Coming Together For Hope, Healing and Recovery

C MING
T GETHER
FOR
FOR
Hope,
Hope,
HEALING,
HEALING,
& RECOVERY
& RECOVERY
A plan to address substance use and misuse in Louisville
2
ACKNOWLEDGEMENTS
Special thanks to each organization and community member who provided insight and
expertise to make this action plan a reality. Our community thanks those who are directly
impacted by substance use disorder, their families, friends, and neighbors who contributed
their experiences to this plan.
Alkermes
Bates Memorial Baptist Church
Beacon House
BOUNCE Coalition
The Brook Hospital
Center for Behavioral Health
Centerstone Kentucky
Dismas Charities Inc.
Family Health Centers, Inc.
Ford Motor Company
Greater Louisville Medical Society
The Healing Place
Humana
Jefferson County District Court
Jefferson County Public Schools
Kentuckiana Health Collaborative
Kentucky Harm Reduction Coalition
Kentucky Injury Prevention and Research Center
Kentucky Recovery Resource Center
REPORT KentuckyOne Health
Louisville Metro Board of Health
COORDINATION AND Louisville Metro Council
Louisville Metro Criminal Justice Commission
PUBLICATION TEAM: Louisville Metro Department of Corrections
Louisville Metro Department of Public Health and Wellness
Louisville Metro Emergency Medical Services
Sarah Moyer, MD, MPH Louisville Metro Mayor’s Office
Aja Barber, MS Louisville Metro Office of Safe and Healthy Neighborhoods
Yu-Ting Chen, MPH, MS Louisville Metro Police Department
Wayne Crabtree, M.Div., CADC Louisville Urban League
Lauren Fenstemaker, MPA Louisville-Jefferson County Public Defender Corporation
Angela Graham, MPH, CPH My Chosen People Inc.
T Gonzales, MSW New Leaf Clinic
Rebecca Hollenbach, MPH, CHES Norton Healthcare Inc.
Ryan Irvine, BS The Office of the Jefferson County Attorney
Mark S. Jorrisch, MD Operation: PARENT
Dave Langdon, BS Our Lady of Peace
Matthew LaRocco, CADC Pediatric Dentistry, Shellie Branson D.M.D.
Ken Luther, MA, MMAS Renew Recovery
Priska Ndege, MPH Schenault Solutions, LLC
Takeisha Nunez St. Francis DeSales High School
Mary Powell, MPH Sullivan University College of Pharmacy
Brandy N. Kelly Pryor, Ph.D. Treatment Advisory Group
Sheila Redella, MS, CADC University of Louisville 550 Clinic
Sam Rose, M.Ed, CHES University of Louisville Hospital
Kathy Harrison Turner, BS University of Louisville Kent School of Social Work
University of Louisville School of Medicine
University of Louisville School of Public Health & Information Sciences
Graphic design: Danielle Waninger Volunteers of America Mid-States
3
CON
TENTS
TABLE OF CONTENTS
PAGE
3 ACKNOWLEDGEMENTS
7 EXECUTIVE SUMMARY
8 SUBSTANCE USE AND ADDICTION
12 TIMELINE OF SUBSTANCE USE IN AMERICA
15 SUBSTANCES OF USE: DRUGS, TOBACCO, ALCOHOL
16 DRUGS
25 TOBACCO
28 ALCOHOL
30 ROOT CAUSES
38 HOPE, HEALING, AND RECOVERY: GOALS TO MEET THE
CHALLENGES OF SUBSTANCE USE DISORDER IN LOUISVILLE
46 ADDITIONAL RECOMMENDATIONS FOR OUR COMMUNITY
54 COMING TOGETHER: CURRENT COLLABORATIONS IN LOUISVILLE
58 APPENDICES
59 APPENDIX 1: CHANGING THE CONVERSATION AROUND SUBSTANCE USE DISORDER
62 APPENDIX 2: GLOSSARY
66 APPENDIX 3. HISTORY AND BACKGROUND OF U.S. DRUG ENFORCEMENT
58 APPENDIX 4: COMMUNITY RESOURCES
70 REFERENCES
4
TABLE OF FIGURES
PAGE
17 1 - Death Rate Due to Drug Overdose, 2011-2016
18 2 - Inpatient Hospitalization and Emergency Department Visits Due to Acute
Drug Poisoning in Jefferson County, KY, 2012-2016
19 3 - Rates of Prescriptions Dispensed by Age and Gender for KIPDA Area
Development District, Kentucky 2016
20 4 - Overdose Runs Performed by Louisville Metro Emergency Medical Services
in 2016
21 5 - Drug Related Death Rates and Counts
22 6 - 2011-2016 Overdose Deaths in Jefferson County, KY
22 7 - Opioid Death Rate, 2011-2016
23 8 - Drug Poisoning Death by Type of Drug in Jefferson County, KY, 2011-2016
23 9 - Average Opioid Related Overdose Death Rates by Race and Sex,
2011-2016
24 10 - Kentucky Adult Marijuana Use Rate, 2015-2016
25 11 - Top 3 Causes of Death in Louisville, KY
26 12 - Percent of Adults Who Are Current Smokers, 2013-2016
26 13 - Average Percent of Current Adult Smokers, 2013-2016
27 14 - JCPS Students Grades 6-12 who Reported Smoking in Past 30 Days
28 15 - Alcohol-Induced Death Rates, 2011-2016
28 16 - Alcohol Induced Death Rates by Race and Sex, 2011-2016
29 17 - Binge Drinking Prevalence Among Adults Aged ≥ 18 Years by Census Tract,
Louisville, KY 2014
29 18 - Alcohol-Related Inpatient Hospitalizations in Jefferson County, KY, January
2015-June 2017
Data Note: We use Vital Statistics data throughout this report. This data indicates
deaths of Louisville residents no matter where their death occured.
FIG
Dear Community MemberS,
GREG FISCHER May Our vision is a healthy Louisville where everyone and every community
or thrives.
Our community, like so many across the country, is facing an opioid

epidemic that has resulted in thousands of overdoses and hundreds of
deaths. Addressing this crisis is a top priority for our city as we work to
prevent substance use disorder, overdoses, and death. As many in our
community know, the issue of substance use disorder does not begin
and end with opioids; there are many substances like alcohol, tobacco,
and other drugs impacting many people across our community.
Substance use disorder is a complex, but not insurmountable problem,

especially when we come together as a community to align our
resources and expertise. Louisville is taking a collaborative approach—
and using best practices from other communities—to bring the epidemic
under control. As with all emergencies, we needed an updated plan to
help us accelerate our efforts to combat the crisis.
We began the work of creating a city-wide plan by convening

community members who are passionate about changing the course
of substance use disorder in Louisville, including: people in recovery,
leaders of nonprofits, law enforcement, health care providers, social
workers, school officials, concerned parents, scholars, and many more.
DR. SARAH MOYER These community members spent last fall working in four groups
Dire
c tor focused on distinct issues: Primary Prevention and Education, Opioid
- Lo
ui Overdose Prevention, Recovery Support, and Expanding Access to
Treatment. They reviewed data, explored best practices and examples
sv
il
from our own city and other communities and discussed potential
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M
solutions.
etr
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epa
From their insights, expertise, and recommendations come this

rtm
comprehensive report and two-year action plan. This plan is designed to

ent of Public Healt
better coordinate ongoing efforts, add new efforts to fill in the gaps, and
engage new partners and resources to tackle the issue of substance use
disorder.
Finding solutions and creating a more resilient community is a task that

ha
requires the involvement of all of us. We look forward to working with

n
you to continue to make Louisville a place where everyone and every

dW
community can thrive.

ell n
es
s
In community,
Greg Fischer
Mayor
Dr. Sarah Moyer

Director, Chief Health Strategist
6
EXECUTIVE SUMMARY
We want a Louisville where everyone and every community thrives. Together we are creating a
Louisville where every person can have a healthy and fulfilling life, and reach their full potential. We
are using our resources to meet the challenges brought on by substance use disorder; we can meet
these challenges at every level of our community, including in our homes, with family and friends,
at work, in our largest institutions, and within government. When we come together we can foster
hope, healing, and recovery in Louisville.
While the challenges of substance use disorder may seem daunting, they can be met
and overcome with a public health approach. It is an approach that has worked for
other issues, including childhood infectious diseases, lead poisoning, and motor
vehicle accidents, leading to a significant increase in life expectancy in the United
States over the past 120 years.
A public health approach involves studying root causes, identifying risk factors,
designing interventions to address these factors, and evaluating the effectiveness of
those interventions. Many stakeholders working together across many sectors can
improve the health of our community.
This report/action plan was designed with the input of many partners from across
Louisville committed to addressing substance use disorder in our community.
In the next two years, Louisville will provide:
Hope
1. Prevent and reduce youth substance use
2. Increase trauma informed care
3. Reduce stigma
HEALING
4. Increase harm reduction
5. Expand diversion from emergency rooms and jail
6. Improve connection to treatment
7. Measure the quality of treatment programs
RECOVERY
8. Establish guidelines for sober living houses
9. Make expungement affordable
10. Improve job placement
7
SUBSTANCE USE
AND ADDICTION
“Alcohol and drug misuse and related disorders are major public
health challenges that are taking an enormous toll on individuals,
families, and society. Neighborhoods and communities as a whole
are also suffering as a result of alcohol- and drug-related crime and
violence, abuse and neglect of children, and the increased costs of
health care associated with substance misuse. It is estimated that
the yearly economic impact of substance misuse is $249 billion for
alcohol misuse and $193 billion for illicit drug use.”
Facing Addiction in America: The Surgeon General’s Report on

Alcohol, Drugs and Health
9
Most people who live in Louisville know someone who has a substance use disorder and the
consequences that come with it. Substance use disorder is a clinical diagnosis that describes
the brain disease caused by the recurrent use of substances such as alcohol, illicit drugs
and tobacco. Substance use disorder is a significant public health issue in our city.2 It is a
community problem that requires community solutions.
The current national opioid epidemic has been called the worst drug crisis in American
history.3 According to the U.S. Centers for Disease Control and Prevention, during 2015
there were 52,404 overdose deaths in the United States, including 33,091 that involved an
opioid. In 2016, an average of 115 people in the United States died every day from an opioid
overdose.4
Like much of the country

and the region, opioid and
other drug use in Louisville
has increased over the past
“I have never been made to feel five years with devastating
results. Hospitalizations
uncomfortable or looked down
and emergency room visits
upon. I appreciate the testing and due to severe acute drug
services offered and the staff.” poisoning rose dramatically
from 2830 visits in 2012 to
- Syringe Exchange Participant
4437 visits in 2016; drug
overdose deaths have also
soared.5
In 2016, the age-adjusted

drug overdose death rate in
Louisville was more than double what it was in 2011.6 Substance use disorder and overdose
impacts every neighborhood. In 2016, Metro Emergency Medical Services (EMS) performed
overdose runs in every single Louisville Metro ZIP Code, without exception.7
While the use of illicit drugs garners significant media attention and community concern,
tobacco and alcohol use remain far more pervasive throughout Louisville and affect many
more people.
While smoking rates have been gradually coming down in recent years, the adult smoking
rate of 25.5% in Louisville remains well above the national rate of 15.1%.8 According to
the CDC National Youth Tobacco Survey, the use of e-cigarettes among young people has
surpassed the use of conventional cigarettes since 2011.9 Electronic cigarette use, particularly
among young people, threatens to reverse the trend of making nicotine addiction less
socially acceptable and of falling smoking rates.
10
”
Alcohol use disorder remains a serious problem across the United States. Government organizations like the
National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration
(SAMHSA) and the Centers for Disease Control and Prevention (CDC) continue to track the effects of alcohol on
public health. The age-adjusted alcohol-induced death rates in Louisville Metro continue to be higher than both
the state and national rates.10
While the challenges of drug, tobacco, and alcohol use across Louisville may seem daunting, they can be met
and overcome. A public health approach to this issue can meet the challenges our community faces; it is an
approach that has worked well in many other arenas, including safe water and air, childhood immunizations,
and prenatal care. This progress has led to a significant increase in life expectancy in the United States over the
past 120 years. The process involves studying root causes, identifying risk factors, designing interventions to
address these factors, and evaluating the effectiveness of programmatic efforts. Many stakeholders working
together across many sectors can improve the health of our community.
This report examines the root causes of substance use disorder specifically caused by recurrent use of illicit
drugs, tobacco, and alcohol in Louisville. It takes a science-based look at the problem as it presently exists.
It identifies a way our community can collaborate on solutions and identifies resources already in place. The
report makes best practice recommendations to bring about the day when substance use disorder in Louisville
is prevented, controlled, and treatment is widely and readily available.
This plan was developed with the contributions of many community organizations and individuals working
together in workgroups to identify strategies that can be undertaken to address substance use disorder in
Louisville. Ten major strategies have been identified for our community to take on over the next 2 years. Our
community will take on these strategies at this time because research and evidence indicate that they can have
the greatest impact drawing on our current community assets. We know much more can and must be done,
and so this document includes the full list of recommendations identified by the workgroups and community
feedback through the planning process.
Never before have we needed to work

