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What Happens When The Heroin Epidemic Hits Small Town America?


This is FRESH AIR. I'm Dave Davies in for Terry Gross, who's off this week. The state of West Virginia's indigent burial fund, which helps with funerals for those who can't afford one, has run out of money for six straight years. One reason, writer Margaret Talbot says, is that the state has the highest rate of drug overdose deaths in the country. For a recent piece in The New Yorker, Talbot spent time in the eastern panhandle of the state, where opioid addiction is widespread and overdose is so commonplace it seems everyone, including kids, knows what one looks like. Talbot spoke with addicts and their loved ones, emergency responders and professionals and volunteers trying to do something about the problem.

Margaret Talbot has been a staff writer at The New Yorker since 2003, and she's the author of a book about her father, the actor Lyle Talbot, called "The Entertainer." Her recent piece about opioids in West Virginia is "The Addicts Next Door."

Margaret Talbot, welcome back to FRESH AIR. In reporting this story, you spent some time with paramedics, EMS teams, that are often called to treat overdoses. And you describe a call that they responded to at a girls Little League practice. Tell us what happened.

MARGARET TALBOT: Yes, it was the first Little League practice for this girls softball team, first of the season, in late March, and they got a call. It was late afternoon, about 5 o'clock. This paramedic who I had been following around - gotten to know, a guy named Michael Barrett, arrived there with his colleague and found a chaotic scene.

There were a bunch of middle school-age girls sitting on the ground comforting each other and crying, there were two little kids running around crying and screaming, and there were a lot of adults trying to help them and escort them away from the scene because two parents who had come to their daughter's practice, a man and a woman, had both overdosed simultaneously and were lying on the field about 6 feet apart and in obvious need of resuscitation.

Their two little - younger children who had come with them were trying to get them to wake up. So Michael and his colleague were able to revive the parents using Narcan, which is the antidote to opioid overdoses - reverses them. But as is increasingly the case, it took several doses to revive them because they had probably had heroin that was cut with something stronger, possibly fentanyl. And so this was the scene that was witnessed by many people in this community who were at this softball practice on an afternoon in March.

DAVIES: You know, what's striking in some ways here are what the EMS team heard from some of the other parents. How did they regard this couple who had, you know, overdosed in their presence?

TALBOT: Yeah. Well, it was very mixed. And it sounds like it was pretty challenging because some parents were very angry - angry that their kids were there to witness this, angry that this happened in this setting - and were saying things, like - apparently, a few people were saying things like, you know, don't - you know, don't use the Narcan. Let them lie. And, you know, others were trying to help the kids who were there.

Later on, when an article appeared in the local paper, many people weighed in on the comments page with, some of them, very harsh commentary, some much more empathetic, really kind of debating this in a public forum.

DAVIES: And the mother who had overdosed responded to some of the comments. What did she say?

TALBOT: She did. She said, you know, she regretted this. She felt shame about it. She had struggled to find treatment for her addiction in the area - hadn't been able to. She tried her best with her children and was trying to get treatment now so that she could get her children back. Her children had been put into the care of a relative.

DAVIES: Tell us about this area and why it seems to have so much opioid abuse.

TALBOT: Well, West Virginia has the highest drug overdose rate in the country. And different parts of the state have been affected more than others - Huntington, W.V., in the western part of the state; some of the coal-mining areas, smaller towns there; but also this area, which is actually the eastern panhandle. It's not very far from Washington, D.C., or from Baltimore. And that's played a role because Baltimore has long been a heroin market, and it's relatively easy to obtain it there. So people call one of the highways the Heroin Highway that connects Baltimore to this area of the eastern panhandle of West Virginia. Martinsburg is the town that I sort of focused on. So that's one reason.

I think also, just in the longer term, although it's an area that has not been as hard hit economically as, say, some of the coal-mining regions, it did have a period where it was more economically thriving. It had a - it was a mill town at one point, and all of those mills are closed now. So some of the kind of employment that gave people, not only work but, I think, a larger sense of meaning has disappeared. And that is part of the story.

