Drug War Chronicle Book Review: "In the Realm of Hungry Ghosts: Close Encounters With Addiction," by Dr. Gabor Maté (2010, North Atlantic Books, 468 pp., $17.95 PB)

Phillip S. Smith, Writer/Editor

In the revised edition of his prize-winning Canadian best-seller, Vancouver's Dr. Gabor Maté has made an important contribution to the literature on drug use and addiction. For more than a dozen years, Maté has been a staff physician for the Portland Hotel Society in Vancouver's infamous Downtown Eastside, home to one of the hemispheric largest, most concentrated populations of drug addicts. The Portland is unique -- once just another shoddy Skid Row SRO, under the management of the Society it is now both a residence for the hardest of the hard-core and a harm reduction facility.

https://stopthedrugwar.org/files/hungryghosts.jpg
As a medical resident at the Portland, Maté has seen it all. The first section of "Hungry Ghosts" is filled with descriptions of his patients and their lives. Much of this is quite literally horrendous: Coked-out women turning tricks in alleys for their next rock and contracting syphilis; suicidal, opiate-addicted women refusing HIV treatments; mentally ill and alcoholic men dying young of liver cancer from Hepatitis C infections; people strung out on crack scrabbling at pieces of gravel on the sidewalk in the hallucinatory hope it's another rock; multi-addicted men and women, blood oozing from festering sores as they search yet again for a vein to hit, people overdosing and then going right back at it, people overdosing and dying.

And yet, despite the misery they are in and the wrecks that are their lives, they keep on using. "Hungry Ghosts" is an extended meditation on why. The second chunk of the book is devoted in particular to addressing that question. Maté offers an extended tour of the latest research into the disease model of addiction, with succinct and understandable (to the layperson) explanations of reward circuits in the brain, dopamine and serotonin flows, and all that good neuro-bio-pharmacological stuff so beloved of NIDA grantees. Repeated use of a substance indeed "rewires" the brain, creating pleasure circuits demanding to be fulfilled and pleasure deficits demanding to be fixed... with that next fix.

But unlike the NIDA people, with what I consider to be their neuro-bio-pharmacological determinism and reductionism, Maté goes a step further. He points out, accurately enough, that no matter what substance we're talking about, only a fraction of users, typically between 10% and 20%, become addicts. The "chronic relapsing brain disease" model may have some utility, but it fails to explain why some people are susceptible to addiction in the first place and others are not.

Maté noticed something about his downtrodden, strung-out clientele in Vancouver. They were almost universally abused as children, and at best, neglected. And I mean abused: Not spanked too hard, but raped, beaten, raped again, exploited, sent into foster care, literally spit on by their parents. It's very ugly.

One story especially sticks with me. A First Nations woman whose mother lives on the Downtown Eastside was given up at birth by her addicted mother, and sent to live with relatives, several of whom repeatedly sexually molested her in especially disgusting ways. She grew up an angry, depressed kid who turned to drugs and drink early. Tired of her life, she saved up $500 when she was 14 and ran away to Vancouver to find her mother. She did find her mother -- too bad for her. Mommie dearest promptly shot her up with heroin, spent the $500 on drugs for herself, then turned her out to turn tricks on the street. And you wonder why this woman prefers a narcotized bliss?

Maté doesn't just rely on anthropology and anecdote. He takes the reader instead into an extended look at the research on early childhood development and identifies messed-up childhoods as the key indicator of future substance abuse (as well as many other) problems. It doesn't have to be as extreme as some of these cases, but Maté makes clear that a nurturing early up-bringing is absolutely vital to the development of mentally and emotionally stable human beings.

Maté also has a startling confession to make: He, too, is an addict. The good doctor has been fighting a lifelong battle with his addiction to... wait for it... buying classical music CDs. He has behaved just like a junkie, he admits, spending thousands of dollars on his habit, lying to his wife, neglecting his kids, even leaving in the middle of medical procedures to run and score the latest Vivaldi. He's suffered the same feelings of compulsion, guilt, disgust, and self-denigration as any other addict, even if he doesn't have the scars on his veins to show for it.

At first glance, Maté's claim almost seems ludicrous, but he's making an important point: Addiction is addiction, whether it's to heroin or gambling, cocaine or shopping, he argues. The process of changes in the brain is the same, the compulsion is the same, the negative self-feelings are the same. We don't blame playing cards for gambling addiction or shopping malls for shopaholism; similarly, drugs are not to blame for drug addiction -- our own messed up psyches are the root of the problem.

And that leads to another important point: Those hollow-eyed addicts are like the rest of us, they are a dark mirror on our own inner problems, and most of us have some. (I'm reminded of a cartoon I once saw of a man sitting by all alone in an empty auditorium under a hanging banner saying, "Welcome to the convention of children of non-dysfunctional families.")

This is important because it stops us from dehumanizing drug addicts. They are not "the other." They are us, different only in degree. They deserve caring and compassion even if it is tough and seemingly fruitless work. Maté chides himself for falling from that saintly pedestal on occasion, and good for him.

Not surprisingly, Maté is a strong advocate of harm reduction and a harsh critic of prohibitionist drug policies and the US war on drugs in particular. By grinding drug users down even further, prohibition serves only to make them more likely to seek solace in chemical nirvana. It's almost as if prohibition were designed to create and perpetuate drug addiction.

