Despite the state’s billion dollar response, West Virginia has led the nation in overdose death rates since 2010, according to a senior policy advisor to the legislature.
Jeremiah Samples, former deputy secretary at the now reorganized Department of Health and Human Resources (DHHR) and current senior policy advisor to the Legislature, presented an analysis of the state’s substance use disorder (SUD) crisis to the Joint Committee on Health on Monday.
“The bottom line is that we have not made enough progress on this crisis,” Samples said. “We’re nowhere near where we need to be, and our data relative to other states, and even our own expectations, has fallen far short. We need to reassess all of our SUD strategies and expenditures through the prism of what is impacting real people in our society.”
A survey conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that 208,000 people in West Virginia used illicit drugs in the last month.
“That’s an average,” Samples said of the number. “It’s a gut-wrenching number to hear, but that’s where we stand.”
Samples also cited a West Virginia University Match Survey that found 359,880 West Virginians used drugs in the past year.
“We can’t sustain that as a society,” Samples said. “That is, it’s crippling to the state.”
In 2010, West Virginia’s fatal overdose death rate per 100,000 people was 28.2. Even after the state spent millions combating the problem, in 2022, West Virginia’s fatal overdose death rate had grown to 80.9 per 100,000 people.
“Our overdose death rate since 2010 has increased by 135 percent,” Samples told the committee. “West Virginia’s overdose death rate is 151 percent higher than the best state in the country, 85.6 percent higher than the national average and 36.4 percent higher than the next worst state (Tennessee).”
Samples cautioned against taking overdose death reports out of context.
“Any downturn is positive,” Samples said. “Those are real lives that people, that are not dying. However, the trend, we’ve had a couple blips where we’ve gone down in the past, but the trends are really what matter, and from a trend perspective, we have increased exponentially since we started leading the nation in overdose deaths.”
According to CDC data, the nation saw a 6.7 percent decrease in overdoses from January 2023 to January 2024. During that same period, West Virginia saw a 1.92 percent increase in overdoses.
“West Virginia is not keeping pace with the decrease in other states,” Samples said. “Before the pandemic, we were at a plateau of sorts. The pandemic hits and fentanyl issues become exponentially worse. Overdose death rates across the country explode. They increased in West Virginia, more so than most states. I think we were perhaps third, we saw the third biggest increase during the pandemic. But the bottom line is, we’re not decreasing at the same rate as some of these other states. So we’re not coming back down to that plateau. We need to get to that plateau and then continue to go down.”
The Current System
Samples explained that West Virginia’s state government response involves “over a dozen agencies,” led by the Governor’s Council on Substance Abuse, founded in 2018, and the Office of Drug Control Policy (ODCP), founded in 2017.
One of those agencies is the Bureau for Behavioral Health (BBH), the designated state mental health authority recognized by the federal government as the single state agency for substance abuse services.
The bureau receives federal block grant funding for substance abuse and prevention. It is responsible for SUD provider infrastructure and manages the state’s Crisis and Referral Line, 1-844-HELP4WV, contract.
“They (BBH) apply for these big federal grants,” Samples said. “They’re responsible for the infrastructure of the state for SUD and their annual budget is roughly $225 million.”
Samples said from 2017 to 2020, BBH was forced to send $34.2 million back to the federal government for funds that were not used from those grants.
“This came up in LOCHHRA (Legislative Oversight Commission on Health and Human Resources Accountability) last year,” Samples said. “We’re unclear from 2021 forward, how much money has been sent back, but it is something that the legislature and the state should explore and investigate.”
In 2023, legislation was passed directing the ODCP to report to the governor’s office. In the DHHR reorganization, the ODCP was placed administratively within the Department of Human Services.
Samples said it is hard to track SUD spending in West Virginia, but the state fiscal year 2025 budget for the ODCP is $2.3 million.
“You can directly attribute hundreds of millions again, in direct expenditures on SUD, just in West Virginia, annually,” Samples said. “And then there’s hundreds of millions more we know that we’re spending that are indirect, for example, child protective services, the child welfare crisis, there are hundreds of millions in indirect costs in just child welfare alone.”
A 2021 study that includes the economic impacts of the crisis by the West Virginia Center on Budget and Policy estimated that the drug crisis costs West Virginia $11.3 billion a year.
Samples also cited a Center for Disease Control and Prevention (CDC) report that found West Virginia experienced 1,335 known overdose deaths in 2022.
“Despite all the investment and expenditure, since 1999 we’ve seen a 1,680 percent increase in our overdose death rate,” Samples said. “Since 2010 which, again, 2010 is when we started leading the nation, [we’ve seen] a 135 percent increase. Since 2017, [we’ve seen] a 56 percent increase. So we have not been getting results. We’ve not been reversing the trend.”
