Chapter 5: ‘Disgusting is a mild word for this’
The opioid epidemic extends to the rural reaches of Pennsylvania farm country, where everyone knows everyone else and proud families try to keep addiction a secret — with deadly results.
By John Luciew | jluciew@pennlive.com
Fulton County is God’s Country. It’s a land of deep family roots and high, rolling hills. It’s laced with corn crops and two-lane country roads.
Everyone seems to know one another.
With about 14,000 residents in a sprawling county that runs south from the Pennsylvania Turnpike to the Maryland line, it’s a small town scattered across a sweeping, mountainous landscape.
There’s plenty of elbow room here, but also isolation.
There’s no local law enforcement. Pennsylvania State Police patrol the entire county from a small, 22-person barracks just outside of McConnellsburg.
Most of the troopers who provide protection here aren’t outsiders. Due to the remote, rural location of this outpost, most soon become members of the close-knit community. Their kids go to the local schools and play on the Little League teams, Sgt. Timothy Cummings said.
Yet none of it — not the mountains, the rural remoteness nor the winding, two-lane roads that make getting around these parts so difficult — could safeguard this slice of God’s Country still seemingly stuck in the Norman Rockwell era.
Opioids moved in, and death followed.
In this story:
- Death reveals a rural community’s shocking secrets
- A coroner marvels at creative ways addicts invent to die
- A social worker uncovers traumas underlying opioid addiction
- In quest of meaningful jobs to restore dignity for recovering addicts
Fatal shame
A big reason for the rise of the opioid epidemic in rural Fulton County is the region’s graying demographics.
Fulton’s coroner affectionately refers to his community as a county-wide retirement home. To ease aging Fulton County’s many aches and pains, well-earned from lifetimes devoted to physical work, a bevy of prescription painkillers have been prescribed.
Coroner Berley Souders says it’s not uncommon to haul away two Walmart bags full of prescription pills, including hundreds of opioids, from the homes of elderly people who pass away here.
Inevitably, some of these high-strength prescription opioids have been abused, Souders said.
Sometimes, it’s by the person prescribed the drugs. Sometimes, it’s a child or grandchild who sneaks into medicine cabinets stocked like small pharmacies.
This is how some people here get hooked. It’s also how prescription pills are sold or given to friends. And it’s how some people overdose and die in the opioid epidemic here.
But even as opioid addiction’s grip tightened around more families in these proud, hard-working parts, the first instinct of many was to keep it a secret.
Otherwise, families that go back generations could be shamed.
These family secrets might have held. After all, the wide-open spaces provide plenty of room for hiding problems.
Then people started dying.
Death creeps in
The opioid overdose crisis here seems comparatively small. One or two deaths in 2014. Three or four the following year.
But in a small community where everybody knows one another, even one death is magnified.
And it wasn’t just the deaths. It was how people were dying.
One overdose death scene, in particular, seemed to shatter any illusions that wholesome Fulton County was safe from the opioid epidemic’s scourge.
A 31-year-old mother with a 2-year-old and a 2-month-old was deeply depressed following the funeral of a family member. So much so, she spent the rest of the day and all of that night in bed.
All the while, she was taking a laundry list of prescription pills, according to Deputy Coroner Robert Fleegle, who quoted from the case files.
A narcotics database report would later show the mother was being prescribed pills from five different doctors. The list of her medications was 21 pages long.
Even earlier in the day at the funeral, the woman was described as appearing “like a zombie,” Fleegle said. “She could hardly walk.”
Things only grew worse after she took to bed.
“She was taking various types of medication throughout the night,” Fleegle said.
All the while, the mother also was tending to her two children, including the 2-month-old son, whom she was breastfeeding.
In the wee hours of the next morning when the woman’s husband checked on her, the baby was at her breast.
But the husband noticed something was wrong.
His wife wasn’t breathing.
Disgusting is the word
At the coroner’s office, Souders and Fleegle had a new case: a mother overdosing while nursing her son.
The woman’s husband called 911, but it was too late.
Fleegle said the toxicology report showed a lethal combination of opioids, including hydrocodone, as well as other drugs, such as Adderall, Xanax and marijuana.
Officially, the cause of death was listed as “multiple drug toxicity.”
The woman’s two children were adopted after Fulton County Children’s Services determined no family members, including the husband, were fit or willing to have custody.
Christine McQuaid, acting director of Fulton’s children’s services, is bound by confidentiality from discussing many details of the case. And she insisted upon protecting the children by withholding the deceased mother’s name.
