By any measure, the opioid epidemic in the U.S. is a complex and major crisis. From the precipitous rise in overdose deaths and increasing rates of hepatitis C infections to a foster-care system overwhelmed by the children of families unable to care for them, “The scale of this problem is even more serious than we think now,” says UVA law and medicine professor Richard Bonnie (Law ’69), and it is “only getting worse.”
But across the University, a broad community of researchers and clinicians is dedicating expertise and resources to address the problem from an array of disciplines.
A system failure
This crisis has been in the making for years and will require many more to resolve, Bonnie says. Those were among the findings of a recent study on the epidemic chaired by Bonnie and commissioned by the FDA. With a committee of experts in public health, ethics, medicine and law (with consultation from UVA law professor Margaret Foster Riley), the study set out to characterize the epidemiology of the epidemic, assess the FDA’s role in contributing to the crisis, provide an update on knowledge and practices in pain and pain management, and offer recommended actions. The committee’s report, “Pain Management and the Opioid Epidemic,” released last July by the National Academies of Sciences, Engineering, and Medicine, found that the epidemic grew from a convergence of factors, including a broad failure within our country’s health-care system to both understand and address chronic pain and to recognize the potential catastrophic impact of wide-scale prescription of opioids.
As the committee’s work documents, drug overdose is now the leading cause of accidental death in the United States, with more than 63,000 deaths in 2016, most of them involving opioids. And research published last year by public policy and economics professor Christopher Ruhm in the American Journal of Preventive Medicine suggests that even these numbers likely represent an underestimation of the actual mortality rate. The unique factor driving this trend, however, and a key finding from the National Academies study, Bonnie says, has been “the inevitable intertwining of the legal and illegal markets.”
As Bonnie explains, valid concerns within the medical community about the undertreatment of pain played a role in sparking the epidemic; between 1999 and 2015, sales of prescription opioids increased nearly fourfold, with 259 million prescriptions written in just one year during that period. “It is totally unprecedented to prescribe that many of these substances,” says Bonnie, and it was inevitable that some of this flood of drugs would find its way into the illegal market, where heroin and more potent synthetic opioids like fentanyl are also found.
“It is totally unprecedented to prescribe that many of these substances.”
The enormous number of opioids being prescribed, however, also led to an increasing incidence of addiction, called “opioid use disorder.” One study from Blue Cross and Blue Shield documented a nearly 500 percent increase in OUD diagnoses among its members between 2010 and 2016. Some with OUD moved from prescription drugs to cheaper and more easily available illegal drugs; in 2015, deaths from illicit opioids such as heroin and fentanyl overtook those from prescription opioids, a trajectory that continued a sharp upward climb in 2016. And the National Academies study points out that “a majority of heroin users report that their opioid misuse…began with prescription opioids.”
Yet, as the study also points out, we still have a poor understanding of pain, pain management, and susceptibility to OUD. Chronic pain, Bonnie says, “is a serious public health problem on its own” and must be addressed in order to turn the tide on the opioid epidemic. The study calls for more research to find the “balance between the needs of people in pain and the impact on society of putting these drugs in the marketplace,” he says.
New approaches to pain management
One initiative within the UVA Health System is addressing that balance, with surprising and encouraging results. It began with the recognition that all patients who come for surgery are at risk for developing OUD, explains Dr. Bhiken Naik, an associate professor of anesthesiology and neurosurgery in the School of Medicine. With this knowledge, he says, the health system committed itself to trying to reduce the use of opioids in surgery through a combination of approaches, including using more non-opioids and instituting protocols designed to reduce the systemic trauma of surgery, called enhanced recovery after surgery (ERAS). Originally developed in Europe, Naik says, ERAS change several standard practices before, during and after surgery—such as no longer requiring patients to fast overnight and allowing them to resume a normal diet the day of surgery. ERAS implementation has been demonstrated to speed recovery by reducing patient stress, rate of complications and length of hospital stays.
A study recently completed by Naik and two fellow anesthesiologists confirmed the success of this effort. The doctors reviewed the records of all patients who came for surgery from 2011 to June 2016—every case at UVA. Over this time, the amount of opioids given during surgery was cut nearly in half. And yet, the doctors found, patient pain scores after surgery actually declined by nearly 2 points over this same period, from an average of 5.13 to 3.29 on a scale of 1 to 10.
“That was a shocking revelation,” Naik says. “We were quite surprised and amazed that we could reduce opioids and reduce pain scores.”
While this approach to pain management has proved broadly effective, Naik says, the physicians’ next major focus will be personalizing medicine for each patient. “Pain cannot be treated in isolation,” he says. “Pain is very influenced by different psychological and social and cultural factors.”
Treating individuals and communities
These factors help explain why the epidemic has hit hardest in rural communities, like those in Southwest Virginia, that are also struggling with economic hardship, higher rates of serious and chronic illness, and lack of access to health-care and addiction-recovery services.
Research conducted by Dr. Megan Gray (Res ’16), a second-year infectious disease fellow in the School of Medicine, has found a nearly sevenfold increase since the early 2000s in the number of patients presenting at UVA’s hospital with infective endocarditis—a serious medical condition—related to injection drug use.
“Fifteen years ago we rarely saw these infections, and now we see them every week,” says Dr. Rebecca Dillingham (Res ’02, Grad ’07), an associate professor of medicine and director of the University’s Center for Global Health. And most of these patients have come from Southwest Virginia, a region now identified by the CDC as at high risk for an outbreak of HIV also related to injection drug use.
“We are often uncomfortable talking about social determinants of health in our country, and yet these factors have a terrible effect on communities,” she adds. A two-day public symposium in the fall organized in part by the center looked at how communities could organize to respond to the epidemic.
Among the takeaways from the conference was the need to destigmatize OUD so that people feel safe to ask for help. “No one wakes up and says, ‘I want to be addicted,’ ” says Dr. Kate McManus (Grad ’12, Res ’13), an assistant professor of medicine in infectious diseases and international health in the School of Medicine, who also helped organize the conference.
That stigma may account in part for why Gray’s research also found that only half the patients admitted for heart-valve infection from injection drug use had any kind of referral for addiction treatment documented in their medical charts.
“The stigmatization of substance use disorder is a huge barrier to being able to care for the whole person,” Dillingham says.
Of great urgency, too, will be prioritizing resources to make health services available in communities where they are most needed—conclusions that echo the findings of the study chaired by Bonnie. “The barriers to providing medically based treatments for addiction have to be removed, and that is going to be costly,” he says.
With the continued national political debate over health-care funding, and in the wake of passage of the tax bill, however, the availability of such resources, and the political will to commit them, is far from certain.
“National leadership is critical on this,” Bonnie says. Given the magnitude and the severity of this crisis, he says, we need a sustained, multifaceted and intensive response. “We can’t lose interest in this after it loses the headlines.”