Karrin has survived every destructive punch that addiction has swung at her.
While in the morass of substance abuse, the state removed her four children from her custody three times over a 10-year span. She was reunited with her children briefly before losing one, a daughter, to a fatal heroin overdose at the age of 23. That was the last of the 11 overdoses Karrin knows about, including the five times her daughter was revived with naloxone, an overdose antidote.
“I had no idea what I put my family through until my daughter was an addict,” said Karrin, who requested that her last name not be published. “I used to say, ‘So what if I disappeared for three weeks. I’m fine.’ But when the shoe was on the other foot, I knew exactly what I had done.”
Today, Karrin is raising her 7-year-old granddaughter and working to help addicts get clean in New Bedford, Massachusetts, where nearly 2,000 people overdosed on opioids from 2014 to 2017, killing 180 of them. In April alone, five residents ages 30 to 59 died of suspected opioid overdoses.
More than 70,000 people died of drug overdoses last year, a 10 percent increase from 2016. Almost 48,000 of the deaths were from opioids, according to 2017 statistics from the Centers for Disease Control and Prevention. The death rate is surpassing the HIV/AIDS epidemic of the 1980s.
“I can’t even tell you how many funerals I’ve been to in the last few years, whether it’s clients, friends or even someone who had a secondary illness caused by drug addiction, like HIV,” Karrin said.
Those on the front lines of southern Massachusetts’ opioid crisis are trying to solve the problem by connecting to one addict at a time. It is a slow, painful process with few victories and scarcer funding. It is also a story playing out across the country, with the need for addiction treatment accelerating beyond the available resources.
Build a relationship
Counselors in New Bedford walk the streets handing out free condoms and Narcan, a brand of naloxone, to homeless addicts. Their hope is that the giveaways will spark a connection so addicts know where to turn when they decide to get sober, possibly years later.
Connie Rocha-Mimoso, director of community health services at the Seven Hills Foundation, which connects addicts to resources they may need, said people come in every day for a cup of coffee, a couple of condoms and maybe some food from the pantry.
“They will still use, but the goal is to build a relationship,” she said. “In the meantime, we are going to talk to them about Narcan and offer them STD testing. Our job is to provide them with supplies so they can decrease the harm to the community. We understand they will be coming here until they say, ‘I’m ready.’”
Seven Hills works with about 3,000 people in Southern Massachusetts, a number that has risen about 30 percent over the past few years, she said. Opioid addicts are the bulk of her clients, who include prostitutes and the homeless, but Ms. Rocha-Mimosa also treats those addicted to other substances such as alcohol and cocaine.
Using harm-reduction tools to create a bond with opioid users until they are ready to quit is the most effective way to steer an addict toward sobriety, Ms. Rocha-Mimoso said.
Users of heroin and similar opioids have the highest relapse rate, more than double those addicted to other substances, according to multiple studies. The relapse rate among opioid users who have successfully completed rehabilitation is 91 percent — 59 percent within the first week of discharge. For other drugs, the relapse rate is about 40 percent.
Medicines such as methadone and buprenorphine help improve those rates, but medication-assisted treatment is expensive and not always available.
Many relapses happen among opioid users because the drug physically alters the structure of the brain that affects decision-making and the ability to respond to stressful situations. Essentially, opioids change the part of the brain that can help a person stop using.
“Being addicted is like being in jail, and you have the key to get out but you don’t know how to use it,” Karrin said.
Ms. Rocha-Mimoso said she hopes the small connections her staff makes will inspire addicts to check into rehabilitation facilities, but she understands it is a waiting game.
“Change is long-term, and it takes time,” she said. “We may have a client who comes in here year after year. But they haven’t had a fatal overdose, committed a crime or contracted HIV. That’s a big thing.”
Joanne Peterson, founder and executive director of Learn to Cope, a Taunton, Massachusetts, support network for families of addicts, said such outreach efforts are effective but target only one user population. Not all opioid addicts live on the street. Some live in homes with spouses and children and hold jobs or go to school.
Karrin is such an example.
“You couldn’t tell me I was addicted,” she said. “I held a job, there was food on the table, our bills were paid.”
There is no simple solution because every situation is different, said Ms. Peterson, who founded Learning to Cope after her now-sober son’s legal OxyContin prescription spiraled into heroin addiction. It’s a common story in the opioid crisis: becoming addicted to legal painkillers and turning to heroin, which is cheaper and easier to access, when the prescription runs out.
Ms. Peterson hands out Narcan, and she brings speakers into her offices to educate family members who often don’t understand why a heroin user can’t just quit. Families need to learn about addiction, understand the physical dependence, and figure out the appropriate treatment and how to access it.
“When a family tries to grapple with this alone, it never works,” she said. “The addict will end up dead, living in the streets or stealing everything they own. The family hits rock-bottom before the addict does, and because of the stigma people don’t want to reach out.”
Lack of funding
The federal government will spend $4.6 billion this fiscal year to fight the opioid epidemic after President Trump declared it a public health crisis to free up funds. But advocates say it’s not enough to reverse the crisis, which the White House estimates is costing the country more than $500 billion a year.
