Where do we go from here? It’s clear the United States is in the midst of an opioid crisis. Less clear is how to end it – or what an “end” would even look like.

By David Thill

Walking down the staircase at Michigan Avenue just south of East Upper Wacker Drive, in Chicago’s Loop, is like descending into another world.

Once you’re down there, in Lower Wacker Drive, you can still see the sunlight streaming in above, though it feels very far away.

The orange lights guide the way for cars careening around the bends in the road. It’s surprising more people don’t get hit, but maybe they do and I just haven’t heard.

Also it’s damp. Everywhere it’s damp.

Lower Wacker, both in appearance and reputation, is a place of danger and filth. Mention to a native Chicagoan that you’re going, and you will likely be met with either a shudder, a warning or both.

Once you get back up those stairs, though, it’s like it disappears; literally, it falls away behind you. For most people, at least.

In a way, Lower Wacker is a good place to live if you have nowhere else to go. Upper Wacker Drive, which runs above it, is like a roof blocking out rain, wind and snow. And the place is sprawling, so even during the wintertime when it gets more crowded, a person can still find a spot to stash their belongings – their belongings could get stolen, yes, but that’s just part of the deal – and spend their nights.

Many of the people who live in Lower Wacker are here at least in part because of heroin. For them, the drug is central to both their survival and recreation.

“Survival” and “recreation” are relative, as are “fair” and “unfair,“ “choice” and “not a choice,” and everything else here: all in the eye of the beholder, all the subject of heated debate.

But to my mind, the debate doesn’t matter much, at least in a way: This is how it is, how it has been for a long time and how it likely will be for any foreseeable stretch of the future.

Matt on Lower Wacker Drive. Photo by Lloyd DeGrane

Greg lives down here. He has a gentle face that seems to always be scrunched in focus, like he’s trying to figure something out. He hunches forward a little, probably because his gaze is directed a little bit down, not straight in front of him. He doesn’t look at you when he talks, or at least he doesn’t look at me. He also looks worn, physically, but mostly mentally.

In Greg’s telling, he didn’t originally have a heroin habit. He was a carpenter in the northern suburbs of Cook County, and he started using heroin on the weekends at first. At some point, he broke his toe. The Vicodin his doctor prescribed ran out, and a friend suggested he just take more heroin: It’s the same thing as Vicodin but stronger, the friend said.

That’s when he began using every day. He first went to jail on a possession charge in 2004, and he’s been in two or three times since, he says. When he was in Cook County Jail briefly, in maybe 2009, he didn’t get much in the way of treatment for his addiction. But “now I hear that they do a lot more.”

Greg says he wants to be clean. He has been in the past, but he’s not now.

 

The beginning

It’s debatable when exactly America’s current opioid epidemic began and what caused it. By some accounts, this epidemic dates back to the late 1990s, when a reframing of pain in the medical world – “the fifth vital sign,” as it was known – led to a surge in opioid prescriptions from doctors for drugs like OxyContin and the Vicodin that became addictive to Greg.

By other accounts, opioids have hit the country in different waves at different times, often affecting black Americans in cities. The epidemic, then, isn’t necessarily new, but now it’s crossing city limits into suburban and rural America. (Read: It’s just getting attention now that it’s a white problem.)

But no matter how you look at it, opioids – both prescription and illicit – contribute to an increasing number of deaths throughout the country, in cities, suburbs and rural towns. At the same time, even more powerful, dangerous and cheap opioids like fentanyl are becoming more widely available.

In Chicago, many people who are addicted to these drugs, particularly heroin, are homeless. They are men and women, black, white and brown.

Many of them, like Greg, have been detained in Cook County Jail.

Addiction is widely considered a mental health issue, and Cook County Jail is considered one of the nation’s largest (by some accounts, the largest) mental health facilities in the country.

Given those factors, it seemed likely that the jail must be affected in some way by the epidemic. Plus it seemed like the jail – simultaneously a beacon of hope and the epitome of misery, depending on how you look at it – had received little coverage in terms of the opioid crisis.

In other words, journalistically speaking it seemed ripe for the taking. I didn’t know exactly what I was looking for, other than a new angle on a crisis that seems to be in the news every single day. So I set out – blindly, but guided by my good faith – with the jail as my starting point. It was not my ending point.