But she said she can’t help thinking the children are better off.
“I think everyone here is just relieved that the children are adopted and that situation is no longer present in their lives,” McQuaid said.
Meanwhile, the absolutely antithetical “Madonna and child” image conjured by a mother fatally overdosing while breastfeeding her son proved too much for many in “God’s Country” to deny.
As Fleegle bluntly stated, “Disgusting is a mild word for this.”
Yet, prescription drug abuse was a problem in Fulton County long before people began dying of opioid overdoses.
“We’re a little bit behind the trend,” McQuaid said. “People can be off the radar here. There’s an element of isolation. But prescription drug use has been a big problem here for years. More than a decade.”
That’s why all of McQuaid’s children’s services caseworkers are trained to keep an eye out for drug use in the home. This includes spotting any signs of drugs or drug paraphernalia, but also noticing the parents’ demeanor. Any telltale signs of lethargy can point to an opioid or heroin addiction, raising alarm bells of concern for any children residing in the home.
Because what if the breastfeeding mother had died alone with her kids?
“That is the worst-case scenario,” McQuaid confirmed. “Our role in the opioid crisis is to make sure the children are safe from abuse.”
If only Coroner Souders could protect opioid addicts from themselves and the many creative ways they find to die.
Creative destruction
Souders never ceases to be amazed at the overdose death scenes he visits.
The job of coroner here used to be straight forward. Ringed by the Turnpike, Interstate 70 and Route 522, tragic traffic accidents were always the grimmest part of the job. The rest were the mostly placid deaths scenes of so many of Fulton’s elderly residents, who often go peacefully at home.
The opioid epidemic has added a bizarre, new dimension to the job Souders has held for a dozen years, plus seven before that as chief deputy.
He tells of one 37-year-old man who had been prescribed a fentanyl patch for persistent back pain. Somewhere along the line, the used-as-directed relief of applying the patch to where it hurt wasn’t enough.
When Souders found the victim in his trailer home, there was a homemade pipe next to the body. It was fashioned from aluminum foil and the hollow shaft of an ink pen.
The man had been using it, along with a lighter, to smoke his fentanyl patch, inhaling the toxic vapors in order to maximize the lethal drug’s high-giving hit.
“It was ingenious,” the coroner said.
But also, deadly.
Something to chew on
A woman’s death had all the earmarks of an opioid overdose, yet there was no paraphernalia by the body. Also, no needles marks, nor drugs to be found.
Souders was perplexed. He’d remain so until the pathologist in Allentown who performs Fulton County’s autopsies phoned with results.
Before making a single incision, the professional medical examiner made a full external inspection of the body. This was all it took to find what had killed the otherwise-healthy woman.
Turns out, she had affixed a fentanyl patch to the inside of her check, an area flush with blood vessels to speed the drug into her system. No doubt, this produced a quicker, more intense high.
It also killed her.
Another woman barely escaped death when she decided to get high by chewing a fentanyl patch. By jawboning the patch, it flooded her system with high-producing effects.
But as the synthetic opioid hit her system, the woman inhaled the fentanyl patch she was chewing and proceeded to choke on it.
She was rushed by ambulance to the medical center in McConnellsburg, where in the nick of time, doctors were able to extract the airway obstruction and save her life.
“If the folks would apply their ingenuity to something constructive, who knows?” Souders mused.
Three of the county’s overdose deaths were young people pilfering the prescription opioids of family members, including a 24-year-old and a 26-year-old who raided their grandmothers’ medicine cabinets, Souders said.
Another man overdosed in his car while parked at the senior center. He’d apparently just scored the drugs from his dealer.
A young woman fatally overdosed in the restroom of the Sideling Hill rest stop of the Pennsylvania Turnpike. The coroner says the woman’s mother was in the process of driving her daughter from Johnstown to Lancaster for rehab.
Alas, she never made it.
In the past three years, Souders has witnessed the many ways addicts here have invented to die, telling of at least two recent fatal overdoses where the victims mixed opioid pills with the diabetic nerve pain drug, Lyrica. The coroner added Lyrica also is being abused in combination with heroin and even marijuana.
“It seems to be the latest thing,” Souders said.
Fulton County’s aging population keeps the area awash in potent medications. But street heroin and its much-stronger synthetic counterpart, fentanyl, have reached the county, as well. Their fatal impact hit like a fist in 2016.
