A ‘glimmer of hope’ seen on opioids

Christopher Peak / New Haven Independent

Jon Rubenstein, Connecticut’s DEA supervisor, shows how small a fatal fentanyl dose can be.

Opioid overdoses killed so many people in the past year that Connecticut’s forensic examiners ran out of cooler space for the bodies. And yet professionals at the front lines of the crisis reported on a few reasons for hope: Doctors are prescribing fewer painkillers, while local law enforcement possesses more tools to reverse overdoses and lock up drug dealers who enabled them.

Those strategies, currently being employed by medical professionals, cops and prosecutors, offered a few bright spots at an otherwise bleak conference last month at Yale Law School about the devastation wrought by pain meds and heroin.

But those in attendance, including the outgoing chief of the Drug Enforcement Administration, were also steely-eyed about the tough challenges ahead. As the speakers reminded attendees throughout the afternoon, the epidemic is worsening, with overdoses expected to claim close to 1,100 lives in Connecticut this year, more than triple the number in 2012.

“We have got to change the culture. We’ve done it before: we’ve done it with seat-belts in the United States, we’ve done it with teen smoking,” Chuck Rosenberg, acting head of the DEA, said as he paced the auditorium stage, his blazer off and shirt-sleeves rolled up. (The event marked his last day on the job.) “We’re actually beginning to see a glimmer of hope — a glimmer but decidedly better than no hope — with a drop in opioid prescriptions.”

Other signs of progress were apparent throughout the day, as experts in medicine and criminal justice assessed their respective fields. Primary care physicians have a better idea of the risk of addiction, yet most still lack formal training. Cops carry a drug that can instantly stop an overdose, yet they don’t have the avenues to help survivors sign up for limited spots for treatment. Prosecutors have shifted attention from petty drug users to the dealers profiting off their overdoses, yet state law and funding hasn’t caught up with their pivot.

One DEA agent said the problem is worse than anything he’s seen in his 28-year career. Jon Rubenstein, Connecticut’s DEA supervisor, said he had never seen fentanyl or industrial tableting machines in his work until the last few years. Now he has got kilos of the drug and eight machines in his office, he said. He added that he’d never seen more heroin on the streets than now.

“This is not a Democratic or Republican thing,” Rosenberg said. “This is a public health crisis, with a law enforcement component.”

Little White Pills

James Gill: 1,076 are expected to overdose in Connecticut this year.

Jump-starting the conversation, four moms shared stories of losing their children to opioids. The parents recounted the first drug their kids took — pills that three sons received for athletic injuries and marijuana that one daughter smoked — and ended with the horror of finding paramedics swarming the house or a child’s body crumpled in a corner.

For Nick Kruczek, it was a little white pill that an upperclassman handed to relax him at his first high school hockey game.

“Turns out it was Oxy,” said Susan Kruczek, a Guilford mom whose 20-year-old son overdosed in 2013. “The pills then turned into heroin.”

After he matriculated at Southern Connecticut State University, Nick told his parents he had a problem with opiates. “I was really naive, ignorant,” Kruczek said. “I had to Google what it was.”

Nick said he needed rehab. But even though her husband worked as a schoolteacher, the family’s insurance wouldn’t cover it. “We put our kid, sick, blindly on a plane to go to Florida,” a spot where several panelists said they sent their children, because of a loophole that charged insurers out-patient rates for treatment in a residential setting.

Rehab seemed to work. Nick came home, took a few more classes at Southern and got a job at a coffee shop in New Haven.

In October 2013, two weeks before his 21st birthday, Nick was admitted to Yale New Haven Hospital (YNHH) after ODing. Doctors brought him back and discharged him. Nick overdosed again the same night.

“He’d call me or send a text every day, just to say, ‘I love you,’” Kruczek recalled. “Then, one day, I didn’t get that phone call or text.” His mother found Nick dead in his apartment.

Nick is one of the scores of casualties from opioids. There have been so many overdoses that Connecticut’s forensic examiners ran out of cooler space for the bodies, said James Gill, the state medical examiner. Last year, fatal overdoses far outnumbered all suicides, homicides and car accidents combined, he said.

And those acute intoxications continue to skyrocket, Gill explained, as fentanyl has become more prevalent. The potent drug was responsible for 57 percent of the deaths last year, including two of the 16 overdoses that swept New Haven in six hours last summer. Fentanyl is so powerful that the DEA recently told its agents to stop conducting field tests. “It can kill you to the touch,” Rosenberg said.

Another mother had one final word she wanted to share. Without calling him out by name, she rebuked Gov. Dannel P. Malloy for referring to “junkies” in his opening remarks.

“These kids aren’t ‘junkies,’” said Lori Jackman, a Tolland mom whose health insurance wouldn’t cover in-patient rehab for her son, Danny Osgood, before he died at 22 years old. “It can happen to anyone. Nobody’s immune. We’re all good parents. Just know that they’re not junkies.”

Rethinking pain

Some speakers, including Annmarie Taylor, another mother whose son died at 27, wondered aloud why the U.S. Food and Drug Administration hadn’t banned high-strength opioids altogether, the way it pulled Opana from the shelves this summer.

