Author: Marc

Happy New Year! I’m sure we’re all hoping that this year brings renewed optimism, through the creative, caring, and sensible use of all that’s available in this era of rapid change. In that spirit, I discuss my thoughts about “good drugs” and share my recent experience of DMT.

My twin boys are now thirteen, so they are approaching the age at which they’re likely to be exposed to drugs of all sorts. Like most parents, Isabel and I are concerned. We’re trying to find the right preparation and the right logic to steer them away from drug experiences that will likely be harmful. What can we say that provides guidance, not prohibition? Should we try to persuade the boys to avoid all drugs? Not a very useful strategy, says Carl Hart, and I agree. Not only would they probably dismiss our counsel and ignore our views on drugs completely — after all, we’d simply be displaying our biases. But on this point I follow Sam Harris. Somewhere in his book, Waking Up — A Guide to Spirituality without Religion, he says something like this: (don’t quote me — this is from memory) I hope my kids will never tell me they’ve experimented with meth or heroin. But I also hope they won’t tell me that they’ve avoided the psychedelics with equal fervor. I like Sam Harris. I like his approach to mindfulness, consciousness, and living with awareness. I’ve also just begun his guided meditation app. I highly recommend it.

There are so many kinds of drugs we could talk about with our kids, and the legal system provides almost no help when it comes to sorting them according to potential risk. After all, alcohol and tobacco are the most hazardous of substances, statistically, and they’re both legal. My intuition is to divide non-medical (“recreational”?) drugs into three categories:

1. Those you should never ever touch: methamphetamine, heroin, crack cocaine. Besides the risk of overdose with heroin and psychosis or stroke with psychostimulants, all three drugs are highly addictive. I want to scare my kids appropriately, using my own past experiences for all they’re worth.
2. Those you’d be best to avoid but probably won’t harm you if you explore cautiously, use occasionally, and learn about the risks: nonaddictive party drugs like ecstasy (MDMA) and ketamine.
3. Those that really are okay if used appropriately: including alcohol, an aspect of human social rituals for roughly ten thousand years…but more interestingly, the psychedelics. If you are not vulnerable to psychosis or other severe mental health issues, then psychedelics can be beneficial in the pursuit of self-actualization or just exploring unique aspects of mind, consciousness, and reality. Of course, tread cautiously. Don’t go into these waters without guidance, companionship, and some degree of knowledge. But these drug experiences are among the adventures available to our age.

The psychedelics were epitomized by LSD in my generation. Psilocybin (magic mushrooms) and mescaline were also quite common. For young people in the current era, psilocybin is still frequently used. More recent additions include ayahuasca and other forms of DMT. These DMT compounds might be most attractive (and challenging!) to today’s intrepid psychonaut. And by the way, psychonaut is a real word; it refers to the exploration of altered states, including but not limited to “mind-altering” drugs.

There’s much to say about the ritualistic use of DMT by aboriginal cultures, the shamanic element, the social contexts considered helpful and supportive, and the limited research conducted so far. This Wikipedia page is a good start. It’s also important to note that psilocybin and MDMA are now being used by licensed psychiatrists to help their patients overcome anxiety, depression, addiction, and other unfortunate habits of mind (see Michael Pollan).

But you can read all this on the net. Let me tell you about my own recent experience.

I wrote about my first ayahuasca trip in this blog a few years ago. After five or six ceremonies, I decided that’s enough. The insights were profound, the hallucinations penetrating and beautiful, but running to the toilet every half-hour got old.

More recently, I heard an intriguing description of a trip with The Toad. Bufo Alvarius secretes a substance (5-MeO-DMT) that is dried and then smoked in a glass pipe. The toad is not killed but respectfully released after its DMT is collected. The trip is supposed to be rapid (5-25 minutes) and intense. Efficient, right? So I joined a friend in the UK for my introduction. We had a shaman usher us into this strange world, a short, tough-talking Brit from northern England who’d spent a prolonged period in the Sonoran Desert learning about Bufo from the natives who used it. John was a no-nonsense guy radiating expertise as well as compassion. His Tibetan bowls, drums, and feathers were ready to accompany us into, through, and out of the hallucinatory state.

