Heroin Hits Home

By the time he was 35, James (a pseudonym) was living in a Shadyside home worth $500,000, driving an Audi A4 and earning six figures. He was seven years into his job as a recruiter for a technology company. His wife was from a wealthy family, and they traveled often. “Every six weeks, we were off to a different place: The Netherlands, Tahiti, Mexico,” he recalls—a good life for a college dropout.

At age 19, James had bought a one-way ticket to Los Angeles. His years trying to “make it” in Hollywood were mostly fruitless, but he retained an actor’s charm and that took him a long way. Upon returning to Pittsburgh, James worked as a kitchen fixture salesman at a mall department store. There, he ran into the mother of a high school girlfriend. She’d always liked James, and he convinced her to approach her husband about a job at his tech consulting firm. The next day, the man came to the store and offered James a position. He sent James to a tailor, paid for four new suits, and paired him with a vice president for recruiting. James’s new job was seeking software engineers and developers and connecting them with tech companies. He was good at it, personable, handsome and able to deliver well-rehearsed lines with seeming sincerity.

His days were busy—but James never scheduled anything in the morning because that’s when he met with his heroin dealer. “I never saved enough for the morning, so I would wake up shaking,” he says. “Just seeing my dealer’s car got me excited.”

During his L.A. days, James started taking illicit prescription painkillers, which were spread around the film industry as readily as headshots. “Vicodin was my drug of choice,” he recalls. “Two or three Vicodin and I would be on point for the afternoon, talkative and friendly”—a necessity for a struggling actor who fit in auditions before and after shifts behind a receptionist’s desk at a gym. James developed a knack for finding pain pills, a skill he carried as he relocated. “They were very easy to obtain in social situations or at a bar. Western Pennsylvania has a very elderly population and someone’s father was always getting hurt at the mill. There are a lot of pain pills.” He befriended anyone at work who’d had an injury.

On Sundays, he and a friend drove to estate sales. Affable James would distract the realtors and family members while his friend ransacked the medicine cabinets. His wife never knew, he says. “We addicts tend to hide things well.”

By his cushy mid-30s, James was swallowing 200 milligrams of OxyContin a day at a cost of about $1,000 a week. He faced a hard truth: Heroin would be cheaper. He could stave off withdrawal by doing seven “bags” (0.1-gram packages) a day at about $10 a bag, cutting costs by half. Before he got home delivery, James frequented a notorious heroin bar in Garfield and parked his car in Homewood and the Hill District. The dealers knew what a white guy in an Audi meant.

A gathering crisis

U.S. heroin use jumped 63 percent between 2002 and 2013, according to a July report from the U.S. Centers for Disease Control and Prevention. Driving this leap were increases among groups that previously had low rates of usage: women, high- and middle-income earners and people with health insurance. The strongest factor predicting heroin use was a preexisting dependence on painkillers: the legal, synthetic cousins of smack, narcotic opioid analgesics that have much the same effect on the body. Four out of five new heroin users had been pill poppers, and the new, growing ranks of heroin users resemble James: white-collar professionals weaned from brand-name painkillers.

Overdose fatalities have quadrupled since 2002, and Allegheny County has kept pace. Averaging 58 a year in the ’80s and ’90s, OD deaths in the county shot up as the millennium turned, reaching 100 in 1999, catapulting to 210 in 2002 and jumping to 308 in 2014. The drug most often involved in local deaths is heroin, found in 50 percent of OD autopsies, according to the Allegheny County Coroner’s Office, but 60 percent involve more than one substance. Alcohol, cocaine, alprazolam, morphine, oxycodone and oxymorphone round out the top seven. Your average Pittsburgh overdose involves a cocktail of street and prescription drugs, washed down with booze.

This OD rate was once unfathomable to the city’s addiction specialists.”I remember back in the ’90s, we all had an emergency meeting because there was a rash of nine deaths,” says Michael Flaherty, Ph.D., clinical psychologist. “Now, that’s an average month.” Flaherty, who last year co-chaired the local U.S. attorney’s task force on overdoses, says the spikes in addiction and ODs are a direct result of the increasing supply of opioids in the form of pharmaceutical painkillers.

