On heroin and harm reduction

Mary Addison Hackett, Seashells, 2014, oil on canvas. 52 × 44". Courtesy of the artist.

There is a photo of you standing outside the house in Borough Park, grin wide, head back, laughing. Slender in faded blue jeans against the brick and white stucco, your hair a mass of thick black curls, a little unkempt. This was you: “the fun one.” On our summer visits to New York, after the long drive south from Ontario, it is you I want to see most of all.

When your daughter was born, I was 5. As I grew older I envied her for having you as a father. We rode the F train to Coney Island, surveying the city through painted windows; ate frankfurters on the boardwalk.

When I was 12, your mother, my grandmother, passed. We stopped visiting New York. I didn’t see or speak to you for fifteen years. By the time I went to college, it was apparent that no one knew where you were.

Suddenly in 2007 you call.

I am living in New York now. You tell your brother, my father, that you are living at a shelter on the Bowery. He comes to town soon after, and the three of us go out to dinner. We don’t speak much of the past. You say you are doing well, and we agree to meet again soon. Your hair is cropped short and you are thin, very thin.

What surprises me most: you have no teeth.

You are not there when I stop by after work. The man at the desk gives me this news, not for the first time. I am tired of relying on luck in order to see you. On my next visit I bring you a prepaid cell phone so we can make plans in advance. This makes you happy.

We walk to B&H Dairy, where I order cold borscht and you cherry blintzes. I show you how to use the phone.

My father calls, tells me he has urgent news to share. I always thought it was cocaine, he says. But it was heroin. He repeats the last word, drawing out the first two syllables. He is wounded, disbelieving. The way his sibling foundered was worse than he had believed. Cocaine is nefarious, sure, but heroin is depraved. He is waiting for me to interrupt — to affirm that I, too, am appalled.

The first time we meet just the two of us, you tell me you have been diagnosed with bipolar disorder. I hardly believe it. You do not conform to any idea I have of a person with bipolar disorder, though the ideas I do have are received, not based on experience. It’s just that you seem to me all right, not terribly different from the way I remember you, though your affect is flatter, hollowed. You wear your defeat.

You complain of ceaseless fatigue, a haze in your head. You list your medications: lithium, Topamax, prazosin, Thorazine, lorazepam, also methadone, more I am forgetting, they are always changing. Frankly I am astonished at, worried by, the number of medications you are taking. The lithium concerns me most. I know that it has dangerous side effects. I know that it is used in batteries. Never once does it occur to me that you seem all right because of the meds and not despite them. You are impressionable and take what I say seriously. The only people you talk to are social workers, counselors, medical doctors, psychiatrists, and you do not seek to inform yourself about your own condition. You are not a skeptic. You do not read. You trust what others tell you. The source is of no relevance.

Within weeks — or is it months? — your behavior seems to me more erratic. You are quick to anger. You demand things of me in your text messages. Usually money. I put fifty dollars’ worth of minutes on your phone; the next day you’ve run out, ask for more. Three, four times in a week, you run out of minutes. I tell you it’s too expensive to be using the phone in this way, and who are you talking to all of a sudden in any case? You say it is your friend Lenny. He is agoraphobic, you add. He rarely leaves the house. By now you think that I am trying to control you, to do you harm, and you begin making accusations. I get you a better phone plan, and for a few weeks, we do not speak.

Later you explain that you adjusted the dosage of your lithium without first telling your doctor. That was you in a manic phase.

I know better now.

Mostly we talk about your daughter, Sophie. She is 21 now and the mother of a boy, 18 months. The father is a young naval officer with whom she has parted ways, but his parents take care of the baby often. You have not seen or spoken to Sophie since long before her son was born. She wants nothing to do with you. You have tried phoning her, you tell me, but she will not take your calls.

You know of her whereabouts, though, because you are in touch with the naval officer’s parents. You call them regularly, hear the latest on Sophie and the baby. They must empathize with you, perceive good intentions. One day they allow you to visit when Sophie is not around. You meet your grandson and you are ecstatic. You talk about it for weeks.

Then one day you phone and they say they will no longer take your calls. They ask you not to call again, hang up.

I am optimistic. This phase will pass; Sophie will come to see that you have changed. I think I know you will be reunited.

We like eating at B&H Dairy and return there often. Today I bring you Tompkins Square Park, a recent book of black-and-white photographs by Q. Sakamaki. In 1986, Sakamaki moved from Osaka, Japan, to the East Village. Throughout the 1980s and ’90s, he documented the park and its surrounding streets, then a gathering place for the city’s marginalized and homeless and a stronghold of the antigentrification movement.

We turn the pages, examine the pictures. I ask you what it was like. You tell me about when you loitered outside an abandoned building turned shooting gallery, waiting in line to buy your next fix. Police officers approached you, but you were neither questioned nor arrested. Instead, they emptied your pockets, took your money. They took everyone’s money. Then they left.

It is difficult to know whether your memory is reliable, whether you can be relied on. But I have no reason not to believe you.

Today is a good day for you. You get new teeth. You are more confident.

July 2013. My eye lands on a headline in the New York Times: “Heroin in New England, More Abundant and Deadly.” I can’t recall the last time I saw heroin in the news. Media coverage of drug use had shifted, or so it seemed to me, to meth.

Officials in Maine, New Hampshire, and Vermont, from “quaint fishing villages” to “the interior of the Great North Woods,” are reporting an “alarming comeback” of “one of the most addictive drugs in the world.” What’s remarkable about the story, according to its authors, is where the comeback is taking place: not in urban centers, but in the smaller cities and rural towns of New England. Experts offer observations. A police captain in Rutland, Vermont, states that heroin is the department’s “biggest problem right now.” A doctor, an addiction specialist, says, “It’s easier to get heroin in some of these places than it is to get a UPS delivery.”

Most of the heroin reaching New England originates in Colombia and comes over the US-Mexico border. Between 2005 and 2011, the number of seizures jumped sixfold — presumably in part because of increased border security — but plenty of heroin still got through. In May 2013, six people were arrested in connection with a $3.3 million heroin ring in Springfield and Holyoke, Massachusetts.

The article describes two addicts in particular, both young women. They sell sex for drug money. One overdosed and died after injecting some very pure heroin. The addiction specialist tells us that he is “treating 21-, 22-year-old pregnant women with intravenous heroin addiction.” The lone man identified is the companion of one of the women. Beyond his name and age, nothing about him or his circumstances is mentioned. All three are white.

