,
kind of counseling his patients
on substance abuse disorders
and what risk they
would be taking on
if they started treatment.
And it was just--
I know you can't really--
it's hard to counsel
or to train physicians
into compassionate care.
But what are some
of the approaches
that you all would
recommend when
it comes to pushing
physicians to implement
science-based solutions,
especially in states
where there's a lot of stigma?
And I mean, Senator
Whitehouse probably
knows that Louisianan
politicians are kind of not
too active on the health
care side of things.
So it presents a
really unique challenge
in trying to get physicians
to implement these,
in a regulation-free
state, especially
when you can't really-- it's a
lot harder to get them to care.
JODY RICH: You know,
that would make
good use of the criminal
justice system--
lock them all up.
You know, I think we've
worked hard to try--
you know, you heard
96% of physicians
don't have a data waiver, don't
have the ability to prescribe.
And of the half,
of the 4% that do,
they're able to, but they don't.
And one other statistic is
that the half that actually do,
almost half of them have
only one or two patients.
So we're really not, as
a field, as a profession,
stepping up to the plate
to address this epidemic.
Now, they roll me out to talk
to the intern applicants,
and I usually talk about
international work.
And I always, as I start talking
about working internationally,
usually about a third of this
group of 20 to 30 young people,
you can see their eyes light up.
It's like, yeah,
I want to do that.
So I was talking to
one of them afterwards.
And he said, you know,
I've been interviewing
around the country.
And he was in a Seattle
program where they actually
train the medical students
how to get a data waiver
and how to prescribe
buprenorphine.
And he said, I went to some
programs, and I asked them,
do you have that?
And they said, oh, not
really, but we're trying to.
We want to.
And in other programs,
he asked, and they
said, what would you
want to do that for?
Why would you want take
care of those patients?
That's kind of a
prevailing attitude.
And then so the next week,
I got rolled out again
to talk to a fresh group.
And I told them that story.
And I said, well,
how many of you
might be interested in learning
how to address this number one
health and medical and social
and public health problem?
And they all-- so that--
the kids coming through get it.
And we need to harness this
as quickly as possible.
We need to get them trained.
Now, the problem is,
they go to medical school
and their professors
don't really know,
because we've all been
trained in the era where
we didn't deal with that.
That's over there on
the side of the tracks,
in those dirty
methadone programs.
And it hasn't been
incorporated in medicine.
So we really need to do it.
And I think you're--
I mean, there are some
doctors that get it.
But I would say most don't.
They never trained in this.
You know, they have a certain
way of addressing addiction.
And usually, it's get the
hell out of my office.
So I think the hope is the
new generation coming through.
Now, the other
challenge is when they
come to residency training.
You know, I love what's going
on in Boston Medical Center.
But that's what we need.
And the problem is, we
don't have the staff that
know how to deal.
So they have to
learn in parallel.
But the medical students,
we've had physicians,
academic physicians come
and do the training.
And they say, why are
you doing the training?
And they say, well, because
I'm getting shamed into it,
because the medical students are
asking me about this treatment.
And the interns are
asking me, like,
why aren't you giving this
evidence-based treatment?
And so they realize
they have to catch up.
MICHAEL BOTTICELLI: Yeah.
I think that is a great
example of advocacy,
because I think we saw
the same thing here,
same thing in Massachusetts,
where medical students were
actually lobbying their deans,
saying you're not giving us
enough medical education.
And I think Brown, along with
schools in Massachusetts,
have now implemented
core competencies as part
of their medical training.
I think we're seeing a new
generation of clinicians.
I think part of
the challenge is,
how do we train up the folks
who are already doing the work?
And not just docs,
but nurses as well.
And I think that the
level of stigma--
you know, our
medical community are
reflections of kind of our
general societal attitudes
around those issues.
And so I do think
that we're beginning
to see that kind of change
in training and change
in philosophy.
AUDIENCE: Hi.
My name is Peter.
I'm in a masters of public
affairs program here at Brown.
I'm appreciating the
saliency of the HIV epidemic,
and applying that in
some context to this.
