Drug Addiction (Discarded syringe in Austin, Indiana [Photo: Christopher Frye, News and Tribune]) Prepared for the Amanda Qualls Campaign April Sellers Summer 2020 1 Table of Contents Drug Addiction: A Summary 3 The Extent of the Problem 4 A New Approach 6 Legislative Action in Indiana 10 Recently Passed Legislation 11 Recently Failed Legislation 15 Legislative Action in Other States 18 Alaska 18 Ohio 18 California 19 Washington 19 Relevant Advocacy Groups 19 2 Drug Addiction: A Summary n early 2015, the city of Austin, Indiana experienced the worst HIV outbreak in the state's history (and one of the worst in the history of the United States), driven by the Isharing of contaminated needles by intravenous drug users. The episode drew national attention to the state's problem of opioid abuse within the state and to its hardline drug policies.1 Despite a high rate of drug abuse, there was no drug rehabilitation facility in Austin.2 Needle exchange programs, which public health experts believed were necessary to contain the outbreak, were prohibited by state law. Owing to his moral opposition to drug use, then-Governor Mike Pence initially resisted calls to lift the ban.3 Only after a weeks-long pressure campaign by local, state, and federal health officials, and the urging of the Scott County sheriff — and two months after the outbreak was detected — did Pence finally issue an emergency executive order allowing a lifting of the ban, albeit short-term and limited to Scott County, where Austin is located.4 Opioid addiction was not the only problem facing the state. Among people seeking treatment for substance abuse in the state between 2005 and 2014, admissions for the use of methamphetamine increased by 66 percent.5 In just the year prior to the Austin outbreak, Indiana was the state with the most meth lab seizures, contributing to 16 percent of the nation's total.6 1 See Kaplan, Sarah. (2015, March 26). Indiana is battling the worst HIV outbreak in its history. Washington Post. https://www.washingtonpost.com/news/morning-mix/wp/2015/03/26/ indiana-is-battling-the-worst-hiv-epidemic-in-state-history/; Goodnough, Abby. (2015, May 5). Rural Indiana Struggles to Contend with H.I.V. Outbreak. New York Times. https://www.nytimes.com/ 2015/05/06/us/rural-indiana-struggles-to-contend-with-hiv-outbreak.html 2 Tribune Wire Reports. (2015, March 25). HIV outbreak in southern Indiana worst in state's history. Chicago Tribune. https://www.chicagotribune.com/suburbs/lake-county-news-sun/chi- rampant-drug-abuse-blamed-for-hiv-spike-in-southern-indiana-20150325-story.html 3 Twohey, Megan. (2016, August 7). Mike Pence's Response to H.I.V. Outbreak: Prayer, Then a Change of Heart. The New York Times. https://www.nytimes.com/2016/08/08/us/politics/mike-pence- needle-exchanges-indiana.html 4 Twohey, Megan. Mike Pence's Response to H.I.V. Outbreak: Prayer, Then a Change of Heart. 5 Indiana University-Purdue University Indianapolis Center for Health Policy. Substance Abuse Trends in Indiana: A 10-Year Perspective. (2017, April). Indiana University-Purdue University Indianapolis. https://pdfs.semanticscholar.org/e81f/ b6f3ad4ba58ec869c11bf55a31ec176a801a.pdf 6 IUPUI Center for Health Policy. Substance Abuse Trends in Indiana: A 10-Year Perspective. 3 Source: IUPUI Center for Health Policy. Substance Abuse Trends in Indiana: A 10-Year Perspective. Elkhart County was no passive bystander to this epidemic: in 2011, the county ranked second in the state for meth labs seized, with 71 such seizures.7 An estimated three-quarters of the inmates at the county correctional facility were there for crimes directly or indirectly related to drugs, usually meth.8 The Extent of the Problem Among the most commonly abused illicit substances in Indiana are opioids (prescription pain relievers and heroin), methamphetamine, and cocaine.9 The substances are procured in a number of different ways. Most individuals who abuse prescription opioids receive them from a friend or relative,10 and they are not difficult to come by: in 7 Elkhart County ranked second in state for meth labs seized. (2012, June 1). The Goshen News. https:// www.goshennews.com/news/elkhart-county-ranked-second-in-state-for-meth-labs-seized/ article_5bd0bfd0-58c3-5eda-82a9-4d5e873517c7.html 8 Huus, Kari. (2009, December 3). Amid recession, meth menace evolves. NBC News. http:// www.nbcnews.com/id/34227273/ns/us_news-the_elkhart_project/t/amid-recession-meth- menace-evolves/#.XzMV4hNKgUs 9 IUPUI Center for Health Policy. Substance Abuse Trends in Indiana: A 10-Year Perspective. 10 IUPUI Center for Health Policy. Substance Abuse Trends in Indiana: A 10-Year Perspective. 