Wicomico County Opioid Community Response Plan. Created by the Wicomico County Health Department in Collaboration with our Community Partners

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1 Wicomico County Opioid Community Response Plan Created by the Wicomico County Health Department in Collaboration with our Community Partners

2 TABLE OF CONTENTS Introduction 4 Programs & Resources Prevention 8 Treatment 12 Enforcement 13 Community Wide Coordination Opioid Operation Command Center 15 Wicomico Opioid Intervention Team 16 Local Behavioral Health Authority 17 References 19 Appendices

3 COMMUNITY PARTNERS City of Salisbury Hudson Health Services, Inc. Government Entities Board of Education Department of Corrections Department of Emergency Services Department of Social Services Division of Parole and Probation County Executive s Office Health Department Maryland State Police Sheriff s Office State s Attorney s Office Peninsula Regional Medical Center Recovery Resource Center Salisbury University Wor-Wic Community College - 3 -

4 INTRODUCTION The heroin and opioid epidemic has affected individuals among all demographics in Wicomico County, as well as across the entire state and country. Heroin and opioid drug dependency surged in Wicomico County and the State of Maryland over the last decade, resulting in an urgent and growing public health threat. Locally, the rate of emergency department visits related to substance abuse disorders (per 100,000 population) is nearly 75% higher than the state average. 1 Substance abuse problems can place a heavy burden on the healthcare system, particularly when persons in crisis utilize emergency departments instead of other sources of care when available. In 2013, the total hospitalization costs attributed to illicit drug use in Wicomico County was over $36 million. 2 This burden is also shared by emergency medical providers and law enforcement personnel. A growing number of first responders face the risk of accidental overdose through the exposure of powerful, illicit substances, such as fentanyl and carfentanyl. That danger is evidenced by the US Drug Enforcement Agency s publishing of safety recommendations, Fentanyl: A Briefing Book For First Responders. The opioid crisis has not only put a strain on the healthcare system, but has also impacted the local criminal justice system. In 2013, the total costs to the criminal justice system in Wicomico County posed by illicit drug use totaled nearly $7 million. 2 The 631 individuals that were incarcerated in 2013 created $13 million in lost productivity, a small percentage of the total $100 million dollars of lost productivity within the County attributed to drug use. 2 $100,561,659 The total cost of lost labor productivity attributed to drug use in Wicomico County in

5 Figure 1. Number of Opioid-Related Deaths Occurring in Maryland, The number of opioid-related deaths in Maryland increased by 70% between 2015 and 2016, and has nearly quadrupled since 2010 (Figure 1). Wicomico County observed a significant increase in the number of heroin-related overdoses in 2016 (Figure 2). This led to the creation or expansion of many of the programs and services discussed later in this document. Figure 2. Wicomico County Heroin-Related Intoxication Deaths,

6 Along with much of the nation, Maryland is experiencing the emergence of a new threat in the form of potent and cheap synthetic opioids, such as fentanyl. Fentanyl-related deaths began increasing in late 2013 as a result of overdoses involving nonpharmaceutical fentanyl, that is, nonprescription fentanyl produced in clandestine laboratories and mixed with, or substituted for, heroin or other illicit substances. Nearly all fentanyl-related deaths occurring in recent years have involved the use of nonpharmaceutical fentanyl. Fentanyl is many times more potent than heroin, and greatly increases the risk of an overdose death. Deaths related to fentanyl have risen dramatically in the state, as well as in Wicomico County. Between 2015 and 2016 the statewide number of heroin-related deaths increased by 62% (from 748 to 1212), and the statewide number of fentanyl-related deaths more than tripled (from 340 to 1119) (Figure 3). Figure 3. Number of Fentanyl-Related Deaths Occurring in Maryland, In Wicomico County, the number of fentanyl-related deaths escalated from an eight year average of 2 deaths per year ( ) to a total of 34 in 2016 (Figure 4)

