Heroin Addiction

Addressing the Stigma that Surrounds Addiction

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nida-banner-science-of-abuse-and-addiction

From the Monthly Blog of Dr. Nora Volkow, Exec. Dir.
NATIONAL INSTITUTE ON DRUG ABUSE

Original Date April 22, 2020

Untreated drug and alcohol use contribute to tens of thousands of deaths every year and impact the lives of many more. Healthcare already has effective tools including medications for opioid and alcohol use disorder that could prevent many of these deaths, but they are not being utilized widely enough, and many people who could benefit do not even seek them out. One important reason is the stigma that surrounds people with addiction.

Man sitting alone in streetlight at night

Stigma is a problem with health conditions ranging from cancer and HIV to many mental illnesses. Some gains have been made in reducing stigma around certain conditions; public education and widespread use of effective medications has demystified depression, for instance, making it somewhat less taboo now than it was in past generations. But little progress has been made in removing the stigma around substance use disorders. People with addiction continue to be blamed for their disease. Even though medicine long ago reached a consensus that addiction is a complex brain disorder with behavioral components, the public and even many in healthcare and the justice system continue to view it as a result of moral weakness and flawed character.

Stigma on the part of healthcare providers who tacitly see a patient’s drug or alcohol problem as their own fault leads to substandard care or even to rejecting individuals seeking treatment. People showing signs of acute intoxication or withdrawal symptoms are sometimes expelled from emergency rooms by staff fearful of their behavior or assuming they are only seeking drugs. People with addiction internalize this stigma, feeling shame and refusing to seek treatment as a result.

In a Perspective published recently in The New England Journal of Medicine, Dr. Volkow tells the story about a man she met who was injecting heroin in his leg at a “shooting gallery”—a makeshift injection site—in San Juan, Puerto Rico, during a visit to that country several years ago. His leg was severely infected, and Dr. Volkow urged him to visit an emergency room—but he refused. He had been treated horribly on previous occasions, so preferred risking his life, or probable amputation, to the prospect of repeating his humiliation. This highlights a dimension of stigma that has been less remarked on in the literature and that is uniquely important for people with substance use disorders: Beyond just impeding the provision or seeking of care, stigma may actually enhance or reinstate drug use, playing a key part in the vicious cycle that drives addicted people to continue using drugs.

Previously on her montly blog Dr. Volkow highlighted research by Marco Venniro at NIDA’s Intramural Research Program, showing that rodents dependent on heroin or methamphetamine still choose social interaction over drug self-administration, given a choice; but when the social choice is punished, the animals revert to the drug. It is a profound finding, very likely applicable to humans, since we are highly social beings. Some of us respond to social as well as physical punishments by turning to substances to alleviate our pain. The humiliating rejection experienced by people who are stigmatized for their drug use acts as a powerful social punishment, driving them to continue and perhaps intensify their drug-taking.

The stigmatization of people with substance use disorders may be even more problematic in the current COVID-19 crisis. In addition to their greater risk through homelessness and drug use itself, the legitimate fear around contagion may mean that bystanders or even first responders will be reluctant to administer naloxone to people who have overdosed. And there is a danger that overtaxed hospitals will preferentially pass over those with obvious drug problems when making difficult decisions about where to direct lifesaving personnel and resources.

Alleviating stigma is not easy, in part because the rejection of people with addiction or mental illness arises from violations of social norms. Even people in healthcare, if they do not have training in caring for people with substance use disorders, may be at a loss as to how to interact with someone acting threateningly because of withdrawal or some drugs’ effects (e.g., PCP). It is crucial that people across healthcare, from staff in emergency departments to physicians, nurses, and physician assistants, be trained in caring compassionately and competently for people with substance use disorders. Treating patients with dignity and compassion is the first step.

There must be wider recognition that susceptibility to the brain changes in addiction are substantially influenced by factors outside an individual’s control, such as genetics or the environment in which one is born and raised, and that medical care is often necessary to facilitate recovery as well as avert the worst outcomes like overdose. When people with addiction are stigmatized and rejected, especially by those within healthcare, it only contributes to the vicious cycle that entrenches their disease.

Find Help Near You

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/find-treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1(800) 273-TALK. Or click on: www.suicidepreventionlifeline.org.

You can also find help through Narcotics Anonymous at 844-335-2408.

