The Public Health Response to Drug Overdose

(soft music) – So one of the first questions is, in your work particular field, and the field is the field of public health, professor Heimer Addiction medicine, doctor Hawk

The field of public health I guess, our director Byron Kennedy, doctor Kennedy Police and security is Chief Campbel And of course Mark Jenkins in the greater Hartford harm reduction coalition which is, I guess the best term would be informed community activism to respond to public health challenges So we have a variety of allied, but different fields so in thinking about drug overdose in the year 2018 what is the field, and I guess we can maybe go in reverse order and then we'll let the chief settle down and just have Robert Heimer give a sense of where are we with overdose And he might want to comment on what happened here in town along August 15th

– Well thank you Thank you Actually I wasn't in town when it happened August 15th So I'm gonna let doctor Hawk, Kathryn respond to that since she was doing all the responding at the time But I do want to point out that what happened on green should best be characterized not as an overdose but as a series of poisonings

And the difference I think is a fundamental one that people who are seeking opiates and who overdose because the doses are higher than they expect, got the drug they wanted and just took too much of it I don't think that the people who took this synthetic cannabinoid on the green really wanted to experience whatever was they experienced, the catalepsy, the catatonia that occurred I think that we do need to differentiate between those two just from the standpoint of how we frame our response Because when it comes to opioid overdoses I think we should focus on, because they are killing more than a thousand people in this state this year It keeps going up every year

It is a massive public health crisis of national importance Our response as a academic community is mostly just been to report on it There have been several attempts to demonstrate that getting Naloxone, the antidote to opiates since the field has been very successful when people have access, when people are using drugs in groups of people and somebody has an overdose and falls out, that the people who are trained, even if they're lay people can respond as well as emergency medical service people or people in the emergency department There's no question about that The question is getting this drug into the hands of people who are, even before the first responders, police, fire, EMS, they are really the first responders

And we also need them to encourage drug uses to use drugs with other people if we're gonna save lives Don't go into the bathroom and lock the door And we've been trying to do that And we continue to try to do that The first community district, Lawson district issue and almost 20 years ago with the Chicago Recovery Alliance and its founder and CEO included died prematurely last week and I think they should be remembered for really being the founder of community based Naloxone and we've been working on trying to explain how well this works when it's scaled up, if we can get enough Naloxone in the community

Mark can talk about this because he does this with incredible skill in Hartford – And although I certainly identify as an addiction medicine physician I am also an emergency physician for those of you who don't know me And so I actually want to take it back a little bit and it is really important what happened a couple weeks ago, to talk about that But I'd also like to talk about sort of, the question of what's was your fields response to overdose increasing, overdoses that we're seeing? And I think, emergency medicine has really I think sort of changed the way they interact and view the scope of the problem and the response to the problem and so its actually been really sort of invigorating to see over the last several years many of my cohorts and colleagues have identifying and more upfront about identifying patients with opiate use disorder, be willing to link patients to treatment and really kind of taking an active role in trying to identify how we can effectively get people into evidence based treatment And by that I mean treatment with Methadone and Buprenorphine

And so that's been one of the, I think the things that it's still certainly evolving in my field for emergency medicine and access to that has certainly been there in addiction medicine But really it's about expanding support and access to that, our ability to talk about how these medications work to our communities – You know when I actually first heard about this I actually got a call from our lead for the city in North Montana about what was going on that morning Shortly after that I actually received via email maybe from them for the deed, you know who had actually been in communication with the call with his faculty We observed what was going on

And so to that extent you know, relating subsequent conversations you know with rip Montana and one of the concerns we actually had was just inter use of opiates And as a result of that, being able to have readily available Narcan and to actually use that Although when they were utilizing that in the field it became pretty clear that it didn't initially suspect that it was opioid based on the lack of response to the Narcan That being said, you actually have individuals that you need to respond to fairly quickly but you don't know that in advance and yet, so you still have to take into particular steps in putting, using Narcan which for us that actually depleted a large part of the supply we had And so then consequently it was in such conversations with safety PH specifically with Commissioner Pinot

