Fentanyl Becomes Deadly Force

Some Excerpts taken from an article By Eric Scicchitano
The Daily Item
July 10, 2017

Fentanyl

The deadly heroin and opioid epidemic is expected to become even deadlier with the increasing presence of Fentanyl in America. According to the DEA, Fentanyl is 50 to 100 times more powerful than morphine, and substantially more potent than heroin. As little as 2 grams of Fentanyl can be deadly. Alarmingly, it is fast becoming the most prevalent active ingredient in counterfeit drugs like Adderall, Xanax, and OxyContin being sold on the streets. During the first quarter of 2017, heroin combined with Fentanyl was detected in 61% of opioids seized for evidence and inspected in DEA labs. It is also frequently laced into marijuana and smoked.

The DEA’s Philadelphia Division warns that Fentanyl is on the rise, with seizures of shipments more than doubling from 167 kilos in 2015 to 365 kilos in 2016. Investigators are trying to determine if an outbreak of Fentanyl is responsible for 51 overdoses which occurred in Williamsport (Pennsylvania) in forty-eight hours. [See my post 51 overdoses in 48 hours] Three of those cases ended in death. According to the National Institute on Drug Abuse (NIDA), heroin and opioids killed an estimated 280,000 people nationwide between 2002 and 2015. Based upon preliminary figures put together through state coroners, more than 4,800 people died of an overdose in Pennsylvania last year. Experts are concerned that the next chapter in the opioid crisis could dwarf what we’ve seen so far. Their concern is based on the proliferation of Fentanyl.

Fentanyl Deaths Map

Let’s take a few moments to discuss Fentanyl. It is a man-made (synthetic) opioid, meaning it is manufactured in a laboratory, but it acts on the mu-opioid receptors in our brain and spinal column in the same manner as the morphine molecule found naturally in opium. Typically, these receptor sites are meant for naturally-occurring endorphins, our “feel good” chemical released by the pituitary gland. Fentanyl is usually prescribed to patients suffering from intractable cancer-related pain and, in some cases, debilitating back pain. My father was given Fentanyl patches for compression fractures near the end of this life. Initially, it was believed Fentanyl would not be abused. Unfortunately, addicts decided to start opening the patch in order to scrape out the medicine and abuse it.

Fentanyl Mapping.gif

As if that were not enough, Fentanyl is being illegally manufactured in labs (primarily in China). It is produced in powder form, and is also pressed into pills, and smuggled into the United States. These knock-off pills are catching users off guard. Fentanyl is 50 to 100 times more powerful than morphine. DEA and border patrol seized more than 10,000 counterfeit pills containing Fentanyl in 2015. An amount as small as 2 milligrams can be deadly. First responders and ER physicians have to use extreme caution in order to avoid accidental exposure. According to the article in The Daily Item, an Ohio police officer accidentally overdosed in May of this year after brushing Fentanyl powder from his uniform during an arrest.

After the recent overdose surge in Lycoming County (Pennsylvania), Todd Owens, Mount Carmel police chief and head of the Northumberland County Drug Task Force, advised first responders to take measures to protect themselves. Chief Owens said his own department stocks medical masks, coveralls and heavy-grade gloves in their cruisers to be worn in the event they encounter heroin.

Heroin Fentanyl and Carfentanil Pics

The above is an illustration of potency betwen heroin, Fentanyl, and Carfentanil.

Carfentanil

Carfentanil is an extremely powerful derivative of Fentanyl. While Fentanyl is up to 100 times more potent than morphine, Carfentanil is 100 times more powerul than Fentanyl. In other words, it is 10,000 times more powerful than morphine. It is not approved for use in humans; rather, it is used in veterinary medicine to sedate large animals, primarily elephants. Yes, elephants! Carfentanil is so powerful that when veterinarians handle it, they use protective gear to avoid breathing it in or absorbing it through their skin. The amount of Carfentanil that can be safely administered to a human is 0.1 mg., compared to 13 mg. needed to sedate an elephant. It is obviously rather easy for an addict to accidentally take too much Carfentanil.

