America On Opioids: The Many Faces Of The Country's Addiction Crisis

The coroner in St. Louis has run out of facilities to store dead bodies.

A fire chief in West Virginia is haunted by a child, “staring at us with a blank face,” as she attempted to revive his father.

In the small New Mexican town of Rio Arriba, one man has lost his brother and much of his social circle to overdose deaths and prison. He blames poverty, hunger and insecure housing ― a constellation of injustices that he sums up as “historical trauma” ― on the high rates of addiction in his majority Native and Latino community.

During HuffPost’s Listen to America tour at the end of 2017, reporters encountered stories ― some heartbreaking, some triumphant ― of opioids and their effects. The fearsome impact of this public health crisis weighed heavily on people’s minds in every town HuffPost’s bus visited. It is a truth so universally acknowledged as to seem cliche: Overdoses are sweeping the country.

Opioid overdose deaths more than quadrupled between 1999 and 2014, and have only continued to rise in recent years. In total, more than 63,000 Americans died of drug overdoses in 2016, according to the latest data from the U.S. Centers for Disease Control and Prevention. And that is likely an undercount, due to investigations that delay results.

“This crisis has been brewing for a long time,” said Nancy Campbell, a professor at Rensselaer Polytechnic Institute in Troy, New York, who has published several books on drug policy and treatment.

“We have to ask ourselves why it came in the form that it did, when it did,” Campbell said. “Those answers do not lie entirely with the medical profession and with changes in how we treat and think about chronic pain. We have to look at deindustrialization and the changes in our lives in different regions in the country.”

To that end, HuffPost sent reporters to the front lines of the opioid crisis across the country, to talk with people in the throes of addiction, as well as the men and women trying to pick up the pieces in a landscape devoid of widespread and accessible treatment options.

There were some reasons to hope things would get better: A nurse who became addicted to Percocet after knee surgery found an outpatient program that has her clean for the first time in 20 years; an east Tennessee native who used to drive several hours a day to North Carolina to get a dose of methadone now has a clinic closer to home, thanks to a relenting local zoning board.

Previously resistant communities are enacting policies that save lives: equipping local emergency personnel with Narcan, the opioid overdose reversal drug, and enacting “Good Samaritan” laws in which those who report overdoses to the police will not be charged with drug-related offenses.

The Affordable Care Act’s Medicaid expansion provision has made addiction treatment affordable for many people who couldn’t pay for it in the past. And medication-assisted treatment, like methadone and buprenorphine, once rejected by abstinence-only treatment programs, are gaining support among lawmakers in states that have been hit hard by opioids.

Still, Campbell doesn’t think policy has progressed much.

“We’ve evolved all kinds of new strategies, which are actually based on old strategies, like drug courts and diversion,” she said. “We’re trying to meet that problem with slightly more benevolent, but still quite punitive, responses.”

In the meantime, people keep dying.

How We Got Here

While the opioid crisis has been getting steadily worse for the last several years, many experts identify the 1990s as the inflection point.

The movement then to treat pain patients more compassionately dovetailed with aggressive opioid marketing from drug companies, which touted the drugs as safe and non-addictive.

“There is a growing literature showing that these drugs can be used for a long time, with few side effects and that addiction and abuse are not a problem,” Dr. Russell Portenoy, then a pain specialist at the Memorial Sloan-Kettering Cancer Center, told The New York Times in 1993.

That turned out to be untrue ― and not based on much evidence to begin with.

“Everybody kind of got on that bandwagon before adequate research was done to really understand the long-term consequences of opioid use,” said Dr. Michael Hooten, an anesthesiologist and pain clinic physician at the Mayo Clinic.

Doctors across the country increasingly prescribed painkillers to patients, with annual non-cancer prescriptions for OxyContin, a popular opioid, increasing almost tenfold between 1997 and 2002, from 670,000 to 6.2 million prescriptions.

But in many cases, opioid prescriptions weren’t well suited to the conditions for which they were being prescribed. In long-term studies of opioid use for lower back pain, for example, opioids don’t work very well at relieving pain.

As opioids became much more prevalent in society, many who took them also noticed and enjoyed the obvious side effects. Opioids have intense effects on the brain, including facilitating sleep and reducing anxiety, leaving many people to feel a sense of well-being after taking them.

“Those may be the people who need the most help,” Hooten said, about those who use opioids for emotional relief or mental health reasons. “Suffering is a part of chronic pain. Opioids are great at treating that suffering component.”

It’s that relief from suffering that appealed to many Americans, who perhaps didn’t realize they were plagued by more than a physical injury. One man in recovery who spoke to HuffPost described the first time he took a painkiller ― a half dose of Lortab, he said ― as a revelation. “Not only did it make me feel better, it made me feel good,” he said. “I had a lot of energy ― I was walking on clouds, euphoric.”

Medical professionals argue that unaddressed mental health challenges ― from mild depression to schizophrenia ― coupled with a lifetime of poor access to proper health care underlies much of the current crisis.

“Most of the drug users I meet here and everywhere I’ve been, have underlying mental health stuff that’s not being treated,” said Hillary Brown, the founder of Steady Collective, a harm reduction program based in Asheville, North Carolina. “And if they had more money, they would be getting legal versions of the illegal stuff they’re using.”

“We don’t live in a country that sides with the poor,” Brown added. “So we don’t have health care and we don’t have mental health care.”

