PowerPoint Presentation

Community Responses to Heroin:North Carolina and Northern KentuckyPresenters:Kim Moser, Director, Northern Kentucky Office of Drug ControlScott Proescholdbell, MPH, Epidemiologist, Injury and Violence Prevention Branch, North Carolina Department of Health and Human ServicesNidhi Sachdeva, MPH, Injury Prevention Consultant, Division of Public Health, North Carolina Department of Health and Human ServicesHeroin TrackModerator: Kelly J. Clark, MD, MBA, FASAM, DFAPA, President-elect, American Society of Addiction Medicine, and Member, Rx and Heroin Summit National Advisory Board

DisclosuresScott Proescholdbell, MPH; Nidhi Sachdeva, MPH; and Kelly J. Clark, MD, MBA, FASAM, DFAPA, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.Kim Moser Speakers bureaus: Pfizer, Merck, Glaxo, AstraZeneca

DisclosuresAll planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.The following planners/managers have the following to disclose:John J. Dreyzehner, MD, MPH, FACOEM Ownership interest: Starfish Health (spouse)Robert DuPont Employment: Bensinger, DuPont & Associates-Prescription Drug Research Center

Learning ObjectivesDescribe the problem of heroin mixed with clenbuterol.Explain the protocol developed by the North Carolina Injury and Prevention Branch to respond to events that involve overdose.Outline regional partnerships and programs implemented in Northern Kentucky to respond to the Rx opioid and heroin epidemic.Provide accurate and appropriate counsel as part of the treatment team.

Community Responses to the Prescription Opioid and Heroin Epidemic

Lessons from Northern Kentucky

https://www.youtube.com/watch?v=leznM7P2O0g&feature=player_embedded#t=0

Cincinnati and Northern Kentucky

Northern KY is home to 450,000 people in 8 counties7

2014 Overdose Deaths - KYThe top 7 counties by overdosedeaths per 100,000 people for 2014 are:Floyd County 55.1 per 100,000Pike County 50.8 per 100,000Campbell County 47.9 per 100,000Kenton County 43.3 per 100,000Boone County 38.0 per 100,000Fayette County 36.6 per 100,000McCracken County 30.6 per 100,000

Ashel Kruetzkamp, MSN, RN St. Elizabeth Healthcare* Includes ONLYJan-Nov overdosesHeroin OverdosesSt. Elizabeth Emergency Departments (Covington, Ft. Thomas, Edgewood, Florence and Grant)

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For every woman who dies of a prescription painkiller overdose, 30 go to the emergency department for painkiller misuse or abuse400%Deaths from prescription painkiller overdoses among women have increased more than 400% since 1999, compared to 265% among men48,000Nearly 48,000 women died of prescription painkiller* overdoses between 1999 and 2010(NAS) grew by almost 300% in the US between 2000 and 2009

CDC Vital Signs July 2013Women and Opiate Addiction

EMERGING PUBLIC HEALTH ISSUES-Northern KY-

Hepatitis C rates:2.7 times that of the rest of the state of Kentucky19.5 times that of the rest of the Nation

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IV Drug Use & DiseaseINFECTIOUS DISEASES SPREAD BY IV DRUG USE (2014)DiagnosisBoone CountyCampbell CountyGrant CountyKenton CountyNKY* Acute hepatitis B77Fewer than 52238 (9.4)Acute hepatitis C910Fewer than 522 44 (10.9)Non-acute hepatitis B1917Fewer than 54080 (19.8)Non-acute hepatitis C 17322366396858 (212.7)HIV cumulative from 1982, living and deceased12015531413719

Source: NKY Health Department Epidemiology Unit

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A CALL TO ACTIONParents Advocating RecoveryLocal hospitalsLaw EnforcementJudges Treatment providersElected Officials

A Community Response

Community Response

Advocacy

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Caseys Law

In _______ states, enacted in 2004 after Casey Wethingtons parents turned their tragedy into advocacy for other individuals suffering from the disease of addiction. This laws allows parents and loved ones to petition the court for involuntary treatment.20

