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062717a Agenda Package
062717 HC BOC Page 1 9:00 am 9:15 am 9:45 am 10 :15 am 10:30 am 11:00 am Harnett County Board of Commissioners Work Session Tuesday, June 27, 2017 Campbell Agreement, Amanda Bader Incentive Guidelines, Debbie Taylor Opioid Forum Discussion County Manager's Report: Motto Placement Closed session Adjourn 062717 HC BOC Page 2 DRAFT NORTH CAROLINA HARNED COUNTY AMENDMENT OF REIMBURSEMENT AGREEMENT THIS AMENDMENT OF REIMBURSEMENT AGREEMENT (the "Amendment"), entered into this __ day of , 2017 , by and between Campbell University, Incorporated , a North Carolina Nonprofit Corporation with its principal place of business in Buies Creek, North Carolina , (hereinafter referred to as "Campbell "), and the County of Harnett, a body politic organized and existing under the laws of the State of North Carolina , with its principal place of business in the Town of Lillington , North Carolina (hereinafter referred to as "Harnett County "); THAT WHEREAS , the parties entered into a REIMBURSEMENT AGREEMENT (the "Agreement") on May 7 , 2012 , to assist in the more efficient flow of traffic in the vicinity of the Campbell University School of Osteopathic Medicine ("CUSOM "); AND THAT WHEREAS , Harnett County has received a grant in the form of a Locally Administered Project-State Contingency Agreement dated from the State of North Carolina Department of Transportation in the sum of Two Hundred Thousand Dollars ($200,000.00) (the "DOT AGREEMENT"), a copy of which is attached hereto and incorporated by reference , to be used to reimburse Campbell for the cost of the construction of public roads adjacent to the new CUSOM Medical School ; AND THAT WHEREAS , the parties are desirous of amending the Agreement to revise certain sections to reflect more recent developments of the CUSOM, Campbell , and Harnett County on the main campus of Campbell and a project of Harnett County abutting property of Campbell on NC Highway 210 near its intersection with Harnett Central Road ; IT IS THEREFORE AGREED, between the parties that the Agreement is amended and restated in total to read as follows : 1. Campbell has caused to be constructed public roads in the vicinity of the CUSOM Medical School as approved by NCDOT at the cost of Campbell. 2. The County will cause to be constructed concrete sidewalks of a minimum width of six (6) feet on the north side of US Highway 421 interconnecting the Campbell tunnel under US Highway 421 at the football stadium with the eastern margin of Keith Hills Road at its intersection with US Highway 421 (the "Stadium Project"), with the exception of a pedestrian bridge (if needed) over a wetland crossing , at a cost not to 062717 HC BOC Page 3 exceed $200,000.00 , from proceeds received from NCDOT through the DOT Agreement. The parties understand that the funding provided by Harnett County is through NCDOT grant funding and no other source . Harnett County shall not be responsible for the payment of any costs outside of the funding agreement and funds received from the NCDOT pursuant to the DOT Agreement. As part of the Stadium Project Campbell will cause to be constructed a pedestrian bridge over the wetland crossing . 3. Harnett County shall require the contractor employed by Harnett County to construct the Stadium Project to maintain at all times during the work on the Stadium Project commercial general and automobile liability insurance in the minimum amounts of Two Million Dollars ($2 ,000 ,000 .00) per occurrence, Five Million Dollars ($5 ,000 ,000 .00) in the aggregate, statutory worker's compensation insurance , and performance and bid bonds in the amount of the contract for the work,. 4. That in constructing said Stadium Project Harnett County will at all times comply with any terms of and conditions of approval and construction as set forth in the DOT Agreement. 5. In consideration of the improvements by Harnett County as set forth herein , the Campbell University Foundation, Inc ., will dedicate an easement along NC 210 for the new entrance to Harnett Central Middle School/Neills Creek Park, not to exceed __ SF as shown on Attachment A hereto. 6 . The terms of this Agreement shall be binding on each of the parties hereto or their successors and assigns . 7. Campbell Unless otherwise set herein , each party (the "lndemnitor") shall indemnify and hold Harnett County the other party (the "lndemnitee ") and their agents , officers , appointees , members, representatives, elected officials , employees, guests, and invitees harmless from any and all claims, liabilities, penalties , damages , expenses , and judgments for injuries or accidents to persons or damage to property of any nature and cause whatsoever arising directly or indirectly from the negligence of Campbell, its trustees, agents, officers , and employees, while performing pursuant to this reimbursement agreement. Campbell's obligation to indemnify Harnett County shall include , without limitations , costs , expenses, and attorney's fees (including those on appeal) incurred in defense of such claims, whether or not such are adequately covered by insurance. The parties hereby agree that under no circumstances shall Harnett County be liable for indirect, consequential , special, or exemplary damages such as , but not limited to, loss of revenue or anticipated profits or other damage related to this reimbursement agreement. The indemnification requirement set forth in this Article shall survive termination of this agreement and shall not limit any other indemnification provisions in this Agreement. 2 062717 HC BOC Page 4 8. No Amendment or modification of this reimbursement agreement shall be binding upon either party hereto or their successors in interest unless such amendment or modification shall be set forth in writing and executed by each party in interest. 9. This Agreement contains the entire understanding of the parties and there are no representations, covenants or undertakings other than those expressly set forth herein . 10. Any and all required notices herein shall be in writing or facsimile transmission to each party as follows: Campbell : James 0 . Roberts P.O . Box 97 Buies Creek, NC 27506 Harnett County: County Manager P.O. Box 759 Lillington, NC 27546 If said notice is sent via facsimile, it shall be deemed received as shown on a confirmation receipt maintained by the sending party. 11. The Campbell University Foundation, Inc. joins this Amended Agreement solely for the purpose of dedicating the easement as described in Section 4. IN WITNESS WHEREOF, the parties hereto have executed this rental agreement in duplicate originals, one of which is retained by each of the parties, this the day and year first written above. CAMPBELL: Campbell University , Incorporated By: -------------- J. Bradley Creed , President ATIEST: James 0 . Roberts, Secretary County of Harnett By : ________________ _ Chairman , Harnett County Board of Commissioners 3 062717 HC BOC Page 5 ATIEST: Clerk Campbell University Foundation, Inc. J . Bradley Creed , President ATIEST: James 0. Roberts, Secretary 4 062717 HC BOC Page 6 Area 1 Right-of-Way Dedication Description Campbell University Foundation, Inc. PIN 0662-34-1818.000 Black River Township Harnett County, North Carolina civil engineering I land surveying The following described area of land lies along the northwestern side of NC Highway 210 in the Black River Township known as Lot Band being a portion of the deed duly recorded in Deed Book 2710, Page 571 of the Harnett County, North Carol i na regi stry, and is more fully described as follows: Commencing at an existing PK nail in the centerline of NC Highway 210, thence N47°59'25"W 31.46 feet to a point located on the northwestern right-of-way margin of NC Highway 210, being the easternmost corner of Campbell University Foundation, Inc. parcel as recorded in Deed Book 2710, Page 571 of the Harnett County Registry; thence with the right-of-way margin the following seven calls : S59°3l'17"W 84.90 feet to a point; thence S58°34'29"W 83.05 feet to a point; thence S56°55'55"W 62.42 feet to a point; thence S54°30'42"W 92.19 feet to a point; thence S52°26'18"W 103.95 feet to a point; thence S51°03'49"W 69.37 feet to a point; thence S50°07'25"W 70.64 feet to a point; thence leaving said right-of-way margin and running with a new right-of-way line the following eight calls: N39°52'35"W 10.00 feet to a point; thence N50°07'25"E 70.72 feet to a point; thence N51°03'49"E 69.57 feet to a point; thence N52°26'18"E 104.25 feet to a point; thence N54°30'42"E 92.58 feet to a point; thence N56°55'55"E 62.78 feet to a point; thence N58°34'29"E 83.27 feet to a point; thence N59°31'17"E 81.83 feet to a point on the northern line of said Campbell parcel; thence with said northern line S47°59'25"E 10.49 feet to the Point of Beginning, said area of land containing 5,658 square feet (0.13 acres), more or less. 03 -m -11 409 Chicago Dnve, Suite 112, Fayetteville, NC 28306 office \ 910-426-6777 fax \ 910-426-5777 license number \ C-2354 On time. every time. \ www.4Dsiteso1utions.com 062717 HC BOC Page 7 Area 2 Right-of-Way Dedication Description Campbell University Foundation, Inc. PIN 0662-24-9062.000 Black River Township Harnett County, North Carolina civil engineering I land suNeying The following described area of land lies along the southeastern side of NC Highway 210 in the Black River Township known as Lot 1 and being a portion of the deed duly recorded in Deed Book 2545, Page 939 of the Harnett County, North Carolina registry, and is more fully described as follows: Beginning at a point located on the southeastern right-of-way margin of NC Highway 210, being the northernmost corner of Campbell University Foundation, Inc. parcel as recorded in Deed Book 2545, Page 939 of the Harnett County Registry; thence with the eastern line of said Campbell parcel S03°52'34"E 24.72 feet to a point; thence leaving said line and running with a new right-of-way line the following four calls: S50°07'25"W 104.06 feet to a point; thence S50°20'08"W 110.86 feet to a point; thence S50°57'22"W 65.08 feet to a point; thence N39°02'38"W 20.00 feet to a point on the southeastern right-of-way margin of NC Highway 210; thence with the right-of-way margin the following three calls: NS0°57'22"E 64.97 feet to a point; thence NS0°20'08"E 110.72 feet to a point; thence N50°07'25"E 118.56 feet to the Point of Beginning, said area of land containing 5,742 square feet (0.13 acres), more or less . 03 ·2IJ ·11 409 Chicago Drive, Suite 112, Fayetteville, NC 28306 office I 910-426-6777 fax I 910-426-5777 license number I C-2354 On time, every time. I www.4Dsitesolutions.com 062717 HC BOC Page 8 Area 3 Right-of-Way Dedication Description The Harnett County Board of Education PIN 0662-34-9584.000 Black River Township Harnett County, North Carolina civil engineering I land surveying The following described area of land lies along the southeastern side of NC Highway 210 in the Black River Township and being a portion of the deed duly recorded in Deed Book 887, Page 630 of the Harnett County, North Carolina registry, and is more fully described as follows: Beginning at an existing 5/8" rebar located on the southeastern right-of-way margin of NC Highway 210, being the northernmost corner of The Harnett County Board of Education parcel as recorded in Deed Book 887, Page 630 of the Harnett County Registry; thence with the northern line of said Harnett County parcel S71 °01'53"E 13.14 feet to a point; thence leaving said line and running with a new right-of-way line the following ten calls: S59°25'03"W 45.35 feet to a point; thence S59°31'17"W 93.83 feet to a point; thence S58°34'29"W 81.47 feet to a point; thence S56°55'55"W 59.94 feet to a point; thence S54°30'42"W 89.44 feet to a point; thence S52°26'18"W 97.21 feet to a point; thence S38°56'11"E 10.00 feet to a point; thence S52°26'18"W 4.76 feet to a point; thence S51°03'49"W 67.75 feet to a point; thence S50°07'25"W 35.92 feet to a point on the western line of said Harnett County parcel; thence with said western line N03°52'34"W 24.72 feet to a point on the southeastern right-of-way margin of NC Highway 210; thence with the right-of-way margin the following eight calls: N50°07'25"E 21.55 feet to a point; thence N51°03'49"E 68.15 feet to a point; thence N52°26'18"E 102.15 feet to a point; thence N54°30'42"E 89.83 feet to a point; thence N56°55'55"E 60.30 feet to a point; thence N58°34'29"E 81.69 feet to a point; thence NS9°31'17"E 93.90 feet to a point; thence N59°25'03"E 36.82 feet to the Point of Beginning, said area of land containing 6,663 square feet (0.15 acres), more or less. 03 ·2D·11 409 Chicago Drive, Suite 112, Fayetteville, NC 28306 office I 910-426-6777 fax I 910-426-5777 license number I C-2354 On time, every time. I www.4Dsiteso1utions.com 062717 HC BOC Page 9 ' j I i I I i I I i I ! I ii ! l I S T A l E O F H O R T H C A R O U H A C O U H T T O F H A A H I T T C V l ' l l ' l C A f t : C l ° " ' " ° ' 5 N l " . v c l o t D I C A ' ! I C I N C C l t ~ l ( ( J l f ~ N , ( ) D t C I C A ' I Q I ' " " " ' - , . A L L O I S T . t , a < : [ $ ~ N l l . £ . . . o f l l Z O N T A L < I K 1 N ) O I S T A N C C $ U J , U S S o n n • S E N O l t D . . . l t t ' A ( W o m a : R O f ' I H D I U T C 0 t 1 " Y ™ " * - T I N i l M O ' W N O I : ( J l f M P l l ( l P ( J r t Y ~ N I O o t ' S O f l l l l C I ~ O N . 9 t o l t s L O C A t t D I N T H C S l . * > l ' o t $ t C I N ~ n o N ( J l f M A A H £ n O C I I M T Y . H ( l l : t H C N t < 1 . J I A A N D I W . U I H O l t e Y A D O P T M S ' 1 . A N O T K S l M l M $ O N W f f l W Y f l l l 1 " ~ t I l ' V I O I T c v n r , ™ ' " ' I 1 M M O W I C I I O f l M I [ M Q P O I T Y s i , , . , . . N I I J D Q O I I I I I U I N O I C O N . ~ ' 5 I . 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G R A P H I C S C A L E ~ i i fl I " " " ' < M D C I C ' , ( l ( I P V O I T J l ( " ' [ W O t ~ ~ O o \ l t . - - - - - - ( l t , : f l : t : T ) l l n c h • 6 0 l l 6 - 4 D s i t e - V - ! ~ , ~ ~ _ _ _ _ , . , , _ I I ; _ - · - - , - - - · - R E V I S I O N S . . . . . : 5 ' ~ i ~ ~ Z • ~ i ~ i 1 1 . I P R O J E C T i W I E R I G H T · O F · W A Y D E D I C A T I O N M A P N C H W Y 2 1 0 B L A C K R I V E R T O W N S H I P N E A i i A N G I E R H A R N E T T C O U N T Y N O R T H C A R O U H A C U £ H T H A R N E T T C O U N T Y E N G I N E E R I N G t G 2 E . u 1 , f O I I I S : l r f f t ~ l b ' I I I C ' . M l l i 1 ' 1 1 2 " " 4 6 P l l o n e : ( l l l 0 ) 1 1 ' - f 1 S 6 F 1 1 ! 