Deadly rise in drug overdoses has states searching for answers; Midwest hit hardest by health crisis: Policy responses include greater oversight of prescription drug use, access to treatment

Across the country, communities are dealing with an epidemic of drug abuse and overdoses. And nowhere is this health crisis more pronounced than in the Midwest: Between 2008 and 2013, the number of heroin-related overdose deaths in this region increased sixfold.

This fall, over only a four-day span, emergency crews in Chicago responded to 74 cases of heroin overdose. The heroin in these instances, police say, was laced with the prescription drug fentanyl (an opioid). Nearly all of the overdose victims survived, in part because first-responders at the scene administered naloxone, which reverses the effects of an opioid overdose.

Earlier this year, in a single rural Indiana county, state and local health officials had to stem an outbreak of HIV — nearly 150 confirmed cases over a four-month period. The cause: use of an opioid painkiller via needle injection.
Ohio health officials, meanwhile, recently released datashowing that fentanyl-related drug-overdose deaths in the state had increased by nearly 500 percent in a single year, from 84 in 2013 to 502 in 2014.
The epidemic is impacting cities, suburbs and rural areas alike, and is the result of changes in the supply of and demand for opioids — both legal and illicit.
“There has been a flood of painkillers onto the market in recent years,” notes Indiana Attorney General Greg Zoeller, who heads up his state’s Prescription Drug Abuse Prevention Task Force. “People are demanding large amounts of prescription medications, some physicians are overprescribing, and much of this medication is winding up in home medicine cabinets or finding its way to the streets where risk of abuse is high.”
Once addicted to an opioid painkiller, an individual is much more susceptible to heroin abuse — 40 times as likely, according to the U.S. Centers for Disease Control and Prevention. Compounding the problem, heroin has become less expensive and more accessible, and it becomes an even more dangerous drug when mixed with fentanyl, a potent painkiller.
Leading cause of injury death
The number of people dying every year from a drug overdose has reached nearly 44,000, more than double the total from just 14 years ago. Drug overdose has surpassed traffic accident as the nation’s leading cause of injury death, the Trust for America’s Health notes. About half of these overdose fatalities involve prescription drugs.
As evidenced by the range of strategies now being employed by states in the Midwest and across the country, no single policy or law will solve this health problem. But policymakers are hoping a multi-pronged approach can prevent overdose deaths and also begin to address some of the epidemic’s root causes.
One of the common legislative approaches, for example, has been to provide immunity to witnesses who seek medical help when an overdose is occurring (providing them protection from criminal prosecution for drug possession, for example).
Some states, too, have adopted laws improving access to naloxone. Most Midwestern states now provide additional legal protections to a health professional who prescribes naloxone or a layperson who administers it “in good faith.” In states such as Illinois and Wisconsin, first-responders must now carry naloxone so that they can use it to prevent overdose deaths.
New laws seek to control drug access
Over the past decade and a half, the CDC notes, the amount of painkillers being dispensed in this country has quadrupled. In Indiana, Zoeller says, one policy response to this trend has been to change the prescribing standards and rules for health practitioners.
“Since these rules took effect, there has been an 11 percent decrease in the amount of opioids prescribed in Indiana,” he adds.
Other control strategies include:
  • laws to clamp down on “doctor shopping” (going from one doctor or hospital to the next in search of a prescription),
  • requirements that doctors physically examine a patient before prescribing him or her painkilling medicine, 
    setting new time or dosage limits for certain prescription drugs, and
  • strengthening oversight of pain-management clinics. (According to the CDC, these clinics sometimes become “pill mills” and the source of large quantities of prescriptions.) 
Nearly every U.S. state has also created prescription drug monitoring programs and, with them, databases that collect information on the medications being dispensed in the state (for example, the name of the recipient, the prescriber, and the drug and the quantity of it being dispensed).
These programs can help identify high-risk patients, prevent “doctor shopping,” and uncover problems with individual prescribers or dispensers (“pill mills,” for example). Though nearly every state now has a database to monitor prescription drugs, the rules are not uniform from one jurisdiction to the next — voluntary vs. mandatory use of the system, for example, or the time given to practitioners to submit the data.
Earlier this year in Illinois, with passage of HB 1, lawmakers shortened the reporting time line. Pharmacies and other dispensers must now provide information to the electronic database within 24 hours. 
Under previous law, the reporting time line was seven days.
“The problem with [seven days] was that people were piling up prescriptions, by going from emergency room to emergency room, before we could catch them,” explains Rep. Lou Lang, sponsor of the bill. Rep. John Nygren is seeking the same change in Wisconsin. He also wants to require doctors to check the drug-monitoring database, both when they make an initial prescription and when they refill it.
Under current Wisconsin law, pharmacies must report when the drugs are dispensed, but physicians’ use of the monitoring program is voluntary. According to Nygren, only 14 percent of physicians in Wisconsin are accessing the database.
“If you’re going to have this tool, this monitoring program, the information needs to be timely, and it needs to be utilized,” he says. “Otherwise, what’s the point?”
To that end, too, he also proposing that law enforcement enter information into the database whenever a prescription drug is found at the scene of a crime or a drug overdose.

States expand treatment, coverage
By better monitoring and controlling access to prescription drugs, states hope to cut demand for heroin — through a reduction in the number of people who become dependent on opioids of any kind. But this doesn’t fix the problem for those already addicted.
“Unfortunately, one of the side effects to reducing the supply of prescription drugs into communities is that addicts turn to other places for their high, including cheap heroin,” Zoeller says.
For states, then, treatment becomes an essential part of any strategy to combat the problem of opioid addiction.
“When you treat people, you not only save lives, you save the state money,” Rep. Lang says, “because they won’t be in our prisons and they won’t be in our emergency rooms.”
As the result of HB 1 being signed into law in Illinois, the state’s Medicaid program must now cover all federally approved, “medication-assisted treatment” options for opioid dependence — the use of methadone and buprenorphine, for example. (Gov. Bruce Rauner vetoed this provision, but the legislature successfully overrode it.)
HB 1 will also expand the use of drug courts: specialized programs that provide treatment and rehabilitation as an alternative to incarceration. In Illinois, more defendants will be evaluated to determine if they should be diverted to drug courts, and prosecutors can no longer unilaterally block access to them.
In Wisconsin, legislators quadrupled funding for drug courts last year, and since then, the number of counties with them has more than doubled. Nygren sponsored the drug-court legislation, and he also successfully sought new state grants for drug treatment in three underserved areas of Wisconsin. Each of these locally based programs will focus on a different treatment option.
The state will evaluate which option works best, Nygren says, and then try to replicate it in other areas.
Unlike Illinois, Wisconsin already has been providing Medicaid coverage for medication-assisted addiction treatment. And Nygren says most private insurers in his state pay for various treatment options as well. 
But he still believes some changes in health-insurer practices would help.
“What we’re hearing is that a lot of times, carriers will require the least-costly treatment first,” he says. “So the concern is that someone has to fail at the least-costly treatment before the more-expensive options are [made available].
“I’m trying to open up a dialogue in our state for our insurers to see this as a more long-term investment, and to fund the most effective treatment in the first place.”


Stateline Midwest: October 20153.23 MB