In 2017 American life expectancy declined for the third consecutive year, something that hadn’t happened since the 1940s. The Centers for Disease Control and Prevention attributed the drop in part to fentanyl, which also appears to be driving down life expectancy in regions of Canada. Solving this crisis will require us to change some of our most basic assumptions about how we perceive drug abuse. We need to treat it as a disease, not a crime, and understand what causes it, rather than simply trying to eradicate it. There are indications that this might be happening in parts of the United States, and the results are encouraging.
Initially, New England states were most severely hit by the fentanyl crisis, but in 2017 Massachusetts, Rhode Island, and Vermont saw their drug overdose death rates decline, likely thanks in part to increases in addiction treatment programs and public-health campaigns. “It could be an indication that increased access to treatment, safer use practices, and prevention methods are working,” said Mario Moreno, former press secretary for the White House Office of National Drug Control Policy. A hallmark of Rhode Island’s strategy is providing access to opioid replacements for incarcerated people with addictions, which appears to stop them from overdosing upon their release. The program has already saved lives, state officials say. Ohio, a state whose Medicaid expansion in 2015 has given many users access to addiction and treatment programs, has also seen its overdose death rate drop dramatically in some of its hardest-hit areas. On the national level, the SUPPORT for Patients and Communities Act, signed by President Trump on October 24, 2018, was a step in the right direction in its provisions for better opioid treatment options, though greater resources are needed.
As with almost any major social movement, change needs to happen at the local level first. Thankfully, even in opioid-ravaged areas like St. Louis, there is hope. After her most-recent fentanyl relapse, during the second trimester of her pregnancy, East Alton resident Bree felt an urgent need to turn her life around and discovered the WISH Center, a St. Louis substance-abuse clinic tailored to pregnant women and infants.
Traditionally, more men die from drug overdoses than women. Women, however, are equally likely to develop drug and alcohol addictions and may be more sensitive to the effects of opioids than men. Withdrawal can be more intense for women, said Robert Glatter, an emergency physician at Lenox Hill Hospital in New York City. “Data indicates that women run a higher risk of drug craving and relapse, which are important stages in the addiction cycle,” he said.
The WISH Center is run by Dr. Jaye Shyken, a maternal-fetal medicine subspecialist who previously worked with pregnant women addicted to cocaine. Now, at the WISH Center, almost everyone she sees has opiate- and opioid-use disorders. Shyken would argue that the way the United States treats opioid dependence is all wrong. “There’s money for in-patient stabilization, three- to six-day detoxes, then they’re discharged, with a telephone number for chemical-dependency treatment,” she said, a quick release that fuels a high recidivism rate. She advocates a type of addiction care called medication-assisted treatment, similar to Baluard’s substitution therapy, which treats people with opioid dependency with replacement drugs, like methadone or buprenorphine. In combination with traditional therapy, this approach gets to the core of the issue for most people: a physical dependence combined with personal problems spiraling out of control.
Opioid addiction is often portrayed as an irreversible rewiring of the brain; the common perception is that once one becomes addicted to these drugs it’s impossible to break free. But according to Shyken’s experience, those able to fix major problems in their lives often break the cycle. The problem for many is that expecting them to get their lives in order and go through withdrawal at the same time is asking too much. At the WISH Center, Shyken prescribes buprenorphine, which is sold as Suboxone or Subutex. Studies have given medication-assisted treatment credit for reducing overdose deaths, and it is frequently described as the gold standard for treating opioid addiction.
Buprenorphine and methadone are controversial because they are opioids, although less powerful than heroin, fentanyl, and other opioids of abuse. Still, methadone dependence is a problem in itself; it is frequently sold as a street drug and causes thousands of overdose deaths per year. Many believe buprenorphine to be a better solution, and it is undoubtedly safer, though it has traditionally been difficult for doctors to prescribe, as it requires a special license from the DEA. The benefits of buprenorphine and methadone are that these drugs prevent debilitating physical withdrawal symptoms—which many often compare to a terrible flu—without (usually) getting the average user high. This helps users get their opioid compulsions under control and their lives in order while, ideally, helping them slowly taper off opioids altogether.
