The drug counselor fixed her eyes on Paul S. Kandarian and spoke the words that changed his life.
“Paul,” she said, “heroin is not an option for you anymore.”
Lynne Deion had told Kandarian the same thing many times before. But on this day in 2015, it was as if gears in his brain suddenly interlocked and began to whirl, and her message took hold.
“It was what I needed to hear at that moment,” Kandarian said. “I haven’t used since.”
People who have recovered from opioid addiction often recall a moment like that: the flash of clarity, the jolt of resolve.
Whether it’s holding a newborn and vowing to be a good parent, or simply waking up one morning yearning for a better life, the time comes — seemingly all of a sudden — when a person with addiction plants feet on the zigzagging road to recovery.
Such journeys occur more often than you might think as news reports trumpet the death toll — in 2017, 2,050 opioid-related deaths in Massachusetts, 47,600 nationwide. Yet the results of a 2016 survey suggest that tens of millions of Americans have overcome a significant alcohol or drug problem in their lifetime.
It’s estimated that out of every 10 people with a substance use disorder, four to six reach the point where they no longer use drugs in a harmful way, although getting there takes time and often multiple tries.
How do they do it? What enables people to get and stay sober?
For many months the Globe posed this question to people in recovery and those who help them. The answers were astonishingly varied, even as they often shared a common human thread. Just as addiction arises from different sources in each person’s life, recovery takes an idiosyncratic path.
‘I needed to stop my brain from working’
For Kandarian, turning the corner felt like a sudden move, but it didn’t come out of the blue. He’d been lurching toward recovery for months. Indeed, he’d tried to get off drugs dozens of times in his life.
Growing up in Taunton, the son of a nurse and a freelance writer, Kandarian started using cocaine in early adolescence. In his senior year of high school, a friend introduced him to the prescription painkiller Percocet.
“All of a sudden,” Kandarian said, “it was like all the weight that’s been crushing me lifted. I felt so good, I felt like I thought I should feel.”
Eventually, in the throes of withdrawal, he let a friend shoot heroin into his vein.
As a young adult, Kandarian lived with his father, Paul E. Kandarian, in Taunton. Confronted from time to time with evidence of his son’s addiction, the elder Kandarian pleaded with him to stop using — and he did go to detox again and again. But always, he would resume using almost immediately afterward. He found work on various construction jobs, but had no goals, no self-respect, no future that he could envision.
Then, in 2010, when he was 21, a fellow drug user joined the military, and Kandarian saw a way out.
While his father was away, he locked himself in their apartment and detoxed alone. He remembers two weeks of ceaseless sweating, cramps so bad he passed out, sleeplessness, hallucinations. As soon as he was well enough to leave, he joined the Army.
His mission: to die.
“I was thinking, ‘I’m just a junkie, I’m going to die anyway,’ ” he said. “It was a way I could die with pride doing something for someone else.”
Kandarian enlisted in the infantry because it had the highest casualty rate, and deployed to Afghanistan for 10 months.
Serving in the Army nourished him, and it wounded him. He forged connections deeper than any he’d known and saw parts of the world he’d never dreamed of. He also saw beloved friends blown to bits. Once, he recalled, he had to retrieve a soldier’s leg from a tree.
But he didn’t die.
Instead, Kandarian came home in 2013 with post-traumatic stress disorder, persistent migraines, damaged knees, and a shoulder that keeps dislocating. In pain, afflicted by nightmares, he bought Percocets within a month of getting home.
“Then,” he said, “I went straight to heroin because I needed to stop my brain from working and thinking.”
In 2015, Kandarian developed a severe infection in his arm from injecting with contaminated equipment. It was so painful he cried out when he moved in his sleep. His father persuaded him to go to the Providence VA Medical Center.
The infection required a hospital stay for intravenous antibiotics, which had to be infused through his neck because his other veins had collapsed from years of heroin injections.
