In 2003, a Lexington Herald-Leader headline called eastern Kentucky the “nation’s painkiller capital.”

At Kentucky’s inaugural statewide opioid symposium last week, U.S. Rep. Hal Rogers suggested an update.

“After all the great strides that we’ve made from ground zero and seeing the volume of treatment beds increased tenfold over the last 20 years, I think it’s time for a new headline,” Rogers said.

“Eastern Kentucky is now becoming the nation’s recovery capital.”

Rogers’ message of hope permeated throughout the conference, where policy experts, nonprofit leaders, law enforcement and other stakeholders met to learn about and discuss various aspects of the opioid crisis.

Attorney General Daniel Cameron has secured over $950 million to date in opioid settlement funds for Kentucky.

The question of how to spend that money was top of mind for the symposium’s attendees.

Background

The epicenter of the opioid crisis was in “our backyard” – eastern Kentucky, Rogers said.

Many doctors didn’t fully realize how addictive opioids were, and aggressive opioid marketing led them to over-prescribe the drugs to people with chronic pain.

At the time, nobody was tracking prescriptions across doctor’s offices, so patients and drug trafficking organizations “doctor shopped” to get multiple prescriptions.

In 2012, the legislature worked to pass a bill regulating opioid prescriptions.

The final bill required pain clinics to be operated by hospitals or physicians trained in pain management, whereas before about half had been owned by opportunistic, untrained entrepreneurs, said Van Ingram, executive director of the Kentucky Office of Drug Control Policy.

The bill also required physicians to use KASPER, an electronic prescription tracking program, to ensure their patients weren’t double-dipping, and to discuss the risks and rewards of opioid use.

The goal was that “when you decide to prescribe opioids for chronic pain, that’s a measured, calculated, deliberate decision made between a patient and a provider, not just as casual decision,” Ingram said.

Later, other measures, like the Kentucky State Police’s Angel Initiative, were established to try and address the crisis with treatment instead of incarceration, said former KSP commissioner Rick Sanders.

Most recently, the legislature passed bills bolstering requirements for recovery housing and ensuring direct insurance payments to substance abuse treatment centers to avoid delays in treatment.

These and other measures have helped, Rogers said, but there is much more work to be done.

Which brings Kentucky to today, with several hundred million dollars to spend on prevention, treatment and recovery.

MOUD

One piece of the puzzle could be MOUD, or medications for opioid use disorder, said Dr. Lori Nation, Kentucky state medical director at Pinnacle Treatment Centers.

In her session, Nation talked about the efficacy of certain medications as long-term treatment for people with opioid use disorder.

While there is a lot of stigma around this method — some people see it as replacing one drug with another — Nation showed several MOUD studies with promising outcomes.

One 2019 University of Kentucky study —KORTOS — looked at the change in key factors from a year before a participant entered a Kentucky opiate treatment program to six months after entry.

Illegal drug use dropped from 96% to 37% and prescription drug use dropped from 73% to 11%. Depression and anxiety, arrests, homelessness and unemployment also declined significantly.

Nation said that she supports using some of the settlement money on research for drugs like ibogaine, which require more research before they can be FDA-approved.

“I think that there is going to be cutting edge research in a lot of different fields coming up,” she said. “And we have to be open-minded about a lot of different options.”

ACES

How can we ensure that fifty years from now, the opioid crisis will be talked about like we talk about smallpox today, asked Terry Brooks, executive director of Kentucky Youth Advocates, during his session.

“My hypothesis is the way that we put the opioid epidemic in the rearview mirror, the way that we make that this generation’s version of polio, is by addressing adversity in childhood today,” Brooks said.

ACES, or adverse childhood experiences, include emotional, physical or sexual abuse, domestic violence, mental illness or substance abuse in households, divorce and emotional or physical neglect.

Children who experience one or more ACES are more likely to be unemployed and engage in health risk behaviors, which can lead to addiction.

Adverse childhood environments, including poverty, discrimination, community violence, poor housing quality and lack of economic mobility, add to those odds, Brooks said.

Kentucky has the fourth highest rate of ACES among its youth in the nation.

“We know that every adverse childhood experience that hits a kid increases the odds of the initiation of any of the seven opioid use behaviors by 12 to 23%,” Brooks said.

“So when we think about those issues, on a national scale, we have to ask, what does the landscape for Kentucky’s kids look like if we know that adversity in childhood is a doorway to addiction and those other societal problems?”

Brooks suggested a framework for finding solutions, modeled off the Centers for Disease Control. The five areas are:

• intervening to lessen immediate and long-term harms;
• connecting youth to caring adults and activities;
• teaching skills ensuring a strong start for children;
• promoting social norms that protect against violence and adversity; and
• strengthening economic supports for families.

For example, Brooks said the Kentucky legislature could pass an earned income tax credit at the state level to strengthen economic supports for low-income families.

He also mentioned an unfunded mandate the legislature passed requiring a trauma-informed caregiver in each school.

He suggested that the General Assembly could fund that mandate in its upcoming budget.

Police and public health partnerships

One of the biggest obstacles facing change is communication across siloes, said Brittany Garrett, senior director of public safety engagement and strategy at PAARI, Police Assisted Addiction and Recovery Initiative.

“Police can’t do it alone. Treatment centers can’t do it alone. We have to work together,” she said.

“… The challenge is getting in the same room, putting our egos and what we think we know about the thing aside and working together.”

As a law enforcement officer, Garret thought arrests were the only tool to address addiction for a long time.

But now, she’s learned that by working with public and behavioral health centers, they can address addiction, save jails money and lessen the burden on the healthcare system simultaneously.

She also said that law enforcement officers who see the same addiction cycle day after day also need to see the hope.

In addition to incentivizing officers for serving warrants or making traffic stops, she said they can be incentivized to connect people to care.

“If you start to incentivize talking to people and referring them to resources, and capturing that data, you’re gonna get every grant under the sun number one, but you’re going to be able to also show the work that you’re doing in the community,” Garrett said.

Helping the homeless

Homelessness, mental health issues and substance abuse are often tied together.

There need to be low-barrier shelters available for those experiencing homelessness and addiction to achieve some level of stability, said Kim Webb, executive director of the Emergency Shelter of Northern Kentucky.

She said the first thing someone needs to get their life back on track is an address.

“In our state you can use a shelter as an address. But if you don’t have a shelter in your community, now you’re relying on an address of a neighbor, you don’t have utility bill in your name,” she said.

Through recent legislation, those without an address can get a state ID, but not a driver’s license. And many shelters, including Webb’s, prioritize those with Kentucky licenses due to limited beds.

Bryan Hubbard, chair of the Kentucky Opioid Abatement Advisory Commission, closed the symposium with a hopeful message.

“While we have been first in affliction and first and the devastation, we shall be first in its conquest,” he said.