The Signs and Story of One in Four

By: Ashley Barton, Student at Wake Forest University School of Law

Photo by Sarah White

Anna swore she would never do it. A proclamation she made when she was fourteen-years-old, sitting in her health class, watching a movie titled “Addiction” on a wheeled-out television stand. Anna’s eyes glossed over the images on the screen, thinking to herself, how could someone do this to themselves? It was easy to judge the teens that appeared on the screen—all from low-income and broken households, clothed in all black, smoking cigarettes on stoops and alleyways—when Anna knew that her life looked nothing like that. That will never be me peeled from her lips with ease. At only fourteen, Anna knew the difference between right and wrong, and addiction strongly fit in the “wrong” box, locked and hidden from sight.

. . .

In November of Anna’s sophomore year in high school, the first teen overdose story hit her small town on Cape Cod. The boy who died was a recent high school graduate, nineteen-years-old, found by his step-mother in the backseat of his car with a needle hanging out of his arm. Technically, he died from hypothermia, after falling unconscious in the driveway of his mother’s house. Anna recognized him from his obituary photograph. She knew him as an older party boy, someone very different from her circle of friends. Her mother asked her about drugs in the high school, and Anna explained to her that they were there, but only if you went looking for them. I’ve never seen them, she told her. If you don’t want to surround yourself with drugs, then don’t spend time with addicts. It was simple. Drug addiction was not a disease. It was a choice. At sixteen, Anna knew that it was a choice she would never make. She watched her classmates experiment with alcohol and marijuana—the gateway drugs—and stood firm in her conviction. She skipped the Friday “basement parties” for movie nights with her family and spent her Saturday mornings and afternoons at the gym and working at the local coffee shop. She was responsible, dedicated, and scholarly. The story of the boy who died was sad, but it was a story removed from her life.

She went to the funeral because that’s what you do in small towns. Every loss is magnified. Death is always personal, even when it’s not. And that’s how it was for Anna when the boy died. Although the boy had already graduated, Anna’s school still offered grief counseling. Her classmates cried in the halls. A group of seniors huddled outside school every morning before the day of the funeral, smoking, hoods pulled over their eyes, sharing memories of the boy. They talked about how well he played football and how charismatic he was. They talked about his mother and his sister and how loved he was. They talked about all the good times, but they never talked about the drugs.

Everyone knew how he died, but no one discussed it. Another young life gone too soon. He was grouped into a category with those lost from car accidents, work accidents, and war. They emphasized his life but brushed his death under the rug. It was taboo to talk about drug addiction because this was Cape Cod: a beach town, the beautiful land that Ralph Waldo Emerson adored and Bostonians flocked to in the summer. So after the funeral, the town settled back in. Soon, the boy’s memory faded from Anna’s mind.

. . .

When Anna turned seventeen, she started thinking about college. For Anna, the question was never if she would go, but rather, where she would go. She was excited for the prospects of a new city and new opportunities to learn. She generated her list of “dream schools” before she sat for the SAT. Her parents called her driven and focused; her friends called her inspiring. She had the world in front of her, and she wasn’t going to let anything stop her.

To help pay for her SAT prep class, she quit her job at the coffee shop and took up a restaurant position as a bus girl. There, she could make more tips and didn’t have to work on school days. Her friend Holly had starting working there when she turned sixteen the year before and told Anna that it would be a perfect way to save money. Anna loved it. Other than Holly, Anna didn’t socialize with any of her co-workers. They were all older than her and a bit underwhelming. They complained about working too little or too many shifts, about being stiffed on a six-top, and about how cold it was in the dining room.

One Friday night shift, Anna sluggishly walked across the dining room, politely asking to clear customers’ plates, but missing a fork here and a spoon there, hoping that the night would be over quickly. Holly, too, was distracted. She wasn’t supposed to work that night, but one of the waiters called in sick, and her boss decided to double up on bus people to make up the deficit. As she stood by the sink, filling the water pitchers, she thought about what time the deuce at table ten would leave and if she would be able to get out in time to go to the grocery store for a pint of Ben & Jerry’s. Somewhere between pondering Pistachio Pistachio and Half Baked, the pitchers overflowed, spilling water on the floor. Holly quickly turned off the water faucet and rushed to the line to get some kitchen towels to sop up the water. But before she got back to the sink, Anna walked in from the dining room, resting three cleared plates on her forearm and holding two glasses in her left hand, slipping on the pooled water. Her feet went from under her, and though she tried to break her fall with her now empty hands, the sink was too slippery to grab ahold of and her whole weight fell to the floor, the plates crashing on top of her.