I stop when I read, “Maine is the first state that has limited access to specific medications, including buprenorphine and methadone.” I open a new tab, search for what the writers mean by the vague phrase, “has limited access to.” Earlier that year, the state enacted legislation to limit how long recovering addicts could stay on methadone, or similar drug‑replacement therapies, before they had to start paying out of pocket. Medicaid patients will receive coverage for a maximum of two years.

I know that for some people, like you, this is not enough time.

Moving to the United States from Canada was, for me, eight years earlier, an easy enough transition. Much is shared between the two countries, and the culture shock was minimal. Yet even after all this time, I still find that certain ideas I’d taken for granted throughout adolescence and early adulthood — ideas about what a good society tries to make available for its citizens — are here not to be taken for granted at all.

At the Bowery shelter you are a model resident. You participate in group. You see a counselor. You follow the methadone program. You are friendly with others. It is on account of this that you are recommended for Section 8 housing, and before long you are moved into a 200-square-foot studio with a single bed, a private bathroom, a tiny kitchen. The facility, a four-story building, is designated for people living with psychiatric disabilities. Your share of the rent is $260. You are also responsible for your own utilities. These are subsidized based on your income.

For a time you find yourself in a vexing predicament. The state has deemed you “unfit to work.” But each of your applications for disability benefits is denied. It is not at all clear how you are meant to survive.

November 2013. The front page of the Saturday paper features a story on buprenorphine under the headline “Addiction Treatment with a Dark Side.” Buprenorphine is an opioid used for maintenance therapy like methadone, but is available by prescription. This is new. Since the 1970s, methadone has been distributed through clinics. People participating in methadone programs must go to the clinic at least once a week, and in some cases every day. This is obstructive, even oppressive. A similar drug that can be had by prescription seems like an improvement. But doctors must receive federal certification to be able to prescribe buprenorphine. Federal law limits how many patients a physician can help with the drug at one time. This means that only people with good insurance, or the ability to pay high fees out of pocket, can access it. “The rich man’s methadone,” the article calls it.

But this — the part that interests me — isn’t what the article is about. The article is about how the drug gets “diverted, misused and abused”; how, since 2003, the drug has led to 420 deaths. (By comparison, there are more than 15,500 deaths from opioid overdose each year.) The article is not about the drug’s demonstrated efficacy at helping people with opioid dependencies that negatively impact their lives. Or about how restricted access to the drug is likely contributing to its diversion and misuse in the first place. Studies report that at least some people are self-treating their dependencies and withdrawal symptoms. I read elsewhere that medication-assisted treatment with an opioid agonist, such as buprenorphine, is the most effective treatment available for opioid dependencies.

This is what you tell me: From the time you were young, you possessed an antiauthoritarian streak. This disposition did not emerge from any particular maltreatment, by family members, say, or teachers; it was your natural orientation toward the world. You were enthralled by the neighborhood kids who attracted trouble even as you yourself did not act out. You desired proximity to danger and rebelliousness. Unlike your brother, you attempted to differentiate yourself from your family not by transcending your class, but by assuming a posture of nonconformity. You liked drugs because you weren’t supposed to like them. For a long time — more than a decade — you were able to manage your use, to keep it, for the most part, recreational.

One time your father found your needle and other supplies for shooting up. He was furious. You wouldn’t hear it. When he died years later his heart was still broken.

I have difficulty reconciling all this with what else you have told me of your past. I know that you worked for the police as a 9-1-1 dispatcher. You were good at your job, liked and respected, and soon you found yourself in a supervisory position. You enjoyed the night shift, especially, and for a long stretch the Bronx was your district. The position is notoriously stressful, but you were sharp, capable, levelheaded, and you excelled.

You were fired when your fidelity to heroin was stronger than it was to your job.

You love your new apartment, can’t believe your good fortune. When I stop to consider it, neither can I.

Sometimes I imagine what you will do with your time. I picture you as a volunteer — with other people who use drugs, maybe, or at a food kitchen or shelter. I feel certain that you will want to do this, that you will do something good, in the way that others did good for you. That maybe we will do something good together. Once, when I am volunteering on American Thanksgiving, I invite you to come along. I know that you have nowhere else to go. You tell me you’d prefer to stay home. A few months later, I make the suggestion once more. Again you decline.

Later I come to recognize this as my own bizarre fantasy, a projection of my savior complex, perhaps. I laugh, not for the first time, at the naïveté of my younger self.

December 2013. Two articles command my attention. The first, a few weeks old, is about a radical clinical trial in Canada comparing the effectiveness of diacetylmorphine — prescription heroin — and the oral painkiller hydromorphone, i.e., Dilaudid, in treating severe heroin dependency in people for whom other therapies have failed. An earlier study in Canada had demonstrated that both diacetylmorphine and hydromorphone are better than methadone at improving the health and quality of life of longtime opiate users. An unexpected finding was that many participants couldn’t tell the difference between the effects of diacetylmorphine and hydromorphone. But the sample group receiving hydromorphone wasn’t large enough to draw scientifically valid conclusions. So the study investigators created a new trial to test this finding.

If hydromorphone were to be found as effective as diacetylmorphine, it could mean offering people the benefits of prescription heroin without the legal barriers and associated stigma. The study results have yet to be published.

Larry Love, 62, a longtime dependent: “My health and well-being improved vastly” during the trial. Love’s doctor applied to Health Canada for permission to continue prescribing heroin to Love and twenty other patients after their year in the trial was up. The applications were approved, although renewal was required after ninety days. The federal health minister responded by creating new regulations to prevent such approvals. He insisted Ottawa would not “give illicit drugs to drug addicts.” Love, four additional patients, and the health-care center that runs the hospital that oversaw the trial are suing the government in turn. The doctor who submitted the applications, Scott MacDonald: “As a human being, as a Canadian, as a doctor, I want to be able to offer this treatment to the people who need it. . . . It is effective, it is safe, and it works. . . . I do not know what they are thinking.”

The second is an editorial about a Canadian bill that, if passed, would set new guidelines for opening supervised-injection facilities. Like syringe-distribution programs, supervised-injection facilities act as a frontline service for people who use drugs intravenously, giving out sterile needles and other paraphernalia. But they go one step further: users may bring in drugs procured elsewhere and inject them under the watchful eye of trained nurses. Staff members offer instruction on safer technique (“Wash your hands,” “Remove the tourniquet before pushing the plunger,” “Insert the needle bevel up”) and monitor for overdose, which they counteract with naloxone. They do not directly administer injections.

