In a day and age when the very mention of “fake news” draws headlines, this news is all too real.
America is deeply mired in a public health crisis: opioid addiction.
Codeine … fentanyl … hydrocodone … methadone … oxycodone … morphine … the list goes on. Opioids are used to “treat moderate to severe pain that may not respond well to other pain medications,” it reads on the popular WedMD site online. So, if you have pain, beware.
And while substantial efforts are being made, even near the unofficial epicenter of the crisis, many more on multiple levels – from legislative and legal to medical and individual – are required.
The problems are fixable, perhaps. Yet, there is no easy fix.
Severity Of The Crisis
Consider the harrowing statistics from across the United States. The numbers are in approximate tallies, because few things can be precisely measured under this dark cloud.
In 2014, nearly 30,000 people died from opioid-related overdoses. It was the highest such death toll on record until 2015’s total of more than 33,000 people, according to the national Centers for Disease Control and Prevention. For 2016, an estimate by The New York Times revealed a higher number, with caution that “all evidence suggests the problem has continued to worsen in 2017.”
Those are only a scant few lowlights. And notably, these numbers don’t include heroin. That drug has its own horror story, although the use of opioids and heroin are very much related. According to the CDC, people addicted to prescription opioid painkillers are 40 times more likely to be addicted to heroin. That’s not a typo – 40 times.
The situation certainly has caught the attention of U.S. Surgeon General Dr. Vivek Murthy. In an unprecedented move, Murthy authored a report in November 2016, titled “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health.” It was the first report by a Surgeon General that specifically addressed substance-use disorders, along with health problems and consequences related to alcohol and drug misuse.
In 2015, according to the report, more than 27 million people nationwide indicated current use of illicit drugs or misuse of prescription drugs, with a corresponding economic impact of $193 billion.
Offering further proof of severity, when Dr. Anne Schuchat became acting director for CDC in January 2017, she arrived with a resume filled with experience dealing with epidemics. Coincidence? Maybe not.
Schuchat began her public health career in 1988 when she came to CDC as an Epidemic Intelligence Service officer. In subsequent years, she played key roles in a variety of CDC emergency responses. Most notably, she served as chief health officer for CDC’s 2009 H1N1 pandemic influenza response; led the CDC team responding to the SARS outbreak in Beijing in 2003; and supported the Washington D.C., field team during the 2001 bioterrorist anthrax response.
Now, Schuchat and the CDC face opioids.
State Of Emergency
The unofficial epicenter for opioid abuse? Ohio largely earns that distinction – and it’s not the kind of No. 1 ranking the Buckeye State desires.
In 2011, drug overdoses were the leading cause of accidental deaths in the state, with one Ohioan dying from a drug overdose every five hours. Drug overdose deaths in Ohio reached an all-time high of roughly 2,500 in 2014. Then that total was eclipsed a year later, with a reported 3,050 overdose deaths. The State of Ohio projected a 25 percent increase in such deaths for 2016.
This past spring, citing that drastic jump in overdoses, the state filed suit against the pharmaceutical industry, accusing drug companies of contributing to the problem by misinforming doctors and patients about the dangers of opioid use and the potential of addiction.
Not coincidentally, like mosquitos attracted to bright lights, national news outlets have descended on Ohio. This snippet comes from CBS News on May 23: “The coroner’s office in Montgomery County ran out of space for the second time this year after it received 13 bodies on Monday, 12 of which were for overdoses. And that came after the office expanded its cooler to hold 42 bodies, up from 36, after facing similar issues last year.”
Not a good look.
While acknowledging the seriousness of the problem, Andrea Boxill, deputy director of the Governor’s Cabinet Opiate Action Team in Ohio, makes this assertion, “The difference between being number one in drug overdoses and being number 10 is very small.”
Adds Eric Wandersleben, director of Media Relations & Outreach for the Ohio Department of Mental Health & Addiction Services (OhioMHAS): “This just isn’t an Ohio thing. This is a national epidemic.”
