By Anonymous

In the early morning hours of August 17, 2017, Michigan State police busted into a quaint, corner walk-in pharmacy on the corner of Warren and Yinger in Dearborn, Michigan, a suburb south-west of Detroit, interrupting the daily deluge of transactions regularly accruing round-the-clock lines out the door at the infamous local “pill mill.”

Dr. Mohammad Derani was arraigned and had his medical licence suspended from the Department of Regulatory Affairs. Derani, who had written over 500,000 prescriptions since January 2017, averaging 43 every work day between 2015 and 2017, ranked among the most prolific distributors of controlled substances in 2015 and 2016, according to sources.

The national epidemic abuse of opioids, which include heroin or prescription pills, is often considered a white rural or suburban issue. Though Arabs and Muslims have not be spared from the epidemic, their ability to surmount the challenges of diaspora and tackle a nationwide drug epidemic shows a success, rather than deficiency, at the intersections of culture and community.

Like millions of Americans, Dearborn’s residents battle a nationwide drug epidemic that claims the lives of an estimated 100 Americans a day. In the city, drug-related arrests have jumped from 500 in 2011 to 1,000 in 2016. Opioid deaths more than doubled across the country as drugs of choice among users transitioned from prescription opioids to hard street drugs like fentanyl and heroin — a transition that coincided with the skyrocketing price of drugs following a period of overprescription.

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Dr. Derani was one high profile case, but many doctors have been involved in fraud, overprescription, or other opioid scams. In June 2017, six southeast Michigan doctors were found guilty of pocketing illegal kickbacks amounting to $132 million in a nationwide insurance fraud scheme.

“Easily 8 out of 10 of our calls and cases were due to overdoses,” Ed, a 22 year-old emergency medical technician and second generation Arab-American, estimates. “Heroin, opioid, drug overdoses are an overwhelming problem, regardless of age, background, or nationality.”

Arab American communities face the tribulations of war at home compounded with the complications of adjusting to what is regarded within the community as a uniquely American problem of addiction. Both professionals and community members note the relative silence their issues are met with in mainstream America, and how that silence is internalized by Arab Americans, discouraging them further from seeking help.

Numerous community professionals and leaders, for years, noted the stigma surrounding mental health and substance abuse in the Arab American community. Silence and denial hamper any discussion around addiction. At funerals for the victims of a disease that claimed no one demographic, at times, deaths became reported by family and community members as heart attacks or as other natural causes. No one wanted to admit the actual cause.

At funerals for the victims of a disease that claimed no one demographic, at times, deaths became reported by family and community members as heart attacks or as other natural causes.
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“People wanted to say these youth had heart attacks, at 18, 19 years old,” said Mona Hijazi, public health lead at ACCESS. “Back in 2016 [when we started these programs] we couldn’t find anyone to talk to regarding these experiences.” Now, the program ACCESS pioneered, the ACCESS Substance Abuse Program (ASAP), boasts frequent community conversations, addiction counseling coaches, and informational resources that have been translated into Arabic.

Hijazi, also ASAP coordinator, is no stranger to the effects of addiction. Having grown up alongside a family member who spent two decades battling prescription drug abuse and addiction, she understands the challenges that many of her clients face. But she also draws upon her experiences in her role as part of the community coalition. “I never talked about [addiction] until I started my work because I felt that I was holding back from people that I was talking to. I actually had to go and talk to my mom and asked her if she would be okay if I said something — and not say who or even go into details — and she said, if you save one mom a heartache, why not.”

Since 2016, Hijazi recognizes that there had been tremendous change. ACCESS and the ICA began to partner up on ASAP, holding frequent talks and informational sessions and seeking community based help. The community outreach has been effective in raising awareness and breaking stigma. “The good thing about this partnership [with the mosque] is the Imam talks about how he can’t save somebody’s child with religion; that this is a medical issue and addiction should be treated as a disease.”