Unfortunately, one of the things
that I'm learning from that
is there is a failure
at the federal level.
But I also see, in terms of
identifying this as a crisis,
advocacy in a crisis mode and
innovation in a crisis mode
might be different than
a long-term strategy.
For instance, with
HIV, we see it
spreading to parts
of the American South
that-- it used to be a
San Francisco, New York
issue 30 years ago.
And now, it's still continuing.
It's not gone anywhere.
So looking beyond 10
years, 20 years, 30 years,
what does advocacy
and innovation
look like when it's not
the urgency of a crisis,
but it's the ongoing
maintenance of prevention
and of maintaining
lower, or reducing
the impact of that crisis?
REBECCA BOSS: So
we just recently
had that discussion
around the refresh
of our strategic plan for the
governor's overdose task force.
And we had, as was
mentioned, four pillars
of the task force plan.
So that was treatment, rescue,
prevention, and recovery.
So our focus was saving lives.
And just like in the
HIV crisis, our focus
still is on saving lives.
We really focused
a lot on the rescue
and on the treatment pillars.
But now, we know that we need
to go to the outer edges really
to have a long-lasting
and sustainable impact
on this epidemic.
And that's to look more at the
prevention and the recovery
ends of our plan, and making
sure, number one, that we're
doing primary prevention,
because ultimately, we
need to go upstream.
We really need to
go further upstream
to have an impact on youth and
others in the community making
healthy decisions, and the
ability to impact that.
And then when people
get into recovery,
are the supports
there to sustain them?
Do they have opportunities
for employment, housing,
social connections,
all the things
that we know that are critical
to sustaining recovery?
And to broaden our efforts,
not only to save lives,
but to work on those outer
edges of the epidemic.
JODY RICH: I would just add
that I came to Brown in '94
to work on the HIV epidemic.
And I'm getting this sense of
deja vu over and over again.
This is a very complex problem.
If this was simply a medical
problem and we could just give
some treatment, that--
it is, but it isn't.
This touches all
kinds of spheres.
And really, to address
this, we don't just
need scientists developing
new medications.
We don't just need clinicians
giving better treatment.
We don't need public policy
people making different laws.
We don't need activists.
We need that and more.
We need everything.
We need all hands on deck.
And it's a complex problem.
We need the best and brightest.
You know, this is where--
Brown University,
we need your help.
We need your help
from every discipline,
to say, OK, how can I apply
what I know about my expertise
to bring to bear
on this epidemic?
And I think that's what we need.
MICHAEL BOTTICELLI: I'll
just add, that's why I think,
not just for this
epidemic, but you
know, we are also seeing
simultaneous epidemics
of suicide in the United
States, of diseases
related to alcoholism.
And that's why I think
we've got to really focus,
and why we have
a broad, I think,
understanding in the
public health community
that we've got to focus
on these root cause issues
and on the social determinants
of what leads to poor health
outcomes.
I don't know if we'll-- maybe--
I don't know if
we'll ever get there.
But clearly, there are
reasons why people do drugs.
There are reasons why people are
in a lot of psychological pain.
There are reasons for a lot of
these waves of public health
epidemics.
And many of them are rooted
in historic inequities
that we have seen in many
of our communities-- things,
again, like poverty and racism
and early childhood trauma
and violence, lack of
educational opportunities
and vocational opportunities.
And unless we get at
some of those things,
I think we'll see--
you know, the
crisis will be over.
People won't pay
attention to it anymore.
We'll move on to the next,
whatever the next epidemic is,
without ever getting
kind of underneath what
really is causing many of these
really poor health outcomes.
I apologize, but we have
time for one last question.
And it'll be over here.
AUDIENCE: Thank you
for being here tonight.
I'd just like to ask what your
thoughts were on the Florida
shuffle, or the corrupt
fraudulent treatment centers,
and how prevalent of
an issue that's become?
