Health Care

How Prescription-Drug Abuse Unleashed a Heroin Epidemic

(Roman Genn)
From the February 29, 2016, issue of NR

Birmingham, Ala. —“Dogfood — yeah, dogfood — because it looks like ground-up dogfood.” He is embarrassed to be talking about this. “Or sand, because it’s brown. Or diesel. Or killa or 911. That’s the influence of rap culture down here.” Young, clean-cut, Eagle Scout–ish white kid, hesitant about using the words “rap culture.” But he goes on, matter-of-factly. He’s been off heroin for only a few months, so the details are fresh in his mind, even if he remains a little hazy on some of his autobiographical timeline. “The 911, they call it that 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 entrepreneur’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, that killa went right out the door ricky-tick.

The young man explaining the current vocabulary of opiate addiction in Birmingham is barely old enough to buy a beer, and his face and voice are soft. He describes the past several years of his life: “dope-sick and stealing,” going from job to job — eight jobs in six months — and 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. He was staying at the Oak Mountain Lodge, which is a nice little classic place.” (In 2013, four police officers and a drug dog had to be treated for exposure to dangerous chemicals after raiding a suspected meth lab in that hotel; the customer reviews online are decidedly mixed.) “I was snorting heroin when I met up with him, and set him up with my connect. 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.’”

He doesn’t know what happened for the next several hours. When he regained consciousness, his junkie buddy’s girlfriend was worriedly ministering to him.

“That was first thing in the morning,” he says. “That night, I did another one.”

Same results. “I’d nodded out from snorting it, but there’s nothing like shooting it.”

He was, for a time, a “pretty good junkie.”

This particular opiate odyssey starts off in a Walgreens, which turns out to be absolutely appropriate. I’m headed up the south coast and then inland on the heroin highway up to Atlanta, starting from the Port of Houston, which connects that city with 1,053 ports in nearly 200 countries and which in December alone welcomed the equivalent of 63,658 20-foot cargo containers of goods into the United States. There was, the feds are pretty sure, some dope squirreled away in there, and in fact all sorts of interesting stuff comes in and out: In May, U.S. Customs seized a Fast Attack Vehicle with gun mounts, headed to the Netherlands. I’ve got a long drive ahead and I’m going to be out of pocket for a bit, and I have a prescription to fill: a Schedule II Controlled Substance, in the official nomenclature, which covers some pretty interesting stuff, including the oxycodone and fentanyl I’ll be hearing so much about in the next few days. Some of us are going to heaven, some of us are going to hell, but all of us have to stop at Walgreens first.

The clerk is on the phone with a doctor’s office: “What’s your DEA number?”

For working-class white guys who haven’t found their way into those good jobs in the energy economy or the related manufacturing and construction booms that have reverberated throughout the oil patch, who aren’t college-bound or in possession of the skills to pay the bills, things aren’t looking so great: While much of the rest of the world gets healthier and longer-lived, the average life expectancy for white American men without college educations is declining. Angus Deaton, the Princeton economist who recently won the Nobel prize, ran the numbers and found (in a study coauthored by his Princeton colleague Anne Case) that what’s killing what used to be the white working class isn’t diabetes or heart disease or the consumption of fatty foods and Big Gulps that so terrifies Michael Bloomberg, but alcohol-induced liver failure, along with overdoses of opioid prescription painkillers and heroin: Wild Turkey and hillbilly heroin and regular-old heroin, too, the use of which 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) et al. So: lots of opiate addicts, fewer prescription opiates.

What was left was diesel, sand — dogfood.

The clerks at this Walgreens are super friendly, but the place is set up security-wise like a bank, and 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 Tusinex cough syrup, and then, almost as an afterthought, the $90 in the till. Walgreens gets robbed a lot: In January, armed men stormed the Walgreens in Edina, Minn., and made off with $8,000 worth of drugs, mainly oxy. In October, a sneaky young white kid in an Iowa State shirt made off with more than $100,000 worth of drugs, again, mainly oxy and related opioid painkillers, from a Walgreens in St. Petersburg, Fla. Other Walgreens locations — Liberty, Kan., Virginia Beach, Va., East Bradford, Pa., Elk Grove, Calif., Kaysville, Utah, New Orleans — all have been hit by armed robbers or sneak thieves over the past year or so, and there have been many more oxy thefts.

