The Opioid Crisis — A cure and its challenge
Editor’s Note: The News has chosen to redact patients’ last names to protect their privacy.
Congress Avenue is quiet. The low hum of the Yale New Haven Hospital complex is only occasionally pierced by the wail of an ambulance arriving in the darkness. The streets are mostly empty, and New Haven is still asleep.
But every day, before the crack of dawn, cars begin to pull in and out of a nondescript parking lot a block further south. A steady stream of people walk in and out of the adjacent building.
This building, the APT Foundation’s Congress Avenue location — which opens its doors at 5 a.m. Monday through Saturday — is one of New Haven’s oldest and most prominent substance abuse treatment centers. Daily, doctors and nurses walk in before the sun rises to administer treatment to individuals with opioid use disorder.
The building, which was constructed in the early 19th century as a school building and has mostly retained its unassuming exterior, is located just one block away from Yale New Haven Hospital. Patients arrive by walking, driving or taking public transportation. Some arrive in medical taxis from around the city or nearby suburbs, others board the 265 route bus and get off right in front of the treatment center’s parking lot.
Patients move quickly. The busiest buses, which arrive just after 7 a.m., unload more than a dozen people at once. From the time an individual climbs the short set of stairs under the foundation’s blue awning to the time they come out of the building, mere minutes pass. Some briefly mill around after, smoking cigarettes or conversing with others. Most leave once they emerge from the facility — sometimes less than two minutes after they enter — walking, driving or crossing the street to wait on the bus in the other direction, which drives toward downtown.
The APT Foundation’s five locations served 7950 unique individuals last year. Hundreds more enter similar clinics’ doors every day in the Elm City alone. Each person varies in background, gender, race and age. But they share one common trait — they are recipients of medication-assisted treatment for opioid use disorder. Their visits are a small part of their routines but a critical one that keeps them stable and alive.
And their visits are symptomatic of a larger problem.
The opioid crisis has emerged as a public health crisis in communities across America. New Haven, like many urban areas, is struggling to curb and address the epidemic on various different levels.
But what makes this crisis so pervasive?
“THE PUBLIC HEALTH SCOURGE”
Opioids, a class of drugs that includes heroin and its synthetic versions, such as fentanyl, have become one of the United States’ leading causes of death. In Connecticut, the toll is high and rising. According to the Centers for Disease Control and Prevention, between 2016 and 2017, the overdose death rate increased significantly — by 12.8 percent.
In the short term, opioids are extremely effective painkillers. Certain forms, such as Vicodin, are often prescribed to patients struggling with post-operation pain. Despite their effectiveness, however, tolerance grows quickly. Within days, dosage has to be increased to feel the same initial pain-relieving effect.
In 2017, the Centers for Disease Control and Prevention reported more than 47,000 deaths from opioid-induced overdose — more than 67 percent of all drug overdose deaths. And approximately 2.5 million people in the United States are currently suffering from opioid use disorder, according to APT Foundation President Lynn Madden.
Connecticut’s rate of drug overdose deaths, within the nation’s top quintile, has also outgrown that of most of its peers. In 2014, the age-adjusted rate was 17.6 deaths per 100,000 people. By 2017, that number had almost doubled, to 30.9. In comparison, the national rates in 2014 and 2017 were 14.7 and 21.7 percent, respectively.
The numbers — staggering as they are — “truly do not tell the whole story,” Madden said. “This is the public health scourge of our time.”
In general, the crisis involves a significant pipeline effect. Prescription opioids are hard to come by in the long term, and they are much more expensive than their illicit street counterpart: heroin, or its synthetic form, fentanyl. Fentanyl is cheaper, more potent and more dangerous.
Opioid overdoses result from the drug’s depressive effect on the respiratory system. When a person overshoots a dose, instead of producing a high, their body fails to react to the carbon dioxide buildup, stopping their breathing.
In the case of the most powerful synthetic opioids, the difference between a high and an overdose is a matter of micrograms, one-thousandths of a milligram.
