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High school, 1997, was off to a great start for Mark Gagarin.

He had been bullied some in middle school, but he was determined that his time at Poway High was going to be different.

“I met this awesome girl, I was playing baseball. I had a lot of friends around me,” he said. He was hanging out with the cool kids, the ones who hung out in the quad.

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[highlight]On the radio…[/highlight]

[box type=”shadow this-matters”]Opioid addiction has claimed thousands of lives in San Diego County. Understanding who is dying and how addiction has changed over the last 15 years is central to confronting the addiction epidemic.[/box]

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Baseball had always been a part of his life. Now he’d earned a spot as the second baseman and leadoff batter for the freshman team. This is at a school that has produced professional baseball players, including Tony Gwynn Jr., who is now on the Dodgers broadcast team, and Alex Dickerson, a Padres outfielder.

But there were some jagged edges. Alcohol blunted them. Maybe he had learning disorders, maybe he just wasn’t smart enough. The drinking came with partying and drugs, especially cocaine.

Baseball, once a relief, became another pressure point. It stopped being fun; it felt like the games mattered more to the parents than the kids. Ball players weren’t even allowed to skateboard during the season to avoid injuries.

“We wanted to have fun, and that’s why we did it,” he said. “But they wanted more than that.”

He and a few other players walked away from the game. Soon, Mark was out of high school entirely. His junior year he dropped out. At 17, he was arrested for breaking into homes looking for things to steal and sell; he said he did it to get money for drugs.

Mark didn’t know it, but he was on the leading edge of a wave of prescription pill and opioid addiction that would sweep through San Diego County in a way no one had anticipated.

Opioid deaths had long been common in downtown San Diego and in City Heights, and those numbers stayed steady. But starting around 2007 deaths spiked in communities where people rarely had died of opioid overdoses. Although the numbers weren’t huge, they marked a significant increase.

Seven people died from opioids in Poway between 2000 and 2007. Twenty-four died between 2008 and 2015. During those same time periods Oceanside went from 51 total deaths to 93. Clairemont went from 13 total deaths to 33. Many of those dying were young, most were white and most were men.

At 17, Mark went into treatment through the McAlister Institute, a network of addiction service providers, including residential and outpatient programs. Around that time, he broke his ankle skateboarding. A doctor prescribed Vicodin.

“It was one of those things where it was like, cool, a doctor can give these to me and I can feel better than ever on them,” he said.

Then at 18 and on probation for that break-in charge, he entered the Sharp McDonald Center, his second rehab stint. He liked it, a vacation stay. The center had volleyball courts and meditation gardens. He was doing cocaine at the time and decided that was the problem, so he gave up cocaine.

But he didn’t stay sober for long.

“I ended up doing a lot of different cocktails or just different things to try to find something that I could still have fun, not get in trouble and live a somewhat normal life,” Mark said.

That’s what he did for the next 10 years.

By 2012, Mark Gagarin, 5-foot-7, former star baseball player, was down to 130 pounds, with a relentless twitch in his left eye. Now 28, he was living with his parents, without a job or money.

“Nobody even knew I was living anymore,” he said. “I had no drive or ambitions for anything, and the craziest part about that was, I remembered when I did.”

Those ambitions — play baseball, start a family, do something with your life — melted away, replaced with some 200 milligrams a day of opioid painkillers, tranquilizers and muscle relaxants. It was the first time he wondered, how did I get here?

“It was just like quicksand stretched around me and it was just me in this abyss of just, hell and darkness and struggle.”

When Mark went to sleep on Feb. 28 he knew he was running out of time. He didn’t care.

Had he died that day, he would have been one of the thousands of victims of a national epidemic.

In San Diego County, there were almost 3,500 opioid-involved deaths between 2000-2015. At the beginning of that period there was one death every 53 hours. But the interval is shrinking. For the most recent year there was a death every 33 hours.

