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Nikki King was 17 years old when she left the mountain hollow where she was raised by her grandparents and sneaked off to the University of Kentucky under cover of darkness. It was 2009, and the advice of her late grandmother Sue King echoed in her head as she drove: Leave. Go to college. And do not let anybody from the bigger, wider world think they’re better than you. To hear more feature stories, get the Audm iPhone app. Sue died of a heart attack in 2000, when Nikki was 9. The opioid epidemic had already begun to infiltrate eastern Kentucky by then, and in Nikki’s mind the drug problem turned into a drug crisis shortly after Sue’s death, when her family went from sleeping with the screen door unlocked to buying new doors—without glass panes, which could be knocked out by burglars. Around that time, Nikki went to a birthday party where her friend’s mom stumbled and smashed the cake into the kitchen counter. Nikki later found her passed out on the toilet, surrounded by vomit and pill bottles.

By high school, Nikki had just one friend who lived with both parents. She remembers a teacher asking her classmates what they wanted to be when they grew up. “A drawer,” one boy said. “You mean an artist?” “No, a draw-er”—someone who draws disability checks and doctor-shops for OxyContin prescriptions. The pills could be had for next to nothing through Medicaid and then resold on the black market for $1 a milligram. It was the only future he could imagine for himself. Nikki knew by then that both her safety and her economic fortunes lay far from Letcher County. But her widowed papaw, Curt King, wanted her to stay home. He thought that Nikki should become a nurse, and that the community college would suffice. It didn’t matter that she had a 4.0 GPA, and he had no reference point for her high ACT score. “He didn’t understand AP classes,” she told me. “He thought that meant I was slow.” The night she ran away, Nikki stopped at an Arby’s halfway to Lexington because she was shaking too hard to drive. She’d been planning the move her entire senior year, covertly applying for scholarships and saving up $800 by working at a comic-book store. But she hadn’t ever set foot on campus, and she worried about Papaw, who was 72 and had never lived alone. She’d waited for him to fall asleep before tiptoeing out the door, and when she imagined him waking to an empty house the next morning, her shaking turned to deep, heaving sobs. Ugly crying, she calls it.

Nikki thought about going back. But then she remembered one of her last conversations with her grandmother. She had forbidden Nikki from going to a certain friend’s house. They’d both heard that the friend’s mom had become addicted to OxyContin prescribed for a back injury, and had started buying pills from a dealer when her prescription ran out. She was arrested for illegal possession, then released on probation without any treatment. When she relapsed, she feared she’d lose custody of her kids for failing a drug test. Her dealer told her she could erase the OxyContin from her system by drinking Clorox. So she did, and it killed her. That was a turning point for Sue. She’d always urged Nikki to go away to college so she could return and use what she’d learned to help people in Appalachia. But after this mother’s death, she changed her mind. “Just go,” she told Nikki. “And don’t come back.”

In the car that night, Nikki cried so hard that she vomited. Then she wiped herself off and drove down the mountain to college. A decade later, Nikki, now 28, has become one of the leading voices on the opioid crisis in rural America—where, some 20 years into the disaster, treatment options remain scarce even as overdose deaths continue to climb. In many rural places, neighbors turn on one another rather than placing the blame higher up—on the pharmaceutical companies that created the epidemic and the impotent regulators and bought-off politicians who enabled it. (In my reporting on the crisis, I’ve seen this attitude over and over. At a recent meeting in rural North Carolina, for instance, the head of the local Kiwanis Club objected to a plan to give people rides to treatment facilities, saying: “I think when they relapse, we should let them die and take their organs.”)

Read: The opioid epidemic might be much worse than we thought The drug-overdose epidemic has already killed over 800,000 Americans—more than have died from AIDS—but the federal government has yet to provide adequate solutions, let alone a level of funding that could stem the crisis. In the absence of help from above, Nikki has figured out a way to get treatment to people in remote, underfunded areas. The program she’s developed is still small and new, but its results are promising, and it appears to be replicable in states that have expanded Medicaid under the Affordable Care Act. Perhaps most important, it bridges the gulf between a medical culture that too often abandons people the moment they become addicted, and a legal system that incarcerates them when they can’t recover on their own. Her aim is to help people with opioid addiction, rather than just locking them up. Video: A Small-Town Plague I first met Nikki in early 2017, after hearing about her work as a National Rural Health Association fellow at Margaret Mary Health, a community hospital in Batesville, Indiana. She was the lead data cruncher on a hospital-wide task force that had achieved a 60 percent reduction in opioid prescribing. I was writing my book Dopesick: Dealers, Doctors, and the Drug Company That Addicted America in Roanoke, Virginia, my reporting base for 30 years. When I asked Nikki to help me understand the genesis of the crisis, she suggested that we meet at Papaw’s body shop, in eastern Kentucky, not far from “Wattsburg,” as I wrote in my notes. Officially known as Whitesburg.

