Mental Health Matters: America’s harrowing heroin-opiate epidemic
January 13, 2016
Cases of heroin use, abuse, addiction and deaths are increasing. Public awareness is growing as this tragedy has oozed out of the inner city and into middle-class, white, suburbia and the countryside.
Northern New England discovered a "mind boggling" and "alarming" rise in heroin related deaths. Vermont Governor Peter Shumlin found a "full-blown heroin crisis."
Heroin and opiate use increased in Southern California and in Nevada. A recent New Hampshire poll found that drug abuse was the most important issue in the presidential race.
In each state, a rise in heroin use overlapped with a decrease in the availability of legally prescribed opiates.
“It wasn’t long before the highly addictive properties of these new long-acting pain medications, particularly oxycontin, became evident and created an immense legally addicted population.”
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So, what's going on? We spend increasing billions on enforcement and drug interdiction at home and abroad, yet the nation's drug problems continue to destroy individuals, families and communities.
The story has many moving parts. One is the "supply side," where the drugs come from. In a new book, "Dreamland – The True Tale of America's Opiate Epidemic," Sam Quinones explores this supply side. He describes the collision of two business locomotives — the pain treatment industry and the black tar heroin industry.
One story tells of man's efforts to find an antidote to the principle burdens of life: pain and sorrow. The opium poppy, a euphoric and pain reliever, grown prolifically on river banks, served the purpose for thousands of years. From opium came morphine and then, in 1898, acetylmorphine, or heroin.
Efforts to provide pain relief, absent the addictive properties of opiates, has been the holy grail of medicine ever since. And each new opiate that claims immense pain relief properties, at first it reports few addictive properties. Knowledge of addiction problems comes later.
Enter short-acting opiates like codeine, hydrocodone, Dilaudid and Demerol — all are effective for acute pain, and all are addictive if given for longer periods. Then came MS Contin, followed by oxycontin, both of which are available from the pharmaceutical giant Purdue Pharma.
Aggressively marketed as providing pain relief with few addictive properties, oxycontin grew into a $3 billion a year financial bonanza. The magic, from a sales perspective, was to emphasize pain relief for chronic pain. After all, there are some 35 million Americans with back pain, not to mention arthritic pain, or chronic headache pain.
Corporate owners and medical practitioners, sensing a new revenue stream, began to open "pain clinics" to blanket America.
It wasn't long before the highly addictive properties of these new long-acting pain medications, particularly oxycontin, became evident and created an immense legally addicted population.
Eventually, in 2007, Purdue Pharma pled guilty to one felony, misbranding. The plaintiffs called Purdue a "corporate drug cartel."
As the addictive qualities of these medications became clear, state regulatory agencies cracked down on "pill mills" — pain clinics dispensing thousands of opiate prescriptions.
So, what does an opiate user, addicted to pain pills, do when the supply is curtailed? Some stop using. Others find alternative sources, family physicians, emergency rooms or illegal sellers to feed the habit. Many learn that heroin, a far cheaper opiate than the legal product, serves as an oxycontin substitute.
Enter the second part of Quinones' story — the rise of a program selling black tar heroin out of one small Mexican county.
The "Xalisco Boys" were not part of the murderous drug cartels. Instead they developed a capitalist dream system for selling heroin retail — fast and reliable — utilizing illegal labor from a few small Mexican communities.
The system was ingenious, much like a pizza delivery service: A given franchise had an owner in Xalisco who supplied high grade black tar heroin, a local manager living in the states who ran the business, a telephone operator who took calls from addicts ordering their dope, and drivers who came to you and were paid a weekly wage, food and housing. The system was clever, designed to avoid law enforcement and lengthy incarceration.
Instead of an inferior street drug that was only 12 percent pure heroin, black tar heroin came up 80 percent pure — an addict's dream.
Quinones explains the genius of heroin dealers who attracted new business by providing free starter kits to addicts at methadone clinics, and even the role of Walmart, where addicts stole goods that they exchanged for opiates.
It's also the story of how middle-class white kids, frequently athletes, were introduced to pain pills by a kindly local doc and later ended up in the morgue after a heroin overdose; and of grieving family, particularly parents, who survive in suffocating silence because of the stigma and humiliation over losing a loved one to drugs.
One story — why America created a legal opiate industry and an illegal one — went untold. That's for another column.
Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. He can be reached for comment at firstname.lastname@example.org.