Night lingers in Appalachia, but there are rays of sunlight

Harry Caudill talked with U.S. Sen. Robert F. Kennedy
during his visit to Eastern Kentucky in February 1968.

In 1963, Harry Caudill of Letcher County published Night Comes to the Cumberlands: A Biography of a Depressed Area, a book that brought national attention to poverty in Appalachia and spurred the War on Poverty. Fifty years later, as part of a year-long series, the Lexington Herald Leader is examining the challenges that Kentucky Appalachians still face on their path to progress, and the story of heartbreak and hope includes the region's contentious battle with drug abuse.

From 2000 to 2010, the number of drug-overdose deaths in Kentucky rose a staggering 296 percent, highlighting the state's drug abuse epidemic that now kills more than 1,000 Kentuckians a year. But communities have started to rise up and fight back against this lethal weapon, and for the first time in 10 years, deaths from prescription-drug abuse in Kentucky declined last year.

Still, the state's highest rates of overdose deaths are consistently found in Eastern Kentucky, where chronic poverty and economic hardships remain and numerous factors make it one of the worst areas in the nation for prescription drug abuse, experts say. Poverty is at the top of the list, reports Estep.

Click here for an interactive version of this map, with individual county data.

Social rank is also a key predictor of drug abuse, which consider how people see their place in the world and their ability to improve their lot, and many people in Eastern Kentucky rank low because of chronic poverty, Robert Walker, a researcher at the Center for Drug and Alcohol Research at the University of Kentucky, told Estep: "It's the belief that I can't do anything to fix this or make my life any better. That is a profound risk condition for drug abuse."

Another factor was the region's chronic health problems, reports Estep. It is well documented that Appalachians suffer from disproportionately poor health and have increased risks of adverse health outcomes, compared to the rest of the nation and the rest of the state; many people addressed these problems with drugs, which unintentionally led to drug addiction.

Public assistance also played a role in the developing drug abuse problem. "Medicaid recipients can get prescription drugs at little cost, and some people then resell them for cash," Estep writes. For example, in Clay County, which has the third highest rate of drug overdoses per 100,000 people, 42 percent of residents were eligible for Medicaid in fiscal 2012, compared with 18.8 percent statewide.

Eastern Kentucky's ongoing battle against pills started well before a decade ago as the area suffered economic devastation of the Great Depression and doctors handed out pills to mask pain for injured coal miners and the sick poor, Caudill wrote, adding that the drudgery of coal-camp life also drove the use of pills.

Fifty years later, Estep writes, "Rising drug abuse added misery to the economic malaise, and corruption among public officials inflamed the drug problem. Drug dealers helped power brokers buy votes, then benefited as some local police and other officials turned a blind eye to their illicit sales."

A story of heartbreak and hope in Manchester

The story of one recovering addict, Melanda Adams, embodies these forces. Her home Clay County was at the center of the prescription-drug explosion, and her father, the county school superintendent, was convicted in a vote-buying scheme that he said he joined to help oust officials who were protecting drug dealers.

Social use of alcohol and drugs led Adams to start abusing drugs, but by the time she was 23, she was snorting as much as $800 worth of OxyContin pills and methamphetamine a day, she told Estep, adding that people start abusing drugs for a variety of reasons, and the shame of their addiction then becomes part of the reason to keep abusing them. "Your soul is tormented, really," she said.

Her craving for drugs led Adams to steal the ingredients that a drug dealer had provided her boyfriend to make a batch of meth, for which she suffered an almost fatal beating that still didn't curb her addiction. After stints in jail and in rehab, police found her agitated and bleeding in her home. She remained in jail for three months, where she suffered from the sharp pain of detoxification and withdrawal. Then she started on the road to recovery, reports Estep.

Fueling problems of addiction faced by thousands, Eastern Kentucky counties used corrupt relationships with local police and political officials in their illegal businesses, which included selling drugs.

Jurors convicted Adams' father, school Supt. Douglas Adams of vote fraud in a number of elections. As part of his defense, Adams said his motivation for getting involved in the most notorious election at issue in the trial, the 2002 primary for county clerk, was that the incumbent, Jennings B. White, had been protecting drug dealers, reports Estep. Adams said he was fighting against White to save his daughter and others who had fallen victim to drugs.

In the late 1990's, Congress designated Eastern Kentucky as a High Intensity Drug Trafficking Area, which led to efforts that helped dry up the county's drug rings. The FBI led investigations, "leveraging charges against drug dealers to pursue investigations of local officials," reports Estep. In the end, more than a dozen public officials or election offers in Clay County had been convicted. This shook up the local political structure, which was necessary for the community to take a stand against drugs, Estep reports.

Now, as a result of greater community awareness, activism against drugs, and targeted law enforcement, drug overdose deaths in Clay County have fallen from 43 in 2011 to 27 in 2012. Coroner Danny Finley also credits this reduction to better practices by many doctors, and new state laws that have cracked down on pain clinics and over-prescribing doctors, reports Estep.

While the fight against drugs is never over, Melanda Adams is proof that there's hope in Manchester and hope for Clay County. "She has clear eyes, a big laugh and a feisty 6-year-old daughter," reports Estep. She runs her own convenience store and says its important for drug addicts who feel trapped to know that they are more than just addicts. "There is a chance," she told Estep. "Give 'em that hope."

FDA wants to limit number of hydrocodone refills available without another doctor visit; approves pure version of drug

"The Food and Drug Administration on Thursday recommended tighter controls on how doctors prescribe the most commonly used narcotic painkillers, changes that are expected to take place as early as next year," Barry Meier reports for The New York Times. "Drugs at issue contain a combination of hydrocodone and an over-the-counter painkiller like acetaminophen or aspirin and are sold either as generics or under brand names like Vicodin or Lortab." (Associated Press photo by Toby Talbot)

"Doctors use the medications to treat pain from injuries, arthritis, dental extractions and other problems," Meier writes. "The change would reduce the number of refills patients could get before going back to see their doctor. Patients would also be required to take a prescription to a pharmacy, rather than have a doctor call it in. The new regulations would reduce by half, to 90 days, the supply of the drug a patient could obtain without a new prescription."

