The Prescription Drug and Heroin Epidemic in Southern Illinois A Call for Community Health Solutions

A resource paper compiled from results of a community forum organized by the

Community Behavioral Healthcare Association of Illinois With background materials prepared by the Center for Rural Health and Social Service Development Southern Illinois University School of Medicine

June 2016

The Prescription Drug and Heroin Epidemic in Southern Illinois A Call for Community Health Solutions Data suggest that the Chicago metropolitan area is in the midst of a heroin epidemic—one of the worst in the country at this time. … Although much data is aggregated at the metropolitan level, it is clear from this analysis that use is growing fastest outside of the central city. … The trend of increased treatment admissions occurring outside of the metropolitan area suggests that access to opiates is increasing throughout Illinois and is not confined to the central city, or to the metropolitan area as a whole. … The highest rates of increase have occurred in downstate Illinois, where treatment admissions have risen nearly 300 percent. A Multiple Indicator Analysis of Heroin Use in the Chicago Metropolitan Area: 1995 to 2002 Illinois Consortium on Drug Policy (ICDP) (2004)1

Introduction The national heroin abuse crisis has continued unabated, and has been complicated and intensified by the rapid increase in the abuse of prescription opioid medications. Current headlines and media reports have sounded the alarm about the “epidemic” of heroin and prescription opiate abuse (collectively “opioid abuse”) and deaths across the country, state and region. Sadly, the opioid crisis in Illinois is not new, and all indicators suggest that it is worse now than when the ICDP report quoted above was published more than a decade ago. The U.S. Department of Justice has declared the increased abuse of opioid prescription medications and heroin, as an “urgent and growing public health crisis”. The Southern Illinois Region has not been spared from this crisis and has experienced a significant increase in drug-related deaths, arrests hospitalizations, and community and family problems. It is a crisis that knows no regional, age, race, education, or income boundaries. The purpose of this paper is to present a working overview of relevant data, research findings, and recommendations that can provide guidance in the effort to develop a regional plan of action to address the prescription drug and heroin abuse crisis in the Southern Region of Illinois.

CBHA and the Prescription Drug and Heroin Crisis in Illinois “I came home one day in 2006 to find my two sons, ages 21 and 23, dead from an overdose of prescription drugs and heroin. One of my sons was a valedictorian of his high school and the other was a 3 year air force veteran”, stated Chris Marler, a parent advocate and a resident of Centralia, Illinois. Ms. Marler made this statement as the opening speaker of a community forum held in Mt. Vernon, Illinois, on August 8, 2014 titled: The Prescription Drug and Opiate Addiction Epidemic in Southern Illinois: A Call for Community Health Solutions. The forum was organized by the Community Behavioral Healthcare Association of Illinois (CBHA) and co-sponsored by the SIU School of Medicine’s Center for Rural Health and Social Service Development, in response to the prescription drug abuse and opiate addiction crisis in communities throughout Southern Illinois. The main focus of the forum was to begin a dialogue for a “regional action plan” to address the problem. CBHA is a statewide trade association of substance use and mental health prevention and treatment providers whose mission is to ensure access and availability to a comprehensive system of accountable, quality behavioral healthcare services for the people of Illinois. CBHA has a long 1

history of engagement with the problem of substance abuse in Illinois and has facilitated numerous meetings to organize community resources and initiate a response. The CBHA and SIU event was attended by 75 individuals, representing the state police, the courts, behavioral health providers, probation officers, schools, teachers, parents, state mental health and substance use divisions, physicians, consumers and local media outlets. The community forum was the first step towards developing a regional action plan focused on understanding the depth of the prescription drug abuse and heroin addiction problem in Southern Illinois and developing a strategy to address the problems. This set of recommendations that were developed by regional stakeholders at the forum are discussed at the conclusion of this paper.

The Scale and Impact of the Opioid Crisis Heroin abuse and addiction is a long-standing standing social problem. However, in the past two decades it has been worsened by a rapid increase of prescription opioid abuse. A Center for Disease Control review of mortality data estimated that of the nearly 44,000 drug related deaths in 2013, more than 24,000 were from prescription opioids or heroin. And, while the age-adjusted rate of opioid analgesic deaths have leveled off in recent years, the death rate from heroin related deaths has almost tripled since 2010 (Figure 1).2

The National Survey on Drug Use and Health (NSDUH) estimated an increase in the number of persons (aged 12 and older) who abuse or are dependent on prescription opioids and heroin from 1.5 million in 2003 (634 per 100,000) to 2.3 million (892 per 100,000) in 2012.3 Other researchers estimate that the total number of opiate abusers is even greater.4 In addition to the loss of life, the economic and social costs of the opioid epidemic have been staggering. One study estimated direct medical costs in 2009 at $2.2 billion, with employment absenteeism and lost productivity accounting for an additional $335 million.5 Other, more difficult to measure, social costs include the impact of incarceration, the spread of infectious diseases such as HIV and hepatitis C, and the damaging impacts on children from neonatal abstinence syndrome 2

and drug related poverty and violence in families. The annual, national total of medical, economic, social, and criminal cost of opiate abuse is estimated to be nearly half a trillion dollars.6

The Opioid Crisis in Illinois Estimating the magnitude of the opioid crisis at state and local level is challenging. The illicit nature of drug use makes it impossible to accurately account for the number of substance abusers. Public health officials and researchers must rely on proxy measures developed from surveys and data collected from coroners, hospitals, Medicare/Medicaid records, emergency rooms, treatment centers and law enforcement agencies. Analysts often apply a “multiple indicator” approach, using a number of approximate measures to assess the scale and epidemiology of heroin and opiate abuse.7 Analysis of these data sources has been used to develop statewide estimates of opioid abuse prevalence,8 but no such evaluation is currently available for Illinois. However, the Center for Disease Control (CDC) and the Illinois Department of Public Health maintain several publicly accessible online data sets that can be used to gauge the changing nature of opioid abuse in Illinois counties and regions. Drug related deaths The number of lives lost to overdose deaths is the most significant measure of the societal impact of opioid abuse. The accurate accounting of drug overdose deaths, however, is complicated by numerous methodological issues. For example, communities may lack the capacity for testing, attributing deaths to specific drugs may be difficult because abusers frequently combine multiple drugs and/or alcohol, or the stigma of drug use may cause some overdose deaths to go unreported. However, because prescription pain relievers and heroin, are the main driver of overdose deaths, total overdose deaths are often considered to be a reasonable proxy for trends in opioid deaths. Recent estimates (2014) from the CDC put the age adjusted rate of overdose deaths in Illinois at 13.1 per 100,000, an 8.3% increase from 2013. While Illinois was one of 14 states to report a statistically significant increase between 2013 and 2014, its overdose death rate ranked 35th among the states, and was well below the national average of 14.7. 9 The Illinois Department of Public Health (IDPH) reports mortality estimates for the State of Illinois, including estimates of drug and heroin overdose deaths (Table 1.) Table 1. Total drug overdose and heroin related overdose deaths in Illinois, Cook County and remaining counties: 2010 to 2015 Year 2015* 2014 2013 2012 2011 2010

