Kentucky's third most populous metropolitan area covers three counties across the Ohio River from Cincinnati. These three counties, Kenton, Boone, and Campbell, are home to 375,000 people, roughly the same population as Tampa Bay, Florida. These Northern Kentucky counties are suburban, affluent, and educated in comparison to the rest of the state. They are also on the frontlines of Kentucky's battle with the opioid crisis.
All three counties were in the top five Kentucky counties for opioid- and fentanyl-related overdoses.2 Collectively, they have average annual rates of opioid overdose that exceed their urban counterparts, Louisville and Lexington. Campbell County is in the top five counties in the state for average annual rate of opioid overdoses, which places it with a cohort of rural Eastern Kentucky counties which have also been greatly affected.3 In 2015, Northern Kentucky's incidence of Hepatitis C reached 19 times the national average.4 By the end of 2017, the incidence of HIV in the region grew by 48%.5 The Northern Kentucky Health Department reports a significant rise in reporting injection drug use among those with HIV. This data prompted the Northern Kentucky Health Department and the state's Department of Public Health to investigate HIV infections among people who inject drugs in Northern Kentucky. The center of the investigation is a two-county infection “cluster” in Kenton and Campbell Counties.Reference DeMio6
Northern Kentucky's proximity to Cincinnati brought it economic prosperity, but increased its exposure to the opioid crisis. Two interstates, I-71 and I-75, connect Northern Kentucky not only to Cincinnati, Louisville, and Lexington, but also to Columbus, Cleveland, and Detroit. In October 2016, Northern Kentucky was designated as a High Intensity Drug Trafficking Area (HIDTA) by the Department of Justice.Reference Wartman7 The designation reflects that the area is a center for illegal drugs, that drug-related activities are having a significant harmful impact on the area, and that a significant increase in federal resources is necessary to respond adequately.8
Methodology
This project consists of interviews with public officials across Northern Kentucky regarding county-level responses to the crisis. In late 2017 and early 2018, eleven interviews were conducted with various county officials, the majority of whom were members of the fiscal court (county legislature). The interviewees were asked questions regarding specific policies in their counties, their opinions on the causes of the opioid crisis, their assessment of the regional opioid crisis, and their views on the efforts of a variety of actors, including the city, state, and federal governments, the public, and civic organizations.
Across all three counties, the Judge-Executive (chief executive of the county) was the primary elected official acting on opioid response policies. The rest of this article highlights the responses of the Judges-Executive.
The interviews elicited the officials' views about the challenges of implementing new policies. Among the most surprising results, political support was repeatedly mentioned as one of the main roadblocks to policy implementation, often ahead of limited financial resources or a lack of policy ideas. There is also a clear need for metrics to determine the efficacy of the policies that the local governments have adopted.
This project consists of interviews with public officials across Northern Kentucky regarding country-level responses to the crisis. In late 2017 and early 2018, eleven interviews were conducted with various county officials, the majority of whom were members of the fiscal court (county legislature). The interviewees were asked questions regarding specific policies in their counties, their opinions on the causes of the opioid crisis, their assessment of the regional opioid crisis, and their views on the efforts of a variety of actors, including the city, state, and federal governments, the public, and civic organizations.
Policy Implementation in Northern Kentucky
There are a variety of policies being implemented across Northern Kentucky. Many of these exemplify common approaches to the crisis, including low-level offender diversion programs, naloxone distribution and training, and drug take-back programs.Reference Parker, Strunk and Fiellin9 In Kenton and Campbell Counties, there are extensive efforts underway, while Boone County's efforts are more modest. The Judges-Executive of all three counties are considering the problem from several sides, including prevention, treatment, law enforcement, and long-term healthcare.
New Programs Targeting the Opioid Crisis
All three counties created new programs to address various parts of the crisis. Some of these programs, for example the development of a regional coordinator for substance abuse and efforts to reduce opioid trafficking, involve the coordination of resources across the counties. Other programs are local and some rely heavily on civic involvement. These include door-to-door information canvassing efforts, the distribution of naloxone, and the coordination of healthcare and advocacy groups.
Jail Programs
Kenton and Campbell County both established opioid-specific diversion programs in their jail systems. Campbell County Judge-Executive Steve Pendery considers jail-based programs as an opportunity for Campbell County to leverage an area where it already spends a significant amount of its budget. Judge Pend-ery noted that over half of the individuals in Northern Kentucky jails have opioid substance use disorder. Campbell County's female-only program remains small with approximately 20 participants. The limited size is a consequence of the program's commitment to providing post-release services, but also the lack of financial resources for expansion.
Kenton County's jail-based program has garnered national attention after journalist Sam Quinones hailed it as a success and a model for future jail-based treatment in The New York Times.Reference Quinones10 The program includes approximately 70 individuals in Unit 104 of the Kenton County jail. While in the program, the participants take Vivitrol — a brand of Naltrexone, which is an opioid antagonist that requires opioid detoxification for use — and attend counseling sessions. When they graduate from the program, the participants are connected with sober-living houses, further Vivitrol treatment, and the opportunity to attend Kenton County's Ten/Ten Program, a drug and alcohol abuse prevention program.
Treatment Availability
Both Kenton and Campbell Counties are expanding treatment options. In Kenton County, that means the ongoing construction of a 200-bed treatment facility jointly operated by St. Elizabeth hospital and with SUN Behavioral Health, an operator of psychiatric hospitals. Kenton County also spent $1 million to purchase a building to lease back to a treatment provider.
