Amid disruption from Covid, the opioid epidemic still rages on
Before it was covered with white paint, a blunt message shouted the status of 33 Oak St. one winter day in 2019.

Amid disruption from Covid, the opioid epidemic still rages on

Deaths by overdose have exceeded the casualties of COVID-19. With the problems and solutions of opioid use even more complicated by the pandemic, a new police chief in Brattleboro, and heightened awareness to shift focus to substance use as a medical condition, can we find a balance between public health and law enforcement?

BRATTLEBORO — Vermont has, by all measures, led the nation in safeguarding its citizens from the coronavirus pandemic, creating a public perception of safety and stability, a reputation of sanctuary from life-threatening danger.

Yet, since the coronavirus struck in March 2020, 186 Vermonters have lost their lives from an altogether different public health crisis.

Drug overdoses.

According to preliminary statistics released by the Centers for Disease Control (CDC) in July, the death toll from the opioid epidemic in the state jumped by 57.6 percent - the highest per-capita spike in the nation.

According to statistics released by the Vermont Department of Health in March, 18 people died from overdoses in Windham County in 2019. The toll is certain to be higher when the final count of deaths is compiled for 2020.

As of Sept. 14, only 291 people in the state have died because of COVID-19 since March 2020 - the lowest per-capita rate in the United States. Twenty people died from the illness in Windham County, and 1,763 cases have been identified over the past 18 months.

All untimely deaths, independent of cause, reverberate through the community, touching parents, siblings, children, and friends. But the opioid epidemic - as unrelenting as it has been heartbreaking - has never gone away here, claiming more young lives than ever, even as it has been pushed off the front pages.

When it comes to the opioid epidemic, Vermont ranks 11th from the bottom in the nation. There are those who argue that the epidemic and overdose deaths pose as deep a challenge to our health-care systems and to our fabric as a community as the pandemic virus does.

“I really hope that we can figure out how to reduce harm,” said Brandie E. Starr, former chair of Brattleboro's Selectboard, who wants to see the community address the problem by taking first steps to put aside judgment and help ensure that people who use drugs can do so more safely.

Otherwise, she said, “It's just going to be heartbreaking. It's going to be heartbreaking.”

'They were individuals who had given me so much'

Each death is a blow, and the human cost is clear in every story from someone who has lost a family member or friend.

“My daughter's ashes are sitting in an urn on my desk, waiting for burial,” wrote the mother of a young woman who died from a drug overdose. “All I keep thinking is, this can't be real.”

“We've lost some wonderful people, one after another,” said Starr. “As far as our circle of friends goes, we have lost 20 humans who we were close to, to deaths of despair, whether that's depression, alcohol, opiates, what have you.”

Beneth Goldschmidt-Sauer, who taught English at Brattleboro Union High School for more than two decades, said that after one recent death she reckoned up how many of her former students had died before their time.

“I went back and listed for myself all the students that I've taught who died,” said Goldschmidt-Sauer. “It was pretty sobering to me.”

She can list approximately 16 former students who have died, including three in rapid succession just this year. Four of the students she knows have died from overdose. Maybe others, too.

“I really try to remember them individually,” said Goldschmidt-Sauer - “not make them into a sort of formless mass, but remember each one.”

“They were such bright spots in my teaching career, each one, and I just want to remember, I want to hold on to that,” she said. “They were individuals who had given me so much and had so much to offer other people, and now they can't.”

“I don't think that any of them wanted to die,” said Goldschmidt-Sauer.

Add fentanyl to the mix

The opioid epidemic in Brattleboro and Windham County has been raging across the nation for more than a decade. According to CDC statistics, 93,000 people in the nation died of drug overdoses since the COVID-19 pandemic struck, a significant increase from the previous year. Whatever is happening in the local region is part of a nationwide problem.

Within the white community, the opioid epidemic has its origins in the way that pharmaceutical firms pushed prescription opiates for pain control, beginning more than a decade ago.

With the settlements from lawsuits against the Big Pharma companies that pushed legal opiates and addicted a generation of young Americans, perhaps our area will receive more financial support for the efforts already taking place.

