The mandala, the Buddhist Wheel of Life, revolves through six realms. Each realm is populated by characters representing aspects of human ­existence–­our various ways of being. In the Beast Realm we are driven by basic survival instincts and appetites such as physical hunger and sexuality, what Freud called the id. The denizens of the Hell Realm are trapped in states of unbearable rage and anxiety. In the God Realm we transcend our troubles and our egos through sensual, aesthetic or religious experience, but only temporarily and in ignorance of spiritual truth. Even this enviable state is tinged with loss and ­suffering.

The inhabitants of the Hungry Ghost Realm are depicted as creatures with scrawny necks, small mouths, emaciated limbs and large, bloated, empty bellies. This is the domain of addiction, where we constantly seek something outside ourselves to curb an insatiable yearning for relief or fulfillment. The aching emptiness is perpetual because the substances, objects or pursuits we hope will soothe it are not what we really need. We don’t know what we need, and so long as we stay in the hungry ghost mode, we’ll never know. We haunt our lives without being fully ­present.

Some people dwell much of their lives in one realm or another. Many of us move back and forth between them, perhaps through all of them in the course of a single ­day.

My medical work with drug addicts in Vancouver’s Downtown Eastside has given me a unique opportunity to know human beings who spend almost all their time as hungry ghosts. It’s their attempt, I believe, to escape the Hell Realm of overwhelming fear, rage and despair. The painful longing in their hearts reflects something of the emptiness that may also be experienced by people with apparently happier lives. Those whom we dismiss as “junkies” are not creatures from a different world, only men and women mired at the extreme end of a continuum on which, here or there, all of us might well locate ourselves. I can personally attest to that. “You slink around your life with a hungry look,” someone close once said to me. Facing the harmful compulsions of my patients, I have had to encounter my ­own.

No society can understand itself without looking at its shadow side. I believe there is one addiction process, whether it is manifested in the lethal substance dependencies of my Downtown Eastside patients; the frantic ­self-­soothing of overeaters or shopaholics; the obsessions of gamblers, sexaholics and compulsive Internet users; or the socially acceptable and even admired behaviours of the workaholic. Drug addicts are often dismissed and discounted as unworthy of empathy and respect. In telling their stories my intent is twofold: to help their voices to be heard and to shed light on the origins and nature of their ­ill-­fated struggle to overcome suffering through substance abuse. They have much in common with the society that ostracizes them. If they seem to have chosen a path to nowhere, they still have much to teach the rest of us. In the dark mirror of their lives, we can trace outlines of our ­own.

There is a host of questions to be considered. Among ­them:

• What are the causes of ­addictions?
• What is the nature of the ­addiction-­prone ­personality?
• What happens physiologically in the brains of addicted ­people?
• How much choice does the addict really ­have?
• Why is the “War on Drugs” a failure and what might be a humane, ­evidence-­based approach to the treatment of severe drug ­addiction?
• What are some of the paths for redeeming addicted minds not dependent on powerful ­substances–­that is, how do we approach the healing of the many behaviour addictions fostered by our ­culture?

The narrative passages in this book are based on my experience as a medical doctor in Vancouver’s drug ghetto and on extensive interviews with my ­patients–­more than I could cite. Many of them volunteered in the generous hope that their life histories might be of assistance to others who struggle with addiction problems or that they could help enlighten society regarding the experience of addiction. I also present information, reflections and insights distilled from many other sources, including my own addictive patterns. And finally, I provide a synthesis of what we can learn from the research literature on addiction and the development of the human brain and ­personality.

Although the closing chapters offer thoughts and suggestions concerning the healing of the addicted mind, this book is not a prescription. I can say only what I have learned as a person and describe what I have seen and understood as a physician. Not every story has a happy ending, as the reader will find out, but the discoveries of science, the teachings of the heart and the revelations of the soul all assure us that no human being is ever beyond redemption. The possibility of renewal exists so long as life exists. How to support that possibility in others and in ourselves is the ultimate ­question.

I dedicate this work to all my fellow hungry ghosts, be they ­inner-­city street dwellers with HIV, inmates of prisons or their more fortunate counterparts with homes, families, jobs and successful careers. May we all find ­peace.

