Dr. Castiel and delegation from Hector Reyes House
As the City of Worcester Commissioner of Health and Human Services, I have developed city-wide initiatives and worked on policy change to address three primary health issues prevalent in our community, those being addiction, mental health, and homelessness, which all tend to occur hand in hand.
Addiction is the largest public health and public safety crisis in this country. Nationally, more than 64,000 drug overdose deaths were estimated in 2016. The overdose death rate in Massachusetts [PDF] increased by 19% between 2015 and 2016. Roughly 2,000 opioid overdoses deaths have occurred in Massachusetts, out of those, 59 occurred in Worcester [PDF].
Although progress has been slow and there is much more work to do, we have implemented some key changes in our community. One of these changes is that as of 2015, all Worcester police officers and firefighters are instructed to carry Narcan during their shifts. Additionally, in partnership with the Worcester Police Department, we hold “drug take-back days,” where community members can safely dispose all drugs in disposal containers that we have placed in strategic areas of the city to encourage safe disposal at all times. Another great project is a partnership with a local non-profit, Aids Project Worcester, which has two components: syringe exchange and community Narcan access and education. The syringe exchange component creates a safe space where community members can exchange used syringes for clean ones while connecting with community and health workers who can help individuals navigate access to treatment. The education component provides training in how to administer Narcan as well as gives Narcan to community members at no cost.
As a result of numerous advocacy and legislative efforts, there is now a standing order in all pharmacies for distribution of Narcan. The standing order enables all community members to access Narcan by paying the copay required by their insurance providers. Understanding that education is a key aspect of access to Narcan, my department along with community partners have trained City of Worcester employees as well as over 35 community organizations, businesses, and youth groups on how to administer Narcan, and education on substance abuse and its causes. Another significant step forward was the opening of a recovery high school along with a youth detox facility. An additional major accomplishment is that the Worcester Police Department is starting a diversion program where those suffering from addiction, who commit a low-level crime, will be diverted to treatment instead of being incarcerated.
Despite all these major short and long-term efforts, we still have a lot to do. One of the most significant challenges is getting primary care providers to provide Suboxone treatment. According to ASAM, only 1% of primary care providers are certified for Suboxone treatment. Medication-Assisted Treatment (MAT) is advocated by the National Institute of Health, the World Health Organization, National Institute on Drug Abuse, the Institute of Medicine, and the White House Office of National Drug control Policy, and yet it is prescribed to a minority of patients. Mental health goes together with MAT, yet we have a shortage of social workers, psychologists, and psychiatrists due to low reimbursement rates. Furthermore, we often fail to acknowledge that most substance use begins in adolescence. Addiction in the majority of cases is a childhood disease. Worcester Department of Public Health’s data demonstrates that kids start using marijuana, cigarettes, and alcohol at the age of 8 and their usage peaks at ages 13-16. Early use along with trauma and genetics predispose kids to addiction.
Based on dialogues with youth from the Worcester recovery high school, we know they began to use drugs because of distressful experiences such as bullying, low self-esteem, and a long history of trauma. The study of Adverse Childhood Experiences (ACES) published in 1998 by Kaiser Permanente in California has now been used as supporting evidence to show ACES to be a predisposing factor to addiction. ACES, such as a parent who has been incarcerated, divorced, mental illness, and substance misuse in the family along with abuse and neglect are important in predisposing to addiction. 64% of families across the U.S. have one ACE, and they occur in all races and ethnicities in the same proportion. Therefore, starting treatment in school with adjustment counselors, social workers, and therapists, along with home visits, is needed to prevent these ACES and their downstream effects. In Worcester, we have launched a pilot program implemented in 4 elementary schools and 1 middle school to evaluate and treat children as an avenue to prevent the adverse effects of ACES.
For decades the U.S. has been treating addiction with incarceration [PDF], which has disproportionately impacted the African American and Latino community (see the documentary 13TH). However, since 2009 overdoses have been increasing, especially, in the white community with many middle and upper-income families affected. These families had social, political, and economic agency, which, led to a shift in the conversation – addiction became a nationally recognized public health issue. Consequently, this resulted in more visible advocacy for treatment. It was only then that our government and community started to emphasize what we have known all along, that addiction is a disease and should be treated as such.
When we start identifying the gaps in our judicial system and the lack of services we provide to those who have been incarcerated, it is evident that we are further perpetuating a cycle of oppression and inequity. For example, when we do not provide educational and employment training as well as access to social support services and treatment options to those who are reentering society, we are only exacerbating the socioeconomic barriers that these individuals have to overcome in order to survive. If the barriers to housing and jobs are not removed, chances of becoming sober are minimal and as a result, the cycle of jail repeats itself. Our recidivism rate at the Worcester county jail is 56% but for participant in the 32 bed STOP treatment program it is 29%. Treatment does work.
In addition to treatment, we need to allocate resources on reentry into our community; assisting those coming out of incarceration with finding jobs and housing. This is essential, and in spite of the increasing amount of data showing that wrap around services work and decrease recidivism [PDF], those services have not been implemented effectively. For example, the Worcester Initiative for Supported Reentry (WISR) program provides such wrap around services and reported that only 8% out of the 48 individuals who participated had been re-incarcerated in comparison to the 34% of other department of correction former prisoners. 100% of WISR participants had housing upon release; 60% were able to maintain continuous employment for at least six months; and 90% of participants referred to substance abuse treatment services accessed the recommended services.
What are the next steps? Treatment is essential, and research has shown that treatment is effective, particularly in reducing morbidity and mortality. We need to begin treatment with MAT when someone presents to the ER in withdrawal or after an overdose. At that time they should be started on MAT with a follow-up the next day at a Suboxone clinic in the hospital until a primary care provider is able to accept the patient.
We need to advocate for all primary care providers to obtain Suboxone certification, and to provide treatment for those suffering from addiction. We cannot pick and choose what patients we see. We need to stop telling people who come to our centers that they cannot be treated and that they need to seek services elsewhere. We took the Hippocratic Oath to do no harm. By not treating patients we do create harm. Let’s all work together to end this epidemic.
Matilde Castiel