Tonawanda News

May 18, 2013

Down the rabbit hole

By Neale Gulley
The Tonawanda News

— Eighteen-year-old Michael Israel never wanted to get hooked, he didn't even want to get high.

Israel, a UB student studying architecture, suffered from Crohn's disease, a painful digestive disorder. When it required surgery a few years ago, his doctor prescribed hydrocodone for the pain.

The addiction quickly took hold. After that, all Michael Israel wanted was help.

"In 2010, he said 'pop, I have a problem, I'm addicted to the pain pills. I can't control myself, ' " his father, Avi Israel, of Buffalo, said. "He did not want to be addicted."

Michael went back to the doctor, who said he'd lessen the dosage and "ween" him off the prescription painkiller, a member of a vast family of opioid drugs derived from the opium poppy. Opium poppies are part of a plant that has been used for its analgesic qualities since before recorded history. They are round, bluish pods at the end of a long stalk — the main ingredient in heroin.

After lots of processing, the pills themselves look like little more than a multivitamin, and more of them are prescribed in the U.S. than ever before.

"The pills are synthetic heroin — heroin made in a lab," Israel said. "No one told us the ramifications of taking this pill."

The ramifications would prove deadly.

Michael couldn't ween himself from the drug, and his frustration mounted. In 2011, Israel found his son in the garage of their Norwalk Avenue home, with the door closed and the car running. He survived the suicide attempt, an act brought on by a cocktail of emotions surrounding his inability to resist the pills he never wanted to need. The Israels, then desperate, tried to check him into an area hospital. He was sent home, and the family called an addiction specialist.

"It took her five minutes to call him back and say 'we have no beds for you,' " Israel said. "Michael handed me the phone and the look on his face was 'I've had enough.' He went into the bedroom ... I heard him cock the gun. I tried to kick in the door ... he pulled the trigger and he died in my arms."

The Centers for Disease Control and Prevention this year classified prescription drug abuse as an epidemic responsible for 60 percent of all overdose deaths in 2010 — the 11th straight year such deaths have risen in the United States. The number of fatal overdoses blamed on prescriptions painkillers was fully four times greater in 2010 than a decade earlier.

Michael didn't overdose. He didn't have to for his addiction to take its deadly toll.

"Our society wants to say 'you got yourself into it, you get yourself out of it,' " Israel said. "My son didn't get into it — he was prescribed into it."

Heroin on the rise

Stories like Michael's haven't gone unnoticed. In fact they've created quite a stir over the past two years among legislators on the state and national levels.

Israel has dedicated the two years since his son's death to lobbying tirelessly for legislation to improve education, treatment and prevention of such abuse and addiction — even testifying before the U.S. and state senates. As a result, new laws like I-STOP have been passed. The legislation will create a statewide database of patients' prescription histories to help to doctors and pharmacists combat "doctor shopping" among patients seeking drugs by fraud.

It will limit the availability of refills on some prescriptions and eliminate paper prescription pads that can easily be forged, among other initiatives. The plan is intended to help the medical community better track patterns of patient abuse. Other, federal legislation like the SAFE DOSES Act, signed into law last year, seek to combat theft of opioid painkillers in the supply chain by increasing penalties.

But as each effort to curb pill abuse is mounted, another, equally disturbing trend is emerging — heroin use.

Dale Kasprzyk, resident agent in charge of the Buffalo office of the Drug Enforcement Administration, said as pills become less available, addicts are turning to their illicit counterpart — a drug with a major rap for ruining lives.

"I think we're doing a really good job of attacking the prescription drug problem but as we continue to limit the availability of those pills, addicts will try to satisfy their addiction and they have now turned to heroin," he said. "The reports coming out of most cities right now is that heroin is on the rise."

In other words, not only is increased pill-form opiate addiction leading to heroin, but the phenomenon is partly a result of success in combating pill pushers.

"You absolutely are seeing, 100 percent, an uptick in heroin," said Anne Constantino, president and CEO of Horizon Health Services, an addiction treatment facility serving the Tonawandas. "And pretty much every young person who comes in addicted to heroin will tell you that they started with pills."

Kasprzyk said addicts look to heroin because they can get the same high for far less money. With the demand in place, he said, supply follows.

"There is as much heroin available in Tonawanda as there is on the East Side of Buffalo, the West Side of Buffalo or in New York City," he said. "We're producing opiate addicts with the pills but it's leading straight to heroin."

