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2017-2018 Issue II Editors' Picks Local

Taking on an Epidemic: Yale’s Researchers Provide Potential Solutions for the Opioid Crisis

Winter 2016—A veteran collapses outside of a West Haven Veteran Affairs (VA) hospital from a heroin overdose; another dies of an overdose in a West Haven facility restroom.

After wartime and American military service, many veterans find themselves with leftover pain, needing medical treatment for relief. But relief arrives in the form of habit-forming opioids, creating a cycle of a pocket-draining addiction. As veterans are often treated with opiates for service-related injuries, adverse side effects arise—creating grave consequences for veterans after military service.

Historically, opiates have commonly been a go-to pain-reliever for military personnel in America. According to CNN, Civil War veterans often injected morphine for pain relief; however, this created an opioid epidemic and the start of military drug abuse. In 1898, Bayer Co. began producing heroin commercially, as people considered it a “wonder drug”. Though effective pain relievers, medical professionals knew little about the poppy-derived drug, and users considered the drug akin to cough suppressants. In 1924, however, researchers discovered the highly addictive nature of such a drug, and thus, governmental push-back and pharmaceutical initiatives have worked to investigate better methods of pain treatment in America, yet we are still enmeshed in this search. (Moghe)

The opioid epidemic still reigns widespread. Opioid dependence manifests itself into portions as high as 26% of patients using opioids for non-cancer related pains.

But veterans are most at-risk for opioid-related addictions. Fifty-percent of older veterans suffer from chronic pain, according to Veterans Affairs officials, and veterans are twice as likely to die from accidental opioid overdoses than non-veterans. Until recently, the U.S. Department of Veterans Affairs almost exclusively treated patients with opioid-containing drugs; in fact, according to a Center for Investigative Reporting’s 2013 analysis, opiate prescriptions spiked by 270 percent over twelve years. (Childress)  In an email correspondence with The Politic, Abbe Gluck, Professor of Law and the Faculty Director of the Solomon Center for Health Law and Policy at Yale Law School, explains that opioids are often “the pain treatment of first resort because they are easy and quick to administer and relatively cheap.”

“Non-drug therapies, such as behavioral therapies, may be more expensive, harder to access and harder to coordinate,” she explains.

Because of these large opioid doses, veterans commonly form addictions, fueling the opioid crisis in America. Veterans suffering PTSD, anxiety, or chronic pain left untreated have higher rates of suicide, yet receiving opioid treatments is also fatal. Yet, opioid prescriptions only provide temporary relief. As Gluck explains, that while opioids are often essential for surgeries and acute pain, “outside of cancer, opioids have not been shown to be effective for managing long-term chronic pain in many other contexts.”

Even when veterans choose the risk of taking opiate pain medications, they only obtain a short-term solution.

However, in an ill-formed attempt to mitigate the epidemic, the VA is ordering a dramatic cutback on opioid medications, resulting in its own fatalities and issues.

Professor of Epidemiology and of Pharmacology and Director of Yale’s Emerging Infections Program, Robert Heimer, who helped host a media roundtable regarding the opioid crisis, stresses the problems with merely cutting back on opiate pain medications with patients already reliant on these medications.

“To talk about recovery from opioid addiction… doesn’t make any sense. You don’t recover from a chronic disease, you manage it. And you don’t manage opioid use disorder by removing people from a medication that their body now needs in order to feel normal,” explains Heimer.

Yale University may be able to find new ways toward reducing the opioid epidemic.

This September, the federal government awarded 9.7 million dollars to the Yale School of Medicine to research nondrug alternatives for pain medication and lead national efforts in doing so.

When asked why the federal government chose Yale University for the grant, Professor Robert Kerns (Professor of Psychiatry, Neurology, and Psychology at Yale University), who is the former director of the VA Pain Management Research Center and co-leads the national resource center for clinical trials on non-drug pain management, explains that “it was a highly competitive process. Over the last eight or nine years…we’ve done a lot of work here at Yale to build our capacities to conduct good science but also promote education and training of the next generation of health professionals, including medical students…and our provider workforce for VA Connecticut.”

Kerns emphasized that PRIME, which stands for Pain, Research, Informatics, Multi-morbidities, and Education Center was the “first federally funded pain research center—a center focused specifically on pain.”

He elaborated on “the incredible investment that Yale has made through informatics and data analytics in the other two centers [PRIME and VA Cooperative Studies Program Coordinating Center], including the Yale Center for Medical Informatics…we put together an application that showed that we here at Yale and the VA Connecticut were best situated to bring all the pieces that were necessary for this new coordinating center in a way that no other university or other organization could compete.”

