Find Brockton on this extremely detailed map of Massachusetts’ opioid crisis

It’s often said that the opioid crisis hurts every community, and in Massachusetts, only a few towns can report they are without an overdose death this century. All have fewer than 2,000 residents.

Yet the epidemic has preyed on some cities and towns with a special vengeance. A new analysis by The Enterprise offers a dynamic picture of where the use of painkillers, heroin and fentanyl has claimed lives in Massachusetts since the year 2000. 

Like so many health crises, the epidemic has hit hardest in poorer communities, though that simplification cannot explain the intricacies of the epidemic’s geography. Income alone does not explain what drives a person to use opioids, nor does it explain why Fall River and New Bedford have led the state in overdose deaths per capita for nearly 20 years, while Chelsea, a marginally poorer community, has hovered near the statewide average.

The Enterprise asked a panel of public health experts to interpret the map prior to its publication. Their insights can help readers track how developments like the rise of fentanyl and the widespread adoption of Narcan, an overdose-reversing nasal spray, have shaped the epidemic in their communities.

Yet the question of why certain cities emerge as hot spots is one that academics typically refer back to locals.

Several experts wondered whether the data made a case for opioid abuse being highest in Massachusetts’ port cities, where smuggling through shipping and marine businesses could make the drugs more readily available. The four communities with the highest overdose death rates last decade were all coastal: Salisbury, Fall River, New Bedford and Wareham.

But there’s been little research to test this theory, and international ports like Salem and Gloucester report far lower death rates than dozens of communities further inland.

Rockland, a landlocked town of 18,000 south of Boston, reported the fifth highest rate of overdose deaths in the state last decade. It’s one of several communities where health experts and local leaders have drawn connections between tough manual labor jobs and high rates of opioid use.

Police Chief John Llewellyn, a former carpenter, said he searched for years to find an explanation for why his town struggled more than its wealthier neighbors before his mind flashed back to the building trades.

“We have people out there getting injured at work, getting prescribed medications and falling into addiction from there,” Llewellyn said.

Still, the reasons why one community suffers more than another can be challenging to isolate using the current data, which measures only the number of people who die within a Massachusetts municipality each year.

What the data can show convincingly is that Massachusetts' problem has grown worse nearly every year since the turn of the century, when an increase in painkiller prescriptions set the nation on its course toward unprecedented opioid addiction and overdose death rates. 

Brockton, Lawrence and Lynn, cities that used to report roughly a dozen overdose deaths per year, now routinely suffer more than 50. Smaller towns like Wareham and Salisbury that began the millennium without a single overdose death are now experiencing annual death tolls on par with cities several times their size.

Statewide, the numbers are even more striking. In 2000, the Department of Public Health attributed 336 deaths to opioid-related overdoses. In 2019, the annual toll exceeded 2,000, a sixfold increase that outpaced the corresponding national surge in overdose deaths. Massachusetts’ rate of opioid overdose deaths now ranks among the top 10 in the nation. More than 20,000 residents here have died in the past 20 years, a scourge that now claims more lives each year than the flu, diabetes or Alzheimer's disease, according to the Centers for Disease Control and Prevention.

Prescription pills give way to fentanyl

The government’s response to surging opioid use during the 2000s included a nationwide crackdown on the doctors and manufacturers contributing to widespread over-prescription of painkillers. 

Monitoring programs gave doctors new oversight over patients cycling between providers for opioids, and criminal prosecutors brought charges against those doctors who continued to overprescribe. 

Facing pressure from regulators, Purdue Pharma also reformulated its notorious painkiller OxyContin in 2010, making the drug far more challenging to inject recreationally.

More:OxyContin maker agrees to plead guilty to federal charges in $8 billion settlement

But dialing back the supply of prescription opioids had unintended consequences. With millions of Americans already addicted, many users switched to street opioids like heroin as access to prescription pills tightened and the resale market grew more expensive. 

Vicky Butler, now an addiction treatment coordinator with Plymouth County Outreach, said she used Percocet and Oxycontin recreationally before the price became unaffordable. Adapting to a changing market, Butler said she watched several friends switch to heroin, despite knowing the transition came with new risks.

“Pills are manufactured by scientists in a lab and regulated so you know exactly what you’re getting," Butler said. “With heroin, drug dealers don’t even know what exactly they’re selling.”

