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Overture An overture of anger: Stats, fear, and ignorance

Statistically, Jason Mark King fits: Young man, in pain from hurt back, prescribed opioid painkillers by a trusted doctor, in more pain from childhood trauma, got hooked, overdosed, dead. Discovered outside his apartment closet, lying naked and dead on the floor, spotted dead through the crack in the door by his crying former fiancé, found dead at age 31 on the first death day of a new death year in the worst drug crisis in American history. Cue the first notes. Big crashing cymbals, the chorus erupts, our opera begins.

“Yes, it was New Year’s Day. We were together eleven years,” says Renee Rimmer, who found Jason at his Brooklyn apartment. “We didn’t get formally married, but we owned dogs together. We bought furniture and houses and cars together. We did everything a married couple did. I wore a wedding band, and he wore a wedding band. That was his idea.”

Renee Rimmer, New York City, 2018 (Photo by Jackie Molloy for The Well)

Our opus opens in 2016, the year an estimated 64,000 Americans would join Jason in dying from a drug overdose. That’s more American deaths than from a half century of Vietnam warring, or from all the car crashes and shootings for the year. In fact, drug deaths in 2016 equaled 21 times the number of those killed in the 9/11 terrorist attacks, only this terror was drugs. The 2017 figures are nearly 10 percent higher, at more than 70,000, with one in 96 people at risk for overdose death versus one in 103 for death by car crash. More people suffer right now from various addictions in America than from cancer. Despite recent preliminary data suggesting that in some states this crisis is leveling off, please hold your applause. Cause for celebration is premature.

Here are the composer’s notes for our opera: Drug addiction is a disease just like diabetes or cancer; some of us are prone to get it because of genetics or lifestyle. We suspect you don’t fully understand this whole “disease” theme in our opera, because you think those suffering from addiction choose that first hit. Why should we bother with the Jasons of the world if they use drugs to deal with the same troubles we all face? One reason to care is that opioids are such strong and special drugs they can create an almost unstoppable physical dependency without us expecting it.

In New York, 20,424 people died from drug overdoses between 2011 and 2017. Over those six years, drug deaths went up by 81 percent.

Which delivers us to the part of this opera that should anger your soul: Thousands became addicted in this crisis not because they chose to experiment or had personal problems but because they took a medicine ordered by their trusted doctor or dentist, who thought it was safe because their trusted world of science—big pharmaceutical companies and government regulators—told them so. The entangled workings of free enterprise, health care, insurance and government not only helped start this overdose epidemic, they haven’t yet done enough to deal with a horror we are still in the middle of. And after all that, let’s add to your outrage, because just as those forces that helped start the crisis are taking stronger action together, the song of opioids has become a dirge for opportunistic criminals who understand our particularly American penchant for addiction. Always smart, always greedy, these global killers are exploiting the internet, 21st century technology, and the potency of a synthetic opioid called fentanyl to create more sufferers, especially among—repeat the melody!—those of us prone to this disease.

The entangled workings of free enterprise, health care, insurance, and government not only helped start this overdose epidemic, they haven’t yet done enough to deal with a horror we are still in the middle of.

But our opera includes an optimistic word in its title. You in the front row of our opus may not have heard of the complex but perfectly known and achievable solutions to it all. Yes, this monster performance can end well, but only if you listen all the way to the final notes. The solutions are there, waiting for your understanding and support. Now listen.

Act 1 The New York Love Story of Renee Rimmer and Jason King

How America’s worst drug crisis kills us

Our opening solo: Renee Rimmer. She met Jason King in a Manhattan bar one night and fell in love over months of movies, couch snuggles and home cooking. They eventually kept house together and, in their first years, moved from New York to South Dakota and back to New York. They didn’t get married, in part, because Renee knew Jason was still young and still struggling with his youth and with childhood troubles that haunted him. The abuse he told her he suffered was mental and physical. But now, as adults, they were happy and building a life together. Renee worked as an executive assistant, and Jason worked for a luxury car company. The couple bought wine glasses together and exchanged goofy valentines.

(Video by Jackie Molloy for The Well)

In 2010, Jason and Renee were back in New York and Jason was driving alone and hit ice. He called Renee with the news. Several cars slid into each other; several discs were herniated. The pain. He did what anyone would do—rush to the closest hospital. “And they gave him a triplicate,” Renee remembers, “which is 90 pills—nine-zero pills—right off the bat. Not 10, not 20. That was his first prescription. OxyContin.” If you follow the doctor’s orders, the pain goes away, especially from oxy, a trade name for a blend of the powerful, dangerous, popular opioid known as oxycodone.

At first, Renee noticed only that Jason sometimes seemed to nod off at odd times. “His behavior began changing. I didn’t know anything about it then. But he started taking more and more of it, and he went back to the doctor for more prescriptions, and he got them, and then he just kept progressing, you know, as his addiction progressed. He liked the euphoria, and his back pain went away, but he didn’t have to feel the pain from his childhood either.”

Renee and Jason planned out the solutions together. They Googled and read pamphlets and talked to friends. He tried 12-step programs. He tried more elaborate rehab, where Renee thinks he learned new ways to get and use the drugs he was supposed to stop. “I went with him to church. He went to a psychiatrist. He began to try everything he could.” But he couldn’t stop the craving, and he could easily get more pills. He began crushing and snorting because powder was faster and stronger than waiting for a pill to take effect. “He would start crying, and I would start crying, and he would say, ‘I’m sorry, I’m sorry, I’m sorry, but I just can’t help it.’ It just overtook him. The drugs overtook him. He became not Jason.

An interlude of linguistics: Plain killers

Scientists who study opioids understand what happens that make people like Jason get hooked. In fact, opioid addiction is a swirl of familiar terms even if their meanings aren’t fully understood. The drugs act on our body’s pleasure centers, spawning emotions like pleasure and euphoria. They also slow down what causes us to hurt, which is why they are “painkillers.” But our smart bodies adjust to these abnormal drugs to try to lessen their effect, meaning as time goes on we have to take more and more to have the same pain-slaying, pleasure-making experience.

This leads to two common terms in the language of drugs: dependence and addiction. The former drives our body to want a drug so we can avoid the physical and emotional horror of withdrawal. You can stop dependence through withdrawal and detox. But you can’t as “easily” stop dependence’s big bro, addiction. That’s when your brain changes to make you crave a drug, and that change doesn’t necessarily end when you stop using. And addiction, in an almost satanic way, breeds another addiction word: relapse. You stop using, but months or years later, the drug or booze or whatever calls you back. You may be clean, but your brain and body and addiction all still gather in a chorus of need.

Death, the subject of so many operas and drug crises, often arrives in two ways. First, you can take so much of a drug that it not only suppresses your pain, but it suppresses your body’s automatic ability to breathe. Painkillers become plain killers. Science tells us that this often happens in combination with other drugs, even booze. You stop breathing because you can’t breathe anymore. Dead. Or perhaps the most operatic of drug dying happens when you get clean, relapse, and then use the same amount of drugs that you needed before, when you were in dependence. That’s too much for your non-tolerant body. Dead.

Over time, as Jason King struggled, the drug use became a wedge. Renee Rimmer grew scared during the nod offs. “Some days, he would just fall off the couch, and I would have to put my head to his chest to make sure his heart was still beating.”

Once, they went together to a pain clinic where Jason received prescriptions. “I walked into that waiting room, and it looked like a bunch of addicts looking for the next fix. At the doctor’s office!” She stepped into a room with Jason to meet the doctor. Jason “literally sat there and told the doctor what he was doing with the OxyContin that he was prescribing to him. I was there. I was right there, sitting next to them. And know what that doctor did? Turned around and gave him fentanyl. I was there!”

As Jason’s drug use worsened, they moved to separate apartments, but they were still best friends and they still had Princess. They share-cared the dog and sometimes met at a subway stop between Jason’s Brooklyn apartment and hers near Penn Station. On the last day of 2015, Jason joined Renee so they could take Princess to the veterinarian. Renee quickly noticed the signs—Jason had been using. But the dog was going back to Brooklyn because Renee and her girlfriends had reservations for a New Year’s Eve dinner that evening. As Jason led the dog back down the subway steps, Renee told him maybe they could get together after midnight. “I can still see him at the bottom of the stairs. He was standing there with Princess, and then he went home.”

Renee and Jason through the years (Photo by Jackie Molloy for The Well)

During the holiday dinner, Jason and Renee kept texting back and forth. Around 10:30pm, he typed that he was getting in the shower. Renee knew repeated showering was sometimes a symptom of his drug use, but she texted him anyway at midnight to wish him a year of happiness.

“I didn’t hear anything, so I thought he must be passed out. And so, after our dinner, I just went to bed and didn’t think anything about it. The next morning, I kept calling him and FaceTiming him and texting, trying to get him on the phone.” It was the first day of a fresh year.

A card from Jason to Renee (Photo courtesy of Renee Rimmer) She and a friend decided to go to Brooklyn to check out his apartment. “We went up and knocked on the door, and we heard Princess inside barking and barking and barking, and we thought we heard Jason snoring, so we went and got something to eat.”

