The Addict Read online

  “How could they not know about me, you must be wondering,” she asked, as if I already knew about her. “I know it sounds improbable. But I let them think it’s my boyfriend’s fault that I never visit them. You know, I don’t know what they believe or how much they just keep quiet to keep the peace. A lawyer and a teacher with a Ph.D., you’d think they’d figure it out.”

  She had a strange tic. Staring at the back of my door, her eyes would dart at me and she would catch herself, blink and jerk her chin like a hiccup, then look away again, the entire ritual ending with a wince-smile. She never held my gaze.

  I wondered what her parents actually knew about her. What had she told them and what had she lied to them about? I also wondered what she would lie to me about. Had she ever had a frank exchange with a doctor since her addiction began? My job is to be sympathetic and skeptical. A doctor’s mind by nature leaps back and forth between intuition and experience.

  Why does addiction intrigue me? To be an addict requires a mental agility and a survivor’s creativity that I admire. But there is more to it. I am interested in the opposite side of myself; I fear the appetite that would control me. This young woman, with her good home and professional parents, should have been a model citizen. What happened?

  With every drug user I meet, I find myself considering two basic questions: How much do I understand about addiction, and how should I address it? With the next asthma patient, I will have a clear and relatively fixed view of what my care should be and how I explain the disease; the same with my next hypertensive or heart failure patient. Although the medications I use for these conditions might change from year to year, based on updates in understanding of physiology and pathogenesis, I never wonder what asthma and arthritis mean to me. But each addict has a story, and the story is the illness, and what writer can resist that? When a Lucy Fields enters my room, I rethink what it is I am trying to achieve, what I care about and value. I ask myself for the hundredth time: Is addiction a medical illness, a loss of will, an obsessive-compulsive symptom, a character disorder, a spiritual condition, or all of these? Or is it something altogether different?

  We are a species that tries to assign blame and admires control. Is addiction a matter of circumstance or weakness? Bad judgment or bad luck? Masochism or machismo? Is the addict someone to be saved or incarcerated? Is she driven by sickness or sin? During my years as a clinician, new drug laws have been passed (three strikes), and new substances manufactured (methamphetamine), and each engendered debate, but altered almost nothing in how I consider these questions. I watch the never-ending array of movies about drug users (Trainspotting, Down to the Bone, SherryBaby) and read the newspaper thinking, simultaneously, that what addicts do has nothing to do with me and my wife and kids, but also that addiction has something important to say to and about us.

  “For some reason I still believe that I could have a meaningful life.” This was the first thing Lucy Fields said and it was probably enough to make me attend to her with an unusual concern and melancholy tenderness. I had certain ideas about addiction and patients’ attempts to recover through my “program.” I was concerned that medical research, my own research, was perhaps too limited in what it told us about caring for drug-dependent persons. But I also knew how difficult it was to move between ideals and practical ways of assisting the one patient in front of me, how fluid my understanding remained as to how best to help.

  Two days each week, I work alongside ten other internists in this clinic. We supply each other with articles to read, and with comfort and courage as we press forward through each day’s schedule. We depend on each other for advice and funny stories. We compare and confess our misfortunes. We serve on the same hospital committees, share a weekly seminar, celebrate one another’s birthdays and successes. We reveal our particular clinical phobias to one another. My colleague Paul becomes upset whenever he sees above-the-knee amputations, even those that are well healed; he says they remind him of his grandfather. I can barely tolerate the sound of retching. And when we bump into each other among all the commotion and small emergencies of everyday practice, we invite each other into our patient dramas. Then we return to our own rooms, cautiously, like men and women in hiding. At least once a week, I am grateful for a colleague’s instruction on something I’ve forgotten since my training twenty years ago, the proper examination of an ankle, the exact sensory distribution of a lumbar nerve. We share the craving for the company of illness because it offers us the opportunity to feel useful. We get along well, I like to think.

  During the remainder of my week, I work in another office in another building, conducting research on addiction. It is clinical research, and therefore does not involve experiments with DNA or cells or mice. Instead, I work with people, many of whom live in the neighborhoods around the hospital, who use chemically active substances. Over the years chemists have determined that there are families of addictive drugs: alcohol, nicotine, stimulants, hallucinogens, marijuana, and, finally, opiates such as Vicodin, my main interest. These drugs are characterized as addictive when lab animals self-administer them to the brink of unconsciousness in a remarkably specific and reproducible way.

  The human brain, with its billions of neurons, doesn’t have particular cell clusters that constitute an alcohol center, a nicotine center, or an opiate center, but it does have a reward pathway, a particular set of neuronal connections that can be turned on by multiple substances and behaviors that provoke good feelings. Each drug family has its own special dangers when consumed (headaches, heart attacks, delirium), but users rarely take these into account because their main goal is to administer pleasure.

