Opioid Forum at UMass Amherst- Part 1: Research Panel

Opioid Forum at UMass Amherst- Part 1:  Research Panel

[APPLAUSE] Dr. Yves Salomon-Fernández is
the president of– you all know this I’m sure because she’s
well-known out here –is the president of Greenfield
Community College. She previously
served as president of Cumberland County
College in New Jersey and interim president of MassBay
Community College in Wellesley. Dr. Salomon-Fernández has
held research, management, and executive positions at
private and public institutions as well as community colleges. She’s also served as
an adjunct professor at Boston College, Salem State
University, and Cambridge College. And I think that the more– the most important things
to mention about her has to do with her career and
her dedication to these issues. Over the course of her career,
she’s distinguished herself as a visionary, innovative,
and entrepreneurial executive committed to access and equity. Nationally she has been
recognized as a thought leader, writing and speaking on
a range of issues related to rural innovation,
workforce development, women’s leadership, and
cross-sector partnerships. Yves recently finished
a book chapter on rural innovation
for new directions in community college,
published by Jossey-Bass. In March 2018, she was named
one of the top 25 women in higher education by Diverse
Issues in Higher Education. She is also a past recipient of
the Massachusetts Women Making History Now award and the New
Jersey Hispanic Leadership award. And I want you to know she’s
also fluent French, in Spanish, and Haitian Creole. So I assume you’re going
speak in English here today, but all right. Yes, today I will. Please welcome our moderator. Thank you. [APPLAUSE] Thank you, Phil. Well, good morning everyone. Good morning. We can do better than that. Good morning. All right. I’m just really, really
excited to be here. And Julie, we know each other. We used to work for
Mayor Menino together. Yeah. Yeah. Yeah. So it’s really
exciting to be here to see east and west meet
here in Western Mass. There are a few things
that I’ve learned about Western Massachusetts
is that we are very passionate about
the human potential and we lead with not only
heart but with courage to tackle really hard issues,
issues like the opioids task force. So I’m delighted
to be the moderator today for both of our panels. We have some extraordinary
leaders, researchers, practitioners, and
law enforcement folks who have deep
expertise in this work and will be sharing with us. Before I introduce
our panelists, I’d like to let you
know that you have index cards on your chairs. And as the panelists
are talking, if you have any questions
please be sure to note them. We will be collecting the cards,
and once the panel is over I will be reading some of the
questions that you’ve asked. So we have multiple
opportunities to engage with you today. We want to hear from you as well
as our distinguished panelists. So I will now introduce them. First we have Dr.
Connie Horgan, and I want you to know that
their full bios are available in your packet. I will simply read
some excerpts so that you know who is speaking
with us this morning. Dr. Horgan is a professor at the
Heller School for Social Policy and Management at
Brandeis University and is the founding director
of its Institute for Behavioral Health. She also leads the
Brandeis-Harvard Center to improve system performance
of substance use disorder treatment, funded by the
National Institute on Drug Abuse. Lastly, Dr. Horgan
serves as a board member for the Massachusetts Health
Policy Forum, the Massachusetts Health Council, and the Greater
Boston Council on Alcoholism. She’s also a standing member
of the National Advisory Council on Alcohol
Abuse and Alcoholism. Welcome, Dr. Horgan. [APPLAUSE] Also leading the panel we
have Mr. Robert Bohler, who is currently a PhD student
at the Heller School for Social Policy at Brandeis. And before coming to
Brandeis he worked in collegiate recovery and
community-based efforts for substance use disorder. Dr. Bohler’s research interests
are in recovery science, opioid policies, and developing
effective subsystems of care that address the
continuum of care. I just awarded you your degree. Thank you so much. [LAUGHTER] [APPLAUSE] [INAUDIBLE] And also joining us today
we have Dr. Friedmann, who is the chief research
officer and endowed chair for clinical research
at Baystate Health, and he is also the associate
dean for research and professor of medicine and quantitative
health sciences. He is the current president
of the Massachusetts Society of Addiction Medicine,
and he was recently appointed to that position. And he also serves as a past
president for the Association for Medical Education and
Research in Substance Abuse, and he is the former
director of the American Board of Addiction Medicine. He will serve as one of
our respondents today. And lastly, our other respondent
is Dr. Elizabeth Evans, who is an assistant professor
in the Department of Health Promotion and Policy
here at UMass Amherst. She serves as– excuse me. She leads several
state, federal, and foundation-funded
projects that are designed to address the opioids crisis. So without any further
ado, I will turn it over to the panel to share some
of their insights with us. And we look forward to
hearing from all of you. Dr. Horgan. Good morning, everyone. I know there’s great human
potential in this room and thank you to Dr.
