January 7, 2020
Story By
Bara Vaida
Illustrations By
Chiara Vercesi
On August 16, 2014, 26-year-old Kevin Flattery posted his last update on Facebook. In the photo, Kevin posed in front of a waterfall with a gray T-shirt, sporting sunglasses on top of his brown, wavy hair. The gentle and relaxed smile gave no hint of the inner turmoil the aspiring filmmaker was facing.
That summer, Kevin, who grew up in northern Virginia, was struggling with an opioid use disorder.
Two years before, he had developed an addiction to painkillers while living in Los Angeles. OxyContin, a potent drug derived from chemicals in the opium poppy plant, was easy to find in his Venice Beach community. He used the pills to help deal with the stress and long hours that come with working in Hollywood. Then he became addicted.
When Kevin realized he had a problem, he returned to his home in Mount Vernon, Virginia. His father, Don Flattery M.B.A. ’77, did everything he could to support his son.
He helped Kevin get into a three-month inpatient substance use disorder detox program. He supported Kevin’s follow-up treatment which involved taking the medication Suboxone, a key drug used in opioid addiction treatment that dampens cravings and helps people move into recovery.
Suboxone worked. Kevin, a 2010 graduate of the University of Virginia, got better and moved to New York City, where he had a job at an entertainment company. At the time, neither he, nor his father, fully understood how opioid addiction changes brain chemistry, making relapses almost inevitable. He stopped taking his Suboxone as prescribed.
“My wife and I were naive,” says Flattery. “We thought this job in New York was great and would be a motivating factor to keep him on Suboxone and in recovery, but he manipulated his usage and ended up losing his job. We didn’t understand that relapse is an integral part of addiction, and we wish we did.”
Kevin returned home. He tried other addiction programs, including Narcotics Anonymous, a group support approach which emphasizes abstinence from all medications, including Suboxone. But over Labor Day weekend in 2014, Kevin died of an overdose, leaving behind his heartbroken parents and friends.
“People should have no illusions that opioid addiction could never happen to you or a loved one,” Flattery says. “This epidemic respects no demographics, education or social standing.”
To channel his grief around the untimely death of his son, Flattery became a parent advocate pushing for local, state and federal policy changes to ensure that others won’t face the devastation of losing a child, sibling, parent or friend to a drug overdose.
He is one of seven William & Mary alumni, parents and faculty profiled in this article. They each have played a role in addressing the nation’s most lethal public health crisis since the HIV/AIDS epidemic in the 1980s.
Fighting the opioid crisis is a multifaceted effort involving law enforcement, behavioral and medical treatment specialists and federal, state and local leaders who set public policy.
Between 1999 and 2018, drug overdoses killed more than 750,000 Americans. Overdoses surpass the number of U.S. military who lost their lives in all of World War I, World War II, Korea, Vietnam and the Persian Gulf wars.
“You cannot overstate the magnitude of the opioid crisis,” says Ted Larsen P ’23, the emerging threats coordinator in the White House’s Office of National Drug Control Policy.
Among the first people in law enforcement to put a dent in the epidemic was John Brownlee J.D. ’94.
In 2001, Brownlee was appointed U.S. Attorney for the Western District of Virginia. The district is located along the eastern edge of the Appalachian mountains, and has been the epicenter of the current opioid crisis.
Appointed by President George W. Bush, the Virginia native and former Army Ranger took on the job of prosecuting drug dealers at the moment the first spikes in opioid deaths surfaced. That year, 19,394 people died from drug overdoses, a 15 percent jump from 1999. Some of those deaths were linked to Oxycodone, the principal ingredient in OxyContin, and caught Brownlee’s, and his office’s, attention.
"This
epidemic
respects no
demographic,
education or
social
standing."
“In 2001, there had been some initial assessments among the team that we had prosecuted lots of drug dealers, pharmacists and doctors [for illicit distribution of opioids] but no one had investigated the company that was making and marketing the drug,” says Brownlee. “So we decided to look into it.”
