PARCA’s 2026 Annual Forum, “From Crisis to Collaboration: How Data, Policy, and Partnership Saved Lives in Alabama,” spotlighted the multiagency collaboration and bold policy decisions that underpinned a sharp decline in overdose deaths in 2024 and 2025 in Alabama. But an April 24 decision by the Substance Abuse and Mental Health Services Administration

(SAMHSA) that severely limits the use of federal dollars for fentanyl test strips could set back that progress. It also signals a departure from the federal government’s previous embrace of harm reduction as a drug policy priority.

In the context of drug policy, harm reduction is a set of practices and supplies that aim to contain and mitigate the dangers of drug use. Examples of harm reduction supplies include the overdose-reversing nasal spray Naloxone and fentanyl test strips, which are used to determine if a given substance is contaminated with fentanyl. New rules announced in a “Dear Colleague” letter sent to recipients of grants through the Substance Abuse and Mental Health Services Administration (SAMHSA) late last month say that funds from the U.S. Department of Health and Human Services (HHS) can no longer be used to pay for fentanyl test strips and certain other supplies. A carveout exists to allow HHS funding to pay for test strips used by law enforcement, public health, and healthcare professionals in the performance of their duties. However, they can no longer be distributed directly to consumers.

Until recently, Alabama law considered fentanyl test strips to be illegal drug paraphernalia. That changed in 2022, when lawmakers approved a law that removed them from the list of banned items. Test strips increased in importance when fentanyl began to make its way into cocaine, methamphetamines, and marijuana, sometimes killing people who had no idea that the drugs they were buying might be contaminated with the deadly opioid. “The No. 1 reason for deaths due to overdoses is the presence of fentanyl and most of the time the drug user doesn’t know they’re using fentanyl,” Sen. Jim McClendon (R-Springville) told the House Public Safety and Homeland Security Committee in early 2022. Lawmakers legalized fentanyl test strips that June. Since then, HHS funding has defrayed the cost of getting thousands of test strips into the hands of community members. The Alabama Department of Mental Health has distributed a total of 4,000 test strips since 2022, and Birmingham’s Recovery Resource Center has distributed 1,800 since 2022. The Birmingham-based Addiction Prevention Coalition distributed 755 fentanyl test strips in 2025 alone.

Rep. Allen Treadaway (R-Morris), one of the bill’s sponsors, spoke at PARCA’s 2026 Annual Forum about how his experience as a police officer in Birmingham informed his thinking about harm reduction supplies like fentanyl test strips. “I’ve been on the scenes of enough folks dying, especially overdosing, and the medics in Birmingham show up and they’re either on time or they’re not,” he said. Getting harm reduction supplies directly into the hands of the people most likely to need then, Treadaway said, “has saved lives. There’s no question about it.”

Rep. Treadway’s assertion appears to be backed by research work done by researchers at a number of institutes, including UAB  and Johns Hopkins Bloomberg School of Public Health. Likewise, there is evidence that access to fentanyl test strips has a positive effect on the behavior of people who use drugs. A 2017 study out of North Carolina found that 81% of people who injected drugs reported testing their supply for fentanyl before using it. Results showing the presence of fentanyl prompted many of them to take steps to avoid overdosing, most often by using less drug than usual. “In contrast to reports claiming that ‘opioid addicts’ lack impulse control and are unable to make healthy decisions,” the authors of the study wrote, “this finding provides additional evidence that [people who inject drugs], when receiving test results indicating potential harm, can change how they inject drugs to prevent adverse health outcomes.”

Under the framework presented in the April 2026 “Dear Colleague” letter, fentanyl test strips, as well as forms of harm reduction that are illegal in Alabama (such as clean syringes), are considered “drug paraphernalia or supplies that promote or facilitate drug use.” SAMHSA funds can be used to pay for overdose reversal supplies like naloxone and infectious disease prevention supplies like wound care, at-home tests for diseases that can be transmitted through needle-sharing, and sharps disposal kits. However, direct-to-consumer harm reduction supplies that aim to contain and mitigate the dangers associated with illicit drug use without explicitly reducing demand for drugs are contrary to the policy orientation of the current administration.

The administration says it will support “public health strategies that focus on prevention, treatment, and long-term recovery,”  consistent with President Trump’s Executive Order on Ending Crime and Disorder on America’s Streets.

