Jill Disis

jill.disis@indystar.com

Joshua Fletcher remembers the day he died.

One minute, he was sitting in his step-father's pickup truck, parked in the driveway of his mother's South Bend home.

It was his 22nd birthday. His friends and family were waiting inside to celebrate.

Suddenly, Fletcher was unconscious, and if not for his mother frantically pumping his chest and trying to restart his heart, he would have never woken up.

His family called 911, worried it was too late. Emergency crews pronounced Fletcher dead on arrival.

The next thing he knew, he was waking up in the back of an ambulance on his way to the hospital.

Fletcher didn't just lose consciousness in that pickup.

He collapsed, seconds after injecting a near-lethal dose of heroin into his arm.

"I just wanted to feel good on my birthday," the now 27-year-old Indianapolis resident says.

"It killed me."

A new kind of addict

Indianapolis authorities and drug experts say heroin use has swelled over the past two years, leading to a troubling number of overdoses and deaths unlike anything the city has seen in more than a decade.

The spike came suddenly, spotted by emergency medical technicians who noticed last year they were responding to more runs related to heroin and its sister sedatives, prescription opioids such OxyContin, Codeine and Percocet.

"I've been in this system for almost 15 years. I have not seen as much heroin in my career as I've seen in the last two years," said Scott Campbell, the east district lieutenant with the Indianapolis Emergency Medical Services department.

Consider these cases, all of which Campbell responded to in the past year:

>A Zionsville teenager who overdosed in the back of his father's SUV while driving around the city with friends. When the teen lost consciousness, his friends panicked and threw him out of the car and into the street.

>A middle-aged man who shot up in the parking lot of an Eastside auto repair shop. Employees of the shop found him slumped over the steering wheel, the car in park and his foot on the gas, burning out the engine.

>A young man found barely breathing in the bathroom of his Eastside workplace. EMS crews found a cooking spoon on the floor and the syringe needle still in his arm.

All of those overdose victims survived. About 630 times last year, EMS crews arrived fast enough to inject the patients with a powerful antidote called naloxone. The drug, used as a nasal spray or inserted intravenously, can reverse a heroin or prescription opioid overdose almost instantaneously.

But too often, authorities say, an overdose is fatal. Last year, 110 people died in Indianapolis from a fatal heroin overdose, a number that has doubled over the past three years.

The typical victim of heroin's resurgence fits a description much like many of the cases Campbell encountered over the past year. Some are teenagers and 20-somethings. Others are middle-aged.

Experts point to a host of reasons why those people are using so much heroin. In an increasing number of cases they didn't start with a syringe needle in their arm — the addiction started in their pill cabinet.

To understand heroin addiction, said Dr. Charles Miramonti, chief of Indianapolis EMS, you have to first understand prescription painkiller addiction.

The U.S. Government Accountability Office traces the painkiller boom back to 1995, when the Food and Drug Administration approved a controlled-release pain pill called OxyContin in response to complaints that patients with cancer and other chronic diseases were not getting the pain relief they needed.

By 2001, according to a GAO report, OxyContin was the most prescribed brand-name narcotic medication for treating moderate-to-severe pain in the country.

Ten years later, prescription pain medication had become a $329.2 billion industry, with a record 4.02 billion drug prescriptions filled in 2011, according to the journal ACS Chemical Neuroscience.

"There's an industry around that," Miramonti said. "You have just this surge of pain medication that has hit the market in the last 10 to 15 years, and you have this giant surge in the emergency department of people who think they require it.

"So they fall back on the emergency departments over and over again."

Painkiller addiction is the kind of addiction that can sneak up on you.

In many cases, it starts with chronic pain, such as a persistent lower back strain or a throbbing side ache.

To numb the pain, a doctor might prescribe a painkiller. Maybe something like Percocet, which was prescribed over 30 million times in 2011, according to the same ACS journal.

Most of the time, the pills do the job. They take the pain away. But many users experience something much more powerful than pain relief.

