When Jim Gillen arrived for work at the Providence Center on February 4, he found a crowd of his clients dressed in black suits, shuffling nervously around the lobby. Gillen, who serves as Manager of the Providence Center’s Recovery Services Division, knew where they were going without having to ask. He held open the door as the group silently embarked on its routine walk to the cemetery and scanned the crowd for the missing patient.
The missing patient was Charles Brown, one of 45 people to die from opiate overdoses in Rhode Island since the beginning of 2014. The 27 deaths recorded in January alone show a sharp increase from the 18 reported in January 2013 and 15 each in January 2011 and 2012. The overdoses—which, according to the state’s Department of Health, have reached “epidemic” proportions—are due in part to a rise in the availability of a powerful painkiller called fentanyl, which was detected in 28 of the overdose victims screened so far. Fentanyl, which is about ten times more potent than heroin, caused a similar wave of overdoses in New Jersey several years ago, killing 133 people between April and December of 2006. The drug is used as a pain reliever in clinical practice and is available as a prescription, intended mostly for cancer patients.
Holly Fitting, Director of Residential and Intermediate Services at the Providence Center, said that many people exposed to fentanyl unintentionally use heroin laced with the drug. The recent spike in overdoses from fentanyl has been compounded by a national increase in heroin usage in recent years. “We’re trying to educate our clients that if they’re going to use, they need to get their drugs from a reliable source,” Fitting told the Independent.
Josiah Rich, Professor of Medicine and Epidemiology at the Brown University Medical School and Attending Physician at The Miriam Hospital, told the Indepedent that heroin addiction often starts with prescription drug abuse. “[People] get injured, start using opiates, use more and more until they can’t stop,” Rich said. “But these drugs are expensive, and when people get tight on resources, the first thing they do is turn to heroin.”
Since prescriptions for opiates like OxyContin and Nicodin are offered by doctors, many users don’t recognize the danger of these drugs. But the rate of overdose from prescription painkillers has more than tripled in the US since 1990, claiming more than 125,000 lives in the last decade.
The past few years have seen a national effort to crack down on prescription drug abuse. People can no longer fill multiple prescriptions for the same drug from different doctors or fill the same prescription at multiple drug stores. State lawmakers are cracking down on “pill mills” across the country by requiring pain management clinics to record prescriptions on a state registry. But current trends suggest that shutting down the supply of opiates will cause users to turn to heroin to get high instead. The transition poses a different and equally dangerous set of problems. “Rather than buying OxyContin tablets that are made by a reputable company, where there’s quality control,” said Rich, “you’re going to buy a packet of powder, and you don’t know what’s in there.”
The increasing popularity of prescription painkillers has led to a demographic shift in heroin use. Patrick McEneaney, Senior Vice President and Regional Director of the Phoenix Houses of New England drug treatment facilities, explains, “The way people are entering into use of these drugs is not the street corner anymore, it’s a medical office building.” As a result, prescription painkillers have become a primarily white, middleand upper-class “drug of opportunity.” According to a study by the Substance Abuse and Mental Health Services Administration, the number of non-heroin opiate admissions for whites totaled over 9000 in 2011, while the admissions for all other races combined was under 1000. The fact that these opiates act as a gateway to heroin means that the demographics of heroin-users have shifted drastically as well. While heroin was most popular among African-Americans and Hispanics in the ‘70s and ‘80s, whites now make up a striking majority of heroin users. Of the 45 people that have died of overdoses in the past month in Rhode Island, 40 were white and five were African-American.
Prescription-drug abuse and overdose rates have been increasing nationally since the start of the millennium, but Rhode Island’s numbers are particularly staggering. With a rate of 15.5 drug overdose deaths per 100,000 people, Rhode Island has the 13th highest drug overdose mortality rate in the country and the highest in New England. Traci C. Green, a researcher at Rhode Island Hospital, told the Providence Journal that Rhode Island’s high rate of mental illness could be a contributing factor to the state’s drug-abuse problem. Given that approximately a quarter of all adults with serious mental illness have substance-use dependence, and that Rhode Island has the highest rate of serious mental illness in the country, Green’s theory seems plausible. Other possible factors include Rhode Island’s high unemployment and high foreclosure rates. Gillen, of the Providence Center, which provides behavioral health care services in Providence and Burrillville, RI, believes that Rhode Island’s drug abuse and overdose rates are inflated because of the state’s small size and comprehensive reporting and record-keeping.
In response to the increase in overdoses, Rhode Island lawmakers and health advocates have attempted to address the factors leading to drug abuse and overdose in the state. In 2012, Rhode Island General Assembly passed the Good Samaritan Overdose Prevention Act, which guarantees legal protection to people who report overdoses. Even more dramatic is the extended availability in recent weeks of Naloxone, a drug that can counter the effects of an overdose. Walgreens began selling the drug (also known by the trade name Narcan) in the spring of 2013 for $16 a dose. In early February, Rhode Island State Police announced plans to train and equip all police officers with Narcan. The drug also recently became available in all licensed treatment clinics and facilities treating people with histories of drug abuse. Narcan, which can be injected or inhaled nasally, restores the signals between the brain and lungs, which become blocked during an overdose.
