a report from Councillor Alanna Mallon, Co-Chair and Councillor Sumbul Siddiqui, Co-Chair of the Human Services and Veterans Committee, for a public hearing held on June 19, 2019 to discuss the results of the City Manager’s Opioid Task Force Report and the recommendations that could be implemented to reduce the harmful effects of the opioid crisis in the City of Cambridge

Atlachment A Opening Remarks by Councillor Mallon Thank you for attending todays Human Services and Veterans Committee hearing on the City Managers Opioid Working Group final report and recommendations. I want to thank the co- chairs of the working group Dr. Assad Sayah and Dr. Branville Bard, as well as the many members of the working group who spent 6 months in 2018 deeply looking at the Opioid crisis to determine strategies and recommendations we can implement here in Cambridge with the ultimate goal of saving lives. I also want to acknowledge that this work was started with Mayor Marc McGovern, who was then Vice-Mayor, who released an alarming report in November of 2017 that was the catalyst to form this group, and I am grateful that he prioritized this work then, and for continuing to do so now. Today we will hear from Claude Alix Jacob our Chief Public Health Officer, as well as members of the working group to go over the recommendations, and how to implement them. We will then hear from Mayor McGovern about a recent Cambridge and Boston contingent who went to Montreal Canada to tour their Safe Injection Sites (SIFs) both static and mobile site systems, as well as a report back on the Statewide Harm reduction Commission that he was a part of. We will have committee questions between each presentation and then go to public comment.

Attachment B HUMAN SERVICES & VETERANS COMMITTEE IS DECOR COMMITTEE MEETING ~ AGENDA ~ 2:00 PM Sullivan Chamber Wednesday, June 19, 2019 Opening Remarks Claude-Alix Jacob, Chief Public Health Officer for the City of Cambridge - Presentation on recommendations from the City Manager's Opioid Working Group Mayor Mare McGovern - Presentation on the Harm Reduction Task Force and trip to Montreal to visit and learn about safe injection sites Questions from the Committee Members Public Comment Discussion from Committee Members Adjournment Page 1 City of Cambridge

machment ( 3/19/201 Addressing the Opioid Crisis in Cambridge JUNE 19. 2019 Cambridge Public Health HeA and +CHA Hath Allance Department State-wide, the overdose death rate went down in 2017 and 2018 from its peak in 2016 Figure 3. Rate of Confirmed and Estimated Opioid-Related Overdose Deaths, All Intents Massachusetts Residents: 2000 - 2018 30.6 22% 29.6 294 -3% - 1% 24% 25.0 Rate 41% /20.1 per 100,000 Residents 9.6 97 9.9 8.9 111 9.6 10.3 100 8.0 8.0 8.2 2005 2010 2002 2003 2004 2006 2007 2008 2001 2000 2011 2012 2013 2014 2015 2016 2017 2018 blic Hea Department 1

6/19/2019 The Cambridge annual overdose death rate is lower than Middlesex County and MA-wide Figure 1. Opioid-Related Overdose Death Rate in Cambridge, Middlesex County, and Massachusetts, 2012-2017 31.6 29.8 30 26.2 26.0 22.3 20.0 23.5 22.5 20 17.3 11.2 10 11.8 10.0 10.6 Rate per 100,000 Residents 7.3 5.6 5,6 2012 2013 2014 2015 2016 2017 • Massachusetts • Middlesex County Cambridge Public Health DePartment Since 2016, the number of annual non-fatal overdoses has dropped in Cambridge 2016 (n =238) 2017 (n=138) 2018 (n = 159) 2019 (n = 49) 20 10 Overdose Incidents Cambride. ublic Heald Department 2

6/19/2019 In 2017, the most ambulance pick-ups happened from a public place, and the largest category was "residence" Ambulance Pickups of Suspected Overdose Patients by Location, 2017 Figure 3. (n = 138) *40 30 Number of Incidents 0 Cambridge Public Health In 2017, almost half of ambulance pick-ups were Cambridge residents Figure 6. Opioid-Related Overdoses in Cambridge by Patient Residence, 2017 (n = 138) Unknown 21.7% Out of State 0.7% Other MA Towns 12.3% Cambridge Waltham 43.5% 1.4% Belmont 1.4% Malden 2.9% Arlington 3.6% Boston 5.8% Somerville 6.5% ImbIM blic He 3

6/19/2019 In 2017, 3 out of 4 people picked up by an ambulance were classified as "not homeless" Figure 4. Opioid-Related Overdoses by Homeless Status, 2017 (n = 138) Unknown 10.1% Homeless 15.2% Not Homeless 74.6% ambrid ublic Healt Department Demographics of Overdose Hospitalization at CHA, 2017 Among Cambridge residents who visited CHA in 2017 for opioid-related overdoses: Male 60% 72% Average Age Average age was 43.5 (n = 97) ambrids ablic Heal Department 4

6/19/2019 Data Source: CPHD. ProEMS Date Updated: 1/20/2018 By: Anna Kaplan Horth Cambridge Non-Fatal Opioid Overdoses 2016 - 2017 Cambridge Higl Cambridge, MA d Nine West Cambridge Mid-Cambridge Wellington-Harrington east cambnage Riverside The Port Cambridgeport Area 2/MIT Overdose Incident Density n = 379 0 0.25 1 Miles 0.5 Esri, HERE. Delorme, Mapmyindia. O OpenStreetMap contributors, and the GIS user commun Substance Abuse Prevention Programs Grant Funded Portfolio • Overdose Prevention & Education Network (OPEN) A four-city regional collaborative with Cambridge as the lead agency (includes Somerville, Everett, and Watertown) to prevent opioid abuse and overdose through policy, practice, and systems change. • Substance Abuse Prevention Collaborative (SAPC) A four-city regional collaborative with Somerville as the lead agency (includes Cambridge, Everett, and Arlington) targeting underage drinking in youths 13-16. • Partnership for Success (PFS) Cambridge-only program targeting prescription drug misuse/abuse among high school students. • Funding for all three grants will lapse in 2020. 5

6/19/2019 OPEN: Overdose Prevention and Education Network • 4 city collaborative • Cambridge, Everett, Somerville, Watertown • OPEN Goals • Prevent the use/abuse of opioids • Prevent/reduce fatal and non-fatal opioid overdoses • Sustainable prevention strategies through policy, practice, and systems change Highlights: • Increased safe medication disposal - 1,258 Ibs collected last year in Cambridge alone • Trained 300+ businesses in overdose prevention & response • Promoted the Good Samaritan Law through MBTA ads and posters • Collect, analyze, and release opioid overdose data; send out a weekly update of all non-fatal ODs in Cambridge ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE CITY MANAGER'S OPIOID WORKING GROUP FINAL REPORT AND RECOMMENDATIONS MARCH 2019

6/19/2019 City Manager's Working Group: The Process • November 2017 report from Vice Mayor Marc McGovern outlined initial opioid recommendations for Cambridge • In response, the City Manager formed an interdisciplinary working group charged with providing policy and practice recommendations to address the opioid crisis in Cambridge • Two co-chairs, 17 members • Met ten times in April-October 2018 • Learning sessions (local data, opioid services, SIFs, etc.) • Working meetings • The group identified gaps in services, brainstormed how to address those gaps, and prioritized five broad recommendations • Released final report in March 2019 Members, Cambridge City Manager's Opioid Working Group Co-Chairs Assaad Sayah, MD, FACEP, SVP and CMO, Cambridge Health Alliance Commissioner Branville G. Bard, Jr., DPA, Cambridge Police Department Members Mark Albanese, MD, Cambridge Health Alliance Louis Cherubino, Cambridge Police Department John Chute, Community Representative Steven DeMarco, Cambridge Police Department Mark Eisenberg, MD, Massachusetts General Hospital Christopher Fischer; MD, Cambridge Health Alliance Ellie Grossman, MD, MPH, Cambridge Health Alliance Meghan Hynes, Access Drug User Health Program Claude Jacob, Cambridge Public Health Department, Cambridge Health Alliance Nancy Mahan, Bay Cove Human Services Gerard Mahoney, Cambridge Fire Department Bill Mergendahl, Professional Ambulance Services Mark McGovern, Cambridge Healthcare for the Homeless, Cambridge Health Alliance Ellen Semonoff, Cambridge Department of Human Service Programs Jared Stanley, Cambridge Police Department Staff Mary Kowalczuk, MSW, Manager, Substance Abuse Prevention Programs, Cambridge Public Health Department Tali Schiller, MPH, Substance Abuse Prevention Coordinator, Cambridge Public Health Department 7

6/19/2019 Working Group Meeting Topics State of Opioids in Cambridge, presented by Tali April 18, 2018 Schiller, MPH (CPHD) Inventory of Cambridge-Based Activities May 18, 2018 Opioids in Cambridge Data, presented by Kristin Ward, MPH (CPHD) Opioid Services in Boston, presented by Monica Valdes May 23, 2018 Lupi, JD, MPH (Executive Director, Boston Public Health Commission) Supportive Place for Observation and Treatment, presented by Jessie Gaeta, MD (Chief Medical Officer, Boston Healthcare for the Homeless Program) Brainstorming an Opioid Services Inventory June 5, 2018 June 28,2018 Legal Implications of Supervised Consumption Sites, presented by Leo Beletsky, JD, MPH (Northeastern University) August 2, 2018 Leveraging Wastewater to Assess the Opioid Epidemic presented by Mariana Matus, PhD, Newsha Ghaeli, and Erin Winslow (Biobot Analytics) Evaluation of the Insite Program, presented by August 23, 2018 Brandon Marshall, PhD (Brown University) Cambridge Opioid Working Group Listening Session August 29, 2018 (Summary of the Listening Session may be found in Appendix 5) September 27, 2018 Brainstorming and refining recommendations October 25, 2018 Prioritizing and finalizing recommendations City Manager's Working Group: The Report • Executive Summary • Development of the Cambridge Opioid Action Plan • The Opioid Crisis in the Commonwealth and Cambridge • Responding to the Cambridge Opioid Crisis • Recommendations • Immediate • Long-term • Implementation, Oversight, and Evaluation • Future Considerations • Appendices Available at www.CambridgeMA.gov/OWGReport 8