Salomon-Fernández for highlighting this, because
that is something that has pervaded all our work in this
project and the excitement in Western Mass
has been amazing. It’s really good to be here,
to be focusing on Western Mass. Our job in this panel is
to focus on the research as background for
what we hope will be a robust discussion, both
with our responders here but also with the
audience as well. We’ll be talking about what
are the unique challenges in Western Mass, but also
the unique opportunities. You have the executive summary. You picked it up as you came in. There’s a full issue
brief that will be posted as this conference ends. It will be posted on
the website today. But before I go on
to the next slide, I would like to acknowledge
our other co-author who you will be hearing from later. Rob Bohler is the lead
author on this report. Michael Doonan is
also a co-author. This slide– just we’ve heard
a lot about our founders. You’ve been great. Thank you for being involved
in this opioid issue, and thank you for
showing your support for Western Massachusetts. Next. The game plan for
today is we’re going to give you a very brief
overview of the issue brief. My colleague Robert
Bohler will be giving– doing most of the presentation. And the first three bullets
up there describe it. He will start out by
talking about the extent of the opioid epidemic
in Western Mass. First will be a focus on
the underlying epidemiology, and then cost and consequences. We’ll go right on to the unique
challenges in Western Mass, and then a discussion
about unique best practices and innovative programs
in Western Mass. And then I will end with
a set of recommendations that come out of our research. These are just what came
out of our perception from the research and
in talking with you. But we hope that there
will be a robust disc– I keep saying robust discussion
between human potential –and robust discussion. This is going to be a
great morning, I think. The next slide
describes our approach. We had a three-pronged approach. We did an extensive
literature review, not just of the
academic literature, but also of what we call the
grey literature reports that may be unpublished. We sort of dug deep. I will say that
in the full report you will see there are
231 references for this. So there really is an
extensive background. We secondly looked at
publicly available data. And then did secondary
data analysis to drill down and
get some data that’s specific to Western Mass. And third, and I
think this might be the most important
part of the report, and this is the 24
qualitative interviews that we did with the key
various types of stakeholders. This was so important
because it allowed us to put a face on the numbers,
a face on the literature. It brought a little passion
in into the numbers, and thank you to
all who participated in being an interviewee. Providers, community coalitions,
criminal justice system, government officials, and
harm reduction specialists. Finally, I’d like to just say,
to give you a little highlight, not to upstage Rob– Dr. Bohler to be. He’s one of our star
doctoral students. So hopefully
there’ll be a doctor that’s not honorary in the
not too distant future. But the themes that
we’ll be focusing on is the importance of
community leadership, which is amazing in Western Mass. The rehabilitative role of
the criminal justice system– you’ve already heard
a little bit about it from the previous speakers. The need to engage more people
in medication for opioid use disorders. We’ve heard a little bit from
Dr. [? Keroack ?] about things that are happening. And finally, the
need for expansion of both harm reduction and
recovery support services. Now, I would like to
turn the microphone over to Dr. to be Bohler. [APPLAUSE] Thank you so much Dr. Horgan. Next slide, please. So we’re going to start
looking at the problem from an epidemiological
perspective, and basically what
that means is we’re going to look at the
distribution of opioid overdose deaths, of opioid use
disorder, and opioid prescribing in the state
and also in Western Mass. Next. Next slide, please. So many people in
this room probably are very aware of the three
waves of overdose deaths in the opioid epidemic. So first we had the prescription
opioid deaths were really driving deaths. And then in 2010 you
had the emergence of heroin deaths and
the increase there. And then in 2013 you
had the emergence of fentanyl and
fentanyl derivatives. And Massachusetts has always
had a slightly higher death rate than the national average. But you can see
here in the brackets that in 2013 this
difference really increased. And so what this
is suggesting is that Massachusetts has been
disproportionately affected by the emergence of fentanyl. Next. Next slide, please. Thank you. So opioid overdose deaths
have been increasing in Western Mass,
and we’ve already talked about this earlier. In 2017 all four
counties saw a decrease and it was below the
state average death rate. But in 2018 all of the
counties either matched or set a record high in
opioid overdose deaths. Taken collectively,
we had a 73% increase from the previous year. This is significant
and it’s concerning. Next slide, please. And so we asked the question,
well, why is this happening. And we really think that
a significant factor here has been the recent increase
in the presence of fentanyl in the illicit drug supply. So historically
Western Mass has had a lower presence of fentanyl. But you can see that over
time, that this is actually converging. So this difference
is getting smaller. And in other words,
what that means is that what happened
a couple of years ago in the eastern part of the
state with a dramatic increase of fentanyl may be becoming a
reality here in Western Mass. And this schematic
here on the right just shows what a fatal dose
of heroin versus fentanyl looks like. So it’s just a few milligrams. And if you can imagine this
being put in an illicit drug supply, if you have a
heterogeneous mixture of these few
milligrams then it’s very likely that the drug
user doesn’t know what they’re getting in each bag. Next slide. So looking specifically at
opioid use disorder prevalence, opioid addiction. There are several counties
in Western Mass that have much higher levels compared
to the rest of the state, particularly Berkshire County
has the highest opioid use disorder prevalence. 1 in 18 people
over the age of 11 are estimated to have
an opioid use disorder. In Hampden County that
number is 1 in 20. And even in the lowest
percentage county, Hampshire County,
that number still represents 1 in every 29 people. So what we’re looking
at is a large proportion of the population that is
susceptible to an overdose. Next slide. And opioid prescribing is
also higher in Western Mass. Both measured by the percentage
of the population that is receiving a prescription
opioid, but also in the number of dosage
units per capita. Also historically we know
that opioid prescribing has been high in Western Mass. There was actually a recently
released DEA database that was covered very
well by the Washington Post that revealed this. Next slide, please. So with the opioid
prescribing, we’re seeing that a lot of people
are being exposed to opioids. And it’s very important to
identify high-risk groups. And these were identified
by both the interview process and also the
Chapter 55 report, which many people
may be familiar with. It was a legislatively
mandated report that provided an assessment
of opioid-related statistics in Massachusetts
from 2011 to 2015. So it’s very important
to identify these groups so that we can
tailor interventions at these high-risk populations. Next slide, please. So next we’ll look at
the problem from a cost and consequences perspective. Next. So the Mass Taxpayers report,
which was released last year, estimated the cost of the
opioid crisis in Massachusetts in 2017 to be $15.2 billion. Most of these costs were wrapped
up in productivity losses and also increased
