U.S. Attorney's Office Joins With Others In Releasing Heroin Community Action Plan

The Heroin Epidemic -- Our Community’s Action Plan

Summary

On Nov. 21, 2013, many of Northern Ohio’s leading institutions gathered for a daylong summit in an effort to find solutions to the region’s heroin epidemic. A Community Action Plan was formulated over the course of several planning meetings and finalized during the summit. The purpose of this document is to serve as a guiding master plan as we move forward as a community. The Action Plan is divided into four specific areas: Prevention and Education, Healthcare Policy, Law Enforcement and Treatment. Inevitably, there is some overlap among each of these areas.

A few disclaimers: this document is a working draft and not written in stone. Some of these items are immediately actionable while others will take more time, research and effort. Some of these items have unanimous support among the planners, others do not. Although certain action items cannot be implemented without new legislation, some of the partnering agencies are forbidden from taking a position on pending or potential legislation. The hope is that this Action Plan will serve as a road map and tie together our various efforts toward the same goals – preventing people from using heroin, helping treat those who have become addicted, choking off both the supply of and demand for heroin in Northern Ohio, and working collaboratively to make our region healthier, safer and stronger.

This action plan was developed based upon input from the representatives of the following agencies and organizations: the United States Attorney’s Office, the Cleveland Clinic, the Cuyahoga County Executive, MetroHealth Medical Center, University Hospitals, Cuyahoga County Common Pleas Court, the Ohio Attorney General, the Cleveland Division of Police, the Drug Enforcement Administration, the Federal Bureau of Investigation, the Ohio State Medical Board, the Ohio State Pharmacy Board, the Cuyahoga County Board of Health, the Cuyahoga County Medical Examiner, the Cuyahoga County Sheriff’s Department, the ADAMHS Board., the Westshore Enforcement Bureau and others.

PREVENTION AND EDUCATION

I. EDUCATING CITIZENS ON THE DANGERS OF HEROIN USE

• Prevalence of the heroin problem.
• Establish a community education plan that highlights the dangers and warning signs of heroin use and overdose death; treatment options; and support groups, resources and prevention opportunities.
• Produce materials to distribute to local school boards, PTA/O meetings, places of worship, community centers and local colleges.
• Initiate a dialogue with the Greater Cleveland Partnership and Downtown Cleveland Alliance to raise awareness of the prevalence of prescription drug and heroin abuse.
• Engage instructors who train health, social service and education professionals.
• Utilize social media to provide information about the epidemic, stressing the connection between prescription pills and heroin.
• Incorporate education specifically on heroin and prescription pill abuse into high school/ middle school health class curriculum.
• Target local school boards, principals, PTA/Os, nurses, psychologists, counselors, social workers, resource officers and DARE officers.
• Review programs to ensure education curriculum is based on the National Health Education Standards and CDC’s Characteristics of Effective Health Education. 
• Town Hall meetings/community forums in different municipalities.
• Continue the work started by Judge Astrab to convene community meetings.
• Educating the public about the dangers of prescription drugs.
• Collaborate with pharmacies to inform customers of proper prescription drug disposal.
• Meet with officials from Wal-Mart, Target and other retail chains that offer pharmacy services.
• Distribute Prescriber’s Toolkit.
• Work with other groups that frequently confront prescription drugs, including embalmers, hospice providers and other local businesses.
• Establish prescription drop boxes in all of Cuyahoga County’s municipalities.
• Expand drug drop-box outreach beyond Cuyahoga County.

II. PRIORITZE HEROIN OVERDOSE AS A PUBLIC HEALTH THREAT

• Conduct pilot prevention programs in high-risk areas.
• Identify high-risk areas and develop intensive plan targeting those areas.
• Establish community task force to take the lead on implementation.