  A lot of my time is spent writing proposals to the federal government to study particular clinical aspects of addiction, and to receive grant funding from the National Institutes of Health if my scientific peers believe my ideas are worthy enough to help addicts. My salary is primarily derived from these grants, plus a certain amount from seeing patients in my clinic office; the majority of them do not use drugs illicitly and remind me how addiction is different from other medical conditions. I recruit drug users through newspaper advertisements, posters, in emergency rooms, and through word of mouth—and have, over the past two decades, interviewed thousands about the quantity and frequency of their drug use, their sleep and moods, their criminal pasts and physical disabilities, their families and sex lives. I usually pay study participants for their time—and addicts have plenty of ways to spend their money—so I have no trouble finding study participants. I attempt to understand why some became infected with HIV or other viruses, and I want to learn how and why some addicts change their self-injurious behaviors. I try to assist them in finding a more merciful existence. I publish articles in scientific journals—reasonable, sensible articles about risk and risk-taking. When I take on a patient like Lucy Fields, who was not enrolled in one of my studies, I think about what I’ve learned and researched and read, and I make an effort to apply it in the clinical setting.

  I live in the city where I work, and outside the hospital I see things that might be addiction related—young men punching each other in the face, a woman talking to herself in a doorway, a man on the sidewalk in front of the convenience store with blood streaming from the scabs on his legs. The bleeding man perturbs me; the psychotic woman in the shadows saddens me. I make lists of what could be wrong with them, but I do so to prevent the feelings from taking me over, because outside the hospital, I am not fearless nor particularly altruistic. I do not go out into the destitute corners of my hometown to rescue the drug users in collapsed buildings and abandoned churches. I sleep on a soft bed; I rest after dark. I eat chicken sausage and white beans rather than going out into the night to find lost and starving souls whom I could bring in and help. I hope that my clinic exam room is a refuge for some addicts who find their way to me, but off-duty, I am essentially selfish. My mission, my purpose, is not a life of self-sacrifice—I see patients, I perform my scientific studies, I write books
, I am a father and husband. Outside of my office, at home, I work to simplify my life, or create a simple way of seeing the world. But in my examination room on the fifth floor of the Ambulatory Care Center, everything is complicated, or at least I tell myself that.

  As Lucy’s internist, I wanted to manage her overall health, and I knew that at some point, if she didn’t flee, this would involve helping her identify, manage, and master the tyranny of her dangerous, destabilizing needs.

  “Do you have a ticket to South Carolina yet?” I asked her.

  I thought again about what she’d said about her parents’ knowledge of her drug use: “You’d think they’d figure it out.” I was sure that during her years of Vicodin use, she’d never gotten to many sensitive subjects in her conversations with them, subjects that universally went along with heavy narcotic use: sex, morality, crime, dubious ethics. I thought of how secretive my own teenaged sons had become, out at night, in cars, with their own dark reasons for doing things. What did I know about them? No matter how adept I was at hearing their sighs, reading into their monosyllables, interpreting their moods, gestures, and sounds and nonsounds—did I really know when they felt defeated or hopeless?

  “Not yet, but I have to get out of here. Even though it won’t exactly be a holiday in South Carolina, I like the heat, and I can probably sit by the pool all day. But I know it won’t be easy to spend four days with them. My mother will ask where I’m working and I’ll tell her I just quit my job, and she’ll say, ‘Why don’t you call your college alumni association and let them help you find a new one. Maybe you’ll meet a nice lawyer.’” She laughed and took another sip of coffee. “That’s a joke. Maybe he could represent me.”

  “You need a lawyer?”

  “Not yet.”

  “Did you just quit your job?”

  “A while ago.”

  “What were you doing?”

  “Working in a Laundromat. The perfect job for the graduate of an elite college, don’t you think?”

  Her rhetorical question let me know that she had judged herself and that she didn’t need to hear from me. Delivering herself into my care was difficult, but she would try to be a reliable narrator, and she wasn’t going to deny who she was. She had the sensibility and style to pull it off. She was letting me know that she was taking a long and winding path toward something honest, even if, at times, she was likely to trivialize and deflect.

  “What do you know about buprenorphine?” I asked.

  Developed in the 1970s, buprenorphine had only been approved as a medication in 2003. Part of my research work has been to study buprenorphine, keeping data on every patient I’ve seen since 2003. What I know is that only 60 percent of my patients who take buprenorphine are still on it six months after starting; the rest have dropped out of care, nearly always returning to the drug that brought them to me. Is 60 percent retention a good outcome or a poor one? How do I compare with other doctors who treat opiate dependence? There is no way to compare because most clinicians, working alone in their offices, do not systematically collect and monitor data about how their patients do. It is shocking how few drug treatment programs can even offer complete and reliable statistics to the inquisitive consumer. There is no incentive, no requirement, for any program to keep figures—let alone release them to the public—and without the facts there is no reason to admit to anything but success.

  “I know that I bought one bupe pill on the street a few weeks ago and it gave me a day off from chasing down Vicodin,” Ms. Fields said. “Not that I have a lot of trouble maintaining my supply.”

  Instead of getting up and walking around, she used the metal-armed chair as a gymnast would use parallel bars, bracing her thin arms to lift her light body into the air and adjust it, never facing me but keeping turned sideways toward the door.

