West Virginia city once battered by opioid overdoses confronts ‘fourth wave’

KFF Health NewsMar 13 2024

From 2006 through 2014, more than 81 million painkiller pills were shipped to this city and surrounding rural Cabell County.

The arrival of prescription opioids onto seemingly every block of Huntington, a city of about 46,000 people, augured the first wave of an overdose crisis. Heroin followed, then fentanyl.

Residents remember Aug. 15, 2016, as the darkest day because on that afternoon and evening, 28 people overdosed in the city. But Huntington had shouldered collective trauma before.

On Nov. 14, 1970, Southern Airways Flight 932 crashed into a hillside just outside Huntington, killing all 75 on board. The dead included football players, coaches, and boosters from Marshall University, located here.

Residents say the tragedy bonded the community in a way that helped prepare it for crises to come. But now that cohesion is being challenged in a city and county once known as the epicenter of the nation's opioid epidemic.

This crisis continues to evolve. Cabell County, like other communities, is in the depths of a "fourth wave" of overdoses fueled by mixtures of drugs that often include fentanyl and other powerful synthetic opioids.

Fentanyl is now ubiquitous — heroin is rarely seen anymore — and toxicology results reveal other synthetics, including carfentanil, a drug used to anesthetize elephants that can be 100 times as potent as fentanyl. Also in the mix is xylazine, or "tranq," another animal tranquilizer that can cause horrific skin ulcers in IV drug users. Increasingly, those drugs are being mixed with stimulants like methamphetamine and cocaine.

Michael Kilkenny, chief executive of the Cabell-Huntington Health Department, recalls coming to the "shocking realization" in 2015 that drug overdose was the third-leading cause of death in the county, after heart disease and cancer.

When the Centers for Disease Control and Prevention tightened guidelines for prescribing opioids in 2016, users turned to heroin. Then came fentanyl. In 2017, Cabell County had the highest rate of opioid-related overdose deaths in the state with the highest rate in the country — five times the national average.

Connie Priddy, an emergency medical services nurse, said that after the dark day of Aug. 15, there was initially a sense of relief. "We saved all 28 people," she said. "Our EMS crews did a wonderful job."

But Priddy, who now leads the county's Quick Response Team, said the euphoria quickly dissipated when officials learned that none of the 28 people had subsequently been referred to addiction resources or received treatment.

Taylor Wilson, 21, was the first known overdose on that August day. Her parents spent the next 41 days searching for treatment options. On the 42nd day, Wilson overdosed again and died from a mix of drugs that included fentanyl, carfentanil, furanylfentanyl, morphine, and hydrocodone.

"She was enrolled at Marshall," Wilson's mother, Leigh Ann Wilson, said. "She was going to be a librarian." Wilson began taking prescription opioids around the time she entered college but was able to quit them. She was then introduced to heroin by a boyfriend.

Priddy said that later, reflecting on the lessons of Aug. 15, "our community really came together and said, 'We've got to do something different.'"

Huntington now strives to be the "city of solutions." Establishing the Quick Response Team in 2017 was a significant step. Within 24 to 72 hours after an overdose, the team — consisting of a peer recovery coach, paramedic, police officer, and faith leader — pays a visit to the person who overdosed or to their family. The team also checks on people whose family members fear they may be at risk of an overdose.

The number of ambulance calls to treat an overdose has decreased by 40% since the team was established. Overdose deaths in Cabell County peaked in 2017 with 202. At that time, Cabell had an overdose death rate that was more than double the rate of the next-highest county in West Virginia. According to the CDC, by June 2023 the number of overdose deaths in Cabell had dropped to 135 for the previous 12 months, while the numbers statewide continued climbing.

"We've expanded over these last few years to provide all kinds of social services along with referral to treatment," Priddy said.

It is about "letting them know that we care," said Sue Howland, a peer recovery coach with the Quick Response Team.

But the mixtures of drugs have presented new challenges. Robin Pollini, a substance misuse and infectious disease epidemiologist at West Virginia University, recently conducted studies of injection drug users in several cities in the state, including Huntington. She found that few people are using only opioids; rather, they're using opioids and methamphetamine.

And the emergence of fentanyl has heightened the risks. Typically administered doses of the opioid withdrawal drug buprenorphine, one of Suboxone's main ingredients, are less effective against fentanyl than other opioids. While the effects of heroin often last four to five hours, fentanyl's high lasts a half-hour to an hour. Consequently, people share and reuse syringes more frequently, furthering the risk of HIV, hepatitis B and C, and endocarditis, said Jan Rader, director of Huntington's Council on Public Health and Drug Control Policy.

Adding stimulants like meth and cocaine to the mix creates another layer of challenges.

Those on the front lines say most stimulant users are unaware they are taking a mix of drugs. That was the case for Jessica Neal, who said she started using methamphetamine in her early 20s, got in trouble with the law, went on the run, became pregnant, and is now in recovery.

Neal, now 33, thought she was using only meth. But a toxicology report from a failed drug test revealed she had also taken heroin, fentanyl, barbiturates, and benzodiazepines.

While some opioid users prefer the contrasting effects of opioids and stimulants, others, particularly people who are homeless, take stimulants to stay awake and safe.

Larrecsa Barker, a paramedic with the Quick Response Team, said regardless of what people report using, she always asks them if they might test positive for heroin or fentanyl. "If so, that means you're definitely one step closer to getting into treatment," she said.

There is no equivalent to Suboxone to treat withdrawal from stimulants. "If you're just using meth, the likelihood of getting into inpatient treatment is slim to none," Barker said.

In 2020, local government agencies, health providers, and Marshall University assembled a resiliency plan. Short-term goals include expanding outpatient and inpatient care; reducing barriers to treatment and recovery services; and providing more substance use education. They're also working to address the underlying social determinants of health, including housing and employment.

Rader, the drug control council director, sees incremental gains in caring for the most vulnerable. She said that Project Hope for Women & Children, a program operated by Marshall Health, has been a godsend. "So many success stories," she said. Rader also lauded the city's founding of the Crisis Intervention Team and the expansion of its shelter capacity. The low-barrier shelter admits people even if they have recently taken a drug.

Yet Pollini, the epidemiologist, said that too often lawmakers limit how local officials can respond. She cites restrictions, and prohibitions, on harm reduction initiatives at both the state and local levels.

She said that clamping down on syringe exchanges not only restricts the availability of syringes but reduces access to free naloxone, fentanyl test strips, and other lifesaving supplies.

Syringe exchange programs must be approved by both city councils and county commissions, and they can withdraw support at any time. "That's a pretty precarious way to operate," Pollini said.

A bill was recently introduced in the West Virginia Legislature that would ban syringe services programs. Some lawmakers have argued that offering clean syringes in exchange for used ones abets drug use.

"It's really aggravating what's happening on the political scene right now, because they're not deferring to the experts in the field," Priddy said.

Pollini said: "Let us do the things that we know work."

Kilkenny, who was recently elected president of the National Association of County and City Health Officials, said he believes if the will is there, overdose deaths could be reduced by 90%. He said he believes in aiming high, and that a public health department has a critical role to play in getting there.

"We want children to have fewer adverse childhood events," he said. "We want families to be more resilient."

As for Neal, she said she made it out of the "madness" and was welcomed into Project Hope. She is raising her baby daughter and working as a Project Hope peer support recovery specialist. Her objective is to help other women get the resources they need to break their addictions.