The Spiral Into Fentanyl

Rebecca* started experimenting with drugs when she was 14. Her friends were doing it and she wanted to try too. She started with weed and alcohol, but less than a year later, she began stealing Xanax from her mother and buying it from her boyfriend, a drug dealer.

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The couple broke up when Rebecca was 16 and she lost all their mutual friends. But she quickly found a new crowd—a group from Huntington High School—and a new boyfriend. He was a heroin dealer. Still reeling from the pain of her last break-up, Rebecca wanted to give it a try. It only took one use for her to become an addict.

“I felt completely numb, euphoric and detached from reality,” Rebecca recalled. It was exactly what she thought she needed.

Within a week her family sent her away to rehab for 10 months. It didn’t work. Neither did her next trip. Or the next one. Rebecca said she has been to rehab 20 times since 2013, completed 10 inpatient programs, been to jail three times and needs two hands to count the number of funerals she’s attended for friends who have overdosed on heroin. But none of that scared her and, at the age of 17, she realized she received a bag of heroin laced with something. She later learned it was fentanyl and people were dying from it. That didn’t scare her either.

“My addict brain would get excited about getting potent stuff and that it was going to do the job,” Rebecca said. “You get a certain warmth in your chest. It’s different than heroin, a different euphoria, more intense at once.”

Intense is an understatement. The anesthetic often used for surgery and to treat cancer patients in extreme pain is 50 times more potent than heroin.

Fentanyl is the latest wrinkle in an epidemic that, despite increased awareness over the last decade, is only getting worse. In 2016, a record 502 Long Islanders died from an opioid overdose. Nearly half (242) were related to fentanyl. As usual, Suffolk County was the hardest hit—180 people died from a fentanyl overdose, up from 86 in 2015, but this has yet to be explained.

“Now you have a whole class of people who take it to the next level and are actually seeking fentanyl. And heroin becomes like…a Tylenol,” said Steve Chassman, LCSW, CASAC the executive director of Long Island Center for Alcohol and Drug Dependency (LICADD).

I-Stop, a computerized system used to track prescription pill abuse, was introduced to halt widespread doctor shopping for medications like OxyCotin in 2013. It’s worked—sort of. Since then, rates of opioid prescriptions have dropped nationwide and in New York—the first time there has been a decrease since 1996, the year OxyCotin hit the market. Yet overdose rates have continued to increase. Users began shifting to heroin, a cheaper, more potent alternative. To make their product more desirable, dealers began cutting heroin with fentanyl, an even less expensive but more potent option. Unlike heroin, which must be derived from poppies, fentanyl can be made in a lab, making it easier to produce.

“This is a business initiative [on the part of dealers],” said Chassman. “It’s cheap, it’s synthetic and it’s potent…[People] are doing three bags of heroin that are 80 percent pure, then getting one mixed with fentanyl. This is the greatest contributor to the overdose rates that have soared on Long Island.”

In an effort to lower rates, Governor Andrew Cuomo signed legislation that allowed NARCAN, an overdose-reversing drug, to be available in drug stores without a prescription. The hope was that by making it more accessible to addicts’ loved ones, it could save more lives. But because fentanyl is so powerful, overdose-reversing drugs like NARCAN don’t always work. Fentanyl floods the brain’s opioid receptor more quickly than heroin and binds more tightly to it, explained David Schlager, MD, who works in the psychiatry department of Stony Brook University Hospital. It can put the user past his or her lethal dose of opioids.

Why is This Happening?

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Elected officials have asked Chassman why, despite the publicity and legislation, is the opioid epidemic is getting worse, not better. Chassman likes to call it the “billion-dollar question” and typically answers with another one: “Why are more Long Islanders, older and younger, trying to anesthetize themselves at a rate we’ve never seen?”

He has his theories: Social media bullying, technology forcing people to work far longer than the traditional 9 to 5, stress induced by watching crisis after crisis play out on 24-hour news networks.

“People are looking to self-medicate,” Chessman said. “These drugs are highly good at anesthetizing for fear, sadness, low self-esteem, harassment and social acceptance or lack thereof.”