Illinois total Total Drug Heroin Overdose related 1,732 804 1,700 711 1,579 583 1,619 266 1,014 113 1,284 149

Cook County Total Drug Heroin Overdose related 670 349 621 321 629 291 612 22 349 2 483 10

Other 101 counties** Total Drug Heroin Overdose related 1,062 455 1,079 390 950 292 1,007 244 665 111 801 139

* Provisional data as of 4/4/16 ** Difference between Illinois total and Cook County Source: Data for 2010-2012 from IDPH personal communication, 11/15/15; Data for 2013-2015 available at: www.dph.illinois.gov/sites/default/files/publications/Heroin-OD-Report-April-2016-040516.pdf www.dph.illinois.gov/sites/default/files/publications/Drug-OD-Report-April-2016-040516.pdf

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While the total number of overdose deaths have fluctuated from year-to-year, the number of deaths attributed to heroin overdoses, has increased steadily since 2012, accounting for an increasingly larger proportion of the total drug overdose deaths. However, some of this increase may also be attributed to increased attention to accurate reporting of overdose deaths. For example, the significant increase in reported Cook County overdose deaths from 2011/2012 to 2013 may have resulted from a 2013 county mandate that required medical examiners to report heroin overdoses.10 Legislation passed in September of 2015 has mandated similar reporting of heroin and opioid overdose deaths throughout the state. The IDPH also provides information on of the population characteristics of overdose fatalities. The most recent year for which this data is completely available is 2014. Table 2. Total drug overdose and heroin related overdose deaths by sex, age group and race/ethnicity in Illinois: 2014 Total drug overdose Total

Heroin overdose

1,700

711

Sex Male

1,103

65%

539

76%

597

35%

172

24%

Under 18

12

1%

3

0%

18 - 24

142

8%

84

12%

25 - 44

764

45%

378

53%

45 - 64

707

42%

237

33%

65 and over

75

4%

9

1%

1,276

75%

474

67%

NH Black

294

17%

169

24%

NH Other

13

1%

2

0%

Hispanic

117

7%

66

9%

Female Age Group

Race/Ethnicity NH - White

Source: IDPH Total and Heroin-related Drug Overdose Deaths Illinois Residents, 2013-2015. See Table 1. footnote for web links

The majority of the reported drug and heroin overdose fatalities in Illinois were male, white, middle-aged (25 to 64) individuals. More than half of the reported heroin overdose fatalities were in the 25-44 age group. Drug related hospitalizations Drug related hospitalizations and treatment admissions provide a measure of both drug use and the impacts of drug use on the health care system. The IDPH IQuery online data system provides an estimate of the number of hospitalization for abuse of opioids. The most recently available data is from the 2009 – 2010 time period and includes the distribution by age, race and region (Table 3). Nearly 80,000 opioid-related hospitalizations were reported over this two–year period, with the majority of the hospitalizations occurring in the Chicago region, among blacks, and those over the age of 40. 4

Table 3. Number of hospitalizations for abuse of opioids (IDPH discharge data) (2009 -2010) Illinois Age Range 10 to 20 21 to 39 40 to 59 60 plus

Count 79,637 Hospitalizations by age range, race, region Number 2,054 20,793 50,672 6,118

Race Black Hispanic Other White Health Dept. Region Champaign Region Chicago Region Edwardsville Region Egyptian Health Dept. Marion Region Peoria Region Rockford Region West Chicago Region

Crude Rate 295 Percent 3% 26% 64% 8%

Number 49,598 5,528 2,918 21,593

Percent 62% 7% 4% 27%

Number 1,061 62,904 2,495 64 816 1,754 1,740 8,803

Percent 1% 79% 3% 0% 1% 2% 2% 11%

Crude rates estimated for two-year time period; per 100,000 Source: IDPH. IQuery. Drug Indicators: Drug related hospitalizations. (http://iquery.illinois.gov/iquery/)

While the 2009-10 IDPH data provides a snapshot of both the scale and distribution of opioid abuse from that period, it predates the significant increases in overdose deaths occurring in the last 5 years. Updates to this data set may reveal significant increases in hospitalizations as well as shifts in the affected populations. The Illinois Consortium on Drug Policy (ICDP) investigated the number of state-funded drug treatment admissions from the national Treatment Episodes Data Set (TEDS), for several of the metropolitan and rural areas (undefined) of Illinois. They specifically analyzed the percentage of admissions for addictions to alcohol, cocaine, marijuana, heroin, methamphetamine and “all other drugs” for 2007 and 201212. While their research does not provide a separate assessment of opioid abuse, it is likely that this data is driven by trends in opioid use, and that their analysis does provide some measure of downstate changes in severity of the epidemic. In all but one of the geographic regions they examined, the percentage of both heroin and “other drug” admissions increased from 2007 to 2012, sometimes dramatically (i.e., heroin admissions in Decatur and Metro East)(Table 4.). The 2012 percentage of heroin admissions either (nearly) matches or exceeds 2012 admissions for “All other drugs” in every region except “Rural” areas. Also, because the “All other drugs” category includes prescription opiates, the total opiate admission rates are even greater than indicated from heroin admissions rates alone. 5

Table 4. Percentage of state funded drug treatment admissions for heroin and all other drugs in selected Illinois metro and rural areas10 Heroin All other drugs Region 2007 2012 2007 2012 Bloomington-Normal 5% 11% 5% 12% Champaign-Urbana 6% 13% 7% 8% Decatur Metro 3% 23% 3% 10% Peoria-Pekin 7% 16% 8% 12% Rockford Metro 24% 24% 5% 9% Metro East 4% 18% 6% 10% Springfield Metro 8% 12% 4% 9% Rural 3% 7% 5% 13% Source: ICDP. Diminishing Capacity: The Heroin Crisis and Illinois Treatment in National Perspective10

