Heroin, OxyContin, and Painkillers

John Perritano

S E R I E S C O N S U L TA N T SARA BECKER, Ph.D. Brown University School of Public Health/Warren Alpert Medical School

D R U G A D D I C T I O N A N D R E C O V E R Y Heroin, OxyContin, and Painkillers Opioids:


Alcohol and Tobacco

Causes of Drug Use

Drug Use and Mental Health

Drug Use and the Family

Drug Use and the Law

Hallucinogens: Ecstasy, LSD, and Ketamine

Intervention and Recovery

Marijuana and Synthetics

Opioids: Heroin, OxyContin, and Painkillers

Over-the-Counter Drugs

Performance-Enhancing Drugs: Steroids, Hormones, and Supplements

Prescription Drugs

Stimulants: Meth, Cocaine, and Amphetamines



Heroin, OxyContin, and Painkillers

John Perritano

S E R I E S C O N S U L TA N T SARA BECKER, Ph.D. Brown University School of Public Health Warren Alpert Medical School


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Series Introduction . . . . . . . . . . . . . . . . . . 6 Chapter One: Opiates and Opioids . . . . . . . . . . . . 11 Chapter Two: Heroin . . . . . . . . . . . . . . . . . 23 Chapter Three: OxyContin . . . . . . . . . . . . . . . 35 Chapter Four: Treatment . . . . . . . . . . . . . . . 47 Further Reading . . . . . . . . . . . . . . . . . . 58 Educational Videos . . . . . . . . . . . . . . . . . 59 Series Glossary . . . . . . . . . . . . . . . . . . . 60 Index . . . . . . . . . . . . . . . . . . . . . . 61 About the Author . . . . . . . . . . . . . . . . . . 64 About the Advisor . . . . . . . . . . . . . . . . . . 64 Photo Credits . . . . . . . . . . . . . . . . . . . 64 Sidebars: This boxed material within the main text allows readers to build knowledge, gain insights, explore possibilities, and broaden their perspectives by weaving together additional information to provide realistic and holistic perspectives. Research Projects: Readers are pointed toward areas of further inquiry connected to each chapter. Suggestions are provided for projects that encourage deeper research and analysis. Text-Dependent Questions: These questions send the reader back to the text for more careful attention to the evidence presented there. Educational Videos: Readers can view videos by scanning our QR codes, providing them with additional educational content to supplement the text. Examples include news coverage, moments in history, speeches, iconic sports moments and much more! Series Glossary of Key Terms: This back-of-the-book glossary contains terminology used throughout the series. Words found here increase the reader’s ability to read and comprehend higher-level books and articles in this field. Words to Understand: These words with their easy-to-understand definitions will increase the reader’s understanding of the text, while building vocabulary skills.

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Many adolescents in the United States will experiment with alcohol or other drugs by time they finish high school. According to a 2014 study funded by the National Institute on Drug Abuse, about 27 percent of 8th graders have tried alcohol, 20 percent have tried drugs, and 13 percent have tried cigarettes. By 12th grade, these rates more than double: 66 percent of 12th graders have tried alcohol, 50 percent have tried drugs, and 35 percent have tried cigarettes. Adolescents who use substances experience an increased risk of a wide range of negative consequences, including physical injury, family conflict, school truancy, legal problems, and sexually transmitted diseases. Higher rates of substance use are also associated with the leading causes of death in this age group: accidents, suicide, and violent crime. Relative to adults, adolescents who experiment with alcohol or other drugs progress more quickly to a full-blown substance use disorder and have more co-occurring mental health problems. The National Survey on Drug Use and Health (NSDUH) estimated that in 2015 about 1.3 million adolescents between the ages of 12 and 17 (5 percent of adolescents in the United States) met the medical criteria for a substance use disorder. Unfortunately, the vast majority of these IF YOU NEED HELP NOW . . . SAMHSA’s National Helpline provides referrals for mental-health or substance-use counseling. 1-800-662-HELP (4357) or https://findtreatment.samhsa.gov SAMHSA’s National Suicide Prevention Lifeline provides crisis counseling by phone or online, 24-hours-a-day and 7 days a week. 1-800-273-TALK (8255) or http://www.suicidepreventionlifeline.org


When pro- and anti-drug information sit side-by-side online, it can be hard for kids to separate fact from fiction.

