Keys to Paradise

I

t is impossible to understand addiction without asking what relief the addict finds, or hopes to find, in the drug or the addictive behaviour. That’s a question I’ve put to many of my substance-dependent patients in Vancouver’s Downtown Eastside, most of whom face illness and an early death as a result of their habit.

The meaning of addicted behaviour...

Vincent Felitti, M.D., physician and researcher

The early nineteenth-century literary figure Thomas De Quincey, was an opium user. “The subtle powers lodged in this mighty drug,” he rhapsodized, “tranquilize all irritations of the nervous system . . . sustain through twenty-four hours the else drooping animal energies . . . O just, subtle and all-conquering opium . . . Thou only givest these gifts to man; and thou hast the keys of Paradise.” De Quincey’s words encapsulate the blessings of all drugs as the addict experiences them—indeed, as we shall see later, the appeal of all addictive obsessions, with or without drugs.

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 attempting to self-medicate conditions like depression, anxiety, post-traumatic stress, or even ADHD (Attention Deficit Hyperactivity Disorder).

Addictions always originate in pain, whether felt openly or hidden in the unconscious. They are emotional anaesthetics. 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,¹ just as if it was actual physical pain they were enduring.ⁱ

The pain pathways in humans are no different. The very same brain centres 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.ⁱⁱ When people speak of feeling “hurt” or of having emotional “pain,” they are not being abstract or poetic but scientifically quite precise.

The hard-drug addict’s life has been marked by a surfeit of pain. No wonder she desperately craves relief. “In moments I go from complete misery and vulnerability to total invulnerability,” says Judy, a thirty-six-year-old heroin and cocaine addict who is now trying to kick her two-decade habit. “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.ⁱⁱⁱ The majority of my Skid Row patients suffered severe neglect and maltreatment early in life. Almost all the addicted women inhabiting the Downtown Eastside were sexually assaulted in childhood, as were many of the men. The autobiographical accounts and case files of Portland residents tell stories of pain upon pain: rape, beatings, humiliation, rejection, abandonment, relentless character assassination. As children they were obliged to witness the violent relationships, self-harming life patterns or suicidal addictions of their parents—and often had to take care of them. Or they had to look after younger siblings and defend them from being abused even as they themselves endured the daily violation of their own bodies and souls. One man grew up in a hotel room where his prostitute mother hosted a nightly procession of men as her child slept, or tried to, on his cot on the floor.

Carl, a thirty-six-year-old Native man, was banished from one foster home after another, had dishwashing liquid poured down his throat at age five for using foul language and was tied to a chair in a dark room in attempts to control his hyperactivity. When he’s angry at himself—as he was one day for having used cocaine—he gouges his foot with a knife as punishment. He confessed his “sin” to me with the look of a terrorized urchin who’d just smashed some family heirloom and dreaded the harshest retribution.

Another man described the way his mother used a mechanical babysitter when he was three years old. “She went to the bar to drink and pick up men. Her idea of keeping me safe and from getting into trouble was to stick me in the dryer. She put a heavy box on top so I couldn’t get out.” The air vent ensured that the little boy wouldn’t suffocate.

My prose is unequal to the task of depicting such nearly inconceivable trauma. “Our difficulty or inability to perceive the experience of others . . . is all the more pronounced the more distant these experiences are from ours in time, space, or quality,” wrote the Auschwitz survivor Primo Levi.^iv We can be moved by the tragedy of mass starvation on a far continent; after all, we have all known physical hunger, if only temporarily. But it takes a greater effort of emotional imagination to empathize with the addict. We readily feel for a suffering child, but cannot see the child in the adult who, his soul fragmented and isolated, hustles for survival a few blocks away from where we shop or work.

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.”^vAméry 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.

Not all addictions are rooted in abuse or trauma, but I do believe they can all be traced to painful experience. A hurt is at the centre of all addictive behaviours. It is present in the gambler, the Internet addict, the compulsive shopper and the workaholic. The wound may not be as deep and the ache not as excruciating, and it may even be entirely hidden—but it’s there. As we’ll see, the effects of early stress or adverse experiences directly shape both the psychology and the neurobiology of addiction in the brain.

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.

I didn’t use for six years,” says Cathy, forty-two-year-old heroin and cocaine user, back in a grubby Downtown Eastside hotel after a long absence. She’s contracted HIV since her return. “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. The rest of us find other ways of suppressing our fear of emptiness or of distracting ourselves from it. When we have nothing to occupy our minds, bad memories, troubling anxieties, unease or the nagging mental stupor we call boredom can arise. At all costs drug addicts want to escape spending “alone time” with their minds, and to a lesser degree, behavioural 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, untrammelled emotion. Adults envy the open-hearted 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.”

