Prescription Pain Medication: The REAL Gateway Drug

“Heroin, prescription drugs, syringes found in Philip Seymour Hoffman’s home, law enforcement sources say.” — CNN (02/03/14 – 10/57am). 

In the wake of today’s news that Philip Seymour Hoffman has died, I find myself one of the many shocked individuals.  I’m sure that I wasn’t alone in wondering if drugs were involved and was this yet another case of a wildly talented celebrity falling prey to a opiate-related fatal overdose.  

Update #1:
As of yesterday afternoon when I started to write this, reports were flying all over the web, most recently that Hoffman, 46, was found dead in his apartment with “a needle in his arm” and that there was presence of heroin in his apartment” confidential sources in the NYPD were allegedly reporting to news outlets such as the Wall Street Journal and CNN.  I use the term “facts” loosely as reports started circulating that the actor died earlier today, then, more recently, it was stated that he actually passed away on Friday (January 31st).  Irrespective of the date and time, it’s a huge loss, but one that will hopefully bring more attention to a hugely widespread problem.
 
Without the “facts”, and disregarding the contrary reports online, it has been well documented through the years that Hoffman was at outspoken about his history with substance abuse, rather than keep the issue quiet like a “dirty” or “shameful” secret.  Understandably, often many suffering substance abusers and their families opt to keep these matters private, which is human nature especially when there is a stigma attached to substance abuse and addiction.  This is a very personal choice and can carry huge repercussions for all involved, regardless of the decision.  Phil Hoffman utilized his status as a celebrity and the attention that comes with it (something he was not a big fan of) to often bring awareness to the impact of his own struggles with substance abuse.  He stated several times over the years that he got sober at age 22, and was reportedly sober for 23 years until a relapse last year that lead to him going to rehab after struggling with snorting heroin.  Brave souls, like Hoffman help bring awareness to the such related elements as the “family disease model” of substance abuse, as he has reportedly lived nearby but not with his family after the events of last year.  
 
Update #2:  Many news outlets such as CNN are reporting that Hoffman was “found with a needle in his arm and 8 empty ‘glassine type’ bags stamped with the ‘Ace of Hearts’ and ‘Ace of Spades’ were found in his apartment” (CNN).  
 
It’s not uncommon for dealers to mark their product, whether by stamping their bags of heroin, placing recognizable logos in home made ecstasy tablets such as the Nike “Swoosh” or Mitsubishi logo to name but a couple.  For years, LSD has had cartoon characters from Micky Mouse to Bart Simpson printed on the blotter which contains the drug.
 
Update #3:  As of 12:27pm, CNN is reporting that, “Police investigating the death of actor Philip Seymour Hoffman have found close to 50 envelopes of what they believe is heroin in his Manhattan apartment, two law enforcement sources familiar with the inquiry said Monday.   A number of used syringes, prescription drugs and empty bags that authorities suspect used to hold heroin also were found in the apartment where Hoffman, 46, was found dead Sunday of an apparent drug overdose on the bathroom floor with a syringe in his left arm, the sources said” (CNN.com).
 
Regardless of whether there were 5 bags or 50, it seems once again the focus is on heroin, with the prescription drug factor being glassed over.  
 
Prescription Opioid based painkillers have been leading to eventual heroin use with an increasing rate for years because, guess what?  Heroin IS an opioid known scientifically as diacetylmorphine.  Opioids include many prescription medications used to treat pain such as morphine, codeine, methadone, oxycodone (Oxycontin, Percodan, Percocet), hydrocodone (Vicodin, Lortab, Norco), fentanyl (Duragesic, Fentora), hydromorphone (Dilaudid, Exalgo), and buprenorphine (Suboxone).  As I mentioned, Heroin is an opioid; one which has become cheaper and more pure.  It used to be that heroin could only be used to get high by injecting it intravenously, however the purity of heroin being sold and consumed has now allowed users to Insufflate (snort) it to get high, however that route leads to ingesting everything else in the drug (impurities, chemicals which it is “cut” with, allowing dealers to have more sellable volume of their product).  Therefore, heroin is sometimes smoked heating it to the point that these additives burn off.  Ask a heroin addict about this and most likely there is no debate; cooking up the drug and injecting it intravenously is the most economical route of use allowing for more delivery of the drug to the central nervous system and a longer high, temporarily satisfying the physical and mental cravings.
 