A WAKE-UP CALL
In August 2018, a mass overdose downtown shook the Elm City. On the New Haven Green — adjacent to Yale’s Old Campus, which would bustle with members of the class of 2022 just days later — 100 overdoses occurred within a 24-hour period. Most individuals involved displayed the characteristic signs of opiate-induced overdose. The city jumped into response, sending patients to local hospitals for treatment by the dozens.
The culprit emerged — K2, the colloquial name for synthetic cannabinoids. The street drugs had caused collective overdoses in the Elm City before — in both January and February 2018, multiple overdoses were linked to synthetic cannabinoids, which target the same receptors in the brain as marijuana.
The public overdoses made national news, garnering even more interest when city officials found that the synthetic cannabinoids, which are themselves often degrees of magnitude more potent than marijuana, had been laced with some kind of opioid.
In the aftermath of the mass overdoses, Mayor Toni Harp commissioned an Overdose Response Task Force. The task force meets monthly and was the first initiative mayoral spokesperson Laurence Grotheer pointed at when asked about how New Haven is addressing the crisis.
“The city is working very closely with the state to confront the issue of substance abuse disorder and the potential for overdose,” Grotheer said.
Although K2 is not an opioid, the task force was an acknowledgement, albeit a small one, that polysubstance abuse is common. Implicit in its focus on opioids was another acknowledgement: Opioid abuse is the one that causes the city the most pain.
THE DOWNSTREAM RESPONSE
In every city and state proposed solution on how to reduce overdose fatalities, one substance comes up repeatedly: naloxone.
Naloxone, often sold under the brand name Narcan, blocks the effects of opioids and can reverse an opiate-induced overdose. The zero-fatality outcome of the August 2018 K2 overdoses can be chalked up to the drug, which, based on the symptoms of overdose exhibited, was the primary treatment given.
Narcan has become a primary pillar of Connecticut’s and New Haven’s plan to tackle opioid overdoses. When newly inaugurated Gov. Ned Lamont SOM ’80 unveiled new measures to address the opioid crisis earlier this month, providing Narcan to first responders and equipping towns and cities with adequate amounts of the drug were at the forefront of his plan. In the Elm City’s Overdose Response Task Force meetings, Harp and other leaders on the issue have pushed for and touted increased trainings to teach residents how to use Narcan and to ensure its wide availability.
Narcan can serve as a final measure to keep fatalities from opioid overdose low. But it doesn’t keep people away from opioids to begin with. It is extremely effective in saving lives, but it cannot stymie the progression of opioid use disorder once an individual is already suffering from the disease.
Opiates target the brain’s reward systems. They are highly addictive. But not all of those who are physically dependent on opiates are afflicted with opioid use disorder, according to Gail D’Onofrio, an emergency room doctor at Yale New Haven Hospital and researcher on substance abuse.
There are three hallmark signs of opioid use disorder that distinguish it from a physical dependence on opioids alone — craving, total loss of control and lack of regard for consequences.
An individual can be physically dependent on some type of opioid without those three conditions. The public often associates individuals’ turning their backs on responsibilities and loved ones with physical dependence. But, in reality, these symptoms — and instability — are actually a result of opioid use disorder, not isolated physical dependence.
Melanie has received treatment at the APT Foundation for opioid use disorder for the past 11 years. She remembers the first time she tried heroin, when she had no intention of becoming a regular user. She understood what the implications were on her commitment to her children and the strains of drug use on her already-tight finances. But just days later, she found herself battling, and losing to, her urges.
“It’s a true disease,” D’Onofrio stressed.
Madden noted that opioid addiction also causes a wide-reaching public health epidemic.
Opioids, even in comparison to other physically dangerous drugs, are highly associated with other risky behaviors, such as needle use. Those who consume the drug through injection, even only occasionally, are at higher risk for disease transmission.
“WE KNOW THAT WORKS”
Opioid use disorder is a medically treatable disease, D’Onofrio clarified. A widely embraced and “very successful” form of treatment for the disorder in the medical community — medication-assisted treatment — takes two common forms: the prescribing and administering of either methadone or buprenorphine.
