It’s been three days since Philip Seymour Hoffman was found dead in a West Village apartment, reportedly surrounded by the detritus of his addiction: a needle, baggies full of heroin, other empty bags, prescription drugs. News stories have retraced his last days, speculated tastelessly on what his death means for the Hunger Games‘ final installment, and wondered whether the drugs that appear to have killed him were laced with fentanyl, a powerful painkiller that’s recently made an unwelcome reappearance in the Northeast’s heroin supply.
Yesterday, though, a test of the heroin in the actor’s apartment found no trace of fentanyl. At the same time, four people, three men and one woman, were arrested in lower Manhattan on suspicion of having sold Hoffman the drugs that may have led to his death. The city’s medical examiner is expected to release an official cause of death for him today.
It’s important to do a few things here, quickly, while our minds are still collectively on addiction and the huge, brutal loss of losing someone so universally beloved to something so vile. The truth is, heroin addicts can stay safer, even when they’re not ready to get clean. And as a city, we can help them.
1. Ask drug users not to use alone.
Before we talk about the dangers of shooting up alone, let’s talk first about fentanyl. While it was irresponsible and kind of gross to automatically presume Hoffman’s death was caused by that — as multiple media outlets did — the reality is that each time fentanyl reappears in the heroin supply, the consequences can be grave, and a reminder of just how unpredictable the drug really is.
Fentanyl has been around as a painkiller since the 1970s, the kind given to patients with serious chronic pain. These days it comes in both a sublingual pill and a sublingual capsule, both of which are relatively easy to crush up and use as an additive in heroin or other drugs. (Fentanyl can also be crushed, snorted or injected on its own.) The last serious fentanyl scare was in 2006; in a three-month period, 17 New Yorkers died after ingesting cocaine or heroin that was laced with fentanyl. The same year also saw deaths in New Jersey, Chicago, Philadelphia and St. Louis. This year, the heroin-fentanyl mixture has been linked to dozens of overdose deaths in both Pennsylvania and Maryland.
The main concern with fentanyl is that it’s very, very strong. “Just a few grains is much more powerful than heroin,” says Dr. Sharon Stancliff, a specialist in addiction medicine. “If you don’t know the quality of what you’re getting and you’re thinking you’re injecting one bag of heroin and it turns out to have a few grains of fentanyl, that’s a much more potent drug.”
Stancliff is also the medical director at the Harm Reduction Coalition, a nationwide advocacy group. As a concept, harm reduction is about reducing drug-related injuries and fatalities by educating drug users and providing them with resources to use more safely. Harm reduction groups pioneered needle exchanges, which try to insure that intravenous drug users don’t re-use or share their needles. (You can find a fuller outline of harm reduction principles here.)
For Stancliff, the current discussion about fentanyl lurking in the heroin supply is just another reminder that when you buy heroin, you never know exactly what you’re going to get. Although the drugs in Hoffman’s apartment were reportedly in bags labeled with Ace of Spades and Ace of Hearts logos, there’s no proof that it’s the same “brand” of Ace of Spades heroin reportedly seen in Brooklyn back in 2008. Heroin, like cocaine and Ecstasy and every other drug, is cut with an unpredictable mixture of additives.
“We don’t know how often fentanyl is really in heroin, but we know it’s sometimes unevenly distributed,” Stancliff says. “You buys ten bags, one’s got fentanyl, the others don’t.”
What’s more, when drug users hear about a death caused by a purportedly stronger brand of heroin like Ace of Spades, she adds, “they will seek it out. They think it’s more bang for their buck.”
Because of the inherent unpredictability, harm reduction groups urge drug users not to use alone. A buddy system means that in case of trouble, the other person or people present can immediately call 911, perform rescue breathing, and, perhaps most importantly, administer naloxone (often marketed under the brand name Narcan).
Naloxone has been around since the 1960s; when sprayed into the nose or injected into a muscle, it counteracts the effects of a heroin or morphine overdose. Quite a few studies have shown that take-home naloxone kits help reduce overdose deaths.
The easiest way to get a take-home naloxone kit is at the Lower East Side Harm Reduction Center, where according to their schedule, they’re given out on Monday, Wednesday, Thursday and Friday afternoons, as well as the last Tuesday of the month for refills. There are many other needle exchange points throughout the city, some of whom also carry naloxone. A complete list of overdose prevention programs in the state is available here (you’ll have to call to check which are still operational and carry naloxone).
