The Addicts Next Door - The New Yorker
Mon, 12 Jun 2017 03:43
Michael Barrett and Jenna Mulligan, emergency paramedics in Berkeley County, West Virginia, recently got a call that sent them to the youth softball field in a tiny town called Hedgesville. It was the first practice of the season for the girls' Little League team, and dusk was descending. Barrett and Mulligan drove past a clubhouse with a blue-and-yellow sign that read ''Home of the Lady Eagles,'' and stopped near a scrubby set of bleachers, where parents had gathered to watch their daughters bat and field.
Two of the parents were lying on the ground, unconscious, several yards apart. As Barrett later recalled, the couple's thirteen-year-old daughter was sitting behind a chain-link backstop with her teammates, who were hugging her and comforting her. The couple's younger children, aged ten and seven, were running back and forth between their parents, screaming, ''Wake up! Wake up!'' When Barrett and Mulligan knelt down to administer Narcan, a drug that reverses heroin overdoses, some of the other parents got angry. ''You know, saying, 'This is bullcrap,' '' Barrett told me. '' 'Why's my kid gotta see this? Just let 'em lay there.' '' After a few minutes, the couple began to groan as they revived. Adults ushered the younger kids away. From the other side of the backstop, the older kids asked Barrett if the parents had overdosed. ''I was, like, 'I'm not gonna say.' The kids aren't stupid. They know people don't just pass out for no reason.'' During the chaos, someone made a call to Child Protective Services.
At this stage of the American opioid epidemic, many addicts are collapsing in public'--in gas stations, in restaurant bathrooms, in the aisles of big-box stores. Brian Costello, a former Army medic who is the director of the Berkeley County Emergency Medical Services, believes that more overdoses are occurring in this way because users figure that somebody will find them before they die. ''To people who don't have that addiction, that sounds crazy,'' he said. ''But, from a health-care provider's standpoint, you say to yourself, 'No, this is survival to them.' They're struggling with using but not wanting to die.''
A month after the incident, the couple from the softball field, Angel Dawn Holt, who is thirty-five, and her boyfriend, Christopher Schildt, who is thirty-three, were arraigned on felony charges of child neglect. (Schildt is not the biological father of Holt's kids.) A local newspaper, the Martinsburg Journal, ran an article about the charges, noting that the couple's children, who had been ''crying when law enforcement arrived,'' had been ''turned over to their grandfather.''
West Virginia has the highest overdose death rate in the country, and heroin has devastated the state's Eastern Panhandle, which includes Hedgesville and the larger town of Martinsburg. Like the vast majority of residents there, nearly all the addicts are white, were born in the area, and have modest incomes. Because they can't be dismissed as outsiders, some locals view them with empathy. Other residents regard addicts as community embarrassments. Many people in the Panhandle have embraced the idea of addiction as a disease, but a vocal cohort dismisses this as a fantasy disseminated by urban liberals.
These tensions were aired in online comments that amassed beneath the Journal article. A waitress named Sandy wrote, ''Omgsh, How sad!! Shouldnt be able to have there kids back! Seems the heroin was more important to them, than watchn there kids have fun play ball, and have there parents proud of them!!'' A poster named Valerie wrote, ''Stop giving them Narcan! At the tax payers expense.'' Such views were countered by a reader named Diana: ''I'm sure the parents didn't get up that morning and say hey let's scar the kids for life. I'm sure they wished they could sit through the kids practice without having to get high. The only way to understand it is to have lived it. The children need to be in a safe home and the adults need help. They are sick, i know from the outside it looks like a choice but its not. Shaming and judging will not help anyone.''
One day, Angel Holt started posting comments. ''I don't neglect,'' she wrote. ''Had a bad judgment I love my kids and my kids love me there honor roll students my oldest son is about to graduate they play sports and have a ruff over there head that I own and food, and things they just want I messed up give me a chance to prove my self I don't have to prove shit to none of u just my children n they know who I am and who I'm not.''
A few weeks later, I spoke to Holt on the phone. ''Where it happened was really horrible,'' she said. ''I can't sit here and say different.'' But, she said, it had been almost impossible to find help for her addiction. On the day of the softball practice, she ingested a small portion of a package of heroin that she and Schildt had just bought, figuring that she'd be able to keep it together at the field; she had promised her daughter that she'd be there. But the heroin had a strange purple tint'--it must have been cut with something nasty. She started feeling weird, and passed out. She knew that she shouldn't have touched heroin that was so obviously adulterated. But, she added, ''if you're an addict, and if you have the stuff, you do it.''
''Just imagine the hole is world peace and the sand traps are nuclear Armageddon and the club is your ability to deal calmly and rationally with complex situations.'' In Berkeley County, which has a population of a hundred and fourteen thousand, when someone under sixty dies, and the cause of death isn't mentioned in the paper, locals assume that it was an overdose. It's becoming the default explanation when an ambulance stops outside a neighbor's house, and the best guess for why someone is sitting in his car on the side of the road in the middle of the afternoon. On January 18th, county officials started using a new app to record overdoses. According to this data, during the next two and a half months emergency medical personnel responded to a hundred and forty-five overdoses, eighteen of which were fatal. This underestimates the scale of the epidemic, because many overdoses do not prompt 911 calls. Last year, the county's annual budget for emergency medication was twenty-seven thousand dollars. Narcan, which costs fifty dollars a dose, consumed two-thirds of that allotment. The medication was administered two hundred and twenty-three times in 2014, and four hundred and three times in 2016.
One Thursday in March, a few weeks before Michael Barrett responded to Angel Holt's overdose, I rode with him in his paramedic vehicle, a specially equipped S.U.V. He started his day as he often does, with bacon and eggs at the Olde Country Diner, in Martinsburg. Barrett, who is thirty-three, with a russet-colored beard and mustache, works two twenty-four-hour shifts a week, starting at 7 a.m. The diner shares a strip mall with the E.M.T. station, and, if he has to leave on a call before he can finish eating, the servers will box up his food in a hurry. Barrett's father and his uncles were volunteer firemen in the area, and, growing up, he often accompanied them in the fire truck. As they'd pull people from crumpled cars or burning buildings, he'd say to himself, ''Man, they doing stuff'--they're awesome.'' When Barrett became a paramedic, in his twenties, he knew that he could make a lot more money ''going down the road,'' as people around here say, referring to Baltimore or Washington, D.C. But he liked it when older colleagues told him, ''I used to hold you at the fire department when you were a baby.''
Barrett's first overdose call of the day came at 8 a.m., for a twenty-year-old woman. Several family members were present at the home, and while Barrett and his colleagues worked on her they cried and blamed one another, and themselves, for not watching her more closely. The woman was given Narcan, but she was too far gone; she died after arriving at the hospital.
