Data Collection Instrument - Undetermined Risk Factors for Fentanyl-related Overdose Deaths - Ohio

Attachment H1
Stakeholder Interview Guide for Coroner/Medical Examiner
Form Approved
OMB No.: 0920-1054
Expiration Date: 03/31/2018
Public Reporting burden of this collection of information is estimated at 1 hour per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required
to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333;
Attn: PRA (0920-1054).

Total Number of Participants:

Date:

Good morning/afternoon. I want to thank you for taking the time to participate in this focus group. My
name is [NAME] and I am a [JOB TITLE] at [ORGANIZATION].
Before starting this discussion, I will provide you some background and details about how information
from this discussion will be used. Since 2013 there has been an increase in fentanyl related overdose
deaths in the state of Ohio. To better understand these deaths, the Ohio Department of Public Health
and the Centers for Disease Control and Prevention are working to gather information to understand
this problem and to identify ways to prevent further overdose deaths.
As part of this data gathering process, we are talking to key stakeholders, such as yourselves, about the
issue of fentanyl associated overdose deaths, and more broadly, about opioid drug use and addiction in
the state of Ohio. We aim to understand the characteristics of individuals using and overdosing on
fentanyl or fentanyl-adulterated products, risk factors for overdose death, behaviors, and prevention
activities that are currently being used or could be used.
Your comments and thoughts, along with your experiences, will provide valuable insight to this
investigation.
Over the course of this discussion [NAME] will be taking notes. All information from this discussion will
be presented in aggregate and will remain confidential. Your name will not be connected with your
comments. This discussion should take no more than 60 minutes. It is voluntary and you may decide to
end it at any time. If you would like to skip a particular question, or would like to end your
participation at any time, please let me know.
We will be audio taping this discussion, but will start the recording after introductions. If you do not feel
comfortable being audio recorded, please let us know.
Do you agree to participate? Y or N
•

Do you have any questions before we begin?

[Introduction] To start with, can we go around and have each of you tell us your name, how long you
have been a coroner or medical examiner in the state of Ohio, and what region you focus in.
START AUDIO RECORDING

•

[Characteristics-Perception] Within your role as a coroner or medical examiner, can you talk about
the types of opioid overdose cases you’re seeing within your jurisdiction?
o Have you noticed a change over time in the number of cases, routes of administration of the
drug, and case demographics?

•

•

•
•

[Characteristics-OD type] When you have an overdose case, how do you determine what substance
were used, and which substance(s) were directly responsible as a cause of death? Are each of the
substances responsible listed separately on the death certificate?
o Does this vary by County
[Characteristics-OD type] What range of drugs are covered by your standard toxicology
immunoassay panel?
o Does this include immunoassay for fentanyl? Does this vary by county?
o Are all positive immunoassay results sent for confirmatory testing, including fentanyl?
o On confirmatory testing, is a negative fentanyl result after a positive immunoassay result
raise the concern for a fentanyl analog? If so, is this tested? If not, How is such a
circumstance dealt with, and how are the results reported?
o Do you feel that doing the testing necessary to identify fentanyl analogs is worthwhile and
cost effective?
 Do you have a dictionary of fentanyl analogs in terms of the location of a spike on
GC/MS testing that is suspected to be a fentanyl analog?
 Do you have a range of fentanyl analog standards upon which to confirm the presence
of a fentanyl analog?
[Characteristics-OD type] Beyond toxicology, are there characteristics of a fentanyl overdose that
are different from other types of overdoses?
[Prevention-Suggestions] From your perspective as a coroner or medical examiner, what do you
think could help you better identify cases of fentanyl-associated overdose death?
o What additional methods, resources, or expertise could help identify cases?
o What do you think could help expand or increase toxicological testing of fentanyl and other
opioids?

•

[Characteristics-Other tests] Given the increased risk of infection for HIV and Hep C in persons
who inject drugs, are these conditions tested routinely in heroin and fentanyl cases?
o If no…are you able to determine their status in other ways?
o If no…is determining their status a priority?

•

[Final] The last question we have for you is what is the most important thing you would like us to
know about opioid use and fentanyl associated overdose in Ohio?

