Telebriefing Transcript

Operator: Good morning my name is Carnesia and I would like to welcome everyone to the State Health Commissioner call with media. I would now like to turn over the conference call to Mr. Lipani, so you may begin.

Matt Lipani: Thank you Carnesia. Good Morning Everyone. I’m Matt Lipani, Central Region Public Information Officer for the Virginia Department of Health. Thank you for joining us today for an update on the Opioid Addiction crisis currently affecting Virginia. Speaking today will be Dr. Marissa J. Levine, State Health Commissioner, representing the Virginia Department of Health Professions is Caroline Juran, the Executive Director of the Board of Pharmacy and Dr. Jack Barber, Interim Commissioner for the Virginia Department of Behavioral Health and Developmental Services. Dr. Levine will be our first speaker and once our speakers are finished we will open the line up to questions. Dr. Levine.

Dr. Marissa Levine: Thank you Matt and Good Morning. As you’ve heard I’m here today with my key state agency colleagues for an important announcement about two actions related to the opioid addiction crisis that we are taking here in Virginia.  So I thank you for joining us this morning.

We are here today in the shadow of the Surgeon General’s report on Addiction in America released just last week which highlights the addiction crisis facing Americans and emphasizes the need for: effective public health steps to prevent and treat substance use disorders, shift in attitudes toward addiction and a coordinated effort among multiple sectors at community and all jurisdictional levels to implement proven approaches.

And we are also here on the Monday before Thanksgiving when families, friends and loved ones will be gathering.

So it is no coincidence that I am here with you today because the facts clearly tell us that the consequences of opioid addiction in Virginia have risen to unprecedented levels and can now be classified as epidemic.  Some of the statistics include which bear that out and really tell the story of the people of Virginia:

  • On average, three Virginians die of a drug overdose and over two dozen are treated in emergency departments for drug overdose each day.
  • The number of emergency department visits due to heroin overdose has increased 89% for the first 9 months of the year compared to 2015.
  • During the first half of this year fatal drug overdoses increased 35% when compared to the same period in 2015.
  • And by the end of 2016, the number of fatal opioid overdoses is expected to increase by 77% compared to just five years ago.
  • In addition, our Department of Forensic Sciences just this month identified the presence of Carfentanil in Virginia. This synthetic opioid is 10,000 times more potent than morphine and 100 times more potent than fentanyl and now given its presence in Virginia, could significantly increase the death rate trends from opioid overdoses.
  • And if that wasn’t enough, we have the continuing prescription opioid crisis most prominent in the far southwest region of the Commonwealth where we are additionally concerned about the growing prevalence of hepatitis C and HIV resulting from injection drug use.

With all of these facts, which as I said are really the story of the people of Virginia, all these facts facing us, today I am declaring a Public Health Emergency for Virginia as a result of the opioid addiction epidemic.

This declaration is an effort to raise continued awareness among all Virginians about this worsening problem and emphasizes that we must treat it as a public health issue as we have done for other health emergencies.  Our law enforcement partners have repeatedly claimed that we cannot arrest our way out of this problem.  I have heard them loud and clear and I agree:

  • Now just to be clear this declaration has no force of law and is not a Governor’s emergency declaration. It is also not an attempt to keep opioid medications from those with chronic pain such as those with cancer pain, who legitimately need those medications.
  • In my 14 years of public health experience in Virginia, I have seen time and again Virginians rising to emergencies, coming together to work collaboratively to solve challenging, and complex issues. That is my hope with this declaration- that we come together to build upon the great work that has already started as a result many efforts like the Governor’s Task Force, the actions of General Assembly, the Attorney Generals efforts, the work of the medical and pharmacy professionals and community coalitions around the Commonwealth. We are all working to support families and communities as they help their family members, friends, neighbors and loved ones get the help they need to fight addiction.

So with all of the above in mind I am taking one more specific step in an effort to lower the death rate and prevent deaths from opioid addiction:

  • Today I have signed a statewide standing order for Naloxone – the rescue medicine for opioid overdose. This could only have been accomplished in close collaboration and consultation with the Virginia Department of Health Professions, its Board of Pharmacy and the Virginia Department of Behavioral Health and Developmental Services.
  • This will now allow anyone in Virginia who believes they or their loved ones are at risk of an opioid overdose to buy naloxone at any of our approximately 2000 pharmacies in the Commonwealth without first having to get a prescription.
  • As we speak we have begun distributing this order to the pharmacies. The pharmacy community has been a great partner in this effort and I know they will work diligently to implement this order as soon as possible.  Realize that it may take time before every pharmacy has the order in place so please check with your pharmacy first.
  • Unfortunately the statewide standing order does not cover the cost of the Naloxone but I am confident that our collective efforts will continue to work to make Naloxone available to everyone who could benefit regardless of whether they can afford it.

