“It Was Not an Unexpected Death”
:An Account from the Opioid Epidemic
Starting in 2021, drug overdoses have killed more than 100,000 people in the United States every year. While politicians used the crack and heroin epidemics of the late twentieth century as a pretext to introduce mass incarceration, mandatory minimum sentencing, three-strikes laws, and racial profiling, all of which disproportionately targeted Black and brown people, so many white people have died of overdoses over the past decade that the rhetoric around the opioid epidemic has changed dramatically. Today, even racist conservatives acknowledge the opioid epidemic as a social crisis—but how to address it remains an open question.
Anarchists fight against the conditions that give rise to drug addiction, the ways that the authorities take advantage of addiction to inflict additional damage on communities, and also against addiction itself. In the following reflection, Angustia Celeste revisits harm reduction strategies through the lens of personal tragedy and grief.
Art by Rena Yehuda Newman.
It Was Not an Unexpected Death
When my best friend died of a fentanyl overdose seven years ago, it was not an unexpected death. It was the statistically probable outcome of her seventeen-year-long struggle with addiction, given the increasingly fatal turn of the opioid crisis.
In our youth, she and I imagined ourselves living outside of societal norms, but with her death, she landed solidly in the middle of the bell curve.
The fact that I had anticipated this did not soften the grief. There are recriminations and shortcomings that you only add up in hindsight. Once I finished considering what actions I might have taken to try to shift the course of events, or at least to take advantage of our time together—something that, in our youth, I had imagined to be infinite—I began to reflect on what the collective “we” did and did not do. I eventually arrived at the truth that my loss was not just an individual one: it was generational, determined by forces greater than those I initially considered in my despair.
I have a certain familiarity with death, both personally and professionally. Someone I care about has died every few years since I was thirteen. Yet grief is something that gets harder with each turn, not easier. This loss cuts back decades into my foundling years, as my friend played a significant role in crafting my worldview when we were teenagers.
Antecedence
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Before I was politicized, she helped me find comfort in the existentialists and the artistic nihilism/hedonism of the Beat generation. Jettisoning the certainty of a higher power for the unknown abyss of human potential made sense to me. With no predetermined destiny, we were to live out our lives in trajectories of our own design. Success, failure, and how we realized our potential were not determined by any deity, but by the opportunities and oppression of our society. This was a different kind of social determinism. It was freeing because of my own privilege, and terrifying because it did not offer the comforting certainty of any specific outcome.
At her memorial, her father put out an archival display of her journals. With horror, I watched our friends and family read very private things about our adolescence. The discomfort was my own—I think she probably would have approved. Her family, to their great credit, had been forthright and honest about her death. Her obituary began poetically with the words, “Succumbed to addiction at 35.”
Her father, clearly still struggling with the loss, pulled me aside and asked me for the origin story of her addiction.
I told him what I could about when we started using heroin, but I did not touch upon why. He wanted to know about the why. Why had we felt so untouchable? Why hadn’t we known it was dangerous? There is a certain cruelty to such questions asked decades after the fact.
I know that we started something that became a bleak mythos and, eventually, a death cult. It began when I was thirteen, she was fifteen, and it was all theoretical: the dark literary proclivities, romanticizing the edges of human experience, the search for the profane and the ecstatic. It was initially a joyous endeavor, an exploration of the unknown, not a doubling down on pain—not at first.
I was struck by two things at her father’s question. First, I was all of nineteen when we began using heroin, and there were many things I had not known about addiction. Second, I had known that I didn’t want to feel anything, and narcotics were a method available to me to achieve episodic negation.
Negation
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As to why I didn’t want to feel anything, without delving into traumatic experiences, I think the ways that we are taught to avoid pain in Western society are deeply damaging. The antidepressants and antipsychotics are intended to achieve a dampening of both the dark and the light, the highs and the lows—evening out life’s extremes to an acceptable middle ground.
Put on medication at thirteen, I learned to seek balance by using a cocktail of neurochemical inputs to manage my internal emotional life. Homeostasis wasn’t something you created by intentional practice in the external world; it was something chemically concocted from within. These drugs did quiet my mind for a few years. They also taught me that the way to deal with pain was to seek a state of hazy indifference. The things happening to me didn’t matter if I didn’t feel their full impact.
Heroin was a reasonable transition between psychotropic drugs and the more varied coping mechanisms I would learn in my mid-twenties. It is a method of dealing with pain that creates more harm, but also provides some emotional reprieve if you are in a very dark place. I don’t regret my use, but I was insulated from the worst consequences of it by class and race privilege. Conversations about drug use must include bodily autonomy, while also addressing the failings of negation as a long-term redress for trauma.