6/19/2019 Recommendation #1: Prevent deaths from overdose and save lives. a.) Incorporate principles of harm reduction into all interactions and create accountability processes to encourage person-centered and compassionate interactions between service providers and clients. b. Make naloxone and overdose prevention education widely available by further expanding naloxone access to other populations. • Provide naloxone upon release from jail, detox, treatment • Schedule and promote free monthly naloxone trainings that are open to everyone who works, lives, or spends time in Cambridge • Bulk purchase naloxone & distribute a kit to every city department c.) Conduct a citywide public education campaign about naloxone. Recommendation #2: Increase coordination among Cambridge city departments and community agencies to improve service providers' capacity to respond to the opioid crisis. a.) Appoint an Interdisciplinary Advisory Committee on substance use to coordinate and strengthen the city's response to the opioid crisis. Responsible for carrying out the recommendations outlined in this report to effect policy, environmental, and systems change to reduce the impact of substance misuse. b.) Explore private funding partnerships to better support and further enhance response efforts. 9

6/19/2019 Recommendation #2: Increase coordination among Cambridge city departments and community agencies to improve service providers' capacity to respond to the opioid crisis. c.) Improve systems for more timely, evidence-based reporting of overdose data, building on the existing overdose surveillance systems developed by the health and police departments. d.) Build and strengthen diverse partnerships and initiatives • City departments, the justice system, local businesses, social service and medical providers, community- and faith-based organizations, and the medical examiner's office. Recommendation #3: Provide public awareness education to reduce stigma and prevent addiction. a.) Promote a citywide anti-stigma /HEND education and awareness campaign THE that emphasizes addiction as a chronic disease, promotes non-stigmatizing STIGMA language, and encourages individuals to seek treatment. b.) Facilitate safe medication disposal to discard prescription medications. c.) Develop a prevention campaign for youth and/or parents. Able Haste 10

6/19/2019 Recommendation #4: Increase access to on-demand treatment and long-term recovery support. a.) Explore the feasibility of developing an Engagement Center Service that is available 24/7 for people with substance use disorder. • Establish one point of entry for substance use treatment & services • Purchase contract additional outreach vans • Expand MAT availability • Create a cross-agency team that meets weekly to review cases b.) Add more options that provide people access to residential and/or medication-assisted treatment when they need it. Recommendation #5: Reduce the supply of dangerous opioids. a.) Expand the Cambridge Police Department's Special Investigations Unit's enforcement focus on distri- bution networks and on individuals profiting from substance sales. b.) Enhance CPD's capability to respond to emergent online distribution by expanding cybercrime trainings and investing in new equipment. 11

6/19/2019 Next Steps • In June 2019, the City Manager will appoint an Advisory Committee with up to 20 members that will implement the recommendations in this report. • Monthly community naloxone trainings. "Each day we are losing 115 Americans to an opioid overdose - that's one person every 12.5 minutes. More than half of opioid overdoses occur at home. If you or someone you know is at risk for an opioid overdose I urge you to get Naloxone, a lifesaving medication that can reverse the effects of an overdose." - VADM Jerome M. Adams United States Surgeon General #GetNaloxone #SaveALife 12

6/19/2019 Tali Schiller, MPH Substance Use Prevention Coordinator [email removed] Cambridge Public Health Health Alliance CHA Health Allane Department 13

Attachment D 15EB ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE CITY MANAGER'S OPIOID WORKING GROUP FINAL REPORT AND RECOMMENDATIONS MARCH 2019

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE LETTER OF INTRODUCTION To City Manager DePasquale, We are pleased to present the Cambridge City Manager's Opioid Working Group: Final Report and Recommendations, a comprehensive plan for addressing and curbing the opioid epidemic in the City of Cambridge. As with many communities across the Commonwealth and the country, Cambridge has been deeply impacted by the opioid crisis. The community has responded to this growing crisis as it always has in times of great challenge. City officials, community partners, nonprofit and social service organizations, and residents have come together in partnership to develop an integrated and robust response across the continuum of prevention, intervention, treatment, and recovery. This collective work has seen results - the overdose death rate in Cambridge decreased from 2016 to 2017, the first decline in seven years, and this downward trend continued through 2018. But the epidemic is far from over. We must do more. Under your leadership and guidance, a working group was formed and then convened a number of times in early 2018 to develop a comprehensive plan of action to address the opioid overdose epidemic. The plan we present to you today is a living document that was : created through the collaboration of subject matter experts, dedicated representatives of community-based organizations, diverse community members, and other city agencies that play a critical role in this public health crisis. In addition to concrete steps and activities, this plan also embodies a set of principles and values that the entire working group shares and supports, and which will guide our work to address the opioid epidemic in Cambridge. Sincerely, Branville G. Bard, Jr., DPA Assaad Sayah, MD, FACEP Commissioner Senior Vice President & Chief Medical Officer Cambridge Police Department Cambridge Health Alliance Co-Chair, City Manager's Opioid Working Group Co-Chair, City Manager's Opioid Working Group CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS | 1

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE TABLE OF CONTENTS 4 Executive Summary.... ....7 Development of the Cambridge Opioid Action Plan.... .. 10 The Opioid Crisis in the Commonwealth and Cambridge... ....14 Responding to the Cambridge Opioid Crisis... Recommendations.. ...20 ..29 Implementation, Oversight, and Evaluation. ............30 Future Considerations... ....30 Appendices..... CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS | 3

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE EXECUTIVE SUMMARY Addiction is a complex disease of the mind and body that can destroy the lives of people who use heroin, prescription painkillers, and other opioids. Between 2013 and 2017, 65 Cambridge residents died from an opioid-related overdose. In addition, a total of 115 people during this same period died from an opioid-related overdose in the City of Cambridge, a figure that comprises both city residents and nonresidents. The Massachusetts Governor's office-through two administrations-has responded with robust services, programs, and policies to combat the growing opioid crisis statewide and locally. City officials and community partners have also responded to the opioid crisis locally to support people with substance use disorder and their loved ones in the community. There are early signs of progress. In 2017, the overdose death rate in Massachusetts decreased 5% from 2016, the first decline in seven years. In Cambridge, there were 12 confirmed opioid-related deaths among residents in 2017, down from 27 deaths in 2016. While this is encouraging news, the epidemic is far from over. Long-term, sustained success can only occur with greater integration, coordination, and expansion of services provided by city and state agencies, hospitals, and nonprofit organizations. A November 2017 report from then-Vice Mayor Marc McGovern outlined the critical need for a robust and multifaceted approach to curbing the epidemic through a series of recommendations for the City administration. In response to the urgent issues raised by that report, Cambridge City Manager Louis A. DePasquale formed an interdisciplinary working group in 2018 that was charged with provided policy and practice recommendations to address the opioid crisis in Cambridge. The working group | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE included representatives from city agencies, nonprofit and human service organizations, medical and behavioral health organizations, emergency services, and the community. Over a six-month period in 2018, the working group immersed itself in learning more about the opioid crisis locally; identifying services and programs currently in place; discussing relevant data collection to better inform the work; and hearing from a range of content experts and people with lived experience. Together, group members identified gaps in services and programs, how best to address those gaps, and how to build upon existing programs and services. Five common themes surfaced from the conversations that informed the final set of recommendations: 1. Improved Coordination - Better coordination among partners and existing initiatives. 2. Service Capacity - Greater capacity to address the challenges and gaps in services. 3. Operational Support - Increased funding to support the work. 4. Citywide Campaign - Enhanced anti-stigma education and awareness. 5. Access to Narcan - Greater access to and awareness of naloxone. As a result of this process, the working group identified five broad, high-level recommendations with immediate and longer-term action steps designed to meet and mitigate the challenges of the opioid crisis in Cambridge. RECOMMENDATION #1: Prevent deaths from overdose and save lives. a. Incorporate principles of harm reduction into all interactions and create accountability processes to encourage person-centered and compassionate interactions between service providers and clients. b. Make naloxone and overdose prevention education widely available. RECOMMENDATION #2: Increase coordination among Cambridge city departments and community agencies to improve service providers' capacity to respond to the opioid crisis. a. Appoint an Interdisciplinary Advisory Committee on substance use to coordinate and strengthen the city's response to the opioid crisis. b. Explore private funding partnerships. c. Improve systems for more timely, evidence-based reporting of overdose data. d. Build and strengthen diverse partnerships and initiatives. RECOMMENDATION #3: Provide public awareness education to reduce stigma and prevent addiction. a. Promote a citywide anti-stigma education and awareness campaign. b. Facilitate safe medication disposal to discard prescription medications. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE RECOMMENDATION #4: Increase access to on-demand treatment and long-term recovery support. a. Explore the feasibility of developing an Engagement Center Service that is available 24/7 for people with substance use disorder. b. Add more options that provide people access to residential and/or medication-assisted treatment when they need it. RECOMMENDATION #5: Reduce the supply of dangerous opioids. a. Expand the Cambridge Police Department's (CPD) Special Investigations Unit's enforcement focus on distribution networks and on individuals profiting from substance sales. Enhance CPD's capability to respond to emergent online distribution by expanding cybercrime trainings and investing in new equipment. While these recommendations focus specifically on addressing the opioid crisis, they could serve as a blueprint for how Cambridge can respond to substance use disorder crises in the future. The recommendation development process and the stakeholders involved provide a thoughtful, strategic path forward for tackling addiction and other related issues. If you see an overdose, DON'T RUN. CALL 911. Help someone who is overdosing by calling 911. The Good Samaritan Law protects you. MASSAGHUSETTS 40435 S.e1131:102 ACHA Cambridge robbe Healtl A billboard in Central Square advertising the Good Samaritan Law in late 2018. | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS 6