There is, however, one hitch.
2. Make naloxone more readily available.
In New York, state law says that naloxone has to be dispensed by a “licensed prescriber,” meaning a doctor, a nurse practitioner, or a physician’s assistant. That’s despite the fact that any Good Samaritan can legally administer naloxone to someone in the midst of an overdose. The law requiring a medical professional to dispense the drug, explains William Matthews, a physician’s assistant with the Harm Reduction Coalition, “creates a huge bottleneck in handing out the kits.”
“Needle exchanges don’t always have a medical person on site,” adds Dr. Stancliff, who works with Matthews. “Many drug treatment programs rarely have one. So there are a lot of at-risk people who can’t get access to them because of that requirement. We really want to move it out of the hands of each individual person needing an interaction with a medical person to get one.”
Last week, a pair of matching bills were introduced into the New York State Legislature that would do just that. Assembly Bill 8637, sponsored by Jeff Dinowitz (a Democrat), and Senate Bill 6477, sponsored by Kemp Hannon (a Republican). The bill says, basically, that medical professionals could issue naloxone kits to “certified training programs,” like needle exchanges and drug rehab support groups, who could then distribute the naloxone kits to people who need them, even when a medical person isn’t around. It would also make it so that doctors who give the kits to others won’t face any criminal charges, civil liablity, or professional disciplinary action for doing so.
The bill appears to be moving fast; on Tuesday, it passed the Senate Health Committee, which is chaired by Hannon.
3. Get help.
There is addiction help available in this city, even if you don’t have insurance, even if you’ve relapsed before, even if you’re not sure whether you’re ready to stop for good. New York City operates a 24-7 hotline, 1-800-LIFENET, for anyone looking for addiction help or mental health treatment. Tell them what insurance you have, if any, and what issue you’re struggling with, and they’ll tell you where to go.
“It’s also a good resource for the uninsured,” says Jaclyn Bronstein, an outpatient therapist specializing in addiction who works both in private practice and at Columbia University Medical Center. “If you tell them you don’t have insurance, they’ll tell you places with a sliding scale.”
Both Columbia Medical and NYU Lagone Medical Center conduct research and clniical trials. Sometimes that research is about addiction. Bronstein says that once the studies are completed, Columbia refers people to treatment facilities around the city, including Bridge Back to Life and the Parallax Center.
There’s also medication treatment available for drug addiction. Earlier this year, I wrote a feature on the use and abuse of Suboxone, a detox drug used to help people beat heroin and other opiate addictions. The feature mostly dealt with the thriving and problematic black market for Suboxone. But when taken under a doctor’s supervision, it’s true that the drug can also help heroin users get clean. Even people who take Suboxone incorrectly — abusing it, buying it on the street, cycling between it and their drug of choice — are lowering their chances of an overdose death, because Suboxone is simply very hard to overdose on. Another option is Vivitrol, an medication taken by injection at a doctor’s office which Bronstein says is increasingly available under most insurance plans; just a year ago, people had to pay a lot of money out of pocket to get it.
“Hoffman’s story is indeed sad and troubling,” Dr. Adam Bisaga says, a professor of clinical psychiatry at Columbia University and an addiction researcher at the New York State Psychiatric Institute. “In some way it is a failure of the treatment system. Apparently he was recently in detox, and, I presume, not on medication to prevent relapse. Most people still get directed towards treatment that relies on detox and participation with 12-step fellowships without medication support. Many get helped, but those that fail are at risk of dying. Of people who take medications, very few are dying.”
“I would like to see in stories reported about him mentions of effective treatment available to people who struggle,” Bisaga adds. “But I guess reporters prefer stories about death than stories about survival and recovery and hope.”
Suboxone remains a somewhat controversial treatment. Dr. Stephanie Santoro, an internist and addicition medicine specialist in New Jersey, doesn’t prescribe drugs like it in her practice. “Unfortunately, in my area, doctors are too comfortable prescribing narcotics,” she says. “They are also quite comfortable prescribing Suboxone which was responsible for 21,000 ER visits in 2011.”
Yet she and Bisaga could probably both agree that working with patients to find a treatment plan is the only way to help anyone get and stay clean.
“The sad end of it is that [many doctors] are not comfortable actually counseling patients and asking about addiction in a non-judgmental way,” Santoro says. “There is this ‘us vs. them’ approach that doesn’t work with people suffering from this disease.”