Research on whether mental illnesses like depression can lead to addiction has been mixed. In 2012, researchers in Washington and California found that depressed people were about twice as likely as non-depressed people to misuse painkillers. A separate study published in 2015 found that adolescents were more likely to use prescription painkillers for non-medical reasons and become addicted. But last year, Harvard researchers found mood disorders did not increase someone’s chances of starting to use opioids. Nevertheless, they did conclude that a person with a mood disorder was twice as likely to continue to use prescription opioids after physical pain went away in an effort to mask emotional pain. And the slide from prescription painkillers to heroin and now to fentanyl is, at this point, an over-documented reality.

It’s also true that stress can lead to addictive behaviors. In 2008, director of the Yale Interdisciplinary Stress Center Rajita Sinha found that chronic stress or trauma can lead to an increase in stressor-produced cortisol in the brain. For adolescents, negative life events that can cause long-lasting stress include loss or divorce of parents, physical or emotional abuse. Trauma causes include physical and sexual abuse. To adapt, the brain essentially rewires itself. Sinha also found that stress can effect prefrontal functioning and lead to low behavioral and cognitive control, which can skew judgement.

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Rebecca recalled suffering from anxiety in high school but not being able to get a grasp on her underlying issues.

“I didn’t know what was happening when I had anxiety attacks in class,” she said. “Then every time I went to treatment, It was like peeling the layers of onion, there’s a lot of emotional turmoil you have to address.”

Other factors, such as family history of addiction, can also increase someone’s likelihood of abusing drugs themselves. But Schlager doesn’t think mental health professionals should focus more on anxiety and depression issues when treating a current addict or one early in recovery.

“[Focusing on what the addict is masking] is overly emphasized and in some ways dangerous,” he said, adding that he frequently works with patients who think if they are treated for anxiety, they won’t need to use anymore. Though self-medication may be a reason someone initially uses a drug, “Once you get addicted to something it takes on a life of its own. The desire to use does not go away once you’re addicted.”

By not addressing the addiction as a separate issue from mood disorders, a patient remains a continued overdose risk. Schlager believes the desire to use, not the need to self-medicate, is the real reason we are still in the midst of a public health crisis that has allowed fentanyl to take hundreds of lives in the last year alone.

The Road to Recovery

An opioid addict must overcome a minimum of two hurdles to get and stay clean: the physical withdrawal and the mental cravings. The physical pain, which produces flu-like symptoms including vomiting, shaking, abdominal pain and muscle spasms typically lasts a week. Narcotic pain relievers like Suboxone and methadone can help lessen symptoms, but getting past physical withdrawal is only a fraction of the battle.

Kristie Golden, the associate director of operations, neurosciences, neurology, neurosurgery & psychiatry at Stony Brook University Hospital, said the amount of time it takes for an addict to get over mental cravings varies from person to person. For some, they never go away. It helps to explain the enormous relapse rates for opiate addiction. A 2010 study conducted by Irish researchers followed 109 opiate addicts in in-patient facilities. Ninety-nine relapsed after being discharged, including 64 within one week. Primary reasons included heavier opiate use prior to treatment and no aftercare.

It doesn’t help that the national average stay in an in-patient facility is only 11 to 14 days, and Chassman has seen addicts get discharged after just three or four days. “Insurance companies had a fiduciary interest in only allotting three or four days for treatment for heroin of fentanyl,” he said. The average in-patient stay for drug addiction can cost insurance companies $30,000 per month. Five days of heroin detoxification is about $3,000. Last year, Cuomo signed legislation that ended prior insurance authorization for immediate access to inpatient service. The law requires that a patient diagnosed with substance use disorder receive a minimum of 14 days of inpatient care if s/he is on an in-network insurance plan. It’s a start, but still barely enough time to get past physical symptoms. A two-week stay quickly puts addicts back around triggers before they have the mental wherewithal to withstand the pressure to relapse.

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“In an ideal world it takes 90 days for the mind to re-route itself, to understand, ‘I have to develop and learn healthy coping skills and how to apply them,’” Chassman said. “But you run into the problem of who is paying for that?”

Vivitrol, which can be prescribed to a patient by a doctor after detox, is a monthly shot that can block the effects of opioids including feelings of well-being and physical pain relief. Approved by the FDA in 2010, there has not been much research on the long-term effects of the drug. And at $1000 per shot, it can be too pricy for all addicts.

In an attempt to reduce relapse rates at an accessible rate, The Family and Children’s Association opened THRIVE, a sober space for recovering addicts, in March. It is a free recovery space on Long Island and it provides education, counseling and activities for addicts and families on-site. The hope is to keep addicts away from the people, places and things that trigger them and provide them with a new community similar to the ones they find in 12-step programs.