Reggie. Photo by Lloyd DeGrane

The only other historic American epidemic I really have some awareness of – albeit through the accounts of others – is the AIDS epidemic of the 1980s and early ‘90s. Ironically, that epidemic affected many of the same people that this current epidemic does. But just as it was back then, I think many of those people are overlooked by the overall narrative.

The AIDS epidemic is almost a mythical piece of history: unreal and unimaginable for someone like me, who didn’t live through it and didn’t experience its horrors. Hearing accounts of it makes me feel helpless.

In many ways, too, the description of the AIDS epidemic reflects that of the opioid epidemic: people literally wasting away, disappearing; entire circles of friends and family erased long before the individual members have reached the prime of their lives; and more than anything, the shame – the shame of actually having the disease, and the shame of having a family member who has the disease.

It’s the shame and isolation of being marked.

 

The science

Science has a long way to go to fully understand addiction. But it might be best to start with dopamine.

Dopamine is a neurotransmitter: a chemical messenger in the brain that travels from neuron to neuron. Among other functions, dopamine helps drive desire in anticipation of reward and pleasure. This is a biological necessity in humans, going back to our ancestors. It motivates us to eat and procreate. But as we’ve evolved, we’ve also developed ways of taking advantage of it. Drugs like heroin are one of those ways.

Heroin and other opioids increase the flow of dopamine in the brain, leading to a cycle of increased desire and pleasure. When a person becomes addicted, that desire increases so much that it overpowers other desires like eating and having sex. It’s like the drug becomes more important than survival.

Scientists agree addiction is the result of genetics and environment, though they’re uncertain how much each factor plays a part. Whatever the case, it’s extremely difficult to stop that vicious desire-to-reward cycle, which is why people so often relapse. It’s also why addiction is increasingly thought of as a chronic disease requiring lifelong treatment.

Photo by Lloyd DeGrane

One of the most promising methods of treatment for opioid addiction right now is medication-assisted treatment, or MAT, using one of three medications: methadone, Suboxone or Vivitrol.

Methadone and Suboxone are both opioids. (Suboxone is the brand name for a combination of buprenorphine, an opioid, and naloxone, the opioid overdose-reversal medication.) Methadone is stronger than Suboxone, but neither is as strong as heroin. Whichever one is prescribed, doctors use it to wean a heroin user off heroin.

The goal is to reduce the patient’s heroin cravings while avoiding withdrawal, though it’s not without controversy.

For one, the idea of using a prescription opioid to treat opioid addiction is not only counterintuitive but perhaps a little ironic. Prescription opioid medications, after all, are largely responsible for making this epidemic as bad as it is.

That’s why naltrexone – brand name Vivitrol – has also recently become a MAT medication. Commonly used to treat alcohol addiction, Vivitrol isn’t an opioid, so any doctor who can write prescriptions can prescribe it. The catch is, it works differently from the other two medications, and because of that, one needs to be clean for at least seven days before they can start treatment. Getting to that point in the first place can be quite a hurdle.

But whichever route one goes, medication is only one component of MAT. It’s widely agreed that the patient needs consistent behavioral health care, like counseling and group therapy, in addition to the medication.

It’s easy to imagine that for someone without a home, job or strong support network – perhaps someone who has just been released from jail – staying on medication and in therapy can be very difficult.

 

The system

Cook County Sheriff Tom Dart conducts business from his office on California Avenue, just south of the Cook County Jail’s main campus.

His voice is slightly hushed when he speaks, slow and deliberate, almost as though he’s thinking out loud. He’s a politically elected leader who doesn’t seem to stick to talking points, but rather says what’s on his mind, or at least seems like he does. This was my impression when I visited his office to learn how the opioid crisis is affecting the jail.

“We are like everyone else. We are overwhelmed and don’t really know the best route to go,” he said on a Thursday morning in November.

The national opioid epidemic has been mirrored in the county jail, he said. “We have just staggering increases in the number of people who are coming in with addictions to opioids.” He added that that segment of the jail population has grown significantly in the last two or three years, even as the jail population as a whole has decreased.

