Medicine Scrambles to Stop Opioid Epidemic
The drugs designed to eliminate pain are causing unimaginable suffering for a growing number of people.
Prescription painkillers, specifically opioids derived from the same plant opium comes from, are fueling the worst drug epidemic in recent history. The pills — and their cheaper and stronger illicit cousin, heroin — are killing more people each year than car crashes. One in every five drug-related deaths worldwide occurs in the United States.
And the crisis shows no sign of abating.
NBC10’s Digital Team spent five months investigating the issue of opioid addiction in the Philadelphia region and beyond. They discovered a generation of addicted people and a public health and law enforcement system ill-equipped to save them.
Officials are scrambling to find new ways to address the crisis as it gains attention after spreading into wealthy suburbs and rural pastures and killing more white users than minority users.
Armed with different approaches and increasing public support, officials are beginning to wage a new war not on drugs, but on addiction.
“Save my kids!” pleaded Cathy Messina as she ushered a female police officer through the door of her Warminster, Pennsylvania, home.
It was late Wednesday evening on Feb. 24, 2014, and the mother of seven had just found two of her sons, 21-year-old Dave and his older brother, overdosing.
The officer was the first to arrive. Cathy and the rest of her family were told to wait outside.
Some 30 minutes earlier, Cathy was worrying about Dave baking brownies for his sister’s service corps group. He volunteered to make them, but Dave was a known procrastinator. When she didn’t smell the goodies in the oven from her home office, Cathy went to find him, stopping first at the closed bathroom where she knocked and yelled to see if he was in there.
Dave had been struggling lately. The handsome, brown-haired former high school athlete had a big smile and wanted to work in sports. But he had been arrested for heroin possession and skipped his court date. That landed him in the county prison for the night. The follow-up hearing was set for Friday.
Cathy and her husband, Chris, were working to get Dave into a treatment program. He had gone to a few consultations (or so he told his mom). She wasn’t sure he was ready for treatment. He told her he had another meeting on Thursday.
After checking the house, Cathy went back to the powder room. She knocked again. Still nothing. The handle was locked. Panic set in. She dropped to the floor and wriggled her fingers under. She screamed when they made contact with Dave’s arm.
Chris came barreling into the room and broke open the door. Dave was slumped over on the floor.
Cathy’s mind raced. Unsure of what to do, she ran to get her older son, who had battled a heroin addiction in the past. He’ll know how to help, she thought.
“I ran up the steps to go ask him what to do. As I just burst into his room, which I usually don’t do, he was also passed out on his bed on his back, and he obviously was overdosing also,” she said.
“Call 911,” she shouted to one of her daughters.
When the 911 operator was on the line, Cathy grabbed the phone.
“Both my sons, both my sons, they’re overdosing. It’s a heroin overdose. I know it is. You just need to get somebody here fast,” she told the dispatcher.
The medics took the boys to different hospitals, Dave to Doylestown and the other son to Abington. They told Cathy to go to Doylestown.
“When I got into Doylestown ER, I just heard the doctor say, ‘Time of death,’ and then I knew Dave died,” she said.
Cathy later learned Dave shot up pure fentanyl. A synthetic opioid used to treat severe pain, fentanyl is 30 to 50 times more potent than heroin. Between 2013 and 2014, it’s been linked to more than 700 deaths across the country when used alone or laced with heroin or other drugs.
“I know he was worried about his court date on Friday,” she said. “I think that he was so anxious about the court date on Friday that he figured, ‘Let me use one more time.’”
The other son, who survived his overdose, told them he and Dave did not know the other was using. Cathy’s never been sure if that’s the truth.
“When I tell parents to use your gut, your instincts, I should have used it a lot of times before that,” she said.
Since Dave’s death, Cathy created the Drug Addiction oVerdose Education (DAVE) group, named in honor of her son, to educate the public aboutr the dangers of drug overdose. Cathy and members of the organization train families about how to use naloxone, the overdose reversal drug . They also distribute emergency overdose kits, containing naloxone, to members of the public.
The facts are staggering.
- In 2014, more than 1,700 people died from drug overdoses in Southeastern Pennsylvania, South Jersey and Delaware, medical examiner reports show.
- Drug overdoses claim more men 19 to 25 years old in Pennsylvania than any other state in the country, according to statistics from the Centers for Disease Control and Prevention.
- Nationwide, more people died from drug overdoses than car crashes in 2014. Half of the more than 47,000 deaths involved the misuse of prescription painkillers.
