Rogers, citing treatment-bed increase, says E. Ky. is becoming U.S. drug-recovery capital; state has launched anti-stigma effort

L-R: Bryan Hubbard, chair of the state opioid commission; Behavioral Health Commissioner Katie Marks; state drug-policy director Van Ingram; Operation UNITE Director Vic Brown, Jeffersontown Police Chief Rick Sanders; and Amanda Peters of the Northern Ky. Office of Drug Control Policy.

By Al Cross

Kentucky Health News

Kentucky, especially its Appalachian counties, continues to be a hotbed of the opioid epidemic. But it is also a leader in fighting it, and getting people into treatment and recovery, the congressman who represents most of Appalachian Kentucky told the Kentucky Opioid Symposium Tuesday.

Rep. Harold "Hal" Rogers of the 5th District recalled a 2003 Lexington Herald-Leader headline that said Eastern Kentucky was the “nation’s painkiller capital” and said, After all the great strides that we’ve made from ground zero, and seeing the volume of treatment beds increase ten-fold over the last 20 years, I think it’s time for a new headline: Eastern Kentucky is now becoming the nation’s recovery capital, and it’s time to spread the message of hope in our commonwealth."

Rogers said Dr. Nora Volkow, director of the National Institute on Drug Abuse, "tells me that Kentucky has had so much success that while other states appear to be making great gains, they're merely catching up to Kentucky."

Rogers (Spectrum News image)

Rogers, a Republican from Somerset, said the battle is "one of the few issues in Frankfort and Washington that is truly bipartisan," and "shows what we can do when we put partisanship aside." But that didn't keep him from making two pointed compliments of Republican gubernatorial nominee Daniel Cameron, who as attorney general appointed most of the members of the Opioid Abatement Advisory Commission, which sponsored the symposium.

The summit began Monday with a keynote address by Sam Quiñones, author of Dreamland and The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth. He reiterated the message he has delivered before in Kentucky, that the solution for the opioid crisis lies in communities, not capitals.

To that end, a panel discussion Tuesday about the course of the opioid epidemic included a local police chief, a regional drug-policy director, two state officials and the director of Operation UNITE, the Rogers-founded anti-drug nonprofit for Appalachian Kentucky.

Jeffersontown Police Chief Rick Sanders said he opened his department for addicts to seek treatment, then did likewise when he ran the state police. He said the idea met resistance from some officers "until we proved that it worked." Now his departnent has three "embedded social workers."

Sanders added, "Two of the biggest problems in law enforcement are addiction and mental health. We're sending way too many people to jail that should be going to hospitals for treatment, and opening up those beds at the jail for people we really need to be afraid of."

Amanda Peters of the Northern Kentucky Office of Drug Control Policy said that as the region gained more treatment beds, it built a "long-term recovery pipeline" with employers and community organizations. She said that can also be done in rural communities, and cited the counties of Grant, Gallatin and Carroll as examples other rural counties could follow.

Van Ingram, director of the state Office of Drug Control Policy, said that 20 years ago, different regions of Kentucky had different drug issues, but "that distinction just doesn't exist anymore."

Behavioral Health Commissioner Katie Marks showed this slide.

State Behavioral Health Commissioner Katie Marks outlined the basic steps to dealing with the problem, in succession: prevent initiation of drug use, prvent misuse, identify the need for treatment early on, provide treatment access and engagement, support completion of treatment, and sustain remission and recovery. She said the final step "is really important when we think about a community response."

Marks also talked about specific stratgeies for prevention and harm reduction, including syringe exchanges, "vital infrastructure" that has still not been established in many Kentucky counties that the federal government considers at high risk for spread of disease among intravenous drug users.

Also, there needs to be more naloxone, the drug that counteracts overdoses, "in the hands of people most likely to witness an overdose or respond to an overdose," Marks said, noting that the state is part of a national effort to determine how best to do that.

This effort is aimed at the stigma of drugs. (Photos by Al Cross)

Marks promoted Unshame Kentucky, an effort to combat the stigma that many people still attach to the subject: "This is a community-driven, statewide anti-stigma campaign, developed by the voices of Kentuckians to say that we are going to unshame, we are going to reduce the stigma of addiction, of seeking treatment, of long-term recovery."

The state's partner in the effort is Shatterproof, a national nonprofit that says it is dedicated to "revolutionizing the treatment system, breaking down addiction-related stigma, and supporting and empowering our communities."

Demon Copperhead author and Ky. native Barbara Kingsolver talks about the opioid epidemic and Appalachia's difficulty with it

Barbara Kingsolver (Facebook photo)

Barbara Kingsolver says she intended her Pulitzer Prize-winning novel Demon Copperhead to be her "great Appalachian novel" that told the story of how the opioid epidemic has ravaged the region, and its impact on children. 

Ezra Klein of The New York Times interviewed Kingsolver, who grew up in Nicholas County, for his podcast, "The Ezra Klein Show." The Times transcribed the interview. It is wide-ranging, but a big chunk has her telling Klein how the opioid epidemic has impacted a whole generation of children who have become orphans and are being raised by grandparents and the foster system — and getting the bulk of their social services at school.

 

"We have a generation of orphans coming up through our schools," Kingsolver said, adding later, "There’s so many more kids in need than there are social networks to catch them — but the caseworkers are so overloaded and so pathetically underpaid. . . . This is something that I think the world needs to know about, this country — voters — need to know about. We need to know how this epidemic has left a generation of innocents that nobody’s taking decent care of. . . . These kids have been left behind. Our burdened public school systems are being asked to raise these kids." 

Klein and Kingsolver also talked about how Central Appalachia was targeted by Purdue Pharma with a drug that was so addictive and with doctors who were told otherwise. "This was done to them," Kingsolver said of her neighbors in southwest Virginia and southeastern Kentucky. "Nobody wants to be addicted."

Winner of the 2023 Pulitzer for fiction

Kingsolver also talked about the stigma associated with addiction and how people have been brainwashed to think it is a moral failing, instead of the brain disease that it is. 

