Opioids and the Addictions of Solace
This page is part of the addiction series, which provides recovery resources for specific addictions (hallucinogens, opioids, stimulants, alcohol, and cannabis) as well as material on trauma, personal healing, and the journey of recovery. View all of the pages by clicking on the Addictions link in the Categories menu or by scrolling to the bottom of this page.
Each page in this series is structured as a series of stories derived from my professional work. That’s what addiction is, ultimately: a complex, layered, interwoven story of human frailty and resilience.
A narrow bridge of crumbling steel stretches across the inlet from upscale neighborhoods on the south shore to strip clubs and run-down stores on the north side. Beneath both ends of the bridge, where its foundations are anchored in the rocky shore, enclaves of the addicted and the homeless spread out among bushes and between security fences. I do not see these makeshift communities as I pass over the bridge in my car, though I know they are there. Instead, my eye is drawn to the view of the ocean – cobalt, smooth, rippling – and to the high office towers ahead, sharp and glittering in the slanting sun. The bridge span rises, eases downward again, carries me toward my destination. I look for pedestrians at the jumping spot: two hundred yards before the north end of the bridge, on the west side. Not at the summit of the curving span, where the altitude would be most effective, but slightly farther down the slope, where the terminus of the fall is just offshore. Jumpers, like most people who attempt to commit suicide, are often ambivalent. Following the impulses of human nature, they hedge their bets. Indeed, many who jump from here, and from the companion bridges to the east and west, do survive. I have pulled them from the waters myself: broken, sputtering, alive.
Recently, a client at the downtown clinic killed himself with an overdose of heroin. He spoke to no one about his plans, gave no warning. He simply disappeared from treatment, and by the time the counselor tracked him down the man was dead. We talked about the incident in our counseling group, about the ones who vanish, who inevitably leave us with the sense that we should have done more, should have seen it coming, should have acted. But the counselor had acted: by carefully questioning the man to evaluate his risk of suicide, by following the due diligence of the counseling profession, by watching for cues – withdrawal, isolation, avoidance – that did not appear. All the counselors have lost clients to suicide, but rarely has any of them lost a client who spoke about suicide. In sharing their despair, clients often defuse it. Those who follow through typically don’t disclose their plans to anyone. They make up their minds, often impulsively, and they go.
But today no pedestrians loiter at the jumping spot. Perhaps they have been held back by the color of the sea, or the shimmer of the sun on rooftops down by the park, or by a glance of acknowledgment from a passerby. Sometimes that’s all it takes: a small and innocent and unknowing act to anchor against the gravity of dissolution.
I hear a rattle, low in the right front quadrant of my car, as though a metal plate has come loose inside the engine compartment. It’s a new sound, another reminder of the terminal momentum of the vehicle. The traffic lanes diverge as exit ramps peel off from the main flow of traffic. I continue straight ahead, down and into the neighborhood of shabby storefronts and old lofts for lease. Ahead, the traffic light turns amber. I slow to a stop beside a redbrick hotel that has been here since I was a boy. Much longer, probably. A remnant of the old city with its loggers and mining magnates and exiles. I wait at the light, listening to the rough idle of the car, looking ahead for a parking spot, scanning faces on the street for any I recognize. I turn and look toward the bus stop to my left. My eye passes over a car in the adjoining lane, its driver waiting to turn at the light. He’s talking on a cell phone. The car is a convertible, the top is down, the leather seats are the color of golden sugar. The body of the car is black, the finish lustrous and waxed. I feel I should know what type of car it is, but I do not. It is the kind of car that many men in midlife – men about my age – seek to drive: sleek, fast, regal. An unequivocal symbol of luxury and financial success.
The driver is half turned toward me, speaking on the phone in the relaxed way of someone accustomed to command. I cannot hear what he is saying, but I see him nod affirmatively as he speaks. He listens, responds, and is not interrupted. He moves with svelte confidence. Something about him looks familiar, and I crank the handle on my side window to roll it down. The traffic light has been red for fifteen seconds before I realize that the man in the adjoining car is a friend from childhood whom I have not seen in many years.
I lean out the window and call his name. He turns, interrupted now, not sure where the voice is coming from. But then he sees me, says something perfunctory into the phone, and puts it down. He raises his hand in greeting, smiles, and calls back with my name. But the light is almost turning. When it does, he will go left, toward the financial district from where I have heard, over the years, scraps of news about him. I will continue straight ahead, into the run-down streets. In the compressed moment of our encounter, I ask him the first thing that enters my mind: where are you going?
