“There’s an old saying in the medical community,” Dr. Jay Butler says, “statistics are people without the tears attached.” He’d know. He’s Chief Medical Officer and Director of the Division of Public Health at the Alaska Department of Health and Human Services and Chairman of the Alaska Opioid Policy Task Force. In the case of that second job description, sad stories are what drive his work.
A couple of weeks ago Alison Kear, the Executive Director of Covenant House, set one of those statistics down on the table at the December 14 Anchorage Assembly meeting. In that ordinary-looking paper bag were the earthly remains of Tucker Sauder, the oldest son of Beans Cafe Executive Director Lisa Sauder. Tucker died of a suspected heroin overdose early on the morning of December 3 at the Sauder family home on the hillside. He was 23-years-old.
His father woke up at 4 a.m. that day with a feeling of dread he couldn’t explain, went upstairs and found Tucker unresponsive in his room. The ambulance didn’t have Naloxone– a medication used to reverse the effects of an overdose–onboard. “It likely wouldn’t have helped anyway, in his case,” Lisa said, “but I do think every ambulance should have it with them. It’s not like heroin overdoses don’t happen up here on the hillside; they happen all over the city.” For Tucker, though, nothing the family or paramedics did could save him.
When Tucker died, friends of the Sauders mobilized and took over, organizing a celebration of life and arranging a short trip to Hawaii for the family immediately after. The trip was a chance to reflect together, wrapped in the warm sun. While the Sauders were gone, Alison Kear, one of Lisa’s best friends, picked up Tucker’s ashes from the funeral home. Alison then called Lisa to ask where to take them. Lisa said, “take him to Covenant House. I can’t think of a more powerful message than that.” After that, Alison took the ashes to the Anchorage Assembly.
“I’m so proud of Lisa,” Alison says, “for having the courage to say, ‘I’m not ashamed of this. I’m not embarrassed by this. It wasn’t my fault.’” Where many families draw the curtains after losing someone to an overdose, the Sauder family did the opposite. Lisa wants his story to be known. If all it took to beat heroin was the will to live and enough love and support behind you, Tucker Sauder would have been a rising phoenix, not another statistic.
Heroin ravaged Tucker. He experimented with drugs before, but around the time he first arrived in Oregon when he was about 20, he was hit by a car and hospitalized. He was prescribed Oxycontin. His family posits that, like so many others who’ve suffered his same fate, heroin followed when the Oxys ran out. He lived on the streets in Oregon for about three years, going long stretches with no communication with his family.
Every once in awhile, Lisa would get a bad feeling and start calling shelters and hospitals and morgues around Portland, giving Tucker’s description. Sooner or later, he’d turn up. Eventually, the Sauders moved Tucker back home to Anchorage after he had open heart surgery to replace a valve that had been destroyed by infection resulting from intravenous drug use. He’d previously spent almost a month on a ventilator fighting a different infection caused by the same thing. His teeth were in bad shape. It embarrassed him, made him not want to leave the house.
Lisa and Alison fought from July of 2016–when Tucker got home–until he died to sign him up for Alaska Medicaid, to start the process of fixing his teeth. It was a medical imperative after the complications with his heart. However, there were so many roadblocks involved in switching him from the Oregon healthcare system to Alaska Medicaid, that they weren’t successful. Lord knows how any of the rest of us would have managed it.
Tucker was reluctant to spend time in traditional 12-step rehabilitation programs once he got home because he was afraid to be in a room full of people talking about how badly they wanted to get high. He tried that before and it didn’t work. Nor did he want to stand in line at the methadone clinic where he’d be surrounded by people who knew where to get heroin. This wasn’t an unfounded fear, apparently. Alison told me that heroin dealers have been known to sometimes show up in those lines looking for clientele, effectively creating a near impossible gauntlet for someone in Tucker’s situation. What he wanted more than anything was to close the door on that chapter in his life.
For a time, he succeeded. He was doing relatively well back home with the Sauders. He had a warm, safe and stable refuge, surrounded by family and friends who loved him. He had financial security, good food to eat (Lisa is a hell of a cook), loving ears to listen and a support system that is probably more well-connected to social services than any in our city.
Lisa and Alison put their heads together and came up with something to give Tucker a purpose–a reason to get up each day. They decided on getting him a puppy. They picked one out and were planning to bring it home for Tucker, but it was too late. Tucker had relapsed. They found him that morning with a syringe nearby.
I grew up in Eagle River when Oxycontin started appearing everywhere. I tried it once, unaware that I was basically putting lab-synthesized heroin into my body. None of us knew at that time. Lucky for me, all that happened was I felt something like being really stoned, and then detachedly realized I was going to barf. Through some miracle totally outside my control, I didn’t happen to feel that sudden familiarity described by lots of addicts when opioid meets neurotransmitter and, for the first time, everything is right with the world. Many of my friends and one of my family members were not so lucky. Opioids reeked havoc on my little town. I don’t know a single person who remained unaffected.
