Bill Kinkle hasn't worked as a nurse in nearly a decade. But the Pennsylvania man never leaves home without emergency medical supplies.

Always on his belt: naloxone, a medication that can reverse an opioid overdose and save a life.

Kinkle, who lives in the Philadelphia suburb of Willow Grove, says his own life has been saved by naloxone more than once.

Nearly 15 months into recovery from heroin addiction, he also carries a card telling others where they can get help. His message, he says, is that “people can recover, they do recover, and they are worth the effort.”

Bill and Trish Kinkle arrive at their new home after picking their three kids up from daycare in Willow Grove, PA. Jasper Colt, USA TODAY

Kinkle handed out those cards at two Philadelphia libraries last month as they hosted what the Pennsylvania state health department called the largest naloxone giveaway ever. About 80 sites participated statewide.

It was just one effort among many, by governments, organizations and individuals, to fight a drug overdose epidemic that killed more than 52,000 Americans in 2015, 63,000 in 2016 and 70,000 in 2017.

2018 might have been a turning point.

“Every year for 23 years, we’ve set a new record for overdose deaths,” says Andrew Kolodny, who researches opioid policy at Brandeis University in Massachusetts. But if provisional data from the first half of 2018 hold up, he says, “it could be the first year in 23 years that deaths don't increase."

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Kolodny points to provisional data from the federal Centers for Disease Control and Prevention. The latest update shows that deaths peaked at 72,775 during the 12-month period that ended in October 2017. Opioids were responsible for nearly 50,000 of those deaths.

After that, the running 12-month total declined slightly each month through May 2018, before ticking up slightly to 70,652 in June 2018. Preliminary data from the second half of the year are not yet available.

“While we don’t yet know if 2018 is going to show a decrease, we’ve got a pretty good inkling that it’s at least not increasing as rapidly,” says Lauren Rossen, a statistician at the CDC’s National Center for Health Statistics.

He's seen addiction from both sides Bill Kinkle built a successful career as a nurse but lost it all to opioid use disorder. Now he's using his experiences to help others. Jasper Colt, USA TODAY

If 2018 was a turning point, there’s still a long way to go.

The crisis began with a wave of prescription opioid overdose deaths in the late 1990s. A second wave emerged with surges in heroin deaths in 2010. The third wave, still crashing over the country, started with a spike in deaths linked to powerful synthetic opioids, especially illicit fentanyl, in 2013, CDC data show.

Fentanyl deaths kept rising in the first half of 2018, provisional data show.

“The number of deaths is still huge," says Daniel Ciccarone, a physician who studies opioid use and supply patterns at the University of California, San Francisco.

Policies and progress vary from state to state

Any progress is uneven. As of June 2018, provisional data show, deaths were falling in fewer than half of states, while rising or holding steady in others.

But some of the states hit hardest by the epidemic have now seen apparent declines – some sporadic, some sustained.

And some of the programs and policies adopted in those states just might offer a road map for others:

Vermont: Five years ago, then-Gov. Peter Shumlin devoted his entire state of the state address to “a full-blown heroin crisis.” Since then, state health commissioner Mark Levine says, Vermont has eliminated waiting lists for opioid addiction treatment. The state pioneered a “hub and spoke” system of regional treatment centers linked to trained primary care providers. The mainstay is medication-assisted treatment, in which drug users get safe doses of narcotic medications such as methadone or buprenorphine, which reduce cravings and withdrawal symptoms. Or they might get naltrexone, a medication that blocks the effects of opioids, reducing their appeal. The medications are paired with counseling and social support.

Rhode Island: The small state was the first to broaden the use of medication-assisted treatment to all prisoners who might benefit. That includes those entering prison during treatment or withdrawal and those who have been opioid-free in prison but risk restarting the drugs upon release. For released prisoners, “the risk of relapse without proper support is, unfortunately, very high,” says Brandon Marshall, an associate professor of epidemiology at Brown University. He advises the state’s overdose task force.

Kentucky: Intravenous drug users can get clean needles – usually along with naloxone kits and information about treatment and other services – at about 50 “syringe service” sites operating under state guidelines passed in 2015. That makes Kentucky a leader in such efforts. Allen Brenzel, medical director of the state’s behavioral health department, says participating communities “are tired of losing their friends and neighbors.”

