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This second installment of Last of the Laowai covers the early days of COVID, beginning with my flight back to China in March of 2020 as the pandemic is popping off. A fellow passenger is suspected of having COVID, and all of us are quarantined in a remote seaside resort in Fujian Province. As is frequently the case, I am on drugs. (For Part I, "I Was Simon Song," which contains an overview of my time in Shenzhen and Beijing, click here ); Part III, "Holes in the Wall, Holes in the Brain," which details events related to the pro-democracy riots / protests in Hong Kong, is available here) Customs page from my passport; 入 means entry and 出 is exit. You can see my flight to the U.S. on 1/14/2020 as the COVID outbreak was burgeoning into an epidemic in China and the first cases were appearing in the U.S., mostly in major cities and on college campuses. As the stamps show, I returned to China on 3/12/2020, about three months after the first COVID cases, which were linked to the Wuhan seafood market, were reported. By this point, the pandemic was on and poppin'. However, the Chinese government's draconian "Zero COVID" lockdown hadn't yet been instituted, and international travel was still largely unrestricted. My flight from New York City to Fuzhou begins in a blur and ends with a moment of awful clarity. Most of my friends and family believe that it's too risky for me to head back to China. By coincidence (unless my boss was trying to kill me), I had been in Wuhan, the city where COVID originated, at the end of December of 2019 - just as the initial case cluster from the seafood market was being reported. Before I left Shenzhen for that business trip, my coworkers had offered confused advice against eating sushi or getting too close to the hundreds of parents and students who would attend the talks that I was giving. Remarkably, I had returned to Shenzhen physically well and not any sicker in the head than I usually was. My family and friends pointed out that this was an epic, lucky W. And, when I returned to New York in mid-January for my yearly holiday visit, it appeared that I had escaped China just as fortuitously as I had dodged COVID in Wuhan. It's now mid-March, and the Chinese healthcare system has been overrun by the virus, whose biology and clinical properties are still largely unknown, and the lockdowns have begun. The discrepancy between what ordinary Chinese people are sharing on social media and the sanitized, state-sanctioned narrative from official news outlets is chilling: "The novel coronavirus outbreak is being contained, and infection numbers are stabilizing," we are reminded each day as Chinese citizens share videos of hospital corridors crammed with sick human beings - some covered in their own waste, others dead. Still, I don't know what other call I could make. My fiancé, my dog, my career, my apartment - my whole, hard-won new life - they're all in China. Really, that life is beginning to crumble as I stumble back into opioid and benzo addiction, but I'm not ready to admit that to myself just yet. As is often the case with me, my emotions swirl below the surface, where they form contradictory eddies, currents, riptides. I'm not conscious of feeling worried about returning to China, but this doesn't prevent my underlying unease from manifesting in my behavior. I've been maintaining myself on buprenorphine (Suboxone) while I visit my family upstate, which allows me to avoid withdrawal without being f*cked up, but during the 12 hours that I have in NYC, I pay one of my old dealers to meet me near JFK airport with something stronger. I've already taken a handful of benzos - everyone pops Xanax before a flight, right? - but I know that it might be an entire year before I can use a needle again, and suddenly it seems very important to me that I not let this opportunity go to waste. I pay D far too much to drive the dope out to me. He agrees to stop at a pharmacy and pick up fresh needles on the way. "I wouldn't do this s*it for anyone else," D chides me. "I know, D, and I really appreciate it," I wheedle. I've missed this liar's dance, which is ritualized, frictionless, soothing. After paying that much for someone to meet me, I'm not going to buy less than a couple bundles, right? And, since I obviously can't carry dope and rigs onto the plane with me, I've got to do it all before I head back to the airport, right? Finding a public bathroom to shoot up in in New York City is like playing an absurdist videogame on difficult mode; it's preposterously inconvenient, and it's meant to be so. As I complete my quest, I conclude that, pandemic or no, I'm glad to be returning to a country whose public restrooms are designed to make it as convenient as possible to void bodily wastes - as opposed to the U.S., where the design premise is that these facilities should be as inaccessible as possible to drug users who want to shoot up in relative comfort, safety, and cleanliness. Eventually, I order an entire breakfast at a run-down diner to purchase the privilege of shooting up in its squalid, single-occupant bathroom. Gotta get through two buns in four hours, I remind myself as I load the first syringe. It's the kind of challenge that brings out my heroism, that makes my spirit sing. Even before the dope hits me and I deliquesce into the warm-molasses demimonde of the poppy, I feel a surge of that unshakeable optimism that is only possible for a junkie who has a full bag of fresh rigs. I return to my table. The food is slop. I have a heavenly breakfast. I'm chatty with the waitress. She's visibly annoyed with me. I enjoy the conversation for both of us. I return to the bathroom, inject an amount of dope that is just as likely to OD me as it is to get me high, and then head directly to the register by the door. I tack on a make-your-day tip. I have no idea how I get to JFK, check myself in, find my gate, and board my flight. The only memory that I have of this process is of two girls in their late teens approaching me as I walk down one of the airport hallways. They wear concerned expressions, which are so similar that I question whether they're sisters. "Are you okay?" "Are you sure you're okay? Do you need some... help with something?" I mumble something back. Somehow, I board my flight. I have no memory of the safety demonstrations or of any of the other preflight fanfare. I'm sure that there are extra announcements related to the pandemic, but they don't register with me. Shortly after we take off, a handsome flight attendant with an inscrutable expression taps my shoulder and gestures to an open row of seats in the very back of the section that I'm in. I stretch my lanky frame out there, and I am instantly unconscious. At some point during the 16-hour flight, a bemused Chinese grandmother rouses me, her expression as natural and as confident as if I were her grandson. She hands me a plastic cup filled with water, which I gulp down greedily. She refills it from a bottle that she's holding, then gestures toward the seatback in front of me, pulling the storage compartment open to show me that she has stashed my in-flight meal there. Xiè xiè , I remember to thank her before I lay back down. She slips a pillow - not a cheap airline cushion, but a real, from-home pillow with a cover - under my head before I pass out again. There is something profoundly, almost spiritually comforting about the old woman. All that pain that you think is uniquely yours, I have seen and borne and more , her smile seems to say. Her face floats up through a warm sea of memory at several points in the monthslong ordeal that follows. *** Please remain seated . We have landed in Fuzhou, the capital of Fujian Province, which is the closest Mainland territory to Taiwan. Adjacent to the west is Guangdong Province, where my Chinese home city of Shenzhen is located. My drug-deluged fog is dissipating: I've reached the point where my memory track will resume. The first thing that I notice is the absence of pre-disembarking bustle. There are no announcements about local time, temperature, precipitation. No one stands up to stretch as we wait to receive the all-clear to retrieve our carry-ons from the overhead compartments. There are no phone calls to let relatives know that we have landed. In the seats directly in front of me, a mother shushes two young girls, one on either side of her. She keeps her arms around them in that archetypal maternal posture for when danger is near. Minutes tick by. Of course it's taking longer than usual, I reassure myself. We're in the middle of a pandemi c . I know that it's a lie. I have the same feeling as I had earlier, when I was talking to D. Rail and air travel in China usually proceed with a fluent, choreographed precision. Something is wrong. Just as I'm starting to feel half-human, a thought slaps me across the face: Oh my God, what if they saw how f*cked up you were and assumed you had COVID? My eyes dart around the cabin as blood rushes to my cheeks, bringing a pins-and-needles sensation. It doesn't seem like anyone is paying particular attention to me, though. Most of my fellow passengers - at least 95 percent, I'd bet - are Chinese. At present, they're maintaining the impassive, eyes-ahead expression required by Chinese social etiquette under distressing conditions. Still, I begin running through my rudimentary Mandarin, struggling to summon the proper words for, "Do not fear; I am not sick of body. I am merely the drug-debauched foreigner who you were warned about in middle school." *** My whole life, I have loved B sci-fi flicks, and the scene that unfolds next is right out of a low-budget biothriller. Please remain seated , we hear again as workers in white, Level A Hazmat suits - the "moon suits" that have a one-piece jumper for the body, a plastic window where the face is, and a self-contained breathing apparatus - walk briskly down both aisles. Almost as soon as I register their presence, one of the workers taps my shoulder and hands me a small, glass rod. My thinking track is still a few seconds behind the motion track for this scene, so it's a moment before I identify it as an armpit thermometer. I consider injecting some levity into the situation by pretending to pull down my pants, but when I raise my eyes to meet the worker's, that impulse dies immediately: She has that brittle, doll-like perfection that some Oriental women are graced with, an ethereal quality that suggests a deathless djinn encased in modern technology. I find none of the softness of the healer about her; in fact, she has the mien and carriage of a cop. How could they know that someone on board has COVID? I wonder as I wait for the thermometer. It's still early days as far as the pandemic is concerned, and it's not yet required to document a negative COVID test before flying. Still, it's not clear to me how things could have gone from green to red during the 16 hours of the flight. My best guess is that another patient vomited or spiked a fever. My thermometer registers a healthy 37 Celsius, but this doesn't change what happens next. I'm hustled off the plane and into the airport, where a phalanx of airport security and local police leads our group through double doors that don't look like they're ordinarily used by passengers. No one asks where we are going. *** As I wrote this, I had to pull out my passport to verify not just the month, but also the year of my flight to Fuzhou. The pandemic was one long blackout. As the days, weeks, months, years wore on, the absurd and the formerly unthinkable became routine. My brain's scornful response, it seems, was to refuse to remember - as though this period of my life wasn't worth the synapses that would've been required to memorialize it. However, as with any blackout, the most vital, emotional, and menacing moments have their way of punching through into the light of recollection. But they come to me in strange hues, out of sequence; I wouldn't believe some of them without independent corroboration. At one point as I wait in yet another pop-up hospital after registering hot at a fever checkpoint, a middle-aged, male doctor slips his hand down the back of my hospital gown, caressing my spine and shoulder. He removes it after a moment, then slides it into the back pocket of the jeans that I left on underneath the gown. I don't react, and he withdraws his hand a moment later, giving my butt a paternal pat. I don't resent this extra, who is playing the part of Handsy Uncle 1 in the 2020 Pandemic Pageant. He's middle-aged, true, but this might be his first role out of acting school, or perhaps he's a dilettante. I'm... what? Amused, flattered, grateful? The memories come in inexplicable pairs; they bear no relation to each other. I remember a phone call with one of my dearest Chinese friends almost 18 months into total lockdown, by which point hundreds of millions of people are experiencing the mental unraveling caused by solitary confinement, which is considered a form of torture for a reason. At 9 a.m., I empty the vending machine at my hotel of the five beers left in it. Then, Peng and I spend two and a half hours belting out our favorite Western hits. We alternate who gets to choose the song. U2, Britney Spears, the Cranberries, Cher, Tupac, various Disney theme songs that shall remain unnamed are all represented. "Ready, set, go," we count down together before simultaneously pressing the play button on whatever YouTube video we are using for music and lyrics. Ordinarily, I never, ever sing. I have an awful voice, and my tonal control leaves everything to be desired. But this morning, I am outrageously, deliriously happy to sing along with Peng. *** It's not just the facts and the timeline that are muddled. My emotional memory, too, is distorted. I am unafraid as our plane is boarded by the public health workers (or whoever they are). I certainly don't fear for my health. By this point, I've been daring God to let me destroy myself for years - calling the universe's bluff as a matter of both style and principle, again and again. I do recall a pang of worry at the thought that I might not be able to get to the oxy that I have waiting for me in a mailbox in Shenzhen. I have some Suboxone with me - simple to travel with because the sublingual strips don't look like medicine, more like little orange Listerine strips. As soon as I realize that I will not be flying on to Shenzhen on schedule, I begin calculating how many days my Suboxone supply will last, devising a taper schedule in my mind. I am overcome by a primal exhilaration, an awakening of a part of me that modern society prefers us to forget that we possess. My whole life, I have read books about natural disasters, wars, plagues. Something's finally happening, I realize with a strange thrill as I board the bus that is waiting for us outside the airport. This is my time; these will be my stories . *** As I write them now, the face of the kindly grandmother from the plane returns to me. I close my eyes so that I can picture her more perfectly. I never found out if she caught COVID from another passenger on the plane, and if so, if she made it. Perhaps she survived and returned home only to perish later on in the pandemic. Maybe she was one of the millions who died because they couldn't access essential medications and medical procedures during three years of lockdown. As I write this, I realize for the first time that I never returned her pillow. Photo from All Trails of a section of southern Chinese coastline; it's reminiscent of the beach outside the coastal resort in Fujian where our entire flight was quarantined after a passenger showed symptoms of COVID. During our two-week stay, we weren't allowed to leave our rooms to explore the hotel, to interact with each other, or to venture outside. However, we were permitted to keep our phones, and we had Internet access, which was a saving grace. I've never seen this section of Mainland China's southern coast before. This stretch of beach reminds me of Cape Cod. It's craggy, argumentative shoreline, prone to the same misty melancholies. I can't see the sun itself, but the fog outside the sliding-glass doors has gone from charcoal to slate to a milky, wispy white. I pull up a chair from the kitchen of the luxurious suite that they've put me up in. I watch the final tendrils of fog part to reveal timid waves lapping at the rocks scattered along the shoreline. I place a four-milligram strip of buprenorphine under my tongue, where it dissolves with an acrid, citrusy tang. I've taken too much already, and my supply is dwindling. If we're kept here for longer than three or four more days, I know that withdrawal is in my near future. Out of all of the events transpiring in a world gone mad, it's the only prospect that truly terrifies me. As I scry my fate in the revealed shoreline, I allow myself a morbid flight of fancy, imagining the last two humans, the inverse Adam and Eve, drifting along this stretch of coast in a cozy, retro little vessel, their skeletal remains curled toward each other like two halves of a broken-heart emoji. *** "Morning, fellow traveler :)" The ping from Weston's greeting jolts me from my reverie. Things are tense between Chinese and foreigners right now. The Chinese are humiliated that the virus is being blamed on them, and that Chinese are being mistreated in the U.S. and other countries; there is a worrying, retaliatory trend of Chinese insisting that foreigners are more likely to carry the virus and to be diseased in general. Accordingly, most of the Chinese passengers in our group had given the handful of foreigners present a wide berth during the 90-minute ride from the airport to this coastal resort, which hasn't officially opened yet, where the local government has evidently decided to let us die in luxury. Weston, though, had plopped himself down in the seat next to me without a moment's hesitation. "A chance to improve my English!" He'd noted cheerily after it became clear that my Mandarin wasn't up to advanced conversation. I didn't need to ask where he was from; Weston's speech was full of the bravado and the distinctive extra "er" syllables of the Beijinger. Really, Weston shouldn't have needed a chance to practice his English, given that he had attended Western Michigan University for the past three years. However, this doesn't mean as much as you might expect: WMU caters to slacker Chinese princelings whose parents are happy to pay upwards of 50K USD a year to ensure that their sons graduate from an American university; they hope that Chinese hiring managers who are reviewing resumes will mistake WMU for the highly prestigious University of Michigan or the not-too-shabby Michigan State University (sorry, guys, the jig is up). Upon discovering that I'm a teacher, Weston sheepishly confessed to paying an ABC - American-Born Chinese - peer to take his humanities and language requirements for him; he studied mechanical engineering. Weston did have blind spots in his vocabulary and spoke with a lilt that could be a little hard to decipher, but I recognized right away that his real motivation for sitting next to me had nothing to do with improving his English; he was there to help me by translating the instructions of the medical workers who had boarded the bus with us. In between his translations, which Weston delivered with an almost cartoonishly intense look of concentration on his face, the two of us had a lively conversation about fate, family, real estate valuation in Tier 1 cities, and our impending doom. So many of my Chinese students saddled themselves with ill-fitting names from pop stars or TV series - or, sometimes, unfortunate attempts at phonetic translations of their Chinese names - but Weston's name fit his chill personality to a T. He had a rich kid's confidence, and I found his swagger comforting under the circumstances. In situations involving a finite supply of male talent, I tend to gravitate toward two guys: One who could become a good friend, the other a low-key crush. Desperate times called for desperate measures, though, and in Weston, I had found a bit of both. Although passengers had been discouraged from sharing nonessential information in the WeChat group for our flight, which we had all been force-added to during the bus ride to the resort, Weston had scanned my QR code so that we could chat privately. We had been quarantine buddies ever since, and we made a point of saying good morning and goodnight. *** The two of us have resolved to put our quarantine to good use. For the third morning in a row, we run through our improvised exercise routine, video chatting as we complete push-ups, crunches, lunges, burpees. We make sure not to begin our drills until after the medical workers pay their morning visits to each room, where they stand in the doorways and observe us taking our temperatures. We can't elevate our body temperature before the morning and evening measurements because anyone spiking a fever will be sent off-site for medical treatment, we have been advised; Weston and I joke that "taken off-site for medical treatment" is a euphemism for being marched out to the water's edge and shot in the head. After we finish a set of 100 jumping jacks, Weston calls for a break. "Watch this," he calls as he takes a prodigious rip from his vape, exhaling a cloud that swallows him up like an over-the-top special effect for the disappearance of a wizard in a high school play. "I'm thinking about working for the company that makes these vapes after I graduate," he tells me. "So cool. The HQ is in Shenzhen, and they give you a free vape and let you vape at your desk, I heard. No limit." "No limit!" He repeats incredulously, shaking his head. I'm laughing so hard that I can't finish my next round of crunches. "What? I'm serious -" I hear my phone ding and then, half a second later, the echo of Weston's notification. Our breakfasts, packaged in disposable plastic containers, have been left on the stools set up outside each of our doorways. We're not allowed to retrieve them until the workers have left the hallway and the all-clear message appears in our WeChat group. We end the morning's exercise session so that we can eat. So far, the food is the most unfortunate element of the quarantine. This morning, it's greasy rice that has no business being greasy and a hard-boiled egg whose yolk is freckled with spots of a blue-green that I associate with Dr. Suess (him, and bread mold). Between the lousy food and our morning workouts, I'm looking forward to getting cut up before I see Jay, my fiancé, whenever this quarantine ends and we're together again. Imagining hugging Jay and Ti Qi the Wonder Poodle germinates a tense, dense feeling in the space between my lungs. We should've been reunited already, I realize an unaccountable three days late. For the first time, I allow myself to consider what is really at stake. *** My stints in rehab and recovery have taught me discipline in organizing my time. I've already implemented a rigid, prison-like schedule for each day. Next up is an hour and a half of Italian and Chinese study. But not before I shower. And I won't shower until I've had my "me time." One nice thing is that, aside from the small children who have been allowed to stay with their parents, we've all been given our own suites. It's not a nice thing, really, to be so isolated. But one actually nice thing is that we have Internet access. This is particularly important because masturbation has an almost cosmic significance for me during times of stress; you know - final exams, legal proceedings, pandemics. Particularly pandemics, as it turns out. It is the best anxiety alleviator that I have at my disposal - my rod and my staff, so to speak. The problem is that my VPN isn't working, meaning that my browsing sessions are being recorded and potentially reviewed. I've run into this situation once or twice before, and I've developed a psychological strategy for overcoming the weirdness. First, I imagine a wizened Chinese censor, a closeted gay from a village with a male to female ratio of 12:1. Decades ago, the venerable Mr. Zhao had sex with his wife exactly one time to produce the couple's allotted one child, then fell into a catatonic stupor until modern psychiatry revived him three years later. Of course, Mr. Zhao has always been far too frightened to browse porn, which is technically illegal in China, let alone gay porn. The most that he's permitted himself are a couple of "men in speedos" and "athletic underwear for men" searches, the kind of stuff that Western boys graduate from by the time we're in 4th, 5th grade. Today, as I navigate the web with one hand, Mr. Zhao reviews my Internet feed in real-time to make sure that I'm not spamming Chinese social media with pick-me complaints about mistreatment of foreigners during quarantine. Mr. Zhao's face, heart, and crotch light up as he discovers Russian gay spanking porn for the first time courtesy of yours truly. I don't do it for me, you see; it's mostly for Mr. Zhao. And it's Mr. Zhao's avid grin that I imagine as my relief arrives. *** After I'm done entertaining Mr. Zhao, I remain sprawled out on a bed that is far plusher than any disaster-time sleeping accommodations have any right to be. Suddenly, a moment of post-petite mort clarity arrives with that startling sting of absolute truth: For the first time in your life, the entire world is as f*cked up as you are. A moment later, the sequela: It has taken the world shutting down completely for you to stop and reflect. Before I begin reading my Italian newspaper, I sit down at the escritoire in the corner of the room. I begin to write. *** Thank you for reading! Part III, the second-to-last-installment of Last of the Laowai, is available here .