. . .

Anna turned eighteen in the hospital. The doctors gave her balloons, cupcakes, and pain medicine to nurture her broken tailbone and wrist. The pain in her wrist was temporary, but her lower back was badly hurt and required surgery. When she left the hospital after her operation, her physician, Dr. Lawry, handed Anna’s mother a slip for a two-week prescription of OxyContin to help with the pain. Take this only when the pain is bad, he told Anna as he handed over the small white piece of paper. She nodded her head in compliance. On the way home from the hospital, her mother stopped at the corner pharmacy to have Anna’s prescription filled. Anna sat anxiously in the passenger seat at the drive-through window, knowing that it had been about five and a half hours since her last pill and that she was quickly approaching the safe period when she could take another. Make it stop, she pleaded. Make the pain stop.

When she got home, she changed into her white, plush robe and curled herself into a ball on the couch. Her mother, seeing Anna’s visible pain, opened the prescription bottle, shook out a single pill and poured Anna a glass of water. She handed both to Anna, along with an ice pack for her tailbone. At the two-week mark, the bruising had turned a yellowish brown color, looking perhaps just as painful as her body felt. Here, this will make you feel better. Anna quickly swallowed the pill and closed her eyes. Soon, the pain became more bearable, and she fell asleep.

When her first bottle emptied, Anna’s mother called Dr. Lawry and asked if it was safe for her daughter to have a second fill of her prescription. Of course, Dr. Lawry said. As long as her pain persists, the pills are always a good back-up. She suffered a tremendous trauma, and the pain will last for quite some time. He advised her to bring Anna back to his office for a check-up and refill her script. Anna’s mother complied, and the following Monday, just over a month since Anna’s fall at the restaurant, Dr. Lawry wrote Anna another script for two more weeks of OxyContin.

. . .

Dr. Lawry was a good doctor. He graduated top of his class from Harvard and completed his residency at Tufts. He pursued the medical profession because he wanted to help people. He wanted to heal those who have been hurt. And that is exactly what he intended to do when he met Anna. He performed her surgery well—despite the risks—and she was going to make a full physical recovery. For good measure, however, he prescribed her a two-week dosage of OxyContin to ease her immense pain. And when Anna’s mother told him that Anna was still in pain after her first prescription ran out, Dr. Lawry believed it was well within his medical discretion to prescribe another two-week dosage. After all, other physicians he knew, both personally and professionally, had prescribed month-long dosages. And he had nothing to worry about with Anna; before writing her script, he had screened her for any signs of prior narcotic painkiller abuse and found nothing to suggest that Anna was susceptible to addiction. She had no addicts in her family , and she was not the type of person he typically feared would abuse his prescriptions: she was hardworking, an honor roll student, and determined to heal her body. He liked her; she reminded him of his own daughter who was just a few years younger, about to start her first year of high school.

Dr. Lawry believed that pain relief was best achieved by treating with morphine post-surgery and prescribing Vicodin or OxyContin to treat patients’ at-home pain. He was aware that over-the-counter pain relievers like ibuprofen could help some patients, but he was worried that for someone like Anna, who had no history of abuse and was in a tremendous amount of pain, that he was doing more harm than good by withholding a prescription for heavier painkillers. Primum non nocere. First do no harm. So he prescribed Anna the pills, smiled, and wished her well in her recovery.

. . .

Soon, the bruising started to fade. Despite the physical signs of her pain diminishing, internally, Anna felt hopeless in her recovery. Any time she bent over or tried to go to the bathroom, pain shot from her lower back, radiating throughout her body. And to make matters worse, Anna’s long recovery had put her behind in school and college prep. She missed the SAT, and while she was once ahead of her classmates, she saw herself falling farther and farther behind. Whether it was the pain or the pills or a combination of both, Anna’s head was always fuzzy, and her efforts at catching up on school work or studying were to no avail. She was miserable and stressed and still in so much pain. More than anything else, she wanted to push through the pain and get back to her life.

