Collaborating to Combat Heroin and Opioid Addiction In Arizona

Running Head: COLLABORATING TO COMBAT HEROIN & OPIOID ADDICTION

1

Collaborating to Combat Heroin and Opioid Addiction In Arizona

Jeff Carpenter

AD561M – Capstone Studies

Norwich University

COLLABORATING TO COMBAT HEROIN & OPIOID ADDICTION 2

Collaborating to Combat Heroin and Opioid Addiction in Arizona

Across the country in large cities, sprawling suburbs and rural towns, heroin and opioid

pill addiction are on the rise. According to the Substance Abuse and Mental Health Services

Administration’s annual survey, heroin use has more than doubled in less than a decade

(SAMHSA, 2014) and overdoses attributable to heroin and painkillers have increased by nearly

forty percent (Kounang, 2015). To put this in perspective in Arizona, more people are dying

after abusing drugs, including heroin and opioid painkillers, than are dying from motor vehicle

accidents (Marrow & O’Connor, 2015). To address this trend, several organizations and

communities have focused on reducing the supply of heroin and opioids while some have instead

advocated for tougher enforcement measures including mandatory sentences for simple

possession offenses. Still others have called for focusing on demand reduction efforts such as a

vigorous public awareness campaign or instituted harm reduction programs like needle

exchanges. While each of these measures is noble in intent, they are failing to adequately

address rising heroin and opioid addiction because they operate in isolation and do not seek to

leverage the strengths of others involved in the fight against heroin addiction. Instead,

effectively mitigating the rise in heroin and opioid addiction in Arizona can only be achieved

with a holistic, collaborative, community-wide campaign that reduces demand, increases

enforcement and incentivizes sobriety.

An Analysis of the Problem

In January 2014, Vermont Governor Peter Shumlin devoted his entire annual State of the

State address to what he called a “full-blown heroin crisis” in Vermont (Seelye, 2014). Later the

same year, Massachusetts Governor Deval Patrick unveiled a $20 million plan to expand services

for opioid addicts and develop a regional plan to combat heroin and pill addiction (MacQuarrie,


2014). In New York City, more people died from heroin overdose in 2013 than in any years

since 2003 (Goodman, 2014) and in Arizona’s urban and rural communities, heroin overdose

deaths have risen by more than ninety percent in the last ten years (Associated Press, 2014;

Walter Cronkite School, 2015). In fact, in 2009 drug overdose deaths outnumbered deaths due to

motor vehicle crashes for the first time and in deaths where a drug was specified, 60% were from

opioid analgesics (HHS, 2013). This increasing rate of overdose deaths combined with the an

overall increase in heroin and opioid use is causing alarm in state capitols around the country

while wreaking havoc in the lives of individuals, families and communities.

The Federal government's Substance Abuse and Mental Health Services Administration's

annual report reflects the rapid growth of heroin and opioid use in each of these states and it

reveals a steady increase annually in the number of heroin users. Those who admitted to using

heroin in the past more than doubled from 314,000 in 2003 to 681,000 in 2013 and aside from a

statistical anomaly in

2006 (SAMHSA, 2014,

p. 128), the estimated

number of heroin users

trended upward for the

entire decade. As

Figure 1 demonstrates,

the total number of

heroin users is still

much smaller compared

to other illicit drugs. However, the increasing rate of use dwarfs the others. It is also interesting

Figure 1 – Percent change since 2002 of people over 12 who have used the listed illicit drug and the total number of users (Elinson, 2013).


to note on the graph the change in the rate of pain relievers usage has remained relatively

unchanged, which has implications for heroin use as will be explored later in the paper.

So how does a drug previously thought to be confined to the inner city and used by

strung-out adult males make its way into suburban and rural neighborhoods, schools and

bathrooms? In short it happens by way of opioid1 pills: synthetic narcotic analgesic pills

prescribed for pain relief (I-SATE, n.d.). As detailed in a recent NY Times article, and often

heard by the author during interviews with heroin addicts, the progression from opioid pills to

heroin occurs when young men and women, often more affluent, begin using prescription opioid

pills such as OxyContin, Percoset, Vicodin and Demerol to get high and then shift to heroin

because it costs less and provides a more intense initial high (Goodman, 2014; ISATE, n.d.).

According to the U.S. Drug Enforcement Agency's Administrator Michele Leohnart, "Over 80

percent of the people who have started using heroin in the last several years started with

prescription drugs” (PERF, 2014, p. 6).

Not all opioid addictions begin with illicit use. Often addiction sets in after a person has

been using opioids legitimately prescribed for pain management. In the U.S. in 2009 there were

over 202 million opioid prescriptions written for chronic pain (Dr. Tory McJunkin, personal

communication, March 5, 2015) while the average amount of opioid per prescription increased

nearly 70% for Oxycodone and Hydrocodone (HHS, 2013, p.13). Given these variables it is

easy to understand how the number of patients becoming addicted to their pain medications has

increased. The problem is magnified when the prescription finally ends, and people turn to

1 The term “opioid” formally referred primarily to semi-synthetic or synthetic (e.g. man-made) opiates, however it is now more commonly used to refer to all opiates (I-SATE, n.d., NAABT, n.d.).


procuring pills illegally (Seelye, 2014). The pills become too expensive and so the person turns

to heroin (Goodman, 2014; HHS, 2015).

In addition to the cost in lives and livelihoods, there is a financial impact of opioid abuse.

