Report offers five strategies to fight opioid epidemic in Appalachia; central part of region had high death rate from overdoses

By Melissa Patrick
Kentucky Health News

The third report in a series that offers "replicable best practices" for Appalachian communities to improve their health offers strategies to address the opioid epidemic, which has swept through much of the region. The other two address smoking and obesity.

The report, Health Disparities Related to Opioid Misuse in Appalachia, Practical Strategies and Recommendations for Communities was created by the Appalachian Regional Commission and the Foundation for a Healthy Kentucky, and also funded by the Robert Wood Johnson Foundation.

Prior research sponsored by ARC shows that residents of Appalachia are more likely to die prematurely than those who live outside the region. And while the report recognizes that multiple factors contribute to this, it says, "Notable trends in opioid-related deaths significantly contribute to the loss of life in Appalachia."

The report says the poisoning-mortality rates in Appalachia is 20.4 per 100,000 residents, compared to 14.4 elsewhere. The rate is 36.6 in Central Appalachia, the ARC subregion that includes all of Kentucky's Appalachian counties. The report points to four Appalachian states, West Virginia, Ohio, Pennsylvania, and Kentucky, which have some of the highest rates of drug overdose in the country.

The report focuses on five specific recommendations in the areas of prevention, increased access to treatment and recovery for opioid-use disorders, harm reduction, long-term recovery supports, and community-based solutions.

“While our nation’s opioid crisis seems to have most significantly impacted Appalachia, I believe the region can be known as a leader in innovative solutions to this pervasive threat to communities throughout our country,” ARC Federal Co-Chair Tim Thomas said in a news release. “I am pleased to see such efforts ongoing in the region, and I hope that the information provided in this brief will help other communities as they work to strengthen their response to this epidemic.”

Before implementing any of the recommended strategies, the report first encourages communities to do a "community needs assessment" to better understand the cultural norms and attitudes around opioid-use disorder and opioid overdoses. The report offers tips on how to do such an assessment, state- and county-level health data, and funding strategies to pay for opioid-related initiatives.

Youth prevention strategies are discussed in detail in the report, including one in McCreary County that is led by the Adanta Regional Prevention Center that has helped its schools implement a teacher-led evidence-based drug prevention program.

The report also encourages increased use of the the prescription drug monitoring programs as a way to decrease the over-prescribing of opioids in the region. The report says a "gold standard" for monitoring if Kentucky's KASPER system, which stands for Kentucky All Schedule Prescription Electronic Reporting.

Another recommendation in the report is to make sure providers understand the appropriate use and dosing of prescription opioids, which continues to be a problem. Kentucky passed a law in 2017 to address this issue that limits most painkiller prescriptions to a three-day supply for acute pain, but it passed with a long list of exceptions and some have suggested that it is not being strictly adhered to.

Strategies to increase access to treatment for opioid use disorder include increasing access to medication-assisted treatment. MAT combined with counseling is considered the gold standard of treatment for opioid-use disorder. Three MAT drugs have been approved, including methadone, buprenorphine and naltrexone.

"To improve access to MAT, communities may seek to increase the number of providers who offer MAT, invest in telehealth programs and integrate behavioral health into primary care and emergency department settings," says the report.

The report also notes the importance of harm-reduction programs. These include syringe exchange programs, the distribution of naloxone, safe drug disposal programs and the prevention and treatment of neonatal abstinence syndrome.

In Kentucky, local governments have approved 52 syringe exchanges, with all but four of them operational. However, about 54 counties that are considered at high risk for HIV and hepatitis C outbreaks among IV drug users still don't have one -- and most of those counties are in Appalachia.

The report encourages the use of drug courts, which are designed to get people with opioid-use disorders into treatment and out of the criminal justice system. Kentucky recently implemented an educational program, called RESTORE, to teach judges and the court staff about opioid-use disorders, treatment and recovery as a way to help them make informed decisions in related cases.

It also points out that supporting long-term recovery for people with opioid-use disorders often involves helping them with "upstream factors," like housing or jobs or passing policies that support them. It also notes the value of providing access to peer support specialist, who can act as mentors to people with opioid-use disorders.

Additionally, it stresses the importance of forming community coalitions that brings everyone to the table to address this issue, including law enforcement, social service providers, schools, health providers and policymakers.

In last decade, cost of opioid-related treatment at UK rose 733% and number of opioid patients rose 481%, Herald-Leader reports

There are several ways to measure the depth of the opioid epidemic that has spread across Kentucky and much of the nation in the past decade; the most common is the number of overdose deaths,which rose from 1,010 in 2013 to 1,565 in 2017.

