Addiction in America: One-on-One with Massachusetts Gov. Charlie Baker

Bernstein:        Morning everyone.

Baker:              Morning.

Bernstein:        As Kris just said, I’m Lenny Bernstein, a health and medicine reporter for The Post.  My guest, as all of you know, Massachusetts Governor Charlie Baker was a member of the president’s commission on opioids.  He proposed, and your legislature passed, the nation’s first limit on prescriptions, first-time prescriptions, for opioid drugs, at 10 days.

Baker:              Seven.

Bernstein:        Seven, sorry.  [LAUGHTER] [APPLAUSE]

Baker:              If I hadn’t said that, Secretary Sudders would have.

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Bernstein:        She would have just announced it, right?

Baker:              Right.

Bernstein:        [LAUGHS] Okay.  And I was going to say that he remains adamantly opposed to the benching of Malcolm Butler during the entire Super Bowl.  [LAUGHTER] So I hear.  So we’ve had almost relentless bad news over the past several years on the opioid epidemic.  One of the few places where good news is coming out is Massachusetts.  You’re overdose rate is down.  As we said, your prescription rate is down because of that great seven-day limit.  And the number of tablets that are being prescribed is down.  How are you accomplishing what’s going on in Massachusetts right now?

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Baker:              Well, first of all, almost all the information that came out recently, which was the 2017 data, which was an improvement for the first time in many years, over the previous year in a number of areas, was referred to in the media—and I this is the right term—as sort of muted commentary.  I mean, I think our view is if you see something where it gets worse by double digits every single year for a really long time, and then, all of a sudden, your prescriptions move down, you have millions of prescribers—tens of thousands of prescribers using your prescription monitoring program for the millions of prescriptions they’re writing, virtually all the time, and then you see a big drop in prescriptions, and you see some leveling off in overdoses, and a decline for the first time in a very long time in deaths.  You know, compared to the trend, that’s all positive.

But I would say that where we are is still very much in the middle of this, and we have a long way to go.  And I do think the legislation that you mentioned previously, that we worked with the legislature on—which included things like requiring all prescribers, as part of their continuing education program, to take and pass a course in opioid therapy and pain management—and some significant increases in support for treatment and recovery services.  And a first investment in school-based assessment programing for middle school and high school kids.  And a whole bunch of stuff in the prevention and education space.  It was designed to help inform patients, coaches, families, practitioners, sort of everybody involved in this mix.

I think all that stuff has helped, but there’s nobody in Massachusetts, I don’t think, who is anything other than sort of breathing a sigh of relief, and recognizing that this means some of the things we’re doing seem to be working.  But we have miles and miles to go.

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Bernstein:        Folks, I should remind you that if you have questions—and we would really love to take them—please tweet them and use the hashtag #PostLive, and I’ll get them on the tablet, and pose them to the governor.  So as you say, the epidemic continues.  It’s still bad.  And most of it is fentanyl.  I think 80% of the folks who overdosed in your state, and in many other places, over the past year or so have fentanyl in their systems.  Nationally, the number of fentanyl overdose deaths more than doubled last year.  What are you doing here about fentanyl?  What can you do here about fentanyl?

Baker:              Yeah.  So the fentanyl and the movement on fentanyl is significant.  You know, as recently as 2014, fentanyl was present in about 30% of the overdose deaths in Massachusetts.  And as you point out, in ‘17, it was present in over 80% of the deaths.  I mean, it is clearly a major force in both overdoses and deaths.  A big part of what we’re doing there is working with our colleagues in the federal government, and with our colleagues in local law enforcement.  And the good news there—okay, it’s kind of a similar story.  The good news there, there have been a whole series of very significant interventions on the law enforcement side.

A lot of people trafficking in enormous quantities of fentanyl have been arrested, and their product’s been taken off the streets.  But the size of some of these drug busts speaks to just how much of this is currently in our communities.  And I would say one of the things that we’ve been talking to the local justice department folks about is doing more.  Part of the problem with fentanyl is it travels through a whole series of relatively hard-to-identify transportation networks to get here, one of the biggest of which is the mail.  I mean, it’s an odorless element that you literally can put inside a paper bag, or a brown-wrapped box, and off it goes.

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Bernstein:        Small envelope?

Baker:              Yeah, exactly.

Bernstein:        It just comes in through the mail.  So what do we do?

Baker:              I think you have to do everything you can to try and take as much of it off the street as possible.  But I would also argue that you still need to think about this as a prevention education exercise, as well as a treatment and recovery exercise.  And recognize that this threat is there.

And for us, that means things like the second piece of legislation we filed, which is designed to create sort of a structured program around recovery coaching.  And taking something that a lot of people have started to incorporate into the treatment and recovery world, and create some standards and some structure around it, so that we can create what I would describe as a more robust, supported, and clinically designed approach to long-term recovery.  Because one of the things most people say about folks who are dealing with opioids is it’s not the kind of thing that somebody’s going to lick in a short period of time.  You have to create some framework to actually help them get better, and to stay with them over time.

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There are a lot of folks who have started to see some benefit with recovery coaches.  We created a pilot program where we embedded recovery coaches in a number of emergency rooms to see if somebody who’s been there and done that—and a lot of the recovery coaches then to be people who are in recovery themselves—would be in a position to engage people who overdoses, and to say, “I’m in recovery.  Can we sort of talk about maybe having you get into recovery at this point in time?”

Again, the results are preliminary, and it doesn’t involve a big sample size at this point, but we have seen some significant positive development in those interactions, translating into people moving into treatment.  And now the key is we have to figure out how to get them to stay in treatment.

Bernstein:        I’ve seen people go straight from the emergency room right back out to the street.

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Baker:              Yeah.

Bernstein:        And just avoid treatment.

Baker:              We have some stuff in our legislation on that too.  I mean, I think the data on people who overdose, needing to find a path into treatment, is pretty powerful with respect to—once you get to the point where you’ve overdosed several times, you’re somebody we really need to figure out a way to get into treatment.  Because you’re heading down a road that, in many cases, leads to a very bad place.

Bernstein:        One of the things you proposed is a 72-hour involuntary hold for people, where you actually would be allowed, against a person’s will, to put them in treatment.  Can you tell us how that would work, and how people’s rights would be protected?

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Baker:              So in Massachusetts, you can currently be civilly committed if you are viewed as an immediate danger to yourself or someone else.  And that’s been in place for years.  It’s called a section.  And we built this using a similar framework, both from a legal construct, and also from an operating point of view, to put this notion in place.

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We spent a bunch of time talking to clinicians in the ERs, to hospitals, to folks who run treatment programs, and said, “How do we figure out some way to create a handoff,” for lack of a better word, “For somebody who comes in, overdoses, gets stabilized, and makes it possible for somebody to use the same legal framework, for all intents and purposes, that we already have for people who are a danger to themselves on the mental health side?  And put these folks into a treatment program for 72 hours?”  Now, if after 72 hours they basically say, “Not interested,” they can leave the program.

Bernstein:        But would you have to show that someone was a danger to them self in order to put them into that program?

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Baker:              Well, yeah.  I guess the theory there would be that if you are somebody who has overdosed and nearly killed yourself several times, you’re getting to the point where it’s pretty clear that we should at least try to get you to take seriously the treatment idea.  And this is where, by the way, I do think the recovery coaches—particularly the ones we’ve piloted—have turned out to be pretty effective ambassadors for treatment generally for folks who are in those situations.

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But it’s really hard to get somebody who’s in the throes of this, who’s probably been Narcan-ed, and therefore, is in a really bad place emotionally and psychologically, to buy into the idea of treatment at that point.  And the thought was 72 hours in a treatment program.  Again, maybe it works, maybe it doesn’t.  But the one thing I’ve heard over and over again, from a lot of the folks I’ve talked to in the addiction community, is you don’t know necessarily when treatment is going to stick.

Bernstein:        It could be the third relapse.  It could be the fourth relapse.

Baker:              Almost everybody I’ve talked to in this space—family members and others—have all said to me exactly that; that the point at which it stuck was a very hard thing to predict, and that you had to presume that there would be relapses, bumps in the road, along the way.

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And I said this when I testified about this issue before the legislature, you know, we all grow up being told by our parents, by our teachers, by our coaches, by almost everybody, that failure is part of success; that there are always obstacles and setbacks in achieving anything of great significance.  We hear that all the time.  It’s a cliché.  I happen to believe it’s true, but it’s a cliché.  When we get into this area of treatment and recovery, somehow, we sometimes forget that.  We forget.

Bernstein:        You’re supposed to succeed the first time.

Baker:              Exactly.  We forget that we’ve told people for years and years that, you know, failure is part of getting there.  And I think particularly for people who are battling an opioid addiction, for many of them, it simply wouldn’t be surprising if it took more than one try to get from here to there.  And I think we should incorporate that in the way we think about treatment generally.  We’ve put 1,100 treatment beds up over the course of the past several years.  We’re going to put another 500 up.

But we really need to also figure out this sort of continuing support model for folks over time so that they have, what I would describe as, sort of the consultative services that go with, in some cases, medication-assisted treatment of one kind or another, to help them stay on the path to recovery.

Bernstein:        With the program.

Baker:              And with the program.

Bernstein:        I mean, people relapse in other areas, in dieting, and with other diseases.

Baker:              Yeah.

Bernstein:        We do not hold it against them.

Baker:              Yes, exactly.

Bernstein:        You are opposed, or at least openly skeptical, about supervised consumption sites; places where—

Baker:              I haven’t heard them called that before.  Is that a—[LAUGHTER]—new term?

Bernstein:        Euphemism.

Baker:              Yeah.  For those who’ve never heard that one before, I think he’s talking about safe injection sites.  [LAUGHTER]

Bernstein:        Well, they—yeah.

Baker:              Supervised consumption sites.

Bernstein:        Supervised.  People bring their drugs in off the street.  They are given clean needles.  They are given clean other kinds of equipment if they’re cooking or they’re smoking.  But most importantly, of course, they are being watched and supervised by people with naloxone and oxygen in case they overdose.  And inevitably, people do.

I went up to Vancouver.  They have 29 of these now in British Columbia.  And quite a few are just popping up in tents in Vancouver itself.  Tell us why you feel the way you feel about those kinds of places.

Baker:              Well, the first thing we should remember is they’re illegal in the United States, which most people would call that a bit of a road block.  [LAUGHTER]

Bernstein:        And yet, some cities are saying they’re going to open one, regardless of the law.

Baker:              I know.  We have some very interesting dynamics going on between state and local and federal government these days on all kinds of things.  [LAUGHTER] My data on this is relatively old.  I do think folks in our administration, who are going to be on the West Coast, are going to take a trip up to Vancouver and see what’s going on up there.

My biggest concern with it is there was little information that suggested that this was a path to treatment.  And I am really interested in paths to treatment because our goal here should be to get people into treatment.  Everybody I’ve ever talked to, who’s in this space, had never said to me that this is the way they want to live the rest of their life.  And I think part of what we need to focus on here is treatment.  And I’m not—the last time I checked in on this—and I’ll be the first to admit, my data is old—there was very little evidence that this was a pathway to treatment.

Bernstein:        I think that’s true, but I also think the folks up there would say to you, “There is no path to treatment until we keep these people alive day after day after day.”  They’ve never had an overdose death in one of these.  Whereas we discussed at the beginning, you have many overdose deaths when people are—

Baker:              Are they still operating as anonymous operations?

Bernstein:        No.  Not in Canada.

Baker:              No, I mean like the people who go there?

Bernstein:        The one I was at, you do not have to leave your name.

Baker:              So how do you know that—they may not have overdosed that time, but how do you know that they aren’t people who’ve overdoses in some other setting after that?