And then along those lines, having conversations with him about seeing what Narcan was available being applied to the state Which they did, so we were really thankful for that And they actually got that pretty promptly Some of the two they actually done a couple summers ago we actually had some similar events but those actions involved Fentanyl So I think being able to respond fairly quickly and then also being able to deploy the resource that you actually need at the time was probably critical and I think certainly Chief Campbel can speak more to that in terms of this could've been much worse

– Things were a little different again from the Hartford side as again, responding to what happened on the green But we kinda knew early on these were, it wasn't, although we had to wait for the forensics to say it wasn't opioid, you know from afar it's like okay I kinda knew what the culprit was because it's happened in various other cities In response to what we've been doing from greater Hartford in relation to making sure Naloxone is available we've been first off one of the only if not the only community based organization in the state for the past two years that's been an overdose prevention education every week for the past two years and make sure that Naloxone is given out free We also understand that intravenous drug users are not adverse to an intramuscular dose of Naloxone

And that's nationally the best practice for administering, for being able to have a sustainable supply But unfortunately not everybody's comfortable with that However, we were able to be on hand Matter of fact, we gave approximately 700 doses to people here in New Haven to be dispersed And we still, for every dose of nasal Narcan that is given out, we can purchase ten times as many kits

And so we need to be able to keep the medication available for those who are adverse to that I guess that's our message if anything right now is for our fellow SSP providers and for agencies and organizations that deal hands on with the population, let's go for a more sustainable method because as said, when in doubt, it needs to be used But if we use up all of those supplies that are on hand what do we do? So we really have to go with a more sustainable model – Good afternoon When it comes to our particular field of law enforcement's response to the drug overdoses it really started well before the green for us

Back last year, 2016, the summer we had 20 overdoses of opioids People were buying what they thought was heroine It was straight Fentanyl 20 people overdosed, we lost 3 of those people As a result of that we had to change the way we respond

Typically, when it comes to law enforcement the fire department, the police department are dispatched from the same room in the police department If an overdose were to come in, that's not a police issue That's a public health issue Fire department typically would respond So we weren't responded but after these 20 overdoses where we lost three people we changed our policy so that anytime an overdose is called in, officers are now dispatched to that overdose so that we could gather any evidence

Evidence including any drugs that are left over, cellphones etc so that we can start investigation Fortunately we were able to do a great investigation with the 20 overdoses and we were able to apprehend the subject who sold this bad batch to people on the street and individuals of nature As a result of that we also started training our officers differently with respect to issuing them gloves, some respirators because that was the major issue some of our forces stand by We see it when you do a large scale bust

A lot of times there are weapons inside We would throw in what we call flash bangs and that can make any Fentanyl or drugs inside become airborne, aerosolize them And that could take the officers out which we've seen happen twice now So training has been making change and when we look at the green I think that a big reason the green wasn't as bad as it could've been is because we had started these progressive changes in how we respond from a law enforcement standpoint We coordinate with the fire department, with AMR, so that when we see overdoses start scaling up we immediately have a plan that is put into action

Sorry for being a little late, but we had three overdoses on the green as I was on the way up here so we had to start our process of scanning out and I think it is that process of seeing the trend, seeing it and getting the reporting immediately Having our intelligence unit out there right away to find out where did the people get this? Is there a particular dealer or is there something on ice? Is this a particular bad batch? Really has helped us with our response So one of the major changes is each situation you learn from You learn, like we were able to make an arrest within four to five hours of the individual Getting a second individual in a hotel room who still had 30 bags on them

Find out who the individual was who gave this to them Where they got their distribution from and where it was coming from which was outside the city So quick, quick response, responses quickly as possible And I think the biggest change for us is also in the totality in understanding that we are not looking to criminalize the victims One of the biggest things during the interviews during the green situation was reporters kept asking, why are these people who have overdose, why are they not being arrested? Because they are victims

Victims and I'm glad that you pointed out they're not victims of overdose, they are victims who were poisoned Poisoned because this is a substance many of them took one hit from and were laid out So it's important that our response and getting the message out to the community that these are people who are preyed upon, they are victims, they have substance abuse disorders, we're not gonna arrest our way out of the situation We have to focus on those who are distributing it, make the arrest there and not with the victims – ADA pill from the Connecticut community for additional regarding

