Report: 'Deaths of despair' decrease across the country, but Appalachia still sees the highest mortality rates

Opioids are one of the biggest drivers of deaths of despair
in Appalachia. (Photo by S. Pollio, Unsplash) 

The U.S. mortality rate from "deaths of despair" has declined by 5%, according to a report by researchers at the University of Chicago and East Tennessee State University. The decrease means such deaths, which are commonly linked to drug overdoses, alcohol and suicide, are hovering near pre-pandemic levels, reports Liz Carey of The Daily Yonder. 

Despite the encouraging news, deaths of despair remain disproportionately high in Appalachia, where drug overdoses are considered the "primary factor driving the difference."

Michael Meit, the director of the Center for Rural Health and Research at ETSU and a co-author of the report, believes the reasons for the higher rate of deaths of despair in Appalachia aren't fully known. He told Carey, "I think there are a lot of complexities to it, and I don’t know if we know all of the answers."

The new report is the "latest update to research started in 2017," Carey explains. "At that time, Appalachian mortality from overdose, alcohol, and suicide was 44% higher than it was in the rest of the country." Despite a decreasing mortality rate since 2017, the number of Appalachian deaths of despair remains stubbornly higher than the rest of the U.S.

The decrease in the number of deaths by despair isn't happening evenly across all age groups. Millennials are a generation that has lost thousands of lives to deaths of despair. Carey reports, "According to a report by Trust for America’s Health, the largest number of deaths from overdoses, alcohol, and suicide in the 25- to 44-year-old demographic has steadily increased since 2017." 

The report singled out opioid addictions and overdoses as the biggest driver of Millennial deaths of despair. As a result of those findings, the Appalachian Regional Commission awarded "nearly $11.5 million in 2023 to nearly 40 projects across the region to address the impact of substance use disorder," Carey writes.

But regional progress is slow. Meit told the Yonder, "You don’t necessarily see a region-wide impact, but you see really strong community-based efforts that impact those communities. And as you reduce numbers in any given community, that has a broader impact across the region.”

Drug cartels turn to a synthetic opioid 100 times stronger than fentanyl, 'killing hundreds of unsuspecting drug users'

The chemical makeup of carfentanil. The drug is legally used to  
anesthetize large animals such as elephants and rhinoceroses. 

Carfentanil is a deadly "weapons-grade" synthetic opioid that illicit drug makers are adding to other drugs as a potent substitute for fentanyl. The drug, which authorities say is "10,000 times more potent than morphine and 100 times stronger than fentanyl, has seen a drastic resurgence across the U.S., killing hundreds of unsuspecting drug users," report Hallie Golden and Jim Mustian of The Associated Press.

Carfentanil's presence in illegal drugs sold in the U.S. has surged since the Chinese government's more recent "crackdown on the sale of precursors used to make fentanyl," AP reports. "Those regulations are likely prompting traffickers in Mexico to use carfentanil to boost the potency of a weakened version of fentanyl."

The sheer potency of carfentanil is what makes it so dangerous for anyone who takes drugs not prescribed by their doctor. Frank Tarentino, the U.S. Drug Enforcement Administration chief of operations for its northeast region, which stretches from Maine to Virginia, told AP, "You’re talking about not even a grain of salt that could be potentially lethal. This presents an extremely frightening proposition."

While some Mexican drug cartels may be making carfentanil in their own labs, others are purchasing it from darknet marketplaces. Regardless of where it originates, it's making its way onto American streets. Golden and Mustian write, "In 2025, DEA labs identified carfentanil 1,400 times in U.S. drug seizures, compared with 145 in 2023 and only 54 in 2022."

Russia used an aerosol form of carfentanil as a chemical weapon to subdue Chechen separatists in 2002, AP reports. It is legally used to anesthetize large animals, such as elephants.

Michael King Jr., founder of the Opioid Awareness Foundation, told AP, “It’s like a biological weapon. If the world thinks we had a problem with fentanyl, that’s minute compared to what we’re going to be dealing with with carfentanil.”

A young farmer and former addict offers hope for recovery: 'The only thing you’re not coming back from is death.'

Nathan Caburn, a successful Mississippi Delta farmer
and past opioid addict. (Photo by C. Bennett, Farm Journal)

Nathan Casburn could be a poster child for a drug-addicted prodigal son, who threw away his farm and family for oxycontin and heroin highs.

Casburn's story is a tale that resonates with opioid-ravaged families and reflects what the love of a father and the support of a rural community can do for addicts who want to go home and begin again, writes Chris Bennett of Farm Journal. "Casburn is a most unlikely survivor. He tells a hellish tale of loss and triumph on the farm — without a shred of blame cast beyond his own shadow."

As a teenager, Casburn obsessively played video games. He told Bennett, "I played every waking moment I could, to the point of fixation. I knew I was different from the other kids and not in a good way; I was geared toward escapes. In my case, an obsession with video games was a symptom of my unhealthy mindset.”

From video game escapes, Casburn went on to alcohol. Bennett writes, "In 2004, on backroad gravel, Casburn, a high school junior, broke two vertebrates in an alcohol-related car crash. The subsequent pain management became a party, legitimized by medical approval in the age of OxyContin. Casburn was in love. Welcome to the wonder world of opioids."

Casner wanted nothing to do with his family's Mississippi Delta farm in Tallahatchie County. He was all about the highs. "Next stop, 75 miles west to Ole Miss and Oxford, and a chain of descent in a college town: DUI’s, car wrecks, arrests, hospitalization, overdoses, academic probation, and legal woes," Bennett explains. "By 2014, with no job, no degree, and no prospects. . . . OxyContin and other legal pharmaceuticals were out of his price range. He responded with the most hellish economic decision of his life. Go home to the farm and tap the vein. Heroin."

