Sitting in the shadow of the Hudson County Correctional Center, former New Jersey Governor Jim McGreevey spoke to MDAdvisor staff about the findings of a report published by the New Jersey Reentry Corporation in September 2018 entitled “Reentry. New Jersey Opioid Addiction Report: A Modern Plague” and about the critical need for addiction treatment reform in New Jersey. Governor McGreevey currently serves as Chairman of the New Jersey Reentry Corporation, which provides for addiction treatment, sober housing, employment and training, identification services and linkage to healthcare for formerly incarcerated persons. He is a fervent advocate for court-involved individuals and those affected by addiction throughout New Jersey.
MDAdvisor: How and when did you become interested specifically in the opioid crisis?
McGreevey: I have personally seen the impact of addiction on the residents of New Jersey for a very long time. When I was Mayor of Woodbridge, I was involved with an organization called Woodbridge Action for Youth. I came to understand that young persons who were grappling with depression and anxiety would move toward drugs as a way of anesthetizing their pain. As Mayor, I saw families that had done ostensibly everything “right,” and nonetheless their children were in the throes of addiction. As an assistant prosecutor in Middlesex County in the juvenile section, I saw young people living in public housing who were peddling drugs because it was the only commodity that could be readily sold within their environment. They were living in some of the most challenging neighborhoods and cities in New Jersey, and when you combine the chaos, trauma and mental health issues they experienced with the close proximity to drugs, addiction became a reality. I also worked with the women of the Integrity House Program at the Hudson County Correctional Center. It is difficult to ignore the issue of addiction when you have seen as much as I have.
MDAdvisor: Describe the magnitude of the opioid addiction crisis.
McGreevey: When the drug crisis was largely in communities of color, it was addressed as a criminal justice issue. Then, opioids started to be prescribed by physicians in the majority community, and our perceptions changed. The overwhelming majority of addiction-related fatalities in New Jersey and across the nation are now opioid-related, and the opioid epidemic has become the defining public health crisis of our time.
In recent years, New Jersey has seen some of the highest annual percentage increases in overdose deaths in the entire country.1 In 2018, New Jersey’s drug death toll set a record for the fourth straight year and now stands nearly four times what it was a decade ago. Almost 3,200 people died of drug overdoses in New Jersey in 2018, and the toll still rises.2 We will likely see another 3,000 deaths in 2019. The costs of the addiction crisis to New Jersey are extraordinary. The state is losing an estimated $1.2 billion in productivity costs every year as a result of the inability of individuals to contribute to the workforce; these are individuals who have died from addiction or who are in halfway houses, treatment programs, hospitals and prisons due to addiction. Over $145 million is spent every year on incarceration costs for those who are in prison as a result, primarily, of drug-related crimes, and $635 million is spent per year on inpatient and emergency department overdose visits.3
MDAdvisor: How has the addiction landscape changed in recent years?
McGreevey: We had been moving in the right direction with managing addictions, perhaps even reaching a level of stability, and then fentanyl came along and changed the game profoundly. Fentanyl is a synthetic opioid that can be upwards of 100 times stronger than morphine and 50 times stronger than heroin. Pharmaceutical fentanyl is used for treating severe pain, typically advanced cancer pain, but it can be diverted for misuse and abuse. However, most recent cases of fentanyl-related harm, overdose and death in the U.S. are linked to illegally made fentanyl. It is sold through illegal drug markets for its heroin-like effect. Fentanyl is often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge—to increase its euphoric effects. Fentanyl is trafficked into the U.S. primarily from China and Mexico. We also have synthetic labs in the United States now. Young adults can order it off the dark web and get it delivered.
It seemed that we woke up one day, and fentanyl was more readily available on the streets of Jersey City, Newark and Paterson than aspirin. I was at a meeting recently educating Latino pastors about the dangers of fentanyl and the fact that a dose the size of a few grains of sand can kill. When it is prescribed by doctors, fentanyl is measured by micrograms, which is one millionth of a gram. But remember that the person mixing the fentanyl may be a guy down the street. He doesn’t necessarily have sophisticated scales and equipment.
