THE OKLAHOMA COMMISSION ON OPIOID ABUSE
FINAL REPORT
OKLAHOMA ATTORNEY GENERAL MIKE HUNTER,
CHAIRMAN

JANUARY 23, 2018

 Oklahoma Attorney General Mike Hunter Addresses the Opioid Epidemic
The opioid crisis has caused the deadliest drug epidemic in United States history. The bad news is, it is
getting worse.
In 2016, drug overdose deaths in the United States claimed the lives of more than 64,000 people, an increase
from the 59,000 deaths in 2015. This jump was the largest increase of overdose deaths ever recorded in our
country.

If Oklahoma is not ground zero, it is close.
The statistics for our state are just as staggering. In the last 15 years, drug overdose deaths in the state have
increased by 91 percent and continue to rise. We lose nearly 1,000 Oklahomans per year due to a drug
overdose. In the last three years, more than 1,300 newborns tested positive for substance exposure and went
into withdrawal the moment they were born.
The epidemic has led to increased use of street drugs because once an addict can no longer feed their habit
on prescription pain medication, they turn to alternatives like heroin and fentanyl. Approximately 80 percent
of heroin users were abusers of prescription painkillers first, and fentanyl is 50 to 100 times more potent
than morphine.
Over the last two decades, this scourge has devastated our state. It has created a generation of addicts,
increased incarceration, ripped families apart, resulted in billions of dollars in lost workplace product ivity,
and dramatically escalated the demand for treatment and rehabilitation.
Oklahoma is too good of a place to allow this to continue happening.
In this report, you will find recommendations from the Oklahoma Commission on Opioid Abuse that are
designed to reverse the nightmarish trend we have been struggling with for far too long.
The recommendations include input from law enforcement officials, the medical community, business
professionals, state legislators, and other stakeholders who came to the table to help.
I am grateful to the commissioners, who volunteered their time, energy and expertise over the course of the
six meetings to develop these recommendations. We believe we have put forth the very best for the citizens
of the state of Oklahoma.
Sincerely,

Mike Hunter
Oklahoma Attorney General
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 THE OKLAHOMA COMMISSION ON OPIOID ABUSE
In response to the state’s opioid epidemic, Oklahoma Attorney General Mike Hunter proposed
legislation to form the Oklahoma Commission on Opioid Abuse on April 26, 2017. State Senator
AJ Griffin and Representative Tim Downing co-authored Senate Concurrent Resolution 12,
creating the commission. On May 17, 2017, the resolution unanimously passed the Oklahoma
House of Representatives and passed by a 38 to 2 margin in the Oklahoma Senate. It was signed
into law the next day by the governor.
The nine-member commission, chaired by Attorney General Hunter, contained a variety of
stakeholders from law enforcement professionals, members of the medical community, private
sector businesses, and mental health and recovery.
Over the course of six public meetings, members focused on the scope of the epidemic and
specifically on problems Oklahoma is facing. In particular, the commission targeted law
enforcement, the medical community, prevention, treatment, and drug endangered children.
Numerous medical professionals, victims, and state and federal agencies delivered presentations
and provided information to the commission regarding the epidemic and the state’s response.
The following is a brief summary of the information that was presented to the commission and
used in formulating the list of final recommendations.

