Heroin Epidemic in SLC Member States: Finding Solutions

8/19/2019 Heroin Epidemic in SLC Member States: Finding Solutions

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THE SOUTHERN OFFICE OF THE COUNCIL OF STATE GOVERNMENTS

P.O. Box 98129 | Atlanta, Georgia 30359ph: 404/633-1866 | fx: 404/633-4896 | www.slcatlanta.org SERVING THE SOUTH

Following a number o distressing revelations, in-cluding a 1969 study linking crime and heroinaddiction and a 1971 report on the growing heroin

epidemic among U.S. service members in Vietnam, Presi-dent Nixon declared a war on drugs.1

More than four decades after Nixon named drug abuse“public enemy number one,” the nation continues tostruggle with drug addiction.2 Each year since 1999, theUnited States has seen a steady rise in the number odeaths from prescription opioid overdose.3 This rise indeaths corresponds with a four-fold increase o opioidpainkiller prescriptions written between 1999 and 2013.4 As states began targeting those overprescribing thesedrugs in an effort to reverse this trend, access to prescrip-tion opioids became more dificult for individuals alreadyabusing them. These new impediments to access, coupledwith the rising cost o prescription drugs and enterprisingdrug trafickers and dealers, led many prescription opi-oid abusers to a more easily accessible and cost-eficientsubstitute—heroin.A With prescription opioid addicts 40times more likely to become addicted to heroin, statesnow are facing another public health crisis.5

A Heroin is a highly addictive Schedule I controlled substance pro-cessed from morphine extracted from poppy plants. Typically sold aswhite or brown powder or black sticky goo, heroin can be injected,smoked, or snorted to produce a quick euphoric effect. Regular use othe drug builds up a tolerance that, over time, requires higher dosesto yield the same effects. (2015 DEA Drugs o Abuse Resource Guide)

Although heroin has remained a public health threat sinceirst rising to cultural popularity in the early 20th century,its recent re-emergence spans a much broader swath o so-ciety. A July 2015 report released by the Centers for Dis-ease Control and Prevention (CDC) found that the groupsmost at risk for a heroin addiction include non-Hispanicwhites, 18 to 25 year-olds, and people living in large met-ropolitan areas.6 While men remain the largest users oheroin, it also was reported that use among women hasdoubled in the last decade.7 Eighty percent o heroin userswho began using in the 1960s reported that heroin wasthe irst drug they had ever used. By contrast, 75 percento heroin users who began using in the 2000s report thattheir irst drug use began with prescription opioids.8 Inlight o reports that healthcare providers in the Southernregion wrote more prescriptions for opioid painkillersthan anywhere else in the country, this fact is particular-ly alarming for the member states o the Southern Legis-lative Conference (SLC).9 In one SLC state, almost threetimes as many prescriptions were written per person ascompared to the nation’s lowest prescribing state.10

In 2013 alone, 43,982 deaths were attributed to drug

poisoning, 8,257B o which involved heroin. 11 As drugpoisoning has surged to become the number one cause

B The actual number o heroin-related deaths may be higher, but therapid rate at which heroin metabolizes into morphine can result ina misclassiication o which drug caused the death.

HEROIN EPIDEMIC INSLC MEMBER STATES:

FINDING SOLUTIONS A REGIONAL RESOURCE FROM THE SLC

S O U T H E R N

L E G I S L AT I V E

C O N F E R E N C E

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T H E C O U N C I L

OF STATE

G O V E R N M E N T S

© Copyright March 2016


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2 HEROIN EPIDEMIC IN SLC MEMBER STATES: FINDING SOLUTIONS

o injury-related deaths in the United States, drugoverdose deaths involving heroin more than tripled

between 2007 and 2013.12 By 2014, 36 states had record-

ed at least one year in which heroin and prescriptiondrug overdoses claimed the lives o more people thancar accidents.13

While the heroin epidemic largely has been concen-trated in the Northeast, Appalachian, and Midwestregions o the country, substance abuse is an issuethat crosses multiple areas o public policy, including behavioral and public health, criminal justice, and so-cial services. As the South continues to lead the way incriminal justice reform, lessons from the plight o oth-er regions allow SLC lawmakers to build on their ef-forts to combat prescription drug abuse and take a pro-active stance in the heroin epidemic. In recent years,this awareness has led many SLC states to pass laws

which expand availability and access to drugs thatcan help treat an opioid overdose and provide limitedimmunity from prosecution for individuals who seekmedical assistance for themselves or another personexperiencing an opioid overdose.

This SLC Regional Resource examines what the SLCmember states are doing to combat the heroin epidem-ic and what policies and/or practices can be imple-mented to mitigate its side effects and ensure a long-term solution.

AN EFFECTIVE HEROIN STRATEGYAs noted by Jack Killorin, director o the Atlanta-Carolinas High Intensity Drug Traficking Area, “theabuse o pharmaceuticals and heroin use are inter-twined;” consequently, many o the policies being im-plemented should work in tandem to address both is-sues.14 States in the SLC region and nationwide alreadyhave begun important work in response to the pre-scription drug epidemic, but there remains more thatcan be done. Although not every state with an estab-lished prescription drug monitoring program requires

its use, Missouri is the only state in the country that hasnot enacted a prescription drug monitoring program.15

As with most issues facing the states, there is no one-size-its-all solution to address the growing heroinproblem. However, many experts agree that an effec-

tive response includes a combination o policies thatfocuses on treatment, prevention, and enforcement.16,17 The most common elements o an effective heroinstrategy include a combination o provisions relatedto (1) naloxone access and training; (2) Good Samar-itan immunity; (3) needle and syringe exchange pro-grams and decriminalization; (4) medication-assisted

treatment; (5) access to treatment; and (6) treatmentalternatives to incarceration. While not intended to be a comprehensive overview o what each SLC stateis doing in each o these areas, this Regional Resource examines recent legislative efforts that support an ef-fective strategy to combat this problem.

Naloxone Access

Naloxone, also called Narcan, is an FDA-approved opi-

oid antagonistC that can be administered to an indi-vidual experiencing an opioid overdose to neutralize

the effects o heroin or other opioids and reverse theoverdose. The drug, which does not produce a high, hassaved thousands o lives. First approved by the FDAin 1971, naloxone usually requires a prescription andcan be injected intravenously or administered throughthe nose. In addition to proving effective at savinglives, naloxone also is a tool for improved commu-nity response and oficer safety. Although naloxonehas been used for decades to reverse opioid overdoses,only recently have states begun to allow physiciansto prescribe, and pharmacists to dispense, the drugwithout fear o civil, criminal, or professional reper-cussions. Additionally, the recent push to expand access

to naloxone has enabled physicians to prescribe thedrug directly, or by standing order, to an individual

C An opioid antagonist is a drug that quickly binds to the samenerve receptors as opioids to block or prevent their activation byopioids in the system. Naloxone will have no effect i administered to someone who has not taken prescription or illegal opioids.D By deinition, the term opiate refers to drugs derived fromnaturally occurring sources (heroin), and the term opioid refersto synthetic and semi-synthetic drugs that produce a similar ef-fect (prescription drugs). In recent years, the term opioid has

been used to refer to all drugs that bind to opioid-receptors toproduce a euphoric effect. The terms are used interchangeablythroughout to relect the statutory language in each state.E A standing order is an order that prescribers write to allow aprescription medication to be dispensed to patients they havenot examined based on meeting a certain set o criteria. In thecase o naloxone, standing orders commonly are provided to


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HEROIN EPIDEMIC IN SLC MEMBER STATES: FINDING SOLUTIONS 3

at risk o experiencing an overdose or to a third-party,

including family, friends, and other individuals, whomay be in a position to assist during an opioid over-dose. Although what deines acting in good faith andthe training requirements for prescribers, dispensers,and administrators o naloxone and other opioid an-tagonists vary by state, every state with a naloxone

access law provides some level o immunity to thoseindividuals. As o October 2015, 44 states, includingall 15 SLC member states, have enacted laws that, tosome degree, expand access to naloxone and otheropioid antagonists.18 However, even within some othese 44 states, expanded access only is available toirst responders, not laypersons.

Good Samaritan Laws

Good Samaritan laws are statutes that provide legalprotection to individuals who assist in the event o

an emergency. Traditionally, these laws have been ameans o encouraging bystanders to assist others inemergency situations without fear o being held li-able for any additional or exacerbated injuries theirwell-intentioned assistance might cause. In recentyears, Good Samaritan laws have been enacted as alife-saving tool for drug overdose victims by encour-aging individuals to seek medical assistance for them-selves or another person experiencing an overdose,without fear o being arrested, charged, or prosecutedfor a drug-related crime. Under most Good Samaritanprovisions in the SLC states, individuals experiencingan opioid-related drug overdose, and/or a third partywho, in good faith, seeks emergency medical assistanceon their behalf, will be immune from criminal chargesfor possession o a controlled substance and/or pos-session o drug paraphernalia i the evidence for thosecharges is the result o seeking medical assistance. Thevariation among these laws relates to what qualiies as“seeking medical assistance” for immunity purposes.As o October 2015, 34 states have enacted laws thatprovide some immunity for seeking emergency med-ical assistance during a drug overdose.19

community-based organizations so they can distribute the drugto anyone who may be in a position to reverse a drug overdose.F In many states, Good Samaritan protections are not limited toopioids; rather they apply generally to controlled substances. Insome instances, this protection also is extended to underage in-dividuals who have consumed alcohol.

