Later that same day, dozens of people spoke out against a proposal to locate a methadone clinic on a commercial street on the New Haven-Hamden border.

During the ongoing battle with COVID-19, there seems to be less attention being paid to opioid addiction, advocates say. But now these two events put opioids and opioid use disorder back in the spotlight. Deaths from opioid overdose in Connecticut have increased nearly 40% over the past three years, hitting 1,356 through the first 11 months of in 2021 and, police say, the state is flooded with ever-more-powerful synthetic opioids.

The incidents on Jan. 13 illustrate two stubborn facts of the war on opioids: 1) The increase in overdoses indicates that the state isn’t winning, and 2) It’s difficult to get the most effective treatments for opioid use disorder to the people who need them.

Steve Hamm Photo.

Fiona Firine, left, her husband, Joe, and their daughter, Isabelle, have become advocates for opioid response reform with their organization, For Cameron.

Programs including methadone and buprenorphine are most effective for people who are diagnosed with having moderate to severe opioid use disorder (OUD), according to numerous academic studies, including one published in February 2020 by the Journal of the American Medical Association. Yet people overwhelmingly end up enrolled in abstinence and detoxification programs, even though they’re effective in only 10 to 15% of the cases. Addiction experts believe stigma and barriers to access deter many from receiving life-saving medications.

While Connecticut has implemented a wide range of responses to opioids, an array of people and groups are now calling for a fundamental rethinking of how to address the condition. They include parents of people who died from overdoses, addiction medicine experts, and leaders of treatment programs.

“We need big changes. Incremental changes haven’t been enough,” said Fiona Firine, a spokesperson for For Cameron, an advocacy organization her family set up in the wake of the death of a loved one. “We should approach opioids with the same intensity that we do COVID. This is an epidemic. It’s a crisis.”

Firine organized an informal Zoom call on Jan. 10 where advocacy groups took turns presenting jointly-agreed-on proposals to state senators and assembly members. They called for the creation of a state “Chief Drug Officer” to coordinate the multi-agency response to the crisis and to educate the public about its severity and urgency. They also asked for spending on additional capacity for in-patient treatment and for additional support for people after they complete such programs. Another proposal seems destined to be controversial at a time when Connecticut has been reducing its prison population: 5-year minimum sentences for people who are convicted of selling drugs containing fentanyl.

Contacted later, two members of the legislature’s Public Health Committee who participated in the call said they’re gathering in formation and have not begun drafting legislation. State Rep. John-Michael Parker of the 101^st District, wrote in an email: “I am still very new to this issue and have a lot to learn.”

State Rep. Jillian Gilchrest.

State Rep. Jillian Gilchrest of the 18^th District and vice chair of the committee, agreed that it’s time for a reassessment. She said she likes the chief drug officer idea and called for a fundamental shift in the way the state deals with opioids. “We need major changes,” she said. “We need to shift to seeing this as a chronic disease rather than a problem that can be solved with quick fixes.”

Resources should be available to fund new approaches or expansions of existing programs. Connecticut and its cities are flush with cash from federal stimulus programs and, starting this summer, they will begin receiving funds from the national opioid settlement with the pharmaceutical companies that profited from over-prescription of legal opioid medications for pain. According to the state attorney general’s office, Connecticut will receive $300 million over 18 years. It’s up to the legislature to decide how to spend it. The settlement stipulates that 70% of the money should be spent on future abatement activities.

The state Department of Mental Health and Addiction Services (DMHAS), the agency with primary responsibility for dealing with the opioid crisis, runs, funds, and/or regulates a wide variety of activities and programs, including the Live Loud Families awareness website and more than 250 addiction care facilities and 45 sober homes. A spokesperson for Luiza Barnat, director for opioid services at DMHAS, said “DMHAS is implementing strategies that have been proven effective in addressing the opioid crisis.” In response to a question about how the settlement money should be spent, the answer was brief: “It should be directed toward practices that have been proven effective.”

Addiction medicine experts at Yale School of Medicine argue that nationally and in Connecticut, more resources and attention should be focused on evidence-based solutions—primarily outpatient medication-assisted treatment (MAT). That’s the use of opioid-based medications in combination with counseling and behavior therapies.

“Despite us knowing what to do, the numbers keep getting worse,” said Dr. David Fiellin, director of Yale’s Program in Addiction Medicine. He was the lead author in 2016 of a strategic plan for the state, which was commissioned by then-Gov. Dannel Malloy.

Much of the response to opioid use disorder is still focused on law enforcement and abstinence, neither of which has been effective at ending the drug crisis. Fiellin called for lessening government support for programs that do not provide medication-based treatment and for establishing new rules requiring all addiction care programs to inform patients about the comparative effectiveness of treatment options.