Finding Treatment That Works

The punitive social response to the crack-cocaine era of the 1980s favored by politicians and law enforcement casts a shadow on the present-day approach to the opioid epidemic. Back then, fear about crime and drug-addicted babies fueled a series of drug policy changes that targeted city-dwelling black Americans, and filled jails and prisons with drug offenders.

In addition to the racial injustice of disproportionately incarcerating black Americans, the carceral response to drugs in the 1980s meant that the United States never developed addiction treatment systems to adequately address the current opioid epidemic.

What that infrastructure would look like is a tougher question. Integrating addiction treatment into general health care settings, where addiction could be treated like other chronic conditions, would be ideal, but it’s a big lift, explained Tom Hill, vice president of addiction and recovery at the National Council for Behavioral Health.

Treatment is also completely counter to the way the medical system traditionally framed recovery from addiction.

“Initially the treatment systems were designed with addiction as an acute illness,” said Hill, who has been in recovery for 25 years. “You get people in, you fix them up and you get them out.”

Today, the consensus of health care professionals is that’s not a realistic depiction of addiction, which is a chronic, often lifelong, condition.

“There’s no one-size-fits-all approach,” Campbell said. “Oftentimes people don’t know what treatment approach will work for them and they have to try more than one, and more than one time. Very few people find an approach that puts them into long-term recovery the first time.”

Given that the majority of people with addiction will need to attempt recovery multiple times, accessibility and affordability are key.

The biggest takeaway from HuffPost reporters during the Listen to America tour was that the story of opioid addiction in America isn’t a monolithic narrative. In some places, like in New Mexico, opioid addiction has been raging for decades, long before doctors started overprescribing pain pills. In other areas, like Montana, opioid addiction is a concern, but not as big of a crisis as meth addiction, which started in the 1990s and never left.

Addressing the unique addiction profiles of different states, cities and among different demographics is something that keeps Campbell up at night.

“Historically most drug crisis situations have been local,” she said. “They’ve been confined to particular areas, particular places, particular populations. Whenever we represent them as national, we probably lose our best chance to understand them.”

― Erin Schumaker and Meredith Melnick

‘Children are the forgotten victims’

HUNTINGTON, W.Va. ― “I had maybe five years on the job, the first time I noticed a child watching us,” Huntington Fire Chief Jan Rader told HuffPost in September, as she drove through her town. “His father had overdosed on the couch.”

“We started doing CPR, and about 10 minutes in, I look over and his son is in the next room. He was probably four years old, sitting on the floor, staring at us with a blank face.”

Rader, featured in the Netflix documentary Heroin(e), is on the front lines of the opioid crisis that has been decimating communities across America.

Her team of firefighters are first responders when 911 is called to the scene of an overdose in Huntington. West Virginia is one of the epicenters for the opioid crisis, with the highest overdose death rate in the country in 2015. Huntington has been hit particularly hard, with one overdose outbreak last year that saw more than a dozen overdoses happen in the area in one five-hour period alone.

“That really bothered me for a long time,” Rader said of the young boy watching his father overdose. “But that’s the norm now.”

As a firefighter for more than two decades ― and the first woman fire chief in the state, as well as the only woman on her staff of around 90 firefighters ― Rader has seen the opioid epidemic worsen first hand: West Virginia’s overdose death rate has nearly doubled over the past 10 years.

One of her biggest concerns is for kids. She estimates that 70 percent of the time her team responds to the scene of an overdose, a child is involved.

“Children are the forgotten victims here,” Rader said. “Children who grow up watching mom and dad overdose, they’ve experienced a whole lot of trauma.”

When it comes to opioid abuse, children can be affected in any number of ways. Rader said she’s seen kids as young as 12 overdose themselves. And some children have been affected before they were even born: An estimated 21,732 American infants in 2012 were born with neonatal abstinence syndrome, a drug withdrawal syndrome resulting from mothers using opioids during pregnancy.

But most often, kids are simply silent witnesses to their parents’ drug abuse ― an experience that can have a long-term negative impact on their development.

“They’re growing up in this environment,” Rader said. “Sometimes they’re playing video games in the next room like [parents using is] no big deal. You go into a house [where] there are children, there’s not even a bed, they’re sleeping on the floor, there’s no food in the refrigerator.”

As firefighters, there is relatively little Rader’s team can do for kids. One local program, Handle With Care, allows law enforcement to send a note to a child’s school if they were present at a police or emergency incident, to let educators know that the child may need some extra support the next day.

But overall, local groups in Huntington ― from Boys and Girls Clubs and churches, to schools and Child Protective Services ― have been “so overwhelmed,” Rader said, as the drug epidemic has grown so rapidly.

Another incident from last year continues to haunt Rader. After her team was called in to a gas station for a suspected overdose, they arrived to find a man passed out in the front seat of his car. He had apparently been driving when he overdosed with his three children in the back seat. His eight-year-old son had had to lean into the front to place the car into park, so that it wouldn’t roll away.

As medics assisted the father, who had awoken belligerent and confused, Rader’s firefighters distracted the kids by taking them into their truck to play.

Long after, Rader couldn’t stop thinking how this would affect the kids down the line.

“What child should have to live like that?” Rader asked. “No kid should have to see that trauma.”

