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An Epidemic in Appalachia

Addiction Treatment Funding in Question as U.S. Health Secretary Promises a Fight Against Opioids

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West Virginia’s opioid overdose death rate is two and a half times the national average, the highest in the country. Last year, 864 West Virginians died from an overdose, up by more than 17 percent from the year prior.

West Virginia Department of Health and Human Resources Sec. Bill Crouch shared those statistics at a press conference Tuesday. Crouch hosted U.S. Health and Human Services Sec. Tom Price for a closed-door meeting about the state’s struggle with substance abuse and what the federal government can do to help.

“We are losing a generation of West Virginians,” Crouch said, “and in some cases with an addicted mother and her newborn baby, I worry we are losing two generations.”

Price said President Trump is committed to battling the opioid epidemic, not just in West Virginia, but across the country.

Shortly after taking office, Trump created a bi-partisan commission on drug addiction, led by New Jersey Gov. Chris Christie, and last month announced nearly $500 million in federal grants awarded to states to combat substance abuse.

Counselor to the President Kellyanne Conway says that’s Trump’s plan- to support efforts on the frontlines.

“This will not be solved from Washington, D.C.,” she said during the press conference. “This will be ameliorated and annihilated at the state and local levels.”

Price said the president’s push to support local efforts is why Price traveling the country to meet with state officials, but it’s also why the administration is supporting two essentially budgetary actions that seem to put substance abuse treatment at risk in West Virginia, at least for some populations.

The first is health care: 170,000 West Virginians received Medicaid coverage when former Gov. Earl Ray Tomblin chose to expand the program as a part of the Affordable Care Act. According Crouch, some 50,000 of those West Virginians also suffer with an addiction.

Medicaid does cover substance abuse treatment, but a Trump-backed plan to repeal and replace the Affordable Care Act would also put an end to Medicaid expansion and result in the potential loss of treatment for those 50,000 West Virginians.

“We have serious concerns about what is going to happen with that population,” Crouch told reporters. “Our crisis right now is difficult to deal with. If we have an additional 50,000 individuals with no coverage, no way to get treatment, we think our problem is going to get light years more difficult.

Considering those difficulties, Crouch was asked about his ability to convince federal officials to keep the expanded version of the program, but the secretary said the ACA repeal comes with something that’s good for West Virginia.

“As a state that wants more flexibility in terms of Medicaid and how we utilize Medicaid monies, that’s very welcome to us,” he said.

“We believe it’s wholly possible and the opportunity exists to provide states the flexibility, the appropriate resources,” Price said of the changes he sees as necessary to the Medicaid system, “so that we can have better outcomes and better coverage for individuals in the Medicaid population.”

The repeal and replace bill that allows for state flexibility, but also ends Medicaid expansion coverage, made it through the U.S. House of Representatives last week, with three supporting votes from West Virginia’s delegation. As it heads to the Senate though, both Senators Joe Manchin and Shelley Moore Capito have expressed concerns.

The second action that may put some substance abuse programs at risk comes in the form of a funding proposal for a federal office. Trump’s administration announced a significant cut to the Office of National Drug Control Policy last week—a 95 percent reduction in his proposed 2018 budget.

Price said while the administration has proposed cutting funding to the office, it is committed to increasing spending to combat the opioid epidemic elsewhere, including through the Department of Health and Human Services, but when asked if the cut was a result of failed outcomes from the office, Price said that was what he was asking state officials.

“That’s exactly what we’re asking and what the commission is going to be asking: what is the federal government actually doing that’s solving the problem, that’s assisting in getting better outcomes and what is it the that the federal government is doing in wasting federal dollars and resources?” Price said.

Under President Obama, the Office of National Drug Control Policy was responsible for coordinating efforts between public health and safety officials to reduce drug use across the country. The office, which is overseen directly by the White House, does not currently have a page on the administration’s website.

The proposals and their effects have some West Virginia advocacy groups speaking out, attempting to sway West Virginia’s leaders to take a different approach.

Members of the group West Virginians for Affordable Health Care stood outside Price’s Charleston meeting in an attempt to speak with him Tuesday, but were denied access to the listening session.

This story was originally published by West Virginia Public Broadcasting. 