I realize that this declaration and the statewide standing order cannot in anyway minimize the loss already experienced by so many families as a result of the opioid addiction epidemic.  However if the declaration and statewide standing order save even one life from here on, it will have been worth it.

This Thanksgiving, as we gather around the dinner table, let us be sure we are familiar with the signs of addiction and substance use. You can visit the Commonwealth’s new website VAAware ( which offers resources on how best to discuss addiction with someone you love.  As we take inventory of one another, also take inventory of the medications in our household, let us also be sure to dispose of them if they are unused, expired or unwanted medications in a safe manner. Thanks to the Attorney General’s office, local health departments and other community partners now have drug disposal bags.  You can find a location near you on the Attorney General’s website. Authorized pharmacies and some local law enforcement agencies also collect and destroy unwanted drugs.  As you take inventory this week, if you identify that someone in your life is struggling with an opioid addiction you need to obtain Naloxone to have on hand just in case. And you can learn more about Naloxone as a result of work by our colleagues at the Department of Behavioral Health and Developmental Services through their Revive! Program.  That information is also available on the website mentioned.

I realize that I’m not bring you cheerful Thanksgiving messages you may have hoped to hear, but when we live in times of epidemic and emergencies it’s important to take every opportunity as an opportunity to be prepared and informed. As we have found in every emergency the better prepared and informed we are, the more likely that we will minimize the risk of the emergency and prevent death and suffering. And in the process we build stronger connections with each other and build healthier and resilient Virginians in healthier and resilient communities.  That is what I wish this Thanksgiving and holiday season and I do so hope that you have a safe and healthy Thanksgiving too.

Now I’m going to ask my colleague Dr. Jack Barber to take a few minutes and make some more remarks.

Dr. Jack Barber: Good Morning everyone. We appreciate you all taking the time out of your morning to hear about the declaration and the opioid problem. Dr. Levine provided a number of excellent facts about the state of the epidemic and the losses the people are sustaining. It’s important to keep in mind that in addition to the deaths and emergency room overdoses there’s a toll that each community is paying for those that are addicted but may not be dying yet. There’s a loss of productivity, there’s a disruption in family relationships there are other health risks that Dr. Levine alluded to. So the problem is that deaths are the tip of the iceberg of an increasing problem that’s taking us over.

In order to combat it, it’s important to try to prevent it whenever possible. So we have individuals from the department working with local communities and the community service boards on prevention efforts out of our wellness office to try to particularly prevent young people from going down this path of addiction.

The Department of Health and Health Professions have done a lot of work and are continuing to do that work for safe prescribing, so that doctors are prescribing the medicines in a safe way, for good indications and not combining them with other medicines that increase the risk. Keeping up with the narcotics that are prescribed through the prescription management program. These things are really important.

The stigma that’s faced individuals with substance abuse disorders has resulted in treatment being inadequate and many cases for a long number of years. In the past general assembly session working with DMAS (Department of Medical Assistance Services) there was an increase in access to Medicaid services or individuals with Medicaid services for substance use disorders that had previously been restricted and there were changes in the number of payment rates for services, services to attract more providers. And set the state up to pursue a waiver from CMS to further expand services for Medicaid recipients.

This is an excellent start; it’s by no means an end to the journey though. There are many individuals who do not have access to coverage or to Medicaid and face serious obstacles in getting treatment and paying for it. And the last thing that Dr. Levine mentioned was naloxone, which is the lifesaving medicine that can be given when someone has overdosed to reverse those immediate effects and allow the person to be taken to the hospital and to be treated and to live. And as long as someone is alive then there is a chance that they can recover and overcome this addiction, and often this is the first step on someone’s path is when the face a serious overdose and become aware of how serious and dangerous the problem is.  So people being aware of the signs and symptoms of an overdose and people being able to use naloxone, which they’ll now be able to get much more readily thanks to Dr. Levine’s order is really important.

Otherwise we just lose the person, there’s no chance of recovery and families are left to deal with this as well. I’ll stop there and turn it over to Dr. Caroline Juran who has a few more remarks to make this morning.

Dr. Caroline Juran: Good Morning, thank you. I’m Caroline Juran, Executive Director at the Virginia Board of Pharmacy. So naloxone is a prescription drug. While the current law has allowed for pharmacist to dispense naloxone, pursuant to the standing order for the last couple of years, operationally it requires individual prescribers to coordinate with individual pharmacies to issue a standing order to those pharmacies. This necessary coordination between individual prescribers and pharmacies appears to be somewhat of a barrier for expanding access to naloxone. A statewide standing order issued by the Health Commissioner will remove the barrier and we applaud the Commissioner’s action. The statewide standing order will authorize any pharmacy to dispense naloxone to any interested person who wants to have the drug on hand for administering to a person they believe is either experiencing or about to experience an opioid overdose.

