Heroin is bad. We're making it worse

It's 11:30 a.m. and Samantha Gibson can't keep her eyes open. She's curled into a plastic chair at the Hamilton County Justice Center, bruised arms dangling at her side, head bobbing slowly as she slips in and out of consciousness.

The nurses here call it "the heroin nod," a sure sign they're dealing with an addict. They see it a lot.

Gibson is 26 and has been using for nine years, since she was a high school senior. Track marks line her arms and neck. A jagged red scar from an infected needle stick slices across her left hand.

She got arrested this morning after using heroin and driving into a parked car. She'll be out of jail in a few hours, which she's happy about, because she's got plans for the afternoon.

"I'll probably go get high," she says.

Gibson's brief stay at the Justice Center on this recent Tuesday morning is a testament not only to heroin's power, but to society's inability to stop it. Years into the heroin epidemic, after hundreds of deaths, thousands of arrests and millions of dollars in taxpayer spending, heroin is winning.

Attempts to slow the spread of the drug across Ohio and Kentucky have mostly failed. Often, the response has been ineffective. Sometimes, it has made matters worse.

The social safety net wasn't built for the heroin epidemic. The system is unwieldy and unfocused, when agility and precision are needed. It is tied to the old ways of doing things, when new approaches might work better.

"We need to hit this from every angle, with every single resource," says Tom Synan, the Newtown police chief who is helping lead a Hamilton County task force on heroin. "That's the only way we're going to solve it."

But that kind of coordinated attack isn't happening, at least not yet.

Jails are housing thousands of addicts, but they lack the resources to provide effective drug treatment. Most courts still insist on zero-tolerance rules that bounce heroin users from the streets to jail and back again. And long-term treatment remains a crapshoot for addicts and their families, who often can't find, or can't afford, quality care.

"Our entire approach to this is wrong," says Dr. Mina "Mike" Kalfas, a certified addiction expert and family physician in Northern Kentucky. "Our approach as a society has failed miserably."

For too long, Kalfas says, policy makers treated the heroin epidemic as a law enforcement problem and put the onus on addicts to get clean or go to jail.

But heroin is as complicated as it is cruel. It comes with an intense physical addiction that alters brain chemistry and punishes those who try to stop using it with brutal withdrawal symptoms.

Threats and punishment alone don't work because addicts want heroin more than anything else. More than their jobs, their homes, their health or even their children. That's why more than 13,000 heroin users spent time in Greater Cincinnati jails last year, and why more than 300 ended up in the morgue.

It's also why Kalfas and others now say new approaches are needed, before taxpayers spend more money and families bury more overdose victims.

"Heroin," Synan says, "is not something you can arrest your way out of."

Gibson, a mother of three from Newport, is a case in point. She is no stranger to the system. Police have arrested her. Judges have sentenced her. Jails have locked her up. Hospitals have patched her wounds. Treatment centers have put her on waiting lists. Children's services has taken her kids. Paramedics have restarted her heart after an overdose.

Society is heavily invested in her. Thousands of dollars already have been spent.

Yet here she sits, in jail again, biding her time until her next fix.

Gibson runs her fingers over her scarred left hand and crosses her legs. It's been several hours since she shot up. She's getting impatient.

"I can't get through the day without heroin," she says.

If the heroin epidemic has become a battle – and many in law enforcement now see it that way – local jails are the overwhelmed field hospitals, the MASH units where the casualties just keep coming.

At any given time, as many as 50 people are receiving medical attention at the Hamilton County Justice Center for heroin addiction. Dozens more are doing the same in cells from Kenton County to Butler County.

Some are in jail on drug charges, but many are in for theft, burglaries, child endangerment and other charges indirectly related to their addiction. They steal or break into neighbors' homes to get money for heroin. They leave their kids alone at home or in cars because they're out trying to buy heroin.

Eventually, thousands of them end up going through withdrawal in jail, stricken with fits of vomiting and diarrhea, cold sweats and aching joints. It's ugly and painful for the addicts, and it's overwhelming for the jail's staff.

A growing number of law enforcement officials say it's also a waste of a great opportunity.

Though far from ideal, they say, jail can be a refuge of last resort for users who are otherwise unable or unwilling to walk away from their dealers and their heroin-addicted friends. "For some addicts, incarceration is the key," says Maj. Charmaine McGuffey, who runs Hamilton County's Justice Center for Sheriff Jim Neil.