Nietzsche's concept of eternal recurrence poses the following question: What if you had to live your life, just as it is and has been, over and over and over again? Would it be heaven or hell or just some lame, lukewarm purgatory? I wrote the following piece, which consists of variations on the theme of eternal recurrence, while tripping on acid during a particularly tempestuous time in my 20's. As usual, I used GenCraft AI to create this image. Let's take Nietzsche's thought experiment one step further. If you could relive one magnificent moment of your life over and over again for eternity, which one would it be? What about if you were forced to relive your most dreadful moment over and over again - which moment would be your Hell? My initial reaction is that my worst episode of combined opioid, benzo, and barbiturate withdrawal would be my personal Hell, but deep down, I know that this is a cop out; the truth is that there have been many moments in which other people have abused, mocked, and chastised me that have scalded my soul far more painfully and permanently. Long ago, countless lovers, and at least 80 percent of a liver away, I became enamored of the works of Friedrich Nietzsche (1844 -1900), a German intellectual whose critiques of philosophy (particularly moral philosophy), culture, and art had game-changing impacts. For those of you who wish to pass on my brief introduction to Nietzsche's works, simply skip down to the bolded section below, where the relevant quote from Nietzsche / my journal entry begin! "God is dead," one of Nietzsche's most famous quotes, established him as one of the leaders of existentialism, a philosophical movement that emphasizes that man is alone in a Godless universe, and that each individual possesses the agency to determine his or her own fate. In Beyond Good and Evil , Nietzsche rejected the Christan "slave morality" traditionally used to subjugate the masses. In Thus Spoke Zarathustra, Nietzsche further developed the concept of the Übermensch, a sort of superman who would rise above the traditional, self-limiting values of the wider culture and self-actualize based on goals and values that were entirely his own. The Übermensch is the master of his own fate, answerable to no one except himself. Nietzsche put a lot of thought into how to best harness humanity's manifold talents and powers. In The Birth of Tragedy, Nietzsche approached this issue through the lens of Greek mythology. Apollo, the Greek god of the sun, represents truth, light, logic, and order. Dionysus, later Bacchus in the Roman pantheon, is the God of emotions, drunkenness, festivals, and madness. Music and mystical revelations arise from the Dionysian state, as well. Nietzsche advocated for the fusion of these two apparently dichotomous forces, which would allow the frenzied, wildly powerful energy of the Dionysian state to be contained, organized, and applied within the logical Apollonian framework. He believed that the ancient Greeks understood and occasionally achieved this - thus explaining their timeless philosophical and aesthetic / artistic contributions. This is a passage from Nietsche's The Gay Science , in which he describes the concept of eternal recurrence: What, if some day or night a demon were to steal after you into your loneliest loneliness and say to you: "This life as you now live it and have lived it, you will have to live once more and innumerable times more; and there will be nothing new in it, but every pain and every joy and every thought and sigh and everything unutterably small or great in your life will have to return to you, all in the same succession and sequence—even this spider and this moonlight between the trees, and even this moment and I myself. The eternal hourglass of existence is turned upside down again and again, and you with it, speck of dust!” Would you not throw yourself down and gnash your teeth and curse the demon who spoke thus? Or have you once experienced a tremendous moment when you would have answered him: “You are a god and never have I heard anything more divine.” If this thought gained possession of you, it would change you as you are or perhaps crush you. The question in each and every thing, “Do you desire this once more and innumerable times more?” would lie upon your actions as the greatest weight. Or how well disposed would you have to become to yourself and to life to crave nothing more fervently than this ultimate eternal confirmation and seal? [This is where my reaction to the above passage begins. Enjoy the flowing, possibly certifiable, most likely cringey, most definitely psychedelic response!] My blackest seconds have stretched on for eons, have been so whimpering-abysmal that they tore chunks from my soul.  And yet my numb, mangled soldier-shell marched on.  What do you do when you get to hell? You keep on walking.  I’ve suffered through spirit-shrieking, shivering, shimmering, shuddering withdrawal, when every cell and atom cried out for the Substance to no avail.  I felt the shit and piss weep down my legs as my backbone-less spine arched into a seizure. I hallucinated baby spiders crawling out of a filthy, overused orifice that opened itself on my bedroom wall, hair sprouting from the moist folds of its accordioned flesh.  The orifice-oracle spoke to me, shared truths that I never should’ve known about myself and the rest of humanity.  "Where did the spiders go?" I wondered as that gossamer hole disappeared.  I’ve quivered broken and bloody, curled up like an aborted fetus inside another wrecked car - my brain bruised, my limb demolished, my knee gashed open to expose the white truth of the bone beneath (the only part of me not capable of lying).  “I need help; I can’t stop using heroin,” I confessed to the State Trooper who cradled me until the medics came. I’ve never accepted “no” from Destiny or any lesser leader. I’ve bashed my bones through brick walls. I laughed lightly, as though I were sashaying through silk curtains.  I’ve slashed my wrists open to let out the rage and the yearning – my soul swelling with such dreadful voltage that I couldn’t contain it anymore, couldn’t breathe or move or think.  Is this what it’s like to be crazy? Does it really matter anymore? I am the junkie archetype: Nodding off on a bench in Thornden park, drooling on myself as passing people spouted concern, disdain, riotous amusement. I bathed in the forbidden waters of their sadistic judgments, an unholy baptism. They'd genuflect if they knew what acrid acid ate me from within. I’ve been the Crazy person talking to himself, blurting blurred prophecies and charred fragments of terrible truths about what might have, would have been. Somehow these sidewalk prophecies always landed a minute too late, two beats out of sync with the rhythm of the rest of the universe.  Once, a little boy had to call an ambulance for me as I overdosed beside him on a bus in Philadelphia. He was calm and brave, one of the few heroes of my sin-soaked story. “I hope you feel better,” he said as they put me on a stretcher and hauled me away.  Blessed are the children. They are the only ones among us who are worth saving.  I’ve been famished and penniless. (Did you stop to imagine what those words mean? Can you even imagine it?). Prostrate and humiliated. A diminished, contemptible, ravenous revenant.  You'd be scared when you met me if you stood between me and what I required to get the Substance into those greedy holes in the crooks of my arms. I went willingly into the involuntary psychiatric hold. (Does it become voluntary when there is no resistance?). A kind, obese, middle-aged woman told me that everyone called her Mama; she showed me how to wear two hospital gowns at once so that my ass wasn’t hanging out. Later on, a terse nurse warned me not to call that patient Mama; said she was manic and hypersexual. But no one else explained how to wear a hospital gown so that I wasn't half-naked. I couldn’t sit or lie down without the insistent bones poking through in all the wrong places, reminding me of the neglected needs of my festering flesh. I knew Hell as Hunger.  Anguished alliteration became prayer by proxy. I begged for money. I did worse things than beg. I conned slickly and wantonly. I took and took and took. I became insatiable, a fundamental force of craven craving. Under the starborn heat of my futile fury, I compressed all of my shame and madness into a cursed, omni-flawed diamond to cut myself with (for by now it was the only thing harder than me). I did anything, anything , to keep the high going, to ward off that terminal sickness called reality - those cold, grainy truths of a ruined and wasted life.  *** But then. I’ve been not just high, but exalted.  I took LSD to see clearly for a never-ending now. I spoke with God. I accepted His tears and His apologies. It’s not your fault, I assured Him. No one could have planned for this. My spirit sprouted chains of technicolor Celtic knotwork, twisted double-helices of DNA. They would around my arms and legs and trunk, shot out from my hands and my heart as though I were a superhero (I am a superhero). They linked me to every single thing that is and was and will be. They revealed everything that ought to be and isn’t, everything that pined to exist but doesn't.  We mourned them together. It seems that God, too, abandons difficult drafts.  I injected molten speedball pleasure into my veins, the likes of which most people will never even hear an echo of a whisper of.  Don’t you wonder? When you come to the ends of your lives, won’t you regret? I laughed in the face of their terror, imagined what it would be like to live without knowing This. It’s right there in front of them, and yet they fear it and judge it and spurn it.  This is a high worth dying for , I thought again and again as I chased it into nonexistence.  I rode bareback the jet-engine thrills of the amphetamine take-offs, waxed laughing-hysterical when three sleepless nights later I was thrown wasted and abraded to the chemical curb, where I spun over and over again until the capricious world collapsed into a kaleidoscopic fantasy.    I’ve paid the 30-gauge cover fee to pass through the portal into poppy-bright eternity. Chemically cocooned myself so that the entire universe became a fawning soulmate, collapsed into a loving embrace. "All is right; your soul is safe,” it lied to me.  I’ve studied under geniuses, received their compliments as a sun-scorched crop gulps the rain that finally comes. “You belong here, living the life of the mind," they said to me. “You are one of us.”  For a time, I found peace in ancient, forgotten books - illuminated manuscripts and their virtuous tales. Test tubes and cell cultures revealed their secrets to me; data was parsed, was sacred, was the future.  “I belong in the field, conducting an entirely different type of research,” was my spirit's unspoken answer.  I spat in the faces of my mentors. They wept for me, forgave me as I drowned myself in decadence.  I’ve passed by the ancient hutong of Beijing, exchanged pain-laden looks with the withered women who mind the 24-hour shops where weeping relatives come to buy funeral garments for their departed loves. Their dead could only rest softly, contented, because life is so hard here. Their duties are finally discharged.   I’ve strolled through the palaces of the Descendants of the Dragon, imagined the lotus-kisses of ethereal princesses who pulled the puppet-strings of empires. Something in them recognized something in me. That was enough. I heard echoes of the concubines wailing that their bastard children had been poisoned, ground up, thrown in the well.  That was the price; it always has been. Remain here and follow the way of the Tao, my ancestors welcomed me. There is wisdom in pain and peace in sacrifice; your torture purifies you. You have traveled around the world to come home. Now your soul will shine again. I’ve slept on sumptuous beds, spread-eagled on sheets with infinite thread counts in five-star hotels where you pull back the curtains to take in the views of the kings and conmen. The refined air in such places vibrates with coppery dominance, iron ambition. Every blood-stained footstep lands with surety of purpose.  I raped every senseless boundary, made love to every much-maligned taboo. I’ve freed myself of the prison of other people’s expectations, judgments, limits.  I am the prodigal son. I walk between worlds. I am a rebel. I am a failure. I am the Ubermensch. A dissolute, deluded, absurdist thing. I’ve embraced friends who became brothers and sisters, who taught me the language of a love powerful enough to be balm to a soul as wretched as mine. They loved all of me: The broken, the wrong, the blasphemous.  I withheld nothing from them as our scarred souls fused together. We laughed at the chaos and the madness and the great, gravity-bending pain. I’ve lain with beautiful, powerful men, sleek and hard, supple and angular. Their taut bodies and slick, holy sweat were the most potent prayer-answers that I’ve ever received.  I worshiped them and glorified them. I used them up, discarded them like come-filled condoms. I took a lover whose name I never knew. We didn’t speak a word of each other’s languages; carnal communication was our only tongue.  His eyes waxed eloquent as he pulled me toward him, thrust himself into another conversation. You are beautiful, and I will remember this moment on my dying day , those moon-bright eyes vowed.  He didn't look back before he closed the door behind him. He joins me often in my dreams. *** This is my life.  I wasn’t made to drive the Lamborghini of this expansive, potent, boundary-pushing mind-body at 45 m.p.h. Forget anyone who would try to persuade me to. Those who would contain me could not truly love me; they love only a diminished, hog-tied soul-simulacrum, an echo-artifact of me.  I was built for this, to live at 0 and 10 instead of 4 or 5 or 6.  The lukewarm and mediocre are anathema to me. My spirit rebels against the suburban and the ordinary.  I reach and seek and stumble. I weep and shout and win.  I’ve lived many lives. I contain multitudes upon multitudes.  I want to see and feel as much as I can before I go. That is my religion.   If the Fate-makers forced eternal recurrence upon me, I would not throw myself down or gnash my teeth. I’d straighten my spine and smilingly do it all over again. I’d sprint through the door to yesterday with a bright grin on my face and the same hungry hole in my soul, my nuclear heart radioactive with that same undiminished yearning.  That blazing hunger to learn, to connect, and to consume defines me; I am nothing without it.  Being me, even if I were presented with a choice, no other option but eternal recurrence would be possible. That is the only true wisdom that I’ve ever gained.  I was built for this. Bring it on.

My reflections on the state of the American political system four months out from the November 2024 presidential elections. For those of you who don't follow U.S. politics, Biden's disastrous performance in a recent live, televised debate has led leading Democrats to call for his withdrawal from the race, which is a drastic measure this far into campaign season. This would almost certainly lead to Kamala Harris running with an as-yet-unknown VP candidate on the Democratic ticket. Despite his criminal cases, Trump, of course, is the Republican contender. This isn't an essay about Trump vs. Biden or Trump vs. Harris, though. It's focused on longer-term, deeper problems with our political situation - you know, the ones that have led Americans and our friends and foes alike to begin speaking seriously about our fall as a superpower and even our potential disintegration. I discuss the climate of fear that took root post-9/11; how, as we approach the end of the Monopoly game, Big Oil, Big Banking, Big Tech, and Big Pharma have acquired far too much control over our political process; our loss of faith in our legal, medical, and military systems; and changes to our national morale and culture that have contributed to what is now an existential crisis. In short, at a time when Americans describe themselves as unprecedentedly burnt out on our own politics and very few people are content with the current candidates, it's meant to answer the following question: Why can't our political system deliver the charismatic, younger candidates who we need to galvanize our country under a renewed conception of what it means to be an American? In August 1969 at the legendary Woodstock Music and Arts Festival, Jimi Hendrix - widely regarded as one of the most talented electric guitarists of all time, who joined the Forever 27 Club along with Janis Joplin, Kurt Cobain, and Amy Winehouse by fatally overdosing on barbiturate sleeping pills just a year later - offered an immortal rendition of the United States' "Star-Spangled Banner" national anthem. During his performance, he alternated strident, stirring sections that were performed in a traditional manner with experimental guitar techniques that mimicked the explosive, chaotic sounds of war. (Illustration by Joe Morse for the L.A. Times). I love my country. I've never been so worried for her. I've been thinking of George Washington's Farewell Address - really just a letter announcing his retirement, which established the two-term limit for American presidents that has been respected ever since - a lot lately. Washington emphasized the need for national unity based on the "common dangers, sufferings, and successes" of the early Republic. He warned against the triple threat of regionalism, partisanship, and foreign entanglements. In particular, he cautioned against nurturing a "spirit of revenge" between the parties that would lead cunning, Machiavellian players to commandeer political power for personal advantage rather than the good of their country. Given the current political climate, it's hard not to hear these words as prophecies for our time. *** Every American who I've talked to about the state of our country has expressed some serious level of worry for its future. The verbiage surrounding these concerns takes many forms. One of the phrases that seems to come up quite a bit is "unprecedented polarity." And the divide between the parties, characterized by an almost complete lack of bipartisanship, as well as the divides within the two major parties, are, in fact, tremendous and historical. But this in and of itself is not the problem; this polarity is by design. As I remind my Chinese students who ask me about each week's political disaster as it unfolds, democracy is meant to be messy. We wear our scandals and our weaknesses on our sleeves. Contrast this with a country like China, where a one-party system leads to a suppression of information that is downright chilling at times*, and the clamor and tumult of democracy don't seem so bad. *I'm not so naive as to think that the American government is on the level with its own people about all of the information that we ought to know. In fact, my time in China has impressed upon me the extent to which many of the things that Westerners criticize the Chinese government for - bribery, corruption, subversion of the legal system for political reasons, secret projects and priorities, and so on - are present in American government and indeed in all countries and systems. Under ideal conditions, the adversarial back-and-forth of the American political system produces an optimized, often centric outcome. It's the bad-faith actors, the "spirit of revenge," and the lack of an overarching national identity and purpose that turn constructive disagreement into chaotic discord. In such circumstances, our system can enter an extinction vortex of sorts, during which the parties move further apart, and the system of checks and balances designed to prevent any one of the three branches of power from achieving unfettered control breaks down. *** Where did we begin to go wrong? Many of the roots of our current woes trace back to changes in domestic operation and foreign policy related to the global ideological conflict of the Cold War, which I believe that the United States needed to take a leading role in, which persisted long after the threats of the Soviet Union and the spread of Communism died down. In my own lifetime, I could say a lot about the climate of fear that developed after the September 11, 2001, terrorist attacks on the World Trade Center and the Pentagon (perhaps "was cultivated" is better language than my passive "developed" here). In the wake of that unprecedented moment of vulnerability - this wasn't Pearl Harbor in the middle of the Pacific Ocean under attack; this was New York City - many ultimately harmful political decisions were undertaken. Every single lawyer who I have ever spoken with has agreed that the Patriot Act of 2001 is unconstitutional - flagrantly so. It allows the government to search your home while you are gone from it without ever notifying you that it has done so . It also gives federal agencies the power to listen in on all Americans' phone conversations, supposedly for keywords related to terrorism although in reality we have no way to monitor the nature and extent of the use of this surveillance power. My respect for President Obama, who as a Senator warned against the insidious dangers posed by the Patriot Act but upon election to the presidency extended it as one of his first acts in office, was permanently diminished by his inability to turn down the expedient advantages that it presented him with in his new role. The Patriot Act is merely one symptom of a wider disease of fear and of a treatment regimen of trying to secure safety through forceful geopolitical dominance. It is a treatment that, like chemotherapy, threatens to kill us before the disease that it proposes to treat. Spending time in China, where my group of expat friends includes Russians, Iranians, Egyptians, and expats from other countries with whose citizens Americans rarely socialize, has given me a unique appreciation for the destruction that the wars in Afghanistan and Iraq have wrought on our international image. One of my first political actions was running around the small town that I grew up in tucking pamphlets about civilian casualties in Iraq under windshield wipers. At least 250,000 Iraqi civilians - and probably twice that or more - were killed by direct violence during the war there. In the wake of the U.S. withdrawal from Afghanistan after more than 20 years of military involvement there, the Taliban, a radical theocratic organization that takes hatred of the U.S. as a primary pillar of its belief system, is once again in power. These wars did nothing to protect Americans from terrorism. Instead, they bred a new generation of terrorists with even hotter, more justified hatred for our country. The "global police power" role that the U.S. government and military have taken on has been economically and politically disastrous. Our defense spending defies all reason and proportion (indeed, almost all conception). We have often come out of these wars and smaller conflicts looking like the bully - because we have often allowed ourselves to become the bully. Our allies in Europe and elsewhere are, of course, all too glad for us to absorb the brunt of the fiscal costs and the hatred associated with protecting international agreements crucial to the existing, Western-led world order. I no longer think of the U.S. as the chiseled, charismatic quarterback of the Western democratic team; sometimes, we seem more like the promising younger player who just made it through Varsity tryouts, who the older, established team members goad into increasingly thuggish bullying of geeks and Goths. We have achieved more during our short time on the map than almost any nation in the history of civilization, but we have done so because we have assumed much greater risks and liabilities than any other player has been willing to. American exceptionalism cuts both ways. My Chinese friends often argue that China would only ever want to be ranked second in global precedence because no wise government would want to assume first place due to the responsibility, resentment, and costs inherent to that position. I'm not sure that this is true under the current leadership of the CCP, but it's a worthwhile concept to consider. No country is too big too fail. No empire stands forever. *** As Americans' attention was focused on the wider world post-9/11, both parties aligned themselves with powerful, globalized corporate interests that gained dangerous influence over our political system. During the past 30 years, Big Oil, Big Pharma, Big Banking, and the lobbies and Political Action Committees under which they operate have worked quietly and efficiently to ensure that the only political candidates with enough money to present themselves to the American public are those who are already beholden to them. Our country has never recovered from the recession of the late 2000s, which crippled my generation.* *As I have noted previously, economists have shown that graduating into a recession has a lifelong impact on earnings. Interestingly, the fact that Millennials are the first generation since the Americans of the Great Depression to be poorer than the one that came before them seems to be tempering the red-tide shift from liberal to conservative that has occurred for previous generations as they aged. In my opinion, the banking fiasco that triggered the recession never really had the wider political and cultural impact that it should have. There were limited, token prosecutions of Wall Street players; there were Op-Ed callouts; and a few politicians from rural constituencies called for systemic reform. But the full, alarming failure of the SEC and other relevant regulatory agencies never really generated the furor that I initially expected it to. Instead of a moment of reckoning and recalibration, we had a bailout. Likewise with the FDA and the OxyContin epidemic that caused the heroin epidemic that has hobbled an entire generation, which I've written about elsewhere . The FDA is a demonstrably, heinously corrupt organization whose leaders walk through a revolving door with top positions in the Big Pharma sector. This is not tinfoil hat theory; this is widely acknowledged truth. Since 1999, more than 560,000 Americans have died of opioid overdoses. Despite the fact that they knowingly marketed a defective "extended-release" formulation of a massive dose of an opioid as potent as heroin and continued to do so for years as evidence of mass addiction and overdose abounded, the Sackler family that owns Purdue has avoided criminal prosecution entirely and walked away with billions of dollars in profits. Our financial and medical systems have been compromised by entrenched, controlling influences largely outside of the reach of regulators. Between Facebook's Cambridge Analytica scandal and the revelations regarding Russian disinformation campaigns during recent U.S. election cycles, Big Tech, too, no longer seems like the future-realizing, democratizing influence that many technophiles hoped that it would be. Even our Supreme Court has refused to hold itself to an ethical code - despite the fact that all lower judges are bound by such codes and recent evidence that has indicated that Clarence Thomas and perhaps other justices have been less than transparent when it comes to their financial disclosures and divulgence of other potential conflicts of interest. And it's not just the Supreme Court whose legitimacy has been called into question. William Esty at Stanford has characterized the overexpansion of the U.S. legal system as "the rule of lawyers rather than the rule of law," which he cites as a key factor driving U.S. decline. Ironically, our legal system became so concerned with the nuances of right and wrong that it became overgrown, so dense and unnavigable that passage through it is guaranteed only to the very wealthy. Even the Constitutional right to speedy trial is no longer guaranteed under the present system. In fact, if all current criminal defendants refused to settle by plea bargaining - a process that did not exist prior to the mass prosecutions of alcohol Prohibition under the 18th Amendment - our system would grind to a halt; it could not sustain the present volume of cases. We incarcerate more people per capita than any other country save perhaps North Korea. Poor people, the mentally disabled, and racial minorities are disproportionately likely to be affected by unfair legal outcomes up to and including execution. Our liberty has been impinged upon, and justice is a bad joke; which of our founding ideals hasn't fallen flat? *** There have been broad, gradual ulcerations of local community and American national culture that have endangered us, as well. In Bowling Alone: The Collapse and Revival of American Community, Harvard political scientist Robert D. Putnam traces the post-1950s decline of social capital in the United States, including bowling leagues and almost all other forms of in-person socialization necessary to the strong civic engagement that made America great and that robust democracies require. In my grandparents' generation, virtually 100% of ordinary citizens participated in volunteer, religious, local political, educational, and other community organizations. In the years since Bowling Alone was published in 2000, social media specifically and technology in general have only further eroded in-person socialization and local community. Today, a minority of Millennials and Boomers make time for such activities. It is a widely acknowledged problem with few easy solutions, and it has serious, dangerous political implications, as well. Democracy has become a once-every-two-years affair. Without the amplifying power of social and political capital that is granted by civic organizations, how much is our one vote worth? Especially when we can't hold our elected officials to account because they have become a separate class whose members often bear no true connections to the communities that they represent? As I have written about elsewhere , I believe that the decline of organized religion has played a key role in the wider problems experienced by American society. Churches and other religious organizations were imperfect solutions to the problems that they helped to address, but perhaps Western democracies required Christianity and other religions to help balance out the vehemence and partisanship of our politics - to remind us that we are all flawed, all human, and all ultimately in this together as Americans. Whereas Eastern countries like China have the benefit of very strong family responsibilities and airtight community solidarity, the Western emphasis on individualism threatens to destabilize toward hedonism and navel-gazing self-preoccupation without a balancing influence. If you ask nearly any Westerner to draw a diagram of the individuals in their lives, they will place themselves at its center; do the same with your average Chinese citizen, and the perceived head of their family, usually a parent and almost never the person drawing the map, will be in the center. National pride, too, has suffered. At the public school where I teach, I am one of only a few teachers who make a point to stand for the Pledge of Allegiance. I teach many first-generation immigrants from Syria, sub-Saharan Africa, and Latin America, and these students typically show much more respect for the American flag and American ideals than the disadvantaged students who I teach whose families have been here for several generations. When did it become acceptable, even cool, to denigrate our nation? Don't people realize that we still have it better here than almost anywhere else at any other time? *** As I often discuss with my students, everyday decision-making hasn't necessarily been improved in the Age of Information, which could just as accurately be termed the Era of Disinformation. Algorithms present us with only that information that tends to confirm our existing biases. The nature of online spaces has created echo chambers in which individuals with similar ideas and preferences engage in comfortable groupthink. The decline of quality reporting due in large part to the death of paper publications, especially those operating at the local level, has played a significant role in this problem, as well. Whereas once the Sunday paper would examine a certain political or social issue in-depth, with considerable weight given to both sides of an issue, people now develop their political views based on one-sided pieces in specialized publications geared to people like them. We often make our political decisions based on social media-disseminated strawmen and stereotypes. When it comes to issues of the moment such as transgender rights, most people are voting for or against the relevant propositions without ever having spoken with or even having met someone in the affected class. This isn't necessarily a new problem, but it is one that has been greatly exacerbated by many of the shifts discussed above. *** Let's return for a moment to the subject of American drug use, which is, after all, a primary part of the raison d'être of this blog. As I've written about elsewhere , the U.S.-led War on Drugs is one of the most catastrophic policy failures in world history. And, contrary to the understanding of many Americans, particularly many Democrats and other liberally-oriented individuals, it is a failure that was created and kept energized by leaders from both parties. Americans have been enthusiastic consumers of mind-altering substances for most of our history, and the prohibition of certain drugs has been even more of an epic failure than alcohol prohibition was. In terms of our use of such substances, in 2017, after opioid prescription had already been cracked down on hard for several years, there were still enough opioids prescribed to keep every American man, woman, and child under the influence of the substances round-the-clock for one month out of the year. As of 2022, the United States made up 4.4% of the world's population, but it consumed over 80% of the world's opioids. The US consumed approximately 99% percent of the world's hydrocodone, which, like oxycodone, is no more and no less than prescription heroin. M ore than one million Americans  have died of drug overdoses since 1999. This is more than all of the American soldiers who have died in battle during all of the wars we've fought since the end of the Revolutionary War. And, as awful as the opioid epidemic has been, American consumption of other legal, prescription, and illegal mind-altering substances tends to be just as extraordinary (again, American exceptionalism cuts both ways). Multiple medical journals that I follow have commented on the recent diagnosis of end-stage alcoholic liver disease, which is classified as a death of despair, in young people in their early 20s , which is all but unprecedented in this country. From the Roman Empire to the Third Riech, superpowers on the verge of collapse have first submitted to wild, intoxicated decadence. Why are we so ill at ease with mental and emotional clarity? *** Now, after many hops, skips, and jumps - and, fittingly, a couple of periods of convenient amnesia - we come to our present election cycle. Whatever you think of Trump's politics and policies, what he did at the end of his term revealed a total disregard for the peaceful transition of power upon which all democracies depend. Trump damaged our reputation among our allies, as well as foreign perceptions of everyday Americans.* *While I was abroad, the Pew surveys that measure how foreign populations think about ordinary American citizens showed historically unfavorable results for most of the surveyed countries. My God, did I witness this firsthand in China. But it is no surprise that Trump got elected, and anyone who says that the nearly half of Americans who voted for him were simply "crazy" is missing the point. Trump spoke to people who have been ignored for too long - especially white, working- and middle-class people such as those of my home city, who have been taking L's across the board for so long now that something drastic was bound to happen. Biden restored a measure of "business as usual," but the reality is that - as the recent debate showed - he is too old to govern. When Americans were asked about this election during the past eight months, they overwhelmingly indicated that they didn't really care for either candidate particularly much. They used words and phrases like "tired, "burnt out," and "distrustful" to describe their feelings about the United States' current politics and leaders. The U.S. political system hasn't produced a charismatic, younger leader who could bring our country out of its morale slump for a long time. Given what I've discussed above, this is hardly a surprise, but it is a profound and dangerous failure. In many ways, in fact, I view Trump and Biden as more similar than dissimilar. Both parties have gone awry. The left has lost itself in identity politics that have sown discord rather than galvanized unity; it has lost sight of what I consider its primary function, which is to protect the interests of the lower and middle classes against the formation of an entrenched, wealthy, governing elite - a phenomenon that has overtaken both parties. The right, on the other hand, has lost its function as a sort of helpful brake pedal for society, a way to make sure that things don't change too quickly or dramatically. Instead, it has peddled an equally destructive politics of minority-blaming. Both parties now blame the other half of American leadership and society for the problems that our country is mired in rather than acknowledging the fact that we all play for the same team, and that it is a key component of their duties to reach across the aisle to achieve workable solutions. Under the current systemic failures, the candidates who are running - even for an office as important as the Presidency of the United States - are a very small part of the political picture that matters. Until we address systemic reform, we won't get the leaders we need, and the leaders who we elect won't be able or willing to change things. From AP U.S. History onward, it was always impressed upon me that not voting for one of the two major parties in the U.S. is giving up half of one's political agency because you can't vote in the primary election that chooses the candidates on a party's ticket unless you are registered as Democrat or Republican. It's also often pointed out that voting for a third-party candidate in the general election threatens to split the vote, which spells disaster for whichever of the two major parties is more affected. I'm at a point where I don't care anymore. From political hyperpolarization to climate change to entanglement with foreign governments to selling out to powerful, globalized corporate interests, our democracy is facing unprecedented challenges, and I'm not convinced that our two-party system can adequately deal with these threats any longer. Business as usual threatens to lead to closing up shop. The time to heed the words of President Washington's Farewell Address is now. The fate of our beautiful, brilliant, world-changing country depends upon it. Let's return for a moment to the subject of drugs and addiction, which are, after all, central to this blog. (mention Blitzed) that's how we've gotten to this final stage, where Trump and Biden are two sides of the sa e coin (both the left and right have lost sight of their true functions) It shouldn't take a war to galvanize us behind our leaders. Let's return for a moment to the subject of drugs and addiction, which are, after all, central to this blog.

