from the ashes

addiction and recovery in the ocean state

The road to Phoenix House begins in a field tucked away on a steep mountainside somewhere in Colombia. That’s where farmers grow bright red opium poppies, away from the watchful eyes of government soldiers and even the occasional DEA agent. Painstakingly, over the course of several weeks, they extract opium sap from the plants’ green seed pods by cutting them with razors. They sell the dried sap, rolled into little brown balls, to cartel employees, who cook the sap in vinegar-smelling acetic anhydride. The mixture is then dried into a white powder or stirred into a thick paste (though this step might happen later in the manufacturing process). It’s ready to begin its journey north, through Central America, to Mexico, and eventually, by way of the American Southwest and New York City, all the way to Rhode Island.

In the month of February alone, the Rhode Island Department of Health reported 21 accidental drug overdoses, the majority of them a result of heroin use; in the same month, Rhode Island EMS workers administered 112 doses of naloxone (sold and marketed as Narcan), a drug to reverse heroin and opiate overdoses. The heroin epidemic in Rhode Island and around the country has garnered attention from state legislators to United States senators, to national media outlets.

And then there are those on the ground level who work every day to clean up the damage.

***

Phoenix House—a nonprofit treatment provider—operates over 130 programs in a total of nine states (as well as the District of Columbia). They provide care for recovering drug and alcohol addicts, from their first steps in detox to recovery support, with the eventual goal of reacclimating—or, in some cases, acclimating for the first time—former addicts to a functional adult life. In Rhode Island, most of Phoenix House’s activity is in Exeter, a town of about 6,000 people a half hour drive drive down I-95 from Providence, just north of URI. Their Exeter facility contains a residential as well as a detox program for recovering addicts. Additionally, Phoenix House also offers services in Providence: outpatient services, assistance for youths involved with the Rhode Island Juvenile Drug Court, and, east on Waterman Street near Wayland Square, the Ottmar Residential Center—a women-only facility.

I spoke with Fred Trapassi, Jr., the vice president of Rhode Island Programming for Phoenix House, on the phone. Trapassi speaks with a not-overwhelming but noticeable Rhode Island accent, a testament to his upbringing and the subsequent years spent helping at-risk youths on the streets of Providence and wherever else in the state people need help fighting their personal demons. Trapassi saw the casualties of heroin use from an early age: friends dying from overdoses, in drug disputes, and, in the 1980s, from undiagnosed HIV/AIDS. “That’s really what got me on the road to looking at people who were struggling with addiction,” he said. “Attempting to get [them] into treatment programs at the time, there wasn’t really a lot available to them in Rhode Island.” In his late twenties, Trapassi started working for the Travelers Aid Society of Rhode Island (now Crossroads Rhode Island), a homeless service organization, through Volunteers in Service to America (VISTA). In 2000, he joined Phoenix House. Eight or nine years ago—Trapassi doesn’t remember, exactly—he started in his current position as VP for Rhode Island Operations.

His time with VISTA informs every aspect of Trapassi’s work today. He is a firm believer in Phoenix House’s philosophy of a “holistic approach,” having seen the incessant head-butting of mental health professionals and addiction specialists. He recalls arguments over whether someone’s bipolar disorder or cocaine habit needed to be addressed first. More often than not in these cases, the answer is to treat both simultaneously. “It really wasn’t looked at together,” he said. Over time, that has become clearer to caseworkers and therapists. “Thank God a lot of that has changed, almost all of that has changed. People realize that probably 70-75 percent of the substance-abusing population have co-occurring mental health issues.” By looking at the whole person, Phoenix House workers aim to help patients from a number of different angles: addiction counseling, psychological and psychiatric treatment, and in day-to-day areas of life like finding and keeping gainful employment. “How do you interview, write a resume, if you haven’t had a job in 10 years?” Trapassi gave as an example of the type of obstacles recovering addicts find themselves up against.

Trapassi’s years of experience also reveal themselves in more subtle ways. He speaks clearly and cogently, but also patiently and compassionately—like he truly wants you to understand. Listening to him, it’s not hard to imagine Trapassi talking to a 16-year-old a few days out from an overdose, explaining to them that help is there if they need it, laying out exactly what the next few months will look like—a difficult journey, but one they won’t be walking alone or without support.