Yet jails are woefully unequipped to seize that opportunity. They are so crowded they often can't hold addicts who commit minor offenses, such as Gibson, for more than a few days or a few hours. And when they can hold them, they rarely offer the combination of counseling and medication-assisted treatment that many addiction experts consider most effective for heroin addicts.

The system essentially treats heroin addiction like any other addiction, but it isn't. What experts call the "life-to-death cycle" moves more quickly with heroin: People get hooked, use and die at a faster pace than they would with alcohol, for example. And what works to treat alcoholics may not work for heroin addicts, yet that's the model many courts still use today.

The hurdles to changing the approach are both financial and ideological. Most jails and courts can't afford to dramatically expand their facilities, and most don't allow medication-assisted treatment that slowly weans addicts off heroin with other drugs, such as Suboxone, methadone and, more recently, Vivitrol.

A few courts in Ohio and Kentucky are experimenting with medication-assisted treatment, commonly known as MAT, and pilot programs in Warren County and south-central Kentucky have shown some promise. But many judges still reject it. They see it as swapping heroin for another potent drug, even if the addict is under a doctor's supervision.

They have some reason to worry, since Suboxone and methadone are powerful drugs in their own right, and are sometimes sold illegally on the street. Vivitrol, which is not a narcotic, blocks the effects of heroin.

Despite the risks, recent research suggests the stigma attached to medication-assisted treatment isn't justified. MAT is recognized across the world as effective for treating heroin and prescription painkiller addiction. While abstinence-only treatment ends in relapse about 95 percent of the time, researchers say, MAT eventually will succeed, under optimal conditions, 50 percent to 65 percent of the time.

"It's still the best we've got," Kalfas says.

It's been successful enough that Michael Botticelli, who leads the White House Office of National Drug Control Policy, wants the justice system to embrace MAT for those addicted to heroin and other opioids. "Evidence is strikingly clear that people with opioid disorder do remarkably better with medication-assisted treatment – along with counseling," he says. "It's our hope that medication-assisted treatment is the standard of care."

But because jails and courts remain wary, MAT is not the standard. Addicts in the justice system must quit cold turkey, go through withdrawal and fight the physical urge to use again without help from another drug. While in jail, they get little more than Tylenol and anti-nausea medicine to help them detox from heroin. Drug counseling is hit or miss, and minor offenders are sober for only a few weeks before they're out of jail.

If they go back to heroin after their release, as many do, they are at a higher risk for overdose, because their tolerance has dropped. Using the same dose they did before going to jail could kill them.

"It's on you when you walk out the door," says Eddie Nunley, a Norwood man who has been in and out of jail for years on heroin-related charges. "A lot of people don't really want help. They want to go out and go back to doing what they were doing."

Nunley, 57, knows from experience: He's in jail again after using heroin while on probation. He says he needs help to get clean, but all the jail can offer is a bed and some over-the-counter medicine to ease his withdrawal symptoms.

"It'll grab you and take control of your life," Nunley says of his addiction. "Hope for mercy is all you can do. You're not going to walk away from it by yourself."

McGuffey doesn't think they should have to do it alone. She says jails have become the largest heroin detox centers in the region and should start acting like it.

On a blackboard near her office, McGuffey has sketched a diagram of all the public and private agencies involved in the successful treatment of addicts, from the probation department to social service groups to treatment facilities.

At the center of the diagram is one word: "Jail."

This is where the addicts are, McGuffey says, so this is where they should be treated. She wants to transform the jail, or part of it, into a locked-down treatment facility that provides drug-assisted treatment, counseling and placement in a strong after-care program. A judge would then order close supervision by probation officers, regular drug testing and continuing treatment.

McGuffey calls this her "perfect world" scenario, but the resources and the will to make such dramatic changes aren't there, at least not yet.

"We're not in a perfect world," she says. "It's very frustrating from all sides of the justice system."

So McGuffey makes do with what she has. She's trying to cobble together an ad hoc treatment system that helps connect released inmates to the social services and treatment they'll need on the outside. She'll get some help in the next year or so, when Sheriff Neil carves out space for 18 beds dedicated to help detox and treat heroin addicts.