Among the dead in Poway, a city of fewer than 50,000, a 15-year-old boy overdosed on morphine in 2009. A 19-year-old man overdosed on a cocktail of methadone, cocaine and tranquilizers in 2010. A 21-year-old man died from heroin in 2012. A 21-year-old woman overdosed on heroin in 2014.

Although traditionally, older people who might have heart, liver or lung disease make up the bulk of unintended drug and alcohol deaths, younger overdose victims are no fluke, said Dr. Jonathan Lucas, deputy chief medical examiner in San Diego County.

In the early 2000s, about 20 people per year who were between 20 and 29 years old died from opioids. Now it is closer to 40 per year.

Christy Enos is a regional director for the San Diego Comprehensive Treatment Center. It’s part of a nationwide network of methadone clinics, including five in San Diego County.

She saw the population coming into her clinics change.

“We’re seeing a lot more younger men coming into treatment, where maybe 10 years ago we had a different patient population,” she said.

Another way to track opioid use is to look at where pills are dispensed. Some ZIP codes are awash in the painkilling, tranquilizing pills. In the East County communities of Jacumba, Boulevard and Guatay last year, the equivalent of more than 100 pills were dispensed for every person, including children. In the tiny North County community of Palomar Mountain, there were 440 pills dispensed for every resident. The county average was 37. These are pills prescribed by doctors. They don’t include what people buy illicitly.

Some of these places have an older population, with median ages in the 50s and 60s. That could correlate with conditions, such as chronic pain, that are linked to prescriptions. The numbers don’t necessarily mean those patients are addicted, but they hint at the flow of legal drugs throughout the county.

The communities with the highest numbers of painkiller pills per person tend to be rural and with relatively small populations. None of the top 10 ZIP codes for prescription pills has a population greater than 3,000.

Another measure of the epidemic is emergency room visits due to opioids. They tripled between 2006 and 2014 for people 20 to 39.

Twenty- and 30-somethings aren’t the majority of opioid deaths, but they do account for more than half the ER visits, according to the California Department of Public Health. Even these nonfatal opioid overdoses can leave devastation in their wake.

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Aaron’s tale

Sherrie Rubin was oblivious as opioids rolled through Poway, a community with a median household income of $96,000 and a poverty rate just one third of the state’s. Unaware even when they came into her home.

Young people in her circle, the children of friends, lost their lives. She can think of six families close to her that lost a child to an overdose. Yet Sherrie saw parents stay silent, out of shame.

“A lot of them would just say their heart stopped, or wouldn’t really say anything at all,” she said. “But 23-year-old young adults don’t just die for no reason.”

If there’s anyone who is attuned to addiction, aware of the damage drugs and alcohol wreak on a family, it’s Sherrie Rubin. Her brother and sister were addicted. So was her biological father.

When he came around, a rare occurrence, he was emotionally and physically abusive to her mother. Sherrie was the oldest and tried to protect them, for example, by telling her father that she needed her mom to take her to the bathroom.

“That’s all I could do as a child,” she said.

She could smell the alcohol on his breath and developed an aversion to it. When her son Aaron was in high school, he would go to parties and drink. So did some of her other children. Her husband saw it as just part of growing up, a rite of passage. Sherrie disagreed.

Often, the drinking followed football games. Aaron wasn’t a natural but he worked hard and got on the team as a strong safety and linebacker. Working out became a big part of his life.

When his parents found out he was using steroids, he switched to Muscle Milk, a protein shake. But signs of a budding prescription pill addiction began to show.

“His sleeping habits were changed, he had sweating off and on, he would get leg cramps, he had flu-like symptoms,” Sherrie said. But they chalked it up to his constant workouts and job as a personal trainer.

In high school in 1998 Aaron started taking painkillers to help with injuries or to recover after football games. It started with Vicodin. It eventually grew to muscle relaxants such as Soma and other opioid pills like Percocet and Norco. During an unsuccessful stint at junior college in Chico, he started using OxyContin.

In 2004, he came back to San Diego, enrolled at Mesa College and joined the football team. And then, suddenly, after the first semester, he asked for help.

