Hoffman and the Terrible Heroin Deaths in the Shadows

It’s a particularly bad time to be an injecting heroin user. That's not to say there's ever a good time. You could argue that things were worse in the '80s and early '90s before syringe exchanges became increasingly available, and HIV was leveling entire communities of drug users. Nonetheless, these are not good times to be cooking drugs off the street and shooting them in your veins. We didn’t need Philip Seymour Hoffman—by all accounts a dedicated father and universally recognized as one of the great actors of his generation—to die tragically with a needle in his arm and five empty bags of dope next to him to know this.

Now that Hoffman is gone the one purpose his passing can offer is to bring into sharp focus the fact that overdose deaths have long been on the rise in the U.S. (according to the Centers for Disease Control and Prevention, deaths from drug overdoses increased by 102 percent between 1999 and 2010), and to more vigorously continue the discussion about what to do about it.

As a recovering addict who still works with active users in communities where heroin is sold on the street, I can tell you that it’s particularly dangerous out there right now. Recently, an unpredictable and hard-to-track bad batch of Fentanyl-tainted heroin dipped and dodged its way through the mid-Atlantic: Camden, Philadelphia, moving west to Lebanon, Pennsylvania, and now Pittsburgh. It also popped up to the south in Baltimore. Health practitioners in North Philly are getting bombarded with faxes from the Centers for Disease Control about the bad bags working their way around the streets, with instructions to warn their patients who might be using. Fentanyl-tainted bags go fast; ironically, when news of a batch laying users low spreads on the streets, heavy users seek the potent bags out by their brand stamp.

Overdoses become advertisements for strong product. So as quick as the alarm goes up the supply runs dry, only to emerge somewhere else on the black market. Tainted drug batches are hard to track and hard to predict. Useful advice that keeps users "safe"—in a relative sense—like not running the whole barrel at once (but injecting a little to see how potent the bag is) can be unrealistic for street addicts trying to quickly get a shot off before getting nabbed by the cops.

Needle users are getting worse infections. A 2010 study shows that infection rates among injecting drug users can be as high as 33 percent. It stands to reason with drug-resistant bacteria tearing through the health system, that people repeatedly sticking themselves in unsanitary conditions with no medical oversight would be a prime breeding ground for skin infections of devastating new power. MRSA and other drug-resistant bacterial infections are hitting needle users with increased frequency and devastating consequences. Injection drug users with resistant infections, many of whom are poor and without health coverage, face massively invasive and expensive medical procedures in order to be cured. Sometimes users require major surgeries, which often result in profound disability. HIV persists and remains a constant concern for public health practitioners, but today there are more ways than ever for injecting drug users to get sick.

More people are using heroin, according to a 2012 Substance Abuse and Mental Health Services Administration survey. The survey found that between 2007 and 2012, the number of heroin users ages 12 and up increased from 373,000 to 669,000. 

Public health professionals have known for nearly a decade that a new cohort of heroin users was in the making as the prescription drug epidemic spread. This is a matter of pure economics. Prescription dope isn’t cheap. In Philadelphia, an 80 milligram OxyContin pill will cost you $40. "Oxys" are safe in that the potency is predictable. Pills usually trade in safer parts of town than the North Philadelphia heroin corners where bullets can fly at any moment and the Narc Squad is always on the prowl. You pay a premium for upscale product, though; for the same amount of money, you could get four bags of heroin that are just as potent. Eventually, heavy users run out of money for pills and seek out cheaper powders. These new users are fueling a surge in heroin purchases in locations as remote as Vermont. Hoffman himself reportedly first relapsed on pills before moving into heroin use.

There is hope. Naloxone, a non-narcotic, easily-dispensed medication, is being hailed as a miracle drug for reversing overdoses. Like Lazarus, an overdosed user on the verge of death will spring back to life when Naloxone mist hits his nostrils. Police are becoming more willing to carry and dispense the drug. More townships are passing Good Samaritan laws that make it safe for other drug users to contact emergency responders in the event of an overdose, without having to worry about getting arrested for having made the call. Advocates want Naloxone, which is safe and non-toxic, to be available over the counter. Had Hoffman followed simple instructions from a Naloxone training session (Don’t use alone. Train those who use with you to administer the drug.), he might still be with us. Not every overdose can be prevented, but we should strive to prevent as many as possible. Naloxone isn’t drug treatment, and many who have their overdoses reversed will continue to use drugs, but we can’t get hung up on this. Dead people can’t get clean. Every reversed overdose is another chance at life.

U.S. drug policies are shifting. Slowly, and not enough, but there is progress. Mandatory minimums are being phased out. Treatment is increasingly available to those caught up in the criminal justice system. As the Affordable Care Act begins to take effect, treatment will become more broadly funded, especially for the poor. There is concern among public health professionals, myself included, that the policy shift will fall short of what we need to change conditions for injecting drug users.

Legal pot isn’t enough. For there to be an American version of Insite, Vancouver's celebrated, medically-supervised, legal injecting space, the U.S. would need to decriminalize entirely. If Philip Seymour Hoffman had taken his last bags to a legal injecting space, would he still be alive? Had he overdosed there, medical staff on call might have reversed it with Naloxone. Had he acquired an abscess or other skin infection, he could have sought nonjudgmental medical intervention. Perhaps injection site staff could have directed him back to treatment.

Safe injecting sites are an amazing, life saving, humanity restoring intervention we can’t have because our laws preclude them. Too frequently, heroin addicts instead utilize abandoned buildings and vacant lots to shoot up in order to evade arrest. The risk for assault, particularly sexual assault for women, in off-the-grid, hidden get-high places is incredible. Overdosed bodies are routinely pulled from such spaces in North Philadelphia.

 There is a particularly chilling aspect to Hoffman’s death that only another recovering addict can feel. He had 23 years clean, and then went back out. Just two weeks ago, I celebrated ten years off my own crippling drug habit. Sometimes I feel convinced that I’ll never relapse and experience that kind of pain and insanity again. Recovery programs warn that this kind of thinking can be dangerous. The addicting substance is characterized as “cunning, baffling and powerful.” It sounds like a cliché until someone with more than two decades clean, with a beautiful family and a career that is the envy of the world trades it in for a glassine envelope of dope and a set of works.

Those of us in recovery need to remain vigilant in maintaining our mental health. There is much work to be done on America’s addiction problem. It involves ensuring effective treatment, expanding the science of the field, and making sure that those who are actively using can do so in a way that is safe and dignified. There is a way to make meaning from the otherwise senseless early death of Philip Seymour Hoffman, and that is to let it refocus our efforts on making sure the smallest number of people possible find the same fate.