– Hey my name's TJ and I'm a young person in recovery For me that means I haven't had a drink or a drug since July 9th of 2016 What I do is am a currently in an emergency department recovery coach with Connecticut community for addiction recovery and I apologize for being late, I was actually working with an overdose patient like 45 minutes ago and working on some stuff in trying to get him to his pathway that he chose he wanted to get treatment a shot Because he's never been through some treatment What is my field's first response? So what we do is we go into emergency rooms and provide recovery support services, not addiction services

So once a person goes to the emergency room and asks for help with substance abuse disorder or they present the substance abuse disorder we then ask, or the hospital staff will ask them if they would like to speak to a recovery coach and that point recovery is initiated in their life and we come in and we go and help them get the needs of their recovery met whatever that may be The main thing is meeting people where they're at And what we do is not a function and I'm actually grateful to not be in a clinical based role in this because what we do is we treat people as a resource right? As a resource to their own recovery Help them figure out what they want to do What we do is ask them questions, we manage and discover our own stuff and we actively listen

Through that we can then help people pick out their recovery, recovery orientated plan which them having chosen their own plan they are more, they are like 10 times more likely to follow through on said plan and make said plan work for them You know it's not the 1980s anymore It's not, here's a medic, don't get high and go to meetings you know Obviously if that had worked we probably wouldn't be sitting up here having this discussion with the public, right? So there's many pathways to recovery and we embrace them all So everybody's recovery process is gonna look like a lot different than that

So what we do is, my boss calls it, laying the buffet out So we help them fix, of choose from options that would fit good for their schedule Most people, we work with their parents You know it's not just an inner city problem It's an everywhere problem

And it's not just opiates So America has been in this addiction crisis for since long before I was even born It's just opiates are causing people to lose their life in a more rapid sense I think one in ten people in the emergency room presents with an alcohol related issue Yeah, I don't like the word service but we work with anybody from alcohol, cocaine, PCP, marijuana, whatever that substance abuse, not substance of choice because the intravenous where they didn't choose the substances that would be the substance they would use

And meet people where they're at We also have recovery community centers which are amazing places where they provide recovery support services that helps people can take and sustain recovery we provide We provide free recovery public training as well as many other related things It's a great way to engage in the recovery community I got sobered on there

There's many many options to recovery Helps with those who are beyond recovery with a non-denominational H meeting where people can come in and not be fearing of what they previously thought about recovery And pretty much I'll pass it back after that before I get going – Alright, that's excellent, thank you very much The second series of student questions has to do with the kinds of collaborations that are necessary to provide integrated services to persons experiencing substance use disorders

And another way of sort of expanding on that is, how do we break down silos between organizations or fields, so that entities that has previously not done a particularly good job communicating can help solve these issues So again, the kind of collaborations needed and how have we been successful or less successful at breaking down barriers across entities to solve those problems This is the collaboration question I want to say that we have enough space in the auditorium for everybody standing that you have to get up and get down here in the front and ask to sit in the middle somewhere and just make yourselves comfortable so feel free to do that as the answers are coming And I guess AJ, that TJ we started, we had you ending but do you want to start this time and talk about collaboration of breaking down barriers? Now if some of the panelists hear the points they would've made having been made by a previous panelist you can just pass the mic and we'll regain a little bit of time

– Absolutely, collaboration is important One of the main goals of recovery is to remove barriers for people There can be a lot of obstacles and people choose other, right? So what we do is we work with people And there's this great thing called the Hope Initiative and it's currently in Manchester and it workings to be in, well I don't know if I'm even suppose to say that but I don't know But there's people who would then present to police department as opposed to being arrested or fined, the police would then help them get treatment in Manchester

What exactly happened was they would drop people off at the emergency room Well what typically happens at an emergency room should be the schedule for AA and also some numbers that are following to call them Treatment is not the option for everyone Treatment is not the option for everybody seeking recovery So everybody's pathway to recovery being different, some people find, hold love, guidance, mentorship in 12 step fellowship and some people find that through outpatient many different ways

