From the start, Jessica* had problems. Learning disabilities impeded her academic and social progress in school, and a broken home stole her sense of security. Not surprisingly, her self-esteem suffered. The Delaware County native fell in with the wrong crowd. They did stupid things—then dangerous things.
When it comes to drug abuse and the struggle to cope, opiates are a well-known scourge. These days, morphine, codeine and heroin have been joined by more modern drugs commonly prescribed to combat pain. Those names are familiar now, too—Oxycontin, Percocet, Vicodin—and they’re a common sight in many medicine cabinets. Most people get along fine when they take them as prescribed. Some, however, don’t fare so well. As much as 15 percent of the population may be “genetically vulnerable to addiction,” says Dr. Neal Shore, who practices addiction psychiatry in Bryn Mawr.
The bulk of a prescribed 30-day supply often languishes in the medicine cabinet for months or even years, and young people target bathrooms at home and elsewhere for unused pills. “‘If Mom and Dad are taking it,’ they figure, ‘what could be wrong?’” says Dr. Richard DiMonte, a Media-based family practitioner and addiction-treatment specialist.
Many kids are grinding up the pills and snorting them to get high. “There’s an epidemic of prescription opiate dependence,” says Dr. Kyle Kampman, a University of Pennsylvania psychiatry professor. “[Users are] younger and across all socioeconomic strata.”
* Fictional name used to protect the subject’s identity.
Kampman estimates that three-quarters of all opiate addictions stem from prescription medications, the balance from heroin. And pills may well lead to heroin.
“Very few of these kids using heroin didn’t start out with prescription drugs,” adds DiMonte. “It’s [ultimately] cheaper for them to get a $10 bag of heroin.”
The typical teenager or young adult getting hooked on opiates could be from a wealthy Main Line family or living in foster care, middle-class or impoverished, a high-achiever or a slow learner. “It hits all walks of life,” says DiMonte.
Drug use becomes a common denominator. “It’s a subculture—they all know each other,” says DiMonte.
Indeed, the omnipresent cell phone makes getting acquainted and staying in touch an easy task. Even senior citizens have become part of the equation, as some have been reportedly selling their pain medications to augment limited incomes.
The good news is that treatment options have increased. And while they can be expensive, the insurance climate in Pennsylvania is favorable.
Now in her 20s, Jessica has been diagnosed with bipolar disorder. Her social circle helped lead her into heroin, and she had a boyfriend with his own set of related problems. By his own admission, her dad spent hundreds of thousands of dollars for services, including multiple stays at residential treatment centers.
Co-occurring disorders are quite common in drug abusers. It’s identifying them, and determining whether they precipitated or resulted from addiction, that’s the real challenge. “Some patients say they have anxiety, but a lot of it may be wrapped up in, ‘Am I going to get help [for the addiction], or will I go into withdrawal?’” says Dr. Laura McNicholas, who’s on the board of the American Academy of Addiction Psychiatry and practices at the Philadelphia VA Medical Center.
Withdrawl is the looming factor in any strategy’s primary goal of weaning a user off the opiate and blocking the desire for it. Among the variety of drugs available for that purpose, Vivitrol is a relative newcomer. Dr. Richard DiMonte prefers it for many of his patients because its extended release “eliminates the need to take a pill everyday”—and, he says, because it works.
From his practice across the street from the Delaware County Courthouse, DiMonte administers Vivitrol by injection once every four weeks. By dispensing with the daily routine, it lessens the chance of relapse caused by missing a dose. Guidelines call for the patient to be detoxed (opiate-free) for at least seven days prior to the initial injection. DiMonte recommends at least a one year treatment to “fix the physical problem” in conjunction with counseling to address the psychosocial aspect of addiction.
Vivitrol is the injectable form of the drug Naltrexone, prescribed for many years to treat alcohol dependence. Though also approved for the treatment of opiate addiction, Naltrexone had been less widely used for that purpose until 2010, when the FDA approved a long-lasting injectable version. It works by blocking sensations experienced by opiate users, even inducing a feeling of sickness—sometimes severe. Clinical trials have been favorable, and drugmaker Alkermes is conducting its own studies to measure longer-term effectiveness. “Most insurances are covering the medication, but out-of-pocket is very expensive,” DiMonte points out.
Indeed, the cost for Vivitrol is now about $1,000 a month, after an increase by Alkermes in response to sluggish sales. While the company has been reimbursing privately insured patients for part or all of their co-payments, the suggestion that Vivitrol is not uniformly accessible rankles some. “Most of my patients are middle class or underserved,” said one doctor. “If there’s no insurance coverage for Vivitrol, then it’s not an option.”
