Twenty miles up the road from my adopted home, the Espanola Valley fans out between the wealthy enclave of Los Alamos and the forests of the Sangre de Christo mountains. The main street of Espanola looks like any dry, dusty burnout of a town west of the Rockies; except for the Indian casino plunked down on the main drag, you might as well be in Barstow, Bakersfield, Yuma, or Calexico. Turn right off the highway toward the shrine at Chimayo and you’ll still find the greenbelt of apple orchards that my father remembers from when he lived here sixty years ago. And inside the trailers and flat-roofed chicken-wire-and-stucco abodes that line the highway, you’ll find the highest rate of opioid use, abuse, and overdose in America. Welcome to the heroin heartland.
In the Espanola Valley, heroin is tradition, it is familial, it spans generations, it is passed down like genes and heirlooms, it is entrenched like the Maginot line. The valley lies on a historical trade route where heroin has been brought from Mexico for the last six or seven decades, and the disproportionate availability of the drug has been compounded by the concurrent push to move old land-grant families off their 500 year-old homesteads, in no small part because of up-pricing of land and housing in response to the locating of the Los Alamos National Lab in an otherwise notably remote part of the nation. Much has been written to try to explain the unique patterns of addiction in northern New Mexico; most recently, an expatriate anthropologist came home to write Land of Disenchantment – an ethnography of his own home territory, and a 360-degree critique of those who blame the lack of highbrow culture, the snobbery toward lowbrow culture, the dislocation from the old familial land grants, and a dozen other one-note knee-jerks as simplistic explanations as to why this little valley beats out the Bronx, urban DC, Los Angeles, and the entire border zone for the dubious distinction of the heroin capital of the United States. The New Yorker published Kristin Valdez Quade’s stunning short story The Five Wounds, which tackled drugs, teen pregnancy, the old-time Penitente faith, low-riders, and a tightly-woven mosaic of a dozen other themes that makes this region seems like another planet unless you’ve spent at least a couple of years wandering around the countryside here. Similarly, there is the mystery of why hepatitis C is so shockingly prevalent here and yet HIV so rare; as good a guess as any is that hep C roared into New Mexico with the big first wave of globally mobile northern New Mexicans in 500 years – the rapid outflux and influx of locals who went to fight in Vietnam – but that HIV never entrenched in a pattern of drug use marked by tight familial bonds and the rarity of sharing needles with outsiders…but then again, that’s just a guess.
Here on the ground, the health care workers who man the front lines of the drug addiction and treatment are an eclectic crew of general practitioners, community health workers, and the very rare addictions specialist, made common by one principle: if it works, then by all means, use it. And the classic means of treating addiction just don’t work here.
The old wisdom says that to kick a habit, you have to go away to rehab, and when you come out, you best not go back to the place you came from – your old friends, habits, dealers, and a rip-roaring relapse are there waiting for you. This works for the globally mobile; I’ve got three or four cities I could equally call home, and if I were to pick up a coke habit in one of those, it wouldn’t be too much trouble after recovery to resettle in another one where I haven’t any connection to the local scene but do have job prospects, a few old friends still on Facebook, and the ability to start a new life fresh the way I have a dozen times before. This does not work for the provincial backwaters of America, where the old urban drug centers are filtering out to these days, and where those in recovery may have nowhere else they have ever called home – nevermind the fundamental lack of funds to pay for inpatient rehab.
The old model says you abstain from all substances – live drug free – and that includes antidepressants, mood stabilizers, and medications that moderate cravings. This came from the early days of AA when – it is forgivable to say – these options didn’t exist. But it’s been a hard transition to the days when we have methadone, Antabuse, and the understanding that many addictions stem from untreated anxiety, depression, mania, schizophrenia – and that treating the behavioral disease often treats the addiction.
The old model says that addicts can quit, once and permanently, and that a failure to quit is a sure sign of moral failing. Now we understand that addiction has a strong physical component; that the norms of quitting are that is takes many tries and many failures before one finally quits for good; and that moralizing over abstinence and relapse is a fairly futile road to go down.
Altogether these new models fall out loosely into a model that has come to be known as “harm reduction.” In essence, harm reduction understands that the habits we call “vices” are partly harmful because of their innate nature, and partly harmful because of the way they are treated at large. We cannot reduce their innate harm as long as the addiction persists, but we can reduce the modifiable harms along the way, and support abstinence as soon as the addict is ready. Or, alternately, we can make sure that these habits cause the maximal cost and suffering possible to addicts and the rest of society. Really, it’s our choice.
