Around America, communities big and small have been staring down a massive flood of opioids. Institutions in those communities have been forced to band together to figure out how to tackle the problem.
Now, thanks to data originally obtained by the Washington Post, the country can see just how widespread the problem has been.
The data, originally compiled by the Drug Enforcement Administration, outlines the movement of every oxycodone and hydrocodone pill from manufacturer to distributor to pharmacy and finally to consumer from 2006-12.
Nationally, 76 billion pills flooded the market during those seven years, according to the data.
A fraction of those 76 billion pills came into Jefferson County.
A fraction filled the medicine cabinets of cancer patients and post-op surgical patients, teenagers and elderly people, across all demographics.
A fraction of these pills were taken from medicine cabinets, filled the streets and changed lives.
A fraction of the pills came to Lake Mills and Fort Atkinson, Watertown and Jefferson.
That fraction of the billions of prescription opioids that impacted lives across the country came to Jefferson County to the tune of 15.7 million pills.
For the approximately 85,000 residents in Jefferson County, that's about 185 pills per person over the seven years.
Each of those pills has a story -- what town they went to, what pharmacy they came from, the person who took them.
Most of them, 5,858,290 of them to be exact, went to Fort Atkinson. Following close behind was Watertown with 5,855,940 pills.
But Watertown is the biggest city in the county, so it would be expected to have more prescriptions. Yet, the towns that were hit the hardest by painkillers per capita were Fort Atkinson and Lake Mills.
In Fort Atkinson, with its population of a little more than 12,000 people, 472.4 pills were distributed per person. That's roughly 67 pills per person per year.
The much smaller community of Lake Mills came in at about 318 pills per person over those seven years -- roughly 45 pills per person per year.
But this data only shows what happened to the county a decade ago.
While it doesn't exactly line up with the DEA data, Wisconsin's Enhanced Prescription Drug Monitoring Program tracks similar information.
The ePDMP data can't be broken down by ZIP code, doesn't cover the same amount of time and shows a much more general view of the issue than the DEA data, but it can help illuminate what it looks like on the ground in Jefferson County today.
From January 2015 to June 2019, 10.3 million doses of hydrocodone and oxycodone were distributed to Jefferson County residents. That comes out to about 121 pills per person over four years -- a decline from the 2006-12 numbers.
Jefferson County wasn't spared from the impact of this nationwide crisis. But compared to other counties in Wisconsin and other regions of the country, Jefferson County has fared pretty well.
The DEA data shows that Columbia County was the hardest hit in Wisconsin, with nearly 20 million pills distributed. And nationally, the region most impacted covers an "opioid belt" of nearly 90 counties stretching from West Virginia through Virginia and Kentucky, according to the Washington Post analysis.
People in Jefferson County were impacted by the opioid crisis, and real lives were hurt. But how was the county able to find a way to stop the bleeding in a way other parts of the state and country couldn't?
The problem solvers
Community members working in health care, law enforcement and criminal justice all had one answer -- trust.
Each community institution has been able to put aside its own interests and work toward the goal of helping the county, according to Chris Barron, executive director of population health at Fort HealthCare.
"The relationships here is the secret sauce," Barron said. "All those relationships throughout the county have helped us be a fairly healthy county and that when there are issues to address, then it's pretty easy to get a network of people together to address an issue."
That network of people has culminated in the Jefferson County Drug Free Coalition -- a body made up of stakeholders from every corner of the county fighting against the problem.
Each member of the coalition has its own territory in which it can best fight the opioid epidemic, but members say they can rely on the others to work together and fit all the pieces together.
No matter how it gets sliced, the opioid crisis began when pharmaceutical companies convinced doctors that painkillers such as hydrocodone and oxycodone -- most commonly known as Percocet and Oxycontin -- weren't addictive, according to the U.S. Department of Health and Human Services.
The health-care system helped start the problem and once the problem was recognized, officials at Fort HealthCare knew policies had to change, according to Barron and Fort HealthCare Pharmacy Director Sarah Pagenkopf.
"Around 2010, we started recognizing we need to be part of the solution and not contributing to the problem," said Barron, who was Fort HealthCare's pharmacy director from 2009-15. "Health care historically could have contributed, with prescribing, and we want to be certain we were no longer, we weren't contributing to that issue."
From Fort HealthCare's perspective, the hospital system has to balance the real life need to treat patient pain and the responsibility it has in preventing the spread of opioids through the county.