so closely with partners throughout
our community to ensure our systems of
care are strong, prevention efforts are
enhanced, and treatment is accessible.
- Jennifer Hancock, LCSW
11
TIMELINE OF SUBSTANCE USE IN AMERICA
This timeline demonstrates how policies and practices have shaped today’s landscape.
1914
The Harrison Narcotics Act: U.S.
federal law that regulated and taxed
1875 the production, importation, and
The First American distribution of opiates and coca
1900
1800 Anti-Drug Law:
San Francisco
ordinance that
outlawed the
smoking of opium in
products.
1920
1789 Temperance opium dens. Prohibition: The
Movement: A public U.S. government
push for temperance 1890 mandated the
— a limitation of The First ban of alcohol 1937
alcohol consumption Congressional manufacturing, The Marihuana Tax
or a total abstinence Act: The First sales and Act: A U.S. federal
from alcohol, with the Congressional consumption law that imposed
founding of the first Act levied taxes with the 18th tax on the sale of
American temperance on morphine Amendment to cannabis, hemp, or
society in Connecticut. and opium. the Constitution. marijuana.
1804 1910 1933 1947

Morphine: Morphine is distilled Driving Under End of Methadone:
from opium for the first time. the Influence Prohibition: Eli Lilly
(DUI): New The 18th Company
York City Amendment introduced
passed the was replaced methadone to
first law by the 21st the U.S. as a
against Amendment to potential aid
driving while the Constitution, those with an
intoxicated. and Prohibition addiction to
came to an end. heroin.
1909
Opium Exclusion
Act: Congress 1924
passed an act Heroin Act: Prohibited the
that barred the manufacture, importation and
importation possession of heroin – even
of opium for for medicinal use.
smoking as of
April 1, 1909.
1898
Heroin Produced: Heroin is first produced
commercially by the Bayer Company. It is dispensed
to individuals who are addicted to morphine.
12
1965
Federal Cigarette Labeling and Advertising Act:
Requires a health warning on cigarette packages.
1965
Drug Abuse Control Amendment: Restricted
research into psychoactive drugs, such as LSD, by 1989
requiring FDA approval. Mothers against Drunk Drivers
(MADD): Formed to stop
underage drinking and promote
1970 awareness of the problem of
Public Health Cigarette Smoking:
drunk driving.
Prohibits cigarette advertising on
television and radio.
1996
Pain the “Fifth Vital Sign”:
American Pain Society
1970 began a campaign that pain
First Methadone Clinic Opens in NYC. was the fifth vital sign.
1973 1996 OxyContin:

Drug Enforcement Agency Purdue Pharma releases
(DEA): By Executive Order, the OxyContin, timed-release
DEA was formed to take place oxycodone, marketed
of the Bureau of Narcotics and largely for chronic-pain
Dangerous Drugs. patients.
1970’s Early
War on Drugs and the 1990s
Controlled Substance Patient Right to Pain Relief
Act: Classified controlled Begins: Doctors began
substances into five prescribing opiates (and other
schedules and put select medications), as patients felt
plants, drugs, and chemical they have a right to pain relief.
substances under federal
1988
jurisdiction.
Anti-Drug Abuse Act of 1988:
Established the Office of National
1964 Drug Control Policy (ONDCP) in the
First Report of the Surgeon General’s Executive Office of the President.
Advisory Committee on Smoking and 1984
Health: Identifies smoking as a cause of The National Minimum Drinking Age Act of 1984:
increased mortality rates. The bill forced all states to raise their drinking age from
18, 19, or 20 to 21.
1960’s
The National Traffic Highway Safety
Association: Confirmed the connection 1986
between alcohol intoxication and Needle Exchange Programs: The first organized public
impairment while operating a motor distribution of drug injection equipment in the U.S.
vehicle. happened in New Haven, Connecticut, and Boston,
Massachusetts.
13
2009
Family Smoking Prevention and Tobacco Control Act:
Gives the Food and Drug Administration (FDA) the power
to regulate the tobacco industry. Also bans flavored
cigarettes, places limits on the advertising of tobacco
products to minors and requires tobacco companies to
seek FDA approval for new tobacco products.
2000 2000
The Drug Addiction
Treatment Act: Enables
qualified physicians to
prescribe and/or dispense
2010
Fair Sentencing Act:
2015
Kentucky Revised Statutes 218A.510
(Kentucky Harm Reduction and Syringe
Exchange): Bill passed allowing local health
departments to operate an outreach
program in which individuals can exchange
narcotics for the purpose of used needles and syringes for clean needles
Reduced the disparity
treating opioid dependency. and syringes.
between crack and
powder cocaine
2001 sentencing; the disparity 2016
Joint Commission on had meant that people Comprehensive Addiction and Recovery
Accreditation of Healthcare faced longer sentences Act of 2016: Section 303 amends the
Organizations (JCAHO): for offenses involving Controlled Substance Act allowing
Added pain management to crack cocaine than for Nurse Practitioners and Physician
patient satisfaction surveys, offenses involving the Assistants to become eligible to prescribe
resulting in increased opioid same amount of powder buprenorphine for the treatment of
prescriptions. cocaine. opioid use disorder.
2006 2012
2006 Patient Limit 30/100: Kentucky House Bill 1:
Allows physicians who Set the mandatory prescribing and dispensing
have been certified to standards for controlled substances in Kentucky. This
prescribe certain drugs legislation led to the establishment of the Kentucky All
for the treatment of Schedule Prescription Electronic Reporting (KASPER).
opioid dependence under
DATA2000 to treat up to 2012
100 patients. Medicare Reimbursement Linked to Patient
Satisfaction: Under the Affordable Care Act, one
2006 percent of total hospital Medicare reimbursement was
Electronic cigarettes: cut, unless hospitals could demonstrate a high patient
Were first successfully satisfaction score.
introduced and marketed
in the U.S.
2005
Controlled Substance Act Amendment: Public law 109-56 removed the
30-patient limit on group medical practices that treat opioid dependence
with buprenorphine.
14
“This plan is necessary to
address the growing
opioid crisis and other
types of addiction, save
and enhance lives, and
allow for family healing.”
- Andrew Davidson, LCSW, LCADC
“I appreciate
being treated
respectfully, as a
human being.”
- Syringe Exchange Participant
15
SUBSTANCES OF USE:
DRUGS, TOBACCO, ALCOHOL
By almost any measure, we are living through the biggest
drug epidemic in American history. Almost half-a-million
Americans have died in the last 15 years from an overdose,
most of them from opioids.
16
DRUGS
On average, 115 people in the United States are dying each day from overdose.11
Substance use disorder is having a devastating impact on Louisville residents and
their families; overdose deaths in Louisville have continued to rise since 2011 (Figure
1). A Centers for Disease Control and Prevention (CDC) study found that while opioid
prescribing has fallen in some parts of the country, opioid prescribing remains
considerably higher than it was prior to 1999.12 Many Louisvillians have turned to street
opioids, such as heroin, which are readily available and are often cheaper. Beyond opioids
and heroin, members of our community and their families are affected by a number of
other substances including tobacco, alcohol, other prescription drugs, and illicit drugs like
methamphetamines and marijuana.
Death Rate Due to

Drug Overdose,* 2011-2016
50
45
Death Rate per 100,000 Population*
40
35
30 Louisville Metro
25
Kentucky
20
United States
15
10
5
0
2011 2012 2013 2014 2015 2016
Figure 1
Death Rate Due to Drug Overdose*, 2011-2016
*Unintentional/ Undetermined; Age-adjusted
Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-
2016 on CDC WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death
Files, 1999-2016, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics
Cooperative Program.
17
Drug use is not a new problem in the United States. The heroin epidemic of the 1960s
and 70s was spurred by soldiers returning from Vietnam who had used overseas. This
By 2015, epidemic, as well as the crack cocaine epidemic of the 1980s and 90s, primarily affected
according to the poor, urban areas, and people of color.13 The federal approach to the issue at that time
CDC, enough was to be “tough on crime,” rather than to enact a public health response strategy.
pills were being
prescribed for Beginning in the late 1990s and early 2000s, the rate of opioid prescriptions began to
every American snowball. By 2015, according to the CDC, enough pills were being prescribed for every
to be medicated American to be medicated around the clock for three straight weeks.14 Opioid medications
around the clock can lead to dependency within just a matter of days; this flood of prescriptions led to a
for three straight surge of substance use disorder.15 There has also been a steady rise in overdose fatalities.
weeks.
The most obvious health impacts of substance use are dependency, overdose, and
premature death. According to the National Institute on Drug Abuse (NIDA), depending on
the particular drug, health outcomes can also include heart disease, stroke, and cancer or
lung disease.16 Substance use can worsen a person’s mental health, isolate them from their
support system, or impact their ability to maintain housing or employment.
Prescribed drugs, when used improperly or in excess—and the use of illicit drugs—can lead
to poisoning or overdose. When this happens in great numbers, it places a significant stress
on our health and human services. In Louisville, hospitalizations and ER visits due to severe
acute drug poisoning, especially due to heroin, have skyrocketed over the past five years.17
From 2015 to 2016, Louisville Metro saw a steep increase in the number of inpatient
hospitalizations and emergency department visits (Figure 2).18
Figure 2
Inpatient Hospitalization and
Emergency Department Visits Due
to Acute Drug Poisoning in Jefferson
County, KY, 2012-2016
Drug-related inpatient hospitalizations

and emergency department visits by
County: 2012-2016. Kentucky Injury
Prevention and Research Center. May
2017. Retrieved from http://www.
mc.uky.edu/kiprc/pubs/overdose/
county-profiles.html. January 2018
18
Hospitalizations for acute heroin poisoning in
Louisville Metro in 2016 were 5 times higher than
in 2012 (Figure 2).19 This trend contrasts to that of
other drugs, such as benzodiazepines and cocaine,
which remained relatively stable over this time
frame. Opioid related hospitalizations were also 2.5
times higher in 2016 than in 2012 (Figure 2).20
A closer examination shows the availability of different kinds of prescribed opioids in our
community. In the Kentuckiana Regional Planning & Development Area (KIPDA), which
includes Jefferson County and surrounding counties, hydrocodone prescriptions were
dispensed to females of all ages at higher rates than males—with the highest dispensing
rate among females ages 65 and older (Figure 3).21
Rates of Prescriptions Dispensed by Age and Gender for KIPDA