Deion, a nurse and licensed chemical dependency professional, stopped by Kandarian’s room, where he lay in pain from withdrawal and the infection. Kandarian, who knew Deion from previous treatment efforts, remembers first ordering her to leave — and then bursting into tears when she stayed anyway.
As he started to feel better during his week and a half in the hospital, Kandarian had a chance to think. For the first time, he envisioned a meaningful future: going to college to get a degree in psychology. Meanwhile, Deion connected him with the VA’s methadone program, and he started on the medication the day after discharge.
Methadone, used to treat opioid addiction since the 1960s, has a long track record of effectiveness. The drug fills the brain’s opioid receptors, quieting the cravings and also preventing heroin from latching on.
Kandarian made a daily pilgrimage from Taunton to Providence to slurp the pink liquid from a little plastic cup. But habits are hard to break. The ritual of shooting up remained alluring. He could get a blunted high from heroin despite taking methadone, and he still wanted to numb his feelings. Time and again, his urine tests revealed that he’d used heroin.
He met with Deion weekly, and it was on one of those visits that she pronounced the familiar — but now suddenly powerful — words.
Later that day, when Kandarian got an urge to shoot up, it was almost easy to resist, because he knew: Heroin is not an option.
A search for meaning
How do people recover? Given the vast numbers afflicted, the science on this critical question is surprisingly thin.
In an informal, open-ended survey earlier this year, the Globe posed that question to physicians, researchers, treatment program leaders, recovery coaches, and advocates — all concerned with addiction care and many in recovery themselves.
Some 125 people were asked in an e-mail: What are the two or three things that people who achieve sustained recovery from addiction have in common?
The 82 replies, although a very high response rate, don’t yield a scientific answer. But they do offer insights.
Support and connection with others were seen as essential to recovery by just over half the respondents. Many — 33 respondents — spoke of emotional benchmarks; people who recover, they said, have rediscovered joy, love, gratitude, and, most of all, hope. An equal number specified that medications, especially methadone and buprenorphine (Suboxone), are critical to recovery from opioid addiction.
Notably, there was no unanimity. There was not one factor that every respondent mentioned.
One physician cautioned against even looking for a common thread.
Dr. Zev Schuman-Olivier, medical director for addictions at the Cambridge Health Alliance, said he’d had patients who recovered with medication and never experienced a deep inner change, and other patients who recovered after a deep inner change but never touched medication.
Still, many survey respondents’ views comport with studies showing that medications — especially buprenorphine and methadone, but also sometimes a newer drug, injectable naltrexone, or Vivitrol — dramatically reduce the risk of opioid overdose and help keep people in treatment, clearing the way for them to rebuild their lives.
But a physician who works with the homeless may have identified the singular key to success.
“People who achieve sustained recovery have MEANING IN LIFE,” wrote Dr. Jessie M. Gaeta, chief medical officer of the Boston Health Care for the Homeless Program, in her e-mailed response. “There is something they have that makes them feel useful, and it also connects them to other people.”
DeSean Duncan didn’t see much meaning in his life as he lay on a gurney in the hallway of the Faulkner Hospital emergency room. It was July Fourth weekend in 2015, and a few days earlier the burly 24-year-old had been kicked out of an addiction-treatment program because he punched someone who’d insulted him. Then he went out and got so drunk and high he ended up in the hospital.
He was exhausted, fed up, and preparing to head back to the street. He’d already been to treatment more times than he could count.
“All it did was make me a better drug addict. Every time I went in, I learned about better drugs and made new connections,” he said. In fact, he’d been introduced to heroin at a treatment program.
Growing up in Mattapan, the rebellious child of a single mother and a father that he says ignored him, Duncan started drinking alcohol and codeine cough syrup at age 13.
People made fun of him for being sensitive, so he learned to hide his feelings. He found a sense of safety and community in street gangs, but that also meant he was stabbed and shot at throughout his adolescence. Eight close friends died. Privately, he grieved them each year on the anniversaries of their deaths, feeling newly wrecked by each loss.