The hospital has contributed to a number of countywide projects to stem the problem. It's worked to increase access to naloxone -- a drug that counteracts an opioid overdose. It's sponsored drug take-back programs around the county to prevent unused pills from spilling into the streets. It's helped with the statewide development of the ePDMP, which stops patients from "doctor shopping" until they get the prescription they want.
But on top of all these programs, the hospital needs to write policies for itself on the distribution of these powerful and addictive drugs.
"How can we not use opioids? Where could we use them more sparingly?" Pagenkopf said. "What adjuvant therapies could we use -- for pain control because there is a need for pain control -- that doesn't focus on the opioids as an opportunity?"
Barron, the person responsible for many of the health care system's policies and initiatives, understands the balancing act when developing policies around opioids and the need to listen to every voice.
"Everyone wants to be part of the solution. So in that respect, we've got people really engaged," Barron said. "The hard part, though, is it's difficult to write a policy around this. It's not so much changing the behaviors, but you don't want to be so restrictive that you're no longer able to treat legitimate pain."
Both Pagenkopf and Barron recognize there is still a long way to go. As the only hospital in Jefferson County, Fort HealthCare has a major role to play in solving this problem, but there isn't just one way forward.
"Where are we headed? Where are we headed is probably in five different directions because no one straight path is going to fix this for us," Pagenkopf said. "What can we do? How do we turn that Rubik's cube a little bit more to get what we need to help those patients out?"
But Fort HealthCare's major role in the reduction of prescription opioids takes a back seat to other aspects of the opioid crisis.
As prescription opioids became harder to get, people started to turn to heroin, a crisis Barron and Pagenkopf acknowledge they have much less ability to solve. This is where the community relationships became important, they said.
"So still a lot of our focus in health care is where we're addressing the things we know we have control over and that's prescription opioids," Barron said. "The part that we don't have a lot of control over is the heroin side, and I think we're going to need help on that. Talking to community partners and (asking) 'What do you need? And how do we support you?' And that'll be a difficult one to solve."
Dealing with heroin in Jefferson County is where Fort HealthCare takes a back seat to other community partners, but that doesn't mean the hospital system isn't ready to step in when asked, according to Pagenkopf.
Data shows a flood of opioids across U.S., many of them generics.
"It's a dance, because they're going to come; at some point, law enforcement is going to say, 'I have this person, this individual that needs the assistance of a behavioral health specialist. I need someone for detoxification,'" Pagenkopf said. "And how do we get those people back on the road to recovery?"
If Fort HealthCare is in the back seat when dealing with the fallout of opioids in Jefferson County, in the driver's seat are the Jefferson County Drug Task Force and Sheriff's Office Capt. Margo Gray.
The task force includes representatives of every law enforcement agency in the county and Gray has been a member in various roles since 2001.
She has seen the drug of choice in Jefferson County change from cannabis to prescription painkillers to heroin to meth.
Gray said that at the beginning of her time on the task force, members were dealing mostly with pot and cocaine. After 2007, she said, law enforcement started to see a lot more prescription opioids, and after 2012, heroin started to hit the county.
Since then, the county has seen a shift to the use of methamphetamine, Gray said.
"From 2008 on, I noticed that we went from a lot of pills and a little bit of heroin, to more heroin and less pills," Gray said.
To deal with the problem, the task force attempted to slow down the supply of drugs into Jefferson County by going after the dealers, Gray said. It wasn't easy to stop that flow, however, because of Jefferson County's central location between the major hubs of Milwaukee, Madison, Rockford and Chicago.
"We really focused on targeting the dealers, the individuals that were selling it within our county, because heroin didn't just stop at the county lines," Gray said. "It went all over, you know. People were running down to Rockford on a daily basis, sometimes two, three times a day just to pick up, 'cause that's where their sources were, or Milwaukee or Madison."
Gray said the task force mostly has been successful removing dealers from the streets as soon as they hear about them. With a decent grasp on the supply, law enforcement is left to deal with the users.
While drug addiction often comes with a spreading web of other legal issues such as property crime, it isn't a problem that law enforcement can arrest its way out of, Gray said.
"We're dealing a lot with the users -- and the users, they need treatment," Gray said. "You can't just enforce laws to remove the issue. You have to work hand in hand with treatment and education and enforcement."
Working hand in hand goes back to the network of community partners that have been able to join forces in the effort to stop the spread of addiction in Jefferson County.
