Sally Weiner ’18 opens her pocket-sized medical kit with care. Inside the pouch are a pair of blue medical gloves, a set of graphic instructions and two doses of naloxone.
“It’s very easy to use. You put it up on someone’s nose and you press it,” Weiner says, holding up the spray. “You can use it on a child. You can use it on a pregnant woman.”
The Yale junior and student in public health first heard of naloxone after reading about police officers in her hometown of Mansfield, New Jersey carrying it on patrol. Naloxone — commonly known by its brandname Narcan — is a medicine that, when injected or inhaled, blocks the effects of opioids and counteracts respiratory depression caused by an overdose. A Narcan kit costs around $50 at pharmacies, but Weiner and many other New Haven residents get the life-saving tool for free.
Four weeks ago, on her first day of school, Weiner walked to the New Haven Free Public Library on Elm Street. It was International Overdose Awareness Day, and the city’s health department was hosting a session to distribute free kits and train the public on how to use Narcan. Weiner provided her name and zip code, and got a kit in return. None of her family or friends struggle with addiction, Weiner says, but she’s kept the medication — in case it may save a stranger’s life.
“There were grandmothers getting Narcan for their family,” she remembers. “It is a midway intervention: You don’t want to break the connection with your family by forcing them to quit, but you also don’t want them to die from an overdose.” Having learned how the medicine worked wonders in her hometown, Weiner is a strong supporter of increasing access to Narcan in the Elm City.
Problems of drug overdose have gripped the nation for several decades, but New Haven recently came into the spotlight when, on June 23, a bad batch of street drugs led to nearly 20 overdoses and claimed three lives in a single day.
Kathryn Hawk, an instructor in the Emergency Medicine Department and a researcher on drug abuse, addiction and HIV at the School of Medicine, says although her department sees overdose patients every day, the June incident was very unusual.
In a typical overdose case, first responders — passers-by, police officers, firefighters — call for an ambulance, which can then provide Narcan on-the-scene and transport patients to a hospital for further life support and long-term treatment. In 2014, a state law gave civil and criminal liability protection to anyone who administers Narcan in “good faith” to an overdose sufferer. The law led to extensive police training, and in the past two years, Connecticut police have saved 100 people with naloxone.
The sudden spike in overdoses in late June put a strain on the city’s Narcan supply, according to Hawk. The day after the overdoses occurred, the Connecticut Department of Public Health had to send an additional 700 doses to the city to replenish its stock.
But Hawk says current Narcan supply in the Emergency Department is in good shape. Since late June, her department has started identifying high-risk individuals — patients who have used emergency care for overdose-related issues before and those with a history of drug and alcohol dependence — to give them free take-home Narcan kits.
What is perhaps more alarming than the numbers in the June incident was the drug involved.
As reports of overdoses started to wind down on the 23rd and residents — many still unaware of the incidents at that time — got ready for bed, a citywide message broke the peace. The city declared a “public health emergency,” warning of “tainted life-threatening heroin” on the streets. No one was sure where the impure drug came from or what led to the catastrophe, and a press conference was scheduled for the next morning.
It was almost 10:30 p.m. when Esteban Hernandez came across a tweet about the overdoses. The City Hall reporter for the New Haven Register was in Pennsylvania for a long weekend, but he immediately got back to work.
“That was shocking. I’ve never heard of that many overdoses in a single day,” Hernandez shakes his head. In the fall of 2013, when he first started covering opioid overdoses in Torrington, Connecticut, three overdoses over a span of four days made big news.
Over the years Hernandez and his colleague have seen an increasing number of overdose cases involving drugs coated in other toxic chemicals. The worst case he’s written about, he says, was one involving heroin laced with a drug used to kill worms in sheep. Then in August, Carfentanil — often used as an elephant tranquilizer — hit Ohio streets and caused dozens of deaths. Although the synthetic opiate has not spread to New Haven, the thought of it sends shivers down Hernandez’s spine.
“It is pretty alarming. There has been an enormous amount of disgusting materials.”
Following the June incident, an investigation by the New Haven Police Department and the Drug Enforcement Administration revealed that victims who intended to buy cocaine unknowingly consumed fentanyl, a drug that also appears as white powder but is 100 times more potent than normal morphine and 50 times stronger than heroin.
The State Office of the Chief Medical Examiner projected 888 accidental overdose deaths in Connecticut in 2016, up from 495 cases three years ago. Of the projected fatal overdoses in 2016, 446 will involve fentanyl, a huge jump from 37 cases in 2013.
The reason why fentanyl has only become popular in recent years is unclear, according to Yale School of Medicine assistant professor Daniel Tobin. But, he says, the pattern of substances involved in overdoses has always changed over time. For example, cocaine overdoses were much more common in the past, but drug trafficking from China and Mexico has given rise to a greater supply of heroin and fentanyl in the United States, resulting in more overdoses on those drugs.
But increasing supply has not been the only factor. After Hernandez’s initial story on Torrington was published in 2013, a man who had struggled with addiction reached out to him for a follow-up. Their 40-minute conversation, which ran the gamut from personal stories to public stigma, left Hernandez in utter surprise.