- Federal health officials estimate nearly 2 million Americans over the age of 12 are currently abusing or dependent on prescription opioids.
- The U.S. Drug Enforcement Administration estimates the cost of abusing prescription drugs alone totals more than $53 billion annually.
People dying from overdoses as a result of abusing prescription drugs outnumbers those dying from heroin and cocaine combined.
“This is, I think, the fault of the medical system,” said Brian Work, MD, MPH, a hospitalist and assistant clinical health professor who teaches public health at Penn’s Perelman School of Medicine.
“Myself, I take some responsibility and I think my fellow physician colleagues have to take some responsibility for having been so free with opiates in the past that so many people were able to develop an unhealthy relationship with opiates,” he said. “And now that wave is crushing over into heroin.”
The epidemic is being fueled by people who are first getting hooked using a legal painkiller. Whether prescribed for an injury or stolen from a parent’s medicine cabinet, these strong tablets make chemical changes to the brain and spur dependency in short order.
Still, prescription painkillers are regulated. So when a user’s supply from a medical professional runs out, they may try to steal them or buy from a drug dealer. But that’s not cheap either — OxyContin sells for a dollar per milligram. A person in the throes of addiction could use at least two 80 mg pills in a day. At $160 per day, the economics are not sustainable.
The evidence shows if they don’t get sober or die, most users will eventually turn to heroin. And there’s no place better to find quality heroin than the City of Philadelphia.
Philadelphia is the heroin hub of the East Coast. The white powder form is smuggled into the city and surrounding suburbs from Mexico by El Chapo’s Sinaloa cartel and a few others from Colombia.
“Here in Philadelphia, we have some of the highest purity levels in the entire country at the retail level,” explains Gary Tuggle, special agent in charge of the Philadelphia Division for the U.S. Drug Enforcement Administration.
Purity levels, which determine how strong the drug is, run between 80 and 90 percent. Twenty years ago, the average levels were 3 to 8 percent. Strong demand and increased competition among drug dealers help keep the price down. A bag of heroin — typically one-fifth of a gram — costs $10. The high will last for about 20 minutes depending on a user’s tolerance.
“It takes hours to get up $10, and it takes two seconds to buy it, do it,” said Michelle Mcguire, a 40-year-old rail-thin blonde from Philadelphia’s Kensington neighborhood. She’s been using heroin for the better part of a decade. “As soon as you do it, you’re already worried about where the next bag’s coming from.”
Heroin users in the worst parts of their addiction want to stave off the painful effects of withdrawal. They’re also chasing the same feeling they experienced with their first high. They push themselves as close to the cliff of overdose as possible. Sometimes, they go too far.
More than 600 people died in Philadelphia from a drug overdose in 2014. Some died chasing a stronger high and others from tainted drugs.
Among the 66 other counties in Pennsylvania, Bucks County, made up of mostly well-off suburban towns, ranked third in deaths with 205.
Dave Messina, Cathy’s son who overdosed in the bathroom, was one of them.
WHY PEOPLE USE
Opioids are designed to mask pain. And starting in the 1990s, doctors began to regularly prescribe them to relieve acute pain brought on by physical injury and surgery. In addition to prescribed uses, opioids are also regularly misused to dull psychological pain: Fear, anxiety, loss, abuse.
And like other legal substances such as cigarettes and alcohol, prolonged use of opioids makes chemical changes to the brain’s pleasure center, teaching the body these substances are good and necessary.
“Our brains are wired to experience pleasure, particularly in the things that keep us alive. Food, for example, is reinforcing … Rather than eating for that pleasure, people start using … and it hijacks the system,” said Dr. Henry Kranzler, an associate professor of psychiatry and director of The Center for Studies of Addiction at the University of Pennsylvania.
The brain’s adaptation also results in a physical dependence. Don’t eat for a day and you develop a headache and become lethargic. Similar physical symptoms manifest, exponentially more painfully, when a person stops chronically using opioids.
“You don’t know what to do. Nobody wants to see their child suffering.” — Patty DiRenzo
“You throw up, you get…your bones jump out of your body. You get diarrhea. It’s just horrible. You get the anxiety to where you can’t sit still,” said Michelle Mcguire.
Sal Marchese, while going through withdrawal at home, told his mother and sister to cut his legs off because the pain was so bad.
“It’s like, you don’t know what to do. Nobody wants to see their child suffering,” his mother, Patty DiRenzo, said.
Fear of that withdrawal just reinforces use.
