Brace yourselves. We’re about to lift the curtain of Southwest Florida’s sunny facade and enter the chaos of heroin addiction, a crisis born out of the opioid prescribing frenzy of the ’90s, the pill mills of the 2000s, the foresight of the Mexican drug lords, and the too-late realization that the supposedly safe OxyContin, Vicodin, Percocet and their cousins were in truth very, very addictive. By the time policymakers cracked down, dealers had stocked up on heroin—the illicit head of the opiate family—and were ready to satisfy the crushing need for relief.
Heroin is today’s crack cocaine crisis. It’s everywhere, grabbing attention on campaign trails, headlining media reports, dominating discussions in treatment centers and law enforcement offices. A new war on drugs.
Nationally, the Centers for Disease Control and Prevention reported a 63 percent increase in heroin usage between 2002 and 2013. In Florida, the state medical examiner reports that occurrences of heroin in autopsies jumped 125 percent between 2013 and 2014.
Southwest Florida hasn’t been spared: EMS calls, ER visits and deaths involving heroin are all up—not to the extent they are in places like New Hampshire, where the state medical examiner called heroin addiction the “Ebola of Northern New England”—but trends are alarming nonetheless.
“We’re all scared to death,” says Brenda Iliff, the executive director of Hazelden Betty Ford of Naples.
The Collier County Sheriff’s Office busted a major drug ring last fall, seizing $2.6 million worth of heroin and arresting 17 traffickers. The victory was sadly short; new suppliers have since stepped up to take their places, says Lt. John Poling, who heads the vice and narcotics bureau. In 2011, his agency had arrested two people on heroin charges; by late 2015, deputies had logged 62 arrests.
Red flags like those had waved vigorously enough that Melanie Black, the executive director of Drug Free Collier, convened a heroin task force last fall. “They were shocked,” Black said after community leaders saw the totality of heroin-related data. One figure: The use of the overdose reversal drug Narcam by Collier EMS leapt 61 percent between 2014 and 2015. Another: Calls for EMS services related to heroin and other opiates increased from 11 in 2014 to 38 in 2015—a relatively small number but representing a 200 percent rate of increase.
Lee Memorial Health System’s emergency departments saw 15 heroin cases in 2010 and 121 in 2014. On top of the 2014 figure were another 165 cases of opium poisoning.
In Lee, Collier and Charlotte counties, 47 people died as a result of heroin use last year. An additional 346 deaths were related to opiate pain pills.
“Heroin has such a strong effect on the pleasure circuitry of the brain. It will almost instantly overcome the brain to want it more and more and more,” says Rosemary Boisvert, the assistant vice president for residential care at SalusCare, Lee County’s primary treatment center. Of the 34 people in residential care that December morning, 10 had sought help primarily for heroin addiction.
The recovering addicts quoted above were not hard to find. They represent the socioeconomic spectrum, men and women, educated and not, victims of childhood abuse and drug-addled homes, honors students born to attentive parents. All were anxious to warn others against following their paths. Opiate withdrawal, they say, feels like dying.
To understand how we got into the heroin mess, let’s start with one of them, 35-year-old Michelle Johnson, whose story shows one common trajectory from occasional pain pill use to a full-blown heroin addiction.
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"You literally feel like you're dying. It's the flu times 100."—Michelle Johnson |
Michelle is sitting on a couch in the Transitional Living Center, SalusCare’s residential program for recovering addicts, comfortable in jeans and a T-shirt, a morning off from her job at a nearby Dunkin’ Donuts.
She grew up in Naples, an honors student, Miss Goody Two Shoes, she says, ruefully. Nothing in her childhood predicted adulthood addiction. Her dad wasn’t around as much as she would have liked, but her mother was her rock—attentive, nurturing, loving.
Graduation brought a burst of rebellion. Michelle smoked pot and tried ecstasy. She got pregnant in the year between high school and her intended enrollment in college. She quit using anything that could hurt her baby, a girl.
“After I gave birth, my doctor gave me my first prescription of Percocet,” Michelle says. She assumes the pills were part of standard obstetric care at the time and didn’t think anything of taking them. But she noticed something. “I liked them right away.”