People often ask me how someone becomes a heroin addict.  Without some other kind of serious psychopathology, no one sets out to become a heroin addict.  The path to heroin use has become increasingly and undeniably paved on the road of prescription opioid pain killers.  The use of those medications starts as either medically needed for pain, or more frequently over the past 10 years, recreationally, especially in adolescents.  Did I mention that Heroin itself is an opioid?  Forgive the sarcasm, it’s fueled by the hypocrisy of pharmaceutical marketing and the subsequent cavalier attitude that surrounds recreational use of prescription medications which is now often accepted especially in adolescents as taking a pill has remained socially acceptable as most people start taking such orally (especially if prescribed for severe pain i.e. recovery from surgery).  Following doctor’s dosing directions doesn’t elimate risk of addiction.  A tolerance for the drug is built quickly and for many addicts who began taking these medications for pain, the dosing schedule wasn’t adhered to for long.  Former NFL players discuss taking huge quantities of painkillers to deal with years of football, from crushing tackles to other injuries and often multiple surgeries.  Whether first taken for medicinal purposes or recreational purposes, there are thousands of stories of quickly building tolerance leading to a vicious cycle of risk taking from crushing up these pills and insufflating (snorting, which appears to be the next step eliminating a pill’s time release mechanism, which doesn’t deliver the dosage as quickly as the addict’s body and mind is demanding).  Pills are even broken down and cooked into an injectable form or “plugged” as in, inserted anally.  It’s true.  Look it up.  
 
While the availability of prescription opioiods remains high, the recent regulations have made them more difficult and more expensive to obtain.  For an addict who requires an ever growing dose, this adds an extra layer of challenge beyond doctor shopping.  Often this might include stealing medicine directly from other’s medicine cabinets, and ultimately stealing the money for the drugs.  The innate drive to satisfy the craving and stay off the unpleasant withdrawal related symptoms has created an increase in theft in all sorts of ways from not just stealing from a family member’s medicine cabinet, but going into elaborate schemes such as pretending to be shopping for a home, but really looking through medicine cabinets while supervised in many instances only by the real estate agent or broker showing the home to persons they think is are perspective buyers.  
 
Usually the initial question I’m asked has many followups.  One question in particular which usually arises from a concerned family member isn’t so much a question for me, but a statement of bewilderment that has a question mark at the end.  Let’s face it too, in the case of loved ones, it’s only natural to project some form of blame on yourself.  This may occur totally unconsciously, but it will lead no where good.  It leads to prolonged enabling, being stolen from, lied to every time you communicate with the individual, not to mention the unwavering panic.  So, the question or statement is soaked in pain and thematically has to do with the total and utter shock being experienced,  that a person they love and hold so dearly has been using needles.  Needles!  The often considered ultimate taboo as far as doing drugs goes.  The fact of the matter is that having an accidental fatal overdose is not limited to intravenous users of drugs, or heroin users in general.  It’s actually more commonly seen in abusers of prescription opioids.  
 
Very publicly, in 2009, the Centers for Disease Control and Prevention stated that addiction to prescription painkillers cause most of the (then) more than 26,000 fatal overdoses each year and that the number of overdose deaths from opioids more than tripled from 1999 to 2006, to 13,800 deaths that year, according to CDC statistics released on August 6, 2010, over 3.5 years ago about deaths occurring over 7 years ago.  Since then, the problem has only become worse.  FDA regulations created in response to this epidemic have made the drugs a bit more difficult to get driving the price of Oxycontin to $1 per milligram, and chronic addicts taking over 100mg per day.  That recipe won’t last long in those who can’t afford to spend $100 on drugs per day.  Also, it requires getting enough.  With an addiction that causes high tolerance and severe physical symptoms during withdrawal that are physically and mentally debilitating, where addicts become depressed, have thoughts of suicide on top of crawling out of their skin, having extreme GI issues such as diarrhea and/or intense vomiting along with flu like symptoms as well.  it’s no surprise users have taken to crime to prevent from becoming “dope sick.”  It’s not surprising then either that heroin available on the street has become more pure and readily available.  
 
“According to the DEA, heroin availability rose in 2012 most likely because of an uptick in Mexican production and traffickers expanding into new markets” (CNN).  Between 2008 and 2012, the amount of heroin seized each year at the southwest U.S. / Mexico border more than tripled.
 