“You wake up and you want a cup of coffee and you want to eat breakfast. I wake up, I need a bag of heroin. I’ll worry about eating later,” said Mike Gellock, a 47-year-old who turned to drugs when his mother died in 2008. “Who wants to live like that? But we do because the drug tells us I’ve got to have the drug at all costs. It’s insane.”
BARRIERS TO CARE
Experts are increasingly agreeing that drug addiction is a chronic disease. Think diabetes, not pneumonia. You can’t go into a program for two weeks or a month and expect to be cured.
Yet that’s how care is largely provided. For drug addiction, there are more obstacles to quality care than any other widely diagnosed chronic disease: There’s not enough treatment. Treatment is hard to find. The onus is placed on the suffering person.
The care that is available often doesn’t last long enough because of a lack of funding — be that government funded programs or private insurance. The result: A cycle of relapse and disenfranchisement that further exacerbates the issue.
Even in Philadelphia, a city described as treatment-rich by officials, people have a one in 10 chance of getting the treatment they need, city officials estimate.
“If you came into the hospital with an overwhelming infection, never would anyone … allow me to treat that person with a little bit of antibiotics up front to save some money,” Dr. Brian Work said. “Yet at the same time, that’s the sort of thing that we often do with substance abuse and mental health issues out in the community.”
Work sees the disparity often. In addition to teaching public health, he’s chairman of the board at Prevention Point Philadelphia. The nonprofit, which started as a needle exchange 20 years ago, cares for 7,000 people a year through several programs including a health clinic, medicine-assisted drug treatment and a needle exchange.
“If you came into the hospital with an overwhelming infection, never would anyone … allow me to treat that person with a little bit of antibiotics up front to save some money.” — Dr. Brian Work
Prevention Point refers more people to drug and alcohol treatment than most other programs in the city. But before people even have the chance to get into treatment, they have an uphill climb.
Often, staff spend weeks working just to get people necessary documentation, like a Pennsylvania ID, so they can qualify for treatment. Then many have to wait again for a treatment spot to open. It could be an extra day or month.
“We all know that if you want to access treatment, the best time is when you’re asking it of me,” said José Benitez, executive director at Prevention Point Philadelphia. “In your motivational moment, if I can’t deliver that [care] within a couple of hours, I think it’s disabling.”
Michelle Mcguire was playing the waiting game this January.
“I’m tired of being tired,” she said.
On past occasions she’s sought help at often overtaxed hospital emergency rooms and urgent care centers where she was treated like “an animal.” After getting the opposite experience at Prevention Point, she’s pushing to get real treatment.
Prevention Point is helping Michelle get a copy of her birth certificate so she can request a state-issued ID. Without their help, she would have to navigate the confusing and difficult process on her own.
Prevention Point is working with the city to shortcut the process. Case managers assess people seeking care and then city social workers decide whether they can waive eligibility requirements. Under the project, a person without ID can get placed into treatment within as little as two hours.
But the fast-track program only operates for 12 weeks at a time. The city lends staff to Prevention Point and can’t dedicate them full time.
“Nobody has the resources to be able to do this consistently,” Benitez said. “Until we put a mechanism in place that adequately funds what’s successful, we’re going to continue to rob Peter to pay Paul.”
A FAMILY’S STRUGGLE
If Sal Marchese wanted to continue at his inpatient treatment program, he was going to have to cough up $10,000 a week, money he and his family didn’t have.
The 26-year-old was 14 days into his stay at a North Jersey treatment facility when funding ran out. They’d been through this before.
His mother, Patty DiRenzo, and sister, Blake Marchese Zetusky, would make exhausting rounds of calls to find openings at treatment centers. When they finally found a spot, Sal would go, but within two weeks, he’d be discharged because the insurance money dried up.
“You’d come home and spend the whole night calling all those numbers and nothing’s available. There’s no beds, no treatment, no funding,” Patty said.
But this time, Sal’s sixth, he was mentally ready for recovery. He wanted to stay. Sal wrote the state, pleading for more time. He called his insurance company. Both requests: denied. At the bottom of his discharge papers, staff wrote “high risk for relapse.”
There was a silver lining. The treatment center had set Sal up with a spot at an IOP, intensive outpatient program. Blake took Sal there the next day, promptly at 9 a.m. like they were instructed.
“I walked in and the lady said, ‘I’m sorry, there is nothing I can do for you. I don’t know why they put this on his paperwork,’” Blake recalled.
The woman said Sal would have to wait until Aug. 1 when they had additional funding. But it was only the middle of July.