By the early 2000s, OxyContin was a popular painkiller that generated about $1 billion in sales for its manufacturer, Purdue Pharma. OxyContin was introduced onto the market in 1995, right as the medical profession was reassessing its longtime resistance to prescribing opioids for anything other than acute pain or terminal illness.
The World Health Organization, pain specialists and patient advocates involved with the HIV/AIDS epidemic were advocating for more aggressive use of opioids to help anyone with pain. People with chronic pain, they argued, were needlessly suffering and opioids could not only relieve physical suffering, but also reduce anxiety and enable faster recovery.
The movement relied on a few small studies from the 1980s that suggested the risk of opioid addiction was low in hospital settings.
States changed their rules to allow doctors to prescribe opioids more liberally. The Joint Commission, an organization that sets hospital standards, emphasized that pain assessments should be monitored along with the vital signs of a patient’s temperature, pulse, breathing rate and blood pressure. Pain became known as the fifth vital sign. Purdue Pharma argued that its OxyContin was safe and less likely to be abused because addiction risks were low. The company also claimed it manufactured OxyContin to be abuse-resistant.
“None of that was true,” says Brownlee, now chair of Holland & Knight’s National White Collar Defense and Investigations Team in Washington, D.C.
In 2003, Brownlee and his investigators gathered millions of documents and emails, and conducted dozens of interviews, shedding light on the company’s marketing practices and its knowledge that its products were being widely abused. The investigation concluded that Purdue Pharma and its top executives knew that OxyContin could be abused and easily crushed, snorted or injected, causing a high as powerful as heroin.
“The prosecutors discovered sales call notes [from Purdue Pharma reps] and corporate training videos that established that the company was falsely communicating to doctors that there was little risk to prescribing OxyContin,” he says. “We followed the evidence, and it showed that a lot of people were being harmed by this criminal conduct.”
Brownlee’s four-year investigation led to the successful prosecution of Purdue Pharma and its top three executives for falsely claiming that OxyContin was less addictive and less subject to abuse than other pain medications. In 2007, Purdue pled guilty to misbranding its product and paid a total fine of more than $600 million. Its three top executives pled guilty to criminal misdemeanor charges, fined $34.5 million, and were suspended from participating in the industry for 12 years.
The case represented a “shot across the bow” of the industry, says Brownlee.
The company agreed to reformulate OxyContin to make it harder to abuse.
Today, the Centers for Disease Control and Prevention says opioids are appropriate for patients who are in active cancer treatment, palliative care and end-of-life care. But it doesn’t recommend them as routine therapy for chronic pain and advises that clinicians should only consider opioid therapy if the expected benefits for both pain and function outweigh the risks to the patient.
Thirteen years after Purdue Pharma’s guilty plea, unscrupulous physicians are still overprescribing opioids and drug dealers are selling new, even more lethal opioids that are killing people.
After Purdue Pharma was forced to change the formulation of its pills, addicts turned to heroin. Not long after, deaths from illicit opioids spiked higher. Drug dealers began mixing heroin with the synthetic opioids fentanyl and carfentanil. Fentanyl is 80 to 100 times stronger than morphine, and carfentanil, an elephant tranquilizer, is 10,000 times more powerful.
Between 2007, when Purdue Pharma changed the way it made OxyContin and 2017, overdose deaths climbed 950 percent.
At the same time, the opioid epidemic was raging in Virginia.
Last March, Thomas Cullen J.D. ’04 followed the footsteps of alumnus Brownlee by becoming the U.S. Attorney for the Western District of Virginia. Cracking down on opioid drug dealers and physicians overprescribing drugs are among his top priorities.
The district is part of the Justice Department’s Criminal Division’s Appalachian Regional Prescription Opioid Strike Force (ARPO), which utilizes investigators from multiple agencies including Justice, the FBI, the Office of the Inspector General in the Department of Health and Human Services and the DEA.
“We are squarely within the epicenter of the opioid epidemic,” says Cullen.
