June 14, 2017

By Courtenay Harris Bond

Tammy spent nearly two decades despairing about her son Michael, who abused opioids for 16 years before recently landing in a Philadelphia jail. Now 30, Michael started on Percocet after a high school sports injury, and his habit escalated, propelling him to heroin when he could no longer get pills.

Michael suffered 10 overdoses that Tammy knows about and was revived each time by the opioid-reversal medication Naloxone. So while news of his recent arrest “brought her to her knees,” Tammy was also relieved. 

“I told Michael, ‘The prison won’t be inside your body anymore,’” she explained. Most important to her, Michael was alive. 

An Out-Of-Control Epidemic 

Across the United States, the scourge of drug addiction has exploded: Once a plague affecting primarily the poor and destitute, heroin – often enhanced with ever more deadly synthetic substances such as Fentanyl – is claiming an unexpected new set of victims across race, class and income, who are typically drawn into substance abuse by prescription painkillers. 

More than 50,000 people died of drug overdoses in 2015, more than any year on record, up 11 percent from the previous year, according to the Centers for Disease Control and Prevention (CDC).  

Pennsylvania is located in the path of two drug-trafficking lines, one from New Yorkto Miami and another from Detroit to Pittsburgh. And Philadelphia is host to the largest open-air heroin market along the East Coast, the “Badlands” in the Kensington and Fairhill neighborhoods of North Philadelphia.

The city had the highest number of people dying in the state from drug poisonings, with 910 deaths in 2016—many of them opioid related—up 26 percent from 2015. That number included 35 that occurred in just five days in December 2016.  

“The numbers are just staggering,” said special agent Patrick J. Trainor, who works out of the Drug Enforcement Administration’s Philadelphia Field Division. “We in law enforcement have not seen anything like this at all. It is just horrific the amount of people who have died.”

“We’re seeing affluent people, people of lower economic status, people of all races,” said Jose Benitez, executive director of Prevention Point Philadelphia, one of the biggest needle exchanges in the country, where the number of people served has more than doubled over the past two years. 

The report also showed that Pennsylvania leads the nation in opioid overdose deaths among young men aged 18 to 24. 

“It’s really moved into the white male community,” said Deb Beck, president of the Drug and Alcohol Service Providers Organization of Pennsylvania. She and others in the treatment community say a lot of young men who suffer injuries from sports or car accidents get hooked on prescription painkillers before turning to heroin. 

“It’s a shame that we’re paying attention now,” she said. “We should’ve been paying attention a long time ago.” Law enforcement, government officials, drug-treatment providers and advocates here and nationally are trying to stem a rising tide of addiction that threatens to overwhelm their capacity to combat the problem. 

Addiction Strikes Fast and Furious 

Because of the aggressive marketing of OxyContin and the liberal prescribing of opioids to treat chronic pain since the mid-1990s, people from all walks of life have become hooked on prescription painkillers. 

“The United States just produces far and above the amount of opioids of any other industrial country,” said Stephen Lankenau, a professor at Dornsife. “There’s just a tremendous amount of these drugs circulating in communities and homes, and as a result it’s an option for people to medicate and self-medicate.” 

For many people, the transition from prescribed drugs to heroin is happening more quickly than ever before. In fact, the risk for opioid dependence dramatically increases after just five days of use, according to statistics from the CDC. 

“It used to be that if somebody entered treatment for a heroin problem, they had a 10-to-12-year drug use history,” said Deni Carise, chief clinical officer at Recovery Centers of America based in King of Prussia. “What we’re seeing now is going from being drug naïve—theyhaven’t done any illegal drugs and don’t know anything about the lifestyle—to heroin use in six to eight months.” 

New prescription-monitoring regulations that went into effect last year in Pennsylvania are limiting access to pills and worsening the heroin problem. As prescription opioids become less available and more expensive, heroin becomes an increasingly attractive alternative, especially the inexpensive, pure varieties coming from Mexico. 

“Unfortunately, the transition to heroin kind of makes perfect sense,” Trainor said. “It’s a lot cheaper and it essentially has the same effect on the body” as prescription opioids. Synthetic opioids, which dealers add to heroin to increase purity and potency, are exacerbating the epidemic of overdose deaths. Fentanyl is 80 to 100 times stronger than morphine and Carfentanil is 10,000 times stronger. The purer the product, the more deadly it is, the better it sells. 

“There is no greater endorsement for a heroin trafficker than when his or her product kills someone,” Trainor said. 

Treatment Isn’t Readily Available 

Further aggravating the crisis is a shortage of available services to help those who are ready for treatment, which can range from abstinence-only 12-step programs to opioid-replacement therapy. The common thread is a lack of funding and access for those most in need. For instance, only 11.8 percent of the 21.2 million Americans who needed drug and alcohol treatment received it in 2014, according to the Substance Abuse and Mental Health Services Administration.

“There’s probably a window of time for people in a given week or month when they would be really open to getting into treatment,” Lankenau said. “If you can reach out to them at that moment then you can get them into treatment. But if the treatment beds aren’t available, or the whole process is too confusing, then the person may say, ‘I’m better off just doing what I’m doing.’” 

