A statement of charges against him says that Dr. Jeffrey Stern excessively used alcohol and narcotics in 2019 and 2020 and since 2019, has had mental illnesses or emotional disorders.

DPH records show that Stern was arrested on Aug. 29, 2020 and charged with possession of drug paraphernalia with intent to use and driving while intoxicated. It was unclear where the arrest took place. In 2019, Stern had temporarily surrendered his medical license in New York and voluntarily agreed to stop practicing medicine in Florida, DPH records show.

In the statement of charges, DPH contends that Stern, who is listed on state records as living in New York City, falsely answered “no” when asked on his 2020 Connecticut medical license application if he had voluntarily surrendered any professional license or was facing possible discipline in any other state.

From 2020 to 2021, Stern also falsely used his Connecticut license to treat patients in New York and violated Connecticut law by prescribing opioid drugs to patients though telehealth appointments, the statement said. During the same period, he also violated state law by prescribing controlled substances to patients who had no demonstrated physical or medical disorders, it said.

From 2020 to 2021, he also prescribed more than a 72-hour supply of a controlled substance to a patient and failed to review electronic prescription drug monitoring records, the statement said.

At the meeting, additional charges were added against Stern after Joelle Newton, a DPH staff attorney, said the health department had received new allegations from the state Department of Consumer Protection’s Drug Control Division about Stern prescribing controlled substances.

Darius Marzec, a Brooklyn, New York attorney representing Stern, objected to the new charges being added and asked that a public hearing in the case be continued to August. The board agreed to the continuance after suspending Stern’s license.

In an unrelated case, the board also voted to reprimand the physician assistant license of Derek William Donovan of Colchester and placed his license on probation for five years because a DPH investigation found that he had used alcohol and marijuana excessively since 2020.

Donovan chose not to contest the allegations and agreed to the punishment in a consent order that was accepted by the board Tuesday.

The order, which said he has an emotional disorder or mental illness, states that Donovan falsified medical records in 2021 and made false written statements the same year to mislead people working on behalf of DPH.

During the probation, Donovan must submit to random drug and alcohol tests, complete a course in professional ethics, undergo therapy and attend support group meetings. Under the order, he is also barred from working as a solo practitioner.

Matthew Carlone, a Wethersfield attorney representing Donovan, told the board that the consent order was a “fair and equitable agreement.”

Between March 19 and June 30, a group of scientists tested waste that had previously been used to detect COVID-19, looking for drugs and chemicals. The researchers found significant increases in three opioids, four antidepressants, and other chemicals in sludge from New Haven.

The analysis, by scientists from the Connecticut Agricultural Experiment Station (CAES) and Yale University, offered the first glimpses of how the pandemic’s stay-at-home orders affected people’s behavior. It also underscored how important human waste can be as a resource for understanding public health and society’s habits. Diseases, drugs and chemicals all show up in feces, providing a major tool for public health studies.

Sara L. Nason, a CAES scientist, is leading the waste analysis, which found increases in fentanyl, hydromorphone and methadone in sludge taken from primary settling tanks in New Haven.

Nason said the goal is to understand how the pandemic changed people’s habits and health.

“We hypothesize that the changes in chemical concentrations will reveal interesting trends that correlate with public health outcomes.”

— Sara L. Nason

Fentanyl’s increase in the New Haven population reflected “both increased use in hospitals for patients on ventilators, and the nationwide trend of increases in accidental overdose deaths from illegal use,” Nason said.

Five years ago, the testing of human feces for substances “was something that I would talk to other people about, funding agencies, and they would kind of roll their eyes and say, ‘Yeah…’ It was not too much on the radar back then,” said Jordan Peccia, a professor of chemical and environmental engineering at Yale University. Peccia is working with Nason on the analysis using frozen samples from another project on which Peccia is working, a COVID-19 testing effort that analyzes sludge from six Connecticut treatment plants. Peccia’s Yale laboratory collects data and publishes the information on a public website. The lab tests the concentrated substance found at the bottom of the tanks where waste entering sewage plants in New Haven, Bridgeport, Hartford, New London, Norwich and Stamford goes to settle.

Peccia and at least eight other scientists hope to expand the sludge testing “to other diseases, to other viruses, to other locations around the world where they don’t have testing,” he said. They have applied for National Institutes of Health funding.

Rising Drug Levels

Besides the opioids, the scientists found six antidepressants in the sludge, and six disinfectants. Sertraline (Zoloft) increased in March, before there were reported shortages of that drug. Three other drugs showed a clear rising trend over the spring: doxepin (Silenor), citalopram (Celeva), and amitriptyline (Elavil). Tracking these drugs during the pandemic was important, Nason said, because studies have linked psychiatric illnesses and COVID-19.

Nason explained it this way: studies have shown “people with psychiatric illnesses are at risk for being diagnosed with COVID-19, and that COVID-19 infection is associated with new diagnoses of psychiatric illnesses.”

Steven Geringer/Yale University Photo

Sludge samples are placed into test tubes at Yale University.

