HEROIN IN

COLORADO

LAW ENFORCEMENT
PUBLIC HEALTH
TREATMENT
DATA 2011 - 2016

APRIL 2018

WORKING TOGETHER TOWARD A SOLUTION.

 Prepared By:
Heroin Response Work Group
http://www.corxconsortium.org/heroin-response-work-group/

Heroin Response Work Group Member Agencies

Addiction Research & Treatment Services (ARTS) Johns Hopkins School of Public Health
Arapahoe County Sheriff 's Department KEPRO
Boulder County Drug Task Force KEPRO Quality Improvement Organization (QIO)
Boulder County Public Health Program
Center for Dependency, Addiction and Rehabilitation Larimer County Sheriff 's Department
Chaffee County Public Health Liver Health Connection (formerly Hep C Connection
Colorado Association of Chiefs of Police Longmont Police Department
Colorado Attorney General's Office Medtronic
Colorado Consortium for Prescription Drug Abuse Millennium Health
Prevention New Beginnings Recovery
Colorado Criminal Justice Reform Coalition Opioid Advisory Group BOCO
Colorado Department of Corrections Organized Crime Drug Enforcement Task Force
Colorado Department of Human Services (OCDETF)
Colorado Department of Public Health and Phoenix Multisport
Environment (CDPHE) Red Rock Recovery
Colorado Dept of Human Services, Office of Children Retired - Law Enforcement
Youth and Families Rocky Mountain Crisis Services
Colorado Drug Investigators Association Rocky Mountain High Intensity Drug Trafficking
Colorado Health Institute Areas (RMHIDTA)
Colorado National Guard San Luis Valley Health Education Center
Colorado Permanente Medical Group Southern Colorado Harm Reduction Association
Denver Public Health and Environment St. Joseph Hospital
Denver Public Health Thornton Police Department
Denver Recovery Group University of Colorado Denver
Denver Springs Behavioral Health Hospital University of Colorado Skaggs School of Pharmacy
Drug Enforcement Administration US Attorney's Office (CO)
Foundry Treatment Center Western Colorado Health Network
Harm Reduction Action Center Westminster Police Department
Jefferson County Public Health Young People in Recovery

Contact:
Co-Chair Tom Gorman, Director, RMHIDTA
tgorman@rmhidta.org
Co-Chair Lindsey Myers, MPH, Branch Chief,
CDPHE
lindsey.myers@state.co.us
 Table of Contents
Introduction......................................................................................... 1
Executive Summary............................................................................ 2
Section 1: Heroin Seizure and Arrest Data..................................... 4
Section 2: Heroin Fatal and Non-Fatal Overdose Data................. 7
Section 3: Naloxone Use.................................................................... 11
Section 4: Disease Transmission and Heroin Use.......................... 13
Section 5: Neonatal Abstinence Syndrome..................................... 16
Section 6: Heroin Exposure Calls..................................................... 18
Section 7: Heroin Treatment Admissions and Client Information 20
Conclusion........................................................................................... 26
References............................................................................................. 27

Heroin in Colorado
 Introduction
On December 29, 2015, Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA) sponsored a
meeting with representatives from the Colorado Department of Public Health and Environment (CDPHE),
the Colorado Department of Human Services (CDHS), the Colorado Attorney General’s Office (COAG),
the Colorado Drug Investigators Association (CDIA), and the Drug Enforcement Administration (DEA) to
discuss assessing Colorado’s heroin problem. This group of partners decided to form a multidisciplinary Heroin
Response Work Group to coordinate a statewide response to Colorado’s emerging heroin problem. Heroin Work
Group members represent diverse backgrounds and include representatives from federal, state, and local law
enforcement, prevention, treatment and recovery organization. The Heroin Response Work Group is now one of
10 work groups under the Colorado Consortium for Prescription Drug Abuse Prevention, a large coalition that
was formed in 2013 to oversee the implementation of the Colorado Plan to Reduce Prescription Drug Abuse.

Phase 1 of the Heroin Response Work Group involved completing an assessment to determine the extent of the
heroin problem in Colorado. This document is an update to the original Heroin in Colorado Report that was
released in April 2017. The Heroin Response Work Group compiled the data in this report from the following
agencies: RMHIDTA, CDPHE, CDHS, DEA, the Rocky Mountain Poison and Drug Center, and the El Paso
Intelligence Center. Each agency reviewed drafts of this assessment and provided edits to ensure the accuracy
of the data presented. Although the Heroin Response Work Group utilized all available data regarding heroin in
Colorado, each data source has unavoidable limitations.

Since the publication of the original Heroin in Colorado report, members of the Heroin Response Work Group
continued to meet to develop and implement strategies to address the identified problems. Current work group
goals for 2017-2018 are to:

• Enhance relationships between law enforcement, treatment and public health.

• Expand Crisis Services to handle opioid use disorder calls and act as a resource for responding law
enforcement.
• Expand medication-assisted treatment in jails.
• Conduct ongoing data monitoring related to Colorado’s heroin epidemic.
• Target opioid and heroin source of supply to reduce availability.