Deaths from drug overdose dropped sharply in 2024 and 2025, due in part to bold policy decisions, the deployment of overdose reversal treatments, and the strategic use of data to target addiction prevention and recovery outreach.    

The story of how that came about was the focus of PARCA’s 2026 Annual Forum – From Crisis to Collaboration: How Data, Policy, and Partnership Saved Lives in Alabama. 

The March 6 event at Birmingham’s Harbert Center featured leaders who helped bring about the decline, including policymakers from the Legislature, public health, and mental health agencies, as well as frontline doctors, first responders, and peer recovery specialists, who are working to combat addiction.  

Video recordings of the program are featured below, along with Governor Ivey’s keynote address at the Governor Albert Brewer Legacy Lunch.

Background 

In the first half of the 2010’s, Alabama had the nation’s highest opioid dispensing rate, with 121 pills dispensed per Alabama resident that year, according to the CDC. Then, in the midst of the pandemic, a surge of fentanyl in the street drug supply sent an already high rate of overdose deaths soaring. Presentation slides available here.

In response, state and local officials teamed to create an innovative set of policies, programs, and partnerships that empower frontline responders and direct service providers to use their experience and expertise to tackle the addiction crisis.  

View each session below. 

Peer Support and the Path Home

John Bayles, Program Director at Birmingham’s Recovery Resource Center, and Stacey Fuller, Case Manager with the Birmingham Reentry Alliance, opened the program with a conversation about their own experiences with addiction and long-term recovery. They shared deeply personal accounts of their paths through addiction, incarceration, and recovery, highlighting how their lived experiences allow them to better assist others. Fuller, an Army veteran and former nurse, talked about the pressure on healthcare providers to prescribe opioids when pain was added as the “fifth vital sign” in the mid-1990s. Both discussed the vital role that peers like themselves can play in connecting with individuals experiencing addiction who may feel angry, guilty, or hopeless in traditional clinical settings. 

Panel One: Confronting the Crisis: Perspectives from Jefferson County 

Panel One reflected the collaborative public health response to the opioid epidemic in Jefferson County. Participants detailed how data-driven strategies and the passage of critical harm-reduction legislation helped reduce overdose deaths. A central theme was the importance of lived experience, as recovery peers and grieving families successfully lobbied to reduce the stigma surrounding addiction and harm reduction. Speakers described the evolution from isolated efforts to a unified community framework that established the Recovery Resource Center and expanded access to treatment. Ultimately, the panel emphasized that sustainable funding and continued partnership are essential to addressing the ongoing challenges of the evolving drug crisis. 

John Bayles of Recovery Resource Center moderated the panel. Participants included: 

• Mark Wilson, MD, Jefferson County Health Officer, 2011-2023 
• Darlene Traffanstedt, Medical Director, Alabama Medicaid Agency 
• Hon. Allen Treadaway, Alabama House of Representatives 

From Crisis to Collaboration: The Formation and Function of the Alabama Opioid Overdose and Addiction Council 

Kimberly Boswell, Commissioner of the Alabama Department of Mental Health, spoke about the strategic efforts to address the opioid and drug crisis through multi-agency collaboration. Presentation slides available here. Commissioner Boswell, State Health Officer Scott Harris, and State Attorney General Steve Marshall co-chair the Alabama Overdose and Addiction Council, which includes numerous committees focused on tackling the crisis through data-sharing, inventive policymaking, and close communication with frontline workers. Commissioner Boswell emphasized the importance of data sharing agreements and a governance structure that make it possible for agencies to use sensitive data to rapidly inform prevention and response efforts, ultimately leading to a substantial reduction in overdose deaths and enabling the creation of a comprehensive, coordinated strategy that targets resources where they are most needed to save lives. 

Innovating and Iterating: Voices from Across Alabama 

The second panel featured perspectives from frontline workers across Alabama who are doing creative work to ensure that people in crisis have access to the support they need. Speakers highlighted the necessity of low-barrier medical clinics and integrated street psychiatry to reach populations who struggle with traditional treatment hurdles. They stressed the importance of empathetic, human-centered care, which includes understanding substance use as a coping mechanism for mental illness and unprocessed trauma. They also discussed the importance of creating space for law enforcement to receive continuing education and engage in dialogue with clinical experts to address technical concerns and facilitate effective collaboration across the different sectors. Finally, the group noted that ongoing education and policy reform would be essential to staying ahead of the crisis, specifically regarding harm reduction tools like expanded drug testing to combat lethal new contaminants. 