And with more opiate addicts starting with a single, innocent looking pill, more and more people are likely to turn to heroin.

Constantino said Tonawandas and other suburbanites are no an exception to addiction trends. 

In fact, they are becoming the rule.

"I think what the public needs to understand is that this isn’t an inner city problem," she said. "In fact, the opiate and heroin problem is suburban."

And while an Oxycontin tablet can cost between $40 and $80 from a drug dealer, the equivalent in heroin can be found for as cheaply as $10 — one reason local authorities are seeing so much of it.

Kasprzyk said a significant increase in the potency of heroin in the past decade also means the drug can be snorted and still produce a high, removing even more of the stigma associated with needles.

Nick Gazzoli, a drug counselor at Horizon, said many addicts begin by snorting heroin, but eventually turn to the needle.

"If you ask a person if they think they'll ever shoot heroin, they'll say no or 'I'm scared of needles,' but you pay for pills until you can't afford it anymore, because your tolerance goes up," he said. 

"Nine out of 10 people, their friend whose already (injecting heroin) shoots them up for the first time, and then they're shooting up. All your preconceived notions about what you would or wouldn't do fall out the window very quickly."

Tracking abuse

While the relationship between prescription opioid use and heroin represents what Kasprzyk called "a perfect storm," the problem still often begins with a single pill.

Local police departments have reported a rise in the number of arrests for possession of controlled substances in recent years.

In 2010, police in the City of Tonawanda made 40 arrests for illegal possession of controlled substances also including cocaine and other such drugs. In 2011 there were 51 arrests and in 2012, the number rose again, to 61.

City Police Lt. Fredric Foels said the majority of those arrests were for pills discovered out of their original prescription bottles, and usually in the wrong hands.

In North Tonawanda, a similar breakdown of arrests wasn't available. Acting Chief William Hall said the department sees about 12 drug arrests each month.

Hard, local data on the prevalence of such drugs is scarce. But numbers provided by the Erie County Medical Examiner support theories on the increased role of opiate-based drugs in local overdose deaths.

Jannine Blank, director at the medical examiner's office, provided data showing death from chemical intoxication in general has only risen since the CDC's ominous benchmark in 2010, from 76 such deaths confirmed in 2010, to 125 in 2011 and 105 in 2012.

Specifically in the Ken-Ton area, a further breakdown shows opiates accounted for the greatest number of deaths in each of those years. In 2010, opiate based drugs alone accounted for half of all chemically induced deaths in Ken-Ton, a category also including death from opiates mixed with cocaine (accounting for an additional two deaths) and deaths due to a combination of other chemicals.

In 2011, six in 10 chemically induced deaths were blamed on opiates. In 2012, five deaths were attributed directly to opiates while cocaine and opiates resulted in one death, ethanol and cocaine accounted for one death, one was attributed to Strychine and another that year was laid to a combination of substances.

The history of abuse

Kasprzyk's 25 years with the DEA in Western New York has given him a unique perspective on drug abuse trends in this area, beginning in the 1980s.

"When I started out the drug of choice was cocaine and crack," he said.

At the time he said Colombian cartels were the controlling enterprise in port cities like Miami, with extensive networks to distribute "tremendous amounts" of cocaine throughout the country. At the time, powdered cocaine was the by far the dominant narcotic, while heroin came predominantly from southeast and southwest Asia, and was expensive, at about $25 per dose, and just 3 to 5 percent pure.

In the late 90s and early 2000s, however, the drug market was poised to change in a big way.

The cartels, with vast illicit trade networks already established as a result of the cocaine boom, had sensed a decrease in the demand for cocaine, he said, and strengthened the drug through the introduction of crack in the early 1990s.

"When they sensed there was a little bit of a reduction in the demand for cocaine, they developed crack, and that really lit things up," he said.

The new, cheaper form of cocaine hitting the streets was able to be smoked, resulting in a brief but intense high that was also more addictive.

While the destruction caused by the crack epidemic would be well documented, especially in poorer communities, throughout much of the decade to come, the cartels also saw an under-the-radar opportunity to get into the heroin business. While Asian heroin in the 80s and 90s cost about $100,000 per kilogram or $25 per dose — the new Colombian heroin was half the price, and much stronger.

The Colombian product cost just $10 per bag, and upped the potency, to a relatively staggering 10 to 15 percent.

