Medicating Isolation

In our new era of nearly unparalleled upheaval, as a pandemic ravages the bodies of some and the minds of nearly everyone, as the associated economic damage disposes of the livelihoods of many, and as even the promise of democracy fades, the people whose lives were already on a razor's edge--who were vulnerable and isolated before the advent of Covid-19--are in far greater danger than ever before.

Against this backdrop, many of us are scanning the news for any sign of hope, any small flicker of light whose gleam could indicate that everything, somehow, is going to be okay. In fact, there is just such a flicker coming from those who have been through the worst of it and have made it out the other side.

I spoke with Rafael Rodriguez of Holyoke, Massachusetts, on a sweltering Thursday afternoon in late July. He had already spent hours that day on Zoom and, though I could feel his exhaustion through our pixilated connection, he was gracious. His salt-and-pepper beard neatly trimmed, he nodded gently in answer to my questions. "Covid-19 has made it more and more apparent how stigmatizing it is to be less fortunate," he said. As we spoke, the number of Americans collecting unemployment benefits had just ticked up to around 30 million, or about one in every five workers, with nearly 15 million behind on their rent, and 29 million reporting that their households hadn't had enough to eat over the preceding week. Rodriguez is an expert in what happens after eviction or when emergency aid dries up (or there's none to be had in the first place)--what becomes, that is, of those in protracted isolation and despair.

Drug-overdose deaths were up 13% in the first seven months of this year compared to 2019, according to research conducted by the New York Times covering 40% of the U.S. population. More than 60% of participating counties nationwide that report to the Overdose Detection Mapping Application Program at the University of Baltimore saw a sustained spike in overdoses following March 19th, when many states began issuing social-distancing and stay-at-home orders. This uptick arrived atop a decades-long climb in drug-related fatalities. Last year, before the pandemic even hit, an estimated 72,000 people in the United States died of an overdose, the equivalent of sustaining a tragedy of 9/11 proportions every two weeks, or about equal to the American Covid-19 death toll during its deadliest stretch so far, from mid-April to mid-May.

What people do in the face of protracted isolation and despair is turn to whatever coping strategy they've got--including substances so strong they can be deadly.

"The solidarity of people looking out for one another is a necessary ingredient when it comes to preserving the lives of those in the deepest desolation."

"I think of opioids as technologies that are perfectly suited for making you okay with social isolation," said Nancy Campbell, head of the Department of Science and Technology Studies at Rensselaer Polytechnic Institute and author ofOD: Naloxone and the Politics of Overdose. Miraculously, an opioid overdose can be reversed with the medicine naloxone, commonly known by the brand name Narcan. But you can't use naloxone on yourself; you need someone else to administer it to you. That's why Campbell calls it a "technology of solidarity." The solidarity of people looking out for one another is a necessary ingredient when it comes to preserving the lives of those in the deepest desolation.

Yet not everyone sees why we should save people who knowingly ingest dangerous substances. "I come from a small town in northeastern Pennsylvania and I have a large extended family there," Campbell told me. She remembers a family member asking her, "Why don't we just let them die?"

Any of us can answer that question by imagining that the person who just overdosed was the one you love most in the world--your daughter, your son, your dearest friend, your lover. Of course you won't let them die; of course it's imperative that they have another chance at life. There are people like Rafael Rodriguez who have dedicated themselves to ensuring that their neighbors have access to naloxone and other resources for surviving the absolute worst. One day, naloxone may indeed save someone you love. Perhaps it already has.

Another technology of solidarity has recently become commonplace in our lives: the face mask. Wearing such a mask tells others that you care about their well-being--you care enough to prevent the germs you exhale from becoming the germs they inhale, and then from becoming the germs they exhale in the company of still others. Face masks save lives. The face mask is a technology of solidarity. So is naloxone. And so is empathy.

"The Sheer Power of Being With Someone in the Moment"

As Rafael Rodriguez slowly told his astonishing story, I could see on my computer screen a spartan office behind him and a single bamboo shoot, its stem curled beneath a burst of foliage. When he was younger, he said, he used food as his coping mechanism for an embattled life, over-eating to the point where doctors worried he would die. Then, at age 23, he underwent gastric bypass surgery and lost a dramatic amount of weight. The doctors were pleased, but now his only means of coping with life's hardships had been taken away. When three of his dearest family members died in rapid succession, he began drinking. Eventually, he sought something that could help him stay awake to keep drinking, and so he started using cocaine. Later on, he needed something that could ease him off cocaine in order to sleep.

"That's where heroin came into my life," he told me.

Using that illegal drug left him feeling ashamed, though, and soon he found himself pulling away from his remaining family members, becoming so isolated that, in 2005, he fell into a long stretch of homelessness. Only after he had spent almost a year in a residential rehabilitation facility and gotten a job that left him surrounded by supportive colleagues did Rodriguez begin to name the dark things in his past that had driven him to use drugs.

"No one ever knew that I was sexually assaulted as a child," he explained. After years in recovery, he is now in possession of a commanding insight. During the most troubled years of his life, he was punishing himself for someone else's grim actions.

Portugal famously decriminalized all substance use in 2001 and multimedia journalist Susana Ferreira has written that its groundbreaking model was built on an understanding that a person's "unhealthy relationship with drugs often points to frayed relationships with loved ones, with the world around them, and with themselves." The root problem, in other words, is seldom substance use. It's disconnection and heartache.

