Opiates are the Opiate of the People: Part 1

‘You never listen!’ says Gale, punchy as always, more irritated than usual. ‘I bet you’ve never had a heroin problem! I bet you’ve never had to just say no!’

Twice offered actually, but both times declined. The second time regretted, perhaps.

When I was a student, I spent a time travelling and working in Northern Pakistan.

That period, the elective term, was at least notionally educational, and for the more serious students it was. The ones that really cared organised for themselves three months experience in cardiac surgery, or anaesthetics, or neurology, and these were the ones that all seemed to get the best jobs in their chosen subjects when they qualified. These were the ones that really flew. Others of us, who struggled more to get airborne, saw it as a kind of study holiday with benefits, and back then when life was kinder and easier for middle-class white boys like me to sort of rattle through life as we pleased and only needed to turn up from time to time, it was an opportunity to loosen ourselves of the shackles of study, kick back, and travel. It was a time for the most perfect freedom.

My friend Andy had recently returned from a mountaineering trip to the Karakorum, where he had climbed to over 6000 metres on Mushtaq Tower and come back changed entirely – lean and fit, with a seared look to the skin and a far-off gaze in the eye which is rare in men who come from Fife. On a big screen in my brother’s flat in Edinburgh, he showed us photos of dragon-teeth peaks and dazzling white ice fields and men in glacier glasses, men draped in the ironmongery of serious climbing, and men drinking tea and puffing on a hookah on the veranda of a wooden government guest house by a deep grey river in a town called Ashkole. We sat around drinking beer; it was dark outside and raining, and I thought I want some of that. I have always revered Andy for all sorts of reasons.

The expedition doctor, a GP from Anstruther, kindly gave me the address for the military hospital in Skardu. He had spent a little time there, met a chap called Ali Mustafa, the duty surgeon, who had drained an abscess for him. He felt sure that Ali would welcome a medical student. I felt sure that he would too and wrote to him, a polite letter in my clearest English on flimsy blue airmail paper saying how much I wanted to study surgery in the Northern Karakorum, and a month or two later, received a reply on a post card, written in smudged red crayon, indicating, or so I thought, that I might come. The card had obviously been a long time in transit and was somewhat water damaged, but it seemed good enough to me, and good enough for my director of studies in Manchester when I presented it to him, saying that I was off to study surgery in Pakistan!

I wasn’t expected.

Of course I wasn’t expected. My post card with its scarcely legible red squiggle was worthless. There was no Dr Ali Mustafa now. There had been, but he was long gone: had left under something of a cloud too, or so it seemed, though people in Skardu were too polite to say, thinking that he must somehow be my friend.

Major Sammi Ulah Khan sat in his office in pressed immaculate tan-coloured Major’s uniform and looked at me through his pale blue eyes. He was flanked by two unranked, bearded men, one with henna adorning his thick black hair, both in sharply creased fatigues. There were post-surgical patients in dressings lying on charpoys in the corridor outside. There were flies everywhere and the place had a thick, ripe, sweet smell, like rotting apples. Skardu military hospital was the drop point for casualties from a slow burn conflict with India, occurring on the frontier glacier, about 20 miles away. Men were taken to the front on the open backs of jeeps: poor boys from Sind and the Punjab, where it is really hot, who had no equipment for glacier fighting.

Major Sammi looked tired. His hospital was full of amputations, frost bite, and bullet wounds. I had travelled for six days by train and rickshaw up the length of the Indus and the Karakoram Highway and was ragged and smelt bad. But no one in Pakistan smelt bad. If your job in Pakistan was to sluice out the polo ponies’ stables after your evening shift in the rendering plant, you still finished the day smelling of primroses.

Major Sammi looked through tired pale blue eyes at the 20- year-old with his crappy red beard and incipient dysentery. Somewhere from the mountains came the far-off drone of a helicopter and Major Sammi seemed suddenly to waken.

‘Of course you are welcome, Dr Dorward,’ he said, in heavily accented yet still cultured English. ‘You may stay for as long as you wish. You may reside in the doctors’ mess.’ He glanced at the door, and his two men jumped to lead me away. Major Sammi twice tapped a thick sheaf of paper on his desk in the decisive manner of busy people in 1985, and reached for his cap from the hat-stand. The drone of approaching helicopters grew louder.

I think I owe a lifetime’s debt to the people of Pakistan. It happened to me, over and over again, for three months. I would end up somewhere, destitute and hungry, at the mercy of stran­gers and a total pain in the arse, and then I would be fed, and given a bed.

A year or two later, just after knocking off a three-day wall-to-wall shift as a junior obstetrician in St Mary’s in Manchester, I was stopped on the pavement outside the hospital by a totally lost, shambly guy in his early thirties dressed in shalwar kameez and a chapati cap, who asked me in appallingly accented English, ‘Too much lost – where, Sir, is this?’ and thrust under my nose a handwritten address somewhere in Droylsden, which was miles away. I said to him ‘Wait!’ which he didn’t understand, so I tried again with forefinger raised for emphasis and said ‘wait!’ and he seemed to get it, because when I dashed off to get my car which was parked in the basement car-park and got back he was still there, bewildered with his scrap of paper, so I picked him up and drove him to Droylsden where his anxious family were waiting for him. They must have thought that I was a taxi. So somewhere from Pakistan I absorbed something, for a while: some alien spirit or essence of the place, of obligation, or generosity.

Memory postcards from Pakistan:

• A dimly lit operating theatre. Flies. That smell again, of rotting fruit. Through a cracked window, a view across to an orchard of apricot trees. A child with peritonitis on the table with her abdomen open, but it’s all far too late.

• My day off, and I walk five miles into the hills, to Satpara Lake, where I swim in cold glacier water. I pass an intricate Buddhist rock carving on the way, set well back from the road, edges worn flat by age and human touch, a well-beaten track still leading to it. At the lake, a boy of 12 or so comes and sits beside me: there is something he wants to communicate with me, urgently, and I don’t understand what it is that he is trying to say. I realise later that he was trying to sell me sex.