The new law would erect application hurdles so onerous it would effectively prevent the establishment of any new sites. The columnist attacks the government for acting on ideological rather than scientific grounds. “Supervised injection sites are places where horrible things take place.” I cringe a little. “The fact is, however, that these activities are even more horrifying when they take place in the streets, and strict prohibition has never been even remotely successful.”

There is, I know, only one such facility in all of North America. It’s called Insite, and it’s in Vancouver.

It is a fall evening and we are on our way to a movie. We pass a small group of Chabad men on the street. It is Sukkot and they are trying to identify secular Jews by sight, inviting them to perform the ritual with the date-tree fronds (lulav) and lemonlike fruit (etrog), shaking them together three times in six different directions. They have a small truck nearby (the Sukkahmobile). You tell me how a Chabad man befriended you once, how you almost became religious. He wanted to help you, and you had no one else. You went to dinners at his house. He would call to ask how you were. You say that he and his family were some of the kindest people you had ever met. But you couldn’t stick with it, and one day you stopped responding.

I take you to see Ballast, that film of austere, understated realism about a drifter boy and a grieving man in the Mississippi Delta. It’s more about tone than narrative, and I am moved by the beauty and sadness of its barren landscapes. I worry that you are bored, you nod in and out; but afterward you tell me how much you liked it. I decide I will take you to movies often.

Within weeks of Philip Seymour Hoffman’s death, a surfeit of reporting:

Why heroin is spreading in America’s suburbs
How Did Idyllic Vermont Become America’s Heroin Capital?
New England town ripped apart by heroin
Today’s Heroin Addict Is Young, White and Suburban
Heroin’s New Hometown: On Staten Island, Rising Tide of Heroin Takes Hold
When heroin use hit the suburbs, everything changed
Heroin in the Suburbs: A Rising Trend in Teens
Heroin reaching into the suburbs
Heroin Scourge Overtakes a “Quaint” Vermont Town
Heroin-gone-wild in Central New York causes jumps in overdoses, deaths
Actor’s heroin death underscores scourge closer to home
Heroin scourge begs for answers
New Wisconsin laws fight scourge of heroin
The scourge of heroin addiction
Heroin scourge cuts across cultural and economic barriers
Colombian, Mexican cartels drive LI heroin scourge
Senate task force hears from Rockland on heroin scourge
Report shows heroin use reaching epidemic proportions in NH
America’s heroin epidemic: A St. Louis story
Heroin: Has Virginia Reached an Epidemic?
United States in the grips of a heroin epidemic
Cheap, Plentiful, Deadly: Police See Heroin “Epidemic” in Region
How Staten Island Is Fighting a Raging Heroin and Prescription-Pill Epidemic
A Call to Arms on a Vermont Heroin Epidemic
Fighting Back Against the Heroin Epidemic
Ohio struggles with “epidemic” of heroin overdoses
Cuomo Adds 100 Officers to Units Fighting Heroin
Governors Unite to Fight Heroin in New England
Police Struggle to Fight America’s Growing Heroin Epidemic
DuPage officials suggest laws to fight heroin
Taunton Launches Plan to Fight Heroin After Dozens of Overdoses

There are many more I don’t write down.

Your disability application is finally approved. You will receive monthly Social Security payments of $780. You are also entitled to the disability that has accrued from the time of your first denied application, which, because it was several years ago, now amounts to several thousand dollars.

There is one condition, however. The state has decided that, given your history, you are unfit to oversee your own finances. You will need someone who can demonstrate gainful employment, preferably a family member, to tend to the money on your behalf.

On a winter morning, early, I take the bus from Prospect Heights to the Social Security office in Bushwick. We have an appointment but we wait a long time. I sign where I am asked to. I attest to my reliability. I assume responsibility.

Soon after I set up a bank account where I am your “representative payee.” Your money is deposited to it on the first of each month. From this account I pay your rent, your utilities. We meet every week or two, for food, for a movie, but always so that I can provide you with cash for provisions.

This works for a while.

On the phone one day you tell me you hurt your arm, a man on the street walked right into you, knocked you down to the ground. When I call a few days later to see how you are feeling, you tell me how strange it is, nearly every guy you pass on the street is eyeing you as if he wants to start a fight. These men, they are always brushing up against you on purpose.

Within a week, maybe two, you begin to ramble about the lock on your door, how it’s broken, and how you’re sure someone is breaking into your apartment to spy on you. You tell me that one day you came home to find a syringe on the floor. Someone planted it there for a supervisor to find, you’re certain of it, other residents want your apartment, they want you gone.

I suggest various ways you might resolve these issues. You have excuses, explanations for why each of my recommendations won’t work. I ask a lot of questions. Your paranoia does not involve state secrets, the CIA or FBI, tinfoil hats or aliens, the twin towers or global-government conspiracy theories, but the elevation of small anxieties and fears to delusions of persecution. I try reasoning with you, but sometimes, in order to empathize, I must suspend my desire to be rational and take part in your fantasy world. I learn there is nothing I can do for you; you are autonomous in overseeing your own health care. I encourage you to see your psychiatrist and wait. Once your medication is adjusted, you are no longer afraid.

Not long after your disability payments kick in, the debt collectors send notices to my apartment. One is on behalf of an old landlord who, years ago, sued you for rent payments you never made. It has been more than a decade, but this debt has not been forgotten. I mail a check.

Here are some things you might do on a given day: Walk to the methadone clinic to pick up your dose (you are required to go three times a week). Wait in line. Take one bus to the Medicaid office (when your pension kicked in, your monthly benefits went up, pushing you just slightly over the minimum-income requirement). Wait in line. Take one bus to see your psychiatrist (you live in Bushwick; your psychiatrist is in Crown Heights). Wait. Take one bus to the Supplemental Assistance Program office (you lost your EBT card and need to request a new one). Wait in line. Take two trains to see your hepatologist at NYU Langone Medical Center. Wait. Walk to the post office (to pick up the check my father has sent you). Wait in line. Walk to the nearest Western Union (where you would cash checks before you had a bank account). Wait in line. Take the bus and two trains to Maimonides Medical Center in Borough Park (you need a colonoscopy). Wait.

I write down statistics, try to make sense of what I’m reading. In 2012, US physicians wrote 240.9 million prescriptions for painkillers, an increase of 33 percent since 2001. The growth can be attributed to a few related factors: patient-advocacy groups calling for better pain treatment; patients, perhaps influenced by pharmaceutical marketing, requesting drugs from their doctors; doctors, some with questionable ethics, overprescribing drugs.

The US government responded in a predictable way. It introduced more stringent prescription guidelines, authorized DEA investigations and closures of “pill mills.” State governments began to use databases to track “doctor shoppers,” patients who sought out prescriptions from multiple physicians.

