Hard to quit

In Asheville, N.C., the red trolley tour usually fills up with retirees and vacationers, but this city of 87,236 in the Appalachians also attracts many wanderers and hippies. Unshaved legs, tattoos, and graying hair are common sights. The pungent smell of marijuana often wafts on the early evening breeze. A typical mid-July weekend brings four arrests for marijuana possession, which many residents do not think should be a crime. Heroin is a greater concern: Asheville’s 12 overdose deaths in the past year might not seem like much, but that number was zero just four years ago.

How did that happen? Is marijuana a gateway drug? Are doctors part of the problem or part of the solution? I asked people online and on Asheville streets what they knew about the overdose epidemic—and learned most pot smokers didn’t know much. Several directed me to Emris “Wizard” Ouroboros, 23, who settled in Asheville last year after his jittery feet carried him through 17 states. He wears a kilt with a wolf’s tail hanging down the side and a cowboy hat altered to look like Gandalf’s from The Lord of the Rings.

“Oh, you looking for Wizard?” people downtown said: “He’s hanging out by the stone monument today.” I found Wizard by the obelisk honoring Zebulon Vance, the Confederate governor of North Carolina. Wizard had a lot to say about hallucinogens like acid and weed, but wasn’t helpful concerning heroin. He “sticks with the green.” So, according to him, do most users in Asheville: Marijuana and alcohol are popular. Heroin, not as much.

THAT BEGAN my Asheville education in who doesn’t use heroin—and to get an idea about who does, I sat down with medical personnel at the Mountain Area Health Education Center (MAHEC), a complex atop a small mountain in South Asheville.

The archway of MAHEC’s education building extends two stories up. Floor-to-ceiling windows bathe the interior with light. In a meeting room with plush leather chairs, three people from the pain management program explained how prescription painkillers (aka opioids) are gateway drugs to heroin in a way that marijuana has not been.

Opioids include morphine-based drugs called opiates. Morphine, derived from poppy seeds, is highly useful for numbing pain—and also highly addictive. Once the body develops a dependence on morphine, it must be weaned off: Otherwise, physical withdrawal symptoms can include diarrhea, sweating, anxiety, and insomnia. Former users describe withdrawal as “the worst flu symptoms imaginable.”

A legitimate prescription for the opioid hydrocodone after a knee surgery can result in a physical dependence on the drug since patients will experience the discomfort of withdrawal if they stop taking it as prescribed. The diagnosis of addiction comes when users begin compulsively seeking and using the drug despite harmful consequences.

Physicians—often well-meaning but sometimes profiteering—ushered into addiction thousands of people recovering from surgery or suffering from conditions like post-traumatic stress disorder (PTSD) or depression. That’s because for many years doctors viewed pain as the enemy, with some prescribing whatever a patient needed to be pain-free, upping the dosage if the patient wanted more. That thinking coincided with the development of OxyContin, a popular time-release morphine pill. Consumption of opioids grew thirtyfold worldwide between 1980 and 2011.

Now, 12 states have fewer people than prescriptions. North Carolina has 96.6 prescriptions per 100 adults. “We wrote a lot of them,” said MAHEC nurse practitioner Carriedelle Fusco, speaking of the medical profession: “We still are.”

MAHEC’s pain management team still treats pain but now focuses on safer opioid-prescribing practices, which might include weaning patients off the drugs or reducing their dosage. But prescription opioids have proven to be gateway drugs: 3 out of 4 new heroin users report first abusing a prescription opioid, according to the CDC.

Many doctors avoid prescribing opioids altogether due to the risk of abuse. But when rural physicians in western North Carolina decide they’re not going to prescribe opioids anymore, Fusco asks them: “Are you going to prescribe Suboxone? Or do you want to deal with the heroin epidemic you’re going to get? Because when you have a vacuum, something will fill it.”

Many doctors believe Suboxone and methadone can fill the vacuum. Suboxone contains an opioid, buprenorphine, and an opioid blocker, naloxone. Together, they are supposed to satisfy the craving for the drug while preventing the opportunity for a further high. Methadone reduces heroin withdrawal symptoms. Some users stay on for a few months, but others are on a path to lifetime maintenance.

