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"It's Just Part of the Game"
Serenity woke up under the I-90 Copley Square bridge overpass in Boston to the uncomfortable sensation of Oscar's calloused hands closing in around her neck and squeezing. She couldn't breathe. He whipped her onto her back, jumped onto her chest, and pinned her down.
"I know what you're doing, bitch," he screamed. "You're making eyes at those dudes across the way. And I'll fucking kill you. I don't care. I'll go back to prison, because in jail I'm somebody, and out here, I'm nobody. Keep fucking with me bitch!"
When he let up his hands slightly, she screamed back at him. "What the fuck is wrong with you? I wasn't doing anything. I swear to God. You know I can be a flirt, but I swear to God I wasn't doing anything. I don't know if you need your meds or something, but you're having a lot of angry outbursts for nothing, Oscar. I didn't do nothing. You know I wouldn't. We're together. I'm not playing with you."
The next morning, she took her backpack and rolled out from beneath Oscar's heavy arm. She crawled out from under the bridge where they had been sleeping the last week — Oscar had been too jealous to allow them to continue staying in the homeless shelters — and made her way to the church in Copley Square. She had scraped together some money last night for their early morning fix, and she sat down in the cool darkness of the early summer morning, prepared herself some heroin, and prayed to God. Send me back to jail, God.
I first met Serenity, a forty-three-year-old white woman originally from a small town in Vermont, in 2010. She had come to Boston eight years earlier seeking recovery from heroin addiction. After several month-long stints in and out of rehabs and detox programs, and after she had graduated from, failed, or dropped out of these programs, she had stayed in Boston. The drugs were plentiful, and to go home would have been to return to the source of her ongoing pain and grief. She could never stop blaming herself for missing the signs that her son was being sexually abused by his grandfather. She would sometimes hear his six-year-old voice innocently asking her, tormenting her, "Why did grandpa make me put his pee-pee in my mouth?"
There was something safe about being in jail, the Boston jail formally known as the Suffolk County House of Correction (figure 1). Maybe it was just that she felt safe from Oscar's hands on her neck or the constant threat of having her belongings stolen by other people in the shelter or on the street. Perhaps, most importantly, she felt safe from her own destructive drug use. Upon admission, users were forcibly detoxed from opioids. Like many other women, the longest amount of "clean" time she had ever accumulated was when she was incarcerated. Even though there was a fairly regular supply of heroin in the jail, she didn't have the money, or the desire, to use inside.
Serenity tells me more when I see her in jail: "I feel calm here. It's crazy. I'm very institutionalized. I'm afraid that if I leave here that I'm just going to be in the spoon [using heroin] by noon."
As a fledgling medical student in the late 2000s, I became fascinated by the questions surrounding why and how women like Serenity had taken up heroin, or why a heroin habit had taken up in them, and their ongoing struggles with using and quitting drugs. When Serenity wasn't incarcerated, she was enrolled as a patient in the Lemuel Shattuck Outpatient Buprenorphine Opioid (OBOT) Clinic in Boston, Massachusetts, one of the community treatment sites where I conducted ethnographic fieldwork (figure 2). There, at weekly appointments, she received a medication called buprenorphine-naloxone (Suboxone) to keep her cravings for heroin at bay. Prescribed by certified primary care doctors, psychiatrists, or addiction specialists, the medication, if taken regularly, could eliminate her cravings and keep her off more dangerous opioids like heroin or fentanyl.
Yet taking buprenorphine couldn't erase the abuse Serenity's children had suffered, the neglect she felt that she had subjected them to, or the guilt that she felt for abandoning them in search of drugs. "Is grief a health condition?" she asked me once, in tears. Serenity would log onto Facebook every chance she could get — on the computers of homeless shelters or job readiness programs or at public libraries — in order to send them messages of love, birthday greetings, and other small reminders that she was thinking of them from several hundred miles away. She was thankful for access to medication, but it couldn't solve her problems of joblessness, homelessness, or multiple-drug-resistant HIV. What it could do was prevent her from being in opioid withdrawal (commonly known among people who use drugs as "dopesick" or simply "sick") and keep a needle out of her arm for that day, or at least for a couple hours.
As a medical student, I saw patients like Serenity in the community clinic where I was completing my third-year medical clerkship in the Roxbury neighborhood of Boston. Many of the patients there struggled with substance use disorders, mental health conditions, and other chronic diseases associated with poverty and lack of access to steady healthcare. Some patients wouldn't show up to their follow-up appointments and were dutifully marked "no-shows" by the clinic's secretaries. The office would call their phone numbers, which were often not in operation, as many patients lived month-to-month and were unable to keep paying their cell phone bills. Several months later, some would re-appear saying they had been incarcerated and then released without medications or any assistance. They were arguably worse off after these stints in jail. What happened to them inside? What happened to Serenity as she was incarcerated over and over again, and how could she ever break this cycle?
