Fentanyl, 100 times more potent than morphine and 50 times stronger than heroin, has become the drug of choice for those addicted to opioids, outstripping heroin and other drugs. In 2018, 760 of the 1,017 opioid-related deaths involved one or more forms of fentanyl. In 2015, only 189 of 729 deaths were fentanyl-related.
Hearst Connecticut Media reviewed the detailed data about the 3,701 opioid-related deaths over four years, from the chief state medical examiner’s office. They paint a picture, in numbers, of a tragedy that is exploding by the year.
The individual cases were analyzed according to the city or town where the deceased lived, not where they died. What they reveal destroys the stereotypes that the opioid scourge is an urban problem or one that primarily afflicts the African-American community.
Every Corner of Connecticut
What Connecticut’s numbers show is that opioid abuse is just as devastating in Sharon, in the northwest corner, population 2,718, as it is in nearby Torrington, which is almost 13 times its size, or in New London, 95 miles away. Only 10 small towns in Connecticut have had no deaths from opioid overdoses in the last four years.“It clearly is not an inner-city problem,” said Dr. Michael Werdmann, an emergency physician at Bridgeport Hospital, where 53 percent of those who come to the emergency department with narcotic overdose as their chief complaint live in Bridgeport.
“They still have that kind of image, that it’s an urban or an inner-city problem, and what this suggests is that it’s an everywhere problem,” he said.
Overall, 60 percent of the hospital’s emergency patients are from the city, suggesting that opioid overdoses are more likely to be from the suburbs than other emergency department cases are.
“Clearly, some of the prescription drugs that have been pushed over the past five to 15 years” have exacerbated the problem, Werdmann said. Doctors were told they were “being really mean and that we weren’t treating pain appropriately” and that opioid medications such as Percocet and Vicodin were not addicting. Doctors would prescribe 30 pills for someone having surgery “and probably 20 of those went unused and were sitting in medicine chests and misused,” Werdmann said.
Opioids turned out to be highly addictive, and companies such as Stamford-based Purdue Pharma, maker of OxyContin, are now being sued over the devastation wreaked by opioids. Connecticut is one of 30 states suing Purdue Pharma, and Attorney General William Tong has joined with other state officials to target eight members of the Sackler family, which owns the company.
Opioid Deaths All (PDF)
Opioid Deaths All (Text)
‘A Disease She Couldn’t Control’
It was an accident while rope-swinging in Vermont that began the route from prescription painkillers to heroin, which led to an overdose for Ashleigh Rector, who died Sept. 27, 2016, at 30, according to her mother Laurel Lopossa of North Haven. Rector missed the water, landed on solid ground and “broke all the bones in her foot” when Rector was 22 or 23, Lopossa said.Rector became addicted to the prescribed opioids and “after that, another person who lives in Hamden, who also passed away, was her friend and he turned her on to heroin,” Lopossa said.
“She was a wonderful person; she was very compassionate toward people,” Lopossa said. “She was more than just an addict. She was so kind toward other people. ... She had a disease she couldn’t control.” Rector had taught skiing at Powder Ridge in Middlefield and in Vermont.
While she also suffered from an eating disorder and went into rehab several times, her mother was shocked to hear of Rector’s death. “I didn’t have a clue. I never expected her to die. It was the furthest thing from my mind,” she said.
“Afterwards, it’s the most devastating thing you ever go through,” Lopossa said. “People think you’re going to get better but you don’t get better. You just live a different way.” There are days still when it is difficult to get up, but “you know you have to keep going,” she said. Friends help get her through, as do grief-support groups, which Lopossa said are growing bigger because of the opioid epidemic.
She said the 30-day rehab stay is inadequate. “They need like a 15-month stay or 12-month stay somewhere because three months isn’t enough time,” Lopossa said. “They have to treat the whole person and they don’t do that a lot of times.”
Pain Was the ‘Fifth Vital Sign’
Dr. Gail D’Onofrio, physician in chief of emergency medicine at Yale New Haven Hospital, called the beginning of the epidemic “a perfect storm” between “Purdue Pharma and physicians telling us that patients should not have pain (and) that these medications were safe. … It was not evidence-based information.”“Pain became like the fifth vital sign,” D’Onofrio said, along with heart rate, blood pressure, respiration rate and oxygen saturation. “If it was more than 4 on a scale of 10, we had to treat pain.”
As people who developed substance abuse disorder turned from prescription drugs to less expensive street drugs, such as heroin, accidental deaths mounted. Fentanyl and its analogs multiplied the problem. According to the chief medical examiner’s reports, other drugs often were found in the system of the deceased, including heroin, cocaine, methadone and alcohol.