In 2010, Purdue Pharma, the producer and patent holder of OxyContin, introduced an abuse-deterrent version of the drug ostensibly impervious to crushing, breaking, chewing, and dissolving, and therefore more difficult to inhale or inject.

That same year, the number of US drug poisoning deaths involving any opioid analgesic (oxycodone, methadone, or hydrocodone) accounted for 43 percent of the 38,329 drug poisoning deaths, a fourfold increase from 1999, when opioid analgesics were involved in 24 percent of the 16,849 drug poisoning deaths.

Following the government crackdown, supply of pharmaceutical opioids decreased sharply. Demand did not. The street price of prescription painkillers inflated, and many pharmaceutical opioid users opted instead for heroin. A rising supply of heroin kept prices low.

According to one study, more than 81 percent of recent heroin users say they switched after first trying prescription painkillers.

You say that one day, out of the blue, you decided to give it up. Just like that.

You call at around eleven on a weeknight to tell me you are going to call an ambulance — you are in pain. Ten days earlier you had surgery on an abdominal hernia. The procedure was supposed to have been minimally invasive, performed with a scope, a few hours all told, and I waited to take you home. But there were complications. They had to cut you open. You were admitted to the hospital, stayed seven nights. Now you are home again but certain that you are not healing properly. When I arrive at your place in Bushwick, the paramedics are helping you into the back of the ambulance. I get in with you. We sit opposite each other. I ask you questions. You are lucid. I expected you to be doubled over, but you are not. The paramedics confirm that your vitals are good. You have no fever. At this point, I am confident that this trip is unnecessary; that there is nothing to worry about except that you are alone, and you understand what that means. But I stay silent as you tell the paramedics to take you to where you want to go.

When we arrive at the emergency room, the triage nurse evaluates you. You tell her about your pain, your recent surgery. Soon you are wearing a bracelet and gown, sound asleep in a bed. It is past midnight. I sit in the vinyl sled-base chair to read, but am more interested in the ER nurses shuffling through the ward, the gurneys wheeling by, bodies and machines, the perverse game of observation and diagnosis. Who among the patients holds the fate worse than all the others? I know that if you’re asleep the pain is not as bad as you said it was.

Not far from your bed, just outside the curtain, a young man in a wheelchair, his neck slackened, his chin drooping close to the chest, vomits. It’s viscous, like cake batter. It pours out of his mouth and covers the front of his gown. He is unconscious and makes barely any sound. Now is a good time for a walk. I head outside, buy some chips from the gas station.

When I return, the young man has been moved to the center of the ward, where, shuddering now, he continues to vomit. The former contents of his abdomen pool and spread on the floor. A nurse approaches. I point to the man and ask whether something might be done for him. The nurse frowns, tells me that the man is getting what he deserves; he has done this to himself. She walks away. Several nurses pass the gurney, but no one looks at the man.

It is 4 AM by the time the doctor sees you. Everything is fine, he tells us. By now the chaos of the ER has quieted. You slept right through it.

Tomorrow, I will get up early and go into work at an office.

For the first time, I resent you.

The morning I visit Insite I awake to a winter sun, a rare reprieve from Vancouver rain. It is still early when I take the bus downtown. The buildings glimmer gold and red under the warming light.

I decided to come here, to make the long trip to Vancouver, because I wanted to see Insite for myself. I wanted to see the place where people who use drugs intravenously can go to inject more safely, the place where, according even to the supportive editorial I’d read earlier, “horrible things take place.” By then I had read enough about supervised injection to know that I thought it less horrible than humane. There is much else for which I would reserve the word horrible, including the treatment by law enforcement of people who use drugs.

Between 1992 and 2000, more than 1,200 fatal overdoses were recorded in Vancouver. Many of these took place in the Downtown Eastside, a neighborhood of ten or so square blocks where more than 4,600 people who inject drugs intravenously were known to live. The HIV conversion rate was the highest in the Western world. (This was due in part to the popularity in Vancouver of using cocaine intravenously: cocaine has a very short half-life, and people injecting the drug habitually might do so as many as forty times a day, as compared with heroin, which tends to be injected one to four times a day.) The city, recognizing that American-style prohibition had failed to bring about any improvement, undertook a kind of crash course on drug policy. A succession of public forums, meetings, demonstrations, and conferences with experts from all over the world brought together drug users and their families, service providers, academic researchers, police, and policymakers to examine alternative approaches — heroin-prescription programs, supervised-injection sites, decriminalization.

In 2003, Insite opened as a pilot research program, exempt from the criminal code. It was not the only new service offered in the city, and it was “no silver-bullet solution,” a disclaimer Canadian policymakers, activists, and other supporters used often to describe its alternative approaches. But because it seemed to stand at the threshold of what progressive-minded people deemed acceptable — because, for many, it seemed intuitively wrong— it received the most attention, and was widely discussed both province- and nationwide. This, too, interested me. Most Vancouver residents initially opposed the facility but came to support it; this took a lot of convincing, and a shift in the way people understand illegal drugs and those who use them. I wanted to know how this had happened.

In 2006, the Conservative Party in Canada won the national election, ousting the Liberals. For the first time since 1993, Canada had a Conservative prime minister; from the start, he began dismantling the country’s social programs. Early on, Insite became a battleground for drug policy across the country. The government tried to shut it down, but the Portland Hotel Society (now PHS Community Services Society), the nonprofit group that runs Insite, mounted a human rights case and took it to the Supreme Court. In 2011, Insite won the right to stay open.

Still, I wondered how long it could last. I wanted to know, too, if something like it could ever exist in the United States.

At 9 AM, five men and women sit on the sidewalk on flattened cardboard boxes, first in line to enter when the doors open in an hour. Outside I meet Russ Maynard, Insite’s program coordinator. He’s with several college students from a health-administration program, there on a class visit.

As a group, we walk through the reception area into the injection room. At first glance, it reminds me of a hair salon. The room is wide and bright, lined on one side by mirrors and a row of numbered bays, thirteen in all. Each has a stainless-steel counter, a sink for hand washing, a sharps container, a plastic chair, and an extraction hood to collect smoke and vapors.

A platform with a curvilinear counter, the kind you see in hospitals, is raised behind the booths. Lining the countertop are bins that contain all the supplies a person would need to inject drugs — a syringe, a cooker for mixing the drug with water, a sterilized-water capsule for flushing the needle, a tourniquet to tie off a vein. There is, too, a tool for crushing pills.