Area Development District, Kentucky 2016
1000
Prescriptions dispensed per 1000 persons
900
800
Figure 3 700
Rates of Prescriptions 600
Dispensed by Age and 500
Gender for KIPDA Area 400
Development District, 300
Kentucky 2016 200
100
2016 Annual KASPER Threshold
Analysis Report. Kentucky 0
Injury Prevention and Research 0-16 0-16 17-24 17-24 25-34 25-34 35-44 35-44 45-54 45-54 55-64 55-64 65+ 65+
Center. 2017. Retrieved from Female Male Female Male Female Male Female Male Female Male Female Male Female Male
http://www.mc.uky.edu/kiprc/ Age in years, Gender
files/drug/2017/2016-KASPER-
Annual-Threshold-Report.pdf. Alprazolam Hydrocodone Oxycodone Buprenorphine-Naloxone
January 2018.22
19
Substance use in Louisville is a community-wide issue, affecting every neighborhood. In
2016, Metro Emergency Medical Services (EMS) performed overdose runs in every single
Louisville Metro ZIP Code, without exception (Figure 4).23
Figure 4
Overdose Runs Performed by Louisville Metro Emergency Medical Services in 2016
Louisville Metro Emergency Medical Services, 2016
Overdoses tax our emergency services and health care providers. Unfortunately, not
everyone who overdoses is able to survive. Substance use disorder is proving fatal for
many Louisville residents; overdose deaths in Louisville have risen every year since 2011
(Figure 5).24
20
Drug Related Death Rate and Counts*
TOTAL # DEATH RATE
YEAR OF DEATHS PER 100,00*
2011 134 18.2
2012 161 21.9
2013 170 22.9
2014 176 27.2
2015 205 27.2
2016 312 43.0
Figure 5
Drug Related Death Rates and Counts
* Age-adjusted
Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause
of Death 1999-2016 on CDC WONDER Online Database, released December, 2017. Data are from the
Multiple Cause of Death Files, 1999-2016, as compiled from data provided by the 57 vital statistics
jurisdictions through the Vital Statistics Cooperative Program.
Regardless of drug, Louisville’s overdose death rate is more than double the national
rate. In 2015, Louisville’s overdose death rate for all drugs exceeded that of Kentucky and
continues to climb25 (Figure 1). In 2016, the rate was 43 per 100,000 residents (Figure 1).
As with overdoses, every part of the Louisville community is experiencing the effects of
drug overdose deaths. From 2011 – 2016, there were overdose deaths in nearly every
Louisville ZIP Code (Figure 6).26
“This program saved my life.”

- MORE Center Participant
21
Figure 6
2011-2016 Overdose Deaths in
Jefferson County, KY
2011-2015 Kentucky Vital

Statistics. Age-adjusted to 2000
U.S. Standard Population.
Opioids are in large part driving the increase in overdose deaths. The age-adjusted
opioid death rates climbed from 2011 to 2016 in Louisville Metro, Kentucky as well as
nationwide. In 2016, Louisville Metro’s opioid death rate surpassed the rate for Kentucky
(Figure 7).27
Figure 7 *
Opioid Death Rate*, 2011-2016
*Unintentional/undetermined;
Age-adjusted
Centers for Disease Control and

Prevention, National Center for
Health Statistics. Underlying
Cause of Death 1999-2016 on
CDC WONDER Online Database,
released December, 2017. Data
are from the Multiple Cause
of Death Files, 1999-2016, as
compiled from data provided
by the 57 vital statistics
jurisdictions through the Vital
Statistics Cooperative Program.
The cause of overdose deaths has changed over time with the change of drug supply. In
2016, overdose deaths caused by synthetic opioid analgesics, such as fentanyl, were 10
times higher than in 2012. Additionally, heroin-related overdose deaths were 7 times
higher than in 2011 (Figure 8).28
22
Figure 8
Drug Poisoning Death by Type of
Drug in Jefferson County, KY, 2011-
2016
*Unintentional/undetermined drug
poisoning death

Prevention, National Center for
Health Statistics. Underlying
Cause of Death 1999-2016 on CDC
WONDER Online Database, released
December, 2017. Data are from
the Multiple Cause of Death Files,
1999-2016, as compiled from data
provided by the 57 vital statistics
jurisdictions through the Vital
Statistics Cooperative Program.
From 2011 to 2016, the non-Hispanic White population had a higher age-adjusted death rate
compared to the non-Hispanic Black population (non-Hispanic White: 18.6 deaths per 100,000
population; non-Hispanic Black 9.5 deaths per 100,000 population), and males had a higher
death rate than females (male: 21.3 death per 100,000 population; female: 9.6 deaths per
100,000 population) in Louisville Metro (Figure 9).29
Figure 9 Average Opioid Related Overdose

Average Opioid Related Death Rates by Race and Sex, 2011-2016*
Overdose Death Rates by
Race and Sex, 2011-2016 Louisville Metro Kentucky United States
COUNTS RATES COUNTS RATES COUNTS RATES
* Age-adjusted
TOTAL 682 15.3 4629 18.1 178131 9.4
Centers for Disease
Control and Prevention, White 576 18.6 4388 19.9 139590 12.0
National Center for Health
Statistics. Underlying Black 90 9.5 184 8.5 19880 8.0
Cause of Death 1999-
2016 on CDC WONDER Hispanic 11 ** 37 4.4 14398 4.6
Online Database, released
December, 2017. Data are Other ** ** 14 ** 3064 2.3
from the Multiple Cause
of Death Files, 1999-2016, Male 468 21.3 2953 23.3 119141 12.7
as compiled from data
provided by the 57 vital Female 214 9.6 1676 13.0 58990 6.1
statistics jurisdictions Racial categories are non-Hispanic
through the Vital Statistics
** Data is suppressed due to counts under 10 or unreliable rates
Overdoses have steeply risen over past years, primarily driven by opioid use and an increase
in fentanyl. Those who are White and men are seeing the highest death rates. There are still
several groups for whom we cannot track overdose death rates, including lesbian, gay, bisexual,
and transgender individuals; current data collection must expand to include these categories.
23
MARIJUANA
The opioid epidemic in the United States has occupied a significant amount of community
and health attention across the country, but other drugs like marijuana remain an
important public health issue. Marijuana is the most commonly used illicit drug in the
United States; in 2015, use in the past month had risen to over 22 million people (ages
12+) in 2015.30 Between 2015-2016, nearly 13% of Kentucky residents over the age of 18
reported using marijuana at some point during the year (Figure 10).31 While the health
effects differ from those of opioids, there are immense short and long-term health
impacts such as inflammation of the airways and chronic bronchitis, declines in short-
term memory, and effects on adolescent brains which are still developing.32
13 %
Figure 10
Kentucky Adult Marijuana Use Rate, 2015-2016
SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health,
2008, 2009, 2015, and 2016 (2008 and 2009 Data – Revised March 2012).
As the number of states that have legalized cannabis has steadily increased, public
health messaging regarding cannabis will need to be responsive. Combatting the
unintended consequences of wider cannabis use has especially been needed in states
where recreational use has been legalized in addition to medicinal use, such as California
and Colorado. If legal, the same public health protections that we use for tobacco and
alcohol need to be applied, including: no driving under the influence, smoking regulations
to protect from second-hand exposure, legal age limits, and safe packaging to prevent
consumption by children.33
24
TOBACCO
It is not surprising that Louisville’s average adult smoking rate from 2013 to 2016 was
24.8%; this rate is well above the national average of 17.9%.34 For many years, Louisville
was the home of Big Tobacco. Firms such as Brown and Williamson, Phillip Morris and
Lorillard were major employers. The city was also surrounded by family farms whose cash
crop was government subsidized tobacco.
Smoking remains
the number Each year smoking is responsible for more than
one cause of 480,000 premature deaths in Americans age 35
and older.36
preventable death
in America today.35
More than 87% of lung cancer deaths, 61% of
pulmonary disease deaths, and 32% of all deaths
from coronary heart disease are attributable to smoking and exposure to secondhand
smoke.34 More than 10 times as many Americans have died prematurely from cigarette
smoking as have died in all the wars fought by the United Sates in its entire history.38
The top three causes of death in Louisville from 2011-2015 –cancer, heart disease, and
chronic lower respiratory disease –all have smoking as a common risk factor.39 While
Louisville and the United States have the same rate of heart disease death, Louisville has
a much higher rate of cancer, making it our leading cause of death (Figure 11).40
Top 3 Causes of Death in Louisville, KY

1. 2. 3.
USA Heart disease Cancer COPD*
169.9 163.6 41.6
1. 2. 3.
Louisville Cancer Heart disease COPD*
Metro 189.9 169.6 51.9
Figure 11
Top 3 Causes of Death in Louisville, KY
Louisville Metro Center for Health Equity: Health Equity Report

2011-2015 National Vital Statistics System, National Center for Health Statistics, CDC
Age-adjusted to 2000 U.S. Standard Population, rates per 100,000.
*COPD or Chronic Obstructive Pulmonary Disease is now known as Chronic Lower Respiratory Disease.
25
According to the Behavioral Risk Factor Surveillance System (BRFSS), although the
smoking prevalence has been declining both in Louisville and nationwide, the smoking
prevalence of Louisville is consistently higher than the nation by 7% (Figure 12).41
The same survey found a higher rate of Black persons who smoke than White persons,
as well as higher rates of male smokers than female smokers (Figure 13).42 This can give
public health officials ideas of where and how to target prevention and cessation efforts.
Figure 12
Percent of Adults Who Are
Current Smokers, 2013-2016

Prevention, National Center
for Chronic Disease Prevention
and Health Promotion, Division
of Population Health. BRFSS
Prevalence & Trends Data
[online]. 2015. [accessed Jan
09, 2018]. Retrieved from
https://www.cdc.gov/brfss/
brfssprevalence/.
Average Percent of Current Adult Smokers, 2013-2016

Louisville Metro Kentucky
TOTAL 24.8 25.8
Figure 13 White 23.3 25.6
Average Percent of Current Adult
Smokers, 2013-2016
Black 28.9 25.6
Centers for Disease Control and Hispanic ** **
Prevention, National Center
for Chronic Disease Prevention Other ** **
and Health Promotion, Division
of Population Health. BRFSS Male 25.1 26.8
Prevalence & Trends Data
[online]. 2015. [accessed Jan Female 23.6 24.8
09, 2018]. Retrieved from Racial categories are non-Hispanic
https://www.cdc.gov/brfss/
brfssprevalence/.
26
According to Jefferson County Public School’s annual Safe and Drug Free Schools Survey,
smoking has been declining among students from grades 6-12, although it refers only to
cigarettes and is not inclusive of e-cigarettes (Figure 14).43 Preventing starting smoking
at younger ages can help reduce overall smoking rates. Additionally, evidence suggests
that exposure to nicotine for junior high school students is connected to other drug use,
including marijuana and/or cocaine, during the high school years.44 Preventing the use
of tobacco cannot only help young people from becoming regular cigarette smokers, but
may help to prevent the use of other drugs in the future.45
Figure 14
JCPS Students Grades 6-12 who
Reported Smoking in Past 30 Days
2011-2016, Safe and Drug Free

Schools Survey, Jefferson County
Public Schools
*Note: Survey question language

was changed in 2013. Data based
on the following questions:
2011-2012: How many occasions (if
any) have you smoked cigarettes or
used other tobacco
products during the past 30 days?;
2013-2016: During the past 30
days did you smoke part or all of a
cigarette?
According to the Centers for Disease Control and Prevention National Youth Tobacco
Survey, the use of e-cigarettes among young people has surpassed the use of
conventional cigarettes since 2011.46 The 2014 CDC survey found current usage rates of
electronic cigarettes at 13.4% among high school students and 3.9% among middle school
students.47 These compare to usage rates for conventional cigarettes of 9.2% among high
school students and 2.5% among middle school students.48 Additional research is needed
to understand the scope of the long-term health effects of e-cigarettes on users. While
e-cigarettes release fewer harmful chemicals than traditional cigarettes, research shows
that the aerosol from e-cigarettes can be harmful to your health.49
27
ALCOHOL
Alcohol use remains a serious problem in the United States. Government organizations
like the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health
Services Administration (SAMHSA) and the Centers for Disease Control and Prevention
(CDC) continue to track the effects of alcohol on the public’s health, which include heart
disease, stroke and mental health issues.50
The age-adjusted alcohol-induced death rates in Louisville Metro are consistently higher
than state as well national rates. Louisville Metro had the highest age-adjusted death rate
in 2015 at 12.8, compared to 7.6 in 2011.51 While the rates were still climbing from 2015
to 2016 in Kentucky and nationwide, the Louisville Metro rates declined by 1.6 deaths per
100,000 population (Figure 15).52
During 2011-2016, the non-Hispanic White population had a higher alcohol-induced

death rate than the non-Hispanic Black population, and males had a higher rate than
females (Figure 16).53
Figure 15
Alcohol-Induced Death Rates, 2011-2016
* Age-adjusted
Centers for Disease Control and Prevention,

