CHILLICOTHE, Ohio — Nine women live in the little house by the railroad tracks. It's early fall, and they're sharing three bedrooms and a single bathroom. They rise each day at 6 a.m., brush their teeth, eat breakfast together and then get into a van to ride a half-mile to all-day group therapy. At dusk they'll be back, typically sitting on the porch, smoking cigarettes, and watching the trains go by.
The conductor will blow the horn. The women will wave, cigarettes brightening with the motion. It's a nice little ritual, and routines such as this — "repetition and reward," as the counselors say — are encouraged for people in recovery from heroin and opioid addiction.
These women dream of returning to normal life. Several have children but lack custody of them. In the grip of addiction, they traded away what they loved most in life for transient jolts of euphoria.
Traci Andrus, 45, is known as "Mom." She had been a city social worker until she needed routine surgery and became hooked on opioid painkillers. Familiar story: The pills led to cheaper heroin, she says, then to all manner of chaos and dysfunction, and unemployment, and jail, and finally this new existence in the little house by the tracks.
"I had a home. I had a brand-new car. I had a life," Andrus says.
Rachel Kerner, 39, is tall, striking and known as "Fancy" because she's always dressed to the nines. She had a good career as a flight attendant, but she used cocaine recreationally, failed a drug test, and lost her job. She also lost a child three weeks after giving birth, and she began abusing prescription opioids. "I didn't really deal with my son's death until I got into rehab," she says.
Lisa Touvell, 49, had steady factory work for years but has always struggled with addiction and a decade ago made the transition from pills to heroin. "I gave up. I couldn't find a job. Two failed marriages. My kids were taken away. I gave up," she says. She wound up in prison for drug trafficking, and she was released in March.
"I'm tired," she says.
These women are trying to survive an epidemic of self-destruction in small-town and rural America. Death rates have risen sharply among whites, particularly women, particularly those with a high school education or less — the white working class that played a key role in the November election. Last year, overall life expectancy in the United States fell for the first time since 1993, when HIV was rampant.
Today there is no emergent virus running amok. Instead, Americans are dying from a rash of pathologies, sicknesses and addictions that experts call "diseases of despair."
In a year-long series, the Washington Post has explored a complex epidemic that combines an oversupply of addictive prescription drugs with a dismaying demand for them among people struggling with pain and hopelessness.
Opioids come in many forms, from prescription painkillers to street heroin. Fatal overdoses from prescription opioids have quadrupled since 1999 and heroin overdoses have gone up about six-fold since 2001. But other drugs also play a role. A Post analysis of federal health data found that white women are five times as likely as white men, for example, to be prescribed drugs for anxiety in tandem with painkillers, a potentially deadly combination.
Meanwhile, the suicide rate among middle-aged white women has risen in parallel with prescriptions for often-ineffective psychiatric drugs. Both have roughly doubled since 1999, the Post found. According to federal health officials, nearly 1 in 4 white women ages 50 to 64 are being treated with anti-depressants.
Binge drinking is also on the rise, as women close the gap with heavier-drinking white males. As a result, the Post found, alcohol-related deaths have more than doubled since 1999 among white women ages 35 to 54. Booze is also a factor in myriad opioid overdoses.
The federal government's response to the opioid epidemic has been slow and halting. The Centers for Disease Control and Prevention issued new guidelines urging doctors to sharply limit opioid prescriptions only this year - fully 20 years after OxyContin, the pill that helped spark the crisis, gained regulatory approval.
Law enforcement agencies have been largely ineffective. Amid pressure from the drug industry, the Drug Enforcement Administration curtailed an aggressive campaign targeting drug distributors suspected of shipping millions of opioids that wound up diverted to the black market, the Post found. Federal officials have said they are committed to combating the epidemic but are focusing more narrowly on doctors, pharmacists and companies that continue to violate the law.
Chillicothe (pronounced "chill-i-COTH-ee") lies in Ross County, population 77,000. Last year, 40 people here died of drug overdoses, almost all from opioids. That number has tripled in the past three years.
