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The center of Logan has shifted to West Logan, four miles but a world away from downtown. Downtown, there's not much besides a few dollar stores and a bunch of boarded-up buildings. This type of migration from the downtown to the strip mall is common.

The Hard Times, Struggles, and Hopes of Addicts in Appalachia

Juliet Escoria

Poverty and opiate addiction have devastated small towns in West Virginia. What can be done to help people take back their lives?

The center of Logan has shifted to West Logan, four miles but a world away from downtown. Downtown, there's not much besides a few dollar stores and a bunch of boarded-up buildings. This type of migration from the downtown to the strip mall is common.

All photographs by Stacy Kranitz

The opiate epidemic in Beckley, West Virginia, is something that reveals itself quickly and casually—on the side of the road, in the parking lot at Walmart, in line at Taco Bell. Burnt bits of aluminum foil, paper packets that once held heroin. People nodding out, buying drugs on playgrounds, smoking heroin on the side of a busy road. It's worse on hot days, immediately after snowstorms, and especially on the first of the month, when paychecks and government benefits come through.

I moved here two years ago, after having spent my entire adult life in either Southern California or New York City. Beckley, with a population of 20,000, seemed impossibly small and foreign to me. I was aware of the drug problem before I moved here, thanks to Oxycontin's nickname of "hillbilly heroin" and movies like Oxyana, and like just about anything else involving drugs, this was an aspect of West Virginia that both attracted and repelled me.

I got sober seven years ago, after spending a dozen years blunted by alcohol and drugs. I liked getting high for all the usual reasons—it distracted and numbed me, and also because drugs are fun. I found a special love in pills, though. With street drugs, you never know exactly what you're going to get, but there is something godlike with pills. The high is as easy and predictable as a light switch.

But then of course came the point where the high was no longer high but just normal, and then my health began to fail, and every day I woke up scared and sore and miserable. In 2009, I was set to go to a grad school program, a dream of mine, and I wanted to be happy, but instead I was just afraid: that I was going to die, that I was going to blow it. So I got clean. It was excruciating at first, and then merely difficult, but eventually it became an easier, better way of life. There are things I miss about getting high, but mostly it was just sad and exhausting.

Read more from our series on Appalachia.

While Beckley may seem bleak and small to an outsider, it's actually one of the more prosperous towns in the southern part of the state, a hub where people go to buy groceries, attend college, and get healthcare. As a state, West Virginia has the highest rates of overdose deaths in the US. You can find anecdotal and statistical evidence of the damage drugs have done here everywhere you go, a seemingly inevitable consequence of the poverty and isolation that so much of the Appalachian region has suffered. If the drug problem in Beckley made itself so clear so quickly to me, I was curious what it looks like to those more entangled in the state.

So photographer Stacy Kranitz and I headed to Logan, two hours west of Beckley. The downtown parts of Logan are beautiful: historic red brick buildings nestled between hills and a river, adorned with signs from the mid-20th century, when the population was at its peak. The colonial-style houses are more often than not dilapidated or vacant—the population of the county has been halved in the past 60 years. And while Logan County used to boast about its resident millionaires, it has since become one of the poorer counties in an already poor state.

Stratton Street, one block away from Main Street, looks promising at first, with a coffee shop and a steakhouse. But if you walk a few blocks west, the sights become increasingly dismal. There's a run-down Dollar General, with people hanging out front who clearly have no better place to be. The houses give way to apartment buildings, still beautiful, but now the bricks are crumbling and the windows are broken and boarded up.

Almost everyone we met lives in poverty or is on government assistance or both, and they all acknowledge that drug use is rampant. They say they feel unsafe, that people don't talk to their neighbors anymore, that you shouldn't be on this street after dark due to the prostitution, robberies, and violence.

Linda and her two teenage daughters share a single washcloth, she says. Still, she is grateful for the apartment because it is clean and not infested with bugs or mice. The rent is $320 a month, which leaves her with only $20 left over from the money she earns at Workforce West Virginia.

Outside an apartment building, we met a woman named Linda* who was obviously high on something—benzodiazepines or opiates or both. There was a flatness to her gaze, a slur to her speech. She was quick to discuss the drug problem—the addicts are terrible, she said, they're ruining the neighborhood—but it was clear she didn't see herself as one of them. Linda wanted to show us her apartment, which she moved into after her recent divorce. There was a thin mattress on the floor where her two teenage daughters sleep. At night, Linda takes the battered armchair. Other than that, the apartment was completely bare.

