Five Questions With: Dr. Josiah D. Rich

Dr. Josiah (Jody) D. Rich has worked extensively to prevent and treat HIV/AIDS and drug addiction among incarcerated populations. / COURTESY ALEXANDRIA MACMADU
Dr. Josiah (Jody) D. Rich has worked extensively to prevent and treat HIV/AIDS and drug addiction among incarcerated populations. / COURTESY ALEXANDRIA MACMADU

Dr. Josiah (Jody) D. Rich, a professor of medicine and epidemiology at The Warren Alpert Medical School of Brown University, has been a practicing infectious disease specialist since 1994 at The Miriam Hospital Immunology Center. He also cares for inmates with HIV and does research in the correctional setting. With extensive expertise in the care and prevention of disease in addicted and incarcerated individuals and an understanding of the importance of strong linkages between the correctional and substance abuse treatment systems, Rich has a unique vantage point from which to understand incarcerated settings’ challenges and opportunities.

His research focusses on the diagnosis, treatment and prevention of HIV/AIDS and co-morbid conditions, especially among incarcerated populations. He is director and co-founder of the Center for Prisoner Health and Human Rights at The Miriam Hospital, www.prisonerhealth.org. Mentoring dozens of trainees, he has inspired several of them to become involved in HIV-related research in correctional populations, which was a major motivation for establishing the center. A co-founder of the nationwide Centers for AIDS Research Collaboration in HIV in Corrections Initiative, Rich has advocated for public health policy changes to improve the health of people with addiction, including improving legal access to sterile syringes and increasing drug treatment for the incarcerated and formerly incarcerated populations.

Rich spoke recently with Providence Business News about the opioid addiction epidemic in New England.

PBN: National news media report that the opioid addiction epidemic is most severe in New England. If that’s accurate, what’s the reason for that, and which opioids are most abused here in Rhode Island?

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RICH: Nationwide, we are in the midst of an epidemic of opiate use disorder. This was brought on by overprescribing opioids by physicians to treat pain. It was exacerbated by regulatory pressures on physicians, as well as illegal and immoral disinformation campaigns by certain bad actors in the pharmaceutical industry.

Opioid use disorder is a chronic relapsing disease that develops in the context of repeated exposure to opioids in the setting of the right genetic risk and high-risk situation. This epidemic is hitting the entire nation; no one knows for sure why the Northeast is harder hit, but that likely has to do, in part, with the illicit opioid distribution networks.

PBN: Gov. Gina M. Raimondo’s budget calls for allocating $4 million to fight the opioid epidemic. What will those funds be used for and how will they be allocated?

RICH: Governor Raimondo asked my colleague, Traci Green, and me to serve as expert advisers to her Overdose Prevention and Intervention Task Force. We assembled a team of experts and helped the task force develop a statewide plan (www.strategicplanri.org). There are a number of important bills that the General Assembly should pass that will facilitate implementing this plan, including improving the prescription monitoring plan, discharge planning, naloxone coverage, recovery housing and others. However, perhaps most important will be to pass the budget with the $4 million allocated to this effort, $2.5 million to support linkage to treatment during incarceration and $1.5 million to support recovery coaches to get people into treatment, among other things.

PBN: Assuming the General Assembly approves the funding of $4 million, are those sufficient resources to address Rhode Island’s opioid addiction problem?

RICH: This problem was decades in the making. Fundamental to fixing it is to change the culture. Changing the culture of physician overprescribing opioids is one part. However, if this is done too rapidly, for many on opioids, it will drive them to transition to illicit heroin. In the past year or two, heroin has become contaminated with illicit fentanyl, which is 50 times more powerful and rapid-acting than heroin and is killing people like we have never seen before. Also, we have to change the culture around the terrible stigma of people who use illicit drugs.

PBN: Are other states implementing successful programs that Rhode Island might adopt; what best practices exist that we could model to successfully combat the problem of opioid addiction?

RICH: Rhode Island has been and continues to be an innovative leader in the fight against overdose deaths. Our current focus on “demand reduction” through markedly increasing treatment with medication-assisted therapy, if we can convince enough physicians to step up to the plate and begin prescribing buprenorphine (whose trade name is Suboxone), will be far more effective than the “supply reduction” approach that has been an abysmal failure with the “war on drugs.”

PBN: Throwing funds at a problem often is an exercise in futility; do you think Raimondo’s proposals will help to significantly reduce the problem; what else, independent of government funding, might help address this societal challenge?

RICH: The best evidence for effective treatment of opioid use disorder involves the use of medications – methadone in a daily liquid dose; buprenorphine in a daily sublingual tablet or strip; or, more recently, depot-naltrexone, whose trade name is Vivitrol, in monthly injections. (Disclosure: My father, who was a co-founder of Alkermes – the manufacturer of Vivitrol – gave me stock in the company.) Detoxification without medications leads to relapse rates of 80 to 90 percent or higher. When people relapse, they are at higher risk of overdose because they have lost their tolerance, and nowadays, with fentanyl, are at a much higher risk of death.

The governor’s budget will go a long way toward strategically heading off as many overdose deaths as possible, in the shortest amount of time and, at the same time, changing the culture from stigmatizing addiction to treating it with effective therapies.

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