This is the second story in a two-part series examining the opioid crisis in Vermont’s largest city. Read the first story, “How Burlington lost ground in its battle against opioids,” here.
In early September, Michael LaChance, chief of the Burlington Fire Department, was making the rounds at the city’s five stations.
Over the department’s radio channel, call after call was being dispatched. Emergency responders would go on to respond to roughly 120 calls during a 48-hour shift. Nearly half were for reports of an overdose or unresponsive person.
As the calls kept coming, LaChance stopped by the Mansfield Avenue station. A firefighter and paramedic suggested sending someone in a utility vehicle to help handle all the reports of possible overdoses.
At one point, another paramedic approached LaChance and told him more somberly, “Chief, we’ve got to do something.”
Burlington is heading toward a grim milestone — it could top 500 overdoses, which includes nonfatal incidents, by the year’s end.
What the paramedic told LaChance that day captures a sentiment widely shared throughout the city — that it needs to dramatically step up efforts to combat a worsening drug crisis driven largely by fentanyl and other dangerous drug mixtures.
That sense of urgency is reinvigorating a longstanding debate about how far to lean into harm reduction efforts such as overdose prevention sites — and to what extent the city should increase police enforcement.
Thanks to incoming money from national settlements with prescription opioid companies, Burlington has begun to invest more in treatment and fund new efforts, including a response team at the fire department and a unique treatment program. But as the Queen City attempts to intervene, significant barriers remain.
‘I cannot compete’
The arrival of fentanyl around the pandemic is called a “third wave” by the U.S. Centers for Disease Control and Prevention, following earlier phases driven by prescription opioids and then heroin. In Burlington and beyond, it is forcing city and state leaders to rethink the treatment systems they have spent years trying to bolster.
Before fentanyl became the dominant substance in the opioid crisis, buprenorphine, a medication to treat opioid use disorder, was particularly effective helping people struggling with heroin addiction, said Tom Dalton, executive director of Vermonters for Criminal Justice Reform. Burlington had focused on expanding access to this form of treatment.
However, in some cases, fentanyl’s potency tempers the effectiveness of buprenorphine, according to Dalton, who explained that the medication has what’s called a “ceiling effect.” At a certain point, upping a buprenorphine dosage has no increased impact on reducing the impulse to use. In contrast, the dosage of another medication called methadone can be stacked to increase its effectiveness against fentanyl.
People who use substances are also sometimes reluctant to turn to buprenorphine. If they’ve been using fentanyl, the buprenorphine can suddenly knock the opioid off from receptor sites in the brain, leading to “precipitated withdrawal,” which Dalton described as “agonizing.”
With the rise in severe fentanyl dependence driving higher tolerance and the need for larger treatment doses, methadone is quickly becoming the medication of choice, Dalton said. However, strict federal regulations make it more difficult to access.
The regulations allow doctors to prescribe methadone for pain relief. But if a patient needs it for drug treatment, they must, with limited exceptions, receive it at tightly regulated dispensaries.
In the Burlington area, the Howard Center’s Chittenden Clinic in South Burlington, over two miles away from downtown, is the only place to go to receive methadone.
Dr. John Brooklyn, the clinic’s medical director, said fentanyl has drastically impacted the methadone dosages he prescribes. Before, a patient would start at 30 milligrams and work up to 100 milligrams after about a month. With fentanyl, people still have to start at 30 milligrams, but they’re often up to 200 milligrams in the first month.
“I’m astounded at how much methadone I have to give people now to compete with the fentanyl that they’re using,” Brooklyn said.
The clinic is open from 6 a.m. until 11 a.m. weekdays with slightly reduced hours on Saturday. For patients just getting started on the medication, they need to travel there in person every two days.
“There’s no doubt that many more people would avail themselves of methadone treatment if it was easier to access,” said Burlington Mayor Miro Weinberger. “And we’ve got to expand that system in the face of what we’re challenged with right now.”
During the past session, the Vermont Legislature approved $2 million — to be paid for from opioid settlement funds — to establish “satellite locations for the dosing of medications,” which could expand methadone access.
