Washington, DC, September 11, 2018 --  

Heroin is being pushed out of big cities in favor of synthetic opioids popularized in the suburbs.

The food court at Washington's Union Station is a place where two worlds come together. Busloads of teenage tourists on school trips from suburbs and small towns around the country swarm the eateries at lunch time, lining up for burgers and nachos using meal vouchers distributed by tour operators. Wandering amongst these crowds are dozens of urban panhandlers, relentlessly asking the naive visitors to "spare some change" or "help me get something to eat."

The young, mostly-white tourists often wear clothes with small-town high school logos and don the red Make America Great Again caps sold both around Washington's tourist sights and in the food court itself. The panhandlers are mostly middle-aged black men with dirty clothes and hair, glassy eyes and a dazed look on their faces that suggests food is not the only purpose of the money they seek. Pocket change is not the only thing migrating from suburban communities to urban ones. As this daily dance can attest, the opioid crisis has spread to the urban core.

But the opioid problem in Washington is markedly different than the one in suburban and rural areas where it originated. Outside the city, addictions are often derived from prescription drugs used to treat pain, whereas in the city, heroin dealers have driven the trend by cutting heroin with cheaper synthetic opioids or selling synthetics outright. While an individual dose of heroin and fentanyl may cost the same on the street, fentanyl is much more profitable since it is extremely potent and a small amount of raw product can be heavily diluted and still give a stronger high. Likely for this reason, it has steadily taken over the market, surpassing heroin in opioid DC overdose cases for the first time in 2017.¹

The synthetics have exacerbated addiction problems in Washington. Drug treatment clinics offer Suboxone and Methadone to sate cravings.² But recovering addicts often fall off the wagon and begin using again -- now with stronger modern synthetics that make the consequences of a relapse more severe. Because the drug is often imperfectly diluted with amateur equipment, individual doses can be lethally potent. In 2017, there were a record 246 deaths in Washington DC due to drug overdoses from opioids, the doses most commonly contained fentanyl but also other synthetics like U-47700, carfentanil and butyryl fentanyl.³

First responders in Washington are well armed with nalaxone. The drug comes as a nasal spray which can be used to administer it to unresponsive addicts with labored breathing until they can be transported to a hospital for further treatment.⁴ Ambulances are a nearly constant presence at Union Station, which is surrounded on the north and west sides by tent camps where homeless Washingtonians take refuge night and day. For those who fear a future overdose by loved ones, a brand name version of nalaxone called Narcan can be bought at the pharmacy counters of Walgreens, one of which is conveniently just off the food court in Union Station.⁵

Treatment drugs are not without controversy -- both the nalaxone used to treat overdoses and the Suboxone used to sate the cravings of recovering addicts. Critics say that nalaxone encourages addicts to take riskier doses of opioids for a more intense high, safer in the knowledge that friends or family can save them from an overdose by administering nalaxone if needed.⁶ In the case of Suboxone and Methadone, critics say doctors are just selling addicts a substitute drug with a less intense high. Other critics charge that both of these these drugs enrich pharmaceutical manufacturers who are largely responsible for the opioid crisis.⁷ It's the drug companies, of course, who created the problem through widespread manufacture and aggressive marketing of synthetic opioids over the past decade.

But if the streets of Washington DC are any indication, simply doing nothing is not an option. It's not just the food court at Union Station with glassy-eyed panhandlers. There are also sidewalks covered with unconscious people in front of the 7-Eleven in the Barracks Row neighborhood, in front of the main post office on North Capitol Street, and along the paths in Franklin Park downtown.

A generation ago, during the epidemic of crack cocaine, it was only urban areas where hard-core addicts were regularly visible, making it easier for the majority of Americans living outside urban settings to dismiss it as a problem of the inner city. If there can be a blessing associated with something so awful as an epidemic of addiction, it's that it is experienced across the country, making the misery of urban addicts harder to ignore.

Notes:

1. DC Office of the Chief Medical Examiner, Opioid-related Fatal Overdoses, January 22, 2018

2. National Public Radio, The Opioid Crisis Is Surging In Black, Urban Communities, March 8, 2018

3. DC Office of the Chief Medical Examiner, ibid

4. DC Policy Center, How the D.C. Region is Responding to the Opioid Crisis, April 30, 2018

5. National Public Radio, Narcan Opioid Overdose Spray Is Now Stocked By All Walgreens Pharmacies, October 26, 2017

6. Doleac, Jennifer L. and Mukherjee, Anita, The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime, March 6, 2018

7. DC Policy Center, Ibid.