I HUNG OUT before sunrise one morning in the cigarette-butt-littered parking lot of Crossroads Treatment Center in Asheville. People in work boots, T-shirts, and jeans or sweatpants formed a line at the clinic doors, as minute by minute more beaten vehicles pulled into the lot. A police officer sat in his car, keeping a watchful eye.

At 5 o’clock sharp, the doors opened and people ascended the staircase to get their daily dose for $14. A worker called out a number from behind a curtained cubicle along the back wall. When a short man walked in, she handed him a small plastic cup of clear fluid: methadone. The woman watched him drink the medicine and then took back the cup. The medication is supposed to be partnered with counseling, but people coming in before the sun just wanted their dose so that they could get to work on time. I didn’t see any counseling going on. (Crossroads says it offers unlimited counseling but the wait time can be long.)

As with any drug, some people become dependent on methadone or Suboxone for the rest of their lives. Others use them as a steppingstone to recovery—a way to control opioid craving while rebuilding a productive life. Many with an opioid dependence wake up at 4 a.m. to drive an hour each way to the closest methadone clinic. These clinics are moneymakers, with Crossroads expected to profit close to $1 million in 2016.

Those who view addiction as a medical disorder say the problem is not a purposeless life but compulsive behavior focused on drug-seeking. Their prescription: reduce the compulsion medically and rebuild relationships with other people. I sat in a meeting centered on this approach just north of Asheville in Madison County (population 21,022), which had four reported heroin deaths and 14 EMT overdose reversals during the first half of 2016. Thirty people—doctors and nurses, police officers, paramedics, county officials, and several current users and parents—sat and tried to come to grips with the crisis.

A county police officer and a paramedic said 90 percent of all thefts in 2014 involved drugs, with 50 percent of those involving prescription medications—so some grandparents have started locking their pain medications in their gun safes. Heather Sharp, director of the Madison Substance Awareness Coalition, noted the neighborly tradition of green bean, corn, and sweet potato casseroles delivered to homes for almost every occasion, but for drug addicts and their families, “nobody brings you a casserole. So, it feels pretty lonely.”

A young woman named Conner Adams took the microphone and said she was an addict for six years: “I went to detox over 12 times. My last year using [heroin and crack cocaine] I went to rehab three times. It just didn’t work for me.” She said giving someone a detox pill or a month of therapy isn’t enough to rebuild an addiction-ravaged life: She needed time, connecting with others, and reigniting passion.

Adams’ passion now is for “harm reduction.” In September 2015 she founded The Steady Collective, a small band of former drug users working to improve community health by reducing the rate of overdose and the spread of disease in Asheville. She and her team build support groups for current and former users. Adams speaks often about the social isolation that comes with drug use. She used to volunteer at an underground syringe exchange where people would come in and ask for a hug, saying, “No one has hugged me in a year.”

ADAMS CLAIMS in 10 months her group has saved more than 600 lives through overdose reversals. On early Sunday afternoons in Asheville, The Steady Collective sets up a small table under a tree in downtown’s Pritchard Park to pass out free condoms, voter registration cards—and free overdose reversal kits. Each kit is equipped with two doses of Narcan: a nasal spray form of naloxone, the overdose reversal drug.

For years, emergency rooms and medical technicians were the only people equipped with this powerful overdose antidote, a small nasal spray that can restart an opioid overdose victim’s breathing in a matter of minutes. But current harm reduction advocates are pushing to distribute it on the streets in order to get it into the hands of true overdose first responders: current users and their families. On one Sunday, women in flowered dresses and wedge heels were accepting free kits, and homeless folks wandered over to learn more. Slowly, the small stack of $75-value kits disappeared.

Pain has been around since Adam and Eve left the garden. Keeping drug users alive may be easier than giving them a reason to live. Stricter law enforcement sometimes drives users to further isolation and depression—for which they self-medicate. Depressed drug users know how to obliterate temporarily any pain they feel: Pop another pill. Snort another line. Shoot up another dose.

Pill or heroin addicts tell different stories about their first addictive kiss. Some got a prescription after a knee injury and knew they were in love the second the first pill kicked in. Others were from good families and tried a pill for the first time at a house party. Others experimented with self-medicating their depression through prescription painkillers, then turned to heroin for its added strength or lower cost. But no matter how they got started, each person says the same thing: It’s really hard to quit.

—Margaret Tazioli, a recent Moody Bible Institute graduate and former editor in chief of its newspaper, is a World Journalism Institute intern