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W.Va. Receives $4.4 Million To Fight Opioids

Federal funding was awarded to West Virginia in response to the overdose risk from fentanyl and other opioids.

The U.S. Department of Health and Human Services’ Health Resources and Services Administration announced $4,404,303 in awards to rural communities in West Virginia on Thursday.

“We designed this program to really help rural communities get this kind of support they need to expand access to opioid use disorder treatment, to address the critical needs of families, who are struggling with addiction issues to focus on prevention, treatment and recovery,” Carole Johnson, the administrator of the Health Resources and Services Administration of the U.S. Health Resources and Services Administration said.

These investments aim to expand access to medication to treat opioid use disorder and prevent and address neonatal exposure.

Expanding Access to Medication to Treat Opioid Use Disorder: $2,000,000 will support two awards to rural communities to establish treatment sites for individuals to access medications to treat opioid use disorder. The use of medication to manage opioid use disorder is the standard of care, but not always readily available.
Preventing and Addressing Neonatal Exposure: $2,404,303 will support five awards to develop and implement interventions in rural communities to prevent, treat and care for opioid exposed infants by focusing on systems of care, family supports, and social determinants of health.

Award recipients include the Marshall University Research Corporation, the West Virginia School of Osteopathic Medicine Clinic, Inc., Community Care of West Virginia, Inc., the Logan County Commission, Southern Highlands Community Mental Health Center, Inc., West Virginia Perinatal Partnership Inc., and the West Virginia University Research Corporation.

Appalachia Health News is a project of West Virginia Public Broadcasting with support from Charleston Area Medical Center and Marshall Health.

Lawmakers Weigh Opioid Treatment Options

Legislators heard from board members of the private donation-funded opioid treatment center Lauren’s Wish during the first interim session this week.

Between March 2021 and March 2022, West Virginia reported 1,403 fentanyl overdoses. In 2021 alone, there were 1,253 opioid overdose deaths in West Virginia, 83 percent of which were fentanyl-related.

Ed Boyle, director of Facilities at Lauren’s Wish, said his organization’s board members, all of whom have been affected by the state’s opioid crisis, found a gap in the opioid overdose recovery process.

“Through this pain and recovery process, these six directors met over a year-long process of studying where as a society we seem to be failing the youth of this state and our communities,” Boyle said. “We came up with the idea of Lauren’s Wish Addiction Triage Center.”

When an individual overdoses and is taken to the emergency room, they are given Narcan and stabilized. Some hospitals have peer recovery coaches to set the person up with a bed in a treatment center, but that bed might not be available for a week or more. That leaves the hospital to discharge the patient back into the environment in which they overdosed.

Boyle said the board of directors at Lauren’s Wish termed the pattern, “treat and street.” To avoid this cycle, Lauren’s Wish Addiction Triage Center was opened as a 28-bed facility at Hazel’s House of Hope in Morgantown.

Dr. Kevin Blankenship is the Medical Services Director of Lauren’s Wish and founder of Jacob’s Ladder, another private patient-centered recovery program located in Aurora, West Virginia.

“We’ve got lots of beds available in West Virginia but most of those are 30-day programs, at best,” Blankenship said. “What I saw was missing was long-term treatment and that’s what Jacob’s Ladder is. Jacob’s Ladder is a six-month treatment program, that then transitions into another three to six months of sober living. The reason for that is because addiction takes time to heal from. Your brain can heal from this, but you’ve got to give it the right environment.”

Blankenship noted the same gap in treatment between an overdose treatment in an emergency room and treatment and recovery bed availability. He also said 28 days is not enough time to heal from opioid addiction.

“If you’re a doctor or a lawyer or an airline pilot, you’ll be entered into a program for two to five years for your addiction, right? For everybody else 30 days, you should be good,” Blankenship said. “They’re not good and we’re not planning for them after they’re done with their 28-day program. So the program itself is too short. There’s nowhere for them to go afterward.”

Programs like Lauren’s Wish and Jacob’s Ladder need to be duplicated throughout the state, Blankenship recommended to lawmakers.