health care burden. If we were to extrapolate this
number to Western Mass, which has about 12% of the
state population, this economic impact would
be about $1.8 billion. Of course we’re
not able to account for variation, which
we know is present, so that’s a crude estimate. Next slide, please. And we know that
different industries are disproportionately impacted. So we know that the construction
and the agriculture industry are greatly affected. And these are definitely
prevalent in Western Mass. Next. And so we heard a
lot in the interviews about this intergenerational
impact of the opioid crisis. So neonatal abstinence
syndrome, which is where babies
are born dependent on opioids, the rates
in Massachusetts are higher than the
national average. But the rates in
Western Mass are higher than the state average. We also heard a lot
about this increase in grandparents that are tasked
with raising grandchildren. And a lot of these grandparents
are of prime working age. Also the foster care system
is experiencing a burden. There has been an increase
in parental drug use nationally for
placements for children. And then specifically
in Massachusetts we’ve seen a 20% increase in
the foster care placements over the last five years. And as we talked
about before, we know that there is a
considerable intersection between the criminal justice
system and substance use disorder. And what was revealed in
some of the data that’s collected by some of the
jails in Western Mass is that this
intersection may even be more prevalent in Western Mass. And we also know that
opioid use disorder among the incarcerated
population is on the rise. Next slide. So now we’re going to switch
gears and talk about some of the unique challenges
in Western Mass. This is just sort
of a brief overview, and we have a lot of
information in the issue brief. Next slide. So many people are probably
familiar with this map here. We have Western Mass,
and it’s made up of urban, suburban,
and rural areas, has the Connecticut
River that bisects it. And we heard a lot about
access to treatment issues. And this was compounded by
limitations in transportation and also rural isolation. We also heard about
these methadone deserts that were present,
and basically what that means is that it was
unrealistic for a person to be able to travel to a
methadone clinic because of distances, and
that really wasn’t a realistic option for them. And next slide, please. And we also heard a lot
about upstream factors. So there’s still a discourse
on whether socioeconomic status has anything to do with the
susceptibility of opioid use disorder. But we know that
this group is more prone to an opioid
overdose because they’re less likely to be able to
access quality treatment. And also they’re less likely
to be able to sustain recovery, for many complex factors. And then also we heard a lot
about trauma in the interviews. And data that was collected
in some of the institutions that we talked to showed
a very high prevalence in the criminal justice system. And also showed a
very high prevalence in children who had parents
that had substance use disorder. And then also we heard
a lot about housing. Having affordable housing
when someone leaves treatment, having that opportunity
when someone leaves from being incarcerated. And we actually had
one interviewer note that if people that are leaving
these previous environments do not have access
to stable housing and to gainful employment, then
they’re destined to use again. Next slide, please. And we heard repeatedly about
stigma in the interviews. And this stigma was manifested
in many different ways. So the general public
gets the message that opioid use
disorder is a disease. And sometimes it doesn’t
resonate with them because it’s not
what they perceive, what their perception
is of a disease. People in recovery, if they
are out about their recovery or people know
about it, are very stigmatized in the workplace. And I think we all
know that there’s these different
pathways to recovery. And some people on one
pathway of recovery may look down on another
pathway of recovery. So this actually
increases stigma within the recovery community. Medications for
opioid use disorder, which have a strong evidence
behind them, many people see them as just
simply substituting one drug for another. And lastly, medical
professionals, we still have a huge issue with stigma
in medical professionals. A state survey that Ros actually
partially funded last year looked at Massachusetts and
they found that over half of family medicine doctors,
internal medicine doctors, and ER doctors, thought that
opioid use disorder was not a treatable condition. So this is over half of
medical professionals. Next slide, please. And so then we’re going to move
into some of the best practices and just some of the
innovative models that we came across
in Western Mass. And again, I’d like to
turn you to the issue brief to get a full picture of this. Next slide, please. And we’ll be talking about
it throughout the continuum of care and also community
collaboration is added as well. Next slide. So community collaboration
is vital for a community. And this can look like having
different types of coalitions, whether they be prevention
coalitions or addiction coalitions or coalitions
specific to opioids. And also have an
aligned leadership. And what this does is it
reduces stigma in a community, it reduces silos, and it
increases the implementation of evidence-based strategies. We were able to work with
representatives from all four of the addiction taskforce
and coalitions, countywide. And they’re doing remarkable
and crucial work in this space. Next slide. Some of the best
practices in prevention are utilization of a PDMP,
using academic detailing towards medical professionals,
education on safe disposal– safe storage and disposal for
patients that are prescribed medications so that it decreases
prescription opioid misuse. And also you want to have a very
strong presence of prevention coalitions. Some of the examples that we
ran across in Western Mass were the Young Adult
Empowerment Collaborative, which is really targeting ages
16 to 25, to reduce misuse and also to identify and
treat early opioid use disorder in this population. And it’s funded by
a grant, and I just want to point out that the
strength of the prevention and addiction
coalitions really made this a possibility
in Western Mass and brought in this grant money. And then also the Franklin
Family Drug Court, which is the first of
its kind in the nation to have this model,
really aims to address this intergenerational
impact of the opioid crisis. Next. And so early
intervention, we talked about the high-risk
populations earlier. Some models aimed at
this high-risk population are very important. And also integrating addiction
services into primary care, making it more accessible
to a larger population. So two of the models that we
highlight in the issue brief are the DART program, which
is a post overdose response program that’s comprised of a
team of police officers, harm reductionists, and
recovery coaching. And they’re very
innovative in that it’s a bonus if they can get the
person linked to treatment, but they’re framed under
a harm reduction approach. So it’s nonjudgmental,
it’s compassionate, and they’re there to meet
people where they’re at. And then also the
EMPOWER Program through Baystate Franklin, which
identifies and supports mothers with opioid use disorder,
both during pregnancy and after pregnancy. Next slide. And then treatment,
and I’m sure we’re going to hear a lot about
treatment during the morning. There’s a ton of
evidence for medications for opioid use disorder,
especially related to mortality. So it’s very important to try
to identify these touch points or places where we can
increase people’s engagement on these medications. Some of those promising touch
points that are emerging are prisons and jails, emergency
