As opioid settlement money continues to flow into Kentucky, counties are having to make major decisions on how to spend it.
Half of it goes to the state's Opioid Abatement Advisory Commission, which allocates funds through a competitive grant making process.
Margaret McGladrey, assistant professor of public health at the University of Kentucky, pointed out smaller counties with fewer resources face greater challenges seeking community input on how to use the funds.
"I think there's certainly a capacity issue when we're asking each of these local governments to engage in communities in decision-making and then spend the money in accordance with that decision-making," McGladrey observed.
The Commonwealth is slated to receive around $900 million statewide across the various settlements involving companies distributing opioids, such as CVS, Walgreens, and Walmart, and pharmaceutical companies such as Purdue Pharma and the Janssen Pharmaceutical Companies of Johnson & Johnson.
According to the Appalachian Opioid Remediation tracker, the state's Opioid Abatement Advisory Commission requires local governments to submit a quarterly form certifying funds were used for their intended purposes but does not ask for specific details about expenditures.
Kate Boulton, senior legal technical adviser for the public health organization Vital Strategies, argued it important to distinguish between state spending inconsistent with the terms of the national settlements or state laws, and spending which is not evidence-based.
"In the first category, I would flag things like shooting ranges, ballistic vests, drug sniffing dogs and vehicles for law enforcement," Boulton outlined. "Those are all real life examples from various parts of the country."
McGladrey recommended to keep families intact and reduce the negative consequences of involvement in criminal legal and child welfare systems, counties should consider using funds for comprehensive medication-assisted treatment.
"Where we can have the most impact with these opioid abatement funds, is supporting our county correctional facilities in implementing medication treatment for opioid use disorder," McGladrey urged.
According to the Kentucky Youth Advocates Opioid Dashboard, in 2020, more than 30% of Kentucky children said they have lived with someone who had a problem with alcohol or drugs.
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By Darian Benson and Mary Claire Molloy for Mirror Indy.
Broadcast version by Joe Ulery for Indiana News Service reporting for the Mirror Indy-Free Press Indiana-Public News Service Collaboration.
It was like a “dream come true” when James Miller’s family moved to the east side of Indianapolis in 1967. They found a home in 46218, the ZIP code that’s a loving shorthand for the collection of predominantly Black neighborhoods.
The area was thriving. That changed by the ‘80s and ‘90s, though, during the rise of the crack cocaine epidemic.
Like many Black men his age, Miller said he used drugs back then — self-medicating instead of talking about mental health.
“We don’t talk about struggling with anxiety and depression,” said Miller, now 64. “But it’s been ingrained in us most of our lives because of the nature of coming to this country.”
Black men have faced the repercussions of systemic racism for centuries. Men of Miller’s age have been hit especially hard: Born in the middle of the Civil Rights Movement, they faced racial tension, discriminatory laws and low-paying jobs.
Trauma built up — and the dire consequences are still affecting them today.
They make up the cohort of Black men born between 1951 and 1970 who are dying of overdoses at the highest rates, according to a data analysis by The Baltimore Banner, The New York Times and Stanford University’s Big Local News. Mirror Indy is collaborating with them and eight other newsrooms to report on the extent of this pattern.
The risk isn’t new. The data analysis, which examined hundreds of counties across the country, found that Black men of that cohort have died of overdoses at a disproportionately high rate at nearly all stages of their lives in dozens of cities.
In Indianapolis, the men from this generation died from overdoses at nearly three times the city’s rate and nearly 10 times the national rate.
Miller, however, has been in recovery for nearly 18 years. He’s now a licensed social worker and fights to help the next generation of Black men.
For most of their lives, the men in that younger generation — who are now in their 30s to 50s — were doing better than their older brothers and fathers. But they are starting to face a disproportionately worse trajectory, the data analysis showed, particularly in Indianapolis, Pittsburgh and Philadelphia.
One significant reason is the synthetic opioid fentanyl. And it’s happening in Miller’s home ZIP code of 46218, which has seen some of the highest rates of fatal overdoses in Marion County for the past three years.