According to Samples, Medicaid is the largest source of treatment funding for SUD in the state, serving approximately 50,000 members with an SUD diagnosis annually.
Medicaid is expected to spend about $140 million on SUD medical and behavioral health claims in West Virginia in 2025. In addition, Medicaid spends approximately $70 million on medication-assisted treatment (MAT) drugs.
“Medicaid’s annual expenditure, when you include MAT and the services, the claims are about $210 million,” Samples said. “Fatal overdoses have increased amongst the Medicaid population from 2018 to 2020, and so we’ve not seen appropriate progress there either.”
West Virginia Medicaid’s Substance Use Disorder Waiver
Since the launch of West Virginia’s Medicaid SUD Waiver, or 1115 Waiver, fatal overdose rates have continued to rise.
West Virginia Medicaid’s biggest SUD expenditure is the 1115 Waiver, which was developed to help increase the availability of SUD prevention and treatment services for Medicaid members.
The waiver was requested by the state and approved in 2017 by the federal government. It allows the state to provide additional services beyond what the federal government requires.
In 2018, the Bureau for Medical Services announced the expansion of services under the SUD Waiver, adding coverage of methadone as a withdrawal management strategy, a Naloxone distribution initiative, coverage of adult residential treatment, peer recovery support systems, withdrawal management services and the use of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) tool to identify SUD treatment needs in the Medicaid community.
The SUD Waiver cost $12.2 million in 2019 and increased to $129.3 million by 2023. The Federal Reserve was responsible for $114 million of the 2023 total. West Virginia paid $15.3 million the same year.
Projected expenditures in 2027 are expected to grow to $161 million, according to Samples.
West Virginia Medicaid has proposed further expansion of the SUD waiver to the federal government. The application is under review with the expiration of the current waiver on September 30, 2024.
Proposed expansions include:
- Expanding peer support to more settings
- Sending quick response teams to clients who have overdosed or are experiencing a crisis
- Providing Medicaid coverage to eligible individuals incarcerated in state prisons starting 30 days before their release
- Offering involuntary secure withdrawal management and stabilization for individuals deemed to be a danger to themselves or others
- Supporting a holistic and integrated approach to treatment
- Education and outreach for Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV) concerning substance use
- Addressing social determinants of health to encourage self-reliance and support continued recovery housing offering clinical-level treatment services.
- Supported house and supported employment
- Offering the TRUST protocol for people with stimulant use disorders
- Reimbursing short-term residential and inpatient treatment services in settings that qualify as an institution that treats mental diseases for Medicaid-eligible adults with serious mental illnesses.
West Virginia’s SUD Outcomes
Samples then shared some encouraging outcomes with the committee from this spending.
According to CDC provisional data, there was a decrease of 9.4 percent in overdose deaths nationally from March 2023 to March 2024. In West Virginia, that same data showed a decrease of 4.91 percent during the same time period.
Samples also cited a decrease in new HIV cases from 153 in 2021 to 100 in 2023.
“This was a really big deal a couple of years ago, Kanawha County alone, which was one of the worst hit counties, saw a 66 percent decrease from 2021 to 2023,” he said. “The 2024 data, which is available online, it’s looking really good. It’s actually even more positive than that. So kudos to everyone that’s worked on that.”
According to a 2022 report from the CDC, 2,400 people were living with HIV in West Virginia.
“Other positives, Medicaid, managed care organizations, providers, recovery homes, they’re starting to make a lot of progress in better measuring our outcomes, better measuring what’s actually happening in the state, so we can pivot and actually make progress on this crisis,” Samples said.
Samples also said he is hopeful about the West Virginia First Foundation, the organization formed by an act of the legislature that is responsible for dispersing West Virginia’s opioid settlement funds.
“The first foundation, this is a new development and something that I think we should have hope for. The foundation stems from efforts by the Attorney General Patrick Morrissey, securing an opioid settlement of approximately $1 billion,” Samples said. “This is the number one per capita opioid settlement in the United States.”
Drugs And Economics
While there are some positive indicators for the future of West Virginia’s drug epidemic, Samples said the state has not had any significant successes but has seen plenty of failure.
“The failures have consequences, the economic impact of the drug crisis,” Samples said. “One study said $8.8 billion a year in impact. Another study said $11.3 billion a year in impact, just on the economy, a 12 percent economic drag on our GDP (Gross Domestic Product), annually.”
Samples said the drug crisis costs West Virginia at least one-eighth of the state’s total economy based on spending on health care, substance use treatment, criminal justice costs, the societal burden of fatal overdoses and lost worker productivity.
The “drag” on West Virginia’s GDP is more than double that of the next highest state, Maryland where substance use disorder-related costs consumed 5.4 percent of its GDP.