Drug use surveys The National Survey on Drug Use and Health (NSDUH) also provides state-level data on the use of tobacco, alcohol, illicit drugs (including non-medical use of prescription drugs) and mental health in the United States. Two elements of the Survey provide estimates of opioid use in Illinois. The most recent survey (2013-2014) estimated that 381,000 individuals had engaged in nonmedical pain reliever use at least once in the last year, and 322,000 had used cocaine, heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics non-medically in the past month.11 The ICDP reviewed survey data from the Youth Risk Surveillance System which reported a nearly 50% increase (2007 to 2013) in the number of Illinois high school youth who reported having used heroin (from 2.5% to 3.8%).12 Needle exchange program estimates Needle exchange programs began in Illinois in 2003 as one way to prevent the spread of infectious diseases among injection drug users, and to serve as a point of contact to access treatment and social welfare resources. Programs currently operate in 5 Illinois communities (Springfield, Chicago, Champaign, Kankakee and Belleville). According to an April 4, 2015 article in the Illinois State Register13, these programs distribute 4.5 million syringes each year to more than 8,000 individuals. Program operators have estimated that there are approximately 120,000 IV drug users in the state. It is likely that the majority of these injection drug users are opiate abusers.

Evidence of opiate abuse in Southern Illinois The Community Behavioral Healthcare Association of Illinois (CBHA) Southern Region consists of the southernmost 33 counties in the state. IDPH county-level drug overdose mortality data show that there were 581 reported overdose fatalities (12% of the state total) in the Southern Region during the most recent 3-year period for which data is available (2013 thru 2014), with nearly 200 of these deaths attributable to heroin (Table 5). While the most populated counties in the Region generally had the highest number of fatalities, drug overdose deaths occurred in every county in the region. Heroin related overdoses were reported in 22 of the 33 counties. Opioid-related hospitalization data were also available at county level. The 2009 -2010 counts and rates for the 33 counties in the CBHA Southern Region are presented in Table 6. 6

Table 5. Total drug and heroin related overdose deaths in Southern Illinois Counties – Three year total (2013 through 2015) County Madison St. Clair Williamson Franklin Jackson Marion Randolph Saline Jefferson Perry Bond Fayette Washington Crawford Massac Wayne Clay Clinton

Total drug overdoses 187 108 35 28 27 24 18 18 16 10 9 9 9 7 7 7 6 6

Heroin related overdoses 75 41 9 6 5 13 9 3 5 2 1 2 3 0 1 1 1 3

County Lawrence Union Johnson Pope Gallatin Monroe Hamilton Richland Wabash White Hardin Jasper Pulaski Alexander Edwards SI Region ILLINOIS

Total drug overdoses 6 6 5 5 4 4 3 3 3 3 2 2 2 1 1 581

Heroin related overdoses 1 2 0 0 0 1 0 2 0 0 0 1 0 0 0 187

5,011

2,098

Source: IDPH. Total and Heroin-related Drug Overdose Deaths Illinois Residents, 2013-2015 See Table 1. footnote for web links.

Table 6. Number of hospitalizations for abuse of opioids (IDPH discharge data) (2009 -2010) Southern Region County

Count

Crude Rate

Alexander

1 to 10

NA

Clay

1 to 10

Edwards

County

Count

Crude Rate

Saline

44

97.1

NA

Fayette

32

86.6

1 to 10

NA

Union

26

82

Gallatin

1 to 10

NA

Jasper

13

77.6

Hamilton

1 to 10

NA

Monroe

41

70.3

Hardin

1 to 10

NA

Crawford

23

66.2

Pope

1 to 10

NA

Bond

20

61.8

Wabash

1 to 10

NA

Johnson

13

52.1

Wayne

1 to 10

NA

White

13

50.4

Marion

157

229.7

Massac

13

49.9

Madison

870

186.4

Richland

13

47.9

St. Clair

690

152.8

Washington

12

47

Franklin

89

129.3

Clinton

28

43.5

Williamson

135

118.4

Lawrence

12

40.7

Randolph

65

112.1

Perry

16

40.2

Jackson

116

110.3

Pulaski

0

0

Jefferson

69

98.3

Illinois

79,637

295

Crude rates estimated for two-year time period; per 100,000. Source: IDPH. IQuery. Drug Indicators: Drug related hospitalizations. (http://iquery.illinois.gov/iquery/)

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Two counties in the Southern Region ranked in the top ten in the state for opioid hospitalizations. Marion County had the second highest rate after Cook, and Madison County ranked 5th. The counties with the largest numbers of hospitalizations were Madison and St. Clair. The number of reported opioid hospitalizations in the Southern region during the two year period approached 2,700. Hospitalization counts, however, offer only a very rough indicator of the scale and geography of opioid abuse, particularly because of treatment access issues in rural counties.

Overview of opioid abuse assessment in Illinois The evidence from reported overdose deaths, hospitalizations, needle exchange programs, and surveys, are not sufficient to present a precise assessment of opioid addiction in Illinois or Illinois counties. However, they do suggest a scale of opioid exposure and addiction that is at least in the range of tens of thousands of people, and it is much more likely that the number of Illinoisans suffering from opioid addiction is counted in the 100,000s. The evidence does suggests a significant increase in opioid-related morbidity and mortality in recent years, along with increasing abuse in downstate counties, and an increase in adolescent use. While new efforts are just beginning to make more information available from state sources, attempts to assess the scope of the opioid abuse epidemic at the local level are hampered by difficulties in assessing the scale of drug addiction and mortality and making this data easily accessible. This lack of evidence is a significant barrier to action for local public health officials. In a few counties, local officials have acted independently to secure actionable information for the public health and social service organizations, and may provide a model for local collaborative efforts. For example, the Madison County Coroner’s Office recently released detailed statistics on prescription opiate and heroin deaths on the Office’s Facebook page, reporting 350 deaths from 2009 through 2015.14

