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���������� Note: The story below captures two chapters of a lengthy project from Huffington Post chronicling the story of how heroin rose to prominence again in the United States, how it is impacting people and families across the country, and how treatment can—but often doesn’t—offer what individuals in the midst of addiction need. The work covers the seemingly bizarre controversy around suboxone treatment, the stigma related to non-abstinence treatments and addiction, and the tragedy of family torn apart by disease. See the link below to continue reading the story.

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Dying To Be Free

Huffington Post; Jason Cherkis, 1/28/2015

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Chapter 1: Life, Abbreviated

The last image we have of Patrick Cagey is of his first moments as a free man. He has just walked out of a 30-day drug treatment center in Georgetown, Kentucky, dressed in gym clothes and carrying a Nike duffel bag. The moment reminds his father of Patrick’s graduation from college, and he takes a picture of his son with his cell phone. Patrick is 25. His face bright, he sticks his tongue out in embarrassment. Four days later, he will be dead from a heroin overdose.

That day, in August 2013, Patrick got in the car and put the duffel bag on a seat. Inside was a talisman he’d been given by the treatment facility: a hardcover fourth edition of the Alcoholics Anonymous bible known as “The Big Book.” Patrick had tagged some variation of his name or initials on the book’s surfaces with a ballpoint pen, and its pages were full of highlighting and bristling with Post-its.

Back in the wood-paneled living room of their Lexington, Kentucky, home that afternoon, Patrick and his parents began an impromptu family meeting about what to do next. Patrick’s father, Jim, took his usual seat in the big red chair, and Patrick’s mother, Anne Roberts, sat on the couch. Patrick took the footrest between them, sitting with his hands on his knees. Was he ready to be home? Did he have a plan to get a sponsor? Maybe he should start looking for a job or apply to graduate school?

Before he entered Recovery Works, the Georgetown treatment center, Patrick had been living in a condo his parents owned. But they decided that he should be home now. He would attend Narcotics Anonymous meetings, he would obtain a sponsor — a fellow recovering addict to turn to during low moments — and life would go on. As they talked, though, a new reality quickly set in. Their son’s addiction was worse than they had thought. It wasn’t just pain pills, Patrick told them. It was heroin.

In her shock and heartbreak, Anne looked away. “I didn’t criticize him for it because I knew he felt so bad,” she explained later. “I knew he felt he had let us down.” Patrick stared at the floor, unable to look at his parents. He’d lost a year to the drug, along with a girlfriend he adored and a job caring for victims of traumatic brain injury — a job that made him feel that he was doing something worthwhile with his life. He didn’t want to be a heroin addict.

Jim had worked for decades as a public school English teacher and taught at aviation camps as an amateur pilot. Anne was in nursing and health care administration. Before Patrick was born, she had even helped run a methadone clinic treating heroin addicts and later had worked in substance abuse and psychiatric wards for the Department of Veterans Affairs. Jim and Anne knew how to be steady in a crisis.

Anne’s thoughts raced to her days at the methadone clinic. So many of her clients had done well: the smartly attired stockbroker who came in every day, the man who drove a Pepsi truck making deliveries all over the state, the schoolteacher who taught full time. She was also familiar with a newer maintenance medication on the market sold under the brand name Suboxone. Like methadone, Suboxone blocks both the effects of heroin withdrawal and an addict’s craving and, if used properly, does it without causing intoxication. Unlike methadone, it can be prescribed by a certified family physician and taken at home, meaning a recovering addict can lead a normal life, without a daily early-morning commute to a clinic. The medical establishment had come to view Suboxone as the best hope for addicts like Patrick.

Yet of the dozens of publicly funded treatment facilities throughout Kentucky, only a couple offer Suboxone, with most others driven instead by a philosophy of abstinence that condemns medical assistance as not true recovery. Even at clinics that offer the medication, the upfront costs and budget limitations render it out of reach for the vast majority who come through their doors. But Patrick had insurance, and Anne, with her treatment background, thought she could find a prescribing doctor.

“Patrick, we can get you the medication,” Anne told her son. “There are other options. We can put you on methadone or we can get you Suboxone. There are other things that you can do besides the 12-step program.”

Patrick knew firsthand about Suboxone’s potential. He had tried it on the black market to stave off sickness when he couldn’t get heroin — what law enforcement calls diversion. But Patrick had just left a facility that pushed other solutions. He had gotten a crash course on the tenets of 12-step, the kind of sped-up program that some treatment advocates dismissively refer to as a “30-day wonder.” Staff at the center expected addicts to reach a sort of divine moment but gave them few days and few tools to get there. And the role of the therapist he was assigned seemed limited to reminding him of the rules he was expected to follow. Still, by the second week, he appeared to take responsibility for his addiction. When they could reach the facility’s staff, his parents were assured of their son’s steady progress. Patrick was willing to try sobriety one meeting at a time.