Heroin in Colorado 1
 Executive Summary
In May 2016, the Heroin Response Work Group was officially established as part of the Colorado Consortium
for Prescription Drug Abuse Prevention. The work group established a number of goals including completing a
preliminary assessment to determine the extent of the heroin problem in Colorado.

Numerous data sources indicate that Colorado is experiencing an increasing problem with heroin. This is
supported by data indicating increased rates of heroin seizures and arrests, heroin overdoses, administration of
naloxone, new cases of hepatitis C, Neonatal Abstinence Syndrome (NAS), heroin exposure and treatment for
opioid use disorders.

Findings:

Section 1: Heroin Seizures and Arrests

Reported heroin seizures in Colorado by law enforcement have increased from 2011 - 2016.
• The number of incidents of heroin seizures increased 2,310 percent from 20 to 482 incidents in 2016.
• The pounds of heroin seized annually increased 615 percent from 16.2 in 2011 to 115.9 pounds in 2016.
From a high of 334.8 pounds in 2015, the number of pounds of heroin seized decreased 65 percent in
2016.
Reported arrests for heroin offenses in Colorado have increased by 152 percent from 91 in 2011 to 229 arrests in
2016.

Section 2: Fatal and Non-Fatal Overdoses

Heroin-related deaths among Colorado residents have nearly tripled in six years.
• 2011 – 79 deaths
• 2016 – 228 deaths
The age-adjusted rate of heroin-related overdose deaths.
• 2011 –1.5 deaths per 100,000 Colorado residents
• 2016 – 4.1 deaths per 100,000 Colorado residents
The age-adjusted heroin-related hospitalization rate increased by 68 percent from 2011-2016.
• 2011 – 1.9 hospitalizations per 100,000 Colorado residents
• 2016 – 3.2 hospitalizations per 100,000 Colorado residents
The age-adjusted rate of heroin-related emergency department visits tripled from 2011 to 2016.
• 2011 – 4.4 per 100,000 Colorado residents
• 2016 – 13.7 per 100,000 Colorado residents

Section 3: Naloxone
The documented use of Naloxone by emergency medical services (EMS) in Colorado to treat suspected heroin
overdoses has increased 248 percent from 2011 – 2016.
• 2011 – 997 events
• 2016 – 3,465 events

Heroin in Colorado 2
 Executive Summary
Section 4: Disease Transmission and Opioid Use Disorders
Reported cases of hepatitis C virus (HCV) have increased, and most people become infected with the HCV by
sharing needles or other equipment for injection drug use (IDU).
• Although HCV surveillance systems do not directly measure acute cases attributed to IDU, potentially
related new cases of hepatitis C have increased. The age-adjusted HCV (acute and newly reported chronic
cases) rate increased by 129 percent from 2012 – 2016.
• 2012 – 366 cases (33.4 cases per 100,000 population)
• 2016 – 894 cases (76.4 cases per 100,000 population)

Section 5: Neonatal Abstinence Syndrome (NAS)

Cases of opiate withdrawal syndrome in Colorado newborns have increased, while state birth rates have
remained relatively stable.
• From 2011 – 2016, NAS rates have increased by 120 percent
• 2011 – 132 cases
• 2016 – 290 cases

Section 6: Heroin Exposure Calls

Calls for heroin related exposures in Colorado have increased 70 percent from 2011 to 2016.
• 2011 – 40 calls
• 2016 – 68 calls

Section 7: Heroin Treatment Admissions and Client Information

• The number of people in treatment for opioid use disorders at State licensed facilities has increased 189
percent from 2,748 in 2011 to 7,949 admissions in 2016.
• The majority of the clients in treatment for opioid use disorders are white males between the ages of 18 and
42 who have never married and are unemployed.

Heroin in Colorado 3
 Section 1: Heroin Seizure and Arrest Data

Heroin Seizure and Arrest Data Findings

In the law enforcement community, intelligence indicating an emerging
threat is often compared with data to help assess the validity of the • Heroin Seizures – Reported
information. In the case of heroin in Colorado, the intelligence indicates an heroin seizures in Colorado
emerging trend which is supported by the increases in heroin seizures and by law enforcement have
arrests for heroin offenses. increased from 2011-2016.
• The number of
The El Paso Intelligence Center (EPIC) tracks data related to drug seizures incidents of heroin
as reported by law enforcement (local, state, and federal). The database seizures in Colorado
is known as the National Seizure System (NSS). This is not a mandatory increased 2,310 percent
reporting process for all law enforcement agencies and not all Colorado from 20 in 2011 to 482
agencies report drugs seized to EPIC’s NSS: incidents in 2016.
• Total pounds of heroin
Figure 1.1 Number of Heroin Seizure Incidents Reported in Colorado
seized in Colorado
500
482 increased 615 percent
448
from 16.2 to 115.9
450
pounds in 2016.
Number of Incidents

400
RMHIDTA drug task
350
forces in Colorado
300
218 seized 427 percent more
250
pounds of heroin, from
200
19.5 pounds in 2011 to
150
102.8 pounds in 2016.
100
20 31 26 • The yearly price per
50
ounce of heroin in Denver
0
2011 2012 2013 2014 2015 2016
decreased $300 from
2011 to 2016. The average
Source: El Paso Intelligence Center (EPIC) 1
heroin purity levels in
There was a 2,310 percent increase in heroin seizure incidents reported
Denver decreased by 10.7
from 2011 to 2016.
percentage points from a
high in 2012 to 2016. There
Figure 1.2 Pounds of Heroin Seized in Colorado
was a 444 percent increase
in arrests for heroin in
334.8
350 Colorado from 2011 to
300 2016.
Pounds of Heroin

