“If you are a victim of crime, a police officer, politician, lawyer or judge; if you are the parent of an addict, child of an addict, or a recovering addict yourself; if you believe that drug users are simply immoral or weak; if you are like millions of other angry citizens, read In the Realm ofHungry Ghosts. I cannot begin to tally how many revelatory, shocking and reassuring words, lines, paragraphs and whole pages I have highlighted in this astonishing book.”
Susan Musgrave, writer and poet
The following are a bunch of excerpts from “The Realm of Hungry Ghosts Close Encounters with Addiction” by Gabor Mate. This is not meant to summarize the book as it is filled cover to cover with revelations. These are just some passages that I found particularly profound. I have included section and chapter titles in order to provide some context. The page numbers are from the first edition. There is no intent to infringe on copyright although given the length of this post, it might seem so. In fact, I recommend that you get a copy at Amazon
Part II: Physician, Heal Thyself
Chapter 9 Takes One to Know One
P. 101
“It is hard to get enough of something that almost works” Vincent Felitti, M.D.
P. 107
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. “I want nothing and fear nothing,” said Zorba the Greek. ”I’m free.” There are not many Zorbas amongst us.
Part III: A Different State: The Addicted Brain
CHAPTER 12 From Vietnam to Rat Park: Do Drugs Cause Addiction?
P. 132
In the cloudy swirl of misleading ideas surrounding public discussion of addiction, there’s one that stands out: the misconception that drug taking by itself will lead to addiction – in other words, that the cause of addiction resides in the power of the drug over the human brain. It is one of the bedrock fables sustaining the so-called “War on Drugs.” It also obscures the existence of a basic addiction process of which drugs are only one possible object, among many. Compulsive gambling, for example, is widely considered to be a form of addiction without anyone arguing that it’s caused by a deck of cards.
Chapter 13 A Different State of the Brain
P. 145
Cocaine’s action may be likened to that of the antidepressant fluoxetine (Prozac). Prozac belongs to a family of drugs that increase the levels of the mood-regulating neurotransmitter serotonin between nerve cells by blocking its reuptake. They’re called selective serotonin reuptake inhibitors, or SSRIs. Cocaine, one might say, is a dopamine reuptake inhibitor. It occupies the receptor on the cell surface normally used by the brain chemical that would transport dopamine back into its source neuron. In effect, cocaine is a temporary squatter in someone else’s home. The more of these sites occupied by cocaine, the more dopamine remains in the synaptic space and the greater the euphoria reported by the user.
Unlike Prozac, cocaine is not selective: it also inhibits the reuptake of other messenger molecules, including serotonin. By contrast, nicotine directly triggers dopamine release from cells into the synaptic space. Crystal meth both releases dopamine, like nicotine, and blocks its reuptake, like cocaine. The power of crystal meth to rapidly multiply dopamine levels is responsible for its intense euphoric appeal.
These stimulants directly increase dopamine levels, but the action of some chemicals on dopamine is indirect. Alcohol, for example, reduces the inhibition of dopamine-releasing cells. Narcotics like morphine act on natural opiate receptors on cell surfaces to trigger dopamine discharge.
P. 146
In any disease, say smoking-induced lung or heart disease, organs and tissues are damaged and function in pathological ways. When the brain is diseased, the functions that become pathological are the person’s emotional life, thought processes and behaviour. And this creates addiction’s central dilemma: if recovery is to occur, the brain, the impaired organ of decision making, needs to initiate its own healing process. An altered and dysfunctional brain must decide that it wants to overcome its own dysfunction: to revert to normal-or, perhaps, become normal for the very first time. The worse the addiction is, the greater the brain abnormality and the greater the biological obstacles to opting for health.
The scientific literature is nearly unanimous in viewing drug addiction as a chronic brain condition, and this alone ought to discourage anyone from blaming or punishing the sufferer. No one after all blames a person suffering from rheumatoid arthritis for having a relapse, since relapse is one of the characteristics of chronic illness. The very concept of choice appears less clear-cut if we understand that the addict’s ability to choose, if not absent, is certainly impaired.
Chapter 14 Through a Needle, a Warm Soft Hug
P. 154
Opiates, in other words, are the chemical linchpins of the emotional apparatus in the brain that is responsible for protecting and nurturing infant life. Thus addiction to opiates Like morphine and heroin arises in a brain system, that governs the wwst powerful emotional
dynamic in human existence: the attachwwnt instinct. Love.