“He came to us and said, ‘I’m sorry, I need help, I have a drug addiction,’” Sherrie said. “And honestly we didn’t ask him what kind of drug.”

Aaron’s parents assumed he abused alcohol and street drugs, like cocaine, and got him a therapist and a psychologist. His father took him to Alcoholics Anonymous and Narcotics Anonymous meetings. They still didn’t realize their son was not the only one, that opioid addiction and overdoses were becoming common in communities untouched by them before. The gap of understanding was still so wide.

“I didn’t know or comprehend that anyone would take prescription drugs for fun or just to take them,” Sherrie said.

In 2005, the Rubins attended the funeral of the son of a family friend, a 30-year-old man who died from opioids. Aaron sat in the second row with his dad.

“My husband started crying and my son put his arm around his dad and said, ‘Don’t worry, Dad, this’ll never happen to me,’” Sherrie said.

One month later, Aaron was in a coma, unresponsive. On Oct. 9, 2005, he had taken a 160 milligram pill of time-released OxyContin at a friend’s house. Then, a few hours later, a second one. Then he went to sleep.

The pills shut down his heart. At 23, he suffered a heart attack and two strokes, one on each side of his brain. His body began shutting down.

Hospitalized, Aaron started having seizures. A couple of friends were in the room with a nurse.

“She yelled at them and said, ‘How long has he been Oxy dependent? How long has he been Oxy dependent?’” Sherrie said. “And honestly, I had no idea what she was talking about.”

Aaron stayed in a coma for a month.

From the ICU and subacute care, Aaron’s parents took him to a brain injury facility in Pomona. They spent a year there.

“That whole year I kept thinking to myself, why did this happen to Aaron? Why our family, why my son?” Sherrie said. “I had no idea that all of these other children and young adults were dying from OxyContin.”

Today he is quadriplegic, unable to speak.

“He answers with his hands and his fingers, one for yes and two for no,” Sherrie said. She is his full-time caretaker.

In 2007 the Rubins came back to San Diego, and Sherrie happened to see an old family friend, Virginia, on TV. She was talking about the OxyContin overdose death of her son, Joseph. She thought back to that moment in the hospital, the nurse asking about his OxyContin dependency, and now it clicked, this was an epidemic.

Over the next decade, Sherrie launched herself into the fight against opioids. She started a foundation, the Hope2gether Foundation (Heroin, Opiate and Prescription pill Education). She started speaking at high schools about prescription pill abuse, starting with Aaron’s alma mater, Poway High.

Understanding the opioid epidemic in San Diego means grappling with the demographics of death. It means understanding that many victims look like Aaron, young white men.

San Diego County residents are an almost perfect 50/50 split between men and women. But men make up two thirds of opioid deaths and opioid-related ER visits.

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Men have always been overrepresented in drug deaths. They make up as much as three quarters of cocaine, alcohol and meth deaths. (Women die disproportionately only from antidepressants.)

Victims are also mostly white.

Fewer than 47 percent of county residents are white yet they make up more than three quarters of opioid overdose victims. Others who die from prescription pill overdoses, such as tranquilizers, are even more overwhelmingly white.

A recent study found nationwide trends of higher mortality for whites, in part because of deaths from drug abuse and suicide. The study found sources of distress among whites such as worsening “self-reported health, mental health, and ability to work.”

Asians and Hispanics are just not using these drugs as much. Asians account for 10 percent of the people in San Diego County, but less than 1 percent of opioid overdose victims.

Hispanics are a bit more nuanced. They make up a third of county residents, but only 14 percent of opioid deaths and a quarter of opioid-related ER visits.

Cracking down

Thomas Lenox was assigned to pharmaceuticals in the San Diego office of the Drug Enforcement Administration in 2008. Up until then, he’d worked cocaine and methamphetamines during his more than two decades in the department.

Just a few months into the job, he got a glimpse at the unfolding epidemic. He was investigating a 26-year-old woman who purchased about 1,500 pills a month by going from doctor to doctor online.

