Within a week, maybe two, you begin to ramble about the lock on your door, how it’s broken, and how you’re sure someone is breaking into your apartment to spy on you. You tell me that one day you came home to find a syringe on the floor. Someone planted it there for a supervisor to find, you’re certain of it, other residents want your apartment, they want you gone.
I suggest various ways you might resolve these issues. You have excuses, explanations for why each of my recommendations won’t work. I ask a lot of questions. Your paranoia does not involve state secrets, the CIA or FBI, tinfoil hats or aliens, the twin towers or global-government conspiracy theories, but the elevation of small anxieties and fears to delusions of persecution. I try reasoning with you, but sometimes, in order to empathize, I must suspend my desire to be rational and take part in your fantasy world. I learn there is nothing I can do for you; you are autonomous in overseeing your own health care. I encourage you to see your psychiatrist and wait. Once your medication is adjusted, you are no longer afraid.
Not long after your disability payments kick in, the debt collectors send notices to my apartment. One is on behalf of an old landlord who, years ago, sued you for rent payments you never made. It has been more than a decade, but this debt has not been forgotten. I mail a check.
Here are some things you might do on a given day: Walk to the methadone clinic to pick up your dose (you are required to go three times a week). Wait in line. Take one bus to the Medicaid office (when your pension kicked in, your monthly benefits went up, pushing you just slightly over the minimum-income requirement). Wait in line. Take one bus to see your psychiatrist (you live in Bushwick; your psychiatrist is in Crown Heights). Wait. Take one bus to the Supplemental Assistance Program office (you lost your EBT card and need to request a new one). Wait in line. Take two trains to see your hepatologist at NYU Langone Medical Center. Wait. Walk to the post office (to pick up the check my father has sent you). Wait in line. Walk to the nearest Western Union (where you would cash checks before you had a bank account). Wait in line. Take the bus and two trains to Maimonides Medical Center in Borough Park (you need a colonoscopy). Wait.
I write down statistics, try to make sense of what I’m reading. In 2012 U.S. physicians wrote 240.9 million prescriptions for painkillers, an increase of 33 percent since 2001. The growth can be attributed to a few related factors: patient-advocacy groups calling for better pain treatment; patients, perhaps influenced by pharmaceutical marketing, requesting drugs from their doctors; doctors, some with questionable ethics, overprescribing drugs.
The U.S. government responded in a predictable way. It introduced more stringent prescription guidelines, authorized DEA investigations and closures of “pill mills.” State governments began to use databases to track “doctor shoppers,” patients who sought out prescriptions from multiple physicians.
In 2010 Purdue Pharma, the producer and patent holder of OxyContin, introduced an abuse-deterrent version of the drug ostensibly impervious to crushing, breaking, chewing, and dissolving, and therefore more difficult to inhale or inject.
That same year, the number of U.S. drug poisoning deaths involving any opioid analgesic (oxycodone, methadone, or hydrocodone) accounted for 43 percent of the 38,329 drug poisoning deaths, a fourfold increase from 1999, when opioid analgesics were involved in 24 percent of the 16,849 drug poisoning deaths.
Following the government crackdown, supply of pharmaceutical opioids decreased sharply. Demand did not. The street price of prescription painkillers inflated, and many pharmaceutical opioid users opted instead for heroin. A rising supply of heroin kept prices low.
According to one study, more than 81 percent of recent heroin users say they switched after first trying prescription painkillers.
You say that one day, out of the blue, you decided to give it up. Just like that.
You call at around eleven on a weeknight to tell me you are going to call an ambulance—you are in pain. Ten days earlier you had surgery on an abdominal hernia. The procedure was supposed to have been minimally invasive, performed with a scope, a few hours all told, and I waited to take you home. But there were complications. They had to cut you open. You were admitted to the hospital, stayed seven nights. Now you are home again but certain that you are not healing properly. When I arrive at your place in Bushwick, the paramedics are helping you into the back of the ambulance. I get in with you. We sit opposite each other. I ask you questions. You are lucid. I expected you to be doubled over, but you are not. The paramedics confirm that your vitals are good. You have no fever. At this point, I am confident that this trip is unnecessary; that there is nothing to worry about except that you are alone, and you understand what that means. But I stay silent as you tell the paramedics to take you to where you want to go.
