State Rep. Kathleen McCarty, R-Waterford, introduced a bill in the state legislature to expand the use of peer “recovery navigators” — individuals who have recovered from opioid addiction and now assist others in the community still using the drug — as a method to address opioid addiction in towns across Connecticut.
The legislation is based on the New London CARES program which was started in 2016 and which brings together medical doctors who specialize in addiction and navigators who know the community. The result is a comprehensive approach to opioid addiction, which McCarty hopes can help prevent overdoses.
“I’d be in support of anything that remotely looks like that,” said State Rep. Joe de la Cruz, D-Groton.
De la Cruz is the co-founder of Community Speaks Out, a Groton-based nonprofit that supports families who are dealing with opioid addiction. De la Cruz said his organization has been sponsoring individuals who want to become peer navigators. “I think it’s the best tool we have right now,” he said.
According to data released by the Connecticut Department of Public Health, there was a 13 percent increase in deaths by overdose between January and October of 2020, compared to the same months in 2019.
There were 1132 drug overdose deaths reported in the state and 292 additional deaths suspected to be tied to a drug overdose between January and November of 2020.
Improving community outreach
According to Jennifer Muggeo, deputy director at Ledge Light Health District, the effort came in response to conversations with family members and police officers that more needed to be done to reach people struggling with opioid addiction.
“We realized that in order to connect with people, we needed people… on the ground, in the community, engaging with folks,” said Muggeo.
With help from a grant from the federal High Intensity Drug Trafficking Areas program, the peer navigator program was born.
Ledge Light partnered with the New-London-based Alliance for Living and the Yale School of Medicine to pair certified addiction medicine physicians with individuals who have recovered from opioid addiction and have a strong knowledge of the community.
The pairs go out into the community to meet and offer assistance, in the form of counsel and treatment with buprenorphine, an opioid agonist that has less potential for addiction than morphine.
Muggeo referred to the combination of medical treatment and peer outreach as “harm reduction” — a way of lowering the negative effects of opioid dependency rather than pressuring individuals to completely eliminate their reliance on any medication.
Gail D’Onofrio, chair of the Department of Emergency Medicine at the Yale School of Medicine and the Physician in Chief of Emergency Services at Yale-New Haven Hospital Emergency Departments, said that peer navigators are trained in motivational interviewing and in how to convince others to accept treatment.
Because peer navigators are part of the community, they can also offer solutions for practical needs like arranging transportation to a needle exchange van or a doctor’s office, finding food, dealing with lapsed insurance or finding a safe place to stay.
The CARES program also has strong connections with local police officers, firefighters and health care providers, and Alliance operates a food pantry and has connections with a homeless hospitality center in Norwich.
For individuals who don’t want to stop taking opiods, they offer strategies to help minimize the risk of death from an overdose — don’t use alone, keep the door to the apartment open while you’re using, make sure someone around has Narcan available. They also circulate needle-exchange vans, which they park outside locations in the community, like a Dunkin Donuts or a public library.
De la Cruz said that in addition to offering one-on-one counseling, the recovery peer can act as a “bridge” between the child and their family members, allowing them to communicate better. He said that in his experience, it can be difficult for a parent to admit that they can’t help their child.
“It’s a community, it’s a family disease,” said De la Cruz. “Discovery mentors are almost the glue that can hold everything together.”
“I Never Thought I Would Live Without Opioids”
Trisha Rios, a peer navigator at Alliance who has been in recovery for nearly 12 years, remembers her first experience with peer navigators. It was the 1990s, and she was in the throes of her own addictions to heroin and crack cocaine.
Rios said she started using when she was 15. From the time she was 18 until she was 31, she was in and out of jail. In 2005, she gave birth to her third daughter while in prison at York Correctional Institute. When she was released in 2008, she went back to using. Her two oldest daughters were living with relatives, while her third child was given up for adoption, she said.
Then in January of 2009 she learned that she was pregnant again. Rios said that was the moment she’d had enough, and she knew that she couldn’t have another child in jail.
Rios stayed clean for the entire pregnancy, giving birth to another daughter, Jada, in October. She never went back to using.
“I never thought I would live without opiates. Being somebody with long-term recovery, encouraging and helping people, that’s my substitute for the opiates,” said Rios.
Since her recovery, Rios has worked in a variety of treatment facilities, including ones that take a harder line with addicts.
She said that the difference between the philosophies became stark after fentanyl hit the streets. Rios said she remembers regularly receiving phone calls about people who had come in for treatment, left the centers and died.
“Working in that environment was really hard, because you’re just watching people die. It was like, really discouraging,” she said.
Rios said that when she came to Alliance three years ago, she knew she was in the right place. As someone who knows what it’s like to be dependent on opioids, Rios said is able to connect with people in a way that someone who hasn’t lived the experience wouldn’t be able to.
“We have a different rapport with people. I can look at somebody or they can look at me, and they’ll know. There’s this really weird connection that happens,” she said.