So she did. When her second prescription from Dr. Lawry was half gone, she returned to school. It was against school policy to be under the influence of prescription pain medication while at school, so Anna had to stick to Advil extra-strength for the school day. On her first day back, Anna tried the over-the-counter medications, but they were useless. Any time she tried to get in and out of a classroom chair, she ached in agony. On her second day, she started to sweat, despite the still-freezing temperatures in New England. I can’t do this. On her third day, Anna snuck a single OxyContin pill from her prescription bottle. The pain numbed. Everything felt better. On the pills, she felt herself again. She focused that day in school. She could transition from classroom to classroom with more ease. She was talking—even laughing—with her friends, even Holly.

When Anna first ran out of her second bottle, she ruffled through her mother’s purse to try to find the old script from Dr. Lawry. There, at the bottom of her purse, stuck between a nearly empty tic-tac box and a grocery receipt, she found the small, crumpled piece of paper, the words Steven Lawry, M.D. followed by a barely legible “OxyContin, 20mg” scribbled in the large white space on the middle of the page. She stared at the handwritten words, her thumb and pointer finger pressing into the corners of the paper, wondering what to do. She knew she couldn’t ask Dr. Lawry for another refill. He, nor her mother, understood how much pain she was in. Yes, it was true that all physical signs of her pain had healed: her wrist brace was removed and the bruising on her tailbone looked more like the remnants of dye from a new pair of jeans than a healing injury. But inside, inside she was dying. Every time she moved, it felt as if a dozen bricks were crashing onto her back. Just because they can’t see my pain doesn’t mean it doesn’t exist. So Anna did what she had to do—she made her own prescription pad bearing Dr. Lawry’s letterhead. Just this one time, she told herself. After this bottle, I will be healed. The pain will be gone.

Anna went into the pharmacy three times before she mustered up the courage to walk up to the counter. She made sure to come on a day and at a time when she knew the pharmacy would be busy—so that maybe the pharmacist who filled her script wouldn’t think twice about whether it was real or fake. She walked up to the desk with a smile and a “hello,” and effortlessly handed the script to the young, vibrant pharmacist behind the counter. She smiled back and asked how Anna how she was doing. “Great!” she said, and grabbed a magazine from the rack next to her as she waited for the script to be filled. She flipped through the glossy pages, not reading a word or seeing a single image, perspiration quickly forming at her brow. The pharmacist disappeared into the stacks. Where was she going? Anna grew more nervous. Chills ran all down her spin. I’ve been caught, she thought.

But then, the pharmacist reappeared, carrying a small bag. “Sorry about that,” she said to Anna. “We ran out in the front and I had to make sure we still had some in the back. Here you go,” she said and handed Anna the package. Anna responded a bit too quickly with a “thank you,” paid in cash from month-old restaurant tips, and walked out the store.

Her pain dissipated the moment the pill flushed down her throat with a swig of cold water. She felt content. Happy, almost. A few days after resuming a daily usage of her pills, Anna told her mother she was ready to return to work. And so she did—she returned to busing tables and collecting tips. Finally, a sense of normalcy returned to her life. She felt nice. She could get back to focusing on school and work, because she felt healed.

But she wasn’t healed. And deep down, Anna knew that. She knew that because every morning she took two pills, and every afternoon before a restaurant shift, she took two more. She knew that without these pills, her normalcy would extinguish. She needed these pills.

And so her life became a continuous cycle of collecting cash and chasing pills. She worked harder at the restaurant, putting more strain on her back, only to make more tips to pay for the next day’s peace. She doubled her shifts. She starting working almost every week day, tossing aside her books to get to work sooner, praying that the restaurant wouldn’t be slow. Praying she would make enough.  Praying to feel nice.

. . .

In December of Anna’s senior year, the second teen overdose story hit her small town on Cape Cod. The girl who died was a recent high school graduate, twenty-one-years-old, found by her eleven-year-old brother in their family bathroom. Anna recognized her name and her obituary photograph. Anna knew the girl was friends with the boy who died two years before, and Anna wondered why his death didn’t stop her from doing drugs. Anna still thought that drug addiction was a choice.