― Sarah Ruiz-Grossman

***

‘You can’t go to no drug house if you’ve got Meta House on your arm’

MILWAUKEE ― Edna Boykins sits in a room she used to hate and unleashes her characteristic cackle, a loud series of staccato “Ha ha has.” These days the 54-year-old Milwaukee native can’t stop smiling, but less than a year ago the space with stained grey carpets and plastic chairs stacked in a corner would have filled her with anger.

Last November, when Boykins started coming to daily group sessions to fight her opioid addiction, she scowled at the walls decorated with the word “mindfulness” and a poster that says “Stages of Change.”

“I was a very evil, nasty person when I came here,” she said, wearing a baggy navy blue T-shirt and draping one arm casually alongside the top of a couch. “[If a counselor] would tell me they loved me I’d tell ‘em ‘F [you.]’ I was an ‘F ‘em’ person.”

Counselors meet in this room every day with the 35 women enrolled in Meta House’s all-female residential drug and alcohol treatment program. The patients live in two brick houses across the street ― many with their children, who also have access to services ― for an average of 90 days. Meta House, which also offers outpatient treatment, is a lifeline for many in a city that’s been so badly hit by the opioid crisis that heroin deaths have increased by 495 percent since 2005.

Boykins should have been dead by the time she enrolled in the program, she said. After having knee surgery in 2000, the nurse and mother of three became addicted to Percocet. After her month-long prescription ran out, Boykins, who had already battled alcohol addiction for just over two decades, started buying pills on the street. By 2014, she was mixing Percocet with OxyContin, methadone, clonazepam and Xanax. She would often snort 120 pills in three days.

In 2016, Boykins turned to heroin because it was “cheaper and plentiful.” “It’s everywhere, it’s in this neighborhood,” she said, pointing out the window. She shakes her right leg vigorously and tucks a hand between the thigh slits in her jeans. “I would hear my heart beat real fast like it was going to explode ... I would hit my chest like that was going to stop [it.]”

“The sick was out of this world,” she said, resting her left hand on her head. “I would have the runs and my body would ache. I’d be nauseated and totally depressed, begging God to kill me. I was getting thoughts of trying to sell my body, but I never did that in my life.”

Boykins felt miserable, and though she had heard bad things about Meta House ― women in detox told her “they’ll work you like a slave” ― she liked that the program forced her to wake up at 6:30 a.m. and attend daily group meetings. Once Boykins dropped her bad attitude she began to learn coping mechanisms for her anger and addiction. “If you’re having thoughts of using, count the little circles in the wall and it will distract you,” she said, pointing at the dotted ceiling. “The mind is not going to hold on that long.”

She recently moved out of the Meta House residence and now lives in an apartment about a mile away, as part of organization’s transitional living program. Before Boykins’ commencement, she got the organization’s logo ― a heart framing the outline of a mother holding a baby ― tattooed on her right forearm.

“[I told myself] If I ever thought about using again I would look at [it] and say, ‘How dare you try to use with that on you? You can’t do that,’” she said, letting out a chuckle. “You can’t go to no drug house if you’ve got Meta House on your arm.”

― Angelina Chapin

***

‘Individuals graduate our program, return back to their community and don’t have their hierarchy of needs met’

RIO ARRIBA, N.M. ― Ambrose Baros is well acquainted with the death that courses through small-town America. In 2011, he lost his brother Bobby to a heroin overdose. Addiction was a fact of life in his community, and at the time it had already taken a heavy toll on his inner circle.

“My brother’s passing was the real tragedy, but I had seen my friends quickly become addicted,” said Baros. “A lot of them passed away from drug overdoses, a lot of them were in and out of jail, struggled with drug use and still struggle with it today.”

Baros was raised in northern New Mexico’s Rio Arriba County, a rugged expanse of craggy mountain peaks, sleepy towns and scenic tribal lands about the size of Connecticut, where the overdose death rate has regularly ranked among the highest in the nation.

Rio Arriba has been grappling with an opioid problem for longer than most other rural communities, beginning in the 1970s when Vietnam War veterans returned home addicted to heroin. In the 1990s, the influx of prescription opioids that ripped through the rest of the country only compounded the longstanding problem.

This devastation has created an intergenerational “ripple effect,” said Barros, as children grow up in a climate where opioid addiction is rampant. There are few people in Rio Arriba today who haven’t been affected by the epidemic in some way.

“Drug use was almost a norm,” said Baros. “It really sent a message that it was accepted.”

In 2014, Baros took over at Hoy Recovery, where he now serves as executive director. The 40-acre, 48-bed residential addiction treatment facility sits at the end of a dirt road in Velarde, a rustic hamlet with a population of around 500.

Although Hoy was initially founded in the 1970s as a 12-step facility for alcoholism, it has changed with the times and now includes a comprehensive inpatient program for people suffering from a variety of substance use disorders.

Largely Hispanic and Native American communities in Rio Arriba once subsisted on agriculture, but Baros believes a systemic lack of opportunitysai has fueled a “historical trauma,” which has led to pervasive drug use and addiction.

The county’s poverty rate has hovered around 25 percent for the past few years, nearly 10 percent higher than the national average. And although unemployment in the county is only slightly above the national rate, quality, high-paying jobs are few and far between.

“There’s a family despair that comes from that environment image, where even if their loved one does get well, where’s he gonna live? He can’t afford to buy his own home,” said Baros. “Where’s he gonna work in this town? There are no opportunities. The school system is horrific. The dropout rate is so high.”

