The Big Fix (20 page)

When I go to put my clothes on for work, I frequently take a moment to breathe a sigh of relief. In that moment, I know my day is full of opportunities. The gratitude I feel puts things into focus. This house, these kids, this life: It is all mine. What a gift. I plan to put it to use. My day is full of the promise. I had so many days in my past when I struggled just to survive. On these quiet mornings in my little home where my only audience is three adoring children, I take a
moment to pray for the strength to make a difference today. I have created my own affirmation that helps me put my life in perspective:

           
I woke up this morning. I was in a bed. This is a good start to any morning.

           
I had food to eat. Another goal accomplished.

           
I was able to use the bathroom indoors. Yes.

           
I texted with a friend and got out some resentments.

           
I felt my feelings.

           
Most of all, I am not digging into my neck, hands, or feet for a place to inject my daily emotions.

           
I am clean—a good start to the day.

I hear some commotion in the next room. Children can be little savages prone to violence. One second they are watching TV, the next second they are smacking each other over the last of the cereal.

“Mommy!” I hear my call to arms. “Eddie is eating all the Cheerios!”

As quickly as the moment of reflection came into my mind, the moment passes. I need to focus on completing the tasks of the morning. Hopefully, I can make it through
the last part of our morning ritual without getting food stains from little fingers on my dress pants. There is also the matter of hair brushing that must be tackled. This is an area I prefer to defer to my husband whenever humanly possible. The screaming involved per stroke of the brush increases my level of annoyance exponentially as I am simply trying to help my daughter. In her mind, this whole process is some form of torture uniquely designed by me to ruin her day.

If only I had more time today to spend with each of them individually. If only I had more time to tell them how much I love them. I have come to the conclusion that I did receive love from my parents, but somewhere along the line I never learned how to love myself. When I discovered that the solution was inside me, I no longer felt broken. I felt teachable. I felt hopeful. It was a process to restore myself to a condition of wholeness. Perhaps I never felt whole. But I now know that I will never allow a substance or a man or a poor choice to dictate my image of myself again. I feel good about myself because I work hard at doing positive things. I want the same for my children.

The yelling starts. “STOP it!” I hear from the next room.

There is a battle over shutting off the TV. My son likes to play with the buttons. If we can make it out the door in the morning, I feel as if I have won some personal battle. As all three kids assemble at the door, I take one final look at the house. Our home is filled with the evidence of happy children and busy parents. I have packed the breakfast snacks, I have packed my lunch, and everyone is dressed and ready for their day.

Outside, as I lock the door, my son asks, “Mommy, will you hold my hand?”

Of course I will, son. We are in this together.

I start dropping off my kids in anxious anticipation of the day ahead. I have a new hire to meet with, my presentation, and one-to-one sessions lined up with each of the staff. The program I run has grown so quickly. I now supervise seventeen staff people, each of whom I'm training to be a peer counselor. Our lived experience bridges the gap within county services. It is a blessing to be able to take all my negative experiences and use them to help someone.

Slowly but surely, I have gotten back into harm reduction as a way to be of service. The death of my mother left a hole in my life. There will be no more Sunday phone calls. I can no longer ask her for advice. I miss her sense of humor. I disagreed with her on politics, social issues, and television shows. When she died, I found pictures she had taken from a Sarah Palin rally. I laughed my ass off. I wish I could have had the chance to ask her why someone who voted for Kennedy and Carter was at a Sarah Palin rally. We ran out of time. The space that was left by her death can't be filled with drugs, food, or self-pity. I filled that hole with action. I knew I wanted to be of service to the community at large. I started receiving messages from users, their friends, and their families seeking information on heroin. Over the course of a few months, I found myself in a role where I feel comfortable—sharing my story of recovery for the benefit of others.

After I drop off my daughter, I quickly push the stroller and rush to the train. We have caught the magic bullet that will get me to work just in time. On the train, as we get close
to our stop, my son points to a homeless man. It has been drizzling outside, typical for a Bay Area morning despite the forecast. The man sits near the door and has a shopping cart with all his belongings next to him. Soon the police will make him move. I remember those mornings when I rode the train for a safe place to sleep.

“Mommy,” my son asks, “why is that man eating on the train?”

I look over to see the man eating a few crackers. It is clear he wants to blend into the shadows. His safety comes from being ignored. Humanity comes from being acknowledged.

“He is homeless and probably hungry,” I tell him.

“What does that mean?” he asks urgently.

I sigh. This is not an easy conversation.

“Eddie,” I explain, “he doesn't have a place to live. Mommy was once homeless like him. Long before you were born.”

