Pubdate: Mon, 10 Mar 2014
Source: New Republic, The (US)
Copyright: 2014 The New Republic
Contact:  http://www.thenewrepublic.com/
Details: http://www.mapinc.org/media/596
Author: Graeme Wood

DRUG DEALERS AREN'T TO BLAME FOR THE HEROIN BOOM. DOCTORS ARE

In 2010, a dentist extracted my wisdom teeth, told me to gargle with
salt water, and sent me home with a prescription for a Costco-sized
bottle of hydrocodone pills. During the procedure, she knocked me out
with propofol- the same drug that killed Michael Jackson-and afterward I
felt no pain. After a few hours, I popped one hydrocodone, more out of
politeness than need. Weeks later, I still felt fine, but I popped two
more, just to see what it was like. Hydrocodone's dreamy, pain-dulling
effect was impressive: I bit my cheek hard enough to draw blood, and it
didn't hurt at all. But the pills made me woozy. I then put the
remaining 57 or so of them into my medicine cabinet, and I have no idea
what happened to them after that. Lost in a move, I guess.

Heroin epidemics don't come and go randomly, like the McRib. They have
clearly identifiable causes-and in this case, by far the largest cause
is doctor-prescribed pills. Every year since 2007, doctors have written
more than 200 million prescriptions for opioid painkillers. (Consider
that there are 240 million adults in the country.) And about four in
five new heroin addicts report that they got addicted to prescription
pills before they ever took heroin.

My experience was typical: Most people who try opiates don't get
addicted. But enough do. Since 2002, the total number of monthly heroin
abusers has doubled to 335,000 nationwide. Some of the addicts get the
pills through a well-meaning doctor or dentist, and many others swipe
leftover pills from their friends or family members. The result for an
addict is the same: Once the pills or money run out, heroin is still
available-and cheap. At about $10 per hit, it can be half the street
cost of pills.

"We seeded the population with opiates," says Robert DuPont, an
addiction doctor who served as drug czar under Presidents Nixon and Ford
and who is now a harsh critic of opiate over-prescription. The supply
shock from easy access to prescription drugs has pushed heroin use out
of cities and into rural and suburban and middle-class areas.
Massachusetts reported a staggering 185 heroin deaths outside its major
cities since November, and Peter Shumlin, the governor of Vermont, spent
his entire "state-of-the- state" address talking about the nearly
eightfold increase in people seeking opiate treatment there since 2000.
"What started as an OxyContin and prescription-drug addiction problem in
Vermont has now grown into a full-blown heroin crisis," he said.

Just 30 years ago, the pills were barely available in the United States,
and the only way to get addicted to opiates was to shoot or snort
heroin, probably bought on a street corner from a man carrying a weapon.
DuPont observed a heroin boom in the late '60s in Washington, D.C., when
users consisted primarily of young black men with criminal backgrounds.
Dupont says these users chose heroin as their first drug, skipping more
benign highs like marijuana. That wave gained energy when American
servicemen began returning from Vietnam, where pure Golden Triangle
heroin-the granddaddy of all smack-could be bought cheap. "Through 1992,
if you went to a methadone program, that's who you'd see," DuPont says.
"It was an aging population of people who began their addiction in the
1970s."

It took the intervention of doctors to bring heroin back, with the
demographic switcheroo we see coming to fruition today. In 2000, the
Joint Commission on Hospital Accreditation released a report concluding
that doctors were undertreating chronic pain and that thousands of
patients were suffering needlessly. Pharmaceutical companies welcomed
the medical profession's decision to supply those patients with
previously unobtainable prescription opiates. Companies zealously
promoted these drugs and underplayed their potential to turn patients-
and any bored friend or relative who decided to play prescription
roulette with the contents of their medicine cabinets-into junkies.

Over the last two decades, pain doctors have been competing with each
other to win the business of addicts. At one point, 25 of the top 50
prescribers of opiates in the United States practiced in Broward County,
Florida. Some of them boasted that they didn't even require patients to
show ID-a frank admission that the clinics welcomed doctor-shopping
addicts and their money. In many cases, they advertised a "No Pill, No
Pay" policy. Some doctors still dispense opioids like Pez, and patients
know exactly where to find them. "Physicians get their practices
reviewed on Yelp, and people who don't get their opiates give bad
reviews," says Michael Ostacher, an addiction psychiatrist at Stanford.

Until recently, the system was rigged to encourage doctors and dentists
to give out opioids with reckless abandon. "Most things in health care
that seem crazy become explicable if you look at the incentive
structure," says Keith Humphreys, a psychologist who worked in the
Office of Drug Control Policy from 2009 to 2010. "If you are a dentist
and you give someone thirty Vicodins, they won't bother you again. And
if they develop a problem, no one blames you." A physician in California
told me he could easily end up with a long line of paying patients out
his door, if he just let word out to addicts that OxyContin flowed
freely from his prescription pad. Better medical education and tighter
regulation have at least begun to slow down the pill flow.

"The result of this is that you probably have opioids in your medicine
cabinet right now," says Humphreys. "And who knows that? People who are
addicted to opioids." Realtors now advise people selling their homes to
clear out their medicine cabinets before an open house, because of the
high risk that addicts will attend the showing solely to swipe pills.
"You don't have to go to a drug dealer anymore," says DuPont. "You just
have to know some college friend who had his wisdom teeth pulled."

For the addict and his or her family, the addiction can of course be
hellish, no matter how it started. But there are two silver linings to
this epidemic, relative to the previous ones. First, there is a movement
to increase public access to Naloxone (brand name: Narcan), an "anti-
O.D." drug that first responders can stick up a victim's nose. Naloxone
strips opioids off the receptors in the addict's nervous system, and if
used in time can keep the addict breathing long enough to survive. Some
worry that the availability of Naloxone will lead addicts to take more
risks-opiate enthusiasts have been known to wear "Got Narcan?" t-shirts,
using the "Got Milk?" logo-but already the drug has saved lives, and
there's no evidence yet that it makes people inject heroin more than
they already are.

Second, we can take slight comfort in knowing that the origins of this
epidemic at least aren't directly tied up in gang violence, or in a
psychologically and morally scarring war in Indochina. If you can choose
which addict to have in your life, the one who starts by furtively
gobbling pills, or the one who is surrounded by violence and one day
decides to drive a spike into his vein and inject a substance sold to
him by a street- corner pusher, you definitely want the former. Docility
and passivity are virtues in an addict, and in previous heroin booms,
the gateways to addiction opened more readily for criminals and killers
than for suburban kids poking through their grandparents' bathrooms.

So while the addicts are more numerous than a decade ago (still only
0.14 percent of Americans), they are also significantly less scary and
perhaps more likely to survive long enough to be helped. Unfortunately,
modern medicine hasn't yet figured out a universally effective way to
wean abusers off long-term addiction; some will be sidling up to a
methadone-clinic window every morning for the rest of their lives. And
their addictions will continue the way they began, just as the doctor
ordered.

Graeme Wood is a contributing editor at The New Republic.