Crossmaglen, Ireland (Spring 2012)
Photography by Andres Rueda
The vein stands up proudly. The tourniquet is satisfyingly tight; the syringe waits like a shark on the bedside table, its new orange needle catches a glint of light, a silver gleam of expectancy, hungry for the vein. One of the small benefits of being a doctor and an addict is that new and clean needles are easily available, and the risk of AIDS and hepatitis B or C and other infections is accordingly low. I had used a bigger green needle to draw up the drug, a needle that can reach right to the bottom of the ampoule, so that not one drop will be missed. I use an orange needle for the actual injection because it is of smaller bore and will penetrate the skin much more easily, leaving less visible evidence.
Beside the syringe lies the pack of Cyclimorph, empty now, and ominous, the rumble of distant thunder at a summer picnic. The particular color of the red and blue packaging is like a beacon to me; if a pack were lying by the side of the road a mile away I would spot it immediately. At this moment I don’t care that it’s my last dose; the future is irrelevant.
The discarded packaging of the needles, ampoules, and syringe lie in a tidy little pile. I put the guard back on the green needle and set it beside the empty ampoule and its top; these need more careful attention, as discarded needles can turn up anywhere, and ampoules can shatter easily, leaving small but sharp shards of glass. The detritus has to be kept together, so that it can be secretly disposed of.
Everything is quiet, the doors are closed, the curtains pulled, all is dark except for the bedside lamp, just bright enough to see what I’m doing, a small island of light. I am alone in the house, just the way I have planned it.
I roll the vein lightly with my forefinger, enjoying the bounce; the vein you can feel is more reliable than the vein you can see. The vein I have selected is on my right forearm, on the inner surface. Sweetly engorged and sensual, it will be difficult to miss. As I am right-handed, my left arm is a better choice, but after months of injecting, the larger veins there have collapsed, and the only veins that remain visible are thin and thready. I still have some attractively superficial veins on the back of my left hand, which would be easy to access, but the marks there will be too easy to see. The hand veins can wait for the time when I become more desperate.
My right forearm is doubly awkward, not only because I will have to use my clumsier left hand to access the vein, but also because the skin on the inner surface of the arm is paler and will show up marks much more vividly. I am pale-skinned at the best of times, and months of regular using have turned me wraith-like. I’ve seen recent photos; I look detached, like a ghost.
But this vein looks good. Not only is it visible and easily palpable, but it is also near a junction, which usually means that it is tethered down by subcutaneous tissues. I have also become more skilled even with my left hand, so it shouldn’t be hard to hit. I am confident.
But if I do bruise, I can always wear long sleeves. I lift the syringe, holding it up to the light, admiring the liquid clarity of the drug. I flick the syringe to rid it of any air bubbles, another small piece of the ritual. I check the needle; I want it beveled down, so it will be less likely to pass through the vein. I line up the needle along the length of the vein and push it in. The needle penetrates the skin easily and painlessly; like a kiss, just a moment’s resistance in the subcutaneous tissues before it pushes through the wall of the vein. Perfect. I draw back on the syringe to confirm I am in the vein. The dark blood froths satisfyingly back into the syringe, a plume of red billowing into the clear liquid of the drug. I have hit the mother lode, a red flag signaling go. Is it joy I feel, or is it more like relief? Joy is too decent an emotion for something like this.
Sometimes, even when I am sure I am in the vein, only a trickle of blood comes back. This might mean that the needle is outside the vein, but it might also mean that the vein simply has a small lumen. I am then faced with an urgent decision. Do I try to deliver the drug? If I do, and I’m not in the vein, I’ll see a resistant little dimple appear at the injection site, a hateful little thing that signifies trouble. Morphine in the tissues is painful and will leave a big bruise. Even worse, I’ll have lost some of the drug. Common sense would dictate I step back from the ritual, be patient, take out the needle, put pressure on the site to limit the bleeding and bruising, be sensible, start all over again, find another vein. But it’s hard when I’m so close, and addicts aren’t patient.
