Transcript Ohio`s Opiate Epidemic - Cuyahoga County Board of Health

Ohio’s Opiate Epidemic
Aaron E. Haslam
Sr. Asst. Attorney General
614-644-0729
Ohio’s Opiate Epidemic
CONTACT INFORMATION
OFFICE – 614 728-9480
CELL – 614 949-4995
EMAIL-
[email protected]
Ohio’s Opiate Epidemic
What is an Opiate?
The term opiate is technically limited to the natural alkaloids found in the resin
of the opium poppy.
The term opiod is technically limited to chemicals that have opium-like effects,
though not derived from opium
Over the years the term opiate is often used as a synonym for opioid, and vice
versa
We are going to use the two interchangeable, for simplicity's sake today, since
for our purposes they cause the same results.
Ohio’s Opiate Epidemic
An opiate works by binding to specific
receptors, which are found principally in the
central and the peripheral nervous systems as
well as the gastrointestinal tract. This binding
causes decreased perception of pain, decreased
reaction to pain and increased pain tolerance.
But can cause sedation, respiratory depression,
constipation, a strong sense of euphoria and
dependence.
World History
they skipped over in school
• Opioids are one of, if not the
oldest, of the world's drugs first
used in the form of poppy;
• The first known written reference
to the poppy appears in a Sumerian
text dated around 4,000 BC
• Homer in several parts of The
Odyssey talks about poppy.
• The recreational use of opium was
popular in modern day Turkey,
Iran an China form about the 15 to
19 centuries
World History
they skipped over in school
•
Thomas Sydenham, the "father of English
medicine" is attributed the quote, "Among
the remedies which it has pleased Almighty
God to give to man to relieve his sufferings,
none is so universal and so efficacious as
opium.“
•
Use of opium as a cure-all was reflected in
the 1728 Chambers Cyclopedia, which included
Subsequently, opioids became the basis of
many popular patent medicines of the
nineteenth century.
•
However the addictive qualities of opiods
were well known Confessions of an English
Opium-Eater (1821);
•
Bayer Pharmaceuticals attempted to develop
an non-addictive form of opiate in the early
part of last century.
World History
they skipped over in school
• Opiods were almost unregulated until the early 1900’s.
In 1891 California law requiring that narcotics carry
warning labels and that their sales be recorded.
California Pharmacy and Poison Act in 1907 made it a
crime to sell opiates without a prescription.
Regulation started, in part, because between 150,000
and 200,000 opiate addicts lived in the U. S. in the late
19th century, between two-thirds and three-quarters of
these addicts were women. This was mainly due to the
prescribing and dispensing of legal opiates by
physicians and pharmacists to women mostly to relieve
menstrual pain.
Source Drug Addiction Research and the Health of Woman 33-52
Ohio’s Opiate Epidemic
• Federally, non-clinical
opiate’s use was de facto
criminalized by the Harrison
Narcotics Tax Act of 1914,
and criminalized by the
Controlled Substances Act of
1970.
• All states have enacted local
laws as well
• In Ohio we have recently
enacted House Bill 93
see also R.C. 2913.01;2913.02; 2925.03;
2925.11; 2925.22; 2925.23; 3715; 3719;
3719.13; 4729.01; 4729.51
Ohio’s Opiate Epidemic
• Why do we use opioids in the clinic or non-clinic
setting
• The analgesic (painkiller) effects of opioids decreased
perception of pain, decreased reaction to pain as well as
increased pain tolerance. Opioids are also well known
for their ability to produce a feeling of euphoria,
motivating some to recreationally use opioids.
Ohio’s Opiate Epidemic
LEGAL OPIATES
Some Legal Opiates are…
hydrocodone, (e.g.Vicodin, Lortab)
oxycodone, (e.g. OxyContin, Roxicodone, Percocet)
oxymorphone (e.g. Opana,)
ILLEGAL OPIATES
Heroin (diacetylmorphine /morphine diacetate )
Opium
Ohio’s Opiate Epidemic
Illegal Opiods
Prescriber misuse, such as prescribing outside of
what is appropriate, failure to monitor use, etc.
Patient misuse, taking too much, crushing,
combing with other drugs “cocktail”, use
without a prescription, etc.