That concludes all of the questions we had for you. Is there anything that you would like to discuss or
add that I did not ask about?
• If not, then that concludes this discussion. I want to thank you for taking the time to talk with us.
• If one of you would like to discuss something outside of the group format, please feel free to contact
me at [[email protected] or XXX-XXX-XXXX].

Attachment H2
Stakeholder Interview Guide for DEA/Narcotics agents
Form Approved
OMB No.: 0920-1054
Expiration Date: 03/31/2018
Public Reporting burden of this collection of information is estimated at 1 hour per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required
to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333;
Attn: PRA (0920-1054).

START AUDIO RECORDING
• Can you talk about the heroin market in Ohio?
o How is the market different across regions?
• Can you describe the types of heroin that are available in Ohio?
o We have read reports of dyed white powder being sold as potent heroin in addition to black
tar and brown powdered heroin? Is this fentanyl being sold as heroin? If so, why are heroin
dealers not selling it as fentanyl?
• Can you describe changes in heroin availability since 2010?
o Have there been changes in the cost and purity of heroin in the state?
• We know there has been an increase in fentanyl-cut, or fentanyl-adulterated, heroin in Ohio since
2011.
o What do you think explains this increase in fentanyl-adulterated heroin in Ohio?
o Where do you think this fentanyl is coming from (e.g., Mexico, India, or China)?
o Is it being sent through the mail?
• What are the current responses, activities and efforts by DoJ to understand and combat fentanyl
related overdose?
o Will there be changes in the response and activities given the increase in overdose deaths
and increase in fentanyl-adulterated heroin?
• What do you think could be done to reduce the amount of fentanyl-cut/adulterated heroin in
Ohio?
o What types of additional resources would DEA need to reduce the amount of fentanylcut/adulterated heroin in Ohio?
•

[Final] The last question we have for you is what is the most important thing you would like us to
know about opioid use and fentanyl associated overdose in Ohio?

That concludes all of the questions we had for you. Is there anything that you would like to discuss or
add that I did not ask about?

Attachment H3
Stakeholder Interview Guide for Drug Treatment services
Form Approved
OMB No.: 0920-1054
Expiration Date: 03/31/2018
Public Reporting burden of this collection of information is estimated at 1 hour per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required
to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333;
Attn: PRA (0920-1054).

Date:

Total Number of Participants:

Good morning/afternoon. I want to thank you for taking the time to participate in this focus group. My
name is [NAME] and I am a [JOB TITLE] at [ORGANIZATION].
Before starting this discussion, I will provide you some background and details about how information
from this discussion will be used. Since 2013 there has been an increase in fentanyl related overdose
deaths in the state of Ohio. To better understand these deaths, the Ohio Department of Public Health
and the Centers for Disease Control and Prevention are working to gather information to understand
this problem and to identify ways to prevent further overdose deaths.
As part of this data gathering process, we are talking to key stakeholders, such as yourselves, about the
issue of fentanyl associated overdose deaths, and more broadly, about opioid drug use and addiction in
the state of Ohio. We aim to understand the characteristics of individuals using and overdosing on
fentanyl or fentanyl-adulterated products, risk factors for overdose death, behaviors, and prevention
activities that are currently being used or could be used.
Your comments and thoughts, along with your experiences, will provide valuable insight to this
investigation.
Over the course of this discussion [NAME] will be taking notes. All information from this discussion will
be presented in aggregate and will remain confidential. Your name will not be connected with your
comments. This discussion should take no more than 60 minutes. It is voluntary and you may decide to
end it at any time. If you would like to skip a particular question, or would like to end your
participation at any time, please let me know.
We will be audio taping this discussion, but will start the recording after introductions. If you do not feel
comfortable being audio recorded, please let us know.
Do you agree to participate? Y or N

Do you have any questions before we begin?

START AUDIO RECODING

[Introduction] To start with, can we go around and have each of you tell us your name, your affiliation,
and the content area/capacity with which you work in.
1. We know that fentanyl is a problem in Hamilton County. Can you characterize the population
using fentanyl and compare them to other types of opioid users, such as prescription opioids and
heroin?
a. Age, poly-drug use, length of use, routes of administration, previous OD, etc.
b. Is this a different opioid epidemic than the 70s?

2.
3.