"Rain or shine, addiction woke Casburn at dawn every day, demanding a morning fix," Bennett writes. "In 2017, at 29, Casburn’s body gave out. After two weeks in intensive care due to a heart valve infection derived from heroin use, he returned home, and checked into rehab. . . . Three weeks after rehab, Casburn was back on the needle."

Then death came knocking. Casburn told Bennett: "I had an out-of-body experience with no drugs involved. I saw everyone going on with life, and me stuck right there dying as an addict. Right then, in the library, I dropped to my knees and threw up a prayer in desperation, but I meant every word. I called out to God for mercy and forgiveness. I told Him that if He would help me, then I’d do everything He asked. That prayer was answered.”

He told Bennett, “All the people around me in our farming community came to help me in one way or another." Bennett adds, "Seven years after crashing to his knees, Casburn has earned a stellar reputation and built a thriving farm life. . . . In March 2024, he and his wife Caitlin were blessed with a baby girl — Nora." He is grateful for a "particularly stalwart source of support — his father, Rea."

Casburn wants people who are addicted to know there is always hope. He told Bennett, "Never, never believe that you can’t get out of drugs. You’re never too far gone. The only thing you’re not coming back from is death.”

Opinion: Understanding how fentanyl 'saturated the U.S. drug supply' could help address the addiction crisis

Naloxone can prevent overdose deaths, but it's expensive.
(Adobe Stock photo)

The current U.S. opioid crisis started with painkiller prescriptions in the early 2000s, but once medical providers started nixing those medicines, heroin's popularity surged, and then fentanyl and its "tsunami" of death entered the market, reports Maia Szalavitz of The New York Times. "Understanding how fentanyl saturated the drug supply, moving from the East Coast of the U.S. to the West, is critical to ending the worst drug crisis in American history."

Drug cartels' greed drove the creation and use of fentanyl. "By 2013, cartels had realized that they could slash their labor, manufacturing and transit costs by replacing heroin derived from farm-grown opium with a powder made in a lab — fentanyl," Szalavitz writes. "Before 2018, 80% of all deaths associated with fentanyl occurred east of the Mississippi. . . . Since 2021, at least two-thirds of America’s 100,000 annual overdose deaths involved a synthetic opioid like fentanyl."

While heroin was considered a more urban drug, "increased opioid prescriptions — followed by sharp reductions — resulted in new heroin users in rural areas," Szalavitz explains. "Illegally manufactured fentanyl began appearing in both urban and rural drug markets. . . . Rural West Virginia and other Appalachian regions were the center of the earliest prescription opioid wave of the crisis, which led to the establishment of new heroin markets in places facing job loss."

Combating opioid addiction and overdose deaths liked to fentanyl is tough because the drug's supply chain and use is now deeply embedded across the country. The drug is cheap to make and buy, and provides an exceedingly potent high for the user. "So, what can be done? The answer is to focus on the drivers of demand, not supply. This means addressing the roots of addiction and treating it compassionately," Szalavitz writes. "We have a great generic opioid overdose antidote, naloxone. . . . And two medications — methadone and buprenorphine — have proved to cut the risk of death among people with opioid addictions by 50% or more when used long-term."

Szalavitz adds that people often start doing drugs because their lives feel hopeless. "Addiction is most often an attempt to escape despair. The condition itself is defined by compulsive drug use despite negative consequences, which is why threats of punishment or even death rarely yield recovery. . . . It’s not coincidental that the exponential rise in overdose deaths has occurred in tandem with a profound increase in income inequality."

The number of children who have lost a parent to drug overdose or firearms climbs; overdose loss is up 345%

Nearly 100,000 children lost parents to a drug overdose
or gun violence in 2020. (Adobe Stock photo)

Over the past 20 years, the number of U.S. children who have faced a parent's death from drug overdose or firearms has increased at an alarming pace. These children are left to grapple with a loss that impacts how they thrive or don't thrive throughout their developmental years and into adulthood.

"Nearly 100,000 children lost parents to a drug overdose or gun violence in 2020 alone – almost three times more than in 1999," reports Deidre McPhillips of CNN. "Overall, more than 1 million children have lost a parent to a fatal drug overdose or gun violence over the past two decades, according to the study published in the Journal of the American Medical Association.

The increase in the number of parent-age deaths from drug overdose is staggering. McPhillips writes, "About 72,800 children lost a parent to a drug overdose in 2020, up 345% from the 16,000 children affected in 1999, according to the study."

The percentage increase in gun-related deaths is not as high as that for drug overdoses, but it's still startling. "There was a 39% increase in children who lost a parent to gun violence – from 18,000 in 1999 to 25,000 in 2020," McPhillips reports. By comparison, the number of children who lost parents due to other causes increased 24% between 1999 and 2020.

"Other research has shown that losing a parent can have negative effects on a child's health, education and livelihood – in both the short and long term," McPhillips adds.

Deaths due to drugs, guns or crime are not as acceptable for children and adults to discuss. Robin Gurwitch, a psychologist and professor at the Duke University School of Medicine, told McPhillips: "When it can't be talked about openly and freely, it makes it harder for children to get the support they need. For children who hold those things inside, the risk of it leaking out into everything from severe behavior challenges to bereavement disorders to other types of mental health challenges – anxiety, depression or their own substance abuse – goes way up."

Opinion: Why prescription drugs have little to do with the current illicit drug epidemic in the United States

The 1990s marked a time in U.S. medicine where doctors were taught to give narcotics.
(Graphic via Life and Limb blog, Edwin Leap)

Emergency physician Edwin Leap explains that U.S. doctors in training during the 1990s were instructed to treat pain with pills. He said a medical career taught him how misdirected those practices were. He adds that the nation's current addictions and overdoses aren't centered on prescription drugs anymore; they're all about super cheap, available and deadly fentanyl -- other opioids are almost an afterthought. An excerpted version of his commentary from MedPage Today is included below.