National Center for Health Statistics.
Underlying Cause of Death 1999-2016 on
CDC WONDER Online Database, released
December, 2017. Data are from the Multiple
Cause of Death Files, 1999-2016, as compiled
from data provided by the 57 vital statistics
jurisdictions through the Vital Statistics
Alcohol Induced Death Rates by Race and Sex, 2011-2016*

Louisville Metro Kentucky United States
Figure 16 COUNTS RATES COUNTS RATES COUNTS RATES
Alcohol Induced Death Rates by Race and Sex, 2011-
2016 TOTAL 539 10.5 2337 7.8 182175 8.5
White 448 11.8 2136 8.0 132753 8.9
* Age-adjusted Black 87 8.6 163 7.4 15754 6.4
Hispanic ** ** 25 4.3 23968 9.4
Centers for Disease Control and Prevention, National
Center for Health Statistics. Underlying Cause of Other ** ** 13 ** 8536 6.4
Death 1999-2016 on CDC WONDER Online Database, Male 396 16.3 1798 12.3 132877 12.8
released December, 2017. Data are from the Multiple
Cause of Death Files, 1999-2016, as compiled from Female 143 5.4 539 3.6 49298 4.6
data provided by the 57 vital statistics jurisdictions *Racial categories are non-Hispanic
through the Vital Statistics Cooperative Program.
28
Binge drinking occurs throughout Louisville with heavier pockets in university areas and in the
east and southeast portions of the county (Figure 18).54
From January 2015 through June 2017 there were alcohol related hospitalizations in every single
ZIP code in Louisville, with heavier concentrations in the west and southwest (Figure 18).55
Figure 17
Binge Drinking Prevalence Among
Adults Aged ≥ 18 Years by Census
Tract, Louisville, KY 2014
500 Cities Project: Local Data for

Better Health 2014. Centers for
Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion,
Division of Population Health.
Available from: https://www.cdc.
gov/500cities/about.htm
Figure 18
Alcohol-Related Inpatient
Hospitalizations in Jefferson
County, KY, January 2015-June
2017
Kentucky Inpatient Hospitalization

Claims Files; Cabinet for Health
and Family Service, Office of
Health Policy. Data are provisional
and subject to change. Counts
represent encounters of care and
could be greater than the number
of individual patients treated.
29
ROOT CAUSES
As detailed in the Louisville Metro Department of Public Health and Wellness 2017 Health Equity
Report, to improve population health, it is important to understand the root causes behind them. Root
causes impact health outcomes because the way an individual experiences a root cause often provides
either an advantage (such as higher income or more access to resources to cope with stress and
adversity) or a disadvantage (such as lower income and higher life stressors). These root causes create
environments with specific choices; the choices that residents make are shaped by the choices that are
available to them.
Root causes can influence the likelihood that someone may begin using substances, what kinds of
treatment they may be able to access, and how likely they are to successfully recover. Addressing root
causes can ensure that people are less likely to begin using substances and more likely to recover. An
examination of root causes is critical to finding long-term, systemic solutions.
These sections address some of the root causes that may contribute to whether an individual begins
using harmful substances or develops a substance use disorder, and whether they can successfully
recover. This is not an all-inclusive list, but rather a general overview of some of the top root causes.
30
EARLY CHILDHOOD
DEVELOPMENT
The World Health Organization (WHO) defines early childhood as the period of life that includes
prenatal to age eight.56 This time period is crucial to health and wellbeing across the life course,
due to rapid brain development and exposure to environments and experiences that can help or
hinder healthy growth.57
Child development is a function of both genetics and the environmental exposures that impact
a person from before they are born and as they grow. A mother’s use of illicit drugs, tobacco
or alcohol during pregnancy can have adverse effects on her baby’s brain development.58 The
incidence rate of Neonatal Abstinence Syndrome (NAS) in Kentucky is one of the highest in
the nation; Louisville is among the top 3 counties with reported NAS cases in Kentucky.59 Early
identification of women who use substances before and during pregnancy is critical to providing
appropriate health services and treatment referrals.
Substance use disorder and the opioid epidemic are impacting children and families in significant
ways. Nationally, the number of children entering the foster care system has increased over the
past several years; between 2012 and 2015, there was a 13% increase in the number of cases
that identified parental substance use as the reason a child was removed from their home.60
In Kentucky, the number of children in out-of-home-care rose by 17% from June 2011 to June
2016.61
During their early years, children need safe and nurturing environments to ensure they develop
the skills to learn, understand, reason and remember as well as to regulate their emotions and
participate in healthy relationships.62 Exposure to abuse and/or neglect in early childhood can
negatively impact development, causing difficulties with learning, regulation of emotions, and
social skills.
Long term, early exposure to childhood adversity can lead to trauma that negatively impacts
health and quality of life well into adulthood. Adverse childhood experiences (ACEs) have been
EARLY
shown to be associated with an increased risk for depression and suicide, sexual promiscuity,
smoking, illicit drug use (including intravenous drug injection) and alcoholism in adulthood.63
Early trauma and addiction later in life are strongly related.64
The child’s primary environment and source of
CHILD
experience is their family. Parents and caregivers—
especially those who have a history of ACEs or other
traumas—can learn skills and access resources to
A
help them provide healthy developmental supports.
HOOD
Families can build resilience in their own homes
when they understand the critical importance of
early childhood experiences, identify their own ACEs
and implement strategies to nurture their children.
B C
Strategies for strengthening families in these ways
DEVEL
include home visitation programs, which ensure
access to prenatal health care, resources for basic
needs like food and shelter, education about caring for
infants, and skill building for developmental discipline
OPMENT
and stress management.
31
NEIGHBORHOOD
DEVELOPMENT
Neighborhood development examines the economic and social characteristics of a neighborhood
and how they came to exist. Not only does this root cause consider what type of business and
developments are happening but it also examines the type of zoning laws and development
decisions that shape the resources of the community. Laws that allow greater development and
marketing of cigarettes and alcohol to vulnerable communities can have negative impacts on
those neighborhoods and can increase the risk of members of those vulnerable communities
developing substance use disorder.
Research shows that the alcohol outlet density of a neighborhood, determined by licensing and
zoning, is related to alcohol use and violence. High alcohol outlet density, defined as having a high
concentration of retail alcohol outlets in a small area, is an environmental risk factor for excessive
drinking. Additionally, one study found that when all other factors were controlled, higher initial
levels of drinking and excessive drinking were observed among
youths residing in ZIP codes with higher alcohol outlet densities.65
Kentucky has a long history with tobacco and alcohol use and there are many decades of research
showing patterns of strategic marketing to lower income communities and communities of color,
in particular Black communities, through point-of-sale marketing. Point-of-sale marketing includes
locating signage promoting cigarettes and alcohol near the check out.66 Research shows there is
a significant impact on smoking behaviors when tobacco companies target advertising toward
low income neighborhoods.67 For example, because lower income
communities have a higher density of convenience stores primarily
marketing and selling alcohol and tobacco products, residents have
more access to tobacco products than to fresh foods or full service
grocers. For those who do not smoke, neighborhoods with high
rates of smoking can also impact their health through increased
secondhand smoke exposure.68
NEIGH
Research suggests that having laws that protect vulnerable
communities from high alcohol outlet density and targeted
marketing would help to reduce substance use and violence in
those neighborhoods.69
BORHOOD
DEVEL
32
OPMENT
HEALTH AND
HUMAN SERVICES
Having access to comprehensive, integrated healthcare services can be a key factor in whether
someone develops and/or successfully receives treatment for substance use disorder. The
National Bureau of Economic Research (NBER) reports that there is a “definite connection
between mental illness and the use of addictive substances.”70 Often, a person with a mental
health issue such as anxiety, depression, bi-polar disorder, or schizophrenia will turn to cigarettes,
alcohol and illicit drugs, because they find it helps them cope or relieve symptoms of mental
illness. Unfortunately, excessive substance use brought on by addiction can trigger mental health
symptoms creating a cycle that may be difficult to treat.71
Expanding access to mental healthcare can ensure that residents are able to develop healthy
coping skills and effectively address trauma and underlying mental health issues before
developing substance use disorder. Additionally, ensuring that integrated services, which
simultaneously treat mental health and substance use disorders, are available and reimbursable
will improve success of treatment.
Other factors, such as having health insurance and the ability to pay for care, proximity to health
care services, and culturally-competent providers can impact a person’s access to quality health
and human services.72,73
Research results reveal a positive impact on uninsured individuals when they access affordable
coverage; after gaining health insurance, these individuals are more likely to successfully quit
smoking.74 Because those with lower incomes
are more likely to both be uninsured and use
tobacco, these results identify a long-term
impact of access to healthcare services for
those with the greatest need and the least
structural support.
HEALTH
AND
HUMAN
SERVICES 33
Education
Substance use disorders can impact anyone, regardless of their level of formal education.
However, research shows a connection between limited levels of education, such as not receiving
a high school diploma, and high rates of substance use.75 This doesn’t mean you’re more
susceptible to developing a substance use disorder if you don’t finish high school, or don’t go to
college. Instead, this reveals that formal education has a greater potential to provide protection
against risk factors that can lead to substance use, through things like steady employment, which
may then lead to steady income, housing, healthcare, transportation, and access to healthy
food.76
For students living in or around poverty, educational attainment in under-resourced schools

becomes all the more difficult.77 Along with the many consequences of not being able to afford
basic needs, children living in poverty can potentially be at a greater risk for substance use
disorders because of school conditions beyond their control, such as unqualified teachers, few
exploratory courses, or limited technology. Additionally, seeing the stark differences between
their quality of life and that of students with a stable income can negatively impact how they
envision their future.78
The interrelationship between education and substance use means that education level can
impact substance use, which in turn can impact future educational attainment. People struggling
with a substance use disorder are hindered in their
ability to succeed in formal education. Lack of formal
education can also impact a person’s income and
ability to access quality healthcare, including mental
EDU
healthcare.79 Once this cycle begins, it can be very
difficult to break.
Educational systems are also opportunities to engage