APT Foundation Photo.

Lynn Madden, APT Foundation chief executive.

Community opposition to the APT Foundation methadone clinic in New Haven shows how difficult it is to make MAT widely available. Dispensing methadone for opioid use disorder is controlled by the U.S. Drug Enforcement Administration and is limited to specialty facilities that are most often located in cities and typically serve hundreds of patients. Residents living near an existing APT Foundation clinic on New Haven’s Congress Avenue have complained for years about people congregating nearby and drug use in the neighborhood, and, though the clinic has made changes in response, the neighbors are not satisfied. They complain that people from elsewhere are channeled to the city for methadone treatment, placing an unfair burden on neighborhoods where the residents are predominantly Black and Latino.

APT Foundation Chief Executive Lynn Madden defends her clinics. “Siting drug treatment programs is very difficult. There’s a lot of misunderstanding of how methadone treatment works, and neighbors have had negative experiences,” she said. Madden called for a broad new state initiative aimed at getting people quick access to MAT via a wide variety of touchpoints—whether it’s a community health clinic, a hospital emergency department, a homeless shelter, an obstetrician’s office, or a church-based social service.

Fiellin and some of his colleagues at Yale helped shape changes in government policy that enabled more physicians to prescribe buprenorphine. Now, they hope to convince the DEA to change regulations for methadone, making it available for prescription by trained and certified doctors anywhere in the state and the country. That way, they argue, it would be easier for people to access the most effective treatments, and the unwelcome congregation problems could be reduced or eliminated.

“We shouldn’t have to rely on large methadone clinics to get treatment to people who need it. The current highly-regulated model of treating people with opioid use problems is outdated and an unnecessary relic of past thinking.”

— Marek Chawarski, opioid researcher

Yale Department of Psychiatry

Chawarski stressed that MAT is not a magic bullet. Besides medications, other approaches are needed. He said there should be improvements in prevention programs in schools. In addition, lifestyle changes can help patients with OUD sustain recovery.

Chawarski, Fiellin and their colleagues face a number of challenges in their effort to expand methadone prescribing—and not just from the DEA (which didn’t respond to a request for comment) and advocates of abstinence-based treatments. Even though general medical practices have been permitted to prescribe buprenorphine for nearly 20 years, not enough of them actually do it. Methadone, with all of its reputational problems, might be an ever-harder sell.

In spite of the evidence that MAT is the most effective treatment for OUD, some people within the recovery community favor other approaches, such as so-called 12-step programs, many of which preach abstinence. Phil Valentine, executive director of Connecticut Community for Addiction Recovery, said that rather than trying to convince people to use MAT, treatment experts should listen to people who are in recovery and their families and see what they want. “We should see if there’s something innovative we can try—whether it’s evidence-based or not—that might have an effect,” he said.

While the advocates for change don’t agree on everything, they agree on one thing: the need for bold changes. “Every system is perfectly designed to produce the results it’s currently receiving,” says APT Foundation’s Madden. “We aren’t achieving the results we want, so let’s change the system.”

You can view Steve Hamm’s documentary Fentanyl Madness 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.

People with opioid addiction often seek treatment in EDs for overdoses and other ailments. Those who receive buprenorphine, a medication that reduces drug cravings, in the ED incur lower health care costs over the following month than those who get a referral to treatment services or receive a brief intervention with a facilitated referral, according to a new analysis of a randomized clinical trial.

The analysis, published today in the journal “Addiction,” compared the estimated health care costs for patients over the 30 days following their ED visit. Those costs included ED care, addiction treatment, inpatient and outpatient costs and medications.

They found patients who received ED-initiated buprenorphine incurred a mean cost of $1,752, compared with $1,805 for those who got brief interventions and $1,977 for those who received referrals alone.

“On average, the costs were lowest in the ED-initiated buprenorphine group,” said Susan Busch, professor of health policy at the Yale School of Public Health and first author of the study. “Those patients did not use additional health care resources, but had better outcomes.”

Photo provided by YSPH.

Susan Busch of the Yale School of Public Health.

Additionally, patients who started the medication in an ED were almost twice as likely to be enrolled in addiction treatment, and used opioids for fewer days, during the 30 days following their ED visits, researchers found.

The analysis included 244 people who arrived at Yale New Haven Hospital’s ED and screened positive for opioid use disorder, Busch said. Similar studies are now being done in other hospital EDs to see whether they produce similar results.

The findings at Yale New Haven Hospital are significant, Busch said, because relatively few people with opioid use disorder receive treatment, and even fewer receive the most effective treatments like buprenorphine.

