A slide into abuse that enthralls, ravages addicts
Dr. Ruth Potee counts empty containers of Suboxone, a drug for people addicted to opiates, to make sure her patient is taking the drug properly. Potee gave a talk during a "Safe and Competent Opioid Prescribing Education" presentation at Baystate Franklin Medical Center Saturday.
Recorder file photo/Paul Franz
Melissa O'Malley, former herion addict, now helps others.
Jeremy Bucci, ADA, in his Northampton office.
Heroin is a life-altering low point in an old line of damaging recreational drugs and usually beneficial medicines, essentially the same substances, born from the opium poppy.
Opium itself was used recreationally and as a medicine for centuries before its active ingredient, morphine, was isolated and purified in the early 1800s.
Heroin was among the earliest and least successful attempts to shave the powerful addictive hook from morphine. The semi-synthetic derivative is two to three times more potent than its parent — and ironically, hugely addictive.
The Bayer Company first named and marketed the drug, initially trumpeted as a miracle drug less toxic and addictive than morphine, according to the Encyclopedia of Drugs, Alcohol & Addictive Behavior.
Thanks to its highly addictive qualities and the rapidly escalating tolerance noticed in patients, heroin’s wholesome reputation was short-lived and it quickly shifted from legal medication to illegal vice.
Today, heroin’s largely forgotten medical link has been re-established by its close association with modern prescription opiates like OxyContin and Percocet.
John, a 28-year-old Montague resident, began taking prescription painkillers for a shoulder injury five years ago.
“And then somebody or other told me you can get high, and that’s how it all started,” he recalls. After abusing OxyContin and Percocet for four years, and becoming heavily addicted to the drugs, he moved on to heroin for simple reasons of supply and demand.
“That’s primarily why I switched to dope, because (pills) were getting almost impossible to find,” he said.
Heroin seemed a thrifty alternative at maybe $10 a bag in the Greenfield and Turners Falls area, compared to $30 for an equivalent dose of prescription painkillers.
He began snorting heroin, but his tolerance quickly increased until he was spending more on the cheap powder than the expensive pills.
Within weeks, a few bags a day became eight to 10.
“Then I found out if I injected it, it was two to three times stronger, so I started injecting a bag or two a day and within days my tolerance was going up again to the point I was shooting 10 bags a day when I could afford it,” he said.
When he couldn’t afford it, he was suffering from withdrawal symptoms — vomiting and sweating, with diarrhea, muscle spasms and cramps beginning within 15 minutes of waking up in the morning.
In one year, he estimates, he spent over $10,000 on heroin ... he is still paying off the debt. Rather than fix his car when it broke down, he said he scrapped it to buy heroin. John said he nearly lost his family, and this winter he nearly lost his arm to gangrene spreading from an abscess at an infected injection site.
John says he was careful always to use new needles and believes his infection was caused by a bad batch of heroin that was circulating in the area at the time.
An article appearing in the Western Journal of Medicine in August 2000 reported a bacterium found in soil and dust contributed to the gangrene deaths of 35 injecting heroin users in Britain and Ireland at the time. Previously associated with infection in farm animals and not commonly found in humans since it infected soldiers wounded in the first and second world wars, researchers theorized the modern outbreak was due to contaminated batches of heroin from a single source.
“When I first went into the operating room, I thought they were taking my arm. I didn’t know that I’d still have an arm until after I’d come out of surgery,” John recalled.
When he awoke, he still had an arm, but without a 9-inch slice of muscle and skin, the incision running up the inside of his forearm through the soft tissue of the inner elbow and into the biceps.
Shaken by that experience and with a new baby to worry about, John says he asked for help and the hospital referred him to one of the few area doctors prescribing Suboxone, which, like methodone, is used to treat opiate addiction.
In March he was back at work, with his arm healing and motion limited but better than he had been led to expect. He has been clean and on a Suboxone regimen since the surgery.
John’s story is not atypical.
The link between prescription drug abuse and heroin comes up in every interview with health and law enforcement professionals dealing with the problem.
Rise of the painkillers
As far as Dr. Ruth Potee is concerned, everything went downhill in the 1990s when pain became a fifth vital sign.