Vermont is poised to get approximately $60 million from a nationwide settlement in July with four pharmaceutical companies - Cardinal, McKesson, and AmerisourceBergen, against which the state had pending lawsuits - and Johnson & Johnson.

Vermont is reported to have a $66 million slice of the pie from the $4 billion settlement against Purdue Pharma.(1)

How that money will be spent is not yet clear. In the meantime, an infrastructure already exists, and more resources can only help.

The challenge is far from new, but the coronavirus created isolation and ended a lot of ordinary social and therapeutic support. The loss of face-to-face services imposed by the pandemic has also been a factor in the surge in death rates from drug overdoses.

Another factor - a relatively new one - is one particular drug, fentanyl, which has become so widely used among those who package and distribute illicit substances. According to Vermont Department of Health statistics, in 88 percent of overdoses resulting in death in 2019, fentanyl was present in toxicology screenings conducted in autopsies.

Long used as a powerful painkiller for patients in hospitals, fentanyl hit the street about eight years ago. It is 50 to 100 times as potent as morphine and significantly stronger than heroin.

That potency makes the drug much easier - and also less expensive - to smuggle and transport, and dealers have a powerful economic incentive to use it to boost the potency of other drugs sold illegally, including heroin, cocaine, and marijuana.

Facing the crisis

The medical term for dependence on opioids and other drugs, including alcohol and tobacco, is substance use disorder, or SUD. The term is relatively new, introduced in 2013 with the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), long a standard for classifying and defining mental disorders.

The DSM has a great deal of power - it is the reason we use labels like attention deficit hyperactivity disorder or autism spectrum disorder, which did not exist by those names and definitions until the 1990s.

For psychiatric conditions, the book creates the interconnection between the health care system and the health insurance system.

Since its first edition in 1952, the book has been the primary reference for reframing human behaviors in medical terms and, inversely, using that structure to assign names to how people behave.

And as science advances the ability to detect, visualize, and document the brain and its complex functions, one thing becomes clear: SUD is far more than a matter of lack of will power or discipline. It is a very serious disease with devastating effects on its victims and their families.

The concept of “deaths of despair” has currency, owing to a widely cited book by Anne Chase and Angus Deaton, Deaths of Despair and the Future of Capitalism, a work that seeks to account for why death rates within the white community have risen so much in the past decade.

The book describes the way in which economic inequality and the sense of a loss of opportunity lie behind a surge in deaths by suicide, opioid addiction, and alcohol dependence that has caused a significant drop in life expectancy for white people, especially white males without a college education.

In a different era, the idea that the loss of about 20 young adults each year in one county in Vermont might have prompted a full-scale marshaling of resources. Now, all this death seems like such a routine part of our daily lives.

And for those who are grappling with reversing these trends, the solutions are not nearly as simple as wearing a mask and getting vaccinated.

Anatomy of an overdose

According to the National Institute on Drug Abuse, “A large dose of heroin depresses heart rate and breathing to such an extent that a user cannot survive without medical help.”

Specifically, opioids work by binding to specific brain receptors, which creates the dulling of pain and euphoria that users expect and seek. The other side of the same coin is that the opioids affect body systems like lungs and heart.

As described on the website of the National Harm Reduction Coalition, an advocacy group for drug policy changes, “If someone can not breathe or is not breathing enough, the oxygen levels in the blood decrease and the lips and fingers turn blue - this is called cyanosis.”

“This oxygen starvation eventually stops other vital organs like the heart, then the brain,” the description continues. “This leads to unconsciousness, coma, and then death.”

Each death is individual, and people can die from overdoses for different reasons and in different ways.

The fentanyl factor. Sometimes people die because they took a dose that was too powerful for their central nervous system to survive it. Fentanyl has a lot to do with that.

Reduced tolerance. A lot of people try hard to fight their dependency and are often in and out of rehabilitation programs. Those who use after having been drug-free are particularly vulnerable, because they may not recognize how their drug tolerance had been reduced as a result of rehab. Sudden deaths after rehab are all too common.