They came back later, “but we heard nothing except Princess still barking. And I said we’re going in, so we went down and got the maintenance people and they opened up the door. You know the little hotel lock they have on the inside? It stopped, and I could see him lying there on the floor, and the maintenance guy saw him too, and he broke down the door, and I lost it and he lost it and we all lost it. His lips were so blue already.” On the floor next to the closet, Jason’s arms were above his head, underwear in grip, like the after-shower progression had stopped progressing. The autopsy: Accidental overdose. Opioids. Traces of cocaine and marijuana.

Renee’s aria to Jason ends with tears: “Some days, I would ask him, ‘Where’s that guy I fell in love with?’ And when he was sober, he would look at me and say, ‘That guy’s not here anymore.’”

Act 2 The Big Why: Slang and blame, tug and pull

The history of America’s worst drug calamity

The history of American drug abuse can be sung in staccato tags: Smack, speed, acid, coke, meth, crack, oxy. What you may not realize is that some of these horrors began in science or medicine. Heroin itself was created in 1874 from morphine and was later offered to help cure people of morphine addiction. Many doctors loved it at first, even prescribing it during surgery or childbirth. But heroin, which was named by the Bayer company, turned out to be just as addictive and was banned in the early 20th century.

Considered a wonder drug by many doctors, Bayer began marketing heroin as a cough suppressant in the U.S. in 1898 (Photo courtesy of DEA Museum)

Likewise, oxycodone was concocted in 1916 to treat pain. But ask why—why misuse any of these—and the symphony of slang becomes a litany: Americans try drugs because of peer pressure, trauma, pleasure, lack of maturity, availability, happiness, unhappiness, injury, hopelessness, adventure, helplessness, poor judgment, impulsiveness, even to impress. Many of those causes can be wrapped in veneers of pain—physical or emotional, social or economic. Remember, Jason King was a young guy with a back injury and childhood hauntings.

Another reason for drug use is simpler: mental illness. The cause often might be depression or anxiety, perhaps the most common untreated illnesses in America, but others turn to drug use because of more severe maladies. One study by the President's Commission shows that 29 percent of opioid abusers also suffered a major depressive episode. Self-treatment is common when you don’t or won’t understand what’s wrong. Merlot, weed, painkillers—they all slay that pain. Have you ever known anyone to take that second glass of whatever after a bad day or bad news? Mirror time.

Why do they do it? Why did you? Don’t you remember that time you felt so down? Why did you drive 100 miles per hour? Why did you get that drunk that night? Can you not re-imagine what it was like or would be like to be insecure and cocky and trying things out and filling up with all of the problems of being young or poor or rich or old or jobless or job-stressed? Did you always make the best decisions? Always?

Yet this litany directs the cause only toward the user, and that’s unfair to the democracy of this opera. Blaming the victim for this disease is sometimes like blaming asthmatics for not breathing well. But let’s bring this complex issue home even more: Do we blame people with diabetes for triggering their disease with bad diet, or do we lack sympathy for a relative who developed cancer because he chose to smoke? What about our overweight friend who can’t control her eating? Was her mother obese? How about her grandmother? Drug overdoses didn’t become the leading death cause for Americans under age 50 only because of bad choices. The rule of opioids and other drugs over dying in our nation started in part with a triumvirate of trust, greed, and good intentions.

Overwhelmingly, most doctors want to help their patients; that’s why they get into the helping business. The medical pressure to treat pain better began in the 1970s and 1980s, when the profession realized it was ignoring a condition that new drugs could treat. For some patients, chronic or temporary pain was simply a given. Early studies reported that opioids could help, but the drugs also were seen as too strong, too addictive. Then an increasing number of studies, reviews, and letters began pushing doctors to address pain, with opioids a logical choice. Some of the later studies and letters supporting greater consideration of opioids can be traced to one now infamous 1980 research letter to The New England Journal of Medicine, which was used and misused to convince doctors that opioids were not dangerous. The later reviews and letters didn’t mention that the positive impact of opioids cited in the 1980 letter were for hospitalized patients, not those with a prescription from a neighborhood drugstore. Over time, the general view of opioids changed, in part because of the desire to help those with chronic pain. These good intentions unleashed the prescription pen of some doctors and dentists, but the real deluge was fueled by the grand salesmanship of one of the most profitable and powerful forces in health care: pharmaceutical companies. Particularly promoted was a brand called OxyContin, but Vicodin and Percocet were available, too.

Not only did the pain management sector of the medical community promote increased use of these painkillers, but the drugmakers sponsored thousands of “education” seminars for doctors at fancy hotels or resorts. Meanwhile, what seemed like small changes at the time contributed to the crisis in unexpected ways: The limits on the strength of certain opioids were expanded to help treat pain—and addiction rates went up. Extended-release pills were developed to increase their impact and even cut risks of addiction, but addiction sufferers learned to crush and snort the pills to get a quick high.

Blaming the victim for this disease is sometimes like blaming asthmatics for not breathing well.

“Drug epidemics are a feature of society,” says Dr. Jonathan Morgenstern, a psychiatry professor and assistant vice president of addiction services at Northwell Health. “The thing that is unusual or unique about this is that it did start with the over-prescription of pain medication…Doctors were being told that we were undertreating pain, and that we needed to do a better job of treating pain for patients, and that these medications were safe and that only a small percentage of people would ever get addicted.”

Dr. Jonathan Morgenstern (Photo by The Well)

What Dr. Morgenstern and his medical kin were told was true, true, lie, lie. Those studies about tiny addiction rates were incomplete science that did not discuss enough about addiction numbers, usage and dosage. That single 1980 letter that helped ignite the opioid wildfire was cited more than 600 times in other studies, often incompletely, improperly or without question. Pain doctors, drug companies, and patient advocacy groups pushed to get pain elevated to a vital sign, along with temp, pulse, and the like. If you have visited a hospital room over the past decade, you probably remember the little faces that patients use to rate their pain from 1 to 10. Meanwhile (we will sing that word many times in this opera), the U.S. Food and Drug Administration (FDA) and other government agencies accepted early industry assurances that opioid addiction was not a major fear.

But let’s share the blame. To give voice to patients, government and industry surveys began to ask them how well their pain was treated, so doctors learned they could improve the resulting scores by paying greater attention to pain. Federal insurance programs, eager to listen to patients, began to include those scores when deciding how much to reimburse doctors or hospitals for care. Again, good intentions produced unintended results: More money actually could be made if doctors prescribed more painkillers. Hospital administrators in charge of balancing the books noticed, applying their own pressure on medical staff. This opera became a grand, well-intentioned roundabout, with patients unknowingly contributing to a crisis that would kill thousands of their neighbors. And them.

To this day, some insurance companies favor cheaper opioids by making their approval faster than more expensive pain management pills or treatment programs. Patient surveys have changed somewhat, but the President’s Commission on the opioid crisis is recommending the elimination of all pain questions. Yeah, and the lobbyists weren’t standing by either: Even after the opioid crisis began, drug companies and the elected officialdom they supported pushed hard for Congress to cut funds or change the rules for certain drug enforcement and monitoring. The pharma industry claimed murky overregulation; the feds found out the changes made it harder to catch potentially dangerous or improper shipments. Guess which powerful industry won?

For drug company bottom lines, the result was amazing. Purdue Pharma cashed in as sales of its OxyContin rose from $45 million in 1996 to an astounding $3.1 billion in 2010. Opioid pill sales skyrocketed, with prescriptions for painkillers expanding from cancer doctors and surgeons to dentists and physicians in other fields who learned that new vital sign: Are you in any pain? Insurance carriers, private and public, went along, in part because opioids themselves were cheap. Even today, the pills that addict you are of course way cheaper than the cost of addiction treatment. If you don’t die first.

The result, as an example from the medical system that employs Dr. Morgenstern: In our death year of 2016, Northwell Health admitted 6,000 addicted or other drug-abusing patients at three hospitals. In 12 outpatient programs, the count was 90,000 outpatient visits, involving 6,000 patients. Multiply that by hundreds of other health systems across this great addicted land, and you see the billions in economic costs accompanying those approximately 64,000 deaths. The President’s Commission offers one estimate of $111 billion based on 2013 overdose deaths, but The Council of Economic Advisers in the White House later proposed that figure was a gross underestimate, with the actual drug overdose impact for 2015 closer to $504 billion. Those “costs” do not include heartache, grief and trauma for those left behind.

Not only did the pain management sector of the medical community promote increased use of these painkillers, but the drugmakers sponsored thousands of “education” seminars for doctors at fancy hotels or resorts.

One federal survey contends that one-third of the American civilian population over age 12, or 91.8 million of us, used prescription opioids in 2016. Of those, about 11.5 million didn’t use them the way they were intended, with more than 3 million outright abusing painkillers. And that doesn’t include those who traveled the direct path from doctor-prescribed pain pills to heroin. An estimated 80 percent of current heroin users started their drug use disorder with painkillers that were legally or illegally obtained, according to the recent report of the President’s Commission. And the tally for that long-time headliner opiate, heroin? The 2016 estimate is about 630,000 Americans addicted, with the number for 2017 even higher.

Dr. Sandeep Kapoor, assistant professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and implementation expert at Northwell Health (Photo by Lee Weissman for The Well) In discussing the healthcare industry as a whole, Dr. Sandeep Kapoor, an assistant professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and implementation expert at Northwell Health, is sad and reflective about all the good intentions turned bad. “There was just this vicious cycle of what I would say was primarily uninformed collusion, where we unfortunately were forced to deal with pain as if it was a life-or-death situation, because if we didn’t deal with pain it would affect our ratings, and if it affected our ratings, it would affect the bottom dollar, because we would then start getting dinged by the federal government. So there was just this convoluted way of hiding the true guiding forces here, which obviously was of financial benefit to so many. But the driver of the majority of clinicians was just doing the best they could to take care of patients.”

