The Bronx Ink

The tiny waiting room of Dr. Andrea Littleton’s Bronx office was overflowing by the time she arrived in the late morning. Some patients sat in stony determination while others paced impatiently in the hallway — clawed by addiction and anxious for the relief that Littleton could provide. One dozed, slouched in his chair beside the inner door that leads to the claustrophobic medical office where, twice a week, Littleton prescribes buprenorphine to opioid addicted patients.

Littleton has worked for 15 years at Care For The Homeless, a non-profit medical center that provides medicine-assisted treatment for the homeless who suffer from opioid addiction. Medicine-assisted treatment is considered the “gold standard” for opioid use disorder, and the medications used are typically either methadone or buprenorphine (also known as Suboxone).

Littleton’s office, situated in Hunts Point in the Bronx, is at perhaps the very heart of New York’s opioid epidemic. In 2018, the overdose deaths per capita in Hunts Point was over 2.5 times the city-wide average, according to a 2019 report from the Department of Health and Mental Hygiene.

Only Staten Island ranks above the Bronx in terms of number of opioid deaths per capita. However, treatment in the two boroughs looks very different. 

“Even though both [Staten Island and the Bronx] are epicenters of the opioid epidemic,” said Littleton. “There are far more [buprenorphine] prescriptions being written in Staten Island, but not necessarily more providers.”

A 2018 research report confirms Littleton’s observation: patients in Staten Island receive buprenorphine 3.6 times more frequently than those in the Bronx. Patients in the Bronx are, likewise, 3.2 times more likely to receive methadone. All this while the Bronx has nearly three times as many physicians who are able to prescribe buprenorphine, according to federal data.

The difference between the two treatments is meaningful. Methadone must be administered under supervision in specialized clinics. Buprenorphine, on the other hand, can be prescribed by certified doctors and can be self-administered in the form of oral tablets. 

“[Buprenorphine] certainly offers more freedom and flexibility,” said Littleton. Some patients refer to methadone treatment as “liquid nails,” she said. “They can’t go anywhere else or have a job or travel even because they have to be there every day.”

Having to show up at the clinic every day to receive treatment is not only a burden on methadone patients. The clinic itself can be stressful. “There is also a lot of stigma,” said Littletone. “People know where [the clinics] are, they don’t feel safe there. And it’s triggering because there might be someone selling right there in the waiting room or right outside the door.”

Finally, the medication itself makes a difference. Buprenorphine lacks some of the negative side-effects that methadone is notorious for. On Buprenorphine, patients “can go about their day feeling normal, they don’t feel high, they don’t feel loopy, they just feel normal,” Littleton added. “Where as a lot of people on methadone feel high, they can’t think clearly, they feel like they can’t maintain their normal activities.”

In 2018, Canadian researchers published guidelines recommending buprenorphine as the preferred first-line treatment for opioid addiction, only switching to methadone for patients who respond poorly to buprenorphine or who express a strong preference.

Salvador, who asked that his last name not be used, is a big man with tired eyes and a tidy grey beard. He is one of those patients who depends on the buprenorphine he gets from Littleton every week.

“When I have these,” he said holding a zip-lock bag containing week’s supply of individually-packaged pills, “I don’t even think about [heroin]. But without them, I have to use.”

But that reliance on Littleton can spell disaster if she is not available. 

Salvador had been clean for nearly two months, he said. But, when Littleton had been away the prior week, he hadn’t been able to find another prescriber. Salvador had gone back to heroin to satisfy his cravings.

“You abandoned me,” Salvador sulked jokingly. But the damage done is no laughing matter.

Now, Salvador will have to endure the unpleasant, and potentially dangerous, process of reinitiating his treatment. Buprenorphine includes naloxone (the active drug in Narcan) which can precipitate withdrawl if patients start treatment too soon after using. Complications from withdrawl, including dizziness and asphyxiation can be severe. He will have to start the first stages of withdrawl from the three baggies of heroin he snorted that morning before he can take his first pill.