It is a common misperception that patients on methadone must be reduced to a dosage of 25 to 40 mg per day in order to be switched to buprenorphine (Suboxone). In reality, physicians around the world have had success with rapid, 5- to 7-day transition protocols that do not require reducing the methadone dose before buprenorphine initiation. I've compiled some review articles and clinical case reports to bring to your physician if he / she is not aware of the possibility of rapid transition from a full maintenance dose of methadone to buprenorphine (Suboxone). Complete Metabolic Panel from ~ 48 hours into a 7+-day Cardiovascular Intensive Care Unit stay after a fentanyl OD almost killed me two years ago. The disruption of the acid-base balance of the human body, evidenced here by elevated bicarbonate, is one of the most dangerous results of an OD. Elevated creatinine indicates kidney stress / damage and possibly a form of muscle breakdown called rhabdomyolysis, which can occur during OD. This hospital stay was when I decided to start this blog. I realized how long it was going to take to get published through the traditional route. I had so much to say about addiction, and the idea that I might just wick out without sharing any of it was suffocating (I think Thoreau is overrated, and maybe one reason that I'm not a huge fan is because my desperation is anything but quiet, and I refuse to take it to my grave). Anyway, this hospital stay was also when a very kind, competent Nurse Practitioner introduced me to the possibility of rapidly switching from methadone to buprenorphine without having to taper almost all the way off of methadone first. In Medias Res: The OD If you are on methadone and it isn't working well for you and / or you are planning to get off of it, then the information that I will share today is potentially more useful than anything else on this blog. In November of 2022, I was tapering off of methadone (which, for the uninitiated, has the most protracted withdrawal of any opioid drug and is reputed to be the hardest substance of all to get off of). I did well for a while, but I pushed the dose downward too quickly, at which point I became too sick to run, at which point, predictably, a strong beam of reality dissolved my "mental health" like the gossamer veneer that it was. I relapsed on fentanyl daily for maybe three weeks. Then, because getting off of methadone and onto fentanyl was clearly worse than pointless, I stopped the fetty for 11 days. Then, because I'm an incorrigible drug addict, I used fetty one more time, at which point I collapsed on the side of the road near my dealer's (I still have no idea who called an ambulance for me, and - given that this was on the West Side of my home city, a ghetto where ODs are as common as sex scandals during American presidencies - I'm shocked that someone cared enough to ring an ambulance [my best guess is that the guy who sold it to me or one of his customers recognized me, but I lost that dealer's number, so I don't know for sure]). Anyway, the point of all of this is that it is extremely difficult to taper from 100-180 mg of methadone / day to the 25 to 40 milligrams a day that almost all U.S. clinics have traditionally required you to reduce your dose to before you can switch to buprenorphine, which is in almost all cases a more effective and less sedating / intoxicating opioid maintenance medicine (I've written about the perils of methadone maintenance in Metha-Don't and about my deep discontent with opioid maintenance more generally in Sword of Damocles ). I could list the whole gamut of methadone withdrawal symptoms - it's like having the true flu for months on end - but the emergent whole is much worse than the sum of its parts. When you're on a high dose of such a potent opioid for an extended period, your body comes to depend upon it at a subcellular level; your entire physiology is guided and permeated by the drug. Being without your opioid substance of choice triggers a fish-out-of-water response that I, with my haughty literary pretensions, can only compare to the Dementor's Kiss in Harry Potter: It's as though all life, all hope, all energy and all goodness are sucked from the world. For this reason, most people on methadone never get off of it. This is a shame on many levels, one of which is that many people on methadone would be more stable and experience fewer side effects if they could switch to buprenorphine (Suboxone). The Science: Full and Partial Agonists at the Mu Opioid Receptor If you need a review of mu opioid receptor dynamics, including full versus partial agonism, antagonism, and binding affinity, now would be a good time to consult my detailed walkthrough of what causes precipitated withdrawal. This is information that I recommend to anyone who loves, treats, or is an opioid addict because making informed treatment decisions without understanding these receptor dynamics is difficult to impossible. The amount of opioid receptor stimulation caused by a ceiling dose of buprenorphine is approximately equivalent to the opioid effect produced by 25 to 40 mg of daily, oral methadone. As a result of this, if someone dependent on a dose of methadone greater than 25-40 mg / day suddenly has their receptors flooded with buprenorphine, that person is going to experience precipitated withdrawal proportional to the gap in opioid stimulation caused by their methadone dose and the level of opioid effect produced by the ceiling dose of buprenorphine (see graph below for detailed explanation). Methadone is a full agonist, meaning that as you increase dose, opioid effect (opioid receptor stimulation) increases indefinitely. On the other hand, buprenorphine (Suboxone) is a partial agonist, meaning that there is a ceiling dose beyond which further increases in dose will not result in more opioid receptor stimulation (opioid effect). If you trace your finger from left to right until you get to the fifth purple triangle on the Antagonist (Naloxone) curve that runs along the x-axis (Log Dose), then go directly upward to the Full Agonist (Methadone) curve above, you're at a position close to the dose / opioid effect that most methadone maintenance patients are used to. If, on the other hand, you start at this fifth purple triangle and go vertically upward to the Partial Agonist (Buprenorphine) curve, you see that the level of opioid effect produced by the partial agonist (buprenorphine) is significantly less than the opioid effect produced by the full agonist (methadone) at these dosage levels. In fact, at any methadone dosage less than (to the left of) the point at which the buprenorphine and methadone curves intersect, which is approximately equal to 25 to 40 milligrams of daily methadone taken orally, there is a buprenorphine dosage that can produce an equal level of opioid effect. As long as this is true, you can switch from methadone to buprenorphine without experiencing significant withdrawal. However, at dosages higher than the ceiling dose of buprenorphine (to the right of the point of intersection of the methadone and buprenorphine curves), which is equivalent to approximately 8 to 16 mg / day of sublingual buprenorphine, increasing the buprenorphine dose no longer results in increased opioid effect - you hit the ceiling effect, and the buprenorphine curve flattens out. If someone is dependent on a daily dose of methadone higher than 25 to 40 mg and you suddenly flood their receptors with buprenorphine, that person is going to experience precipitated withdrawal proportional to the vertical gap between the two curves. Because of these receptor dynamics, most methadone clinics require patients to reduce their dose to 25 to 40 milligrams before they switch over to buprenorphine.* *Patients are also typically forced to wait 2 to 3 days from their final dose of methadone before beginning buprenorphine, which is initiated gradually starting at a very low dose. Unfortunately, this highly uncomfortable switch protocol results in many patients relapsing, and - because of suddenly decreased tolerance combined with the lack of blocking action from buprenorphine or methadone - the overdose risk is exceptionally high in this timeframe. The final key point about the relevant receptor dynamics is that the risk of precipitated withdrawal is greatly overstated in the case of switching from methadone to buprenorphine. True precipitated withdrawal, which is capital "H" Hell on Earth, occurs when a person dependent on a high dose of a full agonist like heroin or fentanyl is suddenly given an antagonist such as naloxone or naltrexone, which blocks all opioid receptor stimulation, resulting in a sudden drop from 120 mph to 0 mph. At worst, dropping from a high dose of methadone to a ceiling dose of buprenorphine is like dropping from 120 mph to 45 or 60 mph. The opioid receptors are still receiving substantial stimulation, and - depending on how high a dose of methadone the patient was dependent on - the withdrawal effects are likely to be mild or moderate (thoroughly tolerable, in other words). Rapid Transition Protocols (AKA the Future) For those of you who prefer to review the literature directly, here is an excellent review article   that contrasts the methadone to buprenorphine switch protocols used in several countries, including Canada, the UK, and the U.S. (both the American Society of Addiction Medicine [ASAM] and Substance Abuse and Mental Health Services Administration [SAMHSA] guidelines are presented for the US). As you will see, all of the protocols save for New Zealand's recommend that the patient first reduce his / her dosage to 60 mg or below, and most recommend 30 mg or less with a gap of 24 to 72 hours between stopping methadone and initiating buprenorphine. These traditional protocols made theoretical sense because reducing the methadone dose to one that provided a level of opioid effect equal to that produced by a ceiling dose of buprenorphine ensured that there was no withdrawal caused by the transition; the body was receiving a stable level of opioid receptor stimulation. However, as mentioned above, the requisite reduction in dose was very difficult for patients to achieve, often necessitating several weeks of moderate to severe withdrawal symptoms before he or she could switch from methadone to buprenorphine. As noted above, relapse - particularly during the 1- to 3-day gap between the last methadone dose and the first buprenorphine dose - was both common and particularly dangerous. These protocols proved to be excessively conservative for multiple reasons. The first is that the body can tolerate some sudden drop in opioid receptor stimulation. Especially when comfort meds like gabapentin and clonidine are provided to smooth the switch, even the withdrawal experienced by someone transitioning to buprenorphine from a daily methadone dose of 100 mg or more is not too severe to be tolerated. The second is that the transition happens gradually, avoiding precipitated withdrawal by allowing the body some time to compensate; this is because methadone clings to the receptor tightly and has a long half-life, meaning that as buprenorphine is introduced at increasing dosages, methadone gradually relinquishes its hold on the receptors - resulting in a smooth, balanced transition rather than an abrupt, one-time drop. *** "We can have you switched from methadone to buprenorphine in 3 to 5 days; you'll be stabilized on it before we discharge you," Sandra, a Nurse Practitioner at the teaching hospital in my home city, assured me; she had the subtle highlights and the kind and comely confidence of the archetypal MILF. Sandra had noted that the methadone that I was taking simply wasn't holding me; my body eliminated it much faster than the average person's, probably because of the synthetic thyroid hormone that I take due to my Graves' Disease. As a result, she observed, I was in significant withdrawal by midday, meaning that I was a better candidate for buprenorphine maintenance.* *Buprenorphine tends to produce a more stable opioid effect because of its properties as a partial agonist. What Sandra was offering sounded too good to be true. All of the staff at my methadone clinic had reiterated the recycled wisdom that the only way to switch from methadone to buprenorphine was by first reducing one's methadone dose to 25 mg a day. Unfortunately, I was currently in the ICU because I had experienced a near-fatal fentanyl overdose during my attempt at this long, brutal taper. "We've had several patients do it, and we've never had one fail," Sandra insisted. "Did they have awful, precipitated withdrawal symptoms, though?" I followed up. "Not at all," Sandra replied. "Some pretty bad GI stuff, for one patient, but we were able to treat it with loperamide. Headache, anxiety, and insomnia for a couple others - treatable with gabapentin and in one case a benzo for a few nights. "None of our patients ended up going back on methadone," she continued, "and the only one who relapsed on his drug of choice was able to stop using it within a week of starting buprenorphine." It turns out that the 25 to 40 mg reduction rule - a safe, sensible limit that was established based on a solid theoretical understanding of the mu opioid receptor dynamics - is in reality unnecessary and harmful. As I completed my research, I read European studies from the past decade in which buprenorphine treatment was rapidly initiated over the course of several days in patients dependent on methadone doses ranging from 40 mg / day to over 100 mg / day. All of these patients were successfully transitioned to buprenorphine, and none of them required emergency treatment for catastrophic withdrawal. In this case, conventional wisdom was plain wrong; it was overly conservative and underestimated the body's ability to rapidly adapt to changing levels of opioid receptor stimulation. For those of you who are clinicians hoping to begin using a rapid transition protocol - or patients hoping to raise the possibility with your physician or other provider - here is a wonderful article that summarizes rapid transfer protocols for high-dose methadone patients; it covers microdosing as well as the use of medications to smooth the transition (including lofexidine, an alpha-adrenergic agonist similar to clonidine).* *This portion of the results presented in the paper was summarized as follows: "In general, transfer from methadone 30-70 mg to buprenorphine was found to be relatively uncomplicated and can be facilitated by lofexidine." Because the ease of the transition depends on gradually ramping up the buprenorphine dose while gradually reducing the methadone dose, some of the protocols initiate buprenorphine treatment with transdermal patches, which smoothly deliver a much lower dose of buprenorphine than sublingual formulations typically provide. In some protocols, transdermal fentanyl and other short-acting, full-agonist opioid medications were used as bridges between methadone and buprenorphine. In certain protocols, withdrawal was briefly (!) precipitated with naltrexone prior to switching to a short-acting, full-agonist "bridge" opioid or beginning buprenorphine treatment. For further support, here is another protocol in which withdrawal was intentionally precipitated with naltrexone before initiating treatment with buprenorphine. Summary The reality is that you can be switched from a full maintenance dose of methadone to buprenorphine in 5 days without experiencing severe withdrawal. It is possible that you will need comfort medications to ease the transfer, but it is very unlikely that you will suffer severe, precipitated withdrawal* of the sort brought on by sudden introduction of an antagonist into the system of a person who is dependent upon a full agonist like methadone, heroin, or fentanyl. *Except for the protocols that intentionally precipitate withdrawal with naltrexone, which is done very briefly before fentanyl or another full agonist with a very high binding affinity is administered as a bridge between the methadone and buprenorphine. It is a sad testament to the reactionary, overregulated nature of psychiatry and addiction medicine in the U.S.* that so few clinicians at methadone clinics know about these rapid transition protocols. *I'm not sure how it works in other countries, but in the U.S., these specialties are among the lowest paid, and they draw med students with low Step 1 board scores - i.e., few well-paying / competitive residency prospects. Despite the fact that they have been under investigation for years, many doctors and nurses at U.S. methadone clinics aren't aware of them, and exceedingly few programs offer them to patients. If you're not able to switch to buprenorphine because the long, intense taper down to 25 to 40 mg of methadone per day is too much for you, there is hope! You should absolutely raise the possibility of an alternate switch protocol with your doctor, Physician Assistant, or Nurse Practitioner. (I recommend printing out and bringing the review articles that I referenced / linked above! If you do most of the work for them, you have a greater chance of getting them to agree to a different protocol.) Alternatively, contact the psychiatry / addiction medicine department of the teaching hospital in your area - the one affiliated with a nearby research university. It is almost always the case that such hospitals will be the most policy-progressive, technically advanced, and least risk-averse clinical facilities in any given region (in my home city, where three groups operate methadone clinics, none of them offers a rapid transition protocol; only the teaching hospital does so, and the staff at the methadone clinics aren't even aware of this). Of course, if worst came to worst and you were suddenly unable to obtain your methadone for some reason, an adapted, at-home version of these rapid transfer protocols could be employed. As always, I'm available to answer questions about individual situations via the "Contact" form on this site or the Concrete Confessional Instagram. I don't provide medical advice; I simply share my own ideas and experiences - to be followed up on with your provider. I am receiving so many questions about tapering and withdrawal these days that I've been joking about starting a high-end "opioid / benzo withdrawal doula" consultancy. There is hope. We do recover. Please, be well.

Most people don't realize that they are addicted to prescription benzodiazepines or opioids until it is too late; the addictive trap has already been sprung. Today, I decided to write about what slipping into addiction to a prescription substance feels like - the self-deceptions, rationalizations, and moving goalposts involved. It's a subtle, gradual, and insidious process, and if you find yourself identifying with any of the warning signs that I explore here, beware . Backing out while it's still possible might help you to avoid serious misery or even save your life. Because sometimes, you have no clue which photo to use. In reality, I have a slew of old pictures of different controlled substance formulations from Chinese manufacturers on my phone / cloud, which I used while trawling pharmacies to see which ones carried my brands of choice and were amenable to bribery. However, I didn't want to tempt / provoke salivation from anyone who has a problem. I'm a great guy, I know. Note: For today's discussion, "dependent" refers to needing a physically addictive medicine to function normally (physically and mentally). "Addicted" means continuing to use a substance despite substantial detriments to your wellness. Doctors traditionally present these states as different, using the example of Type 1 diabetics who are dependent on insulin to regulate their blood sugar but who are not addicted to it - they don't crave it, escalate their use, obsess over it, or use it dangerously. However, I believe that the cognitive and emotional shifts that characterize addiction are more or less inevitable with regular use of some physically addictive classes of mind-altering drugs, including opioids and benzos; as the body's physiology shifts to require more and more of the drug for normal operation, the mind's workings distort to encompass all manner of rationalizations / justifications for escalating use. Those cognitive changes, in turn, are an essential part of what we call addiction. Red Flag 1: Your symptoms are getting worse. When you take benzos and opioids regularly, your body adapts to your intake of physiology-altering substances by trying to maintain physiologic balance (homeostasis). In the case of depressant drugs such as opioids and benzos, this involves downregulation (making less sensitive) the receptors that these drugs bind to. It is also accomplished by upregulation of substances and pathways that oppose the effects of the substance (for example, glutamate, an excitatory neurotransmitter). When the depressant drug that you're taking wears off, you're left with an excess of excitatory neurotransmitters as well as underactive depressant / calming pathways, which increases pain (in the case of opioids) and insomnia / anxiety (in the case of benzos). At this stage in the insidious process, you're likely to be thinking, "Wow, that Vicodin hits my back pain perfectly," or "Thank God for Xanax; I can breathe again." The medication seems like the solution when it is in fact driving the worsening symptoms. This increase in symptoms is inescapable for either class of drugs if you're using them regularly; the only options are to increase your dose, switch to a more potent drug, or take a tolerance break. For this reason, benzos and opioids are not meant to be prescribed long-term unless they are being used as-needed (PRN) with substantial periods of time in between doses. Feeling your underlying symptoms intensify is one warning sign that you're on the path to dependence and addiction. How do you know that your pain or anxiety isn't worsening independent of the effects of the drug? One important clue is context. If you're experiencing heightened back pain and you've just moved a bunch of furniture, it makes sense that you might need your pain medicine more regularly for a couple of days afterward (likewise if a major project deadline is looming and you're feeling more anxious, which causes you to take an extra dose of Xanax on one or two occasions). Most people who become addicted to benzos and opioids aren't consciously abusing them. They are impressed and relieved by how well these drugs work to assuage legitimate pain and anxiety, and - as the red flags mount months and years down the line - they use motivated reasoning to justify their continued use of these highly dangerous medications because they find it hard to think about coping with these symptoms without the most expedient option (because the solutions that are more effective and that work in the longer term for pain and anxiety require a lot of work, and - let's face it - they don't give the euphoric boost of opioids or benzos). Red Flag 2: The medication doesn't last as long and / or you need to up your dose. As I mentioned in Red Flag One, neither benzos nor opioids is meant for regular, long-term use. They're not effective when used in this way*. *With a few exceptions, such as opioid maintenance as an addiction treatment or buprenorphine treatment as a long-term pain management option for chronic pain that doesn't respond to primary or secondary agents and can't be addressed by targeting the source. Again, using opioids regularly exacerbates pain, a phenomenon known as opioid-induced hyperalgesia (if you're interested in the physiology of opioids, I wrote a walkthrough of mu opioid receptor dynamics here , which explains concepts like full / partial agonism, antagonism, and receptor affinity). By a parallel mechanism that involves GABA system downregulation and glutamate upregulation, benzos increase anxiety and insomnia. Depending on the half-life of the specific medication that you're taking, you're most likely to feel these effects as the medications wear off, which is referred to as inter-dose withdrawal. Once you're experiencing inter-dose withdrawal, you've reached some level of physical dependence. From there, you're at high risk of progressing to full-blown addiction. The other half of this Red Flag, namely, needing to increase your dose, becomes relevant as your tolerance builds due to physiologic adaptations that are a universal response to regular intake of opioids or benzos. As these changes occur, you're going to need an increase in dose (or to be switched to a more potent agent, if you're taking an opioid and this is possible). The reason that I classify this as a red flag is because - given that neither class of medication is meant to be used long-term unless it is being used very sporadically under PRN dosing, in which case a dose increase should not be necessary - I can't think of a reason to continue using the medication at this point that isn't suspect. With benzos, you might use them short-term for severe anxiety and insomnia while you're starting a non-addictive medication that takes a few weeks to kick in (for example, an SSRI like Lexapro or an NDRI like Wellbutrin). You should also be working with Cognitive Behavioral Therapy techniques, mindfulness exercises, and other non-pharmacologic tools - in the long term, these are both the safest and the most effective solutions; medications are just a support to use as you develop these more sustainable management tools. For pain, opioids work very well for acute, short-term pain such as pain arising from a muscular injury or post-operative pain.* If you're taking opioids regularly for more than 4-6 weeks, at which point you are absolutely going to develop a physical dependence on whatever medication you're ingesting, you should be focused on treating the source of the pain rather than just masking it with a highly addictive, ineffective (in the long term) substance. *Although NSAIDs are often equally or more effective and opioids are often prescribed unnecessarily after minor operations in the U.S. What procedures are available to decrease your pain by targeting its source - for example, cortisone shots for knee pain or selective spinal nerve blocks for back pain? What less-addictive medications are available - for example, prescription NSAIDS like Sulindac for inflammation-related pain or gabapentin / Lyrica for neuropathic pain? Have you tried mindfulness and Cognitive Behavioral Therapy, hydrotherapy, and / or Complementary and Alternative treatments such as acupuncture? If you're not addicted or heading in that direction, then why are you choosing to up the dose of a medication that will inevitably intensify your symptoms when used regularly? Again, if you're using a PRN medication as sparingly as you should be, then you should not need a dose increase at all. I'm not saying that any of these red flags has 100% applicability. It's not inconceivable that increasing the dose of a benzo or an opioid might be clinically reasonable as a one-time measure while a long-term, primary strategy is being implemented / gaining efficacy. However, the need to increase your dose should be viewed with the highest suspicion because it likely indicates tolerance, which almost certainly reflects some degree of physiologic dependence. Your body is operating differently than it used to or else you would have the same response to the same dose of the medication. If you understand what's at stake, this should worry you. You say: "My doctor will be aware of all of this and let me know if I'm throwing up red flags for addiction, right?" Absolutely, emphatically not. Although it's a sad testament to overwork, unethical practice, and the abandonment of benevolent paternalism in medicine, the testimony of hundreds of thousands of addicted patients shows that - especially in the U.S. - you cannot trust your physician to properly monitor dependence and addiction or even to warn you that they might occur. It is so easy for your physician to sign off on a refill rather than exploring more complex, sustainable options, but it can be hell on Earth to come off of these drugs (even if you are the fabled dependent but not addicted person, and even if you taper low and slow, as you're encouraged to [although your physician probably won't know to do that]). Most physicians won't raise the uncomfortable specter of addiction until something obvious happens - such as requesting early refills or claiming that you lost your script. Red Flag 3: You're taking the medication earlier and / or thinking about it more often. This is where self-honesty can spare you a world of hurt. Although any addict will tell you that the ability to discern one's true thoughts and emotions is eroded by addiction as denial, rationalization, and other maladaptive coping mechanisms evolve, the truth is that, deep down in the core of my being, I always knew that I was in danger of becoming addicted and then, later on, that I was addicted . You've got to be honest with yourself about how much you're looking forward to that Ativan or Vicodin and about the motives behind that anticipation. Are you thinking, "Two more hours until I can take my Vicodin and get some relief?" Are you spending all day looking forward to that nighttime Xanax, motivating yourself to get through some extra work or exercise because you know that it's waiting for you at the end of it? Perseveration about a drug is, in my opinion, the key sign that you're becoming addicted to it. After all, no one thinks longingly about when they can inject their pre-prandial insulin. Scheduling activities around medication is a huge (bright?) red flag. These will be thoughts like: "I'll watch that show later, after I take my Xanny and I'm more relaxed," or "I've got a [insert stressful family / work event] coming up; better make sure that I take my Xanax beforehand." If you ever move up a scheduled (non-PRN) dose, that, too, is a massive red flag. If you're supposed to take an Ativan at bedtime, but you enjoy the relaxation so much that you start having it right after dinner, you're already well on your way to addiction. Red Flag 4: Something embarrassing happens while you're on the medication, but you continue to take it. Maybe you take a Xanax on an empty stomach before a business meeting and get a little loopy / goofy.