I quit using heroin at twenty-one after I became politicized and was able to contextualize my pain within a larger societal framework. I discovered perspective. Movement work made me feel less alone, and I found reasons to live beyond myself. Organizing helped me develop coping mechanisms and skill sets I had not had as a teenager.
Admittedly, I drew the long straw. I was lucky. This fortune was something that became increasingly apparent to me as I began to work at the needle exchange. If I didn’t know the dangers at nineteen, I had certainly discovered them by twenty-one. When I grew tired of being party to the extreme harm I was facilitating for the friends I used with, I stopped injecting.
At that same time, her father used to drive into the city to get suboxone that I had purchased off the black market to help her taper her use. Thus began the next period of trial and error, of bearing witness, the next decade of harm reduction. She never quit for very long, but I won’t say that we failed. We achieved something together—we lengthened her life. Only she could define the meaning of that.
But I understand now, in a way I didn’t before, the limitations of our approach.
Harm
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In the early 2000s, we wanted to propagate the idea that IV drug use didn’t have to be a death sentence if you used clean needles, if someone showed you how to administer Narcan and you kept some at hand. We thought that if you met people where they were at, if you provided a space to discuss addiction that didn’t require abstinence, you could provide people with an eventual exit. If you got lucky, if your source was pure and your practices rigorous, you might be allotted the time you needed to really get clean one day.
It’s not that people didn’t overdose back then—they did. We had friends that died, but not at anywhere near the current rates.
Not everything had fucking fentanyl in it. Xylazine had not yet made an appearance. It was possible to pretend that in a few years, one might not need today’s crutch. Time provided us with tentative hope that with compassionate services, understanding friends, and a bit of breathing room it could be possible to figure out how to move past mere survival.
I eventually quit social work for sex work, and then, after a decade, I left that for the medical field. These various professions share a common labor: taking on other’s suffering. I have been party to many confessions and come to understand the myriad ways people try to survive our bleak consumer culture.
To maintain trauma stewardship, you have to cultivate a certain emotional distance, and this distance is perceptible in the dynamics that emerge within even the most horizontal solidarity model. Distance is all good and fine when the support you are offering is solely material—but what happens when the support people need is emotional?
Don’t get me wrong, material support is important. Thankfully, there are still needle exchanges, there are now fentanyl/xylazine test strips, there is suboxone to manage your use, and if you are fortunate, you might live somewhere where there is a monitored safe injection site. If you are especially lucky, you might even live somewhere that offers legal “safer supply.” Methadone treatment is one of the better ways to manage opioid use nowadays (though recent formulary changes have left many who rely on it struggling with relapse, as highlighted in the podcast Crackdown.)
I support all these interventions. But I also have to say that—if the goal is living and not just surviving—they don’t really get to the heart of the matter.
Harm reduction begs a question that it often does not address. Why do so many people feel indifferent about being alive? Meeting people where they’re at doesn’t mean you shouldn’t try to discuss and change their emotional and spiritual position, if you can. Discussing the insanity of negation is not being judgmental, it’s just being honest.
Lethe
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There is a cult of death that revolves around the hopeless cycle of addiction—and that spiraling trajectory is not as long as it used to be. Statistically, if you are using, even with test strips, even with clean needles, even with Narcan, even with management of use via suboxone, you are courting death. It is this drive to oblivion that I want to discuss.
In the other kinds of solidarity work I do, the desire to survive is very strong. It compels people to cross continents, to leave everything they know just to find a safer place to be. It is not as difficult to reach out in solidarity to people who desperately want to live. However, it is difficult to do so across the river Lethe, the river in Hades that the dead drink from to forget.
I am the way into the city of woe
I am the way to a forsaken people
I am the way into eternal sorrow
One of us wrote those words in a letter during a second period class at some point in the mid-1990s when we didn’t yet know how lost we would become and the ways we would abandon one another along the way.
I am touched both by how melodramatic we were, writing derivations of Dante’s Inferno to each other, and how deeply we felt, already, the suffering of the world. She did not dismiss the fundamental questions and ethical qualms I felt about human nature and the darkness of society. She was the first person, outside of my immediate family, to take my internal emotional life seriously and cultivate my intellectual proclivities.
When I really pause to consider that, it takes my breath away. That intimacy was hard to maintain through the years because it is hard to reach out to those mired in addiction, the trajectory of the illness is ever inward. In my early thirties I hit an emotional wall; I could no longer meet her where she was at anymore. I had tried, and it hadn’t worked.