Christianity Today: How Good Church People Become Addicts – and How They Recover

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Timothy King’s article Just Say No to Shame in the December 2016 issue of Christianity Today includes a very insightful comment: “My recovery from opioid addiction began when I realized my addiction had chosen me.” King fell to the disease of opioid addiction following suffering from acute necrotizing pancreatitis caused by a surgical procedure. He said, “I had known pain before: crutches, casts, and stitches. But until this moment, pain had always been experienced as something outside of myself. Now it was all that was left of me.”

An opioid, from the root word opium, is a class of pain-relieving drugs that can vary in intensity from fentanyl (extreme) to codeine (mild). According to the Department of Health and Human Services, more than 240 million prescriptions were written for legal opioids in 2014 – more than enough for every adult in the United States to have their own bottle. From 1999 to 2014, the period in which opioid overdose deaths quadrupled, so too did the sales of prescription opioids.

The widespread nature of the opioid epidemic that reaches across typical class, race and geographical stereotypes has challenged myths of who drug addicts are. It has also widened the lens, revealing more moral actors participating in the crisis beyond the addict. Years of distorted public policy, overworked and unrestrained doctors, intentionally misleading pharmaceutical marketing, and even watered-down theology that reduces people to disembodied moral characters instead of whole human persons created in the image and likeness of a good God, have all contributed through sins of both omission and commission.

Many opioid addicts began using these drugs for legitimate physical ailments, merely following their doctor’s orders. In fact, the American Society of Addiction Medicine reports that four out of five heroin addicts started with prescription opioid medications, with nearly all reporting that they eventually switched to heroin because of the price.

Our mental picture of an addict should include the high school honors student who breaks her arm skateboarding and is prescribed an opioid by her doctor. Or the middle-aged factory or construction worker who has permanent back pain from his job and is prescribed an opioid by an overworked doctor who misses the fact that his patient is severely depressed. Or a white, college-educated, employed, middle-class Christian (as in my case, and the case of Timothy King, the author of the article) from a good family who grew up in small-town America.

When King’s doctor informed him he had become addicted to pain medication, he told King, “That isn’t a judgment on you. I’m not saying you’ve done anything wrong or that you aren’t still in pain. But we’ve been giving you this pain medication for so long, your body is now dependent on it. It has gone from helping you to hurting you.” The doctor told King he was not going to just take the pain medication away when he needed it. But he asked King to commit to taking less whenever he could. The doctor said, “For a while you couldn’t have made it without the pain medicine. Now to fully heal, you need to eventually stop taking it.”

In July of this year, Congress passed legislation to address the opioid crisis and heroin epidemic. Even the language  of “crisis” and “epidemic” to describe the bill indicates a shift in mentality. The legislation acknowledges a growing medical consensus that the addict is subject to a disease – one with deep biological and psychological roots that often preclude individual choice. This landmark legislation marked an important step forward in reorienting public policy to reflect this new consensus. Framing addiction as a chronic disease does not remove the moral choices involved, but gives us a broader framework for understanding them. We can’t ignore the reality of our bodies, and when it comes to opioid addiction (as well as other addictions), part of the effect of those chemicals is to actually rewire the brain, making it more difficult, if not nearly impossible, to change patterns of thought and behavior.

King discusses one commonly used analogy helping us understand addiction: heart disease. Like all analogies, it doesn’t explain everything, but it has the virtue of pointing out how clogged arteries cannot be cleared up by giving a pep talk to the patient or urging him to stop breathing so hard after climbing a set of stairs. Its causes are found in a mix of hereditary, environmental, and lifestyle choices. It’s also helpful to think about how often our physical state and surroundings influence our actions.

But the sense that addiction is solely a moral problem is hard to eradicate. After I clearly understood my addiction as a disease (which took nearly four decades and several encounters with the criminal justice system), I still battle internally with my self-image to this day. I grew up with the “Just Say No” anti-drug campaigns aimed at warning youth about illegal drugs. In that model, those with moral fortitude say “no,” and moral degenerates say “yes.” Those who said “no” received praise, and those who said “yes” were shamed and punished.

King recalls how he began to back down from taking opioid painkillers. He writes, “I removed the fentanyl patch first and switched to taking only Dilaudid. Within a day I could again feel my body in ways I did not realize I had been missing. At the same time, it felt as if a thick protective comforter had been ripped off from around me while I lay shivering and naked on my bed. Pain that had been blunted refocused and pressed out from the inside. The doctor was right. I could handle the pain now without the same levels of opioids. But I couldn’t  have continued my recovery if it were all up to the strength of my will alone.” King added, “So much more powerful than saying ‘no’ to an opioid was the opportunity to say ‘yes’ to a slow return to a life of flourishing.”

