July 6, 2021

There’s a great deal of pain in Huntington, West Virginia. For decades, the city of 45,000 people on the banks of the Ohio river has experienced the kind of economic decline typical of this corner of America, where the coal seams of Appalachia meet the Midwestern rust belt. Poor, shrinking and home to blue-collar workers who battle chronic pain and ill health, Huntington has proved as susceptible as anywhere to America’s lethal opioid crisis. So susceptible, in fact, that the city’s own leadership describes Huntington as “Ground Zero” for the opioid epidemic.

The past pandemic year has brought with it a wave of viral metaphors to describe various social problems: economic inequality and racial injustice are clumsily referred to as America’s “other pandemics”, while police violence is frequently characterised as an “epidemic”. In many cases, such language is overwrought and overblown.

But when it comes to the lethal problem of America’s opioid addiction, “epidemic” is no misnomer. According to the Center for Disease Control, almost half a million Americans have died of opioid overdoses since the late Nineties, making this the deadliest drug crisis in the country’s history. By the end of the last decade, overdoses were America’s leading cause of accidental death — and nowhere is this more clear than in Huntington.

Yet the relationship between the pandemic and the opioid epidemic is more than merely analogous. In a tragic demonstration of the inescapable trade-offs of fighting a plague, Covid-19 and the steps taken to slow its spread have undone much of the hard-earned progress in the fight against opioid addiction. According to preliminary CDC data, more than 90,000 Americans died of drug overdose — the vast majority because of opioids — in the 12 months leading to November 2020: a 30% increase on the previous 12 months, and the highest annual overdose figure ever.

While opioids have wrought national devastation, overdose rates were higher in West Virginia than anywhere else in the country last year. Huntington and surrounding Cabell County had the highest rate in the state, with 163 deaths per 100,000 people — the overwhelming majority of them from Fentanyl, a synthetic opioid 100 times stronger than morphine, which can be lethal in doses as small as two milligrams. In Cabell County, Covid-19 and drug overdoses claimed roughly the same number of lives last year.

Pastor Steven Little doesn’t need to see the numbers to understand the magnitude of Huntington’s spike last year. As a volunteer on the city’s Quick Response Team, his weekly schedule reflects the fluctuations of drug abuse in the area. QRT was founded in 2017 and aims to provide follow-up visits to anyone who calls the emergency services for a drug overdose within 72 hours. The busier the team, Little explains, the worse things are.

Comprising a paramedic, a recovery coach, an off-duty police officer and faith leaders such as Little, QRT aims to deliver both long-term solutions, by encouraging treatment, and short-term emergency measures, by offering everyone they meet a dose of Narcan — the emergency treatment for an opioid overdose — and training in how it is administered.

Little, who has been sober for 11 years after an opioid addiction he developed as a teenager in neighbouring Kentucky, says he thinks of the community’s response to the opioid epidemic — a patchwork of addiction clinics, churches, local government and hospitals — as “like a net”: “The more strings we have, the stronger the net and the fewer people fall through the gaps.” And so the effects of the pandemic were soon obvious. “We’ve removed the social structures and support system around addicts because of the pandemic,” he says when I meet him at his church’s low-key location, a converted shop space in downtown Huntington. “Isolation is the opposite of what you need for recovery.”

The Huntington Addiction Wellness Center, a recovery centre a few blocks away, is another string in that netting. Charles Ward, HAWC’s assistant director and a recovering addict who has been clean from heroin and methamphetamine for more than three years, says that “the worst thing an addict can do is be alone in his head, something that the pandemic forced us to do.” Ward says he has “lost a lot of people this year. I can name five or six friends that I’ve lost”.

It took “four or five months,” says Katie Keeney, a colleague of Ward’s at HAWC, until the effects of the pandemic on addiction in Huntington started to be felt: “That’s when we started seeing everyone falling off. Fellowship is a huge part of recovery, and everyone was stuck at home or on camera.” It wasn’t just recently recovered addicts, says Keeney, but “old-timers, people with years and years of sobriety. And we’re still seeing the residual effects of the pandemic.”

Outside another recovery centre, Sara (not her real name) takes a drag on a cigarette and explains to me how things unraveled during the pandemic. Furloughed from work, she lost the routine around which she had built her recovery from addiction. “By the end of the year, I wasn’t just back where I started,” she says. “But worse.”

