Cara Kudrenetsky, the daughter gone too soon, lives on in the ink etched into her mother’s forearm: a heart with a peace sign in it. Above it are Cara’s name and her birth and death dates: 7.29.95 – 8.27.12. Cara had drawn a heart just like it once, only in hers, the heart was broken. Cara’s mother, Aimee Austin, a speech and language pathologist at BOCES in Poughkeepsie, had mended it for the tattoo, hoping that her own heart would eventually do the same after her daughter’s tragic death from a heroin overdose.
Heroin is not new. In fact, nearly a century before the illicit drug became the rockstar downer of choice in the ’60s and ’70s, it was developed and sold over the counter by Bayer as a fin-de-siècle alternative to “addictive” pain meds like morphine. Unfortunately, it wasn’t long before heroin addicts abounded — but the drug wasn’t banned until 1924.
Today, heroin is making a comeback, particularly among teens and young adults. Not just underprivileged teens living in the inner cities, not just kids from broken homes or with drug-addicted parents. Heroin, once the scourge of cities and the purview of young urban males, has come to suburbia (according to a study published last year in JAMA Psychiatry, 90 percent of today’s users are white and 75 percent live outside of urban areas). It’s come to the middle class; to the rich; to the children of educated, affluent professionals; to fresh-faced cheerleaders and track stars who, in a different time, may have smoked a couple of blunts now and then as a coming-of-age rebellion. Heroin has come to the Valley. And it’s killing our kids.
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This epidemic is frighteningly prevalent among teens and young adults. Law-enforcement officials point out that families often struggle to spot the signs of it. “You need to identify it in your kids early and get a handle on it,” says East Fishkill Police Chief Kevin Keefe. “Get it at the top of the spiral. When they get to me, it’s probably too late.”
Young people between the ages of 18 and 24 are especially at risk. In fact, according to a Youth Risk Behavior Survey (YRBS), the percentage of New York State high school students who reported using heroin increased from 1.8 percent in 2005 to 4 percent in 2011. In addition, according to the New York State Office of Alcohol and Substance Abuse Services (OASAS) and its Combat Heroin initiative, there was a 222-percent increase in New York State heroin treatment-center admissions in Upstate New York between 2004 and 2013.
In Dutchess County alone, the number of drug-overdose deaths has exploded from nine in 2000 to 79 in 2013, according to Kari Reiber, MD, the county’s commissioner of health. Of the 262 overdose deaths in the county in the past five years, more than 80 percent were opioid-related. “Since 2009,” Dr. Reiber says, “There are more accidental overdose deaths per year than motor vehicle deaths in Dutchess County.”
Of course, the heroin crisis isn’t just local. A national study by the Centers for Disease Control found that the death rate from heroin overdoses doubled across 28 states, including New York, from 2010 to 2012, from 1.0 to 2.1 per 100,000. The total number of deaths increased from 1,779 to 3,635, whereas deaths related to opioid pain relievers decreased from 6.0 to 5.6. Prescription pills are still killing far more people than heroin — both locally and nationally — but with the crackdown on the former, the trend is shifting to the latter.
But why? Why the resurgence of a drug that the bourgeois once found so vile — or at least never talked about? One reason is that today’s heroin, unlike the heroin of decades past, is cheap. Really cheap. In fact, a stamp-bag of heroin (roughly one hit) can cost as little as $5. Compare that to the street price of one OxyContin, which, since crackdowns on “doctor shopping” in recent years (including the implementation of the state-wide Internet System for Tracking Over-Prescribing program in late August 2013), can be $80 or more. The low cost of heroin coupled with the fairly recent street-scarcity and expense of prescription painkillers — and the reformulation of certain prescription meds by pharmaceutical companies to make them less crushable, and therefore less snortable and injectable — has meant that many users are moving from pills to heroin just because it’s easier. Back in the day, 50 years ago, the vast majority of heroin users — 80 percent, according to the JAMA Psychiatry paper — used heroin from the start of their drug abuse. In contrast, a large number of today’s heroin users transitioned from prescription painkillers when they became too expensive or stopped being effective. “The better controls of prescription drugs correlated with the rise of heroin,” says Keefe. “We’re tightening our grip on prescription abuse but what’s slipping through our fingers is heroin.”