7 Figure 4. Number of Fentanyl-Related Deaths Occurring in Wicomico County,

8 PROGRAMS & RESOURCES Wicomico County features a robust network of programs intended to provide the community with a comprehensive array of behavioral health services. The following programs are categorized by the three pillars of the Governor s 2017 Heroin and Opioid Prevention, Treatment, and Enforcement Initiative: Prevention, Treatment, and Enforcement. PREVENTION 211 Maryland 211 is a 24 hour anonymous overdose hotline for youth and adults. Materials were designed and distributed so youth and adults uncomfortable contacting 911 had another way to report drug overdoses. The materials consist of laminated cards with important phone numbers, symptoms of an overdose, and what to do if you are a witness to a drug overdose. This program connects community members to health resources 24 hours a day, 7 days a week in over 180 languages. Community Outreach Addictions Team The COAT team is a collaborative community effort to assist individuals battling opioid addiction. The peer approach is being used to assist individuals into treatment utilizing the skills and knowledge a person in recovery has available to them. The COAT team has helped individuals in recovery as well as assisted families and friends of those suffering through this battle. Linking families to support programs and answering questions that only an addict could answer has been a very beneficial resource for the community. Crisis Intervention Team The Crisis Intervention Team (CIT) program is a community effort joining law enforcement and the community for common goals of safety, understanding, and service to the behavioral health population and their families. The program provides an avenue for the development of community partnerships and collaboration. The CIT program trains police officers to interact with individuals experiencing a behavioral health crisis. Since 2014, the Eastern Shore Criminal Justice Academy has partnered with the Wicomico - 8 -

9 Local Behavioral Health Authority to provide Crisis Intervention Team (CIT) trainings, offering certification by the Maryland Police and Correctional Commission. In 2016, nine classes were conducted and 201 officers received CIT certification. Crisis Response Team The Crisis Response Team (CRT) Coordinator works collaboratively with CIT officers. The CIT officers refer individuals to the CRT Coordinator for further assistance and linkages to needed services. From July 2015 to June 2016, the CRT Coordinator had 336 contacts with 114 consumers. Don t Tag Along Using funding provided by the Maryland Department of Health, the Wicomico County Health Department teamed up with an advertisement agency to develop commercials and public service announcements that can be seen on buses, billboards, social media, and inside magazines. Drug Free Wicomico & Drug Abuse Task Force Treatment professionals are one of the twelve stakeholders who participate in Drug Free Wicomico and the Drug Abuse Task Force, which are community-based coalitions. Collaboration between these treatment and prevention professionals can assist other programs to increase their overall effectiveness. Prevention refers program participants to behavioral health treatment programs while treatment professionals refer consumers to needed services. Good Samaritan Law The Good Samaritan Law establishes that a person who, in good faith, seeks or provides medical assistance for a person experiencing an overdose may be immune from criminal prosecution for specific violations. The bill also protects the person experiencing the medical emergency from prosecution for specific violations. Maryland Screening, Brief Intervention, Referral to Treatment Maryland SBIRT is a statewide health care improvement initiative used to encourage health care providers and patients to discuss alcohol and drug use as part of routine medical visits. The Wicomico County Health Department - 9 -

10 currently uses this resource in their Community Health Services clinics. Additional SBIRT initiatives are currently being planned for Peninsula Regional Medical Center and the Wicomico County Detention Center. Naloxone Naloxone (Narcan) is a prescription medicine used for the treatment of an opioid emergency such as an overdose. The Health Department offers free monthly trainings which are held at the Wicomico County Library and the Wicomico County Detention Center. The Health Department also trains local police departments, Board of Education staff, local shelter staff, and has conducted multiple trainings at Salisbury University in order for the students to be Naloxone certified. Nearly every law enforcement officer in the County carries Naloxone in anticipation of encountering an overdose victim. That need is evidenced by the growing number of people trained in the use of Naloxone. From July 2015 to June 2016, the Wicomico Local Behavioral Health Authority trained 394 individuals. The following year, that number more than doubled to 868. Opioid Misuse Prevention Program The Opioid Misuse Prevention Program (OMPP) is part of the Governor's comprehensive statewide strategy for reducing overdose deaths related to pharmaceutical opioids and heroin. Through the OMPP grant, Health Department staff work closely with stakeholders across the region to reduce unintentional overdoses involving opioids, such as prescription painkillers and heroin. The OMPP provides prevention, outreach, education, and training to individuals, worksites, and community groups in Wicomico County, MD. Overdose Fatality Review Team The Wicomico County Overdose Fatality Review Team (OFRT) is a multi-disciplinary, multi-agency medical review committee established by the Wicomico County Health Department pursuant to Health Occupations Article 1-401(a) 3, Annotated Code of Maryland. The OFRT aims to conduct multidisciplinary, multi-agency reviews of available information to determine the incidence and prevalence of fatal overdoses and the factors that cause or are correlated with overdoses. The team reviews an estimated 25 fatal overdose cases annually