In the injection room, we arrange our chairs in a loose semicircle around Russ, who stands. Russ begins his introduction. Insite is operated by Vancouver Coastal Health, the regional health authority, and PHS Community Services Society, a neighborhood nonprofit that focuses on the hard to house. PHS started in 1991, after a residents association converted a hotel into housing for the homeless. Today it provides residences for 1,200 people across sixteen buildings.

PHS also provides a range of community-based programs, including a credit union, a community drop-in center, medical and dental services, a syringe exchange, and an art gallery. Users of Insite can access all this simply by coming in, and to get them to come in is Insite’s goal. Making contact is the first step toward connecting people, at their request, to vital services they might need. They call the people who use their services “clients.”

Russ presents the group with a moral dilemma. “Imagine you’re working at the front desk and a woman walks in and she’s eight months pregnant, and she wants to come in and inject. You have to make a quick decision. If the line starts getting backed up, there’s going to be an argument, or maybe worse. So what’s going to happen?”

The room is silent.

I try to visualize the scenario, but it tests the limits of my open-mindedness. It is difficult to imagine supporting a pregnant woman’s injection-drug habit.

“Is she going to leave and the clouds will part and the sunshine will hit her face and she’ll see the error of her ways and never use again? Or is she going to take some equipment and go use in an alley or a doorway or a hotel room or something like that? If you do take her in, you can connect her with the nursing staff. You can have her housed by the end of the day. You can connect her with food, with services, all kinds of things. And you forgo all of that if you turn her away.”

Someone asks about the mirrors. They are a critical design feature, says Russ. Staff use them to monitor clients while maintaining a respectful distance. Clients use them to ensure a certain amount of caution when injecting — to pay more attention to doing it properly. Russ: “You want it in your veins. Because there’s a big wash — imagine a wave coming to hit you — and you won’t feel anything for a little while. And if you make a mistake, it means that you have to go back out and perform sex work, or beg, or steal, or whatever it is you do to get the ten dollars you need. And that is stressful.”

Since 2007, the staff at Insite has been able to refer visitors to Onsite, a detox center on the building’s second floor. There are twelve private rooms, each with its own bathroom. Insite connects between 400 and 450 people each year to detox, which, Russ claims, is more than any other project in Canada.

The students leave. One at a time, men and women, young, old, homeless, ordinary, are called in from the waiting room. As they enter, they announce the drug they will be injecting: “down,” “dillies,” “crystal” (heroin, Dilaudid, methamphetamine). The receptionist records their answers in a database, in case of emergency or overdose.

I watch the mirrors from across the room. A stately man in a wool sweater, navy with white snowflakes, drags a fine-tooth comb through his silvery hair, from the top of his forehead back to his nape. He does this twenty or thirty times before tending to his mustache with the same fastidiousness, never breaking focus. Then he pulls a woolen cap over his head and walks out into the sun.

A young nurse examines the arms of a fiftysomething woman. The woman looks afraid. The nurse speaks in soft tones as she runs her hands along the woman’s forearms, helps her to locate a vein that isn’t damaged, scarred, or collapsed. The nurse ties a tourniquet around her biceps. They both pause. The woman, hand trembling, inserts the needle. The nurse removes the tourniquet. The woman pushes the plunger.

Hours later, I see the same woman on the bus, traveling along Hastings Street. I want to speak to her, consider doing so, even as I know it’s not right (privacy). But the woman is with a friend. Instead I watch her, imagine where she’s going, how she will spend her time, what her home is like. If anyone awaits her there.

The woman gets off the bus.

I ask Russ whether he knows any clients who might be willing to speak with me. He hesitates. Donovan Mahoney is doing well, he says. He puts me in touch. Now I am in Donovan’s living room. We sit opposite each other, on separate couches. A series of photographs he has taken hangs on the wall above his head. Today Donovan is a talented photographer. His apartment, the garden level of a house in a middle-class neighborhood, is spacious, with a chef’s kitchen and newly laid blond hardwood floors. He wears khaki pants and a gray sweater, slim-fitting with an overlapping V-neck. A baseball cap covers his partially shaved head of thick black hair.

Donovan tells me the story of his twenties: he followed a girl to Vancouver, fell into coke, then rock cocaine, then heroin. He’d always thought heroin was dirty, but after trying it for the first time he felt its reputation was undeserved.

For a while he made money as a dealer. When he wanted to binge, he would go to the Downtown Eastside, stay in an SRO hotel where no one would find him. Then one time he didn’t go home. He let his monthly rent payments pass, grew paranoid. He left behind all his belongings, including his car. This was in 2001. He lived on the streets, mostly. He didn’t like to feel closed in by walls, especially when he was high. He shoplifted, was caught often, spent many nights in jail.

He was wary of Insite when he first heard about it. On the street, he knew that everyone was working an angle. There’s a forthrightness to interactions that doesn’t exist elsewhere. He found it freeing. But he couldn’t understand what would motivate the staff at Insite.

Now he credits them for helping him to achieve all that he has.

Donovan: “They’re inadvertently showing you that there’s another way of life. You start to have normal conversations. You say to them, ‘What do you do?’ They reply, ‘I don’t know, I’m in a band.’ Of course they are. And then they tell you stuff about what they do with their girlfriend. Or how they went away for the weekend and saw their parents. To me, to an addict, they’re showing me something. There’s a whole other world out there that I don’t even understand. They’re showing you what it looks like to be a normal human being. Which is incredible, because if I’m shooting dope in an alley, I may bump into somebody who’s been through recovery, and they may be able to guide me. But they’re not going to be around when you need them.

“Addiction isn’t nine to five. It’s not like, ‘OK, tomorrow at ten o’clock I’m going to go into recovery.’ It happens and you don’t really see it coming. It’s like, I think right now, if you guys got me in, I think I could go.”

You want to be in charge of your own money. It is frustrating to have to travel to me every time you run out of cash. Together we visit your social worker, talk about how this could work. He needs to make a recommendation to your psychiatrist, to the state, before this can happen. We review your history. For the first time it is affirmed to me that you are likely to take methadone all your life. The social worker mentions your dose — 120 mg — says it’s high, that you haven’t decreased it since beginning the therapy. You acknowledge as much. Still, it has been stabilizing, and the social worker is not concerned.

I tell the social worker that I will share the bank account with you, monitor your spending. Satisfied, he makes the recommendation. We open a joint account. Your monthly checks will be deposited and you will be responsible for paying your bills, for making sure you have enough to get through the month. I will check on the account through online banking. I keep your savings, a few thousand dollars left over from the disability back payments, in a separate account in your name.