Some of our drug opera’s soloists are less circumspect, although they are not talking about Dr. Kapoor and others who understood the dangers and prescribed responsibly. “The doctors I’m very angry at,” said Renee Rimmer, former fiancé of Jason King. “You know what the doctors are saying, ‘Oh, we didn’t know how dangerous this drug was.’ Well, show me your financials. Show me how much money you were paid for writing these prescriptions. Show me the truth. Let’s be transparent.”

“The pharmaceutical companies are in bed with the insurance companies who are in bed with the doctors. It’s about quarterly earnings down on Wall Street,” Renee says. “It’s about money. It’s not about loved ones. It’s not about a father, a mother, a son, a daughter—you know, people. It’s not about people.”

Renee Rimmer at her apartment in New York City (Photo by Jackie Molloy for The Well)

Jon Allen, a Long Island insurance broker in the third year of his recovery as an opioid addiction sufferer, probably has good reason to finger drug companies for his problem. But like any responsibility-accepting addiction victim, he doesn’t. That doesn’t mean he completely absolves them either. “Do I think it’s despicable what they did, how they intentionally misled doctors and how they told them to over-prescribe this medication because they said the likelihood of becoming addicted to OxyContin is less than one percent? Yeah, I think that’s abhorrent. I think that’s hideous.”

Jon Allen (Photo by Chris Suchy for The Well)

To the doctors who thought they were helping their patients, Jon says: “Dude, it’s not your fault. You can’t blame yourself. But some of these other doctors, guess what? They knew what they were doing. It makes me upset more than angry, that somebody would knowingly forgo the lives of people just to make more money.”

Has the political and marketing power of the insurance and drug industries declined during the intensifying crisis they helped cause? President Trump’s commission on the opioid crisis reported that some in the pharmaceutical industry were recently still opposing tougher prescription guidelines. Meanwhile (sing it!), federal rules and insurance companies sometimes still make addiction treatment more difficult to fund than, say, common care for cancer or diabetes.

Dr. Kapoor, who leads an effort to boost addiction education at the Zucker School of Medicine and Northwell Health hospitals, does not shirk his profession’s role in the overdose crisis. But he also respectfully worries that the “blame game,” while essential for preventing more abuses, is slowing solutions to the mess we’re in. “The stark reality,” he says, “is that we have allowed this to go too far, and now it’s affecting every ZIP code and every demographic. So we just have a really serious game of catchup that we have to do.”

Dr. Sandeep Kapoor talks to nurses and physician assistants at a SBIRT training at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell (Photo by Lee Weissman for The Well)

One major challenge is the pervasive, persistent stigma over drug abuse, Dr. Kapoor says. “It’s not just the opioid crisis; it’s addiction in general, which has been around for centuries. We are socially primed not to discuss it. We hide it.”

Dr. Jay Enden, a regional medical director at Northwell Health, agrees that discussion of drug addiction is not mainstream. “Society has to not be opposed to talk about this openly,” says Dr. Enden. “We need to try to help people instead of marginalizing them.”

Dr. Jay Enden, Eastern Region medical director at Northwell Health (Photo by Lee Weissman for The Well)

Jeffrey Reynolds, president and chief executive officer of the 130-year-old Family and Children’s Association on Long Island and a national figure in public health crisis management, says the view that addiction victims are moral failures is declining, but the disease concept still isn’t fully understood or accepted. Too many people still see people suffering from addiction as weak, which is somewhat like telling obese people they need to stop eating so much. Reynolds says: “We’ve got half the world, including some folks who are very smart, saying that, ‘Yeah, I don’t think this is a disease.’”

Jeffrey Reynolds, president and CEO of Family and Children’s Association
on Long Island
(Photo by Lee Weissman for The Well)
An interlude of linguistics: The labels we use

The stigma surrounding drug use extends to its language. For decades, those involved in health care, mental health, and public health have preached that certain patients should not be defined by their disease. In this way, people who suffer from diabetes or schizophrenia are not “diabetics” or “schizophrenics.” The goal is “person-first” language. But the stigma surrounding the role of the sufferer in drug addiction has prevented such linguistic evolution for what have been known throughout modern history as “addicts.”

One reason for the linguistic renaissance is to turn our labels away from blaming the victim. In this way, drug “abuse” becomes drug “use,” extending the name of addiction itself from “drug abuse disorder” to “drug use disorder.” Some science supports the move toward person-first language. One 2010 study by researchers Kelly and Westerhoff showed that clinicians often adopted a more punitive attitude toward patients described as “substance abusers” compared to people with “substance use disorders.”

Yet many people suffering from alcoholism and other addictions still use the traditional terms for themselves, with some rejecting the movement away from that language as avoiding the role of the patient in recovery. The Alcoholics Anonymous organization retains its title, as it does the traditional beginning of its famous meetings, which begin with participants often stating their name and the fact they are alcoholics. Two major federal agencies involved in addiction issues feature the word “abuse” in their formal organization names, as do several scientific journals.

But the trend away from that traditional language is growing: Medical journals, addiction experts and some public officials are eschewing the old labels in favor of a focus on the disorder itself, instead of the person who suffers from it. The editorial team of the peer-reviewed journal Substance Abuse recently adopted a “person-first” editorial policy that avoids using terms like that found in its own publication title. Even the hallowed Associated Press Stylebook, which guides language use for many public information outlets, online and in print, has urged journalists for more than a year to “avoid words like alcoholic, addict, user, and abuser” unless they are quoted or in formal names.

And so, stigma and trust and lies and the power of big corporations and the desire to free patients of pain and much more led to our ongoing rhapsody of overdose death. And then this happened:

  • The leaders of Purdue Pharma, the maker of OxyContin, admitted in 2007 that they misled doctors and others in their marketing of the painkiller, with hundreds of millions paid in fines and scores of more suits pending.
  • Despite some changes, federal and other physician rating services still focus on pain enough that some doctors feel pressure to take risks with prescriptions.
  • And now a popular but pricey addiction maintenance drug, buprenorphine, which can reduce relapse rates during recovery, is becoming more available, at least to middle-class patients with good medical insurance and access to top recovery specialists. There are still lines outside clinics for methadone, the older, cheaper drug.
  • And by the big way, addiction treatment is not a revenue generator for big health systems, and folks in the neighborhood don’t want treatment centers in their backyards, or even down the street.

This operatic sing-song of addiction in America tells us the overdose crisis took years to create, with many forces and players that unknowingly included those who became its victims. But the infuriating complexities also mean the “Big Why” comes down to the tug and pull of moral justification, of greed and heart, of good and evil—the eternal themes of all grand operas. That battle is fought when an overworked doctor writes a quick prescription to maintain ratings or daily patient count instead of taking the extra time to screen a patient for mental health or addiction risk; or when a fast-talking pharma executive hires a professor to conduct a study instead of the professor’s university rejecting the new lab the pharma money would bring; or when a troubled young man decides to accept just one snort from a friend instead of the friend deciding not to offer it; or when a member of Congress quietly votes to cut funds for drug monitoring and enforcement instead of calling for hearings against the move. Over two decades, the blame spreads like recurring themes in a libretto of darkness and death.

Act 3 “Wild Horses,” anus on fire

The brutal, inspiring success story of Jon Allen

Jon Allen, age 7 (Photo courtesy of Jon Allen) Opiates may have slipped into Jonathan Allen’s life because of a torn knee and an orthopedic surgeon, but his brain is what kept them there. His brain and his life and all of what it is to be an American teenager. He didn’t know it when his doctor prescribed the painkiller, but he was already a lifetime victim of a disease about to be triggered by that first pill.

“I don’t blame the doctor,” Jon says. “You know why? When I first took opiates, it was as if my internal monologue said to me, ‘Where has this been all my life?’ It stripped away my feelings of inadequacy; it took away my insecurities, my lack of self-esteem. All of those feelings were gone. It was not the physical sensation of being high or the painkilling. It made me feel confident and secure and funny and handsome…Once that happened, I thought, ‘This is how I should be. This is how I want to feel.’”

Jon Allen is a star of this opera of drugs, the soloist who struts as close to death as you can get and still come back.

Jon and his father (Photo courtesy of Jon Allen) In our libretto, Jon enjoys a solid, middle-American life, with a nice Long Island home, good schools, and a little sister and a mother and father who are there for him. For goodness’ sake, his mother read to him most nights as a child. Jon's life was like so many lives, a life with hopes, fun, challenges, and even some tough lessons: Once, when he was little, a neighbor forgot to pick him up from school, so he stood there outside, crying and waiting with a staffer. His mother, Susan, rushed to get him, but Jon already had vomited in fear that his mother would not return. Later, to reassure Jon, his mother would tell him about the Rolling Stones song “Wild Horses,” about how not even those strong horses could keep her away again. Susan wanted her son to remember the actual image, so Jon did, both the reassurance and the fear.

Jon’s sister, Amanda, a family friend, and Jon (Photo courtesy of Jon Allen) Years later, as a teenager, he was showing a martial arts move to a friend and tore his knee. They rushed him to the doctor for the pain, his first prescription was Vicodin, and it all started. Or rather, as Jon describes it, the painkillers became what would have come in another form anyway—a disease igniter like smoking for lung cancer or obesity for diabetes. Opioids were the trigger on Jon’s Russian roulette revolver.