Despite the success of buprenorphine, getting access to treatment still remains a problem for many Bronx residents. In February 2019, the New York State Department of Health released new guidelines encouraging SAMHSA-approved doctors to “start prescribing buprenorphine, and if already prescribing to increase the number of patients under care.” 

But the question remains, why do these two boroughs, facing the same crisis receive such different modalities of treatment?

From the start, buprenorphine treatment catered to affluent white patients who did not want to be associated with the stigma of receiving treatment at methadone clinics. 

“In the case of opioids,” writes Dr. Helena Hansen, Associate Professor of Psychiatry at NYU Langone. “Addiction treatment itself is being selectively pharmaceuticalized in ways that preserve a protected space for White opioid users.”

Buprenorphine was developed in 1966, but failed at catch on until it’s resurgence 30 years later, which, argues Hansen, coincides with the rise of opioid use in white communities. When buprenorphine was legalized as a treatment for opioid addiction, in the 2000 Drug Addiction Treatment Act (DATA 2000), a group of lawmakers who opposed the DATA 2000 bill foresaw that it would “consign ‘hard core’ users to the existing and widely recognized as failed system.”

Sure enough, as the opioid epidemic exploded in in New York City, buprenorphine was increasingly available only to those who could afford private insurance. Between 2009 and 2016, the number of buprenorphine prescriptions on private insurance increased by over 4.5 times, while the number on medicaid fell nearly by half. In 2016, over three-quarters of buprenorphine prescriptions were paid for by private insurance.

While the city’s $60 million HealingNYC initiative has shown modest success in reducing the number of overdoses city-wide and increasing buprenorphine prescriptions, it hasn’t been enough in the Bronx, where opioid deaths continue to increase. 

“It’s supply and demand,” said Dr. Tiffany Lu, Medical Director of the Montefiore Buprenorphine Treatment Network. “The Bronx does not have enough capacity because it historically had the burden of the disease.”

And while money for outreach and education programs are essential, the greatest hurdle in the Bronx is finding physicians like Littleton and Lu who are able and willing to prescribe buprenorphine.

Under DATA 2000, prescribers are required to obtain special wavers to even be allowed to prescribe the treatment. Completing the requirements can be an arduous burden to already-overextended care providers. Doctors are required to attend eight hours of training and clinicians (including nurse practitioners and physicians assistants) are required to take 24 hours of training.

However, once a physician has a waiver to prescribe buprenorphine, they are only allowed to treat 30 patients in their first year. This cap increases to 100 and 275 patients in their second and third year, but the cap still contributes to the shortage of access to buprenorphine prescribers, according to a letter by the New York State Department of Health. 

Some physicians question the need for a waiver at all. “[Buprenorphine is] a schedule III drug,” said Littleton. “It’s less addicting substance than opiates, but prescribers are able to provide [opiates] at will without training.”

A bipartisan bill, the Mainstreaming Addiction Treatment Act of 2019, has been introduced to both the House and Senate. The bill would allow physicians to prescribe buprenorphine without a DEA waiver.

Still, even some physicians who interact with opioid-addicted patients may be reticent to start buprenorphine treatment. 

Rikin Shah, Chief Resident at St. Barnabas Hospital in the Bronx, is not waivered to prescribe buprenorphine. In the emergency department, where he typically encounters such patients, initiating buprenorphine treatment would require counseling and monitoring, and in a 200-bed room, where other patients require attention, he doesn’t feel that starting new medication is a good idea.

“We may not be able to monitor how they are doing on the medication, whether they need changes in doses, or if they are having any adverse drug/side effects,” Shah wrote in an email. “This is dangerous for our patients.”

Emergency departments are not the appropriate venue for starting addiction treatment, Shah continued, and promoting them as such might lead to an abuse of their resources. 