250
200
150 109.5 115.9
95
100
50 16.2 21.5

0
2011 2012 2013 2014 2015 2016
Source: El Paso Intelligence Center (EPIC) 1

Heroin in Colorado 4
Heroin Seizure and Arrest Data

In Colorado, RMHIDTA supports and funds 11 drug task forces in the more populated counties and
the Colorado State Patrol criminal interdiction efforts. These initiatives are comprised of local, state,
and federal law enforcement personnel. The mission of the task forces is to identify significant drug
trafficking organizations (DTOs) operating in the state, investigate them, and subsequently, disrupt or
dismantle their ability to traffic drugs. The task force seizure data represents 100 percent reporting for
each calendar year.

Figure 1.3 Pounds of Heroin Seized by RMHIDTA Initiatives in Colorado

112.6
120 102.8
88.4
Pounds of Heroin

100
80
53.1
60
40 19.5 23.6
20
0
2011 2012 2013 2014 2015 2016
Source: Rocky Mountain HIDTA 2

There was a 427 percent increase in reported pounds of heroin seized from 2011 to 2016, but a nine
percent decrease from 2015 to 2016.

Figure 1.4 The Low and High Yearly Price per Ounce of Heroin

$2,000
$1,800
The yearly price per ounce of
$1,700
heroin in Denver decreased $300
Cost per Ounce of Heroin

$1,600 $1,800
$1,400 $1,200 $1,300 $1,300 from 2012 to 2016 (at the low end
$1,200
$1,200 of cost).
$1,000
$800 $900 $1,000
$900
$600 $750 $800
$400 $600

$200
$0
2011 2012 2013 2014 2015 2016

Yearly Price per Ounce of Heroin - LOW

Yearly Price per Ounce of Heroin - HIGH

Source: DEA (2011-2016)3

Heroin in Colorado 5
Heroin Seizure and Arrest Data

Figure 1.5 The Average Heroin Purity Levels in Denver

35.00%
31.90%
Average Heroin Purity Percent

30.00%
The average heroin purity levels
25.00%
22.90% 22.00% in Denver decreased by 10.7
20.00% 19.60% 21.20% percentage points from a high
17.20% of 31.9 percent in 2012 to 21.2
15.00% percent in 2016.
10.00%

5.00%

0.00%
2011 2012 2013 2014 2015 2016

Source: DEA/Heroin Domestic Monitoring Program (2011-2016)3

Figure 1.6 Arrests for Heroin - Colorado

3000
2,648
2500 2,195
2000
Number of Heroin Arrests

1,598
1500 1,279
1000 855

500 487
91 169 209 237 251 229
0
2011 2012 2013 2014 2015 2016

Heroin Arrests in Colorado

Number of Heroin Felony Arrests by RMHIDTA Initiatives in Colorado
Source: Colorado Bureau of Investigation4
There was a 444 percent increase in arrests for heroin in Colorado from 2011 to 2016.
Please be aware that this data was reported incorrectly in the 2017 report because it
included all offenses and arrests.

Heroin in Colorado 6
Section 2: Heroin Fatal & Non-Fatal Overdoses

Heroin Fatal & Non-Fatal Overdoses Findings

• Heroin-related deaths
Drug-related deaths, often called drug overdoses, are a leading among Colorado residents
cause of injury death in Colorado. The Colorado Department of have nearly tripled in six
Public Health and Environment (CDPHE) monitors the severity of years.
Colorado’s drug overdose epidemic using a variety of available data, • 2011 – 79 deaths
including mortality data from death certificates and non-fatal data • 2016 – 228 deaths
from hospital discharges and emergency department discharges. • The age-adjusted rate of
While each of these data sources provides valuable information heroin-related overdose
to help understand the burden of overdose data in Colorado, they deaths has doubled in four
also have limitations. For example, CDPHE does not have access to years.
the toxicology reports on death and cannot determine whether the • 2011 – 1.5 deaths per
drugs that are not indicated on a death certificate represent negative 100,000 Colorado
test results or whether the drug was not part of the testing. Thus, a residents
reporting bias exists in data analysis. • 2016 – 4.1 deaths per
100,000 Colorado
However, compared to earlier years, a greater proportion of drug residents
overdose death certificates for 2011-2016 include the specific drug • Colorado’s heroin death
results, which suggests that data quality is improving. Similarly, rates are slightly lower than
hospitalization and emergency department data comes from national rates.
medical billing codes, which vary in their completeness and can • National – Age-adjusted
limit CDPHE’s ability to specify the specific drug or drugs that are rate in 2015: 4.1 per
associated with a non-fatal overdose. 100,0001
• Colorado – Age-
This section of the report includes rates of fatal and non-fatal adjusted rate in 2015:
overdoses, with consideration for these limitations in the data. 2.8 per 100,000
Rates are calculated by dividing the number of overdoses that
occur in specified period of time by the average population (e.g.,
the population of Colorado residents or the population of nation
as a whole). After a rate is calculated, it is often multiplied by
100,000, so that it is easy to determine how many events happen per
100,000 people in the population. The rates reported in this section
are age-adjusted, which means that they allow communities with
different age distributions to be compared. For example, if Colorado
has a slightly younger population than the nation as a whole, it is
important to statistically adjust for the age difference to accurately
compare Colorado’s rates to national rates.