REBECCA BOSS: I'm not sure I
know exactly what the Florida
shuffle is, but I'm
assuming that it's
the kind of recruitment of
individuals who have substance
use disorders to go out of state
for these treatment centers,
and have their families be
thousands of dollars in debt,
only to return to face the
same situation that they
left in the state
where they came from.
We are familiar with that.
And we are--
Can you-- I'm sorry.
I've lost track of the question.
The Florida shuffle
and then what?
AUDIENCE: I just wanted
to know how prevalent
of an issue that's become.
REBECCA BOSS: So I
don't know that we
have the data that supports how
prevalent an issue it is here.
We certainly have
anecdotal stories
from families of
their loved ones
who have been sent off to
treatment, come back, relapse,
and then die.
It's certainly not the outcome
that anyone is looking for.
We work with insurers,
primarily to look at,
what are you funding?
There's residential
treatment programs here.
Family components are really
important to the success
of treatment.
And if somebody is sent
off to another state
only to return here to
a family that has not
been part of a
treatment process,
the outcome is not going
to be as successful
as it could be if we engaged
them in treatment where
they live, which is
really more important.
So the data, in terms of
how prevalent it is here,
maybe Traci knows, or Dr. Rich.
But we certainly have
anecdotal evidence
that that effort
is alive and well
in this state, and impacting
families and individuals,
unfortunately.
JODY RICH: When your child has
this disease, you're desperate.
And you will mortgage your house
and do whatever you have to do.
And unfortunately,
when you say treatment,
when most politicians
say treatment,
they talk about treatment beds.
And they think about this
magical bed that's there.
And somehow, somebody
is going to lay in it,
and then they're
going to get up,
and then they're going to
be done with the disease.
And that's not how it works.
And in fact, what most people
think of as treatment--
go through a detox, go
spend some time in a unit,
which has a bed, and then
go back to your life--
I would say close to
90% of the time, that
results in a relapse.
And in this era, when
there's so much contamination
with fentanyl and
other related drugs,
that can be a death sentence.
So I would say a lot
of these programs
are doing more harm
than good, that you're
better off continuing
to shoot up heroin,
because you won't
lose your tolerance.
And going to those programs
are extremely dangerous.
MICHAEL BOTTICELLI: Let
me add two thoughts.
So I know regulations are not
popular at the federal level
these days.
But one of the reasons I think
that we see-- quite honestly,
in the early part
of this epidemic,
we saw just the explosion
of these rogue pill mills
in Florida, largely for lack
of regulation and oversight.
And I think that's--
so regulation and
oversight of these programs
is particularly important.
And that varies dramatically
by states, by state effort.
The other thing
I'll say is, I think
that we need to provide better
curated information to parents
and other caregivers about
how you determine how to pick
a quality treatment program.
And again, I think Jody said
that people are desperate.
And somehow, they equate
spending a lot of money
with high-quality care.
And that's clearly not the case.
So we need to do a better
job of educating consumers,
if you will, how to pick a
high-quality treatment program.
NIDA and other places have
that on their website.
And the third thing
I'll say is that we
need transparent reporting of
unified outcomes of treatment.
So like we do in other
arenas in health care,
where you as a consumer can look
at apples-to-apples comparison,
in terms of treatment
outcomes for programs.
And we don't have
that right now.
So what you have is a--
it drives me crazy
when I watch CNN
and I see Passages in Malibu
offering the cure for addiction
treatment.
And we have no
oversight and regulation
to get at those kinds of issues.
So I want to thank you
all for being here.
Being from out of state,
I want to tell you
how lucky you are to have
these four folks as part
of your toolbox here
in Rhode Island,
but also, how they continue to
lead national efforts in coming
up with innovative and
science-based approaches
to deal with this epidemic.
So thank you very
much, everybody.
[APPLAUSE]
JILL PIPHER: So thank you.
This has been a fascinating
and inspiring discussion
about how universities and
government agencies can
work together to solve
some of society's really
challenging problems.
And I would like to thank
the American Academy of Arts
and Sciences for the sponsorship
of this important event,
and of course our panelists,
who were just tremendous.
Thank you so much.
[APPLAUSE]
