In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

“People who feel good about themselves don’t do things that endanger their bodies…. Traumatized people feel agitated, restless, tight in the chest. You hate the way you feel. You take drugs in order to stabilize your body.”

In this book I argue that there is no “war on drugs.” One cannot make war on inanimate objects, only on human beings. And the people the war is mostly waged upon are those who have been the most neglected and oppressed in childhood, for, according to all the science, all the epidemiological data, all the experience, they are the most likely to succumb to substance addiction later in life. In our civilized times we are punishing and tormenting people for having suffered trauma.

How do societies move to heal the multigenerational trauma that drives the misery of many Native communities? What can be done to undo the dynamics our past has dictated? Some may balk at such inquiry, fearing the discomfort that comes with guilt. In truth, this is not a matter of communal guilt, but of communal responsibility. It is not about the past. It is about the present.

if we identify with a group of any dimension narrower than all humanity, there must then be others who, by definition, do not belong and to whom, we may believe at least unconsciously, we are superior. That superiority makes us feel entitled to judge, and to remain indifferent.

The false separation between mental health issues, on the one hand, and addictions, on the other—practiced in many institutions and treatment facilities—must be ended. They are inseparable: often the latter are self-medications for the former. Both originating in trauma, they must be addressed simultaneously and together.

They are regarded harshly even by people who make compassion their careers.”

Much as I want to accept them, at least in principle, some days I find myself full of disapproval and judgment, rejecting them and wanting them to be other than who they are. That contradiction originates with me, not with my patients. It’s my problem—except that, given the obvious power imbalance between us, it’s all too easy for me to make it their problem.

My patients’ addictions make every medical treatment encounter a challenge. Where else do you find people in such poor health and yet so averse to taking care of themselves or even to allowing others to take care of them?

I could not rescue people from their pain and sadness. All I could offer was to walk beside them as a fellow human being, a kindred spirit.

people jeopardize their lives for the sake of making the moment livable. Nothing sways them from the habit—not illness, not the sacrifice of love and relationship, not the loss of all earthly goods, not the crushing of their dignity, not the fear of dying. The drive is that relentless.

The moments of reprieve at the Portland come not when we aim for dramatic achievements—helping someone kick addiction or curing a disease—but when clients allow us to reach them, when they permit even a slight opening in the hard, prickly shells they’ve built to protect themselves. For that to happen, they must first sense our commitment to accepting them for who they are. That is the essence of harm reduction, but it’s also the essence of any healing or nurturing relationship.

Her life could have been so different, I thought. I try not to have such thoughts in my day-to-day work … I try to take people as they are at any moment and support them that way. Not judge them or think of an alternative reality they could have, because we could all have alternative realities. I don’t focus on my own ‘What ifs’ much, so I try not to focus on other people’s.

Remy’s conversation is always an exercise in circumlocution. He launches into tirades on any topic, not recalling what he already said or where he was intending to go. He meanders, becoming snagged on the brambles of one thought, getting lost in the bushes of the next.

He was astonished the first day he took this medication. “I’m calm,” he reported. “My mind isn’t going off like a machine gun. I’m thinking instead of just spinning. It’s not fucking going sixty different miles an hour, in twenty different directions. I’m going, ‘Hang on, I’ve gotta do one thing at a time here. Just let’s slow down here.”

“We all have moments in our lives that we wish we could relive … and do over again,” I say. “But for you, this must be a big one.”

How does the addict know she has impaired control? Because she doesn’t stop the behaviour in spite of its ill effects. She makes promises to herself or others to quit, but despite pain, peril and promises, she keeps relapsing.

Addiction has biological, chemical, neurological, psychological, medical, emotional, social, political, economic and spiritual underpinnings—and perhaps others I haven’t thought about. To get anywhere near a complete picture we must keep shaking the kaleidoscope to see what other patterns emerge.

Because the addiction process is too multifaceted to be understood within any limited framework, my definition of addiction made no mention of “disease.” Viewing addiction as an illness, either acquired or inherited, narrows it down to a medical issue.

“The high rates of narcotic use and addiction there were truly unlike anything prior in the American experience,” the researchers concluded. “Equally dramatic was the surprisingly high remission rate after return to the United States.”5 These results suggested that the addiction did not arise from the heroin itself but from the needs of the men who used the drug. Otherwise, most of them would have remained addicts.