“I said, ‘Well, what am I doing in the meantime with him?’ She said, ‘I don’t know. You’re going to have to call places.’ It was frustrating. It was upsetting. Just the look on his face. It’s hard,” Blake said.
Sal eventually got into another IOP but lost his battle with the disease three months later, dying of an overdose in Camden, New Jersey.
The struggles to get Sal care are an experience Patty, who went through treatment for stage four progressive breast cancer in the middle of her son’s addiction, didn’t have to endure when it came to her own medical treatment. She had multiple doctors. Hospital staff coordinated tests, chemotherapy and organized her medicine. They offered counseling.
She never had to make a call or beg for a chemo chair. She still gets follow up care. The juxtaposition angers Patty.
“Why didn’t that happen for my son?” she asked. “I survived stage four cancer, and my son died from the disease of addiction? No, something’s wrong with that.”
MAKE IT LOCAL
Dr. Bankole Johnson thinks the addiction treatment system is too complex to make a real impact. The programs aren’t good enough. There’s not enough coordination of care. It’s too hard for people to find help.
“Really, it’s a matter of blind luck and reputation to find the right place. A lot of people can’t find the right place. Even if they get to the right place, they may not get the best treatment,” said Johnson, chair of the Department of Psychology at the University of Maryland School of Medicine.
Johnson has worked with more than 1,000 addicted people and has been conducting research in the field for more than 20 years.
While people suffering from addiction often talk about going into rehab, he believes outpatient programs are the key weapon in this fight. They’re more practical, cost-effective, and, he’s found, more impactful — especially when they bring services right to people in their home communities.
“These are your your neighbors and these are your sons and daughters, grandsons, granddaughters, nieces, and nephews.” — Jim Kenney, Mayor of Philadelphia
“There might be a period of time whereby somebody should have a break from their environment, maybe a week or two,” he said. “Once it starts running 30 to 60 to 90 days, you have to ask yourself what is actually being treated.”
“You wouldn’t keep every person with diabetes in the hospital for a month or more,” Johnson says. So why do it with addiction?
Treating a person in recovery in their community offers them the opportunity to construct a sober life at home with a stable job and support structure.
Jim Kenney, mayor of Philadelphia, agrees. Forcing people to travel outside of their neighborhood for treatment is counterproductive for their care, he said.
“These are your your neighbors and these are your sons and daughters, grandsons, granddaughters, nieces and nephews,” Kenney said. “We need to get them help because they’re going to wind up dead or in jail.”
Prevention Point credits their ability to interface with so many people who rarely access services with being in the community where they’re needed.
“We have a little more credibility,” Work said. “Number one, we’re accessible, but it also shows we’re willing to come to them.”
Nationwide, on average, only 10 percent of people with addiction problems are able to access treatment. In Philadelphia, city officials say that number is closer to 30 percent, still leaving 122,000 people who need care. It would be impractical to build inpatient facilities to house them all.
“The patients that come to see us, most of our treatments are completely outpatient and intensive outpatient based,” Johnson said.
Treatment regularly doesn’t last long enough for people fighting drug addiction. Like any chronic disease, a lack of periodic care can lead to trouble again. In this case, relapse.
“If they didn’t follow up, and the symptoms of the disease come back, you don’t say that treatment didn’t work. You didn’t stay around to get continuation of that treatment,” said Dr. Neil Capretto, an addiction psychiatrist and medical director at Gateway Rehabilitation Center near Pittsburgh.
Devin Reaves is a licensed recovery clinician and runs Brotherly Love House, a recovery home for young men in Philadelphia’s East Germantown neighborhood. He knows how valuable long-term recovery care is.
The 33-year-old married father of a baby girl has been in recovery for eight years himself. He went through a progression of programs from inpatient to outpatient to sober living that he credits with making his recovery successful.
“I just tried to follow suggestions because early in recovery is a difficult time. There’s people that have been there and I thought it was important to listen to them,” he said. “Recovery is the greatest thing I ever did.”
The amount of care, especially extended care like long-term counseling and supportive housing, available to people seeking recovery is lacking.
Philadelphia has focused its efforts on building community programs to meet people where they live. There are 106 facilities in the city and immediate surrounding areas offering care. Sixty-one of them offer outpatient services.
“People recover in the community,” said Roland Lamb, director of Philadelphia’s Office of Addiction Services. “That’s the reason we put a lot of energy into building supports in the community, making communities stronger, so that they can become much more a support and much more of a protective factor for folks that are struggling with addiction.”
