Pathway from prescription opioids to heroin

The Pathway from prescription opioids to heroin is the recurring progression traced in the book from medical or diverted painkillers to heroin bought through illicit markets. It is not presented as an inevitable sequence for every patient; rather, the accounts show how exposure, dependence, restricted pill supply, price, and the need to avoid withdrawal could combine to make heroin a cheaper and more accessible alternative. The pathway connects clinical practice and commercial promotion to peer networks, drug distribution, and the limits of treatment, making a seemingly personal change in drug use part of a wider social and public-health crisis.

Medical exposure and the expansion of prescribing

The pathway begins in circumstances that do not necessarily look like addiction. Jesse Bolstridge’s mother, Kristi Fernandez, could not identify a single moment when pills took hold of her son. After he was diagnosed with Lyme meningitis at fifteen, repeated football and snowboarding injuries brought him to doctors’ offices and emergency rooms, where he received Oxycodone, Vicodin, and Percocet. By his junior year, he had sustained so many concussions that a neurologist warned he would have to leave football if he were injured again. His account shows how a series of medical encounters can precede a pattern of nonmedical use without a clear dividing line between treatment and dependence.

The book places such histories within a broader change in medicine. When OxyContin was introduced in 1996, hospitals and medical organizations were elevating pain as the fifth vital sign alongside blood pressure, heart rate, respiratory rate, and temperature. The Joint Commission on Accreditation of Healthcare Organizations approved mandatory pain-assessment and treatment standards in 1999. Patient-satisfaction surveys and reimbursement pressures encouraged clinicians to treat pain more aggressively, while pain scales made a subjective experience appear readily measurable. The standards did not define what adequate relief meant, and a high pain score could describe very different experiences in different people. Later, clinicians acknowledged that reliance on pain scales did not necessarily improve patient outcomes and was associated with increased opioid prescribing and abuse.

Commercial promotion reinforced this medical shift. Purdue Pharma presented addiction as exceptionally rare when opioids were taken as prescribed and promoted OxyContin for a wide range of pain, including conditions beyond cancer. As pharmaceutical advertising and doctor-directed marketing expanded in the 1990s, Purdue used prescribing data to target physicians already writing substantial numbers of competing painkiller prescriptions. Its sales representatives made repeated visits and distributed branded materials, including clocks for examination rooms. These practices helped make opioid treatment seem appropriate for common injuries and chronic conditions, while the assurances about low addiction risk could obscure the possibility that medical exposure might lead to dependence.

From pills to an illicit supply

The transition was often accelerated when people who had begun with prescriptions could no longer obtain enough pills through medical or informal sources. In Woodstock, the book describes users who started with prescriptions, then bought heroin and resold portions of their supply to finance the next purchase. The immediate pressure was withdrawal: as dependence deepened, avoiding its physical and psychological pain could become the organizing need. Some users recruited other customers, who in turn brought in more people, allowing a local market to grow through repeated exchange and resale.

Several individual histories make the shift from one drug to another concrete. Ashlyn Keikilani Kessler began taking pain medication after childbirth, when she was prescribed Lortab for mastitis and later oxycodone for lingering back pain. When a new doctor would not continue her refills, she obtained OxyContin through an acquaintance and sometimes took Lortab prescribed to her disabled grandfather. After OxyContin was reformulated in 2010 to resist abuse, she switched to Roxicodone; when illicit pills became harder to find and more expensive, she moved to heroin. She described the sequence as familiar among people around her: pills, then other pills, then heroin. Her account links a change in the available product to a change in the drug people used, rather than portraying heroin as an isolated or wholly separate starting point.

Tess Henry’s experience similarly shows how changes in access could redirect established use. After receiving opioid prescriptions for bronchitis and throat pain, she began looking for pills through dealers when the prescriptions ran out. She later used several kinds of pills, including Dilaudid, Roxicodone, Lortab, and Opana. In October 2014, hydrocodone-based medicines such as Vicodin and Lortab were moved from Schedule III to Schedule II. The change limited prescriptions to intervals of thirty days or less and removed refills, requiring patients to obtain a new prescription for additional medication. Tess attributed the drying up of her dealer’s pill supply to the change. Her dealer then offered heroin as cheaper and easier to get, and she tried it in powder form. The episode illustrates how a measure intended to restrict access to prescription drugs could also alter the illicit market facing people already dependent on them.