ARPO, which is constantly monitoring prescribing data and looking for anomalies, unearthed an unscrupulous physician, Dr. Joel Smithers, from Martinsville, Virginia. Smithers prescribed more than 500,000 opioid pills between 2015 and 2017 to patients who sometimes drove in from hundreds of miles away to get prescription pills. In May 2019, Cullen successfully convicted Smithers on 861 counts of drug distribution. The doctor was sentenced to 40 years in prison in October 2019.
But just enforcing drug laws isn’t going end the epidemic, says Cullen. Communities must also pursue a combination of prevention and treatment measures too.
Toward that end, he created a program to encourage local families impacted by the epidemic to share their stories with schools and community groups. He also partnered with the district’s federal public defender’s office to create a federal drug treatment court. Drug treatment courts allow for nonviolent offenders with pending federal drug charges to enter a medicated-assisted treatment program, under the supervision of a probation officer, as an alternative to prison.
“We need to do a better job treating people, instead of having them cycling in and out of jail,” he says.
"The brain
begs for
opioids
because
taking
opioids is
the new
normal.
That is why
opioid
addiction is
so tenacious."
The threat of opioid addiction isn’t new. In the 1800s, opium derivatives like laudanum and heroin were widely used by physicians to help patients with various ailments. By the early 1900s, there were hundreds of thousands of people addicted to heroin, prompting the U.S. federal government to make it illegal.
Researchers have come to understand that opioids work because they connect to brain receptors processing the body’s own euphoric painkillers — endorphins. Opioids boost the body’s natural abilities to block pain, slow breathing and promote calmness. People become addicted to opioids because the drug changes the wiring of the brain.
The body becomes accustomed to the opioid’s ability to create calmness and reduce pain, and thus craves more and more of it. Without the drug, some people’s brains can no longer function normally. It often takes other prescription drugs and counseling to rewire the brain to resume life without opioids.
In 2018, there were an estimated 20.3 million Americans with a substance use disorder, and 8.1 million of them said they had an illicit drug use disorder, according to the August 2019 National Survey on Drug Use and Health.
There are not enough people trained in addiction counseling to help them all.
For example, there are just 2,416 physicians in the U.S. that are credentialed as addiction psychiatrists, and 1,928 primary physicians certified in addiction medicine, according to the American Board of Medical Specialties. Another 7,500 doctors specializing in addiction will be needed to keep up with the need of patients.
That’s why the work of Sara Wang ’18 and Dr. Charles “Rick” Gressard, chancellor professor at W&M’s Counselor Education Program, matters.
Wang plans to become a primary care physician and to emphasize behavioral health as part of her care.
She is currently an evaluation coordinator at Massachusetts General Hospital’s Center for Community Health Improvement, where her team supports community health programs, including local coalitions focused on substance use disorder awareness and prevention.
Wang graduated with a B.S. in kinesiology and health sciences concentrating in public health. She credits W&M’s emphasis on public service and interdisciplinary learning for contributing to her understanding of the importance of the social determinants of health, such as housing, food, education, employment and behavioral health, when it comes to patient care.
“Medicine doesn’t exist in a vacuum, and it isn’t just about what goes on in the clinic,” says Wang, who grew up in Newton, Massachusetts. “If you are choosing to go into medicine today, you really don’t have a choice but to focus on behavioral health. The opioid epidemic touches so many people.”
Wang is in the process of applying to medical schools. She has spent her past year and a half supporting the Center for Community Health Improvement, which collaborates with community partners on health initiatives in many of Boston’s underserved communities.
The center staffs support groups for those struggling with substance use disorders and helps people navigate resources from housing support to treatment. Wang tracks data around services and outcomes connected to the center’s efforts, so that Massachusetts General can improve services and expand programs.
“We conducted a recent assessment of the community’s health needs, and alcohol and substance use remain among the region’s top concern,” says Wang.
As she has been working in public health, Wang has also noticed a promising trend with regard to the approach of responding to addiction.