Donald Trump had just been elected president, and J. D. Vance’s Hillbilly Elegy had topped the New York Times best-seller list. When I brought up either of those things, Nikki’s demeanor hardened, her accent thickened, and she spoke at a rapid-fire pace that most non-Appalachians would find hard to process. (Tim Putnam, the CEO of the hospital where she works, admiringly refers to these semi-rants as “going all holler.”) Nikki hated Hillbilly Elegy, she said, because Vance treated Appalachian culture as if it were his cross to bear, then turned around and used stereotypes to sell his book—“blaming the region’s problems on things like lack of thrift and a crisis of masculinity” and ignoring “the role of bigger forces in creating this miry pit of social problems.” We went to the town of Jenkins so I could meet the former mayor, who was now living in a self-storage facility. Nikki had been out of high school for only seven years, but already she could tick off the names of more than 20 former classmates who were dead from what the economists Anne Case and Angus Deaton have called “deaths of despair”: suicide, overdose, or alcohol-related illness. In the previous year alone, six friends and relatives had died of drug-related causes. “I’m having to ration my vacation time for funerals,” Nikki told me. Her long-term goal was to return home to work on the opioid crisis in Kentucky, but she was still too young and too female to get anything done in Appalachia, she said. In Indiana she had the ear of politicians, and she spoke so often at national conferences that Putnam, her boss, had gotten used to people coming up to him and saying, “You’re the guy who works with Nikki King!” But in Kentucky, no one would return her calls.

Curt King had long ago forgiven Nikki for running away to college, and had even helped her pay tuition. He drove us around the county in his rusty Ford F-150 pickup while narrating a landscape that existed only in his memory. I was supposed to imagine schools that weren’t shuttered, movie theaters that weren’t caved in, and once-booming coal towns with names like Elkhorn City and Uz (pronounced “you-zee”) and Seco, short for South East Coal Company, where his own father had been a supervisor before the mine closed in the late 1950s. “We would’ve never won World War II if not for the coal that made the steel,” he said. But none of that is here anymore, Nikki kept gently pointing out. We drove through a town called Neon where all the neon signs were burned out. “It’s like growing up in a skeleton,” Nikki said. “You look around and see the bones of when Papaw was little, but I never saw any of it.” Read: The true cause of the opioid epidemic We went to the town of Jenkins so I could meet former Mayor G. C. Kincer, who’d lost reelection and was now living in a self-storage facility. He told me that his most memorable day as mayor was when he went to pick up his blood-pressure medication and found the town pharmacist spread-eagle on the floor, passed out from opioids he’d stolen. Nearly a third of the county reported having a disability, and the workforce-participation rate was down to 43 percent. “If you took 100 job applications right now, you might get 10 people who could pass a drug test,” Kincer said. “I don’t see any hope.”

Nikki didn’t want to hear that. “I think we can beat it,” she said. “I just need somebody to start listening to me.” She’s been saying some version of that ever since.

