Ventura County RESPONDS

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REPORT

VENTUR A COUNT Y

PRESCRIPTION DRUG ABUSE

WORKGROUP

Ventura County

RESPONDS

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VENTURA COUNTY PRESCRIPTION DRUG ABUSE WORKGROUP

Connecting and strengthening local resources to prevent and reduce prescription drug and heroin abuse.

Patrick Zarate, Chair Division Manager

Ventura County Behavioral Health Department Alcohol & Drug Programs (ADP)

Karlyn Bock, RN, M.Ed.

Director, Health & Prevention Programs Ventura County Office of Education

Diana Casey, RN, MSN Community Representative

Janis Gardner

Behavioral Health Advisory Board Rae Hanstad

Prevention Consultant Daniel Hicks

Manager

ADP Prevention Services Janet Kaplan, MA, M.Ed. ADP Prevention Services

Michelle Laba, MD

Medical Director, Ambulatory Care Ventura County Health Care Agency

Robert Levin, MD Health Officer/Medical Director Ventura County Public Health Department

Gary Pentis Assistant Sheriff Ventura County Sheriff’s Office

Rigoberto Vargas Director

Ventura County Public Health Department Celia Woods, MD

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Introduction ... 2

Targets for Action... 3

Target 1: Professional Development ... 4

Target 2: Enforcement & Security

... 6

Target 3: Education & Awareness

... 8

Target 4: Safe Schools

... 10

Target 5: Prevention Policy & Research

... 12

Trend Data at a Glance

... 13

Conclusion ... 14

Acknowledgments ... 15

Resources ... 16

INTRODUCTION

The Prescription Drug Abuse and Heroin Workgroup was launched in February 2012 in response to the growing problem of prescription pain medication and heroin abuse in Ventura County. Labeled a nationwide crisis and epidemic, reports from professionals and the community made it clear that this region was far from immune. Confronting prescription drug and heroin abuse was essential to protecting the public health and safety of all

citizens, including youth.

The Rx Workgroup was convened to understand and address the local problem in a strategic yet timely manner. A collaborative prevention campaign, uniting law enforcement,

educators, health care professionals, County agencies and community members immediately began to identify and understand common problems and applicable resources. Initial

meetings allowed countywide representatives to share local data and information describing the effects of prescription drug and heroin abuse on impacted systems — and on affected individuals and families.

In 2012 in Ventura County there were 56 deaths related to prescription opioids. According to US Centers for Disease Control and Prevention (CDC) 2010 estimates, the exponential effects represented by even one such death is unfortunately wide. (See graphic below.)

The Prescription Drug Abuse and Heroin Workgroup identified five specific local Targets, then developed and began implementing Actions calculated to reduce prescription drug misuse, heroin abuse and overdose in Ventura County. This first report presents the realities, strategies and initial accomplishments of an ongoing dedicated effort at community

transformation.

10

26

108 For every

1 overdose death,

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TARGETS FOR ACTION

The 2013 National Drug Control Strategy advocates four areas of focus to achieve the goals of their Prescription Drug Abuse Prevention Plan: education, monitoring, disposal and enforcement. The Prescription Drug Abuse and Heroin Workgroup is committed to parallel target areas based on countywide conditions and the alliance of a strong multiagency partnership.

1: PROFESSIONAL DEVELOPMENT

GOAL: Expand professional training and development across all sectors. 2: ENFORCEMENT AND SECURITY

GOAL: Support law enforcement, monitoring and security to enhance public safety by deterring drug misuse, abuse and diversion.

3: EDUCATION AND AWARENESS

GOAL: Increase outreach and education for parents, patients and the public to raise awareness of prescription drug abuse and heroin problems and solutions.

4: SAFE SCHOOLS

GOAL: Collaborate with schools, PTAs and Ventura County Office of Education (VCOE) to increase communication channels and prevention opportunities for teachers, parents, students and school personnel.

5: PREVENTION POLICY AND RESEARCH

GOAL: Advance continued research and data analysis to develop key policy actions addressing Rx and heroin abuse.