SB 192AN ACT relating to controlled substances and declaring an emergency.Be it enacted by the General Assembly of the Commonwealth of Kentucky:Section 1. KRS 72.026 is amended to read as follows:(1)[Unless another cause of death is clearly established, ]In cases requiring a post-mortem examination under KRS 72.025, the coroner or medical examiner shall take a biological[blood] sample and have it tested for the presence of any controlled substances which were in the body at the time of death and which at the scene may have contributed to the cause of death.(2)If a coroner or medical examiner determines that a drug overdose is the cause of death of a person, he or she shall provide notice of the death to:(a)The state registrar of vital statistics and the Department of Kentucky State Police. The notice shall include any information relating to the drug that resulted in the overdose. The state registrar of vital statistics shall not enter the information on the deceased person's death certificate unless the information is already on the death certificate;[ and](b)The licensing board for the individual who prescribed or dispensed the medication, if known. The notice shall include any information relating to the drug that resulted in the overdose, including the individual authorized by law to prescribe or dispense drugs who dispensed or prescribed the drug to the decedent; and

NKY Office of Drug Control Policy

Mission Statement

Provide advisory services to Boone, Campbell and Kenton County Fiscal Courts on the best evidence-based treatment and prevention strategies for reducing Substance Use Disorders in our community.

NKYODCP: Goals and InitiativesPrevention and Education: Community EngagementTreatment: Jail SAPs and Vivitrol PilotNeonatal Abstinence Support Network: Mothers and Babies Legislation: State and FederalLaw Enforcement: Supply and Harm Reduction

Regional Education and Prevention

HOMEGET INFOGET HELPGET INVOLVEDRESOURCESHOMEGET INFOGET HELPGET INVOLVEDRESOURCES

Hamilton County Heroin Coalition | Hamilton County Heroin Coalition19843

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Crisis Hotline513 281 7422

Report Heroin Dealers513 352 DOPE (3673)

Get Info

From treatment and prevention to law enforcement activities and harm reduction strategies

Learn More

GetHelp

Direct access to the people and organizations who can provide assistance

Learn More

GetInvolved

From individual and family action steps to neighborhood and community-wide programs

Learn More

Hamilton Countys Epidemic

An opioid epidemic has shattered families and frayed the fabric of Hamilton County communitieson an unprecedented scale.Two key factors have fueled the epidemic:

Heroin is

INEXPENSIVE AND RAMPANT

Heroin is cheap, very potent, and readily available. According to the most recent Ohio Substance Abuse Monitoring Network Report, heroin is highly available in the Cincinnati region.

PublicTreatment is

Decreasing Rapidly

Public funding for addiction treatment continues to plummet. In fiscal year 2009, the Hamilton County Mental Health and Recovery Services Board had $18.9 million available to support addiction treatment. By 2014, this amount dropped to $13.2 million.

About Us and Our Mission.

HCHCs Mission:

The Hamilton County Heroin Coalition provides Countywide and regional leadership and solutions to address the heroin and opiate epidemic both immediately and in the long-term. We are committed to assisting our residents and neighbors with the emergency support that they need, as well as working to prevent the spread of drug use in our youth before it begins. Through collaboration between public health officials, law enforcement, prevention experts and treatment providers, we can make an impact on this pressing public health and public safety issue.

Adequately investing in addressing this problem will produce a cost savings to thecommunity, in addition to saving lives and restoring our families. Every $1 spent onaddiction treatment alone will save Hamilton County taxpayers anywhere from $4to $15, depending on the number of factors taken into consideration. Every $1 spenton prevention can save Hamilton County taxpayers up to $18 in costs stemmingfrom substance use, misuse and addiction.Coalition Members:Coalition Chair: Commissioner Dennis DetersChief Richard Braun, Cincinnati Fire DepartmentMary Haag, PreventionFIRST!Tim Ingram, Hamilton County Public Health CommissionerJim Schwab, President and CEO, Interact for HealthChief Tom Synan, Newtown Police Department, Hamilton County Association of Chiefs of PolicePatrick Tribbe, President/CEO, Hamilton County Mental Health & Recovery Services BoardNeil Tilow, President/CEO, Talbert HouseClick here to access the Hamilton County Heroin Coalition Strategic Action Plan

IF YOU WANT TO LEARN HOW YOU CAN MAKE A DIFFERENCE, PLEASE CONTACT US HERE:

CONTACT US

Understanding Substance Abuse

TreatmentReducing HarmPreventionCutting Supply

Related Links

Community Recovery Project

The Substance Abuse and Mental Health Services Administration

Volunteer Here

COPYRIGHT HAMILTON COUNTY HEROIN COALITION Disclaimer - Site by Unstoppable Software

Overall reactions to this message are positive. While a bit startling and unsettling to some, after further discussion the majority agree that Inject Hope offers the most stopping power, and is a unique and memorable message. Making it the clear, winner across all messages- inject jumps off the page.Messaging Reactions | Overall Feedback

