America has yet to see the worst of the opioid crisis, doctors and nurses caution

                                      PART ONE | PART TWO | PART THREE

When it comes to her past, Natasha Penland holds nothing back.

She was an alcoholic. She formed an addiction to painkillers that eventually led to harder drugs. Opioids so ruled her life she would disappear for days at a time, leaving her newborn with her mom.

At rock bottom, Penland lived in a car. When her mother said she could no longer see her daughter, she would sit outside the child’s bedroom window and watch her play.

“She didn’t even know I was there,” Penland said. “I was literally on the outside looking in, and I never wanted to be on that side again. I knew I couldn’t be her mom if I was using.”

Now she is part of Buncombe County’s hope for taming an opioid epidemic that has led to a surge in overdose deaths, sent hundreds of children into foster care, and left hospitals treating newborns for withdrawal from opioid dependence.

More:An inside look at how heroin overtook Michelle Buckner's life

As local and state governments sue pharmaceutical companies on allegations they flooded the country with painkillers they knew to be addictive, former addicts, social workers and medical professionals on the front line of the crisis are busy battling the disease with their own strategies.

In Western North Carolina, those people include former addicts like Penland, doctors who redefined their careers after witnessing multiple patients die of opioid overdoses and a social services director who personally stops by the homes of recovering addicts despite her own challenges in recovering from cancer.

The obstacles they face are steep.

North Carolina's opioid deaths have risen from fewer than 200 in 1999 to 1,384 in 2016, as reported by the North Carolina Injury and Prevention Branch of the state Health and Human Services Department.

In Buncombe County, from January to August 2017, 230 people suffered an opioid overdose, up from 84 over the same period the year before.

Nationwide, overdose deaths involving prescription and illicit drugs have more than quadrupled since 1999. In 2015, the opioid overdose epidemic killed more than 33,000 people in the U.S. 

5 years clean

If anyone embodies the work of dealing with the nation’s opioid epidemic at its very root, it is Penland. She lost it all then found solid footing again. 

Born in Oregon and raised in a home shattered by alcohol and abuse, Penland entered her 20s as a heroin addict but stopped using at 27, when she was pregnant and living in Hickory. But shortly after her daughter was born, she swapped heroin for painkillers.

“I left my daughter with my mom for what I thought was going to be a couple hours, but I didn’t come back for three days,” she said. “I knew I was going to miss my next high if I went home. My parents thought I was dead.”

Determined to turn her life around, Penland temporarily relinquished her parental rights and consented to her mother raising her daughter. She went through treatment and maintained sobriety before relapsing; then treatment again helped piece her life together.

Now 35, Penland in January celebrated five years of sobriety, and she has been living with her daughter for about that same time.

Tanned, with long, dark brown hair, Penland looks healthy and is the first person in a room to crack a joke. She is what success looks like for parents trying to recover from addiction while their cases are open with the Department of Social Services.

Social workers say she and others like her can best connect with recovering addicts and people on the verge of losing their lives to addiction through the START program — Sobriety Treatment and Recovery Teams — which began in Buncombe County last year and is the first of its kind in the state.

Penland is a family peer mentor. Once parents commit to a plan to stay clean, Penland becomes a key point of contact for the family for the duration of the START program.

"We are our own worst enemies and our harshest critics," said Dan Pizzo, START program supervisor for the Buncombe County Department of Social Services. "It takes someone to say, 'It's OK, we can get through it together, there is a way through,' which is our role at START."

Erasing stereotypes

The introduction of START in Buncombe County is the first large-scale attempt at bridging the gap between social services and families with one or both parents coping with addiction.

It started in Ohio in 2006 and branched into Kentucky a year later. Both are Appalachian region states hit hard by the opioid epidemic.

Kentucky’s opioid overdose death rate ranked as the nation’s sixth-highest in 2015, according to the nonprofit Kaiser Family Foundation. The state recorded 21 deaths per 100,000 residents that year. Ohio, which saw the nation’s third-highest opioid overdose death rate, experienced 24.7 deaths per 100,000. 

