The Tenderloin: Substance abuse and Nate

Published on
December 7, 2010

This is one in a series of articles, running the 5 weeks between Thanksgiving and New Year's, examining the relationship between housing loss and death in San Francisco. Check out the previous articles in the series, Looking for death, and Gunpowder on the streets, and Will losing your home kill you?, and Hidden in plain sight: dying and homelessness, and Be selfish: Give a gift to a homeless person.

I offered Nate a piece of chewing gum when I first met him. His response? He pointed to his toothless mouth and said, "Hey, if I do, it won't be chewing gum any more. It'll be gum gum."

When I laughed out loud, he didn't join in, but kept his eyes looking down at some place off to the left. He did, however, smile to himself, pleased with my response.

Nate and a friend's dog

Nate had a friend take this picture of himself and a friend's dog

For a man who has no access to running water, ever, a man who works hard at recycling (and he's got the nicks and cuts to show for it), Nate is remarkably dapper. His beard is carefully trimmed, his clothes brushed clean and his hands neat. But like many people on the street, Nate can't seem to physically relax; no matter how safe the environment he is constantly vigilant. He rarely makes eye contact, his smile is fleeting and involuntary and his shoulders stay hunched. And Nate's story about how he ended up here is also in many ways remarkably similar to many others'. It's a story of sudden disruption - a financial crisis, an eviction, a job loss, a divorce, a death. A breaking-point fight with a family member.

Nate, a self-described "Tenderloin rat," talks about having trained in the Navy, working on submarine sonar systems, then coming home to be employed by his wife's wealthy family. Nate's income, his business, and his home all came from his wife's family, and Nate, in turn, passed on much of that same money to his own poorer relations. He describes the escalating tensions with them all as his wife slid further and further into serious addiction while nothing was done and no one acknowledged it. He was "expected to just go to work and act like nothing was happening." But Nate finally reached the point where he couldn't take the trauma of his wife's addiction anymore and left. But his own family, once the money flow ended, turned on him too, refusing to take him in. At this point Nate describes how his in-laws made sure Nate would never again have access to his infant son. Something in him broke, he says, "and I chose to divorce myself from society." Twenty-two years later, when he talks about his son, his eyes still well with tears. Nate's had no contact with any of them since 1988 and the hurt is visibly raw, his voice shaky with emotion as he continues to keep his gaze on that spot off to our left.

The unspoken irony hovering between us, one that we're both aware of, is the fact that Nate, himself, is now, and has been for several years, a heroin user.

So how does this happen? The cynical might say Nate was using with his wife before he left. But that would be exceptional, since even a dabbling drug user is unlikely to take a stand that would deprive him of a steady source of wealth from an enabling family. Or is it possible that Nate's story is a total distortion of reality - that his drug-using "wife" is actually himself? That's also unlikely. First, there are the visible arguments against that theory - Nate's lack of delusions, or personality disorders. But the biggest reason that theory is unlikely, even if you discount the evidence before you, is that, frankly, statistically speaking, if Nate used IV drugs in 1988 as HIV exploded through San Francisco, he wouldn't be alive on the streets today.

What's most likely, is that his story is what he says it is. So does everyone on the street inevitably use some drug? And are people only homeless and dying because they use?

Go here to see a slideshow video of pictures I asked Nate to take of his life: what gives him joy, everything he eats, and what makes him feel threatened or afraid.

Is everyone homeless using?

As Lindsay Lohan, Robert Downey, Jr., and Dr. Drew's endless list of celebrities, among so many others, have shown us all, addiction is everyone's problem, not just the homeless. But the pressures to use on the street are extraordinary. Carlo, another man you'll meet later in this series, says "the only way to survive is to find someone, fast. Someone who can protect you." Ed, a street survivor who is now in recovery and a successful businessman, says "You can't avoid it. I mean the streets are so full of drugs and alcohol. And I'm talking about cheap cheap [drugs]." Cheap drugs are an important point. Crack is more likely to get you more and worse prison time (still) than cocaine. Black tar heroin is much more likely than Rush Limbaugh's drug of choice, OxyContin, to cause you serious health complications. Addicts are susceptible to price: a recent article by an ER doctor points out that a massive street price increase means OxyContin users may be switching to heroin with near-lethal results.

But widespread use in San Francisco may be due to more than availability and price. As Ed says, "You're pushed into it. Everybody around you starts to do it. If you're looking at it from the outside and you've never seen it, well it happens...we called them straights, but they eventually do something."

How common is that use? San Francisco, based on our homeless survey, has varying rates of substance abuse - service providers report substance abuse among 17.3% of those in transitional housing, and 43.7% in shelters. Of people on the street, 32% report alcohol abuse and 31% drug use.

