The epidemic of opioid abuse that's swept the U.S. has left virtually no community unscathed, from big cities to tiny towns.
In fact, drug overdose is now the leading cause of injury death in this country: more than gun deaths; more than car crashes.
There were more than 47,000 drug overdose deaths in the U.S. in 2014, according to the Centers for Disease Control and Prevention. That includes unintentional overdoses and suicides. More than half of those were from opioids, including painkillers and heroin.
I went to rural Berks County in southeast Pennsylvania to hear what the opioid epidemic means in a small town, a place where everyone knows everyone and the ripples of addiction spread wide.
Really, I could have gone just about anywhere. No community is immune.
The landscape in Berks County is bucolic: rolling farmland studded with silos and 19th-century stone barns. But that peaceful landscape belies a serious problem. Opioid addiction is deeply embedded in these small towns.
"It's become a crisis," says Phil Salamone, a paramedic in Kutztown, Pa.
He points out that heroin is both cheap and readily available from nearby cities such as Reading and Philadelphia. Salamone says, "There is no exclusive demographic that's using it. It's everybody. It's kids, adults, low income, high income. It's everywhere."
Local paramedics have been able to save lives by using the drug naloxone, also known as Narcan. It reverses an overdose by latching onto receptors in the brain and kicking the opiates off.
"We don't ever have to worry about that medication expiring because it's always used, Salamone says, somewhat ruefully.
The Kutztown ambulance squad has "Narcanned" ten overdose victims so far this year. Salamone says the drug makes paramedics like him look really good. "You have a patient that is unresponsive. We start an IV on them, administer naloxone and they wake up! Just like nothing had happened."
Early one morning last May, a neighboring ambulance squad got an emergency call from Brandywine Heights High School. A girl had been nodding off at her desk. She soon collapsed, semiconscious and turning gray. She had overdosed on heroin.
School guidance counselor David Favata, a certified EMS worker, raced in and got the girl breathing with a bag mask. An ambulance whisked her to the hospital and she did survive, but it was a close call.
It turned out she had done heroin in the school bathroom before class that morning.
School principal Josh Ziatyk recalls her as a great kid, a former cheerleader, with "tons of energy and the world ahead of her." But, he says, "Through the late middle school years into early high school years, there was a change that occurred within her. And little by little, [she] just found herself into a black hole, into a rut, and couldn't get out of it."
The opioid epidemic has galvanized Brandywine Heights and neighboring Kutztown Area High School into action. Between them, they lost six former students to heroin overdose within two years.
Nurses at the middle and high schools now stock naloxone in the event of an overdose.
Both communities have organized groups to spread awareness about opioid abuse and try to prevent it. They sponsor activities to keep young people engaged. Boredom is a problem in a small town, and drugs can easily fill that void.
At Kutztown High, students meet each week as part of a group called Kutztown Strong, which was formed in response to the drug crisis. When I visit, they're busy planning a three-on-three basketball tournament.
After the meeting, freshman Ramsi Ross tells me how angry she gets when she reads social media posts about the overdose deaths of young people. "Everyone's saying like 'rest in peace, you'll be missed,' and I just couldn't help but think, these were your friends! Couldn't you have done something? Maybe you should have got involved in Kutztown Strong and stopped your friends from using."
Of 450 students at Kutztown High, there are about five who are back in school after rehab. And there are quite a few others the staff is concerned about.
Teachers and counselors meet each week with a specialist who has a contract to work in the school. This student assistance team is part of a state-mandated program in Pennsylvania.
They're on the lookout for kids in trouble. It could be eating disorders, anxiety, self-harm, or drug and alcohol abuse. They look for possible warning signs: kids whose grades have tanked or who've changed friend groups.
On the state level, it's hard to get solid data on whether these interventions are effective. But the staff members at Kutztown High say they're providing a crucial support network for kids at risk.
Guidance counselor Andrew Brett has seen a recent pattern: kids who start with pot may pivot to prescription painkillers and sometimes — across the spectrum, from the highest achievers on down — to heroin.
"Kids aren't afraid of it," he tells me. "Years ago, it was,'Well, heroin is for junkies.' And you had to be pretty low, and that was the perception. Well, that's not the perception. It's available and it's cheap. And it's readily available in our community."