“This is a necessary program,” Blankenship said. “You probably need four or five of these around our state, regionally located so that different ERs and hospital systems can take advantage of that. It’ll take a load off of our EMS system, it’ll take a load off of our ERs, the folks in there can take care of the heart attacks and the brain bleeds that are coming into the door, instead of devoting all their time to this.”

According to Boyle, Lauren’s Wish has had 152 clients go through their system and be placed in an aftercare or recovery process like a sobering center or medium or short-term rehabilitation stays.

Blankenship said the Jacob’s Ladder program has been in existence for seven years and has a success rate of 75 percent. He credits the program’s success to the time they give their patients to heal, noting the first two weeks of a 28-day stay would be spent in withdrawal.

“There’s something to be said about time when you’re talking about healing the brain and that’s what addiction is, it’s a brain disorder that can be healed with time and the appropriate treatment,” Blankenship said.

Del. Heather Tully, R-Nicholas, asked Blankenship how Jacob’s Ladder is able to keep track of their patients years into their recovery in order to study the outcomes of this type of treatment.

Blankenship credited the strength of the alumni community of Jacob’s Ladder for a portion of their long-term success but also noted the organization has weekly and monthly contact with each person and is able to tell if they’ve relapsed or struggling.

“That doesn’t mean that none of them relapse,” Blankenship said. “The difference in a relapse from a graduate from Jacob’s Ladder, for instance, versus someone who had spent 28 days, is you find out about it immediately, as soon as they use they’ve picked up the phone, someone’s noticed something, they didn’t make a meeting, they didn’t make a commitment that they had. We know pretty early on. And it’s so much easier to deal with that type of a bump in the road, rather than a full-blown relapse, where you’re out six months, using again.”

Blankenship said the cycle of the 28-day treatment model is inefficient and costly.

“The unfortunate part about the 28-day [treatment], and I hate to even suggest this, but they’re incentivized to have folks relapsed and come back because they can just keep billing, you know, you can’t go for longer than 28 days,” Blankenship said. “But if you relapse next week, come back, I got four more weeks I can bill for. So they don’t really have the incentive to make sure that these folks are out there doing healthy things for the next 10 years, which is what our goal is.”

Del. Amy Summers, R-Taylor, referenced a presentation from an earlier meeting of the Legislative Oversight Commission on Health and Human Resources in which Cindy Beane, commissioner of the Bureau for Medical Services, testified to the implementation of Senate Bill 419 from the 2022 West Virginia Legislative session.

“It’s very difficult for a residential provider to basically track that person who is now not even in the county that they treated the person in a whole other county that might be across the state,” Beane said. “So it’s very difficult for the expectation of the bill for somebody to basically track somebody three years down the road.”

Senate Bill 419 directed the state Department of Health and Human Resources, through the Bureau for Medical Services, to establish a pilot project to evaluate the impact of certain post-substance use disorder residential treatments in West Virginia.

“We had a presentation yesterday through a committee where recovery treatment centers, as you say, are possibly incentivized to have people come back because that’s how they make money,” Summers said. “They think that it’s too difficult to be able to follow people because they say when they leave, they leave and they don’t have the technology to do it. It sounds like you make a phone call.”

Blankenship said the graduates of Jacob’s Ladder are like a family and schedule face-to-face time with one another to check in for coffee or lunch. Also, to enter into the program, the person has to be serious about their recovery. He also noted that 80 percent of people who go through a 28-day program will relapse within three months.

W.Va. First Foundation Plans Next Steps

West Virginia has received $340 million of its current total settlement amount of $867 million from lawsuits against opioid makers and distributors.

The legislature created the West Virginia First Foundation to distribute those settlement funds in the 2023 regular session. Senate Bill 674 legally recognizes the creation of the foundation which was signed into law on March 11.

The foundation will handle 72.5 percent of the state’s settlement funds, while 24.5 percent will go to local governments. The remaining three percent will be held by the state in escrow to cover any outstanding attorney’s fees.