But Carlo also adds that the way to survive on the street is to "never get drunk. Never." Being impaired means being assaulted. Unless you have someone to protect you. And so there is a razor-thin, teetering-on-a-precipice gap between using a substance to fit in and not be a target, versus being assaulted while using.

Once someone uses when homeless, besides the inherent physiologic addictiveness of the substance itself, there are other pressures to keep using. Ed adds, "If you're on the streets and you're not suffering from substance abuse then you may have a worse time of it...I mean what other answer is there, except outright suicide? - and there are plenty of those. There's a false high you get when you use. If you don't even have that, Ouch. That has got to be the worst. Because you're always aware. You're always aware of what's happening to you all the time. On the streets you're a victim, you become a victim, you get kicked around, you go down and down, faster and faster...I mean, how do you do it?...You can't face that without some sort of chemical in you so you don't feel. That's what the street teaches you. It teaches you how not to feel. None of us felt anything."

An even narrower razor-thin gap may exist between using to not feel, versus overdosing.

Again, as Michael Jackson, Heath Ledger, and Anna Nicole Smith sadly have proven, anybody can overdose, even while living in a mansion. You don't have to be on the street. But the numbers of fatalities from overdose, particularly among the young eking out a life on our sidewalks, is shockingly high [go here to read a real-life encounter with overdose death on the streets]. The top causes of young homeless deaths are suicide and overdose - and the line separating the definitions of the two may be blurred.

That stuff will kill you...

Addictions take a massive toll on anyone's health. "I've got a lot of health problems," Nate says. If you live on the street, HIV and hepatitis C, which can be transmitted with IV drug use, may be a de facto death sentence, since their treatment requires prolonged, meticulous adherence to difficult-to-take medications, and consistent follow-through with our complicated medical system. Even if you're lucky enough to have a homeless-welcoming clinic, if you don't have a safe place for your pills, or a way to get back and forth, or a phone, or even a way to keep track of the date, treatment may be essentially impossible for you.

Black tar heroin

Black tar heroin

Besides HIV and hepatitis C, the homeless who use IV drugs suffer from skin infections, some of them wildly virulent, or lethal, and almost all of them disfiguring and resulting, often, in some form of chronic pain. And then there are the rare and vicious infections from IV drugs - botulism paralysis (there were 11 cases here in San Francisco from 2004-5) and endocarditis (where bacteria actually cling, invade and grow onto the valve of your heart as clumps of germs+pus are flung into your blood stream with each beat).

Alcohol has its own lethality. Constant use means you can't even make it through the night without going into withdrawal. The violence associated with alcoholism has made it, in at least one study, the most dangerous drug around. Less well known are the health complications such as variceal bleeds, where you can vomit up your body's entire blood in spattering red gushes, or pancreatitis, where you, literally, digest your insides. Then there's the brain damage of constant alcohol use, resulting in dementia as early as one's 30's or 40's. And, of course, cirrhosis, where your liver fails as it turns to scarred gristle.

Why won't they just quit already?

It's not as though people don't know drugs are bad for you. As Ed says, "We knew it was bad but there were times..." he pauses to get his feelings under control, "there was a time when it would have been a blessing. To be dead."

"And there's the added thing," he says, "where do you go?"

Even for the highly motivated, trying to quit a serious addiction on the street is, like all other aspects of addiction there, extreme. Going into withdrawal (whether from alcohol or opiates) on a sidewalk, where you hallucinate and involuntarily crap yourself, is its own form of vulnerable hell. A person trying to self-detox on the street, reeking of stool, sweating and shaking, would be seen by most of us with contempt, even as they were desperately trying to change for the better.

Detox beds for alcohol are hard to come by. Detox beds for narcotics are nonexistent. There are a few slots at Ward 93 for methadone detox pills, but only for a very, very few. Recovery programs are jammed, especially residential ones.

Accessing these scarce resources is extremely complicated and time intensive. Many programs are also "one substance" in approach, although people on the street often use more than one. "It's hard to sustain a habit on the street," Ed says, "sooner or later they start using alcohol, at least to take the edge off." Numerous studies have shown that prolonged addiction may permanently alter the brain. No one knows what prolonged polysubstance abuse might do, but it's unlikely to be good. And keep in mind that repeated, severe head trauma is common on the street. Head trauma, even mild, has been shown to impair, and even destroy, executive functioning. "Executive functioning" is the part of the brain that allows us to control our impulses, follow complicated paths, defer rewards, make long term plans (and stick to them), and even, early studies suggest, resist addiction. Head traumas can certainly make navigating the byzantine system of substance abuse services a near impossibility.

In fact, if you were to deliberately try to set up laboratory-grade environmental conditions to induce, sustain, and make-inescapable an addiction, regardless of genetics or drug of choice, it would be hard to image a more perfect scenario than that of humans tossed into life on the streets.

So what works? Can't you just lock them up?