Bernstein:        Well, a lot of them are coming back day after day after day, and it gives them a level of comfort where they’re actually taking the drugs in a clean and supervised environment.  And they know if they go down, somebody’s going to jump on them.  There’s one operating anonymously in the United States.  We don’t know where it is, but—

Baker:              Anonymously—[OVERLAPPING]

Bernstein:        Underground, yeah, according to the research.

Baker:              Okay.

Bernstein:        I get emails every time I write a story or every time the subject comes up in The Post, and I bet you get these every day.  And they’re from people who say, “I’m in pain.  If I don’t get my drugs, I don’t function.  I can’t get out of this chair.  I don’t take a lot, but I do take it, and I take it on a regular basis.  And your work is going to make it impossible for me to get my drugs.  You’re sentencing me to a life of pain.”  Now, the research tells us, beyond 12 weeks, that may not be the truth, but it is certainly the way many people that I hear from feel.  Do you get those kinds of emails and letters from people?

Baker:              Yeah.

Bernstein:        And what do you say to them?

Baker:              First of all, we should all respect the fact that people in chronic, long-term pain are playing an incredibly messy and difficult hand to begin with.  And that’s why the legislation we proposed was a seven-day limit on first prescriptions.  With, by the way, a pretty decent exception opportunity for prescribers, if they felt it was critical that that person get more than that.  And it’s presumed by us and by others that chronic pain is a different issue.  And I’ve read the same literature you have that says that there’s not a lot of evidence that it works for people after a certain period of time.

But I think the—when I think about how we got into this situation, some of it was about chronic pain, but a lot of it was about wildly overprescribing for short-term stuff.  And this message about, you know, keep taking it, stay ahead of the pain, and keep taking it, and that just led a lot of people, who were actually going through withdrawal, to think they were actually still dealing with the pain associated with whatever the circumstance was that led them to get the prescription in the first place.

Bernstein:        When, in fact, they may just be sensitive to pain—or to their withdrawal systems.

Baker:              Exactly.  Right.  I mean, I do think by—we didn’t get this in the statute, but we got agreements from our medical schools, nursing schools, social work schools, dental schools, and pharmacy schools, to build into their core curriculum opioid therapy and pain management because I do think there’s a whole generation of practitioners out there who were never really trained around any of this stuff, which creates part of the issue as well.

And one of the things that’s in this legislation we filed was to work with folks in the pharmacy community and in the medical community to see if we can’t come up with a blister pack for really small—you know, wisdom teeth—small time—what I would describe as small-time stuff where why anybody would write somebody a 30- or a 60-day supply for something like that is beyond me.  And if we could give them a tool that made it possible for them to write a much smaller dose, that would be more consistent with what they would probably want to give this to this person if they had a tool available to them, I think they would.

Bernstein:        I think at least now they’re thinking about, “Why am I giving 30 or 60”—[OVERLAPPING]

Baker:              Well, hopefully, for that short-term stuff.  On the longer-term stuff, we actually had a bunch of pain folks, clinicians and advocates, in for a conversation to talk about, “Well, help us understand what some of the alternatives might be, and how can we incorporate those alternatives into either the way our MassHealth  program works, or the way our coverage policies work for commercial insurance.”

And I got to tell you, one of the things that came out of that conversation, for me anyway, as a lay person, is pain’s a very complicated issue.  And it’s not clear to me that you can think about it in a broad stroke; that for long-term chronic pain, there are a lot of different elements at work here.  And what we probably need to do is make sure that we have as many of the tools available to people as possible, and let folks try and figure out which ones work best for them.  But on the really short-term acute stuff, I really do believe that being careful and cautious with this stuff is a big part of what we need to be doing with respect to prevention and education.

For the folks who give me and you, apparently, a hard time on, justifiably, with respect to the binary conversations they seem to be having with some folks in the provider community about their situations, I talk to people all the time who say, you know, “I had a minor procedure and my provider, Dr. Dennis Whatever, wanted to write me a 30-day supply.  I said I didn’t want a 30-day supply.”  They said, “Take it.”  I said, “I don’t want it.”  They said, “Take it.”  And they walked out the door with a 30-day supply, and many cases they don’t fill it.  We do now have the ability to do partial fills in Massachusetts, which is helpful.

Bernstein:        Is that an insurance issue?  The pills are covered, and maybe not with dentistry, but with other things, it’s harder to get coverage for physical therapy and other alternative forms of pain relief?

Baker:              I think sometimes that’s true.  On the MassHealth side, that stuff’s covered without a prior authorization.  I do know a lot of the commercial carriers in Massachusetts have now started to make that available for the same reason.  They see it as an alternative to what has clearly been an ineffective and, in some cases for people, a dangerous solution to the pain problem for many others.

But I do think one of the things we are going to focus on and try and work on is what are some alternatives we can make available for people.  And help educate folks about what those alternatives are, and what kinds of presenting circumstances they would work best in.  Because for the chronic pain sufferers, it’s a completely different conversation in my mind than it is for the short-term stuff.

Bernstein:        Got you.  Here’s a question from someone on Twitter.  She says, “How can we encourage businesses to take a chance on hiring people in early recovery?”  I hadn’t really thought about that, but is it a difficult road to get rehired when you’re in recovery?  Are businesses reticent to do that, and if so, what can we do about that?

Baker:              You know, I’ve always been advised by my mother especially to not answer questions I don’t know the answer to.  [LAUGHTER] That’s a hard question.

Bernstein:        It is a tough question.  It’s a very tough question.

Baker:              What I would say is that, for the most part, I think employers—for the most part—try to be pretty—and there are laws in place as well—try to be pretty good about helping existing employees, who end up with a problem with any kind of substance, okay, alcohol, drugs, opioids, whatever it might be—go into treatment and find their way back to work.  I mean, there’s legislation on this.  There are regulations, and there are corporate best-practices on this, that have all moved very much to support folks, help them get better, so that they can get back to work and be productive again.

With respect to new hires, I guess that’s a more complicated question because I would assume that no one’s required under law to say anything about the fact that they’re in recovery.

Bernstein:        You might have to.

Baker:              But depending upon the nature of their recovery, and what that requires them to do, that may factor into a conversation they would need to have with somebody in HR.  I think I’m going to have to parking-lot that one and do a little homework on it.  I mean, I’m literally processing.

Bernstein:        Fair enough.

Baker:              We have medical marijuana in Massachusetts, which is legal, and I do know there are people who deal with their employers on that issue, because that’s turned out to be an effective way for them to deal with pain and other issues like that.  But even there, you run into issues with folks who do work with the federal government where there are federal requirements associated with drug testing that factor into the medical marijuana space as well.  That’s a good question.

Bernstein:        What role do you want to see the pharmaceutical companies play in the curbing of the opioid epidemic?  Is there anything they can do here, across the nation?  Do you feel they should be funding recovery, funding treatment, in any way as a result of having been involved in the beginning?

Baker:              Well, I guess I’d start with, how about do no harm, right?  Stop promoting these medications with a far more tilted set of statements and promotional notions about the positive side of this stuff without talking at all, or even downplaying, the negative side of it.  And I was pleased to see, I think Purdue said they were going to get out of the business of physician detailing on this.  And I think that’s great, but it’s probably 15 years too late.

Bernstein:        Right.

Baker:              I know there’s a ton of—Massachusetts is one of many states that are involved in all sorts of civil procedures with the manufactures of these products.  And we obviously support the work the attorney general is doing there.  I know there are folks in the pharma space who are working on non-narcotic alternatives to pain management.  I hope they—

Bernstein:        A lot of research going on.

Baker:              —continue to do that.  I think that’s important.  But I would like to see them be a lot more aggressive about—I’m not remembering the terminology here.  There are certain kinds of medications in this space that are far less easy to crush and break.

Bernstein:        Yeah.  You can’t tamper with them.

Baker:              Tamper-proof.  Thank you.  I would like to see them get a lot more aggressive about pricing and promoting the tamper-proof stuff over the traditional stuff.  Because if you look at—they give lip service to that, but if you look at the way all this stuff is priced, for the most part, there’s far more of the tamper-able stuff in the market than the tamper-proof stuff in the market.  But really, I would just like them out of the detailing business completely.  And I would like them to acknowledge the fact that, for very many people in the United States of America, those medications, improperly promoted, have caused an incredible amount of pain, harm, and destruction.

Bernstein:        Okay.  We have about a minute.  You can’t just say “money” in answering this question.  You were on the president’s commission.  You worked very hard.  You proposed many, many ideas of what could be done.

Baker:              Yeah.

Bernstein:        Other than the law enforcement you’ve mentioned, we’ve seen very little movement.  What do you need from the feds?

Baker:              I would love to see—and I can’t say money?

Bernstein:        You can say money, but not just money.

Baker:              Not just money.  Okay.  I would love to see the feds get very aggressive about education, right?  All the folks graduating from all those schools I talked about before.  I would love to see everybody coming out of those schools have to take and pass a course in opiate therapy and pain management.  The feds are in a position to make that—we did that in Massachusetts on a voluntary basis with all of our graduate schools.  The feds are in a position where they can make that happen nationwide.

I would like to see them incorporated into all the CEU programming for everybody who’s a prescriber.  I would like to see—you know, we’re going to figure out how to make recovery coaches a sort of embedded part of the way the healthcare system works in Massachusetts.  I would love to see the feds get really aggressive about recovery coaches, because I think they are a huge opportunity, if we do this well, to really help people who get into recovery stay in recovery.  I mean, many of the things that we’re trying to do here in Massachusetts, that we believe have been successful, the feds have a much bigger playing field, and a much bigger opportunity to turn into reality around the rest of the country.

The feds could give us the ability to put a standing order out there to make Narcan available over the counter.  I mean, they have a lot of tools.  And I guess what I would say is, now that we have a confirmed Health and Human Service Secretary, I would like to see Secretary Azar take this stuff and run with it.

Bernstein:        Governor, thank you so much.  That’s all the time we have.  [APPLAUSE]

Baker:              Thank you.

Bernstein:        The next panel will be on in a moment.

Addiction in the Cities: Perspectives from the Mayors

Zezima:           All right.  Well, good morning, everyone.  I’m Katie Zezima.  I’m a national correspondent for The Washington Post.  I want to introduce my guests here.  We have Mayor Marty Walsh of Boston and Mayor Joyce Craig of Manchester, New Hampshire.  And our discussion today will focus on how local governments across New England are responding to the opioid crisis.  And, before we begin, I want to tell everyone in the audience online and here to tweet questions using the hashtag #PostLive.  We’d love to hear what your questions are and what you’d like to hear from the mayors, so please send us what you’d like to know.

So mayors, you know, I want to start talking about—you know, we have the statistics that are happening; we have about 60 deaths in Manchester in 2017, about 200 in Boston.  Those are just the numbers.  You’re all in the street, and there’s a lot more happening in your communities.  How is this affecting your communities on the ground, and what do you see every day when you go out there?

Craig:              It’s heartbreaking.  It’s affecting everybody in our community.  It has no boundaries, every neighborhood, socio and economic, everybody.  So we’re taking an all-inclusive approach; everybody needs to be involved.  We need to be on this and really start to make some significant progress in eliminating what’s happening.  You know, one death is too many, and we’re having way too many.  And we’re continuing to see the overdoses, so we need to take a community approach and bring everyone together to address this issue.

Walsh:             I’ve been working on this issue since 1997 when I got elected as a representative in the House of Representatives here in Massachusetts, and it’s devastating.  I mean, it’s devastating when you know somebody personally that loses a loved one to addiction.  It’s devastating for the families that have loved ones that are in the grips of addiction.  You know, it’s not a simple solution.  As a mayor—I mean, I think, as a human being it bothers us all.

