Community Responses to Heroin: North Carolina and Northern Kentucky

1. Community Responses to Heroin:
North Carolina and Northern Kentucky
Presenters:
• Kim Moser, Director, Northern Kentucky Office of Drug Control
• Scott Proescholdbell, MPH, Epidemiologist, Injury and Violence
Prevention Branch, North Carolina Department of Health and Human
Services
• Nidhi Sachdeva, MPH, Injury Prevention Consultant, Division of Public
Health, North Carolina Department of Health and Human Services
Heroin Track
Moderator: Kelly J. Clark, MD, MBA, FASAM, DFAPA, President-elect,
American Society of Addiction Medicine, and Member, Rx and Heroin
Summit National Advisory Board

2. Disclosures
• Scott Proescholdbell, MPH; Nidhi Sachdeva,
MPH; and Kelly J. Clark, MD, MBA, FASAM,
DFAPA, have disclosed no relevant, real, or
apparent personal or professional financial
relationships with proprietary entities that
produce healthcare goods and services.
• Kim Moser – Speakers’ bureaus: Pfizer, Merck,
Glaxo, AstraZeneca

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Describe the problem of heroin mixed with
clenbuterol.
2. Explain the protocol developed by the North
Carolina Injury and Prevention Branch to
respond to events that involve overdose.
3. Outline regional partnerships and programs
implemented in Northern Kentucky to respond
to the Rx opioid and heroin epidemic.
4. Provide accurate and appropriate counsel as
part of the treatment team.

5. Community Responses to the
Prescription Opioid and
Heroin Epidemic
Lessons from Northern
Kentucky

6. https://www.youtube.com/watch?v=leznM7P2
O0g&feature=player_embedded#t=0

7. Cincinnati and Northern Kentucky

9. 2014 Overdose Deaths - KY
• The top 7 counties by overdose
• deaths per 100,000 people for 2014 are:
– Floyd County 55.1 per 100,000
– Pike County 50.8 per 100,000
– Campbell County 47.9 per 100,000
– Kenton County 43.3 per 100,000
– Boone County 38.0 per 100,000
– Fayette County 36.6 per 100,000
– McCracken County 30.6 per 100,000

10. 252
447
545
745
1074*
150
350
550
750
950
1150
1350
2011 2012 2013 2014 2015
Ashel Kruetzkamp, MSN, RN— St. Elizabeth Healthcare
*Includes ONLY
Jan-Nov overdoses
Heroin Overdoses
St. Elizabeth Emergency Departments
(Covington, Ft. Thomas, Edgewood, Florence and Grant)

11. For every woman who dies of a prescription painkiller
overdose, 30 go to the emergency department for painkiller
misuse or abuse
400%
Deaths from prescription painkiller overdoses among women
have increased more than 400% since 1999, compared to
265% among men
48,000
Nearly 48,000 women died of prescription painkiller*
overdoses between 1999 and 2010
(NAS) grew by almost 300% in the US between 2000 and 2009
CDC Vital Signs July 2013
Women and Opiate Addiction

12. 0
50
100
150
200
250
300
Born w/NAS symptoms
Born to moms w/Opiate Hx
Projected 2015 Born w/NAS
NKY 2014 Neonatal
Abstinence Syndrome
2014 2015

13. EMERGING PUBLIC HEALTH ISSUES
-Northern KY-
Hepatitis C rates:
• 2.7 times that of the rest of the state of Kentucky
• 19.5 times that of the rest of the Nation

14. IV Drug Use & Disease
INFECTIOUS DISEASES SPREAD BY IV DRUG USE (2014)
Diagnosis Boone
County
Campbell
County
Grant
County
Kenton
County
NKY
*
Acute
hepatitis B
7 7 Fewer
than 5
22 38 (9.4)
Acute
hepatitis C
9 10 Fewer
than 5
22 44 (10.9)
Non-acute
hepatitis B
19 17 Fewer
than 5
40 80 (19.8)
Non-acute
hepatitis C
173 223 66 396 858
(212.7)
HIV cumulative
from 1982, living
and deceased
120 155 31 413 719
Source: NKY Health Department Epidemiology Unit

