2 Gen Approach to Kentucky’s Opioid Epidemic Needed

By Ashley Spalding
February 22, 2018

Click here to view a pdf of the brief.

As one of the states hardest hit by the national opioid epidemic, Kentucky struggles with high rates of addiction, incarceration, overdose deaths and Hepatitis C, as well as neonatal abstinence syndrome (NAS) and a growing number of children entering foster care due to parents’ addiction problems. In order to better address the state’s drug problems, which affect children and families as well as addicted adults, we need to take a two generation (2 Gen) approach that addresses the entire family.

Too many strategies for helping low-income families focus on either parents or children but not both. In contrast, a 2 Gen approach recognizes the connection between child and family well-being and future success, and using this lens fosters the integration and coordination of programs to serve both adults and children.[1]

While Kentucky lawmakers take the state’s drug problems very seriously, strategies for addressing addiction typically focus on either adults or kids. Adults may be incarcerated for drug-related charges or participate in a diversion program and/or receive substance abuse treatment. And children are often removed from addicted parents’ homes in order to provide them with a safe environment and/or address related health issues. A 2 Gen approach to these issues could be more effective.

Opioid Addiction Hurts Kentucky Adults and Kids

Drug addiction is having a devastating impact on Kentucky adults:

  • In 2000, 9 counties in the U.S. had drug overdose death rates of more than 20 per 100,000 people, and 4 were located in Kentucky.[2] By 2014, 64 of Kentucky’s 120 counties had overdose death rates that high — and these rates have continued to rise. Kentucky is tied with Ohio as having the third highest rate of death due to drug overdose.[3]
  • The state also has one of the fastest growing rates of new cases of Hepatitis C, and it is considered to be very close to an HIV outbreak.[4]
  • One of the biggest drivers of Kentucky’s growing inmate population is drugs, which is a major contributor to the jump in female incarceration rates in the state. The number of Kentucky women in prisons or jails has grown by 27 percent over the past 5 years; in 2015, Kentucky had the 5th highest female incarceration rate in the nation.[5]

Kids are being affected by these struggles as well:

  • There has been a surge in the number of children in foster care, with more than 8,500 kids in Kentucky’s foster care system in 2017, an increase of 24.5 percent since 2011. In nearly 25 percent of cases, children were removed from their homes due to drug abuse by the parent.[6]
  • An increasing number of newborns in Kentucky are also acquiring Hepatitis C from their mothers. Kentucky has the second-highest rate of Hepatitis C present at the time of delivering a baby: 5.1 per 1,000 live births, compared to the national rate of 3.4 per 1,000 live births.[7]
  • Kentucky has a growing number of infants with NAS, where the baby is born addicted to drugs as a result of the mother using them during her pregnancy. There were 1,354 cases of NAS in Kentucky in 2015.[8]
  • Kentucky has the second-highest share of kids with a parent who has been incarcerated.[9]
  • Substance abuse and incarceration are both considered to be Adverse Childhood Experiences (ACEs), which research is showing result in significant damage to a child’s immediate and future well-being.[10]

Current 2 Gen Approaches to Kentucky’s Opioid Epidemic

 The state actually has several small-scale programs to address the state’s opioid problems that take a 2 Gen approach in that they address the needs of the entire family — not just the adults struggling with addiction. These programs can serve as examples of what is already working and spur ideas about what may be possible.

Sobriety Treatment and Recovery Teams (START)

 Sobriety Treatment and Recovery Teams (START), a project of the Kentucky Department for Community Based Services (DCBS), takes a 2 Gen approach to addiction in five counties and for parents struggling with addiction who have small children involved with Child Protective Services (CPS). START helps parents treat addiction and keeps kids in the home when it is possible and safe. A social worker and family mentor work together on each case; the family mentor is someone in long-term addiction recovery. Among the other strategies utilized by the program are small caseloads, home visits and getting parents into intensive treatment quickly (which has been shown to lead to better outcomes). The program has been very successful and is listed on the California Evidence-Based Clearinghouse for Child Welfare; compared to typical CPS cases, START has roughly twice the sobriety rates, half as many kids in foster care and saves $2.52 on foster care for every dollar spent on START.[11] The program also exceeds federal standards for preventing repeat abuse or neglect. It should be noted that the program is federally funded and the funding source is expected to be unavailable in the near future.

Drug Court

 Kentucky’s drug court system provides an opportunity for those with addiction problems who become involved in the criminal justice system to enter treatment instead of going to jail. Drug court is typically a two-year program that requires substance abuse treatment, employment and periodic drug testing, and provides case management and supports such as transportation assistance. Close to half of participants have children, including many living with them; 28 percent have children not in their custody.[12] Drug court has been shown to be effective at reducing the chances of ending up back in the criminal justice system after graduating from the program (the recidivism rate is 20 percent versus 57 percent for those on probation convicted of similar offenses 2 years after the probationary period).[13] While drug court works with the child support system, the program could do more to address the whole family rather than just the adult, as discussed below.

