Gateway drugs and prescription painkillers are two of the most commonly used phrases in the discussion about public health today. In New Jersey, where the purity of heroin sold on the streets is higher than anywhere else in the country, and where more people succumb to overdoses after initially starting out with legal drugs, the idea of prescription painkillers being the new gateway drug to heroin use is a terrifying reality.
The Ins and Outs of Gateway Drugs
The term gateway drug has been applied to any number of substances that have been accused of creating a tolerance in drug users, a tolerance that leads them to experiment with more dangerous drugs. The term itself is slightly misleading, as substance abuse is a very complex spectrum, consisting of a number of different factors that go far beyond the simple dynamic of trying a drug (and then that drug becoming a “gateway” for future use).
Mayo Clinic’s partial list of factors illustrates how multifaceted the process is:
- Family history of substance abuse
- Stressful environment at home (due to abuse, financial hardships, etc.)
- Stress at work or school
- Pre-existing mental health conditions (and a family history thereof)
- Peer pressure to consume more of the initial substance or more dangerous drugs
- Access to drugs, whether to the initial substance, more dangerous drugs, or both
- Lack of education about the dangers of substance abuse and its many forms
A gateway drug isn’t a basic process of someone starting with, for example, marijuana, and then becoming a heroin user. Psych Central explains that most of the people who develop a serious addiction to drugs have some combination of the risk factors mentioned above, which explains why some people can smoke marijuana, for example, without going on to use other drugs, and some people will feel more inclined to take dangerous risks after lighting up.
It is “the myth that will not die,” says TIME magazine, and an addiction psychiatrist at McLean Hospital in Harvard Medical School told the social news site Reddit that “most [people] who use marijuana do not become addicted to it.”, 
‘A High Risk of Overdose’
Marijuana’s perception as a gateway drug will continue to be debated by advocates and pundits, but there is no doubt in regard to the long-term dangers posed by the saturation and misunderstanding of prescription painkillers. These are drugs that are legally made and distributed, but abused (either unwittingly or with full knowledge). They are so powerful and addictive that they pave a concrete path to experimentation and ruination with harder drugs (in the form of heroin).
How could such a situation arise? John Jay Hoffman, the acting attorney general of New Jersey, shed some light on the issue when his office announced the arrest of Dr. George Beecher of New Providence. Beecher was arrested in December 2015 on charges of writing prescriptions for more than 60,000 oxycodone tablets, for dozens of people he had never met, examined, or treated.
Dr. George Beecher was arrested for prescribing 60,000 oxycodone tablets for dozens of people he had never met
Oxycodone (sold under the brand name OxyContin) isn’t a mere “feel-good” drug; the government warns that oxycodone carries a “high risk of overdose, which can lead to death,” as well as a chance of causing respiratory depression, which can also be fatal.
In a statement released at the time of Beecher’s arrest, acting Attorney General Hoffman said that Beecher (and the six other people charged in a statewide oxycodone ring that created the false prescriptions and distributed the drugs) made the most of the wave of opioid abuse in New Jersey communities, “where users frequently start with the potent pain pills […] and then are sucked into a dark void of addiction, heroin use […] and death.”
Every 19 Minutes
The overprescription of powerful medications – especially opioid pain medications, which have a similar effect on the brain as heroin does – is quite possibly the most serious public health crisis in the country today. The Centers for Disease Control and Prevention warn that the United States is in the throes of an opioid overdose epidemic, which killed over 28,000 people in 2014. At least 50 percent of all the deaths related to the overdose of an opioid were the result of a drug prescribed by a doctor.
The CDC further reports that in 2010, overdoses were the number one cause of injury and death in the US. Between 1999 and 2010, the number of overdoses rose by 102 percent, and of the 38,329 fatalities in 2010, 60 percent involved prescription drugs. Of those deaths, 75 percent were traced back to opioids.
50% of all opioid overdose deaths were the result of a drug prescribed by a doctor
Not all the abuse is from patients frantically seeking relief from their chronic pain. The National Institute on Drug Abuse (NIDA)writes that 1 in 15 people who take prescription opioids for recreational purposes will try heroin within the following 10 years. In 2010, says NIDA, 12 million people (approximately 1 in 20 teens and adults) consumed prescription painkillers without a prescription, simply doing so to enjoy the powerful and chemical sensations of calm and relaxation.