“Addicts aren’t like everybody else,” Jon says. “We are a small percentage of the population. Not everybody who uses an opiate is going to become addicted to it. But eight to ten percent of the people who take them are going to develop a substance abuse problem. I’m a member of that group, I’m a charter member of that group.”

And so, even as Jon finished high school and went away to college (and didn’t finish because of his growing addiction) and then worked for a car shop, his triggered body and brain led him into a decade of expanding substance use. He tried them all, making choices and following his brain and satisfying his craving.

On the surface, he seemed to friends and neighbors to be one of them. He had a girlfriend, a job, a car, and, eventually, a condo in Flushing, Queens. He and his girlfriend raised rabbits as pets. This was not the back alley, red-eyed, long-sleeved, breaking-and-entering junkie of TV shows or crime novels. “You wouldn’t have looked at me at that time and said, ‘There’s a guy who’s really going through it, there’s a guy who’s struggling.’ But I was struggling. I was sad almost every day, and I was taking these drugs to not feel so down.”

Jon, his ex-girlfriend, Katie, and one of their rabbits (Photo courtesy of Jon Allen) Triggered in full force, his disease spread, worsening his sadness and problems. “I progressed steadily, and the locomotive gained steam for years,” Jon says. “By the time I was 25 years old, I was full-blown dependent on a number of different opiates.” The addiction culminated in three years of the hardest cores: Opiate painkillers, cocaine, ecstasy, heroin, whatever he could find for the inescapable chemical dependency deep in his brain.

What the audience may not understand, though, is that while Jon’s brain forced him to make choices about drugs, he never, ever chose to become what he became: “Nobody wakes up one morning and says to themselves, ‘Hey, today’s the day I’m going to become a heroin addict.’ Nobody is looking to do this.”

“You wouldn’t have looked at me at that time and said, ‘There’s a guy who’s really going through it, there’s a guy who’s struggling.’ But I was struggling.”

“If I’m using heroin and my heroin runs out,” Jon says, “the absence of that heroin is going to trigger a physical withdrawal in me. The neural desperation that I’m seeking heroin with is the same way a starving rat looks for food.”

In this February 2, 2017 file photo, used needles litter the ground at an open-air drug market along Conrail train tracks in the Kensington section of Philadelphia. Pennsylvania Gov. Tom Wolf joined Philadelphia Mayor Jim Kenney on Friday, May 19, 2017, as Kenney outlined findings of the Mayor’s Task Force to Combat the Opioid Epidemic in Philadelphia, a 23-member group that recommends the city consider allowing safe sites where drug users could inject heroin (Photo by Michael Bryant for The Philadelphia Inquirer via AP)

Jon, same as the rat, also wants you and everyone listening to remember—this began with both physical and emotional pain. He wasn’t just a guy looking to get high. Addiction can be triggered “with choices, sure. But maybe you also have some emotional instability, some psychological issues you are trying to mask with substance abuse. Oftentimes, untreated mental illness is symptomatic of addiction...Drugs are the gasoline on the fire that is the problem, but if you remove the gasoline, the problem still exists.”

Jon Allen in his parents’ home in Garden City, Long Island (Photo by Chris Suchy for The Well)

Which brings us to that stereotyped junkie of TV and crime novels, where economic turmoil and a bad homeplace and no prospects for a future could lead to that first hit, even when the doctor doesn’t order it. Hello, stigma. Yet whether the disease starts from your bad homeplace or your local CVS or the jittery, long-sleeved guy in the alley, whether you are Tom Petty or Tom the guy at the parking garage, the result for millions in America has been the same: Hooked and craving like a starved rat. And for thousands—tens of thousands—death.

As he fell deeper into addiction, Jon noticed that what worked before didn’t anymore. He would try to read, but he couldn’t remember the pages he had just turned. He lost his beloved girlfriend, the rabbits, his “normal” life. He became selfish, because heroin and other opiates are a solitary drug. Returning to a challenge from his younger life, he gained weight, then even more weight, turning fearful and paranoid. He worked 60-hour weeks helping manage the car shop to pay for his habit. He bought and got drugs legally and illegally. He also knew he would die. “When I was using, I knew it was going to kill me, but that didn’t stop me. All of your daily decisions revolving around drugs are irrational like that.”

What could prevent Jon’s appointment with death? Maybe it was the luck of a drug-using friend who squealed on him. Jon was arrested. The charges were possession and intent to distribute; he spent a night in Nassau County jail. The next day, Nov. 4, 2015, shuffling in handcuffs, withdrawal already hinting at his brain, Jon was pushed in front of a judge.

And then comes “The Moment.”

Many recovering addiction victims describe the classic “moment of clarity,” that startling, life-changing flash when they decide at least to try to get clean: “Mine is still vivid,” says Jon. “I can still touch that moment.” His is about to arrive in that courtroom. He’s waiting for his case and he listens to the legal talk and the deputy stands nearby and the judge is up there judging and Jon’s attorney is being an attorney and Jon’s standing there in his sweater and jeans and handcuffs and trying to take it all in and he foggily hears his attorney tell the judge that someone was there in the room to support Jon because she loves him.

“I had no idea she was going to be there, so I turned like this, in handcuffs, and I turned around and saw the look on my mother’s face.” Susan Allen was only 20 feet away. To Jon, the distance seemed a mile, but he easily saw her look—the look, from the “Wild Horses” mother, from the one who read to him at night when he was a child. “She wasn’t angry, she wasn’t resentful, she was not any of those things. But I saw her eyes.”

“She was just devastated, she was heartbroken, she just wanted to give me a hug; she just wanted to be there for her son,” Jon recalls. “When I saw my mother’s face, I made the determination there and then to make a change.”

An Allen family photo (Photo courtesy of Jon Allen)

In our opera, such dramas occur. But there was no courtroom hug; that would be melodramatic. This must be the middle act, where the opera’s score settles into broader tempos and deeper contemplation, when decisions are made, when you know louder and angrier songs are approaching whether you’re ready or not. Jon’s moment never faded as he was led away from that courtroom, when he was released later that day, when he went home with his mother and father and other family members. He knew what was on its way, and he stared at it just like he had ignored death as a person with an addiction. Consumed by starved-rat craving, he made a decision that would have been against the advice of most experts. He chose to detox himself.

Jon, afraid, overweight, and fearful of life and facing death if he kept using, didn’t check himself into a detox center. He didn’t accept help from the recovery drugs that are common in the field. He didn’t form a well-rehearsed, job-assigned support team, although he had friends to help. Instead, he jumped into withdrawal at his family home on Long Island, then went back to his condo in Flushing. This was cold, frozen turkey, the most horrid 96 hours of Hades that Queens could offer.

“You take the worst flu you have had in your life, and you multiply it by 50 times, and then you are beginning to scratch the surface of how it detox…Your brain is screaming for more drugs. Every cell of your body hurts. You are sweating uncontrollably, you are vomiting, you wake up exhausted in the middle of the night to sprint to the bathroom because you have diarrhea, your anus is on fire—everything you could imagine. You are frying, you are freezing, you are jumping in the shower, you are too cold, you are too hot…I was vacillating between vomiting and sleeping and screaming and getting in the shower and then out of the shower and screaming again. It was madness.”

Detox usually doesn’t kill you; it just makes you want to die. Jon Allen lived, of course, and he decided to follow the expert path after that. He went into an outpatient recovery program at Northwell Health and then built a program of long-term support. His father took him to his first recovery meeting and sat next to him. He still attends Alcoholics Anonymous and Narcotics Anonymous meetings and weekly therapy. His old girlfriend has become just a great friend. He’s lost 87 pounds. He’s boxing for fun and doing hot yoga for mental clarity. He has a new job as an insurance broker. He’s dating, speaking at rehab facilities, eating well, even appearing on TV and online to describe his recovery. He’s reading again, and remembering what he reads. He knows a few lines from “Wild Horses.” He’s not afraid to tell his story, to sing his solo. It’s been two years and more and counting, but who’s counting? All of the words in this paragraph, starting from the part where detox ends, represent just about the hardest thing a human being can do. Read them again, because Jon Allen lived them and has repeated them, in some part of his addicted marrow, every day since and every day onward.

“You take the worst flu you have had in your life, and you multiply it by 50 times, and then you are beginning to scratch the surface of how it feels in detox.”

“When I look back at what happened to me, it seems like a dream, like I was the star of my own horror movie, except I was the writer and the director of it, too, of course. I was an addict and it was my reality and I did what I had to do. I adapted to that way of life because I was addicted. But now, that guy seems a mile behind me. The Jon who was without a future, who was facing his imminent demise, he seems so far away.”

Pause.

“Most of all, my life is no longer dictated by fear. I lived too many years of my life afraid to fail, afraid to disappoint. I don’t feel that anymore. Today, it’s fall down seven, get up eight. I’m interested in taking a chance on myself, because I believe in myself.”