DAVIES: So this is a national problem, this explosion of opioid abuse and overdose. So let's just review how we got here. I mean, this goes back to the mid-'90s, right?

TALBOT: Yes, that's right. Basically, in the early '90s, there was a kind of backlash against the way chronic pain was being treated. And there was a feeling among doctors and among patient advocates that although pain for, for example, terminal cancer was being managed fairly well and fairly empathetically, that people who had chronic pain conditions from, you know, back pain to neurological conditions to whatever it might be, were not really getting the relief and the care that they needed. And so there was a rethinking that went on about prescribing opioids and a feeling that really didn't have much data behind it that these were not addictive - that they didn't have the - for people who were really in pain, they didn't carry this risk of addiction.

And at the same time the pharmaceutical companies were promoting opioid pills quite aggressively. In 1996, Purdue Pharmaceuticals came up with a reformulation of oxycodone, which is one of the, you know, key opioids. And it was a long release - a slow-release form called OxyContin, and it was supposed to be, you know, something that would last for 12 to 24 hours. It was not supposed to lend itself to abuse, but it became a pill that was because people very quickly figured out that you could snort it or dissolve it - reduce it to a powder and dissolve it in water and inject it.

DAVIES: Right. They would break the little capsules, pour out the powder and then get much larger doses. So it wasn't the time release.

TALBOT: Exactly.

DAVIES: It was a rush - right? - and a high.

TALBOT: Exactly, exactly - and a very effective one.

DAVIES: Right. Eventually the CDC issued new guidelines, you know, saying we shouldn't be treating chronic pain so frequently with opioids. So it got harder to get, but then something else happened, right? The cartels were responded.



TALBOT: Yes. I mean, it's really one of these striking stories of unintended consequences because, yes, so after a while, people started realizing, you know, that there was this potential for abuse, that it was happening, that pill mills were popping up around the country and that these pills were, in fact, causing addiction and - or leading to addiction. And so yes - so then, there was kind of a crackdown and a rethinking, this - as you say, CDC issued new prescribing guidelines. These drug registries, monitoring programs were instituted in almost every state, where physicians and also pharmacies could look to see if people seemed to be doctor shopping or that kind of thing and for pills. And Purdue came up with a new, harder-to-crack, harder-to-abuse form of OxyContin.

So all of those things happened by about 2010. And opioid pill abuse did decrease. But yes, heroin came in to replace it. And that was kind of a response of the drug cartels that became aware that there was this niche - there was this, you know, gap in the market that they could respond to. And they did so, you know, quite effectively.

DAVIES: Right. So plenty of heroin came in, cheaper heroin. How much easier is it for an addict now who may have started with abusing OxyContin? How much easier is it for them and cheaper to get heroin than to get the pills?

TALBOT: Yeah, I mean, I have heard, for example - prices vary a little bit around the country. But whereas the street value of an 80-milligram pill of OxyContin would be maybe - you would pay maybe $80 for it, that for a baggie of heroin that would be kind of the equivalent of that, it would be $10 to $15. So you know, it's quite a bit cheaper and now just quite a bit more available, easier to get a hold of now that there are fewer of these pills kind of washing around in communities.

DAVIES: So that explains why we have so many more heroin addicts now. Why are there so many more overdoses? Is it more dangerous now? Is it a different kind of drug?

TALBOT: Yeah. I mean, I think probably the key reason that we're having overdose deaths right now has to do with fentanyl and carfentanil, which are synthetic opioids that now many of the drug traffickers are using to kind of extend heroin and to be able to pack greater potency into smaller packages, which makes it easier to traffic and more profitable.

And fentanyl is about 50 times - 50 to a hundred times more powerful than heroin. Carfentanil is several thousand, they say, times more powerful than that. Carfentanil is actually used as a large animal and elephant tranquilizer. And these are very, very deadly drugs, so I think that's a lot of it.

DAVIES: There's an awful lot of heroin being dealt in this region. Were the drug traffickers a presence? Did people fear them? Was there violence, you know, related to their activity?