The next step is to make Narcan readily accessible to individuals who, due to poverty or lack of knowledge about the drug, would be less likely to purchase it themselves at Walgreens. At the Community Listening Forum on Overdose Prevention sponsored by Rhode Island Communities for Addiction Recovery Efforts (RICAREs) on February 19, Dennis Dutra of RICAREs suggested supplying all incarcerated individuals with Narcan and offering training in its administration upon release from prison. Fitting, of the Providence Center, told the Independent that many former prisoners resume drug use upon release, unaware that their tolerance has waned during incarceration. According to the World Health Organization, the risk of dying from a drug overdose in the first two weeks after release from prison is up 10 times higher than it is a year after release.
Another important solution raised at the forum is the increased availability of drugs like Methadone and Suboxone, used to control withdrawal symptoms in patients treated for narcotic drug addiction. Medication-assisted treatment has gained popularity in recent years as addiction increasingly becomes understood as a medical rather than a behavioral or criminal issue. The Phoenix Houses’ McEneany told the Independent: “People recognize now that addiction is a brain disease, that drug-use causes the brain to change physiologically. If people see it as a medical issue, they’re more likely to use medical means to fix it.”
The fact that these withdrawal drugs are covered under current healthcare reform is further incentive for this particular route to recovery. Health advocates such as Rebecca Boss, of the Rhode Island Department of Behavioral Healthcare, argue that the drug-abuse prevention community should strive to make these drugs even more accessible by expanding methadone treatment facilities and amending the federal law that prevents physicians from treating more than 100 patients with Suboxone at a time.
Whether discussing Narcan, medication-assisted treatment, or more standard behavioral health treatment facilities, health advocates agree that the most crucial goal for the recovery community is to erase the current stigma—internalized by addicts as shame—surrounding drug use and recovery. Ian Knowles, director of RICAREs, who himself was addicted to drugs and alcohol from age 16 to 46 (he is now 71), says that many problems facing recovering drug addicts—from flawed treatment options to a lack of safe, affordable housing and employment—are a result of stigma. Michelle McKenzie, program director at Miriam Hospital, identifies healthcare as an area particularly affected by shame. Many current and former drug addicts do not reveal information about their addiction to health care providers, fearing discriminatory treatment. The fact that addicts feel compelled to lie to their doctors, whether that fear is justified or not, is, according to McKenzie, a “failure of the healthcare system.”
Stereotypes of drug users in the media perpetuate the stigma. “When you see celebrities in the media who have struggled with addiction, they’re at their lowest point,” McKenzie says. “When people survive and get their life back together, that doesn’t make the front page.” Overrepresentation of minority and impoverished groups as drug users often cause the stereotypes to take on racial and socio-economic characteristics. “The recent rise in drug abuse and overdose among whites hasn’t gotten rid of the stigma,” says McKenzie. “But more people are paying attention.”
Knowles thinks that the only way to overcome stereotypes about drug addiction and reduce stigma is to put positive voices of recovery into the community. “For many years myself and others kept our recovery within a small circle of friends and family,” he says. “But the only way we’re going to make a change is by addressing this issue publicly and by letting people know that recovery is a reality.” Knowles says that stigma surrounding addiction stems largely from ignorance of addiction as a biomedical condition and instead seeing it as a sign of moral weakness. Political campaigns such as Nixon’s domestic “War on Drugs” in the 1970s have created a structural stigma by treating drug-use as a criminal issue rather than a public health issue.
Dutra, a board member at Direct Action for Rights and Equality (DARE), believes firmly in the power of positive recovery stories to encourage others to seek treatment. Growing up in East Providence in the ’80s, Dutra was surrounded by drugs and alcohol from a young age. His father was a marijuana dealer, his best friend’s dad an alcoholic. By age 12, Dutra had begun using marijuana and alcohol. It wasn’t long before he started using cocaine. After becoming addicted to heroin at age 25, Dutra went to prison 30 different times on drug-related charges. He was court-ordered into treatment programs in 1998 and 2000, but relapsed immediately after both. “I didn’t want recovery then. I didn’t think I deserved to live a productive life,” he told the Independent. “Every time I went to prison, all I did was get high behind the walls.”
Finally, Dutra had what he calls a “spiritual awakening” and decided to enter into recovery. He spent six months in inpatient treatment at the Providence Center and went on to join a 12-step fellowship program, in which he continues to participate. The day I met Dutra was his 1000th day of sobriety. “It’s a gift,” Dutra says, nodding emphatically. “I want to send a message to people who are struggling with addiction that recovery is possible.”
While Dutra’s story shows that recovery is possible, it doesn’t mean that recovery is likely. Of the 40 people in Dutra’s treatment class at the Providence Center, only four successfully completed the program. And while the community listening forum featured many people who, like Dutra, have been able to overcome their addictions and use their experiences to help others, the voices of loss and hopelessness seemed to outnumber the voices of success.
Rhode Island native Elise Reynolds began the forum with her story of losing two sons to overdoses. In 2002, her son Paul had been prescribed OxyContin following back surgery after a motorcycle accident and became hooked. Paul’s older brother, Ted, was introduced to OxyContin by a friend soon after. The brothers spent years in and out of treatment until Paul died of a heroin overdose at the age of 22. After Paul died, Ted, who had been clean for three months, relapsed. At the age of 30, Ted died of an overdose.
As Reynolds left the stage, the room was silent. Much of the audience—social workers, doctors, and policymakers—was well-acquainted with tragedy. Many others heard this story and, like Elise, wondered how they could have missed the signs. In smaller numbers, there were the recovering addicts, who heard this story as one that could have been theirs. “It used to be that we were talking to ourselves,” said one of the forum panelists, Craig Stenning. “But right now, people are listening.”