For a year, at least, you manage all right.

I know that, in the late ’80s and ’90s, the rapid spread of HIV through needle sharing galvanized US activists to challenge state laws and distribute hypodermic syringes for free, without a prescription; that the rate of new HIV cases in Vancouver among intravenous drug users persuaded even conservative politicians to consider opening a supervised-injection site; that were it not for the HIV epidemic, many drug-policy reforms in the US and elsewhere might not have occurred.

I find it curious how few articles on the emerging “epidemics” — heroin, opioid — mention the disease. I wonder whether it is because, with antiretrovirals so widely available, HIV is perceived to be less threatening than it once was. I chase the question for a time. I print out medical papers, underline findings. I call an epidemiologist at a prestigious university, who answers my questions patiently. He tells me that some of the best research is being done by an epidemiologist in Kentucky, who has been following a cohort of intravenous drug users since 2008. (Appalachia has disproportionately high rates of nonmedical prescription-opioid use and overdose-related deaths.) No one in the cohort had yet been diagnosed HIV positive, but 70 percent have hepatitis C. I ask why this matters, and he says that rising hepatitis C rates often forecast HIV outbreaks, because the viruses spread through the same behaviors — unprotected sexual intercourse and needle sharing — and both require a certain density of drug users to sustain transmission. But hep C is ten times more infectious, can live outside the body longer, and is extremely difficult to kill; it spreads more easily. A hepatitis C outbreak indicates that all the factors are present for an HIV outbreak.

In many ways, it’s a ticking time bomb, the epidemiologist says, especially since, in rural Appalachian communities, knowledge about HIV tends to be minimal; these populations have not previously had to deal with the disease.

I hang up the phone, look up the data set that tracks syringe‑­distribution programs by state. Kentucky, 0; Tennessee, 0; Georgia, 1; South Carolina, 0; North Carolina, 6; Alabama, 0; Mississippi, 0; Ohio, 2; Virginia, 0; West Virginia, 0; Pennsylvania, 2; New York, 22; Maryland, 1.

You are weak and exhausted, have been for months. Every time we make plans, you cancel. Months pass and I don’t see you. When by routine appointment you see your hepatologist, he sends you to the emergency room. You will need a blood transfusion to give you the hemoglobin that you need. By the time I arrive, the blood has been ordered from the bank, is being warmed. We wait for hours. The transfusion itself will take hours, too. I leave you there alone.

Before I go, the doctor tells me that what you are experiencing is a complication from hepatitis C.

We sit at your kitchen table beside the four-drawer wooden dresser, its surface lined with pill vials and bottles of methadone. I tell you about Insite. You appear bewildered, shocked even. “How can that possibly help anyone get off drugs?”

Your first reaction resembles most people’s, but it’s not what I want you to say. I want you to argue that getting people off drugs need not be the primary goal. I want you to be critical of the status quo —of the morass of law and policy in which you and millions of others are entangled. But you are not. You have only ever been exposed to one idea, one approach: abstinence.

I explain it to you this way: that the most serious harms that arise from drug use — HIV, endocarditis, tetanus, septicemia, thrombosis — come not from the drugs but from external factors. Of all the ways to administer drugs, injecting carries the most risks. The drug solution bypasses the body’s natural filtering mechanisms against disease and bacteria. Access to sterile equipment and hygienic injection conditions can mean the difference between living and dying.

I say, thinking you might relate, that policing has an especially devastating effect on people who use drugs intravenously and are entrenched in street life. When they fear the police, they don’t stop using, they just move elsewhere — to neighboring areas, where they may create new syringe-sharing networks, or to hidden or indoor locations. In such places, needle sharing is more common, because access to clean needles is cut off. When police are around, users avoid carrying clean needles, for fear of being identified as addicts and harassed. Overdoses increase. Precarious witnesses, fearful that police will follow medical personnel to the scene, fail to seek help.

I have stats at the ready. Nearly 500,000 Americans are incarcerated on drug charges. Another 1.2 million are supervised on probation or parole. Overwhelmingly, those affected are black, and not because they use and sell drugs at higher rates — on the contrary. I say that prison is no place for people who use drugs, help does not await them there. Maintenance therapies using methadone and buprenorphine are not available for people with opioid dependencies. Often an incarcerated person will continue to use drugs throughout a prison stay, and the clandestine nature of his use means that he is now more at risk than he might otherwise have been, using unsterile needles and sharing syringes among multiple inmates. Overdose rates peak in the first few weeks after release from prison, with mortality rates higher than what would be expected in similar demographic groups in the general population.

You begin to understand. You agree none of this is good. But still you are uneasy. You maintain it would be better to encourage people to stop using altogether.

A year has passed since I spoke with the epidemiologist. I read in the newspaper that more than eighty people in Scott County, Indiana, have tested positive for HIV, most of them from a small town called Austin. The outbreak can be traced to intravenous use of the drug Opana, an opioid analgesic. The transmission rate has been around 80 percent.

Meanwhile a woman in Austin buys a license to carry a handgun because she fears for her young children. The woman takes pictures of “all this stuff going on” and calls the tip line. “I do nothing but,” she says. On her lawn is a sign: No loitering or prostituting is allowed in front of these premises.

You resent me now. I am trying to help you budget your money. You are spending your entire monthly payment within the first week. When your next deposit comes, I transfer it into the account you cannot access. Every week, I allow you one quarter of your stipend, after deducting your bills and rent. But you won’t stop texting me, asking for more money. I try to reason with you, explain why you need the budget. I try putting my foot down, which amounts to ignoring your texts. You say you are buying a lot of $5 bootleg DVDs (Hitchcock is your favorite), but you forget that I know how to do math. And you are not interested in any of the solutions I come up with — a cheap computer, an internet connection, Netflix.

Every time I say no, I know I am passing judgment on you, on the things you desire for yourself (your collection of Adidas sneakers is by now substantial), what you prioritize. I am measuring you against an ethic of responsibility, a conception of the good life, that I do not want to force you to share. I can recognize this, but I can’t hew my way out of the irony that accepting your irresponsibility only shifts the burden onto me, and this too seems unjust.

You were lucky once. You and my father sold your childhood home for $300,000. You never risked going to prison to support yourself. But before long, your half was gone, and you started spending my father’s share. He cut you off, begged you to stop, but you said no, you had never felt so alive, you were having the time of your life.

We go to the bank and close the joint account, transfer your savings. You have total control.

I feel light.

Your savings vanish within a month.

