The views expressed here are my own and are not necessarily shared by any employer or educational institution I may be affiliated with...but they should be.
It is an inconvenient truth that most of the deaths attributed to heroin could have been prevented, would have been prevented, if not for the drug war, or as I called it in an earlier post, the drug holocaust. Heroin dependency doesn't have to be a death sentence, there are effective medications that can reverse an overdose, and heroin dependency is arguably the most treatable of the substance use disorders. So why all the death? Why the black balloons the other day? While it is true, both overdose and dependency are treatable, all substance use disorders carry with them a stigma that keep people from treatment, and this is doubly true for heroin dependency. But this doesn't have to be the case, we can stop these deaths, we can change the way people look at substance use disorders, but this time it requires us to change, not the the heroin dependent.
While cleaning your daughter's room you come across a hypodermic needle and some other strange objects that a quick google searche helps you identify as her "kit." Suddenly it all makes sense, your daughter is using heroin. You can confront her, get her to promise never to use again, watch her like a hawk, ship her off to rehab, the list goes on. People are doing this all over the United States, families and communities are being ripped apart and the overdose deaths keep rising. What I'm going to tell you isn't a guarantee, but it may be the best chance you have of keeping her alive until she can find a treatment that works. But I warn you, you're not going to like it.
1) Encouraged her to use in front of you.
This is the hardest, but most important step. Everything else hinges on this step. This means you take a hard look at the ugly reality of addiction and make a choice to keep your daughter alive. This requires you to choke back the words "don't you ever bring that shit into my house" because those are the deadliest words you can say. Instead say "I will always love you, you will always be my child, this will always be your home, heroin can never change that." This may not require you actually watch her do the injection, but encourage her to tell you when she is going to use. Ask her to return to the living room when she's done. Check on her often, learn the symptoms of overdose and watch for them. If you have other children in the house this may require some safety precautions.
a) a place to store her kit where the other children won't find it.
b) she will need clean needles, needles should not be use more than once even if she isn't sharing them. In Rhode Island needles are available without prescription and affordable, if this is not the case you may need to contact a needle exchange, or order them online.
c) she will need a safe place to put used needles. An empty plastic detergent bottle makes an adequate sharps container to transport them for disposal.
You may ask if this is legal. The truth is I'm not sure. The greatest risk of arrests and prosecution occurs when purchasing and transporting drugs, assuming the amounts your daughter is purchasing are small it is probably not very likely that you are at risk for legal action, but it is probably possible. You will have to weigh the risks and see if they can be avoided vs. the danger to your child.
If your child is acting out violently, or making threats of violence, step one may not be possible. Step one is about the safety of your child or loved one, but your safety is just as important.
2) Buy Narcan, and learn how to use it.
If your child overdoses you can keep them alive and reduce the risk of brain damage with rescue breathing and Narcon. Narcon is available in and injectable form or one that is administered nasally. The FDA has recently approved a new single use nasal spray for Narcan. Several states have made it legal to purchase Narcan over the counter, if this is not the case where you live a needle exchange may be able to provide you with some. Even if you don't have Narcan, rescue breathing may be enough to keep your child alive until help arrives, but if your child overdoses on the street, all the Narcan in the world won't help her, that's why step one is so important. You should keep Narcan around even if your child hasn't used in a long time. She will be at a higher risk for overdose if she relapses.
3) Consider ALL treatment options ...
...except rapid medical detox. It may seem like a great idea, but it's not. Even if your daughter successfully completes the detox and gets some sustained abstinence under her belt (few get even that) she will be at a higher risk for overdose. Inpatient treatment has the same problem. If your daughter makes it through the withdrawal symptoms she may very well be able to stay off opiates, while she's in treatment. Once she is out her tolerance will be lower and risk of overdose higher. This is not to say people aren't successful at this type of program, but if you decide to go this way steps 1 and 2 become even more important. Some data shows that people who go to abstinence based inpatient treatment are more likely to die of an overdose than people who get no treatment at all. This suggests the treatment can be more deadly than the disease. It's also important to remember that between 60 and 75 percent will relapse in the first three years, most of those within the first couple of months. To put it bluntly she is probably going to use again so instead of trying to prevent relapse, prepare for it. See steps 1 and 2.
Medication Assisted Treatment also called MAT may give your daughter the best chance of a successful recovery as well as provide more safety. There are disadvantages to MAT, the treatment is most successful if used as a long term treatment strategie, and the difficulty of discontinuing the medication. There is also the dependence on a clinic or provider to supply daily doses of the medication, disruption of which will be debilitating to the patient. But there are advantages as well. MAT therapy is cheap when compared to inpatient rehab and certainly cheaper than a daily heroin habit. It's very effective. Of the patients on a MAT program for 1 years 70% are illicit drugs free. You can continue working at your job on a MAT program, raise your children, go to school, and if you do relapse, the medication causes a cross tolerance that reduces the risk of overdose. For many heroin dependent people long term MAT is simply the best option. What's important to remember is to not push your daughter to stop taking her methadone or Suboxone before she is ready. The rules of thumb for methadone is to recommend 2 years of stability on the medication before attempting to taper off. Most will try to taper off sooner, many will stay on much longer, a few will take the drug for the rest of their lives. It's important to remember that it doesn't matter which of these categories your daughter falls into. One is not more sober than the other.
There is no right way to recover, there is no perfect treatment, whether you daughter goes into a Faith based abstinence programs, or a methadone clinic, odds are that her last use of heroin won't be the day before she starts treatment. Relapse is a part of recovery and even in a MAT program it can take months to reach a blocking dose and illicit use to end. But heroin is treatable, your daughter can survive dependency to heroin. Shame however will keep her from asking you for help. Shame will get her to quit her MAT program before she is ready. Shame will drive her away from you and into the streets when she relapses. She may survive heroin, but shame will kill her. It is time to stop waging war on heroin and people who use it, instead let's fight the stigma. Shame is deadlier than heroin.