Listen to thisI have been around drugs for well over 50 years. When I was in junior high and high school, my friends and I all used a variety of drugs from marijuana and psychedelics to cocaine, speed, and barbiturates. For my closest friends and myself, we smoked marijuana daily and used a mix of psychedelics, coke, uppers and downers on the weekends at shows and parties. Ironically, most of us didn’t drink, because drinking was for jocks, not hippies and freaks like us. I followed that usage pattern for about five years, or until I was entering my senior year in high school. After a particularly intense weeklong binge, I suddenly was sick of it and I quit. I was fortunate that I wasn’t predisposed to addiction or dependency, and I found it pretty easy to walk away. I had never done heroin or opiates, only because they didn’t come on the menu during my intense period of using. So, that level of addiction wasn’t an issue for me. I was sober for about two years and then started using psychedelics, marijuana and alcohol when I went off to college. Once again though, I quit after it became boring and tiresome. It didn’t take much effort. I just quit. Since that time, my personal use of drugs have never played a significant role in my life. Outside of periodic heavy alcohol use and overeating, my addictive propensities have been minor. In other words, I dodged a bullet.
Others in my life have not been so lucky. I have several family members who have struggled with alcoholism and drug addiction for decades. I have had close friends die of overdoses and cirrhosis of the liver. Others have lived lives profoundly complicated by addiction and the cycle of use/treatment/use. Some have gotten sober, others haven’t and probably won’t. Addiction will very probably kill them directly or indirectly. That part makes me very sad and angry.
I find myself, like many of us who have people in our lives suffering from addiction, highly ambivalent about how I feel towards those still using in problematic and life-threatening ways. As people, I care for them deeply. As addicts, I find myself being very angry, judgmental, and paranoid towards them. I am very protective of myself and my circle of non-addicted loved ones in the face of possible or even probable scams or predations in the service of addiction. It is a profoundly uncomfortable positioning which I struggle with quite often.
All of this in the context of the fact that I have been an addictions counselor and have trained others and even written manuals on how to work with addiction. In my professional role, I am compassionate and caring towards those suffering from addiction. I have a strong sense of the powerful social forces at play in the lives of those addicted to life threatening substances. I am responsive to their pain and hunger. I want to work with them in ways that makes life more bearable, even if it means continuing to use. It is a very different position emotionally and relationally than when it all becomes personal.
This is not the column I was going to write this month. I had to put that one off when I read a piece in the New York Times this morning, the teaser for which was, “One Year with a Team Trying to Change America’s ‘Deep Hatred’ for Those Who Use Drugs.” The actual title was a bit less charged, “One Year Inside a Radical New Approach to America’s Overdose Crisis.” The article was a deep dive into the actual street outreach efforts of a harm reduction team in New York City and I found the arguments for harm reduction convincing and compelling. But, in a very real sense, they were preaching to the choir. For many years I have been an advocate for harm reduction and so that part wasn’t new for me. What caught my attention was the question of our “deep hatred” for those who are addicted to drugs.
Here was a painful exploration of my own ambivalence towards addicts. A very real exposition of what it means to care for those struggling with a life-threatening relation to substances. At the same time, an acknowledgement of how much we really hate our brothers and sisters who are addicts. For myself, I seem to fall back on dubious frameworks such as hating the addict, but not the person who is addicted. This is regrettably similar to hating the sin, but not the sinner. I am not at all sure such linguistic gymnastics really hold the kind of integrity, I would hope for in my love and caring for others. There is a part of me that finds it extremely difficult to unconditionally love someone close to me whose primary relationship is with drugs or alcohol. I want to love them, but sometimes that kind of love feels very abstract.
In talking with friends and family who have both addicts in their lives and similar inclinations towards unconditional care and love, I find that they also experience a radical aporia between their intention to love fully and their ability to so. Of course, a good deal of this has to do with the relational wreckage addiction seems to inevitably incur. When people steal from you, lie to you, psychologically and sometimes physically abuse you in the service of obtaining drugs, it is hard to remain open and loving.
I have known people who have been able to do that, but it is often at a tremendous cost financially, emotionally, and psychologically. That is why I have such admiration for the street outreach team in the article. Their compassion and caring for the addicts they encounter would appear to be unconditional. Of course, this also tends to be true of CYC workers who do street outreach. The conditions of life on the street seem to flatten any judgmental inclinations we might have towards those we encounter. Suffering and the immediacy of death or harm are so close as to be palpable in any given encounter. It is an ongoing and quite powerful lesson in simultaneously connecting deeply in someone’s life and always being on the edge of a kind of necessary letting go. The connecting can be quite powerful and the letting go sometimes even more so. The relentless pattern of saving and losing life on the street requires a level of compassion and care that is a life art.