Starting in 2010, the number of annual overdose deaths climbed rapidly in Massachusetts, doubling from 522 to more than 1,000 within four years.

Combing through the data, the Department of Public Health found in a 2017 study that people prescribed at least three months of opioids were 30 times more likely to die of an overdose within five years.

And the problem was only getting worse.

"The first big wave of deaths was due to people not being able to obtain prescription opioids anymore and switching to street opioids, which at the time was mainly heroin,” said Allyson Pinkhover, a coordinator for the Brockton Neighborhood Health Center’s substance abuse services. “The next switch we saw is when fentanyl emerged.”

A report released last year by the U.S. Drug Enforcement Administration found the amount of fentanyl confiscated in America surged in 2013 after decades of relative obscurity as a street drug. The DEA said recreational forms of the drug arrive primarily through illegal packages from China and Mexico.

On the ground in Massachusetts, Pinkhover said many users weren’t prepared for the far more potent synthetic opioid.

In 2014, public health officials in Massachusetts found that 40 percent of fatal opioid overdose victims had recently used fentanyl. Within two years, that share climbed to 70 percent.

Driving the rapid transition from heroin to fentanyl, Pinkhover said, was the cheap price and the convenience for street dealers.

“When you have a highly criminalized drug policy, it will always favor the most potent kind of a drug,” Pinkhover said. “It’s easier to sell, and it’s easier to manufacture without law enforcement noticing.”

Last year, the Massachusetts Department of Public Health reported the share of fatal opioid overdose victims who screened positive for fentanyl at 94 percent.

Tentative signs of progress

After seven straight years of rising overdose deaths, 2017 ushered in a brief period of mercy. Fatal opioid overdoses fell by more than 100 that year, offering hope that expanded access to addiction treatment was saving lives.

At the beginning of the decade, Quincy became the first city in the country to equip all police officers with Narcan, a nasally administered drug that reverses the effects of opioid overdoses. Quincy police say they have since administered Narcan more than 1,100 times, reversing 1,034 overdoses. What became known as the Quincy Model has been replicated nationwide, and nearly all police and fire departments in Massachusetts now carry Narcan. 

More:A shot at life: Quincy's Narcan model is saving and changing lives

On the preventive side, detox and long-term recovery facilities have recently added beds in Massachusetts, and the declining volume of opioid prescriptions may be narrowing the pipeline toward addiction.

Still, death rates rose modestly in 2018, and again the following year.

“Whatever pontifications we were making in 2018 did not apply in 2019,” said Dr. Michael Barnett, a Harvard University professor and expert witness on opioid abuse in several ongoing lawsuits against pharmaceutical companies. 

“Everyone is quite certain it’s going to rise again in 2020,” Barnett added.

The arrival of the coronavirus pandemic has raised concerns that more isolation will trigger another spike in overdose deaths. A person saved by Narcan last year may die alone in quarantine. Treatment centers operating with reduced hours and limited face-time could struggle to meet the needs of patients. Anxiety and depression could trigger others to relapse.

Preliminary data in Massachusetts shows deaths are already trending above last year’s figures.

More:State sees increase in opioid overdose deaths

But Barnett and other doctors said the treatments capable of turning the tide of overdose deaths already exist — it’s just a matter of making them more available.

“It’s not rocket science how we help this problem,” Barnett said. “A lot of it has to do with reducing the stigma of addiction treatment delivery in this country.”

As an example, Barnett pointed to detox and long-term recovery facilities. Doctors in Massachusetts struggle to find enough beds for their patients in programs they know are working. But building new facilities typically draws fierce resistance from neighbors and local politicians.

Similarly, safe injection sites remain illegal in most United States jurisdictions, despite interest among doctors in several cities to create the nation’s first licensed program. In 2017, state Sen. Will Brownsberger sponsored a bill to jump-start a safe injection site in Massachusetts, but the Belmont Democrat said he struggled to find a viable location.

"If we had a place where people were ready for it, then we could probably get it done,” Brownsberger told NPR in 2018. “But we don't have that right now.” Brownsberger could not be reached for comment for this story.

Experts say an expansion of treatment programs could provide Massachusetts with a more permanent respite from the overdose epidemic.

“It’s not that expensive. It’s not even that hard to administer. It just needs to be done,” Barnett said.

Abby Raisz created the infographic. Support local journalism by purchasing a digital or print subscription to The Enterprise today.