youth in leadership development opportunities and
extracurricular programs; they can learn such important
skills as positive self-expression, social-emotional
CATI
learning, problem solving, and coping skills that provide
protection against experimenting with and using
substances such as illicit drugs, tobacco, and alcohol.
ON
34
HOUSING
HO
The Substance Abuse and Mental Health Services
Administration (SAMSHA) recognizes the linkage between
substance use disorder and homelessness and vice versa.80
When a person is homeless, they are more likely to use
substances than someone with stable housing.81 People need
to have their basic needs met—including housing—before
they can address behavioral health, substance use disorders,
USI
chronic illnesses and other barriers to a stable life82.
Persons who are homeless and living with an addiction have been deemed “one of the most
vulnerable populations.”83 Undeniably, substance use disorder may be one factor leading to
homelessness; however, substance use may also be the result of coping with homelessness—
increasing the percentage of the population who become addicted to substances. The Office of
NG
National Drug Control
Policy states that of the chronically homeless population “30% have a serious mental illness and
around two-thirds had a primary substance use disorder or other chronic health condition.”84
Researchers state that there is a reduction of relapse when persons struggling with addiction
have stable housing.85
Establishing stable housing and supports leads to increased security and can empower
individuals. Successful supportive housing programs include social support, adaptable treatment
selections, and services that lead to social reintegration. Housing is foundational to addressing
substance use disorder, but housing alone is not sufficient to preventing or recovering from
substance use disorder.86
EMployment
aNd income
EMPLOYM
Anyone can develop a substance use disorder, but the financial resources an individual has—
and whether they have stable employment—can directly affect their stress, the amount and
ENT AND
type of drug they can access, as well as their ability to access healthcare.87 Higher income levels
can provide people greater access to buying alcohol, tobacco, other substances, and buying
them safely.88 Additionally, the income level of an individual with a substance use disorder may
determine whether they are able to seek treatment. There is not a one-treatment-fits-all fix
ICOME
when it comes to addiction; some individuals may have to try multiple types of treatment before
they discover the one that is right for them. Accessing and determining the right treatment can
lead to extensive medical bills which someone with a smaller income may not be able to afford.
Additionally, some insurance providers do not cover certain types of treatment, therefore,
requiring the patient to pay out of pocket.
35
CRIMINAL JUSTICE
The criminal justice system is made up of the many linkages between courts, law enforcement,
jails and prisons. This system is shaped by the laws that govern individuals at the local, state and
federal levels, and determine what actions and behaviors are criminalized.
In 2013, nearly 1 in 35 adults in the United States were incarcerated at some level during the
year; that equated to almost 6.9 million people.89 The numbers of incarcerated people has grown
significantly over the past few decades due in large part to sentencing patterns for substance-
related charges and incarceration of people who use drugs.90 Initiated in the 1980s, the War on
Drugs has expanded the sentences for drug related charges to be nearly 3 times as long today.91
Substance use and addiction have an established connection to the criminal justice system.
Incarcerated individuals have 4 times the rate of substance use and addiction as those who
are not incarcerated.92 There can be significant health impacts for those who are involved
with the criminal justice system, including: losing access to care for chronic health conditions,
mental health issues, and exposure to other infectious diseases.93 Additionally, the impact of
CRI
involvement with the criminal justice system creates other issues for people, including barriers
to housing and employment—additional root causes of health.94 Providing supports and greater
access to the expungement process can help to alleviate these barriers by removing some
offenses from a person’s record.95
Other impacts on individuals extend to their families and communities, and can especially
MI
be felt by children.96 Research shows that having at least one parent jailed during pregnancy
(regardless of if it is the mother or father), plays an
important role in the health outcomes for newborn
children.97 This means that those with substance
use disorder can often have compounding negative
consequences, making their treatment and recovery
more difficult. Laws and policies focused on
NAL
decriminalization and diversion can simplify the path
to recovery.
JUS
TICE
36
TRA
NSPO
TRANSPORTATION
RTAT
Transportation looks at the ways that people are able to move
through a community, whether by walking, biking, driving or taking
public transportation. It examines what infrastructure exists and
what kinds of transportation modes it supports. It also examines
TION
what kinds of laws or policies make the environment easier or more
difficult to navigate.98
Adequate transportation is an essential aspect of having access to services for the prevention
and treatment of substance use disorders. For instance, if an individual does not own a car, they
may be reliant on family and friends to juggle multiple schedules. The cost of regular public
transportation can also be prohibitive to individuals with low incomes. Additionally, routes from
one’s home to a needed service may be long, requiring several transfers, and still may not get
the person directly to where they need to go.99 Consistent and reliable forms of transportation
are needed to get people to and from services and to help ensure successful prevention and
treatment of substance use disorder.100
Impaired driving also has created safety issues within transportation systems resulting in serious
consequences for families, workers, and community members. Alcohol and drugs are a factor in a
significant percentage of transportation-related accidents each year; over a decade from 2003 to
2012, there were 2,041 deaths in Kentucky involving a driver who was intoxicated.101
SOCIAL/ CULTURAL
CAPITAL
SOCI
The social/cultural capital root cause examines the social norms and narratives
surrounding substance use and what social support is available to help people
with substance use disorder. How the media depicts substance use disorder in the
AL/
newspaper, television or movies affects how we deal with the condition in our city,
community, families, and individually. These portrayals have led to negative messaging around
substance use disorder, including depicting people with addiction as having a “moral failure”,
rather than acknowledging that they are dealing with a serious medical condition. Stigma can be
CUL
reinforced by derogatory terms.
The effects of stigma are many; stigma can prevent people from seeking the help they need
and lead to worse health outcomes because they are more likely to drop out of treatment.102
TUR
Additionally, people can face worse care from health care providers who may not think they
deserve treatment. Fear of losing, employment, social support, and housing can further prevent
treatment. Overall, stigma can have a negative impact on persons with substance use disorder by
preventing them from seeking care, and internalizing negative messaging. Stigma can also distract
AL
communities from evidence-based practices and may lead to misguided notions about with
interventions will be most or least successful.103 To improve outcomes for those with substance
use disorder, we must change the predominate narrative.
37
Hope, Healing, and Recovery
Goals to Meet the Challenges of Substance
Use Disorder in Louisville
38
Substance use disorder, like any other significant challenge our community faces,
will take many of us working together in every part of our community and at
every level. A comprehensive and effective strategy must reach across many
sectors and areas of our community. Addressing this public health issue means
we must aim to help people develop skills that allow them to avoid to substance
use and addiction, deal with the immediate effects of substance use, and meet
and overcome the challenges of the long-term effects and impacts of substance
use disorder.
This plan makes specific recommendations for evidence-based best practices

to address substance use disorder in Louisville over the next two years. Best
practices are evidence-based interventions—including policy change—which
have been applied in other localities and have proven to make a difference for
health. The following goals span the levels of the socio-ecological model: public
policy, community, organizational, interpersonal, and individual. We must include
interventions at each of these levels in order to reinforce their impact, and make
sustainable, long-term change.
GOAL:
GOAL:
To reduce the burden of
substance use disorder
in Jefferson County.
39
HOPE
40
HOPE
1 Prevent and Reduce Youth Substance Use
Establish a county-wide coalition in Louisville—representing at least 12 sectors
impacting youth and their families—to develop a 12-month action plan to prevent
and reduce youth substance use by September 2018. Apply for funding to implement
ROOT CAUSES: the plan by 2020.
A CHAMPION: One Love Louisville’s Substance Use Workgroup

B C
2
Increase Trauma Informed Care
Assess current initiatives in Louisville who have integrated resilience, trauma-
informed care, and Adverse Childhood Experiences (ACEs) screening into their work
with young people ages 0-24 by July 2018. Identify opportunities for organizational
collaboration and capacity building to integrate resilience, trauma-informed care,
and ACEs screening across community programming by October 2018. Initiate
training with 50% of Louisville’s youth-serving organizations by March 2019. ROOT CAUSES:
CHAMPION: BOUNCE Coalition

A
B C
3 Reduce Stigma
Develop a public health social media campaign for Louisville in collaboration with
community organizations and residents to promote the understanding of substance
use disorders, including the use of appropriate language around substance use by
ROOT CAUSES: July 2019.
CHAMPION: Louisville Metro Department of Public Health & Wellness
icon key:
BUILT EDUCATION FOOD ENVIRONMENTAL

ENVIRONMENT SYSTEMS QUALITY
HEALTH AND CRIMINAL A EARLY CHILDHOOD

HUMAN SERVICES HOUSING JUSTICE B C DEVELOPMENT
EMPLOYMENT NEIGHBORHOOD SOCIAL/

TRANSPORTATION
AND INCOME DEVELOPMENT CULTURAL CAPITAL
41
HEAL
ING
42
HEALING
4 Increase Harm Reduction
Provide increased harm reduction by securing additional funding sources
for syringe exchange mobile units, and naloxone availability and training for highest
areas of drug use/overdose in the community (i.e., public spaces such as the
ROOT CAUSES: library, TARC buses, government buildings, and businesses) by March 2019.
Expand naloxone administration training to 20% more first responders, local law
enforcement agencies, public safety agencies, and community organizations
by July 2019. Provide at least three additional syringe exchange mobile sites for total
of seven community sites by July 2019.
CHAMPIONS: Volunteers of America • Kentucky Harm Reduction Coalition
5
Expand Diversion From Emergency Rooms and Jail
Expand The Living Room array of services to create a 24/7 urgent behavioral health
environment in order to improve connecting citizens in mental health, substance
use disorder, or co-occurring crisis with immediate peer support, clinical triage and
referral/connection to appropriate community resources by June 2018. Identify ROOT CAUSES:
program funding by September 2018. Be fully operational by March 2019.
CHAMPION: Centerstone
6 Improve Connection to Treatment

Expand peer support to 24 hour coverage in emergency rooms in order to improve
connecting patients with substance use disorder to treatment by June 2018.
Identify program funding for Project ASSERT (Alcohol & Substance Abuse Services,
ROOT CAUSES: Education, and Referral to Treatment) by September 2018. Be fullly operational by
March 2019.
CHAMPION: University of Louisville Hospital
Measure the Quality of Treatment Programs

Develop 10 quality metrics for substance use disorder treatment providers in
Louisville to report, and a plan for how and when data will be shared by December
2020.
7
ROOT CAUSES:
CHAMPION: University of Louisville School of Public Health and Information Science
43
RE
COV
ERY
44
RECOVERY
8 Establish Guidelines for Sober Living Houses
Create and enact an ordinance providing necessary guidelines for sober living houses
(aka “recovery residences”) in the Louisville by Fall 2018.
ROOT CAUSES: CHAMPIONS: Louisville Metro Office of Resilience • Treatment Advisory Group
Make Expungement Affordable

Expand recovery support to increase access to housing and employment by
modifying existing legislation in Kentucky Revised Statute to make expungement
easier and more affordable, including: automatic expungement after 30 days for
9
dismissed misdemeanors, dismissed felonies, and acquittals by February 2019.
ROOT CAUSES:
CHAMPION: Louisville Urban League
10 Improve Job Placement

Establish a taskforce to determine how best to connect people in recovery to quality
employment in Louisville by September 2018. Expand the number of employers
hiring people in recovery by 10% by October of 2019.
ROOT CAUSES:
CHAMPIONS: KentuckianaWorks • Louisville Metro Department of Public Health &
Wellness
45
Additional Recommendations
for Our Community
46
The work of addressing substance use disorders
in Louisville needs many champions!
Which work will you be part of?
PUBLIC POLICY
national, state, local law
Connect with your elected officials!
COMMUNITY
relationships among organizations
How can we link resources together?
ORGANIZATIONAL
organizations, social institutions
Change where you work, learn,
pray, and play.
INTERPERSONAL
family, friends, social networks
Support each other!
INDIVIDUAL
knowledge, attitudes, skills
What you can do!
Here we include additional recommendations brought forward by

knowledgeable, compassionate, and skilled practitioners and other experts in our
community during this plan development process. These recommendations span
the levels of the socio-ecological model: public policy, community, organizational,
interpersonal, and individual. We must include interventions at each of these
levels in order to reinforce their impact, and make sustainable, long-term change.
See the references section of this report for more information about these
recommendations.
47
HOPE
Public Policy—shaping national, state, local law
Increase the age of sale for tobacco products from 18 to 21.104
Restrict marketing/sales of alcohol, controlled substances and tobacco.105
Limit density of liquor and tobacco stores.106
Increase the tax on tobacco and alcohol products to reduce demand and consumption
and prevent youth from starting.107
Implement childcare subsidies to help parents with low-income work more hours, stay
in jobs longer and increase overall earnings.108
A
Implement Paid Parental Leave Policies for working parents. An improvement in overall
B C and mental health has been demonstrated when leave is paid.109
Implement a state-level Earned Income Tax Credit (EITC) to aid wealth building and
alleviate poverty.110
Continue to develop, monitor, and enforce controlled substance prescription tracking

through out Kentucky All Scheduled Prescription Electronic Reporting system
(KASPER).111
Community—linking resources and building relationships

among organizations
A
Implement Youth in Europe Model. Proven, replicated model that has reduced substance
B C
use in Iceland and across Europe in adolescents from 40+% to 3%.112
A
Expand existing resiliency programs including BOUNCE, Compassionate Schools
B C Program, and home visitation programs such as HANDS, Healthy Start, and potential
future implementation of Parents as Teachers home visitation program.113
Continue to educate providers on prescribing practices for opioids, outlining Centers

for Disease Control recommendations, and advising prescribers of existing education
opportunities.114
Enforce prohibition of tobacco and alcohol sales to minors.115
48
Organizational—the changes organizations and social
institutions can make
Create worksite well-being through evidence-based programs that reduce
behaviors risk in work settings.116
Promote safe drug disposal in conjunction with retail pharmacy through

distribution of disposal bags, take-home chemical destruction kits, and/or
increased take-back sites.117
Interpersonal—coming together to support our friends and

family
Tell those you know, love, and care about that they can come to you for support and
help if they are struggling.118
Individual—what you can do

