Anthony De La Rosa was 22 when a player on his college baseball squad introduced him to a new drug: Oxycodone. “We weren’t just smoking weed any more. We would go to practice, come back and snort Oxy in the dorm rooms. At that time, I was told it was a muscle relaxant, so I didn’t know about addiction. I didn’t know anything.”
In fact, Oxycodone is a highly addictive painkiller and a molecular cousin of heroin. When De La Rosa encountered it in 2012, America was awash with opioid painkillers. Doctors prescribed 234 billion milligrams of morphine equivalent that year, nearly 10 times more than two decades earlier. They were emboldened by research, paid for by Big Pharma, which claimed there was little risk of addiction — despite centuries of evidence documenting the dangers of the euphoria-inducing opium poppy.
The marketing power of drug companies and laissez-faire attitude of doctors has fuelled one of the worst public-health epidemics of modern times, which ended up proving ruinous for De La Rosa and millions of others. Middle-aged patients with bad backs became addicts. Teenagers pilfered tablets from their parents. And when the pills started to run out, many turned to heroin. In 2016, 42,200 Americans died from an overdose, more than from either car accidents or gun violence.
I meet De La Rosa, a native of Queens, New York, on a snowy morning at Odyssey House, a publicly funded residential rehab centre in East Harlem. He has a tall, athletic build that befits a former college sports star and is dressed as though he has just come from church: blue cardigan, crisp pale shirt, red striped tie. With a stare at once earnest and intense, he recounts how it all went wrong.
Although people in recovery are encouraged not to glorify the past, he cannot help remembering the good days. “I still have memories of a time when I wasn’t worried, when everything was all right. I liked the feeling I got when I took Oxy. The pills did their job, they always made me feel good.”
I still have memories of a time when I wasn’t worried, when everything was all right. I liked the feeling I got when I took Oxy. The pills did their job, they always made me feel good
But as he abused opioids in greater quantities, De La Rosa turned to petty crime to fund his habit. Once, he stole three expensive watches, including one he had bought for his sister’s birthday. “I was able to sell them for nothing, for $20, just to get high at a pizzeria. It was crazy.” After taking a job in a pharmacy in 2016, he was caught stealing opioid painkillers, arrested and ordered to enter treatment. Following several unsuccessful spells in rehab, he wound up at Odyssey House.
De La Rosa thinks he can beat his addiction this time around because he has started taking Suboxone, a medication containing a mild opioid called buprenorphine. It works by satisfying a person’s physical cravings for opiates and includes a second chemical that prevents them feeling euphoric. “What the Suboxone has allowed me to do is to stop the bleeding and gain some perspective,” he says. “Now, when I wake up in the morning, I don’t think about getting high: I think about constructing a productive day.”
Some experts in drug addiction say Suboxone and other medicines with buprenorphine offer the best hope of stemming the flow of fatalities in this crisis. “I think it is the single thing that is most likely to help us reduce deaths,” says Andrew Kolodny, an academic at Brandeis University and a leading authority on the opioid epidemic.
But others argue that drug abusers will simply be swapping one narcotic for another, potentially becoming addicted to the cure. They believe people can only recover if they practise complete abstinence. “We are in danger of creating a subclass of Americans who will be on pharmaceutical opiates for the rest of their lives,” warns Luke Nasta, who runs Camelot, a rehab programme on Staten Island in New York. “Are we ready to write these guys off, to medicate them and let them go off into the sunset?”
Nasta’s point of view had, until recently, found support at the highest levels of government. In May last year, Donald Trump’s inaugural health secretary, Tom Price, said: “If we’re just substituting one opioid for another, we’re not moving the dial much. Folks need to be cured so they can be productive members of society and realise their dreams.”
We are in danger of creating a subclass of Americans who will be on pharmaceutical opiates for the rest of their lives
This “abstinence v medication” debate has raged in the US since 1914, when the country’s first major narcotics laws were passed, according to Nancy Campbell, a historian at Rensselaer Polytechnic in New York. “It is part of an ideological, cultural conservatism rooted in old moralistic explanations for why people became addicted: because they were weak of will or flawed. I hear echoes of that in the abstinence crowd today. All the evidence in the world would not change their opinion.”
In Washington DC, where Trump has declared the crisis a “ public health emergency”, the pendulum now appears to be swinging in favour of medication. A commission led by Chris Christie, the former New Jersey governor, has backed wider use of Suboxone. And Alex Azar, who replaced Price as health secretary, is a supporter, recently telling an audience that tackling addiction without such medications was “like trying to treat an infection without antibiotics”.
