Fighting the opioid epidemic in Idaho

IDAHO FALLS, Idaho (KIFI/KIDK) - Governor Little says he is committing to combating substance misuse in Idaho. In July of 2019, he tasked the Opioid and Substance Use Disorder Advisory Group with researching, evaluating, and providing recommendations on the following matters from the Idaho Office of Drug Policy official government website:

• 1. Advancing the goals and strategies from the Idaho Opioid Misuse and Overdose Strategic Plan.
•  2. Best practices in other states used to combat opioid misuse and substance use disorder. 
• 3. Prescribing practices including usage of the prescription monitoring program, prescription limitations, and required continuing medical education. 
• 4. Policies directing law enforcement and prosecutors to refer first-time, non-violent drug offenders to local crisis centers rather than arrest and indictment. 
• 5. Policies mandating the reporting of overdose deaths 
• 6. Advice and comments I can make to the White House, Congress, and the Department of Health and Human services surrounding further actions that can be taken at the federal level. 
• 7. How to coordinate and integrate efforts with current behavioral health plans. 
• 8. Various treatment pathways possible to combat opioid and substance misuse. 
• 9. Educational efforts within the medical community regarding pain management, opioid regimens, and alternatives to opioids. 
• 10. Opioid awareness, prevention, and risk campaigns through public and social media using available funds. 
• 11. Data integration and coordination across stakeholder groups to inform decision making and a collective approach. 

Today, October 15, the advisory group presented their recommendations to Governor Little to help him address the opioid crisis in our state. Their action based recommendations will help him and the state builds more effective plans to combat opioid and other substance use and abuse in Idaho. You can view those recommendations here.

Opioid and Substance Use Disorder Advisory Group final recommendations to Governor Little

The Opioid Advisory Group evaluated state, community workgroup, and task force efforts recently performed in Idaho. They provided recommendations on streamlining prevention and recovery activities, providing efficiency in battling opioid and substance abuse, and eliminating duplicative efforts to more efficiently and effectively fight this epidemic. 

“What I think is one of the most critical issues facing our state, which is both opioid and substance abuse, and the statistics seem daunting. Drug overdose deaths in Idaho happen way too frequently, especially among our younger citizens,” Governor Little said.

He said while the rate of prescription drug abuse is decreasing, it is still too high. 

“These problems strike at the heart of our communities. These are our friends, neighbors and family members,” Governor Little said.

He said the bright spot of the advisory meetings is the fact that leaders from various sectors came together to find ways to reverse the trend. He says their recommendations and ongoing efforts to keep their eyes on how to make a meaningful difference in our state will have a significant impact.

Because of recommendations of the advisory group, the state has already taken action on requiring monitoring programs on the rate of prescription refills for narcotics. Governor Little said further action has ensured a compatible system with neighboring states to share data, which has become an effective tool in battling the opioid epidemic. 

Governor Little says he recognizes the importance of telehealth during the pandemic. He says access to healthcare and resources is paramount for those battling substance abuse, chronic pain, mental health. He says access to telehealth has increased in Idaho by over 40fold during the pandemic. He says this access will be a great benefit through the pandemic and long into the future, especially for rural idahoans. He says experts have advised him that the delivery of telehealth for behavioral health is extremely helpful.

In February, all 5 Idaho Supreme Court Justices and Governor Little signed an executive order to instate a new Idaho Behavioral Health Council. This council is a 3 branch collaboration formed to study Idaho mental health and substance abuse. Although the council just started, the governor says because of their hard work and all of the steps they are currently taking, Idahoans can be encouraged that the problems we are facing with the opioid crisis will get better.

Helo Hancock is the CEO of Marimn Health and he spoke during the advisory group meeting today. He says the group aims to make Idaho better as it relates to opioid issues we are facing today. During the meeting, Hancock said he is responsible for providing healthcare on the Coeur d'aLene tribal reservation. He said over the years of working with the tribe, it was frustrating to see how many of their youths they would lose to the opioid crisis. 

