When a patient comes into the St. Gabriel’s emergency room with a 10-year-old prescription for painkillers, they aren’t just cut off cold turkey; a plan is created to taper them down to a safe dose. When the police find someone with stolen pills, they are referred for treatment, not arrest. When people prescribed opioids don’t test positive for opioids in routine medical checkups, questions are asked.

“If you find a person’s urine has a bunch of meth and not their pain meds, you make the assumption they are selling their pain meds to get meth,” family physician Heather Bell, DeVine’s colleague, told BuzzFeed News. “But we don’t kick them out of our clinic. We say, ‘OK, what is going on? Do you need help?’ Then we get them into treatment.”

When Monica came to their clinic, she was treated like any other patient, not as a drug addict or a criminal. “Honestly, if they had shuddered, I would have run out the door,” she said. “I told them all these horrible dark things things I had done, and Dr. DeVine was like, ‘OK, that stuff happened. Now let’s get you better.’”

The team found her an in-patient program at a clinic where she could work on recovering from her five-year addiction to heroin. “I knew I couldn’t do it at home,” she said.

What’s truly unusual about Morrison County is that more places aren’t offering that same coordinated swath of services among doctors, teachers, and law enforcement, drug policy expert Brendan Saloner of the Johns Hopkins School of Public Health told BuzzFeed News. In December, he published a report calling for towns across the US to combine in just that way, promoting safer prescriptions, reducing overdoses, and switching from arrests to treatment.

“Every place will have to do those things its own way, and do it a little different,” Saloner said. “But some things are bottom line, starting with getting people into treatment and treating this like an epidemic.”

In places like Dayton, Ohio, and Huntington, West Virginia, people have turned to these coordinated efforts only at a later stage in the overdose crisis, amid a wave of deaths tied to the drug fentanyl. An opioid 30 to 50 times more potent than heroin, fentanyl began widely showing up in heroin in eastern states after 2013 and has driven drug overdoses to record-breaking levels, exceeding yearly deaths from guns, car accidents, and AIDS at its height.

The basic biology of opioids helps explain why. Opioids supplant natural painkillers produced by the brain and induce a dependence on the drug. The dependence mounts over time as the body demands more and more of the stuff both to get high and stave off withdrawal. That often leads people to seek opioids that are more potent — and more likely to kill.

As little as 2 milligrams of fentanyl, for instance, can be fatal. And its widespread distribution throughout the illicit drug market has been wildly uneven. The resultant death toll has been horrific, with fentanyl linked to about 30,000 fatal overdoses a year, roughly 60% of all such deaths in the US, from a drug rarely found outside hospitals at the start of this decade.

In Dayton in 2017, the toll was particularly harsh: 566 fatal overdoses in one year in the city of 140,000. The outbreak was linked to heroin contaminated with carfentanil, an opioid some 100 times stronger than fentanyl. Emergency responders responded to multiple overdoses a day, and the coroner needed to rent funeral homes to store the bodies.

Last year, however, overdose deaths in Dayton fell to 292, nearly cut in half.

“The first reason for the decline in deaths in Dayton, to be straightforward, is a decline in fentanyl in the drug supply,” Dayton Mayor Nan Whaley told Buzzfeed News. “The second reason is that we have come together as a community.”

Spurred by $1.5 million in federal grants aimed at preventing overdose deaths and stopping break-ins from drug users, the city has over time created a system of quick response teams aimed at connecting people who overdose, and drug users in general, with treatment instead of arrests. Firefighters, police, health organizations, and local businesses have all combined efforts. Teams respond to overdose outbreaks and visit people in their homes before they overdose, offering help instead of jail. People already in jail, meanwhile, are offered medication-assisted treatment that continues after they get out. The city runs a needle exchange and makes sure that firefighters and police officers readily administer Narcan, the overdose-reversing drug. The goal at every step is to get people into treatment.

Although Whaley wouldn’t call Dayton’s drop in overdose deaths a success story, “we are making progress,” she said. “It is expensive,” she added. Emergency responses to overdoses have cost the city more than $1.3 million from 2016 to 2018, and another $500,000 was spent on overdose-reversing drugs from 2015 to 2018. Medicaid expansion in Ohio under the Affordable Care Act, which started in 2014, was essential to paying for the addiction recovery treatment that is the end goal of Dayton’s system, she added. “I would prefer we had more funding for mental health.”

The Cornerstone Outreach Addiction Facility, a treatment center in East Dayton.

Huntington has also seen a drop in overdoses, down 40% from 2017 to 2018. And again, they did it with a collective response that treats the overdose crisis like an epidemic rather than a crime wave. The city of 47,000 was once called the “ground zero” of the overdose crisis after a record-breaking 20 overdoses happened there over just two days. A recent American Journal of Public Health study estimates around 2.5% of the populationthere are injection drug users, rates similar to Baltimore and San Francisco, making the drop all the more remarkable.

“Three years ago, if you overdosed in Huntington, you were treated, and got up, and went home. Nothing happened,” Michael Kilkenny, physician director of the Cabell-Huntington Health Department, told BuzzFeed News. “That doesn’t happen anymore — we changed the protocol to just start you on treatment.”

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