Worst year for overdose deaths feared as fentanyl, COVID-19 afflict Colorado

The opioid epidemic would have presented an unprecedented challenge even if COVID-19 had never hit Colorado.

In 2019, the state logged its highest-recorded number of fatal drug overdoses after a slight decrease in 2018 left some people feeling cautiously hopeful.

Now, provisional data from 2020 leaves health experts worried that the coronavirus pandemic could accelerate the state’s addiction crisis — in more ways than one.

As of July 31, Colorado had seen at least 534 deaths attributed to drug overdose in 2020, according to a spreadsheet provided by the Colorado Department of Public Health and Environment. That’s about half of 2019’s total: 1,062 fatal overdoses were recorded last year.

However, a lag in the data means that total probably doesn’t even represent the full number of drug overdose deaths for the first half of the year, said Kirk Bol, Vital Statistics Program manager for CDPHE.

“Certainly if we keep up this pace, we will see more overdose deaths among Colorado residents in 2020 than we will have seen in any other previous year,” Bol said.

Also worrying: This year’s preliminary data also shows that opioid overdoses, including those attributed to prescription painkillers, heroin, fentanyl or methadone, are increasing at a greater pace than overdose deaths in general. Colorado had seen at least 271 opioid overdoses as of July 31, equal to 62% of 2019’s 433 opioid-related overdoses.

Last year, Colorado saw 214 deaths attributed to fentanyl — a synthetic opioid, many times stronger than heroin, that has been linked to a large increase in opioid-related deaths in recent years. Fentanyl is commonly present in heroin, counterfeit pharmaceutical pills, cocaine and methamphetamine.

The data for 2020 already shows 176 deaths involving fentanyl, or 82% of those counted in 2019.

Increases in methamphetamine and cocaine overdose deaths is not only believed to be driven by greater use of both drugs, Bol said, “but also the methamphetamine and cocaine that’s laced with this highly lethal fentanyl that’s out in the streets.”

Amid a pandemic that’s causing many people to lean on substance use to cope with uncertainty, experts fear that the problem could get much worse.

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COVID-19 causing collateral damage

Health workers frequently call suicides and overdoses “deaths of despair.” They’re often driven by life events.

“Basically, what you’re looking at is events that are related to people … being out of work, you know — bad economic times — (and) having to be indoors a lot of the time,” explained Andres Guerrero, who manages the Prescription Drug Overdose Prevention program at CDPHE. “That has effects on people’s mental health, so it’s not just overdose deaths. We’re also expecting that we’re going to see an increase nationwide in suicides. We’re starting to hear about increased cases of child abuse, domestic violence.”

To combat worsening substance use issues, Guerrero’s team takes a harm reduction-centered approach to preventing overdose deaths. A big part of that is making sure the public has access to naloxone, a life-saving opioid overdose reversal drug.

A “standing order,” issued by CDPHE’s medical director, allows any pharmacy or harm reduction organization in the state to sell naloxone or distribute it for free. This is especially important for people who may have a friend or family member who uses opioids, Guerrero said, as an individual who is overdosing wouldn’t be able to self-administer naloxone.

The state’s naloxone bulk fund, created through 2019 legislation, allows schools, law enforcement, local public health agencies and nonprofits to buy naloxone in bulk at a reduced rate through CDPHE and distribute it in their communities.

Guerrero’s team also tries to educate the public about issues surrounding substance use. For example, a “good Samaritan law” in Colorado protects people who have small amounts of drugs on their person if they seek help someone who is overdosing.

“We want people to know that these laws exist in order to save lives,” Guerrero said. “So as long as you stay there and state your name and wait for the police to show up, you will not be charged in the state of Colorado for small amounts of drugs.”

Improving access to naloxone and educating the public will become even more important, and difficult, during the pandemic. Some people losing jobs and health care may “turn to substances to help cope,” said Dr. Robert Werthwein, director of the state’s Office of Behavioral Health.

Over the last several years, Colorado has leveraged federal grant money to distribute more than 25,000 naloxone kits, Werthwein said.

“We have seen 881 reversals … reported to us” by people who received the kits, he noted. “That doesn’t include those that have not been reported.”

It’s not just despair around fear of the unknown — a novel virus — or the palpable effects of a global economic downturn that experts fear could lead to an uptick in substance use. For patients recovering from lengthy hospital stays where they may have been intubated or hooked up to life support, the pandemic often exacts a crippling mental toll.

People who experience treatment in a hospital’s intensive care unit due to a life-threatening illness experience a condition called delirium at very high rates, said Dr. Thida Thant. Thant directs the consultation-liaison psychiatry service, as well as the Psychiatric Consultation for the Medically Complex Clinic, housed in UCHealth University of Colorado Hospital’s Outpatient Psychiatric Clinic. She’s noticed that COVID-19 patients, who often face prolonged stays in an ICU-like setting, have behavioral health concerns stemming from symptoms of delirium.

The condition can affect a person’s sleep cycle and memory, she said.

Delirium can even cause psychosis, “which is really scary, because often it’s people who’ve never had anything like that before,” Thant added. “They can feel paranoid, they can see or hear things that other people don’t.”

“It can take weeks to months to a year for all of those symptoms to fully go away in someone, even after their medical condition is better,” Thant said. “The patients are dealing with remembering parts of their hospital stay in a kind of confused way, which is really upsetting, if you can imagine.”

