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Treating drug-poisoned residents on the New Haven Green

On the night of Tuesday, August 14, three people who had taken a form of synthetic marijuana collapsed on the New Haven Green. The city’s Emergency Department doctors usually see one or two such cases in a day, so three in one night seemed ominous.

The next morning, between 7 and 8 a.m., another four or five people were felled by the synthetic cannabinoid. Their breathing had slowed, their heartbeat had dropped, and their blood pressure was low. Medical providers and first responders knew something big was happening, but they weren’t sure what was causing it.

By 9 a.m., Sandy Bogucki, MD, PhD, professor of emergency medicine, and medical director of Emergency Medical Services, was at the scene. “The fire department had multiple teams dealing with patients who were down across the entire width of the Green,” she said during a press conference at City Hall the next day.

It was the drug’s rapid onset that initially stymied caregivers. They first suspected that the drug might be laced with an opioid like fentanyl. That’s what the symptoms—passing out and pulmonary depression—suggested, said Andrew Ulrich, MD, professor of emergency medicine and vice chair of operations in the emergency department at Yale New Haven Hospital (YNHH).

By mid-morning, the city’s emergency departments were seeing an unprecedented outbreak. Initial reports of a handful turned into two dozen, then by the end of the day first responders had treated more than 70 people.

Over three days that week, city officials reported that ambulances made more than 108 trips to the emergency departments at YNHH and its St. Raphael’s Campus. No one died, and only a few patients had to be admitted to the hospital. Three New Haven men were arrested and charged with selling or distributing narcotics—one of them, police said, was giving it away free to entice new customers.

The sheer volume of cases was stunning. Aided by social media, the story gained national attention—articles appeared on CNN and in The New York Times—as it unfolded. State and federal officials, including the nation’s drug czar, offered support. Faculty at Yale who specialize in substance use disorder research joined the deans of nursing and public health in faulting “our nation’s inadequate response to a volatile crisis,” and calling for increased funding of drug prevention and treatment programs.

Lessons from a past crisis

On the Green and in YNHH emergency rooms, medical staff knew what they needed to do, even if they weren’t sure exactly what was felling the patients.  Many of those providing care were veterans of a 2016 outbreak in New Haven, when 12 people who thought they were snorting cocaine overdosed on fentanyl. Three patients died that night. In a report published in the Medical Morbidity World Report, a weekly publication of the Centers for Disease Control and Prevention, the emergency physicians on the front lines that night called for wider distribution of Naloxone to counteract opioid overdoses. Since then, Naloxone, also known as Narcan, has been readily available to first responders. It was also what revived patients on the Green.

The other lesson of the fentanyl overdoses was that first responders need to work closely with each other and with hospital emergency departments, as well as relevant city agencies like the police and emergency response departments. “It is important to have open lines of communication when you see patterns and distribution of symptoms that are more common than you’ve seen before,” said Kathryn Hawk, MD, HS ’14, MHS ’16, an assistant professor of emergency medicine who has a longstanding interest in substance use disorders. “It would be a similar response if it were a salmonella outbreak or some other infectious disease.”

During the outbreak, city officials and medical staff reported seamless coordination among the different agencies. “Collaboration was extraordinary,” said Bogucki. “All the different services rose far above their normal functioning to handle this very difficult situation.”

Among the difficulties, apart from the staggering number of cases, was that uncertainty over what they were dealing with. “People were just dropping and nobody knew why,” said Hawk. “When someone collapses in front of you and is not really responding and is out of it, that could be how opioid overdoses sometimes present. … Even though at the end of the day we saw that Naloxone was not necessarily the life-saving antidote that people needed, it was clinically the right thing to do.”

“What made it so complicated was that it was combinations of drugs,” said Gail D’Onofrio, MD, chair and professor of emergency medicine. “People who use drugs don’t generally use just one drug.”

D’Onofrio characterized what happened to those patients not as overdoses, but exposures to the drug. The synthetic cannabinoid, likely AMB-FUBINACA, produced an intoxicating effect, but not one that rendered patients comatose or near death, as an overdose would.

When Naloxone revived patients, that seemed to confirm that opioids were involved. “You never know what you’re getting when you buy anything on the street,” Hawk said.

That’s especially true of synthetic marijuana, a designer drug that can come in different varieties.

“On any given day there’s a lot of stuff from different sources, and it’s not all the same. One of the goals of these drug designers, and ultimately the users, is to create different sorts of highs,” said Anthony Tomassoni, MD, an associate professor of emergency medicine, a toxicologist, and medical director of the Yale New Haven Center for Emergency Preparedness and Disaster Response. Two different forms of the substance that caused the event, distinguished by their packaging, were available on the Green, he said. Some was also sold loose in baggies. “The material itself that seems to have been responsible is opioid-free and a blend of two synthetic cannabinoids.”