Cost aside, Vivitrol has found support. Harold Dalton, a clinical social worker who’s worked closely with DiMonte, has seen “strong, gradual improvement with Vivitrol and psychotherapy.”
The drug does not, however, fit every case. Doctors and counselors say a patient must be ready for Vivitrol. In general, a longtime user is not.
Another option is Suboxone, a synthetic opiate taken under the tongue in tablet or film form. Unlike Vivitrol, it doesn’t block the sensations that come with using. Rather, it reduces cravings by lessening withdrawal symptoms.
Like Vivitrol, Suboxone can be prescribed by a family doctor. Yet it acts in a way similar to Methadone, the older-generation drug available only in a clinical setting. Costs vary depending on dosage level and manufacturer reimbursements, but they’re at least several hundred dollars per month initially. Many insurance plans provide coverage.
Outpatient treatment with Suboxone typically lasts many months, even years. When it’s working, patients say they’re “not high, not sick, and don’t crave,” McNicholas says.
Jessica and her dad found a local outreach counselor who knew how to get through to her. The counselor found her an apartment, ensured that she took her medications for bipolar and for opiate addiction, and provided round-the-clock support. They developed a game plan.
Medical treatment is a key component to recovery, but without simultaneous counseling and community support, most patients are likely to fail. Whether coming out of a residential center or starting treatment on an outpatient basis, they need attention. “Sometimes, I know it’s going to be a hard detox and I’ll say, ‘Let’s get started in rehab,’” says DiMonte. “But I like the whole outpatient approach. People maintain jobs. Many don’t want to be on the ‘grid.’”
A block from DiMonte’s office, Dalton redirects substance abusers at his County Seat Behavioral Health. Like DiMonte, he receives court referrals. At his modest but comfortable offices, patients engage in small-group and individual counseling
sessions in a bid to recapture their lives.
“They need to know it’s a safe place,” Dalton says, adding that most patients come to therapy because of external pressure applied by parents, employers or the court. “They have to have the desire to change—particularly when they’re on [daily] Suboxone. Otherwise, they will cheat. Physical treatment doesn’t solve the head problem.”
A range of insurance companies cover such services, while the uninsured are referred to county providers like Crozer-Chester Medical Center. Beyond the walls of the counseling room, participation in a community-based support program is
regarded as critical to recovery. The classic model—the 12-step program originated by Alcoholics Anonymous and adapted by Narcotics Anonymous—leads patients, with the help of a specific mentor or sponsor, through stages of denial and recognition toward making amends and rebuilding their lives. “Therapy breaks down defense mechanisms,” says Dalton. “Patients get clarity of mind.”
But clear thinking is not easily achieved. Studies have shown that, of rehab-center patients who relapse, most do so in the first month after release. “Once-a-week therapy is not sufficient,” says Jeff Walder, a Newtown Square-based mental health specialist whose team provides on-call support for those dealing with substance-abuse issues.
That support may be as immediate as supplying a pack of cigarettes or recharging a patient’s cell phone. Response is everything. “They expect a 30-second response,” says Walder, only half-kidding. “They’re just looking for a reason to say I don’t care about them, but drugs do.”
Walder and his team also create broader strategies to suit the individual—like job and apartment searches—and manage the client’s meds. “We want to control every single factor in their environment that we can,” says Walder, who receives referrals from doctors, parents, prisons and the patients themselves.
Those in recovery typically are urged to avoid anyone who abetted their habit, but Walder sometimes will include a troublesome boyfriend or girlfriend in treatment. “If there’s an elephant in the room, acknowledge it,” he says.
Often called halfway houses, facilities like Harwood in Upper Darby provide similar services in a 90-day residential setting for patients coming out of rehab centers or prison. The emphasis is on finding a job, and the regimen includes weekly counseling and daily 12-step sessions with outside sponsors. Court-assigned residents who misfire are sent back to jail. State/county welfare usually supports these programs; privately insured patients aren’t eligible. “We have a good rate of landing jobs,” says Harwood counselor and former resident Robin O’Donnell, who also works part time at the Malvern Institute, a private addiction treatment center.
Dennis Deal is the executive director at Malvern, where 50-60 percent of the patients are opiate-addicted and the average length of stay is 25-30 days. This makes outpatient care all the more essential. “Major insurance companies recognize addiction as a chronic disease, and they’re paying for treatment,” says Deal.