"When I was in my residency training, from 1990 to 1993. . . . We were told, over and over, that we should treat pain aggressively and should not be afraid to give narcotics to patients in pain. Who were we to judge someone's pain, after all? The young man who fell onto his knees at work, with a normal blood pressure and heart rate, looking about the room, might well categorize his pain a '10/10,' and we should honor that, respect it, and treat it."

Pain medicines such as hydrocodone and oxycodone (Oxycontin) were first marketed to doctors as a miracle for patients in pain. Given their addictive nature, it didn't take long for the drugs to take hold. Leap writes, "Much of our work as physicians was a balancing act between trying to show genuine compassion, mandated compassion, and appropriate skepticism about pain scales and the lies concocted in pursuit of drugs."

Given doctors' role as the prescription writers who "started" patients on the path to addiction, physicians are now forced to take additional narcotic treatment training. "I have to take a new 8-hour class on proper prescribing habits and pain management," Lead adds. "[But] nobody really argues with me about pain pills anymore. . . .We're only supposed to give a 3-day supply. We tell people that, and they shrug."

The likely reason a 3-day narcotic supply isn't a problem is the availability of fentanyl. "It's just so easy to get the stuff. It's inexpensive, and it's everywhere. It's in drug houses and gas station parking lots. It's in high schools and college campuses," Leap writes. "It's in prisons and homeless encampments. In fact, according to independent journalist Jonathan Choe, it can sometimes be found for 50 cents per dose in homeless camps."

U.S. physicians have little to do with fentanyl's street dominance. Leap writes, "The flood of illegal fentanyl precursors from China, which then become fentanyl and began flowing across the Southern border, continues unabated. . . . It's all rearranging the deck chairs of the Titanic until someone gets a handle on the crisis from a geopolitical standpoint. And yes, that means dealing with the border as well. . . . I'm not blaming one political side or another. I'm just saying that if it isn't taken seriously, then the deaths will keep skyrocketing."

This piece was originally published on Leap's blog, Life and Limb.

After at least 3 fentanyl deaths in 7 months, weekly in small Kentucky county alerts its readers to dangers, details

Most of this week's front page; click it to enlarge.
Photo illustration is based on a DEA image. 

After three fentanyl overdoses since June in Crittenden County, Kentucky, the first recorded in the county of 9,000 people, and another death in which fentanyl could have been a contributing factor, the local editor-publisher thought it was time to alert his readers to the danger.

"Considered by some as the grim reaper of recreational drugs, fentanyl has hit Crittenden County like a reaper’s scythe over last the few months," Chris Evans of The Crittenden Press began his story, which reported the deaths without the victims' names, noted that the county normally has about three overdoses of any drug in a year, then gave a rationale for the story and made it an implicit example to follow: "Observers say small communities like Marion should raise awareness or prepare to see more deaths in their neighborhoods."

Evans quotes local and state officials and writes, "Fentanyl is approximately 100 times stronger than morphine and 50 times more potent than heroin. Illegal manufacturers often lack understanding, ability and precision to make fentanyl. It’s not a forgiving drug. One minuscule mistake is irreversibly deadly."

Dr. Christopher Kiefer of the state medical examiner’s office told him, “High-school-age kids might be swapping pills. That’s not uncommon. They might think they’re getting a mild painkiller pressed in a lab. They might think it’s Oxycodone or Lortab, but it ends up being fentanyl. You don’t have to be using a needle to die of an overdose. . . . It is a dangerous time right now because people don’t know what they’re getting,”

Crittenden County (Wikipedia map)

Evans adds, "The doctor further explains that fentanyl made and distributed on the black market can be dressed or disguised as just about anything. Someone may think they’re getting a pill from a friend’s mom’s medicine cabinet when it’s something far more sinister and deadly." He quotes Marion Police Chief Bobby West as saying that families and friends of drug users can be the best preventers of overdoses, and “Conversations need to be had about this drug and how it can kill you.”

Evans concludes, "The stark reality of this drug is that it can creep undected into any corner of society and become an instant killer. Now, it’s in Marion." His package also includes sidebars about synthetic opioids (fentanyl is one) and a quick-look box giving street names for the drug, how it is used, what it does and what an overdose can look like: "Stupor, changes in pupil size, clammy skin, cyanosis, coma, and respiratory failure."

Evans has made this week's issue available online, here.

Health quick hits: Sacklers could compensate opioid victims, but deny responsibility; blood donations sink to 20-year low

Many family members want the Sackler family to pay for 
their part in the opioid overdose epidemic. (Photo via CNN)

The Sackler family, who owned Purdue Pharma, the maker of the synthetic opioid OxyContin, could "act today to compensate opioid overdose victims," write Regina LaBelle, J.D., and Madison Fields, J.D. in their opinion for MedPage Today. "The family could voluntarily establish a fund to compensate people harmed by Purdue's marketing of OxyContin and allow individuals to choose to release future claims. However, it appears that the family's insistence that they bear no responsibility for the overdose deaths involving OxyContin and their desire to be shielded from future civil litigation [through bankruptcy] will prevent this from happening. . . . Purdue has made the Sacklers one of the wealthiest families in the U.S., with a collective worth estimated at $11 billion."

As blood donations sink to their lowest level in 20 years, the American Red Cross has issued a blood shortage emergency. "There does not appear to be enough donated blood to meet demand among hospitals and patients in need," reports Jacqueline Howard of CNN. "Data from the national organization America's Blood Centers indicates that at least 17 community blood centers have a one-day supply or less. . . . One unit of blood, equivalent to about a pint, is typically collected during a donation, and experts estimate that a single car accident victim can require as many as 100 units of blood."

