Not long after a large steel mill closed in the small town of Portsmouth, Ohio in the mid-1980s, the first pill mill appeared. With a handful of cash at an unscrupulous pain clinic, anyone could get a prescription for Oxycontin or other painkillers. By 2009, there were 10 pill mills in the area. Addiction was so common that pills became local currency: You could use them to buy a refrigerator or pay the dentist.
This culture of free-flowing opiates has been driven by aggressive marketing from pharmaceutical companies. And when insurance money or prescriptions run out, the patients still need a fix—which often takes the form of cheap heroin from Mexico. It's a cycle that's being repeated all across America, and small towns like Portsmouth, with collapsed economies, have been hit hardest.
Across the U.S., fatal heroin overdoses have more than tripled since 2010. Over 10,000 people overdosed on the drug in 2014; almost twice as many overdosed on prescription versions of the same thing.
Inspired by Dreamland, a fascinating 2015 book from journalist Sam Quinones that tells the story of the heroin epidemic in small towns like Portsmouth, photographer Michelle Frankfurter visited Southern Ohio (with support from the Economic Hardship Reporting Project) to show what it looks like.
"I knew I didn't want to do another heroin-type story where you're seeing exclusively addicts and depicting just the mechanics of heroin addiction, because we've seen that—we know what it looks like," says Frankfurter. "In my mind, I'm kind of thinking I want to stay away from "junkies shooting up in McDonald's bathroom" kind of photos. I tried to step back a little bit and do a mix of portraits of people who were in recovery, but also create a portrait of the town, and how this can be a town almost anywhere, anywhere in white America."
"All the jobs went overseas decades ago, and these places just sort of started rotting," says Frankfurter. "Then these communities were just perfectly tenderized for something like an opiate epidemic."
By 2011, the Portsmouth government started working to shut down the pill mills, and the town is struggling to recover. But it will take more than getting people off the drugs to make that happen.
"The heroin epidemic in these communities is like a symptom," she says. "You've got to start somewhere, and getting people clean and drug free is the first step, but there are no opportunities for them, and nothing to do. ... There's no work, and there's just nothing to do, so people do drugs. It's just part of a bigger problem."