On Friday, the FDA announced it had approved a stronger version of hydrocodone, Zohydro ER, for patients who require 24-hour, long-term pain medication. "The new version is the first pure hydrocodone drug approved in the U.S.," ABC News reports. "Hydrocodone is currently sold in combination pills like Vicodin to treat pain from injuries, surgery, arthritis and migraines." Activists against prescription-drug abuse criticized the decision.

U.S. Rep. Hal Rogers of Kentucky's 5th District "said on Friday that top FDA officials had recently assured him they would only approve new opioids like Zohydro if they were marketed in formulations intended to deter abuse," Meier and Eric Lipton report. "OxyContin is now formulated that way, but Zohydro, which is contains hydrocodone without acetaminophen, is not. Its producer, Zogenix, says it will closely monitor use of the drug." Rogers told the Times, “It is like the original OxyContin, so that is real problematical.”        

More than 6.1 million Americans abuse prescription pills, and last year there were 22,133 prescription drug deaths. The problem is most rampant in Central Appalachia, including Eastern Kentucky.

In 2011, about 131 million prescriptions for 47 million patients, or about five billion pills, were written for medications containing hydrocodone, Meier notes. "Prescription drugs account for about three-quarters of all drug overdose deaths in the United States, with the number of deaths from narcotic painkillers, or opioids, quadrupling since 1999, according to federal data." (Read more)

Kentucky ranks high in prescription drug abuse, but also is a national leader in efforts to fight it, state-by-state analysis says

By Molly Burchett
Kentucky Health News

A new report finds many states do not have effective strategies in place to fight prescription drug abuse, but Kentucky scores high on most prevention measures, indicating that the state is working hard to combat the problem.

The Trust for America's Health report found that Kentucky, along with Massachusetts, New York and Washington, scored 9 out of 10 possible indicators of promising strategies to fight prescription drug abuse. Only two states, New Mexico and Vermont, scored 10 out of 10, while 28 states and Washington, D.C., scored 6 or less.

The only indicator Kentucky lacks is a Good Samaritan law, which would provide a degree of immunity from criminal charges or mitigation of sentencing for individuals who seek to help themselves or others experiencing an overdose, says the report. Such laws are in place in 17 states and D.C.

Prescription drug abuse has become a top national and state public health concern. Since 1999, rates have doubled in 29 states, tripled in 10 and quadrupled in four, including Kentucky. The state has the third highest drug-overdose death rate in the country, with 236 people per million people suffering overdose fatalities in 2010.

"Prescription drugs can be a miracle for many, but misuse can have dire consequences. The rapid rise of abuse requires nothing short of a full-scale response - starting with prevention and education all the way through to expanding and modernizing treatment," said Dr. Jeffrey Levi, executive director of Trust for America's Health, in a news release. "There are many promising signs that we can turn this around - but it requires urgent action."

To develop scores for the report, the organization worked with public-health, clinical, injury-prevention, law-enforcement and community organization experts to review a range of national recommendations and examine the 10 indicators. Kentucky received 9 out of 10 points because it:

• Has an active prescription drug monitoring program
• Requires utilization of monitoring program by prescribers
• Is participating in Medicaid expansion, which helps expand coverage of substance abuse services and treatment
• Has a "doctor shopping" law specifying that patients are prohibited from withholding information about prior prescriptions from their healthcare provider
• Requires or recommends prescriber education
• Has a rescue drug law to expand access to and use of naloxone, a prescription drug that can help counteract an overdose
• Has a law requiring health care providers to physically examine patients (or have a bona-fide physician-patient relationship) before prescribing a controlled substance
• Has a law requiring or permitting a pharmacist to require an ID prior to dispensing a controlled substance
• Has a pharmacy lock-in program under the state's Medicaid plan where individuals suspected of misusing controlled substances must use a single prescriber and pharmacy.

Although a cause-and-effect relationship cannot be determined, there are indications these efforts and strategies may be having a positive impact on reducing prescription drug abuse. A recent survey found fewer Kentucky teenagers said last year that they used prescription drugs without a doctor's direction, and this report indicates steps forward in the fight against abuse. There is still much more work to be done.

"We must use the best lessons we know from other public health and injury prevention success stories to work in partnership with clinical care, law enforcement, the business community, community-based organizations, and other partners to work together to curb this crisis," said Andrea Gielen, director of the Johns Hopkins Center for Injury Research and Policy, in a news release. Click here for a full description of the indicators, state scores and the full report.

Middle- and high-school students invited to create 30-second videos discouraging prescription drug abuse, win prizes in contest

Attorney General Jack Conway and his Keep Kentucky Safe partners invite Kentucky middle- and high-school students to compete in the annual Prescription Drug Abuse Prevention Public Service Announcement contest.

Contestants create a PSA to warn Kentucky kids about the dangers of prescription drug abuse. "I want our young people to know that it is never okay to take a prescription pill that was not prescribed to them by their doctor,"  Conway said in a press release.  "These are some of the most addictive substances on the planet, and if taken in the wrong combination, or with other substances, they can kill you."

Participating students should produce a 30-second video showing the perils of prescription drug abuse and submit it by Dec. 6.  Winners will be announced Dec. 13. The first place winner will receive an Apple iPad, donated by the National Association of Drug Diversion Investigators, and the runner-up will receive a $100 Amazon.com gift card donated by the Kentucky Pharmacists Association.

Other partners in the contest are the Kentucky Office of Drug Control Policy, Operation UNITE and concerned parents, Dr. Karen Shay and Mike Donta.

Instructions for submission can be found here.  Examples of  winning videos can be found by clicking here for the 2012 winning video and here for the 2012 second place video.

Fewer teens report using tobacco and abusing prescription drugs, but some attribute latter trend to increase in heroin use

By Melissa Patrick and Melissa Landon
Kentucky Health News

Fewer Kentucky teenagers said last year that they used prescription drugs without a doctor's direction, or tobacco, than in the last such survey. But some addiction experts worry that prescription-drug abuse has dropped since 2010 because young people are using heroin instead.

According to a state survey of young people in 88 percent of Kentucky's school districts, their improper use of prescription drugs has declined steadily since 2004, with the greatest decrease between 2010 and 2012.

