S6E3 Harm Reduction: Compassionate Solutions to Maine’s Opioid Epidemic

In this episode, we interview Gordon Smith, Alex Rezk, Dr. Rachel Solotaroff, and Glenn Gordon on the opioid epidemic in Maine.

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Transcript

[00:00:00] Dr. Rachel Solotaroff: As we have advanced our definitions of a substance use disorder, it’s an understanding that it’s a spectrum disease, right? It’s not black or white, it’s not good or bad, it’s not dirty or clean. It is a severe substance use disorder, a moderate substance use disorder, a mild substance use disorder. If you have five heavy drinking days, and then you reduce that to three heavy drinking days, that is success, that is clinical progress.

[00:00:29] Eric Miller: That was Dr. Rachel Solotaroff, a panelist in today’s episode discussing the opioid epidemic in Maine.

Hello, and welcome back to Maine Policy Matters, the official podcast of the Margaret Chase Smith Policy Center at the University of Maine, where we discuss the policy matters that are most important to Maine’s people and why Maine policy matters at the local, state and national levels. My name is Eric Miller and I’ll be your host. 

Today, we’ll be interviewing Gordon Smith, Alex Rezk, Dr. Rachel Solotaroff, and Glenn Gordon on the opioid epidemic in Maine.

Gordon Smith was appointed by Governor Janet Mills as Director of Opioid Response in January 2019. He is responsible for coordinating and directing Maine’s response to the opioid crisis, including prescriber education and reduction of opioid prescribing, prevention and treatment of substance use disorder, and harm reduction strategies. He stepped down as the Executive Vice President of the Maine Medical Association in January 2019, where he had served as its Executive Vice President since September 1993 and where he began as General Counsel in 1981. He graduated from the University of Maine with the highest distinction in 1973 and from the Boston College Law School, Magna Cum Laude, in 1976. 

Alexander Rezk, a research associate at the Margaret Chase Smith Policy Center, is currently completing his Ph.D. in Anthropology and Environmental Policy at the University of Maine. His research interests focus on disaster and risk management, particularly with regard to the human dimensions of climate change, rural infrastructure and resilience, public health and emergency response. Alex works on various projects related to the opioid crisis, public health and community policy initiatives, such as serving as the Policy Center’s Project Coordinator for the Maine Naloxone Distribution Initiative or facilitating a workforce census and vulnerability assessment of statewide fire response resources in collaboration with the State Fire Marshal’s Office and Maine Emergency Management Agency.

Dr. Rachel Solotaroff, MD, MCR, FACP, is Penobscot Community Health Care’s Executive Clinical Director of Substance Use Disorder Services. She also serves as the Medical Director for two withdrawal management centers in Maine. Dr. Solotaroff previously served as the President and CEO of Central City Concern in Portland, Oregon, an agency providing health care, housing and employment services. At Central City Concern, Dr. Solotaroff oversaw the opening of the $55 million Blackburn Center, which serves as a model of comprehensive solutions for ending homelessness. She oversaw the development of 1,100 new and refurbished units of supportive housing for veterans, people living with serious mental illness, and people in early recovery from substance use disorders. 

Glenn Gordon is a seasoned outreach clinician with Oxford County Mental Health Services. With over 35 years of experience, Glenn has witnessed the evolution of addiction treatment and brings invaluable insight into the complexities of recovery. Serving as a liaison for individuals struggling with substance use, Glenn collaborates closely with Oxford County Law Enforcement to help people access essential addiction resources and navigate the path to recovery. Glenn’s understanding of addiction is both professional and personal. His journey began in his early teens with alcohol and drug use, and at 20, he experienced his first attempt at recovery following a period in jail. After a relapse 17 years later, Glenn recommitted to recovery in 2008 and has maintained his sobriety ever since. Today, he channels his experiences into helping others, bridging the gap between those in need and the resources available to them.

Overdose deaths in Maine have been on the rise since 2013, driven by the increasing presence of synthetic opioids in the drug supply. Fentanyl, a highly potent synthetic opioid, has played a significant role in increasing overdose deaths in Maine. Its presence in the drug supply has made accidental overdoses more likely, even for those who believe they are using other substances. Synthetic opioid overdoses began increasing in 2013, leading to nearly exponential growth beginning in 2014. According to the Maine Drug Data Hub, in 2017, all fatal overdoses in the United States and all fatal drug overdoses and fatal fentanyl overdoses in Maine peaked, then slightly dipped in 2018. In 2019, fatal overdoses rose again and reached a grim milestone of 100,000 deaths in the United States between March 2020 and April 2021. In Maine, drug deaths increased 7% in 2019, 36% in 2020, and an estimated 23% in 2021.

During this time, drug deaths and non-fatal overdoses have also increased due in part to the global COVID-19 pandemic. In recent years, the CDC reported that there has been a 10.6% decrease in drug deaths between April 2023 and April 2024. Legislative progress was made in June of 2021, when Governor Mills signed into law LD 1718, an act to establish the Accidental Drug Overdose Death Review Panel. The panel has since allowed for a deep dive into selected overdoses, both fatal and non-fatal, have made available their first work report in 2024, and have publicly presented plans for the future. 

Prevention efforts in Maine involve a multi-faceted approach. Schools, healthcare providers and community organizations work together to provide education, counseling and support services.

Initiatives may include harm reduction strategies, which we will discuss further with our panelists,  such as access to clean needles and naloxone, a medication that can reverse opioid overdoses. Additionally, efforts are under way to address the root causes of addiction, including poverty, unemployment and lack of mental health support.

Hello, everyone, thanks so much for joining us today. The nature of the opioid epidemic has changed a lot since the overprescribing of opioids, namely Oxycontin, since the 1990s.

While more people have died in recent years than at any other point in this crisis, do we know if more people have an addiction or substance use disorder? And what makes the opioid epidemic  different today than it was from the past, from your perspective? 

Rachel, would you mind starting us off with this?

[00:07:04] Dr. Rachel Solotaroff: Yeah, sure. Well, thanks. It’s great to be here.

There’s sort of a lot of ground to cover here. I mean, knowing about the prescription opioid epidemic itself, we’ve often talked about that in this idea of the triple wave, sometimes the quadruple wave, the first wave of opioid overdose deaths starting in the 1990s with the, you know, abundant prescribing of prescription opioids. And then the second wave came probably 2010 or so, as more, we saw an increase in deaths related to heroin. And then shortly thereafter, the third wave came, which around 2013, 2014, as fentanyl came into the drug supply. And that’s where we saw this, you know, precipitous increase in overdose deaths, the likes of which we’d never seen up until last year had not really tapered off at all. There’s a lot that people say about a fourth wave, which we don’t have as beautifully depicted in graphs and narrative, but which involves polysubstance use, people dying from fentanyl with stimulants such as amphetamine and cocaine.