For the record, in Orlando, Florida, another center of drug activity and attention, Jessica Lipsey agrees. Lipsey is a registered clinical therapist who regularly works with substance abusers. She uses phrases such as “it’s a major, major problem,” “we’re not seeing this get better; we’re seeing this get much worse” and “it’s hard to see if there’s a light at the end of the tunnel.” And she concludes, “It’s just bursting across the country.”
Yet, make no mistake. Officials in Ohio aren’t running from anything. Actually, just the opposite can be said. They are taking a lead role in fighting back.
“We’ve been treating this as an emergency since 2010,” Wandersleben says. “We are literally saving lives every day.”
Exhibit A is the Governor’s Cabinet Opiate Action Team, comprised of leaders from several state agencies. The team, created shortly after Ohio Gov. John R. Kasich was sworn into office in 2011, was created to implement a multifaceted strategy to promote the responsible use of opioids, to reduce the supply of opioids, and to support overdose prevention and expand access to naloxone.
The team’s approach encompasses law enforcement, the medical community, youth drug prevention, and treatment and recovery – with members such as the Ohio Department of Mental Health and Addiction Services, Ohio Department of Health, State of Ohio Board of Pharmacy, and the Ohio State Highway Patrol.
The approach is uncommon, even unorthodox, but it’s proving to be productive.
Essentially, drug users aren’t considered merely criminals. Instead, they are given options to change course. The medical community, meanwhile, is urged to find the right balance between making sure pain interventions are available to patients who need it while taking steps to limit the number of opioid prescription medications. Also, with the idea of preventing abusive behavior before it starts, prevention strategies feature components designed to provide parents, teachers, guardians and community leaders with simple tools. Finally, drug offenders are given access to treatment, including medication-assisted treatment in combination with traditional counseling – along with housing, employment services, relapse prevention and other components to recovery.
Ohio’s Team Approach
The team moved swiftly. Examples: Gov. Kasich almost immediately signed a law to shut down “pill mill” pain clinics. In 2012, Ohio hosted first statewide Opiate Summit, attended by more than 1,000 addiction, law enforcement, policy and medical professionals. That year, Ohio Medicaid introduced coverage of medication-assisted treatment services. Also, the Ohio Department of Health provided seed funding for a pilot naloxone education and distribution program called Project DAWN (Deaths Avoided with Naloxone) in Scioto County.
In 2013, a partnership with local law enforcement was strengthened with the investment of $3 million in behavioral health programs through local jails to reduce recidivism. A focus on prescription monitoring was heightened with the introduction of guidelines for Ohio’s opiate prescribers for safe management of chronic, non-terminal pain. During 2012-2013, more than 16,500 high school student-athletes participated in “5 Minutes for Life” sessions held before or after practices, during which Ohio state troopers, local law enforcement officers and Ohio National Guard members talked about responsible decision-making, leadership and encouraging their peers to live a drug-free lifestyle. Also, in 2014, the extension of Medicaid coverage in Ohio began, making addiction treatment services available to nearly 500,000 more Ohioans, particularly men.
More recent activity shows a continuation of the vigilance.
This year, the Ohio Department of Public Safety Office of Criminal Justice Services provided more than $5.5 million in funding to support 40 local drug task forces throughout the state. As of March 2017, total student attendance across nearly 900 “5 Minutes for Life” presentations (since the program was created) exceeded 132,000, and a total of 2,370 students became ambassadors promoting healthy lifestyles among their peers. The Ohio Automated Rx Reporting System reported a record high of 265,242 requests by prescribers and pharmacists in a single day. (By comparison, the single day high in 2016 was 86,129 prescriber and pharmacist requests.) In addition, the State of Ohio Board of Pharmacy issued a resolution permitting law enforcement and first responder agencies to transfer naloxone among agencies, while Project DAWN programs was expanded to include 58 sites in 45 counties.
Again, this is only a sampling of activity.
The broader use of prescription-drug monitoring and naloxone are especially noteworthy. Under the monitoring program, controlled substance dispensing information is digitally stored, with the data made accessible to prescribers, pharmacies and law enforcement officials. Ohio was an early adopter.
