Of course everybody knew. That's the way it is in small towns. Few things stay secret for long.

In Austin, Ind. — population 4,300 — the police, the mayor, the local health clinic, and the congregations of its 35 churches have all known for years that parts of their town had descended into a jungle of prescription drug addicts.

The ugly hopelessness of it is obvious.

The drug use is centered in the north end of Austin, where many houses are extremely run down. (Lyndsay Duncombe/CBC) Huge clumps of deep and gnarly weeds that used to be lawns now separate the potholed streets from rundown houses with windows that are always covered. Here and there a grimy-looking face gazes droopy-eyed from some worn out piece of furniture sagging on a sinking porch.

For a decade the town has seen people in the north end wasting away, crumbling alongside the dilapidated bungalows in which they live.

What Austin failed to see beyond the drug problem was that the north end of town had also become a reservoir of infectious diseases: hepatitis B and C, HIV.

Indiana's strict anti-drug paraphernalia laws, designed to prevent illegal use of syringes and hypodermics, were making things more dangerous for users.

The pain relievers OxyContin and Opana are powerful opioids when crushed, liquefied and injected. And, for years, users here have been crushing, liquefying and injecting in the darkened corners of their dingy-looking 'hood using whatever needles they could find.

Linda Thomas, right, was a drug user for most of her teenaged years who got clean after going to jail and meeting her husband, fellow recovering addict Jeremy. She now partakes in prayer walks in Austin, Ind., to support the city's addicts. (Lyndsay Duncombe/CBC) Clean, safe needles were scarce. But used needles were everywhere and in plain sight; sidewalks, gutters and overgrown parks were littered with them.

I met Brandy — who wouldn't give her last name ­­­—­ in the middle of one of her Opana afternoons. She's shared needles for years.

"Everybody used after everybody else, because we tried to get into the local Wal-Mart, but they wouldn't sell 'em (hypodermic needles) to us because of our arms," she said pointing to the track marks running down from the inside of her elbow.

Brandy is a steadily unfolding tragedy: HIV positive, hepatitis B positive, hepatitis C positive.

"Actually, I really feel dead," she said. "With HIV, hep C and hep B, you pretty much are."

Now Brandy has a continuous supply of clean needles, thanks to the state finally allowing a needle exchange program in Austin.

Our first concern is their health and the second is to try to enforce the law. - Don Spicer, Austin police chief

She still has all the burdens she had before, but at least she isn't spreading them to others anymore.

Research shows needle exchanges work against the spread of disease. Many health professionals believe the exchanges also get addicts into clinics where they can be tested for diseases, and then, sometimes, into a drug rehab program.

But that research and medical advice still runs up against a strong public intuition that needle exchanges are a way of condoning drug use and signaling to addicts that they don't need to face up to their real problem.

The needle exchange in Austin went ahead only after Indiana took a long, deep breath and steadied itself to the fact that Austin was becoming internationally known for its HIV outbreak — more than 150 new cases in the county in six months, the biggest outbreak ever in a rural American town — and it didn't want that.

Still, the idea of giving addicts the very tools they need to maintain their addiction continued to be a tough a sell in conservative Indiana.

According to some addicts, the Austin Police at first experimented with using the needle exchange as a way to identify and track down drug users. And then arrest them. That only discouraged people from trusting the needle exchange.

Things have gradually changed.

Residents prepare to go on a prayer walk in Austin, where HIV infection rates have reached crisis levels. (Lyndsay Duncombe/CBC) A few weeks ago when a reporter asked the local police chief, Don Spicer, whether he was for or against the needle exchange, he said, "Both."

When I asked him the same question last week, his thinking seemed to have evolved.

"It was against the law for such a long time to possess a needle, so we've had to adapt on the fly and approach it in a different method," he said. "But our first concern is their health and the second is to try to enforce the law."

Americans are used to hearing about the crime, drug, and health problems of their inner cities, but the wasting away of rural towns blighted by drug use rarely gets the same attention.

"This is a culture that has been longstanding here in the community, and we know in many others," says Dr. Jennifer Walthall, Indiana's Deputy Health Commissioner.

It's a culture born out of loneliness, hopelessness, lack of opportunity and a sense of worthlessness.

In time Austin may turn the page on all this. But there seems little doubt this story will soon be arriving in other small towns across the rural Midwest, the so-called heartland of America.