King said goodbye to narcotic pain medication, but indicated it was not an easy goodbye. He said the feeling was like the tremor in your hand when your blood sugar drops. Desire spreads out to every cell of your body as if each one is making its own demand, aching and promising to be satisfied with “just a little more.” Feelings of withdrawal and the troubled sleep that often comes with them are typically intense for the first few days. They can flare up even months down the road as a reminder of what had been, and the perilously thin line between you and the mounting numbers of long-term addicts and overdose victims. For me, I always thought I could control my usage. I was convinced I would never “take too much” and overdose. And yet it happened. I don’t recall anything from the moment I became unresponsive in my parents’ living room, through the ambulance ride to the ER, and ripping out my IV, to being sedated with haldoperidol. I woke up the next morning in a hospital room.

King relates, “I’ve realized that the word ‘addict’ is a particularly useful descriptor for who I have always been. I always resonated with Paul’s lament: ‘I do not do the good I want to do, but the evil I do not want to do – this I keep doing.’ (Romans 7:19) Some who have never experienced the furious grip of chemical dependence are tempted to split the world into addicts and non-addicts…morally bad and morally good.” He added, “I did not realize how fully I had embraced this view until faced with my own opioid addiction.” For me personally, I will admit I didn’t know I could have an addiction problem and still be a good person.

While addiction science has made strides, there is still no silver bullet. Already there are stories of innovative addicts who have found new ways to abuse the medications intended to help them. Any approach that reduces addiction to a mere problem of brain chemistry and fails to acknowledge humans as moral actors will ultimately fail. But leading researchers and those discussing public initiatives have gone a long way to acknowledge the importance of a both/and methodology.

Churches can be cultural epicenters for shifts in societal norms. The longer that addiction is seen as a struggle for the “sinners out there” and not at the heart of the struggle of each and every one of us, the longer this problem will make headlines and remain in the shadows. Remember, sin takes its deepest root in the cover of darkness where it is never given a name.  King concludes, “When our affliction is named for what it is and brought into the light, that’s when darkness may be overcome.”

A Review of “Tweak: Growing Up on Methamphetamines” by Nic Sheff

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“Raw, powerful, and honest.” – The Bookseller

“A raw and sad account, vivid in its depiction of the pleasures and tunnel vision of addiction and the challenges of sobriety.” – Bulletin of the Center of Children’s Books

Nic Sheff writes a memoir that is searingly honest, detailing a downward spiral that seems to have no bottom. He was drunk for the first time at age eleven. In the following years, he would smoke pot regularly, do cocaine and Ecstasy, and develop addictions to crystal meth and heroin. Yet he always felt he could quit and put his life together whenever he needed to. It took a violent relapse one summer in California to convince him otherwise. Nic’s story takes you through the wild twists and turns in the life of a recovering addict. He is a kind soul. Creative, impulsive, curious. He is ever aware of the the pain and destruction he is causing those around him, but his addiction is too strong to just quit, as his family would have liked him to.

When he’s clean and sober, Nic is a sensitive, caring, loving person who is deeply insecure, and just wants to do things right. It is easy to root for him in spite of his insane return to crystal meth, heroin and cocaine over and over. Although I have never shot drugs into my arm, I completely understand being so obsessed with getting high that you will do nearly anything to score. When Nic began shooting dope, he changed from a youthful contender for the prizes of life, such as a promising career as a writer, a hint of leadership, and a quiet kindness that everyone noticed when he was a child, to a street scavenger with no future at all. He robbed his family and prostituted himself to men for drugs.

The exhausting cycle of rob, score, get high, rob, score, get high is finally broken when Nic gets caught breaking into his mother’s property. His father gives him a choice: Treatment or jail. He chooses treatment. This time it works. Nic does not suggest that he has now chosen a better way of life. He simply says, “Using just has no place in my life now, and I can’t see that ever changing.” I’ve been that far down, so I can appreciate this statement; however, it is always advisable in recovery to quit just for today. When and addict says they will never use again, he or she places themselves under such tremendous pressure that it can become overwhelming.

One thing I found particularly positive about this book is that Nic refuses to glamorize drug use. He lets us in to each of his battles, revealing every pain that comes with a life of addiction, with simple straightforward words. He vividly describes infected wounds in his arms from IV drug abuse, severe emaciation, and hallucinations caused by extended, unbroken meth use. Educators, counselors and parents would be well-advised to recommend this book to today’s young adult.