* *I have stories for days, unfortunately. Other people noticing that you're under the influence of a benzo or opioid is often an excellent sign that your body is responding to the medication in a way that indicates heightened risk of addiction; this is because the people who are most affected by a substance's intoxicating effects are more likely to seek out these effects again. And again. And again. Maybe you combine that Xanax with a glass of red wine before a family function and can't remember half of the "great conversations" that other attendees recall having with you that night. Maybe you eat a bunch of food or order a bunch of stuff on Amazon that you don't remember eating / ordering (Ambien shopping hauls that you have no recollection of are so common that there are various slang terms for them - I call them Blackout Fridays).* *Appallingly, it is quite common to get behind the wheel while on Ambien (a z-drug used as a sleeping medication, which acts at the same receptor as benzodiazepines). Most people who this happens to, including at least one U.S. Senator, are mistaken as drunk and cannot recall why they went out for a drive. There is even an "Ambien defense" to murder and other serious crimes that has been used in several countries; this is especially convenient because all benzos / z-drugs are amnesic, meaning that your client can conveniently forget or have spotty recollection of whatever crime he or she is accused of. With opioid painkillers, perhaps you get into a fender-bender and are lucky enough that no one recognizes your pinpoint pupils. Maybe you didn't sleep well and end up nodding off a little at work after you take your morning dose. All medications cause side effects, of course, and if the net benefit of the medication is great enough, then the side effects are worth putting up with (or even trying to rid yourself of with other medications). However, getting to the point where your behavior is impaired and / or embarrassing is a serious red flag because the vast majority of people would discontinue a non-essential medication that was causing them to behave this way - especially when there are non-addictive alternatives and even non-pharmacologic solutions that are as effective as the medications. If you're continuing to use benzos or opioids despite impaired judgment / embarrassing or sloppy behavior while you're on them, you need to have an earnest talk with yourself or a therapist about why you're continuing to use them. Red Flag 5: You're combining your medication with alcohol. Maybe you're like Lucille Bluth from Arrested Development and you mistake the drowsy eye on the "do not consume with alcohol" label for an encouraging, winky eye. The warning labels on these medications instruct you to avoid alcohol while on them for a very good reason. The risk of almost every negative side effect, from impaired judgment to impaired breathing, increases not additively, but multiplicatively or even exponentially when you combine either drug class with alcohol.* *Combining benzos and opioids is similarly dangerous; it carries a significant risk of overdose by respiratory depression (in fact, in 2021, 14 percent of fatal opioid overdoses involved benzos, and in 2020, 17.4 percent of fatal opioid overdoses involved alcohol). Prescription of opioids with benzos is done in some circumstances - such as in the context of end-of-life care or when treating severe pain with a muscular component. In these cases, however, the drugs are usually taken on an alternating schedule rather than at the same time, and blood oxygen levels are carefully monitored, as is respiratory rate. If you are drinking alcohol with your medication to boost its effects, you are evidencing the distorted judgment that is a primary feature of addiction. Get out if / while you still can. Red Flag 6: You're running out early. This is when your doctor is likely to start taking a keen interest in your controlled substance consumption - mainly because this is when he or she crosses a clear line into malpractice if the prescription is refilled early without evidence that it was lost or stolen. If you need more of your medication, you need to okay that with your doctor preemptively, not after the fact. However, as I detailed in Red Flags 1 / 2, if you need more of a benzo or an opioid, you're already on the path to dependence and quite possibly addiction. Running out early is a clear sign that you are already addicted; you're taking more of your medicine while ignoring or discounting the negative effects of going without it for a day or two (or more*). *Like many benzo addicts, I often took a month's worth of my Xanax script in two to three days. No exaggeration. More on the self-deception / rationalization and teleporting internal goalposts that fueled my benzo addiction here . My advice is to get help immediately through 12-Step* or SMART meetings, looking into opioid maintenance**, considering inpatient or outpatient rehab***, or by connecting with another resource. *Info on how to find a 12-Step meeting near you here (bottom of article) **Directories of providers for buprenorphine and methadone maintenance here (bottom of article) ***Tips on choosing a suitable inpatient rehab program here Please believe me when I say that it only gets worse from here, and that, from the bottom of my heart, I wouldn't wish addiction on the world's worst person. Red Flag 7: You're too afraid of withdrawal to taper off of your medication. Maybe you realize that one or more of the aforementioned red flags apply to you; this is good because it means that your self-honesty is intact. You realize that you probably need to taper off of the benzo or opioid that you're on, but you can't set a date to do so (or every time you start, the withdrawal symptoms are so severe that you back off immediately). Regrettably, many doctors will cosign this BS postponement of the inevitable. You're already in a physiologic trap, and it will only get worse with time. The longer that you use benzos or opioids for, the more tolerant you'll become to them and the more dependent on them you will become. You'll need more of your medication to function. However, even if your physician increases your dose, you will experience more intense side effects, continue to feel inter-dose withdrawal, and eventually max out the allowable dosage of whatever med you're on. As discussed ad nauseum above, regular use of benzos increases insomnia / anxiety; regular opioid use increases pain. These are unavoidable consequences that occur for every patient eventually because they result from universal adaptations that the body uses to compensate for the presence of a drug that throws off its physiologic balance. You need to get off of this stuff. Staying on these medications because you can't stand the effects of tapering off is a form of sunk cost fallacy. You should plan on a long taper that ends at a very low dose of a suitable, preferably long-acting medicine (diazepam or Librium (chlordiazepoxide) are frequently used for benzo tapering; methadone or buprenorphine for opioid tapers). You should enlist the help of a physician who will prescribe medicines to help with the process (gabapentin is a godsend for both forms of withdrawal, in my experience; my at-home opioid withdrawal protocol contains some other comfort medicine tips as well as non-pharmacologic suggestions). Please be careful, especially with benzo withdrawal. I've had grand mal seizures from benzo withdrawal that have obliterated whole chunks of memory and permanently altered how I think and feel. With proper guidance from a physician, with a low-and-slow taper assisted by comfort meds and mindfulness techniques, getting off these meds without horrific withdrawal symptoms is eminently doable. People are often shocked by how much of their pain, anxiety, insomnia, and weird miscellaneous symptoms* that appear unrelated to their medication regimen vanish after they get these drugs out of their systems. *Benzo withdrawal in particular has been misdiagnosed as everything from autoimmune conditions to rare neurological disorders. They're funky drugs that put a damper on every aspect of perception, cognition, and emotion, and coming off of them sends all of your systems into overdrive. Frankly, it's a terrifying experience, and the dreadful anxiety as you taper off of benzos lends itself to morbid, hypochondriacal rumination. Chronic pain patients who have been dependent on opioids for years often feel markedly better a month or two after they finish their tapers; the body regains its ability to self-soothe. Likewise, long-term benzo users who taper off frequently report markedly sharper memory and discover that their "Panic Disorder" or "Generalized Anxiety Disorder" either no longer exists or is substantially less severe after a year off of these drugs. A note on long-term effects: You don't want to be on benzos long-term. They cause changes in mood and memory, including a significant increase in the risk of dementia. They impair your ability to think rationally and make you more likely to act impulsively. Withdrawal from them can take two whole years. Opioids, which cause chronic, severe constipation alternating with periods of diarrhea (if it's a short-acting medication), have been implicated in the genesis of GI cancers. They, too, affect mood and memory; they also alter the endocrine syndrome (for example, by causing steep decreases in testosterone levels in many male patients). Some of these effects, too, are likely to be permanent. Red Flag 8: You react in a defensive, dismissive, or otherwise negative manner to reading this article. Be honest with yourself: You know whether you have a problem. Chances are that a good portion of you who chose to click on this article are addicted to your opioid or benzo medication or are on your way there. None of these red flags in and of itself always signals addiction, but your attitude toward reasonable questioning of your use of these medications is extremely telling. If you read my descriptions of why opioids and benzos aren't suitable for long-term, non-PRN use and reflexively thought "Yeah, but..." or "I really need them to get through X, though..." or "This doesn't apply to me," then you need to very rigorously examine why you're reacting so strongly and quickly. Would you feel the same way if you were reading about the risks of a blood pressure medication that you were taking? When in doubt, taper off. The only winning move against benzos and opioids is not to play. With regular use over an extended period, a high percentage of users will become dependent upon and addicted to these powerful, insidious drugs. The risk of addiction is so high with benzos and opioids, and the negative effects of addiction to them so dire, that the benefits are simply not worth the risk. In many healthcare systems, opioids and benzos are virtually never prescribed outside of end-of-life and surgical care*. * I'm not talking about underdeveloped systems, either. I have a physician friend who trained at the University of Queensland in Australia, who said that getting a prescription for opioids outside of very acute, short-term circumstances is essentially impossible; even after surgery, most patients aren't given opioids, and those few who are must take them while still under supervision in a surgical recovery unit in a hospital. Please be honest with yourself and get out while you can. The longer addiction goes untreated - the longer you take a medication for and the higher your dosage goes - the lower the chance that you will recover. If one single person reads this article and stops their opioid / benzo use before it becomes a problem - or more of a problem - then the hundreds of hours that I have put into the dozens of articles on this site have all been worth it. Community input: Can anyone think of any warning signs that I missed? Is there any part of what I discussed that patients and / or providers disagree with? This can be touchy stuff, I know. For clinicians, I know how tough it can be to approach a patient about a suspected addiction, but you must never forget that it is your duty to do so. As always, thanks for reading. Be well.

U.S. physicians are in dire need of specialized training in withdrawing patients from physically and psychologically addictive drugs. I crave dramatic scenery and charged weather - the craggy splendor of the Cascades; the roaring, troubled ocean on a blustery day in Florida, Hawaii, or Hong Kong. The rolling hills of Upstate New York don't exactly qualify, but the summers here have their charms. Lately, we've had these stippled, pastel sunsets in pinks and blues followed by bloodred-and-neon-fuchsia sunrises. It's contemplative scenery, beautiful and temperate. I've mentioned elsewhere that my (very relaxed) editorial calendar now has over 120 items on it. Rather than continuing to add to this list, I've decided to tackle several limited but interconnected topics through a series of psycho-riffs like this one. I've been thinking a lot about how - decades into the opioid epidemic and with hundreds of thousands of Americans dead from prescription drug overdoses since the turn of the millennium - most American physicians are still woefully ignorant about getting their patients off of addictive drugs. Technically, the specialties of Addiction Medicine, Psychiatry, Anesthesiology, and Pain Management should include training on withdrawing patients from mind-altering drugs that are physically and psychologically addictive. The sheer number of requests for information that I get each week from desperate people in benzo or opioid withdrawal speaks to the facts that A) most physicians in these specialties have next to no training in withdrawal medicine; B) that those who do are still using ineffective pharmacology and protocols that are decades old; and C) that, more broadly, many physicians who prescribe these highly addictive substances are not trained in any of the salient specialties and have no idea how to get their patients off of them. Although my At-Home Opioid Detox guide is far from groundbreaking, I've had several readers contact me to express how helpful it was; more than one has mentioned bringing this post to their doctor to obtain prescriptions for comfort meds that their doctors either hadn't been aware of or hadn't understood the logic behind using to ease withdrawal. Make no mistake: No matter how grateful and relieved your patients are when you first prescribe them these insidiously addictive drugs, the vast majority of them will want to get off of benzos and opioids eventually. Neither class of drug is intended for extended use because the effectiveness of benzos and opioids against anxiety / insomnia and pain, respectively, does not hold up in the long term. In fact, a cruel twist of biochemistry and physiology means that taking opioids for pain will in the long term actually increase pain - a phenomenon known as opioid-induced hyperalgesia. In the case of benzodiazepines, similarly, there is a marked increase in insomnia and anxiety / panic caused by interdose withdrawal and other shifts that occur with regular use. You can increase the dosage and move to stronger agents, of course, but eventually, the side effects will become unmanageable. Benzos cause intoxication similar to alcohol, meaning that driving and other daily tasks become dangerous, and they obliterate memory - plus, their long-term use even at therapeutic dosages is associated with marked increases in dementia risk. Similarly, opioids induce memory and mood disturbances as well as chronic constipation severe enough to cause gastrointestinal blockages. They also put the patient at risk of many other serious problems, including aspiration pneumonia. Despite all of this, U.S. physicians with no particular training in using these substances routinely prescribe them for extended, non-PRN (as needed) use. Many readers find it unbelievable that - in my 15 years of being prescribed benzos and opioids by a couple dozen medical practitioners - only two clinicians, one a buprenorphine (Suboxone) provider and one a Family Practitioner who refused to up my Xanax dose, advised me of the risk of physical / psychological dependence and addiction. To this day, I have never had a physician provide a realistic, front-end walkthrough of what it would entail to detox from either of these substance classes despite the fact that they were providing me with quantities that would almost certainly lead to physical dependence if not addiction.* *This lack of discussion of dependence / addiction risk and of what tapering off of a physically addictive substance will likely entail is so commonplace that I believe that it warrants a specific informed consent acknowledgment form to be signed by the patient before a prescription for an addictive controlled substance is issued (similar to the forms used for surgeries and other procedures). I have, however, had multiple physicians who - after it became obvious that I was tolerant / dependent / addicted - advised me that I would probably never be able to get off of these drugs and recommended against trying to do so (this despite the fact that it is nigh on impossible to get a new, daily prescription for benzos in this country because the FDA has finally cracked down decades too late). This is a staggering abdication of the Hippocratic Oath. Hey, how's this for an idea: If you can't get a patient off of a drug, don't start them on it? *** I'm currently writing an article on rapid transition protocols for methadone to buprenorphine switches, and almost all of the salient research was conducted in European countries. As I discussed in Metha-Don't , methadone maintenance programs in the Netherlands, Denmark, and elsewhere in Europe are more advanced and effective in that they offer breakthrough, injectable opioids to patients who continue to use illicit opioids after starting methadone treatment. They also use benzos, gabapentin, and many other adjunctive medications that are almost all prohibited for use by methadone patients in the U.S. for reasons that are archaic, founded in stigma against addicts, counterproductive, and unscientific. This malignant malpractice affects the back end of the process, too. I've mentioned that I'm currently tapering off of methadone, and - despite the fact that the withdrawal syndrome from methadone lasts the longest and is reputedly the most intense of any drug - I have not been offered a single medication to ameliorate any of the host of severe withdrawal symptoms that I'm suffering from. I can't even take over-the-counter Non-Steroidal Inflammatory Drugs (NSAIDS) like ibuprofen or acetaminophen without prior approval from the clinic on account of the fact that they could throw off drug test results. Were I to bring myself to the Emergency Room and ask them to treat my withdrawal on a particularly bad day, and were a physician there to decide that a rescue dose of a short-acting opioid or a single dose of a benzodiazepine was appropriate, I would be subject to disciplinary action by the methadone program (which does not offer either type of medication, or any of several non-benzo, non-opioid alternatives like gabapentin, to detoxing patients). Per capita, the U.S. consumes more of these addictive chemicals than any other population on Earth. Why aren't we devoting research dollars to getting people off of them? Why are despondent patients turning to YouTube videos and people like me for answers? Unfortunately, while I'm not usually one for a grand conspiracy theory, I believe that in this case the answer is rooted in our for-profit healthcare system and the enormous lobbying power that Big Pharma wields in this country. It is not in their financial interest to get people off of these drugs. As every pharma rep knows, the best patients are lifelong patients. As I alluded to above, even those American doctors who clinically supervise withdrawal from benzos and opioids are often using decades-old protocols. The blood-pressure agent clonidine, which is an alpha-adrenergic agonist, is often utilized, and I have found it to be very helpful. However, as I have written about in RIP, Gabapentin , the drug gabapentin, which was once an unscheduled medication in the U.S. and is in my opinion the most helpful non-benzo, non-opioid agent for benzo and opioid withdrawal, is being removed from clinical use following its scheduling in many states. We have had hundreds of thousands of fatal overdoses on these substances since 2000, and we're moving backward in terms of the treatment options on the table for avoiding benzos and opioids in the first place as well as getting people who are addicted to these drugs off of them. Words fail. Truly. I've had at least a dozen doctors prescribe me benzos such as alprazolam and clonazepam. Of the three who I eventually asked for help in tapering off of them, not a single one had heard of British physician Heather Ashton's method for gradual withdrawal from benzos, which involves conversion from whatever benzo the patient is on to an equivalent dose of diazepam, then scheduled, incremental decreases from there. What's particularly pathetic about this is that there is really nothing pharmacologically surprising or revolutionary about her method. The low-and-slow taper using a moderate-potency agent with a longer half-life is the rule in successfully withdrawing a patient from almost any medicine, from a blood pressure regulator to an antipsychotic. As recently as 2015, I had a doctor who was certified in Addiction Medicine tell me that jumping off of buprenorphine (Suboxone) at a dose of 2 mg per day should entail almost no withdrawal symptoms. We now know that this is emphatically not the case, a fact that would have been obvious to any physician who listened to his or her patients in the first place. In reality, the majority of patients who successfully taper off of buprenorphine find it necessary to get down to a dose of 0.2 mg or lower, at which level there are still marked discontinuation symptoms. Why aren't we researching agents such as ibogaine, a powerful hallucinogen that acts at the mu opioid receptor and has been successful in treating opioid addiction, leading to the establishment of a series of ibogaine-based underground treatment centers in Mexico*? *I've had two acquaintances go through ibogaine treatment. It saved one friend's life, miraculously ending a decade-old heroin addiction (he's been clean for over 8 years at this point). The other person came back and relapsed almost immediately. I will either write about ibogaine, or, better yet, solicit a submission from someone who has been treated with it. Even if we don't have brand-new medications ready for clinical trials at the moment, why aren't we at least mixing up our current pharmacological tools - for example, by investigating the use of "rescue" doses during withdrawal from short-acting and long-acting benzos and opioids or by incorporating variable-ratio reinforcement into dosing schedules? By experimenting with novel combinations of full agonists, partial agonists, and antagonists? We're not even trying  to innovate. Can you imagine the outrage and outcry if this many people were dying of a new type of cancer? I have said it before, and I stand by it: The prognosis of severe opioid addiction is worse than that for pancreatic cancer. At that level of risk, almost any treatment option is better than the status quo. So long as we obtain informed consent from patients, we should be embracing any potentially effective treatment. The current treatments' "success rates," which are in reality failure rates of 95-99% for severe opioid addiction, are so abysmal that any other plausible treatment is worth a shot. The arrival of fentanyl and xylazine on the scene* has removed any modicum of breathing room that we might have had in dealing with the epidemic. *I've discussed this shift in the illicit opioid supply here . I have heard of more opioid overdoses these days than at any other time in my life. In this regard, things are not getting better. They are worsening, accelerating. Addiction medicine is the most heavily regulated of all the medical specialties in the U.S. On the other hand, Pain Management physicians - and the many mostly well-meaning but ignorant Family Physicians who prescribe benzos and opioids for extended use despite the lack of long-term efficacy and the fact that they know virtually nothing about the risks thereof - face a deplorable lack of regulation. It's a system with clear priorities. Let's make it as easy as possible for people to get addicted. Then, let's cut off their supply and force them into the chemical torture of withdrawal, which eventually drives many of them into criminal activity tied to obtaining benzos, opioids, and other drugs that they are mentally and physically dependent upon from the black market. That way, our prisons - which cage a greater percentage of our population than any other prison system on Earth save for North Korea's , almost half of whom are there for offenses related to drugs - won't ever be empty. That's a fantastic recipe for a successful society, no? *** Again, by the time that the patient is addicted, the damage is done. At that point, every emphasis should be placed on exploring all available options for harm reduction, medical maintenance, and withdrawal. This is no more and no less than what we would insist upon as a matter of course for any other disease with comparable mortality rates. We need research and training in withdrawal / detox medicine. A fellowship for Psychiatrists, Addiction Medicine practitioners, Pain Management doctors, and Anesthesiologists would be a starting point. Addicts shouldn't have to bring their physicians notes on YouTube videos and blog entries to come up with a plan for getting off of these deadly, stupefying drugs. As I've asserted above, issues of tolerance, dependence, and weaning off of medications should be discussed on the front end, before the patient enters into dependence and addiction. If you're not advising your patients of these risks, then you're not obtaining properly informed consent. Period. Let's bring back paternalistic medicine in the best sense - the sense in which physicians are informed, trusted gatekeepers rather than just legal drug dealers who scribble a prescription for any addictive drug whose print or TV advertisements catch the eye of a desperate patient. For the third time, i f you can't get your patient off of it, then don't put them on it in the first place - or, at the very least, advise them emphatically and comprehensively about the risk of tolerance / dependence / addiction before they start any new medication. It's hard for me to write about this. I am exhausted, I am heartbroken, and I am livid. I have a litany of names and a memory-montage of faces - not just of acquaintances, but of real friends who I have loved and lost to opioid addiction. Several of them died from accidental overdose; two by intentional overdose (suicide); and two from septic infections tied to injection drug use. Many of them had benzos as a part of their stories, too. Their names are Dylan, Rachel, Tom, Jodie, Nyk, Micah, Sandy, Dave, John, Kris, Mike, Luke, Zach. I am sure that I am forgetting a name or two, and I am so sorry for that. No one who is my age should have lost so many of their friends that they can't remember them all when they sit down to write about them. No society can afford to write off the loss of so many bright, young, beautiful souls. And, as I wrote about in my Fourth of July post, I have a fear in my very marrow that the United States' descent into nihilistic decadence and widespread addiction presages its collapse - just as empires from Ancient Rome to the Third Reich and the USSR experienced greatly elevated use of and addiction to mind-altering substances as they collapsed. I am brokenhearted. *** Quick note: I am touched by those of you who have sent your condolences regarding Lou's passing . I recognize that today's post - as well as the follow-up that will be published tomorrow or on Thursday, which contains my meditations on the spiritual, moral, and medical models of addiction - are more desultory / meandering and less polished than most of my writing, and this is a direct result of the sorrow, busyness, and insomnia of the past week (Lou's wake and funeral services, which were attended by hundreds of people, were held this past Saturday; I saw so many friends and relatives who I haven't been in the same room with since before I left for China, which was wonderful but utterly exhausting). We're not even four months into this blog being online, and already I'm starting to feel a real sense of connection and community. Probably because of the nature of the topics that I write about, most people aren't comfortable sharing their thoughts / questions openly, as comments, which I understand. However, I so badly want for you guys to meet each other! To facilitate this, I'm exploring the option to add a forum section, create a Discord server, or find some other way for us all to interface in a more conversational format. As always, I'm open to suggestions! *** Playlist for the Week* *The easiest way for me to express how I'm doing (1) Paper Wings by Rise Against (2) Danny Boy by the Irish Tenors (3) Anytime by Eve 6 (4) No Surprises by Radiohead (5) Miss Atomic Bomb by the Killers

