HUNTINGTON, W.Va. — There was a time when Beth would have laughed if somebody had told her she would wind up selling herself on the streets.
She had loving parents. She had a high school degree. She was 19 and plotting her next move in life.
Then her old friend Amber handed her a little green pill.
"It was an Oxy 80," Beth said, using the slang for an 80-milligram tablet of the opioid painkiller Oxycodone. "She said, 'C'mon, just try it one time.'"
Five years later, Beth was walking a seedy stretch of Sixth Avenue in Huntington and Amber was watching her back while car after car slowed down to check them out.
"I was a little nervous, scared, but I got a pep talk" from Amber, Beth said as she recounted that first night. "She made it like it was fun. She convinced me there was a freedom in it. She said, 'You're making your own money.'"
By that point, Beth said she had already traded sex for drugs with several dealers.
(Beth, as well as Amber's family, asked that they not be identified by their full names to protect their privacy.)
"I had been used to faking it, wearing a mask to survive," Beth said. "I would pretend to absolutely adore somebody to get people to take care of me."
But now she was so desperate for drugs she didn't care how she got the money. And within minutes, a potential john pulled over.
"It was this guy who was well-known down there for picking up girls," Beth said. "He slows down, gives me the head nod, makes a turn into the back alley."
And she went to him.
'We stand to lose a generation'
No place in America has been hit harder by the opioid epidemic than West Virginia. And no place in America was less prepared for the onslaught.
Already grappling with the loss of thousands of coal mining jobs, stagnant growth and an exodus of young people in search of opportunities elsewhere, the Mountain State was a sitting duck when Big Pharma began pumping prescription painkillers into the state.
The House Energy and Commerce Committee is now investigating the pharmaceutical companies and distributors who they say turned West Virginia into the epicenter of the crisis.
Last year, 909 people died in the state's 55 counties, according to the West Virginia Health Statistics Center. Nationwide, opioids figured in two-thirds of the 63,632 fatal overdoses reported in 2016, according to the federal Centers for Disease Control and Prevention.
Some struggling small cities like Williamson (population 3,200) were swamped with an astounding 6,500 pills per person over a decade, creating a new generation of addicts and further fraying the already torn social fabric.
The epidemic also drove many desperate women, as well as some men, into the street for cash, lawmakers and police said.
"A lot of the addicts are from towns that went bankrupt when the coal industry collapsed," said Matthew Perry, the Department of Homeland Security's resident agent in charge, who investigates sex trafficking. "In some places, there just aren't many other ways to make enough money to support a habit."
They go from prescription painkillers to heroin to prostitution.
While some women in West Virginia choose sex work, others are victims of sex trafficking, forced into prostitution against their will. Sex trafficking "is a crime of opportunity, and the pivot point for that opportunity is opioid addiction," said Assistant U.S. Attorney Andrew Cogar.
"Pimps often hold out [the] promise of drugs in return for women engaging in prostitution," he said. "We think that's fueling a lot of the demand and supply."
It's hard to quantify just how pervasive a problem prostitution driven by opioid addiction is in West Virginia, a conservative state that gave President Donald Trump a landslide victory in 2016 (68 percent, to 26 percent for Hillary Clinton).
The FBI compiles annual crime statistics from law enforcementin all 50 states for its annual Uniform Crime Report. But for reasons that are unclear, West Virginia is one of the few states that do not report crimes that fit in the category of "prostitution/commercialized vice."
"The State Police does aggregate prostitution arrest data, and I do not understand why it hasn't been forwarded to the FBI," Cogar said. "But I do know that data exists. And it's troubling."
NBC News has requested those figures from the West Virginia State Police.
Matt Meadows, a probation officer in Huntington, said he sees the steady stream of prostitution arrest reports and there is a sad refrain running through them.
"They go from prescription painkillers to heroin to prostitution," he said. "It's very common."
The West Virginia Human Trafficking Task Force, which includes social workers and concerned lawmakers, is trying to figure out how big the problem has become. The group aims to raise awareness about sex trafficking and fight it by developing a network of service providers, victim advocates, agencies and religious organizations to support trafficking victims — and their children, who are straining the state's foster care system.