The sheriff’s office has implemented some measures to help stem the crisis, including putting boxes at sites throughout the county – courthouses, city halls, the central county offices – where people can drop off used prescription opioid medications. That way, there’s less risk that those medications will be abused.

And the jail has new programs, including one that began last spring in which women detained at the jail receive substance abuse treatment, with the goal of helping them reintegrate into the community successfully upon release. In June, the sheriff’s office, along with the University of Chicago and two community organizations, opened the Supportive Release Center. Currently an experimental research project, the center is a place where newly released male detainees can stay overnight to receive substance abuse and mental health treatment, and a link to outside care.

But right now, one of the surest measures – even if its success is inherently difficult to measure – is the naloxone distribution program the jail began in August 2016. Through this program, detainees are trained in the use of naloxone (brand name Narcan), the drug that can reverse opioid overdoses. Upon discharge, those detainees are given a kit with two doses of the drug, which comes in the form of a nasal spray. (Naloxone also comes in an injectable form.)

Naloxone isn’t a miracle cure; it’s more of an emergency measure. Theoretically its use will pave the way for more substantive options, like substance abuse treatment, which is impossible to administer if the person is dead from an overdose.

“We feel confident we’re onto something good,” Dart said of the program. At the time of the interview, about 1,750 detainees had been trained in naloxone use, and about 930 kits had been distributed.

Dart was pleased with those numbers. But he also said he finds the program “somewhat maddening in its inherent inability to gauge its effectiveness.”

The problem is, since naloxone treats overdoses, you can’t use it on yourself. So the question is whether a newly discharged detainee will use their kit to revive someone else, or if they themselves will be revived by someone else.

Ideally, Dart said, detainees would be trained in naloxone use while in custody and also undergo substance abuse treatment. Then, upon discharge, they’d be referred to community substance abuse programs, saving the naloxone to use on someone else.

“But we know that’s naive,” he said. Many detainees will be back in custody. So now, those who received the training and kits are surveyed by staff if and when they re-enter the jail.

Photo by Lloyd DeGrane

Thirty detainees had been surveyed when Dart sat down for his interview, and through those surveys jail staff had learned of 11 people whose overdoses had been reversed by the kits. That doesn’t indicate who overdosed and who administered the naloxone – whether it was the detainee or someone else – but “it is being used,” said Dart. “We feel pretty confident that what we’re doing is driven by numbers.”

Granted, even if the county really is doing everything in its power to help detainees get adequate treatment – and the sheriff said Illinois is “particularly bad” when it comes to funding substance abuse treatment programs – that doesn’t mean those efforts will have a huge impact. “That leads you to where you’re really left struggling and just trying to stay optimistic while you’re picking things off,” said Dart, “but knowing that it’s just a little pebble in the bigger ocean.”

 

The cycle

Jimmy’s taking a break from a pile of discarded flooring.

It’s about 4 in the afternoon. Here, in Chicago’s Jewelers Row, Jimmy – who says he once owned his own flooring business – makes his living throwing garbage like that flooring into an alley dumpster. It doesn’t pay much, maybe $10 or $20, he says. He’s paid under the table. But he prefers it to panhandling.

Jimmy says that in 2003, newly divorced, he discovered his ex-wife had been having an affair. He had five kids with her, but now, he found out three of them weren’t his. “It destroyed my mind.”

By his account, he’d been drug- and alcohol-free until then. Then a friend offered him heroin. “Here, this will cheer you up,” he told Jimmy.

“You do it once and you’re hooked,” Jimmy says.

He got arrested for drug possession – .01 grams, worth $5, he says – in 2004. After spending two and a half months in DuPage County Jail, he says he left with two years of probation, a $20,000 fine and no belongings.

Withdrawal at DuPage was “30 days of hell.”

No person seems to recount their addiction without recounting their withdrawal. Withdrawal is a looming presence for someone who’s addicted to heroin. Chills, diarrhea, vomiting – “Imagine the flu, times a hundred,” says Jimmy. It’s enough to make a person desperate for more heroin and willing to do whatever it takes to get it: stealing, betraying, abandoning family and friends.

Jimmy says he was clean from 2009 to 2012. He says he quit cold turkey, moved to Indianapolis and tried to start over. But then, he says, “Believe it or not, I burnt my ankle with a cup of coffee, and they prescribed me Vicodins.

