Overwhelmed by overdoses: The rise in drug-related deaths has states still searching for a mix of strategies to properly address the public health crisis

Few if any U.S. states have been hit harder than Ohio by the crushing rise in drug use, abuse and overdose deaths. That state’s rate of overdose deaths was second in the nation in 2017: 46.5 per 100,000. Behind those numbers, too, are tragic stories that have personally touched many Ohio legislators — and helped lead their ongoing search for policy solutions.

“For multiple years, multiple general assemblies, it has been a legislative priority,” says Ohio Sen. Jay Hottinger, a member of the General Assembly since 1995. “If you wrote just a paragraph on each bill, it would be about 17 or 18 pages.”
He was a sponsor of one of Ohio’s most recently passed bills — last year’s SB 119, known as Daniel’s law in honor of a young Ohio man who died from an opioid overdose after years of fighting addiction. Daniel Weidle had found success in his fight through the use of naltrexone (one of the medications federally approved for treatment of opioid-use disorder), but after losing his provider, Daniel got turned down several times in trying to refill his prescription.

Ohio’s new law grants authority to pharmacists to dispense or administer a five-day emergency supply of naltrexone without a prescription, if they can verify the patient already has been on the drug. The goal of SB 119: preventing tragic stories like Daniel’s.

For Hottinger, too, Ohio’s continued fight against drug addiction has become a personal and professional passion for him. His wife’s father became addicted to heroin after being prescribed opioid painkillers for a job injury.
“He was very successful,” Sen. Hottinger says. “He worked for his family, his father’s construction company, that built the 7-Elevens in the central Ohio area. He drove a Corvette and had a pilot’s license and had his own plane.
"Then he hurt his shoulder on the job, got addicted to the pain medications prescribed to him, and eventually got hooked on heroin.
“You hear of people that lose everything; that was true of my future father-in-law,” Hottinger recalls. “He lost the family relationship; he never got to see his grandkids. He battled homelessness. ... I met him two times before he died, and both were at methadone clinics.
“That story is personal to me, but that is a story we hear a lot.”


No. 1 cause of injury death
Since 2011, drug overdose deaths have been the leading cause of injury death in the United States, and they now far exceed deaths from suicide, car crashes and firearms. There were more than 70,000 fatal drug overdoses in 2017, the highest level ever recorded.
Controlled prescription drugs are responsible for the most drug-involved deaths, according to the U.S. Drug Enforcement Agency, and are the second most commonly abused substance (behind marijuana). 
Most individuals who report misuse of prescription pain relievers, the DEA notes, cite physical pain as the most common reason for abuse; these misused pain relievers are most frequently obtained from a friend or relative.
Opioids of all kinds — controlled prescription drugs, illegal synthetic opioids or heroin — account for about two-thirds of the nation’s overdose deaths. In the 11-state Midwest, they were behind 82 percent of these deaths in 2017.

According to the National Institute on Drug Abuse, of those who began abusing opioids in the 2000s, 75 percent reported that their first opioid was a prescription drug. These legally prescribed drugs also are a common gateway to heroin: Nearly 80 percent of heroin users reported using prescription opioids prior to use of this illicit drug.
States have tried to tackle this epidemic in a variety of ways, from enacting legislation to limit the supply of opioid painkillers prescribed by doctors to increasing treatment opportunities. Ohio’s myriad responses in recent years, as well as legislative proposals in that state still under consideration, provide a window into what states have done, or can do, to turn around the disturbing trends in drug use and abuse.


Ohio’s legislative response to date
One of Ohio’s first responses to its rising drug problem came in 2011, with the passage of a bill (HB 93) that helped eliminate “pill mills”: large-volume prescribing operations (a pain management clinic, for example) that dispensed narcotics without a legitimate medical purpose.
With that law in place, Ohio has mandated licensure of pain-management clinics, authorized the state medical board to establish rules on when a physician should review the state’s prescription reporting database, severely restricted in-office dispensation of controlled substances, and restricted some Medicaid beneficiaries to specific providers in order to better monitor their use of prescription drugs (known as a “lock-in program”).
Three years later, legislators took on the problem of “doctor shopping”: when patients visit multiple doctors to either obtain prescriptions for drugs to take more than the prescribed amount, or to sell them illegally. This new law (HB 341) began requiring prescribers to look up and document the patient’s last 12 months of prescriptions — through the state’s automated prescription drug database — before they could initially prescribe an opioid analgesic or a benzodiazepine. The legislation also mandated that prescribers make periodic requests for patient information from the state’s automated database if any course of treatment continued for more than 90 days.
In 2017, Ohio expanded access to medication-assisted treatment programs (HB 49), including the creation of a specialized drug court program. According to the National Drug Court Resource Center, Ohio now has 72 drug-treatment court programs for adults, the most of any Midwestern state.
An alternative sentencing option, drug courts target offenders with drug dependency problems. Treatment, monitoring, graduated sanctions and incentives are overseen by a multidisciplinary team. Drug courts have been shown to reduce recidivism and lower costs.
Nationwide, the number of drug courts has doubled over the past decade-and-a-half.

Like many other states, too, the Ohio legislature has passed laws allowing pharmacists to provide naloxone (the opioid-overdose reversal drug) without a prescription, providing immunity for minor drug offenses when individuals report a drug overdose (known as Good Samaritan laws), and requiring parental consent before opioids can be prescribed.


Possible future actions in Ohio
Sen. Hottinger still believes more can be done in Ohio on the policy side. As originally introduced, for example, Daniel’s Law (SB 119) would have limited the duration of a doctor’s initial prescription for opioid painkillers to three days — a limit that would be consistent with U.S. Centers for Disease Control and Prevention guidelines. (Only three states have set a three-day limit: Florida, Kentucky and Tennessee.)
Ohio Rep. Jim Butler agrees that this type of prescription limit would help, as would a number of other efforts. He has been working on a bill that would add prevention and long-term treatment options, and combine them with increased drug enforcement.
“It’s a complex problem, and there really needs to be a comprehensive solution,” Butler says.
He notes the success rate for treatment is usually less than 10 percent, and people can relapse seven or eight times: “It takes a long time for the brain to heal. When you go to 30, 60 or 90 days of treatment, you may successfully have detoxed and have great support, but your brain hasn’t had time to heal. Also, drug dealers target rehab facilities. ... We need to create centers that offer long-term treatment for those who need it.”
Not everyone needs long-term treatment, Butler adds, but scientific studies show that after long-term abstinence from drugs (18 to 36 months), a person’s brain heals and the potential for relapse goes down 90 percent.
He wants state policies that allow certain individuals to get up to three years of treatment. Butler also believes low-level drug offenders should have their criminal records sealed if they go into treatment, and businesses should be incentivized by the state to hire people in recovery.
Lastly, Butler would like to see stiffer penalties for drug dealers. “In our state, armed robbery is a second-degree felony and heroin selling is a fifth-degree felony,” he says. “We need to make penalties much more strict. … We need to take these people who are so hurting our families and children off the street and put them in prison where they belong.”


Stateline Midwest: March 20192.35 MB