So that’s kind of the high level on the prescription opioid. I can dig a little bit into just prevalence around substance use more broadly. And it’s a little tricky to talk about trends in substance use disorders across a decade because the National Survey on Drug Use and Health, which for me is kind of the reliable national data source that I go to, changed the way it was capturing data and using the different diagnostic criteria for substance use disorder prior to 2019 and then after 2020. Up until about 2019, though, we were seeing a pretty consistent level of substance use disorder in the United States, somewhere around 19 million, 20 million, 22 million. As the data collection methodology changed in 2020, those numbers doubled and we start seeing more numbers like, 41 million, 43 million people with a substance use disorder. But I don’t think that that increase can be discounted as only a change in the way the data are collected.

We know from the rise in overdose deaths, that’s a consistent number and that is predicated on an increase in substance use. We know about additional ER visits among young adults went up precipitously between 2019, 2018, all the way up through 2022. ER visits by young adults for substance use disorders.

We also have some local data, particularly here in Maine, which does tell us, and there’s lots of granularity on this, but we rank among the highest quintile in the nation for people using any illicit substance in the last year, and tend to have a pretty strong record on alcohol use disorder as well, with about seven to nine percent of the population of Maine having an alcohol use disorder. So those are just some broad trends and prevalent snapshots of where we are today.

[00:09:58] Eric Miller: Yeah, thank you. Gordon?

[00:10:01] Gordon Smith: I would just give you a lawyer’s observation as a person that now has the privilege to do drug policy for the state that there seems to be as much usage as ever. And I feel like our job is really just to make more resources available for people who are seeking recovery, also to do good harm reduction so that they have that opportunity and to do as much as we possibly can in the prevention space with young people. But it’s an enormously complicated matter.

And I think anybody would be naive not to acknowledge that a lot of people are using substances of everything from nicotine to marijuana to alcohol. Huge problem in the state to what I primarily work on, which is fentanyl and illicit hard drugs.

[00:10:52] Eric Miller: Yeah. We know how many people use drugs. And Rachel mentioned the National Survey of Drug Use and Health and how it’s difficult to know how many people use drugs in given areas throughout the United States.

Alex, can you discuss some of the data elements and what we can know and can’t know?

[00:11:09] Alex Rezk: Yeah. I think a big component of this conversation is thinking about the factors that impact the visibility of people who use drugs or their relative invisibility. And so our surveillance tools are only as good as the criteria that are being used to count the folks. And that criteria is difficult to winnow down to capture the vast breadth of behavioral norms in community, which is what we’re ultimately describing here, that would constitute, say, substance use to the level of a substance use disorder that may be undiagnosed. You know, we have to take for granted almost in a harm reduction perspective that the vast majority of use is probably invisible. And that brings you back to the human element of the opioid epidemic, which is that these are not statistics.

These are our neighbors, our friends, our family, our peers, our colleagues. We may work every day with high functioning people in the throes of a substance use disorder and not even be aware of that. So, you know, how do you account for that?

Well, folks who use drugs are all around us. In all likelihood, like with many other pathological contexts, the diagnostic rate, like the number of people actually diagnosed, is an undercount of the total number of people suffering from disease. So, you know, we think that there’s likely, maybe a change more in how many of those people are visible than there is a change in how many of those people exist over time. It’s likely that, as we know from historical precedent and the literature would attest, this is not a novel behavior, the use of drugs in human cultures. I’m an anthropologist by training, and the use of drugs is one of the oldest behavioral norms, not only amongst humans and other high-level primates, but across the animal kingdom. So this is something that is substantive in behavior.

So we can think it’s probably relatively consistent as an element of society that needs to be contended with. What we’re seeing now are differences around the context of use that change that visibility rate. So to answer the final part of this question, I think the difference in the epidemic that’s been the biggest is the fatality of the drug supply. And that’s tipped levers on how and when we are notified of the existence of people with substance use disorder or who end up encountering accidental drug overdose. Unfortunately, the metric that’s most relied upon in public health statistics that are communicated tend to be mortality rates because those are the ones that are available to us. And as we like to say at the University of Maine, deaths are not the best barometer for the success of combating the opioid epidemic.

And that speaks to the fact that they’re not necessarily representative of the vast majority of people being impacted by the opioid epidemic. So I think visibility has probably changed more than the total prevalence. And that’s what we tend to think of as we think about achieving things like naloxone saturation.

It’s about identifying people and community where they are. And I guess this is a question about identifying them where they are in the data.

[00:14:03] Eric Miller: Yeah, absolutely. You mentioning drug use is not a novel thing among humans. I’ve read about the lead up to the opioid, opium wars in China and some of the policy discussions around the emperor. And there are some voices that were pretty progressive then. And about drug decriminalization, legalization is really interesting how that relationship or that type of discussion has been around for such a long time. And mentioning community gets me to Glenn, where your involvement in community work, how has the landscape changed from your perspective, especially post-Covid.

[00:14:37] Glenn Gordon: I think about the social and political context. And so the last peak we had in opiate use in the United States was back in the late 60s, early 70s, a lot of political unrest, civil–Vietnam War, civil rights, all this kind of stuff. So that’s our last peak. And what do we know about opiates? They give us comfort. They are a comfort drug. And so in times of crisis, it’s a great source of comfort to people.

So I think as prescription drugs hit the market, and then during the mid 2000s, you know, things are coming. We also run into some political unrest. We run into some civil unrest. And then we get into COVID, right? And the peaks of the fatal overdose numbers are taking place in the midst of COVID and on the tail end of COVID, right?

Where people are isolated, they’re alone and they’re looking for comfort. So they’re turning to a comfort drug opiates. And so I think it’s hard for me, you know, even in a rural community in Maine, see the effects of political unrest, see the effects of COVID in isolation and all that kind of stuff.

And so I think that really speaks to some of the landscape that are, some of the, you know, some of the things we’re seeing with the opioid epidemic in the country. You know, the other thing I think that we just seen is, you know, we went from heroin to fentanyl. We went from increased availability of a drug, increased potency of a drug like we’ve never seen before.