All of this has helped create a culture of hopelessness, which makes long-term recovery incredibly difficult, Baros said.

“A lot of times individuals graduate our program, return back to their community and don’t have their hierarchy of needs met. They don’t have secure housing, they don’t have secure employment, and then it’s a stressful environment to begin with, so they don’t have the skills needed to really overcome all of that,” said Baros. “We need to do a more sophisticated system on the outcomes, one that can rate the quality of life, not just remaining abstinent from alcohol or drugs, but what does your recovery look like?”

Baros has developed a holistic treatment program at Hoy, which incorporates a mix of mainstream medical practices, job and skills training and indigenous practices. There are familiar aspects of recovery ― daily group sessions and clinical appointments with counselors or therapists. But there’s also a sheep shearing operation and an egg farm.

Baros believes hands-on work can be therapeutic, and gives some patients a chance to claim a sense of purpose that addiction may have taken. Hoy also has a spiritual care counselor and two on-site temazcal lodges where patients can partake in traditional sweat lodge ceremonies.

While these approaches can help patients address some of the root causes of their addiction, Baros says the challenge is making it stick when Hoy’s clients return home.

To do that, he believes Rio Arriba must invest in a more robust jobs and housing infrastructure, which can give recovering addicts access to a variety of tools to help them resist triggers for drug use.

“If we don’t offer them supportive housing and employment, then that despair sets in and they don’t see any other life,” said Barros. “And if they don’t see any other life, their body can’t really process that and they go to what makes them happy and comfortable, and that’s drugs.”

― Nick Wing

***

Getting methadone ‘is basically another job’

ASHEVILLE, N.C. ― At 5:30 a.m., street lights illuminate the parking lot of Western Carolina Treatment Center in the morning dark. The place is bustling and packed to capacity. But for the lack of sunlight, it would seem like the middle of the day.

Rusted out beaters pull in alongside luxury SUVs. Teenagers with ear spacers amble up the steps into the clinic alongside well-dressed women in their 60s. Everyone is quiet, everything is orderly. The methadone clinic building has a narrow waiting room and a line of windows like a bank or DMV. One by one, patients are called to a counter, where they take their medicine in front of an employee. Once a month, they are drug tested and meet with a counselor for 10 or 15 minutes. If they pass, they can continue.

Those who pass drug tests can apply for “levels” ― a week’s worth of pills to make the visit weekly rather than daily. But for those on methadone who use marijuana, for example, a daily visit is required.

An older man, who declined to stop for an interview, said there were definitely stories to tell about opioids in the region. “Whether they’re stories you’d want to hear, I can’t say.”

Sam, who asked that we withhold his last name, a 36-year-old from a small town in east Tennessee more than an hour from the clinic, has spent a year waking up at 3:30 a.m. every morning. Along with two friends, he makes the trip across state lines. Six days a week, he has picked up his dose of methadone, only to turn around and get back home by 8 a.m. and make it to work on time.

“It’s basically another job,” he said.

He knows the clinic’s hours and all of their rules. He knows how other area clinics operate ― which ones staff “dick gazers” who go into the bathroom to watch you provide a urinalysis sample, and which ones staff sympathetic people who treat him like a human being.

He knows, to a penny, how much this ride to North Carolina costs him and his friends ― $20 a day for gas and tolls, six days a week, plus $91 a week each to use the clinic. Add in the four speeding tickets they’d receive every year, and the drive started to get pricey.

“By yourself, it would cost close to $220 to $250 a week,” he said. “But that’s still a lot cheaper than doing drugs.”

He’s been following the local struggle to get a methadone clinic opened in Gray, Tennessee, not too far from his house. It looks like, despite significant controversy, that might finally happen.

“They’ve been trying to get a clinic here for 7 to 10 years and people have picketed ― even gas station attendants say ‘we don’t want people like that here,’” Sam said. “Not knowing that they already have people like that and if they had a little help, it would keep them from stealing.”

“They hear the word ‘methadone’ and just hear the ‘meth’ part,” he added.

Pills have been around for a decade at least, but the past two years have led to a big problem in east Tennessee, and the last six months have been particularly stark.

“Heroin is absolutely killing this area right now,” he said. “People who used to take pills are snorting heroin and now it’s only a matter of time before they’re doing it intravenously.”

According to the Tennessee Department of Health, the state ranks second for opioid consumption in the country. And east Tennessee has been hardest hit of any region. Despite the need, there is a dearth of methadone clinics in the area.

It is little wonder that when HuffPost visited the Asheville clinic in late September, more than half the license plates in the parking lot were from Tennessee, even though the state’s border is an hour away at its closest point. Sam pointed out notecards that are posted inside the waiting room, asking for rides from various towns in Tennessee in exchange for some gas money.

Sam had always been a big drinker. He started getting ulcers ― the worst pain he’d ever felt in his life. One of his best friends, a buddy he grew up with, kept offering him pills, but he always said he didn’t want to “be that guy” ― a pillhead, like so many of the kids from his town. His friend offered him half a Lortab ― a mixture of acetaminophen and codeine that is particularly common in the state ― and Sam finally relented, he said. The high was a revelation: It not only relieved his pain, it made him feel better about life. A depression lifted.

“Not only did it make me feel better, it made me feel good,” he said. “I had a lot of energy ― I was walking on clouds, euphoric.”