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An Epidemic in Appalachia

As Opioid Crisis Affects A New Generation, Experts Study Long-Term Effects Of Prenatal Exposure

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A Univ. of Kentucky researchers' images of infants with NAS symptoms. Photo: Via Ohio Valley ReSource

Sue Meeks has worked with children for years as a registered nurse.

Meeks manages the family navigator program at Ohio University Heritage College of Osteopathic Medicine in Athens, Ohio.

Several years ago, she started noticing three and four-year-olds coming into the program with certain distinctive behaviors.

“Children that appear to be neurologically very overstimulated,” she said. “They often aren’t social in your typical way. They don’t respond to trying to calm them or trying to divert their attention to something else, laughing with them, or getting a response from reading.”

She saw delays in language and motor development. The symptoms did not line up with the typical presentation of autism or ADHD for children of that age.

But there was a common denominator: exposure to drugs in the womb.

Neonatal Abstinence Syndrome, or NAS, is the result of severe in-utero drug exposure. It has hit the Ohio Valley hard with more than 16,000 babies affected over the past five years in Kentucky, Ohio, and West Virginia.

West Virginia, for example, has one of the highest rates in the nation with more than 5 percent of babies born diagnosed with NAS in 2017.

Specialists rushed to help these children when they were born. Advancements in treatment have helped relieve withdrawal symptoms for both mother and baby. Now researchers are turning attention to the potential long-term effects. Researchers especially want to better understand how NAS affects the ability to learn so that parents, schools, and communities are prepared to help these children reach their developmental milestones.

Complicated Problem

“It’s a multi-pronged mystery that I’m not sure that we will ever totally solve,” Meeks said.

The research can become complicated because not every child exposed to substances in the womb is diagnosed with NAS, and the severity of NAS symptoms varies from child to child.

Health experts can’t say for sure if developmental delays can be attributed to drug exposure, other factors, or genetics.

“There are many children in our general population that have [neurological disorders],” Meeks said. “So how much can you attribute to the drug use and how much was going to be there anyway?”

Ohio University and Nationwide Children’s Hospital operate an NAS clinic in Athens, Ohio, to research how often NAS causes long-term effects, and also how different drugs affect development.

Early research has mostly focused on opioids.

One of the first studies came from Australia in 2017, where researchers compared the academic progress of 2234 students who had a history of prenatal drug exposure with a group of students with similar demographics but not born with NAS.

The mean test scores of the children born drug-affected were lower than those of their counterparts. The results worsened as the students aged into high school.

Researchers in Tennessee more recently released a study in September that analyzed close to 7,200 children aged 3 to 8 enrolled in the state’s Medicaid program. That study found 1 in 7 children with a history of opioid exposure in the womb required services for developmental delays.

Development delays possibly related to other substances, however, did not seem to affect a child the same way as NAS caused by opioids did, according to Meeks.

“Not to say everything else has gone away, but we’ve seen an uptick in meth use,” Meeks said. “I can’t say it’s more dangerous to the infant, because we don’t know that, but it’s very detrimental.”

A increase in the use of opioids mixed with multiple substances has also complicated the issue as researchers work to figure out how that affects long-term development.

Ohio University is also a part of the Ohio River Valley Addiction Research Consortium, a group of colleges and universities, along with health professionals, law enforcement, social workers and advocates.

A regional research consortium focuses on NAS. Photo: Via Ohio Valley ReSource

The consortium chose to focus on NAS as the first issue for their collaborative research.

OU played host to the group at its most recent meeting in November to discuss the latest research and discuss how they can better study long term-effects.

They hope to work together as this generation of children enters the public school system.

“Everybody knows in the next five to 10 years the school population is going to look very different,” Meeks said.

A Parent’s Perspective

Molly Sawyer is a doctoral candidate in education at Miami University, Ohio, and has 20 years experience as an educator from Montgomery County, Ohio.

She focuses on long term-effects of NAS and best practices for educators to help affected students navigate the school system.

The region’s public schools might face a tough challenge, according to Sawyer.

“I still think we’re trying to figure out right now, at this point in time, how are elementary age students affected?”

Sawyer is uniquely qualified to tackle this subject. She doesn’t just research the issue, she lives it as a foster and adoptive parent. One of her adopted sons was exposed to opioids in the womb.