"We have been trained, culturally trained, to think of addiction in this way, as a personal failing that needs to be punished. Incarceration does not cure addiction any more than it cures cancer. Addiction is a disease," she said. "It’s impossible to describe how terrible this disease is, not just the dope sickness of it but the fact that your entire life has to become just a really difficult, hard work in process of, every morning, getting your means, getting your fix, getting through another day. And nobody wants to live like that." 

Kingsolver told Klein that she hopes her novel will help people have more compassion and think of people with addiction as having a disease and to get rid of the idea that you don't treat a person with addiction until they "hit bottom." 

"That’s how we treat the disease of addiction. And it’s incredibly inhumane. And effective treatment will only happen after we switch over from putting this in the hands of the police and the prisons to medical workers who can meet addicted people where they live and offer them the first steps of clean needles and fentanyl test strips so that they won’t die in the weeks that it will take for them logistically, physically, emotionally, to get to the beginnings of treatment," she said. 

And to those who maintain a moral objection to such "harm reduction" programs, she said, "It’s as if people feel that addicted people deserve to die. Imagine if we looked at any other disease that way."

Kentucky has 84 syringe-service programs in 65 counties; the pandemic slowed their growth, but two have opened this year

State Department for Public Health map, adapted by Kentucky Health News; click on it to enlarge.

By Melissa Patrick

Kentucky Health News

Kentucky has added two new syringe-service programs for intravenous drug users this year, bringing the total to 84 SSPs, in 65 of the state's 120 counties. Hart County opened its program in January and Estill County reopened its program in April.

SSPs are part of what health departments call “harm reduction programs,” which offer a host of strategies to minimize the negative physical and social impacts of drug use. They are also called syringe-exchange programs or needle exchanges, for the best-known element of the prorgams.

Estill County's program reopened after being shut down in 2020 because the Irvine City Council took away its approval, required by state law in a city where a program is based. The Estill County Health Department's program is now in a mobile clinic that goes to multiple locations in the east-central Kentucky county. 

Hart County is in south-central Kentucky, which is served by the Barren River District Health Department. Charity Crowe, a UK Healthcare health-education coordinator embedded in the department's harm-reduction program, told Kentucky Health News that adding more SSPs to decrease overdose deaths is one goal of the Barren River Initiative to Get Healthy Together (BRIGHT) Coalition.

Only three of the eight counties in the district have SSPs. Warren County opened its program in 2016, Barren County in 2018, and Hart County in January. 

Crowe said one of the first steps they took as they worked to get local approvals in Hart County was a survey of local jail inmates, asking f they would use an SSP if it was available. She said 63 inmates, or 64% of the survey respondents, said they would use it.  

"That kind of helped us with getting everything passed through the Board of Health, Fiscal Court and City Council," Crowe said. She praised the efforts of County Judge Executive Joe Choate: "He was a huge supporter of the program and us getting it started, so that helped get everything moving along a lot quicker."

Asked if she had any advice for people in the 55 Kentucky counties that still don't have an SSP, but want one, she said it's important to keep educating people about what they are and why they are important. 

"Just to try to educate people on why we do what we do," Crowe said. "There's so much stigma surrounding the things that we do with harm reduction. . . . We are trying to make our communities a safer place, not just for people that use drugs, but for our kids, our first responders, everybody." 

She also encouraged them to not give up. "Pretty much anywhere that you go, you will get a little bit of pushback," she said. "But in order for us to break that stigma, we just have to keep educating people."

Looking to other counties in the district, Crowe said they have held an educational meeting in Edmonson County and are working to have one in Logan County. She said Logan County's health board of health and Russellville City Council have approved an exchange, but the Fiscal Court has not.

Kentucky Health News graph from state data; click on it to enlarge.

The steady growth of SSPs in Kentucky took a heavy hit from the pandemic, with only eight counties opening a new SSP since 2020. The legislature authorized the programs in 2015.

Syringe-service programs not only exchange clean needles for dirty ones, to decrease the spread of blood-borne diseases like hepatitis C and HIV, but provide education on the safe use and distribution of wound-care kits and Naloxone, which blocks a drug overdose. Other services are infectious-disease screening, vaccinations, and linking people to housing, food access, insurance, medical care, substance-use treatment and behavioral-health services.

Crowe said the SSPs in Hart and Warren counties also use a peer-support specialist who has "been a phenomenal resource for our clients." 

On June 29, a new law kicked in that decriminalized fentanyl test strips in Kentucky, meaning they will no longer be considered drug paraphernalia in the state. Because of this, Kentucky's SSPs can offer them to their clients . Fentanyl was involved in 72.5% of the state's 2,135 overdose deaths in 2022. 

Fentanyl test strips are paper strips that can detect the presence of the powerful opioid in pills and other drugs within minutes. They are considered a low-cost method of helping prevent drug overdoses and reducing harm, according to the Centers for Drug Control and Prevention.

Boyle County named Kentucky's first Recovery Ready Community

Boyle County Judge-Executive Trille Bottom accepts the Recovery
Ready Community certificate from Gov. Andy Beshear. (Screenshot)

Boyle County is Kentucky's first Recovery Ready Community, a designation that reflects commitment to providing residents with access to addiction treatment and recovery support and removing barriers to the workforce. Applications for the designation opened in January.

The certification is designed to encourage communities to provide transportation to and from employment services and job interviews, allowing people to make positive changes while filling the state's need for workers at a time of record-low unemployment, said a news release from Gov. Andy Beshear.

“Boyle County has set a strong precedent that can serve as a model for the rest of Kentucky’s communities,” Beshear said in the release. “I continue to encourage each of the commonwealth’s counties and communities to apply for certification. If we work together to build a safer, healthier commonwealth, we can rise above drug and alcohol addiction in our state once and for all.”

Beshear said at his weekly press briefing that more communities are soon to follow. He was joined at the announcement by several leaders from Danville and Boyle County. Their efforts include free training for overdose response and Narcan distribution, hiring a social worker as an opioid-outreach coordinator to make EMS runs involving suspected overdoses to connect the individuals with treatment, counseling and other addiction support services.