11 Prescription Drug Disposal There are currently nine prescription drug drop-off sites at law enforcement agencies and other partners to ensure the timely disposal of prescription drugs. This program also educates the community on the poundage of drugs that are taken out of circulation due to the boxes. Fliers are dispersed on an ongoing basis to educate people on the nine permanent prescription box locations (Appendix A). Since the establishment of the program in 2013, 4012 pounds of unwanted and used prescription drugs have been collected and properly disposed of (as of April 6, 2017). Prescription Drug Monitoring Program The Maryland Prescription Drug Monitoring Program (PDMP) was created to support providers and their patients in the safe and effective use of prescription drugs. The PDMP collects and securely stores information on drugs that contain controlled substances and are dispensed to patients in Maryland. Drug dispensers, including pharmacies and healthcare practitioners, electronically report the information that is stored in the PDMP database. The PDMP is part of Maryland s response to the epidemic of opioid addiction and overdose deaths. Practitioners authorized to prescribe Controlled Dangerous Substances (CDS) in Maryland must be registered with the PDMP by July 1, Substance Treatment and Addiction Reduction Task Force START Salisbury was formed in 2016 by the Mayor of Salisbury to address the opioid crisis. The purpose of the committee is to develop recommendations on prevention, intervention, and addictions. Temporary Cash Assistance Substance abuse screening services are provided by addictions specialists placed at the Department of Social Services to provide substance abuse screening services to all Temporary Cash Assistance (TCA) applicants, minor parents in a TCA household, food stamp applicants, and recipients who have been convicted of a drug related felony. The services are also provided to referrals from Child Protective Services who are suspected of having substance abuse problems. The Addictions Specialists provide appropriate referrals to agencies within the community. Case Management is done with individuals who are in treatment to address any barriers to completing treatment

12 TREATMENT Adult Forensic Treatment The Male and Female Forensic Program is designed for individuals who are currently incarcerated at the Wicomico County Detention Center. The inmate must meet the American Society of Addiction Medicine (ASAM) placement criteria for Level I care, which can be provided less than 9 hours per week. Groups for the female population are held two days per week and one evening per week. Male inmates can attend group sessions and a work release group is also conducted one evening per week. Participants are required to attend a minimum of one individual session per month along with weekly group attendance. Alcoholics Anonymous and Narcotics Anonymous meetings are held one time per week at the Detention Center for inmates to attend. Adult Intensive Outpatient Treatment The Adult Intensive Outpatient Programs (IOP) are designed for individuals who require more structure and support than a low-intensity, traditional outpatient program, and who do not need a medically managed inpatient program. Treatment is provided nine hours or more during the week. As the patient progresses, they will step down and attend less hours at each phase. IOP provides an opportunity for patients to gain stability and maintain abstinence, and learn and practice behaviors in their social environment which support recovery. Community Outreach Addictions Team (COAT) The Health Department s COAT team is a collaborative community effort to assist individuals that are battling opioid addiction into treatment. COAT is an effort to combat overdoses and provide a smooth transition to treatment services. Since its creation in June 2016, the team has responded to 302 overdose calls for 200 individuals. 55% of them have accessed some sort of community addictions treatment (as of June 30, 2017). In April of 2017, the COAT team was selected as a Promising Practice by the National Association of County and City Health Officials (NACCHO). This national recognition honors outstanding, evidence-based local public health practices. Dual Diagnosis Programs The Dual Diagnosis Program is offered to individuals who are eighteen and older, and who reside in Wicomico County of Maryland. To obtain mental health services the individual would have to be given a diagnosis of a substance disorder and mental health disorder. The client would also have to actively participate in the addictions program to receive mental health services

