On Tuesday, February 23, a new documentary on the opioid crisis premiered on PBS and online. Chasing Heroin, a two-hour FRONTLINE documentary, dives deep inside the epidemic and explores how the problem began, how it’s affecting our nation, and what’s being done to address the issue.
FRONTLINE is U.S. television’s longest running investigative documentary series. They’ve won every major journalism and broadcasting award, including 75 Emmy Awards. Marcela Gaviria, the director, writer, and producer of Chasing Heroin, was asked by a reporter for the Huffington Post what got her interested in making the film.
“I began my career at FRONTLINE reporting on the drug wars. I was born and raised in Bogota, Columbia, and had cut my teeth following the cocaine wars, so it was natural territory for me. The heroin epidemic first came onto my radar back in 2013, after I heard about the spike of overdoses in places like New Hampshire and Vermont. I pitched this story for several years and was really pleased when I finally got the green light to pursue the story.”
Six minutes into Chasing Heroin, a Seattle police vehicle rolls up on three young adults who are loitering in an alley. A young woman is on the ground shooting up heroin. A young man is standing up hugging a girl when he becomes alarmed and says, “oh cops! I hate that!”
Then a police officer gets out of the vehicle and says something that shocks me. “I got you. You’re getting well. Nah big deal. I’m not gonna jam you up.” I have to admit, at this point in the film I got a little teary eyed and emotional. A typical interaction would be for the police to arrest the drug users and bring them straight to jail. However, cops in certain Seattle communities have a different methodology. Instead of arresting nonviolent drug users, at their discretion they can instead direct the addict to treatment, counseling, housing, job training, healthcare, mental health support, and other recovery resources.
In Chasing Heroin, Lt. Leslie Mills was interviewed by FRONTLINE correspondent Martin Smith. After hearing about this progressive policing methodology, he states bluntly, “gee, you’re taking an awful gentle approach.”
She then responds, “we could not incarcerate our way out of the problem. You would arrest a person, they’d be in jail for twenty or thirty days, they would get sober, they would start using again, we continued to arrest them, and they would use, and continue to arrest.”
The Quietest Epidemic
After the exciting intro to Chasing Heroin, which shows a relatively new and experimental crime diversion program in action (which I’ll cover in more detail later), the film zooms out to provide a “bigger picture” look at the opioid epidemic that has swept across the U.S. like a plague.
In Chasing Heroin, Sam Quinoes, author of Dreamland, reports on the epidemic. “Cops, prosecutors, and epidemiologists, public health nurses, county coroners, all of this is being fought by really anonymous folks all across the country because this epidemic is also the quietest epidemic. It’s filled with shame. You don’t have a lot of violence. People die alone in a McDonald’s bathroom toilet, and then when the people die, when the kids die, the parents are so mortified, so ashamed that they keep quiet too, and the thing is left to perpetrate and spread.”
According to The American Society of Addiction Medicine (ASAM):
- In 2014, there were 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin.
- From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999; and the substance use disorder treatment admission rate in 2009 was six times the 1999 rate.
- Four in five new heroin users started out misusing prescription painkillers. As a consequence, the rate of heroin overdose deaths nearly quadrupled from 2000 to 2013.
These statistics are staggering. It’s apparent that the giant leaps in sales of prescription painkillers have undoubtedly been the driving force in this epidemic. But what was the catalyst for this sudden change in prescribing patterns? After all, up until the early 1990’s the U.S. consumed almost no opioids whatsoever, then quickly got to a point where we used 83% of the world’s oxycodone and almost 98% of the world’s hydrocodone.
In the film, Barry Meier, author of Pain Killer, comments on the general view relating to pain relief and its treatment with opioids prior to the 1990’s. “In this country there was a long-running puritanical attitude towards pain, and it resulted in almost a barbaric under treatment of pain, particularly when it came to people with cancer and in the terminal stages of cancer.”
