With Rise Of Painkiller Abuse, A Closer Look At Heroin

Nov 2, 2013
Originally published on November 4, 2013 11:26 am

Abuse of prescription painkillers is a "growing, deadly epidemic," according to the Centers for Disease Control and Prevention.

On Oct. 24, the Food and Drug Administration recommended putting new restrictions on hydrocodone, sold as Vicodin and other brand names.

Dr. Andrew Kolodny believes the restrictions are necessary and will prevent new people from developing addiction. But, he says, there are millions who already have the disease and need access to effective treatment.

"If they don't have access to legal sources [for painkillers], many of them will turn to the black market," he tells NPR's Arun Rath. "And if they can't find black-market pills, they'll buy heroin on the black market."

So while the abuse of painkillers has become a focus for concern, the corresponding rise in heroin use is also prompting calls for action.

The Connection Between Heroin And Painkillers

The number of people reporting heroin use in the previous year increased between 2007 and 2012, from 373,000 to 669,000. Meanwhile, federal data from 2011 finds that nearly 80 percent of people who had used heroin in the past year had also previously abused prescription painkillers classified as opioids.

Opioids — derived from opium — include morphine, oxycodone, hydrocodone as well as heroin, says Kolodny, who is the chief medical officer for the national drug treatment network, Phoenix House, and president of Physicians for Responsible Opioid Prescribing.

Opioids share a similar molecule, he says, and "when they attach to the brain's opiate receptor, they all cause a very similar effect."

They give "both a positive reinforcement — the effect when you take the drug — but also very strong negative reinforcer, which is that you'll feel very sick when you don't have the drug," he says. "Those two factors together make opioids extremely addictive."

Legislating A Call For Help

Several years ago, John Nygren says, his teenage daughter started having trouble.

"She would not come home in the evenings at times. She was not going to school. There were incremental steps along the way, where we saw there were problems," he says.

Nygren is a fourth-generation Wisconsinite, from the small town of Marinette. He now represents the town in the State Assembly.

His daughter, Cassie Nygren, became addicted to the prescription painkiller OxyContin. Eventually, she was drawn to heroin — and overdosed on it in 2009.

Her mother found her on the bathroom floor, "struggling to breathe," John Nygren says. A needle was still in her arm.

Cassie Nygren hadn't been alone in that bathroom, but those who were with her left when she overdosed. Nygren says that was probably because they were afraid of the authorities getting involved.

The paramedics arrived in time to save her life, but she has continued to battle addiction. She's been in and out of treatment and is currently serving time in county jail.

Now, John Nygren is using his position to change things in Wisconsin. He has introduced legislation to give people legal protection when calling 911 about an overdose. It's part of a package of bills to cope with the opioid crisis in his state.

The Rise Of Painkillers

According to the CDC, the amount of prescription painkillers sold to pharmacies, hospitals and doctors' offices across the U.S. quadrupled between 1999 and 2010.

"With the increase in prescribing, what we've seen is that it's led to parallel increases in rates of addiction and increases in rates of drug overdose deaths," Kolodny says. "And it's gotten so bad that the CDC is now telling us there are more people in the United States dying each year from drug overdoses than car crashes."

The United States is completely alone in this trend, Kolodny says.

"The United States has about 4 percent of the world's population, and we're consuming more than 80 percent of the world's oxycodone supply. We're also consuming more than 99 percent of the world's hydrocodone," he says.

In many cases, the prescriptions are entirely legitimate, says Dr. Elinore McCance-Katz, who specializes in addiction psychiatry and is first chief medical officer at the Substance Abuse and Mental Health Services Administration.

"Opioid medications are effective pain relievers and used by the majority of people for that purpose. Individuals do not become addicted to these medications when used as clinically prescribed," she says. "But there are people who have vulnerability to addiction."

McCance-Katz says that opioid addiction is a chronic illness, but, fortunately, "very treatable."

"As people get treatment — and that treatment includes medication and psycho-social treatments — they do recover," she says.

Numbing The Pain

In Glendale, Calif., 18-year-old Preny Ebrahimi is on the other end of treatment.

In her family's apartment, with her mother looking on, she says she struggled in school with attention deficit disorder. Around the time she was 13 or 14, Ebrahimi says, she fell in with the wrong crowd.

First, there was marijuana. Then there were the prescription painkillers, which were easy to find. Then there was methamphetamine, and one day she tried smoking heroin.

"After that day, I just fell in love with the feeling and the numbing pain, and I just kept doing it and doing it and doing it," she says. "And it just ate away at my life."

She says she was using "every day, every hour" for about 18 months.

Eventually, Ebrahimi bottomed out. She had stopped using heroin on her own, but that brought on withdrawal. She stole her father's car to meet a dealer and nearly ran over her father driving away. When she got home, her family confronted her.

"Everybody was just trying to talk to me, and I was going crazy because I didn't want to talk, I just wanted to go be alone and do it," she says. "They were like, 'We don't know what else to do. You need to stop.' "

The pain became too much, Ebrahimi says — for her family and for herself.