Learn which coping and stress management skills work for you; this may include
therapy. There are many resources online; search using terms “stress management”
and “self-care.”119
Learn and practice stress management skills that work for you: exercise, dance, music,
art, spiritual connection, talking things out with a friend, writing in a journal.120
Keep prescription medications out of reach of others, and don’t keep them in your
medicine cabinet when no longer needed.
HOPE 49
HEALING
Advocate for state regulation to allow safe/supervised injection sites based on other
urban models. (e.g., San Francisco, Philadelphia).121
Strengthen supports for public housing providers to avoid eviction when residents are
amenable to treatment for substance use disorder.122
Advocate for incarcerated individuals to keep their health insurance while in

jail.123
Expand medication-assisted treatment (MAT) services by enforcing ordinance

that facilities with MAT cannot be treated in a discriminatory manner with
respect to real estate.124
A
Promote and finance two-generation, family-centered treatment and support for
B C children under foster and kinship care.125

among organizations
Implement quick response teams (QRTs) with LMPD, EMS, social services, and substance
use disorder professionals in high risk Zip codes.126
Expand medication-assisted treatment (MAT) services by expanding providers initiating

MAT in emergency departments or at hospital discharge.127
Promote www.findhelpnowky.org, a real-time substance use disorder treatment

availability locator and information center for Kentucky. The locator contains treatment
providers and treatment openings across the Commonwealth of Kentucky including
community mental health centers; private, non-profit, and faith-based treatment
providers; and providers of medication-assisted treatment.
Advocate for improved mental health and medical services for people who are
incarcerated.128
50
Implement culturally competent care and treatment models to serve the diverse
communities in our city.129
Expand medication-assisted treatment (MAT) services by developing substance use

disorder consultation services at all major hospital systems in Louisville.130

family
Learn how to best support someone who is struggling and help connect them to
resources.

Attend a local Naloxone administration training.
HEAL
Find assistance at treatment and help centers in Kentucky.
ING 51
RECOVERY
Increase funding for the Louisville Affordable Housing Trust Fund and home improvement
loans and grants to help generate a greater inventory of healthy, affordable housing for
low-income residents.131
Utilize Medicaid to reimburse supportive housing programs that co-locate
employment, education, and health services.132
Support efforts to decriminalize the possession and use of illicit drugs to shift from a
punitive model to a treatment model.133

among organizations
Broaden public health-based approaches to rebuild workforce capacity among victims
of past drug epidemics.134
Extend the benefits of public health-based interventions to individuals who were

burdened by criminal justice rather than public health approaches to the disease of
addiction during America’s earlier opioid crisis.135

Be an advocate for employees by promoting prevention, early intervention, treatment,
and recovery.136
52
family
Cultivate strong relationships so that you are able to support each other.

Seek therapy for mental health issues and for unresolved traumatic events in your life.
Find a local support network that helps you keep on the path to recovery.
RE
COV
ERY 53
COMING TOGETHER:
CURRENT COLLABORATIONS IN LOUISVILLE
We know there are many joint efforts in Louisville to address
substance use disorder and its related challenges. Please let us
know if your organization’s efforts should be listed here.
CONTACT US:
https://tinyurl.com/LMPHWOAS
54
BOUNCE Coalition - BOUNCE endeavors to improve the future health of children in
Louisville, fostering the skills to bounce back from adversity with resiliency and grit through
the collaboration of diverse community partners. The BOUNCE Coalition is comprised
of leaders from 17 collaborating organizations which are committed to planning and
implementing evidence-based initiatives that promote child well-being, impact local systems
and policies to reduce risks for chronic diseases, and help youth practice healthy behaviors.
BRICC Coalition - University of Louisville’s Building Resilience in Campus Community

(BRICC) Coalition’s efforts to increase resilience and reduce high-risk drinking target individual,
group, organization and community levels.
Call to Action (CTA) Task Force - This group was convened by a small group
of residents in the summer of 2017 in response to the release of the report called “A Call to
Action: Louisville Heroin and Opioid Response Summit” by US Attorney, John Kuhn, Jr. The CTA
Task Force is a citizen-driven, independent, volunteer, and non-political group with an over-
arching goal to develop a strategic plan based on the key objectives identified in the report.
Drug Enforcement Agency (DEA) 360 Task Force - Coordinated law

enforcement operations targeting all levels of drug trafficking organizations, engaging drug
manufacturers, wholesalers, practitioners, and pharmacists through diversion control to
increase awareness of the opioid epidemic and encourage responsible prescribing practices,
and community outreach and partnership with local organizations following enforcement
operations. This group culminated in the report, “A Call to Action.”
Dual Diagnosis Cross-Functional Team (DDCFT) - This group was

convened by Mayor Fischer in January 2013 to improve the system response to individuals
with co-occurring mental health and substance use disorders who revolve in and out of jail,
community treatment, hospitals and emergency rooms. The DDCFT brings together external
community partners and local government to share information and discuss systemic solutions
specifically related to the varied needs of this population. An outcome of the Dual Diagnosis
Cross-Functional Team, is the Law Enforcement Assisted Diversion (LEAD) which offers
treatment access before the offender is booked rather than being charged and arrested for
non-violent drug crimes. The LEAD pilot will begin in 2018.
Kentucky Harm Reduction Coalition • the Louisville Syringe

Exchange Program (SEP) • University of Louisville Pharmacy
- At least twice a month the Kentucky Harm Reduction Coalition provides free overdose
prevention training to syringe exchange participants and their family members. In between,
SEP participants are given a naloxone voucher they can take to the University of Louisville
Pharmacy to receive free naloxone and training.
55
Louisville Metro Corrections (LMC) and local treatment
providers - When inmates are discharged they may request the Vivitrol shot. LMC
connects them with local treatment providers to continue treatment. (Vivitrol is a monthly
injection which blocks opioid receptors in the brain).
Louisville Metro Corrections • Louisville Metro Department

of Public Health and Wellness’ MORE Center - Provides medication-
assisted treatment and therapy to pregnant inmates.
Louisville Metro Dept. of Public Health and Wellness (LMPHW)

• Volunteers of America (VOA) - These agencies partner together to operate
Louisville’s syringe exchange program, a proven practice to stop the spread of HIV and blood
borne diseases. VOA works with LMPHW to operate four community syringe exchange
locations. Since it began in 2015, Louisville’s syringe exchange program has served more than
14,000 participants.
Louisville Urban League and the Reily Reentry Project - The

project is designed to assist Louisville Urban League clients and others seeking to expunge
their record. The project facilitates the expungement process and covers most, if not all,
related fees at no expense. Participants can enroll in any League program that will equip them
with the tools they need to be more successful as they move into more prosperous futures.
One Love Louisville Substance Use Prevention Group - One

Love Louisville is a comprehensive strategy to reduce overdose, suicide and homicide rates.
This group has worked over the past 2 years in small work groups focused on family support,
treatment, and prevention in the community.
Safe Medication Disposal - Safely disposing of prescription medications helps

to reduce the chances of accidental ingestion or intentional misuse. Many people who misuse
medications, such as opioids, get their first dose by using medications prescribed to other
people. Many Louisville agencies collaborate to ensure the safe disposal of prescription
medication by hosting regular “Drug Take Back” Days or by offering year round safe disposal
options. Those agencies include U.S. Drug Enforcement Office Louisville Division, Walgreens,
CVS Pharmacy, Louisville Metro Police, City of St. Matthews, and the Jefferson County Sheriff’s
Office. - Visit https://www.lojic.org/safe-medication-disposal-locations for map.
The Living Room - A voluntary, peer-operated safe and calming space for adults in
crisis. Centerstone hopes to divert up to 90% of people in crisis from jail, the emergency room,
or inpatient hospitalization. The program is open 24 hours a day, seven days a week. Services
provided include peer support, referrals to community resources and treatment programs, and
health and vital checks. This program is run in collaboration with the Louisville Metro Police
Department and the Louisville Metro Department of Corrections.
56
The Safe City Roundtable - Local officials and citizen leaders whose current
mission is to decriminalize mental illness and addiction in Louisville. The Roundtable’s long-
term goal is to support a shift of community resources to place more emphasis on prevention
and treatment, and less emphasis on law enforcement and corrections. The guiding philosophy
of the Roundtable is that mental illness and addiction are first and foremost health problems,
rather than criminal justice problems. Organizations involved in the Safe City Roundtable
include: University of Louisville School of Public Health & Information Sciences, Jefferson
County Attorney, Centerstone, Metro Council, Metro Corrections, Jefferson County Public
Schools, Jefferson District Court, Louisville Metro Police, CLOUT, Volunteers of America and the
Louisville Metro Department of Public Health and Wellness.
Treatment Advisory Group (TAG) - This group is comprised of providers

from every treatment approach who convene monthly to facilitate collaboration among local
treatment providers and remove barriers to treatment. Additionally, TAG reaches out to
new treatment providers as they open for business within the city. Along with their monthly
meeting , TAG is working with many initiatives to improve treatment and recovery in Louisville.
Young People in Recovery, Kentucky Harm Reduction

Coalition - Partner monthly and on an on-call basis to do safe disposal of discarded
syringes up in parks and areas that have been identified as high areas of injection drug use.
57
APPENDICES
1
CHANGING THE CONVERSATION
Replace stigmatizing words with more neutral language
Instead of: TRY:

ADDICT Person with a substance use disorder • Person with a serious substance use disorder
ADDICTED to X Has an X use disorder • Has a serious X use disorder • Has a substance disorder
involving X (If more than one substance is involved)
ADDICTION Substance use disorder • Serious substance use disorder

NOTE: • “Addiction” is appropriate when quoting findings or research that used the term or if it appears
in a proper name of an organization. • “Addiction” is appropriate when speaking of the disease process
that leads to someone developing a substance use disorder that includes compulsive use (for example ‘the
field of addiction medicine,’ and ‘the science of addiction’).• It is appropriate to refer to scheduled drugs as
“addictive.”
ALCOHOLIC Person with an acohol use disorder • Person with a serious alcohol use disorder
ALCOHOLICS NOTE: When using these terms, take care to avoid divulging an individual’s participation in a named 12-
ANONYMOUS/ step program
NARCOTICS
ANONYMOUS/ ETC.
CLEAN Abstinent
CLEAN SCREEN Substance-free • Testing negative for substance use
DIRTY Actively using • Positive for substance use
DIRTY SCREEN Testing positive for substance use
DRUG HABIT Substance use disorder • Compulsive or regular substance use
DRUG/ Person with a substance use disorder • Person who uses drugs (if not qualified as a
SUBSTANCE disorder) NOTE: When feasible, “Drug/Substance Abuse” can be replaced with “Substance Use Disorder.”
ABUSER
FORMER/ Person in recovery • Person in long-term recovery
REFORMED ADDICT/
ALCOHOLIC
OPIOD Medication assisted treatment • Medication-assisted recovery
REPLACEMENT
OR METHADONE
MAINTENANCE
RECREATIONAL People who use drugs for non-medical reasons • People starting to use drugs •
CASUAL OR People who are new to drug use • Initiates
EXPERIMENTAL
USERS (AS OPPOSED
TO THOSE WITH A USE
DISORDER)
Source: White House Office of National Drug Control Policy