It won’t make the terrified clerks feel any better, but there’s a little bit of poetic justice in that: In 2013, Walgreens 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, Fla., that it enabled untold quantities of the stuff to reach the black market. The typical pharmacy sells 73,000 oxycodone pills a year; six Walgreens in Florida were going through more than 1 million pills a year — each. A few years before that, Purdue was fined $634.5 million for misleading the public about the addictiveness of oxycodone. Kentucky, which has been absolutely ravaged by opiate addiction, is still pursuing litigation against Purdue, and it has threatened to take its case all the way to the Supreme Court, if it comes to that.

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 Walgreens, in the middle of every city and town in the country.

I pick up my prescription and get on my way.

The next afternoon, having driven past billboards advertising boudin and strip joints with early-bird lunch specials and casino after casino after sad little casino, help wanted signs for drilling-fluid businesses and the Tiger Truck Stop (which has a 24-hour Cajun café and an actual no-kidding live tiger in a cage out front), past Whiskey Bay and Contraband Bayou, where the pirate Jean Lafitte once stashed his booty, around the Port of New Orleans, another entrepôt for heroin and cocaine — it is almost as close to Cartagena as it is to New York — I arrive at a reasonably infamous New Orleans drug corner, where I inquire as discreetly as I can about the availability of prescription painkillers, which are getting harder and harder to find on the street.

This particular area was until recently under the control of an energetic fellow called “Dumplin,” who, judging from his police photos, isn’t nearly so cute and approachable as that nickname would suggest. Dumplin ran a gang called 3NG, which presumably stands for “Third and Galvez,” the nearby intersection that constituted the center of his business empire. In March, Dumplin went away on three manslaughter charges and a raft of drug-conspiracy complaints. No Dumplin, but the opiate trade doesn’t seem to have noticed. Little teams of two or three loiter in residential doorways, and business gets done. Who is running the show now? Somebody knows.

Everybody has heroin, but asking about oxy is greeted as a breach of protocol by my not especially friendly neighborhood drug dealer, who doesn’t strike me as the kind of guy who suffers breaches of protocol lightly. He looks at me with exactly the sort of contempt one would expect from a captain of an industry that uses lethal overdoses as a marketing gimmick.

“This ain’t Walgreens, motherf***er.”

‘We partner with Walgreens.”

If Dr. Peter DeBlieux sometimes sounds as if he’s seen it all, it’s possible that he has. As his name suggests, he’s a New Orleans local, and he’s been practicing medicine in the city long enough to have seen earlier heroin epidemics. Now the chief medical officer and medical-staff president at University Medical Center, he speaks with some authority on how changes in global heroin logistics affect conditions in his emergency rooms, which have just seen a 250 percent spike in opiate-overdose cases in one month.

“The first time we’d seen these numbers is when the heroin supply chain moved from the Orient to South America. Before that, New Orleans’s supply traditionally came with everybody else’s supply, from the Far East through New York, and then down to us. By the time it got to New Orleans, it was adulterated, much less pure. But then competitors from South America began bringing heroin along the same routes used to import cocaine. They brought a purer product, which meant more overdoses requiring rescue.” That was in the late 1980s and early 1990s, right around the time when our self-appointed media scolds were bewailing the “heroin chic” in Calvin Klein fashion shoots and celebrity junkie Kurt Cobain was nodding off during publicity events.

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. (Where did it come from? Somebody knows.) 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. If the blend isn’t right . . . medical personnel are known to refer to that as a “clean kill.”

New Orleans has taken some steps to try to get ahead of this mess. One of the things that the city’s health providers had been experimenting with was giving addicts and their families prescriptions for naloxone, sold under the brand name Narcan, which is the anti-intoxicant used to reverse the effects of opiates in people who have overdosed. Put another way: The best clinical thinking at the moment — the top idea among our best and brightest white-coated elite — is to help junkies pre-plan their overdoses. If that’s shocking and depressing, what’s more shocking and depressing is that it really is needful. Essential, even. A few other cities have experimented with it, too, and not long after my conversation with Dr. DeBlieux, New Orleans’s top health officials handed down an emergency order to make Narcan available over the counter. Jeffrey Elder, the city’s director of emergency medical services, said that with the New Orleans emergency rooms seeing as many as ten opiate overdoses a day, the step was necessary. Dr. DeBlieux’s emergency rooms saw seven overdose deaths in January alone.

