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People appearance is not always what we see because sometimes peolple is hiding about what happened around them. Sometimes we see people happy but we really don't know if that person is really happy.

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Fake stained glass window created from mosaic of ecstasy pills- similar to Kevin Champeny, talks about drugs as a way people try to heal themselves

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Uses actual pills (oxy, vicodin) along with other found objects to create a seductive universe you can get lost in

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https://www.kevinchampeny.com/healer/

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As artists, what can we do to address this problem?

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Through this collage, I was trying to make it appear that the woman was addiction’s target, and that the woman is somewhat trapped by addiction and her memories of it.

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I wanted to convey the message of how you can overcome addiction that it could be in the past and people can grow from their experiences that there is always someone that can help they aren’t alone and the addiction can be overcome

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Who is making money off of this problem?

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-How does our sympathy for certain groups shape the way their addiction is treated? (jail versus rehab // crack versus opioids)

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-How can we replace stereotypes of drug users with a more complex understanding of why people use?

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Trump pushes death penalty for drug dealers - Reuters TV

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At an event in New Hampshire, which has been hit hard by the opioid epidemic, President Trump on Monday unveiled his plan to battle the growing crisis in America.

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What is the opioid crisis and why should we care about it?

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A photographer in Ohio documents the opioid crisis (from our first class)

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A photographer in Ohio documents the opioid crisis (from our first class)

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Life on the front lines of the opioid epidemic is an intimate, relentless battle. First responders bring heroin users back from the dead, only to return, often, to the same house and the same person after another overdose. Nurses and doctors pull back the curtains in emergency rooms and see sons and daughters of old friends, that kid from down the block, the cashier at the diner. Families cup their hands around the guttering flame of a loved one's recovery, and all too often see it flicker out.

If there's hope at this moment in the epidemic, which killed more than sixty-four thousand Americans last year, it's that many people in the harrowing center of the crisis want it to be witnessed. They want the depths of the problem acknowledged. There is courage in the willingness to be seen, and that courage is on display in Philip Montgomery's photographs, in this week's issue of the magazine, from an Ohio county gripped by heroin. In this video, Montgomery discusses his experience there, documenting families, users, first responders, and the morgue.

Margaret Talbot is a staff writer and the author of "The Entertainer."
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A Photographer's View of the American Opioid Crisis

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Life on the front lines of the opioid epidemic is an intimate, relentless battle. First responders bring heroin users back from the dead, only to return, often, to the same house and the same person after another overdose.

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Connection between prescription and illegal drugs (from our first class)

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Connection between prescription and illegal drugs (from our first class)

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Adam Ruins Everything - Why Some Prescription Drugs Are More Dangerous than Illegal Drugs

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Faces of Addiction (portraits and brief anecdotes from Hunts Point, The Bronx)

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Faces of Addiction (portraits and brief anecdotes from Hunts Point, The Bronx)

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Painkillers now kill more Americans than any illegal drug

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How opioid painkillers became an epidemic Subscribe to our channel! http://goo.gl/0bsAjO It's a terrifying fact: More than 47,000 people in America died of drug overdoses in what's been widely called an epidemic.

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The Billionaire Sackler Family of Purdue Pharma

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The Billionaire Sackler Family of Purdue Pharma

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The newly installed Sackler Courtyard at London's Victoria and Albert Museum is one of the most glittering places in the developed world. Eleven thousand white porcelain tiles, inlaid like a shattered backgammon board, cover a surface the size of six tennis courts. According to the V&A's director, the regal setting is intended to serve as a "living room for London," by which he presumably means a living room for Kensington, the museum's neighborhood, which is among the world's wealthiest. In late June, Kate Middleton, the Duchess of Cambridge, was summoned to consecrate the courtyard, said to be the earth's first outdoor space made of porcelain; stepping onto the ceramic expanse, she silently mouthed, "Wow."

The Sackler Courtyard is the latest addition to an impressive portfolio. There's the Sackler Wing at New York's Metropolitan Museum of Art, which houses the majestic Temple of Dendur, a sandstone shrine from ancient Egypt; additional Sackler wings at the Louvre and the Royal Academy; stand-alone Sackler museums at Harvard and Peking Universities; and named Sackler galleries at the Smithsonian, the Serpentine, and Oxford's Ashmolean. The Guggenheim in New York has a Sackler Center, and the American Museum of Natural History has a Sackler Educational Lab. Members of the family, legendary in museum circles for their pursuit of naming rights, have also underwritten projects of a more modest caliber-a Sackler Staircase at Berlin's Jewish Museum; a Sackler Escalator at the Tate Modern; a Sackler Crossing in Kew Gardens. A popular species of pink rose is named after a Sackler. So is an asteroid.

The Sackler name is no less prominent among the emerald quads of higher education, where it's possible to receive degrees from Sackler schools, participate in Sackler colloquiums, take courses from professors with endowed Sackler chairs, and attend annual Sackler lectures on topics such as theoretical astrophysics and human rights. The Sackler Institute for Nutrition Science supports research on obesity and micronutrient deficiencies. Meanwhile, the Sackler institutes at Cornell, Columbia, McGill, Edinburgh, Glasgow, Sussex, and King's College London tackle psychobiology, with an emphasis on early childhood development.

The Sacklers' philanthropy differs from that of civic populists like Andrew Carnegie, who built hundreds of libraries in small towns, and Bill Gates, whose foundation ministers to global masses. Instead, the family has donated its fortune to blue-chip brands, braiding the family name into the patronage network of the world's most prestigious, well-endowed institutions. The Sackler name is everywhere, evoking automatic reverence; the Sacklers themselves, however, are rarely seen.

The descendants of Mortimer and Raymond Sackler, a pair of psychiatrist brothers from Brooklyn, are members of a billionaire clan with homes scattered across Connecticut, London, Utah, Gstaad, the Hamptons, and, especially, New York City. It was not until 2015 that they were noticed by Forbes, which added them to the list of America's richest families. The magazine pegged their wealth, shared among twenty heirs, at a conservative $14 billion. (Descendants of Arthur Sackler, Mortimer and Raymond's older brother, split off decades ago and are mere multi-millionaires.) To a remarkable degree, those who share in the billions appear to have abided by an oath of omertà: Never comment publicly on the source of the family's wealth.

That may be because the greatest part of that $14 billion fortune tallied by Forbes came from OxyContin, the narcotic painkiller regarded by many public-health experts as among the most dangerous products ever sold on a mass scale. Since 1996, when the drug was brought to market by Purdue Pharma, the American branch of the Sacklers' pharmaceutical empire, more than two hundred thousand people in the United States have died from overdoses of OxyContin and other prescription painkillers. Thousands more have died after starting on a prescription opioid and then switching to a drug with a cheaper street price, such as heroin. Not all of these deaths are related to OxyContin-dozens of other painkillers, including generics, have flooded the market in the past thirty years. Nevertheless, Purdue Pharma was the first to achieve a dominant share of the market for long-acting opioids, accounting for more than half of prescriptions by 2001.

According to the Centers for Disease Control, fifty-three thousand Americans died from opioid overdoses in 2016, more than the thirty-six thousand who died in car crashes in 2015 or the thirty-five thousand who died from gun violence that year. This past July, Donald Trump's Commission on Combating Drug Addiction and the Opioid Crisis, led by New Jersey governor Chris Christie, declared that opioids were killing roughly 142 Americans each day, a tally vividly described as "September 11th every three weeks." The epidemic has also exacted a crushing financial toll: According to a study published by the American Public Health Association, using data from 2013-before the epidemic entered its current, more virulent phase-the total economic burden from opioid use stood at about $80 billion, adding together health costs, criminal-justice costs, and GDP loss from drug-dependent Americans leaving the workforce. Tobacco remains, by a significant multiple, the country's most lethal product, responsible for some 480,000 deaths per year. But although billions have been made from tobacco, cars, and firearms, it's not clear that any of those enterprises has generated a family fortune from a single product that approaches the Sacklers' haul from OxyContin.

Even so, hardly anyone associates the Sackler name with their company's lone blockbuster drug. "The Fords, Hewletts, Packards, Johnsons-all those families put their name on their product because they were proud," said Keith Humphreys, a professor of psychiatry at Stanford University School of Medicine who has written extensively about the opioid crisis. "The Sacklers have hidden their connection to their product. They don't call it 'Sackler Pharma.' They don't call their pills 'Sackler pills.' And when they're questioned, they say, 'Well, it's a privately held firm, we're a family, we like to keep our privacy, you understand.' "

To the extent that the Sacklers have cultivated a reputation, it's for being earnest healers, judicious stewards of scientific progress, and connoisseurs of old and beautiful things. Few are aware that during the crucial period of OxyContin's development and promotion, Sackler family members actively led Purdue's day-to-day affairs, filling the majority of its board slots and supplying top executives. By any assessment, the family's leaders have pulled off three of the great marketing triumphs of the modern era: The first is selling OxyContin; the second is promoting the Sackler name; and the third is ensuring that, as far as the public is aware, the first and the second have nothing to do with one another.

If you head north on I-95 through Stamford, Connecticut, you will spot, on the left, a giant misshapen glass cube. Along the building's top edge, white lettering spells out ONE STAMFORD FORUM. No markings visible from the highway indicate the presence of the building's owner and chief occupant, Purdue Pharma.

Originally known as Purdue Frederick, the first iteration of the company was founded in 1892 on New York's Lower East Side as a peddler of patent medicines. For decades, it sustained itself with sales of Gray's Glycerine Tonic, a sherry-based liquid of "broad application" marketed as a remedy for everything from anemia to tuberculosis. The company was purchased in 1952 by Arthur Sackler, thirty-nine, and was run by his brothers, Mortimer, thirty- six, and Raymond, thirty-two. The Sackler brothers came from a family of Jewish immigrants in Flatbush, Brooklyn. Arthur was a headstrong and ambitious provider, setting the tone-and often choosing the path-for his younger brothers. After attending medical school on Arthur's dime, Mortimer and Raymond followed him to jobs at the Creedmoor psychiatric hospital in Queens. There, they coauthored more than one hundred studies on the biochemical roots of mental illness. The brothers' research was promising-they were among the first to identify a link between psychosis and the hormone cortisone-but their findings were mostly ignored by their professional peers, who, in keeping with the era, favored a Freudian model of mental illness.

