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An activist sets up cardboard gravestones with the names of victims of opioid overdose outside the courthouse where the Purdue Pharma bankruptcy case is taking place in White Plains, New York, on August 9, 2021. (AP Photo/Seth Wenig)
Main image: An activist sets up cardboard gravestones with the names of victims of opioid overdose outside the courthouse where the Purdue Pharma bankruptcy case is taking place in White Plains, New York, on August 9, 2021. (AP Photo/Seth Wenig)
ToI Investigates'This is a fatal condition. Not everybody survives'

Jewish communities grapple with addiction as fentanyl crisis ravages US

American Jews have not been spared the devastating fallout of opioid abuse, which claimed 107,000 US lives in 2021, though some still struggle with stigmas while seeking help

Luke Tress is an editor and a reporter in New York for The Times of Israel.

Main image: An activist sets up cardboard gravestones with the names of victims of opioid overdose outside the courthouse where the Purdue Pharma bankruptcy case is taking place in White Plains, New York, on August 9, 2021. (AP Photo/Seth Wenig)

NEW YORK — David started dabbling in drugs while he was in college about 10 years ago. He took black market prescription amphetamines to help him stay awake and study, and got into downers like Xanax for his anxiety.

A graduate of a Brooklyn yeshiva, David, a pseudonym, had enrolled in New York’s prestigious Cornell University with the goal of getting into medical school. His family, immigrants from Russia, wanted him to become a doctor and put a lot of pressure on him.

Opioids were never his drug of choice, but they flooded the drug market and he started taking some of the painkillers, mainly OxyContin and other forms of Oxycodone, since the pills were so easily available.

He got his degree in biological sciences and worked a series of jobs in the medical field, but he was struggling with depression and med school wasn’t working out.

“It was a big weight on my shoulders that I just couldn’t overcome, and the embarrassment of not fulfilling those aspirations drove me into isolation, from almost all my friends, from healthy daily activities,” said David, who asked that The Times of Israel withhold his real name for privacy reasons.

He was hooked on the anti-anxiety benzodiazepines and still taking the painkillers when the government started to crack down on prescription opioids. Doctors became reluctant to write prescriptions, making the pills hard to come by. Reluctantly, he began turning to street heroin for a similar high.

Eventually, the heroin started to run scarce too, and suppliers started cutting in fentanyl, a cheap and potent synthetic opioid even more dangerous than heroin. He suspected the powders he bought were laced, but kept using anyway, along with his closest friend.

“An addict can justify almost anything to himself. Rationalization has no bounds. ‘Well, we’re only going to do a tiny bit to test it,'” he said. “But it was just the only thing available. It was the only thing we could get our hands on and we were desperate.”

5-mg pills of Oxycodone, June 17, 2019. (AP Photo/Keith Srakocic, File)

The pair would keep an eye on each other while they were using, with the overdose treatment Narcan at the ready.

“He would come over and I would have all this Narcan, he would have all this Narcan, and we would stand by for each other, but looking back that was just playing Russian roulette,” David said.

Then one day last December, his friend used fentanyl-laced heroin alone and died of an overdose. The friend had just graduated medical school.

“That was the one time he was using alone. I was not able to be with him at that time and believe me, I’m going to regret that for years to come, that I wasn’t able to be there for him,” David said.

“My closest friend in the whole world,” he said. “That sent me into a terrible spiral myself.”

Wracked by guilt and grief, he started having passive suicidal thoughts, such as not minding if he didn’t wake up in the morning. No matter how much he used, he couldn’t get away from the pain caused by the loss of his friend. A few months later, he also overdosed while alone at home.

Flower of joy

America’s overdose epidemic has killed 932,000 people since 1999, is now in its third wave, and has not yet peaked, with deaths from drugs hitting record highs in recent years, according to US authorities. Most of those deaths involve opioids. First it was prescription pills, then heroin, now fentanyl.