Next thing he knew, he’d moved up his dose and then moved on to the more powerful Oxycodone. About a year ago, Sam couldn’t take it anymore and turned to methadone and it’s been pretty successful for him, he said. He just wishes he could get it closer to home.

In early October, Sam got his wish: The Overmountain Recovery Center opened, after much controversy, close to his house in Gray, Tenn. At the time, after a week in the new clinic, Sam reported that it was “a blessing.”

But in the world of drug recovery, nothing is ever simple.

After HuffPost followed with him again recently, Sam said had sworn off Overmountain. He had a falling out with a staff member, who Sam said accused him of dealing drugs because of an incident in which he shared the bathroom with another patient. Sam’s work schedule ― construction jobs that take him out of town ― didn’t work with the clinic’s counseling session requirement.

In another incident, he claimed the clinic cut his dose in half ― from 150 mg to 70 mg ― without any warning.

Deanna Irick, Overmountain’s clinical director, declined to comment on the details of Sam’s account, citing patient privacy concerns. “I think that’s a disgruntled patient that you’re dealing with,” she said.

Irick noted that Overmountain’s drug testing policies follow state requirements and pointed to the center’s high standards as one of its strengths. “I think we’re one of the best treatment centers out there,” she said. “We’re saving a lot of lives.”

Sam had hoped Overmountain would be a lifesaver ― a nearby clinic that could help him stay in recovery ― until it developed what felt like other types of hoops to jump through. Sam didn’t have to face a daily two-hour commute, but monthly drug tests came with a $20 fee if you fail (he’s a regular pot smoker), strict therapy requirements were difficult, and the staff wasn’t willing to work with his unique circumstances, he said.

He’s been off of methadone for a week now, which he describes as “rough,” but so far successful. He said he’s got to have a strong mind, as he doesn’t know what else he’s supposed to do.

“I’ve got to work,” he said.

― Meredith Melnick

***

‘I’ve done this since 1975. Never seen anything like this’

ST. LOUIS COUNTY, Mo. ― Dr. Mary E. Case is used to handling dead bodies. Just not this many.

As the chief medical examiner in St. Louis County, her office has a typical indoor refrigeration unit, where they’ve stored bodies for years. It holds 20 bodies, which used to be adequate. But the recent uptick in opioid-related deaths has forced her to look outside that icebox.

“It’s a phenomenon. We’ve always had drugs, but there’s never been anything like what we see today,” Case said in an interview at her office this fall. “I’ve done this since 1975. Never seen anything like this.”

About five years ago, St. Louis County obtained a portable refrigerated trailer. It’s a portable morgue, intended to be used for circumstances like natural disasters.

But it’s come in very handy for the opioid crisis.

“We have people that die in hospitals,” Case said. “We have people that are dumped at hospitals; we have people that are found dead in parking lots; we have people that are found in restaurant restrooms and gas station restrooms; people that are found at home. There’s just lots of different scenarios.”

During one month earlier this year, there were just five days in which they stored fewer than 20 bodies, their typical maximum. As a result, they stored multiple bodies on the same cart, which made it much more difficult to perform autopsies.

“It’s just the numbers. We have more bodies, particularly on certain occasions, than we have room to store them in our storage facility, which is a cooler,” Case said. “So if we have too many bodies, we put them into the trailer.”

The refrigerator, branded with the name of St. Louis County and featuring a license plate indicating its association with the health department, sits out back of the medical examiner’s office, where it takes up a couple of parking spots.

But even with the additional space offered by the trailer, more bodies are coming in and they’re staying longer, Case said.

Sometimes the bodies aren’t picked up by funeral homes, because it’s a death the family wasn’t expecting.

“They might not have any money to get a funeral home. So that body may stay here for a week, and that’s a huge problem. The bodies come in, and they stay,” Case said.

If they stay too long, she said, there’s a solution. “We contract with a crematorium.”

Many of the people dying of opioid overdoses, Case said, “don’t have jobs, they don’t have any insurance, and they may have families that are stressed by the problems that are created by the drug usage of that member.”

As a result of the surge in deaths and the budget issues that has caused, Case has had to think hard about the way her office spends money.

“Most medical examiner offices autopsy all these people, and they have literally decimated their budgets with that. They can’t keep up,” she said. “There’s so few forensic pathologists that it’s not like you can hire one whenever you need it ― there’s not enough to go around.”

Case made the decision to not autopsy every body that comes in, especially if it’s pretty clear how they died. She said they just can’t afford it.

“When we have somebody in the bathroom with a needle sticking in their arm, we don’t autopsy that person. Many medical examiners will. They’ll say, ‘Oh, they might have died of something else,’” Case said. “The reality is, no, they probably died of that.”

― Ryan Reilly

***

‘The best part is giving people hope when they feel like there’s not any’

BIRMINGHAM, Ala. ― Terri Williams-Glass offers a warm smile as she enters the common room at the University of Alabama at Birmingham’s Addiction Recovery Program. She spots Michael Grammas, a former patient of the recovery program who is now sober and working as an advocate for others living with addiction issues.

They move off to the side near a set of motivational wall art and exchange pleasantries about work and kids. Grammas had stopped by to say hello to the physicians and employees of the program, Williams-Glass included. After a few moments, they part ways: Grammas back to his life ― one where he no longer depends on opioids to get him through each day ― and Williams-Glass back to helping others who are still struggling to get to that point.