I have no idea what love is to most people. I have no idea what love is supposed to be. I have no idea what a healthy relationship should look like. I have no idea what society considers “normal” in terms of falling in love, being in love, and acting on that. Through group therapy, one-on-one therapy, supportive friends, writing, living, reflection, I’ve begun to find out who I am underneath all the protective coverings and drawn curtains and stained, twisted sheets. I’ve started to see myself, my true self, hiding somewhere behind my lungs maybe. Some unreachable center in me. I have an intensity inside of me that can be destructive as hell, but can also cut me wide open so that I feel sadness and joy and freedom and empathy and love like stars burning out and the sun captured inside every living thing. [Excerpt from a blog post at http://nicsheff.blogspot.com.]

Substance Abuse Concerns: Heroin and Prescription Drug Use on the Rise Among Teens

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Curriculum Review,  Jan. 2016, Vol. 55 Issue 5, p6-7. 2p.

It seems as though some teenagers have always dabbled in drugs, but with increasing access to dangerous prescription opioids and cheap heroin, the problem is especially acute. For some students, drug experimentation will lead to addiction. According to the National Institute on Drug Abuse (NIDA), after marijuana and alcohol, prescription and over-the-counter drugs are the most commonly abused drugs for Americans aged 14 years and older. In 2012, nearly 20 percent of American 12th graders said they had abused prescription pills at some point in their lives.

NIDA reports that heroin use has been rising since 2007. Though use among 8th, 10th, and 12th graders is at less than one percent, NIDA emphasizes that heroin use is reported as the biggest drug abuse issue in rural and urban areas. The rate of teens using heroin soared by 80 percent between 1999 and 2009. Twenty-three percent of those who try heroin will become addicted. The New York Times collected statistics about the heroin epidemic that has garnering attention from concerned citizens, politicians, and the media. There has been a 39% increase in heroin related deaths from 2012 to 2013. Ninety percent of first-time users are white. Increasing numbers of first-time users are middle or upper class. Seventy-five percent of heroin users used prescription painkillers before using heroin, with 40 percent of those individuals abusing opioid painkillers.

NIDA has found that some teenagers start taking heroin because it is much cheaper than prescription pills. Serious health problems involved with heroin include infectious diseases like HIV and hepatitis, collapsed veins and infection of the heart lining and valves, death by overdose, and liver and kidney disease. Signs that a teen could be addicted to heroin include acting slow and sedated, then intensely hyperactive, extreme sleepiness, cold and clammy skin, runny nose, pin-sized pupils, disinterest in extracurricular activities and academics, inattention to cleanliness, nausea, unexplained changes in friends, hangouts, and hobbies, weight loss, and an inability to pay attention or problem solve.

Drug overdoses cause more deaths every day than car accidents. Forty-four people per day die of opioid medication overdose. Approximately 1,600 teens begin abusing prescription drugs each day. Children and teens age 1 2 to 1 7 abuse prescription pills more than ecstasy, heroin, crack cocaine, and methamphetamines combined. Twenty percent of teens who abuse prescription pills did so before they turned 14. These statistics are obviously very alarming.

Anywhere, U.S.A.

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You can say that drug addiction could happen to anyone’s child, because it could. You can say that it happens in every community, because it does. But what happens when it’s your neighborhood? The residents of Campbell County, Kentucky know.

When you mention Matthew W. to some of the people who knew him, when he was in high school, even if you don’t use his name at first, they’ll know who you’re talking about. “Of course,” they’ll say. “I figured you meant Matt.” And then the teacher or the counselor or whomever will smile a smile that is genuinely warm and thoughtful, and you will naturally figure that their memories of Matthew are unclouded.

And you can imagine why. His skin is pink gold, the kind of color Norman Rockwell mixed for his cherubs, and his hair has the sort of soft, nape-of-the-neck curl that mothers love to snip and save in baby books. Matthew W., Campbell County High School Class of 2002, is every kid who ever sacked your groceries or lugged an instrument across the field at halftime.

The year since Matt graduated from high school has been a hard one in Northern Kentucky’s Campbell County. This past Friday there was a dramatic community meeting held in the Alexandria fire station. The police chief called it an intervention, employing the word that therapists use when they talk about confronting a person who is an alcoholic. But it was heroin, not alcohol, that prompted the meeting. Nineteen-year-old Mark D. and eighteen-year-old Adam M. had died of drug overdoses within weeks of one another, within months of their high school graduation. The death of Casey W., 23, from Kenton County, raised the local toll.