You show up to an appointment with your psychiatrist, but it is the wrong day. You are confused, delirious. You travel by ambulance to the psychiatric emergency room at a nearby hospital. Your social worker calls to report what has happened. He says you may be showing signs of early-onset dementia. He says you may be abusing your methadone. I tell him about our recent conversation, the one where you told me you were taking Klonopin to sleep at night; the one where you guardedly suggested you may not be taking it as directed.

Two weeks later the social worker calls me again. You have terminated your services with their facility. You are within your rights to do so, and by phoning to let me know, the social worker is breaking protocol. But he is worried, thinks you lied when you said you found a psychiatrist closer to home. He believes you may no longer be fit to take care of yourself. He wants to call Adult Protective Services, would I be all right with that, and might he provide them with my phone number? He says to me, Please, you are the only person H. has.

It takes a few days, but I reach you. I come over with pastries from the Doughnut Plant. You seem all right — lucid, lively. You want to know how I know about it all. You are annoyed that someone would call me. You tell me that you like your new facility, that you are happy not to travel to Crown Heights to see your psychiatrist. Getting around the city is hard now. Scoliosis has you bent in two. You are not lying about the existence of this new facility. But when I ask whether you have a new social worker, someone who can help manage your various appointments, who knows what services you are eligible for, who can connect you with the things you need, who you can talk to about your private thoughts, it occurs to you, for the first time, that you do not. I tell you to look into it.

A few weeks later, I hear from my father that you have started traveling to Crown Heights again.

I met R. through a dating app. Now I am sitting with him in a wooden booth in a dark bar drinking Campari with soda and lime. We talk, and it’s clear he knows a lot of things. He refuses to say much about it, but for years he studied Kabbalah. He also lived in India, studied Buddhism. Now he works as a professor. We share some ideas about politics, enough to make him stand out among the other dates. We seem to be getting along all right.

Recently he has been to Vancouver. I tell him that I’ve also been there. We talk about the Downtown Eastside, and he tells me he knows and respects the work of Gabor Maté, whom I interviewed on my trip. Maté is a physician and harm-reduction advocate, a proponent of safe injection sites, who worked in the Downtown Eastside for twelve years. He’s also a proponent of the healing powers of ayahuasca, which is how R. knows of him. I enjoy this conversation, the overlaps in our knowledge. I tell him about Da Vinci’s Inquest, the Canadian television program based on Vancouver’s chief coroner turned mayor, the same mayor who was in office when Insite opened. R. tells me that he has done, still sometimes does do, heroin. A casual user.

It’s like a test. I can recall the many times I have pointed out, in abstract conversations, that heroin’s reputation does not align with scientific evidence; that although it can be devastating for some, it is not, in itself, any more dangerous than a lot of other drugs, and people who use heroin are unduly stigmatized. But here it is no longer abstract. Will I hold it against R.?

Later, when I mention this detail to a friend, she frowns. “I like the other guy better.”

You are cured of your hepatitis after a course of Sovaldi, a new pill that clears the disease in 95 percent of cases. The price of this near-certain cure: $84,000. Each pill costs $1,000. You are fortunate to live in New York, the state where Medicaid coverage of the drug is the most generous. Many states pay for only the sickest patients. You are, relatively speaking, not that sick.

For the first time I come across an article in the popular press that challenges the accepted narrative. A professor of psychology and psychiatry named Carl Hart says the heroin public health crisis is a myth. He claims the attorney general is overstating the problem. The commonly cited metrics are insufficient and misleading: the number of people who have tried heroin doesn’t tell you how many people have dependency issues.

Weeks later, I underline a sentence in Drug War Heresies, a book that attempts to project and evaluate the consequences of various legalization regimes and drug-policy reforms: “One million occasional drug users may pose fewer crime and health problems than 100,000 frequent users.”

There are more interviews to transcribe. I’ve been procrastinating. Today I am listening to my conversation with Gabor Maté. My friends have been trying ayahuasca, going on retreats, and they all seem to know of him, to hold him in high regard.

I know the quote I want, am waiting for him to say it, fast-forward through my own voice.

He says: “Abstinence is just not a model you can force on everybody. There’s nothing wrong with it for those for whom it works. But when it comes to drug treatment there’s an assumption that one size fits all. And if you’re going to wash your hands of people who can’t go the abstinence route, then you’re giving up.”

He says: “Harm reduction means you give out clean needles, you give out sterile water, you resuscitate people if they overdose. You help people inject more safely. You’re not treating the addiction. You’re not intending to. You’re just reducing the harm.”

We decide to see a movie in Williamsburg. In the back of a livery car, you tell me that one thing you really miss, one thing you think you should try to do, is find a female companion. I agree that this would be ideal, but I’m not sure how to help. I say that maybe you should go online. I show you the dating app on my phone and we laugh at its absurdity. I say there must be sites for older people. But you don’t have a computer, and you don’t have a smartphone. I’m certain you could count the times you’ve used the internet on one hand.

You tell me about the woman in the apartment below you. Whenever you try to shower, she immediately turns on all her faucets and uses up the hot water before you even have time to undress.

I explain the unlikelihood of this — hot-water distribution in a multi-unit building just doesn’t work that way. You seem reassured, but the next time we speak, you complain that the problem continues.

Weeks later, you call in a panic. Con Edison is threatening to cut off your service, and you can’t afford to pay. The bill is several hundred dollars, despite the subsidy you receive. You tell me you had been running your space heater all day, every day, for weeks — the building had kept the heat on low. You either underestimate my intelligence or the shame is too great.

I call Con Edison, take care of your bill. You haven’t sent a payment in six months. When I confront you with this, you insist on your version of the story.

You call a car and ride over to my place because you don’t have money to get you through the month. My father says that if I lend it to you, he’ll pay me back.

“You know what happened?”

You are sitting at my dining table. You are smiling, and you tell me that when you finally met the hot-water villain, you found her beautiful and fell in love.

You gave her a holiday gift: a note and $30. You stuffed it under her door. She kept the money, of course, but she never acknowledged you.

When you leave I give you extra cash for your car ride home.

A week later, you call to apologize for lying to me about the Con Ed bill. This is a first.

The Canadian government releases details of a damning audit. The audit alleges that PHS Services, which runs Insite and in 2013 received provincial-government funding worth approximately $18 million, misused corporate credit cards and reimbursed improper expenses:

$8,600 for limousine rides in 2013
almost $900 per night for a stay in a British hotel
more than $2,600 for a stay in a Disneyland resort for two adults and two children
$5,832 for a Danube cruise

The article reveals many other missteps.

