WCU Stories      September 23, 2019

The Scope of the Epidemic

Opioid use continues to take its toll on communities across the United States. A dramatic rise in the rates of use over the past decade led the Department of Health and Human Services to officially declare an epidemic in 2016.[1] The most disturbing aspect of this unprecedented epidemic is the number of fatal overdoses. More specifically, 70,237 drug-overdose deaths were recorded in the United States in 2017, nearly 10,000 more than in the prior year and the highest number to date.[2] Since 2000 the rate of overdose deaths involving opioids has increased 200 percent. This includes a 21.4 percent increase in the number of fatal overdoses from 2015 to 2017.[3]

The fatality rate, or the number of people who die following an opioid-related overdose relative to the overall population, is another stark indicator of the magnitude of the epidemic. The fatality rate was 6.2 per 100,000 in 2000.[4] This rate more than doubled to 14.7 by 2014 and continued to rise to an all-time high of 21.7 per 100,000 in 2017.[5] More than half a million people have died from a fatal drug overdose since 2000.

We can see similar trends in North Carolina during the same period. In 2000, 3.5 per 100,000 people in the state died from drug overdose involving opioids. This rate increased by nearly five times to 19.8 in 2017.[6] Recent analyses have shown the state’s death rate increased 29 percent from 2016 to 2017, indicating the number of fatalities continues to increase.[7]

The impact of these overdoses is most profound in our local communities, and while opioid-related deaths have been stable in some western counties in North Carolina over the past few years, they have fluctuated in others. Table 1 provides a brief overview of recent County Health Rankings data for those counties with available data. In Jackson County, the number of fatal overdoses increased from 15 to 26 between 2016 and 2018, a 60 percent rise. Overdose deaths have steadily climbed in Macon County also, reaching a high of 19 in 2018. The number of annual deaths has been stable in Cherokee County while it has decreased slightly in Haywood and Transylvania Counties. Despite these auspicious trends, comparing them to the state’s fatality rates highlights the extent of the problem.

Table 1: Number of overdose deaths and fatality rates in select western North Carolina counties

Note: Data drawn from 2019 County Health Rankings.[8] *This measure covers 2012 to 2014. ^†This measure covers 2013 to 2015. ⁺This measure covers 2014 to 2016.

In 2016, 13 people per 100,000 across North Carolina fell victim to fatal overdose attributed to opioid use. In comparison, Jackson and Macon Counties had lower fatal-overdose rates at 11 and 13 that year, respectively. The state fatality rate increased to 14 in 2017 and rose again to 16 in 2018. Although Jackson County experienced a fatal-overdose rate comparable to the state rate in 2016 and 2017, the recent spike in the fatality rate far exceeds the state’s more modest increase.

Opioid-related overdoses remain a primary concern for communities in western North Carolina, but they fail to capture the full extent of the epidemic because they include only fatal incidents. A much larger population of opioid users in these communities has not succumbed to overdose, and many users become involved in the criminal justice system.

Local jails serve as the first point of contact for arrestees as they are processed into the criminal justice system. National data have shown that adults who enter these detention facilities are significantly more likely to report substance use relative to the general population.[9] National data collected from large metropolitan-area jails indicate that one out of ten adult male arrestees tested positive for opioids when they were processed into one of these correctional facilities.[10] In comparison, the National Survey on Drug Use and Health, a community-based survey, indicates 4 percent of the general population reported opioid misuse in the past year and less than 1 percent reported using heroin in the last twelve months.[11] Although these national opioid-use prevalence rates warrant serious consideration, the significantly higher rates among adults admitted to local jails are alarming.  

Opioid and other Substance Use Disorder (SUD) prevalence among adults in the local Criminal Justice System

SUDs are identified by persistent drug use contributing to significant impairment or distress over a twelve-month period, and there are specific criteria used to diagnose them.[12] The designation of an SUD, as opposed to overly simplified reports of substance use, specifically concentrates on high rates of problematic use that contribute to impairment. The current diagnostic approach, found in the Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5), is based on three designations to reflect the severity of a particular SUD, ranging from mild to moderate to severe.[13] This diagnostic scheme is also the current standard used for determining who is eligible for treatment and for billing for services. Despite the significance of this diagnostic classification, few local jails have the full-time personnel available to systematically collect the required information from adults processed into them.