By the end of that year, Fulton County had amassed 11 opioid fatalities.
That might not sound like all that many in the nationwide opioid epidemic, estimated to cost 64,000 lives annually and could kill a half-million Americans in the next 10 years.
But in tiny Fulton County, with just over 14,000 residents, those 11 deaths represented a one-year increase of 267 percent.
Worse, the county’s per-capita opioid death rate of 74 percent catapulted this proud community to the dubious distinction as having Pennsylvania’s highest rate of fatal overdoses based on population.
Time had arrived for this rural community to reckon with the opioid crisis.
Tell me where it hurts
Among the first to recognize and react to the growing opioid crisis was the staff of the Fulton County Medical Center. Not only was the emergency room seeing an increasing pattern of overdose patients, the hospital’s remote location made it an inviting target for pill shoppers.
They come in all forms, with all manner of ailments, all trying to talk their way into an opioid prescription.
Eighteen months ago this might have worked. But a national narcotic prescription database has helped shut down pill-shopping cold, even in a rural community like this one.
“We get people coming in from Bedford, Altoona, Maryland and West Virginia,” said Dr. Douglas Stern, director of the medical center’s emergency department.
“They were coming in for narcotics. It would be a red flag. They’d claim pain, but there was no resulting injury,” he said.
Dr. Stern and his staff have seen all manner of negative reactions after telling the pill pretenders “no.”
A patient claiming a back injury flew into a fit of rage — suddenly showing no signs of pain whatsoever. Another claiming a leg or ankle injury promptly threw down crutches and angrily stomped out of the ER.
Others have made threats, but there’s been no violence.
“People get angry,” Dr. Stern said. “Sometimes I print out the (narcotics prescription) report and show it to them. I’ve had patients ball it up and throw it on the floor.”
Occasionally, the doctor gets a nasty note tucked under the windshield wiper of his pick-up truck, which is parked in his staff space in a nearby lot.
“People know where the physicians park,” he added. “It scared me a little bit. But the emergency department is locked down at night. There are security cameras everywhere, and the State Police are only minutes away.”
Dr. Stern and his staff do make good-faith attempts to treat all claims of pain. But if anything is amiss — and certainly when the narcotics database shows a pattern of pill seeking — they prescribe non-narcotic painkillers.
The medical pendulum for treating pain has swung back from the permissive prescribing practices of the recent past, the doctor said.
“At one point in time, no one was allowed to be in any pain or discomfort,” Dr. Stern recalled. “It would start with an injury, a trauma, a broken bone, kidney stones. The longer you were on this stuff, the harder it is to back off.”
In just the past 18 months, the turnabout in prescribing practices has been both dramatic and decisive.
“It’s already working,” Dr. Stern said. “You can see it working. Little by little, the drug seekers aren’t even bothering to come in anymore. The word is out.”
The message has been sent and received across the medical community, as well.
The over prescribing of opioids simply won’t be tolerated — and the government is watching, Dr. Stern said.
“Doctors are more afraid to write for narcotics,” he added. “The DEA (Drug Enforcement Agency) is watching our every prescription.”
The same national narcotics database that doctors use to check patients’ prescription histories can also be used to track every opioid pill prescribed by physicians.
The prescription crackdown has pushed many of those addicted to pharmaceuticals to street heroin and fentanyl, which can be much more deadly.
This kind of hard-core opioid addiction is among the toughest chemical compulsions to break. The brain chemistries of opioid addicts are irredeemably altered.
But there is something else underlying the relentless addictions of so many.
A family therapist who spent her career rising up the ranks of behavioral health services here thinks she may have found a common link among the vast majority of Fulton County’s addicts.
Her discovery could help break addiction’s hold.
Hidden trauma
Elizabeth Gotwals, administer and owner of Fulton Behavioral Health Services, began seeing a link between her clients suffering from deep-seated traumas and other mental or emotional issues, and those developing opioid addictions.
Gotwals first noticed this connection back when alcohol was the addictive substance of choice. Over the past several years, she has watched as the substance became opioids.
“These people have depression, anxiety and other issues that compel them to self-medicate,” Gotwals said.
Gotwals notes that opioids aren’t merely effective at reliving physical pain. The potent drugs wash away mental anguish, as well.
Her patients tend to be people with traumatic events that have affected their lives: physical, emotional and sexual abuse; fractured families; alcoholism; lack of education; and physical and mental pain.
“All of the problems are here,” Gotwals said.