The largest group of victims are white men, although the number of black men and women who die of opioids is increasing, D’Onofrio said. She said there’s not “a simple answer to this,” but the problem largely started in the Appalachian Valley among miners and other white men who perform manual labor and were prescribed opioids for their pain.
“There was also a lot going on there. ... Companies were sending in massive amounts of oxycodone and people were selling it and doing it illegally,” she said. However, she added, the cost of illicit prescription drugs drove those who had become addicted to heroin.
“The epicenter of the epidemic was primarily in a white area,” D’Onofrio said, unlike the spread of cocaine in the 1980s, which “perhaps ... was not treated as aggressively from a policy point of view because it was in our black communities; it was not in our white communities.”
Also, people overdosing on opioids risk a much quicker death. “If you use just once, you can die,” D’Onofrio said.
In addition to pain from heavily physical jobs, another possible reason why white males dominate the opioid deaths is that “in general, men have more risk behavior. That’s in alcohol, everything” except in smoking, where women are the largest-growing group, she said.
Griswold, Norwich Lead List
By taking an average of the number of deaths from 2015 to 2018 and comparing it to each town’s 2017 population, the most recent available, the relative impact on each town becomes clear. With 27 deaths in four years, Griswold, which has only 11,687 residents, tops the list, with a per capita annual average of 5.78 deaths per 10,000 residents.More telling may be the next four municipalities on the list: Norwich, New London, New Britain and Torrington. Each had 67 or more opioid-related deaths in four years, and all but Norwich showed an increase each year, reflecting the statewide trend.
In some places, the increase was more than 50 percent from 2015 to 2018. Torrington’s toll rose from 12 in 2015 to 13 in 2016, then to 17 in 2017 and 25 in 2018. Plainville, with seven or fewer deaths from 2015 to 2017, recorded 16 opioid overdoses last year.
The biggest cities had the most deaths, but rank lower on the list because of their higher populations. Hartford, No. 10, had an average of more than 56 deaths each year and a per capita average of 4.56 per 10,000 residents. Bridgeport, at 31, ranked below both West Haven and Middletown with an average of more than 46 per year and 3.16 per capita, and New Haven was No. 40, with an average 38.5 deaths per year and 2.94 per capita.
West Haven had an 18-death average, while Middletown had more than 15, but both rank higher on the list of opioid deaths than New Haven because of their smaller population sizes.
Fairfield County ranks as the county with the fewest opioid deaths per 10,000 residents, with an average of 1.47 from 2015 to 2018. Bridgeport accounted for 185 of the county’s 560 deaths over those four years. Without the state’s largest city, the average rate would fall to less than 1.
But while most Fairfield County towns had few opioid overdoses, the challenge is “not to be complacent — that’s the problem,” said Alan Barry, Greenwich’s human services commissioner. He said three years ago a survey of youth in town was conducted, and vaping turned out to be a much larger issue than opioid use.
However, “it did bring this coalition together and now we’re putting together some strategies overall,” Barry said. “If the parents are lackadaisical or giving out mixed messages, it certainly has an impact on their kids,” Barry said.
While the number of opioid-related deaths in some towns is small, each one is devastating to family, friends and the wider community. An example is the town of Griswold, just northeast of Norwich and the two casinos, where 24 people died from 2015 to 2018, which, given the town’s 11,687 population, ranked it at the top of the list of towns in average number of deaths.
The opioid epidemic hit Griswold hard in 2016, when Olivia Elizabeth Roark died on May 29 at 17, the youngest in the state to die that year of an opioid overdose. Ramon Gomez was convicted of sex trafficking of a minor and possession of heroin with intent to distribute in connection with her death, according to the New London Day. According to the state data, Roark died of acute fentanyl intoxication and had recently ingested cocaine. She was one of eight to die of opioid poisoning in Griswold that year.
After Roark’s death, “I just know that we came together as a community, basically saying, ‘No more,” said Miranda Mahoney, coordinator of Griswold PRIDE, which stands for Partnership to Reduce the Influence of Drugs for Everyone. “I think we had 250 people come out for a candlelight vigil.”
Griswold PRIDE is a coalition of businesses, social service agencies, government, law enforcement and residents of Griswold, including the borough of Jewett City, the 1-square-mile hub of the town. The group was formed a year before Roark’s death, but that death “brought together some new players to our coalition,” Mahoney said.
Griswold PRIDE received a five-year, $625,000 grant from the White House’s Office of National Drug Control Policy in 2018 and recently the state Department of Mental Health and Addiction Services awarded $5,000 to the Southeastern Regional Action Council, based in Norwich.