One exception to this trend is found in recent research conducted in a western North Carolina jail that demonstrates the prevalence of SUDs among adults booked into the facility. In a collaborative effort with the Haywood County Sheriff’s Office, researchers from Western Carolina University collected data over the course of one year to identify the behavioral health needs of detainees in the local detention center. The results demonstrated that SUDs were the most prevalent behavioral health condition, with 72 percent of detainees showing signs consistent with a severe SUD.[14] More specifically, 40 percent of adults in the study met criteria for severe amphetamine use disorder while slightly more than one-third (36 percent) met criteria for severe opioid use disorder. A significant proportion of the sample—nearly one-third (30 percent)—met criteria for both disorders, highlighting the importance of considering the complex nature of these co-occurring conditions.

A similar study is currently underway in the Jackson County Detention Center to identify the most pressing behavioral health needs among the population processed through the jail. This federally funded project (Bureau of Justice Administration award 2018-MO-BX-0044) was initiated in June 2019 and will continue through December 2020. Researchers from Western Carolina University are collecting detailed information regarding the prevalence of specific SUDs. To date, researchers have conducted comprehensive behavioral health assessments on a random sample of sixty-four adults admitted to the correctional facility.

The preliminary results indicate that the majority of adults—81 percent—processed into the Jackson County Detention Center meet criteria for at least one SUD. More than two-thirds (66 percent) meet criteria for a minimum of one moderate to severe condition.  Put simply, two out of every three adults booked into the jail are likely to meet criteria for a moderate to severe SUD. The prevalence according to specific substances is also a significant cause for concern, with the majority (64 percent) meeting criteria for amphetamine use disorder, followed by approximately one-third (35 percent) meeting criteria for opioid use disorder and a similar proportion (35 percent) meeting criteria for alcohol use disorder.

One of the most important initial results from a public health perspective is that more than half (55 percent) of adults reported injecting drugs in the past. Among them, two-thirds (66 percent) reported having done so on multiple occasions. This raises significant concern related not only to the transmission of communicable diseases associated with the use of syringes, but also to fatal-overdose risk among injection-drug users.

Another important preliminary finding is that adults who meet criteria for an SUD are likely to have been admitted to the Jackson County Detention Center on multiple occasions in the past year. Among adults processed into the jail in the past, 61 percent meet criteria for at least one severe SUD. A closer examination of specific substances indicates 56 percent of those admitted on multiple occasions meet criteria for opioid use disorder while 46 percent meet criteria for amphetamine use disorder.

Most adults processed into the local detention center are released quickly and promptly return to the community. A brief review of residential status indicates 50 percent of adults booked into the jail who meet criteria for severe opioid use disorder are Jackson County residents. To put this into perspective, the most recent County Health Assessment indicates that 17.5 percent of county residents reported some use of opioids in the past year, and this includes those who did and those who did not have a prescription.[15] This means a substantially larger proportion of the jail population presents symptoms consistent with opioid use disorder relative to nonincarcerated community residents who report any use of opioids. Additionally, almost two-thirds (64 percent) of adults booked into the jail meeting criteria for severe amphetamine use disorder are county residents, making it apparent that engaging the population involved in the criminal justice system with treatment services must be a top priority to enhance community health and well-being.

Opportunities to address Opioid Use Disorder and other SUDs in the Criminal Justice System

Contact with the criminal justice system serves as a critical intervention point for adults with SUDs. It is an opportunity to identify and address the conditions that are likely contributing, at least in part, to criminal activity. Many local jurisdictions are ill equipped to effectively address these pressing needs, but some agencies around the country are thoughtfully capitalizing on this contact to direct adults toward long-term recovery from substance use.

