Manchester, New Hampshire, firefighters try to revive a man who overdosed in a building’s stairwell last year. Salwan Georges/Washington Post

Exclusive data — obtained by The Washington Post from the Centers for Disease Control and Prevention — shows how individual counties moved through the three waves of the opioid crisis: prescription pills, heroin and fentanyl.

A man prepares a shot of heroin in Philadelphia in 2017. Salwan Georges/Washington Pos

In Berkeley County, West Virginia, for example, the trend closely mirrored national ones. Prescription pain pills were the main cause of overdose deaths through 2011. By 2013, drug users turned to heroin, which set the stage for fentanyl.

In Washington, D.C., which has been one of the hardest-hit regions in the nation, overdose deaths were primarily driven by heroin until 2016 when it shifted to fentanyl.

But not every county is the same. In Duval County, Florida, whose largest city is Jacksonville, prescription pain pills remained the primary cause of opiate overdose deaths until 2016. Fentanyl would eclipse pills the following year.

Together, oxycodone, hydrocodone, heroin and fentanyl have killed more than 400,000 Americans since the turn of the century, a quarter of whom have died from fentanyl in just the last six years.

The opioid epidemic has been a major driver of declining life expectancy for Americans. And although each community has experienced the crisis differently, a deeper look at the broad trends of the three waves shows how each drug — pills, heroin and then fentanyl — prepared the way for the next.

For this analysis, The Post used an exclusive research agreement with the federal government to acquire incident-level death data to examine the predominant killers of citizens county by county, year by year.

Rather than telling the story of the epidemic through death rates, as others have done for years, this unique analysis illustrates how the citizens in these counties rapidly shifted their drug use as the opioid epidemic got worse.

By 2011, more than 12 billion oxycodone and hydrocodone pills were being shipped to pharmacies across the country — the high point for shipments — and prescription pills were the predominant killers of opioid users throughout much of the nation.

Over the next several years, shipments slowly declined as a crackdown on illegal diversion, begun in 2006, started to have an effect on overall usage patterns. And in certain areas of the country, especially along the East Coast, drug users rapidly began dying from other opioids at significantly higher levels.

In 2011, pill deaths had risen to nearly 16,000 annually, more than three times the number from a decade earlier. The shipments and deaths were highest in a virtual opioid belt that stretched through West Virginia, southwestern Virginia and Kentucky.

This swath includes 18 of the top 20 counties in per capita opioid deaths nationwide and 12 of the top 20 counties in per capita pill distribution. From 2006 through 2012, death rates in the belt were 4.5 times the national average of 4.6 deaths annually per 100,000. Among the hardest hit counties were Mingo and Logan in West Viginia and Bell and Floyd in Kentucky. They all had more than 39 deaths per 100,000.

Katie Allison’s son, Henry Granju, started abusing opioid pills in 2008 when he was 16 in Knoxville, Tennessee. At first, many of the pills were stolen from parents’ medicine cabinets. Eventually, seemingly without warning, he and many of his friends became addicted.

OxyContin pills lie on the hood of a police car after a drug bust in Yorkshire, Virginia., near Manassas. Michael Williamson/Washington Post

“It was like a fire hose of illegally diverted prescription medication,” said Allison, a 52-year-old stay-at-home mom. “It hit this community while we weren’t even looking. It hit us like the plague.”

After the DEA crackdown, prescription opioids became harder to come by. For Granju and many users like him who were already addicted, that simply meant they began looking to purchase theirs on the street. He pawned his prized possession, his guitar, to pay for pills.

In 2010, one week before he was set to graduate high school, Granju fatally overdosed on opioid pills. He was 18.

The first wave of the opioid epidemic consisted primarily of addiction and deaths from prescription pills. The second wave was made up of heroin. From 2011 to 2014, as deaths from prescription pills plateaued, deaths from heroin more than doubled.

Heroin took over as the dominate drug in many areas already devastated by the pills, especially in the Rust Belt.

