Liz Fitzgerald had been waiting for this.
It was March 10th, 2022, and she suddenly found herself speaking before the family that had upended her life and robbed her of two children.
Fitzgerald has lost two sons to opioid addiction. Kyle, aged 25, died in 2013. Four years later, she lost his older brother, Matthew, when he was 32. Both Matt and Kyle were exposed to the prescription painkiller OxyContin while in high school and developed a years-long — and ultimately deadly — reliance on opioids.
Now, after years of fighting for justice for her sons, Fitzgerald had the chance to directly address the owners of the drug company that had pioneered OxyContin in the 1990s, lied about the painkiller’s dangerously addictive effects, and sold it to millions of Americans.
“My oldest son said to me, ‘You always said those Sacklers were going to know Matt and Kyle’s names,’” Fitzgerald said, in an interview with The Politic. “I always said it out of anger, that these Sacklers were going to know my kids. Who knew that I would have that opportunity?”
The opportunity to speak before the Sacklers was thanks to the $6 billion settlement that the Sacklers’ company, Purdue Pharma, agreed to, constituting a massive payout to state governments and those impacted by America’s devastating opioid crisis. Liz lives in Southington, Connecticut, a small town about an hour’s drive from Purdue Pharma’s Stamford headquarters. “[Connecticut Attorney General William Tong] asked me, ‘Would you want to confront the Sacklers?’ I said, absolutely.”
The deal will give Connecticut approximately $95 million over 18 years to invest in solutions to the opioid crisis and help victims of opioid use disorder. There is no shortage of need for these additional funds: a crisis that began in the 1990s has shown no sign of stopping, with Connecticut experiencing a 500% increase in opioid overdoses since 2010. In 2020, the state witnessed nearly 1,400 deaths due to opioid overdoses. The problem is worst in Yale’s own backyard, with New Haven County accounting for a quarter of the state’s overdose deaths.
Considering how to spend the millions of dollars won in the Sackler lawsuit has forced Connecticut into a reckoning with its opioid epidemic. Overdoses continue to rise, even as the funding and research available to counter them has also increased. This contradiction begs consideration of what has gone wrong in the state’s tackling of the crisis, and what can be done to correct the course.
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Purdue Pharma billed itself as “a pioneer in developing medications for reducing pain.” Its central product, the painkilling drug OxyContin, was released in 1995. The sole active ingredient is oxycodone, an opioid twice as strong as morphine, and the drug’s potency represented an exciting opportunity for Purdue to capitalize on relieving extreme pain and discomfort. The company quickly launched an intense marketing campaign to convince doctors to prescribe the medication to patients. Purdue’s lobbying proved shockingly successful: since its release, OxyContin has generated over $35 billion in revenue for Purdue. The United States is now the world’s largest consumer of opioid medications and is responsible for 80% of global prescriptions for opioid painkillers.
What Purdue’s marketing campaign conveniently omitted was how addictive OxyContin is. Their advertising targeted doctors, using the results of company-funded studies to prove that overreliance on the painkiller would not be a problem. Purdue executives promised the drug’s relief would last 12 hours, but an investigation by the Los Angeles Times concluded that the company knew that the effects wore off hours earlier for most people, forcing users to take the pills with increasing frequency. A report by the Department of Justice concluded that Purdue executives knew about drug users crushing and snorting OxyContin as early as 1996, yet testified for years that they had not been alerted to the drug’s risks until 2000. Even after a 2007 lawsuit concluded that the company’s leadership had misled doctors and patients about the drug’s harms, Purdue continued to sell prescription painkillers and aggressively rebut allegations of a cover-up.
The result of this relentless pill-pushing has been catastrophic. More than one in every five patients who are prescribed opioids will eventually misuse them. Thousands of Americans who were given OxyContin — often only for minor discomfort — suddenly found themselves battling a reliance on the drug. And when prescriptions expired or grew too expensive to maintain, many people struggling with their medicine’s addictive effects turned to more serious opioids like heroin instead. Both Kyle and Matt began using opioids with OxyContin; Kyle was prescribed it for an injury, and Matt was given it by a friend. “That was the start of their full-blown addiction,” said Fitzgerald. “When they couldn’t get the pill, it turned into heroin… And then it just became a life of hell.” Matt and Kyle were not alone: one study concluded that four out of every five people who try heroin started with prescription painkillers.
