11/10/2014 08:01 am ET Updated Jan 10, 2015

Addiction Casebook: What Is The Heroin?

The initial call did not seem promising. On the voicemail, the man's Slavic accent was very thick. His name, and the name of the person who referred him to me, were unintelligible. I wrote his number down, an outer borough area code, and quickly forgot about it.

About a week later he called again, his message now conveying urgency and irritation. It was about his son, who apparently had a problem with heroin. He was told I was the best doctor in New York for this kind of problem. He pleaded for me to call him back. I was familiar with this kind of situation.

I called him back and apologized for my delay. He immediately adopted the deferential stance Eastern Europeans of his generation have for doctors. I did not recognize the name of the Russian doctor who referred him to me -- another feature of cases like this.

He began to rapidly and disjointedly outline his son's problems. I quickly learned that although only in his early 20s, the son was already a career opiate addict, with numerous treatments, arrests and incarcerations to his credit.

The father wanted his son to be seen by an expert, this was clear. Much of the treatment and mayhem had taken place in Queens. He wanted to come to Manhattan to see a big shot who could fix his son. I was the best name he could find. I doubted I could be of much help, but I felt sorry for him now, and since you never know what can happen in this business I offered to meet him and his son.

The initial greeting in the waiting room was not promising. The father sat alone, looking anxious. He was pure Eastern European immigrant: rumpled suit, 5 o'clock shadow, thick neck, coarse hands. He explained that his son was in the bathroom. I invited him into the office. As we waited for his son, the man informed me they were Ukrainian. It seemed it was just he and his son living together in Queens. There was no explanation for the absence of a woman in the house. He worked in the garment district, but he offered no specifics.

He again began to describe the calamities that had befallen his son, and him by extension. The arrests for theft and possession, the cold turkey detoxes at Riker's, the numerous methadone programs, all ending with his son getting kicked out.

And of course there was plenty of psychiatry as well. The son carried diagnoses of anxiety and depression and had been prescribed the usual culprits: antidepressants, tranquilizers, antipsychotics, and probably an anticonvulsant or two from the creative thinker who deduced bipolar disorder from the mélange.

The father was bewildered by all of it. He knew heroin was the enemy, responsible for all the ravages. But why couldn't his son stay clean? He remembered his son as a kind, helpful young man when not in the throes of addiction. The methadone, the psych meds, the psych labels -- these things he did not understand. Perhaps they were perpetuating the problem. He needed an expert to sort this out.

Twenty minutes had gone by and the son was still in the bathroom. Not promising. At last he appeared. He was less disheveled than I expected. He looked to have shaved in the last day or two. He was skinny and looked exhausted. I asked the father to leave the office.

I dispensed with any illusion of taking a formal history and simply asked the son to explain his agenda for meeting with me. It's not so easy to get this kind of information under these circumstances. There's a protocol that must be followed. It's like bargaining for a used car at the dealership. The salesman must first describe the hardship your offer entails, the anger he will engender from his manager, etc. Only then will he reveal his initial price and the negotiation can begin.

The son wove back and forth for 10 minutes in this dance. I dutifully nodded and asked the right questions to move the piece forward. Finally, he complained that his methadone program wasn't taking his needs seriously. "And what were these unmet needs?" I asked. Then he released his motive. "Anxiety." he said. Crippling, paralyzing, unremitting anxiety. He needed my help or it would surely be a return to dope.

I paused to consider my next move. In a few seconds he was out cold. Nodded out right in front of me. Frozen in his last position. I woke him up. "You just nodded out."

"I'm very tired."

He resumed complaining about the inadequacy of his treatment for anxiety. The anxiety was the source of all of his problems. He wanted to know if I had any ideas to treat it. We discussed his current treatment. The methadone program had put him on high dose methadone and high dose Xanax, but this was not touching the anxiety. I asked him if he was experiencing extreme anxiety right at this moment. He replied yes. I paused, and he nodded off again.

I brought the father back in. The son briefly roused. As the father and I spoke his son nodded off, unperturbed by our conversation. I explained that his son was overmedicated and I outlined a plan that was best implemented by the methadone program.

The father respectfully listened as I spoke. When I was finished he looked down at the floor, processing the recommendations I thought. He looked up with a pained expression. "Doctor, please to tell me, why does he like the heroin so much? What is the heroin?"

I thought for a moment. How could I convey what this drug was to this man? I landed on an analogy.

"Mr. S. You work in the city, right?"


"You take the subway every day from Queens, right?"


"Imagine one day you get picked up in a limo and get taken to work. The limo is huge, clean, with leather seats like couches. It has food, drinks, newspapers, whatever music you want. You go for weeks, months, to work in the limo. You get used to it. After a while you can't imagine taking the subway again. Inside you know the limo is not really who you are, but you've gotten used to the limo and you don't want to give it up." I paused for dramatic effect. "Heroin is like the limo."

He followed every word I said with fixed attention. There was a moment of silence where I could see the wheels turning in his head. Then he spoke: "I understand. Now I understand. Thank you Doctor. Now I understand what is the heroin."

We sat together without speaking. It was a powerful moment. The father had gained some understanding.

"Doctor, one more question. What is the methadone?"

Suddenly, the son stirred. He had been so immobile and quiet we had forgotten about him. We both turned to him, this malnourished wretch, bent into an unnatural angle, bizarrely defying the laws of physics by remaining seated. Without opening his eyes, he slurred, "Methadone is like the Long Island Railroad."

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