To the office, he says. For a meeting. He looks healthy, and in good spirits. I think of the skiing and surfing we did together in our teens, of the trips to the mountains we took with his father. I remember both of his parents with great fondness. They must be proud of their son. He has done more than well. And it’s good to see him, after all this time. Our paths have diverged far from each other, as though we inhabit separate worlds. Or, more properly, I have moved away. Out of the culture and milieu into which I was born, far from old friends and the families of my youth. I consistently turned away from those threads of connection, striving against them, until finally they broke. It was the only thing I could do.
My friend responds to my question as though the office is a trifling, unimportant thing. He shrugs, smiles ruefully, indicates by his demeanor that he’d rather be on the golf course, or in the mountains, or with his children of whom I’ve heard only the barest of news over the years. Then he asks me where I am going.
The light turns green. Cars behind us edge forward in their lanes. The oncoming traffic prevents my friend from turning left, but I must go. I shout across the rising clamor, telling him that I’m going to the addictions clinic. He pauses, looks puzzled, seems uncertain about whether he should still be smiling. I’m already moving, easing one arm out to wave goodbye, urging my battered car onward. He waves in return, but slowly. As I pass, I glimpse him in my rearview mirror, watching me go. And I realize that he may not be aware of my profession. He may wonder if I’m a heroin addict going for a pharmaceutical fix. Certainly my old and dusty car would not belie that impression. But it’s too late. The traffic opens up for him. He turns, and his glistening black car disappears into the canyoned streets.
I find a parking spot in the next block, just a few doors down from the clinic. I park the car, slide my anti-theft device over the steering wheel, and reach across to the passenger seat for my briefcase. But something rises within me – a feeling, a tiny blossoming urge – and I settle back into my seat.
I realize that I am happy. The old ghosts of comparison, of second-guessing my chosen paths, of uncertainty and insecurity and competition – they are gone. I have come through. Suddenly it seems hilarious that my old friend might conclude I am an addict. Part of me hopes that he does.
A few years ago I would have emerged from such a glancing encounter with conflicted sentiments. After all, the luxury car and the well-appointed office will never be part of the package of rewards I derive from this work. But driving a luxury car does not suit my temperament. And I have come to terms, finally, with the trajectory of my choices. In the end, it was painfully simple. If I had remained on the track of traditional business, that of my friends and family, I would not have survived. In the early years of my career I scrabbled around in various offices, feeling out of place, trying to surmount the discomfort of wearing a suit, of being an impostor. Like Joseph, I underwent a series of injuries and near-death encounters by way of car accidents and sports mishaps. Eventually I stopped, or was stopped. And I found another way.
My friend will turn left, toward the financial district. With affection, and with the nostalgia of our shared youth, I wish him well. I will go right, out of my car and across the old and cobbled sidewalk. I will nod to the bedraggled man leaning against the wall, his back bent and his head forward. Beneath the awning, I will open the door to the clinic and greet the counselors, the frontline workers, the outreachers. Someone will tell a story about a girl who walked to the jumping point of the bridge but came back. I will hear of the ongoing struggles of clients to score, stop, and heal. One of the counselors will have saved a life this week. By way of these conversations, this gritty discourse from the underbelly of the city, I will continually discover myself. The stories will teach me what to remember, where to go, how to avoid becoming lost. The tales will be enough like my own that they will resonate, echoing and blending inside me.
I go where I’ve been called, away from the towers in the west. I follow the stories of people snatched from ruin, on their way into and back from the labyrinth. I join them, I glimpse myself in them. We’re looking for the same things: completion, solace, peace.
Elias ambles down the street, coffee cup in his right hand. He stops to chat with a wiry adolescent – fourteen, maybe a little older – wearing a baseball cap. The kid is jumpy. Probably coming down from a run of crystal meth or crack cocaine. Like the clinic on the east side, where I saw the suicide note scrawled on the wall, the clinic near the bridge collects stragglers even when it’s closed. The hours are posted, but this doesn’t seem to matter much. Clients show up when they need to. They congregate and loiter and hide out from the rain under the broad awning. I see two other clients catch sight of Elias from across the street. They begin to head over. Elias checks his watch, looks toward the clinic three doors down, and begins to extricate himself from his conversation with the kid. The closure of a street conversation is a fine art: I watch as Elias smiles, turns fully toward the kid, gives a nod of acknowledgment, offers a brief and affirming message, then turns fully away. He takes two long strides, outdistances the clients approaching from across the street, and digs out his keys. He waves to the pair, tells them the clinic will open at noon, and disappears inside.