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE DEVELOPMENT OF THE CAMBRIDGE OPIOID ACTION PLAN Due in large part to the hard work of city and community partners, Cambridge has been able to respond to the opioid crisis and support people with substance use disorder and their loved ones. However, the epidemic is far from over. Cambridge needs to further leverage and expand current services, programs, and tools to fully address critical areas and stem the crisis through prevention, intervention, treatment, and recovery. Intervention Treatment Prevention Recovery Prevention: Addressing the "upstream" causes of opioid addiction and overdose and stopping addiction before it happens. Example: reducing the number of opioid prescriptions and limiting the supply of opioids. Intervention: Preventing serious consequences once opioid addiction has occurred. Example: training bystanders how to administer naloxone, an overdose antidote, and encouraging them to call emergency services. Treatment: Providing medical treatment for people with opioid use disorder so they can recover. Example: medication-assisted treatment such as methadone or buprenorphine (Suboxone) or naltrexone (Vivitrol). Recovery: Maintaining recovery through support services. Example: providing a recovery coach to help people with opioid use disorder with setbacks or relapse. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS 17

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE More importantly, long-term sustained success can only occur with improved integration, coordination, and accessibility of services provided by city and state agencies, hospitals, and nonprofit organizations. In November 2017, the Office of then-Vice Mayor (now Mayor) Marc McGovern released a report that highlighted the severity of the opioid epidemic in Cambridge, outlined services currently available to address the epidemic, and provided a series of recommendations to the City Manager and City Council. City Manager Louis A. DePasquale then formed an interdisciplinary working group charged with providing policy and practice recommendations to address the opioid crisis in Cambridge (Appendix 1). Working group members met ten times over a period of six months in 2018 (Appendix 2) and included representatives from city agencies, nonprofit and human service organizations, medical and behavioral health organizations, emergency services, and the community (Appendix 3). Each of these individuals has been integral to addressing Cambridge's opioid crisis and demonstrates the depth, breadth, and complexity of establishing and building a successful response. The Vice-Mayor's recommendations, together with the five global questions listed below, served as a guide for the City Manager's Opioid Working Group as it set out to identify gaps in the city's opioid response and provide recommendations to fill those gaps. Five Global Questions: 1. What is our capacity to support case management and referrals following an overdose? 2. How can we be more effective in addressing the ripple effects resulting from an acute episode? 3. What else should we consider as part of a targeted citywide awareness campaign? 4. How can we improve access to available treatment options? 5. How can we align the systems to limit the supply (and demand) of opioids in Cambridge? To answer these questions, the working group set out to learn more about the opioid crisis locally; identify response services and programs in place in Cambridge; discuss relevant data currently being collected and any additional data that could be collected to better inform the work; and hear from a range of content experts and people with lived experience. (Appendices 4-5). 8 | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE PILLAR 3- Interestin PILAR -Tradent www ALL Fre month alone trangs _ Bulk purchase maloyone In Purchase stof go chest an _ Exped MAT spher Este sh stroked 0 patel Rever Sutr 35l me , Incruse super not at repare To identify and prioritize recommendations, working group members split into three small groups focused on prevention, intervention, treatment, and recovery. Group members brainstormed existing gaps in services, how best to fill those gaps, and how to further build upon existing programs and services. Common themes surfaced across all three groups: 1. Better coordination among partners and existing initiatives. 2. Greater capacity to address the challenges and gaps in services. 3. Increased funding to support the work. 4. Enhanced anti-stigma education and awareness. Greater access to and awareness of naloxone. Recommendations were discussed, finalized, and prioritized into five broad, high-level recommendations with both immediate and longer-term action steps. This report serves as a culmination of the working group's efforts and provides a detailed set of recommendations to meet and mitigate the challenges of Cambridge's opioid epidemic. This plan focuses specifically on addressing and ending the opioid crisis, but it can serve as a blueprint for the City of Cambridge to respond to any substance use disorder crisis in the future. The process by which the recommendations were developed, including key voices around the table, provides a thoughtful, strategic path forward for tackling addiction and other related issues. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS | 9

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE THE OPIOID CRISIS IN THE COMMONWEALTH AND CAMBRIDGE The number of opioid prescriptions given to Massachusetts residents increased steadily The Commonwealth between 2000 and 2015. When the prescription rate peaked in 2015, about 15% of of Massachusetts Massachusetts residents were being prescribed opioids by a health care provider.! Additionally, about two-thirds of people who died from an opioid-related overdose in 2013 and 2014 had a legal prescription at some point during 2011-2014.2 Figure 1. Prescription History for Fatal Overdoses About 8 in 12 people who died from opioids in 2013 and 2014 had an opioid prescription at some point during 2011-2014. Responding to the growing opioid epidemic in Massachusetts, then Governor Deval Patrick declared a public health emergency in March 2014. Governor Patrick directed the Massachusetts Department of Public Health to take steps to combat overdoses, stop the crisis from worsening, help those already addicted into treatment and recovery, and map a long- term solution to ending widespread opioid abuse in the Commonwealth. Under Governor Charlie Baker's administration, Massachusetts has continued to mount a multifaceted response to the opioid crisis, including enacting breakthrough legislation, revamping the state's prescription monitoring program, and adding 1,200 substance use disorder treatment beds to the system since 2015. Governor Baker signed a second major piece of legislation into law in summer 2018. This new law will strengthen the state's education and prevention efforts, expand the role of recovery coaches, improve access to medication-assisted treatment, and provide liability protections for those who prescribe, dispense, and administer naloxone in good faith. 'Massachusetts Prescription Monitoring Program County-Lével Data Measures (Calendar Year 2015). Boston, MA. November 2016. Accessed January 3, 2019. https://www.mass.gov/files/documents/2016/11/vd/pmp-county-data-2015.pdf. "Massachusetts Opioid Epidemic: A data visualization of findings from the Chapter 55 report. Boston, MA. Accessed December 21, 2018. https://chapter55.digital.mass.gov 10 | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE While the statewide opioid crisis is far from over, there are early signs of progress. Opioid prescription rates in the state have dropped measurably since 2015. As of September 2018, 3.6% of the population received an opioid prescription, a 37% decrease from 2015.3 In 2017, the overdose death rate in Massachusetts decreased 5% from 2016, the first decline in seven years. This downward trend continued through September 2018, the most recent period for which data are available.4 Figure 2. Opioid-Related Overdose Deaths, All Intents, Massachusetts Residents: 2000-2018 • Confirmed • Estimated 2,400 2,200 1,974 2,099 2,000 1,945 1,800 1,710 1,600 1,617 1,400 1,362 1,200 1,000 961 800 600 638 656 660 622 642 614 526 400 506 514 379 200 20002001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 There were 1,617 confirmed and 357 probable opioid-related deaths among Massachusetts residents in 2018. The trend continues to be positive, with fewer deaths likely in 2018 than in 2017.5 There is evidence that fentanyl, an illicitly produced synthetic opioid, is fueling the current opioid epidemic in Massachusetts, as it is across the country. Fentanyl is a fast-acting drug with 50 to 100 times the potency of morphine, making it deadlier than other opioids. Starting in 2017, the percentage of opioid-related overdose deaths where fentanyl was present began to exceed that of heroin or likely heroin. Of the 1,445 opioid-related fatal overdose cases in 2018 where a toxicology screen was available, 1,292 (89%) cases had a positive screen result for fentanyl. Since 2014, the rate of heroin or likely heroin present in people who died from an opioid-related overdose has been decreasing, while the presence of fentanyl and cocaine is still trending upward.® 3 Massachusetts Prescription Monitoring Program County-Level Data Measures (2018 Quarter 3). Boston, MA. Posted November 2018. Accessed December 25, 2018. https://www.mass.gov/files/documents/2018/11/16/Prescription-Monitoring-Program-PMP-Data-County-Overview-November-2018.pdf. *Opioid-related Overdose Deaths by/City-Town - February 2019. Boston, MA: Massachusetts Department of Public Health. Accessed February 22, 2019. https:// www.mass.gov/files/documents/2019/02/12/Opioid-related-Overdose-Deaths-among-MA-Residents-February-2019.pdf. Slbid. Office of the Vice-Mayor, Marc McGovern. City of Cambridge Opioid Working Group Report: Addressing the Opioid Epidemic in Cambridge. Cambridge, MA, November 2017. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS | 11

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE Percent of Opioid-Related Overdose Deaths with Specific Drugs Present Figure 3. Massachusetts Residents: 2014-2018 100 90 80 70 60 50 40 30 20 10 1 2 41 1 Year and Quarter - Likely Heroin - Fentany!- - Prescription Opioid? - Cocaine - Amphetamine — Benzodiazepine Mirroring the statewide trend, Cambridge is experiencing a decrease in confirmed opioid- The City related deaths. In 2017, there were 12 confirmed opioid-related deaths among Cambridge of Cambridge residents, down from 27 confirmed deaths in 2016. Similarly, the number of people who died from an opioid-related overdose in Cambridge-a figure that comprises both city residents and nonresidents-declined from 41 people in 2016 to 21 people in 2017. Figure 4. Opioid-Related Overdose Death Rate in Cambridge, Middlesex County, and Massachusetts, 2012-2017 31.6 29.8 30 26.2 26.0 22.3 20.0 23.5 22.5 20 14.4 17.3 11.2 10 11.8 7.9 10.6 10.0 Rate per 100,000 Residents 7.3 5,6 5.6 2014 2015 2016 2013 2012 2017 Massachusetts Cambridge • Middlesex County Note: Opioids include héroin, opioid-based prescription drugs, and other unspecified opioids. Data for 2018 was not available as of the publication of this report. Data Source: Massachusetts Department of Public Health CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS 12

