Additional reporting was provided by Lisa Bernard-Kuhn of WCPO.com and Zach Toombs of Newsy.
In Cincinnati, a pioneering doctor worked nine years just to start a simple service that research has shown can prevent disease and save lives.
In Boone County, Kentucky, elected officials listened to hours of public testimony about the rise of diseases linked to the heroin epidemic, and then failed to act.
Across the country, other communities are responding to the heroin crisis in radically different ways.
Seattle officials have approved sites where heroin users can inject drugs under the watch of people trained and equipped to respond to overdoses. They would be the first such sites in the U.S.
Two hours to Seattle’s north, the Canadian province of British Columbia has allowed such facilities, called supervised injection sites, since 2003.
Health officials there have approved more than two dozen of them just in the last few months in response to a recent spike in overdose deaths. Now, officials in its largest city, Vancouver, are going even farther. They are permitting heroin to be prescribed by doctors in the hope that safer, controlled doses will keep addicts from overdosing and perhaps wean them off the drug.
As deaths from heroin surge here and across the country, communities are searching for answers. We talked to health officials, government leaders and recovering addicts in Cincinnati, Northern Kentucky, Seattle and Vancouver about the drug crisis and their responses to it. We reported the story in collaboration with the online video company Newsy. You can watch their short documentary here:
Almost everyone we talked to agreed that a truly effective response would be a comprehensive, coordinated system of addiction treatment and recovery run by doctors and other health care professionals. But that is so far off and so expensive that no one is even pursuing it on a large scale, either here or there.
What they’re debating instead is simply how to keep addicted people alive for another day. One more day brings the hope that they will seek, find and accept the treatment they need.
But even keeping them alive is a source of controversy, as communities around the country debate fundamentally different approaches.
Here’s their stories, told through the some of the people on the front lines.
CINCINNATI -- Twelve years ago, Dr. Judith Feinberg saw what was coming. Feinberg, 71, has worked for 35 years researching infectious diseases, and was at the forefront of AIDS research during her 21 years at the University of Cincinnati.
In 2005, she was in the middle of a two-week stint at University Hospital when she noticed an unusual number of heart infection cases. Four cases of endocarditis, a bacterial infection that can eat a hole in a heart valve, and is linked to injecting drugs with dirty needles.
“I said to myself, ‘There’s a heroin problem here,’” she said.
A previous assignment at Johns Hopkins Medical Center in Baltimore, which had experienced what she called “a 20th century heroin epidemic,” attuned her to the signs.
“I knew what would happen,” she said.
She started recruiting like-minded people to make the case that Cincinnati should start a needle exchange.
“When you share needles, you share infectious diseases,” she said.
There is no more efficient way to share a virus than through the tip of a needle. And many of those addicted to heroin inject it with needles already used by someone who’s infected. A steady supply of clean ones is hard to get unless you're a doctor or nurse, and even then, their distribution is restricted.
By 2010, she had enough of a plan to approach the Cincinnati Health Department for its OK. The answer: “We need more information.”
Feinberg, an outspoken and passionate advocate, went back in 2012, and this time got the health department to declare an emergency, which gave her the authority to start the needle exchange. But the mayor, the police and city council weren’t signing on, and the project stalled again.
By 2013 however, the number of overdoses was rapidly increasing and the heroin problem was front-page news. By 2014, Dr. Feinberg had the agreements she needed, nine years after she first noticed the spike in heart infections.
“I think of those nine years with pain,” she said. “I think of all the infections we could have averted.”
NEWPORT, Ky. – Infections of the hepatitis C virus are steadily rising in Northern Kentucky, a spike blamed on the use of dirty needles to inject heroin. But none of the big three Northern Kentucky counties operates a needle exchange, despite health department efforts to start them.
One of the counties, Campbell, also shows up on a U.S. Centers for Disease Control and Prevention map of 220 U.S. counties vulnerable to the next outbreak of the AIDS virus. CDC researchers put the map together after the 2016 outbreak of HIV in rural Scott County, Ind. that was blamed on addicts sharing needles.
Although Campbell County commissioners voted to allow a needle exchange, state law requires a city within the county to also approve it and that has not happened.
County Commissioner Charlie Coleman was the lone Campbell County no vote.
“It’s enabling,” he said. “It’s not just a needle. There’s a kit given with it. And then they have a tourniquet. If that’s not enabling, I don’t know what enabling is.”
Coleman – and others – even deny health department statistics that show a rapid, long-term increase in hepatitis C cases in Northern Kentucky. Hepatitis C cases quadrupled in Northern Kentucky from 2010 to 2016, according to Northern Kentucky Health Department statistics.
“There may be more documented cases, but are they testing more people?” he asks.
