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The United States of Heroin

interior-opioidsPublished in the Sunday Herald on July 2, 2017.

There has never been an epidemic of drug addiction like it in the United States of America. Prescription medication intended to treat acute pain is doing far more damage than crack cocaine or crystal meth or heroin alone ever has. Opiates have become a crutch, a high and a way of life for millions who need a fix to get ‘well’ before they can think of anything else.

According to the International Narcotics Control Board, Americans consume 80% of the world’s prescription opioids, including 99% of the hydrocodone, sold under the brand names Vicodin, Norco and Xodol. In 2015, one in three adults received a doctor’s script for painkillers. Most rely on the drugs to cope with chronic pain, but when taking such an addictive substance, the boundary between use and abuse is invisible and easily crossed.

As regulators have tightened up on overprescription, heroin – cheaper, stronger and easier to get – has come roaring back. By collating records from coroners and medical examiners, the New York Times estimated that around 62,000 Americans died of a drug overdose last year: significantly more than were killed by guns or in traffic accidents, and more than were killed in the Vietnam war.

“You’d have a tough time finding somebody in the United States that doesn’t know somebody, or have a friend, or the child of a friend, who’s addicted to heroin,” says Special Agent James Hunt, who runs the Drug Enforcement Agency’s New York bureau. “It’s that rampant and big a problem right now.”

Economists Anne Case and Angus Deaton have concluded that “deaths of despair,” including overdoses, suicide and liver failure are responsible for declining mortality rates among white working-class Americans, and during last year’s presidential election much attention was focused on post-industrial states reeling from the addiction crisis. But the epidemic does not respect boundaries of geography or social class. It is urban, rural and suburban, and kills the young, the old and the middle-aged.

When Ceire Corcoran returns to her high school in East Islip, a wealthy New York suburb on Long Island, to talk to teenagers about drug addiction, she find their complacency disturbing. “They think they’re immune to it, because ‘it doesn’t happen to kids like us,’ but it does happen to kids like them,” she says. “It’s not happening to the dirtbags. It’s happening to your good kids, your athletes, your valedictorians.”

Her own drug was alcohol, from her first drink at thirteen to her last four years later, enough to black out almost every time. “I didn’t have an ‘off’ button. I’m lucky that I didn’t touch a drug,” she says. Her boyfriend “started with marijuana, then was prescribed pills by a doctor, and before my eyes he became a full-blown heroin addict.” Two days after completing rehab, he overdosed and died.

Another good friend took a fatal shot a year after getting clean. “I saw him on Saturday morning. Sunday evening I found out he was gone.” When Corcoran graduates from university, she plans to become a school health counsellor.

Ceire Corcoran.

Ceire Corcoran.

I met her at Thrive, a community for people in recovery from addiction that opened in March, just off the Long Island Expressway between Islip and Smithtown. “We are the first and only recovery outreach centre on Long Island. And we honestly believe that we need about another dozen,” director Jim Malone told me.

The centre hosts addiction support groups, career advice sessions, yoga classes and open mic nights. A biker rally is planned for the August bank holiday, and I had just missed a talk about applying Buddhist principles to recovery. In the kitchen, behind closed doors, a Heroin Anonymous meeting was in progress. People dropping in are invited to write a message of encouragement on a pebble, and place it in a wicker basket: “faith, freedom, joy, acceptance…”

Officially, there were 493 fatal overdoses on Long Island last year. This underestimates the death toll as it fails to account for suicides, car wrecks, and drug deaths hushed up by families unwilling to admit that their son bound for the Ivy League died in the toilet at McDonalds with a needle in his arm.

A further 770 overdoses would have been fatal but for police or paramedics administering Narcan, a drug that reverses the effects of heroin. This, too, is an underestimate, as it only includes shots given by professionals, not family members or drug buddies. On the New York subway, an ad campaign urges people to learn how to use Narcan nasal spray: “I saved my best friend’s life.” The city will spend more than $10 million distributing the antidote next year, in a bid to reduce overdose fatalities.

Krystle Stoddard first took Vicodin in her early twenties. She was waitressing in a restaurant at the shore, making good money. “Someone said ‘hey, take this, it’ll make you work better, faster, longer,’ and I fell in love. It became a necessity, for every day.” Within a year, she had progressed to “Roxies” – 30mg Oxycontin pills, crushed and snorted.

A close friend died of a heroin overdose when she was twenty-six, so the few times she was offered heroin herself, she said no, but after a failed stint in rehab, a young woman she met there persuaded her there was no real difference between legal and illegal opiates. The pills cost $30 each, and the high didn’t last. Better to buy three bags of heroin.

“You think of heroin, you think of someone homeless on the street corner, begging for money. Now it’s almost a kitchen table kind of conversation. It’s so socially acceptable. Everybody knows somebody that’s using,” she says.

On June 22, 2014, Stoddard accepted she was powerless to control her addiction, “surrendered” and began the painful process of withdrawal. She now leads meetings of Heroin Anonymous. Last month, she was asked to give a talk at a local school, and was shocked to find herself addressing eleven and twelve-year-olds. “I was afraid to share with these little kids, but you want to scare them, and also educate them. I don’t think they understand how quick it progresses,” she says.

In the USA, legal drugs of all kinds are aggressively marketed to hospitals, doctors and direct to prospective patients. “If you watch prime time TV, in-between the commercials for beer, it’s commercials for prescriptions. Anything that ails the human mind or body, there’s a fix for it,” says Lisa Ganz, the clinical director of the Long Island Council on Alcoholism and Drug Dependence.