Boyle County (Wikipedia map)

“When we came face to face with the effects of the opioid crisis on our families, institutions and workforce, we got to work to be informed, responsive and proactive,” Judge-Executive Trille L. Bottom said in the release. “We started a harm-reduction syringe-exchange program. We took a hard look at our jail becoming a place of rehabilitation. We encouraged new treatment and transitional living providers to come to Boyle County, and we trained a lot of citizens in saving lives from overdoses.”

Pam Darnall, chair of the state Recovery Ready Communities Advisory Council, which apprpoved the designation, said “We are inspired by Boyle County’s commitment to continue strengthening its local recovery-oriented system of care through persistent cross-agency collaboration and a willingness to try innovative programs and interventions aimed at increasing positive public health and safety outcomes.”

To learn more about the program and apply for certification as a Recovery Ready Community, click here.

Carrying naloxone, now available over the counter, saves lives; bystanders are present in more than 1/3 of opioid overdoses

Photo by Pete Comparoni, University of Kentucky

By Trish Freeman

Professor, University of Kentucky College of Pharmacy

Chances are you or someone close to you has been directly impacted by the opioid epidemic, which continues to afflict Kentucky. In 2021, the state's overdose deaths reached an all-time high of 2,250, with 90% involving an opioid.

Because bystanders are present in more than a third of opioid overdoses, hundreds of these deaths could have been prevented with naloxone, a lifesaving medication that is accessible, safe and easy to administer.

What is naloxone? Naloxone is a medication that can save someone’s life if they are overdosing on opioid medications, heroin, or other drugs (such as cocaine or methamphetamine) that are mixed or laced with the opioid fentanyl. Naloxone quickly reverses the effects of opioids and helps restore breathing in someone who is experiencing an overdose.

There are two Food and Drug Administration-approved formulations of naloxone: injectable and prepackaged nasal spray. The nasal spray, which is available as generic naloxone, Narcan or Kloxxado, may be easier for loved ones or bystanders without special training to use.

Who should carry naloxone? People who are at high risk for opioid overdose — including those who take high dose opioid medications and those who use illicit opioids like heroin — should carry naloxone. Families with loved ones who are at risk should also have naloxone nearby. Because opioid overdoses sometimes happen in public places, anyone can carry naloxone and be prepared to respond as a community bystander. If you're at risk for an opioid overdose, let others know you have naloxone and where it is located.

Where can I get naloxone? In Kentucky, naloxone is available without a prescription at many pharmacies and through community-based naloxone programs. Many syringe services programs also offer naloxone, along with clean needles and other harm reduction supplies. Soon, naloxone nasal spray will be available over the counter (OTC) at pharmacies and other retail stores that sell OTC products.

To find a location near you where naloxone is available, visit the Kentucky Office of Drug Control Policy website at https://odcp.ky.gov/Stop-Overdoses/Pages/Locations.aspx.

When to use naloxone: Signs of an opioid overdose may include: unconsciousness, very slow or shallow breathing, a limp body and not responding when called or touched.

If you suspect someone is experiencing an opioid overdose, call 911 immediately and give naloxone as quickly as possible. Naloxone is a temporary treatment that can help restore breathing but it’s not a substitute for emergency medical care.

UK study to test effectiveness of kiosk with harm-reduction goods as way to increase access and fight the stigma felt by drug users

An example of a harm reduction vending machine 
in Cincinnati (Photo from Kiosk Marketplace)

By Melissa Patrick
Kentucky Health News

To fight feelings of stigma that discourage intravenous drug users from getting clean needles at syringe-service programs, the University of Kentucky is starting a study that will put a vending machine with syringes and other harm-reduction supplies in an Appalachian Kentucky county. 

"Interest in reduction kiosks is soaring nationwide and the proposed project would provide critical and timely data to inform scale-up of this model, especially in rural areas of the country that have been severely impacted by substance use related harms," says a National Institutes of Health report describing the study.

The vending machine is called KyOSK, for Kentucky Outreach Service Kiosk. It will have "injection equipment, naloxone, fentanyl test strips, hygiene kits, condoms, and other supplies, as well as an innovative call-back feature" to help steer drug users into recovery, says the report. 

Research shows that there is a need for these harm reduction kiosks because people who inject drugs in Kentucky are under-utilizing the 82 syringe service programs that have been established in 63 of the state's 120 counties since 2015. Such programs are part of harm reduction programs that use a host of strategies to minimize the negative physical and social impacts of drug use. 

"Data from our research funded by NIDA’s National Rural Opioid Initiative revealed that nearly half of people who use intravenous drugs had never used the existing staffed SSPs and, over 24 months of follow-up, SSP uptake remained low and program drop-out was not uncommon," says the NIH report. 

The main reason drug users gave for not using the syringe programs was "fear of stigma," the report says, adding that most of those who cited stigma said they would prefer a vending machine or kiosk to get harm-reduction supplies. 

This is not a new idea. The report notes that harm reduction kiosks have been operating around the world for more than 30 years, and research shows that they can expand syringe access. However, the researchers note that few exist in the U.S -- and none in rural areas. 

The hope is that these machines, which do not require interaction with other persons, will allow drug users to obtain harm-reduction supplies more readily.

Early news reports about the grant referred to multiple vending machines, but the grant calls for only one kiosk. A second county with a traditional syringe service program will be used for comparison in the study, said project leader April Young, an epidemiology professor in the UK College of Public Health.

Young said the kiosk site hasn't been decided. "The machine location and design will be determined by a design team involving local and state stakeholders," she said in an e-mail. The NIH report says the machine's contents will be tailored to meet the needs of the community chosen for it.

Up to 400 study participants will get a magnetic swipe card that will give them access to the kiosk. Young said study participants will be screened for eligibility and must be at least 18 years or older. 

As with in-person syringe services, the study will try to direct drug users into treatment and recovery. Young said in the email, "There is also an innovative feature of our design that could help connect study participants to health services, including substance use disorder treatment, HIV testing and treatment, housing assistance, domestic violence support, and Medicaid signup." 