Carol is a twenty-three-year-old resident of the Portland Hotel Society’s Stanley Hotel. Her nose and lips are pierced with rings. Around her neck she wears a chain with a black metal cross. Her hairdo is a pink-dyed Mohawk that tapers to blond locks cascading at the back to her shoulders. A bright, mentally agile young woman, Carol has been an injection crystal meth user and heroin addict since she ran away from home at age fifteen. The Stanley is her first stable domicile after five years on the streets. These days she is active in promoting harm reduction and in supporting fellow addicts. She has attended international conferences, and her writings have been quoted by addiction experts.

During a methadone appointment, she explains what she cherishes about the crystal meth experience. She speaks nervously and rapidly and fidgets incessantly, effects that result from her longstanding stimulant habit and likely from the early-onset hyperactivity disorder she had before she ever used drugs. As befits a street-educated child of her generation, Carol’s every second word seems to be “like” or “whatever.”

When you do, like, a good hit or whatever you get like a cough or whatever, like a warm feeling, you really feel a hit, start breathing hard or whatever,” she says. “Kind of like a good orgasm if you are a more sexual person—I never really thought of it that way, but my body still experiences the same physical sensations. I just don’t associate it with sex.

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 defence mechanism and can enable the child survive 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.”ⁱ

Intuitively, we all know that it’s better to feel than not to feel. Beyond their energizing subjective charge, emotions have crucial survival value. They orient us, interpret the world for us and offer us vital information. They tell us what is dangerous and what is benign, what threatens our existence and what will nurture our growth. Imagine how disabled we would be if we could not see or hear or taste or sense heat or cold or physical pain. Emotional shutdown is similar. Our emotions are an indispensable part of our sensory apparatus and an essential part of who we are. They make life worthwhile, exciting, challenging, beautiful, and meaningful.

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 above.

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, 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 defence. I shall not be moved.”

I enjoy the rush, the smell and the taste,” says Charlotte, long-time cocaine and heroin user, pot smoker and self-confessed speed freak. “I guess I’ve been smoking or doing some form of drugs for so long, I don’t know . . . I think, What if I stopped? Then what? That’s where I get my energy from.”

Man, I can’t face the day without the rock,” says Greg, a multidrug addict in his early forties. “I’m dying for one right now.”

You’re not dying for it,” I venture. “You’re dying because of it.” Greg is tickled. “Nah, not me. I’m Irish and half Indian.”

Right. There are no dead Irish or dead Indians around.”

From Greg, more jollity. “Everybody has to go sometime. When your number comes up, that’s it.

These four don’t know it, but beyond illness or the inertia of emotional and physical exhaustion, they are also up against the brain physiology of addiction.

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.

* * * * *

Aubrey, a tall, rangy, solitary man now approaching middle age is also hooked on cocaine. His face is permanently lined by sadness, and his customary tone is one of resignation and regret. He feels incomplete and incompetent as a person without the drug, a self-concept that has nothing to do with his real abilities and everything to do with his formative experiences as a child. By his own assessment, inadequacy and the sense of a being a failed human being were part and parcel of his personality before he ever touched drugs.

After Grade Eight I grew up on drugs,” Aubrey says. “When I turned to drugs, I found that I fit in with other kids . . . Yeah, it was a big important thing, to fit in. See, as a kid when you picked somebody for a soccer game, I was always the last guy to be picked.

See,” he continues, “I’ve been in institutions a lot, I’ve spent a long time in a four-by-eight cell. So I’ve been by myself a lot. And before then, too. See, I had a rough childhood, going from foster home to foster home. I was shipped off quite a bit, eh.”

At what age were you sent to foster homes?” I ask.

About eleven. My father was killed, hit by a truck. My mother couldn’t take care of all of us kids, and so Children’s Aid stepped in. Me being the oldest, they took me out. I got two brothers. They were younger. They stayed home.”

Aubrey believes he was chosen for foster care because he was “so hyper as a kid” that his mother couldn’t handle him.

I was there for five years. Well, not in one place. No. I got shipped around. They’d keep me for maybe a year and then they couldn’t . . . and I had to go to another one.”

How did it feel to be shunted about like that?”

It hurt me. I was feeling like I wasn’t wanted. I was just a kid . . . It’s like, I’m a kid and nobody wants me. Even in school. The nuns taught me, but I never learned to read or write or nothing. They just pushed me from one class to another . . . I was always disciplined for something, and they’d take me out of that class and put me in a class for four- or five-year-old kids . . . so I felt so uncomfortable. It was hard for me. I felt stupid. I’m sitting there with all these little kids around me, looking at me. The teacher is teaching spelling . . . And they’re doing it and I can’t do it . . . I kept it all to myself. I didn’t want to talk for the longest time . . . I couldn’t even talk to people. I stuttered; I had a hard time explaining myself. I kept it all inside me for so long. When I get hyper I can’t talk proper . . .

