Fifteen years ago, Plumas County had one of California’s highest rates of opioid prescriptions, as well as one of the highest overdose death rates. By 2016, prescriptions were down and the death rate followed. That year zero opioid-related deaths were reported.
This positive statistical trend, however, masks an uncomfortable local reality: Since 2016, Plumas County’s opioid epidemic has shifted from legal prescriptions to underground sources, and the death rate has begun to rise. That is driving public health officials to adjust their approach.
Responding to the spotlight
The community of just under 20,000 residents came under an opioid epidemic spotlight after data compiled from the California Department of Public Health, from 2009 to 2013, found that Plumas County had the highest death rate of deaths from prescribed opioids in the state. The worst year was 2010 with a rate of 40.16 per 100,000 residents, according to the California Overdose Surveillance Dashboard.
The Plumas County Public Health Agency immediately went to work. It launched a campaign to add education around opioids in schools and in the community. It stocked up on naloxone (Narcan), a drug that reverses an opioid-related overdose, said former Plumas County Public Health Agency Director Andrew Woodruff.
In 2015, the county had strengthened its efforts to combat the local epidemic through collaboration with Modoc, Lassen and Sierra counties. They formed the Northern Sierra Opioid Coalition in January 2016. The coalition implemented a series of programs, said Woodruff. Among them were educating the community and prescribers about opioids, and handing out more free naloxone.
Pharmacies and hospitals got on board, working together to implement a prescription drug monitoring program, said Plumas County Public Health Agency Director Nicole Reinert. They created a database so the various pharmacies and hospitals can monitor prescriptions to avoid misuse.
The impacts were almost immediate: In 2016 zero deaths related to opioids were reported; only one death was reported the following year.
Going underground
Then something shifted. While opioid prescriptions continue to fall, deaths began to rise. From 2017 to 2021, death rates bounced between one and two annually. In both 2022 and 2023 three deaths were reported. In 2024 there were four. Public health officials attribute this in part to the way the epidemic has changed as prescriptions dropped.
“It started from overprescribing,” said Reinert. When intervention programs reduced that availability, people turned to illicit street drugs. They had no legal source to feed their addiction, she said, “and now we’re seeing fentanyl.”
While fentanyl is new to the area, methamphetamine has been prevalent for decades. As prescriptions for opioids have fallen, these two drugs are showing up together, said Gary Sanderson, Plumas County’s alcohol and drug administrator.
“A lot of the methamphetamine is causing people to test positive for fentanyl as well,” he said. Nonprescription methamphetamine is increasingly laced with fentanyl. “With more fentanyl in the meth, there is a higher risk to the community for overdose deaths,” Sanderson added.
Fentanyl, a synthetic opioid, has a very high potency that can be fatal even in low amounts. Sanderson said he doesn’t believe that people go straight to heroin or meth. “Typically individuals might go to the black market, through friends or connections, to find the same prescriptions they were being given before,” he said.
Some people have told him the drugs they bought through the black market weren’t the same as the ones being prescribed, potentially leading to addiction to other substances, Sanderson said.
The opioid epidemic of today is “silently killing people.”
Gary Sanderson, Plumas County alcohol and drug administrator
Sanderson said the opioid epidemic of today is “silently killing people.”
As these new challenges arose, Reinert said county health officials began implementing programs for medication-assisted treatment, syringe exchange and substance-use disorder counseling. But funding and resources posed a challenge as they worked to expand access and care.
$6.9 million opioid settlement
In 2018, Plumas joined other counties and cities across California to sue pharmaceutical companies and drugstores who were “accused of misleading marketing practices,” Reinert said. Among them were Johnson and Johnson, Teva, Allergen, Walgreens, Walmart, CVS and Kroger, Reinert said.
They won. The financial award from these lawsuits, which is dispersed in annual allotments, can only be spent on mitigating the opioid epidemic. The first of the funds came in late 2022. The county expects to receive a total of $6.9 million over an 18-year span, Reinert said.
But the funds, overseen by the county administration officer, sat untouched from 2022 until Reinert’s appointment in April 2024. The public health agency had no permanent director during that period, part of a spate of department head vacancies that peaked at 19 of 26 positions between 2020 and 2022. Six department heads submitted their resignations between June and September 2023.
The initial installment of settlement funds built interest over the two years, reaching $2 million by the time Reinert assumed her role as director. She immediately requested oversight of the fund.
“It’s kind of a blessing in disguise.”
Nicole Reinert, Plumas County Public Health Agency director
“It’s kind of a blessing in disguise,” Reinert said. “We’re now able to work systematically in the county to distribute it with this large amount.”