Respondents are somewhat polarized in their reaction to this message. While the majority like the intent, they feel it is difficult to read and understand. Others feel it is less powerful than Inject Hope but agree that it is more hopeful.Of the alternatives, participants prefer Choose because it is actionable. They also feel that it is more gentle than Inject. This makes it a good alternative for placing in family-friendly areas like schools or grocery stores. This message is liked the most, after Inject Hope.Majority feel that this is not the right message, and that Share is somewhat overused. Respondents relate this message to cancer research or breast cancer; of all the messages, it resonates the least with Heroin and is the least liked overall.Some respondents also referenced sharing drugs or needlesnot something we want to promote

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Treatment/Rehabilitation centerPreventionEarly interventionLaw enforcement/Cutting supplyRecovery support

Community IssuesHow the heroin issue is impacting Northern Kentucky ResidentsResidents are extremely concerned with this issue and feel that there is very little being done to help prevent or eliminate the problem. As a result, they feel somewhat hopeless due to the lack of solutions that are currently available. Others are upset or even aggravated by the lack of action related to heroin.Its a crisis that is so out of control.I think its more than just drug abuse. These people are medicating something. They are emotionally hurt They have a hole and are trying to fill it.I can see that there are mechanisms in place, I just dont see them working. Personal ResponseDespite high awareness, under half of residents in either Northern Kentucky or Hamilton County have taken any action in response to the growing community heroin problem. Common actions among responders include spreading awareness, pointing someone to rehabilitation, and reporting drug activity.

Spreading awareness through social media or speaking outEncouraging someone to enter arehabilitation centerReporting drug activityOffering recovery support

Kentucky is considered the heroin capital of the US.I have a friend who uses heroin. What you have to understand is that he isnt a bad guy, he has a great job. He just fell in with some bad people. He doesnt want to get out.You are not talking about low-lives. You are seeing business men usingThoughts & Feelings Related to HeroinThe most visible messages about heroin come by way of news media and seem to leave residents feeling hopeless about the problem and its severity. Northern Kentucky residents are particularly concerned about the rising death rate.Heroin Message OpportunityTreatment, prevention and early intervention are the top rated responses for effectively dealing with Northern Kentucky and Hamilton Countys heroin problems among residents. Over half also recognize the role of law enforcement and recovery support.

Community ResponseThe heroin problem in Northern Kentucky has high awareness and relevancy among residents. Hamilton County exhibits a similar, though slightly lower level of problem awareness.Heroin Awareness & ImpactNearly half of Northern Kentucky and Hamilton County residents have been directly impacted by heroin in some way.

One in five Northern Kentucky residents report losing a friend, family member, or coworker to heroin addiction.

Focus Groups:Three 90-minute groups were conducted in late October, 2015, among 18 Northern Kentucky residentsObjective: deep dive into current attitudes toward heroin addiction in Northern Kentucky, and test message appeal Quantitative Online Survey: A 15 minute online survey was conducted in early November, 2015 among 140 Northern Kentucky residents, and 65 Hamilton County residentsObjective: assess current community awareness and attitudes toward heroin addiction in Northern Kentucky prior to campaign launchResearch Summary

HELPLINE: No wrong door

Individuals and their families who face the challenges of addiction often have no idea where or how to get help for themselves or their loved ones. The typical addiction treatment community has many diverse organizations each providing assorted levels of care, accepting different types of payers, with their own eligibility requirements and enrollment procedures. Negotiating through this maze can be very complicated. Not knowing who to call, being told that they will be placed on a waiting list, or just having to maneuver through an automated answering service can cause a distressed individual seeking help to simply give up trying. Not getting the right kind of help quickly is particularly devastating for individuals with a Heroin addiction as heroin can be so deadly.

Calls answered 24/7 by an experienced and credentialed Addiction Services staff member

Clients can also contact RHAC through the internet or as a walk-in (there are 16 hours of open access time each week).

Credentialed staff person trained to address a variety of questions and issues that tend to fall into the following broad categories:

Frequently Asked QuestionsHelp Getting into TreatmentCrisis InterventionPlacements for treatment made in the best interest of the client taking into consideration the clients recommended:

level of carepayment options availability of services

Data are consistently collected to measure and monitor outcomes

Addiction Services Council uses an integrated electronic health record (EHR) to collect all client, service and billing data.