Mobile medical units can reach more rural residents
in need of addiction care. (HealthAffairs photo)

A new study by the University of Colorado shows that one way to help rural areas fight addiction is to send more mobile methadone clinics to remote areas, reports Julia Milzer of CU Anschutz Medical Campus. "The research focused on the impact of adding new treatment services exclusively to rural Louisiana, where, like in many other remote parts of the country, there are limited care infrastructures and barriers to transportation. . . . The analysis revealed mobile methadone would have a distinct impact in rural communities if these locations were prioritized and recommended operators collaborate with state and local policymakers regarding where to locate them to help maximize their impact." To learn more about mobile methadone, click here.

Family medicine doctors who train in obstetrics could
help fill care gaps. (UIC photo)

A key to solving some of the rural maternal health care shortage could be obstetric training for family physicians. "In the 1980s, about 43% of general family physicians who completed their residencies trained in obstetrics," reports Sarah Jane Tribble of KFF Health News. "In 2021, the American Academy of Family Physicians' annual practice profile survey found that 15% of respondents had practiced obstetrics. . . . In July, the Department of Health and Human Services announced a nearly $11 million investment in new rural programs, including family medicine residencies focusing on obstetrical training."

 Ian Cousins
(Courtesy photo, Undark)

Removing forever chemicals from drinking water is expensive, with consumers the most likely target for paying the bill. Some experts are suggesting a different course to avoid the extreme cost.

The Environmental Protection Agency is set to "finalize an enforceable cap on PFAS in drinking water that will require thousands of utilities around the country to update their treatment methods," reports Charles Schmidt of Undark. Ian Cousins, an environmental chemist at Stockholm University and "one of the world's leading researchers on PFAS exposure, said the public might be better served by a policy that prioritizes hot spots of PFAS contamination."

 

New Mexico schools use wastewater testing to identify student drug use; the science is catching on in other places

Wasterwater testing can pinpoint drug use in schools
and communities. (N.M. Health Dept. photo via WP)

School administrators in New Mexico are using wastewater testing analysis to learn more about student drug use and to help inform their decisions on how to respond. "Using a technique that became popular nationally to spot Covid-19 outbreaks, New Mexico appears to be the first state to test wastewater at public high schools for a range of opioids and stimulants," reports Sara Randazzo of The Washington Post. "Initial data released since last week from more than three dozen high schools. . . included what school leaders and state officials called a surprise: cocaine use in nearly 82% of the campus communities."

Health and school officials plan to use testing results to "guide drug-prevention programs and pinpoint how to allocate resources for addiction services," Randazzo writes. "The tests aren't meant to assist in punitive measures, but to give a snapshot of campus drug use. . . . Fentanyl, a synthetic opioid that has led to a surge in overdoses nationwide, and its metabolite appeared at nine of the 38 New Mexico schools. None showed a heroin presence."

Europe and Australia began deploying wastewater testing to measure illicit drug use around 2010, but the method has been slow to "catch on in the U.S.," Randazzo reports. 

New Mexico may be the first to use wastewater testing in schools; however, "communities in California, Delaware, Virginia and elsewhere started broader municipal wastewater drug-testing programs this year focused on the opioid epidemic, some of it funded by the federal government," Randazzo writes. "Drug overdoses killed more than 100,000 people in the U.S. in 2022, federal data shows, more than two-thirds of those from fentanyl and other synthetic opioids."

The wastewater testing company Biobot Analytics "is working with Marin County, an affluent area north of San Francisco, where drug overdoses are now the leading cause of death for those 55 and under," Randazzo adds. "Matt Willis, Marin County's public health officer, said weekly testing over the past year helped them see in May that xylazine, a powerful horse tranquilizer that is dangerous to humans, was entering the community. . . ."

The overdose crisis isn't over, it's evolving

Suboxone is less effective in treating
some additions. (Drugs.com photo)

Powerful synthetic drugs such as fentanyl, xylazine and stimulants are undercutting the effectiveness of prescription drug treatments, leaving programs and patients struggling, reports Taylor Sisk of KFF Health News. Vermont, a state that pioneered prescription addiction treatments, is facing new challenges to help substance-abuse victims avoid overdoses and succeed in recovery.

Vermont's "Hub and Spoke" program is part of the statewide Blueprint for Health, with "hubs in relatively populous areas of this largely rural state," Sisk writes. "A patient enters the system for assessment and initial induction at one of nine hubs and then, once stable, is transferred to a spoke. If that patient relapses or needs more intensive care, they can be transferred back to the hub. The spokes typically offer Suboxone — the brand name for a combination of buprenorphine and naloxone -- and the most effective for those with mild to moderate opioid dependence — but not methadone, which is more regulated."

The mix of street drugs combined with their potency limits the impact of prescription care. "Suboxone has proved less effective against fentanyl, and commonly used doses can trigger violent, immediate withdrawal," Sisk explains. "Neither Suboxone nor methadone is designed to treat addiction to xylazine or stimulants. . . . The nation has also seen a significant increase in overdose deaths from co-use of stimulants and opioids."

Without effective prescriptions as part of a withdrawal plan, people with an addiction are less likely to succeed during the early days of recovery. "Those who seek help breaking their addictions face treatment options rendered less effective by the prevalence of fentanyl, xylazine, and other synthetic drugs," Sisk reports. "The Centers for Disease Control and Prevention estimates that of the more than 111,000 drug-overdose deaths in the U.S. in the 12-month period ending in April, more than 77,000 involved fentanyl and other synthetic opioids."

