Love is dope . . .
Tom Robbins
When I started writing this book, the verdict on opioids seemed clear cut. These drugs ravaged large portions of the country, causing immediate addiction and vast numbers of unexpected overdose deaths. I soon learned it wasn’t that simple. As was the case with crack cocaine decades earlier, the story of opioids is far more complex than we have been led to believe. I ask that you read this chapter with an open mind and allow the evidence to determine your perspective.
“BLAHHHH!” THE RETCHING sound caused Robin to rush into the bathroom, where I was kneeling in front of the toilet as if it were an altar. “Are you OK?” she asked, a worried look on her face. Three weeks earlier, I had told her I was going to conduct an experiment on myself, during which I’d deliberately go through opioid withdrawal to see what it was like. This was it, fall 2017.
Only a few years earlier, I couldn’t have imagined taking opioids on a consistent basis, let alone voluntarily undergoing withdrawal from them. I was too afraid. Media reports suggested that a person could get hooked after only a few hits. And once addicted, that individual ran the inevitable risk of dying either from an overdose or from opioid withdrawal symptoms. Who needed that? Certainly not me.
In 2014, I gave a book talk in Geneva, Switzerland, that focused on methamphetamine use. During the question-and-answer period, I managed to say a few uninformed things about heroin, despite their being outside the scope of my talk. I said something like “Chronic use of the drug undoubtedly produces physical deterioration; it damages your body.” The fact that I had no evidence for this assertion didn’t inhibit me. The statement just felt like it should be true, and it was in line with my own biases about heroin.
Immediately after the talk, I met Barbara Broers, who was in attendance. Barbara is a professor at the University of Geneva and an internist whose specialty is treating drug addiction. For several years, she worked at a Geneva clinic where heroin addicts are given daily doses of the drug as part of their treatment, in much the same way people take daily doses of a beta-blocker or insulin to control symptoms related to hypertension or diabetes.
Barbara explained that she wanted to learn more about my perspective on the issues I raised in my talk. She invited me for a hike on Mont Salève the following morning. I accepted, even though I didn’t have the proper clothing or shoes. It was winter and cold, and snow was everywhere. To make matters worse, Mont Salève’s peak stood nearly a mile above sea level. Having only recently arrived from New York City, I knew I’d be winded quickly if I exerted myself too much. But my ego overrode my reason. How bad can it be? I thought. If Barbara can handle it, so can I.
I quickly realized that it was I who would be doing the learning, not Barbara. It was clear that I was out of my league on multiple levels. Barbara is a serious athlete, although her modesty prevents her from saying so. She doesn’t own a car but walks, jogs, and cycles everywhere. As we hiked, her stamina was evident: she talked a mile a minute without any signs of fatigue or shortness of breath. She also patiently and carefully listened. I, on the other hand, gasped for air like a fish out of water as I tried to keep pace both physically and intellectually.
“Heroin is one of the safest drugs,” she said in a quiet, matter-of-fact tone. She qualified her statement with the usual pharmacological considerations, such as the need to carefully attend to the dose administered and the user’s level of tolerance. I’m not exactly sure what I said or if I even said anything, but I am certain that the incredulous look on my face communicated, “Get the fuck out of here!” Barbara began by telling me about her experience working with patients in the heroin clinic and how well these folks do with its treatment. Many of them are also afflicted with other illnesses, including psychiatric disorders. She stated that heroin, compared with antidepressant and antipsychotic medications, has far fewer side effects. OK, I could see that; many psychiatric medications have numerous serious side effects. In some cases, the adverse effects are so debilitating that patients refuse to take those medications.
I also knew that heroin is made by adding two acetyl groups to morphine. This minor modification of morphine allowed Bayer Laboratories—yes, the same people who gave us Bayer aspirin—to market heroin as a nonaddictive cough suppressant. It was 1898, and there were minor concerns about the risk of physical dependence caused by the then more commonly used antitussive drugs, morphine and codeine. Both of these drugs are derived from the opium poppy and, like heroin, belong to the class of drugs called opioids. We know now that all opioids, including methadone, oxycodone, and fentanyl, are capable of producing physical dependence. At the time, though, this effect had not yet been observed with heroin, so it seemed an ideal replacement. Eventually, this view would evolve and the medical uses of the drug would be restricted primarily to pain relief. Today, heroin is used medically in several countries, including Ireland and the United Kingdom, but not in the United States.