Needle and Syringe Exchange

and Decriminalization

Needle and syringe exchange programs, or syringeservice programs (SSPs), provide free and new hy-podermic needles and sterile syringes to drug usersin exchange for used ones. According to the CDC, in

2013, 7 percent o the more than 47,000 HIV diagnoses,and 10 percent o the more than 26,000 AIDS diagno-ses, in the United States were attributed to injectiondrug use (IDU).20 Providing access to clean and sterilesyringes has proven to be one o the most effectiveand cost-eficient means o preventing the spread o blood-borne diseases among intravenous drug userswithout increasing drug use.21 While SSPs provideaccess to new syringes and safely dispose o used sy-ringes, they also can act as a “bridge to treatment andprevention services.”22 In many instances, SSPs also

provide naloxone for use in an opioid overdose, testingand counseling for HIV and hepatitis C, on-site medi-cal care, and information and referrals to treatment forsubstance use disorders.23

Despite evidence demonstrating the success o SSPs,attitudes toward these programs vary widely. The2014 National Survey o Syringe Exchange Programsfound 204 programs operating in 116 cities and 33states, although not every state with SSPs has a corre-sponding law to allow them. In 2015, the SLC stateso Kentucky and West Virginia joined those ranks.Research shows SSPs that receive public funding havemore success at reducing incidences o HIV and main-taining already low incidence rates.24 With a ban onexpending federal funds on SSPs dating back to 1988,oversight and funding largely has fallen on the shoul-ders o local and state governments.

Not only do SSPs provide public health beneits forusers, they also protect law enforcement and otherpublic safety oficials from the dangers o inadvertentneedlesticks.25 Most often, these occupational hazards

G Research estimates that the perpetual lifetime cost o treatingan HIV-positive person is between $385,200 and $618,900, com-pared to the estimated cost o 52-cents per syringe for SSPs.H While it will not be addressed in this Regional Resource, statesalso have provided access to clean and sterile syringes by allow-ing over-the-counter sales with or without a prescription.


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occur during the search o a person or his or her be-longings, with one often-cited study estimating thatas many as one in three oficers will have a needle-stick during their career.26 While SSPs can help reducethe chances that a needlestick will result in infection,decriminalizing their possession can help reduce theoccurrence o a needlestick altogether. To provide this

additional protection to law enforcement oficers, statescan fully decriminalize their possession by removinghypodermic needles and syringes from the deinitiono “drug paraphernalia” or partially decriminalize their

possession by providing a limited immunity in certainsearch situations. The latter allows a subject to notifylaw enforcement o the presence o potentially dan-gerous needles or other sharp objects prior to themor their possessions being searched. This pre-searchnotiication or afirmative response to law enforce-ment inquiry can provide immunity from applicable

drug-related charges stemming from such possession. Toprovide the most incentive to individuals to participate

in syringe exchange programs or admit to possession o

such objects, it is important that immunity be provided

for possession o drug paraphernalia and for possession

o a controlled substance as it relates to trace amountsthat may be found in the syringe.

Medication-Assisted Treatment

Medication-Assisted Treatment (MAT) is an evi-dence-based treatment for opioid addiction that focus-es on treating the whole patient through a combineduse o behavioral therapy and medications. Meth-adone has been the most widely used medication totreat opioid dependence for decades. In 2002, the FDAalso approved buprenorphine with and without nal-oxone. Both are maintenance medications that reducecravings for heroin and other opioid drugs and pre-vent or curb withdrawal symptoms for addicts with-out producing the euphoric high o opioids. Meth-adone, which only can be dispensed by federal andstate regulated opioid treatment programs, generallyis effective only for as long as it is taken. Buprenor-

I In order for these provisions to be most effective, at-risk popula-tions also must be educated about the relevant decriminalizationand/or immunity laws. This education could pose consider-able challenges, as these populations may be dificult to reachthrough typical public communications. Thus, treatment cen-ters may be best equipped to disseminate this information toat-risk individuals.

phine, which only can be prescribed or dispensed bya specially trained and certiied physician, has lesspotential to be abused than methadone, but also is gen-erally more expensive per dose. Except under limitedcircumstances, such as pregnancy and naloxone-aver-sion, buprenorphine with naloxone is recommended.Suboxone is a common buprenorphine/naloxone com-

bination. In 2010, the FDA approved extended-releaseinjectable naltrexone for use as a tool to prevent re-lapse. Unlike methadone and buprenorphine, naltrex-one is not a controlled substance and can be prescribedwithout special training or certiication. Like nalox-one, naltrexone is an opioid antagonist. Vivitrol is acommon brand o naltrexone.

Despite widespread support and evidence o success intreating opioid dependence, MAT is not a tool that has been widely embraced.27 In fact, many drug court pro-

grams prohibit opioid-dependent participants fromutilizing medication-assisted treatment. Likewise, in-surance, including Medicaid, may not cover MAT ormay place limits on treatment for substance use disor-ders and how much it will cover.

Access to Treatment

The federal Mental Health Parity Act o 1996 (MHPA)enacted provisions to prohibit large group health plansfrom imposing annual or lifetime dollar limits on men-tal health beneits that were more restrictive than thelimitations placed on medical and surgical beneits.28 In2008, the federal Mental Health Parity and AddictionEquality Act (MHPAEA) extended the parity require-ment to include treatments for substance use disorders.Under the MHPAEA, health insurance plans that electto provide coverage for mental health and substanceuse disorders must provide the same level o beneitsas for traditional medical and surgical disorders and

J Federal law limits certiied physicians to treating no more than100 patients at a time.K Recent changes to the Diagnostic and Statistical Manual of Men-tal Disorders (DSM-5) combine the categories o substance abuse

and substance dependence into the single category o substanceuse disorder. Substance use disorders are measured based on theirlevel o severity ranging from mild to severe, and each speciicsubstance is considered a separate use disorder. For the purpos-es o this Regional Resource, the terms “substance abuse” and“substance use disorder” are used interchangeably, with the ter-minology used in each section mimicking the original source.


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diseases. These parity requirements prohibit, amongother things, inancial restrictions that impose higherco-pays or deductibles and more restrictive treatmentlimitations on the frequency or duration o servicesfor mental health and substance use disorders. Whilethese requirements set a baseline for states that chooseto adopt their own parity laws, they do not mandate

that health plans provide mental health or substanceuse disorder treatments and services; they apply only toplans that elect to provide these services in addition tomedical and surgical beneits.

In 2010, the federal Affordable Care Act built on theMHPAEA by requiring non-grandfathered plans inthe individual and small group markets to provideparity coverage for mental health and substance usedisorders as one o 10 Essential Health Beneits (EHB) beginning January 2014.29

Even when insurance provides coverage o treatmentand services for substance use disorders, one o thelargest obstacles many face is accessing these services.A national shortage o behavioral health providersleaves many with insuficient options for receivingthe care they need. Relatively low salaries and reim- bursement rates have led many providers to focustheir practices on the more lucrative healthcare ields.By one estimate, the addiction services ield will needto ill more than 330,000 jobs by 2020, just to keep upwith the growing demand.30

Treatment Alternatives to Incarceration

Data from the U.S. Department o Justice shows thatincarcerated offenders overwhelmingly are more likely

to have a history o heroin use than the general popu-lation. Reducing criminal activity, incarceration, andL Federal regulations implementing mental health parity un-der MHPAEA for some group plans, qualiied health plansunder the ACA, and Medicaid non-managed care benchmarkand benchmark equivalent plans were inalized in November2013. However, these rules do not extend to insurance provid-ed through Medicaid managed care and the Children’s Health

Insurance Program (CHIP). The Center for Medicaid andMedicare Services (CMS) issued rule proposals in April 2015 toextend parity requirements to these federal-state programs; a i-nal rule has not yet been issued.M Based on 2004 data, the most recent year for which data isavailable, approximately 8 percent o state prisoners reported

recidivism are just some o the positive impacts thatcan result from effective drug abuse policies. Following

years o study on the intersection between criminal justice and drug abuse, the National Institute on DrugAbuse (NIDA) found that drug abuse treatment foroffenders is the “most effective course for interrupt-ing the drug abuse/criminal justice cycle.”31 However,

effective treatment must address the individual needso each offender and requires a continuum o care that begins in prison and continues after release throughcommunity-based treatment programs. For those notincarcerated, drug courts, diversion programs, andtreatment conditions for pretrial release and probationhave shown to be effective. Accordingly, NIDA reportsthat outcomes for individuals who enter treatmentunder legal pressure can be as good as, or even betterthan, those who are not under legal pressure to obtaintreatment.32 For many, a successful treatment program

will include medical, psychological, and social servicesto address the concurrent problems drug-abusing of-fenders often face.