“No,” Patrick told his parents. “I think I can do it. I want to try this first.”

Patrick made for a natural 12-step convert. The rituals of self-discipline were nothing new. He’d kept a journal since the 8th grade documenting his daily meals and workout routines. As a teenager, he’d woken up to the words of legendary coaches he’d copied from books and taped to his bedroom walls — John Wooden on preparation, Vince Lombardi on sacrifice and Dan Gable on goals. He had been a dominant wrestler in high school and a competitive bodybuilder in his early 20s. At his training peak, he measured and recorded his water intake down to the ounce.

Patrick (in red), 16, swiftly pins his opponent.Courtesy of Jim Cagey and Anne Roberts

Patrick went undefeated in county high-school tournaments. He made stickers with the words “STATE CHAMP” written on them in black marker and put them all over the house. But multiple knee injuries — and knee surgeries — ended those dreams. Around the time he graduated from the University of Kentucky, the knee pain returned, and he developed an addiction to pain medications.

Patrick’s habit built steadily and in secret. He needed a Percocet just to get out the door. After a statewide and federal crackdown on pain pills made them too expensive, he switched to heroin. He shot up alone in the privacy of his condo — neither his best friend nor his girlfriend at the time ever saw him with a needle. His habit developed to the point at which he was shooting up a half-gram of heroin a day.

On his first night home from rehab, Patrick attended a Narcotics Anonymous meeting. He woke up the next morning and told his mother of the relief he felt at not having to worry about scoring drugs. “It’s like being normal,” he said. He sounded astonished and grateful. The next morning, he told her the same thing.

Anne had stocked the fridge with Patrick’s favorite mini cinnamon rolls and made up his bedroom before he came home. Although she had long ago taken down most of his “STATE CHAMP” stickers, she had left one up on the frame of his bedroom door. He was an only child and they were close. Now they had to be closer.

Patrick spent the next few days taking steps toward finding a normal routine. He looked for construction jobs, and he thought about enrolling in graduate school for physical therapy. He visited a troubled childhood friend who had become a shut-in, just to keep him company. He made plans to get back in the gym with his best friend, and he apologized to his former girlfriend, hoping for a second chance. “It was the most wonderful conversation we ever had,” Stacey Hawkins recalled. “I said, ‘Everything’s going to be OK. You keep talking this way, I’ll marry you tomorrow.’” Patrick, she added, “felt very victorious, almost.” Over meals, he quoted the Big Book from memory to his mother.

At one Narcotics Anonymous meeting, Patrick ran into two young women he knew from rehab. Those women could be bad news, he confessed to his mother one afternoon in their kitchen. Let’s get out the NA schedule and find a different meeting, Anne offered. Patrick told her he’d already found a later one to attend. He had it covered.

Anne and Jim kept working on a Plan B. Anne was worried that her son hadn’t found a sponsor yet, so she called a friend in AA; he promised to help get Patrick a sponsor after the weekend, when he’d be back in town. Jim called doctors to see if they prescribed Suboxone. He had already put Patrick on a waiting list for a long-term 12-step facility in Lexington. He was told that a spot might open up in six months or so but there were no guarantees.

By Friday night, three days after leaving rehab, Patrick’s willpower showed signs of strain. He came home late, hours after his meeting ended. The next morning, while Anne was out jogging, Patrick left the house, telling his father that he’d be back later. He hadn’t returned by that evening. His parents’ calls went straight to voicemail; their texts went unanswered.

9:17 p.m.: “Patrick, let us hear from you tonight. I hope all is well. Stay strong & take care.”

10:49 p.m.: “We need to hear from you — it’s getting late.”

After attending Sunday church service the following morning, Jim drove to Patrick’s condo. He spotted his son’s car in the lot, knocked on the condo’s door, and then let himself inside. He checked the bathroom. “I tried to open the door, you know, and something was blocking it,” he recalled. “And it was Patrick. He had fallen back against the door.” On the kitchen counter there was a spoon, a cotton ball, a lighter and the cap to a syringe.

In the days and weeks that followed, Patrick’s parents grieved. They notified friends and relatives, wrote a eulogy for their newspaper, and made funeral arrangements. They held the memorial service on what would have been their son’s 26th birthday. At Recovery Works, Patrick’s former treatment facility, his name and photo were added to a memory wall in a common room — another fatal overdose in a system full of them. Staff turnover in the treatment industry meant that soon enough hardly anyone there would remember Patrick at all.

