Office of the Vice-Mayor, Marc McGovern; City of Cambridge

Opioid Working Group Report:

Addressing the Opioid Epidemic in Cambridge

  1. Introduction

As a social worker for the past 25 years with children, I have never heard a child  say that when they grew up they wanted to be an addict. Yet despite other plans, far too many of our children become adults who struggle with addiction. Opioid addiction is ravaging our country and Cambridge is not immune. This killer doesn’t care about race, class, gender, religion, age or zip code. It crosses all demographics and kills without consideration.

This report grew out of a series of meetings held by the Human Services and Veteran’s Committee of the City Council, which I Chair. After our last meeting it was decided that a smaller group of nonprofit leaders, city employees, experts in the field, and community members would meet to author a report that would not only highlight the severity of this epidemic, outline the services currently available in Cambridge, but also offer a series of recommendations to guide the City Council and the City Administration on a plan to address this crisis.

I would like to thank everyone who participated in this work and for all the work they do everyday to support those in our community who are struggling with addiction. I would also like to thank my assistant, Jamila Bradley for all of her work making this report a reality.

Respectfully,

Marc McGovern

Vice-Mayor; City of Cambridge 

Contributors:


Claude Jacob

Cambridge Public Health Department

Ellen Semenoff

City of Cambridge

Mark Albanese

Cambridge Health Alliance


Mark McGovern

Cambridge Health Alliance

Matthew Nelson

Cambridge Police Department

Mary Kowalczuk

Cambridge Public Health Department


Megan Hynes

Needle Exchange Program


Natalia Schiller

Cambridge Public Health Department

Josefine Wendel

Cambridge Public Health Department

Kristin Ward

Cambridge Public Health Department

Louis Cherubino

Cambridge Police Department


Paula Wharton

Cambridge Public Health Department

Sabrina Voegelin

Cambridge Police Department

Steven Demarco

Cambridge Police Department

Table of Contents

  1. Executive Summary
  2. Introduction
  1. Opioid Morbidity and Mortality data: the current situation
  1. National & Statewide Trends
  2. The Cambridge Picture
  1. Cambridge partners and programs addressing the opioid crisis
  1. Opportunities and Recommendations for Local Leadership
  1. Increase public awareness and engagement.
  1. Disseminate current information online, through the website, social media, and press.
  2. Plan community events to educate residents about topics of interest and celebrate recovery.
  3. Develop a resource guide for families and those seeking treatment or assistance.
  4. Offer training about how to reduce opioid-related discrimination.
  1. Publicize the Good Samaritan Law.
  1. Expand the reach of the Department of Public Health’s “Make the Right Call” campaign.
  1. Designate a municipal point person or interdisciplinary committee on substance abuse prevention.
  2. Employ harm reduction models.
  3. Partner with schools to implement programs aimed at preventing the non-medical use of prescription drugs.
  1. Support the roll-out of Screening, Brief Intervention, and Referral to Treatment (SBIRT).
  2. Mandate education about non-medical use of prescription drugs for student athletes and their parents.
  1. Facilitate safe medication disposal for the discarding of prescription drugs.
  1. Install a second medication disposal kiosk.
  2. Promote medication disposal mailers to vulnerable populations.
  1. Make naloxone and overdose prevention education widely available.
  1. Schedule and promote monthly naloxone trainings that are open to the public.
  2. Promote purchasing naloxone at the pharmacy.
  3. Distribute naloxone kits to all city departments.
  1. Expand availability of medication-assisted treatment.
  2. Create a sobering center similar to SPOT in Boston.
  1. Conclusion
  2. Appendix
  1. September 2015 CPHD Report
  2. June 2017 Human Services Committee Report
  3. List of Cambridge Partners

II. Executive Summary

Opioid addiction is a complex disease that can devastate the lives of people who become users.  The disease also profoundly impacts family, friends, and the broader community. The following section describes the opioid situation in Cambridge and how the community is responding.

People who become addicted to prescription or street opioids come from all walks of life. Experts believe that the current crisis  is being fueled by the availability of prescription pain medications, which are highly addictive and a gateway drug to heroin.

Opioid addiction does not respect municipal boundaries. This is especially true in eastern Massachusetts with its densely populated, geographically compact communities. Cambridge, specifically, has a fluid population of students, commuters, and visitors. It is also a hub for people in the region seeking substance abuse treatment and support services, as well as homeless services.

The Cambridge Public Health Department works closely with city and community partners to raise awareness about the disease of addiction and to develop strategies for preventing opioid misuse and abuse, as well as preventing opioid-related overdoses and deaths.