The $609,439 NIH grant, awarded in August, says "The proposed study will test the effectiveness, implementation outcomes, and cost effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C, and overdose risk behavior in rural Appalachia." 

Scott Lockard, public health director for the Kentucky River District Health Department, said he is exploring whether such kiosks could work in the communities he serves. 

"We're exploring the ins and outs of the program," Lockard said. "We're exploring how the program can be utilized to best serve our clients. And I'm looking at potential locations within our district to position these machines so that they can best serve our population." 

Beyond that, Lockard said his agency is getting ready to install "NaloxBoxes" at its local health departments which will allow people in his district to get naloxone 24 hours a day. Naloxone, known by the brand name Narcan, is a medicine that rapidly reverses an opioid overdose. 

"We want to get as much naloxone out in the hands of the people as possible," he said. 

The Louisville Metro Department of Corrections has put "Narcan Boxes" in its jail, and on Friday, Sept. 9, one was used by an inmate to save the life of another inmate, who was overdosing on fentanyl, saving his life, Gladys Bautista reports for WLKY-TV. 

Ky. has 82 syringe exchange programs in 63 counties, the most of any state, but state drug-control official says 'That's not enough'

Stars show syringe-exchange sites; colors show district departments; white counties are independent. 

By Melissa Patrick
Kentucky Health News

Kentucky still has more syringe service programs than any other state, but 57 counties still don't have one, including 21 of the 54 that the Centers for Disease Control and Prevention considers vulnerable to a rapid outbreak of HIV or hepatitis C among people who inject drugs.

"My God, if you've been identified by the CDC as being a county for a rapid HIV outbreak, you need an SSP. There's no ifs, ands or buts about it," Van Ingram, executive director for the Kentucky Office of Drug Control Policy, said at the annual Kentucky Harm Reduction Summit in August. "So we've got work to do yet."

Syringe exchanges are part of "harm reduction programs," which offer a host of strategies to minimize the negative physical and social impacts of drug use. They are also called syringe service programs or needle exchanges.

Such programs have been legal in Kentucky since 2015, but to have one, a community must have approval from its local board of health, the county fiscal court and the city where the exchange is located. 

As of August, Kentucky had 82 exchange programs operating in 63 of its 120 counties, but Ingram said that despite efforts to expand these service programs, "That's not enough. We need more." 

One program that had been approved is no longer operational.

Estill County (Wikipedia map)

Elizabeth Walling, public health director at the Estill County Health Department, told Kentucky Health News that its program closed in September 2020 because the Irvine City Council took away its approval, citing complaints from the community about an increase of needles in public spaces. 

Walling said the health department has made several attempts to get the council to reinstate the program. "We have patients that call about it weekly," she said. "We're still having to refer them out of the county. . . . We still have a lot of requests for it, which we've expressed to the Irvine City Council."

Syringe exchanges provide a range of services that extend beyond the exchange of clean needles for dirty ones in order to decrease the spread of blood-borne diseases like hepatitis C and HIV. Those services include education on safe use and distribution of wound-care kits and Naloxone, which blocks a drug overdose. Other services are infectious-disease screening, vaccinations, and linking people to housing, food access, insurance, medical care, substance-use treatment and behavioral-health services. 

At the Harm Reduction Summit, Alex Elswick, an assistant extension professor for substance-use prevention and recovery at the University of Kentucky, pointed to the value of the exchanges as a place that connects people who use drugs to care, even if they are not yet seeking treatment.

"This is a population that if syringe-access programs did not exist, would be utterly unengaged," said Elswick, who is in long-term recovery. "Think about that. . . . If you didn't have a syringe-access program in your community, where would these folks be going for any kind of care? Not just for syringes, but for care of any kind, for connection of any kind. They're utterly unengaged when you don't have harm reduction in your community."

Fentanyl test strips in short supply

One service that fewer than 30 of the state's exchanges offer is the distribution of fentanyl test strips, even though the powerful opioid was involved in about 73% of the state's 2,250 overdose deaths in 2021.

According to the CDC, Fentanyl is up to 50 times stronger than heroin and 100 times stronger than morphine. The strips only show if fentanyl is in the drug or not, not the amount of Fentanyl.  

A key reasons some programs have been slow to offer the strips is that they are considered drug paraphernalia under Kentucky law, causing some local officials not to support the use of them. 

Susan Dunlap, spokeswoman for the state Department for Public Health, said in an e-mail that the strips require different levels of approval, depending on how a program has been set up and its local protocols.

Scott Lockard, public health director of the Kentucky River District Health Department, said it is exploring the benefits of offering fentanyl strips in their programs and were working to address any legal concerns.

That said, Lockard noted that such strips may not be as important as they once were because fentanyl has become so prevalent. He said his agency is telling all its harm-reduction participants that they should automatically expect that fentanyl is present in every substance they use right now. 

"We want to make sure that we're using them appropriately, that we have all our legal bases covered and that they're beneficial for those people who are coming into our harm reduction," Lockard said. 

Ingram, asked about this at the summit, said the state was still trying to figure out the best way to respond to this challenge.

"I think fentanyl test strips are important," he said. "I think we've got to make ourselves available of them some way, somehow. It's on our radar and it's something we're trying to figure out." 

Russ Read, CEO of the Kentucky Harm Reduction Coalition, called fentanyl test strips an "essential tool" to help save people's lives and to have an opportunity for another chance to seek treatment and get better. 

"Each one of those test strips represents an opportunity for somebody not to die," he said. "And it's a real opportunity for somebody to make a decision . . . that I don't want to use anymore, or I need some help. It gives them another chance. . . . That's what harm reduction is all about." 

Read said the coalition has distributed more than 120,000 fentanyl test strips across the state. 

To learn more about harm reduction programs in Kentucky, go to the KDPH SSP webpage or the new KDPH Harm Reduction Program page.

Keynote speaker at harm-reduction summit calls for not requiring abstinence for drug users to get access to 'recovery capital'

By Melissa Patrick
Kentucky Health News

Helping people in addiction recovery meet their basic needs should not focus on abstinence, but instead should be provided along the continuum of a person's drug use as a way to mitigate harm, with a focus on wellness and autonomy, says an expert who knows recovery from his own experience. 