This is as far as we get in these conversations. My children are too young to understand what “homeless” means, and what it means to use “drugs.” I get asked in emails, “What will you tell your children about your drug use?” I will attempt to be as honest with them as possible. I think it is essential to tell my truth. Rather than hide things from them, I hope my story will help educate them. When we are at social events, my children sometimes ask about beer. Why do adults drink beer if kids can't drink it? Mommy doesn't drink beer. To me, that is the lesson: It doesn't matter what other people do; I make healthy choices for myself by choosing not to have one.

As we stand up to get off the train, my son hands me his breakfast bar.

“Mommy, I don't want this.”

I see the man with the shopping cart smiling at my children. I grab the snack and hand it to him. His face lights up.

“Thank you,” he tells me in a hushed voice as he rips open the snack.

My kids look confused as we step off the train.

“My cook-cooks,” Kelan mumbles. He is referring to his breakfast “cookies.”

“He needed them more,” I tell the boys. I pat their heads and point them toward the elevator.

I hand off my sons to the babysitter with a tight hug and a kiss. Leaving them is painful. I looked into being a stay-at home mom, but the numbers were not in my favor. Between a mortgage payment and health care costs, my husband and I must both work full time. I try to take a day off every few weeks to spend with the kids. They won't be this age much longer. Katie has just started kindergarten. The time has gone by so quickly. It wasn't so long ago she was a tiny baby swinging in my arms. Recently I joined the PTA at the school. My journey from drug-addicted criminal to active community member has been a long one. Between the gymnastics, the dance classes, and soccer, the only bags I deal with anymore contain uniforms and special shoes. I am a changed person.

In the end, I found that, for me, there was no big fix. There was no food, no drug, no relationship, no program alone that could fix the things I didn't like about myself. My life was transformed incrementally when I dedicated myself to pursuing something beyond instant gratification. With seventeen years clean, I still have periodic patches of depression.
I was diagnosed with anxiety in 2012. There are times when it is as much a struggle to get out the door as it was in those days in my room in the Tenderloin.

I may have more material things, but probably less than the average person would suspect. When I go on a business trip, I rarely need more than a backpack.

I plan to visit with my siblings this year. I know this would make my mother happy. We have never been a close bunch, but in the end, we are still a family. I have also grown to love my in-laws. I never thought I could love anything besides heroin. Fortunately, I was very, very wrong.

This is my life today. As I walk through the farmers' market on the way to work, I see the “home bums”—lifetime alcoholics, not necessarily homeless, who prefer to drink outside—sipping their morning medicine. I recognize a few faces. Sometimes they say hello to me. Sometimes they hide their faces in glassy-eyed embarrassment. To see the way many of my companions have aged is enough to bring a tear to my eye. I see the mother who has lost all four of her children to the system. I see the man who walked away from his family after a relapse. I walk behind the man I once had a youthful crush on, now devoid of any teeth or dignity. The crowd has gotten much older here. It seems as if the world of drugs has gotten much harder for these people on the streets. There are fewer places to be an unbridled addict. The hustlers on Polk Street have been replaced by hipsters. The dark net markets make it possible to sell your body and buy your drugs in relative privacy. That's what the young hookers tell me. The world I knew has dissolved into pieces. I am still part of it, yet I am completely removed
from the struggle. I step over someone who is passed out in front of Starbucks. I have to get to work. I know I will see you when I pass by here again.

PART TWO

BEYOND THE WAR ON DRUGS

G
etting off drugs wasn't an individual effort. Sure, I could easily take the credit. “Hey, look at me. I was living next to a Dumpster on a pissy blanket when suddenly I decided to put the drugs behind me! I wanted a different life. From the day I went to jail, I never relapsed. I did it!” That would make for a convenient story—that pick-yourself-up-by-your-bootstraps narrative that the media loves—but that was not my experience. I was responsible for making the decision to stop using drugs. I can own that accomplishment. However, it's important to acknowledge the significant roles other people and organizations played in my recovery, and to understand the vast amount of work
that must still be done so more can experience recovery. To me, it made all the difference that there were people who treated me like I was still a human being during times when I was living like an animal.

For me, recovery wasn't an overnight process—it was a series of events dating back to my active using days—but my journey started at the needle exchange. The very first person I met who had successfully kicked heroin and stayed off for many years was a staff person at the exchange. By talking with us, encouraging us, and simply being there, the staff and volunteers reinforced that all drug users are human beings, deserving of compassion. They provided me with clean supplies for injection, as well as condoms. That made it possible for me to make it through the 1990s without contracting the HIV virus or an STD. I had been an IV drug user for a while before I started using the needle exchange; I was sharing used needles with friends and lovers, with little concern for my health and safety. Needle exchange did not encourage me to use, as some have argued. It allowed me to use safely. The main difference between my friends who died and those who remained free of the virus was the consistent use of safe injection supplies and condoms. Before meeting the staff at the exchange, I can't recall ever having had safe sex. After attending a workshop there, it became my general practice.

