PHILADELPHIA — Five dollars is enough to get high on heroin here in the City of Brotherly Love.
Without it, people addicted to opioids will develop a violent illness from withdrawal. They describe the feeling as an intensified flu — severe body aches, chills, fever, vomiting, and diarrhea. To avoid it, they go instead after the warm, euphoric state that comes from cheap, readily available heroin.
For at least 1,200 people in Philadelphia last year, the pursuit of heroin and other opioids cost them their lives. Too many opioids in the body can make breathing slow or stop, causing overdose or death. In many of these deaths, the drug has been laced with fentanyl, an opioid that is 50 times more potent than heroin. Just a salt-shake amount into the palm is enough to kill someone, and many drug users don’t know they’ve taken fentanyl, or that the hit they just bought contains a higher amount than the last time they used.
“Fentanyl is like throwing gasoline on a fire that was already raging,” said Dr. Thomas Farley, Philadelphia’s health commissioner. “Virtually every overdose that involves any opioids has got fentanyl involved.”
This story of death and addiction is rolling across the country in urban, rural, and suburban settings. Though West Virginia, Ohio, New Hampshire, Pennsylvania, and Kentucky are the hardest-hit states, addiction to opioids has reached people of all backgrounds.
A multitude of factors contributed to this crisis, one that has become so severe that death tolls have actually lowered average life expectancy in the U.S. That trend hasn’t been observed since 1962 and 1963, during a severe flu outbreak.
Opioids kill five times more people than they did just under two decades ago. The number of bodies have overwhelmed pathologists, and some opioid deaths aren’t counted as such because people mix heroin or painkillers with other drugs. This means that the government tally of 42,249 deaths in 2016 from opioids including heroin, fentanyl, and prescription painkillers such as OxyContin is likely low.
Still, the number surpasses the 38,748 motor vehicle deaths or the 38,658 gun deaths also recorded in 2016.
How did this happen?
The most simplified explanation for how the U.S. got here begins with doctors prescribing patients too many pain relievers in the late 1990s. Doctors did this in part because those drugs were falsely marketed as nonaddictive.
Opioids are highly addictive drugs that not only dull pain but also create an intense rush of pleasure by attaching to receptors in the brain. Unlike stimulants that enhance alertness, such as cocaine or Adderall, opioids slow down the central nervous system.
When rates of addiction and death began to increase during the early 2000s, government regulators urged doctors to reduce opioid prescriptions. As a result, people who had developed a dependency on the drugs or who continued to face unbearable pain associated with the reason they were prescribed painkillers in the first place turned to cheap, easily available heroin. By 2010, heroin overdoses had quadrupled compared to a decade earlier.
“It did shift the market away from prescription opioids toward non-medical opioids,” said David Herzberg, University at Buffalo historian on drug policy. “As a consequence of that, I think it’s pretty clear that you had bad public health outcomes. It’s not just that people were dying because they were buying drugs and didn’t know what they were. You had a population of people that had regular contact with the medical system, and you kicked them off from that contact.”
This shift was true for Ben, 32, who played football in college and was prescribed opioids to deal with his injuries. Heroin was cheaper and more available.
“I was a good kid, and I came from a good family,” Ben said. “I was an ordinary suburban kid from a small town where everyone knows your name. I was an athlete, and I got hurt.”
The need to pay for drugs caused him to steal from friends and family.
“The only thing that mattered was getting high,” he said. “You don’t think about anyone else and any consequences … I couldn’t even say how many hundreds of thousands of dollars I’ve stolen from my friends and family.”
Ben, who asked that his last name be withheld to protect his privacy, teaches middle school in the Boston area and has been in recovery from drugs for five years after attending an outpatient service that is operated by the organization CleanSlate.
“I feel, not like a new person, but I feel like how I did before I lost five years of my life,” he said of the years he used prescription painkillers and then snorted heroin.
Similar stories are common. Eighty percent of heroin users abused prescription painkillers first, according to the National Institute on Drug Abuse, and more than 25 million people in the U.S. report they suffer from physical pain.
But other factors contributed to widespread opioid use. Some doctors did create “pill mills” where they trafficked prescription painkillers to their communities for years without law enforcement interference. Certain groups of people began their addictions to opioids as teenagers after finding painkillers in their parents’ medicine cabinets. Drug users also tend to wrestle with depression and anxiety, and areas that struggle with job opportunities can be hard hit. At least a quarter of the people in U.S. prisons and jails are addicted to opioids.
“It was really a perfect storm of many, many factors,” Alex Azar, the secretary of the Department of Health and Human Services, recently said about the opioid crisis. “The government was involved, the private sector, the practice of medicine, drug companies — just go through the list of entities involved in us getting to this terrible, terrible place we are in.”
A reaction to reverse the crisis, he said, would involve just as many actors.