Jess Kirby, director of client services for Vermonters for Criminal Justice Reform, which offers services to counter substance use disorder, told Sisk: “There was a time when we couldn’t have pictured things being worse than heroin. Then, we couldn’t picture things being worse than fentanyl. Now, we can’t picture things being worse than xylazine. It keeps escalating. . . . We have a drug supply that’s contaminated with xylazine and fentanyl, and we know that people are struggling a lot more and are at a lot higher risk. It’s not just an overdose to be concerned about anymore. It’s life-threatening wounds and infections."

Tony Folland, clinical services manager with the Vermont Department of Health’s Division of Substance Use Programs, "said fentanyl is now implicated in about 96% of overdose deaths."

Overdose is now the No. 1 cause of death for people under 40 in most states. Street fentanyl is mostly to blame

 

In most states, the number of Americans under 40 who died from accidental drug overdoses has exceeded any other cause of death. "It's now the top cause in 37 states," a new Stateline analysis shows. Death rates for Americans under 40 "were up by nearly a third in 2021 over 2018, and last year were still 21% higher," reports Tim Henderson of Stateline. "Covid-19 was a small part of the increase, causing about 23,000 deaths total between 2018 and 2022 in the age group. . . . Vehicle accidents and suicide (about 96,000 each) and gun homicide (about 65,000) all took a cumulative toll from 2018 to 2022, according to a Stateline analysis of federal Centers for Disease Control and Prevention data. . . . Overdose deaths, however, took almost 177,000 lives in that time."

A lethal dose of fentanyl
(FDA fentanyl fact sheet photo)

The number of unintentional overdose deaths shows fentanyl's deadly presence in U.S. street drugs. The "fresh wave of overdose deaths is different from the first three," Henderson writes, . . ."driven by drugs spiked with powerful fentanyl." Daliah Heller, vice president of drug use initiatives at Vital Strategies, an international advocacy group that works on strengthening public health, told Henderson: "Somebody might think they're getting a Xanax [for anxiety], or methamphetamine or cocaine. . . They have no experience with opioids; it's not what they're expecting, and now they have a much higher risk of overdose and death." According to the Food and Drug Administration, fentanyl is approximately 100 times more potent than morphine and 50 times more potent than heroin.

To lessen fentanyl's impact, states "are responding with 'harm reduction' strategies that can include warning of the new danger of recreational drugs laced with deadly fentanyl, training and equipping people to counteract overdoses when they see them," Henderson explains. "Nationally, accidental overdoses dominated the increase in deaths in residents under 40 across racial and urban-rural divides, but many disparities exist. The increase in young overdose death rates was 154% for Black Americans, 122% for Hispanic residents and 37% for white people, yet even for white residents, they represented the largest increase. . . The largest urban areas saw increases in overdose death rates of 70%, and rural areas 64%—the largest increases in both areas for any cause of death."

'Recovery-friendly' employers can help both those healing from addiction and the broader community

Cafes and catering businesses can offer flexibility and
support for people in recovery. (Photo by K8, Unsplash)

By providing a job and a supportive structure for people transitioning into drug-free living, employers are helping their broader community, reports Kristi Eaton of The Daily Yonder. "Rural communities ravaged by substance misuse could benefit from people in recovery being active members of the local workforce, say experts in criminal justice, substance misuse, and labor studies." Sometimes called "second-chance workplaces," these businesses offer employment and a place of meaning without drugs.

Kristina Brant, assistant professor of Rural Sociology at Pennsylvania State University, told Eaton, "[These are] employers hoping to adopt specific policies and practices that are going to be supportive of people who are in recovery from substance use disorder. They want to create an environment that's structurally and culturally going to help people in recovery thrive." Eaton adds, "Stable and meaningful employment is a goal for many people in recovery – not everyone, but many people, she said."

Drug misuse recovery can be harder in rural places because of stigma and a culture of "everybody knows everybody's business." Eaton reports, "Being in recovery can still hurt peoples' chances at getting a job, acquiring a place to live and even making friendships, Brant said. . . . Logistics also play a role. Someone in treatment court may be required to attend court several times a week, and a recovery-friendly workplace would be conducive to that."

Black Sheep logo

Some business models are flexible and can adjust to addiction recovery needs. "Brant said there are many examples of recovery-friendly workplaces. Cafes are popular options. One example is Black Sheep Brick Oven Bakery and Catering, located in Jackhorn, Kentucky," Eaton reports. "The restaurant hires. . . folks emerging from incarceration created by the opioid crisis." Brant told Eaton: "You're serving this dual purpose of creating a place that people know will be a supportive work environment, but also bringing something positive to the community. I think that's a really nice model to focus on."

Douglas Swanson, associate extension professional in the Labor & Workforce Development Program at the University of Missouri Extension, said, "Rural communities and employers have greater challenges due to the shallower pools of available workers." Swanson told Eaton: "You can't hire workers who aren't there. This dynamic puts rural employers in the position of needing to look at the potential an employee may have instead of their past."

Do you have to leave Appalachia to find opportunity? One woman did and wants the region to receive more attention

Melissa Smith, center, left her Appalachian home behind
in search of a better life. (Melissa Smith photo via Fox News)

An upbringing surrounded by drug use, crime and poverty made one woman leave her Appalachian home in search of opportunity. She compares the region's problems to intercity issues, reports Teny Sahakian of Fox News. "Melissa Smith, 26, managed to leave her family and her hometown behind four years ago to build a better life, but she fears communities like hers will continue to rot without more attention. National media outlets report daily about the rampant crime and drug use afflicting major cities across the country. But Smith feels the Appalachia region as a whole doesn't get the same level of consideration, causing them to suffer in silence as they face similar issues."