• A postcard of mountains. Guts churning. Starving. Nausea, and breathless in the thin air. Climbing the shoulder of the hill above the hospital to try to get that view across the Indus valley to the high Karakorum and realising too late that this walk would take me days. Dispirited, I return in darkness, loneliness carving out its hollow in my chest.

• Sitting at the end of the day having tea outside a tea-shack by the road. Low sun filters through wood-smoke. Two young men pass by, hand in hand, one wears a garland of yellow flowers in his hair. The smell of stables – polo ponies – and kerosene. A first deep inhalation, K2 cigarettes! and a bubble of contentment swelling.

• Walking in the narrow streets of old Peshawar. Today is Ashura, the Shia day of mourning, but I don’t know that. There are crowds of men in the streets. They grow dense and hostile; there is a tension in the air which I haven’t experienced before, and I’m fearful and try to escape, but can’t. I am locked in, in a flow of men, trapped in a dusty little square ringed by tall, old buildings with wooden grills overlooking the street. Men are beating their chests; men are beating their backs with chains swung from short wooden handles. There are chains, knives and ring-pulls. They cut deeply; there is a frenzy of sweat and blood. Crowded in the shadows behind the wooden grills above are women: I know them by their voices. Their excitation, their crying and murmuring, calls and sobs, are like bird song.

• Reading by paraffin light in the doctors’ mess. It’s cold outside, with the sun down, but warm here. We share tea and chat, and then they go off, altogether, elsewhere, to pray. I realise, months later, that I was occupying their prayer space. They don’t ask me to leave; they don’t want me to feel awkward.

• Opium. A government guesthouse with a verandah, on the banks of the Shyok river. Grey meltwater tumbling from the high glaciers, boulders the size of cars rolling and bouncing down the valley floor. I spend a week in Khapalu with a man who becomes a friend, and the Emir of Khapalu organises a lift for me back to Skardu with a group of five young Afghan men – farmers, smugglers, soldiers, I don’t know, because we don’t share any words. In 20 years’ time this kind of relationship would be impossible, but right now they treat me well: somewhere between a distinguished foreign emissary, and a family pet. They like it when I perform tricks: juggling with three apricots, or reading aloud in English, from Great Expectations. They wear cloth turbans, and immaculate white shalwar kameez, and live out of little canvas shoulder bags with Russian letters on. They carry guns. In the evening after a day of travel they cook rice and oily paratha on a kerosene stove and drink tea as the sun goes down. We sit on the veranda. Slightly furtive, one unpacks his hookah, a wallet of thick brown paper enclosing a wad of brownish paste which melts, burns and bubbles in the bowl, and each sucks deeply on the nectar and leans back on his chair to witness the emerging stars. The youngest hesitates, then offers me the chewed mouthpiece.

In one version of this story I inhaled the cooled smoke deeply, swallowed its sourness and leant back contented and drowsy in my chair to search the turquoise sky for Tarek, the evening star. In another I raised my palm politely to decline, thanked them in the cool Presbyterian way, but … no.

‘Are you listening to me, Doctor! You’ve never used it, so you just don’t know, do you?’

‘No … I … No…’

Gale, I confess it. I was miles away.

A young man in a turban and a black beard hawks and spits into the fire, smiles through the gaps in his teeth, draws on a hookah. The rumble of stones from the river below. The evening star, bright and low in the sky…

Sometimes when I’m at work I have these epic daydreams.

‘So you can’t really say, can you? Don’t get me wrong, you seem like a nice enough wee fellow, Doctor, but every time I come here I get this…’ She makes a yapping on gesture with her right hand in the air between our two faces – yap yap yap – and continues, ‘but really, with all due respect, etc., you have to acknowledge when you admonish me to, what was it, to stop using heroin, stop jagging! Yer kinda speaking through a hole in your, well, you know what…’

A bit of context: Gale uses words like ‘acknowledge’ and ‘admonish’, which is unusual. She’s in her mid-forties. She has intelligent, sparkly eyes and a nice smile, which is hard-won. Scrubbed up and with some serious wardrobe and dental work, Gale might plausibly sit on my side of the desk. She said once, ‘What you have to understand, Doctor, is that most junkies are as thick as shit, but I’m not.’ She also told me: ‘You know the best thing I’ve ever done? Not having children. If you have children, you get a flat and you get benefits, and you can get out of this shit. But I wouldn’t do that to a child. I said I wasn’t going to bring a child into this world, and I didn’t. That absent child? Best thing I’ve never done!’

She is articulate, clever, forceful, foul, likeable, and broken. Her dog had diabetes and was taken away from her and destroyed because she so neglected him. She grieved and grieved for that dog. Today she has an abscess in her groin, discharging thick, blood-streaked pus. She showed it to me behind the curtain, squeezed it a little while I got a swab, and said bleakly, half laughing, ‘Yeuch, that’s minging!’ in a tone of voice which, I don’t know why, enraged me, broke my heart. It prompted me to say that thing I oughtn’t: ‘You just have to … stop … jagging!’ which is what really got her going.

‘What the fuck gives you the right to tell me? With your … head full of teeth and your lovely kids? You don’t know! Lecturing doesn’t help. Do you think I don’t know it all already?’

‘So what should I do?’

‘Just … do your job and be helpful. Stop judging! Listen! People like me, we judge ourselves enough already!’

Okay. Pause. Try to rescue this.

‘I’ll give you antibiotics for your groin. Tell me if it isn’t getting better, and I’ll arrange to have it drained. Now tell me. What else can I say or do that would be helpful?’

She looks at her shoes. Broken plastic trainers. She clasps her hands. The rest of her is fine boned, but her hands are swollen and puffy: she has injected for so long that the fine blood vessels in her hands are destroyed, her feet as well. Scrub up, fix her teeth and her clothes: changed and transformed though she might become, nothing will ever make that better: she’ll always have these odd, puffy hands and feet.

She pauses. She says, ‘You’re always trying to change people. Do you think anyone wants to be like this? I’ve been a junkie for so long now that even thinking about not being a drug addict is painful. I don’t even know if I want to think about it. And every time I’ve tried to stop, I’ve got all these new best pals chapping on my door, shouting “Come on Gale, one last wee burn!”, and I always let them in.’

