The Connecticut Opioid REsponse (CORE) Initiative

Connecticut is dealing with a serious opioid overdose crisis. In 2022, more than 1,450 people died from overdoses, which is a 306% increase since 2012. Even though efforts have been made to tackle this issue, the problem persists and is evolving. One major concern is that illicit (illegal) opioids, stimulants, and benzodiazepines are increasingly being mixed with very strong synthetic (artificial) opioids like fentanyl, which is increasing overdose risk. In 2023, fentanyl was involved in 84% of overdose deaths in Connecticut.

An opioid overdose happens when someone takes too much of an opioid. Many factors affect risk of overdose, such as a person's physical tolerance for opioids (how much their body can handle) and the strength and amount of what they're using. Anyone using opioids could overdose, but some are more at risk than others. People who have survived an overdose are more likely to die from their next overdose. Those who use opioids not prescribed by a doctor face a high risk because they can't be sure what they're taking or how strong it is. Prescription opioids are checked for quality and strength, but street drugs aren't. For example, a fake pill sold as oxycodone or alprazolam (“Xanax”) might actually contain fentanyl or other unexpected and dangerous substances. How someone takes a substance (like injecting) and their physical tolerance level for that substance can play a role. People with low physical tolerance, such as those new to opioids or restarting after a break, are at higher risk. This includes people leaving rehab or being released from prison. Combining opioids with benzodiazepines or alcohol also increases the risk of overdose.

Connecticut will receive around $600 million from legal settlements with prescription opioid makers and distributors. This money is specifically meant to help address the overdose crisis, including preventing opioid use disorder, providing treatment, and reducing harm. It's a chance to use these funds to reduce opioid-related deaths and improve the lives of people affected by substance use and addiction.

The need in Connecticut is substantial. About 118,000 people in the state report using opioids like heroin or fentanyl in the past year for non-medical reasons. But the actual number could be even higher. Around 250,000 people in Connecticut have been diagnosed with a substance use disorder. Among those with an opioid addiction, only 20% got any treatment in the last year.

The opioid settlements in Connecticut and other states are similar to the agreements reached in 1998 with major tobacco companies, known as the Tobacco Master Agreement. The agreement aimed to help states address the serious health and economic impacts of tobacco-related illnesses and deaths. However, despite the potential to make a big difference, less than 3% of the settlement money was actually used for prevention, treatment, or harm reduction.

Connecticut has a opportunity to learn from this example and make better choices with the opioid settlement funds. Luckily, Connecticut’s opioid settlement agreement includes clear rules about how the money can be used. These rules are outlined in Public Act 22-48, "An Act Implementing the Governor’s Budget Recommendations Regarding the Use of Opioid Litigation Proceeds," as well as in a document called Exhibit E: List of Opioid Remediation Uses.

The Connecticut Opioid Response (CORE) initiative began in 2016 at the request of Governor Malloy and is led by the Yale Program in Addiction Medicine. CORE's mission is to reduce the harmful effects of opioids on Connecticut residents by providing support, resources, and care to decrease overdose deaths and address opioid addiction. CORE values include relying on evidence, acting promptly, showing respect, ensuring access, fostering collaboration, and achieving measurable results.

In 2016, CORE published a report outlining a strategic plan to lower opioid-related deaths. This report, based on scientific research available at the time, offered guidance to the state alongside the efforts of the Alcohol and Drug Policy Council (ADPC), a group representing stakeholders across Connecticut. Many strategies from the 2016 report have been put into action by state agencies and local authorities. Key actions include making medications for opioid addiction, like methadone and buprenorphine, as well as the overdose-reversal drug naloxone, more accessible.

In 2023, the Connecticut Department of Mental Health and Addiction Services (DMHAS) asked CORE to update and revise its 2016 report, to help guide the statutorily created Opioid Settlement Advisory Committee (OSAC) that has been charged with distributing state settlement funds. This updated report, released in March 2024, provides an overview of the current state of the opioid overdose crisis in Connecticut, summarizes recent scientific findings, and offers recommendations for priorities that can be funded quickly to address opioid-related harms, such as overdose deaths and addiction.

