Combatting Opioid Overdoses and Addiction: An Overview of Harm Reduction Strategies in the Midwest

Midwestern states have adopted a variety of intervention strategies designed to combat the opioid epidemic and manage the risks associated with injection drug use. These harm reduction efforts include syringe exchange programs; medication-assisted therapy; overdose prevention; public education campaigns; and policies and laws designed to enhance collaboration among advocates, law enforcement and health care professionals.

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Syringe Exchange Programs
Syringe exchanges are harm reduction initiatives aimed at preventing the spread of infectious disease through the safe disposal of used syringes and availability of sterile syringes. Injection drug users can secure sterile supplies, including syringes, alcohol swabs and tourniquets in exchange for used syringes. Syringe exchange programs are said to act as intermediaries between injection drug users and treatment, where evidence shows that users are more likely to seek treatment and counseling.1

States can permit syringe exchanges explicitly by law or exempt syringes and injection equipment from laws prohibiting the distribution or possession of drug paraphernalia. Rules and regulations applied to the distribution and possession of drug paraphernalia vary from state to state, and may also vary dependent upon distribution through pharmacies or syringe exchange programs.

Indiana passed legislation in 2015 allowing for syringe exchanges in the event of a declared public health crisis involving the spread of infectious disease.2 An Illinois law explicitly authorizes syringe exchange programs. Minnesota and Wisconsin have exempted syringes from their drug paraphernalia laws, removing the possibility that criminal charges can be pressed against those using syringe exchanges.3 Michigan law provides an exception to drug  paraphernalia laws to prevent blood-borne diseases. In Ohio, up until 2015, city health departments could declare a public health emergency and create syringe exchange programs. Current Ohio state law allows local boards of health to establish prevention programs for blood-borne diseases without declaring an emergency.4

Table Sources
1 Network for Public Health Law. “Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws.” June 2016.
2 Burris, Scott, “Syringe Distribution Map.” March 1, 2016..
3 The American Society of Addiction Medications. “Advancing Access to Addiction Medications; Implications for Opioid Addiction Treatment.” June 2013.
4 Prescription Drug Monitoring Program Center of Excellence at Brandeis, “PDMP prescriber use mandates: characteristics, current status, and outcomes in selected states.” May 2016.
5 Prescription Drug Monitoring Program Training and Technical Assistance Center. “Criteria for Mandatory Enrollment of Query of PDPM.” July 1, 2016.
NOTES: *Prior approval and other restrictions may apply. **Applies only to individuals previously granted immunity not more than twice.

Overdose Prevention & Good Samaritan Laws
All Midwestern states except Kansas have implemented policies intended to increase access to naloxone, an antidote administered by injection or nasal spray in the event of an overdose.5 Naloxone prevents death from overdose of an opioid drug, such as prescription pain medicines or heroin, by blocking the opioid from the brain for 30 to 90 minutes.6

In Ohio, law enforcement agencies are permitted to purchase naloxone from wholesalers or terminal distributors without a license.7 In Michigan, beginning with the 2016–2017 school year, a school board may require schools to have no less than one employee who has been trained in the use and administration of an opioid antagonist.8

Illinois, Michigan, Minnesota, North Dakota and Wisconsin have implemented overdose immunity laws, often called Good Samaritan laws, which protect individuals from arrest or prosecution for drug possession when they request emergency assistance on behalf of someone experiencing a drug overdose.9 All Midwestern states except Kansas have laws providing criminal and civic immunity to health care professionals who prescribe or dispense naloxone and to others who administer naloxone.10

Four states—Iowa, Michigan, North Dakota and Wisconsin—have adopted policies to allow availability of naloxone without a prescription.11

Medication-Assisted Treatment
Three medications are approved by the FDA for the treatment of drug addiction. They are methadone, buprenorphine and naltrexone. Methadone is the oldest and least expensive, with daily costs below $20. Naltrexone in its just-approved implant form lasts six months to a year and costs approximately $6,000. Methadone and buprenorphine are habit-forming and can be abused, so treatment must be supervised.12  

In five Midwestern states—Illinois, Michigan, Minnesota, Ohio and Wisconsin—the state Medicaid programs cover all three approved drugs, according to an extensive report prepared in 2013 for the American Society of Addiction Medicine.13 The extent of coverage and other requirements, including prior authorization, varies by drug and by state. 