From his perch at King’s Body Shop, where locals gather most mornings to share fast-food biscuits and talk through the problems of the world, Curt King spots trends before the social scientists do. “A lot of the drug problem here in Letcher is only slowing up now because so many people have already died off,” he told me. Indeed, in recent years, the number of overdose deaths has dropped in a handful of eastern-Kentucky counties, including Letcher and neighboring Clay. Experts aren’t sure whether the deaths have reached saturation or whether fewer among the addicted are dying because they’ve switched over to methamphetamine, which is less likely than opioids to result in an overdose. From May 2019: One West Virginia doctor’s redemption Nikki favors the saturation theory, noting that the opioid crisis exploded in eastern Kentucky before spreading to the rest of Appalachia. The first national story about the nascent crisis appeared in The New York Times in 2001 and focused on nearby Hazard, Kentucky, the center of the largest drug bust in state history. The federal prosecutor counted 59 deaths related to OxyContin overdoses in the area in the preceding year. The drugmaker Purdue Pharma had sent an army of sales reps into eastern Kentucky and other regions with high disability rates to promote the idea that pain was vastly undertreated, and that its new drug was virtually nonaddictive. In places where people historically had legitimate workplace injuries, the desperate and jobless were soon pilfering lawn mowers and copper wiring to fund their next OxyContin fix. The medications to treat opioid-use disorder are far more tightly regulated than the painkillers that have gotten people hooked in the first place. When stories started to come out about escalating Oxy-fueled crime, Purdue blamed the people it had helped addict. “We have to hammer on abusers in every way possible,” Richard Sackler, Purdue’s president, wrote in an internal email only recently made public. “They are the culprits and the problem.” (Purdue did not comment on its responsibility for the epidemic, but said, “The causes of opioid addiction are multifaceted and complex.”)

Sackler was hardly the only one to blame users. America’s long history of treating substance abuse as a crime, rather than a disease, dates to the Harrison Narcotics Tax Act of 1914, which outlawed the use of narcotics in treatment at a time when about 250,000 people had an addiction. A century later, we remain more likely to punish a person struggling with a substance-use disorder than to provide help. Only one in five addicted people in the U.S. receives treatment. Still fewer get what doctors consider the gold standard of care: a combination of counseling and medication-assisted treatment, which uses weaker opioids (methadone or buprenorphine, often sold under the brand name Suboxone) to reduce cravings and ease withdrawal, or an opioid blocker called naltrexone. These drugs cut mortality in half compared with abstinence-based treatment programs, and the medical consensus is clear that getting off opioids without them is nearly impossible. Once the brain’s dopamine receptors have been distorted by opioids, every waking thought is overtaken by cravings and a fear of withdrawal—of becoming dopesick, with painful diarrhea, vomiting, fevers, and crushing anxiety. But the use of medication-assisted treatment, or MAT, has faced enormous resistance in the U.S., where many judges, police officers, and even people in recovery view it as a crutch—merely substituting one drug for another—or focus on its potential for misuse. In fact, the medications for opioid-use disorder are far more tightly regulated than the painkillers that have gotten people hooked in the first place. Health-care providers must receive at least eight hours of training before they can prescribe buprenorphine, and then they’re limited in the number of patients they can treat—part of the reason only about 5 percent of physicians are licensed to prescribe the drug.

Sally Satel: The truth about painkiller addiction The result of this thinking was visible everywhere as Nikki showed me around. I asked whether it embarrassed her, letting me see where she grew up. She slammed her fist on the steering wheel and shouted, “Yes!” She wasn’t embarrassed to be Appalachian; she was embarrassed by how desperate things now felt here. “But I’ve gone through the five stages of grief. I’ve been pissed at Big Pharma, pissed at the government. I’ve been pissed at everyone.” “At 14, I could’ve pointed out everybody who would be dead of overdose today, and I would’ve been right. If I can do that at 14, how are we letting them fall through the cracks?”

On the wall of his body shop, Curt King displays a framed black-and-white photograph of miners from the Elkhorn Coal Corporation labeled mine #4 night shift. The men wear overalls and hard hats with headlamps. They smile, their arms crossed, with nary a thought of global warming or a future in which people would learn to pair OxyContin with Xanax for a so-called Cadillac high. A group portrait from the same era—the 1930s—hangs in the Indiana hospital where Nikki works, but in this one men and women are dressed in fur coats and three-piece suits. At least 1,000 of them pose in front of the just-opened Margaret Mary Hospital, named for the two women who donated the money to found it. The civic boosters in the photo couldn’t have envisioned a proposed baby-cuddling program in their hospital for soothing infants born opioid-dependent. Or that drug-involved child-protection cases in their county would escalate 400 percent in the course of four years. Not in a region founded by German farmers and furniture makers, in a setting so quiet and bucolic that the basketball movie Hoosiers was set there.

