Jefferson County Heroin Epidemic - Homepage | OutReach · 2019-03-20 · 4 Jefferson County Heroin Epidemic Summary Since the year 2000, Interstate 20/59, which passes through Birmingham,

Jefferson County Heroin Epidemic

Certified Public Manager® Program 2015 CPM Solutions Alabama

1 Jefferson County Heroin Epidemic

Table of Contents

Team Members .................................................................................................................. 2

Acknowledgements ........................................................................................................... 3

Abstract ............................................................................................................................. 4

Evolution of Heroin ........................................................................................................... 5

The Problem ...................................................................................................................... 7

Solutions ........................................................................................................................... 11

Recommendations ............................................................................................................ 16

References ......................................................................................................................... 20

Appendix ........................................................................................................................... 21


CPM Solutions Alabama Jefferson County Heroin Epidemic

Team Members

Alabama Alcoholic Beverage Control Board

Tonia Stephens: [email protected]

Alabama Department of Corrections

Linda Houston: [email protected]

Alabama Department of Environmental Management

Kelley Hartley: [email protected]

Lisa Hicks: [email protected]

Alabama Department of Revenue

Judia Green: [email protected]

Alabama Department of Youth Services

Terrence Johnson: [email protected]

Ernest Robinson: [email protected]

Alabama Historical Commission

Stacye Hathorn: [email protected]

City of Columbiana

J. Mark Frey: [email protected]

City of Vestavia Hills

Jim St. John: [email protected]


Acknowledgements

The Addiction Prevention Coalition

Reverend J. Sandor Cheka

Bradford Health Services

Penny Barnes, Community Representative

John Nicolini, Counselor

Anthony Reynolds, Regional Director

City of Hoover Police Department

Sergeant Ted Davis

Officer Lance Thompson

Jefferson County Coroner/Medical Examiner's Office

Bill Yates, Chief Deputy Coroner

Jefferson County Department of Health

Dr. Mark Wilson, Health Officer

Jefferson County Sheriff’s Office

Jude Washington

Alabama House of Representatives

Representative Oliver Robinson, Jefferson County

City of Vestavia Hills Fire Department

Jeff Burleson


Summary

Since the year 2000, Interstate 20/59, which passes through Birmingham,

has become a primary thoroughfare for drug trafficking. As a result, there has been

an increase of illicit drug permeation, including heroin, in Jefferson County,

Alabama’s largest county. The largest city in the state, Birmingham has become a

hub for dealers who smuggle drugs to larger cities such as Atlanta, Chicago,

Detroit, Houston, Los Angeles and San Diego.

The elevated drug presence in the Birmingham area, combined with the

increased availability of heroin in general and the decreased availability of opioids

in the form of prescription drugs, has accelerated the use of heroin in Jefferson

County at an alarming rate. The number of heroin related deaths in Jefferson

County doubled in 2012. Two years later that number had more than doubled yet

again. By December 2014, the number of deaths related to heroin had increased by

53% to a startling 137, as evidenced in Figure 1. Sadly, 2015 is proving to continue

this alarming trend.

Figure 1. Number of deaths in Jefferson County due to heroin overdose from 2008 to 2014

137

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140

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2009

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2011

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Our team was assigned the task of researching the precipitous rise in heroin

related deaths in Jefferson County. Specifically, we were charged with identifying

the demographic profile of heroin users in Jefferson County and the cause of their

accidental overdoses. We were asked to evaluate strategies to bring awareness of

the high risk of accidental overdose and death to users and identify potential

prevention strategies. The team studied statistical information, interviewed subject

matter experts and researched solutions suggested by a local task force organized to

address the problem in Jefferson County and evaluated solutions implemented

elsewhere.

Many stakeholders contributed to the concepts outlined in the proposed

solutions, and we appreciate their participation and commitment to reducing the

use of heroin, and associated deaths across Alabama.

Evolution of Heroin

The Bayer Company began commercial production of heroin in 1898 (J.

Burleson, personal communication, March 20, 2015). In pharmacological studies,

heroin proved to be more effective than either morphine or codeine. The first

clinical trials were so encouraging that heroin was believed to be a wonder drug. In

fact, it was initially advertised as a non-addictive alternative to morphine.

However, despite product claims, repeated administration of heroin resulted in the

development of drug tolerance. Patients quickly became heroin addicts (S. Hostafi,

2001).