City and community partners are taking a strategic approach to addressing the impact of the statewide opioid crisis on Cambridge. These efforts are focused on both “upstream” prevention—such as encouraging residents to safely store and dispose of prescription pain medications—to saving lives by expanding the availability of naloxone, a drug that reverses the effects of a heroin overdose.

Many organizations and groups are involved in the local opioid crisis response, including:

·         AIDS Action Committee (Needle Exchange and Overdose Prevention Program)

·         Cambridge Fire Department

·         Cambridge Health Alliance

·         Cambridge Police Department

·         Cambridge Public Health Department

        OPEN (Overdose Prevention & Education Network)

        Cambridge Prevention Coalition

·         Cambridge-Somerville Healthcare for the Homeless

·         CASPAR, Inc.

·         Eliot Community Human Services

·         Emergency Medical Services (Pro EMS, Cataldo EMS)

·         Institute for Health and Recovery

·         Learn to Cope

·         North Charles, Inc.

III. Introduction

        a.) Opioid Morbidity and Mortality Data: Current Situation

National Opioid Overdose Epidemic:  According to the American Society of Addiction Medicine,  drug overdose is the leading cause of accidental death in the US, with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015.  From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999; and the substance use disorder treatment admission rate in 2009 was six times the 1999 rate. 6  In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills. Four in five new heroin users started out misusing prescription painkillers. 94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.

The prevalence of opioid use disorder has reached epidemic status worldwide. This trend is particularly concerning in the United States, where approximately 25% of all worldwide opioid-related deaths occur. Locally, the proportion of opioid-related overdoses is also increasing significantly: as of August 2017, there were 1,990 opioid-related overdose deaths among Massachusetts residents confirmed in 2016, an increase of more than 200% since 2011.

Statewide Opioid Data:

Fentanyl: Legal and Illegal

Fentanyl is an opioid that can be prescribed for pain management. However, it’s also used illegally either on its own or combined with heroin, often without the user's knowledge. According to the DEA, illegally produced fentanyl can be up to 50 times more potent than heroin. Fentanyl is increasingly recognized as a problem across the United States, and particularly in Massachusetts. Toxicology data from recent post-mortem cases indicates fentanyl is adding to the state’s deadly epidemic more than heroin. In the first quarter of 2014, 41% of opioid-related deaths in Massachusetts tested positive for only heroin while 22% tested positive for only fentanyl. By the first quarter of 2016, those numbers flipped to 17% for only heroin and 50% for only fentanyl.


Young People

The fight to curb the opioid epidemic in Massachusetts is also a battle to protect future generations. The percentage of opioid-related deaths for different age groups shows the young people of Massachusetts are especially at risk. From 2013–2014, opioids accounted for more than a quarter of all fatalities in the 18–24 age group. For individuals from 25–34, opioids were responsible for more than a third of all deaths, rising to more than 40% for men in this group. In 2015, roughly two out of every three people who died from opioids were younger than 45.

a.       Opioid Morbidity and Mortality data: the current situation

i.      National & Statewide Trends

The state government began addressing the harm of opioids in 2004, when 456 Massachusetts residents died of an opioid overdose. By 2012, the rate of unintentional opioid overdose deaths among Massachusetts residents had reached a level previously unseen in the Commonwealth (see chart below from the Massachusetts Department of Public Health).

Screen Shot 2017-10-26 at 11.36.41 AM.png

Source: Massachusetts Department of Public Health. Data Brief: Opioid-Related Overdose Deaths Among Massachusetts Residents. August 2017. https://www.mass.gov/files/documents/2017/08/31/data-brief-overdose-deaths-aug-2017.pdf.

In March 2014, Governor Deval Patrick declared a public health emergency in Massachusetts in response to the growing opioid addiction epidemic. The Governor directed the Massachusetts Department of Public Health to take several action steps to combat overdoses, stop the crisis from getting worse, help those already addicted to recover, and map a long-term solution to ending widespread opioid abuse in the Commonwealth.

 

In early 2015, Governor Charlie Baker appointed an 18-member expert panel to develop recommendations to address the opioid crisis.  Recommendations from this group were released in June 2015, along with Governor Baker’s Action Plan to Address the Opioid Epidemic in the Commonwealth.

