Brandi Fincham died twice before paramedics could revive her. She remembers a brief moment of resuscitation in an ambulance and waking up later at the hospital in shock. It took two doses of naloxone, which reverses the effects of a heroin high, to bring her back.

“I was too scared to admit I had a problem,” Fincham said. “My parents didn’t know. No one knew until it got out of hand.”

Fincham is living proof of how pernicious and undiscriminating opioid addiction can be. She graduated high school with a 3.68 grade point average, managing to hide issues with drugs like marijuana and cocaine, and eventually went to work as a certified nursing assistant in West Virginia. Then a friend introduced her to oxycodone, and she got hooked on the high it offered. That’s when her life began to unravel.

When she ran out of options for getting painkillers off the books, she started writing prescriptions for herself under her doctor’s DEA number. Pretty soon, she was fired from her job and attempting to put the pieces back together.

While in a recovery house in Virginia, another resident introduced her to heroin, a cheaper drug offering the same kind of high. It nearly cost her life. Her brush with death gave her the resolve to stay in recovery, but the road has been winding and difficult. Today she’s a recovery coach and office manager for Clean Life Medical, an outpatient addiction treatment practice in Richmond.

Fincham’s success at battling addiction offers a rare glimmer of hope among the staggering number of tragedies as the rise in overdose deaths continues. For the first time in Virginia’s history, more people are dying from heroin and prescription painkiller overdoses than from car crashes. In 2015, around 1,000 deaths were reported. According to the attorney general’s office, Virginia is on track to match or exceed that number when the books close on 2016.

Heroin and prescription drug abuse — and the fatal overdoses that follow — cuts across all demographic and geographic lines. There is no typical heroin or opioid addict. This addiction doesn’t care whether you’re black, white, Latino, or Asian. It doesn’t care about your income level or where you live. It’s not a rural, urban, or suburban problem. Heroin and opioid abuse is a national problem, and Virginia is not immune.

Recognizing the scope of this national issue in Virginia, Richmond Law students at the Public Interest Law Review convened a symposium in September. The event brought together prosecutors, public defenders, and medical professionals to discuss the science of addiction, the scope of the epidemic in Virginia, and the new legal and policy approaches needed to remedy the crisis. Virginia Attorney General Mark Herring, L’90, delivered the keynote address at the symposium, Virginia’s Opioid Epidemic: Treatment and Policy in the 21st Century.

After taking office in 2014, Herring learned about the scope of Virginia’s problem on a listening tour around the state. Since then, he’s been talking a lot about the opioid crisis — with people in recovery, prosecutors, public defenders, medical professionals, nonprofit leaders, and lawmakers.

“So many families say they never thought it could happen to them,” Herring said. “Listening to their stories and seeing how much pain and devastation they’re going through is heartbreaking, and it committed me to doing everything I could to make sure it doesn’t happen to one more family in Virginia.”

Herring’s office prioritized the crisis in Virginia through a plan that pursued the supply side through partnerships with federal, state, and local law enforcement agencies, particularly in Hampton Roads, a region whose ports are often a byway for drug smugglers and suppliers.

The partnership has seen some successes at cutting off the supply. In 2015, the multi-agency collaboration led to the bust of a heroin trafficking ring in Hampton Roads responsible for the distribution of between 30 and 90 kilograms of heroin with an estimated street value between $1.5 million and $4.5 million. Collectively, seven defendants were sentenced to more than 136 years in federal prison.

But prosecuting dealers and distributors of heroin is only part of the solution. Local law enforcement officers told Herring early in his tour that this is not a problem Virginia can arrest its way out of. In fact, there’s a new momentum for treating addiction as a medical problem rather than a criminal issue.

“Something as simple as a sports injury or dental work or a back injury can expose a person to prescription painkillers, which can lead to dependence and addiction,” Herring said. “And when the pills run out, they do something they never, ever thought they would do — they turn to the cheap, potent, and often deadly heroin available on the streets.”

