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Not “why the addiction”, but “why the pain”?

A review of Dr Gabor Maté's book In the Realm of Hungry Ghosts: Close Encounters with Addiction, first published in 2008.

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In the Realm of Hungry Ghosts: Close Encounters with Addiction
By Gabor Maté, MD
First published 2008, 10th anniversary edition in 2018

In the opening of his book, In the Realm of Hungry Ghosts: Close Encounters with Addiction, Dr Gabor Maté makes two salient points that should always be, but rarely are, where all conversations about drugs and drug policy begin:

You can’t wage war against inanimate objects, so the War on Drugs is, in actual fact, a war against people who have, in one way or another, become involved with drugs.
People develop addictions—whether to drugs or otherwise—to cope with, or fill in, for something that’s painful or missing in their lives. If we want to get to the root of the issue, the question should not be “why the addiction?” but “why the pain?”

For twelve years, Maté was a physician taking care of the medical needs of people living in Vancouver’s underprivileged, chaotic and stigmatised Downtown East Side. His patients visit his clinic with chronic and harmful dependence on substances like heroin, cocaine and methamphetamines. In the Realm of Hungry Ghosts is based on this experience, highlighting bigger truths about drug use, addiction, trauma, healing and drug policy.

Maté doesn’t mince words when writing about his medical practice and his patients. He doesn’t dismiss or make excuses for bad behaviour, of which there’s plenty: temper tantrums, screaming fits, empty promises, lies, manipulation, threats and sometimes even violence (to one’s environment, one’s companions, or oneself). There are those who spend money they should have used for basic necessities on their next hit, those who fail to show up for medical appointments despite life-threatening health conditions, those who are stubborn and belligerent and refuse to listen. Some, despite healthcare professionals’ best efforts, die from overdose or from conditions exacerbated by their drug use. Maté admits to losing his temper on multiple occasions, or making threats of his own in attempts to scare patients into compliance. He later regrets this coercive behaviour, but never pretends that the relationship his patients have with drugs isn’t harmful or dangerous, nor does he hide that it can be incredibly frustrating to work with people living at the mercy of their addictions.

Reading In the Realm of Hungry Ghosts, I learnt the importance of recognising that this frustration is ours. It’s an anger born out of the gap between what people with drug dependence do and what ‘respectable’ society expects them to do. But do these expectations align with, or speak to, their experiences and struggles? Do we care enough to set aside judgement and scorn so we can properly investigate what lies beneath addiction, and listen with open hearts when people try to tell us how they got where they are?

Most of the people in the world who use, or have used, drugs don’t develop an addiction. It's like how most people who drink alcohol don’t become addicted to booze. Access and contact don't guarantee dependence. When someone becomes addicted to drugs (legal or illegal), alcohol, gambling or anything else, it suggests that something bigger and deeper is going on with them. In the Realm of Hungry Ghosts investigates these root causes. 

When Maté asks his patients about their lives, he unearths unfathomable pain: physical and emotional abuse, neglect and exploitation, trauma and manipulation, poverty and marginalisation, grief and insecurity. Every patient who sat before him had been a scared, lonely child; had learnt from their earliest years of life that the world is a frightening, dangerous place from which they have no shelter, not even with the adults who should have been the ones to provide stability, love and care. Many had been assaulted or abused by those very adults, leaving them with unresolved trauma for the rest of their lives. Among his patients, Maté finds serious mental health issues and undiagnosed neurodivergence, conditions for which people have been, unknowingly and blunderingly, self-medicating. There are internalised feelings of self-hatred and low self-esteem, deep-seated fears of incompetency and disposability, all of which lead to the vicious and circular addiction-fed belief that one can no longer live, or amount to anything, without the object(s) of one’s addiction.

This isn’t unique to Maté’s patients. While reading a recent CNA article on drug addiction among women in Singapore, I found similarities: 

…women are often introduced to drugs by someone close to them such as a partner or family member. This, according to IMH’s Dr Yong, typically involves a background of abuse, neglect or trauma.

Echoing that, Ms Isabel Tan, after-care case manager at the Singapore Anti-Narcotics Association (SANA), said women in these circumstances would be unable to seek proper help or find healthy ways to cope with feelings of hopelessness, fear and anger.