Nothing changed from the last overdose death. Everyone knew how she died, but no one discussed it. Another young life gone too soon. She, like her friend only two years before, was grouped into a category with those lost from car accidents, work accidents, and war. They emphasized her life but brushed her death under the rug.

. . .

Dr. Jack Fisherman, a polish immigrant, was working for a small private lab in New York attempting to find a way to threat chronic constipation caused by opioid overdose. It was in this lab, working on this project, that he and his colleagues accidentally invented a drug that would go on to save tens of thousands of people from opioid overdoses caused from prescription pill and heroin abuse. Naloxone, an opium derivative itself, immediately reverses a heroin overdose by blocking the chemical effects heroin has on the respiratory and central nervous system, preventing these vital systems from shutting down. In 1971, the FDA approved naloxone to treat overdoses by medical personnel. There was finally a glimmer of hope amongst the dark shadows of opioid addiction. But unfortunately, medical advancement does not always go hand-in-hand with legal advancement, and it would be years before naloxone could truly help those in need.

. . .

Before long, Anna’s tips from busing tables were not enough to cover the costs of the pills. She needed to find a cheaper way to treat her pain. She knew what that meant, but she told herself she didn’t.

First, she tried to get pills from the street rather than the pharmacy, since either way she paid cash. This eased her worries of getting caught at the pharmacy by having to sign receipts and avoiding coming to the pharmacy too often. It’s still legal, she told herself, because the drugs themselves are not illegal. The FDA approves their use. They’re safe. She told herself that what she was doing was no different than the girl who sits next to her in her biology class taking her brother’s Ritalin to help her study. She spent $120 dollars on six pills.

She kept the cycle going for as long as she could. But her pain got worse and her treatment got more expensive. A 20mg tablet wasn’t enough. Soon she needed 40mg, then 60mg, then 80mg. She ran out of money. She got sicker. She knew what that meant, but she told herself she didn’t.

. . .

Anna swore she would never do heroin. But there she was, sitting in her car in a shut-down Taco Bell parking lot, waiting to get her first bag from some guy she had never met. She was scared. She drove thirty minutes over the bridge to Wareham where no one knew her and where drugs were everywhere. She told herself she had to do it. This was the only way to treat her pain. But she was still so scared: scared of what she heard about drugs, because she had still yet to drink alcohol or try marijuana, but yet this—this was where her life was. She was about to purchase heroin, and she was scared of what it would do to her. But she needed to feel normal. She needed to feel nice.

A tap on her window pulled her from her thoughts. Anna rolled down the window. The twenty-something year old pulled the baggie from his sleeve, and Anna handed him a ten-dollar bill. Ten dollars! He nodded, got back into his car that Anna hadn’t even heard pull up next to hers, and drove out of the parking lot.

The baggie was a lot smaller than she had thought it would be.

. . .

A month after Anna took her first hit of heroin, she turned nineteen. It was now 2013. The morning of her birthday, she woke to the soft vibrate of her phone, which had fallen into the crevice between the driver’s seat and center console of her car. Lying next to her was a new friend, someone who didn’t judge Anna, someone who knew what it was like to live in pain. By the time Anna could fish down into the tiny crack to retrieve her phone, the buzzing had stopped, the message Missed Call: Mom gleaming bright across the front screen. She stared at it for a few moments, wondering what excuse to tell her mother when she answered. I worked late at the restaurant—which was not a lie—and decided to stay at Holly’s—which was. Instead, she finished her shift, cashed out, and headed to Wareham for her next score. She tried not to really think about her actions; she just drove, letting her mind wonder, pretending she wasn’t the person who, at fourteen, she had denounced so easily. How did I get here? She just wanted to feel normal again. Nice. Heroin made her feel nice.

. . .

There were more deaths now. The smiling faces of teenagers and twenty-somethings speckled the front pages of the local newspaper, but now the pages were not filled with text of their accolades. Rather, the pages read like warning labels: this drug is tearing apart our families. A column started in the Cape Cod Times titled “Lost to Addiction.” Panic started to set in. People began to realize that addiction was a disease, not a choice. And it was a disease that did not discriminate.

