A short drive from Acapulco, you can find one of the main sources of our heroin epidemic.
Not that anyone in Calvario much cares for — or even knows — of the broader debate over the drug trade. Villagers see little harm in cultivating opium. No one here uses the drug, or its derivative heroin, and the day rate for labor in the poppy fields is many times what is paid for shucking corn.
Isolation breeds a certain detachment. Calvario, though just a few miles from the state capital, is marooned an hour’s drive up unpaved mountain switchbacks littered with boulders and ruts. In the village of around 100 people, there is limited awareness of the outside world. Some farmers are not entirely clear what opium is even used for.
José Luis García, a farmer in Calvario who leases his land for opium cultivation, asked more than once what exactly it was about poppies that drove Americans so crazy. After hearing of the epidemic of addiction in the United States, Mr. García paused for a moment to reflect on the ethics of growing poppies.
“The fault is not with those who cultivate the opium,” he said. “It’s with the idiots who consume it.”
Ah, yes, this is the same rationalization you’ll get from any of the open-air heroin dealers in the Badlands of Philadelphia. If they don’t sell these kids their bundle, they’ll just get it from someone else. Nine times out of ten, this is true.
Except, I was talking to a heroin addict just last week. He’s got about eight months clean, and the turning point came when he snuck out of a rehab center dressed all in black in the dead of night and walked ten miles into Reading to score. When he couldn’t find any smack, he turned around and got back in bed unnoticed by the guards.
Two of the guys he left with were more successful, however, and after they subsequently failed a drug test and were kicked out of rehab, one of them overdosed and died.
My recovering addict acquaintance may well be alive today for the simple reason that on one particular night, no one sold him a bag of heroin.
It seems like no one in Washington County, Pennsylvania is having trouble finding someone to sell them a bag of heroin.
“It’s absolutely insane. This is nuts,” said District Attorney Eugene A. Vittone, a former paramedic who is trying to hold back the tide of drugs washing across Washington County, a Rust Belt community 30 miles south of Pittsburgh. On any day, Vittone said, the county averages five to eight overdoses, almost all from heroin. More are recorded each day in towns just over the county line.
Or, to put it another way:
On the streets here, prescription drugs are selling for about $1 per milligram, or $20 for a single dose. Heroin is much cheaper, at about $8 a stamp bag, [Rick] Gluth [supervising detective on District Attorney Eugene A. Vittone’s drug task force], said. It is also much more potent than the heroin of previous eras, [Neil] Capretto [an addiction psychiatrist and medical director of Gateway Rehabilitation Center] said. Users often start with a single bag, but as their resistance grows, they need increasing amounts.
All of which signals more overdoses and deaths, at least until authorities can find ways to stem the demand and the supply.
“If we had a serial killer killing one-tenth as many [people], we’d have the National Guard here,” Capretto said. “We’d have CNN here every night.”
He’s not exaggerating, at all.
Here’s a recent three-day spell in suburban Pittsburgh:
By 8:42 — 69 minutes after the first report — a county of slightly more than 200,000 people had recorded eight overdoses, all believed to be caused by heroin. There would be a total of 16 overdoses in 24 hours and 25 over two days. Three people died. Many of the others were saved by a recent decision to equip every first responder with the fast-acting antidote naloxone.
The three people who died weren’t shot on live television by a deranged man, but the people who killed them were just as indifferent to any value their lives may have had.
If you give someone heroin, you’re guilty of depraved indifference at a minimum. You might as well put one bullet in a revolver and pull the trigger. And if you don’t kill them today, you’re setting up someone else to kill them tomorrow.
And, virtually no one becomes a heroin addict before becoming addicted to some other opioid first, which means that the real pusher men are the ones that give out the pain medication.
You know, doctors.
Doctors like the one that gave Sonny Mack opioids despite everyone knowing he had an addictive personality.
Sammy Mack had long had problems with alcohol and was not unknown to law enforcement authorities. But as so many others have, his sister said, he turned to heroin after treatment with narcotic painkillers prescribed for an ankle injury he suffered a few months ago. Mack’s divorce was recently finalized, she said. His four children are living with his ex-wife not far away.
Good job, doctor, you killed him. Only took a couple of months, too.
Maybe the fact that he was a well-known alcoholic whose wife was leaving him might have given you a warning sign that a prescription for powerful opioids would fucking kill him within a few months?