As I pass through the grated metal door into the sunshine, a setting from a Fellini film reveals itself. It is a scene both familiar and outlandish, dreamlike and ­authentic.

On the Hastings Street sidewalk Eva, in her thirties but still ­waif-­like, with dark hair and olive complexion, taps out a bizarre cocaine flamenco. Jutting her hips, torso and pelvis this way and that, bending now at the waist and thrusting one or both arms in the air, she shifts her feet about in a clumsy but concerted pirouette. All the while she tracks me with her large, black ­eyes.

In the Downtown Eastside this piece of ­crack-­driven improvisational ballet is known as “the Hastings shuffle,” and it’s a familiar sight. During my medical rounds in the neighbourhood one day, I saw a young woman perform it high above the Hastings traffic. She was balanced on the narrow edge of a neon sign two storeys up. A crowd had gathered to watch, the users among them more amused than horrified. The ballerina would turn about, her arms horizontal like a tightrope walker’s, or do deep knee ­bends–­an aerial Cossack dancer, one leg kicked in front. Before the top of the firemen’s ladder could reach her cruising altitude, the stoned acrobat had ducked back inside her ­window.

Eva weaves her way among her companions, who crowd around me. Sometimes she disappears behind ­Randall–­a ­wheelchair-­bound, ­heavy-­set, ­serious-­looking fellow, whose unorthodox thought patterns do not mask a profound intelligence. He recites an ode of autistic praise to his indispensable motorized chariot. “Isn’t it amazing, Doc, isn’t it, that Napoleon’s cannon was pulled by horses and oxen in the Russian mud and snow. And now I have this!” With an innocent smile and earnest expression, Randall pours out a recursive stream of facts, historical data, memories, interpretations, loose associations, imaginings, and paranoia that almost sound ­sane–­almost. “That’s the Napoleonic Code, Doc, which altered the transportational mediums of the lower rank and file, you know, in those days when such pleasant smorgasboredom was still well fathomed.” Poking her head above Randall’s left shoulder, Eva plays ­peek-­a-­boo.

Beside Randall stands Arlene, her hands on her hips and a reproachful look on her face, clad in skimpy jean shorts and ­blouse–­a sign, down here, of a mode of earning drug money and, more often than not, of having been sexually exploited early in life by male predators. Over the steady murmur of Randall’s oration comes her complaint: “You shouldn’t have reduced my pills.” Arlene’s arms bear dozens of horizontal scars, parallel, like railway ties. The older ones white, the more recent red, each mark a souvenir of a razor slash she has inflicted on herself. The pain of ­self-­laceration obliterates, if only momentarily, the pain of a larger hurt deep in the psyche. One of Arlene’s medications controls this compulsive ­self-­wounding, and she’s always afraid I’m reducing her dose. I never ­do.

Close to us, in the shadow of the Portland Hotel, two cops have Jenkins in handcuffs. Jenkins, a lanky Native man with black, scraggly hair falling to below his shoulders, is quiet and compliant as one of the officers empties his pockets. He arches his back against the wall, not a hint of protest on his face. “They should leave him alone,” Arlene opines loudly. “That guy doesn’t deal. They keep grabbing him and never find a thing.” At least in the broad daylight of Hastings Street, the cops go about their search with exemplary ­politeness–­not, according to my patients, a consistent police attitude. After a minute or two Jenkins is set free and lopes silently into the hotel with his long ­stride.

Meanwhile, within the span of a few minutes, the resident poet laureate of absurdity has reviewed European history from the Hundred Years’ War to Bosnia and has pronounced on religion from Moses to Mohammed. “Doc,” Randall goes on, “the First World War was supposed to end all wars. If that was true, how come we have the war on cancer or the war on drugs? The Germans had this gun Big Bertha that spoke to the Allies but not in a language the French or the Brits liked. Guns get a bad rap, a bad ­reputation–­a bad raputation, ­Doc–­but they move history forward, if we can speak of history moving forward or moving at all. Do you think history moves, Doc?”