The opioid crisis grew even worse in the early 2010s when fentanyl, a synthetic opioid that is much stronger than heroin and reserved normally for excruciating pain, began flooding the black market. The combination of fentanyl with heroin was a toxic mix. Connecticut experienced a 400% increase in opioid overdose deaths from 2013 to 2016, largely driven by increasing rates of heroin and fentanyl abuse. Many people with opioid use disorder did not even realize that fentanyl was in their drug supply: some dealers secretly mix fentanyl into their heroin or other synthetic opioids because it is much cheaper to manufacture, and its effects are much stronger. Just a small amount of fentanyl can be deadly, especially if the user is unaware of its presence. Fitzgerald attributes Matt’s death to fentanyl, which was in the drugs he took without his knowledge. Matt’s daughter recently asked Fitzgerald about her father’s death. “Your dad was poisoned,” Fitzgerald told her.
Matt and Kyle constitute two of the nearly half a million people in the US who died from using prescription or illicit opioids from 1999 to 2019. Overdose and death rates have been increasing even as the rate of prescriptions for painkillers like OxyContin have been decreasing, demonstrating how Purdue Pharma’s “blockbuster” drug has effects reaching far beyond its initial campaign. “[Matt] never knew in a million years that one pill would be the demise of his life,” said Fitzgerald. Now, countless families like the Fitzgeralds have to suffer the consequences.
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In September 2021, New York federal judge Robert Drain announced that he had approved a bankruptcy deal with the Sacklers. The family would give up control of Purdue Pharma, declare bankruptcy, and pay $4.3 billion over nine years to the plaintiffs in thousands of lawsuits. This money would be funneled mainly into two funds: one for compensating victims, and another for investing in states’ opioid crisis responses. In exchange, the Sacklers would be totally immune from all future criminal and civil lawsuits.
The same day the deal was approved, nine states and a handful of cities declared their intention to oppose it. Connecticut Attorney General William Tong led the fight. “This decision is a slap in the face to the millions of suffering and grieving Americans who have lost their lives and loved ones due to the Sacklers’ calculated and craven pursuit of opioid profits,” he said at a press conference. Tong vowed to press forth, and hold the family further accountable. And press forth he did: On March 3rd, Tong’s office announced that it and the Attorney Generals from the other states who had sued had reached a new deal with the Sacklers. The settlement was now worth $6 billion, and while the Sacklers would still be immune from all civil claims, Tong had ensured they remained vulnerable to criminal prosecutions.
Liz Fitzgerald was sitting by Tong’s side as he outlined the new settlement at a press conference. “Other states were folding and caving the more money [the Sacklers] threw at them,” Fitzgerald said. “But [Attorney General Tong] really wanted justice… And I know he fought as hard as he could for as long as he could.” Both Fitzgerald and Tong expressed that the deal was inadequate, with Tong lamenting that he did not win even more money. Fitzgerald recalled being asked by a friend after the deal was announced if she thought the Sacklers were remorseful. “I said, absolutely not. The $6 billion is for the parents to go away.”
Under the terms of the settlement, the Sacklers were required to apologize to the nation and attend a hearing where those affected by the opioid crisis could testify about their struggles. The hearing occurred on March 9th, over Zoom, and featured 28 speakers. Some of those who testified were formerly addicted to opioids. But most were like Fitzgerald, victims of witnessing someone else’s addiction, people who spoke of the horror of watching their loved ones grow reliant on opioids. Richard Sackler, the former president and chairman of Purdue Pharma and one of three members of the family who attended the call, had his camera turned off. So Fitzgerald was forced to tell a black box about the lives OxyContin had ruined, including her own. “I didn’t feel any vindication,” she said about testifying. “But I just felt like I had to… let them know the pain they caused. Not just my family, but the nation.”
The results of the settlement negotiated by Tong could be revolutionary. About $750 million of the $6 billion will go to victims and family members; the rest will go to state, local, and some tribal governments. Connecticut will receive about $95 million from the deal. This whopping number is not even the largest settlement that the state is receiving for opioid assistance. In February 2022, the drug manufacturer Johnson & Johnson and some smaller distributors were compelled to pay $26 billion to victims and states; Connecticut will begin to receive payments of its $300 million share of this deal in July. This money is eagerly anticipated by experts, advocates, and those touched by the crisis. But it also poses a challenge: although experts today largely agree on the most effective ways to combat opioid use disorder, the state’s response has not always reflected these methods. The way that the settlement money is used may be an opportunity to improve this.
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Connecticut attempted to act against the opioid crisis relatively early. It was one of the earliest states in the nation to provide immunity to those who call for help during a drug overdose; to implement a drug take-back program where residents could dispose of unwanted prescription drugs; to create a database enabling physicians to check patients’ history with painkillers; to coordinate a public campaign emphasizing the harms of opioid use; to increase penalties for selling fentanyl. But these actions were largely uncoordinated and representative of the state’s desperate attempts to try whatever it could to combat rising overdoses, a piecemeal approach that undermined Connecticut’s ability to respond in the most effective ways. More fundamentally, the initial state response represented a traditional focus on preventing rather than treating addition. Dr. Robert Heimer, a Professor of Epidemiology at the Yale School of Public Health and infectious diseases expert, explained in an interview with The Politic that this original focus on prevention reflected the larger tendency of governments to attempt to stop drug use altogether, rather than attempting to stop it from becoming deadly.