Interestinly, there are no statistics showing Carfentanil leading to addiction. That’s because even in the case of a seasoned addict a dose the size of a grain of salt can rapidly lead to an overdose and death. Frighteningly, drug dealers have begun cutting heroin with Carfentanil because it is extremely cheap to acquire. Even more disturbing is the fact that addicts in search of the ultimate high are deliberately trying this deadly drug. Rangers at Yellowstone National Park have recently begun issuing warnings to avoid eating the meat of bison killed in the park because the bison might have been sedated with Carfentanil for tagging or medical treatment. The drug can easily enter the bloodstream of those who eat the bison meat. It is most chilling to note that Carfentanil rapidly latches on to the mu-opioid receptors in humans, causing overdose almost immediately.

Moving Forward

Fentanyl moved up the rankings, from the 9th most common drug involved in overdose deaths in 2013, to the 5th most common drug involved in overdose deaths in 2014. The singer-songwriter Prince died of an overdose of Fentanyl in April 2016, according to officials in Minnesota. Philip Seymour Hoffman, a very successful indie film star (and one of my favorites), died of a heroin overdose on February 2, 2014. Although he had a drug problem while in college, he was clean for twenty years. No doubt his system was not able to handle the strength of today’s heroin.

Reports from the Centers for Disease Control (CDC) and the Food and Drug Administration (FDA) showed that deaths from heroin more than tripled during a five-year period, from 3,020 deaths in 2010, to 10,863 deaths in 2014. These deaths are yet another symptom of the broader epidemic of opioid addiction. Just as deaths from AIDS are due to untreated HIV, deaths from overdose are frequently due to untreated addiction. I know of many addicts attending 12-step meetings who are positive for hepatitis-C secondary to sharing needles while injecting heroin. Prince’s death is a reminder that opioid addiction is a disease that can and does affect people from all economic classes and all walks of life.

References

Scicchitano, E. (July 10, 2017). Fentanyl Becomes Deadly Force. Daily Item. Sunbury, PA.

Wakeman, S. (Aug. 5, 2016). Fentanyl: The Dangers of this Potent “Man-Made” Opioid. [Web Blog Comment.] Retrieved from: http://www.health.harvard.edu/blog/fentanyl-dangers-potent-man-made-opioid-2016080510141

Rettner, R. (Dec. 20, 2016). Deaths From Fentanyl Overdoses Double in a Single Year. LiveScience.com. Retrieved from: https://www.livescience.com/57268-fentanyl-overdose-deaths-double.html

 

Local Opioid Abuse: A Piece of the Nation’s Newest Health Crisis

By Steven Barto

I am no stranger to addiction. I started drinking and getting high the summer after high school graduation. It was 1977 and pot and southern rock went hand-in-hand. I found my answer to all the anger, anxiety, depression, insomnia, and feelings of not belonging. Of course, I had no idea where it would lead, or that it would take me nearly four decades to get clean. I’ve said it before: No one wakes up one day and says, “I think I want to be a full-blown alcoholic or drug addict when I grow up. I want to loose all self-respect, most of my teeth, two wives, four jobs, three cars, and my sense of ambition. I’d love to be estranged from family and friends. It’ll be great. Just me and my drugs!” Anyone whose not an addict or alcoholic and thinks it is a moral or deliberate choice doesn’t understand addiction.

Opiate Use Map (2)

Map shows areas of opiate use, with the most prevalence noted in dark pink.

Nationally

The “perfect storm” that got us to a nationwide opiate epidemic is intertwined with influences you’d never expect. Heroin used to be limited to the beatniks, poets, jazz musicians, wild-and-crazy rock stars of the 1950s, 60s and early 70s. But things were about to break loose. Congressmen Robert Steele (R-CT) and Morgan Murphy (D-IL) released an explosive report in 1971 covering the growing heroin epidemic among U.S. servicemen in Vietnam. America saw thousands of military personnel coming home from Southeast Asia addicted to heroin. As a result, President Richard Nixon declared a “war on drugs.” In fact, Nixon called drug abuse “public enemy number one.” Initially, the lion’s share of monies thrown at the drug problem went for treatment, which was a good thing. Unfortunately, this did not remain so in subsequent years. Politicians saw the opportunity to “take back the streets” of America from hippies, druggies, liberals, love children, people of color, and other “subversives” who did not seem to be conforming to the American lifestyle. Emphasis changed to criminalizing addicts and locking them up.