Then, Samples addressed West Virginia’s labor workforce participation rate (LFPR), or, the number of people in the labor force (working or looking for work) as a percentage of the total population 16 years and older. West Virginia’s LFPR is at 55.1 percent in July 2024, according to the St. Louis Federal Reserve.
“We’re no longer last, and I don’t say that in jest,” Samples said. “I mean, we were last place in labor force participation rate from 1976 to 2022, so progress is progress, and we are making some progress in that realm, but the drug crisis is holding us back.”
According to Samples, the economic impact of productivity loss for non-fatal substance use disorders has a reported cost of $316 million dollars and 1,206 jobs to the state, while the economic impact of productivity loss due to overdose fatalities carries an additional cost of $322 million and 5,905 jobs.
“When you look at the unemployment rate, which is at 4.2 percent right now, relative to our labor force participation rate, our labor force participation rate has pretty much been level, but our unemployment rate has gone down,” Samples said. “There’s just people not in the job market looking for work, and this is attributable to the drug crisis.”
West Virginia has the highest death rate for working-aged populations and the second lowest life expectancy in the U.S. at 72.8.
“Even going back to 1990 West Virginia has had a lower life expectancy than the national average, but there’s been a gap that’s built, and even as the national life expectancy has gone down, we’ve gone down more,” Samples said.
West Virginia’s Children Pay A Price
According to Samples’ report, 83 percent of child welfare removals were from homes with known drug use.
“West Virginia’s foster care rate grew 61 percent from 2010, to 2021,” Samples said. “It’s 23 percent higher than the next worst state, and 118 percent higher than the national average.”
Data from the Annie E. Casey Foundation shows that West Virginia leads the nation in its foster care entry rate.
“The difference between the entry rate and the foster care rate, entry foster care rate, is just kids in foster care,” Samples said. “The entry rate is kids coming in.”
Samples said West Virginia has led the nation in foster care entry rates since 2010.
“We are 131 percent worse than the national average, and 54.9 percent worse than the next worst state in foster care entry rates, and that’s Alaska,” Samples said.
In 2000, six out of every 1,000 West Virginia children entered foster care. In 2021, 13 out of every 1,000 West Virginia children entered foster care. West Virginia’s entry rate increased 117 percent from 2000 to 2021.
According to the U.S. Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau, in 2020, West Virginia had the highest percentage of children nationally suffering from substantiated maltreatment with drug abuse by the caregiver.
2020 CDC data also showed West Virginia had the highest rate nationally of infants screened in by Child Protective Services (CPS) with prenatal substance exposure.
Also in 2020, there were 712 babies screened in by CPS in West Virginia with drug exposure, compared to 526 babies screened in California, which has a population of 39.5 million people. West Virginia has a population of 1.7 million people.
“We only have about 17,000 babies born in the state a year,” Samples said. “It’s not a lot. If you extrapolate from our birth score numbers, then you’re looking at and not just the difference between neonatal abstinence syndrome (NAS) and in uterine substance exposure. NAS is worse. The babies basically full-blown addicted, is kind of the simple way to say it. we’re looking at around 2,500 babies every year that are exposed to drugs in the womb.”
The Future
In his final address to the legislature, Samples told lawmakers West Virginia’s drug epidemic response needs to be reevaluated.
“The most important thing we need to do, in my opinion, is we need to measure what matters so that we can then pivot and organically improve our response to this crisis,” Samples said. “We need to measure every aspect of our substance use disorder policies and expenditures, and we need to tie it back to a core societal measure.”
Samples left lawmakers with a list of proposed policy solutions including:
- Mandatory Treatment (Casey’s Law)
- SUD Transparency Act: SUD Outcome and Expenditure Dashboard
- Save Babies from Drugs Act
- Improve CPS Management of Cases with Drug Addiction
- Measure Outcomes of Recovery Homes
- Analysis of syringe exchange outcomes and criminal penalties for illegal needle distribution
- Enhanced drug testing and SUD services for those on government benefits
- SUD Relocation Supports
- Public Reporting on SUD expenditures and program outcomes
- Expenditure and Opportunities Audit:
- Ending Addiction Amongst Inmate Population
- Expand Inmate SUD Services via RSAT and GOALS programs
- Develop a ratio of law enforcement needs across communities and increase funding for more officers
“Our economy still struggling, I would propose that really we look at 10 core measures and that we use a smarter approach, which is really just an acronym for specific, measurable, attainable, relevant, time, evaluated and resourced,” Samples said.
Samples said he is “leaving the legislature next month,” but offered no further information after thanking legislative staff and lawmakers.
“It’s been an honor,” Samples said. “The President and the Speaker have been great to me. You all have been great to me. You know you’re wonderful people, and I’ll just always be available to you, should you need anything. I believe in this body, and I believe what you do, and I believe in your hearts.”
Appalachia Health News is a project of West Virginia Public Broadcasting with support from Marshall Health.