1. The Heroin Epidemic in rural Maryland Rural Health Learning Collaboration Sept. 28, 2015 James A. Cockey, MD, FACP Deputy Health Officer

9. The Cost of Alcohol and Illicit Drug Use on the Eastern Shore of Maryland October 2014

10. Eastern Shore of Maryland – 9 counties, pop. 449,000 - 2013

12. Wicomico County

13. New demographics Increase in pregnant clients Larger numbers of white, male, middle aged patients Change in past drug history Formerly clients had dabbled more with pot, alcohol, cocaine Now a more common route is acute or chronic pain, prescription opioids, addiction, heroin

14. Collateral damage A lost generation Children of addicts Neonatal abstinence Multiple NAS babies Parents absent, high, struggling Older parents of adult addicts Time, money, energy for their children’s addiction Raising grandchildren for dead or incapacitated parents Adolescents experimenting with drugs earlier in life, get into legal system early, affecting job, education opportunities Human trafficking

16. Physician response Highly publicized scandal around local pain management physician - 2012 Physicians are reluctant to prescribe opioids compared to pre-2012. More referrals to pain management and rheumatology practices Some pain management will do procedures only Insufficient pain specialist resources

17. Physicians and opioid prescribing Increased heroin related hospital admissions A few large practices have agreed on universal policies They have experienced “a vast exodus of narcotic seekers” Standardizing opioid prescribing practice seems more important than the specific standards Naloxone not commonly prescribed in primary care

18. Politics Campaigns focused on addictions Maryland governor, Larry Hogan (R) campaigned on heroin epidemic Lt. Governor’s regional summits - 6 locations around the state Lt. Governor’s Task Force To release recommendations on all aspects of drug abuse. New state laws facilitating naloxone distribution Good Samaritan law Hard to get the word out Wicomico County Executive, Bob Culver (R) also focused on heroin epidemic

20. Overdose Response program Maryland state law, grant funds for naloxone – aimed at getting more naloxone into the community SB516 goes into effect Oct. 1 – allows for authorized lay person to dispense naloxone on the street Reduced barriers in law regarding dispensing of naloxone standing orders for pharmacies SB516 goes into effect Oct. 1 – allows for authorized lay person to dispense naloxone on the street

21. Maryland Prescription Drug Monitoring Program

22. Local efforts Prescription Drug Task Force Monthly collaborative meetings – public health, hospital, media, law enforcement, pharmacists, MCO’s, addictions treatment offices Community Pain Management Task Force Overdose Fatality Review Team Collaboration with pharmacies Wicomico Drug Talks Funding for outreach, health promotion Billboards, internet, TV 211 line – training for telephone operators for Life Crisis Drug Drop off boxes Overdose Response Program – naloxone training – all law enforcement has been trained Regular trainings for public

23. 4 WiCo rug drop off boxes for 2 years 2 more recently – 1 in a pharmacy

24. 211 promotion

25. Treatment Same day walk-in evaluations, Monday – Thursday Intake assessment Connect client to IOP or private services rapidly For possible MAT (Suboxone, methadone) more steps involved Mandatory counseling Medication Assisted Treatment clinics – methadone & suboxone

26. Perceived barriers in accessing addictions services Client and family difficulties in accessing treatment Referring provider difficulties in understanding treatment access Ongoing outreach efforts