They don't call 'em pain killers for nothin': Staten Island, NYC's heroin problem

Overdose prevention, drug abuse treatment in NYC and the work that remains

One of the great hazards of drug use and abuse is the danger of overdose. The New Yorker looks at the problem of heroin use on Staten Island, NYC and the state of drug abuse treatment in NYC.

The New Yorker writes about drug addiction and the heroin epidemic that has saturated Staten Island, NYC's least populous borough. Staten Island, having more in common with suburban New Jersey than many who work for the city or in the health care profession. Heroin use is surging nationwide and throughout New York City but most agree that the problem in Staten Island is particularly intense.

The hero of this story is Naloxone, an "opioid receptor antagonist," and the villain is prescription pain killers. Staten Island has been ground zero for NYC's heroin epidemic because it's been the epicenter of NYC's pill problem. Overzealous prescribing of pain medications like Oxycontin, an opioid painkiller often results in addiction and over time, users switch to heroin because it offers a similar high at a much cheaper price. Naloxene, which New York City has recently made mandatory for all police officers to carry, consistently and effectively prevents a heroin overdose.

As one reads through the New Yorker's description of the common path from legitimately prescribed pain killers to prescription opioid abuse to heroin use, one is reminded that heroin is a pain killer. If we take its resurgence as evidence, it is apparently a very effective one.

This is at odds with the common story of addiction. Typically opioid addiction is understood as something that starts with pain but then leads to an addiction, which is seen to be a process separate from pain, which then takes over. The presumption is that the problem begins with the user begins to take pain medication at higher doses than are prescribed and past the point when they are necessary to control the pain.

I have a different theory

Addiction is a complicated process. There is serious evidence, however, that the classic story, the one that came to prominence and was nearly-universally accepted during the "just-say-no" 1980's is that an unwitting individual happens to experiment with drugs and the claws of addiction take hold such that the individual no longer has control of the desire to keep using the drug.

This isn't so much untrue as it is overly simplistic. Much of the belief that addiction simply overpowers the drug user, with the accompanying myth that the drug user will sacrifice all else to get that high has been debunked. In most cases, the story of addiction is more complicated and there are nearly always other factors that sustain drug abuse besides the so-called addictive properties of the drugs themselves. Lack of economic and material options, as well as emotional pain are two key factors.

Which got me thinking about pain killers. My theory is that often people begin using opioids after an injury (though perhaps as often experimenting recreationally) and then they have a perhaps accidental discover, namely that the medication that is designed to manage pain does a terribly effective job at managing pain--not just physical pain but also emotional pain. And they like that.

And who wouldn't? Not being in pain is better than being in pain.

We live in denial of emotional pain

Perhaps Staten Island, with its over-representation of families with police officers and firefighters has a particular difficult with this, or perhaps that's a bit of stereotyping. What is clear is that in many corners of our culture, including all over NYC, physical pain and emotional pain exist on two separate hierarchical planes, one seen as valid and the other as shameful or overwrought. It seems to me to be no accident that we have designed rather wonderfully effective medications for treating physical pain but have been less successful at treating emotional pain. Perhaps the unfortunate bi-product of opioids is less that they are addictive, in the 1980's conception of that term but rather the happenstance that in addition to being effective at treating physical pain they are the most effective pharmaceutical offering we have for treating emotional pain.

What do we do with that pain?

For starters, we need to destroy the hierarchy of pain. We need to perhaps understand the word "pain" in the context of emotionality as not simply a metaphor that borrows the usage from its physiological contexts but as another very real expression of that same phenomenon. Physical pain isn't not emotional and emotional pain isn't not physical. We have to break out the the dichotomy.

Anyone who's struggled with unrelenting emotional pain can understand this connection immediately. Even if substance abuse has never been a part of the picture. When you're drowning in pain, whether it manifests itself as depression, anxiety, grief or a relationship loss. Whether that pain is old or new (but the old sure does get hard to bear) you want it to stop.

The New Yorker rightly expresses, in addition to the obvious policy of making naloxone mandatory for all police officers to carry in NYC, a concern that opioid prescribing be better controlled and that drug manufacturers be held accountable to developing drugs that are less prone to abuse.

It won't be enough, however. The basic rules of capitalism say so: People who are in serious emotional pain will pursue access, even at very high psychosocial cost, to whatever product provides them with relief from that pain. The market needs a better alternative.

What about Prozac?

There are medications that have been developed for the purpose of, in a sense, treating emotional pain. The anti-depressant Prozac was not the first and several drugs have been developed sense but Prozac is likely the most notorious and perhaps even the most effect leap forward in the history of psychiatry. (It should be noted as well that in no serious circles is Prozac seen as "addictive".)

As I've said elsewhere, I think Prozac deserves some of the credit it's been given, but any expert would agree that Prozac is staggeringly less effective as a treatment for emotional pain than Oxycontin is as a treatment for physical pain.

I am hopeful that psycho-pharmacology will yield advancements that are more effective than existing anti-depressants and other classes of psychotropic medications. Still, it's doubtful that medications will get the job done. Why? Because emotional pain, for all of its overlap with physical pain, is more than a physiological phenomenon. It is constructed in ways, and is carried with us in ways that couldn't be accessed by chemical intervention. It exists in our history and in the construction of our world. It exists in the form of broken families, underemployment chronic poverty, lack of opportunity, generational abuse and neglect, suppressed sexuality. It exists in forms that could never be touched by a pill.

It's time for a new understanding of drug abuse treatment

The classic story if addiction needs an upgrade. We see that so well in Staten Island and all over New York City bed everywhere where the pathway to heroine is pain killers. We can't understand addiction---addiction to pain killers---without working to better understand pain.

With the development of opioids like Oxycontin we have an important development in the management of physical pain. The New Yorker is right to demand that we develop new approaches and methods of packaging those medications so they are less prone to abuse. With Naloxone we have an important tool that saves lives. What we don't have is nearly enough tools for treating emotional pain  and until we have them lives will continue to be destroyed by drug abuse. If we want to solve addiction and abide we have to deal with emotional pain (prevent or treat). If we want to solve addiction and abide we have to prevent and treat emotional pain, otherwise people will use the best available tools--even if they are deadly.