Heroin (diacetylmorphine /morphine diacetate )
Opium
Ohio’s Opiate Epidemic
• Since 2007, unintentional drug overdoses have
been the leading cause of accidental death in
Ohio.
Ohio Department of Alcohol and Drug Addiction Services, citing Ohio Department of
Health, “Burden of Poisoning in Ohio, 1999-2008.”
Ohio’s Opiate Epidemic
Ohio’s Opiate Epidemic
• 4 people die everyday in Ohio from unintentional
prescription drug overdoses.
Ohio Department of Health, citing Ohio Hospital Association.
“Hospital discharge data, 2002-2007.”
• Fatal and non-fatal poisonings cost Ohioans $3.6 billion
annually.
Ohio Department of Health, citing Ohio Hospital Association.
“Hospital discharge data, 2002-2007.”
Ohio’s Opiate Epidemic
• Ohio’s overdose death rate tripled from
1999-2006. In the same time frame, the
U.S. death rate (only) doubled.
Ohio Department of Alcohol and Drug Addiction Services, citing Ohio
Department of Health, “Burden of Poisoning in Ohio, 1999-2008.”
Ohio’s Opiate Epidemic
• Rx Opioids were involved in at least 4 out 10
(39%) of fatal overdoses in Ohio in 2009.
• That is more than heroin & cocaine combined
(36%).
Ohio Dept. of Health Office of Vital Statistics cited in Don’t Get Me Started Ohio Literate
Ohio’s Opiate Epidemic
• From 1999 to 2007, Ohio’s rate of opioid
distribution increased 325%.
• During the same time period, Ohio’s
unintentional drug overdose death rate increased
305%.
• Think about the correlation between those
numbers.
Epidemics of unintentional drug overdoses
in Ohio,
1979-2008 12,13,14
12
WONDER (NCHS Compressed Mortality File, 1979-1998 & 1999-2005).
Ohio Department of Health, Office of Vital Statistics, Analysis by Injury Prevention Program.
14 Change from ICD-9 to ICD-10 coding in 1999 (caution in comparing before and after 1998 and 1999).
13
18
Ohio’s Opiate Epidemic
What happened during this time frame?
Ohio’s Opiate Epidemic
• In 2010 in Scioto
County, 9.7 million doses
were dispensed for a
population of 78,000.
That is equal to 123
doses for every man,
woman and child that
lives in the county.
Ohio’s Opiate Epidemic
• In 1997, Ohio’s per capita dosage averaged 7
pills. Ohio State Board of Pharmacy
• In 2010, Ohio’s per capita dosage averaged 67
pills. Ohio State Board Pharmacy
• Increase over 900% in less than 15 years.
Ohio’s Opiate Epidemic
• According to the Ohio
State Board of Pharmacy:
Ohio’s leading per capita
county was Jackson
County at 130 doses per
capita;
Ohio’s Opiate Epidemic
• Compared to:
• Ohio’s lowest county per
capita, which was Holmes
County at 18.2 does per
capita
• 18.2 is more than two and
half times the average per
capita dose for Ohio in 1997.
Ohio’s Opiate Epidemic
The American Association of Poison Control
Centers reported that the number of 13 to 19
year olds calling concerning prescription
drug abuse in Southwest, Ohio increased
from 10,651 in 2000 to 26,378 in 2007.
That is a 247% increase in eight years.
Ohio’s Opiate Epidemic
• In 2007, more than 1 out of 4 teenagers
reported using a Rx drug without a prescription
one or more times during his or her lifetime.
Ohio Dept. of Health – 2007 Ohio Youth Risk Behavior Survey
Ohio’s Opiate Epidemic
• In 2009, Southern Ohio Medical Center
(SOMC) reported 64 infants (5%) being born
with prescription opiates in their system.
• That number increased to 77 (7%) in 2010.
• Real number closer to 25%.
• Consistent throughout Ohio.
Ohio’s Opiate Epidemic
• According to physicians it can take an infant 3
months to process opiate Rx drugs out of their
system
• Spend a majority of that time in the hospital
Ohio’s Opiate Epidemic
• What happens to that infant after he or she is
discharged from hospital?