While at college on a football scholarship, Duncan was introduced to Percocet during treatment for a dislocated shoulder. He learned to crush the pills and snort the powder, and in time he moved on to doing heroin on the streets of Boston.
“I hoped every time I did the heroin, I wouldn’t wake up,” he said. “I felt like I had no purpose in life.”
Now on this holiday weekend, stuck in a hospital corridor, Duncan was ready to head out and get high again. But he wasn’t alone: At his side was his mother, with whom he’d always had a tumultuous relationship. “If you walk out that door,” she threatened him, “you can just forget about me.”
As they talked, Duncan realized that, although he can never remember her saying so, his mother loved him. After all, she was always there when he got into trouble.
So he stayed put, fighting the urge to leave, until the hospital found him a detox bed at 3 a.m.
From there, an insightful case manager changed Duncan’s course: Instead of the inpatient care that never worked for him, he would attend a program where he would spend daytime hours in treatment but live at home. The program provided Suboxone, a medication that killed his cravings, as well as medications and therapy for the bipolar disorder that had been diagnosed years ago but never treated.
Duncan also got connected with SMART Recovery, a network of mutual support groups that focuses on self-empowerment rather than melding with a group. A former gang member and football player, Duncan had plenty of practice with groups. What he didn’t know, he said, was how to be an individual: “I didn’t know who DeSean was.”
Who was DeSean? The seeds were scattered throughout his life, sprouts stomped down but not dead.
As a child, he’d dreamed of becoming a history teacher. As an adolescent, even though he was expelled from three high schools for misbehavior, he’d also been elected class president at one of them. After high school, he attended a summer program that engages inner-city youth in social justice projects, and for the first time felt a sense of purpose.
Now, Duncan realized he wanted to work in human services. He volunteered at the STEPRox Recovery Support Center in Roxbury and eventually was hired to oversee all its day-by-day activities.
Duncan has managed to stay sober through some recent challenges. Earlier this year, he started having seizures — which his doctors blamed on blows to his head while playing football — and had to leave his job at STEPRox, a heartbreak.
Recently he moved to West Warwick, R.I., and today he works as a recovery coach at a Rhode Island recovery center. “I love it here,” he said.
In photos from years ago, Duncan looks tough, scary, like the gangbanger he was. Today at age 28, his features have softened, as if the sensitivity that once invited trouble has risen again to the surface, now an asset.
“I finally recovered,” he says, “because I found my own identity. I found myself.”
A sudden, inexplicable decision
Emily Seaman can’t explain what prompted her to seek sobriety after 10 years of heroin use. All she knows is that she woke up one morning in her Framingham apartment sick and aching for her next fix, as always. But this time, she decided she was done with feeling that way.
She called her mother and asked for a ride to Cape Cod, where she enrolled in the Gosnold treatment program. Her mother, Lauren Seaman, was skeptical; she’d heard it all before, but this time there was something different in her daughter’s voice.
The difference, Emily Seaman says, was simply that this time she was ready.
“I know that is hard to swallow because I hurt so many people, including myself, for so many years over something as simple as I wasn’t ready,” she said. “I had to get to this point in my life. I don’t know why I had to go through so much hell to get there.”
It was, for sure, a lot of hell.
She started injecting heroin at age 12. At the time, her parents were separating, her father was ill, her aunt had killed herself, and Emily fell under the influence of an older man who introduced her to the drug.
Periodically, her parents sent her to treatment programs, but within a short time, she was always using again, often living on the streets. Seaman said she had been sexually abused as a child; she didn’t want to discuss details, but such trauma is a common precursor to addiction.
“There were traumatic events before I started using and traumatic events after. It just kind of never stops,” Seaman said recently. To get money for drugs, she did things that wounded her then, and fill her with shame today.