“In the middle of the investigation, I was at a pharmacy doing an interview and following up on some leads and she actually showed up in the pharmacy and was in line behind me trying to get pills,” he said.

She’d been in and out of rehab and took “almost 50 pills a day.” When he interviewed her a few months later, he found out she had tried to commit suicide by swallowing a whole bottleful.

“Her tolerance was so high it didn’t take effect, and she woke up the next morning,” Lenox said. “I said, ‘What happened?’ She says, ‘I went out to get more pills.’”

There were still plenty of pharmaceutical cases, like this one. But Lenox also stood on the front lines of another trend.

By 2008, a federal crackdown on prescription pills made them much more difficult to score. Now a supervisory special agent at the DEA, Lenox saw the pressure, watched addicts adapt.

“As it became harder for these people to get the opioids, all of a sudden now they’re switching to heroin,” he said.



One of those about to make the switch was Mark Gagarin, now 25.

“We weren’t able to get OxyContin at the time, and they were so similar,” he said. A friend of a friend could get heroin and Mark started shooting up. The first time he tried it he passed out. His friend tried feeding him and throwing him in the shower. Nothing worked.

“I woke up hours later and of course I was like, what happened. And he was like, dude, you almost died,” Mark said. “And the craziest thing is once everything was OK, we were like, OK, let’s go get more of that.”

It made him feel numb, gave him peace of mind.

It wasn’t just easier to get heroin now, it was much, much cheaper than painkillers. According to DEA spokeswoman Amy Roderick, in San Diego, a dose of OxyContin costs approximately $30 on the street, 30 milligrams at about $1 per milligram.

A hit of heroin on the other hand is a fraction of that, only $7 to $12 for Mexican white heroin. Black tar costs even less, as little as $3 dollar per high, she said. ($40 per gram with about 13 hits per gram.)

Nor does getting heroin mean going down a dark alley or dealing with hardened criminals anymore. Sometimes Mark got his heroin in Mexico. But there were dealers throughout San Diego County. He could buy in Poway or Rancho Bernardo.

“It wasn’t like what you would think, like a skid row off the side of freeway, under a bridge, it wasn’t anything like that,” he said. “It was usually kids that drove BMWs whose parents lived around San Diego or Poway that had a fair amount of money.”

Dealers saw the potential customers and followed addicts to new neighborhoods. Heroin literally moved off the streets of San Diego and into homes.

It metastasized from central San Diego to the county suburbs. The San Diego Association of Governments surveys hundreds of arrestees each year about their most recent drug use.

In 2004 the picture looked like this: Four in 10 heroin addicts being arrested said they bought on the street; one in four bought in a house or apartment. And only 6 percent bought in the suburbs, in South County or East County.

A decade later heroin users overwhelming made their buys in a house or apartment. Only one in five bought on the street. And people were buying much more in the South and East County, not downtown. One in four bought in North County.

In 2014, 29 percent of arrestees using heroin had been using prescription pills before. Of those, 82 percent said they started using heroin as a substitute for the pills.

That switch showed up in the overdoses. Rancho Peñasquitos had no heroin overdoses between 2000 and 2008 but six between 2009 and 2015. Carlsbad had two heroin deaths between 2000 and 2008, and nine in the more recent years. La Mesa had nine between 2000 and 2008 but 25 between 2009 and 2015.

As addiction and deaths moved throughout the county, the total numbers climbed. In 2000, there were 165 opioid deaths — this includes heroin — in San Diego County. In 2007 deaths numbered 222. In 2011 the death toll peaked at 272.

Since then, it’s come down slightly. Last year, there were 262 opioid deaths in San Diego County. Ninety-three of those who died were younger than 40. It fell to the San Diego County Medical Examiner to determine the drug, or cocktail of drugs, that killed them.

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Chemical structure of various opioid drugs. Illustration by Ben Chlapek

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Cause of death

The unit’s deputy chief, Dr. Lucas, and his team of investigators get a call whenever cops find a dead body.