The Coalition Against Insurance Fraud estimates "the abuse of opioid analgesics results in over $72

billion in medical costs alone each year" (as cited in U.S. Department of Health and Human Services,

2013, p. 5). Similarly, a study by Hansen, Oster, Edelsberg, Woody & Sullivan (2011) estimate the

cost of opioid abuse to “be between $53-$56 billion annually, accounting for medical and substance

abuse treatment costs, lost work productivity, and criminal justice costs” (as cited in U.S. Department

of Health and Human Services, 2013, p. 10).

To understand the lure of opioids, it is prudent to have a basic understanding of how they

work in the body. According to the National Institute on Drug Abuse (2014), “Opioids act by

attaching to specific proteins called opioid receptors, which are found in the brain, spinal cord,

gastrointestinal tract, and other organs in the body. When these drugs attach to their receptors,

they reduce the perception of pain”. Similarly, according to the University of Memphis’ Institute

for Substance Abuse Treatment Evaluation [I-SATE] (n.d.):

In the brain, heroin is converted to morphine and binds rapidly to opioid receptors. [It] is

particularly addictive because it enters the brain so rapidly. The rush of the drug is

usually accompanied by warm flushing of the skin, dry mouth, and a heavy feeling in the

extremities; this rush may or may not be accompanied by nausea, vomiting, and severe

itching. After the initial effects of heroin have faded, abusers will be drowsy for several

hours. Mental function is clouded by heroin's effect on the central nervous system. It also

slows cardiac function and breathing.


While there exists a large body of knowledge that more fully explains how and why opioids are

so addictive it is apparent from even this rudimentary explanation its hold on people is powerful

in large part because it is rooted in the brain's pleasure and reward chemistry (I-SATE, n.d.). It

is important for those attempting to address heroin addiction to familiarize themselves with these

characteristics in order to have an appreciation of the power of opioid addiction. It is also

reasonable to expect professionals engaged in the fight against the addiction to understand the

evolution of how a person goes from swallowing pills to injecting heroin.

For most addicts who start with opioids (prescription pills), they began by ingesting them

as prescribed – orally. To accelerate the high they either crush and snort the pills or they place

the pill on a small square of tin foil and by using a powerful lighter begin to melt the pill while

inhaling the vapors through a small straw through their nose (HEAR Coalition, personal

communication, May 28, 2014).

Once the person moves to heroin,

they will first use the heroin the

same way and inhale its vapors.

Many addicts who use heroin in

this manner state they would

“never inject heroin with a needle”,

unfortunately in the never-ending

cycle of trying to increase their

high and not get sick from

withdrawals, addicts then begin injecting heroin intravenously after heating it on a spoon (B.A.,

personal communication, June 2013; Perez, Dunnan, & Ford, 2014). Figure 2 highlights indicia

Figure 2 - 1. Brown powder heroin 2. Black tar heroin 3. Empty syringes used to inject heroin 4. Foil with burnt heroin residue 5. Spoon used to heat heroin to inject it (J. Carpenter personal communication, 2013).


of heroin use recovered by the author during the normal course of enforcement duties. While

such “street level” awareness is often unknown and unfamiliar to policy makers, academics and

elected officials it is an important reality for them to embrace if for no other reason than to

develop an appreciation for the downward spiral that leads young men and women to injecting

heroin intravenously. The reality of a young person dying from an overdose with a needle

sticking out of their arm should drive practitioners, policy makers, elected officials, and citizens

at large to address this problem that is eating away at communities across the country.

Implications of Divided Efforts

As heroin and opioid addiction has increased so has the number of private and public

organizations concerned with the problem. As a result, in communities across the country there

is no shortage of individuals and organizations working on the issue. These stakeholders include

law enforcement professionals, including police and probation officers, judges and attorneys,

medical professionals, substance abuse counselors, clergy and even addicts and their families.

What this disparate crowd has in common is they each touch some part of heroin and opioid

addiction. Unfortunately, until very recently what these stakeholders also had in common was a

lack of awareness of the others’ roles as Ritter and McDonald (2008) point out, “Experts in one

domain are not necessarily familiar with, nor aware of, the variety of drug policy responses in

other domains” (p. 15). Practitioners and policymakers often differ in how to combat heroin and

opioid addiction. These differences are often due to very different philosophies. A survey of

interventions aimed at addressing heroin and opioid addiction, and the philosophies that drive

them, reveals why current efforts are not sufficient to mitigate rising heroin addiction.


A Philosophy of Enforcement & Supply Reduction

Since President Nixon declared a war on drugs in 1971 U.S. drug policy has been heavy

on enforcement and supply reduction (Gryczynski et al., 2012; Nicholson, Duncan, White &

Watkins, 2012). Enforcement essentially entails treating all drug use as criminal in large part to

increase the risk for users, which then serves as a deterrent to buying or selling (Weatherburn,

Jones, Freeman & Makkai, 2002). Nicholson, Duncan, White and Watkins (2012) argue, “the

failure to differentiate use from abuse undermines prevention, treatment and the criminal justice

system” (p. 304). They then point to Sabol, Couture and Harrison’s (2007) estimate that more

than half of the 2.25 million incarcerated persons in America are in jails and prisons for mostly

small, non-violent drug offenses as proof that rigid and heavy-handed enforcement does more

harm than good (as cited in Nicholson, Duncan, White & Watkins, 2012, p. 305). Even senior

police executives who recently gathered to discuss the heroin epidemic commented on the

inability of an enforcement-centric policy to have lasting effects on the problem. These leaders

went so far as to state, “While police are still focusing on the major drug dealers and traffickers

of heroin for arrest and prosecution, what has changed is that they recognize that the users will

continue using if they don’t get treatment. Simply arresting them over and over again is not

working” (PERF, 2014, p. 2).