“And it set it all off again. And then in order to get dope I came back to Chicago.”

He says he wants to get clean. Suboxone makes him sick. Methadone works. And if he could afford a methadone clinic, he would go. But according to Jimmy, going to a methadone clinic would cost him $100 a week. He says heroin is cheaper: about $20 a day.

That does not add up. But I hold my tongue.

“There’s dope addicts who are trying to get high, and there’s dope addicts who are just trying to get by,” Jimmy says.

He’s the latter.

“Dope makes me normal.”

Workers from the UIC Hospital street medicine team on Lower Wacker Drive. Photo by Lloyd DeGrane

In late 2015, The Night Ministry, an organization that serves Chicago’s homeless population, began a Street Medicine program modeled after a similar program in Pittsburgh. The idea is for staff to do their work on foot, to go to the people who need services when they can’t come to the services themselves.

Part of this work involves distributing clean needles and naloxone, the overdose reversal medication, to clients. It’s part of an approach called “harm reduction.” Staff know clients use heroin, and it’s not much use urging them to stop – clients don’t often want to be told what to do – so they at least want to help clients use with the least risk possible. (Full disclosure, I volunteered with The Night Ministry from 2016-2017.)

The mid-December Monday I went out with the Street Medicine team was bitter and windy with freezing rain. We made three stops throughout Chicago that day, finishing in the now-familiar expansive and dreadful underworld of Lower Wacker Drive, where the Night Ministry nurse, Sandie Collins, advised me that once we left I should bleach my shoes before bringing them into my house.

Collins has been providing health care for various Chicago agencies throughout the city for more than 25 years. In the past decade, she said, she’s seen the demand for naloxone spike, especially in the last year. And not only has the demand for the overall supply increased; so has the dosage level needed to revive heroin users who have overdosed. Whereas Collins used to be able to revive someone with .04 milligrams, now she’s seen people need as much as 6 milligrams. Once a person has been revived with naloxone, they’ll need a higher dose each subsequent time they overdose.

So, I wonder, does that mean first responders are just going to keep carrying more and more naloxone? There’s got to be a tipping point; they can’t just keep giving more, can they? But then again, they can’t just let people die, right?

Trying to broach these questions delicately, I asked Collins whether Narcan should theoretically lead to something more for the client, like rehab or medication-assisted treatment.

“If they want,” she said. But, she added, most people don’t want treatment. It’s common for first responders, her included, to see the same people needing naloxone over and over.

So is that frustrating, I asked her, to revive someone and know it’s quite possible – likely, even – that you’ll see them again?

“It stinks,” she said. But, “They’re adults. That’s the choice they make.”

Night Ministry staff encourage clients not to use heroin without someone else present, case manager Safiyyah Hassan told me. At least that way, someone will be there to call paramedics if an overdose occurs. Staff used to refer clients to rehab, she said, but clients were unreceptive, even aggressive. So Hassan only refers clients if they request it.

Collins, who has worked in hospitals, said that people often won’t go to the hospital to get treatment for other ailments, because they think the hospital won’t treat their heroin withdrawal.

But wouldn’t the hospital help them start getting clean, I asked.

“They like the high,” Collins replied. “They don’t want to be clean.”

 

A path forward?

I emerged from the Night Ministry’s office in Chicago’s North Side Ravenswood neighborhood as an early afternoon sun tentatively broke through the clouds. Invigorated and ready to knock this story out, I boarded the Red Line L train toward Howard and proceeded to avoid this story completely for about the next month. Every time I returned to it, I’d feel myself falling into a sort of tiny black hole, unsure of where to begin: wallowing over the root causes of this epidemic, speculating about what it might look like when it’s “over,” and wondering both how I fit into all of this and why I have any authority to speculate on it at all.

Finally I realized if I didn’t get moving, I’d never stop wallowing.

Photo by Lloyd DeGrane

Like the AIDS epidemic, the opioid epidemic often seems like a mythical piece of history. But unlike the AIDS epidemic, the opioid epidemic is happening now, and I happen to be living through it. So I’d prefer to try to get a grasp on it rather than feeling helpless.