And they helped set the stage for the opioid crisis.
A full 70 to 75 percent of opioid addicts now being treated by Fulton Behavioral Health also have an underlying trauma or mental health issues, Gotwals said. As a result, she’s convinced treating opioid addiction also must involve treating these underlying traumas and issues.
In many cases, the original, underlying trauma could be the key driver of the addiction, itself.
Pride before the fall
Alas, in a small, intensely private community like Fulton County, the stigma attached to addiction treatment and mental health therapy can be an all-but impenetrable barrier.
“Some families wanted to solve the problem themselves,” said Erin Pistner, a counselor with Fulton Behavioral Health Services. “It can take longer for the family to realize it’s beyond their ability to take care of it.”
Fulton Behavioral Health runs two separate medically-assisted-treatment programs that combine the anti-craving drug, Suboxone, with personalized therapy to deal with a client’s underlying trauma, arming them with coping skills.
The cash-only program, which protects the patient’s privacy by keeping their addiction treatment off the books of health insurance companies, is by far the most popular in a rural area that still places a premium on family secrets.
That program is currently maxed-out with 100 patients, while one for clients on medical assistance has just 18 clients.
Beyond pride, there’s one last barrier to full recovery: If patients are going to move forward from their addictions, they must find meaning in their lives, treatment specialists said.
For many in recovery, this means getting a second chance at a decent job, despite their history of addiction.
The question is, can addiction treatment officials convince companies and businesses here to take this risk?
Help wanted
Returning to meaningful work — not just a job — is seen as one of the last and most important steps in a recovering addicts’ journey back.
Unfortunately, it can be the most difficult step of all.
Across Pennsylvania, professionals working with addicts in rehab and recovery cite this need for meaningful employment as being both vitally important and almost wholly unavailable to most recovering opioid addicts.
This is despite tight employment markets in which many open positions, even those in manufacturing, can go unfilled for months.
Hiring someone with an admitted addiction problem and the possibility of a criminal record related to that addiction is a gamble most businesses simply will not take.
Fulton Behavioral Health Services is currently working with a local manufacturing company on a pilot program to provide its recovering addiction clients with a path to family-sustaining employment — a bridge back to a full life.
Officials were keeping details about the pilot program under wraps, as aspects of the employment partnership were still being hammered out. But the goal is for the local company to hire an undetermined number of recovering clients, who will be supported and monitored by Fulton Behavioral Health staff.
If it works, the program could be a model for both employers in need of workers and recovering substance abusers seeking to rebuild their lives by landing a decent job.
“If you are employed, it is critical,” said Renee Grimm, a recovery specialist who is putting together the employer pilot program for Fulton.
The project is called Workforce Dignity, and it would bridge the last yawning chasm in the recovery process.
“We are working on getting a large employer to open that door,” she added. “We realize the risks they are taking.”
To ease those risks, Renee and her team are offering a true partnership with the employer — a team approach to make this last, most difficult recovery transition actually work for everyone.
Mixed emotions
In the end, recovery means learning to feel again.
The addict, long numbed by opioids, must learn to cope with worries, emotions, impulses and feelings. All the stuff of life.
In a larger sense, all of Fulton County is being re-educated on how to feel and to deal with these emotions, too. First, with the tragedies of the overdose deaths, and since then, the community’s efforts to fight back.
So far, that fight has not included the setbacks of any additional opioid deaths here in 2017.
The closest incident was the death of a young woman in early February that had Coroner Souders utterly baffled.
The victim had a history of drug use, and the death scene had all the signs of a fatal overdose. Yet drug screens and toxicology reports came back negative.
The county paid for a full autopsy and an extra round of toxicology tests. In the end, the cause of death rang with the irony of a New Year’s resolution.
It turned out the victim had lost a significant amount of weight by the start of the New Year. Yet that wasn’t good enough. To begin 2017, the woman placed herself on an even stricter crash diet, Souders said.
The final report determined her potassium levels had plunged so low from all her dieting that her heart had stopped.
The official cause of death was “failure to thrive.”
Looking back, Souders sees his mistake. There had been so many overdose deaths of late, everything but traffic accidents and elderly people passing away began looking like opioids.
Perhaps, the case will mark a welcome return to rural normalcy for the coroner and his residents.
But never again will there be a return to complacency.
Fulton County has seen, felt and experienced far too much for that.
Story originally published on November 17, 2017, on PennLive.com. Photography by Dan Gleiter