108 people who abuse

or are dependent

733 nonmedical users

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PROFESSIONAL DEVELOPMENT

AC TIONS

TARGE T 1:

1.1 PRESCRIBER TRAINING

Elinore McCance-Katz, MD, PhD, Chief Medical Officer, Substance Abuse and Mental Health Services

Administration (SAMHSA), presented one of the first in a projected series of health care professional trainings,

What Every Prescriber Should Know About Addiction to Pain Medicines. Hosted by the Ventura County Medical

Center and featuring other local experts in medicine and law enforcement, this Continuing Medical Education (CME) program addressed physicians, clinicians and other providers, and integrated strategic options for managing patients who develop a substance abuse disorder with prescribed opioids.

Future planned prescriber training opportunities will include:

• Narcotic and non-narcotic pain management approaches for dentists, organized in collaboration with the Santa Barbara-Ventura County Dental Association.

• A CME training for physicians, highlighting non-narcotic pain management advances.

• Prescriber in-service and simplified registration for Controlled Substance Utilization Review and Evaluation System (CURES) prescription drug monitoring program, offered by Mike Small, CURES Manager, California Department of Justice.

Health care professionals who prescribe...are in a key position to balance the benefits of

prescribing opioid analgesics to treat pain against the risks of serious adverse outcomes

including addiction, unintentional overdose, and death. Opioid misuse and abuse, resulting

in injury and death, has emerged as a major public health problem. Appropriate prescribing

practices and patient education are important steps to help address this public health problem.”

– FDA Blueprint for Prescriber Education, 2013

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1.2 ONLINE RESOURCES

Health care professionals can easily access timely information at the new Rx Risk: Prescribers Portal at VenturaCountyLimits.org.

They can download, print and share the Rx Toolkit, including materials in Spanish and English directed to patients and staff about the problems and prevention of Rx misuse and abuse. News about resources, CME trainings, Rx drug disposal locations and upcoming events are updated regularly.

1.3 INFORMATIONAL MAILINGS

More than 2500 Ventura County prescribers and dispensers of medication received their first informational “Rx Risk” packet mailing as an introduction to the Workgroup collaboration and the available training resources, patient handouts, staff materials and future professional development opportunities.

1.4 CROSS-SECTOR MATERIALS ON Rx ABUSE & HEROIN

To provide wide-ranging dissemination of the latest important information on preventing opioid and heroin abuse, the Spanish and English versions of What You Need to Know

About Rx Abuse & Heroin have been expanded.

The Working Together insert for pharmacists and health care providers, as well as a Child Safety handout, are readily available in hard copy or online.

Expand professional training and development opportunities

across all sectors.

GOAL:

Ventura County Responds 5

Lo que debe saber sobre e_{l uso abusivo de}

los medicamentos por receta y la heroína Esto ocurre en el Condado de V entura Los medicament os como Oxicodona son una vía para las drogas Pastillas HER_OÍNa

Prevenir eL uso abus_{ivo de Los oPioides e} n eL Condado de ventura What You Need to Know about

Rx ABUSE & HEROIN

It’s happening in Ventura County

Meds like OxyContin are gateway drugs

PILLS HEROIN

PREVENTING OPIOID ABUSE IN VENTURA COUNTY

Working together to

prevent opioid abuse

• Screen for addiction risk factors • Note symptoms of abuse • When possible, report to CURES

• Use tamper-resistant Rx pads • Report lost or missing Rx pads • Consider smaller quantities of drugs with abuse potential

• Promote safe Rx use and secure disposal • Advocate for increasing CEU credit for mandatory

addiction and prescribing training • Rx abuse prevention signage in exam rooms • If you suspect abuse, say no to addictive drugs HealtH care providers

please post

If you suspect fraud or prescrIptIon abuse, call 911 or your local dea. PREvENtINg OPIOId AbUSE IN vENtURA COUNty

Learn more at: www.venturaCountyLimits.org/prescribers

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ENFORCEMENT & SECURITY

AC TIONS

TARGE T 2:

Ventura County Board of Supervisors declaration

Every Day is Take Back Day

2.1 SAFE AND SECURE Rx DISPOSAL

Secure collection and safe disposal of unused and expired medications is a highly effective strategy for reducing unwanted access to prescription drugs, especially by youth. Safe and confidential Rx disposal bins were initiated in Ventura County Sheriff’s Office jurisdictions and are now actively used and supported by law enforcement in all 10 cities across the county. While Prescription Drug Take-Back Day is a national biannual event, the Board of Supervisors raised the local standard by unanimously declaring Every Day

is Take Back Day in Ventura County.

