With the country in the throes of an epidemic, communities across the nation are being forced to confront the harrowing, and often fatal, effects of opioid abuse. But solutions — such as creating intervention programs in Ohio, providing access to treatment in Alabama, or investing in prevention initiatives in Missouri — cost money.
The Department of Justice recently announced it would award almost $59 million in grants for programs addressing the opioid epidemic across the country. Nearly 60,000 Americans died because of drug overdoses in 2016, with the majority of those deaths attributed to opioids, according to the DOJ.
"These grant awards have primarily been directed to states and communities hardest hit by the opioid epidemic who are experiencing significant increases in the number of overdose deaths and non-fatal overdoses," Attorney General Jeff Sessions said.
About $24 million of the money awarded will go to 50 local governments that are fighting opioid addiction through a variety of measures aimed at prevention and treatment.
Here's a look at three counties that received money, what they're doing to curb opioid overdoses in their communities and how these grants will affect their efforts to save lives.
Jefferson County, Ala.
The Jefferson County Department of Health hadn't planned on getting into the naloxone distribution business. Administering vaccinations, conducting health inspections, operating clinics — those were some of the basic services the department offered in the community. Handing out a life-saving drug designed to reverse the effects of opioid overdose was new.
"At some point, somebody had to say, 'This is a problem we need to address,'" said Mark Wilson, the department's health officer.
The problem largely came onto officials' radar in 2012, when the Alabama county's coroner recorded 58 heroin overdose deaths, followed by 58 again the next year. That number was up from 30 in 2011.
In June 2014, the department coordinated with the U.S. Attorney's Office and the University of Alabama at Birmingham's School of Public Health for a heroin summit to develop a strategic plan for awareness around the growing problem.
Still, the deaths continued. In 2014, 138 heroin overdose deaths were recorded.
Since then, the department has shifted its focus as the opioid crisis has evolved. Jefferson County's health department officials have pushed for opioid-related policies in the state Legislature, expanded access to naloxone and are working to create a 24/7 hotline for people struggling with drug addiction.
These initiatives come at a time when fentanyl overdose deaths are on the rise. Fentanyl, an opioid 50 times more potent than heroin, contributed to 106 of the 251 opioid overdose deaths last year.
Recently, the department examined the accessibility of opioid addiction treatment in the county, which has just under 660,000 residents. Officials determined easy access to the right treatment is a serious problem. That's where the grant money comes in.
The department is working to create a resource center where people seeking help can get an assessment, a referral for treatment and connect with a peer mentor who has recovered after opioid abuse. The $300,000 grant will help expand the center's services for the next three years.
Many times people who need help don't know where to start, Wilson said. They are bounced around from program to program, or are put on a waiting list for a program that may not be right for them. That can have lethal consequences.
"It's sort of a crapshoot or luck of the draw, ultimately, where you end up," he said. "If you're not in an appropriate program you might be more likely to relapse, overdose and die."
Wilson said he hopes that having a resource center to get people to the treatment centers they need will curb those deaths.
"The numbers of overdoses that we have — that 251 number — that is the tip of a huge iceberg, and we don't know how big that iceberg is."
Hamilton County, Ohio
The emergency responders in Hamilton County, Ohio, were fatigued. Many were being dispatched to administer naloxone for repeat overdoses at familiar houses in the same pockets throughout the county. Something needed to change.
About a year and a half ago, Colerain, a township west of Cincinnati, launched the Quick Response Team — a pilot program consisting of a law enforcement official, an emergency responder and a treatment specialist — to try to address the issue. Together, the team conducts follow-up visits with everyone who received a dose of naloxone from emergency responders within the past week. During the visits, the team tries to persuade them to go to treatment.
The team has an 80 percent success rate in getting them there, county commissioner Denise Driehaus said. Driehaus heads the county's Heroin Coalition, which is tasked with addressing all facets of the opioid epidemic in the community, including prevention, harm reduction and treatment.
