Interview with Tom Coderre

Tom Coderre is the Interim Departmental Director at the Rhode Island Dept of Behavioral Healthcare, Development Disabilities and Hospitals. This interview was conducted on September 4, 2018.

So to start off, if you could give us just a brief overview of your role and the work that you do that pertains to the opioid crisis. That would be helpful.

Sure. So my name's Tom Coderre, I am a Senior Advisor to Governor Gina Raimondo in Rhode Island. My role in the governor's office is to help coordinate the state's response to the opioid crisis, and I have other roles that I am responsible for as well, but that's the role I think you want to speak about. In that role, I am a co-chair of the governor's Overdose Prevention and Intervention Task Force, along with my colleagues Dr. Alexander Scott, who is the director of the Department of Health, and Rebecca Boss, who is the director of the Department of Behavioral Health, Developmental Disabilities and Hospitals. So the three of us together manage the work of the task force, which is a very large group of maybe 50-60 people who represent all facets of our community -  from people in government, for people in healthcare sector, manage CARE organizations, hospitals, preventionists, treatment professionals, recovery support professionals, people in recovery themselves. Really, a wide variety of people who care about getting our arms around the overdose epidemic in Rhode Island.

Ok. How long have you been in this role?

I started in this role at the end of January of this year of 2018. Prior to that, I was in Washington DC. I worked as a Senior Advisor and Chief of Staff at the Substance Abuse and Mental Health Services in the previous administration, in the Obama administration. I stayed in Washington a little bit after the end of the administration to do some work at a nonprofit called the Altarum Institute and then got a call from the Governor asking if I would like to come home and help in this effort. She really wanted to bring somebody into Overdose Task Force that had been established back in 2015 when she became governor through executive order. They had a strategic plan, they were doing amazing work, but she really felt like having somebody directly inside the governor's office helping to coordinate all the different pieces - there's a lot of moving parts, this is a multidimensional problem, so the solution needs to better require our multitask and multidimensionals. So she really wanted somebody inside her office that could remember: One, Look at the people who are at the table, can make sure everybody who is that the table is contributing everything they could, and then she also wanted to make sure if there was anybody missing from the table that we used the built-in power of the governor's office to reach out and get them to the table, saying "Hey what can you do, what do you bring to this effort?"

So, you say that you have your new experience, you can look at things from the state perspective but also from the federal perspective from your time at SAMHSA. I guess it would be helpful for the audience if you talked a little bit about SAMHSA, like what it stands for.

Well, SAMHSA is the Substance Abuse and Mental Health Services Administration. It is several operating divisions of the United States Department of Health and Human Services. It's the one that is charged with creating more opportunities people with behavioral health challenges in our country. When I say behavioral health, I'm talking about mental health and substance use disorders. The agency manages two huge federal block grants, and block grants are money that directly goes to the states. Congress in its infinite wisdom, believes that decisions about how to spend that money are best done at the local level, but obviously you need a federal entity to oversee the distribution of those funds, and to make sure that they're being dispersed in a way according to federal law and regulation. So, SAMHSA oversees the substance abuse and prevention treatment block grant as well as the mental health block grant that makes up about two-thirds of SAMHSA's budget. The other third of SAMHSA's budget goes to administering the agency and also a discretionary grant portfolio that they have where they really try to take promising practices and through a series of change builds them into evidence-based practices. Things that then can be widely adopted at the state community level.

 

I know that in the US part of the national conversation is a concern that there are not enough mental health resources, in part because of stigma and a lack of professions allocated resources. For your perspective at SAMHSA, what did you see there and what was your view?

Yeah, it's a complicated question, Jamal. I think what happened is clearly there are negative public attitudes that exist around people who have variable health challenges, there's no question about it. Somebody who has a mental health disorder or substance use disorder - certainly, people look at them differently. As a result, public policies don't live up to what they should for those individuals to make sure that they get the help that they need when they need it. Early on, so their diseases don't get continue to get worse and those individuals and their families continue to suffer. So that is definitely a big part of working in this field, you notice right away that these negative public attitudes exist and they lead to discriminatory public policies. Whether it be lack of funding to support that are necessary whether it's insurance coverage, which depending on your carrier, your conditions may or may not be covered or you may pay significantly more in copays or deductibles for those types of services. You know you also have discriminatory public policies in housing, education, and employment. So that people with these disorders, once they find recovery from their disorder can't always find a place to live, can't always get an education or job-training skills that they need, or meaningful employment, or career advancement. Those are things that we work on at the state level and I worked on when I was at SAMHSA because clearly that's what gets to the heart of what we need to do in this country, is to remove those negative public attitudes so that we can stop the discriminatory public policies that are preventing people from finding or sustaining their recovery for the long term.

