Oblivion: a journey into America's overdose crisis

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Oblivion: A Journey into America’s Overdose Crisis

Zachary Siegel
Master of Arts in Specialized Journalism
University of Southern California
December 2017

TABLE OF CONTENTS

Abstract……………………………………………………………………………………………1

Body Text………………………………...………………………………………………………..2

References………………………………………………………………………………….…….27

1
ABSTRACT

Drug overdose is the leading cause of death among Americans 50 and under. While much
attention has been brought to what’s formally known as the opioid epidemic, overdose deaths
continue to surge and the problem worsens. Diving into the epidemiology of overdoses,
interviewing prominent addiction experts and public health researchers, shows why the problem
will get worse before it gets better unless policy makers come to understand the true complexity
of the problem. This reporter uses firsthand experience with addiction to draw out how we got
here and most importantly, how to get out.

2

Drug overdose is the No. 1 cause of death among Americans 50 and under. Factoring in suicide
and liver disease from excessive alcohol use, enough Americans have died premature deaths
since 1999 to lower the overall life expectancy rate for the first time in two decades (Case and
Deaton, 2017, 23-24). These deaths by drugs and suicide, which have also increased the nation’s
mortality rate, have become known in academic circles as “deaths of despair.”

For me, the despair is not academic. I used opioids and heroin on and off between 2007 and
2012, from the time I was 17 to 22 years old. I’m also a journalist, a profession that traditionally
aspires toward objectivity. But for the last three years I’ve covered the overdose crisis from little,
if any, distance at all. While getting a handle on what drove my addiction to opioids, I
simultaneously tracked the continued rise in prescription opioid and heroin overdose deaths,
which have quadrupled since the year 2000 (Rudd, 2016). My own story of addiction – feeling
alone in a crowded world; battling deep despair and depression over never having a good answer
for: what’s the point?—I realized, was part of a larger trend affecting millions of Americans.
Where people face uncertain futures, economic insecurities and declining quality of life, you find
people seeking oblivion and escape. Such has always been the case, however never have this
many died in their pursuit. Addressing the health of Americans has become an important
political issue, and millions of people who have been left in the dust of economic obsolescence
desperately need help.

I went to Adlai E. Stevenson high school in an affluent slice of Northwest Chicago. In 2017
Stevenson was ranked third best public high school in America (Niche, 2017). But I had too
much noise in my head to reap the benefits of its prestige. Among 4,000 teenagers on track to
futures as powerful executives and professional athletes, I walked the school’s halls while a loud,
relentless voice of criticism droned in my head. That’s on top of typical teenage insecurities.
3
Like being a skinny guy with a Jewish nose that I thought everyone secretly made fun of. One of
my first real girlfriends called me anorexic so I dumped her. You could say I was sensitive.

Solidly middle-to-upper middle class, our parents had access to health care, which also meant
access to prescription drugs – a substantial amount of which fueled a burgeoning market of pills
among students at Stevenson.

My friend Josh’s mom was an artist who worked from home. Inside her office was a safe stocked
with painkillers, sedatives and stimulants. Punching a 5-digit sequence on the keypad would
unlock it. But Josh didn’t know the code so he figured out a workaround. Unscrew the keypad
and open it with a key. Pills inside that safe became my first chemical buffet.

Josh and I got started with the stimulants. Attention Deficit Hyperactivity
Disorder was a common diagnosis among my peers, which meant stimulants to treat it were
readily abundant. Josh would sell his mom’s Adderall, and we’d take some on the side for fun.
Benzodiazepines, a class of drugs used to treat symptoms of anxiety by causing a sedative effect,
came into play after Adderall had us tired of being awake. Inside Josh’s mom’s safe was an
orange prescription bottle with over a hundred Xanax, tiny blue football shaped pills that also
relieved anxiety. Unlike stimulants, few teenagers are prescribed anti-anxiety medication, so
Xanax had a higher value.

By early junior year my nervous system was already naturally heightened and sensitive, so
taking a drug like Adderall only amplified a baseline feeling of foreboding. And Xanax, which I
otherwise enjoyed, made me forgetful – probably because I took way too high doses. Entire days
were rendered in grey, foggy memories. Walking around without a working short-term memory
was frightening. My algebra teacher handed me back an exam I failed, an exam I had no
4
recollection of taking. Yet there was my name at the top of the page, along with halfcocked
attempts to solve lengthy quadratic equations.

Growing up I was the youngest of three. My brother, Robbie, a senior at Stevenson when I was a
freshman, was an effortlessly smart slacker. He’d skate by, performing above average without
even trying. My older sister, Rachel, graduated from high school the year before I became a
freshman. The prototypical golden child, she was off at Syracuse studying fashion and business.
She interned at Vanity Fair and became a fashion editor for various magazines. Constantly
comparing myself to my siblings left me feeling total inferiority. Best just not to try, because I’d
never be as successful as they were.

At the time I didn’t know how to challenge the notion that everything I thought about myself was
real. A harsh voice told me that if I didn’t hide, the world would see me naked. Pills became both
a cloak and a mute button—a way to cope. Xanax, Adderall and Vicodin were all available, and
on any given day I was on at least one of them, sometimes a combination of the three. A cocktail
of pills, sprinkled with daily pot smoking, gave me a cool, quiet head. I told myself that I really
needed the pills, because without them I felt crushed by nerves and doubts.