15. A CALL TO ACTION
• Parents Advocating Recovery
• Local hospitals
• Law Enforcement
• Judges
• Treatment providers
• Elected Officials

16. A Community Response

17. Community Response

19. Advocacy

20. Casey’s Law

21. SB 192
• AN ACT relating to controlled substances and declaring an emergency.
• Be it enacted by the General Assembly of the Commonwealth of Kentucky:
• âSection 1. KRS 72.026 is amended to read as follows:
• (1) [Unless another cause of death is clearly established, ]In cases requiring a post-
mortem examination under KRS 72.025, the coroner or medical examiner shall take a
biological[blood] sample and have it tested for the presence of any controlled
substances which were in the body at the time of death and which at the scene may
have contributed to the cause of death.
• (2) If a coroner or medical examiner determines that a drug overdose is the cause
of death of a person, he or she shall provide notice of the death to:
• (a) The state registrar of vital statistics and the Department of Kentucky State
Police. The notice shall include any information relating to the drug that resulted in
the overdose. The state registrar of vital statistics shall not enter the information on
the deceased person's death certificate unless the information is already on the death
certificate;[ and]
• (b) The licensing board for the individual who prescribed or dispensed the
medication, if known. The notice shall include any information relating to the drug
that resulted in the overdose, including the individual authorized by law to prescribe
or dispense drugs who dispensed or prescribed the drug to the decedent; and

22. NKY Office of Drug Control Policy
Mission Statement
Provide advisory services to Boone, Campbell
and Kenton County Fiscal Courts on the best
evidence-based treatment and prevention
strategies for reducing Substance Use Disorders
in our community.

23. NKYODCP: Goals and Initiatives
• Prevention and Education: Community
Engagement
• Treatment: Jail SAPs and Vivitrol Pilot
• Neonatal Abstinence Support Network:
Mothers and Babies
• Legislation: State and Federal
• Law Enforcement: Supply and Harm Reduction

24. Regional Education and Prevention

25. Overall reactions to this message are positive. While
a bit startling and unsettling to some, after further
discussion the majority agree that “Inject Hope” offers
the most stopping power, and is a unique and
memorable message. Making it the clear, winner
across all messages- “inject jumps off the page.”
Messaging Reactions | Overall Feedback
Respondents are somewhat polarized in their
reaction to this message. While the majority like the
intent, they feel it is difficult to read and understand.
Others feel it is less powerful than “Inject Hope” but
agree that it is “more hopeful.”
Of the alternatives, participants prefer “Choose”
because it is actionable. They also feel that it is more
gentle than “Inject.” This makes it a good alternative
for placing in family-friendly areas like schools or
grocery stores. This message is liked the most, after
“Inject Hope.”
Majority feel that “this is not the right message,”
and that “Share” is somewhat overused.
Respondents relate this message to cancer research
or breast cancer; of all the messages, it resonates the
least with Heroin and is the least liked overall.
Some respondents also referenced sharing drugs
or needles—not something we want to promote