Assessment of the supply of legal and illegal opioid drugs in Illinois The prescription drug and heroin crisis is not only a matter of demand but also of supply. As with the estimates of opioid abuse prevalence, assessment of the supply of prescription drugs and heroin also rely on estimation techniques that provide only a general indication of availability. Heroin The 2014 National Drug Threat Assessment reported dramatic increases in Mexican heroin production and availability, particularly in Rate of seizures and submissions for heroin in grams the North East and North Central parts of per 100,000 people the US.15 The report also notes a 450 significant increase in potency as well as a 400 significant reduction in price. Law 350 enforcement officials in the Great Lakes 300 250 states ranked heroin as the greatest threat 200 in their region. 150 100 50 0

The Illinois State Police track the annual quantity of heroin seized in the state during drug arrests. 16 The quantity of heroin seized has generally increased Figure 2. Illinois heroin seizures, 2000 – 201313a

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from 2005 to 2013. The amount seized in 2013 was the highest reported quantity in the 19892013 record of drug seizures (Figure 2.). Prescription opioids The influence of the availability of prescription opiates on treatment admissions and deaths was examined by the CDC.17 Figure 2 displays the rates of opioid pain reliever (OPR) overdose deaths, OPR treatment admissions, and the kilograms of OPRs sold in the United States from 19992010. During this period, overdose death rates, sales, and substance abuse treatment admissions related to OPR all increased substantially and simultaneously. According to a 2013 report by the Metropolitan Chicago Healthcare Council (MCHC),18 the Illinois Figure 3. OPR sales, treatment admissions and deaths, Prescription Monitoring Program has had a 1999 -2010 Age-adjusted rates per 100,000 population for significant impact on limiting the availability OPR deaths, crude rates per 10,000 population for OPR of prescriptions for non-medical use: “To date, abuse treatment admissions, and crude rates per 10,000 Illinois has done a good job controlling the population for kilograms of OPR sold.17 amount of opioid medication prescriptions written and filled in the state. Illinois currently has the lowest amount of prescriptions by weight per capita than any other state in the nation at 3.7 kg of pain reliever sold per 10,000 people.” However, while Illinois laws and policies may have reduced the availability of pharmaceutical opioids in the state, prescription drug management programs are less effective in surrounding states and Missouri has no program at all. These weaker programs may influence the availability of prescription opiates, particularly in border counties.

Drivers of the increase in use opioid abuse and deaths Researchers and public health analysts describe the current opiate crisis as a fundamentally new phenomena, which spread relatively quickly, impacted new populations and geographies, and caused a reassessment of the effectiveness of previously used methods of treatment and control. In their publications, they provide evidence of the numerous factors that have contributed to the “epidemic” of opioid abuse and deaths. The MCHC report on the crisis referred to this convergence of factors as “a perfect storm”. Some of the most frequently cited “drivers” of the prescription drug and opioid epidemic, include: Chronic pain  Increasing mid-life morbidity beginning in the 1990s, particularly among economically distressed, middle-aged populations, has been identified as a “pain epidemic”19 – research estimates that approximately 100 million Americans suffer from chronic pain 20  Medical research provides evidence of the detrimental impact of chronic pain on the ability to recover from illness and quality of life 21

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One issue that has escaped a lot of scrutiny is the role of the medical profession in this problem. We went off course several years ago when the chronic nonmalignant pain treatments started to include opioid analgesics in almost any dose. Medical "experts" said there would be very little addiction in people who sought pain relief; pain became "the fifth vital sign"; pharmaceutical companies pushed their products very hard and bankrolled the two or three Pain Societies that still exist; and we did not distinguish between acute and chronic pain, which are probably different conditions with different mechanisms and treatments. We had too little knowledge to intelligently determine which patients would truly benefit from opioids, and which were at risk for dependency and addiction. We were unaware of how prescribing these medicines might relate to the widespread misuse of prescription opioids and the transition by some people to the use of heroin and other illicit and potentially lethal drug use. So, we played a significant part in this catastrophe, along with others who provide these drugs to people. But there is almost no discussion of this in the medical literature. Quote from an Illinois physician

Missteps in pain management In an effort to be both compassionate and effective, the medical community and pharmaceutical industry respond with pain management initiatives that focused on the use of opioids, leading to an unprecedented increase in opioid prescriptions.

 An incomplete understanding of opioid pharmacology led practitioners to view opioid pain treatment as safe and effective. It failed to recognize:  the potential for permanent physiological changes to the brain from opioid exposure  the role of genetic susceptibility in opioid addiction  the occurrence of medically induced addiction, even at therapeutic doses  drug tolerance and decreasing efficacy,; resulting in the propensity of users to increase dosage  the severe and dangerous symptoms of opioid withdrawal and high likelihood of relapse  the need for training in pain and addiction management, especially for primary care physicians 22   

The shortage of pain management specialists, especially outside of metropolitan areas Aggressive pharmaceutical marketing Inadequate control over prescription opioid distribution and prescribing practices  patients may receive multiple prescriptions from multiple specialists, or, once addicted, abusively seek out multiple prescribers/prescriptions  lack of control over unused prescriptions allows for diversion to families, friends, and markets

Nature of heroin availability and addiction  Dramatic increase in the availability of high quality, low-cost heroin  Shift in the perception of risk of heroin (and prescription opiates) addiction; perceived as less dangerous, especially by younger people  High quality heroin encourages oral/nasal initiation to use; progresses to injection drug use following addiction Pain treatment as a pathway to addiction  Patients inadvertently become addicted during pain treatment  Medically-induced addictions may go unrecognized and untreated  Ineffective pain treatment methods results in continued post-treatment pain  Medically addicted and those with unresolved pain, seek out illegal prescription meds, and when unavailable or too costly, turn to heroin as a substitute

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Cultural/socioeconomic conditions  Research continues to emphasize the socioeconomic causal factors of drug use 23, 24  Increasing economic inequality; lack of meaningful educational or employment opportunities  Disintegration of family and community support networks

Scott County IN HIV outbreak 2015 “This HIV epidemic in Scott County is a warning cry to the neglect of rural America not just in public health but in the multifaceted and interconnected social determinants that, when left to reach their logical conclusion, lead to disastrous outcomes. Economic downturn, lack of education support, unemployment, uninsured status, these quickly transition to health implications. Hopelessness becomes pervasive and mental health needs surge, and substance abuse is the face of the final common pathway of these unmet needs, and the opiate addiction epidemic surges across our entire nation and I think that it perhaps is at its worst where resources are at the least. When lack of education and hopelessness are bedfellows, a focus on positive behavioral choices, safety and personal protection are lost. “ Jennifer Walthall MD, MPH