EST. POUNDS 0 1000 2000 3000 4000 5000 6000 2009 2010 2011 2012 2013

Source: Ventura County Sheriff’s Office, Sept 2013

VENTURA COUNTY Rx DISPOSAL

Over

7 tons of pills destroyed to date —

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Support law enforcement, monitoring and security to enhance

public safety by deterring drug misuse, abuse and diversion.

GOAL:

2.3 VENTURA COUNTY INTERAGENCY PHARMACEUTICAL CRIMES UNIT

Formed by the Ventura County Sheriff’s Office (VCSO), the Ventura County Pharmaceutical Crimes Unit includes members of law enforcement from VCSO, Simi Valley Police Department and the District

Attorney’s Office Bureau of Investigation. The main mission of the task force is combatting the transfer of legal medication to the illegal market. Fifty-four arrests were made in the first six months of operation and over 120,000 pharmaceutical pills were seized. The Rx Workgroup supports the Unit’s mission and utilizes its relevant data and information to plan activities.

2.2 PRESCRIPTION DRUG MONITORING PROGRAM

The Controlled Substance Utilization Review and Evaluation System (CURES), California’s prescription drug monitoring program, is an online database used to track the prescribing and dispensing of controlled prescription drugs to patients. Operated by the California Department of Justice, CURES allows registered users including prescribers, pharmacists, law enforcement and medical regulatory boards to monitor patient and prescriber history of controlled substance prescriptions. CURES oversight helps to reduce overprescribing, discourages the illegal practice of “doctor shopping” and safeguards patients requiring painkiller medication. The Rx Workgroup strongly encourages CURES compliance and will offer training and streamlined registration for prescribers starting next year.

Parents need to be aware of their children’s online activities to

help stop the illegal purchase of powerful prescription drugs, many

of which have led to fatal overdoses.” –

Ventura County Sheriff’s Office

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EDUCATION & AWARENESS

TARGE T 3:

AC TIONS

3.1 WEBSITE AND SOCIAL MEDIA

Promoting prevention messaging and informational resources across all populations, the VCBH website

VenturaCountyLimits.org is updated frequently and is actively linked to Facebook and Twitter. Current materials in Spanish and English on substances of abuse can be easily accessed, with special pages devoted to prescription drug abuse efforts and other helpful sources. Parents of tweens may look forward to a new text-messaging program, currently in the pilot phase, that will enhance awareness of effective prevention policies.

3.2 DRUG DISPOSAL CAMPAIGN

A multimedia campaign on the importance of safe and secure drug disposal was directed to the public from a variety of angles, including a billboard on CA Highway 33, newspaper and radio ads, medicine chest reminder magnets, clinic posters and brochures. Concurrent outreach to real estate professionals warned of the risks of medicine chest thefts during open houses.

3.3 CHILD SAFETY

Ventura County Public Health Department’s new Rx Child Safety flyer, in Spanish and English, describes the poisoning risks of prescription medications, promotes responsible drug disposal, and offers the warning

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Ventura County Supervisor Steve Bennett

3.4 VENTURA COUNTY’S Rx DRUG ABUSE SUMMIT

VCBH offered its first conference on Rx drug abuse in 2009 and issued an informative and revealing

“Prescription for Change” to treatment and prevention professionals, healthcare experts, law enforcement, policymakers and other key stakeholders.

In 2013, responding to continued increases in prescription drug and heroin abuse, Ventura County’s Rx Drug Abuse Summit was presented to a widespread audience eager for updated information. Faculty included local experts as well as keynote speakers Lisa Girion and Scott Glover, Los Angeles Times investigative reporters of the groundbreaking “Dying for Relief” series. Other expert speakers and panelists focused on

Local Realities & Local Strategies, underscoring the impacts of prescription painkiller abuse and the County’s

commitment to the road ahead.

Increase outreach and education for parents, patients and the public

to raise awareness of prescription drug and heroin abuse problems

and solutions.