In high places, there are stirrings of awareness about heroin’s most recent ferocious comeback, but it has taken a while. Congress 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, currently on ice in the Judiciary Committee. That bill would . . . convene a task force.

Dr. DeBlieux compares the public perception of heroin to the public perception of AIDS (the issues are not entirely unrelated) a generation ago: It is seen as a problem for deviants. AIDS was for perverts who liked to have anonymous 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 New Orleans ghettos. Heroin, this line of thinking goes, is a problem for people who deserve it.

“Nobody cares, because of who is affected,” Dr. DeBlieux says, or at least the perception 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.

Dr. DeBlieux and his colleagues are doing what they can to minimize the damage. University Medical Center distributes that Narcan through a private embedded pharmacy in the hospital, operated by — you won’t be surprised — Walgreens.


Odyssey House is not a happy place. It’s a necessary place.

I arrive too early for my appointment, so I have a look around the neighborhood. It is downscale, and there definitely is a little bit of unlicensed pharmaceutical trade being transacted nearby, but it’s far from the worst I’ve seen in New Orleans. I decide to go pick up some extra notebooks, and I end up — inevitably — at Walgreens. There are 8,173 Walgreens locations filling 894 million prescriptions a year, and that big ol’ record-book fine doesn’t look too 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, whereas heroin is cheap and plentiful. How do we keep up with all those pills? Where do they go? Somebody knows. It’s been only two weeks since there was an armed robbery of a Walgreens in New Orleans, but it wasn’t this one. That one is about 20 minutes away.

I park my car on the street across from Odyssey House, down the block from a sign advertising free HIV screening, and an older white man comes out of his home to stand on the porch, staring at me. He’s still there, still staring, when I go inside the building across the street. Odyssey House is the largest addiction-treatment facility in Louisiana, treating about 700 people a month, about half of them from greater New Orleans. It was founded in response to New Orleans’s first major heroin epidemic, some 45 years ago. Its clients are about half white in a city that isn’t, and predominantly male. About half of its clients are there on court orders, and the other half have simply decided that they want to live. Its CEO, Ed Carlson, has a master’s in clinical psychology and not much in the way of kind words for Louisiana’s former governor, conservative health-policy wonk Bobby Jindal. It’s partly a familiar complaint — Jindal’s rejection of the Medicaid expansion under the Affordable Care Act means that about 90 percent of Odyssey House’s patients have to be covered by general state funds, which are scarce. But it’s also an illustration of one of the hidden costs of privatizing public-health services: the transfer of administrative costs from state agencies onto third parties, including nonprofits such as Odyssey House.

“Under the privatization of the Bayou Health plans,” Carlson says, “it’s like this: I have a guy who shows up, who’s a heroin addict, who’s been in and out of the criminal-justice system, maybe a 20-year heroin addict, maybe semi-homeless, and he wants to get off heroin in our detox. And I have to spend an hour explaining to [insurance bureaucrats] why this guy needs treatment, usually with someone who doesn’t understand treatment at all.” That meant hiring more administrative help. “What it did was, it shot up our costs. Now we have people who all they do all day long is sit down and try to convince somebody that this person needs treatment. And they’ll say, ‘Has he tried outpatient?’ He’s a heroin addict. He’s homeless. He’s here at our door. I don’t have a problem justifying to them that a person needs services, but, once we’ve justified it, then let’s go with the level of services that a medical professional recommends.”

Outpatient treatment? Heroin addicts as a class don’t have a real good record for keeping appointments.

Odyssey’s program is intensive: It begins with a medically supported detox program, which isn’t all that critical for opiate addicts (the popular image of the effects of heroin withdrawal are theatrically exaggerated, as Theodore Dalrymple documented in his classic on the subject, Romancing Opiates) but which is absolutely necessary for alcohol withdrawal, which can be fatal. The reality is that most heroin addicts drink their fair share, too. Detox is followed by a 28-day residential program, followed by housing support and an outpatient program. Odyssey has primary-care physicians and psychiatrists on staff, a separate residential program for adolescents, and more. They aren’t promiscuous with the money — for example, they don’t send methamphetamine addicts to detox, because their withdrawal lasts only a few hours and its main effects are discomfort and a few days of insomnia — but, even so, all this treatment gets expensive, and the city of New Orleans kicks in the princely sum of $0.00 in municipal money for these services, with the exception of some pass-through money from state and federal agencies.