As the crisis deepened, medical experts began to emphasize the need for new forms of treatment for substance abuse. Their research concluded that attempting to prevent drug use through abstinence programs or public campaigns about the dangers of substance abuse did not work. Instead, this research found, the state should prioritize harm reduction, an approach that addresses addiction as it occurs and aims at managing the negative effects of substance abuse.
Yale researchers were at the forefront of this work. In 1970, faculty of the Yale School of Medicine founded the APT Foundation, one of the first organizations in the country to use synthetic medications to treat opioid disorder. APT established some of New Haven’s earliest locations offering methadone and buprenorphine, medications that simulate the effects of opioids without the addictive qualities, and naloxone, a medication that undoes opioid overdoses. In 2015, faculty at the Yale School of Medicine conducted the first-ever randomized trial to compare the effectiveness of buprenorphine treatment with the state’s traditional approach, and found that giving patients buprenorphine made them twice as likely to engage in treatment. Yale received a federal grant to implement the study’s recommendations and funded buprenorphine pilot programs at four other hospitals across the nation.
Harm reduction research in Connecticut culminated with a groundbreaking effort authorized by then-Governor Daniel Malloy in 2016. Malloy tasked a team of Yale medical experts including Dr. Heimer to partner with the state’s Alcohol and Drug Policy Council and write the Connecticut Opioid Response (CORE) plan. It outlined six research-tested strategies for the state to address the opioid crisis. These included some logistical reforms, like encouraging state agencies to improve data-sharing, and programmatic ones that called for harm reduction to become the framework for the state’s response. These programmatic recommendations included increasing access to naloxone, using methadone and buprenorphine as treatment, and allowing for spaces for safe drug use and syringe exchanges.
Nancy Navarretta, the Commissioner of the state’s Department of Mental Health and Addiction Services (DMHAS), told The Politic that the state’s approach has been changing, partly in response to this research. “It’s really important to invest more in harm reduction strategies, so we have been pivoting in that direction… Our focus has really shifted to keep people alive,” Navaretta said. The state now helps fund centers that offer clean syringes and fentanyl strips; it supports the use of the naloxone drug to combat overdoses; it has allowed for spaces where people can safely use drugs. In 2016, the government started sending Yale doctors into hospitals across the state to teach physicians how to administer methadone and buprenorphine for treatment.
In spite of Connecticut’s increased focus on harm reduction techniques, the state’s response has continued to prove inadequate in the face of an enduring epidemic. “Despite us knowing what to do, the numbers keep getting worse,” said Dr. Fiellin, one of the CORE authors, in an interview with the health news website CT Health I-Team. There were over 1,500 fatal drug overdoses in Connecticut in 2021, a number that has been increasing every year. Fentanyl has been driving this worrying trend, with one study concluding that fentanyl-related overdose deaths in the state increased fifty-fold between 2012 and 2018. Overall, Connecticut residents are more likely to die from a drug overdose than from a car accident, homicide, the flu, diabetes, or kidney disease.
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Part of the reason why Connecticut’s shift towards harm reduction techniques has not succeeded in reducing overdoses is because this shift has not been adequately backed up by large-scale investments or legitimate involvement. Connecticut has left the actual implementation of the state’s response to non-state actors rather than local and state institutions. All of the methadone clinics advertised on the Connecticut state website, for instance, are run by non-governmental agencies. This decision reflects the state’s understanding that the community organizations who have the most face-to-face interaction with residents who abuse opioids are better-suited to support their recovery and monitor their treatment’s success. “We have a system of both for-profit and nonprofit agencies that are actually doing the healthcare and social service work for the state, with state money,” said Heimer.
But the gap left by the government’s lack of leadership has not been filled with adequate funding for the groups that actually implement Connecticut’s harm reduction programs. Spending on programs to combat substance abuse is a tiny fraction of the state budget. Staff of the state Department of Mental Health and Addiction Services have staged large protests multiple times over the few years, demanding increased funding. Their advocacy has rarely succeeded. In the absence of state funds, organizations have turned to other funding sources, primarily the federal government’s grants, like the Center for Disease Control and Prevention’s State Opioid Response Grant. From 2018 to 2020, Connecticut received over $18 million each year from a federal substance abuse grant; less than $250,000 was spent every year on methadone treatment programs. Using the cost calculations from a 2017 study, these funds would cover a year of treatment for only 53 people.