Heroin in Colorado 7
Heroin Fatal & Non-Fatal Overdoses

Heroin Overdose Deaths in Colorado

From 2000-2016, there were 11,364 drug overdose deaths among Colorado residents, with age-adjusted
rates rising almost every year. Opioid-related overdoses, which comprise a significant proportion of
total drug overdose deaths, tripled over the 16-year time period in Colorado. Heroin-related overdose
deaths are a subset of total drug poisoning deaths and have more than tripled since 2011.

Figure 2.1 Age-adjusted Rates for Drug Overdose Deaths in Colorado and in the US
25

20
Age-Adjusted Rate per 100,000

19.8

16 15.4 15.7 16.3 16.3

15
15
13.2 14.7 15.6
13.8
13.1

10 8.5 8.9
7.4 8.3
7.3 7.1
5.4 6.1
5.8 5.5 5.8 5.3
5
2.2 2.8 2.8
1.5 1.7 4.1

0
2011 2012 2013 2014 2015 2016

All Drug (Colorado) All Drug( National)

Prescription Opioid and Heroin-Related (CO) Prescription Opioids (CO)
Heroin Related (CO)

Sources: Colorado Department of Public Health and Environment (CDPHE)5

Centers for Disease Control and Prevention

Figure 2.2 Number of Heroin Overdose Deaths in Colorado

250 228
Number of Deaths

200
160
151
150 118
91
100 79

50

0
2011 2012 2013 2014 2015 2016
Source: Colorado Department of Public Health and Environment (CDPHE)5

Heroin in Colorado 8
Heroin Fatal & Non-Fatal Overdoses

Figure 2.3 Age-Adjusted Heroin-Related Overdose Death Rates in Colorado

Rate per 100,000 CO Residents

5 4.1
4
2.8 2.8
3 2.2
1.5 1.7
2
1
0
2011 2012 2013 2014 2015 2016

Source: Colorado Department of Public Health and Environment (CDPHE)5

Figure 2.4 Age-Adjusted Rate of Poisoning Deaths by Heroin* Among Colorado Residents, by
Health Statistics Region, Colorado, 2012-2016

Age-Adjusted Rate
2 of Poisoning Deaths
18
11
(per 100,000 population)
1
by Heroin (T40.1)
16
Statistically Lower than State Average
14
20 Statistically Higher than State Average
15
21 First Quartile (0.6 - 1.8)
12
3 Second Quartile (1.9 - 3.1)
17 Third Quartile (3.2 - 4.5)
5
19
Fourth Quartile (4.6 - 8.1)
4
Region Prevalence Suppressed

10 13

9
8
6

0 25
±
50 100
Miles

* Missing Indicates one or two events in category.

Regions are based on Health Statsitics Regions; more information can be found at http://www.chd.dphe.state.co.us/HealthIndicators/Default.aspx.�
Rates are per 100,000 population in year and sex category.
Definitions used based on NCHS Data Brief, No. 81, December 2011, "Drug Poisoning Deaths in the United States, 1980-2008".
Source: Vital Statistics Program, Colorado Department of Public Health and Environment.

The highest rates of heroin-related death occurred in urban regions of the state, as defined by the
Colorado Health Statistics Regions. Pueblo County had the highest age-adjusted rate of heroin-re-
lated overdoses in 2011-2016 (8.1 deaths per 100,000 residents), which was over three times the
state rate.

Heroin in Colorado 9
Heroin Fatal & Non-Fatal Overdoses

Non-Fatal Heroin-Related Overdoses in Colorado

Not all heroin overdoses result in death. From 2011-2016, there were 2,795 emergency department
visits associated with non-fatal heroin overdose among Colorado residents, and an additional 838
hospitalizations associated with heroin. While rates of heroin-related hospitalizations steadily
increased during this time period, emergency department visits more than tripled. More specifically,
heroin-related hospitalizations increased from 1.9 visits in 2011 to 3.2 visits per 100,000 residents
in 2016. Heroin emergency department visits went from 4.4 visits in 2011 to 13.7 visits per 100,000
residents in 2016.

