Dr. Karla Lacayo remembers a 21-year-old who was brought in to the emergency room by an alert friend who said she was sleepy. As the triage nurses wheeled her in, she turned blue. With the hallmark symptoms of an opioid overdose—slowing respiratory rate, arousal difficulty, constricted pupils—they immediately gave her naloxone, a drug that reverses overdoses. But, resuscitated, she sat up, pulled out her IV—and walked right out the door, despite being counseled that she had just nearly died of an opioid overdose. “My heart was thinking, this girl will be back … and I hope not dead. Her addiction had taken over her. She didn’t want help. She wanted to use again,” recalls Lacayo, an emergency medicine physician with Novant UVA’s Prince William and Haymarket Emergency Departments and the medical director for the Haymarket Emergency Department.
The incident is alarming, but stories of opioid addiction coming to a head in emergency rooms across the nation—and right here in Northern Virginia—have become increasingly common as dependence on the drugs enters crisis territory.
Lacayo says she and her colleagues have seen “significant increases” in opiate overdoses in recent years, with opioids now the majority of drug overdoses being treated in the ER.
Her anecdotal observations mirror the national and local statistics. In 2017, the most recent year available for statistics from the Centers for Disease Control, more than 47,000 Americans died from an overdose of opioids, which include both legal and illegal forms of them: prescription painkillers, heroin and synthetic fentanyl (which is a powerful opioid similar to morphine but is 50 to 100 times more potent than heroin). That staggering number of deaths is on par with the number of Americans killed in the Vietnam War or from AIDS during its peak in 1995. In Virginia, 1,507 opioid deaths in 2017 put the drug as the leading cause of unnatural death in the state, ahead of firearms-related deaths (which saw 1,041 deaths that year).
Opioid addiction in Virginia, like the rest of the nation, is now considered a major public health emergency. But what is being done about it? Quite a bit in Northern Virginia. Interviews with local doctors, hospital administrators, health officials, nonprofit professionals, first responders and counselors reveal one common goal: to save lives. From new emergency room protocols to police officers trained to recognize overdoses to proactive hospital initiatives, this is a snapshot of the extensive work being done locally to combat the opioid epidemic.
“I’m going to help as many people as I can.”
Nick Yacoub was 10 when his neighbor asked if he wanted to smoke marijuana. He heard, “Wanna be friends?” and said yes. By the time he reached high school, he was taking pills from other kids: Percocet, Vicodin, OxyContin. First arrested at 17, then arrested again by Fairfax PD at 19, his drug use had spiraled into heroin, cocaine, crystal meth. He was also dealing. “[I was] doing whatever it took to stay high … on drugs 24/7.” Drug-detoxed in jail, released and into rehab. He began drinking a fifth to a half-gallon of liquor a day post rehab stint. One night, drunk and swerving on the road, Loudoun County PD arrested him for a DUI. He went into alcohol withdrawal in jail, vomiting blood. “There was no medically assisted treatment, there was a trash can.” He went back into recovery, eventually got sober and, before long, he was leading the support groups. “It was the first selfless thing I’d done. That’s the most important part of my story,” says Yacoub. “Service to others helped me maintain my recovery. I’d taken a suggestion: When you’re feeling angry, sad, depressed, feeling like using, help out someone who’s worse than you.”
Yacoub, now 34, celebrates Nov. 22, 2007, as his recovery date. The Fairfax-Falls Church Community Service Board, support groups, treatment centers, a 104-day recovery program, followed by a sober living residence, all helped him dig out his “skeletons” he says. (He notes the youngest in recovery was 14; oldest, 77.)
Yacoub graduated from George Mason University in 2013 with a psychology degree, and is now working as a certified peer recovery specialist for Fairfax-Falls Church CSB, assigned to the year-old Striving to Achieve Recovery program at the Fairfax Adult Detention Center, where he helps inmates who want to recover from substance use disorder. “These men get a healthy sense of pride. They build support. We help them with release planning, employment and housing.”
“I care about the people in the unit,” says Yacoub, who hopes to expand the program. “We don’t want it to be 1% of the jail. Since 80% of people in jail have a problem with substances, we want to offer it to more people … We help people develop a better lifestyle.”
“The conversation has changed.”
