Pubdate: Wed, 25 May 2016
Source: Guardian, The (UK)
Copyright: 2016 Guardian News and Media Limited
Contact:  http://www.guardian.co.uk/guardian/
Details: http://www.mapinc.org/media/175
Author: Chris McGreal
Bookmark: http://www.mapinc.org/heroin.htm (Heroin)

HOW GETTING TOUGH ON PRESCRIPTION PILL MILLS LED TO AMERICAN HEROIN CRISIS

Opioid Deaths in the US Have Multiplied in Recent Years. Chris 
Mcgreal Visits Fort Lauderdale to Explore the Origins of the Epidemic

For James Fata, the transition from prescription painkillers to 
heroin was seamless. The 24-year-old came to Florida to shake an 
addiction to opioid pills, but trying to go through rehab in a region 
known as the prescription capital of the US proved too much. When a 
government crackdown curtailed his supply of pills, Fata turned to 
readily available heroin to fill the void.

"The pills were hard to get. They got to be very expensive. Heroin is 
cheap," said Fata. "Almost everyone that I was close to, anybody that 
was doing pills with me, typically they would at least get to the 
point where pills were not an option. You were either snorting heroin 
or shooting heroin."

Florida was the crucible of the opioid epidemic now gripping the US. 
Before deaths from opioids spiked nationwide the state's south road 
corridor, the Interstate 75, earned the name "oxy express" for its 
easy access to supplies of OxyContin, an extraordinarily powerful, 
semi-synthetic opioid painkiller.

Florida spent years trying to shake off its reputation by driving out 
of business the worst of the notorious "pill mills", but there was a 
consequence that state officials hadn't predicted.

When the addicts Florida had facilitated could not get prescription 
opioids any more, they turned to heroin.

"I'd like to say it's getting better because I see at least things 
are being brought to the surface and there's an advocacy movement," 
Fata said. "But on a numbers level, it's getting worse. On the amount 
of deaths I see, it's getting worse. The amount of heroin use I'm 
seeing, it's getting worse."

Heroin deaths in the US have more than tripled nationwide since 2010, 
and critics say Florida's efforts to contain an epidemic unleashed 
within its borders have had limited effect in curbing one crisis 
while making another worse.

Florida's problems started after OxyContin swept on to the market in 
1996, just as medical authorities began pressing doctors to pay 
greater attention to alleviating pain. Unscrupulous businessmen in 
Florida spotted an opportunity.

Within a few years, hundreds of pain clinics popped up around the 
state dispensing opioid pills to just about anyone who asked. Among 
the earliest and biggest was American Pain in the Miami-Fort 
Lauderdale metro area, with a pharmacy run by former strippers and 
doctors carrying guns under their white coats. It took in tens of 
millions of dollars a year selling OxyContin and its generic, 
oxycodone, to people who travelled from Kentucky and West Virginia 
where the painkillers were known as "hillbilly heroin". They came 
south along the oxy express by bus or the carload, sometimes driven 
by dealers who took a cut of the pills.

At one point, more than 90% of all the prescription opioids dispensed 
by doctors in the US were sold in Florida.

Robert Eaton was introduced to opioids at the age of 24 after 
suffering herniated discs in 2009. After a couple of months of 
therapy and low levels of painkillers, his doctor said he had done 
all he could, then pointed Eaton to the pill mills. "He recommended 
me to go see a pain management doctor. I started seeing him every 
month. Immediately he increased all of my prescriptions."

Eaton reels off a list of hundreds of oxycodone, methadone and muscle 
relaxants he was prescribed each month. "As soon I took that drug I 
was like, 'Whoa, this is good. I need more of this now.'"

Those hooked on oxycodone say that they do not so much feel a craving 
for pills as a fear of not getting them and, as they put it, getting 
sick. If they don't get a fix, they get hit by increasingly intense 
pain from withdrawal   much worse than the pain they were treating.

Eaton quickly came to realise that the doctor wasn't treating him but 
taking his money, writing a prescription, and getting him out of the 
door as fast as possible to get the next patient in.

"Not once did he ever ask me: 'Did your pain improve this month?' 
There was no intention to ever bring the medication level down at 
all. You're walking in and he's prescribing you the max," he said. 
"If you had insurance, it didn't matter. You paid cash."