Concurrent with his psychiatric work, Arthur Sackler made his name in pharmaceutical advertising, which at the time consisted almost exclusively of pitches from so-called "detail men" who sold drugs to doctors door-to-door. Arthur intuited that print ads in medical journals could have a revolutionary effect on pharmaceutical sales, especially given the excitement surrounding the "miracle drugs" of the 1950s-steroids, antibiotics, antihistamines, and psychotropics. In 1952, the same year that he and his brothers acquired Purdue, Arthur became the first adman to convince The Journal of the American Medical Association, one of the profession's most august publications, to include a color advertorial brochure.

In the 1960s, Arthur was contracted by Roche to develop an advertising strategy for a new antianxiety medication called Valium. This posed a challenge, because the effects of the medication were nearly indistinguishable from those of Librium, another Roche tranquilizer that was already on the market. Arthur differentiated Valium by audaciously inflating its range of indications. Whereas Librium was sold as a treatment for garden- variety anxiety, Valium was positioned as an elixir for a problem Arthur christened "psychic tension." According to his ads, psychic tension, the forebear of today's "stress," was the secret culprit behind a host of somatic conditions, including heartburn, gastrointestinal issues, insomnia, and restless-leg syndrome. The campaign was such a success that for a time Valium became America's most widely prescribed medication-the first to reach more than $100 million in sales. Arthur, whose compensation depended on the volume of pills sold, was richly rewarded, and he later became one of the first inductees into the Medical Advertising Hall of Fame.

As Arthur's fortune grew, he turned his acquisitive instincts to the art market, quickly amassing the world's largest private collection of ancient Chinese artifacts. According to a memoir by Marietta Lutze, his second wife, collecting, exhibiting, owning, and donating art fed Arthur's "driving necessity for prestige and recognition." Rewarding at first, collecting soon became a mania that took over his life. "Boxes of artifacts of tremendous value piled up in numerous storage locations," she wrote, "there was too much to open, too much to appreciate; some objects known only by a packing list." Under an avalanche of "ritual bronzes and weapons, mirrors and ceramics, inscribed bones and archaic jades," their lives were "often in chaos." "Addiction is a curse," Lutze noted, "be it drugs, women, or collecting."

When Arthur donated his art and money to museums, he often imposed onerous terms. According to a memoir written by Thomas Hoving, the Met director from 1967 to 1977, when Arthur established the Sackler Gallery at the Metropolitan Museum of Art to house Chinese antiquities, in 1963, he required the museum to collaborate on a byzantine tax-avoidance maneuver. In accordance with the scheme, the museum first sold Arthur a large quantity of ancient artifacts at the deflated 1920s prices for which they had originally been acquired. Arthur then donated back the artifacts at 1960s prices, in the process taking a tax deduction so hefty that it likely exceeded the value of his initial donation. Three years later, in connection with another donation, Arthur negotiated an even more unusual arrangement. This time, the Met opened a secret chamber above the museum's auditorium to provide Arthur with free storage for some five thousand objects from his private collection, relieving him of the substantial burden of fire protection and other insurance costs. (In an email exchange, Jillian Sackler, Arthur's third wife, called Hoving's tax-deduction story "fake news." She also noted that New York's attorney general conducted an investigation into Arthur's dealings with the Met and cleared him of wrongdoing.)

In 1974, when Arthur and his brothers made a large gift to the Met-$3.5 million, to erect the Temple of Dendur-they stipulated that all museum signage, catalog entries, and bulletins referring to objects in the newly opened Sackler Wing had to include the names of all three brothers, each followed by "M.D." (One museum official quipped, "All that was missing was a note of their office hours.")

Hoving said that the Met hoped that Arthur would eventually donate his collection to the museum, but over time Arthur grew disgruntled over a series of rankling slights. For one, the Temple of Dendur was being rented out for parties, including a dinner for the designer Valentino, which Arthur called "disgusting." According to Met chronicler Michael Gross, he was also denied that coveted ticket of arrival, a board seat. (Jillian Sackler said it was Arthur who rejected the board seat, after repeated offers by the museum.) In 1982, in a bad breakup with the Met, Arthur donated the best parts of his collection, plus $4 million, to the Smithsonian in Washington, D. C.

Arthur's younger brothers, Mortimer and Raymond, looked so much alike that when they worked together at Creedmoor, they fooled the staff by pretending to be one another. Their physical similarities did not extend to their personalities, however. Tage Honore, Purdue's vice-president of discovery of research from 2000 to 2005, described them as "like day and night." Mortimer, said Honore, was "extroverted-a 'world man,' I would call it." He acquired a reputation as a big-spending, transatlantic playboy, living most of the year in opulent homes in England, Switzerland, and France. (In 1974, he renounced his U. S. citizenship to become a citizen of Austria, which infuriated his patriotic older brother.) Like Arthur, Mortimer became a major museum donor and married three wives over the course of his life.

Mortimer had his own feuds with the Met. On his seventieth birthday, in 1986, the museum agreed to make the Temple of Dendur available to him for a party but refused to allow him to redecorate the ancient shrine: Together with other improvements, Mortimer and his interior designer, flown in from Europe, had hoped to spiff up the temple by adding extra pillars. Also galling to Mortimer was the sale of naming rights for one of the Sackler Wing's balconies to a donor from Japan. "They sold it twice," Mortimer fumed to a reporter from New York magazine. Raymond, the youngest brother, cut a different figure-"a family man," said Honore. Kind and mild-mannered, he stayed with the same woman his entire life. Lutze concluded that Raymond owed his comparatively serene nature to having missed the worst years of the Depression. "He had summer vacations in camp, which Arthur never had," she wrote. "The feeling of the two older brothers about the youngest was, 'Let the kid enjoy himself.' "

Raymond led Purdue Frederick as its top executive for several decades, while Mortimer led Napp Pharmaceuticals, the family's drug company in the UK. (In practice, a family spokesperson said, "the brothers worked closely together leading both companies.") Arthur, the adman, had no official role in the family's pharmaceutical operations. According to Barry Meier's Pain Killer, a prescient account of the rise of OxyContin published in 2003, Raymond and Mortimer bought Arthur's share in Purdue from his estate for $22.4 million after he died in 1987. In an email exchange, Arthur's daughter Elizabeth Sackler, a historian of feminist art who sits on the board of the Brooklyn Museum and supports a variety of progressive causes, emphatically distanced her branch of the family from her cousins' businesses. "Neither I, nor my siblings, nor my children have ever had ownership in or any benefit whatsoever from Purdue Pharma or OxyContin," she wrote, while also praising "the breadth of my father's brilliance and important works." Jillian, Arthur's widow, said her husband had died too soon: "His enemies have gotten the last word."

The Sacklers have been millionaires for decades, but their real money-the painkiller money-is of comparatively recent vintage. The vehicle of that fortune was OxyContin, but its engine, the driving power that made them so many billions, was not so much the drug itself as it was Arthur's original marketing insight, rehabbed for the era of chronic-pain management. That simple but profitable idea was to take a substance with addictive properties-in Arthur's case, a benzo; in Raymond and Mortimer's case, an opioid-and market it as a salve for a vast range of indications.

In the years before it swooped into the pain-management business, Purdue had been a small industry player, specializing in over-the-counter remedies like ear-wax remover and laxatives. Its most successful product, acquired in 1966, was Betadine, a powerful antiseptic purchased in industrial quantities by the U. S. government to prevent infection among wounded soldiers in Vietnam. The turning point, according to company lore, came in 1972, when a London doctor working for Cicely Saunders, the Florence Nightingale of the modern hospice movement, approached Napp with the idea of creating a timed-release morphine pill. A long-acting morphine pill, the doctor reasoned, would allow dying cancer patients to sleep through the night without an IV. At the time, treatment with opioids was stigmatized in the United States, owing in part to a heroin epidemic fueled by returning Vietnam veterans. "Opiophobia," as it came to be called, prevented skittish doctors from treating most patients, including nearly all infants, with strong pain medication of any kind. In hospice care, though, addiction was not a concern: It didn't matter whether terminal patients became hooked in their final days. Over the course of the seventies, building on a slow-release technology the company had already developed for an asthma medication, Napp created what came to be known as the "Contin" system. In 1981, Napp introduced a timed-release morphine pill in the UK; six years later, Purdue brought the same drug to market in the U. S. as MS Contin.

MS Contin quickly became the gold standard for pain relief in cancer care. At the same time, a number of clinicians associated with the burgeoning chronic-pain movement started advocating the use of powerful opioids for noncancer conditions like back pain and neuropathic pain, afflictions that at their worst could be debilitating. In 1986, two doctors from Memorial Sloan Kettering hospital in New York published a fateful article in a medical journal that purported to show, based on a study of thirty-eight patients, that long-term opioid treatment was safe and effective so long as patients had no history of drug abuse. Soon enough, opioid advocates dredged up a letter to the editor published in The New England Journal of Medicine in 1980 that suggested, based on a highly unrepresentative cohort, that the risk of addiction from long-term opioid use was less than 1 percent. Though ultimately disavowed by its author, the letter ended up getting cited in medical journals more than six hundred times.

As the country was reexamining pain, Raymond's eldest son, Richard Sackler, was searching for new applications for Purdue's timed-release Contin system. "At all the meetings, that was a constant source of discussion-'What else can we use the Contin system for?' " said Peter Lacouture, a senior director of clinical research at Purdue from 1991 to 2001. "And that's where Richard would fire some ideas-maybe antibiotics, maybe chemotherapy-he was always out there digging." Richard's spitballing wasn't idle blather. A trained physician, he treasured his role as a research scientist and appeared as an inventor on dozens of the company's patents (though not on the patents for OxyContin). In the tradition of his uncle Arthur, Richard was also fascinated by sales messaging. "He was very interested in the commercial side and also very interested in marketing approaches," said Sally Allen Riddle, Purdue's former executive director for product management. "He didn't always wait for the research results." (A Purdue spokesperson said that Richard "always considered relevant scientific information when making decisions.")