When we arrive at the emergency room, the triage nurse evaluates you. You tell her about your pain, your recent surgery. Soon you are wearing a bracelet and gown, sound asleep in a bed. It is past midnight. I sit in the vinyl sled-base chair to read, but am more interested in the ER nurses shuffling through the ward, the gurneys wheeling by, bodies and machines, the perverse game of observation and diagnosis. Who among the patients holds the fate worse than all the others? I know that if you’re asleep the pain is not as bad as you said it was.
Not far from your bed, just outside the curtain, a young man in a wheelchair, his neck slackened, his chin drooping close to the chest, vomits. It’s viscous, like cake batter. It pours out of his mouth and covers the front of his gown. He is unconscious and makes barely any sound. Now is a good time for a walk. I head outside, buy some chips from the gas station.
When I return, the young man has been moved to the center of the ward, where, shuddering now, he continues to vomit. The former contents of his abdomen pool and spread on the floor. A nurse approaches. I point to the man and ask whether something might be done for him. The nurse frowns, tells me that the man is getting what he deserves; he has done this to himself. She walks away. Several nurses pass the gurney, but no one looks at the man.
It is 4:00 A.M. by the time the doctor sees you. Everything is fine, he tells us. By now the chaos of the ER has quieted. You slept right through it.
Tomorrow, I will get up early and go into work at an office.
For the first time, I resent you.
The morning I visit Insite I awake to a winter sun, a rare reprieve from Vancouver rain. It is still early when I take the bus downtown. The buildings glimmer gold and red under the warming light.
I decided to come here, to make the long trip to Vancouver, because I wanted to see Insite for myself. I wanted to see the place where people who use drugs intravenously can go to inject more safely, the place where, according even to the supportive editorial I’d read earlier, “horrible things take place.” By then I had read enough about supervised injection to know that I thought it less horrible than humane. There is much else for which I would reserve the word “horrible,” including the treatment by law enforcement of people who use drugs.
Between 1992 and 2000 more than 1,200 fatal overdoses were recorded in Vancouver. Many of these took place in the Downtown Eastside, a neighborhood of ten or so square blocks where more than 4,600 people who inject drugs intravenously were known to live. The HIV conversion rate was the highest in the Western world. (This was due in part to the popularity in Vancouver of using cocaine intravenously: cocaine has a very short half-life, and people injecting the drug habitually might do so as many as forty times a day, as compared with heroin, which tends to be injected one to four times a day.) The city, recognizing that American-style prohibition had failed to bring about any improvement, undertook a kind of crash course on drug policy. A succession of public forums, meetings, demonstrations, and conferences with experts from all over the world brought together drug users and their families, service providers, academic researchers, police, and policymakers to examine alternative approaches—heroin-prescription programs, supervised-injection sites, decriminalization.
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br /> In 2003 Insite opened as a pilot research program, exempt from the criminal code. It was not the only new service offered in the city, and it was “no silver-bullet solution,” a disclaimer Canadian policymakers, activists, and other supporters used often to describe its alternative approaches. But because it seemed to stand at the threshold of what progressive-minded people deemed acceptable—because, for many, it seemed intuitively wrong—it received the most attention, and was widely discussed both province- and nationwide. This, too, interested me. Most Vancouver residents initially opposed the facility but came to support it; this took a lot of convincing, and a shift in the way people understand illegal drugs and those who use them. I wanted to know how this had happened.
In 2006 the Conservative Party in Canada won the national election, ousting the Liberals. For the first time since 1993, Canada had a Conservative prime minister; from the start, he began dismantling the country’s social programs. Early on, Insite became a battleground for drug policy across the country. The government tried to shut it down, but the Portland Hotel Society (now PHS Community Services Society), the nonprofit group that runs Insite, mounted a human rights case and took it to the Supreme Court. In 2011 Insite won the right to stay open.
