LITTLE FALLS, Minnesota — The stomp of boots echoed above her head. Her father had found the empty cashbox. Monica Rudolph, a 25-year-old living in her parents’ basement after her second eviction, had robbed the box to pay for heroin.
She was working two jobs in this small town, waitressing by day and bartending at night, to pay for drugs, but still never had enough. Like a mouse nibbling cheese, she’d steal $30 at a time from her dad’s stash to buy bags of brown powder, until all of the money — $2,000 — was gone.
Now it was a Saturday morning, her father had discovered the theft, and she was shaking from heroin withdrawal. She knew days of knee-buckling vomiting, diarrhea, and stomach pain lay ahead.
“I had nothing. My life was broken down into four- to five-hour increments to get high, to put off feeling sick,” Monica told BuzzFeed News. After realizing the money was gone, her father railed against her boyfriend. Her mother, Louise Rudolph, asked her if she was on drugs. And after years of pretending otherwise on that day in 2017, Monica said yes.
“I just didn't want my daughter to die,” Louise told BuzzFeed News. “Oh my God, I was so scared she would die. I just wanted to get her help."
She opened the Yellow Pages and started calling treatment centers in cities all over Minnesota. Again and again, Monica and Louise heard recorded out-for-the-weekend messages saying to call back on Monday.
Monica was scared too. She knew from past attempts to get clean that it would be at least two weeks before a treatment center could take her, because they needed a diagnosis and referral from a doctor first. And she knew she’d never last. “Mom, I cannot be sick that long,” she told her.
“Why not call the local hospital?” her mother finally asked, the last place Monica would have thought of. Somebody picked up the phone at St. Gabriel’s Hospital in Little Falls. Monica was immediately transferred to a substance abuse counselor, who did her referral over the phone and then asked if she could come the next morning to start treatment.
“My hometown of 8,000 people was the one place in the state that picked up the phone,” Monica said. “Think of all the people like me who don’t have that hometown.”
This small town has managed, in just five years, to curb its drug epidemic — a rare feat in a country where overdose deaths continue to rise, with more than 70,000 last year alone. Nationwide, fewer than one-third of people addicted to opioids can find the treatment that Monica found.
Little Falls didn’t do anything revolutionary. They just spent real money — at least $1.4 million in state grants since 2014 — on basic public health measures: limiting prescription refills, increasing access to addiction medications, and putting drug users in treatment programs instead of jail.
In other words, they began treating addiction as a disease instead of a crime.
And it worked: Emergency room visits to obtain painkillers fell from the top occurrence to out of the top 20 within six months after the hospital started monitoring prescriptions. There are now 100 patients on addiction medication at St. Gabriel’s, and 626 people have been tapered off opioids.
“One thing led to another,” Kurt DeVine, the first doctor Monica saw at St. Gabriel’s, told BuzzFeed News. “We realized we had to do a lot of things we weren’t doing, and that we had to do them together, or it wasn’t going to work.”
DeVine and his colleague Heather Bell became certified to prescribe buprenorphine, the milder opioid they favor to taper patients with opioid use disorders, in 2016. Now they teach people in other Minnesota cities, and as far away as Alaska, how things work in Little Falls through regular online seminars. Another 24 doctors have become certified through their efforts in the state, up from 100 three years ago. They talk to many towns, he said, who aren’t thinking big enough.
“They get Narcan” — an opioid-reversal drug — “or they get one little project and they think that is going to fix it,” he said. “There is no easy answer. It is a lot of work. If we were doing only one thing, just Narcan, our problem would be as bad as anywhere else. You have to do it all.”
Like a lot of places across the US, the overdose crisis snuck up on Little Falls, largely because of a surge in opioid painkiller prescriptions. Those excess pills ended up on the black market, often stolen by teenagers from their parents or grandparents and sold to their friends.
On Thanksgiving Day 2012, a shocking double murder got everyone talking about the opioid crisis. A retired homeowner, Byron David Smith, shot and then executed two teenage cousins, Nicholas Brady and Haile Kifer, who had broken into his house. The cops found prescription painkillers, stolen from another retiree the previous week, in their car.
