NASHVILLE, Tenn. (AP) — It's hard to say whether businessman Kyle Graves hit rock bottom when he shot himself in the ankle so emergency room doctors would feed his opioid habit or when he broke into a safe to steal his father's cancer pain medicine.
For straight-talking ex-trucker Jeff McCoy, it was when he grabbed a gun and threatened to blow his brains out if his mother didn't hand over his fentanyl patches.
For newly minted lawyer Bianca Knight, it happened after hitting the street to find pills when her opioid prescription ran out, as she envisioned her career dreams crumbling.
Addiction to powerful painkillers sneaked up on Graves and McCoy and Knight, ordinary Americans who began taking the drugs legitimately for pain, but like millions of others, got caught up in the worst opioid epidemic in U.S. history.
Now they're fighting the same tough, slippery battle for recovery, owing their lives, they say, to an anti-addiction medicine similar to pills that nearly led to their demise. They credit a Nashville doctor too, an addiction specialist who also works as a Vanderbilt University pain medicine physician — sometimes recommending the same drugs to pain patients that brought the others to the brink.
The ironies and tragedies of the crisis are not lost on Dr. Dan Lonergan, who faced his own dark abyss years ago in medical school, when his older brother died suddenly of a possible opioid overdose.
He's heard criticism about doctors "who get 'em hooked on drugs and then turn around and treat 'em for addiction." And he's seen the finger-pointing from those who think faith and willpower are the answer, who say prescribing opioid drugs to treat addiction is trading one vice for another.
"Doctors have contributed to this problem. In the past three decades we have gotten a lot of patients on medications that can be very dangerous," he said. "The pharmaceutical industry has contributed significantly to this problem. This is a problem that we all need to own."
But to stigmatize addiction as a moral failing rather than a brain disease is wrong, Lonergan says. Research has shown that opioid drugs can cause brain changes leading to uncontrollable cravings for drug use even when it leads to dangerous and unhealthy behavior. To not offer medicine as a treatment, he says, would be like withholding insulin from a diabetic.
This is a snapshot of those in the trenches of America's addiction crisis. More than 2 million people are hooked on opioids. Overdoses from these drugs have killed more than 300,000 Americans since 2000, and they are killing an average of 120 people every day. Even for survivors, success never quite seems certain.
THE FAMILY MAN
Kyle Graves groans slightly as he sits down on the dark leather sofa in his apartment living room, feeling the stabbing pains that a daily handful of pills used to ease. At age 54, he shares the small but comfortable space with his ailing mother, bedridden from a stroke, and two small dogs in Franklin, Tennessee, an affluent Nashville suburb.
Framed thrift shop art posters and secondhand knickknacks decorate the place, fitting decor for a man seeking a second chance at life.
Graves' troubles began more than a decade ago when he sought relief for degenerative arthritis in his hips, shoulders, feet and back. He was prescribed hydrocodone, an opioid drug that works best for short-term pain but is risky and potentially addictive when used long term.
He got several refills for persistent pain. But when he lost his dream job as a car dealership finance manager, Graves found the pills helped get him through that crisis, too.
He was a functioning addict when his sixth child was born — a boy named Joshua Jeremiah who contracted spinal meningitis during childbirth. The infant clung to life for six weeks; his death sent Graves sinking deeper into addiction.
He'd use up a month's supply of pills from pain clinics in days, followed by terrible withdrawals — vomiting, diarrhea, shaking uncontrollably and intense pain. It's familiar territory for addiction patients.
Graves turned desperate after a doctor refused more refills, suspecting he was selling the drugs because opioids didn't show up in a routine urine test — he'd swallowed them all weeks earlier.
With his wife at work and kids outside playing basketball, Graves grabbed a loaded .22-caliber pistol from his bedroom nightstand.
"I thought, 'I really can't hurt myself by shooting myself in the foot or ankle.' I thought that story sounded legit." He pulled the trigger, then called an ambulance.
At the hospital, two shots of morphine "did the trick." The only pain he recalls was when doctors removed the bullet. Graves thinks only his wife suspected the ruse.
She grew weary and left with the kids — the harshest blow to a man who worships family.
Finally, jobless and living in a lonely Nashville motel room, Graves knew he had to seek help. "I lost my wife, my kids, my home," he said. "It just devastated and ruined my life. I never thought anything like that could happen to me."
His sister helped send him to a California rehab center where hard work and prayer were the main treatments. It worked for a time, but after relapsing Graves sought help from Lonergan, who prescribed recovery medicine containing buprenorphine, an opioid drug that reduces cravings and withdrawal symptoms.