Yes, I ran from parties when the cops were called, or from school on days the K9 unit was
sniffing around, but my drug use in high school was fortunately uneventful. My friends and I got
stoned and played computer games in our parents’ basements. Not much danger there.

But by the time I was a junior I had been prescribed my first painkillers: Once when I sprained
my ankle skateboarding, and another time when I had my wisdom teeth extracted. I told the
dentist that I hated swallowing big pills (a lie). He prescribed me a liquid alternative: every one
and a half tablespoons of a yellowish goop amounted to 10 milligrams of hydrocodone, the
active painkiller in Vicodin.
5

After the surgery was done and the pain was gone, I kept chugging. My mom, an operating room
nurse at Rush Hospital in Chicago, told me there was no reason I’d need a refill. But rummaging
around her bathroom I found it. I put cough syrup in the old bottle and swapped labels, a move
that left me with my own secret bottle of liquid hydrocodone.

Math was my last class of the day. Halfway through I began to feel sick with feverish aches,
moving from hot to cold in seconds. I stared at the clock, waiting for it to hit 3:25. When class
finally ended I sprinted to my car, where the orange bottle was stashed inside my glove
compartment. I gulped the last doses. The stolen refill barely lasted a week.

My best friend Sam met me at my car. I told him how sick I felt, and why I’d bolted from class.
Sam’s dad was a pharmacist, and we’d stolen tons of pills that he’d left around the house. “Dude,
you’re in withdrawal,” Sam said, laughing nervously.

Feeling that awful from withdrawal might be a deterrent to most people. But I discovered the
first time I tried OxyContin that the way my body reacts with opioids isn’t like most people.
While pills like Vicodin or Xanax cost around $5 a pop, OxyContin ran $25. So I bought one to
test it out before spending even more money. I shaved off a few lines of an 80 milligram
OxyContin for me and my friends. We each snorted a shiny white line. Minutes later my friends
could barely keep their eyes open. They were so high from the analgesic they could hardly make
a fist. Their phones slid out of their hands.

As for me? I became energized and chatty. While my friends could barely stand, I felt like
reading, doing homework and cleaning my room. I was used to taking opioids of a lesser
potency; but OxyContin was something different. I went home and did bigger lines by myself.
After flooding my system with this powerful painkiller I could finally relate to how Thomas De
6
Quincey describes his first high on laudanum (an alcohol-based opium tincture) in Confessions
of an English Opium-Eater, arguably the world’s first drug memoir: “Oh! heavens! what a
revulsion! what an upheaving, from its lowest depths, of the inner spirit! what an apocalypse of
the world within me!” (De Quincey, 1821, 44).

Apocalypse of the world within me. The external world fades to black, and I float within myself,
exploring my body's warmth like an astronaut of inner-space. Seventeen-years of tension melted
off my bones that night. I had no idea it would spark a five-year plunge.

***

I’ve retold this story to several psychiatrists who specialize in addiction and they all say the same
thing: “Zach, you are genetically vulnerable. Something constitutionally, something about the
way you’re ‘wired,’ is responsible for your irregular reaction to opioids.” I hit all the bases: I
have a natural tolerance (I need more of the drug than novice users), a natural liking (most
people who take opioids actually dislike the effects), and I experience a paradoxical effect (I get
stimulated where most people feel sedated).

“Addiction is mostly genetic,” Dr. Mark Willenbring, an addiction researcher and psychiatrist
tells me, inside his airy office, located a few blocks off the Mississippi River in St. Paul,
Minnesota (2017). “The rest of what causes it is environmental.” That could mean trauma in the
form of sexual assault or coming home from war. Or life could lack social cohesion, strong
bonds and a meaningful identity. My upbringing certainly wasn’t harsh. A loving family with
social and financial capital surrounded me. Still, to Willenbring, who runs an outpatient
addiction treatment clinic called Alltyr, where he treats addiction as a chronic medical condition,
my addiction makes perfect sense.

7
Nearly 90 percent of all addictions begin during adolescence, Willenbring tells me (2017). If a
young person has mental health problems like depression or anxiety, and sprinkles drugs on top
of that, the likelihood of developing an addiction increases dramatically. While I was
experimenting with drugs to get a grip on my anxiety and depression as a teenager, I was
tinkering with the fragile chemistry of my brain, flooding it with opioids during key
developmental moments. After taking large doses at high frequencies, creating steep highs and
low lows, addiction set-in. My brain adapted to the constant presence of external opioids by
manufacturing less and less of its own internal natural painkiller, called endorphins. (Translated
from Latin, endorphin means “morphine within.” The name morphine comes from Morpheus,
the Greek god of dreams.)

The Opioid Epidemic Isn’t What You Think It Is

“Why do we have this thing we call the ‘opioid epidemic?’” Dr. Willenbring wonders out loud,
(2017). Suicides, he notes, have risen by 25 percent in the last 20 years; half a million people die
each year from cigarette smoking; alcohol kills roughly 88,000 people each year. The doctor’s
gloomy list continues: 100,000 people are killed in hospitals just from medical errors. “I’m sure
many more people die from a lack of access to health care and lack of health insurance than die
from opioid overdoses,” he said, sounding exasperated. Ever since the turn of the century, public
health crises in America abound.

The Center for Disease Control and Prevention defines an epidemic as: "The occurrence of more
cases of disease than expected in a given area or among a specific group of people over a
particular period of time" (CDC, 2012). Opioids, it seems, fit the bill, or do they?