4.
5.

c. Are people seeking out fentanyl? Are they a different group from heroin users? If so, are
there novel approaches to treating this fentanyl-using population?
d. Can you identify key risk factors for fentanyl-related overdose deaths?
What do you believe is contributing to/explains the increase in fentanyl-related overdose death in
Ohio? (From the perspective of both supply and demand.)
What is the status of opioid addiction treatment in the state of Ohio?
a. Is methadone available? Buprenorphine?
b. What is the available capacity of treatment?
What role can treatment play in addressing the increase in fentanyl-related overdose?
Is there anything that you would like to discuss or add that is important for us to know that we
didn’t go over?

Attachment H4
Stakeholder Interview Guide for Healthcare Providers
Form Approved
OMB No.: 0920-1054
Expiration Date: 03/31/2018
Public Reporting burden of this collection of information is estimated at 1 hour per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required
to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333;
Attn: PRA (0920-1054).

Date:
Total Number of Participants:
Good morning/afternoon. I want to thank you for taking the time to participate in this focus group. My
name is [NAME] and I am a [JOB TITLE] at [ORGANIZATION].
Before starting this discussion, I will provide you some background and details about how information
from this discussion will be used. Since 2013 there has been an increase in fentanyl related overdose
deaths in the state of Ohio. To better understand these deaths, the Ohio Department of Public Health
and the Centers for Disease Control and Prevention are working to gather information to understand
this problem and to identify ways to prevent further overdose deaths.
As part of this data gathering process, we are talking to key stakeholders, such as yourselves, about the
issue of fentanyl associated overdose deaths, and more broadly, about opioid drug use and addiction in
the state of Ohio. We aim to understand the characteristics of individuals using and overdosing on
fentanyl or fentanyl-adulterated products, risk factors for overdose death, behaviors, and prevention
activities that are currently being used or could be used.
Your comments and thoughts, along with your experiences, will provide valuable insight to this
investigation.
Over the course of this discussion [NAME] will be taking notes. All information from this discussion will
be presented in aggregate and will remain confidential. Your name will not be connected with your
comments. This discussion should take no more than 60 minutes. It is voluntary and you may decide to
end it at any time. If you would like to skip a particular question, or would like to end your
participation at any time, please let me know.
We will be audio taping this discussion, but will start the recording after introductions. If you do not feel
comfortable being audio recorded, please let us know.
Do you agree to participate? Y or N

Do you have any questions before we begin?

START AUDIO RECODING

[Introduction] To start with, can we go around and have each of you tell us your name, your affiliation,
and the content area/capacity with which you work in.
1. We know that fentanyl is a problem in Hamilton County. Can you characterize the population
using fentanyl and compare them to other types of opioid users, such as prescription opioids and
heroin?
a. Can you identify key risk factors for fentanyl-related overdose deaths?
2. What do you believe is contributing to/explains the increase in fentanyl-related overdose death in
Ohio? (From the perspective of both supply and demand.)

3. Can you describe strategies, like lay naloxone, to prevent fentanyl-related overdose deaths and
opioid overdoses more generally?
a. What are some barriers and challenges? Facilitators?
b. What additional programs, services, or resources are needed in Ohio to reduce opioidrelated overdoses?
c. What are some novel approaches to reduce fentanyl overdose?
d. What additional groups do you think should be trained to use Naloxone?
4. Can you describe the way health care providers, harm reduction groups and Project Dawn
coordinate to prevent opioid overdose?
5. Is there anything that you would like to discuss or add that is important for us to know that we
didn’t go over?

Attachment H5
Law Enforcement
Form Approved
OMB No.: 0920-1054
Expiration Date: 03/31/2018
Public Reporting burden of this collection of information is estimated at 1 hour per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required
to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333;
Attn: PRA (0920-1054).

