October 18, 2013
It was a common scene several years ago throughout Fort Lauderdale. Clinic parking lots were filled with cars bearing license plates from Georgia, Tennessee, Pennsylvania and Kentucky. When one vehicle pulled out it was immediately replaced by another, and another after that. These were not snow birds seeking sun and warm temperatures, but rather people trafficking opiates. They shopped at dozens of pain management clinics dotting Broward County, buying hundreds of OxyContin (oxycodone) to take home and sell. At one point, Broward County had more so-called "pill mills" than McDonald's, and a few local physicians prescribed more of the narcotic than the rest of the country combined.
The rampant sale of prescription opioids has dramatically decreased in Broward County in the last few years. A strong law enforcement effort closed the pill mills, arrested physicians, and shut down the supply of drugs. In 2011, Florida (like many other states before it) introduced a prescription drug monitoring program that created a central databank of narcotic sales, significantly reducing so-called "doctor-shopping."
Although extreme, South Florida is certainly not unique. Indeed, prescribed opiates represent a tremendous threat across the country. More people die of prescribed pain medications than heroin and cocaine combined. No part of the country is immune, including rural areas. Long-known for methamphetamine, vast swaths of non-urban America are being hit with Opana, an opioid pain killer containing oxymorphone. The CDC reports that rural residents are nearly twice as likely to overdose on pain medication than people in big cities. Age is not a protective factor either. While data indicate that OxyContin use is highest among 21-24 year olds, use of both prescription and recreational drugs (and suicide) is rapidly increasing among people in their 50s.
Like many efforts to control illicit drug use, not everything has gone as planned. The heavy hand of law enforcement dramatically reduced the supply of prescription narcotics, but unfortunately failed to affect demand. Thousands of individuals who were in no way typical of an "addict profile" found themselves on a slippery slope. Many had started with prescriptions for legitimate pain caused by an injury or procedure. In some cases, far more pain meds were prescribed than necessary. (One client of mine comes to mind: He received 30 hydrocodone tablets after a tooth extraction.) When those prescriptions ran out, many people turned to pain clinics because they had become physically addicted. When the pill mills disappeared, they sought an available and relatively cheap source of opiates: heroin.
The numbers tell the tale of the rise of heroin in Broward County. In the last several years:
South Florida is by no means unique. National trends indicate a disturbing increase in heroin that is, to at least some degree, driven by a law enforcement crackdown on prescription opiates. It is not uncommon for individuals to go from prescription opiates to heroin and back again, depending on availability and price. High-profile overdose deaths like that of Cory Monteith capture the headlines, but such tragedies are repeated countless times across America every day. We are experiencing the formation of a heroin epidemic driven by a huge appetite for narcotics. This demand is supplied by well-organized international drug cartels that are supplying drugs with higher purity at competitive prices.
As this swell of heroin use grows, it brings an increase of injection drug use as well as the certainty of new infections of HIV and hepatitis. While the rate of new cases of HIV related to injection drug use has remained historically stable, this epidemic bears watching. Colleagues in South Florida who, like me, are involved in street- and community-level substance abuse prevention and treatment, are seeing a disturbing increase in injection drug use. A public defender here told me his office is seeing such a dramatic rise of injecting drug users that he fears a "psychological barrier" about using needles has been broken.
People appear less inhibited about what was once considered the "last stage" of addiction: the use of needles. I see it with men using methamphetamine as well. Ten years ago, the "slammers" were a relatively small group among meth users. Today, it seems men progress more rapidly (and with some indifference) to injecting the drug.
All of this is what a friend calls "barefoot epidemiology," that is, drug trends that are observed on the streets and in our offices and clinics. While data are still limited and not scientifically collected, colleagues around the country are reporting the same findings. A rise in injecting drug use is here and very real.
It sometimes seems that we feel better if we can declare war on something. Illicit drug use is an obvious problem upon which we have declared war and spent billions of dollars. A lucrative drug enforcement industry has been created resulting in years of ambitious efforts with dubious success, a system riddled with built-in social inequities, and ironically, a justice system that is now the largest drug treatment provider.
Many of my colleagues working with HIV often remind me that they could never deal with addictions, in effect verbalizing a medical version of "not in my backyard." They seem glad someone is willing to do it, but are always grateful that it's not their problem. Of course, it is very much a problem for us all. There is an unbroken chain from the epidemic of prescription opiate abuse to heroin, and with heroin comes injection drug use. With injection drug use comes HIV and hepatitis. Addiction is a problem that belongs to all of us, especially anyone working with HIV.
We need to advocate for prevention and treatment. HIV and substance abuse go hand-in-hand. Despite reductions in funds, treatment works when it is available. We need to fight for needle exchange. In places like Florida, where it is prohibited, this documented effective intervention of obtaining clean equipment is unavailable to injecting drug users trying to minimize harm. Finally, we need to realize we are all connected. HIV doesn't exist in isolation, but in a social context, and indeed, a context with simultaneous epidemics that desperately need attention and advocacy.