Morphine addicts learned about the euphoric properties of heroin in the early

1900s. They quickly discovered that this euphoric effect was enhanced by

administering heroin intravenously. The abuse of heroin spread quickly. In 1924,

the Heroin Act declared all use, manufacturing and distribution of heroin illegal,

including medicinal heroin. As a result of the Heroin Act, both the production and

the consumption of heroin significantly decreased after 1931. However, drug

traffickers recognized the scarcity, and thus the demand, of heroin and began to


produce and traffic it illegally. The amount of heroin seized by law enforcement

agencies rose gradually at first but the growth of the illicit heroin industry has

exploded worldwide in recent decades, with a tenfold increase since 1970 (S.

Hostafi, 2001).

In recent years, heroin has become less expensive and more readily available

due to increased production in places such as Afghanistan, Mexico and Columbia.

Since the year 2000, Interstate 20/59, which passes through Birmingham, has

become a primary thoroughfare for drug trafficking. As a result, there has been an

increase of drug trafficking and presence in Jefferson County. Birmingham has

become a hub for dealers who smuggle to larger cities such as Atlanta, Chicago,

Detroit, Houston, Los Angeles and San Diego. Birmingham's location on a major

drug trafficking artery ensures that there is an abundant supply of heroin available

in Jefferson County (Jefferson County Drug Task Force, personal communication,

February 20, 2015).

The Problem

Many heroin users become addicted to opioids through the use of prescription

pain killers, often prescribed following an injury or surgical procedure. Others use

pills prescribed to a friend or a family member. Common prescription opioids are

codeine, morphine and hydrocodone, which sells by the brand names of Vicodin and

Lortab; and oxycodone, which sells by the brand name OxyContin. In 2010,

OxyContin, a prescription opioid, changed its formula so that it could not be crushed

and snorted or converted for intravenous use (P. Anson, 2012). Due to this and the

high price of prescription opioids, many have switched to heroin as a more

affordable alternative. According to Anthony Reynolds, Regional Director of

Bradford Health Services, it requires approximately $100 worth of prescription

opioids to achieve the same effect as $15 worth of heroin (personal communication,

April 17, 2015).


Street-level drug dealers thrive on the paradigms of the long-held economic

principle of supply and demand. Dealing in heroin and other illegal drugs, while

dangerous, is highly profitable. Dealers, as Bradford Health Services Counselor

John Nicolini observed, are “purveyors of death” (personal communication. April 27,

2015) and those in Jefferson County are no exception; a confidential informant

reported heroin dealers netting $12,000 profit per week (personal communications,

March 20, 2015).

Because heroin is illegal and unregulated, the potency is highly variable. The

illegal drug market is extremely competitive and dealers respond to consumer

demand by selling increasingly pure and thus progressively lethal doses of heroin.

Adding to the danger, heroin may be cut with other highly potent opioids such as

fentanyl a highly potent post-surgical pain reliever. Due to this variable potency,

using heroin is like "playing Russian roulette" (M. Wilson, 2014).

Bill Yates, Chief Deputy Coroner for Jefferson County, noted that there were

80 deaths attributed to prescription opioids, 137 deaths attributed to heroin and

seven more deaths in which heroin was a contributing factor in 2014. The majority

of deaths occurred in adult, white males. Out of 137 deaths, 120 people were white

and 17 were black, 90 were male and 47 were female. The distribution of death by

age range is depicted in Figure 2 (B. Yates, personal communication, February 3,

2015).

Age at time of death by heroin overdose Number of deaths in Jefferson County in 2014

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Figure 2. Age at the time of death by heroin overdose in Jefferson County in 2014.

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After use, usually by intravenous injection, the victim’s respirations slow and

can altogether stop. This causes all of the body’s tissues to suffer from a lack of

oxygen, especially the sensitive cardiac cells of the heart. After a few minutes

without oxygen, the heart ceases to beat, causing clinical death.

Solutions

Sanders (2001) wrote that the effects of opioid overdose are reversible by the

administration of drugs known as opioid antagonists. These drugs block opioids

from the receptors and allow the brain stem to control respirations. Naloxone is an

opioid antagonist that Field (2006) and the Alabama Department of Public Health

(ADPH) Office of Emergency Medical Services (2013) both identify as useful in

reversing the effects of a heroin overdose. The first steps in supporting an overdose

victim’s respirations rely on manually opening the airway and performing rescue

breathing prior to the administration of an opioid antagonist such as Naloxone (J.