The short-term gains are drastically outweighed by the long-term dangers. Accidental prescription drug overdoses are the leading cause of acute preventable deaths in the United States, killing more people than car accidents. Every 19 minutes, someone overdoses on painkillers.
‘A Drug Dealer in a White Coat’
Grave as the situation is, what makes the matter infinitely worse is the complicity of some people in the medical profession itself. Hospitals & Health Networks magazine, published by the American Hospital Association, writes of how a doctor in Pennsylvania sold oxycodone and other drugs out of his house, making up to $12,000 every week. An internist in Long Island, described by the New York attorney general as a “drug dealer in a white coat,” wrote over $1 million in prescriptions for 5,800 patients. Some of those patients told authorities that the doctor was “too busy” to conduct examinations or ask questions, and was willing to prescribe anything for a personal fee of $300, payable only in cash; other patients claimed that he would go “over the edge to help people.”
While there is an undeniable criminal element to some of the overprescription – another New York internist wrote at least 700 fake oxycodone prescriptions, amounting to 130,000 pills, at a street value of $7 million, for the head of a narcotics ring – it is a matter of willful ignorance for more than a few medical professionals.
An Orange County, California, physician, profiled by the Los Angeles Times in 2012 after losing 14 of his patients to overdoses, refused to accept any responsibility for their deaths. “I don’t allow myself to feel responsible,” he said of patients who abuse the drugs that he prescribes.
Another New York internist wrote at least 700 fake oxycodone prescriptions, amounting to 130,000 pills, at a street value of $7 million
It is possible that some doctors may not even be aware of overprescribing potent (and potentially deadly) medications to vulnerable people, desperate for any kind of relief from their chronic pain. The vice president and director of policy research and analysis at the Center for Alcohol and Substance Abuse at Columbia University points out that doctors tend not to be sufficiently educated about the addiction issues that can arise from their treatments. A great number of physicians do not get training about substance abuse issues during medical school or their residency years. Some are reluctant to bring up the topic of addiction with their patients.
Contributing to the problem is that there are not many trustworthy, robust ways that doctors and medical staff can assess how much pain their patient is truly in; the presence, level, and nature of pain is usually self-reported by the patient, so it is entirely possible for an unscrupulous (or desperate) patient to con physicians. A doctor who is not experienced in dealing with a patient trying to score an extra prescription, or a doctor who is pressed for time and cannot conduct a thorough examination of a patient requesting additional oxycodone, could easily write a prescription that is, ultimately, unnecessary.
Bring everything together, and the United States is very happy to take pills to solve every ailment, medical and imaginary. The Kaiser Family Foundation conducted a survey in 2011 that found that Americans under the age of 18 got an average of 4.1 prescriptions from pharmacies; Americans between the ages of 19 and 64 received an average of 11.9 prescriptions; and Americans older than 65 got an average of 28. Eighty percent of the painkillers in the world are consumed in the United States, even though the country itself accounts for only 5 percent of the world’s population.
A Market for Overprescribing
The sheer imbalance is not very surprising, given the overwhelming influence that the pharmaceutical industry wields. Broadcast media and the Internet run endless cycles of advertisements for prescription drugs. In 2016, an ad aired during the Super Bowl that marketed a drug to help patients struggling with constipation as a result of taking opioid medications was criticized for trying to capitalize on the epidemic of overprescription and overdoses, as the 60-second ad itself reached 111 million viewers and cost $10 million.
But even within medical circles, physicians are constantly told about pharmaceutical solutions to health problems, even when the prescription drugs behind those “solutions” come with a long list of caveats and side effects. The temptation to make tens of thousands of dollars in speaking fees for big drug companies, while promoting those companies’ products by writing prescriptions for them, has raised dozens of questions of medical ethics and conflicts of interest.
The New Gateway Drug
The trend of overprescribing prescription painkillers is a serious issue, but could those substances be thought of as gateway drugs? Yes, says CNN, and it has changed the face of drug addiction in the United States. A generation ago, heroin users were usually low-income people living in urban slums and inner cities. Today, with drugs derived from the same chemical compounds as heroin easily available from a doctor’s office or a family member’s purse or medicine cabinet, heroin users are more likely to live in affluent suburbs.