We met in a church hall, chilly and unadorned. But it was enough. John and his helper arranged two padded bed-rolls which you sat against at first and then lay back on when the DMT hit your nervous system. I’d been feeling afraid of this moment for days. My friend spoke about “ego death” — leaving your personality behind, essentially dying as an individual and becoming connected with the rest of the universe intimately but without control. Sure, I was scared. “Ego death” has the word “death” in it.

For some reason, my fear disappeared the day of the event. I felt ready. By mutual consent, I went first. I was doused in tobacco smoke (an American native ritual) and cleansed of badness with the swoosh of a feather. I sat on the bed-roll. John ordered me to exhale completely, then held the stem of a glass pipe to my lips and lit it from below. Inhale, he said. More, more, keep going! And I did, until it felt like my lungs would burst. And then the room began to dissolve before my eyes. All of its features simply faded to colourful outlines and then…nothing at all. Strong hands helped me to lie back. Close your eyes now — I could still hear his voice. But I wasn’t in the room anymore.

Where was I? Of course it’s nearly impossible to describe. Something like a limitless pink space full of fluctuating colours and…feelings. It was a space of pure emotion. I felt great joy, gratitude that the universe would welcome me so easily. “Marc” meant nothing anymore, but I could still record my experience consciously. And right in the middle of all that joy there was a sort of black hole, called “anguish.” It held the greatest depths of despair, and I recognized a direct trajectory that’s extended through my life, from childhood to the present. The message, if I can call it that, was simple: this is the part of my experience that I thought I could not bear, that has always terrified me. Yet here it is, and it’s just…a feeling. Just loss. This truth seemed incredibly important, and when I came back to the room, smiling up at my companions, groggy and googly-eyed, it was still with me, undiminished.

I don’t want to get into deep speculation as to what I learned from Bufo. But I’m grateful for the awareness it lent me. For weeks I began my day with a simple sense of acceptance. It seemed that nothing in my emotional space needed to be  hidden, or deleted, or modified. It seemed (and often still does) that my sense of reality has no preordained limits, and there is something that can be perceived, something caring and supportive, in the fabric of consciousness itself.

Perhaps in the coming year, the coming years, drugs like DMT will help us discard our preoccupation with our selves and trade our individuality for a connectedness that includes our fellow humans and the planet we share.

 

 

I just got back from a two-day meeting on animal models of addiction. And here’s what I learned: animals way way down the evolutionary ladder also like opioids and psychostimulants. And flies like alcohol. That should make us feel less lonesome.

I was asked to be the keynote speaker for the meeting, because the organizers thought that animal researchers should learn more about human addiction. Well, it was a nice idea, I got a free trip to Chicago, but my work may just be too distant from what these folks think about. They study “addiction” — or more simply drug seeking — in, for example, crayfish, sea-slugs, something called zebrafish, and the common fruit fly (drosophila). Seriously. They listened to what I said about human addiction. I stressed cognitive-emotional factors like “now appeal” and “ego fatigue”, I stressed how difficult it is to make good decisions in stressful environments, especially when memory serves up powerful associations between getting high and relief. I talked about the symbolic appeal that intensifies addiction for us humans. How we’re addicted to what the drug means to us more than to the physiological change it produces. They listened, but I don’t think they got it. And when it came to my spiel about the internal dialogue, the “addict self” and so on, it’s like we were on different planets.

Regardless, I learned a lot from them. For example, I learned that zebrafish larvae (baby fish that look like seahorses) like opioids. These little guys will swim up near the surface of their tank — which is intrinsically aversive to them — to get Vicodan. Yes, Vicodan…through their feeding tube. And I learned that fruit flies will endure 120 volts of electricity to get a nip of alcohol. Yet they won’t do it for sugar. Crayfish get stoked on cocaine and race around recklessly with their claws outstretched. Like, seriously! I also learned that dopamine is the neurochemical by which lower animals identify and pursue rewards. They may even get a dopamine burst when they acquire drug rewards. I could give you more details, but in sum, it’s pretty simple: opioids and psychostimulants cause physiological changes that we interpret as “good” or “rewarding” — “we” being animals from flies and fish to humans. And we do this using the same neurotransmitters — dopamine and serotonin — across species that evolved hundreds of millions of years apart! It’s no accident that heroin and meth are the most addictive drugs we know of. We’re in good company.