Some people go to the community center Some people go to wherever So helping that person identify that Also going into that, we also work with a lot of other organizations so like, CPAR and lowamanic is a resource paid for people so we have connections with a lot of the outpatient therapy A lot of the medication assisted treatment places or medication assistant recovery places all around, we are working, there are a lot of places with when we work with hospitals they're starting to do Suboxone induction in the emergency room so people would then get offered the opportunity to start Suboxone within 12 hours of an overdose

They can then continue that with an outside provider And outside providers do one on one there, do group therapy, regulated urine checks to help people stay accountable What we do is we collaborate So I also work with families as well So I coach families, specifically somebody brought to the emergency room for substance use disorder is not gonna be a problem

Some people they follow through by themselves while other people are connected and they still got family support and they go on to coach the families that have a support them and engage them and you know there's many ways to collaborate with the community If you think about it, so everybody thinks a lot of the answer is treatment right? So we send somebody to treat me, you send your loved one to treatment, boom 90 days, 30 days they're fixed and they're back out in public At that point people are at a, five times, ten times the risk for an overdose where we run into these problems So helping the people find something that exactly works for them and then engaging in supports afterwards That's the main thing, is engaging in community based supports afterwards

One of the many ways out of addiction is connection A connection to our fellows, a connection to other people who are in recovery, and connection to community whether it be the recovering community or the other community People need purpose in their life and our goal is to give that to them Thank you – I think one thing that TJ touched on is where I'll start with collaboration

He said that one thing they'll do is if a person has overdosed they will come in and offer them a pathway to recovery And I think that type of collaboration is something we learned from the green I was out there when the bulk of the overdoses were happening and after about four or five hours one of the things I found the most frustrating was people started overdosing and when I looked they had their wristband from the old New Haven Hospital or St Grayfield's Hospital They had been on the green, overdosed, been transported, treated, released and were back on the green overdosing for the second or third time

So the type of collaboration where you could have someone in the ER, in the hospital, wherever it is that they've been transported to, to give them as you said, the buffet, some options of a different path rather than going back to exactly what they just came from It's crucial And I think collaboration is critical and all of us work in this cycle This is not a law enforcement issue per se only It is all of us working together

It is us working with the churches Both on the green and throughout the city It's us working with substance abuse providers In our city in particular we even experienced some unique situations because we have a number of drug treatment facilities in our city One of them being the Out Foundation

Addiction, prevention, treatment program Every week 1400 to 1600 people come into our city to receive treatment There are some less stringent policies But many people come from more variance rather than have seeking treatment and it becomes an issue and it's important for us to collaborate with them and other treatment facilities so that we can both, identify those who may be having problems and find better ways to get the treatment that they need That doesn't necessarily mean you are less

That doesn't necessarily mean vilify these people by identifying them and finding out why certain subsets of people not responding to the programs that are being provided And that only comes through collaboration It may be through the church that may be being with the one on one level That may be through the drug treatment program It may be through some programs that we've initiated in our department, like our LEAD program which stands for Law Enforcement Alternative Diversion Program where we catch people sometimes with low levels of drugs and we offer them a program rather than putting them into the judicial system

It is this type of collaboration that I think will help us to break the cycle of overdoses and addiction and help us as a community – I don't want to be the bad guy but generally that is my role (laughing) Unfortunately the buffet has too many items that's off the line, if you will And that is that the population that we're charging have been charged to engage here Such as those who've entered ED as a result of overdose leave without the essentials to stay safe that they may have had prior to that initially

Now what I'm saying is, we have to understand, we hear a lot about recovery but we have to respect an individuals right to use drugs and understand that drugs meet the needs of individuals on different levels But you know, and we're not always, as we engage people in these settings at their most critical But not everybody operates on that end of the spectrum So we have to have services, we have to have things available when you talk about meeting people where they're at You have to be able to meet people where they are