After reformulation, abuse rates of OxyContin dropped from 35.6 percent to 12.8 percent.
They don’t start with heroin, but they become so accustomed to the increased pain tolerance and blissful euphoria that they get from their oxycodone that they start to take more of their tablets, even though they may know better. When their prescription runs out and they can’t afford any more, they may resort to stealing pills from other people. When that falls through, they buy oxycodone online or from street dealers. And when they can’t afford the medications anymore, they turn to heroin – cheaper, purer, and instantly deadlier.
In 2010, the makers of OxyContin, Purdue Pharma – who, in 2007, agreed to pay $600 million in fines for misleading doctors and patients in claiming that OxyContin was not as likely to be abused as traditional narcotics – reformulated their product so it could not be abused as easily as it had been. Grinding OxyContin tablets into powder for snorting, or dissolving it in water and injecting the liquid directly into the veins, would not cause the same highs any longer. The New England Journal of Medicine found that within two years of the reformulation, abuse rates of OxyContin dropped from 35.6 percent to 12.8 percent. However, the journal also found that heroin use in that same time period almost doubled.
Writing for CNN, Dr. Sanjay Gupta praises the crackdown on opiates, but laments the unintended consequences of what Dr. David A. Kessler, the former commissioner of the US Food and Drug Administration, called “one of the biggest mistakes in modern medicine” in a May 2016 op-ed for The New York Times on “the opioid epidemic we failed to see.”
The biggest of those consequences is that prescription painkillers, like OxyContin, have become gateway drugs to heroin, which sits atop the mountain of dangerous and illegal narcotics.
Heroin Use in New Jersey
New Jersey has a very good view of that mountain. The mortality rate of painkiller overdoses in the Garden State is three times higher than the national average, and climbs as high as seven times in certain parts of the state. More people in New Jersey overdose on heroin than commit suicide, die in car accidents, or are killed as the result of homicides or HIV/AIDS. Thanks to expensive prescription opioids saturating households everywhere, heroin has moved out of the inner cities and made its home in the suburbs., 
Of all the people who seek treatment for substance abuse in New Jersey, 49 percent of them need help as a result of heroin and painkiller abuse.
That’s enough of a population to make up the fourth largest city in New Jersey, a hypothetical dystopia NJ.com calls “Herointown,” populated not by uneducated low-income people of color hanging out on street corners and back alleys, but by rich, white, well-educated people who make their drug purchases online.
The prosecutor of Monmouth County says that the ease with which prescription painkillers can be obtained is the single biggest contributor to the heroin abuse that has gripped New Jersey. The drug has become economically preferable to getting prescriptions for OxyContin or Vicodin, since at $5, a bag of heroin is less expensive than a meal at McDonald’s.
More than 700 New Jersey residents died as a result of overdosing on prescription medications in 2011 and 2012, according to the New Jersey assistant state medical examiner. By comparison, Hurricane Sandy claimed 37 lives in 2012.
Deaths as a result of oxycodone use come second behind the number of deaths that result from heroin abuse. Eighty-seven percent of the oxycodone victims were white, and 66 percent were male.
Doctors find themselves in the unenviable position of weighing whether or not to prescribe highly addictive substances to clients in severe physical distress. The director of pain management at a rehabilitation facility noted that to deny patients medication is to leave people in a state where “they want to die every day.”
Nonetheless, the pharmaceutical industry is troublingly big in New Jersey. NJ Spotlight reports that Medicare recipients in the Garden State are more likely to be prescribed name-brand drugs over simple generics than any other state. This result is that doctors in New Jersey are leading the trend of “wasteful overprescribing” of products manufactured and distributed by big pharmaceutical companies.
A law professor at Rutgers University-Camden was concerned that New Jersey used more brand-name drugs than any other state in the country. The difference between name-brand drugs and their generic counterparts is not a matter of chemistry or quality, explains Scientific American, but whether the drug is still under patent protection by the company that originally developed it. To a consumer, it’s an issue of price.
