July 31, 2023 – On a white board at the end of the room, across from the sofas, the names of former clients who have died of overdoses in the past few years are listed. Though the town has a population of just 5,000, there are at least 20 names. James Colwell, a 33-year-old former heroin addict, who has been clean for eight years, and who now works at the centre, says that the toll keeps growing. Heroin addiction is actually less common than it used to be, he says, thanks in part to the proliferation of treatment. The problem is that “everyone is on meth. And they’re putting fentanyl in the pills.” The very next day, he says, he is going to the funeral of a middle-aged former nurse who died after accidentally taking fentanyl, a powerful synthetic opiate.

Hazard was named after Oliver Hazard Perry, a naval hero of the war of 1812, rather than for its character. Yet it is an appallingly dangerous place to live. In 2019, even before the deadly pandemic, the town and surrounding area, Perry County, came sixth-from-bottom out of America’s 3,142 counties on a measure of age-standardised mortality. At every age, people were far more likely to die. Opiates, which began to spread around 25 years ago, when doctors prescribed them to former coalminers for chronic pain, are a large part of the reason. But heart attacks are also more common. So are traffic deaths, something local police put down to the refusal of people driving on the winding mountain roads to wear seat belts. Last year the town flooded, and mountain walls slid onto houses. And guns are everywhere. It all adds up to a lot of death. On average, people in Perry could expect to live to just 69 in 2019, compared with 79 in America as a whole.