A 2002 study in the journal Science and Practice Perspectives examined why some users can get hooked on these pills.

According to authors Thomas Kosten and Tony George, when an opioid travels through the bloodstream to the brain, the chemicals attach themselves to brain cells and can trigger a euphoric sensation — not unlike the feeling you get while eating or having sex.

The sensation is enough for many to keep coming back. It's the same feeling that also attracts teenage users who raid their parents' medicine cabinets for pills. Many of those teens mistakenly believe that prescription pain relievers are safer than illicit drugs, according to a 2012 GAO report.

"Nationwide, you've got 15,000 accidental overdoses on prescription narcotics compared to 5,000 for heroin and cocaine," Miramonti said. "No one ever saw that coming."

For more than a decade, prescription painkiller abuse was the game most addicts chose to play. But in recent years, state and federal regulators have begun cracking down on endless and unnecessary refills and prescriptions.

One of the most prominent crackdowns first came in 2011 in Florida, a state known for its "pill mills" — clinics that dole out painkillers but in many cases are not operated by licensed physicians. That year, Florida lawmakers banned doctors from giving out pain medicines directly, with some exceptions.

In 2012, the Drug Enforcement Administration began targeting distribution giants like CVS and Walgreens, monitoring and restricting how much of a painkiller drug, such as oxycodone, they could give out.

Indiana has followed suit. Last year, lawmakers gave Attorney General Greg Zoeller increased oversight over pain management clinics. That change culminated in a new set of emergency rules adopted last October by the Indiana Medical Licensing Board at the direction of Indiana lawmakers. Under the board's new requirements, which went into effect in December, doctors now need to conduct annual drug tests for patients who take chronic pain medication.

In January, the Indiana Medical Licensing Board suspended an Anderson doctor's license indefinitely, based on an allegation that he pre-signed thousands of prescriptions so that his midlevel staff could prescribe controlled drugs, a violation of state law. The doctor had been at the center of an investigation involving 31 drug-related deaths in five counties.

"You have multiple pharmaceutical distributors who are shut down," Miramonti explained.

"Prescribers are tracked. Who gets the prescription is tracked. We're seeing more and more physicians who are coming under scrutiny for their prescribing practices."

Although the crackdown helped address one problem, experts say it worsened another: heroin abuse.

Experts say it's not too much of a leap for prescription painkiller abusers to switch from a medicine such as Oxycontin to an illicit drug like heroin.

Both come from the same family of narcotics, so they provide the same pain relieving and euphoric sensations, though heroin users say the illicit version is significantly stronger.

It's also cheaper. While a painkiller addiction can cost a user hundreds of dollars every day, heroin can cost $50 to $100 per day.

"Distribution, availability, purity and cost of heroin has made it an easy drug of choice," said Aaron Kochar, the director of prevention and education for Porter-Starke Services, a Valparaiso-based mental health facility. "As we've cracked down on the illicit use of prescription drugs, we haven't solved the addiction. They're switching over to heroin."

Playing the victim

Heroin was not the first drug Joshua Fletcher tried. Not even close.

Fletcher started using narcotics at a young age, very young.

At 8 years old, Fletcher smoked his first marijuana joint, introduced by his older brother in a backyard tent.

By the time he hit puberty, he took his first swig of alcohol, some Smirnoff vodka.

Heroin followed at 18. A friend hooked him up with some dope found through a drug dealer. Fletcher snorted it and enjoyed the high. But he avoided addiction.

Then the accident happened.

While driving near his hometown of South Bend in the middle of an ice storm, Fletcher lost control of his car. He spun out and slammed into a telephone pole, shattering his pelvis and fracturing his tailbone.

Fletcher had several surgeries to repair the damage. Each time, doctors gave him something to ease the pain, most often Oxycontin or Percocet.

After a while, they cut him off and sent him to a pain management clinic to treat Fletcher's problems with physical therapy. But he said he played the victim, begging doctors to put him back on.

"Oh, I'm still in a lot of pain."

"I just had this major surgery."

