Inside a stuffy building that smells like stale cigarettes, a man in his mid-20s introduces himself to a crowd of strangers.
Everyone says "hi" or "welcome" in unison, and an aura of family permeates the room.
Without hesitating, the young man begins to tell the room that his brother-in-law is dead after overdosing this past weekend. He tells the room that he's about to be a father, and that his pregnant wife had been looking forward to telling her brother that he was going to be an uncle. But now she can't. Because he's dead.
The room, made up of every kind of person you can imagine, exhales a knowing breath as the young man tells his story. It's a breath of recognition, as if they'd heard this story before. Chances are, they have.
I'm sitting inside a Narcotics Anonymous meeting, one of the thousands held all over the United States every day. It's a place where current and recovering users of illicit and prescription drugs who are stricken with the brain disease commonly called addiction come together to try and beat their demons.
U.S. citizens, while making up less than 5 percent of the world population, use 80 percent of its opioids. An opioid is a medication that relieves pain by reducing signals to the brain. Often times, it affects brain areas that also control emotions.
In 2014, 47,055 Americans died of drug overdoses, almost 15,000 more than were killed in car accidents. 28,647 of those overdoses — or about 60 percent — were linked to opioids, including heroin. (On average, 49.5 Americans die each day from prescription painkillers.) 10,574 of the 47,055 overdoses were from heroin, a drug that users of legal painkillers are 40 times more likely to be addicted to than the average American. Heroin, it turns out, is a common and cheaper alternative to prescription painkillers like OxyContin, Percocet, and Vicodin. The link between heroin and prescription painkillers is impossible to ignore.
"When you look at the staggering statistics in terms of lives lost, productivity impacted, cost to communities, but most importantly cost to families from this epidemic, it has to be something that is right up there at the top of our radar screen," President Barack Obama said about opioid addiction in March, signaling a new tone of recognition from the U.S. government.
The question is, now what?
To understand how the opioid epidemic has gotten so bad, you have to understand the deceptive way in which painkillers have been sold to the American public.
During the 1990s, prescription opioids were pitched as a way to fix a broad range of chronic pains. Sore back? Pop a Vicodin. Neck pain? Arthritis? Have some Percocet. Broken bone? Surgery? Strep throat? Try OxyContin. In 2012 alone, doctors wrote 259 million prescriptions for opioids, enough to give a bottle of pills to every adult in America.
OxyContin — one of the most commonly abused opioids in America today — was first marketed to the American mainstream in 1996 by Purdue Pharma. Within four years, sales of the drug grew from $48 million to roughly $1.1 billion. During that time, Purdue Pharma hosted all-expenses paid symposiums for more than 5,000 physicians, pharmacists, and nurses at resorts across America.
"In the early days of the OxyContin problem, as part of Purdue's aggressive marketing campaign, they were giving out to physicians beach hats emblazoned with 'OxyContin' on them, and CDs with recordings of well known old Swing music, entitled 'Get in the Swing with OxyContin,'" said Dr. Art Van Zee, a primary care general internist in an Appalachia coal mining town that was hard hit by the OxyContin problem.
Van Zee, who published a paper on Purdue Pharma's marketing strategy in 2009, noted some other frightening tactics used by the company in 2001.
As part of its marketing strategy, Purdue Pharma used prescriber profiles to identify doctors across America who prescribed the most opioids. They then targeted these doctors, knowing they had a large number of chronic pain patients. Using what Dr. Van Zee described as a lucrative bonus system, Purdue Pharma dispatched sales representatives to these physicians to sell them (and by extension, their patients) on OxyContin. Purdue ended up giving out $40 million in sales incentive bonuses and spending $200 million on marketing OxyContin in 2001 alone.
But it didn't come without consequences. Purdue Pharma, the only producer of OxyContin, coughed up more than $600 million in a 2007 guilty plea for misleading regulators, doctors, and patients about the risk of OxyContin. Just last year, Purdue Pharma had to settle a lawsuit with the state of Kentucky for $24 million dollars after opioid addiction drove up medical costs, particularly in Eastern Kentucky, where many injured coal miners became addicted to OxyContin after being prescribed the drug.
In both lawsuits, the plaintiffs accused Purdue Pharma of downplaying the addiction and abuse risks of OxyContin, which the company initially marketed as posing a lower threat of addiction than a nearly identical drug called Oxycodone because of its 12-hour time-release formula. The FDA's medical review officer found that "OxyContin had not been shown to have a significant advantage over conventional, immediate-release Oxycodone." Purdue Pharma is just one of just several prescription painkiller manufacturers that have faced lawsuits for misleading users about opioids.
How it Happens
One of the recovering addicts I met, Frank, was first prescribed Vicodin — a highly addictive narcotic that works as a nervous system depressant — at age 14 after having shoulder surgery. He was given a one-month supply.
Before taking Vicodin, he hadn't experimented with drugs of any kind, even alcohol.
"I remember that first pill super vividly," Frank said. "I took it and I was like, 'Wow, this is the greatest feeling I've ever felt.' Since then I have sort of been trying to go after that feeling. I just felt pure euphoria."