North Carolina’s opioid death rate of 11.9 ranked as the nation’s 18th highest in 2015, but that rate represented a 19 percent surge from a year ago.

The START program involves attending treatment programs, joining weekly support groups and learning new coping skills.

Since 2007, Kentucky has served 806 families, according to a report by the state’s START directors, and 95 percent included newborns delivered with substance exposure. Almost 80 percent of children who were part of START remained with or were reunited with their biological parents in the end, the report said. 

Buncombe’s START team of eight people is composed of supervisor Pizzo, an addiction specialist, three social workers and three family peer mentors, all of whom have a history of mental health issues or substance abuse disorders. 

The mentors must have maintained at least three years of sobriety, and they are the key to helping social workers be seen as allies rather than people to be avoided.

“I would love to help de-villainize the department,” Penland, said. “Our goal is not to tear the family apart but to keep them together, and that is not the first thing that comes to mind.”

When social services investigate a call reporting child neglect or abuse, the case is flagged if substances were found in the home. The START team examines those substance abuse cases and meets with the families to decide whether they are a good fit for the program.

During the first four to six weeks of DSS intervention, families are more willing to engage with social workers and commit to treatment plans, Pizzo said.

“If we wait until 45 days before getting something on paper, then it’s too late,” he said. “Addiction breeds in secrecy, so we need to have all the cards out on the table right when we meet with them.”

The transparency allows caseworkers to adjust treatment plans.

Parents are more willing be honest about relapses or struggles when a part of the program, said Paul Dailey, a social worker with START in Buncombe County. He has 10 years of experience working in the substance abuse field.

The perception for many families is that DSS presence means bad news, that the agency intends to take children away and place them in foster care. 

“Child Protective Services doesn’t have the best standing in the community,” Dailey said.

The dance between peer mentor and social worker has also helped to change the culture within Buncombe’s Department of Social Services, said Amber Cook, who manages the START program within the Family In-Home and Prevention department.

“In the beginning parents are extremely vulnerable, going through denial phase, and it is a place that is dark for them and they can’t yet see where they need to be,” Cook said. “With the opioid epidemic and learning that addiction is a disease, we’ve come to realize as social workers that it’s OK to give them all the support we can and it’s OK to hand-hold them even though we are taught not to.”

There is a public misconception about the need to remove children from their homes right away when their parents are using drugs. That’s not always the best option, Cook said.

“We are still statutorily charged with the child’s safety at all times,” said Tammy Shook, recently retired social services director in Buncombe. “But we are also charged with working towards reunification."

Shook said if parents are able to have a connection to their child, they are more motivated to attend treatment and are less likely to relapse.

Buncombe’s START project is equipped to handle up to 30 families.

“I see that there’s true hope in the strategy that we’re coming up with, and I want to be part of that hope," Pizzo said.

Reversing decades of fueling an epidemic

Just as social workers are turning to former addicts to help combat the opioid crisis, a pair of Western North Carolina physicians is cautioning peers on the use of powerful painkillers. 

Dr. Don Teater and Dr. Blake Fagan acknowledge they could have unintentionally made addicts of patients and worry their early career prescribing habits led to deaths.

Teater and Fagan started working together three years ago to address what they felt was a lack of knowledge by doctors on the addictive power of opioid painkillers.

Teater, a primary care doctor in Haywood County, and Fagan, a family physician at MAHEC, said there were opportunities for doctors to learn about opioids in the late 1980s and '90s — but workshops and educational forums were paid for or sponsored by pharmaceutical companies.

He said he had no reason to suspect the medications were potentially dangerous.

“My first reaction to these pills was, ‘This is great; we hate to see people in pain,’” he said. 

In his office, pharmaceutical representatives would show him videos featuring “real people” talking about how they had been relieved of pain thanks to opioids, Teater said. 

“They specifically said, 'Your patients won’t get addicted to this,' so we all believed them and no doctors really questioned it,” Teater said. “But I know a few of my patients who died because of my prescribing.”