Back when Yacoub was at the height of his addiction, there weren’t many opioid protocols in emergency rooms. But now, as the epidemic has intensified, emergency rooms are often the first line of defense, which is why many local hospitals have instituted programs to recognize symptoms, proactively help patients get treatment and to prevent addiction to a painkiller.
In Novant UVA’s emergency rooms, Lacayo says, to treat pain, the doctors try non-opioid medications, such as non-steroidal anti-inflammatories, acetaminophen (Tylenol) or muscle relaxants. Before stepping up to potentially addictive opioids, they have a number of protocols in place that include checking Virginia’s Prescription Monitoring Program (a statewide database that tracks patient prescriptions of controlled substances), analyzing patients’ past use, searching for emerging patterns (essentially looking at addiction risk) and whether or not the patient has been “medication shopping” at multiple hospitals.
“If they’ve had multiple visits to multiple providers prescribing narcotics, that’s a red flag and we don’t prescribe,” says Lacayo. Even if a patient doesn’t present an addiction risk, doctors will only write a narcotics script for three days.
The protocols are similar at Sentara Northern Virginia Medical Center (SNVMC) in Woodbridge. Dr. Debra Lee, director of the emergency department, says she’s conservative with prescription painkillers (and the hospital also instituted a three-day limit). If she prescribes a narcotic, she talks about the addictive properties, how “infrequent exposure can lead down a slippery slope. Even within a few days of opiate utilization there’s an increased risk.”
Getting addicted, she says, “is not a weakness. These are strong, serious medications.”
She admits, even with precautions in place, the risks are troubling to her. “You go into this profession because you want to help,” yet she worries people with excruciating pain, from a kidney stone or dislocated shoulder for example, may start down a path of addiction if prescribed a painkiller. Though she intervenes in addictions, treats overdoses and serves on a committee to prevent ER narcotics, “No doubt I’ve contributed to someone’s opiate addiction,” she says. “I can’t sleep at night because I want to get them help.”
Lacayo says, “I think there’s much more awareness among providers. We’re much more vigilant about how these meds are prescribed. The awareness of the public, that’s a great thing. I’ve tried to prescribe narcotics when someone’s absolutely needed it, and they’ll say they prefer not to take them. We didn’t see that five years ago. With awareness and resources, we’ll turn this around.”
Lee agrees conversations with patients are easier now. She says, “The conversation nationally has changed and progressed, when [we] give options to patients, they often say they want to avoid it.” She urges people to ask their doctors why certain meds are necessary; check underlying problems first.
“Nothing in the natural world can beat that.”
With so many headlines about the opioid crisis, one may ask: How does someone get addicted? Is taking an opioid for pain management really that dangerous? And is addiction really that quick? The answer, say doctors, is yes, it’s dangerous and dependency can be quick. And, like most addictive substances, it comes down to brain chemistry.
“Any individual given an opioid for an extended period of time will be dependent, and manifest withdrawal,” says Dr. Ash B. Diwan of Piedmont Family Practice in Warrenton. He’s board-certified in family practice, as well as addiction medicine, with 14 years experience treating opioid addictions. But not everyone dependent will get addicted, which is a behavior disorder, he says. Most people are OK for, say, a root canal, with a low-dose for two to three days. (And first line for pain is always anti-inflammatory, such as Advil, or an analgesic, like Tylenol, he says.)
Opioid addiction is physiological, Diwan explains. The brain’s outer core is decision making, morality, choices; the inner part, the limbic system, is survival, feeling good. When the dopamine rises 20 times, you feel good; it reinforces behaviors. Drugs bind to the same reward center, and opioids increase dopamine by 1,000. The inner system supersedes the conscious human outer core. Rewired, the brain is hijacked, changing circuitry. “Nothing in the natural world can beat that, but now you need higher doses to feel normal,” he says. “It takes years to go back to normal.”
Similar to what is happening in emergency rooms, Diwan advocates for a multi-pronged approach: awareness and screening, abolishing stigma, understanding treatment and increasing access to care.
But he also says those in the throes of addiction may also need the drug buprenorphine, which is essentially a low-dose opioid, to control the craving and “to wean the patient down and off” of the drug. Counseling, he says, is also a must.
“The goal is creating a connection.”
In addition to preventive measures, doctors are working to get those already addicted into treatment much sooner.