departments, community health centers. And then also it’s
very important that someone, if it’s warranted
that someone needs long term treatment, they should
have that option. And then the levels of
care that they go through, they should experience
a smooth transition. Two of the innovative
models that we highlight are the Franklin County
House of Corrections, which has been providing
buprenorphine since 2016. They also have an
intensive treatment program behind the walls for
eligible participants that– and it’s a voluntary
participation. They actually
refer to the people that participate
in these programs as clients rather than inmates. And then also the after
incarceration support systems through the Hampden County Jail. This supports both recently
incarcerated individuals like senator Markey
talked about, which is a lot higher risk group. And then also it
supports section patients that are leaving the program. And it provides a
comprehensive support services to increase the chances of
having a successful outcomes. Next slide, please. Next slide, please. And then recovery. So we want all pathways of
recovery to be supported. It’s very important to have the
presence of recovery community organizations which are known
in Massachusetts as recovery support centers. And it’s very important to
have recovery support services. And so what these may be are
targeted towards employment, recovery coaching, education. These are all important
areas so that you can allow– facilitate the
process of someone trying to rebuild their lives,
who have opioid use disorder. And there are eight
recovery support centers in Western Mass. Actually two are
newly established. A lot of them employ people
that have lived experience. And they’re able to sort of take
all of these recovery support services and put
them under one roof. And if they’re not there they’re
able to connect their clients to get what they need to address
these social determinants of health. Next slide, please. And then, finally,
harm reduction. So there is a ton of evidence
for harm reduction as well. Yet ideologies still
serve as a huge barrier to having these services. So we know that syringe service
programs, targeted naloxone distribution, being
able to educate a person on safe
injection practices, and providing overdose response
and awareness– these things work and they’re
very, very important. Yet sometimes ideologies
can serve as barriers. And what we found
in Western Mass was Tapestry, which is a
comprehensive harm-reduction services. They provide all of these
services on the left. And they are present in all
four counties in Western Mass. And then another very innovative
model that we ran across was the Harm
Reduction Hedgehogs. And so this is a– they basically have a
peer-based outreach team that goes beyond the brick and
mortar building and goes out and tries to reach hard to
reach high-risk populations. So now I’m going to turn
it over to Dr. Horgan to finish with our
recommendations. Thank you. Here we are, the top 10. This is just our
take on the top 10. You may have different views. Let’s hear about it when
we get to the discussion part of the program. I’ll just get right
into it so that we have enough time to hear you. Number one, and
these are actually– it was hard to pick the order. So these are just 10
things that emerge. But increasing an improvement,
the treatment workforce in two particular
areas, trauma informed care and the physiology
of addiction. And by the workforce
I want to emphasize it’s not just the specialty
treatment workforce. It’s anyone who comes in
touch with an individual who has a substance use disorder. And there’s a lot that needs
to be done in this area. And there are lots
of things that are happening so that
people are better able, or providers and
clinicians are better– or anyone who comes in touch
with individuals can help. Two, we’ve heard a lot about
the task forces and coalitions. It has been amazing
what’s happening out here in Western Mass and the
role that you’ve played in bringing people together. So that’s just been so key
and important to continue and strengthen. Three, we started out the
talk talking a little bit about prescribing practices. We know things are going
in the right direction. We need to continue
interventions that lead to cautious opioid prescribing. Four, increasing the capacity
of medication for OUD. I still can’t say, MAOUD. Doesn’t that sound
sort of weird. But anyway, that’s what we’re
sometimes known as, MAT. And to also increase the
initiation of medications at vital touch points. We’ve heard about the touch
point of the criminal justice system. So being creative about
the initiation points. Five, a perfect segue into
increasing the treatment role of criminal justice system,
not just with medications. Six, provide a robust and
comprehensive treatment and recovering
continuum of care. Frequently there’s a focus
on just the treatment, acute treatment part
of the continuum. We need to look at
the whole continuum from prevention all the way
through to supporting recovery. Seven, we’ve talked
to rural isolation. Using technology as
a cost-effective way to deliver services
to under-served areas, whether it’s
through telemedicine or the digital apps to
address some of these gaps. Eight, to support
the distribution of naloxone and other-harm
reduction strategies. Naloxone has been
widely used here. It’s been amazing what it’s
done with overdose deaths. Nine, provide funding
that is sustainable for the entire continuum of care. Too often we have the seed
funding from the foundations, which we are very grateful
for and it’s terrific, but what happens afterwards
to see that some of this continued. And ten, the need to address
upstream factors related to opioid use disorders. We call these some of the social
determinant kinds of issues. These are key in
solving the crisis. So it’s taking a comprehensive
whole-person approach to this issue. Next. This is my final side. And we’ve used the term unique
a lot in this presentation. There truly are unique
challenges in Western Mass. We hope that we’ve
highlighted some of them. We hope to hear from you,
more talking about it. But I think that what is
widely recognized here, and we’ve recognized, is
the unique opportunity that Western Mass has
taken to come together to solve this problem. So kudos to you for all
that you’ve been doing. This has involved communities,
leaders in communities, the health care system,
and other systems. Criminal justice system, other
organizations, the task forces and coalitions. And lastly but not
least, us academics to pull the research
together and look at what’s evidence-based. We at Brandeis have been
honored to do this work. And I have to say,
I’ve been director of the Institute for
Behavioral Health for longer than I’d like to say. And I have never
been so impressed with the passion,
the dedication, and the commitment of the folks
in Western Mass to this issue. It is truly amazing what
you’re putting in in terms of [INAUDIBLE]—-
where’s Doctor– it’s the human potential is just
has come through loud and clear in solving this problem. So thank you. [APPLAUSE] Thank you Connie and Rob for a
wonderful report, and certainly comprehensive and really
captures a lot of the issues that we face. It’s a pleasure to be here. So as you heard I’m
Dr. Peter Friedmann. I’m the Chief Research
Officer at Baystate Health. And Associate Dean for Research
at the regional campus of UMass Medical School Baystate. You know, I’ve been in this
field for about 25 years. And I think if you’d told me I’d
be speaking to such an august group like this about this
issue when I’d started out, I would have been a
little incredulous that– you know, that things have
really changed dramatically as a result of this epidemic
I think is readily apparent. Not just in my
professional life, but really across healthcare. And the thing for me
that was initially appealing about the family
of disorders around addiction still holds true, and we sort