“When people say, ‘Dr. Shyken, aren’t you just substituting one drug for another?’ I say, ‘Yes, what’s your point?’ It’s saving lives.”
Though this philosophy is disputed by some treatment providers, who stress the importance of abstinence-based recovery, many doctors and addiction experts support it. The renowned Hazelden Betty Ford Foundation, for example, once took an abstinence-only approach, but in 2012 began providing medication-assisted treatment. The WISH Center opened in 2014, and demand for its services has been overwhelming. “The word of mouth is just amazing,” Shyken acknowledged. “It’s not like we’re doing a lot of advertising.”
She also believes that a spiritual approach can be helpful in some instances, a possibility that has been recognized in academic literature. “Spirituality for some people produces chemical changes in the central nervous system that we seek with medication and self-efficacy,” she said.
Opiods are often abused in company with other drugs, however. Bree overdosed on fentanyl and the benzodiazepine Xanax, passing out in her van at a gas station, and had to be revived with Narcan. Benzodiazepine and opioids can be an especially deadly combination, since both drugs slow down the central nervous system, which affects breathing. Indeed, the National Institute on Drug Abuse says that more than 30 percent of overdoses involving opioids also involve benzodiazepines. “We have this whole infrastructure set up now to prevent overprescribing of opioids and address the need for addiction treatment,” said Dr. Anna Lembke, a researcher and addiction specialist at Stanford University. “We need to start making benzos part of that.”
Exclusively focusing on the chemical aspect also overlooks another important factor. “One hundred percent of my patients have experienced childhood trauma or have a mental health disorder, which are tied in,” Shyken said.
Bree, who in her three decades has faced a host of traumas, was prescribed Subutex at WISH, which she takes orally. For the time being at least, she has been able to stay off fentanyl. “We made a promise to ourselves we would never do it again,” she said, looking at her boyfriend, Mike, who has had his own problems with fentanyl.
Six weeks later, she gave birth to their baby, a healthy girl.
Jack Sanders, the fentanyl dealer from suburban St. Louis, was able to find redemption. Before he could escape his nightmare, however, he had to hit rock bottom. After his friend Marcus, who gave him all the heroin he could use in exchange for serving as the muscle on drug transactions, went to prison, Jack lost his heroin connection, even while his habit remained in full force. Broke and suffering from withdrawal, he did the only thing he could think to do: he brandished his .38 and started robbing people, preferring drug dealers.
“I’d look into your eyes, I’d see if you were a killer or not. And if I didn’t think you were a killer, I’d put a gun to your head, and I’d fuckin’ take all your shit,” he said. Guns, cash, drugs—everything. Even, sometimes, shoes, so his victims couldn’t run after him. This was how Jack fed his habit for more than a year. But he was living on borrowed time. The world of St. Louis drug dealing is small, and he eventually robbed the wrong man, someone who came back at him with force. Fearing for the safety of his family, Jack traveled about two hours south to a city called Cape Girardeau, where he lived in a homeless shelter for almost a year.
Cape Girardeau, a pretty river town, held an added benefit for Jack—he didn’t have any heroin connections. So, around 2015, he dried out. It was painful. When he heard that the man stalking him had been murdered, he finally returned to St. Louis and found a psychiatrist who helped pull him out of the pit. “She found out the right medications I needed, antidepressants, stuff like that, and I’ve taken those ever since,” Sanders said.
He’s not kidding himself into thinking that he’s going to shake his past anytime soon. He’s committed too many crimes, hurt too many people, and spread too many dangerous drugs for that. “Now that I’m clean, I have nightmares all the time. I don’t know which ones are real, and which ones aren’t. I see ghosts of people I’ve hurt.”
Jack got out, and is now gainfully employed in his hometown. But the scourge of fentanyl remains, and St. Louis heroin products continue to be manipulated. When fentanyl packages first began arriving from Mexico, Jack and his crew used one part fentanyl for every seven parts heroin. As fentanyl caught on, dealers began competing with each other to offer a stronger product. Before long, said Jack, the ratio was one to six, and then one to four. Today it might be one to two. A higher concentration brings a much greater mortality risk.