Graves has been on the pills for about three years. He says weaning himself "would be a struggle that I haven't wanted to try yet."
He has had setbacks, the most recent in 2015, when money was tight, his youngest daughter was distant and he was facing another Christmas without his kids. He knows they won't come around if he falls back into addiction.
His hopes of rebuilding a life with those five kids, now grown, help keep him clean.
"I'd like to have a house, a place they can come over and have a cookout on the weekend," he said.
"They know I love 'em with all my heart," he said. "They still have issues. I've offered to get them together and talk to them. I guess they're not ready yet."
Graves' triggers are tragedy and misfortune; he tries not to dwell on what the future might bring.
"I don't worry about it a lot right now. Anything could happen, though, that could change that," he said. "You never know."
Pain wakes Graves up at night and greets him in the morning. He takes nothing stronger than over-the-counter pain relievers. He has stopped asking Lonergan for opioid pain pills. The answer was always no.
"I've come to tears in his office," Graves said. "I'm going to get older and it's just going to get worse...what is a guy like me supposed to do?"
He passed an important test a few months ago when another doctor prescribed opioids after shoulder surgery. Graves took the pills as directed, then quit.
He's on disability now; looking after his mom keeps him busy. Sometimes he writes country songs — some sound good enough to be played in clubs 20 miles (30 kilometers) up Highway 65 in Nashville, and it doesn't take much prodding to get him to share one.
"A man's gotta do what a man's gotta do, when he's loving a woman, a woman like you," Graves sings. "He'll sacrifice and give all he's got, to keep the fire burning, to keep the fires hot."
At times, in the middle of the night, when back pain flares, he still fights flickers of temptation.
"It really never leaves you," Graves said. "The voices always still call you back to the darkness. You just have to ignore 'em and go on."
On a country lane 40 miles (60 kilometers) outside Nashville, a lanky tattooed man wearing overalls and a do-rag gingerly leans over to tend sunflower seedlings in his spartan front yard.
Jeff McCoy, 56, is a straight-talking study in contrasts. He's been a meth-using country band drummer, Harley rider and long-haul trucker, but these days McCoy calls himself a house husband — gardening, baking cookies for family and friends, doing crochet and doting on his wife, Joanne. Recovery from opioid painkillers prompted the turnaround.
It started nearly 17 years ago, after surgery for a progressive back injury — could be from baling hay as a boy, or too much time on the road, he's not really sure, but it forced him to retire from trucking. His doctor prescribed Vicodin — painkillers that contain hydrocodone. After a year he was hooked.
"I just went full bore," McCoy says. "I was popping pills like crazy."
When those stopped working, he was prescribed fentanyl patches, powerful opioid medicine often used for intractable cancer pain. Placed on the skin, they deliver medicine gradually. McCoy figured out that yanking them off and chewing them worked faster. He didn't know it can be fatal.
"Phew — what a rush. I'm not gonna lie — awesome. It makes you feel invincible," he said.
Medicated, McCoy says, he felt normal. But then the pain returned and when he ran out of medication, withdrawal symptoms kicked in. "That's when my body was just aching for that opiate," he said.
"I didn't wake up one day and say, 'Oh my God, I'm addicted.' It just happened," he said.
He knew he was in trouble when his wife started locking up the patches in a safe. When he found the key, his mother — who lives nearby — took over doling out the drugs.
"Got to the point where I got on the phone with mom, 'You better bring me that patch right now else I'm splattering my brains all over this living room.' I wouldn't have done it. I don't think I woulda," McCoy said. "Who knows?"
When his wife threatened to leave, he finally got help.
"I came close to losing her, and I love her more than anything in the world," he said. "I'd honestly die for her."
He checked himself in to a detox center, and began a new year, 2009, with two hellish weeks of withdrawal.
"It was rough. It was scary. They locked the door," McCoy said. "It was the best thing that ever happened to me."
He figures he'll be on anti-craving medication for life even though sometimes now he takes just half a pill and still has some left when it's time for a refill. That didn't happen when he was taking pain medication.
"I'd have to suffer until I had my doctor appointment," he said. "That's the worst part about it. You're all high when you got that big ol' bottle of pills, you're all happy party time. Then as it slowly goes down and slowly gets emptier and emptier, that's when the anxiety (hits), 'What am I gonna do, where am I gonna get some more?'"
Now, he says his wife is his addiction. "She's my everything, she's my drug. All she has to do is walk by me and pat me on the head and I'm like a dog in heaven."