Dr. Hoda Amine is a Dearborn-based psychotherapist and social worker treating those suffering from addiction in the city’s east neighborhood. She pinpoints self-esteem issues as the factors predisposing her patients towards addiction. These factors, she identifies, are the result of the liminal status second generation Arab Americans find themselves in as “not quite” one or the other. “They don’t know how to be Arab and don’t know how to be American,” she says. “There’s a lot of pressure from the family and the society. They want to fit in — but they also want to disassociate.”

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The opioid epidemic saw its transition from its prescription drug phase in the 1990s to a heroin and street drug crisis as the influence from the legacy of over-prescription manifested itself in the production and proliferation of street drugs. As drugs became more expensive, many that had become addicted to pain medication, finding their supply running out, turned to street drugs or more potent — and more dangerous — opiates.

While the grassroots efforts in the Arab American community have helped discussion and dialogue proliferate, institutions such as mosques and even law enforcement are also highly involved in community education and emergency treatment around addiction.

Local police nationwide are known for their participation in some of the most invasive, anti-black and Islamophobic policies and practices, including military and intelligence trainings with Israel, widespread surveillance of Muslim and Arab communities, and impunity for police murders of black people. Dearborn PD is the only police department in the state accepting Countering Violent Extremism (CVE) funds, supported by a highly controversial DHS grant issued to sponsor surveillance of mainly Muslim American communities, resulting in more names on the watch list than any city in the U.S. behind New York. However, they are also lauded for their perceived contribution in local addiction recovery efforts. Police partner with groups like the Dearborn-based SAFE substance abuse coalition group, mosques, and local schools to promote substance abuse awareness, and to provide resources such as naloxone, an anti-opioid agent.

This also highlights a complicated relationship between local law enforcement and minority communities, especially considering the deeply embedded role law enforcement has in opioid recovery. Yet despite the police’s public image as the front line in the war on opioids, it is women and progressive youth that have, as those most acutely impacted, made true efforts in changing the culture and breaking the stigma.

Safaa is one example of many who suffered in silence due to the stigma of coming out with an addiction. Like many others, her use started with doctor’s prescriptions, worsening once her tolerance level matched her prescribed supply. In recovery, Safaa realized that there was a need for a confidential support group for women in her community facing addiction. “It’s embarrassing for women to talk about these issues [around men] because there’s a stigma, there’s shame,” she says.

Thankfully, according to studies, women are more likely to seek treatment — however, counselors who work with Arab and Muslim American clients note that these women will seek care only outside of the community gaze.

It’s embarrassing for women to talk about these issues (around men) because there’s a stigma, there’s shame.
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Assembling the first Arab women’s addiction recovery support group, Safaa opened up a space where local women not only have access to confidentiality and support, but where, two years in, informational resources translated into Arabic have been made accessible, and honest dialogue on the issue in private spaces is facilitated. “[We are] the first Arab women’s (addiction’s anonymous) coalition,” she adds. “We do outreach, get together, talk about [drug] abuse.”

Zeinab, a freelancer who wrote for a local paper during the summer of 2016, recalls the response local outlets faced to publishing news on the sudden deaths of young community members, mostly young men, that had overdosed. These platforms received backlash that at times amounted to threats.

However, Zeinab says things are changing. “Yes, there was a backlash after the reported deaths in 2016, but I think our generation kind of shushed the angry voices,” she says. “They paved a way for discussion through organizations like SAFE and even youth programs at religious and academic institutions.” She credits new mediums and voices, as well as existing grassroots spaces, for helping move the conversation forward.

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As these initiatives show, Arabs and Muslims have leveraged social and cultural dynamics to help combat a nationwide epidemic. It is because of — rather than in spite of — cultural tenants in religion, community, and service that they have been so effective at finding and creating solutions for recovery.

And for many of them, the very women, who, while less likely to die of painkiller abuse, are still more at risk, their bearance of the greater share of emotional and social burden in the home and in the community also render them the leaders in this effort.

“As women, we take on so much and we don’t say anything…we approach that especially when it came to substance abuse,” adds Hijazi. “Yet it’s possible to get through this [together], that you’re not alone as a mom, as a sister, as a friend.”

Content warning: descriptions of child abuse

The clinic I took my sister to is housed in a new building; it has abstract paintings on its very white walls and overly quirky sodas in the waiting room. Pain management clinics that pedal opiates strive to look respectable.