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE Many more lives would have been lost if not for the use of naloxone by first responders and bystanders who, in 2017, used naloxone 202 times in Cambridge to reverse suspected overdoses, according to EMS data? Figure 5. Opioid-Related Overdoses in 2017, Cambridge, MA Horn Camondage Cambridge Highlande Agassiz test Cambridgo Cia Cambridge Wellington-Harringto Epst Cambnage Riverside The Port overdose incidents T Stations Cambndgeport Green Line Aros 203T Rec Line 0.5 0.25 1 Miles City Bourdery Data Source: Pro EMS Ambulance Service In Cambridge, opioid-related overdoses tend to be more densely clustered around commercial areas like Central Square. However, in 2017, 22% of patients transported by ambulance for an opioid-related overdose were picked up at a private residence. This challenges the common assumption that overdoses in the city happen only on the street or in homeless shelters. For more information, see the Cambridge Public Health Department's recent annual overdose reports: http://www.cambridgepublichealth.org/publications. "Opioid-related Overdose Deaths by/City-Town - November 2018. Boston, MA: Massachusetts Department of Public Health. Accessed December 5, 2018. https://www.mass.gov/files/documents/2018/11/16/Overdose-Deaths-by-City-Town-November-2018.pdf 13 CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE RESPONDING TO THE CAMBRIDGE OPIOID CRISIS In 2015, the Cambridge Public Health Department (CPHD) completed the city's first Community Health Improvement Plan (CHIP), setting the city's health agenda through 2020. Mental and Behavioral Health and Substance Abuse is one of the four CHIP priority areas, with specific emphasis on addressing opioid prevention and treatment. Cambridge and its many community partners offer a comprehensive range of substance use services across the continuum, including prevention, intervention, referral to treatment, substance use treatment, and recovery support. What follows is a brief overview of many, though not all, of the efforts currently underway to combat the opioid crisis. The Cambridge Public Health Department is home to several initiatives designed to Prevention prevent addiction and overdose. OVERDOSES ARE PREVENTABLE. You can save a life - learn how at OPEN overcose reverseaucet isaberse www.odprevention.org The Overdose Prevention and Education Network (OPEN) is a regional collaborative established to reduce accidental opioid overdoses and the misuse and abuse of prescription pain medications in Cambridge, Everett, Somerville, and Watertown. Led by the Cambridge Public Health Department, OPEN is working with residents and community-based 14 | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE organizations, local hospitals, police, fire, and health departments in all four cities to raise awareness about prescription opioid safety and to prevent fatal and non-fatal overdoses. Some of OPEN's key initiatives include: • Sharing timely information about opioid prevention, intervention, and treatment at community events and through its website, Twitter account, and e-newsletter. • Conducting outreach to all pharmacists in Cambridge to advocate for pharmacy-based naloxone distribution. • Implementing public awareness campaigns about the state's Good Samaritan Law. In 2016, CPHD began a five-year effort to reduce prescription drug misuse among the city's public high school students. So far, CPHD staff have conducted stakeholder interviews with parents and providers and organized a youth focus group where students spoke about drug and alcohol use in their community. CPHD school nurses and CPS staff individually interviewed all seventh and ninth graders to assess their risk for substance abuse using the evidenced-based Screening, Brief Intervention and Referral for Treatment (SBIRT) approach in 2017 and 2018. While prescription opioid use and abuse is low among this population, opioid overdose and deaths due to opioid overdose are still high in the city as a whole. Prevention activities targeting high school students aim to keep the opioid usage numbers low and to eliminate usage altogether. Comprised of CPHD and city partners, the Cambridge Prevention Coalition uses a community-based approach to bring about policy, environmental, and social change around substance abuse focusing on youth and families. The coalition has been in place since the 1990s. The Cambridge Police Department (CPD) has been a critical partner in combating the disease of addiction and overdose. CPD has a comprehensive plan of action to prevent opioid overdose. Key activities include: • Establishing a permanent kiosk for disposal of medication in the lobby of the police department and collaborating with CPHD to encourage residents to safely dispose of unwanted medications at semi- annual "Take Back" events. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS| 15

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE • Facilitating open discussions with the Youth Police Academy about substance use and its effects. • Raising awareness among officers about the stigma associated with substance use disorders and addiction through a mandatory yearly in-service training • Limiting the supply and demand of opioids in the City of Cambridge by encouraging better information sharing across jurisdictions. The Cambridge Health Alliance (CHA) is committed to decreasing opioid prescription rates and improving pain management strategies. Some of the CHA's activities include: Extensive prescriber education on recent opioid prescribing legislation, including building EMR tools to help providers "do the right thing" when documenting patient discussions on risks/benefits. • Four pilot projects at primary care sites to address pain management and opioids: 1) a pharmacotherapist-led protocol to taper opioids; 2) group visits for patients managing pain with chronic opioids; 3) a multidisciplinary consultation service for providers to get advice on challenging pain/addiction cases; and, 4) clinic workflows to use urine drug screens and sign controlled-substance agreements for patients on chronic opioids. An improved primary-care-based chronic pain program at all CHA sites. Launched in : January 2019, this program incorporates elements from all four pilots and provider/ staff education on the biopsychosocial model of pain and scripting on how to talk with patients with chronic pain about treatment strategies. While the program focuses on how to manage chronic pain and not explicitly on how to prescribe fewer opioids, prescribing is expected to continue decreasing as non-pharmaceutical pain treatment strategies are enhanced. Access: Drug User Health Program, a program of AIDS Action Committee, is one of the Intervention state's pilot sites for distribution of Narcan (naloxone), a nasal spray to reverse a potentially. fatal overdose. As one of several state-sanctioned and state-funded syringe exchange programs in Massachusetts, Access distributes and exchanges syringes to people who inject drugs, and provides support and counseling, housing services, anonymous HIV testing, primary and mental health care, and other support services. 16 | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE What is Naloxone? Naloxone (also known by its brand name, Narcan) is a medication that can reverse an opioid overdose. It blocks opioids from attaching to opioid receptors in the brain. Naloxone is active for about 30 to 90 minutes in the body. If you give someone naloxone to reverse an opioid overdose, it may wear off before the effects of the opioids wear off. The person could overdose again. This depends on several things, including: • The person's metabolism (how quickly the body processes things). • How much drug the person used in the first place. • If the person uses again. Naloxone cannot be used to get high and cannot be misused. If you give naloxone to someone who is not overdosing, there are no ill effects. Cambridge Fire Department and Pro EMS Ambulance Service. The Cambridge Fire Department leads emergency medical services for the City of Cambridge. Through a partnership with the city, Pro EMS Ambulance Service provides 911 and non-emergency transport services to the Cambridge service area. Both the fire department and Pro EMS deploy paramedics and/or emergency medical technicians (EMTs) to overdose incidents • : in Cambridge. In these situations, either fire or Pro EMS personnel administer Narcan to patients, as appropriate. The Cambridge Police Department provides a continuum of services, including: • CPD employs a licensed social worker and a recovery coach to review treatment bed listings on a daily basis and to assist individuals in getting into treatment programs. Transporting people to treatment if needed. • Once people are in treatment programs, CPD works with clients and their caseworkers to complete forms and provide information to assist facilities in providing a continuum of care for clients. CPD can help overcome the challenges of getting from detox to a long-term residential program if that path is chosen by the client. Partnering with a social worker to create a clinical social work meeting across jurisdictions for case consults on complex cases and to provide wrap around treatment. Jurisdictions include Arlington, Andover, Methuen, Winthrop, Somerville, Brookline, North Reading, Newton, Watertown, Wilmington, and Stoneham. Cambridge Health Alliance. In an effort to prevent opioid overdose, CHA has built naloxone education into its electronic medical record system, trained providers to give a naloxone prescription with each opioid prescription, and obtained state funding to distribute naloxone kits to patients in primary care and psychiatry clinics. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS | 17

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE Cambridge Public Health Department. The public health department advocates for pharmacy- based naloxone distribution and provides training to local businesses and organizations on how to recognize and respond to an overdose. Additional outreach efforts include training city leaders on naloxone use and first aid in collaboration with CPD and Pro EMS. Data Collection & Information Sharing. Timely and accurate data regarding fatal and non-fatal overdoses is critical to curbing the epidemic with more targeted and precise interventions. The Cambridge Public Health Department has developed a local opioid overdose surveillance system to fill the gaps in information regarding local demographics and geography. In 2016, staff designed a system for collecting and analyzing data from Pro EMS, Cambridge Health Alliance, AIDS Action Committee, and the Massachusetts Department of Public Health, and began generating formal data summary reports in 2017. The Cambridge Police Department uses internal live monitoring of all reported overdoses through Computer Assisted Dispatch (CAD) Alerts and shares cross- jurisdictional data to alert other communities when one of their residents has overdosed in Cambridge. The Cambridge Police Department focuses on overdose hotspots and provides outreach through its licensed social worker, recovery coach, detectives, and other community stakeholders. The department uses knowledge of chronic substance users with high rates. of overdose to intervene and have discussions when an individual may be seeking to use drugs and likely to access treatment. The police department also provides community alerts through resource partners when a trend develops or a spike is recognized regarding overdoses. Referral, Treatment, Cambridge Health Alliance. CHA provides services and resources for adults suffering from substance use and addiction, including providing access to treatment as part of routine care and Recovery at all clinical locations. CHA provides services in community-based settings, as well as more specialized treatment environments, to reduce the stigma attached to substance use. Such services include: Screening and Brief Intervention and Referral to Treatment (SBIRT) in all CHA primary care practices. SBIRT is an evidence-based public health model that provides universal screening, early intervention, and treatment for alcohol and drug-related concerns. Primary Care Behavioral Health Integration in all CHA Primary Care Practices. All practices have embedded mental health coaches, nurse case managers, therapists, and psychiatrists who can address substance use disorders, as well as other mental health concerns. Healthcare for the Homeless Primary Care Clinics at CASPAR Shelter and Cambridge Salvation Army. Though no specific substance abuse services are available onsite, patients can access the full array of CHA services through referral from clinic health care providers. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS 18