Nikki has worked for five years to improve access to addiction treatment in Ripley County. Rampant overprescribing of OxyContin and other opioids was happening here in the late 1990s and early aughts, just as it was in Appalachia, but the crisis didn’t make itself as immediately or as loudly known. In places like Batesville, where jobs were still plentiful, the addicted weren’t accidentally burning down abandoned factories or cutting telephone poles down in broad daylight to steal copper wiring. Read: An ‘overprescription of opioids’ that led to a crisis No, the epidemic rolled into Ripley County more like fog than fire—harder to discern and easier to dismiss. It began showing up in the crime rosters in the mid-aughts, when teenagers and 20-somethings started making the 45-minute drive east to Cincinnati to buy heroin. “By 2008, we were tracking track marks, taking pictures of everybody’s arms,” Shannon Schmaltz, who oversees the county’s probation program, told me. He got to know the names of Cincinnati dealers—“Big Tom” was popular—and started calling Cincinnati police to find out which of the probationers on his caseload had been spotted buying heroin in the city, sometimes trading their shoes or their kids’ baby clothes for it, hiding syringes in the diaper bag. Circuit Court Judge Ryan King’s docket was overwhelmed not just by drug crime but also by drug-related child neglect. “I’ve seen the placement with the foster parent, and then the foster turns out to be using drugs too,” King (no relation to Nikki) told me. “After hearings like that, you just want to quit. You think, My goodness, what are we ever gonna do? What are we doing?” Related Stories Physicians Get Addicted Too

America’s Health-Care System Is Making the Opioid Crisis Worse

Did Free Pens Cause the Opioid Crisis? Nikki and Judge King both attended a countywide opioid forum in 2018, a year after a local woman overdosed in a Chuck E. Cheese bathroom in Cincinnati, as her 5- and 7-year-old children played in the restaurant. Nikki had worked her way up from graduate fellow to manager of the hospital’s mental-health and addiction services, and she was trying to ensure that patients who overdosed and ended up in Margaret Mary’s emergency department got referrals for follow-up care, including MAT. But MAT drugs are nearly impossible to get in rural America, where more than half of counties don’t have a single buprenorphine provider, and methadone is even less available. Counseling services, too, are in extremely short supply—the ratio of residents to mental-health providers in Ripley County is 2,200 to 1. More often than not, patients who overdosed and wound up in Margaret Mary’s ER were treated with Narcan, the overdose antidote, and released. If hospital staff ever saw them again, it was usually for another overdose, sometimes a fatal one.

Elsewhere in the U.S., drug courts—which allow addicted offenders to enter a treatment program instead of going to jail—have been shown to reduce recidivism. But drug courts are expensive to operate and tend to be concentrated in cities and suburbs. Many leave treatment decisions to local judges, prosecutors, and probation supervisors—who may or may not understand addiction medicine. About half of drug courts prohibit the use of MAT; some funnel probationers into abstinence-only 12-step programs, despite overwhelming evidence that they’re less effective for opioid addiction. Read: Chronic pain is an impossible problem Ripley County has never had the resources for a drug court anyway. Two years ago, the county’s probation program for drug offenders required drug testing, but offered only two hours of group therapy a week and no MAT. At the opioid forum, when Nikki heard Judge King describe that as the county’s “drug treatment,” she challenged him. “I think we can do a lot better,” she said. The program she eventually created, with the county judges’ blessing, provides nine hours of group therapy and a variety of social supports, plus MAT. Three nights a week, probationers in the new Courts Addiction & Drug Services, or CADS, program receive cognitive behavioral therapy, job coaching, meditation training, and other services. Nikki talked one of the hospital’s nurse practitioners, Jeff Coy, a former detective, into becoming the group’s first MAT provider. After taking the training course to prescribe buprenorphine, Coy went from thinking of the addicted as “druggies” to seeing them as people with a legitimate disease, not unlike diabetics who struggle to keep their blood sugar under control. “He’s also a preacher, and he cusses,” Nikki said, as if that were everything I needed to know about him. Next she recruited Lindsey Gessendorf, a therapist who’d been running a program for men in jail.

