The opioid abuse epidemic roiling Kentucky over the past quarter-century has affected different regions in different ways, and with varying degrees of intensity. Eastern Kentucky, the first region in the commonwealth to be crippled by widespread opioid abuse, has been Ground Zero for policy makers as they work to find solutions. In recent years, spikes in opioid abuse in Louisville and Northern Kentucky have motivated government offices to direct more resources to those communities.

But there is no part of Kentucky that is untouched by the opioid crisis. Western Kentucky has its own unique set of problems, and community leaders in the Jackson Purchase have banded together to form region-specific solutions to the epidemic under the auspices of the McCracken County Agency for Substance Abuse Policy (ASAP).

As part of KET’s Inside Opioid Addiction initiative, a production team visited the McCracken Co. ASAP during their board meeting to learn more about the roots of the opioid abuse epidemic in Western Kentucky, and what measures are being taken to bolster prevention and treatment efforts for at-risk populations.

Characteristics of the Epidemic in Western Kentucky
The McCracken Co. ASAP is one of over 70 ASAP groups in Kentucky that gather stakeholders from a community’s medical, education, government, and nonprofit sectors to develop programs that curb alcohol, tobacco, and drug use. The county ASAPs grew out of Kentucky’s Agency for Substance Abuse Policy, created in 2000 and now operated through the state’s Office of Drug Control Policy. County ASAPs receive funding through ODCP, but the individual ASAP boards have the authority to design and implement strategic programs that best fit the needs of their communities with regard to substance abuse. The McCracken Co. ASAP is organized by the United Way of Paducah, headed by Monique Zuber.

During a meeting of the McCracken Co. ASAP, several members discussed the main aspects of opioid addiction in the Jackson Purchase region. Most agreed that, unlike other areas in the state that have seen a precipitous rise in heroin overdoses, drug cases in far Western Kentucky have to date mainly been a result of prescription painkiller abuse.

This is due in part to the larger percentage of older people in the region who may receive opioids for chronic conditions, and to the traditional prescribing habits of area physicians, said several ASAP members. Hydrocodone and oxycodone are still prescribed heavily in the region, often from doctors to patients with whom they have had a decades-long relationship.

At the board meeting, Samantha Powell, prevention specialist for Four Rivers Behavioral Health, provided early 2016 data from a Kentucky Incentives for Prevention (KIP) Study. Collecting responses from the nine counties in the Jackson Purchase region served by Four Rivers, the data indicated that outreach efforts to warn teenagers about the dangers of heroin use were effective, but that prescription opioid abuse was still common, as addicts often divert drugs prescribed for illness or injury to recreational uses.

Several guests stated during the meeting that, as prescribing opioid painkillers becomes harder, heroin abuse will spike as it has in other regions in Kentucky.

“It’s happened across the state, and it’s going to happen here, too,” said Dr. Patrick Withrow, a retired cardiologist and the director of health outreach for Baptist Health Paducah who is a committed advocate for drug prevention and treatment. “There are opioid addicts out there whose supply will dry up from prescription drugs, so they will go to heroin. … Some of them have already done it, I’m sure of it. It’s probably much worse than we know right now.”

Emerson Goodwin is the corporate regional director for KentuckyCare, which operates four federally qualified health centers (FQHC) in the region. He said there is a trend among persons who exhibit “pain-seeking behavior” when they visit his clinics – that is, they will engage in risky acts in order to obtain an opioid prescription that allows them to continue using. “We have seen that people will travel,” he said. “If they can’t get what they want from Clinic A, they will go to Clinic B.”

The Jackson Purchase’s proximity to Missouri poses a problem, according to one ASAP member. Missouri’s government does not have a prescription drug monitoring system, unlike Kentucky’s, whose KASPER (Kentucky All Schedule Prescription Electronic Recording) online system served as a national model when it was introduced in 2005. Persons seeking to obtain an opioid prescription thus have an easier time if they are willing to make a short trip.

Overall, Goodwin said that important steps have been taken to curb painkiller prescriptions, but also cautioned that “I just think we have to do a better job in communicating how difficult it is, once an opioid is prescribed, to manage what happens to it after that.”