From then on, when she could, she’d take a pain pill, offered by friends or family who didn’t see the harm in prescription sharing. A doctor at one point wrote her a post-surgery order for Percocet. Friends and family cautioned she was going through too many.
“Pain pills for me, and part of the reason I liked them, was they gave me energy. I could do whatever,” she remembers. “I would clean the whole house from top to bottom—to the point where I was color-coding the closets.”
She was drinking, too, especially as her long-term relationship with her boyfriend, a heavy drinker, deepened and then grew troubled. The pills became her “best friend,” her companion during his long absences, the things that gave her the “backbone” to stand up to him.
Michelle’s doctor cut off her Percocet. But her brother introduced her to Roxicodone, an instant-release form of oxycodone. First she took them by mouth, then she snorted them, then she shot up.
“I was making 50 grand at my job. I had a brand-new car. I had basically everything I wanted. I was living in an absolutely beautiful house on three acres—all the things little girls dream of,” she says. Within months, all of that was gone.
Michelle fell into a cycle of rehab and relapse, each stumble progressively worse. She wiped out her mother’s bank account. She went homeless. She swapped sex for drugs or money. That’s the insidiousness of heroin and other opioids—they’ll push their users to do anything to keep from going through withdrawal.
“You literally feel like you’re dying. … It’s the flu times 100. You don’t sleep—I literally would be up for days,” she says. “You think: What can I pawn? What can I trade? What can I do to make this feeling go away?”
Michelle gave birth to a baby boy—in jail where she was being held for back-to-back arrests for driving on a suspended license. She never took her son home; friends adopted him and promised to keep her in his life. Her teenage daughter went to live with another friend. They haven’t spoken in two years. “That’s where I have so much guilt,” she says.
The death of her mother, a depression deeper than anything Michelle had ever felt, a growing reliance on heroin and the realization that she risked forever losing her kids compelled her to take action.
“I just up and left. I made the decision I was going to come up here and get clean and I wasn’t going back until I was,” she says. Heroin’s grip is finally loosening.
Today’s heroin mess was 20 years in the making. Dr. Aaron Wohl, an emergency physician at Lee Memorial Health System, has studied the opiate issue from its roots and wants the medical community and the public to understand its startling history, and reconsider how we manage pain.
Today’s opiate craze traces back to the 1995 FDA approval of Purdue Pharma’s OxyContin, Wohl begins. Purdue, he says, enlisted a cadre of well-compensated physicians to spread the gospel of Oxy’s wonders, vouch for its safety and distribute starter packs among doctors. (Purdue’s top executives would later plead guilty to criminal charges of misleading the FDA, doctors and patients about the risks of OxyContin addiction and abuse.)
To be fair, pain had been undertreated in the United States, particularly in disadvantaged communities, according to numerous government and medical reports. Fast-acting opioids held the potential to relieve vast suffering. A recently released analysis of National Health Interview Survey data suggests that some 25 million American adults experience chronic pain.
But pharmaceutical marketing efforts went to the extreme, says Wohl. Purdue and other firms embedded the idea that patients should be pain-free, inventing “this epidemic of untreated pain.”
Professional pain management societies jumped on board. By 2001, The Joint Commission, the nation’s primary accrediting agency for hospitals, began considering how hospitals assessed and treated the new fifth vital sign: pain. Medicare started linking hospital reimbursement, in part, to patient satisfaction scores, likely to be lower among uncomfortable patients.
Prescriptions skyrocketed. In 2012, doctors wrote 259 million of them, enough for every adult in the United States to have a bottle, the CDC reports.
“Probably around 2009 is when alarm bells started going off,” Wohl says. “The problem was physicians were pressured; they were afraid not to treat pain. These chronic pain patients were coming into the emergency department as a repository to fill their prescriptions.”
Three years ago, Wohl led the charge to write new guidelines regulating opioid use in Lee Memorial emergency departments. There are eight tenets, including one that gives physicians the right to deny medication when they can’t pinpoint an exact source of pain, such as a broken bone or tumor.
That effort alone won’t solve the opioid problem, but it’s one important step—and one significant message from a subset of the medical community.