I wince. I know how hard these people have worked, how much they’ve done for the hard-to-house in Vancouver. I know this scandal will taint them forever. To open a facility like Insite, to set up crackpipe vending machines (as they have also done) — to challenge the status quo in this way — you can’t make mistakes. It’s like being a politician. Someone will always want to drag you down.

Even as the media narrative continues to focus on heroin use among middle-class youth in suburban neighborhoods and rural towns, I know that other populations are in need of resources and services. A study by the Centers for Disease Control and Prevention shows that rates of heroin use remain highest among males, 18- to 25-year-olds, people with household incomes below $20,000, people living in urban areas, and people with no health insurance or on Medicaid.

I take the subway up to the Bronx to BOOM!Health, a peer-run harm-reduction organization. With a small grant from the Drug Policy Alliance, BOOM! is trying to open the first legal supervised-injection facility in the US. They’ve even set up a model site, a single injection booth fashioned after those at Insite. I meet with the organization’s president and chief programming officer. He tells me that they want to create a pilot study, much like the one in Vancouver. I know that when advocates in San Francisco tried to set up a facility, the opposition was too great. But BOOM! is optimistic; having Bill de Blasio in the mayor’s office presents an opportunity.

I speak with a lawyer specializing in public-health law who argues that a pilot study is not the best strategy. “The people who are moved by evidence are not necessarily legislators. Insite was evaluated every which way. There were so many papers. Most of them are some variation on the theme that it did pretty much what we thought it would do, and it didn’t do anything that its detractors thought it might do. Has that proven very persuasive, either in Canada or the US? Not really!”

Framing the facility as an incremental extension of services already available, he suggests, could prove more effective. “Almost do it under the radar.” He is not sure that he is correct, but claims that, at least to his knowledge, the federal government never busted a single syringe-exchange program; it was always the local cops and sheriffs.

He adds, hesitantly: “But then the question is: Is that model” — i.e., an unsanctioned facility — “exportable to other cities and states?”

When I began to follow the media coverage of the new “heroin scourge,” I didn’t have strong ideas about “addiction,” except that I knew it when I saw it. I believed it was a disease, and that it should be treated as such. But the more I read, the more people I speak with, the more I begin to question this framework. It is clear that no one — no neuroscientist, psychologist, psychiatrist, or physician — can explain what addiction is or account for its contradictions. Tobacco, cocaine, heroin, alcohol, MDMA, amphetamines — are they inherently addictive? Common knowledge suggests they are. But all around me I see exceptions more than the rule, my friends who use, have used, some or all of these drugs, including heroin, casually. I, too, am one of the exceptions.

I conclude that my own point of view is now best represented by the more radical strands of the harm-reduction movement and by legalization; I can argue, morally, intellectually, why these alternatives are better than what we have now.

Following the lead of those in harm-reduction and drug-users’ rights groups, I decide to scrub the word addict from my vocabulary, to avoid using the term drug abuser. The alternatives can be awkward on the page, in a sentence, but it is more important not to reduce a person to this one aspect of her life, not to ascribe all the negative valences carried by these words.

person with a substance-misuse disorder
person experiencing a drug problem
person who uses drugs habitually
person committed to drug use

I try carrying these over into speech. This, too, is challenging.

I meet Judith in her studio. She is 75, a painter of Indian peafowl, roseate spoonbills, reddish egrets, and other birds of refined plumage and delicate bills. Earlier in the winter, her son, Spencer, died of a methadone overdose. We face each other, seated in chairs, a small table and a glass of water between us. Judith looks the part of a painter. She is poised, like her subjects, and speaks of her son’s death with surprising ease.

“Having a son die this way is not the absolute worst thing a mother can experience. I can think of circumstances far worse.”

Her stoicism is not an act. Despite countless visits to detox programs and rehab centers, a frightening prison stay, longtime family support, and the benefit of resources unavailable to most, Spencer was unable to stop using drugs in a dangerous way. Judith understands that she’s not to blame.

I examine a framed photograph of Spencer that Judith has pulled out on my behalf. He’s tall and fit-looking, blue-eyed, sensitive.

Spencer binged. Methadone maintenance never worked for him. Taking anything at all, including methadone, triggered a dangerous cycle. When Spencer overdosed, it was with methadone he received through a program. He had been trying to give up drugs. Judith believes that Spencer was torn between the life he wanted for himself and the life he seemed fated to have. “He had the right to let himself go if he couldn’t be happy.”

Judith tells me that methadone-maintenance therapy is without a doubt a terrible thing. I want to say: Maybe for some people, like your son, but it has also helped many others. But I can’t say it.

Judith says that a person on methadone still has that “all about me” attitude. What she means is that there is a kind of heroin mind, a way of behaving particular to a habitual drug user. The person may prioritize access to heroin above all else, including relationships with loved ones. Lying and stealing are constants in the repertoire of behavior. A person on methadone, Judith is saying, is still in heroin mind.

I make an intellectual case for methadone, say that for some people it can help to stabilize their lives. But Judith stares at me blankly. She is not interested. I want to appeal with a personal example, but I find it hard to come up with one.

She compares those who rely on methadone with those who seek help, and support others, through Narcotics Anonymous, as her son did. The people who commit to these programs, she explains, commit to a life of service. Spencer may have given up on his own life, but he helped save innumerable others. Judith claims the people she met through NA are among the saintliest she knows.

“You should disconnect from your uncle, leave him behind, drop him. He is taking from you without ever giving back.”

I feel defensive, uncomfortable, on your behalf and my own. I feel I’m being perceived as weak for deciding that you, while difficult, are still a person worth knowing.

I say I appreciate the advice.

Judith apologizes, tells me what I really need to do is to find a boyfriend who will treat me like a queen.

I am mistaken. Sophie never does come around. I can’t remember the last time you mentioned her name. Two years, maybe more. By now your grandson must be 8 or 9.

With the right login credentials and some basic biographical information — first and last name, an approximate age, a residential state past or present, a relative’s given name — there’s a lot you can find out about a person, even when Google and Facebook turn up little. When I decide, finally, that I will look for Sophie this way, through databases I can access through my job as a fact-checker, it takes me no more than sixty seconds to locate where she is living.

A trail of email addresses with varying domain names (aol.com, comcast.com, yahoo.com) reveals a few of the websites she’s created accounts on: a daily-horoscope generator, a payday-loan provider (cash4thanksgiving.com). Presumably these sites have lax privacy policies. My heart sinks a little when I think of her needing a payday loan; it suggests her life has not been an easy one.

I will write to her, I think.

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