Linda was enrolled in Workforce West Virginia, which is supposed to help her find a job, but instead seems to have trapped her in a kind of stasis. The classes take up seven hours a day, five days a week; attendance entitles her to $340 a month. This isn't enough to qualify for a housing voucher, so the majority of that money goes to pay her rent, with nothing left over for clothes or furnishings or even food. The resume-building skills she's learning aren't very practical when the available jobs are extremely limited and pay minimum wage.

In the stairwell, we ran into a man named Alan, a friend of Linda who lives across the hall. Alan started to tell us his story—he worked in the mines, but he got into a horrible accident that almost severed his leg. He pulled up his pant leg to show us the scar, and it was massive, eating up his entire thigh.

Alan said he settled his accident with the mine company out of court, something he now regrets. He went through the settlement quickly, and he is now left to survive on $600-a-month disability. He's prescribed Norcos for the injury, but he said he takes them rarely, and always as prescribed, because he's seen too many bad things happen to other people.

When I went home, I tried to fact-check what Alan told me about the mine explosion, but the dates didn't add up. Linda's didn't either—the divorce that put her in the rough spot happened over a year ago, yet she said she had just moved into that building. I don't mean to suggest they were lying; this murky territory is inevitable when it comes to a subject like drugs. The truth becomes something fuzzy and intangible. For me, it meant confusion over cut hours at jobs, and a feeling that no matter where I went, there was someone out to get me. Things like dates and specifics don't seem as important as the reality of Linda and Alan's lives. Maybe Linda isn't the innocent victim of divorce that she portrays herself to be, but that doesn't negate her desperation or pain.

Brian was originally addicted to opioid painkillers, but he switched to heroin while working at a tattoo shop in Huntington. He and his girlfriend moved to Logan to be close to family, but things for them have gotten worse. "It's never been this bad," he said.

By the time we left the building, the sun had gone down, and it was getting dark, so we listened to everyone's advice and headed out. On our way past the Dollar General, we saw a guy with tattoos all over his shaved head and a plastic bracelet around his wrist, the kind you get in a hospital. His name, he told us, was Brian. His newborn son had been hospitalized because he'd been born addicted to Subutex, a.k.a. Suboxone minus the opioid blocker. He and the mother have both been on the medication for years. They had another child a while back, who had been apparently unaffected by her drug use, so the doctors figured it'd be OK for her to stay on it, especially since she'd gone down to the lowest possible dose for the pregnancy.

As he spoke, Brian looked shell-shocked, devastated. He said he didn't want to talk about his baby anymore, but then he'd go right back to talking about him. "I know what it's like," Brian said, about the withdrawal. "It's awful. Your whole body aches. And to know that my baby son is going through that... it just crushes me."

His story begins like so many others—a prescription begetting a downward spiral that swung from pills to heroin. Eventually, he and his girlfriend decided they wanted to get their lives together, so they got on Subutex and moved from heroin-infested Huntington to Logan, where they'd be near her family and away, they hoped, from trouble.

Introduced in 2002 by Reckitt Benckiser, Suboxone was supposed to cure opiate addictions, an antidote to the problems caused by Oxycontin. It's preferred by many health professionals to methadone, partially because it has an antagonist effect that makes it safer than the often deadly methadone, and partially because it is supposed to make its users less sedated. But the Suboxone clinics come with their own host of problems. Besides being expensive—Brian said the pills cost $350 a month—getting the medication can take up a major chunk of the patient's time, as the weekly or monthly appointments can take literally all day. And in West Virginia, a state that received an F from the National Alliance on Mental Illness in its most recent survey from 2009, it can be hard to find the counseling and group therapy recovering addicts are advised to seek out.

Most users prefer Oxycontin, but in recent years, the drug has become expensive and difficult to obtain. Frequently, people crush and then snort Percocet or Lortab (pictured) instead, which is oxycodone or hydrocodone, respectively, mixed with acetaminophen.

Some 45 miles north of Logan sits Huntington, a city right off I-64 that, thanks to its proximity to Cincinnati and Columbus and Detroit, is a gateway for drug trafficking. It's also home to a residential rehab called Recovery Point, which opened its doors in thanks to a private grant and money awarded to the state from a pharmaceutical settlement. It's modeled after the Healing Place, which opened 26 years ago in Louisville; its uniqueness lies in the fact that it's generally run by program graduates rather than doctors, addiction specialists, or social workers.