2 GLOSSARY
Addiction: A stigmatized word for the most severe form of substance use disorder,
associated with compulsive or uncontrolled use of one or more substances. Addiction
is a chronic brain disease that has the potential for both recurrence (relapse) and
recovery.137
Adverse Childhood Experiences (ACEs): ACEs are stressful or traumatic events,

including abuse and neglect. They may also include household dysfunction such as
witnessing domestic violence or growing up with family members who have substance
use disorders. ACEs are strongly related to the development and prevalence of a wide
range of health problems throughout a person’s lifespan, including those associated with
substance misuse.138
Age-adjusted: Age-adjusted rates (as opposed to crude rates) are those that have
taken into account the population’s age distribution and corrected the data accordingly.
This allows data to be comparable from place to place.
Alcohol: Ethyl alcohol, or ethanol, is an intoxicating ingredient found in beer, wine and
liquor. Alcohol is produced by the fermentation of yeast, sugars, and starches.139
Alcohol Use Disorder: Excessive drinking can put a person at risk of developing an
alcohol use disorder. To be diagnosed with an alcohol use disorder, individuals must
meet certain diagnostic criteria including: problems controlling intake of alcohol,
continued use of alcohol despite problems resulting from drinking, development of
a tolerance, drinking that leads to risky situations, or the development of withdrawal
symptoms.140
Binge Drinking: Binge drinking for men is drinking 5 or more standard alcoholic drinks,
and for women, 4 or more standard alcoholic drinks on the same occasion on at least 1
day in the past 30 days.141
Controlled Substances: Controlled substances are drugs that are regulated by state
and federal laws that aim to control the harmful effects of substance use disorders,
physical and mental harm, the trafficking by illegal means, and the dangers from actions
of those who have used the substances. Such drugs may be declared illegal for sale or
use, but may be dispensed under a physician’s prescription.142
Expungement: Expungement is a court-ordered process in which the legal record

of an arrest or a criminal conviction is “sealed,” or erased in the eyes of the law. The
availability of expungement, and the procedure for getting an arrest or conviction
expunged, will vary according to the state or county in which the arrest or conviction
occurred. 143
59
Fentanyl: Fentanyl is a powerful synthetic drug that is similar to morphine and heroin but is
50 to 100 times more potent.
Heroin: Heroin is an opioid drug made from morphine, a natural substance taken from the
seed pod of the various opium poppy plants. Heroin looks like a white or brownish powder,
or as the black sticky substance known on the streets as “black tar heroin.” A heroin overdose
causes slow and shallow breathing, blue lips and fingernails, clammy skin, convulsions, coma,
and can be fatal.144
Medication Assisted Treatment: Medication-Assisted Treatment (MAT) is the use of FDA-

approved medications, in combination with counseling and behavioral therapies, to provide a
“whole-patient” approach to the treatment of substance use disorders.145
Naloxone: Naloxone is a medication used to treat a narcotic overdose in an emergency

situation. It blocks or reverses the effects of opioid medication, including extreme drowsiness,
slowed breathing, or loss of consciousness.
Narcotics: “Narcotic” refers to opium, opium derivatives, and their semi-synthetic

substitutes. A more current term for these drugs, with less uncertainty regarding its meaning,
is “opioid.” Examples include the illicit drug heroin and pharmaceutical drugs like OxyContin®,
Vicodin®, codeine, morphine, methadone, and fentanyl.146
Neonatal Abstinence Syndrome: The collection of symptoms babies experience in

withdrawing from drugs they were chronically exposed to in utero.147
Opioids: Opioids are a class of drugs chemically similar to alkaloids found in opium poppies.
Historically they have been used as painkillers, but they also have great potential for misuse.
Opioid Use Disorder: Repeated use of opioids greatly increases the risk of developing an
opioid use disorder. The use of illegal opiate drugs such as heroin and the misuse of legally
available pain relievers such as oxycodone and hydrocodone can have serious negative health
effects.148
Rate: The rate is the number of persons affected by the health outcome divided by the total
number of people who could potentially be affected. Often death rates are per 100,000 and
other rates are per 1,000.
Recovery-Oriented Systems of Care (ROSC): is a coordinated network of community-

based services and supports that is person-centered and builds on the strengths and resilience
of individuals, families and communities to achieve abstinence and improved health, wellness
and quality of life for those with or at risk of alcohol and drug problems.149
60
Sober living houses: Sober living homes are group homes that are free of alcohol and
drugs for individuals in recovery. They operate like a co-op, where individuals contribute to the
upkeep of the house through rent and chores.
Substance Abuse: A stigmatized phrase used to describe substance use disorders. See
Substance Use Disorders.
Substance Misuse: The use of any substance in a manner, situation, amount, or frequency
that can cause harm to users or to those around them. For some substances or individuals, any
use would constitute misuse (e.g., underage drinking, injection drug use).150
Substance Use Disorders: Substance use disorders occur when the repeated use of
alcohol and/or drugs causes significant problems in a person’s life. These problems can occur
with individual health, at school, work, or at home, using alcohol or drugs even when you
would rather not, and taking risks that can lead to injury, traumatic events, or even death. Not
everyone who uses substances, such as alcohol or drugs, will develop a substance use disorder,
but for those who do, the American Psychiatric Association recognizes that “changes in the
brain’s wiring” occur, along with the development of “intense cravings,” making it incredibly
difficult to stop using the substances.151
Tobacco: Tobacco use may be defined as any habitual use of the tobacco plant leaf and its
products. The predominant use of tobacco is by smoke inhalation of cigarettes, pipes, and
cigars. Smokeless tobacco refers to a variety of tobacco products that are sniffed, sucked, or
chewed.152
Tobacco Use Disorder: More than 480,000 deaths each year are caused by cigarette
smoking. Tobacco use and smoking do damage to nearly every organ in the human body, often
leading to lung cancer, respiratory disorders, heart disease, stroke, and other illnesses.153
Vaping: Vaping is the act of inhaling and exhaling the aerosol, often referred to as vapor,
which is produced by an e-cigarette or similar device. The term is used because e-cigarettes
do not produce tobacco smoke, but rather an aerosol, often mistaken for water vapor, that
actually consists of fine particles. Many of these particles contain varying amounts of toxic
chemicals, which have been linked to cancer, as well as respiratory and heart disease.154
61
3
History and Background of
U.S. Drug Enforcement
Late 19th Century to Early 20th Century

Medicinal and recreational drug use in the United States dates to the country’s inception. In
the 1890s, the popular Sears and Roebuck catalogue advertised a syringe and small amount
of cocaine for $1.50. At that time, there were no federal government agencies regulating
medical and pharmaceutical practice. Doctors often prescribed cocaine and morphine as pain
treatments, and by the end of the 19th century, misuse of these substances had become
significant and a matter of growing public concern.155
To address the burgeoning levels of drug use in the country, the federal government attempted
to regulate and control drugs through taxation. In some states, laws banning or regulating
drugs were passed in the 1800s. The first congressional act to levy taxes on morphine and
opium passed in 1890. It was not until the early 20th century that federal control of drugs
gained traction.156
The 1909 Smoking Opium Exclusion Act banned the possession, importation and use of opium
for smoking. However, opium could still be used as a medication. This was the first federal law
to ban the non-medical use of a substance.
In 1914, Congress passed the Harrison Act, which regulated and taxed the production,
importation, and distribution of opiates and cocaine.
Alcohol prohibition laws quickly followed. In 1919, the 18th Amendment was ratified, banning
the manufacture, transportation or sale of intoxicating liquors, and ushering in the Prohibition
Era. In the same year, Congress passed the National Prohibition Act, which offered guidelines
on how to federally enforce Prohibition.
Prohibition lasted until December, 1933, when the 21st Amendment was ratified, overturning
the 18th.
Narcotic enforcement in the 1920s was closely tied to the enforcement of Prohibition. In 1930,
responsibility for Prohibition enforcement was transferred to the Department of Justice. A new
federal agency, the Federal Bureau of Narcotics (FBN) was established within the U.S. Treasury
to oversee narcotic enforcement.
During the era of Prohibition, marijuana fast grew in popularity as a new recreational drug. At
the end of Prohibition, controlling marijuana use became a focus of Congress and the FBN.
The growth and use of marijuana was legal under state and federal law until 1937. The federal
government unofficially banned marijuana under the Marihuana Tax Act of 1937. The Act did
62
not itself criminalize the possession or usage of hemp, marijuana, or cannabis. But included
penalty and enforcement provisions to which marijuana, cannabis, or hemp handlers were
subject. Violation of these procedures could result in a fine of up to $2000 and five years’
imprisonment. Shortly after passing the Marihuana Tax Act, all states made marijuana
possession illegal.157
Mid-20th Century
After the Second World War, opioids – synthetic opiates – began to enter the market in greater
numbers. These included drugs formulated using Hydrocodone (later popularized in the 1970s
as the narcotic in Vicodin) and Oxycodone (the opiate best known today as an ingredient in
OxyContin). Many doctors – knowing the risks of addiction and dependence – embraced a sort
of “opiophobia”, which caused them to shy away from prescribing pain pills frequently.158
Over the next few decades, Congress continued to pass legislation to control drug misuse
and further criminalized drug use. Examples of such legislation include the 1951 Boggs Act,
which created mandatory prison sentences for some drug offenses and the 1956 Narcotic
Control Act, which further increased penalties for drug offenses and made the death penalty a
punishment for selling heroin to youth.
Federal support for a medical approach to drug misuse then became popular. For example,
methadone became an acceptable and often used treatment for heroin dependence. Congress
also promoted a medical approach to addressing drug use, stating its support for rehabilitation
through treatment in the Narcotic Addict Rehabilitation Act.159
In addition to an emphasis on the medical approach to preventing and responding to drug

misuse there was a heavy emphasis on law enforcement. In 1969, President Nixon would
respond to the rise of illicit drug use, especially heroin, by making the reduction of drug misuse
a top priority.160
The 1970s War on Drugs and the Controlled Substances Act

In June 1971, President Richard M. Nixon officially declared a “War on Drugs,” stating that drug
use was “public enemy number one.” President Nixon’s war on drugs placed greater emphasis
on law enforcement. He sought greater federal control of drugs and pushed for passage of
comprehensive federal drug laws. The Controlled Substance Act (CSA) put select plants, drugs
and chemical substances under federal jurisdiction and created a statutory framework for the
federal government to regulate lawful production, possession and distribution of controlled
substances.161
In July 1973, Nixon authorized creation of a federal agency to enforce the CSA - the Drug
Enforcement Administration (DEA). Later that year, the DEA was place under control of the
63
Department of Justice (DOJ). The Nixon administration highlighted the importance of the
DEA’s role in gaining cooperation and coordination among the DEA, the Federal Bureau of
Investigation (FBI) and other DOJ agencies involved in operations to counter drug use. At the
start, the DEA was given 1,470 special agents and a budget of less than $75 million. Today, the
agency has nearly 5,000 agents and a budget of $2.03 billion.162
Race, Stigma and Discrimination

During a 1994 interview, President Nixon’s domestic policy chief, John Ehrlichman, provided
inside information suggesting that the War on Drugs campaign had ulterior motives, which
mainly involved helping Nixon keep his job.163
In the interview, conducted by journalist Dan Baum and published in Harper magazine,
Ehrlichman explained that the Nixon campaign had two enemies: “the antiwar left and black
people.” His comments led many to question Nixon’s intentions in advocating for drug reform
and whether racism played a role.164
Ehrlichman was quoted as saying: “We knew we couldn’t make it illegal to be either against
the war or black, but by getting the public to associate the hippies with marijuana and blacks
with heroin, and then criminalizing both heavily, we could disrupt those communities. We
could arrest their leaders, raid their homes, break up their meetings, and vilify them night after
night on the evening news. Did we know we were lying about the drugs? Of course, we did.”165
In the mid-1970s, the War on Drugs took a slight hiatus. Between 1973 and 1977, eleven states
decriminalized marijuana possession. Jimmy Carter became president in 1977 after running
on a political campaign to decriminalize marijuana. During his first year in office, the Senate
Judiciary Committee voted to decriminalize up to one ounce of marijuana.166
The 1980s and “Say No to Drugs”

In the 1980s, President Ronald Reagan reinforced and expanded many of Nixon’s War on Drugs
policies. In 1984, his wife Nancy Reagan launched the “Just Say No” campaign, which was an
effort to educate children on the dangers of drug use.167
President Reagan’s refocus on drugs led to a significant increase in incarcerations for

nonviolent drug crimes.
In 1986, Congress passed the Anti-Drug Abuse Act, which established mandatory minimum
prison sentences for certain drug offenses. This law was later heavily criticized as having racist
64
ramifications because it allocated longer prison sentences for offenses involving the same
amount of crack cocaine (used more often by black Americans) as powder cocaine (used more
often by white Americans).168
Critics also pointed to data showing that people of color were targeted and arrested on
suspicion of drug use at higher rates than whites, leading to disproportionate incarceration
rates among communities of color.169
1990s to present
The majority of federal drug legislation over the last 20 years focused on synthetic drugs, as
different synthetic drugs have waxed and waned in popularity with illicit drug users over the
past few decades.
In the 1990s, as the popularity of cocaine decreased, methamphetamine use increased.