Screen Shot 2017-10-26 at 11.40.41 AM.png

Source: Massachusetts Department of Public Health. Data Brief: Opioid-Related Overdose Deaths Among Massachusetts Residents. August 2017. https://www.mass.gov/files/documents/2017/08/31/data-brief-overdose-deaths-aug-2017.pdf.

ii.      The Cambridge Picture

City and community partners offer a comprehensive range of services across the continuum of substance abuse care – prevention, intervention, treatment, and recovery support.  

Please note: The following section summarizes initiatives with which the Cambridge Public Health Department is directly involved, and does not capture the programs and activities of city and community partners.

Coordination, Coalition-Building and Data Collection

2015 City of Cambridge Community Health Improvement Plan

The Cambridge Public Health Department is facilitating the implementation of city’s first community health improvement plan (CHIP), which is setting the city’s health agenda through 2020. Mental and Behavioral Health and Substance Abuse is one of the four CHIP priority areas.  The CHIP outlines specific objectives for addressing opioid prevention and treatment over the next five years.

OPEN: Regional Coalition Around Opioid Prevention

The Cambridge Public Health Department is the lead agency for the four-city opioid coalition, known as OPEN (the Overdose Prevention and Education Network) that also includes the communities of Everett, Somerville, and Watertown. As the lead, CPHD coordinates regional and Cambridge-specific activities to raise awareness about prescription opioid safety and prevent overdoses. OPEN is funded by a federal grant awarded by the Massachusetts Department of Public Health.

Data Collection

The Cambridge Public Health Department has developed a local opioid overdose surveillance system to fill the gaps in information related to local demographics and geography. In 2016, staff designed a system for collecting and analyzing weekly data from Pro EMS, monthly data from Cambridge Health Alliance, and annual data from AIDS Action Committee’s Needle Exchange and Overdose Prevention Program. CPHD will begin generating formal data summary reports in late 2017.  

Treatment

1. Increase number of suboxone providers in Cambridge by funding trainings for any provider (MD, PA, NP) who works with patients with opioid use disorder

2. Work with emergency rooms to encourage buprenorphine induction and connection to providers or methadone induction and connection with methadone clinics.

3. Pilot a mobile bupe clinic

Current Landscape: Programs and Services

Cambridge Police Department: The Cambridge Police Department has evaluated many strategies to combat this illness and formulated a comprehensive strategy collaborating with community partners to reduce the number of overdoses in our community. The following goals have been assigned:

Detectives assigned to the Special Investigations Unit (SIU) along with a staff Licensed Social Worker (LCSW) provide outreach to both potential and actual victims through the use of geo-mapping. Areas within the city have been identified as a result of reports and occurrences of overdose. It is the goal of personnel to make contact with an individual or loved one who has indicated the need for assistance and/or with victims during two identified vulnerable times -- the seeking and craving stage and at the time of overdose. Patrol and/or detectives respond to all reports of overdose along with EMS. A follow-up is conducted either in the field or at the treatment facility to listen and assess needs. A resource sheet is provided to the victim and family to educate and create an awareness. Assistance is provided for after-care placement and treatment. Coaching is provided with follow-up contact by a Licensed Social Worker (LCSW) and detective. The intervention and Coaching services provide for; research of the victim’s history, safety risk assessment, motivational interviewing, treatment options, treatment planning, coordination of care and continuation of treatment referrals.

The Needle Exchange:

Services Offered: Syringe Access. Support/Counseling. Housing. Advocacy/Activism. Naloxone. HIV Testing. HCV Services. Drop-in for NEP clients.

The NEP offers a variety of services to injection drug users, including anonymous HIV counseling and testing, educational groups, an Overdose Prevention and Reversal Program including Narcan distribution, linkages to drug treatment programs, primary and mental health care and other support services. The NEP operates a drop-in center for members of the program where they serve coffee and small meals and provide a safe, comfortable space for people to relax. All NEP services are based in the harm reduction philosophy which encourages personal responsibility in a non-judgmental manner. Approximately 80 people come through their doors each week to exchange syringes and access services.

Recovery Coach Program: In late 2015 several agencies worked together to develop a recovery coach program to target High Utilizers of Emergency Services (HUES) within the city. The pilot is a multi-disciplinary effort conjoining the skills, infrastructure and expertise of public safety, public health and healthcare to provide unique and critical support to a select cohort of Cambridge’s highest utilizers of healthcare and social services, including those struggling with homelessness. A collaboration between myriad of Cambridge based partners and organizations led by steering committee comprised of the Cambridge Public Health Department, Cambridge Police Department, Cambridge Health Alliance and Pro EMS was organized to develop a program to provide these critical support services in a more coordinated manner.