Steven Travis, general counsel, Office of the West Virginia Attorney General testified before the Joint Standing Committee on Health during the first interim session of the year.

“With the passage of Senate Bill 674 and it being signed into law, the next steps for our office is continuing to work in conjunction with the representatives of the local governments to draft and finalize the articles of incorporation, which is the legal document that will create the foundation, Travis said. “I am happy to report that those drafts are in, we believe, near-final form.”

“That money is currently being held in a series of qualified settlement fund accounts, which are fully protected guaranteed accounts such that, at an appropriate time that money can be distributed to the local governments as well as the foundation,” Travis said.

Once the articles of incorporation are finalized, an executive director and board members will be chosen.

The foundation will include eleven board members. The governor will appoint five, and six will be selected by local governments across designated regions. Each board member will serve a three year term.

Del. Mike Pushkin, D-Kanawha, asked Travis how regional directors will be chosen and if the population of each region will be taken into account.

“As the memorandum of understanding stands, the municipalities or counties would select a representative to attend a meeting where nominees would be voted on,” Travis said. “It will be weighted by virtue of the distribution percentages under the MOU such that the percentages within a region will be adjusted so they equal 100. So that if, let’s say, for instance, a county were to receive 25 percent of the total dollars within that region, then their vote would constitute 25 percent.”

The state has a pending claim against Kroger which is set to go to trial on June 5th.

FDA Approves Nasal Naloxone For Over The Counter Use

Until recently, Narcan was only available with a prescription, but the Food and Drug Administration (FDA) has approved a specific naloxone product for use without a prescription: a four-milligram naloxone hydrochloride nasal spray.

Naloxone rapidly reverses the effects of an opioid overdose and is considered the standard treatment.

Lindsay Acree is the Pharmacist-In-Charge at the University of Charleston’s Patient Care Clinic, PharmUC, and an assistant professor in the pharmacy department.

“The motivation is that we’re seeing more and more overdoses,” Acree said. “You know, just because you don’t use a substance doesn’t mean that you don’t have a friend or a family member that doesn’t, so I think that it gives people the opportunity to have it with them, for individuals that they may encounter that have overdosed.”

Narcan nasal spray was first approved by the FDA in 2015 as a prescription drug. As part of the process to change the status of a drug from prescription to nonprescription, the manufacturer provided data demonstrating that the drug is safe and effective for use without the supervision of a healthcare professional.

Still, some worry about the lack of training in using naloxone, but according to Acree, a helpful label will show how to use it.

“Anytime something goes over the counter, it has to be labeled in a way that anyone can understand it, basically,” Acree said. “I mean, it has to be regardless of their level of education, they have to be able to understand how to use it safely and effectively.”

Some advocates, like Amy Saunders, the managing director of Marshall University’s Center of Excellence for Recovery, worry about the unannounced cost of over-the-counter Naloxone nasal spray.

“I think it’s going to maybe make it more accessible to a lot of lot more different types of folks, and in a lot of different types of places and venues,” Saunders said. “But I think the price is going to be really important for us to kind of understand that piece.”

After the FDA’s announcement, Sen. Joe Manchin D-WV released a statement applauding the drug’s approval.

“In the last year, more than 106,000 Americans and 1,400 West Virginians died from drug related overdoses,” Manchin said. “Given the enormous scale of need, it has never been more important to adopt opioid overdose prevention and reversal strategies on a wide scale. Naloxone is an immeasurably valuable resource for our fight against the drug epidemic, and it is proven to be safe and effective for public use. I’m thrilled to see the FDA take this meaningful action to make naloxone available over the counter, which helps reduce stigma and encourages the widespread use of this critical medication during emergencies.

‘Tranq Dope’ Arrives In W.Va.

Xylazine is a non-opioid agent linked to a growing number of overdose deaths across the country. As a non-opioid, the drug poses a threat to humans, in part because it does not respond to typical revival methods like Narcan.

