Cuyahoga County Opiaite Task Force

State: OH Type: Promising Practice Year: 2016

The Cuyahoga County Board of Health (CCBH) has an estimated population of 1.26 million people. The population is predominantly Caucasian (64.6%), (30.2%) African American, (2.9%) Asian and (5.2%) of the populations identifies as being Hispanic or Latino.  English is the predominant spoken language. Since 2012, more people in died in Cuyahoga County from drug overdoses than from motor vehicle accidents, homicides or suicide. The number of deaths directly related to prescription drug abuse increased nearly 500% from 1999 to 2014.  Prescription pain medication continues to be the common factor driving this public health epidemic, with nearly a one to one correlation between the increases in prescribed opioids in Ohio compared to the rise in overdose deaths. In 2014, Cuyahoga County lost 352 residents to opioids compared to340 in 2013 and 308 in 2012. As steps to reduce opiate abuse and diversion were adopted across Ohio, there has been a significant rise in heroin use and overdoses. Heroin now accounts for nearly sixty percent of overdose deaths in Cuyahoga County compared to 18% in 2007.  In 2014 the Cuyahoga County Medical Examiner’s Office (CCMEO) began seeing an increase in the number of overdoses related to fentanyl.  Analysis of data highlighted a 640% increase in fentanyl related overdoses. This widely reported trend of prescription opioid abusers transitioning to heroin with deadly results has been exacerbated be the re-introduction of illicit fentanyl. Fentanyl is now a critical increasing drug threat in Cuyahoga County. In 2014, CCBH was awarded the Ohio Department of Health’s Injury Prevention Grant focused on the use and abuse of prescription medication. The grant focuses on decreasing the fatalities attributed to the misuse and abuse of prescription medication and building an injury prevention focus and initiative within a local health department.  CCBH built a multi-layered systems approach promoting a wide range of initiatives for effective prevention programing utilizing the Prevention Institutes, Spectrum of Prevention Model.  This program incorporates key partnerships on the local level, creating a greater understanding of the public health epidemic and building a plan to address those contributing factors through various, high impact strategies.  1.      Coalition Building, Partnerships, and Coalition Assessment A. Conduct a thorough assessment of the CCOTF to identify missing stakeholders, determine goals and objectives, and increase coalition membership by a minimum of three key stakeholders. 2. Evaluation Plan Logic Model, Surveillance, and Annual Summary of Outcome Measures A. Conduct routine injury surveillance and regular data sharing amongst key   stakeholders, develop and utilize a logic model for regular program evaluation, and provide ODH and the CCOTF with an annual summary of outcome measures. 3.  Policy, Systems and Environmental Change (PSEC) Strategies A.  Select a minimum of three high impact PSEC strategies to implement and measure over the duration of the project.             1. Promote the use of Ohio Automated Rx Reporting System among physicians and prescribers through the Smart Rx educational curriculum and increase access to naloxone education and distribution sites. 2. Create a complement to the standard medical residency program at University Hospitals Case Medical Center by incorporating visits to treatment and detox facilities, drug court, the Free Clinic (needle exchange program), and naloxone education and distribution sites. 3. Assess behaviors, attitudes, and usage among the collegiate population in Northeast Ohio while providing targeted education to both students and faculty.         CCBH has played a significant role in combating this epidemic prior to receiving the ODH Injury Prevention grant. By implementing a collaborative approach through existing partnerships within the Cuyahoga County Opiate Task Force we have been able to address the epidemic from the critical perspective of prevention, treatment, law enforcement, and education. Several milestones have been accomplished with assistance from collaborative partners. MetroHealth Systems has adopted the Smart Rx training curriculum for all staff members with prescribing authority increasing the use of OARRS and reinforcing proper prescribing guidelines.  Since 2013 Project DAWN has distributed 2500 naloxone kits with nearly 250 documented overdose reversals.  Cuyahoga County currently has eight permanent locations for naloxone distribution with additional community events occasionally serving as additional points of distribution.  Cuyahoga County has the highest rate of law enforcement agencies carrying naloxone in Ohio with 36 documented overdose reversals to date.   In 2015 the CCBH, in conjunction with MetroHealth, held the first conference in Cuyahoga County focusing on the stigma associated with the misuse and abuse of prescription medication and the relationships between provider and client. Eight family medicine residents completed the Opiate Prescribing Stewardship curriculum through University Hospitals/Case Western Reserves Prevention Residency program. Websites:    