26. 24% 24% 14% 11%17% 15% 20%
8%
Treatment/
Rehabilitation center
Prevention Early intervention Law enforcement/
Cutting supply
Recovery support
Community Issues
Heroin is a major issue amongst Northern Kentucky residents and they are extremely aware of the impact it has on their community.
“It’s an epidemic.” Almost all respondents agree that drug abuse, specifically, heroin is the most pressing and prevalent issue in their
community.For some this issue is connected other pressing issues in the community like crime, homelessness, poverty and
unemployment.
How the heroin issue is impactingNorthern Kentucky Residents…
Residents are extremely concerned with this issue and feel that there is very little being done to help
prevent or eliminate the problem. As a result, they feel somewhat hopeless due to the lack of solutions
that are currently available. Others are upset or even aggravated by the lack of action related to heroin.
“It’s a crisis that is so
out of control.”
“I think it’s more than just drug
abuse. These people are
medicating something. They
are emotionally hurt… They
have a hole and are trying to
fill it.”
“I can see that there are mechanisms
in place, I just don’t see them
working.”
Personal
Response
Despite high awareness, under half of residents in either Northern Kentucky or Hamilton County have taken any action in response to the growing community
heroin problem. Commonactions among responders include spreading awareness, pointing someone to rehabilitation, and reporting drug activity.
Spreading awareness through
social media or speaking out
Encouraging someone
to enter a
rehabilitation center
Reporting drug activity Offering recovery support
“Kentucky is
considered the
heroin capital of the
US.”
“I have a friend who uses
heroin. What you have to
understand is that he isn’t a
bad guy, he has a great job.
He just fell in with some bad
people. He doesn’t want to get
out.”
“You are not talking
about low-lives. You are
seeing business men
using…”
Thoughts & Feelings Related to Heroin
The most visible messages about heroin
come by way of news media and seem
to leave residents feeling hopeless about
the problem and its severity. Northern
Kentucky residents are particularly
concerned about the rising death rate.
Heroin Message
Opportunity
Treatment, prevention and early intervention are the top rated responses for effectively dealing with Northern Kentucky and Hamilton County’s
heroin problems among residents. Over half also recognize the role of law enforcement and recovery support.
76% 72% 71% 65% 64%69% 72% 71%
55% 54%
Northern Kentucky Residents (n=140)
Community
Response
The heroin problem in Northern Kentucky has high awareness and relevancy among residents.
Hamilton County exhibits a similar, though slightly lower level of problem awareness.
Heroin Awareness & Impact
Nearly half of Northern Kentucky and
Hamilton County residents have been
directly impacted by heroin in some
way.
One in five Northern Kentucky residents
report losing a friend, family member,
or coworker to heroin addiction.
Focus Groups:
• Three 90-minute groups were conducted in late October, 2015, among 18 Northern Kentucky residents
• Objective: deep dive into current attitudes toward heroin addiction in Northern Kentucky,
and test message appeal
Quantitative Online Survey:
• A 15 minute online survey was conducted in early November, 2015 among 140 Northern
Kentucky residents, and 65 Hamilton County residents
• Objective: assess current community awareness and attitudes toward heroin addiction in
Northern Kentucky prior to campaign launch
Research Summary

27. HELPLINE: No wrong door
First Contact
(Phone, Internet,
Walk-in)
Request for
FAQs
Needs Help
Getting into
Treatment
Crisis
Answers Provided
Referral Linkage
Assessment
by Provider
Engagement & Support
Assessment Placement Follow-Up
Crisis
Management

28. Kenton Co Detention Center
• 500 beds but typically house 650 inmates
• 83% of state inmates have a history of drug
use and 53% meet criteria for drug
dependence or abuse.*
• Drug treatment program: 70 male beds, 30
female
* KYDOC Division of Substance Abuse Programing

29. Ongoing Initiatives
• HIDTA Approval for NKY Designation
• Additional treatment: County looking to build
treatment facility
• St. Elizabeth partnership with SUN Behavioral
Health and Betty Ford-Hazelden: 197 beds
• First Step Home treatment model for pregnant
addicted women

30. Thank you

31. Community Responses to Heroin
North Carolina’s Heroin/Clenbuterol Experience

32. Disclosure Statement
• Scott Proescholdbell, MPH, has disclosed no
relevant, real or apparent personal or
professional financial relationships with
proprietary entities that produce health care
goods and services.
• Nidhi Sachdeva, MPH, has disclosed no relevant,
real or apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services.