Molly Sawyer works on NAS issues as a teacher, researcher, and parent. Photo: Via Ohio Valley ReSource

She was inspired to pursue her study when she noticed that some of the research on NAS was lining up with the experience with her son.

“He was a great baby but just was experiencing the world a little different as an infant, and needed us to care for him and respond in a different way,” Sawyer said.

She draws on her studies and six years of experience with her son to help the local school system understand these students and what educators can do.

“The students may not acquire skills the same way others do,” she said. “So, more repetition, more time on task, more one-on-one with teachers may be needed.”

There are also programs that create trauma-informed schools. Teachers learn what these children have gone through and how it can possibly change their brain structure.

Medical professionals can also help these children in the classroom, according to Sawyer’s personal experience, by helping them manage behavioral issues like impulsiveness and hyperactivity.

“For him, there is no off switch,” she said. “There’s nothing you shouldn’t do or touch. There’s just nothing about him that tells him to slow down and think.”

Ultimately, Sawyer is optimistic about the school system’s ability to handle this issue as long as teachers continue to be willing to learn and create relationships with students who may just need extra attention.

Mother and Child Reunion

Elsewhere, treatment and recovery programs work to help mother and baby together.

Project Hope for Women and Children in Huntington, West Virginia, is a residential facility where mothers struggling with addiction can live with their children as they get help.

“We’re building healthy attachments,” Lyn O’Connell, Associate Director of Addiction Sciences for Marshall Health, said. “We’re allowing mom to be there for those developmental milestones so she’s not building more guilt from being disconnected.”

Marshall Health operates Project Hope in partnership with the Huntington City Mission. The program’s goal is to fill the gaps in care for mothers with substance use disorders.

Evidence-based treatment, recovery programs, job training, housing, and parenting courses are just some of what Project Hope offers to mothers. They are also invested in the health of the children, monitoring them for developmental delays.

If a child appears to struggle with meeting a milestone, the staff will instruct the mother how to help.

“Maybe she can encourage more reading in the evening, or maybe they need to help with crawling,” O’Connell said. “We’re helping to strategize to meet those developmental goals. Because we’re not just focused on mom, we’re focused on mom as a parent.”

Project Hope just opened its doors in December and now has seven families living in the 18- apartment complex.

The goal for now is to bring in more families to the Huntington location and then later look into expansion to other regions.

Dr. Lyn O’Connell of Marshall Health at Project Hope in Huntington, West Virginia. Photo: Via Ohio Valley ReSource

Overcoming Stigma

Children and mothers affected by NAS also face challenges from the stigma attached to substance use disorders. Treatment experts hope the country has learned lessons from a previous epidemic.

The rise of cocaine use in the 1980s and 1990s came with a societal worry over “crack babies.” Women struggling with cocaine addiction and their children, predominantly people of color and low socioeconomic status, were subject to shame and ridicule.

Research showed that predictions about prenatal cocaine exposure were overstated, but the stigma still had an impact.

“This moral panic may prevent mothers who use drugs from accessing prenatal care because they are afraid of being judged or mistreated by medical professionals, or of being forced into the child welfare system,” according to the Substance Abuse Mental Health Services Administration.

Specialists around the Ohio Valley urge the public to keep this in mind when discussing mothers and children of the opioid crisis.

“Infants are not born addicted, they’re born with exposure,” O’Connell said. “We don’t want the narrative continuing throughout that child’s life that they were a ‘drug baby.’”

Researchers may not know how many children will experience the long-term effects of prenatal drug exposure or the challenges they will face.

But there are people around the Ohio Valley ready to embrace them and help them overcome those challenges.

“What we want to do is set them up for success,” O’Connell said. “Early intervention is key.”

This story was originally published by the Ohio Valley ReSource.

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An Epidemic in Appalachia

The Doctor And The Epidemic: Three Years At Ground Zero Of The Opioid Crisis

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Dr. Rahul Gupta in his office at the West Virginia Department of Health and Human Resources shortly after taking over as the commissioner for public health. Photo: West Virginia Public Broadcasting

When Dr. Rahul Gupta started work as West Virginia’s chief health officer his state was already ground zero for the opioid epidemic, with some of the nation’s highest rates of addiction and overdose fatalities.