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE • Primary Care-based Addiction Treatment. Almost all CHA primary care practices offer buprenorphine and/or extended-release naltrexone as medication treatment. • Intensive Outpatient Program (10P), Embedded in the Specialty Outpatient Addiction Service Program. This program provides comprehensive care with a focus on patients with substance use diagnoses and other co-occurring mental health disorders. IOP offers treatment with medication, as well as individual and group counseling. For patients not needing the intensity of IOP, there are other counseling services available at the Outpatient Addiction Service program. • No Wrong Door Policy. Starting in February 2019, CHA initiated substance use treatment for patients entering care through the emergency department or being discharged from inpatient units, including prescribing buprenorphine. • SMART Recovery®. Peer support groups located at CHA Malden and CHA Everett sites. Through its affiliation with North Charles, Inc., located in Cambridge, CHA also provides a comprehensive model of methadone treatment and routinely works with other local agencies and community groups to provide health education. Bay Cove Human Services. The Cambridge and Somerville Program for Alcoholism and Drug Rehabilitation (CASPAR), a program of Bay Cove Human Services, provides an Emergency Services Center & Shelter Services 24 hours/365 days for individuals under the influence of alcohol and other substances. At the center, guests receive integrated medical and mental health care, healthy meals, clean clothes, counseling and case management, as well as access to employment, housing, and treatment referrals. Guests of the shelter can access all CHA substance abuse services through referral from clinic health care providers. Bay Cove also provides on-foot and mobile street outreach to unsheltered men and women with substance use and mental health disorders. Staff offer these individuals access to emergency medical and psychiatric care, meal programs, shelters, substance use and mental health treatment, and other social services. Mount Auburn Hospital Prevention and Recovery Center offers intervention, treatment services, and outpatient addiction support through individual and group therapy. The center also provides talk therapies focused on abstinence, maintenance, and relapse prevention as it pertains to all addictions. Learn to Cope Support Group. This free weekly support group offers experienced facilitators, resources, informational material, guest speakers, and free Narcan kits and training for families and caregivers of people who have addictions to opioids, alcohol, or other drugs. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS | 19

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE RECOMMENDATIONS RECOMMENDATION #1: Prevent deaths from overdose and save lives. Addressing the opioid crisis in Cambridge must take into consideration the continuum of opioid use, including preventing opioid use before it begins; getting treatment for those who are addicted; and most immediately, preventing death due to overdose. Cambridge has seen a decline in deaths due to overdose and maintaining this trend is essential to curbing the opioid crisis. Immediate Action Strategies 1. Incorporate principles of harm reduction into interpersonal interactions and create accountability processes to encourage person-centered, compassionate interactions between service providers and clients. Make clear that harm reduction is an approach that celebrates any and all positive change. City leaders learn how to stop an overdose and give CPR at a training at City Hall in September 2018. | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE 2. Make naloxone and overdose prevention education widely available by further expanding naloxone access to other populations. a. Provide naloxone upon release from jail, medical detox, treatment programs for substance use disorder, and other settings where individuals are likely to have decreased opioid tolerance and be vulnerable to overdose. b. Schedule and promote free monthly naloxone trainings that are open to everyone who works, lives, or spends time in Cambridge. Encourage key sectors to attend, such as local businesses and service providers. Bulk purchase naloxone to distribute for free at monthly trainings OR support the purchase of naloxone with a voucher program for distribution in specific supported programs. Distribute a naloxone kit to every city department. ProEMS has piloted a first ii. aid kit with naloxone that costs roughly $125 per kit to assemble. Every city department should receive a kit and be trained in basic first aid (CPR, stopping a bleed, and administering naloxone), for a total cost of $5,000. c. Conduct a citywide public education campaign about naloxone, perhaps adapting materials from the state's Make the Right Call campaign. This public education campaign will aim to increase knowledge, use, and access to naloxone, including awareness of legal protections (Good Samaritan law), awareness of the statewide medical standing order, and availability of naloxone for purchase at pharmacies. The campaign should focus on multiple communities, including people in recovery and active drug users. Materials should be available in multiple languages. Also, the city should consider innovative methods for increasing 911 calls related to overdose. Longer-term Action: Pursuant to the findings of the Governor's Commission on Harm Reduction 3. (Appendix 6), explore the feasibility of implementing fixed-site or mobile safe consumption facilities (SCF) on a pilot basis, in which essential services are provided to reduce substance use and fatal overdose. Such services would include referral to treatment and social services, wound care, medically supervised drug consumption, and access to sterile injection equipment and naloxone in a walk-in setting. Piloting an SCF will require an in-depth planning process with substantial community engagement to fully assess the value proposition and secure public buy-in. A delegation from Cambridge traveled to Montreal in January 2019 to visit a supervised injection facility (Appendix 7). CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS | 21

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE RECOMMENDATION #2: Increase coordination among city departments and community agencies to improve service providers' capacity to respond to the opioid crisis. Although many organizations are currently taking action to respond to the opioid crisis in Cambridge, it is critical that coordination among these diverse organizations and groups be improved. The working group's strategies focus on creating systems that will increase interagency communication and coordination to improve Cambridge's response. Stakeholders come together at the Overdose Prevention and Education Network's annual meeting in June 2017. Immediate Action Strategies 1. Appoint an Interdisciplinary Advisory Committee on substance use to coordinate and strengthen the city's response to the opioid crisis. Committee members would be appointed by the city manager and include representatives from public health, public safety, and health care as well as treatment providers, city representatives, harm reduction specialists, community stakeholders, people who use drugs, and people in recovery. The committee would be responsible for carrying out the recommendations outlined in this report to effect policy, environmental, and systems change to reduce the impact of substance misuse in Cambridge. 22 | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE Explore private funding partnerships to better support and further enhance 2. response efforts. Improve systems for more timely, evidence-based reporting of overdose data, building on the existing overdose surveillance systems developed by the health and police departments. 4. Build and strengthen diverse partnerships and initiatives: a. City departments. Encourage all municipal departments to join the conversation on substance use disorders and develop an understanding of their role in responding to the issue. b. Criminal justice system. Create opportunities within the criminal justice system and the law enforcement community to identify individuals with substance use needs and divert them from the justice system to service options while also giving consideration to consent. C. Local businesses. Work with local businesses to develop safety measures in response to the opioid crisis, including the expansion of overdose prevention trainings currently being offered by the Cambridge Public Health Department. d. Community-based organizations and faith-based coalitions. Create relationships with grassroots organizations that offer recovery and job support to residents and lead other vital initiatives related to substance use misuse and disorders. Medical Examiner's office. Work toward receiving timely confirmatory reports on cause of death and contributing drugs. f. Social service and medical providers. Engage them to provide more culturally competent, low-threshold, and effective care for people who use drugs. Longer-term Action 5. Conduct a Health Impact Assessment. Evaluate further the potential health effects of the recommendations put forward in this plan. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS | 23

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE RECOMMENDATION #3: Provide public awareness education to reduce stigma and offer additional addiction prevention services. There is still a strong, persistent stigma associated with opioid use and addiction that needs to be dispelled so that more people will seek addiction treatment and family and friends, health care providers, and others will better understand how best to support those with addiction problems and how to talk with others about the disease. Immediate Action: Strategies 1. Promote a citywide anti-stigma education and awareness campaign that emphasizes addiction as a chronic disease, promotes non-stigmatizing language, and encourages individuals to seek treatment. Develop a prevention campaign for youth and/or parents. FEND THE SIGMA Chalk messages in Lafayette Square in observance of International Overdose Awareness Day on August 31, 2017. 24 |CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE Explore the feasibility of installing additional medication disposal kiosks in the city. DRUGS DEPOSIT YOUR UNWANTED PRESCRIPTION DRUGS HERE! SHARPS Keep prescription medicine away from our children and out of our water supplyl LOOSE NEEDLES Return NO GLASS CONTAINER PAPERIPLASTE BAGS YES - Accepted | STOP Full? Questiom? DO NOT LEAVE SHARPS CONTAINERS Sam Lipson: (617, 655-3838 OUTSIDE DROP BOX SHARPS BIOHAZARD Medication and sharps disposal kiosks are currently available 24/7 in the Cambridge Police Department front lobby. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS | 25

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE RECOMMENDATION #4: Increase access to on-demand treatment and long-term recovery support. Evidence is clear that easy access to real-time treatment is highly effective in assisting people addicted to opioids. This includes ensuring that there is collaboration among partners and providers across the continuum of treatment and recovery care so that no one falls through the cracks. Immediate Action: Strategies 1. Explore the feasibility of developing an Engagement Center Service that is available 24/7 for people with substance use disorder. a. Establish one point of entry for people looking for information about substance use treatment; connection to overdose prevention and risk reduction services; or immediate placement in a range of treatment programs. Explore the feasibility of purchasing/contracting additional outreach vans. Mobile b. units have been used successfully to deliver outreach and substance use treatment to people who cannot access traditional treatment. The van would be staffed by service providers in Cambridge. Expand the availability of medication assisted treatment (MAT), especially buprenorphine (Suboxone), at Cambridge health care facilities. Facilitate referral and/or provision of MAT at multiple sites including emergency departments, outpatient practices, residential treatment facilities, psychiatric facilities, medical facilities, and primary care sites. d. Create an integrated and cross-agency team of police, fire, EMTs, harm reduction specialists, treatment providers, recovery coaches, and other service providers. Meet weekly to review local overdose data and develop immediate, coordinated, . and integrated responses for people who have given their consent and are facing acutely elevated levels of risk (including factors such as housing, mental health, criminal involvement, or alcohol or substance use). i. Build a culture of "No Wrong Door" to treatment. Implement warm handoffs to treatment after overdose, starting with appropriate MAT induction in emergency departments and a take-home supply of medication. ii. Encourage the alignment of existing efforts to improve coordination of care for patients and clientele. | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE 2. Add more options for people to access to residential and/or medication-assisted treatment when they need it. Dr: Ellie Grossman meets with a patient at Cambridge Health Alliance. Longer-term Action: 3. Establish standardized Emergency Department responses at Cambridge and • Mount Auburn Hospitals following a nonfatal overdose, including a naloxone prescription and initiation of medication-assisted treatment for appropriate patients with opioid use disorder. 4. Review and ensure options for civil commitment under section 35 of Chapter 123 for individuals in immediate danger to themselves and the community. Increase emergency behavioral health resources for people in crisis. Fund emergency services team and employ counselors and other social service providers at emergency shelters. 6. Release an official City of Cambridge guide to navigating local addiction treatment programs and recovery support, integrating information on how to access treatment, harm reduction resources, and emergency/crisis interventions into public education campaigns. 7. Increase the use of low threshold and affirming recovery specialists in behavioral health and medical settings to support individuals in recovery. Base all recovery support on the principles of harm reduction. Increase safe permanent supportive housing, vocational support, employment 8. services, and recovery support services for individuals with substance use disorders. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS | 27