In 2012, prescription-drug abuse among high-school seniors dropped almost a third, to 9 percent from 13.1 percent in 2010. Among sophomores, it dropped to 7.6 from 11.3 percent; among eighth graders, to 2.9 from 5.3 percent; and among sixth graders, to 0.7 from 1.8 percent.

Some feel there's a disconcerting reason for the decline in prescription-drug abuse. "My concern is the unintended consequence is that people have switched to heroin," Karyn Hascal, president of The Healing Place recovery program in Louisville, told Laura Ungar of The Courier-Journal. "The problem is addiction, not the drug of the day." Hascal said The Healing Place has seen addicts who started out using other types of drugs but eventually turned to heroin as a cheaper option.

Although the survey didn't measure heroin use among teens, it asked if any of their four best friends had used illegal drugs in the past year. The results showed a continued slow decline, to 12.2 percent and 15 percent, respectively, among high-school sophomores and seniors.

"Over the past four years we have significantly stepped our efforts to address prescription-drug abuse," Connie Smith, manager of the Substance Abuse Prevention Branch of the state Division of Behavioral Health, said in a news release. "All of our regional prevention centers have been working very hard with their local coalitions to plan and implement effective programs to reduce illegal use of prescription drugs among youth."

The federally funded survey measures use of drugs, tobacco and inhalants; mental health; school safety issues; and gambling. The division said 153 of the 174 school districts at the time took part, with 122,718 students participating. The survey also measures concerns such as school safety issues and gambling. The report said that almost every other area studied had lower numbers in 2012 than in 2008

The survey asked several questions about tobacco. Among high-school seniors, 25.6 percent reported smoking in the previous 30 days, down from 29.4 percent in 2010. Among sophomores, smoking dropped to 18 percent from 21.7 percent; among eighth graders, to 8.7 from 10.7; and among sixth graders, to 2 percent from 2.5 percent in 2010.

Use of smokeless tobacco by high-school students declined in 2012, after rising in each survey from 2006 to 2010. Among seniors, it fell to 15.7 percent from 17.5 percent in 2010; among sophomores, it dropped to 13.4 percent from 15.9 percent. Among younger students, an eight-year decline continued, but at a sharper rate since 2010.

Marijuana use among high-schoolers declined slightly after increasing in 2008 and 2010. The survey also showed a steady decrease in the risk that teenagers associate with occasional use of marijuana. For the full report, click here.

Kentucky Health News is an independent service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Fighting prescription drug abuse? Save your spot for 'The Difference Faces of Substance Abuse' conference Jan. 28-29

Early registration is open for the 2014 Different Faces of Substance Abuse Conference, which seeks to build collaborations and partnerships among Kentucky community members to address the state's prescription-drug abuse problem at the local level.

The conference, to be held Jan. 28-29 at the Griffin Gate Marriott in Lexington, will address all aspects of substance abuse and misuse, and provide opportunities for networking and professional development. Continuing education credits are available for alcohol and drug counselors, social workers, licensed professional counselors and marriage and family therapists.

Topics for Jan. 28 include faces and voices of recovery, children of substance abuse, and drug-use trends and updates. Michael Barry, CEO of People Advocating Recovery, will be the keynote speaker and will talk about combating the stigma of substance abuse.

On Jan. 29, Jennifer Havens, epidemiologist for the University of Kentucky's Center on Drug and Alcohol Research, will discuss her research about the effect of prescription painkiller use in Eastern Kentucky, followed by a session during which stories of recovery will be shared. Participants can also attend three of the following nine breakout sessions:

Registering early guarantees participants one spot among the 250 available. If registration is received by Nov. 1, it costs $100 per person; after Nov. 1, if space remains, the fee increases to $150 per person. Click here to register.

The conference is a partnership of UK's Cooperative Extension Service and state drug abuse prevention gaencies, says its website. Part of its mission is to plan and implement an educational conference for community partners combating drug abuse problems to improve strategies for minimizing and preventing drug abuse in Kentucky counties.

Conway says ruling in his Oxycontin lawsuit means he will seek settlement of $100 million or more

Attorney General Jack Conway says he wants Purdue Pharma to settle for $100 million or more after it missed a deadline to respond to his arguments in his lawsuit over the marketing of Oxycontin, Nick Strom reports for cn|2, a news service of Time Warner Cable. After Purdue Pharma failed to respond to a court motion, "all the admissions the commonwealth sought in the case were deemed admitted" by the circuit judge hearing the case in Pike County.

"Judge Steven Combs ruled Monday that Purdue could not withdraw those admissions which include that the drug maker: misrepresented and/or concealed the addictive nature of OxyContin, knew OxyContin was being abused and wasn’t being used for its stated purpose, continued to market and promote OxyContin despite knowing that, and encouraged physicians to overprescribe the drug," Storm reports. Conway told him, "I expect that a jury would be very very harsh on Purdue Pharma. I’m not going to be really negotiating much less or below nine figures. I want to see something well into nine figures.” (Read more)

Purdue Pharma has been blamed for starting, in Central Appalachia, the national epidemic of prescription-painkiller abuse and deaths. More than 1,000 Kentuckians die each year from prescription overdoses, the sixth highest rate in the country. Forbes ranked the Kentucky as the fourth most medicated state, according to Conway's office. More Kentuckians die from overdoses than in traffic accidents. (Read more) Map by Kentucky Justice and Public Safety Cabinet:

FDA changes painkiller labels to warn expectant mothers, after 2,500% growth in number of Ky. babies born addicted to drugs

The U.S. Food and Drug Administration (FDA) announced Tuesday drug-safety labeling changes and new post-market study requirements for all extended-release and long-acting opioids, and Kentucky political leaders applauded these measures to curb prescription drug abuse.

Long-acting opioids are intended to treat pain but may also lead to drug abuse, dependence or other complications if taken during pregnancy or misused. Now, as part of new FDA safety measures, the boxed warning labels on these drugs will warn expectant mothers that “the use of the products during pregnancy can result in neonatal opioid withdrawal syndrome (NOWS),” says the FDA release.

NOWS is among a group of problems called Neonatal Abstinence Syndrome (NAS) that occur in a newborn exposed to addictive drugs while in the mother’s womb. The baby's addiction can lead to birth defects, low birth weight, sudden infant death syndrome and other health conditions.