Barbara continued schooling me. She said one of her most consistent clinical observations was that heroin is more effective at controlling psychotic symptoms, such as hallucinations, in many patients than are traditional antipsychotic medications. Initially, this was a bit much for me to digest, but once I got over my shock, I could at least see how this might be theoretically possible.
Antipsychotics are the drugs used to treat schizophrenia and other psychotic disorders. The dominant theory purports that psychotic behaviors, including hallucinations and delusions, are caused by overactivation of dopamine cells in the midbrain. Antipsychotic drugs block dopamine receptors and thereby prevent excessive dopamine activity. Supposedly, these drugs eliminate voices in the heads of schizophrenic patients and reduce their delusions. In reality, it’s not that simple. Antipsychotics are not a cure. Many patients report that these drugs don’t necessarily rid them of the voices in their heads, but rather, they make the voices less frightening. In other words, antipsychotics are not magic bullets that selectively target psychotic symptoms. They are blunt tools that cause a cascade of effects on multiple neurotransmitter systems. An important drawback of these drugs is that they produce considerable sedation, often leaving patients feeling lethargic and debilitated.
Heroin also produces a range of neurobiological actions, including some leading to sedation. But, unlike antipsychotics, heroin engenders many positive effects on mood, including remarkable feelings of well-being. So, yeah, I can see how heroin might be more effective than many antipsychotic medications are at quieting the voices in the heads of some patients suffering from psychosis. I also can see how the drug might be more reinforcing. If patients like it, then they are more likely to take it. By contrast, most patients don’t like taking the traditional antipsychotic medications.
After spending an entire day with Barbara, I was convinced that I needed to learn more about heroin. I needed to learn more from her. For example, I still didn’t quite understand why a person would even consider using heroin, especially in the face of the apparently considerable risks. I wanted to know more. I felt extremely uncomfortable, too, being so ignorant about a topic on which I was supposedly an expert. Our conversation lit a fire in me. I was determined to take steps to remedy my ignorance.
Fortunately, I was due for a sabbatical the following year. Barbara suggested that I spend some of my leave in Geneva working in the heroin clinic. This would allow us to continue our interactions while I learned firsthand about heroin in a clinical setting. I jumped at the opportunity.
In 2015, I spent several months in the Geneva clinic where Barbara treated heroin-dependent patients. Early on, I still had to deal with some of my most stubborn prejudices about the drug and the people who use it. I thought most of them acquired their addiction as a result of having been prescribed an opioid medication to deal with some other ailment. I was wrong. Despite the current false narrative, the addiction rate among people prescribed opioids for pain in the United States, for example, ranges from less than 1 percent to 8 percent.1
I now know, too, that most heroin users do not become addicted to the drug.2 Your chances of becoming addicted increase if you are young, unemployed, and/or have co-occurring psychiatric disorders.3 That is why the Swiss ensure that all heroin patients have a social worker, a psychologist, a psychiatrist, and other health professionals as part of their treatment team.4 Not only are medical and mental-health issues addressed, but crucial social services are provided. All patients have housing, and many are employed.
Other myths I held were shattered each day I spent in the clinic. For instance, patients were required to show up at scheduled times twice a day—once in the morning and once in the evening—seven days a week. Like a Swiss watch, so-called junkies were reliably on time. They were almost never late. And as a result of being in the program, their health improved; they were happy and living responsible lives. It became impossible for me to retain the misguided notion that heroin addicts are irresponsible degenerates.
The Swiss introduced this form of treatment in the 1990s, when there was grave concern about the spread of the HIV virus through contaminated needles used to inject street heroin. In response to this growing health crisis, which was left unchecked by the typical law-enforcement approach that emphasizes drug-supply reduction, the Swiss government implemented the pragmatic approach of providing a select group of addicts with heroin, clean needles, and other services as part of their treatment. The approach worked. People stayed in treatment. The number of new blood-borne infections, such as HIV and hepatitis C, dramatically decreased. Petty crimes committed by heroin users also went down. And no heroin user has ever died while receiving heroin in the clinic.
I don’t want to leave you with the impression that heroin maintenance is a panacea. It’s not. It’s not even a cure for heroin addiction; it’s simply a treatment. There are no cures in psychiatric medicine. We don’t have a cure for depression, nor do we have a cure for schizophrenia or anxiety. We merely have medications and therapies that treat symptoms, and this allows patients to function better, despite their illnesses.