4 2018, health care providers "wrote 65.8 opioid prescriptions for every 100 persons, compared to the average U.S. rate of 51.4 prescriptions."11 Methamphetamine is manufactured illegally in clandestine labs12 and, increasingly, being imported from outside the U.S.13 In addition to criminal prosecution, users face an increased risk of contracting certain infections. Intravenous drug use, such as with heroin, cocaine, or meth, increases one's chances of contracting HIV/AIDS, hepatitis B, and hepatitis C through needle sharing and a concomitant increase in the likelihood of engaging in risky sexual behaviors.14 Of the 516 new HIV diagnoses in Indiana in 2017, injection drug use contributed to 10.2 percent of new diagnoses in men and 16 percent of such diagnoses in women.15 Unsurprisingly, the scourge of drug abuse has been costly: according to an analysis published in 2015, opioid abuse cost the state over $650 million in health care costs.16 Speaking to NBC News in 2009, then Elkhart County Sheriff Mike Books stated that the county had a $2 million annual budget for providing health care to housed offenders, and that drug abusers, especially meth uses, quickly ate through the budget, due to mouths "full of corroded teeth, which can cost $12,000 in dental care alone," and "treatment for everything from withdrawal and skin lesions to kidney damage."17 Emergency departments across the state reported 17,311 visits due to drug usage in 2018, including 394 in Elkhart County.18 11 National Institute on Drug Abuse. (2020, April 3). Indiana: Opioid-Involved Deaths and Related Harms. https://www.drugabuse.gov/drug-topics/opioids/opioid-summaries-by-state/indiana- opioid-involved-deaths-related-harms 12 IUPUI Center for Health Policy. Substance Abuse Trends in Indiana: A 10-Year Perspective. 13 Rudavsky, Shari. (2019, September 5). Meth, once the drug scourge of Indiana, is back but in a new and deadlier way. IndyStar. https://www.indystar.com/story/news/health/2019/09/05/resurgence- methamphetamine-meth-stimulant-epidemic-drugs-opioids-cocaine-poly-substance-use/ 2060449001/ 14 IUPUI Center for Health Policy. Substance Abuse Trends in Indiana: A 10-Year Perspective. 15 National Institute on Drug Abuse. Indiana: Opioid-Involved Deaths and Related Harms. 16 IUPUI Center for Health Policy. Substance Abuse Trends in Indiana: A 10-Year Perspective. 17 Huus, Kari. Amid recession, meth menace evolves. 18 Indiana Drug Overdose Dashboard [data set]. (2020, July 16). Indiana State Department of Health. https://www.in.gov/isdh/27393.htm 5 In addition to the monetary cost, there is the human cost. In 2016, over 150 children were removed from homes in Indiana containing meth labs.19 And, of course, there are the overdose deaths, which number in the thousands each year. One thousand two hundred forty-five Hoosiers died from drug overdoses in the same year as the Austin outbreak.20 Two years later, that number climbed to 1,852 — an increase of nearly 50 percent;21 thirty-seven of those deaths were in Elkhart County, representing an increase of 60.9 percent over figures from 2016. A New Approach Indiana's 51st governor, Eric Holcomb, took office in January 2017. Although he had served as Pence's Lieutenant Governor, Holcomb voiced support for expanding needle-exchange programs, indicating that his approach to the drug epidemic would differ from that of his predecessor. Within hours of his inauguration, Holcomb signed an executive order creating a cabinet-level position to combat the state's drug problem "with a comprehensive, community-based approach" relying on drug prevention, treatment, and enforcement.22 He unveiled his "Next Level Agenda," proposing increases in funding for residential treatment and recovery, as well as the creation of mobile intervention teams, and announced that Indiana was "implementing technology statewide that will provide medical professionals access to patients' opioid prescription history far more quickly."23 That spring, Holcomb had begun implementing his agenda by signing into law a number of bills, including those that allowed municipalities to establish needle exchange programs without state approval,24 created a plan to house and treat homeless Hoosiers with drug addiction and/or mental illness,25 and ordered the development of a plan to 19 IUPUI Center for Health Policy. Substance Abuse Trends in Indiana: A 10-Year Perspective. 20 IUPUI Center for Health Policy. Substance Abuse Trends in Indiana: A 10-Year Perspective. 21 Indiana Drug Overdose Dashboard [data set]. 22 Holcomb, Eric. (2017, September 30). Why I am focusing on the opioid crisis. IndyStar. https:// www.indystar.com/story/news/2017/09/30/gov-holcomb-opioid-opioids-opioid-addiction- opioid-epidemic-opioid-withdrawal-opioid-overdose-pain-p/716337001/ 23 Holcomb, Eric. Why I am focusing on the opioid crisis. 24 Public Law 198-2017 (House Enrolled Act No. 1438). 25 Public