For the science geeks among you. A lighthearted look at the history and evolution of addiction, including theories explaining why the genes for addiction are so prevalent in modern humans. Photo of a British Columbian bear from my cousin Julia, a wildlife biologist who has a way cooler life than I do. Who knows; this guy might be going to get some willow bark for his hangover. Drug Use in the Wild (aka Jane Goodall Attends a Chimpanzee Rave) Let's start broad: Human beings aren't the only species that takes medicine to alter its internal state. Grizzly bears, for example, know to rub sore teeth and other injuries against willow trees, whose bark contains salicylic acid - a chemical cousin of acetylsalicylic acid, also known as aspirin. This is learned behavior, and only some groups of bears have this knowledge. I love the image of Papa Bear leading his teething son over to a willow tree to demonstrate this hack. "Not that tree; your cousin Jeffrey rubbed himself against it, and that's why he is the way he is now. Use this one over here - yeah, that's the good stuff." Most of us have heard about experiments in which rats and other animals become addicted to self-administered alcohol, heroin, and cocaine, but is this something that only happens during manmade experiments? In other words, do wild animals like to get f*cked up? There have long been reports of animals seeking out intoxicating substances. In the early 19th century, for example, French naturalist Adulphe Delegorgue recounted South African legends about elephants ingesting fermented marula fruit, after which some of them tangled tusks while others collapsed into a stupor. In the Caribbean, teenaged vervet monkeys know how to imbibe the fermented sugar cane juice produced on nearby plantations. They also like to steal alcoholic drinks from bars. When monkeys get drunk, their staggering, sloppy behavior is eerily similar to what you'd see in any human bar 45 minutes before last call. In an episode of Weird Nature , observers noted that - just as in human populations - some monkeys drank nothing, most drank a little, and a few drank to excess. Try as I might, I can't find any literature on whether these monkeys and elephants have knowledge of hangover remedies, but the image of a hungover vervet monkey stumbling over to a white willow for some relief is almost too good to be true. It turns out that many species appreciate a psychoactive break from reality: Cats tweaking on catnip, dolphins cultivating a pins-and-needles high by eating pufferfish, lemurs coating themselves in secretions from toxic millipedes, which not only repel insects, but also have a narcotic effect. It's not just mammals that have a predilection for psychoactive substance use, either: Some bees reportedly prefer nectar containing nicotine and caffeine. It's sort of like Addy for insects, I guess. Speckled Moths and Sickled Cells: A Quick Recap of Darwin's Theory of Evolution *If you have a basic understanding of Darwin's theory of evolution by natural selection, feel free to skip this section. One of the crucial components of Charles Darwin's theory of evolution is that natural selection roots out genes that decrease an organism's fitness*. *Fitness refers to an organism's capacity to survive and reproduce. For a quintessential example, let's take the Peppered Moth, which was widespread in the UK during the nineteenth century. Most of these moths were white with black speckles, which allowed them to camouflage themselves against the lichen that they liked to land on (see pic). Peppered Moth white phenotype. Before the Industrial Revolution, this was the most common phenotype. Photo from butterflyconservation.org . Although most of the moths had white wings with black freckles, there was a mutation that caused some moths to produce more melanin, which resulted in wings that were almost entirely black. However, this all-black phenotype tended to stand out against the foliage that the Peppered Moths lived in, and for this reason, black-variant individuals tended to be eaten by predators. Thus, the black-variant moths had more trouble surviving and reproducing, so they became less prevalent in the population over time. This was all true prior to the Industrial Revolution. In the 19th century, however, pollution from industrialization and domestic coal fires changed the moth's habitat dramatically. Against this new backdrop, it was the black-variant moths who were able to hide within the soot-covered foliage (see pic). This caused the white-winged moths to virtually disappear. By 1895, for example, 98% of the Peppered Moths in the city of Manchester were black. Black phenotype of the Peppered Moth (left). Unfortunately, the best photo I could find was from the Institute for Creation Research, which is one of those anti-evolution Christian groups. But hey, they take (or steal) a good picture, I guess. This case study illustrates the important point that fitness is specific to a given time and place. As an organism's environment changes, traits that were once favored by natural selection can become maladaptive. Evolution by natural selection isn't always so straightforward. For instance, take the gene for sickle-cell anemia, a human disease that changes the shape of red blood cells. Rather than their normal, disc-shaped form, affected red blood cells collapse into a sickled shape (see pic). Normal red blood cells (disc-shaped) versus sickled ones (collapsed; spindly). I miss med school. Photo from MIT News. These sickled cells do not carry oxygen as effectively. Moreover, they tend to stick together, which leads to blockages that cause painful, damaging interruptions to blood supply. The malformed cells can also accumulate in the spleen. These so-called sickle-cell crises lead to swelling, scarring, and a loss of the oxygen-carrying protein hemoglobin, which can be life-threatening. Why didn't evolution by natural selection wipe out the gene for sickle-cell anemia? Obviously affected individuals would be less likely to survive and reproduce, right? So, over time, evolutionary theory would seem to predict the disappearance of sickle-cell anemia from the human population. Scientists used two key clues to solve this mystery. The first was who gets sickle-cell anemia: It's a disease that predominantly affects people descended from sub-Saharan African populations. The second clue was found in the mechanism by which sickle-cell anemia is inherited. It's an autosomal disease, which means that it is not sex-linked (found on the X or Y chromosome). It is also a recessive disorder, meaning that only individuals who have two copies of the mutated gene - one from mom and one from dad - will have the disease. With a recessive disorder, individuals may carry one copy of the affected gene without themselves manifesting the disease. Although carriers of the sickle-cell gene do not have symptoms of sickle-cell anemia, they do make some malformed red blood cells (just not enough to cause sickle-cell crises). These carriers can, however, pass the mutated gene down to their offspring. Again, if their children inherit another mutated gene from the second parent, then they will have sickle-cell anemia. Putting these two observations together with one final piece of information, scientists made a brilliant deduction. For much of the history of sub-Saharan Africa, malaria has been one of the leading causes of death. The malarial parasite lives in red blood cells; infection is spread through the bite of mosquitoes. What scientists realized was that the malarial parasite doesn't like sickled red blood cells; in fact, affected individuals seldom get malaria. Moreover, even carriers of the sickle-cell gene are protected from the parasite. It seems that they make enough sickled red blood cells to be protected from infection, but not enough to manifest sickle-cell disease. So, the going theory is that the sickle-cell mutation persisted in the sub-Saharan African population because the protection from malaria conferred on carriers and sickle-cell anemics outweighed the deleterious effects of the sickle-cell disease on those who were affected by it. Sickle-cell anemia demonstrates another important point: That genes that seem to be maladaptive in one way might be beneficial in another. So, to recap, Darwin theorized that inherited traits are acted on by natural selection, which favors traits that increase organisms' ability to survive and reproduce. But fitness is context-specific, and genes can be inherited in several modes. That is where things can get tricky. Is Addiction Inherited? It's hard to imagine a behavioral trait more detrimental than addiction. Addiction is dangerous and distracting; it causes harm in myriad ways. It blinds us to significant risks by inducing artificial euphoria that banishes pain and anxiety. From the point-of-view of natural selection, it's particularly relevant that addiction decreases reproductive fitness. Regular use of substances can decrease fertility in both men and women, it can increase the chance of miscarriage and damage to the baby, and it certainly makes both men and women less capable parents than they would otherwise be. These changes drastically decrease Darwinian fitness. Why, then, is addiction so prevalent? Shouldn't natural selection have taken these "selfish" genes out? The first question to ask is whether addiction is really inheritable - in other words, whether differences in individuals' DNA that predispose them to addiction are passed down through families. After all, it's easy to understand how children of addicts could become addicts themselves just by emulating the behavior of their dysfunctional parents. It's not necessary to have a genetic component to explain why addiction runs in families. Scientists have clever ways to parse the available data to answer this question. One method is using twin studies, which compare rates of a disease in identical twins separated at birth. In such cases, the DNA is identical, but the environments are totally different. If both twins end up developing addiction despite different environments, and this happens frequently across many pairs of identical twins*, it suggests that addiction has a genetic component. *And less frequently in fraternal twins, who share 50% of their DNA. The scientific consensus is that there is a powerful genetic component to addiction. In other words, addiction is passed down in families not just because of shared environment and learned behaviors, but also because of genetic differences that influence whether an individual develops addiction or not. As I have written about elsewhere, this is true of Cluster B personality disorders as well as many other mental illnesses and complex behavioral traits Scientists and statisticians use a variable called R, which they refer to as heritability, to describe how much of the variation in a trait within a population is due to genetics. For addiction to various drugs, values between 0.4 and 0.8 have been given for R, meaning that about 40% to 80% of the risk of developing addiction is down to genes. (For those of you who want to consult the literature, Cambridge Core has a great review of the genetics of substance use disorders for various drugs here ). To summarize, the robust data on this topic show that addiction is in fact inheritable and that 50% or more of one's risk of developing addiction is due to genetic differences*. * This is not the most precise interpretation of R because R describes population variation, not individual risk, but because it is the most easily digested and applied formulation, it's sometimes used even by scientists and statisticians. Addiction is a complex behavioral trait that is influenced by multiple genes, so the genetic picture is more complicated than it is for a binary, single-gene trait like wing color in Peppered Moths. Interestingly, some genes that have been associated with addiction are specific to certain substances, and several of them are correlated with the risk of other mental illnesses, too. Quick note: For these next sections having to do with specific theories on why the genes for addiction are so prevalent in modern human populations, I originally wrote one screed, which was unreadably long. I then separated my points into sections, but because they overlap, it's more a case of variations on a theme then entirely self-contained arguments. I stuck to a different line of evidence and angle of approach for each, though. (1) Evolution Takes Time We were able to observe evolution by natural selection so clearly in the Peppered Moths partly because they reproduce so quickly. Peppered Moths emerge from their cocoons, mature, and lay eggs within the space of 4 to 7 days. Their eggs then take 4 to 10 days to hatch, meaning that the full generation time from birth to producing offspring is 8 to 17 days. The Peppered Moth's generation time is so short that hundreds of generations passed by during the first couple of decades of the Industrial Revolution. We were able to see evolution occur so quickly for this reason and also because the selection pressure was so strong: White moths stood out so markedly against the soot-stained backdrop that predators quickly eliminated them, causing evolution at an accelerated pace. In humans, by contrast, evolution typically takes tens of thousands to millions of years. Our species has an average generation time of 25-30 years*, Moreover, for a complex trait like addiction that is tied to many emotional and behavioral traits, natural selection is likely to be slower and gentler. *There is a very interesting article about the average generation time of humans over the past 250,000 years available from the NIH's National Library of Medicine here . For this reason - i.e., that human evolution usually takes tens of thousands to millions of years - most mainstream biologists treat the claims of popular "evolutionary psychologists" with skepticism. Evolution has shaped our capacities for language and for various forms of social behavior, but it can't explain highly specific behavioral responses to modern environments. Even if the genes for addiction are being weeded out by natural selection, evolution hasn't had enough time to have a strong impact yet. There just hasn't been enough time elapsed. (2) Availability of Substances Addiction in its intensely detrimental modern form hasn't been around for that long in the grand scheme*, either. *Remembering that our species first appeared about 300,000 years ago. However, archaeological evidence indicates that early hominid species were using psychotropic drugs as far back as 200,000 years ago. Nicotine from tobacco, opium from poppy plants, cannabis, cocaine from the coca plant - multiple lines of evidence indicate tens of thousands of years of psychotropic substance use all over the world. However, for the vast majority of human history, substance use was naturally limited by availability and the need to dedicate most of one's time and energy to obtaining food, shelter, and other basic necessities. For this reason, ancient civilizations commonly treated these psychotropic substances as special, and there was often a spiritual quality imputed to their experiences with them. It wasn't until the past couple of centuries that we were able to isolate and mass produce the mind-altering substances found in these plants. Techniques to chemically alter these natural substances to produce more potent synthetic ones have only been around for a few decades. So, although ancient humans likely chewed on coca leaves to boost productivity or smoked cannabis to get closer to God (see pic), it wasn't until the modern era that powerful, mass-produced substances were continuously available. Without this condition being met, addiction was a nonissue. I typed "a picture of a happy caveman smoking cannabis by a fire" into Gencraft's free AI image generator and this was the (pretty based, I must say) result. (3) Substance Use Was a Clever Happiness Hack During the tens of thousands of years before modern chemistry made mass-produced mind-altering substances available, ancient peoples used plants like cannabis and coca seeds to relieve pain, boost energy, and enter states deemed more conducive to spiritual experience. Addiction is rooted in the midbrain, which releases feel-good neurotransmitters like dopamine to reward behaviors that help us to survive and reproduce. So, when we eat calorie-rich foods and have sex, for example, we are rewarded with dopamine hits that give us a rush of contentment. Addiction hijacks this system by artificially stimulating these same dopamine-releasing systems, which delivers euphoria that is often much stronger than naturally occurring responses (see chart below). I've seen values of 500 to 750% for opioids. Porn can crank things up to 200 to 250%, so Jenna Jameson on a computer screen might beat the girl next door in 3-D, unfortunately. For most of human history, life has been short and brutish. People were hungry most of the time, and even when they weren't, they suffered from nutritional deficiencies because there wasn't enough variety in their diets. Pregnancy was just as likely to lead to death of the mother and / or miscarriage as it was to a live, healthy birth, and many of the children who made it into the world perished during childhood due to rampant infectious diseases. Something as simple as a rotten tooth could lead to agony and death; skeletal remains of early humans show extensive damage from infection, cancer, and chronic diseases. Early peoples put tremendous effort into building self-sufficient settlements only to have famine, disease, or war decimate them. In this dire context, people whose brains rewarded them for using mind-altering substances actually might have had a better chance of surviving and reproducing. Using the relatively mild, plant-based substances available for the first tens of thousands of years of our species' evolution allowed them to cushion themselves from the harsh realities of the world that they inhabited. From this point-of-view, substance use was an adaptation (and a pretty common one, judging by the co-evolution of human brains and plants that make mind-altering substances through the millennia). Positive psychology has taught us that happy people are more productive, mentally and physically healthy, and resilient. If taking drugs boosted your mental state and this helped you to cope with a fraught environment, then it would have increased your Darwinian fitness, at least at first glance. As mentioned above, it wasn't until the past couple of centuries that potent, highly addictive drugs became widely and regularly available. This was when substance use took a turn, fitness-wise. During the Industrial Revolution in England, when there were mass migrations of people from the country to the cities to work in the factories and other enterprises that sprung up, alcoholism was so prevalent that some factory owners gave their employees Mondays off to recover from the post-weekend shakes. Opium use was another popular pastime, and it often involved imbibing a combination of alcohol and opium known as laudanum. The list of writers, artists, and other famous figures who were opium addicts is staggeringly long; substance use is thought to have played a role in the death of Edgar Allan Poe and other literary legends. Preachers ranted against the evils of intoxicating substances while Op/Ed pieces dissected the roots of and potential solutions to the problem. An 1887 newspaper column called "The Opium Habit - The Most Abject of Slaveries - Is There Any Emancipation?" provided a lively depiction of the plight of the addict: "[they are] hopeless, helpless slaves, mind weakened, lacking energy for any effort toward recovery, rapidly drifting into imbecility and untimely graves. A peculiar feature is that victims craftily conceal it from their nearest friends" (see pic). *Screenshot from the Library of Congress' digital copy of the Southern Standard paper of McMinnville, Tennessee, dated November 19, 1887. The same publication that railed against opium addiction touted a "health-preserving, pure and wholesome" Safe Yeast cure - God knows what that had in it. I have written elsewhere about my belief that the long-term mental, physical, and social effects of opioid maintenance medications like buprenorphine and methadone will parallel those of the opiate wasting syndrome recognized as far back as the Victorian era. By that time, there was a recognized syndrome of physical and cognitive decline in those dependent on opium and morphine, and it was thought that they were at increased risk of GI cancer and other ailments, as well. Thus, addiction in its highly detrimental form is a modern phenomenon. Before that, for most of our species' development, natural selection might actually have favored the genes that predisposed individuals to enjoy mind-altering substances because it helped them to maintain a positive emotional state when contending with a challenging environment. (4) Mind-Altering Substances Might Even Get You Laid Perhaps the effect of mind-altering substances on mating was significant, as well. As comical as it is to imagine a group of early humans chewing coca leaves by the handful to rev themselves up for a prehistoric orgy, the idea has some merit. Humans are a complex, highly social species with nuanced, variable mating rituals. And, as any incel will tell you, competition for mates is intense. If mind-altering substances decreased the mental barriers to mating by alleviating anxiety and inhibitions, it's possible that genes favoring their use would be selected for over the hundreds of thousands of years of our species' development. In layman's terms, getting f*cked up made it easier to get f*cked, and that's a Darwinian win. (5) Addiction as Collateral Damage As we saw in the case of sickle-cell anemia, sometimes a gene for a deleterious trait such as sickle-cell anemia can persist in the population because it confers a strong benefit, such as protection from malaria. I touched on the idea that addicts have particularly adaptive dopaminergic reward systems that are naturally at a low level of stimulation above. As I mentioned, this system evolved to reinforce behaviors that helped us to survive and reproduce - for example, eating high-calorie foods and having sex. Finding food was difficult for our atavistic ancestors, who often spent months and years in near-starvation. Mating certainly wasn't easy, either. Our primate ancestry means that the males of our species are in intense, sometimes violent competition for desirable females, and God knows that being a human female isn't easy, either. Thus, nature served up a nice reward for killing that deer for dinner or scoring that hot, knuckle-dragging biddy by the fire. Individuals whose brains rewarded them strongly for such behavior were more likely to repeat it, and addicts' brains certainly seem to crave - and to come to depend upon - these dopaminergic hits more quickly and strongly than other individuals'. The problem is that this dopaminergic system also reinforces other behaviors, including gambling and drug-taking. Now, this wasn't such a problem in ye days of olde. Our ancestors were too busy trying to survive to squander fortunes in casinos or to smoke weed all day. It's only modern society that has served up enough vice to allow compulsive gambling and drug-taking to become life-threatening problems. Similarly, although the midbrain system did evolve to reinforce sex and eating, it's only in modern environments that nymphomania and overeating have become real threats to health. Before this, the addictive brain evolved because it was more sensitive to the midbrain dopamine reward system, which made addicts more motivated to survive and reproduce than other individuals. The fact that this system has been hijacked by drugs in modern times is just unfortunate collateral damage. (6) Addiction is Tied to Adaptive Behavioral Traits I've written elsewhere about Cluster B personality disorders, which include Narcissistic Personality Disorder and Borderline Personality Disorder. People with these disorders are demonized; they are treated as a scourge on modern society. Addicts share some psychological characteristics and behavioral traits with sufferers of these disorders. Traits common in addicts, including impulsivity, emotional volatility, high anxiety, and selfishness, seem totally maladaptive from the contemporary perspective. The thing is that they only seem maladaptive because we take our current social context for granted. It's only during the past several hundred years - the blink of an eye from an evolutionary perspective - that life has been peaceful enough and society complex enough that we began to place great emphasis upon "prosocial" behaviors such as altruism*. kindness, and nonviolence. * The existence of true altruism in any species is hotly debated by evolutionary biologists . Before then, life was a rough-and-ready affair. When the plague hit or a rival clan showed up with spears and clubs, addicts were the individuals who responded most rapidly and energetically. Whether we fought or fled, our impulsive, anxiety-prone brains helped us to react quickly and decisively. Our selfishness and our tendency to self-isolate allowed us, and likely our relatives, to escape dangerous situations. So, one way to conceptualize addiction is that compulsive drug-taking is a negative behavioral trait that is tied to a cluster of personality and behavioral qualities - including impulsivity, emotional reactivity, anxiety, and selfishness - that served our ancestors well for much of our history. At the molecular level, these differences come partly from variations in dopamine receptors. Different people have variations on the gene that specifies how to make this receptor, and because of this, our midbrain reward system can be more or less reactive (less reactive dopamine receptors mean that individuals need more stimulation to trigger the reinforcing hit). Intriguingly, human migration patterns correlate with dopamine receptor genetics. People whose midbrains demanded change and excitement were more likely to migrate across the Bering Strait crossing, then move all the way to South America. "Calmer" people likely stayed put in Eurasia. These biological differences helped to create culture - for example, consider the value placed on self-regulation, fitting in, and being nonreactive in Asian cultures versus the North American emphasis on vigorous self-defense and florid self-expression. It's possible that addiction is such a problem in countries like the United States and Australia because we are essentially frontier societies. We attracted the people who were restless, independent, impulsive. Our ancestors were the individuals who - after a night of drinking and talking s*it about getting out of dodge - actually woke up the next morning and signed themselves into indentured servitude so that they could make it to the New World. Some of our predecessors were criminals or religious outcasts; they had the courage to thumb their noses at polite society in their home countries and take a big gamble on geographical change. Again, all of these traits were probably useful for the majority of human history and before that, the evolution of the early hominids that we are descended from. The fact is that the kinds of brains predisposed to addiction are also the kinds of brains that were most likely to survive during our tumultuous past. Final Thoughts - You Seriously Read This Far? The genes for addiction evolved because they were correlated with adaptive behavioral traits during the hundreds of thousands of years before modern society made it possible to squat in an abandoned house shooting dope with dirty needles all day. Addicts have a restless, impulsive, sometimes antisocial brain chemistry. This made us and our relatives more likely to survive the war, famine, and disease that characterized much of our ancient history. Understanding this provides insight into why the rates of addiction vary across different societies. Analyzing differences in brain chemistry, particularly those related to the midbrain dopaminergic reward system, helps us to untangle the complex web of hereditary and environmental factors that influence risk of addiction. One worrying trend is the demonization and criminalization of certain brain chemistry profiles, such as those of addicts and Cluster B personality disorder sufferers. It's no coincidence that so many famous figures suffer from these and other mental disorders. The same restlessness and emotionality that cause problems in our social function also allow us to produce gut-punchingly vivid art. These differences also give us the social separation necessary for effective societal critique. Even Machiavellian traits like manipulation and power-hunger can be adaptive if they are harnessed properly. Dark Triad traits - psychopathy, Machiavellianism, and narcissism - are more common in middle and upper management than they are in the general population, and it's thought that this is true because these traits aren't always maladaptive in these settings. When you're a CEO faced with tough budget cuts, being able to emotionally separate yourself from the people affected by your layoff decisions is not necessarily a bad thing. By understanding the origins, strengths, and limitations of different brain chemistry profiles, we can use them to maximum positive effect at both the individual and societal levels. There is absolutely no shame in having any particular mental illness or personality profile. It's not what you're predisposed to that counts; it's what you actually do with the cards that you're dealt. It's possible that if modern society stays roughly the same for tens of thousands of years, we will see weeding out of the genes for addiction from the population (especially with ultra-potent analogs like fentanyl and carfentanil killing people who are predisposed to experimenting with drugs early on in their lives). Again, however, this isn't necessarily a good thing. Were our environment to suddenly shift due to climate change, conflict, or some other catastrophe, those same "negative" traits seen in addictive brains might suddenly be the ones that save us, after all. Thank you for reading! I have a whole "science of addiction" series planned, but because these posts take longer to put together, I've been putting them off until the summer months.