The treatment system for addiction we have failed to build here in the U.S. has brutal and profound consequences for those working in it and those addicts entangled in it. For many of us, the failed project of addiction care is a major disincentive for working with addicts, whether in treatment programs or on the street. To be driven to do this work, often requires a certain history of survivorship of both addiction and the system that surrounds it. As the article put it in relation to one of the members of the harm reduction outreach team,
Mr. Jones knew firsthand how mean the streets of East Harlem could be. He grew up in the neighborhood, at the tail end of the crack epidemic, and had spent rough years there, selling and using hard drugs. He had also spent the past two decades trying to rescue others from similar hardship. The key, he said, was building trust. Almost all the people he and his colleagues encountered were, at one point or another, treated terribly by the very institutions charged with helping them. They were leery as a result, and progress took patience.
Trust is an old theme for those of us working with young people. What Mr. Jones says about the people he encounters is often said about the young people we serve as well. The system is seldom kind to young people and building trust with them also requires patience. It goes without saying that the young people we serve also often have addiction issues and that we find those young people particularly challenging, and they often fail in our programs, To be kicked out of care for usage is a fairly common occurrence. The very idea that we might use harm reduction strategies in our programs, with supervised injection sites, moderated usage, or staff training in reversing an overdose would send many if not most of agency administrators and boards into severe panic mode.
After all, young people who are considered difficult are a hard sell to start with and if you add addiction, you are really asking for the public to see your program in a negative light. The demand from the adult public is that programs exist to discipline and control young people so that they are acceptable members of the dominant society. The idea that a program would not demand socially acceptable behavior is an anathema to most funders and program administrators. Hence, the rules against vulgar language, gang attire, no public displays of affection or sexual behavior, and .no angry outbursts among others. And this is for sober young people. The young people we see as the future. Addicted kids are seen through an even less generous lens. As the article points out,
“There’s still deep hatred in this country for people who use drugs,” said Keith Humphreys, an addiction expert at Stanford University and a former senior adviser to President Barack Obama on drug policy. “But there’s also legitimate frustration and anger at the havoc that people with substance use disorders can wreak. And policymakers have to be very careful about pushing too far beyond what a majority of people are ready to accept.”
And not just policy makers, but program administrators and boards. Of course, this reticence to engage with harm reduction strategies is occurring at a moment when the war on drugs has demonstrably failed and we are in the midst of a third iteration of a opioid crisis that spans generations and rooted in failed regulation of the pharmaceutical industry. Our incarceration of addicts costs us five times what it would cost for treatment and rates of recidivism are ridiculously high. We have seen no reduction in drug use; in fact it is ever increasing and drug overdoses “killing more than 100,000 people a year — more than at any other point in modern history.”
And yet we persist in the continuance of failed policies and practices that refuse the distribution of clean needles, reversal medications such naloxone, access to housing and mental health care for those actively using. Across all the helping professions, we have been trained to meet people where they are at, but apparently not when it comes addicts. We are also trained to practice an ethics dedicated to not harming those we serve and yet we fail to advance practices that could save lives. Finally, we are trained to set aside our biases and judgments in the work we do, but do we do that when we encounter someone actively using? Or do we fall back on the idea that all people should seek sobriety and those who do not are somehow flawed human beings. But is it the individual addict who should be held accountable for the social breakdown that is escalating drug use and the overdose crisis? In the work being done on the street the view can be a bit different,
Here, people struggled with homelessness, substance use disorders and mental health issues at the same time, and it was not always clear which had caused which. “The assumption outside is that they’ve ended up here due to their addictions,” Hilton Webb, a social worker, said. “But it’s often the opposite. People end up on the street because they lose their jobs or their rent goes up. Their mental health deteriorates, and they start taking drugs to cope.”
So, what has failed and what do we need to do about it. At one point in the article the street outreach worker Mr. Jones is reported as thinking,
Lately he had been seized by the feeling that for all their efforts — in the prevention room and on the street and in Albany — they had managed only to place a Band-Aid over a bullet wound. Clean needles, naloxone and a safe place to use were no-brainers. Of course, people should have those things. But what the people he saw every day really needed was housing, mental health care and help with job placement. They needed a pathway to stability and a touch of human decency. What they needed, he often thought, was community. It was community that had saved him. Nature had made Mr. Jones an introvert, and traumas stretching back to childhood had made him a loner. He was not quick to trust or to let people in. But when he showed up at a Hunts Point warehouse one night some 20 years back to volunteer with the New York Harm Reduction Educators, the people he met welcomed him and treated him with respect — and in so doing, created a space for trust to grow. He opened up slowly from there, like a clenched fist finally able to unfold into an open palm.
Perhaps it is here we need to focus, Of course, good harm reduction practices can mitigate the suffering and death associated with how we manage addiction. But, maybe the explanation as to how we got into this ever-escalating cycle lies elsewhere. If we treated more people like they belonged and welcomed them with respect, it might be possible that the drive towards personal oblivion might be muted. If we hated those who we deem unworthy a little less and cared for each other with fewer conditions, then we might have fewer of us falling. A bit of human decency and less judgement or in another term a sense of community. This is foundational in CYC work as a theoretical framing. I wonder what would happen if we took it more seriously in practice, especially with those struggling with addiction.