It is also unique because it addresses what seven-day detoxes, 28-day rehabs, and Suboxone clinics don't—that sobriety isn't about getting off drugs, but about figuring out how to live life without them. Relapses don't happen because someone offers you free drugs on a silver platter. They happen when the dumb shit in life piles up, when you can't find a job or figure out how to feed yourself like a normal human being. They happen because your brain won't stop telling you that you're a piece of shit. Recovery Point considers all of this—ways to cope with job skills, life skills, shame, self-hatred, daily emotions—more than most rehab programs.

The bulletin board at Recovery Point displays the photos of past residents who have since died from their addiction, reminding clients that this is potentially a fatal disease.

As a result, the success rate (meaning the client remains sober for at least one year) is 68 percent, according to the rehab. It's also free for clients, and the operating cost is $25 per day per person, which is a fraction of what it takes to house someone in jail or prison. The program has been so successful that it's expanding: Four Seasons Recovery Center just opened in Bluefield, at the southern tip of the state, and a women's center is slated to open in Charleston, the state capital, this fall.

The state really started focusing on addiction problem in 2012—coalitions were formed, regulations were adopted, and the cause has only picked up steam since then. Most people we spoke with, from police officers to rehab workers to politicians, agreed that things have gotten better in the past couple years, but still the OD rates keep going up, and the new cases of Hepatitis C are multiplying each year. The damage is going to take a lot longer than a couple years to mend.

It's hard to feel pessimistic inside Recovery Point, though. Matt Boggs, the director of development, is a graduate of the program himself, although you would never guess he has a criminal past. He's got the squeaky-clean sheen, white teeth, and the nondescript likability of a business executive. The building is modest—bunk beds to sleep on, Rubbermaid containers in which to store belongings—but clean and comfortable and efficient, a hell of an improvement over a mental hospital or prison.

Derek gives Zach a haircut at Recovery Point. Zach's parents have put him through rehabs and treatment of all kinds before, including a naltrexone implant that prevents the patient from feeling the opiate high and costs thousands of dollars to administer. He ripped the implant out during the drive home, and he still has a scar from it on his stomach. This time, sobriety is something he wants for himself.

In the smoking patio/outdoor gym, we meet Shawn, who looks like what you might imagine when you think of a convicted felon—big, masculine, covered in tattoos. The child of a drug-addicted prostitute, Shawn grew up in the projects in Charleston and started selling drugs at 14. His life is dotted with death—the murder of a friend, a car accident that killed his mother—stints in rehab, and almost ten straight years in prison. What is unexpected is his softness, something he admits is new for him. I see in him something that I have seen in myself during my own recovery—a melting, a thawing, a curious glance at optimism. He told us what it felt like to cry for the first time. He told us what he wants to do with his life now—work with youth who've had lives like his. He told us about his new relationship with God, who is tender and doesn't, as he says, "fit in a box."

Of course, not everyone in Recovery Point and Four Seasons looks like or has a story like Shawn. There's Zach, the son of a gas executive, who grew up flying on private jets. There's Derek, who went to England on a soccer scholarship, has a stutter, and he wants to open a barbershop called Stuttercuts. There's Mike, who has a trust fund. And there's David, whose time in Recovery Point allowed him to accept his homosexuality.

The thing they all seem to have in common, the thing that sets them apart from the people in Logan, is that these guys all have somewhere they want to be. When I asked people in Logan what the best-case scenario for their lives was, they had no answer. The men in Recovery Point have the thing that is sometimes so difficult to find in poverty, or addiction, or a depressed rural area, which is hope. I don't think they entered these programs with this. I think this is something the program gave them, a measure of success less tangible than percentages or dollars saved, but something so powerful and elusive in a region that has been branded as possessing its own unique brand of fatalism.

Becky was strung out on painkillers for three years, stealing checks from a dying family member to maintain her habit. Eventually, she was arrested for grand larceny. She went to jail for nine months, then rehab for another six, and is now clean, sober, and thriving. Chris Houck, Beckley's Chief Adult Probation Officer, believes her success is due to her supportive family and steady employment—she's an assistant manager at sweetFrog, a company that doesn't discriminate against felons.