Like thousands of other opioid users around the country, Frank knew nothing of the risks. As time went on, he found himself craving the opioid high more and more.
By the time he was in his late teens, he was a recreational user of opioid painkillers, taking them before watching movies or going out. In college, he'd keep an ear out for friends who were having surgeries to see if he could buy their extra pills. Over-prescribing was so common that it wasn't hard to convince a broke college kid to pass some over. After he graduated, he'd occasionally go doctor shopping, hopping from one emergency room and clinic to another complaining of back pain in order to supply himself with meds. Within a couple years of graduating college, he was a full-blown addict, popping pills several times a day.
When he couldn't get his meds legally, he turned to drug dealers and online black markets such as Silk Road. When he was 25 years old, a week came during which he couldn't find a place to re-up on his painkillers. Instead, his drug dealer offered him black tar heroin.
"I had known about heroin, but I had just been like, 'It'll never be me, no way, I'll never do it,'" he said. "But I didn't have anything, and I couldn't be sick from withdrawal at work the next day, so I just had to do whatever it took. And when I tried it, I was like, 'this is awesome, this is way better.' And it was infinitely cheaper."
It took six months for him to come out from under the haze of heroin. After facing withdrawal and quitting cold turkey, he was opiate free for two years. But when a half-full bottle of Percocet appeared in his dad's medicine cabinet, his addiction took over again. Not long after, he was found on the side of the road unconscious in his car, having overdosed on heroin.
The near-death experience sent him on a new path to recovery, one that included being open about his addiction to his family and fiancé. He began going to Narcotics Anonymous and is now coming up on 90 days of sobriety.
"This is the most honest I've ever been and I'm finding a lot of joy in just living an honest life free of active addiction," Frank said. "Recovery takes work every day and sometimes that sucks, but it's worth it."
One of the grim ironies of the opioid epidemic is that the drugs themselves have been shown in numerous studies to be ineffective at treating the symptoms for which they are most commonly prescribed.
While opioids do provide temporary relief in certain patients, such as those suffering from acute pain or cancer, the use of opioids for the treatment of chronic pain is far more dangerous than it is useful, and the risks of using opioids at all frequently outweigh the short-term benefits.
"I think it's always important for people to know — treatment providers and patients — that opioids aren't always a very good treatment for chronic pain," said Dr. Mark Ilgen, a psychologist who does research at the University of Michigan in Ann Arbor and the Ann Arbor VA on improving the treatment of alcohol and drug use disorder. "There are better data supporting alternatives for certain types of pain. These other options are sometimes not considered and can be quite effective."
As an alternative to opioids, anyone with chronic pain should consider drug-free treatments like psychosocial interventions, chiropractic work, acupuncture, massage and physical therapy, among others. Unfortunately, insurance companies are far more likely to cover a bottle of pain medication than they are to cover any of these alternative treatments.
Not only that, but opioids can have the opposite of their intended effect. According to Ilgen, anywhere from 30 to in some cases 80 percent of patients enrolled in addiction centers also report some form of chronic pain, and some develop chronic pain after developing an opioid addiction. One hypothesis for why this is the case is that taking opioids for extended periods of time impairs the body's ability to process pain signals, leading to something called opioid-induced hyperalgesia, or the tendency for individuals to become more sensitive to pain signals after prolonged exposure to opioids.
Then, of course, there is always medical marijuana. While according to Ilgen the jury is still out on medical cannabis, many are optimistic about its potential.
Dr. Stephen E. Lankenau, a sociologist at Drexel University, is working on a study, funded by the NIH's National Institute on Drug Abuse; in it, he and his team are focusing on the impact of medical marijuana on the use of hard drugs, and the effects of medical marijuana on the physical and psychological health of its users.
Three years into the five-year study, which focuses on young adults in Los Angeles, Dr. Lankenau and his team are seeing preliminary evidence that marijuana helps patients move away from more dangerous drugs like prescription painkillers, which accords with other international studies on marijuana and drug use.
While medical marijuana may not provide sufficient pain relief for cancer patients, who are common users of opioids, Dr. Lankenau's study suggests it may be useful for treating pain related to injuries, back and joint pain, inflammation and, in some cases, psychological problems like stress and insomnia.
Some patients in Dr. Lankenau's study have turned to medical marijuana because they don't like the side effects of opioids or how they make them feel.
"You don't hear about marijuana overdoses," Dr. Lankenau said. "Certainly, it's a much lower risk profile than opioids."
Kicking the Habit
Now that the opioid epidemic has begun to enter the mainstream, politicians, lawmakers, physicians, and average American citizens are forming a united front against it.
Just last month, the United States Senate overwhelmingly passed the Comprehensive Addiction and Recovery Act (CARA), which authorizes money for drug treatment and prevention programs geared toward addicts, including those in jail. CARA will also increase prescription drug monitoring and expand the availability of naloxone, a fast-acting drug that can reverse heroin and painkiller overdoses. In a time of unprecedented partisanship, the passage of the bill speaks to a growing awareness that addiction transcends culture, class, race, and political affiliations.
