1. Ohio’s Opiate Epidemic
Aaron E. Haslam
Sr. Asst. Attorney General

2. Ohio’s Opiate Epidemic
CONTACT INFORMATION
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3. 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.

4. 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.

5. World History they skipped over in school
Opioids are one of, if not the oldest, of the world's drugs first used in the form of poppy;
The first known written reference to the poppy appears in a Sumerian text dated around 4,000 BC
Homer in several parts of The Odyssey talks about poppy.
The recreational use of opium was popular in modern day Turkey, Iran an China form about the 15 to 19 centuries

6. World History they skipped over in school
Thomas Sydenham, the "father of English medicine" is attributed the quote, "Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.“
Use of opium as a cure-all was reflected in the 1728 Chambers Cyclopedia, which included Subsequently, opioids became the basis of many popular patent medicines of the nineteenth century.
However the addictive qualities of opiods were well known Confessions of an English Opium-Eater (1821);
Bayer Pharmaceuticals attempted to develop an non-addictive form of opiate in the early part of last century.

7. World History they skipped over in school
Opiods were almost unregulated until the early 1900’s. In 1891 California law requiring that narcotics carry warning labels and that their sales be recorded. California Pharmacy and Poison Act in 1907 made it a crime to sell opiates without a prescription.
Regulation started, in part, because between 150,000 and 200,000 opiate addicts lived in the U. S. in the late 19th century, between two-thirds and three-quarters of these addicts were women. This was mainly due to the prescribing and dispensing of legal opiates by physicians and pharmacists to women mostly to relieve menstrual pain. Source Drug Addiction Research and the Health of Woman 33-52

8. 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 ; ; ; ; ; ; 3715; 3719; ; ;

9. 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.

10. Ohio’s Opiate Epidemic
LEGAL OPIATES
Some Legal Opiates are…
hydrocodone, (e.g.Vicodin, Lortab)
oxycodone, (e.g. OxyContin, Roxicodone, Percocet)
oxymorphone (e.g. Opana,)
ILLEGAL OPIATES
Heroin (diacetylmorphine /morphine diacetate )
Opium

11. 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

12. 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, ”

13. Ohio’s Opiate Epidemic

14. 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, ”
Fatal and non-fatal poisonings cost Ohioans $3.6 billion annually.

15. Ohio’s Opiate Epidemic
Ohio’s overdose death rate tripled from 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, ”

16. 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

17. 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.

18. Epidemics of unintentional drug overdoses in Ohio, 1979-2008 12,13,14
MAGNITUDE OF THE PROBLEM:
We have titled our presentation “Ohio’s Prescription Drug Epidemic” This is not an exageration.
Sources for slide: OPDATF Final Report, Page 20
12 WONDER (NCHS Compressed Mortality File, & ).
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).
12 WONDER (NCHS Compressed Mortality File, & ).
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).

19. Ohio’s Opiate Epidemic
What happened during this time frame?

20. 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.

21. 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.

22. 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;

23. 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.

24. Ohio’s Opiate Epidemic
The American Association of Poison Control
Centers reported that the number of 13 to 19
year olds calling concerning prescription
drug abuse in Southwest, Ohio increased
from 10,651 in 2000 to 26,378 in 2007.
That is a 247% increase in eight years.

25. 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

26. 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.

27. 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

28. Ohio’s Opiate Epidemic
What happens to that infant after he or she is discharged from hospital?

29. Ohio’s Opiate Epidemic
Why does the illegal market exists

30. 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

31. 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

32. Ohio’s Opiate Epidemic
Forgery/Alteration of a prescription
This is a felony in Ohio under R.C (deception to obtain a dangerous drug)
Some common methods: computer/copier; hairspray; whiteout; theft of prescription pad

33. Ohio’s Opiate Epidemic
Dr. Shopping
Having multiple doctors who do not know of each other for the purposes of obtaining multiple prescriptions
This is a felony in Ohio under R.C (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

34. Ohio’s Opiate Epidemic
Internet Pharmacies
Only 3.4% of online Pharmacies are legitimate and 83% do not require a valid prescription Source NABP
In 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

35. 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

36. Ohio’s Opiate Epidemic
Theft from Homes
The most common ways juveniles get prescription drugs
Number one way to prevent this is to properly dispose of unused prescription medication immediately after it is not needed. If a family member is in an end of life situation have a plan to deal with this just as you have a plan for the other end of life issues

37. Ohio’s Opiate Epidemic
Pill Mills are “pain management clinics” that either rarely or never provide any medical care other than the writing of and or dispensing of prescription drugs. Most of the pill mills lack professional staff ie RN, LPN, PA’s; do not alter their prescribing practices to tailor to the patient; Rarely have referrals; often do not treat the actual cause but the symptom (pain)
Business model hinges on keeping people hooked and not being treated for underlying cause
Some have also begun to prescribe drugs to help their patients off of drugs. So pay to get addicted-pay to get cured.
Until HB 93 became the law in Ohio many if not most of these were owned by non-physicians a sizable number of these owners were prior felons.

38. 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.

39. Ohio’s Opiate Epidemic
OHIO’S RESPONSE TO THE RX PROBLEM - PREVENTION -ENFORCEMENT -TREATMENT

40. 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

41. 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

42. 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

43. What is Ohio Doing?
PASSAGE OF HOUSE BILL 93

44. the “Pill Mill” bill or “Pill Mill” legislation
HB 93
Also known as:
the “Pill Mill” bill or “Pill Mill” legislation

45. 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.

46. PAIN MANAGEMENT CLINICS
HB 93
PAIN MANAGEMENT CLINICS

47. 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.

48. 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.

49. HB 93 Since January 2011, the State Medical Board
represented by The Office of the Attorney
General, has sanctioned more than 30
physicians for inappropriate prescribing. That
number exceeds the number of sanctions issued
by the Medical Board in all of 2010 for similar
conduct.
On Wednesday October 12th The medical board permanently revoked Dr. Daniel Brumfield license
“I, along with management, came up with a way to increase the number of 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

50. 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.

51. HB 93 Early success of the Bill: Effects of this success
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.

52. Opiate Substitutes
Regulations designed to make it more difficult to abuse prescription painkillers are leading to an increase in heroin addiction

53. Opiate Substitutes
RESULTS
Heroin is making a strong comeback

54. 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.

55. 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…”

56. Ohio’s Opiate Epidemic
After 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.

57. OHIO OPIATE EPIDEMIC
WHY HEROIN?

58. 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

62. 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

63. Ohio’s Opiate Epidemic

64. Ohio’s Opiate Epidemic

65. Ohio Opiate Epidemic

66. Ohio Opiate Epidemic

67. 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

68. Ohio’s Opiate Epidemic
THIS IS NOT A COINCIDENCE!

69. Ohio’s Opiate Epidemic

70. 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

71. 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

72. 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

73. Ohio’s Opiate Epidemic

74. Ohio’s Opiate Epidemic

75. Ohio’s Opiate Epidemic
HOW DO WE ATTACK THE HEROIN PROBLEM?

76. Ohio’s Opiate Epidemic
THE SAME WAY WE TACKLED THE Rx EPIDEMIC! Remember they are both Opiates!

77. Ohio’s Opiate Epidemic
PREVENITON

78. Ohio’s Opiate Epidemic
ENFORCEMENT

79. Ohio’s Opiate Epidemic
TREATMENT

80. Ohio’s Opiate Epidemic
Aaron E. Haslam
Sr. Asst. Attorney General