The Epidemic
Dr. Andrew Kolodny, a nationally recognized expert on the opioid epidemic, spoke to the
commission and explained that in 1996 the culture of prescribing opioids began to change
dramatically. Opioid manufacturers became focused on enticing doctors to prescribe opioids for
common chronic pain conditions. Doctors were told that opioid addiction is rare, that opioids are
safe and effective, and that they are easily discontinued. Unfortunately, opioids are in fact
extremely addictive and are not an effective way to manage chronic pain. Sometimes, opioids
can even make pain worse – a phenomenon called hyperalgesia.
This message from the pharmaceutical industry was especially persuasive due to the carefully
chosen purveyors. Drug companies engaged in multiple strategies including inundating doctors
with scripted propaganda utilizing their peers in pain management, medical societies, hospitals,
and medical boards. This was a brilliant, multi-faceted marketing campaign directed at multiple
levels of the medical community and its messages were found in textbooks, journal articles, and
in the news media; however, the initial evidence that authors were citing was not peer-reviewed
and was, instead, based on a one-paragraph letter to the editor of the New England Journal of
Medicine in 1980.
As “pain” was being concurrently touted as the “fifth vital sign” by these same manufacturers,
doctors were made to believe that prescribing opioids for common conditions was not only
acceptable, but mandatory. With this backdrop, many doctors were rightfully fearful of being
sanctioned for under-prescribing powerful opioids and for not fully treating a patient’s pain.
In the early 2000s, deaths from prescription opioids began rising rapidly. In 2008, the
International Narcotics Control Board released data showing that global consumption of opioid
analgesics for the treatment of moderate to severe pain had increased more than two and one half
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 times in the previous decade. More particularly, the United States was consuming 85% of the
oxycodone and 99% of the hydrocodone in the world, even though the United States only
comprises 4.6% of the world’s total population. As more and more people consumed these drugs,
more became addicted.
By 2009, almost every state in the country, including Oklahoma, experienced a sharp increase in
the number of Americans suffering from opioid addiction. To answer the question of why deaths
involving opioids were rising so rapidly, researchers began examining the number of deaths
compared to the number of opioid prescriptions. They found that as opioid prescriptions rose
meteorically, so did the number of overdose deaths.
In 2016, the Centers for Disease Control reported that more than 64,000 Americans died from
drug overdoses and 11.5 million people misused prescription opioids. Thus, more Americans
died from drug overdoses in 2016 than died in the Vietnam War. This national epidemic has
struck the state of Oklahoma equally hard. Oklahoma has consistently ranked near the top of
states for opioid abuse. In 2014, Oklahoma was ranked number one in the abuse of painkiller
drugs. In 2016, there were 899 drug overdose deaths in Oklahoma which represents a 68%
increase from 2007.

Law Enforcement
Several representatives from the law enforcement community were invited to present to the
commission. Commissioners heard from members of the Oklahoma Bureau of Narcotics and
Dangerous Drugs (“OBNDD”), the Drug Enforcement Agency (“DEA”), the Medicaid Fraud
Unit of the Attorney General’s office, the Department of Health, the Tulsa Police Department
Special Investigation Division, and the New Jersey State Police.
Drug diversion is a major problem for law enforcement. Diversion occurs when legal drugs are
diverted to the illicit market. This can occur through doctor shopping, forged prescriptions, and
employee theft, which is a growing problem. Specifically, diversion occurs in nursing homes as
there is ample access to just about any type of medication, including opioids. Accurate
documentation and the secure storage and disposal of medications are major concerns.
Diversion also occurs when pharmaceuticals are shipped from the manufacturer to the wholesaler
and to the distributors. While the physical diversion of drugs along the distribution path is
occurring and problematic, another cause of diversion is “doctor shopping” whereby patients
visit multiple doctors seeking prescriptions for opioids. Many presenters agreed that the
mandatory use of electronic prescribing would help alleviate the problem of forged prescriptions
and doctor shopping.
Law enforcement also faces the challenge of new, very powerful synthetic opioids, specifically
fentanyl and its analogues. Carfentanil, which is one-hundred times as potent as fentanyl, is
extremely deadly. An amount the size of a few grains of sand can kill a human. Because the
drug is so potent, small amounts of the drug can be easily shipped through the regular postal
system. The minute quantity and profitability of the drug is driving the rapid increase in its
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 availability and use. Data collection and inter-agency collaboration is necessary to adequately
address this growing problem.
Another issue unique to law enforcement officers is the use and availability of opioid overdose
reversal drugs such as Naloxone. Commissioners learned about programs sponsored by the
Department of Mental Health and Substance Abuse Services which are distributing Naloxone to
law enforcement and members of the community. This drug saves lives and should be widely
available.
Finally, drug addiction imposes many costs on society and the criminal justice system. Drug
Enforcement Administration officials stated that in 2016, 60% of overdose deaths were
attributable to pharmaceuticals and 40% were attributable to street drugs. Four out of five heroin
users started out using prescription drugs. This switch from licit to illicit drug use has caused
law enforcement to begin placing a larger emphasis on the abuse of prescription drugs,
understanding that this is where addiction often begins.
One effective tool in fighting the epidemic of drug addiction is the state’s system of drug courts.
Drug courts, and other specialty courts such as family drug courts, exist in seventy-three (73)
counties in Oklahoma. District Attorney Kevin Buchanan expressed the view that these courts,
along with mental health courts, are an essential part of addressing the opioid crisis and that
Oklahoma’s outcomes are among the best in the nation. Commissioner Terri White added that
$50 million is needed to adequately fund drug courts. Diverting those who are addicted to pain
medication from prison to treatment is a necessary step in helping our state recover from the
opioid epidemic.