TALBOT: No. And I think that's one of the reasons it took people a while to pay attention to this crisis because it doesn't involve the kind of turf war violence that, you know, we've seen in some earlier instances of drug trafficking and drug epidemics. So people are - it's - there's this kind of quiet aspect to it which is strange and characteristic of this particular crisis, so people are - some people are driving into Baltimore or - and arranging to get the drugs, bringing them back and then just distributing them in town, you know, low-level distributors, often just people who in some cases are users themselves. So it's not this kind of splashy public profile violent kind of setting for a, you know, drug war kind of set of associations.

DAVIES: Unfortunately, a functioning business, in other words.

TALBOT: Exactly, exactly.

DAVIES: Margaret Talbot is a staff writer for The New Yorker. Her article, "The Addicts Next Door," appeared in a recent issue of the magazine. We'll continue our conversation in just a moment. This is FRESH AIR.


DAVIES: This is FRESH AIR, and we're speaking with Margaret Talbot. She's a staff writer for The New Yorker. Her article, The Addicts Next Door," about the effects of opioid addiction and overdoses in West Virginia appeared in the magazine earlier this month. There is this very effective drug Narcan which can revive overdose patients if they are reached in time. It was interesting that they begin with small doses. Why is that?

TALBOT: Well, because actually sometimes when people are brought around, they aren't initially very happy about it. And they're sometimes angry at being pulled out of their high. And they're sometimes very sick because they go into sort of instant withdrawal and can start, you know, throwing up and just generally being quite sick and feeling quite miserable. So they try and do it gradually so that they're sort of bringing people around without making them either sick or angry or both.

DAVIES: The paramedic you spent time with, Michael Barrett, he had some pretty remarkable stories about addiction and overdoses and a lot of cases where it seemed more than one member of the family would be addicted and overdosing. Can you share some of those with us?

TALBOT: Yeah. I mean, he had one story about three people living in one house. He was first called for the father, who had overdosed. The mother and teenage daughter had called on behalf of the father, took the father to the hospital. Came back later in the day, the mother had overdosed and took her to the hospital, came back, had revived her with Narcan. And the third call he got to the house was for the teenage daughter. And this was all in one day.

And, you know, I picked a day at random to follow him around, you know, just a day that was convenient in March and just, you know, a weekday, kind of average day and thought, you know, maybe I'll see one overdose. He ended up having four overdose calls that day. I was there for three of them. You know, one of them was a guy who was driving and had overdosed. The car was still running. He was on a hill. Fortunately, his foot was on a break - it was on the brake. There was a woman behind him who had a little kid in the car, and she, you know, had called 911. There were a lot of people around. This was the afternoon.

And that evening, there was a woman who overdosed in a 7-Eleven parking lot with a small child strapped into the car seat in the backseat. And, you know, some good Samaritans had called 911. And the first call of that day was a 22-year-old girl who could not be revived, unfortunately. And it was too late for the Narcan. And she died.

DAVIES: You know, I was struck that - you spoke to the county EMS director. And if I have this right, he thought that addicts actually had gotten used to the idea that there was Narcan to revive them if they overdosed and an EMS system that would respond and that it in some ways - it sort of encouraged risky behavior. They had sort of expected this as part of the deal.

TALBOT: Yeah. I mean, I think some people do really worry about that because some EMS people do have these cases where they will go back to the same person or the same house multiple times in one week. And so it's very - it is very frustrating for them. And I think while they very much, you know, believe in saving lives, and they believe that Narcan should be available, they also worry, once again, a little bit about unintended consequences.

The guy I spoke to who was the head of the EMS also really felt that people were purposefully doing this in public more, possibly because they knew there would be someone to save them. And, you know, he felt that was a kind of survival instinct that was understandable from a human point of view, even though it's also very strange to think about really for many of us.

DAVIES: Wow. It's almost like a - it's almost a safety method to use in public, rather than in private because there's a risk you're going to OD.

TALBOT: Exactly.

DAVIES: If people do want treatment, how easy is it to get it?