And I know some folks put their loved ones’ pictures up here.  And, you know, you can’t bring their loved ones back.  And they know what the pain is.  They know what the suffering is.  They know what the stealing in the home is.  They know what the not coming home at night is.  If their loved one got into recovery, they know that happy feeling for a very short period of time, getting that good night sleep when somebody goes into detox and then, when they break out again, that feeling of desperation, and you hope that the police arrest somebody just to get them off the street.  You know, that’s what we’re dealing with every day in the City of Boston.

The numbers you said, the 200 overdoses, I’d say they’re probably higher than that.  I think that people don’t—you know, nobody wants to have their loved one diagnosed as the cause of death an overdose, so it’s probably higher than that, the number.  But it’s truly devastating.  I see some folks here, Mayor Jajuga here.  He has been doing this work as state rep, as a senator, as a mayor.  Too he can talk about his town.  Frank Baker, city council from Dorchester, is here.  We can all talk about stories, but I think they mayor said it.  It’s just a very sad, tragic, part of our job that we have to deal with.

Zezima:           And, you know, the City of Boston has spent millions on recovery programs since you took office.  You’ve opened the office of city outreach.  There is the engagement center.  Can you talk a little bit about what the goal is, what your goal is for the City of Boston?

Walsh:             Well, I think one of the first things—when we created the first Office of Recovery Services in the country in Boston, and that’s really about looking at our system and looking at our services that we provide in the City of Boston.  The way Massachusetts works is the state provides a lot of services through the Department of Public Health, the Bureau of Substance Abuse Services.  As a city, we don’t necessarily provide direct care, but we’re supportive with the state on how do we make sure we get people—try and encourage people to go into detox.

And one of the first things that we did is the minute after we created that office we realized that parents or people didn’t have access into treatment, and they didn’t know how to do that.  I mean, it’s not something that it’s easy, you can pick up Google and say, “How do I get somebody into treatment;” it’s not that simple.

Zezima:           Which I’m sure a lot of people were actually doing because how else do you go about that?

Walsh:             Yeah, and they were.  So we made it as simple as possible.  You pick up the phone and you call 311 and you ask the person on the other end of the phone that you want help or treatment for somebody, yourself or somebody else.  And that’s what we kind of have done in the City of Boston, trying to increase access to treatment.  We work very closely with the state in making sure that we fund detox beds.  We work closely with the nonprofits to make sure that we have halfway houses so we can have this continuum of care.  But still the task is daunting.

I mean, not everyone who is an addict wants to get help.  And so making that first call sometimes is difficult for people to do.  So we try to encourage people.  We have outreach workers in the street now.  We have, I think, five or six people in different parts of the City of Boston trying to encourage people to get into treatment.  When they’re ready to get into treatment, we’re helping them with that.  So what you can do is only provide the tools.

The issue of addiction really started around 1850 when the pharmaceutical companies got together and started crating these pharmaceutical companies and heroin started being produced, so we’re talking about an issue that we’ve been grappling with for 160 years that we can’t quite solve in two or three years or four or five years.  It’s going to take us time to get there.  I think we have better services today than we had in the past, but you can’t say that to a mother who lost their loved one last night because of addiction; it doesn’t matter to them.

Zezima:           And what you said is important.  You know, people have to have the desire to go into treatment; they need to want to take that step, and it doesn’t always happen the first time or the second time or the third time.  How do your outreach workers kind of stay with those people and encourage them to do it?

Walsh:             You keep with them.  I mean, there’s no other way of doing it.  I mean, sometimes people will be fortunate enough to go to detox once and get it and never pick up again, and God love people that have that ability.  Some people might go 15, 20, 30 times.  I mean, people might say, “Oh, my God.  That’s too many times,” but eventually—I think there’s hope for everybody.  You know, there’s hope for any.  I’ve seen people get into recovery that have been down bottom addicted to heroin and alcohol and other drugs, jail time, and they’ve completely turned their life around.  I can tell you of two cases of people that I know that own homes today, and there was no hope for them, so you can’t give up.  And, as cities, we can’t give up on anybody, because that’s our job and that’s our responsibility.  As public officials, you can’t give up on somebody.

Zezima:           And Mayor Craig, in New Hampshire there has been a lack of treatment beds, and there have been a number of treatment facilities that have recently closed, not for lack of need but because of financial problems.  How has the lack of treatment beds in New Hampshire made it more difficult for you as a mayor to try and get the constituents help?

Craig:              Well, obviously, you know, like Mayor Walsh said, we want to make sure that everyone can get the treatment that they need.  And with a lack of beds that’s been a huge challenge.  And when you talk about all of the programs you have in Massachusetts and all that you’re doing and the money that you have, you know, it makes me really understand and feel how far back Manchester and New Hampshire in general is.  When I took office about a month and a half ago—we have a program called Safe Station.  Every fire station is open.  So anybody who needs help can walk in.  There is no stigma.  They’re comfortable in the environment that they’re in, and we provide them with the help that they need—the treatment facility that helped people that went into Safe Station closed.  And so we were in a situation where we needed to provide all of the programs to other entities and get things going so we weren’t falling even further behind.

But it also provided us an opportunity to say, “What’s working and what’s not?”  So we were able to really take a look at—we knew that people were coming in by the hundreds to our fire stations, but they were coming in for different reasons, not always substance misuse but homelessness, mental health issues, so we were able to bring other entities in and make them part of the solution.  So we’re really getting people to where they need to be.  But it is an ongoing challenge that we don’t have enough resources through the state.

We’re also seeing, in Manchester, 65% of the people coming in to our fire stations are from outside of Manchester in addition to outside of our state.  So they know about this one access point, but we really need to do a better job of educating and opening up other access points throughout the state.

Zezima:           I saw it was about 3,000 people used Safe Station in about 18 months.  Correct?

Craig:              Yes.

Zezima:           And the city has partnered with Lyft to help people get from point A to point B, but there is an issue.  Right?  It’s only for Manchester residents.  Can you talk a little bit about that?

Craig:              Well, what we’ve tried to do in looking at what’s been working and what’s not is we identified the significant number of people who are coming into our city for help.  So we’ve worked with the governor and the governor’s office and other government agencies to really do a better job educating people throughout the state on where they can go in their area.  So we’re trying to and hoping that people really look to their neighborhoods and their cities and towns to get the help they need instead of coming to Manchester.  That’s where they’re going to be the most successful, where they have the resources, hopefully the family and friends that can help them through this process, instead of coming to a city they’re not familiar with.  So we’re accepting anyone who comes in, but we really want to encourage people to stay in the areas where they live and get the help that they need.

Zezima:           And I know, Mayor Walsh, you’ve talked about a recovery campus in Boston.  Can you tell a little bit about how that would work?

Walsh:             Yeah, just for the people that are watching that aren’t familiar with Massachusetts or Boston, we have a Long Island, which is part of Boston, which is connected to Quincy by a bridge.  It’s Boston’s island connected to Quincy.  And my first eight months as mayor, within my first eight months, I had to shut the bridge down because it was literally crumbling into the Atlantic Ocean.  Out on that island we had programs; we had a homeless facility; we had a couple of detoxes; we had about three or four long-term home-recovery programs.  So when we closed the island we had to find a place for these programs to go.

And when we did it, we replaced every bed on the island.  But we realized now that we have an island—I made an announcement in January that we’re going to rebuild the bridge back to the island and then come up with a recovery campus idea.  What does that mean?  That means that we’re sitting down now talking about what is the need in the recovery continuum of care.  You know, the detox beds, we have detox beds; we could always use more.  We have holding beds.  What we don’t have is long-term recovery beds, really, enough in the common wealth to be able to sustain, get people into a continuum of care.  So we’re going to be looking at how do we create that type of long-term living environment out on Long Island.  It’s a therapeutic setting.  It’s on the Atlantic Ocean.  You can see Boston; you can see Squantum; you can see Quincy.  It’s an opportunity, really, to think about how do you create beds.

The mayor was talking about Manchester.  You know, when somebody wants to get sober, we have to get the whole state sober.  So I think that you have to think of a system that works not just for Boston.  You can’t leave it up to the individual cities and towns in Massachusetts for, say—I’ll use this as an example—to say, “Boston is only going to take care of Boston.”  You know, because when I got sober, I got sober down in Gosnold down the cape.  So I was able to go down there.  So I think we have to think about how do you create a system that works.

This recovery campus idea, you know, you might have people from all over the states there.  I mean, you have to get out of the neighborhood you’re in; you have to get out of the circumstances that you’re in to get that clear head and get that opportunity to move your life forward.  And that’s really what I’m looking at here on Long Island.  I’ve gotten a little pushback—well, maybe more than a little pushback.  [LAUGHTER] But I’ve gotten some pushback, but I think once it’s explained, people say, “Okay, I get it.”  Because everybody—and when I say this—I can say this today—everybody knows somebody who is either addicted, whether it’s drugs or alcohol, or knows somebody that has somebody in their family addicted.  You couldn’t make that same statement 20 years ago. Maybe you could, but it wasn’t public.  Today it’s more open, so people talk about it.  And I think it’s a better situation to be in as far as people talking about it because then help can happen.  But it’s still a difficult situation.

Zezima:           And in terms of Long Island, you were criticized for taking the bridge down.  And, you know, everyone did get into recovery, but it took a long time, and there was criticism that it added to people on Melnea Cass Boulevard.  Did the situation—

Walsh:             Long-term it didn’t.  I mean, I think the people—well, we do have a homeless facility on Melnea Cass now.  So I guess that’s there.  But, yeah, I got criticized for not caring.  I mean, Long Island is a place I went out to every other Sunday for literally almost 10 years doing a commitment, an AA commitment at a program called Bridge to Recovery.  They changed their name after that.  You know, and I went out there as a private citizen doing that.  But, again, I guess you can make an argument that the bridge didn’t get the proper attention it should have because it was addicts and alcoholics and homeless people on the island, where if that was a bridge going to an island that had high-end condos and other services maybe the bridge would have been fixed.  I mean, I’m not—I’m just saying that, I guess.  [LAUGHTER] [APPLAUSE]

But, you know, what it made us do, it made us—look.  I mean, the opioid crisis isn’t new.  It didn’t happen under my watch as mayor or the mayor’s watch as mayor.  It didn’t happen in the last 10 years.  This has been going on, as I said, for a hundred years.  But it’s public now.  And I think if we didn’t have the abuse of the prescription drugs we still might not be talking about this.  But you know something?  Even without the abuse of prescription drugs, we had a crisis.  We had a drug crisis.  We have people that were using and abusing drugs and heroin and crack and other drugs that came in that wasn’t to the epic proportion it is today.  And I think that we’ve just got to continue to move forward.  Any idea is a good idea.

You mentioned Lyft.  You know, somebody may say, “Well, what’s that do?”  Well, that gets somebody to treatment.  That Lyft, one driver might get somebody to treatment that gets sober and turns their life around.  I think any ideas are worth pursuing in this fight.

Zezima:           One idea that Lenny and the governor talked about are supervised injection facilities.  They’ve been getting some traction in Philadelphia and in Seattle—they are illegal federally, there.  Lenny went up to Canada and did a story on this.  What do you each of you think about the idea of supervised injection facilities?

Walsh:             I’ll go first.  I don’t understand the concept behind it, to be quite honest with you.  You know, I know that people say, “Well, we can watch and monitor.”  First of all, if you’re a heroin addict and you go and buy your heroin wherever you buy it, you’re probably not going to drive across town to the safe injection site to shoot up.  And what happens—if anyone knows the history, as you pay attention to the history of the heroin dealership, heroin coming into the United States of America—when they were selling it on the streets on America, what they decided to do was find where the methadone clinics were.  And when they found where the methadone clinics were, they realized, “These are the addicts, so now we’re going to go and take the drugs over to the addicts, and we can figure it out.”  And what happened was the addicts who were going, they were sitting ducks.  So you’re going to tell me that we’re going to have a safe injection site anywhere and that the drug dealers aren’t going to realize, “Oh, let’s go over here.”