Nikki knew that marshaling funds for a new program would be tough; the hospital was already $3 million in the red. But her goal was for the program to be cost-neutral within six months, through Indiana’s Medicaid expansion. The federal program covers addiction treatment, but health-care providers at Margaret Mary and elsewhere had found that high no-show rates for patients with an opioid dependency meant they couldn’t bill the government enough to break even. Nikki’s program promised to solve this problem: By coordinating with the judges, she could use the threat of jail time to ensure that patients showed up. If the group could achieve a nearly perfect attendance record, the program would essentially pay for itself. Nikki and her staff of hospital employees set up a drug-treatment center in a conference room inside the courthouse. They brought in snacks and covered the walls in homemade signs with inspirational messages. More than half the participants were given some form of medication-assisted treatment. For the first time in Ripley County’s circuit court—and quite possibly for the first time in rural America—judges were turning probationers over to health-care providers just down the hall. “I’ve never heard of that,” Brock Slabach, a senior vice president of the National Rural Health Association, told me. “This is pioneering. Most people don’t see what’s possible until they’ve seen real innovations taking place somewhere else.”

Nikki finds the work gratifying, messy, sleep-robbing. Most of the patients grew up in households where drugs and abuse were common. When Nikki asked them each to name a short-term goal, one participant said he wanted a second pair of pants. Another wished to taste salmon for the first time. When Nikki passed out orange-capped pens for a writing exercise, she unknowingly triggered those who had used orange-capped needles to shoot up heroin or meth, which was just about everyone in the group. Nikki tossed the pens, and Gessendorf quickly changed course to talk about “euphoric recall” instead, explaining that powerful memories of a good high would be a long-term challenge to the participants’ recovery.

Nikki took care of the second pair of pants and the salmon, and replaced the orange-capped pens. But a few weeks later, a patient was caught misusing buprenorphine—snorting it outside the courthouse—and trying to sell it to others in the group. Another threatened to pull Nikki’s fingernails out. When Nikki told me about these setbacks, I thought of the ex-mayor living in a storage facility in Kentucky. Perhaps he was right. What hope did we have? The epidemic has only continued to worsen, and experts don’t know when it will plateau. Barring a flat-out overhaul of the War on Drugs—wherein a significant chunk of the estimated $50 billion the country spends on enforcement and incarceration each year would be funneled into treatment instead—how could a tiny program like Nikki’s be replicated on a large-enough scale to turn back the tide?

“I ask myself that all the time,” Tim Putnam, Nikki’s boss and the hospital CEO, told me. Kenny Shadday tried OxyContin for the first time in 2009, at age 15. He’d just come out as gay, and the pills numbed his anxiety, as well as the pain inflicted by bullies. By 16, he was bouncing between juvenile-detention facilities, children’s homes, and jails. When Nikki launched the CADS program, in October 2018, he had just finished yet another sentence. He joined the inaugural class, and quickly became the most conscientious participant. He was so fearful of not being able to pee when his probation officer showed up to drug-test him at work that he routinely held it for hours at a time. He was also funny, and open with his vulnerability, qualities that made him a staff favorite. Within weeks, his time in the program became his longest period of sobriety (not counting jail time) since he was a teenager. Read: The opioid reckoning will not be just Two months in, Shadday was working 70-hour weeks at McDonald’s when a friend showed up with some meth she was looking to off-load. It was free, he was stressed and tired, and he knew the drug would give him a boost. He regretted it even before his high wore off. Shadday assumed he’d be cut from the program and sent back to jail; that was how probation had always worked for him. But Shadday confessed the relapse to Nikki and Gessendorf the next day, and begged for another chance. For the first time in some people’s lives, the cycle of jail to probation to relapse and back was coming to a close. Gessendorf agreed to go to bat for him with Shannon Schmaltz, the head of probation. She planned to argue that expecting Shadday to get clean on his first try wasn’t realistic. After all, addiction is a chronic, relapsing disease, and most people need multiple attempts at recovery. Gessendorf and Nikki thought that letting Shadday stay in the program might become a turning point for the others as well—a way to build trust that could buttress the entire group.

Gessendorf had her work cut out for her with Schmaltz. Before the CADS program launched, he’d seen only the abuse of MAT medicines, never the successes. When Gessendorf suggested they not jail Shadday for his relapse, his first thought was Are you serious? But Schmaltz was impressed by the CADS program. For the first time in his career, he saw that people like Shadday wanted to get better. Because he knew them. Liked them, even. So he sat down with Nikki and Gessendorf, and together they worked out a three-strikes matrix—additional treatment after one relapse, a few days of jail time after a second relapse, and a court date after a third.