Alex Elswick

Alex Elswick, an assistant extension professor for substance-use prevention and recovery at the University of Kentucky, was the keynote speaker for the virtual Kentucky Harm Reduction Summit Aug. 10 and 11.

"Harm reduction and capital building are the things that we should be doing all the time for everyone," Elswick said. "We shouldn't be waiting until someone becomes abstinent, or until they become involved in the criminal legal system, or until they reach out for treatment. We can go and engage people who are suffering in our communities and we can mitigate harms. And we can build capital right now, without any barriers to access." 

Elswick, who is in long-term recovery, often says that there is nothing special about his addiction to OxyContin and heroin, since it followed the same path as many others have experienced. What he says is special is his recovery, largely because of the abundance of resources that were available to support him, including housing, transportation, employment, education, access to medical and mental-health care, and relationships with family and community.

Elswick calls those resources "recovery capital" and described them as anything that promotes recovery, or anything that improves the odds that a person will be successful in their recovery. 

He stressed that everyone recovery needs such resources, and not just after they stop using drugs. And just like Maslow's Hierarchy of Needs, which describe motivation, he said a person who has an addiction to drugs must have their basic needs met first before they can even consider seeking treatment and recovery.

But the problem, he said, is that we often use abstinence as a precondition to providing these basic needs for people in the recovery process. 

"I want to suggest that we're flipping it upside down. We're expecting people to do the incredibly, in some cases impossible, work of becoming abstinent without providing them with all the resources that they need in order to do so." 

A key example of this upside-down thinking is housing, because there is little to no housing available for people who use drugs or who are in the early stages of the recovery process, Elswick  said. Nor is there housing for people who are abstinent but are on a medication for opioid-use disorder, like buprenorphine or methadone.

Instead, he said, we have sober housing for people who are already abstinent -- and if a person living in one of these houses experiences a recurrence, which is common, they are kicked out. 

He added that the same is true for drug users' access to social services, which often requires a drug test; that people are kicked out of treatment if they relapse, even if they sought treatment for exactly that problem; and that families are often told to deny support of a loved one if they are using drugs, regardless of circumstances.

In each of those circumstances, "You're going to be deprived of your recovery capital, despite the fact that research says that would improve your odds of recovery," he said. And the only way to change this, he added, is to prioritize recovery above abstinence. 

Elswick traced the concept of recovery capital to a study by University of Denver Professor William Cloud, who found that college students with addictions were recovering at a significantly higher rate, than the general population, sometimes with no formal interventions. 

Cloud determined that the students recovered better because most came from relatively privileged backgrounds and had access to most of the social supports that they needed to recover. 

"The value of recovery capital and harm reduction is that it allows us to have a relationship with someone, as opposed to saying, 'Come to me when you're sober'," said Elswick. "It allows us to have a relationship so that that relationship itself can be a therapeutic. That relationship itself can be a component of recovery capital." 

Elswick concluded with pushes to battle the stigma that still plagues drug users, even among health-care providers and treatment centers, and to make medication-assisted treatment for opioid-use disorder more accessible. He cited studies that prove this is the gold standard of care, but 90% of people who need treatment don't get it. 

"My main takeaway message is, I want us to shift the focus away from abstinence toward recovery capital and building recovery capital and mitigating harms, because it's the more effective approach and I think you might find it'll lead to more abstinence than you realize." 

Elswick is the co-founder of Voices of Hope, a recovery community organization.

Harm reduction services, ‘that place between prevention and treatment,’ can make a difference in substance-abuse disorder

Daryl Hams, registered nurse and project director of the Regional Harm
Reduction Collaborative (Photo: Amanda Rossman, Cincinnati Enquirer)

In an article titled "The people who care: How harm reduction strategies for those who use drugs bloomed in the region," Terry DeMio of the Cincinnati Enquirer tells the story of several people, including Kentuckians, who have benefited from such programs and the value of those who work in them. 

One of DeMio's stories involves a nurse, Daryl Hams, who is the project director of the Regional Harm Reduction Collaborative, and how he carried wound-care supplies with him for three weeks in hopes of reconnecting with a man with a "festering abscess," for whom he had already provided supplies once and whom he urged to get and take his antibiotics.  He finally ran in to him at a naloxone-giveaway site and told him he had been worried about him. 

DeMio writes: "The man proudly showed off a wrist no longer bandaged, the abscess healed. He started to walk away. Then stopped and turned back. “It’s been a long time,” the man said, “since anybody worried about me.” 

Another story involves Molly B. True, 41, of Bellevue, Ky., who started using heroin in the late 1990s and told DeMio that she always tried to use safely, but it was hard. And that while she knew there were places across the country where people could get sterile syringes, without judgement, “I remember thinking, ‘Gosh, that’ll never happen in Cincinnati’,” she said.

DeMio writes that in the late 1990s through the early 2000s, people who used intravenous drugs were on their own -- but not today because "there are Daryls" and there is finally an understanding that addiction is a health issue that can't be solved by locking people up in jail. 

"It has taken Greater Cincinnati something like two decades to understand what Daryl and people like him offer," she writes. "It’s called 'harm reduction,' a host of strategies to minimize negative physical and social outcomes from drug use. It's that place between prevention and treatment, where people who use drugs simply are." 

DeMio also writes about the pushback such programs have received and the evolution of how they have come to exist, largely driven by the rising numbers of hepatitis C cases and the rising number of needles being found in public areas. 

"The hepatitis C virus can live in the barrel of a syringe for up to six weeks. People started to realize they, or their children, could get the bloodborne disease," she writes.  

Dr. Judith Feinberg, an infectious disease expert who at the time was a professor at the University of Cincinnati College of Medicine, is the pioneer of harm reduction in Cincinnati. 

Feinberg started gathering research to support the program in 2006 and was finally successful in opening it in 2014, DeMio reports, adding that Feinberg's analysis showed "what newer studies amplify: Syringe services have been associated with a 50% reduction in HIV and hepatitis C." 