Our rocky relationship with opioids, a class of drugs used for both recreational and medical purposes, stretches back to early civilization. Humans began cultivating vibrant, elegant poppy flowers for the opium they produce some 5,000 years ago.

The ancient Sumerians called poppies the “flower of joy,” and the drug can certainly be a blessing. It alleviates pain, aids sleep, induces euphoria and eases death. The ancient Egyptians grew poppies and traded opium around the Mediterranean, and Crusaders brought the drug back to Europe after warring in the Middle East. Some Greek gods were depicted draped in poppies and Homer mentioned the plant in “The Odyssey.”

The British waged two Opium Wars against China in the mid-19th century as Chinese authorities sought to block imports of the drug amid widespread addiction. In the US, opium dens sprang up in New York and other cities in the 1800s and early 1900s.

A soldier stands in a poppy field during eradication supervised by the Mexican Army on the outskirts of Morelia, Mexico, March 4, 2010. (AP Photo/Carlos Jasso, File)

Western medicine has repeatedly embraced opiates, each time believing the drug to be safer than before. Both the Americans and the British used opium during the Revolutionary War, and Benjamin Franklin took it to deal with a painful bladder stone. Opium and morphine were widely prescribed during the Civil War, leaving around 400,000 soldiers addicted and setting off a crisis that would be echoed over 100 years later. Laudanum, a mixture of opium and alcohol, was commonly prescribed for a range of ailments into the early 20th century.

Chemists started to break opium apart in the early 1800s by isolating morphine, starting a process that would make the drug increasingly potent. Heroin was synthesized for the first time in 1874, and Germany’s Bayer pharmaceutical company began marketing it as a non-addictive morphine substitute.

The German Jewish chemist Edmund Speyer, who was later killed in the Holocaust, developed Oxycodone with his partner Martin Freund in 1916. Merck sold it as a pain reliever and cough suppressant. Fentanyl was first created for the Belgian drug company Janssen Pharmaceutica in the late 1950s. It is still used for some medical purposes.

In 1995, Purdue Pharma released a version of Oxycodone with a time release mechanism, which the company said would prevent addiction. The drug, OxyContin, was hailed as a breakthrough and came just as the medical community was beginning to take patients’ pain more seriously as a symptom that needed to be treated in itself.

The company pushed the drug to doctors using aggressive sales tactics, fraudulent marketing and false medical claims, including by obfuscating evidence of addiction, its critics say. The methods were part of a long pattern of unscrupulous behavior by the Sackler family, descendants of Jewish immigrants to New York. The clan’s patriarch, Arthur Sackler, played a major role peddling Valium in the 1950s — America’s first prescription drug crisis — and the family put much of the same playbook to use selling opioids through Purdue.

The company has paid out billions in legal settlements and been bankrupted by the fallout, but the Sacklers remain one of the most wealthy families in the US.

OxyContin pills in Montpelier, Vermont, February 19, 2013. (AP Photo/Toby Talbot, File)

Americans were prescribed millions of the powerful painkillers for legitimate reasons, such as back pain, and became addicted, as Purdue salespeople played down the dangers and pushed higher and higher doses to doctors. Drug abusers quickly figured out how to bypass OxyContin’s time-release mechanism by simply crushing the pill, among other methods.

The government began cracking down on Purdue, after much prodding, in the mid-2000s. The pills became hard to acquire amid regulator scrutiny, and many doctors feared issuing prescriptions due to legal risks, leaving both addicts and legitimate pain patients without access to the drug.

As the supply went down, prices on the street went up, prompting many users to turn to heroin, which was cheaper and easier to come by. The government’s attempts to shut that spigot led users to the latest phase of the epidemic — the fentanyl wave. It has been called the worst drug crisis in American history and is still accelerating.

‘No community’s immune’

Jewish users, activists and treatment providers said the community has been hit like any other, albeit with some specific challenges, including a particularly unforgiving stigma around addiction and a lack of awareness. They repeatedly said the same thing: “Addiction doesn’t discriminate.” US authorities have said Black communities have seen disproportionately high rates of overdose deaths in recent years.

