The depth of the skin is an unimaginable paradox. The distance from the surface to its opposite side is minutely fathomless. The skin is both surface and organ – boundary and bridge – it is simultaneously the site of the sense of touch and the seamless enclosure that separates self from other. Everything happens at the surface. The needle pierces its outer, protective layer (the epidermis), perforates a lattice of nerve endings and passes through the connective tissue of the vascular dermis. Its penetration is a kind of sleight of hand – the act itself doubling back on the meaning of the word: to “pierce,” to “permeate,” to “infiltrate,” and to “understand.” The needle performs a logical and a topological inversion – making a hole and closing it - opening a continuous surface to its other and its opposite. The familiar distinction between outside and inside dissolves like the reflection that absorbs, first, Alice’s hand, and then her whole body as she passes through the looking glass.

On the other side, an inverted terrain -- a moment of misrecognition -- you catch a glimpse of your reflection in a mirror and imagine that you are seeing through to another space -- encountering someone uncannily familiar, yet entirely other. You feel a sense of autonomy, perhaps power, but this dissipates in a moment of recognition, disappointment and self-betrayal. The needle eases into the vein at a 45-degree angle. The plunger retracts and blood backs up into the barrel of the syringe. The reciprocal exchange of fluids threatens contamination on both sides of the skin. What belongs inside seeps out – while the alien – the foreign substance, the parasite – passes through, violating the autonomy of the biological organism and the social order. The reversal is sickening, vertiginous. This moment of penetration, flooded with fascination and revulsion, turns back and over –like a Mobius strip–(a band that is severed, twisted and the ends sewn back together the wrong way -- creating a continuity of outside and inside.)

The image of a needle perforating the skin, always unnerving and repugnant, is, when self-administered, also obscene (which is the original meaning of both “illness” and “disease” – obscenities wrought on the self). In a culture that refuses weakness and fears vulnerability, where the idea of transmission is synonymous with terror, the hypodermic needle, the break in the skin, the release of blood, offend and frighten as much as the specter of illness, pain and dependence do. Those who inject their own palliative (like heroin addicts and diabetics) are stigmatized as much by their association with the needle as by their dependence on a drug. Junkies will joke that they are more addicted to the needle than to the dope – the prick of memory and the anticipation of pleasure. Hand, needle and vein transform each other -- with each injection the needle makes a new opening and, for a time, turns the old surface under.

Who doesn’t long for renewal, regeneration, and return? Who doesn’t feel the impulse to reverse time, the urge to reproduce the skin, the blood, the self – it’s the surge of biology, the imperative of survival – the craving for more than one more day?

Every morning of my childhood I heard the click of my father’s wedding band against the glass as he rolled a vial of insulin between his hands before drawing up a syringe. He didn’t explain. We didn’t speak about it. He never let me watch. His hand first held the needle at the age of 11. He practiced by sticking a syringe into an orange over and over again until he got up the nerve to push the needle into his own skin. He injected himself twice a day for 66 years. He was a type 1, juvenile onset, brittle, diabetic.

My father’s pancreas did not produce insulin – or at least, not on a regular basis. Insulin is the hormone that controls the level of blood glucose, or sugar, the chemical the body produces to feed the brain. Any fluctuation in the supply of blood glucose to the brain will inevitably lead to physical and emotional disorder. Too little blood glucose and the brain starves, too much and the resultant chemical changes can lead to diabetic ketoacidosis, and possibly fatal coma. Like all Type 1 diabetics my father was dependent, for life, on exogenous insulin, which can only be administered through subcutaneous injection. The trick to survival is not to inject too much, which can lead to insulin shock, or too little, which can lead to diabetic coma. It’s a delicate balancing act on a bio-chemical seesaw.

As I grew up I watched my father ride that seesaw. I observed the schizophrenic abnormality of his everyday life without having any knowledge of the cause. If he came home from work even a half hour late he would already be in ketoacidosis -- the symptoms (stumbling, slurring, and giggling) looked like the drunkenness acted out in television sit-coms. At the opposite, (and more frightening) extreme, when his pancreas kicked in and the combination of exogenous and endogenous insulin spiked way beyond normal levels, his body would be possessed by violent jerking and seizing. When I found him like this, in shock, attempting to shout, barely able to choke out an utterance between spasms of pain and humiliation, he would force me to leave the room. He never explained. We didn’t speak about it. He was a quiet man who otherwise never raised his voice in anger. But I know he didn’t want me to see his loss of control – his inability to govern his own body. In the accepted regimen of treatment for diabetes it is the patient’s responsibility to manage his own condition – to self-medicate -- to adhere to a rigid diet and schedule – to manage to stay alive. My father never rebelled against the discipline required by his condition. But, despite his willpower and his nerve, he was “brittle.” He was never able to perform the balancing act -- to bring that bad, sweet blood under control.