Harm Reduction

Collectively, these policies embrace the public healthphilosophy o harm reduction. Harm reduction strat-egies seek to reduce the negative consequences as-sociated with certain harmful behaviors. In doingso, the approach works toward addressing a largerissue by mitigating the severity o equally harmfulside effects. For example, policies that expand nalox-one access and those that encourage reporting over-dose-related medical emergencies can help reduce thenumber o overdose-related deaths; needle and syringeexchange programs help reduce the spread o HIVand hepatitis C among intravenous drug users; med-ication-assisted treatment helps reduce cravings forheroin and other opioids while improving the stabil-ity and functionality o opioid addicts; and providingtreatment and alternatives to incarceration help re-duce recidivism o certain repeat offenders by address-ing the underlying issues.

using heroin or other opiates in the month before their offense.At the same time, less than one-hal o 1 percent o the gener-al population reported using heroin or opiates within the pastmonth that year. (PEW, Public Safety Aspects o the HeroinAbuse Epidemic)


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RECENT ACTION IN THE

SLC MEMBER STATES

AlabamaNaloxone Access

In 2015, Alabama enacted House Bill 208 (HB 208) to

expand access to opioid antagonists approved by theFDA for the treatment o an opioid overdose. UnderHB 208, a licensed physician or dentist, acting in goodfaith, can prescribe an opioid antagonist to a personat risk o experiencing an opiate-related overdose.The prescription, which may be direct or by standingorder, also can be given to a family member, friend,or other individual, including law enforcement, whois in a position to assist the person experiencing theoverdose. As an indicator o good faith, the prescribing

physician or dentist may require a written statement

that provides a factual basis for the individual’s riskand the person’s relationship to the at-risk individual.The Bill also authorizes pharmacists to dispense thedrug pursuant to a prescription.

Additionally, under HB 208, a third-party individualwho receives an opioid antagonist prescription and believes, in good faith, that another person is experi-encing an opiate-related overdose, can administer thedrug. The Bill imposes a duty o reasonable care whenadministering the drug, which can be evidenced by thereceipt o basic instructions and information on howto administer the opioid antagonist.

I acting in accordance with these laws, prescribingphysicians or dentists, dispensing pharmacists, andthird-party administrators are immune from civil andcriminal liability. Alabama does not provide explicitprotections against professional discipline for pre-scribers or dispensers o opioid antagonists.

First Responders

House Bill 208 directs the Alabama Department o

Public Health to approve a training curriculum for lawenforcement oficers who elect to carry and adminis-ter opioid antagonists.

Good Samaritan Immunity

In addition to expanding access to opioid antagonists,HB 208 also provides immunity from prosecution fora misdemeanor controlled substance offense i law en-forcement became aware o the offense solely becausethe individual was seeking medical assistance for an-

other person. To qualify for this immunity, the indi-vidual must act in good faith, upon a reasonable beliethat he or she was the irst to call for asistance; mustuse his or her own name when contacting authorities;and must remain with the person needing medical as-sistance until help has arrived. Alabama law does notspecify that this immunity extends to the person forwhom medical assistance was sought or to someoneseeking their own medical assistance. It also should be noted that Alabama’s Good Samaritan protectiononly applies to misdemeanor offenses and does not ex-

tend to felony controlled substance offenses like mostother SLC states.

ArkansasNaloxone Access

In 2015, Arkansas enacted Senate Bill 880 (SB 880), alsoknown as the Naloxone Access Act, to expand accessto potentially life-saving opioid antagonists. UnderSB 880, a healthcare professional acting in good faithcan prescribe, directly or by standing order, and dis-pense an opioid antagonist to: (1) a person at risk oexperiencing an opioid-related drug overdose; (2) afamily member or friend o an at-risk person; (3) a painmanagement clinic; (4) a harm reduction organiza-tion; (5) an emergency medical technician; (6) a irstresponder; or (7) a law enforcement oficer or agen-cy. An individual acting in good faith may adminis-ter the prescribed opioid antagonist i he or she rea-sonably believes that another person is experiencingan opioid-related overdose.

The Act also provides immunity from civil and crim-inal liability and from professional sanctions to the

prescribing healthcare professional, the dispensinghealthcare professional or pharmacist who acts ingood faith and in compliance with the appropriatestandard o care, and an individual other than a health-care professional who administers the antagonist.


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Arkansas does not set out any training requirementsfor prescribers, dispensers, or administrators o nalox-one and other opioid antagonists.


In 2015, Arkansas also enacted Senate Bill 543, known

as the Joshua Ashley-Pauley Act. The Act providesimmunity from arrest, charge, or prosecution for pos-session o a controlled substance i the evidence forthe charge is solely the result o the individual seek-ing medical assistance, in good faith, for himsel orherself, or another person who is experiencing a drugoverdose. The act o “seeking medical assistance” in-cludes contacting or assisting in contacting 911, lawenforcement, or poison control, and providing care toa person believed to be experiencing a drug overdose.Arkansas does not speciically require individuals to

give their name to qualify for immunity. I related toseeking medical assistance, Arkansas also provides im-munity from penalties for violating a protective or re-straining order or sanctions for violating a conditiono pretrial release, probation, or parole, for possessiono a controlled substance.

These provisions do not provide immunity from anycharge other than possession o a controlled substance.Additionally, they do not prohibit the seizure and ad-missibility o protected evidence in other criminalproceedings nor the detention o an immune individu-al in relation to another investigation or offense.

Syringe Exchange Programs

Although Arkansas does not have a statute directlyauthorizing syringe exchange programs, it is possibleto interpret a portion o the Naloxone Access Act asan indirect authorization for their existence. Arkan-sas is one o two SLC states that speciically allows aprescription for naloxone to be given to a harm reduc-tion organization. Under the Act, “harm reduction or-ganization” is deined as an organization that provides

direct assistance and services such as syringe exchang-es, counseling, homeless services, advocacy, and drugtreatment and screening to individuals at risk o expe-riencing a drug overdose. Despite this statutory refer-ence to syringe exchanges, it should be noted that hy-

podermic syringes, “used, intended for use, or designedfor use in… injecting a controlled substance…” remainclassiied as drug paraphernalia.33

FloridaNaloxone Access

In 2015, Florida enacted House Bill 751 (HB 751), alsoknown as the Emergency Treatment and RecoveryAct, to expand access to emergency opioid antagonistsfor patients and caregivers and to encourage their pre-scription by authorized healthcare practitioners. Infurtherance o this goal, HB 751 authorizes healthcarepractitioners to prescribe the drug to an at-risk indi-vidual or caregiver and authorizes healthcare prac-titioners and pharmacists to dispense the drug pursu-ant to that prescription. While the Act does authorizethird-party prescriptions, it does not speciically au-

thorize standing orders. When dispensing the drug,it must be appropriately labeled with instructions foruse. The Act further authorizes emergency respondersto possess, store, and administer emergency opioid an-tagonists as clinically indicated.

When a physician is not immediately available, an at-risk individual or caregiver who is authorized to pos-sess and store approved emergency antagonists can ad-minister the drug to someone believed, in good faith,to be experiencing an opioid overdose, regardless owhether the victim has a prescription for the drug.

The Act provides civil immunity to individuals whopossess, administer, prescribe, dispense, or store anapproved emergency opioid antagonist from any civ-il damages that result from gratuitously, and in goodfaith, rendering emergency care. Likewise, a health-care practitioner or pharmacist acting in good faithand exercising reasonable care is immune from civil orcriminal liability and professional discipline that mayresult from prescribing or dispensing an emergencyopioid antagonist. Florida does not explicitly provide

criminal or professional immunity for administrationo opioid antagonists.N Florida deines “caregiver” as a family member, friend, or per-son in a position to have recurring contact with a person at risko experiencing an opioid overdose.


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In 2012, Florida became the irst SLC member state toprovide protection for reporting a drug-related over-dose with the enactment o Senate Bill 278, the 911Good Samaritan Act.34 Under the Act, an individualwho, in good faith, seeks medical assistance for some-

one experiencing a drug-related overdose cannot becharged with, prosecuted, or penalized for possessiono a controlled substance i the evidence was obtainedas a result o doing so. Likewise, a person experienc-ing an overdose who is in need o medical assistancecannot be charged, prosecuted, or penalized for pos-session o a controlled substance i the evidence wasobtained as a result o the overdose and need for med-ical assistance.