Attachment is the drive for physical and emotional closeness with other people. It ensures infant survival by bonding infant to mother and mother to infant. Throughout life the attachment drive impels us to seek relationships and companionship, maintains family connections and helps build community. When endorphins lock onto opiate receptors, they trigger the chemistry of love and connection, helping us to be the social creatures we are.
It may seem puzzling that Nature would have given one class of chemicals the apparently very different tasks of alleviating physical pain, easing emotional pain, creating parent-infant bonds, maintaining social relationships and triggering feelings of intense pleasure.
In fact, the five roles are closely allied.
Part IV: How The addicted Brain Develops
Chapter 17 Their Brains Never Had a Chance
P. 181
“The human brain, a 3-pound mass of interwoven nerve cells that controls our activity, is one of the most magnificent – and mysterious – wonders of creation. The seat of human intelligence, interpreter of sense, and controller of movement, this incredible organ continues to intrigue scientists and laymen alike.”
With these words President George H. W. Bush inaugurated the 1990s as “the decade of the brain.” In the United States there followed an inspiring expansion of research into the workings and the development of the brain. When the findings were collated, together with previously available information, a fresh and exciting view of brain development emerged. Old assumptions were discarded and a new paradigm established. Many of the details remain to be discovered, of course – the work of centuries, suggests Professor Jaak Panksepp in Affective Neuroscience – but the outlines are not in doubt. The view that genes play a decisive role in the way a person’s brain develops has been replaced by a radically different notion: the expression of genetic potentials is, for the most part, contingent on the environment. Genes do dictate the basic organization, developmental schedule and anatomical structure of the human central nervous system, but it’s left to the environment to sculpt and fine-tune the chemistry, connections, circuits, networks and systems that determine how well we function.
Chapter 17 Trauma, Stress and the Biology of Addiction
P. 193
The ACE researchers concluded that nearly two-thirds of injection drug use can be attributed to abusive and traumatic childhood events-and keep in mind that the population they surveyed was a relatively healthy and stable one. A third or more were college graduates,
and most had at least some university education. With my patients, the childhood trauma percentages would run close to one hundred. Of course, not all addicts were subjected to childhood trauma-although most hardcore injection users were-just as not all severely abused children grow up to be addicts.
P. 199
Some people may think that addicts invent or exaggerate their sad stories to earn sympathy or to excuse their habits. In myex.’Perience, the opposite is the case. As a rule, they tell their life histories reluctantly, only when asked and only after trust has been established-a
process that may take months, even years. Often they see no link between childhood experiences and their self-harming habits. If they speak of the connection, they do so in a distanced manner that still insulates them against the full emotional impact of what happened.
Research shows that the vast majority of physical and sexual assault victims do not spontaneously reveal their histories to their doctors or therapists.34 If anything, there is a tendency to forget or to deny pain. One study followed up on young girls who had
been treated in an emergency ward for proven sexual abuse. When contacted seventeen years later as adult women, 40 per cent of these abuse victims either did not rec II or denied the
event outright. Yet their memory was found to be intact for other incidents in their lives.
Addicts who do remember often blame themselves. “I was hit a lot,” says forty-year-old Wayne, “but I asked for it. Then I made some tupid decisions.” (Wayne is the one who sometimes greets me with the bluesy chant “Doctor, doctor, gimme the news …” when I’m doing my rounds between the Hastings Street hotels.) And would he hit a child, I inquire, if that child “asked for it”? Would he blame that child for “stupid decisions”? Wayne looks away. “I don’t want to talk about that crap,” says this tough man who has worked on oil rigs and construction sites and served fifteen years in jail for armed robbery. He looks away and wipes his eyes.
Chapter 19 It’s Not in the Genes
P. 202
“The most important finding of research into a genetic role for alcoholism is that there is no such thing as a gene for alcolOlism,” writes the addiction specialist Lance Dodes, “Nor can you lirectly inherit alcoholism.”
P 207-208
More daunting for those who hope for scientific and social progress, the genetic argument is easily used to justify all kinds of inequalities and injustices that are otherwise hard to defend. It serves a deeply conservative function. If a phenomenon like addiction is determined mostly by biological heredity, we are spared from having to look at how our social environment supports, or does not support, the parents of young children; at how social attitudes, prejudices and polices burden, stress and exclude certain segments of the population and thereby increase their propensity for addiction.