“I kind of destroyed my family. My dad was on pain medication and I would steal all his pain meds. I broke my mother’s heart.” At that, she broke down and paused for breath. “My sister and I didn’t have a relationship. I ruined that. Family and friends were afraid of me and I hated myself, I absolutely hated myself.”
At age 18, Seaman started taking Suboxone and experienced her first stretch of extended sobriety. She gained weight, got healthy — and unexpectedly became pregnant.
Following medical advice, she took a different formulation of the medication throughout her pregnancy and in 2012 she delivered a full-term baby girl, Olivia. The baby was born dependent on her mother’s medication and spent four weeks in the hospital.
Living with Olivia’s father in Framingham, Seaman continued to maintain her sobriety and raise her daughter. But after a year, she started using again, and the program where she was getting her Suboxone — instead of helping her get back on track — stuck with its strict policy and kicked her out.
“Then I had nothing and just took off running,” Seaman said. She asked her mother to take care of Olivia and surrendered to heroin.
Until about a year later, when suddenly she’d had enough.
Seaman entered Gosnold with a new attitude. She convinced the physician there, who was reluctant to prescribe Suboxone, that she could not rebuild her life without it.
“Without Suboxone, every day, my whole day is: ‘I want to use.’ . . . And Suboxone takes that away. It helps with craving so you can concentrate on the underlying issues.”
After Gosnold, she spent four months at Right Turn, an Arlington treatment program that uses artistic expression to help heal the damage wrought by addiction.
Today, at age 26, Seaman lives in Framingham with her mother and daughter, now a happy 6-year-old. She has a job caring for elderly people who have dementia, and nurtures herself with artwork, needlepoint, meditation — and regular doses of Suboxone.
“Getting sober was a journey to love myself again,” Seaman said. “Even after four years, I’m not completely there.”
There’s another piece to Seaman’s story.
That day she decided to get sober? She wasn’t alone. Seaman and a friend made the pledge together.
But that friend didn’t have a mother who could pay for months of treatment and provide a home afterward. He relapsed and died of an overdose.
Reaching a moment of clarity, resolving to get sober — sometimes that isn’t enough if the rest of the world doesn’t step up with support.
A serious substance use problem is like a burning house, says John F. Kelly, director of the Massachusetts General Hospital Recovery Research Institute. Short-term treatment can put out the fire by stopping substance use. But to keep the blaze from flaring up again — to prevent relapse — people need the materials to rebuild their lives: jobs, housing, financial security, positive social connection, and day-by-day stability.
People who were addicted to opioids can have an especially hard time acquiring those “building materials,” Kelly said, because they often have criminal records that bar them from employment, loans for education or housing, or even bank accounts. And the stigma is stronger; former heroin users tend to fear disclosing their history, blocking off the social support that could keep them in remission.
For these reasons, Kelly said, “It can be tougher to recover from an opioid use disorder compared to other substance use disorders.”
Paul Kandarian, the man who finally accepted that heroin was not an option, restored his life with the help of his family, especially his father, and the persistence of Lynne Deion and other caregivers at the Providence VA.
Kandarian learned, Deion said, that if heroin wasn’t for him, he needed to find something else. And so he did.
He went to school. In May, Kandarian graduated from the University of Massachusetts Boston with a degree in psychology. Now 30 and living in Framingham, he’s working as a treatment coordinator for low-income people with addiction and mental illness. And he’s looking into graduate school.
Tall and tattooed, a floppy mohawk atop his head, Kandarian comes off as affable and approachable. He relaxes by doing woodworking, including elaborate carvings, and continues to take his daily methadone.
He remains close to his father, an actor as well as a writer, who re-creates their ordeal performing in a play produced by a Rhode Island nonprofit. The younger Kandarian occasionally speaks about addiction and recovery at schools and public events. Sometimes, he spies Deion in the audience.
Does Kandarian think he’ll ever use heroin again?
He has a ready answer: “I’m not going to use today.”