Kelly Dougherty, the deputy commissioner of the Department of Health, said that the state is eyeing locations in Chittenden, Addison and Windsor counties as well as a program within the Department of Corrections. Yet it could be a year or more before access to methadone is expanded.
Part of the delay is because of federal regulations, Dougherty said. For example, one methadone clinic in the state had to make its walls thicker for security reasons. Also, the Drug Enforcement Agency needs to inspect every site, she said.
Weinberger argued the state should do more to expedite the timeline for standing up such clinics.
“If it’s going to take us a year to a year and a half just to create a new resource that is needed during this crisis, something is wrong with the system and we need to consider emergency authorities to accelerate that,” Weinberger said.
Brooklyn was supportive of expanding access to methadone, but said there would still be difficulties competing with fentanyl’s ubiquity.
“The problem is that I cannot compete with the drug dealer who’s going to come to your door at any hour of the day and drop off your fentanyl,” Brooklyn said. “The structure of methadone can’t compete with that.”
And while medication-assisted treatment has been shown to be effective for opioid use disorder, it is not an answer for those who use stimulants, who are finding that drugs such as cocaine and methamphetamine are increasingly being laced with fentanyl.
‘New innovations’
The city has started experimenting with different treatment approaches, in part to try to reach people struggling with stimulant use. Vermonters for Criminal Justice Reform started a program in August 2022 that relies on what’s called contingency management — a behavioral health and drug treatment method that rewards positive actions or conduct, often through financial incentives such as gift cards.
Dr. Richard Rawson, a University of Vermont professor who has worked on contingency management programs nationwide, said the treatment method was developed at UVM by Dr. Stephen Higgens in the early 1990s . The concept, Rawson said, is simple: “It’s positive reinforcement.”
Dalton said that his organization uses incentives for both participation and progress, such as a clean drug test. The gift card rewards start around $12 for each incentive, but increases by a dollar for each successful week to build momentum.
Though it’s not a large sum, the money can be very helpful to program participants, he said. All are living below the federal poverty level and many are experiencing homelessness.
His team is still analyzing data from the first run of the contingency management program, which included over 60 participants, but Dalton said he thinks it’s been a success.
“It’s been a very powerful engagement tool, so it brought in a lot of people who were not otherwise in contact with services in a consistent way that allowed us to develop working relationships with them,” he said.
The program is funded with settlement money from several national lawsuits brought against pharmaceutical companies for their roles in the opioid crisis.
Vermont’s share of those settlements could net around $100 million, though the money will arrive in small increments over long periods of time. As of October, the state had received around $12 million, according to Dougherty. An opioid settlement advisory committee, made up of 17 state officials, lawmakers, municipal officials and treatment providers, makes recommendations to the Legislature on how to distribute the money.
Mayor Weinberger said in an October interview that Burlington had received about $250,000 from the state’s share of the settlement money, but that more is on the way. In an August press release, Weinberger said $75,000 of the city’s share of settlement was sent to VCJR, Dalton’s organization.
As VCJR works to set up another phase of their program, the Department of Health has also eyed a statewide rollout, issuing grants to providers in other parts of the state in October. Dougherty said the state sees the program as an important option given the rise of fentanyl and stimulant combinations.
In March, the opioid settlement advisory committee asked the Legislature for $840,000 for a statewide contingency management program, which the House and Senate approved.
“I think it’s a reflection of where we are in the country, that people are really looking for new innovations and new modalities and opportunities to try to have an impact and so finally some resources are being put into community-based programs with contingency management,” Dalton said.
Also seen as an innovation in Burlington is the community response team pilot at the Burlington Fire Department. In October the City Council approved $182,598 — to be pulled from the opioid settlement funds — for a six-month trial that will put two firefighters in a department vehicle out in the community to respond to reports of overdoses and unresponsive people. To start, the team will be staffed through voluntary overtime only, during weekday daytime hours. An ambulance and additional personnel will only be sent to those incidents if needed.
LaChance, the fire chief, said in an October interview that those call types have helped to drive the fire department’s total calls to a new record — he expects total incidents to top 11,000 by the end of the year. The idea for the new response model rose up through the ranks, LaChance said, in response to firefighters feeling overtaxed by the high number of calls and repeat patients. Firefighters said in interviews that many overdose patients don’t go to the hospital after being revived and are encountered again, sometimes on the same day.
