On a grey, rainy afternoon in Vancouver, I’m handed a naloxone kit. I open it. And when I do, I plant myself firmly in our country’s opioid crisis.
Onto the table fall its contents: two brown vials, a pair of gloves, several packs of sterile swabs and a syringe that peaks quickly into a capped silver needle. The latter is primed with a dose of naloxone, which, when coursing through a body turned cold and blue, will free the brain’s receptors from the suffocating grips of an opioid. “It’s a matter of seconds before he’s pulled back to life,” says a voice. These words ring heavy in the silence of a small room in St. Paul’s Hospital, where a makeshift overdose prevention site sits squarely in the courtyard outside our window, its blue tarps flapping gently in the wind.
Eventually, we turn to each other with a collective relief: the listless man, the jabbing needle, the dramatic revival all merely hypothetical. But we’re told then that drug overdoses claimed the lives of 1491 British Columbians this past year1 and that most of them, concentrated within several blocks of Vancouver’s Downtown Eastside, will involve the very people we’ll come to treat. The opioid crisis, no longer a distant realm of statistics, is right in front of me in flesh and blood. The uncomfortable reality makes me shift in my seat. What have I got myself into?
Several weeks earlier, I felt oddly indifferent to it all. Dr. Robert J. Lifton, a prominent psychiatrist from New York, described the “psychic numbing”2 of rescue workers in the aftermath of the Hiroshima bombings. He suggested that the greater the collective suffering in a tragedy, the smaller our sympathy and willingness to help those who are victimized. As our opioid crisis worsened, it followed that I had long checked out.
The venom of an outsider’s cynicism twisted my perspectives on opioid addiction. It’s no more a disease than a personal choice. Overdose prevention sites simply buttress a moral hazard. The mind of an addict goes only as far as his next fix. The activities in the ill-lit strip of street outside my ground-floor apartment in Toronto, where garbled conversations were heard throughout the night and used needles found the next morning, only entrenched these wayward thoughts.
In this process, there was a part of me I started to lose. This was the part that had held hope and extended trust; the part that saw clearly these individuals within the outlines of a shared humanity, not a broken one. A hole in me had been exposed, and it lacked closure and would remain unfilled, unless I, in some way, got closer to the truth.
“It works like any other inpatient service,” a colleague tells me about the addictions medicine service at St. Paul’s. “Except for some minor differences.”
I find out what that means, soon enough. The patients I approach can be floridly psychotic, or in the throes of a body-wrenching withdrawal. Many of them live on the streets, including the teenagers. And it is not uncommon for drugs to be sneaked onto the wards. It is a medical reality, if not just slightly turned on its head.
I make sure that the first thing I do is visit the Downtown Eastside. Coming from a part of Toronto known for its brand of grit, I tout myself as a battle-tested urbanite. How bad can it be? What I see on a short stretch of East Hastings Street stops me in place.
Weathered souls in tattered clothes push their life’s possessions in overflowing carts. Behind trinkets peddled on sidewalk drapes, many stand sullen in the doorways of shuttered storefronts, drawing on damp cigarettes, or crouch under the cover of pitched tents, shooting, smoking, snorting, selling. Some swing back and forth across the sidewalk, weaving precariously between the crowds. And others drift off into a world far from the one I walk, doubled over or splayed out against whatever surface can support them. I try to muster the mettle to enter the alleys, but I simply can’t bring myself to do it.
The beginnings of those struggling with opioids are as varied as the people who call the Downtown Eastside home. On the service, my work has two parts. The first is to make sure that those who come to hospital receive (or are started on) the opioid-replacement therapies they take at their neighbourhood clinic. For one man on methadone, this has been a daily routine for more than 30 years.
The second part, though, is the harder one.
When tracing the roots of an addiction, I unearth veins of personal destruction and vulnerability, knotted with anger, sadness and frustration, which, over time, have sunk deep into the soul of a person’s existence. Initially, I approach this question of origin like a minefield: weaving carefully around my motive, knowing that my demise, although outside my line of sight, is always near. I’m told to fuck off. Once I’m even threatened with a shoe. But I change my strategy. And in between tears and lowered heads, when my talk turns plain and honest (“How did you start?”), surprisingly, it is returned that way. Their responses follow a similar thread:
Grandpa raised me and my brothers. He was a good man. I mean, he was all right. He gave me my first drink when I was two, I think, to help me sleep. I had my first oxy when I was eight. That was just life on the rez.
I’m sorry I’m late! I had to pack all my stuff into these two bags. We started using again. Things weren’t working out. I’ve never been homeless before. I didn’t expect them to be so heavy.
I don’t know what gets into me. I’m on the bridge, people shouting at me to get down. I know the dope makes it worse. I just can’t help it sometimes, man. I’m trying.
I can’t right the past wrongs or undo the damage done in my patients’ lives. Between stories of love, loss and journeying, the urge to fill the quiet is one I wrestle with. I’m often at a loss as to what to say.
But the outdoor terrace is the setting for many of our conversations. The sounds of the city drown out my thoughts, so I listen.
The terrace is a place I pass several times throughout the day. My patients are stretched out between buildings that bookend it. If not in their rooms, they are likely here, having a cigarette. It’s an ironic barometer for their health. For when these smoke breaks become longer and more frequent, their stay in hospital is nearing an end, signalling my time to broach the question.
“Have you seen one of these?” I ask, naloxone kit in palm.
“Doc,” they always start, despite my assertions I’m not yet one. “Too many times to count.”
Born from the solidarity in eking out an existence on society’s fringes is a sense of community. They were there for each other. There, even in those moments when all seemed lost.
Perhaps this is where I fell short. Where I once considered addiction a chronic issue, like diabetes or hypertension, never bothering to untangle the person from the disease, I now explore and deepen our alliance. This holds great promise when a patient vows to change their habits or quit using — which makes it hard not to feel disappointed, angry or even betrayed when they overdose or return to hospital from its complications. This, I learn, is not about what I lose, but what I gain: an unyielding patience and boundless faith, knowing that the path to recovery, for so many, is rarely ever one that is straight.
I’m left with more questions than answers, but I believe this is a good position to be in. My naloxone kit is still with me, still unused. Yet, every now and then, I will open it and let its contents spill out again onto my table. It reminds me about confronting the many assumptions and judgments I once made about opioid addiction — the ones that we, as a medical community, and a society, continue to make — and that if any of us ever fall too far, we still have the chance to be rescued.
Acknowledgements
Thank you to Dr. Allan Peterkin and Dr. Corinne Boudreau for their support and editing.
The life situations depicted in this article are not specific to any individual; they are all too common.
Footnotes
CMAJ Podcasts: audio reading at https://soundcloud.com/cmajpodcasts/190446-enc
This article has been peer reviewed.
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