In 2016, Rodriguez was hired by the Western Massachusetts Recovery Learning Community in Holyoke, where heroin use constituted a crisis long before opioid addiction registered as a national epidemic. Rodriguez now dedicates himself to supporting others in their recovery from the trauma that so often underlies addiction. And while tight funding and staffing limitations have led many community organizations across the country to reduce services during the pandemic period, the Recovery Learning Community has sought to expand to meet increasing need. When state restrictions capped the number of people the organization could allow into its indoor spaces, Rodriguez and his team improvised, offering services outside. They prepared bagged lunches, set up outlets so people could charge their phones, and distributed hand sanitizer and bottled water. And they continued to offer compassion and peer support, as they always had, to people wrestling with addiction.

Helping those in the midst of painful circumstances, Rodriguez says, isn't about knowing the right thing to say. It's about "the sheer power of just being with someone in the moment... being able to validate and make sure they know they're being heard."

In many situations, he adds, he has helped people without uttering a word.

Criminalization Versus "Any Positive Change"

It's something of an understatement to say that, in the United States, empathy has not been our go-to answer for addiction. Our cultural tendency is to regard signs of drugs or the persistent smell of alcohol as marking users as outcasts to be avoided on the street. But medical science tells us that addiction is actually a chronic relapsing brain disease, one that often takes hold when a genetic predisposition intersects with destabilizing environmental factors such as poverty or trauma.

Regardless of the science, we tend to respond unkindly to folks in the throes of addiction. In her book Getting Wrecked: Women, Incarceration, and the American Opioid Crisis, Dr. Kimberly Sue describes a complex and corrupt system of prosecutors, forensic drug labs, prisons, and parole and probationary systems in which discipline is meted out primarily to low-income people, disproportionately of color, who use illegal substances. An attending physician at Rikers Island in New York, Sue is also the medical director of the Harm Reduction Coalition. The philosophical opposite of criminalization, "harm reduction" is an international movement, pioneered by people who have used or still use such drugs, to reduce their negative consequences.

"Treat people with dignity and respect, respect people's bodily autonomy" was the way Sue described to me some of harm reduction's core tenets. In this country, we typically expect folks to cease all substance use in order to be considered "clean" human beings. Harm reduction instead espouses a kind of compassionate incrementalism. "Any positive change," from the decision to inject yourself with a sterile needle to carrying naloxone, is regarded as a stride toward a healthier life.

In tandem with its decision to decriminalize all substance use, Portugal put harm reduction at the heart of its national drug policies. And as of 2017 (the most recent year for which data are available), nearly two decades after that country's groundbreaking move, the per-capita rate of drug-related fatalities in the U.S. stood 54 times higher than in Portugal.

"While social distancing saves lives, stark solitude can be deadly--both as further reason for using such drugs and because no one will be present with the antidote."

Now, the pandemic has made addiction even more dangerous. In addition to inflicting the sort of widespread hardship that can drive people to opioids (or even greater doses of them) and to take their chances with the potent synthetic opioid fentanyl, Covid-19 has stymied efforts by Dr. Sue and others to provide effective guidance and care. In normal times, opioid users can at least protect themselves from dying of an overdose by using their drug in the company of others, so that someone can administer naloxone if it becomes necessary. Now, however, that safety mechanism has been fatally disrupted. While social distancing saves lives, stark solitude can be deadly--both as further reason for using such drugs and because no one will be present with the antidote. Referring to naloxone as a miracle medicine, Sue said that there is no medical reason why people should die of an opioid overdose.

"The reason they die is because of isolation."

Rx: Friendship

Back in March, one of the first recommendations for reducing the transmission of the coronavirus was, of course, to stay home--but not everyone has a home, and when businesses, restaurants, libraries, and other public spaces locked their doors, some people were left without a place even to wash their hands. In Holyoke, Rafael Rodriguez and his colleagues at the Recovery Learning Community, along with staff from several other local organizations, rushed to city officials and asked that a handwashing station and portable toilets be installed for the many local people who live unhoused. Rodriguez sees such measures not only as fundamental acts of humanity, but also as essential to any viable treatment for addiction.

"It's really hard to think about recovery, or putting down substances, when [your] basic human needs aren't being met," he said. In the midst of extreme summer heat, he pointed out that there wasn't even a local cooling center for people on the streets and it was clear that, despite everything he had seen in his life, he found this astonishing. He is now part of a community movement that is petitioning the local city government for an emergency shelter.

"When you have no idea where you're going to rest your head at night, using substances almost becomes a survival tactic," he explained. "It's a way to be able to navigate this cruel world."

Meanwhile, Dr. Sue continues to care for her patients whose maladies are often rooted in systemic injustice and the kind of despair that dates back to their early lives. Affirming that substance use is indeed linked to frayed relationships, she told me that, in this pandemic moment of isolation, what drug users most often need is a sense of connection with others.

"How do I prescribe connection?" she had asked during our phone call. "How do I prescribe a friend?"

Several days later, while writing this article, I left the air-conditioned space in which I was working and walked a couple of blocks to run some errands. In the stifling midday sun, I saw a woman sitting on the ground. I realized I'd seen her before and guessed that she was homeless. Her arms and face were inflamed with a rash. She said something to me as I passed. At first, I didn't catch it. Her words were garbled and she had to repeat herself several times before I understood.

She was asking for water.

I blinked, nodded, and went into a nearby drug store where I grabbed a water bottle, paid in a few seconds at self-checkout, and gave it to her. And yet, if I hadn't been working on this article, I might not have done that at all. I might have passed right by, too absorbed in my life to realize she was pleading for help.

Amid the sustained isolation of a global pandemic whose end is nowhere in sight, I asked Rafael Rodriguez what lessons could be learned from people who have long experienced isolation in their lives.

"My hope is that, as a society, we gain some empathy," he replied.

Then he added, "Now that's a big ask."