In 2014 during the first “State of Public Health” with Center for Disease Control and Prevention Director Tom Frieden prescription drug abuse and overdose was identified as one of the top five urgent health threats that need to be addressed. Based upon the preliminary data from Ohio Department of Health Bureau of Vital Statistics unintentional drug overdoses caused the deaths of 2,482 Ohio residents. This is the highest number of deaths on record from drug overdoses and reflects a 17.6 percent increase compared to 2013 when there was 2,110 overdose deaths. The increased illicit use of a powerful opioid called fentanyl was a significant contributor to this rise in drug overdose deaths. As we are seeing an increase in prescribers following proper prescribing guidelines, we are experiencing a positive progress in our fight against prescription drug addiction.  However we are seeing a shift in individuals beginning to use more dangerous drugs to achieve a cheaper, more intense high.  Increased tolerance and initiatives to address diversion of prescription medication have created a shift in use to heroin or heroin laced with fentanyl.  Drug poisoning is the number one cause of accidental death in Cuyahoga County with 340 fatalities occurring in 2013 and 352 in 2014. While much attention has been paid to the prescribed opioid analgesic deaths around the country, in Cuyahoga County, death involving heroin surpassed those of prescription opioids in 2012. In 2014 data obtained from the Cuyahoga County Medical Examiner’s Office indicated that fentanyl has re-emerged as a serious drug threat.  Analysis of data in 2014 shows a clear illicit abuse of fentanyl, particularly with heroin. Overdoses directly linked to fentanyl represent a 640% increase from 37 fentanyl related overdoses in 2014 compared to only 5 deaths in 2013.   Data from the end of 2014, and the first quarter of 2015 show that Fentanyl is now a critical, and fast increasing drug threat to Cuyahoga County. Its exponential increase as a cause of overdose deaths in 2014 could very well continue, doubling or tripling the number of decedents in 2015. Benzodiazepines are also a growing co-intoxicant now rivaling the opioid prescription deaths. Alarming rates of growth are found in drug poisonings for alprazolam and diazepam. Benzodiazepines show up in cause of death of heroin related cases 15-20% of the time nearly equaling the frequency of prescription pain medication.   In Cuyahoga County the target population impacted by this public health epidemic has remained comparable to state and national data.  In 2014, the number of drug poisoning deaths involving heroin was four times higher for men than women. However when analyzing overdose death exclusively from prescription medication opiates and benzodiazepines data show women are much closer to the overdose rates of men 1.4 to 1 ratio. Non-Hispanic Caucasian persons, between the ages of 45-60 are the largest age group of heroin involved deaths, but the fastest growing age group is 19-29.  Rates remained steady for several age groups 30-44, 45-60 with over the 60 age group non-existent between 2007 thru 2010. Beginning in 2011 all four age groups experienced and epidemic rise in overdose fatalities attributed to heroin with 19-29 nearly doubling over the past five years.  From a racial demographic breakdown, Non-Hispanic whites make up the largest majority of heroin related deaths in Cuyahoga County reaching (86%) in 2014, heroin related deaths of Non-Hispanic blacks peaked in 2011 at (17%).  Hispanic deaths due to heroin have fluctuated over the past five years fluctuating between peaking in 2014 at (7%). Tracking the incident and residence of heroin related overdoes has offered an interesting perspective with a 372 % rise in fatalities in the suburbs of Cuyahoga County. Prior to 2010 there was very little working taking place across the state addressing the growing  surge in overdose deaths attributed to the misuse and abuse of opioids. The current approach is building upon new collaborative relationships that have not previously existed with an understanding that our nation’s historical war on drugs has not been effective. Our local collaborative brings together local agencies that traditionally have not worked together in addressing health issues impacting the communities we serve.  Public health, law enforcement, and substance abuse treatment agencies working together on advocacy and policy issues is just one example of how we have seen change in the way approach addiction in Cuyahoga County.  Building upon these new relationships we are seen the reemergence of public health and medicine working together on addressing this public health crisis. Locally we have had success on policy development to address prescribing practices, increase in educational curriculums for physicians and collaborating on harm reductions strategies to reduce the burden of this epidemic. The current practice is innovative in how we have built a local collaboration to look at this epidemic from a comprehensive perspective. Since 2010 we have partnered with several agencies building a local platform that includes public health, law enforcement, treatment and the regulatory agencies. Historically public health and medicine have been working in silo’s one agency focusing on the individual and the other a population based approach to care.  