We can’t stem this problem by going into switchback villages in Mexico and preventing poor farmers from scraping poppies. We have to get the doctors to stop creating so many addicts.
I work at a hospital. I have been talking to other physicians, who are more than aware that over-prescription is a problem. As I have noted, I got a huge amount of narcotics for 1) a rotator-cuff problem 2) a painful (!!!) tooth. Here are some considerations: Physicians are aware that some over-prescribe. This is not discussed much outside of the physician lounge. If you become known as a source of narcotics, you can get patients looking for pills, and prison is a possibility. Pain-control physicians are routinely charged with being pill sources, even for those in chronic pain. Chronic… Read more »
Didn’t you recently write a comment in which you said you got like 50 Percocets to deal with a rotator-cuff problem and that you only took one.
That’s 49 times 20 dollars, or enough to pay for your family’s groceries for a month.
Is it any wonder that poor folks are doctor shopping when it’s this easy to get free money?
Yes, I still have them upstairs. Probably several hundreds of $ on the street. But I don’t do that kind of thing.
The major issue, as I was surprised to learn, is that state laws almost FORCE physicians to overprescribe. Since they cannot give refill prescriptions, cannot call them in, and do not want a letter about bad treatment, they give enough pills to sedate an elephant. This guarantees a huge amount of extra meds out there.
So, if you see that I am right, why give me a hard time about it?
I never said that doctors aren’t operating in difficult terrain with perverse incentives.
I just said that they’re killing their patients.
I have no doubts in the fact on the ground that too much is out there. What we are not in agreement on is why there is too much meds out there. You seem to believe that physician discretion is a key factor – physicians prescribe too much because they don’t learn important facts, because they are careless, and possibly because they are lazy. I certainly don’t doubt that this is true in some cases. It is much more likely that external factors are key. The external factors that I believe are important are 1) physician concern that patients get… Read more »
I work at a hospital as well. There is a large amount of discussion around this issue there as well.
The real issue is chronic pain and what to do about it. Telling people they should just suffer is a bullshit answer. Opiods are often the best solution and in fact only real answer short of surgery (which has its own problems).
This is complicated as hell, obviously with no obvious solution.
I am curious – has anyone seen numbers on the source of opiod addiction (what % started on prescription, eg)
link
But its still rare:
” the vast majority of NMPR users have not progressed to heroin use. Only 3.6 percent of NMPR initiates had initiated heroin use within the 5-year period following first NMPR use.”
From the study you cite.
For what it is worth, that study only describes nonmedical pain reliever use, and doesn’t provide any insight into how many people prescribed drugs by a physician get hooked. That number is generally believed (based on prior studies) to be 8-10%.
Even if “only 3.6%” of of NMPR users progress to heroin (and that would NOT be considered a “rare” adverse event), opiate addiction remains a huge problem, socially and medically, as 4 of 5 opiate overdose deaths are not related to heroin but to prescription opiates.
And on the ethics/economics of growing poppies instead of corn: When you are a poor farmer, and you have to eat yourself, feed your wife and children, and possibly get extra money for something like alcohol or candy for the kids, who can blame a farmer for making the economic decision to make 10x the money? Blaming the farmer is not helpful. The farmer makes money because of those who buy the product. This is the drug trafficking rings. We don’t have the poppy issue in the US because we have good policing. There are comparable issues here – notably… Read more »
I don’t really care if you are a poor farmer or a poor hustler from the inner city. If you know what you are doing, you’re a killer.
I don’t disagree, but that’s easy to say when you don’t live in crushing poverty. If we’re not doing all we can to lift said farmers out of poverty and provide them with economic security, it’s bullshit to criticize them.
If I need rent money or groceries I can also just go shoot someone and take their belongings and sell them. After all, who gives a fuck about them?
If your kid was in danger of starving, you would. So would I.
No I wouldn’t. I’d figure out some other way.
Because I am not a conscienceless savage.
This is simplistic. Yes, the farmer is the source. But without the marketing force, the crop has no value at all. The opium poppy has no food value. So, I don’t see that the farmer is the key to the system.
Say whatever you want, but economic logic will win out. You cannot tell a person who is starving to not eat the sandwich in front of them. You need to change the incentive system. Either a high penalty for growing must be imposed, or a reward for growing the right crops, or just an elimination of the distribution system.