But what is also true is that the psychosocial disruptions that led to a diagnosis of heroin addiction are no longer present in most patients enrolled in heroin-maintenance programs. These heroin users are healthier and more responsible. According to the DSM-5, this doesn’t matter. These individuals are still saddled with the label “opioid use disorder”; they are still considered addicts. Except now they are described as addicts in remission. Stated another way, once an addict, always an addict. This classification isn’t unique to opioid addiction. It also applies to other drugs, including alcohol, amphetamine, cannabis, and cocaine.
There is no scientific basis for the continued labeling of these individuals as addicts. This life sentence seems to be based purely on anecdote and convention. It is my hope that this diagnostic travesty is corrected in future editions of the DSM.
This in no way detracts from the success of heroin-assisted programs in Switzerland and other places. Some twenty years after the Swiss implemented their programs, several other European countries, including Belgium, the Netherlands, Germany, and Denmark, now employ similar approaches to treating heroin addiction in those who have failed repeatedly in conventional treatment programs, including abstinence- and methadone-oriented ones. Patients in these programs, like those in Switzerland, hold jobs, pay taxes, and live long, healthy, and productive lives.
Heroin, it turns out, is an effective treatment for heroin addiction. This was big news to me in 2015. I was excited about going back to the United States and sharing what I had learned. At the time, we were being inundated with a continuous stream of dire warnings attesting to the ravages caused by opioids. We were also routinely told that treatment was ineffective or inadequate.
When I returned from Switzerland, I agreed to participate in a panel discussion on “Heroin: A National Epidemic” (the organizers’ words). I almost never take part in panel discussions about drugs because invariably at least one fellow panelist will present erroneous information, but if I correct the person, then I look like a jerk. I agreed to participate this time because I wanted to share what I had learned in Geneva and because the timing was perfect.
Peter Shumlin, then the governor of Vermont, was also a participant. In 2014, as I’ve mentioned, he gained national recognition in response to his focusing entirely on the “heroin crisis” in his State of the State address. He urged Vermonters to view addiction as a health problem and not a criminal-justice issue. The press loved it. Shumlin was seen as progressive and forward-thinking.
He wasn’t. It quickly became clear that he was just another drug-stupid politician. During our discussion, I shared my Geneva experience and explained the treatment successes of several countries. I proposed that we should offer this treatment here in the United States. Shumlin, in a dismissively arrogant tone, responded by saying something like, “Americans don’t need to take cues from any other nation.” I couldn’t believe it. His comment made me angry and left me dispirited. It is precisely this type of willful ignorance that prevents so many people from receiving treatment that actually works, whether it involves heroin maintenance or some other form of treatment.
Unfortunately, many Americans share Shumlin’s view. Perhaps even more troubling is the large number of U.S. physicians and scientists specializing in drug addiction who find the idea of providing heroin to heroin-addicted patients simply wrong. For such physicians and scientists, it doesn’t matter how well this treatment works. Or that it has been scientifically validated. Heroin use, even as a treatment, just feels immoral.
This ideological rigidity is one of the main reasons that heroin-assisted treatment is rarely mentioned in the United States. Heroin maintenance isn’t discussed as a possible treatment option, nor is it taught as part of the medical education that budding physicians and addiction experts must complete. This seems a dereliction of duty.
I sometimes reflect longingly on the discussions I had with Barbara and her team about addiction, opioids, and life in general. Our conversations weren’t constrained by puritanical notions that shame people into constricted and insipid thoughts, expressions, and lives. It was as if the shackles had been taken off my thinking, especially about drugs. I recall a talk that I had with Anne, one of the team’s physicians. In response to my lament that physicians in the United States will probably never consider heroin a viable treatment option, for any condition, Anne said something I won’t soon forget. First, she told me about how her patients often describe heroin in such loving terms. Then, with her eyes fixed on mine, she asked me, “How can I be against love?”
These experiences changed me. They made me question everything I thought I knew about heroin. I no longer believed much of the nonsense I had been taught about the drug. Nor did I now believe, as I once did, that heroin inevitably leads to death or some other tragic end. All the evidence from research clearly shows that most heroin users are people who use the drug without problems, such as addiction; they are conscientious and upstanding citizens.
I recognize that this statement requires some defense.
Since the early 1900s, when heroin was outlawed in the United States, the drug and its users have been denigrated in the popular press, in politics, in art, everywhere. Sure, periodically there have also been sympathetic portrayals of certain heroin users, especially if they were white, young, and physically attractive. But the number of these more compassionate depictions pales in comparison to those that are negative.