Intermission Crooks and technology, our worst friend forever

Crooks and technology, our worst friend forever—how smart criminals have taken over to worsen the crisis

Let’s break from our opera to do the math, the multiplying merry-go-round of drug potency: Morphine revolutionized pain treatment, so it’s our comparison base. Just so you understand what drug power means, morphine is 360 times as powerful as aspirin. Here’s what one Washington Post compilation found: Oxycodone, the ingredient in the painkilling OxyContin, is 1.5 times as potent as morphine. Methadone, used to help heroin addicts recover, is three times as powerful as our base, while heroin itself is up to five times more powerful. The synthetic painkiller fentanyl overpowers morphine by 50 to 100 times. Now comes carfentanil, which is used to tranquilize elephants and also to add to America’s drug crisis—a shocking 10,000 times as powerful as morphine.

This potency comparison is important because it demonstrates how technology is partially responsible for our nation’s overdose calamity. A startling photo prepared by the New Hampshire State Police placed three small vials of opioid-sized particles next to each other to display amounts that could be lethal to the average person. The one marked heroin contains what seems to be a large pinch of salt, maybe a half teaspoon. You’re dead. The vial in the middle is fentanyl, dead from what seemed to be several dozen flecks left on your fingers after you dropped the pinch from vial one. And to the right, inside the vial marked carfentanil? Death in one grain.

Lethal doses of heroin and “synthetic” opioids (Photo by New Hampshire State Police Forensic Lab)

But this intermission isn’t only about technology. It’s also criminal, because the usual-suspect crooks and some brand-new ones have taken over our nation’s overdose business where good intentions and Big Pharma left off. Think online drug bazaars, mail order from China, and small labs from cartels in Mexico. Sadly, most opioid pills sold illegally here are diverted from legal sources born in the U.S.A. But much of the heroin in America comes from processors in Mexico, where those bazooka-toting, machete-slinging outlaws rule entire towns and states. And fentanyl? It’s still easy enough to find through a Google or dark web search. Or, if you’re an aging rock star, you find a friendly doc to help with the aches, one concert at a time. Be careful, or you might kill yourself along with the pain. Prince, death year 2016; Tom Petty, death year 2017.

Right now, fentanyl is what makes the opioid trade so lucrative and easy for crooks; it’s the synthetic pain killer that paves the highway from legal oxy to illegal heroin. Fields of poppies need to be tended and processed to make heroin, but the synthetic fentanyl is all chemicals and mixed in that small lab. Because it’s so potent, transportation comes in vials or bags instead of vans or the holds of ships. The Mexican cartels simply stir in a few fentanyl particles to make their heroin more effective for addicts, or they, or home-grown crooks, use easily obtained pill machines to make fake painkillers that look like oxy but are laced with the magic poison. These fentanyl-tainted options not only create more and more addiction customers, but they also spawn increasing demand for drugs as users build up resistance to the euphoric effects. This is what customer development looks like in the 21st century drug trade, making opioids an addict’s best fiend forever.

This terrifying combination of small particles and criminal efficiency is the biggest part of those 64,000 overdose deaths in 2016, and the 70,000 in 2017. In fact, the number of overdose deaths from traditional prescription opiates is dropping, replaced by an estimated 30,000 deaths related to the synthetic drug fentanyl. That estimate for 2017 is 9,000 more people dead by synthetics than the previous year. The illegal drug labs in the Mexican desert or some barn in West Virginia are just not as precise as pharmaceutical plants. One tip of the fentanyl vial, and a tired pill counterfeiter may inadvertently create a few score accidental deaths. This dance with overdose is not good for customer development; you at least want your users to live for another fix.

Meanwhile, the devices and tests that cops and addiction sufferers alike employ to check the safety of a batch of street junk don’t necessarily work for some fentanyl analogues. As the President’s Commission said in its report, some street drugs “may yield a false negative and a false sense of security.” As in, you are dead. As in, the 2017 presidential commission report said some states were reporting that up to half of all overdose deaths in 2016 and 2017 were related to fentanyl. The commission report, exhaustive as it was, even mentioned a new cheap substitute for heroin flowing out of Russia: Krokodil. In a testament to the wonders of criminal chemistry, a dose of that junk was found to have 54 different components.

Today, fentanyl is a user’s dream and the pusher’s heaven, but fentanyl and its crazily powerful cousin, carfentanil, are the cop’s nightmare. One infamous incident involved an Ohio officer who brushed a little fentanyl powder off his shirt after a drug bust. He soon was dying until they injected him four times with the anti-overdose drug Narcan. (The CDC later revised its warnings surrounding the likelihood of overdose from skin contact alone.) Do you wonder why cops wear masks and gloves during some arrests? Better safe than dead. (BTW, the cop was from the same town where that family SUV portrait went viral last year—the one with the tongue-flopping, passed-out parents in the front seat and the bewildered 4-year-old buckled in the back.)

In this September 7, 2016 file photo, released by the East Liverpool Police Department, a young child sits in a vehicle behind his grandmother, Rhonda Pasek and her boyfriend, James Acord, both of whom are unconscious from a drug overdose, in East Liverpool, Ohio (Photo courtesy of the East Liverpool Police Department, via AP)

And the power. Agents busted a few guys in New Jersey last year with enough fentanyl, if misused, to kill all of New York City and then some. Guess how much was seized for such potential mass murder? One hundred pounds, or about the weight of your average American tween. So much for drug gangsters needing a tractor trailer rig or ocean freighter. One large inconspicuous shipping box would do it.

This concentration of potency and danger in such tiny amounts leads authorities to worry about synthetic opioids becoming a weapon of mass terror: When Russian security forces stormed a Moscow theater in 2002 to subdue a gang of armed hostage takers, the authorities first pumped a strange gas into the building that wound up killing more than 100 of the hostages. The suspected agent? Carfentanil.

Chinese and Mexican authorities are cooperating to slow or stop the flow. But whenever China bans certain formulas of fentanyl for online or mail-order shipment, the dark-souled chemists just change the formula a little to evade or avoid the rules. Are other cooperative law enforcement efforts working? Shortly after President Trump declared last year that the opioid crisis was a national public health emergency, two enterprising New York Times reporters searched online to find a Chinese vendor hawking “chicken nuggets, basketball jerseys, and carfentanil.”

And today’s crooked pushers aren’t only online. Some of them are the outlier doctors, pharmacists or other “pill mill” providers who care more about money than lives. In Portsmouth, Ohio; Mt. Carmel, Pennsylvania; Ft. Lauderdale, Florida; and Flushing, Massapequa, Valley Stream, and Baldwin, New York; the cops have arrested healthcare providers who used their authority and licenses to order and distribute legal pills illegally. A recent congressional investigation disclosed that one pharmacy in a West Virginia town of fewer than 400 souls was shipped 9 million opioid pills in two years’ time. Congress is rightfully going after the companies that shipped those pills, which were enough to supply everyone in town with 23,000 pills each. By the way, West Virginia itself—one of the vaunted, haunted epicenters of the overdose crisis and a state wracked with economic triggers—received an estimated 780 million opioid pills over six years. Just remember, we are the problem. We create this demand. North America uses 80 to 85 percent of the world’s opioids. That’s a lot of pain to be killed.

While we are in the lobby waiting for the opera to resume, let’s take a look at that video they are showing to help us pass the time, the one perhaps from the History Channel that discusses how America already had an opioid crisis that was caused by doctors and crooks and poor regulation and international trade and even the addiction of war veterans recovering from their wounds.

Civil War veterans often turned to morphine to relieve their pain (Photo courtesy of Library of Congress)

The time was the 19th century, and opium dens were rampant, and tens of thousands of Civil War vets and other Americans, rich and poor, urban and rural, were getting hooked. The lessons, forgotten in our most recent fog of bad science and Big Pharma, were that opioids are bad, addictive stuff that can consume society, but you can stop it with a multifaceted collaboration involving doctors, industry, and elected folks, plus lots of cops, money, and new rules. Entire books have been written about this part of our history. Apparently, they were not read by today’s doctors, scientists, drug company executives, federal officials, insurance companies and most certainly the public. You, me. Do we learn from our past?

Crooked docs, rubber gloved cops, cartel chemists, modern technology, a mailed package, Chinese websites, krokodil, nationwide demand, a few grains in a vial. In this new lesson, America’s repeated history calculates to nearly 64,000 in 12 months, now maybe 72,000 in another dozen months, overdosed, found in SUVs and alleys and fancy family rooms, in rock star mansions or the aisles of big box stores or lying on the floor by their closets in Brooklyn.

Intermission over.

Act 4 The Stew of Solutions: Art, science, and Narcan

How we can end this crisis

Operas, like drug crises, are complex creations, often years in the making from intricate forces, tiny to towering. You might expect the solution to the American opioid scourge, which took decades to evolve, would require a similar finale of time and complexity.

That expectation holds true only for lack of will, resources and understanding. The solutions, while not yet all nationwide, are there—many of them tested by research or real life, and ready for the leadership and public support that will mold them into a cohesive, coordinated effort. We may be the victims of forces beyond our control in this overdose calamity, but that doesn’t mean we just sit and count the tens of thousands of deaths from this emergency until the next drug crisis replaces it. We also should benefit from the lessons of a similar nationwide opioid crisis 150 years ago—an opium calamity caused by some of the same forces at work today. That drug disaster was fixed pretty much the same way we can fix this one. In fact, if we work with shared understanding, we might prevent the need for everyone to learn the next slang term that marks a drug crisis. The end of our national opioid trauma is there, waiting.