Smith told Sahakian, "I just pray that something could be done, some opportunities could be created, rehabs could be made more readily available, and these people can get help and realize that there is a better life. But at the moment, it's just not talked about. Nobody talks about it." Sahakian reports, "Smith's grandmother raised her and her siblings in a trailer park in Corbin, Kentucky. Her mother, who struggled with drug addiction, was in and out of jail for most of her childhood. . . . Most of the kids she grew up with had at least one parent addicted to drugs. . . . Smith said she recently watched a YouTube video that featured interviews with Black Americans living in a poor area of California. She was shocked to hear how similar their stories were to her own."

The first wave of the opioid epidemic hit Appalachia during the 1990s and continued to gain steam through the 2000s when coal mine closures happened in quick succession. Smith said the pairing "ignited a cultural and economic downward spiral in rural areas across Kentucky, West Virginia, Tennessee and other states in the region," Sahakian writes. "Although the entire nation is facing a drug crisis, Appalachia is disproportionately impacted, according to the Appalachian Regional Commission. In 2020, overdose deaths of people ages 25 to 54 were 61% higher in the region compared to the rest of the country."

"Smith said many kids she grew up with are now either on drugs, in jail or dead from an overdose and that methamphetamines, rather than opioids, have become the drug of choice ravaging her community," Sahakian reports. "Most families rely on welfare checks or selling drugs to get by, she said, and with only one factory remaining in her town, the ability to work hard and improve one’s life seems impossible. . . Between 2001 and 2021, employment in Appalachia only grew 1.5% compared to 12% for the rest of the U.S., according to the Bureau of Labor Statistics." Smith told Sahakian: "They really don't have the opportunity to kind of improve or pull themselves up by their bootstraps."

Success of medication-assisted drug treatment will rest on providers and pharmacists working together, advocates say

Pharmacists will play a maor role in medication-assisted treatment.
(Photo by Tbel Abusezine, Unsplash)

The federal government has opened the door to addiction treatment wider by removing a requirement that providers be trained and apply for a waiver from the Drug Enforcement Administration to prescribe buprenorphine, "a primary drug used to treat opioid-use disorder," reports Taylor Sisk of The Daily Yonder. "Now, those providers with a current DEA registration that includes Schedule III authority can prescribe it." But that's just the start of a new day in drug treatment.

Dr. Blake Fagan, director of opioid-treatment services for the Mountain Area Health Education Center's family health centers in western North Carolina, is "a longtime advocate for the lifting of the X-waiver," as it was called. "Fagan said that while there have been some 130,000 providers across the country authorized to prescribe buprenorphine, there will now be more than 1.8 million. . . . Dr. Bayla Ostrach, a medical anthropologist with Fruit of Labor Action Research and Technical Assistance in the region, told Sisk: "We know that [buprenorphine is] evidence-based; we know that it's more important than ever with fentanyl and xylazine in the drug supply. We want more buprenorphine prescriptions."

The federal change, made in an omnibus bill late last year, is only one part of helping rural areas address the opioid epidemic. "Ostrach, Fagan, and others who know rural health care and addiction treatment well stress that a lot of education will be required," Sisk writes. "In a recent paper for the Journal of the American Pharmacists Association, Ostrach and their colleagues write that "If prescribing increases but is not matched by increased dispensing, bottlenecks may worsen. Any worsening of buprenorphine bottlenecks could have a disproportionate impact in rural areas where residents may rely on fewer pharmacies to fill prescriptions." Sisk notes, Resistance among pharmacists is a widespread issue. Research Ostrach and their colleagues conducted found that 62%of community pharmacists surveyed had refused to fill a buprenorphine prescription."

Countering phamacists' resistance is part of tackling addiction's stigma. The more opioid addiction and treatment are understood and treatment protocols accepted, the more the medical community can approach it as any other mental/physical disorder. "Ostrach said North Carolina’s pharmacist association has been proactive in providing guidance on the specifics of the act, and that it does appear recent pharmacy school graduates are more willing than their predecessors to dispense buprenorphine," Sisk reports. Fagan told Sisk: “You have to give people time to ask their questions. . . . You have to let them say all those things, get it out, and then tell them the real deal. Tell them stories about people in rural areas who have actually stabilized their lives, or they’ve gotten their kids back from foster care.”

Dr. Travis Williams is a young practitioner advocating for medication-assisted treatment in rural areas. "He’s building collaborative relationships with a peer recovery support specialist and a prevention specialist. He’s working to bring more pharmacies on board," Sisk reports. "It’s about building an addiction prevention ecosystem, Williams stressed. . . . Facilitating medication in treatment is a critical step on the path to building that ecosystem."

DEA chief says U.S. needs laws to keep social-media platforms from being used to promote and sell fentanyl

CDC graph shows large increases in deaths from fentanyl; click on it to enlarge.

The U.S. needs laws to force social-media companies to keep their platforms from being used to promote and sell fentanyl, DEA Administrator Anne Milgram said on NBC's “Meet The Press” Sunday, in a program that was devoted entirely to the drug and the problems it is causing, such as overdoses.

“The border’s an important part of this conversation because most of the fentanyl that we see coming into the United States is coming in through the southwest border,” Milgram said, but “Social media is also a vital part of the conversation. It is what I call the last mile. Because what the cartels need – they’re selling the deadliest poison we’ve ever seen – they need that to … be able to expand and sell more, they need to be able to reach people at massive rates. And that’s what social media’s doing,” The Daily Wire reports.

Host Chuck Todd asked Milgram asked if social-media companies were cooperating with federal law enforcement in trying to fix the problem. She said, “We have not, until recently, gotten nearly as much cooperation as we need. . . . The deputy attorney general convened all of us in April of this year and made it very clear, number one, that the companies have to comply with their own terms of service, which say, ‘This is illegal. You cannot be selling fake pills. You cannot be selling drugs on social media websites’.”