One of Griswold PRIDE’s successes was to train residents in use of Narcan to reverse overdoses, Mahoney said. “We know that the training that we’ve offered … has been used” by bystanders, Mahoney said. In 2018, EMTs responded to 34 overdoses and “in five of those instances, the Narcan was already used by the bystander,” she said. In 2017, all 40 Narcan uses were by first responders, she said.
One of the bystanders who helped save a life in 2018 was PRIDE Chairman Ken Willey, who was talking to a friend in a Jewett City parking lot when “we heard somebody yelling for somebody else to wake up,” he said. “The kid started yelling if anyone had Narcan. I went over, I dosed the kid. He was in the driver’s seat; he wasn’t breathing.” A nurse and doctors arrived from the nearby United Community and Family Services and administered a second Narcan dose.
Patrick McCormack, health director for the Uncas Health District, which serves a number of towns in the Norwich-Montville area, said the crisis has “brought community organizations together that may not have gotten together. … There’s so much partnership around the solution,” he said. That includes the Ledge Light Health District in New London.
Funeral homes and real estate agents have been brought in to decrease the risk that unused opioid prescriptions will be disposed of and that they won’t be stolen out of medicine cabinets during open houses, McCormack said.
“I think the Griswold-Norwich area certainly isn’t unique in having the opioid issue affect the community, nor is it unique in having a positive response,” McCormack said, but he said it’s important to have a broad focus.
“You can’t … target a specific neighborhood,” he said. “They’re doing it in the bathroom of Dunkin’ Donuts; they’re doing it in a family member’s home; they’re doing it in a park.”
White Males Most Affected
Yale’s D’Onofrio said the overdose cases show the extent of the epidemic. “What we know about opioid use disorder is it really is nondiscriminatory,” she said. “It really can affect everyone, no matter their socioeconomic status.”And the group that is most affected is white males, she said.
“This is the third year in a row that the life expectancies for white men in the United States has gone down,” she said, and the decline is the “first time in a century that it’s gone down.”
“It’s all related to opioids,” D’Onofrio said. “Now women and people of color are escalating but it’s notoriously white men” who are dying of opioid overdoses.
According to the state’s data, 434, or 59.5 percent, of the 729 opioid-related deaths in 2015 were white males. While the numbers rose over the next three years to 1,017 total deaths, the 567 white males who died represented a smaller percentage, at 55.75 percent.
A Decade of Death
D’Onofrio dated the epidemic’s start at 2009, when most of the abuse was of prescription opioids such as oxycodone, the generic name of OxyContin, “and now it’s primarily fentanyl analogs,” she said. “It’s white males using heroin,” which is often laced with fentanyl or worse.Fentanyl and fentanyl analogs, which are synthetic opioids, were found in the bloodstreams of 760 of the 1,017 deaths in 2018. A fentanyl analog, a chemically altered version of fentanyl that is often more potent than the original, was associated with 254 of those deaths. Many of these were acetyl fentanyl, according to the state’s data.
A 2017 article in the journal Clinical Chemistry reported that most of the fentanyl and analogs were sold as heroin. The journal cited data from the U.S. Drug Enforcement Agency’s National Forensic Laboratory Information System that showed a 300 percent increase in fentanyl cases between 2014 and 2015, from 4,697 to 14,440.
According to that article and reports from the Centers for Disease Control and Prevention, deaths from synthetics rose from 9,580 in 2015 — itself a one-year spike of 72 percent — to 28,000 in 2017. The largest increase that year was in males aged 25 to 44.
In Connecticut, the number of deaths from synthetic opioids rose from 500 in 2016 to 686 in 2017, the CDC said.
“White males are dying and this is why we’ve had such a coalescence of everyone” across ideologies cooperating to fight the epidemic, D’Onofrio said.
According to Lauretta Grau, a clinical psychologist and research scientist at the Yale School of Public Health, Connecticut is “a little bit behind” the rest of the country in the rise of opioid deaths. “We’re not often the leading edge of a problem,” she said. Fentanyl hit the state in about 2015, about a year after other regions. Once it arrived, however, fentanyl as a street drug spread quickly across the state, she said.
Grau said she used to classify fentanyl as a pharmaceutical opioid, like methadone, because of its use as an anesthetic, for acute pain caused by cancer or surgery or for chronic pain. Now, however, “it is an illicit opioid,” she said.
Opioid Users Develop Tolerance
Helping to drive the epidemic is that people who are prescribed opioid medication develop a tolerance for the drug, so doctors “really tried to limit it to three days if at all possible” and patients should “use them as judiciously as you can,” D’Onofrio said. The Comprehensive Addiction and Recovery Act 2.0, passed in 2018, prohibited doctors from prescribing more than three days’ worth of opioids for chronic pain.Once a patient becomes addicted and can no longer get a doctor’s prescription, “buying pills on the illicit market can be expensive,” D’Onofrio said. “They then almost always move to heroin or fentanyl.” Once a tolerance develops, “you’re no longer getting high; you’re just feeling not sick,” she said.