Three of the six cleaners they found in the sludge are common wipes and sprays with quaternary ammonium disinfectants, known as quats, which scientists in the last decade have linked to reproductive and developmental problems in animals.

Nason said the CAES/Yale team’s research focused on “substances whose use we expect to be affected by the pandemic, such as antidepressants, opioids, and antiviral drugs.” They compiled their key findings in a poster presented last fall to the Society for Environmental Toxicology and Chemistry. They plan to submit research papers for publication this winter.

The findings were mostly detected using a technique called suspect screening, in which a mass spectrometer collects molecular information and matches it through large databases. “Suspect screening is a very powerful technique because you don’t necessarily need to know what chemicals you are looking for ahead of time,” Nason said. “You find whatever signals in your data match the database entries. For example, we did not initially decide to look at disinfectants in the sludge, but we found several of them through our suspect screening analysis.” She added that they used other analytical standards to confirm their key findings, “so we are quite confident in our results.”

Peccia said the expansion of sludge testing could be used to study infectious diseases like norovirus; adenoviruses, which cause fevers, diarrhea, and more; all of the coronaviruses that cause colds; and bacterial diseases like tuberculosis and legionella, which causes legionnaire’s disease.

Sewage As A Resource

The long but spotty history of testing sewage for disease dates to the 1960s and a Yale study of the polio vaccine in Middletown. For at least 20 years scientists have been studying sewage, but much of their work focused on environmental issues. Human waste can reveal whether industry is following environmental regulations, and scientists can test for banned chemicals, such as fire retardants, linked to cancer.

These studies analyze the sludge left in the bottom of primary tanks after the water has settled. Scientists can also collect human waste by sampling the diluted soup of water and solid waste that flows under the streets.

Yale University Photo

Jordan Peccia

Peccia maintains that sampling the concentrated sludge is the most efficient method. Sewage treatment “takes in wastewater and it separates the bad stuff from the water. It puts out clean water, and then you have tons and tons and tons of material that was separated from that wastewater. Most of the bad stuff in the wastewater treatment plant gets left behind in the sludge,” he said.

However they are found — whether in the water known as “influent” or the settled sludge — Peccia said he estimates that more than half of infectious diseases show up in waste.

He said testing sewage could transform how doctors recognize and treat diseases where diagnosis is difficult and not always accurate, such as Lyme disease and other tick-borne illnesses, and Eastern equine encephalitis and other mosquito-carried diseases.

Tracking substances like nicotine, alcohol, heroin and opioids in sewage sludge shows how drug uses changes on weekends. “Those pieces of information are hard to come by otherwise,” Peccia said.

These studies will provide information that will correlate with other studies of human illness and behavior. “If hospital prescriptions and disposals of fentanyl increase over the same period of time as fentanyl concentrations in sludge increase, we can start to put together a story,” Nason said.

“But if that is not the case, the sludge data could be a sign for public health officials that illegal use needs to be further investigated,” Nason continued. “Overall, the sludge findings are most valuable when they can be supported with data from other sources that relate them to public health.”

Severe food needs in Stamford, which has the most COVID-19 cases in Connecticut, reflect the state and national food emergency wrought by record unemployment. Consistent with the national experience, Latino and black residents, who comprise about 40% of the city’s population, are disproportionately contracting COVID-19 and losing low-wage work. Latinos comprise 26% (33,000) of Stamford’s population, blacks 14% (17,000).

The Brookings Institution has reported that more than one in five households nationally were food insecure by the end of April. The Connecticut Food Bank, which services 270,000 people in its region, projects that the pandemic will result in as many as 187,000 additional state residents becoming food insecure.

A 2018 DataHaven survey titled the Fairfield County Community Wellbeing Index found that food insecurity was experienced in Stamford by 17% of blacks, 13% of Latinos, and 9% of residents overall. The pandemic and resulting loss of jobs have heightened that food insecurity. Social services providers say the crisis illuminates ethnic and racial disparities in health and income that lead to food insecurity.

Many immigrants are undocumented and can’t get unemployment compensation, said Catalina Horak, executive director of an immigrant program called Building One Community, which offers educational and social programs. She says immigrants have lost jobs in restaurants, hotels, construction, landscaping, and as housekeepers and nannies without “the luxury of working from home.” According to U.S. Census Bureau estimates, immigrants comprise 34% of Stamford’s population of 129,775.

Melanie C Stengel Photo.

Lines for food were everywhere in Stamford last week. People lineup outside the New Covenant Cafe’s food distribution site.

Building One Community has transformed into a temporary emergency agency with an onsite food pantry. It is also providing gift cards, Horak said. She gets about 100 calls daily from immigrants who are “very, very desperate,” she said.

Horak wondered if, after the pandemic, the Stamford community will “flip the switch and pretend nothing happened.” She said, “It has become more clear than ever that there are huge disparities in Stamford. Are we going to address them by giving money and food to the most vulnerable for a few months, or are we going to use this opportunity to understand the underlying issues and address them?”

“I think that’s what will define us,” Horak said.