In your current role in the opioid task force, what was the most memorable experience that you had, whether it was something that you observed or something that you heard someone say that stuck with you?

Another great question. I've heard so many amazing stories of resilience and recovery from my friends and colleagues in the field as well as everyday people that I've met on this journey. I guess to date, though just in the last couple of months, I think that the most memorable moment for me was attending the opening of a new opening recovery center in Bristol, Rhode Island. If you know anything about Bristol, Rhode Island, but it is the home of the longest running Fourth of July parade in the country. It has a very historic nature, very patriotic town, and it has a street that goes right through the center of it. It's called Hope Street and this is where they wanted to open the recovery center. So working with the health equity zone in that town and they opened a recovery center on hope street, and what could be more memorable or meaningful to have a recovery center on hope street that provides hope that recovery is possible for everyone. When I attended that ceremony, a young man was asked to speak and to give his impressions of why opening this center was so important. He had actually been struggling with addiction himself and went to the center as it was getting started and that's where he started his journey. He talked about how meaningful it was for him to have a place in the community that he could walk into and sit across another individual. Typically, these individuals have lived experiences that you're sitting across from, somebody who's been through a battle themselves. To sit across from that individual and have them share their story with him and say "You know what, I was sitting in that same seat where you are. I know that recovery is possible for everyone. I know it's possible for you to do this. Follow me, I'm going to show you the way." This young man's life, at that moment, turned from so hopeless to hopeful at the recovery center on Hope Street, Bristol.

Wow. Was there anything that you came across in the course of your work that changed your perspective on the crisis or made you see it from a different angle?

I'm a person in long term recovery myself. That's one of the reasons I got involved in this work back in 2003, when I was struggling with my addiction to alcohol or other drugs. I was able to get access to the help that I needed. I got access to long term residential substance use disorder treatment and that started me on my journey. So as I'm doing this work today, I still have the same passion I think, on a day-to-day basis, because of my own personal recovery. I want others to be able find what I found. That was back in 2003 when I got into recovery, so for 15 years, I've been on this journey now and I've had so many amazing things happen to me in this process. I told you I got to go to Washington and be a presidential appointee at a federal agency. That's something that I could never could have imagined, back in 2003, when I was struggling with my own addiction. So I think the things that I see in the way I approach this, I do it through a very personal lens. I think the biggest thing that surprised is, especially when I was at SAMHSA, I would go into these meetings with people that had more letters after their names than I thought existed in the alphabet. They had doctorate after doctorate after doctorate and special certificates and special certifications. It was pretty overwhelming. But I would sit at that table and they would turn to me and say "Well, what do you think Tom?" As I would tell them what I thought, you could hear a pin drop in the room. Everyone listened so intensely. I think it was because, again having the perspective with someone with lived experience, I think it was what made all the difference in the world. It really informed a lot of the policy-making and decision making that took place as a result of that. So, I'm an advocate always to make sure we include people with lived experience around any public policy table where any decisions are being made. The mental health movement, a long time ago, said "Nothing about us without us." I think the addiction recovery movement is doing the same thing now. I think that's important that we're helping to inform these policies that are being made.

That's a great quote, "Nothing about us without us".

Isn't it?

Yeah.

I think we think that whatever field we might be a professional in, we think we have the training, and the skills, the experience to craft the right solution.  Secretly, we do, we have a lot of the pieces to do that. But if you have someone who's been through it, who's gone through the battle and got to the other side. There's a lot of wisdom in that experience, so listening to it, and making sure that it's part of the discussion. Because someone who's been through it can look at something and say "I can tell you that's not gonna work. You might wanna try it this way because of X, Y, and Z reason why that won't work. They see it from their lens, they've been out there and experienced it on the front lines.

Right. So now that the different modalities of treatment, the rehab centers that have sort of a cold turkey abstinence-only approach, group counseling like Narcotics Anonymous, or Medication Assisted Treatment like Methadone or Buprenorphine, in your view, I guess, what are the certain pros and cons of each and how should they be viewed?