"I don't want to lose any women to human trafficking at all, but we stand to lose a generation if we don't act more forcefully," warned Barbara Fleischauer, a member of the West Virginia House of Delegates who sits on the task force.
Amber's dad told NBC News he fears it may be too late for his daughter.
"I wish she would go to prison because then I'd know she was alive," he said. "I know she's having to be hooking and you hate that for your kid. But what can you do but cry and pray every night, and that doesn't seem to be working."
'I had a sweet innocent face'
Now 28, Beth said she didn't drink or smoke marijuana in high school. She was already living on her own and working as a waitress when she first crossed that line.
(Beth, like other sex workers quoted in this article, is being identified by an alias. Her story has been corroborated by the local police, newspaper accounts and interviews with her social workers.)
"I had stopped being friends with people because they were using that stuff, I was that good," Beth said. "Then a friend I hadn't seen since high school called me and needed a place to stay. She was really sick."
That friend was Amber. And she was sick because she was trying to get off drugs.
"So I gave her a place to stay," Beth said. "When she got better, she said she wanted to do it one last time before she quit forever and asked if I would be interested. I said sure."
Years later, Beth said she doesn't know why she agreed, why she let her defenses down.
"I tried it with her and it just took off from there," she said. "My mom's an alcoholic in recovery and my dad may have smoked weed back when he was a teenager. But nobody in my family had been involved in drugs."
One Oxy 80 became another, then another and another.
"In my mind it helped me work better," she said. "I had more energy. I felt more social. There was no hangover."
But already her world was starting to tilt.
Beth had to kick Amber out because she stole. "But I had gotten involved with her people," Beth said. "I had an apartment, I had a car, and they jumped on that."
Before long, Beth was driving dealers around and getting a cut of the money and drugs.
"They used me as the face of their operation," she said. "I had a sweet innocent face and had never been in trouble before."
Things were going so well that she didn't worry when the restaurant fired her for failing to show up for shifts.
"Then I met this older guy who used to take people down to Florida to the pill mills," she said. "They asked if I wanted to drive and they would pay for the gas and the food and I would get drugs. It was 14 hours down and 14 hours back."
After a couple of trips, Beth decided "to get clean" — the first of some two dozen attempts to get off drugs.
"I wound up getting on suboxone for 10 months," she said, referring to an anti-opioid dependency drug. "I found a good job. Then I used one time and I lost my job."
That was in 2011.
"The pills were so expensive and heroin is so huge in Huntington, so I started doing that," she said. "I got to the point that I would sleep with the dealers for drugs."
I had given up on myself. I’d given up on the idea of having a normal life.
For the next three years, Beth said she was in and out of rehab. She lived with her mother for a time and then moved to Virginia to live with her grandmother.
"I started using again and wound up stealing from my grandmother," she said. "I ran for a couple weeks before they caught me and I went to jail."
When she got out, Beth said she tried to go home.
"I wound up back in Huntington with the first girl I used with," she said. That was Amber.
'One foot in prison'
Women with stories like Beth's often end up in Cabell County drug court, which is presided over by Circuit Court Judge Gregory L. Howard in an annex across the street from the imposing county building in Huntington.
Howard takes what the probation officers call a "carrot-and-stick" approach with this especially vulnerable population.
The carrots are modest — colorful rubber wristbands and $10 gift certificates from Subway and Pizza Hut. And when the judge does apply punishment, he generally does so after first consulting the social workers who are trying to help these women get back on track.
There was no carrot for Nicole, the first woman who went before the judge at a recent hearing.
Her transgression? She missed a drug screening to make sure she was not using.
"I'm sorry, I overslept," she said.
Howard, who has heard this excuse many times, shook his head. He upped the number of spot drug screenings Nicole is required to do from two to four times a week. And he ordered her to retake a six-week drug awareness course that meets on Saturdays.
"Do I have to do the course?" a visibly unhappy Nicole asked. "I have kids."
"That's why you can't miss screenings," the judge replied, his voice even.
Nicole made a face.
