Independence Day

This is what you shall do.

by Walt Whitman (from the preface to Leaves of Grass, 1885).

"This is what you shall do;
Love the earth and sun and the animals,
despise riches, give alms to every one that asks,
stand up for the stupid and crazy,
devote your income and labor to others,
hate tyrants, argue not concerning God, have patience and indulgence toward the people,
take off your hat to nothing known or unknown or to any man or number of men,
go freely with powerful uneducated persons and with the young and with the mothers of families,
read these leaves in the open air every season of every year of your life,
re-examine all you have been told at school or church or in any book,
dismiss whatever insults your own soul,
and your very flesh shall be a great poem and have the richest fluency not only in its words but in the silent lines of its lips and face and between the lashes of your eyes and in every motion and joint of your body."

--July 4, 2011

Photo Credit: http://thevirtualworld.blogspot.com

Other Posts, Other Places

News and views from the drug blog at The Fix.

A selection of recent posts I've written at The Fix, where I edit the blog as senior contributing editor. Some stuff you may not have run across. Here’s an even dozen from June:
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Dutch Court Ruling Leaves Cannabis Shop Open to Tourists—For Now
Maastricht pot shop reopens, but Dutch politicians continue with crackdown.

What Really Drives Americans to Drink?
Feeling Thirsty? Average Americans guzzled 20 gallons of beer and 45 gallons of soft drinks per person last year. They also downed 18.5 gallons of coffee and a surprising 20 gallons of milk.

China Unveils Radical New Approach to Drug Treatment
In a stunning about-face, the new drug regulations opt for voluntary rehab over mandatory detention.

25% of Car Crash Victims Test Positive For Drugs
Over 25% of drivers who are fatally wounded in accidents test positive for drugs other than alcohol.

The Crocodile That Dines on Dying Addicts
Russia’s newest bathtub morphine is a nightmare straight from Naked Lunch.

Smoking Bans Don’t Decrease Smoking, Study Finds
Anti-smoking ordinances protect people from secondhand smoke, but they don’t help smokers quit.

The “Buzzed” Driver: Drunk Enough to Matter?
Recent study argues for near-zero tolerance in blood-alcohol levels for drivers.

Traumatic Events Linked to Sharp Increase in Drug and Alcohol Abuse
Drug abusers and heavy drinkers are more likely to ramp up their intake after natural disasters.

Report Spells Out Tragedy of Fetal Alcohol Syndrome
Medical workers are getting better at recognizing FAS, but treatment funds are scarce.

The High Cost of Rehab
The treatment industry is expected to become a $34 billion business by 2014. Do you get what you pay for?

Meth is Less Rewarding When You've Got a Social Life
Animal study shows how a solid social network helps protect against drug abuse--by literally changing the way the brain works.

China's "Brain Acupuncture" Addiction Cure
Brain electrodes are being used by Chinese neurosurgeons to treat heroin addiction.

That Pesky Gambling Question

The DSM-V is set to label problem gambling an addiction.

Nobody has ever bet enough on the winning horse.
— Unknown wise person

I used to gamble. Back when I did, I was also an active alcoholic and a chain smoker. Camel filters, if you’re wondering. And we had a running joke, my wife and I, although the humor leaked out of it for her pretty quickly. We would breach the doors of the gambling palace, and plunge into the dark, icy interior of a casino at Las Vegas or Tahoe, and stand on the edge of the gaming room, taking it all in for a moment. “Ah,” I would say, surveying the roomful of cigarette smokers with drinks in their hands, making bets or hitting buttons at one o’clock in the morning, “my kind of people.”

