Kentucky recorded 19 fewer drug-overdose deaths in 2012 than the year before.
The deaths of 1,004 people instead of 1,023 might not sound like big news, but it was certainly a welcome change after more than a decade of rising drug abuse and deaths.
It wasn't the only good sign, said Van Ingram, head of the state Office of Drug Control Policy.
For instance, one survey showed that drug use was down among Kentucky teens, and a separate federal survey released in early 2013 indicated that Kentucky no longer led the nation in one key measure of prescription-drug abuse in 2010-11, as it did just a few years earlier.
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The number of state residents 12 and older who reported nonmedical use of prescription pain relievers, at 4.48 percent, was slightly below the national average of 4.57 percent, and far below the top rate of 6.37 percent in Oregon, according to estimates from the Substance Abuse Mental Health Services Administration.
"To me, that's a good place to be after all those years of being above the national average," Ingram said.
Not all the news is positive, however.
Although the most recent federal estimate found an overall decline in abuse of certain painkillers, the number of Kentucky residents who said they were dependent on illicit drugs in 2010-11 remained slightly above the national rate.
Overall, there is no reason to think the level of substance abuse in Eastern Kentucky is lower than a decade ago, said Robert Walker, with the Center for Drug and Alcohol Research at the University of Kentucky.
"It's ubiquitous," he said.
Brent Turner, commonwealth's attorney for Floyd County since 2000, was among several police officers and prosecutors interviewed by the Herald-Leader who said the level of drug abuse in Eastern Kentucky is not improving.
"I think it's worse now than when I started," Turner said.
The latest threat is heroin, which many officials fear is becoming a popular substitute as prescription pain pills become harder to find because of a state crackdown. Even as total deaths from drug overdoses declined slightly in 2012, deaths attributed to heroin shot up: from 22 in 2011 to 143 in 2012, according to the Justice and Public Safety Cabinet.
The number has continued to rise this year.
Deaths involving heroin accounted for 19.56 percent of overdose cases handled by state medical examiners in 2012; through the first nine months of 2013, heroin was present in 26 percent of fatal overdose cases, Ingram said.
"There's always another threat," Ingram said.
'Lock 'em up or forget it'
In many ways, Kentucky wasn't prepared to deal with a spike in prescription drug abuse that started in the late 1990s.
The state had a computerized monitoring system aimed at keeping people from getting prescriptions from multiple doctors, but it took weeks to make data available. Most doctors didn't use it.
Education and prevention programs were nonexistent in many places. Police were stretched thin in Eastern Kentucky's rural counties and small towns, where abuse shot up first. Treatment and recovery options were in short supply.
"It was lock 'em up or forget it," said Dan Smoot, a former state police narcotics officer who now heads Operation UNITE, an anti-drug initiative in Southern and Eastern Kentucky.
Each time police and lawmakers developed a response to the problem, the drug threat shifted.
In the late 1990s and early 2000s, there were a number of notorious "pill mills" in the state — clinics where unscrupulous doctors wrote prescriptions to addicts in return for cash, usually with little real examination. One doctor, Fortune Williams, wrote prescriptions for more than 2.3 million pills in 101 days at a Lewis County office he opened in 2000, state medical regulators said.
After authorities cracked down and the state beefed up its prescription-monitoring system, drug abusers started ordering pain pills and anti-anxiety medicines from shady Internet pharmacies. The legislature put new rules in place in 2005 to close off that pipeline.
Then, it became commonplace for Kentucky residents to visit Florida by the carload to get prescriptions because clinics there were poorly regulated and the state had no prescription-monitoring system.
Florida was home to 98 of the top 100 prescribers of the pain medicine oxycodone in 2010. In May of that year, police raided one South Florida doctor and found files on 1,400 patients, most of them from Eastern Kentucky, according to documents in a federal court case.
Police estimated that 60 percent of the pills sold on the black market in Kentucky in 2010 were prescribed in Florida, Kentucky Attorney General Jack Conway said last year.
Florida officials ultimately moved to crack down on pill mills, approving a prescription-monitoring system and tougher rules on pain clinics.
As officials in Florida and other states moved to curb pill mills, however, police started seeing a resurgence of the problem clinics in Kentucky, and not just in the eastern part of the state.
"We see a bunch of them, and they're growing," state police Lt. Todd Dalton told the Herald-Leader in November 2011.
Lawmakers ratcheted up the state's response in 2012, approving a law that mandated tougher standards on pain clinics, wider use of the state's prescription-monitoring system and continuing education on prescribing for health care providers. It also gave regulators power to act more quickly against people prescribing drugs improperly.