8
“So why the magnified focus on the opioid epidemic, while there’s apparently a suicide
epidemic, a tobacco epidemic, an alcohol epidemic and an epidemic of medical errors…” the
doctor continues, his voice trailing off.

Willenbring, a psychiatrist who looks like a psychiatrist, bald with a grey beard and thick-
rimmed glasses, treats addiction with medicine, just like most other diseases. And opioid
addiction is indeed occurring in varied populations across the country at alarming rates. So much
so that on August 11, 2017, President Trump declared the overdose crisis a national emergency.
Some might argue that he did so to appease his supporters. After all, Trump won regions with the
highest mortality rates from overdose, suicide and alcohol use (Monnat, 2016). His margins over
Mitt Romney’s vote tally from 2012 were actually highest in these dying counties, which tend to
dot the Industrial Midwest, Rustbelt and New England, according to research by Shannon
Monnat, a rural sociologist and demographer (2016).

Opioids are killing across demographics, not just people who live in downward communities
plagued by unemployment and access to health care. A 2017 study by Blue Cross Blue Shield
found diagnoses for “opioid use disorder” spiked 493 percent from 2010 to 2016 among their
insured members. Since I graduated high school in 2007, I lost count of how many friends of
mine, most from upper crest families, have died.

Research from Pew Trusts tallied health care costs associated with opioid addiction run an
average of $28.9 billion every year (2017). The human toll, however, is immeasurable.

Considering how serious an issue the so-called opioid epidemic is, and how many different
swaths of America it affects, it’s surprising that we rarely hear from epidemiologists themselves,
the very people who study epidemics. News stories typically include politicians, law
enforcement or grieving family members. In spite of awareness campaigns, bipartisan
9
commissions and federal task forces, fatal overdoses continue to rise. The scientists and
researchers I interviewed who study addiction and epidemiology are frustrated by both the
media’s narrative and the government’s fragmented response.

The standard “vector model of disease,” the model applied to epidemics like HIV/AIDS and
Ebola, helped shape both the public and media’s understanding, while informing the
government's action on the opioid crisis.

That story goes something like this: Uninformed or outright corrupt doctors, manipulated by
greedy Big Pharma, were prescribing their patients into addiction. Under the vector model, these
painkillers are proxies for infectious agents, and exposure to them causes addiction and death en
masse. The danger lies in the properties inherent to the chemical. Drugs and their availability are
the problem.

The epidemic began around 1999, when the death rate from opioids began to increase in linear
fashion with the rate of opioids being prescribed. One hardly needs to study epidemics for a
living to see that doctors were over-prescribing opioids to people who didn’t need them, and that
these pills were killing people. The rate of opioid prescribing increased by a factor of four in a
decade’s time, and so did the number of deaths.

A 1996 speech made by Dr. James N. Campbell, then president of the American Pain Society,
explains how such extreme prescribing began in the first place. "Vital signs are taken seriously,"
Cambell said to an audience of physicians (American Pain Society, 1996). "If pain were assessed
with the same zeal as other vital signs are, it would have a much better chance of being treated
properly." The mandate to measure pain as “the 5th vital sign” was launched, as was America’s
addiction to opioids.

10
The intention behind taking pain as seriously as respiration or body temperature came on the
heels of revelations of an appalling under treatment of chronic pain in America. America’s aging
population was hurting, and opioid pain relievers could provide relief. The move toward
aggressively treating pain coincided with another medical movement: “patient-centeredness.”
Hospitals and other health care providers were graded on patient satisfaction, which had
implications for their rankings and accreditation. If patients said they left a hospital in pain, it
was a knock against the hospital, which in America are businesses like any other where the
customer—or patient—is always right. Patients began to be treated like consumers. Are you
satisfied with your services?

Assessed subjectively, patients would rate their pain level on a scale of 1-to-10—a happy face on
one end, indicating little to no pain and a red, agonizing face on the other, to indicate intense,
severe pain. Without adequate training for pain treatment in medical schools (and little to no
understanding of addiction), physicians prescribed opioids for minor injuries, ranging from tooth
aches to lower back pain, and sent their patients home with 30, 60, even 90-day supplies. But
that isn’t the whole story. Surveys from Substance Abuse and Mental Health Services
Administration (SAMSHA) indicate that the majority of misused painkillers are not prescribed
by doctors (Hughes et al., 2016). People score pills from friends and family, from medicine
cabinets and dealers. Over-prescribing created a reservoir of pills that eventually landed in the
illicit market. Think of the safe Josh and I cracked into.

The epidemic was, at least in part, iatrogenic, meaning it was caused by medical treatment. This
understanding led former CDC director Tom Frieden to say, “The prescription overdose
epidemic is doctor-driven. It can be reversed in part by doctors’ actions” (Lowes, 2016). Just as
unprotected sex fueled the AIDS epidemic, prescription pads were the vehicle transmitting
opioid addiction, overdose and death. Frieden suggests that if these unenlightened doctors would
put their pads down and stop prescribing at such obscene rates, the mortality curve would reverse
11
and we’d get ahead of this wicked problem. You can’t quarantine doctors, so the challenge for
the CDC was to figure out how to contain over-prescribing, in effect containing the epidemic.