adolescents did not receive treatment. Less than 10 percent of those with a diagnosis received specialty care, leaving 1.2 million adolescents with an unmet need for treatment. The NSDUH asked the 1.2 million adolescents with untreated substance use disorders why they didn’t receive specialty care. Over 95 percent said that they didn’t think they needed it. The other 5 percent reported challenges finding quality treatment that was covered by their insurance. Very few treatment providers and agencies offer substance use treatment designed to meet the specific needs of adolescents. Meanwhile, numerous insurance plans have “opted out” of providing coverage for addiction treatment, while others have placed restrictions on what is covered. Stigma about substance use is another serious problem. We don’t call a person with an eating disorder a “food abuser,” but we use terms like “drug abuser” to describe individuals with substance use disorders. Even treatment providers often unintentionally use judgmental words, such as describing urine screen results as either “clean” or “dirty.” Underlying this language is the idea that a substance use disorder is some kind of moral failing or character flaw, and that people with these disorders deserve blame or punishment for their struggles.


And punish we do. A 2010 report by CASA Columbia found that in the United States, 65 percent of the 2.3 million people in prisons and jails met medical criteria for a substance use disorder, while another 20 percent had histories of substance use disorders, committed their crimes while under the influence of alcohol or drugs, or committed a substance-related crime. Many of these inmates spend decades in prison, but only 11 percent of them receive any treatment during their incarceration. Our society invests significantly more money in punishing individuals with substance use disorders than we do in treating them. At a basic level, the ways our society approaches drugs and alcohol— declaring a “war on drugs,” for example, or telling kids to “Just Say No!”— reflect a misunderstanding about the nature of addiction. The reality is that addiction is a disease that affects all types of people—parents and children, rich and poor, young and old. Substance use disorders stem from a complex interplay of genes, biology, and the environment, much like most physical and mental illnesses. The way we talk about recovery, using phrases like “kick the habit” or “breaking free,” also misses the mark. Substance use disorders are chronic, insidious, and debilitating illnesses. Fortunately, there are a number of effective treatments for substance use disorders. For many patients, however, the road is long and hard. Individuals recovering from substance use disorders can experience horrible withdrawal symptoms, and many will continue to struggle with cravings for alcohol or drugs. It can be a daily struggle to cope with these cravings and stay abstinent. A popular saying at Alcoholics Anonymous (AA) meetings is “one day at a time,” because every day of recovery should be respected and celebrated. There are a lot of incorrect stereotypes about individuals with substance use disorders, and there is a lot of false information about the substances, too. If you do an Internet search on the term “marijuana,” for instance, two top hits are a web page by the National Institute on Drug Abuse and a page operated by Weedmaps, a medical and recreational


marijuana dispensary. One of these pages publishes scientific information and one publishes pro-marijuana articles. Both pages have a high-quality, professional appearance. If you had never heard of either organization, it would be hard to know which to trust. It can be really difficult for the average person, much less the average teenager, to navigate these waters. The topics covered in this series were specifically selected to be relevant to teenagers. About half of the volumes cover the types of drugs that they are most likely to hear about or to come in contact with. The other half cover important issues related to alcohol and other drug use (which we refer to as “drug use” in the titles for simplicity). These books cover topics such as the causes of drug use, the influence of drug use on the family, drug use and the legal system, drug use and mental health, and treatment options. Many teens will either have personal experience with these issues or will know someone who does. This series was written to help young people get the facts about common drugs, substance use disorders, substance-related problems, and recovery. Accurate information can help adolescents to make better decisions. Students who are educated can help each other to better understand the risks and consequences of drug use. Facts also go a long way to reducing the stigma associated with substance use. We tend to fear or avoid things that we don’t understand. Knowing the facts can make it easier to support each other. For students who know someone struggling with a substance use disorder, these books can also help them know what to expect. If they are worried about someone, or even about themselves, these books can help to provide some answers and a place to start.

—Sara J. Becker, Ph.D., Assistant Professor (Research), Center for Alcohol and Addictions Studies, Brown University School of Public Health, Assistant Professor (Research), Department of Psychiatry and Human Behavior, Brown University Medical School



analgesic: pain-relieving substance. apothecaries: drug stores. endorphin: a natural painkiller in the body that attaches to the same cell receptors that morphine does. hypodermic: a thin hollow needle used to inject substances under the skin. laudanum: a solution of opium and alcohol once used to relieve pain. synthesize: to chemically produce one substance from another. synthetic: something that was produced artificially rather than derived from a natural substance. tuberculosis: an infectious disease of the lungs.