Inadequate treatment response 22  Stigma – social bias towards addiction as a volitional act, character flaw or lifestyle choice. This bias influences the design, funding, and implementation of enforcement and treatment recovery programs  Failure to understand the extreme nature and severity of opioid addiction:  Focus on short-term, outpatient treatment instead of treating addiction as a chronic condition, usually involving frequent episodes of relapse  Dominance and ineffectiveness of “abstinence only” approaches  Reliance on incarceration over treatment and/or to take advantage of the incarceration period as an opportunity for education and drug treatment  Inability to treat the nearly inevitable comorbidities (e.g., mental health, multiple substance abuse, infectious disease) concurrently  Failure to promote and fund treatment procedures and facilities  Failure to adequately fund and employ the best evidence-based techniques, especially Medication Assisted Treatment (MAT)  Fee-for-service reimbursement structures and multiple payers promote short-term, partial treatments that result in relapse, rather than providing incentives for managed treatment across the full continuum of care

Responding to the Opioid Crisis – Recommended Response Strategies Numerous response strategies have been recommended by researchers, government agencies, and advocacy groups. A number of white papers, reports, position papers, briefings, and research summaries were reviewed to gather a representative collection of the recommendations for action. Five categories of recommendations are presented here, along with indicators of the progress on these recommendation in Illinois. Legal and institutional foundation For the effort to respond to the prescription drug and opioid crisis to be successful, it must be based on a solid foundation of legal, institutional and funding support. The Trust for America’s Health, a national health policy organization, in consultation with public health, clinical, law enforcement and community organizations, prepared a list of actions required for the development of effective state prescription drug policy (Table 7).25 Due largely to the efforts of many of the advocacy 11

organizations in the state, Illinois was one of 17 states having eight or more policies already in place, making it one of the leaders in the nation. Table 7. Trust for America’s Health State prescription drug legal/institutional ranking systems – Illinois assessment - August 2013 Opioid Abuse Legal/Institutional Strategy Indicators in Illinois Existence of Prescription Drug Monitoring Program (PDMP): Has an active program PDMP: Requires mandatory utilization by prescribers Doctor Shopping Laws: Has a law specifying that patients are prohibited from withholding information about prior prescriptions from their healthcare provider Support for Substance Abuse Treatment Services: Participating in Medicaid Expansion, which helps expand coverage of substance abuse services and treatment Prescriber Education Required or Recommended Good Samaritan Laws: Has a law to provide a degree of immunity or mitigation of sentencing for individuals seeking to help themselves or others experiencing an overdose Rescue Drug Laws: Has a law to expand access to, and use of naloxone, a prescription drug that can help counteract an overdose, by lay people Physical Exam Requirement: Has a law requiring healthcare providers to physically examine patients or have a bona fide patientphysician relationship before prescribing a controlled substance ID Requirement: Has a law requiring or permitting a pharmacist to require an ID prior to dispensing a controlled substance Lock-In Programs: Has a pharmacy lock-in program under the state's Medicaid plan where individuals suspected of misusing controlled substances must use a single prescriber and pharmacy

Yes

NO Yes Yes

NO Yes

Yes

Yes

Yes Yes

Source: Trust for America's Health -Prescription Drug Abuse: Strategies to Stop the Epidemic25

Educational recommendations Recommendations for opioid education focus on three groups:  patients  public  prescribers and other health care professionals Patient and public education are the first line of opioid abuse prevention. Pain treatment protocols need to include medication education that ensures that patients clearly understand the risks of addiction, dangers of mixing medications with alcohol or other substances, and the necessity of controlling access to their medicine. Many recommendations include calls for mandatory alcohol, drug and tobacco use, and addiction education programs in middle and secondary schools. Surveys have demonstrated that a substantial percentage of young people misperceive the risks of prescription drugs, and even the dangers of addiction from occasional heroin use. Numerous programs are available from federal agencies for student and community education, such as the Substance Abuse and Mental Health 12

Services Administration’s National Register of Evidence-Based Programs and Practices (NREPP), which includes more than 50 evidence-based prevention activities (http://www.samhsa.gov/nrepp). Providing opioid education and prescribing guidelines to physicians, especially primary care physicians, is a necessary strategy to combat addiction and abuse. The core focus of physician education, beginning in medical school but updated throughout their careers, includes:  comprehensive pain management  addiction medicine and substance abuse screening  opioid prescribing guidelines  prescription drug monitoring program practices The CDC recently released a set of guidelines for primary care physicians to use in the treatment of chronic pain (www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm) along with a set of “prescribing resources” (www.cdc.gov/drugoverdose/prescribing/resources.html) that can be used to practice better pain management and communicate information about pain management to their patients. Dowell, et al., writing in the Journal of the American Medical Association, summarized the CDC guidelines into a set of 12 basic recommendations. (Table 8.)26 Table 8. CDC Recommendations for prescribing opioids for treatment of chronic pain 1) Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred. 2) Establish realistic treatment pain and function goals with all patients. 3) Discuss known risks and realistic benefits of opioid therapy with patients and patient and clinician responsibilities for managing therapy. 4) Prescribe immediate-release opioids instead of extended-release/long-acting opioids. 5) Prescribe the lowest effective dosage. 6) Prescribe only the quantity needed for the expected duration of pain treatment severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed. 7) Evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain and before dose escalation. 8) Incorporate strategies to mitigate risk, including considering offering naloxone when if there is a risk for opioid overdose. 9) Review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. 10) Use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. 11) Avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible. 12) Arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

Continuing educational efforts should also extend to all healthcare providers (physicians’ assistants, nurses, pharmacists) that have contact with patients to ensure that patients receive a consistent message and that risk assessment is taking place at multiple points of contact. The Illinois State Medical Association offers a variety of online resources and continuing education opportunities. (https://www.isms.org/opioids/)