Use of the monitoring programs has been one of the best ways for pharmacists to identify people who are potentially at high risk for opioid use disorder, according to Boxill of the Governor’s Team. She adds there has been substantial increases in queries and reductions in opioid prescribing. The pharmaceutical industry, by the way, is the big part of the equation. This May, state officials sued the industry, accusing drug companies of misleading doctors and patients about the dangers of addiction to painkillers and possibly overdose.
Ohio’s naloxone program saved more than 2,300 lives across state in fiscal 2016, according to published data. Patented in 1961 and approved by the Federal Drug Administration in 1971, naloxone has been labeled the “Lazarus drug” because of its effectiveness in the emergency treatment of opioid overdose episodes. Seventy-five percent of all retail pharmacies in Ohio are offering naloxone without a prescription in 85 out of 88 counties.
In simple view, the State of Ohio has made it more difficult to traffic drugs, decreased the number of opioids prescribed, informed residents about how to talk to their children about drugs, and expanded treatment for opioid abusers.
In an editorial this spring, the Youngstown Vindicator newspaper provided this perspective: “Hardly a day goes by when headlines fail to bombard readers with the latest disturbing and anguishing chronicles of overdoses, deaths and other tragedies linked inextricably to our state’s harrowing opiate crisis. …
“Fortunately for the millions of Ohioans impacted by this crisis, not all is dark and dank. State and local leaders have responded to the crisis with a variety of promising initiatives and have worked together cooperatively to channel limited resources toward maximum effectiveness.”
Perhaps the most promising initiative is Addiction Treatment Program, launched in 2014. The Ohio General Assembly provided $5 million in initial funding that year to establish pilot programs in Allen, Crawford, Franklin, Hardin, Hocking, Mercer and Morrow counties. Legislators authorized OhioMHAS to work with the Supreme Court of Ohio, other state agencies and certified drug courts in each county to develop a program to provide addiction treatment, including medication-assisted treatment, to nonviolent adult offenders in jail with a dependence on opioids, alcohol or both.
An estimated 80 percent of offenders within Ohio’s prisons have documented histories of drug and alcohol addiction.
“For persons involved in the felony system, the best opportunity to achieve a full recovery from addiction may be provided by a certified drug recovery court program,” described Hardin County Common Pleas Judge Scott Barrett during the program’s official introduction. “The combination of intensive treatment and strict accountability to the court provides a winning combination for those who are willing to do the hard work of recovery.”
The program, now out of the pilot stage, appears to be working. The state’s 2016-2017 legislative budget appropriated $11 million to advance the program.
The key to program’s success, contends Boxill, centers on a holistic view from drug arrest all the way through drug treatment – with all of the principal players across multiple agencies and jurisdictions following the same game plan.
“The community’s willingness to understand and accept that this a chronic disease, just like cancer and diabetes is significant,” she says. “So much of our criminal justice system is based on kind of a moral fail. So much of our treatment history has been seen a moral failing or moral choice. To have this kind of initiative take place under the jurisdiction of the court, with the involvement of social services – so you have treatment people around the table – is a really unique way of approaching [this situation].”
Also, offenders aren’t forced to participate. “When you commit a crime, you will be arrested like anybody else. You will be arraigned and assigned a probation officer, like anybody else. The difference is after arraignment, you can make the decision to participate in the program. It is voluntary,” Boxill explains. “The choice to participate can be very empowering and holds the person accountable. … They realize this could be their last opportunity.”
Another component of the Addiction Treatment Program targets to relapse. OhioMHAS has implemented a Community Transition Program that offers individuals returning home from prison a transitional benefit for drug and alcohol treatment and assistance with recovery support services such as housing, transportation, work and education. Other areas of recovery support include peer recovery support, life skills development, relapse prevention/recovery, spiritual support and help with gathering necessary identification documentation.
Similarly, recognizing the role of mental illness is an important component of Ohio’s holistic approach. A recent study from the University of Washington tied an increase in the risk of suicide to prescription opioid use. The study revealed that individuals with depression and PTSD are more likely to be prescribed opioids – for longer periods and in higher doses – for chronic pain than individuals who don’t suffer from these mental illnesses.