The first step was to keep primary care physicians and dentists from doling out months long
supplies for minor injuries or garden variety tooth extractions – effectively reducing the reservoir
of pills to be potentially misused. To help, President Obama’s Surgeon General, Dr. Vivek
Murthy, launched a campaign called “Turning the Tide Rx.” The tagline was, “We, as clinicians,
are uniquely positioned to turn the tide on the opioid epidemic.” The campaign involved a letter
and a pledge for doctors: “to educate ourselves to treat pain safely and effectively; screen our
patients for opioid use disorder; talk about and treat addiction as a chronic illness, not a moral
failing” (Murthy, 2016).

Murthy writes in the letter, “Many of us were even taught – incorrectly – that opioids are not
addictive when prescribed for legitimate pain.” He continues, “First, we will educate ourselves to
treat pain safely and effectively. A good place to start is the TurnTheTideRx pocket guide with
the CDC Opioid Prescribing Guideline” (Murthy, 2016).

The prescribing guidelines crafted by the CDC, in tandem with a board of pain and addiction
experts, ask primary care physicians to use opioids as a last line of defense against pain (Dowell
et al., 2016). The guidelines also suggest, among other things, to reduce patients already on
opioids to doses that do not exceed the equivalent to 100 milligrams of morphine per day. In
March of 2016, the prescribing guidelines were published. But it may have been too little too
late.The epidemic that began with prescription opioids was already evolving into something even
more deadly.
In 2015, 12,989 people died from heroin overdoses, according to the CDC’s yearly mortality
report from the most recent year they have data. (Rudd, 2016). That same year, 12,972 people
were killed by prescription opioids, making 2015 the first year heroin killed more people than
12
prescription opioids like OxyContin and Vicodin (Rudd, 2016). But the CDC also has another
category tracking deaths from synthetic opioids. In 2015, 9,580 people died from these drugs, a
72 percent jump from the year prior (Rudd, 2016). The bulk of these deaths are related primarily
to another substance: illicit fentanyl, a super-potent opioid alleged to be manufactured in China
or Mexico, which is being mixed into batches of heroin. In 2015, deaths from heroin with illicit
fentanyl added nearly doubled the number of people killed from prescription painkillers.
Simply put, the heroin out there—if it is heroin at all—has been spiked with a deadly poison.
Carfentanil, for example, is a particularly powerful analogue of fentanyl, sardonically nicknamed
“Elephantanil,” because it’s primarily used in veterinary medicine to sedate elephants. These
chemicals are not meant for human consumption, yet they’re taking over the heroin supply. A
glimpse at teenage overdose mortality shows how dangerous the heroin supply really is: heroin-
related deaths among 15-to19 year-olds tripled between 1999 and 2015. Jacob Sullum, an editor
at Reason, noted heroin use among the same age group dropped by over 50 percent during the
same period (Sullum, 2017). Teenagers today are much less likely to use heroin, but much more
likely to die from it.
For addiction experts like Willenbring, and other epidemiologists looking closely at the numbers,
the evolution of the crisis means that reducing opioids in the patient population inevitably
mistakes the forest for the trees.

“I’m not downplaying the fact that there is a huge problem with opioids,” Willenbring said.
“Whole counties have been wiped out by OxyContin.” The counties he’s referencing are by and
large in Appalachia, the Industrial Midwest and parts of New England – deep pits of poverty that
have struggled to recover from the 2008 financial crisis. “To me, the deaths we’re discussing are
part of something bigger. They’re deaths of despair – from alcohol, overdoses and suicide”
(2017).
13
For Willenbring, opioids themselves are not the root cause. Leo Beletsky, a professor of law and
health sciences at Boston’s Northeastern University, agrees. They are among a growing number
of experts who argue that the epidemic isn’t what we think it is. The greedy pharma and dirty
doctor narrative, however appealing, is flawed; yet it continues to inform top-down public health
policy.

Rather than proposing a vector model—drugs as infectious agents—they put forth what’s called
a “social determinants of health” critique, in which structural factors, like access to health care
and employment, social cohesion and supportive social networks, better explain America’s
addiction crisis. The problem isn’t that prescription opioids are super addictive infectious agents,
he says, it’s that since 2000, Americans have been facing complex structural problems, causing a
deep decline in quality of life for millions of people, manifest in addiction (2017).

When hundreds of thousands of Americans die prematurely – from obesity, suicide, overdose,
cirrhosis of the liver – something is rotting the public’s health. Tightening the regulation of
opioids has so far done little to address problems driving people toward painkillers in the first
place.

Dramatic increases in deaths from overdose, suicide and alcohol—the so-called “deaths of
despair” – were first expressed by Princeton economists Anne Case and Angus Deaton in their
2015 paper published in the journal Proceedings of the National Academy of Sciences (Case and
Deaton, 2015). Describing their findings to the Washington Post, Case said their work sheds
light on a “sea of despair” flowing across America (Achenbach and Keating, 2017).

Case and Deaton, a married couple and experts in statistics at Princeton, attribute the unexpected
rise in deaths, in part, to reckless prescribing of opioids. But as economists, they see another
problem happening outside of doctor’s offices: “Concentrated economic disadvantage,” they say,
14
is the real culprit driving people to painkillers in the first place (Case and Deaton, 2017). The
pain they’re trying to kill is more abstract than back or knee pain. In an interview with The Daily
Beast, Deaton said that in his view, these drug overdoses are a form of suicide (Mcgraw, 2017).
One ominous signal to the loss of dignity felt by working Americans today: If a robot can do
your job, who values you?

Digging into my own story could help explain why experts like Beletsky and Willenbring reject
the rhetorically powerful, yet technically inaccurate, “epidemic” narrative.