This then leads to drug abuse as a coping mechanism.

In other cases, drugs are used as “self-medication” for chronic pain, exhaustion and weight control. This stems from experimentation or a lack of education or access to information, experts said.

“Like patterns in a tapestry, recurring themes emerge in my interviews with addicts,” Maté writes. “The drug as emotional anaesthetic; as an antidote to a frightful feeling of emptiness; as a tonic against fatigue, boredom, alienation and a sense of personal inadequacy; as stress reliever and social lubricant.”

These are things a drug prohibitionist might dismiss as mere excuse: they all say that, they all play the victim, we’ve heard it all before, but no matter how bad things get, it’s still wrong to take drugs. It’s easy to grow numb and think of these horror stories as mere stories, but Maté reminds us that, for the individual telling it, it is first and foremost experienced as horror:

You can never see and hear it all because, for all their sordid similarities, each story in the Downtown Eastside unfolded in the particular existence of a unique human being. Each one needs to be heard, witnessed and acknowledged anew, every time it’s told.

It’s a multifaceted situation that can’t be reduced to simple causes or binaries. Personal agency is important, and people have the right to make decisions—even ones we don’t agree with—over their bodies and lives. But that isn’t the only factor, Maté argues: addictions do affect people’s brains in ways that impact choice and control. With reference to scientific research and evidence, he points out how addictive tendencies play out in parts of the human brain that govern life-sustaining functions like incentive or reward, motivation, stress regulation, relief of physical and emotional pain, and the ability to feel love. The way an individual’s brain circuits develop and work—for instance, how the brain rewards the person with feelings of satisfaction, joy or relaxation, or how it reacts to stress or anxiety or fear—is affected by one’s environment, particularly the environment of one’s early and most formative years. Addiction is an indication that some brain circuits haven’t matured or developed as they should have, and are firing in ways that reward behaviour that might actually be harmful.

When talking about drug use and drug policy, we tend to veer too hard one way or the other: addiction is either evidence of one’s poor choices and therefore a sign of individual failure, or it’s a beast that has enslaved yet another hapless mortal. We lurch between punishing drug users for consuming drugs and demonising participants in the drug trade (especially those on the lower rungs who are much more within our reach) for pushing substances on poor, helpless victims. In the Realm of Hungry Ghosts advocates the importance of recognising a much more complex interplay.

“Those whom we dismiss as ‘junkies’ are not creatures from a different world, only men and women mired at the extreme end of a continuum on which, here or there, all of us might well locate ourselves,” Maté writes. For some, the notion that a ‘drug addict’ is really not that different from us might be a difficult pill to swallow; how can anyone even suggest that when they’ve made such bad choices, whereas I’ve been responsible and made good choices? But if we could just hold back from knee-jerk judgements and look around us, look within ourselves, it isn’t that hard to see what Maté is getting at.

We live in a fast-paced, high-stress, overwhelming world that has managed to be simultaneously hyper-connected and damaging to genuine relationship- and community-building. We drown in information and bad news—genocide! hypocrisy! exploitation! oppression! the climate crisis!—yet often feel like we have too little control to do anything. There are endless worries: about the cost of living, about the security of our jobs, about how we are perceived, about how we will grow old, about what the world will be like when we are old. We are constantly told to want more, while inequality grows and leaves us worried about not having enough. And this is even before we consider our own shit: the drama that’s unique to each person, each family, each household. It’s no wonder many of us suffer from high stress and poor mental health. When we’re struggling to cope, we start looking for coping mechanisms.

Maté’s vice, he writes in In the Realm of Hungry Ghosts, is (was? I have no idea where he’s at with it now) buying classical music records. He recounts how he buys them impulsively and compulsively, repeatedly drawn to the record store for a new hit to hoard at home. He's clear about the negative effects this habit has had on his life and his relationships (remember, it’s not an addiction if it’s not harmful): his obsession with acquiring ever more records meant he was distracted from or neglectful of his work and his patients. He'd lie to his family about his purchases and emotionally shut himself off from the people who care the most about him, spending thousands of dollars accumulating ever more records in an attempt to fill a void within himself. Instead of addressing lifelong traumas, insecurities and anxieties, his brain glommed on to the instant gratification of a new record as a (short-lived) way to reward and soothe.