But if politicians are serious, they will first have to rewrite more than a century of legislation and regulation that has been designed to promote abstinence over medically assisted treatment. And they will have to find a way of convincing the thousands of sceptics working in the substance-abuse industry, which is comprised of more than 15,000 centres nationwide, two-thirds of which do not offer Suboxone.
Christian, another Odyssey House resident, thinks it is worth trying. The 28-year-old moved here nine months ago to be close to his girlfriend Amy, also a recovering addict who lives in a nearby facility with their two-year-old daughter. “I don’t see how you can have a rampant drug addiction and get clean without Suboxone. Calming my addiction and cravings helps me focus on my family, and on being a better human being and father.”
Before the Harrison Narcotics Act was passed in 1914, there was virtually no regulation of substances such as opioids or cocaine in the US, says Campbell. “Lots of doctors were prescribing and profiting from morphine, which was the main engine of addiction in the 19th and early-20th century. Most of the people who were addicted — about two-thirds — were white middle- or upper-class women. People didn’t regard these sweet ladies as a threat, but there was a feeling something had to be done.”
In the decades after the legislation was introduced, America became one of the most inhospitable places in the world for someone suffering from addiction. Doctors were sent to jail if they practised maintenance therapy — which involves using controlled amounts of opiates to control cravings. This pushed many patients towards the black market and most of those caught using illegal drugs were subsequently jailed.
In 1935, as Franklin Delano Roosevelt battled the Great Depression, his administration struck a New Deal for addicts and opened the first Federal “narcotics farm”. Rather than being put through cold turkey on the floor of a cell, inmates were sent to a 1,500-bed facility in Lexington, Kentucky, where they were slowly weaned off drugs. Afterwards, they received therapy and counselling. It was abstinence — but abstinence with a heart.
The Lexington facility continued to operate until 1975, when it was dealt a fatal blow after it was discovered that LSD had been secretly tested on inmates at the behest of the CIA. But in the ensuing moral panic, an important lesson went unheeded: abstinence had failed. Studies subsequently found that more than 90 per cent of inmates relapsed after leaving the farm.
The Lexington farm and a second facility in Fort Worth, Texas, were the first of several messy compromises designed to deal with America’s burgeoning addiction problem. During the 1970s, for instance, Richard Nixon oversaw an expansion of methadone, an opioid used to provide long-term maintenance treatment. But to counter fears that addicts would use the drug to get high, it was only made available at specially licensed clinics, a policy that still stands today. Many of these are squalid, sad places, and lots of potential beneficiaries are put off by the stigma of having to attend daily.
Suboxone is made by Indivior, a British pharmaceuticals group, which generated $877m in US sales of the drug last year, about 2 per cent more than in 2016. It is often described as a more perfect successor to methadone. Buprenorphine is a milder opiate that is less likely to induce euphoria, while the second molecule, naloxone, dampens any residual high. Doctors have been allowed to prescribe it in their surgeries since it was introduced in the US in 2002, rather than at a special clinic. But onerous restrictions — the product of another political fudge — have made it almost impossible for some addicts to access.
When the Seaview Hospital on Staten Island was opened in 1913, it was the largest tuberculosis sanatorium in the US. Today, the massive urban ruin — which spans 80 acres and once accommodated 2,000 patients — is an eerie, windswept place. The wards, still littered with rusting iron beds and primitive wheelchairs, are connected to a giant morgue by a network of underground tunnels. In 2013, Camelot, a not-for-profit drug rehab group, gave the site a new lease of life when it opened a treatment facility in one of the derelict buildings.
A funereal atmosphere hangs over Camelot when I visit on a freezing afternoon. News has just arrived of a former resident who recently died of a heroin overdose — a 31-year-old who was clean when he checked out but must have started using again. Inside one of the centre’s treatment rooms, Nasta, who has run the rehab programme for more than 40 years, is trying to work out what went wrong.
Nasta’s face is a mask of worry. The 69-year-old slumps his broad shoulders, stares into the middle distance and traces a finger along a deep furrow in his brow. “I take it personal,” he says. “What the hell didn’t I do? How did I fail?” He turns to Andrey Petrovskiy, a current resident. “This is what I’m going to ask all the guys: did you know he was going to relapse?”
Petrovskiy pauses for a while before answering: “Us addicts talk a good game but from what he said in meetings, I thought he had a good chance of staying clean. He did also say he was scared. We all are.” Their fear is well founded. On Staten Island, one of the worst affected areas in New York, an overdose death happens every four days on average — a staggering toll for a community that numbers fewer than 500,000.
