Courtesy Jonathan Gonzalez, Unsplash
Photo by Jonathan Gonzalez via Unsplash
The impact of overdose deaths in the commonwealth is chronicled in reports from the Chief Medical Examiner’s Office of the Virginia Department of Health. A report updated in July projects another record year of overdose deaths in Virginia. First Quarter 2021 data projects 2,576 Virginians will die of drug overdoses this year. Last year set a record, with 2,308 drug fatalities. Overdose deaths have been on the rise each year since 2010, when the state reported 690 drug-related fatalities.
A key tool in battling opioid addiction in Virginia is being put to use by Medicaid recipients, with more than 46,500 Virginians battling substance abuse making use of Addiction and Recovery Treatment Services in 2019. A study released in July by the VCU School of Medicine looked at access, use and quality of care in the program from 2016 through 2019. Addiction and Recovery Treatment Services participation increased by 79% from 2018 to 2019, when Medicaid coverage was expanded in the commonwealth. The increased usage reflects expanded coverage, but the treatment services also were accessed more frequently by people who were previously enrolled in Medicaid. Researchers report that addiction treatment in longer-term Medicaid recipients more than doubled from 2016 to 2019. Opioid treatment rates in the group receiving addiction treatments also doubled, from 32.1% in 2016 to 65.9% in 2019.
“I think that’s great, that there’s been a big expansion in that,” says Dr. Gerard Moeller, director of the Virginia Commonwealth University Institute for Drug and Alcohol Studies, who also acknowledges that the increase in resources has yet to translate into reduction in overdoses.
So what’s going on? Why are numbers of overdoses continuing to rise even as access to treatment is easier?
The ultra-potent synthetic opioid fentanyl is a primary culprit in more overdoses and deaths. Other factors at play include the pandemic and related stresses such as anxiety and depression, job loss and isolation, Moeller says. “Because of the stress, they are using more of every substance,” he says.
Fentanyl, which is showing up in a range of substances, including heroin and cocaine, “has overwhelmed the effects of access to medications,” says Moeller. “It’s really disheartening.”
The spike coincided with the pandemic, but increases in fatal overdoses became evident in the later part of 2019, says Peter Cunningham, a co-leader on the Medicaid expansion evaluation and a professor in health behavior and policy at the VCU School of Medicine.
Fentanyl was the driver in that surge, he says. “It seems to be more easily available, and it’s really kind of taken over from more conventional forms of heroin in what’s driving the current epidemic. It’s in everything,” Cunningham says.
It is the culprit in many of the overdoses in Richmond, according to Julie Karr, opioids coordinator for the city of Richmond and Henrico County Health Districts. She notes in an email that of 215 overdose deaths last year in the city, 189 involved fentanyl. Opioids accounted for 94% of fatal overdoses in the city.
Karr notes that Richmond was already experiencing a major surge in overdose deaths before COVID-19 first surged locally in March 2019. Deaths from overdoses spiked to 37 in the last three months of 2019, then 43 in the first three months of 2020. There were 172 over the remainder of the year. Demographically, the fatal overdose rate among Black people in Richmond rose from 55.5 per 100,000 in 2019 to 100.4 per 100,000 in 2020. The overdose death rate per 100,000 in white people in Richmond rose from 46.3 to 73.7, according to Karr.
“There are a number of factors at play, and it can be difficult to say what exactly did and didn't contribute to the increases in overdoses during the pandemic, but it is a continuation of a trend we were beginning to see take shape prior to the pandemic,” she says. “Reduced access to treatment and care, increased unemployment and housing instability, stress, and isolation all increase vulnerability to overdose, and without question were conditions many people have experienced in the last year and a half.”
In Treatment
Medication-assisted treatment is a key to treating substance use disorders, Moeller notes, along with getting patients to remain in the programs. He cites studies that show that people enrolled and participating in such programs are far less likely to die from not just overdoses, but a number of other conditions and issues, than their peers.
Moeller says VCU and some other health care providers have become more aggressive in reaching out to patients to screen for opioid use disorder when they come into the health system, oftentimes in an emergency room setting. About 80% of the referrals follow through, according to Moeller.
But patients who arrive in an emergency room because of an overdose are a challenge; they weren’t actively seeking medical treatment on their own, they were using opioids, and the next thing they knew, they were awakening in an ER. Only about a third of those patients are ready to engage in treatments, he says.
The Medicare expansion evaluation assessed the program through 2019 but is ongoing. Cunningham says 2020 data is being analyzed. “You could expect there could be a leveling off, not a decrease, but a slowing of the increase of overdoses as the pandemic seemed to ease, but I don’t think we know that yet,” he says.
Cunningham notes how the opioid epidemic has evolved. It started about a decade ago with over-prescribing of legal opioids, and measures were taken such as tightening prescribing guidelines and mandating drug monitoring. That “kind of solved that,” he says, but heroin and fentanyl came increasingly into play. “It’s been a bit of a whack-a-mole,” he adds. “[We] got a handle on one problem, but once that got under control, we saw the heroin and fentanyl kick off.”
Expanded treatment services help, but they do nothing to prevent the problem. Cunningham says that entails a comprehensive approach, dealing with everything from criminal and law enforcement to mitigating economic and social factors. “It’s almost a whole-of-society effort,” he says.