I climb out of my car, lock the door, and stand at the boulevard’s edge. A dozen or more users drift under eaves and along the curb and behind pedestrian commuters who walk fast, with heads down and arms drawn in protectively. It’s as though two speeds define the street. The first and fastest involves purposeful and private movement: the speed of rushing and of escape. At this pace the users are a sidelong blur. Inconsequential, invisible. The second speed – that of the users – is slow, hypnotic, patient. As though in water. Shoulders hunched forward, ragged clothing wrapped to keep out the cold. Even in summer they wrap up, protecting and shivering.
They move at the velocity of dreams, searching for but not finding the fulfillment of every fugitive need: comfort, safety, nourishment, love. They go inward to the welcoming dark. Unlike elsewhere addicts, who do not frequent these streets but rather choose exile and odyssey, opioid and benzodiazepine users (Fentanyl, Oxycodone, Ativan, Xanax, Valium and a host of others) congregate in places like this. They burrow into unmarked and hidden hollows. They search with their eyes: exhausted, pleading, focused on some indistinct space between themselves and others. I must avoid those eyes if I wish to reach the clinic unimpeded. One glance is enough to kindle the ceaseless hope, the reaching, the inevitable disappointment. Perhaps later, on my way out, I’ll move at the half speed of the opioid user. Available, open. But not now. I’m late, Elias has already gone in, the others are no doubt waiting for me inside. I do not relish the demeanor I must adopt: rushing, avoidant. Like every other passing pedestrian. Yet I cannot fill the empty well.
I gaze ahead, toward my destination, feeling eyes upon me from a pair of street dwellers at the corner. They’re assessing, separating me from the background chatter of the morning, wondering about me: am I looking to score, am I selling, have I made a wrong turn in the wrong neighborhood. I walk forward, wondering about them: are they clients of the clinic, why are they out so early, what injury caused the right arm of the taller one to be twisted inward like a broken wing. He protects that side, draws it toward himself with a small turning, rippling motion in his upper body. It’s not the jitter of a cocaine or crystal meth user but a small shudder, as though he can’t shake off the cold. Perhaps he has an injection wound festering beneath his jacket. He carries himself with the shambling gait and slouching movement common to opioid users. This is the manner of their beseeching – for connection, for relief from emotional pain – but addiction draws off their energy. They hover, listless.
I turn beneath the awning, enter the vestibule of the clinic, and close the door behind me. I wonder where else I’ve seen the twisted-arm man. On the streets farther east, perhaps near the waterfront or the streetwalker haunts. But I’m not sure. Thousands of opioid addicts live in this city, at the margins, hiding and seeking. Thousands more come and go, renting welfare apartments, sleeping in cars, couch surfing. Their stories are similar enough that sometimes they blend together in my mind. Their distinctiveness dissolves into the tincture of common struggle. Elsewhere addicts disappear, sometimes for a decade or more, then return from the long arc of their wandering. They have been places, and their tales are always unique. But opioid users are tribal. They frequent, persist, remain. Having nowhere else to go, they hang out.
The vestibule has two doors at right angles to one another. The door on my left is made of glass (recently replaced after a kick from an angry client smashed it). This door opens onto a long hallway that leads into the clinic. I see Elias arranging chairs for our counselors’ meeting. The door to my right is of sheet steel, painted beige, with a hefty deadbolt above the knob. This is the side door to the pharmacy that dispenses medications to addicted clients in the neighborhood. Here, where I’m standing, between the portals of harm reduction and treatment, lies the juncture of the contradictions surrounding approaches to addiction. I’ve known many clients for whom medical support (methadone, Suboxone, hydromorphone, and their variants) provided stability, safety, and a route to recovery. I remember Jake, whose heroin addiction bankrupted his family. He began his healing by resolving to pay them back, starting at ten dollars a week, until he was done. And Leroy, who was once homeless but now drives the city in an outreach van, picking up vulnerable users on cold nights and taking them to shelter. Prescription opioids offer heroin users escape from the drudgery and danger of habit-fueling crime, the toxicity of smack laced with veterinary steroids, the danger of overdose. And yet, prescription opioids can be as tough to kick as heroin. And I am consistently troubled by the treatment strategy of simply giving in, of offering addicts as much daily poison as they require. Healthier poison, perhaps, safer poison, dispensed by a system of judicious maintenance. But prescription opioids and heroin are blood brothers; both hungry, both implacable.