But how do we make sense of the fact that gambling, porn, internet use and sports can also be highly addictive? It seems we somehow have to draw a line from the physiological changes that opioids and stimulants provide, up to the level of “I like this — I want more!” and then back to all kinds of addictive behaviours as well as drugs themselves. Then maybe we can figure out how behavioural addictions — in fact all addictions — really work.

What about the genetics of addiction?

I also learned more about the genetics of addiction. For years I’ve been arguing, much like Maia Szalavitz, that the oft-cited 50% heritability of addiction is mostly due to personality traits. There’s certainly no gene or gene cluster that predicts addiction, though there are genes that can make one more or less sensitive to specific substances, like opioids (the dynorphin receptor gene) and alcohol (which is more complicated). Yet personality traits, which can be genetically shared, predict addiction itself. The most clear-cut example is impulsive personality. More impulsive people are more likely to try drugs, or drink (or drink more) at younger ages, than others. So they and their identical twins (the basis for computing genetic effects) are more likely to become addicted. An introverted or anxious disposition also predicts addiction, for obvious reasons. And, as Maia Szalavitz says about herself, I think I score pretty high on both of these (seemingly opposite) traits. So…my odds started off a little higher than average.

Yet I’ve always emphasized environmental effects. They are so huge and so obvious. From Gabor Maté’s oppressed native populations, to Rat Park, to the ACE studies…yeah, it’s pretty obvious that difficult or stressful or oppressive environments predict addiction. And most of my clients who’ve struggled with addiction have had really shitty times during their childhood or adolescent years. Young people adapt to abuse (physical, emotional, or sexual) or neglect (like rejection by  a parent or step-parent) by trying to make themselves feel better with substances. It’s called “self-medication.” It’s not rocket science.

But here’s what I learned about genetics. Over the history of genetic research, labs could only look at gene-outcome effects one by one. That’s not the way genetics operates. With the huge explosion of computer technology in the last few years, scientists can now look at complex interaction effects. These include, not only genes, but the parts of the DNA that regulate networks of genes. Now things get complicated. I already knew that trauma or early adversity can “set” changes in motion which last a lifetime — called “epigenetic” effects. For example, punitive parenting can set your amygdala on high alert for the rest of your life — i.e., induce trait anxiety. These changes take place at the DNA level, but — and it’s a huge “but” — they are driven by environmental impacts. So, again, environment wins out over inheritance. What I didn’t get until last week is the complexity of the interactions between these environmental impacts and the genes we inherit.

One of the scientists speaking at the conference, Daniel Jacobson, showed us that he can predict fine gradations of autistic behaviour, by data crunching (on the world’s fastest supercomputer!) hundreds of thousands of genetic variables interacting with each other and with thousands of environmental variables. So — once we get better at quantifying environmental impacts (like isolation, abuse, bullying) we may indeed be able to predict addiction, not from genes themselves but from the interplay between gene networks and environmental challenges.

Still, even with all the fancy computing power in the world, I think that environmental challenges will remain impossible to quantify. As I argued with this dedicated scientist at the reception, isolation in Sweden and isolation in New Jersey are entirely different things. The gradations in environmental impact are close to infinite. He disagreed, said it’s a matter of time, but I guess the jury’s still out.

How to conclude? Two things. First, addictive drugs are addictive because of what they do to the nervous system of animals, lots of kinds of animals, not just us. But we humans build all this symbolic stuff — like need fulfillment, warmth, the sense of being in control — on top of that primal impact. Second, we may never be able to accurately compute who becomes addicted, but your chances surely derive from what you were born with (inheritance) interacting in hugely complex ways (development) with the sting of environmental misfortune.

 

Addendum: I realize this post covers two seemingly different topics. Yet they’re deeply connected. Our genes are the basis of our humanity, but we still carry these mechanisms of reward-seeking that go back hundreds of millions of years. After all these aeons of evolution, we still haven’t been able to discard the code for these mechanisms. We still need them. They’re that basic. Think about it.

