Squeezing his 18-month-old baby tight, Anson talks about his first time with heroin. He agrees to share his experience, as long as his surname is left out. “It’s his too now,” he says, addressing his young son. A drug addict, born and raised in a small Indiana town, his only crime as a teenager was to undergo surgery. “I switched from painkillers to heroin, then from heroin to fentanyl.”

Anson is 31 years old but started at 16 – and he’s not the only one. According to data from the National Survey on Drug Use and Health, he is just one of 19 million Americans who have entered a spiral of drug addiction. One of so many young people who moved on to hard drugs through their use of legal medication. He is one of the few who can say he has won his battle. At least for now.

When Anson talks about it, the tone of his voice wavers. “I can’t say that I am completely clean even today, but my goal is to find a balance.” And sometimes “I still use marijuana-based medication to avoid a relapse.” Anson is the victim of an epidemic that cannot be understood by simply criminalising drug use. To understand overdose episodes is to understand that the keyword first and foremost here is, in fact, painkillers. Since the mid-1990s doctors in America were advised to combat physical illnesses with tablets, not therapies ranging from Xanax to Oxycontin, an extremely powerful painkiller produced by the pharmaceutical company Purdue Pharma. “Society would tell us that feeling pain, even at its weakest, was not acceptable.” And until 2004, according to data collected for the book Dreamland: The True Tale of America’s Opiate Epidemic, by journalist Sam Quinones, an Oxycontin representative could earn up to hundreds of thousands of dollars in bonuses, in a multimillion-dollar sales market.

Figures show that the number of people in the United States, who have used prescribed opioids for non-medical reasons at least once, reached 25 million. Furthermore, in 2017, opioids were prescribed to 57 Americans in every 100, according to data from the Centers of Disease Control and Prevention. And at least 218,000 people died of overdoses from drugs such as Oxycontin, from 1999 to 2017. “The issue has never been addressed using education and foresight,” says Anson heatedly.

“If you use heroin, you are considered a criminal to be marginalised.”

Between February and April, members of the Sackler family who own Purdue Pharma were sued by attorneys general in New York, Massachusetts, Connecticut, Rhode Island and Utah as jointly responsible for the current opioid epidemic – an accusation denied by the family and still to be proven in the relevant setting. Meanwhile top executives of Insys Therapeutics, a manufacturer of a fentanyl-based painkiller, were sentenced in early May on charges of bribing doctors to prescribe the drug, even to patients who did not have enough symptoms to be taking it.

These are just two of the cases that have incited public opinion on the subject. Though it remains unclear how this will play out in the courtrooms, the effects of painkillers on the streets of the Midwest are all too clear, and they are giving the bill to people who became addicted years ago. “The government has cracked down on prescriptions but, because of this, people are resorting first to pills with a higher dosage to ease the pains of their addiction then to the black market.” Eric Yazel is a doctor and has worked for years in Jeffersonville, a city in the in the heart of Clark County, in the far south of Indiana, bordering New Albany and Kentucky. He commits himself to 80 hours a week, dividing his time between the emergency room and the Turning Point medical centre, a public residence that offers 30-day treatment programmes to support drug addicts. He is a coordinator at LifeSpring, a day centre open to drug abusers. He teaches at Louisville University Hospital and is the backbone of the Clark County Coalition, which meets every Monday at the Pearl Street Game & Coffee House, just down from Clark Memorial Bridge, which stands on the Ohio River and links Indiana to Kentucky. “We need to win the cultural battle by talking to patients and parents: simply handing out punishments does not solve anything,” explains Eric. A difficult challenge in states where “it is enough to have an empty syringe in your car to be arrested.”

In Jefferson, within the rooms of the medical facilities, Eric has seen dozens of young people like Anson – and the problem is still very much present even today. In 2009, the total number of overdose victims in Indiana was 903. In 2017 it doubled to 1852, 327 of which were from heroin. “It’s mainly because of fentanyl” says Anson. A tasteless and odourless opioid 100 times stronger than moringa and used by drug dealers to cut heroin, methamphetamine and cocaine, it can cause instant death to anyone who takes it. After the crackdown on prescriptions for pills, heroin mixed with fentanyl has become enticing in the eyes of many. “More powerful than Oxycontin and less expensive than Xanax,” says Anson. It’s also easier to find and less complicated to take.

While in Italy we are still debating legal cannabis, local provincial streets are also discovering fentanyl. Since October 2018, a worrying trend is growing. In October 2018 there were 6 arrests for trafficking fentanyl patches in the province of Cosenza, along with 20 grams seized in Rome and 2 grams in Cinisello Balsamo, Milan. There was a further arrest, in April, of a 42-year-old in Salò who was caught with 23 grams of fentanyl in his house and 1,400 euros in cash linked to their sale. To grasp the disturbing potential of this market in Italy, understanding what is happening in America is useful, particularly in the Midwest where finding a cocktail of drugs is so easy.

