Pubdate: Mon, 12 Sep 2016
Source: Globe and Mail (Canada)
Copyright: 2016 The Globe and Mail Company
Author: Alana Hirsh
Page: 23


In the discussion about Canadian drug policy, the unspoken question
is: Why should we take care of drug addicts? I have had to ask myself
this because my job is taking care of people with drug dependence and
mental illness in the Downtown Eastside, Vancouver's notoriously drug
and disease-ridden inner city. What does society gain from assisting
people who engage in illegal activity, who bring their diseases and,
with increasing prevalence, their death, upon themselves?

I am a McGill and UBC-trained family and emergency physician, and have
practised in Canada, the United States and West Africa. I have
delivered babies, treated trauma victims, managed chronic disease, and
comforted dying people.

And, the truth is, in spite of having had my prescriptions forged, my
car broken into, having been threatened and lied to, I enjoy and feel
privileged to treat people afflicted by drug dependence. Drug addicts
are my favourite patients.

I stumbled into addiction medicine during a period of disillusionment
in my medical education. I was leaning toward specializing in plastic
surgery, and had arranged to do my family medicine rotation in
Vancouver, mostly for the chance to explore the West Coast. I
discovered on my arrival that the doctor I was shadowing worked mainly
with pregnant heroin addicts. Sometimes he just sat me in a room with
them: "Ask her to tell you her story," he instructed.

Josie was 16 and pregnant. She had long brown hair and a childish,
angelic face. She came from Winnipeg, where there was a warrant out
for her arrest. The only person she knew in B.C. was her boyfriend,
the father of her child. She was on a methadone program, but was
giving half of her dose to her boyfriend to keep him off heroin (he
was unable to get a doctor). As a result, by midnight every night she
would experience terrible withdrawal symptoms.

Withdrawal has been described to me by addicts as "feeling like you
are going to die," and the physiologic effects of it actually did put
her fetus at risk of death. So she would sell her body to get money
for drugs.

She had no family to turn to - her mother had been shooting her up
with heroin since she was a baby. She was so skinny - only 106 pounds
in her seventh month - and so desperate. "Man, don't ever do heroin,"
she advised me with a rueful smile. She was a good person, a child,
trapped in a horribly addicted body.

Since then, I have listened to hundreds of stories. Debra, born to
parents who were addicts themselves, had a father who sold her to his
friends for extra cash. Jeff's mother died when he was nine months
old, and his father was an alcoholic who beat him. Ryan's mother tried
to commit suicide four times before he turned 10, once by putting her
head in the oven.

I had little in common with these patients. I came from a loving,
upper-middle-class family, and my main exposure to drugs during my
youth was when the police came to school to disseminate the Just Say
No campaign. However, I was raised on my mother's stories: born on a
forest floor in Siberia while her parents fled the Nazis during World
War II, enduring poverty and malnutrition during her formative years
in a displaced-persons camp in Austria. I understood that I had won
the jackpot in the privilege department. As undeserving as I felt of
my privilege, these people seemed equally undeserving of their misfortune.

Not only did working with this population feel meaningful, it was fun.
In the early 2000s, I volunteered with a group called VANDU: Vancouver
Area Network of Drug Users. The first time I entered their office I
felt like I was walking in to Theatre of the Absurd - heroin users
nodded off around the table, while stimulant users bounced off the
walls. But as I sat in the corner and observed, I was humbled and
impressed as they stuck to an agenda addressing compelling issues: a
health network they were forming to do alley patrols and needle
exchanges, a protest they were planning to bring attention to the need
for supervised injection sites. They gradually became my most
formidable instructors in public health and grassroots advocacy.

Their methods reflected the candour and compassion I came to expect
from drug users. When a member who had been kicked off the board of
directors requested to rejoin the group, it was suggested that they go
around the table and have each member say how they felt about it.
"Larry, you can't ask girls for sexual favours in exchange for a clean
needle," one explained. I marvelled at the no-BS approach - if only
such transparency existed in all groups.

They challenged me to reassess my perceptions of right and wrong. They
asked me to steal supplies like Band-Aids, gloves, gauze and needles
from the hospital, and to supervise the illegal supervised-injection
facility (SIF) they were starting (at the time the Canadian government
still opposed SIFs) - a room with a single bathroom where users could
inject themselves. Concerned for my reputation and licence, I bought
myself time by suggesting that I do some research first. After
studying the literature, which showed evidence of morbidity and
mortality reductions with SIFs, and having dealt with the consequences
of unsafe drug use among my patients (HIV, hepatitis, severe skin
infections, heart infections, overdose etc.), I realized that it would
be unethical not to provide this service for people. They helped me
see that just because something is a law does not make it right. Years
later, the government confirmed their prescient public-health measures
by opening Canada's first! legal SIF in Vancouver.

