'Dope-sick' addicts spreading disease, danger

Editor's Note: This is the second part of a three-part series the Courier-Journal is publishing on the growing scourge of heroin in our community. The first report took a look at its devastating effects on children. Next Sunday, we will share the stories of families seeking solace and support as they struggle with the aftermath of addiction. 

The needle brought euphoria, numbness – and disease. But to Brett, the consequences could not match his craving for the needle, for heroin.

Despite the dangers, he shot up – fueling his addiction.

After repeatedly sharing syringes with other addicts, the 30-year-old recovering addict from Louisville must now live with hepatitis C.

“There’s this insanity that goes with addiction," Brett said. "I pretty much wanted to die. I had no self-esteem."

"I was dope-sick."

Thousands of area addicts suffer the same fate. This region of the country – one of the hardest hit by intravenous heroin and painkiller abuse – is being ravaged by the diseases that follow in their wake: hepatitis and HIV. These dangers also reach far beyond addicts and their families, threatening a wide swath of the population.

A drug-fueled HIV outbreak in Southern Indiana struck 191 people last year, giving its epicenter, Austin, a higher incidence of the virus that causes AIDS than any country in sub-Saharan Africa. According to a subsequent report by the U.S. Centers for Disease Control and Prevention, 220 U.S. counties are at high risk for a similarly rapid spread of HIV and hepatitis C among drug users. About a quarter of those counties – 54 – are in Kentucky.

Other recent CDC research shows hepatitis, an insidious liver disease, is already skyrocketing in the region.

Acute hepatitis B rose 114 percent in Kentucky, Tennessee and West Virginia from 2009-2013, even as incidence remained stable nationally, according to one study. According to another study, the rate of new hepatitis C cases among people 30 and younger more than tripled from 2006-2012 in Kentucky, Tennessee, Virginia and West Virginia. More recently, cases of acute hepatitis B and C in Kentucky reached 281 last year, up from 120 in 2003. Cases in Indiana reached 243 in 2014, the latest year for which numbers are available there.

Heroin Resource Guide: Local places to get help

Health experts worry the region could be a harbinger for the nation as the opioid epidemic grows. Dr. Nora Volkow, director of the National Institute on Drug Abuse, said hepatitis C is now the No. 1 cause of death from reportable infectious diseases nationally, and Southern Indiana’s HIV outbreak “was a wake-up call” about that virus for communities across America.

Dr. William Cooke, a physician at Foundations Family Medicine in Austin who treats dozens of patients with HIV and hepatitis, said many communities are ill-equipped to handle the threat. All over the region and nation, he said, there’s too little substance abuse treatment, too little emphasis on the poverty that often accompanies addiction and too little compassion.

“(Austin) has a rural, impoverished, drug-using population. There are places all across America that look like this …Other places are at the same risk,” Cooke said. “The lesson in Austin is we can’t ignore people … If we let a group of people struggle and don’t help them, it affects all of us.”

From addict to liver patient

Brett grew up in Bullitt County; he grew up in a middle-class family. Addiction and illness wasn't part of his plan.

But he grew into it.

Like many of his peers, Brett began drinking alcohol and smoking pot as a young teenager. After trying pain pills in high school, he abused them on and off in early adulthood, eventually favoring Opana as his drug of choice. But when Kentucky cracked down on prescription drug abuse, he said, Opana became difficult to get and very expensive. Heroin was a quarter of the price or less, and widely available on the street.

“I stopped doing Opanas and started doing heroin,” Brett said, who didn’t want his last name used because of the stigma surrounding hepatitis C and drug abuse. “At first, I was just trying to get an opiate fix. But once I started doing heroin, it was about getting heroin.”

Snorting the drug would delay its effect, so he chose to shoot up. Soon the quest to get high gave way to a quest to just feel normal and stave off withdrawal.

Brett knew about the dangers of blood-borne diseases, and at first did what he could to avoid them. He bought own needles every day. But eventually, he stopped caring. Contracting diseases did not concern him anymore, but instead, warned others who wanted to share needles:  “I probably have hepatitis C.”

His lowest point came in spring 2014, when he was living with his mom. Brett said he went into the bathroom to shoot up and passed out on the toilet from an overdose. An emergency worker revived him with naloxone in an ambulance on the way to the emergency room.

Brett’s mom urged him to get help, which he sought at the Jefferson Alcohol and Drug Abuse Center a few days after his overdose. While there, he had an HIV test that came back negative. It wasn’t until that fall that he finally got tested for hepatitis.

“Until then, I didn’t want to get tested because I wanted to keep the possibility of doubt,” he said. “I knew there was a 98 percent chance that I had it. But I still remember being in shock, almost, when I heard that I actually did. It was a heavy thing.”

Now two years sober, Brett has been seeing a doctor who specializes in hepatitis, getting regular blood tests and trying to live a healthy life to keep the disease from progressing. Brett’s doctor last year wrote him a prescription for a medication called Harvoni that can potentially cure the disease. But it costs more than $1,000 a pill and his Medicaid managed care plan denied it.

Brett, who now lives with his girlfriend in Old Louisville and works in a restaurant, hopes to someday get access to one of the new, curative hepatitis drugs. But in the meantime, he tries to eat healthy meals and get lots of exercise, often riding his bike around the city. He also takes care not to spread hepatitis to his girlfriend, who has tested negative so far. Doctors say the disease is usually spread through contact with blood but can infrequently be spread through sex as well.