Rabbi Yaacov Behrman heads Operation Survival, a drug and alcohol prevention program founded in the late 1980s that focuses on classroom education about the dangers of drugs and other threats.

“The Jewish community is unique because there was the feeling that we’re immune to addiction and drugs because of a lack of understanding of how it works,” he said. “Once we created that awareness, people could seek help.”

“No community’s immune from drugs. All communities have the same challenges,” said Behrman, a community advocate in Brooklyn’s Crown Heights neighborhood. Most young people in the community with a drug problem start off experimenting, or succumb to peer pressure, while older people usually start with prescribed pain medicine, Behrman said.

Amudim, a social services organization based in New York, runs ads to boost awareness of addiction in Jewish communities:

There is no reliable data on Jewish drug use, since official sources don’t track religion, and many people in the community hide their abuse, but treatment providers said rates are similar to other groups. Amudim has had over 2,100 opioid cases since 2014, said its CEO, Zvi Gluck. A UJA-Federation of New York survey on the impact of COVID-19 on Jews in New York City and its suburbs found that 10% of Jewish households reported a substance abuse problem. Nine out of ten of those households said they were not seeking help for the problem.

Treatment providers said there were no significant differences between Jewish communities, but that stigma is an obstacle across the board.

“I don’t care what affiliation you come from, there is still a tremendous sense of shame around addiction,” said Rivka Nissel, a social worker and the director of Jewish community services with the Jewish Board, a leading social services agency based in New York. The problem stems from people “not understanding the pain that people go through” and not understanding addiction is a disease rather than a personal failure, she said.

Devora Jaye, a recovery specialist with the Jewish Board’s JCS Recovery program, said any faith-based community likely had the same problem, and that the Jewish community has made progress but still has a ways to go.

A man injects heroin into this arm under a bridge in Aberdeen, Washington, June 13, 2017. (AP Photo/David Goldman, File)

‘People need connection’

Jewish treatment programs provide services to the community in both in-patient and out-patient facilities that serve Jews from a range of backgrounds.

Jaye runs support groups for substance abuse and other issues. Her organization was set up in the 1990s, when most groups met in church basements. Many 12-step programs still have a Christian bent, which can make some Jews uncomfortable or feel out of place.

The people who come to her meetings run the gamut, Jaye said.

“In one of my support groups I have a woman who’s Hasidic, and I have a woman who’s a Reconstructionist lesbian, a Talmud scholar,” she said. “They’re supporting each other and they’re so close because they have this commonality and they both feel their Judaism so strongly.”

“People need connection. That’s what keeps them sober,” she said. Just showing up at a meeting, even virtually, can disrupt the urge to use, which tends to wax and wane. One of her clients was in a crisis last year and attended online support groups for nearly 24 hours straight to ward off a relapse, she said.

Adding to the crisis, the COVID pandemic exacerbated drug use by increasing peoples’ isolation, making medical care harder to obtain, disrupting drug supply chains and stoking stress and anxiety.

In religious Jewish communities, the typically large families can be an asset because someone who’s struggling with drugs has a bigger support network, but it also widens the circle of damage.

Two women hold each other who lost a loved one to opioids during a protest with other advocates outside the Department of Justice in Washington, December 3, 2021. (AP Photo/Carolyn Kaster)

“Addiction never impacts just one person. There’s such a deep effect it has on spouses and children and parents,” said Nate Nagelblatt, the outreach director for Recovery at the Crossroads, a Jewish treatment facility in New Jersey that includes a residential program.

The program is not religious, but gives residents space to pray and observe holidays, and pays attention to cultural nuances, like providing kosher food. The residents, mostly Jews from the New York region, are supervised around the clock and attend structured activities, but have some independence and usually stay for about 90 days. Nagelblatt estimated that half the residents had used opioids.