He said many of the young tribal members were born into a rough family situation and then started following a tough crowd, making bad decisions, and eventually brought children of their into the world, and those children followed the same cycles. Hancock says the tribe decided they need to do something different and arranged a group called the Tribal Collaboration Committee with officials from healthcare, schools, court, police, and many other agencies. The group shared data about what was happening with the youth. 

Based on this data, the committee discovered over half of the youth population is on juvenile probation. They also found reported depression amongst 35% of the population between ages 10 and 24. Hancock says the suicide rates were incredible. 80% of middle schoolers reported living in homes with substance abuse or at least one member of the family having been to prison.  Hancock says this is where the patterns begin and are now playing out in society.

Hancock says the term “social determinants of health” relate to someone’s health and how the individual turns out and the paths they choose. He says this has more to do with family they are born into, not decisions they make or access to healthcare. 

Behavioral health scientists in the 90s developed the adverse childhood experiences test (ACEs) to determine how upbringing correlates to health later in life. Questions on that test relate to abuse, substance abuse, and having more than one parent who has been incarcerated. There are 10 questionson the test and Hancock says if a child answers yes to 4 or more, experts see a correlation to poor health and mental helath, depression, suicide, substance use, and even heart disease in the future. 

Hancock says after scanning segments of tribal youth, well over half answered yes to 4 or more questions on the ACEs test. He says these cycles will continue unless someone intervenes. Hancock says the Tribal Collaboration Committee doubled down. They started a boys and girls club and hired professional behavioral health to work with kids everyday. They staffed behavioral health professionals in schools who see kids at school or wherever they need it. They also introduced child play therapy in counseling offices. Hancock says the committee’s goal was to break down barriers to get these kids help. He says there are so many places where kids can fall through the cracks, including with police, healthcare, government, school, and many more. 

“The kids who need the most help have the least amount of support at home,” Hancock said.

Hancock says investment in prevention is the answer to the opioid epidemic. The purpose of the Opioid and Substance Use Disorder Advisory Group is to get upstream of addiction and prevent substance abuse disorder from starting. Hancock says programs like the ones started on the reservation are showing results from investing in youth. 

Hancock mentioned a core center, which will be a $19 million dollar facility that is designed as a prevention center on the reservation that will begin construction within the next 6 weeks. The core center is designed to attract families and offers counseling, boys and girls club, basketball courts, baseball and football fields, and many other programs. Hancock says the core center will house programs that will change a generation. 

Hancock says the Tribal Committee plans to track the outcomes it will have with Blue Cross Blue Shield of Idaho. He hopes it will create a blueprint for the rest of the country on how to successfully intervene and prevent the challenges we are seeing in our communities. 

“It’s gonna take teamwork. It requires an incredible amount of dedication to all really wrap our arms around these kids and recognize what’s happening and do something about it, rather than waiting until later in life when they’re incarcerated or have other issues and trying to fix it then,” Hancock said.

Hancock says untreated trauma is almost always part of somebody who follows the path of substance abuse disorder. He says trauma sets the course for depression, anxiety, then substance abuse, and then crime. He says it is unusual for healthcare organizations to take the lead and play quarterback but it got to the point on the reservation that Marimn Health knew they had to do better by their kids and their community in order to get upstream of the opioid epidemic.

Marv Hagedorn is the Administrator of Veteran Services. He likened the opioid crisis to the pandemic in that we are reacting to it in the correctional system, nursing homes, commercial businesses, schools and many other areas of life as we all try to keep people safe. He says just like the pandemic, there is an end game we all need to consider and plan for with the opioid epidemic because opioids won't go away. 

Magedorn says his agency oversees and operates the largest skilled nursing homes in the state to include 3 nursing homes. He says there are about 120 residents in those homes throughout the year and they lose about half of them every year. Within those nursing homes, they use opioids for end of life comfort. Instead of giving them all opioids, they seek other treatments first. During the meeting, Magedorn posed the question, how do we transition in the opioid crisis from the control of opioids coming into the country, getting to kids, being misused, and we are reacting to that now, but when do we say opioid use is no longer a crisis? He says no one can define that. 