When the student assistance team wants to intervene, they approach the student's parents first.
School superintendent Kathy Metrick says that conversation doesn't always go so well: "I sat across the table from a parent whose child had been found in possession of all sorts of paraphernalia, and she said he was picking up trash off the street, that he would never do that."
Metrick goes on, "The denial is just so powerful. And you want to say, 'Please save your child!' Because, if we're wrong, yay! That would be the best news ever. But gosh, if we're right and we have a chance to step in now before it's too late, let's do that."
But Metrick knows even if they do step in, that's no guarantee.
Students will likely come back from rehab to the same circle of friends, the same triggers and temptations as before.
This story was produced by NPR's Evie Stone.
MELISSA BLOCK, HOST:
Imagine this scene. We're in rural Pennsylvania. Picture rolling farmland studded with silos and 19th-century stone barns. It's 7:30 in the morning, first period in a high school classroom.
JOSH ZIATYK: This is actually the classroom that the incident occurred in.
BLOCK: A girl was nodding off at her desk at Brandywine Heights High School where Josh Ziatyk is principal.
ZIATYK: It just didn't look right, you know, just didn't look like she normally does.
BLOCK: She was overdosing on heroin.
DAVID FAVATA: She was sort of collapsed on the table, like, with her head on it. She had, like, a labored breathing, was definitely, like, semiconscious.
BLOCK: That's school counselor David Favata. He's a certified EMS worker. And that morning last May, he came running.
FAVATA: We just made - I just made sure we had an open airway, set up the oxygen.
BLOCK: Pumped air through a bag mask. The ambulance came and the student did survive. It was a close call. It turned out she had done heroin in the school bathroom before class that morning. Principal Ziatyk says she's a great kid, a former cheerleader.
ZIATYK: Tons of energy and the world ahead of her. And through the late middle school years into early high school years, that - there was a change that occurred within her. And little by little, just found herself into a black hole, into a rut, and couldn't get out of it. And there's that day.
BLOCK: The teacher who was in the class that day is still so upset by what happened she can't talk about it. In an email, she told me the awful memory of her student's shallow breath and graying face will stay with her forever. I went to Berks County, Penn., to hear what the national opioid epidemic means in a small town where everyone knows everyone and the ripples of addiction spread wide. Really, I could have gone just about anywhere. No community is immune.
This area, around Kutztown, Penn., is not far from Reading and Philadelphia, which means heroin is plentiful and it's cheap. People here call opioids an equal opportunity destroyer in these small towns, afflicting the wealthy and the poor, young and old. But it's the young ones you hear about most. Between two neighboring school districts, they lost six former students to heroin overdose within two years. And they know they're lucky that number wasn't even higher.
PHIL SALAMONE: So this is naloxone. It carries two milligrams in two milliliters.
BLOCK: Kutztown paramedic Phil Salamone shows me their supply of naloxone, a life-saving drug also known as Narcan. It reverses an overdose by latching onto receptors in the brain and kicking the opiates off. Nurses at the area middle and high schools stock Narcan now. Police carry it. And it's in heavy rotation here with the Kutztown ambulance squad.
SALAMONE: We don't ever have to worry about that medication expiring because it's always used.
BLOCK: Salamone tells me they have Narcan-ed (ph) overdose victims 10 times so far this year, including one just this morning. He jokes the drug makes paramedics like him look really good.
SALAMONE: You have a patient that is unresponsive. We start an IV on them, administer naloxone and they wake up just like nothing had happened.
BLOCK: The paramedics in Kutztown have revived overdose victims as young as 15. But for others, it's too late. Statewide, Pennsylvania has one of the country's highest fatal overdose rates among men and women ages 19 to 25.
DERON YOUSE: I mean, these were bright, young, healthy-looking, pretty clean-cut kids.
BLOCK: Deron Youse has seen the toll of addiction up close. He's the funeral director at Ludwick Funeral Home in Kutztown. He's prepared the bodies of young overdose victims, their lives snuffed out early. And he's listened to grieving parents struggling to understand the power that these drugs have.
YOUSE: I know one family in particular had a child that died. He had been in and out of rehab numerous times. And each time he came out, they thought they had it beat. They didn't stop trying, but it defeated them in the end.
BLOCK: Those overdoses were a wake-up call, and the community responded. At Kutztown Area High School, a group of students meets each Thursday morning...