Cambridge Public Health Department: The Cambridge Public Health Department is the lead agency for OPEN. OPEN is a regional collaborative aimed at reducing accidental opioid overdoses, and the misuse and abuse of prescription pain medications in Cambridge, Everett, Somerville, and Watertown. OPEN is working with residents and organizations, local hospitals, police, fire, and health departments in all four cities to raise awareness about prescription opioid safety and prevent fatal and non-fatal overdoses

The Cambridge Prevention Coalition uses a community-based approach for effecting policy, environmental, and social change around substance abuse, focusing on youth and families.
Its members include the Cambridge Public Health Department, the city's Department of Human Service Programs, the Cambridge Public Schools, the Cambridge Police Department, the Cambridge License Commission, drug and alcohol treatment providers, local universities, and emergency medical services. The Cambridge Prevention Coalition became a program of the Cambridge Public Health Department in 2013, relocating from the City’s Department of Human Service Programs. The Cambridge Prevention Coalition was established in the early 1990s.

Prevention

Opioid Crisis News & Events

OPEN shared timely information about opioid prevention, intervention, and treatment at community events and through its website, Twitter account, and e-newsletter.

Community-Level Prevention Strategy Session

OPEN organized and hosted the second annual Opioid Community Summit in May 2016 in which stakeholders from Cambridge, Everett, Somerville, and Watertown developed community-level strategies for prevention for the coming fiscal year.

Pharmacy Outreach

OPEN is doing outreach to community pharmacists to advocate for pharmacy-based naloxone distribution. They have visited every pharmacy in Cambridge at least once, and will be doing follow-up with pharmacists.

School Community:

Medication Disposal

Intervention

Business Community: Overdose Response Training

OPEN is collaborating with and the Cambridge Needle Exchange and Overdose Prevention Program (part of AIDS Action Committee) to offer overdose recognition and response training to Cambridge business owners. We are offering training opportunities to interested businesses with public bathrooms. The first open training has been scheduled for November 16th, 2017.

Bystander Intervention

Source: Massachusetts Department of Public Health. Number of Confirmed Unintentional/Undetermined Opioid-Related Overdose Deaths by City/Town, MA Residents January 2012 – December 2016. May 2017.

http://www.mass.gov/eohhs/docs/dph/stop-addiction/current-statistics/town-by-town-listings-may-2017.pdf

Recommendations for Local Leadership

1. Increase public awareness and engagement.

Recommendation #1: Disseminate current information online, through City website, social media, and press. 

Local leaders should work every day to disseminate information, enhance public awareness, and engage the community as a whole in a dialogue on the issue of substance abuse prevention.  By publicly recognizing victims and families and frequently publicizing municipal efforts, local leaders can become role models and encourage others to recognize the crisis in their communities.

Cambridge already utilizes many different communication channels to reach its residents - the city website, social media pages, press releases, posters and flyers, and advertisements, to name a few. These channels can also be leveraged to address substance use, increasing public awareness of the issue and what can be done to prevent and treat addiction.

Recommendation #2: Plan community events to educate residents about topics of interest and celebrate recovery.

Many communities are involved in planning events that address the issue of substance use. These can run the gamut from educational forums and documentary film screenings, to overdose vigils that commemorate those lost to the disease of addiction, to resource fairs for families whose loved ones have substance use disorder. These events reduce the stigma of substance abuse by providing a safe space and open dialogue for residents struggling with abuse as well as for family members and groups forming to support prevention and recovery efforts.

Recommendation #3: Develop a resource guide for families and those seeking treatment or assistance.

Both the Cambridge Police Department and Mt. Auburn Hospital have developed one-page resource guides for people looking for local treatment and recovery options (see appendix). These have proven useful for people unfamiliar with what resources exist in and around Cambridge, and could be professionally printed and distributed to target populations, as well as added to FindIt Cambridge.  

Recommendation #4: Offer training about how to reduce opioid-related discrimination.

The concept of opioid-related discrimination, also known as stigma, describes the powerful, negative perceptions commonly associated with substance abuse and addiction. Stigma has the potential to negatively affect a person’s self-esteem, damage relationships with loved ones, and prevent those suffering from addiction from accessing treatment.

The Cambridge Police Department currently offers a training during their in-service training period about how to reduce stigma during interaction with drug users. Expanding the scope of this training by offering it to all city departments, as well as other target populations, would help  people provide nonjudgmental, empathic support and create a culture of compassion. 