I reached out to Dr. Jay Butler to get the scope of the problem here in our state. The short answer is: it’s vast. “I’d say the opioid epidemic takes up probably half my time,” Butler says. “I don’t use the word epidemic lightly, but Alaska doesn't have any other single cause of death that’s quadrupled over a period of one decade.”
It took a little longer for the epidemic to hit Alaska, but our problem is not unique. “What we’re seeing is similar to what’s happened nationally,” Butler says. “That’s compounded now with the added danger that when a person thinks they’re buying heroin, it could actually contain fentanyl, or one of the synthetic versions [called U-47700] of it that’s available on the internet.”
Fentanyl is a prescription opioid that is 50 to 100 times as potent as morphine. When I googled U-47700 to find out what the estimated potency is (7.5 times that of morphine), second on the list of results was a web page where you can order it, as if it were shoes. More and more frequently, heroin is laced with fentanyl or a synthetic to increase its potency. What might be a normal dose of heroin is easily a fatal dose if laced with one of these and there’s no real way to tell by looking at it. According to Butler, it’s definitely here.
I asked Butler what we should do with all this. “I look at it in terms of tertiary, secondary and primary prevention,” he says. “Tertiary prevention is steps we can take to prevent the in-stage bad outcomes [overdose deaths] like increasing the availability of Naloxone to reverse the respiratory depressant effects of opioids during overdose and promoting syringe/needle exchange programs to reduce the risk of blood borne pathogens. These are measures that can save lives but don’t treat the underlying problems; they don’t cure or treat the addiction.”
He continues: “Secondary prevention is screening and treatment for addiction, which is limited here.” According to Kate Burkhart, Executive Director of the Advisory Board on Alcoholism and Drug Abuse, there are only twelve state-funded beds in Anchorage. The limited number of rehabilitation programs available to us in Alaska is problematic. This often creates a situation in which a person must wait after going through detox to transition into rehab, making it far less likely they’ll remain clean in the interim.
Butler goes on: “We also have a limited number of people who can provide medically assisted treatment. It’s really a very small minority of providers that have the DEA certification to prescribe Buprenorphine [the generic term for Suboxone, which is used to medically treat opioid addiction]. Really, any physician, nurse practitioner or physician’s assistant could provide Buprenorphine if they go through the eight-hour DEA training. Nationally, there are almost a million providers that have the DEA permit to prescribe opioids, but there are only about 35,000 that have the DEA approval to prescribe buprenorphine. That’s a pretty remarkable inequity.”
Turns out, Tucker wasn’t just being obstinate about not wanting to do traditional 12-step based rehab. A study published in the Journal of Addiction in 2015 found that the risk of a fatal overdose in opioid addicted patients receiving only psychological treatment was twice that of patients also receiving medically-assisted treatment. These findings are not isolated, but most available treatment programs for addicts are still based on a design that was dreamed up back when neuroscience was a new concept and addiction was viewed entirely as a moral failing.
The first line of defense, in Butler’s estimation, is the one that he thinks will prove the most difficult to implement. “Primary prevention is a lot tougher because now we’re trying to address the question ‘why do people self medicate?’ It’s not as easy as just saying that someone’s had a hard life. There are genetic determinants, but we also know that people who have higher numbers of adverse childhood experiences are at higher risk of addiction. Knowing how to prevent those adverse experiences and to mitigate them when they occur is a larger issue.”
He continues: “Another part of primary prevention is addressing the supply of opioids in the community and encouraging more rational pain management and not always going to opioids as the first line.” One example is “when I had my wisdom teeth removed, the dentist told me that if it hurt I should take some Tylenol. My daughter had her wisdom teeth pulled and had about 30 Oxycodone dispensed. This is how we end up with lots of these pills in our household that can then be used inappropriately or stolen.”
“The biggest barrier to treatment is the stigma,” he says. “To address that, we’ve got to look at the neuroscience that shows that addiction is a chronic condition affecting the brain. It’s not a moral failing, it’s not a lifelong string of bad decisions or low intelligence. It’s a disease affecting the brain just as diabetes is a chronic disease affecting the pancreas. After repeated exposures, the way the brain works is altered. It can take months, even years, for full recovery. That’s actually one of the reasons that I hate the term ‘detox,’ because it implies that someone can go into a treatment facility for two weeks and come out good as new.”
Butler cites chapter two of the Surgeon General’s report on Alcohol, Drugs and Health released last month. It’s a relatively easy-to-understand explanation of how the chemistry in our brain changes as a result of repeated exposure to opioids. Chapter two explains how addiction essentially hijacks the functions of three areas of our brains that help to direct us in normal life.
Each region of our brain, when operating as a response to normal stimuli, is useful. We feel pleasure when we eat food or have sex because that’s how we process fuel and reproduce. We feel anxiety or stress when in danger so that we know to avoid it. We prioritize life and regulate our impulses based on our general hierarchy of needs–food and shelter first, and so on.
In the presence of opioids, more dramatically than any other class of drugs, these processes get confused. We feel pleasure in the basal ganglia as a result of the opioid binding to our dopamine receptors, anxiety and stress in the extended amygdala when the drug wears off and the prefrontal cortex does an overhaul in priorities with the top of the list being recategorized toward getting that initial, overwhelming pleasure back into our bodies as soon as possible.