Right now, Quick Response Teams work in three jurisdictions throughout the county, but that isn't enough. The opioid epidemic isn't contained inside neatly drawn township lines.
Last year, 403 accidental overdose deaths were recorded in the county, with 95 percent of those involving opioids, Driehaus said. As of Sept. 15, the number of suspected overdose deaths had already surpassed that, with 427 deaths recorded by the county coroner.
"We have hot spots everywhere throughout the county, so we need the capacity to respond to those hot spots," Driehaus said.
While overdose deaths are rising, a smaller proportion of overdoses are resulting in deaths, said Alex Linser, the commissioner's chief of staff. The county attributes that to its widespread distribution of naloxone.
"It's a complicated statistic, but that kind of window of hope is something we can build on," he said.
With the $400,000 grant the county received, the coalition is working to create a countywide quick response team program that could serve all the county's roughly 800,000 residents. The Heroin Coalition is working to coordinate with all the jurisdictions to make that happen. Driehaus said a countywide program could be implemented in as soon as a month and a half.
Preventing overdose deaths and helping people get treatment is only part of the solution, though. The effects of the opioid epidemic touch several aspects of county government, including the criminal justice system and child protective services, and addressing those issues takes funding.
"We have many, many kids entering the system because they lost their parents or their parents are addicted to heroin and not capable of caring for kids," she said. "The system becomes overwhelmed. We need more funding to respond to that."
St. Louis County, Mo.
County executives don't typically handle prescription drug monitoring programs, but Steve Stenger in St. Louis County, Mo., made it a priority.
Until recently, when Gov. Eric Greitens announced an executive order in July creating a statewide prescription drug monitoring program, Missouri was the only state without one.
Greitens' order comes after the General Assembly failed to pass legislation creating a program.
When Stenger took office in 2015, he began working with officials to create a program at the county level, then allow other cities and counties to join it, which is what many of them have done.
With 48 cities and counties passing legislation to participate, the program covers about 71 percent of the state's population. The county plans to use part of the $400,000 grant it received to hire a full-time employee dedicated to maintaining and expanding it.
The program gives doctors and pharmacists access to a database with information on prescriptions written for opioids throughout the jurisdictions involved, Stenger said.
The database is designed to help prescribers identify patients who could be high risks for abuse and help them make informed decisions based on their patients' medical history with controlled substances.
The idea is to stop prescription abuse before it starts — and before it leads to heroin or fentanyl.
"You've got one epidemic feeding another epidemic," Stenger said, and he knows what the opioid epidemic does to families.
In 2014, his nephew died from a heroin overdose. That experience played into his work pursuing a countywide drug monitoring program.
"I was seeking to avoid for my constituents the same pain that my family went through," he said. "It caused complete devastation in my family."
That year, 203 people died from opioid overdoses in St. Louis County, according to the St. Louis County Medical Examiner's Office.
The county also received another $600,000 grant, which it will use to hire a full-time employee to look at the area's opioid abuse statistics in order to improve the county's response. The data will be used to find out how many people are trying to get multiple prescriptions and how often naloxone is being administered to overdose patients, among other things.
In March 2016, the county, which has just under 990,000 residents, began equipping its law enforcement with Narcan, a nasal spray form of naloxone. Though emergency responders primarily administer the drug, the county learned that sometimes officers would arrive to overdoses before EMS, forcing them to stand by and watch without a way to help.
"They are quite literally watching people die before their eyes," Stenger said.
As of September, law enforcement officers had saved 53 lives by administering Narcan.
Some critics of the drug argue it propels habitual drug users to continue using, exacerbating the problem, but Stenger has a firm response to that assessment.
"What we're trying to do is save lives, and allow for an opportunity for treatment and other intervention," he said. "When someone passes away, there is no opportunity for treatment. There is no opportunity for that family."
Isabel Dobrin is an NPR Digital News intern.