Perhaps the most private member of a generally secretive family, Richard appears nowhere on Purdue's website. From public records and conversations with former employees, though, a rough portrait emerges of a testy eccentric with ardent, relentless ambitions. Born in 1945, he holds degrees from Columbia University and NYU Medical School. According to a bio on the website of the Koch Institute for Integrative Cancer Research at MIT, where Richard serves on the advisory board, he started working at Purdue as his father's assistant at age twenty-six before eventually leading the firm's R&D division and, separately, its sales and marketing division. In 1999, while Mortimer and Raymond remained Purdue's co-CEOs, Richard joined them at the top of the company as president, a position he relinquished in 2003 to become cochairman of the board. The few publicly available pictures of him are generic and sphinxlike-a white guy with a receding hairline. He is one of the few Sacklers to consistently smile for the camera. In a photo on what appears to be his Facebook profile, Richard is wearing a tan suit and a pink tie, his right hand casually scrunched into his pocket, projecting a jaunty charm. Divorced in 2013, he lists his relationship status on the profile as "It's complicated."

Richard's political contributions have gone mostly to Republicans-including Strom Thurmond and Herman Cain-though at times he has also given to Democrats. (His ex-wife, Beth Sackler, has given almost exclusively to Democrats.) In 2008, he wrote a letter to the editor of The Wall Street Journal denouncing Muslim support for suicide bombing, a concern that seems to persist: Since 2014, his charitable organization, the Richard and Beth Sackler Foundation, has donated to several anti-Muslim groups, including three organizations classified as hate groups by the Southern Poverty Law Center. (The family spokesperson said, "It was never Richard Sackler's intention to donate to an anti-Muslim or hate group.") The foundation has also donated to True the Vote, the "voter-fraud watchdog" that was the original source for Donald Trump's inaccurate claim that three million illegal immigrants voted in the 2016 election.

Former employees describe Richard as a man with an unnerving intelligence, alternately detached and pouncing. In meetings, his face was often glued to his laptop. "This was pre-smartphone days," said Riddle. "He'd be typing away and you would think he wasn't even listening, and then all of the sudden his head would pop up and he'd be asking a very pointed question." He was notorious for peppering subordinates with unexpected, rapid-fire queries, sometimes in the middle of the night. "Richard had the mind of someone who's going two hundred miles an hour," said Lacouture. "He could be a little bit disconnected in the way he would communicate. Whether it was on the weekend or a holiday or a Christmas party, you could always expect the unexpected."

Richard also had an appetite for micromanagement. "I remember one time he mailed out a rambling sales bulletin," said Shelby Sherman, a Purdue sales rep from 1974 to 1998. "And right in the middle, he put in, 'If you're reading this, then you must call my secretary at this number and give her this secret password.' He wanted to check and see if the reps were reading this shit. We called it 'Playin' Passwords.' " According to Sherman, Richard started taking a more prominent role in the company during the early 1980s. "The shift was abrupt," he said. "Raymond was just so nice and down-to-earth and calm and gentle." When Richard came, "things got a lot harder. Richard really wanted Purdue to be big-I mean really big."

To effectively capitalize on the chronic-pain movement, Purdue knew it needed to move beyond MS Contin. "Morphine had a stigma," said Riddle. "People hear the word and say, 'Wait a minute, I'm not dying or anything.' " Aside from its terminal aura, MS Contin had a further handicap: Its patent was set to expire in the late nineties. In a 1990 memo addressed to Richard and other executives, Purdue's VP of clinical research, Robert Kaiko, suggested that the company work on a pill containing oxycodone, a chemical similar to morphine that was also derived from the opium poppy. When it came to branding, oxycodone had a key advantage: Although it was 50 percent stronger than morphine, many doctors believed-wrongly-that it was substantially less powerful. They were deceived about its potency in part because oxycodone was widely known as one of the active ingredients in Percocet, a relatively weak opioid- acetaminophen combination that doctors often prescribed for painful injuries. "It really didn't have the same connotation that morphine did in people's minds," said Riddle.

A common malapropism led to further advantage for Purdue. "Some people would call it oxy- codeine " instead of oxycodone, recalled Lacouture. "Codeine is very weak." When Purdue eventually pleaded guilty to felony charges in 2007 for criminally "misbranding" OxyContin, it acknowledged exploiting doctors' misconceptions about oxycodone's strength. In court documents, the company said it was "well aware of the incorrect view held by many physicians that oxycodone was weaker than morphine" and "did not want to do anything 'to make physicians think that oxycodone was stronger or equal to morphine' or to 'take any steps . . . that would affect the unique position that OxyContin' " held among physicians.

Purdue did not merely neglect to clear up confusion about the strength of OxyContin. As the company later admitted, it misleadingly promoted OxyContin as less addictive than older opioids on the market. In this deception, Purdue had a big assist from the FDA, which allowed the company to include an astonishing labeling claim in OxyContin's package insert: "Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug."

The theory was that addicts would shy away from timed-released drugs, preferring an immediate rush. In practice, OxyContin, which crammed a huge amount of pure narcotic into a single pill, became a lusted-after target for addicts, who quickly discovered that the timed-release mechanism in OxyContin was easy to circumvent-you could simply crush a pill and snort it to get most of the narcotic payload in a single inhalation. This wasn't exactly news to the manufacturer: OxyContin's own packaging warned that consuming broken pills would thwart the timed-release system and subject patients to a potentially fatal overdose. MS Contin had contended with similar vulnerabilities, and as a result commanded a hefty premium on the street. But the "reduced abuse liability" claim that added wings to the sales of OxyContin had not been approved for MS Contin. It was removed from OxyContin in 2001 and would never be approved again for any other opioid.

The year after OxyContin's release, Curtis Wright, the FDA examiner who approved the pharmaceutical's original application, quit. After a stint at another pharmaceutical company, he began working for Purdue. In an interview with Esquire, Wright defended his work at the FDA and at Purdue. "At the time, it was believed that extended-release formulations were intrinsically less abusable," he insisted. "It came as a rather big shock to everybody-the government and Purdue-that people found ways to grind up, chew up, snort, dissolve, and inject the pills." Preventing abuse, he said, had to be balanced against providing relief to chronic-pain sufferers. "In the mid-nineties," he recalled, "the very best pain specialists told the medical community they were not prescribing opioids enough. That was not something generated by Purdue-that was not a secret plan, that was not a plot, that was not a clever marketing ploy. Chronic pain is horrible. In the right circumstances, opioid therapy is nothing short of miraculous; you give people their lives back." In Wright's account, the Sacklers were not just great employers, they were great people. "No company in the history of pharmaceuticals," he said, "has worked harder to try to prevent abuse of their product than Purdue."

Purdue did not invent the chronic-pain movement, but it used that movement to engineer a crucial shift. Wright is correct that in the nineties patients suffering from chronic pain often received inadequate treatment. But the call for clinical reforms also became a flexible alibi for overly aggressive prescribing practices. By the end of the decade, clinical proponents of opioid treatment, supported by millions in funding from Purdue and other pharmaceutical companies, had organized themselves into advocacy groups with names like the American Pain Society and the American Academy of Pain Medicine. (Purdue also launched its own group, called Partners Against Pain.) As the decade wore on, these organizations, which critics have characterized as front groups for the pharmaceutical industry, began pressuring health regulators to make pain "the fifth vital sign"-a number, measured on a subjective ten-point scale, to be asked and recorded at every doctor's visit. As an internal strategy document put it, Purdue's ambition was to "attach an emotional aspect to noncancer pain" so that doctors would feel pressure to "treat it more seriously and aggressively." The company rebranded pain relief as a sacred right: a universal narcotic entitlement available not only to the terminally ill but to every American.

OxyContin's sales started out small in 1996, in part because Purdue first focused on the cancer market to gain formulary acceptance from HMOs and state Medicaid programs. Over the next several years, though, the company doubled its sales force to six hundred-equal to the total number of DEA diversion agents employed to combat the sale of prescription drugs on the black market-and began targeting general practitioners, dentists, OB/GYNs, physician assistants, nurses, and residents. By 2001, annual OxyContin sales had surged past $1 billion. Sales reps were encouraged to downplay addiction risks. "It was sell, sell, sell," recalled Sherman. "We were directed to lie. Why mince words about it? Greed took hold and overruled everything. They saw that potential for billions of dollars and just went after it." Flush with cash, Purdue pioneered a high-cost promotion strategy, effectively providing kickbacks-which were legal under American law-to each part of the distribution chain. Wholesalers got rebates in exchange for keeping OxyContin off prior authorization lists. Pharmacists got refunds on their initial orders. Patients got coupons for thirty- day starter supplies. Academics got grants. Medical journals got millions in advertising. Senators and members of Congress on key committees got donations from Purdue and from members of the Sackler family.

It was doctors, though, who received the most attention. "We used to fly doctors to these 'seminars,' " said Sherman, which were, in practice, "just golf trips to Pebble Beach. It was graft." Though offering perks and freebies to doctors was hardly uncommon in the industry, it was unprecedented in the marketing of a Schedule II narcotic. For some physicians, the junkets to sunny locales weren't enough to persuade them to prescribe. To entice the holdouts-a group the company referred to internally as "problem doctors"-the reps would dangle the lure of Purdue's lucrative speakers' bureau. "Everybody was automatically approved," said Sherman. "We would set up these little dinners, and they'd make their little fifteen-minute talk, and they'd get $500."

Between 1996 and 2001, the number of OxyContin prescriptions in the United States surged from about three hundred thousand to nearly six million, and reports of abuse started to bubble up in places like West Virginia, Florida, and Maine. (Research would later show a direct correlation between prescription volume in an area and rates of abuse and overdose.) Hundreds of doctors were eventually arrested for running pill mills. According to an investigation in the Los Angeles Times, even though Purdue kept an internal list of doctors it suspected of criminal diversion, it didn't volunteer this information to law enforcement until years later.

As criticism of OxyContin mounted through the aughts, Purdue responded with symbolic concessions while retaining its volume-driven business model. To prevent addicts from forging prescriptions, the company gave doctors tamper-resistant prescription pads; to mollify pharmacists worried about robberies, Purdue offered to replace, free of charge, any stolen drugs; to gather data on drug abuse and diversion, the company launched a national monitoring program called RADARS.

Critics were not impressed. In a letter to Richard Sackler in July 2001, Richard Blumenthal, then Connecticut's attorney general and now a U. S. senator, called the company's efforts "cosmetic." As Blumenthal had deduced, the root problem of the prescription-opioid epidemic was the high volume of prescriptions written for powerful opioids. "It is time for Purdue Pharma to change its practices," Blumenthal warned Richard, "not just its public-relations strategy."