For US investigators, the rule for intercepting hard drugs is always the same: follow the money.

For the last twenty years, drug dealers have worked hard to divert the attention of authorities. The Xalisco Boys have become particularly famous throughout the United States for their delivery system. The Mexican group, named after their small hometown of Xalisco, are one of the largest producers of so-called “black heroin.”

The leaders of these families have in fact invented a heroin delivery system by car, predicting the era of the gig economy. The strength of this system was its ability to reproduce. The police put ten drivers in jail? Ten more appear. Investigators stop the leaders of one cell? They are replaced by a new one in a matter of weeks. On 12th June 2000, a gigantic operation by the US Drug Enforcement Administration (DEA), “Operation Tar Pit”, busted the system open and removed the advocates who introduced it. But even today, the heirs of the Xalisco Boys continue to perform at full capacity.

And for Midwest consumers, like Anson, the rule is similar to that of investigators but with a different target follow the river. Follow the Ohio River. Along its banks, which flow through Kentucky and Ohio, West Virginia and Indiana, just 8 dollars are enough to buy a ‘bag’ (a dose of heroin). Careful looks are exchanged any time and any place, whether buying or selling, in this forgotten part of America: in public car parks and petrol stations, in front of motel rooms and close to schools, behind churches and in front of rehabilitation centres. Drug dealers await the release of former drug addicts and try to send them straight back into oblivion. From the north of Indiana down to the south, where goods on their way from Mexico end up on the Indiana streets, having been sent to downtown Louisville, Kentucky; from the west to the east, affected by Ohio’s cities such as Columbus.

“But the decision to stop using is down to those who started in the first place.” Lisa Livingston is the founder of the Breakaway facility. With a past as a drug addict and a fearful present, Lisa became a court case after the Indiana Supreme Court revised a previous ruling that would have sentenced her to 30 years in prison for drug possession. In 2017, she opened the residence: two houses over two storeys, located along a tree-lined avenue in New Albany, a few kilometres from Kentucky. “A house for women, run by those who have quit,” explains Lisa. In the first house are residents who must complete a 6-month programme to receive the diploma confirming they are sober. In the second one, by contrast, are a group who have finished their journey. The programme involves 14 women and costs $100 a week: “I can’t say that we get anything out of it financially. Without private fundraising we would have closed a long time ago.”

Breakaway offers an alternative to those who are looking for a second life, whether on probation or not. “The path is hard, but we open up means to get them a job,” says Lisa. There are very young people like Carmada, 19, who started on Xanax at 11 and moved to methamphetamine at the age of 14, before switching to heroin. On probation, she was arrested for illegal drug possession. “My whole family is addicted to drugs. I had to choose between them and me.” Autumn, on the contrary, is 24 years old. Drugs took away all her teeth. She apologises because “I can’t speak very well anymore.” She knows that her dream of becoming a nurse in the future will be difficult to achieve. Not everything works out amongst the graduates of Breakaway. The two houses are dedicated to Carrie, who died at 35 years of age from an overdose, shortly after graduating in 2018. And Nicole, who was killed at 30 by a dose of heroin after weeks of abstinence. “We are aware that once is enough to relapse,” says Lindsey who, at the age of 23, tried everything: pills at 13, methamphetamine at 18, heroin at 22.

“I want a normal life now.”

Indiana has only recently opened its eyes to profiles like Anson and Lindsey. “Really only since middle-class people started dying of overdoses,” explains Eric, who in the Clark County Coalition works alongside educators and psychologists, pastors and social workers, lawyers and doctors, and even county judges. Brad Jacobs has been developing a programme called Clark County Addiction Treatment and Support (CCATS) for just over a year, allowing people arrested for illegal drug possession to enter a programme to integrate back into society. “85% of those I see in court go back to prison for drug possession shortly after their first release,” explains Jacobs. That’s why a project like CCATS is precious. Programme participants really rely on centres such as Lifespring, where Eric works: “In 2016, in Clark County alone, there were 89 deaths by overdose,” he recalls. It was the year when the spotlight of public opinion shone again on the Midwest: “It’s not only the homeless dying of drug overdoses, it’s also middle-class millennials: children of doctors and grandchildren of plumbers, builders and teachers, friends of professors and entrepreneurs.”

In Clark County, thanks to the established educational programmes and to an increase in federal funds, there has been a 40% decline in overdose cases over the past three years. However, in the other Clark Counties of America, what patients like Anson and Lindsey and experts like Judge Jacobs and Dr. Eric care about is that an educational process always prevails over criminalisation. Because heroin addicts are people to care for. “We are all different,” Anson repeats, embracing his little son. “We have come a long way, but the system must understand that we are human beings. We need to work quickly.”