We have also developed a successful relationship with law enforcement working towards changing their attitudes and rethinking our war on drugs strategy.  Local law enforcement has been empathetic to the public health problem of overdose. Since 2010 we have seen an emerging trend with more local agencies changing their attitudes and becoming more involved and supporting harm reduction strategies aimed at reducing the number of overdoses seen in the community. Law enforcement plays a key role as a first responder and with each life saved more agencies are beginning to understand how they can play a role in addressing this crisis. In addition to participating in Harm Reduction Strategies law enforcement also plays a key role in reducing the stigma associated with this illness. Substance abuse is a complex chronic illness. Improved evaluation of community-level prevention and understanding of environmental and social factors that contribute to the initiation and abuse of alcohol and illicit drugs is essential.  Looking at this epidemic from a comprehensive perspective our collaborative identifies resources available leading to a more sophisticated understanding of how to implement evidence-based strategies in specific social and cultural for  those at risk for opioid abuse while working with partners to raise awareness regarding the risk factors contributing to the epidemic with the general community.  
The overall goal of this initiative is to significantly reduce fatalities associated with prescription drug abuse through the development of comprehensive, multifaceted, population-based programs and policies. Reaching this goal will be accomplished by utilizing key partnerships in the community and focusing on addressing the contributing factors linked to the misuse and abuse of opioids. By implementing a collaborative approach, the epidemic has been addressed from the critical perspective of prevention, treatment, law enforcement and education.   These key partnerships are listed below. 1.      The Cuyahoga County Medical Examiner’s Office will continue to conduct the poison death review for Cuyahoga County. Local data has been a powerful tool in helping identify points of intervention and educational outreach opportunities for those at highest risk of overdose while increasing awareness to risk factors leading to this public health epidemic. The Medical Examiner’s Laboratory supports the investigative functions of the Medical Examiner and staff. The Laboratory performs scientific examinations in the areas of Forensic Pathology, Trace Evidence, Serology, DNA, Parentage and identification, Toxicology, Controlled Substance Analysis, and Forensic Chemistry.  Testing often results in the identification of the cause of death by overdose and a detailed analysis of drugs found at the scene.  The Medical Examiner’s Office utilizes and makes available data from these investigations to help prevent these types of tragic deaths from happening in the future. Data is also utilized to monitor the effectiveness of publicly funded projects that are already in place and to identify gaps in the system.  The Cuyahoga County Poison Death Review (PDR) Committee isolates all opiate, benzodiazepine, and heroin related overdose deaths within Cuyahoga County for intensive examination.   2.      The MetroHealth System is one of the largest and most comprehensive healthcare providers in Northeast Ohio, serving the medical needs of Greater Cleveland since 1837.  Since 2013 MetroHealth has been an essential partner and sub-grantee working on several initiatives to address this crisis in Cuyahoga County.  Beginning in May of 2013, Dr. Joan Papp, MetroHealth System, has been instrumental in developing a local naloxone program known as Project DAWN (Deaths Avoided with Naloxone). Since the inception of the program Dr. Papp has been responsible for the increase in the number of dissemination sites in Cuyahoga County, educating over 2500 hundred individuals and documenting nearly 250 overdose reversals because of this life saving program.  In addition to Project DAWN, MetroHealth has been a key partner in the training of local law enforcement agencies in Cuyahoga County increasing the coverage that this life saving drug offers to local communities. Cuyahoga County has the highest percentage local law enforcement agencies carrying naloxone throughout Ohio. In 2015 law enforcement has been responsible for 36 documented overdose reversals enhancing the work taking place through Project DAWN. The MetroHealth System created a policy and systems change by adopting and implementing the Ohio State Medical Association’s SmartRx Education Module.  This module went live April 1, 2015 and will better inform providers about the clinical, legislative, regulatory, and patient education components surrounding the opiate abuse crisis in Ohio.  The SmartRx online training modules offer and interactive and engaging delivery method which provides busy physicians the up-to-date information so they can be part of the solution. The stigma of addiction continues to be one of the greatest barriers to addressing this public health crisis. MetroHealth Systems, in collaboration with CCBH and the Academy of Medicine Northern Ohio, hosted a one day conference that targeted the stigma associated with addiction.  