At The Methadone Clinic

It’s just before 9am when I enter the methadone clinic at the San Francisco Veterans Affairs Medical Center at 42nd and Clement. I’ve been coming here most weeks for the past few years and even though these visits have become part of my routine, I feel a familiar acceleration of my pulse and tightness in my gut.

I take a seat in the waiting area with a handful of men, most older than myself–though it’s hard to tell given the toll taken by the lifestyle of a heroin addict. We wait together for the three-by-five-foot steel plated window to retract and our names to be called. Legs twitch. Fingers and newspapers are fidgeted with. Someone mutters obscenities about a certain bus driver and the extra blocks he had to walk on a bum toe. I nod to a familiar face and try my best to be patient.

At the window I’m greeted by a soft-spoken dispensary nurse who asks how I’m doing today. But unlike the others, I’m not here to receive a dose of methadone, buprenorphine or any other drug. I’ve never been a heroin addict or experienced its legendary withdrawal. I don’t know what it’s like to have served in the military or lived on the street, as many of these men have. No, my presence here is much less dire: I’ve been running a research study on heroin addiction and I’m here to verify the urine screens of our final participant.

The nurse returns with the information I need and I thank him profusely. The clinic has been supportive of our efforts despite the study having dragged on longer than expected, and today’s exchange feels less like an informational transaction and more like a goodbye. As intense as it’s been, I’m going to miss the place.

When I turn to head out I notice a photocopy scotch-taped to the dispensary door. I pause. The pixelated face looks familiar, but I can’t place it. As I approach and read the words “In Loving Memory of…” both the face and its meaning come into focus. It’s a photo of our first study participant. I had met him nearly two years ago to the day.

As we put the final touches on our manuscript and I reflect on my time with the men from the clinic, it becomes obvious that so much of what we’ve learned won’t show up in the pages of a scientific journal. We’ll have the data and our best interpretation of what they mean. We’ll have taken a necessary small step on the long road to new treatment. Missing will be the stories of the people we got to know and our experiences running the study–those little insights accrued along the way that over time start to resemble a perspective. With this in mind, here are a few impressions from my days at the methadone clinic.

Building trust with research participants is essential–especially if you’re asking highly personal questions, and particularly if your participants are recovering drug addicts. There is a suspicion of nosy scientists that a confidentiality agreement alone will not abate. I’m warned about this by Dean Carson, a post-doc from Stanford who is consulting on the project. Dean tells me that recovering addicts can be guarded, but if you can find a way to engage them, the floodgates will open. He reminds me that when you’re using it’s a 24/7 gig. These guys didn’t just like to party, they were professional drug users. Experts. And like most experts, are more than willing to expound upon their knowledge given the opportunity. The key is to show you care about what they have to say while not making a big deal of the terrible things you hear. It’s a fine line.

I’m thinking of Dean as I interview our third participant, John, a heavyset man with a gap in his smile where his front teeth used to be. John has been giving me a hard time about all the paperwork I’ve given him and thirty minutes into a four-hour session is already checking his watch.

Contrary to the early warning signs, the interview is not a disaster. When I ask him to take me through his experience–to share his story–John begins to open up. He tells me about his childhood, how he started using, and even about the hard times when things got really, really bad. He tells me about the time a good friend overdosed on the floor next to him. I ask him what that was like and, practically speaking, what one does in that scenario. For a moment I wonder if my question has come across as insensitive. It doesn’t faze him.

The first thing, he explains, is you take the needle from the dead man’s arm and put it into your own. No sense in letting good junk go to waste. He doesn’t worry about a hot dose or the flash of the other man’s blood still floating in the chamber of the syringe. Next you need to remove yourself from the scene in the event the police come around asking questions. Dead bodies, after all, need to be accounted for. On the street this would be easy–just take off on foot. In the high rise apartment you’ve been squatting in all winter, less so. So what you do is this: roll the body across the floor in the direction of the nearest window, hoist it up, and let it fly.

Holy shit, I’m thinking. And this was his good friend!?

“That must have been really hard,” I say instead after a pause.

From here our session goes off without a hitch and during a lengthy battery of behavioral tests, John and I develop a genuine rapport. He seems to enjoy the questions being asked as much as I’m interested in how he’ll respond. He mentions more than once how jazzed he is to be part of something that could help others get clean–though at one point gets frustrated at a particular thought exercise and lays into me: “Now this is really stupid, man. Y’all just don’t get it. Thing about heroin is, when you’re dope sick, it’s just that: You’re sick. Skin burning, shitting yourself, losing it. Pain like you wouldn’t believe. You just don’t get it man. You score to get well, not to get high. For the junkie it’s now. Whatever it takes. It’s always NOW, NOW, NOW.”

Fair enough.

At the end of our session John shows me pictures of his wife on his smartphone. They had recently discovered she’s HIV positive and had contracted the virus while he was in prison. Unable to support them as he had by selling small amounts of crack and heroin, she had become a prostitute–or “lady of the night” as he put it–to pay the bills. He didn’t blame her though. “You gotta do what you gotta do to survive.” He considers himself lucky that after all those years of needles in and out of fingers, arms and toes, he managed to steer clear of it.