Recommendation #5: Create mandatory Opioid training module for parents of athletes, similar to existing module for concussions

The Massachusetts Interscholastic Athletic Association (MIAA) has released materials on the potential dangers of opioid use and misuse, created for parents of middle and high school athletes and other adults such as coaches, athletic directors, athletic trainers, and school nurses. In Cambridge, coaches review these materials with every team to ensure their understanding; materials are also emailed to athletes’ parents as part of the registration process.  Accessing authorized curricula and developing a training module that parents are required to complete would ensure that every parent gains a comprehensive understanding of prescription opioids, substance use disorders and the associated risks in order to make informed decisions to keep their children safe.

Recommendation #6: Engage people in recovery and current users in the conversation

2. Publicize the Good Samaritan Law.

Recommendation #1: Expand the reach of the Department of Public Health’s “Make the Right Call” campaign.

The MA Department of Public Health has recently released new materials for their awareness campaign, “Make the Right Call”. This statewide campaign stresses the importance of calling 911 if you see the signs of an overdose, and requesting naloxone from your pharmacist to be prepared for an emergency.

Campaign materials have been posted in high-risk areas, such as downtown Boston, but the state did not buy ad space in Cambridge. Promoting this message would be as simple as posting the campaign on bus shelters and garbage cans in high-trafficked areas, such as Central and Harvard Squares.

3. Designate a municipal point person or interdisciplinary committee on substance abuse prevention.

Recommendation #1: Create or appoint a municipal position or committee on substance abuse prevention: In the MMA’s municipal opioid response survey, many cities and towns indicated that they have designated a staff member to lead the municipality’s efforts to respond to the opioid crisis. The designees worked in a variety of departments, including health, police, human services, youth outreach and fire. In some cases, the board of selectmen or mayor serve in this capacity. Some communities created a new staff or department-level position to act as the municipal lead.

Medford created a new position in 2015, a “Prevention and Outreach Coordinator” in the city’s Health Department, to focus on prevention, intervention and treatment of substance use disorder.  This position works closely with the schools and other community organizations on primary prevention, as well as with police and fire departments to create systems for intervention and outreach.

Somerville created a Mayor’s Opioids Workgroup to stay on top of opioid use and fatal/non fatal overdose data in Somerville. The workgroup meets quarterly or ad hoc, and has representatives from Health and Human Services, police, fire, school, healthcare, and occasionally residents.  The workgroup makes recommendations based on best practices to the mayor and updates him on on-the-ground activities.

4. Employ harm reduction models.

Use of harm reduction strategies is a well-established public health approach to reducing negative consequences associated with legal and illegal substance use.  The primary aim of harm reduction is to reduce the adverse health, social and economic consequences of legal and illegal substance use. It can help reduce the impact of substance use for users by providing additional avenues into treatment and recovery, as well as reducing the “nuisance factor” for the community. Examples of evidence-based harm reduction strategies include methadone treatment and needle exchange programs.

Recent trends in Massachusetts and the U.S. in opioid and alcohol use and dependence, in combination with increasing homelessness and resulting public substance use, have contributed to the need to examine new models that help address this issue. Two options include sobering centers and supervised consumption facilities.

As defined by the American College of Emergency Physicians, a sobering center is “a facility that provides a safe and supportive environment for publicly intoxicated individuals – who are primarily uninsured, homeless, or marginally housed – to become sober.”  Sobering centers operate as an alternative to hospitals and jails in many communities.  However, there is no standard definition for what constitutes a sobering center.  

Supervised Consumption facilities (SCFs) are controlled health care settings where people can more safely inject drugs under clinical supervision and receive health care, counseling, and referrals to health and social services, including drug treatment.SCFs have been rigorously studied and found to reduce the spread of infectious disease, overdose deaths, and improperly discarded injection equipment, and to increase public order, access to drug treatment and other services, and to save taxpayer money. Contrary to popular misconception, SCFs have been found to not increase community drug use, initiation into injection drug use, or drug-related crime.

5. Partner with schools to implement programs aimed at preventing the non-medical use of prescription drugs.

Recommendation #1: Support the roll-out of Screening, Brief Intervention, and Referral to Treatment (SBIRT).

In March 2016, the Massachusetts Legislature passed bill House, No. 4056 which outlines the requirements for public schools in the Commonwealth to engage in substance use prevention and education. This school year, 7th and 9th graders in Cambridge Public Schools will be participating in Screening, Brief Intervention, and Referral to Treatment (SBIRT), a validated tool that enables screeners to detect risk for substance use-related problems and to address them at an early stage in adolescents.