He says we will never get away from our senior care people having chronic pain. At the end of their time, we want our family to be comfortable and there will be a need for opioids. Magedor says in that circumstance, we are more worried about comfort rather than addiction. He says there are many applications and needs for opioids and he hopes the recommendations made by the council will be very valuable. He says he hopes the governor and the legislature will take them seriously.

Magedorn said the VA started to recognize the overuse of opioids in treating chronic pain in 2012. 

“In the military, we are invinsible when we join and we do stupid things, thinking that we will never get hurt and then we go to sick bay and they give us opioids to help take care of our pain,” Magedorn said. “Back in my day, I retired 27 years ago, and things are different now. We had morphine, not opioids like they have now. So veterans in active duty, the culture is to treat the pain. A lot of that was done through alcohol abuse during my time. That has changed. Today it’s opioid abuse.”

Magedorn says of the 17 and a half million veterans the VA treats, one third of them have chronic pain. He says that equates to 6 million veterans with daily chronic pain, looking for treatment. He says in 2012, almost 700,000 veterans were receiving opioids. Now it’s reduced by 87% to less than 250,000. Magedorn says this is because the federal system recognized a problem in 2012 and took action. He says now there is a greater movement towards recommending over-the-counter pain treatment options, acupuncture, and other treatments. Magedorn says because of the alternative treatment options the VA are now utilizing, the tides are changing for veterans. 

David Robins works for the Idaho U.S. Attorney’s Office as an assistant U.S Attorney Bart Davis. He says Davis made him the opioid coordinator as an “all hands on deck” effort to champion for the people of Idaho. Robins says the Department of Justice’s efforts to combat the opioid epidemic have been “committed, resolute, and firm in using every tool at its disposal to combat this opioid crisis”. He mentioned that in Idaho, we lose 130 citizens everyday. He says the opioid epidemic is tearing families apart. Because of this, the Department of Justice is deploying tools to meet its challenges. 

He says the DOJ is invested in developing community resources and finances $100s of millions of dollars in grants to state and local partners. That funding goes to specialty courts, children whose parents are addicted to opioids, and efforts in preventing recidivism. 

In the civil division, Robins says prosecutors use the law to rip the prescription pads away from over-prescribers of opioids. He says criminal prosecution is only one dimension of a multidimensional solution to a multidimensional problem and we cannot prosecute our way to safety.

Of those dimensions within the problem, Robins mentioned a predisposal to addiction, sociological influences such as maladaptive mechanisms, societal erossions, economical challenges, the pharmaceutical industry and its handling of prescriptions, and medical problems as a few contributing factors of the opioid crisis. Robins says there is no single solution to the opioid epidemic, only a single goal to end it. He says there are multiple solutions and policy makers are using pieces of the puzzle to most effectively address the crisis. 

Robins says prosecution is a very important piece. He says the DOJ is engaging in prosecution in an effort to protect society. He says the criminal division of DOJ is seeking rehabilitation, deterring the offender, and advancing respect for the law. In this crisis, this serves two functions: One being to serve as an entryway for addicts into treatment pathways. Prison provides a rock bottom that then offers skills to climb out. Robins says this is not universally successful but some have overcome addiction through the criminal justice system. He says the other function is treatment through diversion efforts. 

The DOJ is seeking prosecution of drug traffickers. Robins says some people profit from this crisis and the U.S. brings perpetrators to justice, removing the illegal substances from our communities to stem the flow of illegal drugs into our state. He says this is done through border interdiction efforts. 

Robins says since 2013, China has been supplying fentanyl to the United States and into Mexico. He says the opioid crisis is a geopolitical problem. Through custom and border patrol, Robins says the DOJ prohibits those packages from entering the United States to shut down the veins for packages to come into Idaho from overseas. He says agents seek justice to prevent those drugs from hitting our streets. 

