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Under cover of COVID, fentanyl and isolation fuel spiraling overdose crisis

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Leon Wittner stands with his daughter Grace Wittner next to the headstone of his oldest daughter, Sara Wittner, at Broomfield County Commons Cemetery in Broomfield

on Saturday

. Sara Wittner, who was 31, died of a drug overdose in April 2020, the day before her appointment for a Vivitrol shot. Sara was on a routine to get the injection every 30 days, but when the coronavirus struck, her father, Leon, said scheduling became problematic.

In the 12 months since Sara Wittner's death, Leon and Grace have told her story, over and over.

It goes like this: Sara struggled for years with various substances, first getting caught drunk by Leon, her father, when she was 14. A gifted singer and lover of live music, Sara's use began with weed and alcohol. She moved to opioid pain pills after a surgery and an eight-day morphine drip more than a decade ago. She'd go through spurts of sobriety, with her longest ending shortly before she died in April 2020 at the hands of an overdose that her family says was a direct result of the pandemic.

There were warning signs over the years, stolen pain pills and changes in behavior. Neither Grace, Sara's sister, nor Leon know exactly when Sara graduated to heroin. Leon knew, even if he wouldn't admit it, that his oldest daughter was spiraling long before he caught her smoking heroin in her bedroom. Her use eventually led him to ask a judge to send her to jail on a drug charge. The other inmates called her Jukebox: She'd sing any song they wanted.

The Wittners have chronicled this tragedy to reporters across Colorado and the country. They've described the years of her heavy use, from the time of the surgery to when she finally settled into a treatment program in 2015. They share it because their tragedy is both intensely personal and strikingly familiar, a Broomfield family fighting its own battle against an enemy that killed record numbers of Coloradans last year.

"I spent so much money on sober living houses that we got into, and she was out seven days later," Leon said. His voice is clear and steady as he talks about her addiction, recovery and sudden death. But as he speaks, a small streak of tears pools in a crease beneath his right eye. "I spent $4,000 to get her in there. In my own mind, I had to say, 'Sara, I love you dearly, but I can’t keep doing this because I know you’re going to die, and I have to kind of separate myself from that because I can’t sleep at night.'"

Sara Wittner was one of 939 Coloradans who died from an overdose involving opiates last year, a death toll that was 33% higher than in 2019. Caught between the rise of the powerful opiate fentanyl and the isolation of the past year, Coloradans overdosed at record rates: A nearly 36% increase from 2019 overall, with deaths related to fentanyl more than doubling.

The Gazette spoke with 20 physicians, advocates, treatment providers, family members, health officials and law enforcement agencies about the spiraling overdose crisis. Several called it the worst year of the opioid epidemic yet, a public health catastrophe that's largely fallen out of the spotlight in the wake of COVID. The impacts of the past year will reverberate for years, potentially even a decade, experts said. 

Much of the blame can be laid on the isolation of the pandemic, advocates and providers said, further exacerbated by the stress, anxiety and depression that accompanied it. Those stressors collided with the rise of fentanyl, a substance so potent that a few extra grains of the powder can be lethal. Its presence has ballooned in recent years as prescription opioids are harder to find. Fentanyl, pressed into pills masquerading as legitimate prescriptions or used to cut heroin, meth or cocaine, has filled the void.

"This is the worst overdose crisis Denver, Colorado and the United States has ever seen," said Lisa Raville, the executive director of the Harm Reduction Action Center. Her organization provides clean needles, fentanyl test strips and Narcan, an opiate overdose antidote. In March alone, people working in her program used Narcan to reverse 83 incidents of overdose. "We’re not even plateauing. We need all hands on deck."

Drug cartels pushing fentanyl 

Initially developed as a safe anesthetic 60 years ago, fentanyl impressed researchers, one of whom wrote of its potency and minimal side effects in a 1992 article in the Journal of Pain and Symptom Management.