Yet my philosophical objections seem captious in the face of the bald truth of the prescription opioid programs: they keep people alive, buying time for the ripening of impulses toward health, for the development of supportive relationships, for the mellowing of desperation and the hardening of resolve. Recovery is a slow fix, drawn out over years of delicate and difficult work. Clients coming through alive are the best arguments for harm reduction programs increasingly beleaguered by a society intolerant of the addicted.
I hear a knock on the glass vestibule door behind me. I turn to see a skinny young woman waving, wanting to be let in. She is not someone I know, yet she reminds me of someone I can’t quite place. Dressed in dirty denim and a tight white T-shirt, her dark auburn hair pulled back from a face too pale, she rocks back and forth. The sole of her left shoe – a once white high-top sneaker, the tongue hanging – has come loose near the toe and flaps against the flagstones of the entryway as she moves. She is small. Her eyes are large with ceaseless, needful questioning. Her skin is sallow, the smoothness of her femininity sloughed off. Her sensuality has been thwarted, turned by violence. I recognize her body language: shoulders rolled forward, lower back extended inward and beyond the natural curve of the spine, head forward, arms and hands out of rhythm with her body’s movement. It’s a posture that some of my colleagues call the swan.
She’s a heroin user of several years, has worked the streets, and looks like she’s on medication – an antipsychotic, probably. Something in her slow yet stuttering movement suggests this. Beneath these impressions, which are the navigation and survival skills of my profession, I glimpse her edge of despair. She’s holding out against it, using heroin and likely some cocaine as well. In the same way that most cigarette smokers drink coffee to instinctively balance their biochemistry (nicotine acts as a vasoconstrictor, and caffeine is a vasodilator), many substance users employ a speedball approach: something to get up and out of bed, something else to dull the sharp edge, to deliver oblivion. But the despair won’t go, won’t heal, and as she stands before me, seeing the closed sign at eye level but knocking and waving anyway, I emerge from my ruminations and open the door.
The softening of my facade of resolve is a common experience for me in working with opioid users. They get beneath my skin, like dark and tender bruises. I empathize with their typical history of early childhood abuse or neglect. Often they have been traumatized in the first years of life, when the developmental tasks are of nurturing and nourishment and family bonding. Whereas elsewhere addicts do not quite arrive in the world, opioid users often have a history of arrival into neglect, indifference, or abandonment. They make their way into the world, but they find the world to be cold and impoverished. They retreat inward. They are mendicants, roadside criers, children lost and searching.
She tells me she’s spent the night in the hospital. Her story is fractured, composed of ill-fitting fragments and vignettes. She rambles, she cobbles disjointed scenes together. Hers is a version of a tale I’ve heard countless times from users all over the city: physical and emotional distress, insensitive nurses and doctors, sometimes a ride in an ambulance or a police car. Most opioid users possess a colorful medical history replete with conflicting diagnoses of varying severity. They have fought with the medical community, have drifted between physicians (I once worked with a client who claimed to have visited every physician in the city), and have not found healing.
Angry now, she relates how the hospital staff assumed she was a drug addict feigning illness to get opioid pain medications. She does not indicate precisely what led her to the hospital, and I do not ask. It doesn’t matter much. But she gestures toward the right side of her torso as she speaks, and I assume she is troubled by the gastrointestinal distress common among opioid users.
The sole of the woman’s sneaker slaps the tile with emphasis as she speaks, and I understand how her complaint at the hospital would have been met with great skepticism by the staff. If her appendix had burst they would have worked on her, but I imagine that such a catastrophe would have been required before they took her seriously.
She shares her story with me, and I listen. Perhaps she has a legitimate ailment and was disrespected. Or maybe she went looking to score, hiding the impulse even from herself. I don’t try to figure it all out: the layers of the story, the long and complex history of conflict and trauma, the shame bright as a bonfire behind her dark persona. I sense her aching and trenchant pain. She’s shadowed by it, drenched in it.
I think of the old Jewish midrash that says the divine is to be found in thick darkness.
She gazes beyond me, down the hall, looking for activity in the clinic. She edges ever inward, leaning into our encounter, pressing forward. I smell hospitals and urine and the rancid rankness of the street.