The immunity protection from prosecution cannot be

used as grounds for suppression o evidence in othercriminal prosecutions; however, it can be used as mit-igating evidence. Under Florida’s sentencing guide-lines, evidence o a good faith effort to obtain or pro-vide medical assistance for an individual experiencinga drug-related overdose can be considered as mitigatingcircumstances to reasonably justify deviation from theminimum established sentence for a felony offense. 35


and Criminal JusticeIn Fiscal Year 2015, the Florida Legislature appro-priated $3 million ($1 million in recurring fundsand $2 million in nonrecurring funds) for injectableextended-release naltrexone to treat alcohol- andopioid-addicted offenders in court-ordered commu-nity-based drug treatment programs.36 In Fiscal Year2016, the Legislature increased its commitment tomedication-assisted treatment in the criminal justicesystem with a $3 million appropriation o recurringgeneral funds for naltrexone to treat alcohol- andopioid-addicted individuals in the criminal justice sys-

tem, individuals who have a high likelihood o criminal

justice involvement, or individuals in court-orderedcommunity-based drug treatment.37 With a single dose

o Vivitrol estimated to cost about $1,000, the fundsallow offenders to obtain the medication for free.38

O Vivitrol is the brand name for injectable extended-releasenaltrexone.

In both iscal years, an additional $500,000 in recur-ring funds was appropriated for naltrexone treatmentwithin the state Department o Corrections.

GeorgiaNaloxone Access

In 2014, Georgia enacted House Bill 965 (HB 965) to

expand access to naloxone. Under HB 965, a licensedphysician, acting in good faith and in compliance withthe applicable standard o care, may prescribe an opi-oid antagonist to a person at risk o experiencing anopioid-related overdose, or to a pain managementclinic, irst responder, harm reduction organization,family member, friend, or other person in a positionto assist the at-risk individual. The prescribed opioidantagonist is to be used in accordance with protocolsspeciied by the physician. Pursuant to a physician’sprescription, a pharmacist, acting in good faith and in

compliance with the applicable standard o care, maydispense opioid antagonists. Likewise, a person actingin good faith and with reasonable care may adminis-ter the prescribed drug, in accordance with prescriberprotocols, to another person believed to be experienc-ing an opioid-related overdose.

The Bill provides immunity from civil and criminalliability and professional sanctions to the prescrib-ing or dispensing physician or pharmacist who actsin good faith and in compliance with the appropriatestandard o care. This immunity also extends to anyperson acting in good faith, other than a physician,who administers the antagonist.

Georgia does not set any training requirements forprescribers, dispensers, or administrators o naloxoneand other opioid antagonists.

First Responders

House Bill 965 also authorizes irst responders to ad-minister or provide an opioid antagonist for the pur-pose o saving the life o a person experiencing an

opioid overdose. The statute deines “irst responder”as any person or agency who provides on-site careuntil the arrival o a duly licensed ambulance serviceincluding, but not limited to, persons who routinelyrespond to calls for assistance through an afiliationwith law enforcement agencies, ire departments, and


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rescue agencies. All law enforcement agencies, ire de-partments, rescue agencies, and other similar entitiesare required to notify the appropriate emergency med-ical service system that its personnel possess and main-tain opioid antagonists. All irst responders who haveaccess to or maintain an opioid antagonist must receivetraining deemed appropriate by the state Department

o Public Health.39 Additionally, irst responders mustmake available a report o administering or providingan opioid antagonist to the licensed ambulance servicethat transports the patient.

Under the Bill, a irst responder who, gratuitously, andin good faith, renders emergency care or treatment byadministering or providing an opioid antagonist willnot be liable for any resulting civil damages from thatcare or treatment, or as a result o any act or failure toact in providing or arranging for further medical treat-

ment, absent gross negligence or an intent to harm.

In accordance with existing Georgia law, a licensedpharmacy in the state can issue opioid antagonists toirst responders under a contract with the director oan emergency service provider.40 Additionally, a man-ual o policies and procedures for the safe handling,storage, labeling, and record keeping o all drugs must be written, approved, and signed by the medical direc-tor o an emergency service provider and the phar-macist in charge o an issuing pharmacy. Annually,a pharmacist from the contracting pharmacy mustphysically inspect the drugs to determine compli-ance with appropriate policies and procedures for thehandling, storage, labeling, and record keeping o alldrugs. A written record o all drugs issued to the med-ical director o an emergency service provider must be maintained by the issuing pharmacy and emergen-cy service provider. Within 72 hours o using a drug,the emergency service provider is to transmit a writ-ten record to the issuing pharmacy to provide propercontrol and accountability o the drugs. In accordancewith the law, all outdated, expired, unused, or unus-

able drugs shall be returned to the issuing pharmacyfor proper disposition.

Additionally, HB 965 authorizes emergency medicaltechnicians, paramedics, and certiied cardiac tech-

nicians to administer opioid antagonists pursuant totheir existing professional certiication.


In a webinar hosted by the Southern Legislative Con-ference, Robert Childs, director o the North CarolinaHarm Reduction Coalition, described Georgia’s Good

Samaritan law as the “gold standard” for the Southernregion, and one that “should be replicated by otherstates.” 41

The Georgia 9-1-1 Medical Amnesty Law, also enactedin 2014 as part o HB 965, provides immunity from ar-rest or prosecution for a drug violation to any personwho, in good faith, seeks medical assistance for anoth-er person experiencing or believed to be experiencinga drug overdose, i the evidence is obtained solely as aresult o seeking medical assistance. Likewise, the law

provides protection from related penalties for violat-ing a protective or restraining order or sanctions forviolating a condition o pretrial release, probation, orparole.

This immunity extends to an individual experiencingan overdose who seeks medical assistance or is the subject o a third party’s request. The act o “seeking med-ical assistance” includes contacting or assisting in con-tacting 911, law enforcement, or poison control, andproviding care to the person while awaiting the arriv-al o medical assistance. These provisions do not pro-vide immunity from any charge other than possessiono a controlled substance. They also do not prohibitthe seizure and admissibility o protected evidence inother criminal proceedings nor the detention o an im-mune individual in relation to another investigationor offense.

Syringe Exchange Programs

Like Arkansas, Georgia does not have a statute directlyauthorizing syringe exchange programs; however, thestate’s naloxone access law could be interpreted as in-

direct authorization. Similarly, in Georgia, a licensedphysician can issue a prescription for opioid antago-P A drug violation includes possession below certain amountso a controlled substance or marijuana or possession and use odrug-related objects.


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nists to a harm reduction organization, the deinitiono which includes services “such as syringe exchanges.”While Georgia’s deinition o “drug-related object”does not speciically reference hypodermic syringes orneedles, they reasonably would be considered to meetthe classiication as something intended “to introduce”a dangerous drug or controlled substance into the hu-

man body.42

Kentucky

Suffering from one o the highest rates o heroin usageand hepatitis C in the country, Kentucky took signii-cant steps to ight the heroin epidemic during the 2015legislative session. The focus o Senate Bill 192 (SB 192)is to help addicts receive the treatment and recoverynecessary to overcome a substance use disorder. To ac-complish this goal, SB 192 authorizes a variety o toolsto provide immediate and long-term treatment to indi-

viduals, including the incarcerated and pregnant. Hop-ing to prevent others from becoming addicts, the Billalso imposes harsher penalties for those who provideheroin to others.

Then-House Judiciary Committee chairman, Repre-sentative John Tilley, called the Bill a “truly bipartisaneffort... [with a] three-pronged approach: prevention,treatment, and targeting o trafickers.”43

Naloxone Access

In 2013, Kentucky enacted House Bill 366, which ex-panded access to naloxone by allowing licensed health-care providers to prescribe, directly or by standingorder, or dispense the drug to an at-risk individualcapable o administering the drug for an emergencyopioid overdose.44 In 2015, with SB 192, Kentucky ex-panded this access further to allow the drug to be pre-scribed or dispensed to a person other than the at-riskindividual, or to an agency. As under the 2013 law,a licensed healthcare provider who acts in good faithwill not be subject to professional discipline or relatedadverse actions as a result o providing, dispensing, or

omitting to do so. Under the amended law, this profes-sional immunity also extends to a pharmacist certiiedfor dispensing naloxone.Q An agency includes a peace oficer, jailer, ireighter, paramed-ic, EMT, or authorized school employee.

The person or agency deemed capable o administeringthe drug by a licensed healthcare provider is autho-rized, under SB 192, to receive a prescription for nalox-one, possess the drug and any necessary equipment, andadminister the drug to an individual suffering from anapparent overdose. A naloxone prescription provideddirectly to an individual at risk o suffering an opioid

overdose may also authorize administration by a thirdparty so long as the instructions include a requirementfor the third-party administrator to immediately noti-fy the appropriate local public safety authority to thesituation.

A person who, in good faith, administers naloxoneunder these provisions will be immune from civ-il and criminal liability unless the personal injury isthe result o gross negligence or willful and wantonmisconduct.