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SAFE SCHOOLS

TARGE T 4

:

AC TIONS

4.1 PROVIDED RESOURCES AND FACULTY

The partnership with VCOE encourages development of Rx and heroin prevention training opportunities for local teachers, counselors, school nurses, administrators and other school staff. Providing resources and faculty for a regional Rx Abuse Forum at VCOE multiplied into other successful parent, faculty and school staff events.

4.2 TEACHER EDUCATION

Teachers are vital for educating students about substance abuse. A “Working Together” insert was developed especially for teachers as a companion to the “What You Need to Know About Rx Abuse and Heroin” brochure. The materials help teachers deliver concise prevention messaging to students at the most teachable moments.

4.3 MENTORING

According to the 2013 National Drug Control Strategy, “mentors play a vital role in healthy youth development and substance use prevention.” Ventura County’s Friday Night Live Mentoring (FNLM) program dedicated an entire session to Rx drug abuse and dependence. FNLM staff prepared and co-presented lessons at four different sites with 20-30 students in each audience. At last year’s Annual Youth Leadership Conference, 62 students experienced a Prevention workshop with a prescription and over-the-counter drug abuse session.

Working together to

prevent opioid abuse

• Prescription drug abuse can lead to addiction.

• Prescription drug abuse is illegal.

• Prescription drug abuse can have serious health consequences.

• Just one instance of accidental misuse or intentional abuse of prescription drugs can be deadly.

• It is never okay to share your prescription drugs with others or take another person’s prescription drugs, regardless

of the reason you are doing it.

• It is never okay for your friends to be sharing prescription drugs, for any reason.

teachers

Teachers who have concerns abouT sTudenTs should check wiTh Their school adminisTraTor abouT policies and besT pracTices for follow-up.

PreventIng OPIOId Abuse In venturA COunty www.venturaCountyLimits.org/rx

Ventura County HealtH Care agenCy

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Collaborate with schools, PTAs and Ventura County Office of

Education (VCOE) to increase communication channels and prevention

opportunities for teachers, parents, students and school personnel.

GOAL

:

4.4 SYSTEMATIC SCHOOL-BASED DATA COLLECTION

The data collected from youth through surveys administered in schools provides invaluable information for effective collaborative prevention efforts. The Rx Workgroup will continue support of systematic school-based data collection and reporting, like the California Healthy Kids Survey, to gauge the prevalence of prescription drug misuse and heroin abuse among students in Ventura County.

4.5 VIDEO CONTEST

Straight Up Ventura County Video Contest: “Prescription for Change” challenged Ventura County residents between 12–25 years of age to create their own fact-based videos around Rx abuse topics such as the dangers of sharing prescription drugs, and the safe storage and disposal of unwanted medication. The winning videos were shared with key stakeholders and online as part of ongoing outreach to local youth.

lifetime use by ventura county students:

• 14% of 9th graders and 20% of 11th graders reported misusing Rx painkillers

• 4% of 9th graders and 5% of 11th graders reported using heroin

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PREVENTION POLICY & RESEARCH

TARGE T 5:

AC TIONS

5.1 TRACKING LOCAL DATA

To better understand the prevalence and impacts of prescription drug and heroin abuse in Ventura County, relevant multiagency data from 2008 through 2012 were collected and analyzed. By developing an

established baseline, the Rx Workgroup was able to create a tracking tool for ongoing monitoring, analysis and shared reporting of abuse trends over time. Data will also be used to measure progress and plan new Targets for Action.

5.2 SPECIAL LOCAL RESEARCH

Unique local research efforts were carried out with the Ventura County Jail Inmate population (Pre-Trial Detention Facility and Todd Road Jail locations) and Ventura County Treatment Program participants. Separate survey initiatives collected data to further the role of prescription-type opioid use as a precursor to heroin abuse. Treatment Program findings are provided below and mirror the data collected among the Jail Inmate population (see Trend Data at a Glance).

32% of respondents reported heroin use in their lifetime.

Of those who reported lifetime heroin use, 45% indicated beginning with Rx opioids, then moving to heroin. The rate of transition from prescription-type opioids to heroin was highest among the survey respondents in younger age groups.