His agency and the rest of the Trump administration is setting out to tackle the crisis, as is Congress, but the multitude of complex, contributing factors complicates the response. Washington lawmakers face a dire landscape because the country lacks enough treatment facilities or medical professionals to help the estimated 2.1 million people hooked on opioids.
As they deliberate, local communities aren’t waiting for the federal government. This is true of communities from Philadelphia to Martinsburg, W.Va., to Waldorf, Md., all of which shared their treatment and prevention approaches with the Washington Examiner. Because addiction carries a stigma that leaves some policymakers reluctant to treat it as a chronic illness, local responses can provide more flexibility. It also offers a way for communities to test different strategies to see how well they work and whether they can be replicated elsewhere.
Dozens of addiction experts and health officials said in interviews that priorities for federal lawmakers should include not only long-term funding, but also lifting burdensome regulations that get in the way of people receiving medical care. In the midst of the opioid crisis also lies the reality that even when people get treatment for addiction, they will face a difficult recovery and may not succeed on the first try.
Congress poised to act
Kellyanne Conway, counselor to the president who is also coordinating White House efforts on opioids, has referred to the crisis as a “nonpartisan problem searching for bipartisan solutions,” and lawmakers appear to agree.
Both the House and Senate are formulating bipartisan legislation through open hearings and debate. House leaders hope to pass their bill by Memorial Day, and though the Senate hasn’t set a date for passage, key committee members have posted draft legislation and invited feedback. It isn’t clear whether any additional funding will go toward the legislation, but members are working to distribute $6 billion from the budget deal to various efforts.
So far, the legislation in both chambers contain a range of programs aimed at prevention, treatment, and law enforcement. For instance, draft legislation in the Senate would further empower the Food and Drug Administration to track down fentanyl and mandate that prescription painkillers are dispensed in blister packs to avoid overprescribing and to make it harder for children to access them. While some arguments have surfaced over privacy of medical records in the House, members appear to be moving toward consensus.
“The White House is pleased by Congress’ bipartisan work to try and combat the opioid crisis,” Hogan Gidley, deputy White House press secretary, said in an email. “We look forward to reviewing the legislation with the ultimate goal of ensuring our families and communities no longer suffer from this growing epidemic.”
The White House has taken its own actions. The administration’s health agencies frequently announced new policies or proposals throughout March and April. The FDA urged social media sites to better police opioid ads, the National Institutes of Health said it was investing not only in better treatment for addiction, but in developing nonaddictive treatments to pain. The surgeon general urged more people to stock naloxone, a lifesaving drug that awakens someone who is overdosing.
Carl Latkin, vice chairman of the health, behavior, and society department at the Johns Hopkins Bloomberg School of Public Health, called certain White House and legislative talks “encouraging.” But he added, “The question is: Will there be a gap closed between what’s said and what’s done? The magnitude of the problem is so immense. You need a lot of resources.”
Democrats criticized the Trump administration for not attaching funding to a blueprint it released in March of how it planned to tackle the issue. Like the bills in Congress, it included efforts on law enforcement, prevention, and treatment. Still, other criticism arose over the president’s rhetoric about law enforcement and illegal immigration. Sen. Elizabeth Warren, D-Mass., and Rep. Elijah Cummings, D-Md., wrote in an opinion piece that President Trump’s call to use the death penalty on drug traffickers was the “crudest indication yet of how little he understands about what the problem is or how to fix it.”
While officials have raised concerns about emphasizing law enforcement over health efforts, they also have brought attention to government restrictions that have been an impediment to treatment.
“We won’t be able to jail ourselves out of this problem, but we also will not be able to exclusively treat our way out of this problem either,” said Dr. Rahul Gupta, commissioner for the West Virginia Department of Health and Human Resources Bureau for Public Health.
Several officials and advocates have called for the repeal of a law that does not allow hospitals to have more than 16 substance abuse and mental health beds in order to be reimbursed by Medicaid. The rule, which was created in 1965, intended to promote the expansion of smaller community-based centers. The centers didn’t materialize, and patients instead are placed on long waiting lists.
House Republicans have issued draft legislation to repeal the provision but may run into barriers on cost. The Congressional Budget Office has said that the repeal could cost up to $60 billion in a decade. In the meantime, the Trump administration has encouraged states to apply for waivers through Medicaid that would lift the exclusion, an avenue that roughly a dozen states have pursued.
Another oft-cited barrier is the regulations on prescribing medication to curb withdrawal symptoms. For instance, to prescribe buprenorphine to more than 30 patients, doctors have to go through a government training course and receive a certification.
“Those make it so that there may be many steps between the time when someone is requesting treatment and when they actually receive treatment,” Farley said. “Cutting back on those bureaucratic barriers, which may require changing federal laws, would absolutely be something that we need to do.”