For a long time, doctors had avoided treating pain with opioids due to fear of addicting their patients. That all changed with the new developments in the hospice movement. In Chasing Heroin, Scott Burris, Director of the Temple University Center for Health Law, identifies the catalyst that started the boom in prescription opioid sales. “That movement collides with an opportunistic drug company in the form of Purdue Pharma. They see the opportunity to expand the use of these drugs beyond the cancer wards come into mainstream of medicine, and the drug that becomes the vehicle through which they do that is a drug called OxyContin.”
In another clip of Sam Quinoes, he says “there is no question that the marketing of OxyContin was the most aggressive marketing of a narcotic drug ever undertaken by a pharmaceutical producer. The FDA allowed them to make the claim that because it was a long-acting drug, it might, the stress being on the word might, be less prone to addiction and abuse than traditional drugs. There was absolutely no science to support this idea. Zero.”
After getting FDA approval, now it was time to trick the doctors into believing OxyContin wasn’t addictive. Purdue Pharma launched a series of promotional videos in an effort to encourage doctors to treat pain with opioids.
Here’s what happens on a few of these promo videos, which were shown in Chasing Heroin:
- A prominent pain specialist assuredly claims “the likelihood that the treatment of pain using an opioid drug which is prescribed by a doctor will lead to addiction is extremely low.”
- While another doctor is talking, large text appears on the video that reads “less than 1% of patients become addicted.”
- Voices of a male and female narrator on the video convincingly state “opioids are safe and effective medicines for treating chronic pain,” and “the under treatment of pain is a major public health problem.”
I find it ironic and sad that a marketing campaign focused on convincing doctors that the under treatment of pain was a major public health problem, in fact led to a real public health epidemic of deadly consequence. By 2001, Purdue Pharma was selling more than a billion dollars worth of OxyContin a year. That also set the stage for more prescriptions being written for drugs like Percocet and Vicodin, and consequently sales of these increased significantly.
Pill abuse and addiction reached an all-time high, and newscasters were referring to it as “Pharmageddon.” Luckily, Purdue Pharma didn’t get away with their deception. In 2007, after a four year investigation by Federal prosecutors, Purdue admitted to charges of fraudulent marketing. They were ordered to pay $600 million in fines and settlements, but the damage was already done, and the epidemic wasn’t slowing down. I was intrigued and upset when I learned how this opioid epidemic started. To put it simply, brothers and co-owners of Purdue Pharma Raymond and Mortimer Sackler decided that riches were more important than morality, and tens of thousands have paid the price as a result.
In his riveting article, Kingpins: OxyContin, Heroin, and the Sackler-Sinaloa Connection, Jason Smith writes “an opiate epidemic was released onto the American public, and we’ve been confused about who to blame from the outset. In Broward County, Florida, an addict possessing OxyContin without a prescription received a mandatory three-year sentence. In Virginia, three men pleaded guilty to starting the OxyContin epidemic, and not a single one spent a minute in jail.”
Unfortunately, things have gotten even worse over the past several years. Painkiller addiction paved the way for Mexican drug suppliers. They would soon add to the opioid epidemic by flooding inexpensive and potent heroin into towns and suburbs across the nation. In Chasing Heroin, Sam Quinoes says “they were the first market to understand that the pill market was essentially priming the heroin market. Anywhere there was a town that had a lot of pill users they would set up a store.”
This is where things started to get even more out of control. Prescription opioids were often expensive and low in supply. Thus, many addicts end up turning to heroin. I relate to this on a very personal level, as this was exactly what happened to me. I was addicted to pills, then I could no longer find them, and at that same time I met someone that sold heroin. I started smoking it and went downhill from there.
Treatment for Opioid Dependence
Chasing Heroin explores some of the current and most common treatment approaches being used to reduce opioid abuse. The first treatment modality covered in the film was methadone, an agonist medication that eliminates opioid withdrawal symptoms and cravings. FRONTLINE spent some time in Bremerton, a city connected to Seattle by a 60-minute ferry route, and covered the story of the City Council denying a much-needed methadone clinic.