“That made it clear to everyone that something bad was going on,” investigator Jason McDonald of the Morrison County Sheriff’s Office told BuzzFeed News.
A year later, “we had our first local heroin overdose, of a young woman,” he added. “We knew we had a problem.”
The opioid crisis arrived in Morrison County a bit later than the rest of the country, but its spread there followed a similar pattern — with prescription opioids coming first, then a legal crackdown on pills that left some users desperate enough to try street heroin. That’s what happened to Monica too. She was prescribed Percocet painkillers after a high school car wreck, then started buying stolen pills and finally heroin.
By 2014, the community could no longer ignore the problem: As many as three people were dying of opioid overdoses every year, a shock to the small county of 33,000 people that hadn’t seen them before.
That year, St. Gabriel’s Hospital realized local pharmacies were dispensing far too many painkillers, with more than 100,000 opioid pills prescribed every month. Aided by a $368,000 state grant, the hospital began reading charts of patients to see who was getting so many refills and alerting pharmacies about overprescribing. Within a year, people seeking painkillers went from the top emergency room complaint to less than a top 20 concern. Around 660,000 fewer doses of painkillers have since been prescribed in the county. As of August, the prescription-monitoring program has helped 626 people, more than one-third of the people on high-dose prescriptions in the county, taper off opioids, while crimes related to drugs — the kind of thefts that led to the deaths of Brady and Kifer — have dropped.
But the team there soon realized that lowering prescriptions wasn’t enough, DeVine said. They also had to help the people already addicted to the drugs.
In a clinic, they formed a “care team” — a social worker, a nurse, two doctors, and a pharmacist — who devote themselves to helping people like Monica Rudolph. Usually they prescribe them Suboxone, a medication that combines a mild opioid, buprenorphine, with naloxone, a drug that reverses overdoses. This “medication-assisted treatment” lessens the addictive properties of opioids without triggering withdrawal sickness and is the most effective treatment for people with an opioid use disorder.
In the decade before the opioid crisis, Morrison County had a similar problem with methamphetamines and had created a public task force of health officials, cops, schools, and doctors to deal with it. That task force has since been repurposed for opioids, so that authorities can connect what is going on in schools with changes at pharmacies, traffic stops, and the county jail. There are endless programs, “coffee with a cop” meetings, school talks, naloxone trainings, and even yoga classes at the jail.
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.”
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 population there 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.”
That’s rare in West Virginia, where only about 10% of people who survive an overdose receive addiction treatment afterward. Only about half of the state’s 55 counties have at least one federally certified provider of buprenorphine.
With nearby Marshall University’s help, Huntington now has a “one-stop shop” for drug treatment called PROACT, a former pharmacy location that offers counseling, job, and housing help along with medication-assisted treatment, welded together from four health systems in the region. Unlike Little Falls, which made an effort to create a widespread network of doctors across the state accredited to offer buprenorphine, Huntington has centralized treatment, PROACT director Michael Haney told Buzzfeed News.
“There are a lot of things that we can’t bill insurance for that people need,” Haney said. “Spiritual care is not a billable service. Finding someone a job is not a billable service. We have to find a way to let people have meaningful and productive lives, though.”
So the program found clever ways to save money, such as enlisting church group vans to transport people to appointments across the rural state. Aside from Sunday and Wednesday services, the vans were otherwise sitting in church parking lots.
In Rhode Island, a similar medical program has worked in the toughest of places: the prison system. In 2016, despite some reluctance at the Rhode Island Department of Corrections, a unified prison and jail, the state launched a treatment program for inmates with an opioid use disorder, offering methadone and buprenorphine (opioids that reduce cravings) and naltrexone (which blocks the effects of opioids), as well as counseling, at a cost to the state of $2 million. The overdose death rate for inmates dropped by 61% within a year of them leaving jail , and this alone lowered the fatal overdose rate for the entire state by 12%.