Methadone and buprenorphine, unlike naloxone, are not lifesaving drugs. They cannot pull a person back from an overdose, but D’Onofrio and Madden stressed that they shut down the root of those overdoses to begin with: the disease.
Both methadone and buprenorphine, which are used almost identically except for some specifics about dosage and case-by-case effectiveness, are opiate medications. Like heroin or fentanyl, they are painkillers. Like those two drugs, they attach to the receptors in the brain that control the reward system that causes the withdrawal and craving. But unlike heroin or fentanyl, those on properly administered, orally ingested doses of methadone and buprenorphine — while physically dependent — do not exhibit the three hallmark traits of opioid use disorder.
It is a counterintuitive concept to wrap one’s head around: the most medically sound method of addressing opiate addiction and its many evils is to use another opiate.
For Lisa, a decadelong patient and client at the APT Foundation, methadone treatment took some time and adjustment to become effective in long-term maintenance and stabilization of her addiction. Early on, Lisa found that her cravings were not completely satisfied and turned to nonprescribed opioids during treatment. But since APT was able to fit a proper dosage — too much and patients struggle with symptoms, too little and it does not fully satiate the desire to use other opioids — she has not used anything else.
The proof is conclusive: Methadone and buprenorphine attach to the brain’s receptors and stabilize the lives of people demonstrating opioid use disorder. The physical dependence part is transferred onto the medication. The “hallmarks of addiction,” as D’Onofrio describes them, lessen and eventually dissipate if administered properly.
THE MYTH OF MORAL HAZARD
If medication-assisted treatment for opioid use disorder has been proved effective by some of the world’s most highly regarded researchers and doctors, nothing should stand in the way of the complete eradication of opioid use disorder — and, in turn, opioid overdoses.
In reality, though, the science of methadone and buprenorphine run up against entrenched resistance. For decades, drug use has been demonized as a societal moral failure, not a health epidemic. Addiction, and all of its detrimental consequences, have been viewed as personal, moral choices by individuals.
Madden, who is also a postdoctoral associate with the Yale School of Medicine, and D’Onofrio both point at one critical social issue: stigma.
In a society that has long been told that addiction and substance abuse are a choice, it is really hard to change people’s perceptions about who should get help, and what that help ought to look like. It is even harder when the decision-makers — those who are elected by voters to make or implement policy and regulations — are not necessarily medical or clinical experts.
“For better or for worse, we’re not a technocracy,” Aidan Pillard ’20, president of Yale Students for a Sensible Drug Policy, said. “We have a long history of telling people that drug use is a personal moral choice.”
That long history means that embracing the opioid crisis as a medical crisis with a medical solution is politically burdensome, largely because it demands meeting individuals where they are.
In September 2018, in a 4 1/2-hour hearing, nearly 100 residents turned out to City Hall to air grievances. The hearing featured arguments between local residents and medical professionals associated with the clinic over why residents should have to bear the burdens of such treatment in their communities and neighborhoods.
Misconceptions also easily persist in a system where institutions are often intertwined over time — as many in the Elm City are.
Some of the most important actors in the city’s political scene are also social and cultural institutions. Labor unions have long been one of the city’s most powerful political forces — candidates hoping for New Haven’s vote make alliances with local unions and stump with them on the campaign trail.
Beyond a union affiliation, the city’s political community is also deeply intertwined with its faith-based community. Many local churches have provided important social services over the years. Still, both Pillard and Sylvester Salcedo — an advocate for drug policy reform and founder of the Connecticut Heroin Users Union — surmised that drug use would likely be embraced more as an issue of moral, personal reform and salvation.
Salcedo broached the issue of changing the way substance abuse is regarded and addressed with prominent church leaders when he lived in nearby Bridgeport — a city with a similar demography and set of challenges as New Haven. He was often met with a kindly delivered promise to keep him and the cause in their prayers.
“I felt like the most prayed-for man in the world,” Salcedo remembered with a wistful smile.
A SELF-FULFILLING PROPHECY
The provision of methadone or buprenorphine as part of medication-assisted treatment of opioid use disorder is almost perfectly uncontroversial in the medical community. While the drugs do not inherently eliminate physical dependence on opioids — both methadone and buprenorphine are, after all, technically classified as opioids themselves — they transition individuals away from both the physical dependence on and, more importantly, the loss of control and increasingly addictive nature associated with heroin and fentanyl.
As methadone treatment has received more political scrutiny, some methadone clinics in the area have already closed their doors. But the demand for treatment has not decreased, leading to higher traffic for the still-open facilities and the neighborhoods they are located in.
Salcedo is a retired member of the Navy and an attorney who now spends most of his time and energy on his two young children. Both are students at the John C. Daniels School, a magnet school whose building is separated from APT Foundation’s Congress Avenue location by a crosswalk. The school was built in its location long after the treatment center had already occupied its lot. Salcedo, who is president of the parent-teacher organization, told the News that he has never had his own or heard of other parents’ concerns with the foundation or its clients.
Salcedo is frustrated by the weaponization of the imagery — of school children just 200 feet away from hundreds of drug users — by those who feel animosity toward the APT Foundation or its presence in their neighborhoods. “How they use us” strikes Salcedo as “really, really ridiculous.”
Then, there is also the uncomfortable truth that New Haven is already known as a place where individuals can come to receive treatment. New Haven is caught in a self-fulfilling prophecy. Pillard, Salcedo, Grotheer, and Ward 1 Alder Hacibey Catalbasoglu ’19 all acknowledged the dilemma of well-supported service providers.
The city’s desire to address its own crisis of those struggling with opioid use disorder is delicately balanced with the understanding that providing the services to do so might make “New Haven’s problem” then expand in scope. Those struggling with the disorder in neighboring towns and suburbs — as their own service providers have shuttered or imposed additional conditions to the provision of treatment — will travel to New Haven.
“It is tough to live next to,” Pillard admitted. The concern that out-of-town patients — with their needs fulfilled by New Haven’s services — will bring increased and unwanted social ills is understandable, he recognized.
Grotheer went a step further. When asked if he thought the self-fulfilling prophecy of setting out to provide treatment and services for those with opioid use disorder might attract more individuals from elsewhere — and thereby perpetuate the image that New Haven has an ever-growing problem on its hands — Grotheer said that it has already contributed to the labelling of substance abuse as an “urban issue.”
And as long as substance use disorders are still viewed as reflections of moral character and failure, Madden said, the presence of clinics and treatment centers in neighborhoods also forces their residents to grapple with the question of what that says about their communities if such facilities are needed.
THE CULTURE OF “CHOICE” AND “COMMITMENT”
Madden compares opioid use disorder to chronic illnesses like diabetes. Patients do not get better “all at once,” and it might take adjustment and trials to find the precise prescription and dosage that will result in stabilization. In the meantime, the occasional spike in blood sugar — or use of unprescribed opioids — does not code for complete failure, just additional work and treatment.
What that means for APT — and what makes it a particular target of community ire and political controversy — is that abstinence is not a condition of treatment. Patients are tested regularly, and their doses continue to be tinkered with throughout their years of treatment, but a drug test that shows that a patient is not “clean” does not mean the end of the road but rather a return to the drawing board as to how the clinic can provide more adequate and effective care — whether through dosage changes or other support services such as group meetings.
Although there is no controversy from a medical perspective, Madden attributed the lack of initiative to increase the provision of treatment to the fact that “the treatment is controversial, and the people that need the treatment are also stigmatized or controversial.”
The APT Foundation’s nonrequirement of complete abstinence has faced questioning from community members and politicians. The foundation does not have to answer to most of them, since their funding mostly comes through insurance payments, including Medicaid. The nonprofit organization is a $36 million operation and, aside from treatment payments, gets a grant of approximately $6 million from the state.
The city cannot influence the standards and regulations of APT and other methadone clinics, but Grotheer expressed concern over their methods, questioning the practice of continuing to offer medication-assisted treatment to those who do use nonprescribed substances.