The Medical Community
The medical community holds a unique position in the opioid epidemic because of its prescribing
authority.
Prescribers include medical doctors, osteopathic physicians, dentists, and
veterinarians. Members of each of these groups addressed the commission and one thing became
clear: additional education regarding proper prescribing and risks of addiction is key to
stemming the over-prescribing of opioids. Furthermore, the expansion of prescriptive authority
to mid-level providers is not recommended.
In addition, pharmacists can be a second line of defense against addiction and diversion. While
pharmacists are not prescribers, they do have the opportunity to assist and educate patients.
Additional training and education is needed to give pharmacists the ability to better recognize the
signs of addiction and diversion.

Prevention
The commission was presented with various types of prevention efforts. The Prescription
Monitoring Program (“PMP”), which is administered by the Oklahoma Bureau of Narcotics and
Dangerous Drugs, is a powerful tool which prescribers and pharmacists must use to detect

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 doctor-shoppers and other problematic prescription histories which put patients at risk for
addiction.
The commissioners also learned about the use of screening tools and methods such as “SBIRT”
which stands for Screening, Brief Intervention, and Referral to Treatment. This process uses
screening tools to help identify those most at risk for addiction, engage them in conversation, and
refer them to appropriate services or treatment before they experience a fatal event. This type of
intervention could be especially helpful for children, coaches, and young athletes.

Treatment
Treatment options for those already addicted were also discussed. Many of the presenters
explained to the commission that the stigma surrounding addiction must be eliminated and
treatment must be made more available. Medication assisted treatment (“MAT”) is one option
for treatment. MAT is the evidence-based practice of using medications in combination with
counseling and behavioral therapies for the treatment of opioid use disorder. Drugs like
buprenorphine are used to stop the cravings and reduce withdrawal symptoms. More medical
professionals need to be trained in addiction treatment and authorized via federal waiver to
prescribe buprenorphine. One of the barriers to treatment is the federal limit on the number of
patients that can be treated with drugs like buprenorphine.
In addition to its need for more treatment providers, Oklahoma also needs more avenues of
treatment. There are currently more people than ever before seeking treatment for addiction
driven by the opioid epidemic but, sadly, only approximately 10% of people who need treatment
are receiving it. Every day there are 600 to 800 people on waiting lists for inpatient treatment
services. Increasing the number of inpatient treatment beds as well as the number of outpatient
treatment options is necessary to gaining control of the epidemic.