Deep in the Appalachian Mountains in Kentucky, where Pine Mountain and Cumberland Mountain meet, sits Bell County. For decades, the coal industry fueled the economy of this hardscrabble region. Eventually, however, the coal petered out, the mines shuttered, and the economy collapsed. Many people left the area to find work elsewhere. Unemployment rates were high, and in 2015 nearly two-thirds of adults did not have jobs. The median household income in 2013 was $25,228, and nearly 34 percent of Bell County’s citizens were living in poverty. Many people turned to drugs to lessen the pain that such difficulties can bring. The county’s coroner, Jay Steele, witnessed many tragedies caused by drugs. He saw a little boy in diapers crying near the body of his great-grandfather, who had taken care of him because his addicted parents and grandparents could not. He also watched as the adult children of another man who had just passed away ran to the local pharmacy, hoping to refill their father’s painkiller prescription to feed their addiction. “Day



in and day out, you see the decline of people on drugs,” Steele told The Boston Globe . “Some are just waiting to die.”


Opiates and opioids were the primary type of drug responsible for the tragedies in Bell County. Opiates are drugs derived from natural opium, which comes from the poppy plant. They include morphine, codeine, and most heroin. Opioids, on the other hand, are like opiates in their effects, but they are artificially made. OxyContin is an opioid. Some heroin is synthetic , and so is

technically an opioid rather than an opiate. Due to all the overlap, the term opioid is also used as an umbrella term that can refer to both synthetic and naturally derived substances. Unfortunately, what is happening in Bell County is mirrored in communities across the United States and around the world. During the past 20 years, an emerging opioid epidemic has caused politicians, police, doctors, and others to take notice. For example, the problem became so acute in Vermont that Governor Peter Shumlin

Seed pods of the opium poppy.



devoted his entire 2014 State of the State Address to what he said was a “full-blown heroin” crisis in Vermont. “In every corner of our state, heroin and opiate drug addiction threatens us,” he said. “The time has come for us to stop quietly averting our eyes.” According to the United Nations Office on Drugs and Crime, an estimated 49 million people around the world misused opioids in 2012, the last year such numbers were available. In the United States, 2.1 million people suffer from a variety of medical disorders related to prescription opioid misuse. One of the reasons for these staggering figures has been the burgeoning number of opioid prescriptions written by doctors since the early 1990s. In 1996, for example, U.S. doctors wrote enough OxyContin prescriptions to generate $48 million in sales—a modest figure. By 2002, however, sales for the drug hit $1.5 billion, and by 2010, sales reached $3.1 billion. The According to the American Society of Addiction Medicine, as of 2015: • Opioid addiction occurs among all social and economic classes. • Every single day, 46 Americans die from prescription opioid overdoses; that’s roughly two deaths an hour, or nearly 17,000 each year. • About 8,000 people die annually from overdosing on heroin. • About three-quarters of those who misuse opioid painkillers eventually turn to heroin, because it is cheap to buy. • One in 20 high school seniors has taken Vicodin. • One in 30 high school seniors has misused OxyContin. Source : American Society of Addiction Medicine, “Opioid Addiction Disease, 2015 Facts & Figures.” http://www.asam.org/docs/default-source/advocacy/opioid- addiction-disease-facts-figures.pdf.


drug can vastly improve people’s lives if used correctly. The problem comes when people take the drugs not as prescribed. In 2013 nearly 4.5 million Americans said they had used prescription painkillers within the last month, even though they had no medical reason to take the drugs.


People have been using and becoming addicted to opiates for centuries. Yet it wasn’t until 1972 that researchers at Johns Hopkins University figured out how opiates worked and why the drugs are so addictive. At that time, scientists discovered that human brain cells had a special receptor site that grabbed on to opioid drugs. They also discovered that morphine, the active ingredient in many synthetically derived opioids, had a chemical makeup similar to endorphins , natural

Opioids flood the brain with chemicals that are similar to—but much stronger than—the chemicals that are naturally released during physical activity.

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