Amidst the suffering, I witnessed great capacity for community and
relationship. Mary was a sex worker and lived in a bedbug-ridden hotel
in the Downtown Eastside. Despite her outwardly depressing life, she
was a ray of sunshine. Her short blond hair tufted out like a baby
chick, and she had a little girl's voice and mannerisms. "Doctor
Alana!" she would happily shout down the hallway when she saw me, and
would run over excitedly to hug me or share news. She always thanked
me for coming to the office: "It's just so amazing of you to work with
us, we love you so much!" She died of AIDS in her early 40s. At her
funeral, a young transgender woman cried, "When I had nowhere to go,
she took me in. She taught me how to wear makeup. She was like a
mother to me." For many who have never felt welcome anywhere, the
Downtown Eastside is a place where they feel accepted.

The first time I felt parallels between my life and those of my
patients with addiction issues, I was in my late 20s, going through a
difficult breakup, unsure of the future. One day I looked at my
schedule and found that I was working three jobs, and I had booked
myself to work 29 out of 30 days. I couldn't face my pain, so I was
drowning it in my work. My patients echoed my own thoughts, "I just
feel like such a failure," and I began to resent their relapses. I
left my practice and dove into an Emergency Medicine fellowship. Fast
paced, not a moment to spare, saving lives, no time for weakness - the
perfect field for a doctor avoiding introspection.

For so many drug users, whose stories of trauma and neglect often
began in utero, and who often have untreated mental illness, drug use
begins as a reprieve from suffering. Years later, my own coping
strategies of escapism and perfectionism had helped me to achieve the
"perfect life" I had dreamed of: I had an amazing husband, two
beautiful children and a dog, lived in a beautiful home, and worked as
an ER doctor. But just as the drug user's solution eventually becomes
their downfall, so my efforts to be successful caught up with me. The
stress of multiple moves between countries, life changes, sleep
deprivation from shift-work and babies, and a job that left no room
for weakness took a toll. By the time I was diagnosed with postpartum
depression after my second child, I had been experiencing anxiety and
sadness for at least a year, taxing my marriage, distancing me from
friends, making work an exercise in exhaustion. It took me too long to
seek help, because I was ashamed. ! To not be enjoying my beautiful
life, to not be not coping better with the stress it entailed, to be
suffering from a disease that I learned I had my own stigma toward.

According to writer and addiction doctor Gabor Mate: "We lack compassion 
for the addict precisely because we are addicted ourselves in ways we 
don't want to accept and because we lack self-compassion."

When I finally admitted that I needed help, I was ushered into the
arms of incredibly supportive and effective care by the medical
community. The most surprising thing I experienced when I opened up to
my friends and colleagues about my diagnosis was how often they
responded by sharing their similar struggles. Some were being treated,
some were afraid to ask for help, many were self-medicating. Medical
literature suggests that physicians may have higher prevalence of
depression than non-physicians. In the United States, about one
physician dies by suicide every day.

Self-improvement is noble and what we all strive for, but are we only
loveable and worthy if we change? What if changing requires self-love?
I met Debra, who I mentioned above, in her home many years ago, when I
visited her with a social worker. Formerly a hard-core injection-drug
user, she was off all street drugs, living in an apartment out of the
DTES, and had recently been granted custody of her child. I asked her
what had made her change. She told me how, one day, when she was
working the streets as a prostitute, a john assaulted her in an alley.
She was so beat up that she was confined to her apartment and couldn't
turn tricks. But she was still addicted to drugs and needed money to
support her habit. So, from her room, she started cutting hair for
people. One day she was well enough to go downstairs, and the lady who
worked at the fruit stand told her, "You know, you have a real talent
for haircutting."

"That moment," Debra told me, "was the first time in my life that I
saw myself as something other than what my father told me I was: a …
whore. Suddenly, I was more. I was a hairdresser." It was the start of
a miraculous transformation.

My own effort to practise self-compassion contributed to my husband
and I moving our family back to Vancouver from the United States a
year ago, closer to family, to socialized medicine, to nature. I found
myself back in the DTES, working at a similar job to what I did before
practising as an ER doctor, with people who have difficult lives,
challenging dependencies and mental illness. When I work with them
now, I don't just see people who are suffering, I see myself, and all
of us: human and fragile and needing support to thrive. And I do not
feel ashamed of this. I feel connected. I feel freed.
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MAP posted-by: Matt