Meditations on what I consider to be the three primary models of addiction: The spiritual, the moral, and the medical. My friend Shady atop Da Nanshan Mountain ( 大南山) in Shenzhen, looking cool in that effortless way that only Egyptians can look cool (cigarette not pictured, surprisingly). I miss my poodle, China, and my friends / fiancé deeply and roughly in that order; also, it appears that I've caught a serious case of whatever the opposite of pagoda fatigue is (pagoda craving? pagoda fever?). "The more I see, the less I know, the more I like to let it go / Hey-oh..." - "Snow" by the Red Hot Chili Peppers Note: It just occurred to me that I'm probably the only person on Earth who is interested in reading my stream-of-consciousness intro on mythmaking, forcing the model, and implicit biases. Feel free to search "In science in particular" and start reading from that line if you're strictly interested in, you know, the topic that you clicked on this article hoping to read about. Jerks. In " I Was Simon Song, " I wrote about my experiences in the highly profitable, brutally competitive private education industry in China. Recently, a former colleague sent me an entrepreneurial profile on an educational consulting firm in Beijing, which specializes in matching underprivileged Chinese high school students with research opportunities under American scientists and engineers. I've met the founder of this company twice and am acquainted with his reputation. I'll be nice and put it this way: The article served up a Genius Founder myth on par with anything that Silicon Valley has to offer. What intrigued my colleague and I, however, was the fact that the story of the company's vision and early days was entirely different from the one spun when we listened to the founder's pitch for seed money five years ago, at which point the company intended to serve the children of China's socioeconomic elite. Based on the language of the write-up, I don't think that this is necessarily a case of deliberate distortion; it strikes me as more of a living narrative that evolved to highlight the company's strengths as they became apparent -- while conveniently forgetting goals that weren't attained and customer demographics that failed to take the bait. As human beings, we have terrible trouble coming to terms with our own biases, our lack of objectivity. By our very nature, we are mythmakers, reality-deniers. We cling to the notion of a shared, objective reality despite the fact that every iota of input into our systems is filtered through our hopes, judgments, and expectations. Even when we attempt to adjust for our biases in a deliberate, rational way, we fall far short of anything approaching objectivity. Much of our tendency to warp reality to fit our needs and desires originates within our linguistic programming. Prime us with adjectives suggesting arboreal verdure, and we'll rate the air freshener brand Glade more highly than competitors; ditto with adjectives subtly connected to stunning sunrises and the dishwashing soap Dawn. Many of our most powerful unconscious biases originate in the deepest, oldest parts of our brain, which control autonomic functions like breathing and temperature regulation. Ask people to rate the friendliness of new acquaintances in a chilly room or while holding an icy drink and they will score their new contacts significantly lower than people who they meet in a well-heated room while holding hot chocolate or coffee - even though the people in both groups are trained actors who appear, speak, and behave identically. Part of our unconscious bias is due to coopted neural circuitry that sometimes conflates the literal with the symbolic (cold personalities and cold drinks), which came about as our species evolved its uniquely advanced linguistic capabilities. Another less unconscious component, no doubt, is down to simple magical / motivated reasoning. Memory, on its part, is so fundamentally unreliable that the highest court in the state of New Jersey has recently opined that eyewitness testimony should probably be excluded from court proceedings altogether (an astounding finding, given that a good portion of all criminal and civil trials up to the present day have hinged on such testimony). Even when we do consciously apply a little creative license to reality - more specifically, in the case of the educational consulting company that I mentioned, to capitalist enterprise - can you blame us? After all, one of the ways that we deal with the vast pain and chaos of life is by endowing ourselves with potent powers and narrating ourselves into noble quests. Seeing the world as we want or need to see it is a venerable coping mechanism. Self-delusion saves lives. (Bear with me today, please. I'm going somewhere with this.) It's not just law and business that are affected by cognitive and emotional biases, either. My stepdad, Lou, who passed away nine days ago, suffered for years from mycosis fungoides, a rare, Cutaneous T-Cell Lymphoma (CTCL) in which cancerous immune cells in the skin cause extensive, painful lesions. Despite the fact that this cancer "should" be containable within the skin - something that the leading expert on the disease, an oncologist at Memorial Sloan Kettering Cancer Center in NYC, affirmed - Lou is dead partly because the disease spread to other organs. At one point, Lou's brain was biopsied after a CT scan revealed evidence of infection in his temporal lobe. However, instead of finding signs of the infection that we were told was attacking Lou's brain, the neurosurgeon emerged from the biopsy confident that he had removed part of a second, primary cancer. This finding, in turn, was reversed by the pathology report that arrived a week later, which concluded that the neurons of the biopsied area had demyelination that could have been caused by a stroke, an autoimmune disease such as Multiple Sclerosis, or numerous other conditions. In other words, there was neither infection nor cancer - at least, not as far as the pathologist could discern. At several points, Lou suffered from un- or underexplained symptoms as well as unusual / unexpected side effects of his chemo and radiation treatments. In fact, at one juncture far too long into the treatment process, even the initial diagnosis of mycosis fungoides was called into question. In science in particular, we tend to regard disease entities as having discrete, objective reality. However, cases such as Lou's show just how poorly delineated and lacking in explanatory horsepower our medical models can be (even for a disease such as cancer, which is relatively clearcut and well understood). Everything that we perceive, every thought and emotion that we have is influenced by what we are programmed to expect. We are continuously remodeling reality to fit the schemata that we begin learning as soon as we enter the world. Our understanding of that world begins within ourselves and is projected outward from there; we can no more perceive and understand things that conflict with our schemata than we can view light outside of the visible spectrum or hear sounds outside of the audible range. This subjectivity is further enhanced when we're dealing with psychological illnesses as opposed to physical ones. *Although all diseases are ultimately rooted in biology, of course, meaning that this distinction is an arbitrary and sometimes misleading one. Recently, I've been reflecting on the extent to which the modern, disease model of addiction, which I discuss in more detail below, doesn't fit my own experience. Because I had read about this theory of addiction fairly extensively by the time that I realized that I was an addict and entered treatment, I never really had the chance to observe and analyze my addiction without interference from preformed expectations deriving from the disease model. One of the tenets of this disease model is that addiction is perpetuated in a cycle that begins with use of the drug of choice, which leads to guilt / shame* that motivate further use of the substance, which triggers an additional layer of guilt and shame - and on and on and on. *The guilt and shame can come from embarrassing actions while under the influence or simply from failing to honor one's promise to oneself and others to stop using. The drug use, in turn, provides euphoria and numbness / insulation to help the addict ignore his destruction of his own life. It's a shiny concept. And, for a while, I accepted it as fact rather than filter. After all, it sounded nice and neat; it made a basic sort of sense. (In reality, this probably should have been my first warning sign, for addiction is messy and extraordinarily difficult to corner and examine; it resists all attempts to render it linear, predictable, sane). When this guilt / shame cycle was discussed during treatment groups, I would share that - although after relapsing, I didn't feel these emotions viscerally , in the sense that people usually refer to their emotions - I experienced them cognitively , in the sense that I knew that I should have had and ordinarily would have had these emotional responses to my failure to stay clean. What I really felt during active addiction was an emotional void - nothing at all. Sometimes during withdrawal (or, more rarely, apropos of nothing), my emotions would punch their rotting hands through the dirt above their graves, and I would succumb to horrifying, taboo nightmares and to waking panic attacks accompanied by whole-body shakes and thoughts that galloped toward psychosis. Mostly, though, what I felt when I relapsed - whether after a few days or six months - was a profound easing of internal tension that persisted even after the drug wore off. The ending of the exhausting, day-and-night struggle against myself was an unspeakable relief. To be fair, there was a part of me that was disappointed in myself when I continued to use despite my vows to stop. I felt guilty for dragging select loved ones through hell with me. It's true, too, that I felt humiliated by incidents that occurred during benzo binges . Again, however, I'm not sure that this guilt and shame played a significant role in driving my continued use. It just wasn't strong or consistent enough. What was actually motivating me to use was, by and large, a desire to avoid the agony of withdrawal. That was the first thought on my mind as my sweaty friggin' skeleton jerked awake each morning, and as far as level of motivation went, it was a 10 /10. That my drugs of choice would also numb me to the pain, destruction, and squandered opportunities caused by my addiction was a fringe benefit. The guilt / shame cycle is just one of several components of the disease model of addiction whose validity I justified by filtering my experiences through the provided lens. In this case, I actually created a new, intellectualized form of emotion for myself* rather than admitting the truth - again, that for the vast majority of the time that I spent in active addiction, I felt nothing. *What does "intellectualized emotion" even mean? Feelings are felt; that's kind of the point. Looking back now, my mental gymnastics seem ridiculous. I'm a little surprised that my therapists / counselors and peers didn't question this crock. Deciding that I ought to be experiencing an emotion and terming that recognition an "intellectualized emotion" is goofy. This isn't a frivolous or philosophical point; without understanding what motivates a maladaptive behavior, it is often difficult or impossible to change it. There are several other concepts and predictions of the modern, disease model of addiction that I have realized were either borne out through my confirmation bias or functioned as self-fulfilling prophecies. I touch on another one below. *** It isn't just that I'm fallible in applying  these theories of addiction, either. The models themselves are flawed. And even our best, most current model for addiction don't come close to passing scientific muster. In medieval times and likely for centuries prior to that, addiction was viewed as the result of demonic possession. As archaic as that theory might sound to us now, I believe that this spiritual model originated because it captures important truths about severe addiction, including the utter ruination of the soul and the self, from one's personality / essence to one's innocence / goodness. As I've expressed before, the most accurate metaphor that I can think of for the worst stretches of my addiction is that of being coerced by a dark stranger who puts a gun to my head and dictates my every action. The nightmarish level of dread associated with disobeying this malevolent being's commands cannot be conveyed in words; it is spiritual, and it is Hellacious.* *Interestingly. Eating Disorder sufferers also personify or demonize their affliction - Mia and Ana, for the initiates. I once watched a YouTube video about a young woman with Binge Eating Disorder who described being taken over by a ravenous spirit during her binges, in the course of which she would eat a month's worth of groceries in a few hours. She described not being able to control her hands, of chewing despite not willing herself to chew, of wolfing down regurgitated food despite her revulsion at this act, of "waking up" at the end of the binge and not remembering clearly what had occurred (as though she were recalling a dream or a period of intoxication). Ideas about the demonic essence of addiction are by no means relegated to the ancient past. William Burroughs, the infamous junkie-gentleman who wrote Naked Lunch and other experimental, brilliantly unreadable works in the 1950s -1980s, spoke of an entity responsible for his most addictive and outlandish behavior, including shooting his wife during either a gun-cleaning accident or a drunken game of William Tell (depending on when you asked him). When pressed on the nature of this malignant entity, he clarified that it was no mere literary device - his Ugly Spirit was much closer to an Old Testament demon than a metaphor for human depravity. A close friend of mine was given an exorcism during rehab in Brazil in the 2010s. For the record, Natalie's exorcism didn't work, obviously because the demon was too powerful. You'd believe it if you knew her, trust me.* *The women at this PTSD factory of a treatment facility were forced to drag a decomposing horse from a river in the middle of the night, presumably to impress upon them the horrors of death and decay, and to hit a wasps' nest until the insects went on the attack, probably as a metaphor for the senseless self-torture of addiction. Me being me, I ribbed Nat mercilessly about her "special sacrament," of course. We lived together for a few months, and I'd answer the phone with: "Are you calling for Nat or the thing inside her?" Because it was a studio apartment, we slept in the same bed, and I'd often refer to how lucky I was to have threesomes every night. Of course, the spiritual model isn't all about the dark side of the force. The basic idea is just that the spiritual degradation of advanced addiction precludes a healthy relationship with God; I don't think that many people would argue with that. Not surprisingly, I've known people who credit a renewed relationship with God as the thing that saved them from cer tain death ™. So, long story short, the spiritual formulation of addiction began in the mists of time and persists into the present day. When German philosopher Friedrich Nietzsche, whose concept of eternal recurrence  I have written about elsewhere, declared God dead in 1882, he presaged a massive shift away from spirituality and religion, including spiritual explanations for medical phenomena like seizures and addiction. Humanity needed new theories for explaining its vices. As the spiritual understanding of addiction fell out of vogue, a moral theory of drug abuse and addiction was advanced. Under this model, addiction was seen as the selfish prioritization of short-term pleasure over delayed gratification and fulfillment of one's responsibilities toward others. From this perspective, addiction was the result of selfishness, dishonesty, laziness, weakness, hedonism, and inability to tolerate discomfort.* *I'll have to save this list for the next time that I do one of those "Describe yourself in X adjectives" icebreakers. This model, too, exists because it expresses profound truths about addiction. The moral model is still quite popular, particularly in Southeast Asia and much of the developing world. The level of stigmatization of addiction in China is almost unimaginable to the Western sensibility. In fact, the only comparably vehement Western stigma is that attached to pedophilia. Although this Chinese societal reaction might seem harsh, at first, it's the reality that severe addicts cause more societal harm than almost any other demographic. In advanced addiction, not only is the individual's productivity - his good to society - largely negated, but it is replaced by a set of harmful attitudes / behaviors that tend to infect others. Addicts steal; we lie; we neglect our responsibilities, as well as ourselves, our children, and our elders; we're impulsive, sometimes even violent. Nothing comes before our drug. This is the moral model of addiction. It holds that addiction is no disease, but rather a set of bad decisions that are rooted in character defects such as selfishness, dishonesty, emotional volatility, and a tendency toward unhealthy self-isolation. From this perspective, it might quite reasonably be considered a moral condition with a moral solution - often a solution that involves character change through judicial punishment or some other social sanction. Although it recognizes addiction as a disease in its verbiage, the reality is that the 12-Step program for addiction treatment - as used in Alcoholics Anonymous and Narcotics Anonymous - is essentially A) spiritual in that it proposes a turning over of one's will to a Higher Power as the first half of the cure for addiction, and B) moral in that it proposes the correction of character defects as the second component of the treatment strategy. Unfortunately, the spiritual-moral fusion model of the 12-Step programs falls short in the ultimate test of any theory, which is its ability to solve the problems that it proposes to explain. Compared to evidence-based techniques such as Cognitive Behavioral Therapy, 12-Step programs have significantly lower efficacy*. *Although the Tradition of Anonymity and other facets of the Program that are designed to protect privacy have made it difficult to collect robust data, the most extensive dataset that I am aware of suggests that 12-Step programs are barely more effective than at-home, do-it-yourself abstinence. To be clear, I attend 12-Step groups (although I don't consider myself a 12-Stepper; if you're not involved in the community, it's a difficult-to-understand distinction, I know). I recommend that anyone with the remotest interest in the Program give meetings a shot. The Rooms are filled with wise, wonderful people. Moreover, even if you don't achieve lasting sobriety, you are likely to connect with a valuable community and to learn skills that will improve your life and help to rein in your addiction*. *For those who hold that some 12-Step groups have cult-like characteristics, my reply is that - so long as I'm not hurting other people - I would join any cult, don any tinfoil hat, if it meant release from the hell of active addiction. Shape me, guide me, Dear Leader.   There is, however, a cruel edge to the Program. One of its most famous slogans is "It works if you work it." Unfortunately, I have seen many people who were making earnest, fully committed efforts fail to get clean or relapse afterward (a couple of them after years of clean / sober time, during which they were leaders in the Program). To me, it seems nasty and unwarranted to say that anyone who the Program doesn't work for has failed through their own fault, and this is the clear attitude / implication of the Program when it comes to those cases in which it doesn't work. The Program uses almost legalistic language to cover its lack of explanatory power and its failure to distinguish between subsets of addicted people. For example, it asserts that "addiction is a chronic, progressive disease that over any significant period of time  gets worse." This sort of statement doesn't measure up to my lived experience. Spontaneous recovery from any disease, including addiction, is a recognized phenomenon. I have known fully, desperately addicted individuals who put hard drugs down, ostensibly on a whim, and never touched them again. During my own life, I have had periods when - for reasons that I cannot explain - my own addiction has become less severe or even gone into a sort of remission. As I have gotten older, my addiction has waned rather than intensified. It's become more amenable to management and more emotionally weatherable. Part of this shift is down to skills that I have learned and practiced, no doubt, but some of these changes are nothing more than a sort of internal seasonality that has nothing to do with any constructive action on my part. A hardline 12-Stepper would probably say that the years during which these positive shifts occurred did not constitute "significant periods of time" and would predict that my addiction will worsen and perhaps even kill me in the future. Once again, however, when we're talking about entire months and years spent clean and sober, this is legalistic nonsense. In these and other ways, the moral model of addiction comes up short, one of its fundamental failings tied to a fact that is readily apparent to anyone who knows a severely addicted person - namely, that at a certain point, the addicted individual loses control over his or her decision-making (as evidenced by shifts in neurophysiology as well as the fact that addicts consistently undertake blatantly, horrendously, life-threateningly self-damaging actions, which no individual with the ability to choose to do otherwise would undertake regardless of the fleeting pleasure produced or the fleeting pain avoided by substance use). When addicted individuals lack the ability to choose to stop using, the level of judgment and sanction prescribed by the moral model seems exceedingly cruel. The modern, medical model of addiction as a disease of abnormal neurophysiology - akin to bipolar disorder, eating disorders, and other mental illnesses - is probably the kindest and at the same time the most disempowering of these three models. It explains the strong genetic basis of the disease, as well as the aforementioned inability of affected individuals to make decisions in their own best interests even when their lives are at stake.* *I've written elsewhere about the deterioration in executive function of the Prefrontal Cortex [PFC] and the other structural and functional changes that are observed in the brains of advanced addicts, which erode the ability to make different decisions. Advanced addicts are programmed to use almost to the point of being robots / automatons. At one meeting, I listened to an alcoholic describe how he used to walk down the street to his favorite liquor store, buy a bottle of whiskey, and sort of wake up when he was halfway home - not recalling having made the decision to go purchase alcohol and not quite sure of why or how his feet took him there. Unfortunately, however, this medical model fails to deliver a reliable cure. Using the example of opioid addiction, at best we can currently use maintenance therapies like buprenorphine and methadone - or even treatment with antagonists like naltrexone - to modulate receptor dynamics and stabilize the addicted brain, sometimes enabling cessation of drug use. However, as compared with comparably life-threatening illnesses, our failure rates are still woefully high. For alcoholism, it's estimated that current, evidence-based treatment techniques help perhaps one in 10 of those who enter treatment to achieve long-term sobriety. For severe opioid addiction, on the other hand, even with opioid maintenance treatment, perhaps only two to four percent of patients achieve sustained abstinence time; without maintenance, it's possible that the figure is as low as one percent or even a fraction of a percent. Granted, understanding a disease is different from being able to apply that understanding to treat it, but until we have achieved this latter aim, we lack the most important confirmation that our theory is on point. One of the other problems with the disease model is that it doesn't work to tell people that they suffer from a mental illness over which they have absolutely no control. Despair and fatalism set in, and negative prognoses become self-fulfilling prophecies. Unfortunately, the medical model of addiction - when reconciled with the practical need for empowerment of addicted people - leads to nonsensical catchphrases like "You aren't responsible for your addiction, but you are responsible for your recovery." Exactly who is in control during the transition from active addiction to recovery is, conveniently, left unaddressed, as is the question of how addicts end relapses if they have once again forfeited their agency. This is just one of several logical contradictions and unexplained areas that result from accepting the disease model of addiction. The fact is that such a model is predicated on biological determinism, which holds that our thoughts and emotions - and, by extension, our actions - are caused by changes in our neurochemistry, just as the operation of all of our other organs can be reduced to fluctuating physiologic processes; as we have no evidence of a transcendent faculty of choice that somehow overrides our brain's biochemistry, biological determinism entails a rejection of free will. This, in turn, means that people cannot choose  to recover. Environmental influences, including therapy and medications, can shift neurophysiology so that an individual stops using, but this is not the result of personal decisions as we commonly understand them. To be clear, I believe that the disease model of addiction is the most scientifically valid model and that it also has the most explanatory power. I've written about innovative therapies, including drug vaccines and agonist / antagonist pairs, which promise to utilize our knowledge of the biochemistry of addiction to prevent, treat, and perhaps even to reverse it. But the point stands: When it comes to reconciling apparent contradictions and developing reliable cures, we aren't there yet - not even with our shiny, modern, disease model of addiction. *** In sum, we have three sometimes complementary, often contradictory models of addiction: The spiritual, the moral, and the medical. They arose because they explained and predicted important facets of addictive reality, but all three models have so far fallen short in delivering anything close to a foolproof solution to our addictive problems. Combining them often yields better results than confining treatment to any one model, but - as I've pointed out above - this also leads to contradictions that highlight our confused understanding of the addicted state. I'm interested to hear everyone's reactions. How do you think about addiction? Is it moral, medical, metaphysical? All three? None of the above? How about the role of personal responsibility in addiction? Do addicts choose to become addicts? Is there a point at which addicts can no longer choose to stop using? Do addicts deserve more lenient punishments, such as drug treatment programs instead of incarceration, for crimes committed as a result of addiction - in acknowledgment of diminished agency from brain changes wrought by long-term drug use? Again, I apologize that both I and my writing have been somewhat off this past week. Losing Lou really did a number on me. I'm getting back to my usual, hopefully more polished and less ramble-y style with upcoming articles on: (1) Dangerous shifts in the positions of LGBT community leaders with respect to a) medical transition of transgender kids, and b) associating our community with radical, leftist political views (2) Signs that you're becoming dependent on and perhaps even addicted to your benzo or opioid prescription (3) Rapid transition protocols for methadone to buprenorphine switches (4) An at-home benzo withdrawal guide Thank you all for reading. Really. I wish that I could summon more moving words for how grateful I am that you find my thoughts worthy of your time (and even, sometimes, of your praise). I've restarted my life many times, always with energy and the determination to do better. Then, the pandemic imploded my family, my social circle, my career - every aspect of my life in China. For the first time in my life, I worried that I might have been permanently vanquished rather than temporarily set back. I let myself fall into a terrible, defeatist mindset about my own life and character, and for months I was in an uncharacteristically deflated state (amazingly, I don't get depressed, in general). Having a purpose in answering your questions about withdrawal, relapse, and treatment / recovery has helped to bring me out of that morale slump. It means an incredible amount to me.