She takes a seat and stares across the oblong wooden table out toward a small group of couches located in the middle of the room. The loungers are empty now, but soon they’ll be filled with current patients as they take a break from their recovery work, which includes detoxing, group therapy sessions and outside meetings and counseling.

Tears pool in Williams-Glass’ eyes but don’t leak over the brim as she thinks about the individuals she’s currently working with and those she’s helped in the past.

“The best part is giving people hope when they feel like there’s not any,” she said with a thick voice.

Williams-Glass has been with UAB for more than two decades, starting with the university’s Treatment Alternatives for Safer Communities (TASC) force, which works through drug courts to help people living with addiction receive job counseling and other resources. She continued her work on TASC as she got her masters. She’s now the clinical director at UAB’s Addiction Recovery Program, where she trains staff and develops programs to help those seeking treatment from the facility.

On any given day she could interact with patients as they do their recovery work or help train clinicians on best practices. She also heads up UAB’s Addiction Scholars program, which trains hospital staff members on substance use disorders and how to recognize them when patients enter the emergency room.

The center, Williams-Glass says, is just one small piece of the puzzle when it comes to solving the addiction crisis in Birmingham, where more than 240 people died from overdoses in 2016. She glances back at the bedrooms located behind her, each door pulled tightly closed. There are 20 beds total that serve in-house patients. The center also assists approximately 30 people who once stayed at the facility and are now in an outpatient program.

And while those slots are a long way from eradicating the opioid epidemic, Williams-Glass says she’s happy to do her part. Her hopes for the future include greater access to care, so more people can get the help that they need. This includes equality of care, “regardless of whether people have insurance or their financial standing,” she said.

“People keep dying and this crisis is only starting,” she said. “I’m just trying to save as many as I can.”

― Lindsay Holmes

***

‘Sometimes it feels like knives being pushed through my feet up through my hips’

GREAT FALLS, Mont. ―Tami Duncan feels like she’s standing in a pot of boiling water.

The 51-year-old mother of two can barely get out of bed, and she knows the four-hour round trip journey from Havre to Great Falls on the stiff seats of her son’s old pickup truck will only exacerbate her chronic back, leg and hip pain.

Hours later, Duncan slid a folder of her medical records across the table at an Applebee’s in Great Falls. She was eager to explain one of the less talked about side effects of the crackdown on opioids: chronic pain patients like herself left stranded by doctors who refuse to prescribe large enough doses of opioids to relieve their pain.

Duncan’s son Taran, a burly 20-year-old in cowboy boots, looked on from the chair next to her.

“Just because we look normal on the outside, it doesn’t match what’s going on inside,” Duncan said. “Sometimes it feels like knives being pushed through my feet up through my hips.”

For more than two decades, Duncan took opiates to treat pain from degenerative back, leg and hip injuries first brought on by a car accident. After undergoing back surgery in 1997 and dozens of epidural shots in the years since then, the pain not only continued but worsened.

Until 2007, Duncan had a full-time job delivering mail, but the physical work became too painful to continue. These days, she’s limited to logging a few hours each week as a lunchroom cashier at the local high school.

“There’s a lot of things I don’t do anymore,” said Duncan, wincing as she readjusts in her chair. “Taran cooks, cleans, does laundry, drives me.” Her eyes well up. “He takes really good care of his mom.”

Taran takes a more matter-of-fact approach to caring for his ailing mother.

“If what the doctors are saying is true, she’s going to be in a wheelchair in a couple years,” he said. “I ain’t the type of kid that’s going to put her in a rest home or anything.”

While Duncan would prefer to be off medications altogether, opiates offered her rare, much-needed relief, even if that respite only lasted for a few hours each day.

Life changed for Duncan in 2016, when the CDC revised its opioid prescribing guidelines in response to a nationwide spike in drug overdoses. Suddenly, Duncan’s opioid prescription was slashed dramatically, she said.

Duncan ― terrified by the pain she knew would return with less medication ― pleaded with her doctor to return her to her normal opioid dose. Her doctor refused. In response to Duncan’s repeated requests for a higher dosage, she said staff at her doctor’s office accused her of lying about her pain to get more drugs.

Following the CDC’s new guidelines, which recommend prescribing the lowest dose of opioids for the shortest timespan, many doctors began weaning their patients off opioids in favor of non-drug treatments such as intensive physical therapy. But Duncan said alternative treatments didn’t work for her. She’s still prescribed her old medication, but at a much lower dose.

“It was awful,” Duncan said about withdrawing from opiates. “I was vomiting. I had diarrhea. At night, I would be ringing wet with sweat. I had fever, chills. I didn’t think it was ever going to stop.”

In central Montana alone, there are dozens of chronic pain patients struggling to live their lives without opioids. Duncan is grateful to have her husband, children and friends for support, but not everyone is so lucky. For those without support, isolation, coupled with the stigma patients face for relying on opiates, is almost worse than the pain itself.

“A lot of people think we’re just using them to get high,” Duncan said, adding that several of her friends and fellow chronic pain patients have died by suicide in the last few years. “We’re not. We use them to try to have a semblance of a life.”

“You have to get pissed off at your pain,” she added. “Either you’re going to win and take your life back, or you’re going to let your pain win and you’re going to die. I’ve got a 23-year-old daughter who’s getting married in August. By God, I’m going to be there.”