Now Rios spends much of her time fostering those personal connections, making sure people have food, housing, and that they can set up appointments with primary care physicians. She said that many people also call her to ask for Narcan. Rios said she once even provided it to a drug dealer.
Eventually, Rios said, people start wanting to get clean, and when they do, they know who to call.
Dr. Paul Joudrey, an associate professor at the Yale School of Medicine, said that the goal of CARES is not necessarily to immediately get an addict off of drugs. Instead, he said, the idea is to get addicts to use drugs as safely as possible, and to form connections so that when they are ready to stop using, they can do so safely and with as great a chance of recovering as possible.
Rios said that a key part of her outreach is witholding judgment. Even more than food, or shelter, or anything material, Rios said, people addicted to drugs need a person to trust and confide in.
“The first thing they need is somebody who is going to be there with them and not judge them, and not put expectations on them and just treat them as a human being,” she said.
Kelly Thompson, President and CEO at Alliance for Living, and Muggeo agreed that the stigma surrounding opioid use remains one of the biggest barriers to treatment.
According to Muggeo, making demands or issuing ultimatums doesn’t work.
“These are things that have no basis in science. They have their basis in people’s views of morality, and judgement,” she said. “There are so many false narratives at play in all of this.”
In Thompson’s view, the state needs to stop funding “abstinence-based” programs.
“The science does not indicate that that is the gold-standard best practice for treatment,” she said. “The state needs to lift up what is working for people.”
A need for medical intervention
D’Onofrio said that while recovery peers can be extremely helpful, they can’t be separated from the second part of the CARES program strategy: medical intervention with the advice of a qualified physician.
D’Onofrio said that peer recovery counselors should be integrated into the fabric of emergency departments, and that the focus — first and foremost — should be on prescribing medication that will reduce cravings for the drug.
One advantage of the medication buprenorphine, according to D’Onofrio, is that it can be prescribed by a medical doctor, unlike methadone, which can only be distributed by certain treatment centers.
“You don’t have this thing tattooed on your forehead that you’re going for opioid use disorder,” said D’Onofrio. But one problem with buprenorphine, she said, is the cost. Methadone is much cheaper.
Dr. Robert Heimer, a professor of epidemiology and pharmacology at Yale, said that by sending doctors out into the community, they have been able to reach people who would never have sought help from a medical health facility.
For many people, said Heimer, drug use was actually a secondary concern, the result of mental health problems that were never treated.
“Many people started using drugs because it was the only thing that made them feel better,” said Heimer.
Heimer said he is just beginning to collect statistics on whether their method is more effective than traditional rehabilitation programs. He doesn’t yet have concrete numbers, but Muggeo estimated that the program has reached about 300 people in its first year and a half.
In 2020 they reached fewer people — about 160, she said — a drop that she says is the result of the pandemic.
Joudrey, who travels to New London once each week to drive the needle exchange van around the city, said that he would usually see 4 to 5 people a day. Since COVID, he’s averaged about one person each day.
“The things that are needed to protect people from the virus — social distancing, isolation — are actually quite dangerous to those who use drugs,” said Joudrey.
But D’Onofrio said that the state has also relaxed some rules relating to drug availability.
Doctors are now able to authorize buprenorphine via telemedicine and some patients are able to take methadone home. D’Onofrio said that going forward, she’d like to see addiction physicians be able to prescribe methadone in their offices, and the promotion of safe injection sites.
New approaches to recovery
The main challenge to expanding the CARES program to the rest of Connecticut, McCarty said, is finding a way to fund the program. She said she’s not sure yet what that cost will be. In part, it’s a question of compensating the peer navigators.
Thompson said that Alliance’s four peer navigators receive a starting salary of $40,000, plus benefits, retirement and time off. But she believes that this is far too little.
De la Cruz said he’d like to see navigators receive $18 to $20 per hour — about $37,440 – $41,600.
Alliance receives most of its current funding from a combination of grants from the state, the City of New London and the Community Foundation of Eastern Connecticut.
There are other changes that D’Onofrio said she’d like to see, including providing access to sterile needles and naloxone, the generic version of Narcan, at all medication dispensing locations.
D’Onofrio said that, in her view, jails should be required to provide medication to people who are dependent on opioids, and that there should be mechanisms in place to continue this treatment upon a person’s release.
Rather than providing long-term group therapy or counseling which has little effect, according to Heimer, providing recovering addicts with some type of job counseling, showing them how to navigate the employment market, is critical for their ability to live a stable life.
Heimer said that it was important that the lawmakers drafting the bill not insist that one particular path of recovery was the “correct one” and that society not criticize people who remain in their addiction.
Rios said that she hopes she and her co-workers can be an inspiration for others to stop using for good.
“We all are living proof,” Rios said. “And we don’t have to preach. We don’t have to tell people how we did it. They just see the life that we live. And it’s been amazing.”