Methamphetamine was, and is, produced with legally obtainable ingredients including
pseudoephedrine, a non-prescription cold medicine. Under the Comprehensive
Methamphetamine Control Act of 1996, enhanced criminal penalties were established for the
manufacture and distribution of the drug.170
MDMA, commonly known as ecstasy, rose in popularity in the early 1980s. The DEA then
categorized it as a Schedule I drug of the CSA. It resurfaced in the 1990s, and in recent years
under the street name “molly”.171
Over the past 20 years, 30 states and the District of Columbia have established laws and
policies permitting medical and recreation marijuana use; however, cannabis is still illegal
under federal law. The federal government categorizes marijuana as a Schedule 1 drug of
the CSA, which does not recognize the difference between medical and recreational use of
cannabis. These laws are generally applied only against persons who possess, cultivate, or
distribute large quantities of cannabis.
65
RECOVERY RESOURCES
66
Our community has many recovery resources
in place, but knowing how to navigate those
resources for the appropriate level of care can
be confusing and overwhelming.
Ways to get started:

KENTUCKY HELP
4
nOw hotline AND
treatment locator
1.833.859.4357
https://www.FindHelpNowky.org/
The Treatment Locator has the most up-to-date information on services
available in the state of Kentucky.
CASEY’s LAW
502.574.6188
https://louisvilleky.gov/government/county-
attorney/caseys-law
Casey’s Law is a legal proceeding to obtain a court order for involuntary
treatment for addiction for adults or children.
67
RESOURCE PHONE
Baptist Health Louisville 502.896.7105
The Brook Hospital 502.896.0495
The Brook Hospital - KMI/Substance Abuse Services 502.426.6380
Center for Behavioral Health 502.894.0234
Centerstone Addiction Recover Center 502.583.3951
Certified Counseling Services 502.635.2008
The Cleanse Clinic 502.938.0511
Family Health Centers 502.772.8118
Greater Louisville Counseling Center 502.587.9737
The Healing Place (Men) 502.585.4848
The Healing Place (Women) 502.268.6680
Interlink Counseling Services 502.964.7147
JourneyPure 888.601.0982
Kilgore Samaritan Counseling 502.327.4622
Landmark Recovery 502.632.0315
MORE Center 502.574.6414
The Morton Center 502.451.1221
New Beginnings - Education Counseling Center, Inc. 502.493.7794
New Leaf Clinic 502.435.8321
New Vision, Norton Audubon Hospital 502.636.4961
New Vision, Norton Suburban Hospital - Expectant Mothers Program 502.559.4375
Our Lady of Peace - Adult Outpatient Center
Our Lady of Peace - Children and Adult Services 502.451.3333
Renew Recovery 502.749.6249
Robley Rex Veterans Medical Center 502.287.5960
SelfRefind Louisville Clinic 866.755.4258
Volunteers of America 502.635.4530
Recovery House Inpatient Family Program
Recovery Support Medication Assisted Recovery Pregnant/Parenting/Postpartum
Outpatient Medical Stabilization

68
This is a list of community partners that support recovery in other ways such as navigating recovery resources (the
Angel Program), legal support with DUIs (Clear Vision), job/education help (KYRRC) and child care while in recovery
(Project Keepsafe). Again, this is not an exhaustive list of community resources!
RESOURCE PHONE WEBSITE

The Angel Program (J-town Police Dept) 502.267.0503 https://www.jeffersontownky.com/678/Angel-Program
Choose Well 800.520.4914 http://www.choose-well.org/

Clear Vision Counseling X
502.995.3350 https://www.clearvisioncounseling.org/
Home of the Innocents 502.596.1221 https://www.homeoftheinnocents.org/services/
Project Keepsafe residential-treatment/project-keepsafe/
Michael White’s Kentucky Recovery 502.356.6101 https://www.michealwhitecenter.com/
Resource Center (KYRRC)
Women in Circle 502.213.9058
Substance use disorder is a chronic condition that requires ongoing, lifetime support for the person and their family
members from others that understand the disease. These support groups are a vital part of the recovery process.
RESOURCE PHONE WEBSITE

Alcoholics Anonymous 502.582.1849 http://www.louisvilleaa.org/
Support groups for adults struggling with alcohol addiction using 12 step program.
Narcotics Anonymous 502.569.1769 https://www.nalouisville.net/meetings.html
Support groups for adults struggling with drug addiction using 12 step program.
Smart Recovery https://www.smartrecovery.org/local/
Support groups in person and online using science-based 4-Point Program.
Refuge Recovery https://www.refugerecovery.org/
Support groups that utilizes Buddhist philosophy as foundation of the recovery process.
Al Anon Family Groups 502.458.1234 http://kyal-anon.org/
Support groups for friends/family members worried about a person struggling with addiction.
Celebrate Recovery http://www.celebraterecovery.com/
Christ-centered program designed to promote spiritual healing for any hurt, habit, or hang-up using the 12 steps and their biblical
comparisons.
This list of halfway/transitional/recovery/sober housing has a large range in terms of number of residents, locations,
expectations/rules, years in operation and cost. Recovery is different for every person and requires the right kind of
support at the right time for each situation. This is not a complete list of housing available (or needed) for recovery.
805 Mary Street Gratitude House Kristy’s Love Foundation

91 Psalms House Hope and Favor House Ladies of Promise
Arch to Freedom Hope Sisters House Of Recovery The New Beginning
Augustine Hall Hosea’s House New Legacy Reentry Corporation
Beacon House House of Grace Next Step Recovery House
Brook Street House House Of Hope Our Father’s House
The Burns M. Brady Center Kristy’s Love Foundation Successful Living
Chestnut House Ladies of Promise Talbot House (Wallace House and Hoard
Corner of Hope Recovery The New Beginning House)
CTS Russell (Community Transitional Services) New Legacy Reentry Corporation Transitional House
Dismas Charities Next Step Recovery House Travelers Living
Divine Steps Our Father’s House Wayside Christian Mission
Driven Purpose Hope Sisters House Of Recovery Wellspring (Ardery House & Journey House)
Fountain of Hope Hosea’s House
Graceful Living House of Grace
Gateway to Hope Recovery House House Of Hope
69
5 1.
2.
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56. Early Childhood Development. World Health Organization.
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138. Adverse Childhood Experiences. Substance Abuse and Mental Health Services Administration.
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144. Heroin. National Institute on Drug Abuse. Retrieved from:
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145. Medication-Assisted Treatment. Substance Abuse and Mental Health Services Administration.
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146. DEA Drug Fact Sheet. Retrieved from: https://www.dea.gov/druginfo/drug_data_sheets/Narcotics.pdf.
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147. Kentucky Department of Public Health. Neonatal Abstinence Syndrome in Kentucky. Available from:
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148. Opioids. Substance Abuse and Mental Health Administration. Retrieved from:
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152. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Chapter 40 Tobacco
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153. Substance Use Disorders. Substance Abuse and Mental Health Services Administration. Retrieved from:
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154. What is Vaping? Center on Addiction. Retrieved from https://www.centeronaddiction.org/e-
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155. DEA History in Depth. United States Drug Enforcement Administration. Retrieved from
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156. Ibid
157. Ibid
158. DEA History in Depth. United States Drug Enforcement Administration. Retrieved from
https://www.dea.gov/about/history/Early%20Years%20p%2012-29.pdf. Accessed January 2018.
159. Ibid
160. Ibid
161. War on Drugs. History.com website. www.history.com/topics/the-war-on-drugs. Accessed January 7,
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162. DEA History in Depth. United States Drug Enforcement Administration. Retrieved from:
https://www.dea.gov/about/history/1970-1975%20p52030-39.pdf. Accessed January 9, 2018.
163. War on Drugs. Retrieved from: www.history.com/topics/the-war-on-drugs. Accessed January 7, 2018.
164. Ibid
165. Ibid
https://www.dea.gov/about/history/1975-1980%20p%2039-49.pdf. Accessed January 9, 2018.
167. War on Drugs. Retrieved from: www.history.com/topics/the-war-on-drugs. Accessed January 7, 2018.
168. lbid
169. lbid
77

Coming Together For Hope, Healing and Recovery

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Coming Together For Hope, Healing and Recovery

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C MING

Our community, like so many across the country, is facing an opioid

Substance use disorder is a complex, but not insurmountable problem,

We began the work of creating a city-wide plan by convening

From their insights, expertise, and recommendations come this

comprehensive report and two-year action plan. This plan is designed to

Finding solutions and creating a more resilient community is a task that

requires the involvement of all of us. We look forward to working with

you to continue to make Louisville a place where everyone and every

community can thrive.

Dr. Sarah Moyer

In the next two years, Louisville will provide:

Facing Addiction in America: The Surgeon General’s Report on

Like much of the country

In 2016, the age-adjusted

Never before have we needed to work

- Jennifer Hancock, LCSW

1804 1910 1933 1947

1973 1996 OxyContin:

Death Rate Due to

*Unintentional/ Undetermined; Age-adjusted

Drug-related inpatient hospitalizations

Rates of Prescriptions Dispensed by Age and Gender for KIPDA

Louisville Metro Emergency Medical Services, 2016

“This program saved my life.”

2011-2015 Kentucky Vital

Centers for Disease Control and

Centers for Disease Control and

Figure 9 Average Opioid Related Overdose

Top 3 Causes of Death in Louisville, KY

Louisville Metro Center for Health Equity: Health Equity Report

Centers for Disease Control and

Average Percent of Current Adult Smokers, 2013-2016

2011-2016, Safe and Drug Free

*Note: Survey question language

During 2011-2016, the non-Hispanic White population had a higher alcohol-induced

Centers for Disease Control and Prevention,

Alcohol Induced Death Rates by Race and Sex, 2011-2016*

500 Cities Project: Local Data for

Kentucky Inpatient Hospitalization

The child’s primary environment and source of

For students living in or around poverty, educational attainment in under-resourced schools

Educational systems are also opportunities to engage

This plan makes specific recommendations for evidence-based best practices

A CHAMPION: One Love Louisville’s Substance Use Workgroup

CHAMPION: BOUNCE Coalition

CHAMPION: Louisville Metro Department of Public Health & Wellness

BUILT EDUCATION FOOD ENVIRONMENTAL

HEALTH AND CRIMINAL A EARLY CHILDHOOD

EMPLOYMENT NEIGHBORHOOD SOCIAL/

CHAMPIONS: Volunteers of America • Kentucky Harm Reduction Coalition

6 Improve Connection to Treatment

CHAMPION: University of Louisville Hospital

Measure the Quality of Treatment Programs

Make Expungement Affordable

10 Improve Job Placement

Here we include additional recommendations brought forward by

Restrict marketing/sales of alcohol, controlled substances and tobacco.105

Limit density of liquor and tobacco stores.106