When Shadday was permitted to rejoin the program, Nikki realized that rural America may actually have a few advantages over cities when it comes to knocking down barriers to treatment. After all, her boss knows the judges who are Schmaltz’s bosses. Nikki used to coach a girls’ running club headed by Schmaltz’s wife, and her fiancé coaches the high-school football team. And Margaret Mary Health has community cred among politicians and judges. It’s both professional and homey—the kind of place where Brahms’s “Lullaby” chimes over the loudspeakers whenever a baby is born.

After four months, nearly every participant had stuck with the CADS program, and it had doubled in size from 12 to 24 participants, with more on the waiting list—a good record, given the high failure rate of opioid-addiction recovery. Nikki was in talks with the area’s three largest businesses to provide treatment to factory workers and potential hires who can’t pass a drug test. All was going reasonably well, notwithstanding the fact that every day she felt like the cartoon dog sitting at a table saying “This is fine” while everything around him burns. In late February 2019, Nikki was in a meeting with hospital administrators when one said, in an offhand way, that Medicaid wouldn’t reimburse the hospital for the CADS program, because it was housed at the courthouse and not in a medical facility. He proposed that they shelve the program, and Nikki felt her composure slipping. Maybe they could use a hospital-owned practice in Batesville, someone else suggested. But that was half an hour from the courthouse, too far for many patients. Another practice was closer, just 10 minutes away. Maybe they could co-opt the break room, move a refrigerator around. That was when Nikki lost it, right there in front of the administrators—all of whom were at least two decades her senior. Housing a medical program inside the courthouse had been the whole point, the key to finally making the medical and legal systems mesh. It was the heretofore-missing component, a way to coordinate the carrot and the stick. The fact that people like Gessendorf and Schmaltz knew each other so well now—their quirks, their backstories, the names of each other’s spouses—those relationships, Nikki argued, were what made the program work.

But then she had an idea. “Why can’t I just buy part of the courthouse?” Nikki asked. They could wall off one side of the conference room they were already using and the hospital could rent it for $25 a month. The county commissioners would have to sign off, as would the judges and Schmaltz, who worried, initially, about the appearance of spending taxpayer money to convert the space. But he was supportive. For the first time in some people’s lives, the cycle of jail to probation to relapse and back was coming to a close.

Schmaltz even came in on Saturdays to oversee the construction. He directed probationers with carpentry experience to put up the walls and frame the door. He begged a local hardware store to donate supplies, and he brought in houseplants for decoration. He installed a sign outside the door that read: margaret mary health, ripley county courthouse, suite a. “He’s been on Pinterest,” Nikki deadpanned. Above the entrance, Schmaltz affixed an appliqué he’d purchased on the internet, using a ruler to ensure consistent spacing between the words. make today amazing, it said. Read: What the dark web can teach us about the opioid crisis Last fall, as Nikki and her team prepared to celebrate the program’s first anniversary with lasagna and cake, she put up a PowerPoint: 45 people had completed the eight-month program with no issues; 18 had relapsed once, eight of whom reengaged immediately in treatment. No one had overdosed. In fact, one participant had used a Narcan kit from CADS to resuscitate a relative. “So technically, we’re at plus one,” Nikki said.

Shadday had been promoted at McDonald’s and was training to become a regional supervisor. Whereas he’d arrived at our first interview, back in January 2019, wearing pajama bottoms, he now took pride in special-ordering uniform shirts and a bow tie. He’d been sober for about six months, the longest he’d gone as an adult without being jailed. He was planning to start an LGBTQ recovery group and had become a leader in a post-CADS support group held on Friday nights. Nikki was about to expand the program into an adjacent county and was getting ready to launch a recovery kitchen to teach healthy eating. And she’d more than tripled her staff, thanks in part to a $300,000 grant from the very pharmaceutical company she’d been seething about for years—Purdue Pharma. (“I told Nikki, ‘If you want to treat more people, you just have to swallow your pride and take the money,’ ” Cindy Ziemke, a Republican state representative who’d lobbied Purdue for the grant, told me.)

Nikki’s still working to change the mindset in Ripley County. She’s had heated confrontations with jailers over hard-line bans on prescribed buprenorphine in jails, including once when a pregnant CADS patient relapsed and was arrested. Denying the woman buprenorphine while she detoxed was a potentially life-threatening decision for her baby. Nikki helped arrange for her to get moved to inpatient treatment three and a half hours away.