She’s dying – perhaps not today, but soon. It comes suddenly, this conviction, and I’m unprepared for it. The instinctive understanding – or impression, or assumption – that a client will die is not uncommon in this work. It happens too often in the lives of all the addictions counselors I know. Frequently the feeling is accompanied by guilt, or frustration, or a sense of helplessness. Sometimes it’s just a clear and neutral knowing. But it always comes quickly, without warning, disconnected from the flow of conversation and thought.
An overdose, probably. Next summer, when the heat makes people careless.
The impulse to confront, cajole, or entice an addicted person into recovery is the first casualty in the career of an addictions counselor. And it dies hard. After all, most of us have chosen this career (some deliberately, others by meandering) as a philosophical or even a spiritual imperative. We want to stand for healing in a world suffused with suffering. We spend our first years talking, convincing, drawing clients from their world into ours. And it typically comes as a profound shock when the extended hand is consistently slapped away.
But the addicted – and opioid users in particular – have closed in on themselves. They’re shut tight, hiding. Why would they emerge, when they were beaten back long ago?
Those who persist in this business learn to wait. We persevere through the disappointments: clients who simply disappear, or become threatening, or who return to street life after we’ve devoted months of careful and compassionate work to their recovery. We eventually understand that we cannot bridge the worlds alone. The addicted must at least meet us at the border. We try to make that threshold appealing, by way of health programs and counseling and support. And we send emissaries — many addictions counselors are themselves survivors of some form of addiction. But mostly we practice patience. We hold the door open, listening to the night stories, hoping but not expecting.
Elias has made his way back down the hall, moving slowly, assessing my encounter, deciding finally that he’ll join me at the vestibule. If the woman at the door chooses to participate in the counseling program she will come under Elias’s care, and now is an opportune moment for him to appear. They exchange polite hellos. No names. Not yet. Elias leans into the doorway, not too far, and extends his hand. He holds a small white card. She pauses, he smiles, she takes the card. I ease myself back from the door, turn to Elias, and confirm that the clinic reopens at noon. I know the schedule, I don’t need to check with Elias, but my query allows him to come farther forward, to claim an equal place in the conversation. He knows that I am attempting to transfer her attention. Accordingly, he tries to make a preliminary bond with her in these few seconds of boulevard chat. Opioid users consistently search for that bond, for the stalwart companion who can lead them out of turmoil. Beneath the wreck of their daily lives, opioid users seek deep and nurturing intimacy: out on the streets, inside the fog of Fentanyl or heroin, wrapped in silence and solace. Warm, soft, protected.
She shifts her gaze toward Elias, peers down at the slender white card in her hand as though it’s a grenade, looks at me with a flickering glance, then turns her head toward the street. Enough, or perhaps too much. For most opioid users, a few minutes of straightforward conversation is about the maximum of their emotional endurance. They are hollowed, tired, unable to focus long enough to render a clear picture of their calamity. It’s a coping mechanism they share with cocaine users, gaming addicts, and alcoholics: drift, slide, withdraw, sleep.
But not quite yet. Finally, she asks about the addictions program. This is a good sign: to have the query come at the end, as an afterthought. Perhaps she is almost ready. Elias responds to the question, offers sparse details about the program, invites her to follow up with him later in the day. Fifteen seconds. A typical counseling intervention in the street environment.
Then she departs. Toward the street and the sounds of construction near the waterfront. Into a morning like all the others, when she will choose which of her hauntings to escape.
Elias closes and locks the door. He grins, I raise my eyebrows in the we’ll see expression common to our profession, and we walk down the hallway into the clinic. It was a good encounter. No shouting, no threats of suicide, no medical emergencies. She just might come back. Of hundreds of such encounters every season, a few germinate and grow. One would be enough. One is all we need: to stand for all the others, to hold a place for the possible, to walk across the bridge of despair into healing. I walk past the series of poems Elias has posted on the hallway wall. One is from the Persian poet Rumi, and says:
The breeze at dawn has secrets to tell you.
Don’t go back to sleep.
You must ask for what you really want.
Don’t go back to sleep.
People are going back and forth across the doorsill
where the two worlds touch.
The door is round and open.
Don’t go back to sleep.