Eaton is still not sure how much he spent between the doctors and the 
pills but said it ran to hundreds of dollars a day at its peak. He 
lost his job as a Budweiser delivery driver because the pills 
affected his work. He lost his house. He even sold his stepchildren's toys.

"My best friend died on just the prescriptions alone. His sister 
found him on the morning of his 30th birthday," he said. Eaton missed 
the funeral because he was on the hunt for a fix.

He finally shook his reliance on drugs with the help of a religious 
group and now runs a personal training business.

In 2010, Florida started to crack down on pill mills. American Pain 
was shut down in an FBI raid and its owners were imprisoned. The 
Florida legislature passed laws to kill off other pill mills and 
curtail the largely unfettered prescription of opioids. Deaths from 
oxycodone in Florida dropped 69% in the five years from 2010.

But the clampdown left those already addicted without a ready supply. 
It limited access to pills, forced up prices on the street, and made 
heroin a cheaper alternative. As the drug flooded in from Mexico, 
heroin deaths in Florida more than doubled in 2014 to a record 408. 
Doctors also reported an increase in the number of babies born 
addicted to heroin, and Florida leads the US in new HIV infections, 
which is attributed to needle-sharing by drug users.

The National Institute on Drug Abuse declared a heroin epidemic in 
south Florida two years ago.

The Journal of the American Medical Association Psychiatry has 
documented a shift towards greater use by white people from affluent 
backgrounds and said that most had been drawn to heroin after 
becoming addicted to opioid painkillers. A 2014 study reported that 
75% of those on heroin said they came to it via prescription opioids 
and noted a rise in heroin use as prescription opioid use decreased.

Prosecutors described American Pain the largest illegal prescription 
drug ring in the US, earning an estimated $43m (UKP29m) in three 
years, and said it was responsible for at least 50 overdose deaths in 
Florida alone. The co-owner of American Pain, Jeff George, was sent 
to prison for 20 years for the death of one of those patients. His 
brother, Chris George, received a reduced sentence of 14 years after 
testifying against doctors he hired.

The Florida legislature passed a package of reforms five years ago 
requiring that pain clinics be owned and run by a doctor, and the 
subsequent shortage of painkillers drove the price of pills up on the 
black market.

"As soon as the prices of the pills went up, I knew I would just use 
heroin," Fata said. "I moved to heroin because the price of OxyContin 
turned to more expensive than the price per ounce of gold." Heroin 
was about one-eighth of the price of pills for the same hit and more 
readily available.

Fata said he kicked his heroin addiction when he recognised it was 
going to kill him and is now studying to become a social worker.

With the rise of heroin use has come an increase in deaths from a 
drug that authorities say is up to 50 times more powerful - fentanyl, 
a synthetic opioid frequently laced into heroin by addicts. The Drug 
Enforcement Administration last year issued a nationwide alert over 
what it called an alarming increase in the number of deaths related 
to fentanyl and heroin.

But the rise of heroin does not mean the prescription opioid crisis 
is going away either, and authorities have struggled to get a grip on 
the crisis.

A Lake Worth doctor, Sergio Rodriguez, was sentenced to 27 years in 
prison in 2013 over his role in four opioid overdose deaths. But it 
has proved hard to convict others. Cynthia Cadet wrote more 
prescriptions than any other doctor at American Pain and was paid 
$1.5m. But a jury cleared her of criminal charges after she said she 
could not know if patients were lying about pain levels. She was 
later imprisoned for money laundering.

Janet Colbert is a neonatal intensive care nurse working near Fort 
Lauderdale who was instrumental in getting the pill mills closed 
after witnessing a dramatic increase in the number of babies born 
with opioid addiction, passed on from their mothers. She said that 
jailing a few doctors did not go far enough when hundreds were 
employed in what she regarded as a criminal racket. She would like to 
see the state medical authorities strip them of their licences to practice.

Her organisation, StoppNow, is also pushing for doctors to be 
required to use a monitoring programme that would tell them if a 
patient was obtaining prescriptions from another doctor. The 
programme is compulsory in 20 states but voluntary in Florida.

Colbert said state legislators had told her they would not support 
the measure because it was opposed by the Florida Medical 
Association. "The doctors have a lot of clout and they don't want the 
legislation because somebody's telling them what to do," she said.

The Florida Medical Association did not respond to a request for comment. 
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MAP posted-by: Jay Bergstrom