Potee is a Greenfield physician who includes addiction treatment in her general practice.
“So every time a patient walks into the room you check their heart rate and their respiratory rate and their blood pressure and you would ask them on a scale of 1 to 10 how much pain they were in, and new guidelines came in saying you should treat pain regardless of what the pain is.
“If somebody says they’re in pain you should give them the maximum dose of opiates, actually, strong pain killers, to get them out of the pain. That was sort of the standard of care that was being promoted from the mid-1990s on.”
Prescription-strength painkillers once used principally for crippling bone cancer, acute injuries and the like suddenly became widely prescribed.
“Now, it’s sort of standard of care to give it to people with severe osteoarthritis or uncontrollable headaches. I want to be clear, I believe in treating people’s pain, I just recognize there’s a wide variety of ways to do it and not just with opiates.”
OxyContin arrived on the scene at roughly the same time, amid heavy promotion and claims that it was not abusable because of its slow-release formulation. But Potee says users quickly discovered that could be circumvented simply by crushing it.
And it was readily available. Until recently, poorly regulated pain clinics in Florida, know as “pill mills,” ensured a steady stream of pain pills across the country, flowing straight up Interstate 95 to make New England an epicenter of opiate addiction, Potee said.
Heroin has since become a cheaper substitute in greater supply.
“The final thing is that heroin’s cheap. It’s cheaper than a six-pack of beer and it’s easier to get. I mean, you, at the age of 18, can’t walk into a liquor store and buy a six-pack of beer,” she said.
“Heroin you could score anywhere. I could probably walk three blocks from here and get dime bags of heroin. So it’s cheap and it’s very pure and it’s very addictive.”
Prescriptions entry point
Assistant District Attorney Jeremy Bucci heads the Northwestern District Attorney’s narcotics unit and prosecutes many of the drug cases in Franklin and Hampshire counties. He describes the same situation. Many eventual heroin users begin with prescriptions, often legitimate, become dependent, develop a tolerance and need more than their prescription provides or they can buy elsewhere.
“When they realize heroin is the same drug and it’s cheaper than pills, they tend to segue to heroin, and it usually starts with snorting it, and as they chase the high, many of them will develop an addiction that requires them to inject heroin,” he said.
“The comment was made to me recently that this addiction that they’re seeing now is a little different than what they had seen in the past because it’s sending people that were otherwise not being exposed to heroin use down that road, from a legitimate place.
“Opiate addiction has been around for literally centuries — this drug isn’t something new to what we understand, but it is something that, as it’s being prescribed more and more to remedy pain, is given that stamp of something that is legitimate because doctors prescribe it,” Bucci said.
“It is leading more and more people down this path, and once the people are down the path of addiction and they realize they can’t afford the pills and no doctor’s going to prescribe them any more pills, heroin seems to be the only place that they can go.”
Many heroin users begin with legitimate prescriptions to opiates like Percocet or OxyContin, both brand-name formulations of the synthetic opioid oxycodone, and become dependent. When the prescription ends or isn’t enough anymore, the now-dependent patient turns to purchasing the pills illegally or moves straight to heroin, which has the same basic ingredient and the same effect at a fraction of the cost.
Further softening the transition from pills and easing in new users, heroin is now commonly pure enough to ingest by snorting or smoking rather than injecting.
The grandmothers of Ashley Sims, the 22-year-old Leyden woman who died of a heroin overdose last year, believe she was first introduced to heroin when she was offered an anonymous “line” of a brown substance to snort at a party.
Modern prescription opiates carry the same lethal risk as heroin when abused, and heroin brings additional risks to the table as an unregulated substance manufactured and sold by criminals rather than in a controlled medical setting. There’s no recommended dosage on a bag of heroin and no way for buyers to know exactly what they have purchased.
Travels from the south
According to the National Drug Threat Assessment 2011, a report published by the now-defunct National Drug Intelligence Center and relying mainly on 2007-2009 figures, the more refined white powder heroin was originally produced in Colombia and in the mid-2000s possibly produced in Mexico as Mexican cartels adopted Colombian processing methods to move into the traditionally Colombian market on the East Coast of the United States.