There could be other reasons for the increases in disease, Coleman says. Unprotected sex with multiple partners, even tattoos. “There are other ways hep c and HIV are spread,” he says. “You can’t blame it all on a dirty needle.”
He even questions the cause of the Scott County outbreak, which the CDC has blamed on drug users sharing needles.
“Those people admitted to unprotected sex and to having sex with men,” he says. “It’s not just that they’re using a needle.”
And he denies the often-stated larger purpose of needle exchanges: that they can be portals to treatment, where sympathetic, informed counselors can guide addicts into recovery from addiction.
“I understand that,” he says. “But I don’t believe it.”
Meanwhile, the three most populous counties in Northern Kentucky go without a syringe exchange as the number of new hepatitis C cases reached 1,295 in 2016. The number of HIV cases has held steady, but health officials are concerned that those too will increase as the drug epidemic continues.
"The problem is continuing to grow," said Dr. Lynne Saddler, director of the Northern Kentucky Health Department. "We as a community have not gotten out in front of it yet in spite of all our best efforts."
The nearest exchange is the Cincinnati mobile van, or a 40-mile drive to Grant County or a 30-mile drive to Pendleton County, where the Northern Kentucky Health Department has been successful in opening needle exchanges approved by those communities. Kentucky lawmakers set up many hoops to jump through before a syringe exchange can be legally started.
"There are nine approvals we need to get in order to operate in each one of our counties," Saddler said.
That's a far cry from the Pacific coast of Canada, where a public health emergency has been declared over the heroin crisis and needle exchanges have been accepted for decades. That community is trying ever more radical methods to save lives.
VANCOUVER, British Columbia -- The Downtown Eastside neighborhood of Vancouver has been called “the largest open-air drug market in North America.”
That’s probably true.
Street people, dirty and sweaty from living on the concrete, inhabit the empty doorways and spill out on the sidewalks, stretching out on grimy blankets and backpacks.
Blue plastic bottles that held sterile water used to dissolve heroin litter the sidewalks and streets. A young woman sits on the step of a doorway preparing a needle to inject herself.
It’s estimated that 4,500 active drug users hang out in the neighborhood on any given day.
It’s a chaotic, even frightening scene.
On East Hastings Street, in the middle of the chaos, is a storefront office called Insite. Inside, a man sleeps on the floor in the anteroom. Another changes clothes out of a suitcase.
Used needles can be found throughout the streets of downtown Vancouver. Emily Maxwell | WCPO
This is a facility where drug users can bring their heroin or other drug of choice and inject it at one of more than a dozen booths manned by medical personnel. Clean “gear” -- syringes, cookers, filters, water and tourniquets – is supplied.
Two men in their late 20s, one with his dog, wait to be called so they can inject heroin, or maybe meth, under the supervision of nurses ready with the overdose antidote naloxone if needed.
Insite is exempt from prosecution under Canada’s drug laws. It is the first supervised injection site in North America and it has been operating for 14 years.
To many in the U.S., this is an almost unthinkable idea – permitting drug use in a controlled, supervised, publicly funded setting. In Greater Cincinnati and Northern Kentucky, even needle exchanges, which have been permitted in Vancouver for nearly 30 years, are thought by many to encourage and enable drug use.
But in Vancouver’s public health community, it’s about saving lives.
“You need to keep them alive and keep them as healthy as you can until they can get help,” said Dr. Mark Lysyshyn. “If somebody overdoses and dies, they can’t get treatment.”
Lysyshyn is the medical officer at Vancouver Coastal Health, the public health agency that runs the Hastings Street site and others in Vancouver. He’s been educated and trained at the top universities in Canada and the U.S. and has worked on the H1N1 pandemic and on responses to bioterrorism.
In the public health arena, where he’s worked for 10 years, he says nothing comes close to the heroin and opioid epidemic.
“It’s definitely the most urgent of the issues,” he said. “It’s one that is changing most rapidly and worsening the fastest.”
In Vancouver, as in Greater Cincinnati and Northern Kentucky, heroin and other drugs are being adulterated with fentanyl, drastically increasing their danger to users.
“Our overdose rates over the last five years have just increased astronomically,” he said.
So Lysyshyn wants to expand the number of supervised injection sites.
In April 2016, the British Columbia Health Ministry declared a public health emergency because of the the rising death toll from heroin and fentanyl. That permitted the provincial government to quickly set up 25 “overdose prevention sites” throughout that province, including five in Vancouver. These are similar to supervised injection sites, but are housed in trailers, or even tents, and don’t have quite the same level of medical staffing.