So what I'm saying is, upon release from the ED why is Naloxone not given to an individual? Not prescribed, why is it not put in their hand? An individual who may be an intravenous drug user, why can we not really simply make up a care package, if you would, instead of just giving them that sheet of paper upon discharge saying call me if you want to talk Because at that point a person who is suffering from opioid use disorder knows one thing, that they might be sick at that moment and they don't want to be sick So why do we not make sure they have the tools necessary to keep them safe? Because nobody plans on overdosing It's just a result of how the drug supply has been, you know, permeated by other substances such as Fentanyl that we talk about There are a lot of things we can do when we talk about public health responses that aren't popular

That they are public health responses We have to begin to talk about SIFs We're not talking about SIFs You know, and I'm sure- – What's SIF? (laughing) – Oh, I apologize (laughing) Safe Injection Facilities

The most popular, and there are probably a hundred of these globally and millions of people have visited them, the most popular being Insight, up in Vancouver, British Columbia here in North America have been in operation since, I believe around 2003 They've had millions of people come through their door They've had thousands of overdoses and not one fatality And connected to Insight, is on-site So as a result of these types of harm reduction approaches there's a natural, there's an organic handoff because of, and again how we engage individuals without any type of cookie cutter response, to really work with the individual and we're able to organically make referrals that sometimes others don't

And so therefore we have to have relationships at a different level as well because when we kick a door, we don't, a lot of times people it's about operating in that moment So some of the things we have to do and this goes back to the other also, are we're in the midst of an epidemic just unlike anything this generation has experienced But we've really yet to change a lot of our operational methods So you know, we have to some things that are really not popular and respond in a public health manner – So I think, when you're talking about you know, collaboration that there's the relational piece which often times include leaders and different organizations and different institutions then I also think you have leader those same institutions that actually share

They share information, they share data Or they work collectively on policies you know, that make things better A couple of observations, one of the issues that occurred maybe on the green is when we had some of our first responders there they actually recognize that a person actually felt appropriate after about 20 or 30 minutes of having them taking Bunavail, Zubsolv and yet they could not discharge that person home You know for first responders they are required by state policy that they not assume have that person go to the hospital even though they know that in this particular maybe instance that this person's probably fine And so that from a policy perspective, that actually inhibits and, if you will, it draws down a lot of resources

And about, we had multiple events that were going on in different areas through the city, we pressed hard to begin to respond to that From the data, maybe sharing piece we were fortunate that the Connecticut Department of Public Health you know, has a symptom surveillance system that we were able to see The problem with that surveillance system is that we can't actually see any individual in that database who is not a resident of New Haven And so we were thinking about the multiple folks who actually came from outside the community as we look at that data set itself We wouldn't be able to see those individuals who actually were coming into New Haven

So I think when you were talking about having true collaboration I think also has to include sharing data between different organizations locally, but also from a multitude of state perspective – So I echo everything you guys have said thus far I mean collaboration is really important as far as figuring out how we can get people the services and meet them where they are One of the things that I actually realized kind of sitting up here that I really love is the fact that actually, we actually have Naloxone in our emergency department that we actually are able to send people home with And in part, I've gotten Naloxone from Mark and actually from the State Department of Public Health

And so you know, that is something that we've been doing since August of 2016 and I think it's been a really important service for us to do offer to our patients And one of the things I like about it is it's really part of a continuum of services that we're able to offer Our emergency department has had a private cohort who just served since 1999 and essentially the idea is we have health promotion advocates who are people who are from our community who have expertise in motivational interviewing with meeting, with talking to patients, communicating with patients and providers and they kind of are much like what TJ was saying, they have connections to all of, kind of our level of treatment resources throughout New Haven and really around the state And so they're able to, ideally you would have an oversee physician or clinician you know, that starts the conversation that you were able to work as a team to reiterate the importance of meeting people where they are, getting them what they need and if it's treatment, that is amazing A lot of times it's not treatment and I think there's a lot of road for communicating the information that we hear and we know even if it's not necessarily, people don't walk out the door and say, yes sign me up for treatment today