The most recent measuring stick is the cost of hospital treatment at the University of Kentucky for problems related to opioid addiction. It went up more than 700 percent from 2009 to 2018, reports Linda Blackford of the Lexington Herald-Leader, who got UK to run the numbers.

Traffic rushes past Chandler Hospital in this slow exposure.

In 2009, UK's A.B. Chandler Hospital and Good Samaritan Hospital treated about 1,500 people for opioid-related issues, "ranging from overdoses to blood infections to hepatitis C," Blackford writes. "The cost of those treatments: $7.6 million. By 2018, the number of patients treated for problems caused by opioid addiction had skyrocketed 481 percent to 8,782 and the cost had soared 733 percent to $63.3 million."

According to the data compiled by UK, about 54 percent of the bill was paid by Medicaid, 19 percent is by Medicare "and the rest by private insurers or the patient," Blackford writes. "Figures from the Kentucky Cabinet for Health and Family Services show that 63,000 Kentucky Medicaid patients were diagnosed with opioid use disorder in 2018. The agency estimates the annual per capita cost to treat each of those patients tops $15,000. Using a conservative estimate, that’s almost $1 billion a year from federal and state coffers." The federal government pays 75 to 80 percent of the cost.

"The numbers, while jaw-dropping, are just one small but instructive sliver of the real cost this epidemic is demanding of state and federal coffers as it decimates Kentucky families and communities with one of the highest overdose death rates in the nation," Blackford writes.

“This is just the tip of the iceberg,” Sharon Walsh, executive director of the UK Center for Drug and Alcohol Research, told the Herald-Leader.

Blackford reports: "For UK, which serves as the regional hub for complex medical care for the eastern half of the state, the opioid crisis has affected nearly every facet of health care delivery," from reworking emergency-room procedures to tightening pain-control protocols. "Many doctors now recognize that the crisis was fueled by the over-prescription of pain pills that turned out to be far more addictive than they realized," Blackford notes.

UK collected $264 million in the decade for treating the effects of the epidemic, and has used part of that money to improve its treatment, such as "a special neonatal intensive care area for babies born addicted to opioids. They now stay longer in the hospital with their moms, which is a big expense. From 2009 to 2015, the annual costs for neonatal abstinence syndrome went from about $1.4 million to more than $6.1 million. In recent years, that number has dropped slightly."

The Herald-Leader offers caveats about the data: "The numbers provided by UK only account for in-patient and out-patient treatment . . . and includes only those patients whose billing codes included opioids. They don’t include UK physician visits or the numerous clinics and programs where doctors and counselors work with substance abuse disorder patients. . . . Billing codes are an imperfect way to track opioid-use disorder because many physicians might not include it as part of a diagnosis if a patient is seeing them for a seemingly unrelated disorder."

UK gets $87 million federal grant to reduce opioid-overdose deaths in 16 counties by 40 percent in the next four years

The National Institutes of Health has awarded the University of Kentucky up to $87 million over the next four years, with the goal of reducing opioid-overdose deaths by 40 percent in 16 counties: Fayette, Bourbon, Franklin, Jessamine, Clark, Madison, Boyle, Jefferson, Knox, Floyd, Carter, Boyd, Greenup, Mason, Campbell and Kenton.

"These counties aren’t necessarily the worst hit by the crisis, but each had to meet certain criteria, which included having a jail, at least 25 opioid overdose deaths per 100,000 population, a needle exchange program, and one or more providers who offer medication assisted therapy, such as buprenorphine, for opioid addiction," reports Linda Blackford of the Lexington Herald-Leader. "State health officials have tried to increase the amount of medication assisted therapy available for opioid addiction, but it is not standard practice in numerous treatment centers or hospitals. Drugs such as buprenorphine can satisfy the addictive cravings of opioid use disorders, but they also can be abused or resold on the street."

Read more here: https://www.kentucky.com/news/local/education/article229408479.html#storylink=cpy

Blackford adds, "Combined, the 16 rural and metropolitan counties had 764 opioid overdose deaths in 2017, with two-thirds of them involving fentanyl, UK officials said. They also represent about 40 percent of the state’s overall population."

The grant, by far the largest competitive award UK has ever received, is one of four totaling $350 million. The others went to the Boston Medical Center in Massachusetts, Columbia University in New York City and Ohio State University. It also involves the National Institute on Drug Abuse.

U.S. Rep. Hal Rogers, R-Somerset, said in a release, "This partnership between the NIH, NIDA and UK was sparked several years ago during the National Rx Drug Abuse and Heroin Summit, when I invited [UK President] Dr. Eli Capilouto to share his vision for this project with Dr. Francis Collins, director of the NIH and Dr. Nora Volkow, director of NIDA."