In the final chapters of "Hungry Ghosts," Maté offers a glimmer of hope for beating drug addiction (or gambling addiction or sex addiction or whatever your particular compulsion is). It is a tough path of self-awareness and spiritual practice. I don't know if it will work -- I haven't tried it myself -- but it is important to remind ourselves that addiction is not necessarily a hopeless trap with no escape.

This is good, strong, compassionate, highly informed reading. I heartily recommend this book to anyone with an interest in addiction, addiction treatment, early childhood development, or drug policy. Thanks, doc.

Permission to Reprint: This article is licensed under a modified Creative Commons Attribution license.
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*thumbs up*

What a wonderfully written review.

McD's picture

Writing

I'd like to second the above comment and sentiment: this review is indeed well-written; kudos to the writer, Mr. Smith.

Thank you, Mr Smith

This review is intelligent, clear and insightful. The reviewer both understands and communicates beautifully what this book is all about.

Reviewer isn't thinking critically

The reviewer Phillip Smith seems ignorant of what a genetic predisposition means, and explains. Genetics actually explain the very question you ask:

"Unlike the NIDA people, with what I consider to be their neuro-bio-pharmacological determinism and reductionism, Maté goes a step further. He points out, accurately enough, that no matter what substance we're talking about, only a fraction of users, typically between 10% and 20%, become addicts. The 'chronic relapsing brain disease' model may have some utility, but it fails to explain why some people are susceptible to addiction in the first place and others are not."

As Avram Goldstein has suggested, a person with a genetic predisposition may be trying to correct an imbalance of brain chemistry. And with some addicts, their drug of choice may be doing that, albeit with some severe side effects. This can explain why many users don't become addicts, while many other people do.

It also explains why -- contrary to Gabor Mate -- addicts don't typically get hooked on the first type of drug they encounter. Some opioid addicts, for example, are not at all likely to get hooked on speed, despite considerable exposure. (Though enough exposure, with enough frequency and higher enough doses, will lead to anyone getting hooked on the major hard drugs: opioids, esp heroin; cocaine, esp crack; speed, esp crystal meth; and alcohol.)

Genetic predispositions also can explain why most people with traumatic backgrounds do NOT become addicts. True, childhood trauma especially increases one's risk of drug addiction tremendously. But it doesn't guarantee addiction.

I sense that the reviewer, and many other fans of the environmental explanations for addiction, think that any other explanation justifies the drug war. It does not. Indeed, it was the environmental explanations which were used to justify the drug war to begin with, using language very very much like that found in Gabor Mate's book --- painting a dark and dismal pictures of poor ghettos filled with people of color.

It's also a very inaccurate portrayal. For decades, the typical American addict -- including crack and heroin addicts -- has been white. The poor inner city neighborhoods of color are where these drugs are typically retailed, that's all -- at least in cities where such neighorhoods border on white areas and can be easily accessed by whites. And even then, it's typically on the edges of those neighborhoods. (But the wholesale business is often outside the inner-city neighborhoods of color. *This* is why the sentencing distinctions between crack and powder cocaine is so unfair and racially biased.)

The bogeyman of people like Gabor Mate, Johann Hari and Bruce Alexander is Avram Goldstein, who designed some of the first rat studies and was a pioneer in addiction science, and was one of the first outspoken advocates for harm reduction and even for experiments with legal prescriptions of heroin for addicts. He also went on to help pioneer methadone maintenance (which by far the most effective treatment for heroin addiction, provided the dosage is high enough, and people stay in treatment long enough).

Finally, if you actually read the newsletters from NIDA, you'd know that specific genes have been identified for predispositions to different drug addictions, including nicotine addiction. There is no real scientific debate over this matter. Gabor Mate is the equivalent of a climate-change denialist. And his arguments against genetic explanations greatly exaggerate and misidentify what is meant by genetic predisposition. Indeed he likes to use the word "cause" instead of "predispose" when characterizing the genetic explanations of addiction. And he refers to old studies, prior to our ability to examine DNA itself.

One last note: Just because the drug war is a gov't policy and practice, and NIDA is a govt agency, doesn't mean that NIDA is serving the interests of the drug warriors. American government is NOT monolithic. Not surprisingly, people who grew up under the Reagan-Bush-Clinton era seem to think that govt is one big monolithic bad guy. It's not. I suggest you subscribe to the NIDA newsletters and periodicals. You might be surprised at what you'll learn.

FYI: I'm a recovering heroin addict, and alcohol abuser, with 20+ years of continuous clean and sober time. It required no spiritual awakening. It just required methadone for 10+ years, until the cravings disappeared (methadone dampens them down, and if they can then be ignored, they are not reinforced, and eventually, after many years, disappear). I also score extremely low on the trauma questionnaire that Mate is so fond of. Indeed, I really couldn't have asked for a much better childhood, and I received a great education, including graduate school. (Btw, methadone stopped my interest in drinking too, and there's a neurological reason for this but I'll spare you. I'll just say that there's every indication to suggest that I have a genetic predisposition, esp given how I went through drug after drug in years of experimentation until I found what it seemed I was looking for...)

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