"Republicans and Democrats become equally sick from addiction." said Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP). "It plays on both sides of the aisle beautifully,"
The bill also reflects America's changing attitudes toward the concept of addiction. Once seen as a moral failing, addiction has come to be recognized as a form of mental illness that does not reflect a lack of will or effort. Congress' near unanimous vote essentially says that this is a disease of the brain that we are just as responsible for treating as any other disease, which is a significant step forward.
"It's a health care response rather than a criminal response," Ventrell said.
Two other bills, The Affordable Care Act and the Mental Health Parity Addiction Equity Act, also set the stage for progress, though they have met with limited success. Despite the fact that both bills created an opportunity for more comprehensive addiction care — care that would include medication-based treatment, psychological intervention, and group therapy like Narcotics Anonymous — most people who suffer from addiction still aren't getting the treatment they deserve.
For one, insurance companies regularly deny coverage to addicts in contravention of the law. The Affordable Care Act and the Mental Health Parity Addiction Equity Act require insurance companies to cover addiction treatment the same way they might cover treatment for heart disease or diabetes. Unfortunately, only about 11 percent of the 23 million Americans who needed treatment for an alcohol or drug problem in 2012 actually received it. A March 2014 survey of NAATP found that 63 percent of those insurance coverage denials involve disagreements between what the insurance companies deem "medically necessary" and what a patient or doctor deems medically necessary.
In response, President Obama recently created a federal Mental Health Parity Addiction Equity Act Implementation task force, which will force insurance companies to provide coverage for addicts who need help. Meanwhile, legal action at the state level and through individual lawsuits are beginning to put pressure on the insurance industry.
Coverage is vital to combating the use of opioids. Even though Narcotics Anonymous is a positive and helpful experience for thousands of addicts, experts generally advocate medication-based treatment, which includes drugs like methadone, buprenorphine (commonly known as Suboxone), and naltrexone (commonly known as Vivitrol) to stop the brain from craving the opioid high. Long-term treatment using these drugs, where a patient is slowly tapered off of them, have had tremendous success.
"The science of it is that medication assistance based treatment — whether it's methadone or Suboxone — is the best for heroin or opioid addiction," Van Zee said. "It's pretty clear cut."
And yet, as of now, these treatments still aren't readily available, and are in some cases looked down upon by addiction recovery programs like Narcotics Anonymous. One reason is that drugs like Suboxone can be abused. Another objection stems from what Ilgen refers to as a "puritanical view" of addiction treatment, which holds that sobriety can only be defined as the absence of all mind-altering drugs from the body.
"I'm just amazed at the number of people who don't know there are medication based treatments for opioid dependence and that they are very effective if you do them correctly," Ilgen said.
The problem again comes back to doctors and insurance. In many places, doctors are giving Suboxone treatment when insurance won't cover it. Many physicians offices do not take Medicaid, private, or commercial insurance to cover addiction treatment. In the area where Dr. Van Zee practices, for example, it can cost patients one hundred dollars a week to get their medication. Obama's new task force was created in part with this problem in mind.
Steps are also being taken at the state level to slow the epidemic. In Kentucky, a program known as Kentucky All Schedule Prescription Electronic Reporting (KASPER) tracks controlled substance prescriptions dispensed throughout the state. Using KASPER, doctors can get access to data on how often they prescribe things like opioids compared to their peers.
In 2013, Massachusetts launched a successful opioids task force which has helped bring together over 300 doctors, judges, police officers, prevention experts, educators, and members of the community to tackle the opioid epidemic. That task force has released several reports summarizing what they think the necessary steps forward are to combat overdose, stop the epidemic from getting worse, help enroll addicts into recovery, and map out a long-term solution to ending opioid abuse.
The Washington Drug and Alcohol Commission provides addiction programs like "Protecting Me Protecting You" free of charge to schools across the state of Pennsylvania. That program works in conjunction with the Hazelden Betty Ford Foundation, a 60-year-old institution that has been the leading provider of evidence-based prevention curriculum to K-12 educators on programs ranging from drug abuse to suicide.
As awareness and education at the state and federal level continue to improve, it's also incumbent on us to remember to treat addiction like the brain disease that it is. Far too often, people with addiction problems are dismissed as being self-destructive or unwilling to help themselves. But as the experts continue to remind us, addiction is an illness, not a choice.
The first step of Narcotics Anonymous is to "admit you are powerless over your addiction and that your life has become unmanageable." While the friend or family member of yours battling addiction may truly be powerless, we as Americans are not. We can enforce laws, offer help to those in need, pressure our representatives to acknowledge and combat addiction, and re-visit the way we think about this brain disease running rampant in our country. After all, the evidence suggests that what we've done up to this point hasn't been working.
Update: A previous version of this article referred to Suboxone as the common name for naltrexone; it is actually the common name for buprenorphine. Naltrexone is commonly known as Vivitrol.
If you're seeking treatment, you can call the Substance Abuse and Mental Health Services Administration's (SAMHSA's) National Helpline at 1-800-662-HELP (1-800-662-4357)
Cover photo: Paula Bronstein / Getty