Interesting question. I really believe that there's something to the fact that the best treatment for an individual is the one they're willing to engage in. You know, I think we need to do a better job of assessing people and helping them understand what their diagnosis is. If they have a mild or moderate or severe substance use disorder, we need to let them know that and then we let them know let them know what their options are for treatment for it. Same thing on the mental health side. If we know somebody has Bipolar disorder, we let them know what kind of Bipolar Disorder they have, how severe it is, what kinds of treatments are available. On the mental health side, it seems like we are further advanced on the types of medicine that are available. On the addiction side, there's not a lot options. You have the options that you indicated.  You can have somebody who goes through some type of 12-step based therapeutic program, some type of Medication Assisted Treatment, there's faith-based options for people. It's fairly limited. There's lots of pathways to recovery, but really, if somebody's not willing to engage in it - this is a disease where there's a lot of personal choice and will require somebody to do a lot of self-introspection. If they're not willing to do that work, there's gonna kind of exclude them for a particular treatment or another one. I'll give you an example - we have a program here in Rhode Island we've been doing now for the last year, at our Department of Corrections. I don't know if you've heard about it, but we're offering Medication Assisted Treatment to anybody who's in the Department of Corrections. This is something that's been done around the country but the reason our program's different is because we're giving people choice. There are 3 FDA-approved medications to treat opioid use disorder. What we saw is that lots of folks were coming out of our Department of Corrections, they were being discharged, and they were overdosing. So, getting those folks on Medication Assisted Treatment while they're in the Department of Corrections system is super important. Because when they get out, you want them to be able to immediately be connected to a provider to continue their Medication Assisted Treatment. The last thing you want them doing is having a recurrence, what' s often called a relapse, and not having the tolerance that they once had, or getting some type of synthetic opioid mixed in with the other opioids they're taking, which are far more potent, like fentanyl, and then experiencing an overdose. So we ask people what medication of the 3 medications do you want, and we give them the choice to take which one they will take. The doctor at the Department of Corrections, she's the one that I picked up that statement up from, that the best type treatment for somebody is the one they're willing to engage in. Because that's what her philosophy is. If I only offer Methadone and somebody wants Buprenorphine, they're not gonna stay true to their treatment, and they're not gonna stay true to their treatment, and they're not gonna stay on it when they leave the Department of Corrections custody. So, if somebody wants to be on naltrexone, which is a - I don't want to get too much into the chemical makeup of the different medications - some are partial agonists, and some are antagonists, so they appeal to different people in different ways. So, you really need to work with the patient to make sure that they have the kinds of treatments they're willing to engage in post-incarceration. When you do, you have amazing results. Our DOC program just underwent a study - and guess what? Since we  started giving those patients that choice, we reduced overdose deaths by those being discharged by 61%. It's an amazing statistic, right? Just by offering that kind of choice, and also making sure that they have not a warm hand-off, not a referral to a treatment provider when they leave. But a hot hand-off: a direct connection, a ride to that provider when they leave, safe housing when they leaving, a safe ride to that house. So these are the kinds of things that we're doing that because we noticed from not doing them what the results were. We were not having the kinds of outcomes we've wanted. So, making small tweaks to our programs, we've increased our outcomes significantly.

 

Seems like this is sort of a holistic approach that focuses on medicating medical risk factors that could lead someone to use again and be at risk of overdose.

Exactly, Jamal. This is being done elsewhere in healthcare, where you're seeing community health workers attached to doctor's offices, for helping patients mitigate those risks as well. So, if you've got a patients who you know they didn't pick up their prescriptions after they left you, and you follow up or help them get to the pharmacy to get their prescription, or you have some type of home delivery done for them. It's all these little tools that we have at our disposal that really help improve the outcomes of that care that they're receiving and then their overall health. That's really what we want to see happen for people, that their overall health has improved.

From your perspective, what makes the opioid crisis different from previous substance abuse epidemics?

