IV Drug Abuse: Inside the Clinic

PT listens as patients discuss addiction, AIDS and the promise of a new life without drugs

Harlem Hospital Center

Harlem Hospital Center occupies an architecturally diverse compound on 135th Street and Lenox Avenue in New York City. Although sizable, the 720 bed hospital is virtually alone in serving the medical needs of a community of approximately 500,000. And this is no ordinary community. Since the mid-1980s, the drug problem in its streets and tenements-always a powder keg for health and public safety-has grown geometrically worse. The well-documented crack epidemic has exhausted police, social services and health workers, but it's consequences are many, and not immediately obvious.

Some months after crack first appeared in New York nearly 10 years ago, police began to see a huge rise in the number of heroin arrests. Addicts would often turn to heroin, an opiate comparatively out of favor in Harlem since its hey-day in the mid-'70s, to ease the horrific edges of a crack binge. Dirty needles were shared for the injections among many users in the condemned houses and abandoned lots littering the East Side. As a result, the HIV virus, which causes AIDS (also a newcomer to the inner-city in the early '80s), was given an ideal environment in which to spread.

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An already badly outnumbered and overworked staff at Harlem Hospital Center was soon forced to revamp their substance abuse program when a random sampling of heroin and crack addicts revealed an alarmingly high incidence of HIV infection. Suddenly, the clinics had to cope not only with the users who sought treatment, but also with the wives, husbands, lovers, and children of these users who were infected by HIV in the womb or through sexual contact.

Dr. James Curtis, director of psychiatry at the hospital, directs the operation of the four IV-drug-use clinics in Manhattan. "Without intervention," Dr. Curtis says, "any addict told that he is infected with HIV may well become desperate and possibly go on even more destructive binges, affecting his loved ones and their loved ones in turn. The clinics are very much on the front lines. We very often must deal with those who have simply run out of resources to live a life on drugs, and by that time, they're lucky if they can make it here given their mental and physical state."

It is Dr. Curtis's and the clinical staff's precarious responsibility to offer counseling to these people, to establish their medical condition and convince them that life without heroin is better, even in the face of a deadly disease for which there is currently no cure.

PSYCHOLOGY TODAY received special permission by Harlem Hospital's directors to attend this group-therapy session. The following is a direct account of remarks offered by patients of the IV-drug-treatment program conducted by Dr. Curtis's associates, Dr. Michael Scimeca and Dr. Gopal Ram. The names of the patients are fictitious.

"I was told three years ago that I was HIV positive," said Mary, a forty-year-old mother of three daughters, ages 2 to 12. Last January, Mary began to show the first signs that her immune system was rapidly breaking down. Ordinary colds would last weeks ... then months. During the fall, her T-cell count, a prime indicator of her body's ability to fight infection, had plummeted from a relatively normal level of 1100 to below 200. Her youngest was born with AIDS in 1991.

"I'm scared all the time, but not of getting sick. I live with feeling sick. Being sick is as much a part of me as my arms and legs now. I'm scared for my family. When I have to go to the hospital, what will my daughters do? I don't have no insurance to help them, not to mention the medical costs of having me on my back. I know that they will line me up and say that I'm just another dope fiend or crack head. And I'm not. I've been straight for seven years now."

"What makes you think that you'll be treated so badly?" asked Dr. Ram.

"Now come on. Someone walking into a hospital with no money is going to die from AIDS one hell of a lot quicker than someone with a big check book. When I delivered my baby, I nearly died in the emergency room before I could get close to a doctor."

"I don't know how to reassure you about that," said Dr. Ram. "I cannot speak for those who delivered your baby, but we certainly do what we can in the facility at Harlem. I'd be lying to you, though, if I denied that communities have only so many resources to help people with, and in many ways, doctors are as puzzled about AIDS as you are. But it is similar to all other diseases in that how you act and how well you take care of yourself has a tremendous impact."

"How many of you here are HIV positive?" asked Dr. Scimeca.

Nine of the 12 members of the session raised their hands.

"I know that some of you are taking medication. We have been distributing AZT from this clinic for years now. Do you think that the medicine has helped?"

"I can't sleep at all since I tried it," offered a woman staring into her folded arms. "I can't get no one to help me get to sleep. And you know I've been to see you about this before Dr. Ram."

"Helen, I know you can't get to sleep, and you know that we have been trying different ways of helping," Dr. Ram replied. "AZT has a different effect on each patient, but I think your sleeplessness has more to do with your being depressed than with the medicine you're taking."

"To hell with that. And why shouldn't I be depressed?" Helen began to raise her voice. "There ain't no professionalism here. Where am I supposed to go..."

"What happens when you try to sleep?" asked a man to her left.

"I get these attacks. I feel my head pounding. Something hammering away. I sweat and shake all over till the whole bed's movin'. I just have to get up ... have to get out." She began to cry softly. "I'd give anything to be able to shut my eyes."

"The group is one of the best ways for people, especially people with little or no other emotional support, to cope with this entirely new life," Dr. Curtis reports. "One important thing to realize is that these people have spent a life of secrecy. Their abuse of drugs, usually more than one at a time, is almost always a shadowy affair, kept hidden from friends and family until the abuser's life simply disintegrates from the strain. Yet the secrecy continues even after family and friends are no longer there.

"The introduction of AIDS into the community made secret drug use even more deadly than it was previously. We try to convince newcomers that it is imperative to be tested, not only for them but for their partners. Additionally, we encourage all to discuss their HIV status within the group. Of course, this means breaking the powerful silence and ignorance which has ruled many of their lives. It comes slowly."