"The high itself, that numbing pain, it was just not worth it anymore to put my family and myself through. And I just wanted to stop," she says.

Ebrahimi's parents had her placed in juvenile detention, and a judge mandated residential drug treatment at Phoenix House. She stayed there for five months. It has been a long road — one that has clearly taken a toll on her family.

But Ebrahimi has been clean and sober for almost three years. She has a job now and plans to start college in the spring.

"These years sober have been the best years of my life. I've gained so much trust back," she says. "It's a feeling like no other, honestly, going through all that and being here right now, a place you'd never thought you'd be."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

Transcript

ARUN RATH, HOST:

It's ALL THINGS CONSIDERED, from NPR West. I'm Arun Rath. In a moment, we'll have more on the shooting at LAX. First, meet John Nygren. He's a fourth-generation Wisconsinite from the small town of Marinette.

STATE REP. JOHN NYGREN: It's a middle- to lower-middle-class manufacturing community. We actually build ships as well as paper mills and other heavy manufacturing - typical, you know, Northern Wisconsin community.

RATH: Nygren grew up there on the border with Michigan. He owned a restaurant, started a family and eventually, a career in politics. He's a Republican, and he represents Marinette in the state assembly. Several years ago, Nygren says, his teenage daughter Cassie started having trouble.

NYGREN: She would not come home in the evenings, at times. She was not going to school. There were incremental steps along the way where we saw there were problems.

RATH: Nygren was unprepared for what came next. Cassie had started using the prescription painkiller OxyContin. She was addicted. Eventually, Cassie moved on to other drugs. She met her father for dinner at a pizza place in town, and broke the news.

NYGREN: I remember her telling me that she was addicted to heroin. I was almost - literally - sick to my stomach. You know, my perception of heroin was a big-city problem. Maybe rock stars and, you know, people of that type used heroin but not your very intelligent, 18-year-old, pretty girl who had a bright future ahead of her.

RATH: All around the country, communities like Marinette, and families like the Nygrens, have witnessed a spike in heroin abuse. It's sending people to emergency rooms, ripping apart families, and destroying thousands of lives. That's our cover story today: America's new heroin crisis.

(SOUNDBITE OF MUSIC)

NYGREN: I got a frantic call from her mom one day, and she had gone home to close windows because of an upcoming storm. And she found her laying on the bathroom floor, struggling to breathe. I raced over there. She still had a needle in her arm. And you were, literally, watching your daughter die before you.

RATH: Cassie Nygren had overdosed on heroin. The paramedics arrived in time to save her life. But she continued to struggle with addiction. She's been in and out of treatment, and is currently serving time in county jail. According to numbers from the federal government, the number of people using heroin has grown significantly - by more than 60 percent over the last 10 years. Part of what's so surprising about Cassie Nygren's story and others is the location.

BOB STUTMAN: From 1965 to 1990, the only people that used heroin were inner-city, poor kids. It had nothing to do with ethnicity; it had to do with poverty. Those were the only people who used heroin.

RATH: That's Bob Stutman. He worked for the Drug Enforcement Administration for more than 25 years, and retired in the early 1990s as head of the New York Division. Stutman says the nature of drug use has drastically changed in the U.S. The suburbs and rural areas are getting hit especially hard. He says a lot of it has to do with the rise and abuse of prescription painkillers known as opioids.

STUTMAN: All of these people who are today going to heroin, did not start with heroin. Most of them started with opioids like OxyContin. They used those for a year or two, three; where they got them very cheaply or for free, from medicine chests. And then when they had to buy them on the street, they found out that heroin is about half the price. And that's, in my opinion, the reason we are seeing the new heroin epidemic in the United States.

RATH: According to federal data, 80 percent of people who used heroin in the past year had previously abused these prescription painkillers. Dr. Andrew Kolodny is the chief medical officer for a drug-treatment network called Phoenix House, and the president of Physicians for Responsible Opioid Prescribing. He says these drugs contain very similar ingredients.

DR. ANDREW KOLODNY: The term "opioid" includes drugs which are derived from opium, and they include medications that are commonly prescribed like morphine or oxycodone or hydrocodone, which is the active ingredient in Vicodin. And they also include heroin. And what all of these drugs have in common is a very similar molecule. And when they attach to the brain's opiate receptor, they all cause a very similar effect.

RATH: There's a good chance you've been prescribed an opioid painkiller at some point - for dental work or broken bones, or after surgery. According to the Centers for Disease Control and Prevention, the amount of prescription painkillers sold to pharmacies, hospitals and doctors' offices quadrupled between 1999 and 2010. Experts agree it was largely a well-meaning attempt to manage people's pain. But Dr. Kolodny says the United States is completely alone in this trend.

KOLODNY: The United States has about 4 percent of the world's population, and we're consuming more than 80 percent of the world's oxycodone supply. We're also consuming more than 99 percent of the world's hydrocodone.

RATH: In many cases, the prescriptions are entirely legitimate. Dr. Elinore McCance-Katz is an addiction expert with the Substance Abuse and Mental Health Services Administration.

