David E. Williams: This is David Williams from the Health Business Group. I’m speaking today with Joe Avellone, Democratic candidate for Governor of Massachusetts. We spoke previously about healthcare policy in general. We’re going to speak today about substance abuse.
Joe, it’s great to have you on today.
Joe Avellone: I’m pleased to be here. Thank you.
Williams: Joe, why are you making substance abuse such a high priority issue in the campaign?
Avellone: Well, this is an issue that is quickly becoming a major healthcare crisis in our state. We’ve always had addiction problems, of course, of various types. over our history. But with the development of the new powerful health, the new powerful oral narcotics that had been in the market for the past 15 years, we’ve seen a huge acceleration of young people who are very quickly addicted to these painkillers either by using them recreationally or if it’s just happening or even starting out with sports injuries. And from there, becoming so quickly addicted they move on to other things, in particular, heroin.
And this has been a new phenomenon. Over the past 15 years, the rate of prescribing these drugs had gone up 300% and the rate of actual overdose deaths and prescription pills had gone up 300% in the same time period. So we’re seeing something that is reaching significant public health crisis proportions. It’s really being driven by the use of these powerful oral prescription drugs that then lead to other kinds of addiction.
I have seen the human face of this all throughout the Commonwealth over the last year. I’ve been running for over a year and I’ve been in 130 cities and towns. It really comes up in lots and lots of communities. So it’s affecting lots of communities all across the Commonwealth, certainly in our big cities but also in our smaller towns. And it’s in particular affecting children at relatively young ages in their early to mid-teens. So they first experience this and often are addicted within weeks of starting to take some of these kinds of oral medicines.
Williams: Talk a little bit more about this heroin issue because I’ve heard this as well. People start with oxycontin or something similar and then when their prescription runs out and they found out how expensive it is to buy those pills on the street, they end up on heroin. Is this just something people say for shock value or is it really happening in any significant numbers?
Avellone: No, unfortunately, it’s really happening in very significant numbers. The addiction potential for these powerful oral narcotics – oxycontin, even Percocet, the other kinds of new opiates – is so strong that within weeks of either experimenting or taking for a mild medical problem, the young people in particular are often addicted. And then, they start down this road of taking them out of their parents’ medicine cabinets or their neighbors, et cetera, and using them at parties. But soon, at $30 a pill, which is about what these things cost on the street, they become so addicted that they move to heroin. And heroin to them does not hold the fear that grips all of us who are a little older. It’s much cheaper than these pills at $7 a bag versus the $30 for a pill. It’s now so plentiful and easier to use than it used to be. So there is a very quick transition and before you know it, you have a lot of young people from middle class families who were playing by all the rules and, all of a sudden, went off the rails with taking these prescription drugs and then end up on heroin within months.
And then, the heroin itself, as you know, ushers in all kinds of other issues especially if it’s using needles. You’re exposed to all the blood-borne diseases and also the heavy addiction and the need to find more heroin.
Williams: Now, clearly, the state’s been paying some attention to substance abuse. What are we doing right and what are we doing wrong on this topic in Massachusetts at the moment?
Avellone: Well, we have a substance abuse department in our public health department and we have a drug monitoring program for these prescription drugs. But all of it is not nearly enough to be effective to combat what is really an epidemic.
And I think that’s the point and that’s why I formed the Office of Recovery. In the end, we’re going to need a lot more capacity. We need to do multiple things that we’re not doing now and we’re certainly not doing on the scale in order to meet the need that is out there.
Williams: Have you seen other states or other countries that are doing things better? Are we a laggard here or is it just that the problem has come up so quickly that others have not come up with a good response either?
Avellone: No, I don’t think we are a laggard in the traditional sense. I think if we’re viewing this as a traditional problem at the level that which we all thought it was affecting our population, our Bureau of Substance Abuse is doing an adequate job. But that is not where we are. What is happening is this is mushrooming, it’s affecting many more people. And we are not at all treating it in the way that we should: dealing with it as a crisis, which is really what it is.
Williams: You’ve announced a plan for this area. What are its key components?
Avellone: I’ve announced the formation of Office of Recovery. This will have to be at the state level because it affects so many towns and cities across our Commonwealth. It has to be high in the Office of Health and Human Services, so it will be a direct report in the Executive Office. We’ll take in the current Bureau of Substance Abuse because those traditional roles that are being played there would need to continue, but we need to expand it.