“They’re basically everywhere,” says Aaron (a pseudonym), a 24-year-old rehab patient from a Pittsburgh suburb. “You can get them from kids who hang out at the mall. If someone in school got injured [playing sports], we’d all ask, ‘Ooo, what’d you get?’” Seventy percent of painkillers taken illegally are scored through family and friends, according to the CDC. Aaron took them recreationally throughout his teens, until switching to heroin. “I always told myself I wouldn’t put a needle in my arm, but that didn’t last.”

Because they’re so intertwined with banal suburban landscapes—sold at CVSs and swallowed by family members with bad backs—painkillers seem like manageable recreational drugs, says Flaherty. “It starts out with a desire to get high, but most people do not understand how powerful these drugs are. It becomes reinforced and you have to take more to get high and you become addicted very quickly. At $40 a pill, you can’t afford it, so you turn to heroin.”

And today’s heroin is a lot stronger than the stuff that killed Janis Joplin and acted as a songwriting muse to Lou Reed. The Asian-imported variety of the ’60s and ’70s was about 10-percent pure. The rest was filler, like starch. Because of this, the user had to inject to get a high, which (combined with the rise of crack cocaine) diminished the popularity of heroin during the age of AIDS. “So the Mexican cartels, being the good businessmen they are, introduced a new product,” says Dr. Neil Capretto, medical director of Gateway Rehabilitation Center, a 345-bed facility in Aliquippa. “They created purer heroin and said, ‘Here, you can snort this.’ ” The average purity of heroin on the street is now 31 percent, according to the U.S. Drug Enforcement Agency, and batches with a purity of 80 percent are out there.

Potency levels have been reinforced by market forces, Capretto says. “It has to be that strong to compete with prescription painkillers.”

However, this has not made heroin more expensive. Improved production and distribution have actually reduced the retail price for a pure gram from $3,000 (in current dollars) in 1983 to about $500 in 2012, according to the DEA, making it all the more accessible.

Just as opioid addiction has spread through the social brackets, so has it spread geographically. Drug overdoses were rare in the four counties surrounding Allegheny throughout the 20th century. Years could go by without an OD. But in 2013, Butler County experienced six, Beaver County nine, Washington County 19 and Westmoreland 21.

Dr. John Six, medical director of the Greenbriar Treatment Center, says the makeup of patients at the Washington County facility has changed in the last 10 years. It used to be 50-50 between alcoholics and opioid users, but now the latter comprise two-thirds. “You can get heroin anywhere,” says Six. “It’s cheaper than wine and more available than beer.”

Big business

Once the drug of rock stars, strung-out Vietnam vets and skid row dwellers, heroin has crossed into the American mainstream, and the pharmaceutical industry built the bridge.

Addicts’ lives tend to collapse along well-worn patterns. This is why Capretto was startled in 1999 when a patient came to Gateway with a story that was new to him. “He told me he couldn’t stop taking prescription painkillers,” recalls Capretto. “I thought it was the strangest thing.”

Capretto’s bafflement was understandable. Purdue Pharma had introduced OxyContin, the first blockbuster pain medication, in 1996. Past narcotic analgesics had just filled a niche market, prescribed mostly by oncologists for cancer patients. But Purdue marketed OxyContin for general chronic pain and had to convince physicians to prescribe a narcotic, twice as potent as morphine, for migraines and hernias. In the first six years, the company spent $120 million (in late ’90s/early ’00s dollars) on a marketing campaign, mostly promoting the drug to physicians, according to a report from the U.S. Government Accountability Office. Purdue enlisted advocacy groups for pain conditions and, by 2000, amassed an army of 671 sales representatives. Often repeated in this informational blitz was the “fact” that OxyContin had an addiction rate of less than 1 percent, a claim never verified by the Food and Drug Administration. So not only was OxyContin new, everyone “knew” it was safe.

Nonetheless, “two weeks later, someone came in with the same problem,” recalls Capretto, “and then another one, and I knew we had a very serious problem.”

He and contingents of addiction specialists began addressing the problem at medical conferences. They were rebuffed by the company’s reps, says Capretto. “They told us, ‘To you guys, everything is addiction.’”

Meanwhile, the waiting rooms of Capretto’s peers in pain management and general practice were abuzz with sales reps, gifting notepads and golf balls bearing the OxyContin logo. Capretto recalls the campaigns were particularly intense in western Pennsylvania, home to an older population, many of whom had injuries from factories and lumber yards. “They knew where to go.” Purdue’s sales representatives were divided into territories of up to 140 physicians, called on three or four times a week. Its list of contacted physicians is a tightly held secret, and multiple investigations and lawsuits haven’t pried it from the company’s servers.