Shortly after President Trump declared last year that the opioid crisis was a national public health emergency, two enterprising New York Times reporters searched online to find a Chinese vendor hawking “chicken nuggets, basketball jerseys, and carfentanil.”

In one final concert note, here’s a blueprint for a happy ending to this opera:

  • Create a nationwide movement for families, schools, and mass media to teach Americans to prevent illegal drug use, rather than react to an exploding crisis.
  • Change healthcare training and practices so mental health and addiction are better understood and treated in an integrated instead of isolated way. Expand addiction risk screening to all doctors, clinics, schools and even families.
  • Improve the techniques of addiction medicine and treatment and make them as easily accessible and insurable as the fix for a broken leg. Use recovery coaches and broaden recovery medication.
  • Fund a laboratory moonshot initiative to invent cheaper, non-addictive painkillers or other ways to deal with pain.
  • Go after the crooks locally, nationally and internationally to slow the easy flow of drugs into America, and pass laws to force doctors to check opioid user lists before writing a prescription.
  • Integrate drug courts and other legal reforms that channel some addiction victims into treatment and support instead of prison.
  • Pass laws to punish or prevent rehab predators and illicit providers who prey on Americans with addiction more for greed than treatment.
  • Clean up medicine and research so money, special interests and Big Pharma don’t influence science and treatment so much. Make public officials fight the greed and lobbying power that taint American government and business. *
  • Prioritize local, state and federal resources just enough to transform these ideas into reality. (Hint: It’s sometimes cheaper than not spending the money.)
  • And talk about addiction and mental health like we talk about diabetes or cancer. Stymie the stigma.

* The asterisk: Yeah, we know these are tough, but if everything else comes together, maybe we can focus on the role of money in medicine, if not politics and government.

Each bullet above, like the libretto for our opera, features individual parts. For instance, most U.S. states are still working to effectively monitor opioid users and prescribers. These prescription monitoring programs tell doctors and dentists whether the patient who wants something for the pain has made the same request to others. Such programs also tell regulators and even the cops which doctors and dentists seem to write prescriptions to the same patients, over and over. Sounds great, right? Research shows only 35 percent of doctors sign up and that most opiates are prescribed without checking first.

A critical part of the multifaceted solution also involves something pure and useful: Saving the lives of overdose victims. Before you can detox, before you start treatment, before you move to a “normal life,” you must remain, well, alive. And that means, increasingly, Narcan or other forms of the rescue drug naloxone. Emergency rooms have had it for years, but we need Narcan kits and training in schools, churches, offices, bars, coffee shops, college dorms, even train stations and airports. In some communities on Long Island, like other police departments across the nation, every single cop has a kit in the patrol car and knows how to use it. This nationwide effort to make Narcan more common than wall-mounted heart shockers won’t stop addiction, but it will save lives so some can consider treatment.

Nurses are often the first responders in emergencies related to young people. Northwell Health’s Cohen Children’s Medical Center led a Narcan training seminar for school nurses on Long Island on March 14, 2018 (Photo by Jackie Molloy for The Well)

Jeffrey Reynolds has fought public health crises for decades. He understands the need for Narcan, but he also dryly observes: “CPR doesn’t cure heart disease.” Reynolds preaches that prevention will save more lives than any fancy treatment center he could build. And prevention doesn’t mean scaring teenagers with drug horror stories, Reynolds says. That’s probably too late. Prevention starts when kids are barely old enough to read, by talking to them about emotions and decision-making, and, later, by talking to them about smoking when they are barely old enough to know what it is, by talking to them as they grow about communication, friendship, judgment and temptation, about the role of medicine in their lives, and again, about feelings and how to deal with them. For tens of thousands of Americans, those talks will prevent addiction later.

And for those who fall into the trap? Change is needed for the nation’s entire treatment model. Consider the broken leg—everyone knows where to go and what will happen: You head to the local emergency department or urgent care center, perhaps registering by phone on your way in, then see on an app or blinking sign exactly how many minutes you will wait for your doctor. Your insurance or other coverage is arranged in a few minutes at a front desk. The treatment begins with X-rays, examinations and diagnosis, so the doctors know what they are dealing with. They consult on possible surgery, set the break if they can, have a nurse or other specialist apply the cast, give you medicine on the spot or by prescription, schedule follow-up visits, and even order a series of physical therapy visits so you can fully recover after the cast is off.

Which compares to this: You find out your teenage son is hooked on painkillers, so you call around to your neighbors and spend lots of time on Google looking for the right place or right approach. You consult your pediatrician, who may have heard of a place in the next town over, and you call your insurance company to see what’s covered and not covered. You kinda sorta know the hospital isn’t the right place, but maybe it’s worth an online search. After you find a few options, you call up a place to see if they have an open bed or appointment, but you may not know the right questions to see if that facility is the right fit for your son. Some rehab centers seem to focus only on maintenance drugs, and others seem focused on the old Alcoholics Anonymous 12-step. What will work? What works best? “Then, maybe two weeks later, you’re in,” Reynolds says. “We make it too hard. We have got to modernize the system a little bit.”

One challenge is that while hospital emergency rooms are ready to use Narcan or otherwise save the life of an overdose patient, other doctors are not attuned to how to handle patients who show up with drug use disorders. And what if you are in crisis, what if you decide you want to detox right now and rush to the same place you take your broken leg—the ER?

“If you show up in the emergency room and they ask, ‘What do you need?’ and if you say you are on heroin,” Reynolds says, “they say you need treatment but we don’t do it here. They send you home with a handout. It’s crazy. It’s crazy. If I have any other physical condition, I can walk into a facility and get treatment within, say, sixty minutes. But not with addiction.”

Jeffrey Reynolds speaking about the opioid crisis (Photo by Lee Weissman for The Well)

That’s because of another factor—one so broad and so broadly misunderstood that it seems alarming: Substance use disorders were just not considered a healthcare issue among many healthcare professionals.

What? Say that again: Addiction often was not considered a healthcare issue in the world of traditional health care. Addiction was relegated as an outlier, to be treated only by folks like behavioral health professionals—separate and different from the folks who treat broken legs, tumors or high blood pressure. If you are suffering from addiction or are at risk of addiction, the medical industry’s past response sometimes has been: Take it elsewhere, anywhere—just not in my ER or office. But Northwell Health’s Dr. Kapoor and others say that’s exactly where addiction should be considered, just like any other disease.

“If you show up in the emergency room and they ask ‘What do you need?’ and if you say you are on heroin, they say you need treatment but we don’t do it here.”

Let them explain, using, say, diabetes as a model: If your doctor screens correctly, you are asked about your history, weight and diet, and your blood is tested. If the doctor finds data to show you are at risk for diabetes, the practice is to address it right away. “There is a process in place in which we are regularly trying to prevent people from converting into a diagnosis of diabetes,” says Dr. Kapoor.

But that kind of screening happens much less often for the disease of addiction. “You don’t wake up addicted to opioids or alcohol or cocaine,” Dr. Kapoor says. “There is a journey there, and that journey is full of touchpoints in health care, just like for diabetes, where we can use evidence-based tools to screen our patients…We need to screen, we need to intervene, and we need to offer treatment.”

One major solution already showing benefits nationwide is called Screening, Brief Intervention, and Referral to Treatment, or SBIRT. Dr. Kapoor, SBIRT director at Northwell Health, has seen the tool’s value even though it’s not used as widely as needed in the medical community. A 2017 President’s Commission recommended SBIRT’s expansion from doctors into the field of education, from middle school through college.

First, though, doctors need to be trained how to diagnose and treat addiction, just like they are for diabetes and cancer. And that’s just not happening in enough detail at enough medical schools. Guess how many hours medical students usually spend on diagnosing and treating addiction? Two hours. Not two credit hours. But 120 minutes. Out of four years. Do we wonder why most doctors in traditional health care consider addiction not their problem? “It goes back to our education. If we are talking about getting, on average, two hours of training, how could we take ownership of this?” Dr. Kapoor asks. “The system is kind of set up for failure.”

He and colleagues at the Zucker School of Medicine and Northwell Health are joining other innovative med schools nationwide to challenge that mindset by greatly expanding addiction training.

Dr. Kapoor (Photo by Lee Weissman for The Well)

One model for this training is how doctors treat depression today compared to in the past. Depression, a diagnosable, treatable illness, was once an outlier in medical school as much as addiction is today. But depression is taught now in medical schools, because the evolution has led doctors to understand the disease is brain-based and realize they have a unique ability to spot depressed people and help them. But it is also in part because many medical students have personal experiences with depression, either through friends, family members, or themselves.

“When you talk about addiction,” says Dr. Kapoor, “even if you have had personal experience, socially you hide it, and on top of that, with only two hours of training, we don’t feel equipped or comfortable. It’s not that we don’t care; it’s that no one ever taught us.”

Dr. Kapoor recently led 100 Zucker School of Medicine students through a weeklong, 10-hour opioid education seminar involving 54 faculty members and other facilitators from 20 different departments at Northwell Health. The theme was that addiction “isn’t just an isolated psychiatry issue. It’s an issue affecting every part of health care.” The seminar expanded the total number of hours spent on addiction at the medical school from those 120 minutes of only four years ago, to what is now 26 hours—and counting. And as education changes how doctors are trained, the training affects how they work, Dr. Kapoor proudly says, making the revolution at the Zucker School of Medicine circle back into the health system itself. Nationally, progress like that at Zucker/Northwell is steady but slow, like a faintly chanting chorus behind our opera’s solos: A third of the nation’s medical schools and health systems are offering fellowships in addiction medicine, but that field became a formal medical subspecialty only in 2016 and the pipeline to those fellowships is still being developed. The solutions are still on their way.