Rich, a 26-year-old man from Fort Myers seeking treatment at the David Lawrence Center in Naples, can attest to the pervasiveness of the pills.
“I lived on the East Coast for a while. Pretty much on every corner there was a pain clinic. There were trucks ready to do MRIs in the back. … There were people making fake MRIs, copying them, Photoshopping them and putting your name on them,” he remembers. “If you couldn’t afford the doctor, there were people willing to pay for it for a cut of your prescription.”
Rich, who asked not to use his last name, sits in a small, sparse office in the residential center where he thinks—he hopes—he has finally confronted his addiction. He’d been born to drug-addicted parents. Substance abuse has chased him his entire life.
He remembers, too, what happened in 2011 when the state implemented its prescription drug monitoring program, shut down the pill mills, clamped down on the doctor shopping.
“That’s when heroin started coming in. It was cheaper. The high was more intense and lasted longer,” Rich says.
On the street these days, a prescription pain pill sells at $1 a milligram—about $30 for a typical 30 mg Roxicodone tablet, says Poling of the Collier Sheriff’s Office. A one-tenth-gram bag of heroin is about $20.
Even before the new state policies, Mexican cartels had been ramping up heroin production—cultivating some 10,500 hectares in 2010, according to the White House, and increasing yields by some 50 percent in 2014.
If opiate overdoses were bad, the switch to heroin has been devastating.
“The only thing I cared about was making sure I wasn’t gonna be sick and getting the next one. That’s all I could think about. It consumed my whole life,” Rich says.
In spite of it all, Rich can at least reflect on his experience and imagine a new future. In the last five years, he’s lost 10 friends to heroin.
Of all the illicit drugs, the opiates are particularly hard to beat. Heroin, oxycodone and related drugs bind to opioid receptors, a kind of protein in the brain, spinal cord, gastrointestinal tract and other organs. They reduce the perception of both physical and emotional pain, explains Nancy Dauphinais, the clinical director of the David Lawrence Center’s Crossroads Substance Abuse Services program.
Users go years without feeling so much as a headache, a menstrual cramp, a muscle pull, she says. When the body begins to clear the drug, enflamed nerves come alive, a terrifying experience for people who’ve been numb for all that time.
“People put this nasty stigma on heroin like it’s this horrible, dirty drug, but it’s the same stuff they are putting in the (pain) pills. People don’t realize that,” says Luke, a 25-year-old man from Bonita Springs, who is also seeking help at SalusCare’s TLC.
He says he comes from a solid Christian family, went to private school, did well, wanted for nothing.
But he liked to party. By his teens, he was using alcohol, Xanax and other recreational drugs. Opiate use started at age 20 following meniscus surgery. After his legal prescription ran out, Luke sought the pills by other means and then switched to heroin. He flips through his cell phone and finds a picture of himself, gaunt and vacant-eyed. He’s gained 40 pounds since going into rehab—and he’s not that big of a guy now.
He was anxious to tell his story because he wants to warn others—about the dealers who cut heroin with other drugs, including the deadly painkiller fentanyl, about dirty needles, about the crimes and arrests that accompany use.
Luke sports a scar on his upper arm, the remnants of an infection so severe it nearly cost him the limb. He has hepatitis C. He’s lucky doctors caught it before it started attacking his liver. He’s lucky too, Boisvert says, that he didn’t contract HIV. A number of her patients of late have tested positive.
In policy circles, there’s much debate over how to treat heroin and other opioid users—whether to invoke the get-tough incarceration policies of the ’80s and ’90s or to shift resources to treatment. Part of that debate, frankly, is due to the changing face of addiction. The prescription drug and heroin problem is not relegated to the inner cities but has reached into suburbia, into well-off families like that of Luke or Melissa, a St. Louis native now living in Naples after completing treatment at Hazelden.
She told her story on Jan. 4, a celebratory day for her—the fifth anniversary of going clean. Her cell phone had buzzed all morning with congratulatory messages.