UNIDENTIFIED MAN #1: Guys, we need to get started.
BLOCK: ...Part of an anti-drug initiative called Kutztown Strong.
UNIDENTIFIED STUDENT #1: Oh, I have a good idea, where the girls ask the guys to the dance.
UNIDENTIFIED STUDENT #2: Sadie dance. Sadie dance. We could do that.
UNIDENTIFIED STUDENT #1: We never have those.
BLOCK: The students plan activities - dances, a three-on-three basketball tournament - to try to keep kids busy. Boredom is a problem in a small town, and drugs can easily fill that void. Freshman Ramsi Ross tells me when she reads about overdose deaths on social media, she gets angry.
RAMSI ROSS: Everyone's saying, like, rest in peace, you'll be missed. And I just couldn't help but think, these were your friends. Like, couldn't you have done something? Like, maybe you should've got involved in Kutztown Strong and stopped your friends from using.
BECKHAM SIBISKI: It's scary. It's insane how close it really is to everybody.
BLOCK: Junior Beckham Sibiski thinks about a friend from school who went to rehab. The night before, they exchanged messages on Twitter.
SIBISKI: And I was just like, oh, hey, I'm sorry to hear about everything. I hope everything keeps going all right. Like, you're doing the right thing by going to rehab. Like, you're going to get back on the right path and everything when you come back. And if you need anything, just let me know.
BLOCK: That friend is back in school - one of five back from rehab in this high school of 450 students. There are a number of others the staff is concerned about. Teachers and counselors meet each week with a specialist who has a contract to work in the school, part of a state-mandated program in Pennsylvania. They're on the lookout for kids in trouble. That could be eating disorders, anxiety, self harm, also drug and alcohol abuse.
ANDREW BRETT: We're going to see if there's something substance-related. Again, it's a question mark. I don't doubt it at all. And hearing who this child is hanging out with, I do not doubt it at all. But, you know...
BLOCK: They check for possible warning signs - kids who've changed friend groups or whose grades have tanked. On a state level, it's hard to get solid data on how effective these interventions are. But the staff members at Kutztown High say they're providing a crucial support network for kids at risk. If they intervene, they keep track of how the students are doing later.
BRETT: How are they being successful in their recovery care?
UNIDENTIFIED WOMAN #1: Staying clean, you mean?
BRETT: That's exactly what I mean.
UNIDENTIFIED WOMAN #1: I believe they are.
UNIDENTIFIED WOMAN #1: I really do. They look good.
BLOCK: School counselor Andrew Brett has been at this for a long time and has seen the recent progression. First, kids using pot, then prescription painkillers - and sometimes, across the spectrum from the highest achievers on down, a pivot to heroin.
BRETT: Kids aren't afraid of it. Years ago, it was that, well, heroin is for junkies. And you had to be pretty low and you - and that was the perception. Well, that's not the perception. It's available, and it's cheap. And it's readily available in our community.
BLOCK: When the Kutztown team identifies a kid who seems to be in trouble, they'll reach out to the parents. And as school superintendent Kathy Metrick tells me, that doesn't always go so well.
KATHY METRICK: I sat across the table from a parent whose child had been found in possession of all sorts of paraphernalia. And she said he was picking up trash off the street, that he would never do that. And she was - the denial is just so powerful, and you want to say please, save your child. Because if we're wrong, yay, that would be the best news ever. But gosh, if we're right and we have a chance to step in now before it's too late, let's do that.
BLOCK: But Metrick knows - even if they do step in, that's no guarantee. Students come back from rehab to the same circle of friends, the same triggers and temptations as before. Next Saturday on the program, we'll meet a graduate of Kutztown High, Nikko Adam, and his family. He is a recovering heroin addict just out of his third stint in rehab. His older sister is trying to trust clean Nikko.
UNIDENTIFIED WOMAN #2: It's like spending time with Nikko or spending time with heroin Nikko. It's a big difference.
BLOCK: And how worried are you that the old Nikko will come back?
UNIDENTIFIED WOMAN #1: Oh, I'm so worried. I'm so worried.
(SOUNDBITE OF MUSIC)
BLOCK: And we'll have that story for you next Saturday. Transcript provided by NPR, Copyright NPR.