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Running Head: SHOOTING DOWN

Shooting Down the United States Heroin Epidemic

Bailey M. Nixon

Glen Allen High School

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Introduction

Within the last several decades, astonishing statistics and increasing horror stories have

revealed a sad truth: ​America is experiencing an epidemic unlike any other-the distribution and

use of heroin in the United States. This issue has become an increasingly difficult situation to

combat, quickly claiming lives throughout the nation.

To put it in perspective, Jen Christensen and Sergio Hernandez compare the heroin crisis

to the HIV epidemic when the United States had no treatment to turn to (2017). Similar to this

crisis, the use of heroin in the United States originated in urban, low income areas and has

plagued the lives of many Americans. Contrary to popular belief, however, both researchers

claim that the increase in heroin use has spread so drastically due to the use in small towns and

rural areas compared to industrial and urban areas (Christensen & Sergio 2017). No longer is this

an issue that solely affects large cities across America. In fact, West Virginia, New Hampshire,

and Kentucky are currently the top three states with the most overdoses in the entire country

(Christensen & Sergio 2017). West Virginia alone holds six of the twenty counties in the country

that have the most heroin overdoses (Christensen & Sergio 2017). Additionally, updated research

has introduced that minority groups are no longer the group affected most by the epidemic; it is

white Americans that are using heroin the most. The heroin epidemic extends beyond the classic

minority race stigma; this is an issue that affects individuals from all races nationwide. In a study

done by the Department of Psychiatry at the Washington University in St. Louis, it was found

that heroin use has evolved from an “inner-city, minority-centered problem” and developed into

a issue involving “white men and women...living outside of large urban areas” (Cicero et. al

2014). The impact of this epidemic is enormous and is reaching men and women across the
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country in every age, race, and socioeconomic status. It has become increasingly clear that this

issue must be reviewed and resolved in order to prevent the overdoses of addicted Americans.

But what happens to the individuals who are not aware of the repercussions of their choice to use

heroin? In this paper, the causes and effects of a heroin addiction on a person’s life are discussed

in order to reveal why individuals choose to alter their lives to get high. This subject is extremely

relevant to society today, as this issue has transitioned from a nationwide epidemic resulting less

from race and socioeconomic status, and more on opioid prescriptions and biological

dependence. Given that more individuals are becoming influenced by heroin, it is imperative that

citizens nationwide should become informed on the detrimental effects of a heroin addiction.

Mental Causes of Heroin Addiction

While the recent phenomenon of prescribed opioids has played a major role in the

increase of nationwide heroin addictions, research about the biological causes of addicts provide

insight on the reasoning behind the exponential use of heroin and heroin addictions in the United

States. In an article designed for nurses treating patients with addictions, Georgina Casey

describes the biological causes and effects of substance abuse and addiction. Casey claims that

drug use causes “changes in the brain that lead from recreational use to addiction, and the

neurological mechanisms underlying relapse” (2017). As the brain becomes comfortable with the

use of a drug, it often changes and starts to become dependent upon the chemically altering

substance. She explains the debate between “addiction” and “dependence” within the DSM-IV

and discusses the two types of dependence that occur within an addiction. Physical dependence

occurs due to “repeated use of many chemical substances” that cause tolerance to said substances

(Casey 2017). As a result of continuous use of a drug, individuals experience withdrawal

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symptoms. Similar to physical dependence, psychological dependence refers to the actual

cravings an individual experiences as a result of the repeating use (Casey 2017). Due to brain

cravings, addictions are often hard to overcome. More often than not, the cravings and

withdrawal symptoms make it harder for addicts to make the switch to sobriety. While these

symptoms play a major role in drug addiction, Casey also discusses the dopamine theory on how

individuals become easily addicted as a result of involuntary mental reinforcement practices.

In this theory, dopamine release along this pathway triggers sensations of

reward and pleasure. Illicit drugs work by increasing firing of dopaminergic
neurons, or inhibiting the breakdown or reuptake of dopamine, once it is
released into the synapses. Stimulant drugs act directly on the mesolimbic
system to produce their effects, but other drugs of abuse, as well as activating
this pathway, have their primary actions in other regions of the brain (Casey
2017).