“The man told me, ‘When [drug users] hear of something so powerful, they try and look for [the drug].’”
For his coverage, Hernandez and his colleague scanned through a list of people who died of an overdose, and noticed that the majority of victims tended to be white males aged between 25 and 40.
On a local level, New Haven drug activity is concentrated in The Hill and Fair Haven, as well as on the New Haven Green downtown, according to George Bucheli, who works for the city health department’s syringe-exchange program.
Every weekday Bucheli and his three co-workers take turns driving to those neighborhoods in their outreach van, trading clean needles for ones brought by drug users, who Bucheli refers to as “clients.” Bucheli stresses that the team keeps the exchange confidential and judgment-free. The city started the needle-exchange program 26 years ago in response to the lack of access to sterile needles among drug users, with HIV prevention in mind.
Neighbors can also get food, clothes and on-site Narcan training when they come to the van, Bucheli explains. Having devoted many years to the program, he says he’s built close relationships with his clients, and knows by heart which streets in the city see more drug activity — though he says he’s happiest when his clients do not need him anymore.
“I’ve seen people who gave up drugs come back to the van. They look beautiful — that’s good enough for me. They come to say thank you; some of them just want to hug you. That’s it.”
Bucheli and his needle-exchange program are a part of New Haven’s multifaceted approach to drug abuse, tackling a small piece of the complex puzzle of addiction.
About a decade ago, patients in the state could obtain multiple potentially addictive prescriptions by switching from one physician to another, a practice known as “doctor shopping.” It is has become harder in recent years though, Tobin says, because doctors now compile data and track drug-use history online. However, he adds, this change might have led more people to turn to street drugs.
Hernandez says that based on his experience interacting with people in recovery from addiction, a majority of them recount starting with prescribed painkillers. It’s only when they run out of prescriptions that they start buying drugs from street dealers, which are much cheaper but lack regulation.
To make things worse, more and more dealers are mixing up or substituting pure heroin with other more potent drugs, in order to boost interest in their drugs and make more money, medical school professor David Fiellin says. Under the charge of Connecticut Gov. Dannel Malloy, Fiellin spearheads the Connecticut Opioid Response (CORE) Initiative to come up with a 10-year strategic plan combating overdose in the state.
Fiellin’s team worked over the summer to draft a solution based on data from state agencies. The draft highlighted a number of areas for improvement, including increasing access to addiction treatment, focusing on higher-risk individuals and making naloxone more available. It also emphasized the need to work with the public to raise awareness of opioid-use disorder and the benefits of seeking treatment.
The CORE team published the report on Aug. 24 and accepted public feedback through Sept. 14. Over the past week, it convened to respond and pen a finalized version.
Earlier this year in April, standing in front of a cheering, 10,000-strong crowd on the New Haven Green, Sen. Bernie Sanders declared to his Elm City supporters that addiction and substance abuse must be seen as a health issue instead of a criminal one.
A drug user cannot help but seek the high, Fiellin explains, because with each additional dose, their bodies develop more tolerance to the drug. They need a greater amount to feel the same level of experience each time, or else they suffer from withdrawal symptoms that usually include anxiety, seizures and depression.
“You don’t get the drug to feel good. You get it to not to feel bad,” Hernandez says. As a reporter, he has sometimes felt lonely and helpless trying to convey the message that addiction is not a personal choice. “When they are addicted to it, it’s beyond their control. They are doing it so they won’t feel sick. I wish there could be more public understanding of what addiction is.”
Many of the responsibilities eventually fall on the shoulders of medical professionals, Tobin says. In the old days, the only medication treating opioid-withdrawal symptoms was methadone, which could only be used at centers with a special certification. Patients seeking treatment would have to wait in line at a methadone clinic. There was incredible stigma attached to drug treatment, Tobin explains.
Nowadays patients have another medication option: suboxone, which also treats narcotic addiction but may be prescribed by primary care physicians.
“You go to a doctor’s office, and you sit next to those who have a cold or high blood pressure. It really helps people overcome the stigma,” Tobin says.
To be able to prescribe suboxone, doctors need to undergo a special training and obtain a certification from the DEA.
Tobin argues that the practice is currently underused. “It’s not hard to do, but for whatever reason, doctors are not taking advantage of it.”
Throughout his career, Tobin has taught and spoken widely about how to mitigate the risks of opiate prescriptions. He has met with residents, many of whom are family members of drug users, and still remembers their sense of helplessness and the questions they asked.
“How do I get access to treatment?”
“Where can I get Narcan?”
“What will happen if I call the police in case of an overdose? Will I get fined?”
The day after the flood of overdoses shocked the city, one of the drug users who mistakenly took fentanyl sat down with a radio program, WNHH’s “Dateline New Haven,” and confessed that he had resumed his daily routine. And a couple days after the June 23 incident, officials said the city returned to its “normal level” of overdose response calls.
Hernandez and his colleagues will continue to cover the topic; Hawk and her emergency department will continue to save lives from overdose on a daily basis; Bucheli and his team will continue to go out in their van and trade clean needles. Much seems to have changed; much is left to be done.