The rush and the captured breath

Hail,
And before we start - a brief update on the progress of some characters from earlier posts.

Firstly - Mr Jarusnich, the heavily muscled and deeply uneasy ex-bodybuilder from Serbia. He had been doing well - reduced his methadone from 120 mg to 100mg, dealing with the pain, gradually adjusting to a life without being huge.
Then a few weeks ago there had been a relatively low-speed car accident, and one of his steroid-weakened ligaments (the medial collateral, the one you feel on the very outside of your knee) had been strained. By the time I saw him he was in agony, walking with a stick, scrabbling anywhere for oxycontin or morphine sulphate or heroin - and very very angry.
I didn't normally mind talking to Mr Jarusnich (six foot three and one hundred thirty kilos, he reminded me), but he was angry enough that day that I sent a few people away and we (the nurse and I) conducted our business with Mr Jarusnich in the large (and multiply doored) waiting room.

And the HIV positive man shooting up the morphine tablets? Out of prison, and "lost to followup": not collecting his dose, not answering his phone. I don't know if he's dead or alive - I got the notes down and he'd done this kind of thing before. I keep looking for his name on the patient list each day, but he hasn't booked in.

And the beautiful girl with the brains of a goat - and I don't know that I mentioned her before. Still angry we won't put her on methadone, still tolerating the milder and less "off your face" buprenorphine we give her.

Methadone, by the way, is basically a milder, less satisfying, but publically more tolerable and overall safer version of heroin - nineteen seventies Aerosmith were methadone, the Rolling Stones were pure smack. Father daughter purity balls - methadone, purdah - smack. Chris Claremont - methadone, Warren Ellis - smack.

Her doctor has her on a tightly controlled dose of diazepam - giving her three weeks on three 5 mg tablets, then a month on two and a half or something like this. In the interim she makes do with the handfuls she gets from her friends. She's been on the buprenorphine for three months, she's gained eight kilos - and I've just increased her dose. I have warned her that in three months she will be huge - but it's better than methadone and it's safer than smack.

And in between I've been thinking about drugs and love, about addiction and adulation, about maybe a new use for an old drug, even a new treatment for a very old sickness. And this idea isn't fully clear even to me, which is why after two days of on-and-off writing I don't know that I've got what I'm trying to say across at all. But here goes.

I've been trying for some time to understand what addiction is. I don't mean neurochemically, I mean what if feels like, what it means to the people who suffer from it, how it is experienced by them.

I think I'm doing this partly out of curiosity and partly out of the understanding that if I have to work for a number of months with something I fundamentally don't understand I am going to become either
a) spleen-spasmingly bored,
b) intellectually disaffected
or
c) cut snake crazy (that's what happened with immunology in second year).

And partly because it - addiction - is closer to a lot of us than we think. I have come to believe that I, you, virtually everybody reading this blog, some of us many times, have experienced full-blown addiction.

FIrst, a disclaimer. I know I have said before that my own experience with "things normally thought of as addictive" is limited.

I have never snorted stuff.

I have never injected anything into my own vein.

I have never smoked.

I had marijuana* twice in university and got headspins, I had pethidine and got disappointingly mundane hallucinations.

I have among my close friends one who has had heroin and one who has had cocaine, and when they describe this stuff to me it is as if they are discussing the year they spent among the Venusians, or their experience of sex with vegetables .

I have always thought there is no common ground between us.

But now I reckon I was wrong.

What does addiction actually feel like? As far as I can work out, when I'm talking to my clients, when you're addicted you think about the substance all the time. Thoughts of it come into your head - thoughts about how to get it, how good it is, how good it would be to have some right now.

And things change in your head - presumably neurons extend dendrites, connections are strengthened, things are learned and hardwired - things change so that other stuff becomes less important. You end up doing stuff, stuff that maybe harms yourself or your friends or your family, just to get a taste of the substance. You persist, as the textbooks say, in the face of overwhelming negative consequences - prison, poverty, a blood clot in the lung. You starve other things in your life - your social life, or your career, and you don't even watch as they die.

And when you try to cut down, it hurts. You do all the stuff - you distract yourself, you take deep breaths, you wait for the feeling to pass. But still you get sick, miserable, "lonely" as one man said. Often when you try to cut down the feeling gets so bad that you believe (probably truly) that the only thing that will ease the pain now is the substance. You end up going back, those late night relapses on the telephone when you are at your weakest, and it fucks you around again.

Some of this is familiar, to some extent, for all of us.

When I was thirteen I saw Jennifer Roume. She had black sloe eyes and black hair like Burmese silk, and skin like milk with honey in it. Her teeth - I can see them now if I close my eyes - were even and white and straight, and her lips were that dark bruised cherry red. And she wore the school uniform (a white button up blouse, navy skirt, white socks, black shoes) like nobody else and her hands and fingers were like - and she was, I'm sure you've worked out by now, impossibly beautiful.