Admittedly, cocaine and crack became a serious concern before America fell face-first into the current opiate epidemic. Interestingly, one of the major factors contributing to increased cocaine trafficking was the North Atlantic Free Trade Agreement (NAFTA) signed into law under President Bill Clinton. Goods began to flow into the United States from Mexico at such an increase that border patrol was unable to adequately assure drugs were not coming over the border. There simply were not enough agents to keep up with inspection and enforcement. Prior to the climate of unrestrained trade, President Nixon had ordered that every vehicle returning from Mexico must be searched for drugs. Long lines ensued, and there was no appreciable reduction in drug trafficking.

Heroin and a Handgun

In 1995, The Food and Drug Administration (FDA) approved OxyContin for prescription use. Its active ingredient, oxycodone, was believed since the 1960s to be highly addictive. Purdue Pharma, the inventor of OxyContin, claimed their formula of delayed-release oxycodone would all but eliminate the “rush” experienced by taking the drug in its original form. Purdue launched an extremely aggressive marketing progam, sending drug reps to virtually every family practitioner and pain management specialist, armed with what was eventually deemed a falsified report that less than 1% of OxyContin patients became addicted. Doctors were offered outrageous incentives to prescribe the drug. Purdue Pharma began the practice of sponsoring trade shows and symposiums, often plying physicians with lavish meals and “entertainment.” On the heels of this marketing blitz, the American Pain Society began arguing for medical providers to view pain as the “fifth vital sign.” This is precisely the basis for the How would you rate your pain on a scale of 0-10? question that is asked in every emergency department in America today. Well-intentioned doctors believed it was unconscionable to let patents suffer through severe pain. They didn’t believe Oxy would do more harm than good.

By 1996, Purdue Pharma reported $45 million in sales of OxyContin. As of 2000, the number jumped to over $1 billion. That’s a two-thousand fold increase. Misuse and abuse of opiate painkillers (OxyContin, Vicodin, Lortab, oxycodone) increased significantly beginning in 2000. In 2002, 6.2 million Americans were abusing prescription drugs, and emergency room visits resulting from the abuse of narcotic pain relievers had increased dramatically. By 2009, the total number of visits to ERs for overdose on opiates was 730,000, which was double the number of five years before. More than 50,000 Americans died of a drug overdose in 2016. Heroin accounted for 12,898 of those deaths that year. Synthetic opioids (such as Fentanyl) killed 5,880. Prescription painkillers like OxyContin and Vicodin claimed 17,536 lives.

Companies like Purdue Pharma have restructured the formula of opiate medications in order to make them even harder to abuse. No doubt this had a lot to do with the $635.5 million fine levied against Purdue for intentionally misleading the medical community regarding the potential to become addicted to OxyContin. Typically, addicts crush and snort the drug, or cook it down and inject it. What’s disheartening today is that most people who started out taking and then abusing OxyContin and other opiate pain medication are now using heroin because it’s cheaper – $5 to $7 dollars for enough to be high most of the day versus $10 to $80 for one Oxy, depending on its strength. Heroin is readily accessible virtually everywhere you go, and it is easily converted to a form that can be smoked or injected.

Locally

Front page news in my hometown paper, The Sunday Item, indicates that drug overdoses in Pennsylvania killed nearly 11,000 people in the last three years, fueled largely by heroin and prescription painkillers. The number of deaths has steadily increased year after year. As fatal overdoses have increased, so has public awareness, access to addiction treatment, and legislative initiatives against an epidemic the U.S. Department of Justice describes as the leading cause of death of Americans under the age of 50. It is important to note that this is a disease that affects everybody. Let’s stop playing the New Jim Crow game and stigmatizing, criminalizing, and institutionalizing drug addicts based upon skin color. Heroin and opiate drug addiction is rampant today in all socioeconomic classes, to be sure, but surprisingly it is most prevalent in white males age 18 to 25.

heroin-graph_1185px

The Sunday Item interviewed a man named Steven C., 27 years old, who is a recovering heroin addict attempting sobriety after fifteen years of opioid abuse. When he heard the news of an overdose outbreak in the Williamsport (Pennsylvania) area that sent 51 patients to the hospital in 48 hours, with three patients now dead, Steven couldn’t help but realize, “That could have been me.” Steven was brought back to consciousness from a heroin overdose on August 9th of last year. EMTs adminstered naloxone, which is used in the field to reverse the effects of an overdose, but it didn’t work. His heart had stopped. Thankfully, CPR eventually restarted his heart.