Still others point to a drug policy that seeks to reduce the drug supply as faulty. In

Australia, which has a similar sordid history with heroin, Weatherburn and Lind (1997) suggest

“supply-side drug law enforcement” should only be pursued if the cost to the community equates

to benefits (p. 567). They metrics such as a price increase in heroin, reduced consumption of the

drug among recreational users, a reduction in the rate of initiation into heroin, or a decreased rate

of users becoming addicted (p. 567). Using this logic and given the increasing rate of addiction


in the U.S., it is clear supply-side drug policies alone are not enough to prevent or mitigate

current heroin and opioid addiction.

A Philosophy of Demand Reduction

U.S. drug policy’s emphasis on enforcement has come at the expense of other approaches

to reducing heroin and opioid use, chiefly demand reduction and harm reduction (Nicholson,

Duncan, White & Watkins, 2012; Gottfredson, Kearley & Bushway, 2008). The United Nations

Drug Control Programme, the precursor to the current UN Office of Drug Control Policy

(UNODC) defined demand reduction as, “a broad term used for a range of policies and

programmes [sic], which seek a reduction of desire and of preparedness to obtain and use illegal

drugs” (UNDCP, 1997). This can be achieved through prevention and education programs, drug

substitution programs such as methadone and buprenorphine for heroin, court diversion

programs and other social welfare initiatives designed to address factors that often lead to

addiction such as homelessness and unemployment (UNDCP, 1997; Ritter & McDonald, 2008).

In other words, reducing demand for illicit drugs like opioids encompasses a wide array of

program and initiatives and includes treating those already addicted as well as preventing

initiation to illicit drugs altogether.

There is an abundance of literature supporting demand reduction as the sensible and

effective manner to reduce opioid addiction. These include focusing on drug abuse, not just use

(Nicholson et al., 2012); expanding “opioid agonist maintenance”, otherwise known as

methadone maintenance, for drug-dependent offenders (Gryczynksi et al., 2012); and

implementing a focused media campaign to inform the public of the dangers of opioids and

heroin like the former “This is your brain on drugs” commercials (Chief M. Frazier, personal

communication, March 5, 2015). Even with its many advocates, demand reduction alone cannot


currently mitigate heroin addiction for a number of reasons. Chief among the obstacles to

demand reduction is a lack of access to treatment resources, particularly in rural areas

(Gryczynski et al., 2012; Elinson, 2013); insurance providers paying for treatment

(Massachusetts Department of Public Health, 2014) and lack of treatment facilities altogether

(Seelye, 2015). Still, demand reduction must be a part of any plan to reduce opioid addiction in

spite of these obstacles.

A Philosophy of Harm Reduction

Another tenet of drug policy that has not been widely employed in addressing heroin

addiction in the United States is harm reduction. Harm reduction views people who are

dependent or addicted to illicit substances as “suffering from complex health problems” that are

exacerbated by other social issues such as unemployment or mental illnesses (Parent, 2009, p.

79) and view addiction writ large as a public health issue more so than a public safety concern

(Hedrich, Pirona & Wiessing, 2008; PERF, 2014). Conversely, law enforcement has

traditionally viewed drug addicts differently, particularly intravenous drug users (IDUs), as

Parent succinctly explains:

Within the realm of law enforcement, illicit injected drug users are typically viewed as

criminals engaging in a variety of crimes to support a habit of choice or dependency. The

standard approach of contemporary policing in dealing with illicit drug use in the

community is by way of law enforcement strategies that serve to reduce the supply of

drugs and demand for users. These strategies have a limited impact on habitual IDUs

who, while continuing to use and/or sell drugs, pose a danger to themselves, front-line

police officers and the community at large (p. 79).


It is not a surprise harm reduction has not been widely accepted in the U.S. given this bias by law

enforcement and a U.S. drug policy lending itself to enforcement in general. It is also important

to point out some practitioners classify some demand reduction measures as harm reduction and

vice-versa. For example, opioid substitution treatments (e.g. methadone maintenance) attempts

to reduce demand by decreasing heroin addicts’ desire for the drug (CITE), but such measures

also “reduce harm” by weaning addicts off street heroin with its varying purities and using

needles to using clinical doses in sanitary conditions.

In the U.S., only a handful of states and communities have embraced it as a major

strategy such as Vermont, Massachusetts, and Washington (Parent, 2009; Elinson, 2013; Seelye,

2015). These communities and states are generally viewed as being more socially progressive or

liberal on drug use in general (Renschler & Malatesta, 2001) as evident by Washington and

Colorado recently legalizing recreational marijuana, as compared to conservative Arizona where

possession of even a small amount of marijuana is a felony offense (A.R.S. §13-3405).

Harm reduction critics argue measures like needle exchanges and supervised injection

sites encourage illicit drug use (Parent, 2009). Research has shown just the opposite, that harm

reduction measures reduce the spread of infectious diseases (Parent, 2009), decrease crime

(Gottfredson, Kearley & Bushway, 2008) and reduce heroin deaths due to misuse (Hedrich,

Pirona & Wiessing, 2008; Nordt & Stohler, 2010). In Europe, Australia and Canada harm

reduction is as much a part of their approach to combat heroin addiction and its effects as

treatment (demand reduction) and enforcement (Hedrich, Pirona & Wiessing, 2008). Robert

Childs, Executive Director of the North Carolina Harm Reduction Coalition, offers reasonable

language on the need for harm reduction: “By accepting that not everyone is ready or able to

stop risky or illegal behavior, harm reduction focuses on promoting scientifically proven ways of


mitigating health risks associated with drug use and other high-risk behaviors” (PERF, 2014, p.

