These 15 people got life for non-violent drug charges. Because of their life sentences, they are typically denied access to drug treatment, educational opportunities and even life-saving medical treatments. In short, they are essentially waiting to die.
Jana Drakka was born and raised in a working class Scottish town, a long way from San Francisco, where she was ordained as a Zen priest nearly 25 years ago. At the moment of her ordination, Jana walked out into the streets to work directly with people who suffer with addiction and homelessness. Inspired by Issan Dorsey, founder of Maitri Hospice, Jana began her street ministry by performing memorials for those who died on the streets, or in SRO hotels, serving as a witness for the lives of countless John and Jane Does whom no one else would claim.
Her calling brought her into contact with other helpers, professional people who work directly with mentally ill, addicted, and homeless people, where she learned about harm reduction. As she developed her practice, Jana was able to successfully reach out to people right where they were suffering in the moment, to connect and offer counsel. She also developed Harm Reduction Meditation—a unique approach to meditation she shares with people in need, providing respite in the most dire situations.
Jana has become a familiar figure on the streets of San Francisco—her “Zendo Without Walls”—well-known for her deep compassion, her ability to make connections, her rowdy sense of humor, as well as her political activism in various arenas, including LGBT and sex worker advocacy. After working through an illness and a period of homelessness, Jana is living at a retreat center about an hour away from San Francisco. She travels to the city a few times a month, and trains and ordains other Zen priests to carry on her harm reduction work. Most recently, she was featured in the latest edition of Zig Zag Zen: Buddhism and Psychedelics, a collection of writings from several Buddhist luminaries. I had the honor of speaking with her at length, and I am pleased to share an excerpt of our phone conversation with you.
I'm curious about how you went from living in the monastery to working with people on the street, and I'm also interested in your introduction to harm reduction and how you see it aligning with your Buddhist principles.
Do no harm. There it is, right there: reducing the harm you do to yourself. It absolutely synchronizes completely with Buddhist practice—how to meet everyone where they are. It started out when I heard there were not many memorials happening in the SRO hotels. So when I heard that, I went to a big one that was for everybody that died on the street the first Christmas. I was very moved by it. And then I started to go into the SRO hotels where people lived, and offered memorials there. I noticed that the case managers who worked there—when they were talking to the residents—they had a whole skill set that I didn't have. They were reaching people better; they were supporting people better. I got friendly with some of them, and I just asked one of them: “What is it you're doing? There's something else, some skill set you have.” And he told me, “Oh, it's called harm reduction.” I started going to classes in Oakland, took harm reduction to an advanced level and went on to a wonderful skill set called motivational interviewing. I studied up on that, and was able, then, to meet people much better.
Is this breath worth more than a million dollars? Yeah! [Laughs.] I mean, they're all a gift!
There's a big resource center for homeless people called Mission Neighborhood Resource Center, and they sent a message to the Zen Center, saying, “Would anyone like to try to teach meditation to a group of active drug users?” Well, I was the only one that said “Yes!” [Laughs.] So, that was fierce. That was really fierce. I had a conference room and maybe a dozen people would come. I always provided food. I learned very quickly to do that at the end, and not at the beginning, because if you provide it at the beginning, people run in, eat, and leave again. I mean, you're helping them, but not as much as you could. I ended up doing a group there every week, with a therapist. We started each group with zazen [meditation]. I learned to do short pieces of zazen that were focused on particular issues we were all looking at. Do a minimum of 10 minutes, because 10 minutes is the length of time a craving lasts if you don't interact with it. Everything was at least 10 minutes, so that they could see right away that they had the power over their—I don't like to use the word “addiction”—on their chaotic use of substances.
How receptive do you find people, especially disenfranchised people, homeless people, people very lost in these behaviors to, not just meditation—which a lot of people are resistant to, anyway—but also meditating with a Zen priest?
Well, I don't dress in robes when I'm on the street, unless I'm doing a memorial. But I do tend to wear a little something, like a samue jacket or a hippari, something like that, because I found out that people like it. They love it that a priest is sitting down with them, and they're not used to priests being all warm and friendly. [Laughs] And I have a misspent youth. I can relate. I've been homeless. I've used, you know? I've done things in my life I'm not proud of.