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE RECOMMENDATION #5: Reduce the supply of dangerous opioids. Interrupting the sale and distribution of opioids, whether prescription or synthetic, is critical to ending the opioid crisis. Illicit distribution channels operate just about anywhere (on the streets, in private homes) and there has been a significant increase in online sales and distribution, which will require additional training and focus. Immediate Action: Strategies 1. Expand CPD's Special Investigations Unit's enforcement focus on distribution networks and on individuals profiting from substance sales. 2. Enhance CPD's capability to respond to emergent online distribution by expanding cybercrime trainings and investing in new equipment. 3. Purchase a second TruNarc analyzer to identify substances in the field. TruNarc analyzer is a handheld device that enables drug identification in the field in an easy= : to-use, reliable manner. Using Raman spectroscopy (the same method used in our forensic labs), TruNarc is uniquely able to identify controlled substances, precursors, and cutting agents. The user can scan directly through plastic bags or glass containers to minimize contamination, reduce exposure, and preserve evidence. 4. Work with the Middlesex District Attorney's Office and State Police to provide timely notifications to local detectives about opioid-related deaths. 5. Provide CPD, CFD, and ProEMS staff with an updated training on biohazards, risks associated with an overdose response, and best practices to properly collect evidence from the scene. 28 I CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE IMPLEMENTATION, OVERSIGHT, AND EVALUATION An Interdisciplinary Advisory Committee on substance use will be established by July 1, 2019 and have responsibility for implementation, oversight, and evaluation of the recommendations. The advisory committee will review this plan in its entirety and determine who will take responsibility for each recommendation and its accompanying strategies. The committee will also develop a timetable for completion, including target dates for reaching the goals and interim activities along the way. The committee will develop an evaluation plan with metrics to assess the efficacy and success of the plan and to inform future activities. The committee will report out on an annual basis (every January) to the Cambridge City Manager and release data reports every September starting in 2019. The committee's structure can be informed by the existing Cambridge Food and Fitness Policy Council, which catalyzes action around policies, systems, and practices that make smart food choices and fitness options available to more people in their daily lives and serves in an advisory capacity to city departments on matters related to food and fitness policy issues. The committee will also be supported in its work by the Cambridge Prevention Coalition, which uses a community-based approach to bring about policy, environmental, and social change in Cambridge around substance abuse, and by other groups, such as the CPD Stakeholders and the Senior Policy Group on Homelessness. CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE FUTURE CONSIDERATIONS While the report's recommendations and accompanying strategies are comprehensive, the working group is mindful that there is always more that can be done to address the opioid crisis, as well as substance use and public health concerns that may arise in the future. These include replicating successful programs and services from other municipalities or expanding existing services if additional funding is identified. Such considerations may include: • Population Health Management. Exploring a partnership with Face It Together Health, which provides a range of tools (e.g., intervention, wellness programs, data platforms) for health care, payers, and employers regarding addiction population health management. Establishing a Dedicated Agency or Office for Treatment Recovery Services. Cambridge could use Boston Mayor Marty Walsh's Office of Recovery Services as a model, especially the PAATHS (Providing Access to Addictions Treatment, Hope and Support) anchored to Cambridge Health Alliance as a program which acts as the point of entry and triage for all treatment and recovery support services in Cambridge. APPENDICES 1. Summary of Vice Mayor McGovern's Opioid Report. 2. Topics Presented in Working Group Learning Sessions 3. Members, Cambridge City Manager's Opioid Working Group 4. 2017 Cambridge Overdose Surveillance Report (link to published report) Summary of Listening Session Conducted by Access: Drug User Health Program 6. Members, Governor Baker's Harm Reduction Commission 7. Summary of Site Visit to Montreal (January 2019) 30 | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE Working Group Meeting Topics Appendix I State of Opioids in Cambridge, presented by Tali April 18, 2018 Schiller, MPH (CPHD) Inventory of Cambridge-Based Activities Opioids in Cambridge Data, presented by Kristin Ward, May 18, 2018 MPH (CPHD) Opioid Services in Boston, presented by Monica Valdes May 23, 2018 Lupi, JD, MPH (Executive Director, Boston Public Health Commission) Supportive Place for Observation and Treatment, presented by Jessie Gaeta, MD (Chief Medical Officer, Boston Healthcare for the Homeless Program) Brainstorming an Opioid Services Inventory June 5, 2018 Legal Implications of Supervised Consumption Sites, June 28, 2018 presented by Leo Beletsky, JD, MPH (Northeastern University Leveraging Wastewater to Assess the Opioid Epidemic August 2, 2018 : presented by Mariana Matus, PhD, Newsha Ghaeli, and Erin Winslow (Biobot Analytics) Evaluation of the Insite Program, presented by August 23, 2018 Brandon Marshall, PhD (Brown University) Cambridge Opioid Working Group Listening Session August 29, 2018 (Summary of the Listening Session may be found in Appendix 5) Brainstorming and refining recommendations September 27, 2018 Prioritizing and finalizing recommendations October 25, 2018 31 CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE Members, Cambridge City Manager's Opioid Working Group Appendix I/ Co-Chairs Assaad Sayah, MD, FACEP, SVP and CMO, Cambridge Health Alliance Commissioner Branville G. Bard, Jr., DPA, Cambridge Police Department Members Mark Albanese, MD, Cambridge Health Alliance Louis Cherubino, Cambridge Police Department John Chute, Community Representative Steven DeMarco, Cambridge Police Department Mark Eisenberg, MD, Massachusetts General Hospital Christopher Fischer, MD, Cambridge Health Alliance Ellie Grossman, MD, MPH, Cambridge Health Alliance Meghan Hynes, Access Drug User Health Program Claude Jacob, Cambridge Public Health Department, Cambridge Health Alliance Nancy Mahan, Bay Cove Human Services Gerard Mahoney, Cambridge Fire Department Bill Mergendahl, Professional Ambulance Services Mark McGovern, Cambridge Healthcare for the Homeless, Cambridge Health Alliance Ellen Semonoff, Cambridge Department of Human Service Programs Jared Stanley, Cambridge Police Department Staff Mary Kowalczuk, MSW, Manager, Substance Abuse Prevention Programs, Cambridge Public Health Department Tali Schiller, MPH, Substance Abuse Prevention Coordinator, Cambridge Public Health Department 32 | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE Vice Mayor McGovern's Opioid Working Group Report (November 2017) Appendix III Summary of the Report released by the Office of Vice Mayor McGovern: Addressing the Opioid Epidemic in Cambridge 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 strategies 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. Opportunities and Recommendations for Local Leadership: 1. Increase public awareness and engagement (ongoing). a. Disseminate current information online, through the website, social media, and press. b. Plan community events to educate residents about topics of interest and celebrate recovery. c. Develop a resource guide for families and those seeking treatment or assistance. d. Offer training about how to reduce opioid-related discrimination. 2. Publicize the Good Samaritan Law (ongoing). a. Expand the reach of the Department of Public Health's "Make the Right Call" campaign. 3. Designate a municipal point person or interdisciplinary committee on substance abuse prevention (ongoing). 4. Employ harm reduction models (ongoing). 5. Partner with schools to implement programs aimed at preventing the non-medical use of prescription drugs (ongoing). a. Support the roll-out of Screening, Brief Intervention, and Referral to Treatment (SBIRT). b. Mandate education about non-medical use of prescription drugs for student athletes and their parents. Facilitate safe medication disposal for the discarding of prescription drugs (to be addressed by city manager's advisory group here. a. Install a second medication disposal kiosk. 33 CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE b. Promote medication disposal mailers to vulnerable populations (ongoing). c. Pilot a city-wide free lock-box program. 7. Make naloxone and overdose prevention education widely available (ongoing). a. Schedule and promote monthly naloxone trainings that are open to the public. b. Promote purchasing naloxone at the pharmacy. c. Distribute naloxone kits to all city departments. d. Support program adaptivity and education regarding Safe Consumption Sites and the changing legislature. 8. Expand local options for treating substance use disorder (to be addressed by city manager's advisory group). a. Expand the availability of medication-assisted treatment. b. Connect vulnerable populations to treatment. c. Expand recovery coach programming through dedicated funding for staff and training. 9. Create a sobering center similar to SPOT (to be addressed by city manager's advisory group). 2017 Cambridge Overdose Surveillance Report (abridged) Appendix IV http://www.cambridgepublichealth.org/publications/Substance-Use/2017- Cambridge-MA-Opioid-Overdose-Data-Report.pdf Cambridge Opioid Working Group Listening Session Results Appendix V (Facilitated on August 29, 2018 at Access Drug User Health Program) Goal: We asked to hear from drug users about what is and isn't working in regards to opioid use in the City of Cambridge. About 15 Access participants volunteered to be a part of this feedback session. The information in this session was used to gather feedback about issues relevant to opioid users in Cambridge and incorporate findings in policy recommendations to Mayor McGovern. A. What Services in Cambridge are you currently using? 1. Multi-Service Center 2. Cambridge Housing Authority (CCAN) 3. Intensive Outpatient Program (unspecified) AA/NA 4. First Step 34 | CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE 5. Homeless outreach 6. Access/Needle Exchange Program Notes: People had very positive things to say about First Step, particularly about staff. People expressed that there isn't enough information about what services exist in Cambridge. B. Substance Use Treatment Detoxes and holdings need to be longer 2. In need of more support getting connected to services, particularly CSS/TSS and sober homes while in detox and after. People are getting out of detox after 4 days and are left with no resources or guidance. More holdings. 3. Need more long-term case management and navigation services 4. Lack of Substance Use Treatment services in Cambridge is a moderate deterrent for getting services 5. Lack of beds around the state makes it harder to access services Many people have used the sober shuttle (Everett and elsewhere) and think it's a great model 7. More police outreach 8. Need more services for women C. Housing 1. CORI's continue to be a barrier to housing. 2. In need of services that connect people to temporary and permanent housing and sober homes 3. A greater need for housing resources for women 4. Need for daytime drop-ins that help with resources and give people "something to do." Ideally, these venues would have people who can help navigate through detox and holdings; AA/NA meetings; and accessible low threshold behavioral health treatment. Note: people liked the old Phoenix Center 5. Drop-in for sober people D. Emergency Shelters 1. Lack of clarity and consistency with rules. In need of rule book and for staff to be clear about what people are getting barred for or that they are at risk of being barred. 2. Overall lack of communication between staff and also between staff and guests CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS / 35