“My mother does not drink. My dad drinks occasionally. They were very present. They are known in St. Louis,” she begins. She’s impeccably styled, dressed to go to work at Abuse Counseling and Treatment in Fort Myers where she is interning as part of her graduate studies in counseling. “I never asked for anything. We lived in a nice home in the suburbs.”
She started experimenting with drugs at 13. At 15 she did cocaine for the first time. If you ask her why, the reasons are complicated: deep worries over what other people thought; a vague feeling of not fitting in; a mind that never stopped working; a compulsive need to please people and to fix their problems; her mother’s illness during Melissa’s teen years; the sense that she didn’t have a voice, a say, or a distinguishing quality that made her unique. The drug use—good girl gone bad—somehow set her apart.
“The power of voice and speaking and telling the story is really important,” she says, her reason for doing so now, for delving into a career in counseling that will help others like her.
She snorted cocaine and then heroin. She left one university because of the use, but completed a bachelor’s of fine arts in dance at another, near her parents’ home. For a long time, she lived a double life: presenting herself as a student, a dance teacher, an employee in her father’s insurance and benefits firm, all the while getting high at night and on weekends.
“I had the office next to (my father). I would be giving presentations to CEOs and then at the same time having to go into the bathroom to use,” she remembers. “The lines were getting blurrier and blurrier, and they were starting to cross over.”
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"I want to plant those seeds of wisdom that were planted in me."—Stephanie Wabalas |
Addicts will tell you they won’t get well until they battle the demons that compelled them to pick up in the first place. Those could be the feelings of insecurity Melissa experienced or the chaos of Rich’s childhood or the scars of abuse that Stephanie Wabalas carries.
Stephanie, 26, is a bundle of energy, a bright light at the TLC in Fort Myers where she sought help shortly after moving to Southwest Florida. She knows dark times: a divorce prompted by her father’s sexual abuse of her half-sister; beatings by her brother so horrific that she can point to a dent he left in her skull; the death of a beloved grandmother; molestation by another child who’d been a sexual abuse victim herself.
She announced her homosexuality in the seventh grade (today she identifies as transgender) and life at her tiny, rural Connecticut school fell apart. “I got pushed off the school bus. I was bullied constantly—the crazy lesbian. I got ‘fag’ written on my locker every day.”
She turned 18, moved to Tennessee, met a girl and fell in love. The girl identified herself as straight (she later had two children whom Stephanie helped raise) but moved in with Stephanie regardless. She was an opiate addict. It was the start of a tumultuous, heartbreaking nine-year on-again, off-again relationship filled with betrayals, emotional abuse and lots of drugs.
“I started snorting and instantly fell in love. All the emotional pain and everything is just gone.”
At 19, Stephanie got clean, joined the Army and settled down for what she hoped would be a career. She shattered both hips instead and got a medical discharge. She reunited with the girlfriend in time for the birth of the woman’s second child.
“I was depressed as I could be, but I kind of had what I always wanted—even though it wasn’t true—that I felt I had a family,” says Stephanie, who cared for the infant and her older brother. It ended when the girlfriend’s husband came home and she was forced out.
Life spiraled for years—more bad relationships, more drugs, an extended period of sobriety that ended when the troubled girlfriend bounded back into her life. This time, she’d called Stephanie from Cape Coral. Within two months of reuniting, Stephanie had relapsed and turned to SalusCare.
Here is why recovery is so hard:
Every Stephanie, every Michelle, Luke, Melissa and Rich has to dump his or her whole life out onto the table, examine it piece by piece until they figure out what’s broken and how to fix it. Stephanie lived five years clean. But it’s not until this rehabilitation stay that she faced her wounds and started figuring out how to heal them.
In the process, recovering addicts start to identify the gaping blank spots in their lives—all the growing up that’s supposed to take place in their teens and early 20s that never happened.
“I was a kid,” Melissa says. “I was 31 years old on the outside. On the inside I was a 13-year-old girl.”
Aside from the psychological, they are dealing with very real physical problems.
Heroin triggers long-term changes in the brain. A new study in the Journal of Neuroscience Research detected neurologic anomalies even three years into abstinence.
“Mentally,” says Rich a month into his recovery, “I’m still foggy from the drugs.”