I mean, I’ve heard—I haven’t seen firsthand, but a couple of people I know went up to Vancouver to see the safe injection site in Vancouver, and they said that that block of area out there is a disaster.  There’s people shooting up in the streets; there’s people shooting—there’s drug dealing going on.  I think it’s an idea, I guess, but I just don’t see the rationale behind it because I’m an alcoholic.  If you told me that I could drink safely in this bar and, you know, and whatever happens, well, I don’t—I want to be over here.  So I just get concerned about it.

Philadelphia is just starting it.  There’s no proof.  Nobody has come to me with scientific data saying they work, although somebody I’m sure will come up with scientific data that shows that we’ve been able to save people with Narcan.  I just don’t see how that helps.  I think you actually hurt the addict doing that because now they’re going to be preyed upon more by the drug dealers because they know exactly where they are all day long.  We do have a site in Boston.  Health Care for the Homeless has a room that people go into after they inject.  They can go in it and kind of hang out there.  That’s not an injection site, but it’s kind of after you inject you go in there.  So I’m kind of curious to see how that’s working out.

Zezima:           I was going to ask you about that.  I mean, do you agree with what they’re doing?

Walsh:             Yeah.  I mean, that’s—it’s another thought process on how you do it, and we’ll see what happens.  But I just think the safe injection sites is going to cause a whole bunch of new issues.

Craig:              In New Hampshire we’re so far away from this.  We don’t even have needle exchange.  We don’t have a safe site, like you talked about.  We are so far back that I think there are things that we need to do before we even consider something like that.

Walsh:             People are afraid of the needle exchange.  I mean, when I was a legislator, for a little while it was a tough issue, but then it’s really not.  And then buying needles and trading needles in, it’s really not that big of a deal, meaning that if that can cut down on disease, that’s a positive way to do it and not sharing needles.  And I think that people in New Hampshire or anywhere in the country, I mean, unless you hide in your house, I mean, look outside; there’s heroin on your street and there are people that you love doing it.  And I think if you can preserve them with some other potential health risks down the road, we should try and do that.

Craig:              I absolutely agree.

Zezima:           And would you like to open one in Manchester?  I know there is one in Claremont, New Hampshire that just closed because it was too close to a school with zoning.

Craig:              It is something that we’ve talked about in Manchester, so we are looking at it.

Walsh:             You talk about schools.  I think that we have to do more intervention in our schools earlier.  I think a lot of people say, “Oh, it’s next to a school.”  Well, there’s a good chance in that school there’s kids using drugs.  And I think what we have to do is get to our kids younger in grammar school and as early as grades three, four, and five, and start talking about addiction.  And people might say, “Oh, it’s too young.”  Well, by seventh or eighth grade they’re smoking weed, so, it’s like—

Zezima:           What do you tell them?

Walsh:             I think you have to explain what an addiction is, and I think you have to talk about situations.  And I think that unfortunately a lot of schools now—I mean, Chris Herren talks about growing up in Fall River, Massachusetts.  He was the top scorer.  He’s still the top scorer of all time in Massachusetts.  He partied with his friends; he went to college; he started doing coke and oxys, and it took him on an incredible ride that nearly ruined his life—or ruined one part of his life as far his professional career, but didn’t ruin his life because he’s come back as a stronger human being because of recovery.  But I think you have to tell those stories.  I mean, people need to know that these are real, because a lot of people see stuff on the street.  And kids observe.  Kids know in the neighborhoods who is doing the drugs, who is drinking the booze, who is hanging the corner, who is doing all that; they know that.  So if we think they don’t know, we’re crazy.

Craig:              And their parents are doing it.  And that’s what we’re seeing in Manchester.  We need to really help these kids through this difficult time that they’re having at home so when they’re at school it’s a safe place for them so we can help them through this.  And we have to do more.  I completely agree with you.

Zezima:           Mm-hmm.  It’s affected the foster care programs; it’s touching children as well as adults all over.

Craig:              Absolutely.

Zezima:           Mayor Walsh, you had talked about potentially joining the lawsuits against the pharmaceutical companies.  Where are you on that?

Walsh:             Right now we put an RFI out.  We’re getting with what the legal community is doing.  We’re going to make a decision really soon.  We’re probably going to join the lawsuit.  We’re looking though.  There’s a couple of different things going on.  There’s an investigation going on by the attorney generals, 40 around the country, ours being one.  Maura Healey is looking at how they’re going to proceed forward.  You have individual states that have sued pharmaceutical companies.  And you have kind of class-action lawsuit with cities around America.  So we’re looking at the best approach for us to move forward on how we do it.

You know, I think suing—okay, we’re going to sue and maybe get something back from all the devastation that these drugs have cost us, but I think the suit is really about raising awareness.  For me personally it’s about continuing the conversation and having people pay attention to what’s going on.  I don’t think people really paid full attention to the smoking until they got sued.  And when they got sued and different states won those awards, people started paying really attention to what came out of that.

Zezima:           And do you kind of view this as like the second wave of the tobacco-type lawsuits?

Walsh:             I guess you can say that.  I think that tobacco is devastating, but I think heroin and prescription drugs are more devastating.  And I think that—you know, I heard the governor talk right before me.  And, you know, he was talking about prescribing and certain prescriptions.  And he’s done a really good job legislatively with the legislature doing some great things.  But, you know, if you go in for kidney stones or what have you—I mean, if I asked my doctor tomorrow, “You know, I want a prescription of oxycodone or Oxycontin because I have a bad pain in my back,” they’re going to give it to me.  Do I need 30 prescriptions for kidney stones?  I mean, the pain lasts for 12 hours.  And so I think that we have to think differently about how we do things in this country.

Zezima:           Mayor Craig, you just took office, but is the lawsuit something that you had considered or thought about?

Craig:              Actually the city signed on prior to me taking office, so we are participating.

Zezima:           And, mayor, also talking about the engagement center as well, which has been set up in South End, can you talk a little bit about that and what it offers?

Walsh:             Yeah, our engagement center—so when we had to close Long Island Bridge we had to move our homeless facility off of Long Island.  It made us really think about homelessness in Boston a little differently.  And we literally had a building that was a transportation shop, a sign shop.  We moved the sign folks out of there from transportation; we renovated the building; and we built a brand new homeless shelter in the City of Boston.  Not every homeless person goes into shelter at night.  A lot of people will want to stay on the street.  They just won’t come in; they won’t engage.

So we decided around Melnea Cass Boulevard and Mass Ave we had a lot of people homeless—not all homeless, but everyone down there—everyone describes them as homeless, but they’re not all homeless.  Some just come down for the day and hang out, cause a lot of havoc, and go back to wherever they come from.  But what we decided to do was create a drop-in place for homeless folks that want to hang out for the day and be safe—not hang in the street, not sleep under a bridge, not hang under a tree, but come to a place that will provide them with a cup of coffee, some breakfast in the morning, some lunch, something at night, and then kind of get off the street and kind of let them do what they want to do while they’re there but get them off the street.

So we opened this engagement center.  It was temporary at first.  It’s still temporary for now, and we’re going to think about doing long-term.  And I think we’ve had over—I think in six months about 27,000 visits in the engagement center.  That means repeat people coming in.  And what we’re finding is—I think we’ve got about—Brandon, do you know?  Like 60 people into recovery?  So we have like 60 or 70 people in recovery that were homeless that came into the engagement center and indirectly we’re working with them to counsel them to give them some ideas about maybe if you want to go for help you can go for help.  So what it is, it’s a drop-in center for homeless people.  And so people aren’t seeing the homeless folks in the street, but we’re also not hiding all those people by—we’re trying to engage them with opportunities for recovery.  And I think that it’s worked to a degree.  And in Boston in the last three years, three and a half years, we have housed over 1,300 chronically homeless people that were on the street of Boston that are now in a home in and around the Boston area.  So we’re trying to be creative on homelessness.

And I just want to be clear.  Homelessness and addiction are two different things.  Sometimes they’re the same, and sometimes they’re different.  So when I was in recovery, when I went to detox, they asked us to describe a homeless person.  And what we said was, “A person drinking a bottle out of a brown paper bag.”  And I think it’s important for us as a society to realize that not all homeless people are addicts and not all addicts are homeless people.

Zezima:           And when you closed Long Island and it took a while to get people into recovery, did that really show you the difficulties of placing—you know, just the lack of beds, the lack of treatment, the fact that it took so long?

Walsh:             Well, one that we had—first of all, the programs were surprised because they’re running and then the next day—they’re all nonprofits; most of them were nonprofits—they had no place to go.  So we’re trying to places to site.  And siting a program is very difficult.  And it’s unfortunate, because a couple of programs we tried to site in different areas and people didn’t want them in the neighborhood.  And I said to myself, you know, “Them or those neighborhoods?”  I mean, and it’s really discouraging when we want to put programs in—a good strong program I’m talking about—in a neighborhood that doesn’t want it, especially after you explain it.  I mean, we had a difficult time placing one of the detoxes that was actually pretty much a lock-down detox, meaning that there’s no drug activity going on around the detox.  You go there; you go in for treatment; they shut the door; they lock the door; they don’t let anyone in; you’ve got to visit at certain times of the week; you can’t have visitors all day.

So it is difficult.  And I think that siting these programs is complicated and difficult.  And I think some neighborhoods open their arms, but it’s hard.  And I think that people need to realize that, again, as we site these programs, I mean, somebody might say to me, “Well, you wouldn’t want it on your street.”  Well, I lived in Savin Hill, and there was a house down the street that was for chronically homeless people, and I brought Pine Street in there, and they run a great program.  It’s a single-room occupancy home with common living space that there’s no problems on.  So, I mean, people need dignity.  And I think if we show people respect and dignity and if a neighborhood can do that, it’d be helpful.

Zezima:           Mayor Craig, have you run into some of those issues in Manchester as well, you know, the need for facilities and just the lack of desire for them in certain neighborhoods?

Craig:              We absolutely have.  And right now we’re dealing with the safe and sober homes and finding places to do that.  There really are no rules or regulations about it.  And, you know, things are popping up throughout the city not necessarily safe for all people, so we’re trying to—you know, our fire fighters or police officers are doing amazing work on the streets right now battling this crisis but also trying to make sure that people are safe and where they need to be so that they can get the help that they so desperately need.

Walsh:             And, in my opinion, there’s a big difference between a licensed recovery home by the state and a sober home that’s opened by somebody who is in recovery that’s renting it out for, in some cases, top dollar and not having proper programming.

Craig:              Right.

Walsh:             Because they can’t regulate the clients that are in there.  But a halfway house in Massachusetts by definition they can be drug tested, and if they fail, they can be asked to leave.

Zezima:           And how do you root those out, you know, if they’re just popping up?

Walsh:             It’s hard.  I mean, I’ve worked with the state, before I was in this role, as a rep trying to figure it out.  And a lot of it is regulation and trying to come up with zoning regulation in the community.  And it’s difficult.  And I think that a lot of the bad players in that industry, at least in Boston, are staring to—I think they’re deciding, “This is too much for us,” because Boston is a small town and it’s not that complicated to find out who these people are and kind of go right to the heart of it.

Zezima:           Mm-hmm, and get right in there.  We only have about three minutes left, but I know Mayor Walsh, you went down to Miami to the mayors’ conference and were showing people how to use Narcan.  Can you talk a little bit about that and what both of your plans are for Narcan and what’s it’s doing for the community?