In a statement from a spokesperson, Purdue stated that the company “accepted full responsibility for the actions some of its colleagues took during a period that ended in 2001,” adding, “Since then we’ve dedicated ourselves to combating prescription drug abuse, most significantly by formulating OxyContin and other pain medications with abuse-deterrent properties.”

Doctors’ prescribing habits for pain changed profoundly during the ’90s, bringing a slew of painkillers, new and old, into common use in American households. Since 1999, prescriptions have increased 400 percent.

Despite the universality of pain, not all places have similar rates of painkiller prescriptions, the CDC found in 2014. The Southeast and Midwest have considerably higher rates. Pennsylvania ranks in the middle of total prescribing of painkillers, but in the top 15 of two particularly powerful kinds: long-acting/extended-release opioid pain relievers and high-dose opioid pain relievers.

For patients with pain issues, this seemed like a godsend—even if they didn’t know what they were getting themselves into and, in some cases, neither did their physicians.

Jennifer’s story

In her late 30s, Jennifer Matesa was clobbered by fibromyalgia, a condition affecting the muscles and soft tissues and causing chronic pain and fatigue. She had suffered from migraines since age 14, and had taken Vicodin and codeine for them, but this was something worse. She spent days in bed, writhing in agony. “If I wasn’t in pain, I was living in fear of the pain.”

She had a young son, a few undergraduate college writing classes to teach and a job composing policy briefs for the health nonprofit Robert Wood Johnson Foundation, and she was at the mercy of pain.

So she went to a pain clinic. The physician first prescribed hydrocodone. When that didn’t adequately relieve her pain, he moved her through an escalation of opioids: morphine, OxyContin and lastly fentanyl, a drug used by surgeons and army medics since the ’60s. Jennifer took it through an epidermal patch.

She felt good, active. “One of the great misconceptions about people on pain medication is they just nod off,” she says.

She didn’t realize how much she was taking until her dad was in the late stages of cancer. He weighed 225 pounds and was prescribed a fentanyl patch that released 25 micrograms per hour. Jennifer, who weighed 120 pounds, was absorbing 100 micrograms per hour.

After five years on the patch, its effects began to wear off. She started wearing more patches than she was prescribed and tampering with her prescriptions, changing dates to make it appear she was due for a refill sooner than she was (an act that could have landed her in a federal prison).

Seeking a way to avoid withdrawal, Jennifer got in her Subaru one day and drove to Homewood looking for heroin. Unlike James, she didn’t have a nose for the drug scene. She returned to her Friendship home, empty-handed and disgusted with herself. She was sure if she didn’t stop, she would end up in jail or a body bag. “I could have overdosed many times.”

She considered confessing her medication abuse to her doctor, but he dealt with addicts by sending them to the Western Psychiatric Institute and Clinic to go cold turkey, a nightmare scenario for Jennifer. This showcases another issue of the mass prescribing of narcotics: The doctors trained to deal with pain are not the same ones trained to deal with dependence. A study in The Journal of Pain Research found that only 10 percent of medical schools offer a class in addiction. Physicians know how to get people on pills but not off of them, and no-tolerance policies such as that of Jennifer’s doctor partially come from self-preservation. Doctors have faced discipline from employers and medical boards, and even criminal charges, for prescribing to addicts.

Finally, Jennifer sought the help of a detox specialist. For $700 out of pocket, he weaned her off fentanyl with the help of Suboxone. In other words, she hired a doctor to undo the work of her doctor.

Searching for solutions

One day in January of 2014, three overdose victims were wheeled into the Allegheny County Coroner’s Office. The next day, four more came in. In a week’s time, 22 people in the region had been killed by a “brand” of fentanyl-laced heroin with the street name “Theraflu.” (Dealers sometimes create cutesy names for particular batches; this one apparently copied the name of the popular flu medicine, playing on the flu-like symptoms of withdrawal.)

Mixing high-octane narcotics is often the deadly end game for addicts, says Capretto. “They use heroin just to push back against withdrawl symptoms. They mix it with something else to get high again.” That can break a cardiovascular system that has adjusted to 15 bags of heroin a day.