Reaves says the dearth comes down to poor funding. Recovery facilities don’t often get paid well to offer care. Poor reimbursements leads to shutting up shop or substandard hiring. Under-qualified staff leaves people in recovery with bad outcomes and more opportunities to relapse.
“Recovery gave me the life beyond my wildest dreams. I want to see everybody have the opportunity to do that, but I know the deck is stacked against them,” he said.
TREATMENT WITH DRUGS
If you received a cancer diagnosis and wanted to weigh the pros and cons of different treatment programs, you could quickly compare success rates and methods based on unbiased, industry-accepted standards.
People searching for drug addiction treatment don’t have that luxury.
“In my view, treatment programs need to publish, in some standard way, what their success rates truly are like so that members of the public can decide, ‘Well, I’d like to go here or here,’ or have real choices,” Johnson said.
Without that choice, Johnson says the epidemic will continue on its current trajectory.
Hardly ever does a person go through a treatment program once and stay in recovery forever, experiences shared by doctors, researchers and addicted people show.
Sometimes, the person isn’t mentally ready to face the reality of their disease and the life experiences that led them there. Other times, it’s the program that fails them.
Sal Marchese told Patty he never got one-on-one counseling during inpatient treatment that could make a dent in the core issues that prompted him to turn to drugs in the first place. Even if he would’ve spent a month in a facility and got personal counseling, it probably wouldn’t have been enough.
“As a trained clinician, I can tell you that if somebody’s been through something really serious, 28 days including detox time isn’t enough time to unpack that issue, deal with it, and then put it away,” Reaves said.
Capretto says programs are not as adaptive to patient needs as they should be.
“For me it’s a miracle drug. It gives me the ability to walk through a drug corner and not have the need to use.” — Carlos Sanchez
Some programs focus solely on abstinence. Others only on spiritual healing. Still others provide medicine and limited counseling. Capretto believes combining them all and customizing care to each patient helps lead a person to success.
“I mean we’re not treating computers with viruses. We’re treating complex human beings with minds, bodies and spirits and in an environment that’s complex and changing. We have to be mindful of that and plan it and adjust our treatment accordingly,” Capretto said.
There’s a resistance, by regulators and some physicians, to new treatment therapies and harm-reduction methods like needle exchanges and medicine-assisted treatment, as well.
Carlos Sanchez credits Suboxone, medically known as buprenorphine mixed with naloxone, with keeping him off heroin. He’d been using for a year and a half when he started taking the medicine. He stopped using dope that day.
“For me it’s a miracle drug,” the 42-year-old said. “It gives me the ability to walk through a drug corner and not have the need to use.”
Getting on Suboxone maintenance is difficult. The federal government limits doctors to no more than 100 patients in a program at a time. Some, who capitalize on the demand, upcharge for the drug.
Prevention Point’s Suboxone program, called STEP, has a 70-person waiting list.
“We need more clinics in the city that are structured more like ours for the barest minimum. We will get people on Suboxone, see them through that program, and help them get clean and sober,” Work said.
The Obama Administration proposed in January an additional $1.1 billion to combat the opiate epidemic. The vast majority of the money, some $920 million, will fund increasing access to medicine-assisted drug treatments in states.
Michael Botticelli, Director of the Office of National Drug Control Policy, said the administration has been working to get more doctors trained to dispense Suboxone, expand the patient limits and they’re also pushing to allow nurse practitioners and physician’s assistants to dispense the medicine.
“We know that people who are on the medications stay engaged in care. We know they don’t overdose and die, which is a big issue here,” he said. “So part of our goal, in general and with this money, has been to continue our efforts to increase access to these life-saving medications.”
There’ve been other movements within government to address the epidemic. The U.S. Senate passed the Comprehensive Addiction and Recovery Act (CARA) in March sending it to the House for deliberation. The legislation authorizes funding for prevention and education programs to address the crisis. Critics, however, say the bill doesn’t appropriate funds and will not be as effective.
A week after the Senate’s vote on CARA, the CDC issued long-awaited new guidelines for prescribing prescription painkillers. The recommendations include having patients exhaust using over-the-counter pain relievers like Tylenol and Advil before being prescribed opioids. Doctors are advised to better warn patients about the potential addictive nature of the drugs and prescribe the lowest dose necessary.
Doctors are not required to adhere to these guidelines, because the CDC is not a regulating body, but officials hope physicians will change their practices to prevent this epidemic from spreading even more.