A jump in overdose deaths
Marion County Coroner Alfie McGinty has witnessed the epidemic firsthand over her 27 years working in the office.
When she started during the crack cocaine epidemic, she would see a handful of people die every so often.
“We weren’t seeing nearly what we were seeing in 2020,” McGinty said, “when we went from 250 to over 600 deaths in that short time frame.”
That led her to encourage the coroner’s office staff to learn about people’s previous drug use. Her team found that many older men dying from substances had a history of using cocaine or crack.
“They went through a period of going through recovery and being in rehab or whatever that was, but then a lot of them relapsed,” she said. “And a lot of them were seeking cocaine or crack, but subsequently got heroin, or more recently, fentanyl.”
And when people did receive cocaine, it was often laced with fentanyl.
There are tools and programs now that have shown success in helping people who have substance use disorders, but many Black men are either unaware or afraid to use them.
They’re referring to things such as safe syringe exchange sites, where people can receive clean needles and prevent the spread of infection; fentanyl test strips, which detect the presence of fentanyl in other drugs; and naloxone, a lifesaving medication that can reverse opioid overdoses.
All three are part of a public health approach called harm reduction, which is focused on reducing the risks of drug use. Instead of pushing abstinence, public health officials meet people where they are.
Harm reduction — along with increased public funding and greater societal understanding of addiction — has given Indiana health officials a reason to celebrate. In 2023, the number of Indiana residents who died of overdoses dropped by 19%.
But Black men do not appear to be benefiting from harm reduction initiatives to the same extent as others.
Reluctance rooted in history
Marion County Public Health Department officials know there is a problem.
“We’re clearly missing the mark,” said Madison Weintraut, who oversees the county health department’s harm reduction team. “We’re not reaching some part of the population.”
One reason is awareness. In 2022, the nonprofit Step Up surveyed 500 Marion County residents who injected drugs. Of those surveyed, 63% were unaware of the county’s safe syringe programs — despite advertisements at treatment centers and in emergency rooms. The majority of respondents were Black and many resided in 46218, a ZIP code without its own syringe exchange.
Indy’s Black residents are also generally unaware of efforts to distribute naloxone, according to a project from the Indiana University School of Public Health and nonprofit Overdose Lifeline.
And for those who were aware of harm reduction? Many said they were afraid to participate — because of a fear of police due to the association with drug use.
“We call it double stigma,” said Dong-Chul Seo, the lead researcher for the initiative. “A double stigma of being Black and using drugs.”
The worry is rooted in history.
Gina Fears, who has trained peer recovery coaches across the state, thinks back to the rise of cocaine use in the Black community in the 1970s — and then the War on Drugs that followed.
“We certainly tried to incarcerate our way out,” Fears said. “It did not work, it will not work.”
But even though harm reduction supplies are more available now, Fears believes reaching the Black population was never a priority. She said that’s because health officials, and many Black people, never thought opioids would be the community’s substance of choice.
“When we began to really look at the opioid epidemic, it was not because it was noticed in the Black community,” said Fears, who works for Mental Health America of Indiana. “It was because it was noticed in other communities.”
Now, public health officials are playing catch-up to reach the communities that need help the most. Fears emphasized peer support as a way to bring people into recovery and create community.
Her hope grows as she sees more Black people having conversations about mental health and substance use.
Yet while public health officials are approaching the opioid epidemic differently, that doesn’t mean the criminal justice system is.
Vague laws are a barrier to harm reduction
In Indiana, possessing a needle is a crime. And the legality of fentanyl test strips is murky.
In Marion County, organizations still give out harm reduction supplies. It’s one of eight counties in the state authorized to host syringe exchanges. Participants can get clean needles and reduce the spread of HIV and hepatitis.
“We are freeing up EMTs, police and first responders by giving folks who use drugs the tools to take care of themselves and others,” said Carrie O’Brien, who heads the weekly syringe exchanges program at the nonprofit Damien Center.
The Damien Center, Indiana’s oldest HIV/AIDS service organization, has multiple exchanges on the near east side in ZIP codes near 46218. But only about 13% of participants are Black, O’Brien said.