There was a woman I was working with who couldn't stop stealing dresses. She started to tell me [about it]. She was looking kind of ashamed, and I said, “You know what? When I was about 15, I really got into shoplifting.” And I started telling her about one of my shoplifting episodes. She was so happy! [Laughs.] That's what I call the Issan Dorsey Effect. Issan had an enormously wild life and used all the drugs you can think of. And became a dharma ancestor. Changed, you know? So when they see that I'm just a regular person that has a past life, but it's changed a lot, then it's very encouraging. Whereas if I were someone who was all holy-schmoly, it wouldn't last five seconds! [Laughs.]
Right, they wouldn't be able to relate to you at all.
Right. I don't bring it up right away that I'm a priest. I don't work much indoors, because a lot of the trouble with the folks I work with is they're sitting on the street—not because they like sitting on the street, but because they have no kitchens or dining rooms or living rooms or gardens to hang out in. My groups are usually outdoors in the community garden. I don't do formal zazen, and I don't use the word zazen, because it's a bit odd for people.
We do things like cup-of-coffee meditation or looking-at-the-trees meditation. Basically, I train them to focus their attention on something other than their own thoughts. For example, the woman that was stealing dresses, I took her to a café. She could never understand why she kept stealing dresses. I mean, she was in her 50s and every time she walks into Macy's now, they just throw her out before she does anything! [Laughs.] So, we did soda meditation: We sat and talked, and every time she got upset, she held the soda and felt the cold and listened to the bubbles, and then she could go on with her story. All of a sudden, she went, “Oh my God! I know now; I know!” And I said, “What is it, honey?” And she said, “Well, when it was my eighth birthday, my dad said he was going to buy me this beautiful dress. He went out to buy it and we never saw him again.”
I said, “Honey, you've been stealing the same dress for 40 years!” And she actually laughed. I mean, her life was in a terrible state with addiction and homelessness, but she burst out laughing. And then she said, “You know what, Jana?” I said, “What is it?” She said, “I don't even like dresses.” [Laughs.] But, that's the harm reduction in action. I would never have been able to sit down and talk with that woman if I was dressed as a priest trying to share zazen.
What does a day in your life practicing harm reduction on the street look like?
Basically, the most important part of it is zazen in the morning, so that I'm ready. Get really, really, really, centered before I go out. And often the day would be something like, say, a memorial, perhaps, in the morning, at one of the SRO hotels. We usually do a little bit of sitting [meditation] at the memorials, and then I stay behind after to counsel people. And that's when we really get into working with harm reduction. You know, what's going on in their lives, how they can lessen their suffering—do less harm to themselves. So, the counseling part afterwards is really important. In harm reduction, you can do the best counseling in the world over a cigarette for five minutes.
Sometimes, it's just so important to connect and be able to listen. People are not used to being listened to. And then I usually would have lunch with one of the case managers, because I was running a support group for the case managers as well. And then the afternoon would probably be one of the garden meditation groups. And usually, I would put in a bit at hospice.
[After some discussion of the social services infrastructure in San Francisco.]
So, yeah, we really have a lot of work to do. I really think it's spreading. Our meditation practice and developing compassion and lovingkindness is the way forward. I think that Zen Buddhism is revolutionary. What we need is the spiritual revolution. And that's what's happening. I can see the wheels starting to turn, thank goodness. I'm not playing with false hope, but I'm chipping away at it at a grassroots level.
As long as we can see that there are possibilities...
Yes, it's so simple, just be right here in this moment and realize that our thoughts are all barriers to perceiving reality. That's it. Right there. Not beating yourself up because of your past failures. I mean, this is so important to share with people. This is what counts so much in the shelters, for example: You're not worthless, useless, and a piece of trash! Let's start again and look at what you really are, without those thoughts, without those feelings.
How do people in the shelters receive that information from you?
The thing is, because of harm reduction techniques, I never impose my opinions on them or tell them anything about themselves. It's more about allowing. As you know, you can't really teach this stuff. It's more about putting people in the situation where they begin to see it for themselves.
Right, and there's where something like motivational interviewing...
