• There’s the John C. Daniels School, where parents are dropping off kids and where a man overdosed and died near a rear stairwell over the summer.

• Across the street, there’s the APT Foundation clinic, where clients in recovery from opioid use come every morning for methadone.

• There’s the bodega on the corner, where, he says, APT clients hang around and drug dealers tempt them with offers of heroin and other drugs.

Steve Hamm Photo.

Jose DeJesus, treasurer of the Hill neighborhood’s community management team, said that the APT Foundation clinic has created a magnet for outsiders to come for treatment and hang out in the area.

“The clinic is a thorn in our side. People come to New Haven from all over and they hang out in the Hill,” says DeJesus, who is treasurer of the neighborhood’s community management team.

Just weeks earlier, residents at a Hill community meeting spent more than an hour criticizing APT—complaining that its policies have made the city a magnet for people coming from other cities and towns. Meanwhile, methadone itself is often disparaged. Critics say treating people with the drug, which is an opioid, amounts to trading one addiction for another.

Lynn Madden, chief executive officer of APT, is exasperated by the criticism. She points out that methadone is vastly superior to abstinence-based treatments for opioid use disorder, which is a chronic, relapsing disease. Methadone treatment results in 60% to 80% of patients remaining in treatment for one year or more. Meanwhile, fewer than 10% of people who do not use medication as part of their treatment remain in recovery for one year. She says the foundation’s responses to criticism—including creating a waiting room inside the Congress Avenue clinic and opening a new clinic in West Haven—has largely addressed the loitering issues.

“Despite decades of evidence that methadone is effective, saves lives, prevents HIV, and is inexpensive, there has been no lessening of the stigma for the patients and the treatment, the clinics that offer it, and the people who work in the clinics,” Madden says.

The frictions on Congress Avenue show why it’s difficult for Connecticut to deal with its opioid crisis. The federal government regulates methadone—limiting distribution to specialized clinics, which are mostly in cities. Yet over the past two decades, opioids have spread rapidly to the suburbs and rural communities.

“Methadone should be offered everywhere. Yes, there needs to be regulation and oversight and training, but it should be much easier for people to access it,” says Dr. J. Craig Allen, vice president of addiction services, Hartford Healthcare Behavioral Health Network.

Care Advocates Say More Needs To Be Done

The focus on treating addiction as a crime, the so-called “War on Drugs,” has long put the onus on police to solve the problem—dealing with everything from loitering to drug dealing to shootings. Police say it’s too much. “I think I speak for every police officer in America when I say we’re tired of people seeing law enforcement as the solution,” says New Haven Police Chief Otoniel Reyes. “We’re not able to do that.”

In June, six people died from opioid overdoses in Hartford in a three-day period. Last year in New Haven, more than 100 people overdosed in 24 hours on a drug known as K2, which is not an opioid. New Haven assembled an Overdose Response Task Force and launched new initiatives, including hiring a “street psychiatrist” to help deal with substance abuse problems among the city’s homeless.

But healthcare leaders say more changes are needed. Primary among them is expansion of the number of methadone clinics in the state. Connecticut has 29 clinics, serving 21,288 individuals, according to the Department of Mental Health and Addiction Services. In spite of the growing addiction problem, only two clinics have been added in the past five years—one in West Haven and one in Waterbury.

Several organizations are considering opening new clinics—mostly in the middle of the state, along the shoreline and in the more rural areas. But when they propose new clinics, they typically face fierce opposition. “I have had people grab me, scream in my face and spit at me in hearings,” says APT’s Madden.

Steve Hamm Photo.

Outside the APT Foundation in New Haven.

Organizations that want to open new clinics are working closely with local political leaders and community groups, and plan on putting them in commercial rather than residential areas. They’re also considering more creative solutions. Connecticut Counseling Centers, with methadone clinics in Waterbury, Norwalk and Danbury, is looking at providing mobile methadone treatment, according to President Rob Lambert. Medical staff would interview patients, administer methadone and provide counseling in a bus or RV.

A second major change would make it easier for patients to start and continue treatment. Now, APT has one of the most humane models in the state, health experts say. It admits clinically appropriate people to treatment immediately after evaluations, so they don’t have to wait days or even weeks to begin. All too often, people who have to wait lose their resolve to stay off drugs. Also, APT doesn’t automatically stop treating people if they fail a drug test. The idea is it’s better to refine the treatment plan rather than cut people off, which puts them at risk of overdosing and dying. “They attract patients from all over the place who would rather be treated like human beings instead of like cattle,” says Robert Heimer, a professor at Yale School of Public Health.

In fiscal year 2019, just 42.2% of APT’s Congress Avenue patients came from New Haven. The rest came from other cities and towns, including 9.9% from Waterbury, according to state records.