“We have to tell people what we are handing you right now is totally legal for us to give you, but as soon as you leave our building all bets are off,” O’Brien said. “Folks are scared to travel with these syringes because of the harsh punishments.”
Possessing a syringe to use drugs can be a Level 6 felony that can carry a sentence of up to two and a half years in prison.
In Marion County, the prosecutor’s office filed at least 206 cases charging people with possession of a syringe in 2023 and 2024, according to an office spokesperson — amounting to a new charge on average every four days.
That number is likely an undercount. It only contains cases where possession of a syringe was the lead charge.
Just 10% of those who were charged are Black, the data shows, compared to being about 30% of the population of Marion County.
That doesn’t necessarily ease any fears, though, nor does the data capture how many people were stopped, questioned or arrested by police.
Mirror Indy is awaiting a response to a public records request filed with the Indianapolis Metropolitan Police Department for the number of people arrested in connection with syringe possession in 2023 and 2024, as well as their racial demographics.
Now, Black residents are also hesitant to carry fentanyl test strips.
State law is unclear on whether test strips are illegal. Tools that test the “strength, effectiveness, or purity of a controlled substance” are considered paraphernalia chargeable as a Class C misdemeanor with up to 60 days in jail and a $500 fine to start.
Test strips, though, only identify the presence of a substance. It’s up to local police and prosecutors to interpret the law. A Marion County Prosecutor’s Office spokesperson said no one was charged in 2023 or 2024 for having a test strip.
A freshman state senator from Indianapolis hopes to pass legislation to make the law more clear, but acknowledges it’s been an uphill battle.
State Sen. La Keisha Jackson, a Democrat who represents 46218 and other parts of the east side, said misinformation and stigma about fentanyl test strips have stopped similar bills.
Jackson is hopeful this year will be different. She likened the test strips to at-home pregnancy tests.
“It just says yes or no, you’re pregnant,” Jackson said. “This is the same thing. It doesn’t tell you the potency of it or if there are any other drugs. It just says that it was in fact detected.”
She got the idea for Senate Bill 98 after attending a town hall focused on the opioid epidemic in the Black community. It took place at Martin University, a predominantly Black institution also located in 46218.
She said if the bill passes, it will save lives — but it needs to happen in tandem with more education around harm reduction.
Whether the bill even receives a hearing is up to another Indianapolis lawmaker inside a legislature that is controlled by a Republican supermajority.
State Sen. Aaron Freeman, a southside Republican, chairs the Senate Committee on Corrections and Criminal Law. He did not respond to multiple Mirror Indy phone calls and text messages seeking comment.
‘What can we do?’
While advocates and health officials see state law and the criminal justice system as barriers, they’re finding other ways to help Black men.
McGinty, the county coroner, has fought to make sure public funding is spent on solutions. It’s not just a professional passion for her, it’s also personal. She lost her son to an overdose in 2021.
“I began on that journey with Jimmy, as I call it, understanding what happens during the course of addiction,” McGinty said. “As a mother, I was interested in what can we do?”
When Marion County began receiving significant sums of money from national opioid settlements in 2023, for example, some went to the coroner’s office. Officials are using some of the money to provide free mental health support for Black families and to create an $800,000 grant program for community organizations focused on helping minority communities.
That includes Yvette Markey’s InTouch Outreach. Markey was born and raised in 46218. Like many people from here, the area holds a special place in her heart. In the warmer months, she hosts naloxone training in city parks.
It’s not just systemic barriers that have made Markey’s work more difficult. She said it has also been hard to convince older Black men to practice harm reduction because they’re set in their ways. But some progress has been made.
“They make sure that they have some naloxone in their bag, and the people that run with them have it,” Markey said. “And then they call regularly for it. We might pull up at the gas station, pull up at the liquor store, wherever they are.”
Harm reduction is an evidence-based approach, but it hasn’t been easy getting everyone on board.
For Nate Rush, it was easy to use drugs as an escape from his trauma: poverty, abuse and sexual assault. He started smoking marijuana at 12. By 17, he was using heroin.