of see it playing out here. It’s really the confluence of
the clinical characteristics of the neuro-behavioral
disorder. And it really is a
neuro-behavioral disorder. Folks will debate what
the meaning of a disease is versus a risk factor, and
when does it become a disease. But it clearly is a
neuro-behavioral disorder that affects the
reward pathways, it affects cognition, executive
functioning, and clearly behavior. And it’s the confluence
of those factors with the social and economic
and, yes, political factors that really makes
this interesting to me and that gives this epidemic
its particular character. So it is– and it
is an epidemic. We talk about a
crisis but it really is an epidemic both in
terms of the proportions, but also in terms of thinking
about the disorder, how it is passed. There clearly is
a vector, right. So the vector in order
to catch the disease, one is exposed to it. In this case it’s
exposure to opioids. And we had a situation, as
has been widely reported, where there was a push to
increase prescribing for– I think for well-intentioned
purposes, right. People with pain
disorders seeking care. I think this is
partly also a function of our overstressed
primary care system. So my profession,
physicians, bears some of the responsibility
and burden for this. You know, we’re very busy. We have 15-minute slots. People come in with
complex pain issues. And it’s a lot easier
to just write a script than it is to explain to
somebody how to do biofeedback or where to go
for– or you know, to do all of these other
things or why an opioid may not be appropriate. I want to add to that, also the
amount of stress and anxiety in our society, it’s become
more and more fast paced. More and more benzodiazepines
have been prescribed. That was not really
discussed in the issue brief. But that is a major factor
in the overdose crisis. It really is the
mixture that really led to the initial
increases in deaths. And then the other part
which is fascinating is sort of the growth in heroin
markets outside of urban areas. So like any entrepreneurs,
always looking for new markets. And that sort of accounted
for the first phase. And then in the
current phase we’re in now the advent
of fentanyl, as we saw in some of Rob’s slides,
sort of poured gasoline on the fire, right. So already the illicit
supply was erratic, and this made it
even more erratic. And we had the case
of these folks, at the same time, these folks
who had pain conditions. Many of them who then became– transitioned over to having
this neuro-behavioral disorder. And their docs were telling
them, no, I can’t prescribe. And we’ve seen declines
in prescribing. And then– but declines
in prescribing, but not– we’ve not been aggressive
enough in terms of offering other effective
solutions for people. So we don’t have comprehensive
pain management clinics. We don’t have other approaches. And we didn’t have
a lot of providers who were talking to
people about addiction, knowledgeable about addiction. And when I was in medical
school I didn’t really learn very much about it. In many ways I’m kind of
self-taught, as are many of us in the field. And so docs didn’t know
how to talk about this. And so they would
summarily decrease folks. I recent– I’m one of the
journal editors for the Journal of Substance Abuse Treatment. We recent reviewed a
paper from Vermont, which is not too far
from here, looking at the tapering
courses of folks who were discontinued from opioids. And the median amount of time
for a taper was one month. So people are being cut
off pretty precipitously. We hear cases across
the country of suicides from people who are cut
off from their pain meds. So clear the pendulum has swung
in a direction where we are no longer prescribing as well. We shouldn’t be,
given all the issues, but we need to think about
what are we offering people. And we have to ask
the question, as we stop prescribing where are
our patients going to go? What are they going
to do to get relief? What are they going to do
to deal with the withdrawal issues? And the other
psychosocial issues that come with this disorder. And I think we as physicians
need to think about that. We as providers need
to think about that. In addition, the
stigma, talking about it really makes it challenging. People don’t want to– to give
someone that label is a very difficult thing, to talk
about medication treatment as a chronic in many cases
lifelong thing that people are going to need– a lot of folks don’t
want to hear about that. And we have further issues
out here in the West. We have methadone– we actually
do pretty well in terms of buprenorphine access. But we have methadone deserts. But the treatment
really is stigmatized. People are encouraged
to come off prematurely, and that really
is a major issue. Also in our smaller
communities it’s hard to maintain anonymity. People don’t want
to come forward because the person
sitting at the front desk could be somebody who knows
somebody who knows somebody, right. So there are a lot of
these structural factors. The other thing I
want to just say, that’s not really talked
a lot about in the report, is sort of the other sequelae. So clearly the effect
on maternal child health is really important. We have a concomitant epidemic
of hepatitis C that is raging as a result of injection. And many of those folks are
going to require treatment, so we need to think about how we
expand access to that as well. So the other part of the
report that I thought was very well said is that
really the structural issues, as I mentioned, that make this
interesting for me in terms of the meeting of the
neuro-behavioral disorder with these social and
political factors, those structural factors
are remediable, right. But it requires political
will, it requires financing, it requires a change
in priorities. And that has been
part of the issue, I think, in thinking about this. And it requires
changes in behavior. It requires not just writ
large, but each of us individually as
prescribers, as clinicians, in terms of how we address
folks who have these problems. So we can go down
the list of them. Transportation to
treatment, how do we think about making
that available. How do we increase accessibility
of medication treatment, and how do we decrease the
stigmatization of medication treatment for this disorder. I think a lot of
folks still believe that methadone or
buprenorphine is replacing one addiction for another. And if you have a
true understanding of this neuro-behavioral
disorder that nothing could be
further from the truth. I’m happy to talk more about
that individually if anybody is interested in that. But that really
contributes to the stigma. The high rates– you
know, rates of prescribing have come down to
about 2015 rates. But we still have
fairly high rates of prescribing because it’s
difficult to find time to talk with folks about these issues. And I just want to
close in saying, though, that as the report mentioned,
we have reasons for optimism here in the West. We have very strong
community coalitions. They’re very much engaged in
a large-scale research project that’s coming out of
Boston Medical Center and from NIDA, National
Institute on Drug Abuse, that we are involved with called
the Healing Community Study. So a number of our
communities will be involved in this project. And really, the question that
the Healing Community Study is at asking is if we
take these best practices, providing medication, providing
naloxone, treating folks in transition from jail, dealing
with the structural issues, can we reduce the
overdose rates? The goal is ambitious, to
reduce overdose rates 40% in three years. But that’s going
to be starting– the randomization actually
occurs in October. So coming up. And we’re going to start
to see, it’s across– it’s our state and New
York, Ohio, and Kentucky. And we’ll really
get some answers about whether these
things that we believe, we hypothesize they work, and