Gambling can be defined as an activity in which something of value is put at risk in a situation where the outcome is uncertain. That’s really all there is to it. Howard J. Shaffer and Ryan Martin, whose article in the Annual Review of Clinical Psychology, “Disordered Gambling: Etiology, Trajectory and Clinical Considerations,” takes on all the interesting questions about gambling as an addictive disease, have chosen to favor the term “disordered gambling.” Just as there are divisions between alcoholic drinking, heavy drinking, and social drinking, there are similar states we can call pathological gambling, excessive gambling, and social gambling. On the problematic end of the scale, pathological or problem gambling has proven to be “a more complex and unstable disorder than originally and traditionally thought.” No kidding. Once the neurophysiology of the gambling state of mind came under scrutiny, the parallels with addiction cropped up so rapidly that investigators have been hard pressed to come up with suitable explanations for it all.

The new DSM-V proposes to shift pathological gambling from “impulse control disorder” to the new category of “addiction and related disorders.” So it’s a good time to rethink the question along with the psychiatric community.

In the traditional view, pathological gambling was a matter of exposure to the proper stimuli—it could happen to anyone. But as more and more gambling outlets and opportunities bloomed in Nevada, on reservations and riverboats, and in convenience stores, that view began to fall out of favor, because a funny thing happened. According to Shaffer and Martin, the prevalence of pathological gambling has remained stable over the past 35 years, even as opportunities to gamble have exploded. The lifetime prevalence rate of pathological gambling in the U.S. in the mid-1970s was 0.7%, say the authors, and by 2005, U.S. lifetime rates had actually fallen slightly, to 0.6% or less. Where was the concomitant explosion in the number of pathological gamblers?

Next, researchers got technical, wondering whether certain types of gambling, or certain types of gambling machines, were more “addictive” than others. They quickly ran into the same kind of trouble substance abuse researchers got into when they first tried ranking drugs according to strict hierarchies of addictiveness. In so doing, the staggering metabolic diversity of the human animal got lost in the shuffle, as did the fact that my metabolism and my behavior when taking drugs, or knocking one back, or losing money in a casino, is going to be different from yours.

Then came Internet gambling. In 1996, the first online casino to accept real money began operation, and by 2001, there were more than a thousand. Previously, researchers had to rely mostly on the time-honored but not always accurate system of self-reporting. If you ask people why they gamble, they tend to answer that they do it for the fun, the excitement, the challenge, and the chance to win some money. But what gamblers can’t recall very well are specific patterns of play over time that might benefit researchers. For example, in a 2009 study in which observers actually watched gamblers gambling, one long-standing observation from the self-report literature—gamblers become more liberal risk takers as they approach the end of a gambling session in a behavior called “chasing”—didn’t prove out. When researchers watched actual gamblers in action on the Internet, or playing lotteries, they found that problem gamblers in fact began betting more conservatively as they approached the end of their gambling, the authors write.

Another approach is to consider risk factors of all kinds—neurobiological, psychological, and social—and look for similarities between those for substance addiction, and those for “activity-based expressions of addiction.” The “syndrome model,” or what I usually call the umbrella model, derives from neurobiological research suggesting that “addictive disorders might not be independent: each outwardly unique addiction disorder might be a distinctive expression of the same underlying addiction syndrome…. The specific objects of addiction play a less central role in the development of addiction than previously thought….”

 All of this opens the door to some informed speculation about a broader range of disorders that may lurk beneath the umbrella of the addictive disease concept. Among these are such conditions as body dysmorphic disorder, bulimia, depression, and extreme PMS, which are all found more often in addict populations. In addition, impulsivity and low “harm avoidance” are behavioral traits often found in association with addiction. Shaffer and Martin call these “shadow syndromes,” and they are found to be associated with BOTH substance and behavioral addictions.

But what, exactly, is the high in gambling? The researchers believe that, “similar to ingesting stimulants, there is evidence that gambling is associated with autonomic arousal including elevated blood pressure, heart rate, and mood.” That's not very specific, and could also describe a craving for teddy bears. But recently, fascinating evidence of neurobiological influences on gambling arose when Parkinson’s’ patients on strong dopamine agonist treatments, with no history of gambling whatsoever, began behaving for all the world like pathological gamblers. I cannot imagine a better suggestion of neurogenetic involvement than this unexpected finding. Previous research had shown that dopamine-active drugs were capable of increasing the incidence of other addictions, too. Shaffer and Martin list compulsive eating, compulsive sexual behaviors, and compulsive shopping as activities that can also be boosted with dopamine agonists or diminished by lowering dopamine activity. 