‘Why?’

She looks at me as if I’m stupid.

‘They’ll just keep hammering on my door otherwise.’

‘And they won’t leave you alone?’

‘As my Grandma used to say, “Every stottery cow needs a pal”.’

What?

‘It takes a village to grow a child. It takes a village to grow a junkie too. People like us are the only people we know!’

Gale never chose to be like this. To suggest that she might have just seems silly. When, exactly, did you choose to be what you are? Gale didn’t choose her parents, nor did she choose to miss those few opportunities which arose for her in her school where too few of the teachers had the wit or the time to tell her apart from the crowd. Gale didn’t choose whichever smoky-breathed man it was that climbed into her bed and did whatever it was that he did that set her on her way. (There’s always a man. Someone like Gale may take long enough to tell you, but get to know her well, build that trust, and in the end she might. There’s always a man at the beginning of the story.) Gale didn’t choose that her father be violent. She didn’t choose the bad set she fell in with when she was a child, nor did she choose the rain-hammered tenements where she has lived out her adulthood. She never chose to live in a world where what passes for heroin is passed from hand to hand in tiny cling-film ‘burn bags’, where what passes for the exotic, what once was opium, is flour and baking powder cut with codeine, which is burned on tinfoil and inhaled, or mixed in company with a squeeze of lemon juice, boiled on a spoon and injected, where it sits, bubbling under the skin, and ferments into the kind of smelly, discharging abscess which she brings for me to see, here, today.

She didn’t choose. What happened to Gale, just happened, just the same as for any of us. No one chooses. Not really. In a world so determined, what could that possibly even mean: to choose?

I want to write about free will: about how, in a determined universe, the very idea of freedom makes no sense, because there is no place for it. I want to write about how free will is an illusion, and its consequences – blame, wickedness, responsibility, culpability – are illusions too. I want to make the case that, in such a world, there can be no place for punishment, for harming, restricting, incarcerating a person for the bad things that have happened to them. Things that never happened to the judge, nor to you or me. But when I think of Gale, my argument falls away. Because, illusion or not, Gale wants more than anything to be the kind of thing in the world that chooses, and chooses better. Gale yearns so much to be this kind of thing, a thing that can make choices, that even to think about it causes her pain. She had laughed bleak laughter, with a cold shower of tears, when she showed me her groin, and what she had done to it.

Twice offered, both times declined.

The second time in Pakistan; the first time in a student union, in 1983, one evening, sitting on my own, nursing a half pint, not knowing a soul.

A posh chap in a blazer came and sat by me, started talking about his girlfriend, Sarah, whom it was established, by sheer coincidence, I had known at school. I took an instant, poisonous dislike to him. I don’t know why. Men in their twenties shouldn’t wear blazers.

He said, confidingly, after a while, ‘I’m dreadfully fond of heroin,’ looking at me with raised eyebrows as if to ask ‘Are you?’ I said no. Of course I said no. I loathed him. I walked away, left him to it.

Good choice, I think, though really, for me, no choice at all.

The usual understanding is that it is the drug that enslaves. It is the drug that works the change on people. Get rid of the drug and you get rid of the problem.

My next patient this morning is Mikey. He’s already ten minutes late for his appointment, but I know that whatever I say, I’ll end up having to see him. So while we wait, imagine for a moment you are Mikey’s mother. Remember when your child was a bonny bright tousle-haired wee thing that called you ‘mummy’ and knew, properly, how to love? Remember the time? The time you think of as before? Do you remember how, when he was 12 or 13, he fell in with a group of older boys? Your husband saw no harm in it, but you did. Although you gave him love and treats and sat him down and tried to get him to talk to you, you sensed that you were losing him, but didn’t know why, and you didn’t know what to do, because some devilry, some temptation, made him prefer them to you.

You remember, much later, that sense that something unknown was sucking the blood and vitality from him. How his skin grew pale and grey, almost translucent, his muscle turned to mush that you could almost see the fat and bones beneath. Hard times to recollect, but you must make yourself ask, obsessively, over and over, for a boy so loved, how could it go so wrong?

Do you remember that almost imperceptibly slow transition as he turned from the child you loved, your only boy, into that hungry grey ghost that stole money from your purse? Do you remember the week in Saltcoats at the caravan, when he was 14, when he seemed to get better for a bit, when he ran along the beach with his dog, throwing sticks, and you thought I’ve been imagining it – he’s fine! I’ve been imagining it all? Do you remember how long you spent turning a blind eye to the money that was missing from your bank accounts? Sometimes in the dark of the night you make a reckoning. Twenty years have passed and now he’s 32. Leaving aside the squandered love, the emotional pain and the broken marriage, how much has he cost you? You think about the thefts, the debts paid, the jewellery pawned and lost forever, and tot it up, hating yourself as you do. The money that he stole from your friends, that you made good. You try not to think too much about that one, but at night you can’t not, because the thought comes to you from out of the dark of its own accord.

The damage to the front door when it was kicked in by the police. The costs associated with the law. The taxi fares to and from court. Covering up absences from work with fake illnesses. This bitter accounting is your private addiction. The car you bought, then had to sell. The endless, unpayable loans, and the cleaning job you’ve taken on at night to pay off the interest. Sometimes at night, on your own, you make a reckoning. If you’re honest, you think, it’s about 70K. Give or take.

You have this fantasy that he will be returned to you one day, healed and free of drugs, a little older perhaps, perhaps a little battered, but free and you feel your heart leaping up like a dog, hungry for affection, hungry for the hand that proffers this dream, this cruel dream. You also have a fantasy that he is dead.

At night, it’s this second that calms you.