22). Unlike demand reduction, which attempts to decrease opioid use and initiation to heroin

altogether, harm reduction focuses on individuals already using heroin. This is also why harm

reduction will not singularly slow the rise of heroin addiction in the U.S. Even so, considering

its successes in other Western countries in mitigating heroin use and effects it would be prudent

for its inclusion in any plan to reduce the rise of heroin and opioid.

A Philosophy of Balanced Interventions Needed

It is evident there is an abundance of approaches to countering heroin and opioid

addiction. Ritter and McDonald (2008) call these “drug policy interventions”, which they define

as “any government, non-government, community or individual strategy, response or

intervention [they] expect to impact on drug use and drug harm” (p. 16). Focusing on heroin,

they classified 108 distinct drug policy interventions ranging from mass media campaigns,

school-based education programs, needle syringe programs, international treaties and

conventions, decriminalization and undercover operations (Ritter & McDonald, 2008). Some of

these interventions are complementary such as attempting to simultaneously reduce the drug

supply while working to reduce demand overall through specific interventions. Yet others can

be seen as being in direct opposition to one another like “zero tolerance policing” and

“decriminalization” or “tolerance zones” and “drug free zones” (Ritter & McDonald, 2008, pp.

18-23). Practitioners and policy-makers would be wise to understand this possibility and seek to

find a balanced approach while recognizing how their biases might impede progress in

combating heroin and opioid addiction.


Requirement to Collaborate

As demonstrated, in communities across the country there is a vast array of stakeholders

across multiple disciplines and dozens of drug interventions with varying approaches all working

to reduce rising heroin and opioid addiction. What is needed more than any program or

intervention is a concerted effort that marshals these efforts into a holistic, community-wide

campaign based on collaboration. Fortunately, policy-makers and practitioners are beginning to

share in the realization a new, collaborative approach must prevail. As the Chief Medical

Examiner in Washington, D.C., Dr. Roger Mitchell, recently pointed out during a gathering of

police executives from around the country, “We know that heroin use is not a purely law

enforcement problem; it has public health ramifications, and it crosses lines into education and

economics and housing” (PERF, 2014, p. 20). Even the chiefs of police are acknowledging that

while heroin use has a legal component, it is primarily a medical problem best handled by the

public health community and not public safety officials (PERF, p. 2). This shift in thinking hints

at an admission that U.S. drug policy towards heroin and opioids, in particular at the local level,

is not working. To change this, a community-wide campaign born from collaboration and

cooperation must have several attributes.

Holistic & Inclusive Collaboration

Any plan or campaign intended to mitigate heroin and opioid addiction must holistically

address the problem by incorporating an intelligent combination of interventions and approaches.

A plan that weights the importance of a particular approach or program over others will

invariably produce gaps that result in wasted resources, inefficient programs and lost

opportunities to affect the problem (Nicholson et al., 2012, p. 306). The campaign must also be

an integrated effort that ties together local efforts with state programs and Federal resources in


order to prevent gaps in service and maximize resources as Vermont is attempting to achieve

(Seelye, 2014; Kardish, 2015). This is particularly important in rural communities where a lack

of resources has seriously impeded heroin prevention and recovery efforts, but where

coordination with state programs could compensate (Elinson, 2013; Seelye, 2014).

An effective campaign to combat heroin also recognizes the need to be inclusive and

representational of all involved stakeholders. This is true even if they have very different

philosophies or approaches. For example the Collier County, Florida Sheriff's Office brings drug

treatment providers along when they serve a search warrant at a suspected drug house in order to

offer treatment to low-level offenders "when they are hitting bottom and are most likely to be

receptive" to the idea of getting clean (PERF, 2014, p. 27). This type of unique relationship

between a sheriff’s office focused on enforcement and treatment providers focused on reducing

demand and harm provides a shining example of inclusive drug policy that incorporates very

different drug intervention approaches.

Organized to Collaborate

Central to a community mitigating heroin and opioid addiction with lasting effects is

organizing for success, and that means rethinking who should spearhead the effort to combat

heroin addiction. As Chicago Police Superintendent Garry McCarthy put it, “Law enforcement

is a key partner, but public health must sit at the head of the table” (PERF, 2014, p. 32). This

change is critical. For communities and policy makers to truly mitigate and stem the rise of

heroin addiction they must shift their thinking away from “enforcement first”, which means

moving law enforcement into a supporting role (Nicholson, Duncan, White & Watkins, 2012;

Kardish, 2015). Massachusetts’s “Opioid Task Force” led by the state’s Public Health

Commissioner is a great example of putting public health at the head of the table and the


Governor’s declaration of heroin and opioid abuse as a public health emergency provided the

needed sense of urgency (MacQuarrie, 2014). Critics of such a change in thinking should be

reminded the status quo is no longer working or acceptable. Furthermore if police are saying,

“we cannot arrest our way out of this problem” it is time for some big changes in how

communities address the problem (Chief M. Frazier, personal communication, March 5, 2015).

A community-wide campaign that is holistic, inclusive and founded on collaboration between

stakeholders committed to combating heroin and opioid addiction is the best option to bring

about these needed changes.

A New Way to Address the Problem

The country’s heroin epidemic is worsening under current efforts to combat it. It is

therefore time for communities to learn from the shortcomings of previous attempts and through

collaboration create a robust and pragmatic campaign plan with three broad strategies – reduce

demand, increase enforcement and incentivize sobriety – that will in turn effectively mitigate the

rise of heroin and opioid addiction in Arizona. Each strategy has specific drug interventions or

tactics, intentionally selected to complement others so as to provide balanced effects and prevent

gaps in service and programming. Building on the research literature the campaign plan also

seeks to embrace lessons learned from interventions and tactics proven to be effective in treating

heroin addiction in other countries with similar qualities of life as well as incorporate some

recent best practices from other parts of the country. (See Appendix 1 for a list of the tactics.)