"Forty overdoses? This, in a little sleepy county?" says John Gabis, the county coroner. "You've got to talk to one more parent who's lost a child?"
Chillicothe is a historic town in a transitional landscape. To the north and west are fields of corn and soybeans, a classic, flat Midwestern terrain. To the south and east are the foothills of Appalachia, with winding country roads that, when crossing a stream, narrow to a single lane.
World-famous Native American burial mounds speak to thousands of years of human occupation along the Scioto River. Chillicothe was the first capital of Ohio and a destination on the underground railroad. The downtown boasts vintage Victorian buildings. At the annual Halloween parade, thousands of people lined the sidewalks to applaud an hour-long stream of high school marching bands, firetrucks, vintage cars and hot rods.
This isn't one of those Rust Belt towns where the economy collapsed. People point out that you can still get a decent job here. Major employers include a hospital, a truck factory, two prisons and a branch of Ohio University. There's a retail strip with big-box stores that draws shoppers from several surrounding counties and includes an Applebee's, an Olive Garden, an IHOP and a Bob Evans.
The most visible enterprise is the paper mill, in continuous operation since the late 19th century. Its smokestack dominates the city skyline. The process of making pulp can turn the air quite pungent, but residents have long accepted the stench as "the smell of money."
It's a proud history — but natives say this isn't the place they used to know. Back in the day, the worst thing people did was hide in a ditch and hurl field-corn kernels at passing cars. That's how Tracy Minshall, 47, remembers her childhood.
"It used to be so Mayberry," she says from behind the counter of the addiction treatment center where she works.
Chillicothe was once protected from urban pathologies by its very remoteness. Today, everyone lives in a wired, networked, smaller world.
"Within the last 10 years it's changed significantly. The violent-crime rate has gone up, the theft issues have gone up, all driven by the drug issue," says police detective Bud Lytle.
Residents often blame the drug problem on "the 23 pipeline," a reference to Route 23. The highway brings in dealers from Columbus and Detroit to the north. To the south is Portsmouth, on the Ohio River. Once famous for shoe factories, Portsmouth is now better known as the setting of Dreamland, the acclaimed book by Sam Quinones that described how the proliferation of pain clinics (known as "pill mills") helped create the opioid epidemic.
The government cracked down on pill mills, and deaths from prescription opioid overdoses have leveled off nationally in the past five years. But at the same time, there has been a surge in overdoses from heroin and fentanyl, a powerful, synthetic opioid sold as a street drug and often mixed with heroin.
"Now you can get heroin quicker in these communities than you can get a pizza," said Teri Minney, head of the Ross County Heroin Partnership Project. "They're delivering."
The addicts often shoot up in public places knowing that if they overdose they will be seen and potentially revived by police or paramedics carrying naloxone, the anti-overdose medication, also known by the brand name Narcan. One day in September, police and paramedics responded to 13 separate overdose calls, including one fatality: a man who died in an apartment right on Main Street. Meanwhile, a woman overdosed in her car as it idled at a Valero gas station with her 2-year-old daughter in the back seat. On that single day, seven children in the county were taken into government custody.
"It's the Zombie Apocalypse," says Gabis, the coroner.
The county's health commissioner, Tim Angel, says he sees multiple generations of addicts now. He'll ask a young patient who has come in for treatment, "How did you get involved in this?" and the answer will be, "My mother shot me up for my birthday when I was 14."
Angel shakes his head. "In quaint rural America."
Addiction is like termite rot, eating at the foundation of a community. This cultural self-destruction is particularly pernicious when women with children can't function as mothers. Obstetrician Richard Villarreal says he has delivered many babies born to mothers with opioid addiction.
"You would never expect a lot of moms who are on narcotics. They're nice people, many are well-to-do people, they've experimented and now they're stuck," he says. Soon after the birth, he says, "these babies become shaky and you can't calm them down."
Chillicothe made national headlines more than a year ago because of what became known as the "missing women" cases. In the span of little more than a year, six young women vanished.