Many jurisdictions are implementing pre-arrest diversion programs to address SUDs in the community. In this approach, law enforcement officers connect adults with SUDs to treatment rather than simply arresting and incarcerating them. There are many variations of these programs, but the Police, Treatment, and Community Collaborative has identified five primary pathways between law enforcement agencies and substance use–treatment providers.[16] The self-referral pathway encourages individuals with SUDs to engage local law enforcement agencies with the understanding that the agencies will not arrest them but will refer them to immediate treatment. The Angel Program, started in Gloucester, Massachusetts, is a prime example of this approach, which has been adapted in many jurisdictions.[17] The active-outreach option is based on law enforcement officers’ identifying prospective participants, but instead of making an arrest a treatment provider contacts them and encourages them to engage in treatment. The Westside Diversion Project in Chicago serves as a model for this method.[18] Naloxone Plus programs comprise another pathway and involve a treatment referral stemming from an immediate response to an overdose. Examples of this approach include Quick Response Teams in Ohio, the Stop, Triage, Engage, Educate, Rehabilitate program in Maryland, and Drug Assistance Response Teams in Ohio.[19] Officer-prevention referrals are another law enforcement–based method used to engage adults with SUDs in treatment. The Law Enforcement Assisted Diversion program, initiated in King County, Washington, is a model program utilizing this approach, which has been adopted by many other jurisdictions across the country.[20] Lastly, officer-intervention referrals can be used to connect adults with SUDs to treatment. This option typically involves a law enforcement officer issuing a citation that includes a referral to a treatment provider as part of the initial legal response to the criminal activity. The Civil Citation Network in Leon County, Florida, has demonstrated the effectiveness of this model.[21]

The common theme underlying these approaches is the role of law enforcement officers as the critical link between individuals with SUDs and treatment providers. If officers do not have the opportunity to divert adults to treatment, jails will continue to serve as de facto detention facilities for community residents with SUDs who need services. Many jails do not have the capacity to deliver these services, and most adults are released into the community without a managed-care plan—circumstances highly conducive to jail readmission.[22]

For people with severe opioid use disorder, there are significant risks associated with persistent use, and jail admission can exacerbate many of them. Tyler Tabor, a twenty-five-year-old father with opioid use disorder booked into the Adams County Jail, just outside Denver, is a prime example.[23] Tyler was arrested for two misdemeanor warrants, and during the booking process he informed the jail’s screening nurse that he was a daily heroin user. This information should have put the jail staff on notice that Tyler would likely require medical treatment, but instead, Tyler was placed in a special cell designated for detainees in active withdrawal and experienced some of the most extreme symptoms, including persistent vomiting and diarrhea. This lasted for about twenty-four hours, until he was too weak to walk. He died just a few hours later.

Many conditions can contribute to fatal outcomes among adults with opioid use disorder, and jail admission represents a pivotal moment to address many of them. There are several key procedures required in order to intervene, and a comprehensive assessment is the first step. Unfortunately, most local jails do not have the personnel or the resources readily available to collect this information, let alone provide desperately needed services to adults with the most severe form of the disorder.

North Carolina recently made an effort to address opioid use disorders with the Opioid Epidemic Response Act, but noticeably absent from this legislation is any support for criminal justice agencies to address opioid use disorders within local detention centers.[24] This is especially concerning given the state’s explicit acknowledgement in the revised Opioid Action Plan 2.0 that the needs of criminal justice populations must be addressed.[25] The number of detainees held in the 113 jails across the state has been steadily rising. These circumstances demonstrate missed opportunities to intervene and address opioid use disorders in one of the most at-risk populations in the community.

Although the general trend reflects a widespread failure to initiate meaningful changes in local jails that can reduce the impact of opioid use disorder on communities across the state, some programs have taken innovative approaches. The North Carolina Harm Reduction Coalition is applying the lessons learned in New York State’s Overdose Education and Naloxone Distribution Program through the support and expansion of the Jail-Based Opioid Overdose Education Program.[26] This pilot program, currently taking place in the Durham and Catawba County Jails, is designed to provide information to detained adults with opioid and amphetamine use disorders about ways to reduce the risk of overdose following release, laws that provide access to naloxone and clean syringes, overdose-response procedures, and referrals to treatment or social services. Due to the early stages of implementation, evaluation data are not yet available for North Carolina’s jail-based education program.

North Carolina will not experience a significant reduction in the prevalence of opioid use disorders or fatal overdose until dedicated programs are systematically supported and initiated across the state. Pre-arrest diversion programs offer one set of opportunities, and jail-based programs represent another. Several jurisdictions in the western portion of the state are in the early stages of implementing effective programs, but a lot of work remains before we will see a noticeable impact on the community. Now that these opportunities have been identified, it is time to act and develop locally oriented responses to opioid use disorder and other SUDs.

References