The Office of Recovery will, first of all, increase our capacity. We do not have nearly enough capacity to deal with either detox or rehab or the sober houses along the spectrum. We need to reimburse our providers more to bring more capacity on line. Increasing capacity is the first part of this.
This Office will have a whole series of regional coordinators that will, in a very publicized way, make it possible for people to have one number to call and they know to call this number when they need treatment. One of the problems of intervention is making sure that the treatment is available and that people can get into treatment right when they need it, right when that window is open.
And we know that window’s not open very long. People, when they finally get the resolve that they can actually treat themselves, they have to move on to make a big change and we need to find them and they need to find treatment then. And that’s what the regional coordinators will do.
In addition, I’d like to staff them with people who’ve been in recovery. There’s a large recovery community that can be very helpful to people who are suffering from addiction and really help them clear the course and get into treatment.
In addition to standing capacity and the regional coordinators, we need to change the way insurance coverage works. Right now, part of the problem is gaps in insurance coverage and slow approvals. And that, once again, creates roadblocks in the system where people are stuck in detox because they can’t get to rehab or they’re stuck in rehab because they can’t get into the next step. Or they have to wait for approvals and if the approvals don’t come, once again, they fall back into their addiction and are lost.
Another key component of this is to move away from putting minor drug offenders in jail. Right now, we have many thousands of people in our county jails; about 75% of them are there for drugs or drug-related problems; and a large percentage of those are addicted. The males are in jail in these county jails for approximately a year, and they cost about $46,000 a year. If we were not putting people in jail and were using that money differently, which we will in my administration, that would cover a lot of treatment.
The vehicle for doing this is drug courts. We have about 21 drug courts around the Commonwealth. We need to have about 50, people estimate. We need to make sure we have it in every jurisdiction. These drug courts operate specialized programs that help people not only not go to jail but then move through their recovery and guide them through their recovery. Specialized courts cant do that.
And finally, we need to much more aggressively step up our drug monitoring. We do have a drug monitoring program but obviously, the prescribing patterns are not what they should be. We are over-prescribing either wittingly or unwittingly in a large amount. There are so many of these pills sitting around unused in medicine cabinets. That’s how the diversion occurs, especially with these young people.
I have heard so many stories from mothers and parents of addicted children, of the fact that they were getting prescriptions for wisdom teeth or other relatively minor ailments that they don’t even want. They have so many pills and would have these pills sort of sitting around. And this is a big problem.
So we have to be much more vigilant about our prescribing practices. I’m going to work with the Massachusetts Medical Society on education programs and also with the Board of Registration in Medicine to make sure we have people who are knowingly prescribing the things that they are appropriately dealt with.
So, these are the major components of my Office of Recovery but I want to go beyond that. I think we need to deal with this as a region as well.
Williams: Joe, we’ve been talking mainly about how these prescription narcotics are causing problems in terms of addiction leading to heroin. I want to ask you about two other substances and how and if they fit in here. One is alcohol, the other marijuana. I’ll separate those out.
Alcohol, often people talk about the large impact that it has relative to higher profile and scarier sounding substances. And then on marijuana, we seem to be on a path toward outright legalization as we’ve seen elsewhere, which seems to be going sort of in the opposite direction from a public health standpoint.
How would you view those substances fitting into the Office of Recovery?
Avellone: I think alcohol should be incorporated in that. I spent a fair amount of time in the treatment facilities, for example, the Dimock facility in Roxbury and also SSTAR, which is a wonderful facility in the Fall River area. And clearly, they treat alcohol as an addictive substance like the other drugs that they deal with. There are some differences but they accommodate those differences in the program. It clearly destroys lives just as surely as these powerful opiates do. So I do think that this is part of our issue and a problem that ought to be addressed to the Office of Recovery.
I feel a little bit different about the marijuana. I don’t think that would be the main focus of this right now because I want to deal with the more powerful and addictive drugs that are essentially killing people and ruining lives and destroying families right now. And that’s why, alcohol and in particular, these opiates, especially prescription drugs and then heroin.
Williams: When you put these plans in place for the Office of Recovery, what would be realistic or aspirational to expect the impact to be? Is it possible to really take this problem on or are we really just talking about taking a little bit off the edges of it?
Avellone: No, I think it really is possible. I think we have to understand how acute the problem is right now. Now, just to deal with the overdose deaths alone, which is certainly the tragic end state of this, we have had 11 overdose deaths per 100,000 of the population. So, that’s over 600 a year. And we know that’s just the tip of a very large iceberg of people whose lives are destroyed or being destroyed but are living and going through a living hell every day.