Newspaper headlines routinely read like hysterical heroin-danger warnings: Heroin Suspected in 20 Deaths in 2 Weeks5. Artists regularly produce influential works that cement heroin’s evil reputation. Who among us wasn’t deeply moved when Johnny Cash sang “Hurt,” poignantly describing the horrors of heroin use? Or when Neil Young sang “The Needle and Damage Done,” a song inspired by the death of his former bandmate Danny Whitten, a heroin user?
You might not know this, but Johnny Cash never used heroin, nor did he receive any special training on its effects. So his view of the subject is probably not the most authoritative. Trent Reznor, the front man for Nine Inch Nails, wrote “Hurt,” and he definitely used heroin. But his use alone doesn’t make him an expert either. Equally important, even before Reznor used heroin, he suffered from depression. As I said earlier, people diagnosed with a psychiatric disorder have an increased chance of becoming addicted. This makes it extremely difficult to disentangle the effects of depression from those of heroin when trying to determine the actual cause of Reznor’s misery when he penned “Hurt.” Likewise, Danny Whitten, the inspiration for Neil Young’s song, didn’t die from a heroin overdose; he died from an overdose of prescription sedatives and alcohol.
The point is that a person shouldn’t be considered an expert on heroin merely because she wrote a song, or an article, about the horrors of the drug. Nor should a person be deemed an authority on the drug simply because he used it in a pathological manner. It’s like saying that Donald Trump is a gynecologist because he once had a morbid predilection for grabbing women by the crotch without their permission. Moreover, most popular depictions of heroin use are less than accurate and do not tell the whole story. All one has to do is dig a little, and it becomes abundantly clear that heroin—or any other opioid, for that matter—isn’t the villain it has been made out to be.
When it comes to street heroin, far more concern should be focused on contaminants that may be contained in the substance. Today, illicit heroin is frequently adulterated with stronger opioids like fentanyl and its analogs. The adulterants are often much more dangerous than the heroin itself. These substances produce a heroin-like high but are considerably more potent. This, of course, can be problematic—even fatal—for users who ingest too much of the substance thinking that it is heroin alone or another single opioid. Fentanyl is blamed for the death of rock star Prince. It has been reported that he died after taking a fentanyl-containing pill he thought was Vicodin.
One obvious solution to many of these accidental deaths is to legalize heroin, as we have done with marijuana in eleven states and with alcohol. Legalization would ensure a minimum level of quality control. During Prohibition, alcohol produced in illicit stills frequently contained contaminants that made people sick or even killed them. This problem went away when Prohibition was repealed. In the meantime, we should offer free, anonymous drug-purity testing services. If a sample contains adulterants, users would be informed. As I noted in earlier chapters, these services already exist outside the United States in places such as Austria, Belgium, the Netherlands, Portugal, Spain, and Switzerland, where the first goal is to keep users safe.
In an effort to circumvent the unpredictable nature of illicit heroin markets, some people obtain prescriptions for opioids as substitutes. On the one hand, this is a good thing because the purity of street heroin is frequently poor. Prescription opioids are usually higher quality and pharmaceutical grade. But, on the other hand, popular prescription medications such as Percocet, Vicodin, and Tylenol 3 contain an extremely small dose of opioid in combination with a considerably larger dose of acetaminophen (a.k.a. paracetamol)—and excessive acetaminophen exposure is the number one cause of liver damage in the United States.6 Some users may unwittingly risk liver damage by taking too many of these pills.7 We need to inform people not to overdo it on opioid pills that contain acetaminophen because it can be much more fatal than the low dose of opioid usually contained in these formulations.
THE SAD FACT remains that far too many people are victims of preventable opioid-related deaths. Too frequently, I receive emails, letters, phone calls, and visits from parents who recently lost a child from what was described to them as an opioid overdose. My interactions with these grieving parents are heart-wrenching. As a parent myself, I can’t imagine ever recovering from such a loss. I feel a profound sense of compassion for them, and I provide whatever help I can to these broken parents.
I remember meeting Tatianna Paulino after the death of her son Steven Rodriguez. Steven, who was also known as A$AP Yams, was the founder of the hip-hop collective A$AP Mob. In the early hours of January 18, 2015, his mother learned of his death as she raced down a Bronx highway headed toward the Brooklyn hospital that received his body. Steven had succumbed to an apparent opioid overdose. This seemed consistent with the fact that he had gone to drug treatment once before. It also was consistent with the stories told to the press by some of his friends. A$AP Rocky, for example, said in an interview with The New York Times that Steven “always had a struggle with drugs. That was his thing.”