Networks, price, and substitution

The pathway depended on social connections as well as drug supply. Jesse Bolstridge and Dennis Painter had been close friends since toddlerhood and had partied together since they were sixteen. Jesse initially preferred injecting crushed Roxys, but as their cravings grew in 2013 he turned to intravenous heroin, which was cheaper, stronger, and easier to obtain. Their parents paid for separate out-of-state residential treatment, but both young men returned to use after they came home and reunited. Jesse’s first heroin injection involved drugs Dennis had bought from a Washington, D.C., subdealer. Their story shows how friendship could both connect a person to supply and create a setting in which use resumed after treatment.

The book also situates these personal networks within a regional distribution system. In 2006, Clifton “Lite” Lee brought heroin from New Jersey and New York into Roanoke, where he connected with users across racial and class lines. Two suburban teenagers caught selling heroin to friends led police to evidence involving roughly fifty more young people, most of them students at Hidden Valley High School. By the time Lee was sentenced in 2008, prosecutors said his network had brought about a thousand bags into the region two or three times a week. In a different account of the northern Shenandoah Valley, the arrival of Ronnie Jones in 2012 coincided with a rapid expansion from recreational pill use to a much larger population of heroin users. These episodes show that the prescription-to-heroin pathway could be extended and accelerated by dealers who connected existing demand to a more available illicit product.

The shift to heroin was also associated with the contraction of pill supply. Some suburban users obtained prescription pills through friends, relatives’ medicine cabinets, or people with legitimate prescriptions who passed along what they did not use. When OxyContin’s 2010 reformulation made crushing the pills more difficult, users in one account found them ineffective to misuse or too expensive, while people who had sold pills began selling heroin instead. The change did not eliminate demand; it changed the product and the people who supplied it. The book therefore presents reformulation and tighter access as developments that could redirect use and trade, not as events that by themselves ended the underlying dependence or market.

Treatment, recurrence, and consequences

The transition could continue even after an attempt at treatment. In January 2013, Jesse Bolstridge entered a ten-week program in Jacksonville that included counseling and medical detox, and briefly took buprenorphine, sold under the brand name Suboxone, to help curb cravings. He was weaned off it after three weeks. The book contrasts this short course with the position of the National Institute on Drug Abuse director, Nora Volkow, who supported longer-term medication maintenance alongside behavioral treatment and recovery support rather than detoxification alone. Jesse still owed $25,000 for the earlier program despite having insurance, and his mother could not afford to send him immediately to another facility after a later dismissal. Financial limits, treatment design, and the period after discharge all shaped whether help could be sustained.

Medication-assisted treatment could itself meet resistance. Tess Henry had attended Alcoholics Anonymous and Narcotics Anonymous meetings, but some participants regarded buprenorphine as incompatible with being clean or as merely substituting one opioid for another. Although Narcotics Anonymous had an official policy accepting medication-assisted treatment, members asked to sponsor or mentor Tess declined. The episode reveals a divide between evidence-based treatment and recovery cultures in which medication could carry its own stigma. A pathway from pills to heroin therefore did not end simply when a person reached a meeting or a treatment facility; the kind of treatment available and the welcome a person received also mattered.

The scale of the consequences is visible in the national figures and the individual losses. In 2013, heroin was involved in 8,257 deaths, a 39 percent increase over the prior year. Roughly three-quarters of those who died had begun with the same painkiller pathway described in the stories of Jesse Bolstridge, Spencer Mumpower, Scott Roth, and Colton Banks: a prescription pill. The book’s accounts do not reduce those deaths to a single cause. They trace a chain in which medical exposure could be followed by dependence, a shortage or rising cost of pills, a switch to heroin, and a supply network capable of bringing new users into the market. The result is a pathway shaped by both individual vulnerability and the institutions and markets surrounding it.