The board o each local public school district and gov-erning body o each private or parochial school ordistrict can authorize a school to keep naloxone onthe premises and regulate its administration to anyindividual suffering from an apparent opiate-relatedoverdose. Local schools and school districts are direct-ed to collaborate with state and local health entitiesto develop clinical protocols addressing the supply onaloxone kept at schools and advise on clinical admin-istration o the drug.

TrainingSenate Bill 192 directs the Kentucky Board o Pharma-cy to establish requirements for the certiication, edu-cation, operation, and protocol related to pharmacistsdispensing naloxone. The regulations promulgatingthese requirements must (a) require that any dispens-ing only be done in accordance with a physician-ap-proved protocol and specify the minimum requiredcomponents o that protocol; (b) include a mandato-ry education requirement on the mechanism and cir-cumstances for the administration o naloxone for the

person to whom the drug is dispensed; and (c) requirethat a record o the dispensing be made available to aphysician who signed the protocol, i the physician sodesires. In addition to these required regulation provi-sions, the Board also may promulgate rules to establisha supplemental educational or training component for


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a pharmacist seeking naloxone certiication and maylimit the forms o naloxone and means o administra-tion that can be dispensed by a pharmacist.

In addition to training for pharmacists, SB 192 directsthe state Department o Criminal Justice Training tooffer voluntary in-service training for law enforce-

ment oficers that includes instructional materials onthe detection and interdiction o heroin traficking,the dynamics o heroin abuse, and available treatmentoptions for addicts.


Under SB 192, an individual will be immune fromprosecution for possession o a controlled substanceor drug paraphernalia i he or she, in good faith, seeksmedical assistance for a drug overdose and the evidenceresulted from the overdose and necessary medical as-

sistance. The immunity applies to both the individualrequiring medical assistance and to the individual whoseeks medical assistance. The latter must remain withthe overdose victim until the requested assistance isprovided.

A law enforcement oficer also will be immune fromcivil or criminal liability for false arrest or imprison-ment i an arrest based on probable cause is made inviolation o these Good Samaritan provisions.

I the person requesting medical assistance providesappropriate contact information, it should be report-ed to the local health department. Subsequently, thehealth department must contact the individual to offerreferrals regarding substance abuse treatment, i ap-propriate.

Emergency Overdose Treatment Referrals

In addition to providing immunity from prosecutionfor possession o a controlled substance or drug para-phernalia, an individual seeking assistance at a hospi-tal emergency department for an overdose also can re-

ceive assistance in procuring treatment for a substanceuse disorder. Senate Bill 192 requires that the person be informed o known, local treatment services forsubstance use disorders. Subject to permission fromthe individual or the individual’s legal representative,the hospital can connect the individual with treatment

by contacting an available program on his or her be-half. Additionally, a local community mental healthcenter may provide on-call services in the hospitalemergency department to distribute information ontreatment services for substance use disorder and con-nect an individual who was treated for a drug overdosewith those services.

Syringe Exchange Programs and

Partial Decriminalization

In addition to an increase in heroin use, Kentuckyalso has seen an uptick in cases o hepatitis C and HIV.According to the CDC, the commonwealth has thehighest rate o reported hepatitis C cases in the coun-try.45 In 2013, the most recent year for which data isavailable, the CDC reports the national average to be0.7 cases per 100,000 people; comparatively, the rate oreported hepatitis C cases in Kentucky in 2013 was 5.1

cases per 100,000 people.46

In response to this alarmingtrend, SB 192 also authorized local health departmentsto operate hypodermic needle and syringe exchangesas part o a substance abuse treatment program. Tooperate an exchange program, the local departmento health must receive consent from the local boardo health and the legislative body in the city or countywhere the program will operate. Under the Bill, ex-changed items will not be considered drug parapher-nalia while located at the program site.

Additionally, SB 192 provides some immunity fromprosecution for possession o a controlled substance ordrug paraphernalia as they relate to needles and othersharp objects. Prior to searching an individual and hisor her premises or vehicle, a peace oficer can inquireas to the presence o any needles or other sharp objectsthat could cut or puncture the oficer while search-ing the area. I the subject o the search admits to thepresence o such objects prior to the search, chargesor prosecution for possession o drug paraphernaliaor for possession o trace amounts o a controlled sub-stance on the object will not be incurred. However,

this exemption does not extend to any other drug par-aphernalia or controlled substances that may be pres-ent and discovered during the search.R The deinition o peace oficer varies by state, but generally in-cludes any employee o the state or other public agency with theauthority to make arrests.


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Following the enactment o SB 192, the LouisvilleDepartment o Public Health and Wellness began op-erating the commonwealth’s irst needle exchangeprogram in June 2015. The program, which operatessix days a week at the health department’s down-town headquarters, is funded mostly by the localgovernment.

Although health oficials budgeted for 500 participantsduring the program’s irst year, the irst four monthso operations far exceeded expectations:

» 822 individuals participated in the program, with 325o those returning at least once;

» 55 individuals were referred to an on-site certiiedsubstance abuse counselor;

» 103 individuals were voluntarily tested for HIV, withnone testing positive; and

» 36 individuals were voluntarily tested for hepatitis C,with approximately 14.4 testing positive.

In response to the program’s success, Louisville healthoficials are expanding the program to include a satel-lite needle exchange site at a ire station in southwest-ern Louisville. The community exchange site beganoperating one day a week in October 2015.

A second exchange program was approved in Lexing-ton-Fayette County, which began operating in Sep-tember 2015.

Effectiveness of Substance Abuse Treatment

Contingent on available funding, SB 192 directs theCabinet for Health and Family Services and the Oficeo Drug Control Policy to initiate a pilot program toanalyze the outcomes and effectiveness o substanceabuse treatment services in Kentucky. Data will beanalyzed to determine practices that reduce frequencyo relapse, provide better outcomes for patients, holdpatients accountable, and control health costs relatedto substance abuse. This analysis is intended to help

ensure the commonwealth is addressing appropriaterisk and protective factors for substance abuse in a de-ined population; using approaches that have shownto be effective; intervening early at important stagesand transitions; intervening in appropriate settings

and domains; and managing programs effectively. Ata minimum, the data will come from the state Depart-ment for Medicaid Services, Department o Workers’Claims, and KASPER, the commonwealth’s controlledsubstance electronic monitoring system.

The Cabinet for Health and Family Services and Of-

ice o Drug Control Policy must issue a joint report tothe Legislative Research Commission and Ofice o theGovernor by December 31, 2016, on the indings o thepilot program. The report is to include recommenda-tions based on those indings for optimizing substanceabuse treatment services and recommendations on thecontinued use o analytics to augment Kentucky’s ap-proach to ighting substance abuse in the future.

Expanded Treatment Options

Under SB 192, individuals addicted to heroin and other

opioids now will have access to treatment options thatpreviously were not available. Perhaps the most sig-niicant change is the authorization o medication-as-sisted treatment. Prior to the enactment o SB 192, re-covery options in the commonwealth typically werelimited to 12-step or abstinence-only programs.

Senate Bill 192 requires the state Department o Med-icaid Services to provide beneits for a broad array otreatment options for those with heroin and othersubstance use disorders and to expand the behavior-al health network to allow providers to offer serviceswithin their licensure category. Medicaid managedcare organizations are directed to authorize treatmentfor each diagnosis related to substance use disorder andco-occurring mental health/substance use disordersand to approve coverage and payment for an appropri-ate level o continued care. Beginning January 1, 2016,the Department o Medicaid Services will be requiredto provide an annual report to the Legislative ResearchCommission detailing the number o substance usedisorder treatment providers; types o services offered by each provider; geographic distribution o providers;

and a summary o expenditures on substance use dis-order treatment provided by Medicaid. Additionally,Kentucky now exempts certain residential substanceuse disorder treatment programs from its Certiicateo Need requirements.


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Another treatment option available under SB 192 isa faith-based residential treatment program. Certainoffenders charged with a controlled substance felonyoffense now may be able to utilize a faith-based resi-dential treatment program in lieu o substance use dis-order treatment, i the cost o the program is less thanthe treatment that otherwise would be provided. To

participate, the offender must sign a commitment tocomply with the terms o the program.

Neonatal Abstinence Syndrome

A particular focus o Senate Bill 192 provides substanceabuse treatment for pregnant women. The legislationrequires substance abuse treatment and recovery ser-vice providers who receive state funds to give priorityfor accessing those services to pregnant women. Like-wise, those providers may not refuse access to appro-priate services solely due to a woman’s pregnancy.