Drugs, in short, do not make anyone into an addict, any more than food makes a person into a compulsive eater. There has to be a pre-existing vulnerability. There also has to be significant stress, as on these Vietnam soldiers—but, like drugs, external stressors by themselves, no matter how severe, are not enough.

In the brains of cocaine addicts the age-related expansion of white matter is absent.3 Functionally, this means a loss of learning capacity—a diminished ability to make new choices, acquire new information and adapt to new circumstances. It gets worse. Other studies have shown that grey matter density, too, is reduced in the cerebral cortex of cocaine addicts—that is, they have smaller or fewer nerve cells than normal. A diminished volume of grey matter has also been shown in heroin addicts and alcoholics, and this reduction in brain size is correlated with the years of use: the longer the person has been addicted, the greater the loss of volume.4 In the part of the cerebral cortex responsible for regulating emotional impulses and for making rational decisions, addicted brains have reduced activity.

Stimulant drugs like cocaine and methamphetamine (crystal meth) exert their effect by making more dopamine available to cells that are activated by this brain chemical. Because dopamine is important for motivation, incentive and energy, a diminished number of receptors will reduce the addict’s stamina and his incentive and drive for normal activities when not using the drug. It’s a vicious cycle: more cocaine use leads to more loss of dopamine receptors. The fewer receptors, the more the addict needs to supply his brain with an artificial chemical to make up for the lack.

Why does chronic self-administration of cocaine reduce the density of dopamine receptors? It’s a simple matter of brain economics. The brain is accustomed to a certain level of dopamine activity. If it is flooded with artificially high dopamine levels, it seeks to restore the equilibrium by reducing the number of receptors where the dopamine can act. This mechanism helps to explain the phenomenon of tolerance, by which the user has to inject, ingest or inhale higher and higher doses of a substance to get the same effect as before.

If deprived of the drug, the user goes into withdrawal partly because the diminished number of receptors can no longer generate the required normal dopamine activity: hence the irritability, depressed mood, alienation and extreme fatigue of the stimulant addict without his drug: this is the physical dependence state discussed in Chapter 11. It can take...

Released from a neuron, or nerve cell, a neurotransmitter such as dopamine “floats” across the synaptic space and attaches to receptors on a second neuron. Having carried its message to the target nerve cell, the molecule then falls back into the synaptic cleft, and from there it is taken back up into the originating neuron for later reuse; hence, the term reuptake. The greater the reuptake, the less neurotransmitter remains active between the neurons.

Unlike Prozac, cocaine is not selective: it also inhibits the reuptake of other messenger molecules, including serotonin. By contrast, nicotine directly triggers dopamine release from cells into the synaptic space. Crystal meth both releases dopamine, like nicotine, and blocks its reuptake, like cocaine. The power of crystal meth to rapidly multiply dopamine levels is responsible for its intense euphoric appeal.

These stimulants directly increase dopamine levels, but the action of some chemicals on dopamine is indirect. Alcohol, for example, reduces the inhibition of dopamine-releasing cells. Narcotics like morphine act on natural opiate receptors on cell surfaces to trigger dopamine discharge.

addiction’s central dilemma: if recovery is to occur, the brain, the impaired organ of decision making, needs to initiate its own healing process. An altered and dysfunctional brain must decide that it wants to overcome its own dysfunction: to revert to normal—or, perhaps, become normal for the very first time.

Attachment is the drive for physical and emotional closeness with other people. It ensures infant survival by bonding infant to mother and mother to infant. Throughout life the attachment drive impels us to seek relationships and companionship, maintains family connections and helps build community.

Opiates help make some pain bearable. It has been suggested, for example, that high levels of endorphins help toddlers endure the many bumps and minor bruises they sustain on their rambunctious adventures. It’s not that a toddler’s injuries don’t cause pain; they do. But partly because of endorphins, the pain isn’t enough to discourage him. Without a high level of endorphins he might even want to stop his explorations of the world, so necessary for learning and development.10 A child who complains bitterly of the slightest hurt and is often accused of being a “crybaby” is probably low on endorphins and is likely to be less adventurous than his peers.