It first began emerging in the black market in 2008 or 2009, said Steve Kotecki, a spokesman for the Drug Enforcement Administration in Denver. After regulators and law enforcement began cracking down on the over-prescription of legitimate opioids, fentanyl began to flourish as a cheaper alternative. Small quantities can pack a heavy punch, and it's easy to lace it into other substances.

After the U.S. government stifled the initial supply line from China, illicit dealers started shipping fentanyl ingredients to Mexico and its cartels. Unlike heroin, which requires an entire agricultural cycle and subsequent preparation, fentanyl costs far less to make, Kotecki said.  A small amount of fentanyl can go a longer way. 

"The drug cartels moving to fentanyl has really driven this, and I don't think they’re going to go back to selling safer products like heroin," said Don Stader, an emergency medicine and addiction doctor in Denver. "We are very much going to continue to see fentanyl as the primary illicit in our market, and that’s a big, durable tragedy from the COVID pandemic."

Campaign 2016 Why It Matters Opioid Epidemic

FILE - This Feb. 19, 2013, file photo, shows OxyContin pills arranged for a photo at a pharmacy in Montpelier, Vt. More than 28,000 Americans died from overdosing on opiates in 2014, a record high for the nation. That’s 78 people per day, a number that doesn’t include the millions of family members, first responders and even taxpayers who feel the ripple of drug addiction in their daily lives. A rise in prescription painkillers is partially to blame: The sale of these drugs has quadrupled since 1999, and so has the number of Americans dying from an addiction to them. When prescriptions run out, people find themselves turning to the cheaper alternative heroin and, increasingly, the even more deadly drug fentanyl. (AP Photo/Toby Talbot, File)

Fentanyl's use as an ingredient in other drugs makes it particularly dangerous, experts said. Though users may have a tolerance for certain amounts of heroin or pills, fentanyl's unknown presence can turn a familiar dose into a lethal cocktail. Xanax and OxyContin pills can be re-pressed, with traces or overwhelming amounts of fentanyl. Often, users have no idea that they're ingesting fentanyl, experts said.

"Historically, you were either treated for alcohol use disorder or a drug use disorder," said Jody Ryan, the chief medical officer for the Mental Health Center of Denver. "Now we're seeing a combination of lots of different substances, and a lot of the time patients don’t know what they are using. For example, we had a patient here in urine drug screen return and (she) was positive for nine different items, but the woman remarked to her counselor that she was only using heroin."

While various advocates and providers from across Colorado said they'd seen upticks in alcohol and meth use over the past year, fentanyl's potency elevates it. In 2015, fentanyl contributed to fewer than 5% of overdose deaths here. In 2020, it was more than a third. Kevin Farrington, a supervisory special agent assigned to a federal organized crime drug task force, said the increase was "extraordinary." In 2020, fentanyl contributed to 534 overdose deaths in Colorado, more than doubling its 2019 toll.

Christian Hopfer, a psychiatry professor at the University of Colorado and the medical director of a UCHealth imprint that focuses on addiction, said the death toll was the worst he's seen in his career. 

"I’ve been doing it for 30 years," he said. "I mean, the crack epidemic was pretty bad, but there wasn’t as many deaths due to overdose."

Fentanyl did not suddenly emerge in Colorado in 2020. Experts said its presence had been steadily increasing over the past several years. Kotecki said that in years past, a seizure of 10,000 illicit pills would be a notable feat for the DEA. Now, it happens multiple times a week, and the drug keeps coming.

Tragedy of a missed appointment

Sara was clean for five years. In 2015, she started a two-and-a-half year stay at the Stout Street residential treatment center. She earned sobriety coins, got her own apartment and started working again. Leon keeps those coins now, two reminders in a small blue bag he keeps in his pocket. He'll pull them out and show you, still proud.

During those good years, Sara and Grace rebuilt their relationship. When her older sister was using, Grace didn't want to be around her. When they were younger, Sara would drive them around in her Oldsmobile — they called it the Hoopty — and they'd sing along to Motion City Soundtrack. But as Sara's use spiraled, Grace thought her older sister would die before Grace graduated high school.