13 HG Evaluation and HG Treatment Placement Process Health General Article, Section provides for court ordered evaluations regarding drug addiction. If the person evaluated is found to be in need of treatment, then he or she may be committed to an inpatient treatment program, pursuant to HG, sec The process allows a judge to order a drug/alcohol evaluation prior to the defendant s trial or sentencing. Medication-Assisted Treatment (MAT) The Health Department, along with several other private providers, administers several different medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. These medications include Methadone, Suboxone (buprenorphine), and Vivitrol (naltrexone). Currently, the Health Department serves nearly 300 clients through its MAT clinics. Outpatient Mental Health The Wicomico County Health Department and other private practitioners provide outpatient mental health services for children, adolescents and their families. The Targeted Case Management (TCM) team provides services to individuals with a mental illness that require assistance to enable them to remain in the community. Psychiatric Rehabilitation Programs (PRP) provide services to individuals with a mental illness that require rehabilitative and/or restorative services to enable them to become or remain successful in the community. ENFORCEMENT Adult Drug Treatment Circuit Court Drug Treatment Court is a treatment-focused program that offers intensive rehabilitation services to criminal defendants whose crimes are driven by their addiction. It is a team effort of agencies working together to provide a variety of programs and consistent supervision geared toward supporting and helping participants maintain a drug-free life. The Wicomico County Health Department screens and treats individuals that are referred and admitted to the Wicomico County Circuit Drug Court. To participate in Drug Court, the participants need to meet criteria for ASAM Level II Care. Evaluations can also be completed for participants who are incarcerated at the local detention center

14 Maryland Justice Reinvestment Act The Justice Reinvestment Act of 2016 was passed by both houses of the Maryland General Assembly. Governor Larry Hogan signed the bill into law on May 19, The Act seeks to reduce Maryland s prison population and use the savings to provide for more effective treatment to offenders before, during, and after incarceration. Specific sections of the bill allow for a reduction in maximum incarceration for numerous nonviolent offenses, plus preference for treatment over incarceration of drug offenders. Wicomico County Narcotics Task Force The Wicomico County Narcotics Task Force includes members of the Wicomico County Sheriff s Office, Maryland State Police, Salisbury Police Department and Fruitland Police Department. The Task Force conducts multiple drug enforcement operations at various locations throughout the County in an effort to remove drugs from the streets of the community. Wicomico County State s Attorney Heroin Coordinator The Wicomico County State s Attorney s Office has designated a lead prosecutor to handle all heroin-related cases. In addition to prosecution, this position analyzes drug intelligence and provides a monthly report on the opioid issues to County elected officials

15 COMMUNITY WIDE COORDINATION OPIOID OPERATIONAL COMMAND CENTER In response to this public health threat, Governor Hogan established by Executive Order a Heroin and Opioid Emergency Task Force and the Opioid Operational Command Center (OOCC). The center was established to combat the growing problems of the heroin and opioid addiction epidemic as well as the new threat of synthetic opioids in Maryland. The Opioid Operational Command Center will be a collaborative effort working directly with both local and federal organizations and agencies, as well as 12 state agencies and departments including: the Governor s Office of Crime Control & Prevention, Department of Health, Maryland Emergency Management Agency, Maryland State Police, Maryland State Department of Education, Department of Human Resources, Department of Juvenile Services, Department of Public Safety and Correctional Services, Maryland Institute for Emergency Medical Services Systems, Maryland Higher Education Commission, Maryland Insurance Administration, and the Office of the Attorney General. The Center will be tasked with organizing and coordinating resources for local Opioid Intervention Teams (OIT). The OOCC is tasked with the following objectives: Develop operational strategies to continue implementing the recommendations of the Heroin and Opioid Emergency Task Force. Collect, analyze, and facilitate the sharing of data relevant to the epidemic from state and local sources while maintaining the privacy and security of sensitive personal information. Develop a memorandum of understanding among state and local agencies that provides for the sharing and collection of health and public safety information and data relating to the heroin and opioid epidemic. Assist local agencies in the creation of opioid intervention teams. Coordinate the training of and provide resources for state and local agencies addressing the threat to the public health, security, and economic well-being of the State. The center will facilitate greater collaboration between state and local opioid intervention teams to reduce the harmful impacts of opioid addiction on Maryland communities. As a direct result from increased collaboration, the center will collect and collate data data