DR. ELINORE MCCANCE-KATZ: Opioid medications are effective pain relievers, and used by the majority of people for that purpose. Individuals do not become addicted to these medications when used as clinically prescribed. But there are people who have vulnerability to addiction.

RATH: Many people don't get the drugs from a doctor but from a medicine cabinet, a friend or a dealer. The CDC now calls prescription painkiller abuse a growing, deadly epidemic. Again, Dr. Kolodny.

KOLODNY: With the increase in prescribing, what we've seen is that it's led to parallel increases in rates of addiction, and increases in rates of drug overdose deaths. And it's gotten so bad that the CDC is now telling us there are more people in the United States dying each year from drug overdoses than car crashes.

RATH: What is it about opioids that makes them so addictive?

KOLODNY: Not only do opioids produce a euphoria, but when you get used to taking them on a regular basis, in order to get that euphoria, you need to continue taking higher and higher doses. And once your body is used to the drug, without the drug, you begin to feel very sick. You feel this flu-like illness and literally, feel sometimes like they're going to die. It's like having a panic attack.

So you have both a positive reinforcement - the effect when you take the drug - but also a very strong negative reinforcer, which is that you'll feel very sick when you don't have the drug. And those two together make opioids extremely addictive.

RATH: Both the government and physicians are working to stop the abuse of prescription painkillers. Just last week, the FDA recommended putting new restrictions on hydrocodone, the active ingredient in Vicodin. That has concerned some patient and physicians' groups. They worry that people in pain will lose access to legitimate medications. Dr. Kolodny believes the restrictions are necessary, and will prevent new people from developing addiction.

KOLODNY: But we have millions of people in this country who have the disease already. And if they don't have access to legal sources, many of them will turn to the black market. And if they can't find black market pills, they'll buy heroin on the black market. And what this tells us is that we have to make sure that the millions of people who have this disease, have access to effective treatment.

RATH: Dr. McCance-Katz says that opioid addiction is a chronic illness but fortunately, very treatable.

MCCANCE-KATZ: As people get treatment - and that treatment includes medication and psychosocial treatments - they do recover.

RATH: We visited one young woman who is on the other end of that treatment. Preny Ebrahimi is 18 years old from Glendale, Calif.

PRENY EBRAHIMI: I have my daily problems like everybody, but nothing I can't handle compared to what it was like before.

RATH: Ebrahimi spoke to us from her family's apartment - her mother looking on. She told us she had struggled in school with attention deficit disorder. Around the time she was 13 or 14, Ebrahimi says she fell in with the wrong crowd. First, there was marijuana. Then there were the prescription painkillers, which were so easy to find.

EBRAHIMI: You can honestly find it anywhere - in school, at home. Most people even find it in their own medicine cabinet.

RATH: Then there was methamphetamine. And one day, she tried smoking heroin.

EBRAHIMI: After that day, I just fell in love with the feeling and the numbing pain, and I just kept doing it and doing it and doing it. And it just ate away at my life.

RATH: How often were you using?

EBRAHIMI: Every day, every hour.

RATH: And how long did that go on?

EBRAHIMI: For about a year and a half.

RATH: Eventually, Ebrahimi bottomed out. She had stopped using heroin on her own, but that brought on withdrawal. She stole her father's car to meet a dealer, and nearly ran over her father driving away. When she got home, her family confronted her.

EBRAHIMI: And everybody was just trying to talk to me, and I was just going crazy because I didn't want to talk. I just wanted to go, be alone and do it. My brother came, and he held me. And he was like, what's wrong? He was like, are you high right now? I'm like, no, I'm not. I'm like, I need it. (Starts crying)

And they started talking, and they were like, we don't know what else to do. You need to stop. It was just too much pain for my family, too much for myself. The high itself, that numbing pain, it was just not worth it anymore to put my family and myself through. And I just wanted to stop.

RATH: Ebrahimi's parents had her placed in juvenile detention, and a judge mandated residential drug treatment at Phoenix House. She stayed there for five months. It has been a long road, one that has clearly taken a toll on her family. But Ebrahimi has been clean and sober for almost three years. She has a job now, and plans to start college in the spring.

EBRAHIMI: These years sober have been the best years of my life. I've gained so much trust back. And it's a feeling like no other, honestly, going through all that and being here right now, that - a place you'd never thought you'd be. It's honestly amazing. I can say I'm proud of myself. (Laughter)

RATH: In Wisconsin, Rep. John Nygren is working to change things. As he told us, when his daughter Cassie overdosed, she was not alone in that bathroom. But her friends left her to die, probably because they were afraid of the authorities getting involved. Nygren has introduced legislation to give people legal protection when calling 911 about an overdose. It's part of a package of bills to cope with the opioid crisis in his state.

Wisconsin is not alone. Around the country, states are studying reform and passing laws. Communities are now coming to terms with a new American epidemic.

(CHEERS FROM CROWD)

RATH: This is NPR News.

(SOUNDBITE OF MUSIC) Transcript provided by NPR, Copyright NPR.