The painful truth about opioids

The painful truth about opioids

How EVMS is confronting a public-health crisis Illustrations by Elizabeth A. Lane
Skeleton holding a pill bottle surrounded by pills.

Matt began with morphine. Then it was Vicodin. Then Oxycontin.

When 120 pills a month were no longer enough for the 24-year-old, he turned to heroin. That took less than two years.

Matt was fortunate. After eight months of heroin use, the Chesapeake native sought help. “The places heroin took me,” he says, “they were truly scary.”

Now in recovery and drug-free for 13 years, Matt has seen opioid use — and overdoses — soar. So has the Virginia State Health Commissioner, Marissa Levine, MD.

In 2014, fatal overdoses overtook car accidents in Virginia as the most common cause of accidental death. Last November, Dr. Levine declared the opioid epidemic a public-health emergency.

“This past year saw our greatest rise in opioid overdoses,” she says. When the final numbers for 2016 are tallied in July, they’re projected to be in record territory, approaching 1,300 deaths. And nearly 22 percent of those took place in Hampton Roads.

“Organizations and communities need to come together to learn about this,” Dr. Levine says. “This is our critical issue of the day.”

Swinging the pendulum too far

Skeleton with neck

“Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health,” published last year, reports that a record 27 million Americans used illicit drugs or misused prescription drugs in 2015.

And the Centers for Disease Control and Prevention says that the number of opioid prescriptions written in 2012 — 259 million — was four times the number written in 1999. On an average day in the U.S., more than 650,000 opioid prescriptions are dispensed.

“Before the 1990s, we were undertreating pain,” says Antonio Quidgley-Nevares, MD, the Lydia I. Myers Endowed Professor in Physical Medicine and Rehabilitation and Chair and Associate Professor of Physical Medicine and Rehabilitation. “People were suffering unnecessarily. So the pendulum needed to shift for better pain management, but it shifted too far. Now it’s a real crisis.”

It’s also a complicated one. It galvanized leaders in the region’s medical, education and law-enforcement communities to form the Hampton Roads Heroin Working Group last fall. It led state legislators to pass several bills this year that loosened regulations around lifesaving medications for overdoses. It moved Gov. Terry McAuliffe to approve $4 million for a new statewide Addiction Recovery and Treatment Services (ARTS) program that launched in April.

And it prompted EVMS to explore more alternatives to managing pain and expand education about opioids and addiction.

“Addiction is a disease like any other disease,” says Lisa Fore-Arcand, EdD, echoing numerous EVMS colleagues. In her roles as Associate Professor of Clinical Psychiatry and Behavioral Sciences, Education Coordinator and Co-Director of the Addiction Medicine Curriculum, Dr. Fore-Arcand has overseen addiction medicine in EVMS’ medical education since 1994.

“We’re creating a seamless addiction curriculum from first-year medical school through practicing physicians,” she says. For example, third-year medical students doing clinical rotations must find and talk with 25 patients — at least one in every specialty they rotate through — who have addiction issues. “Our students need to become comfortable asking the right questions and having conversations with these patients.”

Stephanie Peglow, DO (Psychiatry & Behavioral Sciences Residency ’14), knows the importance of those conversations. She returns to EVMS in June after finishing fellowships in addiction psychiatry and addiction research at Yale University, as well as earning a Master of Public Health degree. One of her responsibilities could be a program to treat people with opioid addictions, proposed as a partnership between EVMS Psychiatry and Behavioral Sciences and Sentara Norfolk General Hospital.

“EVMS and EVMS Medical Group can partner with local hospitals, patient-interest groups and community leaders,” Dr. Peglow says, “to increase access to treatment and educate other providers in the judicious and evidence-based treatment of chronic pain. We have the resources to be pioneers in treating addiction and combating the stigma.”

Seeing a disease, not weakness

Standing in a pile of pills

Only 20 when he first overdosed on heroin, Chris says the stigma kept him from getting help for 15 more years. “I didn’t know I had a disease,” he says. “I thought I was just weak, like my dad said.”