Drug Endangered Children
One of the most disturbing topics covered by the commission was the effect of the opioid
epidemic on the youngest Oklahomans. The number of drug-exposed newborns is consistently
rising, and is expected to double in 2017 to over 1,000. Neonatal Abstinence Syndrome
(“NAS”) is a group of symptoms which newborns exhibit after exposure to opioids while in the
womb. After birth, these babies have high-pitched cries, are inconsolable, and shake violently as
a result of the withdrawal they experience. In addition, their hospital stays are weeks longer than
that of healthy newborns and the medical costs are, on average, more than ten times higher.
While we are aware that the problem exists, experts advised us that there is a lack of uniform
data available to comprehensively study NAS.
For children in Oklahoma, there is a lack of substance abuse prevention education in schools.
While some schools implement drug testing and education, most lack the funding and capacity to
implement evidence-based prevention programs. More can be done. The commission was
introduced to programs like “Project Here” in Massachusetts, which provides internet-based
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 screening and educational tools for all of the middle schools in that state. There are also
evidence-based programs in Oklahoma that could be more widely utilized.
In addition to a lack of education, there is also a lack of treatment resources for children and
young adults. Oklahoma has only one accredited recovery high school (the Mission Academy in
Oklahoma City) and it is the only such school in the nation that is privately funded. Sober living
dorms on college campuses are also lacking. Though at least one program exists at Oklahoma
State University, more can be done to support college students who face addiction and need
recovery support.

THE RECOMMENDATIONS
After evaluating the information provided by the presenters, the commission drafted a number of
legislative and policy recommendations that we believe are essential to fighting the opioid
epidemic. Specifically, we recommend the following legislative actions:
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Enact legislation to criminalize the trafficking of fentanyl and its analogues
Enact legislation to mandate the use of electronic prescriptions (“e-prescribing”)
Enact a Good Samaritan Law to grant limited immunity to individuals who call to report
a drug overdose
Enact legislation, such as a tax on the manufacturers, wholesalers, and distributors of
opioids, as a funding mechanism for opioid addiction treatment
Enact legislation that would require medical clinic owners to register with the Oklahoma
Bureau of Narcotics and Dangerous Drugs (“OBN”)
Enact legislation that imposes maximum quantity limits on first, second, and subsequent
opioid prescriptions and includes formal patient notice and informed consent
requirements
Enact legislation that requires opioid manufacturers, wholesalers, and distributors to
register with the OBN
Enact legislation to create a Drug Overdose Fatality Review Board or Task Force to study
causes of opioid overdoses and identify ways to prevent death and refer appropriate cases
for criminal prosecution

In addition to these specific legislative recommendations, we also believe there are numerous
steps that can be taken which do not require legislation. Specifically, we recommend the
following:
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Encourage use of the ODMap application by law enforcement, first responders, and
health officials to track overdose events in real time so that resources can be directed to
“hot-spot” areas and criminal investigations can be conducted, if necessary
Support expanded and improved utilization of the PMP by providers and proactive
programming by OBN administrators which would provide alerts to prescribers and
pharmacists regarding dangerous prescription combinations, high daily dosages of
opioids, and doctor-shopping
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Work together with Oklahoma’s federal congressional delegation to remove the federal
limits on the number of patients to whom physicians can prescribe treatment drugs like
buprenorphine
Create a statewide emergency department (“ER”) discharge database to study overdose
events and aftercare results
Encourage the mandatory offering of Naloxone by prescribers and pharmacists to
individuals receiving their first opioid prescription or those receiving an opioid
prescription in addition to a benzodiazepine
Provide all first responders with Naloxone and training on how to recognize signs of an
overdose and how to use the drug
Encourage nursing homes and long-term care facilities to develop best practices with
regard to medication safety, storage, and disposal and to promote best practices with
regard to accurately documenting patient medications
Pursue rule changes with the appropriate medical boards to require at least one hour of
continuing education for all prescribers every reporting period on proper prescribing and
the risks of opioids and recognizing addiction and diversion
Pursue rule changes with the appropriate board to require at least one hour of continuing
education every reporting period for pharmacists on how to recognize signs of addiction
and diversion
Prohibit mid-level prescribers who are not trained physicians (M.D., or D.O.) from being
allowed prescriptive authority for Schedule II opioids
Propose and provide specific training for law enforcement personnel and investigators
through the Oklahoma Council on Law Enforcement Education and Training (“CLEET”)
on handling opioid diversion investigations
Support the expansion of insurance coverage for evidence-based pain management
treatment options that do not involve opioid prescriptions
Support federal parity laws that require insurance companies to cover addiction treatment
expenses just like any other biological malady
Continue and expand the first responder overdose program through the Department of
Mental Health and Substance Abuse Services, which is providing Naloxone to first
responders
Expand the 19 community-based Naloxone programs in the State to include homeless
shelters
Make more inpatient treatment beds and outpatient treatment options immediately
available
Support the expansion of OSU’s Project ECHO in order to increase the number of
doctors trained in addiction medicine and increase their availability to patients in rural
areas of Oklahoma
Promote and encourage the use of SBIRT tools by primary care and other providers to
increase the identification of addiction and make appropriate referrals for treatment
Promote training for middle school and high school student athletes and coaches on the
risk of addiction to opioid pain medications after sports injuries and encourage the use of
early intervention screening tools
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Explore educational pilot programs for middle school and high school students on the
risks of opioid addiction and early intervention tools
Explore pilot programs for sober living on college campuses and support existing
programs at OSU through DMHSAS
Promote the establishment of drug courts in the remaining four counties that do not
currently have them and encourage legislators to adequately fund drug courts and other
specialty courts throughout the state
Review current drug law to determine drug court eligibility and expand eligibility in light
of recent changes in the law which made some drug possession crimes misdemeanor
offenses