Of respondents who ever misused any Rx opioids, 61% bought or received them from a friend or family member. The top four reasons stated for starting to use heroin instead of Rx opioids were:

• Heroin was cheaper

• Other people I know were using it • Heroin was easier to get

• I wasn’t getting a “good high” from Rx opioids anymore

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Supplemental Data Related to Rx Opioid and Heroin

TREND DATA AT A GLANCE • VENTURA COUNTY 2008–2012

This document is used by the Rx Workgroup to track Rx Opioid and heroin trends over time. Use of these data should be authorized in advance by VCBH.

INDICATOR 2008 2009 2010 2011 2012 ADDITIONAL FINDINGS & NOTES

7 EXPLORATORY/PILOT STUDIES – RX OPIOID TO HEROIN RESEARCH Youth in Ventura County Treatment Programs

% of youth who reported lifetime heroin use that also indicated past Rx/OTC misuse 90% Only half (50%) of the YSAS respondents who reported NEVER using heroin indicated past Rx/OTC misuse. There is a strong association between lifetime heroin use and Rx/OTC misuse.

Ventura County Jail Population

% of inmates who reported lifetime heroin use that reported using Rx opioids before moving to heroin 52% A total of 312 inmates from two jail locations participated in the survey. Among survey respondents, 60% reported using prescription-type opiates not as intended by a doctor during their

lifetime; and 55% reported lifetime heroin use. Out of heroin users, 52% indicated beginning with prescription-type opiates, then moving to heroin. The top 3 reasons selected when answering, “What made you start using heroin instead of prescription-type opiates?” were: (1) it was easier to get; (2) it was cheaper; and (3) other people I know were using it.

Ventura County Treatment Program Participants

% of treatment participants who reported lifetime heroin use that also reported using Rx opioids before moving

to heroin 45%

A total of 489 drug treatment clients in various types of treatment programs participated in the survey. Among survey respondents, 32% reported that they had used heroin during their lifetime. Out of heroin users, 45% indicated beginning with prescription-type opiates. The top 3 reasons selected when answering, “What made you start using heroin instead of prescription-type opiates?” were: (1) it was cheaper; (2) other people I know were using it; and (3) it was easier to get.

8 LOCAL ESTIMATED NARCOTICS “STREET VALUE” DATA*** Cost of Rx Opioids

30 mg. pill of OxyContin/Roxicodone = $15 (10 pills/day)

Cost of Heroin

1 gram of heroin = $50 (injected 4-6 times/day)

$150 $50

Although 80 mg. OxyContin pills were once popular at $80/pill, the 80-mg. pill has been reformulated making it more difficult to abuse. Therefore, the 30-mg. pill is now usually sold on the street. There is speculation that this change in formulation may have had the unintended consequence of increasing the abuse of heroin. ***Price estimates are approximate and subject to fluctuation, bulk buying, etc.,

and equivalent levels of “high” are relative to tolerance and metabolism.

1 CA HEALTHY KIDS SURVEY-LIFETIME USE VENTURA COUNTY STUDENTS Source: Dr. Heidi Christensen, Ventura County Office of Education

Rx Painkiller Misuse

% of 9th graders

% of 11th graders 13%22% 13%20% 14%20%

Painkillers were the most commonly reported Rx-type drugs misused in 2008 & 2010. In 2010, about half as many students reported misusing tranquilizers/sedatives or Ritalin/Adderall as compared to painkillers.

Heroin Use

% of 9th graders

% of 11th graders 4%5% 4%5% 4%5%

There were statistically significant increases in lifetime heroin use from 2006 to 2010 for 9th and 11th graders; the number of students who reported using heroin 4 or more times in their life more than doubled during the same time period.

2 VENTURA COUNTY CALOMS TREATMENT ADMISSIONS* Source: CalOMS, Alcohol & Drug Programs

Heroin as Primary Drug

% of heroin admissions among those 18 or older % of heroin admissions among those 17 and under % of heroin admissions combined, all ages

15% 1% 13% 12% 2% 10% 13% 4% 11% 15% 4% 13% 18% 3% 16%

Rx Opioids as Primary Drug**

% of Rx opioid admissions among those 18 or older % of Rx opioid admissions among those 17 and under % of Rx opioid admissions combined, all ages

2% <1% 2% 2% 1% 2% 4% 2% 4% 4% 2% 4% 4% 1% 4%

*Does not include methadone treatment data.