We know that there are certain areas of the state that are most impacted by opioid addiction. In terms of number of lives lost, Ocean County has in recent years been the epicenter of the opioid epidemic in New Jersey, with the cluster extending into Middlesex and Monmouth Counties. Camden and Essex Counties have also been hit hard. We know that opioid overdose deaths are increasingly driven by heroin, fentanyl and fentanyl analogs, and the epicenters of Ocean and Atlantic Counties have been bellwethers in this regard.3 That said, it is important to keep in mind the fact that the opioid epidemic has spread across all demographic groups, including many groups traditionally less affected by addiction. No one is immune.
MDAdvisor: What makes the incarcerated population particularly vulnerable to opioid addiction and overdoses?
McGreevey: New Jersey has one of the highest conflations between addiction and incarceration. If you are addicted to drugs in New Jersey, there is a high probability that you are court-involved and will at some point intersect with the drug court, county jail and/or state prison. Currently, 19,000 individuals are incarcerated in New Jersey State prisons. Studies suggest that as many as four of every five incarcerated individuals have been diagnosed with substance use disorder.
What happens is as predictable as it is heartbreaking. Individuals who are active in their addiction become incarcerated and do not have adequate access to treatment, like medication-assisted treatment (MAT). Their tolerance wanes, their cravings skyrocket and, invariably, upon release they relapse, overdose and, all too often, die. Despite the high rates of those suffering from addiction, less than 400 incarcerated individuals are receiving MAT in New Jersey. Of the 12 correctional facilities within the state, only two, Mid-State Correctional Facility and Edna Mahan Correctional Facility, offer MAT. Governor Christie and the state legislature, with the best of intentions, grappled with bail reform so that people would not be retained in a prison in perpetuity because of their financial limitations. However, an unintended result has been individuals who are released quickly without the benefit of treatment or a treatment plan, whereas, in the past, county jails were serving as de facto addiction treatment centers and mental health centers.
One of the most vulnerable times for prisoners is when they are newly released. For formerly incarcerated individuals, the risk of overdose death is 129 times greater than that of the general population in the first two weeks following release,4 and that is because there is no safety net. Their drug cravings are high, and their resistance is low. They are released into the chaos and the violence of the streets without benefits of any structure or support system. We just recently lost a young adult on a Sunday night who came out of prison the preceding Thursday.
Formerly incarcerated individuals are in great need of immediate access to healthcare, yet they come out of prison without a Medicaid card, which to me is inexplicable and inexcusable. There is an almost 40 percent chance that the person has hepatitis B or C, a 40 percent chance he or she is suffering from a mental disorder such as depression or anxiety and a 75 percent chance he or she is addicted,3 and yet the person is released with no access to healthcare. In New York, prisoners are released with a Medicaid card in hand. In New Jersey, the Department of Corrections ostensibly has applied for Medicaid, but the process involves mailing the application to the Board of Social Services in the county where the person resides. If the Department of Corrections actually calls to enroll somebody in Medicaid, if they successfully complete the application, if the card is sent to Department of Corrections, if they mail it on a timely basis to the right county Board of Social Services, if the Board of Social Services actually maintains the card, and if I show up to receive the card, then I can have access to Medicaid. Can you imagine knocking on the door of the county Board of Social Services saying, “Hi, I’m Jim McGreevey. I just came out of state prison. Do you have my Medicaid card?” I have never in all the years that I have worked with reentry clients ever met one individual who retrieved his or her Medicaid card from the Board of Social Services. The point is: It’s not happening.
MDAdvisor: What are the problems with the current addiction treatment system in New Jersey?