HEALTHCARE POLICY

I. LEGISLATION

• Immediately actionable:
• Advocate for passage of HB 170 (Naloxone distribution to first responders) by early 2014.
• Advocate for passage of HB 92 (syringe exchange legislation) by early 2014.
• Advocate for drafting and passage of Good Samaritan Law (no harm/liability for reporting overdoses) by early 2014.
• Requires additional discussion and action:
• Advocate for the drafting and passage of a bill requiring OARRS utilization be mandatory for prescribing controlled substances such as opiates/opioids; and prescriber(s) and pharmacist(s) are electronically notified whenever any of the following occurs:
• Controlled substance filled twice in five days.
• Benzodiazepines + opioids prescribed to the same patient.
• Benzodiazepines + amphetamines prescribed to the same patient.
• Opioid doses > 100 Morphine Equivalent Dose (MED).

II. EDUCATION

• Requires additional discussion and action:
• Promote mandatory medical student education to include additional training requirements on pain management and opiate use.
• Establish some mandatory requirement for adding continuing medical education on opiate use over a three-year period and/or prior to renewal of DEA registration; and/or online provider education course.

III. FUNDING

• Requires additional discussion and action:
• Provide for the statewide expansion of OARRS, which will require funding legislation, some of which is already underway.
• Provide for the cost of and training for Naloxone distribution for first responders.

IV. POLICY

• Immediately actionable:
• Enforce compliance of present standards for Admin Rule 4731.21 and advocate that they be updated and revised to include:
• 100 MED limit; special form explaining need to exceed 100 MED; sent to pharmacy and renewed every six months.
• Mandatory OARRS review every three months.
• Compliance checklist, renewed every six months, for opiate preauthorization filled out and sent to pharmacy.

• Adopt uniform chronic benign pain management guidelines, especially for Emergency Departments, thus strengthening the Ohio Opioids and Other Controlled Substances guidelines to include:
• Acute pain prescriptions only in 10-day increments.
• Photo ID requirement.
• Underage parental consent for opiate/opioid treatment of pain.
• Special license or permit for pain management clinics.
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• Requires additional discussion and action:
• Commitment to increased local treatment capacity.
• Additional drug courts and more coordination with treatment.
• Enforcement of parity rules for treatment providing for:
• Partial hospitalization.
• Detoxification.
• Intensive outpatient.
•  

IV. DATA AND INFORMATION

• Immediately actionable:
• Coordinate data sharing, especially between the Attorney General, State Medical Board and State Pharmacy Board, to allow freer exchange of de-identified data in an effort to show trends and better direct community and law enforcement responses.
• Improve and refine data gathering and coding to better track opiate/opioid dependence and overdoses (as opposed to general overdoses); centralized statewide data collection to track heroin deaths, treatment and Emergency Department visits.
• Promote uniformity of practice through State Coroners Association and State of Ohio to identify heroin deaths specifically where possible, as well as deaths caused by other opiate/opioids.
• Promote greater and sustained coordinated efforts between government, medical, treatment, and law enforcement communities to utilize data to combat the heroin crisis.

LAW ENFORCEMENT

I. HEROIN TRAFFICKING/INTERDICTION/DIVERSION

• Federal/State law enforcement will continue to use all assets to prosecute heroin dealing organizations in the Northern Ohio area.
  
• For heroin users, law enforcement will continue to work with the courts to seek diversion and treatment as an alternative to incarceration.  The courts will be encouraged to extend any monitoring period or supervision of heroin users to keep them accountable.  Law enforcement also will explore options to provide information to heroin users for immediate treatment options and resources.  Drug abuse charges will be used to focus attention on an individual’s addiction and recognize a developing problem for both the addict and his/her family.

• For heroin traffickers, sentences should be significant for both deterrence and punishment.  Certain drug traffickers may qualify for significant, enhanced sentences in federal court.
• Case targets and intelligence will continue to be discussed among involved law enforcement agencies to avoid conflicts and duplication of efforts.

• Law enforcement will continue to encourage community involvement in addressing the heroin epidemic.  Involvement begins with educating the community regarding the heroin problem and identifying how individuals and organizations can assist law enforcement.
• Educate law enforcement partners regarding federal forfeiture in drug trafficking cases for equitable sharing purposes and return of money to localities to assist law enforcement in addressing this problem.