Of the more than 40 pain-management clinics state officials were aware of when the law went into effect, 24 have since closed, according to the state Cabinet for Health and Family Services.
There have been declines in prescriptions of the most-abused drugs in Kentucky under the law. From August 2012 through last July, prescribed doses of the painkiller hydrocodone dropped 10.3 percent from the previous year; for oxycodone, the decline was 11.6 percent, according to the Kentucky Office of Drug Control Policy.
With that law and other measures, including Kentucky's model prescription-monitoring system, the state has been at the forefront of tackling the epidemic of prescription abuse, officials said.
"We're one of the top states in terms of addressing the problem," said Mike Townsend, program manager for Recovery Kentucky, which provides recovery services for people with drug problems.
Prescription drugs haven't been the only problem, however.
Abuse of methamphetamine worsened as abusers learned how to combine certain cold and allergy medicine with other ingredients in crude homemade labs, setting off a chemical reaction to produce the highly addictive drug.
In response, lawmakers approved lower limits in 2012 on the amount of the cold medicine that people can buy without a prescription. The number of meth lab responses in Kentucky had gone up for years, hitting a high of 1,233 in 2011, but it dropped to 1,066 in 2012, according to Kentucky State Police.
Today, Kentucky has more tools to deal with substance abuse than a decade ago, officials said.
Recovery Kentucky, which opened a 100-bed center in 2007, now has 1,100 beds available and is planning to add 300 more, Townsend said.
The program uses a 12-step curriculum and peer counseling, but it is not classified as licensed treatment. Many of the beds are set aside for people coming out of prison or who are on probation.
Another program founded after the spike in prescription-drug abuse is Operation UNITE. The initiative, founded in 2003 by Republican U.S. Rep. Hal Rogers, covers 32 counties in Eastern and Southern Kentucky and includes money for drug treatment, prevention and education programs, and drug investigations.
In its first decade, more than 3,000 people started drug treatment with vouchers from UNITE, and its detectives arrested more than 4,100 people. Tens of thousands of young people have taken part in fishing events, camps, school clubs and other drug-prevention programs organized by UNITE.
The program spent $66 million its first decade, although its budget has dropped and it recently decided to cut staff.
Drug court programs are far more widely available than when the prescription drug epidemic started. Such programs cover 115 of the state's 120 counties, according to the Administrative Office of the Courts.
The goal of the program is to provide court-supervised treatment so people can stay out of jail. Participants take part in counseling and education programs, and they must undergo drug tests and pay obligations such as child support and fines.
A panel that includes judges, attorneys, community volunteers and drug court staffers meets regularly with participants to monitor progress and encourage them.
Many people drop out of the program, but more than 6,000 people have graduated since it began. Those who complete drug court are far less likely to be convicted of a new felony than people with similar drug problems who don't go through the program, the AOC has calculated.
Ashley Abner, 31, of Clay County said the program's supervision and support helped her beat addiction.
Before being arrested, she had abused pain pills, anti-depressants and meth for years, selling drugs, conning doctors and hustling her family for money. She started drug court in February 2011 to avoid jail, but she became determined to get clean.
"I wanted to be the kind of person I could hold my head up in public," said Abner, who works at a restaurant while studying nursing. "Drug court's what did it for me."
Waiting for help
Even with the expansion of some recovery options, people often have to wait to get the help they need.
There are about 2,400 treatment beds in Kentucky, but a federal survey estimated that there are 280,000 residents who need alcohol or drug treatment, according to Attorney General Jack Conway's office.
"We need more treatment beds throughout the state," Conway said in an interview.
When addicts decide they want help but are told there is a four- to eight-week wait, they will keep using drugs, said Gary Douglas, a clinician at Kentucky River Community Care, which provides substance-abuse, mental health and other services in Eastern Kentucky.
"Then they spiral even further downward," Douglas said.
The state's ability to provide licensed substance-abuse treatment has declined in recent years, said Walker, the UK drug-abuse researcher.
State funding for substance-abuse treatment has dropped from a high of $41.9 million in 2009 to $35.5 million in the current fiscal year, according to the state Cabinet for Health and Family Services.
However, a Medicaid expansion in the state under the federal Affordable Care Act will begin covering substance-abuse treatment for more recipients next year. The state has not announced which treatment services will be covered, but the expansion should reverse a decline in licensed treatment beds, a cabinet spokeswoman said.