Petrovskiy, now 27, emigrated with his parents to the US from Ukraine aged six and quickly developed a love of American sports. Today, he cuts a burly figure weighing in at 13 stone. But when he entered treatment six months ago he was barely nine stone, having hardly eaten for a year. His descent into what he describes as “pure drug insanity” started as a teenager when he experimented with marijuana and cocaine. “The drugs progressed with the times. It went from weed to coke to heroin. But before heroin, it was the pills — always the opioid pills.”
Over the past four years, I have spoken to scores of people suffering from opioid addiction, and all of them say it began with prescription painkillers. Most of them started out on OxyContin, made by Purdue Pharma, or generic versions of the drug. Some developed a hankering after being prescribed it for genuine pain, while others stole from their parents or bought pills on the street.
It went from weed to coke to heroin. But before heroin, it was the pills — always the opioid pills
When the authorities recognised people were abusing prescription drugs on a large scale, they belatedly tried to choke off supply. “The police started cracking down on the doctors prescribing [illegally], who were getting busted left and right. When supply gets low and the demand is still out there, people start charging a lot of money. That is when heroin came on the scene,” recalls Petrovskiy. He says the street price of a 30mg OxyContin pill went from $12 in 2008 to more than $20 by 2010, taking the cost of his habit to more than $100 per day.
One explanation for the recent surge in fatalities is that they are “ deaths of despair”, caused by the same forces that propelled Trump to the White House. But while that might explain higher levels of addiction, there is another, more important factor driving the spike: the heroin supply in the US has become more dangerous than ever before.
Increasingly, the street drug is being cut with fentanyl, a cheap synthetic opioid designed to tranquillise large animals, which is mostly made in Chinese factories and smuggled into the US. It is 50 times more potent than heroin and much more likely to kill. “It’s not a heroin epidemic out there. It’s a fentanyl epidemic,” says Petrovskiy. “They use it on elephants. Can you imagine what it does to people?”
Because of the infiltration of fentanyl, users cannot work out how much to inject to get high, and small mistakes are proving fatal. People recovering from addiction have always encountered slips but rarely has falling off the wagon proven so dangerous as now. It is against this backdrop that Suboxone supporters say it should be widely adopted: anything that can control a person’s cravings and their risk of overdosing should be embraced.
Some doctors go so far as to claim that the pursuit of abstinence is in fact dangerous. When people wean themselves off heroin, they lose tolerance. Then, if they relapse — as happens so often — they can easily take too much. There are instances of people leaving rehab and overdosing on a fraction of what they are used to.
“There are people who have gotten clean without Suboxone, and a lot of guys would say it’s just another crutch,” says Petrovskiy, who has been on the medication for a few months. “But you need something strong to battle something strong like heroin addiction.” He does not intend to take the drug for a long time, and is about to start gradually reducing his dose until he stops entirely. “I just want to get clean, to feel like my old self again: I don’t remember a day clean since I was 13.”
Nasta is against the use of Suboxone as a long-term maintenance therapy, although he thinks it has some utility in the shaky days after someone has gone through detox. Like lots of drug counsellors — many of whom are former substance abusers themselves — his approach is informed by his own experiences.
He was arrested in his mid-twenties for dealing heroin and sent to a treatment programme. After completing that, he took a job as a counsellor at Camelot and worked his way up to the position of executive director. Many of his contemporaries relapsed during the 1980s Aids epidemic and subsequently contracted the virus via dirty needles. “Within 10 years, they were all dead. There was a period of time where I was going to a wake every week.
“I’m not a purist but I do believe that sincere, repeated attempts should be made at coping with life on life’s terms without the aid of chemicals,” he says. “Counselling is all about opening up, talking about your history and reconnecting with feelings that have been masked by drugs. And Suboxone is a blocker — it cocoons you so counsellors can’t get in.”
Nasta is aware of the theory that widespread use of Suboxone as a long-term treatment could dramatically reduce overdose deaths, but he says it is essential that people deal with the underlying reasons for their addiction. “Otherwise, they’ll go on to stimulants, cocaine, crack . . . They’ll use alcohol. They’ll start taking barbiturates. It’s a life — sure, you’re still breathing — but is it a quality of life?” He is also highly suspicious of those who preach medicine as the solution, given that drugmakers and doctors share a great deal of blame for kickstarting the crisis in the first place. “The government will not have learnt anything as long as they keep relying on the pharmaceuticals industry and the medical profession. They caused it at one end. And now they’re making money by ‘solving’ it at the other.”