Of course, even if healthcare education and practices transform, a person suffering from addiction still needs effective treatment—meaning, it needs to be made more available. The President’s Commission reported that 38 percent of all American counties didn’t even have a treatment option for drug use disorder, with the worst situation among rural counties—55 percent didn’t have an addiction treatment facility in 2016. Clearly, knowing the solutions isn’t the same as effectively implementing them. For instance, guess how many counties in America don’t have special drug courts to divert people with addiction into treatment instead of prison: 44 percent.

After an addiction patient is through detox—usually done with strong support, medication and 24-hour care—Reynolds describes this best possible treatment model with two words: “It depends.” That’s because as addiction begins and continues for so many different reasons, for different drugs and level of use, so too must treatment be individualized. “For some people, it’s riding horses on the beach,” Reynolds says. “For other people, it’s methadone.” With that caveat, good treatment starts with the fact that it should be, well, available. “You should be able to walk in, and the red carpet is rolled out, right then and there, just like for a broken leg,” he says.

OK, so assuming treatment exists and is available, what should it look like? Reynolds and Northwell’s Dr. Morgenstern describe the inpatient model that they (and the President’s Commission) support: Trained and credentialed staff at proper numbers, individual assessment, structure with little free time, group therapy, individual counseling, medication as needed, relapse prevention and counseling, psychological diagnosis and treatment, treatment of accompanying medical disorders, occupational and vocational rehab, and action relating to social and family issues. Inpatient treatment followed by outpatient follow-up usually works best, and the follow-up should be structured, too.

Dr. Morgenstern says the four- to 12-weeks after detox are often the most critical periods for treatment success. “We teach them skills to cope with situations where they have a high temptation to use again,” says Dr. Morgenstern, whose work on substance misuse is internationally known. “And we begin to help them think more clearly about being in recovery, about getting social support when they need it, and beginning to think about the transition back to a more normal life.” In effect, addiction treatment can be like hitting the reset button on a life spent immersed in all of the forces that helped create the opportunity or consideration for drugs that then led to addiction. Or, as Reynolds opines: “If you are using heroin, I can help take that away from your life, but what do you put back in to replace it?” The answer is embedded somewhere in what recovering addiction sufferers call a recovery lifestyle, where support and progress may take many more months or years of therapy or, for some, 12-step programs like Alcoholics Anonymous or Narcotics Anonymous. Some approaches must be permanent—a new life.

The single biggest change in addiction treatment is the use of maintenance drugs that replace the craving for illegal drugs with something less dangerous and more controlled. The concept is not new. Methadone has been around for decades as a treatment for heroin addiction. Some critics see replacement meds as state-sponsored replacement addiction, but that view is becoming increasingly outdated, especially as opioid overdose deaths continue to rise nationwide. A new class of maintenance medications has revolutionized the idea. One of the most popular today is buprenorphine, or “bupe,” which was designed in part as a safer option than methadone. Methadone is old-school and still used to replace heroin, but if used improperly, can lead to a heroin-like high. Buprenorphine, compounded with naloxone as Suboxone, is different in that it can’t be as easily misused. Generally, taking more of it won’t make you higher, and it even usually prevents patients from getting as high if they are still using heroin. For most patients, replacement drug therapy is supposed to be a bridge that lasts six months or a year or longer, with the belief that these drugs are better than heroin. But some stay on them indefinitely, given the better life they can support. Indeed, the science shows that taking a replacement drug like Suboxone with addiction counseling is more effective than counseling alone.

But stigma affects even medicine intervention. The fact that these replacement medicines don’t work for everyone, plus the persistent misunderstandings over their use, is limiting this proven recovery option to only a third of patients treated at private facilities. Reynolds confides that some ER doctors privately tell him they are worried about lines of Suboxone patients forming outside their hospitals. “And I say, that might be your nightmare, but that’s my dream.” Dr. Morgenstern adds, “When patients come in after an overdose and after naloxone reversal, that’s a very dramatic situation.” But such drama doesn’t necessarily mean a patient is ready for drug treatment. A substance use disorder patient whose life has just been saved from overdosing will soon be suffering withdrawal and the need for another fix. That’s why Northwell emergency departments are gradually training doctors to deliver another level of treatment—a single dose of buprenorphine. And that, of course, is when the complexities arrive for treatment for substance use disorders. A dose of bupe lasts only a day or so, so now Northwell and other health systems must be able to guarantee that the patient can go to a replacement medication center for evaluation the next day.

So far, such service is available at two Northwell emergency departments, with Northwell also testing the use of recovery coaches or other face-to-face counseling for bupe patients. “We have a long way to go here, to scale everything fully up,” Dr. Morgenstern says, “but we have begun some very promising efforts.”

Dr. Enden cites statistics about the health system’s progress: In the first half of 2018, emergency rooms screened 29,000 patients for addiction risks, moving 2,000 of those to brief intervention for more screening. Some of those wound up in motivational interviews designed to inspire action against addiction. Of those, 645 were referred for addiction treatment. Some were assigned a “navigator” who could coach them through paperwork, appointments, and other challenges—who also could provide more motivation. Others received help from Northwell’s community partners.

But the damnation of addiction means some, perhaps many, of those 645 never wound up in treatment. The offer of help sometimes isn’t accepted. Northwell is now testing how various ER and other approaches can help various patients. “We don’t know all the things we need, to know which patient will benefit” from which intervention, Dr. Enden says. “It’s not a one-size-fits-all, as you can imagine.”

The realization that an offer of treatment doesn’t necessarily mean a drug patient will accept help fuels the stigma surrounding a more public discussion of the drug crisis. Does a person with addiction need to be ready for treatment before it will work? And even if treatment works, doesn’t relapse often occur in the coming weeks or months? Will someone’s drug-craving brain overwhelm the recovery desires in their heart?

The growing support of replacement drugs is based in part on the damnable difficulties of addiction itself. The formal definition of addiction includes the adjective “relapsing” to acknowledge how the brain creates a lifetime of craving, whether the addiction victim remains sober or falls into drug use again.

Meanwhile, the same dark forces at work on the criminal side of the drug crisis can infect drug treatment itself. Reynolds recently spent two hours lecturing mental health professionals on Long Island about predatory rehab, the greed-based American phenomenon where national TV ads ask you to call for help. You think you are getting someone local, but you wind up connected to a national call center that sometimes pushes you toward an out-of-state facility that is as interested in your out-of-network insurance payments as it is in treating your addiction. The treatment centers, which sometimes feature fancy swimming pools more than trained counselors, actually pay these telephone boiler rooms based on how many patients wind up in one of their beds. These call centers are called “body brokers,” with critics contending the worst of them actually want relapse, at least until the insurance coverage runs out. Over the years a few nefarious healthcare providers even set up shady, walk-in Suboxone clinics that led to some of the drug reaching the streets to be sold illegally. Like heroin.

Jeffrey Reynolds (Photo by Lee Weissman for The Well)

It’s all a small but nasty part of the $35 billion addiction treatment industry that—irony alert!—some Wall Street investment advisors have marked for long-term growth potential. These advisors are not referring to unethical treatment, but still—what does that say about the overdose crisis ending soon? Such predators exploit the “art and science” of addiction treatment, where ratings and measures of success can be murky. If relapse should be an expected part of addiction treatment, does that mean a treatment plan failed if relapse occurs? If a cancer surgeon removes all of a tumor but another tumor grows later, was the first surgery a failure?

Because treatment outcomes can be difficult to assess, Reynolds says some families “wind up asking more questions when they visit a gym” compared to a facility that will determine whether a family member recovers or gets re-hooked. For addiction treatment, what is success? Is it only a lifetime of total sobriety? Or should it be called a transitional victory if a heroin addict who shoots the poison into his veins is gradually moved to only snorting? If an opiate user is sober for a year, but then takes one pill because of a lost job or marriage, is that a failure? If addiction is a journey, shouldn’t we plan for a few bumps in the path?

The President’s Commission reported many other treatment ideas: Addicts respond better with recovery coaches and recovery job training and even recovery residences. Urgent help, especially emergency on-the-spot counseling, might work even through telemedicine, meaning that someday we all will have the ability to talk or text with a trained counselor on our mobile phones. Someday, but not now. These and other ideas are far from nationwide now, in the middle of this opioid catastrophe.

“There is no one magic bullet out there that is going to solve this problem,” Dr. Morgenstern says. Reynolds agrees, acknowledging that the overdose crisis is complex, but there are steps that will make a difference. “Get people into treatment sooner. Ask them at every turn whether drugs or alcohol are a factor in their life. Don’t make it so hard to get them into treatment. Shut down the bad providers. It’s not going to happen overnight, but I don’t think it’s that complex.”

Law enforcement must have a role, of course. But the President’s Commission reported challenges in that area with the “monumentally difficult” example of trying to stop the simple envelope-and-stamp flow of fentanyl and other synthetics. Not only do authorities lack the equipment to detect the rapidly changing drug formulations inside a package, but America doesn’t even have enough trained drug-sniffing dogs.