CONCLUSION
While the formal work of the commission has ended with the issuance of this report, we
recognize that the more difficult work of legislative and policy changes must now begin. The
Attorney General and all of the commissioners express our resolve to work diligently with the
executive, legislative, and judicial branches of government as well as state agency heads and
community leaders to quickly implement the necessary legislative changes and the policy
recommendations discussed herein. Through our work, we wish to honor the memory of all
those whose lives were tragically lost to an opioid overdose by helping to make treatment and
recovery support more widely available to all who are suffering.

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 The Oklahoma Commission on Opioid Abuse Commissioners
Kevin Buchanan was elected as the district attorney for Washington and Nowata counties in
2011. He currently serves as president of the District Attorneys Council. Prior to his current role,
he worked in private practice as a criminal defense attorney. Mr. Buchanan received a bachelor’s
degree from Oklahoma State University and a law degree from the University of Tulsa.
Shanetha L. Collier, D.D.S., is the Dental Director for the Family Health Center of Southern
Oklahoma in Tishomingo, Oklahoma. Dr. Collier is a native of Durant, Oklahoma. She obtained
her undergraduate degree from Oklahoma State University, and then her doctor of dental surgery
degree from the University of Oklahoma College of Dentistry. She currently practices general
dentistry in Tishomingo, Oklahoma.
Chelsea Church, Pharm.D., D.Ph., is the Executive Director of the Oklahoma State Board of
Pharmacy. Ms. Church graduated from the University of Oklahoma College of Pharmacy, and
completed a Primary Care Pharmacy Practice residency in Tuscaloosa, AL.
She was an
Associate Professor with Southwestern Oklahoma State University for thirteen years,
specializing in Internal Medicine. In 2012, she joined the Oklahoma State Board of Pharmacy as
a CLEET-certified Pharmacist Compliance Officer. In July 2017, she was named Executive
Director of the Board of Pharmacy.
Representative Tim Downing represents District 42 in the Oklahoma House of Representatives,
where he currently serves as the assistant majority whip and as vice chair of the Civil and
Environmental Judiciary Committee. He is an officer in the United States Army Reserves and he
previously worked at the attorney general’s office. Rep. Downing received a bachelor’s degree
from the University of Oklahoma, a master’s from Oral Roberts University, and a law degree
from Regent University in Virginia.
Senator AJ Griffin represents district 20 in the Oklahoma Senate, where she currently serves as
the Chair for the Senate Appropriations Subcommittee on Health and Human Services and the
Chair of the Rural Caucus. She is a manager for a non-profit dedicated to improving the lives of
Oklahoma children and families. During her time in the Senate, she has worked to write and pass
legislation to address Oklahoma’s fastest growing substance abuse issue—prescription drug
addiction. Sen. Griffin also authored legislation to better protect victims of child abuse. She
received a bachelor’s degree from Oklahoma State University and a master’s degree from the
University of Central Oklahoma.
Bob Howard is an Oklahoma City businessman involved in several ventures through his
investment company, REHCO, LLC. He is also the president of Mercedes-Benz Volvo of
Oklahoma City and managing partner of Midtown Renaissance, a real estate company engaged
in the redevelopment of Oklahoma City’s Midtown District. Mr. Howard also serves on the
Oklahoma Board of Medical Licensure and Supervision.

