OD Free Marin Doubles Down

Part III: The New New New ("Baby, This Time It's For Real!") War On Drugs

What if you were a County Public Health Officer who also headed a coalition that was going to receive/distribute a large amount of opioid settlement money? What approach would you take to be maximally effective in combatting substance use disorder and overdose fatalities?

One way to do this would be to conduct a sober, public examination of the dysfunctional apparatus through which people with substance use disorder have traditionally been herded. That would require scrutinizing our ineffectual rehab centers, conditions in our subterranean County jail, unequal prosecutions – and acknowledging that these factors hinder patient recovery. To be honest about the lack of efficacy of mandated 12-step programs. To acknowledge how the County's vast income inequality and segregation have fueled substance use and abuse in all classes. To recognize that government agencies like the DEA have proved more problem than solution, sapping billions of dollars away from necessary public services into failed interdiction efforts. And to address the vast damage to public health throughout the County's own long "War on Drugs", which specifically targeted Marin City while turning a blind eye to drug use in affluent neighborhoods.

Then again, such an approach could get you in a lot of trouble. A safer path is performative: First, inflate the 2022 overdose death count by including fatal overdoses that occur outside the County of Marin and/or deaths that are not actually overdoses. Then, during 2023, favor a less aggressive method of tabulating overdoses. Voila! – you can prove you delivered a substantial reduction in overdose deaths. Meanwhile, throw in some Narcan training, rechristen your friends in law enforcement as "justice partners", and promote your friends' rehab centers.

This performative approach would be particularly easy to pull off in Marin County when your coalition, OD Free Marin, has officially partnered with the Alden-Capital-controlled Marin Independent-Journal, which can be relied on simply to repeat the talking points handed out by your law- enforcement-partnered “coalition”. (As a bonus, the weekly Pacific Sun will perform the same PR services for no partnership.)

Which approach do you see Marin County’s Public Health Officer choosing?

On June 9, 2023, I had a 100-minute telephone conversation with Dr. Matt Willis, Marin County's Public Health Officer. The call came in response to repeated questions I had raised about the practices of Mark Dale, who serves on the steering committee of Willis' newly renamed coalition, OD Free Marin (formerly RX Safe Marin.)

Mr. Dale had openly and repeatedly bragged on recorded zoom meetings of the County’s “Alcohol and Other Drug Advisory Board” about having inflated Marin's opioid death statistics. He did this not only by counting deaths that occurred outside the County, but in at least one notable case, a death that was clearly an act of medical malpractice that occurred inside a rehab facility in Southern California. Video extract:

https://twitter.com/marindatanow/status/1645270608991891459?s=46&t=q4VsCWEzorcI3TrikyJ90g

It seemed apparent that the County was engaged in similar practice. For over a year, I had waited patiently for answers from Anita Renzetti, Senior Program Coordinator, about the unusually opaque "coalition" that was RX Safe/OD Free Marin. But when she finally responded on June 7, 2023, she didn't deny in her lengthy answer that RX Safe/OD Free Marin had also inflated the opioid death count in the same manner as Mr. Dale.

During his June 9, 2023 call to me, Dr. Willis largely dodged the question of whether he was including out-of-county deaths in the count. But he promised to set up a meeting with his epidemiology team to discuss how they arrived at such high numbers. That "epi team" call took place last Friday, August 11, 2023, and featured two Ph.D.'s: Haylea Hannah and LeeAnn Prebil.

And surprise surprise! – Prebil and Hannah both indicated that they were including out-of-county overdose deaths in the count. They claimed that there was good reason for this, and indeed, there could be, if OD Free Marin had been clear in their communications about their inflated methodology for the count. But that was never explicitly stated in any of the presentations Dr. Willis had made at the County Board of Supervisors.

One way to look at this is that, having committed to inflated data in published materials and in multiple statements to local media, Willis and his team now have no choice but to try to justify it.

To test the parameters of their out-of-county tabulation, I asked Prebil and Hannah a hypothetical question:

What if you have a Marin “resident” who's a junior at an Ivy League school back East? This is someone who spent the last three years residing primarily outside of the County and the state, and may even be registered to vote in that other state. Someone whose substance use disorder started in that other state. And they then have a fatal overdose on campus, not even in California. Would you include them in the data?

Prebil and Hannah indicated that they would.

But even as Willis' team says they would count people no longer residing in Marin in their overdose count, they simultaneously appear also to be counting brand-new residents of Marin County and “passers-through” in their overdose count. This, among other things, may have played a role in the outsized numbers tabulated for Marin County.

Prebil and Hannah also claimed that their data was entirely collected from death certificates. This would seem to eliminate concerns raised previously about data provided by the Sheriff- controlled Coroner. But there's a catch even to that assurance about the data. (As discussed previously, the State of California is one of only three states in the US that does not require its coroners to be independent of its sheriffs, a conflict that has already resulted in one attempt at legislation – AB 1608 – to establish independence of coroners.) In Marin, the coroner and the sheriff were joined 2010. Seven years later, Marin's Deputy Chief Coroner had to be removed after being charged with “continuous sexual abuse” of his stepdaughter, to which he pleaded guilty. He has been replaced by Roger Fielding who, to be fair, has regularly answered questions about the office.)