People at risk of overdose, certainly including those who use prescription opioid and heroin illicitly, however those using prescription opioid medically for the treatment of chronic pain are also at risk of accidental overdose. Its rapidly becoming standard of care for those prescribed prescription opioids to also be prescribed naloxone. If pharmacists identify patients on prescription opioids for the treatment of pain who have not be co-prescribed naloxone the pharmacists can recommend to the patient or loved one that he or she obtain naloxone to have on hand in case of accidental overdose and by way of this standing order the pharmacist is legally authorized to dispense naloxone to this interested individual.

The Board of Pharmacy certainly encourages pharmacists to become aware of this statewide standing order, to participate in dispensing naloxone to those requesting the drug and to counsel persons on how to recognize symptoms of overdose and how to properly administer naloxone. We also encourage pharmacists to educate patients on how to properly dispose of unwanted prescription drugs as you heard a few minutes earlier. We know medications leftover in the medicine cabinet serve as a source for those abusing prescription drugs. We applaud those pharmacies that have become registered as an authorized collection site allowing patients to bring their unwanted prescription drugs to their pharmacy for destruction. And we encourage other pharmacies and local law enforcement agencies to serve as collection sites.

Increasing access to naloxone ultimately save lives and provide an opportunity for persons with an addiction to seek treatment. I’ll conclude with those remarks and toss it back to Dr. Levine.

Dr. Levine: Thank you Caroline, Thank you Jack. Matt, I think we are ready for questions.

Matt: Great. Operator we will now open the telebriefing up to questions from the participants.

Operator: If you would like to ask a question please press *, then the number 1 on your telephone keypad. Again that’s * then the number 1 on your telephone keypad. We’ll pause for just a moment to compile the Q and A roster.

And you do have a question, caller please state your first and last name and news/media outlet please. Caller your line is open.

Janet Roach: This is Janet Roach from channel 13 news in Norfolk, Virginia. I was just trying to grab a couple of those statistics again. Was that three people in the state of Virginia died from opioid overdose and the number of people seen in emergency room, can I have those numbers again?

Dr. Levine: This is Dr. Levine. This is on average given the rate we’re seeing, three Virginians die from drug overdose every day and more than two dozen are being seen in emergency departments every day as a result of drug overdose.

Janet: Thank you.

Operator: You do have a question, caller please state your first and last name and news/media outlet please. Caller your line is open.

Kerri O’Brien: Kerri O’Brien with WRIC-TV in Virginia here. I was calling, I had a question about the stat about increases in fatal opioid overdoses, it was 77% increase, what was the time period on that?

Dr. Levine: This is Marissa Levine again. When we look at the trend for 2016, if it continues as we expect it, we’ll have increased by 77% compared to what we saw five years ago, I guess, at the end of 2012, 2011.

Kerri: Ok, thank you.

Operator: You have a question with John Ramsey with Richmond Times.

John Ramsey: Hi, how much is the naloxone going to cost on average at pharmacies.

Dr. Levine: Caroline, do you want to talk about that?

Dr. Juran: There are three different types of naloxone formulations, depending on the formulation it can be as cheap as around $70, on average it might be $120. Again depending on the formulation that’s what you’re paying. It is to our understanding that many of the third party insurance carriers are covering the cost so at that point the patient would be paying to copayment.

John: And so the patients who go in without a prescription can still use their insurance?

Dr. Juran: I’m sorry?

John: So if you go in without a prescription to get the naloxone for a family member they’ll be able to use it without a prescription?

Dr. Juran: Right, the standing order is serving as the prescription if you will. And so therefore it is authorizing the pharmacy to process that prescription claim as they would if the patient had brought in a traditional hard copy written prescription.

John: Thank you.

Operator: If you would like to ask a question please press * then the number 1 on your telephone keypad. Again that’s * then the number 1 on your telephone keypad

Dr. Levine: While we’re waiting, Operator, this is Marissa Levine, let me just mention that we posted my comments which include the statistics on the VDH website so that anybody can refer to those.

Operator: You have a question with Jamie Forzato with WTOP-Radio.

Jamie Forzato: Hi this is Jamie with WTOP. You talked about carfentanil. You’re seeing carfentanil in Virginia; can you tell me where in Virginia you’re seeing that? What regions you’re seeing that and is that just one case or multiple cases?

Dr. Levine: Yes this is Marissa Levine again. We’ve had two reports of carfentanil being identified as I mentioned by the forensic scientist, I assume from samples that were retrieved. I believe it was in the Tidewater region and I’d have to find and check the other region.  So it was two parts of the state and that was just very recently. First time we had identified it in Virginia.

Jamie: And can you talk a little bit about how concerned you are about these synthetics that are flooding the market, some of them coming from china, some of them people can order online. Can you comment on these really dangerous synthetics?