Yes. Exactly. Approaching it that way. I'm still in touch with quite a few people. One friend credits the staying-present meditation with her success out in the world now. It wouldn't have happened if she hadn't learned to sit zazen, basically. And also to be completely accepted for who she is. She's transsexual, and how many transsexuals have you seen in Buddhist temples?
I don't know!
[Jana makes a game show buzzer sound and laughs.] When I saw it could work on someone who was as depressed as I was, and so horrified by the world and its actions... And now, I'm sitting here looking out the window at the trees, and the birds are sounding beautiful, the raindrops are coming down, and the chicks have gone quiet. This is nirvana right here. Right here in this moment, with this breath. And we also talk a lot about the preciousness of breath. Because, you know, when we stop to look down upon ourselves, and treat ourselves badly, we don't really think there's anything much precious going on.
For example, one of my guys who has trouble with alcohol, he came to me one day and he said, “Jana, I stayed up all last night!” And I'm like, oh, gosh, what happened? Did he fall off the wagon or something? And he says, “You know, you keep telling us to pay attention to our breathing?” I said, “Yeah.” He said, “I always find it really hard.” And I said, “Yeah...” He said, “Well, last night, I was sitting there, and I took a deep breath, and suddenly I asked myself, is that worth more than a million dollars? And I answered myself yes, because I couldn't buy another one.” And he said, “I got so excited by that idea, so the next breath I thought, is that worth more than a Cadillac? Yes!” [Laughs.] That was his breakthrough night. The whole night long, he sat up thinking this breath is worth more than... you know. He came up and he was laughing and telling me this, and it was wonderful. Actually, he's completely abstentious now. He doesn't drink at all.
That's a great story. I love that idea.
Is this breath worth more than a million dollars? Yeah! [Laughs.] I mean, they're all a gift! The last night of a seven-day sitting, we had this great Irish priest, Paul Haller, and we're all sitting there, beginning to be a bit satisfied. You'd made it through a week of hell. It's the last night and you're feeling good about yourself, and suddenly, he says, “This breath is your last breath.” And you could hear all around you, [Jana gasps]. He gave it a minute, which was kind of scary, and then he said, “The next one is a gift.” And to me, that's it. The next one is always a gift. People can get down with that. And it doesn't matter who you think the gift came from, or where it came from, the fact is that every single one of us gets a precious gift very often.
Ilse Thompson is the co-author (with Stanton Peele) of Recover! Stop Thinking Like An Addict and Reclaim Your Life with The PERFECT Program (with Stanton Peele). She is currently an M.Div. student at Maitripa College, in Portland, Oregon.
Ilse Thompson speaks with Jana Drakka, the San Francisco-based Zen priest, about her approach to helping the homeless, and addicted people through her street ministry.
Dependence on opioids, both prescribed medications and heroin, is one of the most serious public health problems in the United States, with approximately three million people involved. The number of opioid-related overdoses is a national tragedy, with overdose now causing more deaths than automobile accidents. Looking at heroin, the number of deaths associated with heroin rose for the third consecutive year in 2014, with a stunning 39% rise from the previous year.
One of the most effective pharmacologic treatments for opioid use disorders, buprenorphine (brand names: Suboxone, Zubsolv, Subutex), can be prescribed in outpatient settings such as physicians’ offices, which makes it a great option as compared with methadone, which generally requires daily visits to outpatient clinics. Unfortunately for patient access, only physicians are permitted to prescribe buprenorphine, and each MD can prescribe to only 100 patients at a time. Nurse practitioners and physician assistants are not allowed to prescribe buprenorphine for opioid dependence—the only scenario in which the use of a Schedule III medication is confined to physicians.
Christene Amabile, FNP-BC is a nurse practitioner working in the field of addiction medicine at Horizon Health Services, the largest behavioral health organization in Western New York. Paige Prentice is Vice President of Operations for Horizon Health Services and serves on the board of NYASAP (New York Alcoholism and Substances Abuse Providers). Christene and Paige have argued (see page 6 here) that these restrictions do not serve the public but rather create shortages of providers and long wait times for access to buprenorphine, during which times opioid users are vulnerable to overdose and death. They advocate for improving access to treatment by permitting nurse practitioners and physician assistants to prescribe buprenorphine….Richard Juman
Richard Juman: I know that there are regional differences with respect to access to Medication-Assisted Treatment (MAT), especially buprenorphine. It sounds like it can be difficult for people in your region to find the help that they need?