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Kenton Co Detention Center500 beds but typically house 650 inmates83% of state inmates have a history of drug use and 53% meet criteria for drug dependence or abuse.*Drug treatment program: 70 male beds, 30 female

* KYDOC Division of Substance Abuse Programing

Ongoing InitiativesHIDTA Approval for NKY DesignationAdditional treatment: County looking to build treatment facilitySt. Elizabeth partnership with SUN Behavioral Health and Betty Ford-Hazelden: 197 bedsFirst Step Home treatment model for pregnant addicted women

Thank you

Community Responses to HeroinNorth Carolinas Heroin/Clenbuterol Experience

Disclosure StatementScott Proescholdbell, MPH, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Nidhi Sachdeva, MPH, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Learning ObjectivesDescribe the problem of heroin mixed with clenbuterolExplain NC Injury and Violence Prevention Branchs (IVPB) communication protocol developed to respond to events that involve overdose

OverviewNC poisoning and overdose epidemicReported clenbuterol cases, Summer 2015Development of communication protocolIncreased collaboration between local health departments, PH preparedness and response, and State Bureau of InvestigationFuture/Next Steps

NCs Overdose Epidemic

36*Per 100,00, age-adjusted to the 2000 U.S. Standard Population - Transition from ICD-8 to ICD-9 Transition from ICD-9 to ICD-10

National Vital Statistics System, http://wonder.cdc.gov, multiple cause datasetSource: Death files, 1968-2014, CDC WONDERAnalysis by Injury Epidemiology and Surveillance UnitDeath Rates* for Three Selected Causes of Injury, North Carolina, 1968-2014

3636

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Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014 Analysis by Injury Epidemiology and Surveillance UnitMedication or drug overdose: X40-X44, X60-X64, Y10-Y14, X85Medication or Drug Overdose Deaths by IntentNorth Carolina Residents, 1999-2014

In North Carolina as in the United States as whole, deaths due to medication/drug overdoses have been steadily increasing since 1999, and the vast majority of these are unintentional.

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Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014Analysis by Injury Epidemiology and Surveillance Unit

Substances Contributing to Medication or Drug Overdose DeathsNorth Carolina Residents, 1999-2014

ANY mention. Counted once in each line, but can be counted in multiple lines.

The epidemic of med/drug overdose is mostly driven by prescription drugs, specifically prescription opioids. Over time, prescription opioids have contributed to an increasing number of medication/drug overdose deaths and contribute to more deaths each year than heroin and cocaine combined.

Side note: the number of medication/drug overdose deaths to which heroin contributed has increased from 2010 to 2012. Between 2011 and 2012, number of heroin related deaths more than doubled.

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NC Heroin Deaths: 2008-2015*Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2008- 2015**2015 data are provisional and likely increase as cases are finalizedAnalysis by Injury Epidemiology and Surveillance Unit

554% increase from 2010 to 2014

PLEASE KEEP IN MIND THAT 2014 data is provisional and will likely increase.

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Heroin Hosp. and ED Overdoses: 2008-2014Source: N.C. State Center for Health Statistics, Vital Statistics-Hospital Discharge 2008- 2013NC DETECT- Statewide ED Visit data, 2008-2014Analysis by Injury Epidemiology and Surveillance Unit

From 2010 to 2014 a 429% increasefor ED visits

SC

Recent Publications on Heroin Increases

PLEASE KEEP IN MIND THAT 2013 data is provisional and will likely increase.

Adulterated Heroin IncreasesMmwr-RI-6324

PLEASE KEEP IN MIND THAT 2013 data is provisional and will likely increase.

Heroin/Clenbuterol Cases Virginia March 201515 cases reportedCollaboration between state health, poison, health facility and law enforcementExchange of information and lessons learnedRecent presentations and pending publication

NC Heroin/clenbuterol

ClenbuterolA Beta-2-agonist, veterinary medication (horses)Side effectsTachycardia, palpitations, hypokalemia, hypotension, elevated lactate, metabolic acidosisDrug of abuse among athletesInexpensive, readily available (websites)

Heroin/ClenbuterolReports from the field mentioned both dealers diluting and dealers adding for euphoric effectRecently, IVPB connected with community usersMost mentioned that it was intentional and meant to mimic a speedball (cocaine/heroin)Users mention blue heroin in reports

Reports from UsersPerson 1

"I have been talking about this with a group of people. Scramble is a mix they have in the Baltimore area very different from this blue (seems to be synthetic) dope. I have a person working on finding out about this.....we think its a product of the deep web, more info as I get it."

