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LIHUE, Kauai — There was a time, not very long ago, when cautious optimists thought Kauai would somehow avoid the opioid drug crisis sweeping the country.

Rural and isolated as Kauai is — farther from Oahu than any other island in Hawaii — the specter of dirty needles and syringes in garbage cans and people dying from overdoses of drugs like heroin didn’t seem consistent with the island’s image.

Sure, there were methamphetamine users on Kauai and they presented their own set of problems. But, except for the occasional individual heroin user, opioids were not seen as a big problem.

No more. The trend went less noticed than it might have otherwise because Kauai’s population — about 70,000 — is so small that calculating statistically accurate rates of occurrence of anything is difficult or simply impossible.

Today, the Kauai Police Department routinely recovers dirty used syringes and other big-city drug paraphernalia. All manner of prescription pain drugs, like Oxycontin, turn up.

Unsurprisingly, the police and Kauai’s tiny community of treatment providers were the first to notice. Last September, commenting on a rash of suicides — 21 by that time of the year — that clearly constituted an epidemic, police sources said they had started to see a trickle of heroin overdoses.

The numbers were tiny. Police also said that, while they hadn’t seen other dangerous opioids, like fentanyl, they feared it was just a matter of time.

Then, two weeks ago, two experts gave some sobering news to the Lihue Business Association, whose members gather monthly for discussions on a wide variety of issues. In this case, the speakers were Dr. Janet Berreman, Kauai district health officer for the Hawaii Department of Health, and Dr. Gerald McKenna, Kauai’s most prominent addiction treatment specialist.

The national opioid crisis, Berreman said, has outstripped some traditionally widespread causes of death, like motor vehicle accidents, for some U.S. age categories.

Hawaii has lagged the nation in the most worrisome volumes of opioid deaths and severe overdoses, she said, ranking 43th of the 50 states. Within Hawaii, comparisons are more difficult because Kauai’s tiny population frustrates all efforts to calculate death rates per 100,000 people, the standard terminology in public health parlance.

Kauai would rank lowest of the counties, even if a rate could be calculated — well below the 13 deaths per 100,000 experienced in Maui County from 2014 to 2016, according to state figures.

Over the last five years, Berreman said, Kauai has experienced, on average, six opioid overdose deaths per year. That may sound like a very low number, but for a county with a population as small as Kauai’s and where the opioid crisis has not previously been recognized, it’s worrisome, Berreman said.

Still, she said, “we are lagging the national trend.” In a way, she said, recognizing what’s happening “creates opportunities for us. We can see it coming the way we get hurricane and tsunami warnings.”

In a good news-bad news context, Berreman said, Kauai remains fortunate in that drug overdose deaths haven’t yet surpassed the traditional causes of accidental death: drownings, suicide and motor vehicle accidents. “Every one of these cases is a tragedy,” she said of the opioid deaths, “but (these are not) huge numbers.”

But they are numbers and present a social dilemma comparatively new on island, unlike the far longer-lived problem of methamphetamine.

McKenna noted that this is not even the first opioid crisis the country has faced. Morphine came into common use before the Civil War, and many returning wounded veterans were addicts, he said. Some alternative drugs were developed. One was a cough medicine created by the Bayer pharmaceutical company in Germany in 1898: heroin.

McKenna said doctors unwittingly brought about today’s opioid dilemma when, a few decades ago, they were accused of not adequately treating pain. Because painkillers were plentiful and new and more powerful ones kept coming along, physicians took the path of least resistance. Drug companies bear much of the responsibility, he said. The big pharmaceutical companies led doctors to believe that ever larger amounts of drugs would do the trick.

Kauai doctors — led by changes in procedures at Wilcox Medical Center, the island’s dominant hospital—are limiting the amount of painkillers they prescribe and taking a more aggressive approach to identifying patients who doctor-hop to accumulate a large number of pills, McKenna said.

“We have to re-educate physicians on how to treat chronic pain,” he said. Kauai is also notoriously devoid of inpatient drug abuse treatment capacity. There are no dedicated beds for adults and Kauai County is only now constructing a new eight-bed facility for adolescents.

County Prosecutor Justin Kollar is not sanguine about what’s happening.

“We can see the wave coming,” Kollar said. “We are seeing more and more of our drug cases where the police are recovering needles and heroin, far more in the past year. We’re seeing scenes of apparent overdose that, certainly, we were not seeing.

“We started to see that heroin was on island four or five years ago, but it’s really been picking up steam. Fentanyl has been recovered on Kauai during the last few months.”

The island, he noted “has a real lack of treatment options. Only a handful of doctors are involved and the need has far outstripped the supply.”

At the same time, drug users are getting more sophisticated, finding ways to order heroin from China on the Internet. To counter such trends, police on Kauai, Kollar said, routinely employ drug sniffing dogs to inspect packages at post offices and at the Lihue Airport facilities of UPS and FedEx.

In terms of drug abuse, Kollar said, “we are the smallest player in the state. I do think Kauai is still a special place because we do a good job as a community of looking out for one another. We need to focus on preserving that.”

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