Part V: The Addiction Process and the Addictive Personality
Chapter 20 “A Void I’ll Do Anything to Avoid”
P 216-217
Compulsive shoppers experience the same mental and emotional processes when engaged in their addiction. The thinking parts of the brain go on furlough. In a brain imaging study conducted at the University fo Munster, Germany, scientists found “reduced activation in brain areas associated with working memory and reasoning and, on the other hand, increased activation in areas involved in processing of emotions,” when even ordinary consumers were engaged in choosing between different brand names of a given product. Under logo capitalism, it turns out, the vaunted “market forces” are largely unconscious – a feature of addiction that advertising agencies well understand. In previous work the electrical discharges of the brain circuits governing pleasure were also found to be in overdrive durin shopping, in contrast to the rationality circuits. Neurologist Michael Deppe, the lead researcher, said that “the more expensive the product, the crazier the shoppers get. And when buying really expensive products, the part of the brain dealing with rational thought has reduced its activity to almost zero … The stimulation of emotional centres shows that shopping is a stress relief.”
Chapter 21 Too Much Time on External Things
P 228
These, then, are the traits that most often underlie the addiction process: poor self-regulation; lack of basic differentiation; lack of a healthy sense of self; a sense of deficient emptiness; and impaired impulse control. The development of these traits is not mysteriousor, more correctly, there is no mystery about the circumstances under which the positive qualities of self-regulation, self-worth, differentiation and impulse control fail to develop. Any gardener knows that if a plant hasn’t grown, most likely the conditions were lacking. The same goes for children. The addictive personality is a personality that hasn’t matured. When we come to address healing, a key question will be how to promote maturity in ourselves or in others whose early environment sabotaged healthy emotional growth.
Part VI: Imagining a Humane Reality Beyond the War on Drugs
Chapter 23 Dislocation and the Social Roots of Addiction
P 254
On the surface, the differences are obvious: they support wars I oppose and justify policies I dislike. I can tell myself that we r~ dIfferent. Moral judgments, however, are never about the Ob~lOUS; they always speak to the underlying similarities between the Judge and the condemned. My judgments of others are an accurate gauge of how, beneath the surface, I feel about myself. It’s only the willful blindness in me that condemns another for deluding himself; my
own selfishness that excoriates another for being self-serving; my lack of authenticity that judges falsehood in another. It is the same, I believe, for all moral judgments people cast on each other and ~or all vehemently held communal judgments a society visits upo~ itS members. So it is with the harsh social attitudes toward addIcts, especially hardcore drug addicts.
Chapter 25 A Failed War
P 283
The War on Drugs fails, and is doomed to perpetual failure, because it is directed not against the root causes of drug addiction and of the international black market in drugs, but only against
some drug producers, traffickers and users. More fundamentally, the War is doomed because neither the methods of war nor the war metaphor itself is appropriate to a complex social problem that calls for compassion, self-searching insight and factually researched scientific understanding.
The pertinent question is not why the War on Drugs is being lost, but why it continues to be waged in the face of all the evidence against it.
Chapter 26 Freedom of Choice and the Choice of Freedom
P 290
How much actual freedom to choose does anyone human being possess? There’s only one answer: We cannot lznow. We may have our particular beliefs, spiritual or otherwise, about this aspect of human nature-about how it is or how it should be. These beliefs may strengthen our commitment to helping others find freedom or they may become harmful dogma. Either way, in the end we all have to humble ourselves and admit to a degree of uncertainty. There is no way we can peer into a brain to measure a person’s capacity for awareness and rational choice or to estimate how the relative balance of these brain-mind systems will operate when that person is stressed. There is no gauging the burden of emotional suffering weighing down one person’s psyche against another’s, and there is no way to know what hidden life-enhanCing experiences one person may have enjoyed that another has been denied. That is why it’s facile to demand that anyone should be able to “just say no” and to judge them as morally lacking if they can’t.