Reports from UsersPerson 2

I actually talked to someoneabout this and I was saying that I didn't think it was actual dope (the blue stuff). It just wouldn't make sense...I'd think that'd stop people from buying it. I know that I wouldn't buy dope that was blue. Research chem makes sense. I thought research chem makers had had a hard time creating an opioid version over the years, but it does make sense that they'd eventually get there.

Reports from UsersPerson 3

In Baltimore there are two types of heroin: scramble and raw. Raw is hard rocks and is usually sold in tiny glass vials or by weight. Scramble is usually packed into gel caps (looks like a gel cap Advil, for example).

I've also never seen blue scramble. It's usually light, light brown or white.

I'd think that what the guy is talking about is a local issue and not a larger thing.

Reports from UsersPerson 3

Scramble is usually cut with all kinds of things. I hated it but some people love it because the rush is different - I always thought the rush sucked. I've never seen scramble down here or even in DC, but that doesn't mean it isn't. It wouldn't surprise me if people get sick off of it. It's seriously cut with whatever is around that may or may not have some sort of effect on the rush.

Reports from UsersPerson 4 Yeah, a bunch of my friends have started doing it recently. It feels like fentanyl but just keeps getting stronger and stronger. I dont know what the f**k it is but its heavy man... Like people are overdosing left and right. :/ I'll look into it, one of the big guys here in Wilmington is mainly selling it. I'll talk to her. Let you know more when I do!

NC Heroin/Clenbuterol Timeline, 2015

NC Heroin/Clenbuterol Cases

NC Health Alert Network (NC HAN)

NC Provider Letter/Alert

CDC Epi-X Alert

NC Heroin/Clenbuterol Cases by Date, 2015

Development of communications protocol

Development of Injury WarningIVPB had new role in responseIVPB thin bench and lack of response experienceMust coordinate with othersSeveral debriefings with key partnersCreation of Early Injury Warning systemIVPB staff added to NC HAN, Situation Report listsAsked to expand our role

NC Injury WarningCommunication Protocol

ActivationInvestigation/ MonitoringCommunication

Small Test, January-February 2016Carolinas Poison Control emailed 1/22/16 with reported possible new case in central NC (same facility as July)Within 24 hoursAll informal alerts were sentsit.report sent to senior leadership, affected areasMonitoring: No additional cases reported

NC Situation Report (Sit. Report)

Increasing collaboration between key stakeholders

North Carolina Injury and Violence Prevention Branch, Partners

Poisoning Death Study

Comprehensive Community Approach Chronic Pain Initiative

Opioid Death Task Force

Policy and Practice Research

North CarolinaPrevention and Harm ReductionDrug Take BackPrescription Drug

Substance Abuse

SAC Poisoning/Overdose Team Communication, Policy, and AdvocacyEnforcement SBI and Medical & Pharm Board

DPH, DMA, DMH/DD/SAS, ORH

Carolinas Poison Center

Monitoring Program

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PartnersNC Public Health Preparedness and ResponseState Bureau of Investigation (SBI) Information Sharing and Analysis Center (ISAAC)DPH Epi Section Communicable diseases, food borne diseases, etc.Clinical providers in ED (toxicologists)Expanded relationship with Carolinas Poison Center

Tracking & Monitoring

NC DETECT / ED Data Mandate GS 130A480 (a) For the purpose of ensuring the protection of the public health, the State Health Director shall develop a syndromic surveillance program for hospital emergency departments in order to detect and investigate public health threats that may result from (i) a terrorist incident using nuclear, biological, or chemical agents or (ii) an epidemic or infectious, communicable, or other disease.

The State Health Director shall maintain the confidentiality of the data reported pursuant to this section and shall ensure that adequate measures are taken to provide system security for all data and information. The State Health Director may share data with local health departments for public health purposes, and the local health departments are bound by the confidentiality provisions of this section. The State Health Director shall not allow information that it receives pursuant to this section to be used for commercial purposes and shall not release data except as authorized by other provisions of law.