Purdue Pharma, a pharmaceutical company that sells medical products like OxyContin, has been under scrutiny since the epidemic started. The company is under investigation by attorneys general from 41 states. 

Josh Stein, attorney general of North Carolina, is in talks with Purdue Pharma over a potential settlement.

At the end of last year, Purdue pledged to take a role in fighting the epidemic.

It was at the urging of his wife, a marriage and family therapist and substance abuse counselor, that Teater started asking patients if they were experiencing addictive symptoms.

Repeatedly, the answer from patients was that they never meant to abuse their medication.

“I think the responsibility falls on the doctors almost completely,” Teater said. “People don’t start on heroin; they start with pills someone originally prescribed to them."

Teater stopped prescribing specifically for pain, and together with his wife opened a dual treatment clinic. He treated opioid addicts medically with buprenorphine and she counseled them. 

Buprenorphine, like methadone, treats pain and is also called a medication assistant treatment. It is sold under the name of Suboxone or Subutex. Buprenorphine helps people with opiate and heroin cravings and is considered safer than methadone.

The biggest hurdle for medical professionals today is a lack of education, Teater said. In medical school, both Teater and Fagan said they remember learning little about addiction. 

Everything Teater knows about opioids is because of the time he spent independently researching, he said. He went on to earn a master’s degree in public health and now serves as a medical adviser with the National Safety Council. 

“Doctors are not good researchers because we don’t have time. We have to pay money to access medical journals, and most of the time we aren’t even sure who is behind these studies,” Teater said.

The nation is 10 years from where it needs to be when it comes to getting a handle on the opioid epidemic. Fagan matches his colleague in fear that the country is moving too slowly to address the crisis.

The pair travels from offices to hospitals in North Carolina and neighboring states, preaching caution and offering detailed presentations on the doctor's role in the cycle of addiction. Their talks focus on the crippling effects of addiction and how new prescribing practices could dramatically reverse the problem. 

“When I talk to doctors today I say, ‘I am going to teach you about pain, opioids and addiction, and you are going to learn more in this next hour than in your entire life about this.’ When it’s over, all of them in their feedback forms tell me they never learned that information before,” Teater said. He said pharmaceutical companies are still pushing doctors to prescribe prescription painkillers, only now they are marketing the idea of safe prescribing methods.

“The (Centers for Disease Control and Prevention) has shown that even the lowest dose of opioids increases your risk for addiction,” Teater said. “I really don’t think that there is any such thing as safe opioid prescribing.”

Is it enough?

Fagan sees a flaw in prescribing practices: There is no nationwide system to ensure doctors are on the same page. As the epidemic has surged, addicts and dealers have doctor-shopped by crossing state lines.

In North Carolina, doctors can use the Controlled Substance Reporting System to monitor a patient’s prescription history. The system allows them to see cases in which a patient might have been prescribed an unusual amount of controlled substances in the past 12 months.

But doctors in North Carolina cannot retrieve prescription histories from other states.

“People will drive everywhere to find their drugs, and we can’t track them with our North Carolina system,” he said. 

There needs to be a universal system, Fagan said, that is efficient and easy to use.

Doctors have complained to Fagan during his opioid presentations about difficulties trying to access their state’s reporting system – meaning doctors don’t use them as often as they should, he said, or choose when to look someone up based on first impressions.

"We've quickly learned with this epidemic that even the most put together looking person could be an addict," Fagan said. "Meaning our initial three-second judgment of someone based on appearance isn't effective and is rarely accurate."

MORE: Map of WNC Treatment Centers

The STOP Act — Strengthen Opioid Misuse Prevention — was created in 2017 as a statewide response to the drug crisis. Nurses and physician assistants are now required to consult with supervisors before prescribing any opioid or narcotic labeled Schedule II or Schedule III substances — those with a potential for abuse — according to the North Carolina Medical Board.

But with the STOP Act legislation that went into effect this year, soon doctors must look up all patients before prescribing them a controlled substance. 