Still, I wondered how long it could last. I wanted to know, too, if something like it could ever exist in the United States.
At 9:00 A.M. five men and women sit on the sidewalk on flattened cardboard boxes, first in line to enter when the doors open in an hour. Outside I meet Russ Maynard, Insite’s program coordinator. He’s with several college students from a health-administration program, there on a class visit.
As a group, we walk through the reception area into the injection room. At first glance, it reminds me of a hair salon. The room is wide and bright, lined on one side by mirrors and a row of numbered bays, thirteen in all. Each has a stainless-steel counter, a sink for hand washing, a sharps container, a plastic chair, and an extraction hood to collect smoke and vapors.
A platform with a curvilinear counter, the kind you see in hospitals, is raised behind the booths. Lining the countertop are bins that contain all the supplies a person would need to inject drugs—a syringe, a cooker for mixing the drug with water, a sterilized-water capsule for flushing the needle, a tourniquet to tie off a vein. There is, too, a tool for crushing pills.
In the injection room, we arrange our chairs in a loose semicircle around Russ, who stands. Russ begins his introduction. Insite is operated by Vancouver Coastal Health, the regional health authority, and PHS Community Services Society, a neighborhood nonprofit that focuses on the hard-to-house. PHS started in 1991, after a residents association converted a hotel into housing for the homeless. Today it provides residences for 1,200 people across sixteen buildings.
PHS also provides a range of community-based programs, including a credit union, a community drop-in center, medical and dental services, a syringe exchange, and an art gallery. Users of Insite can access all this simply by coming in, and to get them to come in is Insite’s goal. Making contact is the first step toward connecting people, at their request, to vital services they might need. They call the people who use their services “clients.”
Russ presents the group with a moral dilemma. “Imagine you’re working at the front desk and a woman walks in and she’s eight months pregnant, and she wants to come in and inject. You have to make a quick decision. If the line starts getting backed up, there’s going to be an argument, or maybe worse. So what’s going to happen?”
The room is silent.
I try to visualize the scenario, but it tests the limits of my open-mindedness. It is difficult to imagine supporting a pregnant woman’s injection-drug habit.
“Is she going to leave and the clouds will part and the sunshine will hit her face and she’ll see the error of her ways and never use again? Or is she going to take some equipment and go use in an alley or a doorway or a hotel room or something like that? If you do take her in, you can connect her with the nursing staff. You can have her housed by the end of the day. You can connect her with food, with services, all kinds of things. And you forgo all of that if you turn her away.”
Someone asks about the mirrors. They are a critical design feature, says Russ. Staff use them to monitor clients while maintaining a respectful distance. Clients use them to ensure a certain amount of caution when injecting—to pay more attention to doing it properly. Russ: “You want it in your veins. Because there’s a big wash—imagine a wave coming to hit you—and you won’t feel anything for a little while. And if you make a mistake, it means that you have to go back out and perform sex work, or beg, or steal, or whatever it is you do to get the ten dollars you need. And that is stressful.”
Since 2007 the staff at Insite has been able to refer visitors to Onsite, a detox center on the building’s second floor. There are twelve private rooms, each with its own bathroom. Insite connects between 400 and 450 people each year to detox, which, Russ claims, is more than any other project in Canada.
The students leave. One at a time, men and women, young, old, homeless, ordinary, are called in from the waiting room. As they enter, they announce the drug they will be injecting: “down,” “dillies,” “crystal” (heroin, Dilaudid, methamphetamine). The receptionist records their answers in a database, in case of emergency or overdose.
I watch the mirrors from across the room. A stately man in a wool sweater, navy with white snowflakes, drags a fine-tooth comb through his silvery hair, from the top of his forehead back to his nape. He does this twenty or thirty times before tending to his mustache with the same fastidiousness, never breaking focus. Then he pulls a woolen cap over his head and walks out into the sun.