9 1 0 ) 1 1 " " ' 3 4 1 P R O J E C T I H F O R I I A l l O I I S U A V E ' t ' E D I Y . D R o \ M I I S Y · a E C I C E 0 8 Y : P I I O . E C T . . . . . . . . - . . . . . _ , , ~ , O R A W I H G S C A L E H O R I Z O N T A L : 1 " - 6 ' 1 O A T E S U A Y E Y E O O C T O B E R 1 3 , 2 0 1 6 S H E E T N U M B E A 1 O f 062717 HC BOC Page 10 HARNETT COUNTY, NORTH CAROLINA ECONOMIC DEVELOPMENT INCENTIVE GUIDELINES PREAMBLE Harnett County, North Carolina, (the "County") Board of Commissioners ("Board"), has determined that the public interest and general welfare of the residents of the County are directly benefited by fiscally sound economic development policies which promote growth and diversity of the tax base, and result in the creation of more high quality, well paying jobs. Pursuant to its ruling in Maready v. The County of Winston Salem. et. al. the North Carolina Supreme Court and the N.C. Court of Appeals, in its ruling in Delma Blinson et. al v. State of North Carolina: Dell. Inc., et. al, have made clear that the expenditure of public funds to promote economic development is deemed to be for these legitimate public purposes, and is constitutional. The current competitive environment among states which regularly compete for business recruitment projects with North Carolina, and counties and municipalities which regularly compete with the County for such projects, dictates that the County must adopt Economic Development Incentive Guidelines ("EDIG"), which are conservative and fiscally sound, in order to remain competitive in recruiting new projects as defined herein; retaining expansions of existing business facilities currently located in the County; and retaining existing businesses and jobs which are at risk of being lost. It is essential for the County to be successful in recruiting new business facilities and retaining expansions of existing companies in the County in order to effectively address serious indicia of current and anticipated economic challenges in the County. Left unaddressed, these shortcomings N PRALi : 86688 1 .2 062717 HC BOC Page 11 will inevitably lead to an inability to provide services desired by the County's citizens, or require an increase in taxes in order to do so. For these reasons, the Board hereby establishes the EDIG to encourage new recruitment projects as defined herein to locate and existing businesses to remain and expand within the County. This document contains guidelines only. Each new, expansion or retention project as defined herein will be considered for incentive support on a case- by-case basis. The Board takes this action in adopting these guidelines pursuant to authority granted by N.C. Gen. Stat. §158-7.1, as interpreted by the North Carolina Supreme Court in Maready and the Court of Appeals in Dell. GUIDELINE PRINCIPLES These EDIG are based upon, and any EDIG arrangement with a new or existing company must be in compliance with, fiscally sound public policy principles, which at a minimum include: • Any EDI Gs must provide the County a high return on investment, taking into account tax and other revenues realized from the project for up to a ten year period from the date of the start-up of the project. NC Gen. Stat. §158-7.1(d2). • Any EDIG must be preceded by an agreement with the company involved, binding it to minimum levels of taxable capital investment and/ or quality job creation or retention, and providing for recoupment of initial grants and/or reductions in amounts of forward funded grants, in the event that it fails to meet those minimum required levels. NC Gen . Stat. §158-7.1(d2)(2). • Investments of County funds by way of EDIG shall be in items which leave value in the County in the event of a curtailment or closure of the operations within the industrial facility, such as site acquisition, site preparation, internal infrastructure, job training, etc. NPRA Ll :86688 1.2 062717 HC BOC Page 12 • The bedrock of the County's economy is the businesses and industries already located in the County. Consequently, the terms and application of the EDIG should allow existing industries to receive consideration for grants that are on terms equal to or better than those available to a company considering locating its first facility in the County. EDIG PROGRAM PARAMETERS Each project will be considered on a project-by-project basis, using these guidelines established by the Board. These guidelines shall be subject to periodic review and may be modified, amended or terminated, due to changed economic conditions or competitive considerations. In the event of any modification, amendment or termination, EDIG to which the County previously committed will not be affected. In determining whether to make an EDIG to a project, and if so, the amount of such grant, the Board will consider, among other relevant factors, the following matters: • The total taxable capital investment in the project including site acquisition, site improvement, building cost and equipment. • The number, type and quality of full time jobs created or retained. • Wage levels and benefits for jobs created by the project. • Whether the project has a high engineering and design component in the scope of the planned facility. • The potential for future expansions and increased employment. • Site specific issues that impact positively on public infrastructure expansions which will stimulate development in areas of the County, thereby benefiting overall community development. • The potential for the project to attract other companies which would be suppliers to or affiliated with that company. • Other factors promoting the public welfare and deemed relevant by the Board in its discretion. NPRAL I :866881 .2 062717 HC BOC Page 13 In addition to EDI Gs being utilized to attract new jobs and capital investments by way of companies new to the County or expansion of existing facilities in the County, the Board will consider on a case-by-case basis the utilization of EDI Gs when necessary to preserve existing jobs and capital investments which are at risk of being lost. This will apply to situations in which a company is considering the consolidation of operations within a facility in the County or a facility outside of the County; in which a company must modernize its equipment or facility to remain competitive in its market; or in other situations in which a company is considering reducing or eliminating its operations in the County. In the event that an EDIG is under consideration, based upon a company needing to modernize its equipment and/or facility, a grant may be made, in the discretion of the Board, when some jobs will be lost due to modernization, and some jobs will be preserved, if the overall amount of taxable capital investment for the subject company will increase. The Board acknowledges that increasingly recruitment incentives in this State take the form of concessionary leases and sales of real estate, as opposed to or in addition to cash grants. The terms of this EDIG apply equally to the cash value of the reduction below fair market value ofleased or sold real estate, utilized as an incentive. MINIMUM PROJECT QUALIFICATIONS In order to qualify for consideration for an EDIG from the County, the project must meet certain minimum threshold requirements. Meeting these threshold requirements does not indicate that the project will necessarily receive an EDIG, and if so, the amount of such grant, inasmuch as the Board reserves sole discretion in this regard on a project-by-project basis. The minimum project qualifications are as follows: NPR AL I :866881.2 062717 HC BOC Page 14 • The minimum levels of capital investments and new jobs to be created in the County for a new project must be: Capital Investments $1,500,000 to $9,999,999 $10,000,000 to $19,999,999 $20,000,000 or more and/or and/or and/or Minimum Number of New lobs 50 40 20 • The minimum levels of capital investments and new jobs to be created or retained in the County for a retention or expansion project must be: Capital Investments $750,000 to $5,000,000 $5,000,000 to $10,000,000 $10,000,000 or more and/or and/or and/or Minimum Number of lobs (New or retained) 25 20 10 For new jobs or jobs being created or retained to qualify for consideration under these EDIG guidelines, those jobs must pay average wages (taking into account base wages, bonus and performance incentives, and the value of all benefits) which are at or above the average wages paid in the County at the time that the Board considers and acts on the EDIG, and the company must provide health care coverage and pay at least fifty percent of the premiums for such coverage. • The project must involve a facility to be used for manufacturing, distribution, corporate or divisional headquarters, back office operations (e.g. telemarketing, call center, check clearing, etc.), research and development, air courier hub, large scale multi store retail development of at least _100,000 ____ square feet, class A office development of at least _15,000 ____ square feet, large medical facility ( other than individual offices for health care profess ionals), or processes which involve the utilization of high technology or innovative new technologies. • The County reserves the right to consider projects beyond the parameters outlined in this section. Projects outside of the scope detailed herein will only be considered if it is found that the nature of such project would have a significantly transformative and dramatically positive net economic impact on the County. NPRA LI :86688 1.2 062717 HC BOC Page 15 For a project to be considered by the Board for an EDIG, it must meet all of the above minimum project qualifications, except when the Board in its discretion chooses to consider projects for an EDIG which do not meet the parameters set forth herein. Additional qualifications may be required by the Board in its discretion, on a project-by- project basis. EXCLUSIONARY FACTORS Even though a project might meet all of the above minimum project qualifications, it will not be considered by the Board for an EDIG if any of the following factors apply: • If the expansion project would , for any reason, result in a net reduction of the ad valorem tax valuation of all facilities in the County owned by the company, or its parent, subsidiary or affiliated companies. • An EDIG will not be made if that company, or a parent, subsidiary or affiliated company, is not current in all ad valorem tax payments to the County. • No prior commitment to an EDIG shall be binding if the company originally receiving the grant assigns it to another company, unless the Board has consented to such assignment in writing. • The financial condition of the company receiving the grant must not be such that the ability of the company to meet its obligations is in reasonable doubt. • No EDIG will be provided if the project would result in degradation to the environment in the County or would pose a significant risk of an environmental hazard. USE OF GRANT FUNDS EDI Gs under these guidelines will generally be made in installments to be paid in the future, but for extraordinary, high impact projects, such grants may be made at the time of the commitment of the project to locate in the County. All grants may be used for one or more of the following purposes, depending upon the terms approved by the Board: NPRAL I :86688 1.2 062717 HC BOC Page 16 • Site acquisition • Site preparation • Internal site infrastructure • External infrastructure • Other improvements to the Site • Other capital investments • Job training costs not otherwise reimbursed by grants from the Community College system or tax credits pursuant to the state statute • Other purposes which leave value in the community as determined by the Board on a project-by-project basis PROCEDURE FOR GRANT CONSIDERATION The following procedure will be utilized in considering a project for an EDIG : • The company will negotiate the terms of such grant agreement with the County Economic Development staff and the County Manager. Such discussions are negotiations only, inasmuch as the Board has the sole discretion and authority to finally agree to such grants. • The County will conduct a full financial review of the company, to assure that it can meet its performance requirements. Confidentiality of financial records will be protected. • At a time agreeable to the company, given its confidentiality concerns, a public notice and public hearing regarding the proposed grant may be given/held as contemplated by the requirements of N.C. Gen. Stat. §158-7.1. • The Board will approve the terms of the grant agreement by resolution, and in doing so must specifically find that such project will benefit the public interest and promote the public welfare of the citizens in the County. • An EDIG agreement will be executed which contractually binds the County to make the grant, and the company to meet the taxable capital investment and job creation or retention requirements, to which they mutually agreed. A failure of the Company NPRALI :86688 1.2 062717 HC BOC Page 17 to meet its performance requirements will result in the recoupment of a pro rata portion of any grants given previously or a pro rata reduction of any future grants. • The company will provide periodic verification of its compliance with the requirements to which it has agreed as appropriate, and/or at the request of the County Economic Development staff, and by a means agreed upon between the County and the Company on a case-by-case basis; provided however that as a minimum level of verification, the Company shall provide to the County's Economic Development staff, the Employment Security Commission report, NCUI 101 form, which summarize the number of employees, wages paid and unemployment taxes due. CONCLUSION All EDI Gs will be considered on a project-by-project basis and by adopting these guidelines, the Board is not obligated to make any grants. In considering whether or provide EDI Gs for a project and if so how much, the Board will take into account grants made by private sources and other public sources to support the project locating in the County. These guidelines are not retroactive to any project which has been announced prior to the adoption of these guidelines. These guidelines are effective as ofJuly 1, 2017. NPRALI :866881.2 062717 HC BOC Page 18 VI .c ..... ro Q) Cl b.O i:: i:: 0 VI ·o 0.. -0 :2 a. 0 i:: .Q ..... a. ·.: u VI ~ 0.. '° t-1 0 N -.... C: V :g V\ V a:: ,._ V C. V\ C: .Q .... C. ·;:: u V\ V ,._ 0... "'C :§ C. 0 U) t-1 0 !::!. ..... i:: Q) ~ VI Q) a:: .... Q) C. VI 0.. -0 ·5 "ci 0 County Leadership Forum on Opioid Abuse Ill Harnett 12 10 8 6 4 2 0 2 2010 1 ·8 Low, 0.517 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 150.0 125.0 100.0 75.0 50.0 25.0 0.0 Low, 34.5 COUNTY 2011 2012 2013 2014 2015 High, 1.844 Harnett, 0.987 100 NC Counties -Statewide Average: 1.06 High, 141.7 Harnett, 73 .1 100 NC Counties -Statewide Average : 78.3 Data on Prescr]m:ion Rates and Poisonl!)gj)~aths courtesy of NC Dept. of Health and Human Services 062717 HC BOC Page 19 County Leadership Forum on Opioid Abuse Project Description Purpose of County Leadership Forum: To engage local elected leaders in an informed discussion about the opioid epidemic, and develop collaborative strategies that enhance prevention, education, and treatment . .G.o.a!.s;_ • to elevate the awareness of all local elected officials so they have a common understanding of the opioid epidemic in their county; • to discuss its causes, its effects on citizens, and its implications for the county's future; • to educate local elected leaders about successful prevention and treatment programs and provider resources available in their county; • to generate coordinated education, prevention and treatment strategies to reduce the occurrence of opioid addiction, overdose, and death . Target Participants: • County Commissioners • Municipal Council members from every municipality within the county • School Board members and superintendents from every LEA within the county • County Sheriff • Chief District Court Judge for the county's judicial district The target audience for the County Leadership Forum on Opioid Abuse is elected officials. Focusing on elected officials assures that all public policy leaders have a common understanding of the opioid problem and effective treatment options, and have an opportunity to consider collaborative solutions. If there are existing efforts underway in your county, please consider ways to include them in your Leadership Forum . Having all the elected officials know and understand what is available in the county, as well as what might be missing, will strengthen everyone's resolve to reverse the epidemic trends. Examples of other community leaders you might want to include are: • Representative of the county medical society or the local physicians' community (consult w ith Board of Health or Medical Society as needed to identify a participant); • District Attorney or designee; • Chief Executive Officer of your local hospital; • President of the Community College; • Municipal Police Chiefs and First Responders 062717 HC BOC Page 20 County Leadership Forum on Opioid Abuse Forum Planning Guide This planning guide outlines the enclosed resources and materials you will need to hold your forum. It also provides suggested roles and responsibilities that can be tailored to fit your local approach to the forum. This leadership forum project is the result of a collaborative effort between the North Carolina Association of County Commissioners and the following organizations: • NC Division of Mental Health/Developmental Disabilities/Substance Abuse Services • NC Association of Local Health Directors • NC Council of Community Programs • NC State University Consumer and Family Services Department/NC Cooperative Extension Services • NC League of Municipalities Through these organizations, local partners have been engaged and are ready to help you with this effort. The NCACC sincerely thanks these organizations for their contributions to the Leadership Forum project. Forum Packet Contents: Tab 1 • Letter of Invitation from NCACC President Fred McClure: A letter from NCACC President Fred McClure to the Board of Commissioners Chair inviting the county to participate in the County Leadership Forum on Opioid Abuse project: • Project Description: An overview of the purpose of the forum and the target participant groups. • Forum Planning Guide: An outline of materials needed to plan the forum and suggested roles and responsibilities for target participants. Tab 2 • Letter of Invitation from Board of County Commissioners Chair: A sample letter from Board of County Commissioners Chair to target participants. It should be customized to fit the county's unique circumstances and approach to the forum and be sent four-five weeks before the date of the forum. Be sure to include the date, time and location of your forum. • County Statistics on Opioid Use: Charts that provide statistics on opioid use in your county. It should be attached to the letter of invitation sent to target participants and provided as a handout the day of the forum. The data used to create these graphs is updated regularly at the source. If you wish to have more current data by the time your forum is held, please contact Julie Totten at the NCACC, Julie.Totten@ncacc.org. • List of County and City Officials and Others to Invite: A spreadsheet of contact information for local elected officials to facilitate letter mailing. The intent is to provide contacts for all county and city officials but in some cases, contacts may be missing. Please coordinate with your County Clerk to ensure it is complete and accurate. The list can be expanded to suit the nature of your local forum. 1 062717 HC BOC Page 21 County Leadership Forum on Opioid Abuse Tab 3 • Forum Sample Agenda: An outline of suggested format for forum meeting. It should be customized as needed to fit local circumstances and speakers. The amount of time each county should set aside for this forum will range, possibly as widely as two to six hours. Estimate your forum time based on the number of participants and allow sufficient time for discussion throughout the event. • Facilitator Guide & Overview: A guide to help the facilitator effectively run the meeting and consider logistics to be handled in preparation for the meeting. • Idea Generation Worksheet: A template for discussion leaders and scribes at each table to write their group's priority ideas down on paper and share during the forum. • Nametag Template: An Avery label nametag template that can be formatted with names and printed. It is Avery label 5462 and the template is available on www.ncacc.org/opioidforum. • Follow-up Report Template: A template to provide a follow-up report that outlines outcomes and next steps to share with the participants, the NCACC and other organizations. Tab4 • NC Injury & Violence Prevention Branch Overview on Prescription & Drug Overdoses: A supplementary overview of prescription and drug overdose information to provide context regarding the extent of the opioid epidemic. It can be provided as a handout the day of your forum. • Facts and Figures on the Opioid Crisis: A targeted overview of the opioid crisis and how far- reaching the issue is, as published in a joint report from the National League of Cities and National Association of Counties. It can be provided as a handout the day of your forum. • Summary of Additional Resources: A summary of resources counties can utilize in planning the forum. Tabs • A Prescription for Action: Local Leadership in Ending the Opioid Crisis: A joint report from the National League of Cities and National Association of Counties. All enclosed materials are available online at www.ncacc.org/opioidforum. 2 062717 HC BOC Page 22 County Leadership Forum on Opioid Abuse Suggested Roles & Responsibilities 1. COMMISSION CHAIR The role of the Chair is to provide public leadership in addressing the opioid epidemic. The Chair's responsibilities include: • Talk with your county manager about the Leadership Forum on Opioid Abuse concept, review the enclosed materials in the box and discuss the list of forum invitees. • Include a discussion about this request on the agenda of your next Board of Commissioners' meeting. If possible at that time, set a proposed date for the Forum in your county; • Send letters of invitation to municipal elected officials, school board members, judges, and your sheriff, and any other participants you want to include, being sure to include a physician (sample letter and addresses provided); • Host the Forum, present a welcome and set the stage for the purpose of the meeting and desired outcomes. 2. COUNTY MANAGER The role of the County Manager is to help the county commissioners execute their Leadership Forum. The Manager's responsibilities include: • Review the box materials, talk with your Chair, put it on your board's agenda for discussion; • Call your public health director to let him/her know you have received the forum materials and decide next steps; • Contact city/town managers in the county, the school superintendent(s), and sheriff, to enlist their support and assistance; find out whether any of these agencies have existing task forces or committees that could be valued partners in your forum; • Coordinate the forum date with as many of these interested parties as possible to allow for maximum elected official participation, and inform the NCACC of the date so it can be added to the website (email: communications@ncacc.org); • Coordinate with your county clerk to ensure your invitation list is complete and accurate . The list can be expanded to suit the nature of your local forum; • You may find it helpful to appoint a small planning group to help the public health director and LME representative with logistics and program development; agencies you might include could be law enforcement and a court official. (Sample program agenda provided); • Designate a person to be the forum recorder. This person will be responsible for documenting the small group discussion reports. A follow-up report template is provided for this purpose. • Coordinate with County Clerk if public notice is required , depending on expected number of commissioners in attendance. 3 062717 HC BOC Page 23 County Leadership Forum on Opioid Abuse 3. LOCAL PUBLIC HEALTH DIRECTOR The role of the Health Director is to connect all the key county partners (County Manager, LME Director or designee, Cooperative Extension Director or designee, County DSS Director) and take the lead in program planning. The leadership forum materials include facilitator instructions that detail the role and responsibilities of the facilitator. Your County Cooperative Extension Director will share the instructions with the facilitator once identified. The local Public Health Director's responsibilities include: • Call the County Manager to let him/her know you are willing to provide lead support for the forum by working with the designated LME representative to develop the program content, materials, presentations, etc. • Call your LME/MCO Chief Executive Officer to inform him/her that you are ready to begin the forum planning and to find out who the LME designee is to participate in your program. In most cases this will be the LME Medical Director or substance use specialist. If for any reason you have difficulty connecting with your LME Chief Executive Officer, reach out to your regional LME liaison. The liaisons are knowledgeable about the forums and have helped with the planning. A list of regional LME liaisons is included on the "Summary of Additional Resources" page enclosed in this packet. • Connect with the LME designee to plan the program, schedule speakers, including the county DSS director, and contact the County Cooperative Extension Service Director who will help you to identify a facilitator, coordinate all presentations, technology needs, etc. • Attend the commissioners' meeting(s) at which the forum concept is being discussed to speak about the importance of the forum and reiterate your support in making it a success. • After invitation letters have been sent out from the Board of Commissioners, ask your Board of Health to send a follow-up letter encouraging the invitees to participate. It is especially important to have a few medical doctors involved, so if your Board of Health can encourage participation from the medical community it would be extremely helpful. • Along with the LME designee, serve as the discussion leader in the room, including providing opening comments to set the stage for the discussion and handling participant introductions, consider consulting with your facilitator on how to handle introductions from a time management standpoint; • In multi-county public health agencies, assign delegates to help you as needed; • Work with the LME representative to collect all notes and worksheets generated during the forum and review and finalize the summary provided by the forum recorder and give a final report to the County Manager and NCACC (email: communications@ncacc.org ). • Send final report to all program participants with a "thank you" note. 4 062717 HC BOC Page 24 County Leadership Forum on Opioid Abuse 4. LOCAL MANAGEMENT ENTITY CHIEF EXECUTIVE OFFICER The role of the Local Management Entity CEO is to lend his/her leadership and active support to this project by doing the following: • Designate an appropriate staff person who is a subject matter expert to partner with the local Public Health Directors and County Managers in the catchment area to help plan and execute the forum program; • Inform the LME/MCO Medical Director and encourage his/her involvement in the program; • Represent the LME/MCO in as many county forums as your schedule permits. S. LOCAL MANAGEMENT ENTITY REPRESENTATIVES The role of the LME designated staff representative is to collaborate with the local Public Health Director to design the forum and speak as a part of the agenda presentations. Your responsibilities in this role include: • Reach out to the public health directors in your assigned area to introduce yourself and offer your assistance; • Along with your Local Public Health Directors, attend and speak at as many of the county commissioners' meetings as possible when the forum project will be presented; • Help the public health director design agenda presentations that inform the elected officials in laymen's terms about addiction disorders and particularly, opioid addiction; be sure to include prevention methods as well as treatment and recovery options; use as much county-specific data as possible, referring to the county data sheet provided in the leadership forum materials; • Prepare rosters of the substance use disorder prevention and treatment providers and agencies by county that can be used as handouts at the forums with which you are involved; • lend expert knowledge, advice and guidance to the forum discussions, including giving opening comments with the Health Director to set the stage for the discussion. • Work with the Local Public Health Director to finalize the follow-up report and send to the County Manager. 6. COUNTY DIRECTOR OF SOCIAL SERVICES The role of the County Director of Social Services is to participate in the program, and do the following: • Provide as much information as possible about the effect of the opioid epidemic on families and children in the county; • Help lead the group discussions in which ideas will be generated to help with prevention, education, and treatment. • After the Board of Commissioners sends out the letters of invitation, ask your Board of Social Services to follow-up with a simple card or letter to the invitees reiterating the 5 062717 HC BOC Page 25 importance of dealing with the opioid issue to the families in your county and encouraging them to participate . 7. FACILITATOR The role of the facilitator is to help process the group decision-making that takes place as a part of the table-top exercise . A detailed facilitator guide is enclosed in this packet. • Sticky notes and Idea Generation Worksheets should be available on each table; • Participate in the opening comments by describing how the materials will be used in the small group discussions . • Oversee the group discussions and reports, call on groups to report their ideas, engage the assistance of the Public Health Director and LME representative in helping point out any common themes or recommended approaches, summarize actions and collect the idea worksheets. Identifying a Facilitator: This process does not require or demand that the facilitator have any knowledge about this topic, but rather that they have the skills to help the group process their ideas into an action plan. You may already have someone on your County staff or someone el se involved in the project who is ideal for facilitating this discu ssion. Many, but not all, of the County Cooperative Extension Offices have tra ined facilitators on local staff or can help identify a (ES-trained person to help facilitate group discussions reflected on the sample agenda . Contact your County Cooperative Extension Director to connect the Local Public Health Director to the closest CES trained facilitator. In addition, the NC Office of State Human Resources -Talent Management division offers facilitation to public employment divi sions. Contact (919) 733-2601 . 