If all goes as planned, this clinic will prescribe the opiates that she will become addicted to—again. They will dull her constant physical pain. They will dull her psychological torment—the particular trait that makes them so attractive to so many. The doctors involved in prescribing them largely overlook the psychological torment, however; a narrow view of a very complicated problem makes for convenient medical treatment. It makes for compelling media narratives.

It makes for more addicts.

I could start the story of my sister’s addiction by talking about the first pain management clinic she went to, 10 years ago. The one where the doctor was eventually arrested for trading prescriptions for cash. She was prescribed an ever-increasing dose of oxycontin, oxycodone, and eventually a fentanyl patch along with oral narcotics. She became a slow-motion zombie who nodded off while standing, lost her balance, and broke bones from falling. In the time it took her to enunciate a simple sentence, she would forget what she was trying to say. She lost her job, then her health insurance, and, finally, access to her prescription opiates. She spent a week dope sick, without any medical care, and emerged sober.

But that’s only part of The Opiate Story.

My sister’s story of addiction began when she was 4, when the sexual abuse began. A relative would creep into her bedroom at night; so much abuse at such a young age affected the way her pelvic muscles developed. Children lack the words to describe such violations of body, mind, and soul, and like most victims of sexual abuse, she never told anyone as a child. When she finally grew up and told our mother, she didn’t believe her. And because she was abused in New York, the state’s statute of limitations on the crime kept her from pressing charges as an adult.

Her angry, depressed childhood and angry, depressed teenaged years culminated in some pretty severe bouts of anorexia and a suicide attempt at college. But with the help of campus mental health services and continued distance from her home, she gained psychological distance from the abuse, got a decent job, and tasted a semblance of healthy adulthood.

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In her mid twenties, she developed severe pelvic pain, which baffled experts for years. It started out as debilitating menstrual pain, something doctors minimize. Pretty soon it started before her period, lasted beyond it, and then would happen a few random times throughout the month. Within the course of a year she was experiencing severe pain every day, absolutely confounding a growing list of doctors and specialists.

She finally went to one of the best medical centers in the nation for a diagnosis and treatment plan. She saw five specialists the first day there, and at least two of them asked her, point-blank, if she was sexually abused as a child. One of them explained exactly how penetration at such a young age—as well as the struggles against it—can warp the development of pelvic muscles. They explained that an office job which required sitting for hours caused a change in muscle tone that had snowballed into her chronic, debilitating pain.

Children lack the words to describe violations of body, mind, and soul.
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After my sister was diagnosed, the doctors at the medical center said she would need treatment with opiates. They discussed a nerve block, but she was too young and otherwise healthy. They suggested physical therapy and acupuncture too, which didn’t work. Debilitating pain was managed with debilitating doses of opiates. Two bad options, but the opiates made her less miserable.

After she lost her job, she moved back to the same house she was sexually abused in, with emotionally brutal parents who weren’t sympathetic to her plight. She applied for Social Security Disability, a process that takes years in New York.

There isn’t much academic research about the adult life of child sexual abuse survivors, but existing research and anecdotes imply her life is fairly typical. The Adverse Childhood Experiences study of the 1990s proved that child sexual abuse—along with nine other childhood traumas—have lifelong, significant, and surprising impacts on the health and futures of those grown children. Earlier research documented the increased risk of mental illness and drug abuse. But the increased risk of cancer, diabetes, heart disease, and COPD that the ACE study documented were surprising, especially when other risk factors were corrected for. Absenteeism from work and serious financial hardship were even more surprising.

And one of the more obscure metrics? The study linked childhood trauma to chronic physical pain.

At every pain clinic my sister has visited, she talks about the abuse in as few well-rehearsed, stilted words as possible, trying not to cry. And always the doctor says, “It’s OK, we see this all the time here.”

In the 1990s the “war on drugs”—when crack cocaine was framed as Public Enemy #1—was blamed, in part, on youth culture. The “just say no” campaigns targeted kids, while the DARE program, and the phrase “peer pressure,” ingrained itself into our vocabulary. Fast forward a decade, when methamphetamine threatened to gobble up Appalachia and inner cities that had just survived crack.