Ohio’s Opiate Epidemic
Why does the illegal market exists
Ohio’s Opiate Epidemic
•
•
•
•
Rx opiates may sell for as much as:
Hydrocodone $6-8 per dose
Oxycodone/Oxymorphone $1 per mg
Methadone $10-40 per dose
•
Source OPOTA
Ohio’s Opiate Epidemic
Most common ways prescription opiates get on the
street
• Forged/Altered Prescriptions
• Dr. Shopping
• Theft from home/family sharing
• “Bad” prescribers/dispensers “pill mills”
– Drug Traveling Organizations
• Robbery/Burglary of Pharmacies
• Internet
Ohio’s Opiate Epidemic
• Forgery/Alteration of a
prescription
This is a felony in Ohio under
R.C. 2925.22 (deception to
obtain a dangerous drug)
Some common methods:
computer/copier; hairspray;
whiteout; theft of
prescription pad
Ohio’s Opiate Epidemic
Dr. Shopping
Having multiple doctors who do not know of each other
for the purposes of obtaining multiple prescriptions
This is a felony in Ohio under R.C. 2925.22 (deception to
obtain a dangerous drug)
Less common now, but still an issue. Databases have
helped to curb this practice
Common signs included asking for drugs by name; the
patient using variations of their name; wanting to pay
cash only
Ohio’s Opiate Epidemic
• Internet Pharmacies
Only 3.4% of online Pharmacies
are legitimate and 83% do
not require a valid
prescription
In 2006 34 Internet pharmacies
that were “rouge” dispensed
98 million doses of
hydrocodone. That is the
amount that 1,118 average
pharmacies would fill
Due to legislation, now shifting
to lifestyle drugs. Online
Canadian pharmacies not
really in Canada
Source NABP
Source ONDCP
Ohio’s Opiate Epidemic
• Robbery/Burglary of
Pharmacies
• Robberies tend to be
opportunistic
• Burglaries tend to be planned
and many are highly
organized gangs. This, largely
is due to the security features
that pharmacies are required
to have by regulations and
insurance
• You guessed it, these are
felonies under Ohio law
Ohio’s Opiate Epidemic
• Theft from Homes
The most common ways juveniles get prescription drugs
Number one way to prevent this is to properly dispose of
unused prescription medication immediately after it is
not needed. If a family member is in an end of life
situation have a plan to deal with this just as you have a
plan for the other end of life issues
Ohio’s Opiate Epidemic
Pill Mills are “pain management clinics” that either rarely or never
provide any medical care other than the writing of and or
dispensing of prescription drugs. Most of the pill mills lack
professional staff ie RN, LPN, PA’s; do not alter their
prescribing practices to tailor to the patient; Rarely have referrals;
often do not treat the actual cause but the symptom (pain)
Business model hinges on keeping people hooked and not being
treated for underlying cause
Some have also begun to prescribe drugs to help their patients off
of drugs. So pay to get addicted-pay to get cured.
Until HB 93 became the law in Ohio many if not most of these
were owned by non-physicians a sizable number of these owners
were prior felons.
Ohio’s Opiate Epidemic
• Drug Traveling Organizations
– Travel Out-of-State
• In many cases to “pill mills” in other states
• Fill scripts in the prescribing state or
somewhere along the route back to Ohio
or in Ohio.
• Recent trends seen by LE for filling scripts.
• Divert on streets of Ohio.
Ohio’s Opiate Epidemic
OHIO’S RESPONSE TO THE RX PROBLEM
- PREVENTION
-ENFORCEMENT
-TREATMENT
Ohio’s Opiate Epidemic
• PREVENTION
– EDUCATION/TRAINING
• COMMUNITIES
• LAW ENFORCEMENT
• MEDICAL COMMUNITIES
– EMERGENCY ROOM GUIDELINES
• STATE/LOCAL AGENCIES
– TRAINING
• COMMUNITY COALTIONS/SUPPORT GROUPS
– TO HELP HEAL AND PREVENT
Ohio’s Opiate Epidemic
• ENFORCEMENT
– UNPRECEDENDT COLLAORATION ACROSS
THE BOARD
• LOCAL, STATE, FEDERAL
– SHARING INFORMATION FOR INVESTIGATIONS AND
PROSECUTIONS
– ATTACK THE SOURCES AND NOT THE ADDICTS
– EDUCATE LE, PROSECUTORS, JUDGES
– WORK WITH PREVENTIONIST AND TREATMENT
PERSONNEL
– INVOLVEMENT W/ COMMUNITY EFFORTS
Ohio’s Opiate Epidemic
• ENFORCEMENT (CONT.)