Despite these efforts, the lack of medically assisted treatment (MAT) is a concern in Northern Kentucky. MAT is a core component of evidence-based treatment for opioid use disorder and is recommended by numerous professional guidelines.11 Evidence suggests that MAT extends retention in treatment programs, reduces the incidence of future illicit drug use, and limits the spread of HIV.Reference Nosyk, Anglin, Brissette, Kerr, Marsh, Shackman, Wood and Montaner12 Access to MAT is a topic of national concern detailed elsewhere in this volume.Reference Parker, Strunk and Fiellin13 Judges-Executive of all three counties supported MAT and noted that their concern was enabling physicians to make the proper treatment decision. But many officials felt limited in their ability to change the landscape of treatment options. For example, one area methadone clinic manages 1400-1500 patients alone. Judge Pendery pointed to a lack of doctors with the proper credentials to prescribe buprenorphine as one cause for limited treatment options. Since the officials lack control over the regulation of MAT, they rely on subsidizing the creation of new treatment facilities and investing jail resources into treatment programs.
Syringe Exchange Programs
The debate over syringe exchange programs (SEPs) is the clearest example of a lack of political support for approaches aimed at limiting the risks of the epidemic. All three counties currently lack an SEP.
Boone County Judge-Executive Gary Moore, Kenton County Judge-Executive Kris Knochelmann, and Campbell County Judge-Executive Pendery all expressed their exasperation at the struggle to establish a syringe exchange program in the area. In 2015, the Kentucky General Assembly enacted SB 192, commonly known as The Heroin Bill.14 The legislation provided county officials with the authority to open SEPs, but it also required a municipal government to first approve the establishment of an SEP located within its borders.
In Boone County, Judge Moore sought approval of a SEP at the county level in 2016, but lacked the support of the rest of the fiscal court. He said he still believes it is the most important step for Boone County and considers it to be Boone County's largest failure in addressing the crisis. Meanwhile, Kenton County passed a measure to permit a SEP in March 2016 and two months later, Campbell County passed its approval of a SEP.
However, efforts in both Kenton and Campbell Counties have been stymied by the municipal approval requirement. Covington, Kenton County's most populous city, approved a SEP contingent on a neighboring county establishing a SEP at the same time. Since no Campbell County municipal government has approved a SEP, the region remains deadlocked without the adoption of a SEP.
Judge Moore and Judge Pendery point toward a lack of public education about the opioid crisis and the stigma attached to intravenous drug use. All three Judges-Executive summarize the response they have received from municipal governments as: “not in my backyard.” Kenton and Campbell officials have discussed the prospect of a mobile SEP, but they are concerned that the program would not be as effective as it lacks the same regularity and dependability as a physical location. The Judges-Executive pointed toward the benefits of using SEPs to make contact with individuals with opioid use disorder. They view integrating these individuals into the healthcare system as more likely when a SEP is located at a hospital, clinic, or the health department.
The Judges-Executive were troubled by their inability to change the status quo. Their concerns were magnified by recent statistics from the CDC and the Northern Kentucky Health Department, which reflect increasing rates of HIV in their counties and in neighboring Cincinnati. They were well aware of the outbreak in Scott County, Indiana and concerned about what they considered to be a limited time frame for progress. After all of their negotiations, the county officials are left to depend on municipal officials.
The Judges-Executive were troubled by their inability to change the status quo. Their concerns were magnified by recent statistics from the CDC and the Northern Kentucky Health Department, which reflect increasing rates of HIV in their counties and in neighboring Cincinnati. They were well aware of the outbreak in Scott County, Indiana and concerned about what they considered to be a limited time frame for progress. After all of their negotiations, the county officials are left to depend on municipal officials.
Where do the Northern Kentucky counties go from here?
The commitment that county officials have showed to the crisis is impressive. It has consumed a substantial amount of their political capital and time. They have implemented many programs and tapped into community support and resources beyond the capabilities of their respective individual governments.
At the same time, there is a clear perception that much more is needed, both by way of policy reform and also by way of measuring which reforms work best. For example, when asked whether he attributed Kenton County's 20% drop in overdose rates in 2016 to any specific policy approach that Kenton County was taking. Judge Knochelmann could not point to the policy that made the difference. He took the opportunity to also remark that overdose deaths are “one battle” and that the “[opioid] crisis is a war.”
Further, Cincinnati's role in the crisis is unclear. The counties surveyed maintain significant economic integration with the city, but the interviewed Judges-Executive never indicated the impact that Cincinnati made on the crisis in their counties. It is unclear to what degree, if at all, Cincinnati's proximity may be responsible for the crisis in Northern Kentucky and to what degree it could be part of the solution.
Another problem is that county officials do not even have data on the extent of the crisis in their own communities. The enormity of the situation is daunting and confusing. One day they may have statistics that indicate a worsening along one metric (e.g., HIV exposure) and another day they may have data on a metric showing improvement (e.g. reduced overdose death rates). But the officials feel that they do not have the time to await data on which policies are working; they must act now. As other articles in this volume indicate, this problem is not unique to Kentucky.
Several officials are optimistic that public opinion on opioid use disorder is changing rapidly. Every official interviewed remarked that his or her own view of drug use and addiction changed significantly since the opioid crisis arrived in Northern Kentucky. Many of them described their transition from viewing addiction as a choice to viewing addiction as a medical condition. There was a clear shift in support from tougher criminal penalties to the support of treatment in its place.
Judge Pendery explained that he used to believe that individuals had a choice to stop using addictive substances. But now, he believes that “it's not a simple matter of saying no unless you like one in twenty-six success rates.” So for now, Northern Kentucky forges ahead across many policy fronts unsure of where these efforts will lead.