This growing demand which traffickers are becoming more adept at satisfying is unfortunately in part, a byproduct of the DEA’s crackdown on prescription opioids.  I’m not blaming the DEA by any stretch, or advocating for legalizing opioids, but it’s no coincidence that cracking down on regulated substances is going to yield an increase in the market for unregulated alternatives.  It’s similar in nature to prohibition, and for those that watch Boardwalk Empire (not a major spoiler) heroin has become more prominent in its story line.  Authorities are playing “whack-a-mole” with increasingly savvy traffickers whose opportunities for growing revenue and profit are being capitalized in ways that have cartels commissioning “home-made submarines” to deliver thousands of pounds of drugs into the U.S. bypassing the border altogether.  
 
The  Results from the National Survey on Drug Use and Health: Summary of National Findings (for 2012), an annual report published by the Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the U.S. Department of Health and Human Services (HHS) found that about 669,000 people over age 12 had used heroin at some point in the year. About 156,000 of those were first-time users, and roughly 467,000 were considered heroin-dependent — more than double the number in 2002 (SAMHSA, 2013).
 
I don’t have the answers for law enforcement and policy makers, nor do I wish to write about my ideas on that subject.  That’s for another post.   
 
What I tell family members and addicts themselves is that they took a big first step in speaking to a healthcare professional.  It’s a great starting point and I can communicate with the physician providing the opioids, if given permission, preventing many addicts who often have a co-morbid mood or anxiety disorder reason to get high just to rat themselves out, if they ever were going to in the first place.
 
Those who seek my help are also made aware (if they haven’t lived it already) of the extremely high relapse rate for opioid addiction.  Hoffman himself was reportedly sober for 23 years before relapsing and entering treatment last year which was reported to have placed him back in a sober lifestyle, but in retrospect who knows. 
If you or a someone you care about has an even suspected problem with opioids, talk to a healthcare professional and get SAMHSA’s Opioid Overdose Toolkit: Safety Advice for Patients and Family Members is available here as a PDF.  The 6 page pamphlet in the Toolkit especially for the user won’t cure addiction, but it’s already saved many lives, and not just during overdose.  
 
Although I go paperless whenever possible, in this case it’s a good idea to not only print this 6 page pamphlet, but to order hardcopies of the “Toolkit” which can be ordered at SAMHSA’s bookstore here   Handing a loved one a hard copy of the pamphlet that might save their life makes it more likely it will be read than only emailing a link.  It certainly increases accessibility in the case of an emergency or even provoke the seeking of treatment before reaching overdose.  Again, this pamphlet is only one part of the toolkit, but it is 6 pages and  is especially for the addict, while other sections are for family members, treatment professionals and more.  The pamphlet for the addict is available here.
 
While I wrote a great deal more, I’m finding myself increasingly disgusted with the details about what was found in Hoffman’s apartment and the sensationalizing of those items that were allegedly found.  Instead, consider that a hugely talented and very bright individual who clearly had insight to his addictions and for a long period knew he was not immune to potential horrors for himself and family had he not been sober once achieving success and beyond.  
 
In 2006, the year after winning the Oscar for his performance in Capote, he did an interview with 60 minutes.   Hoffman spoke in part about college “partying” calling it what it really was for him, a life threatening situation which needed treatment.  He told 60 minutes, “I went to rehab and I got sober when I was 22 years old. You get panicked… and I got panicked for my life. It really was just that.”  In speaking about ‘young Hollywood’ with the increased fame, fortune, and constant media and public obsession about them, he said, “I have so much empathy for these young actors that are 19 and all of a sudden they’re beautiful and famous and rich. I’m like, ‘Oh my God. I’d be dead.’ You know what I mean? I’d be 19, beautiful, famous and rich. That would be it. I think back at 
that time. I think if I had the money, that kind of money and stuff. So, yeah [I would have died].” 

 

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. 

Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit: Safety Advise for Patients.      HHS Publication No. (SMA) 13-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. 

 
 

The Real Dash: SingleFATHER; TechGeek, MovieFreak, Music/TV/Reading/Writing Junkie, Psychotherapist, RUNNER, Meditator. Mad useful/less info. If that's not enough....see my links.....

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