Walsh:             You know, Narcan is an incredible creation, I guess, invention.  But it’s temporary and it’s short.  We did a demonstration for the mayors around the country showing what Narcan is, because a lot of people are afraid of Narcan as well.  And when I became the mayor I asked my police and fire to all carry Narcan.  Now everyone has it.  It’s important.

What Narcan does, it helps potentially prevent an overdose death.  It’s short-term.  It has saved people’s lives.  But unless we have the next step after the Narcan, we’re back in the same situation again.  Meaning that when you hit somebody with Narcan and they come back, more often than not they’re not willing to, like, go into treatment that minute.  They don’t even realize they had an overdose, that they literally died.  But Narcan allows parents to have a second shot at their kids.  Narcan allows people that are in the grips of addiction to have a second shot at life.  And I think that it’s one of those things that I promote it and I try and get it and try to tell people, “As best you can, get trained in it,” because you never know.  You never know; the person that you administer the Narcan to, that person might go into treatment the next week and get sober and have an incredible life.  So that’s the beauty of Narcan or any type of block.  But one thing I am concerned about it is, on the treatment side, is we’re going way too far into medically treated addiction.

Zezima:           How so?

Walsh:             [APPLAUSE] There’s just too much.  I mean, we’re talking about it in the country; we’re talking about it in cities and towns and the states.  It’s just way too much.  You know, I agree with using methadone and other things to help you wean off, come off the drugs, but not long-term.  We’re going to make pharmaceutical companies rich by allowing them to create drugs to treat the people that they created drugs that got them addicted.  [APPLAUSE]

Zezima:           What are your thoughts on medicated treatment?  [LAUGHTER]

Craig:              No, I agree.  We have a methadone clinic right next to city hall.  And when I go to work every day I see, you know, on Mondays the same people going in and coming out and going in and coming out.  And in New Hampshire we need some regulation; we don’t have it.  And we need to see what they’re doing and make sure it—like, this is supposed to help them, and we’re supposed to be weaning them off, but they’re becoming addicted to these drugs, and it’s a problem.

Walsh:             And there are also people going in there that you don’t see—

Craig:              Right.

Walsh:             —that are getting treated.  But I just get worried that every time we think that we’re going to fix an issue by putting more medicine.  I mean, in Massachusetts this happened; but when I was a rep we started forcing halfway houses to take people on medical—if they were on Suboxone or other drugs, they forced them to take it.  That’s wrong.  I mean, you have bureaucrats making decisions that don’t understand the addiction, and you’re telling people how to change a system.  And I have a real problem with that.

Zezima:           So I feel like we could talk about this for another half an hour, but unfortunately this is all the time we have for this one.  But thank you so much for joining us.  And we will move on to the next part of our program now.

Walsh:             Thank you.

Craig:              Thank you.

Optum Sponsor Segment: Working to End the Epidemic

Temple:           Good morning.  I’m Martha Temple.  I’m the head of behavioral health for Optum.  And I have with me today Dr. David Torchiana who is the CEO and president of Partners HealthCare as well as the board chair of RIZE here in Massachusetts, so I get to call him “Torch” because I’m up here with him.  So, Torch, tell us a little bit about what you’re seeing right now in Massachusetts and, you know, the hope that you’re seeing here today?

Torchiana:       Thanks, Martha.  And I’d like to thank your company, Optum, and The Washington Post for this opportunity to address both the audience here and more broadly.  My perspective is from that of somebody who works in a provider organization, a hospital system.  And we have hundreds of thousands of emergency room visits.  And in looking at the opioid crisis from that vantage point it became evident more than close to a decade, I guess, ago that we were seeing an amazing expansion in the number of heroin overdoses we were seeing in our emergency room.  And when we started looking into this more, we became aware that the incidents in the state of Massachusetts—a very surprising statistic—was three to four times greater than the national incidence of heroin overdose.

So, with the help of our addiction experts at our multiple institutions, we put programs into place to try to connect to folks that were surviving overdoses and to try to ensure that the cycle would not repeat itself.  And these programs sound very simple.  They’re actually quite complex because of the social circumstances.  But the major focus was on getting people into medical treatment and then most importantly making sure that that medical treatment was maintained.  And I know you’ve heard the governor and some of the other speakers say how difficult a task that is.  There are multiple relapses and failures along the way.  But that was the crucial strategy.

So we’ve been at this for a while at our institutions.  I think, for example, I believe MGH under Sarah Wakeman’s leadership has 10 recovery coaches now working from the Bridge Clinic around this program as well as in patient addiction counseling.  But as this was going on there were two other sort of trends that became evident, and the mortality rate continued to rise.  And the two trends that became evident, which I thought had a couple of striking facts behind them, number one, the fact that we’re all aware of, that we’ve heard already this morning, that 80% of heroin use began with the use of prescription opioids.  And the second one was the massive increase in fatal overdoses associated with the introduction of fentanyl into the heroin supply.  And those two things resulted in, I think, a very significant upward pressure on the crisis and on the mortality rate.

And, as you’ve heard, we finally had an inflection point, and it was very distressing to me as a doctor and to most doctors to learn that this was in part caused by decades of prescribing practice and that we were really way out of line with the rest of the world, particularly in narcotic prescribing for acute pain.  I think those things have been well addressed, and the trends are turning in the right direction.  Our governor has been a terrific leader on that front.  But my sense was that those kind of things are going to take time, and the crisis is really trying to save lives in the acute setting and get people into treatment, as I’ve described.

And that’s why we put together this RIZE organization.  It’s R-I-Z-E to avoid some trademark conflict, but the Z represents our wild aspirations that we will ultimately see zero deaths and zero stigma associated with opioid use disorder.  And we’ve congregated a great board.  We have support, financial support from General Electric, Blue Cross, one of our major service workers unions, 1199, and we have a great board composed of leaders in the healthcare space.  And our goal is to try to push the programs such as I’ve described out into other parts of the state and other areas where the resources are less.  And, in addition, establish proof of concept so that we can actually change the payment system and change the way in which opioid use disorders are regarded.

So let me turn the tables.  Martha works for this extraordinary company, Optum, which has a unique perspective because of the multiple lines of business that they’re in between insurance and pharmacy and providers.  They have a unique set of information, unique analytic capabilities to bring to bear on our understanding of this.  So I would ask Martha if you could explain a little bit of this to the audience.

Temple:           Yeah, that’s great.  So at Optum we like to take complex problems and figure out ways to come up with complex solutions.  Right?  There’s going to be nothing simple about how we help to solve this opioid epidemic, and there’s so many components of it.  But we’ve tried to make it simple.  And really we have a taskforce across our company because we realize this cuts across the company.  And the three things that we look at are how we can prevent it, treat it, and then support it.

So prevention has a lot to do with the overprescribing.  We know that 70% of the people that get addicted to opioids started with a prescription drug that they borrowed, stole, or bought from a friend or relative.  And that’s where the overprescribing needs to stop getting that supply on the street.  So we have been working with our Optum Rx division around the CDC guidelines and how we can really enforce the CDC guidelines from a pharmacy-benefit-management perspective, and we’ve been very successful.  Over the last year we’ve put in edits into our system that now have our prescribers at 95% compliance with the CDC guidelines.  So we want to stop the overprescribing.  We want to stop people.  We want to prevent people from going on opioids in the first place.  So a lot of our efforts are around pain management with non-pharmacological methods.  For example, using physical therapy and chiropractors for low back pain, which is a large issue for why people get prescribed opioids in the first place.

When we move into the treat perspective, we’re looking at medications-assisted treatment and evidence-based treatments for those people that have opioid use disorder.  We’ve built a large network.  We’re trying to institute that within our company and how do we get people into those programs so they get to the evidence-based.  And we’ve heard a lot about that this morning.

And then we get to support.  And that’s the most interesting part, the most exciting part.  You heard the governor talk about peer support.  We find that as a great effort that we’re using for people in order for them to get support, is to use peers.  We know that opioid use disorder, like substance use disorders and mental illness, is a chronic condition.  So once we have someone in recovery, that’s not enough; we need to make sure they stay in recovery for the rest of their life.

So that’s how we’re working it.  We’re looking across the healthcare continuum.  We know it’s going to take all of us across the continuum to really battle this epidemic.  So they only gave us a few minutes here this morning, and if there is one thing that you want to leave everyone here with, Troch, what would that be?

Torchiana:       I can never just say one thing.  [LAUGHTER] So I’ll say just a couple of things.  The first one is that the pipeline is obviously the foundation, and work on the pipeline is critical.  We need to really shift the whole sort of mentality around the use of opioids especially for acute pain syndromes.  And that’s underway, but it’s going to take a long time for that to have a significant impact.

The second one, though, I think is the most important.  And that is that we have to start thinking about opioid use disorders as a chronic treatable illness.  That’s what it is.  It’s a chronic treatable illness.  It’s not a character flaw.  It’s not a bad choice.  It’s a disease.  We need to understand it as a disease.  We need to treat it as a disease.  And so the principal thing that I think we need to do as a country is to enhance the understanding of the American public for that very simple fact.  Most of the country does not understand that this is a disease and it is treatable as such.  And so it’s the change of stigma, it’s the change of perception that I think is the most important task that we have at time.

Temple:           And I think events like this are really going to be what can help with that.  This is a great that The Washington Post has sponsored for us to really talk about this in a very open dialogue, so we’re excited about it.

Torchiana:       Right.  Thanks.

Temple:           All right.  Thanks.

[APPLAUSE]

Addiction in America: On the Front Lines of Medicine

Bernstein:        Hello again, folks.  Our next panel is going to explore the issues of treatment and how healthcare professionals are working to combat opioid addiction.  With me, next to me is Bertha Madras, a psychobiologist at McLean Hospital, a professor of psychobiology at Harvard Medical School, and a member of the president’s commission to combat the opioid crisis.  Michael Botticelli is the executive director of the Grayken Center for Addiction at Boston Medical Center.  Mr. Botticelli served as the director of the White House Office of National Drug Control Policy under President Obama, and Dr. Chinazo Cunningham is a professor of medicine at the Albert Einstein School of Medicine and Montefiore Medical Center.

I wanted to start by asking all three of you: if I couldn’t get insulin or I couldn’t get medication for my high blood pressure, and this was rampant across the United States.  Nobody would accept it, nobody would put up with it.  And yet, today, in 2018, a tiny fraction of the people who need treatment for what we completely recognize as a disease can’t get it, don’t get it.  Could you just try to demystify for us why that is?

Botticelli:        So to your point, only about 10 to 14% of people in the United States who need treatment get it.  And if you look at why people don’t get it, one of the reasons is certainly capacity.  That we just don’t have enough treatment capacity.  The second is as much as we talk about this as a disease, we still haven’t firmly embedded this as part of mainstream medical care and you heard the governor talking about this.  So we know that people with untreated addiction are high utilizers of our emergency departments or in our hospital beds or in our child welfare systems.

And we don’t do a good job of identifying people and referring and even starting people on treatment.  So part of what I think is important for us at Boston Medical Center and I want to acknowledge that the Grayken’s are in the audience who gave this magnificent gift for us to continue to do this work—is how do we think about intervening with patients who come into our emergency departments, who are in our hospital beds, pregnant women, and how do we give them good care?  The other piece, and I have to say this; if you look at data, not having insurance coverage and we’ve seen in particularly parts of the state that have expanded Medicaid; we have the lowest insurance rates here in Massachusetts.  That giving people good insurance—because they not only have issues with addiction, but have co-occurring mental health issues and chronic disease conditions.

And the third piece is a stigma.  So when you ask people who even know they need help why they don’t seek care, they are afraid that friends and family are going to find out.  They’re afraid that employers are going to find out.  So we can have the most robust treatment system imaginable, but unless we really destigmatize addiction, and diminish some of the shame that prevents people from seeking care or delays people from seeking care, we’re not going to make a major dent in that 10 to 14% number.