While some studies show that opioids do not have a large effect on the dopamine release process,

it is clear that other brain regions are involved. Drugs often have the tendency to overpower the

chemicals in the brain, causing an unstable reuptake of certain neurons, making the repetition of

drug use occur before an addiction has even begun. In her article, Casey describes the insula,

which feeds into both the amygdala and prefrontal cortex (2017). The insula interprets “stress,

sleep, and drug deprivation,” and causes impulsive behavior when these sensations are not

accurately maintained (Casey 2017). To compare to Casey’s research, a group of researchers at

the Ningbo Addiction Research and Treatment Center in China tested the effect of a drug

addiction on the levels of the dopamine receptor D4 methylation. In general, higher dopamine

levels in a person’s brain causes the need for higher reinforcement from a substance, causing

dependence on drugs that give the brain an elated sensation (Ji 2017). Within their study, there

were 60 individuals addicted to either heroin or methamphetamine and 52 individuals with no

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addiction used as a control (Ji 2017). As stated in their results, “DRD4...methylation levels were

significantly higher in all heroin and meth addicts compared with 52 controls” (Ji 2017). It was

also stated that males who were addicted to either drug were more likely to have increased

methylation levels as well (Ji 2017). Therefore, addicts typically have increased levels of

dopamine and according to their study, this is more prominent in male users. Compared with the

2017 article by Georgia Casey, it can be inferred that dopamine levels do play a role in the

causes of a heroin addiction. As dopamine levels increase, it is predicted that the likelihood for

addictions can increase. Taking into account the current state of our society, it is common for all

races and individuals from socioeconomic statuses to experience this. Therefore, the dopamine

theory disproves the common urban, low-income stigma that addictions are formed based upon

who you are and where you live. While the dopamine theory is an impressive observation about

the causes of addictions, this is not the only feasible theory on why and how individuals become

addicted so quickly to a drug such as heroin.

In an article analyzing the heroin epidemic from the lenses of three historic psychologists,

Nancy Dyer introduces the short and long term effects as well as the causes of addiction from

their perspective. Dyer questions how the symptoms can get as worse as “skin crawling”, but

people are still willing to put their lives through an addiction (2004). Such powerful drug

addictions tend to be aided by the biological expectancy for dependence. Accepting this fact,

Dyer explains her ideas on the concept of causes of addiction as she states:

It is no wonder that this euphoria is found to be so compelling psychologically

and physically; after all, pain and pleasure are our most primal motivators.
Thus, the compulsion to use despite adverse consequences is fueled by very
basic brain functions, perhaps the most important elements to consider when
trying to understand why someone would use such a dangerous, addictive
substance (2004).
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Coming off of a drug as powerful as heroin can be nearly impossible once the brain

acknowledges its neuromic effects. Dyer also references Emile Durkheim who compares an

addiction to a “religious ritual” where individuals use drugs like heroin to find peace just as

many turn to their religion to find peace (Dyer 2004). In many ways this is true, relating to the

dopamine theory, where the drug supplies feelings of euphoria for the user. Dyer claims that

Durkheim’s quote, “religion, or some substitute for it, will always be with us”, is an omen for

current substance abuse within society (Dyer 2004). Because of the brain’s tendency to feed

addictions, assuming the cause of a heroin addiction is based upon race or socioeconomic status

is not only accusatory, but also faulty; biological processes play a major role in the production of

addictions.

Prescription Causes of Heroin

As society continues to prescribe pain relieving opioids for medical purposes, the

correlation between prescription drugs and heroin use has increased. After major surgeries or

other painful health complications, many patients turn to opioids after their prescription

medication has run out. Eventually, heroin often becomes a more viable source of a high because

of lower costs and easy accessibility. Due to the prescription drug to heroin addiction pipeline,

more Americans nationwide are becoming exposed to outlets to begin addictions. With the

current stigma of correlating race and class to causation of addition, society will deem the heroin

epidemic as less credible in areas such as West Virginia and New Hampshire, who suffer some

of the worst levels of heroin users and overdoses across the nation. Due to not only biological

causes of addiction, but also the increase of prescription opioids as painkillers, the levels for all

individuals increase daily as the epidemic continues to plaque many within the United States.
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Regardless of race or socioeconomic status, Americans everywhere can easily obtain heroin,

therefore, easily causing sources of addictions in a variety of individual backgrounds. According

to a study from the Department of Psychiatry at Washington University, there is “growing

evidence that some prescription opioid abusers, particularly those who inhale or inject their

drugs, graduate or shift to heroin...because it has become more accessible and far less expensive

than prescription opioids” (Circeo et. al 2014). Researchers in this study interviewed addicts

through two different programs: Survey of Key Informants’ Patients Program (SKIP) and

Researchers and Participants Interacting Directly (RAPID) program. Specifically within the

RAPID interviews, every respondent, which consisted of over 150, “who indicated heroin as

their primary drug also endorsed lifetime abuse of prescription drugs” (Cireco et. al 2014).