Reinert and her team gathered data and reached out to partners for the best way to spend the money. Almost immediately, she put some into the Plumas County Behavioral Health Department’s wellness centers, which were struggling financially at the time. The Chester and Quincy wellness centers provide community assistance programs, such as help with applications, wellness groups and counseling, and financial assistance. They also contain Haven machines, which offer harm reduction tools. These machines are being stocked partially through funding from the settlement.
The public health agency is working to help expand services at Plumas Crisis Intervention and Resource Center through North Star Navigation Center, PCIRC’s shelter service.
Reinert and Sanderson noted that transportation, time and access to services can be challenging for some people. Reinert intends to use some of the settlement funds to hire a nurse to provide education and wound care via a mobile outreach van. She also plans to use some of the settlement funds for transportation to treatment centers.
“These are really remote sites that often don’t get a lot of services at all,” Reinert said. “We’re trying to meet them where they’re at and trying to expand.”
Reinert also plans to put part of the settlement funding toward support for incarcerated individuals. People suspected of being under the influence may soon have a medical wristband to monitor signs of an overdose, allowing health officials to react quickly.
“The [Plumas] jail is working to purchase a body scanner upon entry, just to ensure there aren’t additional substances,” Reinert said. “If these substances are found, this will not be additional tools for prosecution — this is simply for prevention.”
After people are released from jail, public health officials hope to offer Brixadi, a once-a-month injection used to treat moderate to severe opioid addiction. There is also a fund for people who can’t afford treatment, Sanderson said.
Naloxone (Narcan)
When the opioid epidemic was first identified, one of the earliest public health interventions focused on training the community to use naloxone.
Public Health Coordinator Danielle Blust explained that the stigma surrounding naloxone has remained throughout this process. Some believe that offering naloxone encourages users to continue taking opioids. Other forms of stigma include people believing they don’t need naloxone because of who the drug is intended for.
Blust explained why everyone — with or without addiction issues — should have naloxone: “It isn’t just people who take drugs recreationally, but also those who take them because of their health.”
Blust and Reinert both compared naloxone to a fire extinguisher: “Everyone should have one at their house,” Blust said. “You never want to use it, but you’ll be grateful to use it when you have it.”
“You never want to use it, but you’ll be grateful to use it when you have it.”
Danielle Blust, Plumas County Public Health Agency coordinator
Blust said that as community members, it’s important to know the signs of an overdose and to always carry naloxone. “If you notice someone’s lips are blue, or their skin is pale, or they’re having complications breathing,” those are all signs of an overdose, she said.
Naloxone is provided by the county public health agency and the behavioral health department at no charge. The settlement money is also being used to purchase more naloxone.
Challenges in the data
The county public health department gathers the majority of the data on opioid overdoses. But gathering and interpreting data comes with its own set of difficulties. Plumas County has limited data for several reasons, including its small population, which makes gathering extensive information challenging. Other constraints include resources and staffing limitations, Reinert said.
As the epidemic has moved underground, often health officials have to rely on word of mouth.
“When we’re giving out Narcan through the harm reduction program, and people are reporting ‘I had three friends last week who overdosed and one died.’ That’s how, at times, our county has to gather some of the data,” Sanderson said.
Blust explained that when someone with underlying health conditions dies their death may be attributed to that health concern — even when opioid overdose plays a role. To make interpreting data even more difficult, the county’s size means that even one death can greatly increase percentages and change how the county compares with others, Sanderson said. The California Overdose Surveillance Dashboard isn’t completely reliable either. Blust explained that Westwood is included in the Plumas County data despite being part of Lassen, not Plumas, County.
Sanderson was skeptical about the zero deaths reported in 2016. “I don’t think it was ever zero,” he said, explaining that the absence of deaths was likely related to reporting issues.
Reinert noted that the county’s epidemiologist has been looking at recent opioid overdose data. “We have collected local quantitative data through surveys regarding drug use, needs and readiness for treatment, which we are processing internally,” she said. This data will be paired with emergency room visits, uses of naloxone and monitoring of vital statistics.
Looking forward
Plumas County remains under the state average for opioid prescriptions. But the wave of the underground epidemic has brought new challenges. With the opioid settlement money now being used, officials are optimistic that expanded services will bring positive change.
“This settlement funding is going to be a huge help for this community overall,” Reinert said. Without it, she was skeptical that any of the new programs could be implemented.
Sanderson said many people struggling with addiction feel judgment and shame, which keeps them using substances in the dark, stopping them from seeking support. He said that we need to begin looking at addiction as “a complex interplay between choice and disease.”
As settlement money funds more initiatives and projects, expanding access and care should help combat the opioid epidemic.
“I think we’re moving in the right direction,” Reinert said. “I see momentum not just with partners but with the community. We’re all going to have to work together.”