Getting Wrecked: Women, Incarceration, and the American Opioid Crisis explores what happens to women with opioid addiction inside the prisons and jails in Massachusetts and in the aftermath of incarceration. I wanted to understand this world that was geographically so close to my life at Harvard Medical School in Boston and the Department of Anthropology across the river in Cambridge and yet somehow had such very different lifeworlds and experiences. Thus, I embarked on two years of difficult — at times, seemingly impossible — ethnographic research in the Massachusetts prisons, jails, and drug treatment community to understand how the prison had become a centralized node in the increasingly fraught politics of addiction treatment and recovery. During this time, I conducted semi-structured interviews with over thirty women at these three sites and followed them longitudinally forward as they moved in and out of jail, prison, and home.
Rooted in the methods and theories of sociocultural anthropology as a means to understand how inequality becomes embedded into physical bodies, I sought to explore how medicine, punishment, and drug use became bound up in politics and in the realm of the social. I learned, for example, that my ability to treat addiction effectively would entail addressing far more than what was at my disposal in the clinic as a physician and much more than any single prescription. I could give Serenity a medication to take away her cravings, but I couldn't stop the worlds she lived in from harming her or the ongoing harm she did to herself. My ability to effectively help someone like Serenity escape the cycle of problematic substance use lay rather in understanding and addressing deeper structural and social inequalities, deep-seated social mores and stigmas, and the punitive policing and legislation that contributed to her frequent bouts of incarceration.
Opioids, pain pills, heroin, and fentanyl seem to have dominated news cycles in the last several years as overdose deaths in the United States have reached new heights in fatalities, with over seventy thousand overdose deaths in 2017 noted by the Centers for Disease Control, with the numbers still rising or showing little sign of abating. While opioids are not a new drug, there is newfound and rising awareness of their ubiquity and possible harms, as they increasingly are seen to affect white, suburban, and rural households. I use the term American "crisis" here (as opposed to other frequently used terms like "epidemic") in order to highlight this renewed attention and opportunity to address and intervene on the deaths of a structurally vulnerable group within our country. These deaths are preventable, thus tragic, as a result. But there can be significant harms besides death.
In the pages that follow, I explore the experiences of women on heroin and other opioids who are subjected to everyday violence, oppression, and inequality from many realms: within and from themselves, within their relationships, within their communities and within the judicial system. I followed them as they sought treatment in the community, as they tried to care for themselves in the prison and jail and after release, and as they cycled in and out of various regimes of care intermingled with punishment. These women have struggled mightily with self-care and caring for others throughout addiction, recovery, and incarceration while navigating various biochemical, spiritual, and socially prescribed forms of dependence and freedom.
Anthropologists Eugene Raikhel and William Garriott suggest that we might be able to learn much more about drugs, drug use, and historical and current moral orders by tracing people over time and across space and their substance use via addiction trajectories. As they write, "Addiction cannot be reduced simply to a biological condition, a social affliction or the symptom of some deeper malaise. Rather, it must be seen as a trajectory of experience that traverses the biological and the social, the medical and the legal, the cultural and the political." This is where anthropology's methods — of close and deep ethnographic investigation over time — can elucidate the complexities of a deep social problem like the American opioid crisis. Following the paths of women who used heroin, I kept finding myself at the gates of the local jail or the state prison. Reckoning with women's drug use in America meant reckoning with the carceral state.
This book takes readers through the epistemological orientations and practical applications of the treatment of women who use heroin or other opioids as in criminalization has become one of the primary social responses to the problem of opioid misuse and addiction. In the tradition of critical ethnographies of drug use that draw attention to the uneven playing field upon which the poor precariously build their lives, I use ethnography to interrogate what it means to treat others on a variety of registers. On the broadest level, how do we enact policies or legislation to treat the social problem of drug use? Do we have any means to understand the realities of these policies and practices when they travel behind bars? And what does it mean for the women at the center of such sociopolitical debates, as they dream of better lives for themselves and their families?
* * *
Heroin had been a presence in Boston for decades before Serenity found herself running its streets in the mid-2000s; it's presence dates back well before the current iteration of an American opioid crisis that swelled again in the mid-1990s. Like other large urban centers in the northeastern United States, Boston struggled with the problem of drugs and drug deaths during an early wave of heroin use in the 1960s and 1970s that was also called an "epidemic" at the time. In this context, President Nixon had famously declared drugs "America's public enemy number one," setting off decades of complicated and punitive waves of legislation around heroin, cocaine, and marijuana. And like other major urban cities, Boston also struggled with crack cocaine in the 1980s and waves of other substances including amphetamines, synthetics, and problems related to licit substances such as alcohol and tobacco.