Additionally, 94% of participants said they chose heroin simply because it is cheaper and easier

to find than prescription drugs (Cicero et. al 2014). Represented by such a large amount of

respondents in their research, it is obvious that prescription opioids can act as a gateway into a

heroin addiction. In their final discussion of the study, they noted the heroin crisis has become a

major issue due to three primary reasons: the misuse of prescription opioids, the common use of

individuals using other opioids after prescriptions, and the easy availability of heroin compared

to prescription pills (Circeo et. al 2014). With easier outlets for distribution, more Americans are

discovering and purchasing heroin nationwide to feed their highs.

To counteract the prescription to heroin theory, Jacob Sullum writes to prove that the

opioid crisis has nothing to do with the use of prescription pills. In his article “Don’t Blame Pain

Pills for the Opioid Crisis”, he explains a viewpoint that is not so typical in this field. Sullum

states that opioid addictions and deaths have little to do with prescriptions, but more to do with
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“multi-drug users with histories of substance abuse and psychological problems” (2018). He

references a 2015 review between the prescription to opioid addiction pipeline. In the study,

former patients treated with narcotics were followed for thirteen years, yet only 1 in 550

individuals died from an overdose related to opioids (Sullum 2018). Throughout the article,

Sullum argues that overdose occur less from former treatment and more from past decisions to

experiment with illegal narcotics. While Sullum’s viewpoint counteracts those of Cicero and his

counterparts, his admits that the true cause of an opioid addictions occurs from past drug use.

Thus supporting the increasingly modern view of causes pertaining less to race and

socioeconomic status, and more to previous drug use and biological dependence.

Effects and Implementations of Treatment for Heroin Addictions

Similar to the causes of addictions, the effects tend to vary from addict to addict.

Depending on the person, an addict will either stop using, admit themselves into a type of

treatment, or overdose. In 2014 alone, 10,574 out of the 28,647 opioid related deaths were from

heroin (Christensen & Sergio 2017). As the heroin epidemic has spread and the number of

overdoses have increased, more treatment options have arised for struggling addicts.

Beginning in the late 1960’s, the use of methadone to treat heroin became commonplace.

Even currently, many treatment centers give heroin users methadone to wean them off of their

addictions and prevent harsh withdrawal symptoms. Charles O’Brien writes,

If tolerance and withdrawal symptoms were the only elements of addictive

illness, treatment would simply consist of detoxification, a process that allows
the body to cleanse itself while receiving descending doses of a medication that
reduces withdrawal symptoms…[However], the more difficult aspect is the
prevention of relapse to drug-taking behavior...transfer from a short-acting drug
such a heroin to a longer acting drug such as methadone provides a smooth
transition to the drug-free state (2008).
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While the use of methadone is not an end-all-be-all, it does provide an easy transition from the

use of heroin. According to 1967 article, it was found that a 100mg dose of a methadone

“blockade” was equivalent to the “euphoric action of 80mg or more of heroin” (“New

Treatments for Heroin Addiction”). The same article also recommended the use of cyclazocine

where 4mg challenged 15mg of heroin (“New Treatments for Heroin Addiction” 1967). Around

the same time period, a study was done through the Black Action Methadone Program that tested

the outcomes of addicts who were treated with methadone and social services compared to those

with no treatment. The 223 patients in this program were predominantly black and white males

aging from 18-71 years (Cleveland et. al 1974). After analyzing the retention in program, relapse

on heroin, employment, and arrests one year after their admission, the program featured a

successful treatment rate for 76.6% of the former addicts (Cleveland et. al 1974). Due to the use

of methadone to control heroin addictions, patients in this program were able to end their

addictions and look for employment.

While methadone has been tested and established as an effective form of treatment for

heroin users, many researchers argue that long-term social programs are paramount for success

in addicts. In a 2015 study completed in Bologna, Italy, Raimonda Pavarin researched the

standardized mortality ratios between public treatment center patients and non public treatment

center patients. The Standardized Mortality Ratio (SMR) is based on the deaths found in a study

compared to the average number of deaths that would be expected (Pavarin 2015). The study was

completely voluntary and featured 959 subjects from ages 15 to 64 (Pavarin 2015). Featuring a

large amount of voluntary participants, this demonstrates the desire for addicts to reach out for

help. Pavarin states, “448 subjects went to a PTC...434 went to an emergency department… and
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77 were admitted to the hospital” 2015). Individuals treating in the public treatment center

experienced 18 deaths compared to 29 deaths within the non-PTC group (Pavarin 2015). Due to

their decision to get help and get clean, these addicts saved their lives. After following the PTC

subjects, over 24% successfully completed the treatment, 61% remained in therapy, and 14.7%

ended their treatment entirely (Pavarin 2015). The study was concluded with the suggestion to

treat addicts from a large population scale compared to small and specific groups of individuals

with heroin addictions (Pavarin 2015).