When lunch is finished, Duncan and Taran get ready to head back north. As Taran helped her into his truck, Duncan took a deep breath and prepared for the long journey ahead.

― Hayley Miller

***

‘When someone knows who they are, it’s hard to addict them to something’

NEW ORLEANS, La. ― Around New Orleans, where she was born and raised, Jamilah Muhammed is known as “Mama.”

“Hey, Mama Jamilah,” a five-year-old girl said as she walked past Muhammed, 68, on a park bench on a cool Sunday evening in October in the city’s historic Congo Square.

The girl was heading toward a drum circle a few yards away ― a centuries-old weekly tradition that includes both music and a market, honors African music and dance, and helps build ties that still matter in a city Muhammed calls “very clannish.”

Muhammed believes that sense of belonging is what more people around her need in the face of a national public health crisis about addiction.

Last year, there were more deaths from accidental drug overdoses than from murders for the first time in New Orleans history, Orleans Parish coroner Jeffrey Rouse told The New Orleans Advocate in March. He said the uptick includes a striking increase in drug-related deaths among black New Orleanians.

“I work to maintain the culture of my community because when someone knows who they are, it’s hard to addict them to something,” Muhammed said.

She’s familiar with how people get caught up in the opioid crisis.

“I’ve had physicians offer me opioids for chronic conditions,” she said. “I’m a dancer! My joints hurt! That’s part of being a dancer. When you’ve been dancing for 40 years, stuff hurts! Giving me Vicodin is not going to solve my problem. But I had to know that.”

Addiction in her communities first began to worry her in the 1980s as crack cocaine use surged. Fifteen years ago was the first time she saw prescription painkillers cause comparable devastation to a fellow New Orleanian. “I personally saw how it robbed him of his life, how it robbed him of his livelihood, how it robbed him of his ability to be socially interactive, to make rational decisions, to care for himself, to care for his family,” Muhammed said.

He quit on his own. But she believes that’s rare and wants more people to receive support to avoid addiction and potentially death.

“People are medicating themselves because they’re sad. They’re not bad, they’re sad. Things have happened to them. They’re hurt,” Muhammed said softly. She noted a particular source of trauma in New Orleans: the government’s botched response to Hurricane Katrina. “We have a whole generation of children that went through a horrific period in their lives when we talk about the federal flood of 2005, and people as they went to other places said to them, “Get over it, you’re alive.’”

She’s heard “Just Say No” for too long, she said, and watched doctors ― “the real pushers” ― avoid any blame. She’s tired, too, of public interest in addiction growing only as the crisis claims more white victims.

“Until the addiction of black mothers’ sons is as important as the addiction of white mothers’ sons we will not cure this,” Muhammed said. “So I’m asking everyone to realize this is not a black-white issue ... All the mothers have to come together. ’Cause all of our children are important. All of our communities are important to us. I love my children. All of ’em. And I know that other mothers love theirs. We’ve gotta come together.”

― Akbar Ahmed

***

‘I don’t even understand it myself, let alone trying to explain to a child why mommy died’

CONNELLSVILLE, Pa. ― Mary Sampey’s older sister, Angela Phillips, was her best friend. They shared a bed growing up, supported each other during childbirth and raised their children in the same country town where they spent their childhoods.

One night, just a few months before Phillips died, she confided in her younger sister. Decades earlier, Phillips became pregnant after being raped and had an abortion. Until that moment, the pain and guilt she felt as a deeply Catholic woman weighed on her in secret.

“She thought, ‘I’m going to shut down and get married and have kids and my life will be better,’” Sampey said.

She thinks that trauma left Phillips vulnerable to the disease that killed her ― the same addiction epidemic that’s wiping out an entire generation in Connellsville, a sleepy former coal town about an hour southeast of Pittsburgh.

In the early 20th century, Connellsville’s roaring coke and coal plants sent a steady stream of products to Pittsburgh by rail and barge, and money flowed right back. But Connellsville was hit hard when the region’s steel industry collapsed in the 1970s. Now, median household income sits below $29,000 per year, and nearly 23 percent of the town is below the poverty level.

And like in so many parts of the country, opioid addiction has taken root. In a town of fewer than 7,500 residents, opioid overdoses kill at a rate of one to five people per month, according to the local emergency medical service. And those deaths are just a small fraction of the five to six people who call an ambulance for an overdose every day.

In the midst of this ongoing tragedy, Sampey, 31, has found a higher calling. For nearly four years, she’s worked for Father Bob Lubic, a local priest and chaplain. A little over a year ago, she became the mastermind behind his campaign to combat addiction and the stigma it carries among the faithful, some of whom view the chronic disease as a moral failure.

For Sampey, this mission is personal.

Shortly after she began working for Father Bob, as folks in Connellsville affectionately call him, Sampey’s sister Phillips was diagnosed with thyroid cancer. Doctors removed the tumorous gland, but the surgery left Phillips in chronic pain. She started taking painkillers. Pretty soon, she was hooked. Sampey noticed the change as her sister, once a reliable homemaker and mother of two, became less dependable. She isolated herself and wouldn’t answer calls. Sampey began to see her sister less often, and when she did, Phillips’ would go from a perky, peppy version of herself to dozing off.