‘We Make It Work’

Before the pandemic, more than 57% of Stamford public school children received subsidized school meals, said Associate Superintendent Olympia Della Flora. She predicts that number will rise based on increased unemployment and a statewide surge of applications for Supplemental Nutrition Assistance Program (SNAP) benefits.

The school system now gives Grab-and-Go meals to any Stamford families that have asked for them. Between March 13 and April 29, about 131,000 meals were distributed in multi-meal packages, she said.

Lynn McKee gets food for her 5-year-old grandson from Grab-and-Go and from Filling in the Blanks, a nonprofit that provides items like applesauce, cereal and pasta. Disabled and unemployed, McKee receives $34 a month in SNAP benefits. She doesn’t complain. “I don’t want to be ungrateful,” she said, adding, “We make it work.”

Filling in the Blanks, which provides weekend meals to low-income children, added two weekday distributions in Stamford because “parents really need the extra food,” said Tina Kramer, co-director. The organization is facing a potential loss of $500,000 in fundraising due to canceled events, she said.

Shirl Bond has stopped going to food pantries to supplement SNAP because she is afraid of contracting the virus. “There’s too many people out there,” Bond said. Her 11-year-old daughter gets Filling in the Blanks meals, which Bond said provides “extra food in the house when we run out.”

‘We Can’t Go Back’

The myriad food programs in Stamford are scrambling for food and money due to skyrocketing demand, supply shortages, canceled fundraisers, and fewer volunteers as people stay home. Some organizations have added home delivery, established virtual fundraisers, and closed mobile pantries that are too small to maintain social distancing.

Person-to-Person, which operates food pantries and provides emergency financial help in seven communities, has seen monthly food costs rise from $15,000 to $32,000, said Nancy Coughlin, chief executive officer. She said the agency, which usually fed about 7,000 Stamford residents annually, now serves nearly 1,000 more. A recent virtual fundraiser brought in more than $400,000 with the help of a $200,000 matching grant from two people.

“I worry since we’re not feeling the burden equally, it might be too easy when this is said and done to go back to the way it was,” Coughlin said. “We really can’t go back to the way it was.”

Coughlin has shifted from buying mostly from the Connecticut Food Bank to buying from wholesalers. Grocery stores no longer have surplus food to donate to the Connecticut Food Bank. Now, the food bank can’t meet all of her needs, she said.

Kathleen Lombardo, executive director of the Food Bank of Lower Fairfield County, said she’s competing for groceries with other nonprofit agencies buying food. “If they didn’t take it, the food bank would have it” to distribute to them and other agencies, she said. First responders recently collected 7,000 pounds of food for her food bank.

The Connecticut Food Bank is buying from wholesalers now as well, said spokesman Paul Shipman. He said that from early March through the end of April, the food bank purchased 2.8 million pounds of food, compared to 2 million pounds all last year.

Melanie Stengel Photo.

On the same day that people waited in long lines for food, three women eat lunch on the waterfront deck of Harbor Landing Apartments. The city’s median household income is about $85,000.

Cara Mitchell, food policy manager of United Way of Western Connecticut, explained that worry about running out of food is also a sign of food insecurity, a factor not addressed in the 2018 County Wellbeing Index.

“I hope that whatever we are able to rebuild after this virus will bring a more just food system,” she said, adding, “It’s hard to be optimistic right now with everything’s that’s going on.”

“I think everybody is concerned about what the next 12 to 18 months will look like and how we’re going to get through this,” Mitchell said.

In particular, she is concerned about testing for coronavirus. Will there be enough testing so the disease won’t catch fire again and threaten the lives and livelihoods in her predominantly black and Latinx neighborhood?

Radcliffe, an administrative assistant at Yale University, has been working from home, but last week she began driving her brother to his job at Costco. He lives with her and has no car. She has medical conditions that make her particularly vulnerable to the disease. There is no testing facility in her neighborhood, so she plans on driving him to one elsewhere in the city at least once a week to make sure he’s clear—and she’s safe.

This is Connecticut’s dilemma as it contemplates lifting many of the strictures on businesses that have, so far, prevented an uncontrollable spread of the disease that could overwhelm the ability of the health care system to respond.

Expanding Testing Infrastructure Is Key

On May 20, the state will allow the reopening of offices, all retail stores, the outdoor sections of restaurants, and hair and nail salons. Bars, the indoor sections of restaurants, and entertainment venues will remain closed.

The May 5 report from Gov. Ned Lamont’s office showed that 108,643 tests had been performed in the state so far, and there have been 30,621 confirmed cases and 2,633 deaths. Fairfield County had been hit hardest, with 12,360 cases, followed by New Haven and Hartford counties.

Steve Hamm Photo.

Leslie Radcliffe, an administrative assistant at Yale University, has been working at home. She drives her brother who lives with her to work and also to be tested weekly for COVID-19. She’s worried about the state reopening without enough testing.

Building up testing capacity has been a challenge. In March and April, government and health care leaders scrambled to offer testing across the state. Their quick actions helped prevent hospital intensive care units from being overwhelmed, and they are now expanding services further. For instance, Hartford HealthCare last week deployed mobile testing in Hartford.