Gray said the drug task force -- itself a collaboration of law enforcement agencies -- has been able to work extremely well with the Jefferson County District Attorney's office, Jefferson County Drug Treatment Court and the schools in the county to help those in need.
The education aspect was a huge part of it, Gray said. The task force noticed a large number of the people they were dealing with were in their late teens or 20s and needed a way to stop that trend.
"When we were looking at the individuals that we were having the most contact with, they were late teens, early 20s to late 20s was the majority of the group that was abusing heroin or addicted to heroin," Gray said. "So we kind of started thinking about it. What are we missing? How do we get the word out? The last time anybody really had any drug education in the schools was in fifth grade. So we wanted to make sure that we hit the high school students."
While the community has been able to work together, Gray said, it can feel like "quicksand" when fighting against the powerful pull of these addictive substances.
"An addict can be anybody," Gray said. "It can be a business owner. It can be the neighbor next door, it can be a family member, it can be well-respected individuals in the community because it is a very addictive substance. So we have to keep that in mind when we are dealing with this substance. But I think we're on the right path."
If the path of an addict in Jefferson County starts with an opioid prescription from a pharmacy such as Fort HealthCare and at some point involves interactions with law enforcement, its potential end goes through Craig Holler.
Holler has been the coordinator for the Jefferson County Drug Treatment Court Program since 2017.
As is the case in any public health crisis, there are two ways to look at the problem.
There's the view from 30,000 feet -- 15.7 million opioid pills distributed over seven years and countless lives affected. But there's also the view from ground level. Holler, as the coordinator of drug treatment court and a member of the drug free coalition, is able to see both views.
At both levels, what Holler sees is a community doing what it can to solve the problem through collaboration and creatively using the limited resources it has.
On the ground, drug treatment court itself is a collaboration between a judge, the district attorney, public defenders, probation officers, substance abuse counselors, law enforcement, Holler himself and case managers.
"We get together from all these different points of view and try to come to a consensus as to what's the best direction this person can take to achieve sobriety or maintain sobriety or better their lives long term," Holler said.
Zooming out, drug court fits into the larger web of policy solutions in the whole county. The collaboration on all levels and the work continuing to be done show Holler that the county is giving its best shot at the crisis.
"So when you have that just on a micro level dealing with individuals and then you also have that on a macro level dealing with criminal justice policy or health policy or overall how are we going to combat this," Holler said. "That bodes well for having a coordinated effort to offer services to keeping the public safe, to provide people with the health options to overcome substance abuse."
The problem persists
While all the stakeholders say the community has put its head down and started working to find a complicated solution to a complicated problem, the crisis is by no means solved in Jefferson County.
"So, do I think it's handled? No," Holler said. "Do I think we're handling it the best we can, and using the resources that we have in the most wise manner? Absolutely."
Holler, Gray, Barron and Pagenkopf all have a view from both 30,000 feet and ground level. They all see there is still an issue, that this problem is far from solved.
They see that so far in 2019, nearly 900,000 doses of prescription opioids have been supplied to the county, according to the ePDMP data.
There always will be some prescription painkillers in the county, according to Pagenkopf, because they serve an actual medical use, but the hospital system needs to find the best way to dispense these potentially harmful drugs.
"The goal isn't zero," Pagenkopf said. "The goal is judicious use, appropriate use. I think that that's really where that whole idea and concept of stewardship comes in. Patients have pain, it would be unethical of us not to treat that pain. The idea, though, is that we're treating that pain in the most effective way for that patient so that patient can recover and be pain free."
Pagenkopf and Barron see that as more and more data gets released about the use of opioids, the more questions they have.
"The real benefit in the data is now people are asking those kinds of questions, it's driving you to ask more and dig deeper. And that's what I think is very powerful," Barron said.
"I try not to read too much into the data other than now I'm asking more questions, now I want to want to know more."
Gray and Holler see that as prescription opioids get more difficult to obtain and drug users move away from heroin, the use of methamphetamines and cocaine is increasing in the county.
"It's kind of like a rollercoaster," Gray said. "You might have cocaine up at the top at some point and then heroin or meth down here and then all of a sudden you kind of have a crisscross and the other one is more popular."
Whatever drug is more popular, however many people are currently enrolled in Holler's treatment programs, however many opioid prescriptions are coming out of Fort HealthCare, the problem isn't going away overnight.
As the problem continues, the Jefferson County Drug Free Coalition will continue to meet the second Friday of every month from 8 to 9 a.m. at the University of Wisconsin-Extension Office in Jefferson. Meetings are open to the public.