Preface To The U.S. Edition
In Canada my book has been praised as “humanizing” the hard-core addicted people I work with. I find that a revealing overstatement—how can human beings be “humanized,” and who says that addicts aren’t human to begin with? At best I show the humanity of drug addicts. In our materialist society, with our attachment to ego gratification, few of us escape the lure of addictive behaviors. Only our blindness and self-flattery stand in the way of seeing that the severely addicted are people who have suffered more than the rest of us but who share a profound commonality with the majority of “respectable” citizens.
FOREWORD For many people, addiction is a chronic, recurring problem, and its costs to society are enormous. It has been estimated that state and federal governments in the United States spend more than $15 billion per year, and insurers at least another $5 billion per year, on substance-abuse treatment services for some four million people.
The lingering questions remain, What is effective treatment? and How can it best be administered?
Dr. Maté advocates for harm reduction, a necessary, enlightened, and socially responsible view. While he offers no easy solutions or “cures,” Dr. Maté provides explanations that allow readers to envision a society that does a better job of preventing and healing addiction. —Peter A Levine, PhD, best-selling author of Waking the Tiger and clinical consultant for the Meadows Treatment Center, Wickenburg, Arizona
What is addiction, really? It is a sign, a signal, a symptom of distress. It is a language that tells us about a plight that must be understood. ALICE MILLER Breaking Down the Wall of Silence
Hungry Ghosts The Realm of Addiction Yon Cassius has a lean and hungry look. WILLIAM SHAKESPEARE Julius Caesar
The mandala, the Buddhist wheel of life, revolves through six realms. Each realm is populated by characters representing aspects of human existence—our various ways of being. In the beast realm we are driven by basic survival instincts and appetites such as physical hunger and sexuality, what Freud called the id. The denizens of the hell realm are trapped in states of unbearable rage and anxiety. In the god realm we transcend our troubles and our egos through sensual, aesthetic, or religious experience, but only temporarily and in ignorance of spiritual truth. Even this enviable state is tinged with loss and suffering. The inhabitants of the hungry ghost realm are depicted as creatures with scrawny necks, small mouths, emaciated limbs, and large, bloated, empty bellies. This is the domain of addiction, where we constantly seek something outside ourselves to curb an insatiable yearning for relief or fulfillment. The aching emptiness is perpetual because the substances, objects, or pursuits we hope will soothe it are not what we really need. We don’t know what we need, and so long as we stay in the hungry ghost mode, we’ll never know. We haunt our lives without being fully present.
It’s their attempt, I believe, to escape the hell realm of overwhelming fear, rage, and despair. The painful…
something of the emptiness that may also be experienced by people with…
No society can understand itself without looking at its shadow side. I believe there is one addiction process, whether it is manifested in the lethal substance dependencies of my Downtown Eastside patients; the frantic self-soothing of overeaters or shopaholics; the obsessions of gamblers, sexaholics, and compulsive Internet users; or the socially acceptable and even admired behaviors of the workaholic. Drug addicts are often dismissed and discounted as unworthy of empathy and respect. In telling their stories my intent is twofold: to help their voices to be heard and to shed light on the origins and nature of their ill-fated struggle to overcome suffering through substance abuse. They have much in common with the society that ostracizes them. If they seem to have chosen a path to nowhere, they still have much to teach the rest of us. In the dark mirror of their lives, we can trace outlines of our own. There is a host of questions to be considered. Among them: • What are the causes of addictions? • What is the nature of the addiction-prone personality? • What happens physiologically in the brains of addicted people? • How much choice does the addict really have? • Why is the War on…
The mandala, the Buddhist wheel of life, revolves through six realms. Each realm is populated by characters representing aspects of human existence—our various ways of being.
The inhabitants of the hungry ghost realm are depicted as creatures with scrawny necks, small mouths, emaciated limbs, and large, bloated, empty bellies. This is the domain of addiction, where we constantly seek something outside ourselves to curb an insatiable yearning for relief or fulfillment. The aching emptiness is perpetual because the substances, objects, or pursuits we hope will soothe it are not what we really need. We don’t know what we need, and so long as we stay in the hungry ghost mode, we’ll never know. We haunt our lives without being fully present.