6 062717 HC BOC Page 26 County Leadership Forum on Opioid Abuse Logistical Considerations Venue: The ideal location is one that is easy to get to and has ample parking. If at all possible, use a room with ample natural light, which helps participants maintain focus and energy. Timing: The suggested model is a morning meeting, simply because people are fresher and have fewer distractions early in the day. HOWEVER, whatever time of day gets the most attendees present is the right way to go. Room Set: There will be small group discussions during the agenda, so it will be important for attendees to be able to hear and converse with each other. Use crescent rounds for the room set if possible. If rounds are not available, consider placing rectangular tables back-to-back to form a small square. Participant Table Assignments: Participants should be assigned to sit with individuals they do not routinely work with or interact with. The objective is for each table to have a good mix of viewpoints and interests. This enriches the learning for the attendees and helps create a greater diversity of ideas. • One way to do this is to use colored tent cards to number the tables, and put coordinating sticky dots on name badges alternating commissioners, municipal officials, school board members, law enforcement officers, judicial officials, hospital officials, doctors, etc. Technology: Laptop, screen, and projector are the basic technology needs. Depending on the size of the room and number of attendees, microphones may be useful. Basic Materials: At each chair, place small yellow sticky pads with pens or pencils; on each table place 3-5 Idea Generation Worksheets. Optional Materials: Confer with Facilitator and Health Director on selected group process before deciding whether these are needed: • Sticky-backed flip charts on easels (2) • Wide-tipped Markers Food/Beverage: The agenda is designed in a way that allows the program to be held without a hot meal. Remember though that food equals energy, so you might want to consider providing coffee, sodas, water, and some sweet and savory snacks upon arrival and at a break. 7 062717 HC BOC Page 27 County Leadership Forum on Opioid Abuse Sample Letter of Invitation from Board of County Commissioners Chair to target attendees (Date) (Guest Name and Address) Dear (Invited Guest), Here in (insert name of county) County last year, (insert number from County Data Sheet) people were found dead of an opioid overdose. The total number of legal prescriptions written for opioids in our county was (insert number of prescriptions from County Data Sheet), an average of (insert number from County Data Sheet) pills per person . Regular use of opioid pain relievers -even when used as prescribed by a doctor -can produce dependence, and when misused or abused, can lead to fatal overdose. In North Carolina, as in our nation, the use of prescription pain killers has reached epidemic proportions. Closely related is the alarming increase in the use of heroin. It is time for us as local elected officials to assume a leadership role in reversing these trends. On behalf of the (insert name of county) County Board of Commissioners, I would like to invite you to participate in a County Leadership Forum on Opioid Abuse. Community-wide education regarding the proper use and risks of prescription drugs is essential to lowering misuse and accidental overdose, as is having ready access to reliable treatment and recovery supports. By convening all the local elected officials from our county, as well as representatives from key organizations, we can learn the full effect of the opioid crisis on our county's citizens, find out what resources are available to help our families, and develop collaborative strategies for effective education, prevention, and treatment that can and will make a difference here in (insert name of county). The (insert name of county) County Leadership Forum on Opioid Abuse will be held on (insert date and time of forum) at (insert location and address). If you will join us in this effort, please confirm your participation by contacting (insert name of RSVP person) at (insert email address and phone number for RSVP person). Sincerely, (insert signature) (insert name of Chair) Chair, (insert name of county) County Board of Commissioners 062717 HC BOC Page 28 County Leadership Forum on Opioid Abuse Sample Agenda Welcome & Introductions Opening Remarks: Our Shared Interests in Solutions Understanding Opioid Overuse and Addiction Impact on Families in our County Education, Prevention, and Treatment Tools Available in our County • Drug Drop-off Boxes • Syringe Exchanges • Naloxone • Drug treatment and recovery programs • Stepping Up Initiative What Tools Should We Add to our Toolbox? How Do We Get Started? Bold Next Steps Wrap-Up Concluding Remarks Chair, County Board of Commissioners County Local Public Health Director LME/MCO Chief Executive Officer County Local Public Health Director LME/MCO Medical Director County DSS Director Local Public Health Director LME/MCO Representative Facilitated Group Discussions Group Reports Local Public Health Director LME/MCO Representative Chair, Board of County Commissioners 062717 HC BOC Page 29 County Leadership Forum on Opioid Abuse Facilitator Guide & Overview At opening of forum: The presiding Public Health Director will recognize/introduce program participants. When the facilitator is recognized , he/she can take a few moments to instruct the room in how the presentations and group exercise are inter-connected: • Point out that participants have a small pad of sticky notes and pens/pencils. These are to be used for making notes during the presentations. • As participants listen to the speakers, write down any ideas you think will improve your county's outcomes . Write only one idea per sticky note. • As you think of ideas and write them down, stick the notes on the table at which you are seated. • The objective is for each participant to generate at least 3 ideas during the presentations. • These ideas will be used to guide the small group discussions following the presentations. • ALL IDEAS ARE VALID. WE WANT GREEN LIGHT THINKING! Turn program back over to the Master of Ceremonies/Health Director for the presentations. At the group discussion period following the presentations, return to the front of the room and explain the purpose of the group exercise. STATE THE PURPOSE OF THE GROUP EXERCISE : The purpose is to use your ideas to generate group consen sus about tools, concepts or actions YOU think could help make a difference in the opioid epidemic in your county, and to develop enough details to define next steps. Step 1: APPOINT Instruct the groups to appoint a discussion leader and scribe at each table. The discu ssion leader and scribe use the Idea Generation Worksheets at the table to guide the discussion and document the group's ideas in more deta i l. Step 2: SORT IN SILENCE! {S -10 minutes, depending on size of groups) • At each table, undertake the following exercise in silence: o Compare your notes to those of the others at your table. o Group together notes that have similar or related ideas; o Sorting should move quickly; don't let them over-think it. • Point out that sorting in silence allows the process of identifying common ideas or themes to move much more quickly; similarities/differences can be discussed during the next part of the exercise. 062717 HC BOC Page 30 Step 3: DISCUSS: (30 minutes) • When the sorting has gone as far as is helpful, call the room back to order. • Point out the Idea Generation Worksheets on the tables. Beginning with the ideas that have the most sticky notes, the discussion leaders guide the participants at their tables through the questions on the worksheet. Use one worksheet for each priority idea. • This may take longer than 30 minutes; adjust as needed based on the level of conversation . • When it looks like most groups are finished or discussion is waning, move to the next step. Step 4: REPORT: Group report-outs and recording of ideas (45 minutes) • The Forum Recorder should have the FOLLOW-UP REPORT TEMPLATE open and be ready to record each groups' ldea(s), Partners, Assets, Obstacles, and Lead Person or Agency. This FOLLOW-UP REPORT TEMPLATE serves as the foundation for a Report to the Participants that the county can send out afterwards. • Ask a spokesperson from each table to describe their Priority #1 idea, partners, assets, obstacles, and Lead Person or Agency to move the idea forward (allot 5 mins or so for each table to report); • Go around the room again for Priority #2 ideas, partners, assets, obstacles, and Lead Person or Agency and as many subsequent rounds as time will permit. • ALTERNATE METHOD: if preferred, the table report-outs can be documented using flip charts and markers. In this case, the RECORDER should be at the front of the room with the flip charts, documenting the Ideas, Partners, Asset s, Obstacles, and Lead Person/Agency as reported; the REPORTER would transcribe the notes into the report template afterwards. Step 5: CLOSURE OF EXERCISE • Explain that a final report will be generated and sent to each participant. • Collect all Idea Generation Worksheets; tell participants that ALL ideas and information from the worksheets will be included in the final report, regardless of whether time allowed them all to be reported . • Turn the program back over to the Master of Ceremonies/Health Director for closing remarks. Materials Needed: Small sticky note pads Pens/pencils Idea Generation Worksheets (3-5 per table) Final Report Template open on computer Alternate Method: Flip charts/markers Final Report Template to be completed afterwards 062717 HC BOC Page 31 County Leadership Forum on Opioid Abuse Idea Generation Worksheet Name of Discussion Leader: ------------------------ Table Number: ____________________________ _ YOUR IDEA: Who are the key partners you need or could utilize to help champion this idea? What assets do you already have that can help you successfully implement this idea? 062717 HC BOC Page 32 What are the hidden issues or obstacles to overcome in order to implement this idea? Name of lead person or Agency for idea:---------------------- Timeline to implement idea:--------------------------- NOTES: 062717 HC BOC Page 33 County Leadership Forum on Opioid Abuse Follow-up Report County and Location of Forum:-------------------------- Date and Length of Forum (Please attach agenda):------------------- Number of Attendees (Please attach list of participants):----------------- Name of Person Preparing Follow-up Report:--------------------- Key Ideas and Next Steps: IDEA #1: [insert description] • What specific tool do you want to implement in our county? [insert response] • Who are the key partners you need to help champion this idea? [insert response] • What assets do you have that could help you implement this idea? [insert response] • What are the hidden obstacles to implementing this idea? [insert response] Name of lead person for idea:--------------------------- Timeline to implement idea:--------------------------- IDEA #2: [insert description] • What specific tool do you want to implement in our county? [insert response] • Who are the key partners you need to help champion this idea? [insert response] • What assets do you have that could help you implement this idea? [insert response] 062717 HC BOC Page 34 County Leadership Forum on Opioid Abuse • What are the hidden obstacles to implementing this idea? [insert response] Name of lead person for idea:--------------------------- Timeline to implement idea :--------------------------- IDEA #3 : [insert description] • What specific tool do you want to implement in our county? [insert response] • Who are the key partners you need to help champion this idea? [insert response] • What assets do you have that could help you implement this idea? [insert response] • What are the hidden obstacles to implementing this idea? [insert response] Name of lead person for idea:--------------------------- Timeline to implement idea:--------------------------- IDEA #4: [insert description] • What specific tool do you want to implement in our county? [insert response] • Who are the key partners you need to help champion this idea? [insert response] • What assets do you have that could help you implement this idea? [insert response] • What are the hidden obstacles to implementing this idea ? [insert response] Name of lead person for idea : __________________________ _ Timeline to implement idea:--------------------------- 062717 HC BOC Page 35 North Carolina Injury & V i olence PREVENT I O N Branch Prescription & Drug Overdoses An epidemic of unintentional poisoning deaths continues to affect North Carolina . Since 1999, the number of these deaths has increased by more than 391 percent, from 279 to 1,370 in 2015 (Fig . 1 ). The vast majority of unintentional deaths are drug or medication-related , occurring when people misuse or abuse these drugs (Fig . 2). In particular, opioid analgesic deaths involving medications such as methadone, oxycodone, and hydrocodone have increased s ignificantly in North Carolina . Opioid analgesics are involved in more drug deaths than cocaine and heroin combined but that seems to be changing rapidly (Fig. 3). 1/) .c ... cu G) 0 .... 0 .. G) ,Q E ::, z Figure 1: Poisoning Deaths by Intent: N.C. Residents, 1999-2015 1800 1600 1400 1200 1000 800 600 400 1 ,657 1,370 -unintentional Suicide -Hom icide Unde term ined -A ll Poisoning s 200 -"' M )( )( )( )( )( )( )( )( )( i< ~ >E )( 243 44 0 0 1999 2001 200 3 2005 2007 2009 2011 201 3 2015 Figure 2: Medication/Drug vs Non-Medication Types of Unintentional Poisonings: N.C . Residents, 2015 Of these unintentional poisoning deaths, 92.6 percent are caused by drugs and medications ( over-the-counter, prescription and illicit) (Fig . 2). Seven percent are toxins or chemicals (non-medication/non-drug). Medication/Drug Opioids/Coc aine Other/Unspecified drugs Anti-epi leptic and sedative- hypnotic drugs Non-o pioid iiiffl 47% 43% 2 % 1 % Prescription opioid analgesics , heroin and cocaine are the cause of death in nearly half (47 percent) of these poisoning deaths (Fig . 2). NC PUbllc Health '1E41. TH AND HU'14H :SC"VICE:S NORTH CAROLINA INJURY AND VIOLENCE PREVENTION www.injuryfreenc.ncdhhs.gov 9/16 ----------------------------------------. --~-~ - 062717 HC BOC Page 36 Table 1: N.C. Unintentional Poisoning Death Demographics, 2015 Number Percent Rate Sex Males are dying in greater numbers than females Female 500 36.5% 9.7 (870 versus 500) (Table 1). Male 870 63.5% 17.8 Race Whites and American Indians have the highest rates American Indian 20 1.5% 12.0 of unintentional poisoning deaths (15 .8 and 12.0 per Asian 2 0.1% ** 100,000 persons) among state residents (Table 1). Black 175 12 .8% 7.6 White 1146 83.6% 15.8 Unintentional poison death rates increase with age , Other/Unknown 27 2.0% NA peaking between the ages of 45-54 (27.5 per Age Group 100,000 persons), and then decreasing after age 55 0-14 2 0.1% ** (Table 1). 15-24 118 8 .6% 8.5 25-34 311 22.7% 23 .8 35-44 317 23.1% 24.5 45-54 378 27 .6% 27.5 55-64 185 13 .5% 14.6 65-84 54 3.9% 4.0 >84 5 0.4% 2 .9 '"Indicates <5 deaths; rates are not reported Figure 3: Unintentional Prescription Opioid and Drug Overdose Deaths by Year: N.C. Residents, 1999-2015 Prescription opioid pain medications include such drugs as oxycodone, hydrocodone and methadone. .. Ill .&:. -Prescription opioid pain medications CV C1> are responsible for more deaths than C .... heroin and cocaine combined (Fig . 3). 0 ... C1> .0 If current trends continue, E ::s unintentional poisoning deaths will z surpass motor vehicle deaths as the leading cause of injury death in North Carolina by 2017. 