She has a theory that “the greatest risk of an overdose is after you’ve been in a confined environment,” because those with opioid use disorder lose their tolerance if they are incarcerated or in a rehabilitation program that is not giving the patient medication to treat the addiction, such as methadone, buprenorphine or, less effectively, naltrexone. The advantage of buprenorphine is that it can be given as a prescription, avoiding the stigma of going to a treatment center, she said.
That’s also important in “rural communities [that] are less likely to have accessible treatment programs,” requiring transportation on a daily basis, D’Onofrio said.
“You can stop the physical withdrawal signs, so I’m not going to be sweating and writhing around,” D’Onofrio said. However, “the changes in the brain take more than 30 days. I can’t stop the craving, which is the brain portion. … The risk of dying after one-time use is great.”
Grau said medication is the best treatment and that people who have been in prison or a drug-treatment program do understand the issue of reduced tolerance, “but they still get into trouble because of the big variation of what’s out there at any point in time.”
She also said it’s important to provide supports such as counseling and housing to those recovering from opioid addiction.
Robert Heimer, professor of epidemiology and pharmacology at the School of Public Health, said recommending abstinence from all drugs to those with opioid abuse disorder is not helpful.
“They have an untreated disease, we give them an abstinence-based treatment, which we’ve known for a century is not effective, but it’s our first line of treatment,” he said.
Programs such as Narcotics Anonymous or detoxification programs must be accompanied by medication such as methadone or buprenorphine, he said. Otherwise, “you’re more likely to die than if you had no treatment at all,” Heimer said. “The treatment was worse than the disease by a factor of two. … We need programs that are sensitive to the lives of people who have opioid use disorder.”
Town Data ‘Not Granular Enough’
While the chief state medical examiner provided a breakdown of opioid deaths by town, Heimer said that doesn’t go far enough to determine what populations are using which drugs.“The towns themselves are not homogeneous, so what we’re trying to do right now is define it down to the census tract,” he said. “To look at the level of the town is not granular enough.”
In a study published in 2014 in the journal AIDS and Behavior, he and Russell Barbour, a research scientist in biostatistics at the School of Public Health, as well as Grau, focused on the suburbs of New Haven and Fairfield counties, using a tool known as the community disadvantage index.
The index uses a number of socioeconomic variables, rather than race, to identify who is most at risk of becoming a drug injector. They include whether the person is a single head of household or a renter vs. an owner.
“Drug users were found most often in the poorer census tracts,” Heimer said. “This problem remains economically distributed. Race doesn’t matter as much. … Part of the reason for that is a history of drug addiction tends to compromise one’s ability to earn money and tends to move you down the socioeconomic ladder. … Drug use is downwardly mobile.”
He said at younger ages, men are more likely to abuse drugs but that the ratio tends to even out as users age.
“The injecting has moved into the wealthier neighborhoods,” Barbour said. “Fentanyl was considered a pharmaceutical when we first started this and now is a street drug.” When once there were 20 fentanyl analogs, now there are 40, he said.
Some, such as carfentanil, are so powerful “it would seem to be there would be no level of safety,” Barbour said. Fentanyl analogs “have increased and certainly have contributed to the number of people in the autopsy database.”
Barbour said that even in the wealthier towns of Fairfield County, there are low-income drug users.
“There are even relatively poor areas of Ridgefield,” he said. “The towns are not a geographically meaningful unit to look at this. A town can have a fancy name. That’s not of interest to me.”
Ridgefield, with a population of 25,187 in 2017, had five deaths from 2015 to 2018 and ranks 154th in average number of deaths per capita.
K2 the New Growing Problem
While opioids remain a major threat, the growing problem now is synthetic cannabinoids such as K2, which are not as lethal because they don’t suppress the respiratory system, said Rick Fontana, director of emergency management for New Haven.“We had that dramatic increase but the good thing is we’re starting to see it slow down,” he said. “Now we’re seeing the K2.” He said he and others check emergency calls for heroin, opioids, K2 and use of Narcan every day. On May 2, for example, there were 11 responses for K2 and one for opioids between 10 a.m. and 4 p.m.
Whereas opioids, a user might cease breathing or have shallow respiration, with K2 “you see more along the lines of psychosis, schizophrenia, acting very strange, banging off the walls.”
Some form of synthetic cannabinoid was responsible for the emergency on the New Haven Green Aug. 15 and 16, when dozens of people overdosed, some multiple times. Many recovered without treatment. Felix Ayala Melendez was sentenced to 18 months in prison after pleading guilty to sale of a controlled substance and intent to sell narcotics.
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