“I found getting high as a temporary relief,” said Rush, 70. “Once I started, I couldn’t get enough.”
He said for many Black men, there is fear in admitting substance use or the need for mental health support. It can be seen as a sign of weakness.
Rush, who has been in recovery for more than 30 years, sees it differently. He has directed a recovery program, provided peer support and now trains other peer specialists.
Asking for mental health support is a sign of strength, Rush said.
“It actually means that you recognize you got some challenges and you need help,” he said.
‘I’m finally moving forward’
In 46218, Emmanuel Missionary Baptist Church is flipping the narrative that talking about mental health is taboo, especially in Black churches. The goal is to empower members by encouraging men to talk about their past — including substance use.
That includes James Miller, the man who has seen the crack cocaine and opioid epidemics strike at 46218 over the years.
He’s now nearing 18 years of recovery — and has become a licensed social worker — thanks to the church’s programs, including an addiction ministry for men with lived experiences.
“If I was talking about it from a faith perceptive, I’ll use Romans 12:2, you’re not conformed to this world, but being transformed by the renewing of your mind,” Miller said. “If I was talking to you from a clinical perspective, I would say this is like cognitive behavior therapy on steroids.”
There is even a transitional recovery house on property.
DeAngelo Gaines, 41, found the house through the state FSSA’s Recovery Works program. He appreciates that he can lean on the older men who oversee the house, including Miller.
“I’ve been to a therapist before,” he said. “You know, some white lady with a degree on the wall.”
He said it’s sometimes hard to connect with therapists. It’s easier to talk to the men from the church’s programs because of their shared lived experience.
And it helps the house is away from friends and family who might tempt him, he said. So he’s found consistency living there: doing chores, setting goals and the twice-weekly house meetings.
“I’m really happy,” Gaines said. “It is making me feel good. I feel like I’m finally moving forward.”
Darian Benson and Mary Claire Molloy wrote this article for Mirror Indy.
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By Taylor Sisk for KFF Health News.
Broadcast version by Nadia Ramlagan for West Virginia News Service reporting for the KFF Health News-Public News Service Collaboration
More than three years have passed since federal health officials arrived in central Appalachia to assess an alarming outbreak of HIV spread mostly between people who inject opioids or methamphetamine.
Infectious disease experts from the Centers for Disease Control and Prevention made a list of recommendations following their visit, including one to launch syringe service programs to stop the spread at its source. But those who've spent years striving to protect people who use drugs from overdose and illness say the situation likely hasn't improved, in part because of politicians who contend that such programs encourage illegal drug use.
Joe Solomon is a Charleston City Council member and co-director of SOAR WV, a group that works to address the health needs of people who use drugs. He's proud of how his close-knit community has risen to this challenge but frustrated with the restraints on its efforts.
"You see a city and a county willing to get to work at a scale that's bigger than ever before," Solomon said, "but we still have one hand tied behind our back."
The hand he references is easier access to clean syringes.
In April 2021, the CDC came to Charleston - the seat of Kanawha County and the state capital, tucked into the confluence of the Kanawha and Elk rivers - to investigate dozens of newly detected HIV infections. The CDC's HIV intervention chief called it "the most concerning HIV outbreak in the United States" and warned that the number of reported diagnoses could be just "the tip of the iceberg."
Now, despite attention and resources directed toward the outbreak, researchers and health workers say HIV continues to spread. In large part, they say, the outbreak lingers because of restrictions state and local policymakers have placed on syringe exchange efforts.
Research indicates that syringe service programs are associated with an estimated 50% reduction in HIV and hepatitis C, and the CDC issued recommendations to steer a response to the outbreak that emphasized the need for improved access to those services.
That advice has thus far gone unheeded by local officials.
In late 2015, the Kanawha-Charleston Health Department launched a syringe service program but shuttered it in 2018 under pressure, with then-Mayor Danny Jones calling it a "mini-mall for junkies and drug dealers."
SOAR stepped in, hosting health fairs at which it distributed naloxone, an opioid overdose reversal drug; offered treatment and referrals; provided HIV testing; and exchanged clean syringes for used ones.