Recommendation #2: Mandate education about non-medical use of prescription drugs for students athletes and their parents.

Teenagers benefit in many ways from participation in athletics and activities. Inherent with participation in these programs is the risk of injury. In rare cases, injuries may result in pain that is severe or long-lasting enough to require a prescription painkiller. When students are prescribed pain medication after an injury or surgery, they may receive opioids, which can be misused if not monitored carefully.

The Massachusetts Interscholastic Athletic Association (MIAA) has released materials on the potential dangers of opioid use and misuse, created for parents of middle and high school athletes and other adults such as coaches, athletic directors, athletic trainers, and school nurses. In Cambridge, coaches review these materials with every team to ensure their understanding; materials are also emailed to athletes’ parents as part of the registration process.

There is an opportunity to expand this athlete-focused opioid prevention education to the wider student population, who may also have been prescribed opioids after an injury or surgery. Currently, only the optional 10th grade health class includes units on Drug Misuse and Prescription Drugs. Including a unit in the mandatory 9th grade health class would go far towards educating students about prescription drug misuse. In addition to MIAA, Cambridge should collaborate with the Partnerships for Success grant, which aims to prevent prescription drug misuse and abuse among Cambridge high school students. Their goal is to educate parents and children about safe medication use, addiction risk factors, and the pathway from misuse to addiction. 

6. Facilitate safe medication disposal for the discarding of prescription drugs.

Proper disposal of unwanted medications helps protect the environment, prevent accidental poisonings, and reduce the likelihood that the drugs could be illegally sold or used by someone for whom they were not prescribed. The city currently offers residents several methods and venues for disposing of prescription drugs and other medications at no cost in a safe and environmentally-friendly manner, including a permanent disposal kiosk in the lobby of the Police Department that is available 24/7 and four Hazardous Waste Days per year. Unused medications are collected and taken to an incinerator for destruction by CPD personnel under the direction of a police officer. However, there are several ways to expand opportunities for medication disposal for residents.

Recommendation #1: Install a second medication disposal kiosk.

We recommend adding a second safe medical disposal site for prescription drugs and needles that opens by Spring 2018, with the goal of adding 3 more (total of 5) by spring 2020.

To become an authorized collector, a hospital, pharmacy, or other qualified entity must be a current DEA registrant for controlled substances. In addition, hospitals or clinics that wish to become authorized collectors must also have an on-site pharmacy, which could either be an inpatient pharmacy (not accessible to the public) or an outpatient pharmacy. At a hospital or clinic site, a collection receptacle must be located in an area regularly monitored by employees (e.g., an outpatient pharmacy or hospital lobby), as long as that area is not in close proximity to where emergency or urgent care is provided.

Installing a second disposal kiosk at an approved site, ideally serving the communities of mid- or west Cambridge, would double the number of permanent kiosks in the city. It would be more convenient for residents that cannot travel to east Cambridge or are not willing to visit the police department, making safe medication disposal easier and more likely. This new site would likely require technical assistance with paying for disposal.

Recommendation #2: Promote medication disposal mailers to vulnerable populations.

Residents can request a free, postage-paid mailer from the Cambridge Public Health Department to send unwanted prescription medicines, including Schedule II-V medications, to a company (Sharps Compliance, Inc.) that will dispose of them properly under U.S. Environmental Protection Agency license. Residents can obtain mailers by contacting the Cambridge Public Health Department at 617-665-3872 or emailing naschiller@challiance.org.

This service, offered free of charge by CPHD, is a great option for residents that are not able to drop off medications at a kiosk or hazardous waste day due to time or physical limitations. CPHD currently promotes this service to vulnerable populations through its communication channels, including social media and websites, but additional promotion through city channels would make sure that the message is getting through to the people that need it most.

Recommendation #3: Pilot a Citywide Free Lock-Box Program

Access to safe storage and disposal sites for prescription drugs is an important component for raising awareness around opioids and substance use disorders. Offering Cambridge residents a free lock box, in addition to information about prescription drugs and substance use disorders acts as a tangible tool with practical ramifications aimed at prevention, education, and raising awareness about opioid use within households and communities.

7. Make naloxone and overdose prevention education widely available.

Naloxone (also known as Narcan) is a nasal spray that reverses opioid overdose when administered. Increasing everyone’s access to naloxone, and giving them the training to use it, is a highly effective intervention that reduces overdose deaths. We have three strategies that would increase naloxone knowledge and access in Cambridge.