Well, here in Thailand most of the poppy growing is done in an area called the Golden Triangle, a mountainous regions where Burma, Lao, and Thailand meet. The people mostly belong to tribes that have been there for a long time, but Siam and later Thailand have refused to accept them as citizens. The area is mostly controlled by warlords who were left over from the KuoMinTang armies loyal to Chiang Kai Shek, who decided returning to China after 1949 was not attractive. Some of them are the children or grandchildren of those officers, others are successful competitors who ousted… Read more »
what someone does at gunpoint comes in its own unique moral category.
Kicking people out of rehab because they fail a drug test is totally assholish. That’s exactly when they need you the most, and you fuck them over. Makes no sense whatsoever.
It might seem that way, but you can’t have people sneaking out and bringing product back inside. And there are so few beds that you need to ration them for people who might actually try to get clean while they have one.
I used to be in the business — I was program evaluator for a community based substance abuse treatment provider. So I know what I’m talking about. It always takes multiple attempts to kick. And people who relapse aren’t going to be giving product to others – they’re just going to cop a bag or two. And the idea that you need to reserve the bed for somebody who is going to “actually try to get clean” is bullshit. The guy who cops is actually trying to get clean, he just failed on that occasion. You apparently don’t understand what… Read more »
I have read (but can’t attest for the validity) that a high percentage of addicts are sex abuse victims. If that’s true, making awareness and counseling more available might help.
After major surgery, I was prescribed some major opioids which I took for awhile, but weaned myself as soon as I could because I hate the side effects. (Definitely not a recreational drug for me!) I was able to take the extras to my local police station and drop them in a metal bin, no questions asked. Is that an option in most communities?
The bin at the police station (or other city/county building) is a new thing and it’s spreading, which is a very good thing.
Got that bin in my local New England police station. When I went to drop off the remnants of a prescription it was so full I had trouble getting the pulldown panel open.
I actually get my wisdom teeth out last week (older than people usually get them out, haven’t had dental insurance for years and they finally started hurting really bad). Oral surgeon prescribed me 20 Oxy. Luckily, I have a pretty high pain tolerance and I only needed it for the first two days. But holy shit, it really scared me. Because it made me feel so good. No nausea, just warmth. And calmness. And a feeling that everything was gonna be ok. I flushed that shit down the toilet. No wonder people get addicted to opiates. I wish I’d never… Read more »
Yep.
They don’t even try to screen for that. Most people, like me, will just want to puke the whole time, but around 8% of the population will feel normal and well for the first time in their lives and do almost anything to get more. Even more people are like you, and will enjoy it way too much and have to make a conscious decision not to get lured in.
Wait, shit, I’m part of the 8%? Fuck me. I heard from some friends that it made them want to puke, but I didn’t think it was that weird that Oxy didn’t make me nauseous at all. Shit, I’m never touching that stuff again. Especially since my aunt is an addict.
you probably aren’t. You’re probably on the border. If you were part of the 8% you’d be shooting up right now.
How do you screen for that? Is there a blood test? Is there a validated questionnaire?
If someone fails to “qualify” for opioid treatment, how do you treat them? Tell them to go home and tough it out?
It’s easy to criticize, hard to find an answer.
Ah, this is the question I wanted to ask BooMan. I really agree with him, but he didn’t offer any feasible remedies. If there was some kind of screening test that would be a big help. I am evidently an “addictive personality,” based on the fact that I drank alcoholically from my first drink of alcohol, but luckily I was able to sublimate into other kinds of addiction (reading, mostly, then computers). Then, if you could screen for addictive personalities, or persons at risk for addiction, maybe you could devise a screening test for violent/sadistic/bullying cops.
You screen for it the best you can, but there are three main decisions that are distinct. The first is to ask whether opioid medication is actually required. The United States writes around 98% of opioid scrips for the entire world, so our doctors have a totally different idea of what kind of pain is acceptable from doctors in Canada, Europe, Japan, and pretty much everywhere else. The second is to assess the patient’s risk for abusing the medication, and people who already abuse other drugs (including alcohol) are at much greater risk of abusing prescription drugs. Patients who… Read more »
You didn’t answer the hardest question. What do we do about people who are thought to be “addictive”? Make them come to the office everyday for their day’s supply of pain meds? Leave them untreated? Prescribe something that is ineffective or dangerous (i.e. NSAIDs to a kidney patient)? Tell them that Europeans don’t get pain meds, so suck it up?