II. HEROIN DEATH INVESTIGATION

• The Heroin Involved Death Investigation initiative is being deployed in Cuyahoga County in response to the high number of deaths.  Other localities are encouraged to develop similar initiatives.
• The Cuyahoga County Sheriff, Prosecutor and Medical Examiner, the Cleveland Division of Police and the United States Attorney’s Office will continue to work together on heroin overdose death investigations.
• The goal will remain to prosecute, where appropriate, responsible heroin traffickers for manslaughter in state court or to seek mandatory minimum sentences based on a death enhancement at the federal level.
• Components and protocol for the Heroin Involved Death Investigation are as follows:

 

• A suspected heroin death is encountered by the Medical Examiner investigator related to the City of Cleveland.

• The Medical Examiner investigator puts out a notification to the Cleveland Police investigators deployed to this initiative.

• The Cleveland Police or Cuyahoga County Sheriff’s Office investigators respond immediately and begin an investigation into the source of the heroin.  This involves interviews at the death scene which could be a residence, hospital, etc.  Investigators will focus on information gathering first as opposed to immediate arrests of witnesses and participants.

• Cleveland Police or Sheriff’s Office investigators will recover crucial evidence for immediate review by CPD technicians.

• Cleveland or Sheriff’s Office investigators will work back to the dealer with various techniques including confidential informant and direct drug buys that will support technical evidence and interview statements.

• Cleveland Police or Sheriff’s Office investigators will work in both County and federal court on prosecutions related to Manslaughter and other charges.

• The Cuyahoga County Sheriff’s Office will continue running a parallel initiative handling the suburban heroin overdose deaths.  The Cleveland Police and Sheriff’s Office teams will work together on their cases sharing information, personnel and other assets.  Cuyahoga County Supervising Prosecutor Deborah Naiman will guide the investigations.

• Medical Examiner Administrator Hugh Shannon has initiated the Heroin Alert notification component.

TREATMENT

I. TRAINING IN SCREENING AND BRIEF INTERVENTION

• Train clinicians in SBIRT (Screening, Brief Intervention and Referral to Treatment) so they can recognize the disease of addiction/substance use disorder.
• Train clinicians in Motivational Interviewing so they can respond effectively to clients who are not-yet-ready to change behavior.

II. INCREASE THE VISIBILITY OF HB 93 AND THE 80 MD MED GUIDELINES

• Work with State Medical Board, Governor’s office, and other stakeholders to disseminate and enforce these laws and to encourage wider adoption of the guidelines.

III. INCREASE THE USE OF OARRS (OHIO AUTOMATED Rx REPORTING SYSTEM)

• Increase the use of OARRS by all physicians and pharmacies.
• Integrate OARRS into the Electronic Health Record of all local healthcare systems.

IV. INCREASE ACCESS TO MEDICATION-ASSISTED TREATMENT (MAT)

• Create a model for MAT that assists the community toward a combination of MAT, treatment, and 12-step programs.
• Increase public and private funding for treatment slots in the following settings:
• Detoxification.
• Suboxone clinics.
• Methadone clinics.
• Intensive outpatient treatment.
• Residential treatment.
• Sober housing.

 
V. CREATE A STRATEGY FOR WORKFORCE DEVELOPMENT

• Increase the number of addiction psychiatrists and addiction medicine doctors working in treatment agencies.
• Educate the treatment community about MAT to increase support for its use.

VI. ADVOCATE FOR PARITY IN INSURANCE COVERAGE

• Work with public and private insurance companies to gain true parity for addiction treatment.
• Work with Medicaid to turn on the SBIRT codes in Ohio.

VII. BALANCE OF COMPETING PRIORITIES: CHRONIC PAIN

• Bring together pain doctors and addiction doctors to implement best practices in the area of pain management and addiction.
• Integrate OARRS into the Electronic Health Record  of all local healthcare systems.

VIII. BALANCE OF COMPETING PRIORITIES: PATIENT SATISFACTION SCORES

• Work with hospital quality committees to make modifications in the use of patient satisfaction scores when it comes to patients with addiction.