Figure 2.5 Heroin-Related Hospitalizations & Emergency Department Visits in Colorado

16
Age-Adjusted Rate per 100,000 CO Residents

13.7
14

10.8
12

9.1
10

8 7
6.4

6 4.4

3.2
4 2.8
2.7
2.5 2.5
1.9
2

0
2011 2012 2013 2014 2015 2016

Heroin ED Visits Heroin Hospitalizations

Due to the change in hospital billing codes in October of 2015, results for the year 2015 were
defined as records from 10/1/14 - 9/30/15 in order to select records using one coding scheme.
Source: Colorado Department of Public Health and Environment (CDPHE)5

On October 1, 2015 in the United States, International Classifications of Diseases (ICD)-10-CM

replaced ICD-9-CM for coding information in hospital discharge, emergency department, and out-
patient records for adminis­trative and financial transactions. Since ICD-10-CM is a major expansion
from ICD-9-CM, a national workgroup is charged with determining standard definitions for moni-
toring non-fatal drug overdoses from 2016 forward. This workgroup will release recommendations
after publication of this report. This analysis uses records where only the first-listed diagnosis is an
acute drug overdose. ICD-9-CM codes were used to identify records from 2011-2015 and ICD-10-
CM codes were used to select records from 2016.:
• In 2016, there were 694 emergency department (ED) visits where heroin poisoning was listed as
the first discharge diagnosis, resulting in an adjusted rate of 13.7 ED visits per 100,000 Colorado
residents.
• In 2016, there were 133 hospitalizations where heroin poisoning was listed as the first discharge
diagnosis, resulting in an adjusted rate of 2.4 hospitalization per 100,000 Colorado residents.

Heroin in Colorado 10
Section 3: Naloxone Use

Naloxone Use
Naloxone, commonly known under its trade name, “Narcan,” is a
medication called an “opioid antagonist” used to rapidly counter the Findings
effects of opioid overdose, such as a heroin overdose. Specifically,
naloxone counteracts life-threatening depression of the central • From 2012-November
nervous system and respiratory system, allowing an overdose 2016, the Harm Reduction
victim to breathe normally. Naloxone is a non-scheduled (i.e. non- Action Center trained
addictive) prescription medication. Naloxone only works if a person over 1,100 individuals
has opioids in their system and does no harm if a person is not on experiencing opioid use
opioids. Although traditionally administered by emergency response disorders in Naloxone
personnel, naloxone can be administered by minimally-trained administration.
laypeople, which makes it ideal for treating overdose. Naloxone may • As of April 2018, over
be injected in the muscle, vein, or under the skin, or sprayed into the 500 pharmacies, 200 law
nose. It is a temporary drug that wears off in approximately 30-90 enforcement agencies, and
minutes.6 8 county jails are carrying
naloxone.
Since most overdoses are witnessed and happen over hours, it is
essential that individuals experiencing opioid use disorders have The documented use of
access to this life-saving medication. In Colorado, those experiencing naloxone by emergency
opioid use disorders have had access to naloxone since 2012. In medical services (EMS)
2013, Colorado SB 13-014 was passed to allow for 3rd party access personnel in Colorado to treat
to naloxone, so that the mothers, fathers, roommates, and friends suspected heroin overdoses has
could have access to it, in addition to homeless service providers increased 248 percent from 997
and law enforcement officials. In 2015, SB 15-053 passed, allowing events in 2011 to 3,465 events
pharmacies and harm reduction organizations to dispense naloxone in 2016.
without a physician present, giving further naloxone access to
individuals experiencing opioid use disorders and 3rd parties. As
a result of the new law, the chief medical officer of the Colorado
Department of Public Health and Environment (CDPHE) may issue
standing orders for naloxone to be dispensed by pharmacies and
harm reduction organization employees and volunteers, which will
help expand statewide naloxone access to those who need it most.

As part of the multi-pronged Colorado approach to targeting opioid

use disorders, a Naloxone workgroup was also created within the
Colorado Consortium on Prescription Drug Abuse Prevention.
The Naloxone Work Group focuses on increasing awareness of, and
access to, the opioid overdose reversing drug naloxone in the State
of Colorado, and making clinical, organizational, and public policy
recommendations to achieve this goal.

Heroin in Colorado 11
Naloxone Use

Figure 3.1 Naloxone Use by EMS Personnel in Colorado

4000 3,415 3,465

2,999 3,173
Number of Naloxone

2,639
3000
Use Incidents

2000
997
1000

0
2011 2012 2013 2014 2015 2016

Source: Colorado Department of Public Health and Environment (CDPHE)7

Incidents of EMS personnel using Naloxone increased 248 percent from 997 events in 2011 to 3,465
events in 2016. All cases of naloxone administration were included, regardless of whether the med-
ication was administered prior to, or following EMS arrival on scene, allowing for some non-EMS
personnel administration counts to be included. Data may not be inclusive of all ambulance services.

Heroin in Colorado 12
Section 4: Disease Transmission and Heroin

Disease Transmission and Heroin Use

Injection drug use (IDU) is associated with high risk of bloodborne Findings
infections, including human immunodeficiency virus (HIV), hepatitis
B virus (HBV), and hepatitis C virus (HCV). Each of these viruses can • HCV – In the absence of
be transmitted by sharing needles, syringes, or other drug injection direct measurement of new
equipment (such as cookers, rinse water, cotton) that were used by HCV infections related to
a person who is currently infected. Although curative treatment is unsafe injection practices,
available for HCV and effective suppressive therapy is available for proxy measures can be
HBV and HIV, all can be potentially fatal. used, such as acute HCV
cases and newly-diagnosed
Based on a recent study of people who inject drugs (PWID) in the chronic HCV cases among
Denver metro area, the majority report using non-sterile injection persons 15-29 years of age.
materials, although the proportion of PWID who reported sharing a The rate of reported cases
needle or syringe declined to 35.5 percent in 2012 from 40.9 percent of HCV in these categories
in 2009.9 Syringe exchange programs appear to be having a positive more than doubled in
impact on the availability of sterile needles.9 Onward transmission Colorado from 2012-2016.
of bloodborne infections to others is common through shared IDU • 2012 – 366 cases (33.4
equipment, especially for HCV which is highly infectious and can cases per 100,000
sometimes persist for weeks in a syringe.8 Currently, most new HCV population)
infections are caused by sharing needles or other equipment for • 2016 – 894 cases (76.4
injection drug use (IDU).10 Among drugs used in Colorado, heroin is cases per 100,000
the drug most predominantly injected. population)

