To fight the deadly heroin epidemic, the state of Ohio has helped pay for the life-saving antidote Narcan, expanded drug treatment in prisons and jails and stepped up the state patrol’s enforcement efforts.
Is it enough? Can more be done?
That’s what we asked the directors of five state agencies in a face-to-face dialogue with the WCPO editorial board.
They form the front lines of Ohio’s response to the epidemic, are members of the Governor’s Cabinet Opiate Action Team, and together, direct thousands of state employees and millions in tax dollars.
Here’s who we met with:
Tracy Plouck, director, Mental Health and Addiction Services
John Born, director, Department of Public Safety
Steven Schierholt, executive director, Ohio Board of Pharmacy
Julie Walburn, chief of staff, Ohio Department of Health
Barbara Sears, director, Department of Medicaid
Dr. Mark Hurst, medical director, Department of Mental Health and Addiction Services
Here are excerpts. We annotated some of the responses, with our notes in the gray boxes.
Can the governor declare a statewide emergency over the heroin epidemic and use some of the "rainy day fund" budget surplus to fund treatment?
Julie Walburn: The governor can, in certain circumstances, declare an emergency, but it doesn’t turn on any resources that we aren’t already using. We have a robust response, and we’re treating this as an emergency, and we’re bringing all the resources to bear. A declaration of emergency alone doesn’t do anything that we’re not doing.
Tracy Plouck: The rainy day fund is … to be used if a structural imbalance occurs between revenue and expenditures in the course of a year. It can be called upon if tax receipts are significantly underperforming and there’s a concern that reducing expenditures … would be detrimental to the operations of state government.
The fund is for fiscal imbalance rather than these sorts of circumstances.
WCPO Editorial Board: The state law that authorizes the “rainy day fund” does not specify any requirements on how it can be used.
John Born: To my knowledge, there’s no provision in Ohio law that would trigger some kind of emergency use of funds or the authority for the release of those funds. We’ve said that pretty consistently internally as a department.
WCPO: Kasich has issued executive orders dozens of times to declare emergencies for many different reasons, but none as serious as the drug epidemic that has taken more than 11,000 lives since he took office in 2011. Our editorial, and subsequently several state legislators, called for Kasich to use some of Ohio’s budget surplus, the so-called “rainy day fund,” that now amounts to more than $2 billion.
Walburn: There’s not anything it would deliver to the state that’s not already being implemented. No new money, no new resources it would bring to the state that we don’t already have at the table today.
In terms of authority, there is broad authority for the governor.
WCPO: At least four other governors have declared emergencies as a result of the heroin epidemic in their states: Massachusetts in 2014, Virginia in 2016, Alaska in February 2017, and Maryland in March 2017.
Plouck: In reference to what other states have done, some of them don’t result in anything immediate. It’s more of a public relations approach to call more attention to this issue. We feel we have shed quite a bit of attention and light on this issue.
WCPO: While some details remain unknown in Maryland, the latest state to declare an emergency, its governor did commit to spend an extra $50 million over five years on the problem.
Walburn: Our governor issued an executive order to make sure pharmacies have the ability to do naloxone through standing orders for friends and family. That didn’t require a declaration of emergency, but he did take action with an executive order.
WCPO: In his State of the State speech Tuesday, Kasich said he would seek $20 million from Ohio’s Third Frontier fund for entrepreneurship “to help bring new scientific breakthroughs to the battle against drug abuse and addiction.” The money, if approved, could help speed research projects to the marketplace. But it doesn’t appear as if it would immediately increase funding on the ground for treatment, which is what some local providers have asked for.
Money and manpower
Plouck: Our momentum is continuing in the governor’s budget for ‘18 and '19, which is currently being deliberated by the Legislature. Additionally, we have some federal money coming from the 21st Century CURES Act for additional treatment and workforce capacity related to addiction.
WCPO: The 21st Century CURES Act was passed by Congress and signed by President Obama in December. Included was $1 billion in grants to help states fight opioid abuse. Ohio could see up to $26 million over the next two years.
Plouck: Our department supports the availability of naloxone for first responders. We have a $500,000 earmark for each year of this biennium and we’re proposing to increase that to $750,000. In 2016, that $500,000 alone resulted in more than 2,300 saves.
Walburn: We support 48 Project DAWN sites in 44 counties. They provide free naloxone to families and addicted individuals. The new budget would fund another 20 sites around the state.
WCPO: Project DAWN (Deaths Avoided With Naloxone) is an overdose education and naloxone distribution program. Among its participants in Southwest Ohio are sites in Hamilton, Butler, Clermont, Warren and Adams counties.
Plouck: We’ve increased by 50 percent the number of treatment professionals available in Ohio’s prisons in the last two years.
We’re currently funding mental health or addiction services in 38 county jails right now. We’re proposing to increase from $3 million a year to $4 million a year in this next budget cycle.
Pill mills and drug arrests
Dr. Mark Hurst: In the past two years there’s been about a 20 percent reduction in opioids in the state of Ohio. Over the past five years, there’s been an 80 percent reduction in doctor shoppers
WCPO: Ohio passed legislation in 2011 cracking down on pill mills. The number of opioid pills dispensed dropped 20 percent from 2012 to 2016. However, that number is still 631 million, more than 50 doses per year for every man, woman and child in the state.
Born: In the last six years, we’ve seized more drugs through interdiction efforts than any time in Ohio’s history. Since 2011, we’ve seen more drugs (seized) than we did in the previous year. We’ve tripled the size of our warehouse, now twice.
