How inappropriate prescribing prompted the opioid addiction ravaging small town America

When Angie Gooding returned to Port Angeles, a town of 20 000 people in Washington state at the base of the Olympic mountains, she found that her home town had changed from the one she left 20 years ago. Gooding, who teaches language, arts, and history to 14-15 year olds in Port Angeles’s middle school, was not expecting so many troubled students.

“Maybe it’s because it’s a small town and people know each other’s business, but I started asking my students questions,” Gooding recalls. “I asked why are you always late for class? Why are you so tired?” The children told her of parents having drug parties on school nights, of syringes in their homes, and of incidents of sexual abuse. “They just opened up and told me what was going on,” Gooding tells The BMJ.

Like many small towns in rural America, Port Angeles and other communities in surrounding Clallam County have been hard hit by an epidemic of drug misuse that, according to the Centers for Disease Control and Prevention (CDC), led to more than 52 000 deaths in the United States in 2015, 33 000 of which followed an overdose of a prescription or an illicit opioid.1 The CDC estimates that more than 300 000 Americans have died from overdoses of prescription opioids since 2000.

This prompted US President Donald Trump to declare the epidemic a national emergency in August,2 but the administration has yet to publish its plans for response.