And it does not strike me as surprising to learn that, yes, gambling problems tend to run in families, or that twins studies show that pathological gambling is higher among twins born to pathological gamblers than twins born to non-gamblers. It is the same evidence anyone can bring forth to bolster the argument for neurobiological influences on alcoholism, heroin addiction, and the like. “In sum” Shaffer and Martin conclude, “genetic influences might not determine the development of specific expression of addiction; however, genetics does influence the risk of addiction in general.”

If all of this is true, we should expect to see a corresponding connection between pathological gambling and substance abuse disorders. Some degree of overlap would be good evidence. And we have it in spades. Pathological gamblers are five and a half times more likely to have suffered from a substance abuse disorder. “75% of PGs (pathological gamblers) have had an alcohol disorder, 38% have had a drug use disorder and 60% have had nicotine dependence.” Also, “PGs are 4 times more likely than non-PGs to experience a mood disorder in their lifetime….”

So when I used to stand on the edge of the casino floor, as an alcoholic and a nicotine addict, casually calling those gamblers my kind of people, I think I was more right than I ever could have guessed.

Does all this mean that playing games on the Internet is an addictive behavior if making bets with real money is involved? The authors crunched the studies on that question, and discovered that maybe 1% of the Internet population has used the Internet for gambling purposes, and that “the case of Internet gambling provides little evidence that exposure is the primary driving force behind the prevalence and intensity of gambling…. The relationship between the extent of gambling ‘involvement’ is a better predictor of disordered gambling than any particular game that people play.”

By gambling involvement, the authors mean the number of different kinds of games a gambler plays. The more he or she plays, the more likely they are, or are likely to become, problem gamblers. However, it’s not hard to see where the online notion came from. Gambling folklore has always held that addiction is more of a risk with electronic gambling devices like slot machines and 5-Card Draw machines, than with traditional table games like roulette and craps. But the authors don’t find any convincing clinical evidence for this assertion at all. Internet gambling isn’t more addictive, and doesn’t confer any extra risk on people participating in other forms of gambling.

Here is a list of potential gambling behaviors that Shaffer and Martin believe might be risk factors to look out for in the development of problem gambling, with my additions in parentheses showing the connections to other drug addictions.

--Betting Intensity: how many bets per day. (With alcohol, how many drinks.)

--Gambling Frequency: number of gambling days (Number of drinking days.)

--Gambling Trajectory: tendency to increase the amount of wagered money. (Tolerance, in the case of drugs and alcohol.)

--Gambling Variability: deviation from consistent gambling pattern. (Inability to predict duration or outcome of drinking event.)

But if we list gambling under Addiction and Related Disorders, must we list all the possible variations on the theme—shopping and sex and all the rest, even though the picture is still fuzzy? No, the authors argue, we don’t. Not right this minute. But gambling is ready to join the roster. Shaffer and Martin would like to see their syndrome model of addiction used to identify “core features of addiction and then illustrate these with substance-related and behavioral expressions of this diagnostic class. Conceptualizing addiction this way avoids the incorrect view that the object causes the addiction and shifts the diagnostic focus toward patient needs.”

Shaffer HJ, & Martin R (2011). Disordered gambling: etiology, trajectory, and clinical considerations. Annual review of clinical psychology, 7, 483-510 PMID: 21219194

Graphics Credit: http://gamblinghelp.org/pages/resources/toolkits.php 

How the Drug War Ended

Thoughts on the 40th anniversary of the War on Drugs.

Last week marked the end of four decades of drug wars first unleashed under President Richard Nixon. The event was well publicized, with parades and pronouncements on all sides. But nothing struck me quite like a recent essay by Daniel Lende at his blog site, Neuroanthropology.