Attorney General Jack Conway and his counterparts in other states asked the FDA to act after several states reported an increase in the number of babies born addicted to prescription drugs. In Kentucky, "Instances of NAS have risen 2,500 percent over the past decade – from 29 incidents in 2001 to 730 in 2011," says a Conway release.

“I applaud the FDA for making this change that will better alert physicians and patients about the dangerous consequences of using these powerful prescription painkillers during pregnancy,” Conway said. Also as part of these safety labeling changes, certain educational materials for patients and health care professionals will be modified to reflect the new labeling.

U.S. Senate Republican Leader Mitch McConnell also praised the FDA's decision, saying it is a positive step forward in the fight against the state's prescription drug abuse problem.

Because little is known about the risks of long-term use of long-acting opioids, the FDA is also requiring the drug companies that make these products to conduct further studies and clinical trials to assess the known serious risks of misuse, abuse, increased sensitivity to pain (hyperalgesia), addiction, overdose and death, says the FDA.

"Altogether, the actions we're now announcing are part of FDA's efforts to make opioids as safe as possible for those who need them," said Dr. Douglas Throckmorton, deputy director of regulatory programs in FDA's Center for Drug Evaluation and Research. "This is not the first or last initiative, and we will continue supporting broader efforts to solve the serious public health problems associated with the misuse and abuse of opioids."

As heroin use increases in Kentucky, new report shows its strong connections to abusers of prescription pain medicines

Kentucky's law-enforcement agences, policymakers and public-health advocates have taken serious measures to curb the state's rampant prescription drug abuse problem, and recent state and national news stories suggest that the reduced supply of these painkillers, at least the ones in a non-crushable form, has driven pill abusers to heroin. Now there's research to support this theory.

Non-medical use of prescription pain medication may raise the risk of heroin use, says a new report by the Substance Abuse and Mental Health Services Administration. SAMHSA says people aged 12 to 49 who previously used prescription pain relievers non-medically were 19 times more likely than non-abusers to have started using heroin over the past year.

Proving the connection, the converse was true: Almost 80 percent of those who started to use heroin over the past year had abused prescription pain relievers. These findings are part of a larger effort to identify some risk factors of heroin use, and also to understand the "dependence and initiation that have occurred in the past few years," says a SAMHSA news release.

Heroin use, which had already become a problem in Northern and Central Kentucky, has been spreading to the Southern and Eastern Kentucky. The drug is becoming more popular throughout the state and nation because it is cheaper and easier to get than prescription painkillers, specifically opioid medications.

The number of U.S. heroin users has increased by about 60 percent from 2007 to 2011, says the 2011 National Survey on Drug Use and Health.  And while some can argue for the benefits of prescription medication, that same risk-benefit analysis doesn't apply to heroin, which has only risk.

The SAMHSA report offers another risk of prescription drugs: “Prescription pain relievers when used properly for their intended purpose can be of enormous benefit to patients, but their nonmedical use can lead to addiction, serious physical harm and even death,” said Dr. Peter Delany, director of SAMHSA’s Center for Behavioral Health Statistics and Quality. “This report shows that it can also greatly increase an individual’s risk of turning to heroin use – thus adding a new dimension of potential harm.” 

Kentucky expands list of permanent locations for safe disposal of unneeded or expired prescription medications

Gov. Steve Beshear announced today that Kentucky now has 149 permanent prescription drug disposal locations in 97 counties where Kentuckians can safely dispose of unused or expired medications in order to help curb the state's prescription drug abuse problem.

“The effects of prescription drug abuse are devastating to our families and our communities,” Beshear said in a news release. “Medications, once they are no longer needed for their prescribed purposes, should be disposed of properly to reduce their risk of being diverted and abused . . . "

Counties with permanent disposal boxes are shown on the map below in green. The boxes are monitored to ensure safe drug disposal and are located in law enforcement buildings. There are two pending locations, one in Ohio County and one in Franklin County, as shown in light blue. The 23 counties in white do not have permanent disposal locations.

“One in five of our Kentucky teens has abused prescription medication for an off-label purpose, and that abuse is starting in the home when children have access to their parents’ unused or expired pain medications,” Attorney General Jack Conway said in the news release.

The disposal boxes are funded by Kentucky Agency for Substance Abuse Policy, Operation Unite, Kentucky League of Cities and state and local law enforcement agencies, says the release.  Click here for a complete listing of locations and hours of operation.

Beshear, Stumbo credit law for reducing prescription-drug deaths, but reduction was far outnumbered by rise in heroin fatalities

Deaths from prescription-drug abuse in Kentucky declined last year for the first time in a decade, and top state officials are crediting a law passed by that year's General Assembly.

However, passage of the law has prompted many drug users to switch to heroin, and the increase in heroin deaths (121) was much larger than the decline in prescription-drug fatalities (19).

"Autopsied overdose deaths attributed to the use of heroin increased 550 percent over the previous year, from 22 in 2011 to 143 cases in 2012," a release from Gov. Steve Beshear's office said. The decline in prescription-drug deaths was 1.9 percent, from 1,023 to 1,004, but the release said nothing else about the new problem and did not link it to the 2012 law that cracked down on abuse of prescription drugs.

“The impact of this bill can’t be measured just in the numbers of pills we’ve kept off the streets,” Beshear said in the release. “This bill, I believe, has literally saved lives in Kentucky.”

House Speaker Greg Stumbo, D-Prestonsburg, said, “I’m proud of the results, and the fact that other states are following our lead. Our goal now is to build on these gains and to improve access to treatment, so that abusers can truly escape this deadly cycle once and for all.”

The first quote in John Cheves' Lexington Herald-Leader story came from Van Ingram, executive director of the state Office of Drug Control Policy, which the new law required to begin publishing annual reports on drug overdose fatalities in the state: "There's no great victories here. I'm glad that we're at least seeing a leveling off and some small decline. I've been in this job for nine years and have watched a steady rise in numbers that whole time."

Top counties: Leslie, Clinton, Clay, Estill, Floyd, Nicholas, Perry, Whitley, Monroe (Herald-Leader)

The law, known as House Bill 1 before Beshear signed it, required pain-management clinics to be owned by a licensed medical provider, required all drug prescribers to register with a state monitoring system, and reduced the number of prescriptions for heavily abused controlled substances, a release from the governor's office said.