We stopped by a local fire station, where the men and women on duty talked about all the O.D. calls they took each week. Sometimes they knew the person from high school, or were related to the person. Barrett said that in such cases you tended ''to get more angry at them'--you're, like, 'Man, you got a kid, what the hell's wrong with you?' ''
Barrett sometimes had to return several times in one day to the same house'--once, a father, a mother, and a teen-age daughter overdosed on heroin in succession. Such stories seemed like twisted variations on the small-town generational solidarity he admired; as Barrett put it, even if one family member wanted to get clean, it would be next to impossible unless the others did, too. He was used to O.D. calls by now, except for the ones in which kids were around. He once arrived at a home to find a seven-year-old and a five-year-old following the instructions of a 911 operator and performing C.P.R. on their parents. (They survived.)
Around three o'clock, the dispatcher reported that a man in Hedgesville was slumped over the steering wheel of a jeep. By the time we got there, the man, who appeared to be in his early thirties, had been helped out of his vehicle and into an ambulance. A skinny young sheriff's deputy on the scene showed us a half-filled syringe: the contents resembled clean sand, which suggested pure heroin. That was a good thing'--these days, the narcotic is often cut with synthetic painkillers such as fentanyl, which is fifty times as powerful as heroin.
The man had floppy brown hair and a handsome face; he was wearing jeans, work boots, and a black windbreaker. He'd been revived with oxygen'--he hadn't needed Narcan'--but as he sat in the ambulance his eyes were only partly opened, and his pupils, when I could catch a glimpse of them, were constricted to pinpoints. Barrett asked him, ''Did you take a half syringe? 'Cause there's half a syringe left.'' The man looked up briefly and said, ''Yeah? I was trying to take it all.'' He said that he was sorry'--he'd been clean for a month. Then he mumbled something about having a headache. ''Well, sure you do,'' another paramedic said. ''You weren't breathing there for a while. Your brain didn't have any oxygen.''
The man's jeep sat, dead still, in the middle of a street that sloped sharply downhill. A woman introduced herself to me as Ethel. She had been driving behind the man when he lost consciousness. ''I just rolled up, saw he was slumped over the wheel,'' she said. ''I knew what it was right away.'' She beeped her horn, but he didn't move. She called 911 and stayed until the first responders showed up, ''in case he started to roll forward, and maybe I could stop traffic'--and to make sure he was O.K.'' I asked if the man's jeep had been running during this time. ''Oh, yeah,'' she said. ''He just happened to stop with his foot on the brake.'' Barrett shared some protocol: whenever he came across people passed out in a car, he put the transmission in park and took their keys, in case they abruptly revived. He'd heard of people driving off with E.M.T. personnel halfway inside.
The sky was a dazzling blue, with fluffy white clouds scudding overhead. The man took a sobriety test, wobbling across the neat lawn of a Methodist church. ''That guy's still high as a kite,'' somebody said.
Tara Mayson, Tina Stride, and Lisa Melcher run the Hope Dealer Project, which helps addicts find a spot in rehab. Photograph by Eugene Richards for The New Yorker We were driving away from Hedgesville when the third overdose call of the day came, for a twenty-nine-year-old male. Inside a nicely kept house in a modern subdivision, the man was lying unconscious on the bathroom floor, taking intermittent gasps. He was pale, though not yet the blue-tinged gray that people turn when they've been breathing poorly for a while. Opioid overdoses usually kill people by inhibiting respiration: breathing slows and starts to sound labored, then stops altogether. Barrett began preparing a Narcan dose. Generally, the goal was to get people breathing well again, not necessarily to wake them completely. A full dose of Narcan is two milligrams, and in Berkeley County the medics administer 0.4 milligrams at a time, so as not to snatch patients' high away too abruptly: you didn't want them to go into instant withdrawal, feel terribly sick, and become belligerent. Barrett crouched next to the man and started an I.V. A minute later, the man sat up, looking bewildered and resentful. He threw up. Barrett said, ''Couple more minutes and you would have died, buddy.''
''Thank you,'' the man said.
''You're welcome'--but now you need to go to the hospital.''
The man's girlfriend was standing nearby, her hair in a loose bun. She responded calmly to questions: ''Yeah, he does heroin''; ''Yeah, he just ate.'' The family dog was snuffling at the front door, and one of the sheriff's deputies asked if he could let it outside. The girlfriend said, ''Sure.'' Brian Costello had told me that family members had grown oddly comfortable with E.M.T. visits: ''That's the scary part'--that it's becoming the norm.'' The man stood up, and then, swaying in the doorway, vomited a second time.
''We're gonna take him to the hospital,'' Barrett told the girlfriend. ''He could stop breathing again.''
As we drove away, Barrett predicted that the man would check himself out of the hospital as soon as he could; most O.D. patients refused further treatment. Even a brush with death was rarely a turning point for an addict. ''It's kind of hard to feel good about it,'' Barrett said of the intervention. ''Though he did say, 'Thanks for waking me up.' Well, that's our job. But do you feel like you're really making a difference? Ninety-nine per cent of the time, no.'' The next week, Barrett's crew was called back to the same house repeatedly. The man overdosed three times; his girlfriend, once.
It was getting dark, and Barrett stopped at a convenience store for a snack'--chocolate milk and a beef stick. That evening, he dealt with one more O.D. A young woman had passed out in her car in the parking lot of a 7-Eleven, with her little girl squirming in a car seat. An older woman who happened on the scene had taken the girl, a four-year-old, into the store and bought her some hot chocolate and Skittles. After the young woman received Narcan, Barrett told her that she could have killed her daughter, and she started sobbing hysterically. Meanwhile, several guys in the parking lot were becoming agitated. They had given the woman C.P.R., but someone had called 911 and suggested that they had supplied her with the heroin. The men were black and everybody else'--the overdosing woman, the older woman, the cops, the ambulance crew'--was white. The men were told to remain at the scene while the cops did background checks. Barrett attempted to defuse the tension by saying, ''Hey, you guys gave her C.P.R.? Thanks. We really appreciate that.'' The criminal checks turned up nothing; there was no reason to suspect that the men were anything but Good Samaritans. The cops let the men go, the young woman went to the E.R., and the little girl was retrieved by her father.
Heroin is an alluringly cheap alternative to prescription pain medication. In 1996, Purdue Pharma introduced OxyContin, marketing it as a safer form of opiate'--the class of painkillers derived from the poppy plant. (The term ''opioids'' encompasses synthetic versions of opiates as well.) Opiates such as morphine block pain but also produce a dreamy euphoria, and over time they cause physical cravings. OxyContin was sold in time-release capsules that levelled out the high and, supposedly, diminished the risk of addiction, but people soon discovered that the capsules could be crushed into powder and then injected or snorted. Between 2000 and 2014, the number of overdose deaths in the United States jumped by a hundred and thirty-seven per cent.
Some states became inundated with opiates. According to the Charleston Gazette-Mail, between 2007 and 2012 drug wholesalers shipped to West Virginia seven hundred and eighty million pills of hydrocodone (the generic name for Vicodin) and oxycodone (the generic name for OxyContin). That was enough to give each resident four hundred and thirty-three pills. The state has a disproportionate number of people who have jobs that cause physical pain, such as coal mining. It also has high levels of poverty and joblessness, which cause psychic pain. Mental-health services, meanwhile, are scant. Chess Yellott, a retired family practitioner in Martinsburg, told me that many West Virginians self-medicate to mute depression, anxiety, and post-traumatic stress from sexual assault or childhood abuse. ''Those things are treatable, and upper-middle-class parents generally get their kids treated,'' he said. ''But, in families with a lot of chaos and money problems, kids don't get help.''