Funding priorities included in the 2024 CORE report emphasize improving access to treatments for opioid use and opioid use disorder; reducing overdose risk and deaths; strengthening prevention efforts; building infrastructure for data-driven interventions; expanding the substance use and addiction workforce; challenging community stigma; and addressing social and structural factors that drive opioid-related harms. Scroll to learn more about each priority below.

Medications for opioid use disorder (MOUD), particularly methadone and buprenorphine, are the most effective form of treatment for opioid use disorder (OUD). MOUD have been shown to decrease substance use, reduce overdose deaths and transmission of infections sometimes related to drug use like HIV and Hepatitis C, and reduce criminal behavior. In a recent study of Connecticut, people with OUD being treated with methadone or buprenorphine reduced their risk of fatal overdose compared to those not receiving any treatment (39% reduction with methadone, 34% reduction with buprenorphine).

Priority 1 outlines several strategies to increase access to MOUD across healthcare settings in the state, including certified Opioid Treatment Programs, primary care and mental health clinics, emergency departments, and carceral facilities. Priority 1 additionally encourages interventions that are tailored to the communities they are meant to serve, culturally responsive, and trauma informed, as well as investment in systems that help track and analyze data relevant to MOUD in the state.

Fatal and non-fatal overdoses have been reported in the thousands across the state of Connecticut, but the burden falls mostly on specific cities and specific populations. Research shows that efforts to reduce overdoses will have the greatest possible impact if they focus individuals with the highest risk. These can include:

• People who have recently had a non-fatal overdose
• Those who tend to use opioids alone (not in the company of others who might respond to an overdose if one occurred)
• People who have a history of opioid use disorder and have lost physical tolerance to opioids due to a period of not using (e.g., people coming out of rehab or prison)
• People who are new to opioids or don’t know they are using opioids (e.g., someone using illegally purchased stimulants that may be contaminated with fentanyl)
• People who are unhoused or experiencing housing insecurity

Priority 2 outlines strategies to reduce fatal and non-fatal overdose among these high-risk groups, above and beyond increasing access to medications for opioid use disorder. These strategies include expanding access to the life-saving opioid overdose reversal drug, naloxone, increasing provision of other harm reduction services that reduce overdose risk (e.g., distribution of fentanyl test strips), reducing solitary drug use, and decreasing unexpected exposures to opioids in contaminated illicit drugs.

Connecticut learned during the COVID-19 pandemic that being able to quickly collect, access, analyze, and report data can support successful public health responses. We need the same approach to address the opioid overdose crisis. Many state agencies and other entities currently collect important data that can help guide efforts to address and reduce opioid overdoses. However, these data are collected in separate systems isolated from each other. Being able to confidentially track how people at risk of opioid overdose are interacting with various services and resulting health outcomes will require linking and merging these data, which can then be made available to policy makers, public health professionals, clinicians, and researchers to inform evaluation of existing interventions and development of new ones. Creating this robust data infrastructure can also help the state identify gaps in its data collection and monitor efficacy and impact of programming established or supported with opioid settlement funds.

Priority 3 presents strategies to build out Connecticut’s data infrastructure to support addressing the opioid overdose crisis with informed policy and practice decisions.

Reducing opioid overdoses in Connecticut requires a trained and supported addiction workforce. Connecticut’s ability to pursue the priorities laid out in the 2024 CORE report, such as increasing access to medications for opioid use disorder and harm reduction services, is directly tied to workforce skills and capacity. There is a shortage of workers in the state with specialty training in addiction. This shortage exists in a range of roles including specialty addiction-trained clinicians treating addiction, professionals who do not primarily treat addiction but engage with people who use drugs, and individuals who can serve as substance use navigators, peer supports, or other capacities. The shortage of workers is coupled with a need for infrastructure to support this workforce, disseminate best practices, and offer continuing training as the overdose crisis evolves. Growing and strengthening the multidisciplinary addiction workforce in Connecticut will directly facilitate expanded access to and quality of treatment, prevention, and harm reduction services.