It’s not just cheap and accessible, though. It’s very pure — and more dangerous than ever. The mix of affordability, accessibility, and opiod-induced euphoria makes heroin particularly appealing to cash-strapped, pleasure-seeking teens and young people who, by virtue of their youth, rarely have a sense of their own mortality. Despite its ostensible affordability, though, that wash of euphoria actually comes at a very high price. The number of “bad batches” has risen sharply. As heroin has boomed, so have the number of enterprising operators, hoping to maximize profit by cutting the heroin with sedatives and other drugs. Fentanyl, a synthetic opioid used to manage severe pain (it’s often prescribed in the form of transdermal patches, like Duragesic, to treat cancer pain), is one of those drugs. Fentanyl is estimated to be from 50 to 100 times more potent than morphine and five to 15 times stronger than heroin. Unfortunately, it’s impossible to tell from looking at a bag whether or not it’s laced, so using, even once, is tantamount to a game of Russian roulette. Even if you don’t get a bad batch, you’re still in real danger. “With continued usage, tolerance goes up, so increased amounts are needed,” explains Mario Malvarosa, MD, an addiction specialist at the Lexington Center for Recovery in Poughkeepsie. And more heroin means an increased risk of overdose. “There are side effects, and one of them is respiratory depression.” Essentially, many people die of overdose when their bodies “forget” to breathe.
Addicts fear withdrawal. Kicking heroin induces powerful cravings and wretched side effects. “When you suddenly stop, there are withdrawal symptoms which are usually the opposite of what the person was experiencing,” says Dr. Malvarosa. The symptoms include nervousness, jitters, muscle aches and pains, chills, tremors, diarrhea, vomiting, and excessive salivation.
In the old days, “treatment” meant a visit to the free methadone clinic. Today’s treatment programs are much more comprehensive. Many take insurance, and many offer crisis intervention services. But, though you may not find many of today’s young heroin-addicted Valley residents standing in line nodding off outside the free clinic, you will find that their addictions are very real and as dangerous — if not more so — than those of 50 years ago. Today, the many treatment options for heroin and opioid addiction include hospital-run and independent outpatient programs, intensive in-patient rehab centers and detox programs, and dual-diagnostic treatment (which can include treatment for addiction plus cognitive behavioral therapy [CBT] for co-existing mental or emotional disorders, such as anxiety, depression, and other conditions). And yes, there are some private rehab facilities that look more like country clubs than drug-treatment centers, for those who can afford it.
But heroin is different than many other drugs that have been abused by teens and young adults in recent decades. Heroin is generally not used by those wanting to party. While it does produce a high, and is frequently the next — and, sadly, often the last — step in a long line of other drugs that may start with a “gateway” drug like prescription painkillers, it is also sought by kids looking for an escape, relief from depression, anxiety, or other emotional pain, and, because of the inherent shame heroin use bears, teens often snort or shoot it alone.
In Cara Kudrenetsky’s case, depression was an ongoing problem. The second of Aimee Austin’s five children, Cara was in a DARE (Drug Abuse Resistance Education) program in elementary school and, as a teenager, she liked to draw and take pictures. She had a knack for going into her bedroom, plastered with posters of Kings of Leon and Jimi Hendrix, with brown hair and reemerging with blue or pink hair. She loved to cook and hoped to attend the Culinary Institute of America after she graduated high school. Her dream was to open a vegan restaurant in New York City, even though she could never resist a burger.
“She was beautiful,” says her mother, Aimee. But she didn’t feel beautiful. She felt ugly and had low self-esteem. She struggled with her weight and thought she wasn’t popular. Even after she managed to lose 70 pounds by improving her diet and exercising, she didn’t feel much better. “For some reason she had this void that she needed to fill.”
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When Cara was 15, she was prescribed Ambien to help her sleep while she was sick. Her mother gave her the whole bottle to administer to herself, only to find Cara staggering out of the bathroom and jabbering incoherently one day. It wasn’t long before Aimee started finding pieces of drinking straws around the house. She didn’t realize that her daughter was crushing and snorting her pills until she found a straw with some white powder next to it. Other than that, Cara was good at hiding her highs.
One day, Aimee came home to find her kitchen a mess, with batter on the ceiling, flour and cooking utensils everywhere — and Cara nowhere in sight. When Cara did return, she was incoherent. Another time, her mother found a couple of white pills on Cara’s bed that turned out to be OxyContin. She lectured her daughter about the dangers of drugs, but Cara cried about her body and her lack of friends. Pretty soon, Cara was stealing her mother’s prescription pills from her drawer. “They have the commercials on TV, ‘Lock up your prescriptions,’ ” Aimee reflects. “But of course they weren’t talking to me; they were talking to everyone else.”
Cara asked a counselor at her school for help. Her mom took her to a treatment facility, which turned her away because their insurance wouldn’t cover it. So Aimee took her daughter to a mental-health hospital, where she was given psychotropic drugs for four days and then released. She was told to take her to another facility in Westchester but had no way of getting her there regularly. Without intervention, Cara kept using. She was alone in her room a lot, getting high before meeting friends.