Virginia's new prescription for the opioid crisis
A 40-minute documentary called Heroin: The Hardest Hit from which these stills are taken, is among the efforts Virginia is making to change the mindset of how people think about addicts. Experts believe removing the stigma associated with addiction will increase support for the most effective recovery options. The film can be seen at hardesthitva.com.

Treatment and prevention of addiction is complicated when it comes to opioids, a class of drugs that includes both the illicit drug heroin and common, legally prescribed painkillers like oxycodone, codeine, morphine, and fentanyl.

The drugs target opioid receptors on nerve cells in the brain to create pleasurable effects and relieve pain. That particular chemical dynamic makes them highly potent and easily addictive, according to James C. May, director of planning, development, research, evaluation, and substance use 
disorders services for the Richmond Behavioral Health Authority.

May’s experience observing addiction started in a lab. He was involved in planting drug delivery systems into the brains of rats. In the most illustrative trials, he remembers training rats in a small box to push one lever for food, and then adding another for water. Once the rats were trained on both the food and water levers, a third delivering an opiate substance was introduced.

“The rats would stop pressing the bars for food and water and would just press the bar for the opiate until their arms were feeble and bleeding. And they would stop eating until the end,” May said. “I saw something happening that just blew my mind. I look back many years later; that was my first exposure to what addiction does to the brain.”

That pathological pursuit of reward and relief isn’t a biological response confined to lab rats. It’s one of the major factors that contribute to a diagnosis of substance use disorder for 1.9 million Americans.

“That’s what we have going on in the streets today,” May said. “We have people who don’t understand how addictive opiate substances are, and every day they get up and they’re chasing the drug. Sometimes they’re not eating or drinking water.”

Prescription practices haven’t helped. In 2012, health care providers wrote more than 259 million prescriptions for opioids, more than enough to give every American adult a bottle of pills. Among new heroin users, four out of five report misusing prescription painkillers prior to using heroin. Legal opioids are often easier to get initially, but when the brain gets hijacked — and users change priorities to seek rewards from the high — all bets are off.

In Richmond, heroin has been the No. 1 illicit drug of abuse since 1999.

“This isn’t new to us,” May said, “but the scope is new.”

And it differs throughout the state. Southwest Virginia has a prevalence of prescription opioid abuse, while other areas have seen an uptick in heroin. Every locality has been affected.

Timothy Coyne, L’86, is the public defender for the city of Winchester and five counties in rural northwest Virginia. In his area of the state, home to 230,000, deaths related to opioid overdoses have been on the rise. In 2012, it had one death attributed to opioids in the area. In 2014, that number had climbed to 33, and in 2015, it had 30 deaths. In one week last September, it had eight nonfatal overdoses.

Local prosecutors and public defenders acknowledge the problem has grown over the past 15 years to epidemic proportions. Increasingly, illicit drug manufacturers and dealers are cutting heroin with other substances to expand the supply and increase the street value. One of the additives, fentanyl, is a synthetic opioid largely to blame for the increase in overdoses. It’s 50 to 100 times more powerful than morphine, making its mixture with heroin an often deadly combination for users who don’t know the strength of the drugs.

We have people who don't understand how addictive opiate substances are, and every day they get up and they're chasing the drug. Sometimes they're not eating or drinking water.

Henrico Commonwealth’s Attorney Shannon Taylor, L’95, recalled a mother’s comments to the Richmond Times-Dispatch: “It’s not that kids haven’t been abusing drugs; it’s that kids are abusing drugs that are killing them.”

In her role as county prosecutor, she’s eager to find ways to connect people who suffer from addiction disorders to the recovery community.

Part of that solution, Taylor said, is expanding access to drug treatment courts. These judicially supervised entities exist in 30 localities in the state and have been successful in dealing with people charged with drug offenses and nonviolent property crimes. The rate of new convictions for drug treatment court participants is around 34 percent compared to 53 percent for people who do not participate in drug treatment. While treatment courts won’t solve all of the problems, they have shown success at keeping people out of prison and on the road to recovery. Graduation from drug court requires a year in the program, which includes access to community services boards and regular drug screening; an ability to recognize relapse triggers and an action plan to deal with the temptation to use; four months of sobriety; and full-time employment or enrollment in school.