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 John Scully, Director of the Oklahoma Bureau of Narcotics and Dangerous Drugs, is
serving as an ex officio member of the commission, per Senate Concurrent Resolution 12. He
has been the director of the OBNDD since March 2016. Prior to his appointment, Director Scully
was a member of the Oklahoma City Police Department for 32 years, where he served in many
capacities, including deputy chief for the final eight years of his tenure. He received both a
bachelor’s and master’s degree from Southern Nazarene University. Director Scully is a graduate
of the FBI National Academy in Quantico, Virginia, the Police Executive Research Forum in
Boston, Mass., and the DEA Drug Unit Commander Academy in Quantico, Virginia.
Layne Subera, D.O., is a doctor of osteopathic medicine. Dr. Subera currently practices family
medicine at the Skiatook Osteopathic Clinic. Dr. Subera is board certified in Family Practice and
Osteopathic Manipulative Treatment by the America Osteopathic Board of Family Physicians.
He is a member of the American Osteopathic Association, the American College of Osteopathic
Family Physicians, the Oklahoma Osteopathic Association, and the American Academy of
Professional Coders. Dr. Subera received a bachelor’s degree from Oklahoma State University
and a doctor of osteopathic medicine degree from Oklahoma State University.
Kevin Taubman, M.D., is the president of the Oklahoma State Medical Association and is an
assistant professor in the University of Oklahoma School of Community Medicine, and
Department of Surgery and Vascular Fellowship Program director in Tulsa. He completed his
general surgery residency at Kern Medical Center at the University of California, San Diego. Dr.
Taubman completed his fellowship in vascular/endovascular surgery and interventional
radiology at the Heart and Vascular Institute of the Penn State University Milton S. Hershey
Medical Center. His specialties include carotid artery disease, arterial aneurysm, peripheral
arterial disease, and venous disease.
Terri White, Commissioner of the Department of Mental Health and Substance Abuse
Services, is serving as an ex officio member of the commission, per Senate Concurrent
Resolution 12. She was the first female to be appointed by then-Governor Brad Henry as
Oklahoma Secretary of Health from 2009 to 2011. She has been recognized by The Journal
Record newspaper as one of Oklahoma’s top “Achievers Under 40” and is a three-time honoree
of The Journal Record's “50 Women Making a Difference.” In 2014, she received the “Kate
Barnard Award” from the Oklahoma Commission on the Status of Women, an award created to
honor women who have made a difference in Oklahoma through public service. In 2011, she was
inducted into the University of Oklahoma’s Anne and Henry Zarrow School of Social Work Hall
of Fame. She is also volunteer faculty with the University’s School of Medicine and is a Henry
Toll Fellow with the Council of State Governments. Ms. White received both her bachelor’s and
master’s degrees from the University of Oklahoma.

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 DISCLAIMER
This report is not intended to address the immense impact opioid abuse has had on the State of
Oklahoma nor does it calculate the damages the State has incurred or will incur as a result of the
opioid epidemic.

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