Under SB 192, a petition may not be iled to termi-nate the parental rights o a woman solely on the ba-sis o her use o a non-prescribed controlled substanceduring pregnancy i she enrolls in, and maintains sub-stantial compliance with, a substance abuse treatmentor recovery program and a regimen o prenatal care asrecommended by her healthcare practitioner through-out the remainder o the pregnancy. After a womanhas completed treatment, or six months o substantialprogram compliance after giving birth, whichever isearlier, the court must seal any records relating to apositive test for a non-prescribed controlled substance.The sealed records may not be used in any future crim-inal prosecution or petition to terminate parentalrights.

Corrections Reinvestment in Substance

Abuse Treatment

In 2011, Kentucky adopted a series o criminal justicereforms as part o its justice reinvestment initiative.Among the provisions enacted in the 2011 Public Safe-ty and Offender Accountability Act (House Bill 463),

the Department o Corrections is required to measureand document the cost savings resulting from these re-forms and reinvest a portion o those savings as direct-ed by statute. Furthermore, in addition to the 25 per-cent already being distributed to the local corrections

assistance fund, SB 192 o 2015 directs that 50 percento the savings, up to $10 million in 2015-2016, be al-lotted to speciic substance abuse programs and re-sources: evidence-based treatment programs in countyor regional jails and local detention centers; addition-al treatment resources at community mental healthcenters; addressing neonatal abstinence syndrome

through community residential treatment services forpregnant women; traditional treatment programs pro-vided by the Kentucky Agency for Substance AbusePolicy; purchasing an FDA-approved extended-releasetreatment for medically assisted treatment programs;developing additional individualized alternative sen-tencing plans; and enhancing the use o rocket docketprosecutions in controlled substance cases.

Increased Penalties for Heroin Trafficking

Coupled with the effort to improve access to treatment

for substance use disorders, Kentucky also ampliiedefforts to crackdown on the suppliers o heroin. Sen-ate Bill 192 created a new felony for importing heroinand irst-degree aggravated traficking in a controlledsubstance. The offense o importing heroin is deinedas “knowingly and unlawfully transporting, by anymeans, any quantity o heroin into the commonwealthwith the intent to sell or distribute the drug.” Know-ingly and unlawfully traficking 100 or more grams oheroin constitutes the crime o irst-degree aggravat-ed traficking in a controlled substance. An individualconvicted o either crime must serve at least 50 percento the sentence imposed before being eligible for probation, shock probation, conditional discharge, or pa-role.

The Bill also expands the scope and increases thesentence for the existing crime o irst-degree traf-icking o a controlled substance. First, the Bill addsS A rocket docket refers to the speedy disposition o cases andcontroversies by a court or tribunal, often by strictly adheringto the law pertaining to iling deadlines and other procedur-al matters.T

Shock probation is a sentencing strategy under which a judgeorders a convicted offender to prison for a short period o time before suspending the remainder o the sentence in favor oprobation. The intended outcome is that the initial shock oexperiencing prison will provide an effective deterrent fromrecidivism.


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fentanyl to the list o controlled substances includedin the crime o traficking. Second, the Bill imposesincreased sentencing requirements for traficking oheroin. When less than 2 grams o heroin is discoveredand the offense is committed while possessing morethan one item o paraphernalia, then the convicted in-dividual must serve at least 50 percent o the sentence

imposed before being released on parole, i the totalityo the circumstances indicates that the traficking wasa criminal activity. Likewise, the conviction for all of-fenses o selling 2 or more grams o heroin, and secondor subsequent offenses for less than 2 grams o heroin,requires at least 50 percent o the sentence is served be-fore being eligible for any form o early release. Thenew “50-percent-served” requirements do not applyfor irst-degree traficking o controlled substancesother than heroin.

In addition to these crimes, SB 192 provides that anyoffender convicted o homicide or fetal homicide inwhich the victim’s death was the result o an overdoseo a Schedule I controlled substance, including heroin,must serve at least 50 percent o their sentence prior to being eligible for early release.

LouisianaNaloxone Access

In 2015, Louisiana enacted House Bill 210 (HB 210) toexpand access to opioid antagonists for the treatmento a controlled substance overdose. Under HB 210, a li-censed medical practitioner can, directly or by standingorder, prescribe or dispense an opioid antagonist with-out having examined the individual to whom it will beadministered i two conditions are met: (1) the drug isprescribed or dispensed for administration through anFDA-approved device and (2) the practitioner providesthe individual receiving and administering the drugwith all training required by the state Department oHealth and Hospitals (DHH). Likewise, a licensed phar-macist may dispense an opioid antagonist pursuant tothe direct or standing prescription o a licensed medical

U Fentanyl is a synthetic opioid typically used for treating painin cancer patients and extreme chronic pain. Classiied as aSchedule II controlled substance, fentanyl is 100 times strongerthan morphine and 30 to 40 times stronger than heroin. Fen-tanyl has begun to surface in heroin mixtures, increasing thepotency and risk o overdose for the already deadly drug.

practitioner. A licensed medical practitioner or phar-macist who prescribes or dispenses an opioid antago-nist in good faith is immune from civil or criminal li-ability or professional discipline resulting from the actor omission.

The Bill also extends civil and criminal immunity to

an individual who, in good faith, administers an opi-oid antagonist to a person reasonably believed to beundergoing an opioid-related drug overdose, absentgross negligence or willful and wanton misconduct inadministering the drug.

Training

House Bill 210 directs the DHH to establish trainingrequirements for individuals who receive and admin-ister an opioid antagonist to ensure safe and proper ad-ministration o the drug. The training, which is to be

provided by the prescribing or dispensing practitioner,must, at a minimum, address: (1) techniques on how torecognize an opioid-related overdose; (2) standards andprocedures for storage and administration o opioidantagonists; and (3) emergency follow-up procedures,including the requirement to summon emergency ser-vices either immediately before or immediately afteradministering the drug. The Bill also directs the DHHto promulgate a set o best practices for use by licensedmedical practitioners in prescribing and dispensingopioid antagonists. These best practices must addressmany o the same items required in the training for lay-persons who receive and administer the drug.

First Responders

Prior to expanding access to opioid antagonists forthird-party individuals in 2015, Louisiana enacted apair o bills in 2014 to expand access to the drug forirst responders: House Bill 754 (HB 754), under thePublic Health and Safety Title, and Senate Bill 422(SB 422), under the Criminal Law Title.

Under HB 754, a irst responder may receive a pre-

scription for an opioid antagonist, maintain possessiono the drug, and administer it to anyone believed to beundergoing an opioid-related drug overdose. The Billdeines “irst responder” as a peace oficer, ireighter,or an EMS practitioner. Prior to receiving a prescrip-tion, the irst responder must complete the necessary


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training to safely and properly administer the drug.Additionally, a record must be kept o each instancein which the drug was administered. A irst responderwho administers an opioid antagonist to a person be-lieved to be experiencing an opioid-related drug over-dose is immune from civil, criminal, and professionalliability or discipline for any outcomes resulting from

the administration o the drug, absent gross negligenceor willful and wanton misconduct.

House Bill 754 authorizes a law enforcement agencyor ire department to enter into a written agreementfor afiliation with an ambulance service provider orphysician for the purpose o obtaining a supply o anopioid antagonist or to obtain the training necessaryto safely and properly administer the drug.

Similarly, SB 422 authorizes irst responders to ad-

minister an opioid antagonist, without a prescription,upon encountering an individual exhibiting signs oan opiate overdose. Likewise, prior to administra-tion, the irst responder must complete the necessarytraining on safe and proper administration o thedrug. A notable deviation from HB 754 is that SB 422deines “irst responder” as a law enforcement oficial,emergency medical technician, ireighter, or med-ical personnel at secondary schools and institutionso higher education. Additionally, there is no explicitrequirement to maintain records o administering thedrug. Furthermore, SB 422 provides immunity onlyfrom civil liability to a irst responder who adminis-ters an opioid antagonist in a manner consistent withaddressing opiate overdose. This immunity extendsto civil damages that result from any act or omissionin rendering care, or as a result o any act or failureto act to provide or arrange for further medical treat-ment or care for the person involved in the emer-gency, absent gross negligence or willful and wantonmisconduct.

Under both 2014 bills, the training for irst responders

must, at a minimum, cover techniques on how to rec-ognize symptoms o an opioid-related overdose; stan-dards and procedures for the storage and administra-tion o an opioid antagonist; and emergency follow-upprocedures. Additionally, the state Department o

Public Safety and Corrections is directed to developand promulgate a set o best practices for use by a iredepartment or law enforcement agency. Those bestpractices should include, but are not limited to, train-ing necessary to safely and properly administer an opi-oid antagonist; standards and procedures for storageand administration o the drug; and emergency fol-

low-up procedures.


Senate Bill 422 also provides immunity from prosecu-tion or penalty for possession o a controlled substanceunder certain circumstances. A person who experi-ences a drug-related overdose and is in need o medicalassistance shall not be charged, prosecuted, or penal-ized for possession o a controlled substance i the evi-dence was obtained as a result o the overdose and needfor medical assistance. Likewise, a third party who,

in good faith, seeks medical assistance for another in-dividual experiencing an overdose is immune fromprosecution or penalization for possession o a con-trolled dangerous substance i the evidence is obtainedas a result o seeking the medical assistance. A notableexception in Louisiana’s Good Samaritan law is thatthird-party immunity does not apply i the person ille-gally provided or administered a controlled substanceto the individual needing medical assistance.