33. Learning Objectives
• Describe the problem of heroin mixed with
clenbuterol
• Explain NC Injury and Violence Prevention
Branch’s (IVPB) communication protocol
developed to respond to events that involve
overdose

34. Overview
• NC poisoning and overdose epidemic
• Reported clenbuterol cases, Summer 2015
• Development of communication protocol
• Increased collaboration between local health
departments, PH preparedness and response,
and State Bureau of Investigation
• Future/Next Steps

35. NC’S OVERDOSE EPIDEMIC

36. 36
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Deathsper100,000population
Year
Motor Vehicle Traffic (Unintentional)
Drug Poisoning (All Intents)
Firearm (All Intents)
*Per 100,00, age-adjusted to the 2000 U.S. Standard Population
α - Transition from ICD-8 to ICD-9
β – Transition from ICD-9 to ICD-10
National Vital Statistics System, http://wonder.cdc.gov, multiple cause dataset
Source: Death files, 1968-2014, CDC WONDER
Analysis by Injury Epidemiology and Surveillance Unit
Death Rates* for Three Selected Causes of Injury, North Carolina, 1968-2014
α

37. Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014
Analysis by Injury Epidemiology and Surveillance Unit
Medication or drug overdose: X40-X44, X60-X64, Y10-Y14, X85
Medication or Drug Overdose Deaths by Intent
North Carolina Residents, 1999-2014
1,306
1,064
203
38
0
200
400
600
800
1,000
1,200
1,400
Numberofdeaths
All intents
Unintentional
Self-inflicted
Undetermined
Assault

38. Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014
Analysis by Injury Epidemiology and Surveillance Unit
Substances Contributing to Medication or Drug Overdose Deaths
North Carolina Residents, 1999-2014
684
202
246
0
100
200
300
400
500
600
700
800
900
Numberofdeaths
Prescription Opioid
Cocaine
Heroin

39. NC Heroin Deaths: 2008-2015*
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2008- 2015*
*2015 data are provisional and likely increase as cases are finalized
Analysis by Injury Epidemiology and Surveillance Unit
554% increase from
2010 to 2014
63
75
37
76
147
179
246
174
0
50
100
150
200
250
300
2008 2009 2010 2011 2012 2013 2014 2015*

42. Heroin Hosp. and ED Overdoses: 2008-2014
Source: N.C. State Center for Health Statistics, Vital Statistics-Hospital Discharge 2008- 2013
NC DETECT- Statewide ED Visit data, 2008-2014
Analysis by Injury Epidemiology and Surveillance Unit
213
252
213
311
474
643
1,127
76 75 58
101 122
195
0
200
400
600
800
1000
1200
2008 2009 2010 2011 2012 2013 2014
ED Hosp
From 2010 to 2014
a 429% increase
for ED visits

43. Recent Publications on Heroin Increases

44. Adulterated Heroin Increases
Mmwr-RI-6324

45. Heroin/Clenbuterol Cases
Virginia March 2015
• 15 cases reported
• Collaboration between state health, poison,
health facility and law enforcement
• Exchange of information and lessons learned
• Recent presentations and pending publication

46. NC HEROIN/CLENBUTEROL

47. Clenbuterol
• A Beta-2-agonist, veterinary medication (horses)
• Side effects
– Tachycardia, palpitations, hypokalemia, hypotension,
elevated lactate, metabolic acidosis
• Drug of abuse among athletes
• Inexpensive, readily available (websites)

48. Heroin/Clenbuterol
• Reports from the field mentioned both dealers
diluting and dealers adding for euphoric effect
• Recently, IVPB connected with community users
– Most mentioned that it was intentional and meant
to mimic a ‘speedball’ (cocaine/heroin)
• Users mention ‘blue heroin’ in reports

49. Reports from Users
Person 1
"I have been talking about this with a group of
people. Scramble is a mix they have in the
Baltimore area – very different from this blue
(seems to be synthetic) dope. I have a person
working on finding out about this.....we think its a
product of the deep web, more info as I get it."

50. Reports from Users
Person 2
I actually talked to someone…about this and I was
saying that I didn't think it was actual dope (the
blue stuff). It just wouldn't make sense...I'd think
that'd stop people from buying it. I know that I
wouldn't buy dope that was blue. Research chem
makes sense. I thought research chem makers had
had a hard time creating an opioid version over
the years, but it does make sense that they'd
eventually get there.