While this study proved effective for a number of addicts, working with large groups may

not always create successful outcomes. In contrast, many addicts thrive knowing they have the

full attention from their supporters. Without feeling cared for and appreciated during the process,

addicts will not be able to overcome the mental urge to relapse. John Owens supports this idea

with his personal viewpoint of effective treatment for heroin users. He claims that there must be

a “therapeutic team which will aim at a long-term continuous sympathetic contact with the

individual patient” (1967). This team must include doctors, a social worker, a psychologist,

probation officer, occupational therapist, and a clinical pathologist who will work united together

in order to come up with the best solution for the individual (Owens 1967). In a facility such as

the one Owens proposes, an addict is much more likely to successfully overcome their struggle

with heroin and opioids. In order to combat the heroin epidemic, programs like these are

necessary for change. Implemented in an effective and neat manner, these programs have the

power to change the lives of addicts with no other options. To parallel Owens’s point of view,

Charles O’Brien states that “the treatment of addicted patients must always be individualized”

(2008). O’Brien also believes in the power of mental and behavioral treatment in addition to
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medical detoxification. He claims that the “key to successful treatment is long-term prevention of

relapse by behavioural and pharmacological means” (2008). With a balance between the two,

heroin addicts should receive effective treatment powerful enough to combat their previous

burges.

ORBIT Correctional Program

Local to Henrico County, Virginia, the ORBIT Program represents an ideal image of a

balance between medical and behavioral treatment. Featuring 137 Henrico-based inmates, the

program includes a four-step process to not only end addictions, but also start new beginnings for

the participants’ lives. The first step in the program is called “Rise”. This step features two

phases of recovery, that aim to detoxify and adjust the participant into jail life. During this step

(and throughout all steps), the participants are involved in numerous relapse prevention and

coping classes as well as groups that allow them to share their experiences with others. The

second step features the “green team” where inmates work inside of the jail to demonstrate

commitment and responsibility. Those who move onto step two are well-trusted and allowed

minimum security in the jail. The third step is a major turning point for the inmates in this

program. When reaching this step, participants are able to leave the jail on work release where

they find real jobs to save up their money as well as attend therapy groups outside of the jail.

Leaving the jail creates a lot of trust between the correctional officers and the inmates. Finally,

the fourth and final step for this program is home incarceration.

Nora Burnette and Lisa Harvey, two women in the program, describe the ORBIT

program as life changing. Nora Burnette explained that she “[did not] feel like [she] was an

inmate” (personal communication, April 20, 2018). Burnette shared her story of opioid abuse
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and how she wound up in the the ORBIT program. Before she was arrested, she was “beyond

control” and had lost grasps with her former life. She explained how the classes, groups, and

lessons learned in this program have “taught [her] not to be triggered” and have given her hope

for the future (personal communication, April 20, 2018). Lisa Harvey shares a similar story

about her alcoholism that led her life astray. At the beginning of her prison sentence, Harvey was

“too proud to ask for help” (personal communication, April 20, 2018). However, after relapsing

on home incarceration and returning to the ORBIT program, she knew that it was time to take

control of her addiction. A couple months into her second round of the program, she began

leading a Relapse Prevention group for participants at the jail. Harvey explained that this was

very “eye-opening” and helped with her own personal coping (personal communication, April

20, 2018). Both women continuously repeated their gratitude for the program and admitted that

ORBIT saved their lives. Treatment programs such as ORBIT safely and successfully improve

the lives of struggling addicts who would otherwise be suffering in jail. By not only being

medically treated, but also admitted into classes, participants in this program are pushed and

supported to make the right choices both in and out of jail.

Conclusion

This paper enforces the conception that the heroin epidemic in the United States has

reached a point where change must be instituted. Using a variety of research methods including

research journals and surveys, it has been found that heroin majorly affects the lives of addicts.

This subject is extremely relevant to society today, as the epidemic has transitioned from an issue

predominantly focused on race and socioeconomic status, to an epidemic caused by opioid

prescriptions and biological dependence.​ ​Given that more individuals are becoming influenced
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by heroin, it is imperative that citizens nationwide should become informed on the detrimental

effects of a heroin addiction.

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