Easier and faster access to medication-assisted treatment and efforts to blunt the impact of fentanyl helped to significantly reduce the number of opioid-related overdose deaths in Chittenden County in 2018, according to experts at the forefront of the opioid epidemic in Vermont.
People struggling with opioid addiction who want to start medication-assisted treatment (MAT), which blocks the effects of withdrawal, no longer have to wait to get started, thanks to an expansion in the number of providers offering it. They also can now receive immediate MAT in the emergency rooms of University of Vermont Medical Center and Central Vermont Medical Center.
While people continue to use heroin, fentanyl test kits allow them to analyze their intended doses for the presence of the synthetic opioid, which is 50 times as potent as heroin and an increasing factor in overdose deaths across the state, said the experts who work with opioid use disorder. Wider availability of naloxone, a drug administered to reverse overdose effects, also has kept people from dying, the experts said.
“You’ve had this coming together of a whole bunch of strategies that were directly targeting active users and high-risk users,” said Bob Bick, chief executive officer of Howard Center, the region’s largest agency for people struggling with mental health and substance use disorders.
All of those strategies – as well as continued efforts to cut the amount of opioids prescribed by medical professionals – contributed to a 50 percent drop in opioid-related overdose deaths in Chittenden County during 2018 according to preliminary data released by the Vermont Department of Health in late February. The number of fatalities in the county fell from 35 in 2017 – a record since the state began tracking data by county in 2013 – to 17 last year.
Statewide, however, deaths from opioid-related overdoses continued to climb in 2018, involving 110 people, compared with 108 the prior year. In a positive sign, the rate of increase slowed to 2 percent between 2017 and 2018, down from a 12 percent jump in fatalities from 2016 to 2017.
Steps to Enhance Successes
“As we learn what works, it’s vital that we translate these lessons across the state,” said Stephen Leffler, MD, chief population health and quality officer for the UVM Health Network, which includes UVM Medical Center and Central Vermont Medical Center in Berlin, as well as four other hospitals in Vermont and northern New York.
A recent federal grant from the Substance Abuse and Mental Health Services Administration will allow UVM Health Network to expand the Emergency Department MAT program to all network hospitals, boosting the chance to stop overdoses outside of Chittenden County, Dr. Leffler said.
Since CVMC started using MAT late last summer, “they are already showing positive results,” he said. “This is a statewide, team effort.”
Dr. Leffler and others leading the fight against opioid use disorder in Chittenden County said a multifaceted approach has worked to cut overdose deaths. It’s a group effort that includes treatment providers, medical professionals, law enforcement, state agencies and other support services.
When Mayor Miro Weinberger appointed Chief del Pozo in 2015, he tasked him with creating a plan for the Police Department to address the opioid crisis. The City and the Police Department organized monthly CommunityStat teams with multiple partners throughout Chittenden County, as well as State agency representatives.
Known as CommStat, it applies a crime-reduction model to “morbidity and mortality” related to opioids, del Pozo explained. The team studies intelligence about where death and risk are occurring, develops effective tactics to combat them, rapidly deploys those tactics, then relentlessly assesses and follows up on the results.
“As a community, we’ve evaluated the science and research and taken a comprehensive approach in every place possible,” del Pozo said late last month after he spoke at a Cultural Awareness Conference focused on opioid use disorder for UVM College of Medicine students. “No other part of the state has done so much, backed by science, so persistently in one place.”
Fentanyl a Major Factor
Overdose deaths typically stem from a combination of substances. Fentanyl played a role in 75 percent of the 2018 deaths, the state data shows, up from 69 percent in 2017 and 17 percent in 2013. The number of overdose deaths involving fentanyl has almost tripled over the past three years.
Howard Center operates Chittenden Clinic, one of the state’s designated “hubs” for MAT, particularly methadone distribution. The agency also oversees the Safe Recovery Program, where active users can get a clean needle exchange, fentanyl test kits and naloxone for themselves or their friends and family members. At Safe Recovery, opioid users have told staff they had tested doses with the kits and, upon finding fentanyl present, took less of that dose or discarded it entirely, said Bick, the Howard Center CEO.
Heroin users don’t always know their doses are laced with fentanyl. That’s why preventing illicit and unintended use of fentanyl is crucial to addressing the loss of life, Bick said.
“We know that relapse is part of the recovery process,” he said. “So we wanted to make these widely available.”
In late 2018, Safe Recovery instituted low-barrier, immediate access to MAT, aimed at active users who come for clean needles without the intention to seek treatment, Bick said. Once there, they speak with people they know and trust, who might ask whether they would like to start treatment on the spot. “We are seeing the people who need us the most, and we need to be able to see them when they ask for help,” said Grace Keller, program coordinator of Safe Recovery, when she spoke on a panel for the Cultural Awareness Conference on opioids.
Keller emphasized the importance of moving quickly: Some clients at Safe Recovery who had to wait just 24 hours for an appointment died in the meantime, she said.
Methods to Reduce Risk
As fentanyl has proliferated among opioid-related fatalities, prescription opioids other than fentanyl prescribed for pain now play a more minor role than they did five years ago, according to the Department of Health figures. In 2013, prescription drugs were involved in 65 percent of overdose deaths; they were part of the mix in 28 percent of fatal cases last year.
That’s partly due to changes that UVM Medical Center has implemented since 2016. It started tracking opioids prescribed by its physicians and, after seeing the figures, those who prescribed the heaviest amounts began cutting back – with dramatic results. The medical center’s total number of opioid prescriptions has dropped by 60 percent, and prescriptions for more than 50 pills at a time have fallen by more than 70 percent.
“We are going to double down on the strategies that look like they are succeeding and showing promise,” Burlington Mayor Miro Weinberger said during a recent interview about the overdose death statistics on Vermont Public Radio.
“We’re not quite ready to announce it yet, but we have some new innovations and interventions planned that are going to take that even further.”
There’s opportunity to augment current tactics that work, Bick agreed. Across the state, 36 agencies are designated to offer naloxone, but Howard Center’s programs alone have distributed more than twice the amount of naloxone as all the other agencies combined, Bick said. Many more could take that step to prevent overdose, he said.
Someone who dies, Bick pointed out, never has a shot at recovery. “Our goal is keeping people alive.”
This story was reported by Carolyn Shapiro, for the UVM Health Network.