there is smaller scale work that suggests that they work. But we’re really
going to start to see. The other thing
that’s really exciting is our jails are doing more in
terms of providing medication treatment to inmates. We are involved with the Justice
Community’s Opioid Initiative, which is studying a very
innovative legislative mandate here in Massachusetts,
where seven jails, including three here in the West, were
mandated to provide all three of the FDA-approved
medications for opioid disorder for folks who are on
them when they come in, but also in transition
back to the community. And I really believe we’re going
to show dramatic improvements in terms of the
risk of overdose. We heard that folks
leaving jail and prison have 130 times the risk of
overdose as others, largely because of the detoxification. So we have reason for optimism. We have new harm
reduction services in many of our larger cities. So I just want to end
by thanking all of you for your hard work in
addressing this crisis. We still have a long way to go. But I think we’ve really
made tremendous progress and I’m grateful for
all your efforts. Thank you. My name is Liz Evans. I’m an assistant professor
here at UMass Amherst, and I know I’m between
you and our break. So I will share a
little bit about what I want to say in
response to the report. And then I very much
welcome the discussion that we planned to have it
in the afternoon, or later. So I did want to share a
little bit about myself, how I got into this type of work,
how did I become a researcher. So years ago as an
undergrad in San Diego I paid for school by working
in the jails at night. So my job was to
interview people. I was a research assistant. And as people were
arrested and booked I sat with them for 30 minutes,
an hour, collecting information about their health and
welfare, and really kind of hearing their stories. And it was sort of
through that process of talking to hundreds of
men, women, and juveniles that I learned a lot about
the nature of addiction that had not really ever
been exposed to before. And this was during the 1990s,
during the war on drugs. So I heard a lot of
stories from people about the trauma they’d
experienced, how they came from families and communities
where substance use was sort of typical, normalized. It was the way they
were using to cope with adversities in their life. And I kind of saw by talking
to people that they really weren’t that different from me. They had just been
arrested, incarcerated, but weren’t really
all that different. And I kind of saw how
they were not the enemy. They were the people
who we had to figure out how to better help in some way. And I started questioning is
it– is the criminal justice system the best way to
resolve this problem. Remember, this was during
the time of the war on drugs. People typically
were not offered treatment in those settings. And I would tend to see
the same people come in and out of the jail. I was there most nights. So I’d see the same people again
and again, week after week. So I started questioning can we
really incarcerate our way out of this problem. At that time though I myself
was only 19, 20, 21 years old. Pretty young. I wasn’t yet ready to launch
research that could actually investigate solutions or
alternatives to the situation. And I actually went
off, did other things. Years later, though,
I landed a job at UCLA in major addiction
research shop there. And just a side note. How did I get that job? It was really
because of the work that I did as an undergrad. So we’re here on a
university campus. I just want to take
a moment to say if you’re a student,
how you spend your time as a student really matters. You could end up calling
upon that experience in ways that you don’t expect later
in life to put it to a purpose that you don’t really
understand until maybe later. So I encourage the students,
especially, yes go to class, take the test, do what
you need to do to progress towards your degree. But also get involved. Go out into the world
to make a difference in some way about something
that you care about. Many of the people
here today want to work with you in some
way and help the school up the next generation
of problem solvers. So during my time at UCLA,
I was there for 17 years. I was a project
director where I worked on a huge portfolio of work,
more than 30 or so studies of addiction. And I didn’t understand until
maybe my first year or two that these were very
special studies in that we were doing longitudinal
prospective cohort studies. So that’s just a
fancy academic way of saying we were
recruiting people, usually from either prisons or
jails or treatment settings, or maybe community clinics. We would recruit people
who had addiction. And then we would follow
them forward in time, interviewing them over time. Also acquiring their records
to understand what service systems were they encountering. But by interviewing
them I mean that we were talking to them not just
every month or every year, but every 5 years, 10
years, 30 some years. So by studying people
over their life course we could really track the
nature of addiction, what happens to people over time. And I wanted to share
a few lessons learned from that body of work and
it connects to the report. One thing we found,
and it really resonates with what we
kind of accept today, is addiction is a
chronic health condition. What does that mean? Well people often spend
many years of their life caught up in addiction,
using the substance. There are cycles of
abstinence and return to use. And it’s a very cyclical
type of health condition. So the work that I
was a part of helped to provide empirical
evidence to document the nature of the condition
such that maybe now more of us do endorse the idea that it is
a chronic health condition that is challenging to address. Also we were able to look at the
different types of addiction, so opioid use disorders versus
methamphetamine or alcohol or let’s say marijuana. And it really stands
out, as many of you– I’m sure all of you know
–opioid use is especially lethal and especially
persistent compared to those other substances. People don’t mature out of use. It’s not as if they age
and sort of slough off the use of that substance. No, they tend to continue
to engage in it over time. And they die out. They don’t mature out. So these premature deaths
are common occurrences that are avoidable. But all is not lost. When we study people
over time we also see that people do manage
to achieve recovery. Recovery is possible. And we became very
interested in, well how do people achieve recovery,
especially lasting recovery. So what do I mean by that? I mean they could
stay in recovery for five or more
years of their life, is how we ultimately defined
it for our research purposes, and we could argue whether
that’s appropriate or not. And then we became
interested in, well, what then predicts
or is associated with that lasting recovery? It turns out, well, treatment
with the medications is a very critical
turning point event. So if people stay engaged with
treatment, with medications, it lowers their risk
of continued use, and of course death,
but also results in many other positive health
and social improvements. But, that medication is
effective only for so long as people continue to take it. It’s not a cure. It’s not as if someone
can take that medication and they’ll be done
with treatment. They need to continue
to engage in it as is consistent with a
chronic health condition. The longer people stay
engaged with that treatment, the better they tend to do. But it isn’t all just about
the medication treatment. There are other factors
related to lasting recovery. So we saw from our
research that those who had lower
psychological distress were more likely to
achieve lasting recovery. So what does that mean? Well, that’s really,
we’re talking about co-occurring mental
health disorders like depression and anxiety, and other
health conditions. Those are very prevalent