"We're doing what we can," McGuffey says. "I'd love to have 100 more beds tomorrow, but we're not going to get 100."

A few jails are starting to do more. Campbell County, for example, hopes to open a new 108-bed jail wing with a substance abuse program focused on heroin users by the end of 2016. For now, though, most jails handle a heroin addict like any other inmate.

"There's no follow-up care," says Noel Stegner, co-founder of NKY Hates Heroin, an advocacy group in Northern Kentucky. "And when it hits the court system, you're fighting an even bigger battle. It's all brick walls."

McGuffey's frustration grows every time she releases a heroin addict back into society. Many of them have endured withdrawal and have gone weeks or months without heroin, but they're still addicts.

And they know it.

Sometimes, McGuffey says, families ask her not to release a relative because they fear the addict will rush right back to the drug and overdose. Sometimes, the addicts themselves ask her to keep them locked up.

"It's heartbreaking," McGuffey says. "There are people who call us and beg us to keep them where they're safe. They know they're going to go out and use again."

Expanding jails and treatment is expensive, however, and counties that have been cutting budgets since the recession rarely have millions of dollars available to pay for it. "It's such a challenge that we face," says Greg Hartmann, the commissioner who launched Hamilton County's heroin task force early this year. "We've got treatment capacity issues. We've got money issues. We can figure out who the heroin addicts are, but how do we get them help?"

No one knows the challenges better than judges like Kim Burke, who oversees Hamilton County's drug court. She deals with nonviolent offenders who are allowed to remain out of jail if they accept more stringent probation and promise to participate in treatment programs.

Burke's court can't do it all – almost all its programs are abstinence-only and in-patient care is hard to come by – but it may be the best chance most addicts get to change their lives. The judge routinely meets one-on-one with addicts and usually can find out-patient programs for them within a week. Her court is even experimenting with an in-patient program at Talbert House that uses Vivitrol to help addicts get clean.

Still, heroin is tough to beat, even when help is available. At least once a week, her docket is packed with addicts in the program who flunked drug tests.

"Heroin is different," Burke says. "The problem with heroin is people die. Your next relapse could be your last relapse."

Gina Moore-Yaden doesn't sleep well at night. She can't.

She has to check in on her son when he's home, to make sure he is breathing, not overdosing. She understands the risk of relapse and overdose because her son is a heroin addict. She also knows, first hand, how hard it is to find effective treatment and to keep an addict in a program.

Three times, she has managed to get her son, a reluctant 31-year-old, into a detox center. And twice he has walked out, leaving her to find him, notify the detox center he was gone, and go to court for a civil warrant to arrest him so he could be ordered back into treatment.

"It leaves you so worn out, and so drained and hopeless," Moore-Yaden says.

Just as it has overwhelmed the justice system, heroin is wreaking havoc with a health care system still struggling to respond to a growing crisis. Doctors are stymied by complicated rules related to medication-assisted treatment, while treatment facilities have long waiting lists and, in some cases, programs that don't meet the needs of their patients.

Though some communities are working on it, there is no go-to agency, public or private, to coordinate care for addicts. For the families of those addicts, particularly the parents, the lack of a wrap-around system leaves few good options.

"The biggest problem is, parents don't know where to go," said Joan Arlinghaus, a member of the grass-roots group Northern Kentucky People Advocating Recovery.

Often, they look to one another for help. They find parents who've already been through the blur of emotions, confusion and questions and, somehow, survived it. Or watched their child die. They find each other on Facebook or in parent-support meetings, they gather in courtrooms when their kids have hearings, and they do their best to navigate the system together.

Holly Specht of Fort Thomas, whose son Nicholas died from a heroin overdose behind her locked bathroom door, is one of the volunteer moms. She's appeared at a distraught mother's door after dark, offering hugs and a resource guide that her nonprofit organization NKY Hates Heroin created. She's taken parents to court hearings where they have to ask a judge to order treatment for their unwilling child.

"They're scared," Specht says.

They don't know what to do, or how to do it, and they are terrified that if they don't, their child will die.

"You need to have somebody readily available that can literally walk with you through the different processes," Moore-Yaden says. "We don't have that. I am calling all of these different resources by myself. I have been in tears I don't know how many times."

And then there is the constant worry.

"You're also wondering, are they alive in the other room?" Moore-Yaden says. "It's beyond emotionally draining. I am sick."