You may want to blame the oral surgeon for prescribing me those bottles of liquid hydrocodone.
But the only receptors inside your mouth are pain receptors. That’s why dentists prescribe so
many damn painkillers, because inflicting pain is part of their job. And pain is real. What was the
surgeon supposed to do? Watch me writhe?

Plus, he had no idea that I already had a taste for pills. That’s the difference between me and
patients who are stable on opioids: I was a teenager struggling with anxiety and depression, who
used opioids not to relieve physical pain, but to dull a constant pang of doom. Despite the
alarming overdose rates, the majority of people who are prescribed opioids do not become
addicted, overdose and die. Those who obtain pills on the black market or from their parents’
safe are the ones most likely to die.

Yet the former CDC director Tom Frieden, who called the epidemic “doctor driven,” would
blame my surgeon (Lowes, 2016). Frieden said that the pills doctors are prescribing—or liquids,
I guess in my case—are just as addictive as heroin. That’s why the CDC’s response to the opioid
crisis is squarely focused on limiting access. For one, it costs nothing to tell doctors to reduce the
rates of prescribing. And it’s right in line with how America tackles all drug epidemics – telling
people they’re bad, and that they cause addiction and death.
15

“That opioids are these deadly, addictive substances goes hand-in-hand with American
Calvinism,” Willenbring said (2017). “What goes along so well is that we’re simply a bunch of
whiners who want a pill for all of life’s problem. This minimizes the distress, agony and
dysfunction that chronic pain causes. The underlying narrative is: you sissies, you just need to
buck up, get off your rump, quit whining and go to work.”

The CDC’s singular-focus on opioid pain relievers in the patient population is causing collateral
damage to those who have chronic, intractable pain. Their complex diseases sometimes require
opioids to simply get through the day. Willenbring and Beletsky argue that if mere exposure to
opioids caused addiction—as the vector model proposes—we’d be in the middle of a far worse
crisis. Pain patients poke a wide hole in the notion that opioids are infectious agents. The real
rates of iatrogenic addiction among people who have chronic pain, who remain stable on high
doses of opioid pain relievers over long periods, is conservatively estimated at .7 to 6.1 percent
(Kertesz, 2017). While the rates are high enough to warrant extreme caution, this patient group is
not dying in droves, yet their treatment is in jeopardy.

Sherry Sherman is a 51-year-old nurse from New Jersey who has a debilitating pain disorder
called arachnoiditis. At times, she says it feels like her skin is on fire. She has been on high doses
of opioids since the early ’90s. “I’m not addicted,” she said (2017). “I will go into withdrawal if I
don’t take them, but that means I’m physically dependent, not addicted.”

Addiction is defined as compulsive drug use that persists despite negative consequences.
Sherman has no negative consequences from using painkillers as prescribed, while maintaining a
close relationship with her doctor at Johns Hopkins. I, on the other hand, nearly failed out of
college while shooting up heroin. “I have all the sympathy for people who become addicted to
16
opioids,” she said. “But I’m simply not one of them. And the opioid epidemic is killing me”
(2017).

Sherman is a victim of the revised CDC guidelines that suggest limiting the amount of opioid
pain relievers doctors prescribe. These are pills Sherman needs to get out of bed, to do her job
(she’s a nurse), to take care of her family. “The government is interfering with my pain
treatment,” she said (2017).

Part of the CDC’s guidelines, crafted in direct response to the opioid epidemic, recommend the
dose of opioids for pain patients like Sherman be reduced to less than or equal to 90 milligrams
of their “morphine milligram equivalent” per day (Dowell et al., 2016). When Sherman’s pain
flares up, and it often does, she has been prescribed to take opioids that amount to nearly 800
milligrams of morphine equivalent, shattering the CDC's recommended dosages. Since the
guidelines came out, her doctors at Johns Hopkins have cut her daily dosage in half. “It
sometimes takes her hours to get out of bed,” Mike, her husband, said (2017).

In June 2017, the FDA requested that extended-release Opana, the brand name for oxymorphone
hydrochloride, an opioid used to treat moderate-to-severe pain, be pulled off the market because
of its “abuse potential” (FDA, 2017). It’s one of the pills Sherman takes for breakthrough pain.
Meaning, when her pain is bad, that’s the one for quick relief.

The story behind Opana is that the pills led to a massive HIV and Hepatitis C outbreak in Scott
County, a small, rural part of Indiana bordering Kentucky (Siegel, 2017). IV drug users were
melting Opanas down and shooting them up. Even more alarming, injecting Opana led to cases
of a rare and serious blood disorder called thrombotic microangiopathy, which occurs from
damaged blood vessels, resulting in clotting. “The benefits of the drug may no longer outweigh
its risks,” the FDA wrote in a June 2017 press release. “We are facing an opioid epidemic – a
17
public health crisis, and we must take all necessary steps to reduce the scope of opioid misuse
and abuse,” FDA Commissioner Scott Gottlieb, M.D., said in the same brief (FDA, 2017).

Something else is unique about rural Scott County, where the outbreak occurred. In a county of
24,000, 2 percent, or some 500 people, were injection drug users. Indiana has 92 counties and
Scott County has the highest unemployment rate and the lowest life expectancy in the state.
(Indiana Gov, 2016). On top of that, 19 percent of its residents live below the poverty line and 21
percent never finish high school. What’s Opana’s role? It helps people escape a life with a bleak
future.