“Traditionally, at most hospitals, patients who came to the emergency department in need of addiction treatment were discharged with a list of local treatment centers they could try calling for an appointment,” says Dr. Darren Morris, director of clinical operations for emergency medicine, at Virginia Hospital Center in Arlington. “Now, if a patient comes to our emergency room in opioid withdrawal and is interested in treatment, we’ll start them on evidence-based medical treatment with buprenorphine immediately, right on the spot in the ER, and we partner with the VHC outpatient addiction treatment program, Arlington County and other local organizations to directly schedule a next-day appointment. Studies have shown starting this treatment in the emergency department doubles the likelihood of the patient starting and continuing treatment compared to just a referral.”
That’s Inova’s thinking too: Get the patient treatment, stat. The medical center’s Comprehensive Addiction Treatment Services offers inpatient detox and outpatient, a partial hospitalization program, dual-diagnosis programs, sober living and relapse prevention, along with medication-assisted therapies, such as buprenorphine and naltrexone (a similar drug for dependency weaning) injections.
Novant’s Prince William also has a detox unit and an intensive outpatient program for substance abuse and recovery. Virginia Hospital Center has inpatient and outpatient addiction treatment programs and Sentara works with local and statewide centers.
Of course, someone struggling with addiction must want help. That’s why two of Inova’s ERs, Alexandria and Mount Vernon, are running a HERO (Helping to Engage in Recovery Opportunity) pilot, launched last year, where peer recovery specialists talk with patients. “The goal is to create a connection,” says Maria Hadjiyane, senior director of behavioral health adult ambulatory services. “There’s somebody there to say, ‘This is my story, this is how I got help. This is how I got sober. I’d like to help you.’ We’ve had some success with that.”
Novant UVA Culpeper Medical Center also has an initiative where local community organizations provide peer recovery specialists or social workers to work with a patient facing addiction, leading them to treatment, therapy, groups and support.
A Bipartisan Effort
In Rep. Jennifer Wexton’s (D) 10th district, from NoVA to the Winchester area, she’s met with police, providers, advocates, a recovery center and hosted a roundtable on the epidemic. A member of the bipartisan Freshmen Working Group on Addiction, she’s introduced and passed the EFFORT Act in the House to expand research. If passed in the Senate, it would expand opioid research at the federal level. “This is an issue I’ve been working since my time in the state senate. I’ve continued to work across the aisle to find solutions here in Congress,” she said via her communications director. “The opioid crisis has impacted too many families in my district and across Virginia, leaving devastation and heartbreak in its wake.”
In September, President Trump announced $20 million for Virginia for the epidemic. Almost $2 billion in federal grant money is going to states and localities nationwide.
“I was surprised at how quickly it worked.”
The front lines of the opioid crisis aren’t just in hospitals.
Police and other first responders have also found themselves faced with confronting the opioid crisis in a health care capacity. Case in point, they now carry naloxone—the fast-acting opioid overdose reversal drug—and train community members on how to use it.
When a call came over Alexandria PD radio about someone doing CPR on an unresponsive person near Mill Road, narcotics commander Lt. Michael Kochis was nearby. Finding no pulse or breathing, he thought it was too late. The person’s friends said they’d been at a party, so Kochis sprayed naloxone in the victim’s nostrils. The person gasped and coughed as medics arrived.
“I was surprised how quickly it worked,” Kochis says, touting the lack of liability and side effects of the drug if it’s not an opioid overdose. “Any officer would’ve done the same. Medics do this every day.” Virginia EMS workers reported 7,775 uses of naloxone in 2018.
Like Fairfax and Arlington counties, which also have opioid task forces run through the county government, the city of Alexandria’s opioid task force has undertaken a multitude of efforts. The police department created a “recovery bag” initiative in early 2019. When detectives interview a person at the hospital, they give them a bag with a burner phone, preprogrammed to the narcotics unit, treatment and resources. “If we can get these people help right after they almost died, they’re more willing to hear the message,” says Kochis.
Other state and local agencies are also referring people to treatment, forming community partnerships, meeting with treatment clinics and recovery programs, and substance abuse coalitions, to combat the problem.
