COVENTRY, RI — More than eight years into his opioid-addiction treatment, Paul Moore was shooting cocaine into his arms and legs up to 20 times a day so he could “feel something.”

The buprenorphine he took to quell cravings for opioids couldn’t satisfy his need to get high. Moore said he treated himself like a "garbage can," ingesting any drug and drink he could get, but soon enough, alcohol and weed had almost no effect unless he vaped the highest-THC medical marijuana available.

Cocaine, however, especially if it was mainlined — now that could jolt him from his lifelong depression to euphoria.

It was early 2017 and Moore was sleeping in his car. When he was high — which was all time — he was banned from the house he shared in the Providence suburb with his wife and two adult children. He was working in the phone department at Walmart and had lost the will or ability to do the art he studied in college or write the poetry that was his passion.

By September, he attempted suicide for maybe the fifth time, he'd lost count.

"I had been sober," said Moore, 49. "I thought, 'I can’t be sober again."

Like most people with opioid addiction, he had other addictions that could not be helped by the medication for his opioid-use disorder. Moore, who’s been in recovery program now for 16 months, suffered from what's known as "polysubstance use disorder."

Federal data show nearly 60% of adults with a prescription pain-pill addiction and 77% of those with heroin addiction are also addicted to at least one other drug or alcohol.

The country is in an "addiction crisis," not just an opioid one, said Tom Coderre, a former Obama Administration health official, who is now a senior adviser to Rhode Island Gov. Gina Raimondo.

When Coderre returned to his home state to head the governor's addiction response in January 2018 he refused to call himself the "opiod czar" as some urged. Even in 2015, when a task force appointed by Raimondo proposed a "strategic plan for overdose and addiction," the state realized it had a bigger problem. In the first eight months of that year, cocaine was a contributing cause of death in 44 of 119 overdose deaths.

Like many state officials, Coderre thinks money ought to be available to cover treatment for a wide range of addictions, as well as the mental health and social needs of people with addiction.

"There are many pathways to recovery," said Coderre, a former state senator who has been in recovery from alcohol and crack cocaine since 2004. "People need options so we are trying to be innovative and recognize that not one size fits all."

In 2017 and 2018 alone, the Department of Health and Human Services and other federal agencies unleashed $11 billion to fight the opioid epidemic. Last week, President Trump announced he was releasing nearly another billion to make the opioid-overdose antidote naloxone more available and to enhance medication-assisted treatment offerings, considered best practices for the addiction that has been labelled a national epidemic.

Meanwhile, state health officials have been urging the federal government for flexibility in spending anti-opioid money. Earlier this year, Mark Stringer, director of Missouri's Department of Mental Health, called on a Senate Appropriations subcommittee to start transitioning from opioid-only grants to states' existing "Substance Abuse Prevention and Treatment" block grants to meet changing demands.

Sen. Rob Portman, R-Ohio, introduced legislation in June that would let states use some of their "State Opioid Response" grant money to fight the “resurgence of psychostimulants," including meth and cocaine, to better "address the on-the-ground reality of addiction in my state and many others.”

Meth and cocaine are pouring into the United States, providing ample alternatives for the already-drug-addicted population as well as newcomers. Benzodiazepines, which treat anxiety and depression, are regularly misused and dangerously combined with stimulants and alcohol, experts say.

Few are dying as fast as those who overdose on opioids. And polysubstance use is particularly lethal when the synthetic opioid fentanyl is part of the mix of drugs. In 2016 and 2017, 200 people died a day from an overdose, 130 of them from an opioid, according to Department of Health and Human Services data.

"Opiates have gained so much attention because of how lethal they are, but with alcoholism, meth, amphetamines and coke, there’s still an addiction pandemic outside of that," said Scott Strode, founder of the national sober active community organization, The Phoenix. "We're often just treating the symptoms — like giving an Advil for a brain tumor — when people are saying 'Help save me,' from the toxic environment that created the situation for them."

Suboxone was the 'miracle drug' to end her addiction

Caitlin Laws of Myrtle Beach, South Carolina, said she started using opioids at 14. By 18, she was shooting them.

“I’d use anything I could get my hands on,” she said, including black-tar and powder heroin, fentanyl and OxyContin. Then at 20, she got on Suboxone, which her doctor called “a miracle drug” that would end her opioid-use disorder.

It worked. She stopped using opioids. But the medication did not deter Laws from using other kinds of drugs to alter her state of mind. This was addiction, she said, and she could not stop.

“I used cocaine for a long time after getting on Subs,” says Laws, referring to the Suboxone. “It was the only drug I knew I could feel through the buprenorphine.”

Somehow, she was able to kick the cocaine. The "breaking point," she said, was "probably the fact that I was getting threats of my parents taking custody of my daughter."

She’s been sober since 2013 and is a happily married mother of two young children, Flynn, 10, and Ryan, 3.

"My life is honestly normal," said Laws. "I am working on the start of a blog to be called 'Caitlin Chronicles,' and it’s going to be, basically, my story."

She also runs a social media support group for pregnant women in medication-assisted treatment. Suboxone, she said, may have saved her life, but she doesn’t think opioid addiction should be the nation’s sole concern with addiction.

“All drugs need to be focused on,” Laws said. “I don’t know too many addicts that are drug-specific. Most want anything they can get their hands on.”