This process happens more quickly in some people than in others. In those with a genetic predisposition to addiction, combined with a higher number of adverse childhood experiences, it can happen rapidly. One of the scarier graphics in the Surgeon General’s report shows fMRI images of three brains after stopping use of cocaine. The brain on the left, belonging to a person without a history of cocaine abuse, shows two bright red splotches indicating regular levels of dopamine receptors after cessation of cocaine use. The middle and right brains belong to someone who had a history of cocaine abuse at one month and at four months after cocaine use stopped. Both of the latter images show two yellow splotches where the red should be, indicating that even after four months without cocaine regular levels of dopamine receptors have not returned. In relatable terms, since dopamine is responsible for feelings or pleasure, that means that an addict who stops using drugs can predictably face many long months without the ability to feel good.
Sometimes, the response I hear from people when talking about this issue is a dismissive one. Something like, “I guess he shouldn’t have tried heroin in the first place.” But, as Butler points out, the opioid epidemic is a different animal. “We’ve almost all been touched by this epidemic,” he says, “I saw one survey before the election asking voters to rank what was most important to them and one issue that was high on the list, whether they voted for Clinton or Trump, was the opioid epidemic. We often tend to classify addiction as starting with risky behaviors, but in this case we know that 80 percent of people who use heroin started with prescription opioids. Not with some drug dealer in some parking lot, but a trusted physician or healthcare provider or a well-meaning family member who’s sharing extra medication. It’s a story of the road to hell being paved with good intentions. Most providers have prescribed opioids in an attempt to treat pain but the risk has not been worth the benefits.”
Indeed, if the only way to convince you that this problem is worth your attention is to express it in terms of your tax dollars, I will add one more staggering number from the Surgeon General’s report: “Substance misuse and substance use disorders are estimated to cost society $442 billion each year in health care costs, lost productivity and criminal justice costs.”
For sake of comparison, the United Nations has estimated that it would cost $30 billion a year to end world hunger. It would cost $20 billion a year, according to Housing and Urban Development, to house all the homeless people in the United States. According to the Census Bureau, it would take $175.3 billion to bring every person in the U.S. up to the poverty line.
Lisa and I sat down to have lunch last week and to talk more about her oldest boy. “I’ve had a meeting with the governor's office already this week to talk about what we can do at a state level to make sure that this doesn’t continue to happen because we’re going to lose a whole generation of really smart kids,” she says. “We already are losing them. We talked about how traditional methods of treatment that have worked for past generations aren’t as effective for this one, among other things, but it was really just an information gathering meeting. I believe we’ve got to do something different than what we’ve always done.”
If there is a silver lining around this god-awful tragedy, however thin and meager, it’s that people with influence are finally starting to make moves. “Senator Sullivan was down at Beans [Café] the other day and he was talking to a young woman who’s a heroin addict, who’s been trying to get help and eventually they figured out that she’s his wife’s cousin,” Lisa says. “Here he is, a United States Senator, and here’s his wife’s cousin at a homeless shelter and can’t get help for her addiction, so he’s gotten involved. He held a roundtable meeting this summer to talk about the opioid problem. It’s encouraging that people at all levels are talking about it; we just have to figure out what to do, how to put all these good intentions into actions.”
She went on: “We have to talk about this. For so long, people were ashamed. Nobody wants to admit that their child is a heroin addict. We need to get over that. I’ve joked [about how] Tucker was always an overachiever [and] if he was going to be a heroin addict, he was going to be the best damn heroin addict there is. He did everything 110 percent. People that have that addictive personality can find a positive outlet for it or a negative outlet and unfortunately Tucker never found it.”
“People were always drawn to Tucker,” Lisa says, “He always had a lot of friends, was so charming, if you met him once you remembered him.” After a spell, I asked Lisa if her husband, Tucker’s dad, is as outgoing and vivacious as she is. “No,” she said, “he’s a little more introverted. Tucker is more like me than any of our kids.” At this, we both looked down at the counter in front of us. I imagine she was wondering how many more times she was going to slip and say “is” and then suffer another blow to the heart when a voice reminds her that her grammar in that statement was inaccurate.
She went on, explaining that Tucker was never under any illusions about how it was all going to turn out if he couldn’t get clean. “I used to tell Tucker, ‘If you don’t stop using you’re going to end up in jail or dead.’ He knew. We talked very frankly. But he went through so much, medically. So much suffering and pain with the pneumonia and being on the ventilator for almost a month and then open heart surgery and after all that to still have that undeniable pull for that drug. It’s just astounding. I’m just thankful he was home and we all had a chance to reconnect with him, get to know him again, before he left.”
A special fund has been created at Covenant House that is designated to help fund gaps between treatment services. If you’d like to help, all you have to do is write “Tucker Fund” in the memo section of a check made payable to Covenant House. Contact Covenant House at 907-272-1255.
CORRECTION: A previous version of this story misquoted Dr. Jay Butler as stating there are about 5,000 providers that have DEA approval to prescribe buprenorphine. The number is around 35,000.