We meet here every month, roughly a dozen counselors who work in different parts of the city. We share our stories in turn. We’re all collectors: of strange tales, of incidents soaked with intensity, of urban legends and odd vignettes. We hear from one of the counselors about a man with a long-standing and expensive cocaine habit who has managed to run a business and raise his kids and convince his wife he has a chronic sinus infection. We hear about the migrant agricultural laborers working near the river: their bosses supply them with heroin – free, at first – to enable them to work longer days, work through injuries, work through the abrasive anxiety of being far from home and safety. They become addicted, of course, and become hostages to drug debt. We discuss the possibility of sending a staff member to educate the workers about their dilemma.
Never is there a scarcity of stories. A client who was doing well in recovery beat her roommate almost to death, and is now hiding from the police. A client discarded used needles at his bedside where his three-year-old son found them. A woman who helped her husband stop drinking found a small stash of vodka hidden in the water reservoir of the clothes iron. She had been preparing to press a cotton shirt when she discovered it.
We talk about a drug-related kidnapping, a death from overdose, a guy who came to the clinic looking for bus fare to get out of town before drug debt enforcers found and killed him. But it’s not all shadow. A glimmer of illumination spreads itself among the clutter. A client has become smitten with one of the counselors and has written her an endearing, respectful declaration of his affection. A second client has gone back to college. A third has stopped using altogether and is taking steps to reunite with his family. We share these challenges and triumphs, still marveling, after all the years most of us have put into this work, at the craziness and beautiful vibrancy of it all. We have the sense that we’ve scraped down to the bedrock, somehow, that we’ve been invited into a molten and dangerous and transformative earth.
Most of us also see clients privately, in offices in other neighborhoods where no one kicks in the door. Those clients are better dressed, wealthier, and often terribly ashamed of their vulnerability. They prefer alcohol or Ativan to heroin. They don’t shoot up behind the strip club but take their medicine in the dark enclosures of their cars, in underground parking lots, in the corporate washroom over lunch. Sometimes they get through a workweek without using, then let themselves loose during weekends of furtive, explosive revelry.
Our conversation turns frequently to the childhoods of clients, to their personal histories, which are typically replete with trauma and abuse. A few of us work with children, in situations of family turmoil and violence. We can reliably guess which kids will grow into addicted adults, or end up on the streets, or spend decades in prison for a plethora of crimes. Almost always, the kids who experience poor parenting, who inhabit high-risk home environments, are more likely to struggle with substance use. They often become involved with gangs and crime; they fall into cadres of aggression and predation.
No childhood is perfect. Things go wrong, accidents happen, traumas take place even in the most well-intentioned homes. And later, in adolescence and adulthood, sometimes people choose addiction as the primary means of coping with such wounds. It’s unusual to encounter someone with a significant history of childhood trauma, neglect, or abuse who is not a substance user or addict in some fashion. Eating disorders, gambling, sexual addictions, and many other behaviors are, to a large extent, the means by which unfinished emotional themes from childhood are carried forward.
The imprinting of what will later become addiction almost always begins during the early life of a child, in the experiences of the crucial developmental years. To overlook this fundamental reality, which is plain to the addicted and to those who work with them, is to invent a fable: that Odysseus is companionless, is solely responsible for his predicament and deliverance. The old conception of addiction as a simple choice, or as a moral flaw, is a collusion in the mythology of separation. As a society, we have chosen to cast off the addicted, to cut them adrift. We have not tightened their bonds to us as they have cried out from the mast, we have not rowed them beyond the shore of their suffering. Instead, we have made of them castaways, that they may lie on cold streets among the bones of the dead.
The Sirens sing to the addicted, crying beauty. And the user, the junkie, the acolyte, the stoner – they go. Why would they not? What else have we offered them? What appeal have we made that would reclaim them from that dream? The essential task of parents, and of the extended community, is to row the child past shoals and phantom lights and into safe harbor. Our collective abrogation of this primary obligation accounts for much of the steady increase in addiction, depression, and other associated ailments. We see the teen junkie behind the mall or the homeless woman beneath the overpass and we move on, skittish. We encounter the alcoholic in our own home and become overwhelmed. We have no context, no knowledge, no strategy.
Other possibilities exist. The skein can be untangled back to its source.
