For mindlovemisery’s prompt: opposing forces. The prompts are admit/deny and presence/absence.
The pairs bring up my current sadness right away. I am struggling with the realization that we have a pervasive legal substance that works at the opiate receptor, is all over the US, and I have to send out urine tests for ALL of my chronic pain and opiate overuse and anyone on any controlled substance. You say, “but it’s legal”. I say, “Overdose and death risk. I can’t ignore it.” Here is the resulting poem.
admit to yourself you deny your addiction
the presence of the drug means the absence of the one I love
With the DSM-V, there is no longer a separate diagnosis of Opioid Dependence and Opioid Addiction. The two are combined into Opioid Use Disorder. Opioid Use disorder can be mild, moderate or severe. And all of the addictive substances have the same list. So here is Tobacco Use Disorder.
According to the DSM-5, there are three Criterion with 15 sub features, and four specifiers to diagnose Tobacco Use disorder. Use of tobacco products over one year has resulted in at least two of the following sub features:
A, Larger quantities of tobacco over a longer period then intended are consumed.
1. Unsuccessful efforts to quit or reduce intake of tobacco
2. Inordinate amount of time acquiring or using tobacco products
3. Cravings for tobacco
4. Failure to attend to responsibilities and obligations due to tobacco use
5. Continued use despite adverse social or interpersonal consequences
6, Forfeiture of social, occupational or recreational activities in favor of tobacco use
7. Tobacco use in hazardous situations
8. Continued use despite awareness of physical or psychological problems directly attributed to tobacco use
B. Tolerance for nicotine, as indicated by:
9. Need for increasingly larger doses of nicotine in order to obtain the desired effect
A noticeably diminished effect from using the same amounts of nicotine
C. Withdrawal symptoms upon cessation of use as indicated by
10. The onset of typical nicotine associated withdrawal symptoms is present
11. More nicotine or a substituted drug is taken to alleviate withdrawal symptoms
Additional specifiers indicate the level of severity of Tobacco use disorder
1. 305.1 (Z72.0) Mild: two or three symptoms are present.
2. 305.1 (F17.200) Moderate: four or five symptoms are present.
3. 305.1 (F17.200) Severe: Six or more Symptoms are present
We have much more stigma attached to Opioid Use Disorder, but list for Tobacco Use Disorder is the same. Most chronic pain patients on long term opioids qualify for at least mild Opioid Use Disorder. UW Telepain says that if they only have withdrawal and tolerance, then it is questionable if they qualify. They also have said that “we don’t know what to do with patients with mild opioid use disorder”.
I find our culture peculiar. People get accolades for saying “I am quitting smoking.” or “I am a recovering alcoholic.” But it’s not ok to say “I am a recovering opioid addict.” People will shun you. Demonize. Gossip. It’s all addiction, so we should stop the demonization and stigmatization and help people and each other.
The photograph is not a brain. I took this about a month ago: it’s a brain size mushroom that was in the church lawn…
The last two days have been at the 20th Annual Fundamentals of Addiction Medicine Conference in Washington State, 15 lectures. Everything from science trying to understand addiction via studying dopamine in ratbrains to the last presentation: Snohomish County started a program two years ago that pairs a social worker with a county sheriff or deputy to work with the homeless.
The county is trying to stop the revolving door of homeless to arrested to jail to homeless. 95% of the county homeless are addicted to heroin and some to methamphetamines. They don’t access services when they are “dope sick”. They describe heroin as being 10x worse than the worst influenza. I think of withdrawal from opioids as having all the pain receptors turned as high as they can go and screaming at once.
The sheriff and social worker go to the camps. They get to know people and offer services. They have helped over 100 people get their identification replaced. When someone is arrested, their homeless encampment is often stolen. No honor among thieves, you say? The rat studies address that: in addiction the brain puts the drug first, in front of food, water, sex. Some rats will access the drug until they die, just like people. I think of it as the person losing their boundaries to the drug. The conference used the phrase “incentive salience” — dopamine is released when the person or rat is cued that the drug is now available and again when the drug arrives. More on that in another write up.
At any rate, the clients do not get to appointments. So the deputy and social work start at the beginning: they make the appointment, go knock on the tent that morning, remind the person to get dressed, take them to get food and coffee and then take them to the appointment. Then they return them to their camp.
After two months, the first sheriff and social worker were so successful that the program was expanded.
They have 206 chemical dependency evaluations.
232 have gone to detox. The detox is 3-5 days. They are taken straight from there to inpatient treatment, 30 day minimum, but ranging from 30-90 days. After treatment, clients are taken straight to sober housing, with a 6 month supported stay and intensive outpatient treatment.
85% get through the detox.
59% graduate from the treatment
50% go on to sober housing and intensive outpatient.
Their first clean and sober client is two years out.
50% of the homeless who agree to the program getting to sober housing is huge. Recidivism and incarceration drop, so it is making a true difference.
The program is expanding. They have a Community Court set up, much like Juvenile Drug Court, modeled after a program in Spokane. If the person agrees to drug treatment, they can do that instead of jail. This is for minor offenders. The sheriff says that once the homeless person is incarcerated, everything is stolen. They then steal food and supplies for a new camp when released and it happens again. If the client completes the program, low level charges may be dropped. They are setting up a service center right by the court where the clients are sent immediately to talk to a chemical dependency person, to get medical treatment, dental emergencies, centralized services because these people do not have transportation.
The social worker is in kevlar and heavy clothes as well and is never to go in the encampments without the law enforcement officers: it’s usually private land so it would be trespassing anyway.