among this population. And it’s something that
needs to be addressed in addition to the addiction. Also those who have
more social support for entering treatment
and staying in recovery, they’re more likely
to engage in that and feel able to
stay in recovery. And yet they’re often
living in communities where they do face
so much stigma, like we saw from the report. Not just from
family and community but also health care providers. So that’s a major
area to focus on. How do we change
the narrative such that receipt of the
medication is seen as a thing we want people to do. It’s a positive thing for
them to engage in treatment. It should be something that’s
easy and encouraged to do. Another thing related
to lasting recovery was when people could be
employed, or find another way to have a meaningful
contribution that they could give back to
society in some way. So if you spent 10 or more
years of your life engaged with addiction, you’ve
really eroded your capacity to be employed. How can we work together
to provide opportunities for people to feel
they have a way to give back, despite
their history of addiction. And then lastly, we
also found that people who could be abstinent
for 5 or more years were more likely to remain
abstinent for the next 10 years or so. And it’s this idea
of, well, maybe people do need lasting
treatment engagement. It might be a lifelong type
of treatment engagement, not a one-time or several
months type of engagement with treatment. So I came to UMass
to do something with all of this knowledge. I had done that type of
work at UCLA for 17 years. Part of the reason
why I came here was because of the nature of
the opioid epidemic in Western Mass, and I felt like I could
bring my research to bear, to make a difference. But I needed help. And I reached out to Risa,
who you met earlier today, and she introduced me
to Jennifer Kimball, who introduced me to
[? Sheri ?] Sullivan, Ruth [? Poti, ?] Peter
Friedmann, so many people. And it’s just to illuminate how
we need like all hands on deck. So I’m excited to be
here today to figure out how can we all work together
to resolve the epidemic. Thank you. We have some very interesting
questions for the panel. And I’ve tried to organize
them a little bit because I’ve seen a number of themes. But I will read this comment
followed by two questions that are related. One comment is
that someone said, at what point will be stopped
calling it an opioid crisis and view this substance
abuse epidemic as a whole, so a new substance doesn’t
slide into the void. A very valid point. So moving on to the questions. This person wrote, I
understand the research team has parsed the data and
created 10 recommendations. What I’m wondering about is
whether the panel could share their thoughts on prevention. What are some ideas
that you have, and also what are your thoughts around
the overdose prevention sites? Any one of you can
comment on that. [INAUDIBLE] the question. One is about prevention. So the notion of primary
prevention I think is really key. So working with parents, and
educating children about that even though the
prescriptions are prescribed and for their
appropriate use they– well, they have a
window of safety, right. They clearly have
issues around addiction that I think, particularly
in the 90s and before, we didn’t really appreciate
the extent of which. So talking– clearly education
is a major part of it. I think doing more around
disposal is important. So if anybody has opioids
in your medicine cabinet, or benzos for that matter,
if you’re not act– you know, taking an active course
of it, they really should be disposed of properly,
either at one of the buyback sites or mixed with coffee
grounds and disposed of, crushed up. They say not to flush
them, but if you have no other choice it’s
better than having them present. Clearly that has been
a big big part of this. And then the other
part of the question was about overdose
prevention sites. So now I’m putting on
my Massachusetts Society of Addiction
Medicine hat, and we have come out in favor of
developing overdose prevention sites. The legislature has
said that they– there there have been
a number of bills and that they would pass a bill
if a municipality would come forward being willing to do it. And one has, the
town of Somerville. So it’ll be a very
interesting year to see how that progresses. There will be some advocacy
work going on in October to try to make that– push that forward. I do think the evidence
is pretty clear that for communities
that have these sites, they do a lot in terms of
reducing overdose deaths, clearly. But also infectious
complications, abscesses, and also needle litter,
which is a big issue for a lot of our communities. There are legal hurdles. I think the US
attorney in our state has said that he
would prosecute. But it’s not the
first time that there has been states’ rights issues
around these kinds of things. There is a legal formula
to try to make this work. So I think it is something
that eventually we will see in this country. As you know, they
are present in Canada and around other
countries around the world and have been highly effective
in preventing deaths. So we’ll see. Thank you. Dr. Horgan. Thank you. The term crisis, that
does seem to indicate that this is something
that short term we can just go in, zoom in and fix
it, and it’s going to be over. That’s not true. Maybe we should start
using other language. Opioids are part of looking
at the whole problem. The problem, specifically
related to opioids, will be long lasting. But there are other
issues, and you have to look at everything together. I just like to use two examples. Peter mentioned, when you’re
thinking about the crisis, look at what other
things it involves. We’ve talked about the hepatitis
C. Other aspects– there are other intersections with
medical issues that are key, and it’s part of looking
at the whole package. The other issue is, when we
think about opioids shouldn’t think about it as a silo. Most people who
are using opioids are also using other substances. And we’ve mentioned
benzos, which is certainly a huge issue, but please,
let’s not forget about alcohol. And most people are using
both alcohol and opioids. And alcohol is a problem
in and of itself. So let’s start looking
at the broader things and thinking of things
more comprehensively. Just on the
prevention approach, I am going to turn it back
over to Rob to talk more about prevention in the report. But the prevention– Peter, you very rightly
pointed out the problem of what about people who have a
problem and are experiencing incredible problems because
of the greater difficulty in obtaining opioids. And that is a huge issue. And this is a chronic problem,
and we need to deal with it. But we also need to
focus on prevention in terms of prevention, stopping
the problem in the first part. So prevention is key to have it
not happen in the first place. But we have to clean
up our mess also. So what are we going
to do about it. And that’s important. Rob, you’ll have the
last word on this topic. What? OK. I’ll be very brief. So, I appreciate whoever
posed that question. They’ve obviously
done their research by referring to overdose
prevention sites and using that type of language. It’s very, very interesting
that they recently did a study, and they either called them
overdose prevention sites or safe injection facilities. And I think 40% of
people supported the overdose prevention
sites, but only 20% supported the safe
injection facilities. They’re the same exact thing. And I think what it
really highlights here is how important
language is, and how we talk about
substance use disorder. There’s also studies
looking at calling people substance abusers versus a
person with a substance use disorder. And using language like
referring to people as addicts. This is all stuff
that increases stigma, and so we really need
to look at our language, both in the general population