And treatment is neither uniform nor static. Conventional meets holistic at Mirmont Treatment Center in Lima, which offers pain-management counseling and meditation for recovering patients. “This enhances traditional detox for those addicted to opiates,” says medical director Dr. David Jones.
There’s no magic potion—medically or psychologically—for treating addiction. It’s a matter of trying to find what works for each individual. Doctors, therapists, crisis counselors and advocates all have perspectives and war stories that concur and clash.
“No one is ever really cured of addiction problems,” says DiMonte. “They just learn ways for controlling their impulses.”
In high school, Jessica started smoking marijuana, then graduated to cocaine. Next stop: rehab—six times. Two years ago, she found a new drug of choice.
Like heroin, the most popular prescription painkillers are derived from opium, which consists of dried liquids obtained from the opium poppy fruit abundant in Afghanistan, Pakistan, Thailand, and other countries overseas and in South America. Its uses and abuses have been with us since ancient times. An opiate taken into the system activates a receptor in the brain, releasing a large amount of naturally occurring endorphins, which chase pain and may provide a sense of euphoria. Continuously high levels promote dependence.
“All of a sudden, you’ve found a solution to all your problems—it’s the absence of psychological pain,” says Bryn Mawr-based psychiatrist Dr. Neal Shore, emphasizing that pain is not purely physical. “Then the euphoria wears off, and you need more and more. It hijacks the reward centers of your brain circuitry; only the drug provides the reward [at that point].”
Patients and the medical establishment didn’t bargain for this when the current crop of painkillers emerged in the 1990s, born of the desire to provide more aggressive pain control. From 2002 to 2010, of the two million new users of pain relievers
for nonmedical purposes each year, 1.4 million became dependent (a 50 percent increase), according to the federal government’s National Survey on Drug Use and Health. A 2010 study conducted by the National Institute on Drug Abuse showed that as many eight percent of middle- and high-school students had abused an opiate-based painkiller during the past year. “With high availability and perceived safety, kids start to experiment—and some are more susceptible to dependence than others,” says Kampman.
While the most worrisome, kids and young adults aren’t the only populations involved. “It’s across the life span,” says the American Academy of Addiction Psychiatry’s Dr. Laura McNicholas.
Patients of all ages were undertreated for pain years ago, says McNicholas. Morphine, available only by injection in a hospital setting, entailed the fear of addiction even though it provided less than optimal absorption. In the new generation of painkillers, improved formulations have actually increased dosage levels, but with greater tolerance for most patients. And the fallout has been abuse.
Meanwhile, the war in Afghanistan loosened the Taliban’s control of the poppy fields, triggering overproduction of heroin and lowering its cost sharply in the illicit drug trade. Consequently, heroin use spiked, many addicts switching from
prescription meds when they dried up or grew too expensive. The reverse also holds true. “Some patients take prescription drugs to stave off [heroin] withdrawal,” says the Malvern Institute’s Dennis Deal. “Once you get hooked, the amount you need goes up.”
And along with it, the cost, leading to criminal means to get the money—a familiar pattern. For two decades, Deal served as clinical director at Eagleville Hospital, the only one in the state specializing in substance-abuse treatment. He’s
especially concerned about the growing tendency for users to snort or swallow powerful, time-release pills after crushing them. It approximates the “rush” of injected heroin.
Bob Stutman, a former high-profile Drug Enforcement Association official, shares Deal’s apprehension. “When a kid smoked too much marijuana, he didn’t die,” says Stutman. “With PCP, he didn’t die. But kids using opioid drugs—one minor mistake, and they can die.”
The numbers back him up. Drug overdose is now the leading cause of accidental death in this country, with opiates accounting for about two-thirds of the cases. The leading cause of death overall among 15- to 25-year-olds is drug abuse, again with opiates being the main culprit.
Locally, the trend is unsettling. According to the federal Centers for Disease Control, 345 deaths resulted from accidental drug overdoses in Chester, Delaware, Montgomery and Bucks counties combined in 2009. Shockingly, that represents a 100 percent increase in Chester County alone compared to 10 years earlier—and a spike of 84 and 74 percent in Delaware and Montgomery counties, respectively.
The tally for lives derailed or ruined is far greater.
Jessica’s plan has produced positive results: eight months clean and a new lifestyle. She maintains her own apartment, attends community college, and is entrusted with closing down the restaurant where she works. Such stability is a huge departure from her desperate days of using. But her father knows all too well that life is fragile. “She wants to be a drug counselor,” he says. “Every day is a jorney for her.”