With more than a billion in opioid settlement dollars coming to Ohio, advocates argued it must be directed to evidence-based strategies.

Ohio ranked fourth among states in 2020 for drug overdose mortality, with a majority of deaths caused by opioids.

Beth Macy, a journalist, wrote the best-selling book "Dopesick," which examined the origins of the opioid epidemic. She said real change can happen at the community level with a shift in mindset, with addiction viewed as a treatable medical illness rather than a moral failure and crime.

"In the middle of the worst drug epidemic in the nation's history, we need to start figuring out where all these bureaucratic, unnecessary hurdles are," Macy urged. "Only 12% of folks with OUD (opioid use disorder) even managed to get treatment in the last year. As the wealthiest nation in the world, that's horrendous."

Ohio will get about $1 billion dollars over 18 years in a major opioid settlement, but additional money is expected from pending lawsuits. Macy speaks Friday at the Prevention Action Alliance's annual breakfast in Columbus about her upcoming book "Raising Lazarus," which dives deeper into the issue of opioid addiction and highlights successful treatment practices.

In her research, Macy discovered the opioid treatment landscape lacks coordination and structure, but she noted some communities and organizations are seeing success.

"Even if you have, say, a conservative community that maybe historically has only viewed addiction through a drug-war lens, even some of those communities are figuring out how to make positive change," Macy pointed out.

Ohio's new Relapse Reduction Act increases penalties for selling drugs near treatment facilities and to those undergoing treatment. Opponents argued it approaches addiction as a crime. Macy countered harm-reduction practices such as medications to stave off cravings or needle exchange can get people on the path to recovery.

"Once they start to make these incremental changes, they can actually see, 'Oh, maybe I can get better.' " Macy explained. "But it's this matter of 40% of folks with opioid use disorder don't want to even try to get better because they've tried before, and they've been stigmatized, or they haven't been able to access it. "

Sometimes it is as simple as needing a ride to a local clinic, or getting help to apply for Medicaid. She added expanding access to treatment medications is needed, as certain practitioners need special certification to prescribe medications to treat opioid use disorder.

Texas may soon join other states with legalized fentanyl test strips, used by those with drug addictions to detect the presence of the often lethal opioid known as fentanyl.

Support for more harm-reduction measures appears to have bipartisan support ahead of the 2023 legislative session, which begins this week. Right now, the strips are still classified as drug paraphernalia, making it a crime to possess them.

Katharine Neill Harris, a drug policy fellow at Rice University, is encouraged Gov. Greg Abbott has signaled his support for the change.

"They're another tool that can reduce risks," Neill Harris contended. "They don't encourage risk. They're not a drug themselves, so there's not any sort of abuse potential related to them."

Abbott has also said he wants to make Narcan, a drug used to reverse opioid overdoses, more readily available across the state. Until now, Texas lawmakers have argued fentanyl test strips and other harm-reduction tools facilitate drug use.

The Centers for Disease Control and Prevention reports overdose deaths involving fentanyl in Texas rose almost 400% from 2019 to 2021, accounting for more than 1,600 deaths in fiscal year 2021. Neill Harris believes more needs to be done to address the issue.

"Test strips are not going to prevent every single overdose," Neill Harris acknowledged. "To me, if they prevent one overdose, then that makes them worth it. We need many, many things to tackle this crisis. It can't just be one thing."

She is urging lawmakers to adopt broad legislation on the issue, because experts are already seeing a rise in non-fentanyl opioids implicated in drug overdoses, which could potentially be detected with strips-testing.

"Rather than having to go back to the Legislature every two years to legalize some new drug-checking technology for whatever the new crisis of the day is, I think it would be much more prudent for the Legislature to allow for other drug-checking tools," Neill Harris added.

West Virginians could soon be able to purchase naloxone, brand name Narcan, without a prescription.

Earlier this month the Food and Drug Administration fast-tracked the application for an over-the-counter spray version of the overdose reversal medication submitted by Maryland-based Emergent BioSolutions.

Advocacy groups said they are balking at the price, which has skyrocketed over the past few years.

John Kennedy, director of Musicians for Overdose Prevention, expects an over-the-counter price tag of at least $100, which he said is cost-prohibitive for people who need it most, and for nonprofit groups working to distribute Narcan at the community level.

"At 80 to $90, a Narcan kit, someone who's a user, they can't afford that," Kennedy pointed out. "If we're distributing 2,000-3,000 kits a year, which we are, that's into the hundreds of thousands of dollars, and we can't afford that either."

According to data from Health Affairs, Narcan nasal spray has a list price of around $150. In a news release, Emergent BioSolutions -- which has not yet confirmed a cost if an over-the-counter spray were approved -- said so far, millions of doses of prescription Narcan have been distributed across the U.S.

Kennedy believes the high cost is aimed at getting local and state governments to pay for stocking large quantities of the medication in health departments, fire stations, and ambulances. He noted states and municipalities have received hundreds of millions of dollars from opioid settlements.

"Emergent BioSolutions is positioning themselves to kind of move the funds from one big pharma company, which is Purdue through the governments, and now we're moving it directly into the pockets of another big pharma company," Kennedy contended.

He also pointed to the growing presence of fentanyl mixed into illicit drugs as a reason to ensure widespread and affordable access to naloxone.

"Now fentanyl is in pills, in meth, in cocaine and just about every powdered substance," Kennedy added.

According to the CDC, more than 1,300 West Virginians died of a drug overdose in 2020.

Boston's 'Mass and Cass' area, with its large homeless population and open-air drug market, remains a trouble spot for city officials, but staff at the nearby Engagement Center say they are making inroads and helping drug-overdose survivors get the help they need.

Researchers interviewed 59 overdose survivors, more than half of whom were living on the street, to find out what was preventing them from getting treatment.

Jeff Desmarais, research and evaluation scientist at Institute for Community Health, said a lack of basic amenities, such as housing and access to a cell phone or proper ID, made a big difference, but that it also came down to a personal touch.

"Having staff that really care about folks and treat them with respect and dignity was one thing that folks were drawn to and helped them engage in and stay in care," Desmarais said.

More than half of Black and Latinx overdose survivors said they had encountered some form of discrimination in trying to access city health services. A lack of available treatment beds due to staffing shortages is also preventing people from getting clean.

The opioid epidemic, along with a lack of affordable housing and COVID, have all contributed to the increase in homelessness in the 'Mass and Cass' area. The Engagement Center offers the nearby population help to find housing, medical care, jobs, or even just a warm cup of coffee and a shower.

Yailka Cardenas, associate bureau director for recovery services with the Boston Public Health Commission, said some staff at the center have experienced addiction and homelessness themselves and can meet people where they are.

"No matter what they come to us with," Cardenas said, "we always try our very best to come up with a solution, and they feel very supported that even if we can't figure it out that day, we will figure something out for them within a timely manner."

Cardenas said personal relationships go a long way in helping people get clean, and that the Engagement Center can serve as a model for other day facilities serving similar populations. She said survivors, many of whom experience instability and trauma on a daily basis, report feeling safe and welcomed at the Engagement Center, which is the first and most important step in helping them change their lives.