“Great to meet you Pete,” John says.

“Take care of yourself,” I reply.

“You too brother.” And then John envelops me in a giant bear hug.

I go home that night with a renewed pride in humanity. That John seems to have found a way back from all that darkness is a powerful thing. I think maybe we aren’t all that different in our basic needs to be seen and heard, to love and be loved, and that we should keep this in mind as we try to wrap our heads around the confounding nature of drug addiction. When treated with a bit of candor and respect, John reciprocated wholeheartedly. And as Dean might point out: he’s the expert, not us.

Josh Woolley, an assistant professor at the University of California, San Francisco medical school and the study’s principal investigator, begins his lectures by talking about his early days as a psychiatry resident. Patient after patient, Josh kept looking to his Rx pad wanting to prescribe them “a friend.” Wellbutrin, it turns out, is only a partial substitute. A 2010 meta-study published in the Public Library of Science reveals loneliness, or the lack of meaningful social relationships, as a leading predictor of mortality(1). The effect of loneliness on life expectancy was greater than that of obesity and on par with smoking. The research coming out of Josh’s lab aims to address this sad reality by developing interventions for mental illness, including drug addiction, that help people with relationships and combat social isolation(2).

Our study at the clinic examined the relationship patterns of heroin addicts and whether treatment with a hormone that promotes social bonding could help with their rehabilitation. Oxytocin, sometimes referred to as the “love drug,” has shown promise as treatment for both social dysfunction and substance abuse(3)–but the research is still in its infancy.

Working with the men from the clinic, I saw more and more the implications of Josh’s work. I saw men thirsting, at times stumbling, for connection. For them, coming to clinic and interacting with doctors, nurses, fellow patients, and even nosy scientists, was a way of being part of a community–of keeping tethered to life.

Now not every session ended in a bear hug. One participant told the other patients at the clinic we weren’t to be trusted. His chief complaint was that in a classic bait-and-switch maneuver, we had used an attractive female to recruit him and then stuck him with “some dude” for the whole day. Another turned the testing room upside-down during a break, going as far as taking all the latex gloves out of their boxes and strewing them around the room. I returned from the bathroom greeted by a sea of blue hands and my participant in silent protest.

For the most part, though, the men I met wanted to engage. The challenge often became getting them to talk less so that we could finish our sessions in the allotted four hours.

Throughout the two years I worked on the study the main reasons I kept hearing for why these men were getting sober were to avoid jail time, qualify for housing programs, and to rebuild ties with children, wives, parents, and friends. The ones that had made it past those first sober months, enduring setback after setback to achieve extended sobriety and stability, seemed, at least to me, to have figured out that last part.

One of the pleasant byproducts of being around the clinic was making small talk with past study participants. These encounters were usually brief–a few cordial words spoken in passing–but reminded me of the peculiar camaraderie that fueled the place.

The last time I saw John, though, he wasn’t doing so hot. While waiting for another participant, I noticed him slumped over a chair in the waiting area.

“How’s it going?” I said, expecting a flash of the patchy grin I had become so accustomed to seeing.

“Oh…hey…man,” said John, not taking his eyes from the floor.

The larger than life man I had gotten to know all those months ago now looked crumpled and nervy. Sweat poured off his forehead onto his hands, which he was rubbing together in an effort to suppress the tremors that rattled them–a common sign of opiate withdrawal. My participant arrived and all I could do was tell John to take care.

“Uh…yeah…alright man,” he said.

Seeing John in that shape reminded me of life’s ability to hit you on the head, seemingly out of nowhere, and knock you on your ass. It happens to us all on occasion–the unexpected loss of friend or loved one, stress at work, a breakup. But for the recovering addict the blow is somehow harder, more devastating. You wonder if they’ll be able to pick themselves back up.

Thankfully this works the other way too.

A few weeks after my encounter with John, I run into another former participant, Mike. I remembered Mike for his blank stare and monosyllabic answers. I recall asking him if he uses nicotine and his deadpanned reply of “No,” while I watched wisps of dipping tobacco drip from the corner of his mouth. There were times during our sessions together that I wondered if he was even aware of my presence in the room.

Today Mike is an entirely different person. Our eyes meet and he smiles.

“Hey, great to see you, man. How’s that study of yours coming?”

“We’re chipping away, analyzing the data,” I reply. “What have you been up to?”

Aside from the knee replacement he needs and the extra weight he needs to drop for the surgery, he tells me he’s been doing really great and has started selling peanuts two days a week at the hospital.

“How’s that going?” I ask, still surprised by the awakening I’ve witnessed.

“It’s good for me,” Mike says. “It keeps me connected.”

Citations:

1. Holt-Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk: a meta-analytic review. PLoS medicine, 7(7), 859.
2. woolleylab.ucsf.edu
3. McGregor, I. S., & Bowen, M. T. (2012). Breaking the loop: oxytocin as a potential treatment for drug addiction. Hormones and behavior, 61(3), 331–339.

[The names of patients have been changed and certain details have been altered or omitted to protect their privacy. All study participants provided informed written consent in accordance with the guidelines of the University of California, San Francisco. The opinions expressed in this article do not represent those of the Department of Veterans Affairs.]