Researchers developed synthetic cannabinoids in the 1980s to study the receptors in the brain that respond to marijuana. In 2009, a new version called AMB-FUBINACA (or simply "Fubinaca") emerged as an alternative to medical marijuana. It was never brought to market, but the patent is in the public domain. Over the years synthetic marijuana has become a designer drug that can be modified by its makers. It is usually made overseas and smuggled into the country, then mixed with some type of herb or leaf to make it smokable. While synthetic marijuana can have a depressant effect, some forms of it cause aggressive behaviors in users.

A 2015 article in the New England Journal of Medicine reported increasing use of synthetic cannabinoids, sometimes leading to user deaths. Two years later the journal cited another public health concern—new “ultrapotent” synthetic cannabinoids.

Tests negative for opioids

The first drug samples that New Haven police sent to the federal Drug Enforcement Agency tested negative for fentanyl or other opioids, but subsequent samples tested positive for Fubinaca. Fubinaca was responsible for a 2016 outbreak in New York City that affected more than 30 people. Collapsing and pulmonary depression, as seen on the New Haven Green, are consistent with Fubinaca, said Hawk.

“The substance involved was a short-lasting, but rapid-acting version of the drug,” said Bogucki. “People who smoked it or ingested it in some way tended to go down very fast, almost right in their tracks.”

Yale is also doing its own lab work on about 20 urine samples collected from patients. Yale labs are not set up to test for synthetic marijuana—tests for marijuana don’t work on the synthetic drug because of the different chemical composition—so that work has been sent to outside labs. In-house, the lab does more than 10,000 drug screenings annually and covers nine types of drugs, including heroin, cocaine, and barbiturates, said Thomas Durant, MD, HS ’18, a fellow in laboratory medicine who’s handling the testing along with clinical fellow Dustin Bunch, PhD. Physicians want to know what else the patients may have ingested. Yale faculty are planning to publish their findings in a medical journal.

While the results of the tests will add to general knowledge about drug use and could help in public health planning, they won’t necessarily provide immediate help to first responders or emergency room doctors who must act quickly. “You’re going to be initiating treatment well before your lab results come back,” Durant said.

Indeed, on the Green, medical responders had to handle the cases right in front of them. By the time they reached the emergency room, Ulrich said, no patients were in danger

“The ones who were out of it and required someone to rub their chest or wake them up in some way, when they woke up, they also stayed very much awake. They weren’t going back down deeper, so whatever was causing them to go so deep so quickly was getting out of their system quickly,” Ulrich said.

The emergency room, he added, had no trouble keeping up with the flow of patients. “We didn’t bring extra people in. We didn’t bring more resources in. By the time we noticed large numbers of patients coming in, we realized that these patients were going to be fine,” he said.

Medical staff kept the patients for observation, to make sure that they were awake, alert, and able to walk safely. “When we see someone who’s taken drugs and we don’t know what they are, we don’t immediately discharge them,” Ulrich said. “We watch them for a while.”

In such circumstances, said D’Onofrio, physicians make sure patients are breathing and that their airways are working. They check blood sugar to rule out hypoglycemia. “We have this routine that we go through to make sure the person is safe,” she said. “Then we can start to sleuth what drug is causing this so we can get the word out.”

And, Ulrich said, they tried to get patients into treatment programs. “As you can imagine, we were not very successful,” Ulrich said.

Not only did many patients reject rehab, some also went right back to the Green for more—just 47 patients accounted for the 100-plus transports to the hospital. New Haven Police Chief Anthony Campbell reported that some patients went back to the Green four or five times, their hospital bracelets still on their wrists.

“I’m having a difficult time wrapping my head around that,” said Hawk. “People went back and did it multiple times after being transported to the hospital. This is the power of addiction.”

That so many patients rushed from their hospital beds to seek another high speaks to the difficulties of dealing with substance use disorders. “We know that it is a chronic relapsing disease,” said New Haven Mayor Toni Harp, during a press conference at the height of the crisis. Although the crisis was handled “so smoothly,” it placed a burden on city resources, she said, calling for a coordinated response among all three levels of government. “We know that it is happening nationwide,” she said, adding that she hoped that her counterparts in other cities and officials in state and federal government “can learn from our experience.”

In the emergency department, D’Onofrio also recalled the fentanyl crisis of 2016 and the lessons learned then.

“This is the second time when we luckily learned to get in touch with the Department of Public Health and police and press to make sure that people understand that something bad is happening,” she said. “When people started coming in, we recognized it, we sounded the alarm, the appropriate people were notified, and we received a lot of help from the surrounding EMS system and the police.”