Using alone. Most experts on substance-use disorders would say that using alone is one of the greatest dangers. When someone who is overdosing is alone, their odds of surviving are worse.

When people with housing insecurity were provided with motel rooms subsidized by government funds as part of state COVID-19 emergency health measures during the past year, the risk of overdose escalated accordingly as drug use moved out of the public eye and into private quarters.

The effects of an overdose can be reversed by administrating naloxone, also known by its trade name Narcan, an essential tool for police, firefighters, emergency responders, social workers, and other front-line workers.

As described on the website of the Vermont Department of Health, “When administered during an overdose, naloxone blocks the effects of opioids on the brain and restores breathing within two to eight minutes.”

Since 2016, the Department of Health has issued a standing order to allow distribution of naloxone, normally a prescription medication, for opioid overdose prevention. The order allows Medicaid and health insurance to cover the cost of the nasal spray at a pharmacy. It is also available at several distribution points in the area.

Since 2013, state law protects those calling for emergency medical assistance - whether a user needing aid or a bystander - from being “cited, arrested, or prosecuted” for breaking related laws. It also carves out an exception for violating a “condition of pretrial release, probation, furlough, or parole.”

Some people believe that anyone who lives in Brattleboro or Windham County should routinely carry Narcan in one's backpack or purse.

Some have questioned whether overdose deaths happen intentionally. The obvious answer from those working on the front lines - or otherwise intimate with the problem - is that people with substance use issues by and large want to live. Although there are rare occasions of suicide by overdose, it is important to otherwise draw a sharp distinction between these two very distinct public health issues when it comes to calculating the deaths of despair.

Quite the contrary, many users of opioids are actively trying to recover - a process that requires persistence in the face of almost certain failure. Most people with substance-use disorders relapse after going through rehab, some 10 or more times.

Periodically, on social media, some decry the availability of naloxone - always with the implication that for people with substance-use issues, the availability of an antidote is a way to continue use of drugs without consequence.

“While it's lifesaving, [naloxone] is very unpleasant for both the recipient and the people who provide the remedy,” Susie Walker, the executive director of Turning Point in Brattleboro, told The Commons in 2017.

“It's not as if anyone would think, 'Hey, I'll take all I want and then top it off with Narcan,'” Walker said.

Public safety officials are often alerted to the potential of violence when responding to a scene where someone is coming out of an overdose because of administration of Narcan.

One front-line worker described trying to get across Whetstone Brook where it runs underneath the bridge between Canal Street and Flat Street with a homeless encampment on the south side of the river, an area known as China Beach, because they had heard someone screaming, “She's dying, she's dying!”

The river was high, and the front-line worker was tumbled around while trying to ford the waters. Upon arriving at the scene, the worker had to administer four doses of naloxone to revive the woman who had just overdosed.

“And she just came out swinging,” the front-line worker said.

Policy paradoxes

Opioid addiction might be a public health crisis, but various forms of crime or violence connected to it are never far away.

There is a fundamental tension between taking a public health approach (potentially treating drug users as medical patients) and using the criminal justice system to try to stem the flow of drugs into the area (potentially treating those very same people as suspects).

It is possible to agree, as many in the area do, that that SUD is both a public safety and criminal justice problem, and that connection creates paradoxes in terms of public policy.

Drugs do not come without crime - both in terms of the laws on the books for possession and distribution of the drugs themselves - and the crimes that users often commit as a result of desperation for money to purchase the drugs.

From those seeking justice for those who have been lost - children, siblings, parents, friends, and others who have been lost to overdose - to those who have experienced trauma from thefts in homes and automobiles, the problem is not one of compassion so much as law and order.

The addresses and locations of drug trafficking are widely known, and many local residents ask why the Brattleboro Police Department cannot do more to address the criminal activity and shut down a distribution system that is an open secret locally.

In particular, bereaved parents indict the police for knowing who was dealing drugs to their children, for knowing where the drugs are sold, yet seemingly doing nothing to stop it.

