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Overdosed on opioids: a deadly opioid epidemic sweeping the country has lawmakers working hard to find solutions.

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What Are Opioids?

Opioids are a class of drugs that act on the nervous system to relieve pain. Long-term use can lead to physical dependence and withdrawal symptoms when stopped. Opioids are classified as narcotics and include illegal heroin as well as legal prescription pain relievers such as morphine, codeine, methadone, oxycodone, hydrocodone, fentanyl and hydromorphone. You might know them better by their trade names: OxyContin, Percodan, Percocet, Vicodin, Lortab, Norco, Fentora, Dilaudid and others.

State legislators are battling a lethal epidemic that is killing more people a year than motor vehicle crashes. More than 47,000 Americans died of a drug overdose in 2014--18,900 from prescription painkillers and 10,600 from heroin, according to the American Society of Addiction Medicine. Heroin overdoses alone have quadrupled since 2000.

"Everybody knows someone who's been affected--a family member, a friend, an acquaintance," says New Hampshire Senator Jeb Bradley (R), who chaired a task force on the epidemic last year.

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There is also the expense. The total annual costs to society associated with prescription opioid abuse was estimated at $55 billion in a study published in Pain Medicine in 2011. The estimate includes health care and criminal justice costs and the loss of productivity in workplaces.

The responses from statehouses as well as from the federal government reflect a growing concern about how to stem the tide.

President Barack Obama called for an increase in funding earlier this year to expand treatment and prevention programs, crack down on illegal sales and improve access to the opioid antagonist naloxone. And at press time, U.S. senators were debating the level of funding for the Comprehensive Addiction and Recovery Act.

State legislators from both sides of the aisle are working to enact comprehensive packages of legislation to address this widespread problem, which transcends politics and blurs the boundaries separating the public policy areas of criminal justice, international drug trafficking, social services and health care.

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"This isn't about normal procedure, or partisan politics. It's a life-or-death, literally, a life-or-death situation," says Alaska Senator Johnny Ellis (D).

A Two-Pronged Problem

Looking at data from 2014, the Centers for Disease Control and Prevention recently reported that the "opioid overdose epidemic includes two distinct but interrelated trends: a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin."

Overdoses of both kinds of opioids--pain pills and all forms of heroin--have surged, but several studies have found the increase in heroin use began before tighter restrictions were placed on prescription opioids.

Abuse of opioid pain relievers is the strongest risk factor for heroin abuse. According to the CDC, 75 percent of new heroin users were first addicted to pain pills. But it is unclear whether a crackdown on the availability of prescription pain relievers has led to the rise in heroin use.

It appears more likely that an increase in the availability of heroin in the U.S., along with lower prices and greater purity, have all contributed to the rising rates of abuse and death, according to the CDC.

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"It's become the drug of choice. People are using it instead of marijuana or crystal meth," says Illinois Representative Lou Lang (D). "The cost of heroin is so low that you can get high for $5. You can't get high on marijuana for $5."

Attack on Many Fronts

Increasingly, states are treating the problem as a public health issue that requires a multi-pronged response.

There's a balance to maintain. "We need to curb abuse," says New Mexico Senator Craig Brandt (R). "At the same time, we need to make sure we don't make it more difficult for those who need pain medication to receive it," says the disabled veteran who lives with chronic pain.

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Bradley, from New Hampshire, says there are several areas to consider. "We can make the situation better, but it's a combination of beefed-up law enforcement to arrest drug dealers, better education, and prevention and treatment programs--and some personal responsibility, too."

In the United States, health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills.

To reduce overprescribing of opioids, nearly every state has strengthened its prescription drug monitoring program. Improvements have included making programs mandatory, ensuring that information in the prescription database is current and requiring prescriber education on using a drug monitoring program. Current information and informed use of these programs can reduce "doctor shopping," a tactic used by some patients to obtain several prescriptions from more than one physician without triggering concerns about misuse.

