Ohio, Kentucky and Indiana are seeing an increase in heroin use as pain clinics known as “pill mills” have begun to shut down, making prescription opiates more difficult to obtain. Ann Barnum, Senior Program Officer, Substance Use Disorders at The Health Foundation of Greater Cincinnati, says several communities in the Ohio River Valley are taking steps to fight opiate abuse.

According to Barnum, four people died every day of an opiate overdose in Ohio in 2010. Officials responded by cracking down on pill mills, the minimally regulated pain clinics that prescribed a tremendous number of prescription opiates. Barnum notes in rural Scioto County, Ohio, the 10 pain clinics along the banks of the Ohio River prescribed 35 million pain pills a year, equivalent to 460 pills for every man, woman and child in the county of 76,000 residents.

“We’ve been slammed by the prescription drug epidemic,” Barnum says. “Now that we’ve closed down pain clinics, people who used to use drugs such as OxyContin, Percocet or methadone that were prescribed for pain relief have turned to shooting or snorting heroin.” In Hamilton County, which includes Cincinnati, one person dies every other day from an unintentional drug overdose, she says.

“Some of them are young, and some are older adults who get a prescription for a narcotic and don’t understand their tolerance level, and don’t know they can’t use these pills with other medications, or mix them with alcohol.”

In the past several years, treatment programs in the area have seen a shift from predominantly cocaine, methamphetamine and alcohol, to heroin and prescription drugs, according to Barnum. “It’s only taken two or three years to go from 20 percent of clients being on heroin or prescription drugs to 80 percent,” she notes.

Treatment centers have begun responding to the shift by changing their programs. “Detox from heroin and prescription drugs is very different from detox from other drugs,” she states. “It’s become a necessity to use medication-assisted therapies.” Many patients addicted to heroin won’t stay in treatment without it, she adds. “In our area, many people have relied on abstinence methods, based on models that have been used for years, but they have never been as successful with heroin as they were for alcohol, cocaine or methamphetamine.”

The entire community needs to be concerned about treating opiate addiction because of the costs associated with heroin addiction, says Barnum. “There are increases in burglaries and purse snatching, and increased costs for the police and the criminal justice system.” In addition, communities must bear extremely high medical costs associated with heroin use, she points out. People using heroin are much more likely to contract hepatitis C, an inflammation of the inner lining of the heart chambers known as endocarditis, and other blood-borne illnesses.

In Portsmouth, Ohio, considered the center of the state’s opiate epidemic, practically everyone in the community has been personally affected in one way or another, Barnum observes. “They’ve been extremely motivated to do something about this,” she says. Residents have banded together to push for legislation to allow the closing of pain clinics. They have established needle exchange programs to reduce illness and infection from injection drug use, and have opened programs to distribute the opioid overdose antidote drug naloxone, through a program called Project DAWN. They have increased treatment capacity, and instituted screening, brief intervention and referral to treatment (SBIRT) to catch early cases of substance abuse and treat them. Clinicians are being trained in better ways to recognize and treat pain.

In Hamilton County, a women’s substance abuse treatment program has opened a maternal addiction program for pregnant women who are addicted to opiates. They are working with local hospitals and physicians to ensure that babies are healthier, the mothers receive treatment, and spending on neonatal intensive care decreases. Another agency is working to distribute naloxone to opiate-addicted clients who are leaving detoxification and intensive treatment services. These clients are significantly at risk for overdosing if they relapse.

“These communities are leading the way in telling the rest of us what needs to be done, and what barriers are in our way,” Barnum says. “We are developing responses that are driven by and accountable to our communities.”