An overdose is often obvious.

“People have dozens of medication bottles and pills all over the place,” he said. “Those are the easy ones.”

Opioids kill primarily by slowing down a person’s breathing. It can take several minutes for oxygen to stop flowing to the brain, killing the person. Fluid builds up in the lungs.

“The fluid becomes foamy and it can actually start coming out of the nose and mouth and so when you die, when you’re found, you have this, what they call a foam cone, dried just sitting on your face,” he said.

The death might not be that direct. Smaller overdoses might not kill, but might lead to the lung fluid buildup and then pneumonia.

What Lucas and his team see more of are drug cocktails, a trend that is also mirrored across the country.

Of the almost 3,500 opioid deaths between 2000 and 2015 in San Diego County, fewer than one quarter involved just a single substance, and only about one in 10 was from heroin alone. The vast majority of users are mixing.

By contrast, two thirds of the methamphetamine deaths in the county during that time were from meth alone.

Combining an opioid such as heroin or codeine with a benzodiazepine such as Xanax or Ativan allows addicts to calibrate their highs.

“Those also have an additive effect,” Lucas said. “And actually the benzo-opioid combination is a huge component of the deaths that we see.”

Mark knew those cocktails well. At 25, he entered rehab again, this time at Sharp, to kick the heroin addiction. Soon, he fell back to prescription pills. They seemed cleaner, more respectable.

“If I was on pills then it wouldn’t be as bad, I’d just be kind of like a regular person with a doctor’s note,” he said. With prescription pills, “you’re not a heroin addict.”

The pills were expensive, but he had a friend whose father had passed away from cancer and left behind bottles of them.

In 2012, at 28, he employed a Monday through Sunday pill case, like the ones patients with chronic conditions have. He’d mix in his own combinations and take them throughout the day.

That included two 80 milligram pills of OxyContin, three or four Xanax, three or four Vicodin, five Somas and 20 milligrams of Valium.

“I never seemed to make it,” he said. “I would always get to Wednesday and they’d all be gone.”

He didn’t have a job and was collecting unemployment. For two years he rode a constant cycle of high and withdrawal.

“I’d be sick all the way up until I’d get my unemployment money and then from that point I would end up getting whatever I needed, just to get well for a little bit,” he said.

He’d go whole weeks doing nothing but being dope sick.

“It was literally hell,” he said.

That’s where Mark found himself the night of Feb. 28, 2012.

“I went to sleep, I didn’t have any hope in the idea of getting sober and starting to change,” he said. “I was just at a place where I didn’t really care anymore.”

Cleaning up

When he woke up the next morning, Feb. 29, something had changed.

“I don’t know what it was that was in me or what had happened but … I woke up and I knew at that time, I was going to die,” he said. “I knew it was like, I got to go, I need to go and get help now.”

It wasn’t the first time he’d said that. But this time, he said, it was different. He realized the problem wasn’t heroin or OxyContin or any one drug. It was the addiction, not the rotating cast of chemicals. And he knew he didn’t have a lot of time to get help.

“I knew I was really good at talking myself back into doing stupid things,” he said. “I need to leave and go to a place and try all of these things that I had tried in the past that I never really fully went for.”

Mark asked his parents for help. By lunchtime that day he enrolled at Tender Loving Mercy in Oceanside.

“When you have an addict that says, ‘OK, I want to get help,’ that’s a very short window,” Sherrie Rubin said. Because as soon as the agony of withdrawal hits, “They’re going to say, ‘No, I don’t want to do this.’”

Mark was lucky he was able to get treatment within that window. He was also lucky he came to his realization voluntarily.

Alfredo Aguirre is the director of San Diego County Behavioral Health Services. His agency oversees drug and alcohol treatment centers, both contracted and county run.

“On one hand, there’s almost a spiritual awakening by the individual that, I better get my act together or I’m gonna be dead by 27,” Aguirre said. Others come to that realization through law enforcement and court-mandated sobriety and recovery.