That was 2015, and 735 state residents died from overdoses that year. 

Preliminary data for 2017 show there were 1,011 overdose deaths last year, a record high for the state.

“Not a day goes by that I’m not constantly thinking about it,” Gupta said. “We’re losing three, three-and-a-half West Virginians per day. So, the clock’s always ticking in my head.”

The epidemic takes an emotional toll on Gupta not only because the loss of life, but because he sees how it has impacted the loved ones of people with opioid use disorders.

“When I hear about parents that say ‘I’d rather have my child arrested and put in prison because that way I know that person will be alive.’ That’s the most heart wrenching part of this,” Gupta said.

After three years on the front lines of the crisis as commissioner of the Bureau for Public Health, Gupta is leaving West Virginia next month to become Senior Vice President of the March of Dimes organization.

Reflecting on the fight against the opioid crisis during his time in West Virginia, Gupta is hopeful that he is leaving behind tools that will allow the state to overcome the epidemic. And he says his experience has strengthened his resolve to continue advocating for solutions in his new position.

The Stigma Barrier

Like other health officials, Gupta has struggled with a lack of resources to address addiction treatment needs in rural communities. But he says the stigma surrounding opioid use disorder is perhaps the biggest barrier for public health workers.

Dr. Rahul Gupta signing an order expanding availability of the overdose-reversal drug naloxone. Photo: West Virginia DHHR

“This particular epidemic has taken really extreme toll in terms of dividing the country,” Gupta said. “Half of the country literally feels that it’s a disease of choice. Whereas, if you think about the science and the changes that happen to change the chemistry in the brain, you’re not the same person anymore.”

Research shows the words we use or the false ideas we hold about addiction can prevent us from implementing scientifically-back strategies to approaching the epidemic, such as medically assisted treatment or needle exchange programs.

“We all have an opportunity to behave differently, to empathize,” Gupta said. “But also help propagate that stigma, whether it’s the terminology we use or the actions we take.”

Gupta’s inward reflection on the way he addressed the epidemic made him believe eliminating stigma is the most important step toward progress.

Data Lessons

While the data surrounding the crisis are grim, the numbers are not entirely negative.

Preliminary data predict overdose fatalities for the state will rise again this year. But the rate at which they are increasing is slowing down. That means some steps the bureau has taken are working, such as expanding access to the overdose-reversal drug naloxone and supporting overdose follow-up teams. 

Another strategy Gupta says he is proud of is the creation of a data profile based on the 830 residents who fatally overdosed in 2016.

“We found some really interesting characteristics,” Gupta said. “We found that majority of these individuals, eight out of 10, were actually coming in contact with the healthcare system prior to their deaths, prior to the overdose.”

Credit: Alexandra Kanik / Ohio Valley ReSource

Gupta called this a “social autopsy” and local health departments call it one of the most important developments the health bureau made during Gupta’s tenure.

It helps identify who to look for and how to connect people to resources they need.

“It’s a lot easier if you can see a person or the representation of a person. Dr. Gupta allowed locals and the state to do that,” Kanawha Charleston Health Department Public Information Officer John Law said.

The Water Crisis

Of course the opioid epidemic was not the only challenge Gupta faced as a public health official in West Virginia. He served as executive director of the Kanawha Charleston Health Department from 2009 until he became the bureau’s commissioner.

There he dealt with another high-profile crisis when the coal-cleaning chemical MCHM leaked from Freedom Industries into the Elk River in Charleston, leaving 300,000 people in nine counties without usable water.

“Doctor Gupta was probably the acknowledged expert at the time in how to address the water crisis when he was here at the Kanawha Charleston Health Department,” Law said.

One of the first actions Gupta took after MCHM was discovered in the water supply was to shut down the area’s restaurants as a precaution.

“He, in a really innovative way, started making plans for reopening the restraunts a couple of days later,” Law said. “They had to submit a plan about how they would use water that didn’t come through the system. But we got those places back open.”

He then continued to spearhead the discussions about the water crisis, including a meeting in Washington D.C. at Sen. Joe Manchin’s office with the Centers for Disease Control and Prevention.

Law said whether it was the water crisis, the opioid epidemic, or the recent surge of Hepatitis A, it was Gupta’s clear vision for public health that made him an asset to the people of West Virginia.