But in April 2021, the state legislature passed a bill limiting the number of syringes people could exchange and made it mandatory to present a West Virginia ID. The Charleston City Council subsequently added guidelines of its own, including requiring individual labeling of syringes.
As a result of these restrictions, SOAR ceased exchanging syringes. West Virginia Health Right now operates an exchange program in the city under the restrictions.
Robin Pollini is a West Virginia University epidemiologist who conducts community-based research on injection drug use. "Anyone I've talked to who's used that program only used it once," she said. "And the numbers they report to the state bear that out."
A syringe exchange run by the health department in nearby Cabell County - home to Huntington, the state's largest city after Charleston - isn't so constrained. As Solomon notes, that program exchanges more than 200 syringes for every one exchanged in Kanawha.
A common complaint about syringe programs is that they result in discarded syringes in public spaces. Jan Rader, director of Huntington's Mayor's Office of Public Health and Drug Control Policy, is regularly out on the streets and said she seldom encounters discarded syringes, pointing out that it's necessary to exchange a used syringe for a new one.
In August 2023, the Charleston City Council voted down a proposal from the Women's Health Center of West Virginia to operate a syringe exchange in the city's West Side community, with opponents expressing fears of an increase in drug use and crime.
Pollini said it's difficult to estimate the number of people in West Virginia with HIV because there's no coordinated strategy for testing; all efforts are localized.
"You would think that in a state that had the worst HIV outbreak in the country," she said, "by this time we would have a statewide testing strategy."
In addition to the testing SOAR conducted in 2021 at its health fairs, there was extensive testing during the CDC's investigation. Since then, the reported number of HIV cases in Kanawha County has dropped, Pollini said, but it's difficult to know if that's the result of getting the problem under control or the result of limited testing in high-risk groups.
"My inclination is the latter," she said, "because never in history has there been an outbreak of injection-related HIV among people who use drugs that was solved without expanding syringe services programs."
"If you go out and look for infections," Pollini said, "you will find them."
Solomon and Pollini praised the ongoing outreach efforts - through riverside encampments, in abandoned houses, down county roads - of the Ryan White HIV/AIDS Program to test those at highest risk: people known to be injecting drugs.
"It's miracle-level work," Solomon said.
But Christine Teague, Ryan White Program director at the Charleston Area Medical Center, acknowledged it hasn't been enough. In addition to HIV, her concerns include the high incidence of hepatitis C and endocarditis, a life-threatening inflammation of the lining of the heart's chambers and valves, and the cost of hospital resources needed to address them.
"We've presented that data to the legislature," she said, "that it's not just HIV, it's all these other lengthy hospital admissions that, essentially, Medicaid is paying for. And nothing seems to penetrate."
Frank Annie is a researcher at CAMC specializing in cardiovascular diseases, a member of the Charleston City Council, and a proponent of syringe service programs. Research he co-authored found 462 cases of endocarditis in southern West Virginia associated with injection drug use, at a cost to federal, state, and private insurers of more than $17 million, of which less than $4 million was recovered.
Teague is further concerned for West Virginia's rural counties, most of which don't have a syringe service program.
Tasha Withrow, a harm reduction advocate in bordering rural Putnam County, said her sense is that HIV numbers aren't alarmingly high there but said that, with little testing and heightened stigma in a rural community, it's difficult to know.
In a January 2022 follow-up report, the CDC recommended increasing access to harm reduction services such as syringe service programs through expansion of mobile services, street outreach, and telehealth, using "patient-trusted" individuals, to improve the delivery of essential services to people who use drugs.
Teague would like every rural county to have a mobile unit, like the one operated by her organization, offering harm reduction supplies, medication, behavioral health care, counseling, referrals, and more. That's an expensive undertaking. She suggested opioid settlement money through the West Virginia First Foundation could pay for it.
Pollini said she hopes state and local officials allow the experts to do their jobs.
"I would like to see them allow us to follow the science and operate these programs the way they're supposed to be run, and in a broader geography," she said. "Which means that it shouldn't be a political decision; it should be a public health decision."
Taylor Sisk wrote this story for KFF Health News.
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