But when Sara was clean, they went to concerts together again, including to see Say Anything and Motion City Soundtrack. Sara had taken her sister to a concert to see those bands when Grace was 10. Sara had gotten so drunk they'd gotten kicked out.

In Sara's sobriety, the pair hung out constantly, so much so that Grace grew slightly exasperated. Sara got another job and a $23,000 pay bump. Her bosses wanted her to get her bachelor's degree so she could move up in the company.

She was skateboarding to work, a reminder of when the sisters were kids and they would sneak off to the skate park. She and Leon began speaking publicly about addiction; they participated in a state campaign to reduce the stigma around addiction and recovery. It's that level of openness that's led to Leon and Grace's willingness to speak now.

In December 2019, Sara relapsed. The family had gone to New York, a trip that had been postponed after Gina, Leon's wife and the girls' mother, was diagnosed with stage four ovarian cancer. During the trip, Grace noticed that her sister would disappear, spending an hour getting a bagel, or wouldn't be in the hotel room in the middle of the night.

Sara re-entered treatment and got clean again in January and February 2020. She started taking Vivitrol, an injectable that can curb cravings and relapses. She was scheduled to get her second dose on April 1. She and Grace were planning to go to a concert in Phoenix.

Then the world shut down, and her appointment was canceled. She would have to hang on for a while longer.

Seeking to shed emotional pain

Had the COVID pandemic not happened, fentanyl would not have disappeared, and based on the past several years of data, it would likely have still led to more overdose deaths in 2020 than in 2019. But its combination with the isolation and stress of the pandemic has been cataclysmic. 

Stader, the ER doctor, and Adam Barkin, another emergency medicine physician in Denver, both said they'd seen a noticeable uptick in opioid use issues coming through their doors. They attribute the rise in substance abuse to the stress and anxiety caused by the pandemic, with deaths accelerated by fentanyl. A U.S. Census Bureau survey found that in December, as much as 44% of Coloradans reported indications of anxiety and depression.

"People have more time on their hands than they know what to do with, they can’t go to movie, they can’t have those releases that they so often rely on, to provide stress release," Barkin said. "And people are stuck in their homes, stuck in their apartments, unable to find those releases. It’s not uncommon for people to then turn to either relapse on a substance use or return to substances to try to find some other way to find relief, essentially."

The pandemic's immediate emergence, and the hasty lockdowns it prompted, threw a wrench into the machines of Colorado's addiction treatment industry, advocates and providers said. Many treatment centers and clinics immediately set about building virtual infrastructure, and most said they were back up and running in that capacity soon after Colorado shut down. Though it was a difficult transition, most said it went as smoothly as could've been expected.

"Organizations that had resources could seamlessly move into electronic based healthcare platforms and offer services virtually, and they did it quickly," said Angela Bona, the director of adult outpatient services at the University of Colorado's Addiction Research and Treatment Services. "There are some organizations, especially some that are rural, that had more challenges in transitioning to virtual services, but they were able to make accommodations for patients to continue care, so there wasn’t a hiccup in services in that regard."

Still, the lack of in-person meetings, interventions and one-on-one conversations still had an impact on users seeking help. The stress inherent in the pandemic could be further exacerbated by the loss of a job or income, said Ryan, of the Mental Health Center of Denver.

Multiple experts said that the opposite of addiction is connection. The pandemic all but severed those connections, leading people to relapse or begin using for the first time. 

'Carnage' will continue

There are ways to mitigate the crisis, and experts stressed that ground has been gained in recent years. While the past 12 months hasn't wiped out those gains, it has left providers, families, clinics and the state in general with years of trauma and downstream effects with which to reckon.

Rob Valuck, who leads the Colorado Consortium for Prescription Drug Abuse Prevention, predicted that addictions and relapses developed over the past year will lead to deaths and struggle for a decade. Stader, the Denver ER doctor, said that the state would "be dealing with the carnage of this increase" for decades.