The point of sharing his own experience is not to draw false equivalence between his shopping habit and his patients’ devastating drug dependency, but to demonstrate that spectrum, or “continuum”, on which so many of us (all of us?) live. When there is pain and stress and anxiety, we all reach out for something that will soothe us and make us feel whole, even if for a little while. What looks obviously like a bad idea to other people might, in that moment, feel like the best, even only, option for ourselves. That we might actually be wrong about its beneficial quality is separate from how it feels at that point.

Addiction isn’t just about illicit drugs; it can also be about prescription drugs, alcohol, gambling, sex, pornography, voyeurism, gaming, shopping, even work. All these things can be destructive, disrupting healthy routines, ruining relationships, pushing people further and further apart and compounding harm rather than addressing it. It’s just that illicit drugs tend to be the most criminalised and stigmatised, while other sorts of addictions—like workaholism and compulsive shopping—are actively encouraged by our capitalist, consumption-driven systems. Some of the really horrible side effects of the drug trade and use—desperate people stealing or robbing to fund their need, or overdosing on tainted, toxic supply—are caused or exacerbated by criminalisation.

If our goal is to maximise well-being for everyone, then we have to look beyond the judgemental framing of particular addictions and ask how we can heal pain that drive people into the tricky embrace of things that ultimately harm them. A person who stops using illegal drugs but develops an addiction to alcohol or pornography is not healed, even if law enforcement agencies claim victory; they’ve merely shifted from one method of self-harm to another in their quest to feel safe and whole.

What should we do, then? Maté offers a guiding star: “Each addicted person needs to be met at exactly the place where they find themselves at that moment.” It’s something I’ve heard from many others doing frontline harm reduction work with people who use drugs, and completely opposite to Singapore’s current prohibitionist approach. 

In Singapore, drug users are branded as criminals, guilt-tripped into thinking of themselves as burdens on their family and society. They are made to fear the repercussions not just of their drug use, but of admitting to drug use. In the CNA article, women who used drugs feared seeking help or treatment not just because of social stigma, but also because they worried about losing jobs and even custody of their children. While it’s true that chronic and harmful drug dependence might affect one’s ability to hold down a job or performing caregiving duties—although this isn’t an inevitable outcome of drug use—much of this is a consequence not of drugs, but of a “zero tolerance” prohibitionist policy. The article does go on to talk about the sort of care and support that women who use drugs need and might be able to get, but the fact remains that Singapore’s current approach prioritises policing and punishment, and that people are forced into drug abstinence rather than allowed to make decisions about their own bodies and lives. This might work for some—and if they feel better, stronger and more fulfilled in their lives, we should be happy for them—but not for all. The problem with the drug war is that those who don’t succeed on a forced path to abstinence and ‘recovery’ face even more shame and blame for their ‘failure’.

What Maté argues for in his book is deep and prolonged amounts of kindness and patience. People need to be met where they are, and sometimes they’re not in places in their lives where they feel ready or able to leave their drug use behind. What they need is not our anger, judgment and policing, but care and kindness that keeps them as safe and well as we can possibly manage, and provides them with the space to work through complex traumas. Over time, as they begin to feel safe and supported, they might reach a place within themselves that makes them ready for bigger and long-lasting changes in favour of their health and well-being.

Last month, K Shanmugam, Minister for Home Affairs and Law, talked about the need to consider the victims of drug use, even going as far to declare an annual Drug Victims Remembrance Day. It’s part of a narrative that he’s trying to sell: that those of us who seek an end to the War on Drugs and state killing of low-level members of the drug trade are irresponsibly biased in favour of ‘perpetrators’ instead of those whose have faced terrible harms. But anyone who’s paid any attention to my work, or that of the Transformative Justice Collective, should know that we care about people who use drugs, and their families, friends and communities. What we’re pointing out is that some of these harms aren’t inflicted by drugs per se, but our criminalisation of drugs. And what we—and Maté, in this book—point out is that criminalisation and punishment is counter-productive when dealing with the issue of harmful drug use, because prohibition doesn’t meet people “at exactly the place where they find themselves at that moment”, nor does it ask that all important question: Why the pain?

Thank you for reading! As mentioned above, Altering States will always be free to access, so please share this with anyone who you think might be interested.