Thursday, June 15, 2017
Opioids: An American health crisis
Overdose deaths in the United States involving prescription opioids have quadrupled since 1999, according to the Centers for Disease Control and Prevention. Ninety-one Americans die daily from an opioid overdose and more than 1,000 are treated daily in emergency departments for not using prescription opioids as directed. In 2016, Gov. Terry McAuliffe and Virginia Health Commissioner Marissa Levine declared the opioid addiction crisis a public health emergency in Virginia.
At VCU and VCU Health, efforts are under way to combat this public health crisis — through addiction treatment, pain management, health care policy, education and research. This multipart series provides a snapshot of those efforts.
uite a few things make Tavara Webb happy these days: seeing her 6-month-old baby girl develop day by day; being part of her teenagers’ lives; buying a car; and hearing the words, “your urine is clean.”
It’s been almost a year since the Richmond resident has heard otherwise. Webb is part of the VCU Health Obstetrical Addiction Program that treats new and soon-to-be moms with drug addictions, particularly opioid addictions. Clinicians have worked with close to 40 patients since it began in February 2016. The program’s inner workings emphasize a multidisciplinary approach that includes drug treatment, drug counseling, psychology sessions and social-work provisions. After a patient delivers her baby, the team works closely with newborn providers to monitor neonatal abstinence syndrome, and provides social support to mothers once discharged.
Outside of VCU Health, female inmates from Henrico County and Richmond City Jails also participate in the program, based out of the VCU Health Nelson Clinic. Additionally, program clinicians provide care at Riverside Regional Jail and Rappahannock Regional Jail, and coordinate transition of care for inmates once they’re released.
Webb became part of the program after revealing to her nurse that she was addicted to oxycodone while pregnant and a patient at the Nelson Clinic. At the time she was also struggling with homelessness and self-esteem, but said the program has helped her connect with services, manage withdrawal and adopt a well-rounded outlook on her future.
“Prior to me starting that clinic, I felt like there was nothing I could do to get back on my feet,” Webb said. “But, everything was the opposite when I stopped doing the drug.”
What are opioids?
Opioids are a prescription drug most commonly used to medically relieve pain, particularly after surgery or injury. Examples of opioids are morphine, tramadol, oxycodone and methadone. Heroin is also considered an opioid, but is illegal.
Even when used as prescribed, opioids can have serious side effects, including depression, nausea and physical dependence, whereby users have withdrawal symptoms when they stop taking medication. There’s also the risk of tolerance, which leads to users taking more of the medication to get relief.
Today, nearly half of all U.S. opioid overdose deaths involve a prescription opioid, according to the Centers for Disease Control and Prevention. According to CDC data, national death rates from synthetic opioids, including fentanyl, rose 72.2 percent from 2014 to 2015, 33,091 Americans died from opioid overdose in 2015, and 91 Americans die daily from an opioid overdose. Its prevalence in various communities isn’t exclusive and anybody can fall subject to its addiction.
“Opioids work on the part of our brains that cause pleasure by increasing the level of dopamine in our brains. So, each time someone uses opioids, they get a spike in the level of dopamine. That reinforcing pleasurable effect is part of what can cause addiction,” said Sebastian Tong, M.D., a VCU Health family medicine physician who leads the VCU Health Obstetrical Addiction Program along with Mishka Terplan, M.D., a professor in the Department of Obstetrics and Gynecology and Psychiatry and associate director of addiction medicine.
The idea for the program originated after Tong began receiving calls from local correctional facilities asking for help with their female inmates, some with child and in withdrawal from drug addiction.
He wasn’t surprised.
“Based on the increasing drug overdose death rates that I was hearing about in Richmond, and also speaking anecdotally to other clinicians, I suspected that there was a huge unmet need,” Tong said.
Opioids in the news
In November 2016, Virginia Gov. Terry McAuliffe and State Health Commissioner Marissa J. Levine, M.D., declared the opioid addiction crisis a public health emergency in Virginia. The statement was in response to the growing number of opioid overdoses, and issued a standing order allowing all Virginians to obtain the drug Naloxone, which can be used to treat narcotic overdoses in emergencies.
In February, McAuliffe signed four bills into law to address the state’s ongoing epidemic. The bills included one to examine processes for providing local social services to infants exposed to opioids in utero. Because the opioid epidemic has medical and social implications, it’s critical that lawmakers are involved, said Janet K. Abraham, a clinical social worker in VCU Health Women's Health who practices with the Department of Obstetrics and Gynecology.
“So many of these women have social hurdles that drive them to drug abuse before, during and after giving birth,” she said. “Our goal is to align them with the appropriate mental health strategies and social services that position them for success and help them best care for their children.”
VCU Health Obstetrical Addiction Program patients engage in weekly psychosocial counseling and support groups, led by a clinical psychologist along with VCU doctoral psychology students. Patients also see a physician for weekly obstetrical and addiction care. During these visits, eligible patients are prescribed medication-assisted treatment in the form of buprenorphine, a partial opioid agonist approved to treat opioid use disorder. Buprenorphine has been shown to improve abstinence from illicit substances as compared to counseling-only models. A high-risk clinic obstetrics social worker is available to connect patients with resources and the team works closely with the inpatient obstetrics/newborn social workers.
Even with the careful crafting of a program that includes outreach however, Tong said he realizes some things are still out of his control. It’s frustrating, he said.
“Despite having a comprehensive team that includes a social worker and a psychologist, participants often struggle with social needs, such as housing, where there are limited resources,” he said. “If you happen to currently live next door to a drug dealer, it’s much harder to stop using.”
Other specificities, too, factor into addiction tendencies, like genetics and the experience of childhood trauma, said Terplan.
“Most people use or have used drugs and alcohol, however only a minority develop an addiction to the drug. Among people who used heroin in the past year, for example, only 20 percent or 25 percent will meet criteria for an addiction,” he said. “So the question is why some people develop addiction and others don’t.”
Webb was introduced to opioids after suffering a neck injury during a 1998 car accident, two days after she graduated from John Randolph Tucker High School. As a mom struggling with drug addiction then, she can tell the difference in her parenting style now.
“When my older kids where younger, I would say, ‘I can’t wait for them to start walking. I can’t wait for them to start talking,’” she said. “Now, my mind has just been clearer. I’ve gotten a place now. I have a car. Those were things I thought were over for me.”
As she works to stay drug free and rebuild her life, Webb, 36, still attends a weekly psychosocial support group at VCU Health. When she talks about her present-day life, she can feel the stares of those in the group who seem amazed at her progress. When she sees others she knows are still on drugs, she’s amazed, too.
“I see them and I think, ‘Did I ever look like that?’” she said.
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