You might not guess it from his slight frame and shy smile but Andrew Kolodny burns with a sense of injustice about how America is handling this epidemic. He believes the current model, where people are treated with therapy in residential facilities, should be replaced by a massive increase in access to Suboxone. “America has plenty of rehab beds. We do not need any more. It is not an answer to the opioid crisis,” he says.
He points to growing evidence suggesting that opioid addiction is fundamentally different from other substance-abuse disorders, and that it leads to long-lasting changes in the brain which cause constant cravings. A 2011 paper published by Stanford University showed patients who were dependent on opioids developed abnormalities in the brain’s neural reward-processing network. Researchers noticed a reduction in the amount of grey matter in the almond-shaped mass that plays a role in how we process emotion and fear.
I don’t think that abstinence approaches work for opioid addiction. I think that many people just need their prescription
People with opioid addiction describe their cravings as intolerable. The analogy most commonly used is dying of thirst. “You’re dehydrated, you’re sweating, you’re cold, you’re hot, your stomach is cramping, you’re doubled over in pain, you can’t catch your breath,” says Amy from Odyssey House. “You’re not able to think properly at all, because you’re just thinking about one thing, and that’s feeling better. You feel you’re going to die.”
Given that such cravings can be controlled by Suboxone, Kolodny thinks it could dramatically reduce rates of relapse and overdose deaths. “I don’t think that abstinence approaches work for opioid addiction. I think that many people just need their prescription. You can keep giving them a refill and they’ll do really well.” But isn’t the logical conclusion that some people will be on medication for ever? “I don’t like to say ‘for life’,” he says. “But I’d say for a very long time.”
Anything even approaching a “drug-for-life” is anathema to Nasta and many others in the rehab field, but Kolodny argues it is unfair to treat opioid addiction differently from other chronic diseases caused by unhealthy lifestyles. Many sufferers of these illnesses could in theory control them with a better diet or more exercise but they are not denied medicine because of that fact.
“What would happen if type 2 diabetes were not treated?” he asks. “People would go blind, have limb amputations or go into renal failure. It would be a public-health disaster. And that is basically where we are right now with opioids.”
You’re dehydrated, sweating, cold, you’re hot, your stomach is cramping, you’re doubled over in pain
As the overdose death toll rises, there are signs of a shift in opinion towards Suboxone. The Hazelden Betty Ford Foundation, the best-known name in US addiction treatment, started recommending the drug be used in 2013 at the behest of its medical director, Marvin Seppala. The switch was seen as a groundbreaking moment for the field because Hazelden, founded in 1949, has been one of the biggest proponents of abstinence.
Most substance-abuse programmes in America are based on the 12 steps, a method pioneered in 1935 by Bill Wilson and Bob Smith, the founders of Alcoholics Anonymous. Step one involves admitting that you are powerless over your addiction. The subsequent steps require you to believe in a higher power, normally God, and to place yourself in their care. Many backers of medical treatment find the programme queasy for its quasi-religious bent. Compared with medically assisted treatment, there is not much quantitative proof underpinning the effectiveness of the 12-steps programme, although there is plenty of anecdotal evidence suggesting it works very well for some people.
Convincing the roughly 250 counsellors who work for Hazelden to back Suboxone was not easy, says Seppala, because many of them thought it preposterous that the pharma industry would have the solution. “There was a fairly generous mistrust of the house of medicine in general, so when Suboxone came along it was seen from that same sort of vantage point. People didn’t see it as something they could support.” He recalls receiving a four-page letter from Kellie Lund, a counsellor, who had been with Hazelden since 1983, which predicted the policy change would “wreak all kinds of havoc”.
Two years ago, Lund approached Seppala at a meeting and gave him a hug. Despite her initial opposition, she had become a convert. “I was so afraid the clients would relate to Suboxone as a mood-altering street drug, and would sell it to each other to get a buzz,” she recalls. “I was concerned people could not have a spiritual reawakening if they were numb with medication. But it really surprised me — they are much more stable in their cravings and much less overwhelmed, which means they are able to get more out of treatment.”
Changing hearts and minds is only part of the battle. Even once a patient has decided they want to get on Suboxone, many of them struggle to find a doctor able to prescribe due to strict rules introduced in 2000 to stop it being abused. These regulations have been loosened as the opioid crisis has raged, but only very slightly.
Doctors and nurses who want to become prescribers must first complete eight hours of training, after which they must abide by stringent caps on patient numbers. There are roughly 50,000 people certified to prescribe the drug in the US but nearly three-quarters of them are forbidden from treating more than 30 patients at a given time. The result is a chronic shortage of professionals able to prescribe the drug, especially in some of the states most ravaged by the epidemic, such as West Virginia, New Hampshire and Maine. This shortage means doctors who have been certified are able to pick which patients they treat. In the private US healthcare system — where profit reigns supreme — many choose to prioritise patients who can pay in cash, rather than those covered by Medicaid, the government scheme for people with low incomes.
