The Belonging Agenda – Tackling the opioid epidemic, substance use disorder, and mental health from a public health perspective

“The opposite of addiction is not sobriety, but belonging.” That’s the quote from Marty O’Brien, founder of Lewiston’s Grace Street Recovery Services, that kicked off this mayoral campaign. Pain, although one of the most isolating experiences a person can have, also unites us. A universal human experience, it can drive us apart, or bring us together. For too long, for too many people in Lewiston pain has meant stigmatization and isolation. Below, I outline what we can do to change that, and the scale of the problem. While the opioid epidemic is the most specific and overwhelming example, “deaths of despair”—suicides, overdoses, and diseases caused by drugs and alcohol—are now killing Americans at a rate equivalent to the peak of the AIDS crisis. That means tackling the opioid epidemic must be seen as part of a broader paradigm shift, away from criminalization, to a society that views suffering as a call to fulfill our moral duties to care for each other.

Unfortunately, Lewiston stands out right now both as a community that both disproportionately suffers from this epidemic, and has done far less than other similar municipalities. Other communities have demonstrated how to achieve results without increasing regressive property taxes. They took this pain emergency seriously, affirmed common values, created coalitions to work together, and made smart policy interventions. It’s time for us follow suit. The mayor of Lewiston has a unique role in helping to craft the policy consensus necessary to articulate a vision, pursue resources necessary to drive program, and convene the coalition necessary for the design and implementation of the strategy.

These proposals are well-established, evidence-based policy interventions. As such, it’s hard to imagine them sparking any controversy, though I do suggest some innovations helpful for our local context. Over the course of this election, I hope these policies will become consensus positions among the candidates running for office, to demonstrate our unity in moving to solutions. Our community would do well to have every candidate affirm their support of this common-sense plan. The political will that unity provides is the only way we will be able to do implement the new ideas necessary to succeed.

The Epidemic

Last year, more Americans died from drug overdoses than in the Vietnam War.  The Center for Disease Control and Prevention flagged Maine as one of the worst states in the country for increases in death from overdose.  Androscoggin County has the third highest overdose rate in the state, with someone in Lewiston dying nearly every other week on average, mostly from opioids. Lewiston has twice as many overdose deaths as we should, given the size of our population.  As a Lewiston police officer described to me, it affects people from every walk of life: “from Knox Street to Pond Road.”

How opioids became so prevalent

Opioids have been around for a long time. To understand why they have become a problem now, I recommend this summary of the epidemic’s history from Vox’s German Lopez.  In it, he details how the one hundred million Americans who suffer chronic pain became the target of a massive push from the pharmaceutical industry to make enormous profits from prescribing painkillers.  (Reminiscent of the big tobacco lawsuits, several states are now suing major pharmaceutical companies for their knowing deception of the public.) As the government cracked down on these addictive prescription practices, making the pills harder to come by, people turned to heroin, as only ten percent of people with substance use disorder receive any kind of specialty treatment.

Public health, not criminalization: the paradigm for effective policy

The “wars” on drugs and crime have failed.  We already have the highest incarceration rate in the world, the effects of which have devastated communities of color. Punitive policies have not had any impact on crime reduction since at least 2000. More of the same is not going solve any problems.  Opioids, and substance use disorder generally, are matters of public health.  We need to make sure people can access treatment.

Tackling the epidemic requires a broad coalition of stakeholders—not just law enforcement.  It requires evidence-based treatment, stigma-reducing public education, training for providers, and support for those managing chronic pain.

Other communities in the state, like Westbrook, have formed exactly these kind of municipal coalitions.  Unfortunately, despite our disproportionately high overdose rates, Androscoggin County in general, and Lewiston municipal government in particular, have done little to lead a coordinated local response.  As a matter of life and death, we must change.

As mayor, my goal will be to implement the best practices outlined below. There is reason for hope.  Not only have other communities found ways to implement similar initiatives, some communities stand out as remarkable success stories without having to spend unrealistic levels of new resources.  Brunswick, for example, saw no overdose deaths in 2015, defying the national and statewide trends of dramatic increases, with many crediting their commitment to ensuring immediate treatment options for people as the primary reason.  Meanwhile, one of the state’s leaders in opiate substance use disorder, Grace Street Recovery Services, operates in Lewiston.  So far, local and municipal governments outside of the Lewiston-Auburn area have been more interested in collaborating with them than Lewiston and Androscoggin County.  We clearly can do better.