“We need to optimize our resources to taking care of the sickest patients and to those who are at risk of losing their life…. More often than not, although withdrawal symptoms are uncomfortable, they are not life threatening,” Shah’s email continued. “Emergency departments become in a way suboxone/methadone clinics as patients can find coming to the [emergency department] the most convenient way to treat their withdrawals.”

While some physicians may be reticent to provide treatment for medical reasons, their own stigma towards addiction may be just as big a barrier.

“Lack of knowledge and fear of the unknown are big factors, and the other is stigma,” said Littleton. “People get concerned about [treating] the patient who has an addiction and what that means.”

Some providers worry that treating addiction is like “opening up a Pandora’s Box,” said Littleton. They think “if we talk about [your addiction] we’re going to talk about all that trauma that you had as a child and I don’t have the resources to give you the support to deal with that, I don’t have access to good mental health [services] that I can connect you with… and I can only address so many things in 15 minutes.”

Littleton walks through these traumas with almost every patient she sees. Raymond, who had recently been released from Rikers on drug charges and asked that his last name not be used, told Littleton that he’d been using speedballs (a mixture of heroin and cocaine) since age 11, when his father introduced him to the dangerous cocktail.

Littleton didn’t blink when Raymond said that he’d had a relapse. Like Salvador, he relied on heroin to tide himself over after leaving prison, before coming for treatment. Instead of discharging patients who relapse, punishing “dirty urine” by terminating treatment, Littleton stresses the importance of patience and understanding. 

“Many [patients] will have a relapse, and that’s okay,” she said after seeing Raymond out. “Addiction is a spectrum… [and] we do them a disservice by discharging them.”

Once physicians can normalize their understanding of addiction, and see the effect of treatment, those fears and stigmas will fade, Littleton said. “It’s just understanding that… anybody can have opioid use disorder and have perfectly normal lives otherwise.”

Treating opioid addiction is no simple task, and buprenorphine is not a silver bullet, said Lu, the doctor from Montefiore. But, access and supply are the only way to get this life-saving drug into more hands.

“[Being trained to prescribe] buprenorphine is the lowest threshold that anyone can do.” Lu said. “My message to all my colleagues is: please do something, get yourself trained, offer it, because if you don’t offer it you’re basically saying you’re not interested in treating the disease in any way.”

Jonathan Calderon woke up on a hot June morning, wrapped in a wrinkled red and black blanket, soaked in cold sweat. It was his fourth night and fourth day crashing on his friend’s small couch without heroin. He had no money and no strength to go back to the street.

That’s when he logged onto Facebook on his friend’s phone. On the top of the news feed was a photo of his 7-month-old daughter, tilting her head in a smile. “Why am I here instead of being at her side?” Calderon thought to himself.

In his 24 years, Calderon, a Mott Haven native, had spent 14 years using and selling drugs, and the last four years doing heroin. Drugs, he said, once relieved his loneliness. Selling drugs even lifted him out of poverty, temporarily. But now, all he had was two knife-slash scars in his arm and leg, four tattoos and a broken down body. Calderon realized that he was about to condemn his young daughter to a life with an absent father on drugs. But he wanted to be able to participate in her childhood. He decided that he had to stop letting heroin control his life.

Calderon’s problem was not unique. Many of the city’s drug users and their families had endured even worse. Last year, 782 New Yorkers died of drug overdoses. Of those, 420 deaths involved heroin. In the past four years, the city had seen a steady growth in the death toll of drug poisoning, according to a study released this August by the city’s Department of Health and Mental Hygiene.

More than a quarter of those deaths occurred in the Bronx. During 2012, among every 100,000 residents in the Bronx, 8.8 died of drug poisoning involving heroin. From 2012 to 2013, 16.6 percent of the deaths happened in Hunts Point and Mott Haven, the neighborhood with the most heroin-related deaths in New York City since 2010.