Incrementally, almost imperceptibly, the child is diverted from security and safety. Later, the confused teenager unravels into a conflicted young adult who clings to a sole dependable ally: the substance that never breaks its promises. Small and unremarkable steps, spread across many years. All so natural, so easy, a salmon swimming downstream. Then one morning you awaken with blood on your cheek, a mournful aching in your bones. The sheets are fetid, your mouth tastes of bile, you look out the window and you don’t know if it’s morning or evening. The room is cold, and you cannot warm yourself. Outside, water drips steadily from the corner of the roof. If the ungovernable forces of change grant you a moment of clarity, you will move toward the breeze from the open window and your heart will crack open. Some smothering force will lift and allow you to fall into your lethargy, your sadness, your bewilderment. You will stagger beneath the weight of your regret. You might take that weight and fashion it into the ballast of a new sea change.
Or you may sniff the aroma of the street – gasoline, cooking oil, wet pavement warmed in the sun – and head out again. Because your back aches, your legs are shuddery and jangling, your scalp feels tight. After a fitful sleep you’ve already begun to sweat with the slow slither of withdrawal. Your teeth hurt, and in your gut a tightening knot of anxiety begins to writhe.
But more than these, more pressing than the appeals of your body drawn across your sinews like tearing parchment: that primal, implacable urge. It rises within you, feckless and seductive and irresistible. It wipes you clean of imperfection, smooths you into linen pressed and warm. You recognize that nothing else matters, that you have surrendered completely.
You follow the chimes of the ever-ringing temple. Bells clamor and clang inside you. The promise of that sweet music, its covenant to enter and possess you with its peaceful simplicity, earns your devout and lasting allegiance. You hold fast and are swept away.
The daily choice of addicted people – use, or not use – is not unique to their exiled clans and cultures. We are all offered such choices: to die slowly, by means of countless small abrasions to the spirit; or to fight for a single, unvarnished moment of truthfulness.
Muted sounds from the street make their way down the hall: the clatter of a scaffolding going up, a short screech of tires, a man’s raised voice calling, his tone both angry and pleading. Someone brushes against the door, and though my back is to the entrance I glimpse the ghost of a shadow on the floor. It flickers, then moves on.
The day is brightening. We’ve discussed a dozen or more scenarios – risks, approaches, catastrophes, recoveries – and have made our choices about how to proceed in each. We’ve decided upon the basic details of many interactions, but we have no way of knowing in advance whether any of our strategies will assist clients to heal, or to stop using, or to stay alive. We make guesses, and we will stride into upcoming situations with the confidence of hard-won experience. We are not simply casting about. But human character is mercurial. Its transformations are deep currents that we cannot see, in which we play the smallest of roles. We go out, and watch, and hope.
At noon we take our diverse paths into the labyrinth of the city. Two of the counselors will do outreach this afternoon, visiting homeless shelters and health clinics and tangles of forlorn men standing on street corners, hungry. Sometimes the counselors take pizza into the camps and hidden enclaves near the courthouse. Today they will walk the long street that was once the city’s bright heart but is now a ramshackle mess of crumbling shops and street fights.
The others are returning to their various clinics. Elias will open the glass door and welcome the clients who have begun to cluster at the entrance. I will go to teach a class in addictions counseling. Many of my students will themselves be recovering from long histories of substance use, yearning to give something back, bootstrapping themselves into a career. This year, like every year, a few will relapse. They’ll head out again, shouldering their shame, hiding from their peers. A small number will fight their way back. The rest will vanish. For years after, I will search for them, asking on the street, hoping for good news or final knowledge of their demise. They will stay with me, these phantoms.
But the students who relapse are a tiny fraction of the total. Most have found new habits, have made new allegiances. They’re five or seven or ten years along the track of their healing. They’ve gathered themselves up, made their way through their haunted alleys, and are moving on.
I navigate the entryway, edging past the oncoming traffic of clients both frenetic and withdrawn. The more energetic among them are cocaine or methamphetamine users; the quieter folks are addicted to opioids and benzodiazepines. I glimpse a couple of marijuana users – young, probably here by court order or under pressure from their parents – and one elderly alcoholic, his threadbare coat missing two buttons.
Beyond the vestibule, where the edge of the awning’s shadow meets the cobbled sidewalk, I glimpse the woman with whom I spoke earlier. She stands partly in the shade of the awning. Her lower body is dark and half hidden. But from the waist up she is illuminated by full daylight. Beneath her denim jacket, her shirt is patterned in faded floral patterns I had not noticed before. She squints slightly. Her mouth is pulled to one side as if with indecision or anxiety. She holds herself still, gazes sidelong down the street. She looks tired, and forlorn, and very young. And finally I recognize her. She’s Ophelia, the avatar of sadness. Shakespeare found her drifting in the waters of European mythology, fashioned her into a symbol of disillusionment, and gave her a role in Hamlet, the most influential work – after The Odyssey and the Bible – in Western literature. In the play, after Hamlet rebuffs Ophelia and accidentally kills her father, she becomes wild with bewilderment and grief. She wanders the grounds of Elsinore castle, singing and chanting in a manner reminiscent of many opioid users I’ve known: mournful, romantic, plaintive.