Field, 2006).

Rescue breathing is a foundation of any cardiopulmonary resuscitation (CPR)

training, and is required of emergency medical service personnel in Alabama when

treating an opioid overdose (ADPH, 2013).

The effects of a lethal dose of heroin can be seen as quickly as one minute

after injection. Response time is critical. Putting opioid antagonists in the hands of

first responders is the most immediate way to prevent deaths from heroin overdose.

In the 2015 Alabama legislative session, Representatives Allen Treadaway

and David Faulkner of Jefferson County introduced House Bill 208, which upon the

Governor’s signature on June 4, 2015, became Act 2015-364, authorizes physicians

and dentists to prescribe an opioid antagonist to people at risk of experiencing an

opioid-related overdose or to someone who is in a position to assist another person

who is at risk of experiencing an opioid-related overdose. The law also provides


immunity for physicians or dentists who prescribe an opioid antagonist and for the

people who administer the opioid antagonist. For the people who seek medical

assistance for another person who has overdosed, Act 2015-364 provides immunity

from prosecution for possession or consumption of alcohol if they are under the age

of 21 and immunity from prosecution for certain controlled substance offenses.

Finally, the law requires training about the use of opioid antagonists for certain law

enforcement officers (HB208, 2015).

Although the U.S. Attorney's Office, State and local authorities have handed

down more stringent sentences for those who traffic heroin, over the past few years,

the number of deaths from heroin overdoses continue to rise. Certainly, drug

trafficking interdiction and strict sentencing are important aspects of the solution,

but law enforcement agencies are understaffed, jails are overcrowded and the high

demand for heroin ensures that there are new dealers eager to replace those whom

they arrest (Jefferson County Drug Task Force, personal communication, February

20, 2015).

Representative Oliver Robinson from Jefferson County believes the long-term

solution must address the demand for heroin. We must educate children, teens and

parents about the dangers of heroin, the effects of heroin on the body and the

damage that heroin addiction does to families. It is crucial to focus on the entire

family, especially the children who constitute our next generation (personal

communication, February 20, 2015). According to Reverend J. Sandor Cheka of the

Addiction Prevention Coalition, the most effective drug prevention programs for

children and teenagers are peer based, led by students who are willing to invest

time and understand the problems associated with addiction. Each school chapter

of a peer-led addiction prevention program must also be supported by a faculty

sponsor who cares about and connects with the children (personal communication,

May 14, 2015). The resulting abstinence among students who participating in a

peer-led addiction program is reported in Figure 4.


Self-Reported Year End Results for Peer Based Drug Counseling 2011 - 12 2012 - 13 2013 - 14

Abstinence from Alcohol 78.3% 80.4% 88.9%

Abstinence from Marijuana 85.1% 82.2% 90.7%

Abstinence from Illegal Drug Use 91.5% 100% 100%

Abstinence from Medication Abuse N/A N/A 97.7%

Figure 4. Self‐Reported Year End Results for Peer Based Drug Counseling.

To reiterate, many heroin users begin their dependency on opioids by taking

prescription opioid pain medications. According to Cheka, 64% of high school users

acquire prescription drugs from family members, often without their knowledge

(personal communication, May 14, 2015). Prescription drug monitoring and

prescription drug drop-off programs may help prevent access to opioids and

subsequent addiction.

In an effort to detect diversion, abuse and misuse of prescription drugs

classified as controlled substances, the Prescription Drug Monitoring Program

(PDMP) was created. Mandatory reporting began in 2006, and anyone dispensing

controlled substances is required to report the activity to the database controlled by

Alabama Department of Public Health. The goals of the program are to educate

prescribers, dispensers, law enforcement and the public about diversion, abuse and

misuse and to provide a central information source that can be used to provide

information about an individual’s prescription history, reduce abuse and to assist

with possible drug diversion cases.

The Drug Enforcement Agency discontinued their successful prescription

drug take-back events in September 2014. These events allowed individuals to

safely dispose of prescription drugs from their homes. The final collection day

resulted in 5,624 pounds of prescription drugs collected from Alabama households


deposited at 100 drug take-back sites across the state and 309 tons nationwide from

5,495 drug take-back sites across the U.S. As of October 2014, certain private

entities, such as pharmacies and doctors’ offices, are allowed to collect prescription

drugs. Currently, there are a few drop-off sites made available through grant

money in Jefferson County.