Steven’s reported drug of choice was “lean,” a.k.a. purple drank, or syrup. The concoction is a mixture of a flavored soft drink with cough syrup containing codeine and promethazine. The opioid codeine is one of the naturally occurring chemicals found in the opium poppy. In medicine, codeine is used as a cough suppressant as well as a pain reliever. Some people also use codeine to get high because it can relieve stress and produce sedation with mild euphoria. Opioids, including codeine, also stimulate the release of histamine, which can lead to itchiness, nausea, vomiting, and other unpleasant symptoms.
Promethazine is an antihistamine used to treat allergy symptoms, such as itching, runny nose, sneezing, itchy or watery eyes, hives, and itchy skin rashes; it’s also used to reduce nausea, vomiting, and insomnia. In practice, promethazine, as well as other antihistamines, can eliminate many of the negative side effects produced by opioids. But, I suspect, the primary reason for its inclusion in the lean drink is its pronounced sedating properties.
Tatianna knew her son suffered from sleep apnea and wondered if it played a role in his demise. She was concerned that the portrayal of her son’s death as a “drug problem” seemed too simple, too convenient. It didn’t explain the actual cause of his death. Nor was it an accurate enough explanation to ensure that Steven’s experience could be used to prevent something similar from happening to someone else’s child. A lot more seemed to be going on here. Sure enough, Tatianna learned that her son was under considerable pressure to produce hit recordings. He was also broke, and, to add further insult to injury, he was being squeezed out of the group he had put together. Given these stressful circumstances, it’s not difficult to see how Steven’s use of opioids might have been a way for him to decompress. Opioids certainly are well-suited for this task.
The problem is, however, that most lean concoctions contain both an opioid and an antihistamine. If a nontolerant person takes a large dose of an opioid combined with an antihistamine, especially an older one, such as promethazine, which is heavily sedating, that person’s chances of experiencing fatal respiratory depression increase dramatically. The evening before his death, Steven drank lean. What’s more, his toxicology report revealed that he had also taken oxycodone (an opioid) and alprazolam (a benzodiazepine a.k.a. Xanax). Both are also known for their anxiety-relieving and euphorigenic effects. But when they are combined with other sedatives, especially at large doses, these drugs can become deadly.
I can’t say whether Steven was aware of the potential dangers of mixing opioids with other sedatives. If he wasn’t, he certainly wasn’t alone. Several celebrities have died as a result of combining opioids with other sedatives: DJ Screw, Pimp C, Heath Ledger, Cory Monteith, Philip Seymour Hoffman, and Tom Petty, among others. Headlines announcing these deaths almost always single out the opioid as the killer, which is not only less than accurate but also incredibly irresponsible.
It is certainly possible to die from an overdose of an opioid alone, but such overdoses account for a minority of the thousands of opioid-related deaths. Most are caused when people combine an opioid with alcohol, an anticonvulsant, an antihistamine, a benzodiazepine, or another sedative. People are not dying because of opioids; they are dying because of ignorance.
Explaining these facts to Tatianna was difficult because I felt for her. I also felt fortunate to have had the opportunity to get to know her and to learn more about her son. I remember her telling me that Steven could light up a room with his smile, that he was delightfully mischievous, that his entire body shook when he laughed. She also met my son, Damon, who was only a few years younger than Steven was. She told me how lucky I was to have him. In one of our meetings, she turned to me and sadly said that she wished public-health messages would simply state, “Don’t combine opioids with other sedatives.” “Perhaps,” she continued, “my son would be alive today.” I was heartbroken and speechless. I couldn’t imagine what I would do if the shoe were on the other foot.
Her simple message was spot-on. I was determined to help spread it. I grew increasingly frustrated with politicians who overstate the harms of opioids alone. This merely diverts attention and resources away from the real concerns and decreases our ability to take the most appropriate steps to keep people healthy and safe. The undeniable fact is: Opioids have been used safely for centuries. They’ve been used to lessen people’s misery and as important instruments in the physician’s toolbox. We, as a society, should recognize that people will always use these drugs, whether authority figures like it or not.
The first time I did heroin I was well over forty. It wasn’t a youthful indiscretion, as many politicians disingenuously claim about their own drug use. It was deliberate. It was also unremarkable. My friend Kristen asked if I would be interested in trying heroin with her. She had never done it but wanted to try it. Same here. So one Friday evening, we did. Unlike in the movies, we didn’t use needles. (By the way, nor do most heroin users.) We each snorted a short, thin line. Immediately, we detected the nice, characteristic opioid effects, including a dreamy light sedation, free of stress. We talked, reminisced, laughed, exchanged ideas, and carefully documented our drug effects. After they had worn off, we called it an evening and went home.