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Improved reporting and surveillance recommendations There is a serious lack of timely, easily accessible, locally focused substance abuse data available in the state and region. Such information would be extremely useful in assessing the burden of drug abuse in communities and counties, identifying population at risk and/or emerging abuse trends, guiding the planning and evaluation of prevention programs and prioritizing the allocation of resources. Prescription monitoring surveillance is also a critical ingredient in the prevention of prescription opioid abuse. Illinois has operated a prescription monitoring program (PMP) since 2000. The Illinois State Medical Society has recommended improvements to the PMP including use of PMP data as a mechanism to alert physicians to patient vulnerability, and pilot programs to integrate PMP data into electronic health records systems.27 The Illinois Governor’s Office recently announced, that as part of the Illinois Department of Human Services efforts to improve the Prescription Monitoring Program, that the agency will track opioid morbidity and mortality. The availability of this data “will provide opportunities to evaluate policies with implications for preventing both prescription drug and heroin overdoses.”28 Treatment recommendations The most frequently cited treatment recommendations focus on the design of treatment programs and increased access to substance abuse treatment, particularly to medication-assisted treatment. “Despite the volitional act that initiates

Effective treatment for opioid addiction must acknowledge the serious physiological and psychological impacts of dependence:  must be comprehensive, addressing medical, psychological and social needs, integrating substance abuse and mental health  must include medication-assisted treatment (MAT)  must adopt a “chronic care model”, much like is used for treating diseases such as diabetes, that employs longterm treatment, acknowledging the likelihood of relapse, even after long periods of sobriety  must be greatly expanded to compensate for the significant lack of treatment assets, particularly in rural areas must greatly expand the number and training of substance abuse specialists at every level of medical care including integration of peers with lived experience into the primary care setting must expand access to MAT to county jails and state prisons needs to include detoxification and long-term treatment of medically-addicted individuals during their transition to non-opioid pain treatment regimes must adopt alternative pain reduction strategies and continue to address the needs of those with chronic pain

opioid use, any resulting dependence and addiction are largely mediated by genetics and permanent changes in brain physiology, not merely social/ environmental factors. Therefore, even after prolonged abstinence, there are persistent symptomatic effects and dysphoria, making opioid addiction a chronic, relapsing illness, not a purely behavioral problem” Confronting the Crisis

   

Two recent studies examined the adequacy of current treatment resources in Illinois. An assessment in the American Journal of Public Health found “significant” gaps between treatment need and capacity in Illinois, estimating the rate of opioid abuse at 6 per 1,000, but the availability of MAT at only 2.2 per 1,000. At the 2010 population levels, this represents a capacity shortage that would leave approximately 23,000 drug addicts without access to treatment. 29 14

The Illinois Consortium on Drug Policy analysis of treatment capacity in Illinois noted the dramatic decrease in state funding in the past decade and determined that:  Illinois ranked “first in the US for the decline in treatment capacity” between 2007 and 2012  Ranked 3rd worst, behind Tennessee and Texas, in state funded treatment capacity.12 Fortunately, recently passed legislation in Illinois guarantees public and private insurance coverage of medically-assisted treatment, without life-time treatment limits. While the law has been passed, it still remains to be funded and implemented. Support for funding should be boosted by the (conservative) estimates that “for every $1 invested in addiction treatment programs yields a return on investment of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft alone. When savings related to health care are included, total savings can exceed costs by a ratio of 12 to 1”.30 Law enforcement The role of law enforcement in the opioid crisis has often focused almost solely on investigation, arrests, and drug confiscations. Numerous recommendations point to a greatly expanded role for police in the opioid crisis. “This is not something we can arrest our way out of … Addiction is not a crime, it is a disease, and police can be a voice to facilitate treatment for people who are suffering.” Police Chief Campanello Southern Illinoisan 11/15/15

Police are often the first responders to opiate overdose cases and can play a critical lifesaving role through the administration of overdose reversal medications. Recently passed legislation will require overdose reversal training for police and fire departments and grants from the CDC will help to pay for training and equipment.

Police departments in many states are also adopting a new program to directly fast-track willing users into treatment programs, by-passing the criminal justice system, and disposing of drugs and paraphernalia without charges for possession. The police department in Dixon, Illinois also helped to set up a community forum, a hotline for those users who are looking for treatment, and training sessions on the use of overdose-reversal drugs. An expanded role for the courts has also been demonstrated to be effective and “drug courts” provide a path for diverting addicted individuals away from life-damaging incarceration directly into treatment programs. Recent changes in Illinois law also help to fund and expand access to drug courts.

Current Activities in Illinois There are numerous local, regional and statewide initiatives that are already underway to combat opioid addiction. Significant activities at state level include the near unanimous passage of legislation that will directly address the opioid epidemic, and the successful application for funds to improve the state’s PMP. Local initiatives include the grant-funded development of a project that will deliver an opioid reversal program to one rural community. Opioid Crisis Act

In September 2015, Illinois legislators passed the “Opioid Crisis Act”, which strengthened laws and policies to respond to the prescription drug and heroin. Some of the major provisions of the Act are summarized in Table 9.

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Table 9. Major provision of Illinois Public Act 99-840 (HB1) the Opioid Crisis Act Changes to health insurance coverage Medicaid - Removes requirement for prior authorization for medication-assisted treatment (MAT) - Allows treatment providers to determine length of treatment and eliminates the life-time treatment limits - Requires coverage for all FDA approved MAT drugs, including methadone - Requires coverage for overdose reversal medications and pharmacist training for administration and provision of these medications (when filled without a prescription) - Requires that mental health and substance abuse benefits be comparable to other medical benefits - Requires coverage for overdose reversal medications and pharmacist training for administration and provision of these medications (when filled without a prescription) Private insurance providers - Expands requirement for coverage of overdose reversal medications, acute inpatient treatment, detox and stabilization - Requires that mental health and substance abuse benefits be comparable to other medical benefits - Requires that providers publish their substance abuse treatment and medication policies Establishes Drug Overdose Prevention Provisions - Authorizes pharmacist-initiated overdose medication dispensing without doctor’s prescription - Allows prescribing of overdose reversal medications to families, friends and service providers - Protects health professionals and lay people from liability for administering overdose reversal medications - Requires training of police, fire fighters, first responders and school personnel in the use of overdose reversal medications Expands Prescription Monitoring Program to ensure clinical guidelines are followed when prescribing controlled substances Establishes a Medication Take Back Program to dispose of unneeded prescriptions Imposes new documentation requirements for prescribing Schedule II narcotics. Expands access to Drug Courts Institutes drug prevention education for Illinois middle, junior and high schools Source: Heartland Alliance for Human Needs and Human Rights31