The drug is then sold, smuggled and dealt until it reaches the end user, likely after being “stepped on” — cut with any cheap powdery substance to increase the volume and the seller’s profit — at every stop along the line.
The end user risks injecting a variety of adulterants, including talcum powder, which can build up in the bloodstream, or strychnine, a rat poison that, like heroin, once had medical applications. Unsterile conditions can result in bacteria being added to the drug, resulting in gangrene or tetanus.
Opiates have a very narrow margin between the quantity it takes to get high and the quantity it takes to kill you. An unexpectedly pure dose is more likely to kill the user than a bag diluted with whatever is at hand.
The act of habitually sticking yourself with a needle carries other dangers: collapsed veins, abscesses, infections from dirty skin or dirty needles, HIV and hepatitis.
“Once you start injecting you have Hep C as far as we’re concerned,” said Potee.
“Locally, people don’t inject much, probably because they think it’s gross, but eventually people do move to the injectables,” Potee said. “People understand there’s a risk to infection with injectables, but you can get HIV and Hep C (through snorting) ... it’s just a little harder.”
Everyone has medical horror stories, first- or second-hand, from a dose cut with yeast causing massive inflammation to an infected injection site developing into gangrene, but the cost to the user’s health is often the last thing mentioned by recovering addicts, following the havoc it wreaks in their personal and family lives.
‘I was a garbage disposal’
Melissa O’Malley fell down a flight of stairs in 1994, and a resulting pain prescription eventually became a habit that spiraled out of control.
“One day I was really sick, withdrawing from my meds and somebody had some heroin and I just stuck my arm out,” she said.
“I was a garbage disposal for anything that could make me feel better.”
“That life was hell,” she said. “I lost my kids, I lost everything.”
She still had her car, and to support her addiction she would do favors without question. She once gave someone a ride and ended up involved in a home invasion case.
Once she was clear of that case, she moved from Cape Cod to Charlemont, where she thought she would be safely away from her drug-filled environment on the Cape.
Although she continued using prescription pills, she managed to win her children back from the state. But as soon as she had them, she moved back to the Cape, where she started dealing, lost her children a second time and wound up in jail on a 16-count indictment. She wrote to Spectrum Health Systems from jail and secured her release into a six-month residential treatment program in Worcester. From there, she moved into the Beacon House for Women in Greenfield for seven months, and she has now been clean and sober for four years.
Terrence, who preferred not to use his last name for this article for legal reasons, was in jail facing serious charges this March for the second time in less than two years since he began using drugs.
At 25, he describes himself as a “late-bloomer” in the drug world.
“I have actually tried almost everything ... within a year’s time,” Terrence said. “I drank, but I never tried weed or anything else until a year and a half ago.”
At that time, he lost his job as a personal care assistant. This left him unemployed for the first time since he was 16 and on prescription drugs following dental and hernia surgeries.
In total, he estimates he was on prescriptions for three or four months, and somewhere during that time became dependent, a change he didn’t notice until the prescriptions ended.
He then began finding pills elsewhere.
“Once Percocets didn’t work anymore, I got into heroin,” he said.
“Cheaper, worked quicker.”
The switch to heroin came about six months in, and it took another six months to move from snorting to injecting.
Heroin worked faster but he needed more of it and he didn’t have a job, so he began stealing. He has been arrested twice now on charges stemming from strings of overnight break-ins in the area.
One arrest probably saved his life. He was in mid-overdose on “everything,” as he put it.
“If I wasn’t in custody I literally could have died,” he said.
A shot of Narcan — a brand-name for naloxone hydrochloride, a substance approved by the FDA to reverse the effects of an opiate overdose by taking over opiate receptors in the brain — woke him up swinging into a state of immediate withdrawal.
While he was free and using, Terrence says he couldn’t recognize the changes in his behavior. His mother would tell him he was acting differently, doing things he never would sober, but he didn’t recognize it.
“A sober mind is a really powerful thing,” he said. “People can explain to you over and over again when you’re intoxicated and you don’t see it ’til you’re sober.”
“I thought my mom was exaggerating. I now see I was a little bit off my rocker at the time,” he said.
“I wish every day I hadn’t done it.”
Wednesday: Life on drugs, life of crime