PART I Hellbound Train What was it that did in reality make me an opium eater? Misery, blank desolation, abiding darkness. THOMAS DE QUINCEY Confessions of an English Opium Eater
Drug addicts are often dismissed and discounted as unworthy of empathy and respect. In telling their stories my intent is twofold: to help their voices to be heard and to shed light on the origins and nature of their ill-fated struggle to overcome suffering through substance abuse. They have much in common with the society that ostracizes them. If they seem to have chosen a path to nowhere, they still have much to teach the rest of us. In the dark mirror of their lives, we can trace outlines of our own. There is a host of questions to be considered. Among them: • What are the causes of addictions? • What is the nature of the addiction-prone personality? • What happens physiologically in the brains of addicted people? • How much choice does the addict really have? • Why is the War on Drugs a failure, and what might be a humane, evidence-based approach to the treatment of severe drug addiction? • What are some of the paths for redeeming addicted minds not dependent on powerful substances—that is, how do we approach the healing of the many behavior addictions fostered by our culture?
CHAPTER 1 The Only Home He’s Ever Had
My patients’ addictions make every medical treatment encounter a challenge. Where else do you find people in such poor health and yet so averse to taking care of themselves or even to allowing others to take care of them?
“The reason I do drugs is so I don’t feel the fucking feelings I feel when I don’t do drugs,” Nick, a forty-year-old heroin and crystal meth addict once told me, weeping as he spoke. “When I don’t feel the drugs in me, I get depressed.” His father drilled into his twin sons the notion that they were nothing but “pieces of shit.” Nick’s brother committed suicide as a teenager; Nick became a lifelong addict. The hell realm of painful emotions frightens most of us; drug addicts fear they would be trapped there forever but for their substances. This urge to escape exacts a fearful price.
Except for the rare fortunate ones who escape the Downtown Eastside drug colony, very few of my patients will live to old age. Most will die of some complication of their HIV or hepatitis C or of meningitis or a massive septicemia contracted through multiple self-injections during a prolonged cocaine run. Some will succumb to cancer at a relatively young age, their stressed and debilitated immune systems unable to keep malignancy in check.
As Daniel drives me home, we’re listening to CBC on the car radio, broadcasting its whimsical afternoon cocktail of light-hearted patter, classics, and jazz. Jolted by the disharmony between the urbane radio space and the troubled world I’ve just left, I recall my first patient of the day.
they can do it to me every time?” She coughs as the tears trickle down her windpipe. She’s like a child telling her story, asking for sympathy, pleading for help. The tale she tells is a variation on a theme familiar in the Downtown Eastside: drug addicts exploiting each other. Three women Madeleine knows well give her a hundred-dollar bill.
Some people are attracted to painful places because they hope to resolve their own pain there. Others offer themselves because their compassionate hearts know that here is where love is most needed. Yet others come out of professional interest: this work is ever challenging. Those with low self-esteem may be attracted because it feeds their egos to work with such powerless individuals. Some are lured by the magnetic force of addictions because they haven’t resolved, or even recognized, their own addictive tendencies. My guess is that most of us physicians, nurses, and other professional helpers who work in the Downtown Eastside are impelled by some mixture of these motives. Liz Evans began working in the area at the age of twenty-six. “I was overwhelmed,” she recalls. “As a nurse, I thought I had some expertise to share. While that was true, I soon discovered that, in fact, I had very little to give—I could not rescue people from their pain and sadness. All I could offer was to walk beside them as a fellow human being, a kindred spirit.
I don’t know who he is or the path that led him to Vancouver’s skid row, where he pushes cocaine and slaps around the emaciated women who steal, deal, cheat, or sell cheap oral sex to pay him. Where was he born? What war, what deprivation forced his parents out of their slum or their mountain village to seek a life so far north of the equator? Poverty in Honduras, paramilitaries in Guatemala, death squads in El Salvador? How did he become the Spic, a villain in a story told by the rake-thin, distraught woman in my office who, choking on her tears, explains her bruises and asks that I don’t hold it against her that she failed to show for last week’s methadone visit.