It’s a different legal response than during other emerging epidemics. Taylor and Coyne both recall that the reaction to the crack epidemic in the early ’90s was to increase mandatory minimums.

“What’s encouraging now is that people are realizing that addiction is a disease and treating it as such,” Coyne said.

Education is a key part of that effort to change the mindset of how people approach addicts. They are mothers, fathers, sons, and daughters who could be any one of our family members. Removing the stigma of addiction is an ongoing challenge to opening up recovery options.

In 2015, the attorney general’s office sought to take on that effort and produced a 40-minute documentary, Heroin: The Hardest Hit, which features stories of people in recovery and of the families of those who died. The film has been viewed more than 50,000 times online, and DVDs have been distributed throughout the state to middle school and high school classrooms. A recently launched website, hardesthitva.com, provides access to the documentary, facts about the opioid epidemic and deaths in Virginia, and connections to recovery resources.

Herring has attended screenings throughout the state, often watching the documentary alongside people in recovery. He said the success of this film has been its intentional strategy to disrupt an overly simplistic narrative — that “drugs are bad, don’t do them” — with the faces and stories of Virginians affected by this crisis.

Virginia's new prescription for the opioid crisis
Stills from Heroin: The Hardest Hit. Mark Herring, L'90, Virginia's attorney, general, is shown above right.

A collaborative approach to combating this problem has been a key piece of Herring’s plan. He formed a regional task force in Hampton Roads to solidify the partnerships that have been fighting on both the supply and demand fronts.

The recovery community also has been an important voice for ideas and policies that can help people struggling with addiction and the community services that they need.

Naloxone, a drug that reverses the effects of opioid overdoses, is now more widely available because of legislation that took effect in July 2015 allowing pharmacies to dispense it with fewer restrictions to citizens. First responders have also worked to ensure ample supplies for their service calls.

The state has also created safe reporting laws to try to remove any misgivings people may have about calling for help when an overdose happens and provide an affirmative defense against criminal charges for them when calling to seek medical assistance.

Among the greatest hopes for those in the recovery community is easier access to treatment, including same-day services. If someone battling addiction seeks help, he or she often can’t afford to wait days or weeks to enter treatment. Time could be a matter of life or death.

“It’s important to remember that addiction and substance use disorder don’t make someone a bad person,” Herring said.

Herring also said Virginia needs to ensure its safe reporting laws remove the concern that calling for help could end with criminal consequences.

Physicians have an important role in addressing abuse. Herring said he would like to see all doctors ask patients about a family history of substance abuse before prescribing opiates and share information on the warning signs of dependency.

“Everybody’s got a role to play, and I think the medical community has a special and important one in how they prescribe medicine,” Herring said. “Expanding the medical community’s engagement with the issue is critical from diagnosis to recovery.”

Herring said he’s hopeful because of the relatively new bipartisan momentum behind treating addiction as a medical concern, a guiding principle of the state’s common-sense approaches to the opioid epidemic.

“When we started working on this almost three years ago, the issue resonated with lawmakers in a bipartisan way, with advocates, and with the law enforcement community,” Herring said. “People were able to come together, and this issue has continued to generate bipartisan support and action. We also continue to see people’s understanding of addiction get better. These are all encouraging signs to me.”

Herring said he draws an important lesson from the many families he’s talked with who have experienced loss due to the epidemic.

“Seeing parents and families who have suffered heartbreak and turned that into action and hope for other families keeps me hopeful,” Herring said. “These are incredibly powerful drugs. We can’t pretend like this is a problem that has a simple solution that’s going to go away easily.”

Paul Brockwell Jr. is a writer and editor at the University of Richmond.