But the drugs can also carry their own concerns or tradeoffs, he notes. People overdose from the drug methadone, also an opioid. VIVITROL® requires complete detox first, otherwise someone could easily overdose. Buprenorphine has to be taken every day, while VIVITROL® is an injection taken once a month. With these factors in mind, NIH is calling for the development of more treatments.
The long, individual path to recovery
While medication prescribed during outpatient treatment is one way for people to rid themselves of drug addictions, some aren’t successful at treatment without coupling medication with being in a facility that has more intense, supervised care. If the government chooses to invest in this area, evaluating its success would take several years.
And as Congress debates that issue, a mental health and addiction treatment center is being built and has begun operating in Waldorf, Md., a town less than an hour drive south from the Capitol.
The facility, Recovery Centers of America, is light-filled and has the feel of a college campus. It has begun accepting patients and contains a cafeteria, gym, tennis court, and an art and music therapy studio. On the wall are pictures of famous people who have struggled or succumbed to addiction or mental health troubles: Heath Ledger, Robin Williams, Drew Barrymore.
The building is emblematic of how many lives have been marred by the opioid crisis and the process someone will need to go through to reach recovery from drugs.
“One of the things we have learned in the science of it all is that if you don’t get somebody care when they decide they want it, by the next day, they change their mind. And by the next day with this epidemic, they could be dead,” said Deni Carise, chief scientific officer at Recovery Centers of America.
The detox rooms, where someone can expect to spend their first week in recovery, contain two beds, a television, and a spacious restroom. Patients can expect to spend 30 days at the facility but are then encouraged to get into a program such as Narcotics Anonymous so they can be around people who don’t use drugs or alcohol. Making it to 90 days is considered a milestone.
Some may have to take medications for the rest in their lives. If a person makes it to five years in recovery, his or her chance of relapse falls to less than 15 percent.
For many, the transition from treatment back into society isn’t easy and can take multiple attempts.
Scott Weisenberger, CEO of the rehab facility, noted that most people tend to socialize in bars or at other events that involve alcohol or other addictive substances.
“Nobody likes to feel like an oddball,” Weisenberger said. “You can only go to one of those functions for so long and have to nurse a Coke. There is this whole social part that can cause a lot of pressure.”
Carise, who shared that she had an addiction to cocaine earlier in life but sought treatment in her 20s, said it’s not uncommon for people who are in recovery from drugs to seek thrills by riding motorcycles or going parachuting.
“Regular stimulation is hard to feel when you’ve been high for a long time. None of us got sober to be bored and have a dull life,” she said. “We got sober to have an exceptional life.”
Local communities take action
If Congress makes rehab available to more people, the development of additional facilities will take time. For some, it will continue to be costly or unavailable, and drug users often don’t want to participate. Therefore, some of the approaches taken by local communities aren’t necessarily aimed at getting people into treatment right away, but at reducing death tolls or decreasing incidence of HIV and hepatitis C spread through drug use.
These strategies, known among the public health community as “harm reduction,” can face resistance.
Philadelphia health officials, for example, have set up training for doctors to prescribe fewer painkillers and have been working on how to make access to treatment easier. The city is also moving forward with setting up an injection site that would allow people to take drugs with medical professionals nearby who would revive them if they overdose, and would keep treatment referrals on hand.
City officials are determining where the site will be and where the funding will come from, and have been holding community meetings so people can ask questions or voice concerns. The process, begun in January, was expected to take six to 18 months.
“Those opposed are concerned about condoning or promoting drug use,” Farley said. “Then, there are others who just don’t want it in their neighborhood.”
He often gets questions about why he wouldn’t implement treatment and prevention programs.
“I say, ‘We are doing prevention, we are doing treatment. This is just one piece of that,’” Farley said. The injection sites are expected to save between 25 and 75 lives a year.
“You can say that’s not enough to make it worth it, or you can say if one of those 25 to 75 happens to be your daughter, it’s worth everything,” he said. “Every drug user is somebody’s child. … This is among the things we need to do to save as many lives as possible in the crisis.”
Other community prevention plans take shape
Other communities are aiming to replicate similar programs to those in Philadelphia, such as needle exchange. One has been operating in Martinsburg, W.Va., for a year, reaching more than 200 people. It’s in a bright neighborhood where trees have started to blossom despite the unusually cold early spring day.
Angie Gray, a red-haired native West Virginian who is the nurse director of the Berkeley County Health Department, had been pushing for the program for several years and raised the $72,000 necessary to get it running.
“They are calling me their little pit bull, some of my friends in the recovery world,” Gray said. “I get frustrated because we have no time to waste on this. People are dying and have been dying for a long time. And so, it’s time for us to all just start working together and do what needs to be done to curb this.”