The setting for this specific campaign plan is the Phoenix-metropolitan area to both illustrate

how the plan might be applied and to provide the author with a realistic and actionable plan for

further implementation. Each strategy is listed below with an introduction followed by specific


tactics supported by discussion and a literature review to justify the inclusion of the tactic in the

campaign plan.

Strategy 1: Reduced Demand

Specific strategies, or interventions, intended to reduce demand for heroin and opioids

must occur at both “ends” of the addiction cycle: before a person has ever experimented with the

drug, or become “initiated”, and after a user has become addicted. On the front end reducing

demand takes the form of awareness and education. For the addict, demand reduction includes

specific measures to move the addict from using heroin illicitly by offering alternatives to using

and injecting heroin unsafely. These latter interventions look a lot like harm reduction measures.

For the sake of this campaign plan, harm reduction falls under demand reduction and is a vital

component of the campaign plan.

Tactic 1. Institute a vigorous public awareness campaign with a robust age-

appropriate social media component on the dangers of opioid experimentation and heroin

focused on high-school age adolescents. In 2013 the average age of a person who first uses

heroin was 24.5 years old (SAMHSA, 2014, p. 60), which means early high-school age

adolescents are the prime demographic to educate on the dangers of opioids and heroin. While

there are high school age students dependent and addicted it seems prudent to make them aware

of the dangers of opioids well ahead of the age they are most likely to face the choice to use or

not use opioids. Additionally, 68% of Millenials get their news from social media, so this media

strategy must focus its efforts there (Bennet, 2013). Furthermore, nearly 80% of 12 to 17-year

olds already perceive “great risk” in using heroin (SAMHSA, 2014, p. 71) therefore a public

education media blitz using social media will reinforce the dangers already perceived. The

January 2015 statewide airing of “Hooked: Tracking Heroin’s Hold on Arizona”, a wonderfully


produced documentary by Arizona State University’s School of Journalism, should also be

replayed in all public schools. Lastly, the media campaign should also aim to educate the

community at large on the dangers of keeping unused opioids in their residence and inform them

of where they can properly dispose of them.

Tactic 2. Reform pain management protocols statewide with stringent safeguards

for the most abused opioids and mandate providers and pharmacists utilize the Controlled

Substances Prescription Monitoring Program (PMP). In 2011, Arizona ranked 5th highest for

opioid prescription rates and 6th highest for prescription drug abuse with over 250 million

painkillers prescribed by providers (AZ State Board of Pharmacy, 2013; Hendricks, 2014). In a

state of six million residents, this is unacceptable. In 2013, the State Board of Pharmacy and the

Arizona Pharmacy Association issued new guidelines for dispensing controlled substances,

which contained six specific recommendations. The guidelines, however, are not binding and,

therefore, add only marginal value to the fight against opioid addiction. As part of this campaign

plan elected officials should enact legislation or policy mandating two of the recommendations,

specifically that pharmacists (and prescribing providers) must check the Arizona PMP prior to

dispensing controlled substances and pharmacists must require a government-issued

identification for all patients. Currently, the recommendations use the language "should" instead

of "must". As part of the legislation, there should be strict sanctions against any provider that

violates the protocols. As part of his emergency declaration, Massachusetts Governor Patrick

required physicians to register with his state’s PMP so Arizona leaders have a precedent should

they need one (MacQuarrie, 2014).

Tactic 3. Expand the availability of opioid substitution treatment (OST) and

increase access for low-income residents. There are two primary opioid substitution treatments


available to those addicted to heroin and opioid analgesic pills: methadone and buprenorphine

(NIDA, 2014). There is a third pharmacological treatment as well (naltrexone or “Vivitrol”), but

it is relatively new and its use limited (NIH, 2014). Methadone and buprenorphine (Subutex and

Suboxone) are very different medications and function very differently in the body, yet both

have been shown to be effective in reducing opioid addiction (Hedrich, Pirona & Wiessing,

2008; Gryczynski et al., 2012). An added public benefit from OST is the research shows it also

lowers income-generating crimes (e.g. theft, shoplifting, fraud) and drug-related crimes

(Löbmann & Verthein, 2008; Gottfredson, Kearley, & Bushway, 2008), which in turn lowers

public safety costs and increases a community’s quality of life.

If policy-makers and practitioners in Arizona truly want to combat the heroin epidemic

in the state, they must act to increase access to these treatments, including absorbing the cost for

those who cannot afford treatment. In the year following Governor Shumlin’s 2014 State of the

State address, Vermont increased spending 40% on drug addiction-related treatments (Kardish,

2015) and Massachusetts Governor Patrick’s proposal for more treatment options carried a $20

million dollar price tag (MacQuarrie, 2014). The cost of expanding OST options for addicts is

costly, but so is doing nothing. As for public opposition to expanded services for drug addicts

Renschler and Malatesta (2001) found "community action can reduce resistance to harm

reduction measures in local areas and increase acceptance of pragmatic action" (p. 478). What

can be considered more pragmatic than saving lives?

