Overdoses have now passed car crashes and gun violence to become the leading cause of death for Americans under 55. The epidemic has killed more people than H.I.V. at the peak of that disease, and its death toll exceeds those of the wars in Vietnam and Iraq combined. Funerals for young people have become common. Every 11 minutes, another life is lost.
So why do so many people start using these drugs? Why don’t they stop?
Some people are more susceptible to addiction than others. But nobody is immune. For many, opioids like heroin entice by bestowing an immediate sense of tranquility, only to trap the user in a vicious cycle that essentially rewires the brain.
Getting hooked is nobody’s plan. Some turn to heroin because prescription painkillers are tough to get. Fentanyl, which is 50 times more potent than heroin, has snaked its way into other drugs like cocaine, Xanax and MDMA, widening the epidemic.
To understand what goes through the minds and bodies of opioid users, The New York Times spent months interviewing users, family members and addiction experts. Using their insights, we created a visual representation of how the strong lure of these powerful drugs can hijack the brain.
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YOU NATURALLY PRODUCE ENDORPHINS, the body’s own version of opioids, which act in the reward circuits of the brain to make you feel good after you work out, hug a friend or eat your favorite foods.
A drug like heroin creates a tidal wave in the reward circuits of the brain. To an outsider, it looks as though you have passed out. But on the inside you feel like a master of the universe, like you’re being “hugged by Jesus,” as one user said; there’s peace in your skin and not a single feeling of pain.
You may remember this exact moment for years to come: where you were, what you wore, what you saw and what you heard. You may chase this feeling for years.
As the high wears off, the brain regains its balance – but not for everyone. That’s the opioid trap for many people: In the beginning, no serious ill effects are apparent. But the brain rewires little by little with each use.
YOU’RE CHASING THE SIREN
Even a thousand more doses will never bring back the experience of that first time. The brain balances its own endorphins like a thermostat. When an external source keeps flooding the brain, it throws that system off.
Like other drugs, opioids produce a surge of dopamine, a chemical messenger that tells the brain that “taking this drug is good, repeat it.” The brain’s response to opioids and the surges in dopamine they cause can rewire circuits in the brain.
The brain’s response to these chemical changes make life difficult without the drug. Stress and irritability creep in, so you take more opioids to cope. Soon, nothing else in life provides any satisfaction.
The pleasure and reward cycles flip: You get less pleasure from the drug, but want it all the more. The more you seek and take the drug, the more the brain adapts to the drug and demands more.
THE FINAL TRAP
You may not even realize you are physically dependent until you experience withdrawal for the first time.
There might be crippling pain, vomiting, insomnia, spasms, hot and cold flashes, goosebumps, congestion and tears. All this on top of debilitating anxiety and depression. You might feel like you’re having the worst flu of your life, or like a demon is crawling out of your skin.
This misery could last for weeks.
Dying from withdrawal is uncommon, but it doesn’t feel that way at the time. These harsh symptoms can make quitting seem impossible.
THE BRAIN SCREAMS
Scoring the next fix feels like a race against the clock of withdrawal. You may feel like only a fix can save you. It makes no sense, but this compulsion takes over all logic, judgment and self-interest. You may do things you never thought you could.
Sell your body. Abandon your child. Steal from your mother. You might lose your job. Lose your home. Lose your loved ones. In this sad stage, families are torn apart.
Sharing needles can make things even worse, and bring about hepatitis and H.I.V.
A shadow of your former self lives in shame.
You’re now addicted to opioids and you no longer take the drug to get high, but to escape feeling low. The brain has adopted a new form of compulsion that can reassert itself even after years of sobriety.
YOU HIT ROCK BOTTOM
Perhaps after a run-in with the law. You fear withdrawal. You dread confronting why you started and who you have become. Willpower alone may not be enough, and quitting cold turkey could increase the risk of overdose.
You may not have access to treatment. You may not be able to afford it. Or you’ve heard that quitting is impossible and that taking medication to help is simply swapping one drug for another.
Treatment centers that promote abstinence are at odds with the medical standard of care — long-term use of medications, like buprenorphine, methadone and naltrexone. But only about 25 percent of outpatient centers provide them.
These medications soften the cravings without causing euphoria. They help reset the brain’s thermostat, so it can stop thinking about opioids 24/7 and the hard work of recovery can begin.
Every person is different, and underlying issues, such as mental health problems, can affect a treatment plan. But therapy and community help increase the chances you stick with it.
RELAPSE IS A NORMAL
After abstaining from the drug, your tolerance decreases even if the cravings remain intense. The same amount of the drug that you took before can result in overdose, especially if it’s laced with fentanyl or mixed with benzodiazepines and alcohol.
In an overdose, your body is unable to handle the drug and your breathing slows or stops.
Seventy-seven percent of opioid overdose deaths occur outside medical settings, and more than half occur at home. This year, the surgeon general advised Americans to carry naloxone, a life-saving medication to resuscitate victims.
Once revived, you may feel anger and shame, or face stigma and judgment, which can fuel the cycle.
For the families of those who are addicted, life has become a rollercoaster ride.
RECOVERY IS COMPLICATED
Experts say treatment could require six months to 20 years. One expert says the average person could relapse four or five times over eight years to achieve a single year of sobriety.
Some people may have to remain on medications indefinitely; for others, a doctor may taper them off. But doctors don’t know when the brain has reset itself and is no longer at high risk for substance use.
Factors like health insurance, housing and income can determine how long you remain on medication. Like a child, you also need to learn new behaviors and rebuild your life. It’s a journey to accept, control and heal the feelings that led to addiction.
Only one in five people who need treatment for drug use actually receive care, and only about half of those are given medication, experts say. Those given medications rarely receive them for long enough.
Whether the nation’s healthcare system and society can catch up to the opioid crisis remains to be seen. People can recover and lead meaningful and happy lives again, even if medication is required indefinitely.