The grant's leader in Kentucky will be In Kentucky, the grant’s principal investigator will be Sharon Walsh, director of the UK Center on Drug and Alcohol Research. She will work with the state health and justice cabinets "to lead a team of 20 researchers and community partners," Blackford reports.

Walsh told her, "The goal is to show meaningful change in the overdose death rate in a short period of time and to do so in a way that can reveal what evidence-based interventions are effective in the community. What will work? Is it distributing more naloxone? Is it educating people better about evidence-based treatment? Is it expanding access to treatment and decreasing barriers? For example, if we pay for someone to have transportation to get to their treatment program will that help them stay in treatment?"

Read more here: https://www.kentucky.com/news/local/education/article229408479.html#storylink=cpy

Rogers' release said, "The first year of the study will focus on collecting data, assessing local needs, and determining the best prevention and treatment interventions to implement in each community through healthcare, behavioral health and justice systems. . . . The four-year grant will allow UK to earn full funding each year as benchmarks are achieved."

Report offers Appalachian residents four strategies to decrease high obesity rate, aimed at deadly obesity-related diseases

By Melissa Patrick
Kentucky Health News

A new report offers practical strategies to help Appalachian communities tackle their high rates of obesity, which is causing many in the region to develop chronic, obesity-related conditions.

The report, Health Disparities Related to Obesity in Appalachia: Practical Strategies and Recommendations for Communities, was created by the Foundation for a Healthy Kentucky, the Appalachian Regional Commission and the Robert Wood Johnson Foundation.

Previous ARC reports have documented the region's high rates of obesity and obesity-related conditions, like heart disease, stroke and diabetes, which have contributed to people dying from these chronic conditions more frequently than those elsewhere.

The report notes that in 2012, 31% of Appalachian adults were obese, compared to 27% elsewhere in the U.S. The rate was highest, 35%, in Central Appalachia, which is the subregion of the ARC service area that includes all of Kentucky's Appalachian counties.

The report details four strategies to help Appalachians battle obesity: establishing healthy behaviors in young people, increasing access to healthy food and beverages, creating safe communities that support physical activity, and increasing physical activity and healthy eating among adults.

Before getting started on any of these prevention strategies, the report suggests doing a "community needs assessment" to determine what the community is already doing about obesity and establish what else could be done. The report offers tips on how to do such an assessment, links to state- and county-level health data, and a long list of recommendations for funders.

The report emphasizes establishing healthy behaviors in early childhood, pointing out that child care and schools are uniquely positioned to influence healthy habits. The focus is two-fold, including strategies to increase the availability of healthy foods and beverages in schools and programs that promote physical activity among youth.

The report notes that "farm to school" programs are one of many ways Appalachian schools are working to increase the availability of healthy foods. According to the Kentucky Department of Agriculture, Kentucky has more than 900 schools participating in these programs, Brenda R. Kelly reports for the Kentucky School Board Association website.

Focusing on strategies to decrease obesity in young children is important because studies show that children who are overweight in kindergarten are four times more likely to be obese in eighth grade, compared to those who are not overweight in kindergarten.

"Policies that ensure healthy foods are available for purchase in rural Appalachian communities - such as the tax credit for farmers who donate their products to local food banks that has been enacted in Kentucky and West Virginia - are essential," Ben Chandler, president and CEO of the foundation, said in a news release. "But grocers cannot afford to stock fresh produce that rots on the shelf, so we also must enact policies and strategies shown to increase consumption of these foods."

The report notes that such policies could include ones that allow farmers markets to accept Supplemental Nutrition Assistance Program, commonly known as food stamps, and Women, Infants and Children nutrition program benefits; or policies that increase taxes on sugar-sweetened beverages.

The report offers several suggestions for creating safe communities that support physical activity, including ones to create safe routes to school or that invest in public trails, parks and recreational facilities, noting that grants are often available for such endeavors.

One such grant program featured in the report was funded by the foundation through its Investing in Kentucky's Future initiative. The $3 million grant was used to implement various health programs across seven communities, including one in Clinton County that used its funds to build walking trails to schools and add exercise equipment to public parks.

Strategies are also offered to increase physical activity and healthy eating among adults, like offering tax credits for worksite wellness programs, community-wide campaigns to promote physical activity, and social support interventions, like walking clubs.

McConnell says he will introduce bill to raise to 21 the legal age to buy tobacco products anywhere in the nation

By Al Cross and Melissa Patrick
Kentucky Health News

Senate Majority Leader Mitch McConnell said Thursday that he would sponsor legislation to make 21 the legal age to buy tobacco products in every state – a change that 12 states have recently adopted, but one that failed to pass the Kentucky legislature this year.