Chapter 27 Imagining an Enlightened Social Policy on Drugs
P 301
“The War on Drugs is cultural schizophrenia,” says Jaak Panksepp. I agree. The Var on Drugs expresses a split mindset in two \’ays: we want to eradicate or limit addiction, yet our social policies are best suited to promote it, and we condemn the addict for qualities we dare not acknowledge in ourselves. Rather than exhort the addict to bother than the way she is, we need to find the strength to admit that we have greatly exacerbated her distress and perhaps our own. If we want to help people seek the possibility of transformation within themselves, we first have to transform our own view of ur relationshjp to them.
P 305
To expect an addict to give up her drug is like asking the average person to imagine living without all her social skills, support networks, emotional stability and sense of physical and p ychological comfort. Those are the qualities that, in their illusory and evanescent way, drugs give the addict. People like Serena and Celia and the others whose portraits have appeared in this book perceive their drugs as their “rock and salvation.” Thus, for all the valid reasons we have for wanting the addict to “just say no,” vve first need to offer her something to which she can say “yes.” We must provide an island of relief. e have to demonstrate that esteem, acceptance, love and humane interaction are realities in this world, contrary to what she, the addict, has learned all her life. It is impossible to create that island for people unless they can feel secure that their substance dependency will be satisfied as long as they need it.
Chapter 28 A Necessary Small Step: Harm Reduction
P 314-316
What is harm reduction?
Harm reduction is often perceived as being inimical to the ultimate purpose of “curing” addiction-that is, of helping addicts transcend their habits and to heal. People regard it as “coddling” addicts, as enabling them to continue their destructive ways. It’s also considered to be the opposite of abstinence, which many regard as the only legitimate goal of addiction treatment. Such a distinction is artificial. The issue in medical practice is always how best to help a patient. If a cure is possible and probable without doing greater harm, then cure is the objective. When it isn’t-and in most chronic medical conditions cure is not the expected outcome-the physician’s role is to help the patient with the symptoms and to reduce the harm done by the disease process. In rheumatoid arthritis, for example, one aims to prevent joint inflammation and bone destruction and, in all events, to reduce pain. In incurable cancers we aim to prolong life, if that can be achieved without a loss of life quality, and also to control symptoms. In other words, harm reduction means making the lives of afflicted human beings more bearable, more worth living. That is also the goal of harm reduction in the context of addiction.
Although hardcore drug addiction is much more than a disease the harm reduction model is essential to its treatment. Given our lack of a systematic, evidence-based approach to addiction, in many cases it’s futile to dream of a cure. So long as society ostracizes the addict and the legal system does everything it can to heighten the drug problem, the welfare and medical systems can aim only to mitigate some of its effects. Sad to say, in our context harm reduction means reducing not only the harm caused by the disease of addiction, but also the harm caused by the social assault on drug addicts.
We will look shortly at some harm reduction measures. First, however, we’ll dispense with two prevalent arguments against harm reduction: that it squanders resoLirces on undeserving people who are the authors of their own misfortune and that it justifies and enables addiction.
If our guiding principle is that a person who makes his own bed ought to lie in it, we should immediately dismantle much of our health care system. lany diseases and conditions arise from self-chosen habits or circumstances and could be prevented by more astute decisions. According to a recent study by British Columbia’s health officer, the provincial government spends $1.8 billion dollars on diseases caused by unhealthy Iifest) les. ‘f The average per capita health care cost for those with no risk factors is “$1,003 compared with $2,086 per capita for those with three risk factors, including smoking, being overweight/obese and physically inactive.”, All of these factors, we might say, represent “choices,” and even after a heart attack, for instance, some patients will continue to bring these risks upon themselves. The same is true of people with chronic bronchitis who persist in smoking skiers who brave moguls and steep slopes despite having sustained fractures and people who remain in a stressful marriage despite requiring treatment for depression or anxiety. No cardiologist, respiratory specialist, orthopaedic surgeon or psychiatrist would refuse treatment on the ground that the problem was “self-inflicted.”
When it comes to drug addicts, some people believe e ought to apply different criteria. One afternoon in August 2006 I called a CBC radio program to discuss Insite, Vancouver’s controversial supervised injection facility for drug users. Just before the moderator turned to me, he interviewed an RCMP officer. Dozens of addicts who have overdosed at Insite have been successfully resuscitated, the host pointed out. Lives have been saved that might otherwise have been lost. That’s not necessarily a good thing, the Mountie spokesman explained. “It’s well known that negative consequences are the only major deterrent to drug use. If you are saving people’s Iives, you are sending the message that it’s safe to use drugs.” This officer, on behalf of Canada’s national law enforcement agency, seemed \filling to let people die in the hope of teaching a lesson. He seemed unaware, or not to care, that in the 1990S Vancouver’s injection users had received an average-, of 147 such “lessons” every year in the form of overdose deaths, without any discernible deterrent effect.