“I think Dr. Gupta will take his public health vision and his knowledge of public health policy on a national level and be successful wherever he goes,” he said.

Marching On

Gupta hopes to keep working to combat the opioid epidemic in the Ohio Valley in his new role at the March of Dimes. He plans to help the organization focus on mothers with opioid use disorder and their babies born affected by the drugs in the mother’s body, a condition known as neonatal abstinence syndrome.

Credit: Alexandra Kanik/Ohio Valley ReSource

Data from last year show nearly 51 babies out of every thousand live births in West Virginia were found to be affected by drugs, the highest rate in the Ohio Valley and among the highest rates in the nation.

“Every baby may cost up to a million dollars to the state in terms of all the care that has to be provided in the first few years of life,” Gupta said. “And we don’t even know the long-term impact as of yet.”

West Virginia has been Gupta’s home for nearly a decade. He worked alongside his neighbors to tackle some of the states most challenging health problems.

And what he learned about the people leads him to believe they will one day overcome the addiction crisis. 

“People who are the most resilient, that spring back and fight for the right reasons, and, at the end of the day, are able to find solutions when we feel that there aren’t any,” Gupta said.

Gupta’s last day with the Bureau of Public Health is November 4.

The state Department of Health and Human Resources has announced a nationwide search to find his replacement.

This story was originally published by the Ohio Valley ReSource.

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An Epidemic in Appalachia

New Ohio Data Show Sharp Increase In Overdose Deaths From The Opioid Fentanyl

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Photo: Mary Meehan/Ohio Valley ReSource

New official state data from the Ohio Department of Health show 4,854 people died of drug overdoses in 2017, a 20 percent increase from the previous year.

The new data add to evidence from around the Ohio Valley showing deaths related to the opioid crisis continued to rise in 2017 as state records begin to reflect the fatalities related to the powerful drug fentanyl.

Fentanyl Fatalities

Ohio Department of Mental Health and Addiction Services Director Dr. Mark Hurst said illegally produced fentanyl was the driving factor in the fatality increase.

“Not only the fentanyl alone, but also fentanyl which is sometimes mixed with other street drugs like cocaine, heroin and methamphetamine,” he said.

The data show fentanyl was involved in 71 percent of all overdose deaths. Cocaine-related  deaths increased 39 percent and methamphetamine deaths were up 130 percent.

A recent report from the Kentucky Office of Drug Control Policy found 1,565 died from drug overdoses last year, up 11.5 percent from 2016.

Fentanyl played a factor in more than half of the overdose cases in which a toxicology report was available.

“Fentanyl is the deadliest and most addictive drug our nation has ever seen,” Van Ingram, KODCP executive director, said in a news release. “The fact that people continue to use it – despite the obvious risk – shows just how addictive these drugs are. That’s why we have to make every effort to intervene with a comprehensive treatment response.”

Preliminary data in West Virginia indicate there were 1,011 overdose deaths last year, a record high for the state.

Statistics indicate the grim totals will not decrease this year.

West Virginia’s Chief Health Officer Dr. Rahul Gupta said the total number of fatal overdoses so far in 2018 indicate a higher toll in his state than last year.

Glimmer of Hope

But the news is not entirely bleak.

In Ohio, deaths related to prescription opioids and heroin were reported at an eight-year and four-year low, respectively.

Ohio Gov. John Kasich said it’s important to highlight successes in the fight against the epidemic.

“That doesn’t mean we fly a banner that says ‘Mission Accomplished.’ But every once in a while I think it’s important for the public to see that there are bright spots,” Kasich said.

Kasich attributed the decrease to statewide efforts to reduce the supply of misused prescription opioids.

In West Virginia, the projected rate of increase in overdose fatalities appears to be leveling off, according to Gupta.

“From ‘17-’18 it’s projected at about 6 percent [increase],” he said. “So we’re certainly seeing a flattening of the curve. Up, but they’re not as up as they were from ‘16 to ‘17.”

Gupta anticipates fewer overdose fatalities in future months due to evidence-based approaches to the opioid epidemic across the region. Those include the availability of naloxone, increased medication assisted treatment and the reduction in opioid prescriptions.

This story was originally published by the Ohio Valley ReSource. 

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