Summer 2024 life updates, including information on my stepdad's terminal cancer; progress on my never-ending methadone taper, which I've nicknamed the Arduous March ( à la Kim Il Sung); plus, Jay's fiancé visa and our plans to relocate. Summer dinner al fresco with Lou (my stepdad) on the left followed by me, my close friend Andrea, and my older brother, Stephen. We live in the Great Lakes region of Upstate New York, which is replete with wineries; picturesque little lakeside towns crowded with boutiques, restaurants, and parks / museums / libraries; plus, so many great hikes that you could spend your entire life hitting the trails around here and never run out of fresh options. Note: I visited with Lou yesterday afternoon. At that point, he was uncomfortable, but he was still himself. Shortly after I published this post yesterday evening, Lou lapsed into unconsciousness. I passed a peaceful night in the chair next to his hospital bed, which we had set up in my mom's sunroom. I gave him his medications using an oral syringe at 10, 12, 2, and 4. My mom woke up in the middle of the night to spend a couple of hours beside him. She lowered the bed's safety railing so that there wasn't any barrier between the two of them. There was a light breeze, and the sky was a beautiful indigo when the sun began its long journey this morning. I went to check on Lou one final time before I left for the clinic at six a.m., and I discovered then that he had passed on. Rest in Peace to one of the finest men that I have ever had the privilege to know. I'm so far past exhausted that my vision is strobing and shuddering. Lou, my stepdad, is dying in the next room. There is an oxygen machine at the foot of his hospital bed that makes a sound like an air compressor. For decades, Lou ran a family business that sells custom hardware for industry. Now, near the end, he hallucinates construction projects. From time to time, he asks me whether the lumber has arrived and if the tiles are ready to be laid. "Don't worry about a thing, Lou, " I reassure him. "All of your projects are right on schedule." *** Lou is the picture of a middle-class business owner in suburban America. He's an honest, reliable businessman who is a fixture in his community; an easygoing, humorous guy who is quick to crack a joke, to forgive, and to show up on the doorstep of any friend or family member who has a weekend reno project and could use an extra set of hands and a sixpack. None of this diminishes the fact that he is dying a king's death. People have flown in from all over the country to pay their respects. They hold his hands and say sweet, sacred, private things. They thank him for being there for the parties, the trips, the high points; then they hug him and thank him for staying by their sides during the depressions, the deaths, and the divorces, too. I have gone yearslong stretches of my life without crying. These days, I've wept every single day. *** Lou healed a great many wounds that our family had sustained. I've mentioned before that my mom and dad are intense people. Opinionated, sometimes even judgmental; rigid in their views and ways of doing things; fearsomely intelligent and hypercompetent when it comes to their careers. My mom needed someone like Lou to balance her out. Someone who was laidback, unintellectual; someone who was almost childlike in his simplicity and humor, at times. Lou brought out a completely different side of her. This is one of the great miracles of love, I suppose - that the eyes of the lover are like mirrors for showing the rest of the world the best possible version of the beloved. The grafting together of the family trees had other benefits. Neither of my brothers has children (yet), but Lou's daughter has a young son who recently lost his dad in a hunting accident. So, my mom became a grandmother. Another hole filled in; another gap soldered. *** Lou taught me how to paint, to drill, to drywall. He showed me how to balance a Bacardi and Coke in one hand while I varnished baseboards with the other. He demonstrated how to wield power tools in such a way that (most of the time) blood didn't come gushing out of me afterward. Lou was such a gentle, capable teacher. He taught me about a great many practical things. Without ever giving me an iota of advice - simply by showing me how he lived his life - he instructed me in far more important matters, as well. *** If God exists, then He seems to be a fan of jarring juxtapositions. I sit here restless and aching. I get up from time to time to sponge water or ginger ale into the mouth of a man who is much sicker, who will never get well. I can't escape the feeling that there's a lesson that I'm meant to learn that I'm still missing. If this were a TV show, I'd be running around with my fellow characters yelling "Where's the clue? Where's the clue?" Is the point that addictive suffering is ultimately - at least technically - self-imposed, optional? That it's a sin to suffer so (ostensibly) needlessly? Or is the point that all life is suffering? That suffering is the point, in some ways, and that I shouldn't be so weak as to want to avoid it? *** I'm hesitant to write this next part because I'm appalled at how selfish my reaction was. But this is a blog - in name if not always in format or particulars - and if I can't be fully honest here, what's the point? During one moment when Lou was discussing his decision to come home to die instead of continuing his futile struggle against the cancer that's riddling his body, my mom said this to him: "No one wants you to go, Lou, but no one wants you to stay here and suffer." That phrase "stay here and suffer" ate away at me like acid. I've often talked about how, had I known what life had in store for me when I was 16 or 18, I would have found the courage to hang myself. Enduring what was ahead of me would have been unfathomable. Likewise, if I had a kid who I knew would never recover from severe addiction, I believe in all honesty that I would kill my son or daughter rather than let addiction torment and consume them (it's rumored that Nancy did this to her son, the iconoclastic punk rocker Sid Vicious, who was facing a lengthy prison term for murder, but I'm not sure if that's biographical fact or imaginative apocrypha). *** The most apt metaphor for addiction that I've ever come up with is laid out here in my post on Junji Ito's The Enigma of Amigara Fault. The mill of addiction grinds slowly, but it grinds exceedingly fine. By the time that addiction is done with you, there is no "you" left. You are nothing but a substance-seeking revenant, a tortured, twisted shadow of who you started out as. This is not hyperbolic language. If anything, it falls short of the terrible truth. Other than perhaps eating disorders and advanced dementia, I don't know of any other illness that so completely devours the soul of the person suffering from it. Granted, those other disorders might wipe out the you in you, but addiction takes it one step further by replacing it with something primal, hungry, scheming. The quiet part that no one ever says is that, even if you stop using, if the disease is far enough along, it might be too late. Some people might be able to "recover" in the sense of not using anymore, but that doesn't mean that they can regain their true selves or live an existence that is anything less than an endless, agonizing struggle against themselves. *** In my communications with non-addicts, I've often heard versions of the old platitude that "If you hadn't gone through all that, you wouldn't be the person you are today." My response is that I wish I hadn't had to become the person that I am today. That person can be strong, cool, and capable, sure, and he has a few positive qualities that might not have come to be without the trials and suffering that he's gone through, but the cost to myself and to those around me has been far too high. There were a great many serious character flaws in the early me that needed addressing, no doubt. But I could've learned through lessons much gentler than those that addiction put me through - and there would have been more me left over at the end of the process, too. No one deserves this. And this kind of suffering and damage is never justified, never fruitful enough to be "worth it." I wouldn't wish addiction on a f*cking amoeba, truly. *** I've been in opioid withdrawal for weeks. My bones ache in a deep way that I haven't felt since my adolescent growth spurts. My joints creak like an old man's. My anxiety is electric these days, a sort of agitated, whole-body vibration that hits like a premonition of doom. I've given up on getting more than two or three hours of sleep at a stretch, and even these brief interludes are troubled. I've gotta get out of here! I panic as I wake up from a REM-rebound uber-nightmare, my heart racing, my arms and neck breaking out in gooseflesh, my sheets soaked with sweat. *** I've alluded to the fact that I'm currently coming off of methadone. If you're not familiar with my story, here's a short synopsis: After an extended clean stretch, I relapsed hard on oxy, benzos, and barbiturates while living in China. I came home toward the end of the pandemic deathly sick from withdrawal, and I went on methadone as a sort of stopgap because my daily dose of oxy (600 mg) was so high that stopping that at the same time as the benzos and phenobarb was shutting my body down. For reasons detailed here and here , I detest being on opioid maintenance. Granted, this is nothing unusual; after the six- to 12-month pink cloud period, most people do. Being on maintenance is living a simulacrum of life rather than a true existence. I feel so fake, so altered, so dishonest in my relationship with reality. Everything that I say and do is on point; no outside observer would realize that this is a chemically directed tableaux in which I perform the actions, speech, and feelings of everyday life (rather than everyday life itself). I'm constantly under the influence of a powerful opioid, and the sickest part of it is that I can't even feel it anymore: My body is fully tolerant to the drug, so I don't feel any positive effects from it. Come to think of it, I don't seem to feel anything at all. (Until I drop my dose again, that is, at which point the emotions come surging back). Deep down, I realize how muted my soul is. It's like someone has applied the damper pedal to my entire being. My writing is garbage, and I have very little creative drive. I'm basically a hermit; I turn 19 out of 20 social invitations down. *** Methadone is reputedly the hardest drug of all to come off of, and - while my taper thus far stops short of being my worst withdrawal experience - I have nicknamed it the Arduous March for a reason. I feel like I'm going through chemo and radiation. I have all of the typical, pernicious opioid withdrawal symptoms, but I also have a profound, sapping fatigue that leaves me doubled over and gasping twice while walking up a 10-step staircase. I'm dripping with sweat from the second that I get up to perform the smallest task. Trivial chores exhaust me. I am so sensitive to light, sound, and touch that I sometimes extinguish all of the lights, close the blinds, and cover my eyes and ears while I perform mindfulness exercises. On top of all of this other glory, methadone withdrawal causes an icepick headache that is unlike anything I've ever felt. It makes it hard to read, to write, to think. *** The last time that I tried to get off of methadone, which was almost two years ago now, I overdosed on fentanyl after 12 days of drastic dose decreases. I collapsed on the side of the road (long story) and nearly died. I was in the Intensive Care Unit for over a week. That was, incidentally, when I decided to start a blog because I realized that I might not have the years that it takes to publish my manuscripts through the traditional route (and also because I liked the idea of more extensive, back-and-forth communication with my readers). With that incident in mind, I'm taking things slowly and trying not to focus too much on numbers or self-imposed deadlines. As long as I'm moving forward and the dose is going down, I can pause for a breather if need be. Tapering off of methadone can take years, but I know myself: I don't have the patience for that. Eventually, I'll get frustrated; I'll relapse just to self-sabotage and hurry things along. *** Thus, I'm trying to balance tapering off on a non-geologic timescale with not going so fast that I push myself into relapse because of the severity of the withdrawal. It's a delicate balance, but so are many things in medicine and in life. It's particularly tough to take this on without Jay, my fiancé, by my side. His immigration visa is still held up by delays from the Consular closures during COVID. Unfortunately, not knowing when he will be able to move to the States has made it very difficult for me to make any plans about staying here and preparing for his arrival vs. going back to China to spend time with him while we wait (I had planned to return to China this summer, but Lou's illness changed things on that front). To tell you the truth, though, I'm not entirely sorry that Jay's not here to see this. I'm at a level of physical and mental sickness that activates that atavistic crawl-into-a-hole-and-die impulse. I've always been a loner, and it's easier for me to go through this on my own. My life is a liminal zone these days. I'm trying to channel John Milton's concept of active waiting and use this weird, in-between time to get my head and body right so that I can meet whatever life throws at me next head on. *** One of the most rewarding aspects of this blog has been seeing how many people in withdrawal or early recovery contact me with questions. Many are considering maintenance, and I lay out the pros and cons of buprenorphine and methadone as honestly as I can for them. For others, I've functioned as a sort of opioid / benzo withdrawal doula, guiding them through the process by telling them what to expect at each stage, what they can do to manage symptoms, and where they can find informational and treatment resources. I've frequently provided technical info to bring to their doctors because even clinicians who are otherwise competent often have blind spots when it comes to addiction, especially in the U.S. I'm surprised by how many people have gotten in touch, and I'm grateful to be of some small service. A chance to leverage vast personal pain to lessen someone else's suffering is one of the most beautiful things that any human being can experience. *** Lately, I've been thinking about a philosophical book called I and Thou , written by Holocaust survivor Martin Buber, which I attempted to read during high school (it's famous as one of the densest philosophical works of all time, partly because Buber's arguments rely upon the nuances of various formal and informal modes of address in German). Buber's thesis was that, after surviving a true Hell like the Holocaust, there are only two options: One is to despair, to live as though there is no God; the other is to hold onto meaning, or at least the hope of meaning, by living as though God exists and every single thing is a message from Him. I'm not sure that I accept a word of it, of course, but it's a radiant concept. *** I recognize that many of life's challenges are cyclical or recurrent, and that change occurs in upward spirals rather than neat, linear progression. Still, time seems like an anguished imposition rather than a venerable friend of late; pain layered on pain layered on pain. It's almost too much to take, sometimes. All of the glorious moments are there too, of course. But for some reason, they've just never held the same weight for me. I judge myself hard for that. Aren't I too old to be an angsty Emo teen? Isn't it a moral failure or at least seriously immature to focus too much on the negative? I've got an old, dark soul, and I'm haunted by all of the people that I've lost. *** Summer Playlist: (1) Spirits by the Strumbellas (2) Phantom Limb by the Shins (3) Cotton by the Mountain Goats (4) Sometime Around Midnight by the Airborne Toxic Event (5) Pompeii by Bastille (6) Zombie by the Cranberries (7) Helplessly Hoping by Crosby, Stills, Nash, and Young (8) In the Sun by Joseph Arthur (9) Bach Is Back (and a bunch of other classical / modern hybrids) by the Piano Guys (10) Don't Bring Me Down by ELO

A compilation of 75 writing prompts related to addiction / recovery, spirituality, and creative writing / fun. My Aunt Sue underneath a big ol' tree on the Hawaiian island of Maui. We called this spot the Green Cathedral because of the way that light filtered down through the arches of the trees and the heavy hush that fell there. I appreciate the idea of personal holy places, individualized rituals, and Gods / Higher Powers of our own understandings, and my journaling has helped me to piece together and practice a bespoke spiritual system that is much more meaningful to me than anything spoonfed to me when I was younger. Whenever someone asks me what to get a friend or family member as a rehab / early recovery present, I recommend a journal. There is something inherently cathartic and perspective-giving about journaling, and every treatment system seems to make use of this somehow. I've often heard people who don't ordinarily write grumbling about being asked to do so during treatment groups, but I have never, ever seen a blank page at the end of the process. The first book that I wrote was a 100,000-word autobiographical doorstop that I ejected from myself like an unwelcome excretory function during an eight-week post-acute-withdrawal frenzy after I took a leave of absence from med school and relocated to Oregon to teach in my early 20s. It's fascinating to look back at this (95% unpublishable) manuscript now and see that - while I had accepted that addiction would kill me if I didn't stop using - I hadn't surrendered yet. I was still doing things my way, and my storytelling reflected that. My attempts to order and rationalize and make comical were a way for me to convince myself that things were still basically okay, that I was going to be able to remove drugs from my life and essentially continue on as the same old, business-as-usual Brian. I couldn't grasp that the only way forward was by letting go of all of my old assumptions, expectations, entanglements, and entitlements. I had to relinquish a dream or two, as well. Looking back now, it couldn't be more obvious that I still had massive work to do. At the same time, it's interesting to compare my thoughts on addiction and recovery now with what I wrote about them then. The reality is that I have changed hugely in terms of personality, values, and spiritual sense in the intervening years, but this has been almost impossible to appreciate from the trenches of my relapse / recovery cycles. It's this kind of perspective that journaling lends itself to, and I believe that it can make the difference between life and death (or at least between having a life worth living and a life of staying stuck in the same old mud). For today's post, I've organized writing prompts into three categories: Addiction / Recovery, Spirituality, and Creative / Fun. If you're just starting out with journaling, I recommend writing for 20-30 minutes per day. It can be helpful to do so in a comfortable space and at a consistent time if that is possible. If you're choosing between inpatient treatment programs, I recommend asking them about how they incorporate journaling and creative activities into their programs (more on that here ). In my experience, the ideal journaling mindset is a state of flow that is almost meditative, in which your focus is on each word as it crosses from mind to paper and there is no worry about overall structure / pacing / revision. You might want to reserve five minutes at the end of a 30-minute writing session to read over your entry and add any thoughts / emotions / connections that seem important during your second pass through. Some of these prompts are original; the rest were modified from sources all over the web. Let's get started! Addiction & Recovery (1) Write down as many details as you can about one memory that you'll never forget. (2) Write about one of your most positive / negative childhood memories. (3) What person in your life has most influenced who you are today? How and why? (4) Describe yourself in 3 adjectives, then 5 adjectives, then 100 words (not just adjectives!). (5) What's the adjective that you would most like to become? Why? (6) How are you doing right now? Let it rip! (7) What are two recovery-related objectives that you'd like to accomplish tomorrow? (8) What's the most surprising or disappointing thing that you've learned about yourself during recovery? (9) What's something that you've never admitted to yourself before? (10) What's the most motivational thing that you've heard or experienced that will help you to maintain your recovery momentum? (11) Describe your biggest trigger* in a single word or phrase. *Triggers are stimuli that make you want to use. Examples include holidays, parties, money, depression, anxiety, loneliness, a certain street or restaurant, a specific memory, paraphernalia. (12) What has been recovery's greatest gift to you thus far? (13) What does the word "freedom" mean to you? (14) What does the word "serenity" mean to you? (15) Write four questions that you want answers to. How are you going to get those answers*? *Consider addressing these four questions to someone you know who is in long-term recovery. (16) What does unconditional love look like to you? Have you ever felt it? Have you ever given it to someone else? (17) Write a goodbye letter to the things that you need to let go of during recovery. You can focus on attitudes, behaviors, places, and perhaps even people. (18) Write about three people in your life who irritate you, and come up with a list of three positive qualities for each person. (19) Write a "not-yet"* list *Not-yets are negative consequences of addiction that you haven't experienced yet but that can or will occur if you continue to use. You can draw up this list based on peers' stories, reflecting on the course that you were on before entering treatment / recovery, and keeping in mind the three endpoints that the Program identifies for the progressive, frequently fatal disease of addiction: Jails, institutions, and death. (20) Dear past me: (21) Dear present me: (22) Dear future me: (23) Imagine talking to your children / grandchildren or other young people in the future about substance use and your addiction / recovery. How will you explain your experiences, including both the mistakes you made and how you got better? (24) How do you hope to use your sobriety to help others one day? Are there certain individuals / communities that you especially want to reach out to? (25) Write a letter to one of the five people who you love the most (not necessarily for delivery!). Spirituality (1) If you could make peace with one troubling memory from your past, which one would it be and why? (2) Make a 10-item gratitude list. *These are most effective when they are highly descriptive. So, rather than saying that you're grateful for "having time to relax," you might write that you are grateful "to be curled up on this tattered but comfy sofa under a cotton quilt that smells like my cat with a trashy romance novel open in my lap." That's probably goofy and a bit much, but the idea is to be vivid enough with your wording that rereading your description actually brings you back to this moment and this feeling. (3) What was the most spiritually impactful moment of your life (positive or negative)? Think outside the box (e.g., using "the now" or "the present" as an answer)! (4) Identify a passage from the Bible, Quran, Torah, Tao Te Ching, or other spiritual text that speaks to you powerfully. What is its message and why does it matter to you? (5) Gripe to God about your strongest grievance with him / her / it. What's making you feel bitter, defeated, that life is unfair, that your burdens are too great to carry? Do you think that there is a reason for why you're being asked to shoulder that burden? (6) Write a short, specific prayer* for difficult moments. *Example: "God, please help me to remember that this negative feeling won't last." You can also create mantras such as "Lord, reveal my purpose" and "God, guide me forward in peace." (7) What are your deepest values? What parts of your current life challenge or conflict with those values? (8) Describe your relationship with your Higher Power.* *The god or gods of your understanding. If you don't have a connection with a Higher Power, do you desire or plan to seek one? Describe what your ideal Higher Power would be like and what role he / she / it would have in your life. (9) What feels most forced / rigid / obligatory in your life? What feels more natural, unopposed, flow-y? (10) What is your relationship with your intuition like? How does it express itself in your life? (11) Have you ever experienced or witnessed a miracle? (12) Do you believe that the universe speaks to you or with you? If so, what is it telling you today? What are you saying to it? (13) Who is my highest self? How does he or she walk through the world? What purpose does he or she have in it? (14) Are there spiritual signs / synchronicities* that have appeared in your life in the past? Are any guiding you now? *I would define a sign as an answered prayer, a communication from God / the universe / the Higher Power of your understanding. A cliched example would be getting a call with a job offer after praying for guidance with work / career. Synchronicities are signs involving events that occur together or repetitively in a way that you interpret as significant, that seems to be more than chance alignment. (15) Were there any times when you felt abandoned by your Higher Power? Do you still believe that to be the case? (16) What does "surrender to a Higher Power" mean to you? (17) If you don't believe in God or are unsure about a Higher Power's existence, is there another way that you conceptualize / define / approach spirituality? Do you believe that spirituality is a fundamental human need? (18) What are some indicators that your spiritual self is troubled? What practices help you to restore your spiritual health? *For example, perhaps angry outbursts are a sign of spiritual stress; you might use a 15-minute meditation / yoga / prayer session first thing in the morning or last thing at night to restore balance. (19) What do you want your first intentional thought to be in the morning? (20) What's one specific thing that you can do to help one specific person today? (21) What do you believe happens when you die? Whether you believe in it or not, what would heaven be like for you? (22) What spiritual "season" is your life passing through at the current time? Is it a time of growth / purpose / abundance / regression / despair / reflection? What do you think you need to learn or do to maintain it (if it's positive) or to progress past it (if it's negative or challenging)? (23) Who was the most important spiritual guide / mentor / teacher in your life? What lessons did he or she impart? (24) What gives your life meaning? (25) What are some of your biggest unanswered questions? Creative / Fun (1) Write a scene involving a character getting arrested for a crime that his or her parents aren't angry about him or her committing. (2) Write a dialogue-based scene in which your character looks into the bathroom mirror and sees / speaks with a person from another time and place (person can be real, imaginary, literary). (3) Write a short story that contains the line "If she looked back far enough, she could see..." (4) Pick five random words and write a short story that contains all of them. (5) Write a passage or a short story about the concept of transcendence. (6) Pick a random image of a single person and describe this character as you would introduce him or her in a short story. (7) Write a story, scene, or poem following the abecedarian* format. *In which the first line or sentence begins with a, then b, and so on. Feel free to start at another place in the alphabet if you'd prefer. (8) Imagine a new type of vampire that survives on something other than blood. Write a short story based on such a character. (9) Write a scene / short story involving a character who cannot speak more than one, two or three words at a time.* *You could also use the classic conceit of a character who can only repeat back parts of what someone else has said to him / her or a character who must avoid certain words (e.g. "no"). (10) Pick a zoomed-out photo of a natural or manmade landscape from a place that you've never been and write the most vivid possible description of it using rich, sensory language. (11) Write a passage based on an original simile or metaphor.* *Similes use the words "like" or "as" in making a comparison, as in "He was as strong as an ox"; metaphors do so directly ("He was an ox"). You might want to play around with other forms of figurative language, including phonetic devices such as alliteration (e.g., "Brian begs you to buy beautiful, blue business binders"). (12) Misheard lyrics: Think of a line from a song that you misheard and use that line as the title or first sentence of a short story. (13) Write a short story / scene in which something occurs that one character can never, ever forgive another character for. (14) Write a scene / short story in which a character acts "out of character." (15) Write a scene / short story that begins with the line "I don't know what you want from me..." (16) Eavesdrop on someone else's conversation in a public place; write a scene that incorporates actual lines from it. (17) Write a scene / short story based on a character's first and / or last name.* *For example, the Irish name Brian refers to a high place such as a hill, so I might write about a character named Brian Churchill who is a priest who gets high all the time. There are many websites devoted to explaining the origins and meaning of first names and surnames from various countries / languages. (18) Create a scene / short story in which a younger or older version of a character travels through time to confront himself or herself about a crucial decision. (19) Write a scene based on one color (consider its metaphorical associations, such as red with blood and passion, blue / purple with royalty, and so on). (20) Write a one- or two-sentence horror story (you can impose even shorter limits for a challenge!). *Example: As I'm getting him ready for bed, my son says, "Daddy, look beneath my bed for monsters." Like always, I peek below the bed, but this time, I see him, another him, tremblingly peering out at me while whispering, "Daddy, there's somebody on my bed." (21) Invent a word, perhaps a combination of two existing words, and make up a scene or short story that incorporates it. (22) Write a scene from a non-human point-of-view. *Suggestions: Pet or wild animal, ghost / angel / mythical creature, inanimate object such as a couch or letter opener. (23) Write a story that takes place during an interesting / important ancient or modern historical event. (24) Pick an intriguing building that you can find a virtual tour of and write a scene or short story that takes place in a specific area of it.* *Be sure to include a vivid, multisensory description of the room or space in which your story transpires. (25) Write a scene / short story involving a prophecy made and / or fulfilled. Community Bulletin: During the next three months, I will begin featuring guest authors writing about addiction and recovery. If you are interested in submitting a piece for this blog, please use the Contact form or email concreteconfessionalblg@gmail.com to let me know! Material can be published anonymously if that is your preference. I hope that some of you will share other prompts below!

"All that we see or seem / Is but a dream within a dream." Edgar Allan Poe If you have ever traveled alone in a country very different from your homeland, then you have likely experienced dissociative symptoms. Being the only foreigner in a crowded square filled with the sounds of an unknown language and the smells and sights of a strange culture could trigger dissociative symptoms in anyone. I chose this picture because - after two years of martial law and lockdown during COVID in China - strolling through the nearly empty Harbin Snow and Ice World, with its massive ice sculptures of Notre Dame and the Taj Mahal, felt almost like tripping. Psychiatry recognizes a state called "Paris syndrome," a condition of severe cultural shock typically experienced by Asian tourists in France, which I believe is brought on by sudden dissociative symptoms. People suffering from this condition may believe that there is a conspiracy against them; that they are being tracked; that they are being subjected to racist treatment; or that they are in a dream / hallucination. I've had similar experiences at several points during my years in China (cue CCP surveillance joke), and I know that other expats have, as well. Introduction When you look up the definitions of dissociative symptoms like derealization and depersonalization in medical resources, you'll more often than not find vague language like "feeling detached / disconnected from yourself," "being cut off from your thoughts and feelings," or "experiencing unpredictable shifts in identity." The essence of dissociation is feeling numb, detached, unreal. The issue with this sort of generic language is that it doesn't do much to differentiate dissociative symptoms from other symptoms of anxiety / depression / personality disorders / psychosis / PTSD and other conditions that can involve dissociative symptoms and with which dissociative disorders can co-occur. In the absence of more specific description, many people are left with the mistaken assumption that dissociation always involves dramatic amnesia or radical identity shifts of the type seen in the hotly contested Dissociative Identity Disorder (DID). In fact, the lifetime prevalence of dissociative disorders is between 10 and 20%, which is shockingly high given how infrequently we talk about these symptoms and disorders. Dissociation is a common response to abuse, trauma, and other stressors. I suspect that people don't feel as comfortable discussing these symptoms because they may be perceived as "crazier" than anxiety or depression, for example. I have a theory that dissociative symptoms are the "canary in the coalmine" for many serious psychological problems. I also believe that digital technology, the stimuli-bombardment of the developed world, and the fact that modern humans live so much of our lives in the cerebral sphere may be responsible for a rise in dissociative symptoms. The use of and withdrawal from many psychoactive substances can contribute to dissociative symptoms, as well. Benzodiazepine withdrawal is absolutely notorious for causing severe derealization and depersonalization. The combination of the two is disturbing beyond words. It's as though you've suddenly woken up to your life being a video game. That might sound cool to some people. Until you've experienced it for 30 seconds, that is. I've come up with several metaphors for explaining these symptoms, which I plan to write about in more detail in another post. The best way that I can describe them in brief is actually not metaphorical at all. I'm a lucid dreamer, although I frequently wake up as soon as I realize that I'm dreaming. Dissociative symptoms feel almost exactly like that moment of becoming lucid during a dream. All of a sudden, some element within me or present in my environment triggers my brain's "something isn't right" reflex. For me, this often prompts a scan of my surroundings, which typically includes examining my own dream-body. A dizzying moment of introspection follows as my brain realizes that its assumption that it was progressing through ordinary, waking reality was completely off-base. This looking within as I become lucid often involves realizing that there are gaps in my memories or something else that doesn't jibe between what I'm seeing in my surroundings and what I expect to see based on my understanding of who and where I am. Sometimes, I realize that I don't recognize any of the other people in a dream (although this doesn't always trigger lucidity for me). There is often an uncanny valley quality to their features when I examine them more closely, as well - as though my brain created their facial features by averaging the faces of actual people who I know. At other times, I might recognize a setting that I've dreamt of before, notice that one of my scars is missing, or realize that the title of a book changes from one moment to the next. Dissociation involves that same alien epiphany and that same take-off anxiety that I and other lucid dreamers feel as we jolt ourselves awake after realizing that we are dreaming (although with practice, it's possible to train oneself not to wake up immediately). That underwater, vaguely intoxicated character of dreams is often present with dissociation, too. The texture of space and time shift just a little. Sample Symptoms I hadn't planned to write this post at this time, but while I was reviewing archives of an obscure 2000s forum for another post, I came across a list of dissociative symptoms that was much more specific and helpful than the ones that I'd seen in the past. Unfortunately, there was no source attributed. If anyone knows where the following list came from, please let me know so that I can properly give credit. Without further ado, you might be dissociating if you: (1) Find yourself staring at one spot, not thinking anything (2) Feel completely numb (3) Feel like you're not really in your body, like you're watching yourself in a movie (4) Feel suddenly lightheaded or dizzy (5) Lose the plot of the show or conversation that you were focused on (6) Feel as if you're not quite real, as though you're in a dream (7) Feel like you're floating (8) Suddenly feel like you're not a part of the world around you (9) Feel detached and far away from other people, who may seem mechanical or unreal to you (10) Are very startled when something / someone gets your attention (11) Completely forgot what you were thinking just a moment ago (12) Suddenly cover your face or react as if you're about to be hurt for no reason (13) Can't remember important information about yourself, like your age or where you live (14) Find yourself rocking back and forth (15) Find yourself becoming very focused on a small or trivial event (16) Find that voices, sounds, or writing seem far away, and you sometimes have trouble understanding them (17) Feel as if you've just experienced a flashback (perhaps rapidly) but you can't remember anything about it (18) Perceive your body as foreign or as not belonging to you Questions Has anyone never experienced any of the above? Does anyone have an alternate way of describing their dissociative symptoms? Have any of my recreational user / substance abuser / addict readers experienced flare-ups of dissociative symptoms that correlate with their substance intake? Does anyone who has experienced persistent dissociative symptoms and / or a formally diagnosed dissociative disorder feel comfortable sharing what that is like? This is a topic of great interest to me, and I appreciate anyone who is willing to share via comment or DM.