51. Reports from Users
Person 3
In Baltimore there are two types of heroin: scramble and
raw. Raw is hard rocks and is usually sold in tiny glass
vials or by weight. Scramble is usually packed into gel
caps (looks like a gel cap Advil, for example).
I've also never seen blue scramble. It's usually light, light
brown or white.
I'd think that what the guy is talking about is a local issue
and not a larger thing.

52. Reports from Users
Person 3
Scramble is usually cut with all kinds of things. I
hated it but some people love it because the rush is
different - I always thought the rush sucked. I've
never seen scramble down here or even in DC, but
that doesn't mean it isn't. It wouldn't surprise me
if people get sick off of it. It's seriously cut with
whatever is around that may or may not have
some sort of effect on the rush.

53. Reports from Users
Person 4
Yeah, a bunch of my friends have started doing it
recently. It feels like fentanyl but just keeps
getting stronger and stronger. I don’t know
what the f**k it is but its heavy man... Like
people are overdosing left and right. :/ I'll look
into it, one of the big guys here in Wilmington is
mainly selling it. I'll talk to her. Let you know
more when I do!

54. 7/7/2015, 6pm
Email from Carolina
Poison Control-report
of ‘possible’
heroin/clenbuterol
7/8/2015, 7am
IVPB sends soft
‘alert’ email sent to
overdose community
and Epi Section.
MMRW/Hoffman
7/9/2015, 3pm
What is IVPB
‘investigation
process’? (3-5
possible cases)
7/9/2015, 5pm
Senior leadership
looped in and asked
for IVPB response
7/9/2015
Reporting hospital
developing case
definition/survey
(additional cases
reported)
7/9/2015
Waiting for lab
confirmation, most
leaving against
medical advice (AMA)
7/9/2015, 6pm
NC should send out
media alert (based on
2-7 cases)
7/9/2015, 6pm
NC should send out
media alert (based on
2-7 cases)
7/10/2015, 9am
State Epi asking for
update on
communication/
media alert
7/10/2015, 4pm
Carolina Poison
Center sends out
media alert (9 cases)
7/11/2015
Handful of media
outlets pick up alert
7/15/2015
10 cases reported to
date, several
pending/some
outlying counties but
connection with
reporting county
7/17-7/19/2015
New potential cases
reported
7/19/2015
CDC Epi-X alert
(18-cases)
7/20/2015
NC HAN/Letter to
providers (18 cases)
NC Heroin/Clenbuterol Timeline, 2015

55. NC Heroin/Clenbuterol Cases

56. NC Health Alert Network (NC HAN)

57. NC Provider Letter/Alert

58. CDC Epi-X Alert

59. NC Heroin/Clenbuterol Cases by Date, 2015
0
1
2
3
4

60. DEVELOPMENT OF
COMMUNICATIONS PROTOCOL

61. Development of Injury Warning
• IVPB had new role in response
• IVPB ‘thin’ bench and lack of response experience
– Must coordinate with others
• Several debriefings with key partners
• Creation of Early Injury Warning system
• IVPB staff added to NC HAN, Situation Report lists
• Asked to expand our role

62. NC Injury Warning
Communication Protocol
1. Activation
2. Investigation/
Monitoring
3. Communication

63. Small Test, January-February 2016
• Carolinas Poison Control emailed 1/22/16
with reported ‘possible’ new case in central
NC (same facility as July)
• Within 24 hours
– All informal alerts were sent
– sit.report sent to senior leadership, affected areas
• Monitoring: No additional cases reported

64. NC Situation Report (Sit. Report)

65. INCREASING COLLABORATION
BETWEEN KEY STAKEHOLDERS

66. North Carolina Injury and Violence Prevention Branch, Partners
Poisoning Death Study
Comprehensive Community Approach
Chronic Pain Initiative
Opioid Death Task Force
Policy and Practice
Research
North Carolina
Prevention and
Harm Reduction
Drug Take Back
Prescription
Drug
Substance
Abuse
SAC Poisoning/Overdose
Team Communication, Policy,
and Advocacy
Enforcement
SBI and Medical &
Pharm Board
DPH, DMA, DMH/DD/SAS,
ORH
Carolinas Poison Center
Monitoring
Program

