If you have access to HBO, you should watch their new documentary Heroin: Cape Cod, USA. It is also an excellent companion to the book Dreamland: The True Tale of America’s Opiate Epidemic, which details the rise of pain pill addiction and the resulting shift over to heroin among the pill abusers.
The documentary follows eight heroin abusers in their early twenties and also follows some of their families. Two of the users die of overdoses before the documentary is completed. The stories they tell are chilling.
The most frightening story to me are the kids who get into pills not through thrill seeking, but by injury. Two are hurt in car crashes, another suffers a soccer injury. They are prescribed opiates and they get hooked on them. It is not long before they are shooting heroin. Now not everyone who is prescribed opiates for injury is going to end up a heroin addict, but certain people — those perhaps with a genetic disposition toward addiction — see their lives fall apart.
In my last blog post, Pain Myth, I said that I would still continue to give IV or IN opiates to patients in pain. i continue to do that, but this documentary only adds to my concern.
Four moments from the film caused me particular thought.
One of the kids says opiates don’t make the pain go away — it is still there — you just don’t care about it anymore. Now I have observed this. I load someone up with fentanyl. Their pain may still be a self-reported 8, but they are clearly zoned out and in la-la-land. (Do I give them more? I generally don’t.) My concern here stems from my belief that stopping the pain stops the cascade of neurological change that acute pain can cause that has been reported to lead to chronic pain. If they feel the pain but don’t care about it, have I stopped the change? Should I be medicating down to the four of less pain scale we use, even though they are singing The Farmer in the Dell? I think maybe nobody really knows the answer to this question.
All the heroin kids’s focus is on the next hit. I used to think that drug seekers had to have something better to do than call 911 just to get one dose of pain meds and maybe two pills to go. One day I picked up a guy wearing a New York Giants coat while he was watching the Giants play on TV. He had a history of pancreatitis and he was having abdominal pain. Now, surely I thought, his pain has to be legitimate because he is going to miss the Giants game, but maybe that need for the next dose is that great. I wonder what role I am playing in the cycle? Some of the kids talk about robbing others, stealing and committing acts of prostitution to get the money for their next fix. So what are their choices? Jump someone? Burgle someone’s house? Commit an act of prostitution? Or call 911? I think of all the options, my giving them some fentanyl and taking them to a place where they can be encouraged to enter substance abuse seems like the best alternative.
One of the girls who ends up dying has a personal code where she won’t rob or steal or hurt anyone else to get high. She gets her money from striping, dancing on the pole and later prostituting herself. She has a real tough girl attitude and talks about going to the ED and being patronized and disrespected. I have seen others just like her sitting in triage getting into shouting matches with the triage nurses when they think they are being treated shabbily. She also looks like a friend of mine who used to be an addict but got her life back through sports addiction instead. There is a point where the girl is crying on camera talking about how tired she is from it all. As a father it breaks your heart. She is only twenty-three years old. She doesn’t make it to twenty-four.
They show scenes from the family support groups. One mother says if their child had any other disease, people would be bringing the family casseroles, but she has never gotten a cassarole. They struggle not knowing the best way to help their child. They can kick them out of the home, but worry the child will end up dead or never seen again, or they let them live at home, and in a way enable the drug life to continue. In Dreamland, there were stories of parents driving their drugsick kids to meet the heroin dealer because they couldn’t bear to see their child suffer.
One of my daughters is 15 and she has told me she has friends who abuse percocets. I have given her all the warnings I can. She is an athlete. What is she tears an ACL and is put on opiates? How do I protect her?
One last thought. Heroin today is everywhere, but as it is particularly now in white and often upper class communities. Because of that there has been a strong push for gentler law enforcement and to treat the crimes associated with heroin use more as social issues than as strict criminal activity as was the case back in the 70’s when heroin was ravishing the black inner cities. I wonder how those kids’s families felt when their child was sent away to prison for ten years for buying a bag of heroin to chase off their drug sickness?
If this job doesn’t teach you tolerance and empathy for all people, you have no business being in it.