Campbell County Detention Center’s Chemical Dependency Program (CPD)

A new substance abuse treatment program in one of the state’s local county jails, the Campbell County Detention Center, shows promise in assisting mothers and their families. The Chemical Dependency Program (CDP) is a 6 month in-patient treatment model for women inside the Detention Center Recovery Unit, followed by an 18-24 month outpatient follow-up care program in the community.[14] While mothers are incarcerated, the children of CDP participants are connected with physical and behavioral health services. After release from jail, there is intensive case management and wrap-around services that include therapy for both participants and their children. Follow-up from CDP lasts two years and includes home visits (a minimum of an hour a week for the first six months and then a minimum of an hour a month).

The program is currently funded through two sources. This first is a private foundation in northern Kentucky and the second is the local Board of Health. This funding will last through summer 2019. They partnered with collaborating community agencies who are able to bill Medicaid for services once the women are released. The outside funding helps with the cost for the jail services as well as one agency that cannot bill Medicaid for case management services. The program is currently looking for other funding sources for July 2019 and hope by that time to have good data on outcomes, which will make it possible to receive more support.[15]

Advances in Neonatal Abstinence Syndrome (NAS) Research and Treatment

 New research on NAS in Kentucky is beginning to change some previous practices. Rather than take babies immediately from their mothers and treat mothers separately, mothers are encouraged to bond with them while also receiving treatment. Research is showing that caretaker involvement and other protective factors can offset the risks for poor outcomes associated with NAS (including fatality, abuse and neglect in the first year and cognitive and speech impairment and/or behavior problems further down the road).[16] It is important to develop a plan of safe care in NAS cases that provides a seamless continuum of care for the caretaker and the child. The state just received a new grant to address the opioid epidemic and one of its numerous activities will be promoting coordinated care for women with an opioid use disorder who are pregnant or postpartum as well as supporting employment for those re-entering from correctional settings.

While these small-scale efforts exist, a 2 Gen approach is largely absent from most conversations about the opioid epidemic and an overwhelmed foster care system. Much more work along these lines is needed.

Challenges and Opportunities with a 2 Gen Solution to the Opioid Epidemic

While there are numerous challenges to further developing a 2 Gen approach to the opioid epidemic in Kentucky, but there are also many opportunities to make progress.


Kentucky’s current state budget is in a crisis and considered the most challenging in recent history, with key areas having experienced a decade of budget cuts. In this context, it will be difficult to keep up current levels of investment, not to mention investing in additional, innovative approaches. State social workers already have unmanageably high caseloads and are underpaid — which leads to high rates of turnover, making the implementation of any new approaches difficult.

Drug courts have also been at risk of being cut in recent budgets — and family drug courts ended for this reason in 2010.[17] In addition, while drug court works with the child support system, the program could do more to address the whole family rather than just the adult. There have been some discussions about potentially piloting more of a 2 Gen approach in Bullitt County by working closely with the Department for Community Based Services.[18] However, so far the Administrative Office of the Courts has not had further conversations along these lines, in part because they too are understaffed.

Other funding streams for the current 2 Gen programs described above are also at risk, which will make it difficult to sustain these important programs.

In addition, discussions around issues with the adoption and foster care systems do not involve exploring ways kids could stay in their homes or with family members while parents receive substance abuse treatment and supports. Related to this is that the state’s Kinship Care program, which provides a monthly stipend for relatives who care for children in lieu of foster care, has been closed due to a lack of state funds.

The state also recently made steps backward by trying to incarcerate its way out of the state’s drug problem rather than increasing access to treatment.[19] Research shows this approach doesn’t work and is costly — to Kentucky families and to the state budget, making it harder to make needed investments.[20]

Access to treatment is another challenge. Kentucky’s Medicaid expansion has been important to increasing access to substance abuse treatment; however, new changes in the program will reduce the number of Kentuckians receiving Medicaid.[21] And currently a very limited amount of residential treatment is available to accommodate mothers with newborns — and even more limited availability for mothers who need to bring older children with them.[22]


Still there are some exciting opportunities for a 2 Gen approach to these issues in Kentucky.

Legislators held an all-day hearing in 2017 on the opioid epidemic that included invited testimony by several presenters who advocate treating kids and adults together — including by the University of Kentucky NAS researcher Henrietta Bada, whose research is described above, and also a residential substance abuse treatment provider that enables children to stay with their parents as they receive treatment.

It is also promising that the governor’s budget proposal includes additional investments in several crisis areas including funding for the state’s social workers that will increase salaries and reduce caseloads, the re-opening of the Kinship Care program and additional funding to address the opioid epidemic.

In addition, recent recommendations from the state’s Justice Reinvestment Work Group — which are in House Bill 396 — are framing the need for criminal justice reforms in terms of women and families, which seems to be gaining traction.[23] The group recommends reducing incarceration in a number of ways, including lowering charges for drug possession, and reinvesting savings from these reforms into expanding access to treatment.[24]

Another opportunity is that research on the START program’s effectiveness is powerful and will help to advocate for a 2 Gen approach.