That can lead to depression or anxiety, especially for someone returning home who may not be able to connect with loved ones because the virus is still a threat, she explained.

“Some things I’ve heard from patients, it sort of reminds me of the HIV epidemic in the ‘80s, where you come home and there’s this fear about contagion,” Thant said.

To try to help patients deal with those issues in healthy ways — instead of turning to substance use or letting the problems worsen — providers such as Thant try to make sure they’re connected to resources. Doctors try to take patients off of opioid painkillers and other potentially habit-forming medications before they leave the hospital, she said, unless they have a condition that warrants a longer prescription.

Every patient who’s admitted to the University of Colorado Hospital for a COVID-19-related reason can get a referral to the Department of Psychiatry, Thant said. The department conducts behavioral health screenings over the phone for mood, anxiety and memory changes, and can connect patients with a therapist or psychiatrist.

Eventually, Thant said, the hospital plans to launch a virtual therapy group where COVID-19 survivors can connect with others who share their experiences.

Rural areas face unique issues

The areas of the state with the highest rates of overdose deaths tend to be in rural Colorado, according to a data dashboard maintained by CDPHE. Between 2017 and 2019, Rio Grande, Las Animas and Conejos counties had the highest overdose rates.

Family practice nurse practitioner Amy Leibli said she’s seen substance use issues worsen since 2017, when she first began working in Canon City, located in Fremont County in central Colorado.

The county saw a total of 34 fatal overdoses from 2017 through 2019 — a number that may seem small but which represents an age-adjusted death rate similar to that of Denver County, which saw 522 overdoses over the same period.

“I’ve noticed an increase in the homeless population and a greater increase in the use of what I would call the harder street drugs, because of the crackdown on … pain medications,” Leibli said, noting that homelessness and substance use often go “hand in hand.”

Patients often develop a substance use disorder after they’re prescribed pain medication, she said, and then they move to heroin or meth when they can’t access those any longer. Lately, she’s noticed that street drugs are cut more frequently with fentanyl and other substances.

“The issue with overdosing at this time is those that seek out treatment, get rehab, but don’t get in the proper type of rehab facility, and then go back to using,” she said. “Their tolerance is so much lower, and they think they can use that same amount after they come out of rehab, and that’s what causes the overdose.”

Leibli also believes the stigma associated with getting treatment for a substance use disorder can stop people from accessing life-saving services.

Leibli received her medication-assisted treatment, or MAT, certification in 2019, allowing her to treat substance use disorders with medications that block cravings or ease withdrawal symptoms. She’s also one of 39 fellows, supported by the Colorado Center for Nursing Excellence, who were chosen to receive a psychiatric mental health nurse practitioner certificate, thanks to a $1.5 million grant from United Health Foundation. The psychiatric certification will allow her to provide therapy and prescribe medications for mental health concerns, both of which can be helpful in preventing and treating addiction.

Valley-Wide Health Systems, where Leibli works, doesn’t currently provide all MAT services at its Canon City location, but she can refer patients who need certain prescriptions to a mobile health unit operated by Front Range Clinic.

The unit is one of several funded through the Office of Behavioral Health, which received federal grant money for the program. It provides medication-assisted treatment for substance use disorders to patients in far reaches of Colorado.

Licensed practical nurse Connie Pacheco works on Front Range Clinic’s mobile health unit, where she sets up patients for a virtual visit with a MAT-certified provider who can prescribe medications for substance use disorders. Inside the mobile unit, Pacheco can administer Vivitrol — an injection used to curb opioid cravings — run urinalysis tests, and take patients’ vitals.

At some of the other rural locations where Pacheco drives the van, she hasn’t seen any patients. “We still drive out and just try to touch base,” she said.

Schedules are flexible, so she encourages patients to make an appointment before stopping by.

Jason Hotchkin, a peer coach who recently started working on the mobile unit with Pacheco, offers 24/7 telephone support to patients with substance use disorders and helps connect them with resources.

Pacheco and Hotchkin agree that stigma — even among doctors — is a huge barrier to patients receiving lifesaving treatment for substance use. Sometimes, patients who use medication to overcome an addiction are “looked at as, they’re really not quitting,” Hotchkin said.

“Some towns don’t want us there at all,” Pacheco added, saying that in places where some agencies support the mobile units, “we may get pushback from other agencies.”

Though the consensus among experts with experience treating substance use is that medication-assisted treatment saves lives, CDPHE acknowledges that stigma is still a big issue, especially in less-populated areas of Colorado.

“In very rural areas … everyone in town knows everyone’s business,” Guerrero, the Prescription Drug Overdose Prevention program manager at CDPHE, said, “and so that makes it very difficult to seek treatment.” One strategy to combat that, he said, could be adding other medical services on the mobile units.

“We want to make sure that people have the resources to be able to reach out and not feel ashamed — not feel like they should feel bad about that in any way,” Guerrero said. “It’s a positive thing to seek out treatment, and that’s one of the best ways that we can prevent overdoses, quite frankly, if we can get more folks into treatment.”

Anyone experiencing a mental health or substance use crisis can call the Colorado Crisis Services hotline 24/7 at 1-844-493-8255 or text “TALK” to 38255 to be connected with a trained professional.