Rather than saying APT should change its policies, some healthcare advocates call for other methadone clinics to become more like APT. That way people who don’t live in New Haven might seek treatment in their own communities. “APT gets a bad rap. I think it would be better for other clinics around the state to adopt their model,” says Mark Jenkins, founder and chief executive officer of the Greater Hartford Harm Reduction Coalition.

When New Haven Mayor Toni Harp launched the Overdose Response Task Force, she hoped that one of the solutions would be for the federal government to permit more doctors throughout the state to treat patients with methadone. But she quickly discovered that’s a nonstarter. “The federal government stands in the way,” she says.

Methadone is more heavily regulated than the other medication-assisted treatments for opioid use disorder because it’s more easily abused, which could result in an overdose.  That’s why patients have to report to the clinic every morning to take their medication.

While the federal government seems unlikely to make major changes in methadone regulations, Neeraj Gandotra, the chief medical officer for the federal Substance Abuse and Mental Health Services Administration, says expanding access to treatment is a priority. His agency is exploring the use of telemedicine to help increase access in rural areas to buprenorphine, a medication-assisted treatment that isn’t as highly regulated at methadone. He says federal agencies are looking at other approaches for methadone, but it’s premature to discuss them.

For its part, Connecticut has adopted an all-hands-on-deck approach to dealing with opioids. That includes an awareness campaign called “LiveLoud” and efforts to expand access to treatment. Programs aimed at expanding the number of care providers prescribing buprenorphine have been less successful than had been hoped, but officials at the Department of Mental Health and Addiction Services are open to working with federal agencies to increase access to medications, including methadone. “The goal is to blanket the state with as many options as possible,” says Commissioner Miriam Delphin-Rittmon.

The Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Helpline is 1-800-662-HELP (4357).  It is a free, confidential, 24/7 referral and information service for individuals and families facing mental and/or substance use disorders.

SAMHSA provides information on buprenorphine and a practitioner locater here.

For a list of methadone treatment programs in Connecticut click here.

Now 37, Evans hasn’t used illegal drugs since 2006. He is married and has a 3-year-old daughter, a home in Trumbull, and a sales job at a software company. He attributes his sobriety to counseling and medication to treat his addiction. “It’s allowed me to live a life,” he said.

Research shows that medication-assisted treatment (MAT) for opioid addiction is effective because it eliminates drug cravings, but the use of MAT in Connecticut is not keeping up with the epidemic, said Dr. David Fiellin, director of the Yale Program in Addiction Medicine, who works with the state to address the opioid crisis.

Derek Torrellas Photo.

William Evans has been on medication-assisted therapy since 2006. He’s treated by Dr. Peter Rostenberg, a primary care physician.

“We are, at some level, playing catch-up,” Fiellin said. “I think it’s going to take, unfortunately, a number of years” to meet the need for MAT in the state, he said.

The Need And Treatment Gaps

Connecticut ranks in the top 10 of states with the highest rates of fatal opioid overdoses, according to the National Institute of Drug Abuse, which said the state rate more than quadrupled from 5.7 deaths per 100,000 people in 2012 to 24.5 in 2016.  In 2017, 1,038 people died of opioid overdoses in Connecticut, up from 729 in 2015 and 917 in 2016, state medical examiner figures show.

There are no “reliable estimates” of the number of Connecticut residents with opioid use disorder (OUD), Fiellin said. Roughly 2 million people are addicted to opioids in the U.S., with 72,000 fatalities in 2017, according to preliminary figures from the Centers for Disease Control and Prevention.

Three drugs have federal approval for treatment of opioid use disorder. They are methadone, administered only in federally regulated sites; buprenorphine, for which medical professionals must be trained before prescribing; and naltrexone, for which training isn’t required, but is in limited use because patients must be drug-free for seven days before taking it.

Yale School of Medicine Photo.

Dr. David Fiellin, director of the Yale Program in Addiction Medicine.

Addressing opioid addiction with medication-assisted treatment reduces overdoses, illicit drug use, cases of HIV and criminal behavior, Fiellin said. The practice is endorsed by federal health agencies and the state government. Advocates contend that since OUD is a chronic brain disease, it should be treated with medication as other diseases are.

About 3,800 practitioners are licensed in Connecticut to prescribe buprenorphine, according to federal figures provided by the state Department of Consumer Protection. That number includes doctors, psychiatrists, nurse practitioners, and physician assistants who work in private practices, emergency rooms, health clinics and substance abuse facilities.

But state and local health officials say there’s a dearth of primary care physicians who treat opioid use disorder with MAT. Also, few residential treatment programs use MAT, opting for no-medication, an approach that increases overdose risk after discharge, Fiellin said.

