Since Virginia State Health Commissioner Marissa Levine declared the opioid addiction crisis in Virginia to be a public health emergency in November 2016, efforts — such as improving treatment availability and changing the culture around addiction through education — are underway on the national and state levels to combat the opioid epidemic, a crisis that has escalated in the past few decades.
According to the National Institutes of Health, opioid medications are commonly prescribed in small amounts after injuries and surgeries, acting on opioid receptors in the nervous system to reduce pain. These drugs act as artificial endorphins, which modulate pain by binding to pain receptors. However, using too much causes the nervous system to rely on these artificial endorphins, decreasing the production of natural endorphins. This creates a reliance on the opioid drug to relieve chronic pain. Therefore, these patients become addicted to these opioids, as only opioid medications can alleviate chronic pain that they now experience.
The chronic reliance on opioid medications has resulted in a crisis that many call “the opioid epidemic,” which has penetrated both local and national domains.
In the United States, drug overdose is the leading cause of accidental death with 52,404 lethal drug overdoses occurring in 2015. Addiction to opioid medication is driving this epidemic, and, according to the Centers for Disease Control and Prevention, nearly 115 Americans die every day from an opioid overdose. Similarly, in Virginia, drug overdoses kill more people than motor vehicle accidents and gun deaths, and there were 1,420 deaths related to drug overdose in 2016.
However, Christopher Ruhm, a public policy and economics professor at the University, said the number of drug deaths involving opioids may actually be higher than official figures indicate.
Ruhm has been analyzing death certificates, looking at the record of all deaths from drug overdoses. He found that, in fatal overdoses, multiple drugs — including opioids — are usually used in combination, but the death is not attributed to opioid overdose.
“There is incomplete recording of the overdoses where the deaths are involved,” Ruhm said. “In about 20 percent of drug overdoses, they list an unspecified drug category for the overdose death, but they don’t list the drugs involved.”
Richard Bonnie, a professor of law, public policy, psychiatry and neurobehavioral sciences at the University, said this opioid crisis is not recent and stems from the introduction of morphine in medical practices in the 19th century when physicians were able to finally give patients a true pain reliever rather than less potent remedies like whisky. However, doctors would prescribe morphine for general, mild medical conditions such as headaches, masking the pain rather than treating it.
In the 20th century, pharmaceutical companies created other drugs of the opioid class, including hydrocodone, oxycontin and codeine, while heroin — another opioid — became the drug of choice for poorer individuals. Later, two highly influential articles further perpetuated the over-prescription of opiates. One denied evidence of high addiction rates with prescription of opioid medications while another recommended that pain be included as a vital sign. Vital signs are typically measurable bodily functions like heart rate, blood pressure and oxygen saturation. Including a pain rating for each patient could have resulted in the treatment of pain when it wasn’t necessarily what the patient was being seen for.
In addition, at the national and local levels, several factors have aggravated the crisis, leading more people to depend on opioids. Bonnie said the emotional and physical pain of economic recession, as well as the spread of opioid medications from the legal to the black market have contributed to the scale of this opioid problem nationally.
“What you had is the emerging of the huge market for legitimately prescribed drugs and then the illicit market for opioids … As well as those than began in the illicit market such as heroin and fentanyl,” Bonnie said. “That is totally unprecedented.”
To tackle the magnitude of the crisis, lawmakers at the state and national level are hoping to alleviate this crisis with specific policy implementations. At the national level, there has been a shift from cold-turkey treatment to a more medically based, long-term treatment through methadone maintenance therapy. Methadone is a medication that blocks opiate medications’ euphoric effects by changing the nervous system’s response to pain.
The U.S. Food and Drug Administration asked the National Academies of Sciences, Engineering, and Medicine to convene a committee — chaired by Bonnie — updating the FDA on the opioid crisis and to identify actions to take.
The committee’s framework for the FDA recommended an opioid prescription monitoring program, which is a culture change among prescribers that will provide better access to treatment for opioid use disorder, medications that prevent overdose — such as Naloxone — and increasing access to healthcare through Medicaid expansion.
The committee also suggested a change in the way that individuals view pain treatment through education.
“It takes a long time to educate the public that opioids are not the best solution for their problem and that there are other solutions that people may not have access to like acupuncture, yoga and other non-pharmacological responses,” Bonnie said.
Since declaring the state of emergency with regards to the opioid crisis, the state hosted a datathon, in which the University participated, on Sept. 28 and 29 to investigate solutions to the growing opioid addiction epidemic. Among the many solutions offered at the datathon, the University’s team recommended the implementation of a prescription monitoring program.
Additionally, Dr. William Hazel, secretary of Health and Human Resources from 2010 to 2017, helped co-chair the Governor’s Task Force on Prescription Drug and Heroin Abuse opioid crisis in which 51 recommendations to the state government to relieve the crisis were made in January 2017. The committee recommended creating a program for needle exchange to avoid spreading disease like hepatitis and HIV. Additionally, they have increased the availability of Naloxone by expanding the ability of law enforcement and EMS personnel to carry the drug.
Other recommendations include increasing availability of treatment through creation of a treatment program through Medicaid, educating students and healthcare providers about the proper way to prescribe pain medications, working with law enforcement and changing the culture around drug use.
However, Hazel said the crisis is far from over.
“Churchill made a speech and said that this isn’t the end,” Hazel said. “It’s not even the beginning of the end. It may be the end of the beginning. That’s where we are in dealing with the epidemic.”
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