Lysyshyn showed us one down a trash-strewn alley in the Downtown Eastside. As people loitered in the alley, a security guard opened a gate and let us inside a small outdoor waiting area. At a picnic table, a client smoked something out of an encrusted glass pipe. When the door to the metal trailer swung open, a woman could be seen searching for a vein with needle in hand.
In 2016, just at the Insite facility, more than 8,000 used its services, and the staff rescued someone from an overdose 1,781 times, Vancouver Coastal Health reports. No deaths have been reported at them.
“All of these sites are working,” Lysyshyn says. “Nobody’s dying at them.”
And as long as they are alive, there is hope for a better life.
SEATTLE -- Thea Oliphant-Wells started injecting heroin as a teenager in Seattle. That was the start of what she says were “many years of problematic, chaotic drug use.”
Physical and emotional abuse as a child led her to heroin, she says. “It was just my way of coping,” she says. “Heroin is a fabulous pain killer. People have very deep spiritual pain and that was a big factor in my youth.”
But she survived, both the trauma of her childhood and the years of hard drugs.
In a life-changing turnaround, she attended college, earned a master’s degree and is now a licensed social worker, helping people who are in the same lost place she was years ago.
She credits the people who worked at the Robert Clewis Center in downtown Seattle, a health center that runs a needle exchange. That is where she found compassion, encouragement and understanding, qualities that, as a heroin addict, she found in short supply on the outside.
“It changed my life,” she said. “That’s what started my recovery – people who saw me as me and helped me think about what my goals were beyond just surviving for the day.”
“I had people who were not judging me for my use and they were very respectful of me as a person and were very compassionate and caring,” she said. “And that’s really where my recovery began. I started to recover a sense of self that was worthy of something different or better or healthier.”
Too often, surviving is the main goal of someone with a serious drug abuse disorder. Holding a job, caring for children, connecting with family – those goals come far behind scoring dope.
“There were times when I was functioning and could hold a job,” she says. “And there were definitely times when I was not functioning, and sleeping outside, homeless and unkept.”
“Some days I would look at myself in the mirror and not even recognize who I was. Because I was really losing myself.”
She tried detox and inpatient treatment, but kept returning to the drugs.
Then a beating, along with the years of drug abuse, put her in a hospital for a month.
Her care there included a transition plan for when she was released.
“I had nurses who were phenomenal and who were willing to go the extra mile to make sure I had a safe plan for discharge from the hospital,” she said.
She was able to go home to her family, reconnect with her mother, and get medication to wean her off of heroin.
After earning her master’s degree, she was hired as a social worker at the Robert Clewis Center, where her recovery began. She has been sober for 11 years.
One life saved.
SEATTLE -- At 6-foot, 3-inches tall, with close-cropped hair, chiseled features and a booming voice, John Urquhart is a commanding presence, the very image of a law-and-order guy.
As the sheriff of King County, Washington, he is the chief law enforcement officer in a community of nearly 2 million people, the county home to Seattle, where drug use and homelessness are rampant.
Seattle and King County are about to begin an experiment that Vancouver started 14 years ago: give drug addicted people a place where they can inject heroin or their drug of choice in a supervised, safe space without being arrested.
The sheriff is all for it.
“I was a street soldier in the war on drugs,” says Urquhart, a 41-year veteran of law enforcement and a former street-level narcotics officer. “The war on drugs didn’t work. It’s been a failure.”
Like many who have witnessed the carnage of the heroin epidemic, he’s desperate for answers and ready to try new approaches.
“We have people literally dying in doorways half a block from my office, if not right in front of my office in downtown Seattle,” he says. “We have needles everywhere. We have a heroin epidemic.”
“This gives them someplace to go where it’s clean, it’s safe and they can be revived if they die. Because that’s going to happen, no question about it.”
Stacks of syringes found in Jose Rizal Park in downtown Seattle. Emily Maxwell | WCPO
But sheriff, isn’t using heroin illegal?
“Until we stop treating addiction as a police problem and start treating it as a health problem, we’re never going to make any headway whatsoever,” he replies.
His deputies are under orders not to arrest anyone going in or out of a needle exchange.
But safe sites are not the answer, he says. They are merely a way to slow the rising death toll, and keep users alive for another day, a day that they might seek treatment.
“What’s the solution?” he asks. “The clear solution is treatment – treatment on demand. Until that happens, perhaps this is something we can try to see if we can keep people from dying.”
Even the toughest, hard-core addict can change. As long as they're alive.
VANCOUVER, British Columbia -- Joseph Patrick Walter Smith is a 55-year-old, HIV-infected, ex-con who has weathered years of heavy drug use and prison.
Now reformed, he is back on the gritty streets of Downtown Eastside Vancouver. But this time, he’s helping others who are in the same desperate place he was years ago.
