Dreamland (31 page)

Many doctors, however, didn’t understand that methadone, while it was long-lasting and therefore effective as a maintenance drug, was not a long-lasting
painkiller
. It relieved pain for only a few hours. So patients took more and more of it through the day to get pain relief. The drug built up in their bodies, causing overdoses. As methadone prescriptions rose, so did overdose deaths involving methadone—from 623 in 1999 to 4,706 in 2007.

A decade after OxyContin’s release, meanwhile, 6.1 million people had abused it—that is to say, 2.4 percent of all Americans. In macro terms, these were small numbers. But through history, illicit drug scourges have always involved a tiny minority of Americans. Baltimore, with a robust heroin market dating back decades, is considered the country’s heroin capital—with the DEA and the city’s health department estimating that roughly 10 percent of the city’s residents are addicted. The crack epidemic, at its height, involved fewer than half a million users a year nationwide, according to SAMHSA estimates.

But, as with crack cocaine, the numbers of new opiate addicts by the 2000s
were
enough to throw hospitals, emergency rooms, jails, courts, rehab centers, and families into turmoil, especially in areas where abuse was new.

Subsequent studies showed that almost all those who ended up addicted to OxyContin had already used a small-dose opiate pain reliever—Vicodin, Percocet, Lortab—which contained nonopiates such as acetaminophen or Tylenol. These pills were the first tentative steps doctors took in managing patients’ pain as opiates became de rigueur. From there, some patients grew addicted.

Street addicts had for years used Lortab or Vicodin. But in large amounts, the acetaminophen in these pills damaged an addict’s liver. Plus, in many areas, heroin was not available, or was so weak and expensive that addicts avoided it. What all that meant was that for a long time people who abused these small-dose painkillers didn’t often progress beyond them, and they rarely died from them.

But in 1996, timed-release OxyContin arrived—in doses of 40, 80, and, for a while, 160 mg of oxycodone. OxyContin often served as an addict’s bridge between these milder opiate painkillers and heroin.

OxyContin contained only oxycodone, and much more of it. When Vicodin or Lortab stopped being enough, when legitimate patients asked for more, doctors now had OxyContin, at ten times the strength. And for those already addicted, not only did OxyContin pack a bigger dose, it was easier to liquefy and inject than the milder pills. All you had to do was suck off the timed-release coating; you didn’t need to separate out any Tylenol or acetaminophen. Oxy habits easily grew to 200 to 300 mg daily, quantities rarely possible with Lortab or Vicodin without causing massive liver damage.

What happened next was what the Man figured would happen when he first encountered OxyContin in Wheeling, West Virginia. Heroin use crept higher. Addicts’ tolerance to OxyContin rose. Many stopped snorting the pills’ powder and started injecting it for the stronger rush. Their habits hit hundreds of dollars a day. They were now fully hooked on the morphine molecule and no longer fearing the needle. They saw no reason not to switch to the far cheaper heroin. Others went to heroin much earlier because not only was it cheaper but it could be smoked, too, and they could tell themselves that they didn’t need to inject it, which was true while their tolerance was low.

Either way, a government survey found that the number of people who reported using heroin in the previous year rose from 373,000 in 2007 to 620,000 in 2011.

Eighty percent of them had used a prescription painkiller first.

But all this took years to become clear.

Collision: Ground Zero

Columbus, Ohio

In another era, it’s possible that Operation Tar Pit might have dismantled, or permanently crippled, the heroin networks from the tiny county of Xalisco in Nayarit, Mexico.

But because they weren’t like typical top-down drug organizations, the Xalisco Boys’ networks coughed and sputtered but did not die. The cell owners remained in Mexico and reconstituted their U.S. operations. Experienced drivers, meanwhile, used the vacancies Tar Pit created to start their own cells. Santa Fe hasn’t been without a Xalisco tiendita since Enrique started it in 1997. Wholesale suppliers multiplied in the vacuum left when Oscar Hernandez-Garcia and his wife went to jail. Competition lowered prices and expanded the supply of tar heroin headed to the United States. Meanwhile, more young men raised their hands to fill the driver slots. Most important, they were now recruited from families unrelated to Xalisco’s first heroin clans. These new heroin workers had watched the families in the Tejeda clan prosper and wanted in on the business. Their entry into the business expanded the available heroin workforce and kept labor costs low. Soon, the Feria del Elote was bursting with traffickers and bandas once again.