States along with the Affordable Care Act have expanded substance abuse treatment and required insurance to cover it. A handful of states have passed syringe exchange programs, and others have initiated drug take-back programs for unused medication. A lot of attention has gone toward increasing access to naloxone: 45 states passed legislation in the past five years that varies from authorizing law enforcement and other emergency personnel to carry naloxone, to allowing sales of the drug without a prescription.

"The goal of everybody is to make sure we have something safe and effective and available throughout the state," said Alaska Representative Paul Seaton (R) during debate over pending legislation to make naloxone easier to obtain.

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To encourage people to call 911 or otherwise seek medical attention, for themselves and others, 34 states and the District of Columbia have enacted Good Samaritan laws. These provisions provide immunity from prose cution for certain offenses, assuaging fears a person may have about calling authorities.

The scope of immunity varies by state. Some laws are restricted to a few offenses while others provide immunity from all controlled substance violations, including violations of pretrial release and probation conditions.

"We couldn't fix the problem by arresting everyone," says former Representative John Tilley (D) from Kentucky, who helped enact legislation before becoming the state's justice and public safety secretary. "SB 192 is a comprehensive piece of legislation that eliminates barriers to treatment and will save lives."

A New Approach: Treatment

Treatment for opioid addiction encompasses a wide variety of approaches, but increasingly states are authorizing medication-assisted treatment that combines behavioral therapy with medication that can relieve withdrawal symptoms and psychological cravings associated with addiction. Studies have shown medication-assisted treatment can reduce recidivism rates.

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In 2015, lawmakers in Indiana and New York authorized courts to order medication-assisted treatment as a condition of diversion. Indiana and five other states also passed legislation increasing access to medication-assisted treatment for people who are incarcerated or have recently been released.

States have also been expanding access to existing treatment by increasing funding. West Virginia Governor Earl Ray Tomblin (D) established an advisory council on substance abuse in 2011, and since 2013 the Legislature has allocated $39 million to drug treatment programs, doubling available resources.

Additional state attention has been focused on expanding diversion, programs that provide an alternative to traditional criminal justice proceedings. Twenty-six state legislatures have passed laws to create pretrial diversion options, including drug courts that help those with substance abuse issues get treatment in lieu of incarceration.

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Other states have established diversion programs and drug courts without legislation. The legislature in New Hampshire is expected to expand state diversion options this session by increasing funding for drug courts.

In addition to diversion, states have lowered penalties for possession of small amounts of drugs while maintaining or increasing penalties for larger quantities and drug trafficking offenses.

Referring to Kentucky's new law, Tilley says, "You can't find any evidence to suggest that sentence lengths deter drug abuse, especially when you are facing a heroin epidemic, but traffickers deserve an appropriate sentence and they will feel the brunt of this law in Kentucky."

Working Together

"Illinois is ground zero for the heroin crisis in America," which is hitting "every community in Illinois," says Lang. "Constituents are dying." Lawmakers worked on comprehensive legislation last year to attack the problem and overrode a partial veto by the governor to enact the Heroin Crisis Act.

Lang says the bill, with Representative John Anthony (R) as co-sponsor, had bipartisan support from the beginning. "We wanted to make sure we didn't let politics get in the way. I'm a Democrat from a suburb of Chicago. Anthony's from central Illinois and an ex-cop," Lang says. "I feel satisfied that we passed a good piece of legislation. I hope it has the intended impact." It resulted from the work of a task force, which developed recommendations after holding hearings across the state on the epidemic and how best to attack it.

New Hampshire has also been hit especially hard by the overdose epidemic. "With almost 800 people having died from heroin and opioid overdoses in the last two years, in a state of 1.3 million people, that's just a staggering number of folks who are friends and neighbors who have succumbed to this terrible affliction," says Bradley. "The son of a couple I know passed away from a heroin overdose. He and my son knew each other in school. Nobody is insulated."

This year the New Hampshire General Court passed Bradley's bill, a comprehensive measure that modified criminal penalties, strengthened the state's prescription drug monitoring program, enhanced prevention measures and education, and increased access to treatment.