“Her eyes would roll back in her head, she’d be very tired, then she’d be up again,” Sampey recalled. “It became very clear she was addicted to these prescription pain pills.”

Phillips’ husband had a drinking problem, which didn’t help. After later separating from him, she went to rehab. It’s there that she met the man who would introduce her to heroin. From there began a cycle of relapse and rehab. Leaving her young daughters with her parents, Phillips attempted to get clean by living with her brother in Pittsburgh, distracting herself by working in his florist shop.

She relapsed there for a final time.

Sampey was at home making pepperoni rolls for her church youth group when her stepfather arrived at her door. He was “white as a ghost” when he told her they needed to talk.

“Immediately I knew what he was going to tell me,” Sampey said. “It was a very out of body experience. I was eerily calm. I was not emotional. It was kind of like, this is it.”

Sampey’s numbness broke the next day when she had to sit Phillips’ young daughters down to tell them their mother was dead.

Over the past year, Sampey has described the details of her sister’s addiction to packed pews and classrooms full of high school students. On an afternoon in October, she did the same for HuffPost with a matter-of-fact calmness. But when she remembered that moment she sat her 5- and 7-year-old nieces down, her voice became raspy.

“I don’t even understand it myself, let alone trying to explain to a child why mommy died,” she said.

“We told them mommy took too many pills and didn’t wake up, and she didn’t mean to,” she added, sniffling and gingerly wiping away a tear. “Mommy couldn’t help it. Mommy took too much medicine and didn’t wake up.”

It’s that sort of empathy she now helps Lubic preach.

In his sermons, Lubic urges his fellow Catholics to love people with addiction, whom he says feel undeserving of God’s love. It’s a strategy Sampey wishes she’d used with Phillips. She recalled her sister once saying she feared God had abandoned her because of her abortion and opioid addiction.

In both sermons and public assemblies, Lubic encourages those listening to talk about their fears and personal struggles instead of turning to drugs and alcohol for comfort. He and Sampey organize Nar-Anon group sessions and host other support groups in partnership with a local addiction specialist center. Lubic’s appearance helps soothe those wary of a clergyman’s conservative judgment. He sports a mohawk, earrings and a styled beard, and calls himself a “punk rock priest.”

Sampey’s official title is director of evangelization, but she calls herself a community activist, and her goal is to help people and their families with addiction. If people they help decide to become Catholic, they’re welcome to seek spiritual guidance, but that’s not the mission.

“I don’t get all Jesus-y with them,” Sampey said. “Anything that I do is not a cover for conversion. I’m not there trying to make them Catholic. As people who are Christians, our job is to love other people.”

In Lubic, she seems to have found more than a boss and religious teacher, but a colleague who understands and is committed to alleviating social and individual anguish.

“There’s a sense of acceptance and belonging that you get with Father that you don’t typically have,” Sampey said. “You know from the get-go that this person isn’t going to judge you.”

A year after losing her best friend and sister, there’s something sacred in that alone.

― Alexander C. Kaufman

***

‘Even small towns have to be vigilant’

WARNER ROBINS, Ga. ― The first pills were yellow oblong tablets.

They were sold on the street as Percocet in June, but they were not Percocet. Instead, they were a mix of two deadly synthetic opioids, U-47700 and cyclopropyl fentanyl, making their first appearance in Georgia. They left a swath of users throughout the middle of the state struggling to survive, hospitalized and breathing through ventilators. Five died.

In late August, the pills were now round and white ― and still contained cyclopropyl fentanyl. The second wave of overdoses that month left seven people aged 25 to 60 hospitalized. They were found all over Warner Robins, a city of more than 70,000 that boasts an Air Force base. One case was found in nearby Centerville.

The symptoms ― troubled breathing and need of a ventilator ― were similar to the first round. The new pills, however, were much more sophisticated.

“Not to give kudos to whoever is making this, but these are a lot better,” Jennifer Parson, Press Information Officer for the Warner Robins Police Department, said in late August. This batch of white, round pills “looks very real,” the only differentiation being they’re slightly thicker and glossier on the top than actual Percocet, she said.

Parson called the overdoses a top priority for the department, saying it was an issue the force was committed to solving. The danger of unregulated opioid pills like these lies in their unknown dosage. People have no idea how much they’re taking, and whether that could lead to a ventilator ― or death.

“We know addiction is an issue and a problem, but this is dangerous and you don’t need to take the risk. You’re taking your life into your own hands.”

According to Parson, the big concern in town used to just be heroin.

The Warner Robins police department started seeing an influx in the drug’s use about two years ago. But these bad pills are something new.

Parson, who used to be a reporter, spoke of the fear in the department over the unstable nature of these pills and the threat of other opioids for the greater community. She also described the risk the police were taking when dealing with the influx in overdose calls.

News reports about officers in other parts of the country overdosing from mere skin contact with an opioid substance is something that’s often on the minds of Warner Robins police officers when they go out, she said.

Officers in Warner Robins don’t currently carry Narcan (Narloxone), the prescription medicine that reverses an overdose. However, Parson said agencies in northern Georgia, which have seen a higher influx of cases, are considering doing so.

While Parson said the opioid problem has typically been considered a northern Georgia problem surrounding the Atlanta area, this latest round of overdoses demonstrated how it’s creeping into the rest of the state.

“It’s a problem across the country,” Parson said. “It just goes to show even small towns have to be vigilant.”

― Lauren Weber

Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.