News of the drug Narcan spread across the community. Family members enrolled in overdose education programs. They paid closer attention to sweatshirts missing their hood laces, kitchen drawers missing their spoons, belts weathered and torn. They noticed the itchy and flushed skin, the disappearances, the thirst and desperation of their loved ones.  They learned to keep a dose of Narcan hidden in the pockets of their purses, bedside tables, and medicine cabinets.

Anna’s mother started to recognize the signs of drug use in her daughter. Anna tried to explain away the symptoms. Anna thought she was hiding it well; her mother knew that she was not. Anna’s mother was scared for her daughter: how could someone with so bright of a future, someone so opposed to breaking the law, end up here?

. . .

Anna’s mother made an appointment with Dr. Lawry. She was worried about her daughter and had heard that there was an antidote that could save her life. Dr. Lawry welcomed Anna’s mother into his office but explained to her that there wasn’t much he could do without Anna there. Unfortunately, he explained to her, there were legal barriers preventing him from prescribing Narcan to Anna’s mother directly. She herself was not sick, and because Narcan was a prescription drug, he could not write a prescription for someone who was healthy. Anna’s mother cried in his office. She felt hopeless. He told her about the overdose education programs; they were a way she could help without breaking the law. He was sorry he couldn’t do more.

It pained Dr. Lawry that his hands were tied. It pained him because he felt responsible. He had given Anna the pills; he didn’t recognize that someone like Anna could have developed an addiction. However, he knew that as a physician, he had signed an oath to abide by rules, regulations, and orders of his profession. He could not help a mother fearing her daughter’s safety.

. . .

Anna’s mother went to an overdose education program. She learned how to save her daughter’s life. Following the completion of her training program, she was given Narcan to be able to administer the drug to her daughter, in the event that she overdosed. For the first time in months, Anna’s mother felt hopeful. She purchased a single dose for around 20 dollars. She kept it in her purse, right next to the same nearly-empty tic-tac box where Anna had pulled the old, crumpled script from Dr. Lawry nearly a year earlier.

. . .

Anna swore she would never use a needle. But now, at twenty-one years old and nearly two years after she took that first baggie of heroin from the dealer in the shut-down Taco Bell, here she was. Her arms garnished with a tough and track-marked scared surface, looking more like the limbs of a birch tree than the flesh of an honor roll student. She was sick all of the time. Anna told herself that she never used heroin for the high, just for the pain to go away. But now, a day didn’t go by without aching pain radiating through every pore in her body.

Her mother revived her three times on Narcan. She watched her daughter fight for her breath, clinging onto life. Soon, the Narcan set in. Anna’s eyes opened. Her mother grabbed her, tears pouring down her face, praying for this to be the last time.

. . .

In November of 2015, the FDA approved the first nasal spray version of naloxone. Rather than having to inject her daughter in the very same way that causes her near death, Anna’s mother could now administer the drug to her daughter nasally. The FDA granted fast-track designation and priority review for Narcan nasal spray, recognizing the seriousness of the epidemic. We cannot stand by while Americans are dying, said the acting commissioner. Finally, the law was starting to catch up with the needs of the country. Anna’s mother was eager to purchase this new drug. She went online to purchase it. The website was pink, like the walls of Anna’s bedroom. Anna’s mother hovered over the How to Get tab and entered her zip code. The following message appeared in big, bold letters:

In Massachusetts, residents can purchase NARCAN Nasal Spray without a prescription, directly from a pharmacist.

Anna’s mother felt relief for the first time in years. She could purchase Narcan whenever, wherever, and safely administer the drug to her daughter if she needed it. She clicked Contact This Pharmacy and ordered a new dose. The next day, she picked it up at a local pharmacy.

. . .