On Marissa King’s 18th birthday, she was raped.

King loved to volunteer backstage at theaters near her hometown of Kalamazoo, Michigan. Then an older, married man got her drunk and assaulted her, said her mother, Nancy, a 61-year-old director of a nonprofit devoted to overdose prevention.

Although Marissa was already an addict at that point, the trauma pushed her over the edge, her mother said.

“That’s when things really got bad for her,” she said.

Friends told Marissa that she shouldn’t have gotten drunk or looked the way she did.

“That victim-blaming made her think ‘something is wrong with me,’ ” Nancy said. “She didn’t want to press charges because she thought it was her fault.”

After that, Nancy started noticing changes in her daughter. She was evasive, she constantly had migraines, she stayed out of the house.

A Taunton, Mass., detective searches the car of man who was stopped in May after he picked up a prostitute. Drugs were found in the vehicle. Salwan Georges/Washington Post

“Now I recognize that was heroin and withdrawals,” Nancy said. “I didn’t get that at the time.”

Marissa, 21, died on Jan. 15, 2012. Since then, her mother has counseled addicts in Michigan.

“We’re talking about it more; we’re taking away that stigma so people know they can reach out for help and say they’re scared,” she said. “We need a war on trauma, not a war on drugs.”

The heroin death rate never surpassed that of prescription pills, but it served as a transition into the illegal market for many of those already addicted to pills. There, they would find an even deadlier drug awaiting them.

Fentanyl has been used in the United States for decades, most of that time as a legally prescribed medicine. The drug, an opioid 50 times more powerful than heroin, had been given primarily to patients in excruciating pain.

Starting in 2013, it began to flow into the country illegally in unprecedented quantities, the vast majority of it coming from China. It found its way into the hands of drug users primarily by being cut with heroin.

Timothy Allan Mauldin had been ordering fentanyl off the dark web from China for about three months when he overdosed for the first time, a secret he kept hidden from his wife, Lauren, 35. She had little reason to think the national opioid crisis was part of her life.

He was 36, the vice president of a software company in Austin, Texas.

“We had West Elm furniture, cute dogs and jobs in the tech industry,” she said.

After she watched paramedics revive him at their home with naloxone, a drug that counters overdoses, she learned the truth and confronted him in a hospital. He promised Lauren he would stop. She believed him.

She had no reason not to: He was “the smartest person I’ve ever known,” she said. “Every time he made a promise, he never let me down.”

A week later, on June 18, 2015, Timothy took a dose of butyrfentanyl, a variant of the drug. This time, it was lethal.

From 2013 to 2017, fentanyl overdose deaths rose nearly tenfold to 28,869.

Ohio, the center of the heroin crisis, rapidly became a center of the fentanyl epidemic. So did West Virginia, which was at the heart of both previous waves. The fentanyl belt ranges from western Ohio through southeastern West Virginia.

Nationally, federal agencies were overwhelmed by fentanyl, and so were first responders at the local level.

Firefighter and paramedic Andrew Morrow in Biddeford, Maine, had been to hundreds of overdose scenes. On Jan. 23, 2017, he found his daughter, Amber Pearl Morrow. White powder and a rolled-up $20 bill were on the counter.

“It didn’t feel like it was real,” he remembered.

She and a friend snorted what they thought was cocaine. It turned out to be pure fentanyl. Amber, who was transgender and worked at an assisted-living community, was 21.

On the day Andrew returned to his job after grieving for Amber, he responded to another overdose call.

While many resources across the country are going toward stemming the tide of fentanyl deaths, some experts say it is time to start paying attention to what may be the fourth wave of the crisis.

It does not involve another opioid. Instead, there is mounting concern about an older menace that is increasingly getting cut with heroin and fentanyl: methamphetamine.

Deaths from meth have more than tripled since 2014. Along with West Virginia and the Northeast, the Southwest and states likes Alaska and Hawaii have all seen their death rates spike in recent years.

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