Prescription Drug Monitoring Program

The Illinois Prescription Monitoring Program (PMP) collects information on controlled substance prescriptions dispensed in Illinois and uses its web site allows prescribers and dispensers to view a current or prospective patient’s prescription history. The goal of the PMP is to assist prescribers and dispensers in the effective treatment of patients seeking medical care. Illinois also recently received a $3.6 million Center for Disease Control grant to improve the state’s Prescription Monitoring Program. Plans for improvements include:  Shortening the reporting period for prescriptions dispensed from weekly to daily  Developing an online system to identify “high risk” patients - those who get medications from five or more prescribers and five or more pharmacies in a six-month period  increase the number of prescribers using the system (15% first year, 20% years 2 to 4) Rural Opioid Overdose Reversal Program

Clay County Hospital received a $100,000 Department of Health and Human Services grant to participate in a pilot project to reduce drug overdose deaths in rural communities. The Rural Opioid Overdose Reversal (ROOR) program provides funds that can be used for the purchase of opioid overdose reversal drugs (naloxone) and the training of licensed healthcare professionals and emergency responders in rural areas. 16

Building a Comprehensive Strategy for the Southern Region The prescription opioid and heroin epidemic is a tremendous burden on the people of Illinois and has resulted in inestimable harm to families and communities in every corner of the state. A thorough understanding of the complexity of this epidemic makes it clear that the scale and scope of the resources needed to address this epidemic go far beyond the passage of new laws or funding from a few federal grants. Action, equal to the scale of the problem, will be required. The combined community response from a partnership of health care and insurance providers, state agencies, courts, schools and colleges, faith organizations, businesses and clubs throughout the state is needed to be able to assess and implement recommended actions, change attitudes, educate health professionals and community members, identify and dedicate funding resources, and begin to address some of the root causes of addiction in our communities. The Southern Region is fortunate to have a number of well-establish health networks. Agencies and organizations in almost all of the counties in the region are already engaged in broader, multicounty coalitions, and most of the county public health offices have already identified opioid abuse as a priority on their assessment of needs (IPLAN). Many also have experience responding to substance abuse crises from previous efforts to address methamphetamine abuse. Health coalitions in the Southern Region include:  Madison County Partnership for Community Health  Healthy Southern Illinois Delta Network (HSIDN)  Jackson County Healthy Communities Coalition (HCC)  Franklin-Williamson Counties HCC  Healthy Southern 7 Region Coalition  Hamilton County Health Coalition  Perry County HCC  Randolph County All Health Coalition  Southeastern Illinois Community Health Coalition Numerous community organizations, many with missions dedicated to substance abuse, are also active in the Southern Region. Examples of these community organizations, include:  Awareness Against Drug Abuse (AADA)  Alliance Against Methamphetamine Abuse (AAMA)  Massac County Drug Awareness Coalition (MCDAC)  Rising Up for Change  Alexander Pulaski Action Coalition (APAC)  Madison County Heroin Task Force  Metro East Coalition Against Meth + Other Drugs  Harrisburg Celebrate Recovery Program  Celebrate Recovery Pinckneyville The CBHA seeks to form a coalition of networks in the Southern Region that will use the strength of community collaboration to respond to the opioid crisis. A roadmap (Table 10) for action was created by representatives from the state police, the courts, behavioral health providers, state probation, schools, teachers, parents, state mental health and substance use divisions, physicians, consumers and local media outlets. The task of organization and action lie ahead. 17

Table 10. CBHA Southern Region recommendations for addressing the opioid crisis The Prescription Drug and Heroin Epidemic in Southern Illinois A Call for Community Health Solutions Expand Public Education/Awareness & Build Community Partnerships:  Increase Public Education Efforts  Build Community Partnerships, including faith-based organizations, courts, providers, police, schools, etc., to develop a Regional Action Plan  Expand Programs to Enable Proper Disposal of Prescription Drugs  Promote efforts to increase the availability of naloxone in the community as a safe antidote for opioid overdose  Support Good Samaritan Laws  Develop “Neighborhood Watch” groups in collaboration with local law enforcement Increase Access to Substance Abuse Treatment:  Support measures to increase funding and capacity for addiction treatment, especially increasing the number of detox, residential beds and the number of Medication-Assisted Treatment programs  Leverage HIT to improve clinical care and reduce abuse  Expand the Screening, Brief Intervention and Referral to Treatment (SBIRT)  Expand Insurance Coverage of Substance Abuse Services  Fund and expand Drug Courts  Continue efforts to integrate drug abuse treatment and primary care Ensure Responsible Prescribing Practices:  Provide Education for Healthcare Providers  Increase Regulation of Pill Mills aimed at Interventions  Track Prescriber Patterns  Make Rescue Medicines More Widely Available (such as naloxone)  Train 911 operators to help callers use naloxone on overdose patients to help their odds of surviving  Ensure Patients Receive the Pain Medications They Need; Do not Over Prescribe Improve Prescription Drug Monitoring Programs:  Encourage the state to Utilize PDMP to Improve Access to Substance Abuse Services  Ensure PDMP Operate Efficiently and Effectively  Link PDMP to Electronic Health Information Exchanges and EHRs  Provide Needed Resources for improving PDMP Support Law Enforcement Efforts:  Support police, probation officers and others in the criminal justice system efforts to address the supply side of the prescription drug and heroin problem  Educate police, probation officers and others in the criminal justice system about the nature of addiction so that it becomes a treatment issue instead of merely a law enforcement issues  Support law enforcement role in their efforts to reduce overdose deaths