Varied Treatment Programs Prove Effective
Later in the meeting, Goodwin discussed KentuckyCare’s project that introduces medication-assisted treatment (MAT) programs in each of the region’s four FQHCs. He acknowledged that in Western Kentucky there is a reluctance to embrace MAT as a modality for those trying to overcome their opioid use disorder, and several other ASAP members agreed. After studying data on long-term treatment and success rates, Goodwin came to a different conclusion.

“Some people may prefer abstinence, and that’s okay. For the longest time, we preferred abstinence,” he said. “But, as we kept looking at the data and kept talking to experts in this area, we thought – and the need is there – we need to really look seriously at medication-assisted treatment. And that’s why we’re bringing MAT to market, because we think the data’s there that it will help some people. Does it help everybody? No. But, I don’t think we know of one thing that helps everybody.”

Aside from medication-assisted treatment, Goodwin said his KentuckyCare programs also offers behavioral services in association with Four Rivers. He said the programs design an individualized treatment model for each patient, which may incorporate MAT and/or counseling and will “meet each patient where they are.”

Other treatment facilities in the region include Centerpoint Recovery, which treats men and uses a peer-based approach where successful enrollees can become counselors. Ladies Living Free, a division of Paducah Lifeline Ministries, offers an abstinence-based program for women rooted in Christian principles. The Merryman House in Paducah, which offers comprehensive services to abuse victims, coordinates with area treatment programs to serve its patients when needed. And additionally, ASAP members from both the Paducah Independent School District and Paducah Public Schools also coordinate with Four Rivers and other facilities to help students with issues ranging from their own drug use to how to cope with parents who are addicted to drugs.

These programs are succeeding, but more needs to be done to help those suffering from substance use disorder in the face of a persistent stigma about addiction, according to the ASAP members.

“People are hesitant to come forward and admit they have a problem because other people continue to look down on addicts,” said Ellen Walsh, director of prevention services at Four Rivers. “There’s still a lot of controversy, I think, over whether addiction is a disease or not, or if it’s a choice. We still hear arguments about that.”

Bolstering Prevention
Going forward, the ASAP members agreed that they and other stakeholders in the Jackson Purchase need to devise and implement comprehensive drug prevention models that help all at-risk groups, starting in the schools and reaching out to families in need.

“What I think is really wonderful about Paducah is that we’ve come together to really provide the kind of wraparound services to families in crisis, to children in crisis, so their futures can look different,” said Monique Zuber. “What we’re really looking at is prevention, and how can we combat the problem before it gets started. Because we just don’t want to treat a symptom. We want to look at the root problem.”

Ultimately, such a prevention model for the region will be a holistic one that addresses the social conditions that may lead a person to develop behavioral health issues and then turn to opioids for relief. Catherine Fuller, an attorney with Kentucky Legal Aid in Paducah, observed that “every day stressors” such as economic and social instability are triggers for such downward spiral, and that it will take a community-wide effort to assist persons for whom rent, food, and everyday needs are not secure.

“People don’t know how to cope with it, so they turn their coping skills to drug usage, to try to escape,” Fuller said. “And unfortunately, children are affected by it.”

Dr. Withrow, whose outreach program in conjunction with other prevention advocates has reached more than 2,000 people in area schools and correctional facilities, offered his own perspective on addiction’s allure in a broken social system.

“One of the things we’re having to battle with – you’ve heard me say it before – is nurture. We’re dealing with a lot of families where there’s a single parent, not enough money, not enough support, not enough structure, not enough role modeling – the kids are really just behind the 8-ball when they first start,” he said. “And if you’re dealing with kids like that, that’s trouble… The social situation of our families and kids pre-disposes these kids to use. They have a hole in their soul that they’re filling with drugs.”

Jason Amyx, who works with area children through the Necco foster care and social services branch in Paducah, said that he has a constant focus on prevention, which will only succeed if kids know that there is a network of support to help them deal with personal issues when they arise.

“We start planting seeds now, that way, if something happens, kids know what to do. They know where to go, they know that there’s hope, we’ve exposed them to alternatives, dealing with stress, seeking out resources, how to choose friends, and the list goes on,” he said. “Hopefully, we prevent their situation from getting worse. And if it does get worse, we’ve given them the tools they need.”

Several members of the McCracken Co. ASAP attended KET’s Inside Opioid Addiction Forum in February 2017 to offer more insight into the opioid crisis in Western Kentucky and their evolving programs in treatment and prevention.