Strategy 2: Increased Enforcement

For too long enforcement has been the preferred focus area for U.S. drug policy at the

expense of other approaches and strategies (Nicholson et al., 2012). Any viable campaign to

reduce heroin and opioid addiction must include enforcement strategies; however, those


interventions must look different than they have in the past. As FBI Director James Comey

articulated, “We need to figure out how we can support all our state and local partners….We

can’t arrest our way out of this problem, but arrests, especially when focused on international

trafficking organizations, are a huge part of the solution” (PERF, 2014, p. 9). Increased

enforcement does not simply mean more arrests and prosecutions, but rather the right kind of

arrests and convictions. For example, heroin addicts who support their habit by dealing are not

major traffickers but instead engage in "subsistence dealing” (PERF, p. 25). These should not be

the targets of law enforcement efforts. Rather, law enforcement at all levels should focus efforts

on non-subsistence (i.e. high-volume) dealers and traffickers and the laws should be written so as

to provide them no quarter. Increased enforcement also equates to not prosecuting those who

call 911 in an overdose situation. The higher good in those situations is to save a life, not arrest

an addict.

Tactic 4. Rigorously prosecute non-subsistence dealers and traffickers. Initially, this

does not sound much different than current enforcement measures. However, there are two subtle

points to which this Tactic points. First, “non-subsistence” dealers must are defined as non-

violent heroin addicts who buy and sell to support their habit, not to create income. While some

law-enforcement officers may balk at this distinction, it is an important one. By focusing on

those profiting from illicit heroin and opioids law enforcement can apply resources previously

concerned with those simply trying to “score” their next “hit”. The one significant problem with

this Tactic is suspects often arrested for simple possession turn into “confidential informants” or

“CIs” who in turn lead investigators to the larger dealers and trafficking syndicates. Therefore, if

there are no simple possession charges, there is limited access to larger dealers and trafficking

networks.


Secondly, drug traffickers entering the southern U.S. border are by and large U.S. citizens

according to Center for Investigative Reporting, which is contrary to the perception they are

Mexican nationals (Hesson, 2013). As U.S. citizens, they cannot simply be incarcerated and

then deported upon the conclusion of their sentence as is often the case with foreign nationals

arrested. Instead, these arrested couriers and traffickers should have mandatory sentences that

are punitive and lengthy. However, with stricter sentencing law-makers should also revisit drug

possession thresholds for what is considered possession for sale should and then those standards

should be uniform across the southern U.S. border states to prevent one state from becoming a

more lucrative crossing point for traffickers.

Tactic 5. Investigate all overdose deaths and prosecute dealers whose products

contributed to overdose deaths. Law enforcement agencies, in conjunction with medical

personnel, should begin to earnestly investigate overdose deaths and attempt to identify the

supplier of the drugs in order to prosecute them to the fullest extent of the law with the

appropriate murder or manslaughter crime. While this does occur at times, it is not a matter of

standard operating procedure and often the county attorney is unlikely to charge anyone for the

crime (C. Boughey, personal communication, April 13, 2015). For example, the author's agency

considers overdose deaths as non-criminal incidents, and they are not routinely investigated other

than to rule out any foul play (J. Carpenter, personal experience, 2015). A dealer who provides

an illicit substance that results in the overdose death of an individual has vicarious liability in the

death of that subject and should be held accountable for it.

The other value of investigating drug-related overdoses is it provides both public health

and public safety officials (law enforcement and emergency medical services) keener insight into

drug-related trends that in turn allows for stakeholders to adjust their efforts. For example, in


January of this year in New Jersey there was a spike in overdose deaths resulting from heroin

laced with fentanyl, another strong narcotic, which caused the Drug Enforcement Agency to

publish a nationwide alert (Leger, 2015). For trends like these information and data-sharing

agreements between stakeholders are key and can help raise awareness and even prevent deaths

(PERF, 2014).

Tactic 6. Enact an Arizona “Good Samaritan” law, which shields a person against

prosecution who calls 911 in an overdose situation. As indicated earlier in this paper, overdose

deaths due to heroin and opioids continue to increase nationally, however in many of these cases

those who are with the victim never call 911 out of fear of prosecution for using or possessing

the same drugs (PERF, 2014; NCSL, 2015). To address this issue twenty-two states and the

District of Columbia have enacted “Good Samaritan” laws that “provide immunity from low-

level criminal offenses…when a person who is either experiencing an opiate-related overdose or

observing an overdose calls 911 for assistance or seeks medical attention for themselves or

another” (NCSL, 2015). Currently, no such law exists in Arizona. There is no good reason for

not having such a statute. The law can be constructed to prevent career criminals from escaping

prosecution and using the law to circumvent law enforcement actions such as calling during the

execution of search warrant (NCSL, 2015). At the end of the day, it is in the government’s best

interest to decrease drug-induced deaths and enactment of a “Good Samaritan” law helps to do

just that.

Strategy 3: Incentivize Sobriety

In addition to reducing demand and increasing enforcement, the third pillar of a

collaborative plan to mitigate and reduce heroin and opioid addiction is to incentivize sobriety.

According to the American Society of Addiction Medicine (2011), “Recovery from addiction is


best achieved through a combination of self-management, mutual support, and professional care

provided by trained and certified professionals” (ASAM, 2011). As many of the other strategies

discussed address mutual support and professional care this pillar attempts to match the internal

motivation of an addict to “get clean” with external best practices in order to maximize the odds

for the heroin addict to get sober. While relapses are expected in opioid addiction (Green, 2015)

most recovering addicts with whom the author has spoken attributes the final point to get clean to

various external factors ranging from incarceration to loss of family relationships to near-death

experiences (B.A., personal communication, 2015; ASU, 2015). These losses can be defined as

incentives to get clean and stay clean, and a holistic campaign plan seeks to address these

incentives with programs and initiatives proven to be effective.