“Our approach is to get people the help they need,” says Joshua Price, supervisory special agent with the Virginia State Police and coordinator of the Northwest Virginia Regional Drug and Task Force (Winchester and Front Royal area). “No one plans to be addicted.” When they interview those suffering from addiction, some people say they developed addiction from a prescription, some not. The police say they see a lot of heroin overdoses—which is cheaper than legal opioids and easier to get on the street.
The task force’s deadliest year, 2017, saw 40 opiate deaths and 190 injuries. In 2018, there was a reduction, which Price attributes to the increased use of naloxone. But in 42 toxicology results, 40 are fentanyl-related. They’ve had to purchase laser equipment to detect fentanyl (and other controlled substances) to prevent first responder deaths from exposure to fentanyl-laced narcotics.
“I knew something was terribly wrong.”
For the Atwood family, the awareness of naloxone came too late.
“If you knew him for 15 minutes, you’d never forget him,” says Mark Atwood, of his son, Chris, who died of a heroin overdose in 2013, after battling addiction for six years.
The son of an attorney and a personal trainer, Chris was bright, outgoing, popular (he was Reston’s South Lakes High School’s homecoming prince as a write-in in ninth grade). An empathetic listener, he even helped talk two friends out of suicide.
Things spiraled at 15. He’d admitted experimenting with drugs and smoking marijuana since 12. (With anxiety and ADD, he called his head “a never-ending hamster wheel.”) His family took him to rehab. He escaped. They tried a Pennsylvania treatment center and a Utah wilderness program that he liked, and AA and Narcotics Anonymous, but “most of the time we couldn’t tell if he was actively using,” says his dad. Recovering on buprenorphine, he didn’t want to rely on it. He tried to wean himself. In January of 2013, he overdosed and was revived. After another month in rehab, he planned for a sober house.
That’s when his sister, Ginny, drinking coffee at her desk at work, felt something wash over her. “A God moment,” she calls it. “I knew something was terribly wrong, so I went home … and found him.” Chris had a fatal overdose. She wishes she had the reversal drug naloxone, but their family didn’t know of it. “All those rehabs—no one had ever told us about it. A treatment center could’ve written the prescription.”
“Three days later, we knew we had a mission,” says Mark Atwood. “We started the foundation right away.” As executive director of The Chris Atwood Foundation, Ginny Atwood Lovitt says the organization has gotten three state laws—in as many years—passed to increase access. It has dispensed over 15,000 doses of naloxone, trained groups how to administer naloxone, given short-term housing grants—and saved 400 lives.
In 2015, it’s important to note, the Virginia Health commissioner issued a standing order that allows anyone to obtain a prescription for naloxone from a pharmacy without a prescription.
“There’s a tremendous thirst for knowledge.”
For the Atwood family, that crucial element of knowing about the overdose drug was missing. A recent $16 million gift from the Russell Hitt Family for a new awareness program, Act on Addiction, at Inova hospitals is aiming to change that.
Over 1,000 people attended the first summit in October 2019. “There’s a tremendous thirst for knowledge and assistance, and a need for easier access to treatment,” says Dr. Michael Clark, chairman of Inova Health System’s Psychiatry and Behavioral Health and Opioid Task Force.
He notes the nature of the crisis is complicated and changing.
“While opioid prescribing itself has peaked and started to come down a bit, because of efforts on education and limiting prescribing, we’ve seen a rise in illicit heroin use and synthetic opioids like fentanyl,” Clark says.
As fatality headlines warn, heroin’s more highly potent cousin, fentanyl, can be lethal. On the street it might be laced into cocaine, marijuana or meth. Clark also warns about other mixtures, like benzodiazepines or alcohol mixed with narcotics pain relievers. (One SAMSHA report of treatment admissions showed it had increased 570%.)
The limits for prescribing will have “minimal impacts in terms of the total risk pool of patients” consuming substances, he says.
Echoes Diwan, the pain and addiction specialist in Warrenton, “Just because doctors aren’t giving [opioids] as much, it hasn’t slowed down the epidemic … Numbers are increasing with overdose, even though the numbers of prescriptions are coming down.” As police are seeing on the front lines, many are turning to illegal forms of it on the street.
“We can put a large dent and crush this epidemic, but we have to implement effective treatments. Medication is very useful and counseling is equally useful, and if it prevents overdose and death, we’ll keep them on [medication-assisted treatment] as long as required.”