“It may be [on this] street or [at] this address today, and then six months later it's over there, and then it's over here,” Mike Fitzgerald, Brattleboro's police chief from 2014 until his retirement last year, told The Commons in 2019. “So it's not like we all know 123 Main St. [a hypothetical address] is the drug house and everyone who wants to come to Brattleboro goes to 123 Main St. because it's the drug house. It may be that [location] for a short period of time, and then it's moved to Pine or Maple.”

“I am not disagreeing with anyone who calls this police department and says there's drug dealing going on,” Fitzgerald continued. “However, what you see and what you perceive for what is your opinion is quite a bit distant from what I can prove in a court of law.”

Despite attempts at crime interdiction, only one of four drug houses that were active in Brattleboro in 2019 has been taken down.

But certain law enforcement strategic decisions, even those made for the best of reasons, can have devastating consequences: At least one long-running court case had at its center the claim that a son who had died of an overdose was sold the drugs by a confidential informant to the police.

This summer has ushered in rampant theft of catalytic converters from parked cars - a national trend, according to the National Insurance Crime Bureau, which reports a more than 17-fold increase in such theft from January 2019 to December 2020.

The devices, which convert the vehicle's exhaust to more environmentally tolerable emissions, are built using precious metals like platinum, palladium, or rhodium and thus carry a high price on the black market and cost a great deal to replace.

The thefts have not conclusively been linked to the drug trade - criminals can be motivated by easy money in its own right or by the drugs that can be bought with the proceeds - though that does not stop people from presuming the connection.

Petty crime can sometimes seem rife in Brattleboro - and the assumption that drugs have a lot to do with it is reasonable.

In the various Brattleboro groups on Facebook, one often finds comments that accuse the criminal justice system of running a “catch and release” program for people caught with drugs or arrested for minor crimes. The same names of perpetrators going through the court system keep hitting the Reformer police blotters and the police scanner Facebook groups. Some group members there promise vigilante justice if someone tries to take their property.

“I lost my fiancé 20 years ago and watch my stepson struggle every day from these same drugs,” said one person on a private Facebook group, commenting about a post about a young woman found overdosed in her car at a local enterprise. “Time to lock them up, if not in rehab, then in jail. But take them off the streets where they are killing themselves and others.”

“The only way things can change is if we stop giving addicts breaks too,” wrote another commenter, claiming to be citing Ohio policy, though The Commons could find no evidence to confirm the assertion. “If found in possession give them 30/60/90 days, after 90 days a year. If given Narcan immediate 30 days no trial they go from ambulance straight to cell.”

A seller's market

The economic disparities between rural Vermont and metropolitan areas make selling opiates a thriving enterprise in this area.

According to one source who maintains herself on opiates and lives in a stable home situation, she can buy what she needs in Hartford, Conn. for one quarter the price of the same doses in Brattleboro.

Another source who works in law enforcement and spent time on police forces in southern cities said that the markup could be as much as tenfold.

The economic incentive to bring drugs up from southern cities and sell them in Brattleboro and surrounding towns is powerful - a 4-to-1, maybe even a 10-to-1, return on an investment is a strong motivator. When one network is knocked down, another one materializes to take its place.

According to the National Coalition for the Homeless, substance use is both a cause and an effect of homelessness, and vice versa.

By one measure, 38 percent of people experiencing homelessness also were dependent on alcohol and 26 percent abused other drugs. In contrast, a government study pegged the rate of adults who have abused substances within the last year to 8.4 percent of the overall adult population.

So it's hardly a surprise that during the COVID-19 shutdown, when Gov. Phil Scott's state of emergency sheltered people without housing in area motels, like the Quality Inn on Putney Road, those spaces became newly vulnerable to the same sort drug activity.

And those living in a recent project designed to create a path to permanent housing for people who are homeless - Great River Terrace on Putney Road - have also fallen prey to the same drug distribution forces.

EMS and police calls to these places have became regular business.