And if I do have to try again, the blood that has trickled back might clot in the syringe, and I may lose the drug. Suddenly I am in a panic. Quick, strap on the tourniquet again, find another vein, anywhere, who cares if it’s a hand vein, who cares if it bruises. When I pull out the needle, it may ooze blood, stain and spot the bedclothes or stain my shirt. I usually wear dark clothes just in case, but pressure with a tissue is a secondary issue now. I throw away the needle; I’ll look for it later. But I may have trouble finding a vein; I may have to try a number of times, each time in increasing desperation, sometimes sticking in needles almost at random where I think a vein should be, with each attempt leaving a bloody bruise.
This time I am certain; the blood has bubbled freely and easily back into the syringe, and there is no doubt I am in the vein.
I slip off the tourniquet and slowly press the plunger fully in; the drug goes in easily, no sense of resistance that might suggest the vein wasn’t patent.
I act quickly to prepare for the rush. My movements are practiced; I whip out the needle and throw the syringe away. I’ll pick it up later. I press my left hand firmly on the site with a dark red paper tissue. A white tissue would show up the blood too obviously and might turn up somewhere inconvenient. The firm pressure will restrict localized bruising and make the injection site less easy to spot. Firm pressure will also help keep the vein patent for future use, so I’ll keep the pressure on even during the rush.
I take off my glasses, switch off the light, lie back, and close my eyes. Alone in the dark, in my own little bubble, no light, no noise, I wait.
Within seconds, I feel a tingle coming up my right arm, then a wonderful warm tidal wave stroking my whole skin, my whole body; it seems to find a centre deep within my chest. I try to savor each moment, each instant, but just as quickly as it comes it is gone.
Was it worth it?
I wish I could turn back time a few seconds. I also feel a bit cheated. It is only a few hours since I last used. I wish I’d held off for a few hours. I’d still have the drug, and the rush would have been better.
I am slightly sedated but not overly so. I could walk down the street, exchanging greetings and conversing as normal, my voice only slightly deeper, my pupils dilated. My wife would know, but she might not challenge me; I’ll meet any challenge with hostility.
The drug makes me feel pleasantly languid, like I’m wrapped in cotton wool. Morphine dries me up. My mouth is dry, my nose won’t run, my bowels won’t move, it’s hard to pass urine, and I won’t get any erections. I feel the morphine itch, but it’s not distressing, just asking for an agreeable scratch. I lie in the dark for a few minutes, hiding away as long as I can.
Within minutes, reality starts to pull me in. The fog lifts, leaving the modest euphoria that lingers after the rush—but it too begins to leak away. I start to worry about getting rid of the evidence. I get up, and look on the floor for the syringe I hastily discarded. For this I turn on the wall lights, the glare harsh and unforgiving on the little piles of detritus. I stand blinking in the light, finding the syringe, sticking point down in the carpet, as if it was a little dart. I collect the packaging and the sharps, hiding them until I can dispose of them later. The paper stuff goes in the normal rubbish, hidden in a plastic bag, secreted at the bottom of the bin. In a few days I’ll take the needles and empty ampoules to the surgery sharps box.
I am becoming more aware that it was my last ampoule of Cyclimorph.
I’ve been through withdrawal before and it was pitiless; nothing could have prepared me for how cruel it was. I know theoretically that withdrawal effects should not begin until about six to eight hours after the last dose, but such is my fear that I begin to feel uncomfortable after only a few hours.
Long before the symptoms start I can’t settle. I start to feel cold and sweaty. I feel a draught from the window that would make even a normal person shiver. But is it a draught, or is this the beginning of the withdrawal? My skin feels prickly and uncomfortable; the hairs stand up; or maybe it is my fear playing tricks. I have no defense.
In preparation, I have collected the medications to alleviate the symptoms; loperamide for the diarrhea, diazepam for the anxiety, mefenamic acid for the muscle cramps. But I also know that they will have only a minimal effect.