Up in the United States, the Boys no longer had to rely on the limited universe of older junkies. A younger and much larger population of heroin users was emerging—casualties of the nation’s pain revolution. This synergy between pills and heroin happened first in one place. OxyContin’s popularity was spreading west just as the trafficker I call the Man brought Xalisco black tar heroin east. They collided in central and southern Ohio. Roughly drawn, the region with Columbus to the north, and including parts of West Virginia and eastern Kentucky to the south, became the barometer for all that followed elsewhere in the country.

Among the first to take its full measure was a doctor named Peter Rogers, who in 2003 was at Nationwide Children’s Hospital in Columbus, in the adolescent medicine department. Tall, thin, and spectacled, Rogers had specialized in addiction for almost twenty years by then. He’d treated kids on cocaine and crack. He’d seen them on meth, scratching scabs and grinding their teeth. He’d seen youths on ecstasy, LSD, pot, and as full-blown alcoholics. But before one evening in February 2003, Peter Rogers had never seen a teenager addicted to heroin.

Rogers was at home that night when a nurse called. A sixteen-year-old girl was in the ER with her parents. The girl was shivering and throwing up. It was heroin withdrawal, her parents said. The nurses didn’t know what to do.

Rogers drove in, certain that it couldn’t be heroin, and not sure what he would do if it were. The girl was small and blond and looked like a cheerleader. But she had track marks up her arms. Her face was pale and worn. She had diarrhea, and pains in her legs, stomach, and back.

“She said she’d started with pain pills she got from her friends. The pills got a little expensive. Boyfriend was a heroin user and he injected her with heroin for the first time,” Rogers remembered. “She used for a while, then she’d run out of money. Her parents realized something was really wrong. She told them.”

As it happened, two months before, Rogers had taken a course in Cleveland in how to detoxify people addicted to opiates. He never thought he would actually use the information.

“I called the physician who taught the course. He said he had not seen any adolescents using heroin, but he gave me some ideas. I plugged her into an IV, hydrated her, gave her something for her nausea. I learned a lot from her.”

This first heroin addict was from the wealthy suburb of Powell, a fact that surprised Rogers almost as much as learning that she was only sixteen.

“Where do you get your heroin?”

“From Mexicans.”

“Where do you find them?”

She named a neighborhood not far from Children’s Hospital that white girls from Powell did not frequent.

Rogers kept her in the hospital for three days. He spoke to her parents. She had admitted she was a heroin addict and was now detoxed, the parents said, so she was fine and could go home. Rogers had a different view, one learned from years as a recovering alcoholic himself. If she doesn’t get long-term treatment, she is not going to stay sober, he told the parents. She’s going to die, end up in jail, or be a chronic underachiever.

“They didn’t believe me,” Rogers said. “A few months later, the parents called. They said she’s using heroin again. I saw her again, readmitted her. I think they were getting the message.”

Once he admitted that girl to detox that night in 2003, it seemed to Rogers as if floodgates opened somewhere. Word spread among addicts that you could go to Children’s and get detoxed. Peter Rogers watched the new opiate epidemic emerge out of nowhere and file through his clinic. Hundreds of kids. They were all white, suburban kids from well-to-do homes. Most were girls. One was a tennis champ. Another was the daughter of a Columbus cop. One was the daughter of a thoracic surgeon; there were several children of doctors, in fact.

All had started with pills. Many said they’d seen friends die. They had no idea where else to go. “The first kid showed up and word got out. I noticed that we got a lot of kids during that first six months from a place called Lancaster [a Columbus suburb]. It turns out these kids were coming to Columbus, buying heroin, going back to Lancaster.”