***

Once it gets to Mexico, the raw heroin is usually cut for the first time—though not the last time—before it reaches its consumers. Lately, the cutting agent of choice has been fentanyl, an extremely powerful painkiller typically reserved for cancer patients or anyone who has become physically tolerant to opiates like Percocet or Vicodin or Oxycodone. It is approximately 100 times more powerful than morphine, and 30-50 times more powerful than heroin. Even low doses—as little as 0.25 mg, about the size of a quarter of a grain of sand—of fentanyl can be fatal, and not only to heroin users.

On March 18, the DEA issued a “Nationwide Alert on Fentanyl as Threat to Health and Public Safety” which warned, among other things, that fentanyl “can be absorbed through the skin” or accidentally inhaled, meaning law enforcement officials or anyone else that comes into contact with the compound is at risk. When heroin users, who rarely if ever come into contact with heroin in its pure form, overdose, fentanyl is often responsible. Of the 27 accidental overdose-related deaths in Rhode Island this year (as of February 13, 2015), 19 involved fentanyl.

The mixture continues moving north.

***

“They’ve truly hit rock bottom by the time they come to us.” Trapassi was talking about the people who eventually find themselves at a Phoenix House facility. This might come after an overdose, loss of employment, on the recommendation of a judge in a drug court (though no one is ever required to go to Phoenix House specifically—everyone who enters one of their programs does so on a voluntary basis and “can’t be court-ordered into a particular program”), after some time behind bars, or simply when enough is enough. In some cases, Phoenix House residents in their teens and twenties find themselves cut off from their parents, often after stealing from them. “It doesn’t mean they don’t love them anymore,” Trapassi explained. “They just can’t have them around because of that collateral damage that so many people who are addicted to drugs and alcohol create. They wreak so much havoc in the lives of the people around them who love them and care about them.”

Of course, there are many cases in which addicts have burned their bridges completely with family, friends, and former romantic partners—or never had a social support structure to begin with. The goal of Phoenix House’s programs is to rebuild those bridges. “Our mission,” as Trapassi put it, “is to help people not only achieve recovery, as important as that is, but it’s also to get their lives back.” This can be a lengthy process. “Not everyone can go from being a drug addict to an alcoholic to being drug free.” Residents have the option of receiving what is known as “medical-assisted therapy,” meaning they wean themselves off of their drug of choice with a substitute like methadone—though some quit without it. They relearn basic social skills, from job interview advice to how to have a relationship that isn’t centered around drugs or alcohol. Trapassi acknowledges that these may not seem like difficult tasks to someone looking in from the outside. His counter to that is that many residents are coming out of years of deep drug use, and in instances where residents grew up in abusive or otherwise turbulent environments, never learned basic social skills that we take for granted. Staffers expect that residents “are going to try to play [them].” The goal is not only to get them off of heroin or their drug of choice, but to restructure their cognitive outlook on the world in general.

With the goal of lasting rehabilitation—or, in some cases, “habilitation”—in mind, Phoenix House offers programs “along the entire treatment continuum” and for all age groups. From the initial detox, to recovery, to reintegration into society, patients don’t have to leave the Phoenix House orbit, giving them a level of comfort they may not get in other programs. Some Phoenix House alums, especially recovering veterans, live in Phoenix House residential communities long after they’ve become drug free. This also helps address one of the many unfortunate realities of drug addiction: Relapse is common. Staffers and upper-level management recognize that relapse is “part of the disease” of addiction, and while obviously an active user can’t continue to live in a Phoenix House community, generally speaking if someone relapses and comes asking for help, they’re welcomed back into whatever level of care is appropriate. Discharge is a “last resort,” as Trapassi put it. Short of an egregious offense like physical assault or bringing drugs into the program and sharing them with other residents, the transgressions of those who are accepted into Phoenix House are forgiven.