Prescription Drug Monitoring Programs
Prescription drug monitoring programs, or PDMPs, are state-run databases containing prescribing and dispensing information about controlled prescription drugs. PDMPs can assist health care professionals and prescribers in combatting over-prescription where patients may have multiple prescriptions from multiple prescribers. Every state in the nation, except Missouri, has a PDMP in place. Wisconsin was the last Midwestern state to implement its PDMP in 2013. 

PDMP laws vary from state to state. In six Midwestern states, queries are not mandated for prescribers or dispensers, but five Midwestern states have adopted differing mandates.14 Indiana and Minnesota require that only opioid treatment, worker’s compensation or pain clinic prescribers query the PDMP. North Dakota requires opioid treatment programs to check the PDMP monthly and dispensers to check if they are aware of certain patient risk behaviors. In Wisconsin, prescribers must check the PDPM unless the prescription is for less than three days and not refillable. Other limited exceptions may also apply. The most comprehensive PDMP mandate, in place in Ohio, requires all prescribers and dispensers to query the PDMP when initially prescribing, and to make subsequent checks at regular intervals.15 

Canada
Canada has made similar efforts to address the opioid overdose epidemic by implementing strategies and policies to reduce drug harm and fatality. Data are not collected on drug overdose deaths to calculate provincial or national rates to compare to the United States. However, evidence indicates that the numbers of deaths are increasing. 

Naloxone access in Canada has been increased in part by exempting it from its controlled substance status, along with the introduction of programs that provide education on naloxone administration and take-home kits for family members of persons using opioid drugs.16 Naloxone is available in more than 500 pharmacies throughout Alberta free of charge with a valid prescription. Physicians in Ontario may prescribe naloxone to public health units and substance abuse programs. In Saskatchewan, physicians can prescribe naloxone to friends and family of drug users, and in Manitoba, medical doctors may prescribe naloxone without seeing the patient.17In British Columbia, officials are preparing to open five supervised injection sites.18 There are already two sites in Vancouver, the first in North America.19 

In June 2016, as part of a larger national drug strategy, Canada’s health minister unveiled a $40 million plan to create a national prescription drug monitoring program. 


References
1 Brooner, et al.,“Drug Abuse Treatment Success Among Needle Exchange Participants,” Public Health Reports, 1998; vol. 133(supplement1): 129–139.
2 Smith, Nathan, “Four States Passed Needle Exchange Legislation in 2015, Two More in 2016.” May 24, 2016.
3 Burris, Scott, “Syringe Distribution Map.” March 1, 2016.
4 Britton, Tara. “Syringe Exchange Programs in Ohio.” The Center for Community Solutions. March 2016.
5 Network for Public Health Law. “Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws." June 2016.
6 San Francisco Department of Public Health, “Naloxone for opioid safety,” p. 4. January 2015.
7 State of Ohio Board of Pharmacy, “Law Enforcement Agencies Seeking to Obtain Naloxone Hydrochloride (Narcan).” Jan. 1, 2016.
8 Michigan Legislature. Feb. 17, 2016. House Bill 5379. Retrieved June 22, 2016.
9 Network for Public Health Law.
10 Ibid.
11 Ibid.
12 Tabachnick, Cara. “Breaking Good: Vivitrol, a new drug given as a monthly shot, is helping addicts stay clean.” The Washington Post. March 13, 2015.
13 The American Society of Addiction Medications. “Advancing Access to Addiction Medications; Implications for Opioid Addiction Treatment.” June 2013.
14 Prescription Drug Monitoring Program Center of Excellence at Brandeis, “PDMP prescriber use mandates: characteristics, current status, and outcomes in selected states.” May 2016.
15 Prescription Drug Monitoring Program Training and Technical Assistance Center. “Criteria for Mandatory Enrollment of Query of PDMP.” July 1, 2016.
16 Health Canada, “Section 56 Class Exemption for Barbituric Acid and its Salts, Naloxegol and its Salts, Methylnaltrexone and its Salts, and the Salts of Nalmefene, Naloxone and Naltrexone.” May 26, 2016.
17 CCENDU Bulletin, “The Availability of Take-Home Naloxone in Canada,” March 2016.
18 Laanela, Mike. “Five new supervised injections sites coming to fight Vancouver’s fentanyl overdose crisis.” CBC News. June 10, 2016.
19 Westfall, Jordan. “Federal response may worsen overdose epidemic.” July 1, 2016. Vancouver Sun.