Leah Nelson of PARCA facilitated the panel. Participants included: 

• Reggie Parker, Owner, Parker Counseling and Consulting Services 
• Will Rutland, MD, UAB Heersink School of Medicine, Medical Director, Street Psychiatry Clinic 
• Jonathan Riley, CRSII, OD2A Outreach, People Engaged in Recovery 
• Leah Leisch, MD, Assistant Professor, UAB Heersink School of Medicine 

Governor Albert Brewer Legacy Lunch

Governor Kay Ivey provided the keynote address for this year’s Governor Albert Brewer Legacy Lunch. In her address, Gov. Ivey outlined a clear trajectory of progress and commitment in Alabama regarding two pressing issues—the opioid crisis and education reform. The Governor emphasized Alabama’s progress in combating opioid overdoses and detailed substantial efforts to improve the state’s education system, highlighting measurable improvements and ongoing initiatives. Through strategic programs, legislative action, and community involvement, Alabama has made significant gains in reducing overdose deaths and improving educational outcomes, with continued focus on sustaining and accelerating this progress for future generations.

See how children in all 67 counties of our state are faring in education, health, economic security, and more. VOICES believers that every child in Alabama should have access and opportunity to thrive and become all they can be, and hopes that by utilizing this book’s insights, we can identify the challenges, set priorities, track our progress, and achieve real outcomes for children and families.

Access the 2025 Alabama Kids Count Data Book here.

The 2025 County Data Profiles are also available for each of Alabama’s 67 counties and the state. These four-page reports provide even more disaggregated data on the indicators presented in the 2025 Alabama Kids Count Data Book. 

Want to see this data at the national level? Visit the national KIDS COUNT Data Center to access hundreds of indicators, download data and create reports and graphics!

The sharp drop in overdose deaths in 2024, both nationally and in Jefferson County, wasn’t an accident, according to members of the task force that works to combat the epidemic of drug-related deaths. Instead, it resulted from public policy changes and the geographically targeted deployment of resources.

Figure 1. Trends in Accidental Drug and Opioid Overdose Deaths in Jefferson County, 2012-2024. Source: Jefferson County Coroner’s Office data.

Printable PDF available here.

Thanks to those interventions, Jefferson County saw its first decline in overdose deaths since 2018. According to data from the Jefferson County Coroner’s Office, drug overdose deaths peaked in the county in 2023, with 483 accidental drug-related deaths. That is more than double the number of people who died by homicide (197) in Jefferson County in 2023. And it is more than triple the number of overdose deaths Jefferson County experienced in 2012.

Accidental overdose deaths from opioids began rising in the 1990s with the proliferation of prescription pills. That was followed by a resurgence in heroin use, which was in turn followed by the arrival of fentanyl, an extremely potent synthetic opioid. Beginning in 2020, traffic fentanyl surged into Jefferson County, resulting in a skyrocketing death toll from overdoses.

In Jefferson County, the arrival of fentanyl hit the Black community especially hard. Historically, White deaths from drug overdoses had greatly outnumbered Blacks. But by 2023, Black overdose deaths eclipsed whites.

Figure 2. Trends in Overdose Deaths By Race, Jefferson County. Source: Jefferson County Coroner’s Office data.

Health officials nationally and in Alabama have been working to catch up with the epidemic. In 2017, Governor Kay Ivey established the Alabama Opioid Overdose and Addiction Council, which pulled together the state departments of Public Health and Mental Health, local health providers, and a broad coalition of health care providers, drug treatment non-profits, and first responders. Much of the coordinating and data-gathering work has been funded by the Centers for Disease Control and Prevention and its Overdose Data to Action grant program. According to the CDC, factors driving the decline in overdose deaths include the “widespread, data-driven distribution of naloxone, which is a life-saving medication that can reverse an overdose; better access to evidence-based treatment for substance use disorders; shifts in the illegal drug supply; a resumption of prevention and response after pandemic-related disruptions; and continued investments in prevention and response programs like CDC’s flagship Overdose Data to Action (OD2A) program.”

