wjcasino 5 | How the Opioid Crisis Devastated Families, Communities, and, Ultimately, a Country

Kateena Haynes’s smile warms the room as she weaves through playing children at her feet to get to the computer room, chatting with staff as she goes. There, the walls are lined with desktop computers for kids to do their homework. A few minutes later, walking around back under the hot Appalachian sun, she notes the outstanding construction tasks for the new Boys & Girls Club gymnasium, which would officially open later that year, and beams at the progress. Haynes runs the youth development center in Harlan, Kentucky, but even if you didn’t know her official title, you’d quickly figure out that she’s the heart of this place.

And if anyone knows Harlan, it’s Haynes. She was born and raised in the southeastern Kentucky city, and she has dedicated her life to helping its children. While Haynes has had many success stories in her program, she holds on to the upheaval that the children had to endure—and the odds they had to overcome.

During the winter of 2010, 13 of the approximately 60 kids in the Boys & Girls Club of Appalachia had a parent die of a drug overdose. One was a young girl whose father had just returned from prison and asked her to inject opioids into his arm. She said no, knowing he had already had too much.

“He wound up getting out and coming back home and overdosing in the bed with his daughter in the bed with him,” Haynes said in a 2024 interview with Encyclopaedia Britannica.

That girl grew up to be a nurse, and Haynes said she has avoided using drugs. But that was not the case for many who grew up in Harlan county and the countless other areas affected by the U.S. opioid epidemic. Ultimately, understanding how things got so bad in Harlan requires a deep dive into America’s winding and complex relationship with drug addiction.

wjcasino 5 - From opium to Oxy: How history set the stage for the opioid epidemic

According to the U.S. Centers for Disease Control and Prevention (CDC), more than 800,000 Americans died of opioid overdoses between 1999 and 2023. The drug that drove the initial phase of the epidemic was OxyContin, or oxycodone hydrochloride, a narcotic painkiller that can produce a euphoria similar to that of heroin. For its part in producing and distributing OxyContin, pharmaceutical giant Purdue Pharma agreed in 2025 to pay $7.4 billion to all 50 U.S. states, Washington, D.C., and four federal territories. Harlan is expected to receive at least $10 million over 18 years to establish treatment, recovery, and prevention efforts throughout the community.

Humans have used opioids for centuries. Clay tablets from early civilizations show prescriptions for opium, the natural medicinal source of opioids derived from opium poppy plants. Some religious scholars suggest the drug is mentioned in the Bible as rosh, a poisonous plant that represents sinfulness, though there is no widespread agreement about which plant in particular rosh describes. In the 19th century opium was given to injured soldiers to numb their pain and was used in up to one-third of all lethal poisonings in England, many of which were because of lack of regulation. By then it was clear that overdoses were never far when opium was near. The drug also played a role in years of conflict, known as the Opium Wars, between China and European powers throughout the mid-1800s.

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In the complex evolution from the opium plant to widespread synthetic opioids, the 19th century was a critical turning point. American dental surgeon William Thomas Green Morton first demonstrated opioids’ use for anesthetic purposes when combined with ether in 1846, not long after the popular and wildly powerful pain medications morphine and codeine were isolated from opium. These drugs were widely available and could be used without a prescription. Then in the latter half of the century, heroin was synthesized; it also didn’t require a prescription until 1914.

Before 1874 all opium-related drugs were considered natural opioids. Heroin, synthesized via chemical manipulation of natural opium, was the first in a class of semisynthetic opioids. It is much more powerful than natural opioids—and much more addictive. Though heroin would be a scourge for the second half of the 20th century, the perilous power of morphine dominated the first half.

Learn more about the difference between opioids and opiates.

In 1929 the National Research Council’s Committee on Drug Addiction was created with a very specific first target: morphine. While their researchers were at work on understanding addiction and regulating the use of morphine, meperidine, the first entirely synthetic opioid, was created, ushering in a new era of increasingly potent drugs that carry massive overdose risks. At the same time access to other addictive opioids became more common. While the early-to-mid-20th century brought the use of hydromorphone and hydrocodone for pre- and postoperative pain, the distribution of opioids entered a new era in World War II.

The U.S. gave members of its military medical kits that each included single-use morphine injections to provide pain relief to injured troops waiting for advanced medical personnel. Though they had labels that read “Warning: May be habit-forming,” those labels far understated the drug’s addictive potential. After the war some medical kits were sold or stolen by those seeking morphine doses, and others who’d become addicted turned to heroin when morphine wasn’t available.