The folk understanding holds that it is the drug that makes you its slave. On the face of it, that makes a lot of sense. A generation of psychological experimentation dating back to the sixties seems to have proven it. If you place laboratory rats in Skinner boxes (cages, measuring 7" by 8" arranged in banks), provide each individual rat with food, water and free access to morphine, your rat will preferentially feed on morphine and neglect the rest. The rat will neglect everything, in fact, until it is too weak to reach the teat on the bottle with opiate – at which point it will die. Some resist; some are resistant to the allure of the drug, and continue to thrive, insofar as thriving is possible, but the vast majority don’t. The dice are loaded against you if you are a rat in a Skinner box with access to morphine. That’s the argument for legal prohibition: get rid of the morphine in the cage and your rats do fine. The model seems to work well, for rats. It’s extraordinary how quickly, how easily, it has been generalised to people.

They start off as diverse as everyone else that we know, but for people who fall to using street heroin quite quickly it works its thing, quite quickly you start conforming to a kind. Like the rats in their cages, your skin goes grey, your teeth rot in their gums, your coat, your hair, your clothes are dirty and you stop looking after yourself. You become antisocial. You adopt the junkie voice – a kind of gravelly whine, a querulous beseeching that is enraging and intolerable to be around – and you are constantly, crudely, wheedling and manipulative, in order to obtain not just drugs, but any kind of trivial advantage at all. That’s the worst: you are sick, as sick as it’s possible to be. But kindness doesn’t seem to work in the usual way: it seems to make things worse. The kinder I am to you, the more you use me. The more of myself that I offer you, the harder I am betrayed. I feel used. There is nothing worse than being used.

The model is beguiling. How quickly, how easily people can seem to conform to it, like rats locked in their cages.

Mikey’s turned up for his appointment at long last.

‘My mum says that this is my last chance. She says that if I let her down again, then I’m out.’

I check his date of birth and do a kind of double-take. He’s 32! With his baseball cap and his half hoisted jeans showing his grubby Bawbags boxers, he looks like a teenager. He’s even been brought along by his mum, who’s a patient of mine as well. A respectable, well-kept woman, dogged by the shame of it, she has tried so hard for the boy – she works as a receptionist in a car wash during the day, and has a cleaning job at night. There’s a kind of low-level gangster in my neck of the woods that scents out the boys whose mothers love them still, like sharks scent blood. You bleed the child, then you bleed the mother: it’s an income stream that’s good for years. Mikey’s mum has just sold her house and is moving out, into a caravan. You can almost smell the blood in the water.

Despite the many harsh words that have passed between us, I quite like Mikey. Hidden deep, imperceptible to most, he has some of his mother’s kindness, her intelligence. Though not today. He stares up at me through wide open, imploring eyes.

‘So I’m back, Doctor. You’ve just got to help me.’

There’s a gleam of sweat on his grey skin. He’s shaking. His mouth smells like a blocked drain in summer. The spiderweb tattoo on his neck is livid and sharp. He looks like shit. Mikey had been on a prescription for 30ml of methadone, which isn’t a lot, for a couple of years, and had been doing okay. He had a job in the car wash for a bit, but lost it, because they found out that he was on methadone, and then he’d stopped picking up his prescription, which is always a bad sign.

‘It’s snakes and ladders, Doctor,’ which is something that relapsed heroin addicts say. ‘But this is it, if I carry on like this, if ah dinnae stop jagging, I’m deid. Ah’ve got tae clean up. Besides,’ he says, solemnly, ‘I’ve got the bairn now. It’s a new start.’

The bairn?

‘Aye, did you no ken? I’ve got a grandchild now. Last Tuesday. My daughter says I cannae see her unless I clean up…’

Daughter? Granddaughter?

One of the paradoxes of heroin addiction is how oddly it ages you. Mikey’s lungs are the lungs of a heavy-smoking 60-year- old. Every morning he coughs green pus, his tubes having filled with phlegm; he has chronic obstructive pulmonary disease. He also has coronary artery disease, though we don’t know it yet, and in 10 years’ time he will have angina, or heart failure, or be dead. He has liver cirrhosis from hepatitis C, and he walks with a stick. His skin is finely lined and thin, like a 60-year-old, and his skin hangs from his belly like a man who once had muscle or fat, and has lost it.

Mikey is frightened that his mother will be angry with him and throw him out of the house. Mikey is prone to stealing and to having tantrums. Mikey has no bank account of his own. Mikey whines and wheedles and lies around all day playing on his computer. Mikey is a lost 15-year-old, locked in time, locked in the body of a dying old man.

‘So how are you going to clean up?’

He looks at his trainers. Looks up at me.

‘I can’t believe that I’m saying this again…’

A tear of self-pity.

‘I know I’ve let you down, Doctor, and I’m sorry. I’ve let my mum down too. I’ve let my daughter down. I’ve even let myself down…’

One aspect of Mikey’s unlovable childishness is his habit of trying to make everyone else around him into his mum.

So get to the point Mikey.

‘I’d like another prescription for methadone. Please.’

I pause. I nod. Okay.

‘Here’s how it works…’

Here’s how it works. It’s about harm reduction: palliation, not cure. There is no cure.

Mikey will get no prescription today. Mikey will have to step over a series of tiny, tiny hurdles before he gets his metha­done. Call this paternalistic? This is paternalistic. Mikey will have to chew on a wad of absorbent cellulose, a kind of dry swab, so that I can collect his saliva to determine what he is actually taking. Removing the deceit creates the possibility of truth telling, opens a space in which an honest conversation can happen. Nothing enslaves like lies: both deceiver and deceived. I stopped taking urine samples a while ago: too many faked tests, too many bottles of children’s urine, spiked with methadone – a cold, greenish sample. That’s why they make methadone green.

Baby steps to adulthood.

Mikey will be required to never miss appointments, to never be late, and to turn up at the chemist every day to be given his methadone, under supervision, to ensure that he isn’t selling it on to those other grey wraiths that haunt the chemist’s door on methadone days.

Mikey will be required to come back to see me in a few days, on time, having had no opiates for 24 hours, so that I can see that he is withdrawing: I don’t want to create an opiate habit where there was none before, although in Mikey’s case, this seems quite unlikely.

I will see Mikey every week, step up his methadone in slow increments, 5 to 10ml at a time, until he eventually hands me spit samples that are free of drugs. He will start to look better. He will wash, get his teeth fixed, lose that maddening, wheedling tone he adopts when things are bad. He will start to be … honest.