Policies and strategies

#1: Address Root Causes: Prevention and Wellness

  • Require all pharmaceutical salespeople to obtain a local license in order to sell their products. Revenue from these licenses will help fund these policies and strategies below. The licensure also will require disclosure of all material they use to lobby medical providers in Lewiston, as well as how much money they spend on meals, gifts, etc. to court their customers. The Affordable Care Act has required pharmaceutical companies to disclose the dollar amounts spent on advertising to physicians, which can be accessed in an online searchable database here. Unfortunately, it is difficult to ascertain which companies are communicating to what doctors, and the substance of the claims they are making in their pitches are not ascertainable. The public has a legitimate interest in ensuring that, when pharmaceutical companies make claims, communities are able to assess their validity. That requires disclosure, and the corporations making enormous profits off these claims—particularly when they have a track record of misleading people—can reasonable be required to cover the costs (through a license fee) of a public assessment of them. We cannot continue to have public health endangered because pharmaceutical companies push profit-motivated propaganda. Disclosure of their practices will allow local independent review of the claims they are making to make sure this epidemic can be addressed at the root far better and earlier.
  • Educate employers about the causes of chronic pain and what they can do to help their employees avoid it. For example, few employers know that the Maine Department of Labor, for free, will do a comprehensive evaluation of employee workstations.  Simple solutions, like moving a computer screen up or down a few inches, can prevent years of pain.
  • Work with large employers to create citywide wellness days that encourage physical activity, showcase our parks and trail systems, and educate people about health practices. Many large employers, like St. Mary’s, Bates, and the city’s own municipal workforce, already work with their insurance companies to give their employees financial incentives to eat well and stay active. The city could help pull together all the wellness programs, the leaders of local athletic events like the Triple Crown 5ks and the Dempsey Challenge, to create incentives to participate in these events, provide a coordinated set of educational opportunities about health and well-being, and showcase the exciting trail systems that our city is steadily building.  Not only will this help improve the long-term prospects of health and over-reliance on prescription drugs, it can also help to change the reputation of our city.

#2: Immediate treatment interventions

  • Ensure that treatment services are made available within twenty-four hours of anyone who survives a drug overdose. We know that forcing people into treatment before they are ready does not work, but that just makes it more important to ensure everyone who is ready for treatment gets it immediately. Hospitals, law enforcement, and treatment providers must all work together to achieve this goal.
  • Ensure that no one waits more than one week to access treatment. While this sounds like a lofty goal, given the challenges of capacity, and a large portion of Lewiston that lack health insurance, Brunswick’s Addiction Resource Center (ARC) has expanded their caseload by “400 percent in ten years, but the budget and staffing have been relatively flat” thanks to “workflow systems designed by industrial engineers and scheduling software made for hair salons,” according to the Portland Press Herald. See below for the proposal on convening the workgroup to create this action plan.
  • Ensure the wider availability of naloxone. Naloxone is a very effective antidote to opioid overdoses. Police officers typically are first at the scene when an overdose occurs. Other similar cities to Lewiston, like Westbrook, already require officers to carry naloxone. We should as well. Cities like Baltimore have gone a step further, and issued standing orders for naloxone, making the medication much more readily available.

#3 Education

  • Educate 100% of providers who might prescribe opioids on the CDC prescription guidelines. These guidelines summarized here contain all the best research of what we know to be the benefits and risks of opioid prescription, as we well as useful checklists to cover when prescribing.  Because the medical providers in Lewiston serve so much of Central Maine, it’s critical for our whole region that all local providers understand these guidelines.
  • Increase the number of providers licensed to deliver medication-assisted treatment. People are getting diagnosed with opiate addiction at eight times the rate they are receiving care. Part of this has to do with capacity; there simply aren’t enough doctors trained in providing this treatment.  Check out this moving story of a Maine doctor who discovered his unintended role in fueling one of his patient’s addictions, and how it spurred him to get trained in providing treatment.  We should develop a clear set of goals locally to make sure that we have the capacity to deliver treatment to our region.
  • Public education to reduce stigma and misinformation around substance use and mental health issues. The CDC guidelines include not just information for doctors, but patients as well. Every institution in our city—large and small employers, hospitals, schools, faith communities, etc…–has a critical role to play in ensuring we connect people with the right information, and reduce stigmatization. Substance use is hard to discuss, because mental health issues in general are still considered taboo. At the campaign launch, I did my best to share my story of depression and the way it affected my life. That kind of vulnerability never comes easy, but it’s the only way we are going to change hearts and minds about this epidemic.  I talked to a woman who, as part of her twelve-step recovery, wanted to find a way to plug into public education efforts, and, after asking around various city departments, was told there were no opportunities to do so. This must change.  Peer support is essential for treatment and sustaining recovery. There should be weekends where every faith leader gives their homily on the topic.  There should be a day a year when every major city leader comes together with people sharing their stories of recovery to celebrate progress, connect people with resources, and recommit to doing more.
  • Data collection. Reliable data is easily available about drug overdose deaths, but not necessarily about emergency room visits, treatment options and efficacy. We should create clear metrics to track our progress and work with experts, particularly at the University of Maine and the Department of Health and Human Services, to assess the efficacy of our strategies.