 

Doctors are taught from year 1 Medicine (if not before): First, do no harm. And yet, in treating addicted individuals, doctors often do more harm than good — by obstructing or totally derailing the recovery process. That should never happen! I want to show you what I mean by telling you part 2 of Sally’s story — the first part of which appeared a few posts ago.

That post was about the value of pharmaceutical opioids for supervised “maintenance” or tapered withdrawal, and about my failure to use a publishing opportunity to educate doctors. In contrast, this post is about quitting, “getting clean” as people still say, without any supervision. Because you can and you want to. A lot of people quit that way.

And yet, incredibly, doctors often advise against it!

Sally (a resident of the UK) wasn’t taken care of properly in her teenage years, became a heroin addict in her mid-teens, became a prostitute soon after, endured physical and sexual violence, including rape, and finally dragged herself off the street by sheer force of will. At that point her soul was flattened. She had little fight left in her. Just enough. She was cared for by a friend for several months; she slept on a spare sofa. She was afraid of noises, afraid of silence, afraid of the night…because the man who had raped her was still out there. Until he killed himself. Good riddance.

Sally struck out on her own, found a stable relationship with a man, had a couple of kids, found a better relationship, had another kid. Life started to settle down — a much as it can with three young kids at home. Now her days are spent soothing, caring, teaching…giving her kids a lot of what she didn’t get enough of. A couple of nights a week she works with elderly people who need help. And if there are hours to spare, house-cleaning and all the rest of it. She and her partner are making it work.

When Sally got in touch with me to start psychotherapy, she was taking eight 30-mg tabs of codeine a day, prescribed by her doc, plus 10-20 tablets of codeine (12.5-mg) mixed with paracetamol (acetaminophen) which she got over the counter. Having survived Hep-C (with successful treatment) it was a wonder her liver hadn’t given up the ghost. But no, she was very much alive: vivacious, generous, funny, smart and pretty. She had made it to 40 and had every intention of staying alive.

I don’t tell my clients they have to stop taking drugs, but if they want to quit, if they want to cut down, let’s see what we can do. Sally wanted to quit. Although the codeine relaxed her and gave her the energy she felt she needed to keep house, images of opiates could hardly be kept apart from images of life on the street. And she tended to obsess about her next dose for too much of her day. She wanted to have done with it. Yet, withdrawing from heroin had been so grueling — it still terrified her. So the solution was obviously to taper gradually.

We talked about tapering in our sessions. I wanted her to reduce her paracetamol intake first, since it put her at great risk. But the rest…we can go slow, I said. With that message from me, she took matters into her own hands. From one week to the next her daily dose went down and down. She was proud and excited about her “detox” (as she put it). She was down to nearly half the amount of codeine she’d been on for years. She was the one pressing me: let’s go down another two tablets this week. I don’t think I need my second morning dose. She started to skip doses…and that meant she had a reservoir of spares, just in case. She was tailoring it, shaping it, doing it. She was the boss.

Until she was assigned a new doctor. Much younger, armed with the latest policies and trends. He knew enough about addiction to help her, and she needed help, he insisted. No, he would not prescribe Valium to carry her through the very end of her taper and possible withdrawal symptoms — not even 15 or 20 tabs. Valium is very addictive, you know. But that was okay: they’d taper together. She’d come to the office every week — not an easy trek for a mother of three small kids, but it was important for him to see her, to monitor her. And she would reduce her intake by one tablet — 30 mg — at a time, he insisted. But she had to agree that every time she reduced her dose, she’d have to maintain the new level. She couldn’t go back up. Not even for a particularly bad day. He knew what was best for her. Did she agree? Did she have a choice? If she didn’t agree he’d stop her prescription, and then she’d be in danger of paracetamol poisoning again, unless she went back to heroin.

I saw Sally next a few days after that visit. Her energy was gone. Her smile was sad and cynical. She’d gone back up to her previous high dose, including the paracetamol torpedoes, because…because it wasn’t her recovery anymore. That’s how she put it. And it was none of his damn business and she didn’t like his rules and she didn’t like him. But the threat of a sudden withdrawal trumped all that. That was the power he wielded, and he knew it.