Tactic 7. Mandate opioid substitution treatment (OST) for heroin and opioid users

incarcerated or on supervised release and lower their terms with acceptable OST progress.

A litany of research shows a strong correlation between substance abuse and criminal activity

including James (2002), who found “nearly 70% of jail inmates reported regular use of drugs in

the month prior to the offense for which they were currently incarcerated, and about 50%

reported using alcohol or drugs at the time of their offense” (as quoted in Kopak, Vartanian &

Hoffman, 2014). Additionally, Sabol, Couture and Harrison (2007) estimate more than half of

the 2.25 million incarcerated persons in America are in jails and prisons for mostly small, non-

violent drug offenses (as cited in Nicholson, Duncan, White & Watkins, 2012, p. 305). When

these individuals complete their sentences or some portion of the sentence, they are frequently

released on some form of supervised release (e.g. parole) during which they are expected to

refrain from illicit drug use. To verify compliance they are often required to submit to drug

testing via occasional urinalysis for controlled substances.


Instead of simply expecting probationers to refrain from illicit drug use out of fear of

sanctions, it would make for even better policy if they were required to participate in opioid

substitution treatment such as methadone and buprenorphine, which research has demonstrated

“that probationers enrolled in opioid agonist maintenance reported marked reductions in heroin

use, cocaine use, and income generating criminal activity over time, consistent with the

established body of evidence supporting the effectiveness of such treatment” (Gryczynski et al.,

2012, p. 36). If policymakers and community leaders are serious about wanting to reduce

recidivism among opioid and heroin users, they would heed the research and mandate opioid

substitution treatment for those formerly addicted to the drug. Such a policy would increase the

likelihood of convicted users successfully integrating back into society, improve the

community’s quality of life by reducing crime and freeing up law enforcement and emergency

medical resources for other endeavors.

Tactic 8. Enhance pre-charging diversion programs for non-violent, simple

possession arrests with additional transition resources. Currently in Arizona’s most populous

county, Maricopa County, when a person is arrested only for possession of a usable quantity of

heroin or opioid pills (a.k.a. “simple possession”) and they meet certain criteria (e.g. no prior

serious or dangerous convictions, limited number of previous convictions for similar charges, not

on felony probation, etc.) they are eligible for an alternative to prosecution (TASC, 2015; S.

Pokrass, personal communication, April 13, 2015). If the person has no criminal history they are

offered the program before the charges are ever filed (“pre-file”) and once the program is

completed, the incident does not appear on the defendant’s criminal history (S. Pokrass, personal

communication, April 13, 2015). If the subject has previous criminal drug use history they can

be offered a true diversion program in that prosecution is suspended for the defendant to


participate in the program, which in Maricopa County is known as “Treatment Assessment

Screening Center" or "TASC" (TASC, 2015: S. Pokrass, personal communication, April 13,

2015). If they complete the program their record shows the charges are dismissed "with

prejudice" and it will appear in their criminal history. In both cases, if the person does not

complete the terms of the diversion program the charges are reinstated, and the subject will

normally end up on probation or incarcerated.

While these diversion programs are certainly a step in the right direction they do can

more to reduce recidivism and decrease heroin addiction by offering substantive transition

services for addicts who seek treatment and show acceptable progress (PERF, 2014; Green,

2015). Seattle’s “Law Enforcement Assisted Diversion (LEAD) program" is an example of this

new approach, and though it is a pilot program it is showing some marked successes (Green,

2015). If a person is found be in possession of heroin and they meet additional criteria (less than

three grams of the drug, no violent felony convictions, not involved in promoting prostitution or

"exploiting minors in a drug-dealing enterprise") they are handed off to non-law enforcement

personnel and not even charged with the crime unless they do not complete the terms to get

clean, with LEAD assistance, or they commit new crimes (PERF, 2014; Green, 2015). This type

of diversion program achieves for what Parent (2009) advocates when he wrote, “police leaders

and managers need to operationalize the concept of harm reduction in the policies and

procedures of the police agency” (p. 80). The most significant difference in LEAD and what

currently takes place in Maricopa County is the former “cuts out the criminal-justice system”,

seeks to immediately stabilize the person with food and shelter and then assess them and

transition them to longer-term services for drug treatment, housing and even job training (Green,

2015). It should be noted Seattle’s pilot run of the program was paid for through private


foundation (PERF, 2014, p. 24) even as it expands and local governments begin to put public

money into it now that its successes have become apparent (Green, 2015).

Tactic 9. Encourage public-private partnerships in the fight against heroin and

opioid addiction to include increased grant funding to reinforce successful treatment

programs and initiatives. Many of the strategies already discussed rely on the state and local

governments taking aggressive actions to stem the rise of heroin addiction. They are needed

steps; however the government cannot alone solve this problem. There is a host of private

organizations already hard at work and any campaign plan to mitigate heroin addiction must

encourage partnerships between them and government agencies. This includes faith-based

programs proven successful in treating addiction as well as the faith community at large as it can

bring to bear enormous resources in the form of volunteers, substance abuse counseling, facilities

for meetings and awareness. Additionally, private foundations like those that funded Seattle’s

LEAD program must be engaged and encouraged to support innovative programs that reduce

demand, increase enforcement or incentivize sobriety.