“What keeps me here?” muses Kerstin Stuerzbecher. “In the beginning I wanted to help. And now … I still want to help, but it’s changed. Now I know my limits. I know what I can and cannot do. What I can do is to be here and advocate for people at various stages in their lives, and to allow them to be who they are. We have an obligation as a society to … support people for who they are, and to give them respect. That’s what keeps me here.” There’s another factor in the equation. Many people who’ve worked in the Downtown Eastside have noticed it: a sense of authenticity, a loss of the usual social games, the surrender of pretense—the reality of people who cannot declare themselves to be anything other than what they are.
It is invigorating to operate in an atmosphere so far removed from the regular workaday world, an atmosphere that insists on authenticity. Whether we know it or not, most of us crave authenticity, the reality beyond roles, labels, and carefully honed personae.
CHAPTER 2 The Lethal Hold of Drugs Nothing records the effects of a sad life so graphically as the human body. NAGUIB MAHFOUZ Palace of Desire
“What keeps me here?” muses Kerstin Stuerzbecher. “In the beginning I wanted to help. And now … I still want to help, but it’s changed. Now I know my limits. I know what I can and cannot do. What I can do is to be here and advocate for people at various stages in their lives, and to allow them to be who they are. We have an obligation as a society to … support people for who they are, and to give them respect. That’s what keeps me here.” There’s another factor in the equation. Many people who’ve worked in the Downtown Eastside have noticed it: a sense of authenticity, a loss of the usual social games,
the surrender of pretense—the reality of people who cannot declare themselves to be anything other than what they are.
On the physiological level, drug addiction is a matter of brain chemistry gone askew under the influence of a substance and, as we will see, even before the use of mind-altering substances begins. But we cannot reduce human beings to their neurochemistry; and even if we could, people’s brain physiology doesn’t develop separately from their life events and their emotions. The addicts sense this. Easy as it would be to pin responsibility for their self-destructive habits on a chemical phenomenon, few of them do so. Few of them accept a narrow medical model of addiction as illness, for all the genuine value of that model.
Beyond the addict’s immediate orgasmic release of the moment, drugs have the power to make the painful tolerable and the humdrum worth living for. “There is a memory so fixed and so perfect that on certain days my brain listens to no other,” writes Stephen Reid—author, incarcerated bank robber, and self-described junkie—of his first hit of narcotics, at age eleven. “I am in profound awe of the ordinary—the pale sky, the blue spruce tree, the rusty barbed-wire fence, those dying yellow leaves. I am high. I am eleven years old and in communion with this world. Wholly innocent, I enter into the heart of unknowing.”2 In a similar vein, Leonard Cohen has written about “the promise, the beauty, the salvation of cigarettes.” Like patterns in a tapestry, recurring themes emerge in my interviews with addicts: the drug as emotional anesthetic; as an antidote to a frightful feeling of emptiness; as a tonic against fatigue, boredom, alienation, and a sense of personal inadequacy; as stress reliever and social lubricant. And, as in Stephen Reid’s description, the drug may—if only for a brief instant—open the portals of spiritual transcendence. In places high and low these themes blight the lives of hungry ghosts everywhere. They act with lethal force on the cocaine-, heroin-, and crystal-meth-wired addicts of the Downtown Eastside. We will return to them in the next chapter.
CHAPTER 3 The Keys of Paradise Addiction as a Flight from Distress Dismissing addictions as “bad habits” or “self-destructive behavior” comfortably hides their functionality in the life of the addict. VINCENT FELITTI, MD
It is impossible to understand addiction without asking what relief the addict finds, or hopes to find, in the drug or the addictive behavior.
Far more than a quest for pleasure, chronic substance use is the addict’s attempt to escape distress. From a medical point of view, addicts are self-medicating conditions like depression, anxiety, post-traumatic stress, or even attention deficit/hyperactivity disorder (ADHD). Addictions always originate in pain, whether felt openly or hidden in the unconscious. They are emotional anesthetics. Heroin and cocaine, both powerful physical painkillers, also ease psychological discomfort. Infant animals separated from their mothers can be soothed readily by low doses of narcotics,2 just as if it were actual physical pain they were enduring. The pain pathways in humans are no different. The very same brain centers that interpret and “feel” physical pain also become activated during the experience of emotional rejection: on brain scans they “light up” in response to social ostracism just as they would when triggered by physically harmful stimuli.