Experts like Dr. Morgenstern and Dr. Kapoor warn our opera’s audience against any belief that cops and dogs will police us out of the opioid crisis. The notion that law enforcement by itself or even mostly will end the opioid crisis is as faulty as an infamous 1980 medical journal letter that was used improperly to discount addiction fears from opioids. “If you read the literature,” Dr. Morgenstern says, using cops and courts to end addiction is “widely recognized among experts to be a failure, although among politicians it sells well as a get-tough approach. What we really need to do is focus on demand reduction, which is through prevention programs and education. We just are not going to solve the problem through law enforcement alone.”

“There is no one magic bullet out there that is going to solve this problem.”

Ah, demand reduction. That sounds a lot like prevention and education working better than focusing more on the crooks, who would have less of a market if we could prevent more people from developing addiction. Demand reduction sounds like primary care doctors learning how to detect and refer addiction patients to treatment, instead of having parents of an addicted teenage boy scour the internet for days or weeks. Demand reduction sounds like doctors checking the patient’s name in a database before writing a painkiller prescription, or like regulators and insurance companies making it easier to approve addiction treatment, or like doctors deciding not to attend fancy drug company “education seminars” at beach resorts. Demand reduction also sounds like using replacement meds that are proven to work for some addiction patients.

Demand reduction does not sound like a Tennessee dentist writing a prescription for 10 days of opioids when one pill—not even one day’s worth—did the pain-killing trick for a middle-aged patient who had a tooth removed. The patient is the brother of the author of the sentence you are reading right now—a brother who is mentally ill and trained to take his medicine as instructed. See how it works? See how this opera keeps returning to its themes? See how those 64,000 deaths from 2016 went to 72,000 in 2017?

“This is the imperative,” Reynolds says. “We need to look at all of the options on the table and also figure out where did we go wrong and how do we fix it? But we do know how.”

Mrs. Winslow’s syrup was considered a wonder drug in the 19th century until a wave of fatalities among infants changed public opinion. The active ingredient in the medication was morphine (Photo courtesy of DEA Museum)

In fact, the effectiveness of the solutions can be proven. Despite the increase in overall overdose deaths from 2016 to last year, several states experienced fewer deaths. In most cases, these were states (Massachusetts and Vermont) that implemented multifaceted solutions, including increased treatment options for people with addiction. Some of those options were funded by a $1 billion grant program announced by President Trump when he declared the opioid crisis a public health emergency.

But the national increase in deaths related to synthetic opiates demonstrates that the resources committed so far to the crisis are not enough. “A billion dollars is a lot of money,” Dr. Morgenstern observes, “but it’s not commensurate with the scale and scope of the problem.” If Northwell had more resources, it could boost drug education and prevention, recovery coaching, and expand both ER responses and post-ER treatment, he says.

And so, the passionate Reynolds continues to cajole, criticize, and testify, and Dr. Morgenstern and Dr. Kapoor and the other driven doctors at Northwell continue to improve what they do. The real key to ending the crisis is coalescing public understanding into pressure at all levels of government, health care, business, politics, law enforcement, and even family life. Given the need for such broad action, the opioid calamity also is a mess waiting for leaders, the savvy, committed state and national voices focused consistently on the changes in their field—and on the public good.

“I think that health care has an important role in both fixing the problem and in providing leadership and direction,” says Dr. Enden. “But this is a human problem; it’s a community problem. The solutions have to be there, too. There are many people and places and things to say this is how it all started. But there are many people, places, and things that could be part of an intelligent and rational response.”

The solutions are there, waiting.

Finale An Epiphany of Rage and Hope

And so, in our opioid opus, the chorus comes onstage for the final notes, with the chants starting at the darker, lower register of discouragement: The drug companies that share some responsibility for the opioid crisis will avoid blame, medicine will change only slowly, society won’t fully address mental health issues, addiction prevention will not be a priority over [fill in the blank], the crooks will find new ways and technologies, with law enforcement always reacting rather than preventing—and with politicians and presidents unwilling to allocate enough money to help Americans who, in the end, may focus more on using drugs than voting.

But the sopranos in our opera’s finale ring higher in united encouragement: In pockets of places across America, people who care and who are willing to get on stage will play and teach the right notes. Mental health will continue to be understood better; money will be appropriated to what matters, for the health of society. The young people who are the greatest victims will grow up to replace us. The Northwell Healths of the world will continue to transform how they teach and practice medicine, and the smartest cops will realize they must band with treaters if they ever want their business to dwindle. More and more and more arrests will be made; vial upon bag upon boxful of fentanyl will be seized. Treatment facilities will get faster, better and better-known, with red carpets awaiting those who want treatment; support will be longer term. Schools and parents will talk more to kids over their entire lives. Doctors and dentists may expand their vital signs to include the most vital of all—How are you feeling, really? And Big Medicine will learn its lesson to make sure another opioid crisis doesn’t start from their prescription pens—despite Big Pharma still standing firm, all lawyered up because of the avalanche of lawsuits but still spewing money to push their product on consumers and to boost their influence in capitals across the land. In this encouraging aria, voters will write letters, attend meetings, demand the solutions that exist, waiting. And why should they do that?

“It’s like the #MeToo movement, or maybe ‘You, Too,’” says New Yorker Renee Rimmer, thinking of her love, former fiancé Jason King, lying dead on January 1, 2016, the opening note of our opera of death, lying on an apartment floor in Brooklyn, blue-lipped and pumped with opiates. “This needs to be on the public stage. If no one’s talking about it, nothing will be done. If no one is talking about what is happening, then no one is going to say that happened to me, too, and you, too, and you and you.”

Renee Rimmer (Photo by Jackie Molloy for The Well)

Jon Allen, the recovering addiction victim on Long Island, knows the day-at-a-time drill, the road to a future. For him, helping others is part of a recovery-centered life. “I’m no different than that guy who relapsed nine times; I’m not. For somebody to look at me and say that’s guy’s special, that guy’s unique—that is bullshit. The fact of the matter is I made a decision to change my life, and I battled hard to do it.”

Jon reminds us to avoid the stereotypes, to understand how disease works in general and how this disease works in specific and to not forget that an addiction patient’s desperation is similar to that of a starving rat. “We gotta crush the stigma. Look at the scale, look at the scope of this epidemic. We have affluent grandmas who are addicted to OxyContin,” he said. “All of us are affected; it’s not just somebody sleeping in an alley.”

And Jon will keep singing his story.

“When somebody’s saying, ‘Hey, I saw you on TV, on the news, about this recovery stuff,’ there’s still part of me that’s saying, like, that’s not even me. I’m still that lonely, tired, sad, overweight, depressed heroin addict. That still lives in me. That still lives in me a little bit, and I don’t think that will ever leave.”

And to Jon, that’s OK. He can sit with that. He can live with recovery, but recovery can’t be all he has: “I don’t want that to be the final note of my story.” Instead, his encore includes a career, a family, a life. “You know what matters? I’m happy every day. I laugh almost every single day. I laugh. Audibly. I didn’t laugh for three years on opiates, out loud. I didn’t cry for three years, not one time. Now I cry whenever I feel moved to cry. You know what? I am allowed to cry.”

Jon and his family enjoy a Thanksgiving gathering (Photo courtesy of Jon Allen)

Jeffrey Reynolds has no time to bow: “If we come out of this crisis by bringing addiction medicine up to the level of other kinds of medicine, if we can educate and empower families to know how to find the right treatment and know what to ask, if we can get the bad actors out of this space and find a whole new level of excellence, that would be great.” The real question is: Where’s the will to get us out?

“All of us are affected; it’s not just somebody sleeping in an alley.”

As our opioid opera concludes, we clearly need a better ending, better than death and anger, even better than laughter and willpower and wings in the breeze. We need another word.

“There is hope,” Dr. Kapoor says. “Even through the darkness, there is a way forward. It will take time, and it will take some personal insight and readiness, but it’s possible. We can make a big dent in this if we start working together.”

Renee and Reynolds, Jon and Kapoor, Jay Enden. If they, in the footlights of America’s worst drug catastrophe, retain faith in solutions, perhaps we can, too. “We can never give this up,” says Dr. Enden, “because we have precious lives that are at stake. We have people who need us, so we have to find a way. And we will.”

Renee Rimmer (Photo by Jackie Molloy for The Well)

If anyone’s still listening, let’s dedicate the closing notes in this finale to those who join the rage of understanding. The solutions to our overdose calamity depend on energy and action from the very people who didn’t cause this mess: You. The audience. The stage is yours. Final kettle drum roll and cymbals. The opioid crisis may reflect who we are, but it’s not who we have to be.

About the Author

David Everett, a writer, editor, and teacher, has traveled the world as a journalist with his feature writing and investigative reporting earning many awards, including from the National Press Club, Society of Professional Journalists, and Overseas Press Club. David’s work has appeared in publications, including The New York Times, Philadelphia Inquirer, Detroit Free Press, Chicago Tribune, Los Angeles Times, Boston Globe, Miami Herald. He taught and directed creative writing and science writing programs for graduate students at Johns Hopkins University and founded and led a summer writing conference in Florence, Italy, and Bar Harbor, Maine. He retired from Hopkins in 2016 to write and edit privately. David has lectured, presented, or read at conferences, festivals, and universities nationwide, and continues to teach at the graduate and undergraduate levels. His latest writing appears in a new online magazine, The Outlier, where he serves as managing editor.

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