After the “Theraflu” massacre, David J. Hickton, U.S. Attorney for the Western District of Pennsylvania, commissioned a task force to come up with public policy ideas to curb the death rate. Capretto and Flaherty co-chaired the group.

Unsurprisingly, the group’s report, released last fall, proposed no single solution. It has more than 50 ideas, including “town hall” meetings in places affected; an increase in prescription “take backs” where people can turn in unwanted medication for disposal; and overdose education programs in jails and probation offices, which see an influx of at-risk people.

“All solutions have to be community-based,” says Flaherty. “You can’t expect state or federal funds to be there.”

Noting that “physicians have played a significant role in the recent epidemic of overdose deaths,” the report calls on the area’s hospital networks, such as UPMC and the Allegheny Health Network, to take the lead in training physicians about painkillers.

The report also suggests a local database of overdose deaths, which police and public health officials can use to foresee another spate like “Theraflu.” “Our data [about overdoses] is generally two days late,” says Dr. Karen Hacker, director of the Allegheny County Health Department. “I’d like to get minute-to-minute availability.” To this end, the department is creating a program where the county’s emergency dispatchers would file daily reports.

Allegheny County is fortunate to have a coroner’s office that does its own lab work, Hacker says. This shaves a few days off the forensic process. But she’d prefer the coroner’s team not be the one to discover a deadly batch. “If they do, we’re already late.”

Hacker has issued a county-wide standing order allowing anyone to purchase the anti-overdose prescription drug naloxone (sold under the brand name Narcan) at a pharmacy. “It essentially means they can buy it with me as the prescribing doctor.”

A tool of ER doctors, the OD “antidote” is increasingly being carried by police and even the family and drug buddies of addicts. Currently, EMS workers in Allegheny County carry it, but city and county police officers do not. Hacker says the current obstacle is price. Naloxone nasal spray is $40 a pop and an injector costs $400.

Flaherty says these small public policy adjustments can lower Allegheny County’s overdose rate, but national reform of pain management, with improved training and oversight of physicians, is needed to return to 1980s numbers. “The number of overdoses is tied to the number of prescriptions [of opioids]. There is a direct relationship.” He says he is hopeful about new medication-free approaches to pain, such as electrical stimulation of the brain.

Aside from a brief relapse into Vicodin usage, Jennifer Matesa has been managing her pain without chemical assistance since her detox. (The setback was statistically likely; the National Institute for Drug Policy puts relapse rates at 40­–60 percent.) She attributes her success to a mix of nutrition, exercise, rest and meditation, and she wrote about her experience in the book “The Recovering Body.”

“At the time [before going to the pain clinic], I wasn’t paying attention to how much I was sleeping, what I was eating, whether or not I exercised. I had my son, my work, my big garden, and I just wanted to get everything done in the day.”

James’s landing wasn’t as soft. His switch to heroin kept costs down initially, but as his addiction grew, so did its price. At his peak usage, he spent $1,600 a week on heroin and various pain pills.

His downfall came from an affair with a coworker. His lover’s husband called their boss, and James was fired. Without his job, James couldn’t afford his habit. He got by selling belongings and running up tabs with his dealers, but as withdrawal symptoms set in, his only choice was rehab.

In late 2014, he entered a 21-day program at a halfway house for ex-cons. “This was not the rehab you’d find Robert Downey Jr. in,” he says. “We’re talking wife beater [shirts], shaved heads and prison muscles.” But it was the only one that would accept James the day he called; he couldn’t wait for another institution.

James’s post-rehab life is in stark contrast to the one he once lived. He lives with roommates he met in Narcotics Anonymous and works a few hours a week canvasing for a home repair company—on foot; he sold the Audi for drug money. Things with his former paramour are “complicated,” as he struggles to schlep to her home in the suburbs, and she’s become frustrated with his topsy-turvy life.

Looking back on his years of devouring opioids, he says his habit was partially fueled by insecurity. In his former world, “people were judged by what cars they drove, where they went on vacation. I always felt like I didn’t belong there. I wasn’t worthy. I got there by a fluke.”

Now when the existential dread brews, he has nothing to reach for (save his NA sponsor’s number in his phone) when before he could have popped an Oxy or shot-up a bag. “They call them painkillers because that’s what they do,” says James. “Whether physical or psychological, they kill your pain.”