The first and only time that Nikie Martin tried to get high on fentanyl, she and her husband passed out in the car from its potency.
She considers herself lucky that was her only experience with the drug — a synthetic opioid up to 100 times stronger than morphine — that has rapidly become the deadliest in Virginia, killing 813 people in 2018, up from 770 in 2017, according to data released this week by the state medical examiner’s office.
The spike in fentanyl deaths comes as overall drug overdose deaths decreased from the previous year for the first time since 2012, though the annual death toll was still higher than every year on record except for 2017.
In the two years since Virginia rolled out the Addiction and Recovery Treatment Services, or ARTS, program, an effort to increase access to substance use recovery treatment, more people are being diagnosed with substance use disorder and are receiving addiction treatment, and fewer people are visiting the emergency room for and dying of drug overdoses, facts that state officials see as evidence that the program is beginning to move the needle on an addiction epidemic that has taken thousands of lives.
The goal of the program is to reach more people like Martin, who first tried heroin shortly after graduating high school and later switched to pain pills. For more than a decade, she battled with her addiction — sometimes staying clean for periods, including while she was pregnant with her son, Noah — and then falling back into drug use when the stress of an abusive boyfriend and sick parents pushed her to a breaking point.
The cycle continued until two years ago when Martin, a Henrico County native, became the fourth patient accepted to VCU Health’s MOTIVATE Clinic. The clinic was among the first in the Richmond area to open under the ARTS program.
“It completely changed my life,” Martin said. Although she’d been to other rehabilitation programs before, the personal attention she received at MOTIVATE Clinic made it feel safe, she said. “It was hard to find a place to go and find that support, and I finally found it. There is not one day I feel like messing up.”
One of the key components to launching the ARTS program was to increase the Medicaid reimbursement rate for services that use medication-assisted treatment, combining medicine that prevents withdrawal symptoms and counseling to help people in recovery. In the program’s first year, the number of medical providers offering substance use treatment rose from 1,087 to 2,965.
With Medicaid expansion, which went into effect Jan. 1, an estimated 60,000 people with substance use disorder will be newly insured through Medicaid, increasing their access to treatment.
An evaluation of the first 15 months of the ARTS program by Virginia Commonwealth University School of Medicine’s Department of Health Behavior and Policy, which the state hired to monitor the program’s outcomes, found that Virginia is “well prepared” to provide treatment to new Medicaid members. It also noted a 10 percent increase in Medicaid members diagnosed with a substance use disorder and a 16 percent decrease in opioid-related emergency department visits among members, according to Peter Cunningham, who is leading the evaluation.
“We know that the ARTS program is working,” said Dr. Jennifer Lee, the director of the Department of Medical Assistance Services.
For all Virginians, overdose-related emergency department visits dipped for the first time since 2015, down from 17,420 in 2017 to 15,782 in 2018, data from the Virginia Department of Health show.
Although these indicators show a positive trend, Cunningham said his team will need at least another year of data on overdose deaths before it can determine the program’s success at curbing the addiction crisis.
“Ultimately, that’s going to be the measure of success,” Cunningham said. “Are we saving lives?”
Drug overdoses killed 1,484 Virginians in 2018, according to preliminary data, a 3.4 percent decrease compared with 2017 — the first time the number has decreased since 2012, when 799 people died of an overdose. Still, drug overdose remains the leading cause of unnatural death in the state.
Fatalities have been driven by opioids, which caused or contributed to death in more than 80 percent of last year’s fatal overdoses. Fentanyl was involved in 55 percent of overdose deaths, and illicit opioid deaths have continued to increase after surpassing prescription opioid deaths in 2015, according to the medical examiner’s report.
Cocaine- and methamphetamine-related deaths also increased in 2018.
The city of Richmond had the most deaths caused by opioids in the state last year, with 91. Chesterfield County was the only locality in the region to see a year-over-year increase in drug deaths in 2018, up to 75 from 68.
But measuring success in the fight against addiction goes beyond the death toll, Cunningham said. His team will also be tracking relapses, ability to find and keep employment, and other social and personal achievements.
“There are so many other people who suffer from addiction that are going to have bad outcomes other than a fatal overdose,” he said. “We’re going to look at this holistically.”
Approaching addiction as a whole is one of the keys to treating it effectively, said Dr. Mishka Terplan, an addiction medicine physician and director of VCU’s MOTIVATE clinic.
He said that, while there’s still much that medicine doesn’t know about the brain and substance use disorder, research shows it has similar relapse and recovery rates to other chronic diseases such as cancer and diabetes.
At the clinic, he has seen his patients turn their lives around, get jobs and be reunited with their kids. He has also seen people go back to using.
But, so far, none of the roughly 800 patients at the clinic has died of an overdose.
In his experience, the right combination of medication — such as buprenorphine, which helps patients avoid withdrawal symptoms — and personalized counseling give a person the best chance at recovery. He also makes sure all of his patients have naloxone, the overdose-reversal drug.
“It’s about relationships,” Terplan said. “The goal is recovery … however someone navigates that.”
Martin, one of the clinic’s first patients, remembers that when she first called the clinic, the receptionist gave her Terplan’s phone number. He responded to her within 10 minutes.
Martin has a job, she’s appealed to the governor to get her criminal record expunged, she and her husband are looking at buying a house, and she’s focusing on raising her son to avoid the mistakes she made.
The 33-year-old said she gives credit to God, her 9-year-old son and the treatment she receives at MOTIVATE Clinic.
And while Lee, the state Medicaid director, celebrated the progress of the ARTS program and the leveling-out of overdose deaths, she acknowledged that there is still much work to be done.
The agency is working to increase outreach to pregnant women and populations that are at a higher risk for substance use disorder, such as those in jails and prisons, as well as to attract more treatment providers in areas of the state that lack them, like Southside and far Southwest Virginia.
Meanwhile, Cunningham and his team at VCU will continue to monitor the program to track its successes and challenges, particularly as new Medicaid members flood the provider network this year.
“Before ARTS, there was very little for substance use disorder for Medicaid. We kind of went from zero to something much greater than zero in the space of about two years,” Cunningham said. “Now, with Medicaid expansion, we’re going to see much bigger increases in utilization and demand. We all have to make sure that the system is capable.”