Before he died my father told me that he had never really “felt right.” Even as a child he never felt “normal.” Insulin injections had kept him alive but they never made him well. And he was lucky – lucky to have been born after the discovery and introduction of insulin transformed the acute, rapidly fatal course of diabetes into a somewhat manageable chronic illness. Had he been born before insulin from the pancreas of pigs was made available as a staple substitute for human insulin he might have lived into adolescence but he would likely have been the mirror opposite of the man he came to be.

I imagine him at 17 without insulin therapy -- he would still be tall but much thinner, weaker, depressed, his boyish face always anxious, drawn and grey. He is constantly seizing, sweating -- his brain is starving, his organs gradually failing. He is anhedonic. Feeling no pleasure of his own he can only observe the pleasure of others and know that he is somehow on the outside. So he is angry, undisciplined, aggressive, even “wild.” His friends are experimenting with an illicit drug that causes them to experience dizziness and weakness -- a kind of drunkenness or high. They aren’t aware that the drug is extracted from the pancreas of a pig and full of porcine insulin, which mimics the effect of human insulin. When they take this drug their bodies are flooded with exogenous insulin, which produces a drastic drop in their normal blood sugar levels creating the illusion of a “high” that is in reality the first step toward a diabetic coma. But when my father tries the drug he doesn’t get “high,” he gets “well.” The insulin doesn’t flood his system it fills his lack – his dangerously high blood sugar drops, he suddenly feels “right,” close to “normal.” The drug’s mimicry -- like that of any drug -- tricks the body and it stops devouring itself. Of course, he wants more. He wants to feel even better. It isn’t easy, the drug is illegal, expensive, and it has to be injected to take effect -- but pain is imperious, obeying only the force of the thing that suppresses it. With the drug, he has moments of magic, of balance, he “feels right” -- without it, anhedonia, depression, wasting and, ultimately, death.

At the moment the needle first penetrated his skin he passed through the looking glass into a world of illicit behavior, dependence, and stigma. From that point on he would be willing to overcome any obstacle of morals, of stigma, of repugnance, or risk, to secure and inject the illicit drug. He would become dependent – for life. He would hardly have a choice. He would not look back.

“Feeling right” is a product of the brain’s chemical information system – a network of interlocking Neurotransmitters and Receptors designed to transmit and receive endogenous chemicals like the “pleasure” hormone dopamine. A vast array of neuro-transmitting chemicals are intrinsic to the nervous system which does, in effect, have its own heroin, its own cocaine, its own version of every psychoactive compound that can affect the brain. Dopamine modulates an astonishing array of human behaviors including voluntary movement and emotional arousal. Too much dopamine in the brain may cause hallucination, mania, psychosis -- too little of it can cause depression, even paralysis. Genes determine the structure, production and regulation of every protein in the human body. A gene defect or mutation can result in abnormal or missing proteins – proteins that in some cases may be responsible for the defective production or regulation of the hormones, neurotransmitters, and receptors essential for reward, pleasure and satisfaction – the brain’s reward system. This is part speculation. Neuroscientists understand the reward system as such but haven’t yet identified a specific genetic mutation that might cripple it.

It is possible to imagine (if not yet to prove) that a person, let’s say a woman, might be born with a genetic deficiency that causes a failure in the production, transmission or reception of an endogenous opoid like dopamine, in the same way that my father was born with a genetic deficiency in the production and transmission of insulin. As a result of her genetic mutation she might live in a constant state of anhedonia - unable to achieve normal levels of pleasure and satisfaction or to cope with stress or pain. She might present any number of symptomatic disorders, (depression, schizophrenia, attention deficit, hypoglycemia, etc.) a collection of related diseases triggered by the genetic deficit and potentially amplified by circumstance and environment. Unlike a diabetic, the root cause of her condition would remain undiagnosed.

I know this woman. I’ll call her “A____.” I met her at a needle exchange. A____ once told me that she has never “felt right” -- she never felt like a “normal person ought to feel.” Sharp and funny when she’s not depressed or violent, A____ is bi-polar, suffers from, anxiety, paranoia, hepatitis C and hypoglycemia. She hasn’t the resources necessary to obtain adequate medical care so all of her related disorders go untreated.