Those who have addiction or treat it know there's no one answer or set of solutions to the problems that lead people to abuse drugs and alcohol. Nearly half of those suffering from addiction also have a mental health disorder. And fewer than 10% of those who have co-occurring addiction and mental health disorder get any kind of treatment.

The best treatment, experts say, is like that of any other chronic condition. “There would be a biological, psychological and social aspect to any chronic disease,” said Navdeep Kang, a behavioral psychologist who has been a front-line treatment advocate in the opioid epidemic in Greater Cincinnati. “And truly comprehensive treatment would address all of those aspects. That would be for diabetes, heart disease, substance-use disorder.”

Opioid treatment not a 'home run'

CleanSlate Outpatient Addiction Medicine is based in New Bedford, Massachusetts, and operates in 11 states. It provides integrated mental health and addiction treatment for crack cocaine and Adderall addictions in the Northeast or meth in Indiana, said Dr. Tracey Cohen, CleanSlate's chief clinical officer. Care coordinators and peer counselors who are also in recovery are key.

Opioid treatment is "not a home run" if other addictions are "unaddressed and untreated," said Cohen, a psychiatrist and addiction medicine physician. While she'd "never say there's too much spent on opioid use disorder," she thinks grants are needed to support work addressing polysubstance disorder as well.

Tess Ford needed in-patient treatment, confidence — and all new friends, the 30-year-old said. She got the treatment during a 90-day stay at New Directions for Women in Costa Mesa, California. The confidence and friends came during twice-weekly workouts at The Phoenix. She continued after her discharge and now is a volunteer rock climbing instructor and training for yoga teacher certification.

"The advice I give to people is 'Don’t talk to your old friends,'" said Ford. "One thing I did this time. I found a new group of friends."

Ford says she was put on medication when she was 13 for anxiety, which helped convince her she wasn't normal. Soon, she was drinking to fit in and wound up addicted to opioids and other drugs.

"I’m a little quirky and I really hated that about myself so I tried really hard to conform," said. Drinking and drugs would "quiet all the noise in my head."

Strode, who founded The Phoenix in 2006, was addicted to alcohol and crack cocaine until he entered recovery 22 years ago. He believes his addiction sprung from childhood trauma and the emotional abuse living with an alcoholic father who suffered from mental illness.

The center’s code of conduct — "anything that isn't nurturing isn't welcome" —acknowledges the history of trauma many people with addiction disorders have, he said. Anyone is welcome as long as they’ve been sober for 48 hours, which "removes the shame and reduces the duration of relapse."

"They're finding healthy nurturing attachment I didn’t have when I was younger," said Strode. "For a lot of our folks, it's the first time they're finding that."

BEYOND A BAND-AID SOLUTION

Research shows substance-use disorders involving more than one drug last longer and are more difficult to treat so require more tailored and intensive treatment.

"When strategies are too tightly focused on a particular addictive substance, they fail to take into account the high likelihood that individuals will simply replace one addictive drug for another if the underlying causes of addiction have not been adequately addressed," said Linda Richter, director of policy research and analysis at the Center on Addiction.

"This is glaringly evident now, as we see the opioid epidemic morphing into a stimulant epidemic, driven largely by a narrow focus on addressing the opioid crisis with band-aid solutions that have not tackled the more complex underlying drivers of addiction."

Dr. Mina “Mike” Kalfas, a certified addiction physician in Northern Kentucky, said addiction should always be the focus, but he cautioned that those with opioid use disorder are not likely to abandon these “downers” for long. And they are still woefully under-treated.

He pointed to adolescents, who often start using drugs in a partying mode, drinking alcohol or smoking marijuana or maybe swallowing some pain pills to have fun. Some of them develop an addiction to opioids. And all along their drug-use path, Kalfas said, “They learn bad coping skills."

“Everything hits the fan and they reach for something to get numb," says Kalfas. "Then they reach for other drugs.”

It may appear users are “switching” from heroin or fentanyl to meth or cocaine, including crack. But Kalfas warned, “That is such a mistake. Almost all of them will go back to heroin. Their brain is so wired to the opioid.”

He’s all for additional help for people with other addiction disorders, as long as the opioid addiction is also treated.

First mom left, then bullying, booze and drugs

Paul Moore's early years are a jumble of traumatic memories that include his mother moving out when he was a toddler and bullying at school because he was overweight. He started drinking at 14. Alcohol "was like a magic button and woof! All my fears and worries were squashed," he said. "I thought, 'I've never felt as good as I do now.'"

He has been diagnosed with bi-polar and post-traumatic stress disorders, but Moore credits a recovery program he elects not to name for his continuing sobriety. He now journals, volunteers at a food pantry, helps care for his very ill mother and mother in law, who is in hospice. He hopes to write a book.

"Addiction grows in dysfunction and with neglect at home and in school," he said. "More awareness of this and community outreach could lead to positive growth for future generations."

Moore got back the home and family he lost, but many people grappling with his level of addiction and mental health challenges never do. That's among the reasons Coderre says Rhode Island decided to go far beyond medication-assisted treatment, to include prevention, robust counseling services — which came after Moore could benefit from them — and wrap-around services that include peer supports in recovery and assistance with housing, jobs and education.

"Addiction frequently robs us of our relationships" says Coderre. "It takes time to rebuild those relationships. Sometimes the recovery community becomes that community."

O'Donnell reported from Rhode Island and McLean, Va. DeMio, of the Cincinnati Enquirer, reported from Cincinnati and Northern Kentucky.