Cash started disappearing from wallets in the house. Aimee’s childhood piggy bank, once hefty with spare change, suddenly felt awfully light. Cara worked at a nearby Subway and she babysat. She had plenty of money to buy drugs.
While there are many treatment options, many are finding it difficult to access them, argues Elaine Trumpetto, executive director of the Council on Addiction Prevention and Education (CAPE) in Dutchess County. In 2013, 89,269 people were admitted to treatment facilities for heroin and prescription opioid addictions in the state, up 40 percent from 2004, according to Governor Cuomo’s office. Although state laws require treatment programs to provide services to those who can’t pay and there is financial aid available, CAPE says getting into rehab is complicated. And given the number of heroin users, the need is overwhelming. In 2011, a National Institute on Drug Abuse survey concluded that 4.2 million Americans who were at least 12 years old had used heroin at least once in their lives. It is believed that 23 percent of users become addicts. Heroin is more likely to send someone to rehab than any other hard drug — twice as likely as crack, and more than four times as likely as cocaine.
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“This disease that we’re facing, the prevalence of overdose and addiction, can be prevented,” Trumpetto says. “Addiction is a preventable disease. The economic devastation that this costs families, counties, our states and our nation is monumental. You’ll consistently be funding enforcement and treatment if you don’t get in front of the problem and invest in prevention. You’re going to repeat this cycle over and over again.” Prevention is a better bargain for society as a whole. For every dollar spent on it, $12 to $18 is saved on treatment, according to the Department of Health’s Center for Substance Abuse Prevention.
“Treatment is a short-term solution,” Trumpetto says. “Prevention is a long-term vision.”
Until Cara died, the summer of 2012 had been the family’s best ever. She seemed to have stopped taking pills. She had a boyfriend whom the family adored, and her relationship with him was blossoming. She appeared to be happier than ever. The whole family barbecued and enjoyed each other’s company. They all went to the Jersey Shore; for the first time since she was a young child, Cara felt comfortable enough with her weight to go to the beach. They all went to a music festival in a big RV they rented. Michael, the oldest boy, had taken up the guitar and joined a band. They made a few appearances on the main stage of The Chance Theater in Poughkeepsie, and the family would all go watch. “I remember Cara smiling a lot,” Aimee says. “She wanted to live. There’s no doubt in my mind she wanted to live.” She was maturing quickly. She seemed to have gotten a handle on her demons.
Her boyfriend, though, was using drugs, and Cara would get angry at him for it — because, Aimee assumed, she had gotten clean and wanted him to as well. But Cara would overdose not long thereafter. “She painted a picture that I wanted to see, who maybe she even wanted to be,” says Aimee. “But that wasn’t what was happening. You never can believe the child. They’ll tell you everything is fine. And you want to believe everything is fine because it’s easier. You want them to be well.” A week before Cara passed away, Aimee found another straw. She suspected it had been Michael’s.
Aimee got home at 1 a.m. on a Monday. She had gone to Florida with her eldest daughter to look at a college. She checked on Michael, who was asleep. Cara’s door was closed, so she thought she’d let her sleep, too. She didn’t know that Cara’s boyfriend was in her downstairs bedroom with her. Aimee awoke the next morning and went through her routine with her youngest son, having breakfast and getting dressed. That’s when the boyfriend came storming up the stairs, screaming that Cara was unconscious and foaming at the mouth. Aimee ran down. Cara lay in her bed, motionless. They called 911 and put her on the floor and started CPR, as instructed. Aimee begged for her to cough back to life. She didn’t. When the paramedics arrived, they tried reanimating her with a defibrillator. They couldn’t. Cara had gone into cardiac arrest and would never regain consciousness. She was declared dead moments after arriving at the hospital. The medics never administered Narcan because they didn’t know there was heroin in her system. The boyfriend insisted they had only smoked weed. But the toxicology report was clear. Aimee was taken aback when the police asked her about heroin. To her, heroin belonged with inner-city junkies. She didn’t even know what it looked like.
It had happened quickly, as it often does with heroin. Less than a year from the time her mother realized she was taking prescription pills, Cara was dead, just days before her senior year of high school would begin. When they cleaned out her room, the family found a small baggie of heroin. In the back of her drawers, they found many more empty baggies. Texts on Cara’s phone to her boyfriend mentioned “powders.”
Michael is now older than his sister was when she died. They were close. He didn’t know she was using heroin, and he blames himself. It’s been hard on him, on all of them. “We’ve fallen apart,” says Aimee. “It’s very hard to piece your family back together.” She hasn’t done much to Cara’s room. She has started speaking about her at forums on addiction. “It wasn’t the dream I had at all for my daughter to be the poster child for a heroin overdose,” she says. “But Cara’s dead and that’s the end of the story, really. Her story is over. But there are other people’s stories that can have a happy ending.”