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE 3. Concerns about food and food safety. People would like to be able to bring in more food 4. Showers should be cleaned more frequently 5. Frequent reports of meds being stolen by staff 6. Unclear rules around lockers. People should be able to access their belongings while they are barred, or at least be able to retrieve their medications etc. 7. General cleanliness concerns 8. Participants expressed a need for staff to have more compassion and empathy for guests 9. Need for counselors and case managers at shelter round the clock Notes: People raved about Firststep, particularly because of the staff. May be a good model for staffing at shelter. Many people voiced that they would use more services in the city if staff were more compassionate, empathetic and non-judgmental. E. Behavioral Health and Recovery Support 1. Overall lack of mental health services, particularly low-barrier services 2. People need services on demand, around the clock. Lots of crises at night and there is no one to talk to. 3. Need more AA, NA meetings 4. Need more recovery coaches F. Public restroom (Portland Loo in Central Square) 1. Needs sharps containers 2. Emergency pull cord or Narcan smash box that contacts 911. 3. There should be a light that goes on if someone is in there like an airplane G. Overdose prevention 1. Smashboxes for Narcan 2. Staff at shelter and elsewhere need more Narcan training 3. Recovery support services 4. Sober shuttle 36 I CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS

ADDRESSING THE OVERDOSE EPIDEMIC IN CAMBRIDGE Members, Governor Baker's Harm Reduction Commission Appendix VI Marylou Sudders, Commissioner, Massachusetts Department of Health and Human Services Monica Bharel, MD, MPH, Commissioner, Massachusetts Department of Public Health Jeffrey N. Roy, Massachusetts State Representative, 10th Norfolk Cindy Friedman, Massachusetts State Senator, 4th Middlesex Martin J. Walsh, Mayor, City of Boston Marc McGovern, Mayor, City of Cambridge Jessie M. Gaeta, MD, Boston Health Care for the Homeless Program Matilde Castiel, MD, Commissioner, Worcester Health and Human Services Robert Roose, MD, Mercy Medical Center Armando Gonzalez, Massachusetts resident Aubri Esters, Massachusetts resident Deirdre Calvert, LICSW, Column Health Gary Langis, Education Development Center Frederick Ryan, City of Arlington Police Department Leo Beletsky, JD, MPH, Northeastern University Summary of Site Visit to Montreal (January 2019) Appendix VII In January 2019, a delegation from Cambridge traveled to Montreal to tour harm reduction and safe injection facilities. This delegation included Cambridge Mayor Marc McGovern,, • : Chief of Staff Wilford Durbin, and four members of the City Manager's opioid working group: co-chair Commissioner Branville Bard, Jr., Dr. Mark Albanese, Dr. Ellie Grossman, and Chief Public Health Officer Claude Jacob. The trip was intended as a fact-finding mission regarding harm reduction strategies on behalf of the Massachusetts Harm Reduction Commission. During a two-day visit, the group visited with service providers, program staff and elected officials that included representatives from CACTUS Montreal, LAnonyme, GRIP Montreal, Spectre de Rue, Old Mission Brewery, as well as the Mayor of Montreal. 37 CITY MANAGER'S OPIOID WORKING GROUP: FINAL REPORT AND RECOMMENDATIONS |

Cambridge *CHA Public Health Cambridge Department Health Alliance

Attachment E OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV WEDNESDAY, JUNE 19, 2019 COMMITTEE ON HUMAN SERVICES AND VETERANS OFFICE OF MAYOR MARC C. MCGOVERN Harm Reduction Observations from fact-finding mission January 17-18, 2019 Strategies in Montréal

OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV Delegation included members of the Cambridge Opioid Work Group • Dr. Mark Albanese, Director of Cambridge Health Alliance's Adult Psychiatry and Addiction Services • Montréal's experience putting into practice opioid-use related harm reduction strategies • The provincial-municipal partnerships that support SIS operations • How SIS facilities interact with the surrounding neighborhoods • The impact those policies have had on individuals with opioid addiction • Work Group Co-chair Dr. Branville Bard, Police Commissioner • Dr. Ellie Grossman, Cambridge Health Alliance's primary care lead for behavioral health integration • Claude Jacob, Chief Public Health Officer • Wilford Durbin, Chief of Staff. Overview Meet with supervised injection services (SIS) operators, city officials, and community leaders to understand:

Montreal Hochelaga-Maisonneuve Social Services Centres (CIUSSS) Services • Integrated University Health and • GRIP Montreal • City of Montreal Police Department • Ministry of Health and Social • Mayor Valerie Plante, City of • Mayor of Borough Mercier- • Mission Old Brewery Municipal/Community Partners OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV • SIS CACTUS Montreal • Dopamine • L'Anonyme (mobile facility) • Spectre de rue SIS Facilities Site Visits & Discussions

Ouébec na at Sarvices sociauy Santé places Crime in public places services equipment rehabilitation • supervised injection • referral to • sterile injection • opiate therapy Awsyringes discarded • counseling We Nequipment sharing injection in public Users have access to: equipment, supervised injectable opioids injection services and Access to injection prescription of places in public places. rehabilitation injection services equipment Crime = Losyringes discarded • supervised injection in public • counseling • referral to I equipment sharing • sterile injection Users have access to: Access to injection equipment and services supervised injection SOURCE: GOUVERNEMENT DU QUÉBEC, 2014: 23 rehabilitation equipment services in public places places = • sterile injection • referral to • counseling syringes discarded Access to injection Injection in public $ HIV equipment Crime = Users have access to: V equipment sharing OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV measures to injection equipment access programs (Cloutier 2013) Comparative effects associated with the addition of harm reduction Caption: J: Decrease = No change JW: Greater decrease Jd: Significant decrease Characteristics Effectiveness of harm reduction Effects Cloutier, M. Nurs. Public Health General Direction Prevention and response to equipment and supervised injection and inhalation opioid overdoses " Richard injection services; in Québec: Access to "Harm Reduction Services

have time/injection limits reported back to community sterile water, syringe, tourniquet, filter, fentanyl Any illicit material left on site is secured and People are escorted to the injection room, most Materials provided: alcohol swabs, sterile cooker, Room is equipped with defibrillator, oxygen, heart rate monitor, naloxone care providers "Bat phone" in injection room Injection users wait in a community common test strip turned over to police for analysis, results OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV SIS Operation

out of overdose and call ambulance onsite dangers of certain drug mixtures OPS facilities do not have a nurse on duty ("Superman," "Spiderman," etc.) • Visitors give a nickname to access services • Name and information is not verified • Allows service providers to advise visitors on • Unlike supervised/safe injection services (SIS), • During emergency, service providers take person • When nurse is present, overdose is handled • Shortage of nurses in Montreal • Follows injection users across SIS sites Overdose Prevention Services (OPS) Centralized information system OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV SIS Operation Continued

drugs • Syringes, sterile cooker, swabs, etc. • Harm reduction information on various • Sexual health information • Condoms • Fentanyl Strips • PREP both Available for Pickup: facility, or access sterile materials, or Injection users can either use SIS OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV Drop in Center: Access to Preventative Materials

OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV • Outreach programs to drug users, sex workers, homeless • Constituent efforts in low threshold lead to higher-threshold services • Wages do go to addiction, but were earned through legitimate labor, contributing to society • Defend rights to health care, educate, destigmatize, advocate for drug user community, HIV prevention • Low threshold programs • Day labor offered average 3.5 hours per day, cash payments at end of each day • Good behavior leads to more hours, end goal of contracted service with local company Nested Services: "Put social workers into Public syringe drop/off boxes Day Programs Access to counseling and recovery programs Good Neighbors Committee the basic fabric of services" Jobs Program

Québec da Santé et Services sociaux OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV Organizations offering SIS are already providing: and medical referral treatment health nurses services. equipment • basic health services, counselling • social services, addiction • training and job placement • HIV and HCV screening by public • access to sterile injection "Harm Reduction Services in Québec: Access to injection and inhalation equipment and supervised injection services; Prevention and response to opioid overdoses," Richard Cloutier, M. Nurs. Public Health General Direction

OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV

OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV dinal cav

OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV

Estimated 40% of users are homeless One-on-one distribution in the back, Monitor for sex exploitation and STD Cover 12 neighborhoods in one night, on call Received more support than pushback from prevention core to mission prevent and treat soft tissue infections Becoming a popular model in Canada users Operators see higher percentage of women encourages counseling, some testing of drugs, Two psycho-social workers on bus as all times community OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV Mobile SIS: L'Anonyme

Larre d'or OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV L'ANONYME J

Fentare Feck GO OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV Other Harm Reduction Strategies ANALYSE ANALYSIS REGINLY