McConnell said at a Louisville news conference that his move was prompted by the epidemic of "vaping" with electronic cigarettes among students in high schools and even middle schools.

"The most serious threat involves the use of vaping devices for teens under 18," who can get them from 18-year-olds at school, he said. "By raising the age that you can legally purchase to 21 tobacco won't be in most high schools presenting fewer opportunities for children to get their hands on vaping devices."

The change is favored by the nation's largest tobacco company, Altria Group, which recently bought 35 percent of Juul Labs, maker of the most popular vaping device. Altria tried unsuccessfully to get a "tobacco 21" bill passed in the recent session of the Kentucky General Assembly. Like most major lobbying interests, it has been a major contributor to McConnell's political causes.

Altria Vice President David Fernandez told lawmakers at the Feb. 25 committee meeting why they supported the bill : "Putting tobacco on par with alcohol makes sense and we do hope that doing that will also persuade policymakers to approach tobacco regulation a bit more reasonably."

Speaking in general on April 17 at a tobacco conference, Elizabeth Anderson-Hoagland, who was recently the policy analyst with the Kentucky Tobacco Prevention and Cessation Program, outlined some of the restrictions Altria is trying to avoid, like a ban on flavors and menthol, or rules that would limit the amount of nicotine allowed in e-cigarettes, or "pre-market review" requirements that are placed on new products.

Amy Barkley, regional advocacy director for Campaign for Tobacco Free Kids, said that while her organization has supported legislation to raise the nationwide age to purchase tobacco to 21 in the past, they couldn't comment specifically on the bill that McConnell will introduce because they haven't seen the language.

"While we strongly support raising the age of sale for tobacco to 21, we are deeply concerned that tobacco companies have worked to add special interest provisions to state and federal Tobacco 21 bills that shield the industry from other regulations to protect kids and public health, such as prohibitions on flavored tobacco products," she said in an e-mail.

She added, "We also urge Congress not to exempt active military personnel from Tobacco 21 legislation as Sen. McConnell is proposing, particularly in light of the military’s recognition that tobacco use harms troop readiness and health and costs the government billions in health care costs annually. The military is actively working to reduce tobacco use within its ranks, and Congress should support these efforts by passing a tobacco 21 bill without a military exemption."

L-R: State Sen. Julie Raque Adams, state Rep. Kim Moser,
Foundation CEO Ben Chandler, U.S. Sen. Mitch McConnell .
(Photo: Foundation for a Healthy Kentucky)

McConnell spoke at the offices of the Foundation for a Healthy Kentucky, with foundation President and CEO Ben Chandler and two Republican state legislators who have pushed for legislation to limit young people's access to tobacco products.

Sen. Julie Raque Adams of Louisville said the vaping epidemic has reached her own family. She said that when her two teenage sons got physical exams for health insurance, nicotine showed up in their blood. "They said, 'We don't smoke, Mom. ... All we've done is vape.' . . . Even my own kids didn't understand that there was nicotine and addiction in that vape."

She said many teenagers "think that it's an innocent kind of habit," and "By raising this age to 21 we send a very clear message that we're doing this for the health of those young people."

When a reporter noted that higher taxes on tobacco products have been shown to be the most effective way to prevent use by young people, Adams noted that the legislature didn't include electronic cigarettes in its big tobacco-tax increase last year, but "I think you'll see that on the table." The proposed tax on e-cigs was removed at the eleventh hour after lobbying by Altria.

Rep. Kim Moser of Taylor Mill, who sponsored the new law that will make all Kentucky schools that don't opt out tobacco-free in July 2020, said raising the legal-purchase age to 21 "in no way is telling adults what they should do." But when questioned, she acknowledged that 18-year-olds are considered adults: "Point taken, but I think it's still about exposure to a very addictive substance."

McConnell, asked why people who are old enough to vote shouldn't be able to buy tobacco products, acknowledged, "Some people will look at it that way." Asked what he would say to them, he said, "We're gonna do it this way."

Earlier, McConnell said, "As you all know, I'm in a particularly good position to enact legislation and this is gonna be a top priority that I'll be working on."

As he turned the microphone over to Chandler, a Democrat who won a seat in Congress over candidates he supported, McConnell said, "Probably the first time we had a first joint press conference." Chandler said they had one about the Blue Grass Army Depot.

"We're very excited about your interest in this subject," Chandler told McConnell. "The health of our people, the health, particularly, of our children is a nonpartisan issue if there ever was one."