This was an absolutely inspiring presentation. It starts with outreach and intervention, and gives people choices. They will soon be opening a temporary site, up to 15 days with medical support and beds, for when a client is ready but the social worker needs to arrange the detox, the treatment, the housing. Sometimes when a client is finally ready, there are no beds. And they don’t want to send them to detox and then back to the streets. The sheriff says that he was “volutold” for the program, but he, the deputy and the social worker are all clearly inspired by the program and enjoy their work and that it is making a difference.
Any write up on addiction fits today’s Daily Prompt: messy.
“Siqalo used to be the most promising child in our house … the last born. He got the best of everything. We took him to better schools than we did his younger sister and brother. He did well for the better half of high school.Then he met up with the wrong friends, and never even got to matric,” Fanele Ngcobo tells GroundUp about his son.
Siqalo is 22. He has been a whoonga user since 2015. By 10am, he has already smoked his second fix. Without the drug he struggles to function. Withdrawal effects – which people refer to as “arosta” – include stomach cramps, vomiting, and extreme anxiety.
Whoonga is a mixture of marijuana and heroin and rumoured to contain anti-retrovirals, detergents and even rat poison. Active addiction has spread in KwaZulu-Natal townships such as KwaMashu and iNanda. Hundreds of people now live in Durban’s ‘Whoonga Park’,
Siqalo was a keen soccer player, says his mother, Sizakele. Now his worn, black soccer shoes peek out from under the bed in his old room at home in iNanda, Durban.
“He always went for practice with his friends at the local playground. But after a while, soccer wasn’t the only thing he and his friends were playing with; he was also experimenting with dangerous drugs,” she says.
Siqalo lives in so-called Whoonga Park, under a bridge next to the Berea railway lines in Durban. The park has become a den for whoonga users. They have bright beach umbrellas to protect them from the heat and black plastic bags for shelter. The activities under the bridge are in plain view. People trade and smoke. In the afternoons and at night, many take to the city streets to hustle for food and the money they need to buy their fix.
“There are no beds here. Even if you can get a blanket or sheet to sleep in, it doesn’t last a week. The police will burn it,” says Siqalo. “So it’s easier just to use cardboard and plastic as it is easy to find in the streets. Although I miss home, I cannot go back home like this. I need to be clean. My family doesn’t trust me around the house and for good reason because I’ve stolen their money and appliances too many times. I tried to be clean when they first fetched me, but arosta is too painful – nobody can understand. But I still want to go home.”
Cooked meals, showers and clean clothes
Nobuhle Khuzwayo from eMpangeni, KwaZulu-Natal, is one of those trying to get off whoonga. She attends the iSiphephelo Centre housed at the Denis Hurley Centre in Durban, where she gets cooked meals and clean clothes three times a week. For a few hours she is free of whoonga.
Co-founder of the centre Sihle Ndima says it is a place of safety for young girls and women living on the streets of Durban. It offers meals, counselling, clean clothes and showers.
“Many of them return back to the streets soon after classes, and the work we do seems like failure, because in the end they go back to using whoonga,” says Ndima. “We work with a rehabilitation centre in Newlands East, Durban, and they offer free help.”
Khuzwayo, who is 30, came to Durban seeking a job in 2014, but after numerous failed attempts, she was left homeless and desperate.
“The shoe factory I was working for closed down after a month. Thereafter it was difficult to get employment. I had been staying at the Dalton hostel with some friends, who later introduced me to smoking. They would tell me it was marijuana, but after becoming a frequent smoker … I would get headaches, pains and stomach cramps when I hadn’t smoked. I just could not cope without it. When I confronted them, they told me it was in fact whoonga. I was already deeply hooked,” says Khuzwayo.
She could no longer live at the hostel. She moved to Whoonga Park. To get money she would have to resort to sex work, crime or selling cigarettes. She found a boyfriend who sold cigarettes at taxi ranks to help get them food and the R30 a day they needed to buy whoonga.
“To survive on the streets, I got myself a boyfriend because you can’t survive a day alone under the bridge as a woman. There are men known as amaBhariya, who claim to own the spots in Whoonga Park. They do not smoke or deal the drug; they do not speak local languages or even English. They are ruthless. They rape and kill women under the bridge and make sure the park functions the way it does. They wear blue workmen’s clothes and hats and use the underground drains to move around. So if you don’t have a man to protect you, they will always take advantage of you,” says Khuzwayo.
Merchants outside the park sell whoonga for R30. “They are usually in the streets or in nearby flats but not many sell whoonga under the bridge,” she says.
Khuzwayo has now moved to a local shelter, paying R20 a night. Her closest friend had TB and when she died it was a turning point.
“I am tired of this life. I am determined to change. I don’t want to die a senseless death without dignity,” she says.
She is now a part-time cleaner at iSiphephelo. After attending all counselling and life skills classes she will qualify for rehab. “After rehab, I am going to go back home and stay with my sister in eMpangeni. You cannot stay away from whoonga in the city,” says Khuzwayo.
Siqalo and Khuzwayo say whoonga users are known as amaPhara. “Because we look like zombies. We’re dead people walking. We sleep standing. We stab you for your phone and sell it for a fix. Plastic and rubble is our shelter, faeces and rubbish are everywhere, and we run from police who destroy our things and chase us away every week. But we always come back. We can’t survive anywhere else,” says Siqalo.
Khuzwayo says she has seen people high on whoonga killed by trains.
“You can’t save them, because it’s like the railway shocks you, and you’re unable to move … seeing the train come at you but unable to run. I’ve seen some getting crushed in half and some losing their limbs. Even a security guard, who was chasing us one time, got stuck and the train crushed his foot.”
“One way or the other, you’re lucky to survive under the bridge.”
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