“It’s hard to stay motivated when you feel as though you are not making a difference,” LaChance said.
But LaChance also sees the new team as a benefit for the community as well, with those firefighters being out in the field in a more proactive role, rather than waiting in the fire station for the next call.
“I want them to be engaging with the folks in the high-use areas, I want them to be engaging with business owners on Church Street, just to let them know that we’re there,” LaChance said.
Some of the new approaches that local leaders have been pushing for in Burlington, however, have run into stiff opposition.
‘The least interesting thing’
In June 2022, Ed Baker, a social worker and harm reduction advocate, invited Kailin See to appear on the public-access television program he hosts called the Addiction Recovery Channel.
See, who directs two overdose prevention sites in New York City — the first to open in the country — described them succinctly to Baker’s viewers: “It’s a room or a facility where previously acquired, illicit substances or prescription medication can be consumed under the supervision of trained staff who will intervene in the event of an overdose or other medical emergency.”
“The least interesting thing that happens in the drug consumption room or an overdose prevention center is the consumption itself,” she continued. “It’s everything — all of the beautiful support work, counseling and education and relationship building that can happen when you actually allow people to consume the drugs they want to consume the way they want to consume them in a safe and controlled environment.”
From November 2021, when the New York City sites opened, until June when See spoke with Baker, 360 overdose interventions had taken place at the centers, she said. Staff at the sites had to call an ambulance only five times during that period.
Advocates like Baker are pushing for the model to be adopted in Burlington. “To me it’s kind of a no-brainer that if we were going to open one overdose prevention center in Vermont, it would be in Chittenden County,” Baker said.
But such proposals have historically faced stiff opposition from key figures — the same month that See appeared on Baker’s show, Gov. Phil Scott vetoed a bill that would have simply studied the creation of such sites. Without the state’s endorsement — and funding — there are no plans to develop an overdose prevention site anywhere in the state.
Dougherty, the deputy commissioner of the health department, said she could see overdose prevention sites “playing a role” but also cautioned that they wouldn’t be a “panacea.” While it might make sense for an area such as Burlington, for the rest of rural Vermont it could be a tough sell due access issues in more far-flung locations, she said.
At a recent meeting of the opioid settlement advisory committee, members discussed overdose prevention sites, Dougherty said. So far, the state has only asked those that would provide the service what their budget would be, but no formal proposals have been requested. Dougherty said legal hurdles remain, including a federal law that prohibits “maintaining drug-involved premises.” The New York centers opened in defiance of that law.
“The logistics and the legality issues would have to be worked out,” Dougherty said.
Dalton, from Vermonters for Criminal Justice Reform, said he is an “absolute” supporter of overdose prevention centers, and said he would take it a step further, providing what some advocates call “safe supply” where prescribed medications are provided in place of illegal drugs, a concept in use in Vancouver, Canada.
“The idea that we’re willing to provide syringes to people to inject dangerous opioids, we’re willing to potentially give them a place to do it but we want them to bring the toxic drugs to that place, watch them overdose and then save them instead of giving them access to a safer option in the first place makes no sense to me and can only be stigma based,” Dalton said.
While Dalton, Baker and others advocate to push further into harm reduction efforts, others argue that the city needs to turn its focus to enforcement.
‘Turning the tap’
In the September version of his monthly report to the city’s police commission, Burlington Police Chief Jon Murad devoted four pages to the subject of the drug crisis.
The final page was titled “turning the tap.”
“There are many tools for addressing the substance-use crisis that Burlington is experiencing. Four of them are shown here,” the chief wrote. “Decarceration,” “de-prosecution” and “harm reduction” were pictured under an illustration of a spigot with water flowing. A fourth, street-level enforcement, showed the water at only a drip.
“For the past few years, three have been turned all the way up while one, on a street level, has been nearly shut down. The current mix is not working,” Murad wrote.
In a late September interview after his report came out, Murad was adamant that arresting anyone who suffers from substance use disorder is “absolutely not where anyone wants to go and it’s not effective either.” But he also said that “going hands off” with street-level enforcement “hasn’t given us what we want either.”