“Even with people that go through drug court it often takes two, three, four times before they really stick to the program and stay and really stick to their sobriety,” he said.

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From there, what services addicts can access depends on their finances — or their family’s finances — and their access to private health insurance.

“We know we are in essence basically the safety net for the low income community,” he said.

For Aguirre, providing drug and alcohol treatment also means providing a broad range of options for patients. That can include narcotic treatment providers, often known as methadone clinics.

Debbie Hamilton is the clinic director of the Fashion Valley Comprehensive Treatment Center.

The clinic provides crave-blocking medication such as methadone, Suboxone and Vivitrol. Doctors with the clinic prescribe it as part of treatment plan that includes comprehensive counseling.

“(The medication) kind of helps them focus on their recovery and the treatment plan and treatment goals that they work on with their counselor instead of just focusing on using,” Hamilton said.

Every day, patients visit the clinic and take their assigned dose in front of a nurse. If they manage to stay clean and make progress on their goals, such as enrolling in school or finding housing, they can earn some medication to take at home.

“After about three to four months that they’re in treatment we can start them out on a weekend take home,” Hamilton said.

In San Diego, it usually takes between nine and 12 months for patients to wean themselves completely off their medication dose. But that’s only part of the recovery.

“I think there is some myth that when you get clean and you stop using drugs that life is beautiful and wonderful after that,” Hamilton said. “Well, guess what, life goes on and the same stuff that was happening before, the bad staff and the disappointments and blowups with family or partners, those still happen.”

Counseling and recovery involves learning new coping skills.

For Mark, March 1, 2012, stands as his first full day sober. He ended up staying in Oceanside for a year. That was year one.

“I was like an infant, like brand new, ready to look at things differently, ready to learn differently and ready to maybe accept all those things that I didn’t accept growing up,” he said.

He also had to learn basic life skills. At 28, he started figuring out how to pay taxes and hold a job.

“Year two, I went into this frantic dash to help people,” he said. He started working, getting a job at an electrical company. And got involved in his church. There, he met his future wife.

Year three, he tackled adult school and finally got his GED.

“I thought I had so many learning disorders growing up, that I just wasn’t smart enough,” he said. He was asked to be a speaker at his graduation.

He enrolled in college, a four-year program to get his journeyman electrician license.

Year four, he returned to Poway High to speak to students about drug and alcohol addiction. And he got married. As he said his vows at the wedding ceremony, he thought for the second time in his life, “How did I get here?”

Mark knows he’s fortunate. He can think of more than a dozen people close to him who didn’t make it.

“Casey, Ramon, my best friend Lewis, this girl Stephanie, just a lot of people I can think of that just didn’t make it,” he said. “Didn’t get the chance to, you know.”

Some numbers indicate opioid use is flattening in San Diego, but it’s not for sure. What is certain is that, as in the rest of the country, people seeking an opioid high are turning to an even more powerful drug, fentanyl.

“(There’s) not only a trend in the number of deaths that are increasing due to fentanyl, but we’re seeing the emergence of these synthetic fentanyls or fentanyl analogs that people are synthesizing to act like fentanyl,” said Lucas, the deputy medical examiner.

Last year there were 29 deaths related to fentanyl, the highest number in county data going back to 2000.

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[/box][/one_half]Before, price made those drugs prohibitive. Now, cheaper versions manufactured in China are smuggled locally, he said.

Special agent Lenox at the DEA also worries about the surging fentanyl. He’s particularly worried about those illicit pills.

“Just in the last year, seven people in San Diego County, I believe, overdosed and died from the clandestine fentanyl, whereas two years ago there was nobody. Zero,” he said. “And we’re up to seven.

“How high will it go?”

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Click here and tell us what you think about this project and what aspect of opioid abuse we should look at next.

Leo Castaneda wrote this story while participating in the California Health Journalism Fellowship, a program of the Center for Health Journalism at the USC Annenberg School for Communication and Journalism. [/two_third]