Bernstein:        Dr. Madras?

Madras:           Well, I’d like to add number four to that in terms of the NSDUH data that you’re quoting, and that is a number of people with substance use disorders in the country don’t feel they have a problem and don’t seek treatment.  A smaller proportion is involved with opioids.  But that’s certainly true and part of the reason is that when they attend to a physician, the physician is not asking the appropriate questions and if we go back, we found out that 10 years ago, less than 30% of medical schools even educated physicians on addiction.  That’s a major gap in medical education.  Years ago, I organized three medical education conferences in Washington and I invited every dean of every medical school to show up.  And out of the 130 or so medical schools, not one dean came to listen to our message that we have to educate physicians on addiction.  We have to educate them on opioid prescribing, and we have to educate them on pain management.

Botticelli:        One of the things, I want to kind of chime in here; if you look at of those who are getting treatment, the biggest referral source to treatment in our criminal justice system, 36% and only eight percent of referrals are coming from our healthcare delivery system.  So we really haven’t seen this as a disease and the other thing: I’m a person in recovery and one of the phrases that I want to do away with is the fact that people have to hit bottom before we can motivate them to seek care.  [APPLAUSE] We don’t wait—we don’t say to people with hypertension, “We’re going to wait until you have a heart attack before we have structured intervention”.  We’re doing screening and prevention, we’re doing early intervention to monitor symptoms along the way.  We are motivating people through structured interventions to seek care.  Right?  So we really have to do a better job of if we really believe that this is the disease, thinking about various evidence-based structured intervention programs and identifying and motivating people to seek care at various intervention points.

Bernstein:        Dr. Cunningham, you have a perspective on access.

Cunningham:   Absolutely, right.  So the thing about substance abuse treatment or addiction treatment is we have completely fractionated systems, right?  So could you imagine that if you ask somebody to go for their diabetes in one place to a different provider and then everything else separately?  And so that system that we have created really causes tremendous problems and really the whole person is not cared for.  So I think one of the big issues here is we need to integrate addiction treatment into all of the rest of the medical treatment that we provide.  So into primary care, and then think about specialty treatment for people who are complicated or who need that additional expert opinion.

But for a lot of people, that might not be the case.  And so for hypertension and for diabetes, that’s what we do.  It’s managed for the most part by primary care providers and then when people have complicated issues, then the experts get involved.  But really, it’s taking care of one person by one provider really with comprehensive care and we don’t do that with addiction treatment.

Bernstein:        But excuse me one second.  Why would a primary care doc want to take that on?  Even if it were just a couple dozen; two dozen, three dozen people.  In an already overburdened practice?

Cunningham:   Right, so what you’re asking really has to go with stigma.  Absolutely.  So why would a doctor want to take on somebody with diabetes or somebody with hypertension?  Well, that’s our job.  I mean, we’re physicians.  This is what we signed up for [APPLAUSE] I would argue that it has to be incorporated into education, right?  We get trained on diabetes and hypertension, not on addiction.  And then it has to come through—all the way through.  So I also would say is why would you want to take care of addiction?  Well, people with addiction do touch our healthcare system.  They are there.  We’re just not having the conversations, we’re not doing the screening, we’re not doing the treatment.  So we sort of close our eyes—a blind eye.  So addiction doesn’t discriminate.  People with hypertension and diabetes have an addiction, and we really just need to be screening and to be treating those patients so they do touch our system.

Bernstein:        You were going to say?

Madras:           I was going to say that what we had about a century ago is a joint disconnect between conventional treatment and the healthcare system.  And what we have to do now is essentially create a Manhattan Project on reforming medical care and treatment and bringing those two solitudes together and implementing evidence-based treatment that is, in fact, the carrot and the stick would be reimbursement; to impose the highest possible standards on both the conventional treatment centers, as well as on the compelling the medical community to address this issue.

Bernstein:        So reimbursement is too low, there’s no incentive for folks to get into the treatment—

Madras:           And for an average GP or internist who is not a specialist in addiction, they need supplementary support.  They need behaviorists that are trained, and I think medical schools have to step up and revolutionize the type of training they’re giving.  Not only to physicians but to a cadre of people who are behaviorists.  Because so many of our current problems, which include obesity, as well as addiction, as well as many other behavioral health problems.  Cardiovascular disease and so on.  There isn’t a cohort of people that can facilitate a physician’s proactive and help them do the behavioral interventions while the physician administers prescriptions for medications assisted.

Bernstein:        Michael?

Botticelli:        But this is where I often think—and I will channel Dr. Nora Volkow, who is the director of the National Institute of Drug Abuse, the world’s foremost research.  And she has said many times, “Yes, we need to continue to innovate, but we know what to do here.   We know what works and part of this is how do we go from some of these innovative models that we know to be effective and make sure that they are the standard of care and replicated, right?”  So we have highly effective models.  One that was started at Boston Medical Center that looks at integrating primary care and addiction treatment.  So we have over 700 people who walk into our primary care clinic every day, indistinguishable from any other patient so they don’t look stigmatized, and they’re getting comprehensive, judgment-free and highly respective care.  And not only are we giving them addiction treatment, but we’re looking and making sure that they’re stably housed, that they have employment opportunities.  So we see at 12 months, 70% of those patients still retained and engaged in care.  Right?  So we have these models that are effective.  And part of our goal, not only at Grayken, but also nationally; we’ve got to replicate these models.  And to Dr. Madras’s point, we have to make sure that the reimbursement structure is there to be able to support that kind of work.

Bernstein:        Folks, the hashtag for your Twitter questions is PostLive and here’s one that comes in: Can someone discuss is opioid treatment—is it segregated by race and income?  Do minorities and the poor have more trouble getting treatment and care than other folks?  You’re nodding, Dr. Cunningham.

Cunningham:   Right, so I work in the South Bronx, and my patient population is 99% people of color.  I’ve been doing this for 20 years.  This is not new there.  This is new, I think, in the suburbs and rural America and in white populations.  And really, our response has been different.  I think it’s great that we’re up here talking about this and really what we need, but this is not new.  What I would say is a couple of things: a lot of the traditional treatment centers are in communities of color.  So those are the methadone clinics.  And they are effective, but they are in the communities of color, for the most part.

I think when buprenorphine came out, this provided a lot more opportunity to provide treatment in widespread communities.  So now, we can really provide it in any setting because of the limited regulations around it.  But a lot of the problems we’ve seen have to do with prescription opioids.  And what we do know from the data is that communities of color have actually not—have had disparities in are and were less likely to be prescribed opioids.  So if you take that and you look at what the data show now, which is that deaths that are opioid-related are much higher in whites than in people of color.  A lot of that is because of the prescription opioid issue and, in fact, the disparities in people of color have actually been protective.  In addition, because the methadone clinics have been in communities of color, there has been access to treatment more in communities of color.  So this is an interesting phenomenon where the disparities in care have actually been protective for people of color, and the sort of more widespread prescription opioids have actually hurt the white population.

Botticelli:        I do think that we have to acknowledge that for particularly communities of color, our response historically has been an overwhelming criminal justice response.  That people in our jails and prisons, largely people of color, are there because [APPLAUSE]     of—so part of our reform is not just healthcare system reform, but criminal justice reform.  So we’ve got to think about how do we divert people away from our jails and prisons in the first place?  How do we make sure that people in jails and prisons are getting good evidence-based treatment and that we’re getting them good reentry services on the way out?

Data that Massachusetts has put together shows that those that are coming out of our correctional facilities are at 120 times the risk of an overdose.  But we’ve seen good models.  So Rhode Island actually just did this very interesting study where they looked at getting people in our jails and prisons on a medication-assisted treatment.

Bernstein:        Can you explain for folks why that is?  The 120 times?

Botticelli:        Sure.  So one of the things we know is one, people who are in our jails and prisons don’t often have access to any treatment at all, but particularly medication-assistive treatment.  And we know that you’re at heightened risk for an overdose when you go through a period of not using.  And then you start using again at the same levels.  So your tolerance is way down and that’s where your risk goes way up.  And that clearly, is born out in the Chapter 55 data that we have here in Massachusetts.  So part of this is: how do we start and get people on good medication-assistive treatment and then transition them to the community so that there’s no interruption in care.

Bernstein:        Keep them on it.

Botticelli:        Keep them on it.

Madras:           And the good news is that in the commission report, we recommended that drug courts be implemented in all 96 federal courts so that we can expand it.  When I served as deputy drug czar in the country, what I found is that drug courts serve less than 10% of the people who would be eligible for it.  And a drug court essentially gives you a choice of treatment or prison.  And I think this is a much more humane way of dealing with people who have felony convictions and also have an addiction.  We also recommended in the commission report that there be treatment in our prison system so that people do not come out with loss of tolerance to opioids and then die within weeks or a few months of release from prison.  We also recommended a number of steps to take on the release of prison to help individuals gain a restoration of their hope, their employment, their communities, and recovery housing for them.  So the commission did deal quite extensively with the prison population or the population that’s involved with the criminal justice system.

Bernstein:        We know sitting here today, based on research that 40 to 60% of the people who become addicted to opioids and other drugs are going to relapse at least one time before they get better or whatever happens.  So at least once they are going to relapse and many people I have spoken to have relapsed six, seven, eight, ten times.  Can we bend that curve in any way?  Is there work going on to bend that?

Cunningham:   So the patterns that we see with that are similar to other chronic illnesses.  I don’t think it’s really that different.  So if you take somebody, for example, with diabetes who is trying to lose weight; how many relapses do they have in terms of getting off of their diet, right?  The same thing with smoking.  So I think that this is really a common phenomenon with chronic diseases that require major behavioral changes and we all know, behavioral changes are very difficult.  How many of us have said we’re going to exercise every day?  We’re going to try and lose weight or whatever and it’s hard to do that and we have periods of time when we don’t sort of follow the path that we know we should be following.

So I don’t think addiction is actually any different than a lot of other chronic illnesses.

Bernstein:        Except that a relapse can be fatal.

Madras:           Yes.

Cunningham:   Right.

Bernstein:        So it’s much more important that we do something.

Madras:           I think research is trying to understand why people relapse, and it’s very clear that some of the reasons are stress, cues, and you go into a community where you’ve used—you see paraphernalia or you see cues of other people using and you relapse.  And trying to understand the wide array of what is going to trigger a relapse and to train people how to avoid those triggers is what the current state of the research is.  Because I think the kind of relapse that we see with some other diseases, non-compliance with medications.  For example, in diabetes are somewhat different than the relapses that we see with addiction.  And these differences have to be reamed out with very exquisite research that targets wide swaths of the population.

Bernstein:        So if I were theoretically able not to go back to my previous environment, do you think there would be fewer relapses?

Madras:           Not going back to your previous environment, if there’s a stress; for example, your spouse has decided to leave you and take your children because they don’t want to live with a person who has had this history of opioid use disorder.  All of these stressors can trigger a relapse.  How does one deal at an individual level with those kinds of stressors and how to train people to try to recognize that this stressor is likely to get them into a position of wanting to use again?  Going back to the friends who have trained you.  May I just give a quick anecdote?  One father quit his job to rescue his son from an opioid addiction and he drove in separate cars with his son to a new place in Oklahoma from Texas to try to rescue his son, take him away from his friends and his friends held a little farewell gathering and gave him a prescription opioid and the father showed up at the meeting point and the son didn’t because he died of an overdose because his friends just triggered that craving.  He had been drug-free for months and the father knew that rescuing his child would mean removing the environment.