In 2010, Purdue introduced a reformulated capsule that is harder to crush or dissolve. The Centers for Disease Control subsequently issued new guidelines stipulating that doctors should not routinely treat chronic pain with opioids, and instead should try approaches such as exercise and behavioral therapy. The number of prescriptions for opioids began to drop.
But when prescription opioids became scarcer their street price went up. Drug cartels sensed an opportunity, and began flooding rural America with heroin. Daniel Ciccarone, a professor at the U.C.-San Francisco School of Medicine, studies the heroin market. He said of the cartels, ''They're multinational, savvy, borderless entities. They worked very hard to move high-quality heroin into places like rural Vermont.'' They also kept the price low. In West Virginia, many addicts told me, an oxycodone pill now sells for about eighty dollars; a dose of heroin can be bought for about ten.
A recent paper from the National Bureau of Economic Research concludes, ''Following the OxyContin reformulation in 2010, abuse of prescription opioid medications and overdose deaths decreased for the first time since 1990. However, this drop coincided with an unprecedented rise in heroin overdoses.'' According to the Centers for Disease Control, three out of four new heroin users report having first abused opioids.
''The Changing Face of Heroin Use in the United States,'' a 2014 study led by Theodore Cicero, of Washington University in St. Louis, looked at some three thousand heroin addicts in substance-abuse programs. Half of those who began using heroin before 1980 were white; nearly ninety per cent of those who began using in the past decade were white. This demographic shift may be connected to prescribing patterns. A 2012 study by a University of Pennsylvania researcher found that black patients were thirty-four per cent less likely than white patients to be prescribed opioids for such chronic conditions as back pain and migraines, and fourteen per cent less likely to receive such prescriptions after surgery or traumatic injury.
But a larger factor, it seems, was the despair of white people in struggling small towns. Judith Feinberg, a professor at West Virginia University who studies drug addiction, described opioids as ''the ultimate escape drugs.'' She told me, ''Boredom and a sense of uselessness and inadequacy'--these are human failings that lead you to just want to withdraw. On heroin, you curl up in a corner and blank out the world. It's an extremely seductive drug for dead-end towns, because it makes the world's problems go away. Much more so than coke or meth, where you want to run around and do things'--you get aggressive, razzed and jazzed.''
Peter Callahan, a psychotherapist in Martinsburg, said that heroin ''is a very tough drug to get off of, because, while it was meant to numb physical pain, it numbs emotional pain as well'--quickly and intensely.'' In tight-knit Appalachian towns, heroin has become a social contagion. Nearly everyone I met in Martinsburg has ties to someone'--a child, a sibling, a girlfriend, an in-law, an old high-school coach'--who has struggled with opioids. As Callahan put it, ''If the lady next door is using, and so are other neighbors, and people in your family are, too, the odds are good that you're going to join in.''
In 2015, Berkeley County created a new position, recovery-services co¶rdinator, to connect residents with rehab. Yet there is a chronic shortage of beds in the state for addicts who want help. Kevin Knowles, who was appointed to the job, told me, ''If they have private insurance, I can hook them right up. If they're on Medicaid'--and ninety-five per cent of the people I work with are'--it's going to be a long wait for them. Weeks, months.'' He said, ''The number of beds would have to increase by a factor of three or four to make any impact.''
West Virginia has an overdose death rate of 41.5 per hundred thousand people. (New Hampshire has the second-highest rate: 34.3 per hundred thousand.) This year, for the sixth straight year, West Virginia's indigent burial fund, which helps families who can't afford a funeral pay for one, ran out of money. Fred Kitchen, the president of the West Virginia Funeral Directors Association, told me that, in the funeral business, ''we know the reason for that was the increase in overdose deaths.'' He added, ''Families take out second mortgages, cash in 401(k)s, and go broke to try and save a son or daughter, who then overdoses and dies.'' Without the help of the burial fund, funeral directors must either give away caskets, plots, and cremation services'--and risk going out of business'--or, Kitchen said, look ''mothers, fathers, husbands, wives, and children in the eye while they're saying, 'You have nothing to help us?' ''
Martinsburg, which has a population of seventeen thousand, is a hilly town filled with brick and clapboard row houses. It was founded in 1778, by Adam Stephen, a Revolutionary War general. The town became a depot for the B. & O. Railroad and grew into an industrial center dominated by woollen mills. Interwoven, established in the eighteen-nineties, was the first electric-powered textile plant in the U.S. The company became the largest men's-sock manufacturer in the world, and at its height, in the nineteen-fifties, it employed three thousand people in Martinsburg. The Interwoven factory whistle could be heard all over town, summoning workers every morning at a quarter to seven. In 1971, when the mill closed, an editorial in the Martinsburg Journal mourned the passing of ''what was once this community's greatest pride.'' In 2004, the last woollen mill in town, Royce Hosiery, ceased operations.
It's simplistic to trace the town's opioid epidemic directly to the loss of industrial jobs. Nevertheless, many residents I met brought up this history, as part of a larger story of lost purpose that has made the town vulnerable to the opioid onslaught. In 2012, Macy's opened a distribution center in the Martinsburg area, but, Knowles said, the company has found it difficult to hire longtime residents, because so many fail the required drug test. (The void has been filled, only partially, by people from neighboring states.) Knowles wonders if Procter & Gamble, which is opening a manufacturing plant in the area this fall, will have a similar problem.
The Eastern Panhandle is one of the wealthier parts of a poor state. (The most destitute counties depend on coal mining.) Berkeley County is close enough to D.C. and Baltimore that many residents commute for work. Nevertheless, Martinsburg feels isolated. Several people I met there expressed surprise, or sympathy, when I told them that I live in D.C., or politely said that they'd like to visit the capital one of these days. Like every other county in West Virginia, Berkeley County voted for Donald Trump.
The Interwoven mill, derelict and grand, dominates the center of Martinsburg. A local police officer has proposed turning most of the mill into a rehab facility. Photograph by Eugene Richards for The New Yorker Michael Chalmers is the publisher of an Eastern Panhandle newspaper, the Observer. It is based in Shepherdstown, a picturesque college town near the Maryland border which has not succumbed to heroin. Chalmers, who is forty-two, grew up in Martinsburg, and in 2014 he lost his younger brother, Jason, to an overdose. I asked him why he thought that Martinsburg was struggling so much with drugs. ''In my opinion, the desperation in the Panhandle, and places like it, is a social vacancy,'' he said. ''People don't feel they have a purpose.'' There was a ''shame element in small-town culture.'' Many drug addicts, he explained, are ''trying to escape the reality that this place doesn't give them anything.'' He added, ''That's really hard to live with'--when you look around and you see that seven out of ten of your friends from high school are still here, and nobody makes more than thirty-six thousand a year, and everybody's just bitching about bills and watching these crazy shows on reality TV and not doing anything.''