Sometimes, finding help is difficult because there is no help. Transitions Inc., Northern Kentucky's largest addiction services center, has about a two-week wait for detox, with only three beds for women and eight for men, and about a three- to four-month wait for residential recovery services, the kind of in-patient care that's most effective for heroin addicts. Waits at other treatment facilities can run six months or longer.

Delay is more than an inconvenience. Every day without treatment is a day more of heroin for most of those turned away. Another chance of dying.

"It's a race against time," says Specht.

Finding medication-assisted treatment for addicts is difficult, too, even for those not tied to abstinence-only policies in court. Suboxone, a narcotic used to ease addicts off heroin, is tightly regulated because of justifiable fears it could be sold on the street.

Federal law limits a doctor to 30 Suboxone patients his or her first year of prescribing the drug, and 100 after that. It's an unusual approach, because no other drug is limited by the number of patients. Legislators have proposed eliminating the caps, but nothing's been decided yet.

The problem, some physicians say, is the need for medication-assisted treatment far outstrips their ability to provide it. Few doctors in Northern Kentucky are licensed to prescribe the drug, and others are overwhelmed with requests to take on new heroin patients. Kalfas, the certified addiction specialist from Northern Kentucky, has been maxed out for more than a year.

"I have easily turned away 50 or more people in the last six months," he says.

The shortage of doctors licensed to provide the treatment is another problem, says Jeremy Engel, a Northern Kentucky activist and family physician who has been at the forefront of the heroin battle for nearly three years. He says more doctors need to step up and take responsibility for treating addicts.

"The treatment and cure for the heroin epidemic is medical first, and that requires physicians," Engel says. "Much like you can't put out a forest fire without firefighters. You can't fight a war without soldiers. We need more doctors to get engaged."

It's 4:30 p.m. and Samantha Gibson is ready to go. She's been locked up now for more than five hours and is about to be released from the Justice Center. Her offense is minor and there isn't enough room to keep her overnight.

She's feeling agitated but still has some time until withdrawal symptoms start.

"I feel it in my skin first," Gibson says. "And then I sweat real bad."

She says she tried to get into a rehab program last year, but all of them had long waiting lists. Instead, she spent about two months in jail. She went through withdrawal there and stayed clean for several months after she got out.

Then Gibson started hanging with old friends, and quickly picked up old habits, including heroin. She now spends between $20 and $40 a day on the drug.

A deputy hands her a paper bag filled with her belongings: Her purse, driver's license, hand lotion, a pack of Marlboros. She carries her things outside and lights a cigarette, taking a long, slow drag.

She digs around some more in her purse and finds $25 cash. "That's what I have to my name," she says.

It will be enough to get her through the rest of the day.

What's wrong with society's approach to heroin?

In more than two years of reporting on the heroin epidemic, The Enquirer has interviewed dozens of physicians, addiction specialists, law enforcement officials and policy makers. They don't always agree, of course, but there is some consensus on what's wrong with society's response to the problem:

Heroin addiction is treated like a crime, not a disease. It can be both, of course, but arresting, jailing and releasing addicts without treatment is risky for the addicts, who are at greater risk for overdose after they're released, and costly for taxpayers, because so many return to jail or overdose and require medical treatment.

Treatment isn't readily available. Waiting lists for in-patient treatment facilities are long, often many months. Out-patient help is more accessible, but finding a comprehensive program that combines counseling and, possibly, medication-assisted treatment can be a challenge.

Most courts still focus on abstinence-only treatment. Research shows medication-assisted treatment can be more effective than abstinence when combined with counseling. But courts and jails typically endorse abstinence-only programs that frown on using other drugs, such as Vivitrol or Suboxone, to treat addicts.

Access to medicine-assisted treatment is hit or miss. Addicts often can't get medicine even when their doctors want to prescribe it. While those drugs can be dangerous and abused, fears of their misuse have led to complicated and sometimes arbitrary rules that limit the number of patients doctors can treat.

The stigma attached to heroin addiction is large. Estimates on how many Americans use heroin are all over the map, from a few hundred thousand to more than 1 million. Most agree, however, that the number has gone up. Yet the stigma remains so strong that addicts hide, go untreated and let their newborns suffer with withdrawal, rather than seek help.