A crucial aspect in the long-term solution is treating recovering heroin

addicts so that they do not return to their habit. Heroin addiction is both

physiological and psychological; such a complex problem cannot be properly

addressed with either short-term inpatient treatment or outpatient treatment.

According to Anthony Reynolds, Regional Director of Bradford Health Services, 86%

of recovered heroin addicts relapse. Those who have been most successful have

participated in a year-long sober living program which combines pharmaceutical

intervention to restore their brain chemistry with psychological and social therapy

(personal Communication, April 27, 2015).

The final piece of the long-term solution is raising awareness. In August of

2014, Jefferson County Health Department led stakeholders in the Jefferson

County area to develop a strategic plan that would reduce the ill effects of heroin

and prescription drug abuse. Ultimately, they developed the “Pills to Needles:

Action Plan." In the plan, there are five strategic priorities which are: Public

Awareness, Partnership with Law Enforcement, Medical Community Engagement,

Effective Research and Policy and Access to Resources. Heightened awareness and

education are key to a long-term solution. It is vitally important that providers are

educated regarding the over prescription of controlled substances, and that

providers, in turn, educate patient populations and their families about the risk of

prescription drug use. It is equally important that education and public awareness

take place among parents and in communities including schools, churches and other

organizations.


Recommendations

Opioid antagonists

The Opioid Antagonists Act 2015-364, which provides for the prescription

and administration of an opioid antagonist would be bolstered by an expansion of

the Good Samaritan Act, AL Code; Section 6-5-332, to provide immunity to those

who administer an opioid antagonist (see Appendix).

Opioid antagonists are expensive. Currently, a two milligram dose of the

opioid antagonist Naloxone costs $41. A patient experiencing a heroin overdose

usually requires two doses. Financial aid for municipalities wishing to purchase

Naloxone for their first responders should be researched and considered. One

example of such a proactive measure can be seen when Blue Cross of Northeastern

Pennsylvania contributed funds in partnership with the Pennsylvania Department

of Drug and Alcohol Programs which made Naloxone available to police and campus

security officer across northeastern and north central Pennsylvania (Matrisciano

2015). Similar corporate sponsorships should be sought and considered in Alabama.

We further recommend an awareness campaign about the immunity provided

by Opioid Antagonists Act 2015-364, the technical use of an opioid antagonist and

its life saving benefits.

Bulk Currency Legislation

We recommend a state law that parallels the section of Patriot Act of 2001,

which prohibits the smuggling of bulk currency through Alabama. Such a law

would allow Alabama law enforcement officers, particularly those engaged in drug

interdiction, to stop the smuggling of bulk cash used in drug transactions. This

would decrease profit in the sale of heroin by confiscating cash derived from the sale

of drugs being smuggled through Jefferson County on Interstate 20/59 and charging

the driver with a crime.


Subsections of the Patriot Act of 2001, which prohibit the smuggling of bulk

currency and falls under the U.S. Immigration and Customs Enforcements (ICE)

Homeland Security Investigations (HSI) allows the Jefferson County Drug Task

Force, Interdiction Division, to stop traffic violators to search and seize their

vehicles for drugs and large sums of cash. Due to the lack of a bulk currency law in

Alabama, an officer who locates a large amount of currency during a traffic stop can

seize the money, but cannot arrest the driver unless a crime has been committed or

outstanding warrants exist.

Without a bulk currency law in Alabama, law enforcement officers are forced

to continue allowing suspected drug traffickers found with large volumes of money

to continue their route and carry out potential drug trafficking operations.

Therefore, legislation to enact a bulk currency law and a commitment to increase

resources for those involved in narcotics enforcement in Jefferson County, and their

abilities to intercept drugs and illegal drug sales profits is also recommended.

Prescription Drug Drop-off Programs

Prescription drug drop-off expansion and awareness campaigns are needed to

help eliminate easy access to prescription pills in the home. Internet searches

reveal only three available drop-off sites in Alabama, all of which are in Mobile and

Baldwin counties. Although articles on AL.com report that drop off sites are

available in Vestavia Hills and Mountain Brook, the location of these drop of sites

were not readily available to the public. These drop-off points cannot be properly

utilized if the public cannot find them.