Even for staff members at the facility who stick around, it can be hard to keep straight all the names and faces of the dead. In the months before Patrick’s death, Sydney Pangallo, 23, a recent Recovery Works alumna, suffered a fatal overdose. Dan Kerwin, 23, attended a Recovery Works program in the spring, and his sister found him dead of an overdose during the July 4th weekend. Tabatha Roland, 24, suffered a fatal overdose in April — one week after graduating from Recovery Works. And in November, Ryan Poland, 24, died of an overdose. He too was a Recovery Works graduate.

There’s nothing uniquely tragic about these results. The problem is not with heroin treatment at one facility in Kentucky over the span of a few months. The problem is with heroin treatment.

Chapter 2

The opioid epidemic took hold in the U.S. in the 1990s. Percocet, OxyContin and Opana became commonplace wherever chronic pain met a chronic lack of access to quality health care, especially in Appalachia.

The Centers for Disease Control and Prevention calls the prescription opioid epidemic the worst of its kind in U.S. history. “The bottom line is this is one of the very few health problems in this country that’s getting worse,” said Dr. Tom Frieden, director of the CDC.

U.S. HEROIN USE BY YEAR

“We had a fourfold increase in deaths from opiates in a decade,” Frieden said. “That’s nearly 17,000 people dying from prescription opiate overdoses every year. And more than 400,000 go to an emergency room for that reason.”

Clinics that dispensed painkillers proliferated with only the loosest of safeguards, until a recent coordinated federal-state crackdown crushed many of the so-called “pill mills.” As the opioid pain meds became scarce, a cheaper opioid began to take over the market — heroin. Frieden said three quarters of heroin users started with pills.

Federal and Kentucky officials told The Huffington Post that they knew the move against prescription drugs would have consequences. “We always were concerned about heroin,” said Kevin Sabet, a former senior drug policy official in the Obama administration. “We were always cognizant of the push-down, pop-up problem. But we weren’t about to let these pill mills flourish in the name of worrying about something that hadn’t happened yet. … When crooks are putting on white coats and handing out pills like candy, how could we expect a responsible administration not to act?”

As heroin use rose, so did overdose deaths. The statistics are overwhelming. In a study released this past fall examining 28 states, the CDC found that heroin deaths doubled between 2010 and 2012. The CDC reported recently that heroin-related overdose deaths jumped 39 percent nationwide between 2012 and 2013, surging to 8,257. In the past decade, Arizona’s heroin deaths rose by more than 90 percent. ���������� City had 420 heroin overdose deaths in 2013 — the most in a decade. A year ago, Vermont’s governor devoted his entire State of the State speech to heroin’s resurgence. The public began paying attention the following month, when Philip Seymour Hoffman died from an overdose of heroin and other drugs. His death followed that of actor Cory Monteith, who died of an overdose in July 2013 shortly after a 30-day stay at an abstinence-based treatment center.

In Cincinnati, an entry point for heroin heading to Kentucky, the street dealers beckoning from corners call it “dog” or “pup” or “dog food.” Sometimes they advertise their product by barking at you. Ohio recorded 680 heroin overdose deaths in 2012, up 60 percent over the previous year, with one public health advocate telling a local newspaper that Cincinnati and its suburbs suffered a fatal overdose every other day. Just over the Ohio River the picture is just as bleak. Between 2011 and 2012, heroin deaths increased by 550 percent in Kentucky and have continued to climb steadily. This past December alone, five emergency rooms in Northern Kentucky saved 123 heroin-overdose patients; those ERs saw at least 745 such cases in 2014, 200 more than the previous year.

For addicts, cravings override all normal rules of behavior. In interviews throughout Northern Kentucky, addicts and their families described the insanity that takes hold. Some addicts shared stories of shooting up behind the wheel while driving down Interstate 75 out of Cincinnati, or pulling over at an early exit, a Kroger parking lot. A mother lamented her stolen heirloom jewelry and the dismantling of the family cabin piece by piece until every inch had been sold off. Addicts stripped so many houses, barns, and churches of copper and fixtures in one Kentucky county that the sheriff formed a task force. Another overdosed on the couch, and his parents thought maybe they should just let him go.

NORTHERN KENTUCKY HIT HARD BY HEROIN OVERDOSES

Chemistry, not moral failing, accounts for the brain’s unwinding. In the laboratories that study drug addiction, researchers have found that the brain becomes conditioned by the repeated dopamine rush caused by heroin. “The brain is not designed to handle it,” said Dr. Ruben Baler, a scientist with the National Institute on Drug Abuse. “It’s an engineering problem.”