“I have a lot of issues. A lot of the reason why I use is to get rid of those thoughts and emotions and cover them up.” The question is never “Why the addiction?” but “Why the pain?” The research literature is unequivocal: most hard-core substance abusers come from abusive homes.
Levi quotes Jean Améry, a Jewish-Austrian philosopher and resistance fighter who fell into the grasp of the Gestapo. “Anyone who was tortured remains tortured.… Anyone who has suffered torture never again will be able to be at ease in the world.… Faith in humanity, already cracked by the first slap in the face, then demolished by torture, is never acquired again.”7 Améry was a full-grown adult when he was traumatized, an accomplished intellectual captured by the foe in the course of a war of liberation. We may then imagine the shock, loss of faith, and unfathomable despair of the child who is traumatized not by hated enemies but by loved ones.
I asked fifty-seven-year-old Richard, an addict since his teens, why he kept using. “I don’t know, I’m just trying to fill a void,” he replied. “Emptiness in my life. Boredom. Lack of direction.” I knew all too well what he meant. “Here I am, in my late fifties,” he said. “I have no wife, no children. I appear to be a failure. Society says you should be married and have children, a job, that kind of stuff. This way, with the cocaine, I can sit there and do some little thing like rewire the toaster that wasn’t working, and not feel like I’ve lost out on life.” He died a few months after our interview, succumbing to a combination of lung disease, kidney cancer, and overdose.
“The whole six years I craved. It was the lifestyle. I thought I was missing something. And now I look around myself and I think, What the hell was I missing?” Cathy reveals that when she wasn’t using, she missed not only the effect of the drugs but also the excitement of drug seeking and the rituals the drug habit entails. “I just didn’t know what to do with myself. It felt empty.” A sense of deficient emptiness pervades our entire culture. The drug addict is more painfully conscious of this void than most people and has limited means of escaping it.
At all costs, drug addicts want to escape spending “alone time” with their minds. To a lesser degree, behavioral addictions are also responses to this terror of the void.
Human beings want not only to survive, but also to live. We long to experience life in all its vividness, with full, untrammeled emotion. Adults envy the openhearted and open-minded explorations of children; seeing their joy and curiosity, we pine for our own lost capacity for wide-eyed wonder. Boredom, rooted in a fundamental discomfort with the self, is one of the least tolerable mental states. For the addict the drug provides a route to feeling alive again, if only temporarily. “I am in profound awe of the ordinary,” recalls author and bank robber Stephen Reid of his first hit of morphine. Thomas De Quincey extols opium’s power “to stimulate the capacities of enjoyment.”
“I get all excited, whatever you’re into.… I like playing with clothes, or I like going out at night in the West End when there’s not a whole lot of people, walking down back alleys, singing to myself. People leave stuff out. I look for what I can find, scavenging, and it’s all so interesting.” The addict’s reliance on the drug to reawaken her dulled feelings is no adolescent caprice. The dullness is itself a consequence of an emotional malfunction not of her making: the internal shutdown of vulnerability. From the Latin word vulnerare, “to wound,” vulnerability is our susceptibility to be wounded. This fragility is part of our nature and cannot be escaped. The best the brain can do is to shut down conscious awareness of it when pain becomes so vast or unbearable that it threatens to overwhelm our capacity to function. The automatic repression of painful emotion is a helpless child’s prime defense mechanism and can enable the child to endure trauma that would otherwise be catastrophic. The unfortunate consequence is a wholesale dulling of emotional awareness. “Everybody knows there is no fineness or accuracy of suppression,” wrote the American novelist Saul Bellow in The Adventures of Augie March; “if you hold down one thing you hold down the adjoining.”8
When we flee our vulnerability, we lose our full capacity for feeling emotion. We may even become emotional amnesiacs, not remembering ever having felt truly elated or truly sad. A nagging void opens, and we experience it as alienation, as profound ennui, as the sense of deficient emptiness described earlier. The wondrous power of a drug is to offer the addict protection from pain while at the same time enabling her to engage the world with excitement and meaning. “It’s not that my senses are dulled—no, they open, expanded,” explained a young woman whose substances of choice are cocaine and marijuana. “But the anxiety is removed, and the nagging guilt and—yeah!” The drug restores to the addict the childhood vivacity she suppressed long ago.