It wasn't just that doctors were writing huge numbers of prescriptions; it was also that the prescriptions were often for extraordinarily high doses. A single dose of Percocet contains between 2.5 and 10mg of oxycodone. OxyContin came in 10-, 20-, 30-, 40-, and 80mg formulations and, for a time, even 160mg. Purdue's greatest competitive advantage in dominating the pain market, it had determined early on, was that OxyContin lasted twelve hours, enough to sleep through the night. But for many patients, the drug lasted only six or eight hours, creating a cycle of crash and euphoria that one academic called "a perfect recipe for addiction." When confronted with complaints about "breakthrough pain"-meaning that the pills weren't working as long as advertised-Purdue's sales reps were given strict instructions to tell doctors to strengthen the dose rather than increase dosing frequency.

Over the next several years, dozens of class-action lawsuits were brought against Purdue. Many were dismissed, but in some cases Purdue wrote big checks to avoid going to trial. Several plaintiffs' lawyers found that the company was willing to go to great lengths to prevent Richard Sackler from having to testify under oath. "They didn't want him deposed, I can tell you that much," recalled Marvin Masters, a lawyer who brought a class-action suit against Purdue in the early 2000s in West Virginia. "They were willing to sit down and settle the case to keep from doing that." Purdue tried to get Richard removed from the suit, but when that didn't work, the company settled with the plaintiffs for more than $20 million. Paul Hanly, a New York class-action lawyer who won a large settlement from Purdue in 2007, had a similar recollection. "We were attempting to take Richard Sackler's deposition," he said, "around the time that they agreed to a settlement." (A spokesperson for the company said, "Purdue did not settle any cases to avoid the deposition of Dr. Richard Sackler, or any other individual.")

When the federal government finally stepped in, in 2007, it extracted historic terms of surrender from the company. Purdue pleaded guilty to felony charges, admitting that it had lied to doctors about OxyContin's abuse potential. (The technical charge was "misbranding a drug with intent to defraud or mislead.") Under the agreement, the company paid $600 million in fines and its three top executives at the time-its medical director, general counsel, and Richard's successor as president-pleaded guilty to misdemeanor charges. The executives paid $34.5 million out of their own pockets and performed four hundred hours of community service. It was one of the harshest penalties ever imposed on a pharmaceutical company. (In a statement to Esquire, Purdue said that it "abides by the highest ethical standards and legal requirements." The statement went on: "We want physicians to use their professional judgment, and we were not trying to pressure them.")

No Sacklers were named in the 2007 suit. Indeed, the Sackler name appeared nowhere in the plea agreement, even though Richard had been one of the company's top executives during most of the period covered by the settlement. He did eventually have to give a deposition in 2015, in a case brought by Kentucky's attorney general. Richard's testimony-the only known record of a Sackler speaking about the crisis the family's company helped create-was promptly sealed. (In 2016, STAT, an online magazine owned by Boston Globe Media that covers health and medicine, asked a court in Kentucky to unseal the deposition, which is said to have lasted several hours. STAT won a lower-court ruling in May 2016. As of press time, the matter was before an appeals court.)

In 2010, Purdue executed a breathtaking pivot: Embracing the arguments critics had been making for years about OxyContin's susceptibility to abuse, the company released a new formulation of the medication that was harder to snort or inject. Purdue seized the occasion to rebrand itself as an industry leader in abuse-deterrent technology. The change of heart coincided with two developments: First, an increasing number of addicts, unable to afford OxyContin's high street price, were turning to cheaper alternatives like heroin; second, OxyContin was nearing the end of its patents. Purdue suddenly argued that the drug it had been selling for nearly fifteen years was so prone to abuse that generic manufacturers should not be allowed to copy it.

On April 16, 2013, the day some of the key patents for OxyContin were scheduled to expire, the FDA followed Purdue's lead, declaring that no generic versions of the original OxyContin formulation could be sold. The company had effectively won several additional years of patent protection for its golden goose.

Opioid withdrawal, which causes aches, vomiting, and restless anxiety, is a gruesome process to experience as an adult. It's considerably worse for the twenty thousand or so American babies who emerge each year from opioid-soaked wombs. These infants, suddenly cut off from their supply, cry uncontrollably. Their skin is mottled. They cannot fall asleep. Their bodies are shaken by tremors and, in the worst cases, seizures. Bottles of milk leave them distraught, because they cannot maneuver their lips with enough precision to create suction. Treatment comes in the form of drops of morphine pushed from a syringe into the babies' mouths. Weaning sometimes takes a week but can last as long as twelve. It's a heartrending, expensive process, typically carried out in the neonatal ICU, where newborns have limited access to their mothers.

But the children of OxyContin, its heirs and legatees, are many and various. The second- and third-generation descendants of Raymond and Mortimer Sackler spend their money in the ways we have come to expect from the not-so-idle rich. Notably, several have made children a focus of their business and philanthropic endeavors. One Sackler heir helped start an iPhone app called RedRover, which generates ideas for child-friendly activities for urban parents; another runs a child- development center near Central Park; another is a donor to charter-school causes, as well as an investor in an education start-up called AltSchool. Yet another is the founder of Beespace, an "incubator for emerging nonprofits," which provides resources and mentoring for initiatives like the Malala Fund, which invests in education programs for women in the developing world, and Yoga Foster, whose objective is to bring "accessible, sustainable yoga programs into schools across the country." Other Sackler heirs get to do the fun stuff: One helps finance small, interesting films like The Witch; a second married a famous cricket player; a third is a sound artist; a fourth started a production company with Boyd Holbrook, star of the Netflix series Narcos; a fifth founded a small chain of gastropubs in New York called the Smith.

Holding fast to family tradition, Raymond's and Mortimer's heirs declined to be interviewed for this article. Instead, through a spokesperson, they put forward two decorated academics who have been on the receiving end of the family's largesse: Phillip Sharp, the Nobel-prize-winning MIT geneticist, and Herbert Pardes, formerly the dean of faculty at Columbia University's medical school and CEO of New York-Presbyterian Hospital. Both men effusively praised the Sacklers' donations to the arts and sciences, marveling at their loyalty to academic excellence. "Once you were on that exalted list of philanthropic projects," Pardes told Esquire, "you were there and you were in a position to secure additional philanthropy. It was like a family acquisition." Pardes called the Sacklers "the nicest, most gentle people you could imagine." As for the family's connection to OxyContin, he said that it had never come up as an issue in the faculty lounge or the hospital break room. "I have never heard one inch about that," he said.

Pardes's ostrichlike avoidance is not unusual. In 2008, Raymond and his wife donated an undisclosed amount to Yale to start the Raymond and Beverly Sackler Institute for Biological, Physical and Engineering Sciences. Lynne Regan, its current director, told me that neither students nor faculty have ever brought up the OxyContin connection. "Most people don't know about that," she said. "I think people are mainly oblivious." A spokesperson for the university added, "Yale does not vet donors for controversies that may or may not arise."

The controversy surrounding OxyContin shows little sign of receding. In 2016, the CDC issued a startling warning: There was no good evidence that opioids were an effective treatment for chronic pain beyond six weeks. There was, on the other hand, an abundance of evidence that long-term treatment with opioids had harmful effects. (A recent paper by Princeton economist Alan Krueger suggests that chronic opioid use may account for more than 20 percent of the decline in American labor-force participation from 1999 to 2015.) Millions of opioid prescriptions for chronic pain had been written in the preceding two decades, and the CDC was calling into question whether many of them should have been written at all. At least twenty-five government entities, ranging from states to small cities, have recently filed lawsuits against Purdue to recover damages associated with the opioid epidemic.

The Sacklers, though, will likely emerge untouched: Because of a sweeping non-prosecution agreement negotiated during the 2007 settlement, most new criminal litigation against Purdue can only address activity that occurred after that date. Neither Richard nor any other family members have occupied an executive position at the company since 2003.

The American market for OxyContin is dwindling. According to Purdue, prescriptions fell 33 percent between 2012 and 2016. But while the company's primary product may be in eclipse in the United States, international markets for pain medications are expanding. According to an investigation last year in the Los Angeles Times, Mundipharma, the Sackler-owned company charged with developing new markets, is employing a suite of familiar tactics in countries like Mexico, Brazil, and China to stoke concern for as-yet-unheralded "silent epidemics" of untreated pain. In Colombia, according to the L.A. Times, the company went so far as to circulate a press release suggesting that 47 percent of the population suffered from chronic pain.

In May, a dozen lawmakers in Congress, inspired by the L.A. Times investigation, sent a bipartisan letter to the World Health Organization warning that Sackler-owned companies were preparing to flood foreign countries with legal narcotics. "Purdue began the opioid crisis that has devastated American communities," the letter reads. "Today, Mundipharma is using many of the same deceptive and reckless practices to sell OxyContin abroad." Significantly, the letter calls out the Sackler family by name, leaving no room for the public to wonder about the identities of the people who stood behind Mundipharma.

The final assessment of the Sacklers' global impact will take years to work out. In some places, though, they have already left their mark. In July, Raymond, the last remaining of the original Sackler brothers, died at ninety-seven. Over the years, he had won a British knighthood, been made an Officer of France's Légion d'Honneur, and received one of the highest possible honors from the royal house of the Netherlands. One of his final accolades came in June 2013, when Anthony Monaco, the president of Tufts University, traveled to Purdue Pharma's headquarters in Stamford to bestow an honorary doctorate. The Sacklers had made a number of transformational donations to the university over the years-endowing, among other things, the Sackler School of Graduate Biomedical Sciences. At Tufts, as at most schools, honorary degrees are traditionally awarded on campus during commencement, but in consideration of Raymond's advanced age, Monaco trekked to Purdue for a special ceremony. The audience that day was limited to family members, select university officials, and a scrum of employees. Addressing the crowd of intimates, Monaco praised his benefactor. "It would be impossible to calculate how many lives you have saved, how many scientific fields you have redefined, and how many new physicians, scientists, mathematicians, and engineers are doing important work as a result of your entrepreneurial spirit." He concluded, "You are a world changer."