Appalachia’s ever-present and ever-evolving opioid epidemic has a new cutting agent on the block: xylazine, a sedative medication meant for veterinary use, that is now being mixed into illicit supplies of opioids and fentanyl.

The U.S. Drug Enforcement Administration recently issued an alert warning of a “sharp increase in the trafficking of fentanyl mixed with xylazine,” which is also known as “tranq” or “tranq dope.”

In January of this year, the New York Times reported from Philadelphia, an epicenter of xylazine use, on the devastating reality for people who shared first-hand accounts of using the drug, whether intentionally or not.

Leigh Brooks, medical director of the medically assisted treatment program at Bluestone Primary Care in Princeton, West Virginia, said she has seen positive xylazine tests in her patients since August 2022, noting that she never sees xylazine without fentanyl also present.

“When I talked to the patient about it, she had no idea that what she ingested was xylazine,” Brooks said. “So that kind of sparked my interest. As far as you know, if one patient’s got it, I’m probably going to have multiple patients that are going to come back with that xylazine.”

Brooks said her biggest concern is how to educate her patients to handle the side effects of xylazine, given its resistance to Narcan.

“It creates a longer lasting high when people do ingest it with fentanyl, even though we don’t think that they’re actually going out on the street saying, ‘I want xylazine,’” Brooks said. “On the streets, it is called tranq dope. What is happening is it’s just being cut with some of these illicit drugs. So people don’t really know that they’re ingesting them.”

Joshua Schrecker is the senior director of Clinical Affairs at Aegis Sciences Corporation, a toxicology and medication monitoring laboratory that has been tracking the use of xylazine for years.

“We had the prescription opioid epidemic, and then it became the illicitly manufactured fentanyl epidemic,” Schrecker said. “And now we’re seeing adulteration of illicit opioids, traditional illicit substances, like cocaine, with sort of a hodgepodge, or mixing of drugs, kind of at its foundation. The reason that these substances are oftentimes added to other drugs is they have somewhat similar effects on the end user.”

Some who obtain the mixture think they’ve purchased an opioid and are surprised to wake hours later, craving the opioid high more than ever, according to Brooks. The drug has also been shown to cause large open wounds when used by humans, sometimes leading to amputation.

“We do know that some of the side effects that happens is dry mouth, they get drowsy, at first, an increase in blood pressure and increase in heart rate, then heart rate, lowers blood sugar goes up, patients develop hypothermia, and then they go into respiratory distress,” Brooks said. “And also at the injection site, they can get necrotic tissue at those injection sites.”

Necrotic tissue means dead body tissues. Xylazine kills the tissue where the drug was injected.

“Where it’s not a human drug that was never designed for human use, it’s not on the controlled substance list, because it’s a veterinary medicine,” Brooks said. “And that’s another reason why it’s kind of like appealing for the illicit market to use xylazine in a mixture is because the fact that it’s not controlled, it’s lower costs, but also lower risk of law enforcement scrutiny.”

Federal lawmakers including Sens. Shelley Moore Capito, R-W.Va., and Joe Manchin, D-W.Va., recently introduced the “Combating Illicit Xylazine Act” to classify the drug as a controlled substance, among other measures.

“Prescription drugs very much stay the same over time, you know, there might be one or two new drugs that are approved, that we’ll begin testing for, but within the kind of subset of these novel and synthetic illicitly manufactured compounds, they shift and move all the time,” Schrecker said. “When a drug is either internationally or nationally scheduled, the pattern that we typically see is that scheduling occurs, that positivity will drop off, and it becomes replaced with a new substance that’s very similar, acts in a similar manner.”

While most experts agree that scheduling the drug as a controlled substance is the next step, researchers, scientists and physicians alike brace for the next new filler agent to emerge on the illicit market.

“No matter what they take off the street, what drug taskforce takes off the street, how they re-schedule, different medications, that illicit market is so financially driven from, like the cartels, and other illegal activity, that they bounce back with something with bigger, stronger, faster,” Brooks said.