Not only does the increased purity lend itself to addiction, more importantly, it means the drug can be snorted instead of injected, a fact Kasprzyk said eliminates the stigma associated with heroin for many first-time users.

"Now you've got a lot of middle-income suburban kids who don't want to inject it and so they snort it," he said.

With prescription opioids more prevalent and cheaper, and with stronger heroin on the streets, Kasprzak said a perfect storm was brewing for opiate addiction throughout the United States beginning around 2000.

Identifying the rising trens, the Buffalo DEA office also recently formed what's called the tactical diversion squad to investigate prescription drug cases. It includes DEA agents in conjunction with police from Amherst, Lancaster, Buffalo, Depew and the Erie County Sheriff's office.

It was the diversion squad, he said, that played a lead role in the arrest of North Tonawanda's Dr. Matthew Bennett. The family care physician was arrested after an investigation found that the 46-year-old doctor did not examine many of his patients when prescribing pills and would often trade items at his home such as toiletries and even a gas grill for opiate-based prescription medications including Roxicodone, Oxymorphone and Xanax.

"They're the busiest group in the office," he said.

'Prescribed into it'

Just as the perfect storm was brewing, America's medical professionals were also being taught to more aggressively treat pain though opioid medication, Kasprzyk said. 

In 1995, the president of the American Pain Society, Dr. James Campbell, first suggested that pain should be better quantified and treated.

Just a few years later, in 2001, new standards were released by The Joint Commission —  a not-for-profit body that accredits and certifies more than 20,000 health care organizations and programs — based on the popular new mandate that pain should be treated "as the 5th vital sign."

According to an unrelated CDC report issued this year, the number of legitimately filled prescriptions for painkillers since that time has risen in lockstep with overdose trends. 

The number of painkillers sold to pharmacies, hospitals and doctors' offices was four times larger in 2010 than in 1999, before the new guidelines were issued. Similarly, opioid overdose deaths rose from 4,030 in 1999 to 16,651 in 2010 — a 400 percent increase.

The American Medical Association, in response to a News inquiry into the reasons for abuse, outlined a platform including physician education, public awareness, better storage and disposal of such drugs and increased access to what Michael Israel needed so badly — addiction treatment and recovery programs.

But the AMA, along with many in the medical community, also warn against discouraging physicians from prescribing pain medication when it's needed most.

“As policymakers craft solutions to address prescription drug abuse ... it is critical that we do not unintentionally discourage physicians from appropriately treating pain or reduce access to prescription drugs for patients who are suffering,” AMA President Jeremy Lazarus said in an email to the News.

He said the AMA works hard to inform physicians about appropriate pain management through a variety of education initiatives. Over the next two years, he said the AMA will host 12 free webinars for prescribers on various topics "related to the intersection of addiction, pain management and opioid use."

"It is important for physicians to evaluate their patients for risk of opioid abuse, and to monitor their response in a way that improves pain and function and avoids harm,” he wrote.

'We have no beds for you'

While prevention and education are agreed upon solutions among counselors, police and the medical community, just as pressing is the need for the kind of treatment that Michael Israel couldn't find.

Policymakers say residential, in-patient resources have been lacking in Western New York even as other areas, like New York City, have a surplus of treatment beds. Kasprzyk said area treatment facilities like Horizon "are bursting at the seams."

Horizon admits about 450 people each month to its addiction treatment programs, and up to 2,000 people are undergoing treatment there at any given time. But where residential treatment is concerned, the waiting list is consistently about 35 people.

“The progression into very serious addiction is rapid, and it’s very life threatening because as you’re trying to get off opiates your tolerance is decreasing. If you use the drug again there is a high incidence of overdose,” Constantino said.

But slowly, things are changing.

Just this week, a $3.8 million state grant was awarded to Horizon Village through the Office of Alcohol and Substance Abuse Services to construct and operate an additional 25-bed treatment facility in this area.

The new beds will be constructed "as soon as possible," Constantino said, at Horizon's Sanborn campus, where a 50 bed facility already exists. Another, separate, 25-bed facility for veterans is also slated to open this fall.

"They did hear and acknowledge the problem were having here in Western New York," she said. "We identified this issue in 2007 and the trends were shocking then. This really happened because of a lot of advocacy here, and outrage by parents who were frustrated by their inability to find services for young adults and children."

Parents, she said, like Avi Israel.