This article appears in the November '17 issue of Esquire. Subscribe Today

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The Secretive Family Making Billions From the Opioid Crisis

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You're aware America is under siege, fighting an opioid crisis that has exploded into a public-health emergency. You've heard of OxyContin, the pain medication to which countless patients have become addicted. But do you know that the company that makes Oxy and reaps the billions of dollars in profits it generates is owned by one family?

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Over the past year, the Globe spent time with an East Boston heroin addict as she struggled through recovery and the prospect of losing her children to the state. Nearly every key moment was witnessed by a Globe reporter or photographer. Brave, broken, loving, at a loss, this is Raquel and her story.

Raquel Rodriguez paces around her cramped East Boston apartment, chain-smoking Newports in the early evening darkness.

Her two daughters race toy shopping carts across the living room, shrieking with delight as they clatter past.

A failing smoke detector beeps. The smell from the overflowing litter box fills the air. Santa and snowmen decorations crowd the coffee table.

Tomorrow, when she takes her first dose of methadone, Raquel will take a step toward recovery. But tonight, she's still a junkie. And she's scared. Scared of withdrawal. Scared the state will take her girls anyway.

Raquel has tried to quit heroin many times in her 47 years, mostly to please probation officers. This time, though, she wants to quit for good, she says, determined to do right by her daughters, ages 4 and 5.

The odds are against her. She hangs out with junkies, counting many as friends. She is bipolar and severely overweight. She has no job, no teeth, no degree beyond the GED she earned in prison. She gets by on Section 8, food stamps, and disability checks for mental illness.

Her dealer, a fellow user, is moving into Raquel's place with his wife because their apartment has no heat. So there will be easy access to what she is so desperately trying to avoid.

Drugs have been the one constant in Raquel's life. Born poor in Chelsea, the daughter of an addict and an alcoholic, Raquel is haunted by memories of sexual abuse and drug use as a child. By 19, she said, she was pregnant and selling crack.

"I never wanted to stop using drugs. That's what my life was," Raquel said, her voice husky. "I was a junkie, a rundown, a whore."

Between stints in prison for prostitution and drugs, she got pregnant again, and then twice more. Her oldest daughter, now 29, was raised by her grandmother; the next three - a girl and two boys - were relinquished to foster care.

The two decades that followed were a blur of selling drugs and using drugs and sleeping with men to get money for drugs. Then she got pregnant again in her early 40s, and vowed to do things differently. In 2009, she had Mimi, a funny, wide-eyed girl; less than two years later, Estrella was born, a shy, serious tomboy - both born drug-free, Raquel said. Estrella's father, a Salvadoran landscape and construction worker named Jose, was different from the other men. He drank too much, but he didn't do drugs. He was quiet, supportive. And he stuck around.

Raquel's life on the streets wasn't over though. A few months before giving birth to Estrella, she was picked up for prostitution in Chelsea. "I was trying to make some quick cash," she told police, according to the arrest report.

That arrest, coupled with a probation violation, led to a year in prison. Jose, by then a steady presence in Raquel's life, took care of the girls while she was gone.

For the next few years, Raquel says, she continued to steer clear of heroin. But then she let an addict stay with her. And just like that, she was a junkie again.

She started taking the bus to Chelsea to buy drugs in the square. She had a little extra money from her Uncle Bobby, an Army veteran, who thought he was just helping her get by. On a gray morning at McDonald's, a few weeks before she geared up to quit, the transaction was almost invisible. Sitting at a table, the dealer handed Raquel a bus pass, drugs concealed underneath. The bathrooms were closed, so Raquel asked the man to watch the girls and headed to the nearby Dunkin' Donuts to get high.

The children, unconcerned by her absence, continued playing with a toy doctor's kit.

Their mother reappeared 10 minutes later looking alert, almost refreshed. Her mascara was smeared, but her green eyes were clear.

Raquel is a woman of rapidly shifting moods, quick to anger and quick to laugh. She is demanding and dramatic, but also affectionate and generous, giving away cigarettes, opening her home to friends in need. And she is remarkably organized - budgeting around the arrival of benefit checks, juggling welfare appointments, always arriving early.

Above all else for her are her daughters. She frets over them constantly, and relies on them to take care of each other and, sometimes, her. When Raquel starts to panic or cry, as she often does, they comfort her with back rubs.

Watching the girls chase each other around the apartment the night before she started on methadone, Raquel worries that she can't do it. Drugs are too much a part of who she is.

But she must. If she relapses, she'll lose them.

The next morning, Raquel wakes up "dope sick" - freezing one minute, burning up the next, her stomach cramped and skin crawling. After Jose takes the girls to school, Raquel takes the bus to Chelsea to get high.

Later that morning at the clinic, she swallows her first "happy cup" of red liquid methadone. She starts with 20 milligrams, the first step toward the 100 or so milligrams where most people level out. Many clients stay "on the clinic" for a few years, some far longer.

At first, Raquel continues to use, gradually weaning herself off heroin as her daily dose of methadone rises. Her routine remains largely the same. She spends mornings drinking shakes at McDonald's, surrounded by other people from the clinic. The idea of getting a job never seems to come up.

Mary Ann Sullivan, a volunteer at the Salvation Army community center in Chelsea where Raquel goes for lunch, has watched Raquel get clean and relapse before. Chelsea is a hard place to stay sober, Sullivan said. Addicts are everywhere, trying to "drag you back in."

By mid-January, Raquel is up to 65 milligrams, and struggling. She's wetting the bed, and her hair is falling out. Her short-term memory is also failing: "I'm forgetting how to take buses," she says, dressed in pajama bottoms at Dunkin' Donuts, her hand wrapped around a large coffee with eight Sweet'N Lows.

Like other people living on the margins, Raquel has figured out ways to get what she wants. She orders "Frozen" boots for the girls from a shoplifter who charges her half price and gets dentures from a woman who claims to be licensed in Colombia. She buys the antianxiety drug Klonopin and other prescription drugs for $1 or $2 a pill on the street.

At times, the Klonopin, on top of the methadone, puts her in a fog, eyes glazed, speech slurred, nodding off in the middle of a sentence with a cigarette burning between her fingers. Raquel swears she isn't doing heroin, and her urine screens from the clinic confirm it.

It is a momentous day. Mimi is graduating from kindergarten. Then Raquel, wearing a tight T-shirt dress and leopard necklace, will graduate from a trauma and addiction program.

It had been a dark spring. In April, depressed and suicidal, Raquel spent almost a week in a Boston psychiatric hospital, a bleak ward with peeling paint and a stale cafeteria smell.

After she got out, she attended a three-week outpatient addiction program in Jamaica Plain. And she emerged feeling hopeful.

She stopped taking Klonopin and hanging out in the square. She threatened to kick Jose out for coming home drunk. As the weather warmed, she took her girls to the playground and bought them ice cream.

The children she gave up years ago have been on her mind. She wants to find them. She knows where her oldest daughter is - in prison for selling drugs, her children being raised by adoptive parents.

On the day of the graduation, Raquel stands outside Mario Umana Academy in East Boston with Estrella, Uncle Bobby, and Jose. "My first time seeing my babies graduate," Raquel says.

Then she spots a family with a balloon and realizes she is empty-handed. So she rushes to the nearby Shaw's and finds a big, blue "Frozen"-themed one for Mimi and a bunch of white carnations. For a few moments, everything feels OK.

Then the lit tip of her cigarette grazes the balloon, and it deflates instantly. Raquel erupts into tears. She hustles down the street to buy another one.

Inside at the ceremony, Mimi stands on her tiptoes and waves, smiling furiously. "Mommy!"

Raquel blows her kisses. When Mimi gets her certificate, Raquel clasps her hands, a wide, proud grin on her face.

A few hours later, at the conclusion of her therapy program in Jamaica Plain, Raquel starts to cry.

"I didn't think this was going to work," she says when she gets her certificate of completion. "It never works."

Then she beams: "I'm going to put this in a frame."

Raquel is a mess. Aching, cramping, sweating. Food doesn't stay down, and when it does it runs right through her.

She is convinced she needs more methadone. But the clinic won't up her dose until a doctor evaluates her. She just has to tough it out for a few more days.

But she doesn't want to tough it out. "It will be your fault if I relapse," she remembers yelling at her counselor.

Her heroin supplier is staying with her again, and it's almost too easy. After eight months of treatment, Raquel is using again.

The relapse lasts less than a week, she says, and she stops when the clinic at last ups her methadone.

But the damage is done. On Aug. 27, the state takes the girls.

They are whisked away from camp, where, according to court documents, Raquel was unable to speak in complete sentences when she dropped them off, depositing the girls with "poor hygiene and inappropriate clothing."

At home that afternoon, Raquel is outraged, screaming at Jose, screaming that the Department of Children and Families has no proof of her relapse. As dusk settles, she grows inconsolable. Crawling into the bed she often shares with her daughters, she clutches Estrella's giant stuffed bear and wails: "I want my babies."

Her kitten-sized dog, a Chihuahua Yorkie mix named Angel, chews on the toys and prescription pill bottles strewn on the floor. Jose sits silent on the couch.

"Maybe I'm not good enough for them, maybe they need someone better than me," Raquel says, nearly whispering."I'm nothing but a junkie."

Raquel and Jose arrive separately at the DCF office for their weekly visit with the girls, loaded down with Halloween costumes and chocolate milk.

In the month Mimi and Estrella have been gone, the distance between the couple has grown.

At a court date a day after the children were taken, Jose broke down, quickly, quietly, wiping his eyes with his gray tie after learning it would be a few months, at least, before the court would consider sending them home. Raquel reached out to hold his hand, but he ignored her.

The hourlong visit takes place in a small room filled with toys, a social worker keeping close watch outside an open door as the girls dive into snacks, thrilled to see their mom. When it ends, Raquel kisses the girls goodbye and they climb into the van, going where exactly, she does not know. As the door starts to close, Mimi looks back and her face collapses.

"Mimi, stay strong," Raquel calls out, her eyes welling up. "It's almost over."

Then the door slams shut.

The rest of the fall was hard. Raquel got pneumonia and came home from the hospital on oxygen and with a walker. She is still taking methadone, staying busy going to therapy and working on her relationship with Jose, who has started taking her to the church where she was baptized. He wants to adopt Mimi in case something happens to Raquel.

The next court date is in February, but it's unclear what it will take to get the girls back. For a time, DCF wanted Raquel to go into a residential treatment program. She balked at that. If she's away too long, she could lose her Section 8 voucher, leaving no home for the children.