Strange, the cocaine calms me down.¹ And the pot. I smoke five or six joints a day. That relaxes me, too. It takes the edge off. At the end of the day I just lay back with it. That’s just what happens, that’s my life. I smoke a joint and I go to sleep.”

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.”

No less a figure than the young Dr. Sigmund Freud was enthralled with cocaine for a while, relying on it “to control his intermittent depressed moods, improve his general sense of well-being, help him relax in tense social encounters, and just make him feel more like a man.” ²ⁱⁱ Typical of all users, Freud was slow to accept that he had a dependence problem.

Enhancing the personality, the drug also eases social interactions, as Aubrey and Shirley both testify. “Usually, I’m feeling down,” says Aubrey. “I do coke, I’m totally a different person. I could talk to you a lot better now if I was high on cocaine. I don’t slur my words. It wakes me. It makes it easier to see people. I’ll want to start a conversation with somebody. I’m usually not very interesting to talk to . . . That’s why most of the time I don’t want to be with other people. I don’t have that drive. I stay in my room by myself.”

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.

Nicole is in her early fifties. After five years as my patient she revealed that, as a teenager, she’d been repeatedly raped by her father. She, too, has HIV, and the ravages of an old hip infection have left her hobbling around with a cane. “I’m more social with the drug,” she says. “I get talkative and confident. Usually I’m shy and withdrawn and not very impressive. I let people walk all over me.”

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 addict. No matter how much he may acknowledge the costs of his addiction, he fears a loss of self if it was absent from his life. In his own mind, he would cease to exist as he knows himself.

Carol says she was able to experience herself in a completely new and positive way under the influence of crystal meth. “I felt like I was smarter, like a floodgate of information or whatever just opened in my head . . . It opened my creativity . . . .” Asked if she has any regrets about her eight years of amphetamine addiction, she is quick to respond: “Not really, ’cause it helped bring me to who I am today.” That may sound bizarre, but Carol’s perspective is that drug use helped her escape an abusive family home, survive years of street living and connect her with a community of people with shared experiences. As many crystal meth users see it, this drug offers benefits to young street dwellers. Strange to say, it makes their lives more liveable in the short term. It’s hard to get a good night’s sleep on the street: crystal meth keeps you awake and alert. No money for food? No need for hunger: crystal meth is an appetite suppressant. Tired, lacking energy? Crystal meth gives a user boundless energy.

Chris, a personable man with a mischievous sense of humour, whose well-muscled arms sport a kaleidoscope of tattoos, completed a year-long prison term a few months ago and is now back on the methadone program. In the Downtown Eastside he’s known by the strange sobriquet “Toecutter,” which he earned, legend has it, when he dropped a sharp, heavy industrial blade on someone’s foot. He continues to inject crystal meth with dogged determination. “Helps me concentrate,” he says. There’s no doubt he’s had Attention Deficit Disorder all his life and he accepts the diagnosis, but he declines treatment. “This smart doctor once told me I’m self-medicating,” he smirks, recalling a conversation we had years ago.

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 mid-thirties. With his wispy blond facial stubble and 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.”

Your old lady . . .”

Yeah, I look upon the coke as my old lady, my family. It’s my partner. I don’t see my own family for a year, and I don’t care, ’cause I’ve got my partner.”

So the coke is your life.”

Yeah, the coke’s my life . . . I care more about the dope than my loved ones or anything else. For the past fifteen years . . . it’s part of me now. It’s part of my every day . . . I don’t know how to be without it. I don’t know how to live everyday life without it. You take it away, I don’t know what I’m going to do . . . If you were to change me and put me in a regular-style life, I wouldn’t know how to retain it. I was there once in my life, but it feels like I don’t know how to go back. I don’t have the . . . It’s not the will I don’t have; I just don’t know how.”

What about the desire? Do you even want that regular life?”

No, not really,” Jake says quietly and sadly.

I don’t believe that’s really 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.

If you had a regular life and somebody said to you, ‘Hey, you could be in the Downtown Eastside hustling all day and blowing three or four hundred dollars a day on rock,’ you’d say, ‘What? Are you crazy? That’s not for me!’ But you’ve been doing it for so long, it’s become normal for you.”

Jake then shows me his hands and arms, covered with patches of silvery scales on a red, inflamed field of skin. On top of everything else, his psoriasis is acting up. “Do you think you could send me to a skin specialist?” he asks.

I could,” I reply, “but the last time I did, you didn’t show for the appointment. If you miss this one, I won’t refer you again.”

I’ll go, Doc. Don’t worry, I’ll go.”

I write out the prescriptions for methadone and for the dermatological creams Jake needs. We chat a little more, and then he leaves. He’s my last patient of the day.

A few minutes later, as I’m about to check my voicemail messages, there’s a knock. I pull the door ajar. It’s Jake, who made it to the front gate of the Portland but has returned to tell me something. “You were right, you know,” he says, grinning again.

Right about what?”

That frog you’re talking about. That’s me.”

references

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