While the national average of prescribing brand-name medication is 21.2 percent, 28 percent of New Jersey residents receive products that are exclusive to the manufacturer.
The Rutgers-Camden professor notes that brand-name drugs tend to be significantly more expensive than generics. Generics can sometimes do just as good a job as the brand-name medications in serving patients, but the companies producing generics do not have the clout or financial influence to push their products that the manufacturers of brand-name medications do. And the professor points out that “with a lot of the pharmaceutical industry set in New Jersey,” that might explain why New Jersey doctors prescribe brand-name drugs as much as they do. More prescriptions, more use; more use, more dependence; more dependence, the higher the likelihood of being compelled to seek out more, or other, drugs.
‘In Their Pocket’
According to NJ Spotlight , an internal medicine doctor in Union City, whose orders for brand-name pharmaceuticals amounted to 42 percent of his total prescriptions; the average in New Jersey is just 28 percent. That same doctor received $8,500 in speaking fees from the company producing the medication he prescribed and ranked fifth in the country for doctors who prescribed the drug. He further received $28,050 from another company for using their products and was seventh in the country for doing so.
Some New Jersey doctors are trying to go against the current. One, in Millville, only prescribed 16 percent of brand-name drugs to his patients, preferring generics wherever possible. However, he tells NJ Spotlight that pharmaceutical companies are so aggressive in their marketing to consumers that patients frequently pressure doctors to give them brand-name medications despite the risks.
Those companies “have the government and the regulators in their pocket,” the doctor says, suggesting that New Jersey’s position as the leading brand-name prescribing state in the country is unlikely to change.
The Purity Problem
At a 2013 conference on the effects of the opioid epidemic in New Jersey, the first assistant attorney general pointed out that 40 state residents die every day as a result of overdoses, and 728 people lost their lives in 2012. Sussex County lost 12 people from overdosing on heroin, prescription drugs, or a combination of both, which is another problem confronting officials.
In addition to the presence of pharmaceutical companies that can lean on doctors and patients to demand, prescribe, buy, and use brand-name drugs, New Jersey also suffers from having some of the most chemically pure heroin in the country, putting it at the center of a narcotics distribution network. The heroin found in Newark is 50 percent pure; San Antonio, on the other hand, has heroin of merely 8.7 percent purity. The strength of the heroin leads to addictions that take hold much faster than anywhere else in the country.
The heroin found in Newark is 50 percent pure; San Antonio, on the other hand, has heroin of merely 8.7 percent purity.
New Jersey’s strategic coastal location, dense population, and access to major cities like New York City, Baltimore, and Philadelphia make it a very attractive target to smugglers and distributors. The product originates in Colombia and makes its way to New Jersey through highways, airways, and the ports systems. In Paterson, bags of heroin are sold for just $3.
But the main reason that such a thriving market exists can be traced to the environment that pharmaceutical companies have helped create. At the conference, the Sussex County prosecutor said that his office has investigated burglaries where the perpetrators ignored money and valuables, and instead made off with the prescription drugs in medicine cabinets. Teenagers, who see commercials for brand-name drugs on every medium, believe that there is no harm in recreationally abusing medications with familiar names like Percocet, Vicodin, or OxyContin, which they may be compelled to do by peer pressure, stress, or after consuming alcohol or marijuana.
At the conference, a woman described the fate of her sister-in-law, a former resident of Warren County, who was prescribed Xanax, oxycodone, oxymorphone, Flexeril, Cymbalta, and Benadryl by five doctors in two states. She overdosed in December 2012. In the ten months before her death, she had been written 140 prescriptions for literally thousands of pills from 68 different doctors.
The Battle of New Jersey
According to Pacific Science magazine, there are numerous organizations, like the Centers for Disease Control, the Food and Drug Administration, and nonprofits and medical advocacy groups, that are doing what they can to try and stem the flow of prescription painkillers becoming the new gateway drug to heroin use. But much remains to be done; the president of the American Medical Association tells the Huffington Post that doctors are on the front lines of a war that is crippling communities across the country.
In New Jersey, where pharmaceutical companies have tens of millions of dollars to spend on selling their products to doctors and patients, and where the heroin is better than anywhere else in the country, the battle is going to be a long one.