800 700 600 500 400 300 200 100 0 Heroin -cocaine -Prescription Opio id Medication 738 364 293 1999 2001 2003 2005 2007 2009 2011 2013 2015 • Number of times mentioned-Cases a re not mu tually exclusive-Deaths ca n h ave more than one drug. Key Organizations Working to Reduce Prescription and Drug Overdose in North Carolina Organization N.C. Medical Board (NCMB) N.C . Board of Pharmacy Controlled Substance Reporting System (CSRS) Project Lazarus, Inc. Wilkes County Operation Medicine Drop Carolinas Poison Center Injury Prevention Research Center (IPRC), UNC-CH N .C. Injury & Violence Prevention Branch Governor's Institute North Carolina Harm Reduction Coalition Office of the Chief Medical Examiner (OCME) ·~ Publlc/Jea/th IWU "".""MtUMU fSA"stN¥1Lt> Contact Information David Henderson (david.henderson@ncmedboard.org) Jay Campbell Ocampbell@ncbop.org) Alex Asbun (alex.asbun@dhhs.nc.gov) Fred Brason (fbrason@projectlazarus.org) Meg Langston (meg.langston@ncdoi.gov) Dr. Anna Dulaney (anna.dulaney@carolinashealthcare.org) Agnieszka Mccort (magnes@email.unc.edu) Scott Proescholdbell (scott.proescholdbell@dhhs .nc.gov) Dr. Sara McEwen (sara .mcewen@governorsinstitute.org) Robert Childs (robert.bb.childs@gmail.com) Alison Miller (alison .miller@dhhs.nc.gov) I nj ury Epidemiology & Surveillance UniU 9 19 -707-5425 / www.injuryfreenc .ncd hhs.gov State o f North Carolina / Department of Health and Human Services I www.n cdhhs.gov N.C . DH HS is an equal opportunity employer and provi der. FIN AL. 9/16 N.C. Division of Public Healt h/ www.ncpublichealth.com T he N.C . Injury and Violence Prevention Branch is supported b y Cooperative Agreeme nt NU17CE002728-02-00 from the Centers for Disease Control and Preve nlion (CDC). NORTH CAROLINA INJURY AND VIOLENCE PREVENTION www.injuryfreenc.ncdhhs.gov 9/16 062717 HC BOC Page 37 Fact and Figures on the Opioid Crisis WHAT IS AN OPIOID? As used in this report, opioid refers broadly to substances that bind to opioid receptors in the brain and body. This includes drugs commonly prescribed to relieve pain like hydrocodone (e.g ., Vicodin} and oxycodone (e.g., OxyContin, Percocet}, as well as substances like heroin that are produced and sold illicitly. N 30,000 25,000 20,000 THE SCALE OF THE CRISIS 15,000 ~------=-,~====:;__ In 2014, the latest year for which national data is available, nearly 30,000 individuals died from opioid overdose in the U.S. This number increased steadily during the last two decades, from 6,242 deaths in 2000, to 12,991 in 2005, and 19,687 in 2010. 10,000 5,000 2000 2005 2010 2015 Source: Centers for Disease Control and Prevention In 1991, health 1~1111 Meanwhile, Mexican professionals wrote heroin production 76 MILLION increased from ~II! opioid prescriptions ;~ 8 METRIC TONS - in the U.S. TO t-1 ~~Q In 12 STATES .the 50 METRIC TONS number of prescriptions written for painkillers between 2005 and 2009. In 2 011 , t h ey wrote exceeded the number of Source : National Institute on Drug Abuse 219 MILLION. people in the state. 6 NACo -NLC : A PRESCRIPTION FOR AC I ION 062717 HC BOC Page 38 + OVERALL, AMERICANS CONSUME UPTO 80°k OF THE WORLD'S PRESCRIPTION OPIOIDS. Source: Centers for Disease Control and Prevention On an average day in the U.S., accord i ng to the Department of Health and Human Services, health care professionals dispense more than EACH DAY: 650,000 OPIOID PRESCRIPTIONS. 3,900 People initiate nonmedical use of prescription opioids for the first time. 580 78 People use heroin for the first time. People die from an opioid- related overdose. Source: U.S. Department of Health and Human Services : .. · : NACo · NLC: A PRl:SCRIPl ION f'OR AC rlON 7 062717 HC BOC Page 39 County Leadership Forum on Opioid Abuse Summary of Additional Resources State & Federal Prevention & Education Sources 1. Substance Abuse and Mental Health Services Administration: https://www.samhsa.gov/ 2. SAMHSA Treatment Locator: https://findtreatment.samhsa .gov/ 3. NC Department of Insurance, Operation Medicine Drop: http://www.ncdoi.com/OSFM/SafeKids/0peration%20Medicine%20Drop%20for%20Safety%20P rofessionals.aspx?sec=omd 4. Governor's Institute on Substance Abuse: http://governorsinstitute.org/ 5. Generation Rx -Safe Medication Practices: http://www.generationrx.org/ 6. Mental Health First Aid USA: https://www.mentalhealthfirstaid.org/cs/ 7. "A Prescription for Action: Local Leadership in Ending the Opioid Crisis," a joint report from the National League of Cities and National Association of Counties: http://opioidaction.org/wp- content/uploads/2017 /01/NACo-NLC JointOpioidReport FINAL 12.15.16.pdf 8. NC Department of Health and Human Services, Division of Mental Health, Developmental Disabilities and Substance Abuse Services Proposal to Address: Substance Abuse and Mental Health Services Administration Funding Opportunity Announcement No . Tl-17-014 CFDA No. 93.788 -State Targeted Response to the Opioid Crisis Grants: https://ncdhhs.s3.amazonaws.com/s3fs-public/NC%200pioid%20STR%20Final%20Narrative.pdf Data Sources 9. Prescription Rates by County: http://www.ncdhhs.gov/divisions/mhddsas/ncdcu/prescription- rate s-by-cou nty 10. NC Controlled Substances Reporting System Utilization by County: http://www.ncdhhs.gov/divisions/mhddsa/ncdcu/csrs-utilization-by-county 11. Poisoning Data: http://www.injuryfreenc.ncdhhs.gov/DataSurveillance/Poisoning.htm 12. Prescription and Drug Overdoses: http://www.injuryfreenc.ncdhhs.gov/About/PrescriptionFactSheet2015-0ct2016.pdf 13. Opiate Deaths by County 1999-2015: http://www.injuryfreenc.ncdhhs.gov/DataSurveillance/poisoning/AIIOpiatePoisoningDeathsbyC ounty-1999-2015.pdf 14. National Institute on Drug Abuse -Overview of Prescription Opioids and Heroin: https ://www .drug abuse .gov /pu bl icatio ns/resea rch-reports/relationsh i p-betwee n-p rescri ptio n- d rug-a buse -heroi n-use/introd uctjo n 15. Port City Daily (New Hanover County) Opioid Articles: http://portcitydaily.com/?s=opioid 16. New Hanover County PSA on Opioid Abuse, featuring Elected Officials: http ://news. n hcgov .com/news-releases/2017 /04/new-ha nover-cou nty-prod uces-opioid - epidem ic-pu bl ic-service-a n nou nce ment/ 062717 HC BOC Page 40 County Leadership Forum on Opioid Abuse Treatment Support Services 17. Alcohol & Drug Council of NC: https://alcoholdrughelp.org/ 18. Alcohol & Drug Council of NC -Women's Services: https://alcoholdrughelp.org/getting- help/womens-services/ 19. NC Pregnancy and Opioid Exposure Project: http://www.ncpoep.org/ 20. Recovery Communities of NC : https://rcnc.org/ 21. North Carolina Treatment Accountability for Safer Communities (TASC) Fact Sheet: https://ncdhhs.s3.amazonaws.com/s3fs-public/documents/files/factsheet13 .pdf 22. Local Management Entity associated with your region and drug treatment support facility 062717 HC BOC Page 41 County Leadership Forum on Opioid Abuse DHHS Regional LME Liaisons LME/MCO NAME EMAIL Alliance Behavioral Healthcare Yvonne French Y)LO n ne. french (a)d h hs. n!;;.gQv Cardinal Innovations Healthcare Janet Breeding janet.breeding(a)dhhs.nc.gQv Solutions Eastpointe Dennis Williams dennis.d.williams(a)dhhs.nc.gQv Partners Behavioral Health Yvonne French y_vo n ne. french (a) d h hs. nc.gov Management Sand hills Center Dennis Williams dennis.d.williams(a)dhhs.nc.gov Trillium Health Resources Dennis Williams dennis.d.williams(a)dhhs.nc.gov Vaya Health Yvonne French Y)l.Qnne .french(a)dhhs.nc.gQv Substance Use Disorder Contacts LME/MCO NAME EMAIL Alliance Behavioral Healthcare Kimberly Hayes Khay_es(a)alliancebhc.org Alliance Behavioral Healthcare Suzanne Davis-sdavis-rna ceos(a)a 11 ia oceBH C.Q rg Marens Cardinal Innovations Healthcare Allison Crotty a I lisQn .crQtty_(a)ca rd i oa Ii n nQvatiQns,Qrg Solutions Cardinal Innovations Healthcare Amy Weatherman amy_.weatherman(a)cardinalinnQvatiQns.Qrg Solutions Cardinal Innovations Healthcare Christine Beck christine .beck(a)cardinalinnQvations.Qrg Solutions Cardinal Innovations Healthcare Lynn Widener ly_nn .widener(a)cardinalinnovations.or£ Solutions Eastpointe Courtney Boyette cboy_ette(a)eastgointe .net Eastpointe Lynnette Gordon lgordon(a)east12ointe.net Eastpointe Victoria Jackson vjackson(a)ea st12ointe.net Partners Behavioral Health Diane Morrison dmQrrisQn@12actnersBHM .Qrg Management Sandhills Center Lucy Dorsey ly!;;y_.d Qrsey_@sa nd hi I lscenter .Qrg Sand hills Center Gene McRae genem(a)sandhillscenter.org Trillium Health Resources Mary Bartek Ma[Y..Bartek(a)trilliumnc .org Trillium Health Resources Michelle Stanley Michel le,Staoley_@tril liumm;.Qrg Trillium Health Resources Sarah Mooring Sarah.Mooring(a)trilliumnc.Qrg Vaya Health Brenda Chapman brenda .!;;ha 12ma n (a)vay_a h ea Ith .org Vaya Health Jeff Brooks Jeff.Brooks@vay_ahealth .com 062717 HC BOC Page 42 062717 HC BOC Page 43 Letter from Task Force Co-Chairs T he epidemic of overdoses and deaths from the abuse of prescription painkillers and heroin has devastated countless families and communities across the country. In August, 2016 alone -as this joint task force convened by the National Association of Counties and the National League of Cities carried on its work -news reports informed us of 174 overdoses in six days in an Ohio city; 8 overdoses in 70 minutes in a Pennsylvania county and 26 overdoses in 3.5 hours in a West Virginia city. Although news outlets often provide l ittle more than a running tally of the epidemic, lead ers at the local level experience the human costs of this public health crisis one life at a time. We confront the tragedies of this epidemic in rural counties and in urban cities, and no portion of society is immune from the devastation . Families are shattered without regard to income, race, ethnicity, gender, edu cationa l attainment or family structure. As city and co unty leaders e ntrusted with preserving the health, safety, and vitality of our communities, it is our duty to act w ith urgency to break the cycles of addiction, overdose, and death that have taken hold in so many corners of this nation. To that end, the report that follows features recommended policies and programs that are designed to help local leaders address the opioid epidemic. These recommendations reflect several core convictions: that addiction is an illness; that although law enforcement is critical to an effective response to this epidemic, we cannot simply arrest our way out of a crisis of addiction; and that to stem the tide of th is e pidemic and combat the stigma that often accompanies it, we must build partnerships across ~W.frZ-a~ our communities and with our counterparts at the local, state and federal levels. As we embrace these convictions, we recognize that they differ from those that informed our nation's response to previous drug epidemics. During the crack cocaine epidemic of the 1980s and 1990s, addiction was criminalized -through policies like mandatory minimum sentences and three strikes laws -resulting in mass incarceration of African- Americans and Latinos. Our communities of color continue to feel the detrimental effects of these policies. It is important that we reflect upon past policies and their impact on our communities as we formulate our response to an epidemic that threatens every community across the country. Further, although it is not in our power to change the past, we can help to undo some of the damage caused by our prior responses. First, we ca n expand and r e plicate the compassion for those strugg lin g with add iction and the public support for diversion and treatment programs to individuals throughout the criminal justice system. Second, we can support sentencing reform legislation that would retroactively apply to individuals still serving time for non-v iolent drug-related co nvictions. It has been said that in every crisi s lies the seed of opportunity, and the opioid crisis presents an in va luable opportunity for c ity and county officials: an opportunity to assess the way we respond to addiction and to formulat e lasting and equitable responses that promote h ea lth, safety, and opportunity for all members of our communities. JUDGE GARY MOORE Boone County, Kentucky Task Force Co-Ch ai r MAYOR MARK STODOLA Littl e Rock , Arkansa s Task Force Co-Cha i r NACo -NLC : A PRESCR IPT IO N FOR ACTION 3 062717 HC BOC Page 44 List of Task Force Members NATIONAL ASSOCIATION OF COUNTIES MEMBERS Co-Chair -Judge/Executive Gary Moore, Boone Co unty, Ke ntucky Commissioner Matt Bell, We b er County, Ut ah Commissioner Doug Corcoran, Ross Cou nt y, O hi o County Executive Kathy Dahlkemper, Er ie Cou nty, Pe n nsylv ani a Dr. Vidya Kora, Commissioner, La Po rte C ou nty, Indiana County Council Member Waymon Mumford, Fl o rence Co unty, So uth Carolina Supervisor Leticia Perez, Ke rn County, Cal ifo rni a County Executive Mark Poloncarz, Eri e Cou nty, N ew Yo r k Commissioner Greg Puckett, M e rc er Cou nty, West V irginia County Executive Steve Schuh, An ne Aru nde l C ou nty, M aryl a n d Commissioner Judy Shiprack, M ul t noma h Cou nty, Oregon NATIONAL LEAGUE OF CITIES MEMBERS Co-Chair -Mayor Mark Stodola, Li ttle Rock, Arkansas Counci lmember Walt Allen, Covin a, Ca li forn i a Executive Director Geoff Beckwith, M assach u setts Mu n i cipa l Associati on City Manager Lee Feldman, Fort Lauderda l e, Fl o ri da Councilmember Leta Mach, Green belt , Maryland Council President Ceasar Mitchell, A tl anta, Georgia Councilmember Joel Navarro, Tempe, A r izona Mayor Nan Whaley, Da yto n , Ohi o Police Chief Nick Willard, M an c h este r, N ew Ha m ps hi re Councilmember Lavonta Williams, Wich it a, Kansas Mayor Stephen Williams, H untington, W est Virgi n ia N ACo -NLC : A PRESCR I PTIO N FOR ACTIO N 5 062717 HC BOC Page 45 Table of Contents I. INTRODUCTION: RESPONDING TO A CRISIS .............................. 1 0 11. RECOMMENDATIONS FOR LOCAL LEADERS ........ . . .................. 14 Lea di ng i n a Crisis ................................................................................................ 1 7 1. Set the Tone in the Local Conversation on Opioids 2. Convene Community Leaders 3. Foster Regional Cooperation 4. Educate and Advocate to State and Federa l Partners 5. Ensure Progress for All in Formulating Responses to Addiction Focus i ng o n Pr evention an d Ed u ca t io n ..................................................................... 2 1 1. Increase Public Awareness by All Avai l ab le Means 2. Reach Children Early, In and Outside of Schools 3. Advocate for Opioid Train i ng in Higher Education 4. Embrace the Power of Data and Technology 5. Faci l itate Safe Disposa l Sites and Take -Back Days Exp a n d i ng Tre atment ............................................................................................ 27 1. Make Naloxone Widely Availab l e 2. Intervene to Advance Disease Control by Implementing a Clean Syringe Program 3. Increase Avai l ability of Medication-Assisted Treatments 4. Expand Insurance Coverage of Addiction Treatments 5. Employ Telemedicine So l ution 8 NACo · NLC : A PRESCR I PTI O N FOR ACTIO N 062717 HC BOC Page 46 Re ass e ssing Public Safety and La w Enforcement Appro aches ........................................ 33 1. Reduce the Illicit Supply of Opioids 2. Consider Alternatives to Arrest 3. Divert from the Criminal Justice System 4. Facilitate Treatment in Jails 5. Support "Ban the Box" Initiatives Ill. RECOMMENDATIONS FOR STATE AND FEDERAL LEADERS ....... 4 0 Sta t e Re comm e ndati on s ......................................................................................... 43 1. Establish or Strengthen Prescri ption Drug Monitoring Programs 2. Institute Guidelines for Pre scribing Opioids 3. Support Greater Availability of Medication-Assisted Treatments 4. Structure Medicaid Programs to Promote Safe Opioid Prescription Practices and Access to Treatments 5. Explicitly Authorize or Remove Barriers to Clean Syringe Programs Federal Re co mme n datio ns ..................................................................................... 44 1. Expand Access to Medication-Assisted Treatments 2. Provide Funding for Local Efforts to Address the Opioid Crisis 3. Partner with Local and State Officials to Reduce the Supply of Fentanyl and Carfentanil 4. Allow Ind ividuals in Custody to Continue Receiving Medicaid Benefits Until Convicted, Sentenced and Incarcerated and Require States to Suspend, rather than Terminate, Medicaid for Individuals in Jail ACKNOWLEDGMENTS ........................ . . ................... 