One month after Opana was pulled from the market, Sherman lost access to a drug she’d been
stable on for years. “The pill itself doesn’t cause people to inject it and get HIV or Hepatitis C,”
Sherman said. “Right when news came that they were going to pull it off the market, I called my
doctor and told him he needed to write me a prescription for something else” (2017).

Sherman is one of the lucky ones whose doctor is willing to bend the guidelines and keep
prescribing opioids. Others aren’t so fortunate. Pain clinics across the country are being
investigated and shut down for overprescribing. There’s no tally of how many patients have been
affected by a nationwide crackdown, but reports of suffering pain patients are slowly trickling in.

Dr. Mark Ibsen ran a pain clinic in Montana. After an investigation led by the Montana Board of
Medical Examiners, he had to shut down his clinic for overprescribing (Cates-Carney, 2016).
One of Isben’s patients, 67-year-old Robert Mason, was left without opioids and had nowhere
else to turn. No other doctors would prescribe the high doses his condition required. His pain
became so unbearable that he killed himself shortly after Ibsen’s clinic was closed.

18
“He didn’t like taking the drugs,” his daughter, Shane Mieski, said. But he had tried alternative
treatments and nothing else worked” (Cates-Carney, 2016).

Opioids for people like me are harmful, and it’s best I stay away from them. But opioids when
taken by as prescribed by patients like Sherman and Mason, help them live their lives. Opioids
taken alone are not infectious like HIV or Ebola, where exposure leads to infection. Plenty of
people are exposed to opioids without much problems other than constipation. The “opioid
epidemic” is something else entirely.

“Look,” says Beletsky, “doctors and Big Pharma may have helped spark the opioid crisis very
early on, but there’s a new overdose problem we’re facing, and it isn’t pain patients taking
prescription opioids” (2017).

Beletsky refers to the Iron Law of Prohibition–a term used to describe a process by which law
enforcement crackdown on drugs drives up their danger and potency–to explain how clamping
down on prescription painkillers caused a mass exodus toward lethal drugs like heroin and illicit
fentanyl (Beletsky and Davis, 2017).

In 2010, pain clinics in Florida churning out massive amounts of oxycodone to addicted patients
began to get raided. These clinics were called “pill mills,” and unscrupulous doctors dealing in
prescriptions for cash ran them. Drug overdose deaths increased to 2,905 from 1,804 between
2003 and 2009 – the peak of pill mill proliferation (Tavernise, 2014). After cracking down on
shady prescribers, overdoses plunged by 23 percent from 2010 to 2012. It seemed shuttering pain
clinics fixed Florida overdose problem.

But the Iron Law of Prohibition posits that enforcement strategies create more potent, dangerous
substances. Patients who lost their prescription to opioids, whether they really had pain or not,
19
had nowhere else to turn but the illicit marketplace: many transitioned to using heroin. As a
result, more people are dying now in Florida than during the peak of the pill mill crisis. Florida’s
health department estimates over 5,300 people in the state died from drug overdoses in 2016 –
significantly exceeding the number of deaths caused from pill mills (Swisher, 2017).

While the CDC keeps doctors overprescribing in their crosshairs, a new overdose crisis has
emerged.

Similar trends occurred across the United States. For years, heroin deaths remained relatively
stable while deaths from prescription painkillers soared. But heroin deaths have since spiked
dramatically, tripling between 2010 and 2015 (Rudd, 2016). As heroin deaths rose, so did deaths
from illicit fentanyl.

The crackdown thus far has created more problems than it’s solved: Pain patients needing
opioids can no longer get them; and people who illegally obtained prescription opioids to feed
their addiction turned to a deadlier market. As prescription overdoses drop, heroin and fentanyl
overdoses steeply rise.

The Crisis’s Third Wave: Illicit Fentanyl

The opioid crisis began with prescription painkillers in the late ’90s. By 2015 the No. 1 killer
was heroin (Rudd, 2016). Now, the crisis is taking its third, most deadly turn: illicit fentanyl.

Fentanyl is a highly controlled painkiller used to treat cancer and help mitigate end of life pain.
Several orders of magnitude more potent than heroin, fentanyl kills pain more effectively than
any other painkiller. But creative chemists began to synthesize bootleg fentanyl to sell on the
black market. The fentanyl that’s flowing across the East Coast, and now making its way to the
20
Midwest, is a far cry from the fentanyl patients are prescribed for pain. The majority of illicit
fentanyl imported to America originates from industrial chemical labs in China (Kinetz and
Desmond, 2016). Ingredients needed to synthesize fentanyl are also sent by mail, and there is
little law enforcement can do to stop the uber-potent opioid from flowing.

Juliette Kayyem, who studies national security at Harvard’s Kennedy School, is a loud voice for
closing what she calls a loophole in the postal system, and that she says allows international
packages into the country unfettered (2017). During the 2001 anthrax scare, Kayyem was sent a
bag of white powder that turned out to be a prank. She thinks illicit fentanyl is way scarier than
anthrax.

“These packages containing illegal fentanyl evade security screening,” said Kayyem, who also
works closely with Americans for Securing All Packages, a Washington D.C. based group that
advocates for closing the shipping loophole. “We’re not sending a rocket to Mars,” Kayyem said.
“We just need simple data screening for packages – we don’t know if 20 different addresses in
Russia are sending stuff to one address in America” (2017).