Both the Cincinnati Enquirer and The Post wrote about the growing threat of heroin among teenagers and young adults. Reporters were careful to talk about heroin use by kids all over Greater Cincinnati, but it was pretty hard to miss the fact that the deaths of these three in Northern Kentucky had prompted their attention. Their high school graduation pictures formed a gallery of heartache. Matthew W.’s picture could have been among them. He knows that now.

When Matt tells his story, he’s still trying to make sense of it himself. Sometimes it seems like a whirlpool of events, snapshots and memories that trail off to nowhere. The part that seems clearest is the part that’s the furthest away. Growing up Catholic in an Alexandria subdivision, going to St. Mary’s School and then Campbell County High School with his friends. The same crowd that signed up for AP classes, played together in the band, and spent weekends going to movies or playing cards.

It was in the ninth grade that Matt’s depression began. He told his mother he was sad, but it was more than that. He felt like he was living in darkness, that everything he did was a chore. His family doctor dismissed it as a phase. Routine adolescent doldrums. But as the months plodded on, the shadows never lifted. By the time he was 16, he was “self-medicating” with alcohol. He partied at the homes of a few like-minded friends whose parents were absent, and arranged weekend sleepovers so he could sober up before facing his parents. The drinking alleviated the depression, but as a depressant itself, alcohol became a double-edged sword. Downing a whole bottle of Jim Beam in the span of two hours became almost commonplace.

In October of his senior year, Matt’s depression was deep. His grades suffered, and music became less of a passion. On a particularly miserable fall afternoon, he made not one but two suicide attempts. First, he shut himself inside the garage and ran his dad’s ’84 Thunderbird until he passed out from the fumes. The car ran out of gas and he woke up. Then, he went inside and dug through the family medicine cabinet, collecting old pills and the painkillers he’d saved from foot surgery. He arrived at a friend’s party, pockets bulging with pills, and proceeded to wash them down with swigs of Jim Beam. Then he stumbled outside and passed out near U.S. Route 27. People from the party had to drag him back to the house, tearing his clothes and scraping his head along the pavement.

When he returned home the next morning, Matt had a black eye and his clothes were in shambles. This time he didn’t use the sleepover excuse. He told his parents what he’d done. They hadn’t known about the drinking. Hadn’t the doctor said not to worry? This was “just a phase.” Matt’s parents got help immediately, taking him to a therapist who specialized in adolescents. The therapist prescribed Zoloft for Matt’s depression, and insisted he start attending AA meetings. Matt took the Zoloft and went to therapy, but continued to drink. Only after four months did he start attending AA meetings.

In January 2002, after binge drinking, Matt tried heroin for the first time with a classmate named Chad. Chad was on the fringes of Matt’s circle at high school, a brilliant guy in Matt’s estimation, who could come to class stoned and still perform well enough to rank in the top five percent of the class. Chad had been using heroin for about a year and was happy to show Matt the way. Within seconds of shooting up, Matt felt like he was saved. He was on a high that cast daily life as a mere caption to his new picture of health. Twenty milligrams, $20, one fix, and Matt had never felt better. Today, it’s hard for him to recreate the precise rationale that got him there. Only that, at the time, “putting a needle in my arm made sense.”

In the 1990s, when cocaine began to lose its cachet, Columbian drug traffickers needed to diversify, so they added heroin to their product line. Once they got into the business, they refined it, producing a purer heroin that was also cheaper. The higher-quality, more affordable powder could be snorted, which actually helped people become users. It’s one reason that heroin use rose in the United States during the ’90s. A survey by the Department of Health and Human Services found that between 1993 and 1999, overall admissions for heroin treatment at public hospitals increased by 11 percent. But that’s an average. Some parts of the country (especially the Seattle grunge scene) were especially hard-hit.

Things always seem to happen later in our part of the world, and heroin has been no exception. Police and drug rehab professionals speculate that when Northern Kentucky law enforcement started clamping down on illegal OxyContin distribution, the local Oxy traffickers phased in heroin to serve their customers’ habits. “We saw OxyContin users, and when that was being controlled there was the swing to heroin,” says Dr. Mike Kalfas, medical director of the St. Luke Alcohol and Drug Treatment Center. “I can’t prove it, but it’s sure a logical conclusion.”

Heroin changed Matt’s life instantly. Before, he had been sleeping 14 hours a day, but once he started using, he was happy and life became manageable. He took every opportunity to get high, in his room, in the garage, at Chad’s house. Once, during an AA meeting in a church basement, he shot up in the restroom. He convinced his mother that he was in control because he only used twice a week. If he forced himself to maintain some sort of schedule to his using, he reasoned, he wouldn’t become an addict.