In the country, an increasing number of young people started using heroin in the beginning of their adult life. According to the National Survey on Drug Use and Health, in 2012, 18 to 25 year olds accounted for 43.6 percent of illicit drug use. In 2012 alone, 156,000 persons started to use heroin, with the average age of initial use at 23.

Grow Up Fast, Smoking Weed

Growing up in Mott Haven to drug-addicted parents, Calderon had only met his father once and did not see his mother much before he was 12. He was shuffled between his relatives’ houses, feeling unwelcome everywhere. School wasn’t any better. He said he was bullied through elementary school to junior high, and dropped out of high school after only a few months.

He didn’t remember having a toy, or going to the zoo, or holding his parents’ hands. He promised not to let this happen to his own child.

“I had to grow up fast to defend myself in the street,” he said.

He smoked his first hit of marijuana at the age of 11. “Gimme some of that or I’ll tell your mom,” he remembered telling his 14-year-old cousin.

On his 12th birthday, he smoked his second joint with friends in a park near Westchester Avenue. The weed slowed him down and made him laugh. He liked it.

By 13, he was smoking several times a day and selling it. Street-smart and an early developer, he was pulled in by a gang in the neighborhood. Surrounded by 18 to 20 year-olds who gave him money and taught him how to sell drugs and to put down street fights, for the first time in his life, Calderon felt embraced and thought that it was love.

From a Pothead to a Pill-head

One thing led to another, and at 17, Jonathan discovered “Opana,” a prescription painkiller that was able to freeze everything out for him. After taking the orange-colored pill, he liked to run around while the surroundings faded out. In this blurry world, he felt relieved from the pain and stress of loneliness.

In 2013, the U.S. Department of Health and Human Services warned that “crushing, chewing or dissolving” pills such as Opana ER “will result in uncontrolled delivery of active opioid and can lead to overdose or death,” and ordered the manufacturers to change the package labels, directing prescriptions only be given for “severe pain” instead of the formerly “moderate-to-severe pain.”

For this reason, in 2012, Opana ER, the long-acting analgesic, adopted a new formulation that resists being dissolved.

But back in 2006, when Opana ER first came on the market, Calderon didn’t know he could open up the pills and snort them. He only took “Opana” in pill form.

The same year, his street business went to a new level. He started to sell heroin in small bags with a star stamped on it.

At that time, Calderon said, all the heroin sold by local gangs had brand images stamped on the bags. The names were derived from a large range of things -“Blue Spider,” “Daddy Yankee,” “MySpace” and “Walking Dead,” to name a few.

His left hand still bears a tattoo of a star and a dollar sign.

In 2007, a bag of heroin cost around $10. A bundle of 10 bags cost $50 to $ 80. Sometimes, Calderon was able to sell about 15 bundles to up to 30 people in a day. A daily revenue of $500 was commonplace. On a good day, he could make $1000.

The money flipped his whole life around, from a street kid with no regular home to an 18 year old with his own place. He paid monthly rent of $500 for a basement studio in a three-story building on Cypress Avenue.

It wasn’t just the housing situation that changed. In a neighborhood where 41 percent of the population lived below poverty level, he often spent $150 on a pair of Levi’s jeans and $300 on Jordan sneakers. In fact, he had so many sneakers that he used to wear different shoes everyday for a month.

By 19, Calderon had saved up $10,000. Not able to put the street money into a bank account, he dug a hole in the wall in his closet to store his fortune behind his True Religion jeans and Polo shirts.

But the $10,000 saving was just a small token of what he had made. He spent most of them on clothes, liquor, cab fare. Some nights, with friends, he would spent $100 at nightclubs. He once squandered $1000 at Sin City Cabaret.

Every morning when he turned on his phone at 6 or 7 a.m., it would ring non-stop because addicts in the neighborhood had been craving heroin all night long. After taking care of the business, he would swing by a store to get cigarettes, rolling papers and marijuana in the street. Then he went back home, put on some music, usually Rap or R&B. He liked Meek Mill’s “I Am a Boss” and Trey Songz “Already Taken” the most. And then he would start to smoke.

