The COVID-19 pandemic, while costing thousands of lives in Connecticut and worldwide, also has seen a rise in the number of victims from an ongoing epidemic: the opioid crisis.
A cluster of 20 cases last weekend in New Haven County, including 12 in New Haven, was just a more visible example of how opioids, in particular fentanyl, have spiked since the pandemic began in March, according to Dr. Gail D’Onofrio, chief of emergency medicine at Yale New Haven Hospital.
“The COVID epidemic has really exacerbated the opioid epidemic,” D’Onofrio said.
While it’s difficult to determine exact causes, D’Onofrio said, “COVID has created a lot of challenges for individuals with addictions. Social isolation “makes people use alone more often and they’re at higher risk of overdose.”
In addition, people who use illicit drugs may face “disruption of access to care as well as access to their drug supply” and may get more powerful drugs. “And there’s always the despair and anxiety related to COVID that we are all experiencing,” she said.
There were no fatalities in New Haven when the overdoses took place last weekend, which is fortunate because the drug suspected of causing the overdoses was one that has killed users in other states, according to New Haven Health Director Maritza Bond said. Known as “gray death,” it is a powerful combination of synthetic opioids.
But statewide figures for the months of March through May show that deaths from opioid overdoses rose 21.4 percent between 2019 and 2020, rising year over year for each month through April, before dipping a bit in May.
According to the state health department, there were 560 confirmed fatal drug overdoses by mid-June, and 275 more pending confirmation. That compares to 1,200 known deaths from drug overdoses in all of 2019, which was an 18 percent increase from the year before.
The deaths caused by fentanyl overdoses have also increased, with the percentage of fentanyl-related overdoses hovering about eight percentage points higher compared with 2019. However, that percentage actually has dropped some since February, when 91.2 percent of fatal overdoses were linked to fentanyl.
“One of the challenges is the accurate measurement of the number of overdose events,” said Dr. David Fiellin, director of the Yale Program in Addiction Medicine. Many people may not seek treatment, “or they may be seen by the first responder but may never be seen in the ER,” he said.
That’s because of the increased use of Narcan, which can revive someone who has overdosed, reducing the need for medical care. Not only do first responders carry the antidote with them, but it is given to patients and families who come to the Emergency Department as part of the hospital’s harm-reduction efforts, D’Onofrio said.
While Hartford and New Haven counties recorded the most Emergency Department visits because of suspected drug overdoses, this year Windham County has come close. Windham County has a three-month rolling average rate of 31.62 ED visits per 100,000 population in June 2020, compared with 34.98 in New Haven County, 33.38 in Hartford County, 30.37 in Litchfield County, 27.74 in New London County, 27.66 in Middlesex County, 19.22 in Tolland County and 18.97 in Fairfield County, according to state reports.
The three-month rolling average rate of ED visits per 100,000 population in June 2019 by county were: 30.76 in Windham, 35.91 in New Haven, 36.18 in Hartford County, 29.26 in Litchfield, 31.11 in New London, 30.12 in Middlesex, 27.83 in Tolland. and 19.28 in Fairfield, state reports show.
“It’s probably important to recognize that any impact of COVID as well as the disease itself is likely to vary from region to region and probably county to county and city to city,” Fiellin said.
While he believes the pandemic plays a role, Fiellin said it’s difficult to know how large a factor it is. “We all anticipated that this is the type of massive change in society that would be associated with an increase, but unfortunately we may not know for a while the extent of the change over time,” he said.
D’Onofrio said what also has to be taken into account is that visits to hospital emergency rooms were down as much as 40 percent in April, and “they were all COVID visits. … Now we’re back to 75 or 80 percent of our usual Emergency Department visits” and opioid overdoses are on the rise, she said.
D’Onofrio said it’s hard to determine accurate overdose numbers, because it’s possible more people have not come to the Emergency Department, fearing exposure to COVID, or have died at home and so would not be counted in hospitals’ reports to the state Department of Public Health.
Fiellin said “social isolation and individuals not having the ability to reach out to their practitioners,” many of whom were only available online, are likely factors in the rise in overdoses. “The stress of the situation can lead to triggers and relapse.”