The conference, titled Opioid Use Disorder, the Associated Stigma, and How to Use Key Prevention Tools was held at MetroHealth Systems on September 23, 2015.  Nearly 200 individuals, primarily physicians, social workers, and nurses, attended the event.  MetroHealth Systems had over 23 different departments represented at the conference and approximately 52 different organizations were present.  Sam Quinones, author of the book Dreamland, provided the keynote address.  Through conference evaluations, 93% of attendees stated the conference achieved its goals and 95% reported they found the speakers to be excellent.  This conference could be replicated in other hospital systems throughout the state.  3.      University Hospitals and Case Western Reserves School of Family Residency program has been a collaborative partner with the Cuyahoga County Board of Health since 2003. This educational program offers physicians in residence training an opportunity to gain a public health perspective prior to placement into a permanent medical system. Over the past decade in Ohio, opiates have been the leading cause of overdose related death only recently to be overshadowed by heroin as regulations around opiate prescribing have evolved.  Prescribing stewardship, abuse and addiction screening, and referral for drug treatment are important skills that primary care providers need in the face of this epidemic. Through an interactive and community-based experiential curriculum, family medicine resident physicians gained increased awareness of the association between prescribed opioids and overdose related morbidity and mortality; a greater understanding of the biology of substance addiction; improved self-efficacy in identifying opioid risk behaviors, counseling patients on opioid use, and referring patients to local resources when necessary; and an increased awareness of the important ways medicine and public health can align to curtail the epidemic of opioid related deaths. Eight family medicine residents at Case Western Reserve University were engaged in the learning activities focused on minimizing formal in-person didactics and emphasized community-based activities. Residents were divided into two small groups and each went through the curriculum over a two week time period. Pre- and post-assessments were used to assess attitudes and beliefs around opiate prescribing, opioid abuse, and addiction treatment as well as provider perceived self-efficacy in screening for abuse, addiction, and safely prescribing opiates to patients. An orientation to the public health problem of opiate abuse and addiction was first presented along with access to the SCOPE of Pain on-line curriculum, which is focused on teaching learners to safely and competently manage chronic pain patients using opiates through a case-based format.  Residents were then guided through community-based experiences at a methadone clinic and naloxone distribution site. There were plans to take residents to an outpatient detoxification and treatment center; however, scheduling conflicts at the treatment facility precluded.   This program would be valuable to be replicated and used as a model across the state.   4.       Based upon the results of policy scans conducted on the campuses of Case Western Reserve University and Baldwin Wallace University we have determined the need for increased education and awareness regarding misuse and abuse of prescription medication on college campuses. Targeted education continues to be delivered to both students and faculty that raises awareness to the misconceptions surrounding the opiate epidemic.  BWU, in collaboration with the CCBH, is hosting a one day regional collegiate prevention and recovery conference.  This conference will be held on November 30th, 2015 and is targeting at least 10 Northeast Ohio campuses.  This conference will serve as a means to expand the survey onto other campuses to assess attitudes and behaviors among college students towards substance abuse.  Based upon the results of the survey, and knowledge gained from the conference, Northeast Ohio campuses will be better equipped to create and/or strengthen existing policies that would reduce prescription drug abuse or overdose on college campuses.  In addition, a partnership with Oakview Behavioral Health Center at Southwest General Hospital has been expanded upon.  Jim Drozda, LICDC, has become an active member of the CCOTF and is working the BWU towards prevention messaging for college students.    5.      Cuyahoga County Opiate Task Force Activities. The Cuyahoga County Opiate Task Force (CCOTF) met on a bimonthly basis throughout 2015. Agendas are created and disseminated prior to the meeting and minutes are sent following the meeting. A coalition assessment was conducted in 2014. As a result of this assessment the task force selected the following three recommendations to implement in 2015: eliminate existing gaps in membership by gaining at least three new key stakeholders, establish more concrete subcommittees, and develop a strategic action plan that is inclusive of definitive annual goals. The CCOTF conducted a strategic planning session as part of the February meeting to begin to formulate a plan of working towards the above mentioned recommendations. To date, in 2015, the task force has increased its membership by 10 new partners, including a school administrator, a pharmacist, and members of the faith based community. Three subcommittee have been formed, Education and Training, Advocacy and Policy, and Treatment. Time is allotted during each regularly scheduled CCOTF meeting for subcommittees to meet and report out to the overall membership. The overall membership also determined that the main goals of the task force included implementing and/or promoting high impact harm reduction strategies and reducing the stigma associated with addiction through targeted education and prevention messaging. Since its, inception membership has grown tremendously and the list of accomplishments of the CCOTF have been numerous.   ·         Hosted the first countywide, comprehensive Opiate Conference in 2012 ·         Participated in biannual drug take back days, collecting 100,000 pounds of unwanted or expired medication to date. · Worked with local law enforcement and the Cuyahoga County Sherriff’s Office to establish over 30 permanent medication drop boxes collecting 21,000 pounds of prescription medication since 2013. ·         Educated over 2000 middle and high school students using The pHARMING Effects, Brain Power, and Generation Rx programs · Convened over 200 youth from across Cuyahoga County to participate in the We Are the Majority Youth Prevention Rally, two years in a row ·         Successfully graduated over 400 participants from the county Drug Court Program ·         Established multiple Project DAWN locations which have distributed more than 2,500 naloxone kits and documented nearly 250 lives saved ·         24 local law enforcement agencies are now carry naloxone in Cuyahoga County ·         Hosted a physician education conference titled, The Role of the Prescriber in Prescription Drug Abuse ·         Created a mandated physician education module at MetroHealth that is inclusive of OARRS usage, screening tools, and proper prescribing guidelines ·         Convened a regional opiate task force work group and serve as a mentor for newly formed coalitions in Trumball and Mahoning County. ·         Collaborated with the National Association of City and County Health Officials to create policies and strategic messages surrounding opiate abuse ·         Recipient of the 2014 Recovery Resources Exemplar Award ·         Vince Caraffi, Chair of Task Force moderated Key Note Session at NACCHO 2015 Annual Meeting ·         Allisyn Leppla, Injury Prevention Coordinator invited to speak at the Midwest Injury Prevention Partnership in November on Innovation and Collaboration to address the opioid epidemic. ·         On behalf of the United States Department of Justice of Ohio, Vince Caraffi was invited to speak at the City of Atlanta’s initial Summit on Opioid Abuse. ·         Working with Judge David Matia, Cuyahoga County’s Drug Court, to develop a curriculum for local judges on the benefits of a local drug court.   Recognized as one of the top five counties most heavily impacted by prescription drug overdose, in 2010 the Cuyahoga County Board of Health was invited to partner with the Ohio Department of Health for an education and awareness campaign titled Prescription for Prevention: Stop the Epidemic. Since that initial campaign the Cuyahoga County Opiate Task Force (CCOTF) has grown to a coalition of 120 individuals representing over 50 agencies in Cuyahoga County.   Because of the strong partnerships of the CCOTF, CCBH was able to successfully apply for an obtain a five year Injury Prevention grant focused exclusively on reducing accidental fatalities attributed to drug overdose.  This grant began in January of 2014 and will run through December 31, 2018.  Knowing that this is an epidemic that will not be resolved within the five year time frame, it is the goal of CCBH that this project will continue to receive funding and support well past 2018.  However, if funding ceases to exist, the strategies that have been put in place will continue to have a lasting positive impact on reducing fatalities.  In addition to the strategies, the strength of the collaborative partnerships that have been formed will continue to fight opioid abuse and overdose regardless of future funding. Substance abuse is a complex illness and collaboration is crucial in addressing the needs of the communities we serve. This collaboration has different components: federal, state, and local government agencies pooling resources; education, health, and police officials sharing ideas and data; and government, business, and nonprofit sectors building coalitions, all in service of the common goal of combating substance abuse. The Cuyahoga County Board of Health has experienced the benefits of successful collaboration and will continue to build partnerships focusing on prevention, treatment, and recovery.   The Cuyahoga County Board of Health did not receive any funding to conduct this project until 2014. In 2014 we were awarded $400.000.00 for a five year Injury Prevention Grant focusing on the misuse and abuse of prescription medication. Based upon the local success and leadership we have received an increase in awards over the past two years enhancing our local efforts and have been asked by the Ohio Department of Health to act as a mentor for local coalitions in two other counties in Ohio.  The terms of the grant determined that one FTE be dedicated to the project.  