The general consensus is that this sort of treatment provides the best chance for helping some — fewer than you’d think — of the chronically addicted, homeless and semi-homeless, destitute, low-bottom population. There’s no cheap way to do it. “There’s really only two things we know, from a scientific standpoint, about addiction,” Carlson says. “The first thing we know is that when a person has a problem with addiction and they have that moment, that break in the wall of denial — if they can access treatment at that point, then they’re more likely to engage in the treatment process and to be more serious about it. The other thing we know is that the longer we keep people in treatment, the longer they’re going to stay clean and sober.”

In total, it costs just under $1 million a month to run Odyssey House and provide those services to its 700 or so patients. And what do the funding agencies get for that money? A one-year success rate of a little more than 50 percent — which is significantly better than that of most comparable programs. Beyond that one year? No one really knows. “The fact is that most people who need addiction treatment don’t really want it,” Carlson says.

It isn’t clear that there really is a solution to the opiate epidemic, but if there is, there’s one thing you can be sure of: It is going to cost a great deal of money. “We have waiting lists for all our programs,” Carlson says with a slight grimace. “We could probably double in size and still have waiting lists.”

Homelessness in New Orleans isn’t the only model of heroin addiction, or even the most prevalent one. Up in the land of Whole Foods and Starbucks and yoga studios in one of the nicer parts of Birmingham, it looks like a different world. But it isn’t. More white people, more Volvos — same junkies.

Danny Malloy doesn’t sound like he belongs here. He has a heavy Boston accent, and he still shakes his head at some aspects of life in the South: “We measure snow in feet up there, but it’s inches down here,” he scoffs. There’s a little snow blowing around, and a few streaks of white on the grass. “No plows, no salt trucks, and nobody knows how to drive in it.” He ended up in Alabama the way people end up places. His parents were divorced when he was very young, his alcoholic father eventually sent him to live with an aunt, and he later sought out his estranged mother in Birmingham. “I didn’t know her,” he says. He was already a blackout drunk and had found his way to the pills, which he was both consuming and dealing.

“I never realized I had a problem. I thought I was having a good time. I got into prescription pills. I really liked them — I mean like really liked them. It took probably three years of me dabbling in those before I was fully addicted, and every day I had to have Lortabs. I got into OxyContin and was selling those. I got set up by someone and sold to an undercover police officer. So I was arrested for distribution, and I was facing time. At that point, someone came along and said, ‘These pills are expensive, and you can’t sell them any more. So why don’t you do heroin?’ I said I would never do that. I don’t want to use a needle. But, eventually, like a good drug addict, I was like, ‘Let me try that.’ The rest was history. I’ve been to 15 or 20 rehabs, including psychiatric hospitals, arrests, detoxes, methadone rehabs. I couldn’t get rid of it. I did that for about seven years. Things got . . . really bad.” He’d been a college student, majoring in “whatever started at noon,” but he ended up being kicked out. “The first time I ever thought maybe I had a problem was when I got arrested and my face was down in a puddle with a cop on my back. That’s what it took.” Eventually, he put himself on a Greyhound and checked into the Foundry, a Christian rehab facility. “I never looked back. I turned my life over to God, and He took away the desire to use.” He pauses as if reconsidering what he’s said. “It isn’t magic.”

Alabama doctors write more opiate prescriptions per capita than those of any other state. And where there is oxy, there will be dogfood. “The pills lead to heroin,” Malloy says. “You see these doctors getting arrested for running a pill mill. Well, they have hundreds of people they’re prescribing to, and when they tighten down on that, the next thing is the heroin.”