In 1947 the Committee on Drug Addiction and Narcotics was established, revamping the effort begun in the 1920s. This renewed focus on controlling the manufacture and distribution of drugs was, in part, spurred by the creation by German researchers of methadone. Methadone had shown potential to mitigate symptoms of opioid withdrawal, a potential that had yet to be fully realized. Though research funding began to trickle in, progress stalled as no stream of financial support was established until the 1960s.

That decade was known for massive societal shifts in the United States driven by the civil rights movement, feminist advocacy, and the rise of a distinct counterculture grounded in the questioning of long-held beliefs. For some, this attitude of rebellion led them to try—and in some cases become dependent on—illicit drugs. The increased use of marijuana, LSD, and eventually cocaine, heroin, and amphetamines led to crackdowns on pharmacies that distributed these drugs as well as a greater focus on prevention and treatment.

In 1962 the White House Conference on Narcotic and Drug Abuse was convened with the goal of determining how to better collect data about drug use, how to manage the use of both narcotic and nonnarcotic drugs, and what treatments could help those facing addiction. That year federally funded mental health centers were established nationally.

The next major move, the Controlled Narcotics Act of 1970, sorted drugs into five schedules, or categories, based on addictive potential and harmfulness, as well as their medical utility. Heroin, which had a spike in use in the late 1960s and early ’70s, was classified as a Schedule I drug, meaning it had a high potential for addiction and no accepted medical use. Cocaine was labeled a Schedule II drug, meaning it had some medical utility. Despite growing attention throughout the presidencies of John F. Kennedy and Lyndon B. Johnson, the official War on Drugs was not launched until 1971, when Pres. Richard Nixon declared “drug abuse” to be “public enemy number one.” The Drug Abuse Council was founded the same year, as the result of the Ford Foundation’s research, and helped to provide funding for research through 1978.

Initially the War on Drugs was praised as a long-awaited intervention for a serious public safety issue, but in hindsight many have called the effort a failure, both ethically and politically. Even with increased attention on the country’s drug problem, the use of crack cocaine soared throughout the 1980s. It was affordable and provided quick access to euphoria, and its ability to be smoked allowed people to receive smaller portions—all of which made it more cost-effective than powder cocaine, which has historically been seen as a symbol of wealth.

Instead of going after large dealers or manufacturers, Nixon’s War on Drugs led to mass incarceration because it targeted people selling relatively small quantities of drugs, which often meant prison time for young Black men in urban areas who were charged with low-level drug offenses. The War on Drugs also brought the use of mandatory minimum sentences, which disproportionately affected Black communities. Those found with five grams of crack cocaine received a mandatory five-year prison sentence. It took 100 times that amount of powder cocaine to earn the same sentence, meaning that a high-level powder dealer could receive a lesser punishment than a low-level crack dealer. Though statistics show that overall drug use is similar between white and Black communities, four in five crack cocaine users were Black. Nixon’s former White House counsel, John Ehrlichman, gave an interview in 1994 in which he explained the intentional targeting of these communities:

The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people.… We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.

Today many see the War on Drugs as having meted out the disproportionate impact of incarceration on historically underserved communities—a pattern that the quickly emerging opioid epidemic would only exacerbate. While the War on Drugs perpetuated stereotypes about Black communities, public response to the opioid epidemic capitalized on and furthered derogatory caricatures of rural white communities before the epidemic spread to all corners of the country.

As cocaine use grew across the United States, so did addiction. The number of cocaine users increased by approximately 1.6 million people between 1982 and 1985 alone. So when Purdue Pharma’s OxyContin (its brand name for oxycodone) was approved by the U.S. Food and Drug Administration (FDA) in December 1995, concerns about drug addiction were prevalent—which made Purdue Pharma’s marketing of OxyContin as less addictive all the more appealing, even if it wasn’t true.

wjcasino 5 - The epidemic

The major problem with OxyContin extended beyond the drug itself. In fact, studies at the time of its release showed that it wasn’t more effective than other opioid analgesics on the market. What set OxyContin apart and led to the opioid epidemic was the marketing and publicity around it.

In the five years after the FDA approved OxyContin, Purdue Pharma trained more than 5,000 medical professionals at all-expenses-paid conferences, often in resort locations, to aggressively promote the drug. While there, these clinicians were trained and recruited for a Purdue Pharma speaker’s bureau that encouraged promoting OxyContin use to colleagues in environments such as grand round presentations in hospitals. The company studied physicians’ prescribing patterns in order to better tailor their sales pitch to individual doctors—especially those with the highest rates of opioid prescriptions. Though this strategy was not unique, the amount of money spent on incentives and aggressive, misleading marketing campaigns were distinctive. The company spent $200 million in 2001 alone marketing OxyContin. Sales representatives also earned bonuses that sometimes outweighed their annually salary, incentivizing them to find physicians who would overprescribe the medication.