We as a society have long ago decided that each of us has an absolute right to make really bad health decisions. As long, that is, as we are capable of stating that we know the consequences. You are allowed to drink yourself to death quietly in your home. We've chosen this approach for many reasons, but when it comes to addiction, one of the enduring reasons this stance doesn't waver is because you can't actually make someone quit. As soon as you stop enforcing a rule, the user goes back to using. The legal limits of coercing abstinence is no doubt a subject that plagues, on an almost weekly basis, Lindsey Lohan's judge. And no one on the street will ever have access to that level of resources for recovery. But the challenges are even bigger than that.

The real problem with trying to come off an addiction on the street may be the same reason Nate doesn't really make eye contact. The same reason he can't physically relax, even in a safe place. From a homeless perspective, when you're out there, people erase you, to the point where "you have to make noises to be seen on the street," Ed says. "If you've got the moxie to be pissed off, that happens, but after a while, you get so used to it that [other people] don't exist. The outside world doesn't exist. It's like a blur around you. I don't see other people, they don't see me. You get numb to it all." Ed explains, "Once you get there [on the street], no matter how you got there, it's a downward spiral. And unless you take the steps necessary to be - to be vulnerable enough to let someone help you, you can't get out."

Ed feels he knows what it takes to be able to get out "but I only know it in retrospect." What is this miraculous secret to stopping an inevitable downward trajectory? Few studies have been done on people who've successfully left homelessness and substance abuse. Life situations are so unstable, and the combined stigma of homelessness and drug use is so intense, finding those people for a research study would be challenging. But what Ed reports, and what the one study from Canada found, another study of homeless youth in Ohio found, and what is anecdotally said among those who work in the field all coincide. Ed tells the powerful story of how, during a prolonged hospitalization, one VA nurse made a real connection with him and talked him into changing. "Villages, community, that is the way out. It's the only way out. When I got to the point where people didn't want anything from me, not money, not drugs, not anything except me as a person...that's when, through a series of lucky steps, I was able to get out." To Ed, the only key to success lies in making a real human connection with someone "outside." The Ohio study goes so far as to say that making such a connection with a service provider may be more important that addressing mental illness, substance abuse, or sexual abuse issues. The answer may be as powerful, as simple, and as impossible, as that.

Because how in heaven's name does anyone create that kind of connection with a person who is struggling and addicted and frantic and traumatized on the street? How do you break through the pressure of a life spent dying out in the open? How do you reach through the "blur" of being erased?

A win-win

I attended needle exchange sites one evening and another afternoon for this story. These programs, while doing good - both for themselves and others - offer dignity and compassion to people that the world, in general, no longer sees or acknowledges. Needle exchange may be saving all of us whopping amounts of money through "cost-effective" years-of-life-saved and (literally) 500 overdoses reversed here in San Francisco and untold numbers of HIV and hep C infections prevented. Each one of those numbers is a dot on a map of our neighborhoods, many of them concentrated dark red like so much spilled blood in the Tenderloin.

Those numbers are important, and vital achievements from needle exchange. But the folding tables, the needle supplies, the little cookies that a staffer bought with his own money to put on a paper plate to share - those are just trappings. It is the kindness, the eye contact, the genuine concern, and the quiet acceptance of wherever one person may be in their struggle, those are the priceless offerings that are given each week. As Melissa, the site leader, said, "We don't push people, but they know we're here if they reach a point where they want help." Each of these gestures and acts of respect and kindness is like a fragile thread of a spider's web - individually soft and tenuous. But over time they weave a strong pattern for the people who come, a pattern of hope and belief, connection, self-worth and dignity. It may be that no one walks proudly into needle exchange. But they sure leave with their head held higher. They have done something good for themselves, and good for our community, all while being seen, as Ed would say. And that, truly, is the magic of needle exchange.

It is rare to find such a win-win the world of homelessness and death.

Want to help keep needle exchange and the overdose prevention project going? Go here and here to give a little tiny something of your time or resources this holiday season. Share in the comments section and come back Thursday to learn about Starving in the Financial district and Ken. Stay tuned for more on The California Endowment Health Journalism Fellowship series of articles by Doc Gurley on homelessness and mortality. There will be an article every Tuesday - find out who's dying in your neighborhood, what's being done about it, and what you can do to help. This article was produced as a project for The California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communication & Journalism.

*Identifying traits are changed to protect confidentiality, and accompanying street photos are NOT of patients.

Doc Gurley is a Harvard Medical School graduate and is a practicing board-certified internist, and the creator of the Memoriam app - the first, and only, app to allow disaster-relief workers to speak for the dead. You can follow Doc Gurley on Facebook. You can get more health posts at, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley's joyhabit and iwellth twitter feeds - so you can get topic-specific, effective, affordable tips on how to nurture your joy and grow your personal wellth.