Rumors spread in town that a serial killer was on the loose.
State and local police and the FBI found no consistent pattern, except one: drug addiction and the social dysfunction that comes with it, including prostitution. One woman committed suicide, the coroner ruled. Another was fatally shot by a man convicted this summer of murder. Two were found dead of apparent overdoses. Two remain missing.
The only serial killer here, authorities say, is opioid addiction.
In the war against self-destruction, victories tend to be small, incremental and fragile. The epidemic is addressed piecemeal, by churches, police, judges, nonprofit groups and volunteers.
The little house by the railroad tracks is a grass-roots operation. The owner runs Safe Haven, the place where the women go daily for therapy. The house manager, Cheryl Beverly, has her own organization called Cheryl's House of Hope.
As autumn turned colder and winter arrived, the house by the tracks saw successes as well as setbacks.
Traci Andrus — "Mom" — dropped out of the Safe Haven program and moved out of the house. She said in a recent email that the program had restricted her ability to come and go, and that her family needed her. She wrote that she is clean and sober, working at a convenience store in a gas station and looking for an administrative job.
Rachel "Fancy" Kerner, the former flight attendant, graduated from the Safe Haven program and got a job in a department store. Earlier this month, she announced on Facebook that she'd been clean and sober for a year, and is "grateful for God giving me a 2nd chance at life." She wrote: "Anyone out there struggling, just remember, you can do this, don't ever give up on yourself."
Lisa Touvell, the former factory worker, is doing well. She got a job at a discount store and earlier this week moved out of the house by the tracks and into her own apartment.
Hope is essential to battling addiction, and so is money, and that's an urgent issue in Ross County. Congress recently approved, and President Obama signed, health legislation that includes funding to fight the opioid epidemic. But Ross County voters last month rejected for the first time in three decades a property tax levy that funds a variety of health services, including a weekly clinic for addicts and a program to distribute naloxone to people with family members at risk of overdosing.
Angel, the health commissioner, described the failure of the levy as "devastating." He was forced to cancel the weekly clinic and send the roughly 70 patients to another facility. Layoffs are a possibility; Angel himself lost his job when the health board on Dec. 15 terminated his contract.
The coroner, Gabis, blames the levy's failure in part on "opiate fatigue." He says, "There is a Darwinian mind-set that the addicts got themselves into this, why are we rescuing them over and over?" The police and paramedics who confront the epidemic daily are wearing down, too, Gabis said: "The human response is to turn off the emotions when dealing with this."
There are some positive signs. On Nov. 18, hundreds of high school students gathered outside the Ross County courthouse for a rally against drugs. And their parents are learning the signs of addiction: Missing spoons. Missing jewelry. Deteriorating hygiene. Bad skin. Isolation.
Lytle, the police detective, has a story about that. He says Appalachian families such as his are very close-knit. Earlier this year, he noticed that his daughter Taylor, 22, had lost weight and developed skin problems. When she complained of constipation, something clicked.
"Tell me what's going on," he said.
"Taylor, don't lie to me."
She told him the truth: More than a year earlier, she had hurt her back lifting a patient at work, where she was a nursing assistant. A doctor gave her a prescription for 120 Percocets with two automatic refills. That was 360 pills. After those ran out, he gave her a scrip for 60 more and warned her about addiction. Too late. She had no problem finding pills on the street.
After the confrontation, she kept using, and at one point vanished for two days, a harrowing experience for her parents in light of the "missing women" issue in Chillicothe. She was found in a dope house down in Pike County, taken to an emergency room and then brought back home, where she went through withdrawal — "dope sick," as the addicts say — as her family monitored her.
"It is like having the flu and laying in the street while people run over you while you're puking," Taylor said one day this fall in a meeting room at the law enforcement complex in Chillicothe.
She's 23 now, and hopeful, with plans to go back to school to get a nursing assistant's license. She says she is grateful that she grew up in a happy, stable home and that she had family support and resources.