OD2A funding to the Alabama Department of Public Health and the Jefferson County Department of Health has supported the creation of a data-gathering and sharing program that is providing real-time information about where overdoses are occurring. Emergency medical services providers and hospitals are reporting overdose encounters as they happen, allowing public health officials to zero in on communities and even specific neighborhoods where overdoses are on the rise. Jefferson County’s Health Department has worked with the Jefferson County Coroner’s Office, health care providers, and researchers at the University of Alabama at Birmingham and other local agencies to gather, analyze, and act on the data.

With the data mapped and analyzed, partners from the healthcare and treatment community, first responders, and public health officials routinely meet to discuss patterns and develop a concerted approach to overdose prevention. Figure 3 shows the concentration of overdose deaths by zip code, for the peak year, 2023. Using the slider and directional arrows, you can cycle through years of data to see the rising numbers and shifting geographic concentration.

Figure 3. Mapping Overdose Deaths By Zip Code, by Year. Source: Jefferson County Coroner’s Office data.

Policy changes identified and lobbied for by the Overdose and Addiction Council set the stage for the interventions that appear to be driving down deaths. First, in June of 2022, the Alabama Legislature decriminalized Fentanyl test strips. Before the change, the strips that allow the detection of potentially fatal levels of the drug were considered drug paraphernalia, discouraging their availability and use.  Then, in March 2023, naloxone was made an over-the-counter medication, increasing access to the overdose-reversing treatment and allowing for distribution in the community.

In the wake of the changes and with an influx of funding from both federal and state opioid settlement money, a coalition of groups pushed out resources and training to make the life-saving resources available. The Alabama Department of Mental Health significantly increased naloxone distribution, distributing 46,482 kits at Back-to-School events, End Addiction Walks, and conferences and trainings for treatment providers serving high-risk individuals, local and rural law enforcement officers, and first responders. JCDH has an online Naloxone education portal on its website, www.jcdh.org, and sends Naloxone Kits and Fentanyl Test Strips by mail at no cost to people who request the kits through the website. In addition, JCDH provides both products through dispensing boxes at its health centers and at distribution boxes in other community locations.  JCDH also partners with local EMS, police, fire and rescue, and some independent pharmacies to provide the supplies as well.

Using Jefferson County Coroner’s data, the Jefferson County Health Department identified particular neighborhoods where overdose deaths were on the rise. To counter the trend, the department found avenues to distribute free Naloxone and Fentanyl test strips. They also launched public information campaigns, advertising the dangers of the drugs and resources for treatment services, in some cases, displaying the messages on the public transit buses that served the affected areas.

Jefferson County Health Officer Dr. David Hicks applauded the cooperation and the progress but stressed the need to sustain the effort.

“As we continue to address the challenges posed by overdose deaths in our community, it is crucial to recognize the progress we have made and the work that still lies ahead,” Hicks said. “Our collective efforts in prevention, education, and treatment are making a difference, but we must remain vigilant and committed to saving lives. Together, we can build a healthier and safer Jefferson County.”

PARCA is involved in an effort to encourage similar efforts to share, analyze, and act on data. The Birmingham-Jefferson County Justice Governance Partnership brings together county government, municipalities, multiple law enforcement agencies, schools, health providers, non-profits, and community groups to develop a common understanding and cooperative solutions to community challenges. For more information, visit the BJC-JGP website.

VOICES for Alabama’s Children published the 2023 Alabama Kids Count Data Book today, marking the 30th edition of the book published by the nonprofit. For the 8th year in a row, PARCA worked with VOICES as a data partner for the project.

– Children of color and children in poverty are shown to have much poorer outcomes and much poorer achievements in education.

– Child population continues to decrease. Over the last year, the number of children grew in only 20 of 67 counties.

– Children in Alabama are becoming increasingly more diverse ethnically and racially. While white and Black child populations are declining, since 2000, Hispanic children grew approximately 276%. The Asian/Pacific Islander population grew by 120%.

– The infant mortality rate has slightly decreased from 8.1 to 7.6 per 1,000 live births from 2011-2021. In real numbers, that means that 443 babies did not live to their 1st birthday in 2021. Maternity care is critical. 34.3% of Alabama counties are defined as maternity care deserts. More than 28% of Alabama women had no birthing hospital within 30 minutes, which is more than double the U.S. rate.