"Since the law was passed, 20 non-physician-owned pain management facilities have closed," the release said. The "Cabinet for Health and Family Services has issued cease-and-desist letters to another four pain management facilities operating outside the scope of state regulations."

"Of the 1,004 overdose fatalities in 2012, 888 were found to be unintentional, 59 were suicides and 57 remain undetermined," the release said. "Alprazolam (Xanax) remained the most-detected controlled substance in overdose deaths, present in 41 percent of all autopsied cases. Morphine was found in 32 percent of autopsies, followed by hydrocodone at 26 percent and oxycodone at 24 percent."

"Autopsies often found more than one drug present," Cheves notes. "The youngest overdose fatality was 16; the oldest was 72. Slightly more than half of the victims were men. Leslie County (population 11,170) reported the state's top per-capita rate of an annualized 85 fatal overdoses for every 100,000 people. The county had 11 overdose deaths in 2012, up from eight the previous year. In descending order, the other leading counties were Clinton, Clay, Estill, Floyd, Nicholas, Perry, Whitley, Monroe and Magoffin." (Read more)

Read more here: http://www.kentucky.com/2013/07/26/2734183/kentucky-drug-deaths-decline-slightly.html#storylink=cpy

As prescription painkillers become harder to get and abuse, heroin replaces them in Eastern and Southern Kentucky

Heroin use, which has been a problem in Northern and then Central Kentucky after the state began cracking down on prescription painkillers last year, has been spreading to the Southern and Eastern parts of the state. Heroin is becoming more popular throughout Kentucky because it is cheaper and easier to get than prescription painkillers, specifically opioid medications, reports Valarie Honeycutt Spears of the Lexington Herald-Leader.

While an 80-milligram OxyContin costs between $60 to $100 a pill on the black market, heroin costs $45 to $60 for a multiple-dose supply, reports The Partnership at Drugfree.org.  With national and state efforts to curb prescription drug abuse, including the reformulation of OxyContin that makes the drug more difficult to crush and snort, heroin can also be easier to obtain and abuse.

As drug users turn from prescription drugs to heroin to get their high, Northern Kentucky and major cities like Lexington and Louisville are struggling to address the problem, says an Operation UNITE press release. Operation UNITE is a regional anti-drug coalition fighting substance abuse in Southern and Eastern Kentucky counties (map).

Most Southern and Eastern Kentucky counties are just beginning to see the signs of heroin use, says the release. Dan Smoot, CEO of Operation Unite, told Spears that heroin’s spread throughout Kentucky was inevitable. “We knew it was coming. We just didn’t know when it would hit,” he said.

Rowan County was hit before most Eastern Kentucky counties, said Smoot; the most recent example of increased heroin use occurred July 9, when Operation UNITE agents arrested a known prescription drug trafficker attempting to bring a large quantity of heroin into Beattyville, says the release.

Uncertainty about what heroin users are actually getting makes the drug especially dangerous, says Paul Hays, law-enforcement director for Operation UNITE. “You don’t know the purity of the heroin,” he said in the release. “Dealers will often ‘cut’ the drug with other substances in order to boost their profits. There’s no way the public knows what they’re shooting up.”

This increased risk can be deadly, and although there's no evidence of an increase in heroin overdose deaths in Eastern Kentucky, a task force has been created to address this fatal problem in Lexington. There have been 29 heroin overdose deaths in Fayette County so far this year, seven more than the amount of overdose deaths in all opf 2012, Fayette Coroner Gary Ginn told the newspaper.

Read more here: http://www.kentucky.com/2013/07/22/2726235/heroin-problem-surfaces-in-southern.html#storylink=cpy

Kentucky, insurance companies are applying lessons learned in state's hurried transition to managed-care Medicaid

By Molly Burchett
Kentucky Health News

Gov. Steve Beshear rushed to transplant Medicaid into a new bed called managed care, hoping the new medium would save money and improve health, but his administration didn't take time to condition the soil, fertilize the ground or oil the machinery in 2011. This month, managed-care company Kentucky Spirit proved to be the self-plucking bad weed, fleeing the state as it cited unbearable costs.

Kentucky’s hurried transition to Medicaid managed care has been anything but smooth for many doctors, hospitals and other health-care providers. They have complained about late payments and burdensome reimbursement processes.

It's also not been smooth for the state or the managed-care firms, which are subsidiaries of insurance companies. There have been court battles, tension-filled negotiations, dropped contracts, allegations of a contract breach and now the departure of Kentucky Spirit, pushing its 125,000 clients to one of the other two companies operating outside the Louisville region.

Most important, patients have suffered from the rapid switch and ensuing wrangles.  They complain that prescriptions previously covered by the old "fee for service" system are now denied as not being"medically necessary" by managed-care firms, which the state pays a set fee per person. Patients in rural areas complain because they must drive long distances to find providers in their Medicaid company's network.

But there have been improvements in delivery of health care, particularly in the areas of vaccinations and other preventive services, says the state Cabinet for Health and Family Services. Those include a 33 percent increase in flu vaccinations and an increase in immunizations for children, more well-child visits, increased smoking-cessation consultation, and more than a 50 percent increase in diabetes testing, cabinet spokeswoman Jill Midkiff said.

State and companies made some missteps

Amid those encouraging signs for the future, most of the news about managed care in the past 10 months has been about Kentucky Spirit's potential departure  which occurred July 6. The cabinet is preparing legal action to seek damages from Kentucky Spirit for abandoning its contract; the company, a subsidiary of St. Louis-based Centene Corp., says it didn't break the contract and took every step possible to make a smooth and orderly transition. The state Court of Appeals ruled that Kentucky Spirit could end its contract without a two-month transition period for patients because the state had plenty of time to make arrangements for the company's departure.

It's not clear that the state can recoup damages, or lost taxpayer money, from Kentucky Spirit, though it is having to pay the other two companies more because Kentucky Spirit was initially the low bidder for a managed-care contract. CoventryCares and WellCare of Kentucky are paid an average of about $100 more per month per Medicaid patient.