Brooks said her clinic would be most helped by obtaining Clinical Laboratory Improvement Amendments (CLIA) status. To be CLIA waived means being able to test for all substances in the sample in a timely manner, in the office.

“In the state of West Virginia, I cannot do a point-of-care urine drug screen for fentanyl,” Brooks said. “We’re very much behind the curve, that right there is of the utmost importance that gets changed to where just my standard drug test cups will have fentanyl in it so I can be able to test for fentanyl because you never see xylazine without fentanyl.”

In medically assisted treatment settings, like Brooks’, these tests are vital to caring for her patients. A full panel would allow Brooks to treat her patients in a timely and effective manner.

“The illicit markets going nowhere,” Brooks said. “It’s here to stay. It’s one of the things where we have to manage it. And I really do think that you have to kind of look at it from an economic perspective of how to manage that market.”

Federal, State And Local Officials Warn Against ‘Tranq Dope’

Federal authorities are calling the emergence of fentanyl mixed with xylazine a public safety threat.

The U.S. Drug Enforcement Administration issued an alert Monday warning of a “sharp increase in the trafficking of fentanyl mixed with xylazine,” which is also known as “tranq” or “tranq dope.”

Xylazine has flown under the radar of federal officials because of its status as a veterinary drug. Meaning, it is not a controlled substance and therefore not subject to review by federal authorities.

The United States Food and Drug Administration (FDA) originally approved xylazine in 1972 as a sedative and analgesic for use in veterinary medicine.

Xylazine is a non-opioid agent that’s been linked to a growing number of overdose deaths across the country. As a non-opioid, the drug poses a threat to humans in part because it does not respond to typical revival methods like Narcan.

Leigh Brooks, the medical director of the medically assisted treatment program at Bluestone Primary Care in Princeton, W.Va., has seen firsthand the effects that xylazine and other novel psychoactive substances (NPS) have had on people’s lives.

“I see a positive xylazine test, probably one or two a week and this has been since August of 2022,” Brooks said. “But we do know that some of the side effects that happens, like dry mouth, they get drowsy, at first, an increase in blood pressure and increase in heart rate, then heart rate, lowers blood sugar goes up, patients develop hypothermia, and then they go into respiratory distress. And also at the injection site, they can get necrotic tissue.”

Federal authorities are calling the emergence of fentanyl mixed with xylazine a public safety threat.

Joshua Schrecker is the Senior Director of Clinical Affairs at Aegis Sciences Corporation, a toxicology and medication monitoring laboratory that has been tracking the use of xylazine for years.

The DEA reported 23 percent of fentanyl powder contained xylazine in 2022. Despite this alarming report and many others about the rise of xylazine, federal, state, and local law enforcement do not have the tools necessary to effectively monitor its spread or put prevention measures in place.

On Tuesday, federal lawmakers, including Sens. Shelley Moore Capito and Joe Manchin, introduced the “Combating Illicit Xylazine Act” to classify the drug as a controlled substance, among other measures.

The Combating Illicit Xylazine Act, if passed, would:

Classify its illicit use under Schedule III of the Controlled Substances Act.
Enable the DEA to track its manufacturing to ensure it is not diverted to the illicit market.
Require a report on the prevalence, risks, and recommendations to best regulate the illicit use of xylazine.
Ensuring all salts and isomers of xylazine are covered when restricting its illicit use.
Declaring xylazine an emerging drug threat.

Xylazine is essential in veterinary medicine with large animals. According to Sen. Manchin this legislation would not infringe upon the rights of veterinarians, farmers, cattlemen or ranchers.

“In the last year, more than 106,000 Americans and 1,400 West Virginians died from drug related overdoses,” Manchin said. “It’s heartbreaking to lose so many of our fellow Americans and West Virginians to this devastating epidemic, and Congress must take meaningful action to address the crisis, which includes the surging threat of the highly dangerous xylazine drug. I’m proud to introduce this bipartisan, bicameral legislation to ensure our law enforcement agencies have the tools they need to monitor and control the spread of illicit xylazine, while ensuring its continued access for veterinary medicine.”