TALBOT: Not very easy. And that's, you know, that's a real issue. There isn't enough. People also, of course, face the problem of paying for treatment and will face it even more if they end up losing their Medicaid coverage because most of the people I spoke to there who had gotten any kind of treatment had gotten it through Medicaid or Medicaid expansion under the ACA. And so people were very worried, even though this was a, you know, West Virginia's a state that voted for Trump.

And many people I spoke to were Trump supporters, but they were also very, very worried about what was going to happen to their health coverage. So paying for it is a huge issue. But also, yeah, just availability, there aren't enough treatment centers. There aren't enough doctors who specialize in addiction medicine. There aren't enough doctors offering medication-assisted treatment like methadone and Suboxone and Vivitrol. So yeah, it's a problem.

DAVIES: You met three women who've formed a little project to try and deal with this problem of people needing treatment and having to wait - it not being available - the Hope Dealer Project. Tell us about these folks and what they do.

TALBOT: Yeah, they're three really amazing women who live in this Martinsburg community and who all had some kind of experience of addiction with - not themselves, but loved ones and their families or close friends. And they realized that there were people who wanted to get into detox, who wanted to get into treatment, who had no way to get there because the closest place they could go was several hours away - a several-hour drive.

So they started volunteering to drive people, you know, strangers, who were often sick and in withdrawal, to these facilities and just doing it on their own time and without training, really, but they were learning on the job. And they had had the experience of living and working with people who are addicted in their own families. So they are doing that. And they're hoping, you know, to sort of expand this project. And yeah, they've taken on this kind of remarkable thing themselves.

DAVIES: What did they tell you about the experience? What's it like driving a stranger for hours who's confronting this wrenching decision?

TALBOT: I think it's really one of those difficult, raw, existential kinds of experiences. I mean, they, you know, oftentimes, people are seeing hospitals along the way and they're saying - they're kind of begging to stop and just be checked into this hospital. But they can't be because they have a bed waiting for them at a particular facility. And, you know, the hospital's not going to be able to help them. And they're often sick and throwing up and feeling generally miserable.

And - but, you know, very - I mean, there's a lot of trust and risk-taking on both sides of the person willing to put themselves in the hands of the stranger to drive them and of the person, of course, of the women from the Hope Dealer Project who are doing it. And they say that it's very hard when they get to the point that they have to leave the person at the hospital because they formed this kind of war bond or trauma bond in a way, you know, of being together in the car all these hours. And then they have to see them go through the doors and the doors shut behind them and just hope that it'll work out for them.

DAVIES: One of the things you mentioned was someone was talking about when someone overdoses, the funeral is different - about who gets invited and kind of just how it's handled.

TALBOT: Right, right, yeah. I mean, there was a woman I talked to who had actually had 13 friends who had overdosed and died. And she was actually a photographer in the town - a wedding photographer - and was, herself, not in addiction, but had had all these friends, high school friends, friends from her early 20s. And yeah, she was describing going to one funeral. You know, she started going to so many funerals. It was reminding me a little bit of the AIDS crisis, when people would talk about how often they would be going to funerals during those years for friends or young people.

And yeah, I mean, because I think the parents in this case didn't really want the friends around because they didn't know who among the friends might have been the person who first sold them the heroin or first used heroin with them. And so they felt very unwanted at this funeral. And she - that was very sad for her, but she also understood why a parent might feel that way.

DAVIES: Margaret Talbot is a staff writer for The New Yorker. Her article on West Virginia is "The Addicts Next Door." We'll hear more from her after a break. And we'll meet actor Sam Elliott, who stars in the new film "The Hero." I'm Dave Davies, and this is FRESH AIR.


DAVIES: This is FRESH AIR. I'm Dave Davies in for Terry Gross, who's off this week. We're speaking with New Yorker staff writer Margaret Talbot. She spent time investigating the opioid crisis in West Virginia, which has the highest overdose death rate in the country. Her article, "The Addicts Next Door," appeared in the magazine earlier this month.