"As far as they're concerned, I'm a junkie, and I'll never be anything more," she said.

Sitting alone in her apartment on a windy afternoon, Raquel turns off her oxygen to smoke a cigarette. There is no Christmas tree this year, no stockings hung on the door. A pile of unwrapped gifts - dolls and jewelry kits from the Salvation Army - cover the couch.

When the girls come back, Raquel plans to celebrate all the holidays they missed: putting together Halloween costumes, cooking a Thanksgiving turkey, showering them with Christmas gifts.

Mimi and Estrella seem to be adjusting to their temporary life in foster care. There are fewer tears during supervised visits, fewer wrenching goodbyes - a shift that brings their mother both comfort and pain.

"Sometimes I feel like they don't even miss me," she says, lips trembling.

The gray afternoon grows dim. Raquel looks around the empty room and lights another cigarette.

Produced by Russell Goldenberg, Elaina Natario, Laura Amico, and Emily Z. Fortier

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Over the past year, the Globe spent time with an East Boston heroin addict as she struggled through recovery and the prospect of losing her children to the state. Nearly every key moment was witnessed by a Globe reporter or photographer. Brave, broken, loving, at a loss, this is Raquel and her story.

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Animated history of crack and mass incarceration

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Animated history of crack and mass incarceration

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Jay Z: A History of the War on Drugs from Prohibition to Gold Rush

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There Was No Compassion During the Crack Epidemic

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There Was No Compassion During the Crack Epidemic

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There was no wave of compassion when addicts were hooked on crack

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Pharmaceutical Companies' role in the opioid crisis- John Oliver

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Pharmaceutical Companies' role in the opioid crisis- John Oliver

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Opioids: Last Week Tonight with John Oliver (HBO)

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The racial bias is inescapable: A drug crisis that is largely affecting suburban and rural whites is being treated with a drastically different attitude and approach in words and imagery than those used to characterize heroin use in the 1970s, crack cocaine in the late 1980s, and the drug problem plaguing America's people of color and urban poor today.

Elected officials, the criminal justice system, and the American media have adopted a "kinder and gentler" tone around the opioid crisis. The attitude and phrasing of a recent New York Times article-titled: "In Heroin Crisis, White Families Seek Gentler War on Drugs"-is both an example and an illustration. As is Time's just-published photo story "A caring lens on the opioid crisis." The visual language is just as illuminating. The opioid crisis has been framed as a threat from outside, with drug users facing an "illness or a "disease" rather than a personal moral shortcoming.

You can see in this photo how demonstrators cast addicts who have died from drugs as victims, and in the inset photo, literally as an angel. In another photograph, you can see how the same group, FedUp!, has co-opted the quilt as a protest symbol reminiscent of the AIDS crisis.
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The largely white drug "epidemic" we're facing now bears little resemblance to the scenes of squalor, sociopathy, and criminality depicted in this 33-photo Getty package shot in the Bronx and published in June. And photos from the urban "war on drugs" don't look much different today than they did 30 years ago.

The photo above by Scott Applewhite, also shot in the Bronx, appeared in 1989. It was published to illustrate an eight-week federal anti-drug initiative characterized by armed police raids on inner city crack houses. Suffice it to say police in general have taken a different approach to white opioid drug users (more on that later).

Over the years, photographers have produced many landmark photo stories and bodies of work about drug addiction. The subjects and the settings have been uniformly harsh, the subjects primarily indigent and wayward, and the environs largely decrepit. Those stories include Larry Clark's "Tulsa," shot in the mid-1960s and published in 1971; Jessica Dimmock's "The Ninth Floor," shot in the Flatiron District of Manhattan and published in 2007; Michel Du Cille's Pulitzer Prize winning work in 1988 documenting crack addiction in Miami.

Another important photo story in the canon of addiction is Eugene Richards's " Cocaine True Cocaine Blue." The project was shot primarily in New York and Philadelphia from 1988 to 1992 and published in 1994. The Instagram post above captures the visual tone and sensibility of that historical investigation. Notice the difference in tone between the historical work and a opioid story in June in The New Yorker shot by Richards in one West Virginia county.

On an #opioid epidemic fueled by cheap highs and small-town despair over limited prospects: https://t.co/FOp4oj1lgI @NewYorker #longreads pic.twitter.com/fP50D4TYSy

- Longreads (@Longreads) June 2, 2017

This tweet depicts four of six Richards images that illustrated the story. In the top left photo, the girl playing in the yard lives with her grandmother. She lost her father to a heroin overdose. The top right photo shows people running a project that helps place addicts in rehab. The middle photo shows a mother, a recovering addict, showing off her newborn. And the last photo is a doctor who offers free public classes in the use of Narcan, the drug that reverses opioid overdoses.
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What are the larger themes of photo coverage of the opioid crisis, centered on rural and suburban white America, and where do they contrast with coverage of drugs in cities? Photos are almost always shot in color rather than the starker black and white. We typically see daytime or well-lit indoor photos, as opposed to night action on seedy streets or dark alleys. There is minimal engagement with courts, jail, or the police. And there is a stress on domesticity. The photos often are shot at a home, the spaces mostly tidy or pulled together. Bedroom portraits are common.

Opioid stories typically stress the bonds and commitment of family, extended family, and community.

#KARMA
WHITE FAMILY OVERDOSE
A photo of Courtney Griffin, who died of a heroin overdose w/her sister Shannon, left, and her mother Pamela pic.twitter.com/U4Jc9ylnwF

- CRIMES AGAINST MELAN (@CrimesMelan) April 21, 2017

This image in the tweet above appeared in The New York Times "gentler drug war" story mentioned above. It's a photo of Courtney Griffin, who died of a heroin overdose in 2014. The picture in the center show Courtney closely flanked by her sister and her mother. Emphasizing love and closeness, as well as nostalgia and irony, the photo exemplifies how the opioid imagery stays away from pain, despair, isolation, and, of course, relationship problems.

Victims are often depicted in a sympathetic light, with an emphasis on family bonds and survivor grief. A sub-theme of opioid crisis coverage: Many stories showcase children who have been saved by loving grandparents.

Children of Heroin Crisis Find Refuge in Grandparents' Arms https://t.co/wjVwFzxkAB

- The New York Times (@nytimes) May 21, 2016

In the photo accompanying a Times story, notice the child safe in her bedroom, the letters on the wall spelling out her name, reinforcing identity and continuity. This pattern is a dramatic contrast to the narrative of broken homes, addicted babies, mothers depicted as unfit, the engagement of state agencies, and children routinely placed into foster care that is so characteristic of drug stories focused on black families in cities.

This photo, in contrast, comes from a two-part series in The Washington Post in 1989. It chronicled the life of six-year-old Dooney Waters, who lived with his mother in a Prince George's County crackhouse. According to the original article: The locks on the door had been replaced with balled-up socks. The walls were full of holes kicked in by addicts, and white paint patches sporting grafitti were spread indiscriminately. Dooney's father, a former convict, ultimately separated him from the complex, and his mother.

Opioid stories, on the other hand, tend to focus on treatment and recovery.

This photo by Jahi Chikwendiu appeared in a Washington Post article highlighting a recovery house in Bowie, Maryland. Opioid stories consistently stress close-knit towns and support communities.This is a reunion picnic with residents, graduates, family members, and supporters. Of course, the bonding and intimacy in these photos obscure the alienation and the emotional isolation that go hand in hand with addiction.

The issue of responsibility is largely absent until the theme of recovery comes into play. At that point, users and addicts are often shown exercising remarkable will and winning the battle with the disease. Photos stress dignity, help-seeking, coping skills, and self-reliance in the face of poverty and other challenges.

Consider this AP photo of a young man showing a picture of himself after a near-fatal overdose in 2015. It's like it can't be the same person, the Nike "Just Do It" accentuating a sense of agency over addiction.

This photo was featured in a major article on the opioid crisis published this month by The New York Times Magazine. Faith, love, and patriotism are themes that often lace photos of the opioid crisis.

In this photo from Getty, we see a look of conviction on the man's face and an American flag in the background. This formerly homeless man started a wildly popular Facebook group after his friend died of heroin and is now a sought after drug counselor. What's more American than bringing nationalism, patriotism, and a sense of can-do to a problem otherwise riddled with shame?
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When you do see photos of actual drug use, the images are typically clinical and objective, as opposed to desperate and dingy. After all the crafted photojournalism like the images you see above, it's jarring to see these user pictures more in the style of stock photography.

This photo by John Moore is part of a Getty story about New London, Connecticut, which is suffering an unprecedented heroin and opioid pain pill epidemic. You'll notice that the user wears a crucifix, a symbol of faith and a visual buffer with the drug use. Unlike other drug scourges, where photos of users using were common and showed faces, many opioid portraits hide the users' faces. We hardly ever see anguish, craving, or the high, the rush, or the stupor. The subjects look as if they are doing a routine task, like brushing their teeth.

Compare this to a frame from a Getty package in May 2015 on the rise of synthetic marijuana, or K2, in New York City.

This photo by Spencer Platt shows a black male drug user unceremoniously splayed out on an East Harlem sidewalk.

Of course, there are exceptions.

A mass killer: St. Louis heroin deaths hit new high. Heroin overdoses surpass homicides https://t.co/QDS9MMkFXJ via @stltoday pic.twitter.com/Gt87vuWlgg

- David Carson (@PDPJ) February 18, 2017

This tweet captures several photos from a St. Louis Post-Dispatch story that the public found widely disturbing. Administration of heroin in most opioid stories is visualized in a casual way. In the unusual instance that depiction is blatantly graphic or inordinately casual though, a much stronger impact has been elicited. In this case, a couple is photographed shooting up at home, the woman six months pregnant. Beyond the act of administration, however, the rest of the imagery still conforms to many of the domestic norms described above. The February 6, 2017 photo was made in the kitchen, as the couple apparently prepared a meal. The place looks otherwise spotless; both wear clean clothes, and the dishes on the far counter seem to be washed. In the accompanying images by photojournalist David Carson, the drug use fits a larger routine. It might be a horror, but it's a particularly antiseptic and contained one.

In light of campaign politics and now the debate over healthcare, geography has been almost as prominent a theme in the opioid crisis as demographics. A great deal of the towns are down-and-out, suffering from poverty and a loss of industry. In many cases, however, the photography softens the blow.

