With 96 fatal overdoses in just the first four months of this year, Mannix said the opioid epidemic ravaging western Ohio and scores of other communities along the Appalachian Mountains and the rivers that flow from it continues to worsen. Hospitals are overwhelmed with overdoses, small-town morgues are running out of space for the bodies, and local officials from Kentucky to Maine are struggling to pay for attempting to revive, rehabilitate or bury the victims.
As their budgets strain, communities have begun questioning how much money and effort they should be spending to deal with overdoses, especially in cases involving people who have taken near-fatal overdoses multiple times. State and local officials say it might be time for "tough love": pushing soaring medical costs onto drug abusers or even limiting how many times first responders can save an individual's life.
"It's not that I don't want to treat overdose victims, it's that the city cannot afford to treat overdose victims," said Middletown Council Member Daniel Picard, noting this industrial town in northern Butler County might have to raise taxes in response to the crisis.
The debate comes as demand for opioid antidote medication surges, creating new challenges for police and emergency crews already emotionally drained as they watch their communities — and, in some cases, families — torn apart by opioid addiction. Often, the only thing separating whether an overdose victim goes to the hospital instead of the morgue is a dose of naloxone, also known by the brand name Narcan, a medication that can reverse the effects of opioid overdoses.
Two doses of an injectable form of naloxone, Evzio, cost $4,500, up from $690 in 2014. The price of other forms of the drug, including the nasally administered Narcan, typically range from $70 to $150 per dose, officials say.
Compounding the costs, the potency of the newest batches of opioids often means first responders must administer multiple doses of naloxone to revive patients. Health officials say powerful additives to the illicit market — such as fentanyl and carfentanil, an elephant tranquilizer — are to blame.
Even if saved, an opioid user often is back on drugs within days, if not hours, officials say. Here in Ohio, first responders say it's not uncommon for overdose victims to have previously been revived with naloxone at least a half-dozen times.
Some officials and residents are starting to ask how a community can bear to try to help those who do not appear to want to help themselves.
The debate has shades of the divisive policy debates about drug treatment and tough jail sentences during urban America's crack epidemic in the late 1980s and 1990s. But in the suburban and rural communities that largely escaped that epidemic, the debate this time is far more intimate, as residents' traditional views about law and order — and how to spend limited resources — are being tested by a growing number of addicts.
"You got half the population, probably more, who have been affected by this, and they understand and get it, that this is a disease," said Scott Gehring, head of Butler County's Community Health Alliance. "And then you have the other side, and it's very easy for them to say these people are just a burden."
In Maine, Gov. Paul LePage (R) has pushed to make overdose survivors pay for their Narcan. LePage also vetoed a bill to expand access to the medicine, but the legislature voted to override him.
In towns across Ohio, similar debates are emerging as legislators ponder both the fiscal and emotional costs of an opioid epidemic that killed nearly 4,000 people in the state in the last year, according to the Ohio's Health Department. Though figures for 2017 are preliminary, many Ohio officials anticipate this year's toll will be even higher.
Larry Mulligan Jr., mayor of Middletown, said the city has spent $100,000 on Narcan in the first six months of the year, a tenfold increase from what the town spent during all of last year. Paramedics in Middletown have responded to nearly 600 overdose calls in 2017, already eclipsing the 2016 total, according to city officials.
Picard, the council member, has proposed a controversial three-strikes policy in which first responders wouldn't administer Narcan to repeated overdose victims. In 2016, Ohio EMS units administered at least 19,570 doses of Naloxone, according to state records covering the first nine months of the year.
"First responders are reaching a new level of frustration responding to multiple calls, for repeated victims, and they just don't feel like they are making progress," Mulligan said. "We can't just keep reviving people. We have to address solutions."
In Maryland, concerns about funding also have forced the Baltimore Department of Health to ration its dwindling naloxone supplies, providing kits to areas where the need is greatest.
With the help of an algorithm, Leana Wen, Baltimore's health commissioner, makes decisions about where to supply naloxone kits, prioritizing needle exchanges because addicts who inject drugs are at a high risk of overdosing.
More funding is starting to trickle in from Maryland and charitable groups, but Wen cautions that current funding models are not sustainable because of the scope of the epidemic.
"If this was any other illness, we would never accept rationing of an antidote," she said.
Congress last year approved a bill to provide $1.1 billion to help address the opioid crisis, and local officials hope that even more federal funding is coming. Several pharmaceutical companies who manufacture naloxone are providing the drugs free or at a discount to first responders and state health departments.
In Kentucky, officials pay for naloxone with a mix of federal funding and settlement money from a tobacco lawsuit. Officials say they have enough naloxone to go around, for now.
"I wouldn't say we are doing great, but we are treading water — we are holding our own," said Van Ingram, executive director for Kentucky's Office of Drug Control Policy, a state that saw 1,404 overdose deaths last year.
The cost of naloxone often isn't the only issue in dealing with overdoses. In recent weeks, Butler County Sheriff Richard K. Jones has drawn national attention for vowing that his deputies will never carry Narcan because he doesn't want them playing the role of paramedic.
But Jones — a conservative firebrand who recently advocated that the U.S. military bomb drug cartels in Mexico — says his views also symbolize the community's transition from frustration to desperation.
People in the nation's heartland, Jones said, are fed up with "enabling these people" amid a surge in drug-related foster care cases, property crimes and emergency room visits.
"I've had three babies born in my jail in 18 months, and the last one was born in the toilet," said Jones, noting that the female population in the Butler County jail more than doubled in recent years because of drug-related offenses. "The judges, to save the babies, sentence the mothers to jail. But when the women get here, they induce labor so they can get back out and do more heroin."
Butler County's chief prosecutor, Michael T. Gmoser, gets angry when he hears about community opposition to naloxone.
He worries that such views are undercutting southwestern Ohio's reputation for decency and civility.
"What the hell business do we have saying, 'You don't get Narcan to treat your sickness; we are going to let you die'?" Gmoser said, pounding his fist on his desk. "I don't care how many times that sick person comes back asking for another shot of Narcan."
The sheriff's stance also puts him at odds with the broader law-enforcement community. According to the Bureau of Justice Assistance, 38 states have implemented naloxone programs for police officers.
"It's not just the opioid users themselves that we are protecting," said Keith Cain, the sheriff in Daviess County, Ky., and the chairman of bureau's Drug Enforcement Committee. "What about the child who gets into mommy's or daddy's stash?"
Instead of rebelling against Narcan, drug policy advocates say local officials should focus on getting more users into treatment. Not far from Butler County, in Miami County near Dayton, officials are doing just that.
County paramedics and police now respond to between 50 and 100 overdose calls per month. But in the city of Troy, the county seat and home to 25,000 residents, a paramedic, a police officer and an addictions counselor hit the streets every Wednesday to follow-up with those who they've previously saved.
After approaching a woman slumped over a picnic table in a city park last week, the counselor spoke with Kelly Bruner, 30, about her options. Bruner agreed to be transported to a rehabilitation center.
Bruner said in an interview she has overdosed on heroin 13 times in the past year, and she has been revived with Narcan 10 times. Bruner said she and her friends have now started doing "CPR on each other," after hearing of Picard's three-strikes proposal in nearby Middletown.
"As long we know you have a pulse and a heartbeat, we aren't going to call the cops, because no one wants to use that Narcan," Bruner said. "Because if we can only get Narcan three times, that means there are only two more left before we die."