The Interwoven mill, derelict and grand, still dominates the center of Martinsburg. One corner of it has been turned into a restaurant, but the rest sits empty. Lately, there's been talk of an ambitious renovation. A police officer named Andrew Garcia has a plan, called Martinsburg Renew, which would turn most of the mill into a rehab facility. Todd Funkhouser, who runs the Berkeley County Historical Society, showed me around one day. ''Martinsburg is an industrial town,'' he said. ''That's its identity. But what's the industry now? Maybe it will be drug rehab.''
In the past several months, I have returned to Martinsburg many times, and spoken with many addicts there. I learned the most about the crisis, however, from residents who weren't drug users, but whose lives had been irrevocably altered by others' addiction.
Lori Swadley is a portrait and wedding photographer in Martinsburg. When I looked at her Web site, she seemed to be in demand all over the area, and her photographs were lovely: her brides glowed in afternoon light, her high-school seniors looked polished and confident. But what drew me to her was a side project she had been pursuing, called 52 Addicts'--a series of portraits that called attention to the drug epidemic in and around Martinsburg. It was clear that Swadley had a full life: her husband, Jon, worked with her in the photography business, and they had three small children, Juniper, Bastian, and Bodhi. Her Web site noted that she loved fashion and gardening, and included this declaration: ''I'm happy that you've stumbled upon our little slice of heaven!'' The 52 Addicts series seemed like a surprising project for someone so busy and cheerful.
We met one day at Mugs & Muffins, a cozy coffee shop on Queen Street. Swadley is thirty-nine, tall and slender, and she looked elegant in jeans, a charcoal-colored turtleneck, and high boots. She and her husband had moved to Martinsburg in 2010, she told me, looking for an affordable place to raise children close to where she had grown up, in the Shenandoah Valley. Soon after they arrived, they settled into a subdivision outside town, and Swadley started reading the Martinsburg Journal online. She told me, ''I'd see these stories about addiction'--whether it was somebody who'd passed away, and the family wanted to tell their story, or it was the overdose statistics, or whatever.'' Many of the stories were written by the same reporter, Jenni Vincent. ''She was very persistent, and'--I don't know what the word for it is'--very in your face,'' Swadley said. ''You could tell she wanted the problem to be known. Because at that time it seemed like everybody else wanted to hide it. And, to me, that seemed like the worst thing you could do.''
It turned out that thirteen of Swadley's friends had died of opioid overdoses. I said that it seemed like an extraordinarily high number, especially for someone who was not an addict. She agreed, but there it was. All thirteen were young men'--Swadley had met most of them when she was in her early twenties, and she had been a tomboy back then. The first time she heard that a friend had died, she had been photographing a wedding for some mutual friends. They were sitting around a bonfire at the end of the day. When Swadley spoke of a crazy horror film that she and a guy named Jeremy had made in high school, somebody mentioned that he had recently died, from a heroin overdose. Swadley felt like she'd been punched in the gut. She threw up, and wrecked her car on the way home.
At the time, Swadley was hanging out with her old crowd in bars and restaurants every weekend. One by one, the group dwindled. Many of them'--''the preppy boys, the hippie boys'''--got into heroin eventually, she said. They tried to help one another, but ''we were in our twenties'--we had no clue.'' She'd call rehab places on friends' behalf and have to tell them that the price was staggering, and that in any case it might be six months before they could be admitted. As the overdoses piled up, she was appalled to find that sometimes she had trouble keeping track of which friends were dead.
The funerals had a peculiar aspect. ''The parents didn't want anyone to know how it had happened, and they tried to keep the friends out,'' she said. At the services for one friend'--a sweet, goofy guy with shaggy blond hair'--Swadley and her friends got close enough to the casket to see that his hair had been shorn, so that ''he looked clean-cut.'' She went on, ''It was clear that his mother didn't want us there. It was understandable'--she didn't know if any of us had been supplying him.''
One day, Swadley decided that she needed to write down all thirteen names, before she forgot one. In January, 2016, she started photographing addicts in recovery. In her introduction to the series, on Instagram, she wrote about her friends who had died and about Martinsburg's lack of rehab centers. She found the town's culture of denial enraging.
For the first few portraits, Swadley reached out to her subjects, but soon people started coming to her. She took their pictures, asked them about their lives, and told their stories in a paragraph or so. There are now two dozen images in the series.
''You're the first person I've met who didn't become a pastry chef after suffering a nervous breakdown working in a corporate job.'' In one of the portraits, an E.R. nurse hugs her daughter, Hope, from whom she'd been estranged. They had reconnected at the hospital, when the nurse saw Hope's name listed as a patient in the emergency room. Swadley photographed a Martinsburg woman named Crystal, who'd been hit by a car one night when she was walking to her dealer's house; Crystal was now clean, but she was confined to a wheelchair. A woman named Tiffany posed holding a snapshot of her younger sister, Tabby. Both women had started off on pills'--Tabby had developed a problem after a gallbladder operation left her with a thirty-day supply of meds'--and then became heroin addicts. Tiffany had received treatment, but Tabby had fatally overdosed while she was waiting for a rehab bed. Swadley took the portrait in a park where Tiffany had once begged Tabby to stop using. When I called Tiffany, she told me that she had recently lost a second sister to heroin.
Swadley hopes that her photographs will someday be displayed all around town'--in coffee shops, restaurants, perhaps the library. She wants a public reckoning with the stories she's collected. ''The whole point of this project is to show naysayers out there that people do recover,'' she said. ''They are good people. I want to show people they deserve a chance. I want it in people's faces, so they see that it could be their neighbor, or their best friend.''
One day, Swadley told me about a local effort against heroin addiction, called the Hope Dealer Project. It was run by three women: Tina Stride, who had a twenty-six-year-old son in recovery; Tara Mayson, whose close friend had gone through periods of addiction; and Lisa Melcher, whose son-in-law had died of an overdose, and whose thirty-two-year-old daughter, Christina, was struggling to overcome heroin addiction. All three had known addicts who wanted to get clean but had no place to go. Last fall, like car-pool moms with a harrowing new mission, they had begun driving people to detox facilities all over the state'--any place that could take them, sometimes as far as five hours away. The few with private insurance could get rehab anywhere in the country, and the Hope Dealer women were prepared to suggest options. But most people in town had Medicaid or no insurance at all, and such addicts had to receive treatment somewhere in the state. Currently, the detox facility closest to Martinsburg is about two hours away.
Stride works full time at the General Services Administration, in Washington, but spends up to twenty-four hours a week giving rides to drug users. The other two focus on reaching out to addicts and families. Stride noted, ''I have to talk to the addict, or the client'--that's what we try to call them'--all the way to that detox center. Because they're sick. And we pass hospitals all the way, and they're begging, 'Just take me there'--they can help me!' But they really can't, the hospitals.''
When Stride and her client arrive at a detox facility, nurses are waiting at the door. At that point, Stride said, ''they're, like, 'What do you mean, you're leaving me?' '' She went on, ''They're scared, because now it's reality. They know they're not going to get their dope or their pills. For them to walk in those doors, that takes a lot. They're heroes to me.''