McGreevey: We have an incredibly fragmented system in New Jersey. The New Jersey Department of Human Services is in charge of providing Medicaid dollars for drug treatment programs. The Department of Health is involved with the licensing system for medical, behavioral and addiction treatment services. The Department of Corrections is ostensibly charged with providing healthcare prior to prisoner release. The Department of Education is engaged in prevention. There is no overarching singular person in charge, and I know this in life: Unless someone is specifically in charge of getting something done in a timely way, with clear, identifiable benchmarks, it’s not only messy, but it’s not measurable and not necessarily moving in the right direction.
Young people come in to residential treatment for a period of two weeks to 30 days. They will be out for three months, will use again, will overdose and will go into the next treatment facility for two weeks. This is repeated maybe six times. Outside of a miracle, nobody ever gets cured in 28 days. Both the Obama and Trump White House administrations have stated that it takes between 12 and 18 months to recover from opioid addiction.
Many different resources in New Jersey control a piece of the puzzle and may be doing a great job, but no one owns the entire process. Our reentry clients tend to traverse through all of these systems with greater frequency than the average population. They move through hospitals, clinics and treatment centers. Sadly, they move through the state and local police departments and the criminal justice system. I think individual institutions and programs do a tremendous job of advocating, and protecting and caring for the persons that are within their space, but for our clients to get back to a place of sobriety, a place of productive, law-abiding healthy citizenship, someone like the staff at the New Jersey Reentry Corporation has to traverse these systems with them.
When you are a parent, and, all of a sudden, your son is robbing your house, and you find a heroin needle in his bedroom, you have to do something, but most likely you don’t know what to do. I’ve attended community meetings and events, like a vigil I just attended in Kearny, and it is upsetting to meet parents who have lost their children to addiction. In New Jersey, we have a well-intentioned 1-800 number (1.844.732.2465 or 1.844.ReachNJ), but a 1-800 number is not a plan. A 1-800 number is a referral source at best. It doesn’t connect a family to treatment or MAT. It doesn’t help a family grappling with the psychiatric problems and with the pharmacological problems or with the decisions about Suboxone or Vivitrol or viral loads for hepatitis C and the interaction of drugs. There needs to be a system, and we need leadership. I think every single leader in the state understands that we have to do better and has an aching recognition that the current system doesn’t work well.
MDAdvisor: Despite its many problems, why is New Jersey an optimal starting point for fixing the system?
McGreevey: I would argue that New Jersey has all the requisite strengths to provide for an excellent design in infrastructure. We have top-flight medical schools, hospitals, physicians, treatment providers, healthcare public policy experts and the pharmaceutical industry. If you were to ask where one could design the best treatment infrastructure, protocol and system, one could readily say New Jersey. But we need a table around which all those pieces and all the right individuals can come together, set forth a specific concrete game plan and then develop a county-by-county blueprint of action with an infrastructure design, which is the hub-and-spoke model.
MDAdvisor: What are the best practices that could put New Jersey at the forefront of addiction treatment?
McGreevey: I’m a great proponent of MAT with Suboxone or Vivitrol. Leading thoughtful minds, people like Dr. Petros Levounis at Rutgers New Jersey Medical School and University Hospital, Dr. Ramon Solhkhah at Hackensack Meridian Health, Jennifer Velez at RWJBarnabas, Dr. Mark Rosenberg at St. Joseph’s, Dr. Erin Zerbo at Rutgers Health, and Dr. Kaitlan Baston at Cooper University Health Care and Cooper Medical School of Rowan University, understand the critical nature of MAT to alleviate cravings and assist persons to return to a productive life.
MAT has become the national standard of care for opioid addiction treatment in recent years. Studies have shown that adherence to MAT cuts the risk of a fatal overdose in half and doubles the chance of recovery.5,6 In order for MAT to be effective in achieving and maintaining sobriety, research indicates that treatment should be provided on a long-term basis.3 Additionally, in order to effectively recover and maintain long-term sobriety, best practices indicate that addicted individuals need a robust support structure and comprehensive wrap-around services.3
A number of other states have implemented successful addiction treatment programs that provide models and best practices for both the general population and the incarcerated/reentry populations. Vermont integrated a statewide hub-and-spoke model of care that consists of a network of specialized treatment centers throughout the state, which has seen substantial success in expansion of care, addiction prevention and treatment and cost savings.