Robins says an organized crime task force has been putting money into investigating drug trafficking since 1982. He says there are 2,500 agents who have apprehended more than $3 billion in assets form drug runners, 10s of thousands of pounds of drugs and made 10s of thousands of arrests. 

Robins says because of efforts like the organized crime task force and the National Heroin Initiative, the DOJ is effectively disrupting the supply of opiates into our country. He says the Len Bias Law states that if a prosecutor is able to prove beyond reasonable doubt that a drug trafficker sold drugs that caused a fatal overdose, the supplier can be charged with reckless homicide and serve a 20 year mandatory minimum sentence or potentially a life term. Robins says this tool is valuable in recognizing the seriousness of this epidemic.

Robins mentioned convicted individuals are also offered the opportunity to cooperate with law enforcement and if they produce results that result in apprehension, the offender can alleviate that mandatory minimum sentencing. He says producing evidence can help break the supply chain in an effort to aid law enforcement in protecting the community and ultimately address the opioid crisis head on. He says because there is no single solution to the crisis, all agencies must remain vigilant for a long time and this is something the DOJ is committed to doing.

Josh Tewalt is the Director of the Idaho Department of Corrections and oversees 25,000 felony offenders. He says a lot of drug-related issues are interconnected with criminal activity. He says substance abuse disorder is one of the precursores for crime and this disorder, mental illness and behavioral health can co-occur and manifest in the form of crime. He says understanding the why and doing something about it is a charge for criminal justice and public safety. 

“You have these people that keep falling off a cliff and so do we build a fence on the cliff or put an ambulance down in the valley? And the reality is, you do both,” Tewalt said.

Tewalt says within IDOC, out of the total number of people who have an addiction to substances, one in four identify opioids as their drug of choice. He says in 2015, there was a 2:1 ration between those addicted to prescription pills compared to heroin users. Now, he says that number is inverted with a 2:1 ratio of people using heroin in lieu of prescription pills. He says this speaks to the importance of addressing the supply issue and now we have to do something about the demand factor. 

Tewalt says IDOC has implemented two pilot programs to include voluntary treatment and recovery coaching. The treatment aspect is community based program that started in 2018 and since then, Tewalt says IDOC has referred 97 people on felony supervision to medication for opioid disorder (such as Suboxone). He says the Department of Corrections has learned lessons from that, the most important one being that timing matters. Tewalt says that getting people quick access to treatment without delay significantly improves outcomes. The longer delay, the larger the drop in success rates. 

Tewalt says IDOC is now recognizing the importance of peer support and recovery coaching. He says it helps those struggling with addiction to maintain motivation, stay engaged in treatment, and it helps them navigate the correctional system that can be complex to people who are new to it. 

He says medication alone was not an indicator of success and tht people who chose medication only were not successful in that process. He says the highest form of success came from those who took a combination of medication paired with support systems and outpatient substance abuse treatments. 

The Department of Health and Welfare is looking to help in custody offenders. Tewalt said one pilot program at Pocatello Women's Prison treated women with moderate to severe substance abuse disorder. DHW offered two positions including case management and recovery coaching. They have recognized that engagement is the greatest indicator for success in treatment. Tewalt says it is difficult for homeless and hungry people to be engaged because their needs go unmet. Health and Welfare case managers will help them understand the disorder and stabilizing factors that can help them be successful.

Tewalt listed the LSIR as a rating system that IDOC uses to assess the potential risk to society for each offender. He says there are 10 domains and traditionally, IDOC has been willing to do something about 3 or 4, but not other areas. He ways offenders need to have their basic needs met to be engaged in treatment. 