Further, DeMio reports that such programs cost less than $2 a day per person.

"Compare that to the lifetime cost of HIV treatment which is about $350,000 per person. The annual cost of hepatitis C treatment? About $84,000 per patient," she writes.

In addition, Feinberg cites research from the Centers for Disease Control and Prevention that says "people who use drugs are five times more likely to enter treatment." 

Feinberg told DeMio that these programs not only provide a place to get things, like sterile syringes, drug-cooking devices, alcohol wipes, naloxone, HIV and hepatitis C testing and condoms, but are also meant to offer a supportive environment that treats people with dignity.  

“You have a totally supportive, nonjudgmental rapport so that if, or when, they are ready (for treatment), you are there," she said. 

Billy Golden, a harm-reduction coordinator at Caracole, works at a drive-up
syringe exchange. (Cincinnati Enquirer photo by Amanda Rossmann)

For a woman named Molly, that support had a name: Billy Golden, a harm-reduction coordinator at Caracole in Cincinnati, who told DeMio about the importance of making the exchange a safe space for people who use drugs.  

If a client was there for three minutes, Billy says he made sure, “for three minutes of the day, that person was more than their drug addiction." 

Billy helped Molly get a doctor who understood addiction, DeMio reports, adding that Molly has been in methadone treatment since September and manages her drug use, using maybe twice a week instead of what used to be several times a day. 

“My life is exponentially better,” Molly says. “I am a different person. I buy Christmas presents. I have a bed now. . . . My ultimate goal [is] to continue to volunteer, and maybe it will lead to some actual, real job in harm reduction. I feel like that’s where I belong.” 

In mid-January, Molly was unanimously appointed to the Harm Reduction Ohio board of directors, which DeMio writes "is indicative of another pillar that the National Harm Reduction Coalition advocates: Ensuring that people who use drugs and those with a history of drug use routinely have “a real voice” in programming and policy designed to serve them."  

In a separate story, DeMio shows the timeline for harm reduction efforts in southwestern Ohio and Northern Kentucky. 

45 share recovery stories in Addiction Recovery Week in Wolfe County, nation's most vulnerable to disease outbreaks from drugs

Tinley Creech, Darian Creech, Connie Campbell and Ashton Burks pose after doing the virtual 5K as part of Wolfe County Addiction Recovery Week. All are in the same household. (Photo provided)

By Katie Pratt
University of Kentucky

Recovering from drug addiction can take many years with many bumps in the road along the way, as Wolfe County resident Dena Brooks can attest. Brooks has been in recovery for nearly six years. Today, she stays busy raising her daughter and working as the director of the Wolfe County senior citizens center.

“My life is finally where it should be now,” she said. “I have a new home, a new job and am very involved with the community.”

But getting to this point in her life was not easy. For years, Brooks used pills and then progressed to meth. She went to federal prison for nine months on a drug conviction. After her release, she sought help at a drug treatment center so she could regain custody of her daughter. After leaving the center, she stayed sober for three years before she relapsed. She was arrested on another federal drug charge but has since had her conviction overturned. Since then, she has been determined to stay sober.

“Drugs do not discriminate,” she said. “If my story can help one person, it is worth telling.”

Brooks was one of 45 Wolfe County residents who shared their drug recovery stories as part of Wolfe County’s Addiction Recovery Week, organized by the Wolfe County office of the University of Kentucky Cooperative Extension Service, Wolfe County Schools Family Resource and Youth Services Center and the Agency for Substance Abuse Policy.

During the week, the organizations hosted in-person and virtual events to celebrate those in their community who are recovering from drug addiction and to provide them with resources to support their continued sobriety.

“It was such a positive thing to see somebody finally caring about recovery and praising people who are in recovery,” Brooks said. “No one has done anything like this for Wolfe County before.”

Wolfe County (Wikipedia map)

Wolfe County is consistently one of the state’s poorest counties and faces many drug-related issues with little resources. It leads the nation for the vulnerability of its population to an outbreak of HIV or Hepatitis C because of the opioid epidemic and a lack of a local syringe exchange. In 2018, it had one of the state's highest per-capita rates for drug arrests.

Alyssa Cox, family and consumer sciences extension agent, had been working with her extension colleagues Heather Graham and Jessica Morris and community partners to create the recovery week prior to the pandemic. While the pandemic changed how they delivered their programming, it did not change the week’s focus.

“The goal of this week was to bring awareness to the challenges of addiction recovery and to rally behind our local residents who fight this battle every day,” Cox said.

One of the week's highlights was the opportunity for people in recovery to share their stories and personal photos during a Facebook Live event. As their stories were told, Morris, the county’s 4-H youth development agent, lit a sparkler in their honor.

“Often, you hear about the drug busts or people saying, ‘That’s just another drughead.’ It is so nice for extension to show us that they care and brag on us,” said Tosha Turner, who also shared her recovery story during the event. “It really means a lot.”

Turner has been in recovery for four years. She was addicted to pills and meth. Her drug addiction led her to robbery. She sought treatment after going to jail for her first felony.

“I was as bad as they come, because I didn’t care about anyone or anything when I was on drugs,” Turner said. “If I can recover, anyone can do it.”

She said her daughters are the reason she stays in recovery. Since she has been in recovery, she has worked and saved money to purchase a car. She is now going back to school to become a nurse.

In addition to sharing local recovery stories, extension and its community partners offered socially distant yoga in the park. Individuals in recovery received vouchers for 10 free yoga sessions, thanks to the Agency for Substance Abuse Policy. Each participant also received a free yoga mat.

Graham, who is Wolfe County’s extension agent for agriculture and natural resources, spearheaded a countywide road cleanup in which participants received a cleaning kit and could clean any road in the county they chose.

The extension office also hosted a Recovery Run, which was a virtual 5K that individuals could participate in to honor someone in recovering from addiction. Race participants received a free T-shirt and resources related to substance use and addiction that they picked up through an extension drive-thru event. The Agency for Substance Abuse Policy also offered a free, drive-thru Narcan training for anyone interested.

Cox said due to the success of the week, extension plans to host the event again in 2021.