The Official Response

Federal and state funding for the opioid and heroin problem in Pennsylvania has been increased 19% to $76 million for the current fiscal year. The funds include $5 million for grant money to provide naloxone for emergency responders, which is proven to reverse the effects of narcotic overdose in most cases, and $2.3 million to establish specialty courts for handling drug-related criminal cases. Great strides have already been taken in fighting this epidemic. Pennsylvania restricts opioid prescriptions to seven days for minors and those discharged from hospital ERs. Emergency room physicians are not allowed to see patients for follow-up visits or refills. Each instance where an opioid prescription is filled is recorded on a state-wide database in order to stop “doctor shopping” or getting refills “too early.” According to the Sunday Item article, the prescription database has been accessed by doctors 8 million times since it was launched.

An estimated 2 million Americans are addicted to painkillers, and another 591,000 are addicted to heroin. Although we’re beginning to made headway regarding opioid prescriptions, much remains to be done regarding heroin addiction. It is noteworthy that taking opioid pain medication for longer than three months makes patients up to forty times more likely to become addicted to heroin. Senator Gene Yaw (R-23) of Williamsport told reporters, “I have said many times that I don’t expect to see positive results for at least ten years. It took a long time to get into the situation we find ourselves and we can’t expect a change to happen overnight. We are addressing many issues and eventually together they will make a difference.” It is abundantly clear that there is a risk of progression from alcohol and other drugs (especially opioid painkillers) to heroin.

heroin-use_1185px

Concluding Remarks

What can you do? Most importantly, as public service announcements state on TV in Pennsylvania, “Mind your meds.” Please don’t react to this suggestion by simply saying drug addicts should be able to be trusted, otherwise they’re just thieves. Or, that they should have better impulse control. Addiction is not about willpower, nor is it a matter of a moral deficiency. Virtually anyone who uses opiates for pain for longer than three months can become addicted. That is the very nature of the morphine molecule found in these medications. It is extremely difficult for an opiate addict to “just say no” to the screaming of their mu-opioid receptors in the brain and spinal cord once the morphine molecule has latched “lock-and-key” into place. Opiates are far more potent than naturally occurring endorphins.

I really had no idea how difficult it can be to quit drinking or taking opiates once your body gets used to the chemical reaction and the euphoria. I have not had a drop of alcohol, a line of cocaine, or a joint since 2008. It was not so easy for me to give up opioid painkillers. It’s a two-edged sword. First, there’s the initial legitimate need for pain relief. Doctors recognized this in the 90s when they decided to not let their patients suffer in chronic agony. Although I was in recovery for other substances, I thought I could use pain medication safely. I’d abused it in the past, sure, but now I was “sober” and I needed help with severe back pain. I didn’t want the drug in order to “party.” The other edge of the sword is the neuropsychology of the addiction itself. These types of medications actually restructure the brain. Sometimes the effects are permanent, as when memory or IQ or motor skills are compromised. Thankfully, this is not the case for me.

If you or someone you know is struggling with a drug or alcohol problem, please consult your physician for a phone number to the nearest help line. You will also find AA and NA phone lines in the phone book or online. If you are a Christian facing addiction, consider Celebrate Recovery. Facebook has numerous groups you can join. You call also email me at stevebarto1959@gmail.com and I will reply as soon as I can.

References

The Sunday Item. (Sunday, July 9, 2017) Sunbury, PA http://dailyitem.com

Karlman, J. (February 16, 2017). Timeline: How Prescription Drugs Became a National Crisis. Retrieved from: http://fox5sandiego.com/2017/02/16/timeline-of-how-prescription-drugs-became-national-crisis/

Moghe, S. (October 14, 2016). Opioid History: From Wonder Drug to Abuse Epidemic. CNN Online. Retrieved from: http://www.cnn.com/2016/05/12/health/opioid-addiction-history/index.html

Sandino, J. (May 13, 2015). A Timeline of the Heroin Problem in the U.S. Addictionblog.org Retrieved from: http://drug.addictionblog.org/a-timeline-of-the-heroin-problem-in-the-u-s/

Tribune News Services. (December 8, 2016). More than 50,000 Overdose Deaths. Chicagotribune.com. Retrieved from: http://www.chicagotribune.com/news/nationworld/ct-us-overdose-deaths-20161208-story.html

Governor Tom Wolf Signs Opioid Bills Into Law

Gov. Tom Wolf signed into law a package of legislation meant to curb addiction to prescription painkillers and heroin in a state that saw more than 3,500 people die last year of drug overdose. New laws mandate seven-day limits on painkiller prescriptions like oxycodone for both minors and emergency room patients who are treated and released.

