Officer Sean Brinegar arrived at the house first — "People are coming here and dying," the 911 caller had said — and found a man and a woman panicking. Two people were dead inside, they told him.
Brinegar, 25, has been on the force in this Appalachian city of Huntington, W.VA. for less than three years, but as heroin use has surged, he has seen more than his fair share of overdoses. So he grabbed a double pack of naloxone from his gear bag and headed inside.
A man was on the dining room floor, his thin body bluish-purple and skin abscesses betraying a history of drug use. He was dead, Brinegar thought, so the officer turned his attention to the woman on a bed. He could see her chest rising but didn't get a response when he dug his knuckle into her sternum.
Brinegar gave the woman a dose of injected naloxone, the antidote that can jumpstart the breathing of someone who has overdosed on opioids, and returned to the man. The man sat up in response to Brinegar's knuckle in his sternum — he was alive after all — but started to pass out again. Brinegar gave him the second dose of naloxone.
Maybe on an average day, when this Ohio River city of about 50,000 people sees two or three overdoses, that would have been it. But on this day, the calls kept coming.
Two more heroin overdoses at that house, three people found in surrounding yards. Three overdoses at the nearby public housing complex, another two up the hill from the complex.
From about 3:30 p.m. to 7 p.m., 26 people overdosed in Huntington, half of them in and around the Marcum Terrace apartment complex. The barrage occupied all the ambulances in the city and more than a shift's worth of police officers.
By the end of it, though, all 26 people were alive. Authorities attributed that success to the cooperation among local agencies and the sad reality that they are well-practiced at responding to overdoses. Many officials did not seem surprised by the concentrated spike.
"It was kind of like any other day, just more of it," said Dr. Clay Young, an emergency medicine doctor at Cabell Huntington Hospital.
But tragic news was coming. Around 8 p.m., paramedics responded to a report of cardiac arrest. The man later died at the hospital, and only then were officials told he had overdosed. Then authorities found a person dead of an overdose elsewhere in Cabell County and think the death could have happened a few days earlier. They are investigating whether those overdoses are tied to the others, potentially making them Nos. 27 and 28.
It's possible that the rash of overdoses was caused by a particularly powerful batch of heroin or that a dearth of the drug in the days beforehand weakened people's tolerance.
But police suspect the heroin here was mixed with fentanyl, a synthetic opioid that is many times more potent than heroin. A wave of fatal overdoses signaled fentanyl's arrival in Huntington in early 2015, and now some stashes aren't heroin laced with fentanyl, but "fentanyl laced with heroin," said Police Chief Joe Ciccarelli.
Another possibility is carfentanil, another synthetic opioid, this one used to sedate elephants. Police didn't recover drugs from any of the overdoses, but toxicology tests from the deaths could provide answers.
A battle-scarred city
In some ways, what happened in Huntington was as unremarkable as the spurts in overdoses that have occurred in other cities. This year, fentanyl or carfentanil killed a dozen people in Sacramento, nine people in Florida, and 23 people in about a month in Akron, Ohio. The list of cities goes on: New Haven, Conn.; Columbus, Ohio; Barre, Vt.
But what happened in Huntington stands out in other ways. It underlines the potential of a mysterious substance to unleash wide-scale trauma and overwhelm a city's emergency response. And it suggests that a community that is doing all the right things to combat a worsening scourge can still get knocked back by it.
"From a policy perspective, we're throwing everything we know at the problem," said Dr. James Becker, the vice dean for governmental affairs and health care policy at the medical school at Marshall University here. "And yet the problem is one of those that takes a long time to change, and probably isn't going to change for quite a while."
Surrounded by rolling hills packed with lush trees, Huntington is one of the many fronts in the fight against an opioid epidemic that is killing almost 30,000 Americans a year. But this city, state, and region are among the most battle-scarred.
West Virginia has the highest rate of fatal drug overdoses of any state and the highest rate of babies born dependent on opioids among the 28 states that report data. But even compared with other communities in West Virginia, Huntington sees above-average rates of heroin use, overdose deaths, and drug-dependent newborns. Local officials estimate up to 10 percent of residents use opioids improperly.
The heroin problem emerged about five years ago when authorities around the country cracked down on "pill mills" that sent pain medications into communities; officials here specifically point to a 2011 Florida law that arrested the flow of pills into the Huntington area.
As the pills became harder to obtain and harder to abuse, people turned to heroin. It has devoured many communities in Appalachia and beyond.
In Huntington, law enforcement initially took the lead, with police arresting hundreds of people. They seized thousands of grams of heroin. But it wasn't making a dent. So in November 2014, local leaders established an office of drug control policy.
"As far as numbers of arrests and seizures, we were ahead of the game, but our problem was getting worse," said Jim Johnson, director of the office and a former Huntington police officer. "It became very obvious that if we did not work on the demand side just as hard as the supply side, we were never going to see any success."
The office brought together law enforcement, health officials, community and faith leaders, and experts from Marshall to try to tackle the problem together.
Changes in state law have opened naloxone dissemination to the public and protected people who report overdoses. But the city and its partners have gone further, rolling out programs through the municipal court system to encourage people to seek treatment. One program is designed to help women who work as prostitutes to feed their addiction. Huntington has eight of the state's 28 medically assisted detox beds, and they're always full.
This story was produced by STAT, a national publication covering health, medicine, and life science. Read more and sign up for their free morning newsletter at statnews.com. You can also follow STAT on Twitter and like them on Facebook.