Almost half of counties still lack syringe exchanges, including 20 of those most vulnerable to drug-related disease outbreaks

By Melissa Patrick

Kentucky Health News

Most Kentucky counties now have harm-reduction programs to fight drug abuse, but the coronavirus pandemic has slowed their expansion and complicated the work of their syringe exchanges.

Still, they've all continued to offer some level of service during the pandemic. Sixty-three counties have harm-reduction programs, and one more is in the works, but that will still leave 56 of the 120 counties without one. 

Tony Cox, director of the Bracken County Health Department, which has the newest program, encouraged those counties to be open-minded.

"Communities are hesitant, and we do understand their concerns, but I would encourage any and all communities to educate themselves, along with their policymakers and even the citizens in the community, to find out exactly what a harm reduction/syringe exchange program is really all about," he said. "It is about getting dirty needles off the street and off of our playgrounds and off of the places we go, certainly that's a huge part of it. But it is also a program that is about helping the people in our community as well that need help because they are addicted to drugs. Be open minded and get educated." 

Such programs have been able to stay open through the pandemic because the Department of Public Health designated them an essential service.

"To ensure public safety, programs adopted strategies including face coverings, moving to outside stations, creating distance in their spaces, some appointment-only programs, limiting hours/days and decreasing number of infectious-disease testing times," the department said in an e-mail.

Harm-reduction programs are designed to prevent outbreaks of HIV and hepatitis C, which are commonly spread by the needle sharing among intravenous drug users. They also provide health screenings and vaccines, and connect drug users to treatment. 

They were approved in Kentucky under a 2015 law that requires approval by the county health board, the fiscal court and the city where the exchange is to be located.

Five added since last round-up

Kentucky has 74 operational syringe exchange locations in 63 of its 120 counties. Since mid-July 2019, when Kentucky Health News did its last syringe exchange roundup, five more counties have been marked on the state Cabinet for Health and Family Services map of exchanges and the counties deemed most vulnerable to HIV and hepatitis C outbreaks.

Besides Bracken, the new counties are Christian, LaRue, Marion and Martin.

Bracken County Health Department photo on Facebook

Christian County's program is the latest to be approved, but is not yet operational. Bracken County's exchange is still marked as not yet operational on the state's map, but it started operating July 8. 

Among the 54 Kentucky counties that the U.S. Centers for Disease Control and Prevention has identified as being most vulnerable to outbreaks of HIV and hepatitis C among IV drug users, 34 have operational exchanges.

The vulnerable counties that have not approved an exchange include Bell and Clinton, which rank sixth and 11th on the national list of 220 vulnerable counties; Cumberland, Casey, Edmonson, Harlan, Johnson, Lawrence, Lewis, Menifee, Monroe, Rockcastle and Wayne, also in Appalachian Kentucky; and eight in the rest of the state: Carroll, Gallatin, Green, Breckinridge, Grayson, Green, Allen and Hickman.

Harm reduction and the pandemic

Christie Green, public health director of the Cumberland Valley District Health Department, said their program saw a brief dip in participation in March and April, and it has since increased. Early in the pandemic they only offered services every two weeks as a way to limit interactions, she said, but have since gone back to their weekly schedule. 

"As restrictions were lifted," she said. "most of our participants preferred to come every week."

Green said they also increased usage of their mobile harm-reduction unit in Clay and Jackson counties. "So, instead of bringing them into the van, which is set up kind of like a little lab on the inside, we shifted it all to outside, under a canopy with a table beside the van," she said. "If someone wants a test, then we mask them and bring them inside." 

Scott Lockard, public health director of the Kentucky River District Heath Department, which has a program in each of the seven counties in the district, said its use has held steady or better. 

"People are still thankfully coming in and getting the supplies they need, because the last thing we would have wanted to see was a big uptick in HIV or hep C right now too," he said. "Our services are being utilized more than ever."

John Moses, harm-reduction team leader at the Lexington-Fayette County Health Department, said it has seen a steady increase in participation, with record numbers in the last month.

"The good thing about our program is that we were able to continue all of our services through the syringe exchange with really minimal interruption because of covid," he said. "We simply moved our program outside and are using our mobile unit to see our clients."

Jamey Whaley, harm-reduction and peer-support specialist with the Buffalo Trace District Health Department, said that one of the biggest changes he's seen in its program since the beginning of the pandemic is a shift from methamphetamine to heroin, because limited meth supply has driven its price up.

"So I have seen more people who have gone in the direction of heroin, which is a little unsettling because of the risk of potential overdose," Whaley said. He added that he has seen some of the program's former participants relapse since the pandemic hit, and that he has added a good number of new participants. 

Whaley said Buffalo Trace shut down its program down for six weeks at the beginning of the pandemic and re-opened in mid-May. Since then, "I've been very busy, especially the last month I have really been steady." 

Only a few in the works

Logan County has received approval from its Board of Health for a syringe exchange program, but still needs the approval of the Russellville City Council and the county Fiscal Court. 

Alexis Bigham, who was the public-health educator at the Barren River District Health Department when interviewed, and now works on harm reduction in Edmonson County through the University of Kentucky, said two of the district's eight counties (Warren and Barren) have exchanges.

The agency wants Logan to be next "because we have a lot of people traveling from Logan County to here in our Warren County program." she said. But the pandemic has put that push on the back burner because everyone at the health department has been working on covid-19.

The Lincoln Trail District Health Department is based in Hardin County, but its efforts to start a program there haven't been successful. In the meantime, Marion and LaRue counties have joined adjoining Nelson County in the program, largely due to local support, said Melissa Phillips, a harm-reduction specialist.

"You really need both pieces, you need your buy-in from your policymakers, and data is usually what sells them, and knowing that there is no cost associated with it," she said. "And when you have a local champion, it makes the process so much smoother. They really do a lot of the leg work for us."

She said the need in Hardin County is supported by data on drug arrests, HIV and hepatitis C, but the pandemic has slowed the effort, largely because they aren't able to participate in face-to-face meetings with policymakers and the community, which she said is an essential part of the process.