Before this period opioids had traditionally been reserved for severe acute pain, used in the palliative care of cancer patients, for example. But Purdue Pharma’s marketing focused on expanding the conditions for which doctors would prescribe OxyContin, leading to a tenfold increase in prescriptions for pain unrelated to cancer in just five years.

This gave rise to the targeting of rural areas such as Harlan. Mining and logging in these regions often led to workplace injuries, making them hotbeds for marketing of pain relief medications. Still, that wasn’t all that made Appalachian communities vulnerable. Since the 1990s Harlan had struggled with addiction and unemployment as the coal industry declined, with more than 25 percent of Harlan county’s population of about 25,000 falling below the poverty line as of 2025. As feelings of hopelessness spread, so did the drug epidemic.

“The conditions were just right, because there was a loss of hope because the coal mines were starting to shut down,” Haynes said. “And with Purdue Pharma, they were literally pushing their drugs, so if you had a coal miner who got injured and he was prescribed [OxyContin], then he learned quickly he could make money selling his [OxyContin].”

Tom Vicini, president and CEO of Kentucky drug prevention and recovery organization Operation UNITE, explained in a 2024 interview with Encyclopaedia Britannica how this can happen. In early drug roundups law enforcement discovered that people selling opioids in the area needed money to feed their addiction, he said. If they were able to buy and resell others’ prescriptions, both parties could potentially make a profit off the drug.

Though there is evidence that marketing of OxyContin may have been less aggressive in cities, they were far from immune. Doctors in New York City and other large metropolitan areas received funding from opioid giants and in turn promoted their products as a gold standard for pain relief. And with TV and other advertisements repeating claims of a 1 percent addiction rate, OxyContin advertising appealed to both new patients and longtime chronic pain sufferers. As the country would learn, the actual rate of addiction is much, much higher, with some researchers reporting it as high as 26 percent.

According to the National Institute on Drug Abuse, prescriptions were the most common entry to opioid addiction throughout the 1990s and 2000s—up to 75 percent of all addictions began this way. And prescriptions became more prevalent: Annual opioid prescriptions grew from between 2 and 3 million in 1990 to 11 million by 1999. Even as the addictive potential of OxyContin was publicized, other pharmaceutical companies followed suit in manufacturing generic or brand name pills, including the firms Johnson & Johnson, Endo, Teva, and Allergan. By the 21st century, Purdue Pharma alone had made $1.1 billion in OxyContin sales, more than 20 times the sales of 1996.

Working at the behest of these large corporations were individual prescribers who were incentivized to dole out increasing amounts of opioids. As word spread in Harlan about a doctor who would write prescriptions for OxyContin with no questions asked, one resident said people “lined up around the street like a commodity cheese line,” a reference to government-distributed “welfare cheese” given out to low-income citizens in the 1980s. Ali Sawaf, the doctor who wrote these prescriptions, was convicted in 2002 for overprescribing OxyContin and other drugs that fueled an addiction epidemic in Harlan. Still, many blamed those who became addicted.

With the War on Drugs rhetoric weighing heavily on people’s minds, there is intense stigma associated with drug use and dependency. Through the 1990s and 2000s, the public began to shift from viewing addiction as a moral failing to seeing it as a disease—but this change has been gradual. For some the spread of addiction to all corners of the country, including to cities’ most “elite” residents, prompted this change. Highly publicized deaths involving opioid overdoses—including that of Australian actor Heath Ledger, which was caused by an accidental overdose of a mix of oxycodone and other drugs—further influenced public perception, leading to a renewed awareness of the addictive potential of prescription drugs. Although drug overdoses have long plagued Hollywood, Ledger’s death hit the public differently in light of the rising opioid crisis, especially given OxyContin’s role in his death.

Despite shifting attitudes on the subject, a 2017 study by researchers from Johns Hopkins University found that nearly four in five people think that those struggling with addiction are themselves at fault. Stigma and feelings of shame not only incentivize individuas to hide their addiction, but it can also keep many people from getting help by generating of a network of barriers. Structural stigma, for example, includes negative views held by society that influence the creation of policies that discriminate against those struggling with addiction, such as limiting the development of local treatment centers and the availability of medication for opioid use disorder (MOUD), reducing access to quality care. Self-stigma is internalized shame that can prevent someone from seeking treatment, either because they do not feel they deserve help, are embarrassed about their addiction, or because they lack systems of support.

