By James Pilcher and Lisa Bernard-Kuhn
Cincinnati.com, June 15, 2014
In Burlington, Vermont, the police chief sees soccer moms hooked on heroin. In Knoxville, Tennessee, addicts desperate for help are waiting six months to get into treatment facilities. In Ohio, a Republican governor who had long called for the repeal of Obamacare sidestepped the General Assembly to enroll his state in a Medicaid expansion under the Affordable Care Act because the state badly needed the included federal help to treat an overwhelming surge of heroin addicts.
The United States is in the grips of one of the worst heroin epidemics in its history, due in part to a flood of cheap doses of the drug, which can be had for as little as $4 apiece, ordered on dark corners of the Web and delivered to front doors in the suburbs. In some regions, such as the Great Lakes states, heroin is deemed "highly available" by local police in more than three times the number of communities as it was just seven years ago.
The resurgence of the deadly drug has sparked a flurry of action from governors' mansions and statehouses across New England and the Midwest to small-town police stations from Northern Kentucky to Wisconsin. Even Capitol Hill and the White House are weighing in on what's become a full-blown health crisis that cuts across geographic, social, racial and economic boundaries.
"It's really on the top of everyone's radar from a public health perspective," said Thomas MacLellan, director of homeland security and public safety for the National Governors Association.
Government studies estimate the number of heroin users is around 330,000 and growing, up about 75 percent from five years ago and up almost three times compared with the decade low of 119,000 in 2003. It's a level of regular usage not seen since heroin's peak in the mid-1970s, when government studies estimated 550,000 regular users. Although heroin represents a small fraction of the nearly 24 million Americans who misuse drugs overall, heroin use is growing faster than all others.
"We've got soccer moms on heroin. … You walk down any street in any town in Vermont right now and chances are there is at least one house where someone is dealing with this," said police Chief Michael Schirling of Burlington, Vermont. He said heroin trafficking cases there increased fivefold in two years. "This is a completely underground, behind-closed-doors phenomenon."
No way out : Heroin addicts trapped in deadly maze
All told, heroin and related opioid pain pills have killed more than 125,000 in the U.S. in the past 10 years.
One very early victim of the developing crisis was Casey Wethington of Northern Kentucky, who died in 2002 of a heroin overdose at age 23.
"Within six months of learning about Casey's heroin addiction, we were burying him," said his mother, Charlotte Wethington, of Morning View in southeast Kenton County.
"We have a tremendous amount of needless deaths – tens of thousands," said Wethington, now an anti-drug activist pushing for increased awareness among local and state officials across the country. "These statistics are real people. And those who knew them, their lives will never be the same again."
Interactive : Availability of drugs in the U.S.
Heroin hot spots: Great Lakes, New England, Mid-Atlantic
Governors and other state officials nationally are scrambling to control the epidemic, which a wide range of government statistics indicate is worst in the Great Lakes, New England and Mid-Atlantic regions along with New York and New Jersey.
In the Great Lakes, for instance, the Drug Enforcement Administration's National Drug Threat Assessment reported that 9 percent of law enforcement agencies deemed heroin highly available in 2007. By 2013, 40 percent of police agencies reported heroin as highly available. In New England, the percentage of police agencies seeing heroin as highly available rose from 40 percent to 55 percent over that same time. In New York and New Jersey, high availability jumped from 30 to 45 percent.
At least 18 state legislatures addressed new heroin bills this year, according to the National Conference of State Legislatures. Subjects range from allowing easier access to drugs that counteract heroin and other opiate overdoses for first responders and even the public, as well as leniency for low-level heroin offenders who agree to treatment. Some states also are debating legislation that would toughen sentences for major drug crimes and trafficking involving heroin.
Vermont Gov. Peter Shumlin in January went so far as to devote nearly his entire State of the State address to what he called the "rising tide of drug addiction and drug-related crime spreading across Vermont."
"In every corner of our state, heroin and opiate drug addiction threatens us," Shumlin said. "It threatens the safety that has always blessed our state. It is a crisis bubbling just beneath the surface that may be invisible to many, but is already highly visible to law enforcement, medical personnel, social service and addiction treatment providers, and too many Vermont families."
In Massachusetts, after deaths from heroin and opioid drugs spiked more than 90 percent since 2002, Gov. Deval Patrick declared a public health emergency in March. "Sometimes it takes a crisis with big numbers to get the public's attention," said Public Health Commissioner Cheryl Bartlett.
Under Patrick's emergency declaration, the state invested $10 million to create a court diversion system for nonviolent drug offenders, getting them treatment, and spent another $20 million into the overall drug treatment system.
"Heroin is such a harsh drug that no one figures that it will be a part of their lives either through themselves or someone they know until it's too late," Bartlett said.
In Butler County, home of U.S. House Speaker John Boehner, the number of children being removed from their parents' custody doubled between 2010 and 2012, with heroin accounting for more than half of cases in 2012. Across Ohio, heroin addictions, demand for treatment and overdose deaths all prompted Gov. John Kasich, a stalwart Republican, to opt to go along with Obamacare measures despite the political consequences.
Across the Ohio River in Kentucky, heroin abuse is "spreading like a cancer," Senate Minority Leader Mitch McConnell, R-Ky., told a Senate narcotics group in May. "We are losing close to 100 fellow Kentuckians a month to drug-related deaths. This is more lives lost than to fatal car crashes."
Overall drug abuse deaths now exceed car fatalities nationwide, according to the Centers for Disease Control and Prevention and the National Institute on Drug Abuse, the federal agency that studies drug abuse and policy.
In Knoxville, 73 people died from drug overdoses last year, more than from homicides and traffic accidents combined. Opiates of some sort were involved in at least 36 of those deaths. "Heroin got here later than other places, but it is here now full-blast," Knoxville Police Chief David Rausch said.