However, officials were slow to offer testing in dense urban neighborhoods and convalescent homes, where some of the state’s most susceptible and vulnerable people live. Analysis of data shows that black and Hispanic residents experienced hospitalizations and deaths due to COVID-19 out of proportion with their representation in the state’s population of 3.5 million.

Now, with a target for reopening just a few weeks away, government and health care leaders are scrambling to put an adequate and sustainable testing infrastructure in place wherever it is needed. During his daily COVID-19 briefing on April 30, Lamont said: “Testing is important for businesses as we reopen. Testing gives the consumer confidence that they’re going to be safe at that open-air restaurant. Our testing is on track. We’re expanding that. It’s a real priority.”

At the same briefing, Dr. Albert Ko, who is professor of epidemiology and medicine and department chair at the Yale School of Public Health and the co-chair of the governor’s Reopen Connecticut Advisory Board, estimated that the state would need to be able to perform about 42,000 tests per week (6,000 per day) to reopen safely. On that day, 2,315 tests were reported statewide.

Just two days earlier, however, Dr. Thomas Balcezak, the chief clinical officer for Yale New Haven Health, said the health system had at that point tested just 30,000 people at its facilities ranging from Greenwich to New London since the beginning of the outbreak. “We have to as a state test 30,000 individuals a day,” he said.

Interviewed on WNPR’s Where We Live program on May 4, Stamford Mayor David Martin said, “We are a long way away from where we need to be with testing.” Josh Geballe, the state’s chief operating officer, said later that day that a shortage of swabs had slowed testing, but the issue is being addressed.

Melanie Stengel Photo.

Workers prepare to test a woman at the walk-up site on Chapel and Day streets, New Haven.

Tracing and Isolation Are Also Critical

In Connecticut and across the country, government and health care leaders are facing the same dilemma: They want to reopen their economies, yet not enough is known about the spread of the disease to do so with full confidence that it can be done safely. That’s because many of the people who are infected do not know it, there are no vaccines or treatments, and it is unclear if people who recover gain immunity. In addition, the most common tests for the disease take two to three days to deliver results, and there are many false positives and false negatives. The situation is nebulous—like a surgeon operating on a patient by candlelight.

Several research organizations have published recommendations setting out criteria for reopening. One of the reports, Roadmap to Pandemic Resilience, issued by the Edmond J. Safra Center for Ethics at Harvard University, calls for massive-scale testing, tracing and supported isolation (TTSI). “We recommend a level of TTSI ambitious enough to replace collective quarantine as a tool of disease control,” the report says.

The report recommends 5 million tests per day nationally by early June, increasing over time to 20 million per day. Other organizations recommend extensive testing, as well. Based on the Harvard group’s formula, Connecticut, with roughly 1 percent of the U.S. population, should be performing 50,000 tests per day by the time it reopens—considerably more than the 6,000-per-day level the state is aiming to achieve.

As of May 4, Connecticut ranked 13^th among the states for its level of testing so far. Rhode Island, New York and Massachusetts rank first through third, according to data collected by Johns Hopkins University.

Dr. Sten H. Vermund, the dean of Yale School of Public Health, agrees that massive testing and tracing are needed. He advocates the use of the kind of test that requires only about 15 minutes to deliver results. As of now, a minority of Connecticut’s tests are this type. Most of those are administered at a single facility near Interstate 95 in New Haven. “These tests will make it much safer to open the state,” Vermund wrote in an email.

Contact tracing will be critical, too. The Emerging Infections Program at Yale School of Public Health has pitched in with New Haven’s health department and the state Department of Public Health to activate a tracing program in the New Haven area. It’s an all-volunteer effort, mostly involving nursing and public health students. About 400 people call the known contacts of people who have been diagnosed with COVID-19 and advise them to self-quarantine. Elsewhere around the state, municipal health departments are coordinating volunteers who are tracing contacts.

Quarantine is especially challenging for economically disadvantaged people who often live in close quarters. Dr. R. Douglas Bruce, chief of medicine at Cornell Scott-Hill Health Center in New Haven, spoke to a patient recently who lives in a house with six other people. All seven have COVID-19. “COVID has shown a spotlight on health equity issues in our community. Not everyone has access to the help they need,” he said.

Steve Hamm Photo.

COVID-19 testing is available at the St. Raphael’s campus of Yale New Haven Health.

In New Haven, first responders who have been exposed to the virus are quarantined in dormitories at the University of New Haven, but this level of protection isn’t available to most people. The city has approached hotels and motels about accepting people in quarantine, but, so far, none have agreed to do so.

New Haven, with its fulsome health care and public health resources, provides a case study in activating testing, tracing and isolation. Yale New Haven Health was the first to open a testing facility on Long Wharf next to I-95. Then it became clear that the disease was especially active in densely populated neighborhoods occupied predominantly by people of color.