After five to ten days in detox, patients are released. ''When our clients get clean and the drugs are out of their system, they believe they're O.K.,'' Stride said. ''And they're not. That's just getting the poison out of their bodies. So we try to explain to them, 'No, you need to go through rehab, and learn why you are using, and learn how to fight it.' Some will do it. Some won't. And then our issue becomes how we're going to find them a bed in rehab. If beds are all full, a lot of times they come back here to Martinsburg, because they have nowhere else to go.'' Stride tries to keep those clients under constant watch. ''That addict brain is telling them, 'You know what you need, and it's right here'--go get it.' ''
Stride usually drives clients to a detox center immediately after picking them up. But once she had to keep a woman overnight at her home, because a bed wasn't available until the morning. She told me, ''All I said was 'Please, don't rob me. I'm here to help you. But I guess if you are gonna rob me there's not a whole lot I can do about it.' This young lady had to go through the night'--she was so sick, she didn't sleep. I tried to stay up, but I knew I had to drive four hours to the detox place, and four hours back. So I slept some. We were up at 4 a.m., and at the detox place at eight. And she's doing good now'--she calls me to touch base sometimes.''
The Hope Dealer women and I met near an apartment complex that Melcher manages, and drank mochas that she had bought at McDonald's. Melcher, who is fifty-three, with abundant blond ringlets and a warm, husky voice, told me that she loved flower arranging and refinishing old furniture'--activities that would be occupying her days more often if there weren't a heroin crisis. Stride, who is forty-seven, wore her hair in a ponytail and had curly bangs; Mayson, who is forty-six, had long, sparkly nails.
At one point, Stride said, ''Please don't think I'm rude,'' as she picked up her phone to read a text.
''He's in!'' she cried. ''He made it!''
The women cheered.
They had spent the previous day working on behalf of a woman and her twenty-one-year-old son, a heroin addict. He had private insurance, so they had signed him up for rehab in New Hampshire. ''We had a plane ticket ready, and they were ready to go to the airport,'' Stride said. ''I left them, and then the mother called me and said, 'My son's lips are blue'--he's overdosed. What do I do?' '' Stride became teary. ''And I said, 'Call 911. I'm coming right back over.' ''
Samantha Engelhardt (right), a recovering addict, shows her newborn baby to the photographer Lori Swadley, who has been documenting the opioid epidemic in the Martinsburg area. Photograph by Eugene Richards for The New Yorker Stride went on, ''So he was in the hospital, and then his mom reached out to me late last night and said, 'He's been released.' First question I asked is 'Where is he?,' because we're afraid he's going to run. And she said, 'Instead of putting him on a plane, can we drive him? Because I want to know he makes it.' And I said, 'Yes, you can.' So they are driving eight hours to take him to his detox. Detox was good to go'--so we know for the next seven to ten days he's safe.'' After that, the man was set to go to Florida, to attend a thirty-day program that Stride respected.
Melcher said, ''Praise God, he made it,'' and the women all nodded.
Mayson, who works at the Department of Veterans Affairs and has two adult children, said that the Hope Dealer women had become like sisters. When one of them has a hard day, she can count on one of the others to tell her to rest and recharge'--or, as Melcher often says, to ''breeeathe.''
As mothers, they felt that they had a particular ability to communicate with women who needed help with their addicted children. Stride said, ''I remember when I first found out my son was an addict. I was devastated. I didn't know who to turn to, who I could trust. And I worked and worked to find my son a place, and that's rough. Hearing 'No' or 'We can't take him today, but we can take him a week from today.' 'No, you need to take him now. My son's gonna die.' So now, when moms reach out to us, we're, like, 'We've got this.' ''
Melcher said, ''When you're in that space? Oh, my gosh, you can hardly breathe, you're a cryin' mess.''
Stride nodded and said, ''So when we come in and say, 'Mom, we're gonna take care of your child,' I don't care if that child is fifty years old'--you see a relief.''
On May 21st, I received an e-mail from Melcher, informing me that Christina, her daughter, had fatally overdosed on heroin. Christina, she said, had completed rehab several times, and had been clean for ninety days before relapsing. Melcher refused to hide the fact that Christina had ''lost her battle with addiction,'' but added, ''When a child passes away, the last thing a mother wants to say is that the child was an addict.'' Melcher plans to continue her volunteer work, in honor of Christina's ''beautiful but tortured life.''
John Aldis doesn't look like a maverick. He's seventy-one, white-haired and pink-cheeked, with a neat mustache, half-rimmed spectacles, and a penchant for sweater vests and bow ties. You could imagine him being cast as the Stage Manager in a production of ''Our Town.'' But two years ago Aldis became the first doctor in West Virginia to offer free public classes to teach anybody'--not just first responders and health professionals'--how to reverse overdoses with Narcan.
Aldis is a family practitioner with a background in public health and tropical medicine. His mother taught nursing, and his father was an obstetrician. ''We never made it through the second feature at the drive-in,'' Aldis recalled. ''He would always be summoned over the loudspeaker to attend a birth.'' There was no question in Aldis's mind that he would become a doctor, too. He spent most of his career in Asia and Africa, as a U.S. Navy physician and as a medical officer with the State Department. He retired in 2001. He and his wife, Pheny, a medical technologist, bought the house where he'd lived as a small child, in Shepherdstown. They filled it with art and antiques, acquired two Jack Russell terriers, and prepared for a quiet life filled with visits from their two daughters and the grandkids.
But Aldis soon became aware of the opioid epidemic in the Eastern Panhandle'--several people he'd hired to work on his house were ''good fellows'' who were also addicts. ''When I started to see it, I could not look away,'' he told me. He took a job at the New Life Clinic, in Martinsburg, where he could prescribe Suboxone, one of the long-term treatments for opioid addiction. He found it enormously frustrating that addicts were often urged to quit heroin cold turkey or to stop taking Suboxone (or methadone or naltrexone, the other drugs used to treat addiction and counteract withdrawal symptoms). In his view, this was wholly unrealistic. Most addicts needed what is known as medication-assisted treatment for a long time, if not the rest of their lives. He found the work at the clinic the most satisfying he'd done since graduating from medical school, forty-six years earlier. Patients struggled, and many of them failed, but when one of them told him, ''Doc, I talked to my mom for the first time in three years yesterday,'' that was, Aldis said, ''just the greatest thing.''
Aldis is generally a forbearing man, but he can be dismissive of people who don't share his sense of urgency. As he wrote to me in an e-mail, ''The lack of understanding of medication-assisted treatment among otherwise reasonably intelligent people at all levels of our community is astounding and (for me) completely unacceptable.''
