In Brief:
Milwaukee County has one of the worst rates of overdose death in the nation. Its mortality rate, in fact, is eighth-highest in the nation among jurisdictions with populations above a half-million people.
The county has seen an especially dramatic spike of deaths among its Black population, with fatal overdoses increasing by 75 percent between 2020 and 2022.
The county is now trying to address these issues in new ways, thanks to a new source of funding. Milwaukee County has received more than $100 million from opioid settlements reached in 2021 and 2023. It's devoting that money to prevention and treatment programs, but not only through the Department of Health and Human Services.
Every county department, with the possible exception of the zoo, has been affected by the opioid epidemic, says Jennifer Wittwer, director of the Milwaukee County Behavioral Health Division. In recognition of that fact, they were all invited to submit proposals for projects using settlement funds. The county has funded 15 different projects so far, with grants going to the sheriff’s office, the medical examiner and the Office of Emergency Management.
These involve all kinds of different approaches, including supplies of naloxone, commonly known by the brand name Narcan (which is used to restore normal breathing after an overdose), patrol officers and housing assistance, education and outreach, vending machines stocked with harm-reduction supplies and interventions for incarcerated adults and youth in detention.
The settlement funds are game-changing, Wittwer says, and the projects draw on established best practices. But implementation is just beginning, and it’s too soon to gauge their impact. She is matter of fact about the urgency. “If we weren’t doing the things we’re doing, how much worse would the problem be?” she asks.
It's a reasonable question about a problem which has had constantly shifting dimensions over three decades.
An Epidemic in Waves
Wittwer has been with the county for 14 years. Prescription opioids began to push overdose deaths upward in the 1990s, but by the time she arrived heroin was a bigger problem. Within a few years, synthetic opioids became the biggest cause of mortality, driven by a growing supply of illicitly manufactured fentanyl.
Nationally, the death toll has moved into a range six times as high as it was in 1999. Fatal overdoses in 2023 were at least 50 percent higher than just four years ago.
One of the reasons fentanyl is responsible for such a large percentage of deaths is that the risks for exposure to it continue to expand. It’s added to other drugs such as heroin and cocaine, in part to make it possible to make more doses and profit from the raw drug, but also to create a bigger high. It can be found in counterfeit prescription drugs that wouldn’t be expected to contain it, packaged in bottles that look authentic, or pressed into pills that look like other drugs.
Deaths among Black drug users aren't going up because of more drug taking. Fentanyl is being mixed with cocaine at increasing rates. “Because they don’t identify as opioid users, they don’t perceive themselves to really be at risk,” Wittwer says. “But they are.”
In recent years, xylazine, a non-opioid sedative also known as tranq, which has been approved for animals but not for people, has been mixed with fentanyl to extend the high it causes. Wittwer is especially worried about this trend. “Narcan typically can’t revive someone whose supply has been adulterated with xylazine,” she says.
Moving Upstream and Down
In 2019, Milwaukee County was the first jurisdiction in the nation to pass a resolution declaring racism to be a public health crisis. In addition to education, prevention and treatment, long-term plans for addressing its drug crisis include moving upstream and addressing the social determinants that can lead to substance abuse disorders.
“We’re focused now on reviving people, or giving them harm reduction supplies, but at the root of all this is systemic racism and poverty,” Wittwer says. “By the time we’re giving them treatment it’s almost too late.” The infusion of settlement funds may create opportunities for upstream investments in things such as sustainable income or equal opportunity for safe and affordable housing.
An overdose dashboard developed with partners including the county's Office of Emergency Management, the medical examiner's office, the Wisconsin Department of Justice and the Medical College of Wisconsin provides a continuously updated view of fatal and nonfatal overdoses, including which drugs are involved and the days on which overdoses are occurring. It also draws on GIS data to track these events by Census tract. Milwaukee County has had a reputation as one of the most segregated communities in the country, Wittwer says, and the maps show higher rates of both fatal and nonfatal overdoses in minority neighborhoods.
(Milwaukee County)
RAND Corporation scientists recently produced a study examining whether a similar “continuum of survivorship” exists for those who lose family members to overdoses. They added questions about this to a long-standing RAND survey. The responses led them to conclude that overdose loss has disrupted the lives of 1 in 8 American adults.
The potential for overdose bereavement to increase overdose risk has been overlooked, says Alison Athey, a RAND behavioral scientist who co-authored the paper. “To my knowledge, there are no overdose postvention policies or practices endorsed by key decision-makers,” says Athey.
Health departments could incorporate grief and trauma resources in their services, or possibly financial help if the deceased was the primary earner for a family, she says. A few have begun doing so.
A postvention project has been proposed for the next round of Milwaukee County funding, says Wittwer. “That’s a very high-risk group of individuals,” she says. “Think about the children of families where one or both parents have been lost to an overdose — those kids barely stand a chance.”
First responders also feel the toll. After being called to the same house 12 or 15 times to revive the same person, they can lose hope themselves.
(Milwaukee County)
An Unanticipated Outcome
Wittwer represents her county as a member of the Opioid Solutions Leadership Network, an initiative of an Opioid Solutions Center launched by the National Association of Counties (NACo) in 2022. Counties were a driving force in opioid litigation and settlements and recognized that NACo could play a vital role helping them make the most of an opportunity to undo some of the damage the epidemic had caused them. The center was created to meet this need.
The leadership network is one of three “pillars” for the center, says Samantha Karon, who joined NACo in 2022 to oversee its launch. The network is comprised of 30 individuals from 15 states — including elected officials, health directors and county managers — focused on directing funds to strategies that could change the trajectory of the opioid crisis. The other pillars of the center’s work are helping counties assess and prioritize eligible expenditures of settlement funds and identifying administrative tools that will enable them to be good stewards of this novel funding stream.
Members of the leadership network met repeatedly last year, including trips to each other’s jurisdictions to see services and strategies in operation. The second visit was to Milwaukee. “Everyone was saying the same thing,” Wittwer says. “When the landscape keeps changing, it’s very hard to get traction.”
For her part, Wittwer is encouraged that the county’s decision to use the settlement funds in this way has brought county stakeholders together on a regular basis, to plan, report out on projects and identify ways to strengthen partnerships and leverage resources.
“That’s been one of the unanticipated outcomes of the methodology Milwaukee County has had,” she says. “I think it’s making us much stronger as a community.”