Materials Distributors of Pharmacies #1 Injection 46 40 49 40 90 49 274 139 46 74 161 Total 1245 24 84 12 Community group 16 49 30 50 84 12 20 26 23 231 55 27 47 792 113 Pharmacies 14 Rehab centers OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV clinics Private LO 10 86 Hospitals 17 14 12 22 18 16 12 35 16 19 19 CLSC 249 Centre-du- Région Gaspésie-lles-de-la- Chaudière-Appalaches Lanaudière Total Abitibi-Témiscamingue Montérégie Laurentides Estrie Mauricie Outaouals Côte-Nord Madeleine Laval Québec Montréal Capitale-Nationale Nord-du-Québec Bas-Saint-Laurent Saguenay-Lac-Saint-Jean Prevention and response to opioid overdoses," Richard Cloutier, M. Nurs. Public Health General Direction "Harm Reduction Services in Québec: Access to injection and inhalation equipment and supervised injection services; Number of injection material centers in Quebec (2014)

9-1-1 EMERGENCY (give 2 compressions of 5 cm deep per secon or start giving CPR if you have been trained, using the bamer mask. or pain (rub the centre of their chest hard). of breathing. administration: 4. Perform chest compressions immediately If they are unresponsive 3 minutes after 2 Call or have someone call 9-1-1. 3. Administer a dose of naloxone. If they are unresponsive: If they are unresponsive: 1. Try making them respond to sound (yell their name) 5. Administer another dose of naloxone. drugs and shows the following signs: • Laboured or snore-like breathing, or absence • No response to sound or pain. The person might have used medications or illicit If the person seems to be unconscious: Recognizing a possible overdose as possible. Quebec BE at the same time, • use supervised injection services, when availat opiaid overdoses, in Québec, naloxone is available • avoid using drugs when you're alone. To prevent the risks linked to overdose, pharmacy. To find a pharmacy near you that has • when you're in a group, don't all uso drugs free of charge and without a prescription at any naloxone anytime, call Info-Santé toll free at 811 or go to sante.gouv.qc.ca/en, Finding a Resource. - have naloxone on hand. Naloxone is a medication used as an antidote for a clean mat on the preparation gel or alcohol swabs. with a clean cloth or alcohol Clean the preparation surface equipment on it. If possible put and water, or use an antiseptic Wash your hands with soap Clean hands and a clean surface on which to put the injection equipment BEFORE INJECTING and pull. Grab the loose end in your mouth Holding the toumniquet in place with your fingers and stretch it out lightly. thumb, pick up the loose end with your free OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV and between the tie and the arm Make a small loop to slide the free Ouébec SE arm with your thumb and let the other end hang on the outside of your arm. the injection site. Hold the end on the inside of your Loop the tourniquet around your arm, 5 cm above Reducing risks injection ONE KIT ONE HIT requiarty. Replace it your tourniquet. end. Make sure to keep it stretched end of the tourniquet over the other Keep it extended and place the loose so it stays in place. USE A TOURNIQUET BEFORE INJECTING on fait avancer le Quebec ENSEMBLE>. • Medium risks • High risks ON WHERE YOU INJECT LEVEL OF RISKS DEPENDING

side of the cup to remove as much lieuid as possible SMALL BAG the previously emptied amal bag. Run the damp end of the The strips are not 100% After 10 minutes, the result is no longer valid. that stace an er doctor 3 minutes. since the test is very sensitive Only a very small amount of the substance is needed, his the cotton aunt ho damo end of the annlicato trask the tablet or tock and run or 30 seconds in the water lor 3 ceconds applicator in the cup the end of the soplicator TABLET OR ROCK All forms of substances can be tasted. pycent those to which an acidifier (vitamin C, vinegar) has been added. Take the test strip our of its package just before doing the test. 15 seconds. Be careful not to go past the The he he love re tor no *Ror the uaul prenaration and applicator in the bottom of the cup. (up to the first line from the bottom). run the dame end of the cup Using a syringe This testing method is the most reilable. rock of plastic bag • Using the cup, tablet, TEST THE SUBSTANCE PREPARE THE SAMPLE FOR TESTING PREPARE THE CONTAINER OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV Applicator Test strip detect fentanyl and CONTENTS OF THE TEST KIT The test kit is intended for drug some of its analogues. users to reduce risks of overdose. *• Keep the test strips at a temperature between 2 and 30 °C** How to use test strips to information on the presence of fentanyl in drugs so it can better While not obligatory, your participation is very important! inform drug users and improve its interventions. To participate, Montreal's regional public health department is looking to collect please fill out the anonymous online questionnaire: bit.ly/fentanyiMTL witnesses of overdoses who call 911 from charge The Good Samaritan Drug Overdose Act can protect How to use test strips to detect fentanyl and some of its analogues INTERPRETATION OF RESULTS dentify who has naloxone and knows how to use it Call 911 if there is an overdose. Repeat the test. Test strips with no control bar (on the right) should be thrown out. Using substances obtained on the black market is never 100% safe. Other powerful on the concentration of fentanyl in the sample tested NEGATIVE doesn't contain fentanyl concentration. The fact that the result appears slowly or quickly doesn't provide information INDETERMINATE considered positive substances similar to fentanyl could be in the drug. INVALID Interpretation of results showing two coloured lines of different intensities is limited; consider it positive or repeat the test, to be safe. The sample contains fentanyl or some of its analogues. The test doesn't determine the • Test the effects of the substance: reduce the dose. POSITIVE contains fentanyl or certain analogues • Avoid using alone. • Use SIS. Regardless of the result, if you decide to use the substance, do the following: • When several people use together, avoid using all at the same time;

Médicaments opiacés [Draudo: coene etc E cigarette, vapoteuse, vape. Médicaments opiacés injectés Cigarette électronique OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV shoulder muscle (st a PO" angle) Laboured or snore-like breathing. or absence of breathing Québec BE START giving CPR if you using the barrier mask have been trained. RUB the centre of their chest (sternum) hard YELL their name TALKTO THEM loudly No response GIVE 2 compressions (5 cm deep) per second =180 to sound or pain POSSIBLE OPIOID OVERDOSE: WHAT TO DO The person might have used medications or illicit drugs • Parform chact comaressions in: 2 min IF YOU ARE ON YOUR OWN WITHOUT A PHONE: REPEAT STEPS 4 AND 5 is unresponsive as long as the person • Find a way to call 911 and follow instructions • Inject a dose of naloxone • Lay the person on their side and shows the following signs: Remove • Stone nalavone in a cool dark clace 911 ldministration of naioxone seems to be unce IMMEDIATELY RESPOND TO SOUND PERFORM OR PAIN OF NALOXONE OF NALOXONE CALL OR HAVE CHEST COMPRESSIONS CALL INJECT INJECT ANOTHER DOSE SOMEONE TRY MAKING THEM A DOSE hey are unrespon Lay them on their side. Explain what just happened and how it's important that they be seen by a health professional Tell the person that they should not use opioids in the next few hours to avoid another overdose. Stay with them while wating for melp. The Good Samantan Law provides protection for overdose witnesses and victims. IF THE PERSON WAKES UP. They mean sardens socia RECOGNIZING A POSSIBLE OVERDOSE

OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV PULLED FROM COMMISSION REPORT Harm Reduction Commission Overview

Commission Overview meeting. Copies of all presentations and reading materials requested and considered by the be issued no later than March 1st, 2019. http://www.mass.gov/lists/harm-reduction-commission-meeting-minutes. Commission are posted on a publicly available webpage: http://www.mass.gov/orgs/harm- vote of the Commission, the Senate and House Clerks were notified that the findings would were subject to the open meeting law and minutes were taken and approved for each states/countries that have established harm reduction strategies - including supervised ([email removed]). 2018. Commission was charged with reviewing the evidence base and experiences of other consumption sites - to address substance use disorder. reduction-commission. • Minutes of the Commission's meetings may be found online: • The Commission met seven times from October 2018 through February 2019. All meetings • The Commission's findings were to be submitted to the Legislature by February 1st, 2019. By • An email address was created for members of the public to submit comments and questions: • The Harm Reduction Commission was established in Section 100 of Chapter 208 of the Acts of • The Commission's full charge may be found in Appendix A. In developing its findings, the

22 Commissioner, Worcester Department of Public Health Massachusetts Resident Massachusetts State Senator Massachusetts State Representative Mayor of Cambridge Director of Psychotherapy, Column Health Mayor of Boston Chief Medical Officer, Boston Health Care for the Homeless Program Chief of Police, Arlington Police Department (now retired) Chief of Addiction Medicine and Recovery Services, Trinity Health of New England Training and Technical Assistance Specialist, Education Development Center Massachusetts Resident Commissioner, Massachusetts Department of Public Health Associate Professor of Law and Health Sciences, Northeastern University Title / Affiliation Secretary, Executive Office of Health and Human Services, Massachusetts Harm Reduction Commission Members Cindy F. Friedman Frederick Ryan Gary Langis Robert Roose, MD Aubri Esters Armando Gonzalez Martin J. Walsh Marc McGovern Jessie M. Gaeta, MD Jeffrey N. Roy Name Marylou Sudders (Chair) Matilde Castiel, MD Deirdre Calvert, LICSW Leo Beletsky, JD, MPH Monica Bharel, MD, MPH

OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV linkages to other services. transmission. • These sites can also provide a safe space where people may receive harm reduction materials and • These sites keep people who use drugs alive and help reduce the public health risks of disease Harm Reduction Commission Recommendation 1 of 2 have been implemented. municipalities, must foster a culture of harm reduction throughout the state and expand the Supervised consumption sites are an effective harm reduction tool in the countries where they array of harm reduction resources. In order to continue to combat the opioid crisis, the Commonwealth, in partnership with its

OFFICE OF MAYOR MARC C. MCGOVERN, MAYOR@CAMBRIDGEMA.GOV prohibitions on supervised consumption sites. • An additional challenge is the federal government's strongly stated current stance against supervised Harm Reduction Commission Recommendations 2 of 2 Commonwealth's efforts to combat the opioid crisis. Any pilot program must receive local approval and include a rigorous evaluation of the outcomes A pilot program of one or more supervised consumption sites should be part of the for individuals and impact on the surrounding area and municipality. individuals who would staff a supervised consumption site and any state criminal and civil laws that may pose a barrier. In order to pursue a pilot program of one or more supervised consumption sites, the challenges the Commonwealth must address include any gaps in legal protections for organizations and