A____ has always lived on the “other” side - in a “third world” at the blind spot in a reflection of the first. Like the mirror image, both sides, the two worlds, are a product of only one side – the first world. Both Alice and A____ apprehend the mirror “as a pure surface, a continuity of the outside and inside, of reverse and right sides.” ii Alice imagines the reverse image of her room in the glass to be a “looking glass room” estranged from and more fascinating than her own. On her side of the glass there two blind spots, one at the surface of the glass itself, (the fireplace below the mirror), and another at the doorway to the room beyond. Alice thinks this passage leads to something other. The reversal of asymmetrical objects in the reflection creates this uncanny illusion – once through the glass Alice first realizes, with some disappointment, that the looking glass room is identical to her own – but on turning back toward the mirror she sees that the “wrong” side of everything there is disturbed, altered and distorted. For Alice, the “wrong” side is a space of fascination and play from which, when threatened, she can awake, but for A____ it is an inescapable topology of poverty, alienation, trauma, and pain. Unlike Alice, A____ cannot pass through. She becomes enmeshed at the mirror’s surface, caught up in its complex inversions. No opening in sight, A____ makes a hole and fills it.

Someone has to help her, teach her – you can’t just decide to try heroin. Someone has to show her how to dissolve the sweet white powder over a flame, how to draw it up into a syringe, how to wrap a tourniquet around her arm to make the vein stand out, how to make the hole, how to slide the needle into the vein, to draw blood back into the syringe, to loosen the tourniquet, to push the plunger down and release the “sugar” [the street name for heroin] into her blood.

It hits, and she falls. The needle shatters the glass. Released from its surface, her body saturated with pleasure, her pain dissipated -- at last, she “feels right.”. Words are inadequate, unnecessary – She floats in a painless, sexless, timeless state – immune to boredom or anxiety, in a purity of perfect narcissism.

When the heroin enters her blood stream it crosses the blood-brain barrier – a cellular coating that prevents most substances that are carried by the bloodstream from affecting the brain. Sixteen seconds after she injects, the drug is carried in the blood to the right chamber of her heart where it mixes with the venous blood returning from the rest of her body. Then it is pumped through her lungs, returned to her heart and pumped into the brain. Significantly diluted at this point, it passes through the capillaries of her brain into the spaces between the neurons. Heroin is not biologically active in its own right because of the two acetic acid groups that allow it to rapidly pass through the blood-brain barrier. But when the heroin reaches A____’s brain, her brain chemistry activates it; first, stripping out the acetic acids and producing a psychoactive form of morphine; next, liver enzymes attach sugar molecules that initially deactivate the morphine then combine with other chemicals in the brain to convert it into a hyper-psychoactive “sugar.” In this state it binds to A____’s opiate receptors and “turns them on,” as it simultaneously stimulates dopamine release by suppressing the natural ongoing inhibition of dopamine neurons.

All of us are always on the drugs our bodies make. A____’s need and desire are pre-determined by a lack – an absence on the social side of the skin and a void on the biological side. She knows she can’t go back to the state of torpor and pain. She wants to keep on “feeling right.” But, It can never really be “right.” It can’t make her whole. Too many compromises will be required. Too many barriers, both social and biological will be crossed. Regardless of the cost or the risk, A____ needs to sustain the illusion of completeness the drug offers and that will require ever-increasing doses. Heroin, like most drugs (licit and illicit), is a pretender, a parasite -- it is all mimesis. And A____ comes to depend on its mimicry – but perhaps that is what “feeling right,” even the notion of “right,” always is.

Her very first “taste” of heroin makes her sick. The first injection always provokes nausea and vomiting, but the drug acts on the brain to suppress the memory or emotional affect of the nausea, to erase any sense of repugnance at vomiting. The heroin begins to change A’s brain chemistry. It shuts down the part of her brain that cares if she feels nauseous, or hungry or cold so she doesn’t mind retching and being sick “behind sugar.” After just a few more “tastes” she learns that she can’t bear being sick without it.

Heroin interacts with the limbic system – the center for pleasure and pain, memory and motivation. The precipitous surge of dopamine released in response to the heroin in A____’s brain produces unimaginable sensations of pleasure and satisfaction – beyond anything she has ever experienced before. Her brain records her body’s response in a picture-memory of the event, which subsequently triggers her desire for another hit. After each flood of dopamine the levels recede below base line – and the next spike doesn’t go as high. Time after time the rush feels less intense and the crash harder. Her brain stops producing its own endogenous dopamine, shutting down the already handicapped operation of her genetically deficient reward system.