“The other thing you worry about is change in the drug supply,” he said. “There is some concern that the events that we saw over [last] weekend may be higher doses than people were anticipating.” Some may have relapsed after a long period of abstinence and not realized how strong the drug was.
“Most of the opioid overdoses are fentanyl, but we’re seeing other issues with cocaine intoxication and other stimulants like PCP,” D’Onofrio said. “We’ve seen a lot of people present with alcohol issues,” which is harder to treat because alcohol detoxification can bring seizures and delirium tremens so an inpatient stay at a hospital or treatment center is needed.
“That’s harder to get people into treatment. There are only a certain amount of beds that are available for inpatient alcohol detox,” she said.
Dr. Richard Greiner, associate director of emergency medicine at Bridgeport Hospital, and director of the Milford Hospital ER, said the numbers of patients coming to the Emergency Department has increased some. “We typically average about 30 overdoses a month in Bridgeport and seven in Milford,” he said. In May, those totals were 49 and 10.
Greiner said those increases came despite a 40 percent drop in patients overall. “A lot of our volume has gone down,” he said.
“During COVID the one that never went down and went up a little bit was behavioral health and mental health,” he said.
He said those who come to the hospital “are the survivors for the most part,” and it’s hard to know how many people died of overdoses at home. But with more Narcan out in the community, “I think we’re doing a better job of treating people,” he said.
Greiner said the support system in health care “was hobbled during COVID … It wouldn’t be surprising at all if that population was not getting the care they need and not getting support.”
He said it’s difficult to compare the number of overdoses before and during the pandemic.
“Are people closer together so they can’t go anywhere, so there’s always somebody there to witness and overdose? There’s so many things that could be contributing that we don’t know about,” he said.
Dr. Reed Idriss, vice chairman of emergency medicine at Danbury Hospital, said he and his colleagues in Nuvance Health’s hospitals in Norwalk and New Milford have not seen a rise in overdoses or “what we call Narcan alerts.” He said it was “disturbing and makes me concerned for our communities” if COVID is causing an increase in opioid overdoses.
“The distribution routes sometimes will hit certain parts of the state before others,” Idriss said. “I wouldn’t be surprised at all if [New Haven is] on the front end of this. … It’s probably just a matter of time” before other areas feel the impact.
Bond, the New Haven health director, said, “We’re still tracking and monitoring it on a daily basis,” adding that the weekend non-fatal spike was “nothing to be majorly concerned about.” The city plans to hire a street outreach worker and will meet with community partners this week to determine what else can be done, she said.
New Haven Emergency Management Director Rick Fontana said while last weekend was quiet, there were 22 overdoses between Wednesday and Friday afternoon. He said the higher numbers of overdoses have forced the city to ask the state to forward more Narcan. “That Thursday and Friday we depleted a lot of our supply. AMR did, as well,” he said.
Fontana said the opioids were so powerful that some users needed three or four doses of the antidote in order to restore their breathing. He said he couldn’t determine whether the more recent overdoses were from “gray death.”
Fiellin said getting accurate information about opioid overdoses is both important and difficult to get in a timely way. “There is an important message to get out there around the need for accurate and timely information in respect to opioid adverse events in order for the medical community, the harm-reduction community and the public health community to be able to mount an efficient and accurate response,” he said.
Buprenorphine is an effective treatment, the doctors said, but while they can offer it in the hospital, doctors need a federal waiver to prescribe it after the patient is discharged. There is a mandated eight hours of training to use the medication, itself an opioid.
D’Onofrio also emphasized the need for prompt treatment, which she said saves lives. “Treatment is not optional. It should be offered to anyone,” she said.
She also advised users to be careful, taking advantage of New Haven’s needle-exchange program and trying a small amount of the drug before risking a large dose in case it is more potent than expected, not using alone and keeping in touch with loved ones.
Fiellin said, “The other thing that I’ve noted in some of my patients is that the epidemic has also been a way for individuals who are doing well in their treatment to contribute to society.” Building temporary hospitals, providing care for others can become “motivation for individuals who are not doing well to seek more intensive treatment to make sure during this uneven time … that their addiction is under control.”