Illicit fentanyl isn’t new, but it’s never been seen at this huge a scale.
Fentanyl showed up only sporadically in heroin supplies up until roughly four years ago. Cities
like Chicago’s West Side, where I purchased my heroin for years, had typically short-lasting
outbreaks of fentanyl contamination. Between April 2005 and December 2006, a potent batch of
fentanyl produced in a clandestine lab in Toluca, Mexico, killed nearly 350 people in Chicago
(Schumann et al., 2008). Once the origin of the fentanyl was traced to the underground lab, law
enforcement shut it down and overdoses went back to baseline levels. Such tactics are no longer
working.

21
Daniel Ciccarone, a prominent researcher of heroin and drug markets at the University of
California San Francisco, says we need to rethink fentanyl’s presence in the heroin market today.
He thinks we’re witnessing a mad experiment taking place in the global drug economy. “It could
be that suppliers are trying to bypass traditional manufacturing methods by using synthetic
fentanyl analogues [chemical cousins of fentanyl]. Clearly, their experiment is a massive failure”
(2017). Dealers don’t make money off of dead customers.

Ciccarone’s work attempts to track how and where heroin is being manufactured today.
Cultivating agricultural opiates like heroin requires swaths of land in a sunny climate. But the
market is turning toward synthetic means that require only a basic knowledge of chemistry to
yield enough product to wipe out a town. Another deadly outcome stemming from the Iron Law
of Prohibition is that crackdowns also create more compact drugs. A kilo of heroin takes up
space that tiny amounts of fentanyl do not, making it easier to ship and traffic. “Under the Iron
Law of Prohibition, efforts to interrupt and suppress the illicit drug supply produce economic and
logistical pressures favoring evermore compact substitutes,” Beletsky and his co-author Corey
Davis wrote in a 2017 article that appeared in the International Journal of Drug Policy (Beletsky
and Davis, 2017).

Heroin is slowly being replaced with fentanyl. The change is most prevalent in small cities along
the Ohio River Valley, where overdoses are among the highest in the country. More than 4,000
people died from drug overdoses in Ohio during 2016, a 36% jump from the previous year’s
3,000 deaths (Johnson and Candinsky, 2017). Cuyahoga County, which makes up part of
Cleveland, had some 400 fentanyl-related deaths between 2015 and 2016. The county coroner's
office is projecting 2017 will see more than 600.

Willenbring often brings up the plight of regions like Ohio. “Why is the epidemic a regional
issue? These areas have very poor health care systems, lax regulation and poorly trained
22
doctors,” Willenbring said. “Look at Appalachia and the South, their death rates, infant mortality
rates, are third world. They’re like Uganda.” Willenbring explains how a large portion of the
labor force in these areas are aging and worn out. If you sprinkle in unemployment, severe
economic distress, loss of jobs and identities, on top of pain and disability, what do you get?

“Despair,” he says (2017).

Illicit fentanyl is more akin to the presence of bathtub gin during America’s failed flirtation with
alcohol prohibition than it is like heroin. When alcohol production went underground, purveyors
sold bad batches that killed thousands of Americans. A sinister story long forgotten, which says a
lot about America's approach to drug epidemics, even includes government agencies like the
Bureau of Prohibition poisoning the alcohol supply in an effort to stop illicit drinking. New
York’s Chief medical examiner during the 1920s referred to government sanctioned poisoning as
“our national experiment in extermination.”

“By the time Prohibition ended in 1933, the federal poisoning program, by some estimates, had
killed at least 10,000 people,” writes Deborah Blum, author of the “Poisoner's Handbook” in a
Slate article.

“We’re witnessing a poisoning crisis,” said Ciccarone, principal investigator of a study called
Heroin In Transition that aims to track America’s heroin supply. Ciccarone and his team in San
Francisco witness the heroin market’s volatility first hand. If any other product was poisoned at
this level federal agencies would get to the bottom of it, he said. “We’re just counting dead
bodies and testing them for the poison after the fact” (2017). Ciccarone thinks the FDA and the
CDC ought to contain fentanyl, the real killer agent, from spreading. But it’s primarily being
tackled through law enforcement, who collectively throw their hands up and say: “We can’t
arrest our way of this.” But still, they keep trying.
23

There are Ways Out

Coming from a depressive realist, who for years has watched the overdose crisis blossom into a
death spiral, believe me when I say there is some hope in all of this. There are lessons to be
learned. There are fixes out there.

America isn’t alone in the struggle to conquer a public health catastrophe of this sort. Countries
in Western Europe have prevailed by using an arsenal of public health solutions that have so far
gone untapped in America. High caliber research backs interventions such as easy access to
medications like buprenorphine and methadone, safer opioids that stabilize an individual’s opioid
addiction, and can reduce mortality rates by upwards of 50 percent (Siegel, 2016).

Putting addiction treatment to the side, there are other, more acute approaches for tackling
overdoses from lethal drugs like fentanyl. For one, setting up testing centers so people can check
their drugs for the presence of fentanyl. This will alert users that their batches are tainted.
Another approach is drug consumption rooms, where people can go to safely inject under the
supervision of medical staff. No one has ever died from an overdose inside a safe injection
facility (Dooling and Rachlis, 2010). But the political will to implement these measures, which
run counter to America’s often punitive, Calvinist roots that drive our conception of drug
addiction as sinful, will be among the largest hurdles to overcoming this crisis.