Legislation also establishes curriculum on safe prescribing for medical school students and professionals seeking license renewal, boosts the frequency prescription drug prescribers and dispensers utilize and update the Pennsylvania Prescription Drug Monitoring Program (PDMP), and widely expands potential drop-off locations for unused prescription drugs. The move came five weeks after a rare joint meeting of the state House of Representatives and Senate at which Wolf called for action addressing the opioid and heroin addiction crisis as the end drew near in the 2015-2016 legislative session.

Last week, the General Assembly adopted the bills

Governor Wolf said, “I am proud to sign a package of bills that represents the work that we have all done together to address the heroin and opioid abuse crisis and begins to curb the effects of this public health epidemic in Pennsylvania.” State Senator  Gen Yaw (R) of Williamsport, PA was the prime sponsor of two of the bills. He compared the Legislature’s work to the strength of a rope. Each bill represents a single strand. “Alone, they might not be fully effective, but together, they can strengthen the rope and our collective efforts.” He said he appreciates the support of the legislative leadership, and remarked that he is thankful for the governor’s prompt signing of the bills into law.

Glenda Bonetti, director of Northumberland County’s Drug and Alcohol Program, fully supports the prescribing limits. She estimates the average age of first-time opioid users who seek help through her office as 17. In her experience, many who become addicted tend to progress to heroin. Bonetti is grateful for the legislative action, but said it took opioid abuse to become prevalent in the middle and upper classes to get noticed. She said, “The reason it’s becoming more publicized is because it’s not just the impoverished who are affected. It’s affecting wealthy families, not just poor people.”

– by Eric Scicchitano, The Daily Item, November 3, 2016

Me Included

I recently took the time to read President Obama’s report Epidemic: Responding to America’s Prescription Drug Abuse Crisis (2011), published on the monthly blog of Dr. Nora Volkow, director of the National Institute on Drug Abuse. (Sept. 14, 2016) According to the president’s report, prescription drug abuse is the nation’s fastest-growing drug problem. While there has been a marked decrease in the use of such illegal drugs as cocaine, data from the National Survey on Drug Use and Health (NSDUH) show that nearly one-third of people aged 12 and older who used drugs for the first time in 2009 began by using a prescription drug non-medically. The survey found that over 70 percent of people who abused prescription pain relievers got them from friends or relatives, me included.

I started taking opioid pain medication for severe low back pain in 2004. The pain became debilitating, and I was approved for Social Security Disability Income in 2009. Being an addict and an alcoholic, I should have realized that one pill was too many and a hundred was not enough. At one point, I was seeing three different doctors and going to several different pharmacies in order to avoid suspicion. I could not keep up with my cravings. When I could no longer get enough pain meds through doctors and  ERs, I started stealing medication from everyone in my family. I realized just the other day that I have been taking medication from loved ones since 1984 when I started helping myself to my mother-in-law’s Tylenol with Codeine. Although there have been periods where I was able to stop taking opiates, it started all over again about a year before my father died. Following a family intervention, I went to a rehab center for 21 days. I relapsed ten months after I left the rehab. I managed to get clean again until August 20 of this year when I stole oxycodone tablets from my mother. It appears I may have done irreparable damage to my relationship with her. Ironically, that was my greatest fear.

Although a number of classes of prescription drugs are currently being abused, the president’s 2011 action plan primarily focuses on the growing and often deadly problem of prescription opioid abuse. The number of prescriptions filled for opioid pain relievers (some of the most powerful medications available) has increased dramatically in recent years. From 1997 to 2007, the milligram-per-person use of prescription opioids in the U.S. increased from 74 milligrams to 369 milligrams, which amounts to 402 percent. In 2000, retail pharmacies dispensed 174 million prescriptions for opioids. By 2009, 257 million prescriptions were dispensed, which is an increase of 48 percent. Opiate overdoses, once almost always due to heroin use, are now increasingly due to the abuse of prescription painkillers.