Cessation
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I remember the day our friendship ended. She probably didn’t realize it at the time, or perhaps ever, but that day was our last chance to renew that bond, to strengthen ties, to find a reason to be in one another’s lives in a meaningful way. We were in the same city for once and made plans to meet up for lunch. I took time off between seeing high-end clients downtown and sat in that diner for two and a half hours waiting. I figured she was using again, although she didn’t say. I figured she was trying to cop, and it was taking longer than expected, but she didn’t let me know why she was running late or if she was coming at all.
I couldn’t linger any longer over coffee wondering about the state of our friendship. As far as I could tell from our correspondence, she didn’t remember anything about my life anymore, where I lived, how things were with my kids and chosen family, what I was working on politically. She wasn’t present. She was wrapped up in mythos about heroin, art, literature, and aestheticism, and there was a level of self-involvement and dis-ease that had become bleakly narcissistic.
I left the café. When I got to the train platform, I saw that she had finally texted. She had arrived three hours late. That was my moment, my opportunity to forgive, reach out and make amends for all the things we hadn’t said to one another, all the things we hadn’t done. But I was angry, angry about the last couple years, about the shambles of our connection, about how selfish her addiction had made her. I was exhausted by cumulative losses and I couldn’t continue to invest in people in my life who didn’t reciprocate. I didn’t text back.
I still saw her father, mother, and brother on occasion, because I coparent with her cousin. I continued to get news of her life, but we never saw each other or spoke again. Five years later, she died, without our ever speaking about what had ended our friendship. Death became the final arbiter of our conflict. I was left to argue with myself about the rightness of the choices I had made.
I was being protective of my time, my energy, and my heart. But I was wrong. The continuation of our friendship probably wouldn’t have changed the outcome, but I missed those last five years. I never got to hear her version of things. We didn’t correspond, we didn’t share stories about our lovers, travels, writing, or artistic endeavors. Knowing I would lose her and she couldn’t be present, I gave nothing more and I got even less. It didn’t soften the loss when she died—it only made the grief worse. I couldn’t say I had done everything I could have, because I hadn’t.
I guess I imagined, until the day I got that phone call, that we would reconnect one day when she figured out how to get clean without me. That was the ultimate failure of my harm reduction practice, my empathy and my earthly obligation. I took the symptoms of her addiction personally, let them drain me dry, estrange us. Someone I loved had been in pain, and I had turned away.
Loss
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It is said that no one gets clean until they themselves are ready. But this saying leaves out something essential. Love, family, friends, and social connections all provide a positive impetus towards the desire to be present, to live life, to bear the cost of trauma. These tendrils connected to our heart and soul make suffering worth it. These are the things people find reasons to live for.
She died alone, on her knees in the bathroom of her apartment in New Orleans, kit in hand, after breaking out of the DIY arrangements she had made to be locked alone in a client’s apartment to get sober. She died, like so many, trying to get clean and relapsing. The drugs she got that day were stronger than her tolerance allowed for. There was no poetic gesture, no allegorical final words. Examining the record she left behind, it seems that her last twenty-four hours were scary, haggard, hallucinatory, and dark, filled with suffering, a desire for a reprieve, and one final go at numbness.
A few years later, her partner also fatally overdosed. When I heard about his passing, it seemed to me that soon there would be no one left to remember their life together. I thought I had come to terms with the brevity of our time upon this earth, but I hadn’t.
Amnesia
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A few times a month, when I worked the ER, I would cut someone’s homemade tourniquet off, rouse them from unconsciousness with Narcan, and wait. Wait for them to come around, wait for them to wake up, pensive and sorrowful or angry and resentful. Wait for them to inevitably tear out their IV and leave against medical advice. Or, even more depressing, they would try to leave with it in, which we didn’t accommodate. I always tried to talk people into staying to get IV antibiotics if they had abscesses, so that those won’t become septic. I would try to talk people into chatting with a social worker to see if we could connect them with rehabilitation services.
Every shift, I encountered people who had been conditioned to treat all kinds of suffering with opioids and now found that their doctors were unwilling to renew their pain medication. The rehab facilities only had so many spaces, the pain clinics even fewer. The pendulum has swung back and there is an entirely new generation of providers who don’t consider the consequences of the flawed treatment modalities of the last twenty years to be their responsibility.