Vicini of Operation UNITE also spoke about how the stigma associated with addiction can intersect with other stereotypes, creating worse outcomes: “That’s what people look at. Harlan county, a lot of times it’s just a bunch of kind of uneducated coal miners, which is very unfair, and it’s very, very untrue,” said Vicini, who was born in Harlan. “Sometimes when you have that negative attitude toward you, you embrace some of that yourself.”

Long after the opioid epidemic was widely recognized in the early 2000s, rates of opioid overdoses continued an unbridled rise across the country, reaching a peak during the COVID-19 pandemic and its aftermath. In 2022 more than 81,000 Americans lost their lives to opioid overdose, likely because of interruptions in treatment and psychological hardships caused by isolation, boredom, illness, or loss of work. This was especially prominent in people 20 to 39 years old, with opioid overdoses causing more than 20 percent of overall deaths in this age group in 2022, according to a study in The Lancet. Overdoses were the largest accidental cause of death for this cohort.

The physical withdrawal symptoms associated with quitting opioids make it hard to recover from opioid use disorder. Withdrawal can range from extreme physical symptoms such as vomiting and muscle spasms to emotional symptoms such as anxiety and depression. To help people recover, there has been a growing movement to make MOUD accessible.

MOUD includes methadone, buprenorphine, and naltrexone—with the former two considered by the World Health Organization to be “essential medicines” to treat opioid use disorder. MOUD normalizes neural chemistry and blocks the euphoria of opioids and is often paired with behavioral therapy to provide a comprehensive treatment plan that addresses both the physical and psychological effects of addiction and withdrawal.

Peer support services are also crucial to successful recovery, especially in such communities as Harlan. Early studies show these interventions may improve rates of opioid abstinence and access to medical therapies. Support specialists who are themselves in long-term recovery from drug addiction are at the core of these services. These workers are trained and certified, and they often focus on one-on-one support to provide hope and a model for recovery while also reducing stigma. This treatment strategy differs from support groups such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), which may take different forms but rely on a group of people holding one another accountable through shared experiences and mutual support.

That doesn’t mean these two approaches are mutually exclusive—in fact, many people rely on multipronged approaches to treatment and community support to recover from drug addiction. In Harlan numerous peer support specialists come from their day jobs to support AA or NA group meetings, which are held every evening in a building just down the alleyway bordering a bank.

Though significant gaps still remain, the shift in understanding opioid use as a public health epidemic rather than a personal moral failing has ultimately advanced the accessibility of recovery care across the country. But meeting the urgent need for support also requires funding—and there were companies that made a lot of money as a result of mass addiction and suffering.

Lawsuits and repairing communities

Large-scale lawsuits, often initiated by state attorneys general, began in the early 2000s, when West Virginia claimed that Purdue Pharma had misled medical professionals about the addictive potential of OxyContin in their aggressive marketing of the drug. The company admitted no fault but chose to settle, paying $10 million to the state over four years, to be used for drug recovery and prevention services.

That was just the beginning. In 2007 Purdue Pharma and three of the company’s top executives were fined a total of $634 million for lying to the public about OxyContin’s risk of addiction. Later that year Kentucky sued the company, and they eventually settled, with Purdue agreeing to pay $24 million to the state. But there was a pivotal clause in that agreement: The judge granted a request to unseal the court documents, making Purdue Pharma’s strategies public and unveiling the marketing strategies that propelled the spread of addiction.

Over the next decade a series of other high-profile cases involving Purdue Pharma were settled. They were brought by state and federal governments alike, including one suit brought by Canada that took more than a decade to settle, with the company ultimately agreeing to pay $20 million to individuals and health providers. Purdue Pharma declared bankruptcy in 2019.

No single settlement was as large as the $7.4 billion agreement Purdue Pharma reached with all 50 states, Washington D.C., and four U.S. territories in June 2025, to be paid out over 15 years to support prevention, treatment, and recovery programs. This resolution to pending lawsuits came just a year after the U.S. Supreme Court overturned what would have been a $6 billion settlement paid out to state and local governments. A large portion of the $7.4 billion is to come from the Sackler family, the former owners of Purdue Pharma.

Major retailers that distributed OxyContin, including Walmart and Kroger, reached similar settlements for their roles in the opioid epidemic.

Although the bell can’t be unrung, there is a breadth of research about how best to invest these abatement funds—and early evidence shows the funding may be helping to change the future of the opioid crisis. In the United States deaths from drug overdoses decreased approximately 27 percent in 2024 from the year prior, with opioid-related overdose deaths dropping by 30,365 cases. One of the states most exemplary of this change is Kentucky, where overdose deaths decreased more than 30 percent the same year.