In the first part of this piece, I explain what happens when a receptor is stimulated. I define and present examples of foundational terms, including receptor affinity, full agonist, partial agonist, and antagonist. In the second section, I explain how withdrawal works and how precipitated withdrawal differs from ordinary withdrawal. I spend some time over on Reddit writing campy r/nosleep horror stories, answering questions about the physiology and pharmacology of opioid addiction, and presenting thinly veiled advertisements for this blog. One of the phenomena that I consistently read misinformation about is precipitated withdrawal. This isn't surprising, given that understanding receptor dynamics requires detailed knowledge of biochemistry and cellular biology, including how probabilistic quantum effects manifest at this level. However, this widespread misunderstanding is alarming because - short of death - precipitated withdrawal from opioids is probably the most torturously awful thing that can happen to an addicted body (it's roughly equivalent to having every tissue in your body be hurt in every way that it can be hurt all at once - plus having your neurophysiology plummet into the abyss). I don't remember much about my experience with precipitated withdrawal, which was triggered by overuse of naloxone (Narcan) by the EMTs and doctors who were treating me for overdose. My memory is probably so limited because I was also high on benzos at the time. I have, however, heard stories from three friends who have experienced precipitated withdrawal under varying circumstances.* *Desperate addicts will sometimes induce precipitated withdrawal by taking an opioid antagonist such as naloxone (Narcan) or naltrexone as a last-ditch effort to get clean. I will say more about this later, but if you stop reading now, please know that this never, ever works out, and that it will definitely, certainly, assuredly be one of the three most unpleasant experiences of your life. To emphasize the importance of avoiding precipitated withdrawal, I'll quote those friends here: Friend 1: "I thought that I had died and my soul was in hell." Friend 2: "[Friend 1] is right; it's so dysphoric and terrible that it like takes you to another dimension." Friend 3: "My mom walked into my bedroom while I was taking a sh*t on the floor..." Precipitated withdrawal occurs when someone dependent on opioids is put into sudden, severe withdrawal because of a rapid drop in the stimulation of their mu opioid receptors, which can be triggered by ingestion / administration of a partial agonist or an antagonist. If you just read that definition and thought "I don't know what most or all of that means," then you're in the right place. I've structured my explanation of precipitated withdrawal around three simple questions: (1) What is a receptor? (2) How do receptors work? (3) How does precipitated withdrawal occur? First Things First: What Are Receptors? If you're a Millennial like me, then you might vaguely recall learning about receptors in high school biology. For today's purposes, a receptor is a protein spanning the cell membrane that binds a molecule (in this case, an opioid drug), which is known as the receptor's ligand. Receptors are highly specific for their ligands, which can either be activating or inhibiting. Binding of activating ligands (known as agonists) leads to changes within the cell that can contribute to a variety of downstream outcomes, such as: A nerve cell (neuron) releasing a feel-good neurotransmitter like dopamine or an inhibiting neurotransmitter like GABA (gamma-amino butyric acid) A skeletal muscle cell contracting An immune cell such as a macrophage engulfing a bacterium and digesting it through oxidative reactions and other processes Right now, we're concerned with the opioid receptors that bind opioids / opiates like morphine, heroin, oxycodone, and fentanyl. They are found not just on nerve cells (neurons), but also in plentiful numbers in the GI tract.* *Because there are plentiful mu opioid receptors present on the cell membranes of the epithelial cells of the digestive tract, opioid intoxication causes severe constipation, and, conversely, opioid withdrawal causes nausea / vomiting. One of the most popular and effective over-the-counter antidiarrheal medications, Imodium (loperamide), is an opioid that doesn't cross the blood-brain barrier very efficiently (I've discussed the use of dangerously large quantities of Imodium as a "poor man's methadone" elsewhere). There are five types of opioid receptors, but the only one that we need to worry about to understand precipitated withdrawal is the mu opioid receptor. It is the "classical" opioid receptor that is responsible for euphoria, analgesia (pain reduction), sedation, and respiratory and heart rate depression. When opioids are taken regularly for weeks or months, it's changes to the mu opioid receptors that lead to tolerance and addiction. So, the picture so far is not terribly complicated. On the surface of some cells are the mu opioid receptors, protein structures that bind opioid drugs, which leads to the release of the feel-good neurotransmitter dopamine (as well as other effects in the brain and elsewhere in the body, including the GI tract). Generic model of receptor action from Principles of Biology. A ligand, in our example an opioid drug, binds to the extracellular domain of a receptor located in the cell membrane, which activates the receptor and triggers an intracellular response. After a time, the ligand dissociates from the receptor, which is then reset and can potentially be activated again. A given cell will have many types of receptors present in its membrane. The cellular response triggered by ligand binding is mediated by second-messenger molecules that are shared by different receptor types, so the response of the cell depends on the net stimulation / inhibition occurring at all of the different receptor types at a given moment. Okay, we come to a Choose Your Own Adventure juncture. If you're up for a more detailed discussion of mu opioid receptor dynamics, as well as a brief consideration of why we have these receptors in our brains and bodies, read the rest of this section. If you want to nope out, just skip ahead to "How Do Receptors Work?" below. A more realistic and detailed schematic of mu opioid receptor dynamics from a research publication. Unless you've got a solid foundation in cell bio or you're feeling particularly masochistic, don't worry about the details depicted; just try to absorb the overarching concepts. Here, we can see two nerve cells communicating at a synapse. Opioids bind to the extracellular domain of mu opioid receptors present on the presynaptic nerve cell, which leads to the activation of a molecular complex with three subunits (α, β, and γ) that is linked to the intracellular domain of the receptor, whose activation occurs by phosphorylation of guanosine diphosphate (GDP) to guanosine triphosphate (GTP); the activated complex then effects the intracellular response to ligand binding by inhibiting a calcium channel. The resulting decrease in influx of positively charged calcium ions into the presynaptic cell inhibits the release of glutamate, an excitatory neurotransmitter. Consequently, less glutamate diffuses across the synapse to the postsynaptic membrane, where it binds to and activates sodium (Na+) and Calcium (Ca++) channels; because activation of these channels inhibits the postsynaptic cell, the decreased activation of these channels that results from opioid receptor activation in the presynaptic cell membrane activates the postsynaptic cell. This postsynaptic cell activation, in turn, can eventually lead to the release of dopamine in the midbrain pleasure centers, for example. It's a complicated picture incorporating many inverse activation / inhibition effects, but the overall picture is: Opioid drugs bind to and activate mu opioid receptors in the presynaptic cell membrane --> a three-component molecular complex associated with the intracellular domain of the mu opioid receptors is activated by phosphorylation of GDP to GTP --> Calcium ion channels in the presynaptic cell membrane are inhibited --> Less glutamate is released into the synapse --> Decrease in stimulation of the sodium (Na+) and calcium (Ca++) ion channels in the postsynaptic cell membrane --> Activation of the postsynaptic cell, which produces effects such as release of the euphoria-inducing neurotransmitter dopamine in the midbrain pleasure centers Molecular and cellular biology are complex and computational. If you've got a good eye for detail, you'll see that there is already a complicating wrinkle in that mu opioid receptors are also found in the post-synaptic cell membrane, where they exert a different, balancing effect mediated by other types of ion channels. As I tell my students, science hinges on two things: observation and asking the right questions. Some of you might be wondering why the human brain conveniently manufactures proteins to bind opioid drugs, in which case, bravo - you've made your science teachers proud. In 2024, you've probably heard of endorphins, those feel-good chemicals released by exercise and other, um, activities. Well, "endorphin" is actually a portmanteau of endogenous (meaning made by the body) and morphine. It turns out that we have receptors that bind (exogenous) opioid drugs because our body manufactures similar chemicals that block pain and have feel-good properties. Maybe now you're wondering why plants make these chemicals (in other words, do plants get high?). The answer is that they make similar chemicals for different reasons (for example, to aid in defense against insects, communication between cells, or because they play a role in cellular metabolism). All eukaryotes - species such as plants and animals that have nuclei in their cells - manufacture similar families of proteins because much of their genetic code is shared due to common ancestry; evolution always repurposes existing proteins rather than creating novel protein structures, which would be a tremendous waste of metabolic energy. What we see over the long history of humans and psychoactive plants is that the two have coevolved (evolved together). I touched on this fascinating concept in my discussion of the evolutionary biology of addiction, and I plan to dedicate an entire post to it eventually. How Do Receptors Work? A simple way to conceptualize receptor dynamics is that receptors operate like light switches. Ligands that activate receptors are known as agonists. When an agonist binds to its receptor, the receptor is switched on, and some intracellular response is triggered. In the case of the mu opioid receptors discussed above, the binding of an opioid drug to the receptor leads to phosphorylation of GDP to GTP, which activates a molecular complex associated with the intracellular domain of the receptor. This, in turn, opens ion channels that lead to other downstream effects (for example, the release of the pleasure-inducing neurotransmitter dopamine within the midbrain pleasure centers). After an agonist binds to its receptor and the intracellular response is triggered, the ligand eventually dissociates, which leads to the receptor switch being flicked back to the "off" position. There are also ligands that bind to the receptor and lock it in the off configuration. Such inhibitors are known as antagonists. For opioid receptors, naloxone (Narcan) and naltrexone are important examples of antagonists. As long as the antagonist is bound to the receptor, no activating intracellular cascade can be initiated. As is often the case with biology - which a brilliant mentor of mine referred to as the "science of exceptions" - the situation is more complicated than a binary, 0 or 1, on or off response. In addition to full agonists and antagonists, there are also partial agonists. Because quantum effects come into play at the level of receptor dynamics, we must remember that events are often based on probability rather than certainty. When a partial agonist binds to a receptor, there is a chance that it will be activated, in which case the relevant intracellular chains of events will be triggered. However, unlike when full agonists bind, when partial agonists bind to their receptors, it is not always the case that the receptor is activated; sometimes there is no response. Depending on the receptor and the ligand, there might be a 0.2 (20%), 0.5 (50%), or 0.9 (90%) chance that the receptor will be activated, for example (see graph below). Graph from NAABT.org that shows the level of mu opioid receptor stimulation / opioid effect provided by antagonists, partial agonists, and full agonists. Concentration increases logarithmically from left to right along the horizontal (x-axis); opioid effect, which is proportional to degree of receptor stimulation, increases from bottom to top along the y-axis (vertical). An antagonist locks the receptor in the "off" configuration, so no opioid receptor stimulation occurs while the antagonist is bound (because no agonist can bind to trigger stimulation). Whereas opioid effect increases proportionally to dose in an indefinite manner with full agonists, we see a ceiling effect with partial agonists, which means that, past a certain point, further increases in dose will not result in more opioid receptor stimulation (the dosage at which this occurs, as well as the corresponding level of opioid receptor stimulation / opioid effect, is unique to each partial agonist and depends on the probability that its binding leads to receptor activation, which can be any value between 0 [0%; antagonist] to 1 [100%; full agonist], not including 0 and 1 themselves). Another way to summarize these receptor dynamics is through the analogy of a traffic light: A full agonist is the green light, an antagonist is the red light, and a partial agonist is the yellow light in between. Buprenorphine is one example of a partial agonist whose unique receptor dynamics make it suitable for opioid maintenance therapy. There is a ceiling effect that manifests with buprenorphine and other partial agonists. At some drug dose / blood concentration, all of the available opioid receptors are bound; the level of mu opioid receptor stimulation is maxed out, and further increasing the blood concentration of buprenorphine will have no effect. This ceiling effect allows buprenorphine users to stabilize their mu opioid receptor stimulation at a level of receptor stimulation / opioid effect that is less than that provided by full agonists like morphine / heroin, oxycodone, and fentanyl. This level of stimulation is sufficient to prevent most withdrawal symptoms, but not high enough to lead to the full-fledged opioid intoxication that addicts become accustomed to. Furthermore, because buprenorphine clings very tightly to the mu opioid receptor (see discussion of affinity below), it prevents other full-agonist opioids from binding and causing greater intoxication and / or overdose. For all of these reasons, buprenorphine is the ideal opioid maintenance treatment. As I have argued elsewhere, it has rendered methadone almost clinically obsolete (more on that here). Some agonists and antagonists cling to their receptors more tightly than others. We use receptor affinity to describe how tightly a ligand binds to its receptor, which depends on both the rate of association and dissociation from the receptor. There is a parameter called the dissociation constant, Km, which we use to describe affinity; the lower the Km, the higher the affinity. Consider, for example, a situation of opioid overdose, in which too many of the opioid receptors are turned on. In this scenario, we need to bind antagonists (naloxone) to as many receptors as possible to make sure that the agonist drug molecules don't bind to and activate the remaining ligand-free receptors. If we put enough of the antagonist into the patient's blood, we might also be able to push whatever opioid drug the patient has taken off of some of the receptors, thereby decreasing the extent of opioid receptor stimulation and opioid effect, which increases breathing rate, restores consciousness, and so on. If the opioid that was ingested binds to the mu opioid receptor with very high affinity, however, we might not be able to knock it off the receptors with the antagonists at our disposal.* *Again, naloxone is the opioid antagonist of choice for overdoses. It is called Narcan and is available in injection and intranasal formulations. I have saved at least two lives by administering Narcan. I have had my own life saved at least three times in this manner (I guess I'm running a deficit, now that I think about it). In my opinion, all U.S. adults should be trained in Narcan use and keep it in their car, purse, desk, or wherever. You might not know that a loved one is an addict until they are overdosing, and in this scenario, Narcan could keep them around. With very few exceptions, administration of Narcan will not hurt the person if it turns out that they are not overdosing on opioids. One of the reasons that fentanyl overdose kills so many people is that it has a very high binding affinity (see graph below). Graph from a research paper on mu (μ) opioid receptor binding affinities of various opiates / opioids. You will see many parameters, including Km and Ki, used to quantify affinity. In this example, logarithmic dose increases along the x-axis (horizontal) from left to right, and % receptor binding increases from bottom to top along the y-axis (vertical). The curves that are left-shifted indicate that these drugs have relatively high receptor affinities; relative to other chemicals with right-shifted curves, they have a higher percentage of bound drug at a lower drug concentration. We can see that sufentanil has one of the highest binding affinities, whereas tramadol, a very weak mu-opioid receptor stimulator that also acts as a serotonin-norepinephrine reuptake inhibitor (SNRI), has the most right-shifted curve, representing the lowest receptor affinity. Many variables, including molecular composition, GI absorption, and ability to cross the blood-brain barrier, influence how much of a substance is necessary to cause opioid effects. In general, the higher the affinity, the lower the drug dose necessary because the receptors will be bound tightly and efficiently even when the drug concentration isn't very high. Thus, fentanyl and its analogs are active at doses measured in millionths of a gram (micrograms), whereas doses of tramadol require 50 to 100 thousandths of a gram (milligrams), equivalent to 0.05 to 0.1 grams, to exert any appreciable opioid effect. Antagonists, too, have binding affinities. Arrival of the Cenobites: What Is Withdrawal? To understand the nature of opioid withdrawal, we've got to get a handle on how the body adapts to chronic opioid intake. Opioids are powerful depressants with significant effects on nearly every tissue in the body. For example, ingesting opioids leads to the release of dopamine in the brain, which induces euphoria; decreases breathing rate and heart rate; and slows gastrointestinal mobility (the speed at which food is broken down, absorbed, and moved through the digestive tract). The body's natural response to regular intake of any exogenous substance is to counteract the effects of that substance. Thus, the body attempts to maintain a state of balance, known as homeostasis, by upregulating substances and triggering physiologic mechanisms that have opposing effects. In the case of opioids, one of these counteracting substances is a neurotransmitter known as glutamate, which - as I teach my AP Bio students - is sort of like the gas pedal for the central nervous system. Upregulation of glutamate partially opposes the depressant effects of opioids, so - when an addict continues to take opioids for a long period of time - the decreases in heart rate and respiratory rate caused by opioids are less severe. This phenomenon of decreased physiological response to a drug that occurs with chronic intake is known as tolerance. It's not just heart rate and respiratory rate that are balanced out with time. The euphoria caused by opioids decreases as well. In fact, one of the nasty little biological quirks involved in addiction is that tolerance to the subjective, psychological effects of the drug, such as euphoria, builds more quickly than tolerance to the objective, physiological effects, such as slowed respiratory and heart rates - putting the user in danger of overdose as he or she chases that euphoric high by taking doses of the drug that cause dangerous depression of the heart and respiratory rates. With long-term ingestion of a substance, the body can also downregulate and desensitize the receptor system that mediates the drug's effects. For example, it can decrease the number of receptors for the drug present on the cell membrane or render those receptors less responsive to agonists when they bind. Addiction is the state in which the body has come to depend on a certain level of receptor stimulation, without which it enters withdrawal. Withdrawal occurs when the addicted person stops ingesting the dose of the substance that their body has come to depend upon, without which it can no longer function normally. One way to conceptualize withdrawal symptoms is to think of them as the inverses or opposites of the effects caused by ingestion of that drug. So, because opioids have anticholinergic effects that dry out mucous membranes, during opioid withdrawal, the mucous membranes become overly wet / active - leading to teary eyes (lacrimation), runny nose, and increased saliva production. Likewise, opioids have a depressant / sedative effect on the central nervous system (CNS), meaning that they decrease its responses to stimuli and dampen its overall speed and level of activity. Because of this, the CNS becomes hyperactive during opioid withdrawal, leading to dilated pupils, oversensitive ears and eyes, racing thoughts, and insomnia. This depression of the CNS due to opioid ingestion also leads to decreased respiratory and heart rates. Thus, during withdrawal, heart rate and breathing rate both increase (see summary table below). Table of opioid intoxication symptoms versus opioid withdrawal symptoms. Withdrawal symptoms can be thought of as the inverses or opposites of the corresponding symptoms of intoxication. They are caused by a sudden decrease in intake of the drug that the person is addicted to; because that person's body has activated compensatory mechanisms to counterbalance the effects of the drug, his or her physiology is out of balance without it. Now, opioid withdrawal typically occurs gradually after intake of the substance to which the person is addicted decreases or stops. The precise timeline for withdrawal onset is correlated with the half-life of the drug of choice - meaning how long the effects of that drug last (a shorter half-life means that they disappear more quickly). So, for a short-acting opioid such as fentanyl, withdrawal starts within a few hours and peaks within 24 hours. For intermediate-half-life drugs such as morphine and heroin, withdrawal starts after 12 to 14 hours and peaks around 48 to 72 hours. For long-acting opioids such as buprenorphine and methadone, withdrawal begins after 24-48 hours and can take 7 to 10 days or more to peak. A few hours might not seem like much time for the body to adapt to such a dramatic physiologic change. Indeed, it takes six to eight weeks of abstinence for new receptor creation to begin to reset the affected receptor systems, at which point a return to physiologic baseline ("normal") occurs. However, even if the body is only given a few hours to self-regulate in response to decreased intake or cessation of a substance, it can activate short-term, balancing responses that significantly mitigate the symptoms of withdrawal. We arrive at the central issue of this article: Precipitated withdrawal. Precipitated withdrawal occurs when withdrawal is suddenly initiated by decreasing the level of opioid receptor stimulation via administration of an antagonist, which locks the mu opioid receptors in their "off" configuration. As discussed above, depending on the receptor affinity of the antagonist relative to the receptor affinity of the opioid drug that has been ingested, the antagonist might even knock some of the opioid drug off of the receptors that its bound to and activating. This results in a sudden, full-intensity withdrawal syndrome that the body has had no time to adapt to, leading to physiologic shock that further amplifies the withdrawal symptoms. Precipitated withdrawal is a waking nightmare; it is one of the worst things that can happen to an addicted body. If too much naloxone (Narcan) is administered during an overdose, precipitated withdrawal is triggered.* *I have experienced this myself; zero stars on Yelp - absolutely do not recommend. There are some kinds of pain that take a permanent chunk out of your soul. Crucially, precipitated withdrawal can also occur when a partial agonist is given to someone dependent on a high enough dose of a full agonist. If you refer back to the first image in the "How Do Receptors Work?" section, which shows opioid effect on the y-axis versus logarithmic dose on the x-axis, you see that - beyond a certain dose, at which the ceiling effect of the partial agonist is achieved - no more opioid effect is generated by further increases in dose. Now, if someone is dependent on a dose of a full agonist that is below or equal to the equivalent partial agonist dose at which the ceiling effect of the partial agonist comes into play, everything is kosher - when the ceiling dose of the partial agonist is administered, there will be enough opioid receptor stimulation to keep the person's body happy. Beyond that dose, however, precipitated withdrawal occurs because the partial agonist cannot provide enough opioid receptor stimulation to keep the body at the level that it is used to (and thus out of withdrawal). The severity of the precipitated withdrawal symptoms will be proportional to the gap between the two curves (in other words, the difference between the level of opioid receptor stimulation / opioid effect that the addicted person's body is used to versus the ceiling level of receptor stimulation / opioid effect that the partial agonist is able to provide). This comes into play with the two drugs used for opioid maintenance therapy in the U.S., which are methadone and buprenorphine. Methadone is a full agonist, whereas buprenorphine is a partial agonist. The ceiling effect of buprenorphine, which most patients reach at a daily dose of 8 to 16 milligrams of sublingual buprenorphine, is equivalent to the opioid stimulation provided by about 25 to 40 milligrams of (oral) methadone. For this reason, most clinics in the U.S. traditionally recommended that methadone patients decrease their dose to 25 to 40 milligrams before switching to buprenorphine. However, there are innovative, rapid transition protocols that do not require this difficult-to-achieve reduction, which I discuss in a forthcoming post. There are many online opioid dosage converters, which are handy if you're switching from one opioid to another and you want to ensure maintenance of the same level of opioid receptor stimulation so that your body experiences neither intoxication nor withdrawal. This one from the Oregon Pain Guidance site uses morphine equivalents to convert between substances. Keep in mind that there is significant variability in these converters; part of this is because some of them focus on pain reduction, whereas others use respiratory depression or other parameters to gauge equivalence. Pay attention to route of administration (how the drug gets into your body), as well. This is particularly important for drugs such as morphine, which require much larger oral dosages compared to injected or sublingual doses because they are subject to extensive first-pass metabolism by the liver. Whenever you switch from one opioid to another, you will benefit from a phenomenon known as incomplete cross-tolerance, which means that you will likely need 5% to 15% less of the new opioid than these equivalent dosage calculators predict (unless you are using one of the calculators that builds incomplete cross-tolerance into its model). Pain management protocols constructively use this effect by periodically rotating patients from one opioid agent to another, which slows the development of tolerance and the need for dose increases. Congratulations! (No Sarcasm Intended, For Once) If you've made it this far and understood 50 to 75 percent of what you've read, then you're well on your way to a solid understanding of opioid receptor dynamics, which is crucial to making decisions about pain management and opioid addiction treatment as well as interpreting the exciting research that is being undertaken at the moment. Speaking of that research, my editorial calendar - which is currently crowded by 104 planned pieces, which I will hopefully churn out more quickly now that school is out for the summer - includes a piece on the simultaneous use of agonists and antagonists. While logic seems to dictate that either the agonist effects will outweigh the antagonist effects or vice-versa, in reality, the receptor dynamics are much more complex and interesting. In fact, it turns out that such an agonist / antagonist pairing might allow effective treatment of pain without the buildup of tolerance even when the opioid is used for extended periods. I also plan to write about the delta and kappa opioid receptors, which have completely different effects compared to the mu opioid receptors, some of which counteract the mu opioid receptor's effects. For this and other reasons, these receptors are promising therapeutic targets. In addition, the very next science-y post that I have planned discusses novel, rapid protocols for transition from methadone to buprenorphine. Community Updates I'll be happy to answer any questions about specific clinical situations below (keeping in mind that, although I finished my first year of medical school, I'm far from a doctor, and you should use any feedback that I provide to inform your discussions with the appropriate clinical professionals). Please follow me on Instagram. Although there's not much activity over there yet, at the moment, it's the easiest way to communicate aside from the Contact form here. We're currently nearing 90 days since the blog went online, and the number of views that I'm getting is beyond what I expected for the first 9-12 months. This is wonderful, of course, but it also means that I've had to adjust my plan for building out this Concrete Confessional project. At the moment, I'm postponing the launch of our Entropy, Inc., Discord server. Once again, thank you for reading! Your interest and support mean more to me than you could know. I'm still in the middle of an Arduous March of a methadone taper, which I hope to finish by the end of the summer, and having this project to occupy myself and assist others is saving me.