And then there are cases where someone enters a Phoenix House program, and a day later says, “I’m out of here.” It could be because they owe someone money or they want the free day of detox—regardless of the reason behind it, people leave AMA (against medical advice) all the time. But for those who stay, when they act poorly—and it is all but guaranteed that at some point in the recovery process, they will—the Phoenix House reaction is to care for them, let them know what they did wrong and why it’s wrong, and move on. It’s about helping residents live normal lives. “How do you recapture that, and once you’ve recaptured it, how do you maintain it?” is how Trapassi sums it up.

***

There are a number of ways for heroin to cross the U.S.-Mexico border. It can be hidden in the wheel well of a car, on someone’s body, or in someone’s body. Law enforcement officials have even found well-ventilated underground tunnels going across the border. A drug runner arrives from New York City, a little over 2,000 miles away, to pick up the shipment, then turns around and drives all the way back. He delivers it to a stash house somewhere in the far reaches of the Bronx, or Queens, or Harlem—far from the gleaming avenues of Midtown and lower Manhattan. At this stage, it almost definitely gets cut, or “stepped on,” again. It probably won’t be cut with anything as powerful as fentanyl this time, but more likely chalk, talcum powder, or even dirt if it’s black heroin.

The heroin mixture gets transported to smaller, regional stash houses in places like New Haven, Portland, and Providence. Law enforcement officials have also found stash houses in smaller cities like Warwick and Cranston, and even in many rural communities. The heroin gets stepped on one more time, for good measure, and to stretch the supply as far as possible. Once the drug is distributed to street-level dealers, it gets sold in a number of ways: in houses, supermarket parking lots, even bus stations.

If a heroin user isn’t expecting a package to be cut with fentanyl—which, for the most part, they don’t—they’ll be surprised when they inject the drug that instead of the slow, pleasant feeling of euphoria that they associate with shooting up, they’ll feel a terrifying rush that can knock them unconscious and, in some cases, stop their breath. If someone finds them in time, they can call 911 and hope emergency responders get there quickly enough, or administer Narcan via an injection in the upper thigh or a nasal spray. The drug counteracts the effects of an opiate overdose and can get the user breathing again.

There are a lot of “ifs.” If they live alone, or no one finds them for a few hours, or whoever finds them doesn’t have Narcan on hand and is too scared to call the police or 911, their odds of getting through the ordeal quickly diminish.

***

Trapassi had only good things to say about Rhode Island’s response to its heroin crisis, calling it “fantastic.” As of last year, State Police officers are required to carry Narcan at all times and are trained in administering the drug, as are all EMTs in the state, including those at Brown. There have even been Narcan training sessions at the State Capitol. While this may sound like an obvious step, compare the situation in Rhode Island to that of a city like Baltimore: though one out of every 10 Baltimore city residents is considered a user of heroin, city police officers are often too afraid of a liability suit to administer Narcan, and are awaiting passage of a bill by the Maryland State Legislature expressly authorizing them to do so. In addition to the State Police, Trapassi has also found judges in the state judicial system to be well-educated when it comes to addiction treatment. “When it comes to drug addiction,” he said, “a lot of times remanding them into treatment is far better than incarcerating them.” Given the high rates of relapse among incarcerated addicts once they’re released from prison, it’s a sensible as well as a compassionate approach.

Getting medical insurance companies to cover more extensive addiction treatment programs (“Most people are lucky if they get 30 days”) is a critical change, though Trapassi named education and changing our mentality about addiction as the top priorities in combating Rhode Island’s—and New England’s—heroin problem. Phoenix House’s new detox facility in Quincy, Mass. was due to open on a Monday, with 64 open beds. Trapassi expected every one would be full by the end of the week. “It’s clearly become an issue beyond anything I’ve ever seen,” he said with a tone of sadness. The addicts coming into detox are getting younger and younger, he said. None of them expected to end up there.

“They didn’t wake up one morning and say, ‘I want to be a drug addict.’” They’re not “scumbags.” Trapassi asks all of us to remember one thing: “I don’t think that there’s a family in this country that has not been touched in some way by alcohol or drug abuse. Those are all people who were loved, are loved. The people that you meet on the street … that come into treatment, aren’t any different.” The Phoenix House way is to look at addicts as who they once were, or who they might become. When I asked Trapassi about the philosophy of Phoenix House, he responded: “Our philosophy is to reclaim disordered lives.”