4 8 N ACo -NLC: A PRESCR IPTIO N FOR ACTIO N 9 062717 HC BOC Page 47 Responding to a Crisis As the opioid epidemic has taken hold, city and county leaders are taking action . The number and scope of programs in place are a testament to the problem-solving skil ls of local officials. With both determination and imagi nation, local leaders are expanding p r evention and treatment programs a nd giving more flexibility to public safety perso nnel who interact daily w ith ind iv iduals strugg ling wi t h addiction. Knowing that loca lities cannot end th i s epidemic alone, these lead ers are actively seeking partnerships and exploring innova tive strategi es that cha ll enge old conventions about the stigma of addiction. In early 2016, th e National League of Cities and the Nati ona l Association of Counti es convened a joint task force to identify the l ocal pol i cies and practices that reduce opioid abuse and related fatalities. The task force met twice, in Washington, D.C., and in n orthern Kentucky. These meetings, coupl ed with countless co nversations with local officials from across the cou ntry, inclu di ng public health directors, prosecutors, law enforcement officials and substance abuse directors, enabl e d the t ask force to prod u ce th is report and its re commendations. The recommendations are a imed at city and county officials and are divided into four sections: 1) lead e rsh ip, 2) educ ation and prevention, 3) treatment and 4) public safety a nd law enforcement. Several of the recommendations a re accompanied by existin g l ocal practices from cities and counties. The report a lso includes recommendations for state and federal officials, who are pivotal partners in local efforts to combat opioid m isuse, dive rsion , overdose and death. The contents of this report, in addition to expanded case studies a nd further resources t o aid l ocal officials in addressing the opioid cris i s, ar e available online at http://www.opi o ida ction .o rg /. N ACo -NLC : A PRESCRIPTIO N FOR A CTION 13 062717 HC BOC Page 48 Leading in a Crisis In early 2016, the Massachusetts Municipal Association published a report for local leaders on the opioid crisis aptly titled "An Obligation to Lead." The opioid epidemic, wrote the association, "presents more than an opportunity," and is a "mora l duty that all of us who are privileged to serve in local government must embrace fully." We wholeheartedly echo those sentiments and call on city and county leaders to assume l eadership roles in local efforts to reverse the trends of the opioid epidemic. It has become apparent that this epid emic can ravag e any community in the nation regardless of its size or composition. In the face of such a threat, which has taken far too many li ves and torn apart countl ess families, l oca l officials must lead with energy, urgency and compassi on. There is much to be accomplished in reversing the opioid epidemic, and few are better positioned to carry out this work. N ACo -NLC: A PRESCR IPTIO N FOR ACTIO N 17 062717 HC BOC Page 49 Recommendations 0 Set the tone in the local conversation on opioids. As local government officials, we are privileged to speak to our constituents with the authority and legitimacy that comes with public office and the trust and empathy derived from l iving daily in the communities we serve. From this invaluable position, we must set the tone in conversations about opioids by breaking the silence and speaking candidly and compassionate ly about the crisis in our cities and counties. However, we must also highlight and uplift local efforts to prevent further abuse of opioids and the overdoses and deaths that result from such abuse. In short, we must define our local struggles with the opioid crisis so that those struggles do not define our cities and counties. By setting a constructive and compassionate tone in conversations on opioid abuse, we can achieve the imperative of chipping away at the stigma of opioid addiction. Stigma can prevent parents and teachers from speaking with children about the dangers of opioids, prevent individuals struggling with opioid addiction from seeking the treatments they need and prevent cities and counties from providing these treatments. As local leaders, we must normalize conversations about addiction and its treatment to empower individuals, families and governments to take actions needed to address the opioid crisis, without fear of the stigma that such actions may bring. Convene community leaders. It is imperative that local government officia ls be in regu lar contact with community leaders who work with populations affected by the opioid crisis and who are thus well positioned to contribute to effective local responses. City and county leaders should form o r join loca l task forces of leaders from various sectors of local government and across the community to assess the causes and impacts of opioid abuse and the solutions needed to decrease rates of abuse. Elected officials, health officia ls-including behavioral h ea lth and substa n ce abuse directors- judges, prosecutors, public defenders and law enforcement officials, among others, should be involved in the task forces. Joining them should be education officials, representatives from l oca l medical societies, directors of treatment facilities, parent advocates and faith lead ers. The Community Anti-Drug Coalitions of America (CADCA) helps to establish or strengthen l oca l coa litions to create and maintain safe, healthy and drug-free communities. CADCA can point to community coalitions in an area or walk l oca l government officials through the process of starting a coa l ition. The organization also offers a variety of resources for loca l coa litions, including technical assistance and training and media and marketing strategies. 18 NACo -N LC : A PRESCR I PTIO N FOR ACTIO N 062717 HC BOC Page 50 e Foster regional cooperation. Just as it imperative that local government officials establish regular communication with leaders in the community, it is also vital to establish or strengthen lines of communication with neighboring governments. Although the causes and impacts of the opioid crisis may differ in neighboring communities, solutions are more effective when coordinated among the various governments within a region. Regional cooperation is perhaps most important in law enforcement, given that drug trafficking often cuts across local lines. In northern Kentucky, the counties of Boone, Campbell and Kenton and the city of Bellevue have formed a regional task force that enables their law enforcement departments to work cooperatively in drug enforcement. Whether through formal task forces like northern Kentucky's or through less formal regular meetings, regional cooperation should not be overlooked. ~ Educate and advocate to state and federal partners. Although we firmly believe that the opioid crisis must be confronted and addressed locally, we are also cognizant that many important decisions that affect this crisis are made at the state and federal levels. City and county officials should educate their state and federal counterparts on the effects of the opioid crisis on local communities and advocate for actions from those levels of governments that can help reverse trends of opioid misuse. State and national membership organ izations, like the National League of Cities and the National Association of Counties and their sister organizations in states, are well positioned to assist local officials with state and federal advocacy. See the section on "Recommendations for State and Federal Officials" for specific state and federal actions that can help local governments address the opioid crisis. Ensure progress for all in formulating responses to addiction . Communities of color continue to feel the detrimental effects of the criminalization of addiction , which today is being replaced by a new focus on harm reduction and improved public health. Moving forward, we must give ongoing attention and action to the racial disparities relevant to addiction and to its treatment. Both the National League of Cities and the National Association of Counties should continue programs of research, information sharing , educational programming, advocacy and technical assistance in the fields of addiction and addiction treatment beyond the duration of this task force. NACo -N LC: A PRESCRIPTION FOR ACTION 19 062717 HC BOC Page 51 Focusing on Prevention and Education It is said that an ounce of prevention is worth a pound of cure, and this certainly applies to our efforts to fight the opioid crisis. Given the staggering number of overdoses and deaths from the opioid crisis, a heavy focus is placed, with good reason, on treatm e nt. But that focus and urgency should not diminish our determination to prevent others from becoming addicted in the first place. Preventing individuals from abusing and becoming dependent on opioids will save l ives, preserve the health and vibrancy of our communities and result in sign ificant fiscal savings for loca l governments, many of which are struggling to fund addiction treatments. By approaching prevention and education efforts with the same urgency and determination with which we work to reverse overdoses and arrest drug traffickers, we can begin to create the cultura l transformation needed to free our commun iti es from the grip of the opioid crisis. NACo -NLC : A PRESCR IPT ION FOR ACTION 21 062717 HC BOC Page 52 Recommendations 8 Increase public awareness by all available means. As local elected leaders, we are uniquely positioned to spread information about the dangers of prescription painkillers and the lethality of heroin and other illicit opioids. From traditional forms of communication, like town hall meetings and pamphlets, to newer forms, like Face book and Twitter, we have numerous platforms through which to communicate with our constituents. We must fully use these platforms to increase public awareness about the dangers of opioids, and we must be thoughtful and creative in crafting our messaging. Further, we must actively look for new opportunities to commu nicate with constitu e nts, especial ly those who may be at greater risk of opioid abuse and addiction. The Ocean County, N .J., prosecutor's office has done this through its "fune ral cards," which contain information about the dangers of prescription painkillers alongside instructions for proper disposal of remaining prescriptions. The prosecutor's office gives these cards to funeral directors, who then hand them out to families of deceased individuals. TOOLS AND EXAMPLES PARENTS WILi! ii.iS CHANGED SUKI YOU wm A 111• .1ouu11 YOURSltVEs. KNOW HOW ro HEtr ·-~RESOURCES • lWN ABOUT THE IJTfST DRUG RENDS AND WHAT COMMON ITEMS MAY INDICATf RISKY BEHAVIOR. FIND OUT WHERE TO I.LUM MORE OR GET Hll.P. fRlf SION50REDSYLOCAL ORGANIZATIONS THAT CAA£ MAY 15-22 2016 MILL~EEK MALL I MACY'S CENIER COURT Th in kin g O utsid e the Box In Erie County, Pennsylvania, paren ts are educated about the symptoms of adolescent drug abu se through open-b e droom displays loca ted in shopping malls. Reach children early, in and outside of schools. Children should be educated at the earliest possible age about the dangers of prescription painkillers and illicit opioids. C lassrooms provide an excellent opportunity to do so. The 22 N ACo -NLC : A PRESCR IPTI O N FOR ACTI O N 062717 HC BOC Page 53 National Institute on Drug Abuse offers free resources for teachers, including lesson plans, activity finders a nd student-targeted pamphlets that answer questions like, How do opioids wo r k? How do people get add i cted to opio id s? Out-of-school recreation programs also provide valuable opportunities to engage children and youth on these topi cs. Local elected officials should also call on each parent in the community to speak regularly with their children about the dangers of presc ripti o n and illicit opioids. According to the Red Ribbon Campaign, an initiative of the National Family Partnersh i p that asks parents to pledge to educate their chi ldren about drug abuse, ch ildren of parents who speak with their teen s regularly about drugs are 42 percent less likel y to use drugs than those whose parents do not, yet only one-fourth of teens repo rt having these conversations. Advocate for opioid training in higher education. Students in health-related undergraduate and graduate programs, in addition to those in medical, p harm acy, nursing and dental schools, should receive appropriate tra ining on pain management and substance use disorders. City and county leaders should assess the extent to w h ich this training is provided in educational institutions within their jurisdiction and use their positions as elected leaders to advocate for greater training where needed. Although the importance of opioid prescription training for medical and dental students i s self-evident and overarching, local leaders should a lso advocate for drug abuse intervention NACo -NLC : A PRESCR IPTIO N FOR ACTIO N 23 062717 HC BOC Page 54 training for all students in health-related fields. The Screening, Brief Intervention and Referral to Treatment (S BIRT) program is an evidence-based approach endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA). It promotes universal screening of all individuals to identify use, early risks and abuse in order to intervene appropriately. Basic SBIRT training is available via a free app developed at the Baylor College of Medicine. 8 Embrace the power of data and technology. Local leaders must recognize the potential of data and technology to advance efforts in fighting the opioid crisis. When properly collected and analyzed, data can help cities and counties better understand the causes of opioid abuse in communities and fine-tune their responses. Data related to overdoses and deaths, for example, can help local leaders focus public awareness efforts on neighborhoods facing greater rates of opioid-related harm . City and county leaders should assess where data is being collected within local government and to what extent it is being shared between different departments and local, regional and state governments. In addition, city and county leaders should advocate for greater data col lection and use of data and technology. Coroners should list with specificity the drugs that caused opioid-related deaths so public health and law enforcement officials can adjust r esponses accordingly. Administration of the overdose antagonist naloxone should be tracked closely to better target overdose prevention and treatment efforts. Mapping technology ca n also provide information to individuals about resources such as safe disposal locations, pharmacies that dispense naloxone and facilities that offer treatment services. C, Facilitate safe disposal sites and take -back days . Cities and counties must ensure that there are a sufficient number of accessible, safe disposal sites within their jurisdiction so members of the community can dispose of unneeded opioids. Local pharmacies, physicians and law enforcement can serve as important partners in efforts to provide and promote safe and convenient disposal sites. Information about these sites shou ld be widely shared through traditional and web-based forms of communication. Cities and counties should also host period i c drug take-back days so community members can dispose of unneeded opioids at a convenient location whi l e also creating public awareness about the dangers of prescription drugs. Th e Drug Enforcement Administration (DEA) partners with local communities across the country to host national take-back days. On April 30, 2016, Franklin County, Ohio, collected 4,000 pounds of prescription drugs, and the DEA reported that 447 tons were co llected overa ll throughout the country. 