In Harlan these abatement funds have been used to establish a position for a case manager and advocate for Casey’s Law, which allows family or friends to commit to treatment a loved one struggling with addiction. Van Ingram, executive director for the Kentucky Office of Drug Control Policy, told Encyclopaedia Britannica that there are more mental health resources now than ever, but that there’s never enough—not just in Harlan County, but in rural America as a whole.

As Haynes, CEO of the Boys & Girls Club of Appalachia, and others work to provide mental health resources for their community, Ingram said he is impressed by the growth of Harlan’s recovery community.

Said Haynes: “We started a counseling program, grief counseling, before it actually became a program of Boys and Girls Clubs of America. We were doing it first because the need was there, and we couldn’t wait for them to develop a curriculum.”

Haynes and her colleagues developed a protocol for the kids if a relative died, taking them out to dinner and keeping them occupied while the family managed funeral arrangements.

Haynes also worked to make her operation “trauma-informed,” which involved training sessions and meetings with other community agencies to advocate for children who have experienced what she calls “horrific situations and circumstances.”

She tries to mentor these children and give them opportunities that level the playing field, Haynes told Encyclopaedia Britannica: “It’s hard for some people to see beyond these mountains…especially these kids, who are seeing their parents use drugs, and they’re just hopeless.”

Simultaneously, other Harlan organizations have been working on prevention. Both Vicini and Haynes go into schools to provide education about drugs and addiction, as well as opportunities such as field trips and mentoring partnerships to keep kids engaged in their own futures.

The city’s small size enabled the opioid epidemic to spread quickly, but the intimate, close-knit relationships that the community provides have also allowed it to be a safe haven for many, including some who came there for recovery and never left.

With a combination of local efforts led by the city’s drug court and various recovery programs, including some focused on job reentry, Harlan has become an example of what an engaged recovery community can look like—and advocates believe that overdose rates are declining because of it.

Overdoses are decreasing on the national level, as well. According to a study published in the Journal of the American Medical Association, 2023 marked the beginning of “a new wave of sustained deceleration [in overdose rates]…after 2 decades of increase.”

The new wave: Dangers of fentanyl

The epidemic entered a new—and perhaps even deadlier—phase with the introduction of fentanyl. Though it has been around since 1959 as a pain reliever, illicitly manufactured fentanyl has grown increasingly popular since it became a major part of the U. S. illegal drug market in 2013. Drugs such as methamphetamines or cocaine are increasingly laced with fentanyl. In 2022, 6 out of every 10 of the millions of fentanyl-laced fake prescription pills collected by the U.S. Drug Enforcement Administration (DEA) contained a potentially lethal amount of the opioid, up 50 percent from the year before. Though a small segment of people who use drugs seek out fentanyl, many of those buying laced pills are unaware of its presence until it is too late.

Fentanyl is the one of the most potent pharmaceutical opioids and is 100 times more powerful than morphine. A dose of the drug equivalent to just five to seven grains of salt can be lethal, which is partially why it’s responsible for 70 percent of overdose-related deaths. And growing numbers of illegally obtained drugs are laced with fentanyl because its potency allows smaller doses of the pure drug to be sold while providing the same level of euphoria and even higher addictive potential, increasing both profits and demand. Even if it puts customers in danger, the money outweighs the risk for some sellers.

As in previous drug epidemics, the fentanyl crisis disproportionately affects lower-income communities, highlighting the continued need for intervention resources and prevention efforts. Research investigating the use of MOUD such as buprenorphine for those addicted to fentanyl is ongoing. In the meantime the popular opioid antagonist naloxone, which can reverse an overdose, is becoming more widely available. The drug is often administered through nasal spray, and boxes containing naloxone doses (sometimes called NaloxBox or by the brand name Narcan) are more commonplace across the country.

In a February 2025 U.S. Senate hearing, Sen. Dick Durbin of Illinois spoke about the growing risk of fentanyl:

In just a decade this synthetic opioid [fentanyl] has emerged as the deadliest drug in American history. All it takes is two milligrams—that’s a fraction of the size of a penny—to cause an overdose. It is so cheap that dealers are lacing lethal amounts into street drugs like cocaine and heroin, and their buyers are none the wiser.

Yet if communities can harness the growing concern about fentanyl for change, it may give a second chance to those struggling with substance use disorder. Since 2022 Harlan county has held an annual drug summit to bring together more than two dozen exhibitors with a focus on continuing to bring down overdose rates, even in the face of fentanyl.

Along with increased efforts to provide those struggling with addiction transitional housing, reemployment, and improved treatment accessibility, Harlan and other communities hit hard by opioids have another key tool: love.

“There’s people that came here for treatment and never left, because they were loved,” said Dan Mosley, Harlan county judge executive. “That’s truly what makes our place special.”