At 35, Chris went through addiction treatment. Since then, the Norfolk native has lost several friends to the disease. “It’s insidious,” he says. “It isolates you. And it’s a miserable way to live.”

Not only is addiction a disease, Paul Aravich, PhD, Professor of Pathology and Anatomy, takes it a step further. “Addiction is a form of brain injury,” Dr. Aravich says. An expert in brain anatomy, he presents regularly to Congress and the Virginia General Assembly about the ways addiction reorganizes the brain and changes its chemistry.

With 100 million Americans living in chronic pain, Dr. Aravich fears that the pendulum may swing too far back the other way. “We have a moral imperative to treat pain,” he says. “People with cancer and the terminally ill, some of them need opioids to function.”

Yet other patients might respond better to different medications, says Aaron Vinik, MBChB, PhD, the Murray Waitzer Endowed Chair for Diabetes Research, Director of Research and the Neuroendocrine Unit at the EVMS Stelitz Diabetes Center and Professor of Internal Medicine.

For patients with diabetic nerve pain, “I don’t recommend opioids as the first-line medication,” Dr. Vinik says. Their detrimental effects extend well beyond the risk of addiction and overdose. “These drugs markedly interfere with hormone production.” Long-term opioid users often become diabetic and obese, he explains, exacerbating the suffering for which they needed pain management.

Dr. Vinik has led two recent studies on non-opioid pain medications and serves on a national task force that’s developing guidelines for managing pain.

“Pain doesn’t happen in a vacuum,” Dr. Vinik says. About two-thirds of the patients he treats for pain also have depression, and about a third have anxiety. “When you try to relieve pain by just prescribing opioids,” he says, “it’s like being a bull in a china shop.”

“When you try to relieve pain by just prescribing opioids, it’s like being a bull in a china shop.”

Aaron Vinik, MBChB, PhD

Educating primary-care physicians about the range of pain-management options is vital. “I had a patient who tried everything, including opioids,” Dr. Vinik remembers. “Then we treated her with botox, and she was cured. Pain management should be tailored and specific. We have to find the right key for the lock.”

When the “lock” of chronic pain keeps people from living their lives, Skye Ochsner Margolies, PhD, Assistant Professor of Physical Medicine and Rehabilitation, takes a comprehensive approach.

“The physical problem of pain is real,” she says, “but we have to treat the other components as well.” Along with depression and anxiety, other challenges, such as sleep deprivation, the patient’s ability to work and the impact of pain on relationships with family and friends, must be addressed.

Dr. Margolies offers a skills-based therapy group for people in chronic pain, and EVMS Physical Medicine and Rehabilitation recently added acupuncture to its pain-management options. “We’re coming at pain from the biological, psychological and social angles,” she says. “Life may look different with chronic pain, but it can still be meaningful.”

People hugging

Finding a happy ending

Helping others in recovery makes life meaningful for Matt and Chris, who went through addiction treatment. But for people with untreated opioid addiction, staving off the terror of withdrawal is often their life’s focus. If they overdose in the process, the drug naloxone — now available without a prescription — will save them if administered in time. But then what?

“When patients are revived, that’s the prime time for them to learn about treatment,” says Virginia Beach Health Director Heidi Kulberg, MD. The state’s newly launched ARTS program, she says, is a first step toward the multifaceted treatment the disease of addiction requires.

Dealing with relapse is often part of treatment, Dr. Fore-Arcand says, and she emphasizes compassion.

“We don’t get angry at people who have diabetes and eat sugar or with people who have heart disease and eat high-fat foods,” she says. “So, why do we get so angry at people who have the disease of addiction and relapse?”

After 30 years in recovery, Chris says simply, “We are good people who have a bad disease.”

To learn more about opioid addiction in Virginia and resources available to help, visit curbthecrisis.com.