I was struck by how inconsistent my experience was compared with the chaotic heroin-use scenes typically portrayed in the popular culture. This reinforced my belief that horrible outcomes are too often misattributed to heroin. I no longer feared the drug or pictured a ruinous outcome if I took it. I was now a heroin user. In fact, heroin is probably my favorite drug, at least at the moment.
But, to be clear, I am not an addict, and I don’t say that to distance myself from those who may struggle with heroin addiction. It’s just a fact. I don’t jones for the drug, nor do I use it daily. In fact, the frequency of my heroin use is about as occasional as that of my alcohol use. I have never failed to meet my obligations as a result of the drug or its effects, nor have I involuntarily experienced symptoms that would suggest that I have a problem. I don’t bang (not that there is anything wrong with injecting), nor do I have tracks. I have never nodded off or slurred my speech after taking the drug. No one could tell that I am a heroin user simply by looking at me. The same is true for most other heroin users.
My heroin use is as rational as my alcohol use. Like vacation, sex, and the arts, heroin is one of the tools that I use to maintain my work-life balance. All our lives are filled with pain, stress, and heartbreak. In order for me to remain relatively intact psychologically and to be a humane person, I have developed successful strategies to mitigate the inevitable harm caused by difficult people, impossible situations, unrealistic expectations, and myriad other life stressors. But, to be absolutely clear, I also enjoy heroin for the mere pleasure of its effects.
A few years ago, I was asked to do a three-year bid as department chair. I was honored to have been asked but wanted to consult with others before deciding. Many of my wiser friends and colleagues—some who had previously served in similar administrative roles themselves—advised me not to accept the position. They feared I’d get bogged down in petty departmental politics and be waylaid from my own work. Several echoed the sentiment often attributed to Henry Kissinger: “Academic politics are so vicious precisely because the stakes are so small.”
In the end, though, I agreed to serve. I wanted to help shape the future mission of our department. I wanted to make sure we were doing our share to include, as part of our faculty and student body, individuals from groups that had been and continue to be shut out of elite institutions. I also wanted to give back to a department that had been so generous and supportive of me and my work. My service as department head would be my way of saying thank you.
During my tenure as chair, my gratitude was eroded. For example, I sadly learned that it would be difficult, if not impossible, to increase the number of black faculty members beyond token levels. Black candidates, it seemed, not only had to have an extraordinary academic record but also had to be deemed nonthreatening. If a current faculty member felt threatened by the candidate’s independence, intellect, popularity, success, whatever, it was a wrap. The applicant didn’t stand a chance. Of course, “nonthreatening” is a vague and capricious factor that is never explicitly stated during hiring discussions. Instead of focusing on the applicant’s record, these meetings too often descended into innuendo and whispering campaigns based on rumors from anonymous third-party sources. The anonymous information is usually disclosed by faculty members who are the biggest proponents of “diversity.”
In the university setting, the term diversity has replaced the spirit of redress and has come to represent anybody from black faculty to military veterans. Well, I am both, but have yet to be subjected to discrimination because I’m a veteran. I now cringe whenever I hear colleagues going on about the importance of having a diverse campus community.
Operating within this context caused me a great deal of cognitive dissonance, especially because a large part of my job as department chair consisted in advocating for our faculty. Sometimes it meant presenting before a university committee a persuasive tenure or promotion case on behalf of a colleague. Other times it meant negotiating to secure a coveted university apartment for her or helping to guarantee a spot for his child in Columbia’s K–8 primary school. I frequently wondered, “How can I continue to serve on behalf of people who actively undermine my just efforts?” It was dispiriting.
One of my favorite ways to unwind and rejuvenate is to watch live comedy shows. It helps me not to take myself too seriously. I love laughing, especially laughing at myself. I’m reminded that I, too, am fallible and flawed. As a result, I try to be more understanding and forgiving of others, even if they disappoint me. Comedy has helped me to be a better person.
So has heroin. There aren’t many things in life that I enjoy more than a few lines by the fireplace at the end of the day. Billie Holiday’s soul-stirring voice sets the scene and mood: “God bless the child that’s got his own.” Holiday herself was an avid heroin user. She was criticized, of course. Her response, according to biographer Farah Jasmine Griffin, was that neither of her parents used drugs and she outlived them both: “Heroin not only kept me alive—maybe it also kept me from killing.”8 I know the feeling.