Recommendation #1: Schedule and promote monthly naloxone trainings that are open to the public.

AIDS Action Committee’s Needle Exchange Program, located in Central Square, is one of the state’s pilot sites for the distribution of free naloxone to high-risk populations. They also employ a full-time Outreach Coordinator, who gives overdose prevention and response trainings to individuals and organizations that express interest.

Having scheduled, monthly naloxone trainings at a set location (e.g. the main library branch) would encourage more residents to become trained. A pre-determined schedule would be easy to plan, rather than the ad-hoc trainings currently available. A dedicated promotional strategy could significantly increase the number of residents that are trained in naloxone response.

Recommendation #2: Promote purchasing naloxone at the pharmacy.

There are two ways to access a naloxone rescue kit from a pharmacy:

  1.  Obtain a prescription from your prescriber and take it to a pharmacy that stocks naloxone.  Many pharmacies are able to fill naloxone prescriptions or can order what they need.

  2.  Go directly to a pharmacy with a naloxone standing order and request a naloxone kit.  For pharmacies with naloxone standing orders, a prescription is not needed. The customer’s insurance will be billed and a co-pay or full price will be charged depending on the insurance coverage.

Most of the pharmacies in Cambridge have a standing order for naloxone and stock it. Although prescribing best practices dictate that all high-risk patients should be co-prescribed naloxone with their high-dose opioid by a doctor, this is not always the case. Both patients with an opioid prescription, and people who have been trained to respond to an overdose, should feel empowered to purchase naloxone at their pharmacy.

Normalizing the purchase of naloxone at the pharmacy means both sides of the interaction need to feel comfortable; both pharmacist and patient should be encouraged to feel safe. We recommend working with both pharmacists and patients to normalize this transaction.

To this end, the Cambridge Public Health Department is reaching out to local pharmacies to advocate for pharmacy-based naloxone distribution. Although all pharmacies in Cambridge are legally allowed to dispense naloxone under a standing order, there continues to be confusion about how to implement the new law. The health department hopes that talking to pharmacists about barriers to implementation, and providing support and resources, will encourage them to be more comfortable with this complicated issue.

On the patient side, the state’s Public Health Department has designed a free postcard to help residents feel more comfortable requesting naloxone from their pharmacist (see inset). Making these cards available for residents at medical and other high-trafficked locations, and using the messaging developed for them to promote accessing naloxone at your pharmacy, will increase the number of kits in people’s hands in an overdose emergency.

Recommendation #3: Distribute naloxone kits to all city departments.

Certain city departments work with high-risk and vulnerable Cambridge populations every day. Although ProEMS, fire paramedics, and police officers are equipped with naloxone and are trained to respond to an emergency, every second counts during an overdose. We recommend that all interested city employees attend one of the monthly overdose prevention and response trainings, and that every department’s first aid kit be equipped with a naloxone kit. In this way, city employees will know what to do in the case of an emergency and have the tools to respond. Training city employees will also give a good example, and hopefully residents will follow suit.

Recommendation #4: Support program adaptivity and education regarding Safe Consumption Sites and the changing legislature

While currently illegal, overwhelming academic and clinical evidence makes clear that Safe Consumption/Injection sites are a proven and effective form of harm reduction. The appropriate municipal and related instrumentalities of the City of Cambridge should be in dialogue with officials at the county and state level to better understand the research, benefits and models that this form of harm reduction may have to offer in the current climate and scope of services.

8. Expand local options for treating substance use disorder.

Recommendation #1: Expand the availability of medication-assisted treatment.

City departments, emergency services, healthcare providers and substance use disorder treatment programs should vigorously continue its efforts to increase the provision of medication-assisted treatment (MAT) in all forms as standard practice, and facilitate referral and/or provision of MAT at multiple sites including emergency departments, halfway houses, outpatient practices, residential treatment facilities, psychiatric facilities, medical facilities, primary care sites and police departments. All consumers should be offered all options of treatment available to them, including all FDA-approved versions of MAT. Treatment programs should introduce these agents and offer both agonist and antagonist medications, within the treatment program. Integrating MAT into all treatment/healthcare settings will ease patients’ burden of navigating the complex treatment system. All barriers to the use of MAT should be identified and reduced. In addition, work with other systems and elected
officials to increase safe permanent supportive housing, recovery houses, vocational support, and recovery support services for individuals with substance use disorders, eliminate barriers to longer retention at treatment facilities, and eliminate housing discrimination against individuals enrolled in medication-assisted treatment and special populations.