Baby steps to adulthood.

I will space out his appointments, space out his visits to the chemist, dispense him a little more trust, as if trust is the potency that heals him. Perhaps in time he will get a job, come off benefits, have a little money to buy things for his granddaughter. Perhaps his daughter, in time, will let her father see her child.

After a few long years, Mikey will come to see me, or my successor, and say, ‘By the way, Doc, I came off the methadone.’ And I or my successor will raise an eyebrow, and he will say, ‘Aye, I just looked at myself in the mirror, and I said, fuck it, 52 years old … I stopped about four months ago, and I’ve not looked back.’

‘Was it a struggle?’

‘Nah. It was the bairn really, she just looked at me one day and she says “why are you still on that shite grandpa?” She’s off to college next year! She wants to be a nurse…’

It happens. Every year, I see it, once or twice, maybe.

Mikey will have grown up. And the ghost of his dead mother will be singing and dancing among the clouds.

But today there is a snag. He comes back to see me five days later, bang on the appointed time. He is pale and shaky. His pupils are dilated and he looks like he has a fever. He is antsy, tamping down his own irritation, mustering all the niceness he can find so that nothing can stop me from giving him the methadone that he needs. He has clearly had no opiates for the 24 hours that we agreed. He’s kept up his side of the deal. He looks at me impatiently, tamping down his impatience.

‘There’s a snag…’

His face says Oh, fuck…

‘What…?’

‘The sample you gave me … it was yours, wasn’t it?’

‘You saw me chewing it. You put it in the bag. Is there a problem?’

I’ve seen this before. I’ve encountered this problem before. This problem is far commoner than you might think.

‘There wasn’t any heroin in the spit sample.’

‘But that’s not … I’ve been using every day for weeks … There’s something wrong with the test…’

‘There was some codeine, some gabapentin, some tramadol, but no heroin.’

‘… right…’

‘So that crap you buy from the friend, whatever, who sells you what you think is heroin?’

The penny is…

‘He’s not your friend. It might be all kind of crap you’re smoking, but it’s not heroin.’

… the penny finally drops.

‘Fuck.’

The withdrawals are imagined? But he still has gooseflesh. His heart is racing, he is sweaty, he shakes, his pupils are dilated, his nostrils flare like a trapped animal’s. But they are imagined.

Pause.

‘So will you still give me my methadone, Doctor?’

So it’s not the substance that is the problem. Not just the substance.

Listen to Gale. That’s what she keeps on saying to me:

‘Can you not listen to what I’m trying to tell you, Doctor? It’s not people that use drugs, it’s communities! Do you drink alcohol? With your doctor friends?’

I don’t respond to this one – never do – it’s unprofessional.

‘All drug use is cultural.’

From time to time, in different cities, in different countries, the state is successful in the war it wages against those people that buy and sell the substances it deems illegal. For a time at least, the amount of heroin in the stuff that’s sold as ‘heroin’ drops to zero, near enough. In Toronto, in the nineties, the police, by a fluke, intercepted all the heroin being imported by a monopoly supplier, and for many months there was an absolute heroin drought. The effect on the city’s drug trade was remarkably small. Traders still bought and sold small wraps of what they called ‘heroin’. Their clients still got together in groups and cooked it up and smoked or injected it. It still burned holes in their lungs, and fizzed and fermented under their skin, and they still experienced something of what it was they sought to experience, and they still withdrew from the drug when they couldn’t access it. The odd cohesive culture of heroin use continues, even in the absence of heroin.

Listen to Gale: ‘Every stottery cow wants a friend.’

But, as always happens, a new supplier soon fills the gap in the market left by the old. What is bought and sold as ‘heroin’ once again contains heroin. In Toronto there was a terrible spate of drug-related deaths. Users, unaware that their product had been cut to zero, had lost their tolerance, and didn’t know to adjust their dose. When they went on injecting their usual bag, back to full strength now, they fell like trees, stopped breathing, suffocated on their vomit.

Another post card from Pakistan:

On the hill above Skardu there was a UN monitoring station. I climbed up to it, one afternoon, curious about the aerials and satellite dishes, and keen to talk to someone, anyone, who wasn’t a Muslim man from the Punjab.

The station was manned by a young Australian soldier only a year or two older than myself. He had been there for weeks, and seemed utterly unconcerned by his isolation.

He offered me tea and offered me ‘something stronger’. In a diplomatic shed round the back, he had a tiny brewery, a bubbling kit of yeast and hops and barley secretly sustained by the generations of young Australians rotating through. I spent the afternoon drinking strong, cloudy beer. I hadn’t had alcohol for three months, and somewhere at the back of my head I worried about my tolerance, but I didn’t want to seem rude. He asked me, in passing, whether I would be prepared to spy for the UN: perhaps see my way to reporting numbers of casualties, levels of gunshot wounds, evidence of unusual intensification of the fighting among my military hosts? But I declined. That would be a kind of betrayal. The soldier said ‘No worries, mate!’ and we fell to talking about rugby, climbing and girls.

I stumbled home in the evening, cold, drunk, feeling watched and judged, though nothing was said by anyone. I fell into my bed and was sick that night, and ill the next day. My hosts shook their heads and said ‘Jalluhb’ (dysentery), and had the cook prepare me sweet bland food like custard, putting my illness down to too much chilli for my western stomach. That was a low: a miserably lonely point.

I tend to the socially liberal, on just about everything.

Without thinking about it too carefully, without really committing, I’ve suspected for ages that the criminal justice system’s persecution of drug users has just had the effect of making everything worse, for everyone. Then, a couple of years ago, I went to a talk by the journalist Johann Hari about his book, Chasing the Scream, at the Edinburgh book festival. Hari is a charismatic speaker: fiercely bright, articulate, clear, passionate, convincing. I queued up after to talk with him, which is a thing I almost never do. I queued for over an hour, and when it was my turn at last, as happens, just splurged, ‘Your book, it’s changed my life!’ which it had, and does, but I was number 200 in a long line of fans, and the man was glazed over and tired. He shook my hand and smiled, wished me well, and signed my copy of his book.