16 that will be used to save lives. This collaboration will focus on three primary focus areas: prevention, treatment, and enforcement. OPIOID INTERVENTION TEAM The Overdose Intervention Team (Appendix B) is a collaborative effort that aims to: Develop a unified strategy to reduce non-fatal and fatal opioid overdoses. Integrate all stakeholders into the OIT from local, State, and Federal government agencies as well as private and non-profit sectors. Coordinate stakeholders operations to achieve a unified strategy. Explore funding requests for programs. Identify strategies needed to address priorities. Establish policies and procedures for pooling all available data sources on overdoses from state and local resources, including but not limited to, hospital emergency department data, emergency medical services data, and law enforcement data. The Wicomico County Opioid Intervention team has identified several immediate action items based on collaborative discussions: Expand the capacity of the Community Outreach Addictions Team by securing funds for additional peer support specialists and a full time supervisor. This will increase the Team s ability to respond to overdose calls and link additional individuals to treatment resources. Secure funding to provide a 24/7 detoxification facility on the campus of Hudson Health Services, Inc. Hudson currently offers inpatient residential treatment services. However, the community is lacking a facility that can assist individuals begin the detoxification process without a lengthy admission process. Increase collaboration and data collection for potential overdose clusters (an unusually high incidence of reported overdoses occurring in close proximity in

17 time and/or location). These clusters are important to the OIT in that they may signal a potentially more fatal opioid is in circulation. Additional action items that have been identified through regular OIT meetings: Obtain TruNarc Handheld Narcotics Analyzers that can be used to detect illicit substances without putting law enforcement in danger. Require the Maryland State Police Training Commission to make Narcan training mandatory for all entry level officers as well as part of their continued in-service training. Establish an OIT Director for each jurisdiction to ensure the sustainability of the OOCC s goals and objective, monitoring all aspects of the OIT s collaborative efforts and ensuring coordination within each jurisdiction to avoid overlap in operational duties. Require all emergency medical service providers make the use of ODMAP mandatory. ODMAP can be used to collect and report real-time overdoses. By allowing first responders to enter data identifying whether or not the incident is fatal or non-fatal and whether or not Naloxone was administered in a simple oneclick system that takes seconds. LOCAL BEHAVIORAL HEALTH AUTHORITY The Local Behavioral Health Authority (LBHA) serves as the Local Addiction Authority (LAA) and Core Service Agency (CSA) for Wicomico County, overseeing publicly funded mental health and addiction services. The LBHA is an entity within the Wicomico County Health Department (WiCHD). The LBHA oversees a network of providers that deliver behavioral health services to residents in Wicomico County. In addition to overseeing the provision of these services, the LBHA directly awards public funds to support behavioral health services not reimbursable by the fee-for-service system. The current goals of the LBHA are: Moving toward an integrated system of care; Improving access and quality of service throughout the continuum of care; Building infrastructure to support system capacity to collect, analyze and track data to improve service outcomes;

18 Developing and implement population based efforts to promote wellness, improved overall health and ensure safety to people in care, their families and communities; and Reviewing the array of services provided to individuals requiring in-patient care to develop specific strategies to address hospital capacity. The LBHA collaborates annually with Somerset and Worcester Counties to produce a comprehensive Tri-County Behavioral Health Resource Guide. This guide, while not inclusive of every service or behavioral health provider in the tri-county area, represents an effort to help the citizens of the region become more aware of the services that are available to them. The guide is available at:

19 REFERENCES 1. Maryland State Health Improvement Process. Accessed from: 2. The Costs of Illicit Drug Use and Alcohol Abuse on the Eastern Shore of Maryland, January Business Economic and Community Outreach Network At Salisbury University. 3. Drug- and Alcohol-Related Intoxication Deaths in Maryland, Maryland Department of Health, Behavioral Health Administration. Accessed from: %20Overdose%20Annual%20report.pdf

20 APPENDIX A

21 APPENDIX B

22 If you know anyone struggling with addiction, please call or July

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