I think the thing that makes the opioid crisis different from other epidemics is how deadly it's been. You know, we have lost now - this is now the leading cause of accidental death in the United States - opioid overdose. I don't have the numbers right in front of me,  but we've lost like 70,000 people last year to this epidemic. Those numbers are staggering. We've lost more people now to opioid overdose than we lost in the entire Vietnam War. So, the numbers are staggering and the amount of death that we are seeing as a result of this epidemic is really what differentiates from other epidemics. Don't get me wrong, it has many of the qualities of other epidemics, right? The things that make something an epidemic, they don't change, and this certainly has all of those qualities as well. I think the deadly nature of it, and I think how rapid we saw it take hold in this country I think is another thing that makes it different. The third thing that I can say that makes it different, is it's changing little-by-little. It started out as over prescribing, an issue of over prescribing opioids by doctors. It moved to people being cut off those prescriptions because we realized that was the problem and we set up systems like Prescription Drug Monitoring Programs, PDMPs, which prevented people from shopping doctors, across state borders. We really were able to clamp down on the things that were happening. But that forced people then into the street, right, to find illicit substances. They were buying counterfeit pills, they were buying heroin on the street, and frequently these substances were cheaper, they were more available, and so the people got hooked on those. Then you saw it rapidly changed when synthetics were introduced into the market. Things like fentanyl, which came on the scene being shipped from China to Mexico and comes across the border frequently, is what we're told anyways, by our drug enforcement agency. That has changed the face of this epidemic even more, because now what is the size of a speck of salt can actually kill somebody. Something like that being dropped into a bag of heroin, added into a counterfeit Oxycontin pill, or having your cocaine laced with it, when you didn't expect it. These are the things that we're seeing nowadays, and so that's kind of how this has been changing.

I know that some regions of the country are trying out harm-reduction reduction policies such as supervised injection sites, or needle exchanges, what are your thoughts about those approaches?

 

I'm fully supportive of harm-reduction strategies to curb the epidemic. Listen, people are dying. As I already mentioned, the numbers are staggering. You can't help somebody find recovery if they're dead. You can't engage them if they're dead. We need to keep people alive. If harm-reduction strategies will help us do that, we need to consider them. Now, that being said, not all harm-reduction strategies are created equal. I understand that we have to build public support for these strategies, and we have to consider what the cultural barriers are to implementing them. We have to make sure we're doing it in a responsible way, and that harm-reduction strategy is a means to an end. It's a means to help engage people, reduce the harms, keep them alive, engage them into treatment ultimately, and help them find sustained recovery for the long term. Those kinds of harm-reduction strategies I can support. Here in Rhode Island, on August 31st - August 31st was International Overdose Awareness Day, so just a couple days ago, and we did a series of events here on Rhode Island, where we had remembrances for those who were lost in communities across our state. They were very, very moving events, mostly held in parks, with candles, and luminaries, and recovery quilts, which had the names of people who had been lost to the epidemic. We also gave out fentanyl test strips at these events, because that's one of the new up-and-coming harm-reduction strategies that are out there, that people who are actively using drugs need to know whether there's fentanyl contaminating their drug supply, so that they have that warning before they use those drugs that they could be lethal. The dose that they take could be lethal. These are things that are really worth exploring more. As far as something like syringe exchange programs, they've been around for a long time, and they've been here in rhode island for a long time. We have the evidence, we know that these programs help reduce the spread of infectious disease, and help the public health ultimately. So clearly there's a great amount of evidence to support that.

Given your personal experiences, what is the number one thing that you wish the public knew about individuals struggling with opioid use disorder or substance abuse disorder, who are trying to get on a sustainable path of recovery?

I think there's a lot of things folks need to know. There is great ignorance in our society at large about people who get addicted and develop dependencies to these drugs. I think the first things I would want them to know is that these are not bad people trying to get good. These are sick people trying to get well. Addiction is a disease and the American Medical Association told us that in the 1950's. We have lots of evidence around the neural biology of addiction, around prevention, treatment, recovery support services. There was an entire Surgeon General's report done in 2016 by Surgeon General Murthy called Facing Addiction in America, which has all the science you need to know about addiction contained within it. If you're somebody trying to find out what the truth is I think that's a great place to go. Speaking of truth, here in Rhode Island we are partnering with the Truth campaign nationally, who recently launched both television ads and digital adds around knowing the truth. Because we found that through doing some research that there was things about opioid use disorder that people didn't know. They didn't know the lengths that people would go to once they became dependent on opioids. They didn't know that it could happen to them. They didn't know that somebody could get addicted after a sports injury, going to a doctor, getting prescribed, and getting a legitimate prescription, and then end up getting addicted to that prescription. So I think I'd people to know those things and a whole lot more, but that would be a good start Jamal.

What role or responsibility do you think pharmaceutical companies like Purdue should have in the effort to alleviate the crisis?