When Kentucky Spirit first threatened to leave in October 2012, it said it was losing money due to "faulty data" the state provided during the bid process. The two other companies received the same information.

"There were no flaws in the state's data book," CoventryCares CEO Michael Murphy told Kentucky Health News. But he said the companies miscalculated because the data book didn't refer to retroactive payments. That led to a loss of $50 million for Coventry in the first quarter of 2012, he said. Now, he added, the company has a greater understanding of the system.

WellCare, asked if the state provided faulty data, did not answer as definitively. "Medicaid programs are expansive and complex, and it is not unusual for any state to provide data during a RFP [request for proposals] process that may have anomalies or other issues that could negatively impact rates if left unaddressed over time," said Mike Minor, president of the firm.

Schedule seemed politically influenced

Both companies said the state's transition to managed care was rapid and taught difficult lessons. That raises questions about whether haste made waste. Kentucky Spirit blames the state for its losses, and providers blame managed care companies for reimbursement issues, but evidence continues to clearly indicate two problems: too little time and money.

The state has been using managed care in the Louisville region through the not-for-profit Passport Health Plan since the late 1990s, and had long considered expanding it to other parts or all of the state to save money as Medicaid costs burgeoned, especially during the Great Recession.

Gov. Steve Beshear proposed statewide managed care in the budget he gave the General Assembly in early 2011, called a special legislative session to authorize it in March 2011, and signed the legislation on March 25 of that year. The state requested proposals from managed-care companies two weeks later, and bids were due less than two months later.

Contracts were finalized July 8 but implementation was not scheduled until Oct. 1. It was delayed until Nov. 1 "at the insistence of the Kentucky Hospital Association," which "asserted more time was needed for hospitals to negotiate contracts with plans," says a University of Kentucky report published last year and funded by the Foundation for a Healthy Kentucky.

"Several informants told us that they believed that the upcoming election for Kentucky’s race for governor was a primary contributing factor in the rapid implementation timeline," the report says. "Beshear’s office saw the closing of this gap as a major issue that needed to be addressed before the November election," which was held Nov. 8. That effectively delayed most publicity about complaints regarding implementation until after the election.

"There is no doubt that the commonwealth’s rapid transition from a Medicaid fee-for-service program to a managed-care program raised a number of unforeseen challenges," said Minor, of WellCare.

"Certainly, the short timeframe . . . made for a difficult transition," said Midkiff. "Despite the negative portrayal of the managed-care companies, much progress has been made . . . and we expect that progress will continue."

Implementation timeline from UK's Medicaid managed care report

In October 2012, the managed-care companies continued to be dissatisfied with their fees, claiming they were inadequate to provide quality care, says the UK report. In January 2013, the state gave CoventryCares and WellCare 3 to 5 percent rate increases.; Kentucky Spirit asked for 21 percent, Murphy said, but got only 1 percent.

Murphy said the state had reduced rates below those established by the federal Centers for Medicare and Medicaid Services. "We want to establish base rates for primary care services that we hope the state will continue," he said.

Minor said, "While there were legitimate prompt-pay issues during the first six months of implementation of Medicaid managed care, we are now well past those issues."

Looking ahead

Murphy said some of CoventryCares' initial failures were due to the company's lack of understanding, and it has found Health and Family Services Secretary Audrey Haynes and her actuaries very cooperative and transparent, helping improve the system. "CoventryCares had to first figure out the problems going on with providers and payments. We had to understand the risks we had, and things have settled down quite a bit, especially regarding the pre-authorization process," he said. "We've stopped the bleeding."

Murphy said health-care providers will bear the burden of Kentucky Spirit's departure. To resolve issues faced by providers even before that, the cabinet has held regional forums across the state. Reception at the forums has been positive, and providers have been grateful for the opportunity to address any problems or complaints they have with the cabinet and Medicaid staff, said Midkiff.

Some providers still complain, saying that they should not have to meet with managed-care and state officials to receive payment for services already provided to Medicaid patients.

Starting in January 2013, primary care providers were supposed to be paid Medicare rates for Medicaid services over a two-year period, but some providers have yet to see that rate increase. Murphy said Coventry is planning to pay the increased rates as soon as the state's application is approved by federal officials.

Murphy said managed care should not be about the money, but about the member. He said primary care is at the core of improved health outcomes. Minor said WellCare has also made it a goal to establish relationships with primary-care providers.

But for those primary-care providers facing financial difficulties in wake of payment cuts, it is about the money because they need it to keep their practices open.

One of providers' latest complaints is CoventryCares' recent limit on dispensing certain prescription pain killers, to a 15-day supply. The move was made "to curb the manipulations going on with opioid painkillers," said Russell Harper, the company's director of government relations.

Murphy said, "It's not everybody, but there are physicians that don't want to engage in health care." He acknowledged that the prior-authorization process between doctors and pharmacists can be a hassle, but it's just another facet of managing the health care of Medicaid patients. That, and saving money, are what managed care is all about.

Foundation breaks down poll by region to show differences among Kentuckians' views on health topics and issues

The Foundation for a Healthy Kentucky has released regional breakdowns of the Kentucky Health Issues Poll, conducted for it and the Health Foundation of Greater Cincinnati last fall. Each breakdown outlines respondents’ answers to various KHIP questions and then compares regional responses to statewide findings.

Statewide KHIP results showed that most Kentucky adults do not have dental insurance, view health-care costs as a financial burden, favor a statewide smoke-free law, support integration of mental-health and medical services, and say they need more information about how the Patient Protection and Affordable Care Act will impact them personally. The Foundation for a Healthy Kentucky offered these snippets from the regional breakdowns, available by clicking each link:

Western Kentucky: Residents were less likely to have dental insurance and less likely to know someone who had experienced problems as a result of abusing prescription pain relievers.

Greater Louisville: Adults were more likely to have dental insurance, support the legalization of marijuana under any circumstance and be concerned with air quality.

Greater Lexington: Adults were less likely to have been prescribed a pain reliever that could not be purchased over the counter and less likely to change or limit their activities when they hear of an air quality alert being issued.

Northern Kentucky: Adults were less likely to have visited a dentist in the past year and less likely to have a favorable view of the Patient and Affordable Care Act.