“This is where people can go, old and young, and meet other people in recovery,” said Chassman, who advocated for the center with LICADD. “It’s unrealistic to say, ‘You’re addicted to the most powerful narcotic on the planet and when we release you after four days, don’t ever show another symptom.’”

Sometimes, an addict can’t even get one day in treatment. Nationwide, 23.1 million Americans needed treatment for drugs and alcohol in 2012. That’s 8 percent of the population. Only 2.5 million received it at a facility that specialized in drug and alcohol detox or rehabilitation, according to the federal Substance Abuse and Mental Health Services Administration. That means 90 percent of addicts never received the help they needed. Rebecca remembered friends who called an in-patient center looking for help only to learn there was a wait list for a bed and Golden has heard the same from addicts who tried to get into an outpatient program. Golden said it’s often because as the crisis has grown, treatment centers have struggled to keep up, something Chassman believes has been fatal.

“If you’re ready and want [help] and the treatment center says, ‘Call back in 2 weeks’…There’s no two weeks. There’s only now,” he said. He added that LICADD has built connections with rehabilitation and detox facilities for six decades and uses them to help patients find treatment on-demand.

Time is always of the essence when treating opiate use—one bag of heroin laced with fentanyl can kill someone, even if it’s the first time they’re using. In an effort to catch the disease early and prevent it from happening in the first place, Stony Brook University Hospital rolled out a screening and prevention protocol SBIRT in February 2016. The program trains clinicians to screen patients for risky behavior that could indicate addiction or potential for addiction. During the training, providers are instructed to connect patients with resources, which can range from a support group to a NARCAN kit. All 11 hospitals in Suffolk County followed suit, as did Stony Brook’s primary care settings such as Family Medicine.

“Starting the conversation has not always been routine,” Golden said. “When you have primary care physicians routinely asking about alcohol and drug use, our hope is it will help those providers better understand their patients and to catch things earlier on in the person’s life in order to help them access whatever they need to prevent a lifetime of addiction.”

On June 14, the New York State Senate passed a bill package that added six new derivatives of fentanyl to the controlled substance list, which is regulated by the Department of Health. The package, which passed in Assembly and will now reach Governor Cuomo’s desk, also called for tighter penalties for dealers. Bill 2761, known as Laree’s Law, establishes that if a dealer sells a controlled opiate substance that results in someone’s death, s/he can be charged with homicide. If convicted, the dealer can spend up to life in prison. Currently, a dealer who sells a fatal dose of opiates is typically charged with criminal sale of a controlled substance, which carries a sentence of 5 to 25 years depending on his or her record.

To get drugs off the streets, the Suffolk County Police Department introduced an anonymous hotline last year, which allows people to call in tips about drug rings and dealers to 631-852-NARC. It has led to 32 arrests since April 2016. The department understands the need for a multi-faceted approach and is also focusing on prevention. In 2015, it implemented drug education program The Ugly Truth. The program informs parents of signs of substance abuse, explains physical and emotional consequences of drug use and provides families and addicts with resources. Participants can also receive NARCAN training and take home a kit. The program has been presented about 50 times across Suffolk County, including schools and libraries. The department also instituted Project Medicine Cabinet, a drop-off receptacle where people can discard expired or unused medications, in each police precinct. The aim is to prevent people—and their families—from misusing the drugs which can lead to fentanyl and heroin abuse and overdose.

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Even though time is of the essence, it can take a while for programs to take hold, which could explain why the problem is getting worse before it gets better. And a person has to be open to hearing the messages.

“I wasn’t ready to surrender,” recalled Rebecca. “I was just trying to please [my parents] or [go because] my habit got too expensive…I went for all the wrong reasons.” Rebecca had three weeks in recovery when we spoke and is planning to earn the last credit she needs to graduate high school. “This is the first time I’m taking the initiative. My parents gave up. They did the tough love thing. They did everything they could. It’s like, ‘Shit or get off the pot. This is your life.’”

* Name has been changed at person’s request

The LICADD 24/7 hotline for Suffolk County is 631-979-1700. Other New York state residents can also call 1-877-846-7369.

beth ann clyde

beth ann clyde

Beth Ann Clyde is a social strategist of Long Island Pulse. Have a story idea or just want to say hello? Email or reach out on Twitter @BAClyde.