It's tragic what the pharmaceutical companies are alleged to have done to create this crisis. Using false marketing, false claims, that the opioid products that they were selling were non addictive. To have aggressive marketing campaigns to doctors and other prescribers. To really push these products onto consumers in a way that was irresponsible. So, I believe pharmaceutical companies, manufacturers, distributors, they're all being sued right now by states. Our state has a cedant state court, many of our municipalities have signed on to the multidistrict litigation. It's being heard in federal court, and I believe that we'll see some type of judgement, whether it's a judgement by the court or a settlement that was similar to the tobacco settlement of a few decades ago where you saw how companies had to really take a hard look at their behaviors and then make restitution and be held responsible for the harm that they've cause and the impact that they've had on society. I think that will be decided in the court and I'm one person that thinks that they have a great responsibility to not only take care of the harm that they've caused, but go to great lengths to make sure that they never do anything like this ever again.

 

If someone gave you a magic wand that allowed you to change any policy at the state level, or at the federal level, in order to more effectively alleviate the crisis - which policy would you change?

A magic wand, huh?

Yes.

Do you have such a wand at your disposal?

Not currently.

I think I would - there's a lot of things I'd love to change, but I'm working with our governor to find ways to make sure that we have effective prevention treatment and recovery support programs here on Rhode Island. I think they need to be available on demand - and what does that mean? I think we're far under-resourcing  prevention, treatment, and recovery support. We don't pay for those things like we should, and therefore we can't get the results if we don't have the capacity in the system. On the prevention side, we know countries like Iceland who have implemented effective prevention programs across communities in Iceland and seen major reductions in use and substance use. Now the treatment side, if we offered treatment-on-demand, if we took care of all the waiting lists, and created more capacity in our system for people who are struggling, and made those resources available exactly when that person needed. We have this saying that there's a "window of willingness" where somebody reaches out and seeks treatment or help for their substance use disorder. That window is really short. The best time to help them is right now. So we have to offer that treatment on demand, and then we have to extend that treatment for in some cases, for years. This is a chronic condition, addiction is a chronic brain disease that has the potential for recurrence and long term recovery. So, if it is a chronic condition like we say it is, why are our treatment programs 30 days? 60 days? 90 days? You'd even be hard pressed to find one of those nowadays. But what we really need to do is to have access to the kinds of things I had access to, which is long term - I was in a treatment program for 5 and a half months. After that treatment program, I went to a recovery house where I spent 2 and a half years. I had wrap-around services, I had both psychiatric services, I had detoxification services, long-term residential substance use disorder treatment, and then recovery support programs. Even sober social activities. I went back to school, I got my bachelor's degree when I was in recovery. I started working again. I had my hope restored because I had the support that wrapped around me. If I had a magic wand, that's what I would do. I would make sure that we increased the level of capacity in our system to do the kinds of things we know are effective. That we know work, and that we know reduce substance use, help people recover from it, and sustain that recovery for the long term.

Great. I think that's all the prepared questions that I had. Were there any additional thoughts or ideas that you'd like to share?

I think we covered a lot of ground here. I really appreciate the opportunity to talk to you. I know what I was being held out as a model in some respects, of the work that's being done around the country. When I was at SAMHSA that made me very proud, as I traveled and heard people talk about the things that were happening in my home state, and I was really excited about it. Now that I'm back here working, it's great to see this continue to be a bipartisan issue in Washington. We're seeing a lot of great resources come into Rhode Island from the government, which is wonderful. We're working with managed CARE organizations here locally and nationally to make sure that we improve the standards that they have to make sure people get the help that they need when they need it. We have really, communities that are coming together. Our task force theme in 2018 is communities coming together, and we're seeing more and more communities want to be part of the solution. That's what it's going to take to really solve this addiction crisis that we have in our country. Make no mistake about it. Sure, you really hear a lot about opioids. As I said in our interview, the reason you're hearing a lot about them is because of the staggering statistics around death that have occured because of this epidemic. But we have an addiction crisis. We have a poly-substance use crisis in our country. Alcohol is still the most widely used and abused drug out there, that people continue to suffer from alcohol use disorder. We have problems with stimulants, as well as all the other drugs up and down the list. As one of my friends like to say, "From alcohol to Xanax. Everything in between. A to Z." We have an addiction crisis in this country, and the only way we're gonna to solve it is to improve our prevention treatment and recovery support programs.

Very well said. It's looking at a larger picture here, of not just opioids, but this is an issue that finds multiple kinds of substances that involve abuse disorders.

Absolutely. Opioids are getting the attention right now, but you remember when people were talking a lot more about - we went through the 80's, right, which was a crack cocaine epidemic at the time. You remember the amount of attention put on alcohol, particularly drunk driving. There was a period that we went through that. This opioid epidemic now is not much different than the heroin epidemic that we went through back in the 60's and 70's.