– WORK OUTSIDE TRADITIONAL
JURISDICITONAL CONSTRAINTS
• INCLUDING OUT-OF-STATE
AND FINALLY WE GOT SOME HELP WITH MUCH
NEEDED:
LEGISLATION
What is Ohio Doing?
PASSAGE OF HOUSE BILL 93
HB 93
Also known as:
the “Pill Mill” bill or “Pill Mill” legislation
HB 93
EMERGENCY CLAUSE
• Passed as an emergency bill – meaning the bill
went into effect the day it was signed into law by
the governor (5/20/2011).
• Also, public health/safety required the bill to be
enacted immediately.
HB 93
PAIN MANAGEMENT CLINICS
HB 93
• A pain management clinic is defined by the bill as:
– A primary component of practice is treatment of
pain or chronic pain;
– The majority (50.1%) of patients for the facility are
treated for pain or chronic pain through the use of
controlled substances, tramadol (treat) and
Carisoprodol (relieve), and any other substances
specified by the medical board.
– Any other identifying criteria est. by Medical Board.
HB 93
• If not a legitimate pain management clinic more
commonly known as a “pill mill.”
• Many pills were getting on the street because of
these “pill mills” or “bad prescribers.”
• This bill was designed to help take regulatory
action against both.
HB 93
Since January 2011, the State
Medical Board
represented by The Office
of the Attorney
General, has sanctioned
more than 30
physicians for inappropriate
prescribing. That
number exceeds the number
of sanctions issued
by the Medical Board in all
of 2010 for similar
conduct.
On Wednesday October 12th
The medical board
permanently revoked Dr.
Daniel Brumfield license
“I, along with management,
came up with a way to
increase the number of nonpain patients by asking
patients to bring a friend. In
hindsight that was a terrible
idea,”
This was done to get around
House Bill 93, or
HB 93
• What HB 93 does:
– It assists law enforcement by giving us access to information
to assist in investigating and prosecuting cases involving
many health care professionals
– It assists LE in working w/ many regulatory agencies by
allowing LE and RA’s share information that was previously
confidential with each other and other law enforcement
agencies.
– It also shuts down non-physician owned and operated pain
clinics
– It also allows better monitoring of all pain clinics
– Finally, it creates guidelines for pain clinics and those
physicians operating pain clinics.
HB 93
• Early success of the Bill:
– Majority of “pill mills” shut down because they cannot meet
the licensing requirements;
– Have information to go after the single bad prescribers
• Effects of this success
– More pills coming from out of State;
– Increase in demand has drove up cost of Rx pills on the
street causing a crossover to Heroin, which is much
cheaper and easier to get post HB 93. A ballon (1/10th of
gram) going for $10 in Columbus, $30 in more rural
areas.
Opiate Substitutes
• Regulations designed to make it more difficult to
abuse prescription painkillers are leading to an
increase in heroin addiction
Opiate Substitutes
RESULTS
• Heroin is making a strong comeback
Ohio’s Opiate Epidemic
Heroin was first synthesized in 1874 by an
English chemist it was independently resynthesized 23 years later by another chemist
working at Bayer pharmaceutical company in
Germany.
From 1898 through to 1910 Heroin was marketed
as a non-addictive morphine substitute and
cough suppressant.
Ohio’s Opiate Epidemic
After World War II,
the Mafia took
advantage of the
weakness of the
postwar Italian
government and set
up heroin labs in
Sicily. The trade
shifted away from
Sicily in the late
1970s.
• Don Corleone: “When –
when did I ever refuse an
accommodation? All of you
know me here. When did I
ever refuse, except one time?
And why? Because I believe
this drug business is gonna
destroy us in the years to
come…”
Ohio’s Opiate Epidemic
After 1973 the Golden
Triangle opium production
region, supplied about onethird of heroin consumed in
US. Today the heartland of
the Golden Triangle remains
the second largest producer
of heroin, after Afghanistan.