Nagelblatt’s program focuses on working with families as well as the addicts themselves. The families of addicts tend to have their own traumas, he said.

Nagelblatt speaks to wives who fret when their husband leaves the house for groceries, worrying he will overdose or relapse. One mother found her son overdosing and brought him back with Narcan. Now, whenever she calls his name in the house and he doesn’t immediately answer, she panics.

The families need and deserve to heal, and when they have recovered, they are better situated to help a member with an addiction, Nagelblatt said.

For the addicts, the treatment focuses on more than just the addiction.

“None of my clients woke up one day and said, ‘Hey, I have a great idea. Why don’t I become addicted to opiates?’ That doesn’t happen. There’s always a preceding event,” he said. “There’s a purpose in this behavior. If we just take it away without understanding what’s going on beneath the surface, they’re not far away from relapse.”

Discarded syringes in an open-air heroin market near Philadelphia, Pennsylvania, July 31, 2017. (AP Photo/Matt Rourke, File)

“The addicts I work with tend to be incredibly sensitive people. They tend to be incredibly kind and caring and giving and understanding of others, very empathic, so things hurt them more which opens up to more trauma,” he said. “There aren’t many people in my book who are better than a recovering addict. They’re leaning into their pain, they’re processing their emotion.”

Many of his clients have died of relapses, which takes a toll, but he’s motivated by the ones who do well. Some people showing up to alumni events have been clean for years. One client, whom another facility had given up on, sent him an email telling him about the Passover after he got clean. He had been married for many years and said the holiday with his wife and kids was the best he ever had.

David, the addict with whom we started this story, credits Recovery at the Crossroads with saving his life.

After his friend died, he began using alone, and overdosed while at home. As the overdose was setting in, his father called him on an Amazon Echo device with a video connection, which they had installed at each other’s houses partly for peace of mind, since his parents were aware of David’s substance abuse.

His father, who lived 10 minutes away, saw what was happening, rushed over and called the Hatzalah emergency service. The first responders brought David to Coney Island Hospital and saved his life.

David decided to get help, and went with his family to see a rabbi in Brooklyn who works in the field of addiction. The rabbi referred David to Recovery at the Crossroads.

“I knew I had to go. I was ready to do anything. I knew I needed help and I knew it wasn’t within me to just stop this on my own,” he said.

“They didn’t just address the need for abstinence, they addressed the need to work on the reason that brought me into the world of drugs, which for me was anxiety and depression, then the grief of losing my friend,” he said.

He went into the program distressed and severely underweight, and came out healthy and revived 94 days later.

Addiction may be stigmatized in many Jewish communities, and social pressures were one factor in David’s addiction, but his Jewish background and community connections were also crucial to his recovery. He had previously been in a non-Jewish rehabilitation program, which he said was far less comfortable and accepting. At Recovery at the Crossroads, nine out of the ten people in his residential program were Jewish, which created a more supportive environment.

“There were people that learned in yeshivas for most of their lives and there were people that were businessmen and women, mothers as old as 50s or 60s that had alcohol issues,” he said. “It was really a rainbow of different types of people but we were all very happy to help each other in the process.”

“There’s a spiritual element to recovery and I think it was important to incorporate my experience of Judaism,” he said.

David is now staying at a sober living house for Jewish men outside New York City and working at a health clinic. “I’m loving my recovery,” he said.

A man lies on a sidewalk in San Francisco as the city deals with a surge in overdoses, April 26, 2018. (AP Photo/Ben Margot, File)

The rising tide

The fentanyl that nearly killed David is now the main factor in America’s spiraling overdose crisis. The potent synthetic drug is making its way into other drugs, causing them to be even more dangerous and unpredictable, and turning up in fake prescription pills, poisoning thousands who never regularly used opioids like a toxic river spilling over its banks.

According to the CDC, 107,375 Americans died of overdoses in 2021, the highest number ever recorded. The devastating toll represents about one overdose death every five minutes.