It's important that they hear the things that we know from our data sets and our public health colleagues that you know, about the evidence for certain treatments and about Naloxone, even if you can get that message across you know it's important to communicate that The other thing I wanted to say is that we have, well I guess it's actually a continuation which is, one of the things that helps reduce stigma associated both with drug use, with seeking help for drug use, and with accessing harm reduction techniques which are really important for meeting people where they are We know that if you walk up to somebody and say, don't use drugs, that is not a conversation starter But one of the things I'm really grateful for is you know, how can I help you today? Do you know about Naloxone? Is this, can we talk about a way to help keep you safe until you're ready to enter treatment? These are the questions that I think are really able to help us make improvements at least in a clinical perspective The other thing is from a kind of coordination is really working collaboratively with Department of Public Health, with other state agencies around Medical Examiners Office, criminal justice system, around how can we know what's going on in other areas and how can we really help understand what's happening with this, with these overdoses and these deaths in our community? And I'm gonna let Robert talk a little bit more about that

– Yeah, in the spring of 2016 we were invited by the governor to come up with a plan for the state and how to respond to lowering the number of overdose deaths Our team, involving people from medicine, emergency department, school, public health, came up with a comprehensive plan One of the key parts of it was to get the state agencies to collaborate and share data That's been about the least successful part of our plan We can't get one state agency to share data with others

Not even, not only share data with us So this is a consistent problem that we're gonna have to fix if we're gonna have any impact on trying to understand the full scope of the problem and how we can effectively respond to it But I want to point out more broadly that when we're talking about substance use disorders and opiate use disorders, we are talking about a chronic and treatable disease Like most other chronic diseases, if you don't treat it, it does not get better The difference I think with opiate use disorders and some of the other use disorders is that people do, if they can live long enough, get better on their own

Recovery, abstinence is a possible thing but for most people, until that happens, and that's a life-long process, treatment for opiates with agonus medications is key to their survival Abstinence does not work in the short-run for people diagnosed with opiate use disorders So we have to do two things for people like that We have to expand opportunities for getting opiate agonist for treatment for their disorder and we need to provide them with Naloxone and training and how to use it and how to respond to witnessed overdoses for responding to the emergencies when the treatment itself is insufficient – So just because of time I've won't be calling three of you for this pair and then the other three of you for the final pair

And it's just time, otherwise I'd want to hear from each and every one of you So the questions are, what challenges does New Haven experience that may be different from those of other places? And I should've said this is gonna be for Dr Kennedy, Mark Jenkins and Professor Heimer And are there differences in responses to drug overdoses in different parts of the country? Differences in experiences and responses to those experiences? So what challenges do we have that may be different from other places? And what experiences from elsewhere that we can apply here? So it'll be Dr Kennedy, Professor Heimer and Mark Jenkins

– I think one of the things that's unique, this you know challenge always do within public health, resources always come up When you're talking about resources we've heard a couple of them, one being just Narcan and having the availability of that We were first in to both, a couple weeks ago some of them available when we actually had some of our spikes up in the State Department of Health So it was huge being able to put that into the hand of our first responders and then to coordinate that And then also we were enrolled to do some sort of just training and do some distribution, not only within our staff but also some of the community providers

When you talk to some of the other agencies that are on the green, you know they may take approaches where they are still prescribing it but just instead you can actually just hand it out We've actually had that mentioned several times today, is it's easier just to put it in somebody's hand rather than just writing a scrip And so I think being able to have more of a access to that where you don't have to be a clinician to have to go through a separate training And I also do think too, that one of the challenges when moving about would perhaps in the state of Connecticut that New Haven is I think a desirable place to live and as a result of that it actually can may be a magnet for folks who want to come here because we have so many resources, we have so many assets and so whether they're coming here for school, coming here for work, people coming here just to spend the day but also means to have other folks who come here for other things, including what actually happened a couple weeks ago So anything you being able to kind of address the resource piece but also people that's from the high demand that comes in from the outside

And then coordinating some of the resources that we actually do here, do a better job of that – Alright, thank you professor – From my point of view I think the biggest challenge in New Haven is that no good deed goes unpunished (laughing) We have a treatment program in New Haven, The OUT Foundation that has expanded its services, it's reach, with a very effective model of providing opiate agonus care And in doing so, by bringing in more people for treatment they have been criticized and called the root of the problem when in fact opiate agonus treatment is the solution for opiate use disorder