Connecticut’s current system gives community organizations the responsibility for the response but not the necessary funding, which renders the state government’s embrace of harm reduction largely symbolic. The critical steps the CORE plan called for — a plan authorized by the government itself — have largely been ignored, despite then-candidate Lamont’s espousal of support for CORE in his 2018 race. Lamont also promised to appoint a state “drug czar” to handle the state’s response to the opioid epidemic; no such position was created. Thus, even as the state proclaims its support for innovative new approaches to the crisis, its rhetoric has largely proved hollow. Steve Werlin leads the Downtown Evening Soup Kitchen (DESK), a service group that provides assistance to unhoused and vulnerable residents of New Haven. Werlin explained that the state government has allowed DESK to keep naloxone at its physical locations, but receives the medication as a donation from another organization. “[State and local governments] are supportive in the sense that they have said they’re supportive of harm reduction approaches,” he said about DESK’s relationship with the state. “But at the end of the day, funding for that naloxone is primarily coming from other places.”
For years, the state attributed its underinvestment in addiction services to chronic budgetary shortages. Money from the settlements with companies like Purdue Pharma and Johnson & Johnson provides an opportunity to fund the programs that state officials have rhetorically embraced. Indeed, the plan put forth by Governor Ned Lamont in February 2022 for the hundreds of millions of dollars Connecticut won from the Johnson & Johnson lawsuit mentioned using the money on harm reduction.
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But the failure by some local and state officials in Connecticut to implement a robust response to the opioid epidemic may not just be a result of insufficient investment in harm-reduction techniques. Rather, some activists have labeled it the result of a fundamental misunderstanding of the crisis, one that overlooks the crucial role that mental health plays in opioid use disorder. Advocates continually emphasize that substance abuse often occurs with, or results from, mental health issues. Jason Bokowski, a public relations representative from New Haven’s Narcotics Anonymous group, has seen the intersection of these two crises up-close, at NA meetings. “A very high percentage of the addicts are diagnosed. They’re not just suffering from drug addiction,” Bokowski said.
Scientific research has confirmed this fact time and time again: adults with mental health disorders are significantly more likely to abuse opioids. “We have all these detoxes and rehabs but they don’t address the mental health aspect,” said Bokowski. “I definitely believe there should be more emphasis placed on the mental health part.” One 2013 study concluded that four in every ten young Americans with a serious mental health condition also had a substance use disorder. But despite the intimate ties between opioid use and mental health, behavioral health programs have often separated treatment for drug abuse disorder from treatment for mental disorders. “We have to stop thinking of healthcare as medical care, and have to start thinking of healthcare as wellness,” said Heimer. For Connecticut to fully overcome its opioid epidemic demands attention to the trauma that often undergirds addiction; without addressing these issues, overdoses and deaths appear likely to continue to rise.
Both Kyle and Matt Fitzgerald suffered from mental disorders that made their experimentation with OxyContin in high school more risky. “Mental health issues came before the addiction,” she said. “That’s important to know, because a lot of the time in substance abuse, they are trying to treat the addiction and not really treating the cause.” Fitzgerald described the difficulties her sons faced while managing mental health problems and opioid addiction: they often encountered stigma from medical professionals, who believed they could not get better or failed to account for their mental health problems while treating them.
John Labieniec, who works at Continuum of Care CT, a nonprofit dedicated to supporting those struggling with or recovering from opioid addiction in New Haven, shares this concern. Labienic is in recovery, and expressed frustration with the short-term approach towards. “Treatment centers are based on a 30-day model… treatment from addiction doesn’t end in 30 days,” he said. “To think that people are going to be fixed in 30 days? It’s just absurd.” Fitzgerald also witnessed the shortfalls of this treatment model through her son Matt’s experiences. He was often placed into intensive care facilities, but they rarely worked. “Matt was admitted to six facilities in one week,” Fitzgerald said. “So yes, I have an issue with the fact that mental health is not treated like medical health.” As Connecticut weighs how to spend the money it is set to receive from high-profile lawsuits against pharmaceutical companies, the solution may not lie in an expansion of existing programs but in a total transformation of the state’s response.
Frustrated by the inadequate mental and substance abuse support both of her sons had received, Fitzgerald became inspired to fight for improvements to the way that America understands and approaches substance abuse. She joined the board of Tri-Circle, a nonprofit organization that provides counseling to those affected by addiction disorders, whether personally or by a loved one’s affliction. When she was debating if she should get involved in substance abuse advocacy, this concern with mental health loomed large, and she made sure to ask the director of Tri-Circle what the organization’s vision for treatment was before joining. Her eagerness to fix the healthcare system is always grounded in the loss of her two sons. “I have 15 years of stories. That’s why I feel things need to be changed,” Fitzgerald said. “More people just need to keep on pushing and pushing and pushing, and somebody’s going to listen. Somebody, hopefully, is going to do their job.”