DEA 360 Baltimore:An Intelligence Assessment

2013, Week 47:The Arrival of our Deadliest Drug Epidemic Ever

Imagine if, Everyday, a Plane Fell From the Sky

197 deaths ' per day in the

United States '

' 72,000 deaths- 2017 - CDC

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' • •

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1990’s – Big Pharm & the 5th Vital Sign

2010 - Rapid Increase in Heroin Deaths

Mid 2013 - Fentanyl

How We Got Into This Mess

U.S. Prescription PracticesStarting Addictions that Progress to Heroin Use

4/55% / 80% / 99% /30X

Ankle Sprains?92%; 10%

Foreign Policy, Dec 2018Kathleen E. McLaughlin

Opinion: "China Killed Prince"???

• Fentanyl - Deadliest Export

• Fueled Unprecedented OD's

• U.S. Life Expectancy Lower

8

Fast Forward from Toluca& the Cyber-underworld

160,000

Vast Chemical and Pharmaceutical industries - combined with lax regulation, low production costs, and government corruption

The Pipeline Meets a Changing Drug Supply

• Cheaper, More Potent Drugs are Readily Available ...

• While More Treatment is Not

Time for a Seismic Shift

Tough on Crime? Or, Smart on Crime!

It's a Treatable Brain Disease!

Barriers to Substance Use Disorder Treatment

• Only 10% Get Specialty Addiction Treatment

• Treatment Options Don't Exist ...

• OR, If they Do Exist, are Unaffordable ... Or

• Have Long Waiting Periods

Heroin: A Plant Based OpioidSource Regions

Heroin Markets

Heroin+: Sinoloa Cartel

Ivan Guzman

Alfredo Guzman

Ismael Zambada

The Synthetic Storm: CJNG

Fentanyl is Now an Adulterant Found in Many Recreational Drugs!Nemesio Oseguera

Fear of Adulteration Has Never Been Greater Case in Point: Cocaine

Counterfeit RxModern-Day Russian Roulette

Counterfeit RxModern-Day Russian Roulette, Part 2

Street EconomicsIn 3 Easy Lessons

2 Pills= $160vs

4 Caps=$40

H= 3-4xvs

F= 16-24x

1 kg H= $25k to 60k+

vs1 kg F=

$4,000 to $60K

Mexican Trampoline & Narco-Superhighways"Los Cincos"; "Los Dos Laredos"; "Traps, Mules & Ants"

"Diablito","Comida China", "Fire", "Got Nyl?"

31 - 10 Operation Fountainhead

Heroin Mill & Tabletop:Baltimore Style

Street Ready

What Really Hurts the Cartels

• Law Enforcement– It’s a Crime Scene Too– Protect the Scene, but also

Yourself– Next 3 Logical Steps– Use Opioids? Treatment

Works & Recovery is Possible• Public Health

– Continuing Med Ed Creds &Rounds

– Crisis Intervention Teams– Take-Down Protocol

• Community & Schools• Mapping

BRMLE, PH & Community Collaboration + Best Practices

Situational AwarenessMapping - An Award Winning Best Practice

The 2015 Baker Public Health Impact Award Winner:

Making a difference in an epidemic of fentanyl deaths in Maryland - Geographic Information System (GIS) and Collaboration with the DEA

Ok! So Now We're More Aware. What's Next?Better prevention, treatment & recovery servicesBetter data on the epidemicBetter pain management

Better targeting of overdose-reversing drugs

Better research on pain and addiction

Scheduling: a CollaborationOperation Mike & Mike?

DEA SFL-1 Mike at DEA HQ

OCME in Baltimore DEA Baltimore Mike at US Embassy Beijing

Best Practices

Use PDMP

Remove Effective Treatment BarriersBuprenorphine / Methadone

Discuss Risks & Benefits with Patients

Follow Best PracticesScreen for Substance Abuse / Mental Health IssuesPrescribe Lowest Effective Dose

What Can Doc's Do?

TURN

THE

TIDE,!' PRESCRIBING OPIOIDS

FOR CHRONIC PAIN

ADAPTED FROM CDC GUIDELINE 00 Opioids can provide short-term benefits for moderate to severe pain. Scientific evidence is lacking for the benefits to treat chronic pain.

IN GENERAL, DD NOT PRESCRIBE OPIOIDS AS THE FIRST-LINE TREATMENT FOR CHRONIC PAIN (for adults 18+ with chronic pain> 3 months excluding active cancer, palliative, or end-of-life care).

Best Practices

How will my pain be managed before, during and aftersurgery/injury?

How much discomfort is usually associated with thisprocedure/injury?

What non-narcotic pain control options do I have?What side effects can I expect?How will I manage long-term pain?

What Can Consumers Do?

The 6 Key IndicatorsWhat Can Your State Do?

Lagging Behind, But ImprovingMaryland's Report Card

The Courage to Changevs Too Big to ail

Veterans AdministrationBaltimore, MD"Opioid Decision Taper Tool"

FDA"Rationalized Prescribing"

Johns Hopkins HospitalBaltimore, MD"20 Common Operations"

Sinai HospitalBaltimore, MD"Local Anesthetics & Nerve Blocks"

• MAPPA’s 20 Years of Prevention Partnering

• Run In My Shoes

• U of MD & Yale re: Buprenorphine in ER

• Maryland’s PDMP is now Mandatory

• Peer Recovery Specialists

• Drug Treatment Court

More Good Things

Questions?

Structure BookmarksFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigure