By Matthew Hay Brown
Sentinel Staff Writer

SAN JUAN, Puerto Rico -- Sharif Yamín is probing his left arm for a vein.

The 31-year-old former carpet cleaner is taking a midday break from the work that occupies him now -- begging change from the bankers and businessmen of the Hato Rey financial district -- for another hit of heroin.

"I don't like it," says Yamín, who has gone to an abandoned construction site to shoot up. "But if I don't do it, I get sick."

Up to 20 percent of the illicit drugs that reach Puerto Rico from South America stay on the island.

Yamín, who says he spends $50 to $60 a day on cocaine and heroin, is one of an estimated 75,000 addicts in this U.S. territory of 3.9 million -- nearly 2 percent of the population.

Their dependence is draining the island economy of uncounted millions in lost productivity and health-care expenses -- to say nothing of its social impact.

"It's behind three-quarters of the problems here," says Sister Rosemarie González, the founder and director of a 50-bed substance-abuse treatment program in San Juan. "It's causing breakups in the family, violence, accidents, murder, stealing. Now these people become parents, and you're going to have abuse, more violence."

And users are getting younger. In a survey released this past fall by Puerto Rico's Office of Drug Control, one in six public-school 12th-graders here reported using an illegal drug in the previous year.

"We're seeing kids starting to inject themselves at 12 and 13 years old," says José Vargas Vidot, founder and director of Iniciativa Comunitaria, a nonprofit organization that runs a needle-exchange program and other services for addicts here.

The government addresses substance abuse with a combination of prevention messages aimed primarily at schoolchildren and treatment for those already hooked. A network of methadone clinics operated by the Administration of Mental Health and Addiction Services to wean addicts from heroin is running at capacity, with 9,155 patients.

But that covers barely a quarter of the 36,123 islanders who reported using the highly addictive opiate in a 2002 study by the Center for Addiction Studies at the Universidad Central del Caribe in Bayamón. Programs offered by municipalities and private agencies do not make up the difference.

This treatment gap means the mortality rate among drug addicts here is twice that of the mainland United States, center research director Héctor Colón says. The HIV-infection rate among addicts is more than three times as high. Adjusting for population, overdose deaths occur more than twice as frequently.

"We've been calling it a public-health emergency," Colón says. "We're trying to get people to understand that we need to expand services."

Victor Doraño, a consultant to the Administration of Mental Health and Addiction Services, says the agency is looking at ways to increase capacity.

"There are many more who need it and who are also willing to seek help for it," says Doraño, a psychiatrist. "The most important thing we need to do is have the slots available so that in case they come in for treatment, we won't turn them away."

'Easy to find'

They come out to meet cruise ships, offering handmade palm flowers to tourists, demanding compensation for guiding cars into parking spaces. Or just begging.

Not all of Puerto Rico's heroin users are homeless. But the addicts who live in the cobblestone streets and alleys of Old San Juan are perhaps the most visible manifestation of drug dependence in the island.

A middle-aged man asking for change on the Calle San Francisco rolls up a sleeve to show an abscess in his elbow that has opened clear through to the bone. Another, sitting on the sidewalk along the Calle Norzagaray, sticks a needle into a bloody leg.

A young woman stands by the corner of Luna and O'Donnell, her feet flat on the cobblestones, her body bent double at the waist, her arms and head and hair dangling to the ground. She is dreaming the sueño mono, the monkey dream of the user on a high.

"Drugs is easy to find," says José Rodríguez, now in a treatment program for his addiction to crack. "If you don't know a place, you ask. It's like asking directions."

Iniciativa Comunitaria outreach worker Carlos Andrillón and volunteer Evelyn Velázquez pull up at Los Tubos at midmorning on a sunny weekday. A dozen homeless men bed down in the honeycomb of stacked pipe sections at this garbage-strewn former construction site in San Juan.

Andrillón and Velázquez carry a plastic bag full of clean syringes. Addicts emerge from Los Tubos with used needles to exchange. They get the replacements and return to the pipes to shoot up.

"When you start using, you feel different -- strong, powerful," Sharif Yamín says. "Then you start doing it all the time, and you just get sicker and sicker. It doesn't make you feel good anymore. You have to do it just to stop feeling bad."

After 10 years injecting himself, Yamín has difficulty finding a blood vessel that will take a shot. He slides the needle into the thin flesh inside the biceps, winces and spits out a curse. He tries again on the broad flat of his forearm. No luck there, either.

Switching hands, he sticks himself in the other forearm and, finally, success: Dark blood flows into the syringe, joining the clear narcotic solution. He pushes down on the plunger, launching the admixture into his body.

Yamín says he wants to get help. When? Tomorrow. Just like Noel Roldán, an unemployed 25-year-old living with his mother at the Las Gladiolas public-housing project in Hato Rey. And José González Soto, 30, a bartender with an apartment nearby.

"It's not easy like people think," Yamín says. He describes withdrawal: fever, headache, pain in the bones, stomachache, diarrhea. Also, hallucinations, anxiety, paranoia. "It's like the flu," he says, and then corrects himself. "It's like three times the flu."

A daily dose

The truck pulls up to a shaded section of sidewalk in the Luis Lloréns Torres public-housing project. It's the daily visit of the mobile methadone clinic to one of San Juan's most dangerous neighborhoods.

The addicts settle into a loose line. The 150 who are enrolled in the government program here rely on daily doses of the synthetic opioid analgesic to stave off the craving for heroin. Two armed police officers keep an eye on the proceedings.

A 40-year-old man who will identify himself only as "Indio" downs his dose in a single gulp. He says he has been addicted to heroin for 11 years. He spent time in a residential drug-treatment program, he says, but couldn't stay off the drug. But now, he says, the methadone seems to be working.

"The program is good -- it helps those who want to help themselves," he says. "I'm praying that I can change."

Not everyone is getting the same opportunity.

Glorín Ruiz, a longtime advocate for the homeless, says rules that require addicts to produce paperwork, submit to examinations and make regular visits can make participation in the government program prohibitively difficult, particularly for those who live in the streets.

"A lot of things have become so inaccessible that really it's a big hassle to use it as a solution," she says. "And then the big excuse is it doesn't work."

Victor Duraño, a consultant to the government, says the administration of mental-health and addiction services is trying to make its methadone program more accessible.

"We have homeless people," he says. "But there can be problems for some people to either obtain the paperwork necessary to get in or to obtain the transportation to get the medication."

Another obstacle to addressing substance abuse, critics say, is the disagreement among government agencies about whether to treat it as a public-health issue or a matter for law enforcement.

"We have paid a big price for over-criminalizing the drug activities," says psychologist Salvador Santiago Negrón, president of Carlos Albizu University in San Juan. "Our laws are harsher than any place in the U.S. mainland, which has the unintended consequence of having very crowded jails with less services for the people who really need it.

"We are putting a lot of people in jail who should really be in treatment," says Negrón, who chairs a panel named by former Gov. Sila Calderón to study the causes of violence in Puerto Rico. "We inherit this puritanical perspective of the United States of making this like a moral crusade rather than a health problem."

There does not appear to be an easy solution. A suggestion by San Juan Mayor Jorge Santini earlier this year that homeless addicts could be taken into custody and forced into treatment provoked an outcry. Critics said such efforts would be ineffective and possibly illegal.

Self-help

"You've got to want it," José Rodríguez says. "If you're not ready to give yourself a chance, it's not going to work."

After years of smoking crack, Rodríguez now is giving himself that chance. The 53-year-old former factory worker and hospital housekeeper last August checked himself in to the Hogar del Buen Pastor, the Home of the Good Shepherd run by Sister Rosemarie González in the Puerta de Tierra barrio of San Juan.

In a one-time movie theater on the busy Avenida Ponce de León, 42 men and eight women are living communally, doing chores, learning job skills and attending meetings to discuss their substance abuse.

"It's like a family," González says. "They learn how to relate with each other, to solve problems, to support each other, to be responsible. Many missed out on regular development when they were growing up because they got involved in drugs."

The program, which helps participants find apartments and jobs, can take up to two years. About 20 percent complete treatment successfully. Many of those have come back two, three or four times before getting clean for good. Those statistics make the program more successful than most -- a reason the waiting list to get in is 300 names long.

This is Rodríguez's second stay with the program. He lasted 41/2 months in 2002 before walking away to be with a woman.

"I was thinking I had it licked," the stocky former Army sergeant says. "But it was just sleeping. It didn't work out, and I was back on the streets, playing the same tune."

Now he lives in a room with seven other men and runs the kitchen at the center. Soon he will begin looking for work as a cook. He says he is determined this time to finish the program.

"All I need every day is to stay strong and stay focused. Be aware of my surroundings, be aware of temptations, be aware of bochinches" -- local slang for rowdiness. "I need to keep a low profile."

On the plus side, he says, he's feeling stronger and healthier.

"Since the day I stopped, it's just been better," he says. "I'm starting to enjoy life. . . . All I can say to the brothers and sisters out there is to try to get themselves help."

Matthew Hay Brown can be reached at mhbrown@tribune.comor 787-729-9072.

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