Clark urges a greater need for identifying people, helping them into treatment, and better screening and referring to treatment for those with depression, anxiety and other psychiatric problems, which carry increased risks for substance use disorder. “If you can get [those] under remission, it makes it easier to treat substance use disorder.”
The state of Virginia, along with a number of Northern Virginia counties, are suing Purdue Pharma, owned by the billionaire Sackler family, the makers of prescription drugs like OxyContin. Similar to other states suing, the suit alleges Purdue convinced Virginia doctors to prescribe millions of opioid pills, downplaying addiction risks. The state is also suing Teva Pharmaceuticals and Cephalon, alleging similar claims about products that include fentanyl. While Purdue has reached a settlement with more than 20 states for billions of dollars, as of press time, the case with Virginia was still ongoing.
“We’re on the right track, but there’s a lot more we need to do.”
The stats on young people and opioids are particularly troubling. NICUs often treat babies born to addiction (in Virginia, eight babies per 1,000 births are born with neonatal abstinence syndrome), while people ages 20 to 24 were seen in emergency departments for fentanyl/heroin overdoses more than any other age group. In 2016, 3.6% of adolescents ages 12 to 17 reported misusing opioids in a nationwide survey. In Fairfax County’s 2018 youth survey of eighth, 10th and 12th graders, 2.9% said they’d misused a prescription pain reliever in the last month, a decline from 4.4% in 2017.
“The bad news, 2.9% represents 900 students,” says Dr. Benjamin Schwartz, director of epidemiology and population health for the Fairfax County Health Department. “We asked in the survey why they’d used painkillers. More said to relieve pain than to get high.” With prescriptions in medicine cabinets, “This is a problem we can solve. It’s not like breaking up a drug cartel. We need people to not store in the location where it could be misused.”
Schwartz stresses all ages are at risk in all parts of Virginia; it’s not just in urban or rural areas. “Fairfax County, despite the wealth, is not spared the risk,” he says. He wants people to realize opioids take a greater toll than other causes of unnatural death here. “In the last five years, the number of deaths have taken off.”
With the highest total number of deaths in the state (thanks to a large population), Fairfax created an opioid task force in January 2018. The coordinator, Sarah Bolton White, shares five priorities: education; prevention and collaboration; early intervention and treatment; data and monitoring; and harm reduction.
“I’m humbled by the amount of damage this does to people’s lives. At focus groups at treatment facilities, I’ve heard stories of lives getting ruined, how incredibly difficult this is to beat. I have a ton of respect for people trying to beat this,” Bolton White says.
For people who have already lost someone, the concerted push by hospitals, county governments, organizations came too late, but it’s undeniable how much work is being done to save more lives, to prevent more tragedy, to find hope in the crisis. Chris Atwood’s sister says she’ll continue to work toward that goal. “Their lives have value,” says Lovitt of the people her brother’s foundation aims to help. The work, she says, helps to “keep Christopher alive. He knew intellectually heroin had ruined his life, and he hated it. But his brain was saying no. His brain had learned that opioids are necessary for survival.”
Does this Virginia Tech researcher hold the key to a vaccine?
The National Institutes of Health’s National Institute on Drug Abuse recently awarded Dr. Mike Chenming Zhang, a professor of biological systems engineering at Virginia Tech, with a two-year, $3 million grant to develop a vaccine to counteract opioid addiction. NIH could add $5 million and three more years to the grant.
The vaccine is aimed at preventing the drug from getting to the brain. Working with a team of collaborators and grad students, the experiment involves injecting mice with the vaccine to see if they produce antibodies toward particular opioid molecules.
“We’d been studying the vaccine with nicotine. Nicotine molecules are small, like opioid molecules. Small molecules don’t illicit immune response in human bodies. But the more antibodies a vaccine can generate, the more small molecules can be prevented from entering the brain,” says Zhang.
At a recent NIH meeting, Zhang heard the testimony of a mother who lost her son. “As a researcher, you feel her pain. As a parent of two boys, I feel her pain as a loving pain. I cannot imagine the parent losing the child, nothing is more painful than that,” he says. When he received the grant, starting work in July 2019, “We were very thankful, happy we could potentially do something to help people with their loved ones, help the nation address the opioid crisis. If we can save a life, it’ll be rewarding.”