A crucial first step in tackling the problem of prescription drug abuse is to raise awareness through the education of parents, youth, patients, and healthcare providers. Although there have been great strides in raising awareness about the dangers of using illegal drugs, many people are still not aware that the misuse or abuse of prescription drugs can be as dangerous as the use of illegal drugs, leading to addiction and even death. In addition, prescribers and dispensers, including physicians, dentists, and pharmacists, all have a role to play in reducing prescription drug misuse and abuse. Most receive little training on the importance of appropriate prescribing and dispensing of opioids to prevent adverse effects, diversion, and addiction.

Outside of specialty addiction treatment programs, most healthcare providers receive minimal training in how to recognize substance abuse in their patients. Most medical, dental, pharmacy, and other health professional schools do not provide in-depth training on substance abuse; often, substance abuse education is limited to classroom or clinical electives. Moreover, students in these schools only receive limited training on treating pain. A national survey of medical residency programs in 2000 found that, of the programs studied, only 56 percent required substance use disorder training, and the number of curricular hours in the required programs varied between 3 to 12 hours. A 2008 follow-up survey found that some progress has been made to improve medical school, residency, and post-residency substance abuse education; however, efforts have not been uniformly applied in all residency programs or medical schools.

Educating prescribers on substance abuse is critically important, because even brief interventions by primary care providers have proven effective in reducing or eliminating substance abuse in people who abuse drugs but are not yet addicted to them. In addition, educating healthcare providers about prescription drug abuse will promote awareness of this growing problem among prescribers, so they will not over-prescribe the medication necessary to treat minor conditions. This, in turn, will reduce the amount of unused medication sitting in medicine cabinets in homes across the country.

The president’s report indicates that all of this will take tracking and monitoring. Forty-three states have authorized prescription drug monitoring programs (PDMPs). PDMPs aim to detect and prevent the diversion and abuse of prescription drugs at the retail level, where no other automated information collection system exists, and to allow for the collection and analysis of prescription data more efficiently than states without such a program can accomplish. However, only 35 states have operational PDMPs. These programs are established by state legislation, and are paid for by a combination of state and Federal funds. PDMPs track controlled substances prescribed by authorized practitioners and dispensed by pharmacies. PDMPs can and should serve a multitude of functions, including assisting in patient care, providing early warning of drug abuse epidemics (especially when combined with other data), evaluating interventions, and investigating drug diversion and insurance fraud.

In summary, the president’s report states that research and medicine have provided a vast array of medications to cure disease, ease suffering and pain, improve the quality of life, and save lives. This is no more evident than in the field of pain management. As with many new scientific discoveries and new uses for existing compounds, the potential for diversion, abuse, morbidity, and mortality are significant. Prescription drug misuse and abuse is a major public health and public safety crisis. As a nation, we must take urgent action to ensure the appropriate balance between the benefits these medications offer in improving lives and the risks they pose. No one agency, system, or profession is solely responsible for this undertaking. We must address this issue as partners in public health and public safety. Therefore, ONDCP will convene a Federal Council on Prescription Drug Abuse, comprised of Federal agencies, to coordinate implementation of this prescription drug abuse prevention plan and will engage private parties as necessary to reach the goals established by the plan.

The Accidental Addict

Up until a few months ago, Susan started her day by getting high. She’d crush a cocktail of drugs that included Oxycontin and Roxicodone, two forms of the narcotic painkiller Oxycodone, and then snort them so they’d get into her system faster. Within hours the symptoms of withdrawal would set in. An unbearable panicky feeling, muscle cramps, diarrhea and nausea. So she’d quickly snort another round. If there were no drugs left, she’d find a way to get more. Either from someone she knew or by buying them from a dealer.

This scenario wouldn’t seem shocking if Susan were a junkie living on the street, but that’s not the case. She’s a 32-year-old, well-educated, middle-class mom holding down a job as a nurse. Her spiral into addiction started seven years ago, when she was 25 and often in debilitating pain. After finally being diagnosed with fibromyalgia, she was relieved to have a name for her condition and a prescription to ease her suffering. “The Oxy didn’t just take away the pain. It gave me energy and helped me feel less stressed,” says Susan. “When I took those pills, it was like I could get everything done.” But soon the drug stopped giving her that false sense of control, and she needed to take more and more just to feel normal. When popping pills wasn’t working, she started snorting them. By the time Susan realized her drug habit had become a problem, this real-life “Nurse Jackie” was powerless to quit.