Altria's tobacco-21 bill failed in Kentucky after one state senator said "Tobacco is still king," but Chandler and McConnell said Kentucky is finally getting away from the culture of raising, using and defending tobacco. "We had an enormous number of people who made some or all of their income off of tobacco in one way or another," McConnell said.

A 1997 poll by the Louisville Courier Journal found that 18 percent of Kentucky adults had some economic interest in tobacco, many from their shares of farm estates that included federal tobacco allotments. Chandler said that the state once had 60,000 tobacco farmers but now has fewer than 4,000. "It's unbelievable how we have receded from the tobacco culture in a fairly short period of time," he said.

Those allotments, and the price supports that went with them, were abolished in 2004 by a bill McConnell sponsored, but he noted that farmers were compensated "for the asset created when Alben Barkley was majority leader" of the Senate in 1940 and got the tobacco program passed. Barkley had won re-election in 1938 by defeating Chandler's grandfather, then-Gov. A.B. "Happy" Chandler, in the Democratic primary.

Raising the legal age to 21 won't hurt tobacco farmers because most of their crop is grown for export, said U.S. Rep. James Comer of Tompkinsville, a farmer and a former state agriculture commissioner. He told WKMS in Murray that McConnell's proposal is "the right thing to do," 

Report offers Appalachian residents ways to decrease smoking rates; they are more likely to die from smoking-related diseases

By Melissa Patrick
Kentucky Health News

It's well documented that people in Appalachia die sooner than other Americans, and are more likely to die from smoking-related diseases. It doesn't have to stay that way; a new report offers a detailed list of strategies and policies proven to decrease smoking, the cause of many premature deaths.

The report was created by Appalachian Regional Commission, the Foundation for a Healthy Kentucky and the Robert Wood Johnson Foundation.

The report notes that in 2014, about 20% of Appalachian adults were smokers, compared to 16% of adults elsewhere in the U.S. Those rates were highest, 25%, in Central Appalachia, the subregion of the ARC service area that includes all of Kentucky's Appalachian counties.

The report adds that smoking is a key factor in deaths from heart disease, cancer and chronic lower-respiratory disease, which are three of the four leading causes of death in the U.S., and that these diseases occur more frequently in Appalachia than in the rest of the country.

As a way to decrease smoking-related deaths, the report recommends four approaches to reduce smoking in the region: youth prevention, increased access to tobacco cessation, strong anti-tobacco campaigns and policies that decrease exposure to second-hand smoke.

"Here is a fresh set of evidence, practical advice, and local examples of the tactics and tools Appalachian communities have used to reduce tobacco use and improve health," Ben Chandler, president and CEO of the foundation, said in a news release. "Some of Appalachia's most glaring health disparities are found in the central region that includes Kentucky and West Virginia, so the approaches can have an outsized benefit here."

Before settling on any of these approaches, the report encourages communities do a "community needs assessment" to best determine which strategies their residents are willing to undertake. The report offers tips and links on how to do such an assessment; recommendations for funders; and links to state- and county-level data on a range of tobacco and health related topics.

The report offers several community-based strategies to decrease youth smoking, which is important because 90% of adults report they started using tobacco products when they were teens.

Suggested youth prevention strategies included educating parents, teachers, health professionals and youth about the risks of smoking and electronic cigarettes, restricting access and expanding smoke-free policies. The report also encourages Appalachian communities to form coalitions to promote and support these strategies.

The General Assembly recently passed a law to ban the use of all tobacco products in all Kentucky public schools and events. It will go into effect July 1, 2020 and gives school boards three years to opt out.

Policy-based strategies in the report include raising the minimum age to buy tobacco products from 18 to 21 and increasing the price of tobacco products. In Kentucky, such policies would have to be passed statewide since state laws pre-empt any local regulations on distribution, sale and regulation of tobacco products.

Last fall's Kentucky Health Issues Poll found that 66% of Kentucky adults supported such a law and 30% opposed it. Bills to raise the age to buy tobacco products from 18 to 21 have been introduced for several years, but haven't gained much traction.

As for raising the cigarette tax, it's not likely that Kentucky's lawmakers will do that again anytime soon since they increased it by 50 cents to $1.10 per pack in 2018, which at 83 percent was the largest increase in the state's history.

The report also advises Appalachian communities to increase their access to tobacco-cessation products. One way it says to do this is to partner with work and faith-based organizations. As an example, the report points to the Faith Moves Mountains program, which provided cessation treatment to 590 smokers across 26 rural churches in Appalachian Kentucky. The state has a quitline (1-800-QUIT-NOW).