Bremerton had been hit with heroin addiction extremely hard, and the City Council was considering allowing a methadone clinic in their community to cut down on opioid abuse and overdose deaths. However, after consideration and debate, in 2011, the City Council put a halt to the idea of having a methadone clinic after learning about some of the negative associations with clinics. They heard that along with methadone clinics come loitering, panhandling, breaking into cars, drug dealing, selling methadone, and other unwanted behaviors in the community. Having worked as a counselor at a methadone clinic myself, I can say all of these things did happen, and they did so frequently
However, scientific research has established that methadone treatment is associated with decreases in the number of overdoses from heroin abuse, increases in retention, and decreases in drug use, infectious disease transmission, and criminal activity.
Chasing Heroin also investigated drug courts. Drug courts first arrived on the scene in the 1980’s. In the documentary, Robert Dupont, MD., former Director of the National Institute on Drug Abuse, says “we have a system that identifies the drug use as a problem, and it requires them to stop, and drug courts do a wonderful job. You don’t just refer them to treatment, you require them to go to treatment. You gotta use that stick to get people in there and get them to stay there so they get well.”
Drug courts are designed to closely monitor participants, and they must provide clean drug screens on a regular basis, and engage in intensive addiction treatment for at least a year. Advocates for drug court say the only way to get addicts to stop using is to give them a choice between incarceration or treatment. Opponents of drug court say it is too harsh, strict, and inflexible. During the film, Jasmine Tyler, drug policy analyst for Open Society Foundations, gives her opinion on drug court. “The problem with drug courts is that they continue to think there’s a moral failing in the individual and that somehow waking them up and shocking them with the criminal justice apparatus will create some level of sobriety for that individual, and it’s just not realistic.”
One of the other types of interventions displayed in the film was a pre-booking diversion program that allows officers to redirect low-level offenders engaged in drugs or prostitution activity to community based services instead of jail and prosecution. FRONTLINE spent a year with police officers in Seattle that were part of this program, which is called Law Enforcement Assisted Diversion (LEAD). Along with these officers, FRONTLINE also followed counselors and addicts that were part of the program.
The LEAD program had so much success over the past four years since trying this radical experiment that they gained national attention. In July of 2015, the team was invited to the Capitol to present the outcome of their four year experiement. In Chasing Heroin, a gentlemen on the LEAD program reports on how things went at the Capitol. “I think we created a lot of momentum. We got a lot of people excited about it, and I could sense that the administration wants to use their last 18 months or so as a way to shine the spotlight on criminal justice reform.” Other cities across the country are starting their own LEAD programs, and finally people are catching on that arresting addicts is not the best solution to the problem.
The final treatment intervention covered in the documentary is Suboxone, a partial agonist-antagonist medication that is less powerful than methadone, with less stigma and side effects associated with it. Dr. Thomas McLellan, former Deputy Director of the Office of National Drug Control Policy and interviewee in Chasing Heroin, believes that heroin addiction should be treated like a chronic illness, with long term outpatient treatment and access to methadone or Suboxone. To date, however, these medications are highly restricted. In a private doctor setting, Suboxone can only be prescribed to a maximum of 100 patients a year.
The following dialogue from Chasing Heroin explains this further:
Dr. Phil Capp of the Swedish Medical Center in Seattle: “I can only prescribe so much Suboxone and I’m limited by the Federal Government.”
FRONTLINE Correspondent: “Why?”
Dr. Capp: “It’s a good question. I think that the DEA wanting to keep a very close eye on prescribers to make sure that prescribers don’t turn into pill mills where medicine is not being used properly.”
FRONTLINE: “But let me understand this. We’ve had doctors and pharmaceutical companies promoting OxyContin without any limitation on how much they can prescribe.”
Dr. Capp: “The irony is not lost on me. I can prescribe enough OxyContin to put half of this city to sleep.”
Looking to the Future
In my opinion, Chasing Heroin did an excellent job showing us how the opioid epidemic started, how it’s affecting our nation, what types of treatment interventions are being used, and how far we still have to go. Many of the respondents in the film are of the opinion that opioid addiction is a public health issue, not a criminal justice problem. One of the main themes of the documentary was that our current belief that addiction is a moral failing and personality issue is holding us back from making real progress.