Some harm-reduction advocates in Philadelphia are urging the city to open “safe injection facilities,” a controversial step. Such sites would allow individuals to inject themselves in sheltered spaces with medical services and links to treatment, staffed by people who could administer Naloxone - also known by the brand name Narcan - an opioid-overdose-reversal drug. The only such facility in North America is in Vancouver, British Columbia, although Seattle and Vermont are considering opening sites. 

“You take some of that off the street - the public injection, the public intoxication, the needle discard - and you put it in a structured environment where people can get a lot of support and love,” said Paul Cherashore, who heads the Philadelphia Overdose Prevention Initiative along with Paul Yabor (see sidebar) and Dan Martino, another activist. So far they have more than 1,381 signatures supporting the idea of supervised injection facilities. 

“Safe injection sites could help to normalize someone’s life,” Lankenau said. “You’re coming to a clean, safe space where there are people there to help. It may not happen the first day, the first week, the first months, but the whole idea of harm reduction is meeting people where they are.” 

Stigma: The Ultimate Hurdle 

An unspoken barrier to support for those in the grip of addiction is the stigma attached to drug use. Dr. Neil Capretto, medical director for Gateway Rehab, with more than 20 facilities in western Pennsylvania and Ohio, says that, ultimately, the public needs to shift its thinking about substance-use disorders. “People may choose to initiate drug use but no one chooses to develop the disease of addiction,” he said. 

Benitez of Prevention Point agrees that stigmatization gets in the way of addressing this crisis, but he also wonders whether some of the public outcry about the opioid problem has to do with so many white people dying. 

“When the crack epidemic hit in the ‘80s, it was arrest, arrest, arrest,” he said. “Right now we have Caucasian kids, suburban kids passing away. Now we’re talking about getting people into treatment, not prison. That is a stark change.” 

President Obama called last year for more prison-diversion programs, such as drug courts, offering violators treatment instead of incarceration. This approach is growing in popularity as the nearly four-decades the long War on Drugs has failed and states grapple with overflowing prison populations. As of 2015, there were drug courts in 35 of Pennsylvania’s 67 counties. 

Tammy, however, sees jail as a blessing for her son Michael, who was arrested for a crime that his drug habit drove him to commit but that his family did not want specified because his case is in court. 

“Like I told him last night on the phone when he started crying about maybe getting 15 to 30 years, I said the last 15 years have not been any different,” she said. “While I’m devastated that it ended up like this, I get to visit him in a prison.” 

There are no easy answers, and the epidemic continues to surge. City Health Department officials project that overdose deaths could reach 1,200 in Philadelphia this year, an increase of 30 percent over 2016, when the tally was 30 percent higher than 2015. Opioids are plentiful, potent and cheap on the street. Addiction is a chronic problem that has no lasting “cure.” Repeat relapses are common, and staying clean requires a commitment to recovery that few can muster. But the bottom line, many in the treatment field agree, is shifting how society views those with substance-use disorders. 

“I think it comes down to how we ethically view the value of life,” said Jeanette Bowles, a social worker who has done outreach in Kensington and who is also a doctoral candidate at Dornsife. “We can say, ‘Somebody who uses heroin has a problem,’ but the question is, is death an acceptable consequence for that problem? I would argue that it’s not.” 

Efforts To Reverse The Opioid Crisis At The National, State And Local Levels: 

• In March, President Trump signed an executive order to create a new addiction commission, to be chaired by New Jersey Gov. Chris Christie. The president said the commission’s aim is to improve treatment options, stop the flow of drugs into the country and prevent people from getting hooked in the first place. 
• More than 5,000 people have overdosed nationwide since 2013 on Fentanyl or other synthetic opioids. This wave of deaths spurred drug policy experts and medical professionals recently to brief Homeland Security officials and the House Energy and Commerce Committee about the synthetic opioid problem. Four senators have introduced legislation that would appropriate $15 million to fund efforts to block Fentanyl – exported primarily from Mexico and China – from entering the United States. 
• To try to improve access to treatment, a national help line went into effect in November (1-800-662-HELP). This spring, Pennsylvania has responded to more than 9,873 calls, 35 percent of which ended in transfers to treatment, said Jennifer Smith, acting secretary of the Department of Drug and Alcohol Programs. Pennsylvania officials are also trying to create “warm handoffs” where substance-abuse specialists help people who enter hospitals for drug emergencies move directly into treatment programs. 
• State officials have been striving to curb the epidemic through a Prescription Drug Monitoring Program that requires doctors to check a database when dispensing opioids. New prescribing guidelines for opioids have also been developed for physicians and dentists. *About 570 drug take-back boxes are distributed throughout the state, mostly in police stations but also in some pharmacies, where people can dispose of unused medications. The goal is to keep these pills from making their way into the illegal market or falling into the hands of those they were not prescribed for. 
• State officials are working to disseminate the opioid-reversal drug Naloxone. All state police and 600 municipal police departments now carry it, and a standing order allows anyone in Pennsylvania to buy Naloxone at pharmacies without a prescription. 
• Philadelphia Mayor Jim Kenney convened a special opioid task force in the fall, chaired by Philadelphia Health Commissioner Dr. Tom Farley, to design a plan to reduce opioid abuse, dependence and overdose. (Read the task force report at phila.gov/opioids)