"It's been a pretty good, seamless bipartisan process," Bradley says. "Everybody realized the eyes of New Hampshire were on us and we had to do our work and get this legislation out."

CDC Grants to States

Recognizing that the overdose epidemic requires a multifaceted approach, and that "states are key partners in our efforts on the front lines to prevent overdose deaths," U.S. Secretary of Health and Human Services Sylvia M. Burwell announced in September that 16 states will receive extra funding to aid in their fight against prescription drug overdoses.

The Centers for Disease Control and Prevention launched its $20 million grant program with four-year awards of up to $4 million each to Arizona, California, Illinois, Kentucky, Nebraska, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont and Wisconsin.

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The funding is intended to help those states expand their prescription drug monitoring programs; educate providers, health insurers and patients about the risk of prescription drug overdose; and respond rapidly to emerging drug overdose issues. The funding also can be used for investigating and responding to the connection between prescription opioid use and heroin abuse.

Kentucky plans to use its $4 million on a partnership involving the state's Injury Prevention and Research Center, the Department of Public Health and the University of Kentucky's College of Public Health. The project will combine academic investigation with practical public health initiatives. Illinois, which received $3.6 million, will track heroin morbidity and mortality rates and analyze prescribing and overdose trends in "high-burden" communities.

California received $3.7 million to address problems that have hit particularly hard in several rural northern communities as well as the large urban areas across the state.

Julie Nagasako of the California Department of Public Health says officials in government, local communities, the health system, law enforcement and education are working together to address the issue. Officials will identify communities that could benefit from greater attention, and ask, "How can we share and use the data at both the provider and community level to target intervention and prevent overdose and misuse?"

The state also will roll out pilot programs to help doctors who prescribe opioids to approach pain management in a more comprehensive way. Nagasako says the purpose is to pinpoint promising policy solutions for the state legislature to consider.

From California to Maine, no state is immune from opioid abuse, and each has enacted legislation addressing some aspect of the problem. But an issue this complicated requires an attack on many fronts. "No legislation will solve the problem totally," says New Hampshire's Bradley. "There's a whole range of things that are going to get us out of this."

5 Go to ncsl.org/magazine for more information.

OPIOIDS

By the Numbers

7.9 and 9

Rate of opioid deaths per 100,000, in 2013 and 2014

63%

Increase in heroin use from 2002 to 2013

26%

Increase in heroin overdoses from 2013 to 2014

9%

Increase in drug overdose deaths from opioids from 2013 to 2014

100%

Increase in drug overdose deaths involving synthetic opioids, between 2013 and 2014, including prescription fentanyl and illegally manufactured acetyl fentanyl

45%

Proportion of heroin users who also abuse prescription opioid painkillers

400%

265%

Increase among women (top number) who overdosed on prescription pain relievers compared with men, between 1999 and 2010

It Matters Where You Live

The number of opioid pain pill prescriptions written per 100 residents varies by state. Per-capita costs from prescription opioid abuse vary as well. The 10 states with the highest per- capita cost are called out in yellow.

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Up and Up

The rates of drug-poisoning deaths in the U.S. from opioid analgesics and heroin between 1999 and 2014.

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Jane Hoback is a freelance writer based in Denver. NCSL policy experts Amber Widgery and Karmen Hanson contributed to this article.
Where Do
They Get the
Pills?

The Sources of Abused
Prescription Painkillers

Received from a friend or relative for free      55%
Prescribed by one doctor                         17.3%
Bought from a friend or relative                 11.4%
Received from another source                      7.1%
Taken from a friend or relative                   4.8%
Obtained from a drug dealer or stranger           4.4%

Source: CDC, 2011.

Note: Table made from pie chart.
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Title Annotation:DRUG ABUSE
Author:Hoback, Jane
Publication:State Legislatures
Geographic Code:1USA
Date:Apr 1, 2016
Words:2272
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