The CDC said 71,238 of those deaths involved fentanyl, up from around 58,000 the year before. In New York, overdoses kill more people than homicides, suicides and car accidents combined, and 80% involve opioids. Over 932,000 Americans have died of an overdose since 1999, according to government figures.

During an opioid overdose, the user may lose consciousness, and their breathing can slow or stop, cutting the supply of oxygen to the brain in a condition called hypoxia, which can cause death and brain damage in minutes. Overdoses can also result in choking, cardiac arrest and seizures.

The number of users is likely not climbing like it did earlier in the crisis, when prescription pills were easily available, but the drugs have become more dangerous. Fentanyl can be produced by amateur chemists and is up to 50 times more powerful than heroin. It cannot be detected by sight, smell or taste, and a minuscule dose of two milligrams can be lethal. Even more powerful opioid analgesics like carfentanyl have started appearing.

The DEA said 42% of pills it tested for fentanyl contained at least two milligrams.

Two milligrams of fentanyl, a lethal dose for most people, placed next to a penny for scale. (DEA/Public domain)

Most of the fentanyl in the US is smuggled in from Mexico. Cartels import precursors from China, then manufacture the synthetic opioid and press the drug into pills, often disguising it as Oxycodone or other medications, including non-opioids like Adderall. Earlier this month, Mexican prosecutors seized 1,200 pounds of fentanyl at a warehouse in Culiacan, enough to produce millions of pills, and a day later, confiscated another half-million pills in the same city. The DEA seized 20.4 million counterfeit pills in 2021.

“There are now this flood of pills that are being made at home that are marketed as genuine OxyContin pills and in reality they just contain a lot of inert filler plus a dash of fentanyl,” David said, noting the danger for users who had been dependent on prescription pills. “Someone is used to a very consistent Oxycodone dosage, and all of a sudden they’re hit with this ‘hot spot’ in these fake pills.”

Fentanyl is cheaper to manufacture than other opioids, since producers don’t need to grow and harvest, and is easier to hide from authorities. One researcher estimated that producing fentanyl is about 1 percent of the cost of producing heroin. Fentanyl has largely replaced heroin in some areas, and in many places, it’s difficult to find heroin that is fentanyl-free. Heroin itself is also dangerous, causing overdoses, addiction and a range of damaging health effects, especially for those who inject the drug.

Fentanyl is also cut into other hard drugs, such as cocaine and ecstasy, for the feeling of euphoria it provides. A bad batch can wreak havoc, with the DEA warning of “mass overdose events.” Last year, over the span of a few days, six people died on Long Island from a batch of cocaine laced with fentanyl. Over the July 4 weekend, nine people died in Florida’s small, rural Gadsen County. In Washington, DC, in April, 10 people died in a mass-casualty fentanyl incident, the city’s second this year.

The overdose-reversal drug Narcan during training for employees of the Public Health Management Corporation (PHMC) in Philadelphia, Pennsylvania, December 4, 2018. (AP Photo/Matt Rourke, file)

The most vulnerable

The drug is most dangerous not to regular users, but to the young and inexperienced, many of whom think they are buying prescription pills. David called the most vulnerable people the “opiate naive.”

“Those that are buying bags of powder, they know to be careful. They know to be taking tiny bits,” he said, adding that these people will likely have safety measures in place, like a supply of Narcan.

At the same time, some experienced drug users actually prefer fentanyl because it’s cheaper and doesn’t need to be injected, among other reasons.

Nagelblatt said that it’s often his clients who are doing well who are in the most danger. Success is not always total abstinence — he had one woman come in who had been using four bags of heroin a day, and in the entire year after she completed the treatment program, she used a total of three bags. She relapsed, but barely, and got the rest of her life together.

“Someone who uses four bags of heroin every day, for years, their body will build up a tolerance. It’s more first-time users, and this is something that breaks my heart, it’s the people who get clean and relapse who are most susceptible to dying,” he said.