For anthropologist Daniel Lende, the tipping point was a clutch of superb—and superbly horrifying—photographs of drug war victims in Mexico. The old, the young, the innocent. Nothing but blood and death and dying. “Despite years of living in Colombia,” Lende writes, “I’d never really come face-to-face with the costs of the drug war there.” And, up until a few weeks ago, he had been “the good scientist, waiting for more evidence, and the good anthropologist, waiting for something that makes better sense.”

If anything is in short supply in the never-ending, no endpoint, no endgame war, it’s better sense, not bullets. These were the pictures, and there was no way of making the pictures theoretical.  And one photo in particular—a dead grandmother, huddled in a protective embrace meant to shield her two dead grandchildren—finished it off for Lende. “We can’t squirm away, we can’t simply forget or say it’s not so bad. It is that bad. These photos show it.”

It’s all too easy to blame it on drug thugs, so Lende doesn’t bother. Besides, “for too many years, the Mexican government treated drug trafficking like just another corruption, manageable and profitable for those in power. And now the violence has hit as a storm of torture, death, and gruesome display.”

Do we really believe it can’t happen here? U.S. government officials are, as Lende writes, supposedly built from sterner stuff. “Their corruption is not easy money and institutional decay. It’s the sheer rigidity of their approach—an approach of annihilation and denial eerily reminiscent of drug users themselves. It is tyrannical more than puritanical. A war can never be lost, no matter the cost, even if the enemy (demand) comes from our own people.”

Lende is not in favor of legalization—far from it.  “Releasing drugs to the unfettered powers of the capitalist market is not a good option. If they can’t even handle mortgages, what would happen with drugs?” Besides, it’s obvious enough that alcohol, tobacco, and prescription drugs cause enough mayhem as legal drugs.

So, what to do? We can’t go forward, and we can’t go back. Or so it sometimes seems. Lende offers up four suggestions; small ways of making improvements at the margin, where such improvements often start.

--Fairness in drug regulation. Similar drugs should be treated in similar ways. Witness the entanglement the criminal justice system got itself into with huge sentencing disparities between crack cocaine and powdered cocaine; disparities that amounted to racial profiling.

--A focus on consequences rather than simple possession. For example, alcohol is legal, but not drunk driving. “Similar policies that target harmful behaviors users commit are an utter necessity.”

--Mandated restitution and treatment, rather than jail. Lende argues that drug courts can help provide “the long-term protection of the community and the rehabilitation of individuals found to commit acts in counter to commonly established laws.”

--An emphasis on small, immediate costs to drug abusers: “fines for possession, obliging users to show up in court and face social judgment… and one or two day jail sentences are all ways to generate change using a criminal justice approach.”

But is there really any evidence that social interventions of the kind Lende champions can really make a difference? As it happens, yes. Consider smoking. Taxes, warning labels, and social changes in tolerance for smoking have all had a direct effect.

Full Disclosure: Daniel Lende used "The Chemical Carousel," my book about addiction, in one of his anthropology classes at the University of Notre Dame, although we both made zero money out of the deal. He's now an Associate Professor in Anthropology at the University of South Florida. I also fully disclose that he’s a great guy and has proven to me that this is not your mother’s anthropology anymore. It’s a terrific essay. Read it in full here.

Photo Credit:  www.presstv.ir

Why are Treatment Centers Afraid of Anti-Craving Medications?

Using What Works

Why do so many drug treatment centers continue to shun science by ignoring medications that ease the burden of withdrawal for many addicts? That’s the question posed in an article by Alison Knopf in the May-June issue of Addiction Professional, titled “The Medication Holdouts.”

“Nowhere else in medicine,” Knopf writes, “are the people who treat a condition so suspicious of the very medications designed to help the condition in which they specialize.”

Acamprosate, a drug used to treat alcoholism, is a good case in point. A dozen European studies examining thousands of alcohol test subjects found that the drug increased the number of days that most subjects were able to remain abstinent. But when a German drug maker decided to market the drug in the U.S., fierce advocates for drug-free addiction therapy came out in force, even though the drug was ultimately approved for use.