DHW also piloted a recovery coach program that has served 274 females so far. Tewalt says 35 of them were in the community and 30 voluntarily engaged in medication treatments while in custody. He says the next step for the correctional system is to expand available medication for in-custody addicts. He says IDOC is under a new medical services contract to provide medication system wide. IDOC has adopted the mindset that service needs to start while inmates are in custody in order to guarantee success rather than releasing them and testing their success on medications while in the community. Tewalt says they are expanding peer mentorship within custody. He says many inmates want to find purpose and give back. He said credential programs will be available for in-custody inmates to become certified recovery coaches. He says IDOC will also adopt individualized case management to connect reentering citizens to ongoing support upon reentry. He says these efforts are aimed to decrease recidivism and increase success.

One of the questions asked during the meeting included how we can confront pharmaceutical companies for giving false messaging to our doctors about prescribing opioids and what efforts are being made or could be made to counteract that messaging.

Hagedorn said these issues to need be addressed through policy at the state level. He said prescription abuse and addiction typically starts with injury and we need to evalutate the parameters involved with prescribing to adolescents. 

He said the governor supported mandatory checking of prescription drug monitoring system to help prescribers monitor when the last prescription was filled for a narcotic. He says we need awareness around prescribing. He says checking the last fill date sometimes results in the patient you least expect may be overfilling. He says this monitoring system may help but there is still a lot more awareness that needs to be done.

Robins said the task force recommends communication and education. He says we can't control this just on the doctor side and the public needs to be educated about what opioid addiction does to our community, kids, businesses, and economy. He says the state needs to put greater effort into outreach to help people understand the significant impact the crisis is having on Idaho.

Robins says making sure the information is received is also important. He stated Mexican oxys (pressed fentanyl and heroin to make it look like oxys) are on the street in Idaho. He says some people don't know what they have and are overdosing on this dangerous conconction of illegal substances. Robins says the only way to combat that is to educate our youth and perfect the information. He thinks billboards and visiting schools to discuss these dangers may show increased success in the public’s reception of this issue.

Tewalt said while education is critical, so is addressing the need of ACEs. He said the ACEs test will be used in prison systems.

Tewalt says within IDOC, “We are beginning to understand people are introduced to opiates and are self-medicating trauma.”

Like the rest of the country, Idaho is struggling with the opioid epidemic and has seen an increasing number of drug overdose deaths in the last two decades. According to the National Center for Health Statistics, in 2019, 265 Idahoans died from a drug overdose, a 9.5% increase from 2017.

According to Bureau of Vital Records & Health Statistics, from 2010-2018, reported drug overdose related deaths from natural and semisynthetic opioids (including oxycodone, hydrocodone, codeine, and morphine) increased 82% and were the most frequently reported type of drug on overdose death certificates in Idaho.

However, in that same time period, reported drug overdose related deaths involving psychostimulants with abuse potential (primarily methamphetamine) increased by 350% and in 2019, they surpassed opioids for the leading cause of drug overdose related deaths in Idaho. 

Overdose deaths caused by synthetic opioids, including methadone and fentanyl, have also remained in the top three substances involved in drug overdose related deaths, increasing 54% between 2010 and 2018. Heroin is also becoming an increasing concern. According to Idaho State Police, between 2014 and 2018, drug overdose deaths reporting heroin increased by almost three-fold and the arrest rate for heroin increased 500%. 

According to Centers for Disease Control and Prevention, in 2018, the rate of opioid prescriptions dispensed per 100 Idahoans was 61.87, a 27% decrease since 2009. However, that is still higher than the national prescribing rate of 51.4 prescriptions per 100 persons.

According to the National Survey on Drug Use and Health, in 2019, Idaho ranked 8th in the nation for past-year pain reliever misuse among persons aged 12 and over. Nearly 4.5% of Idahoans aged 12 and older reported misusing pain relievers in the past year, but adults aged 18 to 25 are at particular risk; 5.6% reported misusing pain relievers in the past year. According to Centers for Disease Control and Prevention, among youth, approximately 1 in 7 Idaho students have misused a prescription pain reliever in their lifetime.

According to the Centers for Disease Control and Prevention, Idahoans aged 12 and older misused 64,000 prescription pain relievers in 2019.