“There is a new wave of understanding that opioid addiction is a behavioral health issue and should be treated as such, and that it shouldn’t be criminalized,” she says.
Gressard, like Wang, is providing hope to people suffering from addiction. He has been treating substance use disorders for 50 years.
He came to William & Mary in 1993, when the university received a state grant to create one of Virginia’s first master’s programs in addiction counseling. In 2009, he co-founded the New Leaf Clinic, W&M’s on-campus, alcohol and substance use disorder clinic.
Graduate and doctoral students working on their clinical mental health degree staff the center, supervised by faculty in the School of Education.
On the second floor of the Monticello Avenue building, graduate and doctoral students offer counseling services and explore alcohol and drug use disorder issues. Among the techniques that New Leaf’s counselors use to help patients with their addictions is motivational interviewing. The technique is a goal-oriented counseling method that aims to encourage people to change self-destructive behaviors and make healthier choices.
Through the New Leaf Clinic, there are now 100 people who have been trained in substance use disorder counseling and are working in their communities to help others overcome their addictions, Gressard says.
When Don Flattery was looking for treatment options for Kevin, he had trouble finding high quality addiction programs. Further, most of them focused on abstinence. When Kevin used Suboxone, counselors in Narcotics Anonymous shamed him, Flattery says.
“He was told, ‘you’re not really in sobriety,’ or ‘you’re not really in recovery because you are substituting one addiction for another,’” Flattery says. “That bias against medication assistance was keeping people from getting good treatment.”
There has been a long and contentious debate within addiction circles about the best approach for treating opioid addiction. The most dominant approach is the decades old, 12-step model utilized by Alcoholics Anonymous and Narcotics Anonymous. This method underscores that abstinence from all opioids is the only way to truly be in recovery. It isn’t clear from evidence that this approach works for opioid addiction.
Another approach is combining talk therapy and counseling with medication, such as Suboxone. This drug connects to brain receptors the way opioids do, without producing a high. It helps a person through the long and physically painful process of withdrawal. Evidence has shown that medicated assistance treatment (MAT) such as this, cuts opioid overdose deaths by 75 percent, according to the American Society for Addiction Medicine.
However, as of 2018, only 41 percent of the nation’s 12,029 substance use disorder facilities permitted any use of medication for treating those seeking help with their addiction, according to amfAR, a nonprofit that supports HIV/AIDS research.
After Kevin died, Flattery decided to leave his job, and focus his attention on raising public awareness about the opioid epidemic, as well the need for better treatment options.
“I felt so helpless, so I just plunged into advocacy,” he says.
He became a citizen advocate member of the Virginia Governor’s Task Force on Prescription Drug and Heroin Abuse, chaired the advocacy committee of the nonprofit Fed Up Coalition, became a board member of Physicians for
Responsible Opioid Prescribing and became a member of the White House Parent Advisory Council. He also became an informal advisor to Virginia Senator Tim Kaine, who named an opioid treatment bill after Kevin.
Between 2014 and 2018, Flattery pushed for policies to reduce overprescribing of opioids, questioned the FDA approval process of new opioids, helped his local community develop a parent resource toolkit to help others get treatment information, and advocated for lawmakers to make MAT a more standard part of opioid treatment. In 2018, he and his wife left D.C., and moved to a small town on North Carolina’s coast.
He continues to work with local opioid addiction groups in North Carolina.
“Awareness is still needed,” says Flattery. “Fighting the epidemic requires continuous attention and involvement.”
"There
is a new
wave of
under-
standing
that opioid
addiction
is a
behavioral
health
issue and
should be
treated
as such."
Only 20 percent of those who needed substance use disorder treatment obtained it during 2017, according to the National Survey on Drug Use and Health.
Jack Rollins ’09 is working to increase American’s access to substance use disorder services. He is a senior policy analyst at the National Association of Medicaid Directors, the organization that facilitates and augments the federal and state policy work of Medicaid leaders. Medicaid is the joint federal and state health insurance program for low-income Americans.