– In 2022, the percentage of Alabama high school students meeting college and career ready requirements was 79.1% from 76.5% in 2021.

– 2023 Work-based learning programs (Dual Enrollment and Career Training Programs) are estimated to have had an economic impact of $420,209,126.

– From 2015-2023 there has been a 16.9% increase in the number of children entering foster care services. Parental drug use is the leading reason for children entering foster care, making up 44%, followed by neglect at 22%.

– 10.4% of children in the state are living in extreme poverty. Black and Hispanic populations are disproportionately affected (38.3% and 36.7% respectively), while white children make up 13.5% of children in extreme poverty.

See how children in all 67 counties of our state are faring in education, health, economic security, and more. VOICES believers that every child in Alabama should have access and opportunity to thrive and become all they can be, and hopes that by utilizing this book’s insights, we can identify the challenges, set priorities, track our progress, and achieve real outcomes for children and families.

Access the 2023 Alabama Kids Count Data Book here.

Want to see this data at the national level? Visit the national KIDS COUNT Data Center to access hundreds of indicators, download data and create reports and graphics!

Alabama’s population increased by 34,000 last year to 5.1 million, driven by increased domestic migration and a decreasing number of deaths, according to the latest population estimates published by the U.S. Census Bureau, covering the period between July 1, 2022 and July 1, 2023.

That’s the 15th fastest rate of growth among U.S. states and ranks 11th in terms of the number of people added. Still, Alabama’s growth rate trails other Sunbelt and Mountain West states, including Southeastern neighbors like Florida, Georgia, Tennessee, and South and North Carolina.

Alabama’s death rate fell from the third-highest in 2021 to the sixth-highest in 2023. Still, more people died in Alabama than were born here, according to the 2023 estimates. But the gap narrowed. Births were up by about 150, and the estimated number of deaths in 2023 was down by almost 10,000 from the 2021 peak of the Covid-19 pandemic.

Most of the population change resulted from people moving in from other states. The state received 30,744 domestic migrants, 2,000 more than moved in the year before. International migration into Alabama increased to 5,364 net new arrivals, or about 1,000 more than the year before.

In 2023, Alabama’s rate of domestic immigration was the 10th highest in the U.S. However, Alabama still has one of the lowest rates of international immigration among states, ranking No. 45.

Texas and Florida added the most people. New York, Illinois, and California saw the biggest declines. All the Southeastern states, with the exception of Louisiana and Mississippi, recorded population increases. That pattern has been consistent since 2020.

Census population and change estimates for counties, metro areas, and cities will be released later in the year. Use the tabs and menus in the visualizations to explore the data.

The percentage of Alabamians without health insurance rose between 2019 and 2020, according to the latest estimates from the U.S. Census Bureau. In 2020, 11.8% of the population under 65 was uninsured, compared to 11.6% in 2019.

Printable PDF available here.

Nationally, the uninsured rate declined from 10.8% to 10.4%. Alabama ranks 39^th among the states in the percentage of its population with health insurance.

Comparison Among States

The latest estimates come from the Census Bureau’s Small Area Health Insurance Estimates (SAHIE). The Bureau has built an interactive tool for exploring the data in depth at the national, state, and county levels.

With the implementation of the Affordable Care Act in 2014, Americans gained access to health care exchanges and subsidies, which increased the percentage of people with health insurance. The law also encouraged states to expand Medicaid eligibility in order to provide health insurance to more low-income individuals. To date, 12 states, including Alabama and several other Southeastern states, chose not to expand Medicaid. Those states tend to have higher percentages of their population uninsured.

Three Southeastern states did expand Medicaid eligibility. Those states have a smaller percentage of the population uninsured than Alabama: Kentucky, 6.9%; Louisiana, 9.6%; and Arkansas, 10.2%.   

Health Insurance By County

Dekalb County has the highest percentage of the population without insurance, at 19%. Dekalb and other counties across North Alabama have a greater share of residents who are Hispanic compared to other parts of Alabama. Nationally, the health insurance rate is much lower among Hispanics than in other demographic groups. On the other end of the spectrum is Shelby County, which has the lowest percentage without insurance, 9.3%

Coverage For Children: A Bright Spot for Alabama

Alabama ranks in the top 20 when it comes to providing health insurance to children. Only 3.6% of individuals 18 and younger lack health insurance, largely thanks to the ALL Kids, Alabama’s Children’s Health Insurance Program (CHIP). The program is administered by the Alabama Department of Public Health and Blue Cross Blue Shield of Alabama (BCBSAL) to provide medical, mental health, and substance abuse services through their preferred provider organizations (PPO).