Their treatment model is a very broad harm reductionist base one where people get the kinds of services they need and want instead of being forced to manual services to chase people away from services They are providing in-house treatment for people co-infected with hepatitis-C, they're doing a really good job on training people on responding to opioid overdose and yet the mayor of this town insists on trying to denigrate what good they've done and that is a real shame and that is a real challenge How are we gonna get a more, a better understanding into the head of the mayor that this expansion services that having more people in treatment is better than fewer people in treatment – Alright, Mark Jenkins – Again, I don't want to offend anyone but you have Yale, and you have New Haven

The two don't always necessarily go together So from a community based organization standpoint a lot of them can't stand you Because they can't get around you You know? So it's not about silo, it's about a castle that gets all the services and has all the resources and you have agencies who really are versed with dealing with particular segments of the population that can't receive the funding to possibly carry out that mission So from the outside looking in it's not unlike other areas and organizations

(sigh) You know, there's been a lot of suggestions since the incidents on the green and ideas, things like dropping center I know just came out of someone who does a lot of work on the green through Cornell Scott It is hill health, right? Something that we've just done at Hartford this past Friday on international overdose awareness day we opened up our first harm reduction dropping center So it's really a low threshold attempt and we did it right in a hard population which has its own set of challenges but the idea is to really be able to reach people in their environment, in their space and time And to offer some match services and match traditional hours, evenings and weekends and offer a set of tools that have value to them which in turn helps to build relation And we work very closely, as a matter of fact we wouldn't exist without DPH and I'll shout out Marianne Buchelli who's here with us today because she's done so much to make sure that this medication, Naloxone, has- (laughing) (talking at once) – Yeah, we see you

Okay thank you – A lot of this wouldn't take place or even, I mean when I tell you they've had to take a lot of heat because of the shit I've done And tried to make sure because, to make sure that this medication and these services are delivered into the hands of the people who need them most, when they need them and that could mean anything from syringe exchange, we do it all, safe sex kits, you know we make sure that in the inner city we've got Magnum condoms, you know and they say, why Magnums? Because everybody has big egos (laughing) You know, so there is but they also have clarity that everything we do there is a reason Everything is about reducing barriers

It's about reducing barriers and access to other avenues of care And it's really just about keeping people alive – Good, thank you Oh, as it is – Yeah, just let me just leave it briefly after maybe after Marianne, she's important on reductive strategies cause I think part of the idea is thinking about for some of our own clinics and actually overall there's better ways to actually sort of leverage sort of direction we, which we post even attend to in the best way

– Alright, so another block of questions and this will be for Dr Hawk and TJ Aitken and Chief Campbel So what public health community or government effort do you feel has made the biggest impact on reducing overdoses and why? And then how can we expand on this? And then a related question, if you had limited funds how would you appropriate them to address the question of the issue In other words, where should the bulk of efforts be placed? And examples are education, criminal justice, recovery programs, medications to treatment harm reduction, so the related question is, what do you think has made the biggest impact and then, given limited funds where would you put the bulk of your energy, so I think you have a microphone so Chief Campbel you can go first, then we'll go to TJ Aitken and we'll give Dr Hawk the last word

– So if I had, is it limited funds, or unlimited? – Well it's gonna be limited funds The question reads unlimited funds and then the answer is a little less interesting so we're gonna do you have limited funds – So with limited funds I think one great thing about having limited funds is it forces you to pull more collaboration And I think to echo what Dr Kennedy was saying, one of the things sitting down with the mayor talking about these overdoses, both a couple years ago and this year, is talk about greater collaboration

I think that the greatest change that I've seen has come about through education We're educating along the lines of how Narcan and Naloxone can be extremely helpful, about access to it Both educating law enforcement, first responders and the larger public I think there needs to be a lot more education I think that education helps with the de-stigmatization

When people feel like it's an issue like a person having asthma or diabetes versus something that is to be put in the shadows, I think then more people can openly talk about it and that education helps with it So I would say I would use those funds for a greater education, and not simply educating the public, but educating the different silos on how to better communicate, how to better have the harm prevention programs directly address clientele who may not be responding Maybe some recovery services can be applied Everyone's trying to do the right thing I believe that the hearts of everyone involved are sincere and they're looking to really save lives