She taught him to crochet, a hobby for summer months when it's too hot to bake. Cooking, cleaning and grocery shopping are also therapeutic for a man who hates to sit still.
Back pain still bothers him; he spends a chunk of each day flat on his back to rest it. His addiction medication helps a little, and he worries about not being able to find a doctor to prescribe it, if he or Lonergan were to move away.
Special training is required to prescribe that medicine in an office-setting instead of the kind of treatment clinics where methadone, another opioid recovery medicine, is prescribed.
Still, McCoy says he doesn't worry about relapsing.
"I can honestly say I don't even think about pain medication," he said. "I'm not tempted one iota."
He jokes that his life now is "boring as hell, but I'm happy."
"The only thing that makes me different" from other addicts "is I finally wanted to stop," McCoy said. "If I can survive with no life, come on, it's worth it, but you gotta want to."
At the end of three grueling years in law school, after graduating with honors and passing the bar exam, Bianca Knight had a nagging question too tough for even the smartest lawyer.
"How do I know if I have a problem?" she asked Lonergan, the Vanderbilt physician who treats McCoy and Graves.
Knight had spent the past two years medicated. Every day. On hydrocodone pills a different doctor had prescribed when she injured two spinal disks lugging around heavy law books.
They helped with the pain, along with steroid injections, but she found the pills did something else.
"They also gave me a euphoric feeling and helped me get through my long day in law school," she said. "It made it all easier."
Knight, 37, is nearly blind from a rare optic nerve condition she developed several years ago. It may have added to her challenges but she wasn't going to let it stop her from pursuing a career. She knew of blind attorneys, and a state program for the disabled paid for a reader who helped with her law school homework.
When she got her first opioid prescription, she was given a vague warning that some people can become dependent on the drugs, but thought, "that won't happen to me."
Opioids made her feel energetic, not impaired. Soon Knight was thinking about them all the time, and taking far more than the prescribed amount.
"Toward the end, I resorted to buying off the street," claiming to have had dental work and no insurance, Knight said. "Eventually someone can point you in the direction of someone looking to get rid of some drugs."
But resorting to street pills made her worry about her safety and the legal ramifications, picturing her career dreams crumbling if she didn't seek help.
When she asked whether she had a problem, the doctor explained addiction and told her the average person doesn't think about opioid pain pills 24/7 and carry them around in a purse.
Knight agreed to try buprenorphine treatment. Attending church and support group meetings also help, she says. She was able to continue medication treatment when she became pregnant last fall, which helps with her ongoing pain. She says the baby is extra incentive for her to stay clean.
"Now I've got someone else counting on me," Knight said.
Still, relapse is in the back of her mind and Knight said she knows future challenges could make her vulnerable.
"For anyone in recovery, it is a daily struggle and I'd be a fool not to think so," Knight said.
Dr. Dan Lonergan says relapse is the biggest risk for patients recovering from opioid addiction. The drugs work by attaching to chemical receptors in the brain and sending signals that block pain and create pleasurable feelings. Repeated use can lead to drug tolerance, meaning increasingly high doses are needed to produce the same effect. In recovery, patients lose that tolerance so resuming the drugs can be fatal.
Addiction medicine — buprenorphine and methadone — act on the same drug receptors but produce much milder effects, along with reducing cravings and withdrawal symptoms.
As a pain specialist, Lonergan sometimes prescribes opioids to patients with no history of drug abuse. But for patients taking medicine for their addiction he won't, no matter how strenuous their pleas.
"Every day in my practice there are conflicts like that," Lonergan said.
His double focus on pain and addiction is personal. When he was a second-year medical student, Lonergan got an early morning phone call from his distraught father with the news that his older brother was found dead on the couch. The young man used powerful painkillers for severe headaches and other medical problems, and his death was considered a possible accidental overdose.
"There may be some therapy for me in treating patients with addiction, but you never recover from the loss," Lonergan said softly. "There's still a hole there that will never be filled."
Lonergan says the opioid crisis is compounded by not enough specialists trained to treat it and a persistent stigma, especially in Bible Belt states like Tennessee. He says patients' families can sabotage their recovery efforts by telling them church, not medicine, is the answer.
Many of Lonergan's patients are on addiction medication long term, though some can be weaned off. What he has found though, is that most need other addiction fighting tools, too — counseling, group meetings, social support, learning to manage life's problems "in more old-fashioned ways," he said.
Even with all that, he said, "there's still a lot within the patient that has to come from the heart."
Follow AP Medical Writer Lindsey Tanner on Twitter at @LindseyTanner.