Ohio: Ohio is among many states that are using Medicaid expansion to get more people into treatment. It's also using federal grants to train more providers. But Ryan Hampton, a recovery advocate and author who lives in California, says he saw something more when he visited hard-hit Dayton in late 2017: “A true disaster response,” had taken hold, he says, with volunteers “blanketing the city with naloxone.” Social workers and peer counselors were knocking on the doors of overdose survivors to offer help as part of a program run by the local sheriff’s office. Casey Steckling, a social worker and founder of Dayton Recovers, says “the truth is that there are thousands of people getting better here … there’s a realization that there’s hope.”

Pennsylvania: Under a series of disaster declarations, officials from 15 agencies meet once a week to address the opioid crisis, says state health secretary Rachel Levine. The state has developed its own hub-and-spoke treatment system. More than 32,000 people have called an addiction help hotline. Under orders Levine signed in 2015, anyone in the state can get naloxone without a prescription. The state gave away more than 6,100 kits of the drug in December. The state also runs public service announcements aimed at lifting the stigma around addiction. “It’s a medical condition,” Levine says. “It’s not a moral failing.”

Calls for more study, more money, a broader approach

If overdose deaths did decline or level off in 2018, Kolodny cautions, it will be “impossible to draw a straight line” to any program or policy.

“The truth is we don’t know what factors are having the greatest impact,” he says. “It needs to be studied.”

Ciccarone, the University of California, San Francisco, researcher, advises a broad approach.

“All good answers need to be on the table and be funded,” he says. “States that are doing better didn’t just use one monolithic answer.”

The Trump administration awarded states and communities $1 billion last year for treatment and prevention. The Obama administration spent $1 billion on such grants over the two previous years. Some states have provided substantial additional funding.

Still, Ciccarone says, “we haven’t devoted enough money yet.”

Pennsylvania’s opioid response is in many ways a model, the American Medical Association said in a December report. But the report, the first in a series that will feature several states, also outlined ways in which Pennsylvania falls short.

For example, the AMA said, half of addiction treatment facilities there still offer no medication-assisted treatment, despite evidence that it’s often the best choice.

Bill Kinkle discusses his recovery with his addiction medicine doctor, Aviva Fohrer, MD. Jasper Colt, USA TODAY

The AMA also said the state could do more to promote alternatives to opioids for pain treatment.

Recovery advocates have their own wish lists. Social worker Devin Reaves, executive director of the Pennsylvania Harm Reduction Coalition, wants more syringe service sites. Just two legal sites operate in Pennsylvania.

“They are going to save more lives and save taxpayer dollars” when fewer people contract HIV or hepatitis C, Reaves says.

No U.S. city or state allows a tactic that many recovery advocates support: Supervised injection sites where people can use drugs in front of observers trained to intervene in an overdose.

Some state and federal law enforcement officials strongly oppose such sites.

Hampton, the California activist who was impressed by the Ohio response, has been in recovery himself for more than three years. He wants to see more long-term recovery services that address housing, jobs, and social and medical needs.

“If we can get someone past year five of recovery," he says, "they’ve got an 85 percent chance of sustaining their recovery.”

Whether the apparent slowdown in deaths can be sustained is another question.

“It’s very volatile drug market, and we don’t know when a new fentanyl will come on the scene," says Marshall, the Brown researcher. "We are always trying to play catch up.”

Bill Kinkle shares a moment with his son Isaiah before dinner at his home in Willow Grove, PA. Jasper Colt, USA TODAY

Vermont’s Levine says the challenges remain daunting.

“A lot of the underlying factors that produced this crisis haven’t changed very much,” he says. Those factors, he says, include an “epidemic of social isolation.”

One thing that has changed, Ciccarone says, is how many Americans view people with drug use disorders.

“Society has softened its stance on what it means to be dependent on a drug,” he says. “The fact is that it’s ubiquitous among the wealthy and un-wealthy. … It’s an American problem.”

Kinkle, the Philadelphia recovery advocate, hopes his fellow Americans will keep trying to save people like him.

“My biggest fear is that we are going to take our foot off the gas," he says. "Now is when we have to put our pedal to the floor.”