In 2015, West Virginia University's Injury Control Research Center, along with several state and county agencies, started investigating ways to make naloxone'--the generic name for Narcan'--more widely available, in the hope of saving people in the throes of an overdose. Aldis attended a talk on the subject by the center's deputy director, Herb Linn, and afterward he told him, ''Let's not study this anymore. Let's just start a program.'' Linn recalls, ''I told him, 'Just do it! You could actually prescribe it to your patients.' ''
Aldis taught his first class on administering Narcan on September 3, 2015, at the New Life Clinic. Nine days later, a woman who'd attended the class used Narcan to revive a pregnant woman who had overdosed at a motel where they were both staying. During the next few weeks, Aldis heard of five more lives saved by people who'd attended the class.
''Before you say anything, let me tell you which TV shows I don't want spoilers on.'' In his seminars, Aldis addresses why addicts' lives are worth saving. That might seem self-evident, but at this point in the opioid epidemic many West Virginians feel too exhausted and resentful to help. People like Lori Swadley and the Hope Dealer women and John Aldis must combat a widespread attitude of ''Leave 'em lie, let 'em die.'' A community sucked dry by addiction becomes understandably wary of coddling users, and some locals worry that making Narcan easily available could foster complacency about overdoses.
William Poe, a paramedic, told me, ''The thing about Narcan is that it kind of makes it O.K. to overdose, because then you can keep it in your house and keep it private. And a lot of times we're the wake-up call. I remember one time, we had a kid who had O.D.'d, and we had him in the ambulance. A call came over the radio'--someone about his age had just died from an overdose. And the kid was, like, 'I'm so glad you guys brought me back.' '' It was humiliating when an ambulance showed up at your house and carted you out, pale and retching, but it also might push you to change. Then again, Poe mused, when most of your neighbors'--not to mention your mom and your grandma'--already knew that you used heroin, shaming might have little effect.
This past winter, I watched Aldis teach two classes in Berkeley Springs, an Eastern Panhandle town, at a storefront church between a convenience store and a pawnshop. The bare trees on the ridge above us were outlined like black lace against the twilight. Inside, a few dozen people, mostly women, sipped coffee from Styrofoam cups in an unadorned room with a low ceiling, tan carpeting, and rows of tan chairs.
Aldis touched briefly on what an overdose looks like, but acknowledged that the attendees probably already knew. (''Oh, Lord, yes,'' a woman behind me said.) He demonstrated how to spray Narcan up a patient's nose'--take-home kits come in atomizer form'--and announced that at the end of class he'd be writing prescriptions, which those in attendance could get filled at a pharmacy. If they had Medicaid or private insurance, the kit would cost only a few dollars; if they didn't, it could cost anywhere from a hundred and twenty-five to three hundred dollars. At the first meeting I attended, in November, a few women began to cry when they heard that. At the second, in January, Aldis had some good news: the state had agreed to provide a hundred and eighty free kits.
Aldis told me that he'd like to see Narcan ''inundating the community.'' It carried no potential for abuse, and couldn't harm you if someone gave it to you mistaking some other medical emergency for an overdose. ''They ought to be selling this stuff next to the peanut butter in the Walmart,'' he liked to say. And free supplies of Narcan should be everywhere, like fire extinguishers: ''kitchen cabinets, your purse, schools, gyms, shopping malls, motels.''
Aldis had been invited to Berkeley Springs by Melody Stotler, who ran a local organization for recovering addicts. She said to the class, ''Unfortunately, there are people in this community who don't understand addiction, who don't think Narcan should be out there.''
''They say we're enablers,'' Aldis put in. ''Somebody who has a heart attack'--are we enabling them by giving them C.P.R.? 'But their cholesterol's too high! We shouldn't have saved his life!' '' People laughed ruefully.
Aldis introduced Kathy Williams, a former patient of his and the mother of two little girls. She had twice saved people with Narcan. One time, while she was driving, she spotted a car on the side of the road, and a man lying on his back next to it. The other time, a neighbor in her apartment complex knocked on her door and said that a guy was overdosing in the parking lot. ''So I grabbed my Narcan kit, and I ran out there,'' she recalled. She saw a woman tending to a man. ''What had happened was that these two had stopped at Kmart. She went in to pick up her layaways, and when she came out he had just done shooting up, and said, 'Please take me home.' Well, he was overdosing from Kmart all the way. By the time I got there, he was in the back of the car, completely blue, and I had another guy help me pull him out'--a neighbor, 'cause where I live, I been there almost thirty years now, and I know everybody. A couple people saw me running, and they started running, too, because they said, 'Kathy's running'--something must be going on.' We gave him two doses of Narcan, and by the time the E.M.T. got there his eyes were just starting to flicker, and I really thought we were too late.'' The man began to stir.
A woman named Tara, who was at the January meeting with her teen-age stepdaughter, told me that she had revived a guy who lived in the trailer park where she did some babysitting. He'd refused to go to the hospital, even though he was ''puking like he was possessed.'' I asked Tara'--who was thirty, and had a soft, kind face'--if the man had said anything to her after she saved him. ''Every day, the next four days after that, he thanked me every time,'' she told me. ''He also said it was stupid and he'd never do that again, which wasn't true, because he was arrested for driving under the influence of heroin a few weeks ago. Nodded out in the McDonald's parking lot. Someone called the police.''
Tara wasn't judging. She was a recovering addict herself'--seven years now. She was studying to be a medical assistant.
Dr. John Aldis, at his home office in Shepherdstown. In 2015, he became the first doctor in West Virginia to offer free public classes to teach anybody'--not just first responders and health professionals'--how to reverse opioid overdoses with the drug Narcan. Photograph by Eugene Richards for The New Yorker Jason Chalmers loved his children, that was for sure. He crawled around on all fours, pretending to be a pony, to amuse his daughter, Jacey, and her younger brother, Liam. He submitted to Jacey whenever she wanted to cover his face with makeup. When Jacey was six months old, Jason wrote a letter to his grandparents in which he described the ''absolute, overwhelming'' love that he felt for his daughter. ''It's not for or about me any more,'' he wrote. ''That's probably for the best because I never did well with myself. She deserves a father who's going to love her unconditionally and so help me God, I'm going to do it. Maybe she's the answer to why I'm still here.''
Liam was born in 2009. His mother, Angie, had struggled with an opioid problem, and had taken Suboxone to combat it during her pregnancy. She told me that she also ''might have used'' heroin ''a couple of times.'' At the hospital, Jason felt that something was amiss with his son. His mother, Christine Chalmers, recalled, ''He says, 'Mom, this baby is in withdrawal. They can't release him'--he's in terrible pain. If we take him home, he's going to scream and scream and scream, and we won't have anything to help him.' '' (Suboxone can cause withdrawal.) ''So we called the doctor and, by golly, they checked him over, and he was in total withdrawal. He was on morphine for two solid weeks in the hospital.''
Jason, who grew up in Martinsburg, was a heroin addict for most of his life, a fact that puzzled his family almost as deeply as it saddened them. He grew up in an attractive, wooded development on a country road, with horses and dogs, and a kindhearted mother. His grandparents lived in the development, too, and Jason and his two siblings waited for the school bus together on a wooden bench that a neighbor had carved for them.
