SAN FRANCISCOMEDICINE - California Society of Addiction ...

Addiction and Recovery
Lessons in Urban Survival
A Hustler Tells All
Eisha Zaid
“
You can tell a lot by a person’s shoes.
One look tells me if they are worth
my efforts,” he said.
My patient, a forty-something gentleman,
was educating me about what he
called “urban survival.”
As a native of the Tenderloin, he relied
on certain tactics to make ends meet. He
was an expert-level street hustler. He was
one of the successful ones and was capable
of making a small fortune, probably
enough to pay rent and live comfortably
in a nice apartment somewhere outside
the Tenderloin.
Sadly, he burned through his earnings,
spending massive amounts on one
thing—crack cocaine.
“Sometimes it feels like I am drowning
just thinking about how much money
I owe. But I want it [crack]. I need it. And I
have to get it.”
*****
Cocaine is derived from the leaves of
Erythroxylon coca, a plant endemic to the
Andes. In historical records, cocaine chewing
was documented in South America
as far back as 4,000 years ago, and for
the last hundred years the plant has had
medicinal uses because of its vasoconstricting
effects. 1,2 Cocaine has multiple
actions, including that of local anesthetic,
CNS stimulant, appetite depressant, and
vasoconstrictor. The effects are largely
mediated through the inhibition of norepinephrine,
dopamine, and serotonin
uptake. 3
Cocaine has become a popular street
drug that can be sniffed, smoked, or injected
intraveneously. As a recreational
agent, cocaine has variable purity. The
purest forms are white powder, while less
pure forms are more yellow and have been
cut with other drugs, such as lidocaine, caffeine,
methamphetamine, ephedrine, and
phencyclidine. 3 When cocaine is heated
in an alkaline solution, it transforms into
“crack,” which is sold in 100–150 mg
“rocks” that can be smoked, while a “line”
weighs 20–30 mg and is snorted. 3
*****
When I first met him, he was completely
suicidal and was brought into the
SFGH Psychiatric Emergency Services after
being placed on a 5150 hold for being a
danger to himself. After the initial evaluation,
he was transferred to the inpatient
psychiatric unit. At the time, he had no
home and was completely out of money.
He was a tall, thin, middle-aged man
with a pinkish complexion. His hair was
combed and slicked back. He wore a lime
green collar shirt over blue hospital gown
pants. His two front teeth protruded outward
and had been eaten away and were
stained brown.
During our first meeting, it was as
though everything was in slow motion.
He moved aimlessly and spoke slowly
when recounting the details of his suicide
attempt. He had a flat affect, showing little
facial expression. He appeared remorseful
but remained deeply depressed. At
times he would become teary-eyed when
talking about being abused as a child and
about his life in the Tenderloin. He was
diagnosed with bipolar and polysubstance
dependence.
“When I get low, I get really low and go
into these dark bouts of depression. There
is no reason to live for me. No one gives a
shit about me,” he said.
His past addiction was alcohol; his
current substance was cocaine. His heavy
drug use required excessive amounts of
money, which he often did not have. Thus
he borrowed from street lenders and still
had to pay back his debt.
The chronic use had left his life in
shambles. He went from having it all—a
condo, a girlfriend, and a stable job—to
having nothing. He was living on the
streets, had made many enemies, and
relied on hustling to get his daily fix.
He had been admitted to our inpatient
unit numerous times before for suicide
attempts and was in and out of residential
treatment programs. He was followed by
a case manager and was plugged into an
extensive network of social support services,
but he had difficulty committing to
appointments and taking his medications.
The hospital had become his security net,
a revolving door for him.
*****
Addiction to drugs results from alterations
in neurochemical processes, which
ultimately lead to increased drug-seeking
behavior. Cocaine, like many other drugs of
abuse, is highly addictive because it blocks
dopamine uptake and results in increased
dopamine levels in the nucleus accumbens.
4 With respect to behavior, dopamine
promotes reward-seeking behavior. 5
Interestingly, with increased cocaine
use, dopamine release results from exposure
to certain stimuli, such as drug
paraphernalia or environmental cues,
findings that have been demonstrated in
animal models. 6 This conditioned response
explains the drug-seeking behavior observed
in chronic users, who are driven
to do whatever it takes to get their neurochemical
fix.
*****
Over his two-week hospitalization, I
Continued on the following page . . .
www.sfms.org June 2010 San Francisco Medicine 33