Our crazy increases, and so we used to have to harvest and go through all this stuff and import, you know, it was really complicated. But now we can make it–mass produce an opiate that’s 50 to 100 times as strong. So that’s changed the landscape.

The other thing I think some barriers that are broken down, we think is IV drug use was a fairly isolated thing and a lot of people didn’t do it. People are scared of it. There’s a lot of fear and yet we’ve broken through that fear. Like now IV drug use is much more normalized and commonplace like it’s never been before. That’s another thing that’s added to the landscape. People are getting stronger drugs, more potent, they’re getting into their systems. It’s increasing the potential for not just increasing the addiction part of the opiates, rapidly getting addicted to opiates because of the potency and the means of getting it into the bodies and all that stuff. I think all these things are like other factors that really play into what we see over the last 15, 20 years and those things start to even out a little bit really now in the tail.

Like my experience is seeing a small decrease in opiate use and seeing an increase in stimulant use and probably substance use, which I’m sure we’ll get into a little bit later in the talk.

[00:17:03] Eric Miller: We will, absolutely. And I appreciate you discussing opioids in the real sense in that they serve as a means of comfort for people. And so I think that’s missing from the conversation–in mainstream talking heads in the cable news, talking about, if I know this, people who are addicted to that and not necessarily what’s happening to those folks.

And so the risk of use segues nicely because there are theories to why so many people use these types of substances. What are some of the primary risk factors for opioid and other substance use disorders in Maine? And how can some of those factors be addressed?

And in the clinical sense, Rachel, I know that you work with this quite a bit.

[00:17:46] Dr. Rachel Solotaroff: Yeah, yeah. I think that there’s a standard set of risk factors which are present, as Glenn pointed out, through over time and across geography that are common in Maine. So there’s a genetic predisposition that we know. There’s been a lot of work done around traumatic events, particularly in childhood. The incidence of an adverse childhood experience increases someone’s risk of a substance use disorder by anywhere from 4 to 12 times. So history of trauma is a profound risk factor.

Co-occurring mental health disorders, particularly those that are untreated. Sometimes I think of, in some ways, as you were saying, Glenn, just social dislocation, living in a fragmented modern society in and of itself can cause some mental health disturbance. Sometimes the social environment, the availability of substances, what’s around, there is social impact.

Then there are often, and I’m careful to say this, but there are economic factors that lack of meaningful wage, difficulty with unstable housing. I have colleagues though, just as a side note, who have grown up in rural Maine, and sometimes take offense when I say that. Like I grew up in a rural poor place, that doesn’t mean that I use, so I don’t think that there is, I’m always careful not to say those are collapsing categories.

One doesn’t necessarily lead to the other, but there’s an association there. And if I can just talk about the housing issue, because I think this is one of the things that is distinctive about Maine, there is abundant evidence about the bidirectionality of substance use disorder and the absence of safe and affordable housing. And we know that when people don’t have safe and affordable housing, it can increase the risk of substance use, and it’s bidirectional. An increase of substance use can make somebody more likely to end up without safe and affordable housing. 

But the abundance of research tells us that it’s addressing the structural factor of the absence of housing is what helps to address homelessness and helps to address people’s underlying substance use disorder.

And this isn’t a podcast about housing, but we know how pronounced the housing crisis is in Maine, particularly around affordable housing. And so I thought that was one worth calling out here because we see it in data, but to Glenn’s earlier point, we see it every day among our brothers and sisters and neighbors. What the impact is not just of being on the street, but being an unstable or unsafe or unaffordable housing.

[00:20:13] Eric Miller: Yeah, absolutely. Glenn, what are some of the risk factors that you see are most pronounced when interacting with other folks with substance use disorder?

[00:20:22] Glenn Gordon: I do have a little bit of a skewed perception, I think, because of the nature of a lot of my time for referrals are coming through law enforcement or through hospital emergency departments or sometimes other different things like that. So I sometimes, I’m so into it, I have a very sometimes skewed perception of that. But I think Rachel really spoke to a lot of those things.

I mean, I think what I see is in folks I’m working with multigenerational poverty, trauma and abuse, ACEs, you know, adverse childhood experiences, multi-generational substance use, you know, real difficulties sometimes with basic needs. So I mean, not food, shelter and clothing like Rachel was talking about. I think that’s a huge, a huge factor.

I mean, and sometimes just to gain any traction in getting some people, some assistance is really like starting out, really addressing really those basic needs. In the folks that I encounter and work with on a daily basis, there’s a lot of co-occurring mental health issues and they vary in complexity and severity. But it’s very rare that I don’t encounter depression and anxiety at one of the spectrum, bipolar and schizophrenia at the other end of the spectrum.

Sometimes the substances are being used to manage that for people who are not getting into it. Sometimes that is actually when they first start using substances, it’s actually helping them with any mental health issues they have, but eventually it starts to go in the other direction over time. All those things, I think the other thing is just the availability. 

I think even adding to some degree, this is what I see is we’ve broken down barriers by legalizing. I’m going to go out on a limb here a little bit, but by legalizing, marijuana is, in my opinion, and in people I encounter, it’s broken a barrier to altering your state of consciousness, is okay. I’m encountering really young folks getting introduced a lot freer, I think maybe then again, like I have a skewed… But being introduced to drugs at a younger age and with a lot less comfortably. They’re comfortable getting introduced by their family and older friends and even parents to substance use at a younger age. So I think it’s breaking a thought like, oh, this really isn’t that big a deal.

[00:22:27] Eric Miller: Sure. Yeah, that’s really interesting. The self-medicating element of it too, to help treat another health condition that one is dealing with, and then that can lead to a substance use disorder that then interacts with various other health conditions that folks have is really interesting.

Gordon, from your point of view at the Governor’s Office of Policy Innovation and Future, and we’re going to really get into policy interventions to prevent fail and non-fail overdoses later, but addressing some of these risk factors specifically, what are some that you all are trying to prioritize?

[00:23:02] Gordon Smith: Well, I think Rachel did a great job of talking about the things that I normally talk about. I would start with genetic predisposition and quickly get into ACEs and trauma. We know why people use drugs. They use drugs not so much to get high, but to escape the memories of that trauma. 

The one thing that Dr. Solotaroff did not mention was systemic racism and oppression and cultural issues. We see this in Maine’s indigenous population. We see it in Maine’s BIPOC population. And we should not ignore it. It’s very much now, in a way, you could say, well, it’s covered with adverse childhood events, but it’s more than that.