Treatment facilities are overwhelmed, with wait times of six months or longer. "We have 40 beds available, and we're increasingly having to turn people away," said Ginger Marshall, the volunteer alcohol and drug treatment coordinator for the local Lost Sheep Ministry.
"This is just overwhelming everyone. It doesn't help that most insurance only pays for 30 or 60 days of treatment, when it can take that long just to get the drugs out of your system."
The opioid connection: Drugmakers pushed pain pills
The government, law enforcement and medical experts now concur the heroin surge can be traced to the rise of prescription painkillers such as OxyContin, Vicodin and Percocet. The drugs are heroin's chemical siblings – containing compounds derived from or similar to opium.
"Heroin is just a symptom of the prescription drug problem," said Joseph Rannazzisi, deputy assistant administrator of the Drug Enforcement Administration, during a U.S. Senate hearing in May.
Driven by drugmakers' promotion of physicians' wider use of painkilling drugs – advocacy later called into question by federal regulatory action and in state and federal courts – doctors wrote millions of prescriptions for opioids over the past 15 years. From 1999 to 2010, sales of opioid painkillers increased about 300 percent, according to the Centers for Disease Control and Prevention. The drugs are now prescribed to 12 million Americans a year.
Drug companies "told us addiction is extremely rare. They told us opioids worked well for chronic pain," said Andrew Kolodny of New York, president of the national Physicians for Responsible Opioid Prescribing. "They told us that it wouldn't be hard to get patients off of opioids. That was all totally not true."
In fact, hundreds of thousands of people got hooked on the painkillers. With the reformulation of prescription opioids to make them harder to abuse and government crackdowns aimed at curbing legal and illegal prescription of the drugs, those addicted to pills turned to heroin.
Mexican drug dealers met the new demand with cheap heroin and made it so that customers didn't have to risk their safety or reputation by being seen going to street corners to get it. Mexican heroin, which dominates the American market, sells for $4 to $10 a dose compared with $40 to $80 for an 80 milligram opiate pain pill. Perhaps as important, the new powder heroin can be snorted instead of injected, removing a psychological barrier for some users.
"People are going to go where the drugs are, and right now, the cheapest and easiest way to keep that addiction going is through heroin," DEA spokesman Rusty Payne said. His agency first noted the painkillers-to-heroin "cycle of addiction" in 2009.
In Vermont's Rutland County, population 63,000, doctors in 2011 prescribed more than 1 million individual doses of oxycodone, the primary ingredient in OxyContin and other opioids. That's according to Jim Baker, chief of police in the city of Rutland, who said the numbers came from local pharmacists.
"Now we have people openly admitting a heroin habit of 20 bags a day, and I haven't talked to a single person who did not get started by using the pills," Baker said. "I've been blown away by the depth of the addiction problem. I've been doing this a long time, and I've never seen anything like this."
Nora Volkow, director of the National Institute on Drug Abuse, the federal agency that studies drug abuse and policy, says surveys show about 80 percent of recent heroin addicts switched from opioid pain pills. Those same surveys show about 3 percent of the nation's 2 million opioid pill addicts turned to heroin since 2007, a percentage that she predicts will grow.
The nexus with pain treatment makes heroin "a very sensitive issue" for policymakers "because we can't just do away with opioid medication," Volkow said.
Feds say they were surprised, but others warned early
U.S. Attorney General Eric Holder acknowledged the epidemic "snuck up on us" at a national law enforcement summit on heroin in April. But he also pledged renewed attention to "an urgent public health crisis."
Holder cited a rise in investigations and heroin seizures by the DEA over the past three years and the Justice Department's commitment to specialty drug courts that let addicts get treatment "and return to their communities before incarceration."
Last year, the DEA seized more than 2,100 kilos, or about 2.3 tons, of heroin at the Mexican border. That's more than triple the amount seized in 2008. DEA officials say they weren't targeting heroin; there's just more crossing the border.
At the summit, Holder acknowledged more needs to be done. "Addressing this ... will require a combination of rigorous enforcement and robust treatment."
At the same time, the explosion of heroin users, addicts and overdose deaths has some critics asking why it took so long and whether a faster response by public officials – at all levels – could have slowed or prevented heroin's resurgence. Much of the criticism is aimed at the Food and Drug Administration's handling of the approval of the original opioid pain pills for wide use.
"This did not sneak up on us," said Kolodny, who is also chief medical officer for Phoenix House, a New York-based drug treatment nonprofit organization. "The opioid epidemic began in the late 1990s, and very early on we saw people who were addicted to opioids move over to heroin. Had the FDA been doing its job, I don't think we would have an epidemic today."
Wethington, the anti-drug activist, said the fervor with which government officials are acting is encouraging, but it is much delayed. "I was trying to sound the warning bell, and nobody was listening," said Wethington, who now works as an addiction and recovery counselor.
Unable to find local help from doctors, law enforcement or treatment centers, before and after her son's overdose, Wethington pushed for changes to Kentucky law to allow families to petition courts to intervene and order addiction and rehab services for drug addicts – even if they had no criminal record.
"I never understood the concept of letting an addict crash and burn before you intervene," she said. "This is a public health crisis. Addiction is a chronic disease."
Kentucky adopted the Matthew Casey Wethington Act for Substance Abuse Intervention in 2004 – modeled after an existing Florida law. Ohio adopted a variation of Casey's law in 2012. Advocates in at least 11 other states, including Indiana, Arizona, New York and Florida, are working to do the same.
"I get calls from people all over the country who ask me how can I get Casey's law in my state. It's bittersweet because we couldn't save our own son."