Hari argues that the war against drugs, at least in the US, is a race war, but by a different name. That it started as an employment strategy for agents of the US Agency for Firearms, Alcohol and Tobacco, whose jobs were threatened in the 1920s by the repeal of prohibition, and then, almost immediately doubled up as a tool for the oppression of black culture; at the time heroin was the favoured tipple for black musicians. He states as an iron law, that prohibition leads to the maximum concentration and potency of the prohibited substance. He cites coca leaf and cocaine; opium and heroin; beer and the blinding ‘white lightning’ that appeared in the US at the time of prohibition, and disappeared as soon as prohibition was repealed.

It’s prohibition itself that leads to most drug-related harms. In those countries, such as Portugal, where heroin users are tolerated and are provided with safe facilities for injecting, heroin deaths almost disappear. In those countries where prohibition is repealed, there is a modest bump in substance misuse, and massive reduction in substance-related harm.

Hari tells the story of an undercover police officer in a US inner city who is monitoring the activities of a group of ‘hoppers’, adolescent boys who use push bikes to shuttle between street level drug dealers and a central depot, so that the street dealer is never carrying more than a small, disposable amount of narcotic at any one time. One of the children approaches the police officer, offers him money to go into a local shop, asks that he buy him alcohol. The police officer declines, noting that the child is carrying on him hundreds of dollars’ worth of pills and powder, but still needs to ask a grownup to buy booze. When substances are prohibited, the regulation of their production and sale reverts from the state to gangsters and children.

The book introduced me to the famous ‘Rat Park’. Rat Park was an experiment conducted in the late seventies by Canadian psychologist Bruce K. Alexander. Alexander sought to undermine the traditional view that it was the narcotic that caused addiction. He repeated the Skinner box experiment with populations of caged rats, addicted them to morphine, but then varied the scenario. He demolished the cages and built for them instead an alternative environment: a rat paradise, with plenty of space, plenty of wheels to run around, wood to gnaw on, balls, tunnels and platforms for the rats to play on, lots of opposite sex rats, and private spaces for rat families to grow and thrive. There was as much morphine available as in the Skinner boxes, but none of the rats showed any propensity for addictive behaviour. A few tried the morphine, a few returned to it, but there was no problematic drug use.

Addicted rats, moved from their cramped Skinner boxes into ‘Rat Park’, rapidly re-socialised, found mates, had pups, rapidly stopped preferring the morphine bottles to the food. A few twitched and shivered for a bit, but soon settled. There were no problems with withdrawal. It seems that it wasn’t the morphine causing the problem after all; and their addiction certainly wasn’t the fault of the rats. It was the cages all along. Odd though, how the long science of rats in cages, and rats in parks, has served over the years to construct the phenomena it purports to explain.

Nonetheless: the law isn’t helping.

Though Derek would disagree.

Derek’s involvement with the law goes back to babyhood. He knows what he’s talking about. He was born in London, but his mother, who was in and out of prison, was unable to look after him, and so he was adopted by a Scottish couple. By some mystery of genes or culture, he has kept his accent. He sounds like Sid James. He sounds like a Cockney character in a 1950s comedy. Sometimes I think he puts it on for effect.

Derek is resilient. Derek’s a survivor. He had no enabling mother to keep him fed and housed – and thus alive, for long enough for his body to rot like Mikey’s.

The adoption failed. I read his notes. He had unmanageable behavioural problems, so he went into care, and then a succession of foster homes – fostered long enough to break the hearts of the new parents, but never contained for long enough to thrive – then back into care for the final stretch, and then the world.

Derek has been buying and selling drugs for as long as he can remember. He has had few options having missed school, not a hope of a job, and no work ethic anyway – how would he have a work ethic? – then the blight of an early prison sentence. That’s him set. He started with glue, then small amounts of grass, MDMA, heroin, of course, cocaine when possible, lots of speed.

Derek is slippery and dodgy, but he has a bit of banter to him. He once took a call on his mobile when he was in my surgery room. He was in with a penile discharge. I thought he had the clap (gonorrhea), and was poised to take a swab, when his phone went. This was early in the first phase of our relationship, way back, years ago. He flashed me a little smile, pointed with his finger at the screen, mouthed the words ‘Do you mind, Doc?’ Which I do! God, I really do! I shook my head and hissed, but he took the call anyway. People always seem to. I’m about to show him the door, tackle out or not, when I find myself distracted and deflated by the end of his call.

‘… tiny little place, you’ll not miss it … tenner bags … okay … okay … fine, plenty! ... You’ll have it all mind? … okay, but don’t let me down pal! ... yep, okay!. ... cheerio then, luvya!’

‘Luvya?’ I say, curious, realising I have misunderstood how this kind of relationship works. It’s clearly not at all like it is on the telly.

‘Sure,’ he says, roguishly, ‘Old friend. Old, old friend.’

Derek is whip thin and younger than his years: dyed black hair, skinny faded jeans, black ankle boots, tightly muscled, clean and well tattooed. I suspect he carries a blade, but he leaves it at the door when he comes to see me. He’s all smile and wit and charm when he comes to see me.

‘I’ve always had the greatest respect for doctors. You guys work your arses off to get to where you get to!’

My relationship with Derek has occupied two distinct phases. The first, over a three-or-four year period, interspersed by brief periods in prison, when I would see him every month for a prescription for methadone: a low, unchanging dose, occasionally he would have heroin in his urine, occasionally cocaine, but he seemed unconcerned by it. He didn’t see his drug use as a problem, as such, just a way of life, so in that sense, none of my concern really. The methadone kept him well, kept him on a level and free from temptation. It meant, I suspect, that he didn’t need to dip into his own supply. Is this a legitimate purpose for medicine? I don’t know really. I suspect it is. But I suspect most people would disagree. Derek, in the second phase of our relationship, certainly disagreed. Derek, back then, had resilience and bounce and charm, and I didn’t judge him. I didn’t need to judge him: he always treated me with respect. Then young Derek disappeared. Young Derek died.