Consistent project evaluation is a key component of the CCOTF and ODH IP grant.  In the fall of 2014, key stakeholders of the CCOTF were identified to participate in the completion of the community needs assessment.  Data sources included, but not limited to case reviews from PDR and the CCME’s office, United Way 211, Cuyahoga County Project DAWN, the Cuyahoga County Judicial SWOT Analysis, the ADAMHS Board, MetroHealth and OARRS usage rates, policy scans and survey results from BWU and CWRU, the Youth Risk Behavior Survey, the Quality of Life Survey conducted by the Health Improvement Partnership of Cuyahoga County (HIP-C), and the ODH Cuyahoga County Injury Profile.  The results of the needs assessment were used to strategically select PSEC strategies that will make an impact on achieving the outcome measures set in place with the five year evaluation plan logic model.  In 2014, the CCOTF also conducted a comprehensive coalition assessment.  This assessment was used to steer future direction regarding structure, leadership, subcommittees, strategies, and goals.  Annually, the first meeting of the year is used as a strategic planning session to revisit past goals and set goals in place for the upcoming year.  In addition to the community needs assessment and evaluation of the CCOTF, the CCBH worked with ODH and the Ohio State Center for Health Outcomes, Policy, and Evaluation Studies to develop a five year evaluation plan logic model.  This model will be used to evaluate the project throughout the duration of the grant.  Evaluation measures include the growth and sustainability of the CCOTF, completing a required community needs assessment, and evaluating all of the selected PSEC strategies.  This logic model is shared with key stakeholders of the CCOTF and strategies can be revised if its determined that a particular strategy is no longer the best method to achieve a desired result.  Used in combination with the logic model, the ODH Core Violence and Injury Prevention Program (VIPP) also provided an Injury Prevention Sub-grantee Evaluation Plan Template.  This template is required to be completed and submitted to ODH on an annual basis.  Project evaluation will be ongoing utilizing the developed Logic Model and Injury Prevention Evaluation Plan.  Evaluation will also be based upon increased coalition capacity, affected systems change, impacted environmental changes, increased policies, and ultimately a decrease in prescription drug overdose deaths.  
Sustainability of activities will be supported through the established connections and key partnerships of the Cuyahoga County Opiate Task Force. The progress made towards achieving the PSEC strategies have already made an impact on creating systems-wide policies and strategies that have influenced individual and organizational change.  For example, The MetroHealth System has already adopted a policy and systems change of implementing the SmartRx physician education module.  The module is sustainable and will continue if funding ceases.  The CCMEO will also continue to review fatalities associated with PDO should the funding cease to exist. The proposed objectives collectively and complimentarily support a continuum of policies and evidence-based practices and strategies that hold much promise in reducing fatalities associated with the misuse of prescription medication beyond the proposed project timeframe.  By implementing proposed activities, the task force will have the potential to leverage additional funding by in-kind contributions from CCBH (office space, staff time, travel, etc.), Cuyahoga County Executive’s Office and the Alcohol and Drug Addiction and Mental Health Services Board (future funding for the expansion of Project DAWN), the United States Department of Justice (future funding for the expansion of Project DAWN), and coalition members (staff time, travel, etc)
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