  “Once we decide to start you on this medication, we’ll be seeing each other quite a bit. You’ll need to come in to see me two or three times a week for the first few weeks, then less and less often if all goes well. I’ll want to see how you’re doing, and in the beginning, I’ll make sure we have the right dose so that you’re comfortable. We’ll talk.”

  “I like to talk. I’m talkative.” She looked very sweet, and slightly dispirited.

  I smiled. I liked that she liked to talk (because it isn’t true of me), that she was not overly earnest, that she was funny and self-mocking. I could be her straight man. I prefer to do the questioning. I am most comfortable in this conventional medical role with its restricted emotional tone, and I appreciate patients who run through their charged lists of complaints and are not unhappy when I ask a few questions, give short answers, and mostly listen. Is this part of what attracted me to medicine, or did it only grow out of my years in this room, where my feelings are so often half-hidden or contained when I deliver good and bad news every day?

  If I am addicted to something, it is my need to ask questions. I have an unquenchable urge to delve, to draw things out of patients, to hear secrets, to hear everything. I like knowing secrets; not to know them is to miss a patient’s life. I have difficulty with patients who are restrained or nearly silent. Plenty of the people who come in are surly and are in no mood to do more than list their symptoms. Others are unable to describe how they feel in more than a few words. Some patients are just naturally private.

  Medical offices are demoralizing. Disheartened air is still left in the room by the last patient. Often addicts arrive and don’t really want their lives changed—they hold on to the belief that maybe their lives are okay the way they are. I have to capture them quickly. They have to be convinced by my conviction and full attention, even when they aren’t ready to change. Some addicts just want the next prescription and nothing more. They are eager to go. Some expect me to ask them questions—they have been to plenty of counselors, psychologists, and social workers over the years and are used to giving a little conversation in exchange for their medication.

  But some addicts simply want a medical visit that allows them a chance to explain themselves free of authoritative comments and judgments. If I didn’t listen, it would be a violation of responsibility and trust. I ask questions because it’s my job—the new medical culture encourages internists (not only psychiatrists) to enter the worlds of patients, to absorb their contradictory, resonant stories of illness, to learn their ordeals, strengths, and psychological responses. But I also listen because I have a need I don’t understand.

  “At each visit—and I’ll tell you the schedule in a few minutes after I get through some more screening questions—I’ll ask if you’re still using Vicodin, and I hope you’ll tell me the truth. But I’ll also be collecting urine and sending it to the lab to check what you have in your system and confirm what you say.”

  Before Lucy arrived, I had already seen three patients, each with very different problems than hers—and had enjoyed the morning’s successes. My first patient was ninety-five years old and was feeling so well she had decided to move out of her daughter’s house and into a place of her own. The second, a tiny man in his fifties, arrived, as always, with his wife and talked about his heartburn and his sweaty palms and how little he ate (his fingers moved in circles to demonstrate the portion sizes) in order to lower his blood pressure, which I’d told him was elevated. These small victories, holding off the inevitable decline of old age and chronic disease, are the satisfactions of an internist’s work life. The third patient was a man of sixty with a burning along his lower posterior ribs that I diagnosed as shingles, herpes zoster, a recurrence of the chicken pox he’d had as a five-year-old. Offering a simple and usually effective treatment—antibiotics—for his obvious discomfort put me in a good mood.

  My nine daily office hours are like a baseball game—they are innings, segmented, discrete. One after the next, they allow pauses and changes of thinking, arguments and counterarguments, different pitches. To a great degree, I have come to depend on the one-on-one orderliness of medicine in a room surrounded by property and
possessions that are mine but not mine. I move through my small world efficiently. I appreciate surprises, although I don’t like all of them. In my forty-fifth year when I met with Lucy, I was still surprised that both my parents were dead, and that my older son would be leaving for college in five months. But years with patients have convinced me that everything is possible. Decades past residency training, I believe it is even possible to strike the right note and help most patients who see me as I am, with a scar above my eyebrow and my hair buzz-cut. Still, I wonder if they remember what I look like when they leave my office? Do they think about something I said? Anything I said? Is it easy to keep me distinct from anyone else who provides them service once or twice a year?

  I needed to know certain things about Lucy that would influence whether I would give her buprenorphine. This would help me determine if it was the right medication for her—and how we would proceed. I needed to know, for example, if she used any other addictive drugs.

  “The medication buprenorphine blocks the effects of Vicodin and any other narcotic you might be taking, as you know, but it doesn’t block cocaine. Do you use cocaine?”

  Buprenorphine is not a substitute for cocaine—there is no comparable medication treatment for cocaine and doctors are pretty much incapable of affecting how patients use cocaine, so patients who used Vicodin and cocaine rarely stick around my office for treatment. If Lucy was a regular cocaine user, I would probably not treat her with buprenorphine.

  “I used it a few times about ten years ago.”

  “But not recently.”

  “Not at all.”

  Did I believe her? I’ve found that even patients who invent their histories eventually disclose the truth if they stick around.

  “Do you drink alcohol?”

  “Not anymore. I used to, quite a bit.” These preliminaries seemed new to her, as if she hadn’t visited a doctor in a while.