Since heroin is the substance most predominantly injected, as rates of

opioid use disorders continue to rise, Colorado is more vulnerable to
outbreaks of bloodborne disease driven by IDU.11 Such outbreaks have been previously documented
in other states, most dramatically in Indiana where a co-outbreak of HIV and HCV driven by IDU
occurred in 2015.12 In June of 2016, the Centers for Disease Control and Prevention (CDC) con-
curred that “Colorado is at risk for an increase in viral hepatitis or HIV infections due to injection
drug use,” based on a CDPHE assessment of nine variables related to substance abuse and IDU.13 This
type of analysis, using variables in lieu of direct measurement of IDU-driven transmission of disease,
is necessary because public health surveillance systems are not fully funded to monitor new HCV
infections related to unsafe injection practices. Eight counties have established a legal basis for syringe
access based in Colorado state law (CRS 25-1-520). Currently, seven counties have operational points
of service, with ten total access points for distributing sterile syringes. However, with very limited
resources available, none of these sites fully met the criteria for “comprehensive syringe services pro-
grams” as defined by CDC.14

Heroin in Colorado 13
Disease Transmission and Heroin Use

Figure 4.1 HCV Cases in Colorado: Acute and Newly Reported Chronic Cases Among Persons
15-29 Years of Age

1000
900
Number of HCV Cases

800
700
600
500 894
400
594
300 508
366 398
200
100
42 23 33 40 41
0
2012 2013 2014 2015 2016

Hepatitis C, Acute Hepatitis C, Chronic (Confirmed and Probable cases)

Source: Colorado Department of Public Health and Environment (CDPHE)15

Figure 4.2 Rates of Hepatitis C in Colorado Counties in 2016

Source: Colorado Department of Public Health and Environment (CDPHE)15

Heroin in Colorado 14
Disease Transmission and Heroin Use

Rates of newly diagnosed cases of HIV in Colorado remained fairly stable from 2011-2017. The
average yearly rate for new cases is 365 persons per year. In approximately 60 percent of all new cases,
male-to-male sexual contact was the leading cause of new exposures. IDU has historically accounted
for a small percentage of new diagnoses, averaging 3.7 percent between 2011 and 2017.

Figure 4.3 Newly Diagnosed Cases of HIV in Colorado

500 50%

450 432 45%

415
400 382 382 383 382 40%

Percent Injection Drug Use

350 327 35%
Number of Persons

300 30%

250 25%

200 20%

150 15%

100 10%
3% 2.8% 3.7% 3.1% 6.5%
3.4%
50 5%
3.6%
0 0%
2011 2012 2013 2014 2015 2016 2017

Persons Exposure Category: % Injection Drug Use

Source: Colorado Department of Public Health and Environment (CDPHE)15

Heroin in Colorado 15
Section 5: Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome (NAS)

The U.S. National Library of Medicine defines Neonatal Abstinence Findings
Syndrome (NAS) as, “a group of problems that occur in a newborn who • Cases of infants born
was exposed to addictive opiate drugs while in the mother’s womb.”16 with neonatal abstinence
This includes drugs from both the opiate and opioid families. NAS is syndrome (NAS) in
often caused by a woman taking prescription opioids in pregnancy, but Colorado have increased,
using heroin, methadone or buprenorphine during pregnancy can also while Colorado birth rates
cause NAS. As the mother continues to use these substances during have remained relatively
pregnancy, the unborn child is at risk of developing a dependency. stable. From 2011-2016,
Among infants exposed to opiate or opioids in utero, 55-94 percent cases of NAS births have
will exhibit signs of withdrawal, according to a literature review by increased 73 percent.
the American Academy of Pediatrics.17 Withdrawal symptoms often • 2011 – 168 cases
include central nervous system irritability (such as tremors, high- • 2016 – 290 cases
pitched crying, etc.), temperature instability, and gastrointestinal • From 2011-2016, NAS
tract dysfunction exhibited by poor feeding, loose stools, vomiting, rates in newborns
dehydration, or poor weight gain. Symptoms commonly occur within addicted to opiate drugs
two to three days after birth. Withdrawal symptoms also may occur in have increased 69 percent.
babies exposed to alcohol, benzodiazepines, barbiturates, and certain • 2011 – 2.6 per 1,000
antidepressants. Data on long-term developmental outcomes related to births
NAS are limited. • 2016 – 4.4 per 1,000
births
The NAS data presented in this section originates from hospital discharge
coding based on the International Classification of Diseases (ICD)-9-CM
for 2011-2015 and ICD-10-CM for 2016. It is not possible to determine from these codes what caused
the NAS for these infants.18 Therefore, the cases of NAS reported here likely were caused by a variety
of different drugs, including, but not limited to heroin.