Burlington Detective Sgt. Phil Tremblay told the City Council on Oct. 10 that during a January 2023 bust in Essex Junction, police seized 13,500 bags of fentanyl and more than a kilo of cocaine. Tremblay told the council that the five men from a Philadelphia-based group who were arrested that day had been operating in the Burlington area for a year and a half.
“So you can do your own math in terms of how much drugs, in a year and a half’s time, were coming up and hitting our community,” Tremblay said.
Tremblay and other members of the Burlington Police Department stressed to the council that they are lacking the ability to fully respond to the drug crisis in the city. The answer, they argued, is something they’ve long called for — hiring more police officers.
In 2016, the police department’s street crimes unit consisted of four officers and one sergeant. With many vacancies in the officer ranks, today the unit is staffed only by people who voluntarily choose to work overtime.
The police aren’t the only ones arguing that enforcement is lacking in Burlington’s drug crisis. An open letter written by former Progressive City councilor Jane Knodell and Burlington resident Andy Vota has been making the rounds and gathering signatures in the city, with hundreds of names listed as signers as of Nov. 22. While the letter advocates for a “holistic approach,” it also said that “harm reduction alone will not address this crisis.”
Among the public safety priorities, the authors of the letter write that the city should increase “Enforcement and other deterrence actions against illegal public consumption of drugs and alcohol” that would include drug diversion for non-violent offenders.
Dalton immediately dismissed the push for more enforcement.
“For many years, every politician, every police chief, every governor would say ‘we can’t arrest our way out of this crisis,’” he said. “And now suddenly, we’re starting to hear people who think hey, maybe we can arrest our way out of this crisis. We’ve gotten amnesia around that.”
But even among some Progressive members of the City Council, the plea from Burlington officers seemed to find a receptive audience. After Tremblay’s presentation, Councilor Gene Bergman, P-Ward 2, asked how the department would address “open-air” drug activity. Sitting inside City Hall, he gestured to the nearby City Hall Park, a center of illegal drug activity in downtown Burlington — to support his point.
“I am actually not hearing a plan to deal with what seems to be the impunity that is occurring out our doorstep — the seat of government,” Bergman said, adding later that the drug dealing “is making folks feel that they cannot come to the heart of their city, that they can’t walk from their house to their business, that they can’t bring their kids to the splash pad that we spent so many dollars on.”
Deputy Chief Brian LaBarge said it was an “important question.”
“I’ve been here over 18 years,” he told the council. “I’ve never seen the city in this type of shape and we’re doing the best that we can with what we have.”
‘Built for a hurricane’
Brooklyn, the Chittenden Clinic medical director, said Vermont has a huge number of people seeking drug treatment.
He cited statistics from a federal government survey, the National Survey on Drug Use and Health. In Vermont, about 2.6% of the adult population is receiving medications for opioid use disorder, he said. That figure is 22 times higher than the national average. The bottom line, he said, is that access to treatment in Vermont is robust.
“The problem is that our system was not built for a tsunami, it was built for a hurricane,” Brooklyn said.
To correct that system, Burlington’s mayor argues that it’s time for a “dramatic new focus” from the state.
“There is no way for us to succeed on this issue without clear leadership from the state, which has the public health authority that controls the great enormous resources for working on this issue,” Weinberger said.
Dalton wondered if following Covid-19 many were suffering from “crisis fatigue” and compared the present situation to being in a pot of water as it’s brought slowly to a boil. “You don’t notice it as fast as if you step into it. There’s all these psychological dynamics that have kind of made us in a place where we’re not having the sense of urgency that we need.”
For Brooklyn, he said that Burlington in particular finds itself in a “disaster.”
“I don’t think finger pointing is going to help because I don’t think there’s any one thing that happened,” Brooklyn said. “I think it was just the confluence of things that happened and hopefully we can make some changes but I truly think that we have a lot of treatment now. We could expand it but the system’s not necessarily broken. It just needs to be souped up a little bit.”
Disclosure: Patrick Crowley was employed by the Burlington Fire Department in 2021 and 2022.