Before noon he would have showered and put on some cologne and had his waist-length hair braided. He’d put on his dashing new clothes and sneakers, ready to show up on the street where he hung out with other gang members till midnight. Calderon enjoyed looking nice and being respected on the street. But sometimes his mind strayed from the non-stop chatter between gangsters about who had been beaten up or who had been killed.

“I wish I was born in another country where there was no drugs or violence, living a normal life with my parents,” Calderon said.

Live to Dose, Dose to Live

In 2009, a girlfriend showed Calderon a new way of taking “Opana.” He started to crush it into powder and snorted it. This could create “legal high,” the same as heroin, but via prescription narcotics.

From 2003 to 2012 in New York State, drug-poisoning deaths involving opioid analgesic increased from 186 to 914, reaching a peak of 940 in 2010, according to a study released by the state Department of Health. Most of the victims aged 45 to 64, the age group 20 to 44 being the second large. From 2003 to 2012, death toll of the later group grew almost five folds.

Like many other drug users who started with opiod analgesic but then switched to heroin, the more accessible, less expensive substitute, at 21, Calderon started to use the heroin he had for sale, after he and his girlfriend ran out of “Opana.”

One snort of heroin always brought him a rush of energy in his body and he would start to scratch– “the good itch” –all over his body. He could feel the excitement breaking through his normal shyness. After the burst of happiness, Calderon would go into to a deep sleep that he would try to fight away. On a given day, he would snort up to ten bags of heroin. He followed the voice in his head, “Go get it. Go get it.”

In about a year and a half, he used up all his savings. But the voice didn’t stop chanting.

He started to sell things, like his jewelry and AirJordan sneakers, until he was down to one outfit, and one pair of shoes.

Calderon began to cash in on his scrappy reputation on the street. Other heroin dealers loaned him 10 or 20 bundles. One person loaned him 50, expecting him to pay back $2,500. Instead, he snorted it all.

That was the beginning of his trouble on the street. Once he was slashed in one arm and leg. The wound opening didn’t heal for two weeks. He was 23.

By the end of 2013, Calderon was emotionally repulsed by heroin, tired of all the chasing, hunting and disappointing his family. But his body couldn’t handle withdrawal. In addition to the chills and the sweats, the fevers, compulsive vomiting and sometimes incontinence could drag on for days.

He had to get high to feel normal. He was sick of it.

“I don’t need my life back. I need a new life.”

Calderon knocked on his mother’s door, after four days this June at his friend’s.

“I need help, mom,” he said.

Having always blamed herself for Calderon’s addiction, the mother instantly broke into tears and hugged him.

The day after, she sent Calderon to detox at St. Barnabas Hospital, where he rested for about a week, getting health checks until all the remnants of heroin were removed from his system. Methadone was used to curb his cravings.

At the end of the treatment, Calderon was referred to a six to nine months residence treatment program at VIP Services where he participated in group discussions and various therapy sessions during the daytime.

Having stayed clean for more than three months, he started to go to classes at Eagle Academy to prepare for GED test. Beyond the test, he plans to be trained for a Primary Care Paramedic License with which he hopes to become a phlebotomist.

“I think by handling people’s blood and urine samples, I could help people dealing with their problems,” Calderon said that he had wanted to become a phlebotomist since he was 17 or 18.

His daughter is turning one in less than a month. Calderon is counting days – she may be one and a half year old when he finishes Primary Care Paramedic training, is out of the treatment center and on track for his new life.

“In a couple of years, when she’s grown up a little bit, I want to get a half sleeve tattoo with her name and face on it,” Calderon said, by then he would have removed the star and dollar tattoo on his hand.

He has his mother and grandmother’s name tattooed on his arm and neck.

On his other arm was a tattoo from long ago that says “Dreams and Nightmares.”