WCPO: National data show a substantial increase in heroin availability in the United States. According to National Seizure System data, heroin seizures in the U.S. increased 81 percent over five years. Traffickers are also transporting heroin in larger amounts. The average size of a heroin seizure doubled from 2010 to 2014.
We recognize that we can’t stop it. But what we can do is disrupt the supply and drive up the cost of that supply.
We’ve doubled the number of drug canines in Ohio.
WCPO: The state patrol uses 33 dogs trained in narcotics detection, a spokesman said. They are spread across the nine state patrol districts. The Wilmington district, which covers nine counties in Southwest Ohio, uses four.
What used to be a traffic stop that maybe before no one knew about has turned into an international drug cartel being dismantled.
WCPO: Born acknowledged that law enforcement can only do so much. Changing behavior and treatment is where the answer lies.
We do know that we have impacted the supply lines. Demand is the side where you’re going to solve this, not the supply side.
Almost everything we’re seeing is coming across the southwest border from Mexico.
Kentucky and all the states around Ohio are part of an effort called the six-state trooper project, where our goal is to not only to disrupt the supply side, harass the supply side to the point of driving up the cost of shipping to and through Ohio, but also that same effort for the entire Midwest.
WCPO: The project also includes the Indiana State Police, Kentucky State Police, Pennsylvania State Police, Michigan State Police and the West Virginia State Police.
A lot of the fentanyl, as you saw in the last seizure, is being shipped by parcel.
Being able to ship that in much smaller amounts, makes interdiction much more difficult. Which means information sharing and intelligence becomes that much more important.
The impact of Medicaid expansion
WCPO: Kasich pushed hard to expand Medicaid in Ohio, and did it despite a reluctant Legislature. It made health care more accessible to hundreds of thousands, many of whom suffer from addiction. He has since spoken up in favor of maintaining the expansion, despite some calls to scale it back.
Plouck: Medicaid expansion has been huge in terms of access to treatment. People who previously did not have access to services can now access through Medicaid.
Of the approximately 700,000 people who were enrolled as a result of the expansion, about a third had addiction-related disorders. And more than 500,000 individuals have actually received one mental health or addiction service through the expansion.
Barbara Sears: For the first time in Ohio, we’re looking at the whole person, both their physical health and their mental health, and being able to have someone case manage that in one picture.
We recognize Vivitrol as a key component to solving this issue. In 2012, we only had 100 Vivitrol prescriptions out there (through Medicaid). Now in 2016, it’s over 30,000.
How can you encourage hospital systems to be more engaged?
Walburn: Our staff is working with hospital physicians to create an emergency department toolkit that would help to create a protocol for how to handle overdose individuals when they come into the hospitals and how to discharge them from the hospitals with directions to resources to what’s in the community. We are working on that now and hope to have that ready for release in the coming months.
Hurst: The question is not only providing treatment, but providing the right kind of treatment. The evidence is very clear that when providing medication with the right kind of talking therapy, recovery rates improve markedly. Those medications include things like Suboxone, methadone and Vivitrol.
Plouck: You could bring all the money in the world down on the state of Ohio and there would still be challenges. Quite candidly, there is insufficient workforce.
Another thing we’re doing in addition to the $15 million, we’re setting aside $5 million for prescriber workforce.
We can’t manufacture folks out of medical school quick enough to help with this problem so identifying existing prescribers – primary care, ob gyn, psychiatrists, as well as physician assistants and APRNs (advanced practice registered nurses) who can also prescribe to see if additional education, stigma reduction, medical assistance, any kind of mentoring might be helpful to get them connected in a way that they are educated and comfortable with serving individuals who are addicted.
Hurst: The way we used to treat addiction is not effective. And that being that you receive treatment for a given period of time – days, weeks, even months – and then we say you’ve got what you need you got out in the community we hope you do well with that. This is a lifelong disease. It’s not until you reach a year of abstinence that you have a chance of having long-term abstinence.
WCPO: Unfortunately, addiction is still treated that way, as documented in our series Heroin: Fixing a Broken Treatment System.
These are not immoral people that are doing this. They may have done things that they regret or we don’t approve as a consequence of their addiction, but that is the brain’s response to the chemical.
Our take: We agree with Dr. Hurst that addiction is a lifelong disease and requires continuing treatment and attention, just as chronic diabetes and heart disease do. Unfortunately, addiction treatment today suffers from a lack of coordination, a lack of best practice guidelines and a lack of funding, among other problems.
This is where state leaders, starting with Gov. Kasich, could exercise the substantial power and influence of state government. The Ohio Department of Health and the Department of Mental Health and Addiction Services, for example, could bring hospital system leaders in the state together to press for more and better addiction treatment and help create guidelines and funding to do that.
And we repeat our call for the governor to declare a statewide emergency over the drug epidemic. He has the authority and the power to do so and could immediately make money available to local communities that could save more lives.
These state agencies and their leaders have responded to the drug epidemic. They’ve stepped up the interception of illicit drugs, reduced the over-prescribing of narcotics, and helped fund life-saving naloxone.
But the bottom line is the fatalities keep rising.
Drug overdose deaths have increased by 72 percent since Kasich took office in 2011. (That's not counting the number of deaths in 2016. Those figures have not been released yet by the Department of Health.) This is not to blame the governor for these deaths.
But it is past time to unleash the full power of the state to treat this epidemic.
For more on our community's response to the drug epidemic, please go to Heroin: How Do We Respond?