Little says that not only is the isolation of quarantine a pandemic a problem, but we’ve given “people stuck in the madness a bunch of money”, referring to the federal stimulus checks given to Americans during the pandemic. He recounts the story of a a mother of six who “got all this money and blew it and overdosed and died… That’s not a knock on the stimulus, people need that.”

Everyone I speak to in Huntington agrees that remote support is no substitute for the face-to-face help offered before the pandemic, which was suspended for crucial weeks. If there’s any silver lining, Little says that it’s that “the pandemic has highlighted the great need for the structures and support systems to fight the epidemic”.

Arguably, however, the most troubling aspect of the opioid epidemic is not how much progress has been lost thanks to the pandemic, but how little had been made in the first place. Prior to 2020, overdose deaths from opioids peaked in 2017. But this crunch point had been a long time coming. Purdue Pharma, the manufacturer of OxyContin, were worried about bad publicity surrounding addiction to their blockbuster painkiller within a few years of the drug’s launch in 1996. In other words, the opioid crisis was two decades old before the numbers even started to move in the right direction. And while overdose deaths declined after 2017, the falls were modest; the data also points to an uptick in overdoses in late 2019, suggesting that the pandemic cannot fully explain the failure to make continued progress.

Huntington’s latest step in the fight against opioid addiction is a lawsuit against the three biggest drug distributors in America — McKesson, Amerisource Begern and Cardinal Health — which it alleges “wholly ignored their legal obligations” by “shipping massive quantities of drugs to distributors, pharmacies, and dispensaries without performing any checks — with devastating consequences for America”.

The trial, which is ongoing in a courtroom in Charleston, the state capital, has the potential to be a major turning point, and not just locally. In the overwhelming majority of lawsuits relating to opioid addiction, companies have managed to reach out of court settlements. And so Huntington and Cabell County’s decision to go to trial is a rare courtroom test of the claim that the pharmaceutical firms who flooded neighbourhoods with addictive painkillers are liable for the damage done both by those pills and by their knock on effects, including the spread of illegal opioids like heroin and fentanyl.

Whatever its outcome, the trial has helped provide a fuller picture of the crisis. According to Craig McCann, a data consultant called as witness, 110 million doses of hydrocodone and oxycodone were shipped to Cabell County and Huntington between 2006 and 2014. Thomas McGuire, a Harvard University economist who testified in the trial last month, estimated that the harm by prescription opioids to Cabell County was worth $3.3 billion. The city and county are seeking $2 billion to help fight addiction.

And these aren’t the only stark metrics by which the epidemic can be measured. According to the West Virginia Department of Health and Human Services, five in every 100 babies born in West Virginia in 2017 suffered from Neonatal Abstinence Syndrome, a condition newborns suffer after the sudden discontinuation of exposure to substances used by their mothers that can have lasting consequences.

Meanwhile, the firms on trial argue that they are not responsible for the lethal cocktail of poor physical health and socioeconomic decline that made residents in this corner of West Virginia so susceptible to opioid addiction. They also point the finger at the doctors — some nefarious, others naive — who were prescribing the painkillers so readily, and the US Drug Enforcement Agency, who were slow to identify the problem.

Of course, the temptation of opiates is nothing new. As Patrick Radden Keefe recounts in his recent book about the Sackler family behind Purdue, Empire of Pain, the history of opiates is terrifyingly cyclical. Morphine was prescribed with great enthusiasm after the American Civil War. But relieving the pain of battlefield wounds came at a high price with an estimated one in four Americans addicted to the drug by the end of the 19th century. Around the same time, the German pharmaceutical firm Bayer marketed a new opiate, heroin, as a less addictive substitute to morphine. In fact, it was far more powerful than morphine and just as addictive.

Almost a century later, the Sackler family would make similar claims about Oxycontin, but again the link between opiates’ pain-killing abilities and habit-forming tendencies proved seemingly inescapable. Indeed, back in Huntington, the pandemic’s impact on overdoses is merely a reminder that the opioid epidemic hasn’t made an unwelcome return; it never ended.

According to the shallow concerns of America’s political cycle, “left behind” America had its moment half a decade ago. Trump’s 2016 win brought fresh attention to the problems of white working-class Appalachia; the rust belt was suddenly central to politics and as Hillbilly Elegy flew off the shelves, every pundit imposed their own priors on to the story of decline.

Eventually, however, that story became old news. America’s elites moved on to other issues, racial equity foremost among them. But Huntington, and places like it, are still there. And still struggling against the same epidemic they have been fighting for almost a quarter of a century.