Emotionally drained people often lack physical energy, as anyone who has experienced depression knows, and this is a prime cause of the bodily weariness that beleaguers many addicts. There are many more: dismal nutrition; a debilitating lifestyle; diseases like HIV and hepatitis C and their complications; disturbed sleep patterns that date back, in many cases, to childhood—another consequence of abuse or neglect. “I just couldn’t go to sleep, ever,” says Maureen, a sex-trade worker and heroin addict. “I never even knew there was such a thing as a good sleep until I was twenty-nine years old.” Like Thomas De Quincey, who used opium to “sustain through twenty-four hours the else drooping animal energies,” present-day addicts turn to drugs for a reliable energy boost. “I can’t give up cocaine,” a pregnant patient named Celia once told me. “With my HIV, I have no energy. The rock gives me strength.” Her phrasing sounded like a morbid reconfiguration of the psalmist’s words: “He only is my rock and my salvation; he is my defense. I shall not be moved.”
Cocaine, as we shall see, exerts its euphoric effect by increasing the availability of the reward chemical dopamine in key brain circuits, and this is necessary for motivation and for mental and physical energy. Flooded with artificially high levels of dopamine triggered by external substances, the brain’s own mechanisms of dopamine secretion become lazy. They stop functioning at anywhere near full capacity, relying on the artificial boosters instead. Only long months of abstinence allow the intrinsic machinery of dopamine production to regenerate, and in the meantime, the addict will experience extremes of physical and emotional exhaustion.
Shirley, in her forties, addicted to both opiates and stimulants and stricken with the usual roster of diseases, also confesses to a sense of inadequacy without her drugs and sees cocaine as a life necessity. “I was thirteen when I first used. It took most of my inhibitions away, and my uneasiness, my inadequacies—how we feel about ourselves I guess is a better way to put it.” “When you say inhibitions, what do you mean?” I ask. “Inhibitions.… It’s like the awkwardness a man and a woman feel when you first meet, and you don’t know whether to kiss each other, except I always felt that way. It makes everything go easier.… Your movements are more relaxed, so you’re not awkward anymore.”
all costs, drug addicts want to escape spending “alone time” with their minds. To a lesser degree, behavioral addictions are also responses to this terror of the void.
Many addicts report similar improvements in their social abilities under the influence, in contrast to the intolerable aloneness they experience when sober. “It makes me talk, it opens me up; I can be friendly,” says one young man wired on crystal meth. “I’m never like this normally.” We shouldn’t underestimate how desperate a chronically lonely person is to escape the prison of solitude. It’s not a matter here of common shyness but of a deep psychological sense of isolation experienced from early childhood by people who felt rejected by everyone, beginning with their caregivers.
Another powerful dynamic perpetuates addiction despite the abundance of disastrous consequences: the addict sees no other possible existence for himself. His outlook on the future is restricted by his entrenched self-image as an addict. No matter how much he may acknowledge the costs of his addiction, he fears a loss of self if it were absent from his life. In his own mind, he would cease to exist as he knows himself.
Chris recently came into the clinic with a fracture of his facial bones, sustained in a street brawl over a “paper” of heroin. Had the blow struck an inch higher, his left eye would have been destroyed. “I don’t want to give up being an addict,” he says when I ask him if it’s all worth it. “I know this sounds pretty fucked up, but I like who I am.” “You’re sitting here with your face smashed in by a metal pipe, and you’re telling me you like who you are?” “Yes, but I like who I am. I’m Toecutter. I’m an addict, and I’m a nice guy.”