In these serene moments, I reflect on my day, hoping that I wasn’t the source of anyone’s anguish. I replay interpersonal interactions with the goal of seeing things from the other person’s point of view. I am acutely aware of my role and responsibilities, recognizing that my interactions with others, especially subordinates, can cause anxiety or bruised feelings that negatively impact the individual’s subsequent interactions with their loved ones or with others.
Heroin allows me to suspend the perpetual preparation for battle that goes on in my head. I am frequently in a state of hypervigilance in an effort to prevent or minimize the damage caused by daily living in my own skin. When heroin binds to mu (μ) opioid receptors in my brain, I “lay down my burden” as well as “my sword and shield,” just as described in the Negro spiritual “Down by the Riverside.”
The world is alright with me. I’m good. I’m refreshed. I’m prepared to face another day, another faculty meeting or obligatory function. All parties benefit.
I recognize that my experience with heroin wildly conflicts with depictions of the drug as causing users to become emotionally numb. Certainly, extremely large doses of the drug can produce this effect; they can even render a person unconscious. But such effects are virtually nonexistent for and are definitely unwanted by most who seek to enjoy heroin-related effects. Statements attesting to the “numbness” caused by heroin are gross mischaracterizations. They reduce heroin’s effects to something like a deprivation of feelings. It is, precisely, the feelings—forgiving, open, and tranquil—produced by the drug that inspire me to be a more empathetic person. In other words, heroin enhances my ability to feel.
Also, it’s important for me to make clear that my use of heroin—or any other drug—isn’t usually a solo pastime. Regularly, some of my closest friends and I bond over the sweet, earthy smell of burning opium.
“I spoke some foolish things to her.” Fabrice made me laugh as he ran down a blow-by-blow account of an embarrassing night he spent with a mutual friend in Paris. He had had too much alcohol and now wished he could take back his words. He can’t.
Fabrice and I were in a Prague hotel. We had been invited to give presentations at a congress on drugs. Neither one of us was particularly excited about the prospect of speaking to this audience. It was largely composed of psychiatrists who refer to themselves as addictionologists. If ever there was a group of individuals resistant or immune to solid evidence inconsistent with their own worldview, this was the group.
I had just arrived from New York City after a nine-hour flight. I was exhausted. In addition, during the two weeks prior, I had given talks in Los Angeles, Lubbock, and Boston. I did this while still teaching my twice-weekly course at Columbia and my Friday night course at Sing Sing. By now, I was suffering from a respiratory infection and felt mildly feverish and achy. I also had a persistent cough that made my scratchy, sore throat feel worse.
It had been nearly a year since I last saw Fabrice. I’d missed him. No matter how much time passes between our meetings, we always pick right back up from our previous time together, without awkwardness or weirdness. Fabrice is family.
Sitting in that unremarkable hotel room, we smoked opium and laughed almost nonstop. We told stories that highlighted faux pas made by each of us. We made plans to see each other more frequently, despite residing in different countries. We exchanged new information we had learned from our research and about our drugs of choice. We inquired about each other’s families and plotted a holiday together soon.
The hours flew by. Thankfully, opium had lessened my symptoms just in time for dinner, where we met with other congress presenters. Many of them enjoyed wine or another alcoholic beverage with their meal. This no doubt relaxed them and facilitated their own social interactions. Fabrice and I were already there. It turned out to be a lovely evening, and the congress wasn’t bad either.
My ongoing experience with opioids continually forced me to update my thinking. Shortly after completing my PhD, a former professor suggested that I watch the 1996 film Trainspotting. This professor implied that I’d learn something important about heroin withdrawal. I watched it, and as a result, I thought I was informed.
In 2017, I rewatched it. This time, I cringed, especially during the withdrawal scenes. It was too sensationalistic and corny, and by portraying opioid withdrawal as a near-death experience, the film reinforced incorrect and harmful stereotypes about the drug and its users. I knew this depiction wasn’t representative of most users’ experience, because by now I had been through mild heroin withdrawal on more than one occasion. Never had I been terrorized by visual hallucinations during the detox. Never had I experienced the agonizing pain that purportedly drives users to do anything to get another hit. I had experienced absolutely none of that Trainspotting bullshit.
Granted, in the past, I had only used low intranasal doses of heroin for no more than about ten consecutive days at a time. Nonetheless, this pattern of use was enough to produce some withdrawal symptoms when I abruptly stopped using. The symptoms would start about twelve to sixteen hours after the last dose. At most, I felt like I had a case of the twenty-four-hour flu: chills, runny nose, nausea, vomiting, diarrhea, and some mild aches and pains. The bottom line is that it was unpleasant but certainly not dramatic or life-threatening.