Syringe exchange can also prevent a myriad of medical conditions, including HIV, hepatitis C, endocarditis, and soft tissue infections. But in the U.S., in terms of syringe sales and exchange programs, our public health policies have actually gone backward: Funding for such programs is banned at the federal level. In many states, it is a crime
just to possess a syringe without a prescription, and even in states where it isn't, many users still report that pharmacies refuse to sell them syringes. HIV infection rates are actually going up in Miami and certain communities in Indiana. After a recent cluster of HIV cases broke out in Indiana, it took a state emergency order to get a needle exchange program in place. In addition, there are frequently no proper avenues for disposal of the syringes, which are hazardous medical waste. I am a living example of why we need to lift the federal ban on syringe exchange.

I also give a lot of credit to public health clinics like the ones I went to in San Francisco, which provide health care for the homeless and made it possible for me to progress in my recovery. No clinic ever asked me to leave because of my disheveled appearance. No one ever turned me away for being a junkie. Conversely, when I was sleeping outside, local residents would sometimes pour bleach on me from their apartment windows while screaming slurs at me. I had people throw bottles at me, laugh at me, throw trash at me. I was made to feel less than human. But the public health workers I encountered reassured me through their actions that someone cared for my well-being. I remember a long conversation I once had with a doctor at a health center who commended my efforts at trying to take care of one of my wounds despite my living on the streets. Twenty years later, this doctor is now one of my coworkers. When I think of how I want to treat others, I frequently reflect back on my experiences at that health center.

The clinic was also a place where I could openly discuss my issues with drugs and alcohol. I didn't have to hide any
of my medical history. Because I was able to speak my truth, I was supported in making positive health choices. The clinic staff provided me with alternatives to the grind of daily use. They discussed ways to reduce my intake while giving me information on available services in the community.

Many users who contact me fear (or have had) the opposite experience. They are terrified to disclose to medical professionals any portion of their addiction history. They're afraid of repercussions at their place of employment, from their parents under whose health plans they're covered, and from the health care professionals themselves. Expanding substance abuse services provided in the primary care setting could go a long way toward destigmatization and reducing the harm caused by both legal drugs and illicit substances. Managed health care organizations could provide peer educators on-site who offer confidential counseling, education, and referrals that are not linked to a person's general medical record.

The next critical step in my journey was medication-assisted treatment (MAT). MAT offered me an alternative to my routine of injecting heroin six to eight times a day. Methadone is one such treatment—it's the most heavily researched and widely used. It is often called the “gold standard” for MAT. But my experience with the long lines at the methadone clinic reminded me of my time in jail, when inmates were herded like cattle anytime they needed food, medication, or to move around.

The first time I went to the methadone clinic, my only goal was to stop using heroin on a daily basis. Methadone allowed me to detox from heroin at my own pace instead of
going cold turkey. I paid $12 a day to get my medication. I had to “dose” every single day at the clinic for twenty-one straight days. The dosage was reduced daily until I completed the detox. As a direct result of the methadone, I was able to quit heroin for three months. I was able to stop supporting my habit with sex work. I was able to let my scars heal, to make a few friends. While some would argue I wasn't really “clean,” that wasn't actually my goal at first. It was an important stepping-stone and an early success because I was able to temporarily quit using drugs on a daily basis as a direct result of the program.

When I returned to methadone treatment after a five-year absence, I had to find a different clinic. My new one was surrounded by people selling pills, heroin, and crack. The police were constantly surveilling the area around the clinic. As a private pay client, I received no counseling. Clients who were on public benefits were forced to sit through weekly counseling, even if they had been clean for years. I was told this was so the clinic could bill the government the maximum amount for that patient. I was required to pay daily and be at the clinic by 2:00
PM
every day or I would not receive my medication. At the time, I was paying $35 per day to live in a hotel, and my rent was due by noon. By the time I gathered enough money to pay for my room or else face being homeless, there was not always enough money to pay for my methadone. After a few days of missing my dose, I quit going to the clinic. I wanted to stop using, but I could not afford it or manage to keep going to the clinic. I faced brutal withdrawals from this long-lasting opiate therapy.

From my observations, the methadone clinic system is antiquated and cumbersome. It is widely known as “liquid handcuffs.” Methadone requires daily dosing, per federal requirements, every single day for ninety days, unless a patient is lucky enough to live in a state where the clinic is closed on the weekends. It may take a patient a few years to be able to accumulate the benefits and switch to once-a-week dosing. While working in a hospital-based clinic for over four years, I was shocked at the level of bureaucracy involved in getting a client even one take-home dose of methadone. I once overheard a client tell another person in the elevator, “I have had to come here almost every day for the past eight years.” I was disgusted by this. Whether or not the patient is “clean,” the system creates an unfair burden on him or her. There is little incentive for addicts to completely discontinue use of illicit drugs when we tell them at the outset, “We don't trust you enough to manage your own medications.”