I’ll tell you what. Is it quantum mechanics to figure out how to emulate every other industrialized country in the world and how they treat pain? Because even the second worst country is nearly 100% better than we are on this issue. But to answer your question more substantively, the hardest problem is fixing this without making life completely miserable for people who have severe chronic pain. But if we can set them aside just for a thought experiment, these medications are usually not appropriate for anyone who isn’t in severe chronic pain. They’re basically appropriate for hospice care… Read more »
Okay, so your doctor gave you 20 pills with a street value of approximately 400 dollars. You used about $50-$100 worth for your own needs and then went to the police station and flushed $400 down the figurative toilet.
How many people feel like they can’t just flush $400 down the toilet?
Sorry, mixed up commenters. You literally flushed them down the toilet.
You shouldn’t do that, by the way. But good for you anyway.
We can’t possibly STILL have a drug problem in the good ole USA! That would mean that we’ve wasted a trillion dollars ( or thereabouts) on our program to control said drugs. It would also indicate the possibility that that program ( DEA, prisons, midnite raids etc.) may, in fact, have made
things much, much worse. “Chasing the Scream” by Jonathan Hari, if you want to understand more about addiction, and the negative effects of current policies and attitudes.
I was actually reading an excerpt from that earlier today. Thanks for the recommendation.
You act like doctors just have to stop prescribing, and that would be it. I’m a physician (who does not prescribe opiates), and let me tell you, it’s not nearly so simple. What exactly are you supposed to do about chronic pain? There are no really appropriate alternatives to narcotics for people who need them. Leaving people in pain is just frankly cruel. If you give someone not enough pills, they are hassling you with phone calls, dealing with pain while they wait for you to call them back, and suffering. Meanwhile we are entering an era when our getting… Read more »
Okay, genius. The doctor had a choice. Give an alcoholic who is probably depressed (perhaps clinically) because he’s losing his wife and kids powerful opioids to treat some pain he’s feeling or tell him to tough it out and rely on less addictive medications.
The doctor made his choice and his patient was dead within months.
You tell me the doctor did the right thing.
I tell you that the doctor straight up killed his patient in a totally foreseeable way.
I know that you are very passionate on this subject. However, doctors do specific things. They seldom ask about the patient while treating a condition to do the whole patient work-up. How specifically was the physician to know that the patient was vulnerable? And what exactly does an “addictive personality” mean? I don’t think there is such a thing – there is not a consensus on this.
Okay, dataguy, imagine that all you know is this: Sammy Mack had long had problems with alcohol and was not unknown to law enforcement authorities. and this: Mack’s divorce was recently finalized…His four children are living with his ex-wife not far away. So, you know that he’s an alcoholic and that he’s had enough run-ins with the law that the local community is well aware that he has a drinking problem. His doctor should be aware of this as well, and if he isn’t he should be able to surmise that his patient is a drunk either through common sense… Read more »
How, exactly, is the doctor supposed to know this? The doctor may ask, “Do you drink much?” and the guy replies, “Oh, I like the occasional drink with my friends, but not often.” Trouble with the police? How is the doctor supposed to find out about that? “Have you ever been arrested?” “Certainly not, doc. Jeez, what kind of a person do you think I am?” Why would the doctor know anything about the guy’s divorce? I feel your passion, but you’re demanding more of the doctor than our society allows. It is clear that there has to be some… Read more »
There are many things that you don’t give people or give people responsibility for without a thorough vetting. You don’t let them set off commercial fireworks. You don’t let them drive public transportation, especially airplanes. You don’t let them them leap into battle in an infantry squad. You don’t let them have custody of their kids in a divorce dispute. I could go on, but the point is that doctors need to consider the act of prescribing opioids as a potentially fatal decision, and short of that a decision that can completely wreck their patient’s life. It’s akin to handing… Read more »
BooMan, why don’t you do some interviews with physicians who work in the pain control and addiction fields and find out, from their perspective, what the barriers are to safer prescribing practices? Do doctors need state laws changed to permit smaller prescriptions with some ability to give refills, as one of your other commenters suggested? Would something as simple as a patient questionnaire help? Do doctors need medicare billing codes for an initial narcotic consultation before a prescription and then for follow-up? I suspect that without a specific billing code, most physicians seeing a guy for an ankle injury can’t… Read more »
I agree with you. And, so far, the kind of stuff they’ve come up with is totally inadequate precisely because doctors seem to think they can hand an eight year old a gun and let them go on their way because the kid’s ankle hurts and they’re short on time. You can wait for the government and the insurance companies to tell you how not to kill your patient whose only problem is ankle pain or you can stop killing them on your own by figuring it out and giving a shit if they live or die. If I… Read more »
You sound like this is very personal for you.