Every day I see stories and accounts of the death and destruction resulting from this epidemic. I hear about governmental task forces and lawsuits against corporations, gigantic statistics highlighting tens of thousands of deaths and overdoses, all of which, for me, serve to make the epidemic larger than life.

At the risk of sounding judgmental, I think the narrative surrounding the opioid epidemic gives people like me – people who aren’t in positions of “power,” who aren’t addicted to these drugs and aren’t aware of anyone they know who is addicted – people like me who are perhaps the vast majority of people in this country – permission to dismiss it as “sad” and something that “needs to stop,” while we expect that the people who we perceive do have power use that power to “do something.”

Realistically, anything I do will have very little bearing on the big picture. I know that. But this epidemic is not larger than life – it’s very much a part of life – and I’d prefer to at least pretend I have some small ability to do something rather than simply dismiss it as sad and keep hearing about the death, destruction, task forces, lawsuits and whatever else finds its way into our news cycle.

And for me, “doing something” begins with figuring out what’s beneath all that sadness, what might alleviate – not end, just alleviate – that sadness, and where I fit into it all.

So with that:

First, the root causes: They go back decades and centuries. But overall I believe this is the fundamental result of who we are as a society.

I don’t mean that as an indictment on American culture. But I do believe we are a culture of release, and we have found an endless array of ways to achieve that release: as evidenced, for example, by pornography, Absolut billboard ads and reality television. Opioids are a form of release, whether from pain or living. As with other addictive substances, they are dangerous when misused, and that has led to this epidemic of overdoses. That’s my opinion.

Second, the way forward:

The Chicago Recovery Alliance, which supplies the needles and naloxone that the Night Ministry’s Street Medicine team distributes, has a motto: “Any positive change.”

That tenet, Street Medicine Director David Wywialowski told me, is central to the work he and his team do. Any bit of progress, no matter how small, is a success, he said. It’s not because they want to settle for small accomplishments; it’s because it’s necessary. Sometimes that one small positive change – like keeping a person from overdosing another day – is all you can ask for. Ending that person’s addiction – or, even more tenaciously, ending opioid addiction altogether – is nearly impossible. Try for that and “you can burn out,” said Wywialowski.

“I always tell folks, ‘Listen, let’s be realistic here,’” Sheriff Dart said. “We’re not going to change all of this behavior. Our task is to make things better.”

Given the scientific evidence, it seems to me the most basic way to make things “better” right now is simply medication-assisted treatment. Suboxone, methadone, Vivitrol and behavioral therapy are not as often talked about as short-term remedies like naloxone. But these medications are potential long-term solutions.

They definitely will not work for everyone, and they most certainly will not work quickly. But they’re the best we have right now.

Addiction, overdose and opioids will always be present in our world, as will homelessness, criminal injustice and every other form of injustice one could think of. If we’re going to look realistically at any of it, we have to look at the facts while understanding that it’s more complex than any analysis or statistic can reveal, and it’s more complex than any person can truly understand without experiencing it.

Which brings me to my final point:

Where do I fit into all of this?

I do know I’m not going to be treating addiction. And I do know I’m not going to be lobbying Congress or the federal government to make medication-assisted treatment more widely available, because I don’t lobby Congress or the federal government at all, at least not now.

I know I’ll probably continue reporting on the epidemic, if for no other reason than that I feel some kind of urge to.

That might be because I know that if things had been just the tiniest bit different in my life – if I had gone to a different high school, had a different friend or met a different coworker, had a different hobby, experienced a different injury or visited a different doctor – I could have ended up addicted just as easily as anyone I’ve talked to or heard about. When I run through the possibilities in my mind, it’s often unsettling to me how lucky I was.

I’ve heard that addiction “could happen to anyone.” Personally I think that too easily invites the added qualification “but not me.” I know this easily could have happened to me. And it still might happen to me, perhaps not with opioids, but with something else as yet unknown.

And if I meditate on that, I’ll just wallow, and then fall into that black hole. Which is why I think – just like with medication-assisted treatment and harm reduction – the small steps are the surest way forward.

Author’s note: This was an especially challenging story to write, and I appreciate your taking the time to read it. With that, I welcome any comments or questions, whether on the article itself or on this issue more generally. If you would like to email me at david.c.thill@gmail.com, I will gladly read your message and be in touch. Thank you.