Christene and Paige: There are similar needs across the states, because of the federal limitations imposed on the prescription limitation of buprenorphine. It is very difficult to meet the buprenorphine needs here in Western New York. Issues include restricted access (because federal limitations dictate that only qualifying doctors with specialized eight-hour training can prescribe buprenorphine, and there is a 100 patient limit). As a result, there is a shortage of doctors that do prescribe buprenorphine, and although nurse practitioners and physician assistants are able to prescribe all other controlled substances in NYS (including buprenorphine for pain management), they are unable to prescribe it for the treatment of opiate use disorders (OUD).
There are other issues as well. There can be problems with insurance companies denying coverage. Also, some doctors that do prescribe only accept cash (often as high as $300 for the initial appointment and $175 for each follow-up appointment), which many patients can’t afford. When you have a condition that can benefit from a medication to help control it, and you are ready to do something about it today…you need the medication today. The barriers here can result in this medication not being available for days or weeks—days to get prior authorization by an insurance company for coverage and days, or weeks, to locate a doctor that can see the patient for the medication assessment.
RJ: How do the physicians in your area manage the 100 patient limit? Do they tend to maintain 100 patients on buprenorphine and set up a waiting list, or do they have to aggressively titrate down and then discharge patients in order to make room for new patients who can't find treatment?
CM/PP: We can only speak about the physicians within our agency. We maintain the 100 patients per physician limit. This in turn creates a waiting list for those who are in need of Medication-Assisted Treatment with buprenorphine (Brand names: Suboxone, Zubsolv, Subutex). Currently, within our agency, patients wait four to six weeks to see a physician for their buprenorphine prescription. The wait for this medication is similar at other agencies and in private practice offices. We are unaware of any prescribers who quickly taper medication in an attempt to assist new patients. It is simply unacceptable that people have to wait this long for a potentially lifesaving medication.
Another unfortunate aspect of this scenario is that, in part, this high demand for buprenorphine, and the low supply, give buprenorphine a high “street” value. There is a misconception that patients (or others) want buprenorphine to get high. Buprenorphine, is a partial opiate and when used properly, does not produce a “high.” The value and intended purpose of this medication is to curb withdrawal symptoms and manage the relentless cravings that are often experienced by individuals with an opiate use disorder. It’s a demand versus supply issue. The demand is extremely high and the supply is limited. One of the ways to manage the limited supply is to allow nurse practitioners and physician assistants to prescribe buprenorphine for opioid use disorder. This in turn would reduce the demand, thus decreasing the diversion of buprenorphine, “on the street.”
RJ: What do you find is the best way to manage patients who are waiting for Medication Assisted Treatment?
CM/PP: This is perhaps one of the most challenging aspects of working in the field of substance use disorders. We try a combination of strategies to manage patients on a waitlist for MAT. First, intensifying treatment at the outpatient level, hoping the increased support can help them hang on. We also attempt to provide them with comfort meds—something that can help curb the nausea, joint aches and other ailments associated with the withdrawal that happens when patients attempt to control their use. When that fails, we attempt to get them into a more structured setting, which means inpatient or intensive residential. This is obviously a more costly alternative.
Additionally, while someone is awaiting their appointment for MAT with buprenorphine, it is important to discuss safety issues, since clients with an opiate use disorder are often times at high risk for overdose. We teach clients how to avoid the behaviors that put them at risk for illness and overdose. Our agency provides opiate overdose prevention training with Narcan and we provide this training to clients, their families and to any interested community members. Of course, if nurse practitioners and physician assistants could prescribe buprenorphine to treat opiate use disorders there would not be the need to have people on a waitlist, or it would be markedly diminished. We believe that it is imperative that the law is changed to allow this to happen.
Richard Juman—a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years providing direct clinical care, supervision, program development and administration across multiple settings—is also former President of the New York State Psychological Association. [firstname.lastname@example.org] Find him on twitter—@richardjuman
What can be done to get medications like Suboxone to more people?