[1] Annie E. Casey Foundation, “Creating Opportunity for Families: A Two-Generation Approach,” 2014, http://www.aecf.org/m/resourcedoc/aecf-CreatingOpportunityforFamilies-2014.pdf.

[2] Centers for Disease Control, “Drug Poisoning Mortality: United States,” https://blogs.cdc.gov/nchs-data-visualization/drug-poisoning-mortality/.

[3] Kentucky Office of Drug Control Policy, “2015 Overdose Fatality Report,” https://odcp.ky.gov/Documents/2015%20KY%20ODCP%20Overdose%20Fatality%20Report%20Final.pdf. Centers for Disease Control, “Drug Overdose Death Data,” https://www.cdc.gov/drugoverdose/data/statedeaths.html.

[4] Bill Estep, “’We Have an Epidemic.’ Kentucky Now Leads the Nation in Hepatitis C Infection Rate,” May 19, 2017, http://www.kentucky.com/news/state/article151550027.html.

[5] Ashley Spalding, “Group Provides Insight Into Growth of Kentucky’s Inmate Population,” Oct. 13, 2017, https://kypolicy.org/group-provides-insight-growth-kentuckys-inmate-population/. John Cheves, “Kentucky Locks Up More Women Than Most States. Will Lawmakers Change That?,” Lexington Herald-Leader, Nov. 20, 2017, http://www.kentucky.com/news/politics-government/article185696838.html. Amber Duke, “Annual U.S. Department of Justice Data Shows Kentucky Incarceration Rates Surging,” Kentucky Smart On Crime, Jan. 16, 2018, http://kysmartoncrime.com/annual-u-s-department-of-justice-data-shows-kentucky-incarceration-rates-surging/.

[6] Legislative Research Commission, “Kentucky’s Foster Care System,” Program Review and Investigations Committee, Draft Oct. 12, 2017.

[7] Estep, “’We Have an Epidemic.’”

[8] Dr. Henrietta Bada, the Director of the Division of Maternal and Child Health of the Department for Public Health and Professor of Pediatrics at the University of Kentucky, Testimony at the Interim Joint Committee on Health and Welfare, Sept. 20, 2017.

[9] Kentucky Youth Advocates, “Minimizing the Impact of Parental Incarceration on Children,” February 2018, https://kyyouth.org/wp-content/uploads/2018/02/KYA-Issue-Brief-Parental-Incarceration_Feb2018.pdf.

[10] Substance Abuse and Mental Health Services Administration, “Adverse Childhood Experiences,” https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood-experiences.

[11] Sobriety Treatment and Recovery Teams Fact Sheet.

[12] Administrative Office of the Courts, personal communication.

[13] Administrative Office of the Courts, “Summary of Specialty Court Statistics.”

[14] Campbell County Detention Center, “Chemical Dependency Program,” Testimony to Interim Joint Committee on Judiciary, June 8, 2017.

[15] Kristie Blanchet, a social worker involved with the program at the Campbell County Detention Center, personal communication.

[16] Bada, Testimony at the Interim Joint Committee on Health and Welfare.

[17] Deborah Yetter, “Volunteers Pony Up to Restore Family Drug Court Lost to State Budget Cuts,” Courier-Journal, Aug. 15, 2017, https://www.courier-journal.com/story/news/2017/08/14/amid-opioid-crisis-group-raises-funds-restore-family-drug-court/537728001/.

[18] Administrative Office of the Courts, personal communication.

[19] Ashley Spalding, “New Version of Drug Bill Would Have Serious Consequences for Addicts and Criminal Justice System,” March 30, 2017, https://kypolicy.org/new-version-drug-bill-serious-consequences-addicts-criminal-justice-system/.

[20] Ashley Spalding, “New Study Provides More Evidence Harsher Penalties Are Not Solution to State’s Drug Problems,” July 11, 2017, https://kypolicy.org/new-study-provides-evidence-harsher-penalties-not-solution-states-drug-problems/.

[21] Ashley Spalding, “House Health Repeal Plan Would Worsen Kentucky’s Drug Problems,” Kentucky Center for Economic Policy, March 10, 2017, https://kypolicy.org/house-health-repeal-plan-worsen-kentuckys-drug-problems/. Dustin Pugel, “Changes to Medicaid Waiver Request Move Further in the Wrong Direction,” Kentucky Center for Economic Policy, Aug. 1, 2017, https://kypolicy.org/changes-medicaid-waiver-request-move-wrong-direction/. The Medicaid waiver was approved Jan. 12, 2018.

[22] Conversation with Steve Shannon, Executive Director of the Kentucky Association of Regional Mental Health-Mental Retardation Programs, (KARP),Inc.

[23] HB 396 18 RS, http://www.lrc.ky.gov/record/18RS/HB396.htm.

[24] Justice Reinvestment Work Group, “Kentucky CJPAC Justice Reinvestment Work Group: Final Report,” December 2017, https://justice.ky.gov/Documents/KY%20Work%20Group%20Final%20Report%2012.18.pdf.