Far from being an inner-city problem and a poor-white problem, heroin is if anything more prevalent in some of the wealthier areas around Birmingham, says Drew Callner, another recovering addict and a volunteer at the Addiction Prevention Coalition in Birmingham, a faith-based organization aimed at realistic preventative measures and connecting addicts with recovery resources. “Heroin is easier to get, and it’s cheaper.” His father was a child psychologist, he was planning on becoming one himself, and he was a trust-funder — twice. “Yeah, I blew through two trusts,” he says, snorting.

He’d been a Marine and wanted to become a firefighter, but the only thing he could commit to for the long term — 15 years — was oxy and heroin. Beyond the depleted trust funds, the deficit that seems to weigh on him most heavily is that of time. He is 32 years old and has spent nearly half of his life as an active drug user. “Going back to school is interesting,” he says. “I’m in some English 101 class at 8:30 in the morning, that I’ve taken four or five times” — there were five or six colleges, and five rehabs in four years — “and I’m in there with a bunch of 18- and 19-year-olds. It’s humbling. Humiliating. But when you get sober, you need something to ground you.”

He’d derailed his life before it had really gotten under way, but his roommates in his last residential program — which he got out of just last week, with seven months’ sobriety — were a personal-injury attorney, a senior banker, and an accountant.

“And then there was me.”


They call it the “red flag.”

Some heroin addicts fall in love with the ritual of shooting up. Some of them have been known to shoot up when they don’t have any heroin, just to feel the calming presence of the needle in the arm. The ritual is familiar enough to anybody who has spent any time in that world: You put the chunk of tar or bit of powder in the spoon, squirt a little water in with the syringe, heat it up to get it to dissolve, drop a little pinch of cotton into the spoon for a filter, pull the heroin solution up through the cotton into the syringe, find a vein — this isn’t always easy, and it gets harder — work the needle in, pull the plunger back . . .

And then, you see it: the red flag, a little flash of blood that gets pulled into the syringe and lets you know that you have found a vein, that you aren’t about to waste your junk on an intramuscular injection that isn’t going to do anything except burn and waste your money and disappoint you and leave you with a heroin blister. Certain addicts become, for whatever reason, almost as addicted to the needle — and addicted to the red flag, to the sight of their own blood being extracted — as to the heroin itself.

“When I couldn’t get heroin, I would just shoot anything,” Malloy says. “I would load up hot water and shoot it, just to feel the needle. I had to load it up and shoot it — it was a routine. So I started shooting Xanax, Klonopin, trying to shoot Vicodin, but that never works.”

“I was the opposite,” Callner says. “Every time I shot up, I would hear my mom’s voice, telling me I’m a piece of sh**. Plus, I’m not very vascular, so I had to shoot up on the outside of my arm, which meant looking at myself in the mirror. There was just something about that, five or six times a day, looking yourself in the eye and seeing the deterioration. And hating it.”

“I remember using dull, dull needles, and having to stab myself until I found a vein,” recovering addict Dalton Smith says. “But I was obsessed with when you got the needle in, and pulling it back and seeing the blood. The red flag.” Smith sometimes shot up imaginary heroin, convinced that bits of carpet lint were heroin. “The fuzz — I remember seeing the fuzz from the carpet in my rig.”

None of these guys comes from Heartbreak Hill. Some of them came from some money, came from good schools, went to college, had successful, high-income parents. But there was also divorce, and addiction in the family — one young recovering addict is in the precarious situation of having to live with his alcoholic father — and a general sense of directionlessness. They are from that great vast America whose people simultaneously have too much and too little.

One or two breaks in a different direction and Dalton Smith might have been the youth minister at your church. (He still might be.) He’s got that heartbreakingly distinctive shamefacedness that you see whenever you’re around young addicts or young prisoners (there’s some substantial overlap on that Venn diagram) or other young people with woeful self-inflicted injuries, a shadow across the face that says that while he may be trying to have faith in whatever Higher Power sets His almighty hand on recovering junkies in Alabama, that everything happens for a reason and that he’s right where he’s supposed to be, he’d really give anything to be able to go back and change one thing on that chain of decisions that led to his messing his life up nearly irreparably before he was old enough to rent a car from Avis. He’s 22 years old. There’s a long chain of bad decisions that goes back to the beginning of his self-destructive career as a drug addict, and at its beginning is a twelve-year-old child. And now he knows a lot of words for heroin.

“Down here, they sometimes call it ‘boy.’”


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