Disulfiram, naltrexone, acamprosate, methadone, buprenorphine—the evidence for all of them is solid. Knopf cites the case of buprenorphine:

“‘There are scores of peer-reviewed journal articles that evaluate the success of buprenorphine,’ says Nicholas Reuter, MPH, senior public health adviser in the Division of Pharmacologic Therapies at the federal Center for Substance Abuse Treatment (CSAT). ‘It's well established that the data and the evidence are there. Not treating patients with a medication consigns most of them to relapse, adds Reuter. While some opioid-addicted patients, as many as 20 percent, do respond to abstinence-based therapy, ‘That still leaves us with the 80 percent who don't,’ he says.”

Dr. Charles O'Brien, one the nation’s most respected addiction professionals and a Professor of Psychiatry at the University of Pennsylvania, is incensed that anti-craving medications are not more widely used. “It's unethical not to use medications,” he says. “This is a subject that I feel very strongly about.” O’Brien told Addiction Professional he no longer cares who he offends on the subject. “If you're discouraging people from taking medications, you are behaving in an unethical way; you are depriving your patients of a way to turn themselves around. Just because you don't like it doesn't mean you have to keep your patients away from it.”

And at the Association for Addiction Professionals, “the prevailing philosophy is pro-medication,” Knopf writes. Misti Storie, education and training consultant for the group, told Knopf that the “disconnect” at treatment centers is due to a “lack of education about the connection between biology and addiction.” Counselors working in centers that do not allow anti-craving medications are in a tough spot, Storie acknowledged.

It is continually astonishing that treatment centers--where the primary goal is supposed to be the prevention of relapse, even though the success rate remains abysmal--would spurn medications that often help to accomplish precisely that goal. Relapse rates hover around 80%, by an amalgam of estimates, so it’s not like rehabs are wildly successful at what they do. What’s really behind the resistance?

What stands between many addicts and the new forms of treatment is “pharmacological Calvinism.” I would love to claim this term as my own, but it was coined by Cornell University researcher Gerald Klerman. Pharmacological Calvinism may be defined as the belief that treating any psychological symptoms with a pill is tantamount to ethical surrender, or, at the very least, a serious failure of will. As Peter Kramer quoted Klerman in Listening to Prozac: If a drug makes you feel better, then by definition “somehow it is morally wrong and the user is likely to suffer retribution with either dependence, liver damage, or chromosomal change, or some other form of medical-theological damnation.”

Photo credit: www.life123.com

For Smokers, Nowhere to Run and Nowhere to Hide

(With love and apologies to Martha and the Vandellas.)

That wonderful song goes on to declare:

'Cause I know
You're no good for me
But you’ve become
A part of me.

The song is not about cigarette addiction, but it could be. Full Disclosure: I smoked cigarettes myself for almost 25 years. And then, after several failed attempts, I quit. I out myself on this subject because a paper from the May 25 issue of the New England Journal of Medicine (NEJM) decries what the authors call the “denormalization” of smoking—and I find myself agreeing with them, smokeless though I may be. I recently visited New York, coincidentally on the day that smoking outdoors in New York City became illegal. Okay, that’s not quite fair to say—it became illegal to smoke in Central Park, or at Brighton Beach, or along the newly pedestrian mallways of Times Square. There is no smoking along the High Line. There is no smoking at any park, beach, or pedestrian mall. As both the tobacco industry and anti-smoking activists well know, this was an iconic victory that has the potential to change smoking laws in virtually every other American city.

It’s a fascinating progression, starting in the 70s when the Civil Aeronautics Board decreed non-smoking sections on domestic airline flights, to the recent New York City Council Decision to ban smoking en plein air, so to speak. Thomas Farley, New York City Health Commissioner, summed it up as follows in a public hearing: “I think in the future, we will look back on this time and say ‘How could we have ever tolerated smoking in a park?’”