"I guess," she said, slumping in her chair. "I will do it."
"It's not really optional," Howard said.
Nicole already knew that.
"The bulk of the people we deal with already have one foot in prison," probation officer Lauren Dodrill said. "They are mostly great people, but they have a drug problem."
More than 1,300 adults and nearly 300 juveniles statewide in 2016 and 2017 have appeared in drug courts like the one Howard presides over, according to the state Supreme Court of Appeals.
To avoid incarceration, many agree to take part in state-approved alternatives like the Women's Empowerment and Addiction Recovery program, which is based in Huntington and specially designed to help women break the cycle of drug dependency and, in many cases, escape the streets.
"Not using drugs is actually the easy part," Dodrill said. "Changing behaviors, habits, that's the hard part."
Meadows, the Huntington probation officer, said the women they monitor "are not the stereotypical prostitute."
"They have done things they are not proud of just to buy dope," he said. "There is a lot of shame. But here they have a chance to reclaim their lives — they're treated with a bit of dignity."
And yet, barely half make it through the program, which typically takes a little over a year, he said.
That is why — ahead of the court hearing — Howard met with the probation officers and social workers to review the cases.
For someone like Nicole, who had been doing well, the decision was made to sanction her in a way that wouldn't be so harsh as to potentially derail her recovery — but was strong enough to reinforce the message that missing drug screenings is not acceptable.
Nicole was followed by several women who were in court to collect carrots.
"You are doing better than we thought you would," Howard told a beaming woman named Linda and invited her to come up and take one of the gift cards arrayed before him — her reward for making it past one of the major mileposts on her road to recovery. "I'm proud of you."
"Oh, thank you," Linda replied as the courtroom erupted in applause. "My kids love pizza."
There were more kudos from the judge and cheers for several other women who collected wristbands and gift cards, including a young woman, Carly, who informed the judge she had just landed a job at a McDonald's.
"They just took my sizes for my uniform," she said.
All Carly needed now were shoes with nonslip soles. But rather than give her money — and perhaps endanger a person still wrestling with temptation — activist Necia Freeman volunteered to find a pair for her.
Because that is what Freeman does.
For half a dozen years, Freeman has been running a ministry through the Lewis Memorial Baptist Church called Brown Bag and Backpacks that provides sex workers with meals, a Gospel tract and a number they can call when they are ready to leave the life.
"The girls love Vienna sausages and Capri Sun drinks," she said, adding that many of them rarely eat more than once a day. "We give them a pack of Pop-Tarts and soft snacks like yogurt because a lot of them have dental issues. And we give them spoons because we saw them trying to scoop yogurt out of the containers with their fingers."
Hitting rock bottom
All the johns became a blur as Beth worked the streets. All she could think about was getting high.
"I had given up on myself," she recalled. "I'd given up on the idea of having a normal life, of having a marriage, children, the white picket fence. Any ambition like that was just gone."
All she wanted, needed, was another fix.
"You literally live from moment to moment," she said. "You don't want to be sober because that's when reality sets in."
Beth said she did things she would never have dreamed of doing sober, like trying to rob a CVS in September 2015 with a note that said she had a gun.
"I wound up doing some time for that," she said. "I got clean in jail, got out, came back, and relapsed."
When the drug dealers she relied on most began getting arrested, Beth said she took a friend's advice and decamped for Lynchburg, Virginia. There she posted an online ad for men "looking for a 'date' and within five minutes there were five guys hitting me up."
One encounter went really bad.
"There was a guy I met up with at a motel and we did some stuff and I passed out," she said. "I woke up 45 minutes later and he had taken me to some trailer out in the country. He took my phone and chained me up. I had to drug him to get the chains off and get away."
Beth said she didn't dare report this to police. But it rattled her and she moved on to Roanoke, Virginia, where she tried again to get straight.
"I had dried out after an eight-month run," she said. "I called my mom and told her I wanted to come home for Christmas."
Warily, her mother agreed. Soon, Beth was on a Greyhound Bus home to West Virginia. Once there, she ran into an old friend who she "used to use with" who told her about a place for women like her in Charleston called Recovery Point.
