A son’s mistake, a family’s grief and the cruel lessons of the fentanyl epidemic

Justin Pearlman was settling into his latest rehab, a $95-a-day treatment center in Pennsylvania, when the Tribune reached him for an interview about his struggle with heroin addiction.

It was 2007, and Pearlman was part of a wave of young people in suburban Chicago who had fallen under the spell of a drug that had become so pure and accessible it had lost its traditional sense of menace. But its effects remained as unforgiving as ever: Pearlman described a chaotic existence of arrests, overdoses and fruitless trips to rehab.

“I definitely believe in a power that’s greater than myself,” he said. “So many people have died from one use. Why wasn’t it me?”

Fourteen years later, it was him.

Pearlman died of a fentanyl and heroin overdose last September after what his mother calls his reluctant return to illicit opioids. It came after a long period of recovery, and according to his mom, only out of desperation when he could no longer access medication that had prevented a painful withdrawal.

Fentanyl, an ultra-potent synthetic opioid, has changed the odds even for experienced drug users, let alone someone whose tolerance evaporated after years of abstinence. It’s unclear if Pearlman fully appreciated that danger.

His death has left his mother, Lea Minalga, founder of a Kane County support group for the parents of drug users, adrift in grief.

“I don’t blame him one bit that he bought that little bag of heroin because I know exactly why he did it,” she said. “I just wish he would have told me, because we were that close. My whole house was full of (the overdose-reversing agent) Narcan. I would have sat there with him if he wanted to try it. That’s a huge regret of mine.”

She said Pearlman eventually overcame his addiction with the help of Suboxone, an opioid-based medication that suppresses the craving for the drugs. As time passed, he mended threadbare relationships with his family and friends and became a successful salesman at his father Elliot’s industrial container company.

“He’d reached a point in his life where everything was going great,” Minalga said.

Then, last fall, Pearlman made two fateful decisions.

First, he weaned himself off Suboxone, saying he wanted to experience life without the medication. But as with any opioid, quitting Suboxone can produce uncomfortable withdrawal symptoms. When those surfaced, Minalga said, he tried to restart the medication but was unable to find a provider who could see him immediately.

Federal law has draped Suboxone in red tape, including a limit on how many patients a provider can treat. The regulations are aimed at preventing unethical doctors from running pill mills, but some researchers have found they discourage providers from offering the medication at all.

Dr. Bradley Stein, director of opioid policies, tools and information for the RAND Corp., said other factors are also at play.

Many doctors who are licensed to prescribe the medication treat far fewer people than they’re allowed to, sticking with only a handful of familiar patients, he said. Insufficient reimbursement and a lack of patient services such as counseling figure into the shortage, too.

Stein said better education and treatment systems would encourage more doctors to prescribe the drug, similar to how primary care physicians overcame their reluctance to use antidepressant medications.

“It’s easy for us to point to these (regulatory) barriers,” he said. “I think it’s far more complicated than that.”

Pearlman’s lack of access to Suboxone led to his second decision: He apparently went looking for relief in an illicit marketplace that had changed radically since the heyday of his use.

Fentanyl is cheaper, easier to produce and far more powerful than heroin, and in recent years it has taken over the streets. Dealers typically mix the drugs to stretch their profits, or just switch to fentanyl outright.

That has caused fatal overdoses nationwide to more than double in just six years. Kane County has seen its own increase, reaching more than 60 opioid-related deaths in each of the last two years. This year, it’s on track to hit 75.

“A very large percentage are fentanyl,” Coroner Rob Russell said. “Very few of them aren’t these days.”

Sometime on the morning of Sept. 28, or maybe the night before, Pearlman took what he likely thought was just heroin (Minalga said text messages on her son’s phone indicated he’d been seeking the drug). A fentanyl test strip would have revealed its true properties, but there’s no sign he used one.

When Minalga checked on him in the basement of their St. Charles home, he was dead, his left hand still grasping a syringe. Russell’s office determined the cause of Pearlman’s death was fentanyl and heroin intoxication. He was 41.

Government officials from Washington, D.C., to Chicago are increasing the availability of fentanyl test strips, but they’re not infallible. Lyndsay Hartman, who runs the Kane County harm reduction group Point to Point, said the strips indicate just the presence of fentanyl, not its strength, so users still don’t know exactly what they’re getting.

Other potential remedies remain in limbo. Safe consumption facilities, which provide health workers to oversee drug use, aren’t sanctioned in Illinois. A more radical approach underway in Canada — prescribing regulated doses of heroin or fentanyl — isn’t even on the radar in the U.S.

“We’ll never be able to keep on top of the supply we have now because it’s so volatile,” said Hartman. “We’re way behind where we need to be if we actually want people to survive.”

The particular tragedy of Pearlman’s death is it’s hard to say whether any of that would have mattered. Experts say the heavy stigma around opioids encourages people to keep their consumption a secret, especially when they relapse.

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“He didn’t want to disappoint anybody and he probably thought he would disappoint us, but he wouldn’t have,” Minalga said.

On a beautiful morning last month, Pearlman’s loved ones interred his ashes at Union Cemetery in St. Charles (the family decided to delay the ceremony until the weather was warm). The mourners formed a semicircle around his grave marker, quietly weeping as the Rev. Nathan Pacer of St. Patrick Catholic Church led them in prayer.

Later, over a lunch Elliot Pearlman hosted at his son’s favorite restaurant, Minalga rued a drug market turned deadlier than ever and called for tougher measures to stop the flow of fentanyl into the U.S.

But most of all, she paid tribute to her son’s years of effort.

“I remember years ago he used to say heroin would call his name every day,” she said. “He was probably the greatest hero I ever met because he kept trying so hard to overcome it all these years. And he did. (The overdose) was like a mistake, an accident. It wasn’t supposed to happen.”

jkeilman@chicagotribune.com

Twitter @JohnKeilman