Leaning on his crutches, paunchy, ­one-­legged, smiling ­Matthew–­bald, and irrepressibly ­jovial–­interrupts Randall’s discourse. “Poor Dr. Maté is trying to get home,” he says in his characteristic tone: at once sarcastic and sweetly genuine. Matthew grins at us as if the joke is on everyone but himself. The chain of rings piercing his left ear glimmers in the bronzed gold of the late afternoon ­sun.

Eva prances out from behind Randall’s back. I turn away. I’ve had enough street theatre and now I want to escape. The good doctor no longer wants to be ­good.

We congregate, these Fellini figures and ­I–­or I should say we, this cast of Fellini ­characters–­outside the Portland Hotel, where they live and I work. My clinic is on the first floor of this cement-and-glass building designed by Canadian architect Arthur Erickson, a spacious, modern, utilitarian structure. It’s an impressive facility that serves its residents well, replacing the formerly luxurious ­turn-­of-­the-­century establishment around the corner that was the first Portland Hotel. The old place, with its wooden balustrades, wide and winding staircases, musty landings and bay windows, had a character and history the new fortress lacks. Although I miss its Old World aura, the atmosphere of faded wealth and decay, the dark and blistered windowsills varnished with memories of elegance, I doubt the residents have any nostalgia for the cramped rooms, the corroded plumbing or the armies of cockroaches. In 1994 there was a fire on the roof of the old hotel. A local newspaper ran a story and a photograph featuring a female resident and her cat. The headline proclaimed, “Hero Cop Saves Fluffy.” Someone phoned the Portland to complain that animals should not be allowed to live in such ­conditions.

The nonprofit Portland Hotel Society, for whom I am the staff physician, turned the building into housing for the nonhousable. My patients are mostly addicts, although some, like Randall, have enough derangement of their brain chemicals to put them out of touch with reality even without the use of drugs. Many, like Arlene, suffer from both mental illness and addiction. The PHS administers several similar facilities within a radius of a few blocks: the Stanley, Washington, Regal and Sunrise hotels. I am the house doctor for them ­all.

The new Portland faces the Army and Navy department store across the street, where my parents, as new immigrants in the late 1950s, bought most of our clothing. Back then, the Army and Navy was a popular shopping destination for working ­people–­and for ­middle-­class kids looking for funky military coats or sailor jackets. On the sidewalks outside, university students seeking some slumming fun mixed with alcoholics, pickpockets, shoppers and Friday night Bible ­preachers.

No longer. The crowds stopped coming many years ago. Now these streets and their back alleys serve as the centre of Canada’s drug capital. One block away stood the abandoned Woodward’s department store, its giant, lighted “W” sign on the roof a ­long-­time Vancouver landmark. For a while squatters and antipoverty activists occupied the building, but it has recently been demolished; the site is to be converted into a mix of chic apartments and social housing. The Winter Olympics are coming to Vancouver in 2010 and with it the likelihood of gentrification in this neighbourhood. The process has already begun. There’s a fear that the politicians, eager to impress the world, will try to displace the addict ­population.

Eva intertwines her arms, stretches them behind her back and leans forward to examine her shadow on the sidewalk. Matthew chuckles at her crackhead yoga routine. Randall rambles on. I glance out eagerly at the ­rush-­hour traffic flowing by. Finally, rescue arrives. My son Daniel drives up and opens the car door. “Sometimes I don’t believe my life,” I tell him, easing into the passenger’s seat. “Sometimes I don’t believe your life either,” he nods. “It can get pretty intense down here.” We pull away. In the rearview mirror the receding figure of Eva gesticulates, legs splayed, head tilted to the ­side.

–

The Portland and the other buildings of the Portland Hotel Society represent a pioneering social model. The purpose of the PHS is to provide a system of safety and caring to marginalized and stigmatized ­people–­the ones who are “the insulted and the injured,” to borrow from Dostoevsky. The PHS attempts to rescue such people from what a local poet has called the “streets of displacement and the buildings of exclusion.”

“People just need a space to be,” says Liz Evans, a former community nurse, whose ­upper-­tier social background might seem incongruous with her present role as a founder and director of the PHS. “They need a space where they can exist without being judged and hounded and harassed. These are people who are frequently viewed as liabilities, blamed for crime and social ills, and . . . seen as a waste of time and energy. They are regarded harshly even by people who make compassion their careers.”