"AZT scares the hell out of me," said a man in his late twenties sitting off to the side. "Between the methadone to kick the heroin habit and AZT, life's a joke. I can't hardly gather the strength to get up in the morning. I can't taste my food, or smell, and my body hurts so much that I just want to forget the whole damn thing and give it up."

Many in the group looked up from the floor at the mention of this and nodded in agreement. "I mean, how sick do you have to be to get well?"

"I've been medicating myself since I was thirteen," interrupted Helen, an ageless woman with powerful shoulders that poked from her sweater. "I made more mistakes than I was due. Now I've got AIDS and I'm gonna die. Why should I go on medicating myself with AZT until it's all over. I'm no addict anymore. To me, drugs are just another way of keeping me quiet. Always have been. I don't want those last few years if I just go on sleeping for fourteen hours a day and feelin' like sleeping for the other ten."

"I can't sit here and tell you that AZT will be your miracle drug," said Dr. Scimeca. "One of the things you've got to face is that this medicine is a matter of risks and benefits. AZT helps to stave off the infection, but it has some nasty side effects. You have to decide what is going to help the most. No one's going to make you take it, and in some instances, it only helps to a marginal extent. But without it, I know the chances of you just ... deteriorating are considerably better. It's a matter of weighing your fears as much as anything else."

"Fears! HIV is the only thing that ever scared me in my whole life," said Jane. "I never have found a way to deal with it. I've been toughing it out with men my whole life. Ain't none of them ever scared me. My father, my husband ... they were burning up with anger their whole lives. They beat me, twisted me around, and then they just died. But they were simple. I knew how to beat 'em. AIDS is a woman to me. It's trying to fight something inside. Where do I start?"

"Jane, how long have you been straight?" asked Dr. Ram.

"Fourteen years."

"How many people do you know who were addicts fourteen years ago are alive today? Not a whole lot I'd imagine. By accomplishing that, you are a success story. You already have resources to fight."

"There are some things that you can't fight against, though," offered a man sitting near the doorway. "I'm an ex-police officer, ex-drug addict, and ex-con. Like everyone else here, I've done wrong to myself and my family. I've seen drug issues from all perspectives, and after I got clean, I thought I could make a difference as a drug counselor at school. When I began speaking to kids, I started to feel important for the first time in my life, as if all the shit I'd gone through meant something. But I was let go a couple of weeks after my boss found out about me being positive. Now here I am. I may not even be sick for ten years but I can't get a job. I'm branded as something that no one can even get close to, much less give a job to."

"It's true", said Mary. "Friends I'd had for ten years just about left town when they found out. And I can see now what they were thinking. I mean, my God, what with HIV, tuberculosis and everything else, it's a wonder people open the door in the mornin'."

"But Mary, you're talking about HIV as if you can give it to someone at work if you look at them funny," said Earnest. "I got it from sticking needles in my arms, and no one who ain't an addict has to sweat over catchin' it that way. To me, AIDS is just another reason for prejudice. That's all. It doesn't matter if you've been off drugs thirty years. To the world, you're still a junkie. And if you have HIV, no matter how or why, you're just a germ and that's reason enough to hate you."

"So what if that's true? I've been living with prejudice all my life," said Janice, a heaviset woman from the back row. It was the first time she had spoken during the session. "It's still just hate. And your choice is the same. You either let it get you or you don't. And believe me, feelin' hate all the time ain't going to make you feel much better when the time comes to be sick or not. This is my family," she gestured to two young women just behind her. "I'm lucky to have them. When I don't have the guts to fight, they do it for me."

"I watch my baby getting sicker every day," said Mary, staring into a cup of coffee. "I wake up every day knowing that I didn't just mess up my life, but that I poisoned my baby. I cry every day for her, and I want to give up half the time, but I have two other girls to think about. Now if I can deal with that, you can deal with findin' a job."

"Yeah. You do have a family," said Earnest. "But what if you don't. What the hell are you supposed to do if nobody believes in you. I lost the last of my family three years ago. I have to fight for me now. And who can believe doctors? What does anyone who don't have HIV have to tell me? As if the man behind the desk is going to give a shit if I live or die. It's a paycheck to him, and you're all fools if you don't know that."

"Ernest, none of the staff here are getting rich, believe me," said a nurse standing near the doorway. "If we wanted a fat paycheck, there are other ways..."

"You all go to families at the end of the day though," Ernest spat. "You go home, eat a big dinner, watch TV. I'm here with nothing, do you understand?"

"So you're pissed," said the man next to him. "So what? What do you want the nurse to do, bleed for you? If you're really sitting there waiting for this woman to solve your problems, you're gonna be pissed off till you die. If that's what you want, go ahead, but don't be telling anyone here that they're fools."

"That's real easy. Just go off and figure shit out. No help. No family," Ernest said.

"You find some family then," said Janice. "You stop being hurt all the time and take a look around ... how 'bout at the people in this room. And you know," she smiled, "it seems to me you always left here with something, Earnest."

"Besides the coffee," Mary said.

Figures vary among the four clinics that Dr. Curtis directs, but approximately 60 percent of those who appear at the clinic doors in Harlem are HIV positive. "And we have the facilities to see just a small fraction of those addicts who would accept help," says Dr. Curtis. "At least in the short term, the medical community is perplexed in dealing with HIV. Any hope simply lies in stopping the spread. And distributing information is not enough. A solution will only come from a comprehensive network of social services. It is imperative that these people not be left to die alone, because they won't. Unless we intervene, their families, and others, may well follow."

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