None of this is cheap: At SalusCare, detox costs $800 a day; a residential stay costs $300 a day or a program fee of $8,400. At the David Lawrence Center, residential treatment can cost up to $16,500 for a 28-day stay (although treatment length varies according to need). Both organizations work with insurers and offer discounted rates to patients who qualify. Both also receive government funding.
The cost to incarcerate someone in Florida, the fate of plenty of addicts for the drugs themselves and for related crimes, is $49 per day or $18,000 per year.
There are some bright spots in this new war on drugs.
Wohl and his colleagues are seeing fewer opiate-seeking patients in the emergency room. Physicians, overall, he says, are re-thinking the use of opioids, armed with mounting research about their harm and their ineffectiveness when taken long term. Doctors are starting to push for alternatives to medication, such as physical therapy, a benefit that insurance companies tapered off years ago when OxyContin hit the market.
A new study by Johns Hopkins University researchers suggests that 1,029 fewer people in Florida lost their lives to prescription painkiller overdoses over a 34-month period than would have if the state hadn’t cracked down on the pill mills and doctor shopping.
And some experts believe addiction rates will taper off over time as prescription drugs, the gateway to heroin, grow ever more expensive and harder to obtain.
“We want to attack it before it gets any higher,” says Black, the Drug Free Collier director, referring to the multiagency Heroin Task Force.
Treatment is evolving, too. Some facilities, like SalusCare, emphasize abstinence and are tailoring non-medicinal approaches for their patients. Others are seeing good results in medication-assisted rehabilitation programs.
Hazelden launched a Comprehensive Opioid Response program in 2013, combining 12-step therapy and counseling with the opiate-blocking drugs buprenorphine and naltrexone, which help ease cravings. Nationally, Hazelden patients on the program are staying in treatment longer and are more likely to return to residential treatment if they relapse.
Dauphinais at the David Lawrence Center is hopeful that an extended-release form of naltrexone, called
Vivitrol, might help more addicts turn the corner. The medication is administered in the form of a 30-day shot.
“We’re seeing a growing availability and use of it to help folks,” she says. “Individuals report fewer cravings, they report fewer days using drugs or alcohol, and they report being more successful in their treatment.”
The drug is expensive, some $1,400 per injection. State policymakers, however, think subsidizing that cost is cheaper than subsidizing treatment or jail and has been trying to make the treatment more accessible for more people.
And what of the recovering heroin users themselves?
All are optimistic—though tremendously aware of the precariousness of their situations.
Melissa is in a long-term relationship and enjoying the company of her partner, his children and grandchildren. She’s nearly done with her master’s degree. “I don’t make any excuses,” she says of her college work. “I don’t care about fitting in. … I don’t care about being the popular one or well-liked. I care about being kind and loving and available.”
Stephanie has received a housing voucher for veterans and is moving into her own apartment. She’s become active in a local church and bonded with congregants as well as the many others who’ve helped her achieve sobriety. She intends to give back. “I want to plant those seeds of wisdom that were planted in me.”
Luke is not rushing his stay at the TLC. Drugs dominated his life for 10 years, and he has a lot of catching up to do. “I missed a lot of discovering who I am and what my hobbies and likes are. I am basically a blank slate, starting from scratch on everything. That’s kind of scary, but it’s exciting at the same time.”
Rich admits to being nervous, but he’s making solid plans. More than anything, he wants to build a relationship with his 6-year-old daughter. His whole life has been about dysfunction; he’s ready for some stability. “I’ve wasted too many years doing this.”
And Michelle, she is easing her way back into life. She has begun a letter to her daughter, tearfully, searching for words that might heal. “I lost myself. I lost my kids. I lost my mother. It would have been so easy to continue going on that same path—I was so hopeless, but I knew there was something better and I truly wanted it.”
These stories are reasons to cheer, but let’s remember the stark truth: Stephanie alone has watched a dozen people quit treatment during her stay at SalusCare. The drug houses, she says, are just around the corner. Rich had been clean 13 months before a relapse; earlier in his life, Luke quit so many times that he “quit quitting.”
These are early battles in the heroin war.