Jake, methadone-treated opiate addict and heavy cocaine user, is in his midthirties. With his wispy blond facial stubble, lively body movements, and a black baseball cap pulled rakishly low over his eyes, he could pass for ten years younger. “You’ve been injecting a lot of cocaine recently,” I remark to him one day. “It’s hard to get away from it,” he replies with his gap-toothed grin. “You make coke sound like it’s some wild animal, stalking you. Yet you’re the one who’s chasing it. What does it do for you?” “It cuts the edge off everyday life down here, of dealing with everything.” “What is everything?” “Responsibilities. I guess you could call it that—responsibilities. So long as I’m using, I don’t care about responsibilities.… When I’m older, I’ll worry about pension plans and stuff like that. But right now, I don’t care about nothin’ except my old lady.”
I don’t believe that’s true. I think deep in his heart there must live a desire for a life of wholeness and integrity that may be too painful to acknowledge—painful because, in his eyes, it’s unattainable. Jake is so identified with his addiction that he doesn’t dare imagine himself sober. “It feels like everyday life for me,” he says. “It doesn’t seem any different from anyone else’s life. It’s normal for me.” That reminds me of the frog, I tell Jake. “They say that if you take a frog and drop him in hot water, he’ll jump out. But if you take the same frog, put him in water at room temperature and then slowly heat up the water, he’ll boil to death because gradually, degree by degree, he becomes used to it. He perceives it as normal.
CHAPTER 4 You Wouldn’t Believe My Life Story
Spiritual teachings of all traditions enjoin us to see the divine in each other. Namaste, the Sanskrit holy greeting, means, “The divine in me salutes the divine in you.” The divine? It’s so hard for us even to see the human. What have I to offer this young Native woman whose three decades of life bear the compressed torment of generations? An antidepressant capsule every morning, to be dispensed with her methadone, and half an hour of my time once or twice a month.
CHAPTER 5 Angela’s Grandfather
CHAPTER 6 Pregnancy Journal
CHAPTER 8 There’s Got to Be Some Light
Primo Levi, the insightful and infinitely compassionate chronicler of Auschwitz, called moments of reprieve those unexpected times when a person’s “compressed identity” emerges and asserts its uniqueness even amid the torments of a man-made inferno. In the Downtown Eastside there are many moments of reprieve, moments when the truth of a person arises and insists on being recognized despite the sordid past or grim present.
The moments of reprieve at the Portland come not when we aim for dramatic achievements—helping someone kick addiction or curing a disease—but when clients allow us to reach them, when they permit even a slight opening in the hard, prickly shells they’ve built to protect themselves. For that to happen, they must first sense our commitment to accepting them for who they are. That is the essence of harm reduction, but it’s also the essence of any healing or nurturing relationship. In his book On Becoming a Person, the great American psychologist Carl Rogers described a warm, caring attitude, which he called unconditional positive regard because, he said, “it has no conditions of worth attached to it.” This is a caring, wrote Rogers, “[that] is not possessive, [that] demands no personal gratification. It is an atmosphere [that] simply demonstrates I care; not I care for you if you behave thus and so.”1 Unconditional acceptance of each other is one of the greatest challenges we humans face. Few of us have experienced it consistently; the addict has never experienced it—least of all from himself. “What
“It also gave me this happy feeling that was tinged with a little bit of sadness. Her life could have been so different, I thought. I try not to have such thoughts in my day-to-day work.… I try to take people as they are at any moment and support them that way. Not judge them or think of an alternative reality they could have, because we could all have alternative realities. I don’t focus on my own ‘What ifs’ much, so I try not to focus on other people’s. Only … there was this split second when I had two images in my brain: Celia at the worst moments I’ve seen her and then Celia singing to her kids, living on a farm somewhere with her family.… And then I dropped both images and just listened to that lovely voice peacefully drifting towards me.”
“As I purged that shit, I realized I had to bring light back into my life. Otherwise, all the horror I’d seen and done would have been for nothing. There’s got to be some light. I believe there is a truth—for lack of another word, I’ll use ‘spiritual’ truth. It’s not God or this or that, but the fact is, the world is good, it all equals up to good, and
I want that goodness in me.