She pulls up a map on her computer. It was assembled by the Centers for Disease Control and Prevention, and illustrates the communities at risk for an outbreak of hepatitis C or HIV because of high opioid use.
“Do you see West Virginia?” she asks.
The state is not visible underneath the multitude of red dots identifying communities in West Virginia at risk of an outbreak.
“That’s us,” Gray said, pointing to the cluster of red dots. “It’s scary. Because if this happens … I don’t know if the state will ever recover. Financially, it’s huge.”
A hepatitis C cure can carry a list price of $100,000, and HIV treatment across a lifetime can cost more than $350,000 per person.
“If I prevent one case of hepatitis C, I can pay for the [needle exchange] program we put on during the past year twice,” Gray said.
Getting support was difficult, however, because offering needles to people who use drugs was seen as enabling.
“I say you don’t understand addiction, because whether I give them a clean needle or not, they are going to use,” Gray said. “They will knowingly use sharing with someone who is HIV positive because the addiction is driving them to do that, and we need to break that. Until we do … it’s for the whole community’s benefit to teach people who are injecting drugs healthier, safer practices.”
At the clinic, nurses give out Band-Aids, tourniquets, bleach, needles, sterile water, naloxone, and containers to dispose of the needles. The more people use needles, the duller they get. Reusing the same needle can not only spread infectious diseases but can create wounds that become infected with bacteria or fungi.
The clinic doesn’t provide treatment for addiction, but a rehab facility is expected to be built in town next year thanks to $3 million from the state recouped after an opioid settlement. Until then, the closest treatment center is a two- to four-hour drive away, depending on which facility is accepting new patients or is covered by a person’s medical plan.
“We are minimizing loss of life until we can figure this out,” Gray said. “We try to keep them healthy in that addiction until we can bridge them into recovery.”
The town has another program, aimed at prevention for children, known as the Martinsburg Initiative. It uses the Adverse Childhood Experiences study, a measure that helps to predict which factors in a child’s life can contribute to more difficult health outcomes, whether drug abuse, diabetes, or heart disease. An “ACE score” is a measure of one to 10 factors, from neglect to poverty and abuse, that constitute a difficult childhood. The higher the score, the more likely someone will face troubles as an adult.
“What I have found is that if there is substance use in the household, then you can almost go ahead and add almost three or four more ACEs,” said Tiffany Hendershot, the project director. “Once you reach four, you’re more likely to have a host of other issues — social issues, behavioral issues, emotional issues, health issues.”
The Martinsburg Initiative , begun in December, aims to identify children with higher scores and connect them to adult mentors, and to equip parents with community resources. Hendershot, who is also a social worker, said she hopes tackling the root of these issues and building connections within the community will lead to long-lasting impacts.
“We can’t reduce the [ACE] number, but we can work with the child to be more resilient,” she said.
The plan received a $135,000 grant connected to a federal program administered by the Office of National Drug Control Policy, and advises with the CDC. The initiative operates at eight schools and covers 4,000 children grades one through five.
“What we have done and keep pushing forward is a national model for prevention,” said Maury Richards, Martinsburg police chief.
States stress need for funding
States and local communities that have implemented opioid-reduction programs say long-term federal funding would bolster their efforts. Pennsylvania’s health department has encouraged more judicious use of prescription painkillers, expanded access to medication to treat addiction, and has set up a website to track health outcomes.
“Without sustainable funding to the states, it’s going to be extremely challenging,” said Dr. Rachel Levine, physician general at the Pennsylvania Department of Health.
Gupta, of West Virginia, said opioids permeate areas that lawmakers may not consider.
“We have to look at child welfare services, medical examiner’s, and all the other services that the state and its citizens are paying for,” he said. “Rather than put out a number, it’s very important that Congress understand the scope of the problem and how wide and deep this problem is.”
If the federal government does not act, public health experts say the situation will continue to worsen. Yet, the wrong actions could do more harm than good. Past U.S. drug wars are considered to be failed efforts.
Hezberg, the drug policy expert from the University at Buffalo, said that addiction and the difficulties that come with it will always be around.
“The real question isn’t, ‘Will we will survive this crisis?’ The question is, ‘Will we put in place policies that will prevent the next crisis?’ We are never going to eliminate it,” he said. “But in history, when the policies have been stupid and uninformed and vicious, the next crisis is brewing before the current one is even over.”
In a recent interview, Surgeon General Jerome Adams said he was heartened through his travels to observe communities that were implementing strategies that worked.
“I absolutely think this is surmountable,” he said. “You have got law enforcement, business, health, faith-based groups all coming together in a way I have never seen in my 20 years in public health.”
“I’m optimistic,” he continued. “And as I go around the country,I’m hopeful about the opportunity that exists to turn this tragedy into a story that ends with healthier communities. We know what to do; we just have to get the message out.”