And so I think that that’s the one factor, along with all the economic things that have been mentioned. If we really eliminated childhood poverty, eliminated any and gave and ensured everybody had a warm home and a roof over their head, food security, equal opportunity, along with that systemic oppression and discrimination and racism is unequal opportunity. The perception, because I’m in this situation, that I will never have a chance to go to college.

I will never be able to get a good job. So unequal opportunity is also part of that, those systemic issues. 

But the last point I’ll make, that I was starting to make, is that if we eliminated all these social conditions that we struggle with, that are very difficult to eliminate. I mean, housing being number one, we can’t just snap our fingers and come up with 85,000 units of housing, which we need in the state, and make those affordable for people. But if we were able to house everyone and give everyone economic security, then drug use, in my opinion, would drop exponentially.

There may be 10% of what it is now. 

We will never, as has been mentioned earlier in the podcast, we will never eliminate all entirely people using substances, legal or illegal. But the tremendous damage that we’ve seen from the war on drugs and all the things we’re here to talk about today, we can do a lot better than this. And I hope we do. And we’re working on it.

[00:25:24] Eric Miller: Yeah. And I think that that’s part of something that is difficult to grasp about the length of the opioid epidemic is that it’s so holistic and how it can manifest in sub-chaotic substance use.

Alex, do you have anything you like to add to the risk factors point?

[00:25:41] Alex Rezk: Yeah, I think that my panelists, my co-panelists here touched on most of the really salient points. Jumping off of where Gordon’s comments came in, I think my contribution to this was really just going to be pointing us towards in a policy sense. The question sounds at the front end as if it’s framed more from a clinical perspective. I think that in a policy sense, we think of these things as broadly falling under this category of social determinants of health. We addressed a handful of them in this conversation.

 I think of them as falling into two broad categories, one of economic precarity and one of social marginalization. They speak to broad alienation socio-economically within society, that it predisposes people to negative health outcomes, not just in the context of the opioid epidemic or substance use disorder, but across multiple contexts that public health governance is concerned with. This is an issue that’s contended with in nutrition and food science, for example. Food and health equity and access to different kinds of things isn’t just an issue here.

I think the thing I’d also point to that we haven’t specifically called out, but the Gordon you alluded to is the role of the war on drugs in reinforcing systemic alienation, and primarily, as Glenn mentions here, issues of stigma, and then I’d add criminalization and medicalization. One thing that was just mentioned I think that’s salient to draw out is we’re talking now about the opioid epidemic and the current war on drugs. But this in many harm reduction corners and in a kind of interdisciplinary historical perspective is not the first drug crisis. This is just the most recent drug crisis. And with opioids, there have been mortality crises throughout the 20th century that the primary fatality population for were racial and ethnic minorities that at the time held less power and public health governance, and so those crises were less visible.

And there’s, you know, a literature body that discusses the visibility of the modern drug crisis relative to historic ones as based on which populations of concern are suffering the most negative outcomes in the public view. So I think that’s also a conversation about, again, maybe not totally unrelated to my comments on locating prevalence, maybe locating also a reflexive eye towards how we are looking at the issue and who we’re choosing to include or disinclude when we think about exposure and mortality.

[00:28:14] Eric Miller:  Yeah, really interesting. Glenn, your comments about the propensity of folks to use drugs in the face of legalized marijuana makes me think about the education component of it and how the population writ large approaches substances. There’s caffeine, which is a substance that everyone agrees is fine, and people use it every day. Then there’s prescription pills and people have, I think, a better understanding of that and how it works nowadays and how that can really go awry after the overprescribing of OxyContin. 

Then there is this reckoning going on with, DARE maybe wasn’t the best way to educate young people about substances. If we think that marijuana is just as bad as heroin, then maybe if people experiment with marijuana, then they’ll think that heroin also isn’t that bad or not a big deal. It’s interesting that you mentioned that the availability and destigmatization of marijuana may lead to folks thinking that heroin is also something that isn’t too big of a deal. 

But to move on to what Alex is saying about harm reduction. Alex, if you wouldn’t mind discussing what harm reduction is, what that means, and what harm reduction strategies are being implemented in Maine to address the opioid crisis.

[00:29:30] Alex Rezk: Sure. I think harm reduction, depending on the perspective from which you’re approaching it, occupies multiple spaces. It’s simultaneously a policy framework and it’s also almost a social justice or social advocacy movement. There’s general definitions for harm reduction that are adopted by various groups. For example, the National Harm Reduction Coalition, which a lot of the stakeholder collaborators we work with in Maine refer back to as a legitimizing organization, refers to harm reduction as a set of practical strategies and ideas aimed at reducing ultimately the negative outcomes associated with using drugs. And it’s a movement for social justice, in their view, built on a centering of respect for the rights and dignity of people who use drugs.

I think you can also think of it in a sense as a framework from a policy standpoint focused on positive change around working with people who use drugs without judgment, without coercion and discrimination, or having specific policy preconditions to engaging with services and programs, to make policies and frameworks focused around harm reduction, as low barrier as they could possibly be. I think that there’s some wiggle room depending on the stakeholder involved, and I think it’s a politically malleable term, so it captures a lot of diversity of thought when we talk about harm reduction.

[00:30:48] Eric Miller: Yeah, it’s such an interesting concept that is understanding the notion that people will be using substances, as we’ve already discussed in previous questions here, and then accepting that and what’s the safest way to do it. And that’s one way of defining it.

Glenn is an options liaison, you have one foot working with public safety entities, and then you’re also acting in a way that you’re doing some harm reduction services yourself. How do you think that that policy really changes how folks can interact with getting medical care or finding health care of their own?

[00:31:23] Glenn Gordon: Yeah, that’s a great question, Eric. I think the thing about working in the options and working in this capacity of dabbling in all the arenas in the community. I think one of the things about harm reduction is it just gives a chance to have conversations.

I think in that process of talking to people about harm reduction who are in whatever state of change or willingness to engage with an options liaison, it gives a chance to sit down with people and just build a relationship, and to talk with them about what’s going on with them. I think because we’re coming from this harm reduction standpoint, we’re showing that we really don’t judge. We were just here to talk to people, have a conversation, and engage with folks.