Rogers was an early witness to heroin’s new mainstreaming. The drug had for years appealed to rebellious kids from a seedy urban corner of America’s counterculture. “I remember at eleven and twelve years old seeing pictures of [Sex Pistols bass player] Sid Vicious and thinking he’s the coolest,” one twenty-six-year-old recovering addict, a musician, told me. “Sid Vicious, [New York Dolls’ guitarist] Johnny Thunders, Lou Reed, and William Burroughs, but also Charlie Parker. It was punk and jazz that made heroin so sexy and appealing, exciting and dangerous and subversive and not the norm. Then I saw the football players and the cheerleaders getting into it. These are people I turned to heroin to get away from.”

To the suburban kids hooked first on pills, heroin fulfilled the dream of the adventures they’d never had in their quiet towns. Part of heroin’s new appeal was that it kept them at the edge of a hazardous yet alluring dreamland. Finding dope every day could take them on a wild ride through worlds they hadn’t known existed, which, however scuzzy or harrowing, left them with fantastical stories that awed their peers.

“You’re as much addicted to going and buying it as to going and using it,” one addict said. “You feel like James Bond. It’s a crazy fantasy.”

By the end of that year, Nationwide Children’s Hospital, which had never admitted a teenage heroin addict that anyone could remember, had protocols for treating them. Rogers asked them all where they got the heroin: Mexicans, they said. Rogers called Columbus police. An officer told him they knew that Mexicans were selling the dope. We arrest them, the officer said. In a day or two, another comes in and takes their place.

Meanwhile, Rogers said, “I was living at the hospital. I was taking care of these kids. None of the other physicians really knew how to treat this. We were not ready for this. It was a whole new phenomenon. I called all over the country. What we were doing in Children’s Hospital in Columbus was not something that anybody else was doing that I could find. We kept treating these kids. They kept coming in.”

Rogers battled with insurance companies, who had apparently never heard of treating heroin addiction in teenagers. A couple years in, he gave a speech at the annual meeting of the American Academy of Pediatrics in Boston, describing what he was seeing to a sparse and bewildered audience.

“They weren’t seeing any of this. They were thinking, ‘Why do we need to learn about this?’”

Canaries in Coal Mines

Portsmouth, Ohio

For years after it closed, David Procter’s Plaza Healthcare clinic would be known as the “boot camp for dirty docs.” But Procter’s influence went far beyond the unscrupulous doctors he brought to town. Instead, he showed Scioto County that starting a pain clinic was easy. Given an opening in Ohio state law, all you had to do was lease a building and hire a doctor who had a DEA permit to write prescriptions for Schedule II narcotics.

Pain clinics were now sprouting up across America as the opiates became commonly used for chronic pain, and the undertreatment of pain was identified as a public health problem. Not all pain clinics were pill mills. But as opiates became the principal treatment for pain, the pain clinic was often prone to abuse. It attracted patients relentlessly demanding drugs. Doctors found it hard to maintain standards. Some clinics were never legitimate, but many others started with good intentions and were simply pushed off course by patients’ constant demands.

No place in America had more of these shady clinics per capita than did Scioto County, Ohio. Over the first years of the new century, a local junkyard owner, an attorney, a prison guard, an ex-bailiff, and a couple of convicted felons, as well as several doctors, all opened clinics, hiring doctors with permits to write the prescriptions and see patients at a rapid clip. Jody Robinson cashed in his car stereo shop to open a pain clinic through which he became, according to a later indictment, one of the region’s biggest pill distributors.

Portsmouth became America’s pill mill capital. The clinics were some of the only locally owned businesses to form in decades in Scioto County. People said the area’s entrepreneurial spirit had drained from Portsmouth. In a twisted way, the pill mill showed that locals could still be as entrepreneurial as anyone. Billboards for pain clinics greeted travelers along the highways entering town. Drug dealers and users for miles around came to Portsmouth to stock up on pills.

One key to the pill mill explosion was the discovery of locum tenens lists, a clearinghouse for doctors around the country seeking temporary employment. Many of these doctors were desperate. They had license problems, or couldn’t get malpractice insurance, or were alcoholics. These were the docs Procter had hired. Now other clinic owners did the same and quacks flocked to Portsmouth. Tracy Bias, a convicted felon, opened three pain clinics and hired doctors from New Mexico, Michigan, and Iowa, as well as two from other parts of Ohio.