The report cited that suicides in which opioid overdose was the cause of death more than doubled from 1999 to 2014. Further, in the report’s analysis of National Center for Health Statistics data, suicide deaths related to prescription opioids accounted for 97.7 percent of all opioid-related suicides.
In response OhioMHAS is Stepping Up, literally.
Stepping Up is a national initiative targeted at reducing the number of people with mental illnesses in jails. For its part, OhioMHAS is collaborating with other organizations and local experts, including those representing sheriffs, jail administrators, judges, community corrections professionals, treatment providers, people with mental illnesses and their families, mental health and substance use program directors, and other stakeholders.
‘The Stepping Up initiative focuses on creating long-term movement to raise awareness of the factors contributing to the over-representation of people with mental illness in jails, and then using practices and strategies that work to decrease those numbers,” says Julie Spohn, OhioMHAS behavioral health/criminal justice coordinator.
As of February 2017, 31 Ohio counties had passed resolutions in support of Stepping Up Ohio.
In much the same way, OhioMHAS introduced the Start Talking! Program in 2014 to encourage youth to stay away from drugs. Published national data indicates that children of parents who talk to their teens about drugs are 50 percent less likely to use than those who do not. Start Talking! delivers tools that are free of charge to parents, schools and communities to help get the conversation started.
The inherent challenge, Spohn believes, is that often with drug abuse people don’t want to talk. Spohn calls it “whispering because it’s still so tied up in shame.”
In his “Facing Addiction in America” report, Surgeon General Vivek writes, “Most Americans know someone with a substance use disorder, and many know someone who has lost or nearly lost a family member as a consequence of substance misuse. Yet, at the same time, few other medical conditions are surrounded by as much shame and misunderstanding as substance use disorders.”
Later in the report, in reference to a “treatment gap” for drug addiction, Vivek points to the fear of shame and discrimination as contributing factors to not seeking treatment (along with the inability to access or afford care, and lack of screening for substance misuse and substance use disorders in general health care settings). “Substance-use disorder treatment in the United States remains largely segregated from the rest of health care and serves only a fraction of those in need of treatment,” he notes.
Continuing To Advance
The State of Ohio is seeking to change that perception, as is Judy McGlone, director of nursing at The Recovery Village of Columbus, part of Florida-based Advanced Recovery Systems, which has expanded into Ohio and treats substance abuse issues and co-occurring mental health disorders.
The Recovery Village of Columbus is an 80-bed facility that opened in mid-July. Thirty beds are reserved for detoxification patients, 20 beds for residential patients and 30 for partial hospitalization. Additionally, in September 2016 Advanced Recovery Systems acquired the former Bariatric surgical hospital in Groveport, Ohio, a 50,000-square-foot medical facility.
In lockstep with the Governor’s Cabinet Opiate Action Team and OhioMHAS, McGlone believes in a multifaceted, holistic approach. “There is no one way, and it take a whole treatment team. The focus must be on getting [patients] medically stabilized while they are in detox. Then it becomes a ‘focus on where they got to this place,’” says, McGlone, who formerly worked for The Ohio State at its drug and alcohol detox center.
“Ultimately, it doesn’t matter what one uses; it’s why and what got them to that point. You need to get to the core of what the issue is.”
Officials in Ohio are confident they are getting to the core of their own issue with opioids. There is strong legislation support and cooperation within the criminal justice system and medical profession. There have been steady implementation opioid overdose prevention programs and the promotion of public-awareness campaigns. At the same time, death tolls still are mounting. In Montgomery County – the county that CBS News profiled in May – there were 360 fatal drug overdoses recorded by June 1, less than half the way through 2017.
The battle rages.
Consider what Gov. Kasich had to say back in 2014, three years after he took office and three years before today. His words: “We’re making real progress in fighting prescription drug abuse in Ohio, because we made up our minds to fight the problem head on. … But we still have more work to do because illicit drug abuse remains a huge problem in our state.”