Treatment and Prevention

Through our research, it became apparent that addiction, particularly to

opioids, requires a long-term systematic treatment approach. Treating opioid

addiction is as complex as treating traumatic brain injury. As stated above, the

relapse rate is 86%. However, Vivitrol (naltrexone) which blocks the effects of


narcotic drugs has shown promising results when included as a part of a year-long

sober living program with psychological treatment. We recommend enhanced

treatment and prevention programs, in which heroin addicts receive long-term

treatment in sober living programs including both pharmacological and

psychological intervention. As discussed above, heroin addicts have an alarmingly

high rate of relapse and such long-term treatment plans have proven to be more

successful than outpatient or short-term inpatient treatment programs in providing

the care necessary to treat heroin addiction. (J. Nicolini, personal communication.

April 27, 2015).

Public Awareness

Finally, we recommend campaigns to promote heightened awareness about

the growing heroin problem. Parents must understand the problem, and children

and teens must understand the dangers. Although children and teens best respond

to peer-based programs, open and honest dialogue in the home, and in schools, is

necessary to lay the foundation for prevention. Furthermore, we must reach out

with educational programs targeting addicts so that they will know about both the

life-saving law which made opioid antagonists more readily available and about

treatment options available to help them overcome addiction. Finally, similar to the

Zero Meth campaign designed to raise awareness to users of meth, we must inform

heroin users of the substantial risks of injecting heroin. Users need to know that

pure heroin kills, heroin mixed with fentanyl kills, and that it is a high that can

literally take their breath away.

The Pills to Needles: Action Plan, discussed above, is an excellent model for

addressing the heroin problem in its multiple facets. It is an example of how the

members of a community facing the heroin crisis have cooperated to develop a

strategic plan of action which addresses five specific areas though which they may

address the problem.


Conclusion

The problem of heroin deaths in Jefferson County is a dynamic issue which

must be approached on multiple levels. The problem of saving an addict's life from

overdose may be addressed in immediate terms by making opioid antagonists more

readily available. However, the pervasive availability of heroin, educating users,

potential users and families about the dangers and ultimately heroin addiction

itself require not only opioid antagonists to save the lives today but also more

comprehensive, long-term and strategic solutions. Such solutions must include

increased staffing of law enforcement and specialized drug task forces assigned to

eradicate these drugs, laws to stop the smuggling of drug money through Alabama,

prescription drug monitoring programs, prescription drug drop-off points, enhanced

treatment and prevention programs to reduce the number of heroin addicts in the

future, and a heightened awareness of users that heroin is highly unregulated,

inconsistently prepared, and sold to them with no regard for their life.


References

Alabama Department of Public Health Office of Emergency Medical Services. (2013). Alabama EMS patient care protocols (7th Ed.). Montgomery, AL: Author. Alabama. Pending Laws. HB208 (2015). An Act Authorizing Administration of Opioid Antagonists. 2015. Alabama Acts 2015-164. June 2015. Anson, P. (2012, July). New OxyContin Formula has Many Users Switching to Heroin. American News Report. Retrieved from http://americannewsreport.com/new-oxycontin-formula-has-many-abusers- switching-to-heroin-8814984 Field, J. M. (Ed.) (2006). Advanced cardiac life support: Provider manual. Dallas, TX: American Heart Association. Hosztafi, S. (2001 Aug). The History of Heroin. Acta Pharm Hung; 71(2):233-42. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11862675 Matrisciano, A. (2015, May). Blue Cross of Northeastern Pennsylvania Funds Naloxone for Local Law Enforcement. Blue Cross is now Northeastern Pennsylvania. Retrieved from https://www.bcnepa.com/OurCompany/News/Press/Release.aspx?id=4073 National Institute on Drug Abuse. (2013, October). Drug Facts: Heroin. Retrieved June 17, 2015, from http://www.drugabuse.gov/publications/drugfacts/heroin

Sanders, M. J. (2001). Mosby’s paramedic textbook (Rev. 2nd ed.). St. Louis, MO: Mosby.

Wilson, M. (2014 June). Heroin Epidemic in Birmingham. (Opinion by Mark E. Wilson. MD. AL.com Retrieved from http://impact.al.com/opinion/print. html/entry=2014/06/heroin_epidemic__in_birmingham.html

Cover Photo: Copyright: <a href='http://www.123rf.com/profile_arskabb'>arskabb / 123RF Stock Photo</a>


Appendix

The Good Samaritan Act, Suggested amendment in red.