JP, as he’s known, was a self-described career criminal. “I was really good at what I did,” he says. “I was a burglar, a high-end burglar. Corporations and stuff like that.”
He was also a hard-core drug abuser, mostly cocaine. “I’d have a kilo and whittle away at a kilo until it was gone,” he said. “When it was gone … back to work.”
He contracted hepatitis C, and was infected with it for 25 years, dropping to 96 pounds. He believes he contracted the AIDS virus while rummaging through a trash can on the street and piercing his thumb with a used needle.
He started hanging around the Vancouver Infectious Disease Centre, a downtown clinic that serves the down and out, three-quarters of whom are infected with hepatitis C, 15 percent with the AIDS virus. That’s where he met Dr. Brian Conway, who has run VIDC for 20 years.
“He saved my life,” Smith says. “He gave me a purpose.”
Conway saw something in him and recruited him to do street outreach in the Downtown Eastside.
“This guy was street-entrenched,” Conway says. “Detached. He didn’t give a darn about anything.”
Now, JP heads out on the center’s weekly pop-up clinics in the Eastside, where the staff brings doughnuts and coffee to entice the Eastside denizens to come in for a health screening and, if needed, a referral to the clinic.
One life saved. Saved, so he can save others. A success in the midst of so much failure.
And that’s why Conway, a physician, is OK with tactics such as supervised heroin injection sites. As long as someone is alive, there is hope.
“If the only intervention I have is to watch you shoot up and make sure you don’t die, I’ll take it,” he says.
The real answer, he says, is better, more accessible treatment. But in Vancouver, as in Cincinnati and Northern Kentucky, treatment is inadequate to handle this epidemic.
“It is woefully and unspeakably underfunded,” Conway says. “It’s not even close to meeting appropriate needs.”
Drug treatment, he says, must be easy to find, easy to get in and easy to afford.
“We can’t tell them it’s going to be two weeks and here’s the 30-page document you have to fill out,” he says. “Here’s a cup of coffee and a chair and a pen and good luck. You have to make it easy.”
Right now, it's anything but easy. But sometimes, survivors still find their way out.
Kaitlynn Hornsby began abusing pain pills at the age of 15, “escaping from reality,” as she says. Her pregnancy at that age ended in the loss of the baby. The baby’s father was already abusing pain pills, and that was how her drug journey began.
Now at 23, she has been sober for 18 months, studies social work at Cincinnati State, works part-time at Talbert House and parents her 3-year-old daughter.
“Life is great,” she says.
She’s fortunate to have survived.
Like so many others, her pain pill habit turned into a heroin habit. She lived in a South Fairmount house with her then-boyfriend’s family. They were heroin users.
She was tricked into using it for the first time. She was handed a white powder to snort and told it was a crushed pain pill. It was heroin, a drug she once considered off limits. The next day, when told what she had done, “I was like, ‘Oh, I’ve already done it, I can do it again.’”
Her descent into the pit of drug addiction deepened.
“I lived to get high and that was all I was living for,” she says.
She shared needles with other users. “When you’re in that state of using drugs and you need something, you’re going to get it one way or another,” she says.
Needle sharing led to an abscess in her arm that became so bad she could barely move her fingers.
Hospitalized for it, her treatment there reflected how health care institutions often treat the complicated problems of addiction.
When she complained of heart pain, staff suggested it was merely “anxiety.” It turned out to be endocarditis, an infection of the inner lining of the heart, which can be caused by sharing needles.
Cut off from heroin in the hospital, she began to withdraw. Hospital staff, she says, did not help ease her suffering. “They did nothing for me,” she says.
So she had friends deliver heroin to her room.
Already on a waiting list for drug treatment, she got the call while in the hospital. She had to be there the next day or lose her spot on the list. “I signed myself out (of the hospital) and went and got help, because I needed help,” she says.
She’s pieced her life back together since then. Custody of her daughter, college, work.
“I have money in my pocket right now,” she says with some amazement. “That’s crazy. I never kept a dollar in my pocket before.”
She would have used the Cincinnati needle exchange but she didn’t know about it. “They have somebody there to talk to who probably understands the struggle they’re going through,” she says. “It needs to get done.”
HOW TO SAVE A LIFE?
Although they live thousands of miles apart, Kaitlynn, JP and Thea share a similar story. The details are quite different, but each survived years of drug abuse and changed because they stayed alive long enough to find someone, some way, to help create a new life.
The drug epidemic is not going away anytime soon, unfortunately. Some experts predict years of overdoses and fatalities. Many more people will, undoubtedly, die. As communities here and across the country try to respond, maybe the question they should try to answer is: How can we save one life?