I think the biggest, from my standpoint, people are ready to do what they’re ready to do, and I’m not trying to force their hand to do anything. But this is really an opportunity to sit down, try to keep people safe because they want to be alive, their families want them a lot, and it gives me a chance to just really just sit down and have good talks. I think that’s one of the biggest things that has come about from me doing harm reduction activities with folks in the community.

[00:32:33] Eric Miller: Yeah, it’s amazing what a connection can mean in terms of one’s personal health. Rachel, from your view as a clinician, what type of approach, attitude, or relationship do you have with harm reduction?

[00:32:46] Dr. Rachel Solotaroff: Yeah, I think Gordon and Glenn captured a lot. I just want to take a big picture look and then maybe talk a bit about harm reduction and alcohol use disorder as well, which is a really powerful intervention and concept. I think what’s worth noting is as the science of substance use disorders has advanced, harm reduction isn’t an exceptional practice or something that operates alongside substance use treatment.

It is part and parcel of the very definition of a substance use disorder. As we have advanced our definitions of a substance use disorder, it’s an understanding that it’s a spectrum disease, right?

It’s not black or white, it’s not good or bad, it’s not dirty or clean, it is a severe substance use disorder, a moderate substance use disorder, a mild substance use disorder.

If you have five heavy drinking days and then you reduce that to three heavy drinking days, that is success, that is clinical progress in the same way, forgive the term clinical, but it’s human progress. It’s life progress in the same way that getting your blood pressure down from 160 to 140 is still a good day. I had the joy of seeing Bill Miller, one of the founders of Motivational Interviewing speak once. He said, addiction is the only disease where anything less than perfection is considered failure.

And I see, I think that new, that definition of harm reduction really speaks to that, because it’s both harm reduction, but it also can be an improvement in your substance use disorder. So I talk with folks about that a lot, and I, just to generalize the concept a bit, work with a lot of people who have alcohol use disorder, and we talk about harm reduction there. Put a, if you’re at a bar, put a glass of water on the bar, along with your beer or your drink or whatever it is.

Make sure you’re eating. Make sure that you take vitamins. Things that might increase your nutritional sustenance, might improve your metabolism of alcohol.

I caution people a lot, don’t let yourself get shaky. We know a lot about this idea that if you go into mild withdrawal, that increases the risk of severity of withdrawal down the line. So those are all things I think just if people think of, I don’t think harm reduction is a fringe practice anymore.

It’s very much what we do every day, but it’s really broadly applicable in a lot of different substances that people may use.

[00:32:46] Dr. Rachel Solotaroff: Yeah, I really appreciate that nuance of how harm reduction could be applied as a practice. Gordon, do you have anything you’d like to add to this harm reduction discussion before we go into naloxone availability, which you’re welcome to discuss as a priority in Maine?

[00:35:25] Gordon Smith: Well, naloxone availability is harm reduction. First and foremost, but I think I’d make just two points. I mean, in its simplest form, harm reduction is just meeting the individual where they are and trying to keep them as safe as can be and give them the opportunity to be the best version of themselves today as is possible.

Dr. Solotaroff, as usual, has said it very well, a reduction in use would be seen as a very positive thing. We’re really in a different element. We’re in a different phase of this now where, you know, I do work with many older gentlemen who are really giving back and help serve as recovery coaches and things and their sobriety date is like 1986.

And they literally have not used any substances, including alcohol, since that date. That really isn’t the reality very much today. And that’s okay.

I mean, if someone can do that, what a marvelous thing. But I think if we set that up as the standard, and it’s been said here just a couple of minutes ago, that anything less than that is a failure, no. Because then you’re really setting that person up for failure.

We know that it takes a person six, seven times at least for recovery really to kick in perhaps. We know it takes 29 times to quit smoking. So why should we be surprised that not everybody gets this the first time?

So to me, it’s, are they trying? We are at a point where some of our harm reduction activities now, we get some real backlash from. And I’m afraid that in some cases we may be losing ground on that.

And there’s a number of reasons for it, but it’s interesting. You know, I had some very credible people with me this week who talked very seriously about whether our anti-stigma campaign has been so successful in boosting up the pride and empowerment of people using drugs that the pendulum has actually swung too far. And that now the rights of drug users to continue to use without regard for community consequences is really becoming a problem.

I’m not saying that’s the case, but I’m saying that we’re now beginning to see some of that. And it’s an interesting thing. Because these were people on our own team.

These were not people who were against what we’re doing. They were saying, you know, we really should do more when working with people on harm reduction to encourage them to actually get better. And I’ve always felt that it’s our obligation to absolutely make them know, let them know that we are there for them when they are ready.

It’s my obligation to make sure we’ve got enough beds. We’ve got enough beds in each piece of the continuum. But there are people who actually feel as dangerous as a drug supply is today.

And as much as we want these people to reconnect with their families, while I don’t support involuntary treatment, I do think we need to do more to encourage people to use less and get better more quickly.

[00:38:37] Eric Miller: Alex, do you have, from your vantage point, looking at and working with harm reduction organizations, how stigma affects their business and how clientele work with them?

[00:38:48] Alex Rezk: I think Gordon highlights the complexity of the issue here with his comments. The point I was trying to address, I think, is captured essentially in this. When we refer to harm reduction, there’s a plurality of voices represented by that term, and it’s inclusive both of a treatment-oriented recovery model, but then also of stakeholder contingencies and constituencies that are comprised of folks who view harm reduction as a policy framework in which there’s no implied or implicit emphasis on a recovery ramp out of use, but rather a focus on increasing the safety of use when and where it occurs, because in that framework, it centers drug use as something that’s going to be normative or intrinsic as part of the human experience.

And because of that, we have to, in a policy sense in their view, find ways to make it safer and that’ll be the best intervention for the harms. The other thing is that when people refer to harm reduction, we’ve been prioritizing here harm reduction of substance use disorder. There’s also an entire disciplinary framework in which the term is used in referral to ameliorating the harms of the war on drugs, which is addressing political outcomes and socioeconomic harm.

So it’s like, you know, which component of the harm reduction are we discussing at any one time and how many of those dimensions can we address with any given policy vehicle? I think, you know, no policy intervention is perfect. And the stigma lines and the discursive tension points that arise, and we’ll touch on momentarily, you know, are produced by that discontinuity.

But it’s a constant challenge.

[00:40:37] Glenn Gordon: So I just have two things. And just thinking about, you know, the community I live in. So one of the things that I think we could think about in terms of harm reduction is still some more education.

Because people, I think Gordon was talking about this a little bit, but one of the situations we had in this community was a lot of discourse about discarded syringes. We’re encouraging people to use substances by giving out syringes.