Milgam also said law enforcement needs to be able to get information from social-media companies. Asked if there was something the DEA does not have that Congress could give them that would help them address the issue, she said, “So we talk a lot with Congress about social media. We talk a lot about the need for these platforms – essentially, one of the main ways we see Americans dying right now is through social media, the purchase of pills, fake pills on social media. So, again, if we’re after, how do we stop 110,000 Americans from dying?” She said Congress was “a place to start.”

Rural court officials shift from abstinence-only approach to drug defendants to medication-assisted treatment

A strip of Suboxone film, an opioid-addiction medication (Photo by
Craig F. Walker, The Boston Globe, Getty Images via KFF Health News)

Rural judges and other court officials are shifting their stance on medication-assisted treatment programs for addicts facing drug charges. "A study conducted a decade ago found that barely half of drug-treatment courts offered medication treatment. Those that didn't cited uncertainty about its efficacy and noted political, judicial, and administrative opposition. But research in the years since has persuaded many of the most insistent abstinence-only advocates," reports Taylor Sisk of KFF Health News. "By 2022, more than 90% of drug courts located in communities with high opioid mortality rates that responded to a survey said they allow buprenorphine and/or methadone, the medications most commonly used to treat addiction. . . . Federal legislation has lowered the barriers to it. And Bureau of Justice Assistance funding for treatment-court programs now mandates that medication for substance use disorder be provided."

Judge Duane Slone

The evolution of Judge O. Duane Slone is an example. As a prosecutor in charge of drug cases in Cocke, Grainger, Jefferson and Sevier counties in East Tennessee, who becanme a judge in 1998, "Slone believed abstinence was the only path to recovery. But in 2013, after consulting with substance-use-disorder experts, he relented, introducing medication as an alternative to incarceration for pregnant women. . . . Building from evidence-based research, Slone has launched programs that show how a judge, and a region, can trade an abstinence-only, lock-’em-up approach for one that offers a full range of paths to recovery."

Eventually, Slone founded a drug-recovery court. "It allows defendants with nonviolent drug-related charges to avoid jail time by entering treatment and counseling," Sisk reports. But this type of court was so "resource-intensive, relatively few people can be enrolled. So in 2013, Slone introduced the Tennessee Recovery Oriented Compliance Strategy, an alternative to jail for those who aren't considered at high risk of recidivism but are deemed in urgent need of treatment. Many are pregnant women or mothers of young children. . . . Both the recovery court and TN-ROCS offer three medication options: buprenorphine, methadone, and naltrexone. . . . Since TN-ROCS' launch, Slone said, his community has seen a decrease in property crimes and its jail population."

Monica Christofferson, director of treatment-court programs at the Center for Justice Innovation, told Sisk she has seen a "huge shift" among judges, prosecutors, and law enforcement agencies away from the stigma associated with medication treatment, but rural areas still face unique challenges. "The relative unavailability in rural areas of medication treatment is certainly a problem. A shortage, Christofferson noted, is not only an issue in itself but also a barrier to overcoming stigma," Sisk reports. "More openings available [in treatment programs], more success stories. More success stories, less stigma. Fewer provider options also mean one bad actor — a provider who overprescribes or is otherwise negligent — perpetuates the stigma. Strict oversight is essential."

How much money are your local and state governments getting from opioid settlements? KFF Health News has it

Companies that made, sold, or distributed opioid painkillers have begun paying more than $50 billion in settlements to state and local governments, and the payments will stretch over nearly two decades, KFF Health News (formerly Kaiser Health News) reports. It obtained documents from the court-appointed firm administering the settlements, showing the exact amounts that local governments have been allocated so far. To see them, click here.

Appeals court OKs plan that shields owners of Purdue Pharma from future lawsuits; they must give it up, donate

Purdue Pharma's headquarters in Stamford, Connecticut
(Photo by Drew Angerer, Getty Images, via The New York Times)

A federal appeals court has approved a settlement by Purdue Pharma, the maker of OxyContin, that protects its billionaire owners, the Sackler family, from future lawsuits. The Sacklers would give up the company, which would take the new name Knoa, "with its profits being sent to a fund to prevent and treat addiction," reports Geoff Mulvihill of The Associated Press.

"Family members would also contribute $5.5 billion to $6 billion in cash over time, or about half of what the court found to be their collective fortune, much of it held offshore. At least $750 million of that money is to go to individual victims of the opioid crisis and their survivors. Payments are expected to range from about $3,500 to $48,000."

Tuesday’s decision by The U.S. 2nd Circuit Court of Appeals in New York also protects the family from lawsuits "over the toll of opioids, even though they did not file for bankruptcy," AP notes. "The court’s ruling reversed a 2021 ruling that found bankruptcy court judges did not have the authority to approve a settlement that would offer bankruptcy protections for those who have not filed for bankruptcy."

The deal "would end claims filed by thousands of state, local and Native American tribal governments and other entities," AP reports. "Sackler family members have been clear that without the protections, they won’t hold up their part of the deal. . . . Several states had withheld support for the plan, but after a new round of negotiations last year, all of them came on board."

The sole remaining objector was the Office of the Bankruptcy Trustee in the Justice Department, which "did not immediately say whether it would appeal Tuesday’s ruling to the U.S. Supreme Court, ask the Circuit Court to review its decision or accept the ruling as is," AP reports. "Even without an appeal, it could be months before the bankruptcy plan takes effect."

Feds try to head off the newest big danger in illicit drugs; xylazine is cheap and causes rotting flesh wounds

Xylazine is legal only as a sedative for animals.
(Photo by Derek Montgomery, The Washington Post; click to enlarge)

Pain pills, heroin, synthetic opioids, fentanyl--what else can drug mixers cut into illegal drugs? Xylazine, that's what. It's a central-nervous-system depressant that is often mixed with fentanyl and can cause a deep stupor, reports Caroline Anders of The Washington Post: "It's known to cause rotting flesh wounds that, left untreated, can lead to amputations." Worsem it's a drug seller's dream: "It's extremely inexpensive, allowing sellers to extend their stores of heroin and fentanyl even further, and some users say it extends the sedative and euphoric effects of the opioids," Anders reports.