Further, the report says Kentucky serves as an example of how states can pass laws to reduce out-of-pocket costs for cessation treatment, pointing to Senate Bill 89, which requires all insurance policies sold in Kentucky, including Medicaid, to cover all tobacco cessation services recommended by the U. S. Preventive Services Task Force.

Medicare was not included in this bill, but anyone on Medicare, or Kentuckians who are uninsured, can call the quitline to get access to cessation treatments.

The report also encourages Appalachian communities to launch anti-tobacco communication campaigns that are designed to resonate with their local residents, as some have done with the "tobacco prevention barns" found throughout Appalachia.

It also recommends implementing policies that reduce exposure to secondhand smoke. As of April 1, 35.5% of Kentuckians are protected by smoke-free laws covering all indoor workplaces and public spaces.

Kentucky has 16 confirmed cases of salmonella from pre-cut melons; health officials say you should throw it all out

CNN image

Health officials are advising Kentuckians to throw away all of their pre-cut cantaloupe, watermelon and honeydew, since 16 cases of salmonella have been linked to these products.

The Kentucky Department of Public Health advises that all pre-cut melon be thrown out because the label may not clearly indicate that the product came from Caito Foods from Indianapolis, which distributed the fruit. The products have been sold under several brands and labels.

Caito issued a voluntary recall of these pre-cut melons April 12 in 16 states, including Kentucky. The recall also advises stores to quit selling these products. The recall does not include whole melons.

Salmonella Carrau is a bacteria that makes people sick. Symptoms usually develop 12 to 72 hours after exposure and include diarrhea, fever and stomach cramps. The illness usually lasts four to seven days. Children under 5, adults older than 65 and those with weakened immune systems are at the greatest risk of being severely affected. The release notes that most adults recover with antibiotics.

These infections are part of a nine-state salmonella outbreak that have all been linked to the pre-cut fruit. So far, the Centers for Disease Control and Prevention reports that 93 people have been infected with the disease and 23 people have been hospitalized because of it. No deaths have been reported. Most of the sick have been adults over 50.

“Exposure to salmonella bacteria can be debilitating and potentially life-threatening, especially for small children and individuals with weakened immune systems,” Dr. Jeff Howard, the state's public-health commissioner, said in a news release. “Anyone experiencing signs or symptoms of illness should seek medical care and clinicians should be aware of this ongoing outbreak to ensure suspected cases receive testing and investigative follow-up."

The news release notes that salmonella infection is an extremely common infection in the Kentucky so lab testing is needed to confirm if an illness is linked to this outbreak.

Eight Kentuckians among 60 indicted for illegal prescribing or health-care fraud as a result of major federal investigation

Rob Duncan, U.S. attorney for the Eastern
District of Kentucky, announced the cases.
(Associated Press photo by John Minchillo)

Sixty health professionals in five Appalachian states, including Kentucky, were charged Wednesday with "illegal prescribing of more than 32 million pain pills, including doctors who prosecutors said traded sex for prescriptions and a dentist who unnecessarily pulled teeth from patients to justify giving them opioids," report Sari Horwitz and Scott Higham of The Washington Post.

Those indicted included "31 doctors, seven pharmacists, eight nurse practitioners and seven other licensed medical professionals" who wrote more than 350,000 illegal prescriptions in Ohio, West Virginia, Kentucky, Tennessee and Alabama, according to federal indictments filed in Cincinnati. “That is the equivalent of one opioid dose for every man, woman and child in the five states in the region that we’ve been targeting,” Brian Benczkowski, the assistant attorney general in charge of the Justice Department’s Criminal Division, told the Post.

Those indicted in Kentucky, according to the USA Today Network, include:

•  Dr. Denver Tackett, who ran a dental clinic in McDowell, is accused of prescribing Oxycodone and hydrocodone that were not reasonable for the treatment of a patient's illness or injury. He also is accused of pulling teeth from six patients who had no need for extractions, as well as submitting claims to Medicare and Medicaid for procedures he did not perform.

•  Dr. Christopher Nelson of Louisville's Bluegrass Pain Consultants, is accused of teaming with a Florida pharmacy, AssuredRx, to defraud Medicare and Tricare, a health-insurance plan for veterans, by inflating drug costs. Nelson is accused in a kickback and bribe scheme to funnel customers to Assured Rx for drugs used for pain, including controlled substances. Nelson has pleaded not guilty.

•  Dr. Ijaz Mahmood, who operates a clinic in Elizabethtown, charged with authorizing prescriptions for drugs, including controlled substances, through presigned, blank prescriptions and directing employees, including some who weren't licensed to practice medicine, to perform medical services on patients. Mahmood told a Courier Journal reporter that he didn't want to discuss the charges.