Botticelli:        Here again, yes, we need more research, but here again, the evidence is pretty clear about what we need to do.  If we want to reduce relapse rates for people with opioid use disorder and reduce mortality from fatal overdoses, getting people on one of the three FDA-approved medications is one of the simplest things that we can do, right?  [APPLAUSE] So I will tell you, but part of it is—and again, we have this great dataset to be able to look at that, that only five percent of people who are experiencing a fatal overdose are getting on a medication and if they get on a medication, we can reduce mortality of a fatal overdose by 50%.

Bernstein:        Five percent get medical access to treatment?

Botticelli:        Five percent.  Of those people who are even getting treatment, this is nationally better here—much better here in Massachusetts.  Only 20% of people who are getting treatment are getting on a medication and we need—and part of this is—yes, we need to expand treatment capacity, but we’ve really got to understand and be crystal clear that preventing relapse and preventing overdose deaths and again, this is not saying that people don’t need all of the other behavioral supports and recovery supports.  Because we clearly know housing and employment can be really destabilizing to someone’s recovery.  But it’s crystal clear that getting people on a medication reduces relapse rates and reduces overdose death.  And just as a nation, we are not doing a good enough job of getting people on a medication when they need it on our treatment programs and in our emergency departments and in our hospital beds, and in our primary care clinics.

Cunningham:   And I would also argue too—I completely, 100% agree with what you’re saying, but I think a big problem is is we continue to fund the programs that don’t provide evidence-based treatments.  We are doing what we’ve been doing for decades and it doesn’t work and look where we are?  And so I think we really need to change the way that we fund treatment in this country.  Because funding programs that don’t provide medication-assisted treatment is not evidence-based treatment.  So I think that the money has to follow the data in terms of what works.

Bernstein:        We have about three minutes left.  There’s something you all have mentioned that I want to bring up, but I’m going to give you each about a minute to talk about it.  Sorry about that.  You all mentioned stigma.  I went and looked up some polling on stigma and as of the middle of last year, 36% of those polled still believe that addiction is a personal weakness.  It seems to me that lies under everything.  You all have mentioned it as underlying a lot of what goes on.  How do we attack that?

Madras:           Well, one of the most what I would call despairing pieces of data that came out very recently is that when—and Dr. Alan Leshner and Dr. Nora Volkow both promoted the concept of addiction as a brain disease.  They felt that that concept would relieve the stigma and also help engage the medical community.  What recent research papers show is that the designation of addictions of brain disease does not destigmatize it, and that’s really a massive problem because the stigma not only lies within families, within the healthcare community.  People are afraid they’re going to be dismissed by their physician.  But it lies even amongst people with opioid use disorder because some of them say, “Well, I’m not a heroin addict.  I got through iatrogenic addiction, through my prescription opioids.  I’m different from those folks.”  There is a stigma in every sector of society that has to be addressed in different ways.

Bernstein:        Michael?

Botticelli:        So we’ve seen over time, not just with addiction, but with issues of HIV and others that, often, we see these diseases as “diseases of other.”  So I think there are some things that we can do to kind of diminish that stigma.  One is being more open.  For those of us in recovery, those of us who have been affected by this disease need to be much more open about who we are.  We change people’s minds by personal stories and I think we have to create that this is not something or other.  I actually think our employers have a huge role in diminishing stigma by how they think about this.  We’re a very large institution.  We have 7,000 employees who have been personally touched by this and what Kate Walsh as a CEO does in signaling to our employees that it’s okay to ask for help, that we really care about you I think becomes really important.  And then the third is kind of fairly simple, yet hard, is change our language.  So there’s lots of evidence to show that the language that we use is highly judgmental and highly stigmatizing.  Actually, the AP Style Guide, Lenny, put out guidance to all journalists in stopping using words like addict and junky and substance abuser.  We have seen that those—

Bernstein:        Right, we’re trying.

Botticelli:        We can see that those have a direct—there are some people who haven’t gotten that memo yet and we’ll work on that.  [LAUGHTER] But we need to change our language because that has a direct impact and I’ve got to tell you, I remember in a very personal way, knowing that I needed help and I was too afraid to ask for it because I was afraid people would think I was stupid, that I was weak-willed, that I didn’t have the character that I needed.  And we really need to do a better job of really understanding that this issue affects all of us and again, I think that there are lots of opportunities for us to create and to really destigmatize.  And one final thing and I have to give a shout out to Secretary Sudders.  If you haven’t seen a “State Without Stigma” Campaign, it is beautiful in terms of the narrative that it tries to tell those exact stories.  And I think every state and every community should replicate that kind of anti-stigma campaign. 

Bernstein:        I have to cut us off here.  I’m sorry.  [LAUGHTER] I’ll let you have a very brief final word.

Cunningham:   My final word is, in addition to all of these other things, I think we have to bring it into the mainstream and particularly in healthcare.  The more it’s sort of mainstream, treated like other chronic illnesses, I think, the more that also will reduce stigma.

Bernstein:        Thank you very much.  [APPLAUSE] Thank you.

Addiction in America: On the Front Lines of Our Communities

Zezima:           Good morning, everyone.  So this is our last discussion of the day so it’s your last chance to ask questions and see what you’d like to know.  So I want to introduce my guests on stage: Dr. Thomas Andrew is a forensic pathologist at White Mountain Forensic Consulting Services.  You served as the chief medical examiner for the State of New Hampshire for 20 years.  Joanne Peterson is the executive director and founder of Learn to Cope, which is a non-profit organization that provides support and resources to the families of individuals struggling with opioid addiction and other drugs.  And Sheriff Kevin Coppinger is the chief law enforcement officer in Essex County, Massachusetts.  So we’ve obviously heard a lot about the government response and we’ve heard about the medical system.  And I really want to focus this panel on the ripple effects of the opioid crisis; the families, the people in law enforcement, pathologists, teachers, others who are affected by the crisis that we have right now.

So, Joanne, I want to start with you, actually.  We hear the numbers of overdose deaths in people who have overdosed.  All of those people have parents and friends and siblings.  So I want to talk to you a bit about your story and Learn to Cope and if you could talk about how this is affecting the families of people who are using opioids right now.

Peterson:         Sure, thank you.  And good morning, everybody.  Thank you very much for having me today.  So the families often are left behind in this issue and I, myself, have been a family member since I was a child and then, obviously, later in life, it happened in my own family with one of my children.  And I knew as a child that the family was left behind because it was always all about, “How can we fix this or how can we fix that?”  Or there was a lack of this or a lack of that and then I would go to school.

Zezima:           And you had some addiction issues when you were a very small child with your family members?

Peterson:         Right, right.  So we have grandparents, we have spouses, we have siblings, and we have children of those who suffer from addiction and that’s what our job is at Learn to Cope.  I started it almost 15 years ago and it was because our family needed help and families still today need help.  So I think one of the most important things for families is support, education, resources, and hope.  And when you are not educated on the disease and the concepts of the disease and treatment and how we can be a part of their recovery, rather than nagging and saying, “Why can’t you just stop?”  More learning that this is something that they can’t just stop on their own and then we stop blaming ourselves.  Because the first thing you do when it happens to your child or your spouse or your parent is, “What did I do wrong?  Did I do too much of this?  Did I do not enough of that?”  And so at our meetings, when somebody walks into a meeting or any meeting like ours; there are other groups out there.  Just being welcomed, having somebody put a hand on your shoulder and say, “It’s okay.  I know how you feel.”  There’s something to be said about peer support and you should always get therapy.

We don’t try to replace therapy, but having peer support and being with people that understand you, that are not going to judge you, that are not going to judge your spouse or your children; that was a huge piece of my recovery.  I think I grew up with stigma my entire life, so when it happened in my adult life, I thought, “No, I’m not going to live the rest of my life this way.  This is a disease.  This is something that we need help with, that my loved one needed help with, and so I came out and when I did that, there were thousands of other people that were going through what I was and today, we have 25 chapters across the State of Massachusetts.

We’re very grateful to Marylou Sudders, the Department of Public Health, the Baker Administration and even before then, Mike Botticelli, who recognized that when families are able to get support and education, sometimes that can make the difference in that person’s life and they might end up getting stronger in the long run and the deaths are really, really difficult.  In my office, there are not many weeks that go by that we don’t deal with a number of them.  We get many crises calls today where people are just finding out that their daughter or husband or son or grandchild is using heroin and, you know, the pills.  There’s been a lot of great work done; we still have a lot more to do.  We’re very grateful for what’s happening as far as the prescriptions.  But there’s still a multitude of prescribing going on where there are people on multiple prescriptions that they might do better without, like a mixture of them.  So we have a long way to go, but my role really, and the role of the many volunteers, who are amazing, with Learn to Cope and the staff is to take care of those families because they are left behind; very much so.

And there are kids in school right now that might have witnessed an overdose the night before or that might have lost their parent and is in foster care or that is being raised by grandparents that should be retiring now and are trying to figure out how to afford daycare, thinking, “Wow.  I’ll be 75 at their graduation if I’m lucky”.  So those are the things.  I’m here to remind everybody of the things that we might not think about or have to deal with.  It’s a very scary thing to think, “Wow, I had plans for my future, for my retirement.  I wanted to travel”.  And now, instead, they’re worried about what the effects are going to be later and if they’re going to be able to take care of that child up until their 70s and 80s, and sometimes, 90s.

Zezima:           As you said, this is straining the nation’s foster care systems.  It’s just rippling in schools and one place that it is very sadly affecting is coroner’s offices and Dr. Andrew, you are the chief medical examiner for the State of New Hampshire, which has one of the highest per capita fentanyl overdose death rates in the country.  And you left that job because of seeing the opioid crisis and you had a quote.  There was a story about you.  It was not in The Washington Post.  It was in the New York Times.  But it was a very good quote from my very good friend.  [LAUGHTER] But I just wanted to read this quote because I think it really gets to the heart of what we’re trying to talk about here and you said, “I found it impossible not to ponder the spiritual dimension of these events for both the deceased and especially those left behind.”  Can you talk about what you saw in your job and how it leads you to the path that you’re taking right now?

Andrew:          Certainly.  It sounds bizarre on the surface to have spent 20 years as a forensic pathologist and then pivot towards seminary training.  But for me, it’s a natural progression.  I’ve spent the vast majority of my professional public health life on the assessment end counting the costs of this particular public health disaster, which has been a slow, unfolding tsunami for the last decade or decade-and-a-half.  And just like the toll that it takes on families, there is a toll that it takes, I think, on the provider as well; at least for me.  I realized a couple of things.  That 20 years is probably the appropriate amount of time for a public agency to be under the leadership of one individual.  Twenty years is a good time for a fresh look, a new face, new direction.  You don’t want to get stale and feel like you’re getting beat up and you’re doing the same old, same old.

But if you look at the spectrum of public health service—I’m not gifted in the treatment end.  I spent some time secondary prevention when I was a pediatrician.  But I feel more called now to be on the primary prevention end by mentoring young people and hoping to be somewhat of an inoculant against them getting started in these behaviors in the first place.  And part of what drove me in that direction was this endless drumbeat of previously healthy and to a large extent, still healthy young people, whose lives have been ended by misuse of these agents.  Some of which started as a recreational attempt to achieve this altered state that’s sort of part of the human condition.  But some, in their 30s and 40s, who got prescribed into addiction and that is particularly tragic.

Zezima:           And Sheriff Coppinger, we actually talked about this last year for a few stories.  But this is also taking a toll on law enforcement.  You were the police chief in Lynn for a long time.  You were on the force for decades.  Now you’re the sheriff up in Essex County.  Can you talk a little bit about what law enforcement is seeing?  It’s really changing your jobs.  You’re becoming much more social workers, kind of first line out there on the opioid crisis.