“The medication is fairly widely used” among those who seek treatment, she said. But “only about 20 percent of people with opioid use disorder are in treatment, which is woefully low. Many people that have this disorder are just simply not in treatment.”

Patients who begin buprenorphine in an ED setting typically continue it on an outpatient basis, she said.

The new findings could have a significant impact in Connecticut, where emergency departments treat a relatively high number of opioid-related cases.

In the fourth quarter of 2014, the most recent data available, there were 246 opioid-related ED visits per 100,000 people in Connecticut. That’s well above the national rate of 183 per 100,000 people during the same quarter, according to the federal Agency for Healthcare Research and Quality.

In 2014, Connecticut ranked in the top 25 percent of states with the highest opioid-related ED visit rates among men. The rate for women was among the middle 50 percent of the nation, data show. Connecticut also ranked among the top 25 percent of states with the highest rates of opioid-related inpatient hospital stays, for both men and women, in 2014.

Connecticut, like the nation, has seen its number of opioid-induced ED visits soar in recent years. Back in the first quarter of 2005, for instance, the state saw 163 visits per 100,000 people while the national rate was 83 per 100,000.

A previous analysis of the Yale study, released in 2015, found that patients treated in EDs for opioid-related problems with buprenorphine fared better than those who merely were referred to treatment programs.

The new analysis, Busch said, shows physicians, insurers and others who may worry about costs that the medication’s benefits outweigh its price tag.

“We know that the opioid epidemic has devastating consequences for individuals, yet many people are not in treatment,” said Busch. “This is one high-value, effective way to get people the help they need.”

Researchers have conducted the first known random trial comparing three treatment strategies for people dependent on opioids who seek emergency care. The opioids include hydrocodone and oxycodone, in addition to heroin and morphine.

Among the more than 300 people in the trial, patients in emergency departments who received buprenorphine, a medication that reduces opioid cravings, had greater success than those treated in other ways, researchers found.

Opioid addicts often seek care in hospital emergency departments for overdoses or other issues, according to researchers. Once they receive that emergency care, they usually receive referrals for addiction treatment.

“The patients who received ED-initiated medication and referral for ongoing treatment in primary care were twice as likely than the others to be engaged in treatment 30 days later,” Dr. Gail D’Onofrio, chairwoman of emergency medicine at Yale School of Medicine, said. “They were less likely to use illicit opioids of any kind.”

In the study, opioid-dependent participants who came to Yale-New Haven Hospital’s emergency department between April 2009 and June 2013 were split into three groups: one group received a list of treatment services; another received a “motivational consultation” and referral, and the third received a “brief intervention” and treatment with buprenorphine that subsequently was continued with their primary care doctors.

“ED physicians (traditionally) take care of the immediate concern but don’t treat the underlying problem,” added D’Onofrio.

Those who received the medication from the hospital also were less likely than others to need inpatient treatment at a residential facility, according to Dr. David Fiellin, a professor of medicine at Yale who co-led the Yale team with D’Onofrio and oversaw participants’ ongoing buprenorphine treatment in primary care.

Previous research at Yale has found buprenorphine to be effective when used in primary care, but this study aimed to expand the reach of the treatment into emergency departments, according to Dr. Patrick O’Connor, professor of medicine and chief of general internal medicine at Yale.

“Effectively linking ED-initiated buprenorphine treatment to ongoing treatment in primary care represents an exciting new model for engaging patients who are dependent on opioids into state-of-the-art care,” he said in a statement.

The findings should be confirmed in other emergency departments, researchers say, but are encouraging.

“This really represents a new paradigm,” D’Onofrio said, noting that emergency departments typically treat other chronic diseases, such as high blood pressure and asthma, with medication that is then continued in primary care.

“For addiction, we’ve never done that,” she said. “That’s what’s really exciting to me.”

Reaching addicts in emergency departments is crucial, she said.

“That’s where the patients are,” she said. “And otherwise it will be a revolving door.”

Emergency department treatment has the potential to prevent additional ED visits as well as deaths, she said.

Addiction to prescription and illegal opioids is a growing epidemic globally, according to the National Institute on Drug Abuse, which is part of the National Institutes of Health and partially funded the Yale study.

There are an estimated 26.4 million to 36 million people using opioids worldwide, according to the institute. In 2012, about 2.1 million people in the United States were addicted to prescription opioids and 467,000 were addicted to heroin.

“There’s been a tremendous rise in opioid dependence and overdoses,” D’Onofrio said. “It’s an incredible epidemic. We know that treatment does work, but we have to get people into treatment and that’s the hardest part.”