That was the experience of Elizabeth Brico, a 30-year-old mother of two who has battled heroin addiction for nine years. She recently moved from Seattle to Florida, where she has struggled to find a doctor that would accept a Medicaid payment for Suboxone. After working her way through her remaining supply, she has had to stop taking the medicine altogether. “I haven’t found a programme where a doctor doesn’t charge hundreds of dollars a visit,” she says.
These limits have had a chilling effect on the number of prescriptions being written. At the end of 2017, the number of patients starting a treatment like Suboxone was 82,000 per month, according to Iqvia, a data provider, compared with the three million who started on an opioid painkiller.
“I started messing around with painkillers like OxyContin and, as most people find out, pills are expensive. So then I started shooting heroin,” says Charles Russell, 30, who has just celebrated 16 months of being sober. It is the longest period he has gone without drugs since he started abusing opioids 10 years ago. As his addiction worsened, his life fell apart. He was thrown out of The Drums, an indie band where he played guitar, and moved to Los Angeles to become a tour manager for a comedian. Before too long he lost that gig as well and wound up living near Skid Row, a notoriously dangerous area where thousands of homeless people live. One night he was mugged by someone who broke into his car and stole his phone and wallet.
No one wants to get clean at a methadone clinic. All I found were people to go and get drugs with
After not hearing from him for weeks on end, his parents became so worried that they flew to LA and tracked him down. “They came out, scooped me up off the street and brought me back home. But I continued to use drugs. The heroin was pretty terrible in Connecticut, so I started doing meth and smoking crack too.”
Things came to a head on a fateful night in early 2017. Using $400 of bitcoin on the dark web, Charles bought half an ounce of pure methamphetamine, and it turned up a couple of days later in his parents’ mailbox. That night, his mother found him taking the drug in the family bathroom, while a search of his coat turned up a crack pipe. His parents checked him into a local rehab that was covered by their health insurance, which turned out to be a grim, depressing place.
A second try at rehab was much more successful. This time, Charles’s parents sent him to Silver Hill, a luxurious facility located on a 44-acre campus surrounded by Connecticut woodland. “I lived in a mansion — an 8,000 sq ft mansion — and there were only 10 of us.” Charles was adamant that he did not want to take Suboxone, in large part because of his earlier experience with methadone, a drug he describes as “liquid handcuffs”. He had attended a clinic while living in Los Angeles but he says it was a waste of time. “No one wants to get clean at a methadone clinic,” he says. “All I found were people to go and get drugs with. As far as my treatment goes, it is very important to me that I’m not on an opioid.”
After six weeks of therapy at Silver Hill, Charles moved to a “sober-living home” in Manhattan, a halfway house for people recovering from addiction, where residency is contingent on the ability to pass drug tests. The facility is housed in a salubrious brownstone in the Upper West Side on a street where neighbouring properties sell for north of $10m. Its owner and operator, Transcend Recovery, caters to well-heeled millennials with deep pockets and substance-abuse problems.
It is here that I first meet Charles, who is chatting with the professional chef who cooks meals for residents. He moved out of Transcend last year after living there for nearly seven months but returns regularly to catch up with residents and staff. “It was great being around other young people who had some of the same problems but, at the same time, being held accountable. Transcend was such a huge part of my recovery: the people who work here and the people who lived here are some of my closest friends.”
Charles received the best rehabilitation money can buy. His treatment at Silver Hill cost between $50,000 and $60,000 — which his parents paid for in cash because it was not covered by insurance — while the rent for a shared room at the sober house costs up to $10,000 per month.
Although Transcend is less than an hour’s drive from the Camelot facility in Staten Island or Odyssey House in Harlem, it feels like a different world. But Luke Nasta believes a version of Charles’s experience — without the private chef and swanky zip code — provides a model for how addiction should be treated. He plans to launch a “reintegration housing scheme” to support people once they have finished rehab: “We’ve been telling the government for years that this is what is needed to finish the job.”
No matter which side of the rehab debate you come down on, there is little doubt that something must be done to stop the huge numbers of Americans dying from opioid overdose. Suboxone is not a magic pill — few medicines are — but it might offer the best hope of holding back the tide. The people who took part in this article are the lucky ones. They still have a story to tell.
David Crow is an FT correspondent in New York
The names of some interviewees have been changed
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Accepting our addictive natures is a challenge / From Dr Robert Lefever
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