Let’s face it, most of the U.S. population can’t understand why addicts continue to use drugs despite significant negative consequences. Dr. Nora Volkow, Director of the National Institute on Drug Abuse, believes that over time exposure to drugs like opioids disables the part of the brain that regulates impulse control. In the documentary she states “all of these drugs with repeated administration erode the function of the frontal cortex. The easiest metaphor is driving a car without breaks. You may very well want to stop. If you don’t have breaks, you won’t be able to do it.”
She is not alone in this theory. Many people believe drugs act on the frontal cortex, however, the Olds Experiments of the 1960’s suggested that drugs don’t act primarily on this part of the brain, and that their biggest impact is on the midbrain, which is our reptilian brain that is unconscious.
Dr. Kevin McCauley, creator of the educational film Pleasure Unwoven, makes a compelling presentation on YouTube showing the exact mechanisms in the midbrain he believes lead to addiction. According to Dr. McCauley, addiction is a dysregulation of the midbrain dopamine (pleasure) system due to unmanaged stress resulting in symptoms of decreased functioning, specifically:
- Loss of control
- Persistent drug use despite negative consequences
Note: Dr. McCauley states drugs act on the midbrain, and the frontal cortex is no longer in control.
One thing is certain. There are many different theories of addiction. Many experts are not on the same page, and that can make progress slow. Despite all of this, the question still remains: How long is it going to take for us to turn the corner and start to see a reduction in the number of opioid overdose deaths and addicted individuals? In Chasing Heroin, Dr. Tom Frieden, Director of the Centers for Disease Control and Prevention, gives his two cents on the subject. “Well it took fifteen years for it to get this bad. I don’t think it’s going to be turned around in fifteen months. It depends on how quickly we work, how intelligently we work, how quickly doctors improve prescribing patterns, and how quickly communities establish support systems for people with addiction, or at risk for addiction, that decrease the risk that they will get addicted to, and die from an addictive substance.”
The narrator of the film reveals that “earlier this month, the Obama Administration requested more than $1 billion in new fundraising for addiction treatment. It is also considering relaxing the rules on prescribing medications like Suboxone.”
Upon further investigation, I found an article on WhiteHouse.gov that related to this, titled FACT SHEET: President Obama Proposes $1.1 Billion in New Funding to Address the Prescription Opioid Abuse and Heroin Use Epidemic. What I find interesting is that the article shows $920 million of the budget would “support cooperative agreements with States to expand access to medication-assisted treatment for opioid use disorders.” Don’t get me wrong, I think Suboxone and methadone can be a huge help. However, I also know for a fact that most people don’t want to stay on these medications for the rest of their lives, and that means there will come a point when they have to detox off of them.
Many opiate abusers have such bad cravings when they come off methadone and Suboxone that they relapse soon after getting off the medications, and the vicious cycle continues. These medications my temporarily relieve opioid withdrawal symptoms and cravings in the short-term, however, in the long-term they actually exacerbate biochemical imbalances. When an individual tries coming off these medications, they experience severe dopamine and endorphin deficiencies, which produce physical symptoms, mental symptoms, and cravings, and this often leads to relapse.
For example, in one large study in 2010, persons tapering with buprenorphine (partial opioid agonist drug in Suboxone) during a nine month period, whether initially or after a period of substantial improvement, led to nearly universal relapse. In another study, two groups of opioid-addicted youth were evaluated to monitor the effectiveness of different taper approaches. One group was detoxed for two weeks. The other was given Suboxone for nine weeks then tapered for three. The results showed that the longer taper was more effective, although after 6, 9, and 12 month evaluations there were increased rates of opioid use in both groups.
Luckily, with proper natural interventions such as nutrition, supplementation, and exercise the body can be restored to balance and health while coming off all opioid drugs. This can help reduce cravings, increase energy, and boost mood and motivation, which also increases the chances that counseling and self-help meetings will be successful. I’m excited that things are slowly starting to take a turn in the right direction, and I can’t wait for us to look back on this “dark age” of addiction treatment from a new level of awareness, empathy, and effective treatment strategies. My guess is it will take many years, but at least we’re moving in the right direction.