But Fletcher's pleas didn't work. So he turned to what he thought was his only option: heroin, once again.

Reconnecting with friends, Fletcher found dealers. He told himself he would only snort it — never shoot up.

His resistance to injecting the drug didn't last long. The feeling of getting high through a direct injection into Fletcher's bloodstream was a euphoric sensation better and more powerful than anything he had felt before.

He couldn't escape.

"Usually there's a tingling in your throat. Your whole body just becomes like Jell-O," Fletcher says. It's just like a state of being between complete consciousness and unconsciousness.

"When you're shooting up, it's instantaneous."

Beyond the addiction

It's enough of a problem, officials say, that heroin use and availability has become so widespread.

But there are plenty of factors exacerbating the troubles.

First off, as suppliers come up from Mexico on their way to bigger drug trades in Chicago, they are stopping off in Indiana cities to set up smaller shops, said Kochar, the Valparaiso-based drug education specialist.

Authorities say that drug trade contributes to the violence in the city.

And a lot of that violence is deadly.

Last week, a man was killed after injuring four SWAT officers in a shootout at in a home southeast of Fountain Square. The officers were there to raid a heroin operation, police said, and found heroin, more than $120,000 in cash, 13 guns and hundreds of prescription pills and what is believed to be hundreds of thousands of dollars worth of stolen merchandise.

In February, four people were arrested and charged in connection with a quadruple homicide on the Southeastside. Indianapolis Metropolitan Police said the suspects wanted to rob the victims of drugs and monetary profits from the sale of illegal narcotics, including heroin.

"It's a growing problem," said David Allender, captain of covert operations for the Indianapolis Metropolitan Police Department. "I think it drives a lot of the violent crime: car break-ins, house break-ins. They steal the items, and they sell the items or trade it to the dealers for heroin."

Crime statistics reflect the growing drug trade. Narcotics detectives last year busted more than 70 heroin cases, many involving drug rings and dealers, about 200 more than the previous year.

And the amount of heroin has spiked, too. Last year, detectives seized more than 1,050 pieces of heroin-related evidence, including needles, cooking spoons and the drug itself. That is about 300 more pieces of evidence than in 2012.

So far the rise in heroin use hasn't led to a rise in all violent crime.

According to preliminary crime numbers from the Department of Public Safety, violent crime was down 1.8 percent in 2013 from the year before.

And while robberies last year were up about 9 percent, instances of aggravated assault dropped more than 16 percent in 2013 from 2012.

"If you're looking for higher crime because of heroin use, I don't think we're there yet," Public Safety Director Troy Riggs said. "But let's deal with it now before we start seeing increases in crime."

Riggs said the number of deaths attributable to heroin is still a cause for concern.

Last month, the Police Department announced a pilot program equipping officers with naloxone.

Meanwhile, Riggs said he wants police to get ahead of the curve on crime before it worses.

"Let me also be clear: This is not like a crack cocaine epidemic," he said. "This is a different drug. Crack cocaine is very violent, and it came into cities quickly. The Police Department missed the warning signs through EMS. We're catching the warning signs now."

Crime isn't the only cause for concern in regards to heroin.

There is, of course, the drug itself. Experts say a lot of the heroin in the drug trade is more potent today.

It's also more lethal.

When heroin first started gaining attention in the 1970s and 1980s, the purity of the drug was relatively low, about 5 percent, said Mike Medler, director of the Indianapolis-Marion County Forensic Services Agency, which processes crime scene evidence for Marion County.

Over the years, Medler said, that purity level of heroin has increased to as much as 50 or 80 percent, creating a more powerful drug.

And in some cases, Medler said, manufacturers are cutting heroin to increase its potency with depressants like Fentanyl or morphine.

"There's no quality assurance in the illegal drug world," Medler said. "There is none. When these thing are manufactured, obviously they're not checked. You just don't know what you're using."

The result is a higher rate of overdoses. If users don't know how strong a dose is, they can miscalculate how much they think they need for the high they want.

The consequences can be deadly.