And so people, you know, we try to have these conversations, and they’re hard conversations to have, to understand that we actually, when people engage in a syringe exchange program, that actually tends to reduce the numbers of discarded needles that are found in a community. That it tends to decrease disease: HIV, hepatitis, and that kind of stuff. And I don’t think people always understand that.

And statistically, there’s enough support to say that that is true.

And I also find a lot of the folks that I have that are engaging with, like Maine Access Points are engaging with the Church of Safe Injection, are actually better about, they’re more conscientious about what they’re doing with used syringes and that kind of stuff. So we’re not actually, I don’t, you know, but I don’t think the community understands or sees it that way.

And some education around that kind of stuff is helpful.

Conversations are not always easy to have, and people sometimes dig in their heels, but I think it’s still something we need to kind of continue to try and do. And I think this piece about harm reduction that’s important to that, you know, like I’m one of those old school people who got clean and sober and 12 step programs, you know, and it’s always like, you want to get a chip.

You want to celebrate an anniversary. And at the end of the day, I’ve come to see work in this field, like it was really about quality of life. You know, are you happy today?

Are you doing what makes you happy? You know, I remember going to a recovery coach training and they said, recovery is what you say it is. And I thought, well, that’s absurd.

You know, and yet, as I work in the field and I talk with people and I see things change, I go, I realize the beauty of that. And so today, for example, I went to visit somebody in their house and I hadn’t seen them in a little bit. And I thought physically, they looked a lot better than I’d seen them in recent months.

I said, you really look great. And they said, yeah, I really, I’m doing good. I really am like, I go like two or three or four days, then I use it for a day or two.

And then I’m like, she’s happy. The person’s happier. They look way healthier.

And I go, what’s wrong with that? That’s what harm reduction is about for me. It’s not about, it’s like in that moment, my life is a little bit better because I have reduced my risk and what’s wrong, what’s wrong with that?

Not a thing. Yeah.

[00:43:05] Eric Miller: And speaking of reducing risk, have you encountered in your, out in the field work in the community, how many folks have Narcan or Naloxone with them or loved ones have it? How has that changed in the past five years?

[00:43:21] Glenn Gordon: I think Maine has done a tremendous job of providing access for ​​Naloxone. And we’re lucky in Oxford County. I mean, in the last five years, it’s just been amazing.

We’ve got like a lot of, you know, between the option programs, we have two recovery centers now in Oxford County, the Hills in Norway and the Larry Lomani Recovery Center in Rumford.

We’ve got a couple, you know, the hospital is really working close with us, the healthy communities, coalitions in Oxford Hills and the River Valley. And between all of us just working and talking together, the distribution of the Loxone is really, we’ve done a tremendous job in educating people and getting it out there in a variety of ways, talking at high schools, going into businesses, talking to churches, and meeting individuals where they are, you know, going into homes, meeting people one-on-one, discreetly when people want that, we can just go and meet them.

Maine Access Points is in our community. And so all these things, and we’re all talking to each other, working together, which that’s been an amazing thing that everybody, you know, a lot of times, sometimes people work in silos and around this issue, we’ve all kind of come together and to try and work for the benefit of the community. It’s been incredible.

I think it’s definitely playing a critical role, if not one of the primary roles in the reduction of fatal overdoses in this area.

[00:44:35] Eric Miller: Yeah, that’s great. Rachel, for you as a clinician, as having, I imagine, prescribed Naloxone yourself on several occasions. How has the change to over-the-counter availability changed your dynamic, or what have you seen as a clinician in how Naloxone has helped?

[00:44:56] Dr. Rachel Solotaroff: Yeah, I haven’t. We, as part of our workflow, we ask about Naloxone at every visit. I actually ask everybody whether they’re there for a stimulant use disorder or even alcohol use.

It means it’s just part of, do you need it? The MA says it, I say it. I can’t give you any data on what people are doing over-the-counter.

Most of the folks I see have MaineCare, and so it ends up, I think, being more affordable just to be able to. We’re lucky to have pharmacies right in our clinic. I think it’s more affordable for them to pick it up at the pharmacy there, as opposed to paying out of pocket for it. But to be fair, I haven’t actually done the price comparison myself.

But I think that from where we sit clinically, just the state emphasis on this is a ubiquitous universal precautions approach comes right into the, it’s from the community, from the recovery center into the exam room. It is like putting on a pair of gloves.It’s really becomes universal precautions.

[00:45:58] Eric Miller: Yeah. The community element, Alex, would you like to comment on the community availability of naloxone? 

[00:46:03] Alex Rezk: Sure. I’m sure Gordon can expand on this as well. But to the question around naloxone and to more broadly, what the state is doing with the opioid epidemic in a harm reduction lens since 2019. All credit to Governor Mills who actually began naloxone distribution with law enforcement during her tenure as Attorney General back in 2016, predated this program.

One of her first executive orders launched was what would become the Maine Naloxone Distribution Initiative. This is a pretty unique program and a national one because it is a collaborative endeavor between state public health officials, the governor’s office of policy innovation in the future, community stakeholders working in harm reduction contexts or in service programs, the University of Maine and a bunch of other collaborative program stakeholders. That you don’t normally see where these programs typically come through explicitly a clinical distribution or public safety distribution stream.

But since 2019, we’ve had immense success in the distribution of naloxone, ultimately having about 585,000 kits of naloxone doses, rather distributed as of September of this year with an accompanying 10,000 plus voluntarily reported overdose reversals coming out of those distribution interactions.

Something that we’ve endeavored to do through this program is target the entire state, the distribution scheme is built off of an all-access kind of model, whereby four primary tier one purchasing and distributing organizations, including Bangor Public Health in the northern portion of the state, Maine General Harm Reduction in central and mid-coast Maine, Portland Public Health in the southern and more urban portion of the state, and then Maine Access Points as a statewide peer distributor, providing naloxone distribution to pretty much any corner of Maine you may find yourself in. They operate by distributing to a subsidiary network of tier 2 organizations that down numbers over 620 strong.

Those groups, those networks that have been leveraged to get naloxone out into the community are the proof in the pudding is in those reversals. What we know about overdose reversals is that the ones that are surveyed are an undercount, and a likelihood of the ones that take place. Because the vast majority of reversal reporting is done at these touch points with people who use drugs that occur in context, like interactions at syringe exchange programs or mutual aid exchanges.