Although Brett doesn’t notice any symptoms now, he knows his disease puts him at risk for all sorts of liver problems. Up to 70 percent of hepatitis C patients will go on to develop chronic liver disease, according to the CDC. Up to 20 percent will eventually develop cirrhosis, and up to 5 percent will die of cirrhosis or liver cancer. Brett said he’s constantly aware of these dangers and why he faces them.

“This is something I did to myself."

A widening danger

While casual contact like hugging can’t spread hepatitis or HIV, risky drug use, sex and any exposure to infected blood can.

“So really,” Cooke said, “everyone is at risk.”

“It threatens our first responders. They have to constantly be on guard about needle sticks,” Van Ingram, executive director of the Kentucky Office of Drug Control Policy, said. “The general public at large is more at risk when any disease rates rise” as quickly as they have in this region.

The diseases spread in various ways. HIV – which can be transmitted through semen and other bodily fluids in addition to blood – is mainly spread by having unprotected vaginal or anal sex with someone who has HIV, or sharing used needles, which can harbor live viruses for up to 42 days. But it also can be transmitted to health care workers by needle sticks, or from mother to child during pregnancy, birth or breastfeeding, especially if the mom isn't taking medicine.

Hepatitis B and C, which are caused by separate viruses, are easier to catch than HIV because there are higher levels of virus in the blood. Hepatitis B is more often contracted through sex or accidental needle sticks than hepatitis C, but both types are commonly spread by sharing tainted needles.

During the Southern Indiana outbreak, which was mostly tied to injecting Opana, Cooke said nearly 600 people were found to have hepatitis C, three times the number who contracted HIV.

In other places with high levels of IV drug abuse, such as Appalachian Kentucky, HIV has not taken hold. But CDC Director Dr. Thomas Frieden said “all it took was one person with HIV coming in” to start Indiana’s worst-ever outbreak, and the same thing could easily happen elsewhere.

Addicts may also be spreading both diseases without knowing it. Up to three in four people with hepatitis C, and one in eight with HIV, don’t know they have it, experts say.

“Hepatitis C is called the silent killer. People tend to be symptom-free until very late,” Thomas Nealon, chief executive officer of the American Liver Foundation, said. “There should be a national mission to test people.”

But when it comes to addicts, there’s another complication: their constant drive to get high means many don’t try hard to avoid getting sick – or get regular medical care.

Like Brett, recovering heroin addict Kevin Murphy of Louisville said he was only concerned about his next fix when he was in the throes of his addiction. He figured if he contracted hepatitis by sharing a needle, “so be it.”

And he did.

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Stopping the spread

Communities are trying to control these drug-fueled diseases, but it hasn’t been easy.

Louisville, Lexington and Austin are among the cities that have started syringe exchange programs, where addicts can trade dirty needles for clean ones. And health officials expect more to pop up now that Congress has effectively lifted the nation’s long-standing ban on federal funding for such programs. Though the money still can’t be used for the syringes themselves, it can now go toward costlier expenses such as staff, vans and substance abuse counseling.

Locally, a Kentucky law passed last year gave communities the authority to start needle exchanges, and Indiana began allowing counties with drug-related epidemics of HIV or hepatitis C to request public health emergency declarations, paving the way for syringe exchanges there. Recently, Indiana’s public health commissioner extended the declaration for Scott County until next May, meaning Austin can continue its program for another year.

Officials say needle exchanges are an important part of a comprehensive strategy to control disease.

“We need every tool we can get,” Ingram said, “and a syringe exchange is a good tool.”

But critics argue these programs enable drug use, and many area residents reject the idea of using public money to fund them. So the prospect of more syringe exchanges in the region remains uncertain.

Also uncertain is the prospect of more treatment for drug addiction and the diseases it spawns.

Doctors say there’s not nearly enough substance abuse treatment locally or nationally, especially in rural areas. In Scott County, Cooke said, some people try to treat their addictions with Suboxone they buy on the streets.

“It’s frustrating,” he said. “These people want help. They’re asking for help.”

Meanwhile, many patients living with drug-related viruses can’t get the medications they need either. Insurers are generally good about covering HIV treatment, Cooke said, but not so good about paying for the new, high-priced hepatitis C drugs even though untreated hepatitis can lead to expensive problems down the road.

“You generally go basically from a healthy liver to a scarred liver before they treat it,” he said. “How is that OK?”

Nealon said the story is similar across the nation, and he shares Cooke's outrage.

“Here we have a disease that’s incredibly contagious. We can cure it. But with Medicaid in particular, there’s a remarkable series of hurdles they have to get past,” Nealon said. “We’re sentencing people to a life of misery.”

Still, providing better access to medicines is only part of the answer, Cooke said. Solving the drug abuse crisis, he said, will require attacking its root causes, such as poverty, unemployment, unstable housing and lack of education.

“Until those things are really addressed, it may not be HIV or hepatitis C, but it’s going to be overdoses or something else,” he said. “That’s just not the way we should let our neighbors live. We have a higher responsibility to them.”

Reporter Laura Ungar, who also covers health for USA TODAY, can be reached at (502) 582-7190 or lungar@courier-journal.com.