•  Dr. Scotty Akers and Serissa L. Collier, who also used the last name Stamper, are charged in an indictment with distributing the opioids hydrocodone, oxycodone and fentanyl between August 2016 and May 2018. Both are from Pikeville.

•  Dr. Mohammed A.H. Mazumder of Prestonsburg, who owned Appalachian Primary Care, is charged with telling his employees, who were not doctors, to receive patients at the clinic when he was not there. The indictment says a medical technician evaluated patients, then two receptionists called pharmacies with prescription orders for opioids and other controlled substances under Mazumder’s name. The clinic then submitted claims to Medicare and Medicaid as if Mazumder had examined the patients and ordered the prescriptions.

•  Dr. Sai P. Gutti, who has offices in Pikeville, Harold, Paintsville, Whitesburg and Belfry and also saw patients in Frankfort and other Kentucky towns, is accused of eight counts of health-care fraud by ordering medically unnecessary drug tests for Medicare and Medicaid patients.

•  Gary Green of Louisville is accused of failing to inform the Drug Enforcement Administration when he transferred and stored controlled substances in the offices of Guaranteed Total Construction, for which he acted as a registered agent; of furnishing false and fraudulent information in, and omitting material information from documents required to be made, kept, and filed.

The Justice Department says it has targeted doctors, health-care companies and drug manufacturers and distributors for their roles in the opioid epidemic that killed 47,600 Americans in 2017. "Benczkowski said he created the Appalachian Regional Prescription Opioid Strike Force late last year to target the region, which has been devastated by the epidemic," the Post reports. "The department analyzed several databases to identify suspicious prescribing activity and sent 14 prosecutors to 11 federal districts there. . . .Once they had the data indicating suspicious prescriptions, investigators used confidential informants and undercover agents to infiltrate medical offices across the region. Cameras and tape recorders were rolling as they documented how medical professionals used their licenses to peddle highly addictive opioids in exchange for cash and sex, officials said."

The indictments merited a statement from Attorney General William Barr: “The opioid epidemic is the deadliest drug crisis in American history, and Appalachia has suffered the consequences more than perhaps any other region.”

Keynoter at harm-reduction summit says syringe exchange programs need to partner with drug users to be truly successful

By Melissa Patrick
Kentucky Health News

COVINGTON, Ky. – Syringe exchange programs must partner with drug users to have the most impact. That was one of many messages that resonated with the nearly 500 attendees of the state-sponsored 2019 Harm Reduction Summit in Northern Kentucky on April 9.

Nearly 500 people attended the 2019 Harm Reduction Summit
on April 9 in Northern Kentucky.  (Photo by Melissa Patrick)

Jon Zibbell, a senior public-health scientist at RTI International, an independent, nonprofit research institute, was the keynote speaker. He praised the state's efforts for harm reduction, saying Kentucky is recognized across the nation as a leader on it.

At the same time, he stressed that there is room to do more in these programs to better meet the needs of the people they are supposed to serve. But first, he said, you have to ask the people who use drugs what their needs are.

"This population has insights and expertise that can help inform the planning, delivery and review of harm reduction services," Zibbell said.

Harm reduction is the primary purpose of a syringe exchange. It not only passes out clean needles and syringes as a way to decrease the spread of HIV and hepatitis C, which are commonly shared by the sharing of needles among intravenous drug users; it also provides health screenings and vaccines, access to treatment, and a safe place for people to reach out for help.

The legislature authorized the exchanges in 2015, subject to approval of local governments. They have approved 52 exchanges, all but four operational. That said, about half of the 54 counties that are considered at high risk for HIV and hepatitis C outbreaks among IV drug users still don't have one.

Latest, updated map of syringe exchanges and vulnerable counties (Click on it for a larger version)

Zibbell talked about the many challenges of helping drug users stay safe, including the influx of fentanyl into the market, which has created what he called "market unpredictability;" the use of multiple drugs among opioid users, which increases their risk for overdose; and the increase in the number of non-opioid drugs, like cocaine and methamphetamine, that also have fentanyl in them.

He said no one knows better than the drug users themselves the reality of these challenges, and that's why we need to be talking to them about it.

Zibbell said much of the data used by harm-reduction programs comes from law enforcement, government data sets and mortality records, not the people on the streets who "have critical knowledge and expertise. . . . People that use drugs have an insight and a knowledge about drugs that we desperately need."

He said the principles of harm reduction support his call for bringing drug users into the programs as consultants. One calls for drug users and those with a history of drug use to "routinely have a real voice in the creating of programs and policies designed to serve them." Another says users are called to be the "primary agents of reducing the harms of their drug use," and such programs should empower them to share information and support each other with strategies to do so.

