The Addict. One Patient, One Doctor, One YearRichard Balon, MD
Wayne State University, Detroit, MI, USA
By Michael Stein; William Morrow (An Imprint of HarperCollins Publishers); New York, New York; 2009; ISBN: 978-0-06-136813-4; pp 275; $25.99 (hardcover).
Personal accounts of serious illness—written by patients, their families, or treating physicians—are attractive reading. They may provide a wealth of information about the illness and give inspiration for other sufferers, hope that the illness could be conquered, and some insight. Personal accounts of substance abuse seem to be appearing more frequently, although it is difficult to figure out why. Possible reasons include the difficulties conquering substance abuse, widespread consequences, or because as a society we finally realize the seriousness of the problem. Or maybe, as the author of this book notes, it is because “We live in the age of addiction. Addiction to chocolate and exercise and shoes and love” (p 25).
Dr. Michael Stein, an internist treating opiate addicts, tells the story of one addict from his viewpoint as her treating physician. Also of interest, this patient abused an illegally obtained prescription medication—Vicodin, a combination of opiate hydrocodone and acetaminophen—and was treated with buprenorphine, a relatively new pharmacologic treatment for opiate dependence.
The book is divided into 3 parts and 10 chapters, and follows a year of encounters between Dr. Stein and his patient, Lucy Fields (a fictional name). After briefly introducing Lucy, Dr. Stein discusses Vicodin, the “most prescribed medication in the Unites States—far surpassing penicillin, Lipitor, and Prozac” (p 6). He reminds the reader that “11 million Americans take opiates for nonmedical, recreational purposes” (p 7). As with other substances, we see a spectrum of use—“enjoying the Vicodin, having a little fun with it; using it more often, spacing their doses evenly across a weekend day, then evenly across an entire week; then doing anything to get it, having some physical need for it and finding themselves in search for an ever-increasing need for a pile of pills, or moving to heroin for a bigger, faster feeling” (p 7). Dr. Stein notes that by the time most Vicodin addicts enter his buprenorphine program, “they are typically using 40, 60, or 80 pills a day (needing higher doses to achieve the same effect over time), often spending a few hundred dollars daily on their drug use” (p 10). He explains how his buprenorphine program is structured and how the medication works in the brain. Finally, Dr. Stein notes that he works 2 days a week as an internist and the rest of the week he treats addicts and conducts research.
Lucy’s story evolves gradually. She comes from a middle-class family, attended a good college, but has never held a stable job reflecting her education. She has abused Vicodin for years and cannot remember what normal feels like, but she says, “…for some reason I still believe that I could have a meaningful life, maybe do something valuable.” She started using substances at age 13, first alcohol, then Robitussin—which contains dextromethorphan—and finally Vicodin. Although she felt sick the first time she took Vicodin, by age 29 she has been using the drug for 15 years. After all those “wasted” years of living on the fringe, she finally wants to quit. Dr. Stein examines her, sends her urine for drug screening, and schedules an appointment for 5 days after Lucy stops Vicodin, when she would be in the early stage of withdrawal and the best time to start buprenorphine.
Lucy’s story is intertwined with those of other opiate addicts and more information about opiates. Dr. Stein compares opiates—as opposed to fast-acting cocaine—with eating a big meal because “…afterward you are satisfied, sleepy, full, warm next to a fire, and that feeling doesn’t wear off for hours. But when it does, it is as if you are starving, each cold cell is hungry, and you haven’t eaten in days” (p 69). To describe some users’ strong attraction to opiates, he cites one addict who states, “If God made anything better, He kept it for himself.”
After starting buprenorphine, Lucy is doing well and is not using Vicodin. Dr. Stein felt that Lucy was bound to him because she had to visit frequently to get her buprenorphine. He hopes that he can “help her change a life she had been unsuccessful at changing on her own.” However, it is not easy. As Lucy plans to visit her parents in South Carolina—which is a huge task for her—it is becoming more obvious that she has some unresolved trauma in her past. Dr. Stein suspects molestation but does not explore it. Lucy also is depressed. Right or wrong, Dr. Stein does not treat her depression. As a psychiatrist, the untreated depression and Dr. Stein’s feelings about other opiate addiction treatments poses some problems for me. It seems that Dr. Stein favors buprenorphine over methadone and Narcotics Anonymous based on his personal feelings rather than any solid data. I am more troubled by other issues. Dr. Stein writes that he was not sure if Lucy suffered from depression, but he knew that if she saw a psychiatrist he would be told, “I can’t tell you if your patient is depressed until she stops using Vicodin. Have her get clean for at least 3 months and then come to see me” (p 127-128). True, at one time this was the mantra, but today we do not wait 3 months to treat depressed addicts with antidepressants. Dr. Stein correctly notes that most addiction counselors are former addicts with little training and less than half are licensed (p 109-110). He makes an eloquent comparison, saying, “Imagine if depression counseling in America was offered only by people recently depressed, none of whom had been to graduate school to learn the well-studied dos and don’ts of skillful psychological treatment and specific protocols that might work best” (p 110). Yet he admits that medical school did not prepare him to care for narcotic-dependent patients. Also, it is not clear if Lucy received any formal psychotherapy. Finally, I was a bit surprised by the statement that “Drugs, like sex, are literally self-annihilation, a form of controlled madness” (p 177).
Nevertheless, Lucy struggles successfully with her treatment until she attends her sister’s wedding and relapses. As noted earlier, it is obvious that Lucy’s family life is involved with her addiction. She has had relationship problems with her sister, parents, cousins, and other relatives. After her first year of buprenorphine treatment, she reveals that she suffered a profound trauma at age 8, although she was not molested. Nevertheless, with help from Dr. Stein and buprenorphine, Lucy stops using again, continues her job, enrolls in a school, and buys a car. In the book’s final pages, Dr. Stein notes that he had been seeing Lucy for 3 years and she is halfway through graduate school and doing fairly well. However, he notes there always is a risk of false dreams and false confidence (p 275), relapse is always a possibility, and holding off the submersion into relapse must be improvised (p 275).
The Addict is a moving story of an individual’s struggle with addiction. This book helps us understand the emotions and feelings of persons suffering from addiction. In addition, Dr. Stein’s openness about some of his issues and struggles combined with his compassion and profound interest in his patients is moving. Any reader would agree that we need to treat addiction with the same seriousness and investment as any other mental or physical illnesses. Regardless of my criticism of the author’s approach to psychiatric treatment of addiction and mental illness, this book provides insight into the mind of an addict. It is great, worthwhile reading.
Annals of Clinical Psychiatry ©2009 American Academy of Clinical Psychiatrists