Still, I had to face the question of why media portrayals of heroin withdrawals were so inconsistent with what I knew from my own experience and from what I’ve read in the scientific literature. Perhaps the amount of heroin I was using was too low? Or perhaps I needed to use on more consecutive days? I also knew that many avid opioid users report that withdrawal from longer-acting opioids, like methadone, is far worse than it is from heroin. Taking these issues into account, I remembered that I had in my possession a large pill bottle of extended-release morphine. The pills once belonged to a relative who had been prescribed them for pain prior to dying. It didn’t seem right to let the pills go to waste.
So, as part of my experiment, I began taking daily oral doses of morphine, about 30 to 45 mg, and continued for approximately three consecutive weeks. I also used heroin during this period. I planned my “quit day” to be about forty-eight hours prior to a major talk I was scheduled to give. In this way, I would have at least an entire evening to deal with the symptoms. I was going to prove, once and for all, at least to myself, that withdrawal was an inconvenience that could be dealt with without failing to meet major obligations.
It was shortly before midnight, but I couldn’t sleep. I was experiencing one of the worst withdrawal symptoms I had ever felt. It wasn’t the nausea, vomiting, or even diarrhea. Each had subsided. Besides, there was no more food to get rid of. It wasn’t my cravings for the drug. I could take it or leave it. What I really wanted was sleep.
But that wasn’t in the cards. The pain in my abdomen was too intense for me to be able to drift off. It was agonizing and unremitting. It was a pain that I would not easily forget. It was a new pain, unlike any I had previously experienced. It was so intense that it radiated throughout my entire body. The light touch of Robin’s hands on my leg or arm to soothe me merely exacerbated the pain. It lasted for hours, and nothing seemed to alleviate it. We tried aspirin and ibuprofen; neither worked. Cannabis and triazolam—both failed, too. Triazolam is a benzodiazepine and is used to treat insomnia. I wasn’t afraid to take it in this situation because I had only a small amount of opioid in my system.
At this point, Robin hoped I’d go to the emergency room. She gently floated the idea. The distress plastered across her face, however, told a different story, a more urgent one. She was worried, deeply worried. And this worried me. It’s true, my abdominal pain was absolutely dreadful. But I knew that it wasn’t life-threatening and that it would eventually lessen. Robin didn’t know this though.
I had to do something. Act fast. I crushed two 0.25 mg triazolam tablets and snorted them. I knew the drug would reach my brain quicker if I snorted the pills than if I swallowed them. I also knew that two pills would definitely knock me out. Within fifteen minutes, I was sound asleep for the next six hours. Robin, vigilantly monitoring my status throughout, was relieved.
When I woke, the abdominal pain was still present but not remotely as intense. Minor flu-like symptoms, including a runny nose and slight queasiness, also remained. None of this particularly bothered me. I was just relieved that it played out as I thought it would and that it was over. Well, almost over. I shifted my attention to preparing for my upcoming talk, which was going to take place in less than two hours.
After the host introduced me, I started a talk titled “Everything You Thought You Knew about the Opioid Crisis Is Wrong.” Then I told the audience that my talk came at a fortuitous time because I was in the midst of opioid withdrawal. They all laughed, of course; no one seemed to believe me. By all accounts, the talk went quite well. The room was full. Attendees appeared engaged and stayed put until the end. Relevant questions and comments followed. In sum, the talk concluded without a hitch.
Going through opioid withdrawal wasn’t a particularly pleasant experience. And I don’t have plans to do it again anytime soon. But I am glad to have done it. This experience confirmed a few things I already knew. First, opioid withdrawal is not life-threatening. The same cannot be said for alcohol withdrawal. You will not read within these pages that I conducted an alcohol withdrawal self-study. Second, withdrawal symptoms do not equate to addiction. Despite the fact that I underwent opioid withdrawal, I have never met criteria for opioid addiction. Similarly, we would not label a person an addict on the mere basis of experiencing withdrawal symptoms after abruptly discontinuing an antidepressant. Finally, media portrayals of opioids focus almost entirely on negative outcomes—and even these are often exaggerated. This situation led me to act and speak out. I want to help people see through the “opioid crisis” hysteria and all the damage it causes. I also want to ensure that others are afforded safe opportunities to benefit from the serene bliss opioids can offer, should they so choose.