I bet the doctor feels terrible if he/she knows about this death. But did the guy tell his doctor about his police record, or his alcohol problems, or his divorce?
Certainly doctors have no business accessing a police record when making treatment decisions… what are you saying?
Without looking at the case file you are just making a conclusion up.
There are other options for pain management aside from opiates. A post-surgical pain management plan should step down from opiates to non-opioid analgesics. Somehow, the rest of the world manages to take care of their chronic pain patients while using a fraction of the opiates used by the US, even on a per capita basis. And now PF has gotten an indication to use OxyContin in children as young as 11. Was off-label use in this patient population not enough, that they needed the ability to aggressively (or in Pharmaspeak, “proactively”) market in this patient population? On another note, what… Read more »
It is true that European countries are far less likely to prescribe opiates for treatment of chronic pain. That doesn’t mean that the alternatives are particularly successful.
Here’s a relatively old paper on the subject:
http://www.sciencedirect.com/science/article/pii/S1090380105000868
I think we’re still behind on the science for a great solution to this problem. A stagnating NIH/NIDA budget is not helpful.
How well did the US military opium eradication project work in Afghanistan? At last count, production was way up and the junk is flooding Russia, European countries, and even Iran that makes a greater effort to keep the stuff out.
The illegal drugs and narcotics industry is pure capitalism with a heavy dose of multi-level marketing. Public consumption clinics that provide the drug of choice is the best way to prevent accidental overdoses AND put the dealers out of business, and that in turn reduces the numbers of new addicts.
Mark my words, somewhere in some police station today, some cop or worker is harvesting the pills from those dumps and making serious bucks on the side. That’s a good answer, probably 98% of the time, but cops are not without weak links.
Not that there aren’t nurses who use, but you can always bring unused/expired meds to a hospital or acute setting where they can be properly disposed of.
Trust a nurse over a cop any day.
If I had to blame any one actor for the problem, I’d have to blame the system itself that doesn’t attempt to find the right dosage for each individual, and doesn’t monitor said individuals, instead sending them out into the FreeMarket with an addictive substance while saying, “good luck!”. As others have said here, opioids can make you feel calm and at peace, and they can make you feel very nauseated and sick, and they can kill pain and leave you feeling normal. If you feel sick from them, well, you’re probably “out of luck” in the sense of having… Read more »
I agree about the inadequate follow-up. I’m a veterinarian rather than a physician, and we’re fortunate that addiction is not a problem for our patients. Their owners are another matter, but I can count on one hand the number of patients I’ve seen prescribed anything stronger than tramadol or cat-sized doses of buprenorphine to go home. But the point is, high-risk drugs can be completely justifiable as long as adequate precautions are taken. And if you need pre-testing (genetic?) and follow-up, that in itself discourages use in cases where the meds aren’t absolutely needed. I also wonder if part of… Read more »
I don’t mean genetic testing so much as testing the drug by starting low and titrating up slowly so that the doctor and nurse can figure out how much drug is required to stop the pain, compared to how much drug is going to annihilate the pain and get the patient high, putting the patient at risk for addiction if they continue using a higher dosage than necessary. Pain isn’t a normal condition whether acute or chronic, but if we start low enough to get the patient down to a 1-2 / 10 on the pain scale, I think this… Read more »
I meant the genetic testing more as a goal for the future, and not just as a screening test risk of addiction but also for which adjunctive pain medications and strategies might best help reduce the use of addictive drugs in each patient.
No one is yet asking exactly how we got into this fix over the past 50 or so years. And why the problem seems to be increasing now. Surely, it couldn’t be the fact that the global financial geniuses have decided that all we deserve is an austerity economy with jobs that can’t support families. Surely it couldn’t be the fact that unemployment puts stress on families and bodies that can wind up creating physical and emotional pain. Surely it couldn’t be a corrupt law enforcement system that can put stuff back on the street as fast as it confiscates… Read more »
I agree with you. Except for ‘addicted politics’. I would have said, ‘addled politics’.
Another record opium crop in Afghanistan. Thank you, CIA.