By the first week in February 2002, Matt had spent all his savings on heroin. Stuck for cash, he asked his mother for money to get his girlfriend a Valentine’s Day gift. She gave him two twenties and asked for the change. Matt was gone for ages, and when he returned he had a card and a box of chocolates. Change from the $40? He insisted his mother had only given him two tens. The next day, Matt’s mom walked into his room when he wasn’t around and saw a cup of rubbing alcohol sitting out. Suddenly, the whole picture fell into place. She knew he was injecting heroin.

In early February of the following year, 12 months from the day Matt’s family faced his heroin addiction, 400 or so citizens of Campbell County crammed into the meeting room of the Alexandria fire house. The meeting had been called a couple of weeks after eighteen-year-old Adam M. died of an overdose. The idea was put together by law enforcement officers from several agencies, the county coroner, and the Commonwealth’s attorney, but it was Alexandria’s Chief of Police, Mike Ward, who organized it. He was sticking his neck out by hosting the meeting. Insiders said community leaders were worried about how it would make Alexandria look. But in the face of the tragedies, keeping up appearances didn’t seem so important to Chief Ward.

The conventional method of cleaning up a community drug problem, using informants to make controlled buys, then arrest dealers, wasn’t working. There was significant drug-fighting expertise on the south side of the Ohio River. Officers were prepared to deal with kilos of cocaine coming into the area, or an enterprising farmer harvesting marijuana. But keeping a kid from overdosing on a hit of heroin he bought five minutes before in another state seemed impossible. Unless you could keep him from using drugs in the first place. This was the intention of the intervention meeting at the fire house.

On April 2, 2003, Matt W. was one year clean. He was a freshman at a local university. During his first year of college, he attended NA meetings in Lexington, which was a two-hour round trip from campus. He continued to read books he purchased at an AA meeting. He kept busy, playing in the marching band, did tutoring for the math department, and carried 18 credit hours in the fall. In the winter, he started going home on weekends, and began rehearsing again with the band he’d put together in high school. It had fallen apart when he started using heroin.

One night he went with friends to a party where people were drinking and smoking hash. He turned on his heels and went back to his dorm. The same kind of struggle can be set off by the simplest of things. “I’ll wake up and I think it’s a gorgeous day, and I say ‘What a great day to be high!'” When that happens, he counters it with something equally simple. He simply remembers his mother crying one year ago on that February night before he went into treatment. When you talk to Matt now, he still doesn’t know everything there is to know about his addiction, or why he chose to do what he did. Nor does he know why he chose to stop when he did. But he’s learning about himself, which is one of the great gifts of recovery. He’s not afraid to go home again. After all, he comes from a good place.

References

Mandrell, L. and Vaccariello, L. (2003). Anywhere U.S.A., Cincinnati Magazine, 36(10), 62.

How Heroin Kills

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The following information appeared in The Sunday Item, April 3, 2016, Sunbury, Pennsylvania.

Teresa Stoker gently pulls a sterling silver necklace from beneath the neck of her gray sweatshirt and holds it out beyond her chin. Ashes of 27-year-old Mark Stoker are piled inside a tiny cylinder, strung next to an imprint of her youngest son’s right thumbprint. His two siblings keep their brother’s ashes in keepsake key chains. Their mother has one of those, too. Mark died February 4, 2016 of a heroin overdose inside a New Columbia motel – one of 13 tri-county residents dead or suspected to have died of a drug overdose in 2016, according to coroners from Northumberland, Snyder and Union counties.

Mark was alone when motel staff found him after he failed to check out of his room. He was alone the day before, overdosed again in heroin and dumped by an acquaintance in the parking lot of a Burger King in Williamsport, PA, rain pouring onto his unconscious body, until passersby came to his aid and dialed 9-1-1.

He was supposed to be at his mother’s home in Shamokin Dam that day. They were supposed to have dinner and watch TV together. That had been the routine for days. He had stayed off heroin for six months, but he was growing irritable. His suboxone prescription was running short. He didn’t have consistent rides to counseling. He tried to make it work. He sliced the medicated film in half. As his supply dwindled, he sliced it in fours.

When Teresa pulled into her driveway on February 3rd, she could see through the blinds hung in the front window. “I knew he wasn’t in there,” she says.