Conclusion

Alabama has policy options for decreasing the number of people who lack health insurance. Recent federal legislation has provided additional incentives to expand Medicaid. An analysis by PARCA and the Center for Economic Development and Business Research at Jacksonville State University found that expanding Medicaid coverage to low-income adults in Alabama would actually save the state almost $400 million per year over the next six years. Much of that savings would come through having federally supported Medicaid coverage pay health care costs that are currently paid for by other state programs. Expansion can be handled by expanding coverage under the government program or a through insurance policies subsidized by Medicaid funding but offered by private companies.

– Economic Security: While 16% of Alabamians live in poverty, 23.9% of Alabama children live in poverty (ex. a household of 4 making $24,750 or less). Further, 1 in 5 children in Alabama are food insecure.

– Education: Poverty leads to significant disparities in education. For Alabama 4th graders in poverty, only 37.9% are proficient in reading and 12.1% are proficient in math.

–  Safety and Permanency: In 2021, 3,453 children entered foster care. While cases can have multiple causes of entry, 48% of cases involved parental substance abuse.

See how children in all 67 counties of our state are faring in education, health, economic security, and more.

Access the 2021 Alabama Kids Count Data Book here.

Expanding Medicaid coverage in Alabama could save the state almost $400 million per year over the next six years – more than enough to cover the cost of expansion – and have an average positive economic impact of $1.89 billion per year over that same time frame.

These findings are based on analysis conducted by the Public Affairs Research Council of Alabama and the Center for Economic Development and Business Research at Jacksonville State University.

The analysis was supported by the Daniel Foundation of Alabama, the Community Foundation of Northeast Alabama, the Community Foundation of Greater Birmingham, the Mike and Gillian Goodrich Foundation, and the Women’s Foundation of Alabama.

Medicaid is a federal healthcare program administered by the states. The federal government funds approximately 71% of Alabama’s current Medicaid costs. The state’s General Fund covers the balance.

Medicaid covers approximately 925,000 Alabamians – the majority are children. Low-income adults are only covered if they are caretakers of someone under 19, pregnant, over 65, legally blind, disabled, or in a nursing home. The income limits vary by program but can be very low. For example, the income threshold for a caretaker is 13% of the federal poverty level or $3,445 per year for a family of four.

Since 2014, states have been able to expand their Medicaid programs to cover adults earning up to 138% of the federal poverty level, $36,570 for a family of four. Initially, the federal government would cover 100% of the cost. From 2018 onward, the federal government covers 90%.

Alabama is one of 12 states which have chosen not to expand Medicaid. If Alabama chose to expand Medicaid, this would extend access to coverage to more than 280,000 people. The state would be responsible for 10% of the cost. Policymakers have expressed concern about the state’s ability to cover these increased costs – a reasonable concern given the troubled history of the state’s General Fund.

However, recent changes to federal law, including those in the various COVID relief packages, change the equation.

Our analysis finds that over the next six years, expanding Medicaid in Alabama could:

• extend coverage to as many as 283,636 people.
• create an average of 20,083 new jobs per year.
• have an estimated positive economic impact of $11.36 billion.

Our analysis estimates covering that expanded population through Medicaid would cost an average of $225.4 million per year. However, expansion would result in the federal government paying $397.88 million in annual expenses currently paid by the state. As a result, the state could expand coverage, and at the same time, reduce or reinvest the amount paid to support healthcare for low-income Alabamians by $172 million annually.

Read the full report.

VOICES for Alabama’s Children recently released its 2020 Alabama Kids Count Data Book last month. This annual statistical portrait is meant to provide a roadmap for policymakers who seek to improve the lives of Alabama’s children. PARCA provides research support for the project.

The Data Book can be used to raise the visibility of children’s issues, identify areas of need, set priorities in child well-being, and inform decision-making at the state and local levels.

See how children in all 67 counties of our state are faring in education, health, economic security, and more.

View the 2020 Alabama Kids Count Data Book here.