Offstage, so that we are not witness to her final calamity, Ophelia plunges into the river and is drowned. We do not know for certain if her death is a suicide; but whether inadvertent or intentional, her demise is the turning point of Hamlet’s tragic tale. He is propelled forward by it, to his own eventual death.
Ophelia possesses many guises in Norse and Celtic mythologies. She is a personification of the earthly feminine, of innocence, of spiritual love. She preserves her integrity and beauty as long as the principles of love prevail. But when these are forgotten, or thwarted in their authentic purpose, her bewilderment turns her fey. She becomes a madwoman: hiding in attics, haunting moors, living alone on an island in the windswept sea. Ophelia and her mythological sisters die because the world is cold and nothing but love will warm them. As with opioid users who have not found consistent and nurturing bonds, they come adrift, and go under.
Since Hamlet, the image of the drowned girl has been a popular artistic motif, a symbol of unearned suffering, and a compassionate caution against indifference. She is the natural world abandoned, natural law spurned, natural human love – personal, familial, communal – turned from affection to isolation. In the nineteenth century, when opioid use was rife among writers and artists (Coleridge, Byron, Shelley, Keats, Dickens, Elizabeth Barrett Browning, de Quincey, Baudelaire, Lewis Carroll), the painter John Everett Millais completed a famous portrait of Ophelia floating downstream, pale and dead and yet still singing. He used as his model a girl of nineteen named Elizabeth Siddall, who would later marry Dante Gabriel Rossetti, an English poet, painter, and opioid addict. For the Ophelia portrait, Elizabeth dressed in a floral gown embroidered with silver thread and lay for long periods in a full bathtub. Her red hair spread across the water. Millais painted from a few feet away and kept the bath warm with oil lamps placed beneath the tub. But he became so absorbed in his work that he forgot to replenish the lamps. The flames stuttered and the water cooled. Elizabeth, however, did not complain. She grew chill and waited, modeling perfectly a dead girl in cold water.
Millais eventually noticed her predicament and retrieved her from the tub. But she did not recover from hypothermia. She developed the type of persistent ailment – deep chill and relentless cough – common to many opioid addicts I know from the street. And ten years after playing Ophelia in the bathtub, Elizabeth Siddall died from an intentional opioid overdose. She had been depressed, had given birth to a stillborn child, had painted a self-portrait that depicts her as gaunt and haunted – the opposite of her reputation, among artists of the day, as a muse and great beauty. She was drawn under by the archetypal currents of frailty, carried downstream, and lost. Perhaps she became Ophelia in the cold water of the tub. Perhaps she surrendered herself completely to that symbol of innocent suffering.
Standing half in the shadow of the awning, pale and uncertain, my Ophelia resembles a small and skittish bird. Many details of her appearance – the tilt of her head, the slight fluttering motion of her hands, the way she brushes an errant strand of hair from her face – remind me of the countless opioid-addicted men and women I’ve known. She could be any one of them: drifting, drowning. Of all the cultures of the addicted, opioid and benzodiazepine users live nearest to the edge of collapse and surrender and suicide. They become paralyzed by the cold. Sometimes they come ashore. The reciprocal love of family and children draws them back, or the danger of losing a spouse, or the joy of finding one. Or simple defiance of their own growing self-hatred. They reverse the inward spiral by finding bonds stronger than their own fragility. They come to be held by such bonds the way an infant is carried in the dark. But they must first call out, before the cold water lays final claim to them.
I exit the clinic and make my way down the sidewalk. Ophelia gazes in the opposite direction and does not see me. She stands, immobile, negotiating with herself. Such moments are private, and easily spoiled by well-intentioned interventions. She must decide. I leave her to it, hoping I will meet or hear of her again. I glance back to see Elias, still near the door, fiddling needlessly with the notice board, stalling. He’s making himself visible, waiting for her to choose. I turn toward the bridge, and a ruffled sea in the far distance, and the cobbled street bright in the freshening day.