That’s created tension.

“There has been a lot of push back from doctors who say the system is clunky, that it takes too long to look people up and that it’s not always accurate,” Fagan said. “It takes about three minutes to look someone up, which doesn’t sound long, but it is when you are seeing 30 patients a day.”

As of January, doctors are limited to prescribing up to five days of opioids for acute pain, Fagan said. Acute pain typically lasts no more than six months and is not considered a dangerous injury.

Surgeons are limited to prescribing a seven-day supply of opioids.

Fagan said it will take years before these reversal strategies slow the practice of overprescribing.

Lingering concerns in outlying counties

While doctors attempt to make an old system work and abide by new prescription policies, in the state’s most rural counties recovering addicts struggle for access to any help at all.

In McDowell County, social services director Lisa Sprouse said she wants to integrate a program similar to START but lacks funding and staffing. So she has started a joint peer mentor-social worker duo to work with one family in McDowell. It may not be hundreds of families, Sprouse said, but it’s a start.

“We have no outside funding for this experiment except sources who have volunteered their time to work with one family,” she said.

Sprouse sometimes goes to the homes of families with open cases because there is no one else available.

Counties like McDowell, Macon and Clay are forgotten, Sprouse said. Although they have services offered through Vaya Health, like walk-in-crisis centers, she said the efforts aren't doing enough.

"People are going to services through Vaya and participating in group treatment settings, and it's not working," Sprouse said. "Our clients continue to use meth, heroin and opioids." 

Counties surrounding Buncombe have fewer options for helping families and addicts.

Buncombe, for example, was the only Western North Carolina county to win funding from a $15.6 million federal grant in May. At least 80 percent of the money is allocated for support outreach, engagement, treatment and recovery services.

This was part of the state-targeted response to the opioid crisis proposal created by North Carolina agencies last year. 

DSS supervisor Patrick Betancourt, of Macon County, and Sprouse said they feel the burden of being forgotten counties in an epidemic that’s allowed too many people to fall through the cracks. 

"Even though we squeak the wheel quite loud, the larger counties have the ability to fund the initiatives in ways we can't," Sprouse said.

In addition to helping families survive the opioid epidemic, she is battling her own disease. 

Less than a year ago, she was diagnosed with ovarian cancer and has undergone 18 rounds of chemotherapy. Still, Sprouse missed only a handful of days of work in between treatments. She just couldn't leave her staff shorthanded.

"You give and give and sometimes you have nothing left to give, but you just keep going," Sprouse said. "I just know this is the work I am called to do."

She rarely speaks about her illness and instead keeps the attention focused on children, who she said are suffering the most.

She said the sheriff’s office, first responders, homeless shelters, churches and volunteers have provided support to her and her team.

The county's circumstances, she said, are a breeding ground for the opioid epidemic.

“We are the working poor,” she said. “Factories, textiles and industries all used to support our families. Now, there is hardly anything for them.”

Without greater intervention, the short-term outlook is bleak, said Fagan, the MAHEC family physician.

“We haven’t hit the peak or the decline in Western North Carolina,” he said. “Think of opiate use disorder as a swift-moving river – there are people in the river and they’re drowning and we have to jump in and pull them out. 

“But someone has to run up the river and see who’s pushing them in.”

In WNC, the people trying to help are Sprouse and Crystal Sweatt, the recovering addict helping women cope with their own struggles at the McDowell County Ministries shelter. It's Shantel and Zack Wyatt, who became foster parents after becoming alarmed by the number of children being neglected by addicted parents; and Jennifer Grayer, the Moses H. Cone Memorial Hospital nurse practitioner who witnesses the pain of newborns going through withdrawal and sympathizes for mothers who used during pregnancy.

Their efforts, Sprouse said frankly, so far aren't enough.

"My small opinion is that things are getting worse, and we have a long way to go before they get better."

Alexandria Bordas is a reporter at the Asheville Citizen Times. You can reach her at abordas@citizentimes.com.