Eastern Kentucky: Adults were more likely to rely on home remedies or over the counter drugs instead of going to the doctor and recognize that drug poisonings/overdoses were the leading cause of unintentional death in Kentucky.

“Local health issue data can be extremely useful for policymakers and health officials, especially those working on local initiatives to improve the health of their community,” said Susan Zepeda, president and CEO of the foundation.

The poll was conducted Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati.  A random sample of 1,680 adults from throughout Kentucky was interviewed by telephone, including landlines and cell phones.  The poll has a margin of error of plus or 5.3 percentage points. The poll is available online, under the “Data and Reports” tab on the foundation's website.

Sick of all the bad facts about Kentucky's health? Here's encouraging news about oral health and drug treatment

Despite the plethora of bad news about Kentucky's poor health status, there are many positive initiatives for Kentucky's oral health and substance abuse treatment, which were stories buried under health news headlines about Medicaid expansion and low health rankings.

The Kentucky Board of Dentistry recently established the position of public heath dental hygienist, permitting hygienists to go into Kentucky schools to assess teeth on the front lines, which will provide basic preventive dental care to underserved kids with tooth problems through local health departments, Al Smith, left, reports in an opinion piece for the Lexington-Herald Leader.

"These hygienists will be able to do school fluoride varnish programs, place sealants, refer kids in pain, and promote dental health programs (like brushing and better nutrition) in the schools without being supervised by a dentist," Dr. Rankin Skinner, director of the Clark County Dental Health Initiative, told Smith. "I think this is a major step in developing dental health program like ours across the state and moving our kids towards better health in general."

The initiative, comprising 17 dentists and 127 volunteers, was selected as a national model by a national association of all the health departments. "It isn't often that a private volunteer program in Kentucky sets a national standard," Skinner told Smith.

Meanwhile, in Florence, Kentucky's first lady, Jane Beshear, a Democrat, joined her Republican co-chair of Recovery Kentucky, Lexington homebuilder Don Ball, to celebrate the Brighton Recovery Center's fifth birthday and nearly 800 graduates.

Brighton is one of the 10 new homes for Recovery Kentucky, a program that is also becoming a national model, Smith writes. Since its inception during the Fletcher administration, the program has provided supportive housing and addiction recovery programs to over 10,000 men and women, writes Smith.

Beshear said the next steps are for her and Ball to create more drug-free housing and jobs for graduates of the program, Smith reports. This goal creates hope for other successful initiatives and shines a ray of light at the end of a dark and dreary tunnel.

Could Medicare Part D be an inadvertent enabler of prescription drug abuse?

By Molly Burchett
Kentucky Health News

An examination of the Medicare Part D program that Congress established a decade ago, dedicating billions of dollars to subsidizing prescription drug purchases for 35 million elderly and disabled Americans, uncovers the program's risky lack of oversight -- and suggests that it might be contributing to Kentucky's prescription-drug abuse epidemic.

An analysis of Medicare prescription records by ProPublica, an independent, nonprofit newsroom, found that the program has failed to properly monitor safety, ProPublica's Tracy Weber, Charles Ornstein and Jennifer LaFleur write in The Washington Post. And despite their findings that many providers prescribe antipsychotics, narcotics and other drugs known to be dangerous for older adults, Medicare officials told them it's not their job to monitor for unsafe prescribing or to stop doctors with criminal histories.

The largely unchecked prescribing habits of Medicare providers and the increased availability of prescription drugs suggests that Part D has inadvertently enabled prescription drug abuse, by making drugs available for abuse by Medicare patients, their friends, acquaintances and family members, particularly teenagers. A 2010 national survey by the U.S. Department of Health and Human Services found that 65 percent of teens who report that they have abused prescription medicine got them from friends, family and acquaintances rather than illegal drug dealers.

In Kentucky, drug overdose, mostly from prescription drugs, is the leading cause of death, and the widespread availability of drugs and easy access to drugs are some reasons for this trend, says the 2012 combined report from the Kentucky Justice & Public Safety Cabinet. In addition to taking the lives of loved ones, drug overdose takes a huge financial toll on the state, and a recent study shows that the Medicare program bankrolls the single largest percentage of drug overdose inpatient hospitalizations.

Inpatient hospitalizations for drug overdoses by percentage of total charges,
among Kentucky residents treated in Kentucky acute-care hospitals, 2010

Medicare alone was billed for 30 percent of all inpatient hospitalizations for drug overdoses in Kentucky from 2000 through 2010, totaling over $440.7 million, says a report by the Kentucky Injury Prevention Research Center. During those 11 years, the number of unintentional drug-overdose hospitalizations of Medicare beneficiaries increased 222 percent.

The fact that almost a third of overdose hospitalizations involve Medicare patients is concerning, said Van Ingram, executive director for the Kentucky Office of Drug Control Policy. In addition to these alarming statistics, Medicare and Medicaid incurred nearly $4 million worth of charges for drug-overdose visits to emergency rooms in 2010, which represents 41 percent of the total charges, says the KIPRC report. Also, during the period from 2008 to 2010, the number of unintentional Medicare drug-overdose emergency visits increased almost 44 percent.

Among prescription drugs, opiates and similar narcotics are most likely to be abused and most likely to lead to death. Since Medicare Part D began covering prescription drugs in 2006, drug overdose deaths involving opiates have increased almost 80 percent in Kentucky, says the KIPRC report.

ProPublica's Prescriber Checkup database shows that 30 percent of Medicare Part D patients have filled at least one narcotic prescription. The most common drug provided by Part D in Kentucky is hydrocodone-aceteminophen, which is an opiate painkiller known commercially as Lortab, Lorcet or Vicodin. Part D paid more than $12.6 million on 958,933 claims for hydrocodone-aceteminophen from 2007 to 2010.

Medicare officials told ProPublica that the government isn't responsible for monitoring these types of prescriptions because that is the duty of private health plans administering the program. Yet, health plans aren't given the tools to do so, the reporters write, and no one party has been slated the task of ensuring safe medication-use. This complacent mentality suggests Medicare officials, who also say it's not the providers' duty to "prevent inappropriate prescribing for individual patients," could be passively contributing to the drug-safety issue of prescription medications covered by Part D.