Increased Penalties for Heroin Distribution

In 2014, Senate Bill 87 was enacted to increase theminimum sentence for distribution or possession withintent to distribute Schedule I narcotic drugs fromive to 10 years. Similarly, the state also increased theminimum number o years that must be served priorto being eligible for probation or a suspended sentencefrom ive to 10 years. No changes were made to themaximum sentence o imprisonment, which remained50 years, and the maximum ine, $50,000. At the sametime, the state established stiffer penalties i the Sched-ule I narcotic is heroin or a mixture or substance con-taining a detectable amount o heroin or its analogues.

The penalties for conviction o a irst offense for distribution or possession with intent to distribute remainedthe same, but for second or subsequent heroin-relatedoffenses, the maximum sentence was increased from50 years to 99 years.


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MississippiNaloxone Access

In 2015, Mississippi enacted House Bill 692 (HB 692),known as the Emergency Response and Overdose Pre-vention Act. Under the Act, a licensed practitionermay, in good faith and in compliance with the applica-

ble standard o care, prescribe, directly or by standingorder, an opioid antagonist to a person at risk o expe-riencing an opioid-related overdose. The practitioneralso may issue a prescription to a registered pain man-agement clinic, family member, friend, or other per-son in a position to assist the at-risk individual. Pursu-ant to a prescription, a pharmacist, acting in good faithand in compliance with the applicable standard o care,may dispense opioid antagonists.

Following the receipt o a prescribed opioid antago-

nist, an individual, acting in good faith and with rea-sonable care, may administer the drug to a person be-lieved to be experiencing an opioid-related overdose.Additionally, HB 692 authorizes emergency medicaltechnicians, acting in good faith, to administer opioidantagonists as clinically indicated.

A prescribing practitioner, dispensing pharmacist, ad-ministering EMT, or third-party administrator, actingin accordance with these provisions, is immune fromany civil or criminal liability, or any professionalsanctions, where applicable.


House Bill 692 also enacted the Mississippi MedicalEmergency Good Samaritan Act. The Act providesimmunity from arrest and prosecution for a drug vi-olation to any person who, in good faith, seeks medicalassistance for someone experiencing a drug overdose ithere is evidence that the person is under the inluenceor in possession o a controlled substance. This immu-nity also extends to the individual for whom the thirdparty sought medical assistance or for an individual

who, in good faith, is seeking medical assistance. Theterm “seeking medical assistance” is deined by theAct as contacting or assisting in contacting 911, lawenforcement, or poison control, or providing care toa person experiencing or believed to be experiencinga drug overdose while awaiting the arrival o medical

assistance to aid the person. Under this immunity, anindividual also cannot be subject to penalties for viola-tion o a protective or restraining order, sanctions forviolations o pretrial release, probation, or parole con-ditions based on a drug violation, or certain propertyforfeiture for a drug violation. In the SLC region, Mis-sissippi is the only state that extends this Good Samar-

itan immunity to civil forfeiture. The immunity doesnot limit admissibility o evidence in connection withthe investigation or prosecution o a crime for a de-fendant who does not qualify for the immunity or forother crimes committed by a qualiied person; limit theseizure o evidence or contraband otherwise permitted by law; or abridge the authority o law enforcement todetain or take into custody a person in the course o aninvestigation or to effectuate an arrest for any other of-fense. Unlike other SLC states, Mississippi law does notstate that the immunity applies only i the evidence is

the result o seeking medical assistance.Missouri

O the 15 SLC member states, Missouri is the onlystate that has not yet enacted provisions to authorizenaloxone access for laypersons; however, in 2015, leg-islation was under consideration that would have al-lowed this access.

First Responders

In 2014, Missouri enacted House Bill 2040, which au-thorizes qualiied irst responders to obtain and admin-ister naloxone to a person suffering from an apparentnarcotic or opiate-related overdose. A “qualiied irstresponder” includes state and local law enforcementagencies, ire department or district personnel, and li-censed emergency medical technicians with a licensedambulance service. Qualiied irst responders must re-ceive training on recognition of, and responding to, anoverdose, as well as administration o naloxone to anoverdose victim.

The Bill authorizes any licensed drug distributor or

pharmacy in the state to sell naloxone to qualiiedirst responder agencies, allowing the agency to have astock o the drug for administration.

In 2015, House Bill 538, which passed the House but didnot receive a vote in the Senate, would have allowed


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anyone age 18 or older to obtain naloxone from a li-censed pharmacist or pharmacy technician. The Billalso would have provided civil, criminal, and profes-sional immunity to dispensers and administrators oopioid antagonists.


Missouri has not enacted laws to provide immunity toGood Samaritans or overdose victims who seek emer-gency medical assistance during a drug overdose.

North Carolina

In 2013, North Carolina became the irst Southern stateto adopt laws authorizing expanded access to opioidantagonists for opiate-related overdoses and limitedimmunity for Good Samaritans, with the enactment oSenate Bill 20 (SB 20). In the same year, the state alsoenacted a partial syringe decriminalization law. In

2015, North Carolina reined those laws and expandedthe scope o its response to the heroin epidemic in Sen-ate Bill 154 (SB 154).

Naloxone Access

In 2013, SB 20 authorized practitioners, acting in goodfaith and exercising reasonable care, to prescribe, di-rectly or by standing order, an opioid antagonist to aperson at risk o experiencing a drug-related overdoseor to a family member, friend, or other person in a po-sition to assist an at-risk individual.47 As an indicatoro good faith, the practitioner can require a writtenstatement supporting the conclusion that the personreceiving a prescription is indeed at-risk or in a posi-tion to assist an at-risk individual. Under the law, aperson who receives a prescription can administer thedrug, using reasonable care, to another person based ona good faith belie that the individual is experiencinga drug-related overdose. Evidence o using reasonablecare includes the receipt o basic instruction and in-formation on how to administer the opioid antagonist.Under SB 20, which remains current law, prescribingpractitioners and third-party administrators o an opi-

oid antagonist are immune from civil or criminal liability for these authorized actions.

In 2015, SB 154 amended the state’s naloxone accessstatute to authorize pharmacists to dispense an opioidantagonist pursuant to a valid prescription. The Bill

also extends immunity from civil and criminal liabili-ty to dispensing pharmacists.

In Fiscal Year 2015-2016, North Carolina appropriat-ed $50,000 for use by law enforcement agencies andthe North Carolina Harm Reduction Coalition topurchase naloxone.48


Although North Carolina established limited immuni-ty for Good Samaritans and overdose victims in 2013,SB 154 amended those provisions to clarify the scopeo protection. Under the new law, which became ef-fective August 1, 2015, an individual who seeks medi-cal assistance for a person experiencing a drug-relatedoverdose has limited immunity from prosecution formisdemeanor possession o a controlled substance,felony possession o cocaine or heroin, and violation

possession o drug paraphernalia. For immunity to ap-ply, all o the following conditions must be met: (1) theperson sought medical assistance for an individualexperiencing a drug-related overdose by contacting911, a law enforcement oficer, or emergency med-ical services personnel; (2) the person acted in goodfaith when seeking medical assistance and reasonably believed that he or she was the irst to call for assis-tance; (3) the person provided his or her own name to911 or law enforcement upon arrival; (4) the medicalassistance was not sought during the execution o anarrest warrant, search warrant, or other lawful search;and (5) evidence for prosecution o the offense wasobtained as a result o the person seeking medical as-sistance. The immunity also extends to the individualfor whom medical assistance was sought. Additional-ly, the immunity protects both parties from arrest orrevocation for violating conditions o pretrial release,probation, parole, or post-release.

A law enforcement oficer who, acting in good faith,arrests or charges a person immune under these GoodSamaritan provisions is not subject to civil liability for

the arrest or iling o charges.

Partial Syringe Decriminalization and Disposal

In 2013, North Carolina enacted provisions that par-tially decriminalized the possession o hypodermicneedles. Under the law, prior to searching a person or


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his or her premises or vehicle, an oficer can inquireabout the possession or presence o a hypodermicneedle or other sharp objects that could cut or punc-ture the oficer during the course o the search. I theindividual alerts the oficer o the presence o a hypo-dermic needle or other sharp object prior to the search,then the individual may not be charged or prosecuted

for possession o drug paraphernalia for those objects.In 2015, North Carolina enacted House Bill 712, whichexpands this immunity by also including prosecutionfor residual amounts o a controlled substance con-tained in the needle or sharp object.