Cornell Scott and the Fair Haven Community Health Care opened testing centers on April 22 in the Dixwell and Fair Haven neighborhoods so people who don’t have cars could walk to get tests. The city opened another walk-in center in the Dwight neighborhood on May 1. Most recently, on Tuesday, clinicians began testing homeless people in a tent erected near their encampments in the city’s East Rock Park and under Interstate 91.

New Haven Mayor Justin Elicker said the city and its health care partners reacted to the crisis at first with an all-hands-on-deck approach. While things have begun to settle down, there are still a lot of unknowns. “We know about the hot spots because people have been tested there, but because our testing is so limited, there are probably other hot spots that we haven’t spotted yet,” he said.

Of particular concern across the state are convalescent homes and housing facilities for the elderly. In New Haven, clinicians from Fair Haven Health Community Health Care tested all 2,500 residents at the sprawling Bella Vista senior living complex. Hartford HealthCare is in the process of testing residents in facilities that it operates. However, many senior housing facilities and nursing homes haven’t been able to test comprehensively.

Elicker eyes the planned reopening of the state on May 20 with trepidation. He called on the Lamont administration to provide detailed guidance on how to open businesses safely. He worries that so many of the supplies and testing resources that are needed are not yet available. “Right now, the testing is only for people with symptoms,” he said. “We need to start testing people who are asymptomatic as well. Ideally, you’ll want to test the entire population on a regular basis. That’s unlikely, but we have to prioritize and get going.”

The board also suspended the license of a family medicine physician from Westport, saying his excessive drinking of alcohol presents a “clear and immediate danger” to the public.

In the Norwalk case, the board also reprimanded Dr. Martin Perlin and limited his ability to prescribe painkillers.

Between 2013 and 2015, Perlin prescribed high doses of opioids without adhering to standard safeguards, state Department of Public Health records show. One of the patients was incarcerated during the time that Perlin prescribed drugs for him, the records show.

Perlin denied the allegations, but chose not to contest them. Under a consent order, the board imposed a permanent restriction on Perlin’s license barring him from prescribing painkillers except for patients in acute pain, not to exceed 15 days, and for terminally ill patients.

In the Westport case, DPH records show that Dr. David S. Parnas underwent alcohol detoxification at Norwalk Hospital in February, when he reported that he drank a pint of vodka a day for the past two years.

In May, he enrolled in HAVEN, a confidential state program for health-care professionals dealing with substance abuse issues, but records show that he has provided the program with no evidence of abstinence or recovery. DPH officials said they cannot verify that Parnas can practice medicine safely.

Parnas’ attorney, Glenn Gazin of Stamford, told the board that Parnas has been safely working at a New Canaan walk-in clinic without complaint for the past month. The doctor monitoring Parnas’ work has been pleased with the quality of care he is providing, Gazin said. He added that Parnas attends Alcoholics Anonymous meetings nearly every day.

This is the second time this year that the medical board has disciplined Parnas. In March, it had reprimanded him and placed his medical license on probation for two years for his failure to appropriately prescribe narcotics to patients.

In March 2013, Parnas surrendered his permit to prescribe controlled substances, a consent order he signed in March said. A DPH consultant found that Parnas failed to document narcotic prescription doses, failed to adequately evaluate pain and did not adequately monitor medication use by patients between 2008 and 2013, the consent order said. Parnas did not contest the allegations.

On Tuesday, the board also fined a family practice physician from New London $2,000, reprimanded him and placed his license on probation for six months for endangering a patient on Dec. 2, 2013, records show.

The patient complained to DPH in 2014 that Dr. Steven P. Johnson let the person drive to the emergency room from Johnson’s office with symptoms of a loss of energy, dizziness and a heart rate of 31. A DPH consultant found that Johnson had placed the patient at “extreme risk” for a heart attack and should have transported the patient by ambulance to the emergency room.

By signing the consent order, Johnson chose not to contest the allegation while admitting no wrongdoing.

Two board members, Michele Jacklin and Dr. Robert Green, voted against the consent order, saying the penalty should have been more severe given the serious nature of the incident.

On Tuesday, the medical board also disciplined three doctors for misconduct or lapses in care in other states. State law allows the Connecticut board to discipline doctors who have licenses in Connecticut when they have been disciplined in other states.

The board reprimanded Dr. Vlad Frenk, an anesthesiologist from Stamford, for writing anesthesia records between 2004 and 2008 indicating two different procedure dates when he knew they were performed on a single patient in New York on a single date. New York officials said he also failed to properly treat two patients, records show.

In 2013, New York officials fined Frenk $10,000 and placed his license on probation for three years, records show. New Jersey officials also reprimanded him in 2015.

The board also reprimanded Dr. Thomas D’Amato of Bayonne, New Jersey, in connection with discipline he had received in New York state in 2015. New York officials had placed his license on probation based on allegations that in 2010, he filed false reports about two patients, saying he had performed psychiatric evaluations on them when he had not, according to a DPH consent order D’Amato signed in March,

The order said D’Amato in 2010 also filed a false report when renewing his New York license, saying he had not resigned any hospital privileges when in fact, he had done so the previous year.