Around 40 percent of those struggling with opioid use disorder are covered under Medicaid. Though the program covers inpatient and outpatient services, as well as MAT drugs, there are staff and facilities shortages, and treatment still remains out of reach for people who aren’t eligible for Medicaid.
Rollins worked with lawmakers as they debated the SUPPORT (Substance AbuseDisorder Prevention that Promotes Opioid Recovery and Treatment) Act, a bipartisan measure that passed Congress in October 2018. That bill contained language to loosen prohibitions on state usage of federal dollars for substance use disorder treatment.
“As lawmakers were debating the act, they would come to us, and we’d run ideas past our state directors and get their feedback and communicate back to lawmakers,” he says.
Rollins also helps states look for other ways to pay for treatment and prevention programs and to promote the usage of MAT.
A top priority for Medicaid directors is developing tools to measure the effectiveness of addiction programs. The federal government has been prosecuting a growing number of fraud cases against unscrupulous treatment facilities that instead of helping people into recovery, encourage drug use to keep reimbursement money flowing.
“We know we don’t have good quality metrics,” he says. “But we’ll get there.”
Rollins became interested in public health as a philosophy and government major at W&M.
“I came out of college focused on political theory and ethics and had ideas of what our society should look like,” he says. “I thought health policy was where I could translate my high-minded ideas in a more practical way.”
Rollins has been encouraged by media attention on the opioid epidemic and public leaders’ focus on implementing policies to help more people.
“I feel hopeful,” says Rollins. “The public conversation around the epidemic has forced an understanding that there are so many facets to this ... and we have seen leadership from governors and state leaders in a way that we hadn’t before.”
There are some early signs that the epidemic may be easing. Preliminary data from the CDC show drug overdose deaths in 2018 were down three percent from 2017. This is the first decline in decades.
Ted Larsen, father of current W&M student Nicole Larsen ’23, is working to extend that decline in deaths. He is part of the team at the White House’s Office of National Drug Control Policy (ONDCP), that establishes policy goals and priorities for the federal government. The office funds seven federal grant programs to address substance use disorder. Two of the largest and best known are the High Intensity Drug Trafficking Area (HIDTA), which has an annual budget of about $280 million and Drug-Free Communities (DFC) Support Programs, with a budget of $90.9 million. HIDTA provides assistance to federal, state and local authorities to coordinate efforts to combat drug trafficking. The DFC programs are allocated to states and localities to fund education and drug use disorder prevention programs.
Larsen joined the ONDCP in 2019 to work with James Carroll, the office’s director. Larsen, who has an extensive background in counterterrorism, was recruited by Carroll to join the office and focus on future or emerging drug threats.
Prior to the ONDCP, Larsen worked for decades in military intelligence for the U.S. Army around the globe. He retired in 2008 as a lieutenant colonel and joined the Office of the Director of National Intelligence, where he was assigned to the NationalCounterterrorismCenter’sOffice of National Intelligence Management for Counterterrorism and was there until he moved to the ONCDP.
Currently Larsen is developing the criteria to help policymakers and law enforcement identify the evolving and emerging threats on the drug use disorder landscape.
One worry is an expansion in illicit methamphetamine use into the opioid epidemic. Meth abuse has mostly occurred in the western part of the U.S., while the opioid epidemic is concentrated in Appalachia, New England and the Mid-Atlantic states.
Data, however, is showing that people are increasingly mixing meth with illicit opioids, creating a potential deadly combination, according to former FDA Commissioner Scott Gottlieb.
That is worrying to Larsen: “We are in the midst of the opioid and synthetic opioid crisis, but when these are combined with meth or other psychoactive substances, it is a huge problem.”
But he remains hopeful that combined efforts of law enforcement leaders, physicians, public health leaders, parent advocates, and federal and state government officials are working.
“We certainly are not out of the woods yet, but over the last several years, great progress has been made to alleviate the crisis,” says Larsen.