Sally got a script for Valium from a shady mail-order pharmacy. Valium wasn’t a risk for her. She was saving it for when and if she needed it.

But I don’t think she will need it. She got her old doctor back again, and even though he isn’t knowledgeable about addiction, he’s willing to continue the monthly prescription he’s provided for years. Now it’s Sally’s turn again. She’s tapering. At her own rate. The drawer of unused tablets is filling up again. And she’s smiling again. She figures she’ll be down to zero in another month or two. I occasionally remind her that she can take a few extra if things get particularly rough. People need to know that recovery isn’t a straight line.

Why on earth coerce or scare someone out of their addiction when they want to quit and it’s within their power to do so? Why would you take that away from someone, when it means so much to them?

My brother’s a great doctor — a GP. He’s helped a lot of people. He’s kind and generous and smart. But he doesn’t pretend to be God. And he doesn’t pretend to know his patients better than they know themselves.

 

 

 

 

I haven’t been blogging since last spring, and even then it was pretty sketchy for a couple of months. Why the melt-down? For one thing, I was on drugs. Uh-huh, it’s true. And I was in pain and fairly miserable. So today’s post is about my own drug use, not anyone else’s. No theories to postulate, no models to spin, nothing very abstract at all. Just a field report: what it was like for an old veteran like me to get back on opiates…then off again.

Since moving to the Netherlands nine years ago, this was my third — yes third — spinal surgery. You wouldn’t know it. I’m limber, I can do anything from a 2-hour Tai Chi class to a half-day of zip-lining. But my spine has this uncool tendency to grow too much bone, called stenosis. The bone squeezes my nerves, and then I get pain. For example, leg pain. Sciatica.

The MRI confirmed what my nerves were telling me (about my bones). Not enough room in this town for both of us. So a surgery was planned and I asked my doc for some oxycodone — lots of it — or an equivalent. I’m not fond of pain.

I don’t for a moment think that people who need opiates for bodily pain are more decent, correct, or upstanding than people who need them for psychological pain. (I’ve needed them for both in my life.) It’s a false dichotomy passed down through generations of puritans. Suffering is suffering, and opioids are nature’s first-line defense. (That’s why your nervous system manufactures buckets of them.) But we’d be foolish to overlook the addictive properties of any drug that makes us feel better — and that part is psychological. In the case of opioids it’s physiological too. (See my debate with Maia Szalavitz in the comment section, last post.) Hence the notorious feedback effect: what you take to reduce your suffering leads to more suffering. Super bad planning!

Anyway, there I was, feeling no pain — or at least less pain — in both departments. So a couple of weeks after my operation I was faced with the inevitable quandary: did I still need these drugs to control the physical pain…or was I really just starting to crave their psychological embrace, that caress of warmth, as I have in the past?

This is obviously an important question when it comes to treating former addicts with opiate painkillers. The statistics are clear: those with previous drug problems are far more likely to get addicted to opiates prescribed for pain than those with no such history (who rarely do get addicted). That does NOT mean that opiate painkillers should be withheld from former drug users when they need them. What it means is that patients and doctors need to communicate honestly, in depth, and tread carefully, when patients find themselves in that grey zone — often not really knowing whether they’re asking for a refill to deal with physical pain or to deal with the profusion of psychological issues that former addicts contend with.

Well, I said I wasn’t going to get all abstract and theoretical. I really just wanted to tell you about my own experience and what it taught me. Doctors in the Netherlands don’t see themselves as judge, jury, priest, rabbi, cop and shrink all at once. They’re not being driven by guidelines shaped by profit and reinforced by fears of being disciplined or sued. So…decisions about what to take and how long to take it are shared between doctor and patient. As they should be.

That meant it was largely up to me. Two weeks after the surgery, with my pain considerably reduced, I had to admit that I liked the feeling the drugs provided. Yet it was no longer the grand euphoria itself that I (and almost everyone else I know) tend to get from oxycodone the first few days. That part was getting boring. No, this felt like addiction. Like I don’t want to stop, I’m afraid of being without it, how many do I have left? Will the doctor refill my script when I ask? Would I have to beg?