Priority 4 details strategies to expand and strengthen the clinical and non-clinical addiction workforce, inclusive of doctors, advanced practice providers, registered nurses, pharmacists, social workers, public health professionals, harm reduction professionals, recovery support specialists and substance use navigators, peer support specialists, and others.

Prevention efforts can be considered across the lifespan, from youth through old age. Primary prevention focuses on preventing a particular harm or disease from ever occurring. In the context of the opioid overdose crisis, this might involve combating initiation of nonprescribed opioid use. Secondary prevention targets the highest risk groups after initiation, and progression from initiation to more regular or riskier use. This can include identification of and intervention with people at increased risk for overdose, efforts to prevent progression of opioid misuse to opioid use disorder, or early treatment for people with diagnosed opioid use disorder. Tertiary prevention aims to lessen the consequences of disease and associated harms, once developed. This might include efforts to reduce the fatality of overdose events, prevent other harms related to opioid use like infectious disease transmission, and provide opioid use disorder treatment. Where primary prevention is for everyone, secondary prevention targets those most at risk of harms or disease, and tertiary prevention targets those who have already experienced harms or developed disease.

Priority 5 offers strategies along the prevention continuum, with prospective immediate and long-term impact. Importantly, Priority 5 emphasizes a need to develop the evidence base for primary, secondary, and tertiary prevention interventions to ensure that prevention efforts funded with opioid settlement dollars have the intended effect. To that end, Priority 5 includes strategies that support not only implementation, but also evaluation, of prevention efforts.

Opioid use, opioid use disorder, and medications for opioid use disorder are heavily stigmatized in our society. Lack of education and sharing of inaccurate information threaten public understanding of opioid use disorder, how it develops, and how it can be treated. A recent survey conducted by Shatterproof demonstrates that Connecticut residents are less willing on average, when compared to a national sample, to want someone with opioid use disorder to marry into their family, be a close friend, or spend an evening with them socializing. The language used to describe people with opioid use disorder can have a big effect on public sentiment. Research suggests that efforts to use of person-first language, emphasize efficacy and benefits of treatment, and use of sympathetic narratives — stories that humanize people with addiction, can make a difference. Education to confront stigma and promote accurate information about opioid use, opioid use disorder, treatment, harm reduction, and people who use drugs is needed for the general public as well as for professions that often come into contact with people who use drugs and those with addiction. These include healthcare professionals, social workers, first responders, and media professionals.

Priority 6 provides strategies to address and reduce community-held stigma by increasing access to accurate information, sharing stories of treatment success, and promoting the use of person-first language when talking about addiction, substance use, and people who use drugs.

Inequity in social, economic, and environmental factors can influence negative health outcomes like addiction and overdose and create barriers to addiction treatment. In Connecticut, the largest number of deaths and greatest burden of opioid-related harms falls on racial and ethnic minorities; people who are unhoused, unemployed, uninsured, and those recently incarcerated. Disparities in access to care and outcomes of that care are influenced by factors related to geographic location (e.g., urban or rural), race, age, sexual orientation and gender identity, developmental and physical ability, as well as culture, language, and citizenship status. Using a health equity lens and prioritizing structural solutions can meaningfully reduce opioid-related harms, improve access to and retention in treatment for opioid use disorder, and be cost-effective in the long-term.

Priority 7 outlines strategies that target social and structural determinants of health, including access to affordable housing, access to basic needs (e.g., food, employment, legal assistance, transportation, childcare), and provision of behavioral health care, in pursuit of long-term improvements in social, racial, and economic justice.