“As a clinician working the field, the part that’s emotionally taxing is that the clients, not all the time, but sometimes the clients who die are the clients who were doing so well, and that kills me,” he said. “One time, one use and that’s it, this person’s not here anymore.”

“It’s important to remember that this is a fatal condition. Not everybody survives.”

Many of the victims don’t know they are taking opioids at all. Eli Weinstock, 20, was a sophomore at American University’s School of Communication. He was a fan of hip-hop and Quentin Tarantino films, and interned at a Spanish language program. He collapsed at home in Washington, DC, in March 2021.

“He was a fun, quirky and creative guy,” said his mother, Beth Weinstock. “He didn’t intend to die, and he wasn’t struggling with a substance use disorder.”

Three months after Eli’s death, the coroner’s report said there were two substances in his body — Kratom, a legal stimulant, and fentanyl. Eli may have intended to take Kratom, not knowing it was spiked with fentanyl, or he may have thought he was taking something else entirely.

Users may see prescription medication abuse as a safer way to do drugs: they may have been prescribed opioids in the past for legitimate reasons, and pills don’t carry the stigma of harder drugs like heroin. A college student might buy a blue pill stamped with the letter “M” and the number “30,” and check on Google to make sure it’s safe.

“If you look it up, it’ll show you a picture of the real prescription Oxycodone, and then you look at that pill that you just got from your friend and you think, ‘Oh, it looks exactly like that,’ but it’s not. It’s been illicitly stamped,” said Weinstock, a doctor who has immersed herself in learning about the drug that killed her son. “It’s particularly cruel.”

Fentanyl pills disguised as Oxycodone. (Cuyahoga County Medical Examiner’s Office via AP)

It’s not clear why there are lethal doses in single pills. Weinstock said producers, many of whom are amateurs, may get sloppy and add in too much fentanyl, or high-level manufacturers just might not care who they kill as collateral damage. Weinstock rejects the term “overdose” to describe fentanyl deaths, since it implies the person meant to take the drug and was accustomed to a certain dose, and instead refers to the fatalities as accidental ingestions or poisonings.

For young people, the epidemic is especially acute. Overdoses, mainly due to fentanyl, became the leading cause of death for Americans aged 18-45 last year, surpassing suicide, COVID, gun violence and car accidents.

Young people often buy the pills over social media, communicating with dealers using coded emojis, then paying with apps, the DEA said in a report this year titled “One Pill Can Kill.”

Snapchat, under pressure over the drug trade on its platform, said it had taken down 140,000 accounts for drug offenses in the second half of 2021. The company carried out surveys as part of its effort to combat the drug trade, and found that only 27% of teens were aware fentanyl is in fake pills. Young people considered the drug less dangerous than heroin or cocaine, the survey said.

Eli Weinstock. (Courtesy)

Six months after her son’s death, Weinstock and her 22-year-old daughter, Olivia, decided to put their grief to use. They established BirdieLight, a nonprofit that educates young people about the dangers of fentanyl and distributes test strips that can detect the drug.

The name “Birdie” stems from an inside joke Eli had with friends, joined with the symbol of a canary in a coal mine, carrying a light. The Weinstocks put the two words together and noticed Eli’s name in the middle, so it stuck. Their first funding was a small grant from their synagogue.

They focus on educating young people, since the trend of adulterating pills and other drugs became widespread only a few years ago, so some educators are still catching up. She and Olivia visit high schools, colleges, Jewish groups and others around the country to inform them of the dangers of fentanyl, teach them about using more safely, and distribute test strips. The young people are attentive to the message, she said.

“I think this is the greatest public health crisis of this young generation, more so than COVID,” Weinstock said. “They get it, they’re scared. They know that their peers or even themselves are using drugs, recreationally or perhaps first-time use, and they just really are scared because they don’t know how to stay safe.”

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