When that feeling came creeping in, I knew I was approaching a fork in the road. The pain is still there, but it’s not that bad anymore. I could quit now, or quit a month from now. Either way, I’ll have to do some tapering — more if I wait a month. I still need them, “legitimately,” for pain…but I don’t really need them.

Yet the bigger issue (for me as a former addict) was that I was starting to ruminate about the drugs. This was occupying too much of my thoughts. It was anxiety provoking. It was a stupid-ass waste of time. I started ruminating about the rumination, and then I ruminated about that, and…you get the point.

One night I lay in bed for literally three hours trying to decide whether to quit right now or wait for a few more weeks. I mean, why rush it? I still had over 30 tablets. Enough for several days of being pretty high (did I say “high”? I meant pain-free of course) and if I was going to get a refill, I’d better call my doc tomorrow since a holiday was coming up. Better not forget, except that…

Finally there was nothing to do but take the package to the bathroom, grit my teeth, tear each tablet from its bubble wrap (an ancient form of torture still used in Europe) and plunk it in the toilet. One after another. I left myself seven for what I expected to be a mild withdrawal. (It was.) And I went back to bed.

What I didn’t expect, the bonus card I’ve held out to people in addiction — clients, friends, strangers met online — was that I felt fabulous. Just lying there in bed. That’s the only point I wanted to make. This was the thing we call “empowerment” — this was choice, this was a treaty between my “addict self” (yes, he lives on) and the rest of me. This is what I generally hold out for other people with addiction problems. This was me taking care of me.

What I learned from this brief return to the Promised Land was really quite simple: Empowerment and self-care (self-compassion) come together with a thunderclap when you quit. On your own — even if it takes some effort. Because it’s time. Because you want to.

That’s the pot of gold.

Last post I shared a conundrum with you. I’d written a chapter for a book for addiction doctors. But when I learned the title of the book I decided (after all that work!) to withdraw it. Was that the right thing to do? Your comments convinced me it wasn’t.

My chapter urged practitioners to view addiction as a learned habit, not a disease, and showed show how the brain changes corresponding with addiction fit our understanding of learning rather than pathology. And it seemed compatible with a book that was supposed to “create space for clinicians to go beyond narrow guidelines….to reflect more of the ‘art’ of working within addiction medicine.” I thought my chapter would fit right in.

Until I read the proposed title: A prescriber’s guide to methadone and buprenorphine for opioid use disorder. How could a “prescriber’s guide” advocate moving beyond conventional guidelines? At best I’d have to rewrite the thing. And even then, my whole argument for moving beyond the “disease label” starts to unravel when it comes to the prescription pad. (see last post for details) In sum, my chapter in this book would be a sellout! Not just a poor fit but a surrender to the opposition!

That’s where you guys came in. I asked commenters to give me the benefit of your perspectives, and that’s what you did. There were good arguments on both sides, but a majority of you articulated good reasons why I should have left the chapter in.

For example, Matt had this to say:  “I don’t quite understand why you would not offer your unique perspective to anyone, especially physicians, and especially since they asked for the chapter to begin with. There are so many physicians who would be exposed to your ideas who may have had no idea they existed.”

For “my ideas,” read “progressive conceptualizations of addiction that step around medicalization.”

Annette wrote that “your role is, undoubtedly, to EDUCATE. The world is shifting…Mental health advocates are talking openly about the impact of social, economic and political structures on our (fragile) mental health, so those of us who understand this need to keep educating.”

But Shaun came up with the coup de gras: “I imagine two scenarios,” he wrote. “ONE: a well-meaning doctor who has learned it all from the book of NIDA, Chapter Volkow, TIP63: Patient has life-long disease of brain that compromises free-will. They will manipulate and lie. I will insist that they pee in a cup [and] have medication discontinued if they test positive… Chance of getting on with life, zero.

“TWO: Having read Marc’s chapter, start by seeing a person who, for whatever reason, has learned to use heroin as a valid way dealing with life. Through collaboration and honest dialogue, with voluntary additional services that they may or may not request, I will prescribe their methadone without fuss and making them seem like I’m doing them the world’s biggest favour. I will…not wield [my] autonomy like a weapon…I would…’provide a scaffolding’ of methadone ‘to support a vision of future self,’ rather than use methadone as a straight jacket to constrict their right to breathe.”