Those individuals, he said, might not be, “100 percent committed” to getting well.
That cultural misconception and stigma, Madden explained, is pervasive, and the primary challenge in improving access to treatment. The language of getting “clean,” as if relapsing makes one “dirty” or otherwise inferior, is representative of a larger cultural discomfort with addressing patients as patients, instead of “criminals or deadbeats.”
The medical treatment of substance abuse is still a relatively young — although well-backed — clinical practice. The early treatment of opioid use disorder was largely based in programs like Alcoholics Anonymous, which center around the concept of self-help.
The belief that complete commitment and willpower can control disease and recovery is still deeply embedded in the country’s social culture. Melanie and Lucia — who has struggled with her own substance use disorders and whose boyfriend receives treatment at APT — both adamantly told the News that actually getting “clean” from their addictions, even with methadone treatment, depended on “making a choice” to do so, and then committing to that choice.
“The stigma is both endogenous and exogenous,” Madden said. “It’s cultural, but it’s also internalized by people, because all of us are a product of our culture.”
We do not chastise diabetics, Madden mused, for needing medication to stabilize their lives — some who suffer from Type 2 diabetes can manage their disease and eliminate the risk of spikes and dips in blood sugar through lifestyle and choices alone, but most need some kind of long-term supplementary treatment.
PATIENTS, PEOPLE AND POLICY
Madden has spent the last few years looking for clues from the HIV/AIDS epidemic on how to further the advocacy that will hopefully transform the opioid crisis. During the HIV/AIDS epidemic, persons who had HIV or AIDS were “completely vilified” and denied adequate care and cultural understanding of their challenges.
HIV/AIDS activists’ work to overcome the deep cultural stigma assigned to the disease and its sufferers serves as the primary historical parallel from which Madden tries to draw — opioid use disorder is a disease that is often medically manageable. But its cultural perception and associations hinders the delivery of treatment.
“We have to stop marginalizing people who have substance use disorders and try to find ways about thinking about their lives and stories and challenges and hopes and dreams like we do everyone else,” Madden said.
But policy efforts at both the state and city level focus on preventing opioid use and minimizing the fatality rate of opioid overdoses.
On April 1, Lamont — in conjunction with the Department of Public Health and the Department of Mental Health and Addiction Services — announced two new initiatives to counter the opioid crisis. The first, LiveLOUD, is a statewide awareness campaign. The other is the launch of a new smartphone app, NORA, short for Naloxone and Overdose Response App. The free app instructs individuals on how to administer Narcan.
In the press release announcing the launch of the initiatives, Lamont and Lt. Gov. Susan Bysiewicz ’83 focused on informing the public on the issue and publicizing access to resources.
“Educating the public is a critical component of addressing the opioid crisis,” Bysiewicz said in the press release. “We believe the LiveLOUD campaign and NORA smartphone app will make it easier for people across the state to learn about what services are available to them.”
Public awareness campaigns and prevention of further proliferation of the disorder have long been the primary ways in which government has addressed the opioid crisis, Madden explained, because they seem more, “politically palatable.”
“There isn’t a lot of political will, in general, no matter what level of government that you’re at, to actually provide the treatment,” Madden said about the lack of policy initiatives related to the provision of medication-assisted treatment.
But at the New Haven level, Madden cited city officials’ willingness to cooperate in expected ways, given the cultural conceptions still widely associated with medication-assisted treatment.
Since the K2 overdoses — when Harp and the city faced criticisms such as Republican state Sen. Len Fasano’s claims of poor and lacking policy — Madden has had “excellent, ongoing conversations” with Harp and relevant staffers and have settled on “a good path forward together.”
The city and the APT Foundation will work together to prevent overdoses and educate the New Haven Police Department. They are also partnering with other organizations to tackle mental health and first aid. Addressing some of the contributing factors to the crisis, Madden believes, will potentially put New Haven at the forefront of combating the national opioid crisis.
“This is the kind of issue that is happening all over the United States,” Madden said.