House Bill 712 also established a pilot program fordisposing o used needles and hypodermic syringes.The one-year pilot program, in consultation with andcollaboration between the State Bureau o Investiga-tion and the North Carolina Harm Reduction Coali-

tion, will begin in two counties to provide biohazarddisposal receptacles for used hypodermic needles andsyringes. The program also will provide limited im-munity for participants from possession o drug par-aphernalia and residual amounts o a controlled sub-stance in the disposed needle or syringe. The StateBureau o Investigation must report to the appropriatelegislative oversight committees on the results o thepilot program after one year. I the program is deemedto have been successful, then it may continue in theoriginal counties for another year and expand to twoadditional counties, for a total o four.

OklahomaNaloxone Access

With the enactment o House Bill 1782 (HB 1782) in2013, Oklahoma became the irst SLC member state toauthorize access to opioid antagonists for individualsat risk o experiencing an overdose. Under the law, airst responder can administer the drug when encoun-tering an individual exhibiting signs o an overdose.The irst responder, which includes law enforcementoficials, EMTs, ireighters, and medical personnel

at secondary schools and institutions o higher educa-tion, is not required to have a prescription to adminis-ter the drug, and is covered by the state’s general GoodSamaritan Act.49 The same legislation also authorizesa provider, upon request, to prescribe an opioid an-tagonist to an individual for use when encountering

a family member exhibiting signs o an opiate over-dose. Information on how to identify the symptomso an overdose, instructions on basic resuscitationtechniques, instructions for proper naloxone adminis-tration, and the importance o calling 911 for help alsomust be provided with the prescription. Additionalprovisions o HB 1782 specify that the administering

family member is covered under the state’s generalGood Samaritan Act.

In 2014, Oklahoma continued to expand access to nal-oxone with House Bill 2666 by allowing the drug to bedispensed or sold by a pharmacy without a prescrip-tion under the supervision o a licensed pharmacist.

In 2014, legislation (Senate Bill 433) was under con-sideration to provide limited liability against civildamages arising as a result o administering an opioid

antagonist, in good faith, based on a reasonable belieor actual knowledge that the victim is experiencing anopioid drug overdose. A version o the Bill passed theSenate but did not receive a vote in the House.


Although legislation has been introduced in recentyears,50 Oklahoma has not enacted Good Samaritanlaws speciically related to the administration o anopioid antagonist or immunity from prosecution re-lated to seeking medical assistance for onesel or an-other person experiencing an opioid overdose.

South CarolinaNaloxone Access

In 2015, South Carolina enacted House Bill 3083(HB 3083), known as the South Carolina OverdosePrevention Act. Under the Act, a prescriber, acting ingood faith and exercising reasonable care, may issue awritten prescription for an opioid antidote to a personat risk o experiencing an opioid-related overdose ora caregiver for that person. The prescriber also mustprovide the person or caregiver with overdose infor-

mation that addresses: (1) opioid overdose preventionV “Caregiver” is deined as a person who is not at risk o anoverdose but who, in the judgment o a physician, may be ina position to assist another individual during an overdose, andwho has received the required patient overdose information onthe indications for and administration o the opioid antidote.


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and recognition; (2) opioid antidote dosage and admin-istration; (3) the importance o calling 911 for medicalassistance with an opioid overdose; and (4) care for anoverdose victim after administration o the antidote.The prescriber must document in the medical recordthat this information has been provided. The Act alsoauthorizes a prescriber, acting in good faith and exer-

cising reasonable care, to issue a standing order for airst responder to possess an opioid antidote. A phar-macist, acting in good faith and exercising reasonablecare, may dispense an opioid antidote pursuant to aprescriber’s written prescription or standing order.Neither the prescriber nor pharmacist who prescribesor dispenses an opioid antidote according to these pro-visions will be subject to civil or criminal liability orprofessional discipline as a result o an act or omission.

Likewise, in an emergency, a caregiver who has re-

ceived the requisite opioid overdose information mayadminister an opioid antidote to a person they believe,in good faith, is experiencing an opioid overdose. Iadministered in accordance with these provisions, thecaregiver will not be subject to civil or criminal liability.

First Responders

House Bill 3083 also expands irst responder access tonaloxone and other similar drugs approved by the FDAfor treatment o an opioid overdose. The Act deines“irst responder” as an emergency medical servicesprovider, law enforcement oficer, or a ire departmentworker directly engaged in examining, treating, or di-recting persons during an emergency. Under HB 3083,a irst responder must comply with all applicablerequirements for possession, administration, and dis-posal o an opioid antidote and administration deviceand may administer the antidote in an emergency i theirst responder believes, in good faith, that the personis experiencing an opioid overdose. I acting in accor-dance with these provisions, the irst responder will not be subject to civil or criminal liability or professionaldiscipline as a result o an act or omission. In addition

to authorizing irst responders to obtain an opioid anti-dote, the Act authorizes the state Department o Healthand Environmental Control to promulgate regulationsto implement these provisions, including appropriatetraining for irst responders who carry or have accessto an opioid antidote.

Good Samaritan ImmunityAlthough legislation has been introduced in recentyears,51 South Carolina currently does not have a stat-ute that provides immunity from prosecution to thoseseeking medical assistance for themselves or for an-other person experiencing an opioid overdose.

TennesseeNaloxone AccessIn 2014, Tennessee enacted Senate Bill 1631 (SB 1631) toexpand access to opioid antagonists. In good faith andexercising reasonable care, a licensed healthcare prac-titioner is authorized, under the law, to prescribe anopioid antagonist, either directly or by standing order.The prescription can be issued to someone at risk oexperiencing an opiate-related overdose or to a familymember, friend, or other person in a position to assistthe at-risk individual. To establish good faith, the pre-

scribing healthcare practitioner can require a writtencommunication from the recipient that provides a fac-tual basis for concluding that the individual is at riskor is in a position to assist the at-risk individual.

An individual who receives a prescription for an opioidantagonist can administer the drug, using reasonablecare, to another person believed to be experiencing anopioid-related drug overdose. Evidence showing theuse o reasonable care in administering the drug in-cludes the receipt o basic instruction and informationon how to administer the opioid antagonist, includingsuccessful completion o the state’s online overdoseprevention education program.

Absent gross negligence or willful misconduct, thelicensed healthcare practitioner who prescribes ordispenses an opioid antagonist and any person whoadministers the drug are immune from civil liabilityfor these actions. Likewise, a licensed healthcare prac-titioner who prescribes, dispenses, or administers anopioid antagonist is immune from disciplinary or ad-verse administrative actions.

Training

Under SB 1631, the commissioner o the TennesseeDepartment o Health (TDOH) is directed to createand maintain an online education program to edu-cate laypersons and the general public on the appro-


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priate techniques and administration o opioid antag-onists and follow-up procedures for dealing with anopioid-related drug overdose.

First Responders

In 2015, Tennessee enacted Senate Bill 871 (SB 871),known as the Addiction Treatment Act, which directs

the TDOH commissioner to provide training recom-mendations for irst responders on the appropriate useo opioid antagonists, including provisions concerningthe appropriate supply o the drug for administration by irst responders.


Under the Act, anyone who, in good faith, seeks med-ical assistance for an individual believed to be experi-encing a drug overdose shall not be arrested, charged,or prosecuted for a drug violation based on evidence

that is the result o seeking medical assistance. Thisimmunity also extends to the overdose victim i he orshe makes the call for help or is the subject o another’scall. The immunity also prohibits protected individ-uals from being subject to penalties for violation o apermanent or temporary protective order or restrain-ing order or sanctions for violation o conditions opretrial release, probation, or parole based on a drugviolation. Evidence o irst aid or other medical assis-tance provided to someone experiencing a drug over-dose can be used as a mitigating factor in a criminalprosecution for which immunity is not provided.

These immunity provisions do not limit the admissibility o any evidence in connection with the inves-tigation or criminal prosecution o a defendant whodoes not qualify for immunity or other crimes com-mitted by an immune individual. Likewise, they donot prohibit the seizure and admissibility o protectedevidence in other criminal proceedings nor the deten-tion o an immune individual in relation to anotherinvestigation or offense.

Partial Syringe DecriminalizationIn 2015, Tennessee also enacted Senate Bill 924 to pro-vide partial immunity for the possession o drug para-phernalia. Under the Bill, prior to searching a personor person’s premises or vehicle, an oficer can inquireabout the possession or presence o a hypodermic

needle or other sharp object that could cut or puncturethe oficer during the course o the search. I the indi-vidual alerts the oficer o the presence o a qualifyingobject prior to the search, then the individual may not be charged or prosecuted for possession o drug par-aphernalia for the needle or sharp object. Unlike theother SLC states with similar provisions, Tennessee

does not extend this immunity to residual or traceamounts o a controlled substance on the needle orother sharp object.


Under the Addiction Treatment Act, Tennesseeplaced limits on the authorized use o buprenor-phine for treatm

Heroin Epidemic in SLC Member States: Finding Solutions

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