In the Realm of Hungry Ghosts

Detective Paul Gillespie works in Canada, pursuing sex abusers who prey on children. He describes the worst things he sees as the numbed, near-catatonic children who have accepted that their abuse is their life.

Those children often grow up to become criminals. Cops treat them with more contempt than they do the average citizen. Maté describes the addicts as the front line soldiers in the War on Drugs. He gives several of their brief biographies, which show them as tragic figures. 

Maté asks whether the aims of the War on Drugs are achievable and valid. Based on his research and his opinions, the answer is no, and the war is unjustifiable. Money goes toward outcomes that never get realized. Vivien Stern, a fellow at the prison research studies center in London, agrees, saying that “The U.S. pursues the war on drugs with an ignorant fanaticism” (290).

The War on Drugs has not curbed drug use, the resulting prison incarcerations, or the production of the plants used to make the drugs. Further, the black market profits are astronomical. As long as there is a demand for illegal drugs, there will be producers willing to supply them. And because the demand is so high, the sellers can charge whatever they like. Much of the crime surrounding various drug empires is a result of how much money there is to gain on the black market; the desire to control territory is great.

Exacerbating the situation, the US aggressively promotes its views on addiction. Given America’s superpower status, many other countries feel compelled to go along with American drug policy. 

The War on Drugs assumes that addiction is a choice. Therefore, punishments act as deterrence.

Steve is an addict who spent 18 years in prison. Steve does not feel free because he is still in thrall to addictive urges. He also lives his life under what he sees as the control of others. He sees Maté because he must drink methadone under supervision, which he resents. He says his life does not feel different than his life in prison, because he is always told what to do.

Maté contrasts freedom in society with internal, emotional freedom. Someone not incarcerated is free, according to society’s definition. In the absence of free will and choice, however, that person is not free.

Research shows that OCD shares some features with addiction. Parts of the engine lock together in the brain. But everyone behaves according to automatic brain systems. When people act out of a behavioral trigger, they are not acting freely. According to one Dr. Schwarz, the “mind itself is a process” (304). Some people will have more freedom than others. “Unlike the addict, the person with OCD does not anticipate his compulsion with any pleasure” (306). The choice to get treatment exists, but Maté believes that it is naïve to demand that people make that choice. There is no way to gauge the weight of someone’s emotional suffering, so rote prescriptions can’t exist in every case.

Maté then asks, how does the experience of choice arise in a brain? The time between input and output, or impulse and action, can be so quick that they appear to happen simultaneously. The cortex can only interrupt in a brief window of less than half a second. Addicts experience an amplified version of this because their circuitry remains impaired by drugs.

Later in the chapter, PHS discharges an addict named Terence involuntary for theft. He has alienated every caregiver who has ever helped him, but Maté does not believe that Terence was making a choice at the moment of the theft. He experienced “an inability not to, given the opportunity” (311).

Maté views one of the central questions facing addiction physicians to be that of how to create the circumstances that afford the possibility of freedom. 

Redemption, for Maté, is not synonymous with total abstinence from drugs. He uses Chapter 27 to describe what he calls a humane stance towards addicts and policy. The current system should not only improve but transform, because the system has no place for compassion.

In order to truly help addicts, medical professionals, and all members of society, must keep the question in mind: “The fundamental question is whether or not we recognize these people as human beings who are legitimately part of the social fabric and who deserve compassion and respect” (315). One avenue Maté believes is worth exploring is the combination of  research on emotional and mental states with the neurology of addiction. It is unwise to try to change behaviors without understanding how the behaviors arise. But in order to treat addiction effectively, physicians must relinquish their sense of superiority.

Addicts cannot love themselves while treated as outcasts. The War on Drugs creates more, unjustifiable stresses that exacerbate the very problem it ostensibly fights against.

Another avenue for change that Maté advocates is the decriminalization of drugs. Critics of decriminalization often treat it as interchangeable with legalization, but this is a false equivalency. People without severe pain will rarely seek out chemical dependency. If society can accept that addictive drug use is a response to pain, decriminalization carries less of a stigma, because stigmatizing an escape from suffering would be irrational.

Maté closes the chapter with a brief biography of Dr. William Stewart Halsted. He was a father of modern surgery, and addicted to morphine until the day he died. By today’s standards, he would be in jail. 

Maté discusses harm reduction in light of the fact that societal change may never come. There are challenges in how critics perceive harm reduction: Critics view it as admitting that there’s no cure for addicts, and of helping addicts to stay addicted.

The arguments against harm reduction rely on two claims: that harm reduction initiatives squander resources and coddle addicts. They ask, why should society try to reduce the amount of deaths for people who should be responsible for their own addictions? Given his view that addiction is a chronic disease, reliant on factors encoded in childhood, Maté asks whether people with lung cancer would receive the same treatment. He states that, “Harm reduction is as much an attitude and a way of being as it is a set of policies and methods” (336).

Maté views methadone clinics as a way for addicts to transfer their heroin dependence to a legal substance. Not all drugs have a legal correlate, however. For instance, cocaine does not have a legal equivalent to methadone, so users have to cease their usage in order to definitively avoid the legal consequences of taking cocaine.

Needle exchanges are another version of harm reduction; they do not pretend to cure the addiction, but offer a cleaner, less potentially harmful way of injecting drugs without contracting diseases through shared needle use.

Some addicts will not accept substitutes for their drug. In these cases, Maté advocates supervised injection sites such as the one offered by the North American Opiate Medication Initiative, or NAOMI. Vancouver is one of several pilot locations attempting trials of controlled heroin administration. While Maté finds the results encouraging, others, such as a White House spokesperson in the drug control agency, see NAOMI as “an inhumane medical experiment” (338).