America's poorest white town: abandoned by coal, swallowed by drugs https://t.co/rwh9sPzbfR pic.twitter.com/6UEO8YAgOO

- The Guardian (@guardian) November 12, 2015

This photo led a Guardian story titled: "America's poorest white town: abandoned by coal, swallowed by drugs." The photo by David Coyle shows a house along Crystal Creek in Beattyville, Kentucky. Adopting a documentary style, there is an eerie quiet and a haunting beauty to the scene. Beattyville might be a town under siege, but the photo imparts a sense of dignity to the desperate locale.

You can compare that bucolic scene to the one above by Michel du Cille which was part of his 1988 Pulitzer Prize winning photo essay on crack cocaine addicts in a Miami housing project. Far from sympathetic, the black-and-white image and the harsh light gives the housing project the feel of a prison.

The visual narrative around the opioid crisis has largely sidestepped criminality. In fact, many opioid stories depict police as social advocates fighting for the community, as exemplified by the July Times Magazine cover story. In some cases, they are even a lifeline for users thanks to first responders who carry the drug Naloxone for reversing an overdose.

Contrast this August 2015 arrest photo from East Harlem, the charges unspecified, (shot in this case by Spencer Platt for Getty Images), with the NYPD Instagram post below, from May.

As a form of public service announcement, the two officers promote their use of Naloxone spray accompanied by an account of how they "saved a man from a potentially fatal overdose" just the week before. In fact, the visual stories hardly address the dealers and distributors of opioids at all. (That's in shocking contrast to the drug action, and even a dealer waving a fistfull of bills, in this story about drug abuse among the homeless in Chicago published in 2015 by The Daily Mail.)

I'm not sure what the race or ethnicity was of the person the NYPD rescued, but a thorough news image search reveals that most articles about Narcan or Naloxone either feature white drugs users or addicts, photos of white people who are being resuscitated (such as in this slideshow), or else they feature trainings or simulations with white volunteers and, almost exclusively, white mannequins.

There is a clear double standard in the visual framing of the opioid crisis. The gentler tone presents a marked departure from historical drug coverage, and the bias in the depiction of the problem as it plagues urban people of color feels baked in. What is even more concerning is the prospect for closing this perceptual gap. Besides racial disparity in journalism, the dog-whistle politics of President Trump is encouraging divisiveness and driving a deeper wedge. Still worse, the GOP leadership is patronizing addicts and states with proportionally larger populations of afflicted rural white populations with the promise of increased prevention and treatment funding as part of its argument for repealing Obamacare.

Kinder and gentler is only relevant until you see the omission. And then it compounds the disease.
CJR's health care reporting is sponsored in part by a grant from the Commonwealth Fund. ICYMI: How drug reporting is changing
Michael Shaw is publisher of the nonprofit visual-literacy and media-literacy site ReadingThePictures, an analyst of news photos and visual journalism, and a frequent lecturer and writer on news imagery, photojournalism, and documentary photography. Follow ReadingThePictures via Twitter and Instagram.

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Photos reveal media's softer tone on opioid crisis

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The racial bias is inescapable: A drug crisis that is largely affecting suburban and rural whites is being treated with a drastically different attitude and approach in words and imagery than those used to characterize heroin use in the 1970s, crack cocaine in the late 1980s, and the drug problem plaguing America's people of color [...]

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PEMBROKE, N.H. - The first time Patrick Griffin overdosed one afternoon in May, he was still breathing when his father and sister found him on the floor around 1:30. When he came to, he was in a foul mood and began arguing with his father, who was fed up with his son's heroin and fentanyl habit.

Patrick, 34, feeling morose and nauseated, lashed out. He sliced a love seat with a knife, smashed a glass bowl, kicked and broke a side table and threatened to kill himself. Shortly after 3, he darted into the bathroom, where he shot up and overdosed again. He fell limp, turned blue and lost consciousness. His family called 911. Emergency medical workers revived him with Narcan, the antidote that reverses opioid overdoses.

Throughout the afternoon his parents, who are divorced, tried to persuade Patrick to go into treatment. His father told him he could not live with him anymore, setting off another shouting match. Around 4, Patrick slipped away and shot up a third time. He overdosed again, and emergency workers came back and revived him again. They took him to a hospital, but Patrick checked himself out.

Back at his mother's house and anxious to stave off withdrawal, he shot up again around 7:30, overdosing a fourth time in just six hours. His mother, frantic, tried pumping his chest, to no avail, and feared he was dead. Rescue workers returned and administered three doses of Narcan to bring him back. At that point, an ambulance took him to the hospital under a police escort and his parents - terrified, angry and wrung out - had him involuntarily admitted.

The torrent of people who have died in the opioid crisis has transfixed and horrified the nation, with overdose now the leading cause of death for Americans under 50.

But most drug users do not die. Far more, like Patrick, are snared for years in a consuming, grinding, unending cycle of addiction.

In the 20 years that Patrick has been using drugs, he has lost track of how many times he has overdosed. He guesses 30, a number experts say would not be surprising for someone taking drugs off and on for that long.

Patrick and his family allowed The New York Times to follow them for much of the past year because they said they wanted people to understand the realities of living with drug addiction. Over the months, their lives played out in an almost constant state of emergency or dread, their days dictated by whether Patrick would shoot up or not. For an entire family, many of the arguments, the decisions, the plans came back to him and that single question. Even in the cheeriest moments, when Patrick was clean, everyone - including him - seemed to be bracing for the inevitable moment when he would turn back to drugs.

"We are your neighbors," his mother, Sandy Griffin, said of the many families living with addiction, "and this is the B.S. going on in the house."

In Patrick's home state of New Hampshire, which leads the country in deaths per capita from fentanyl, almost 500 people died of overdoses in 2016. The government estimates that 10 percent of New Hampshire residents - about 130,000 people - are addicted to drugs or alcohol. The overall burden to the state, including health care and criminal justice costs and lost worker productivity, has ballooned into the billions of dollars. Some people do recover, usually after multiple relapses. But the opioid scourge, here and elsewhere, has overwhelmed police and fire departments, hospitals, prosecutors, public defenders, courts, jails and the foster care system.

Most of all, though, it has upended families.

All of the Griffins speak of nonstop stress. They have lived through chaotic days: When the parents called the police on their children (both Patrick and his sister, Betsy, have been addicted to drugs); when Dennis, the father, a recovering alcoholic, worried that every thud on the floor was Patrick passing out; and when Sandy was, by turns, paralyzed with a common parental fear - that she had somehow caused her children's problems - or was out driving around looking for them on the streets.

For much of his adult life, Patrick, who once dreamed of writing graphic novels, has had no job and no prospects. He has a lengthy record of arrests, and the times he has been clean, he has always seemed to be on the verge of derailing his family once again. He got money to buy drugs by selling them at a profit.

Dennis, 66, a retired iron worker who also worked at a light bulb manufacturing plant, spends his days on the phone, trying to assist his addicted son with lawyers, counselors, insurance companies, even politicians - a whole new career he never sought and one he now fears may never end.

Patrick's younger sister, Betsy, 29, who used to shoot heroin with him, is in recovery and has a job, but Patrick's influence is a constant threat.

And Sandy, 59, a waitress, is determined to maintain a sense of peace, even as she is constantly on guard, knowing that her children could at any time pick up a needle. That comes with a question she can never push away - if they did, would it be for the last time?

"It's a merry-go-round, and he can't get off," Sandy said of Patrick and his overdoses. "The first couple of times, I started thinking, 'At least he's not dead.' I still think that. But he's hurting. He's sick. He needs to learn to live with the pain of being alive."

An Intervention

One day in July, Patrick's family staged a spur-of-the-moment intervention in his mother's living room in Pembroke, a pre-Revolutionary town in central New Hampshire not far from the state capital, Concord. In her apartment, up a set of steep, dark steps, the curtains were pulled against a blistering midday heat. Floor fans thrummed but did little more than push around the thick, dead air.

Sandy sat by Patrick on the sofa, a pillow clenched to her stomach. Dennis told Patrick he could no longer live with him and urged him to seek help.

Patrick shot down every suggestion.

"My father would never have put up with any of this," Dennis erupted.

"Your father was from the Stone Age," Patrick shot back. "There are better ways to handle these situations these days."

Dennis turned to his ex-wife.

"Aren't you going to -" he started to say.

"What am I going to make him do?" Sandy said sharply, anticipating a rebuke for being too soft on their son. "Don't put the finger on me, because that's what you're doing."

Dennis told Patrick, who had overdosed once again the night before, that he should turn himself in to the "safe station" program at the fire department, which helps people with addiction find treatment. Patrick scoffed. He did not even look at his parents.

"You've detoxed in jail before," Dennis said, "so it can't be worse than that."

"You have no idea how bad that was," Patrick said.

"Then why are you still using?" his father pleaded. "That makes no sense to me."

"I know it doesn't, Dad," Patrick snapped, "because you're not a heroin addict."

As a young teenager, Patrick had been bullied, and later he was diagnosed with attention deficit hyperactivity disorder, his parents said. He said he started self-medicating at age 14 with beer and marijuana, then moved on to cocaine and crystal meth. "All I wanted to do was get high and forget," he said. The meth made him vomit, so he turned to prescription painkillers that his friends stole from their parents. When the government tightened the supply of painkillers, Patrick sought out heroin and fentanyl.

"I thought, 'Nothing is going to kill me,'" he said.

Years later, he was diagnosed with major depression and borderline antisocial personality disorder, his family said, and more recently, post-traumatic stress disorder, illnesses that often go hand-in-hand with substance misuse. He has worked with mental health counselors for years, his family said, and has been on and off antidepressants.

For anyone in New Hampshire seeking heroin and fentanyl, a ready supply awaits, just over the state line in Massachusetts. The old mill towns of Lawrence and Lowell have long served as hubs of major drug distribution networks that funnel opioids throughout New England. Law enforcement officers say that dealers there often drop baggies of drugs into the open passenger windows of cars stopped at red lights.

Back when Patrick had a job at an auto-parts store and as a banquet server, his morning routine involved driving to Lawrence before work and scoring his daily fix.

Then he would shoot up with heroin or fentanyl at the wheel of the car while driving back to New Hampshire.