I’m not so sure on that, myself. James Colgrove, Ronald Bayer, and Kathleen Bachynski of the Mailman School of Public Health at Columbia University wrote the paper, entitled “Nowhere Left to Hide? The Banishment of Smoking from Public Spaces,” in the NEJM. The authors note that more than 500 towns and cities in 43 different states have already enacted laws banning smoking “in outdoor recreation areas.” At first, as the authors summarize the history, it all seems like a sensible compromise, built on common courtesy. First airplanes and buses, then restaurants and bars, began setting aside seats for non-smokers. By the early 90s, the first data on secondhand smoke was rolling in. Schools, convention centers, and finally even private workplaces either banned smoking or created smoke-free areas. But even then, the primary motivator, according to the researchers, was that secondhand smoke was “unpleasant and annoying,” not deadly. Smokers weren’t being asked to refrain from public smoking for the good of their own health, but as a courtesy to others.

The solid scientific evidence kept accumulating, however—even though tobacco cigarettes were, and still are, completely legal products for adult Americans to purchase and consume if they so choose. Now the arguments shifted to the innocent bystanders, those within the six-foot ring, the immediate smoke zone surrounding a smoker, and the elevated risk of lung cancer, heart disease, and asthma that smokers were subjecting them to. In 1993, the Environmental Protection Agency (EPA) classified secondhand smoke as a Class A carcinogen, and more school, stadiums and offices proscribed smoking.

So far so good, really, from a public health standpoint. But now comes the bend in the road. Suddenly, parks and beaches were being added to the no-smoking roster. “As the zones of prohibition are extended from indoor to outdoor spaces, however, the evidence of physical harm to bystanders grows more tenuous.” In 2008, the authors report, “The editor of the journal Tobacco Control dismissed as ‘flimsy’ the evidence that secondhand smoke poses a threat to the health of nonsmokers in most outdoor settings.”

This confusion was much in evidence at public hearings last fall on the proposed outdoor smoking bans. While Health commissioner Farley argued that 57% of New Yorkers showed nicotine by-products in their blood, he also argued that exposing young children to adults in the carnal act of smoking was detrimental to the public health and welfare. “Families,” he said, “should be able to bring their children to parks and beaches knowing that they won’t see others smoking.” This is really quite an astonishing assertion, given the range of bad habits youngsters are exposed to as they go about a normal day in the adult world. The authors are particularly concerned about this push to stigmatize smokers. “Given the addictive nature of nicotine and the difficultly of quitting smoking, strategies of denormalization raise both pragmatic and ethical concerns.” Furthermore:

The decline in U.S. smoking rates since the 1960s has coincided with the development of a sharp gradient along the lines of socioeconomic status. Whereas about one fifth of all Americans are smokers, about one third of those with incomes below the federal poverty level smoke. These data are especially pertinent to the question of bans in parks. Since smokers are more likely to be poor and therefore dependent on free public spaces for enjoyment and recreation, refusing to allow them to smoke in those places poses potential problems of fairness.

The anti-tobacco movement, frustrated by the slow pace of gains over several years of active efforts, with rates of smoking remaining essentially unchanged, has to face the fact that an outright ban on cigarettes is a ticket to black market, crime syndicate hell. But a de facto ban is something altogether different, and “steadily winnowing the spaces in which smoking is legally allowed may be leading to a kind of de facto prohibition.” More and more employers prohibit smoking in doorways, within ten feet of doorways, anywhere on university campuses, and so on. No one has voted to make cigarette smoking illegal. But the public space in which this legal activity can be pursued is disappearing. And here is where the tough questions start: “In the absence of direct health risks to others, bans on smoking in parks and beaches raise questions about the acceptable limits for government to impose on conduct,” the authors conclude. Not to mention issues of personal autonomy, individual choice, and the stigma attached to addictive behavior. Perhaps the ACLU will soon take an interest in the civil rights of outdoor smokers, where the only health being hazarded is the smokers’ own.