I remmeber how I used to feel when I saw her. I remember the thump in the chest, the dry mouth, the pounding. They say beauty is 'heart stopping', or 'breath taking', and that's what you feel, that's what you experience. I remember how nothing else - my family, my friends - nothing came close (except, unsurprisingly, the writing of abyssmal poetry and sessions of futile gymwork and teen preening) to challenging the hold her picture had on my head.

I remember enduring her evident contempt, seeing her holding hands with Craig whatsisface and feeling everything turn to ice inside me. There's a reason they call it a crush, too. I still believe now that I would rather have acute pancreatitis or cholera or bilateral rib fractures than loneliness or jealousy.

I don't know if I was smart enough at the time to do the math, work out the ineluctable social mechanics of it, as fixed and unchanging as the movements of the stars. There is a reason those fairy stories about the beautiful princess marrying the orc are called fairy stories.

But I can honestly say I thought about her all the time.

And sometimes I wouldn't see her for a few weeks and I would be happier, things would go better, and then she'd turn up again, or she'd smile at me in math class, and bang. The heart kicking inside the ribs, the speechlessness, the rush and the captured breath. Back down to zero again. Sometimes my face would ache from grinning.

Now, I'm about the squillionth person to say love is an addiction. But a few nights ago I tried to put myself back there, back in that thirteen year old's head (and believe me, it's happened a lot of times since then), and I tried to imagine how hard it would have been for me to give up on Julie Roume, to go without.

And I was thinking - what would have helped? There were no patches. There was no teenage boy Roumeaholics Anonymous (but by God, there were enough of us to form one - hopeless adulation for that girl swept through the hetero male population of my school like a plague) where we could stand up and say "My names Bill Bloggs and I've been desperately in love with a girl who laughs at me for five years". I suppose for some of the other boys there was the methadone of other forms of release - my fidelity was as absolute as it was hopeless.

And then the other day I was reading about naltrexone (they call it Revia in the US). Naltrexone is an opiate antagonist, literally something that "struggles against opiates." It stops someone getting the rush from heroin. People on naltrexone can take remarkable amounts of opiates like heroin or morphine and get next to no effect at all (This can be good, like if you give something like naltrexone to a patient who has overdosed on heroin, or if you want to take something that will decrease the reward your body gets from injecting oxycontin. It can be bad, say, if you are the person who had just shot up and then some clown comes and ruins your two hundred dollar high, or if you have a naltrexone implant and you are crossing the street and get run over and they try to give you morphine for pain in hospital.).

You get it as tablets (one a day), an implant (in the skin of the belly, low and near the groin) or a once monthly injection (like a vaccination). It's not actually used that much over here, it works while it's in there but people often don't want it in any more. I have seen two people who have surgically removed their own implants.

So naltrexone - so far, so what. Naltrexone, unlike methadone or buprenorphine doesn't only work in opiate addiction. It has been used - with moderate success - in the treatment of gambling addiction. It seems to have some promise in the treatment of alcohol addiction. People are trialling it for nicotine addiction, pornography addiction (one of the more controversial ones), even the predominantly female "mall addictions" of shopping, eating and petty theft.

Now there are about a billion unchallenged assumptions in this line of thinking, which I don't have time to get to here. I am not at all saying that pornography addiction is an addiction in the same way that heroin is. I'm not even sure on the way we use the concept of addiction, I suspect we label a lot of people as unwell when in fact they've just made different choices to us. I don't think naltrexone should be put in the drinking water at schools - I am not saying there is any evidence at all that it would "work", as far as I know there isn't and it doesn't. And I know I'd rather live in a culture where Shakespeare's hundred and sixteenth sonnet and songs like "All I want is you" or "Desire" were written down instead of medicated away.

But it's an interesting idea. We may deny it, but we medicate rage and sorrow, fear and loneliness and boredom. If it worked, who would not want to fix a broken heart?

Anyway. Pure fantasy. But I did wonder the other night about that chubby, funny-speaking, unbearably lonely boy, me as a thirteen year old. I found myself seeing myself as if from a distance, small and clear down the wrong end of a telescope, and wondering whether naltrexone might have done something for (as well as to) thirteen year old me.

Whether if a tablet a day could have kept me speaking to my friends and family, stopped me trying harder and harder at something where the reason I couldn't succeed was because I had to try too hard, struggle to do what others found effortless - and what were the ethical responses to that?

At thirty nine I feel it would have been a bad idea to give naltrexone to a thirteen year old kid to stop a crush. But we do weirder things, we give other psychoactive drugs to children. And making a decision about someone else's medication, weighing up the side effects for someone remote from you in space and time, the consequences of being treated versus not being treated - that's always easy to do.

But I wonder if I'd asked myself back then, thirteen year old me, hunched and miserable on the bed while everyone else went out. I wonder what I would have thought of a way out, whether I would have wanted it so. Whether I would have preferred the disease or the cure.

Anyway, thanks for listening.

John

* Yes, I know it's not usually thought of as addictive. I put it in to show how boring my drug life has been.