A child can also feel emotional distress when their parent is physically present but emotionally unavailable. Even adults know that kind of pain when someone important to us is bodily present but psychologically absent. This is the state the seminal researcher and psychologist Allan Schore has called “proximal separation.”

research now strongly suggests that the existence of relatively few dopamine receptors to begin with may be one of the biological bases of addictive behaviours.4 When our natural incentive-motivation system is impaired, addiction is one of the likely consequences.

Without the requisite stimulation during the critical period allotted by Nature for the visual system’s development, the child’s brain would never have received the information that being able to see is needed for survival. Irreversible blindness would be the result. What is true for vision is also true for the dopamine circuits of incentive-motivation and the opioid circuitry of attachment-reward, as well as for the regulatory centres in the prefrontal cortex, such as the orbitofrontal cortex—in

The importance of this point cannot be overstated: emotional nurturance is an absolute requirement for healthy neurobiological brain development.

“Human connections create neuronal connections”—in the succinct phrase of child psychiatrist Daniel Siegel, a founding member of UCLA’s Center for Culture, Brain and Development.8 As we will soon see, this is particularly so for the brain systems involved in addiction.

The child needs to be in an attachment relationship with at least one reliably available, protective, psychologically presen...

Attachment, as we’ve already learned, is the drive to pursue and preserve closeness and contact with others; an attachment relationship exists when that state has been achieved. It’s an instinctual drive programmed into the mammalian brain, owing to the absolute helplessness and dependency of infant mammals—particularly infant humans. Without attachment he cannot survive; without safe, secure and nonstressed attachment, his brain cannot develop opti...

Since the brain governs mood, emotional self-control and social behaviour, we can expect that the neurological consequences of adverse experiences will lead to deficits in the personal and social lives of people who suffer them in childhood, including, Dr. Joseph continues, “a reduced ability to anticipate consequences or to inhibit irrelevant or inappropriate, self-destructive behaviors.”

The three dominant brain systems in addiction—the opioid attachment-reward system, the dopamine-based incentive-motivation apparatus and the self-regulation areas of the prefrontal cortex—are all exquisitely fine-tuned by the environment.

Another effect of early maternal deprivation appears to be a permanent decrease in the production of oxytocin,fn1 which, as mentioned in Chapter 14, is one of our love chemicals.9 It is critical to our experience of loving attachments and even to maintaining committed relationships. People who have difficulty forming intimate relationships are at risk for addiction; they may turn to drugs as “social lubricants.”

Not only can early childhood experience lead to a dearth of “good” brain chemicals; it can also result in a dangerous overload of others. Maternal deprivation and other types of adversity during infancy and childhood result in chronically high levels of the stress hormone cortisol. In addition to damaging the midbrain dopamine system, excess cortisol shrinks important brain centres such as the hippocampus—a

situations or activities that for the average person are likely to bring satisfaction are undervalued because, in the addict’s life, they have not been rewarding—for example, intimate connections with family.

Some people may think that addicts invent or exaggerate their sad stories to earn sympathy or to excuse their habits. In my experience, the opposite is the case. As a rule, they tell their life histories reluctantly, only when asked and only after trust has been established—a process that may take months, even years.

no matter how valuable or worthy an activity may be, one can relate to it in an addicted way.

definition of addiction: any repeated behaviour, substance-related or not, in which a person feels compelled to persist, regardless of its negative impact on his life and the lives of others.

no addiction in the history of the world ever alleviated more suffering than it ended up causing.

There is no such thing as a good addiction. Everything a person can do is better done if there is no addictive attachment that pollutes it.

Attunement is, literally, being “in tune” with someone else’s emotional states. It’s not a question of parental love but of the parent’s ability to be present emotionally in such a way that the infant or child feels understood, accepted and mirrored. Attunement is the real language of love, the conduit by which a pre-verbal child can realize that she is loved.

Even our 24/7 self-exposure to noise, emails, cell phones, TV, Internet chats, media outlets, music downloads, videogames and non-stop internal and external chatter cannot succeed in drowning out the fearful voices within.

Of all the groups affected by the forces of dislocation none have been worse hit than minority populations, such as the Australian Aborigines and North American Native peoples mentioned by Dr. Dupont, and the descendants of black slaves brought to North America. Among the latter, people were separated not only from their places of origin, their cultures and their communities, but often also from their immediate families.