About $1 billion will be distributed to the states and American Indian tribes. States with the highest mortality rates will receive larger shares. That is good news for people like Ms. Rocha-Mimoso who rely on state funding that trickles down from the federal government. Massachusetts had the sixth-highest opioid-related overdose death rate in the nation, according to the most recent statistics from the National Institute on Drug Abuse.
Yet Ms. Rocha-Mimoso said the amount of funding is not enough.
“We have great initiatives to help addicts, but the only thing I worry about is the funding,” Ms. Rocha-Mimoso said. “Trump declaring it a public health crisis has helped, but I would like to see more money freed up.”
The opioid policy research group at Brandeis University estimates that treatment for everyone who needs it would cost $6 billion annually for a decade.
“It’s going to take politicians’ kids to start dying for us to get the funding we need,” Karrin said.
Money isn’t going as far as it did in 2014 or 2015, when the epidemic was in its early stages. Back then, Ms. Rocha-Mimoso had the funds to send someone to inpatient therapy for three weeks. Now, her clients require counseling for mental health, trauma, homelessness and substance abuse.
Although Ms. Rocha-Mimoso remains positive, a recovering addict named James who still visits Seven Hills paints a much grimmer picture.
“Connie is struggling right now,” he said. “Every year she doesn’t know if she can keep the doors open.”
The opioid epidemic has spawned many problems that require money. Hospitals and Medicaid are burdened with the costs of treating infants born with opioid withdrawal symptoms, child welfare agencies are struggling to keep up with the number of children put into foster care, and schools are taxed with special needs of children showing the effects of their mothers’ addiction.
Those costs are straining the system. Every 25 minutes, a child in the United States is born with withdrawal symptoms after being exposed to opioids in the womb, according to the Substance Abuse and Mental Health Services Administration. That created $2 billion in excess Medicaid costs from 2004 to 2014, including $462 million in 2014 alone.
The Department of Health and Human Services says the opioid crisis caused a 10 percent increase in the number of children placed in foster care from 2012 to 2016. As of 2016, roughly 397,600 children were in foster care, costing taxpayers roughly $19,000 per child, or a total of $7.5 billion.
That accounts for only two of the costs related to the opioid epidemic.
“In Massachusetts, people are dying in droves,” Ms. Peterson said. “The cost to those left behind goes beyond just addiction treatments.”
The battle for a bed
For many people in search of recovery, treatment is often unavailable or unaffordable. Most addicts start in a detoxification process to get through the withdrawal, but the wait for a spot can range from days to weeks.
The battle to land a bed in a detoxification facility is why so few addicts receive treatment. Of the 21.7 million U.S. residents abusing substances, only about 11 percent get help, according to the Substance Abuse and Mental Health Services Administration.
“There are a lot of detox facilities, but the problem is there are so many people who need them, you can’t get a bed,” Ms. Peterson said. “The epidemic is just massive.”
In 2016, the Obama administration granted some states, including Massachusetts, a waiver of an obscure Medicaid rule that prohibits the use of federal money for addiction treatment in facilities with more than 16 beds.
Prior to the Obama-era rule change, a 1965 Medicaid law limited funding for “institutions for mental disease.” That largely shut off badly needed federal funds as addiction centers struggled to line up private or local funding.
The opioid legislation that Mr. Trump signed in October removed the Medicaid prohibition and created a grant program for states to help recovery centers improve quality.
But the problems are greater than a limited number of beds. In most states, detox facilities will admit addicts only if they are using, but the effects of withdrawal can last up to seven days after quitting. It’s one of the reasons opioid addicts have such a high relapse rate.
“It’s set up so you basically have to use again and just hope you don’t die in order to get into detox,” Karrin said.
Ms. Peterson agreed, saying she knows of addicts who started drinking alcohol while going through opioid withdrawal just to land a detox bed.
For those lucky enough to land a bed in a detox center, insurance usually stops paying after the third or fourth day, not nearly enough time for addicts to flush their systems, advocates say.
“The heavy withdrawal is three or four days, but after that, there is sleeplessness, depression and other medical issues,” Ms. Peterson said. “Withdrawal symptoms last a while.”
Some addicts find their biggest hurdle in the gap between detox and finding a treatment facility, when recovering addicts are especially vulnerable.
If someone in recovery can’t get into a treatment facility, they most likely will end up in the same environment of drug use. But now the body’s tolerance for drugs has lowered, dramatically increasing the chance of a fatal overdose.
It was during this period that Karrin’s daughter got her first glimpse of mortality. The daughter’s roommate at a treatment facility left and died from an overdose in less than a day because she was shooting heroin at the same level as she did before she entered rehab.
“My daughter told me when she heard about my friends overdosing she just assumed it was because they were all in their 40s and had been using for so long something had given out,” Karrin said. “But this was someone her age. It made it real for her.”
Unfortunately for Karrin, though, the grasp of addiction was too strong for her daughter to quit.