Even while Jack and Bree are recovering, fentanyl deaths in the St. Louis area remain on the rise.
In Grand Forks, North Dakota, the college town by the Red River where this story began, the tragic fentanyl overdose death of eighteen-year-old Bailey Henke served as an alarm bell for the members of the community, almost all of whom, in early 2015 when Henke died, had never even heard of fentanyl. The city has taken a multipronged approach to confronting the epidemic, enlisting the mayor’s office, the police department, the public-health office, addiction counselors, and doctors. In one of the most conservative states in the country, on both the city and state level, people put aside politics to confront the quickly rising toll of fentanyl and opioid overdoses.
“Bailey’s death shocked us to our core and caused the community to look deep within itself,” said Grand Forks’ mayor, Michael R. Brown. “Because we’re in the Midwest, we think we’re isolated from these types of things, but I’m very proud of our response.”
Brown is a part-time mayor and a full-time obstetrician-gynecologist. His background as a doctor gives him an informed perspective on this drug crisis, and he has been open to progressive ideas like medication-assisted treatment. He has spearheaded an initiative, largely inspired by Henke’s death, called the Grand Forks Call to Action, which focuses on opioid abuse. It kicked off in May 2017, when he and other civic leaders spoke before an audience of more than two hundred locals to discuss the crisis and potential solutions. “We know addiction is a disease, and in order to save lives we must be a community that is welcoming people into the services they need,” he began.
“There’s been a lot of new thoughts on how we treat addiction,” affirmed Michael Dulitz, the project coordinator for the Grand Forks Public Health Department’s Opiate Response program. “Nowadays individuals aren’t being arrested for overdosing, which is a strong change.”
Grand Forks police lieutenant Brett Johnson acknowledges that even while his department has employed new tactics to confront the NPS crisis—having received special tech training to combat the Dark Web menace—the police can’t arrest their way out of this problem. The opioid deaths of Henke and others have changed perspectives of officers in the department and others in the community. “It’s not just your stereotypical drug user that’s using these substances,” Johnson recognized. “It cuts across all societal groups, not just what you would traditionally think of as a drug user.”
“We have to educate our way out of the problem,” said Mayor Brown.
In December 2016, President Obama signed into law the 21st Century Cures Act, a wide-ranging bill that helped streamline the approval process for new drugs, provided funding for medical research, and gave $1 billion in state grants to fight the opioid epidemic. North Dakota received $2 million, which was distributed among five cities, including Grand Forks, which received $180,000. This money was, in part, used to create Michael Dulitz’s position within the city’s Public Health Department, and he has been implementing a number of harm-reduction tactics.
Dulitz is a former paramedic who was treating opioid overdoses on the street level in nearby Fargo as the crisis heated up. “The summer of 2015 was when I realized there was a big problem here. We were pulling [overdose victims] out of cars, where their friends were speeding away. There were a lot of questions about fentanyl, and we weren’t getting a lot of answers. It was assumed to be heroin at first. And it wasn’t until later that we realized it was illicitly produced fentanyl.”
He went on to receive a master’s in public health from the University of North Dakota, in 2017, and began his position later that year, helping lead Grand Forks’ progressive opioid crisis response, which includes a partnership with a local pharmacy to distribute free harm-reduction kits—which have naloxone, fentanyl test strips, plastic containers to carry needles, and condoms. These are handed out to those in need in the community. “Their availability has been spread rapidly by word of mouth,” Dulitz reports. He purchased fifteen hundred fentanyl test strips from DanceSafe for a dollar each, in the process becoming an early municipal adopter of this approach.
In many regards, Grand Forks has been a model city when it comes to compassionately confronting the problem head on. Further, owing to a rules change at the North Dakota Board of Medicine that took effect at the beginning of 2018, state residents with opioid use disorders are now able to access medication-assisted treatment providers via telemedicine, a system that involves communicating with doctors in other places, using a technology similar to Skype. This allows for access to opioid addiction drugs like buprenorphine and methadone in areas with no medication-assisted treatment providers.