Private practitioners in addiction care are mainly psychiatrists and addiction specialists, not primary care doctors, experts say.

Dr. J. Craig Allen, medical director at Rushford, which operates addiction and mental health services at facilities across the state, has conducted buprenorphine training but says, “There are so few people actually prescribing the medication.” He said the “challenging behaviors” of people with OUD can deter primary care physicians.

But not Dr. Peter Rostenberg of New Fairfield, a primary care doctor and internist who has been using MAT since 2003. He has prescribed Suboxone, a brand name of buprenorphine, to some 500 patients. As part of their treatment, he requires them to attend group therapy. “Isolation is addiction and socialization is recovery,” Rostenberg said.

Rostenberg, who received a federal award for his OUD treatment, said his typical patients come to him “in desperation,” often after being unsuccessful in residential abstinence programs. Generally, after taking buprenorphine, they “flourish in life,” he said. “They feel really good because they are losing that craving.”

Emergency departments in 11 acute care hospitals and VA Connecticut Healthcare now prescribe buprenorphine, which also eases withdrawal symptoms. In the first four months of 2018, there were at least 3,090 ER visits for suspected drug overdoses among CT residents, the state Public Health Department reports.

Dr. Peter Rostenberg of New Fairfield.

Of the state’s 19 correctional facilities, two prisons and three jails provide methadone treatment, with a fourth jail to be added within six months. In 2016, 52 percent of fatal opioid overdose victims were incarcerated at some point, according to the state Department of Correction. Dr. Kathleen Maurer, the agency addiction services director, said the department’s treatment efforts, limited by finances, is “a work in progress.”

Outpatient clinics in New Haven and New Britain offer MAT to newly released inmates with OUD and physical and mental illnesses.

Fiellin said treatment gaps are statewide, but are most acute in northwestern and northeastern Connecticut. Even in cities with several treatment options, there is not a sufficient mix of services, which can mean long waits, inadequate hours of operation and insurance hurdles, he said.

About 50 percent of the people being treated for OUD are covered by Medicaid, 30 percent by private insurance, and the rest either have no insurance or are covered by federal veterans’ benefits, Fiellin said.

Lauren Siembab, MAT director for the state Department of Mental Health and Addiction Services, said she knows of just 15 primary care doctors who take Medicaid and treat OUD with medication.

Local Efforts To Use MAT

The federal government, to stem the rising opioid crisis, has given Connecticut $15.5 million in recent grant money.

In southeastern Connecticut, the nine-town Ledge Light Health District is using federal dollars in an aggressive effort to increase MAT; expand use of naloxone, an overdose reversal drug; provide clean syringes to reduce blood-borne diseases; and hire “recovery navigators,” who go into communities looking for people with OUD to refer them to MAT and social service programs.

Jennifer Muggeo, co-facilitator, Opioid Action Team.

Jennifer Muggeo, the district’s supervisor of special projects and co-facilitator of the region’s Opioid Action Team, said that from the start of the navigators program in April through August, 80 people with OUD were located and at least 50 began treatment. In 2016, 40 people in the district died from opioid overdoses, she said.

“We need to expand access to treatment and people should have a choice,” Muggeo said.

Allen, of Rushford, said the lack of primary care doctors treating OUD also stems from a historic absence of addiction curricula in medical schools and post-graduate training, a situation that “doesn’t make sense,” he said, explaining that often diseases are worsened when a patient also has a substance abuse disorder.

Medical schools at Yale, Quinnipiac and the University of Connecticut have addiction in their curricula.

Evans’ Recovery

For Evans, life “drastically changed for the better” after getting treatment from Rostenberg. Evans said he began snorting opiates in college and eventually became consumed with getting increasing amounts as his tolerance grew. He spent the $10,000 his grandmother gave him for graduation and exhausted his salary at a car rental company. “I knew I was going to hit a wall where I was not going to be able to support this addiction anymore,” he said.

Derek Torrellas Photo.

At home, Evans enjoys playing the guitar.

Evans said his addiction robbed him of the ability to maintain relationships, save money and achieve goals, and made him unreliable. Suboxone, he said, doesn’t make him high, but takes away his cravings and allows him to feel normal.

Counseling and support groups helped him change, he said. He stopped associating with friends who took drugs, changed his phone number so dealers couldn’t reach him, and avoided bars. Two friends have died of overdoses, Evans said.

He’s been married for five years. He dotes on his daughter. He plays tennis, golf and guitar. And, he said, “people can count on me.”

The state Department of Mental Health and Addiction Services provides information on medication-assisted treatment. For information click here.

The Substance Abuse and Mental Health Services Administration provides a list of 1,137  CT doctors, nurse practitioners and physician assistants who are licensed to administer buprenorphine and have requested to be listed. To find licensed practitioners click here.