While her mother drove to the pharmacy to get the Narcan, Anna sat in her car with her new friend, the one who understood her pain, and waited for her dealer. It was raining out. The rain dripped down the dashboard like the sweat trickled down her back. She needed to feel nice. She needed to feel normal. Anna waited. She waited and she listened to the rain. She brought her knees up to her chest and rocked in the seat. At only ninety pounds, she could curl up neatly in the driver’s seat of her small sedan and pull her hoodie over her sopping wet hair, praying for the pain to go away. She heard a tap at her window—one that has grown far too familiar—and rolled down the window. She paid twenty dollars. She handed one baggie to her friend, and swore to herself she wouldn’t take the rest. She opened the baggie, put the heroin on the spoon, and began to heat it up. She wrapped the cotton lace from her sweatshirt around her arm. She squeezed it tight. She found a vein.

Anna felt the pain leave her body. She felt nice. She fell asleep. She fell deeper asleep.

. . .

In perhaps the most tragic of all ironies, Dr. Jack Fisherman, the very man who invented naloxone nearly forty years earlier, lost his own son to a heroin overdose in 2003. His stepson Jonathan was thirty-two years old when he slipped into a coma from a heroin overdose. He had told his girlfriend that he was “going to get high one last time.” And that is exactly what he did. He injected a lethal batch of heroin into his veins and fell into a deep sleep, one he never woke from. And so Dr. Fisherman, despite having provided hope to so many families, realized that this epidemic was so large, so powerful, that even he could not prevent it from inflicting tragedy upon those closest to him.  He consoled his wife, and they cried together, just like the other tens of thousands of parents around this country grieving the loss of their loved ones.

. . .

Anna’s mother got home and put the Narcan on the counter. She wasn’t ashamed of the drug. She was thankful for it. She called Anna, hoping that she would be home soon. Anna didn’t pick up. She called one more time. Still, no answer. Anna’s mother grew anxious. She felt a pit develop deep in her stomach.

. . .

Anna’s friend woke up before Anna did. She nudged Anna, but Anna didn’t respond. She shook her a bit harder. She called her name. Anna didn’t move. Her friend panicked. She didn’t know what to do. She pushed the hair off of Anna’s face, revealing Anna’s paler than usual skin. Oh my God, she shouted. Oh my God. She heard Anna’s phone begin to buzz. Anna’s friend moved Anna to the passenger seat. She put the car in drive. She was terrified. She didn’t call 911 because she was scared of being caught with drugs. She was Anna’s friend, but she couldn’t go to jail. She had her whole life ahead of her. She wasn’t an addict. So she drove Anna’s car to the emergency room, parked it right outside the large doors, and called a cab. She hoped someone would find her.

. . .

“I pledged to be the people’s lawyer”, said Attorney General Maura Healey in a press release in the summer of 2015, “Today, my office stands ready to live up to that pledge and to fight for and protect all Massachusetts residents.” AG Healey pledged to continue working to remove the barriers to treatment. To make sure that every Massachusetts resident plagued by the opioid epidemic was cared for. Anna’s mother wept as she read AG Healey’s words. She wept for the boy in 2010, and for the girl in 2012, and for her daughter in 2015. And she wept for all the mothers and fathers and sons and daughters, who would watch their loved ones go into a doctor’s office expecting to be healed, and only end up sicker.

. . .

Anna swore she would never do it. A proclamation she made when she was fourteen years old, sitting in her health class, watching a movie titled “Addiction” on a wheeled-out television stand. But now, Anna’s body is in the casket and the question she asked herself four years prior still stood: how could someone do this to themselves?

Perhaps the answer is much simpler than Anna ever thought. There are approximately one hundred million people living with pain in the United States. One hundred million people searching for help to end their pain. To feel nice. To feel normal. When OxyContin was first approved by the FDA years ago, it was a godsend for those one hundred million people. But what no one could foresee—what no one wanted to fathom could be a consequence of something legal, something FDA-approved—was that these pills create pain in the form of addiction, abuse, and senseless, tragic overdose deaths.

Opioid addiction cuts across the usual divide between legal and illegal drugs. Opioids treat pain, and the distribution of legal opioids has increased substantially over the past twenty years. Oxycodone production has risen by over 4000 percent from 1993 to 2012. There are more pills on the market to treat more pain: a legal—but deadly—combination.

Anna’s mother urges her community to speak about addiction. She wants people to understand that saying “no” to drugs isn’t as simple as knowing the difference between right and wrong. Addiction can’t fit in a box, locked and hidden from sight.