There were glimmers of an explanation here and there. Jason's parents had divorced when he was eight, and he was a shy, anxious kid; when he was twenty-five, he was given a diagnosis of obsessive-compulsive disorder. His older brother, Michael'--the publisher of the Shepherdstown Observer'--told me, ''If you gave us a bag of Reese's peanut-butter cups when we were kids, Jason would eat fifty of them. I'd eat five. I would've liked to eat fifty, but I was, like, 'Nah, I'll eat five.' '' Maybe, Michael suggested, this was evidence that Jason had a genetic predisposition for addiction. But who knew, really?
In high school, Jason was ''smart, good-looking, and athletic,'' Michael recalled, but he became the ''king of the stoners.'' He barely got his diploma. It was the beginning of a self-destructive pattern. Jason did things while he was on drugs, or trying to get drugs, that filled him with shame; to blot out those feelings, he'd get high again. He got into using heroin, then into selling it. A friend's father was a dealer, and Jason went to work for him, driving up to New York to procure drugs and driving back to Martinsburg to sell them. He introduced heroin to a girlfriend'--a good student who had a scholarship to an excellent university. She dropped out, overdosed, and died. He got a tattoo of the girlfriend's initials next to a dove, and a tattoo of Jesus, and a tattoo that represented his addiction: a desperate-looking demon with a gaping mouth. He went to jail dozens of times (drug possession, credit-card theft) and had a series of nearly fatal overdoses. In 2002, he stole his grandfather's checkbook and emptied his bank account. Christine urged her father to press charges, both because she felt that Jason had to be held responsible and because she felt safest'--and could actually sleep at night'--when he was behind bars. He lied to her, and stole from her, and after using heroin he would pass out on her deck, in her garage, at the end of her driveway.
Jason did not go to college, and he could not keep a job for long; he worked for a few weeks at a mini-mart, but got fired when his background check came in. He'd get clean in jail, and write contrite letters to his family. Then he'd return to Martinsburg and start hanging out again with his addict friends. Michael moved to Chicago to start a career as an advertising copywriter, and their sister, Antonia, went to work for the school system. Jason, now in his thirties, was stuck'--walking everywhere because he couldn't get a driver's license, and showing up at his mother's house in the middle of the night to beg for milk and cereal.
In 2008, Jason wrote to his grandparents, ''If I was a gambling man, which if you look at my track record my whole life has been a gamble, I'd have to say there's not enough time left in the world to make good on the pain I've caused.'' He observed, ''Damaged people can be dangerous because they know they can survive, but for some reason they don't know quite how to live.''
Christine Chalmers had struggled financially to raise three children as a single mother. But in 2002, when Jason was twenty-six, she was doing well as a real-estate agent, and she sent Jason to a monthlong rehab program in Colorado that cost ten thousand dollars. She recalled, ''I went after a couple of weeks, for parents' weekend, and you know what? It was so worth it. He'd been on heroin for ten years at this point, and it was the first time in all that time I saw him like my boy. He says, 'It's like a new world, Mom'--I can see things, I can smell things, I can feel things.' '' She paused. ''I thought, You know what? If I never have anything else, he had a month, and I had a weekend, and he was my boy.''
On April 28, 2014, Jason fatally overdosed. He was thirty-seven. His death did not come as a surprise: he had started telling Christine that the worst part of overdosing was waking up.
''Take heed! For your journey is filled with long delays and unexpected service changes!'' After an overdose death, an autopsy is usually performed. Because of the epidemic, coroners in West Virginia are often backed up. It took two weeks before Jason's body was returned to the Chalmers family. Afterward, Christine thought about how consumed she had been by her attempts to save Jason and, later, to protect his children from him. One day, Michael and Antonia had been cleaning up Jason's apartment, and they brought over to Christine the contents of his kitchen cabinet. Christine told me, ''There were a couple of cans of peas, and I had never served peas'--I didn't like them. And I said, 'I didn't know Jason liked peas!' There's your boy, your baby, and you never knew he liked peas. Such a simple thing. But I started crying, because I thought, What did we know about him as a person?''
When the man who sold Jason his final dose of heroin went on trial, Christine testified. ''But, you know, from that point on I have felt terrible about it,'' she said. ''The guy got ten years. And in some sense his life was saved, because he would have ended up the same as Jase. But when I look at him I know he'd just done the same things Jason did. I mean, who knows who Jase sold to? Who knows who lived or died because he sold to them?''
Christine, who is now sixty-four, and works full time as a secretary in the Berkeley County government, has found herself raising Jacey, who is in the third grade. (Liam lives with his mother, in another state.) One of the biggest collateral effects of the opioid crisis is the growing number of children being raised by people other than their parents, or being placed in foster care. In West Virginia, the number of children removed from parental care because of drug abuse rose from nine hundred and seventy in 2006 to two thousand one hundred and seventy-one in 2016. Shawn Valentine, a program director for a nonprofit that helps children navigate foster care , says that although the goal is to reunite children with their parents, this happens in ''less than twenty-five per cent of the cases we are involved in.'' A major reason is that parents often can't get access to recovery programs or medication-assisted treatment, because of waiting lists and financial obstacles.
Valentine said, ''I had a six-year-old once tell me that he had to hold the stretchy thing on his mom's arm. What would happen if he just didn't want to do that? He told me, 'Well, she would smack my head down, so that powdery stuff got all over my face.' ''
Christine and Jacey live in Martinsburg, in a pretty bungalow with a porch swing and a glider, and a front door with bright-yellow trim. Down the street, there's a couple with five adopted children whose parents were addicts. Across the street, a woman named Melissa lives with her elderly father and her youngest sister's two little boys. Their mother was a heroin addict, and lost custody of the kids two years ago. At the time, Melissa, who is a medical technician at a nursing home, was working and living in Maryland'--she is divorced, and her own children are grown. She rushed home to Martinsburg to care for her nephews, whom I'll call Cody and Aiden.
One afternoon, I sat talking with Melissa and Christine on Christine's front porch, while Jacey and the boys ran around in a ragged, laughing pack. Christine served some brownies that she had baked. Melissa recalled that, when her sister lost custody, her nephews' caseworker told her that Aiden, who was then a toddler, would be quickly adopted, but that eight-year-old Cody, who bore more obvious signs of trauma, would probably languish in foster care. Melissa said that she couldn't stand to see them separated. ''I was, like, 'What choice do I have?' '' she said.
Christine patted her on the knee. ''Good girl,'' she said.
Jacey kept a close eye on Aiden, who kept wandering over to the neighbor's yard, where there was a new Chihuahua puppy.
Christine said, ''The sad thing about it is there are so many of these kids.''
''Yes!'' Melissa said. ''Aiden's pre-K teacher told me forty per cent of the kids in her class are being raised by somebody other than a parent.''
''That means forty per cent have been found out,'' Christine said. ''Who knows what's going on with the other parents?''
Jacey is a bright, curious kid, with pearly pink glasses and a sprinkling of freckles. The first time I met her, she catalogued her accomplishments in gymnastics. ''I can do a handstand, a round-off, I'm working on my back handspring,'' she said. ''I can do a front flip. I want to try a back flip, but it's kinda hard. I still have a lot more ahead of me.''