24 N ACo -NLC : A PRESCR IPT IO N FOR ACTION 062717 HC BOC Page 55 Expanding Treatment As society has embraced the need to medically treat addiction rather than in ca r cerate those with a substa nce use disorder co nvi cted of a crime, the need for treatm ent longer than 90 days has grown and overwhelmed city, county and state governments' ability to respond. But we do know how to treat chronic illness. Nearly the same number need treatment for diabetes (29 million) as those needing treatment for substance use disorder (21 million). Yet roughly three of four diabetes patients receive treatm ent while only 12 percent of those with substance use disorder do, according to estimates from the Centers for Disease Control and Prevention. Society is in short supply of drug treatment specia li sts to carry o u t medication -assisted treatments and dispense methadone, buprenorphine and naltrexone. Training programs are necessary for health professionals, and more patients shou ld be served by doctors in private practice. Arbitrary caps shou ld be removed on the number of patients undergoing medication-assisted treatments, at least during the present epidemic. N ACo -NLC : A PRESCR IPT IO N FOR A CTI O N 27 062717 HC BOC Page 56 Recommendations 8 Make naloxone widely available. Local leaders should work to ensure that nal oxone, an overdose recovery medication, is made widely available in each community and provided to all city and county first responders. Nearly 40 states now grant some broad authority to pharmacists-such as through a standing prescription order from the state's public health director or by a co llaborative drug therapy agreement-to distribute naloxone not only to those with an opioid prescription but to those who support or act as caregivers to people suffering with addiction, and in some cases to the general public. This practice should be operational in all 50 states and territories. Bulk purchasing agreements by organizations such as the U.S. Communities Government Purchasing Alliance can make this life-saving drug available to cit ies and counties at a significant discount, easing the cost burden on local government. The administration of naloxone should be followed by medical holds, referrals or "warm handoffs" to counseling and treatment services that help individuals address the underlying drug abuse that led to their overdose. Without follow-up services, administering naloxone can amount to d elaying a lethal o verdose, rather than saving a life. e Intervene to advance disease control by implementing a clean syringe program. Safe disposal of unused prescription medications and needles contaminated with blood are importa nt steps to protect against outbreaks o f HIV and hepatiti s. Establishing places or programs to deposit used syringes and needles not only helps w ith disposal, but also opens a path for individuals seeking substa nce use treatment. At a minimum, l ocalities can provide information on hospitals, cli n ics or other health facilities and providers w ho wi ll 28 NACo -NLC : A PRESCRIPTION FOR ACTION TOOLS AND EXAMPLES Recovery coaches in Ocean County, N .J. The Ocean County prosecutor's office has lau nched the "Recovery Coach Program," a volu ntary program that connects in dividua ls revived by naloxone with treatment options once they are stabilized in emergency rooms. Working with area hospitals, the program matc h es an overd ose victim with a recovery coach, who, if the patient is willing , will work with the person for up to eight weeks and help steer him or her toward recovery. Free or subsidized treatment is available for willing participan ts. The coaches are typically in recovery t hemselves, whi ch officials say provides a p e rspective that doctors and law enforcement officia ls cannot. Early in t he program, up to 70 perce nt of overdose victims had agreed to participate in the program . 062717 HC BOC Page 57 receive or exchange contaminated syringes and needles for new ones. One such program, The Point, developed by the Center for Health and Social Research at SUNY Buffalo in collaboration with the Erie County, N.Y., Department of Health, provides information on l ocations where an individual can access clean needles and syringes. Increase availability of medication-assisted treatments. A regimen of long-term (six months or more) medication exchange (such as methadone, buprenorphine or naltrexone replacing heroin), psychological counselin g, peer-to-peer support networks and close patient monitoring is the evid e nce-based model to address addiction and co-occurring mental health problems. Such sophisticated medication-assisted treatment requires highly trained practitioners and access to often costly medication. At present there are too few drug treatment specia l ists to meet the growing demand. Progress can be made if more health professionals, such as licensed practical nurses, can undergo training to properly administer medications such as buprenorphine and naltrexone. Both the federal government and county governments (such as Erie County, N.Y.) have expanded the availability of such training programs. N ACo -NLC: A PRESCRIPT ION FOR ACT IO N 29 062717 HC BOC Page 58 Efforts are in place to make better use of community health centers to increase treatment services. Likewise, rules that limit the number of patients to whom any single physician can prescribe buprenorphine are barriers to increasing treatment. Instead of capping the level of physician treatment, doctors in private practice should be incentivized to treat more patients struggling with a substance use disorder. Increasi ng the cooperation between city and county governments to enhance the number of beds for long-term medication-assisted treatment is critical to overcoming this health crisis. G Expand insurance coverage of addiction treatments. Local leaders should advocate for including addiction treatments in all health insurance plans and removing limits on such treatments. In addition, city and county officials should work to ensure that the health plans of local government employees cover addiction treatments. Given that cities and counties together employ several million individuals, including addiction treatments in local government health plans represents a significant step toward enabling individuals to access affordable treatments for substance abuse. 0 Employ telemedicine solutions . Although the nature of addiction treatment often requires in-person visits with medical professionals, telemedicine can enhance these treatments. Advances in technology have expanded access to health professionals and extended the capacity of each individual service provider to meet the growing needs ofthose with substance use disorders. For paramedics responding to calls, telemedicine can facilitate immediate support to patients. The technology is also useful in serving rural populations, where distance between first responders and patients is often a critical factor. The U.S. Department of Agriculture has awarded Distance Learning and Telemedicine grants to establish telemedicine networks to provide treatment for medical conditi ons, including mental health and drug addiction treatment. These grants are also designed to expand and improve rural counseling centers with mental, behavioral and psychiatric care services and substance treatment services, and to support mobile health units providing onsite care a nd telemedicine video conferencing with doctors and specialists. 30 NACo -NLC: A PRESCRIPTION FOR ACTION 062717 HC BOC Page 59 Local leaders should advocate for including addiction treatments in all health insurance plans and removing limits on such treatments. NACo -NLC: A PRESCR IPTION FOR ACTION 31 062717 HC BOC Page 60 Reassessing Public Safety and Law Enforcement Approaches Cities and counties have been fighting the "war on drugs" for nearly five decades, and unlike many other wars, this war is waged on American soil. Because this war has largely failed to differentiate between individuals struggling with addiction and traffickers who profit from addiction, communities, and in particular communities of color, have suffered extensive casualties in the war. The end result of this criminalization of addiction has been a cycle of over-incarceration that fails to address the root causes of drug abuse in our communities and costs taxpayers trillions of dollars. In recent years, and with the onset of the opioid epidemic, local governments are reassessing and shifting approaches to drug enforcement. Although law enforcement agencies continue to carry out the important task of aggressively pursuing the drug traffickers and cartels that are flooding our communities with illicit drugs such as heroin and fentanyl , they are placing a greater focus on alternatives to arrest for those whose low-level criminal behavior is rooted in addiction. NACo -NLC : A PRESCRIPT IO N FOR ACTIO N 33 062717 HC BOC Page 61 Good Samaritan laws that provide legal protection for individuals who report overdoses have also been widely embraced. Local law enforcement and public safety officials must continue to work closely with health care providers, addiction treatment facilities, and drug courts to identify such alternatives. Equipped with the discretion to use these alternatives, local law enforcement officials can continue to play a crucial role in helping to break the cycle of addiction that, as past efforts to criminalize addiction have made clear, cannot be solved through arrest and incarceration. Recommendations 0 Reduce the illicit supply of opioids. City and county leaders should facilitate partnerships between local law enforcement and their state and federal counterparts to identify the flow of illicit drugs into communities. They should use all available l aw enforcement resources to incarce rate drug traffickers. Local law enforcement agencie s should work closely with DEA's State and Local Task Force Program. Th e program's ability to combine federal resources w ith state and local officers' detailed knowledge of their jurisdictions l eads to high ly effective drug e nforcement investigations. By targeting drug traffickers and the supply chain of drugs, local l aw enforcement can dramatically reduce the availabi lity of drugs in communities. Reducing supply is especially important as drug dealers TOOLS AND EXAMPLES Drug Market Intervention in High Point, N .C. First piloted in 2004 in High Point, N.C., Drug Market Intervention (O M/) is a strategy for shutting down overt drug markets and improving life for residents in the surrounding communities. DMI identifies particular drug markets and street-level dealers, arrests violent offenders, creates "banked" cases-or suspends prosecution-for nonviplent dealers and brings together dealers, their families , law enforcement officials, service providers and community leaders for a call-in meeting that makes clear that selling drugs openly must stop. The strategy also includes a critical process of racial reconciliation to address historical conflict between law enforcement and communities of color. are increasingly lacing heroin with lethal drugs like c arfentanil, which is used to sedate large animals. Drug u sers are typically unaware that the drugs they are purchasing are laced in this way, resulting in greater frequency of lethal overdoses. In August 2016, in a span of just two 34 N ACo -NLC: A PRESCR I PT IO N FOR A CTI O N 062717 HC BOC Page 62 days, Cincinnati's emergency services responded to more than 60 heroin overdoses, many of which resulted from batches of heroin laced with carfentanil. Active and collaborative drug enforcement is key to preventing further tragedies . Consider alternatives to arrest. City and county leaders should empower local law enforcement officials to u se alternatives to arrest for individuals who commit low-level crimes associated with drug abuse and often co- occurring mental health issues. Illicit drug use and low-leve l possession of drugs continue to be treated as criminal behavior throughout the country, leading to millio n s of arrests each year. However, many local law enforcement agencies have taken the position that arresting users for possession is not an effective way to change behavior. Instead of criminalizing drug addiction, communities are now addressing the problem as a treatable disease that requires intervention and treatm e nt. The International A ssociation of Chiefs of Poli ce states that law enforcement leaders "should strive to create innovative partnerships with public health providers and rehabilitation experts to help line officers respond more effectively to substance abusers with an increa sed array of alternative solutions to inca rceration." Local law enforcement officers are among a community's best resources in the effort to identify individuals with who need treatment for a substance use disorder and divert those individuals to needed treatment services. As an alternative to arrest and incarceration, local law enforcement officers should be able to refer drug addicts to loca l, community-based drug treatment programs to break the cycle of drug use. Lo ca l governments should train local law enforcement officia ls on resources that are available for drug treatment programs and how individuals who need treatment can access these programs. N ACo - N LC: A PRESCR IPT IO N FOR ACT IO N 35 062717 HC BOC Page 63 TOOLS AND EXAMPLES Seattle/King County LEAD Program In 2011 , Seattle and King County began piloting the Law Enforcement Assisted Diversion Program (LEAD) to address low -level drug and prostitution crimes in targeted city neighborhoods and parts of King County. The program 's goals are to improve public safety and public order and to reduce the criminal behavior patterns of people who participate in the program. LEAD is a coalition of law enforcement, public health, city and county officials, community stakeholders and private -sector supporters. LEAD is a pre-booking diversion program that empowers street-level public safety personnel to make decisions about arrests. Rather than moving persons with substance use disorder into the criminal justice system, LEAD participants begin working immediately with case managers and social workers. In the case o f persons suffering from addiction, LEAD participants have access to trained clinicians who specialize in medication-assisted treatments and have been the key providers in the region for street-level outreach. Treatment services may include substance use disorder treatment, mental health support, housing and job training. LEAD has been independently evaluated by researchers from the University of Washington . They find that the program reduces recidivism significantly among participants (both on a prelpost-parti cipant- only analysis and when compared with a selected group of controls) and also reduces criminal justice spending. e Divert from the criminal justice system. City and county officials should advocate for diversion from in carce ration for n onvio lent individuals whose low-level c riminal behavior stems from thei r drug addiction. Many com mun ities t hroughout the country have established drug courts to help individ u al s struggling with addiction enter a substan ce abuse program instead of serving time in jai l. Drug courts employ a program designed to reduce drug use relapse and criminal recidivism through risk and needs assessment, judicial interaction, monitoring and supervision, g raduated sanctions and incentives, treatment and various rehabilitati on servi ces. A multidisciplinary team of judges, prosecutors, defense attorneys, community corr ections, socia l workers and treatment service professiona l s often manages the courts and provides targeted treatment servi ces to drug offende rs . Althoug h drug courts have higher i nvestment costs, especially in t reatme nt services, many communities have experienced extensive savings associated with victim and criminal justice system costs because of fewer crimes, rea rrests and incarcerations. On average, drug co urts save an es tim ated $5,680 to $6,208 per offender. 