The Department of Health and Human Services has had to release best practice guidelines for tapering high-dose chronic pain patients because doctors, fearing professional sanction from licensing boards, are cutting people off in unsafe ways. I try to remind providers of the historical trajectory that got us here, pointing out that commodifying suffering in this particular manner reaped fiscal rewards for those in power and that this has been the cost. Richard Sackler of Purdue Pharma, who brought us OxyContin, has now been given approval for a patent for a new form of suboxone to be used for the treatment of opioid addiction. His family is expected to pay roughly $6 billion dollars in a bankruptcy settlement in exchange for immunity from future opioid lawsuits. Slickly marketed nasal spray Narcan sells over the counter for $45 a dose, despite research showing that Narcan costs less than 5 cents to manufacture and exposing unethical profiteering. They’ve found a way to profit on both the illness and the cure—on both the living and the dead.
Many of my critical care colleagues don’t acknowledge these larger trends. When I have to, I reprimand them for their tendency to blame people for their own suffering. It is an uphill battle. We do not create spaces that are free of judgment—the emergency room is full of judgment. What is the point of saving people’s lives only to continue to burden them with stigma? Stigma still kills.
I’ve since quit the ER, after witnessing too much death during the pandemic, and now I run a community-based free clinic that embraces harm reduction. So, it seems, harm reduction still has a place in my life. I don’t want to abandon it, I just want to change its cadence.
The treatment landscapes haven’t changed all that much. I always used to wonder what the point of having an accepting users’ group at the exchange, when all of the rehab programs we referred people to were rigid and abstinence-only. We need a way to articulate sobriety as a good goal without being moralizing or punitive about it.
If trauma is the gateway drug to addiction, then treatment modalities that deal with the body’s inherent sympathetic and parasympathetic response to trauma should be part of treatment. I don’t have a clear vision of a way forward, but I recommend somatic therapies over talk therapy because treatment based on trauma response and physical recalibration makes sense to me.
I want us to talk more openly about death. Not in a harsh or insensitive way, not to shock or judge or scare people. We must not spiritually anchor our labors in darkness. But we also can’t take a neutral approach to the kinds of addiction that are a passive form of suicidal ideation, statistically speaking.
How do you qualify a death wish? Given the changing molecular structure of what you can purchase on the streets these days, can we agree that the opioids now in circulation will generally not give their user enough time to shift course? Expanding services for suboxone scripts is offering some hope to buy more time, to help people safely manage their use. But I still maintain that IV drug use is not a choice we should easily accommodate without other services. The ultimate destination for all our labors should be health—better health and a life you can show up for. Why stigmatize the symptoms and not address the real issues at hand? Housing, dignified work, social connections, a relationship to the earth—these should be the aspirations of our practice.
It is not enough to use clean needles, it is not enough to offer fentanyl/xylazine test strips, it is not enough to help manage use with suboxone, it’s not enough to provide medical supervision for maladaptive coping. Ultimately, if we don’t address the profound alienation at the heart of the capitalist system, we will be hard-pressed to convince those we love that life is indeed worth living, and worth being present for.
I remind myself every morning now, even on those mornings I would rather not wake up, that we make our amends through our actions. We reach for our highest aspirations by examining our failures. I do not think I could have brought her more clean needles; she knew where to get them. I do not think I could have bought her more suboxone, suggested a better rehab, or coordinated a plan for intervention more clearly with those who also struggled for her. We attempted some combination of all those things, however imperfectly. But there were conversations we didn’t have.
Absolution
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I think our mistake came years before, in the way we tried to delineate our feelings of difference. A life lived in defiance of norms once seemed holy to me, but somewhere in the process of jettisoning conventions and differentiating our path we ventured so far off track that we got lost. Whatever the punk gods of our youth told us, self-destruction isn’t disruptive to the social fabric—it has been co-opted. We’ve been sold. There are many things about this carceral society worth resisting, but numbing the pain keeps us far from that struggle. My friend never made it to any place of social conflict because she lost the battle with herself years before.
Forgiveness
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I forgive my thirteen-year-old self for my romantic delusions. I forgive my nineteen-year-old self for my destructive habits. I forgive my twenty-one-year-old self for my naïve belief in harm reduction practices that never got us closer to health, that just kept us treading water. The only thing I do not forgive myself for is walking away.
I should not have stepped off the platform and onto that train. I should have turned around, gone back to the café and told her that I wanted her in my life. I should have told her that I loved her, not the easy comforting kind of love, but the kind you suffer for, the kind that makes living worthwhile. Then, even if I had lost her later anyway, I wouldn’t have lost so much of myself.
You can reach Angustia Celeste here.