Needle exchanges were the original harm reduction program: can’t stop addicts from shooting until they decide to cut it out, but you can help prevent them from suffering HIV and making the rest of us pay for the indigent care of drug users who then get AIDS. Condoms for teenagers came along next; most of us realize that teenagers have been having sex since the dawn of time, are not going to stop soon, and maybe we would all benefit from the reduction in budgetary and social stress at large if teenagers were not were not also trying to raise children. Thus, condoms.
In rarefied places like the Espanola Valley, harm reduction has been taken to new levels. At the first intake visit for outpatient drug treatment in one clinic, patients are not given anything except a couple of tools: a quick how-to on CPR, and an apparatus containing intra-nasal Narcan – a reversal drug that block opioids at the receptor level and yanks a person wholesale out of an overdose, immediately. And then at the next visit, Suboxone: an opioid that works half like heroin and half like Narcan, Suboxone blocks the cravings of addiction and the skin-crawling tortures of withdrawal without producing a noticeable high. This allows heroin addicts to transition back to the business of being sober in the setting of their own home and their own community, even if their neighbors and cousins are shooting up in the next room. It was invented for the upper class pill addict who didn’t want to be seen at the local methadone clinic; turns out it works spectacularly well for the impoverished heroin addict who can’t afford the niceties of inpatient rehab. (Except that I cannot prescribe Suboxone without special training and DEA waiver. I got permission to prescribe as much Percocet, Oxycontin, and Demerol as I dang well please when I graduated from residency and got my general DEA license; I can addict as many folks as I want to opiates with the meager training I got in residency to write pain medications. To treat addiction with a medication in the same class and a far safer side effect profile, I need eight hours of documented training and special dispensation from the feds. The only other medication I know of with such similarly strict regulation is Accutane, an acne medication so wickedly teratogenic that women are required to swear on paper they are using two forms of birth control before they receive it.)
So we spend so much time to treat addicts who are – needless to say if you’ve ever had one in your circle of friends and family – not always the most gracious or rewarding people to work with. Why? Some people ask, and I’ve heard that asked more than once around these parts. Why spend so much time and effort on folks so far out on the burnout end of the human race? The answer “because they are people” is apparently sometimes not enough, so here’s another reason: because every addict, every overdose, every burnout dysfunctional junkie who crosses the ER threshold blue and unconscious ripples out in a thousand predictable and unforeseeable directions to create an expanding shockwave of harm. Addicts here are not isolated family-less homeless individuals; an overdose here is not a back-alley affair – it’s likely to happen in a home, with extended family nearby, witnessed by children. Post-traumatic stress is endemic here, not in the least because of dealer-on-dealer violence, but also because of witnessed overdoses, the constant fear of police intervention taking away a mother or a father (or CYFD come to take away a sister, brother, or cousin), the eternal wailing siren of emergency services, and the constellation of low-level terror and neglect that surrounds criminalized drug use. Moreover, addicts in rural communities like the Espanola Valley are often not homeless, dislocated, far from family; they are often breadwinners and heads-of-household – and the morbidity and mortality of this demographic compounds the generational poverty which drives a near-guaranteed future of addiction and hopelessness.
Addiction begets addiction; trauma begets trauma; poverty begets all of the above, and vice versa too. The cycle has to break somewhere, and that breakage begins by cracking the ancillary harms done by drugs: reducing overdoses, treating addiction in the community with substitution drugs like Suboxone, accepting that the old drug-warrior models often cause more rather than less harm, and realizing that the time for innovation has come. The Espanola Valley may hold onto a couple of unique cultural quirks, but it is becoming increasingly representative of addictions in America: rural, occurring inside the family unit rather than in streets and alleys, and completely not amenable to outdated models of prevention, risk-reduction, and treatment.
The old Hippocratic Oath asked that doctors first, before anything else, do no harm. Physicians don’t swear by the Hippocratic Oath anymore (and for good reason – really, go ahead and read it), but that sentiment in particular isn’t a terrible one. Even so, perhaps it’s time to ask more of medical providers as a whole, a new, stronger imperative: first, reduce harm.
It is not enough to stand back and keep our hands to ourselves if we don’t know better what to do. It is time now to end the policy of harm – of jailing low-level offenders, of making HIV a reasonable consequence of drug addiction, of ensuring trauma in the children of addicts - and invoke the means we already know to remove harm. And then treat the problem. We have the means; we have only to invoke the will to do so.
Dedicated to the memory of Amy Winehouse, and to the still-vibrant A.H., who taught me – the hardest way and the beautiful way – the price of addiction, and the meaning of recovery.
Cross-posted from my recently relocated and relaunched blog, America, Love It or Heal It.