P 324
(2006 Letter To Prime Minister Harper)
This is a difficult population to work with. Because of their uniformly tragic early childhood histories they do not well know how to take care of themselves and they do not readily seek help from health providers. The SIS is a link-for some their only Iink between their street lives and the health care system and, for many, it is one of the first institutions they have encountered where they feel treated in a supportive, humane way. For the physically and emotionally wounded people they are, that is no small matter … The SIS is far from a full answer to the complex problem of drug addiction, but it is an innovative and necessary small step, a project Canada can be proud of, one that in time will be emulated in many jurisdictions around the world.
APPENDIX III The Prevention of Addiction
A word about prevention, which is often teamed with harm reduction, treatment and law enforcement as one of the four pillars of social policy toward addiction. In practice, only the fourth – and least helpful – of these so-called four pillars receives unquestioned and generous financial support from governments.
The prevention of substance abuse needs to begin in the crib, and even before then, in the social recognition that nothing is more important for the future of our culture than the way children develop. There has to be much more support for pregnant women. Early prenatal visits should be an opportunity not only for blood tests, physical exams and nutritional advice, but also for a stress inventory in the woman’s life. All possible resources should be mobilized to help her experience a pregnancy that is emotionally, physically and economically as stress-free as possible. Employers and governments need to appreciate the crucial importance of these gestational months to the infant’s developmental well-being and, even more so, the crucial importance of the first months following birth and the first years. From any point of view – psychological, cultural or economic – that is the most cost effective approach. Children who are emotionally well nurtured and brought up in stable communities do not need to become addicts.
In my family practice days I often found myself in the ludicrous position of having to write letters explaining why it would be preferable, say, for a woman to stay at home a few months longer after the birth of her infant so that she can continue to breast feed. Our society has become so detached from this natural physiological and emotional parenting activity that it has to be justified on medical grounds. Rather than pressuring new parents-mothers or fathers-to return to work quickly, we should not spare resources to help them remain with their children for as long as possible, if that is their preference, during the crucial early developmental period. The financial savings to society would be enormous, not to mention the human benefits. If, on the other hand, early daycare is either unavoidable or happens to be the preferred option, we need to ensure that these facilities have the trained staff and the resources to provide not just physical care, but also emotional nourishment. That ought to be the case not only in daycare but throughout the child’s education.
In the case of at-risk families, the benefits of early intervention in the form of supportive home nursing visits have been well established. Such programs need to be far more broadly available, given the many troubled families in our society.
When it comes to drug education, most governments appear to view prevention largely as a matter of informing people, especially young people, that drugs are bad for them. A worthy objective, certainly, but like all behavioural programs, this form of prevention is highly unlikely to make a significant impact. The reason is that the children who are at greatest risk are the least open to hearing the message, and even if they do hear it, they are the least capable of conforming to it. Intellectual knowledge, while important, is a poor competitor for deep-seated emotional and psychological drives. If this is true for many adults, it’s even more so for children.
Children who have been abused by adults or are for any other reason alienated from adults, do not look to grownups for advice, modelling or information. And yet, as we have seen, these are the children most prone to substance use. We have witnessed the same problem with attempts to prevent or eliminate bullying: the dynamics of bullying or victimhood are rooted deep in a wounded child’s psyche. This is why moral preaching and the plethora of antibullying programs have little or no impact on the growing bullying tendencies among youth. Programs aimed at changing or preventing behaviours always fail if they do not address the psychological dynamics that drive the behaviours in question.
If schools and other childrearing institutions are to engage in drug education with a view to prevention, they need first to create an emotionally supportive relationship between teachers and students in which the latter feel understood, accepted and respected. Only in such an atmosphere can the necessary information be transmitted effectively and only in such an atmosphere will young people develop enough trust to turn to adults with their problems and concerns.
All adults concerned with the care of young people need to remember that only healthy, nurturing relationships with adults will prevent kids from becoming lost in the peer world-a loss of orientation that leads rapidly to drug use.