"Heroin is a god-awful respiratory depressant," said Campbell, the Indianapolis EMS district lieutenant. "You will stop breathing, and then you will eventually die."

Even those rescued from death don't always fully recover. Left unconscious long enough before revival, an overdose victim already is facing permanent damage, such as loss of motor functions or memory.

In January, Campbell responded to a cardiac arrest call at an Eastside house. He arrived to find paramedics already in the basement of the house, pumping repeatedly on a man's chest in an attempt to keep him alive.

A woman in the home told medics the man had overdosed from heroin. He may have been unconscious for hours before his friends called 911.

Paramedics hooked the man up with an IV and eventually needed to use a defibrillator — electric shock — to try to restart his heart.

The treatment was successful, to a degree. The man registered a pulse, and paramedics loaded him into an ambulance.

He never regained consciousness during his trip to the hospital. Campbell doesn't know if he ever did.

"Anoxic brain injury is a bad, bad thing," Campbell said. "There's massive cell death."

Campbell doesn't run into a lot of the same users on runs, and the fates of those people are unclear.

But something stuck with him the day he saw that man come back from the brink of death.

As Campbell helped the paramedics, he looked around at the other people in the room. Some looked concerned for their friend, but others looked less interested.

One man was slumped in a chair with a vacant stare on his face.

"If you saw somebody doing CPR on a family friend or a loved one, you would know the gravity of the situation, would you not?" Campbell said. "You understand that when we are pushing on your chest, that means you are not alive, and when we're breathing for you, that means you are not alive.

"We were doing that to this guy, and a couple of them were sitting around smoking cigarettes."

Road to recovery

Getting clean wasn't easy for Joshua Fletcher.

At the peak of his addiction, Fletcher's heroin habit was costing him at least $200 a day, and he was combining the drug with other substances as well, including cocaine, marijuana and any prescription pills he could still get his hands on.

He ended up homeless, mostly couch-surfing from apartment to apartment. With barely enough money to sustain his habit, Fletcher turned to family members and begged them for money that he would funnel toward drugs.

Not even the near-fatal overdose at his birthday party could shake him.

Then one day, when Fletcher was 25, something changed.

"I had a moment of clarity," he says. "I just saw my life in shambles, where everything around me sucked. I hated the way that I felt.

"It was like a never-ending internal decay."

He entered a northern Indiana treatment clinic. The withdrawals were painfully intense, but he persevered and eventually moved down to Indianapolis where he could attend a full-time treatment facility called Progress House on the Near Eastside.

Today, Fletcher works as a peer counselor at that facility. He is three years sober and hopes to keep up the pace, despite temptations to slip back into addiction.

He feels that temptation because "that's what was comfortable to me," Fletcher says. "Whenever I was happy, sad, any kind of emotion, that's what I'd use as a cure-all."

He still has the scars — the track marks on his arms — but it's different now. They're covered up with elaborate tattoos.

Some are prayers, reminders of his belief in good and evil and his ability to overpower his drug influences.

Another tattoo covering up a large track mark on his left arm is a tree that reminds Fletcher of one he used to visit with his grandfather.

"He was the closest thing to a father I ever had," Fletcher says. "He actually got to see me sober before he died."

The treatment center where Fletcher works hosts about 85 men suffering from all kinds of addiction, but heroin and prescription pain medication abusers have been cropping up more in recent years.

Five years ago, about 10 to 15 percent of addicts the center saw were addicted to narcotics. Now it's 40 percent.

And just entering a treatment center isn't a guarantee of success. Only about 40 percent of Progress House's entrants make it through the full 90-day program.

Although Fletcher says he tries to help those people recover, ultimately it's a decision they can only make.

"It doesn't matter how bad things are, you can always get better. You just have to be willing to do the work," he says.

"I strongly encourage that you get treatment. Otherwise, you're going to be living ugly and dying ugly."

USA Today contributed to this article. Call Star reporter Jill Disis at (317) 444-6137. Follow her on Twitter: @jdisis.