(I suggest you to read these comments in their entirety.)

When I read Shaun’s comment I was still reeling from a psychotherapy session I’d had with Sally (fictitious name) a few hours earlier. I’d been meeting (online) with this fortiesh English woman for psychotherapy every week or two for about eight months, during which time I’ve tried to help her get on with her life, make peace with her demons and self-doubts, and keep her codeine habit within safe limits. This session she talked about her years of heroin addiction and hooking. It wasn’t the first time, but the level of detail, the pain she expressed so vividly, made me more aware than ever of the grinding inhumanity of the life she’d lived.

How did Sally get into heroin? When she was 14, a teacher at the children’s home began touching her genitals. She wasn’t angry at the time, she says, but her perception of adults changed entirely from that point on. A couple of months later, a math teacher–she remembers him as being very old, with bad teeth–started making advances. This time, she threw a chair at him. She got kicked out of school for her troubles, and that’s when she got to know Mike, who introduced her to heroin.

Sally had a pattern of running out of one children’s home and landing in another. She hated them all, she told me. Her parents came to visit her often enough, but they didn’t take her home with them. Maybe that was the problem. Her mom had told her she couldn’t handle her tom-boy ways. Sally liked looking for bugs under rocks rather than dressing nicely. That’s just Sally being Sally, the family concluded. And she became an outsider in her own home. By adolescence she’d often end up swearing at her mom, sniffing glue and hanging out with the wrong kids on the corner.

So it was the usual culprits: inadequate parenting, child abuse, growing up without any real protection…Sally’s credentials for drug use would include a pretty high ACE score. But Mike was the catalyst.

He started off as her friend, someone to love her and listen to her. Then he became her pimp, demanding that she go out and find money to score more dope. Her young body was all that stood between his well-being and withdrawal symptoms. He’d beat her up if she refused–broken ribs, a couple of teeth knocked out– except when he got worried about damaging the merchandise.

Sally’s life stabilized after all. She went out at night, looked for men, got the money up front, until she had enough to score. Then went back to Mike and shot up. This went on for years. Her mother saw her once, sitting at a street corner, head lolling back, almost unrecognizable because she was so thin. But she just kept driving. That’s just Sally being Sally. Skeletal and bruised, waiting for a man degraded enough to look past the bruises for 20 minutes of warmth. That’s who she became. Until she was rescued by a man who got her off dope, as long as she’d never look at another man again.

The real story of Sally’s addiction is so diametrically opposite anything resembling a disease. The web of social, economic, and familial factors, the absence of a social safety net, the play-it-safe inclination of child-welfare services that weren’t interested in the child’s version of events. That’s where the problem arose. So where was it to be solved? In a doctor’s office? In a methadone clinic?

At least once a year someone would demand sex without pay or else they’d hurt her, badly, they warned. And she’d have to “service” this man anyway, get it over with as soon as possible, because the night was wearing on. There weren’t many hours left to find a paying customer. And she needed to buy heroin. Her stomach was already knotting, her muscles cramping, the nausea rising. She couldn’t face it, not tonight. She couldn’t face Mike empty-handed and she had nowhere else to go.

Sally told me that she’d cry every day, even once her life had moved on. She just couldn’t process all she’d been through. Now, today, I couldn’t shake my own grief. That’s when I read Shaun’s comment. And that’s when I realized I should have submitted my chapter after all.

The horror of Sally’s circumstances could have been prevented if opiate substitutes had been available, without prohibitive costs, without further degradation. She would have left Mike, would have left the street, if she could have found a way out.

I’m not beating myself up about it, but I made a mistake. My reluctance wasn’t wrong. The “prescriber’s” shingle unfortunately strengthens the inclination to make OST (opioid substitution therapy) the goal of addiction treatment. It was my decision to withhold the chapter that was wrong.

I should have contributed the chapter to help doctors see OST as scaffolding, a means to an end, rather than an end in itself. That way, the social-developmental roots of (psychological) addiction and the doggedness of physiological dependency could have been specified as parallel aspects of an opioid habit, distinct but convergent, making it all the more insidious. Both are real. Both may need to be challenged head-on. And there’s no universal formula for which should come first.