Four years passed, the same Derek pitches up, but old now. Dyed black hair all gone, his scalp is shaved, and no longer fit, or quick, or lean, and the face is lined and sun-damaged. I can see now how he’ll age. He has a deep suntan.

‘Haven’t seen you for a long, long time!’

‘I’ve been away!’

‘Holiday?’ I ask stupidly.

‘You could say so … long holiday, Belize, care of Her Majesty…’

‘Ah…’

A word to potential drug smugglers:

According to Derek, Caribbean airport customs get junior staff from British embassies to stand with them, once or twice a week, to help to pick out the large numbers of low-level drug mules trying to take advantage of the easy-going cocaine trade active in that part of the world. According to Derek, who is, admittedly, in most areas, highly unreliable, the local customs officials complain that these people all look the same to them: they don’t find it so easy to pick out the fiends from the family holidaymakers. The embassy staff can do it in an instant. For them, it’s a bit of a laugh, according to Derek. The one who picked him out was perfectly polite, even slightly apologetic. ‘English guy. You’ll know the type. Suit. Oxbridge chap, bit of a wanker, nice enough though.’

‘You’ve been in prison? For four years?’

As I say, Derek is resilient.

‘Yep – shared cell. Concrete floor, nothing to sleep on but a mat. That’s why I’ve come to see you: I think I may have done something to my back…’ And it’s true – he is standing a little oddly.

‘Shared cell…?’

He grimaces. Bats away a bad memory. ‘Sure … but nothing I’m not used to. It was just like being back in care again!’

Right. Resilient.

‘Methadone?’

He raises his hand and shakes his head. ‘Defi-nate-ly not! No-thank-you, Doctor! Four years free! Don’t want any more of your methadone or any other crap. No way, hos-ay. Not a chance. Prison’s set me free of that…’

I wait for the scam. There is no scam.

‘So how did you stop?’

Derek had been on a prescription for methadone for 15 years, and whenever he was released from Scottish prisons, he’d need a little more. He had never shown the slightest interest in stopping before.

‘Well, I had to. I was in a cell...’

‘And?’

He laughs at my ignorance.

‘It’s not like here. It’s a good job being a prison guard in Belize. You get paid well. There aren’t any drugs in Belize prisons, not even weed. It’s a question of professional pride for them: the guards just won’t stand for it.’

Right.

Derek is more transformed than anyone that I have ever met. He has put on weight in the years since his return, lost his hair and most of his looks. He has married a girl much younger than himself, Loti, from the Czech Republic, and they have a baby, whom they fret over: whenever the child is sick, or has a cold or a rash, they bring her in. It’s charming, in its way, given the story.

I see most of my drug addict patients on a Tuesday afternoon. It suits me better to have them all together – more manageable. Derek and Loti have been waiting for an hour or so to see me, while I work my way through my clinic, running late as usual. When I call them through, Derek puffs a bit when he stands. He has a bit of a fat person’s waddle, and I think he’s letting himself go. He jabs a finger at his watch, charmlessly, as they come through, and as they sit down he says, ‘I see you’re still in the drug-dealing business, Doc!’ which really riles me. Loti undresses the child, cooing as she does, and it strikes me that she knows nothing at all about her husband’s past.

‘Lock the fuckers up, I say, and throw away the key. It’s the only thing that works…’

‘Derek! Ze child!’ says Loti, covering the infant’s ears, and Derek smirks. Contentment has been bad for Derek.

I find myself missing the man I used to know.

Listen to Gale.

She has been addicted to heroin for almost as long as she can remember. And the time before that, is a time so painful, she won’t think about it. She resents being asked to try.

The thought of being free of drugs, is painful too. Gale can hardly imagine a world without that protective veil.

From my perspective, none of this is Gale’s fault: she is as the world has determined. It would be inhuman to blame her. She has made choices, true, but none of these has really been hers to make. It is as if Gale has no agency: no control over her own world.

On the other hand … if, to be considered an adult in the world, a person has to make decisions for themselves, own these decisions, and seek to be as free as possible to make these things called choices, then Gale, in that important sense, is scarcely an adult at all. And if, to seek freedom and agency in the world is an important attribute of personhood, then, in that sense, Gale scarcely counts as a person. To be fair to Gale, she wouldn’t see things in that way, not at all. Gale would hate the implication: she’d punch it right back, and quite right too. And I don’t see myself in that light either. From where I stand, I make choices all the time, and they’re mine and no one else’s. Illusion or not, whether it makes any sense to an outsider, it’s how the world feels to me, and how I want it to be: to be a thing that makes choices, that’s part of what makes living precious. It’s part of what makes me a person. And, thinking about it, that’s how I treat friends and family as well – as if they were persons, as if they were things that made decisions and choices too, as if they valued these things, just as much as I do. That seems like a question of respect. The most basic kind of respect.

Another paradox of heroin: nothing is ever your fault, yet, everything is your fault.

It’s not just a paradox of heroin.

All of this matters. Not least because I see Gale every fourth Tuesday afternoon, and if I’m to follow through on this commitment, I need a plan. I need a cohesive, practical theory, that works.

The theory is this: In every interaction that I have with Gale, my duty is to try to act in such a way as to increase her agency. To increase her capacity to make the kinds of choices that the best version of herself would make.

This entails:

• Turning up. Listening to her. Not fading out. Not engaging in epic daydreams;

• Not colluding with her drug use. Not expecting it;

• Being incredibly paternalistic (She’s 42! But doing this anyway);

• Encouraging conversation about the ‘best version of Gale’. Acknowledging how that conversation hurts, but powering on through;

• Being nice to her when she’s nice to me, and chilly when she’s not;

• Making a relationship with her and using that relationship as a tool for change;

• Listening to her talk about her new dog. Seem interested. It emerges that the best version of Gale is the one that looks after animals. She walks her new dog every day, clearly loves him, cares for him – this is encouraging;

• Reduce her methadone, bit by bit, since she’s no longer using heroin. Since she stopped using heroin, she’s looking better: clean, better dressed, teeth fixed. (Getting your teeth fixed is an investment in a future. Good sign, I think.)

