A doctor handed Melissa Morris her first opioid prescription when she was 20 years old. She'd had a cesarean section to deliver her daughter and was sent home with Percocet to relieve post-surgical pain. On an empty stomach, she took one pill and lay down on her bed.
"I remember thinking to myself, 'Oh, my God. Is this legal? How can this feel so good?' " Morris recalls.
Soon, she started taking the pills recreationally. She shopped around for doctors who would write new prescriptions, frequenting urgent care clinics where doctors didn't ask a lot of questions and were loose with their prescription pad.
Morris's path started with Percocet and Vicodin, commonly prescribed pain medications for acute injuries and illnesses. When those drugs no longer got her high, she switched to Oxycontin pills. Then she started injecting Oxycontin. After that, she got her hands on Fentanyl patches, a highly addictive and potent opioid. She'd chew on them instead of applying them to skin as the package directed.
When doctors got wise to Morris' shopping tactics, her supplies of the pills diminished, and she turned to heroin, instead.
She started stealing to fund her addiction. Morris then got into the drug trade herself, dealing methamphetamine and other illicit substances, to raise money to buy more heroin.
"You can buy a gram of heroin for 50 bucks," she says. It's relatively cheap. "That's why so many people here have turned to heroin."
Morris lives in Sterling, Colo., a city of 14,000 that's a two-hour drive northeast of Denver. The biggest employer is a state prison. Since 2002, the death rate from opioid overdoses in Logan County, which includes Sterling, has nearly doubled, according to data analyzed by the Colorado Health Institute. Morris says she has known at least 10 people in her community who have overdosed on a mix of drugs in the last few years.
Sterling is far from unique. Rural areas and small cities across the country have seen an influx not only in the prevalence of prescription opioids, but in illicit ones like heroin. According to the U.S. Centers for Disease Control and Prevention, opioids were involved in more than 33,000 deaths in 2015 — four times as many opioid-involved deaths as in 2000. A recent University of Michigan study found the rates of babies born with symptoms of withdrawal from opioids rising much faster in rural areas than urban ones.
Like Morris, many new heroin users find themselves using the drug after getting addicted to prescription drugs first. The CDC reports three out of four new heroin users report abusing prescription opioids prior to trying heroin. In the U.S., heroin-related deaths more than tripled between 2010 and 2015, with 12,989 heroin deaths in 2015.
As the drug use reaches into more communities across the country, researchers are scrambling to both diagnose what causes some people and some regions to be more susceptible to opioid abuse, and to devise solutions. Dr. Jack Westfall, a family physician and researcher at the University of Colorado and with the High Plains Research Network, works with a network of rural clinics and hospitals in the state. He says many doctors on the Plains are feeling frantic.
"We don't know what to do with this wave of people who are using opioids," he says. "They're in the clinic, they're in the ER, they're in the hospital. They're in the morgue, because they overdosed."
For more than a decade, opioids have been a key part of a rural doctor's pain management for patients, Westfall says. Treatment options are often fewer in a rural area; alternatives like physical therapy may not be available or convenient, so drugs are a prime option.
Some researchers think larger economic, environmental and social factors leave rural Americans at particular risk, says University of California, Davis, epidemiologist Magdalena Cerdá. After the 2008 recession, rural areas consistently lagged behind urban areas in the recovery, losing jobs and population.
"You have a situation where people might be particularly vulnerable to perhaps using prescription opioids to self-medicate a lot of symptoms of distress related to sources of chronic stress — chronic economic stress," Cerdá says.
Plus, the specific types of jobs more prevalent in rural areas — like manufacturing, farming and mining — tend to have higher injury rates. That can lead to more pain, and possibly, to more painkillers.
"One of the things that is counterintuitive to most of what we think of as [being part of life in] a small town is that rural people have much larger social networks than urban people," Dombrowski says.
In some cases, his research suggests, rural residents know and interact with roughly double the number of people an average urban resident does — giving rural people more opportunities to know where to access drugs.
"So some of those social factors of being in a small town can definitely contribute," he says.
"It's not a fundamentally rural problem," says, Tom Vilsack, Barack Obama's secretary for the U.S. Department of Agriculture, who led the Obama administration's interagency push to curb opioid abuse. "But it's a unique problem in rural America because of the lack of treatment capacity and facilities."
That lack of treatment is definitely a problem in Sterling, where patients often have to drive a long way to get care.
Melissa Morris relies on Suboxone, a prescription combination of buprenorphine and naloxone that's used to help wean people off heroin or other opioids. Morris says she doesn't get high when taking it, but does avoid the vomiting, diarrhea and sweating that comes with opioid withdrawal. She puts it under her tongue to let it dissolve and take effect.
Morris, who has been off heroin since 2012, makes a two-hour drive to a clinic to pick up her supply of Suboxone. It's in short supply in many rural communities, in part because few rural doctors have gone through the required training to prescribe it.
There's there's a six-week waiting list to get an appointment with the only doctor in Sterling who is certified to prescribe the drug, Morris says. Other areas of Colorado's eastern Plains have no doctors at all who are legally able to dispense Suboxone.
A new effort from University of Colorado researchers could help there, with plans to train 40 primary care doctors, their clinical care teams, and nurses in Colorado's Plains and southern San Luis Valley.
Morris acknowledges that close social ties in her town may have contributed to the spread of opioids there; opioid users, she says, tend to "stick up for each other." Those bonds can spread drug use quickly, but they also cut other ways, she says. Just recently she recruited two opioid-dependent friends to the clinic she goes to weekly for treatment.
"I used to sell them pill and heroin," says Morris, who is now helping these friends get clean. "And so I do have hope. I've seen those success stories."
This story comes to us from Harvest Public Media, a collaborative public media project reporting on important stories in rural America.