“You can look down this way, and I can point them out - you can get heroin there and cocaine there, and that is where they sell meth,” one resident, JoAnne Rodriguez Heckman, told The Commons this summer [see sidebar, 'You killed Joe'].

One of the challenges with the opioid crisis is that it is a dirty secret. It is difficult to market a town as a tourist destination when drug deals are cut on the back stairway of the town's downtown transportation center and people are using and sleeping under bridges.

These tensions play out in an area that depends on tourist revenue and has seen many second-home owners take up temporary residence during the pandemic. The region's economy depends to a great extent on tourist dollars.

Brattleboro is a crossroads - it is both a main entry point for tourists into Vermont and a main drug distribution point on the Interstate 91 corridor.

It is a friendly, welcoming tourist town that markets itself as such. Yet there are places in the area where one would not advise anyone to stay.

But there is just no ignoring or compartmentalizing the opioid issue anymore.

In April, The New York Times published a comprehensive article about the opioid crisis in the United States.

The dateline was Brattleboro, Vt.

Stigma and secrecy

The stigma associated with substance use disorder is strong, carrying secrecy and shame for any family or circle of friends - and for the user.

For those who work directly with the problem of SUD, stigma and secrecy may be the greatest problem.

“[There are] real, observable, negative consequences that have come from stigma and discrimination in this population, including a sort of internalized sense of lack of value and self-worth among individuals,” said Kurt White, senior director of outpatient programs and community initiatives at the Brattleboro Retreat. “Systems that are not necessarily set up to be compassionate and understanding.”

“When we categorize something as a moral failing or a legal problem, we stigmatize people,” said Susan Walker, the executive director of Turning Point, a nonprofit that provides support for people in recovery. “And then people don't want to seek help, because it casts them in a negative light, and so people do put off seeking help long after they realize they need to.”

Most sad stories about the losses of young people are not told; rather, they are just held in the privacy of grieving family and friends. Overdose deaths are not generally acknowledged as such in the newspapers, and most obituaries of people who die before their time leave the cause vague.

But not every obituary is veiled in secrecy. Jonquil Clouet-Boyle was a gifted artist and warm friend who died on April 29 this year of an overdose while she was staying in New Orleans. Her family was open in her obituary - both about her extraordinary gifts and beauty as a person, and about the way she died.

“Jonquil was haunted by and suffered great sorrow, which was hard for her to express, because of the loss of many of her beloved young friends in Brattleboro and beyond, due to accident, suicide, and overdose,” the obituary read.

“Opiate misuse disorder is a ferocious and punishing illness - it was for Jonquil, and is for so many people in our communities,” the obituary continued. “Jonquil expressed at the end of her life frustration and pain that people could only see her addiction, because there was so much more to her.”

So where's the balance?

The idea that opioid addiction is a medical problem rather than a moral failing or criminal behavior has been adopted at a policy level in Brattleboro, with service organizations working directly with the police and other official agencies.

While some in the community push for an approach focused on criminal justice and incarceration, others argue that the Brattleboro strategy saves lives.

“Jail time for an overdose discourages people from calling 911 during an overdose,” wrote a commenter on one Facebook strand. “If we adopted this way of thinking, thousands more would die each year, as people would be afraid to call 911 for fear of facing jail time.”

That's really the point of the harm reduction approach, which is all about keeping people alive - and then treating substance-use disorder - rather than putting them in jail.

It is also about closing down the supply network, and Brattleboro Police are directly involved in a cross-state task force involving several federal agencies, focused on rolling up drug supply networks and arresting major distributors.

In 2019, the U.S. Department of Justice announced the execution of a “multi-agency, multi-jurisdictional law enforcement effort that focused on drug trafficking in the area of Brattleboro, Vermont.”

The three-day operation, which resulted in the arrest or charging of 16 people on federal and state drug-trafficking charges, involved federal, state, local, and county officers, and federal and state prosecutors. The search of three residences and a hotel room yielded approximately 1,000 bags of heroin and 70 grams of cocaine base.