Dr. Levine: This is Marissa again. I would say that I am so concerned that I’ve declared a public health emergency. That’s certainly a significant part of this over and above all the other issues, but it gets to the point that at this point there’s people who are addicted and they’re injecting and they don’t know the potency of what they’re injecting and that’s why I think we’re very concerned about the potential for overdose deaths

Jamie: Thank you.

Dr. Juran: And Dr. Levine this is Caroline Juran again.  I’ll just add also we’ve been very successful in the last year and a half, the Board of Pharmacy working in coordination with the Department of Forensic Science as they are identifying new synthetic chemicals that are not presently scheduled as a schedule 1 drug for instance. They are notifying the Board of Pharmacy and based on the harm that has been seen and the lack of medicinal value for that chemical, the Board of Pharmacy is able to expeditiously place that chemical into schedule 1 which would then criminalize it and that’s been working very well in the last 18 months or so.

Operator: The next question is from Luanne Rife with the Roanoke Times.

Luanne Rife: Hi this is Luanne Rife with the Roanoke Times and I was wondering if you could talk a little bit about the changes with Medicaid as far as covering treatment and who would that cover and would that increase access suboxone?

Dr. Levine: Dr. Barber.

Dr. Barber: So the main action that were taken during the last session were to make sure that substance use disorder treatments was available to all Medicaid recipients prior to that time there were certain services restricted to primarily pregnant women and so all the services will be available to all Medicaid recipients. Then the rates were increased I’m not sure on every particular service to attract more providers to provide those services for Medicaid recipients and then the next steps is to apply to CMS for waivers to allow some more in-patient and residential services to be paid for by Medicaid. That would make those at higher level services more available for individuals with Medicaid.

Luanne: If I might follow up with that.

Dr. Barber: …would not be included in that sorry.

Luanne: so from what I understand, pregnant women can get treatment but once they have their baby they are no longer eligible, is there any effort to continue offering some type of treatment to new mothers?

Dr. Barber: If they have Medicaid then now the services stay accessible to them. If they lose Medicaid then there are other sources of treatment services, but it is more difficult for uncovered people to find the services they need and to have them paid for. They are often not able to pay for them themselves. It remains an impediment for individuals who are not covered.

Matt: Are there any further questions?

Dr. Juran: Hi this is Caroline Juran; I would like to clarify one statement with respect to the reporter that had the question in regards to the pricing. When I indicate an average price of around $120 or so, that is for the narcan nasal spray. Again the different formulations do cost/vary in price. The auto injector is significantly more expensive than that, but the narcan nasal spray is about $120 for a twin pack.  I just wanted to clarify, thank you.

Dr. Levine: Thank you Caroline.

Operator: You have a question from Janet Roach WCVE-TV 13.

Janet: Dr. Levine the carfentanil that you said that has been found in the Hampton Roads area, when you say the presence of it, was this someone who died from an overdose or how did it surface?

Dr. Levine: I’d have to get the details; I believe it’s from materials confiscated through law enforcement action. Those are the substances that are generally tested by our forensic services department, so we can certainly get additional details for you.

Janet: Ok, that will be great.

Matt: This is Matt, Operator we have time for one more question.

Operator: We have a question from Kerri O’Brien from WRIC-TV.

Kerri: Just a question about in terms of treatment, we’ve done a series of stories now here in central Virginia about the opioid crisis and everyone tells us they’ve got waitlist for folks and if you have someone who says I really need help today. The chances are they can’t get into treatment for another 2-3 months. Is there anything on the state’s end that is being done to deal with that issue?

Dr. Barber: I think, and others may want to chime in because the Department of Health and Health Professions is working on this as well. The predominant, immediate thing that was done was to expand those services for individuals with Medicaid, there are other services that are funded by federal block grants and local sources of money and the funding for those I think are fairly stable but not increasing.  There are efforts to increase the number of physicians who can prescribe suboxone so that that particular treatment is more available to individuals and then education of physicians about suboxone and how to use it so they can get waivers. And the number of individuals that can be treated by a physician has been increased by the feds. So there are those efforts to expand treatment, obviously there’s an enormous amount more that needs to be done particularly for the uncovered.

Dr. Levine: This is Marissa Levine. Just to comment back to a prior question, we got confirmation that carfentanil has been found in Fairfax and Hampton Roads. One due to a drug seizure and the other was a result of an overdose. I think that’s it.

Matt: Thank you Dr. Levine, this concludes our telebriefing and I’d like to thank you for joining us today. There is a press release going out today on this as well. It should be in your inboxes and if not it should be there shortly and it will also be on our website in our newsroom section. Again than you for joining us and would also like to thank our operator Carnesia for her assistance on the telebriefing.

Operator: This concludes today’s conference, you may now disconnect.