Chris Hayes, the host of MSNBC’s “All in With Chris Hayes,” once asked Beletsky, “If there
was, say, $100 billion to spend and five policies you could implement by waving a magic wand,
what would they be?” (2017). Beletsky’s first policy proposal had nothing to do with drugs
whatsoever. “First, a serious jobs program,” he said.
24

Beletsky and Willenbring, with the help of Case and Deaton’s research, do not think blaming
doctors and attacking the supply of prescription opioids will solve problems like poor health
care, a lack of jobs and an overwhelming feeling that there is no place in society for people being
technologically left behind.

“The crisis is and has always been regional,” Willenbring said. “There is no epidemic in
Minnesota. The most damaged places are the Ohio River Valley, up into Pennsylvania, the Rust
Belt and the Coal Belt” (2017). The same places that voted overwhelmingly for Trump, are home
to the same people who perceive their slice of the economy disappearing (Monnat, 2016).

My parents threw every resource they had at my addiction. My dad, who runs a successful
company, was able to spend over $100,000 on my treatments. My mom, a nurse in one of
America’s best hospitals, helped navigate the care I received. That care, which lasted over the
course of two-years, included multiple medical detoxes, a 90-day inpatient stint inside a
residential treatment center, followed by outpatient group therapy while living in a “sober
house"--a pro-recovery residence for people trying to stay on the recovery road.

Heroin had me for five years. It took a little bit over two years to recover from it. Recovery for
me was as much physiological as it was existential and developmental. Addiction is a long
metabolic process that requires exposure to the drug in both higher frequencies and quantities.
That takes a toll on your chemistry. All the heroin left me dealing with depression and insomnia
long after I had kicked – that’s the physical. To walk through lingering damages, I had to come
up with an answer to that dreaded question, that one that merely by being alive forces us to ask:
What’s the point? This isn’t to say that I’ve founded the ultimate meaning to my life because I
kicked heroin, but day-today, what keeps me walking, is knowing that my presence in the world
matters to people.

On heroin I was a ghost. My family, my friends, the people I loved, they missed me. I had to
combat that voice in my head, the same voice that echoed throughout my skull in high school,
25
the one that told me nothing mattered, that left me paralyzed by feeling pointlessness. This is
where recovery for me is also developmental. It's not a coincidence that I kicked at 23. My
developing brain—too damn slowly if you ask me—could finally imagine a future in which I
was there. During my late teenage years and early 20s, I had no conception of a future. There
was nothing to live for, no goal to walk toward. Doing heroin during my adolescence enclosed
me inside a 4-to-6 hour timetable: do a shot or be sick. But at 23, when I found myself living
outside the tunnel of myopia heroin produced, I no longer felt I had to retreat from the world.
Now, at 28, five years heroin free, I'm (statistically) at the same risk of developing addiction as
the general population (NIDA, 2016). I'm recovered.

Recovery doesn’t happen inside a vacuum. My biology and individual experience is nested in
society. As part of the millennial generation, growing up only knowing war and financial crises,
we’re uncertain about our futures. Bernie Sanders and his campaign galvanized many educated,
liberal millennial seeking economic justice. We’ll never make as much money as our parents.
We don’t feel secure in the world. Whether we find comfort in opiates or binging Netflix, we’re
seeking comfort.

This uncertainty signals a much deeper and more systemic challenge that’s going to require a
whole new way of thinking about the world and drug use – and that acknowledges the
importance of this issue from the perspective of economic displacement of factory workers from
Ohio, and millennials across the nation trapped into trying to obtain the now unattainable
American Dream that once was our birthright. These pains and insecurities, unless they are
addressed with care and caution, may change the politics and economics of America for
generations to come. And from my perspective as a former heroin turned journalist - worst of all
- unless we get a handle on the complexity of the drug problem and its underlying causes - the
continued misdiagnosis of the opiod epidemic by doctors and policy makers will continue to lead
to an increase in deaths from drug overdoses.

26

27
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Achenbach, Joel and Keating, Dan. “New Research Identifies ‘Sea of Despair’ Among White
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Willenbring, Mark. Interview by Zachary Siegel. Phone interview. Chicago, July 11, 2

Asset Metadata

Creator Siegel, Zachary A. (author)

Core Title Oblivion: a journey into America's overdose crisis

Contributor Electronically uploaded by the author (provenance)

School Annenberg School for Communication

Degree Master of Arts

Degree Program Specialized Journalism

Publication Date 09/26/2017

Defense Date 09/25/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Addiction,chronic pain,Epidemiology,fentanyl,heroin,memoir,OAI-PMH Harvest,opioid epidemic,opioids,overdose,Pain

Language English

Advisor Cole, K. C. (committee chair), Sender, Stuart (committee member), Smith, Roger (committee member)

Creator Email zachary.siegel1@gmail.com,zasiegel@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-435359

Unique identifier UC11265643

Identifier etd-SiegelZach-5772.pdf (filename),usctheses-c40-435359 (legacy record id)

Legacy Identifier etd-SiegelZach-5772.pdf

Dmrecord 435359

Document Type Thesis

Rights Siegel, Zachary A.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Abstract (if available)

Abstract Drug overdose is the leading cause of death among Americans 50 and under. While much attention has been brought to what’s formally known as the opioid epidemic, overdose deaths continue to surge and the problem worsens. Diving into the epidemiology of overdoses, interviewing prominent addiction experts and public health researchers, shows why the problem will get worse before it gets better unless policy makers come to understand the true complexity of the problem. This reporter uses firsthand experience with addiction to draw out how we got here and most importantly, how to get out.