Recommendation #2: Connect vulnerable populations to treatment.

The City should ensure that people experiencing nonfatal overdoses revived in the field or in emergency departments have unfettered access to services including dedicated centralized coordinators, peers, removal of financial/ insurance barriers until services can be identified, and use of MAT as bridge. Hospitals, shelters and health providers should create systems and protocols for warm handoffs from emergency departments to treatment providers. A lack of coordination in response to nonfatal overdoses places those needing help at risk of overdosing again or slipping through cracks and missing out on continued access to support and services. Individuals who are discharged from emergency medical care following an opioid overdose have an increased risk for repeat overdoses. MAT induction and care coordination in emergency departments would provide immediate access to treatment and resources. Emergency departments throughout the city should develop protocols to induct individuals on buprenorphine when clinically appropriate, and should explore the development of hospital based urgent care clinics to provide immediate access to individuals needing stabilization with the goal of connection to longer term treatments.

Recommendation #3: Expand Recovery Coach Programming through dedicated funding for staff and training

Per the Cambridge Recovery Coach Access Program model, clients will be identified by CHA Healthcare for the Homeless, the CHA Emergency Department, the Cambridge Police Department, and city’s partner EMS provider Pro EMS. These clients will be referred to the program to be connected with a Recovery Coach and focus will be on the highest users of emergency services (HUES) who are now seeking recovery services. A community based approach has been shown to be the most effective in assisting these individuals. These trained Recovery Coaches can connect with clients in the Cambridge Hospital Emergency Department, shelters, and other community locations, including the streets. The Recovery Coaches will assist clients and advocate on their behalf, leveraging the resources and support of community partners. The recovery coaches will maintain consistent contact with clients in an effort to keep them on track and help them navigate a complex system. Coaches work to assist clients with obtaining health insurance, identification, disability or veteran’s benefits, recovery services and transitional housing. In October 2015 eight recovery coaches, including six Pro EMS paramedics, were trained through the Connecticut Community for Addiction Recovery (CCAR) Recovery Coach Academy over five (5) days and completed Ethical Considerations for Recovery Coaching over two (2) days. These courses are widely recognized as the “gold standard” for Recovery Coach training. Supervision related to client interactions will be provided by a Cambridge Hospital Emergency Department RN experienced in substance abuse and behavioral issues who was also trained as a Recovery Coach. This team member will provide much needed experience and supervision to this new group as they continue to gain experience. Pro EMS has been providing administrative and financial support, resources and infrastructure as needed. The Cambridge Recovery Coach Project began in October 2015 and is currently functioning under the 501-C-3 METI project.

9.) Create a sobering center similar to SPOT

In response to the to the city’s increase in opioid overdoses, which are magnified among people experiencing homelessness, Boston Health Care for the Homeless Program (BHCHP) has implemented a program called Supportive Place for Observation and Treatment (SPOT). The SPOT offers engagement, support, medical monitoring, and serves as an entryway to primary care and treatment on demand for 8-10 individuals at a time who are over-sedated from the use of substances and who would otherwise be outside on a street corner, alleyway, or alone in a public bathroom, at high risk of overdose.  In the first four months of SPOT’s opening, the program has cared for nearly 200 individuals in over 800 different encounters.

SPOT is:

SPOT is not:

While the immediate goal is to reduce the harm associated with use of opioids and other substances in a population who lacks stable housing and supports, our ultimate goal is to help medically-complex individuals gain access treatment for substance use disorders on demand, including medication-assisted therapies or detoxification. We recommend that Cambridge implement a similar program model based on the City’s needs that works in conjunction with existing agencies, providers and the police.

Our goals for this new service are ultimately to respond with an effective program model that:

  1. Prevents fatal overdose;
  2. More effectively connects highest-risk individuals with addiction treatment; and,
  3. Addresses the impact of SUD on our patients, our organizations, and our neighborhood.

Conclusion

Addressing the opioid epidemic in Cambridge will not happen overnight. It will take time, resources and collaboration. The purpose of this report is to lay the foundation for a coordinated citywide response that local providers, the police, city departments and stakeholders can build upon to educate the community, support people with substance use disorders and develop strategy to address the specific needs within our city. It is our hope that the implementation of these recommendations will optimize the programs that already exist in Cambridge, in addition to creating a more robust and multifaceted approach to this issue.

Appendix

a.       September 2015 CPHD Report

b.       June 2017 Human Services Committee Report

c.       List of Cambridge Partners