In the summer of 1977, one of my informants, Jean, found herself scared and alone — only 14 years old — in the middle of Boston's infamous "Combat Zone," a small cluster of streets near Downtown Crossing and the Chinatown district. The Combat Zone ate up everyone who came to play. It was an equal-opportunity space for destruction or bliss. The Pussycats, the Naked I Lounge, and the Glass Slipper all promised ephemeral or forbidden pleasures. During its worst years, a Harvard football player was stabbed to death in a robbery gone awry, the House Ways and Means chairman Wilbur Mills was seen dancing onstage at a burlesque house, and a Tufts associate professor of anatomy murdered his mistress. In a profile of the so-called Combat Zone, two Boston Globe reporters noted that places like the Combat Zone always seemed to exist in big cities "as long as society, and life, has the ability to maim, and then ostracize the maimed, there will be a place for the maimed and the ostracized ... a place where all acts and people who commit such acts, rejected by society, congregate."
It was here that Jean first tied a belt around her arm and experienced the rush of intravenous heroin. Like many other teenagers, she had tried a couple of drugs before. When she was ten, she would occasionally sneak her grandfather's beers from the refrigerator when her mother wasn't looking. With an older boyfriend, she had smoked weed and even done quaaludes. But she had never done heroin, also known on the street as dope, H, smack.
Jean had recently run away from home, dreaming of getting into the fashion business. The reality she landed in was dismal and couldn't be further from a life in fashion: she was sleeping in the park and begging for food and spare change. One day, Jean was panhandling in a corner of Boston Common near the subway when a group of teenage girls approached her asking if she wanted to party with them. Too young to be properly scared, she followed them into an alley off the intersection of Beach and Essex Streets in Chinatown in pursuit of a good time.
The girls trooped down into a basement room that was dark and full of broken beer bottles and dirty mattresses on the floor. There were small clusters of people in various states of euphoria and consciousness lying around. Sugar, the ringleader of the group of teenagers, told Jean to offer up her virgin arm in the eerie candlelight of the basement. "It's fun," she said. "You'll like it."
Someone tied a belt as a tourniquet around her skinny arm. They told her to squeeze her fist tight and shut her eyes. Sugar saw a flash of blood return and knew she was in the vein, then she emptied the chamber into Jean's arm. Was it over, Jean wondered? She looked down at the needle in her arm and felt a wave of nausea rush over her. Then everything was black.
"Where's the bathroom?" she managed to ask. She ran toward the dirty toilet in the dark shooting gallery, hugging the bowl, her stomach churning in distress.
Jean was confused, wondering to herself: "What the hell? Why do people do this shit? Everyone else seems to like this, and I'm throwing up." Jean thought maybe she got a "bad bag," so the next day, she tried it again. This time, she told me, she became "hooked" on the feeling. The rush of physical and emotional relief it provided was like nothing else she had ever experienced in her life. Since Sugar had offered her a place to stay, acquiring and using heroin several times a day simply became part of their daily routine together.
Three weeks later, Jean recounted, "I started waking up craving it." She had no idea that she would become physically sick if she didn't have it, that she was now physically dependent on opioids, her brain chemistry already acclimated to the presence of the substance. Now her body would be wracked with the anxiety, nausea, and flu-like pains of opioid withdrawal if she was unable to access heroin.
In the beginning, it was hard for Jean to hit her own veins. She had to pay people to shoot her up by giving them some of her dope. But as generous as heroin addicts can be, sharing dope gets old. It always creates tension: "Who used too much?" "You didn't leave me any." The dope becomes all-consuming. Jean soon learned to find her own veins.
Money in the Combat Zone came fast and easy. The drugs were plentiful. Jean was able to wield her childlike, light-skinned African American features to chat up older men who would take care of her, set her up in apartments in Dorchester and Roxbury that they kept on the side, hidden from their wives. She was able to do it all: buy nice high heels, shop, shoot dope, go to a different club every night. These men paid for her car and her rent and gave her a little spending money on the side. But they were respectable, middle-class black businessmen in Roxbury with families, and they didn't like the idea of dope. Dope was dirty. They liked a little bit of danger but not that kind of danger.(Continues…)
Excerpted from "Getting Wrecked"
Copyright © 2019 Kimberly Sue.
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