Christine has been honest with Jacey about Jason's addiction, in the hope that it will keep her from ending up on a similar path. But it would be hard to keep the truth from Jacey: she remembers finding her father's needles, and she remembers him getting high. He often dropped into a state of suspended animation'--still standing, bent over at the waist, head dangling near his knees. Jacey told me that she and Liam used to think it was a game: ''It was, like, he's dead, but he's also alive. You could tap on him and talk to him'--he'd just be snoring there. But you could also feel that he was breathing. We would put our hands up to his nose and we could feel the air coming in and out.''
Last fall, Jacey won a statewide poster-making contest, called ''Kids Kick Opioids,'' that was sponsored by the West Virginia attorney general's office. Jacey's poster'--one of two thousand entries'--included a photograph of Jason, in a backward baseball cap and baggy shorts, holding a grinning Liam on one hip and Jacey on the other. She had written a little passage about how much she missed him after he'd ''died from taking drugs,'' and how she wanted to ''hug and kiss him every day.'' She wrote, ''It is very sad when kids don't have their daddy to play with.''
Christine said of the poster, ''I think Jason would have wanted it. Jason wanted so badly for people not to follow him.''
At one point, Jacey was lying on the porch floor, drawing a rainbow with some colored pencils, when Christine said she thought that it was wrong to send opioid addicts to prison.
Jacey piped up. ''Yeah, but they should take them away from their home town. Also, get them help.''
''Yes,'' Christine said. ''Long-term help. A month is not enough.''
''But take them away from, say, Martinsburg,'' Jacey said, looking down at her rainbow. ''Maybe take them across the world.''
Recently, Martinsburg has begun to treat the heroin crisis more openly as a public-health problem. The police chief, a Chicago transplant named Maurice Richards, had devised a progressive-sounding plan called the Martinsburg Initiative, which would direct support services toward children who appeared to be at risk for addiction, because their families were struggling socially or emotionally. In December, Tina Stride and several other local citizens stood up at a zoning meeting to proclaim the need for a detox center. They countered several residents who testified that such a center would bring more addicts, and more heroin, to their neighborhoods. ''I'm here to say that's already here,'' a woman in favor of the proposal said. ''It's in your neighbor's house, in the bathroom at Wendy's, in our schools.'' She added, ''We're talking about making America great again? Well, it starts here.''
That night, the Board of Zoning Appeals voted to allow a detox center, run by Peter Callahan, the psychotherapist, to occupy an unused commercial building in town. People in the hearing room cheered and cried and hugged one another. The facility will have only sixteen beds and won't be ready for patients until December, but the Hope Dealer women were thrilled about it. Now they wouldn't have to drive halfway across the state every time an addict called them up.
John Aldis, who was sitting next to me during the vote, breathed a sigh of relief. He said later, ''It's like that Winston Churchill quote: 'This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.' ''
This spring, Berkeley County started its first needle-exchange program, and other efforts are being made to help addicts survive. The new app that first responders are using to document overdoses allows them to input how many times a patient is given Narcan; when multiple doses are required, the heroin tends to be adulterated with strong synthetics. Such data can help the health department and law enforcement track dangerous batches of drugs, and help warn addicts.
Some Martinsburg residents who had been skeptical of medication-assisted treatment told me that they were coming around to the idea. A few cited the Surgeon General's report on substance abuse, released in November, which encouraged the expansion of such treatment, noting that studies have repeatedly demonstrated its efficacy in ''reducing illicit drug use and overdose deaths.'' In Berkeley County, it felt like a turning point, though the Trump Administration was likely to resist such approaches. Tom Price, the new Secretary of Health and Human Services, has dismissed medication-assisted treatment as ''substituting one opioid for another.'' It was also unclear how most addicts would pay for treatment if the Affordable Care Act was repealed.
Martinsburg residents, meanwhile, tried to take heart from small breakthroughs. Angel Holt, the mother who'd overdosed at the softball practice, told me that she and her boyfriend had stayed clean since that day, and she was hoping to regain custody of her children. She'd been helped by the kindness of an older couple, Karen and Ed Schildt, who lived in Thurmont, Maryland. A year earlier, the Schildts had lost their twenty-five-year-old son, Chris, to a heroin overdose. They were deeply religious, and when they heard what happened to Angel Holt and Christopher Schildt they decided to reach out to them. The fact that their son had the same name as Holt's boyfriend surely meant that God had put the couple in their path. Karen texted Holt words of encouragement almost daily.
In February, I spent an afternoon with Shawn Valentine, the nonprofit program director , who introduced me to Shelby, her twenty-five-year-old daughter. Shelby had become addicted to opioids at twenty-one, when she was depressed and waitressing at a Waffle House. Her co-workers always seemed to know how to get their hands on pills. When the meds got too expensive, Shelby turned to heroin.
Shelby, Valentine, and I were sitting in Valentine's kitchen, along with Shelby's sweet fifteen-year-old brother, Patrick. Shelby said, ''People don't realize what the brain goes through when you're addicted'--it's like a mental shutdown. Everything is gray. You have these blinders on.'' As she described it, the constant hunt for heroin imposed a kind of order on life's confounding open-endedness. Addiction told you what every day was for, when otherwise you might not have known.
For close to a year, Shelby had been in a program in which she put a dissolvable strip of Suboxone on her tongue every day, and attended group and individual therapy. (The word ''assisted'' in ''medication-assisted treatment'' indicates the primacy of the need for recovering addicts to figure out why they are drawn to opioids.) Shelby said that Suboxone helped curb her craving for heroin, without sedating her. ''There are triggers,'' she said. ''But the urge to run a hundred yards down the street and try to find my ex-dealer and pay him, then shove a used rig in my arm real quick? That's gone.''
She can now be trusted not to sell treasured things for drug money: her little brother's video-game console, her mom's four-leaf-clover necklace. Her long auburn hair, which she used to wash and comb so seldom that her mother once spent four hours trying to untangle it, is now silky and soft.
In tight-knit Appalachian towns, heroin has become a social contagion. Peter Callahan, a psychotherapist in Martinsburg, said, ''If the lady next door is using, and so are other neighbors, and people in your family are, too, the odds are good that you're going to join in.'' Photograph by Eugene Richards for The New Yorker Valentine told me that, if Shelby had to be on Suboxone all her life, ''I'm absolutely on board with that.'' She turned to Shelby. ''Whatever it takes for you to be a healthy, productive human being.''
Recently, Shelby's mother told her, ''O.K., I'll let you take the truck without me, to take your brother to the movies.'' Shelby recalled, ''I was almost, like, 'Pinch me, wake me up'--this can't be true.' Because without her truck there's no working. That's how she makes her living. She said, 'Here's a piece of trust. Don't throw it away.' ''
Shelby and her brother drove to the mall and saw a horror movie. It was not a very good one, they agreed, but it didn't matter. They headed home in the dark, and the moment they got there Shelby placed the keys to the truck in her mother's hand. '...
Shawn Valentine's title has been updated to clarify her role in the foster-care sector.
Submitting . . .