"I looked at my mom and said this was the kind of place I need," Beth said. "So I called, packed my bag, and have been here ever since."
That was 14 months ago.
Path to sobriety
Recovery Point is a 92-bed long-term facility for women in Charleston that is supported by federal grants, donations and fundraising drives. It is in a low, gray industrial-style building, and many of the patients have walked in Beth's shoes.
It is also a stone's throw from some of the seediest streets in the West Virginia capital. And every time Marie, a social worker at the center, drives by and sees "the girls" working the street, her heart breaks a little.
"I did it for six years," said Marie, who is from a nearby state and was a college student when she came down with lupus and got hooked on the painkillers prescribed by her doctor.
Within weeks, Marie said, she graduated to heroin and soon started doing sex work to support her habit.
"You'll do anything for the next high," she said. "You'll meet somebody who will act like some kind of Prince Charming, and they wind up selling you."
Several stints in jail convinced her she needed to make a change.
"The last time I got paroled, it was to a long-term treatment program in Kentucky," she said. "I was ready. I wanted a different life. I knew if I went back out on the street, I would die."
Marie, who is 27 and asked not to be identified by her full name, got sober, finished school and landed a job at Recovery Point.
As a phase coordinator, she helps recovering women transition from one phase of treatment to the next. Women start with the detox program, which takes three to seven days and introduces them to the Twelve Steps, the philosophy pioneered by Alcoholics Anonymous.
If they make it through the grueling first few days, they are assigned a bunk and a shelf for their belongings. They are required to attend daily drug awareness classes. And they are assigned a "72 hour buddy," the first of several peers who help them adjust and get back on their feet.
Needless to say, no drugs or alcohol are allowed. Residents are also barred from using cellphones or driving cars. They must refrain from violence, making racial threats and having sex.
If they break any of those rules, they're out.
"All of our girls, they do all the cooking, cleaning, yard work, maintenance," Marie said. "They learn all those life skills while they are here."
As they move up from one phase to the next, they are given more freedom — and more responsibility.
They are required to find jobs on the outside, but they have a strict curfew. In time, they are allowed to spend some nights away until they are ready to live on their own again.
At that point, some get tapped to be mentors for the newbies.
Marie said it takes from nine to 14 months for most patients to graduate, although some like Beth take longer.
Since the program started two-plus years ago, 18 women have completed it, and 16 of them are still sober, Marie said.
Eleven of the graduates are still at Recovery Point, working as staffers, she said. And they are now building an apartment building behind the facility "where the girls can live."
But many women don't make it. And many arrive with a mindset forged by years on the street that everybody can be conned.
"They learn really quick that they can't pull that stuff with me," Marie said. "I know when they're lying."
'I just want to be happy'
Beth's days now begin at 6:30 a.m., when she wakes up in a dorm room crowded with bunk beds that she shares with 44 other women.
The rest of the day is structured around chores and meetings where the women sit in a circle and smoke cigarettes and share their stories and draw support from one another.
At 10:15 p.m., it's lights out. And another day of sobriety is in the books.
I don’t want other people to go through what I went through.
Beth is close to completing Phase 1 of her recovery and preparing for the next phase, which will require her to get a job outside the protective cocoon she has been living in.
"The last time I held a job was back in 2012," she said.
Beth said she has some short-term goals, like the 10th high school reunion this summer that she is thinking about attending. She also has a court date coming up for the attempted CVS robbery where she hopes the judge will take her rehab into consideration and expunge the arrest from her record.
Long term? "I just want to go back to school — I am a super nerd," she said, adding that she doesn't know what she would study, but that she finds the idea of being back in a classroom is comforting.
What she doesn't see in her future right now is a man.
"I don't crave a husband anymore," she said. "I just want to be happy. I don't want other people to go through what I went through. I don't want people to feel like they can never be loved."
But the past is always present for a recovering drug addict.
Last fall, Beth said she was doing her chores and found herself staring at an all-too-familiar face: Amber.
"We caught up some," Beth said. "She told me this time she was going to get sober. She lasted three days and she was gone."