Of course, the program isn't without its flaws, the most obvious being that there are only so many beds. The program is also 12-step centric, and 12-step programs aren't for everybody. And it also doesn't allow for psychiatric medication of any kind, including antidepressants, mood stabilizers, or antipsychotics. This makes sense, because as Terry Danielson, the director of Four Seasons in Bluefield, said, "We're trying to medicate ourselves out of a system that has to do with overmedication." But this could potentially be dangerous if an addict is both desperate for help and seriously mentally ill. And while the drug-free detox ensures that clients are truly willing to do the work to be sober, it can also be a deterrent. Two heroin addicts we spoke with in Beckley, for example, felt held back by the fact that there is no state-funded medicated detox.

At the ribbon-cutting ceremony for Four Seasons on July 22, the crowd was filled with all types—politicians, judges, neighbors, ladies from the nearby church. None of these people seemed to look down on the addicts. Back in Beckley, we met with a probation officer who had one of his most successful clients with him, and they clearly had a deep respect for each other. We met with the police, and they took us to the home of a heroin-addicted couple who had been in trouble for prostitution and theft, because they wanted us to see that the epidemic is affecting "good people." Since the epidemic has touched everyone, no one can sit back and pretend it is someone else's problem, or that addiction only happens because a person is corrupt or weak. "What doesn't kill you makes you stronger" is a little simplistic for a situation this complicated, so let's settle on the idea that every source of pain leaves room for greater empathy.

Terry Danielson, the director of Four Seasons, assists with the official ribbon-cutting portion of the ceremony on July 22, 2015. He said the majority of residents did not go to jail or prison for drug charges. Instead most of their convictions were drug-related, i.e. robbery, burglary, and larceny. Strangely, the state sees this as a big difference. If an addict is convicted for robbery, he or she will still be entitled to things like food stamps, which is not the case for possession or distribution charges.

Pastor Simmons, representing the church where Four Seasons has their classes, opened the ceremony with a prayer. As he spoke, one of the church ladies behind me whispered "Amen." He prayed to restore these men back to their families, and again they whispered "Amen." Four Seasons is allowing hope to come back into the community, he told us, in response to which came a loud "Amen."

Toward the end of the ceremony, Terry stood up at the podium to introduce his staff to the audience, all of whom were in long-term recovery. They were dressed up, looking like shiny, respectable members of society in their ties and collared shirts. Each of them represented someone who had made it through addiction, thanks to the help of a recovery model just like this one. And it occurred to me that it might be possible for the recovery and understanding to continue to spread, just like the addiction. The staff members said their names one by one, each qualifying themselves as recovering addicts, the way a person does in a 12-step meeting. After each name, the church lady said "Amen."

Juliet Escoria is the author of Black Cloud (CCM/Emily Books 2014) and Witch Hunt (Lazy Fascist 2016). Her writing has appeared in Prelude, Dazed, the Fader, Electric Literature, Nerve, and other places online and in print. For more, go to julietescoria.com.

See more photos below.

Later in the day, the previously empty porches and street fill up with a handful of children and their mothers. The children want to talk, surrounding us on their bicycles, asking if we are missionaries. The mothers are more reticent, but they warn Stacy to put away her camera, so nobody steals it.

Mike describes himself as a "mix of gangster and redneck." His girlfriend is a criminal justice major at nearby Bluefield State College, and she has attended almost every open function and meeting at Four Seasons to better support Mike. He says this support has been instrumental in his recovery.

Despite the opioid blockers in Suboxone, it is still sold frequently on the street, used mostly just to stave off withdrawal until the user can find something else. It comes in both pill and sublingual film form (which is dissolved under the tongue).

This is David's second go-around at Recovery Point, after relapsing on alcohol the first time during a lunch break. He feels optimistic now, thanks to having recently "grown more comfortable" with himself due to the counseling he's received at the facility.

Lieutenant Jason McDaniel works exclusively with drug crimes for the Beckley Police Department. He says that the Oxycontin epidemic hit Appalachia first, because doctors were told that it was a non-addictive "miracle drug."

Shawn spent about ten years in prison on drug charges. He says one of his biggest obstacles in the rehab was learning to live alongside people who haven't been in the prison system. In prison, you can lose your life over the words "bitch" or "punk," but in the outside world, people throw these terms around. It takes some time to get used to, he explains.

Stephanie and Charlie struggle with their heroin addiction, which costs them $200 to $300 a day, each. They would both love to get off it, but they feel held back by the lack of resources in the area. Suboxone and methadone clinics are expensive, and often have months-long waiting lists. "This is a doomed life," Charlie says.