At present, opium poppies
are mostly grown in
Afghanistan, and in the
Golden Triangle. There is
also cultivation of opium
poppies in the Sinaloa region
of Mexico and in Colombia.
OHIO OPIATE EPIDEMIC
WHY HEROIN?
Ohio’s Opiate Epidemic
A balloon of heroin ( approx 1/10 of a gram) retails on
the street for about $10 in Columbus.
Retails for up to $30 in the more rural counties.
Heroin is cheaper and easier to get as the price for
prescription painkillers rises as a result of the
crackdown on pill mills and bad prescribers.
Ohio’s Opiate Epidemic
• As of March 21, 2012 test results revealed that
106 people died in Cuyahoga County of heroin
overdoses in 2011; 25 women and 81 men.
• About 82 percent of the people who overdosed
on heroin last year in Cuyahoga County were
white. Fifty-one percent of the deaths occurred
in Cleveland; the rest occurred in the suburbs.
•
Source Plain Dealer
http://blog.cleveland.com/metro/2012/03/heroin_deaths_rise_again.html
Ohio’s Opiate Epidemic
Ohio’s Opiate Epidemic
• http://executive.cuyahogacounty.us/pdf_execut
ive/en-US/PressReleases/2012/20072012%20HeroinDeaths0917.pdf
Ohio Opiate Epidemic
http://executive.cuyahogacounty.us/enUS/HeroinCalltoArmsInitative-092412.aspx
Ohio Opiate Epidemic
http://executive.cuyahogacounty.us/enUS/CC/HeroinInitiativepartnership.aspx
Heroin trends are changing
• Law enforcement reports seeing it in upscale
suburbs
• Many young people from upscale suburbs using
heroin
• The new drug trafficking model coming to Ohio
from Mexico uses savvy marketing and low
prices to push black-tar heroin
Ohio’s Opiate Epidemic
THIS IS NOT A COINCIDENCE!
Ohio’s Opiate Epidemic
• http://articles.latimes.com/2010/feb/14/local/
la-me-blacktar14-2010feb14
• http://articles.latimes.com/2010/feb/15/local/
la-me-blacktar15-2010feb15
• http://articles.latimes.com/2010/feb/16/local/
la-me-blacktar16-2010feb16
Black-Tar Heroin
• Sugar cane farmers from Mexico have perfected
an ingenious way to sell black-tar heroin in the
United States
• The business model places a premium on
customer convenience and satisfaction
• Instead of the customer driving to a dangerous
neighborhood, the order is phoned in and a
driver brings the heroin to you
Black-Tar Heroin
• This new model encourages users to bring in
new customers, rewarding them with free heroin
if they do
• These organizations are small and decentralized
• There is no all-powerful leader and they rarely
use guns
• Competition among the networks has reduced
prices, further spreading heroin addiction
Black-Tar Heroin
• Networks generally avoid major cities and stick
to suburbs and more rural areas
• Networks arrived in Ohio around 1998
• Especially successful in parts of Appalachia and
the Rust Belt with high rates of addiction to
OxyContin and other prescription painkillers
• They market their heroin as a cheap, potent
alternative to pills
Ohio’s Opiate Epidemic
http://www.newsnet5.com/dpp/news/local_new
s/cleveland_metro/Cuyahoga-County-to-launchheroin-initiative-Four-dead-this-year-in-PortageCounty-from-overdoses
Ohio’s Opiate Epidemic
http://www.latimes.com/news/nation-andworld/la-na-blacktar0208ss,0,7690985.htmlstory
Ohio’s Opiate Epidemic
HOW DO WE ATTACK THE
HEROIN PROBLEM?
Ohio’s Opiate Epidemic
THE SAME WAY WE TACKLED
THE Rx EPIDEMIC!
Remember they are both Opiates!
Ohio’s Opiate Epidemic
PREVENITON
Ohio’s Opiate Epidemic
ENFORCEMENT
Ohio’s Opiate Epidemic
TREATMENT
Ohio’s Opiate Epidemic
Aaron E. Haslam
Sr. Asst. Attorney General
614-644-0729
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