But just dealing with overdoses, those are the statistics. They’ve gone up to 11 per 100,00 from 7 1/2 per 100,000 just ten years ago. So, it’s rising rapidly. That’s a big change. We heard about the fact that we had 185 overdose deaths just in the last three or four months, and we know that was a very incomplete number because it didn’t even deal with Boston and Springfield, our major metropolitan areas. We know that even at 11 per 100,000, which has been released as statistics, it’s certainly going to be more than that next year and rising relatively rapidly.
So, I know this is an issue that we can definitely, if we treat it aggressively, do something right. We know that treatment plan works and we also know that right now, we’re not treating it adequately at all.
The biggest thing of all the Governor can do and which I would certainly do is to take the stigma away from addiction. I think part of why we treat this inadequately and why people don’t seek treatment is because of our attitude about it.
However, I think we now recognize that this is a health problem and this is something that the Governor needs to take the lead in. It’s not a moral issue. It’s a health issue and we have to treat it that way. If we can remove the stigma, then a lot of things become easier. Getting people into treatment, moving people away from jail sentences and enabling people to rebuild their lives, which they can if we can get them the right treatment.
Williams: Joe, you talked about the societal cost here and even some hards cost in terms of the cost to incarcerate someone. But in setting up an Office of Recovery like this, I’m sure there are new budgetary expenditures that are needed. What’s the order of magnitude of those and how do you finance such an effort?
Avellone: The cost is about $1,000 per person but the benefit to cost ratio of treatment is huge. Many studies show that it’s something like seven to one. And those benefits come from several different sources. First of all, let’s just start with jail. Right now, we’re putting literally thousands of mostly young people in jail for minor drug offenses related to their addiction. That’s at $46,000 a year because as I said, in the county jails, the males are there for about a year.
If we just, next year, incarcerate 500 less, then that’s a fraction of the 10,000 people that are in the county jails. That’s $23 million plus for treatment. So that covers an awful lot of treatment. Literally, incarcerating people less almost covers the whole total cost of the treatment. In addition to that, the healthcare cost is much less. If people are successfully treated, there are many fewer trips to the emergency room and they have many fewer other high costs due the healthcare issues that the population with addictions have.
So this is more about moving money in the budget that we already have because of new expenditures that we’re not incurring. And I believe that we can do this without a big increase in the budget. That’s why it has to be done as a high priority in the Governor’s Office because it’s going to take moving dollars away from some parts of our budget and into others. And doing that in a very, I would say, calculated way. It’s going to take leadership to do it but I think the analysis will bear us out that we can move the dollars and accomplish much.
Williams: Joe, you have been having a quite a comprehensive discussion here about issues of substance abuse in a Commonwealth and in your plans that will be able to address it. Are there topics that we have not addressed that we should do today?
Avellone: Thank you, David. I would like to talk about the regional initiative I’m proposing. I’m going to, once elected, pool together the other Governors and the whole Congressional delegation in the region. So with six states – that’s six governors, 12 senators and 21 congressmen – I believe that we can be more successful in some respects with this operating as a regional initiative.
And the first is to go put a lot a pressure in the FDA. The FDA needs to have a much higher safety profile when approving new narcotics. And I think this is a failing. I think they were essentially suffering now from something that they should have done ten years ago. I think going forward, we have to make sure that they’re not approving narcotics that are powerfully addictive and yet easily available. That really is what has led to this great acceleration.
I also believe we can put some pressure on the pharmaceutical industry as well.
As a region, we have a lot more clout to deal with the FDA and with the pharma industry. I also think we can work together to cut down on the smuggling of heroin. The second half of this is the fact that heroin is so available and young people in particular moved to it as prescription drugs become harder to find than the heroin. We need to shut down the heroin pipeline and I think we can do that more effectively as a region.
I think also as a region we can learn best practices from each other and potentially even share facilities to deal with the ups and downs of our capacity needs. So, I believe this is something that we can effectively treat as a region and I intend to lead our efforts to do that.
Williams: This is David Williams of the Health Business Blog. I’ve been speaking today with Joe Avellone. He’s been talking about substance abuse and has proposed an Office of Recovery to address these issues.
Joe, thank you so much.
Avellone: Thank you very much, David. It’s my pleasure to be here with you.
—April 2, 2014