She loses the rush, the high, the sensation of pleasure but now she has to have the drug just to keep from being sick. Without it she falls ill – the physical symptoms, at first, look like a severe cold or the flu (always accompanied by depression, and dysphoria) but they get worse, much worse. Another, stronger dose of the drug is the only way to “fix” it. She is trapped on the seesaw of the endorphin rush -- the chemical embodiment of Freud’s compulsion to repeat. Entirely dependent, unable to distinguish herself from her craving, she is suspended in a narcissistic loop -- hand > needle > vein > drug > -- a closed circuit of gratification. Like a biological parasite, the drug tricks her brain into thinking that it is an integral part of her - a necessary component of her biological system -- that “fixing” is equivalent to survival. She cares about nothing else and she will do anything to keep the circuit closed.

A____ has been on the street and more or less alone for years. Like most addicts her progression from genetic sensitivity, to abuse, to dependence is mirrored by a narrative of betrayal, dissipation, violence and loss -- all of her relationships gradually unravel in erratic oscillation between hope and disappointment, recovery and relapse, truth and lie.

Her last lover, the one she called “her rescuer,” walked away after yet another relapse. She is sad and angry – she “could still quit for him… why wouldn’t he trust her one more time?” I don’t attempt to answer but I know. I know that he found himself on one side of a situation that doesn’t really have two sides. A____ is like that band that has been severed and twisted and the ends sewn back together the wrong way. She is a bewildering, non-orientable topology. Her lover might keep tracing the surface but he would never make it to the other side. I know. It is virtually impossible to sustain a relationship with an addict. Love requires trust. Trust requires reciprocity – two-way - two beings in correlation. A____ is an autopoetic system – operationally closed with no reference to, or respect for, an other, an outside. She can only iterate on her own drive, her compulsion, her need, her own reflection. She is trapped in a narcissistic loop – she goes on being ill and -- frustrated, betrayed, disillusioned – he lets go.

He wouldn’t walk away if she had cancer – however much he might want to escape. He might blame her but he wouldn’t leave, or not as soon, if she discovered she had AIDs or HIV. He would probably stay if she were diabetic. Because, however devastating, none of these illnesses would create the impossible, simultaneous distance and dependence that addiction does. 

Of course she has tried to quit – over and over again. In her struggle for autonomy over her own body it’s not a question of desire or will, good vs. evil, psychology vs. biology – on the contrary, psychology is biology. Neuroscience is clear. Addiction is not a “problem” it is a chronic relapsing brain disease. Yet, while 75% of the general public accepts the “disease model” the same percentage believes that “lack of willpower” is the primary problem that addicts face. Oh, our culture and its insistence on the power of the will – its propensity to blame the victim. For the addict the “lack of willpower” is just one of many by-products of the disease itself – caused by the alterations to the brain the drug makes. It’s the perfect example of the insidious circularity, the Mobius strip of addiction. What do we hold against the drug addict – that they intentionally cross the boundary between the safe and normal and the abyss - that the condition is somehow triggered by a choice? Is survival a choice? Is frailty? We can’t forgive the addict, that one tragic moment that is repeated over and over, again and again. No love can survive in the libidinal economy of the addict that eventually excludes all but the drug. A____’s rescuer can’t keep hoping in the face of her absolute self-enclosure so he lets go.

And she keeps falling – slipping along the twisted and contorted surface – without orientation, plummeting, dissolving and disappearing. Careening back into the awful material real. From the other side of the mirror I watch her dizzying, disorienting, irregular, oscillation. At the same time I see my own reflection interrupted and refracted as hers passes through it -- the familiar lines and surfaces dispersed into noise. I cup my hands around my eyes and press my face against the glass, trying to peer through the static into the un-illuminated space that absorbs her. I see a blank expanse – a near vacuum -- its dimensions defined by the tortured personas, bleak histories, pained memories and decimated bodies of the most impolitic social “other” – the needle junkie. I am reluctant to pass the boundary the glass provides – I am afraid to get closer -- as though addiction were contagious – or the needle itself a kind of virus – as though the addict were like a parasite seeking a host -- as though I could stay safe inside my own skin.

I want to look away (these are bodies that one just doesn’t want to see) but my encounter with A____ fixes my gaze, draws me through and shatters my assumptions.

Follow me.

You may begin to question. 

Don’t look away.

You may begin to perceive the invisible yet material threads of connection that tie these bodies together in parasitic relation.

Come closer -- close enough, at least, to listen.

Come closer and listen to a body of social and biological evidence – like a pulse that proves that the blood, that carries “sugars” to the brain, is what we all share – it is the source of the kinship of all our bodies.

We are all living with addiction.

This page is a tag of:

Comment on this page