What's the catch regarding the death certificate data? Toward the end of the conversation, Prebil and Hannah conceded that the information for the death certificates in "the vast majority of overdoses" was derived from the Sheriff-Coroner. That could be a problem given that California's Sheriff-Coroners are not actually required to possess any medical training. (Autopsies for the Marin Sheriff-Coroner, which are not always performed, are contracted out to Dr. Cohen, an independent contractor who works for multiple counties. Dr. Cohen's very busy schedule means that getting a full coroner's report can take half a year or longer.)

But the larger issue is conflict of interest. When there is so much additional money feeding back into law enforcement agencies for drug interdiction and drug arrests, any coroner office that is controlled by a law enforcement agency, no matter how honest, has an inherent conflict of interest.

While this concern may seem academic, it is actually very concrete. Recall that law enforcement, unlike you and me, enjoys a measure of “qualified immunity.” As Marin County-raised law professor Michelle Alexander has explained, law enforcement officers lie routinely.

That conflict of interest with a Sheriff-controlled Coroner is what AB 1608 had tried to address. But the legislation received no support from Dr. Willis, the County's Public Health Officer.

When I asked Willis on June 9, 2023 about his lack of public support for the failed bill, he told me that while he agreed with the proposed legislation, he only had so much bandwidth. But a public statement of support would have taken less than a few minutes to formulate and place on the County website, or the then-Rx Safe Marin (now OD Free Marin) website. Was the issue "bandwidth", or was it more the difficulty in challenging the very powerful office of the Sheriff?

I asked Prebil and Hannah how many of the overdose deaths recorded as "accidental overdoses" might actually be suicides. They indicated that this was the determination of the Sheriff-Coroner. When asked how they determine whether an overdose death is due to one substance or another when a toxicology screen shows multiple substances, they again said it was the determination of the Sheriff-Coroner.

It is the job of the epidemiologist to work with the data they are able to derive. It is also their job to communicate clearly the parameters of their analyses. But when it is so obvious that the data is compromised, do they not also have a responsibility to communicate shortcomings in the data itself?

I repeatedly stated fairly common concerns about the conflicts of interest inherent in data from a Sheriff-controlled coroner, and the silence from Prebil and Hannah on that point was telling.

I also asked Prebil and Hannah about the number of overdose and other deaths that occur in rehab centers, something I have noticed in reviewing the Sheriff-Coroner's logbook. On that point, too, they had no substantive answer. (A large part of OD Free Marin's approach relies on rehab centers, which arguably stand to benefit from opioid settlement cash. Rehabs have historically been a troubled industry, and which has particularly violent roots in Marin County through Synanon, which later morphed into Cenikor. A excellent multipart series on the rehab industry, "American Rehab" is available from The Center for Investigative Reporting/Reveal.)

OD Free Marin has been on a bit of a media tour since its inception. The partnership with the Marin Independent-Journal should raise eyebrows, as we traditionally expect reporters to maintain a necessary tension with government entities, not form "partnerships". I note a short-list of failures in recent reporting on the County's overdose numbers in both the Marin Independent Journal and The Pacific Sun.

1. Both publications ran with Willis' overdose fatality numbers without any further investigation/ inquiry about their veracity.

2. Pointedly, the Marin I-J declined even to note that the high 2022 numbers included overdose deaths that occurred outside of Marin, even though Willis' team is finally admitting (at least to this reporter) that it is part of their methodology. The Pacific Sun also declined to note the methodology that was used to derive such high 2022 numbers, and has not updated its earlier reporting.

3. Because neither publication acknowledged the irregularity of including overdose deaths that occurred outside of Marin, they were unable to explain to readership how irregular it is for epidemiologists to do this without clear indication.

4. Neither publication included any information in their reporting about how decades of criminalization of (mostly poor and largely minority) people who suffer from substance use disorder has contributed to death, illness, and a surge in the illicit market, as addicts often become involved in drug sales to support their own habits.

5. Neither publication concedes that the far more dangerous fentanyl crisis is the direct result of a crackdown on prescription opioids, a reality that is reflected in the name change from Rx Safe Marin to OD Free Marin.

6. Neither publication mentions the shortcomings of our county's often deadly rehab centers in their hyping of the overdose deaths.

7. In her reporting, the Pacific Sun's Nikki Silverstein includes the salacious detail that "Even infants are brought to emergency rooms with fentanyl ODs", but declines any mention of how the "justice system" (Dr. Willis' euphemism for law enforcement, judges and jails) has stymied recovery, leading to many more deaths than the clickbait "infants die!' premise. And while there have been isolated, very tragic cases of infants accidentally poisoned by addicted parents, it's worth remembering that the "crack baby" media coverage of decades past, which The Pacific Sun was not immune to, turned out to a media-created urban myth.

And of course, the elephant in the room ignored by both the IJ and The Pacific Sun: Four decades ago, both publications were hyping stories about the crack epidemic, alternately dehumanizing Black Marin City residents caught in a politicized crackdown, and refusing to acknowledge that even though cocaine was being used at a higher rate in white neighborhoods, white communities were barely policed at all.

Now that the opioid epidemic has hit a largely white population, the public health response, while still heavily centered on policing (or "justice system" as Dr. Willis terms it), is on the surface far more empathetic. At least white neighborhoods, for the most part, aren't having SWAT teams break down their front doors, yet. But the ongoing racial and class disparity in enforcement – and why Dr. Willis chooses to continue to ignore its public health effects – was part of the 100-minute conversation he and I had in June. It was a revealing conversation, which I'll write up later this week.

©️Eva Chrysanthe 2023