"I'd get these looks from people who would see me using," Patrick recalled. "Some guy started yelling at me and honking. They didn't know that I needed to get this in me so I wouldn't be sick anymore."

At one point on that steamy day in July, several hours into the family intervention, the conversation reached a lull. Patrick stepped out of the room and padded down a hallway in his bare feet.

He pulled a box from beneath his sister's bed and disappeared into the bathroom. Ten minutes later, he returned. His eyes drooped. He slouched on the sofa. He twitched and tugged at his goatee and plugged and unplugged his cellphone, an unlit cigarette in his hand.

Yes, he acknowledged a few minutes later. As his parents despaired over his future, he had been getting high.

'Needles All Over'

Patrick was high again a day later when he was arrested at a Burger King with a bag of Xanax bulging from one of his socks. He was charged with possession with intent to distribute, then blacked out.

He awoke in a small, concrete cell, charged with three felonies and two misdemeanors. Bail was set at $10,000 cash.

In jail, he was kept from all drugs, including Suboxone, an opioid substitute that eases withdrawal symptoms and that Patrick had been prescribed by a doctor years earlier as part of an effort to transition him into treatment. New Hampshire is among several states that have banned Suboxone from prisons because inmates often sell it to each other, sometimes leading to overdoses.

Patrick went into an intense withdrawal, with extreme vomiting and diarrhea, in a cramped 6-foot-by-8-foot cell that he shared with another inmate. His cellmate, who stayed on the top bunk, faced the wall and tuned him out, Patrick said. He said a second mattress was placed on the floor next to his lower bunk in case he fell out during a seizure.

"I was sweating," he said. "My eyes wouldn't stop watering. My nose wouldn't stop running. And I was so sleep deprived, I was seeing things." The worst of his symptoms persisted for more than 10 days. The aroma of food made him nauseous. Patrick, who is 5-foot-9, dropped to 133 pounds.

He spent seven weeks in jail, then 28 days in an inpatient treatment program as his legal case made its way through the courts.

By early October, the program was done, he was temporarily released on his own recognizance, and he had been drug-free for almost three months. And yet his family churned with anxiety. Having him locked away in jail was gloomy and unsettling. But it was nothing compared with the dread of having him out.

"He's going to come back and do the exact same thing, and I don't know how to stop it," Dennis said before Patrick was released and moved back in with him.

"That's what happens every time," Dennis said, sitting at his dining room table in his spare, tidy home. "I find needles all over the house. They're in back of the toaster. They're in the bathroom, underneath the vanity. They're upstairs. They're in the basement."

Still, this time, Patrick seemed different.

Patrick and his father joined a gym and began working out together. Patrick muscled up and put on 30 pounds. Color returned to his gaunt face.

But without drugs, Patrick said, he felt lost. He was not in treatment, had no mental health counselor and no job. If he wanted treatment to help him keep his resolve, he could not afford it. He had no insurance - incarceration automatically cost him his Medicaid benefits. His parents had long ago spent their savings to pay for lawyers, counselors and legally prescribed medications.

His stint in jail had also cost Patrick his slot with his mental health counselor, who had taken on so many new patients in Patrick's absence that she had no room for him when he returned.

What he did still have was his family.

Since Dennis retired a few years ago, he has spent much of his time trying to cope with his son's addiction. On many days, he waits for return calls from people like Patrick's public defender to find out the status of his legal case, or from the Medicaid bureaucracy to restart Patrick's benefits. He sometimes calls the offices of New Hampshire's top politicians to urge them to crack down harder on opioids.

"You wait for retirement, you wait for that magic age when your kids are grown and you can actually do something," Dennis said. "All I see is me just dying. I don't want them to die before me."

Diverging Paths

Patrick's sister Betsy has also been in and out of rehab and jail. But she is in recovery now and her life looks far different. She has a job working at an animal rescue shelter. She bought a car and started community college this month, her sights set on becoming a veterinary technician.

All of it raises a question: Why is one person from the same family, the same background, and who has the same attraction to drugs, able to stop, but another cannot seem to?

Sandy and Dennis have an older daughter, Jane, 37, an apprentice carpenter, who is not addicted. She has tried to distance herself from the family drama and has moved out of the area. Although she visits often, moving away has left her with what she describes as survivor's guilt.

"I had to make a conscious effort to put space between myself and them, for my own self-preservation," she said. "I'd already come to terms with the fact that my brother was going to die - I've already mourned him."

Jane has thought long and hard about why some people from the same background become addicted and others don't. She thinks she was spared because she never tried opioids in the first place.

"I don't know anyone who just 'tried' it and then stopped," she said. "Watching Pat do this was heartbreaking, but watching Betsy - who was outgoing, did well in high school and was planning on college - was super frustrating. I wanted to shake her, and say, 'You know how this goes. Knock it off.'"

Sandy said that Betsy, who completed a highly structured treatment program and underwent cognitive behavioral therapy, seemed more motivated than Patrick to quit.

And Betsy, who started using drugs at 19, said she suspected that Patrick had a harder time quitting because he had started when he was 14. A Surgeon General's report in 2016 said that the younger people are when they start taking drugs, the more likely they are to become addicted long-term. "His brain is still that young," Betsy said. "As intelligent as he is, this is his only coping mechanism."

It was especially difficult getting clean while her brother was still using, Betsy said, as she cuddled a frisky mutt outside the animal shelter. Now, Patrick stays with his father and Betsy lives with her mother; everyone is wary that if the siblings lived together, they could drag one another down.

Patrick said Betsy had succeeded where he had not because she had found passion in her work. She saw glimpses of herself in the shelter dogs and their painful pasts; when she was 8, her parents divorced and her father was drinking. She said she sometimes had to take care of him.

"She loves those dogs," Patrick said.

He said that during periods when he has been clean, he tends to take on too much, as he did last year when he signed up for multiple coding courses at community college. He said the heavy caseload left him frustrated, with failing grades. That preceded the relapse in May when he overdosed four times in a single afternoon.

Like many parents in families torn apart by drugs, Sandy has blamed herself. For a time, she wondered if she was too permissive, even as she reported her children to the police and kicked them out of the house.

At Al-Anon sessions for families of alcoholics, Sandy learned what are known as the four C's - "You didn't cause it, you can't control it and you can't cure it, but you can contribute to it." She said she came to understand that she had been an enabler. "Even though you think you're helping them, you're not," she said.

Now, Sandy sounds almost fatalistic about addiction.

"You could be the best parent in the world, but if it's going to happen, it's going to happen," she said. "It doesn't matter what walk of life you come from."

Patrick lives with his father, but he often feels crowded by him and visits his mother a lot, usually for supper.

As a late fall day turned to dusk, Patrick lounged on an overstuffed chair in her living room. He said he had not used drugs since he went to jail in July and had applied for a job at a local packaging plant. But he also said he had no self-confidence and no idea how to break free from his cravings.

"I'm afraid I'm going to screw it up all over again," he said. "That's what happens every time."

He said he knew he was not a sympathetic figure, that people may look at his life and wonder why he cannot pull himself out of this hole, especially with so much family backing.

"I feel like I've got nothing to offer," he said. "I'm depressed all the time, and I'm isolating myself. I don't really know what sober people do."

His eyes welled with tears and he scraped them, hard, with his open palms.

"I don't want people to pity me," he added. "But I don't want to lie to people about my past, either. I have a hard time asking for help. I always say, 'I got this.' But I never got this."

Seeking Solid Ground

On an unseasonably warm night in late October, Sandy attended a support group for parents of addicted children.

On this evening, 17 people showed up at the group, called Families Sharing Without Shame. All had adult children either in the throes of addiction or in recovery. As they sat in a circle, they shared their horror at discovering the drug use going on under their roofs. They drew nods of recognition when they said they finally understood why their teaspoons were vanishing from their kitchens (powdered opioids are heated in a spoon with water to convert them to a liquid that can be injected).

Unlike some of the other parents, Sandy seemed battle hardened, like one who had been immersed in a war for a long time.

"I lost myself 10 years ago," she told the group. "I couldn't go to work, I couldn't get out of bed." She said she was consumed by codependency, in which "you are addicted to this human being to save them."

She said she had realized that she had to save herself. Among her escapes: She learned to play the violin and bought a pair of kayaks.

"Being selfish is not a bad thing," she told the other parents, some of whose children would die in the ensuing weeks.

But if Sandy has gotten better, Patrick still struggles.

"He suffers more than anybody," she said later that night after the group broke up. "He wants to be a man, a man who has a wife and kids and a car and a job. He wants to be that man and he doesn't know how to be that man."

The next morning was a spectacular New England fall day, warm and bright, with leaves ablaze in a kaleidoscope of copper and crimson. Sandy and Patrick took the kayaks to a lake and went for a long paddle.

Out on the water, there was no chance he would relapse because he had not hidden away any drugs. Besides, he was busy paddling, soaking up the sun on his face and watching the light dance on the water. Out there, he didn't have to look back over the ruins of the past or stress about what might come next.

But eventually they would have to return to shore, where life, for both Patrick and his family, would always seem on edge.

Over the next two months, things would look up for Patrick. He got the job at the packaging plant. His Medicaid benefits were restored. He was on antidepressants and was back in counseling.

And at a court hearing earlier this month, his legal case was more or less resolved: In a deal worked out with the prosecution, he planned to plead guilty to two misdemeanors, with the other charges dropped. Any jail sentence would be suspended as long as his good behavior continued and he stayed in counseling.

For drug users and their loved ones, though, the worry never ends. No day can be ordinary. The threat of relapse is constant.

When Patrick recently texted Sandy, saying, "I love you," her first thought was that he was about to kill himself. She frantically called him back. Patrick told her he was fine, he had just been thinking about her.

For a moment, Sandy caught her breath.

To understand more about why New Hampshire has been overwhelmed by the opioid crisis, here are some of the reasons. Help shape our opioid coverage by taking a survey here.

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PEMBROKE, N.H. - The first time Patrick Griffin overdosed one afternoon in May, he was still breathing when his father and sister found him on the floor around 1:30. When he came to, he was in a foul mood and began arguing with his father, who was fed up with his son's heroin and fentanyl habit.

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sis sees the doc and he says "PILLS" ..... she walks back to the cause of her mental illnesses, numb

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Yelmi Alay✋