To address it, experts said, the state and federal government need to increase funding and support for treatment programs. Valuck said Colorado was meeting about a third of the treatment need currently. That's better than most states, he said, but "being able to say we suck less, that's still not reassuring." 

Darlene Tad-y , a doctor and the Colorado Hospital Association's vice president for clinical affairs, said there needed to be more access to medication-assisted treatment, which includes controlled distribution of drugs like methadone to help users taper off of opioids. Medication-assisted treatment clinics need to be stood up in jails, hospitals and in broader communities, she said, the stigma around asking for help needs to be torn down.

Raville, of the harm reduction center, advocated for wider acceptance of the strategies her clinic offers. Though clean needle exchanges may be controversial, they cut down on the spread of infection and, just as crucially, can act as a gateway into treatment. It's at those types of clinics that drug users can be given Narcan, which in turn saves lives. To combat the hidden presence of fentanyl in other drugs, her clinic distributes strips that people can use to test their drugs for its presence. Other experts said the efforts underway at Raville's clinic should be embraced more fully.

Money and resources need to improve, but the stigma and approach to addiction has to change, too, said Andres Guerrero, the manager of the state's overdose prevention unit.

"It’s going to also take into account that we have to fund properly the programs and the agencies that are doing this work if we want to see these numbers come down more quickly," he said. "I really can’t say — 10 years, five years, I don't know.  I think also just looking at an alternative way of looking at substance abuse. Locking people up in jail or prison for substance abuse problems doesn’t fix the substance abuse problems."

Raville has also pushed for the creation of safe use spaces: monitored, controlled areas where people can use illicit drugs under the watch of providers, who can ensure they don't overdose, or if they do, they're not alone. It's a preferable alternative to shooting up in an alley or in a Starbucks bathroom, she said.

Drug addiction, particularly to a substance like heroin, is already an isolating drug, experts said. That isolation — ratcheted up further by the pandemic — is dangerous in and of itself. While providers like Stader and clinics like Raville's have taken to distributing Narcan in an effort to curb deaths, the antidote is worthless if no one is around to use it on an overdose victim.

"The juxtaposition of, 'If you use drugs, don't use alone' — that has an effect on people not being able to go out, of not being able to meet with people they were meeting with before," Guerrero said. "It does raise the risk. If you use alone, it does raise the risk, not just of overdose but all sorts of negative effects."

Or, put more bluntly by Stader: "People who overdose alone die."

050221-news-opioids 08

Grace Wittner sits next to the headstone for her older sister, Sara Wittner, at Broomfield County Commons Cemetery in Broomfield

on Saturday

.

'I knew she was dead'

Sara overdosed alone. By mid-April 2020, it had been 44 days since she last received the injection that was helping her avoid a relapse. She was set to get it, finally, on April 17, a Friday. She died Thursday morning.

Grace's worst fear had been that she would find her sister dead. That morning, she walked down into the family's basement to ask Sara if she wanted breakfast. She knocked on her door, but there was no answer. She felt her stomach turn.

"I wanted to puke," Grace said. "I knew going in there she was dead. I already knew that."

Leon and Grace's husband administered Narcan — everyone in the family has some — and began CPR. They called 911. Then Leon called his pastor, who said a prayer before first responders took Sara away.

He and Grace had braced themselves for this moment, back before Sara had gotten clean for those good years. But no preparation could've helped.

"No way in the world you can ever grieve your child until they're gone," Leon said. "It still blows my mind just how much that hurt."

Their pastor had always told Leon that if Sara could get past the heroin, "she's going to change the world." She loved music and kids. When she was clean, she began talking about raising a family of her own. She giggled in a high pitch, a laugh that picked up pace as it continued. 

Sara was one of hundreds of sons and daughters, sisters and brothers, who overdosed in Colorado last year. The response to the epidemic must be multifaceted, experts said. The Wittners have a part to play in that effort.

"I want people to understand what's happening," Leon said. "… I know that no matter what, Sara would want us to keep her story out there."

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