Chances are, you know a Susan even if you don’t realize it. “After alcohol and marijuana, prescription pain relievers are the most widely abused drugs in the United States,” says John Coleman, PhD, president of the Prescription Drug Research Center. Why are pills so ripe for abuse? They’re easily available. Last year, 139 million prescriptions were written for hydrocodone-containing drugs like Vicodin (up from 112 million just four years ago), making them the most-prescribed drugs in the country. They’re also highly addictive. Especially painkillers like Vicodin, Percocet and Oxy, which come from opium or a synthetic version of it. They are actually chemically related to heroin, but without the stigma. “People who would never dream of trying an illicit street drug may be prescribed Vicodin or Percocet for pain relief after a car accident,” says Coleman, “and after just a few weeks they can end up dependent on these drugs.”

“About 10 percent of the population has a genetic predisposition to addiction, whether it’s to painkillers, alcohol or substances like nicotine,” says Russell Portenoy, MD, chairman of the Department of Pain Medicine Palliative Care at Beth Israel Medical Center in New York City. “A personal or family history of alcohol or substance abuse suggests that you may be one of those people.” Other risk factors include suffering from a psychiatric condition like depression, anxiety or bipolar disorder, or having experienced past trauma such as sexual or emotional abuse.

Unfortunately, most people who become addicted to narcotics can’t stop on their own. That’s what Susan is in the process of doing. Her wake-up call came one morning when she realized she’d finished a month’s worth of her prescription in less than a week. This time, instead of trying to get more pills, she decided she’d had enough. She sat on the bathroom floor, sweating and shaking. She opened the phone book and called one rehab center after another until she found one with a bed open for her. She went in to treatment the following morning.

Addiction is defined as the compulsive need for and use of a habit-forming substance (such as heroin, alcohol or narcotic pain medication) characterized by tolerance and by well-defined physiological symptoms upon withdrawal. In other words, persistent compulsive use of a substance known by the user to be harmful. If you’re struggling with addiction, please pick up your phone book or go online and find the number for Narcotics Anonymous or Alcoholics Anonymous. Don’t wait 30 years to seek help like I did. Know this: If you find that when you drink or take narcotics you cannot control the amount you consume or, if when you want to, you find you cannot stop, then you are at that jumping-off point where it will never get better. Only worse.

How Heroin Kills

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.

Opiate Epidemic

The following are excerpts from the cover story in National Review dated February 29, 2016, titled From Oxy to Overdose: How Prescription-Drug Abuse Unleashed a Heroin Epidemic, by Kevin D. Williamson.

Ground Zero in the opiate epidemic isn’t in some exotic Taliban-managed poppy field or some cartel boss’s fortified compound. It’s right there at Walgreen’s, in the middle of every city and town in the country.

The author begins with an interview of a heroin addict he conducted in Birmingham, Alabama. The addict described several street names for heroin. “Sand, because it’s brown. Or diesel. Or killa or 911…the 911 they call it because they want you to know it’s potent, that you’ll have to go to the emergency room.”

That’s a weird and perverse and nasty kind of advertising, but then dope-buying psychology isn’t very much like Volvo-buying psychology. Crashing is just another part of the ride. One spiteful dealer boasts about spiking his product with excessive amounts of fentanyl, an all-business pharmaceutical analgesic used for burn victims and cancer patients, that particular dealer’s plan being to intentionally send overdosed users to the hospital or the morgue…for marketing purposes. Once the word got out about the hideous strength of his product, addicts were scrambling to try it.

The young man being interviewed is barely old enough to buy a beer. He describes the past several years of his life “dope-sick and stealing,” going from job to job. Eight jobs in six months. Robbing his employers blind, alienating his family, descending. He was an addict on a mission. “You’re always chasing that first shot of dope, that first high. And the first one for me almost killed me. I was 17 or 18 years old, and I met a guy who had just got out of prison, doing a 13-year sentence for heroin possession and distribution…I was snorting heroin when I met up with him, and set him up with my connection. He offered to shoot me up, and I wanted to do it. And I remember him looking me in the eyes and telling me, ‘If you do this, you’ll never stop, and you’ll never go back.’ And I said, ‘Let’s do it.'”

