Ohio’s Opiate Epidemic

Aaron E. HaslamSr. Asst. Attorney General

614-644-0729

Ohio’s Opiate Epidemic

CONTACT INFORMATION

OFFICE – 614 728-9480

CELL – 614 949-4995

EMAIL-

Aaron.Haslam@OhioAttorneyGeneral.gov

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 Historythey 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 Historythey 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 Historythey 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 OPIATESSome Legal Opiates are…hydrocodone, (e.g.Vicodin, Lortab)

oxycodone, (e.g. OxyContin, Roxicodone, Percocet)

oxymorphone (e.g. Opana,)

ILLEGAL OPIATESHeroin (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).13 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).

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 ControlCenters reported that the number of 13 to

19year 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. ShoppingHaving 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 PharmaciesOnly 3.4% of online

Pharmacies are legitimate and 83% do not require a valid prescription Source NABP

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 Source ONDCP

Due to legislation, now shifting to lifestyle drugs. Online Canadian pharmacies not really in Canada

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 HomesThe 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 EpidemicPill 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 93Since January 2011, the

State Medical Boardrepresented by The

Office of the AttorneyGeneral, has sanctioned

more than 30physicians 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 non-pain 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 re-synthesized 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 EpidemicAfter 1973 the Golden Triangle opium production region, supplied about one-third 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.

Source BCI&I

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_executive/en-US/PressReleases/2012/2007-2012%20HeroinDeaths0917.pdf

Ohio Opiate Epidemic

http://executive.cuyahogacounty.us/en-US/HeroinCalltoArmsInitative-092412.aspx

Ohio Opiate Epidemic

http://executive.cuyahogacounty.us/en-US/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_news/cleveland_metro/Cuyahoga-County-to-launch-heroin-initiative-Four-dead-this-year-in-Portage-County-from-overdoses

Ohio’s Opiate Epidemic

http://www.latimes.com/news/nation-and-world/la-na-blacktar0208-ss,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. HaslamSr. Asst. Attorney General

614-644-0729

81

82

83

84

85