In contrast, for end users of the drugs, the harm-reduction approach provides amnesty for anyone calling in a drug overdose, and simple possession is generally dealt with by a citation to court. In most cases, for individuals who are in the criminal justice system at a low level, rehabilitation services are provided as an option.

This approach accords with what are seen as best practices in the United States, though other nations have heightened the public health framework by decriminalizing illicit drugs and providing extensive support services.

Nations like Portugal and Switzerland have achieved success by decriminalizing drug use and creating structures and policies that help people with substance-use disorders manage their addiction and create a context in which they can kick their habit.

The question of whether Brattleboro and Vermont are doing enough is really a national question, and it is unlikely that the United States will take a similar path.

“I think it is useful when different countries take different approaches, and we can study what's been done to see what the best solutions might be,” said Kurt White. “At the same time, not every country has the same setup and the same needs.”

“The United States is basically a continent-sized country that bridges two oceans, and it has a very different sort of geography and regional differences,” he added.

“There are some very smart people who think that if the government cut the illicit market control, that might be a better way to go,” White said. “I don't think that is politically viable in the United States at this point. And I am not sure we have the strong evidence that would really persuade people to move in that direction.”

A long road to rehabilitation

The problems of the United States when it comes to substance abuse are imprinted in the streets of a town like Brattleboro, where tourists are encouraged to come and drug deals happen on the back streets and in some motels.

A simple request on two Facebook pages for personal stories about the addiction crisis brought scores of responses, more than can be shared here. Every tragedy is individual, but the story is general and the harm that the opioid addiction crisis causes across the fabric of our society is clear.

Right now, public safety agencies and nonprofit organizations are working hard to manage the public health crisis that substance addiction represents. The question of whether the resources are adequate is complex, since true rehabilitation from a deep addiction can take a long time, not a three-day detox or a 14-day rehab.

One source for this story said that it was only until his 10th overdose, when he had actually died and then came back to life, that made him try to really make it in rehab. He spent a year in an expensive program, one that he could afford because he came from money. He has not used drugs for more than a decade now, but it took a lot of money and work to get there.

Another source described how she got into traveling to Hartford with her boyfriend in order to move drugs when she was in her teens, and she talked about getting caught dealing and spending two years in prison before she was 20.

She was able to stop using drugs in prison, and she was set up with some kinds of menial work after she was released on probation. She relapsed and was put back in prison for four months. After that, she was able to kick the drugs, and she earned a college diploma that qualified her as a substance abuse counselor.

As a drug trafficker, “I felt like I could control everything, like I was just in the stars,” she said, describing the exhilaration of making good money and feeling like she could manage her heroin use. “At the end, I realized I was just a junkie.”

Glimmers of hope?

Kurt White noted that drug epidemics have their cycles in recent American history, and that while this has been a dire cycle, he sees some positive signs.

“There is good news and bad news with these things, as there normally are in a drug epidemic - it lasts a certain amount of time and you have to try to treat the people, and prevent, and get them into recovery,” said White. “You make sure treatment is readily available, and then you work on prevention in the next generation.”

“The good news is that young people are not starting to try illicit opioids in the same way they were 10 or 15 years ago,” White said. “There are fewer new people coming into the pipeline, which is really good news. That's probably the way we will stop having this as an epidemic at some point.”

It's hard to know how things will change, or to hope that next year's drug overdose toll will be less than this year's. Perhaps the only place to start is just by acknowledging the human cost - how it feels to lose a child or see a brilliant friend die far before her time.

Brandie Starr has other suggestions, too.

After learning of the death of Jonquil Clouet-Boyle, Starr posted a heartfelt note to her friends on Facebook on April 30.

“My dearest, sweetest friends,” she wrote. “If you use, please never use alone. Do not allow societal shame to keep you hidden. You are bright and beautiful, and I know the pain of this planet is often too much. I will never judge you for finding your moment of reprieve.”

“Know that there are people out here who love you as you are, where you are,” she continued. “I love you.”

“And to those of us who do not use, please always carry Narcan - you just never know whose light you might be able to keep on.”

She concluded the message: “Hugging so many of us in my heart this morning.”

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