The board also reprimanded Dr. Sharad Kothari of Lenox, Massachusetts in connection with discipline handed out by Massachusetts officials in February.

Officials in that state reprimanded him for giving the superintendent of his building 60 tablets of a narcotic without examining or creating a medical record for the person, DPH records show.

An analysis of state data in a national report by the Dartmouth Atlas Project also shows that Connecticut’s Medicare program relies heavily on brand-name drugs, versus generics, especially in wealthy towns in Fairfield County – a factor that could be contributing to the state’s ranking in the top 10 nationally in prescription drug spending per patient.

Connecticut seniors spent an average of $2,795 on medications in 2010 – 45 percent higher than the lowest-spending state, Minnesota, and the highest rate in New England.

The new report provides an in-depth look at how prescription drugs are used by Medicare beneficiaries, age 65 and older, in the program’s Part D drug benefit, which had 37 million enrollees in 2012. It shows wide variations in the use of both effective and risky drugs among the 306 regional health care markets across the U.S.

Jordan V. Harrison Graphic

While the underlying health status of populations is a factor in prescription drug use, “it really does not explain the variations in drug use intensity that we observed,” said Dr. Nancy Morden, a lead author of the study.

The geographic swings in prescription quantity and quality “suggest that there’s something in the regional practice culture, and perhaps in the patient culture, that is driving these patterns,” she said.

Data included in the report, from 2010 Medicare claims, shows that Connecticut fares better than average in prescribing “effective” drug therapy to patients with certain serious conditions, such as heart attacks and diabetes. More than 81 percent of patients hospitalized for heart attacks were continuing to receive the recommended beta-blockers seven to 12 months after a heart attack  – higher than the national average of 78.5 percent.

In the area of discretionary medications, Connecticut’s use of antidepressants for seniors was slightly higher than the national average – 19.1 percent, compared with 18.8 percent. The rates among hospital regions varied – from a low of 15.5 percent in Milford, to a high of 22.6 percent in Meriden.

Similarly, patients receiving care in Stamford and Greenwich had higher-than-average rates of prescriptions for newer sleep sedatives, such as Ambien – 11.1 percent and 10 percent, respectively, compared to 7.6 percent nationally. That was double the prescription rate for patients in Putnam and Derby.  By state, the use of so-called “sedative-hypnotic” medications by Connecticut seniors was the highest in New England, the data shows.

While the newer sedatives initially were considered safe, recent reports have shown they can cause persistent drowsiness, as well as other side effects that may be more pronounced in the elderly, Morden said.

The prescription rate for dementia drugs also varied, from a high of 9.3 percent in Meriden, to a low of 5.3 percent in New Milford. The statewide rate was lower than the national rate of 7 percent.

Generally, the use of “high-risk” medications in Connecticut also was lower than the national average.

The researchers said the regional differences in the use of discretionary and high-risk drugs, some of which have uncertain benefits, raise concerns.

“[The] regional variation highlights the absence of a ‘best practice’ consensus” for the drugs, the report says.

Overall, Connecticut patients filled a lower-than-average number of prescriptions in 2010 – 46.5 per patient, compared with 49 percent nationally. Still, the state’s costs per patient were high. By hospital area, Meriden had the highest drug spending — $3,248 per patient — while Winsted had the lowest spending– $2,354 per patient.

Morden said the research team found no correlation between higher spending and the rate of “effective” drugs being dispensed – dispelling the notion that higher spending means better care. Instead, spending is driven by the number of prescriptions – which were below average in Connecticut — and medication costs, she said.

“If you see high spending, without high quantities, it’s fair to assume that your prescribers are selectively using more expensive products,” she said.

Connecticut’s proportion of brand-name prescriptions, versus generics, was the highest in New England, at nearly 30 percent. All other neighboring states were well below the national average of 26.3 percent. By hospital area, Greenwich, Stamford and Norwalk had the highest brand-name usage rates, with Greenwich nearing 40 percent.

Branded drugs are generally more expensive than their generic alternatives, although they are therapeutically equivalent. Nationally, only a few communities, including South Miami, Fla., and Encino, Ca., had brand-name use rates as high as Greenwich.

For some illness types and severities, only brand names are available. But the Dartmouth team found that illness explained only 27 percent of brand-name use; the reasons driving the choice remain largely unknown.

Ellen Andrews, executive director of the Connecticut Health Policy Project, said differences in physician practice styles could explain some of the spike in brand-name use.

“There’s a lot of geographic variation in how doctors prescribe,” she said.

She also noted that prescription costs are just one piece of the health-care picture, which includes hospitalization rates and other measures.

While the study focuses on drugs, it shows that Connecticut’s Medicare spending on other services also is high. The state ranked ninth highest nationally in 2010 in non-prescription medical expenditures.

Morden said that generally, high use of brand-name drugs “doesn’t make any sense, clinically” and is likely driven by patient or prescriber preferences. Because the complex Part D Medicare structure leaves patients responsible for a significant portion of drug costs, income could be a factor in decision-making.