Section 6-5-332

Persons rendering emergency care etc., at scene of accident, etc.

(a) When any doctor of medicine or dentistry, nurse, member of any organized rescue squad, member of any police or fire department, member of any organized volunteer fire department, Alabama-licensed emergency medical technician, intern, or resident practicing in an Alabama hospital with training programs approved by the American Medical Association, Alabama state trooper, medical aidman functioning as a part of the military assistance to safety and traffic program, chiropractor, or public education employee gratuitously and in good faith, renders first aid or emergency care at the scene of an accident, casualty, or disaster to a person injured therein, he or she shall not be liable for any civil damages as a result of his or her acts or omissions in rendering first aid or emergency care, nor shall he or she be liable for any civil damages as a result of any act or failure to act to provide or arrange for further medical treatment or care for the injured person.

(b) Any member of the crew of a helicopter which is used in the performance of military assistance to safety and traffic programs and is engaged in the performance of emergency medical service acts shall be exempt from personal liability for any property damages caused by helicopter downwash or by persons disembarking from the helicopter.

(c) When any physician gratuitously advises medical personnel at the scene of an emergency episode by direct voice contact, to render medical assistance based upon information received by voice or biotelemetry equipment, the actions ordered taken by the physician to sustain life or reduce disability shall not be considered liable when the actions are within the established medical procedures.

(d) Any person who is qualified by a federal or state agency to perform mine rescue planning and recovery operations, including mine rescue instructors and mine rescue team members, and any person designated by an operator furnishing a mine rescue team to supervise, assist in planning or provide service thereto, who, in good faith, performs or fails to perform any act or service in connection with mine rescue planning and recovery operations shall not be liable for any civil damages as a result of any acts or omissions. Nothing contained in this subsection shall be construed to exempt from liability any person responsible for an overall mine rescue operation, including an operator of an affected facility and any person assuming responsibility therefor under federal or state statutes or regulations.


Appendix (continued)

(e) A person or entity, who in good faith and without compensation renders emergency care or treatment to a person suffering or appearing to suffer from cardiac arrest, which may include the use of an automated external defibrillator, shall be immune from civil liability for any personal injury as a result of care or treatment or as a result of any act or failure to act in providing or arranging further medical treatment where the person acts as an ordinary prudent person would have acted under the same or similar circumstances, except damages that may result from the gross negligence of the person rendering emergency care. This immunity shall extend to the licensed physician or medical authority who is involved in automated external defibrillator site placement, the person who provides training in CPR and the use of the automated external defibrillator, and the person or entity responsible for the site where the automated external defibrillator is located. This subsection specifically excludes from the provision of immunity any designers, manufacturers, or sellers of automated external defibrillators for any claims that may be brought against such entities based upon current Alabama law. Such immunity shall also apply to the administration of an opioid antagonist as provided by Act 2015-364.

(f) Any licensed engineer, licensed architect, licensed surveyor, licensed contractor, licensed subcontractor, or other individual working under the direct supervision of the licensed individual who participates in emergency response activities under the direction of, or in connection with, a community emergency response team, county emergency management agency, the state emergency management agency, or the Federal Emergency Management Agency shall not be liable for any civil damages as a result of any acts, services, or omissions provided without compensation, in such capacity if the individual acts as a reasonably prudent person would have acted under the same or similar circumstances. The immunity provided in this subsection shall apply to any acts, services, or omissions provided within 90 days after declaration of the emergency.

(g) Any person, who, in good faith, renders emergency care at the scene of an accident or emergency to the victim or victims thereof without making any charge of goods or services therefor shall not be liable for any civil damages as a result of any act or omission by the person in rendering emergency care or as a result of any act or failure to act to provide or arrange for further medical treatment or care for the injured person if the individual acts as a reasonably prudent person would have acted under the same or similar circumstances.

(Acts 1966, Ex. Sess., No. 253, p. 377; Acts 1975, No. 1233, p. 2594; Acts 1981, No. 81-804, p. 1427; Acts 1987, No. 87-390, p. 558, §1; Acts 1993, No. 93-373, §1; Act 99-370, p. 595, §3; Act 2006-104, p. 134, §1; Act 2011-579, p. 1253, §1.)

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Jefferson County Heroin Epidemic - Homepage | OutReach · 2019-03-20 · 4 Jefferson County Heroin Epidemic Summary Since the year 2000, Interstate 20/59, which passes through Birmingham,