In addition to indicating that providers should not industriously discourage dangerous prescription drug usage, ProPublica’s examination of Part D data showcases numerous examples of Medicare officials failing to act against providers with troubled prescribing backgrounds. Such examination initiates a worthwhile discussion about the program's role in encouraging, or well, at least not actively combating, prescription drug abuse. Click here to visit Kentucky's Medicare Part D Prescriber Checkup. Individual doctors can be looked up.

Spring-clean the cabinet and dump your drugs Saturday, April 27

Dump your unwanted prescription drugs this Saturday, April 27, from 10 a.m. to 2 p.m. as part of the National Prescription Drug Take-Back Day, which in the past has coordinated with local law enforcement to haul in more than than 2 million pounds or 1,018 tons of prescription medications.

According to the Drug Enforcement Administration, the National Prescription Drug Take-Back Day aims to provide a safe and convenient way to throw away unwanted or unused drugs, keeping them out of the wrong hands while also educating the general public about the potential for abuse of these medications.

This is a great opportunity for those who missed the previous events or those that have accumulated unwanted, unused prescription drugs since the last event to safely dispose of them. Click here to find the nearest collection site and here to learn more about the DEA initiative.

FDA requires OxyContin pills to be non-crushable to deter abuse

The Food and Drug Administration announced Tuesday that it would block generic, crushable versions of OxyContin from coming to the market and approve the reformulated, non-crushable OxyContin, which deters abuse of the powerful painkiller.

U.S. Senate Republican Leader Mitch McConnell applauded the move. “Given the public health epidemic of prescription drug abuse and the ravaging effects it has on families all across Kentucky, this announcement is great news and will prevent an influx of crushable, generic OxyContin from coming to market,” McConnell said in a release.
 
OxyContin is a potent drug designed to treat severe pain. Without abuse-deterrent formulas, addicts can crush the pills to get an immediate heroin-like high. The reformulated product has properties that make the tablet harder to crush, break, or dissolve and that prevent it from being injected in order to achieve a quick high, an FDA press release said.

Drug overdoses are now the leading cause of death in Kentucky, and law enforcement, lawmakers and health providers have expressed their concerns that crushable, generic versions would worsen the problem.

The FDA decision came on the same day manufacturer Purdue Pharma’s patent on the original drug was set to expire, and McConnell has been actively meeting with federal officials on behalf of those concerned. Rep. Hal Rogers, R-5th, also lobbied for it. (Read more)

In an editorial, the Lexington Herald-Leader points out that the move means a continued OxyContin monopoly and more profits for Purdue Pharma, which "paid $600 million in fines in 2007, and three of the company's executives paid a total of $34.5 million, after they pleaded guilty to misleading doctors and the public about OxyContin's addictiveness. . . . We wonder why Rogers and McConnell aren't calling for Purdue to voluntarily share its new formulation."

National Rx Drug Abuse Summit, a Kentucky product, seeks to make the nation face up to its problem

The second annual National Rx Drug Abuse Summit, organized by Eastern Kentucky's Operation UNITE, called for a national commitment to combating the country's drug-abuse problem

U.S. Rep. Hal Rogers, R-5th District

"People of great passion and perspective are here wanting to make an impact in their communities," said U.S. Rep. Hal Rogers, who first funded Operation UNITE. "The first step is we have to admit there is a problem. I don't think the country is there yet. We've got to face up to it. We've got to make this known ... and that we're not going to hide from it." Rogers was quoted in a news release.

UNITE (Unlawful Narcotics Investigations, Treatment and Education) serves 32 counties in Eastern Kentucky. It was created to fight illegal drug use through a comprehensive approach that includes educating youth and the public and coordinating substance abuse treatment while providing support for families affected by abuse.

In Kentucky, drug overdose is the leading cause of death and is more fatal than motor vehicle accidents, and the number of Kentucky drug-overdose deaths nearly quadrupling from 2000 to 2010. The nation has seen a similar trend, with the number of overdose deaths more than tripling over the decade.

“We can stop this epidemic,” Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, said at the summit. “But we need everyone working together in an all-hands-on-deck approach.”

Themes highlighted at the summit included the need to provide better education about drug abuse, the need for greater use and seamless integration of state prescription-monitoring programs, the need to facilitate effective treatment and recovery programs, and the need for abuse-deterrent narcotic formulations.

“We were extremely pleased that so many individuals representing such a broad cross-section of interests shared their knowledge and expertise,” said Karen Kelly, who is leaving Operation UNITE to become district director on the Rogers congressional staff. To read more about the summit, click here.

Most Kentucky adults don't know that drug overdose is the leading cause of death in the state, but those in the east do

Drug overdoses, driven largely by prescription drug abuse, overtook motor vehicle accidents as the leading cause of unintentional deaths in Kentucky back in 2010 and remain the state's leading cause of death. From 2000 to 2010, the number of drug-overdose deaths in Kentucky rose a staggering 296 percent, highlighting the state's drug abuse epidemic that now kills more than 1,000 Kentuckians a year. But a recent poll suggests many Kentuckians are not fully aware of the state's drug problem.

In an effort to gauge awareness of the problem, the Kentucky Health Issues Poll asked Kentucky adults whether traffic accidents, falls, firearms or unintentional drug overdoses resulted in the highest dumber of deaths in the state each year. Only 44 percent of Kentucky adults correctly indicated that drug overdose is the leading cause of unintentional Kentucky deaths; 43 percent incorrectly identified traffic accidents as the leading cause.

Respondents from Eastern Kentucky, where the problem is most prevalent  were more likely to correctly identify it as the leading cause of death, at 69 percent. However, only 29 percent of Louisville-area respondents did.

“Experts have reported significant prescription pain reliever abuse in eastern Kentucky,” said Susan Zepeda, presient of the Foundation for a Healthy Kentucky, which co-sponsored the poll.  “It is no surprise that the Kentuckians most aware of this issue are those who are living in this region.  Awareness is the first step towards curbing this trend – it is up to all of us to get involved and take action to reduce the toll of this health crisis.”

The poll was conducted for the foundation and The Health Foundation of Greater Cincinnati from Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults throughout Kentucky was interviewed by land line and cell telephones, and the poll's margin of error is plus or minus 2.5 percentage points.