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References and recommended readings 1) Kane-Willis, K., Schmitz-Bechteler, S. Institute for Metropolitan Affairs. A Multiple Indicator Analysis of Heroin Use in the Chicago Metropolitan Area: 1995 to 2002, 2004. http://www.roosevelt.edu/CAS/CentersAndInstitutes/IMA/ICDP#publications . Published: March 2004. Accessed February 2, 2016. 2) Hedegaard H, Chen LH, Warner M. Drug poisoning deaths involving heroin: United States, 2000– 2013. NCHS data brief, no 190. Hyattsville, MD: National Center for Health Statistics. 2015. 3). Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. 4) Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain physician. 2012;15(3 Suppl):ES67-92. 5) Inocencio TJ, Carroll NV, Read EJ, Holdford DA. The economic burden of opioid-related poisoning in the United States. Pain medicine (Malden, Mass.). 2013; 14(10):1534-1547 6) Gilson AM, Kreis PG. The burden of the nonmedical use of prescription opioid analgesics. Pain Med 2009; 10:S89-S100. 7) Kane-Willis, K., Schmitz, S. Heroin Use in Illinois: A Ten-Year Multiple Indicator Analysis, 1998 to 2008. Roosevelt University The Illinois Consortium on Drug Policy. http://www.roosevelt.edu/CAS/CentersAndInstitutes/IMA/ICDP#publications. Published: June 2010. Accessed February 2, 2016. 8) Meiman J, Tomasallo C, Paulozzi L. Trends and characteristics of heroin overdoses in Wisconsin, 20032012. Drug and alcohol dependence. 2015;152:177-184. 9) Rudd, RA, Aleshire, N, Zibbell, JE, Gladden, RM. Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014. MMWR. January 1, 2016. 64:1378-1382. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm 10) The Southern Illinoisan Editorial Board. Voice of the Southern: Shedding the heroin blind spot. http://thesouthern.com/news/opinion/voice-of-the-southern/voice-of-the-southern-shedding-theheroin-blind-spot/article_a4c96234-28aa-5c1d-bd41-28fbd32bcb1a.html. Published: Oct 7, 2015. Accessed January 15, 2016. 11) Substance Abuse and Mental Health Services Administration, Population Data / NSDUH, 20132014 NSDUH State-Specific Tables, NSDUHsaeIllinois2014, 02/16/2016. Available at: http://www.samhsa.gov/data/sites/default/files/1/1/NSDUHsaeIllinois2014.pdf 12) Kane-Willis, K., Giovanni Aviles, Barnett, D., Czechowska J., Metzger, S., Rivera,R., Waite, B. Diminishing Capacity: The Heroin Crisis and Illinois Treatment in National Perspective. Roosevelt University The Illinois Consortium on Drug Policy. http://www.roosevelt.edu/CAS/CentersAndInstitutes/IMA/ICDP#publications . Published: August 2015. Accessed February 2, 2016. 13) Olsen, D. Needle-exchange program promotes safety, trust to fight HIV, hepatitis. The State Journal Register (online) http://www.sj-r.com/article/20150404/NEWS/150409712 . Published: Apr 6, 2015. Accessed February 2, 2016. 14) Madison County Coroners Office. NEWS RELEASE: Updated Drug Death Statistics: Thursday July 16, 2015 https://www.facebook.com/Madison-County-Illinois-Coroners-Office204493942949752/?fref=nf . Accessed February 2, 2016. 15) Drug Enforcement Administration. 2014 National Drug Threat Assessment Summary November 2014 DEA-DCT-DIR-002-15 http://www.dea.gov/resource-center/dir-ndta-unclass.pdf 16) Illinois Criminal Justice Information Authority. Illinois Uniform Crime Reports (I-UCR) Drug Index arrests. http://www.icjia.org/research/overview#tab_research-overview . 17) Vital Signs: Overdoses of Prescription Opioid Pain Relievers United States, 1999—2008. (MMWR) November 4, 2011 / 60(43);1487-1492. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm 18) Metropolitan Chicago Healthcare Council Prescription Drug Abuse: An Illinois Public Health Crisis December 2013 http://illinoispoisoncenter.org/prescription_drug_abuse_whitepaper_RL . Published: December 2013. Accessed February 2, 2016. 19

19) Deaton, Angus and Anne Case. Rising morbidity and mortality in midlife among white nonHispanic Americans in the 21st century Proceedings of the National Academy of Sciences www.pnas.org/cgi/doi/10.1073/pnas.1518393112 .Published: September 17, 2015. Accessed February 2, 2016. 20) Tsang, A., et al. Common chronic pain conditions in developed and developing countries: Gender and age differences and comorbidity with depression-anxiety disorders. Journal of Pain 2008; 9(10):883-891. 21) IOM (Institute of Medicine). Pain and disability: Clinical, behavioral, and public policy perspectives. Washington, DC: National Academy Press. 1987. 22) Beacon Health Options. Confronting the Crisis of Opioid Addiction: A Beacon Health Options White Paper. http://beaconlens.com/wp-content/uploads/2015/11/Confronting-the-Crisis-of-OpioidAddiction.pdf . Published: June 2015. Accessed: February 2, 2016. 23) Walker, R. Social Determinants, Inequalities and Substance Abuse http://www.cdar.uky.edu/robertwalker/downloads/Social%20Determinants%20-%20Pathways%20%20Aug%202011.pdf Published: August 2011. Accessed February 2, 2016 24) Goode, Erich. The Sociology of Drug Use. In: 21st Century Sociology. Bryant, C.D. and Peck, D. L. Ed. Thousand Oaks, CA: SAGE Publications, Inc., 2007. I-415-25. SAGE knowledge. http://knowledge.sagepub.com/view/sociology/n42.xml Web: Dec. 12, 2015. . Accessed February 2, 2016 25) Trust for America’s Health. Prescription Drug Abuse: Strategies to Stop the Epidemic http://healthyamericans.org/reports/drugabuse2013/release.php?stateid=IL. Published October 7, 2013. Accessed February 2, 2016. 26) Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain— United States, 2016. JAMA. 2016;315(15):1624-1645. Available at: http://jama.jamanetwork.com/article.aspx?articleid=2503508#ArticleInformation 27) Illinois State Medical Society. Recommendations for Deterring Improper Use of Opioids: Recommendations to the Illinois House Task Force on the Heroin Crisis and the Illinois General Assembly. https://www.isms.org/opioidplan/. Published February 2015. Accessed February 2, 2016. 28) Office of the Governor, State of Illinois. “Illinois awarded CDC funding to combat prescription drug overdose”. September 4, 2015. http://www3.illinois.gov/PressReleases/PrintPressRelease.cfm?SubjectID=2&RecNum=13322. Accessed February 2, 2016. 29) Jones CM, Campopiano M, Baldwin G, McCance-Katz E. National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment. American Journal of Public Health. 2015;105(8):e55-e63. 30) U.S. Department of Health and Human Services. Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. http://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf. Published 2013. Accessed February 2, 2016. 31) Heartland Alliance for Human Needs &, Human Rights. Daniel Rabbitt. The Heroin Crisis Act: What You Need to Know about the New Law. http://www.issuelab.org/permalink/resource/22917. Published: November 16, 2015. Accessed February 2, 2016.

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