While Rosenberg acknowledged “we have this crack, this poison in our medicine cabinets,” he argued that a ban is not the right way for the government to get involved. “I would never want to be in a world in which we are standing between a patient and her doctor,” he said. “That strikes me as dangerous.”

Instead, Rosenberg suggested that the while the feds shouldn’t tell a doctor what to prescribe, they can monitor what he’s putting on his prescription pad.

Every state except Missouri has some type of database to monitor prescriptions. Rosenberg recommended that his successor take those systems national. Currently, about three dozen states share a “degree of interconnectivity,” Rosenberg said, but the feds could do much more.

“We need a robust, mandated prescription drug monitoring program to help good doctors avoid harming patients who are addicted and help us find bad doctors,” he said. “We need uniform access, we need a uniform set of rules and we need everyone to participate. It’s absolutely crucial, and I think it’s something that the federal government can do — if it so chooses.”

Daniel Tobin, an associate professor of medicine at Yale, suggested the medical community also revisit the way doctors learn about pain. For two decades after 1996, doctors were told to view pain as the “fifth vital sign,” along with heart rate, blood pressure, respiratory rate and temperature. Only last year did the American Medical Association change its guidance.

To update doctors on the latest research, Tobin said, regular training should be mandated. That should start in medical schools, he continued. Since there’s a severe lack of pain specialists four for every hundred patients with chronic conditions — medical schools need to teach the subject to primary-care physicians, Tobin said. Currently, only five medical schools in the nation offer that instruction, he said.

Early evidence suggests that new laws in Connecticut are having some effect. While heroin and fentanyl overdoses continue to climb, oxycodone poisonings have started to decrease, Gill said.

Police’s new enemy

Rosenberg admitted that law enforcement “made mistakes” in how they handled the crack epidemic that tore through urban areas in the 1990s. This time, “we are not going to prosecute or enforce or incarcerate our way out of this mess,” said Rosenberg, a former federal prosecutor. “No chance.”

Local police, meanwhile, have adapted their training to beat back the rising number of overdoses.

“Now, the enemy is different. Instead of being in the form of a bullet, it comes as a white powder,” Chief Anthony Campbell said. “We’ve had to change the way that we approach these calls.”

A state task force is increasing access to drugs like methadone and buprenorphine that can wean a person off their addiction — a strategy correlated with a drop in overdoses in Baltimore. By the end of next month, through a program called Law Enforcement Active Diversion, cops will start directing those who possess drugs to treatment with these medications.

And thanks to advocacy within the Department of Correction, since Oct. 2013 inmates in New Haven’s jail have been allowed to continue taking methadone if they had already started receiving treatment outside, but inmates can’t start a treatment regiment inside lockup, said Colleen Gallagher, who focuses on addiction services within the state’s prisons and jails.

Perhaps most importantly, officers now carry Narcan, a nasal spray that blocks the brain’s receptors from taking up opioids.

“Narcan has given us a golden opportunity. Narcan has provided us a chance to save these people, and we should not squander it,” said Maureen Platt, the state’s attorney in Waterbury. “I personally know of people who have been brought back with Narcan seven or eight times. Ultimately, that individual is going to be in a place where Narcan is not going to be available. We cannot waste that opportunity.”

Justice after overdoses

Prosecutors, too, are developing an expertise in how to charge cases involving opioids. Both federal prosecutors and the state’s attorney are investing resources to go after dealers whose illicit drugs led to an overdose.

The cases appear deceptively simple, with text messages, GPS data and a body as proof that a deadly sale occurred, said Assistant U.S. Attorney Rob Spector. But there’s many roadblocks to getting the right evidence to win the case, including locked cell phones, a lack of evidence (like dime bags) at the scene, multiple drugs in a victim’s system, and uncooperative relatives and friends, he added.

Because of those challenges and a high legal burden of proof within Connecticut’s statute, prosecutors are able to bring charges in only about 50 of the hundreds of overdoses each year, according to Platt. The main obstacle for the state’s attorney has been establishing that dealers “acted recklessly with extreme indifference to human life,” the evidence needed to find a person guilty of a first-degree manslaughter.

In 2008, the State Supreme Court threw out a conviction on that charge, finding that the dealer had to know the drugs were likely to cause the person’s death — a near-impossibility for a dealer who expected repeat customers. “We cannot say that the defendant, as a layperson, knew of the toxic effects and quantities of the subject drugs” — less common substances than alcohol and marijuana — “that would be lethal,” the court wrote.

That means that even though victims’ families might beg for a more serious charge, the state’s attorney often instead can only pursue a case of selling narcotics, Platt said. A second-degree manslaughter charge, which requires proof of causation between the sale and the death, comes with only a 10-year sentence, while a narcotics sale can carry up to 15 years for someone who’s addicted or 25 years for someone who was sober, Platt explained. Even with a statement from the victim, a usual sentence is four to seven years, she said.

“Even if we are fortunate enough to put together a viable case, the sentences do not reflect the loss to the family or the loss to society of the victim who has passed,” Platt said.

Comments

comments