Two months after his death, Mark’s family is left to reconcile love and pain, guilt and forgiveness – within themselves and within their own relationships fractured by a loved one’s fatal drug addiction. “He was the link that brought us together, and he was the one that pulled us apart,” says his sister and eldest sibling, Desiree. “He wasn’t long for this world,” adds Teresa. “He fought this to the very end,” says his brother Matt. “Mark didn’t really have a choice.”

The Stoker kids’ father died early in their lives. Mark was only 2 years old. Matt wonders if it was the impetus for mental health issues Mark would develop in life, particularly depression. Anxiety and depression are often evident in the psyche of a drug addict, according to the National Institute on Drug Awareness. “Addiction is a mental health issue,” says Dr. Rachael Levine, Pennsylvania’s physician general, who is among the officials at the forefront in addressing the Keystone State’s heroin and opioid addiction crisis. “It is not a moral failing.”

Mark sought help, and sometimes he sought it himself. He was no stranger to rehab. He’d been in and out of treatment several times, both in Pennsylvania and elsewhere. His family stood by his side the best they could, the only way they knew how. They encouraged him to lead a clean life, showed pride when he landed new jobs, sat bedside when he was hospitalized for an overdose. “Sometimes I look back and think we were fooling ourselves,” Matt says.

Matt and Desiree were the academics in the family. The former is enrolled in the physician assistant program at Pennsylvania College of Technology, and the latter is a registered nurse at Geisinger Medical Center in Danville, PA. Mark was no fool, either. His mind was for mechanics. He once rebuilt his own motorcycle after he wrecked it. Then he sold it and traded up for a better ride. His career path was in electrical work. On one job, he was hanging by a harness from a helicopter 200 feet above the ground repairing high-voltage lines. His family describes him as witty and charming, kind and sensitive, resilient and rebellious.

A quick learner, fearless in life’s pursuit, Mark hit dirt bike jumps taller than himself before he was a teen. He took quickly to Black Diamond slopes when he began to ski and bagged an eight-point buck on his first hunt. He was just 10 when he picked up on how to drive a stick shift. Accidents along the way created a need for pain relief. It’s very important to note that the American Society of Addiction Medicine found 4 in 5 new heroin users started by abusing prescription painkillers. Count Mark among the 80 percent. According to Mark’s mother, he was given pain meds at 14 when he had a wisdom tooth extracted. He took painkillers at 16 after having his gallbladder removed. Again, he took narcotic pain medication at 18 after being involved in a motorcycle accident.

Mark was 23 in 2012 when he developed painful kidney stones. His behavior suddenly changed. He became withdrawn, choosing to spend more time than normal alone in his bedroom. He was in legitimate need of relief from pain, but looking back, this is when his family says they first recognized signs of addiction. He’d been abusing oxycodone he was getting from three separate doctors. Maybe he needed relief the next summer when he stole Vicodin from his mother’s medicine cabinet.

It was September of that same year when Mark’s family first saw him experience a heroin overdose. He had borrowed his sister’s car. She found him slumped over in the driver’s seat as the engine idled – eyes glazed, sweat pooled in a cup holder. Mark’s sister dialed some of his recent calls on his cell phone. Someone told her, “He might be doing heroin.” She flipped out. The pock marks on the back of Mark’s hands weren’t bug bites as she thought on first glance. They were injection sites.

There would be more overdoses for Mark between September 2013 and the night he died in February 2016. Once his mother got a call from a Virginia state trooper. Mark overdosed in a hotel room while he was out of state on a job. Another time he was dumped at the doors of Evangelical Community Hospital in Lewisburg, PA, “dead on arrival,” as Teresa says. Attempts at recovery followed. Twenty-eight days at a Virginia facility didn’t take. The Stokers were more hopeful after a 28-day stay at Father Martin’s Ashley in Maryland, but again it didn’t help. He walked out of a rehab in White Deer, PA one week after he checked himself in.

Jobs, friendships, girlfriends – all lost by Mark to addiction, an addiction that strained an already complicated relationship, and ultimately led to his loss of parental rights to his daughter. He spoke often about the little girl, wrote about her in his journal. Teresa holds dear the few photographs she has of the two together.

A study on addiction by the Center for Rural Pennsylvania determined only 1 in 8 Pennsylvanians can afford treatment services. Geisinger Health System’s latest needs assessment says lack of insurance, cost of care, and transportation are barriers to treatment. More importantly, there simply aren’t enough providers to meet demand.

Mark had health insurance through the Health Insurance Marketplace. His mother says it didn’t cover the $150 monthly cost for suboxone, or the $100 cost per session for addictions counseling. His mother was in counseling herself, and with Mark out of work, she was covering all the bills. “We all knew he should be on [suboxone]…but we couldn’t afford it,” Teresa says.