Coppinger:      Sure.  Well, first of all, good morning, everyone.  I have a confession to make, though.  I listened to Mike Botticelli a few minutes ago, saying folks used the words “junkie” and “addicts” and I was one of those 30 years ago.  I freely admit that, but that was the sign of the times.  That’s when nobody recognized what this addiction is doing to society.  So I’ve come full circle, as I think law enforcement has.  You just said it, Katie.  We look at this now as a disease and we look at the negative effects it has on society as a whole.  So as a police officer, I’ve seen what happens to the individuals who are addicted, as well as the victims of their crimes.  And I’ve watched the criminal justice system transform into more of a, “Let’s fix the problem, instead of just hiding it under the covers, so to speak.”

So, when I decided to run for sheriff and I’ve been in office for just a little over a year, I saw opportunities because there’s more we can do.  And in the sheriff’s department up in Essex County, we run a detox program.  Now, the good news is it’s a detox program.  It’s 28 days; 42 beds for men, and 42 beds for women.  The downside of it is you have to be arrested to get there.  Now, sometimes folks need that; need that little push or incentive to seek treatment and successfully complete it.  I’m proud to say, on the male side, we have an 87% success rate of completion.  Females, 80%.  But the beauty about it is and the point I want to make is we work very closely with the judges in our district courts—particularly in our drug courts, with our district attorney, defense attorneys, probation, and local police.  We’re looking for solutions to the problem and to use a quote from one of the judges up in Essex County, it gives—and by the way, I’m not going to call them “junkies” anymore.  I’m going to call them clients.  It gives the clients options.  And as the judge would say, “It gives them a taste of corrections.”  Now, our detox facility is a separate standalone unit within the jail and house of correction itself.

They don’t mingle with the general population.  We target the low-risk offenders, usually at pre-trial folks who come in.  Yes, they detox for a couple of three days or maybe longer, depending on their addiction level, then we program them.  We go through treatments and rehab for the rest of the 28 days.  It’s run by private healthcare and private mental health folks.  And then upon successful completion of that 28 days, they go back in front of the judge.  This is where the options come in.  hopefully, they succeeded and they have the desire to get their lives back and get on track and maybe the judge will send them home.  Maybe he’ll put an electronic bracelet on them, which we can handle, and they’ll send them back into society so we can still keep track of them.

They may have to report to one of our offices of community corrections for programming during the day or perhaps, drug testing.  Or sometimes, they have to come back into the jail itself and serve a sentence or get further treatments.  But the big push we’re doing now is the re-entry efforts.  What I saw as a police officer, where I saw the gap was; when they come out of jail, they go back to their communities and as some of the previous speakers mentioned before—that’s when they’re so highly susceptible to overdose and die.  I’ve seen it many times on the street.  I hate to say it, but you see these folks.  They think they can go right back to the same dosage they’ve been taking, and they die on our streets.  That’s the gap we’re trying to fix now.  So we’re looking for initiatives.  We’ve come up with plans.  We’ve created a new re-entry unit.  We’re partnering with anybody we can find.  One of our best partners is PAARI, the Police Assisted Addiction Recovery Initiative out of Gloucester.  We have two recovery coaches that we’ve obtained through them from a grant through AmeriCorps.  They’re wonderful.  So our plan—and by the way, when the clients come through our program and they go back to the communities, they’re leaving with an individualized treatment plan.

We have the experts in the field develop that.  They go back, we’re reaching out to our community partners, including our recovery coaches, including healthcare agencies, faith-based agencies, social service, municipal agencies; anybody that can help the individual.  You want to send them back with a little toolbox where if they’re having a bad day or they’re not succeeding in where they want, they have a phone call to make, they have a friend.  Somebody can pick them up and get them back on track.  Because once they’re out of our jurisdiction, so to speak, there’s only so much we can do.  But we can attack this as a community problem, which that’s why we’re all here today.  This is a community, a societal problem.  We’re doing this together, and hopefully, we’re going to make that impact.

Zezima:           And Joanne, your community is a big part of what you do as well.  Can you kind of take us inside a meeting?  What people ask; I’m sure there are people who are just coming for the first time and people who have been for quite some time.  But can you kind of tell us a little bit about what the questions people are asking and just how people are attempting to cope, as your organization is named?

Peterson:         Sure, so when somebody walks in, as I said earlier, the first thing that they get is support from other people that are at these meetings and the volunteers, who are amazing.  They get a packet full of information with the continuum of care, different drugs that are out there.  There’s something in there about pregnancy and addiction.  Because when they’re coming into our meeting, it could be anything.  It could be parents that just found out their daughter is pregnant that just came to them that’s using.  It could be someone that just found out that their son is using heroin.  So in that meeting, there can be a whole carte blanche of things going on.  So what we make sure that we do when they come is first they feel the support, and then we have guest speakers to educate us; usually professionals in the field or people that are in recovery.  We like to learn about every single form of treatment that’s out there: methadone, naltrexone, Subutex, suboxone, 12-steps.  So we like to have open minds at our meetings so that no one will get judged for what form of treatment their family member is on.

So if somebody raises their hand and says, “I’m so happy.  My daughter has been on the streets for years and today, she went to a methadone clinic.”  And everyone there should be just supportive about that and not saying, “That’s trading one drug for another.”  Or if somebody else raises their hand and said, “My son is going to AA meetings”, everybody should just be supportive and say, “That’s great.  He’s not using heroin today.”  We leave it to the professionals to come and teach us about what the different treatment options are and we don’t judge any of them.  We don’t judge 12-steps.  We don’t judge Smart Recovery.  We don’t judge methadone or suboxone.  So when someone comes into a meeting, they get resources within a very short amount of time.  We usually see parents come in, either they are divorced and with their new spouses and they’re all working together, or we see grandparents coming in to support their sons or daughters or their grandchildren.  But I guess the main thing is we hear this all the time that, “If it wasn’t for peer support and the people that I’ve met at this meeting, I don’t think my son or daughter would be alive today.”

And we’ve also heard things like, “I don’t think I would be alive today.”  Because there is nothing worse than being blindsided with this and losing the dreams that you had for your loved one; especially when it’s your son or daughter and then ultimately, unfortunately, when people lose their children, which we have that happen a lot.  We actually have to have a protocol at our meetings, because when you first walk in, you might be asked, “Would you like to share?  Is there anyone that has had a tough week?  Is there anyone that would like to share?”  Someone will raise their hand—and this has happened numerous times—and say, “I lost my daughter this morning and this is the first place I want to be.”  And then what do you do?  You can’t just say, “Okay, next.”  So we support that person right away.

Zezima:           What do you do?

Peterson:         But then you also have someone that it’s their first meeting.  So we have people go over to that person to support them because now, they’re even more afraid.  But this is it.  This is what it is.  And people shouldn’t be afraid to reach out and get help from a group.  Not just ours, but other groups because they’re not easy to listen to sometimes.  Some of the things that go on, but you might see that same couple or person that was there a month before and could barely speak because they’re in such crisis.  You might see them three months later smiling, helping somebody else, raising their hand and saying, “My daughter got her 30-day chip today.”  So we also provide hope.  We have to keep hope alive at every meeting.  We even have parents who, many of them who sadly have lost their kids and will still come back and say, “I’m surviving”, and say things like, “I still have my Learn to Cope family that helped me get through that.”  So everyone that’s in that room always—even me, myself today, will always have way in the back of their head, that fear of I could lose this person.  And so it’s nice to know that you have these people in your life that if that does happen, you’ll still have that family, those people that you can talk to besides therapy.

Zezima:           And I’m curious how each of you are dealing with this every day.  How do each of you individually cope, individually process what you have seen or are seeing on a daily basis?

Coppinger:      Well, I’ll start.  You have to focus on the positives.  We’ve all seen the negatives.  We’ve heard the stories.  One of the earlier speakers said, “This disease affects everyone.  It does not discriminate in any way.”  But there are successes out there.  So you have to look at those and focus on them, learn from them, and make your initiatives even better so we can continue to do this.  I would just like to throw one little plug out there.  It’s been talked about a little bit, though, but I’m a firm believer, and we need to do more in the prevention piece.  In my old career, we did a lot.  You look at the next generation coming up, the kids in the schools.  A lot of folks talk about that.  There’s a lot of theories about it.  These kids today, it’s not unfamiliar to them to take a pill for medication.  I’ve heard the term “Ritalin generation” used a couple of times about the kids coming up.  So they’re used to taking the prescription medication.  So when they get to that inquisitive teenage years and they open up their medicine cabinet and they see those extra oxycontin or oxycodone or other prescription meds, they could just use those and that starts the addiction process.

We need to put more and more efforts into our prevention efforts with the kids and let’s face it: if we were here 25 years ago today, we would be smoking a Camel right now.  [LAUGHTER] We’ve pretty much irradiated cigarette smoking, at least for the most part of it.  And we need to do more with this whole—in combination with everything else, the interdiction and the treatment and rehabilitation.  But it’s a multifaceted approach.

Zezima:           I also just want to—if anyone has questions, please post them to #PostLive on Twitter.  Joanne, how do you cope with this?

Peterson:         Some weeks are better than others.  I’ll be completely honest.  I’ve just been introduced to yoga, which is very helpful.  I used to ride my horse, which there would be terrible days and I would go to the barn and just ride around and I had to think of where my shoulders were and my hips and my knees and my ankles to get my mind off of that, but my family at one time did approach me and say, “Would you please slow down a little bit?”  On weekends, we would be sitting by the fire, camping, and my phone would ring and I’d be, “I’ll be right back”.  And an hour later, I’d come back.  So I had to really realize that it wasn’t just affecting me what I do, plus personally.  It was also affecting my family.  But I do have to say, I have an amazing team from Learn to Cope; an amazing team of people, some of them are here today and the volunteers and if they know that I need some rest, they will approach me and say, “You need to take a rest”.

And we’ve had to have grief counseling for our team.  Very recently, we spend a day with somebody that helped us out, because we don’t realize sometimes how much we’re carrying on our shoulders and when we get those calls that someone just lost their loved one, that’s a really tough call, and sometimes, we don’t even know that it’s affecting us.  We’re in robot mode and then all of a sudden, you’re crying for no reason, sitting in line at Duncan Donuts and you don’t realize the trauma that you go through dealing with this crisis on a day-to-day basis.  So I rely a lot on my friends, my team, and my family.

Zezima:           And how about you, Dr. Andrew, when you were doing this?

Andrew:          Well, I’ve heard things that are just incredibly on point.  When you’re talking about the hope and the resilience piece of this, it really is in the community and in families.  We leave ourselves to the tender mercies of the so-called experts at our peril.  To some extent, the experts have gotten us to where we’re at.  I’m a doctor.  I’m married to a doctor.  Love doctors.  [LAUGHTER] But the point of this being a community-wide issue, a society-wide issue and us pulling together as members of that community and that society is what’s going to make this a success.  You had said if we had been here 25 years before, the Camels would be all lit up.  This is a measure of how long this sort of thing takes.  It may not be in my lifetime that we make the kind of progress that we’ve made with cigarette smoking as opposed to these drugs of abuse.  But the fact that we’re all talking together and we’re not in our separate silos anymore; the fact that you actually got medical people, community people, law enforcement people, lay support people all sitting down, talking together, not only here, but in other venues, that’s what fires me up.

That’s what gives me the hope that we’re going to just kick the pajamas off this thing. [LAUGHTER] And we’re going to win it.

Zezima:           So, we only have about a minute left.  I just want to say there are Learn to Cope members here.  Thank you for coming, these photos of your loved ones.  We really appreciate having you here, so thank you very, very much.  [APPLAUSE] So this is about all of the time we have.  I wish we had more.  I’d like to thank Dr. Andrew, Joanne Peterson, and Sheriff Coppinger.  If you want to watch video clips and other highlights from the program, visit WashingtonPostLive.com and thank you for everyone in the audience and everyone online for joining us today.  We really appreciate having you here today.  [APPLAUSE]