**Rx opioids includes: OxyContin, Methadone, or other opioids/synthetics.

3 VENTURA COUNTY NON-FATAL OPIOID-RELATED EMERGENCY DEPARTMENT VISITS Source: California Department of Public Health, EpiCenter, California Injury Data Online # of total ED visits related to opioid overdose among those 18 and older

# of total ED visits related to opioid overdose among those 17 and under 11214 12610 14614 17724 Data parameters include: non-fatal ED visits; “opioids” was the drug category diagnostic; and the health consequence was “poisoning” (i.e., overdose).

4 VENTURA COUNTY MEDICAL EXAMINER TOXICOLOGY FINDINGS Accidental Deaths

# of total accidental drug and/or alcohol deaths # of accidental deaths involving opioids # of accidental deaths involving heroin # of accidental deaths involving other Rx drugs

77 34 23 22 68 38 17 18 74 42 16 23 95 48 27 24 103 44 43 25

2008-2011 Source: VCBH Drug and Alcohol-Related Deaths, Ventura County (Rx Workgroup, Nov. 2012)

2012 Source: VCBH analysis of ME data by K. L. Hunnicutt, MA

5 VCBH DUI PROGRAM PLACE OF LAST DRINK (POLD) SURVEY - IMPAIRED DRIVING Source: Analysis of Place of Last Drink Survey % of POLD respondents who reported using drugs on the day of their arrest for DUI

Of those: % of POLD respondents indicating Rx use

% of POLD respondents reporting heroin use

8% 36% 4% 7% 38% 4% 8% 46% 1% 10% 45% 5% 10% 42% 4%

Rx use is general and includes all types of Rx (i.e., it is not limited to opioid/pain killers like the other indicators listed in the table). Data is representative of survey completion year.

6 VENTURA COUNTY SHERIFF’S OFFICE DISPOSAL RECORDS Source: Ventura County Sheriff’s Office

Rx & Heroin Disposal — Estimated Weights

Pounds of Chemically Altered/Pharmaceutical Drugs Pounds of Heroin

Total # of permanent disposal bin locations

343 N/A N/A 1,886 1.6 5 3,467 24.3 6 2,915 9.8 8

Estimated total weight of pharmaceuticals disposed of = 14,126 pounds (2006 through Sept. 2013). YTD 2013: 5,475.7 lbs. Rx; 3.2 lbs. Heroin through 9/5/13.

2006: 40.11 lbs. Rx; 4.8 lbs. Heroin. Data not available 2007-08.

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TREND DATA AT A GLANCE • VENTURA COUNTY 2008–2012

This document is used by the Rx Workgroup to track Rx Opioid and heroin trends over time. Use of these data should be authorized in advance by VCBH.

7 EXPLORATORY/PILOT STUDIES – RX OPIOID TO HEROIN RESEARCH Youth in Ventura County Treatment Programs

% of youth who reported lifetime heroin use that also indicated past Rx/OTC misuse 90% Only half (50%) of the YSAS respondents who reported NEVER using heroin indicated past Rx/OTC misuse. There is a strong association between lifetime heroin use and Rx/OTC misuse.

Ventura County Jail Population

% of inmates who reported lifetime heroin use that reported using Rx opioids before moving to heroin 52% A total of 312 inmates from two jail locations participated in the survey. Among survey respondents, 60% reported using prescription-type opiates not as intended by a doctor during their

lifetime; and 55% reported lifetime heroin use. Out of heroin users, 52% indicated beginning with prescription-type opiates, then moving to heroin. The top 3 reasons selected when answering, “What made you start using heroin instead of prescription-type opiates?” were: (1) it was easier to get; (2) it was cheaper; and (3) other people I know were using it.

Ventura County Treatment Program Participants

% of treatment participants who reported lifetime heroin use that also reported using Rx opioids before moving

to heroin 45%

A total of 489 drug treatment clients in various types of treatment programs participated in the survey. Among survey respondents, 32% reported that they had used heroin during their lifetime. Out of heroin users, 45% indicated beginning with prescription-type opiates. The top 3 reasons selected when answering, “What made you start using heroin instead of prescription-type opiates?” were: (1) it was cheaper; (2) other people I know were using it; and (3) it was easier to get.

8 LOCAL ESTIMATED NARCOTICS “STREET VALUE” DATA***