While the report did not single out states or regions, it found that higher spending in some areas was fueled by “greater use of brand-name drugs that in some cases may not provide significant additional benefits to patients.”

Nationally, the report found that seniors in the Miami region had the most prescriptions – nearly 63 per patient in 2010. Manhattan also was high, at 54 prescriptions.

Seniors in Miami also had the highest average spending on prescriptions, at $4,738; and the highest rates of at least one antidepressant prescription and dementia medication.

Manhattan held the top spot for sleep sedatives, with 15.3 percent of patients receiving a prescription.

The researchers said they hoped the report would prompt policymakers to take steps to equalize care, so that it is not a function of a patient’s zip code.

“Regional variation of the magnitude presented in this report . . . presents an opportunity for policymakers to study successful regions that provide effective care efficiently, determine what factors lead to this success, and disseminate these systems more broadly,” they said.

The report by Connecticut Voices for Children – the first comprehensive study of its kind in the state – also found significant racial disparities in arrest rates: Black students were 3.7 times more likely to be arrested than white students, and Hispanic students were 3.2 times more likely.

“The overall number of arrests have declined, which is an encouraging trend,” said Sarah Esty, the report’s author and a former policy fellow of Voices for Children. “However, there remains a great deal of work to be done in terms of students being arrested for behaviors that likely could have been handled without police involvement . . . and in the disturbing disparities in arrest rates.”

Because the data is from 2011, it does not reflect several recent initiatives designed to reduce Connecticut’s school arrest rates. Two years ago, the Court Support Services Division began screening police summonses of juveniles and kicking back those it deemed inappropriate for prosecution. In addition, juvenile justice advocates have been working directly with districts to reduce arrests and address racial and ethnic inequities.

But the report also does not reflect what some advocates worry could be a rise in school-based arrests in the aftermath of the shooting at Newtown’s Sandy Hook Elementary School last December. Many schools opened this month with increased security in place, including armed guards.

The 2011 data shows 2,936 Connecticut students, or about one in 200, were arrested during the school year – down from a peak of 3,396 students arrested in the 2008 school year, and down 3 percent from 2010.  The state’s 20 largest districts arrested students at vastly differently rates – from 1 arrest per 1,000 students in Trumbull, to 27.8 arrests per 1,000 students in Meriden.

Besides Meriden, the highest arrest rates among mid- to large-size school districts were in: Area Cooperative Educational Services, a regional school district serving greater New Haven (27.1 arrests per 1,000 students), New London (23.1 arrests), Ansonia (18.3), and Waterbury (17.1). In comparison, the statewide rate was 5.7 arrests per 1,000 students.

The report cites several large districts that were able to keep their arrest rates below the state average, including Hartford (4.6 arrests per 1,000 students), Stamford (5.0) and Bridgeport (5.0).

Within districts, arrest rates at individual schools varied widely, suggesting that much of the variation is driven by differences in school practices, not simply by differences in the student population, Esty said.

In New Haven, for example, Wilbur Cross High School had 56 arrests, for a rate of 43.4 arrests per 1,000 students, while four other high schools had rates of 1 to 5 arrests per 1,000 students.

“The fact that children of the same age who live in the same town, but happen to attend different schools, are arrested at markedly different rates suggests that (likely factors are) school climate; school rules and rule enforcement; the behavior of staff and their capacity to manage challenging student behavior; the presence and culture of police in the school; and student composition and student behaviors,” the report says.

The review found that 11 percent, or 342, of the arrests were for low-level school policy violations in which arrests were “likely avoidable.” For example, there were 41 arrests related to skipping class, 26 for profanity or obscene language, and eight for improper cell phone use. Another 724 arrests, or 23 percent, were classified as “questionably necessary,” including physical altercations without injuries, obscene behavior and false fire alarms.

Fighting that resulted in minor injuries was the most common reason for arrest, followed by drug and alcohol offenses. There were 156 arrests of elementary school children (grades kindergarten to six), including more than 10 students in grades three and below — and at least one kindergartener.

Schools in poorer, more urban districts arrested students at substantially higher rates than schools in more advantaged suburban districts. Students in the poorest urban areas — Bridgeport, Hartford, New Britain, New Haven, New London, Waterbury, and Windham — were arrested nine times more often than students in the wealthiest suburban areas, the analysis found.

Although white students were 62 percent of Connecticut’s student population in 2011, only 35.3 percent of the students arrested were white. Black children were 13.2 percent of the state’s students, but 27.6 percent of those arrested, while Hispanic students were 18.6 percent of state students, but 34.2 percent of those arrested.

In addition, students with special education needs were arrested at rates 2.8 times higher than their peers. The State Street School in Waterbury, an alternative program serving students with social, emotional and mental health needs, had the highest rate of arrests among all schools: 34 arrests among 77 students.

Experts say school arrests fuel recidivism in the criminal justice system and often take the place of more intensive interventions that can lead to better outcomes for children.