Date:
Total Number of Participants:
Good morning/afternoon. I want to thank you for taking the time to participate in this focus group. My
name is [NAME] and I am a [JOB TITLE] at [ORGANIZATION].
Before starting this discussion, I will provide you some background and details about how information
from this discussion will be used. Since 2013 there has been an increase in fentanyl related overdose
deaths in the state of Ohio. To better understand these deaths, the Ohio Department of Public Health
and the Centers for Disease Control and Prevention are working to gather information to understand
this problem and to identify ways to prevent further overdose deaths.
As part of this data gathering process, we are talking to key stakeholders, such as yourselves, about the
issue of fentanyl associated overdose deaths, and more broadly, about opioid drug use and addiction in
the state of Ohio. We aim to understand the characteristics of individuals using and overdosing on
fentanyl or fentanyl-adulterated products, risk factors for overdose death, behaviors, and prevention
activities that are currently being used or could be used.
Your comments and thoughts, along with your experiences, will provide valuable insight to this
investigation.
Over the course of this discussion [NAME] will be taking notes. All information from this discussion will
be presented in aggregate and will remain confidential. Your name will not be connected with your
comments. This discussion should take no more than 60 minutes. It is voluntary and you may decide to
end it at any time. If you would like to skip a particular question, or would like to end your
participation at any time, please let me know.
We will be audio taping this discussion, but will start the recording after introductions. If you do not feel
comfortable being audio recorded, please let us know.
Do you agree to participate? Y or N
•

Do you have any questions before we begin?

[Introduction] To start with, can we go around and have each of you tell us your name, how long you
have been in law enforcement here in Ohio, and the content area/capacity with which you work in.
START AUDIO RECORDING

•

Can you describe the illicit opioid market in your jurisdiction?
o What are the characteristics of the drug markets for heroin and other opioids?

•
•

Can you talk about how drugs found on the scene of an overdose are used to identify fentanyl cases?
What determines whether drugs found on the scene are tested by investigators?
 Paraphernalia found?

 Multiple overdoses per scene?
o Do you think there needs to be an increase in testing of drugs found on scene? Why or why
not?
o How long is the time frame from when a drug is found on the scene to when it’s tested?
o Do you share drug test results with local health department and coroners/MEs?
•

What is your perspective on the use of naloxone by Law Enforcement?
o Is it effective?
o How does your district purchase it? Is the supply of naloxone adequate for your need?
o What route of administration do you use (nasal vs. IM)?
 If nasal, are more doses necessary to reverse fentanyl cases?
 What is your perspective on lay naloxone?
• Can lay persons effectively administer naloxone?

•

Do your jurisdiction dispense naloxone to persons leaving jail or prison?
o If so, is this program effective? Limitations?

•

What do you think could help law enforcement combat the increase in fentanyl and fentanyl
adulterated heroin found in Ohio?

That concludes all of the questions we had for you. Is there anything that you would like to discuss or
add that we did not ask about?
• If not, then that concludes this discussion. I want to thank you for taking the time to talk with us.

Attachment H
Stakeholder Interview Guide State level meeting
Form Approved
OMB No.: 0920-1054
Expiration Date: 03/31/2018
Public Reporting burden of this collection of information is estimated at 1 hour per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required
to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333;
Attn: PRA (0920-1054).

START AUDIO RECODING
[Introduction] To start with, can we go around and have each of you tell us your name, your affiliation,
and the content area/capacity with which you work in.
[CDC Introduction] Begin with introduction about what we’re doing, and how we’ve met with
Treatment services directors in various regions of Ohio.
[Question] Can we start by talking about how you see your role and your organization’s role in
addressing the current Heroin/Fentanyl problem in your state?
[Question] What are some of the key challenges facing Addiction services in the state of Ohio?
•
•

Issues we’ve heard about:
Resources, both in terms of Funding and supply of trained physicians; can we leverage more
primary care physicians, who can work in conjunction with Addictionologists?
o Mental Health co-morbidities in the User population
o Medicaid reimbursement for Addiction services

[Question] What is the current status of opioid disorder treatment in Ohio?
•
•
•
•

What is the current capacity of MAT? (Buprenorphine and Methadone)
What is the current capacity of abstinence-based treatment?
Does access differ by county?
Payment/Provider challenges?

[Question] Can you characterize the population using fentanyl and compare them to other types of
opioid users, such as prescription opiois and heroin?
•
•
•
•

Age, poly-drug use, length of use, routes of administration, previous OD, etc.
Is this a different opioid epidemic than the 70s?
Are people seeking out fentanyl? Are they a different group from heroin users? If so, are there
novel approaches to treating this fentanyl-using population?
Can you identify key risk factors for fentanyl-related overdose deaths?

[Question] What do you believe is contributing to/explains the increase in fentanyl-related overdose
death in Ohio? (From the perspective of both supply and demand.)
[Final Question] Is there anything that you would like to discuss or add that is important for us to know
that we didn’t ask about?