But I think that sometimes we're reinventing the wheel Sometimes I think that could have great traction like many of the programs you mentioned are not getting the traction that they need I think a lot of times our egos and our arrogance as Americans gets in our way because there are a lot of models and programs that internationally we could adopt and I believe save lives But that requires a great deal of humility New Haven is a city on a hill and I see that what we're doing, including today's discussion is something that is different than what I see happen around the country

There are a lot of places that this would not happen because they won't want to talk about the reality that this is effecting, not just in abin and large cities but this is a national epidemic Any other country that has five, six percent of the world's population that at some point we've used 90 to 95% of the world's manufactured opioids, how is that not a national epidemic? We're getting it, a little more under control We've seen productions from the pharmaceutical standpoint of public safe given out on 16, 17% but it needs to be much higher than that So I would say much more education and more communication between the silos entity – Thank you

So if I had limited funds, the main thing with that, my thought process in that aside from the diversification, I'm definitely for harm reduction and I'm definitely for medication assisted treatment recovery One of the main things I think about though, so everybody's recovery process being different right? Like, abstinence based recovery's the only thing that worked for me But that's not what works for everybody and finding that, and you know obviously I didn't get in people's sober business, I got in the keeping people alive business too One of the main kind of things I was thinking too when we were going around, I hear this word stigma, and I hear this word stigma and like, it's like stigma, the big blue elephant in the room that everybody's talking about, right? So if I asked everybody in this room, whatever you're doing, stop right now and whatever you do do not imagine a big blue elephant, what was the first thing you thought of? A big blue elephant right? Me too So it's like being like a racial slur kind of thing

The more we say these words, the more power we give to them The more we say drug addict, the more power give that word The media can portray a lot of things, we see a lot of things like the opiate crisis, da, da, da, you know like, also I kinda wanted to jump into this other idea in like when we promote recovery and advocate for recovery it in turn creates prevention and in turn creates education So I was raised by my father and my brother who were then relapsing on opiates was then I felt, I used him in my research to help get him into treatment, my younger brother who is a recovering opioid addict as well that has been in recovery for 18 months and I used my research to help him but what we do in recovery is we create leaders and what's the main quality of having a leader in recovery is you create other leaders My younger brother who use to look up to what I had in recovery, now is a leader in recovery in the young people's recovery community

It doesn't discriminate between race, class, sex, or affiliations, it doesn't really matter It's effecting everybody It's effecting our young people, it's effecting old people, it's effecting loved ones I heard somebody talk kind of about sharing data right? We openly share data with just about everybody who asks for data kind of One of the main things in June we had, in June we had seen approximately 1500 people in the emergency rooms

We've connected 97% to care 97% to some form of care or outside support, whatever that may be So that's like the kinda like the main thing If I had the limited funds you know personally I think community centers are a great thing, whatever form of community center they may be and we meet people where they're at and stuff like that is definitely important Recovery coaching treatment you know obviously, it could really go on and on but the main thing about unlimited funds is the first equivocation of set of funds

– Great thanks, and so actually kind of following on that note is one of the things that hasn't really come up today is insurance and the ability to access recovery and so I would actually say one of the biggest things that the government has done around, not necessarily preventing the overdoses from worsening but I think medicaid expansion is huge And I think the ability for people to, not just in Connecticut, but across the country to have insurance to access treatment whether it be opiate agonus treatment, which we're lucky enough in New Haven to have programs that do provide sliding scale but that is not the case in other parts of the country And whether it's for that or in-patient treatment or for other services, for psycho-therapy, for intensive out-patient treatment, insurance is really unfortunately an important part of being able to access that So I think that's an important thing that has not come up yet today As far as if I had unlimited funds, I think expanding access to treatment, the criminal justice system hasn't really come up with that much today and I think we have a group of individuals that we know have an extraordinarily high rate of opiate use disorder who have an extraordinarily high rate of overdose and death upon release and Dr

Maur who is on the front row, I just want to point her out, she's been doing really amazing work as far as trying to really bring recovery to our high risk populations (applaud)

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