As each hour passes the symptoms become real: muscle pains and abdominal cramps and diarrhea and fatigue. I am cold, then hot, my skin rasps and prickles and burns. My nose drips constantly, my eyes water. Dabbing them repeatedly with a paper tissue will make my eyes and nose red and raw. I glimpse myself in a mirror, my face is white, except for my cheeks, which are flushed bright red, beads of sweat on my forehead.
Individually the physical symptoms are no worse than a bad flu. Put me in a warm room, with plenty of fluids, and they’d be tolerable. But I am like a vibrating string. I cannot sit for even a moment. Once up I have to sit down again. I try to go to bed, but I can’t get comfortable. The sheets are rough and unpleasant, and my sweat soon turns them damp and rank. And I know this will continue for the next 48 hours at least. Only 48 hours, only two days, but nothing has ever unmanned me like withdrawal; nothing has ever left me so lacking in courage.
I shiver and sweat, and counting down the minutes. I stay well-hydrated, though I feel nauseated. Some junkies vomit copiously, but that’s not how it affects me; neither do I hallucinate nor have nightmares. Instead, I have no appetite, and when I eat, food is tasteless. I’m too distracted to read, and my eyes are watering so much my vision is blurred. My emotions are so labile I burst into tears regularly, great gusts of self-pity.
I switch on the television; George of the Jungle is playing, a comedy. I try to stay with the movie for a few minutes, but I find sitting tiring.
I go for a walk outside. I see a father walking along the roadside, holding his children by the hand. It’s like a knife. Why can’t I be like that, be a normal dad, with normal interests and normal concerns? I remember it; I remember walks and family picnics, birthdays, holidays, Christmas. The memories seem to come from a far distance, a long-lost place. How did I lose it? “A devil in the house,” my wife calls it, no matter how many times she tries to push it out it keeps on getting back in again. The drug has come between us, has ruptured that bond, that presumption that we were a couple and a family, that we would meet everything together and handle it together. I have betrayed that trust; I have promised her again and again that I would stop, that no, I’m not acting strangely, and no, I haven’t used, and no, there’s nothing wrong with my voice, and yes, I’m clean, that this was definitely the last time; but I’m like all addicts, you know I’m lying because my lips are moving.
I get angry when my lies are challenged, when she asks about a blood-stained tissue, or wants to see my arms to check for bruises, or finds a stray needle or empty ampoule. I make up some story: I had a blood test today, or I banged my arm on the car door, the ampoule must have been there from a few months ago. It sounds stupid even as I’m saying it, but it’s all I’ve got. What about the kids, she asks, supposing Jack or Katie had hurt themselves on that needle, how would you feel? I have no answer, I think I care, but the drug comes first every time.
I check the time constantly, willing the minutes to pass. Forty-eight hours, I tell myself, only 48 hours to get through, but only a few hours have gone, and the time drags. I lie down again; I get up again. Doubling up with a spasm of abdominal pain, I go to the kitchen to drink some water, endure yet another episode of diarrhea. I am dirty and sweaty, I take a bath, which warms me up, but I am too agitated to stay in it for long. Getting out of warm water is a shock; I am instantly freezing, I urgently scrub myself dry.
And then the first night; I dread the night, darkness was my friend, but now the hours stretch ahead of me.
I promise to myself, this is the last time. This is definitely the last time, I won’t put myself through this ordeal again; this time I’ll stay clean. I promise.
This article is an adapted version of a longer autobiographical work. The episode discussed in this narrative occurred around 1998; better treatments, such as lofexamine, have since been developed to alleviate withdrawal symptoms for those entering detox.
DR. LIAM FARRELL is a former GP from Crossmaglen, Ireland. He is a writer and broadcaster and has been a columnist with the British Medical Journal since 1994. His book of selected columns, The Flagon with the Dragon, is available from Amazon as a Kindle e-book. He can be contacted at: firstname.lastname@example.org.
Highlighted in Frontispiece Spring 2012 – Volume 4, Issue 2