By Dan Levin, The New York Times
ELIZABETHTON, Tenn. — Shortly after his first-grade class let out for the day, Nash Kitchens sat with a dozen other young children at a library and played a murder mystery game that had a surprising plot twist.
The victim was a restaurant worker who had been found dead in a freezer. The killer, the children would discover, was heroin laced with fentanyl, an often fatal opioid.
Nash, who at 7 years old has a relative who has struggled with addiction, was wide-eyed as Jilian Reece, a drug prevention educator, talked about an ongoing opioid epidemic in their small rural community. She then demonstrated how to administer Narcan, an overdose reversal nasal spray.
“It’s just like a little squirt gun,” she told the group of children, before passing around the small plastic device for them to hold and squeeze. At the end of the session, each child received a blue zippered bag containing two doses of Narcan to take home.
Like scores of communities across America, Carter County, Tennessee, which includes Elizabethton, has been struck hard by an opioid crisis that has ravaged families and reshaped how a generation of young people are being raised. Nationally, few cities have been spared as more than 400,000 Americans have died from opioid overdoses.
In Carter County, where 56,000 people live in a cluster of small cities and rural towns on the North Carolina border, nearly 60 people have died from opioid overdoses since 2014. That year, 8.1 million painkiller prescriptions were written in Tennessee, more than the state’s population of about 6.5 million.
Desperate to save lives, county health officials have embraced a practical — if radical — strategy for stemming the tide of addiction: teaching children as young as 6 how to reverse an overdose.
In the past three years, the county’s drug prevention coalition has given Narcan training to an estimated 600 young children and teenagers in after-school programs, babysitting classes and vaping cessation courses. Some of the young people have in turn trained their peers and taken a leading role in distributing Narcan at community events, like a back-to-school bash last fall where one child gave out 70 doses.
At least 100 young people have returned for additional doses, said Reece, the coalition’s director, typically after going through their personal supply.
But in a region where socially conservative attitudes prevail — and addiction is often seen as a sin — health workers have encountered strong opposition from residents, school boards and police officers who consider Narcan to be a waste of resources and the training inappropriate for children.
Drug prevention educators in eastern Tennessee said many schools and some counties have rejected their requests to teach harm reduction training in class, or to allow them to distribute Narcan to students and parents on school grounds.
“Lots of people say children don’t need to think about these things,” said Reece. “But I’d rather a kid should go through the trauma of giving Narcan than see their parent die.”
Sherry Barnett, the region’s overdose prevention specialist for the state of Tennessee, said only three schools in eight counties have allowed her to provide students Narcan training. “We’re in the Bible Belt,” she said, “and a lot of schools here don’t like to admit drugs are a problem.”
To get around such obstacles, Barnett, a nurse practitioner, has provided Narcan training at community events like high school basketball games, tailgates and a summer camp. She has trained students at McDonald’s, and in classrooms at the invitation of a sympathetic teacher.
With first- and second-graders, she presents a picture of opioids, explains that if someone takes too much they can fall asleep and stop breathing, and then shows how to “open, insert, squirt” the Narcan spray, letting each child push the plunger.
For adolescents, the training is as much about destigmatizing drug use as reversing overdoses.
Barnett often starts lessons by sharing details about her own three-year struggle with opioids. She was a nurse with her own health care clinic when she began abusing prescription opioids, after filing for a divorce and then the untimely death of her husband. Her addiction eventually led to snorting around 50 pills a day, having her clinic raided and a 14-month prison sentence.
Her honesty packs an emotional punch, she said, pointing out that many students have asked her how they can encourage a parent to confront their addiction and focus on recovery. “I’ve never had a child who was offended or scared,” she said of the training. “It’s the adults who think it’s inappropriate.”
Yordi Mendez, 16, grew up surrounded by drug use. At 13, he said he tried cocaine that his father had left in a bathroom, and he has seen two friends die from overdoses. He was caught vaping at school and is among nearly 100 students who since June have received Narcan training because of court-ordered vaping cessation classes, taught by the Carter County Drug Prevention Coalition, the same group Reece leads.
Learning how to administer Narcan, Mendez said, inspired him to join the coalition’s youth board, whose 35 members range from fourth grade through high school.
The youth board has come up with an array of strategies for reaching their peers, such as a mental health lending library with books on depression and anxiety. After finding that many children in low-income housing were taking care of their younger siblings, the coalition last March began teaching babysitting seminars that include Narcan training along with lessons on changing diapers and first aid techniques.
“We’ve had a lot of experience with kids who find it easier to listen to other kids as opposed to adults,” said Jocelyn Marr, 17, the youth board president, who teaches the class and created the murder mystery opioid game.
The Elizabethton Public Library, where the recent murder mystery game was held, is on the front lines of Carter County’s opioid crisis. The library’s staff, who were first trained to administer Narcan six years ago, said they have found drugs in the bathrooms, hidden inside DVD cases and stashed inside James Patterson books, which are so popular that they have become a drop-off location for drug deals.
And people frequently research drug treatment centers on the library’s computers, which are the only source for free public Wi-Fi in the county. Others, librarians said, have offered to pay overdue book fees with strips of the opioid addiction treatment Suboxone.
The library has taught Narcan lessons since 2016 as part of its parenting classes, and has also incorporated the training into its youth babysitting seminars, said Ashlee Williams, the children’s librarian, who often teaches the classes with Marr.
“It’s sad for our community, for our country, for everyone, that it’s come to this,” said Williams. “But I feel like if we didn’t do the training, it would be a disservice to the kids themselves.”
At the recent murder mystery session, the children ranged in age from 5 to 16. Several had been through the training before, but their parents thought they could use a refresher. Some of the children had a parent who has struggled with addiction.
Over slices of pizza, the children read aloud clues, though none guessed that the victim had died of an overdose. Once Reece revealed the plot twist, she led a discussion about opioids and encouraged the children to keep Narcan in their backpacks.
Nora Blohm, 8, whose father is an emergency room nurse, said that opioids “smash” the brain’s nerve receptors. Nolan Loveday, 10, described an overdose as using “too much drugs.” When Reece asked what they should do after administering Narcan, Nolan’s twin brother, Lennox, gave the correct answer: call 911.
Like most of the children, Nash was too young to fully grasp the complexities of addiction, but he understood enough to know that he can save a life with Narcan.
“Drugs are bad things that could kill you,” he said. “Now I know how to use it. I feel good because I like helping people in danger.”
In a community where drug use and stigma are rife, several parents said they hope the class teaches their children to be less judgmental of addiction. “Not only know why we don’t want to do drugs,” said Nash’s mother, Kelly Kitchens, “but why we still love the people that do.”
While the specifics of the class were too complex for Mia Pierce, a 5-year-old girl who sat coloring throughout the lesson, her mother, Tiffany Pierce, said she simply wanted her daughter to be aware of opioids and addiction, which have consumed Mia’s father and grandfather.
If only Pierce, 24, had been taught how to recognize an overdose at her daughter’s age, she said, she might have known at 10 years old to call 911 after finding her father, an intravenous drug user, unconscious.
“I would have felt more prepared,” she said. “It’s great for kids to learn. I don’t think it’s ever too early.”