Dr. Mary Jeanne Kreek has been studying the brains of people with addiction for 50 years. In the 1960s, she was one of three scientists who determined that methadone could be a successful maintenance treatment for an opioid addicted person. Over the years, various drug czars from both political parties have consulted her at Rockefeller University in ���������� City, where she is a professor and head of the Laboratory of the Biology of Addictive Diseases. According to Kreek, there’s no controversy over how opiate addiction acts upon the brain.

“It alters multiple regions in the brain,” Kreek said, “including those that regulate reward, memory and learning, stress responsivity, and hormonal response, as well as executive function which is involved in decision-making — simply put, when to say yes and when to say no.”

A heroin addict entering a rehab facility presents as severe a case as a would-be suicide entering a psych ward. The addiction involves genetic predisposition, corrupted brain chemistry, entrenched environmental factors and any number of potential mental-health disorders — it requires urgent medical intervention. According to the medical establishment, medication coupled with counseling is the most effective form of treatment for opioid addiction. Standard treatment in the United States, however, emphasizes willpower over chemistry.

To enter the drug treatment system, such as it is, requires a leap of faith. The system operates largely unmoved by the findings of medical science. Peer-reviewed data and evidence-based practices do not govern how rehabilitation facilities work. There are very few reassuring medical degrees adorning their walls. Opiates, cocaine and alcohol each affect the brain in different ways, yet drug treatment facilities generally do not distinguish between the addictions. In their one-size-fits-all approach, heroin addicts are treated like any other addicts. And with roughly 90 percent of facilities grounded in the principle of abstinence, that means heroin addicts are systematically denied access to Suboxone and other synthetic opioids.

On average, private residential treatment costs roughly $31,500 for 30 days. Addicts experience a hodgepodge of drill-instructor tough love, and self-help lectures, and dull nights in front of a television. Rules intended to instill discipline govern all aspects of their lives, down to when they can see their loved ones and how their bed must be made every morning. A program can seem both excessively rigid and wildly disorganized.

After a few weeks in a program, opiate addicts may glow as if born again and testify to a newfound clarity. But those feelings of power and self-esteem can be tethered to the rehabilitation facility. Confidence often dims soon after graduation, when they once again face real life with a still-warped brain hypersensitive to triggers that will push them to use again. Cues such as a certain smell associated with the drug or hearing the war stories of other addicts could prompt a relapse.

“The brain changes, and it doesn’t recover when you just stop the drug because the brain has been actually changed,” Kreek explained. “The brain may get OK with time in some persons. But it’s hard to find a person who has completely normal brain function after a long cycle of opiate addiction, not without specific medication treatment.”

An abstinence-only treatment that may have a higher success rate for alcoholics simply fails opiate addicts. “It’s time for everyone to wake up and accept that abstinence-based treatment only works in under 10 percent of opiate addicts,” Kreek said. “All proper prospective studies have shown that more than 90 percent of opiate addicts in abstinence-based treatment return to opiate abuse within one year.” In her ideal world, doctors would consult with patients and monitor progress to determine whether Suboxone, methadone or some other medical approach stood the best chance of success.

A 2012 study conducted by the National Center on Addiction and Substance Abuse at Columbia University concluded that the U.S. treatment system is in need of a “significant overhaul” and questioned whether the country’s “low levels of care that addiction patients usually do receive constitutes a form of medical malpractice.”

While medical schools in the U.S. mostly ignore addictive diseases, the majority of front-line treatment workers, the study found, are low-skilled and poorly trained, incapable of providing the bare minimum of medical care. These same workers also tend to be opposed to overhauling the system. As the study pointed out, they remain loyal to “intervention techniques that employ confrontation and coercion — techniques that contradict evidence-based practice.” Those with “a strong 12-step orientation” tended to hold research-supported approaches in low regard.

Researchers have been making breakthroughs in addiction medicine for decades. But attempts to integrate science into treatment policy have been repeatedly stymied by scaremongering politics. In the early 1970s, the Nixon administration promoted methadone maintenance to head off what was seen as a brewing public health crisis. Due to fears of methadone’s misuse, however, regulations limited its distribution to specialized clinics, and it became a niche treatment. Methadone clinics have since become the targets of NIMBYs and politicians who view them as nothing more than nuisance properties. In the late ’90s, then-���������� City Mayor Rudy Giuliani tried unsuccessfully to cut methadone programs serving 2,000 addicts on the grounds that despite the medication’s success as a treatment, it was an immoral solution and had failed to get the addicts employed.