Zibbell said working in partnership with people who use drugs helps a program better understand its clients and their needs, which will result in better outreach and service. Further, he said it will ensure the program is community-friendly, improves the "cultural competency" of the workers and reduces the stigma often associated with drug use.

"We need to know where the drugs are on the street, we need to know how people are injecting, we need to know if people are getting tested, if they've been vaccinated," he said. "Having that connection to the population gives us that entry. "

Takeisha Nunez, supervisor of the syringe exchange at the Louisville health department, also came with the message of partnering with drug users. Her focus was on African Americans, who she said have been slow to embrace them.

Nunez said African Americans' historical mistrust of government and the medical system has been an obstacle for them to participate in syringe exchanges, which in Louisville are primarily located in government buildings or medical centers.

In response to a Facebook question about why more African Americans don't come to the Louisville exchange, one client replied: "They are afraid. I have shown them my card and everything, but they don't believe that they won't get arrested."

Further, she said there is a lot of resentment about these programs. Another person on Facebook wrote, "Where was all this compassion when there was a crack era and you was locking up the black and brown people? No one was the angel of compassion for our community."

Nunez said, "We have to figure out ways to break down those barriers."

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Bevin signs bill making all Ky. school property and events free of tobacco and e-cigs by July 2020, unless school boards opt out

By Melissa Patrick
Kentucky Health News

Gov. Matt Bevin has signed into law to ban the use of tobacco products in all Kentucky public schools and events, a policy that has taken several years to pass. It will take effect July 1, 2020.

Rep. Kim Moser

"It's not only going to help kids become less addicted in the future and improve overall health, but I think it will actually improve the light in which Kentucky is looked upon as a healthy state," said state Rep. Kim Moser, the bill's sponsor. "I really feel like this is a step in the right direction and I just think the messaging is so critical, especially for kids."

Moser, a Republican form Taylor Mill in Northern Kentucky, said it's important to recognize that e-cigarettes and other tobacco products not only create what are often life-long addictions to the nicotine, they also can prime the adolescent brain for addiction to other drugs.
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Moser and Sen. Ralph Alvarado, Bevin's running mate for lieutenant governor and a longtime advocate for tobacco-free schools, said the alarming increase in teenagers' electronic cigarette use in the last year was likely the main reason the bill was able to pass this year.

"The more people started realizing what a problem this is, I think that really shed a lot of light on this whole tobacco-use issue," Moser said.

Sen. Ralph Alvarado

Alvarado, a Winchester physician, credited a group of Johnson County Middle School students for educating legislators on the rampant use of e-cigarettes in schools. Among other things, they told them that some students have become so addicted to the nicotine that they can't even make it through one class without going to the bathroom to use a device.

The most popular device for teens, made by Juul Labs, is easy to hide because it looks like a large computer flash drive. One Juul pod has the equivalent of a pack of cigarettes, and some kids are going through about eight a day, Alvarado told lawmakers on the Senate floor.

The students were actually pushing a Senate bill that would have created an anonymous hotline for students to report concerns about e-cigs and tobacco use . The bill made it all the way to the House floor, but wasn't called up for a vote. Alvarado, who presented the tobacco-free schools bill in the Senate, said he planned on inviting the students to the ceremonial signing of the bill because of the role they played in getting it passed.

"I think they gave everybody a little insight on what happens in the classroom, what happens on school grounds," he said. "I think they also had an instrumental part in being able to open some folks eyes in terms of how big this problem is becoming with vaping and tobacco use in our schools."

The tobacco-free schools measure, House Bill 11, prohibits the use of all tobacco products, including electronic cigarettes, on school-owned property and school-sponsored events in all Kentucky schools. Tobacco use will be permitted on field trips that are off school property if students are not present.

The bill does not ban the possession of tobacco products, just their use. Enforcement is also left up to individual school boards. School boards have also been given three years to opt out of the ban.


As of July 2018, only 42 percent of the Kentucky's 173 school districts have 100% tobacco free school policies, covering 57% of the state's students, and many of them have not updated their policy to meet new standards for electronic cigarettes.

"Up to 225,000 more Kentucky students will be protected from secondhand cigarette smoke and e-cigarette aerosol at school thanks to the tobacco-free schools bill," Bonnie Hackbarth, vice-president of external affairs for the Foundation for a Healthy Kentucky, said in a news release.

Moser said it took "many voices' to get this "positive piece of legislation" passed, and expressed her gratitude for them all. "I'm just excited for Kentucky," she said. "Looking forward, I think every step we take toward improving our health is a good step for Kentucky."