The grant covers six years of research; the trials include two phases. The first phase includes the demonstration phase in which the center will “build infrastructure and support for the enactment of the trials,” says Kerns, “Contingent on the success of the demonstration phase, then they will move to an implementation phase, which is an additional four years of funding to conduct the trials.”

The first two years include infrastructure and developmental steps while securing projects with the institutional review board—necessary for the conduct of human subjects research—and planning recruitment and engagement of participants in the trials.

The next four years are the conduct of trials themselves.

“Our centers will work in partnership on these twelve trials,” explains Kerns.

One factor that may contribute to the research of nondrug opioids is Narcan or Naloxone, which is medication that rapidly reverses an opioid overdose. In fact, the veteran who collapsed in a West Haven Veteran Affairs was resuscitated by Narcan, known as an “opioid antagonist.” Narcan, a brand name for Naloxone, allows the victim to breathe normally by reversing the depression of the respiratory and central nervous system. Naloxone is both non-addictive and usable by laypeople. Usually, people can administer Naloxone through injections or nose sprays, and it is a temporary drug.

Although long used by emergency medical technicians, movements are working to expand access to the drug to distribute it to first responders, drug users, and their family members.

Heimer lists Naloxone as an integral tool in solving the opioid crisis.

“The answer is to curtail inappropriate opiate prescribing, expand treatment, make sure that there’s enough Naloxone—the antidote for opioid overdose—out there, so that we can minimize the number of deaths while we’re waiting for people to get into treatment,” Heimer answers in a question about steps to solvency.

Naloxone, though only a mitigating tool, can decrease the potential devastation of today’s opioid crisis as we work toward ameliorating the situation.

Kerns highlights that this drug may be extremely beneficial in solving the opioid crisis in Connecticut in America as the team works to find a nondrug medical treatment for pain relief.

“VA broadly and VA Connecticut is pushing hard to provide access to naloxone kits to patients who are receiving opioid therapy and their significant others,” Kerns explains. “It’s a way of giving them a tool to reverse an overdose, an accidental overdose almost immediately… This can help save lives. Nationally, dozens, if not hundreds, of lives have been saved by the availability of this therapy.”

With the research that the Yale School of Medicine conducts, the agenda “seems aimed at investigating those alternative therapies for long-term pain and developing an empirical base to support them,” says Gluck. The team may find methods to utilize Narcan and other less-researched therapies to find a long-term solution to the opioid crisis.

Gluck explains, “The results could provide important data for the veterans community and beyond with respect to the cost, accessibility and efficacy of opioid alternatives.”

However, the Yale School of Medicine’s research cannot stand alone in working toward a better drug situation amongst veterans. Not only must research and science progress, but the government must implement changes as well.

Heimer says, “Whether it’s medication, physical therapy, acupuncture, mindfulness, hypnosis, medical marijuana…or other drugs that aren’t opioids that reduce the underlying problem—inflammation, the autoimmune responses—it’s gonna take a long time to find which is best.” During this research period, governmental institutions need to effect change.

One suggestion Heimer gives is a change in insurance policy, which will not only impact the veteran’s opioid crisis but the general population’s opioid crisis. He suggests in the years of Yale’s and other institution’s research, patients should not need to pay a copay for alternatives methods of pain treatment that require repeated procedures.

“If you have to pay $30 to see someone 3 times a week, that’s a whole lot more money out of your pocket than if you pay $30 to get a renewable prescription for opioids at the cost of one copay,” explains Heimer. He emphasizes the need increased access to these alternative, albeit temporary, methods of pain treatment to reduce fatalities and the number of new patients addicted to opioids.

Though Yale has obtained the 9.7 million dollar grant, whether the results will significantly work toward solving the opioid crisis in the near future is still uncertain.

“It’s going to be a very long time. And the reason is that almost all medical innovation…better procedure or better medication demonstrated in a clinical trial—it takes about 14 years for those things to become a standard of care. It’s also a large social and society-wide problem, it’s going to take those 14 years at least for any new findings…to become a standard of care,” says Heimer.

The grant itself is already a large push forward by the federal government to find solutions to this rampant crisis. If the government continues to facilitate research and discussion on solving this issue, the grant-funded research may initiate change in the current American drug climate for veterans.

If veterans and the general population have access to non-drug, non-habit-forming pain relief, we can reduce the severity of America’s opioid crisis. No longer will veterans need to choose between the untreated suffering of chronic pain, PTSD, anxiety, and other mental health affliction and the risk of opioid addiction if the Yale School of Medicine succeeds in the research toward nondrug treatment.

Soon, those who have served our country will finally have access to the safe, permanent pain relief and care they deserve.