36 NACo -NLC : A PRESCRIPTION FOR ACTION 062717 HC BOC Page 64 Diversion courts have a particularly positive impact on our nation's veterans. According to a 2011 study from the U.S. Department of Veterans Affairs (VA}, veterans are nearly twice as likely to die from an accidental opioid overdose than their civilian counterparts. Veterans' treatment courts offer an opportunity for those suffering with substance abuse or mental health issues to receive assistance in accessing their earned benefits, obtaining targeted treatment and connecting with a peer mentor who understands their challenges and pain. There are already over 200 such courts, and local jurisdictions can receive assistance in setting up their own veterans' treatment court through the Justice for Vets initiative. e Facilitate treatment in jails. Local leaders should work to ensure that inmates in local jails who struggle with addiction receive proper treatment for their illness, including medication-assisted treatments, with a special focus on pre-release treatment and service coordination. Treatment programs in jails offer an opportunity to break the cycle of drug abuse and criminal behavior that ensnares many individuals who come into contact with the criminal justice system. Jails can implement low-cost treatment programs to provide these individuals the treatment they need. Statistics demonstrate that incarcerated individuals who struggle with opi oid addiction and receive little or no treatment are much more likely to relapse into drug use and criminal behavior on their release. These individuals also are more likely to suffer a lethal overdose shortly after being released. Treatment programs in jails have consistently been shown to reduce the cost s associated with lost productivity, c rime and incarceration ca u sed by heroin use. Providing treatment services to fit the needs of the individual is an important part of effective drug abuse treatment for c riminal justice populations. Drug treatment should address is sues of motivation, problem solving and sk ill building for resisting drug use and criminal behavior. Treatment programs during incarceration should also facilitate the development of healthy interpersonal relationships and improve the participant's ability to interact with family, peers and others in the community. N ACo -N LC : A PRESCRIPTI O N FOR A CT IO N 37 062717 HC BOC Page 65 TOOLS AND EXAMPLES Kenton County detention center treatment program It is estimated that roughly 80 percent of those booked in to the Kenton County detention center in northern Kentucky are incarcerated for charges that are either directly or indirectly related to substance abuse disorders. In 2015, jail directors dedicated a 70-bed dormitory in their facility to substance abuse treatment, adding to the 30 beds already designated for such trea tment. The volu ntary, application-based six-month program provides inmates with cognitive-behavioral therapy, intensive counseling individually and in groups, spiritual program'!1ing and, prior to their release, a naltrexone injection to block the effects of opioids for 30 days after release. Inma tes are also connected to community services before they are released, including organiza tions that help them attain health insurance. As of mid-2016, nearly 200 inmates had completed the program, and the recidivism rate was less than 10 percent. 8 Support "Ban the Box" initiatives. City and county officials should change hiring practices to prohibit questions regarding past criminal history on applications for local government jobs and hiring by vendors under government contract. Among the biggest challenges individuals convicted of drug offenses face is securing employment and housing after release from jail. The inability to find a job or a place to live leads many to return to their previous criminal activities and remain in the grip of opioid abuse and associated criminal behavior. One program used in more than 100 cities and counties is the "Ban the Box" initiative. This initiative prevents prospective employers from asking about the criminal background history during the early stages of the application process. The goal of the initiative is to ensure employers first consider the job candidate 's qualifications without the stigma of a criminal record . To support local efforts to enact "fair-chance" policies, the National Employment Law Project (NELP) has developed best practices and model policies for local governments. The NELP toolkit provides model administrative policies, sample resolutions, ordinances, state executive orders and model state legislation. 38 NACo -NLC : A PRESCRIPTION FOR ACTION 062717 HC BOC Page 66 TOOLS AND EXAMPLES Tallaha ssee Ban t he Bo x initiativ e In January 2015, Tallahassee moved to adopt a new set of municipal hiring guidelines for criminal background checks. City officials recognized that in 2014, more than 1,700 formerly incarcerated individuals returned to Leon County, Fla ., and almost 200,000 more are expected to be released in Florida during the next five years. To help remove employment barriers for people with criminal convictions, the city manager can now inquire about criminal history and conduct background checks later in the interview process, rather than at the start. Of the 816 criminal background screenings conducted in 2014, excluding those for public safety jobs, 15 percent had criminal histories. Of those 15 percent, 11 percent were hired and 4 percent were denied on the basis of their background as it applied to positions . / N ACo -NLC: A PRESCR IPTIO N FOR ACTIO N 39 062717 HC BOC Page 67 Federal and State Recommendations As we call on city and county officials to lead efforts to address the opioid epidemic across our local communities, we recognize that these local efforts will be far more effective when carried out in partnership with state and federal counterparts. The following recommendations call for state and federal actions that can complement local efforts to reduce the rates of opioid dependence, overdose and deaths in our communities. In the crafting the recommendations, the task force referenced the National Governors Association's 2016 report, "Finding Solutions to the Prescription Opioid and Heroin Crisis: A Road Map for States." State Recommendations 0 Establish or strengthen prescription drug monitoring programs (PDMPs). Most states collect data on controlled substances dispensed in the state, including opioids. States should require medical professionals to use PDMPs to assess potential abuse or diversion before prescribing opioids, and they should require those who dispense opioids to report each prescription to the POMP within 24 hours. 8 Institute guidelines for prescribing opioids. In March 2016, the Centers for Disease Control and Prevention (CDC) published opioid prescription guidelines with recommendations to help prescribers determine when to initiate opioids for chronic pain, how to se l ect opioids, set their dosage, duration and discontinuation and how to assess risk and address the harms of opioid use. States should adopt the CDC guidelines or similar guidelines that achieve the same goal. Support greater availability of medication-assisted treatments. States should assess the factors that limit medication-assisted treatments in their c ities and counties and take actions to help increase the availability of such treatments. Barriers to medication-assisted treatments in state statutes should be reassessed and training of primary care physicians in administering medication-assisted treatments shou ld be required or incentivized . NACo -NLC : A PRESCRIPTION FOR ACTION 43 062717 HC BOC Page 68 e Structure Medicaid programs to promote safe opioid prescription practices and access to treatments. According to the National Association of Medicaid Directors, compared with their privately insured counterparts, Medicaid participants are twice as likely to be prescribed opioids and have six times the risk of opioid-related overdose deaths. States should address these disparities through their Medicaid plans by limiting opioid prescriptions, promoting the use of non-opioid pain management methods and optimizing timely access to medication-assisted treatments like buprenorphine and naltrexone. C, Explicitly authorize or remove barriers to clean syringe programs. In addition to protecting communities from the outbreak of infectious diseases like HIV and hepatitis, syringe exchange programs provide important opportunities to connect individuals struggling with drug addiction to treatment services. States should support these programs and remove statutory barriers to their establishment in cities and counties. Federal Recommendations 0 Expand access to medication -assisted treatments. One o f the greatest impedim e nts to the treatment of individuals struggling with addiction is the limited number of practitioners who can prescribe buprenorphine. To prescribe buprenorphine, practitioners must apply for a special li cense that limits the number of patients they can treat. Recently, the federal government took action to increase the limit from 100 to 275 patients. The federal government must continue to make policy changes to allow other medical professionals (such as nurse practitioners) to dispense such medications. 8 Provide funding for local efforts to address the opioid crisis. Local governments are struggling to find sufficient funding to provide medication-assisted treatment programs, expand drug abuse prevention and education efforts , purchase sufficient quantities of naloxone and implement useful drug take-back programs. The federal government must quickly pass l egislation to prov ide emergency supplemental funding to assist local governments through grants that would help expand and improve existing efforts to address the opioid epidemic in local communities across the nation. 44 NACo -NLC : A PRESCRIPT IO N FOR ACTION 062717 HC BOC Page 69 0 Partner with local and state officials to reduce the supply of fentanyl and carfentanil The increasingly lethal synthetic forms of opioid, which can be up to 10,000 times stronger than morphine, are quickly becoming the leading cause of opioid overdose in lo cal commu n iti es as drug traffickers lace heroin with these stronger opioids to create a more potent product. First responders often have to use several doses of naloxone to revive persons who have overdosed on heroin laced with fentanyl and carfentanil. The federal government must devote extensive resources to federal, state and local law enforcement efforts to stop the illicit trafficking of fentanyl and carfentanil. NACo -NLC : A PRESCRIPTIO N FOR ACTION 45 062717 HC BOC Page 70 e Allow individuals in custody to continue receiving Medicaid benefits until convicted, sentenced and incarcerated and require states to suspend, rather than terminate, Medicaid for individuals in jail. Under current federal law, federal Medicaid matching funds cannot be used to pay for treatment of jail inmates-an estimated 64 percent of whom struggle with addiction. This statutory exclusion applies not only to individuals who have been convicted of crimes, but also to pre-trial inmates who make up a majority of jail populations and are presumed innocent until proven guilty. To avoid violating the federal exclusion, states typically terminate Medicaid benefits when an inmate is booked into jail, meaning he or she must reapply on release, further interrupting access to treatment in the post-release period when many individuals relapse and overdose. The federal government should provide greater flexibility in the Medicaid program for justice-involved populations and should require states to suspend, rather than terminate, coverage for incarcerated individuals. Doing so will allow counties and cities to better coordinate systems of care and treat previously undiagnosed individuals with substance abuse disorders. N ACo -NLC: A PRESCR IPTIO N FOR ACTIO N 47 062717 HC BOC Page 71 Acknowledgments In carrying out its work over the last several months, the task force was generously supported by several corporate sponsors of the National Association of Counties and the National League of Cities. We are grateful to Aetna, the Centene Corporation, the Consumer Healthcare Products Association, Esri and the U.S. Communities Government Purchasing Alliance for their support and partnership. The task force is also grateful for the partnership of the many organizations that contributed to our work and the publication of this report, including the Office of National Drug Control Policy, the Substance Abuse and Mental Health Services Administration , the American Medical Association , the National District Attorneys Association, the National Association of County Behavioral Health 48 NACo -NLC : A PRESCRIPTION FOR ACTION and Developmental Disability Directors, the National Association of County and City Health Officials and the National Association of State Alcohol and Drug Abuse Directors. Lastly, we are grateful to the Kenton County Detention Center and the NKY Med Clinic in Covington, Ky., for allowing the task force to visit their facilities and observe their commendable work in treating individuals struggling with addiction. Staff to the task force, primary report authors and ongoing points of contact for this report are: James Brooks and Yucel Ors for the National League of Cities and Hadi Sedigh for the National Association of Counties. 062717 HC BOC Page 72 Resources NACo-NLC Opioid Report Portal www.opioidaction.org National League of Cities www.nlc.org National Association of Counties www.naco.org White House Office of National Drug Control Policy https://www.whitehouse.gov/ondcp Suqstance Abuse and Mental Health Services Administration http ://www.samhsa.gov/ American Medical Association https://www.ama-assn.org/ National Ass ociation of County and City Health Officials http://www.naccho org/ National District Attorneys Association http ://www.ndaa.org/ International Association of Chiefs of Police http://www.theiacp.org/ National Association of County Behavioral Health and Developmental Disability Directors http://www.nacbhd.org/ National Association of State Alcohol and Drug Abuse Directors http://nasadad.org/ Community Anti-Drug Coalitions of America www.cadca .org The Red Ribbon Campaign www.redribbon .org 062717 HC BOC Page 73 Gina Wheeler From: Sent: To: Subject: Attachments: 7thheaven@windstream.net Thursday, June 1, 2017 5:31 PM Gi na Wheeler Motto Placement IGWT Harnett County Admin.pdf; IGWT Harnett County Court Hou se.pdf Gina here is a mock up that our sign company was able to suggest for the two locations. Would you please forward to the board for review and final approval. Feel free to contact me if I can be of any assistance. Rick Lanier USMAC 336 -798-7700 Sent from Mail for Windows 10 1 062717 HC BOC Page 74 18 " ta l l (I ' m Gu e s s i n g ) Ca s t al u m i n u m le t t e r s Cl e a r Fi n i s h Br u s h e d - I ne e d th e he i g h t o f th e do o r s or th e si z e o f th e ex i s t i n g le t t e r s Wh a t size are the doors? 062717 HC BOC Page 75 ,. -... ~ .. Flat cut 3/8" aluminum letters painted white - I need the height of the windows! Approx 4" will not know if scaled properly until I get the size of the windows