Xylazine is FDA-approved for veterinary use; its illegal use began to be noticed in the early 2000s, but "then became rampant in Philadelphia, and is now spreading across the United States. The Drug Enforcement Administration said the sedative was present in 23 percent of fentanyl powder and 7 percent of pills it seized in 2022," Anders writes. "Over 3,000 people died of xylazine-related overdoses in 2021 — triple the fatalities recorded the year before. But, importantly, those overdoses were all from mixtures of xylazine and opioids like fentanyl or heroin. . . . It's unclear exactly how xylazine interacts with opioids, though researchers are looking into the question."

"Last month, the Biden administration designated xylazine mixed into fentanyl as an emerging threat . . . . trying to prioritize federal resources to address the drug from the supply and demand side, both boosting testing and treatment and restricting the illegal supply of the tranquilizer," Anders reports. "In March, lawmakers also introduced bipartisan legislation that would classify the drug as a controlled substance." Rahul Gupta, director of the White House Office of National Drug Control Policy, told Anders that one of the key lessons the government learned from the fentanyl crisis is that "this two-pronged approach is crucial," Anders reports. "He said focusing only on how to cut off the drug supply is futile." Gupta told her, "If we do not address the unmet treatment needs for people with addiction, we will continue to suffer the same fate."

The government's move to criminalize xylazine hasn't made everyone happy. "Harm-reduction advocates argue the government is heading down the wrong path ... saying that the approach will just lead manufacturers and dealers to come up with new, potentially more dangerous substances to cut into their supply," Anders writes. "In the coming months and years, the administration's plan to tackle the crisis from multiple sides will be tested. But regardless of its effectiveness, experts say there will always be a new emerging threat." Mary Sylla of the National Harm Reduction Coalition, told Anders, "It's literally like whack-a-mole, right? We try to stop this here, and then something else pops up."

Alabama produces three Pulitzer Prizes, including two by a news outlet that's now online-only, and a book of history

The winner of the Fiction prize,
Appalachia's first since 1958

Two online-only publications covering Alabama and Mississippi, including the states' rural areas, were among Monday's winners of Pulitzer Prizes in journalism. In prizes for books, one on a rural Alabama county won the prize for History, and the Fiction prize went to Barbara Kingsolver's latest book based in rural Appalachia.

The top Pulitzer, for Public Service, went to The Associated Press for its coverage of the besieged Ukrainian city of Mariupol, and the finalists were the Austin American Statesman for its coverage of the school massacre in Uvalde, Texas, and The Washington Post for its investigation of the fentanyl crisis. Perhaps indicating how close the Austin paper came to winning, the Uvalde shooting was mentioned among major news events in the script introducing the announcement of the prizes. 

The prize for Local Reporting was shared by two online-only publications: Mississippi Today, for Anna Wolfe's investigation that revealed how a governor steered millions of  "welfare dollars to benefit his family and friends, including NFL quarterback Brett Favre," and AL.com, for the series by John Archibald, Ashley Remkus, Ramsey Archibald (John's son) and Challen Stephens that revealed "how the police force in the town of Brookside preyed on residents to inflate revenue, coverage that prompted the resignation of the police chief, four new laws and a state audit," the announcement says.

AL.com is owned by the Newhouse family's Advance Publications, which stopped printing its newspapers in Birmigham, Mobile and Huntsville this year. It won another Pulitzer, for Commentary, Kyle Whitmire's  "measured and persuasive columns that document how Alabama's Confederate heritage still colors the present with racism and exclusion, told through tours of its first capital, its mansions and monuments – and through the history that has been omitted."

Barbour County (Wikipedia)

A book about a southeast Alabama county, Freedom’s Dominion: A Saga of White Resistance to Federal Power, by Jefferson Cowie of Vanderbilt University, won the History prize. The announcement said Barbour County, where George C. Wallace was born and raised, was "shaped by settler colonialism and slavery," and the book "illustrates the evolution of white supremacy by drawing powerful connections between anti-government and racist ideologies."

The Fiction prize was shared by Kingsolver for Demon Copperhead, "a masterful recasting of David Copperfield, narrated by an Appalachian boy whose wise, unwavering voice relates his encounters with poverty, addiction, institutional failures and moral collapse–and his efforts to conquer them," and Hernan Diaz for Trust, "a riveting novel set in a bygone America that explores family, wealth and ambition through linked narratives rendered in different literary styles, a complex examination of love and power in a country where capitalism is king." Kingsolver lives in southwest Virginia and grew up in Kentucky; her Fiction prize was the first to go to an Appalachian writer since James Agee of Knoxville won it for A Death in the Family in 1958, reports Lilly Knoepp of Blue Ridge Public Radio.

Race and ethnicity figured in other rural-oriented prizes. The Audio Reporting prize went to the staff of Gimlet Media, "notably Connie Walker, whose investigation into her father’s troubled past revealed a larger story of abuse of hundreds of Indigenous children at an Indian residential school in Canada, including other members of Walker’s extended family, a personal search for answers expertly blended with rigorous investigative reporting."

African American banjo and fiddle player Rhiannon Giddens, a native of North Carolina, and Michael Abels won the Music prize for "Omar," an opera "about enslaved people brought to North America from Muslim countries," the announcement says, adding that the work "respectfully represents African as well as African American traditions, expanding the language of the operatic form while conveying the humanity of those condemned to bondage." For the full list of prizes, click here.