This time poverty shouldered the blame, and pop culture gave us Breaking Bad.

Now, America is in the midst of an opiate epidemic that is drastically thinning our ranks. America’s mean lifespan is declining, largely due to opiate overdoses and suicide. People are willingly casting off their mortal coil, or only persisting in it if they can numb the hell out of it.

We love blaming the evil pharmaceutical companies that flooded America’s streets with very dangerous, very addictive painkillers under the false pretenses of safety. They deserve it; but it’s also crucial to note that only 25% of America’s current opiate addicts got started using legally prescribed medications—progressive addiction to alcohol, street drugs, or illegally distributed prescription medication are responsible for the rest. Addiction, something a leading addiction researcher wants to rename “ritualized compulsive comfort-seeking,” is often a direct, logical consequence of childhood trauma.

Pharmaceutical companies aren’t the only villains; adults who sexually abuse children only get convicted about 20% of the time. Our national disinterest in preventing other forms of child abuse and childhood trauma is reckless and immoral.

Maternal home visiting programs—which provide the parents most likely to abuse their children with emotional support, life skills, parenting skills, and case management—actually prevent abuse from starting, and prevent most Adverse Childhood Experiences (ACEs). They dramatically improve the lives of children and their families. But at least 90% of eligible families are not served by the Maternal, Infant and Early Childhood Home Visiting program (MIECHV). Even the Titanic had enough lifeboat seats to save half its passengers. After the Titanic sank we made changes; why don’t we have a national discourse or hear a peep from our elected leaders when thousands of children die directly from abuse, and millions are cursed with ACEs every year?

Meanwhile I’m left struggling to decide if opiate addiction is my sister’s best, or worst, option.

I remember her addicted. Her skin was nearly numb, all the time, but her scalp itched constantly. She would scratch it until she gouged out chunks of flesh, leaving open sores and streaks of pink in her blond hair, and dried blood and skin shards under her chipped nails. She would fall over. She could barely speak in sentences. And I was always worried about her overdosing.

When my sister lost her job, she lost her health insurance. Eventually she got Medicaid, but for a few months she had no coverage. No coverage meant no legal opiates. She went through withdrawal (no clinic in a two-hour radius was willing to take her), and started life without any heavy-duty opiates. Her pain stabilized, and between alcohol and some low-level narcotics she was able to get through the day.

But for reasons unknown to me or her doctors, her pain suddenly became worse, and her anorexia is relapsing. She went from a size 12 to a size two in a matter of weeks. The last time my sister was anorexic she was so weak I couldn’t hear her voice unless she was sitting next to me. She’d pass out from low blood sugar. It’s a familiar refrain; her entire life has been, essentially, slipping from one self-destructive coping mechanism to another and hoping no one will notice.

Our national disinterest in preventing child abuse is reckless and immoral.
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While addiction is always a source of shame, anorexia is a source of pride. It is the execution of something most women want to accomplish, a prize most women covet. I know from personal experience that anorexia is a sort of mind game that can only be played by a very active, very discontent mind. Anorexia—not depression or substance-abuse disorder—is considered the deadliest mental illness.

The option I want for my sister is a genuinely healthy life. But she has no clear path to that. For her, a healthy life requires income allowing her to live on her own. It requires trauma specific therapy, psychotherapy, psychiatry, and pain management. It requires a community where child abuse victims are believed. Where their wrecked lives are considered evidence as readily as a burglary victim’s shattered window. A community where abuse victims have access to justice and compensation whenever they’re ready for it.

Under her scars and scabs and tattoos and snark, my sister is still there. My other half, my best friend, the only person I’ve ever trusted, the only healthy, long-term relationship I’ve ever had. The person who can make me laugh by reciting a joke I heard when I was 14. The person who will ask me how I am and can tell if I’m lying when I say “fine.”

Like millions of others my sister needs to figure out how to play the hand she was dealt. I don’t know a better way for her to play it.

For now I’ll help her get opiates.