One of the most impactful ways local and state government can encourage these partnerships

is to provide funding via grants or contracted services for those programs and initiatives with a

proven record of impacting the heroin problem. In Arizona, one of the most successful addiction

recovery programs is the faith-based Teen Challenge and Jewish Family Services provides

contracted social services throughout metropolitan Phoenix (J. Carpenter, personal experience,

2014). While some organizations, like Teen Challenge, often choose to operate by way of

fundraising exclusively there are other ways public entities can partner with private and faith-

based organizations. For example, one of the greatest needs for recovering heroin addicts is a

mentor or sponsor who has been through recovery themselves and who can encourage and hold


accountable the newly recovering heroin user (G. Cappelletti, personal communication, May 28,

2014). Grants to private treatment organizations that have recurring staff or facility costs could

reduce fundraising needs and allow the organizations to focus on their work. Other programs are

run strictly by volunteers, such Parents of Addicted Loves Ones (PALS) and Narcotics

Anonymous (NA), so funding may not be needed as much as collaboration and inclusion in

policy discussions.

Final Touches: Funding & Organization

In addition to government grant funding and private foundations, the initiatives and policy

changes called for in this campaign plan require funding to implement and become effective.

This is particularly true in Arizona given the Governor’s recent budget proposal cut social

service spending considerably (Hansen & Sanchez, 2015). To offset the expenses of the

increased social services and programs of this campaign plan, policy makers should divert a

percentage of all asset forfeitures seized under the state Racketeering Influenced and Corrupt

Organizations (RICO) Act (A.R.S. § 13-2314) to the appropriate government agency charged

with administering funds to combat heroin and opioid addiction. Currently, assets seized under

the state’s RICO Act are split between the respective County Attorney’s office and the law

enforcement agency conducting the investigation (Hensley, 2009). These funds can then be used

to pay for non-recurring law enforcement expenses such as new equipment and training (D.

Head, personal communication, July 2014). At the conclusion of the state's 2014 fiscal year, the

state’s cumulative forfeited monies account was more than $90 million dollars according to the

Arizona Criminal Justice Commission's quarterly RICO Report (2015). This is an over-

simplification of the asset forfeiture process for sure, however even if ten percent of the seized


funds were reallocated to the strategies in this plan the state would have sizeable resources to put

towards a decline in heroin and opioid addictions and deaths.

In addition to creatively funding this plan, there must be some new thinking on how to

marshal the stakeholders into a coherent and efficacious entity. In Arizona this means the

Department of Health Services must lead the efforts to address heroin and opioid addiction,

however with the support of the Legislature, the Governor should create a new statewide task

force with regional presence. The task force must exhibit wise leadership, sound stewardship,

and inclusive participation. It will recommend policy and legislative changes, facilitate

communication between stakeholders, assess grant and funding applications, and serve as a

trusted agent by stakeholders, public and private, by bringing coherence and unity of effort to the

fight against heroin and opioid addiction. This task force would include representation from the

law enforcement community, courts and judicial staff, educators, treatment providers, medical

professionals, the faith community, and even former addicts and family members. The

organization would not necessarily be an enduring organization and it would have a limited

charter, but it would be the first time the state has attempted to organize a community-wide,

holistic, collaborative effort to implement a detailed plan to mitigate heroin and opioid addiction.

Conclusion

The heroin and opioid pill epidemic in Arizona and across the country is not getting

better on its own. The number of young adults experimenting with opioid pills is growing, the

rate of initiation to heroin is increasing and the number of overdose deaths due to both is

climbing (SAMHSA, 2014). Even so, there are a number of public and private organizations

committed to the fight, and they are making some measurable gains in raising awareness and

treating individuals' addictions. Unfortunately efforts to combat this evolving scourge remain


fragmented due to conflicting philosophies about how to go about addressing the problem. This

has resulted in a lack cohesion and purpose in the collective fight. To truly mitigate and reduce

the effects of heroin and opioids in Arizona, a new plan based on collaboration and community

should be implemented.

The plan laid out in this paper seeks to overcome conflicting philosophies and previous

shortcomings in the fight against heroin by embracing drug interventions proven most effective

elsewhere and integrating them with sensible policy changes to address gaps in Arizona’s

collective efforts to combat heroin and opioid abuse. Specifically, the plan’s nine detailed tactics

provide applicable, practical steps for policy makers to implement along with the

recommendation of a new statewide task force chartered to serve as the focal point for this new

initiative and creatively funded with no impact on the state’s reduced budget. By focusing on

interventions and tactics aimed at the three discussed strategies of reduced demand, increased

enforcement and incentivized sobriety this plan can have a significant impact on Arizona’s

accelerating heroin and opioid problem because the status quo is simply not acceptable.


Appendix 1

Tactic 1. Institute a vigorous public awareness campaign with a robust age-appropriate social

media component on the dangers of opioid experimentation and heroin focused on high-

school age adolescents.

Tactic 2. Reform pain management protocols statewide with stringent safeguards for the most

abused opioids and mandate providers and pharmacists utilize the Controlled Substances

Prescription Monitoring Program (PMP).

Tactic 3. Expand the availability of opioid substitution treatment (OST) and increase access for

low-income residents.

Tactic 4. Rigorously prosecute non-subsistence dealers and traffickers.

Tactic 5. Investigate all overdose deaths and prosecute dealers whose products contributed to

overdose deaths.

Tactic 6. Enact an Arizona “Good Samaritan” law, which shields a person against prosecution

who calls 911 in an overdose situation.

Tactic 7. Mandate opioid substitution treatment (OST) for heroin and opioid users incarcerated

or on supervised release and lower their terms with acceptable OST progress.

Tactic 8. Enhance pre-charging diversion programs for non-violent, simple possession arrests

with additional transition resources.

Tactic 9. Encourage public-private partnerships in the fight against heroin and opioid addiction

to include increased grant funding to reinforce successful treatment programs and

initiatives.


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Collaborating to Combat Heroin and Opioid Addiction In Arizona

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