Data and health directors' observations suggest that pandemic lockdown increased overdoses, which declined as state reopened

Graph from Kentucky Injury Prevention Research Center, University of Kentucky

By Melissa Patrick

Kentucky Health News

Apparent overdoses reported by Kentucky hospitals and ambulance services shot up in the two months after Gov. Andy Beshear declared a state of emergency because of the covid-19 pandemic, and have been on a downward trend since the state started reopening in mid-May.

"I don't want to give false hope," Dana Quesinberry, research core director for the Kentucky Injury Prevention and Research Center, said as she explained the data on hospital emergency departments' and emergency medical services' reports of "overdose encounters," a term KIPRC uses because overdoses may be suspected but not necessarily confirmed.

"We are still at higher levels than we've ever been, but the fact that we are seeing that decline over the last few weeks is very important," Quesinberry said. "There is hope that we are making progress again, so whatever triggered the increase is being managed or mitigated in some way." 

She said the data coincides with preliminary reports that also shows an uptick in overdose deaths during April and May. Quesinberry said official 2020 overdose death numbers are not yet available, but "Preliminary data indicates that we have had increases in drug overdose deaths during covid." For April, "We are still looking at a monthly count that exceeds at least anything in the prior couple of years, in a month total." She added later, "We are seeing increases in May as well." 

Quesinberry, an assistant professor for the Department of Health Management and Policy at the University of Kentucky, said researchers will need to explore what triggered the peak in overdose encounters and then look at what slowed it down.  

"We know that there has been an impact on the opioid epidemic during covid and we are working very hard to understand what that impact has been," she said, adding later, "This is a time of tremendous uncertainty driven by the pandemic. It's important to understand that it has consequences beyond the spread of infectious disease."

Public health reports coincide

"Covid has had a huge impact on substance use because it has led to more isolation," John Moses, team leader for harm-reduction services at the Lexington-Fayette County Health Department. "I have a feeling that we are seeing a lot more people relapse and go back to using again. I think that people who maybe work full time and only did drugs on the weekend were laid off and now may be doing drugs seven days a week. We know that when people are isolated like that, there is a lot more depression and that always has an effect on drug use."

Moses said his county is on pace to equal the number of overdose deaths in 2017, which were the most ever. "Last year Lexington-Fayette County had a total of 122 overdose deaths; we are already at 107 for the year," he said. "Last year we did a really good job of getting the overdose rates down, but thanks to covid, I believe that we are seeing more overdose deaths." 

Moses also noted that anytime there is an interruption in the drug supply, which has been seen during the pandemic, more fentanyl comes into the community.  He said it is being mixed in with heroin, methamphetamine, cocaine and even THC vape cartiridges, and "This disruption in the drug supply has caused more fentanyl to be here, and more overdoses."

Christie Green, public-health director of the Manchester-based Cumberland Valley District Health Department, said she had heard anecdotally that there were several overdoses about three weeks ago related to a batch of pressed pills that were being sold as Xanax, but were mostly fentanyl -- a synthetic opioid that is much stronger than heroin. 

"This is the first time that I've gone through something that is socially stressful like covid . . . while working so closely with people who are active in substance-use disorder, and it's just been really hard on them," Green said. "A lot of their social supports are gone. I really worry about them, honestly."

Marcy Rein, public-health director of the Whitley County Health Department, said her health department signed up for a system called ODMap in May to track overdoses in the community, along with about 40 other counties and health departments in the state.

"The system allows us to look at the big picture, to look at the maps to see if we have hotspots in a particular area or not," she said. She said a rash of overdoses in May prompted them to join the system. 

Rein said preliminary data shows that the pandemic is having an impact on rates if suspected overdoses: "We're not saying that covid causes the increase in overdoses, but certainly some of the factors that go along with covid most certainly put people at higher risk, like the isolation and also the economic impact."

Andrea Brown, public-health director of the Bourbon County Health Department, said it saw an increase in overdoses in April, and started keeping track of those numbers more diligently in May after signing up for ODMap, which she said only records EMS-related encounters, at least for now.

She said the EMS-only data shows that from from May 5 to July 19, almost two and a half months, Bourbon County had 28 overdoses and five fatalities. Brown estimated that the county had 11 overdoses in April but wasn't sure how many died.

"We are still getting overdoses," she said. "I feel like last year we may have had 12 overdose deaths, something in that ballpark, so if we've already had five between May and July, then I think we are really, once the data actually comes out, we're probably going to see a much higher increase." 

Brown said the health department's harm-reduction syringe exchange has been giving out more Narcan, which can block the effects of an overdose, "so I think the word on the street is probably getting around that there has been an increase of overdoses in our community. The Narcan is definitely a hot ticket item right now."

Jamey Whaley, harm-reduction and-peer support specialist with the Maysville-based Buffalo Trace District Heath Department, said some of his syringe-exchange participants have reported an increase in overdoses where they have had to administer Narcan. He said he is also seeing people relapse and return to the program. 

"I don't know if that's because of the covid and the mental-health side of it that has made them decide to go back to using," he said. 

Scott Lockard, public health director at the Hazard-based Kentucky River District Health Department, said Eastern Kentucky has seen an influx of pressed tablets with fentanyl and carfentanyl, noting that Lee County saw a huge uptick in overdoses from a substance called "smurf dope" just a few weeks ago. WLEX-TV reported July 1 that smurf dope is a bright blue substance that is a mixture of methamphetamine or heroin and fentanyl. 

"I think any time you see a different substance than what people normally utilize, there is an adjustment period in how they use it and the strength, the purity level of it when it is a fentanyl or carfentanyl," Lockard said. "If somebody has been abusing Suboxone, which is a pharmaceutical-grade substance, and then now they are dealing with these pressed tablets, that's where I think it increased a lot of the issues that we were seeing with the increase in overdoses."

He said anecdotally, based on what he hears from EMS, law enforcement and harm-reduction people, there have been fewer overdoses near the end of June and in July.

For help in finding treatment for substance-use disorder for yourself, a friend, or loved one, the state has a website: findhelpnowky.org.