She gets down to 3ml daily of methadone, then gets stuck. But that’s nothing! You wouldn’t notice 3ml of methadone!

Her tolerance for opiates drops to nothing too. I forget to discuss this detail with her.

Back in the late eighties I worked in A&E in a small town in Lancashire. The medicine was fun, though frightening. During my first couple of shifts on nights, I was supervised by Ronald, an ex-army charge nurse with blue tinted glasses and a wispy moustache, who called me ‘Sir’. There were no other doctors as such during that first week. Ronald sat smoking in the nurse’s tea room with the other nurses while I saw the patients, helped by an Indian nursing auxiliary called Izzie. When we saw a patient that Izzie and I couldn’t handle – a fractured femur, say, that needed splinting – I’d call Ronald through, and ask him in my shaky young voice, ‘How exactly do you … ah … splint a fractured femur?’ and Ronald would respond, bracingly, ‘You’re in charge, Sir,’ with a kind of resentful smirk, and wait for my instructions. He made me feel like the posh young lieutenant on his first day in the trenches, losing his head.

What a bunch these nurses were! What a coven. Ronald (Sir!) with his snake-thin hips and crappy moustache, and Heather with her knitting and Players No6 that she kept in a jewelled ­cigarette case with little snappy clips. She talked about ‘Pakis’ (she ‘hated Pakis’) and when there was a death from that community, and the public corridors would fill with the wailing of bereaved, she’d clip her mouth tight shut and shake her head in disgust and say, ‘They’re not like us … Pakis…’ That was what the world was like in 1989. Heather, I think, will be dead by now.

On night four I was napping in the relatives’ room when there was tapping on the door, and someone poked their head round and said, ‘Do you want a cuppa, Pete?’

I don’t much like being called ‘Pete’, but I liked John, especially as he showed me the way to the night canteen and introduced me to Wendy, the jolly night-shift cook, who cooked us a mid-night breakfast while we sat and drank tea and chatted. Loneliness, and the long night-time hours spent in a rainy town near Wigan, had made me porous, and, besides, John was younger, brighter, had been around the world a bit, and thought that Ronald was a twat. I choked with laughter and relief; hot brown tea came shooting down my nose, as can happen.

John had trained as a nurse, but wanted to be a musician. He’d lived for years in a squat in Berlin, written some songs, been on the radio a few times, learned German. I had a friend, Gordon, best friend at school, who had followed the same trajectory. John thought perhaps that he had known him. We talked about hanging out in squats in Berlin, drinking beer, watching the swans drifting on the lakes and the young folks dressed in black, rolling by on bikes.

‘So why did you…’

‘Come back?’

‘Yeah.’

‘Married now. Two kids. Respectability called!’

Later, there was a crash call: a young woman came in, blue, scarcely breathing, eyes wide with panic and the immediacy of death, and John, who had seen it all before, nodded and said, ‘Tension pneumothorax. Ever done a chest drain, Pete?’ I shook my head, and John said, ‘First time then!’

And John sat by her head as the girl stretched herself out, arms reaching to his, as he comforted her, whilst saying to me, ‘Left side!’ and ‘Between the third and fourth intercostal space, over the rib, not under … that’s right…’ And as I threatened to push too hard bayonet-style on the metal introducer, said, ‘Not too hard … There you go, love, we’re in…’ (to the girl), and breathed, ‘Well done, Pete, high five…’ as we reviewed the chest x-ray after, saw the plastic chest drain sitting in the right spot, the lung re-inflating, and the girl, all pink now though shaken up, being wheeled to the ward.

A few months later, there was another crash call. A man, 32 years old, found by his wife collapsed at home. Not breathing say the ambulance crew enroute. They think it’s an overdose, likely heroin. I know what I’m doing, by this stage. I take the head end, which is the technical bit, and my colleague the chest compressions. I ask her to stop a moment, while I open the man’s mouth, stabilise the chin, thrust the jaw forward, introduce a laryngoscope, view the larynx and the vocal cords, suck out vomit from the trachea, introduce a laryngeal tube, connect it to oxygen, 100 per cent, noting as I pass, the smell of alcohol and vomit, the dilated pupils, the pallor of his lips, the sheen of sweat, new coldness gathering on the man’s skin.

‘I think he’s dead,’ says my colleague after a bit. ‘I think we should stop.’

‘Me too,’ I say, noting the puncture mark in the crook of the left elbow, which neither my colleague nor myself had made. Bits of history have filtered through to us from the relatives’ room. He had been off drugs for years, his wife had told the nursing staff. Then, an unwelcome visitor, an old friend from his past, turned up. They’d had a couple of beers, maybe a joint. They were sat listening to their music. She had no idea.

There was wailing in the corridor when we stopped. The wife, the kids. Heather with her mouth clipped tight shut.

‘Have you seen the name on the card, Sir?’ says Ronald, later, with a smirk, because I clearly haven’t clocked what’s happened yet.

I hadn’t recognised him. It was John, the nurse-musician from Berlin. His face was upside down so I didn’t really get to see him. And besides, the dead look different.

‘Doctor?’ says Gale.

I’ve drifted off again. A sad memory, dropping in, visiting me of its own accord, like an old friend from the past. I shake myself back into the here and now. It doesn’t bother Gale at all, these absences of mine. I wouldn’t say that we were like old friends exactly, but there is a kind of comfort to our relationship now, which is rare and precious. 3ml of methadone! For three years! We laugh about it, but she just can’t get any lower, she gets withdrawals. However ‘in her head’ they are, as I point out to her, they’re real enough for Gale.

She has a little dog-walking business. She dresses fine, in an outdoorsy kind of way, and hasn’t used heroin for 18 months, which is a record.

‘There’s something I’ve been meaning to discuss with you…’

She raises her eyebrows. I’m listening…

‘It’s about your tolerance – the risk of overdose…’

‘I’m never going to use again, Doctor, don’t you worry!’

‘Sure,’ I say, ‘but if you do…’