“When I was using, I had tunnel vision,” she now recalls. “I didn’t really notice that life was still existing around me. I just knew my little world. What I wanted was what I revolved around—when was I going to have my next fix or next toke or whatever. Now I actually go for walks a couple of times a day, and I go out and I see all the people, and all the tourists. And I say, ‘Hi … how you doing …?’ I don’t know what’s wrong with me … and it’s so strange.… It’s a good feeling, I’m liking it, but it’s all so weird. Is this going to stop, is this going to change anytime soon? I’m not trying to be pessimistic. It’s just that it’s so unusual, so foreign to me.”
PART II Physician, Heal Thyself The meaning of all addictions could be defined as endeavors at controlling our life experiences with the help of external remedies.… Unfortunately, all external means of improving our life experiences are double-edged swords: they are always good and bad. No external remedy improves our condition without, at the same time, making it worse. THOMAS HORA, MD Beyond the Dream: Awakening to Reality
CHAPTER 9 Takes One to Know One It’s hard to get enough of something that almost works. VINCENT FELITTI, MD
Rae is suspicious. “Have you been obsessing and buying?” she’s asked me a number of times in the past few weeks. I look directly at my life partner of thirty-nine years, and I lie. I tell myself I don’t want to hurt her. Nonsense. I fear losing her affection. I don’t want to look bad in her eyes. I’m afraid of her anger. That’s what I don’t want.
Addictions, even as they resemble normal human yearnings, are more about desire than attainment. In the addicted mode, the emotional charge is in the pursuit and the acquisition of the desired object, not in the possession and enjoyment of it. The greatest pleasure is in the momentary satisfaction of yearning. The fundamental addiction is to the fleeting experience of not being addicted. The addict craves the absence of the craving state. For a brief moment he’s liberated from emptiness, from boredom, from lack of meaning, from yearning, from being driven or from pain. He is free. His enslavement to the external—the substance, the object, or the activity—consists of the impossibility, in his mind, of finding within himself the freedom from longing or irritability.
PART III A Different State of the Brain Recent brain imaging studies have revealed an underlying disruption to brain regions that are important for the normal processes of motivation, reward, and inhibitory control in addicted individuals. This provides the basis for a different view: that drug addiction is a disease of the brain, and the associated abnormal behavior is the result of dysfunction of brain tissue, just as cardiac insufficiency is a disease of the heart. NORA VOLKOW, MD Director, National Institute on Drug Abuse
CHAPTER 11 What Is Addiction? Addicts and addictions are part of our cultural landscape and lexicon. We all know who and what they are—or think we do. In this section of the book we’ll look at the subject from a scientific perspective, beginning with a working definition of addiction. We also need to dispel some common misconceptions.
The key features of substance addiction are the use of drugs or alcohol despite negative consequences and relapse. I’ve heard some people shrug off their addictive tendencies by saying, for example, “I can’t be an alcoholic. I don’t drink that much,” or “I only drink at certain times.”
Addiction is any repeated behavior, substance-related or not, in which a person feels compelled to persist, regardless of its negative impact on his life and the lives of others. Addiction involves: compulsive engagement with the behavior, a preoccupation with it; impaired control over the behavior; persistence or relapse despite evidence of harm; and dissatisfaction, irritability, or intense craving when the object—be it a drug, activity, or other goal—is not immediately available. Compulsion, impaired control, persistence, irritability, relapse, and craving—these are the hallmarks of addiction—any addiction. Not all harmful compulsions are addictions, though: an obsessive-compulsive, for example, also has impaired control and persists in a ritualized and psychologically debilitating behavior such as, say, repeated hand washing. The difference is that he has no craving for it and, unlike the addict, he gets no kick out of his compulsion.
“Dependence” can also be understood as a powerful attachment to harmful substances or behaviors, and this definition gives us a clearer picture of addiction.
The very essence of the opiate high was expressed by a twenty-seven-year-old sex-trade worker. She had HIV and has since died. “The first time I did heroin,” she said to me, “it felt like a warm, soft hug.” In that phrase she told her life story and summed up the psychological and chemical cravings of all substance-dependent addicts.