A new medication developed in the 1970s, buprenorphine, was viewed as a safer alternative to methadone because it had a lower overdose risk. “Bupe,” as it’s become known, was originally approved for pain relief, but knowledgeable addicts began using it as a black market route to drug rehabilitation. Government approval had to catch up to what these addicts had already field tested. After buprenorphine became an accepted treatment in France in the mid-’90s, other countries began to treat heroin addicts with the medication. Where buprenorphine has been adopted as part of public policy, it has dramatically lowered overdose death rates and improved heroin addicts’ chances of staying clean.

In 2002, the U.S. Food and Drug Administration approved both buprenorphine (Subutex) and buprenorphine-naloxone (Suboxone) for the treatment of opiate dependence. Suboxone combines bupe with naloxone, the drug that paramedics use to revive overdose victims. These medications are what’s called partial agonists which means they have a ceiling on how much effect they can deliver, so extra doses will not make the addict feel any different.

Whereas generic buprenorphine can produce a high if injected, Suboxone was formulated to be more difficult to manipulate. If an addict uses it improperly by injecting it, the naloxone kicks in and can send the person into withdrawal — the opposite of a good time.

In the U.S., the more abuse-resistant Suboxone dominates the market, making it the most widely prescribed of the medically assisted treatments for opioid addiction.

Neither Suboxone nor methadone is a miracle cure. They buy addicts time to fix their lives, seek out counseling and allow their brains to heal. Doctors recommend tapering off the medication only with the greatest of caution. The process can take years given that addiction is a chronic disease and effective therapy can be a long, grueling affair. Doctors and researchers often compare addiction from a medical perspective to diabetes. The medication that addicts are prescribed is comparable to the insulin a diabetic needs to live.

“If somebody has a heroin dependence and they did not have the possibility to be offered methadone or Suboxone, then I think it’s a fairly tall order to try and get any success,” said Dr. Bankole Johnson, professor and chair of the Department of Psychiatry at the University of Maryland School of Medicine. “There have been so many papers on this — the impact of methadone and Suboxone. It’s not even controversial. It’s just a fact that this is the best way to wean people off an opioid addiction. It’s the standard of care.”

But as the National Center on Addiction and Substance Abuse study pointed out, treatment as a whole hasn’t changed significantly. Dr. A. Thomas McLellan, the co-founder of the Treatment Research Institute, echoed that point. “Here’s the problem,” he said. Treatment methods were determined “before anybody really understood the science of addiction. We started off with the wrong model.”

For families, the result can be frustrating and an expensive failure. McLellan, who served as deputy director of the White House’s Office of National Drug Control Policy from 2009 to 2011, recalled recently talking to a despairing parent with an opiate-addicted son. The son had been through five residential treatment stays, costing the family more than $150,000. When McLellan mentioned buprenorphine, the father said he had never heard of it.

Most treatment programs haven’t accepted medically assisted treatments such as Suboxone because of “myths and misinformation,” said Robert Lubran, the director of the pharmacological therapy division at the federal Substance Abuse and Mental Health Services Administration.

In fiscal year 2014, SAMHSA, which helps to fund drug treatment throughout the country, had a budget of roughly $3.4 billion dedicated to a broad range of behavioral health treatment services, programs and grants. Lubran said he didn’t believe any of that money went to programs specifically aimed at treating opioid-use disorders with Suboxone and methadone. It’s up to the states to use block grants as they see fit, he said.

Kentucky has approached Suboxone in such a shuffling and half-hearted way that just 62 or so opiate addicts treated in 2013 in all of the state’s taxpayer-funded facilities were able to obtain the medication that doctors say is the surest way to save their lives. Last year that number fell to 38, as overdose deaths continued to soar.

WAIVER REQUIRED

In multiple states struggling to manage the epidemic, thousands of addicts have no access to Suboxone. There have been reports by doctors and clinics of waiting lists for the medication in Kentucky, Ohio, central ���������� and Vermont, among others. In one Ohio county, a clinic’s waiting list ran to more than 500 patients. Few doctors choose to get certified to dispense the medication, and those who do work under rigid federal caps on how many patients they can treat. Some opt not to treat addicts at all. According to state data, more than 470 doctors are certified in Kentucky, but just 18 percent of them fill out 80 percent of all Suboxone prescriptions.

There’s no single explanation for why addiction treatment is mired in a kind of scientific dark age, why addicts are denied the help that modern medicine can offer. Family doctors tend to see addicts as a nuisance or a liability and don’t want them crowding their waiting rooms. In American culture, self-help runs deep. Heroin addiction isn’t only a disease – it’s a crime. Addicts are lucky to get what they get.

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