“Arresting children for behavior that could be handled in the school takes students out of the learning environment, sets back educational progress, and results in additional costs,” said Ellen Shemitz, executive director of Connecticut Voices for Children. She said the data suggest a need for policy changes “to prevent unnecessary involvement with the juvenile justice system, to keep children where they belong – in school.”

The report recommends that state policymakers and the Department of Education provide assistance to schools to reduce arrests, and require districts with police stationed in schools to create formal school-police agreements that set clear ground rules concerning arrests.

Esty said she was hopeful that the increased police presence in schools following the Newtown shooting would not lead to more arrests, but instead to “closer partnerships” between schools and police and more conversations about constructive interventions. Training for police working with youths is key, she said. Connecticut has no uniform standards for training.

“There are a lot of ways that Newtown can impact what happens,” she said. “If school districts aren’t doing the training and are putting police in schools without having those conversations . . . that’s a cause for concern.”

The 2011 data on arrests is available here.

Access a ‘toolkit’ designed to reduce school arrests, prepared by the Child Health and Development Institute of Connecticut, here.

Read a previous story by C-HIT on school arrests here.

Cape Cod, Mass., tops the country in the use of stimulants, with 16 percent of the population filling at least one prescription, compared to a mean of 2.6 percent nationally.

Gainsville, Fla., has the highest utilization rate of antipsychotics – 4.6 percent of residents, well above the national mean of .8 percent.

Usage rates of the three classes of mental health medications vary widely across the U.S., with Connecticut in the middle, according to a new study by the Yale School of Management.

The study found that much of the geographic variation could be explained by access to health care and pharmaceutical marketing efforts, rather than by the underlying prevalence rate of the psychiatric disorders.

For all three classes of medications, use rates were higher in areas with better access to health care, as measured by the number of physicians in a three-digit zip code area. More surprisingly, the study found that in regions of the country where pharmaceutical companies spent the most money marketing drugs, the utilization rate of psychotropic medications was at least 10 percent higher than in areas with the lowest marketing expenditures.

The study is the first to demonstrate that “marketing efforts have a substantial impact on utilization rates,” said Marissa King, assistant professor of organizational behavior at the Yale School of Management and the study’s lead author. “There’s a huge geographic variability in utilization rates, and it appears that part of the puzzle is marketing.”

King and co-author Connor Essick of the Yale School of Public Health examined 2008 national data on retail prescriptions for antipsychotics, stimulants and antidepressants. They mapped patterns in usage rates, both across the country and within states. Clusters of high use were identified, including one in the south, centered on Tennessee.

Within Connecticut, the New Haven area had the highest rate of antidepressant use – 14.7 percent, compared to the mean of 10.4 percent nationally. Stimulant use was highest in Stamford – 3.9 percent, compared to 2.6 percent nationally. Antipsychotic use was highest in the Hartford area – 3.8 percent, compared to the .8 percent national mean.

The Bridgeport area recorded the lowest rates of stimulant and antidepressant prescribing (1.6 percent and 7.4 percent, respectively), while antipsychotic use was lowest in the Stamford zip code area (1.3 percent).

Nationally, the study found that use of the psychotropic medications was lowest in the western part of the U.S., with clusters of high use in other regions. In a large area of the South centered on Tennessee, for example, use of antidepressants, antipsychotics and stimulants was 40 percent higher than in the rest of the country. Residents in this region were 77 percent more likely than people outside the cluster to be using stimulants, the study found.

The cluster in the South overlaps with an area known as the “stroke belt,” an 11-state region that has been recognized by public health authorities as having an unusually high incidence of stroke, cardiovascular disease and lung cancer. The finding of a high use of psychotropic drugs in that region raises questions about possible links between mental health treatment and other health outcomes, King said.

King said she was surprised that the geographic differences in usage were not explained by the underlying prevalence of depression or related mental health disorders. The exception was stimulant use, which correlated to states’ ADHD prevalence rates.

“I was definitely surprised that prevalence wasn’t a determining factor,” she said.

Instead, the study points to other reasons for the variability – namely, pharmaceutical marketing efforts and access to health care. Pharmaceutical companies pay doctors to promote their drugs and are likely to direct marketing dollars to areas that have large numbers of physicians, the study says. Antidepressants, antipsychotics and stimulants are among the most heavily marketed – and highest-grossing – medications.

“By shaping patients’ and physicians’ knowledge about existing treatment options, as well as perceptions about the appropriateness of given treatments, marketing efforts may be an important factor in health care utilization,” King and Essick wrote.

Because of recent public disclosures by drug companies of their payments to doctors for speaking and consulting services, King and Essick were able to track correlations between marketing expenditures and prescribing rates. The correlations were not exact: expenditures were from 2008 and 2009, while prescriptions were from 2008 only. Federal “sunshine act” provisions require pharmaceutical companies to report all payments to physician speakers and consultants beginning this year; some drug companies have already started providing that data.

King said she expects the public disclosures of physician payments to prompt more studies of prescribing and usage patterns.

“I think with the sunshine act, having the information available to researchers on a much larger scale will help us look at how marketing is influencing prescribing behavior,” she said.