In 2013, Maryland implemented a health home State Plan Amendment, which allowed the state to reimburse opioid addiction treatment agencies that provide care coordination with a particular focus on the treatment of addicted persons with co-occurring chronic disorders. Rhode Island has implemented a program which combines the elements of both the Vermont and Maryland models in order to facilitate the linkage of buprenorphine prescribing in Medical Health Homes. Additionally, Rhode Island, which is a national leader in addiction treatment within corrections, recently introduced a new model of MAT within the Department of Corrections that has resulted in a 60 percent reduction in overdose deaths among those recently incarcerated.3
MDAdvisor: What is the New Jersey Reentry Corporation (NJRC) recommending to address New Jersey’s addiction crisis?
McGreevey: The NJRC recommends that the Department of Human Services name an Addiction Treatment Hub in each county to serve as a resource for individuals suffering from an addiction, based on best practices in addiction treatment, including medication-assisted treatment and treatment of its co-occurring disorders. Each hub should be connected to an office-based opioid treatment (OBOT) pharmacy. Each county should additionally establish a 24/7 opioid treatment provider (OTP), which will serve as a crisis center for individuals in need of immediate intervention. In order to support these initiatives, the state must make necessary licensing provisions, ensure that services are sufficiently reimbursable through Medicaid and establish a statewide health information exchange (HIE).
MDAdvisor: is there enough political will to implement this njrc report and its recommendations?
McGreevey: There are many outstanding advocates for fixing the addiction treatment system in New Jersey. Senator Joe Vitale, Chairman of the Health and Human Services Committee, is a dear friend who is passionately concerned. Carole Johnson, Commissioner of the New Jersey Department of Human Services, is a tremendous advocate. Senate President Steve Sweeney, Assembly Speaker Craig Coughlin and Assemblyman Jon Bramnick all care deeply about this issue. Former Health Commissioner Shereef Elnahal has also been a great advocate. And I should say that there are also people in the federal administration who really care about this issue, particularly in Human Services.
Government should legitimately have the de facto requirement to set forth a functional blueprint for addressing addiction, and what I have proposed to the Governor’s office is a statewide uniform effort. We need to take the disparate elements, particularly from the medical community, the hospital community, the treatment community, insurance companies, county government and state government, and bring them to the table. I am respectfully requesting to participate on a statewide task force with the critical members of the cabinet. I know going in that not everyone is going to agree on the solution, but at a minimum we would know what our assets are. At a minimum, we would be able to connect assets in a rational framework and be able to provide a critical pathway for families to receive assistance on a county-by-county basis.
MDAdvisor: Where do you get your passion for supporting the addicted population in New Jersey?
McGreevey: I love what I do, and I intend to support the reentry population for the rest of my life. They are the most vulnerable population when it comes to addiction. But this is not only about the reentry population; these problems are applicable to everybody. This is not a Republican nor Democratic issue. This is not an urban versus suburban issue. This isn’t a Latino, African American or Caucasian issue. This is a New Jersey issue that is ravaging our young adults. We are literally at war here. The fact that we all keep doing the same thing year in and year out, accepting the pain, and the agony and the hurt of families who bury their young ones is unacceptable. It is amazing that we haven’t grabbed this by the collar and done a better job already. That is what is particularly frustrating to me and why I am so passionate about this issue.
Hon. Paul W. Armstrong, J.S.C. (Ret.), served as a New Jersey Superior Court Judge from 2000 to 2017 and is currently a Senior Policy Fellow (Judge in Residence) at the Bloustein Institute for Planning and Public Policy of Rutgers University, where he teaches healthcare ethics and law in its graduate programs. Janet S. Puro, MPH, MBA, is Vice President of Business Development and Corporate Communications at MDAdvantage Insurance Company.