Heroin in Colorado 16
Neonatal Abstinence Syndrome (NAS)

Figure 5.1 Colorado NAS Cases

290
Data from the Colorado
300 242 244
216 Department of Public Health
207
250 and Environment indicates that
NAS Cases per Year

168
there was a 73 percent increase
200
in NAS cases among Colorado
150 infants from 2011-2016.
100

50

0
2011 2012 2013 2014 2015 2016

Source: Colorado Department of Public Health and Environment (CDPHE)18

Figure 5.2 Colorado NAS Rates

4.4
4.5
3.7 3.7
Similarly, although Colorado
4
3.3
recorded birth rates remained
3.2
3.5 relatively stable from 2011–
NAS Rate per 1,000 Births

3 2.6 2016, the rates of NAS, which

take into account changes
2.5
in birth rates, increased 69
2 percent during this time
1.5 period. This indicates that the
1 increase in NAS in Colorado is
not due to more infants being
0.5
born in Colorado.
0
2011 2012 2013 2014 2015 2016
Source: Colorado Department of Public Health and Environment (CDPHE)18

Heroin in Colorado 17
Section 6: Heroin Exposure Calls

Heroin Exposure Calls

The Rocky Mountain Poison and Drug Center (RMPDC) is part Findings
of the national network for the American Association of Poison
Control Centers (AAPCC).19 They are responsible for a wide variety • Exposure to heroin calls
of public health projects and services aimed at reducing the incidence increased 70 percent in
of toxicity, disease, and injury. The RMPDC collects data on callers Colorado from 2011-2016.
reporting incidents of “exposures” or requests for information on • Exposure to heroin calls
various drugs, including illicit drugs such as heroin. increased 149 percent in the
The AAPCC defines an “exposure” as an incident where there is actual or nation from 2011-2016.
suspected contact (e.g., ingestion, inhalation, absorption, etc.) reported
with a particular substance. By contrast, an “information” case is when
a caller contacts the poison center with questions about a particular substance; however, there is no
identifiable exposure involved. The AAPCC database tracks both exposure and information calls and
is updated almost immediately.20

Figure 6.1 Heroin Exposure Calls - Colorado

68
70 64
Number of Heroin Exposure Calls

60

50 40 42 40
39
40

30

20

10

0
2011 2012 2013 2014 2015 2016

Source: Rocky Mountain Poison and Drug Center (RMPDC)19

Exposure to heroin calls increased 70 percent in Colorado from 2011 - 2016.

Heroin in Colorado 18
Heroin Exposure Calls

Figure 6.2 Heroin Exposure Calls - National

7,849
8,000
Number of Heroin Exposure Calls

7,000 5,697
6,000 4,929
4,432
5,000 3,983
3,152
4,000

3,000

2,000

1,000

0
2011 2012 2013 2014 2015 2016

Source: American Association of Poison Control Centers (AAPCC)20

Exposure to heroin calls increased 149 percent in the nation from 2011-2016.

Heroin in Colorado 19
 Section 7: Heroin Treatment Admissions and
Client Information

Heroin Treatment Admissions and Client Information

The data in this section comes from the Colorado Department of

Human Services, Office of Behavioral Health. The agency’s Drug and Findings
Alcohol Coordinated Data System (DACODS) provides information
• There was a 189 percent
on substance abuse treatment admissions in Colorado at state-
increase in heroin treatment
licensed facilities.
admissions disorders from
Figure 7.1 Heroin Treatment Admissions In Colorado State Facilities* 2011 (2,748 admissions) to
2016 (7,949 admissions).
9,000
• The majority of the clients
Number of Heroin Treatment

8,000 admitted for treatment for

7,949
7,000 heroin use disorders are
6,971
white males between the
Admissions

6,000
5,675
ages of 25 through 34 who
5,000 have never married and are
4,000
4,031
unemployed.
3,000 3,483
2,748
2,000

1,000

0
2011 2012 2013 2014 2015 2016
*Clients who identified heroin as their primary, secondary, or tertiary drug of use on their admissions DACODS.
Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Figure 7.2 Colorado State Heroin Treatment Clients by Gender

Please note that in Figures
64%
60% 7.1 - 7.11, the n-values rep-
Treatment Admissions

resenting the total number

Percent of All Heroin

70%
60%
40%
of responses are some-
36%
50% times discrepant because n
40% cannot be reported in the
30% data if there are less than
20% 10 responses per category
10% (to comply with HIPPA
0% and 42-CFR Part 2 privacy
2011 2016
n = 2,784 n = 7,949
rules).