“It was idiotic not to do this,” Josiah Rich, director of the Center for Prisoner Health and Human Rights at the Miriam Hospital in Providence, told BuzzFeed News. Without drug treatment in prison, he said, “they are going to overdose as soon as they get out.”
Little Falls overcame similar reluctance from Minnesota prison officials to start offering drug treatment in the local county jail in September 2017.
“They told us it was frowned upon,” said DeVine of St. Gabriel’s.“We said they could frown all they like. We were going to do it.”
The results speak for themselves. The average jail time for inmates who started on Suboxone treatment dropped from 17 days in 2016 to 1 day by 2018, with fewer committing crimes after their release. And 100% of prisoners now stay on their medication while in jail.
“We went to the jail, talked to all the correctional officers — and let me tell you, that’s a tough crowd. We got them convinced enough to do it in there,” DeVine said.
Officials in Little Falls, Huntington, and Dayton all said that the gains in their towns would never have happened without infusions of money they’ve received from the federal government.
First off, all three rely on Medicaid and the Affordable Care Act — which spent $9 billion last year across the country on treatment for substance use disorders, including Monica’s in-patient recovery program. But the towns have also received new pools of state and federal money. Since 2016, Congress has passed spending bills providing an extra $2 billion for state and city grants to address the overdose crisis, on top of $1.9 billion given to its main drug prevention and treatment agency.
“As a critical access hospital, any new program is always funded with grant dollars,” St. Gabriel's Health foundation director Kathy Lange told BuzzFeed News by email. Without a fortuitous state grant in 2014, “this program would have NEVER happened because we don’t have the extra money.”
For Little Falls, that $368,000 state grant was followed by another $75,000 grant a few years later. A $1 million state grant making the city one of eight hubs for addiction treatment in Minnesota came in 2016. And another $293,000 state grant that started last year pays for the hospital’s medication-assisted treatment program, part of a worldwide network of teleconferences to train medical personnel on dealing with the overdose crisis.
That all helps, because the salaries of the clinic team total around $300,000 a year, not including the two doctors. The hospital has had to work hard for every grant, and is working with state legislators to try to find more funding, Lange said. Right now, they are waiting for $650,000 promised last year in a federal spending bill. “I have not yet seen a check or acknowledgement,” she said. “Waiting on that any day!”
It still doesn’t cover everything. The people from the more than a dozen organizations, pharmacies, county and city agencies on the Morrison County Prescription Task Force all volunteer their time. Coordinating patient care, vital to patients with physical or mental health challenges common on top of an opioid use disorder, has only been reimbursable by Medicaid since July, and in 15-minute increments that don’t cover costs. Much of the work that DeVine and Bell do is also unreimbursed. “We are always looking for more grants,” Lange said.
As a snowstorm blanketed Little Falls this January, just ahead of a polar vortex that sent wind chills down to –50 degrees, the task force volunteers met at St. Gabriel’s Hospital over lasagna to see what was working, and what still needed to be done.
Yoga has gone over quite well in the jail, with about 30 men and 5 women now taking the classes. The town’s drug court has 13 participants, in recovery instead of in jail. But there are, as always, money problems. The insurance that paid the monthly $20 for recovering drug users to work out at a local gym has expired. And the sheriff’s office needed $300 to burn the 180 pounds of painkiller pills they had collected from users in voluntary “drug take back” events.
“It’s expensive, because it’s hazardous waste,” McDonald, the sheriff's office investigator, told the group. He planned to see if the DEA would pay to burn the pills.
On the Monday after that meeting, Feb. 4, with a respite from winter actually sending temperatures above freezing in Little Falls, a new person started work at St. Gabriel’s clinic.
It was Monica Rudolph. Monica who had used heroin for five years. Monica who had robbed her father’s cashbox for heroin. Monica who has walked in the door there at the hospital unwashed and in the throes of withdrawal. She has now been trained through a federal program to serve as its first rural “peer” counselor, a former drug user who helps coach people through their recovery.
“My life has come full circle,” she said. “I’m really excited to give something back.”