and how we speak, but also, definitely also in the medical
and psychosocial spaces as well. You know, in echoing the
polysubstance use problem that we have, a study
that actually came out of Boston Medical Center
showed that over 80% of the opioid overdose
deaths, there’s also another substance
present other than opioids. So that really
highlights that this is a polysubstance epidemic. And we’ve been seeing
a large increase in the use of stimulants,
particularly methamphetamine. And there’s actually been talk
about this fourth wave that could be happening with the
increase in methamphetamine. And I think something
that’s very important is that all of this
money that is coming in– and don’t get me wrong,
we need more of it to address the opioid crisis
–but all the money that’s coming in, we should be
considering how can we build infrastructure that can support
all substance use disorders, not just opioid use disorders. Thank you. Thank you. So speaking to
infrastructure, this question comes from a family
support specialist in Berkshire County who says
that her agency has access to her clients’
cell phone numbers, who also happened to be very
socioeconomically challenged. But a cell phone is
very important to them. So if we have
access to databases that include information such
as cell phone numbers and email addresses, why do
we not use these as a way of engaging
folks more directly? Technologies like that are
ones that have happened just in the last 10 years. And so it does present
amazing opportunities to create innovative
interventions or different ways of engaging with people. So we do use that technology
now for our long-term follow up studies. So it is a critical way
that we stay in touch with people over time. We use the way that they prefer. So it often is their phone
or texting or different ways through that technology. Also others are embedding that
into health interventions. So there are certain
groups who specialize in using that technology to
re-engage people with care, to stay in touch, to make
them feel more connected. So there are especially
like cell phone apps that are all about how do we use
an app to help people recognize stressors in their life. And to recognize
that and then do something else besides
using substances in response to that stress. So that’s work that I’ve
been engaged in in the past. And I would be eager
to talk with anyone who’d be interested in that
type of work going forward. First has to do
with the DEA which has placed a moratorium on
mobile methadone clinics. Do you have some thoughts
on whether it’s time to revisit this restriction. And also related, what are
we doing about affordable safe housing. These would help increase
sober living options and that might be an
opportunity for us. I think probably Dr. [? Boti ?]
may talk a bit about this later. The regulations right now,
especially on methadone in my opinion, are
inhibiting access to treatment that has
been proven to save lives. And I know actually
here in Massachusetts, during the interview process
in talking with BSAS, there is a funding
proposal moving forward on trying to identify
these methadone deserts and to do something about them. I just wanted to say
something about methadone. And you’re absolutely right,
that the methadone rules were developed for a
different epidemic, for a prior epidemic
of heroin use. And at a time when we
really didn’t understand the benefits of greater access. And we’ve seen internationally
that office-based prescribing of methadone is effective. It’s done in Britain. It’s done in Australia. And we don’t have
that option available. So you’re– so to be
able to expand access, not just mobile clinics, but
also for hopefully trained physicians to be able to
prescribe this outside of a clinic setting really
would help improve access. The whole question
of sober living is a really, really
important one. So we have– as we know,
there is a strong association between substance use disorder
and homelessness, particularly for certain populations. And housing is a huge
issue in our region, and sober housing in particular. You know, that is really
key in terms of recovery. As a matter of fact, I did
some work a number of years ago looking at– longitudinally at folks who had
completed treatment programs, and we were interested– I was interested
in– you know, I’m a doc, so I was
interested in things like how does medical
care improve outcomes, mental health care. Really, the two things that
we demonstrated that improved long-term outcomes, one
was housing assistance, and the other was
employment assistance. So those are the two
things that we really need to think about how we
make those things available. As you know, felony charges
make it difficult to get to– often to get housing. And drug use is very much
associated with that. So there are a lot
of structural issues like that we need to do
more in terms of addressing. Wonderful. [INAUDIBLE] I will be very brief. There are some very interesting
experiments going on with how to better
incorporate payment for social
determinants of health into the health care system. Some insurers have some model
programs that are going on. So I think we’re at the
very beginning stages. There are innovations
going on in housing. There’s something going on
with Medicaid in New York state experimentally. So stay tuned and be part of
doing things in this area, because it is a
social determinant and it’s important broadly,
beyond just opioids. This is something where you’re
looking at the whole person. So that’s– There are a couple of questions. A couple of folks who are
interested in your research into juvenile issues. And there is also a
concern with parents whose children are
removed from their care due to opioid incidents. What are your thoughts on those? What are you seeing in
terms of the research? What implications
do you think it has here for us in Western Mass? Well, in our research we know
that people with the condition, they are embedded
in their families, and it’s important
to involve them as much as we can in their care. So families can
be a great source of support for people who are
seeking or already in recovery. But sometimes they might
need a little education on how can they be
supportive and helpful, and not inadvertently
undermine the recovery process. So that’s something
I’m interested– I’m working in that
space now –to hear how people in recovery want
their allies, the allies in their life, to work with
them in partnership to help them stay engaged in treatment. And I’ll just follow up on
that by talking about a few of the innovative
models that we discussed in detail in the issue brief
that were sort of aimed at dealing with
the family issue, the intergenerational impact. And so the Franklin
Family Drug Court, which was the first in the
nation to really really take a crack at looking
at the entire family and treating the
entire family, they have some really promising
preliminary results in being able to have a– sort of take a life
trajectory approach. And so more and more
research is coming out that trauma is a huge factor
in the development of substance use disorder and
that trajectory. And so being able to take
a life course approach– and if I remember correctly, I
think that 100% of the children had experienced at least
one adverse childhood event in this program,
where their parents were in substance use, had
substance use disorder. And another program
was the EMPOWER Program through Baystate Franklin. And they really looked
at the power imbalance that can sometimes happen
between parents that lose their children and
the Department of Children and Families. And they tried to tailor
their interventions to try to decrease
that power imbalance. So that’s very important to
have that context when you’re addressing family issues. [INAUDIBLE] So many, many,
many thanks to our panelists. We really enjoyed your
presentations and comments today. [APPLAUSE]–

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