Men Women
Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Heroin in Colorado 20
Heroin Treatment Admissions and Client Information

Figure 7.3 Colorado State Heroin Treatment Clients by Age

50% 46%
45%
40% 36%
Treatment Admissions

31%
Percent of All Heroin

35%
28%
30%
25%
20% 16% 15%
15%
9%
10% 6%
2% 1% 5% 3%
5% 1% 1%
0%
17 or 18-24 25-34 35-44 45-54 55-64 65+
Under

2011 n = 2,234 2016 n = 6,355

Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Figure 7.4 Colorado State Heroin Treatment Clients by Race

77.6% 77.3%
80%
Treatment Admissions

70%
Percent of All Heroin

60%
50%
40%
30%
16.7% 17.1%
20%
10% 2.7% 2.6% 3.0% 3.0%

0%
White Black Hispanic/Latino Other

2011 n = 2,724 2016 n = 6,989

Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Heroin in Colorado 21
 Heroin Treatment Admissions and Client Information

Figure 7.5 Colorado State Heroin Treatment Clients by Marital Status

68.9%
65.0%
70%
60%
Treatment Admissions
Percent of All Heroin

50%
40%
30%
15.4% 13.1%
12.7% 11.1%
20%
5.0% 4.9%
10% 1.9% 2.0%

0%
Never Married Widowed Separated Divorced
Married

2011 n = 2,748 2016 n = 7,949

Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Figure 7.6 Colorado Heroin Treatment Clients by Military Status

96.1% 97.5%
100%
Treatment Admissions
Percent of All Heroin

90%
80%
70%
60%
50%
40%
30%
20% 3.9% 2.5%
10%
0%
2011 2016
n = 2,748 n = 7,949

Non-Veteran Veteran

Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Heroin in Colorado 22
Heroin Treatment Admissions and Client Information

Figure 7.7 Colorado State Heroin Treatment Clients by Primary Source of Income
45% 43.0%
39.2%
40%
Treatment Admissions

33.2%
Percent of All Heroin

35%
28.9%
30%

25% 20.4%
20%
13.2%
15%

10% 7.0%
5.2% 4.9%
3.9%
5% 0.7% 0.6%
0%
Wages Public Retirement Disability Other None
Assistance Pension

2011 n = 2,748 2016 n = 7,949

Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Figure 7.8 Colorado State Heroin Treatment Clients by Employment Status

58.2%
60% 55.8%

50%
Treatment Admissions
Percent of All Heroin

40%

30%

18.2% 18.9%
20%

11.2%
8.7%
10% 7.2%
5.6% 5.8%
4.6% 4.0%
1.8%

0%
Full-Time Part-Time Unemployed Disabled Inmate Other

2011 n = 2,718 2016 n = 7,949

Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Heroin in Colorado 23
Heroin Treatment Admissions and Client Information

Figure 7.9 Colorado State Heroin Treatment Clients with History of Mental Health Issues

60% 50.9%
46.0%
Treatment Admissions

50%
Percent of All Heroin

37.6%
40%
31.1%

30%
16.4% 18.0%
20%

10%

0%
Yes No Unknown

2011 n = 2,748 2016 n = 7,949

Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Figure 7.10 Colorado State Heroin Treatment Clients by Source of Illicit Drugs
42.1%
45%
40% 34.4% 34.0% 35.3%
Treatment Admissions
Percent of All Heroin

35%
27.4%
30%
25% 20.9%
20%
15%
10%
3.0% 2.9%
5%
0%
Stranger Street Friends Family Other
Vendor

2011 n = 2,696 2016 n = 7,804

*Includes school, internet, refused to respond, and unknown
Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Heroin in Colorado 24
Heroin Treatment Admissions and Client Information

Figure 7.11 Colorado State Heroin Treatment Clients by Source of Treatment Referral

2011 N = 2,234 2016 N = 6,355

Criminal Justice Criminal Justice

27.5% 34.5%

Voluntary
Voluntary 65.5%
72.5%

Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Table 7.1 Characteristics for Clients in Treatment in 2016

Table 7.1 Characteristics of Colorado State Clients in Treatment in 2016

Heroin Prescription Opioid All Treatment

User User Admissions
Male 60.4% 55.2% 72.7%
Ages
18-24 28.0% 16.4% 17.1%
25-34 45.8% 45.7% 36.3%
35-44 15.4% 27.3% 22.2%
White 77.3% 79.3% 67.0%
Marital Status
Married 13.1% 22.8% 15.2%
Never Married 68.9% 52.9% 60.3%
Employment Status
Full Time Employee 18.9% 24.5% 33.3%
Unemployed 58.2% 46.5% 42.8%
History of Mental Health
50.9% 52.8% 29.9%
Problems
Source of Drugs
From Friend 35.3% 26.9% 34.2%
From Stranger 34.4% 23.8% 17.1%
Criminal Justice Referral 34.5% 21.9% 47.6%

Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS21

Source: Colorado Department of Human Services, Office of Behavioral Health, DACODS 21

Heroin in Colorado 25
Conclusion

The data in this assessment indicate a recent increase in the number of treatment admissions for
heroin in Colorado. To reduce the adverse impacts of heroin use and trafficking, greater effort needs
to be placed on a coordinated response to the ongoing issue. This will require a joint effort by the law
enforcement, prevention, treatment and recovery communities working together to curb the harmful
impact heroin is having in Colorado. Members of the Heroin Response Work Group are committed
to using the information presented in this assessment to identify, implement and evaluate strategies
to address gaps in data collection and reporting related to heroin and to prevent adverse outcomes
associated with heroin use in Colorado.

Heroin in Colorado 26
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peds.2011-3212
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Heroin in Colorado 27