67. Partners
• NC Public Health Preparedness and Response
• State Bureau of Investigation (SBI) Information
Sharing and Analysis Center (ISAAC)
• DPH Epi Section
– Communicable diseases, food borne diseases, etc.
• Clinical providers in ED (toxicologists)
• Expanded relationship with Carolinas Poison
Center

68. TRACKING & MONITORING

69. NC DETECT / ED Data Mandate
GS § 130A-480
(a) For the purpose of ensuring the protection of the public health, the State Health Director
shall develop a syndromic surveillance program for hospital emergency departments in
order to detect and investigate public health threats that may result from
(i) a terrorist incident using nuclear, biological, or chemical agents or
(ii) an epidemic or infectious, communicable, or other disease.
The State Health Director shall maintain the confidentiality of the data reported pursuant to
this section and shall ensure that adequate measures are taken to provide system security
for all data and information. The State Health Director may share data with local health
departments for public health purposes, and the local health departments are bound by
the confidentiality provisions of this section. The State Health Director shall not allow
information that it receives pursuant to this section to be used for commercial purposes and
shall not release data except as authorized by other provisions of law.
*Effective 1/1/2005
*Law modified in 2007 to allow sharing of reported hospital ED data with CDC

70. NC DETECT Overdose Visits
Source: North Carolina NC DETECT

71. Access to NC DETECT
• NC DETECT web application access for
– Local Health Departments
– Data Providers (Hospitals, EMS, Poison Center)
• Authorized users are able to view data from
– Emergency Departments
– Carolinas Poison Center
– Pre-hospital Medical Information System (PreMIS)
• Training webinars provided by DPH, NC DETECT
• Datasets shared with researchers after DUA and
IRB approval

72. Hot Topics Dashboard
Click on a point to
access line listing

73. Reach Back Mode
• When authorized, NC DPH can review medical records
• Reach back mode been utilized in 2 overdose situations
– TTP (Opana ER, IDU): 12 hospitalizations in TN
– Heroin/Clenbuterol
• Use of NC DETECT to find general heroin cases can then
be retrospectively reviewed to see if there are other
indications of adulteration (heart palpitations, X, Y, Z)
• OR during outbreak to potentially find additional cases
meeting definition

74. EVALUATION

75. Evaluation of Protocol
• What triggers an activation?
• Who initiates first alert to activate the
protocol?
• Who receives the notice?
– Most effective communication channel for each
target population?
– How to best reach most at risk in shortest time?
• How much time does it take to go from first
alert to a communication notice?

76. Evaluation of Protocol
• Balancing potential public panic vs.
responsibility to alert of injury dangers
• When to consider “case closed”?
• Expanding NC State Injury Prevention Program
– Always prevention, increasingly reactive

77. NC’S NEXT STEPS…
CDC Prescription Drug Overdose (PDO)
Prevention for States (PfS)

79. For more information…
Scott Proescholdbell, MPH
scott.proescholdbell@dhhs.nc.gov
Nidhi Sachdeva, MPH
nidhi.sachdeva@dhhs.nc.gov
Injury and Violence Prevention Branch
NC Division of Public Health
www.injuryfreenc.ncdhhs.gov | www.injuryfreenc.org

80. Community Responses to Heroin:
North Carolina and Northern Kentucky
Presenters:
• Kim Moser, Director, Northern Kentucky Office of Drug Control
• Scott Proescholdbell, MPH, Epidemiologist, Injury and Violence
Prevention Branch, North Carolina Department of Health and Human
Services
• Nidhi Sachdeva, MPH, Injury Prevention Consultant, Division of Public
Health, North Carolina Department of Health and Human Services
Heroin Track
Moderator: Kelly J. Clark, MD, MBA, FASAM, DFAPA, President-elect,
American Society of Addiction Medicine, and Member, Rx and Heroin
Summit National Advisory Board