A young nurse examines the arms of a fiftysomething woman. The woman looks afraid. The nurse speaks in soft tones as she runs her hands along the woman’s forearms, helps her to locate a vein that isn’t damaged, scarred, or collapsed. The nurse ties a tourniquet around her biceps. They both pause. The woman, hand trembling, inserts the needle. The nurse removes the tourniquet. The woman pushes the plunger.
Hours later, I see the same woman on the bus, traveling along Hastings Street. I want to speak to her, consider doing so, even as I know it’s not right (privacy). But the woman is with a friend. Instead I watch her, imagine where she’s going, how she will spend her time, what her home is like. If anyone awaits her there.
The woman gets off the bus.
I ask Russ whether he knows any clients who might be willing to speak with me. He hesitates. Donovan Mahoney is doing well, he says. He puts me in touch. Now I am in Donovan’s living room. We sit opposite each other, on separate couches. A series of photographs he has taken hangs on the wall above his head. Today Donovan is a talented photographer. His apartment, the garden level of a house in a middle-class neighborhood, is spacious, with a chef’s kitchen and newly laid blond hardwood floors. He wears khaki pants and a gray sweater, slim-fitting with an overlapping V-neck. A baseball cap covers his partially shaved head of thick black hair.
Donovan tells me the story of his twenties: he followed a girl to Vancouver, fell into coke, then rock cocaine, then heroin. He’d always thought heroin was dirty, but after trying it for the first time he felt its reputation was undeserved.
For a while he made money as a dealer. When he wanted to binge, he would go to the Downtown Eastside, stay in an SRO hotel where no one would find him. Then one time he didn’t go home. He let his monthly rent payments pass, grew paranoid. He left behind all his belongings, including his car. This was in 2001. He lived on the streets, mostly. He didn’t like to feel closed in by walls, especially when he was high. He shoplifted, was caught often, spent many nights in jail.
He was wary of Insite when he first heard about it. On the street, he knew that everyone was working an angle. There’s a forthrightness to interactions that doesn’t exist elsewhere. He found it freeing. But he couldn’t understand what would motivate the staff at Insite.
Now he credits t
hem for helping him to achieve all that he has.
Donovan: “They’re inadvertently showing you that there’s another way of life. You start to have normal conversations. You say to them, ‘What do you do?’ They reply, ‘I don’t know, I’m in a band.’ Of course they are. And then they tell you stuff about what they do with their girlfriend. Or how they went away for the weekend and saw their parents. To me, to an addict, they’re showing me something. There’s a whole other world out there that I don’t even understand. They’re showing you what it looks like to be a normal human being. Which is incredible, because if I’m shooting dope in an alley, I may bump into somebody who’s been through recovery, and they may be able to guide me. But they’re not going to be around when you need them.
“Addiction isn’t nine to five. It’s not like, ‘OK, tomorrow at ten o’clock I’m going to go into recovery.’ It happens and you don’t really see it coming. It’s like, I think right now, if you guys got me in, I think I could go.”
You want to be in charge of your own money. It is frustrating to have to travel to me every time you run out of cash. Together we visit your social worker, talk about how this could work. He needs to make a recommendation to your psychiatrist, to the state, before this can happen. We review your history. For the first time it is affirmed to me that you are likely to take methadone all your life. The social worker mentions your dose—120 mg—says it’s high, that you haven’t decreased it since beginning the therapy. You acknowledge as much. Still, it has been stabilizing, and the social worker is not concerned.
I tell the social worker that I will share the bank account with you, monitor your spending. Satisfied, he makes the recommendation. We open a joint account. Your monthly checks will be deposited and you will be responsible for paying your bills, for making sure you have enough to get through the month. I will check on the account through online banking. I keep your savings, a few thousand dollars left over from the disability back payments, in a separate account in your name.
The Best American Essays 2017 Page 29