Those are likely back to our discussion of prevalence, not the vast majority of, let’s say, non-surveilled community reverse overdoses. That’s a little bit of context about naloxone, its presence in the state and where we think we’re going from here on that front. I would say with a view towards this community focus on naloxone and this question of prevalence and whether mortality is going in one direction or the other and risk is going in one direction or the other.

One thing we are certainly seeing is naloxone is one of these interventions that is highly reliant upon the quality of education in the context of policy around it. Because it is an inert tool in and of itself. It needs to be activated by a person.

This means we’re focused on education around being a proactive, active bystander, education for people who use drugs around naloxone, focused on safe use and not using a loan, and then modulating our response with naloxone to the polyproduct landscape and the co-intoxicant landscape, which has been very volatile during COVID. As we’ve seen a lot of non-opioid veterinary sedatives, for example, play a large role in triage and wound care exposure related risks and in the success of overdose reversal attempts with NARC.

[00:49:46] Eric Miller: Yeah, the change in co-intoxicants have really been something that is shocking and at a human level and from a research perspective, very interesting in how these things have developed and changed over the years. Gordon, do you have anything you would like to add with regard to the distribution of naloxone and its availability in the state and looking at other policy interventions that can be implemented in the future to help address fatal and non-fatal overdoses?

[00:50:11] Gordon Smith: Well, no, I think Alex has said it well. We’re very proud of that.

We purchased with public money over half a million.

Well, now over 550,000 doses of naloxone. It’s still not everywhere where we’d like to have it. There are some barriers sometimes, but we’ve made tremendous headway when you realize that we didn’t even have naloxone in the state authorized.

So about 2017, so we’re very proud of it. I think it’s been one of the most important things we’ve done along with the option program and having more recovery available. I don’t have a lot of new initiatives.

I really think what we need to do is properly resource all of our programs, intervention, treatment, harm reduction, recovery, support. I think we’re doing the right things. We just need to do more of them and all across the state.

We have over 100 recovery residences, but we still have six counties that have zero to two. Of course, that’s up in the northern tier. I’m studying Hancock, Washington, Rooster, Somerset, Upper Penobscot, Piscataquis.

We need a lot more of those resources up in that area. I think we’re doing the right things. We just need to keep doing those things.

[00:51:25] Eric Miller: To close out the conversation, I’d really like to discuss stigma and its role in opioid use disorder and substance use disorder.

How can we promote a more compassionate and understanding approach to substance use disorder? Glenn, what’s something that you’ve noticed about stigma and how it can play a role in one’s use with a substance and how at risk they are?

And then tug at that thread a little bit in order to understand one’s use and their risk.

[00:51:53] Glenn Gordon: Sure, absolutely. So I think the biggest thing is people don’t want to seek help or reach out or reveal that they have a substance use disorder because they’re just afraid of being, they already have enough shame and guilt about it themselves, but to go, I don’t want to ask for help. I think I should be able to do this by myself.

I should be able to figure this out. I don’t want to go away to treatment. I don’t want to lose my job.

All these things that they potentially see are happening. You know, based on their perception of how they are viewed as a stigma. So I think it’s very, it can be very paralyzing for folks and keep them from seeking treatment frequently.

Probably the number one factor in why people don’t really reach out and seek help is because they don’t want people to know and they don’t want to be judged.

[00:52:45] Eric Miller: Yeah, that makes a lot of sense. When interacting with patients, Rachel, do you feel like it’s changed in how forthcoming people with a substance use disorder are with you, or do you have to look for certain signs and then target that threat a little bit in order to understand one’s use and their risk?

[00:53:02] Dr. Rachel Solotaroff: Yeah, I think you just, we keep saying, you start from where you are. How can I help today? I think if you take out your clipboard and you’re like, sometimes when you’re doing inpatient admissions for withdrawal management, you have to be more specific because you have to set up treatment related to very specific histories.

But particularly in a clinic, the beauty of that is you hopefully have the opportunity to engage people over the long term so you don’t have to get these really comprehensive histories which can be at best alienating and at worst traumatizing and driving someone away. I always tell folks at the beginning, my only rule is please don’t worry alone. That’s all I ask.

You can show up, you can call, whatever. But if I don’t know, if we don’t know, it doesn’t have to be me. I mean, we have wonderful medical assistants and all kinds of folks that they might connect with better than me, but we can’t help if you keep it to yourself.

With full understanding that in the past, very likely efforts to reach out have given you the message, don’t reach out. So we as a health care community need to fully own that, but I will do my best. I will go to the mat for whatever you need, but please don’t worry alone.

I don’t know, maybe that’s not effective, but that’s what I tell people all the time, and maybe after the first or second time, when something happens to their medication or they have a return to use or they have shame. I missed my kid’s birthday, these things that cause this tremendous guilt and shame. After one or two times though, they start to think, okay, maybe I don’t need to manage that on my own.

[00:54:43] Eric Miller: Yeah, I really like that saying, don’t worry alone. They might have to use that for myself. Alex, do you have, from your vantage point, looking at and working with harm reduction organizations, how stigma affects their business and how clientele work with them?

[00:54:59] Alex Rezk: Yeah, for sure. I think an important thing to recognize here is, and we’ve touched on already, stigma can be bi-directional, right? There is stigma as it reflects off of the stigmatized population.

We know that fear of reprisal, as Glenn’s pointed to, is a major barrier to entry, to even engaging with help when and where it’s needed, and that’s informed by historic and systemic harms, and it’s a learned fear of systemic help, in a way. In the more prevailing way that stigma is typically discussed in harm reduction, there’s stigma from systemic sources onto the community of people who use drugs. And in the context of the harm reduction organizations, we work with a naloxone distribution.

You know, stigma’s most potent impact has been the fomenting of misinformation. I think ultimately stigma is ultimately about fear. Stigma comes from a place of lack of awareness, lack of access to good information.

A lot of misinformation and misconception underpins systemic stigma that people who use drugs are exposed to, and then that produces tension in the everyday work of harm reductionists. In early naloxone distribution in the state, before our program matured, for example, stigma was a tension point both in community when discussing just doing education around naloxone, fear of having, you know, needle access, fear of injectable versus intranasal, fear of the presence of being a bystander for an overdose response. Could you yourself experience an overdose by being proximal to somebody who used drugs?