You also write about a guy named John Aldis, who was, I guess, a retired physician - right? - who wanted to make Narcan - this drug that can revive overdosed addicts - more widely available. He wanted to hand it out - train people and hand it out to everybody, not just, you know, medical professionals. What's his experience been like?

TALBOT: Yeah. So he had been a military and State Department doctor. He had retired from the State Department, moved back to this area where he was from and then started realizing how bad the epidemic was. And so he became the first doctor in the state of West Virginia to offer classes in how to use Narcan for just - yeah - ordinary people, not EMT or medical professionals but people who might come upon somebody, you know, overdosed in the aisle at Walmart or who had people in their family who they worried about all the time.

He offers classes in the community. And there were a lot of women, a lot of mothers there. And there are people who have the idea of having Narcan boxes on the walls of, you know, the gym or community, like you have a defibrillator because the anticipation is that this is going to be happening more and more in many places.

DAVIES: The overdose deaths are getting a lot of attention because it's a terrible toll, you know, a leading cause of death now. But there's also this underlying tragedy of addicts who survive and whose lives are ruined. I mean is there a sense that it's fundamentally changed the communities they live in?

TALBOT: Yeah, I think it has because it affects a lot of people in their 20s, 30s, 40s. So it's people who are of parenting age, who have young children. So there's really a lot of collateral damage for children - been a real toll on the foster care system and also babies born with neonatal abstinence syndrome - so in withdrawal and requiring morphine.

You know, somebody I talked to who had some experience working on the AIDS epidemic in Africa was saying that there's this way in which it's the sort of hollowing out of the middle. So there's, you know, children and a lot of grandparents raising their grandchildren because their own children are in addiction or have died. So yeah, I mean I think people, you know, also miss out - if they're in addiction in their 20s and 30s, they miss out on a lot of kind of the experiences that you have of building a life.

And that's why I think some kind of therapy and psychosocial supports are really important because otherwise I think you come out of it feeling like, what have I lost, and where do I begin and feeling a lot of shame.

DAVIES: This is such a tough subject. I'm sure it was difficult for you at times talking to people about this and then particularly, you know, parents who were struggling with addiction and who have kids. And I wonder if you felt yourself judging them or struggling not to or just how you process that.

TALBOT: You know, it's always hard to see kids who are caught up in something like this and have no recourse or very little recourse, nothing to say about it. So that's painful to see. I really felt like this addiction is something that nobody chose. Nobody wanted it. It's a pretty miserable life, you know? I think people think about it as something that produces euphoria or something. I think, mainly it's numbing, and so I think people are often escaping mental and emotional distress that's pretty bad for them to have gotten addicted in the first place. So mainly I think I actually had a lot of compassion for the people I talked to. You know, I did talk to people who were trying, you know, so - and struggling, so I felt for them in that effort.

DAVIES: You know, those who need treatment in West Virginia are more likely to get it even though there's a shortage. They're more likely to get it if they are on Medicaid. And West Virginia is one of the states that took the expansion of Medicaid under the Affordable Care Act, Obamacare. You know, so many more people are covered. And you know, every county in the state voted for Donald Trump who wants to repeal and replace Obamacare, and now there's this bill in the Senate that would certainly make big changes. I'm wondering how that whole debate is playing in West Virginia.

TALBOT: You know, I have not been back there since the new Senate bill came up. But you know, I have talked to Dr. Aldis and others including a woman in the piece who is in a treatment program using Suboxone or buprenorphine and actually doing quite well but who was able to pay for it through Medicaid. So there are a lot of people who are just personally very worried about their future ability to get any treatment for themselves or for their family members. So I don't know, you know, to what extent people are thinking about this in a larger political sense. They're certainly thinking about it in an immediate personal sense.

DAVIES: Well, Margaret Talbot, thanks so much for speaking with us.

TALBOT: Thank you.

DAVIES: Margaret Talbot is a staff writer for The New Yorker. Her article about the opioid crisis in West Virginia is "The Addicts Next Door." Coming up, we meet actor Sam Elliott. He stars in the new film "The Hero." This is FRESH AIR.

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