Another progressive change in North Dakota occurred in 2017, when the state updated its Good Samaritan law to protect people who seek medical help for overdose victims, granting them immunity from drug-possession charges. This law makes a real difference. Tanner Gerszewski, the friend whose apartment Bailey Henke died in, said he knew people in high school who didn’t call in when their friend overdosed, because they thought they would go to jail. Gerszewski himself may have been worried about this exact thing; he moved his drugs from his apartment to his van at the very moment Henke was overdosing. “I thought, ‘This is a big deal, they go through and search my house, there’s a death in my place, that’s not good,’” Gerszewski said, though he adds that because another friend was performing CPR on Henke at the time, and they were waiting for an ambulance, Gerszewski didn’t believe there was anything he could do to help the situation.
If and when the opioid scourge is contained in Grand Forks, it will leave behind a larger legacy. According to Dulitz, the response to the crisis has caused the community to rethink how it addresses other types of addiction. “Now they’re even treating alcohol as an addiction and reducing stigma around it,” he said. “More treatment options are available.”
Laura Henke, Bailey’s mother, is generous and quick to laugh. She tends to immediately agree with the person she’s speaking with, to give him or her the benefit of the doubt. Hailing originally from Hallock, Minnesota—near the Canadian border, about an hour north of her current home in Grand Forks—she’s the very definition of “Minnesota nice.” But despair nonetheless lurks within her since Bailey died.
Still disturbed by the events surrounding the evening he passed away, she is no longer in touch with Tanner Gerszewski, and when asked by a documentarian if she forgives Kain Schwandt—Bailey’s friend, who was also with him that day—she responded, “I’d like to, I guess forgive him for Bailey, because Bailey would want him to be a better person.”
Schwandt said alcoholism and drug abuse runs in his family, and admits that he was a reckless drug user when Henke was alive—and afterward. He even overdosed on a fentanyl patch about three months after Henke died, before spending about a year and a half in a Duluth, Minnesota, prison. He wasn’t charged in Bailey’s death, but rather pled guilty to conspiracy to possess heroin with intent to distribute. He got his GED behind bars and received early release after completing a drug treatment and behavioral program. He has stayed clean of opioids and other drugs since; the key, he imparts, is avoiding the old crowd he used to take drugs with. Instead, he is concentrating on work, building vinyl and carpet floor installations with his stepfather. “I’m just working and staying out of trouble the best I can. And I’m on probation for another two and a half years, so that’s another good motivator.”
Gerszewski has a harder time putting on a brave face. He has never been able to remember everything about the night of Bailey’s death, because he was so high, and even that tragedy didn’t slow down his drug abuse. Still in the throes of opiate dependency on January 7, 2015, just days after Bailey died, Gerszewski saw his girlfriend, Jade Nelson, overdose on heroin—also at his apartment—though she was transported to the hospital and survived. Heroin and marijuana were found in Gerszewski’s home, and he was charged with intent to distribute, for which he did about three months in jail. “Seeing Bailey die, and then having my girlfriend OD, and then doing jail time, losing my freedom, everything…. I just sat in jail one day and thought, ‘Jesus, what am I doing? Either I’m gonna die or I need to stop, because this just isn’t working.’” He has gotten clean since then, but his conscience continues to nag at him. “There’s still that guilt of, ‘Why did he die, and why did I survive?’ I almost wish it were the other way around.” He is seeing a psychologist, is on depression medication, and has made it his mission to help prevent deaths like Bailey’s, spreading the word about the horrors of fentanyl.
Laura Henke and her husband, Jason Henke, have the same mission. After Bailey’s death they started a scholarship at his high school in his memory. They have also been generous in talking with the media about his death, and Laura even went so far as to help me track down contact information for Bailey’s friends and his hospital medical records.
Before departing the pizza parlor where we met to talk, Laura took me to the back of the restaurant, to show off a wall of scribbling above one of the booths. Hundreds of people have signed their names and written messages on the wall, forming layers upon layers of pastel Crayola marker and loud primary colors, so that the specific words have become hard to make out. But as she pointed I saw her son’s name, written in huge orange letters near the top of the wall. “Bailey Henke Forever,” it said. Below that, in black letters is a smaller message, which Bailey’s mother added after his death. It read: “Laura Henke Forever Also!!”