And so the afternoon of February 4th, one day after Mark’s life was saved after he was found in the parking lot of the fast-food restaurant, came a familiar phone call to Teresa. One the whole family expected and equally feared. It was the state police. They didn’t tell her, but she knew. This time, Mark was dead.

“Change is Possible”

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In a first in Pennsylvania on March 9, 2016, the Upper Darby Township Police Department in Delaware County announced it will connect residents battling with addiction to a treatment center. According to Michael Chitwood, Police Superintendent, “the police station will be transformed into a safe haven for individuals caught up in addiction. Police officers are now taking a greater role in rehabilitation efforts, offering assistance to residents struggling with any type of substance abuse. People can come in, request help, and we will reach out and seek that help for them. Period.”

The program, known as Change Is Possible, was created to combat the heroin epidemic that is sweeping our nation. Referral to the treatment facility will assist individuals to determine what coverage their private health insurance or Medicaid provides. If someone is lacking health insurance, the treatment center will seek funding through county and state programs already available. Individuals seeking help can stop by the police station on weekdays between 9:00 a.m. and 5:00 p.m. A police officer will perform a background check and contact the treatment facility.

“The number one war in America right now is drug addiction,” emphasized Mayor Thomas Micozzie. “It’s killing the fiber of our communities. It’s not only our youth – it’s the middle-aged accountant, it’s the housewife who suddenly had a dental problem and got hooked on opioids.” “This is about saving lives,” added Superintendent Chitwood. “If we can save a life, we’ve accomplished something.”

Heroin is an opioid drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin usually appears as a white or brown powder or as a black sticky substance, known as black tar heroin. Prescription opioid pain medications such as Oxycontin and Vicodin can have effects similar to heroin when taken in doses or in ways other than prescribed, and they are currently among the most commonly abused drugs in the United States. Research now suggests that abuse of these drugs may open the door to heroin abuse. Nearly half of young people who inject heroin surveyed in three recent studies reported abusing prescription opioids before starting to use heroin. Some individuals reported taking up heroin because it is cheaper and easier to obtain than prescription opioids.

When it enters the brain, heroin is converted back into morphine, which binds to molecules on cells known as opioid receptors. These receptors are located in many areas of the brain (and in the body), especially those involved in the perception of pain and in reward. Opioid receptors are also located in the brain stem, which controls automatic processes critical for life, such as blood pressure, arousal, and respiration. Heroin overdoses frequently involve a suppression of breathing. This can affect the amount of oxygen that reaches the brain, a condition called hypoxia. Hypoxia can have short and long-term psychological and neurological effects, including coma and permanent brain damage.

Drug Overdose Deaths Hit Record Numbers

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The Centers for Disease Control and Prevention announced that drug overdose deaths hit record numbers in 2014, with more than 47,000 deaths nationwide. CDC has outlined steps for stopping the overdose death epidemic. Pennsylvania Department of Drug and Alcohol Programs Secretary Gary Tennis issued the following statement in response:

Like the rest of the nation, Pennsylvania is in the throes of the worst overdose death epidemic ever. In 2014, nearly 2,500 Pennsylvanians died from a drug overdose. With one in four families in the Commonwealth suffering with the disease of addiction, Pennsylvania, at the direction of Governor Tom Wolf, has made addressing this epidemic a priority. The Department of Drug and Alcohol Programs is working hard with its partners in the Department of Health and the Department of Human Services and other agencies to execute a plan to stem the rising tide of overdose deaths.

We have become a nation awash in prescription opioids due to the historic and ill-fated medical movement toward overprescribing for pain over the past two decades. Opioid prescribing has quadrupled, and today four out of five individuals with heroin addiction start out with prescription opioids. Our initiatives therefore focus largely on prescription opioids, as well as preventing overdose deaths and expanding access to clinically appropriate treatment.

“The record level of opioid overdose deaths around the country and here in Pennsylvania is tragic,” said Department of Health Secretary Dr. Karen Murphy. “My department is working expeditiously to address this crisis on all fronts. Our primary goal is to work at prevention as well as providing treatment for those in need.”

The Pennsylvania Department of Health is leading an effort to build upon the prescribing guidelines already created, including guidelines to address emergency department pain treatment with opioids, opioids in dental practice and opioids to treat chronic non-cancer pain. These guidelines give healthcare providers direction for safe and effective pain relief practices, with greater emphasis on non-opioid therapies and greater caution to prevent addiction and diversion.