This particular opiate odyssey starts off in a Walgreen’s. What seems to be killing what used to be the white working class isn’t diabetes or heart disease or the consumption of fatty foods and Big Gulps from 7-Eleven, but alcohol-induced liver failure, along with overdoses of opioid prescription painkillers and heroin. The use of heroin has increased dramatically in recent years as medical and law-enforcement authorities crack down on the wanton overprescription of oxy and related painkillers. Which is to say: While we were ignoring criminally negligent painkiller prescriptions, we helped create a gigantic population of opioid addicts, and then, when we started paying attention, first thing we did was take away the legal and quasi-legal stuff produced to exacting clinical standards by Purdue Pharma (maker of OxyContin), and other drug manufacturers. So, lots of opiate addicts, but fewer prescription opiates available.

The clerks the author encountered at the Walgreen’s in Birmingham are super friendly, but the place is set up security-wise like a bank. That’s to be expected. This particular location was knocked over by a young white man with a gun the summer before last, an addict who had been seen earlier lurking around the CVS down the road. This is how you know you’re a pretty good junkie: The robber walked in and pointed his automatic at the clerk and demanded oxy first, then a bottle of cough syrup, and then, almost as an afterthought, the $90 in the till. Walgreen’s gets robbed a lot. In January, armed men stormed the Walgreen’s in Edina, Minnesota, and made off with $8,000 worth of drugs, mainly oxy. In October, a sneaky young white kid made off with more than $100,000 worth of drugs, again, mainly oxy and related opioid painkillers, from a Walgreen’s in St. Petersburg, Florida.

In 2013, Walgreen’s paid the second-largest fine ever imposed under the Controlled Substances Act for being so loosey-goosey in handling oxy at its distribution center in Jupiter, Florida that it enabled untold quantities of the stuff to reach the black market. The typical pharmacy sells 73,000 oxycodone pills a year; six Walgreen’s in Florida were going through more than 1 million pills a year at each location. That’s six million doses of oxy. A few years before that, Purdue Pharma was fined $634.5 million for misleading the public about the addictiveness of oxycodone.

The current spike in overdoses is related to a couple of things. One proximate cause is the increased use of fentanyl to spike heroin. Heroin, like Johnnie Walker, is a blend. The raw stuff is cut with fillers to increase the volume, and then that diluted product is spiked with other drugs to mask the effects of dilution. Enter the fentanyl. Somebody, somewhere, has got his hands on a large supply of the stuff, either hijacked from legitimate pharmaceutical manufacturers or produced in some narco black site in Latin America, for the express purpose of turbocharging heroin. Fentanyl, on its own, isn’t worth very much on the street. It might get you numb, but it really doesn’t get you high, and such pleasures as are to be derived from its recreational use are powerfully offset by its tendency to kill you dead. But if the blend is artfully done, then fentanyl can make stepped-on heroin feel more potent than it is.

In high places, there are stirrings of awareness about heroin’s most recent ferocious comeback, but it has taken a while. Congress recently held hearings, and Senator Kelly Ayotte, the charismatic young New Hampshire Republican, introduced the Heroin and Prescription Opioid Abuse Prevention, Education, and Enforcement Act of 2015. The bill is currently on ice in the Judiciary Committee. One of the key aspects of the bill would convene a task force.

The public perception of heroin is like that of AIDS a generation ago. It is seen as a problem for deviants. AIDS was for perverts who liked to have sex with men at highway rest stops, and heroin is a problem for toothless pillbillies who turn to the needle after running out of oxy, and for whores and convicts and menacing black men in ghettos. Heroin, this line of thinking goes, is a problem for people who deserve it. Nobody seems to care because of who is affected. There are two problems with that. One, it’s unethical. Two, it isn’t true. It isn’t just the born-to-lose crowd and career criminals and deviants and undesirables. It’s working-class white men and college-bound suburban kids too.

There are 8,173 Walgreen’s locations filing 894 million prescriptions a year, and that big record-breaking fine doesn’t look so big up against $77 billion in sales a year. CVS does $140 billion a year, filling one-third of all U.S. pharmaceutical prescriptions. In a country of 319 million, there were 259 million opiate-painkiller prescriptions written last year. There were 47,000 lethal overdoses in the U.S. in 2014, almost 30,000 of which were prescription painkillers and heroin. Some 94 percent of heroin users told researchers that they got into heroin because the pills they started on became too expensive or too difficult to find. Heroin was cheap and plentiful. How do we keep up with all those pills? Where do they go? Somebody knows. It’s time we address this rapidly growing health concern head on.