Buprenorphine, another opiate replacement therapy, is also a powerful medication that allows patients to make sensible choices about their medical care without excessive rules and regulations. It was in the trial stage at a clinic in San Francisco during a time when I was considering my options for treatment, and I had some friends who participated in the trial. I was impressed by how much freedom people in the trial seemed to enjoy with buprenorphine compared to daily dosing of methadone. They were treated as if they had a medical issue (which it was), not a criminal one. The patients had the freedom to go for days without visiting a clinic. Because addiction is now treated as a chronic medical condition, patients today can use buprenorphine and other
newer medical interventions with fewer restrictions. With buprenorphine, in a relatively short period of time, the patient may be able to receive a month's worth of take-home medication.

Not to say there are no issues with buprenorphine. I hear reports of doctors refusing to prescribe the much cheaper generic form of the medication. With HMOs, there may be only a handful of plan doctors, leaving hundreds of patients on the waiting list. In private practice, the costs for the medication can be quite prohibitive, including $450 for the initial visit, plus hundreds more for office visits, urine tests, and blood work. Many providers refuse insurance because their waiting rooms are full of patients willing to pay cash. For patients desperate to get off opiates, the monthly cost of MAT can easily surpass that of food, rent, or a car payment.

My hope is that we can reform these systems to make them more affordable, more equitable, and more patient friendly. Despite the potentially high profit margins for providers, waiting lists can take months. In some states, like Kentucky, concerns around buphrenorphine “pill mills” have even caused some clinics to close or severely restrict the number of patients an individual practice can take. There is no shortage of need, only a shortage of hope.

In the final piece of my journey to recovery, I was ready to commit to total abstinence from all drugs. I perceived this to be my last chance. I felt as if I had tried everything else. I'd been offered the chance to go to treatment a few years prior, but I refused—I didn't want my parents to have to take out a second mortgage on their home to send me to rehab. At that time, I knew I was not going to stop using
drugs. This was my reality. When I was finally ready, I was lucky. I was able to stay in a residential treatment facility for a little over ninety days. This gave me enough time to learn to cope with my emotions. This gave me enough time to learn how to avoid people who were using. This gave me enough time to find both a job and stable housing. Even if I wasn't completely “ready” to leave at the end, I had a good start.

In today's environment, ninety days in rehab is a junkie unicorn—a fantasy for anyone without money. The standard stay in treatment is only twenty-eight to thirty days. As private insurance companies and government-run programs like Medicaid look to cut costs, it appears there is an emphasis on quantity of patients over quality of care. While more patients are churned through the system, there is little work being done to verify patient outcomes. Generally, this information is provided through self-report, which can be extremely unreliable considering the sensitive nature of substance abuse. In addition, short-term inpatient rehab is barely enough time for an opiate user to be able to recover from post-acute withdrawal syndrome, or PAWS. PAWS happens in the period after detoxification during which users may experience anxiety, mood swings, low energy, depression, and, in the worst-case scenario, thoughts of suicide. They may discover they have some condition that they've been covering up with drugs, and feel the impulse to self-injure. If I had gone through shorter-term rehab, by the time I started to feel a little better, it would have been time to go! Aftercare, if offered, is often both minimal and optional. Even after ninety days in rehab, I completed another
three months of aftercare and just short of four years in a sober living environment (SLE).

SLEs, which generally are not covered by insurance, are houses managed by a former resident or another person in recovery. The rules vary as much as the amenities do. The SLE I lived in was made up of single rooms in an old converted hotel in one of the worst areas of San Francisco. I received no counseling, but was required to attend church or twelve-step meetings during my first year. My rent was kept low with the hopes that I would save money to transition into my own place. There was no kitchen, a shared bathroom down the hall, and broken furniture. It was perfect for me at the time, though I had numerous friends balk at the mere suggestion of moving there.

There is little in the way of regulation and standardization in the SLE industry. The barriers to starting an SLE are nearly nonexistent, and the need is great. What constitutes a sober living house? Even with the research I did, it was difficult to find an answer to that. Anyone with a rental property can open a building and call it sober living. This is confusing and dangerous for those seeking substantial support after treatment. Some have rigid standards by which a resident can be put out in the street on the same day he or she has a positive urine test. Some have no real system for locking up medications, making theft commonplace. There are sober living places that look like luxury apartments, while others have parolees stacked in bunk beds. If the period after treatment can be the most dangerous time, then we need some standardization in programming to safely house those who are trying to stay clean.