#4 Connecting Law Enforcement to Public Health Strategies

  • Resource cards. Law enforcement officers should not be expected to be the ones primarily responsible to carry out public health strategies, but there are many things they can do to be supportive. Westbrook police officers, for example, carry business-card size lists of treatment resources for the people they find who are struggling with substance use disorder. Lewiston police officers should be equipped with resources like these.
  • Many police departments across the state are beginning to carry Naloxone, thanks in large part to a program from the Attorney General’s office that covers much of the cost. Police officers, often the first at the scene of an overdose, can administer this life saving drug immediately. It treats only opioid overdoses, can cause immediate revival, has few side effects, and people can be trained easily on its administration. As one Lewiston police officer told me, even officers who were skeptical about carrying this treatment are now coming around, thanks to the prevalence of Fentanyl.  One Lewiston officer was exposed to it in the line of duty, which could have caused a near instant death. Carrying naloxone thus is a matter of officer safety, as well as public health.
  • Training officers to emphasize treatment. Officers have wide discretion in when to book someone for drug possession, and when to divert people into treatment. Officers should be trained not just to emphasize treatment, but on how to make that intervention. Strong working relationships should be built with the network of local organizations working to fight the epidemic such that communication and follow up occur easily.

#5 Coalition building and staffing

  • Building a broad coalition to implement these strategies. Tackling the epidemic requires coordination across a broad array of agencies and institutions. The city cannot just legislate change; broad political will and a team attitude must be fostered to get this done. The mayor’s office is uniquely positioned to drive the construction of this alliance.
  • Borrowing from models inside and outside Maine. In Maine, Westbrook has a great model, actually chaired by their police department: the Community Approach to Stopping Heroin (CASH) coalition.  North Carolina, a state facing similar challenges to Maine, has developed an excellent model to build community capacity, called Project Lazarus. Both of these models give good ideas on how Lewiston can start our own local taskforce to coordinate our response.
  • Municipal staff. Westbrook hired a part-time person to staff their coalition. Other municipalities have public health staff. We should include expanding municipal public health capacity as part of our strategies to ensure sustainable leadership. Once resources are raised, we should have some at least part-time staff dedicated to coordinating this work.

#6 Financing

  • Medicaid expansion. Because Lewiston is home to so many childless adults below the poverty line, there are many people who lack insurance. Therefore, they lack the financial means to pay for their treatment. A referenda to pass Medicaid expansion will be on the ballot this year, and voters in Lewiston should support this measure’s passage.
  • Connecting uninsured with navigators that can access coverage on the exchanges. Some people do qualify for subsidized health insurance and they don’t realize it. Local “navigators” can help people qualify to find appropriate insurance, and should be connected to providers to help ensure this happens.
  • Private foundations. Foundations like Robert Wood Johnson have helped fund treatment programs and coalitions assembled for this purpose. Other in-state foundations that focus on health care, like the Maine Health Access Foundation, have recently prioritized interventions in the opioid crisis and have a history of investing in Lewiston. We need to take advantage of these opportunities.
  • Attorney General’s Office. The Maine AG office has paid for police departments to access naloxone. We need to position ourselves to access these resources.
  • Federal grants. In April, the federal Department of Health and Human Resources announced Maine will receive $2 million of federal funding to tackle the crisis. Lewiston obviously stands out as a municipality in desperate need of these resources and we should aggressively pursue them.
  • Pharmaceutical sales representative license fees. The policy outlined above should generate modest amounts of revenues, and they should be directed to public health initiatives in the city.