You know, we had that, but then also, we had stigma coming from within the partner context of collaborators inside the state architecture that were helping facilitate programming. A good point is stigma that was coming from law enforcement pockets, where there were learnings based on older misinformation about, let’s say, the impact of naloxone distribution on the prevalence of drug use in community, that saw certain parts of the state come on board with naloxone distribution more slowly than others over time. Most of that’s flattened out now, and the best antidote to that has been education.

So I think, you know, that is the best way to address the misinformation component of stigma. And then I think in policy, the other one that gets back to this harm reduction framework is just viewing people who use drugs as holistic persons, and dismantling where we can the reflexive systemic kind of processes that medicalize and criminalize people who use drugs, because that ultimately makes it more difficult to find out what their needs are and meet them where they are. And I think that is the ultimate touch point there.

Stigmatizing material intervention that we’re trying to focus on is compassionate overdose response education and naloxone distribution as opposed to traditional. Some of the specific details in that change are a focus on rescue breathing and a de-emphasis on medical intervention via pharmaceutical products and modulating response to meet the use of the person so that the response is as less traumatic as it can be. I think the ultimate message in my mind is that one size doesn’t fit all in the response landscape and non-stigmatized policy context takes that into account.

We’re going to treat you with dignity while we find what does work. That is ultimately a de-stigmatized response, I think, is creating the subjects of policy or of discourse or of data as dignified individuals, not just statistics.

[00:58:24] Eric Miller: Gordon, do you have anything you’d like to add on the point of stigma?

[00:58:28] Gordon Smith: No, I think it’s pervasive in everything we do. Stigma not only against the disease, other types of stigma regarding sexual identity, sexual orientation, gender, and the answer really have to be education. We need a lot of it.

That’s the only way it gets better, I think, is people will take the time to listen and get educated that these are people just like they are. The disease doesn’t discriminate. I think we can make a lot of headway.

[00:58:59] Eric Miller: Yeah, that’s great. We’ll have links in the description of the episode for folks that want to learn more about data, programming, what have you about the opioid epidemic in Maine and the policies that we have been discussing here today. To finish things off here, is there anything that we haven’t discussed that you’d like to address?

Alex, we’ll start with you. If you have any parting thoughts as we leave off this conversation, we covered a lot of ground.

[00:59:22] Alex Rezk: Something that’s on top of mine for me right now is how we approach the problems we’ve discussed here today in the midst of a shitting political and policy landscape. We’ve just spent a not inconsiderate amount of time discussing education and combating stigma and misinformation. I think we’re in a moment where there is an opportunity for a lot of that to get a lot worse, and we’ve seen some of that happen in the past year here in Maine.

Whether it be stigma at a municipal level impacting the good work our syringe service programs do with Maine CDC, or it be in fears from the public about things like naloxone access proximal to youth in schools, or the different ways in which harm reductionists are engaging with the public around education to fulfill that meet people where they need component. Because if you’re doing safe use education, you have to teach people to safely use the ways they’re using, which always doesn’t mean things are going to be as politically correct as folks might want them to be, because the clinical discussions can get into uncomfortable spaces. I think that we’re going to have to be vigilant to maintain clear lines of communication, education, and reorienting the discourse back to the clinical precedent and the legitimizing literature that serves as a foundation for much of the programs that are currently underway as these things get worse.

Because I feel like we will have communication tension in the months and years to come. 

[01:00:51] Eric Miller: Yeah. In this time of social media, I think everyone here can agree that it’s been difficult to get everyone on the same page with regard to what’s going on in general. So Gordon, about your vantage point of the opioid epidemic as we move forward.

[01:01:08] Gordon Smith: No, we’re making progress. We need to, regardless of whether we get any help from the federal government and our federal partners, we’re lucky to be in Maine. We have an amazing group of people helping us, and I’m optimistic that we can continue to make progress.

[01:01:24] Eric Miller: Yeah, that’s great. Rachel, how about you? Any closing thoughts?

[01:01:28] Dr. Rachel Solotaroff: I’m reminded of what a mentor of mine, when I used to work primarily in ending homelessness, would say. He said, you got to do enough for long enough. We didn’t have a chance to touch on the drop in overdose rates that we’ve seen in the last, in 2023.

And there’s a lot of different explanatory hypotheses for those.

But the bottom line of those is to keep doing them. Whatever it is, keep doing them.

I mean, there is, to Alex’s point, a lot to be done. And if we keep doing what we are doing as well, doing enough for long enough, we’re going to continue to make headway.

[01:02:00] Eric Miller: The drop in fatal overdoses has certainly been an encouraging sign. Glenn, you could take us out with any closing thoughts that you have.

[01:02:08] Glenn Gordon: Thanks, Eric. You know, the one thing I just think that, you know, from a community standpoint, we’re seeing, you know, we’ve had this rise in community recovery centers. So we’re having more conversations.

We’re celebrating recovery. We’re having rallies. So we’re more visible.

I think more people are out there. More people are talking about it. I think it’s helping to reduce stigma and encourage people to come out and talk about their substance use problems.

I think we’ve seen a big change working as collaborations in our communities to changes in the hospitals and how people are treated coming into the hospital, emergency departments, more access, more willingness to treat substance use disorder immediately. I think, as we say often, community is really the cure. I think sometimes when you get into small, sometimes you’re standing at 30,000 feet and sometimes it’s hard to see, and yet you can be in a local community and you can see all the good that’s happening in all the progress towards having these conversations and really celebrating recovery and people really feeling a little bit more free to put themselves out there and go, hey, I have this problem, hey, I have this problem, hey, I recovered from this problem.

I think it’s hard to quantify the success of that too, but I do believe that we’re communicating more, that people are getting more educated about resources, is playing a role in the reduction of fatal overdoses and access to the resources and recovery and allowing people to reach out and connect. I think that’s been a really super positive thing in Oxford County over the last five years. The landscape has changed so dramatically compared to when I started this job 40 years ago and I am very pleased about that.

[01:03:38] Eric Miller: That’s great. The opioid epidemic especially, like many of the prevailing policy issues in Maine, it’s disheartening and encouraging signs, and this is no exception, the opioid epidemic.

Thank you all for taking the time to chat and discuss your expertise as the opioid epidemic relates to Maine and taking time to chat with us.

If you enjoyed this episode and the previous discussions we’ve had on this podcast, please consider donating to the Maine Policy Review by visiting the journals website linked in the description. Our team comprises Barbara Harrity and Joyce Rumery, co-editors of Maine Policy Review. Jonathan Rubin directs the Policy Center.

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