*Effective 1/1/2005 *Law modified in 2007 to allow sharing of reported hospital ED data with CDC

NC DETECT Overdose Visits

Source: North Carolina NC DETECT

Access to NC DETECTNC DETECT web application access forLocal Health DepartmentsData Providers (Hospitals, EMS, Poison Center) Authorized users are able to view data fromEmergency DepartmentsCarolinas Poison CenterPre-hospital Medical Information System (PreMIS)Training webinars provided by DPH, NC DETECTDatasets shared with researchers after DUA and IRB approval

Hot Topics Dashboard

Click on a point to access line listing

Reach Back ModeWhen authorized, NC DPH can review medical recordsReach back mode been utilized in 2 overdose situationsTTP (Opana ER, IDU): 12 hospitalizations in TNHeroin/ClenbuterolUse of NC DETECT to find general heroin cases can then be retrospectively reviewed to see if there are other indications of adulteration (heart palpitations, X, Y, Z)OR during outbreak to potentially find additional cases meeting definition

Evaluation

Evaluation of ProtocolWhat triggers an activation?Who initiates first alert to activate the protocol?Who receives the notice?Most effective communication channel for each target population?How to best reach most at risk in shortest time?How much time does it take to go from first alert to a communication notice?

Evaluation of ProtocolBalancing potential public panic vs. responsibility to alert of injury dangersWhen to consider case closed?Expanding NC State Injury Prevention ProgramAlways prevention, increasingly reactive

NCs Next stepsCDC Prescription Drug Overdose (PDO) Prevention for States (PfS)

NC CSRS Utilization for public health surveillanceCommunity Interventions in high burden areasMobilization by local health departments and key partners, LE, substance abuse, healthcare facilities, providers/dispensersProfessional trainingPolicy EvaluationNC has passed several overdose specific laws (e.g. Good Samaritan/Naloxone Access) and other policy changes (e.g. ED policies, community outreach policies)This grant allows us to better understand the impact of these laws and policy changesRapid ResponseBased on the dynamic nature of epidemic, this strategy will be based on changes to the epidemic occurring in the state and will be in collaboration with CDC.For example, heroin combined with fentanyl has resulted in several outbreaks in other states

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For more informationScott Proescholdbell, MPHscott.proescholdbell@dhhs.nc.gov

Nidhi Sachdeva, MPHnidhi.sachdeva@dhhs.nc.gov

Injury and Violence Prevention BranchNC Division of Public Health

www.injuryfreenc.ncdhhs.gov | www.injuryfreenc.org

Community Responses to Heroin:North Carolina and Northern KentuckyPresenters:Kim Moser, Director, Northern Kentucky Office of Drug ControlScott Proescholdbell, MPH, Epidemiologist, Injury and Violence Prevention Branch, North Carolina Department of Health and Human ServicesNidhi Sachdeva, MPH, Injury Prevention Consultant, Division of Public Health, North Carolina Department of Health and Human ServicesHeroin TrackModerator: Kelly J. Clark, MD, MBA, FASAM, DFAPA, President-elect, American Society of Addiction Medicine, and Member, Rx and Heroin Summit National Advisory Board

First Contact(Phone, Internet, Walk-in)

Request for FAQs

Needs Help Getting into Treatment

Crisis

Answers Provided

Referral

Linkage

Assessment by Provider

Engagement & Support

Assessment

Placement

Follow-Up

Crisis Management

Chart136323410919146931912920153739713190633501114180755622110230848683142221990817146270104086514827010718571763621180941191471116293216565010718541774001222103416126112501014207290121599218139313061064203381

All intentsUnintentionalSelf-inflictedUndeterminedAssaultNumber of deaths1,064

Sheet1Column1All intentsUnintentionalSelf-inflictedUndeterminedAssault199936323410919120004693191292012001537397131902002633501114180200375562211023020048486831422212005990817146270200610408651482702007107185717636220081180941191471200911629321656502010107185417740020111222103416126120121250101420729020131215992181393based on county tables201413061064203381All intentsUnintentionalSelf-inflictedUndeterminedAssault199936323410919120004693191292012001537397131902002633501114180200375562211023020048486831422212005990817146270200610408651482702007107185717636220081180941191471200911629321656502010107185417740020111222103416126120121250101420729020131215992181393201412871052198361

Chart1120814123492412911044835114046440182525192125058930662642353577022485077619863770177757171443870918479651212149624175183684202246

Prescription OpioidCocaineHeroinNumber of deaths

Sheet1Column1Prescription OpioidCocaineHeroin1999120814120002349241200129110448200235114046200344018252200451921250200558930662200664235357200770224850200877619863200977017775201071714438201170918479201265121214920136241751832014684202246Prescription OpioidsHeroinCocaine1999120418120002344192200129148104200235146140200344052182200451950212200558962306200664257353200770250248200877663198200977075177201071738144201170979184201265114921220136241831752014709221252