Colgrove J, Bayer R, & Bachynski KE (2011). Nowhere Left to Hide? The Banishment of Smoking from Public Spaces. The New England journal of medicine PMID: 21612464

Photo Credit: www.thinkstock.com

Steve Earle and the Ghost of Hank Williams

Book Review: I’ll Never Get Out of This World Alive

Musician Steve Earle made a solo name for himself with Guitar Town and Copperhead Road after playing in legendary country and bluegrass bands as a young prodigy. He was nominated for a Grammy, his reputations soared, he added rock and roll to his range—until 1991, when Earle put out the aptly named live album, Shut Up and Die Like An Aviator. Shortly thereafter, he was dropped by his record label for long-standing drug problems, and landed in prison with a heavy sentence for possession of heroin. He completed rehab successfully, earned his parole in 1994, and has gone on since then to make several highly successful albums, guest star in the TV series The Wire, and write music for the New Orleans-based series Treme.

And now he has written a novel called I’ll Never Get out of This World Alive, set mostly in San Antonio, with a main character who is an aging doctor and a heroin addict. Doc’s specialty is quick but relatively safe and sterile backroom abortions, commonly performed on illegal immigrants. His license to practice long ago taken away, Doc takes in enough to make his daily pilgrimage to the parking lot where his longtime dealer works the streets. The book’s title is taken from the name of a Hank Williams song, which is appropriate, because whether or not you enjoy this novel may depend upon your reaction to Hank’s ghost hanging around the main character, begging for a drink and some attention. Things get even stranger when a young Mexican girl, Graciela, falls under the doctor’s care, and begins to exhibit signs of stigmata and the power to heal drug addicts. Rather than choosing to tell his tale straightforwardly, Earle is working more in the tradition of Latin American magical realism. This is no One Hundred Years of Solitude, but a lot hangs on belief, and the power of unseen forces to organize events in unforeseen ways.

Earle has a fun, quick touch with character description and the telling anecdote, explaining, for example, that local narcotic detective Hugo Ackerman “rarely hurried even when attempting to catch a fleeing offender. He had worked narcotics for over a decade, and in his experience neither the junkies nor the pushers were going far. He caught up with everybody eventually.”

Set in 1963, the book carries us through the Kennedy assassination and other cultural events as background. And we get a nice, deft description of what starts the doctor down the road toward smackdom: “Then in the first year of his residency he befriended a crazy old pathologist who worked the midnight shift in the county morgue, and it was he who introduced Doc to the miracle of morphine. From that very first shot it was as if he’d discovered the one vital ingredient that God had left out when He’d send Doc kicking and screaming into the cold, cruel world.”

I won’t say that Mr. Earle should give up his day job on the basis of this outing, but I do think that critics who have dismissed his efforts have overlooked some of what the author is attempting to say about addiction, and about recovery--that recovery involves all kinds of intangibles like faith, hope and charity, and that these attributes can present themselves in myriad disguises. (And a lot of critics got it: Michael Ondaatje wrote that this “subtle and dramatic book is the work of a brilliant songwriter who has moved from song to orchestral ballad with astonishing ease.”)

I think this book is, in fact, written very much with addicts in mind. The shade of Hank Williams doesn’t dog Doc everywhere just because Steve Earle is a huge fan. Hank Williams was also a vicious, go-to-hell alcoholic and drug addict who could not make the turnaround Steve Earle has made, and therefore could not even get out of his twenties alive, let alone this world.  Earle has Doc stand in for him when it comes to lessons learned: “Doc was immediately sucked in by the big lie that all junkies want to believe in spite of daily evidence to the contrary, that this shot was going to be like that first shot all those years ago. He tied off, found the money vein in the back of his arm, well rested now because he had always reserved that one for the big shots, the teeth rattlers, and it stood at attention like a soldier on payday.”

I won’t give out any spoilers here, as the miraculous Graciela bleeds from her wounds and lays hands on dying addicts to save them. It’s the stuff of, well fiction—but fiction informed by the author’s firsthand voyage into heroin bondage. Steve Earle is living proof of the overarching theme of his book: redemption in its many guises.

Photo Credit:  http://www.troubashow.com/