To Ganz, rising rates of addiction cannot be attributed simply to greed, or malfeasance or misunderstanding of the risks: our modern culture of instant gratification, constant stimulation and pressure to keep up with friends on social media is at fault, too. “I think the flooding of the market with a highly-addictive substance contributed [to the epidemic]. But there was still a demand from people to feel something other than what they feel every other moment.”

Messages of support at Thrive.

Messages of support at Thrive.

How much blame the pharmaceutical industry should bear is now a matter for the lawyers. The Attorney General of Ohio, Mike DeWine, has brought a lawsuit against some of the biggest companies, accusing them of spending “millions of dollars on promotional activities and materials that falsely deny or trivialise the risks of opioids while overstating the benefits of using them for chronic pain.” The city of Chicago, and counties in New York, California and West Virginia have also sued for damages.

In 2007, Purdue Pharma admitted that it “misbranded” Oxycontin, misleading regulators and general practitioners about the potential for addiction and abuse. To resolve criminal and civil charges the company paid a $600 million settlement – an amount recouped in just six months of sales of the drug. All told, the US market for opioids is currently worth more than $12 billion per year.

An investigation by the West Virginia Gazette Mail found that in the course of six years, 780 million hydrocodone and oxycodone pills were shipped to the state: enough for 433 pain pills for every man, woman and child. Clearly, too many distributors, doctors and pharmacists have been willing to turn a blind eye in return for a cut of the profits.

In 2011, a pill addict, David Laffer, shot four people dead in a robbery at a chemist’s on Long Island. The following year, New York’s state legislature passed I-STOP, a law designed to prevent people from getting prescriptions from multiple doctors, and Purdue changed the formula of Oxycontin to make it harder to snort or inject. Meanwhile the Mexican cartels, never ones to miss a business opportunity, were making heroin cheaper and more available than ever before.

“We dried up the source of the pills, and then everybody moved over to what they’re buying on the street, and we wonder why we have so many overdoses,” says Nora Milligan, the founding editor of Addiction 2 Recovery magazine.

Milligan was hooked on heroin by eighteen, lived on the streets and went to prison, but cleaned up enough to become a registered nurse, get married, and have a son (and a drink problem). Then a doctor prescribed Xanax for her anxiety, and within two years she had found her way back to heroin.

At sixteen, her son was a heroin user too. Helping him finally provided Milligan with a reason to quit drugs herself. She has her clean date, October 15, 2009, tattooed on her arm, alongside “love, hope and healing” in Khmer, the serenity prayer in Balinese and “pater, in manus tuas commendo spiritum meum” – the last words of Jesus Christ, according to the Gospel of Luke.

Her son is still struggling with addiction. Three times, he has been pulled back from the brink of a fatal overdose by Narcan. At the Intensive Care Unit of St Catherine’s hospital in Smithtown, where Milligan works, young men and women like him pass through every few days. “The kids are seeing it. They’re going to funerals every week,” she says. “We don’t have to tell them that people are dying.”

Nora Milligan.

Nora Milligan.

The advent of fentanyl, a synthetic opioid up to a hundred times stronger than heroin, has made an already desperate situation worse. Police officers searching for it use rubber gloves: a cop in Ohio almost died after unthinkingly brushing some white powder off his uniform with his fingers.

Heroin and knock-offs of brand name opioids are often laced with fentanyl. Many people have died after taking it unintentionally, but to some hardcore users, it is a higher high, with the added thrill of being lethally dangerous.

“The attraction to it is that it’s a stronger drug,” says Milligan. “To a heroin addict, it’s like ‘mix me a stiffer drink, make it a double.’ You’ve got all these at-home chemists that are adding it in. And what they’re putting in it is too much.” Almost half the overdose deaths on Long Island last year were attributable to fentanyl.

On the campaign trail, Donald Trump repeatedly promised to “end the opioid epidemic in America,” but as president, he has yet to appoint a Director Of National Drug Control Policy and at one point threatened to all but eliminate the agency’s budget, before backtracking under pressure from Senators of the worst-affected states.

By drastically cutting Medicaid funding, the stalled Republican health care bill would deprive thousands of drug-dependent people of the health insurance they need to get treatment. The Comprehensive Addiction Recovery Act, passed with bi-partisan support and signed by President Barack Obama, theoretically allocated $181 million to combat the epidemic, but the money must be re-allocated each year in the budget, making it vulnerable to cuts.

Ganz, Corcoran, Milligan and Stoddard all told me that on Long Island the biggest obstacle they face is a “not my child” attitude among parents unwilling to acknowledge the scale of the crisis. The stigma associated with drug addiction remains strong. In local newspapers, obituaries are often written in euphemisms, to disguise the true cause of death.

A month ago, a young man arrived at the St Catherine’s ICU in a critical condition following an overdose. Once he was well enough to be discharged, Milligan tried to check him in to a neighbouring hospital to wean him off drugs (without disclosing she was a nurse) and was disheartened by the “nasty” and dismissive way staff turned him away.

Drug rehab is a burgeoning market, and there are treatment centres scattered all over Long Island, but typically, health insurance only pays for up to five days of methadone or suboxone-assisted detox and two weeks of rehab. “If you don’t follow that treatment period with safe community support, all you’ve done is lower their tolerance and sign their death warrant,” Milligan says. “You send them back into a high risk area with a low tolerance and they’re dead.”